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made cyanide an unlikely etiology. Law enforcement personnel with the New Jersey State Police responded to the outbreak and tested samples of the heroin involved; the presence of clenbuterol, a  2 adrenergic receptor agonist, was reported.
Information regarding the atypical reactions to heroin use was disseminated by NJPIES and local public health agencies to the general public, public health agencies in neighboring states, national toxicology organizations, and federal agencies. One patient reported atypical symptoms on multiple occasions after using heroin but only sought medical attention after seeing a flyer informing heroin users of suspected drug adulteration.
Case 1. The first reported patient was a man aged 21 years who went to the emergency department (ED) of a New Jersey hospital January 28, 2005, complaining of chest pain, palpitations, and shortness of breath, which had begun soon after intranasal exposure to what he believed was heroin. While in the ED, his highest recorded heart rate was 137 beats per minute (bpm), and his lowest recorded systolic blood pressure was 69 mmHg. On physical examination, the patient had tachycardia, tachypnea, pale skin, and mydriasis (dilated pupils). Laboratory studies revealed the following serum values: potassium, 2.2 mmol/L (reference range: 3.5-5.3 mmol/ L); glucose, 243 mg/dL (reference range: 65-115 mg/dL); CO 2 , 13 mmol/L (reference range: 22-32 mmol/L); an elevated anion gap; and an elevated lactate level (1). An electrocardiogram (ECG) revealed ischemic changes. The patient required intravenous fluid replacement, potassium supplementation, and an intravenous calcium channel blocker for persistent tachycardia. His laboratory, ECG, and vital sign abnormalities resolved during his 4 days in the intensive care unit. The patient left against medical advice on the fifth day of hospitalization with no apparent remaining impairments. Case 2. A man aged 23 years visited the ED at the same New Jersey hospital on January 29, 2005, a day after the patient in case 1. The man had headache, nausea, palpitations, chest pain, and anxiety after intranasal exposure to heroin the night before. He had no known connection to the patient in case 1. While in the ED, he was tachypneic and hypotensive; he had a widened pulse pressure (120/48 mmHg) and was persistently tachycardic (120-122 bpm). He was noted to have agitation and mydriasis on physical examination. Laboratory serum values included potassium, 2.9 mmol/L, and blood glucose, 157 mg/dL. The patient was admitted to the intensive care unit and discharged from the hospital on the fifth day with no known impairments.

# Provisional Case Definition for Future Cases
To facilitate uniform reporting of future cases of heroin adulterated with clenbuterol, a provisional case definition (Box) was created by CDC, in coordination with PCCs and public health agencies involved with this investigation. Because the assay for clenbuterol is not available in the majority of laboratories, only eight of the 26 cases described in this report were confirmed; 16 cases were classified as probable and two as suspected.

# BOX. Provisional case definition- for heroin-related clenbuterol toxicity

# Clinical Description
After reported heroin use, signs, symptoms, and laboratory findings  indicating clenbuterol toxicity include tachycardia, hypokalemia, palpitations, hyperglycemia, chest pain, hypotension, nausea, shortness of breath, agitation, or tremor. Laboratory Criteria for Diagnosis - Biologic: Detection of clenbuterol in urine or blood samples, as determined by a commercial laboratory. or - Environmental: Detection of clenbuterol in environmental samples (e.g., heroin), as determined by the Drug Enforcement Agency, the Federal Bureau of Investigation, or other appropriate agency.

# Case Classification
- Suspected: A case in which a potentially exposed person is being evaluated by health-care workers or public health officials for poisoning by clenbuterol. - Probable: A clinically compatible case in which a high index of suspicion for clenbuterol exposure exists (e.g., patient history regarding location and time of day), or a case with an epidemiologic link to a laboratory-confirmed case. - Confirmed: A clinically compatible case in which laboratory tests of biologic or environmental samples have confirmed exposure. A case can also be considered confirmed without laboratory testing if a predominant amount of clinical and nonspecific laboratory evidence of clenbuterol was present.
Editorial Note: Clenbuterol is a  2 adrenergic receptor agonist with a rapid onset and long duration of action approved for limited veterinary use in the United States (2,3). Clenbuterol is also used illicitly as an alternative to anabolic steroids in humans and livestock because it can increase muscle mass (4,5).
Most adverse health effects are related to its stimulation of  2 adrenergic receptors and clinical manifestations, including hypokalemia, hyperglycemia, hyperlactemia, agitation, tachycardia, and hypotension (6). Adverse human health effects have been reported previously in a case of clenbuterol ingestion (7) and from ingestion of meat from livestock fed clenbuterol (3). However, the 26 cases described in this report are the first published accounts of poisoning from clenbuterol associated with reported heroin use. Whether these cases represent adulteration of a single source of heroin before widespread distribution or adulteration of multiple sources is unknown. Also unclear is whether the substance used by each patient was heroin contaminated with clenbuterol or pure clenbuterol sold as heroin. The presence of adulterants in heroin is common. In some years, substances such as caffeine were detected in more than half of samples tested (8). Widespread poisoning secondary to adulterated heroin has occurred before as in the case of scopolamine-adulterated heroin reported in four states during the mid-1990s (9).
For various reasons, the 26 cases described in this report likely represent a fraction of actual cases of clenbuterol poisoning. Patients might not have medical evaluation for fear of legal repercussions. Passive reporting to public health agencies or PCCs might not have occurred because ED physicians, hospital intensivists, and the patients themselves might have presumed that the effects were related to a known coingestant. The identification of potential cases during the PCC record review process might have been limited by each center's database classification. The etiologic agent in suspicious cases might have been coded by using words other than "heroin" or "clenbuterol," such as "unknown drug" or "presumed coingestant."
Communication and cooperation among PCCs, EDs, CDC, and local public health agencies allowed for coordination of an appropriate response to the clenbuterol incidents. Local public health agencies and PCCs (available 24 hours a day at telephone 800-222-1222) should be notified of any case of suspected or known human exposure to an adulterated product. Early and rapid collaboration among local, state, and federal public health and law enforcement agencies might be necessary to identify, respond to, and minimize the effects of unintentional or intentional adulteration of substances used by the public.

# Mercury Exposure -Kentucky, 2004
In November 2004, a student aged 15 years brought a small vial of liquid mercury onto a school bus and into a high school in Kentucky. A subsequent investigation revealed that mercury had been in the student's possession for more than a year and that substantial amounts had been spilled in multiple locations. This report describes the results of that investigation, which indicated that 1) duration of exposure was associated with the amount of mercury absorbed by exposed persons and 2) extensive multiagency collaboration facilitated an efficient response. The investigation further revealed that, although mercury exposure is common, clinicians might not be aware of how to evaluate and treat patients with mercury exposure. State and federal health agencies should provide schools, clinicians, and local health department staff with readily accessible guidelines- for use in mercury spills and exposures.
On November 10, school officials at a county high school in rural Kentucky discovered approximately 15 students playing with liquid mercury in the school cafeteria. School officials separated the students, confiscated and bagged their clothes, and closed the cafeteria. Local health department and environmental protection officials were notified. Questioning revealed that a boy aged 15 years had brought a vial of mercury to school on a school bus. Parents were advised to consult their health-care providers about whether their child should be tested for mercury exposure. Several children were tested at the local hospital, but none had concentrations exceeding background levels other than the student who brought the mercury to the school.
During November 10-24, local and state health department staff coordinated a public health investigation of the mercury exposure, and the U.S. Environmental Protection Agency (EPA) conducted an environmental investigation. Law enforcement and health department staff interviewed relevant observers and persons who directly handled the mercury. Serum and 24-hour urine mercury samples (measured in micrograms per liter ) were collected for all persons who reported substantial exposure (i.e., persons who were known to have handled the mercury on multiple occasions or who spent 1 hour or more in rooms or vehicles during periods in which those places were known to be contaminated) and were tested at a local hospital. EPA and Kentucky Department for Environmental Protection (KDEP) personnel collected environmental air samples (measured in nanograms per cubic meter ) at implicated locations and conducted ongoing cleaning and environmental assessment until ambient mercury levels were brought within acceptable limits (i.e., <3,000 ng/m 3 ) (2) or the site was deemed unrecoverable.
EPA and KDEP officials assessed the student's school and home environments and initiated cleanup procedures. The school cafeteria contained mercury levels ranging from 5,280 ng/m 3 to 36,600 ng/m 3 . The school was closed by the school superintendent to limit the potential for exposure of children and to facilitate cleaning of the cafeteria. After 2 days of cleanup, heating, and venting, EPA deemed the school safe for students to return.
Approximately 15 school buses were also tested and/or cleaned. The family's mobile home and possessions were deemed unrecoverable (ambient mercury was >50,000 ng/m 3 at outset of investigation and later reduced to 11,550 ng/m 3 ) and were removed and destroyed. The family van (14,950 ng/ m 3 reduced to 1,285 ng/m 3 ) and an additional vehicle (>50,000 ng/m 3 reduced to 174 ng/m 3 ) were eventually cleaned and returned to the family. However, a third vehicle (41,275 ng/m 3 reduced to 36,610 ng/m 3 ), belonging to the family of a friend of the student, was determined unrecoverable and removed by EPA.
During the cleanup process, more liquid mercury was collected than could be contained in the vial that the student had carried to school. The student claimed that he had found the mercury in the trash of a dentist's office during a visit on November 9. Investigation revealed that the mercury was kept in a storage area at the dentist's office that doubled as a restroom for patients. Examination of dental office records indicated that the student had visited the dentist on August 29, 1997, August 21, 2003, and November 9, 2004. Additional evidence suggested that the student had mercury for several months before the school exposure. Under further questioning, the student admitted having obtained the mercury during a previous visit to the dentist (presumably the August 2003 visit). Investigators suspected that the student took mercury during each of the last two visits, accounting for the excess mercury recovered in the cleanup process. EPA personnel disposed of all remaining mercury in the dentist's office.
Nine family members, including the student, had lived in the mobile home during different periods preceding the incident. In addition, the student's friend and his family, including a pregnant female, indicated that they had spent considerable time in one of the contaminated vehicles. Moreover, an additional 12 persons were said to have spent substantial amounts of time in the mobile home.
Blood concentrations were obtained for the student and seven family members who were living in the mobile home. Blood mercury levels ranged from 32 g/L to 72 g/L (normal: 0-10 g/L) (3). The 24-hour urine mercury concentrations obtained from seven of these patients ranged from 28 - Such as a toxicological profile for mercury (1).

# MMWR
August 19, 2005 g/L to 496 g/L (normal: 0-19 g/L) (4). The student had the highest mercury levels for both blood and urine (i.e., 72 g/L blood and 496 g/L for initial urine concentration). Urine mercury concentrations were directly associated with amount of time spent in the mobile home. Three of the children, including the student, lived in the contaminated home for 15 months and had urinary concentrations ranging from 193 g/ L to 496 g/L, whereas three of the children who lived in the home for only 10 weeks had urinary concentrations ranging from 28 g/L to 68 g/L. The additional family member, a woman who had not been in the mobile home since June 2004, had a urine mercury concentration of 241 g/L. Three additional persons, who were exposed to the contaminated vehicle that had to be destroyed, had urinary mercury levels ranging from 4 g/L to 8 g/L. An infant born to one of these persons in May 2004 had no signs of mercury exposure. Five family members, including the student responsible for the initial exposure, were chelated by using succimer. The three adolescent family members with the longest exposures received chelation in multiple sessions. Final urine mercury levels were 48, 44, and 35 g/L, for the student and the two other children, respectively. Several of the children living in the mobile home experienced itchy rashes and headaches. In late 2003, one girl aged 13 years residing in the mobile home had experienced several months of illness consistent with mercury exposure (e.g., unexplained tachycardia, hypertension, desquamation of soles and palms, rashes, diaphoresis, muscle pain, insomnia, vomiting, and behavioral and psychiatric changes). She was hospitalized for approximately 30 days. Mercury toxicity was not considered at the time, so testing was not performed. The patient improved with a cardiac stent concurrent with removal from the exposure setting.
After the investigation, the Kentucky Department for Public Health (KDPH) held a meeting with all agencies involved to discuss lessons learned. Participants agreed to 1) better identify a lead coordinator for future investigations, 2) continue to increase coordination and communication between all agencies, and 3) increase awareness of school and local public health officials regarding mercury exposure. KDPH produced a flyer for schools that was distributed on April 15, 2005. Information related to the dangers of mercury and the proper response to a mercury spill also was sent to all local health departments. that period, 10 of which were associated with schools and five with residences only. After publicity mounted regarding the case described in this report, the local health department and the Kentucky Regional Poison Center received numerous inquiries from private citizens about quantities of mercury in their possession. Thus, local public health officials and health-care providers should be familiar with the symptoms of mercury exposure, how to respond appropriately in cases of spills, and what local resources are available for mercury cleanup and disposal.
During this investigation, a strong association was observed between the duration of exposure and remaining levels of mercury in patients. Compared with three children who had recent exposures of 10 weeks' duration, a woman who had been exposed for 8-10 months but left that setting approximately 5 months before the November incident had substantially higher levels of mercury, as evidenced by high urine concentrations. Children exposed for 15 months in the mobile home had substantially higher levels than those who had only 10 weeks' exposure. Only those children who experienced the 15-month exposure were recommended for chelation. Finally, although the family acquaintances were exposed to high levels of mercury (i.e., in their contaminated vehicle), their exposures were periodic and brief, which might have resulted in limited mercury levels.
The mercury exposures described in this report, which occurred in multiple locations and resulted in extensive property loss and intensive cleanup efforts, highlight the utility of multiagency collaboration in investigations. Collaboration of local, state, private, and federal officials improved the response time and investigation outcome. This coordination is essential to mount a public health response to exposures such as this, which quickly outstrip local resources.
The events described in this report also underscore the need for appropriate and consistent medical advice for clinicians when responding to similar events. Resources are needed at the local level to help health-care providers and public health officials recognize, evaluate, and treat patients with mercury exposures.

# Update: Interim Guidance for Minimizing Risk for Human Lymphocytic Choriomeningitis Virus Infection Associated with Pet Rodents
On August 12, this report was posted as an MMWR Dispatch on the MMWR website ().
In May 2005, CDC received reports of illness in four solidorgan transplant recipients who were later determined to have been infected with lymphocytic choriomeningitis virus (LCMV) from a common organ donor (1). Three of the four organ recipients died, 23-27 days after transplantation. This report updates information about the ongoing investigation and provides interim measures for reducing the risk for LCMV infection from pet rodents associated with this outbreak.
Epidemiologic investigation traced the source of the virus to a pet hamster recently purchased by the organ donor from a pet store in Rhode Island. LCMV testing of other rodents at the pet store identified three other LCMV-infected rodents (two hamsters and a guinea pig). All four pet rodents had been supplied by a single distributor, MidSouth Distributors of Ohio. Preliminary test results determined that four (3.4%) of 115 hamsters sampled from the Ohio distributor had active LCMV infection. On the basis of sequence analysis, the LCMV from the transplant recipients, the donor's pet rodent, and from rodents obtained from the Rhode Island pet store and the Ohio distributor were determined to have the same lineage (i.e., likely to share a common source). Under the authority of the Ohio Department of Agriculture, the MidSouth facility was quarantined. The MidSouth owner voluntarily depopulated the facility; the premises also will be disinfected.
LCMV test results for the sampled rodents and records reviewed at the Rhode Island pet store and at MidSouth Distributors indicate that LCMV-infected pet rodents might have been transported from the Ohio facility to pet stores in the northeastern and midwestern United States as early as February 2005. Ohio authorities and CDC are working to determine which stores and states have received potentially affected shipments from the Ohio facility. CDC also is conducting an ongoing traceback investigation of the breeding facilities that supplied MidSouth Distributors.

# Background Information
LCMV infection in humans with normal immune systems usually causes either asymptomatic or mild, self-limited illness. Aseptic meningitis also can occur in some patients, but the infection is rarely fatal (2). However, LCMV infection during the first or second trimester of pregnancy can cause severe illness or developmental defects in the fetus, including hydrocephalus, psychomotor retardation, blindness, and fetal death (3). The frequency with which developmental defects occur after in utero LCMV infection is not known. In addition, LCMV can be a serious infection in persons with impaired immune systems.
Pet hamsters and guinea pigs are not known to be natural reservoirs for LCMV. However, pet rodents can become infected if they have contact with wild house mice (Mus musculus) (e.g, in a breeding facility, pet store, or home). Although infection of other animals with LCMV might be possible, documented infections in humans have occurred only after exposure to infected mice, guinea pigs, and hamsters (2,4). Most human cases are associated with wild house mice, which are considered the primary reservoir (5).
Serologic testing of pet rodent species for antibodies against LCMV has not been reliable; the tests have not detected antibodies in animals with active infections demonstrated by other tests (i.e., immunohistochemistry staining of tissues and virus isolation). The unreliability of serologic testing is of concern because certain species of pet rodents infected with LCMV can shed virus for up to 8 months without signs of illness and thus can be a source of infection for humans (4,6).
A large outbreak of LCMV infection associated with pet hamsters sold by a single distributor was reported in 1974, when 181 symptomatic human cases were identified in 12 states; no deaths occurred (7). The outbreak was controlled by voluntary cessation of the sale of pet hamsters and subsequent destruction of the infected breeding stock. Stores were advised that all caging material be decontaminated or destroyed before receiving new animals. In addition, the public was informed of the risk for infection from hamsters purchased during the outbreak at stores supplied by the affected distributor (8).

# Pet Stores with Potentially Infected Rodents in Stock
Two national retail chains have temporarily stopped the sale of potentially affected rodents (e.g., hamsters, guinea pigs, gerbils, rats, chinchillas, and mice) originating from MidSouth Distributors since February 2005. Pet stores that have received rodents from MidSouth Distributors since February should contact the appropriate authority in their states (i.e., state health department or state department of agriculture) for additional information and guidance.
Although LCMV is known to infect hamsters and guinea pigs, data are insufficient to determine the potential for infection of other rodent species (e.g., chinchillas, dwarf hamsters, or gerbils). However, husbandry practices in breeding facilities, distribution centers, and pet stores make cross-contamination with LCMV of other species a possibility. CDC is working with retailers in the pet industry to consider appropriate testing of these other rodent species.
Practices that can lead to cross-contamination of rodents include 1) housing healthy rodents in the same room or bin or in cages near potentially infected rodents (i.e., rodents from the MidSouth Distributors facility in Ohio); 2) handling or caring for rodents without washing hands or changing gloves after handling other rodents and between other animal-care activities, such as cleaning cages; 3) placing rodents in cages that previously housed other rodents without first decontaminating the cages with bleach or other appropriate disinfectants; and 4) reusing materials (e.g., water bottles, food dishes, bedding, or toys) that might be contaminated by potentially infected rodents.
Pet rodents that did not originate from MidSouth Distributors of Ohio and were not exposed to potential cross-contamination can be sold or distributed as normal. In addition, nonrodent species (e.g., ferrets and rabbits) can be sold or distributed as normal.
Pet stores are advised to work with state authorities to minimize the risk for transmission of LCMV from affected rodents to humans. Options considered by state authorities include 1) stopping sale or distribution of all rodents originating from MidSouth Distributors of Ohio since February, 2) stopping sale or distribution of hamsters and guinea pigs originating from MidSouth Distributors of Ohio since February, or 3) allowing distribution (i.e., sale or adoption), provided that appropriate educational material (e.g., state-approved informed consent or fact sheet) is provided to purchasers of pet rodents originating from MidSouth Distributors since February. Educational material should disclose the specific LCMV risk in this population of pet rodents and potential outcomes in humans, including birth defects and fetal deaths. If sale of rodents is allowed to continue, populations at high risk (i.e., pregnant women, women who think they might become pregnant, and persons with weakened immune systems) should be advised against purchasing a pet rodent (9).

# Preventing LCMV Infection in New Supplies of Rodents
Efforts are under way to ensure that animal facilities and equipment in retail outlets are disinfected, that new supplies of rodents come from sources free from LCMV, and that crosscontamination between new supplies of rodents and potentially infected animals will not occur. Surfaces, cages, and any reusable equipment that has been in contact with affected animals, their waste, or bedding material should be cleaned and disinfected by using a household disinfectant according to the manufacturer's instructions. Persons who are pregnant or have compromised immune systems should not engage in cleaning and disinfection related to these affected animals or other rodents. CDC and other partners will work with breeders and retailers in the pet industry to implement quality-assurance programs to minimize the risk for LCMV infection in rodents that are sold to the public.

# Previously Purchased Pet Rodents
Testing of individual pet rodents in households is not a recommended strategy to minimize risk for LCMV infection; the probability of any one rodent in the United States being infected is low. The greatest infection risk for a pet owner is likely to occur soon after purchase of a pet rodent. Thus, most exposures likely already have occurred for existing owners and substantial added risk is unlikely to result from continued ownership of the rodent. However, women who are or who plan to become pregnant and persons who are immunocompromised should avoid contact with all rodents.
To prevent any possible infection of other rodents in stores, owners should not return pet rodents from MidSouth Distributors to pet stores. For legal, ethical, and wildlife conservation considerations, owners should not release pet rodents into the wild. Persons who no longer wish to keep their pet rodent should consult a veterinarian.
CDC continues to work with state public health officials and retailers in the pet industry to educate the public regarding safe handling of pet rodents and has prepared educational material for reducing the risk for LCMV infection from pet rodents. Rodents and other pets from any pet store pose some risk for transmitting certain infectious diseases and should be handled appropriately. Additional information about reduc-ing the risk for infectious diseases from pets is available at . More detailed information about LCMV is available at / spb/mnpages/dispages/lcmv.htm. under which public health and emergency management work together); 2) detecting and declaring emergencies; 3) protecting persons (e.g., use of quarantine and isolation); 4) managing property; 5) mobilizing professional resources; and 6) advanced topics (e.g., legal implications of public communications during emergencies). The course also provides an interactive case study to reinforce learning points delivered during lectures.
Detailed information about PHEL and copies of the CD-ROM containing all of the course components are available from PHEL field coordinators at telephone, 770-220-0608, or email, wbradford@mcking.com or wrushing@mcking.com.

# Notice to Readers

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The Partners in Information Access for the Public Health Workforce is a collaboration of CDC and other federal agencies, public health organizations, and health sciences libraries. The group has created a website () to help members of the public health workforce find and use information effectively. The content of all linked sites has been reviewed by the group's editorial board.
The website's links are organized into 10 main categories: health promotion and health education, literature and guidelines, health data tools and statistics, grants and funding, education and training, legislation, conferences and meetings, finding people, discussion and e-mail lists, and jobs and careers. In addition, the website offers news items of interest to public health practitioners and links to several In 2003, U.S. adults reported spending an average of 5 days in bed during the preceding 12 months because of illness or injury. Younger adults had fewer bed days than older adults, and adults aged 18-44 years had the fewest bed days.
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