Il a été mis sur pied par Environnement Canada, en collaboration avec la ville de Montréal, le ministère de l’Environnement du Québec et les direc-tions de santé publique dont celle de M
Trang 1P r é v e n t i o n e n p r a t i q u e m é d i c a l e , M a i 2 0 0 5 3
tréalaise montre que les concentrations
de NO2, un polluant principalement issu
des véhicules, suivent un gradient selon
l’achalandage des routes et que la
con-centration est environ le double entre les
sites les moins et les plus exposés(12)
Quelles sont les mesures
préven-tives, individuelles et collectives?
Le médecin peut jouer un rôle significatif
auprès des personnes à risque ainsi qu’un
rôle actif dans sa communauté Ainsi, des
données suggèrent que d’éviter les efforts
physiques intenses lors des jours les plus
pollués pourrait prévenir l’aggravation
d’une maladie existante (MCV, MPOC, asthme)
Il est donc recommandé :
• d’identifier les personnes plus à risque
(plus vulnérables ou davantage exposées),
• de les informer de l’existence du système
d’avertissement de smog (INFO-SMOG),
• de les conseiller quant à la pertinence de
réduire leur niveau d’activité physique
lors des jours de forte pollution, surtout
au moment les plus critiques de la
jour-née, par exemple en fin d’après-midi,
• de leur suggérer de surveiller leurs
symptômes, d’ajuster leur médication au
besoin et de consulter le cas échéant
Cette intervention ne peut cependant
prévenir qu’une partie des effets aigus
attribuables à la pollution de l’air et une
petite fraction de l’ensemble des effets
totaux Il serait évidemment inacceptable
de recommander à ces patients de limiter
leur activité physique lors des jours de
pollution modérée, vu leur fréquence et
l’impact positif de l’activité physique en
général Notons que ces conseils
peu-vent s’ajouter à ceux faits pour la chaleur
accablante (recommandations faites aux
mêmes personnes vulnérables de réduire
l’activité physique, de s’hydrater et
sur-tout de rechercher un endroit plus frais ou
climatisé) puisqu’en été, les jours de
chaleur accablante sont souvent associés
au smog
Par ailleurs, le médecin peut jouer un
rôle actif dans sa communauté en
défen-dant publiquement l’importance d’actions
visant à réduire l’exposition des personnes
les plus vulnérables ou les plus exposées,
celles-ci étant généralement les plus
défavorisées économiquement Il peut
aussi collaborer avec la Direction de santé
publique et ses partenaires Le rôle de ces derniers est de diffuser les messa-ges publics en cas d’avertissement de smog (voir INFO-SMOG), de quantifier les impacts sanitaires de la pollution de l’air
et de sensibiliser les décideurs et la lation quant à leur ampleur, d’identifier les populations à risque et de promouvoir des actions visant à réduire la pollution à la source (revoir la réglementation, adopter diverses mesures incitatives, promouvoir
popu-le transport colpopu-lectif et actif, instaurer
un programme d’entretien des véhicules, modifier les modes de chauffage, réduire les émissions industrielles, )
Des expériences vécues ailleurs trent les bénéfices réels de la diminu-tion de la pollution atmosphérique(2)
démon- Mentionnons quelques exemples :
• une baisse de la mortalité cardio- vasculaire de 10 % suite au bannisse-ment du charbon à Dublin,
• une réduction des décès et des sations pour maladies respiratoires suite
hospitali-à la fermeture temporaire d’une usine (principale source locale de pollution) dans la vallée de Utah,
• une baisse des hospitalisations et consultations pour asthme à Atlanta associée à la restriction des véhicules lors des jeux olympiques de 1996,
• une réduction des bronchites suivant
la baisse des niveaux de pollution dans l’ancienne République Démocratique Allemande
Surveillance de la qualité de l’air?
Il existe au Canada comme dans la rité des pays un système de surveillance
majo-de la qualité majo-de l’air et ce, ment dans les grandes villes Le program-
principale-me INFO-SMOG a débuté en 1994 dans
la grande région de Montréal Le pro- gramme couvre maintenant huit régions
du Québec pour la période estivale alors qu’il est opérationnel en hiver que pour le grand Montréal Il a été mis sur pied par Environnement Canada, en collaboration avec la ville de Montréal, le ministère de l’Environnement du Québec et les direc-tions de santé publique dont celle de Montréal
Ce système permet de prédire 24 res à l’avance, à partir des conditions météorologiques, le dépassement des valeurs-guides pour l’ozone et les par-ticules fines et d’émettre un avertisse-ment le cas échéant L’avis est par la suite confirmé ou infirmé selon les concentrations observées aux sites d’échantillonnage Cette information est affichée sur les panneaux routiers; elle est également communiquée par les médias
heu-et est accessible sur les sites internheu-et des organismes ci-haut
• Identifier les personnes à risque, soit les personnes vulnérables (patients porteurs
de MCV, MPOC, asthme, diabète) et plus exposées (demeurant près des routes achalandées ou de sources industrielles, travaillant à l’extérieur, ).
• Les informer du programme INFO-SMOG.
• Leur conseiller de réduire leur niveau d’activité physique à l’extérieur lors des jours de forte pollution.
• Leur suggérer de surveiller leurs mes, d’ajuster leur médication au besoin
symptô-et de consulter le cas échéant
• S’impliquer dans sa communauté pour promouvoir des mesures visant à réduire
la pollution atmosphérique
Interventions préventives du médecin
lavoieverte.qc.ec.gc.ca/atmos/ dispersion/main_f.html
Trang 2Un bulletin de la Direction de santé publique de Montréal publié avec la collaboration de l’Association des médecins omnipraticiens de Montréal dans le cadre du programme Prévention en pratique médicale, Volet Information, coordonné par le docteur Jean Cloutier
Ce numéro est une réalisation du secteur Environnement urbain et Santé
Responsable du secteur : Dr
Louis Drouin
Rédacteur en chef : Dr
Louis Patry Édition : Deborah Bonney Infographie : Manon Girard Auteur : Dr
ISSN (version imprimée) : 1481-3734 ISSN (version en ligne) : 1712-2937 Dépơt légal — Bibliothèque nationale du Québec, 2005 Dépơt légal — Bibliothèque nationale du Canada, 2005 Numéro de convention : 40005583
la santé publique Cet impact ne survient pas que lors des quelques jours de smog, mais bien sur l’ensemble de l’année, en été et en hiver Le médecin peut contri-buer à la prévention de ces effets délé-tères par ses actions directes auprès des patients vulnérables et par son action communautaire Ce n’est que par l’ensem-ble des actions concertées sur les sources
de pollution de l’air que des bénéfices importants seront réalisés Ces actions auront aussi un impact bénéfique sur les émissions de gaz à effet de serre, res-ponsables des changements climatiques, dont l’un des effets sera l’augmentation
du nombre et la sévérité des épisodes de chaleur et de smog dans le futur
1 Judek S, Jessiman B, Stieb D, Vet
R Estimation de la surmortalité
causée par la pollution
atmosphé-rique au Canada, Santé Canada et
Environnement Canada, 30 aỏt 2004
2 Brunekreef B, Holgate ST Air Pollution
and Health, The Lancet, 360:
1233-1242, 2002
3 Brook RD, Brook JR, Rajagopalan
S Air Pollution: the “Heart” of the
Problem, Current Hypertension Reports,
5:32-39, 2003
4 Health Aspects of Air Pollution Results
from the WHO Project “Systematic
Review of Health Aspects of Air
Pollution in Europe” WHO, Regional
Office for Europe, 25 p., 2004
5 Brook RD et al Air Pollution and
Cardiovascular Disease A Statement
for Healthcare Professionals From
the Expert Panel on Population and
Prevention Science of the American
Heart Association, Circulation, 109:
2655-2671, 2004
6 Stieb DM, Judek S, Burnett RT
Meta-Analysis of Time-Series Studies of Air
Pollution and Mortality: Effects of
Gases and Particles and the Influence
of Cause of Death, Age and Season J
Air & Waste Manage Assoc
52:470-484, 2002
Conclusion
7 Stieb DM, Judek S, Burnett RT Analysis of Time-Series Studies of Air Pollution and Mortality: Update in Relation to the Use of Generalized
Meta-Additive Models, J Air & Waste Manage Assoc 53:258-261, 2003.
8 Pope III, CA Epidemiology of Fine Particulate Air Pollution and Human Health : Biologic Mechanisms and
Who’s at risk? Environ Health Perspect,
108(suppl 4):713-723, 2000
9 Pope III, CA et al Lung Cancer,
Cardiopulmonary Mortality, and term Exposure to Fine Particulate Air
Long-Pollution, JAMA, 287 (9): 1132-1141,
2002
10 Bates DV, Caton RB: A Citizen’s Guide to Air Pollution, David Susuki Foundation, Vancouver, Canada, 2nd
edition, 452 p, 2002
11 Breton MC et al Association entre
les concentrations polliniques de
l’Ambrosia spp et les consultations
pour rhinite allergique à Montréal
Soumis pour publication
12 Smargiassi A, Baldwin M, Berrada K
Étude pilote de la variation spatiale des niveaux de particules associés au transport routier à une échelle locale
à Montréal Direction de santé que, Régie régionale de la santé et des services sociaux de Montréal-Centre,
publi-30 p et annexes, 2003
Association des Médecins Omnipraticiens
de Montréal
Nombre moyen de jours par mois ó les concentrations d’ozone et de
particules fines ont été élevées à au moins une station de mesure
Grande région de Montréal - Années 2001 à 2003
Ministère de l’Environnement du Québec http://www.menv.gouv.qc.ca/
Heat Waves www.santepub-mtl.qc.ca/Environnement/chaleur Santé Canada et qualité de l’air http://www.hc-sc.gc.ca/hecs-sesc/ qualite_air/a_propos.htm
Source : Ministère de lʼEnvironnement du Québec
0 2 4 6 8 10
Jan Fév Mars Avril Mai Juin Juil Aỏt Sept Oct Nov Déc
Trang 3Une personne normotendue âgée de 55 à 65 ans a 90% de ris-La prise en charge de l’HTA doit se faire rapidement
º Traiter l’HTA réduit les risques d’ACV de 40%, la mortalité et les événements associés aux maladies cardiovasculaires
Il faut augmenter le dépistage de l’HTA
º 95% des cas d’HTA ont une étiologie inconnue, sur ce, 60 % auraient une origine environnementale et 40% une génétiqueL’implication du patient dans son suivi est un gage de succès
º Plus de 33% des patients hypertendus ne considèrent pas l’HTA comme un problème important
le patient
Faciliter la prise
de la médication (die, heure fixe)
l’Hta est silencieuse
l’Hta se dépiste
DIAGNOSTIC
La prise de la T.A est inhérente à la pratique médicale Elle peut cependant aussi être évaluée par l’Auto-mesure à domicile
et par la Mesure Ambulatoire de Pression Artérielle (MAPA)
RAPPEL des conditions idéales pour la prise de T.A.
Garder la mesure la plus élevée
RAPPEL sur l’Auto-mesure de la T.A à domicile : avoir deux valeurs, et ce, matin et soir, sur une période initiale de 7 jours.
Trang 4•Diminution de la consommation d’alcool
pharmacologique
gique, nécessitant souvent une thérapie combinée
•S’ajoute au traitement non pharmacolo-algorithme pour le diagnostic et le suivi de l’ Hta
Hypertension
s tade 1 140-159 (Syst.) ou 90-99 (Diast.) stade 2 160 – 179 (Syst.) ou 100-109 (Diast.) stade 3 ≥ 180 (Syst.) ou > 110 (Diast.)
L’urgence « relative » est définie comme une hypertension sévère ou accélérée : HTA stade 3 ou signes fonctionnels associés (cardiaque, neurologique, rénal)
Symptômes, HTA grave, intolérance au traitement antihy- pertensif ou atteinte d’organes cibles?
ISSN : 1481-3734 (version imprimée); ISSN : 1712-2937 (version en ligne)
Trang 5M a r c h 2 0 0 1
The symptoms of CO poisoning are insidious and non-specific, and the history sometimes unreliable
To make such a diagnosis,
it is imperative to remain suspicious.
It is essential to try to identify the source of exposure to CO even though it
is sometimes difficult to do so and may require turning to specialised resources
Every year in Québec, about 15 people die from
carbon monoxide (CO) poisoning
A total of 117 poisonings were reported to the
Quebec Poison Control Centre in 1988 compared with
1853 poisonings in 1998, the year of the ice storm.
Among the 958 cases reported in 1999, accidental
poisonings (excluding those in the workplace)
repre-sented 70% of cases.
CO, the great impersonator…
Symptoms of CO intoxication can be mistaken for:
• the flu or food poisoning (especially among
children)
• migraine or stroke
• psychiatric problems or alcohol intoxication
• cardiovascular disease (angina, infarct)
The clinical features of CO poisoning vary greatlydepending on:
1 the level and duration of exposure to CO
2 the physical effort expended during the exposure
3 the health status of the person exposed
An intoxication can also affect a group of people:
this option should be considered when several people
in the same household, working at the same place,
or participating in the same activities present similarsymptoms at the same time
How does CO exert its toxic effects?
CO is a chemical asphyxiant
• Anoxia due to a lack of oxygen in the tissues isthe principal toxic effect CO has an affinity forhaemoglobin that is 245 times higher thanthat of oxygen The CO absorbed combines withhaemoglobin and forms carboxyhaemoglobin(HbCO)
Its toxicity also results from:
• a decrease in the oxygen-carrying capacity ofhaemoglobin, making the quantity of O2evenless available to the tissues
• binding of CO with the myoglobin of myocardialand skeletal muscle cells
• binding of CO with cytochromes, inhibiting thecellular respiratory cycle
If you suspeçt CO poisoning
When obtaining a patient’s clinical history, toms should be documented, and risk conditionsand sources of exposure identified A patient shouldalso undergo a complete physical examination, aswell as an ECG and neurological testing Specialattention should be paid to cognitive functions Aneuropsychological evaluation is also recommended
symp-However, neuropsychological resources are scarce
révention
en pratique médicale
Not always easy to diagnose!
The story of Ms B.
For the last two weeks, Ms B., who lives
in a downtown condominium complex,
has been suffering from headaches, nausea,
and vomiting The CO detector installed in
her apartment has gone off a few times
and indicated concentrations of 100-150
ppm (parts per million).
The municipal fire prevention service
visited her home and recommended that
the ventilation system in the building’s
garage be inspected Following an episode
of more acute symptoms, including loss of
consciousness, Ms B went to see her
Trang 6• Dynamiting
- dynamiting generates CO that canmigrate underground and affect workers orresidents living near the work site
• Use of methylene chloride or dichloromethane,
a solvent used in paint remover, the production
of plastics, the coffee decaffeination process,and the pharmaceutical industry This solvent
is partly metabolised into CO
How do you interpret haemoglobin (COHb) levels?
carboxy-Normal values
Non-smokers: less than 2%
• Endogenous production arising from the down of haemoproteins (haemoglobin, myoglo-bin, etc.)
break-Smokers: between 3% and 9%
• Varies by extent of smoking habit
• Upper value of 9% possible if very heavy smoker
Sources of exposure
Sources of exposure that may be linked to a
resi-dence, a place of work, sporting events, or leisure
activities should be identified
Dangerous levels of CO are produced when a motor,
a heating system, an appliance or a tool that uses
fuel (gas, oil, propane, naphtha, natural gas,
kerosene, wood, etc.) is defective or when it is used
in an enclosed, poorly ventilated environment
Because CO is odorless and non-irritant, it is
impos-sible to detect its presence without a measuring
device
Principal sources:
• Heating, cooking, and refrigeration systems
- furnaces, gas stoves and hot water heaters
- back-up systems used during power failures
(heaters, generators, etc.)
- propane refrigerators, gas stoves, barbecues
• Motor vehicles
- automobiles, trucks, snowmobiles, etc
• Industrial and maintenance equipment
- propane lift trucks
- ice resurfacing machines used in arenas
- concrete and floor polishers
- compressors
• Motor appliances and tools
- chain saws, mowers, pumps, etc
• Certain industrial processes
- metallurgy, chemical synthesis industry, etc
• Ischemic heart disease or disturbances of cardiac rhythm Carboxyhaemoglobin levels of 2% to
6% are sufficient to exacerbate angina attacks or cardiac arrythmias
• Pulmonary disease
• Anaemia (O2delivery is perturbed)
• Fever, hyperthyroidism (increased need for O2)
• Pregnancy
• Foetus: greater affinity of foetal haemoglobin for CO Foetal COHb can be 40% to 60%
higher than the mother’s
• Increased ventilation in children and young adults
• Physical exercise in a poorly ventilated environment contaminated with CO
The story of Ms B.
The physician asks for a globin: her level of COHb is at 15 % and
carboxyhaemo-Ms B does not smoke.
Health conditions at risk and other risk factors
Several factors can influence the measured level
of COHb:
• Duration and intensity of exposure
• Length of time between end of exposure andwhen blood sample was taken
• 1 hour and 20 minutes at 100% O2
• 23 minutes at 100% O2and at 3 atmospheres(hyperbaric chamber)
When interpreting results, various conditionsunconnected to CO exposure that could generateCOHb should also considered:
• Pregnancy: increased endogenous production
• Any increase in the destruction process of redblood cells and other haemoproteins, e.g.:severe haemolysis: COHb 5%
• Exposure to methylene chloride ordichloromethane
Adapted from: Monoxyde de carbone - Critères d’une intoxication et d’une exposition significative :
Fichier des maladies à déclaration obligatoire, Comité de santé environnementale du Québec, 1998.
Remember that a high level of COHb will
confirm a diagnosis but that a normal level of COHb does
not necessarily rule out
this diagnosis The level of COHb is not necessarily correlated to symptoms or prognosis It should not be the only basis for choosing a treatment.
Trang 7Symptoms and clinical features related to carboxyhaemoglobin concentration
Adapted from INSPQ, Direction des risques biologiques, environnementaux et occupationnels, Galarneau L., Martel R., Lévesque B., Sanfaçon G., Gauvin D., Auger P., Septembre 2000, Les risques d’intoxication au monoxyde de carbone associés au dynamitage en milieu habité Avis Scientifique, page 6
Symptoms and features
Possible coronary pain in people with angina exacerbated by low-level exertion Headache
Headache, dizziness, nausea, hyperpnea, tachycardia Confusion, loss of consciousness, nausea, hyperpnea, tachycardia Visual and aural disturbances, intellectual dysfunction, muscular weakness Coma, convulsion, cardiopulmonary dysfunction
Death
What are the complications associated with CO poisoning?
In the fœtus
The fœtus is especially sensitive In utero death is
possible even if the mother is only slighly cated Poisoning can also provoke developmentalproblems and lesions caused by cerebral anoxia inthe foetus
intoxi-In children or adults
In addition to cerebral oedema, metabolic acidosisand cardiac, pulmonary and renal complications canresult in a patient’s death; the most insidious effect
is onset of neurological, behavioural, and psychiatricmanifestations following an asymptomatic period of afew weeks after exposure, which explains the impor-tance of carrying out a neuropsychological evaluation.Manifestations are varied and include: cognitivefunction, memory or personality impairments, irri-tability, impulsive behaviour, psychosis, dementia,cortical blindness, parkinsonism, peripheral neuritis,syndrome similar to multiple sclerosis, and auto-nomic nervous system dysfunction (urinary and faecalincontinence)
To provide proper follow-up, we suggest seeing thepatient again 3 weeks after an acute accidentalexposure to ensure that no delayed sequelae havedeveloped
The story of Ms B.
Because of the confusion she is presenting,
the pneumologist at Montreal’s Sacré-Coeur
Hospital has decided to hospitalise Ms B and
provide her with four treatments in a
hyper-baric chamber.
• Coma
• Any residual neurological symptom,other than headaches, regardless oflevel of COHb, after 4 to 6 hours ofnormobaric oxygen therapy
• Any history of loss of consciousnessduring or after exposure to CO, even ifbrief and resolved
• Angina, arrythmia, or signs of ischemia
at ECG
• Any pregnant woman who has beenexposed and whose COHb levels areover 15%*
• Any patient with COHb levels over 40%
• COHb levels between 25% and 40%, ifprolonged exposure or if sample collectionwas delayed
If unsure, contact the physician in charge
of the hyperbaric centre at Montreal’s Hôpital du Sacré-Coeur at:
The circumstances surrounding CO
poisoning, the medical history, and a
complete physical exam are more
important to consider than COHb alone
when deciding whether or not to treat
a patient in a hyperbaric chamber.
When should a patient be referred
for treatment in a hyperbaric
chamber?
Patients with CO poisoning should be treated with
100% oxygen Hyperbaric oxygen therapy (100%, 3
atmospheres) is used in certain cases to reduce CO
levels in tissues more rapidly and to prevent delayed
sequelae that could develop as a result of severe
intoxication
Trang 8Is this a reportable disease (MADO)? YES
How can CO poisoning be prevented?
The pamphlet entitled “Le monoxyde de carbonetue… Y en a-t-il chez vous?” lists the measures totake if there are sources of CO in a residential build-ing You can consult this document on the followingWeb site: http://www.cspq.qc.ca/cse/pub/doc/text32.htm,
or order it from the public health department bycalling 528-2400, extension 3219
In the workplace, methods of control should beimplemented at the source (preventive maintenance
of machines and tools, using electric equipment), inthe environment (general and local ventilation),and with workers (information, work methods, ade-quate personal protection equipment, if necessary)when there is a CO source Industrial CO detectorscan also be used
révention
en pratique médicale
Association des Médecins Omnipraticiens
de Montréal
A publication of the Direction de la santé publique
de Montréal-Centre published in collaboration with the Association des médecins omnipraticiens de Montréal,
as part of the Prévention en pratique médicale programme coordonnated by Doctor Jean Cloutier
This issue is produced by the Occupational and Environmental Health Unit
Head of the unit: Dr Louis Drouin Editor-in-chief: Dr Louis Patry Editor: Jo Anne Simard Design: Rouleau•Paquin Graphic design: Manon Girard Texts by: Dr Suzanne Brisson, Dr Louis Patry,
1301 Sherbrooke East, Montréal, Québec H2L 1M3 Telephone : (514) 528-2400
http://www.santepub-mtl.qc.ca
Legal deposit – 1 st trimestre 2001 Bibliothèque nationale du Québec National library of Canada ISSN: 1481-3742
Resources
• Agencies and their functions
Environmental health team on call at the
Direction de la santé publique de
Montréal-Centre (DSP)
(514) 528-2400
• Monitor reported events
• Contact attending physicians if necessary
Commission de la santé et de la sécurité
du travail (CSST)
(514) 906-2911, 24 hours a day
• When poisoning occurs among workers,
inspectors can investigate workplaces and
ensure that required corrective and
preventive actions are taken
Montreal fire prevention services
911
• Intervene in emergency cases
They can measure the concentrations of
CO in the air, proceed with an evacuation of the
premises, and stabilise the situation in the
buildings.
Quebec Poison Control Centre
1-800-463-5060
• Source of toxicological referrals.
Sacré-Cœur de Montréal Hospital
Interuniversity occupational and
environ-mental health clinic
(514) 849-5201, extension 2360
• Occupational and environmental health
consultation
• Post-exposure follow-up
Are CO detectors effective?
CO detectors are an effective prevention methodwhen there are potential sources of CO in a residence.They continuously measure CO concentration in theair, simulate the effects of CO in the human body, andset off an audible alarm before CO concentrationreaches levels that pose a health risk It is important
to read the manufacturer’s instructions carefully toknow where to put the detectors and the measures totake in case the alarm goes off Finally, it is essential
to find out what caused the alarm to go off and tocorrect the problem
Residential CO detectors should not be used in trial settings There are specific CO detectors for com-mercial and industrial use
indus-To report CO poisoning to the
DSP Montréal-Centre 24-hour service: (514) 528-2400
• From 8:00 a.m to 5:00 p.m.,
ask for the person on-call in occupational and environmental health.
• Outside regular working hours,
follow the voice-mail instructions
to be exposed to this source of CO.
The same day, a health worker from the public health department goes to her home In view of the high concentrations
of CO measured in the building, other residents affected by CO are sought out.
A neighbour also reports symptoms including loss of consciousness Because
of her losing consciousness, both she and her 9-year-old child will receive two treat- ments in a hyperbaric chamber Upon recom- mendation from the public health unit, the Fire Prevention Service forbids auto- mobile access to the building’s under- ground garage as long as corrective mea- sures have not been taken The investigation will show major defects in the CO detec- tors as well as in the garage’s ventilation and exhaust systems Residents will have
to wait several months before they can use the garage again.
Trang 9Colder temperatures have arrived and with
them the unwelcome possibility of carbon
monoxide poisoning Accidental carbon
monoxide poisoning is avoidable and can be
prevented.
Carbon monoxide (CO) poisoning often occurs in
northern climates such as ours here in Quebec.
CO can be generated by faulty or poorly
maintained heating systems, or by internal
combustion motors functioning in a poorly
ventilated environment.
Any fuel is a source of CO, including petroleum,
gas, diesel, fuel, derosene, oil, heating oil,
naphta, coal, natural gas, propane, wood, etc.
Dynamiting also generates CO that can penetrate
underground and affect workers or residents
living near the work site.
CARBON MONOXIDE POISONING
Prevention
Be wary of CO
• CO is an odourless, colourless, and non-irritant gas Consequently, it is
impossible to detect its presence without a measuring device.
• CO detectors are an effective protection method when there are tial sources of CO in a residence The pamphlet entitled “Un avertisseur
poten-de carbone peut sauver poten-des vies Protégez-vous1” contains pertinent tion on choosing and installing residential CO detectors.
informa-• Residential CO detectors should not be ued in industrial settings There
are specific CO detectors for commercial and industrial use.
• Never leave the motor running while
you are digging a car out of a
snow-bank.
• Never leave a car running in a
garage, even if the garage door is
open.
• Never start a car using a remote starter
when the car is in a garage.
• Never use a gas stove instead of the
main heating system, even for a short
period of time.
• Never use a barbecue, Hibachi, or
fuel-burning heater inside a house, cottage,
mobile home or any other building.
• Never use a lamp, a stove, or any other
outdoor open-flame appliance in an
enclosed space.
• In a mobile home or a house, never
block off the air in takes or extractor
fans of fuel-based appliances
• Never run motor tools (mowers,
hedge-cutters, chain saws, generators, etc.) in
an enclosed or poorly ventilated space
(house, garage, workshop, shed, etc.).
What you should never do
HOW TO PREVENT CARBON MONOXIDE POISONING2
• Remove snow from around a car before turning on the ignition.
• Install one or several carbon monoxide detectors in the house or mobile home
if there is a potential source of CO.
• Check regularly to ensure that all appliances and tools that use fuel are in good
working order; follow maintenance and safety instructions in the user guides.
Ensure that qualified personnel perform yearly maintenance.
• Make sure that furnace exhaust ducts and the chimney are in good condition.
• Make sure that no bird’s nest or other debris, or accumulation of ice or snow is blocking the chimney.
• Have your chimney swept regularly.
• Use the right type of appliance in the right place: some items are made only for
tents and others for use outdoors.
• Ensure that there is a permanent air inlet and an outdoor vent for all fuel-using
products.
• Make sure that when the kitchen or bathroom fan and the air exchanger are used,
combustion gases are not drawn back into the house
• For propane refrigerators, choose a new model that is vented to the outdoors
and has integrated CO detector.
• If you use a fuel-burning heating system, have it verified by a qualified contractor
at least once a year, or when changing or replacing the system.
• Generators should be installed outdoors and in such a way that gases will not
be trapped or drawn into building through a window or other opening.
What you should do
1 An electronic version of the pamphlet « Un avertisseur de carbone peut sauver des vies Protégez-vous » is available in French at www.inspq.qc.ca/cap/depliants.htm
2 Based on the pamphlet “Carbon Monoxide kills Is there any in your home?” available on the Internet at: ww.inspq.qc.ca/cap/depliants.htm.
Trang 10en pratique médicale
Lymphogranuloma venereum - “LGV”
Lymphogranuloma venereum (LGV) is a
sex-ually transmitted infection (STI) caused by
Chlamydia trachomatis serotypes L1, L2 and
L3 Unlike serotypes A-K, LGV serotypes are
invasive.
Epidemiological situation
LGV was formally described for the first time
in 1900 LGV is endemic in some parts of
Africa, Asia, South America and the
Caribbean In January 2003, an outbreak of
LGV among men who have sex with men
(MSM) was reported, first in Europe
(Amsterdam, Paris, London) then in the United
States.
In Canada, as of 3 November 2005, 36 cases of
lymphogranuloma venereum (LGV) had been
reported to the Public Health Agency of
Canada since January 2004 In Quebec, a case
of LGV was reported in 2004, and 24 cases in
2005 (23 in Montréal and 1 in the Eastern
Townshipse) Up to 83% of these cases were
observed in the latter half of 2005 All cases
were in men who have sex with men (MSM)
aged 21 to 55 years (average age: 38 years).
The principal clinical manifestations were the following: genital or anal papule or ulcer (4 people); anal symptoms: pain, tenesmus, dis- charge (19 people, 2 of whom had bloody stools), and inguinal lymphadenopathy (4 peo- ple); joint inflammation was also observed in 1 individual Based on the nosologic definition currently in effect in Quebec and Canada, 9 of these cases were confirmed and 15 were prob- able cases.
A large majority of MSM for whom LGV was reported in 2005 had had sexual relations in gay saunas during the incubation period; up to 70% knew they had human immunodeficiency virus infection; about one third had used at least once during the past year, one of the fol- lowing drugs: marijuana, poppers, ecstasy or smoked cocaine; and just over one out of five had had sex with a partner who usually lives outside Québec, either during a trip a patient
had taken or when a partner was visiting Québec; partner living in Belgium (1), France (1), Latin America (1), and the United States (2) Fisting (a sexual practice that consists in inserting
a finger, fingers, or the fist into the anus) and ing sex toys were very rarely reported.
shar-Transmission
LGV is transmitted through sexual relations (oral, anal or vaginal) involving contact with:
vagina, mouth or throat) infected with LGV, with or without visible lesions
penis, anus or vagina.
A pregnant woman infected with LGV can transmit the infection to her newborn during childbirth, when the baby passes through the vagina.
A person who has infected but is not treated can transmit LGV for several weeks or even months after contracting it.
Epidemiological characteristics of lymphogranuloma venereum cases reported in Montréal in 2005
(n = 23) %
During the incubation period
( when travelling or with a partner visiting Quebec )
During the past year
Trang 112 P r é v e n t i o n e n p r a t i q u e m é d i c a l e , M a r c h 2 0 0 6
Clinical picture
LGV is commonly divided into three stages:
Primary LGV
zThe incubation period is 3 to 30 days.
z One or several small painless papules at site of inoculation (vagina,
penis, rectum, sometimes cervix, but also in the mouth and pharynx
following exposure through fellatio or cunnilingus); they may
ulcer-ate
z Primary lesions resolve spontaneously and can easily go unnoticed.
Secondary LGV
months) of primary lesion.
chills, malaise, myalgias, arthralgias; occasionally by arthritis,
pneu-monitis or hepatitis/perihepatitis; rarely cardiac lesions, asepctic
meningitis or ocular inflammatory lesions
three patients).
Inguinal secondary LGV is characterised by painful
inguinal and/or femoral lymphadenopathy (usually
unilat-eral); painful lymph nodes are referred to as buboes The
groove sign (inguinal nodes above and femoral nodes
below the inguinal ligament) was once considered
pathog-nomonic for LGV Cervical lymphadenopathy has been
described in cases where patient had had oral sex LGV
particularly affects lymph tissues
Anorectal secondary LGV is characterized by acute
proc-titis with bloody, purulent or mucous discharge from the
anus, sometimes accompanied by constipation or tenesmus.
Tertiary LGV (chronic, untreated)
Most patients recover spontaneously with no lasting effects following
the secondary stages However, some patients develop the following
complications one, two or several years after disease onset:
z chronic inflammatory lesions leading to scarring and fibrosis:
lymphatic obstruction causing genital elephantiasis;
rectal strictures and fistulae;
z significant destruction of genitalia (esthiomene).
Disease duration may be prolonged in people with human
immunode-ficiency virus (HIV).
Having LGV can increase the risk of acquiring or transmitting
HIV, other STI and other bloodborne pathogens such as hepatitis
B or C virus.
Diagnosis
The symptoms and signs of LGV are very similar to those of other STI, other infections, drug reactions, malignancies or inflammatory bowel diseases.
Laboratory testing should be used for diagnosis Generally, testing is not indicated for screening purposes
Nosologic definition
Confirmed case
Presence of the three following conditions:
1 one of the three following clinical manifestations:
z proctitis; or
z inguinal or femoral lymphadenopathy; or
venereum (LGV);
AND
2 test result positive for at least one of the following non-specific tests:
zChlamydia trachomatis isolated in an appropriate clinical
speci-men; or
zdetection of Chlamydia trachomatis using nucleic acide
amplifi-cation technique; or
z serological dectection with a microimmunofluorescence test or
com-plement fixation test of a significant increase in specific Chlamydia
trachomatis antibodies between a serum sample taken during the
acute phase and one collected during convalescence; or
single specific antibody titre for Chlamydia trachomatis > 1:256;
or
z serological detection with a complement fixation test of a single specific
antibody titre for Chlamydia trachomatis > 1:64;
AND
3 samples that have tested positive with culture or nucleic acid
ampli-fication testing, confirmation of one of the serotypes of LGV (L1, L2 AND L3) with DNA sequencing or RFLP.
Probable case
Presence of the two following conditions:
1 one of the following three clinical manifestations:
z proctitis; or
z inguinal or femoral lymphadenopathy; or
z sexual contact with a confirmed case of LGV;
AND
2 test result positive for at least one of the follownig non-specific tests:
zChlamydia trachomatis isolated in an appropriate clinical
speci-men; or
zdetection of Chlamydia trachomatis using nucleic acide
amplifi-cation technique; or
z serological dectection with a microimmunofluorescence test or
com-plement fixation test of a significant increase in specific Chlamydia
trachomatis antibodies between a serum sample taken during the
acute phase and one collected during convalescence; or
single specific antibody titre for Chlamydia trachomatis > 1:256;
or
z serological detection with a complement fixation test of a single specific
antibody titre for Chlamydia trachomatis > 1:64.
Lymphogranuloma venereum
Trang 12Bubo aspiration can relieve symptoms However incision/drainage or excision of nodes is not helpful and may delay healing.
The following treatments are recommended:
First line: Doxycycline, 100 mg, per os, twice a day X 21 days Alternative: Erythromycin 1 , 500 mg, per os, 4 times a day X 21 days Possible: Azithromycin 2 , 1 g, per os, once a week for 3 weeks.
1 Erythromycin dosage refers to the use of erythromycin base Equivalent dosages of other preparations can be substituted (with the EXCEPTION of the estolate formulation, which is contraindicated in pregnancy) During pregnancy, use erythromycin, but NOT the estolate formulation.
Erythromycin can interact with two classes of HIV medications: protease inhibitors and reverse transcriptase inhibitors.
2 While some experts believe azithromycin to be effective in the treatment of LGV, there is not enough clinical data to confirm this belief.
Patients with LGV should be followed until tests are negative (test of cure) Surgery may be required to repair genital/rectal lesions caused
by tertiary LGV.
Treatment of sexual partners
Sex partners from the last 60 days preceding onset of symptoms should
be contacted so they can be informed of their exposure, and be ated and treated Partners must be treated even if they do not have symptoms Asymptomatic partners are treated as follows:
evalu-zAzithromycin, 1 g, per os, single dose OR
z Doxycycline, 100 mg, per os, twice a day X 7 days.
Informing one’s partners can be difficult In most regions of Quebec, a public health professional specialising in STI can help a patient find ways to talk with partners The professional can also contact partners and give them confidential advice, without revealing the identity of the person who is infected
In Quebec, LGV treatment is free for people who have been diagnosed with the infection and their sex partners.
Lymphogranuloma venereum
Suggestions for intervention
lymphogran-uloma venereum, particularly in men who have sex with men.
serological testing (complement fixation or immunofluorescence).
Specify on the lab requisition that LGV is suspected.
Eliminate other causes of genital ulcers (syphilis, herpes…) and
check for concomitant STBI by proceeding with appropriate tests
Treat suspected cases without waiting for definitive test results.
Report the case to the Montréal Public Health Department LGV is
on the list of reportable diseases in Quebec and is currently under
increased surveillance; an epidemiological investigation will be
undertaken.
Provide counselling to the patient
The following precautions help reduce the risk of contracting LGV:
anus, vagina or mouth; use a new condom with each partner;
use a latex glove when inserting fingers or the fist into the anus; use a new glove with each partner;
reducing the number of sex partners decreases the possibility
of having sex with a person who is infected.
Thicker and well-lubricated condoms are recommended for anal relations, while thinner, unlubricated or flavoured condoms are suggested for oral sex (sucking) A dental dam can also be used for oral sexual relations.
It is important to recognise the symptoms of LGV and to consult a physician, who will make a diagnosis.
People can get LGV more than once in their life.
Tests
(The availability of LGV tests varies by laboratory)
Culture and nucleic acid amplification testing (NAAT)
Bubo aspiration, swab of a lesion, or rectal, vaginal or urethral swab
should be performed (or urine sample, if NAAT is to be performed,
since a urine sample is not appropriate for culture).
zC trachomatis culture testing is not readily available in Quebec
chain reaction (PCR), ligase chain reaction, transcription mediated
amplification, and strand displacement amplification NAAT have
only been approved in Canada for urine samples and endocervical
and urethral swabs They have not been approved for use with rectal
or oropharyngeal swabs or for lymph node biopsy or bubo aspiration.
In these circumstances, a negative test result does not exclude LGV,
and any positive test must be confirmed with a specific test.
and non-LGV serotypes Samples that test positive with culture or
NAAT testing should be sent for testing to specifically identify LGV
serotypes: DNA sequencing or restriction fragment length
polymor-phism (RFLP) Font-line laboratories send samples that are positive
with culture or NAAT tests to the Laboratoire de santé publique du
Québec (LSPQ); the LSPQ then sends the samples to the National
Microbiology Laboratory in Winnipeg, where samples are tested
specifically for LGV It takes about 7 to 10 days between the time the
sample is sent to Winnipeg and the LSPQ receives the result.
Serology
Serological tests do not distinguish the different Chlamydia
trachoma-tis serotypes However, because of the invasive nature of LGV,
serolo-gy titres are in general significantly higher in LGV than in non-LGV
C trachomatis infections Thus, a microimmunofluorescence titre >
1:256 or complement fixation titre > 1:64 (or seroconversion with a
4-time increase in titre) suggests an LGV serotype.
Trang 13Association des Médecins Omnipraticiens
de Montréal
A publication of the Direction de santé publique
de Montréal in collaboration with the Association des médecins omnipraticiens de Montréal as part of the Prévention en pratique médicale programme, Information component, coordinated by Doctor Jean Cloutier
This issue is produced by the Health Protection Sector
Head of the Sector: Dr John Carsley Editor-in-chief: Dr John Carsley Editor: Blaise Lefebvre Graphic design: Blaise Lefebvre Translation: Sylvie Gauthier Texts by: Dr Gilles Lambert
In collaboratin with: Élizabeth Lacombe
1301 Sherbrooke Street East, Montréal, QC H2L 1M3 Telephone: (514) 528-2400, Fax: (514) 528-2452
http://www.santepub-mtl.qc.ca email: jcloutie@santepub-mtl.qc.ca
ISSN (printed version ): 1481-3742 ISSN (on-line version): 1712-2945 Legal deposit
Bibliothèque nationale du Québec, 2006 National Library of Canada, 2006 Agreement number: 40005583
révention
en pratique médicale
4 P r é v e n t i o n e n p r a t i q u e m é d i c a l e , M a r c h 2 0 0 6
The provincial campaign “It’s about LGV” is
designed for gay and bisexual men Its main
objective is to inform them that a “new”
sexu-ally transmitted infection (STI) is now in
Quebec Another goal is to make gay and
bisexual men aware of the signs and symptoms
of LGV so that they can recognise them and
consult a physician rapidly Finally, the
cam-paign aims to promote the adoption of safe
address opens up the STBI page on the Montréal
Public Health Department Web site By clicking
on “LGV”, the user can then access:
- the campaign tools
(poster, flyer, tract, etc.),
- articles on LGV
(statistics, evolution of the epidemic, etc.),
- a quiz to test one’s knowledge of LGV,
- resources
zan information letter for health professionals,
to encourage information sharing on syphilis and LGV, and to mobilise health professinals
to participate in STI prevention among gay and bisexual men Health professionals can regis-
ter by sending an e-mail containing their name, title, organisation and e-mail address to:
infolettre-syphilis@santepub-mtl.qc.ca.
The campaign tools will be widely distributed
to various associations and places where
peo-Ressources and references
Direction de santé publique de Montréal
Partner notification service: tel.: (514) 528-2400 ext.: 3840
To order educational or promotional material: tel.: (514) 528-2400 ext.: 3817
Fax: (514) 528-2441 The clinical presentation, diagnostic procedure and treatment sections are adapted from the
following documents:
“Interim Statement on the Diagnosis, Treatment and Reporting of Lymphogranuloma
venereum (LGV) in Canada”; Public Health Agency of Canada, March 2005 and
“Énoncé provisoire sur le diagnostic, le traitement et la déclaration du lymphogranulome
vénérien (LGV) au Québec”; Direction générale de santé publique du Québec, June 2005.
Ministère de la Santé et des services sociaux
Définitions nosologiques, Maladies d'origine infectieuses - Maladie à déclaration
obliga-toire au Québec 5th Edition June 2005
http://publications.msss.gouv.qc.ca/acrobat/f/documentation/preventioncontrole/05-268-01W.pdf
Health Canada
Canadian STD Guidelines (1998)
www.phac-aspc.gc.ca/publicat/std-mts98/index.html
(the 2006 edition of the Guidelines will be available in winter 2006)
Lymphogranuloma venerium (LGV) Epi Update
www.phac-aspc.gc.ca/publicat/epiu-aepi/std-mts/lgv_e.html.
Lymphogranuloma venereum (LGV) in Canada: Recommendations for Diagnosis and
Treatment and Protocol for National Enhanced Surveillance
www.phac-aspc.gc.ca/publicat/lgv/lgv-rdt_e.html.
Centers for Disease Control (United States)
Sexually Transmitted Diseases - Treatment Guidelines 2002
www.cdc.gov/STD/treatment/
Provincial information campaign “It’s about LGV”
ple from the gay community meet to socialise,
to community groups and medical clinics, and
to the written and electronic media that serve this community
Yeah, but it’s easy to treat when it’s spotted early
Otherwise, it can cause serious damage.
I read that
LGV has come
to Quebec I didn’t learn about
it in the papers