The following are pre-publication drafts of articles from the Morbidity and Mortality Weekly Report 44(05) dated Friday, February 10, 1995 . Late- breaking articles, and final editorial revisions are not included. Therefore, these articles should not be quoted without consulting the official printed copy that is released to the public, as received from the CDC. Also, please refer to the printed copy for any charts or graphically represented data. Table of Contents ----------------- Update: AIDS Among Women -- United States, 1994 Update: Influenza Activity -- United States, 1994-95 Season Human Rabies -- West Virginia, 1994 Pregnancy-Related Mortality -- Georgia, 1990-1992 Notice to Readers: Publication of Guidelines for the Prevention and Treatment of B Virus Infections in Exposed Persons Addendum: Vol. 43, Nos. 51 & 52 Erratum: Vol. 44, No. 4 Errata: Vol. 43, No. 50 Monthly Immunization Table ----------------- Update: AIDS Among Women -- United States, 1994 In 1993, human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) was the fourth leading cause of death among women aged 25-44 years in the United States (1); in addition, the incidence of AIDS is increasing more rapidly among women than men (2). Women with AIDS reported in 1994 represented 13% of the cumulative total of 58,448 cases among women. This report presents characteristics of women and men reported with AIDS in 1994, summarizes trends in cases reported during 1985-1994, and describes findings of an HIV seroprevalence survey among childbearing women during 1989-1993.* AIDS Surveillance In 1994, of the 79,674 persons aged greater than or equal to 13 years reported with AIDS, 14,081 (18%) occurred among women-- nearly threefold greater than the proportion (534 [7%] of 8153) reported in 1985; in addition, the proportion of cases among women has increased steadily since 1985 (Figure 1). The median age of women reported with AIDS was 35 years, and women aged 15-44 years accounted for 84% of cases. More than three fourths (77%) of cases among women occurred among blacks and Hispanics, and rates for black and Hispanic women were 16 and seven times higher, respectively, than those for white women (Table 1). In 1994, the Northeast region accounted for the largest percentage of AIDS cases reported among women (44%), followed by the South (36%), West (9%), Midwest (7%), and Puerto Rico and U.S. territories (4%). In the Northeast, most cases among women occurred in urban areas; 1.4% of women with AIDS in the Northeast resided outside metropolitan statistical areas (MSAs) compared with 10.2% of women who resided outside MSAs in the South. Of all cases among women, 61% were reported from five states: New York (26%), Florida (13%), New Jersey (10%), California (7%), and Texas (5%). In 1994, 59% of AIDS cases among women were reported based on criteria added in the 1993 expanded AIDS surveillance case definition (3). This total included 7181 women with severe HIV-related immunosuppression (CD4+ T-lymphocytes less than 200 cells/uL or percentage of total lymphocytes less than 14), 557 with pulmonary tuberculosis, 376 with recurrent pneumonia, and 164 with invasive cervical cancer. In 1994, 41% of women with AIDS reported injecting-drug use; 38%, heterosexual contact with a partner at risk for or known to have HIV infection or AIDS; and 2%, receipt of contaminated blood or blood products; 19% had no specific HIV exposure reported. Of all women with AIDS who were initially reported without risk but who were later reclassified, most had heterosexual contact with an at-risk partner (66%) or a history of injecting-drug use (27%) (4). In 1994, of the 5353 women reported with AIDS attributed to heterosexual contact, 38% reported contact with a male partner who was an injecting-drug user; 7%, a bisexual male; 2%, a partner who had hemophilia or had received HIV-contaminated blood or blood products; and 53%, a partner who had documented HIV infection or AIDS but whose risk was unspecified. HIV Seroprevalence in Childbearing Women Using findings from the HIV Survey in Childbearing Women (SCBW) (5), an estimated 7000 HIV-infected women delivered infants in the United States during 1993. Assuming a perinatal transmission rate of 15%-30%, approximately 1000-2000 infants were perinatally infected with HIV during 1993. From 1989 through 1993, the annual prevalence of HIV infection among childbearing women remained relatively stable (1.6-1.7 per 1000), although prevalence varied regionally: in the Northeast, prevalence decreased from 4.1 to 3.4 per 1000; in the South, prevalence increased from 1.6 in 1989 to 2.0 in 1991 and remained stable through 1993. Reported by: Local, state, and territorial health depts. Div of HIV/AIDS, National Center for Infectious Diseases; Office of Women's Health, Office of the Director; Div of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, CDC. Editorial Note: In 1994, as in previous years, the AIDS epidemic among women continued to disproportionately affect racial/ethnic minorities, primarily in the Northeast and South. AIDS among women was primarily associated with two modes of HIV transmission: injecting-drug use and heterosexual contact with an at-risk partner. The proportion of women in 1994 with unreported risk will decrease substantially after investigation by local and state health departments because, after follow-up, most women are found to have a recognized risk for HIV. Heterosexual contact is the most rapidly increasing transmission category for women (6). The disproportionate impact of HIV/AIDS among women in racial/ethnic minority groups reflects social and economic factors that have not been completely defined. Despite the methodologic limitations associated with use of race/ethnicity, these data have assisted in the development and implementation of community-based prevention efforts. The increase in the proportion of cases associated with heterosexual transmission will complicate accurate ascertainment of mode of transmission. In particular, women are more likely than men to be reported initially without a risk for HIV because both women and their care providers may not recognize or report the risk behaviors of the woman or her partners (6). High rates of sexually transmitted diseases are associated with the use of noninjecting drugs and with the exchange of sex for drugs, money, or personal items that may account for increased heterosexual transmission among some women (7). In addition, some women who have sex with other women may be at risk for HIV infection if they inject drugs or have partners with high-risk behaviors (8). Findings from the SCBW indicate that approximately 7000 infants are born to HIV-infected women in the United States each year. Recent advances in the prevention of perinatal HIV transmission emphasize the need for women to know their HIV-infection status. Zidovudine therapy has been recommended for infected pregnant women and their newborns as an effective means for reducing the risk for perinatal HIV transmission (9). The Public Health Service is developing draft recommendations to establish policy regarding HIV counseling and testing of pregnant women to reduce vertical transmission and promote referrals for on-going health care. Women at highest risk for heterosexually acquired HIV infection include those whose heterosexual partners have high-risk behaviors (e.g., injecting-drug use), adolescents and young adults with multiple sex partners, and those with sexually transmitted diseases. To reduce HIV transmission to women, prevention programs should emphasize consistent condom use, the need for substance-abuse prevention and treatment services, and counseling to support decisions by women and their partners to reduce risk behaviors. Efforts to improve the prevention of HIV transmission in women also should include the development and evaluation of additional measures such as the female condom and microbicides. References 1. CDC. Annual summary of births, marriages, divorces, and deaths: United States, 1993. Hyattsville, Maryland: US Department of Health and Human Services, Public Health Service, CDC, 1994:18-20. (Monthly vital statistics report; vol 42, no. 13). 2. CDC. Update: acquired immunodeficiency syndrome--United States, 1994. MMWR 1995;44:64-7. 3. CDC. 1993 Revised classification system for HIV infection and expanded surveillance case definition for AIDS among adolescents and adults. MMWR 1992;41:(no. RR-17). 4. CDC. HIV/AIDS surveillance report. Atlanta: US Department of Health and Human Services, Public Health Service, 1994;6(no. 1):20,25-7. 5. Gwinn M, Pappaioanou M, George JR, et al. Prevalence of HIV infection in childbearing women in the United States. JAMA 1991;265:1704-8. 6. CDC. Heterosexually acquired AIDS--United States, 1993. MMWR 1994;43:155-60. 7. Edlin BR, Irwin KL, Faruque S, et al. Intersecting epidemics: crack cocaine use and HIV infection among inner-city young adults. N Engl J Med 1994;331:1422-7. 8. Chu SY, Hammett TA, Buehler JW. Update: epidemiology of reported cases of AIDS in women who report sex only with other women, 1980- 1991. AIDS 1992;6:518-9. 9. CDC. Recommendations of the U.S. Public Health Service Task Force on the Use of Zidovudine to Reduce Perinatal Transmission of Human Immunodeficiency Virus. MMWR 1994;43(no. RR-11). * Single copies of this report will be available until Friday 10, 1996, from the CDC National AIDS Clearinghouse, P.O. Box 6005, Rockville, MD 20849-6003; telephone (800) 458-5231. ----------------------------------------------------------- Update: Influenza Activity -- United States, 1994-95 Season Influenza activity has increased throughout the United States since late November 1994; however, the level of activity* has varied widely in different parts of the country. This report summarizes results of influenza surveillance in the United States from October 2, 1994, through January 28, 1995. From November 27, 1994, through January 21, 1995, most influenza activity had been reported from the Northeast (Figure 1). Regional influenza activity was first reported the week ending December 3 in New York, and widespread activity was first reported the week ending January 7 in Connecticut and Virginia. Regional or widespread activity also was reported by Kentucky, Maryland, New Jersey, and Pennsylvania during the first 3 weeks of January. All other states reported either sporadic activity or no activity until the week ending January 28, when regional activity was reported for the first time in Arizona, Florida, and Wisconsin. From October 2, 1994, through January 28, 1995, a total of 686 influenza virus isolates were reported in the United States by the World Health Organization collaborating laboratories. Of these, 487 (71%) were type A, and 199 (29%) were type B. Of the 216 influenza A isolates that were subtyped, all have been type A(H3N2). Laboratory-diagnosed influenza has been reported from all regions; however, 84% of all isolates have been reported from the Mid-Atlantic and South Atlantic regions. In the Mid-Atlantic region, influenza type A accounted for 94% (259 of 276) of all isolates; in the South Atlantic region, influenza type B accounted for 59% (176 of 297) of isolates. As of January 27, influenza isolates were reported from 41 states; type A had been identified in 39 states and the District of Columbia, and influenza type B had been identified in 22 states and the District of Columbia (Figure 1). During the 17 weeks from October 2, 1994, through January 28, the proportion of pneumonia and influenza deaths among total deaths reported from 121 U.S. cities slightly exceeded the epidemic threshold** during 5 weeks but has not exceeded the threshold for any 2 consecutive weeks. Reported by: Participating state and territorial epidemiologists and state public health laboratory directors. World Health Organization collaborating laboratories. Sentinel Physicians Influenza Surveillance System of the American Academy of Family Physicians. WHO Collaborating Center for Surveillance, Epidemiology, and Control of Influenza, Div of Viral and Rickettsial Diseases, National Center for Infectious Diseases, CDC. Editorial Note: The increase in influenza activity in regions of the United States during December and January suggests the potential for increased activity in other regions during this influenza season. The timing of influenza activity can vary widely from one season to another; in some previous seasons, substantial influenza activity has occurred during April and May. Influenza vaccine can be administered after influenza activity has begun in a community; however, in these circumstances, short-term antiviral prophylaxis may be indicated because antibody may not develop until up to 2 weeks after vaccination (1). Health-care providers should be informed about findings of influenza surveillance, particularly when influenza types A and B are cocirculating, because of the availability of antiviral agents to treat and prevent influenza type A (1). Reference 1. ACIP. Prevention and control of influenza: part II, antiviral agents--recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR 1994;43(no. RR-15). * Levels of activity are 1) sporadic--sporadically occurring influenza-like illness (ILI) or culture-confirmed influenza, with no outbreaks detected; 2) regional--outbreaks of ILI or culture-confirmed influenza in counties having a combined population of less than 50% of the state's total population; and 3) widespread--outbreaks of ILI or culture-confirmed influenza in counties having a combined population of greater than or equal to 50% of the state's total population. ** The epidemic threshold is 1.645 standard deviations above the seasonal baseline calculated using a periodic regression model applied to observed percentages since 1983. This baseline was calculated using a robust regression procedure. ----------------------------------- Human Rabies -- West Virginia, 1994 On October 15, 1994, a 41-year-old male resident of Wirt County, West Virginia, died from rabies. This report summarizes the clinical course, epidemiologic investigation, and probable exposure history of this case. On October 4, the man was examined at a local hospital with a 1-day history of shaking, speech difficulties, unwillingness to bring liquids to his mouth, vomiting, and severe anxiety. During examination, he had good long-term recall but a short attention span and became extremely agitated when anyone approached him for examination. A white blood cell count (WBC) was 13,600/mm superscript 3 (normal: 5000-10,000/mm superscript 3), and urinalysis indicated greater than 80 mg/dL ketones (normal: absent), 100 mg/dL protein (normal: absent), trace blood (normal: absent), and carboxy acid tetrahydrocannabinol of 79 ng/mL (normal: absent). Preliminary diagnosis was acute psychotic reaction associated with use of ethanol or marijuana or ingestion of other drugs. The man declined further examination and treatment and left the same day without being admitted. On the evening of October 4, the man was examined at a regional hospital with extreme agitation and muscle tremors; he was admitted to the intensive-care unit for apparent encephalopathy. Findings on admission included an oral temperature of 101.1 F (38.3 C) and pulse of 64 beats per minute. Laboratory test results included a WBC of 18,100/mm superscript 3, creatinine phosphokinase of 1912 IU (normal: 5-50 IU), and a lactic dehydrogenase of 1000 U/L (normal: less than 300 U/L). Following evaluation, the preliminary differential diagnoses included rabies, tetanus, viral encephalitis, acute hemorrhagic encephalitis, and drug toxicities or withdrawal. Efforts to control spastic movements included treatment with valium, librium, ativan, phenobarbital, and morphine. Because of frequent expectoration of frothy saliva from the mouth, he was placed in isolation. On October 6, he was paralyzed with pavulon/tracrium to control extreme agitation and spastic muscle activity, mechanically ventilated, treated with acyclovir for possible viral infection, and then transferred to a tertiary-care facility. On October 6 and 7, serial computerized tomographies of the brain revealed low attenuation in the left temporal lobe suggestive of inflammation or neoplasm. On October 6 and 10, cerebrospinal fluid specimens were obtained, but findings were nonspecific. Serologic tests were negative for eastern equine, western equine, St. Louis, and California group arboviral encephalitides. A serum sample and nuchal biopsy specimen obtained on October 7 and a brain biopsy specimen (left temporal lobe) obtained on October 10 were tested for rabies. On October 12, the West Virginia Bureau of Public Health Laboratory diagnosed rabies by both fluorescent antibody stain and demonstration of Negri bodies in the brain tissue, and treatment with paralytic/sedative drugs was terminated; the patient died on October 15. Subsequent confirmatory analysis at CDC included detection of rabies neutralizing antibody in serum and the detection of rabies antigen by direct fluorescent antibody staining of the nuchal biopsy specimen. The specific viral RNA was identified as a variant associated with the silver-haired bat (Lasionycteris noctivagans). Interviews with friends and family members on October 15 indicated that, in late June or early July 1994, the decedent and two acquaintances had shot a bat from the front porch of his house and that the decedent had examined the head of the bat by opening its mouth and feeling the teeth. Descriptions of the bat were consistent with the red bat (Lasiurus borealis). Postexposure rabies immunoprophylaxis was administered to 48 persons (15 medical technicians, 12 registered nurses, four physicians, two licensed practical nurses [LPNs], one LPN student, one physician assistant, one housekeeper, one secretary, and 11 family members and friends). Reported by: MS Hardman, MA Ballesca, MD, DM Senseng, MD, Roane General Hospital, Spencer; S Spencer, SD Hanna, MD, BM Louden, MD, MA Morehead, MD, P Anderson, St. Joseph's Hospital, Parkersburg; B McTaggart, A Khan, MD, AA Marfin, MD, PJ Marks, MD, E Sang, MD, MA Fisher, MD, RW Farr, MD, Robert C. Byrd Health Sciences Center of West Virginia Univ, Morgantown; J Merrill, Mid-Ohio Valley Health Dept, Elizabeth; C Slemp, MD, F Lambert, Jr, DrPH, D Dodd, L Haddy, MS, State Epidemiologist, West Virginia Dept of Health and Human Resources. Viral and Rickettsial Zoonoses Br, Div of Viral and Rickettsial Diseases, National Center for Infectious Diseases, CDC. Editorial Note: This report describes the 21st case of human rabies reported in the United States since 1980 and the first from West Virginia since 1979. Of the 21 cases, 11 are presumed to have been acquired inside the United States, and nine have been attributed to bat-associated virus. As a result of exposure to these 21 human rabies cases, at least 880 persons have received postexposure rabies immunoprophylaxis at an estimated direct cost of $900,000 (1). Although a specific exposure to rabies was not elicited before this patient's death, a presumptive diagnosis of rabies had been considered early during hospitalization. As a consequence, the initiation of strict isolation practices reduced the number of persons exposed and, therefore, eliminated the need for postexposure prophylaxis for health-care workers involved with the patient's transfer to and care at the tertiary-care facility. This case emphasizes that prompt collection and analysis of antemortem specimens in suspected cases of human rabies may expedite diagnosis and minimize unnecessary exposures and treatments. Bat rabies is enzootic in the United States, and cases have been reported from all 48 contiguous states. Although distinct variants of rabies virus have been confirmed in red bats, this case is the first in which the silver-haired bat variant has been potentially linked with red bats. Because the natural history of rabies virus circulation among bats is not completely understood, mammalogists should collaborate with local health departments in the taxonomic identification of bats submitted for rabies diagnosis. In addition, CDC requests that brain tissue from rabid silver-haired and red bats be forwarded from state diagnostic laboratories to CDC's Viral and Rickettsial Zoonoses Branch, Division of Viral and Rickettsial Diseases, National Center for Infectious Diseases, telephone (404) 639-1050. Exposure to potentially rabid animals (e.g., downed bats and other wild animals) should be avoided. However, postexposure prophylaxis is recommended for all persons bitten by such animals and for nonbite exposures involving contamination of lesions or mucous membranes with potentially infectious materials such as saliva (2). Because some bat bites may be less severe--and therefore more difficult to recognize--than bites inflicted by larger mammalian carnivores, rabies postexposure treatment should be considered for any physical contact with bats when bite or mucous membrane contact cannot be excluded (3). Because reduction of bat populations is neither feasible nor desirable as a means of controlling rabies in bats, rabies-prevention programs should emphasize the exclusion of bats from human dwellings to minimize direct contact with humans and companion animals. References 1. Fishbein DB, Robinson LE. Rabies. N Engl J Med 1993;329:1632-8. 2. ACIP. Rabies prevention--United States, 1991: recommendations of the Immunization Practices Advisory Committee (ACIP). MMWR 1991;40(no. RR-3). 3. CDC. Human rabies--California, 1994. MMWR 1994;43:455-7. ------------------------------------------------- Pregnancy-Related Mortality -- Georgia, 1990-1992 Many pregnancy-related deaths are preventable. State-based surveillance is important for identifying such deaths and developing prevention strategies. Surveillance for pregnancy-related deaths based only on ascertainment through death certificates underestimates actual deaths (1-7). However, when this surveillance method has been supplemented by linking death certificates of reproductive-aged women to birth and fetal death records, ascertainment has increased 1%-153% (1,2,4,6,7). In 1994, the Division of Public Health, Georgia Department of Human Resources, assessed the completeness of reporting of pregnancy-related deaths during 1990-1992 by comparing current death-certificate-based surveillance with a supplemental method of linking women's death records and infants' birth records. This report characterizes the increase in the total number of pregnancy-related deaths identified and presents specific causes of pregnancy-related deaths in Georgia. In this analysis, pregnancy-related deaths were defined as the immediate result of complications of pregnancy, events initiated by the pregnancy, or an exacerbation of an unrelated condition by the physiologic or pharmacologic effects of the pregnancy that occurred up to 1 year after giving birth or pregnancy termination (8). For both surveillance methods, deaths among women during pregnancy or post partum were first identified, then categorized by specific cause, and coded as pregnancy-related using the American College of Obstetricians and Gynecologists (ACOG) and CDC definitions. In Georgia, physicians, medical examiners, and coroners are required to indicate on the death certificate, regardless of cause of death, whether the decedent was pregnant at the time of death or had given birth within the preceding 90 days. For the current surveillance method, deaths during pregnancy or post partum were identified by manually reviewing each death certificate for this notation or for a cause of death related to the pregnancy or selected key words (e.g., cesarean delivery). For the record-linkage method, females were identified who died within 1 year of delivering a live-born infant by linking death certificates for females aged 10-49 years who died during 1990-1992 to birth records for 1989-1992. A probabalistic method was used to calculate the likelihood of a correct linkage based on use of the mother's first and last names and date of birth. All death and birth record matches identified by the linkage were manually reviewed. The pregnancy-related mortality ratio during 1990-1992 was calculated as the number of pregnancy-related deaths divided by the number of live births during the period. During 1990-1992, a total of 210 deaths among women during pregnancy or post partum were identified by death-certificate review and record linkage. Of these, 73 (35%) were pregnancy-related, 65 (31%) resulted from a medical problem unrelated to the pregnancy, and 72 (34%) resulted from injuries (Table 1). Of the 135 additional deaths identified by record linkage, 118 (87%) were caused by injuries and medical problems unrelated to pregnancy (Table 1). Although 35 (26%) of the 135 deaths occurred within 90 days of giving birth or pregnancy termination (i.e., the specified time in Georgia for indicating a recent pregnancy on the death certificate), this information was not indicated on the death certificate. As a result of record linkage, the pregnancy-related maternal mortality ratio during 1990-1992 increased 30%, from 16.8 deaths per 100,000 live births (based only on death-certificate review) to 21.9 per 100,000 (based on combined death-certificate review and record linkage). The three leading causes of pregnancy-related death-- hemorrhage, embolism, and infection--were the same for deaths identified by the current surveillance method and the combined methods (Table 2). Compared with the current surveillance method, record linkage resulted in increased case ascertainment for all but two specific causes of death (pregnancy-induced hypertension and anesthesia complications). The largest percentage increase in pregnancy-related deaths (200%) was for cardiomyopathy. Reported by: V Floyd, MD, C Hadley, MN, Family Health Br; M Lavoie, MA, Center for Health Information; Office of Perinatal Epidemiology, Epidemiology and Prevention Br; K Toomey, MD, State Epidemiologist, Div of Public Health, Georgia Dept of Human Resources. Div of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion; Div of Field Epidemiology, Epidemiology Program Office, CDC. Editorial Note: In Georgia, ascertainment of pregnancy-related deaths improved substantially when death certificates were linked to birth records--a result also documented in other states (2,4,6). However, compared with other states, the percentage increase in pregnancy-related deaths in Georgia was lower. This finding may reflect more complete death-certificate-based ascertainment in Georgia and the linkage of live-birth records only instead of both fetal death and live-birth records. The variation among states in the percentage of additional pregnancy-related deaths identified by linked records (1%-153%) also may be associated with such factors as differences in definitions of maternal death, variables used to match records, and methods used to link records. A year 2000 national health objective is to reduce the maternal mortality rate to no more than 3.3 deaths per 100,000 live births (objective 14.3). The findings in this report indicate that the pregnancy-related mortality ratio in Georgia is higher than previously estimated (9) and that efforts must be intensified to attain the objective. State health departments should enhance ascertainment of pregnancy-related deaths through linkage of birth and fetal death records to death records of reproductive-aged women to more accurately track pregnancy-related mortality. References 1. Allen MH, Chavkin W, Marinoff J. Ascertainment of maternal deaths in New York City. Am J Public Health 1991;81:380-2. 2. CDC. Misclassification of maternal deaths--Washington state. MMWR 1986;35:621-3. 3. Speckhard ME, Comas-Urrutia AC, Rigau-Perez J, Adamsons K. Intensive surveillance of pregnancy-related deaths, Puerto Rico, 1978-1979. Bol Asoc Med P R 1985;77:508-13. 4. CDC. Enhanced maternal mortality surveillance--North Carolina, 1988 and 1989. MMWR 1991; 40:469-71. 5. Comas A, Navarro A, Conde J, Blasini I, Adamsons K. Misreporting of maternal mortality in Puerto Rico. Bol Asoc Med P R 1990;82:343- 6. 6. Dye TD, Gordon H, Held B, Tolliver NJ, Holmes AP. Retrospective maternal mortality case ascertainment in West Virginia, 1985 to 1989. Am J Obstet Gynecol 1992;167:72-6. 7. Rubin G, McCarthy B, Shelton J, Rochat RW, Terry J. The risk of childbearing re-evaluated. Am J Public Health 1981;71:712-6. 8. CDC. National pregnancy mortality surveillance coding manual. Atlanta: US Department of Health and Human Services, Public Health Service, CDC, 1992. 9. Ledbetter JG, Galvin VG. Healthy Georgians 2000. Atlanta: Georgia Department of Human Resources, Division of Public Health, Center for Health Information, October 1993. ----------------- Notice to Readers Publication of Guidelines for the Prevention and Treatment of B Virus Infections in Exposed Persons Cercopithecine herpesvirus 1 (B virus) infection is widespread among Macaca genus primates; the virus is the biologic counterpart of herpes simplex virus in humans. B virus infection in humans is recognized as a rapidly ascending encephalomyelitis with a fatality rate of approximately 70%. The need for guidelines in prevention and treatment of human B virus infection was recognized in 1987 after a cluster of four symptomatic infections occurred among persons in Florida. CDC and the National Institutes of Health consulted primate veterinarians and herpesvirus experts to develop guidelines for preventing B virus infection in persons who work with macaques (1). Recommendations intended to minimize the risk for infection of laboratory workers exposed to B virus-contaminated primary rhesus monkey cell cultures were published in 1989 (2). Guidelines for primate handlers were expanded in 1990 in response to the recognition of filovirus infection in quarantined primates (3). Human infections with B virus remain an uncommon result of macaque-related injuries, and optimal diagnostic and therapeutic approaches are unclear. However, the increase in the use of macaques for research on simian retrovirus infection and hepatitis has expanded the number of potential incidents of human exposure. In January 1990, Emory University and CDC sponsored a B virus working group intended to formulate a rational approach to the prevention, detection, and management of human B virus infections. Written guidelines were developed based on information from published and unpublished cases, knowledge of the behavior of herpes simplex virus, and expert opinion. These guidelines (4) are intended to assist institutions in which macaques are handled in developing and enforcing effective standard operating procedures and quality-control interventions and to enable local physician consultants identified by the institutions to evaluate and treat persons with potential B virus exposure. Such institutions should keep a copy of these guidelines in bite/wound kits at the work site. Institutions also should provide copies of these guidelines to injured employees referred for medical evaluation; to the emergency rooms, clinics, or offices where injured employees will seek care; and to employees to give to their personal physician. More information on the guidelines is available from B Virus Guidelines, Division of Viral and Rickettsial Diseases, National Center for Infectious Diseases, CDC, Mailstop G-19, 1600 Clifton Road, NE, Atlanta, GA 30333. References 1. CDC. Guidelines for prevention of Herpesvirus simiae (B virus) infection in monkey handlers. MMWR 1987;36:680-2,687-9. 2. Wells DL, Lipper SL, Hilliard JK, et al. Herpesvirus simiae contamination of primary rhesus monkey kidney cell cultures: CDC recommendations to minimize risks to laboratory personnel. Diagn Microbiol Infect Dis 1989;12:333-5. 3. CDC. Update: Ebola-related filovirus infection in nonhuman primates and interim guidelines for handling nonhuman primates during transit and quarantine. MMWR 1990;39:22-4,29-30. 4. Holmes GP, Chapman LE, Stewart JA, et al. Guidelines for the prevention and treatment of B-virus infections in exposed persons. Clin Infect Dis 1995;20:421-39. ------------------------------- Addendum: Vol. 43, Nos. 51 & 52 In the article "Hemorrhage and Shock Associated with Invasive Pneumococcal Infection in Healthy Infants and Children--New Mexico, 1993-1994," the following person should be added to the credits ("reported by") on the fourth line on page 950: J McLaughlin, PhD, Univ of New Mexico Hospital, Albuquerque. ----------------------- Erratum: Vol. 44, No. 4 In the article "Acute Pulmonary Hemorrhage Among Infants-- Chicago, April 1992-November 1994," on page 67, the sentence beginning on the fifth line was incorrect. The sentence should read, "For six of the infants who underwent bronchoscopy, the procedure was performed within 2 weeks of the initial presentation with pulmonary hemorrhage." ----------------------- Errata: Vol. 43, No. 50 In the article "State-Specific Trends Among Women Who Did Not Receive Prenatal Care--United States, 1980-1992," on page 939, in the second sentence of the third paragraph, the maximum value in 1992 declined to 5.7%, rather than 4.8%. The fourth paragraph should read: "For 1980-1981, the percentage of women who did not receive prenatal care ranged from 0.18% (Vermont) to 3.64% (New York) (Table 1); for 1991-1992, the percentages ranged from 0.30% (Rhode Island) to 6.07% (District of Columbia). When compared with 1980-1981, during 1991-1992 the percentage of women who did not receive prenatal care declined in nine states (Florida, Kentucky, Minnesota, New Jersey, New York, Oklahoma, Rhode Island, South Dakota, and Utah) and increased in 41 states and the District of Columbia; in eight states (Delaware, Illinois, Indiana, Louisiana, Michigan, Pennsylvania, Vermont, and Wisconsin) and the District of Columbia, the increase was greater than 100%." On page 940, the fourth sentence in the second paragraph should read, "For example, the comparison of data for 1980-1981 with 1991-1992 demonstrated slight decreases in the percentage of women who did not receive prenatal care in nine states and substantial increases in eight states and the District of Columbia." On page 941, the state-specific percentages were incorrect for several states. The following table contains the corrected percentages and replaces Table 1. -------------------------- Monthly Immunization Table To track progress toward achieving the goals of the Childhood Immunization Initiative (CII), CDC publishes monthly a tabular summary of the number of cases of all diseases preventable by routine childhood vaccination reported during the previous month and year-to-date (provisional data). In addition, the table compares provisional data with final data for the previous year and highlights the number of reported cases among children aged less than 5 years, who are the primary focus of CII. Data in the table are derived from CDC's National Notifiable Diseases Surveillance System. DISTRIBUTED BY GENA/aegis, your online global gateway to a world of people, information, and resources. 714.248.2836 * 8N1/Full Duplex * v.34