HICNet Medical News Digest Sun, 19 Dec 1993 Volume 06 : Issue 56 Today's Topics: [MMWR 17 Dec 93] Viral Gastroenteritis Related to Consumption Oysters [MMWR] HIV Transmission Between Two Brothers with Hemophilia [MMWR] Resurgence of Pertussis [MMWR] Estimates Future Global Tuberculosis Morbidity/Mortality [MMWR] Approval Haemophilus influenzae vaccine for children/infants Epidemological Bulletin from Institute of Tropical Medicine +------------------------------------------------+ ! ! ! Health Info-Com Network ! ! Medical Newsletter ! +------------------------------------------------+ Editor: David Dodell, D.M.D. 10250 North 92nd Street, Suite 210, Scottsdale, Arizona 85258-4599 USA Telephone +1 (602) 860-1121 FAX +1 (602) 451-6135 Compilation Copyright 1993 by David Dodell, D.M.D. All rights Reserved. License is hereby granted to republish on electronic media for which no fees are charged, so long as the text of this copyright notice and license are attached intact to any and all republished portion or portions. The Health Info-Com Network Newsletter is distributed biweekly. Articles on a medical nature are welcomed. If you have an article, please contact the editor for information on how to submit it. If you are interested in joining the automated distribution system, please contact the editor. E-Mail Address: Editor: Internet: david@stat.com FidoNet = 1:114/15 Bitnet = ATW1H@ASUACAD LISTSERV = MEDNEWS@ASUACAD.BITNET (or internet: mednews@asuvm.inre.asu.edu) anonymous ftp = vm1.nodak.edu Notification List = hicn-notify-request@stat.com FAX Delivery = Contact Editor for information ---------------------------------------------------------------------- Date: Sun, 19 Dec 93 22:39:44 MST From: mednews (HICNet Medical News) To: hicnews Subject: [MMWR 17 Dec 93] Viral Gastroenteritis Related to Consumption Oysters Message-ID: Epidemiologic Notes and Reports Multistate Outbreak of Viral Gastroenteritis Related to Consumption of Oysters -- Louisiana, Maryland, Mississippi, and North Carolina, 1993 On November 17, 1993, the state health departments of Louisiana, Maryland, and Mississippi notified CDC of several outbreaks of gastroenteritis occurring in their states since November 12. Preliminary epidemiologic investigations identified consumption of oysters as the primary risk factor for illness. On November 16, the Louisiana Department of Health and Hospitals (LDHH) had identified the Grand Pass and Cabbage Reef harvesting areas off the Louisiana coast as the source of oysters associated with outbreaks in Louisiana and Mississippi. Tagged oysters associated with outbreaks in Maryland were traced to the same oyster beds. The oysters harvested from these areas had been distributed throughout the United States. On November 18 and 19, the LDHH and CDC notified state epidemiologists of the potential for oyster-associated illness; outbreaks of oyster-associated gastroenteritis subsequently were identified in Florida and North Carolina. Collaborative investigations by state health officials, the Food and Drug Administration (FDA), and CDC were initiated to determine the magnitude and characteristics of the multistate outbreak, identify the etiologic agent, and trace the oysters. This report summarizes the preliminary findings of the ongoing investigation.* As of December 2, the investigation had identified 23 separate clusters of ill persons in four states. These clusters have accounted for acute gastroenteritis in at least 180 persons who consumed oysters in a variety of settings, ranging from an individual family meal to a 3-day festival attended by 19,000 persons. Similar clinical features of gastroenteritis predominated in all clusters. In Maryland, where 90 ill persons were identified, clinical features included diarrhea (83 [92%]), vomiting (64 [71%]), nausea (60 [67%]), abdominal cramps (55 [61%]), and fever (40 [44%]). For ill persons from Louisiana, Maryland, and Mississippi, the median incubation period was 34 hours (n=146 persons), and median duration of illness was 37 hours (n=137). Raw or steamed oysters were the only food associated with illness; attack rates among the 23 groups ranged from 43% to 100%. Oysters from 20 of 23 outbreaks were traced to the implicated harvest area; oysters or their tags were not available from the other three clusters. Three persons were hospitalized, and at least four cases of secondary transmission have been reported. In one Maryland cluster, associated with a 3-day event beginning on November 12, primary cases first occurred on November 13; secondary cases first occurred on November 18 (Figure 1). Stool specimens were examined by electron microscopy (EM) and reverse transcription-polymerase chain reaction (RT-PCR) methods. Small round structured viruses or Norwalk-like viruses were detected by EM and confirmed by RT-PCR in 13 of 26 stool specimens from ill persons in Louisiana, Maryland, Mississippi, and North Carolina. Oysters associated with several of the outbreaks are being analyzed for the presence of Norwalk-like viruses by RT- PCR. In addition to the notification of state and territorial epidemiologists by LDHH and CDC on November 18 and 19, four public health measures were implemented to prevent further outbreaks associated with the contaminated oysters. First, on November 16, LDHH implemented National Shellfish Sanitation Program (NSSP) procedures for shellfish harvesting closures and recall procedures for oysters from the implicated harvest area (1). Second, on November 18, public health officials in Maryland, North Carolina, and Virginia initiated investigations to identify, detain, and recall all Grand Pass and Cabbage Reef oysters harvested during November 9-11 that had reached the retail markets in their states. Third, on November 23, FDA issued a statement advising consumers that all oysters harvested before November 16 from the Grand Pass and Cabbage Reef areas should not be consumed. Fourth, on November 24, CDC issued a follow-up memorandum to all state and territorial epidemiologists and public health laboratory directors alerting them to the outbreaks and instructing appropriate handling of laboratory specimens if additional outbreaks are suspected. The continuing investigation in Louisiana, Maryland, Mississippi, and North Carolina includes efforts to trace contaminated oysters from the implicated harvest area through large distributors to retailers and consumers. Reported by: C Conrad, Seafood Sanitation Program; K Hemphill, Molluscan Shellfish Program; S Wilson, L McFarland, DrPh, State Epidemiologist, Office of Public Health, Louisiana Dept of Health and Hospitals. K Coulbourne, Talbot County Health Dept, Easton; S Qarni, MD, Baltimore County Health Dept, Baltimore; S Poster, Harford County Health Dept, Bel Air; C Groves, MS, C Slemp, MD, E Butler, D Matuszak, MD, D Dwyer, MD, E Israel, MD, State Epidemiologist, Maryland State Dept of Health and Mental Hygiene. J Cirino, Bureau of Marine Resources; D Cumberland, L Pollack, MD, B Brackin, MPH, M Currier, MD, State Epidemiologist, Mississippi State Dept of Health. H Morris, Beaufort County Health Dept, Washington; M Bissett, S Evans, Craven County Health Dept, New Bern; B Respess, Pitt County Health Dept, Greenville; B Jenkins, J Maillard, MD, R Meriwether, MD, JN MacCormack, MD, State Epidemiologist, North Carolina Dept of Environment, Health, and Natural Resources. B Creasy, J Veazey, K Calci, S Rippey, PhD, G Hoskin, Food and Drug Administration. Div of Field Epidemiology, Epidemiology Program Office; Viral Gastroenteritis Section, Respiratory and Enteric Viruses Br, Div of Viral and Rickettsial Diseases, National Center for Infectious Diseases, CDC. Editorial Note: Because oysters from the beds implicated in this outbreak were shipped to at least 14 states,** public health officials, health-care providers, and the public should be informed of the possibility that consumption of oysters from these beds may be associated with clusters and isolated cases of acute gastroenteritis in their states. The cases of gastrointestinal illnesses identified by this investigation were recognized because they occurred as part of discrete clusters; however, it is likely that many isolated cases occurred but were not recognized or reported. For example, a previous study of persons who attended a national convention in Louisiana determined that the risk for acute gastroenteritis was higher among persons who consumed raw shellfish than among those who did not, even though no "outbreaks" were identified (2). Oysters can be traced to their harvest beds because of the regulation requiring sacks of oysters to carry a tag identifying their harvest date and the bed from which they were harvested (1). In this multistate outbreak, these tags facilitated the rapid identification and closing of contaminated beds, provided the link for illness occurring simultaneously in several states, and enabled a product recall. Investigations of shellfish-associated outbreaks of gastroenteritis have implicated a variety of pathogens, including Vibrio species, Salmonella typhi, Campylobacter species, hepatitis A, and Norwalk-like viruses. For most reported outbreaks, however, an etiologic agent is not identified; these outbreaks may be of viral origin (3). Gastrointestinal illness associated with the consumption of virally contaminated oysters characteristically is self- limited and not life-threatening. However, the likelihood of more severe disease may be increased for persons who are immunocompromised or have other chronic problems (e.g., alcoholism; hepatic, gastrointestinal, or hematologic disorders; cancer; diabetes; or kidney disease). The etiology of this multistate outbreak was determined rapidly because specimens were collected and handled appropriately and new PCR-based assays were available (4,5). To enable examination of specimens for viral agents in such outbreaks, the following methods are recommended: 1) collection of large- volume stool specimens in clean, dry containers during the first 48 hours of illness and storage at 39 F (4 C) and2) collection of acute- (within 1 week of onset of illness) and convalescent-phase (3-4 weeks after onset) serum specimens. FDA, NSSP, and the Interstate Shellfish Sanitation Conference have developed guidelines to protect consumers by controlling the harvesting, handling, and processing of shellfish products (6). Additional efforts are required to develop new assays for screening for viral pathogens in these products before distribution to consumers and to evaluate the effectiveness of various food-preparation practices in decreasing the risk for infection associated with the consumption of molluscan shellfish. References 1. Office of Seafood, Shellfish Sanitation Branch, Food and Drug Administration. National Shellfish Sanitation Program manual of operations: part II, 1992 revision. Washington, DC: US Department of Health and Human Services, Public Health Service, Food and Drug Administration, 1992. 2. Lowry PW, McFarland LM, Peltier BH, et al. Vibrio gastroenteritis in Louisiana: a prospective study among attendees of a scientific congress in New Orleans. J Infect Dis 1989;160:978-84. 3. Morse DL, Guzewich JJ, Hanrahan JP, et al. Widespread outbreaks of clam-and oyster-associated gastroenteritis: role of Norwalk virus. N Engl J Med 1986;314:678-81. 4. CDC. Recommendations for collection of laboratory specimens associated with outbreaks of gastroenteritis. MMWR 1990;39(no. RR-14). 5. Jiang X, Wang J, Graham DY, Estes MK. Detection of Norwalk virus in stool by polymerase chain reaction. J Clin Microbiol 1992;30:2529-34. 6. Ahmed FE, ed. Seafood safety. Washington, DC: National Academy Press, 1991. *Because the outbreaks in Florida have been linked to consumption of oysters from harvest areas other than the Louisiana coast, those outbreaks are not included in this report. **Alabama, California, Florida, Illinois, Louisiana, Maryland, Mississippi, Missouri, New Jersey, North Carolina, South Carolina, Tennessee, Texas, and Virginia. ------------------------------ Date: Sun, 19 Dec 93 22:40:48 MST From: mednews (HICNet Medical News) To: hicnews Subject: [MMWR] HIV Transmission Between Two Brothers with Hemophilia Message-ID: Epidemiologic Notes and Reports HIV Transmission Between Two Adolescent Brothers With Hemophilia In July 1992, the National Hemophilia Foundation and CDC received a report from a hemophilia-treatment center of a 19-year-old man with hemophilia (patient 2) who recently had seroconverted for antibody to human immunodeficiency virus (HIV). This report summarizes the findings of an investigation by CDC and state and local public health officials, which determined he was infected with a strain of HIV nearly identical to that in his previously infected older brother (patient 1).* Case Summaries Patient 1, who has severe factor VIII deficiency (hemophilia A), before 1985, received factor VIII concentrate made from plasma that was neither screened for HIV antibody nor heat-treated. Review of medical records indicated that in 1983 he had an episode of pharyngitis and diffuse lymph node enlargement compatible with an acute retroviral syndrome. In 1985, when first tested, HIV antibody was detected in his serum. His CD4+ T-lymphocyte count ranged from 400 to 550 cells/uL during 1987-1991 but declined to 110 cells/uL in 1992. Patient 2 also received unscreened factor VIII concentrate before 1985 to treat severe hemophilia A. Since 1985, however, he had received only screened and heat-treated factor concentrate, and beginning in 1988, he received only concentrate that was heat-treated and monoclonally purified. HIV-antibody tests performed annually during November 1985-April 1989 were negative. When his serum was next tested in January 1992, HIV antibody was detected. A stored plasma specimen drawn in April 1991 also contained HIV antibody. His CD4+ T- lymphocyte count was 1102 cells/uL in 1985, 846 cells/uL and 500 cells/uL as measured from the same specimen in two different laboratories in 1987, and 70 cells/uL and 120 cells/uL at two different times in 1992. The brothers have two uncles with hemophilia and HIV infection; one uncle visited their home daily to weekly but did not live with them. This uncle was HIV-seropositive when first tested in 1985. Laboratory Findings Nucleotide sequencing of HIV-1 DNA indicated that the viral strains present in both brothers were genetically similar. Proviral DNA from peripheral blood mononuclear cells obtained from each brother and from the uncle with whom they had frequent contact was amplified by polymerase chain reaction. DNA fragments encompassing 345 nucleotides of the V3 and flanking regions of the gene encoding the HIV-1 envelope glycoprotein (gp120) were sequenced after cloning into M13 vectors. Genetic analysis indicated that two variants, or quasi-species, were present in both brothers. Variant A was the predominant species (15 of 21 clones) in patient 1 and the minor species (one of 20 clones) in patient 2, with an average intravariant nucleotide divergence of 1.8% between the two brothers. Variant B was the minor species in patient 1 (six of 21 clones) and the predominant species in patient 2 (19 of 20 clones), with an average intravariant nucleotide diversity of 3.5% in the B variants between the two brothers. The average nucleotide difference between variants A and B in the two brothers was 6.2%. Only one HIV variant was present in the uncle; that variant differed from variant A by 10.2% and variant B by 10.8%. Epidemiologic Investigation Information concerning factor concentrate administration during the period in which patient 2 most likely was infected (October 1988 [6 months before his last negative HIV-antibody test] through April 1991) was obtained by review of medical records and interviews with the two brothers. During this period, patient 1 received factor concentrate infusions at home approximately 10 times per year and patient 2 approximately five times per year. Each brother reported always self-administering infusions and never receiving assistance from anyone else, including the other brother. They reported routinely administering their infusions at different times of the day and in different locations in their home. On the infrequent days when both received infusions on the same day, they reportedly never administered factor concentrates in the same room at the same time and never used each other's infusion equipment. Contaminated needles and other infusion equipment used were reportedly kept in one puncture-resistant container. Both brothers recalled sharing a razor on one occasion, most likely during 1988, when they both cut themselves and bled slightly while shaving. They did not recall which brother used the razor first. Patient 2 was not aware of any other contact with his brother's blood or bloody body fluids. In October 1988, patient 1 had bleeding hemorrhoids; however, his blood reportedly never soaked through his clothing and never contaminated his sheets, toilet seats, or other environmental surfaces. From October 1988 through April 1991, the two brothers were not hospitalized at the same time and made no visits to the dentist, emergency department, or outpatient clinic on the same day. Neither brother reported receiving tattoos, acupuncture, or injections other than factor concentrates nor recalled having had a needlestick injury or open skin lesions. During this period, the two brothers shared a bedroom and routinely slept in the same bed at night. Their mother and sister also lived in the household; the sister tested negative for HIV antibody, and the mother declined to be tested. The brothers denied having had sex with any common sex partners or with each other. In 1990, patient 2 had unprotected sexual contact with two women; one tested negative for HIV antibody in 1992, and the other could not be located. During 1989 and 1990, patient 2 had acute gastrointestinal bleeding and received transfusions of six units of red blood cells from seronegative donors later determined not to be infected with HIV. Reported by: A Brownstein, MPH, National Hemophilia Foundation, New York City. W Fricke, MD, Center for Biologics Evaluation and Research, Food and Drug Administration. Div of HIV/AIDS, National Center for Infectious Diseases, CDC. Editorial Note: The laboratory and epidemiologic findings from this investigation indicate that patient 2 became infected with an HIV strain that had previously infected his older brother. The presence in each brother of two variants of HIV, each with DNA sequence concordance similar to that reported for other infections known to be epidemiologically related (1-3), strongly supports the hypothesis that their infections are related. However, the more than 3-year interval between seroconversion in the two brothers strongly suggests that the brothers were not infected by the same source (e.g., contaminated clotting factor concentrate administered in 1985 or earlier). Although this investigation was unable to determine precisely how patient 2 became infected with HIV, transmission most likely occurred during the reported blood contact (i.e., the episode of razor-sharing) or other blood contact that went unrecognized or unreported. Factors accounting for an increased likelihood of blood contact included possible bleeding related to hemophilia or its treatment, the presence of used needles in the home, and the close physical contact between the brothers. However, it is also possible that transmission occurred through an exposure, such as sexual contact, that was not identified by the investigation. The limited ability of the brothers to recall events 2-3 years earlier and the inability of the investigators to independently confirm information provided by the brothers made determining the precise mode of transmission difficult. Seventeen previous studies in the United States and Europe have examined the prevalence of HIV infection among nonsexual, nonneedlesharing household contacts of persons with HIV infection; none of the 1167 contacts who were followed for more than 1700 person-years in these studies were infected (95% confidence interval for the rate of transmission=0-0.2 infections per 100 person-years) (4). However, HIV has been transmitted in households in which opportunities existed for percutaneous, skin, or mucous-membrane contact with HIV-infected blood. This report is the second documented instance of HIV transmission between siblings with hemophilia; the first report documented opportunities for percutaneous blood exposure associated with intravenous infusions (2). Cases of HIV transmission also have been reported in households in which needles were shared for medical injections at home (5), cutaneous exposure to blood occurred during home health care (6,7), and there was presumed but undocumented blood contact between young children (3). The findings in this report re-emphasize the need for precautions to prevent contact with blood in households and other settings--especially those in which health care is provided. Adherence to guidelines for preventing blood exposure in health-care and other settings (8-10) may reduce the risk for blood contact and transmission of bloodborne pathogens even in homes and other settings in which the risk is already extremely low. References 1. Ou C-Y, Ciesielski CA, Myers G, et al. Molecular epidemiology of HIV transmission in a dental practice. Science 1992;256:1165-71. 2. CDC. HIV infection in two brothers receiving intravenous therapy for hemophilia. MMWR 1992;41:228-31. 3. Fitzgibbon JE, Gaur S, Frenkel LD, Laraque F, Edlin BR, Dubin DT. Transmission of human immunodeficiency virus type 1 with a zidovudine resistance mutation between two children. N Engl J Med 1993;329:1835-41. 4. Simonds RJ, Chanock S. Medical issues related to caring for HIV-infected children in and out of the home. Pediatr Infect Dis J 1993;12:845-52. 5. Koenig RE, Gautier T, Levy JA. Unusual intrafamilial transmission of human immunodeficiency virus. Lancet 1986;2:627. 6. Grint P, McEvoy M. Two associated cases of the acquired immunodeficiency syndrome (AIDS). Communicable Disease Report 1985;42:4. 7. CDC. Apparent transmission of human T-lymphotrophic virus type III/lymphadenopathy-associated virus from a child to a mother providing health care. MMWR 1986;35:76-9. 8. CDC. Recommendations for prevention of HIV transmission in health-care settings. MMWR 1987;36(suppl 2S). 9. CDC. Update: universal precautions for prevention of transmission of human immunodeficiency virus, hepatitis B virus, and other bloodborne pathogens in health-care settings. MMWR 1988;37:377-82,387-8. 10. Simonds RJ, Rogers MF. HIV transmission--bringing home the message [Editorial]. N Engl J Med 1993;329:1883-5. *Single copies of this report will be available free until December 17, 1994, from the CDC National AIDS Clearinghouse, P.O. Box 6003, Rockville, MD 20849- 6003; telephone (800) 458-5231. ------------------------------ Date: Sun, 19 Dec 93 22:43:18 MST From: mednews (HICNet Medical News) To: hicnews Subject: [MMWR] Resurgence of Pertussis Message-ID: Current Trends Resurgence of Pertussis -- United States, 1993 From January 3 through December 4, 1993 (weeks 1-48), 5457 pertussis cases were reported to CDC--an 82% increase over the number reported during the same period in 1992 (3004) and the highest annual number of cases reported since 1967 (Figure 1). Compared with 1992, the number of reported pertussis cases increased in 35 states, especially those in the New England, middle- Atlantic, North Central, and Mountain regions (Figure 2). During 1993, large outbreaks have occurred in Chicago and Cincinnati. This report summarizes epidemiologic characteristics of pertussis cases reported through December 4, 1993. Characteristics Of 4989 persons with pertussis for whom age was known, 2218 (44.4%) were infants (i.e., aged less than 1 year); 1031 (20.7%), aged 1-4 years; 563 (11.3%), aged 5-9 years; and 1177 (23.6%), aged greater than or equal to 10 years. Of 1976 infants for whom age in months was reported, 1555 (78.7%) were aged less than 6 months and 421 (21.3%), aged 6-11 months. Vaccination Status and Complications Supplemental reports about vaccination status and complications were available for 744 (13.6%) cases. Of 596 persons for whom vaccination status was known, 368 (61.7%) had received fewer than three doses of diphtheria and tetanus toxoids and pertussis vaccine (DTP)*. Of 207 children aged 7 months-4 years who were "age-eligible" to have received three doses of DTP, 33 (15.9%) had received no doses, and 97 (46.9%) had received fewer than three doses. Of infants with pertussis for whom data on disease severity were available, 212 (65.2%) of 325 had been hospitalized, 45 (15.8%) of 285 had had pneumonia confirmed radiographically, and five (1.6%) of 305 had had seizures resulting from pertussis. Of the 5457 persons with pertussis, seven died. Outbreaks Chicago. From July 1 through October 30, a total of 226 persons with suspected cases of pertussis were reported to the Chicago Department of Health. Of these, 70 (31.0%) persons tested culture-positive for Bordetella pertussis; an additional 96 (42.5%) persons met the CDC clinical case definition for pertussis** during outbreaks. Of the remaining 60 cases, 29 (48.3%) did not meet the clinical case definition, and 31 (51.7%) are still under investigation. Of the 166 persons whose illness met the case definition or who had culture-confirmed pertussis, the median age was 9 months (range: less than 1 month-35 years). Most (127 [76.5%]) of these cases were reported by a single pediatric teaching hospital, and 70 (42.2%) persons were hospitalized (median hospital stay: 5 days). Of 111 persons aged greater than 2 months with pertussis for whom previous vaccination history was available, 52 (46.8%) were not up-to-date with DTP vaccinations. Of 61 persons with pertussis aged 7 months-4 years, 30 (49.2%) had received fewer than three doses of DTP, and six (10.0%) had received no doses. Cincinnati. From July 1 through October 30, a total of 285 suspected cases of pertussis were reported to the Cincinnati Health Department: 164 (57.5%) cases were culture-confirmed; 102 (35.8%) occurred in infants. Nearly all (265 [93.0%]) cases were reported by a single large teaching hospital, and 95 (33.3%) persons were hospitalized. Measures to control this epidemic included introduction of an accelerated DTP vaccination schedule (doses given at 1, 2, and 3 months of age) for infants. Investigation of this outbreak is ongoing. Reported by: J Wilhelm, MD, T Kenyon, MD, E Mihalek, K Brusealas, Chicago Dept of Health; S Shulman, MD, E Bergman, Children's Memorial Hospital, Chicago; R Daum, MD, Wyler Children's Hospital, Chicago; BJ Francis, MD, State Epidemiologist, D Robinson, Illinois Dept of Public Health. M Adcock, PhD, J Daniels, MD, V Wells, MD, Cincinnati Health Dept; C Christie, MD, S Reising, PhD, Children's Hospital Medical Center, Cincinnati; TJ Halpin, MD, State Epidemiologist, Ohio Dept of Health. R Finger, MD, State Epidemiologist, Dept of Health Svcs, Kentucky Cabinet for Human Resources. National Immunization Program, CDC. Editorial Note: Based on the number of pertussis cases reported through December 4, the projected total number of cases for 1993 will be the highest reported since 1967. Since 1976 (when the lowest number of pertussis cases [1010] was reported), the number of reported cases in peak years has steadily increased (Figure 1); in 1990 (the last peak year), 4570 cases were reported. Despite the recent resurgence in pertussis, the number of cases reported in 1993 represents a more than 96% decline from the annual number reported during the prevaccine era (i.e., before 1948). Complications associated with pertussis may be severe, especially among infants. Rates of complications among infants during 1993 have been similar to those reported during 1980-1989, when 69% were hospitalized, 22% developed pneumonia, 3% had seizures, 1% had pertussis encephalopathy, and 0.6% died (2). The two groups currently at greatest risk for severe complications are infants aged less than 6 months (the age by which children are recommended to have received three doses of DTP) and preschool-aged children who are undervaccinated. The finding that approximately 50% of preschool-aged children with pertussis in 1993 were undervaccinated underscores the importance of timely vaccination of children according to the recommendations of the Advisory Committee on Immunization Practices (ACIP)***. During outbreaks involving primarily young infants, introduction of an accelerated DTP vaccination schedule (doses given at ages 6, 10, and 14 weeks) should be considered; for preschool-aged children, receipt of three or more doses is highly protective against severe disease caused by pertussis (4). Pertussis incidence is usually characterized by a cyclical pattern, with peaks occurring at 3- to 4-year intervals; the increase in reported cases in 1993 coincides with the expected cyclical peak. However, the total number of reported cases has increased in each successive peak year since 1977 (Figure 1); reasons for this resurgence of pertussis are unclear. Vaccination coverage with three or more doses of DTP among children aged 2 years has remained relatively stable but low (approximately 70%) since 1962 (CDC, unpublished data). Furthermore, the proportion of reported pertussis cases among children aged 1-4 years has not increased during 1980-1993. These observations suggest that the recent increase in pertussis incidence is related neither to a decrease in vaccination coverage nor to a substantive reduction in DTP vaccine efficacy. As the incidence of pertussis has increased, the proportion of reported cases among persons aged greater than or equal to 10 years has increased--from 15.1% during 1977-1979 to 19.8% during 1980-1989 and 26.9% during 1992-1993. Adolescents and young adults play an important role in transmitting pertussis to susceptible infants because vaccination-induced immunity to pertussis wanes with increasing age (beginning approximately 4 years after the last dose) (5- 8). In addition, pertussis among adolescents and adults is often atypical and is frequently not diagnosed (9). In addition to prevention through vaccination, control of pertussis and interruption of transmission requires prompt recognition of disease by health- care providers and timely administration of effective antimicrobials (i.e., erythromycin or trimethoprim-sulfamethoxazole) to persons with pertussis and their close contacts (8). Health-care providers should consider the diagnosis of pertussis in persons of all age groups who develop a cough lasting more than 7 days. Because only 10% of pertussis cases are reported (10), surveillance must be enhanced. In addition, all cases should be investigated promptly. In the future, introduction of new acellular pertussis vaccines for use in adolescents or young adults may potentially reduce the disease burden in these age groups and among young children. References 1. Medical Research Council. The prevention of whooping cough by vaccination. Brit M J 1951;1:1463-71. 2. Farizo KM, Cochi SL, Zell ER, Brink EW, Wassilak SG, Patriarca PA. Epidemiological features of pertussis in the United States, 1980-1989. Clin Infect Dis 1992;14:708-19. 3. ACIP. Diphtheria, tetanus, and pertussis: recommendations for vaccine use and other preventive measures--recommendations of the Immunization Practices Advisory Committee (ACIP). MMWR 1991;40(no. RR-10). 4. Onorato I, Wassilak SG, Meade B. Efficacy of whole-cell pertussis vaccine in preschool children in the United States. JAMA 1992;267:2745-9. 5. Lambert HJ. Epidemiology of a small pertussis outbreak in Kent County, Michigan. Public Health Rep 1965;80:365-9. 6. Jenkinson D. Duration of effectiveness of pertussis vaccine: evidence from a 10-year community study. BMJ 1988;296:612-4. 7. Bass JW, Stephenson SR. The return of pertussis. Pediatr Infect Dis J 1987;6:141-4. 8. Biellik RJ, Patriarca PA, Mullen JR, et al. Risk factors for community-and household-acquired pertussis during a large-scale outbreak in central Wisconsin. J Infect Dis 1988;157:1134-41. 9. Herwaldt LA. Pertussis in adults: what physicians need to know. Arch Intern Med 1991;151:1510-2. 10. Sutter RW, Cochi SL. Pertussis hospitalizations and mortality in the United States, 1985-1988: evaluation of the completeness of national reporting. JAMA 1992;267:386-91. *Three doses of DTP is the minimum number required for effective protection against pertussis (1). **Cough illness lasting greater than or equal to 14 days without other apparent cause. ***DTP at ages 2, 4, 6, and 15 months, with an additional dose at age 4 6 years (3). Diphtheria and tetanus toxoids and acellular pertussis (DTaP) vaccine may be used for the fourth and fifth doses in the series, beginning at 15 months of age. ------------------------------ Date: Sun, 19 Dec 93 22:44:03 MST From: mednews (HICNet Medical News) To: hicnews Subject: [MMWR] Estimates Future Global Tuberculosis Morbidity/Mortality Message-ID: <5RDuec4w165w@stat.com> International Notes Estimates of Future Global Tuberculosis Morbidity and Mortality Tuberculosis (TB) is the leading cause of death associated with infectious diseases globally. The incidence of TB is expected to increase substantially worldwide during the next 10 years because of the interaction between the TB and human immunodeficiency virus (HIV) epidemics. This report uses TB notification data (i.e., cases reported to the ministries of health and collected by the World Health Organization [WHO]) to estimate the future global public health impact of TB and assesses the present and future contribution of HIV infection to TB. Morbidity The incidence of TB in 1990 was calculated for each WHO region by first estimating the incidence in some of the most populated countries in each region for which notification data were considered reliable (i.e., the data were provided by programs with established surveillance systems) (1). For countries without reliable notification data, annual risk of infection was used to estimate incidence (2). Incidence estimates were then applied to the populations in subregions and then used in calculating regional totals. For projections of future TB incidence, regional age-specific incidence rates for 1990 were first derived by applying regional data on the age distribution of reported cases to the estimated crude incidence rates. Based on the assumption that future age-specific trends will remain stable, trends in regional reporting rates during 1985-1990 were applied to the 1990 regional age- specific incidence rates to derive such rates for 1995, 2000, and 2005. These rates were subsequently applied to regional age-specific population projections (3,4). During 1990, an estimated 7.5 million incident cases of TB occurred worldwide (Table 1). Approximately 4.9 million cases (66%) occurred in the Southeast Asian and Western Pacific regions; India (2.1 million), China (1.3 million), and Indonesia (0.4 million) accounted for the largest number of cases. By 2005, the incidence of TB may increase to 11.9 million cases per year--an increase of 58% over 1990. Demographic factors (e.g., population growth and changes in the age structure of populations) will account for 77% of the predicted increase in incidence; epidemiologic factors (e.g., changes in incidence rates associated with the HIV epidemic) will account for 23%. For example, incidence rates for Africa may increase by 10 additional cases per 100,000 population per year during 1990-2005, primarily because of the HIV epidemic. In the Southeast Asian, Western Pacific, Eastern Mediterranean, and American regions, age-specific incidence rates are expected to decline during 1990-2005; in comparison, age-specific rates in Eastern Europe, Western Europe, and other industrialized countries may remain stable. However, because of population growth, the total number of new cases in these regions will continue to increase. HIV Infection The estimated impact of HIV infection on TB incidence was based on reported HIV seroprevalence data among patients with TB (5), assumed changes in HIV seroprevalence by region through 2000, and the estimation that 95% of HIV-associated TB cases are attributable to HIV infection (4). For 1990, an estimated 4.2% of all incident TB cases were attributable to HIV infection. This proportion may increase to 8.4% in 1995 and to 13.8% by 2000, when more than 1.4 million cases will be attributable to HIV infection (4). During 1990- 1999, an estimated 88.2 million persons will develop TB; 8 million of those cases will be attributable to HIV infection (4). Mortality Estimates of TB deaths for 1990 were derived using 1) published case- fatality rates of 7% for industrialized countries (6), 2) estimated case- fatality rates of 15% for Eastern Europe, 3) an estimated case-fatality rate of 20% for Central and South America, and 4) the assumption that all cases reported to WHO were treated and that 5% of treated cases were not reported for other regions. Based on these considerations, an estimated 40%-50% of new cases were treated in 1990; assuming a case-fatality rate of 55% for persons not receiving treatment and 15% for those receiving treatment, the overall case-fatality rates for other regions ranged from 35% to 40%. In estimating future mortality, the proportion of persons with cases treated was assumed to remain at the 1990 level. The number of TB deaths associated with HIV infection were estimated by applying these same case-fatality rates to the estimates of HIV-attributable cases. For 1990, an estimated 2.5 million deaths occurred from TB, of which 116,000 were associated with HIV infection (Table 2). In 2000, an estimated 3.5 million TB deaths will occur (39% more than in 1990), and approximately 0.5 million will be associated with HIV infection. Almost half of these HIV- associated deaths will occur in sub-Saharan Africa. During 1990-1999, an estimated 30 million persons will die from TB; approximately 3 million of those deaths will be associated with HIV infection. In Southeast Asia, 12.3 million deaths from TB will occur during the decade, of which approximately 1 million will be associated with HIV infection. Nearly 6 million TB deaths are projected in sub-Saharan Africa, of which approximately 1.5 million will be associated with HIV infection. Reported by: PJ Dolin, PhD, Imperial Cancer Research Fund, Cancer Epidemiology Unit, Radcliffe Infirmary, Univ of Oxford, Oxford, United Kingdom. MC Raviglione, MD, A Kochi, MD, Tuberculosis Program, World Health Organization, Geneva. Editorial Note: The estimates of current TB incidence in this report, which are based primarily on notification data, are similar to those produced by other methods and document the substantial public health burden of TB in developing countries (7,8). Moreover, because TB cases are generally underreported, estimates of incidence based on notification data are likely conservative. Similarly, estimates of TB mortality should be considered to be conservative (8): earlier estimates used a case-fatality rate of 50% for HIV- associated cases, while the current estimate did not assume that mortality was different between HIV-positive and HIV-negative persons. Because TB mortality is highly related to case finding and treatment, projections beyond 2000 were not made. The use of short-course therapy in well-managed national TB programs has reduced TB-associated morbidity, even under the most adverse circumstances (e.g., in countries with high prevalences of HIV infection) (9). The use of this intervention for persons with smear-positive TB is also among the most cost-effective health interventions available (10). The potential benefits of these and other strategies for TB control should be evaluated by those countries most severely affected by TB and by donor countries and organizations that invest in health-care programs in countries with high rates of TB. References 1. World Health Organization. Tuberculosis notification update, July 1992. Geneva: World Health Organization, Division of Communicable Diseases, Tuberculosis Program, 1992; publication no. WHO/TB/92.169. 2. Cauthen GM, Pio A, Ten Dam HG. Annual risk of tuberculosis infection. Geneva: World Health Organization, Tuberculosis Program, 1988; publication no. WHO/TB/88.154. 3. United Nations. Global estimates and projections of population by sex and age, 1988 revision. New York: United Nations, 1989; publication no. ST/ESA/SER.R/93. 4. Dolin PJ, Raviglione MC, Kochi A. A review of current epidemiological data and estimations of current and future incidence and mortality from tuberculosis. Geneva: World Health Organization, Tuberculosis Program, 1993 (in press). 5. Narain JP, Raviglione MC, Kochi A. HIV-associated tuberculosis in developing countries: epidemiology and strategies for prevention. Tuber Lung Dis 1992;3:311-21. 6. Raviglione MC, Sudre P, Rieder HL, Spinaci S, Kochi A. Secular trends of tuberculosis in Western Europe. Bull World Health Organ 1993;71:297-306. 7. Murray CJ. Health sector priorities review: tuberculosis. In: Jamison DT, Mosley WH, eds. Disease control priorities in developing countries. New York: Oxford University Press, 1993. 8. Sudre P, Ten Dam G, Kochi A. Tuberculosis: a global overview of the situation today. Bull World Health Organ 1992;70:149-59. 9. Styblo K. The impact of HIV infection on the global epidemiology of tuberculosis. Bull Int Union Tuberc Lung Dis 1991;66:27-32. 10. Murray CJL, DeJonghe E, Chum HJ, Nyangulu DS, Salomao A, Styblo K. Cost effectiveness of chemotherapy for pulmonary tuberculosis in three sub-Saharan African countries. Lancet 1991;338:1305-8. ------------------------------ Date: Sun, 19 Dec 93 22:44:45 MST From: mednews (HICNet Medical News) To: hicnews Subject: [MMWR] Approval Haemophilus influenzae vaccine for children/infants Message-ID: Food and Drug Administration Approval of Use of Haemophilus influenzae Type b Conjugate Vaccine Reconstituted with Diphtheria-Tetanus-Pertussis Vaccine for Infants and Children Haemophilus influenzae type b (Hib) conjugate vaccines have been recommended for use in infants since 1990, and their routine use in infant vaccination has contributed to the substantial decline in the incidence of Hib disease in the United States (1-3). Vaccines against diphtheria, tetanus, and pertussis during infancy and childhood have been administered routinely in the United States since the late 1940s and have been associated with a more than 90% reduction in morbidity and mortality caused by infection with these organisms. Because of the increasing number of vaccines now routinely recommended for infants, a high priority has been placed on the development of combined vaccines that allow simultaneous administration with fewer separate injections. One product combining Hib conjugate vaccine with diphtheria and tetanus toxoids and whole-cell pertussis vaccine had been licensed by the Food and Drug Administration (FDA) (4). On November 18, 1993, the FDA approved the reconstitution of the previously licensed Hib conjugate vaccine (tetanus toxoid conjugate) (PRP-T), with a previously licensed diphtheria and tetanus toxoids and whole-cell pertussis vaccine (DTP), allowing simultaneous vaccination for Hib disease, diphtheria, tetanus, and pertussis in a single injection. PRP-T, manufactured by Pasteur Merieux Serums and Vaccines and distributed by Connaught Laboratories, Inc. (CLI) (Swiftwater, Pennsylvania) as ActHIB (trademark)*, and by SmithKline Beecham (Philadelphia) as OmniHIB (trademark), is now licensed to be reconstituted with DTP manufactured by CLI. ActHIB (trademark) is distributed as 10 single-dose vials of lyophilized PRP-T, packaged together with a multidose vial of CLI DTP for reconstitution. Other licensed formulations of DTP have not been approved by FDA for reconstitution of PRP-T vaccine and may not be used for that purpose. PRP-T reconstituted with CLI DTP has been licensed for use in children aged 2 months-5 years for protection against diphtheria, tetanus, pertussis, and Hib disease. Previously unvaccinated younger children should receive doses of the PRP-T-CLI DTP combination at ages 2, 4, 6, and 15-18 months. Based on comparable antibody responses to each of the components of the vaccine, PRP-T reconstituted with CLI DTP is expected to provide protection against Hib disease, as well as diphtheria, tetanus, and pertussis, equivalent to that of already licensed formulations of other DTP and Hib conjugate vaccines. The Advisory Committee on Immunization Practices (ACIP) recommends that all infants receive a primary series of one of the licensed Hib conjugate vaccines beginning at age 2 months and a booster dose at age 12-15 months (5). The ACIP also recommends that all infants receive a four-dose primary series of diphtheria and tetanus toxoids and pertussis vaccine at ages 2, 4, 6, and 15 months and a booster dose at age 4-6 years (6-8). Reported by: Office of Vaccines Research and Review, Center for Biologics Evaluation and Research, Food and Drug Administration. Childhood and Respiratory Diseases Br, Div of Bacterial and Mycotic Diseases, National Center for Infectious Diseases; National Immunization Program, CDC. References 1. Adams WG, Deaver KA, Cochi SL, et al. Decline of childhood Haemophilus influenzae type b (Hib) disease in the Hib vaccine era. JAMA 1993;269:221-6. 2. Broadhurst LE, Erickson RL, Keiley PW. Decrease in invasive Haemophilus influenzae disease in U.S. Army children, 1984 through 1991. JAMA 1993;269:227-31. 3. Murphy TV, White KE, Pastor P, et al. Declining incidence of Haemophilus influenzae type b disease since introduction of vaccination. JAMA 1993;269:246-8. 4. CDC. FDA approval of use of a new Haemophilus b conjugate vaccine and a combined diphtheria-tetanus-pertussis and Haemophilus b conjugate vaccine for infants and children. MMWR 1993;42:296-8. 5. ACIP. Recommendations for use of Haemophilus b conjugate vaccines and a combined diphtheria, tetanus, pertussis, and Haemophilus b vaccine: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR 1993;42(no. RR-13). 6. ACIP. Diphtheria, tetanus, and pertussis: recommendations for vaccine use and other preventive measures--recommendations of the Immunization Practices Advisory Committee (ACIP). MMWR 1991;40(no. RR-10). 7. ACIP. Pertussis vaccination: acellular pertussis vaccine for reinforcing and booster use--supplementary ACIP statement. Recommendations of the Immunization Practices Advisory Committee (ACIP). MMWR 1992;41(no. RR-1). 8. ACIP. Pertussis vaccination: acellular pertussis vaccine for the fourth and fifth doses of the DTP series--update to supplementary ACIP statement. Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR 1992;41(no. RR-15). *Use of trade names and commercial sources is for identification only and does not imply endorsement by the Public Health Service or the U.S. Department of Health and Human Services. ------------------------------ Date: Sun, 19 Dec 93 22:45:21 MST From: mednews (HICNet Medical News) To: hicnews Subject: Epidemological Bulletin from Institute of Tropical Medicine Message-ID: IPK - EPIDEMIOLOGICAL BULLETIN Vol 3e / No.46 Date: 11/20/93 Institute of Tropical Medicine "Pedro Kouri" National Epidemiology Office Ministry of Public Health ------------------------------------------------------------------ Cuba. Cases and Cumulative of selected notifiable diseases. Week ending 11/20/93. (46th week) ------------------------------------------------------------------- DISEASES IN THIS WEEK CUMULATIVE RATES+ 1992 1993 1992 1993 1992 1993 ------------------------------------------------------------------ TYPHOID FEVER * 1 46 179 0.4 1.8 TUBERCULOSIS 15 10 501 573 5.2 5.9 HANSEN DISEASE 5 7 259 161 2.7 1.6 PERTUSSIS * * 1 11 0.0 0.1 SCARLET FEVER 8 3 565 332 5.9 3.4 TETANUS * * 2 * 0.0 * ASEPTIC MEN. 61 77 3750 2935 39.2 30.3 BACTERIAL MEN. 30 22 1611 1019 16.8 10.5 VARICELLA 316 193 102305 39551 1071.3 409.3 VIRAL HEPATITIS 553 220 29047 13537 304.1 140.0 MALARIA * * 11 15 0.1 0.1 LEPTOSPIROSIS 51 26 508 667 5.3 6.9 MENINGOCOCCAL D. * 1 130 66 1.3 0.6 SYPHILIS 209 226 9664 8115 101.2 83.9 GONORRHEA 507 399 23354 16831 244.5 174.1 ACUMINATA COND. 57 39 2194 1669 22.9 17.2 MEASLES 1 * 10 3 0.1 0.0 RUBELLA * * 6 5 0.0 0.0 MUMPS * * 3 2 0.0 0.0 ACUTE AMEB. D. 16 3 701 1434 7.3 15.0 ------------------------------------------------------------------ Source: 1992, MND (Written Report) EIG-IPK. 1993, MND (Phone Report) EIG-IPK. * Means 0 reported case. + Period adjusted rate. Medical Consultations of Acute Diarrhoeal Diseases by age groups. Cases and Cumulative. Week ending 11/20/93 (46th week). ------------------------------------------------------------------ IN THIS WEEK CUMULATIVE AGE CASES MEDIAN 1992 1993 GROUPS 1992 1993 (1986-1992) ------------------------------------------------------------------ <1 2652 3243 3593 174995 144799 1 - 4 3144 3922 3235 197339 179427 5 - 14 1986 2072 2117 126727 130331 15 - 64 6306 7196 6306 446868 450294 > 65 749 856 612 45812 46453 ------------------------------------------------------------------ Source: MND (Phone Report). Acute Respiratory Infections. Cuba, Weekly Index by age groups. Week ending 11/20/93 (46th week) ------------------------------------------------------- AGE WEEKLY EPIDEMIC EPIDEMIC GROUPS INDEX INDEX THRESHOLD ------------------------------------------------------- < 1 439 619 734 1 - 4 282 347 431 5 - 14 82 96 121 15 - 64 27 36 46 > 65 23 28 35 ALL AGES 59 75 87 ------------------------------------------------------- Source: MND (Phone Report). Index x 10000 inhabitants. Notified Outbreaks. Week 11/18/93 - 11/24/93. ----------------------------------------------------------------- DISEASES NUMBER OF OUTBREAKS CASES PROVINCES ----------------------------------------------------------------- F.T.D. 5 88 VILLA CLARA 3/32 SANT.CUBA 2/56 ----------------------------------------------------------------- Source: DIS. Meningococcal Disease. Cuba. More important indexes. Week ending 11/24/93. ------------------------------------------------------------------- AGE MORBIDITY MORTALITY LETHALITY GROUPS CASES RATES DEATHS RATES RATES 1992 1993 1992 1993 1992 1993 1992 1993 1992 1993 ------------------------------------------------------------------ 0-5 85 36 8.5 3.7 15 8 1.5 0.8 17.6 21.6 6-14 14 8 1.1 0.6 2 1 0.1 0.0 14.2 12.5 >15 31 21 0.4 0.2 10 9 0.1 0.1 32.2 42.8 ALL AGES 130 66 1.3 0.6 27 18 0.2 0.1 20.7 27.6 ------------------------------------------------------------------ Source: DIS, EIG-IPK Cumulative and period adjusted rate x 100000 inhabitants. Lethality expressed as percentage. _________________________________________________________________ This bulletin was prepared with the 64% of provinces-days- information. The provinces: Villa Clara, Cienfuegos, Sancti Spiritus, Camaguey, Granma and Santiago de Cuba have contributed with the 100% provinces-days-information. The offered indexes are provisionals and were taken from the daily report of the Direct Information System (DIS) remitted by Provincial Centers of Hygiene and Epidemiology, from the weekly phone report of Mandatory Notifiable Diseases (MND) remitted by National Statistics Division of the Ministry of Public Health, and from the Reference Laboratories of the Institute of Tropical Medicine "Pedro Kouri". _________________________________________________________________ This is the weekly IPK-Epidemiological Bulletin emitted via Electronic Mail. The numbering plan agree with the IPK- Epidemiological Bulletin edited by Institute of Tropical Medicine "Pedro Kouri" and it is an abbreviated version. IPK - EPIDEMIOLOGICAL BULLETIN Vol 3e / No.47 Date: 11/27/93 Institute of Tropical Medicine "Pedro Kouri" National Epidemiology Office Ministry of Public Health ------------------------------------------------------------------ Cuba. Cases and Cumulative of selected notifiable diseases. Week ending 11/27/93. (47th week) ------------------------------------------------------------------- DISEASES IN THIS WEEK CUMULATIVE RATES+ 1992 1993 1992 1993 1992 1993 ------------------------------------------------------------------ TYPHOID FEVER * 28 46 207 0.4 2.1 TUBERCULOSIS 10 7 511 580 5.2 5.8 HANSEN DISEASE 3 1 262 162 2.6 1.6 PERTUSSIS * * 1 11 0.0 0.1 SCARLET FEVER 7 2 572 334 5.8 3.3 TETANUS 1 * 3 * 0.0 * ASEPTIC MEN. 61 121 3811 3056 39.0 30.9 BACTERIAL MEN. 35 33 1646 1052 16.8 10.6 VARICELLA 370 158 102675 39709 1052.4 402.2 VIRAL HEPATITIS 543 223 29590 13760 303.3 139.3 MALARIA * * 11 15 0.1 0.1 LEPTOSPIROSIS 8 33 516 700 5.2 7.0 MENINGOCOCCAL D. 8 * 138 66 1.3 0.6 SYPHILIS 283 194 9947 8309 101.9 83.9 GONORRHEA 436 368 23790 17199 243.8 174.2 ACUMINATA COND. 40 42 2234 1711 22.8 17.3 MEASLES 1 * 11 3 0.1 0.0 RUBELLA * * 6 5 0.0 0.0 MUMPS * * 3 2 0.0 0.0 ACUTE AMEB. D. 25 6 726 1440 7.4 14.7 ------------------------------------------------------------------ Source: 1992, MND (Written Report) EIG-IPK. 1993, MND (Phone Report) EIG-IPK. * Means 0 reported case. + Period adjusted rate. Medical Consultations of Acute Diarrhoeal Diseases by age groups. Cases and Cumulative. Week ending 11/27/93 (47th week). ------------------------------------------------------------------ IN THIS WEEK CUMULATIVE AGE CASES MEDIAN 1992 1993 GROUPS 1992 1993 (1986-1992) ------------------------------------------------------------------ <1 2667 3096 3663 177662 147895 1 - 4 3262 3814 3470 200601 183241 5 - 14 2087 2890 2206 128824 133221 15 - 64 6340 7263 6340 453208 457557 > 65 726 818 626 46538 47271 ------------------------------------------------------------------ Source: MND (Phone Report). Acute Respiratory Infections. Cuba, Weekly Index by age groups. Week ending 11/27/93 (47th week) ------------------------------------------------------- AGE WEEKLY EPIDEMIC EPIDEMIC GROUPS INDEX INDEX THRESHOLD ------------------------------------------------------- < 1 390 620 734 1 - 4 245 345 428 5 - 14 77 96 121 15 - 64 25 36 46 > 65 22 28 36 ALL AGES 53 75 86 ------------------------------------------------------- Source: MND (Phone Report). Index x 10000 inhabitants. Notified Outbreaks. Week 11/25/93 - 12/01/93. ----------------------------------------------------------------- DISEASES NUMBER OF OUTBREAKS CASES PROVINCES ----------------------------------------------------------------- F.T.D. 2 209 PINAR DEL RIO 1/10 CAMAGUEY 1/199 ------------------------------------------------------------------ VIRAL HEPATITIS 1 8 CIUDAD HABANA ----------------------------------------------------------------- Source: DIS. Meningococcal Disease. Cuba. More important indexes. Week ending 12/01/93. ------------------------------------------------------------------- AGE MORBIDITY MORTALITY LETHALITY GROUPS CASES RATES DEATHS RATES RATES 1992 1993 1992 1993 1992 1993 1992 1993 1992 1993 ------------------------------------------------------------------ 0-5 91 37 9.0 3.6 17 8 1.6 0.7 18.6 21.6 6-14 14 8 1.1 0.6 2 1 0.1 0.0 14.2 12.5 >15 33 21 0.4 0.2 12 9 0.1 0.1 36.3 42.8 ALL AGES 138 66 1.3 0.6 31 18 0.3 0.1 22.4 27.2 ------------------------------------------------------------------ Source: DIS, EIG-IPK Cumulative and period adjusted rate x 100000 inhabitants. Lethality expressed as percentage. _________________________________________________________________ This bulletin was prepared with the 67% of provinces-days-information. The provinces: Ciudad de La Habana, Villa Clara, Cienfuegos, Sancti Spiritus, Camaguey, Granma and Guantanamo have contributed with the 100% provinces-days- information. The offered indexes are provisionals and were taken from the daily report of the Direct Information System (DIS) remitted by Provincial Centers of Hygiene and Epidemiology, from the weekly phone report of Mandatory Notifiable Diseases (MND) remitted by National Statistics Division of the Ministry of Public Health, and from the Reference Laboratories of the Institute of Tropical Medicine "Pedro Kouri". _________________________________________________________________ IPK - EPIDEMIOLOGICAL BULLETIN Vol 3e / No.47 Date: 12/04/93 Institute of Tropical Medicine "Pedro Kouri" National Epidemiology Office Ministry of Public Health ------------------------------------------------------------------ Cuba. Cases and Cumulative of selected notifiable diseases. Week ending 12/04/93. (48th week) ------------------------------------------------------------------- DISEASES IN THIS WEEK CUMULATIVE RATES+ 1992 1993 1992 1993 1992 1993 ------------------------------------------------------------------ TYPHOID FEVER * * 46 207 0.4 2.0 TUBERCULOSIS 27 12 535 592 5.3 5.8 HANSEN DISEASE 11 3 274 165 2.7 1.6 PERTUSSIS * * 1 11 0.0 0.1 SCARLET FEVER 10 2 582 336 5.8 3.3 TETANUS * * 3 2 0.0 0.0 ASEPTIC MEN. 75 89 3886 3145 39.0 31.2 BACTERIAL MEN. 38 26 1629 1078 16.3 10.6 VARICELLA 352 209 103027 39918 1034.2 395.9 VIRAL HEPATITIS 441 253 30031 14013 301.4 139.0 MALARIA * * 11 8 0.1 0.0 LEPTOSPIROSIS 52 44 568 744 5.7 7.3 MENINGOCOCCAL D. 1 * 139 66 1.3 0.6 SYPHILIS 219 167 10166 8476 102.0 84.0 GONORRHEA 495 366 24283 17565 243.7 174.2 ACUMINATA COND. 35 40 2269 1751 22.7 17.3 MEASLES * * 11 * 0.1 * RUBELLA * * 6 * 0.0 * MUMPS * * 3 1 0.0 0.0 ACUTE AMEB. D. 42 6 768 1446 7.7 14.3 ------------------------------------------------------------------ Source: 1992, MND (Written Report) EIG-IPK. 1993, MND (Phone Report) EIG-IPK. * Means 0 reported case. + Period adjusted rate. Medical Consultations of Acute Diarrhoeal Diseases by age groups. Cases and Cumulative. Week ending 12/04/93 (48th week). ------------------------------------------------------------------ IN THIS WEEK CUMULATIVE AGE CASES MEDIAN 1992 1993 GROUPS 1992 1993 (1986-1992) ------------------------------------------------------------------ <1 3088 3006 4314 180750 150901 1 - 4 3573 3811 3682 204174 187052 5 - 14 2306 2649 2210 131130 135870 15 - 64 7460 7717 6405 460668 465274 > 65 833 880 681 47371 48151 ------------------------------------------------------------------ Source: MND (Phone Report). Acute Respiratory Infections. Cuba, Weekly Index by age groups. Week ending 12/04/93 (48th week) ------------------------------------------------------- AGE WEEKLY EPIDEMIC EPIDEMIC GROUPS INDEX INDEX THRESHOLD ------------------------------------------------------- < 1 385 618 732 1 - 4 247 341 425 5 - 14 83 95 120 A5??I?????$???$???H??? 36 46 > 65 24 28 36 ALL AGES 56 74 85 ------------------------------------------------------- Source: MND (Phone Report). Index x 10000 inhabitants. Notified Outbreaks. Week 12/02/93 - 12/08/93. --------qm?------------------------------------------------------ DISEASES NUMBER OF OUTBREAKS CASES PROVINCES ----------------------------------------------------------------- - - - - ----------------------------------------------------------------- Source: DIS. Meningococcal Disease. Cuba. More important indexes. Week ending 12/01/93. ------------------------------------------------------------------- AGE MORBIDITY MORTALITY LETHALITY GROUPS CASES RATES DEATHS RATES RATES 1992 1993 1992 1993 1992 1993 1992 1993 1992 1993 ------------------------------------------------------------------ 0-5 91 37 8.8 3.5 17 8 1.6 0.7 18.6 21.6 6-14 14 8 1.0 0.6 2 1 0.2 0.0 14.2 12.5 >15 34 21 0.4 0.2 13 9 0.1 0.1 38.2 42.8 ALL AGES 139 66 1.3 0.6 32 18 0.3 0.1 23.0 27.2 ------------------------------------------------------------------ Source: DIS, EIG-IPK Cumulative and period adjusted rate x 100000 inhabitants. Lethality expressed as percentage. _________________________________________________________________ This bulletin was prepared with the 47% of provinces-days-information. The provinces: Camaguey and Granma have contributed with the 100% provinces-days- information. The offered indexes are provisionals and were taken from the daily report of the Direct Information System (DIS) remitted by Provincial Centers of Hygiene and Epidemiology, from the weekly phone report of Mandatory Notifiable Diseases (MND) remitted by National Statistics Division of the Ministry of Public Health, and from the Reference Laboratories of the Institute of Tropical Medicine "Pedro Kouri". ------------------------------ End of HICNet Medical News Digest V06 Issue #56 *********************************************** --- Editor, HICNet Medical Newsletter Internet: david@stat.com FAX: +1 (602) 451-6135 Bitnet : ATW1H@ASUACAD ******************************************************************************