Morbidity and mortality

MISSING IMAGE

Material Information

Title:
Morbidity and mortality
Uniform Title:
Morbidity and mortality (Washington, D.C. : 1952)
Running title:
Weekly mortality report
Weekly morbidity report
Morbidity and mortality weekly report
Abbreviated Title:
Morb. mortal.
Physical Description:
25 v. : ; 27 cm.
Language:
English
Creator:
United States -- National Office of Vital Statistics
Communicable Disease Center (U.S.)
National Communicable Disease Center (U.S.)
Center for Disease Control
Publisher:
The Office
Place of Publication:
Washington, D.C
Publication Date:
Frequency:
weekly
regular

Subjects

Subjects / Keywords:
Communicable diseases -- Statistics -- Periodicals -- United States   ( lcsh )
Mortality -- Periodicals -- United States   ( lcsh )
Morbidity -- Periodicals -- United States   ( mesh )
Mortality -- Periodicals -- United States   ( mesh )
Statistics, Medical -- Periodicals -- United States   ( lcsh )
Statistics, Vital -- Periodicals -- United States   ( lcsh )
Genre:
federal government publication   ( marcgt )
statistics   ( marcgt )
periodical   ( marcgt )

Notes

Additional Physical Form:
Also issued online.
Statement of Responsibility:
Federal Security Agency, Public Health Service, National Office of Vital Statistics.
Dates or Sequential Designation:
Vol. 1, no. 1 (Jan. 11, 1952)-v. 25, no. 9 (Mar. 6, 1976).
Issuing Body:
Issued by: U.S. National Office of Vital Statistics, 1952-Jan. 6, 1961; Communicable Disease Center, 1961- ; National Communicable Disease Center, ; Center for Disease Control, -Mar. 6, 1976.
General Note:
Title from caption.

Record Information

Source Institution:
University of Florida
Rights Management:
All applicable rights reserved by the source institution and holding location.
Resource Identifier:
oclc - 02246644
lccn - 74648956
issn - 0091-0031
ocm02246644
Classification:
lcc - RA407.3 .A37
ddc - 312/.3/0973
nlm - W2 A N25M
System ID:
AA00010654:00145

Related Items

Preceded by:
Weekly mortality index
Preceded by:
Weekly morbidity report
Succeeded by:
Morbidity and mortality weekly report

Full Text


S 6N I C l/ ALECADISEASE CENTER


Vol. 16, No. 19







Week Ending

May 13, 1967


U.S. DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE P

BUREAU OF DISEASE PREVENTION AND ENVIRONMENTAL CONTROL


EPIDEMIOLOGIC NOTES AND REPORTS
CANINE RABIES -Guam

Three cases of canine rabies have recently been
reported from Guam, an area which had previously been
free of rabies. The first case was in a stray mongrel,
approximately 5 months of age. possibly brought to the
island from southeast Asia. The dog was noted to be
hyperexcitable on March 2, with anorexia and general
paralysis following. He was found dead on March 6. The
head was sent to the Medical Preventive Medicine Lab-
oratory in Honolulu and then referred to the Hawaii De-
partment of Agriculture Pathology Laboratory. There
rabies was diagnosed by fluorescent antibody technique


I II ""I 'w
M ,,, .l 1 ; ams . .
Mo.sles- Louihinina . .
Surveillance Siumm arni
Ralhi, s in Go Internet i anal Noes
numainan allies D ath Onta ). ('ilna a . 150
QLur arantinei l M asure.s ................... .. iil(
current t Tra nds
Influenza- 1967-Pinal county Arizona (
Public Health Service Advisory Committ 'i On
I I ..... .... I
on March 13. The diagnosis was confirmed by the Virus
Reference Unit at the NCDC on March 20.
The second case of canine rabies was in a "play-
mate" of the first case. The exposed dog was noted to
(Continued on page 150)


CASES OF SPECIFIED NOTIFIABLE DISEASES: UNITED STATES


(Cumulative totals include


revised and delayed reports


through previous weeks)


19th WEEK ENDED CUMULATIVE, FIRST 19 WEEKS
MEDIAN
DISEASE MAY 13, MAY 14, 1962- 1966 MEDIAN
1967 1966 1967 1966 1962- 1966
Aseptic meningitis ....... .......... 36 33 22 562 524 515
Brucellosis............................. 9 9 5 80 76 122
Diphtheria ...... ........ ...... ... 1 2 2 39 53 88
Encephalitis, primary:
Arthropod-borne & unspecified ........... 33 21 464 460 -
Encephalitis. post-infectious ....... ..... 28 24 310 318 "-
Hepatitis, serum ..... ................. 43 25 723 470
Hepatitis, infectious .................... 771 660 769 14987 12878 16925
Malaria ............................ 27 2 2 721 102 33
Measles rubeolaa) ..................... .. 2.257 8.095 17,937 44,454 142.413 242,275
Meningococcal infections, total ..... .. 50 93 56 1.114 1,887 1,249
Civilian ............................. 49 88 1,031 1,662 -
Military.......... ......... .... ......... 1 5 --- 83 225 -
Poliomyelitis, total ................... .. .- 1 1 6 8 25
Paralytic .......... ...... ........... 1 1 5 7 20
Rubella (German measles) ......... ...... 2,128 1.960 24.801 28.443 -
Streptococcal sore throat & scarlet fever .. 10,452 9,246 7,678 225,305 215,970 202,029
Tetanus ................. .... ... ..... 1 5 4 54 42 72
Tularemia ........ .... ......... .. 5 2 54 52 71
Typhoid fever ................... ...... 2 7 7 117 104 120
Typhus, tick-borne (Rky. Mt. spotted fever) 3 3 26 11 12

Rabies in animals ....................... 92 80 96 1,697 1,685 1,685

NOTIFIABLE DISEASES OF LOW FREQUENCY
Cum. Cum.
Anthrax ... 1 Rabies in man........... .......
Botulism .................................... .... Rubella, Congenital Syndrome ... ...... ... ... 2
Leptospirosis .................. ................ 12 Trichinosis: NYC-1, Wash.-l .... ....... 32
Plague .................................... ........ Typhus, marine: Calif.-l, Fla.-l, Tex.-l ......... 12
Psittacosis: Calif.-l, NYC-I ................. .... .. 14 Polio, Unsp. .. ....... .. ...... ....





Morbidity and Mortality Weekly Report


CANINE RABIES-Guam
(Continued from front page)


become weak and ill but showed no signs of aggres-
siveness; he died 34 days after the death of the first
rabid dog. The head was sent to the same laboratory in
Honolulu and was diagnosed as infected with rabies by
fluorescent antibody technique on April 10.
No details are known about the third case. except
that the dog's head was found to be FA positive and
Negri body positive on May 6. The tests were carried out
by the Army laboratory and confirmed by the Hawaii
Department of Agriculture Pathology Laboratory.
Two children were exposed to the initial case. The
first child began post-exposure antirabies prophylaxis
with duck embryo vaccine one week after being bitten.
The second child was also treated with DEV alone.
beginning about 2 weeks after the biting incident. There
were no known human exposures to the second canine
case.


There were four human wound exposures connected
with the third case of confirmed rabies: two in navy
personnel now at sea, one in the prosector that removed
the head and cut himself in the process, and one in a
person not identified in the report.
The Department of Public Health on Guam conducted
an island-wide rabies control program, during which some
2,800 dogs and 300 cats were vaccinated and almost 2,000
stray dogs were killed. Although there is no embargo on
the importation of dogs into the island at present, such
a measure is being considered.



(Reported by Dr. Anna t' h .. Deputy Director, De-
partment of Public Health, Guam; Dr. Fred Lynd, Veter-
inary Pathologist and Director of the Hauwaii Department
of Agriculture Pathology Laboratory.


SURVEILLANCE SUMMARY
RABIES IN GEORGIA st Quarter, 1967


For the first quarter of 1967 (January through March),
26 cases of rabies in animals have been reported in
Georgia. This represents a substantial increase over the
totals of 15 cases recorded for the same quarter in both
1966 and 1965.
Among the confirmed cases in 1967 are 13 raccoons,
8 gray foxes, 2 red bats, 1 cow, 1 striped skunk, and 1
dog. The dog developed rabies 9 days after arrival from
Iowa. The cases were scattered throughout 18 counties,
mostly in south Georgia.


The 15 cases in the first quarter of 1966 were in rac-
coons and were concentrated in 10 counties in south
Georgia.



(Reported by Dr. J.H. Richardson. Director, Public Health
Veterinary Section, Epidemiologic Investigations Branch,
Georgia Department of Public Health; and the Rabies
Control Unit, Veterinary Public Health Section, Epi-
demiology Program, ACDC.)


INTERNATIONAL NOTES
HUMAN RABIES DEATH-Ontario, Canada


On January 13, 1967, a 4-year-old girl from Richmond,
Ontario, Canada, died of rabies. The child had been bit-
ten and scratched on the face by a cat in her home on
October 21, 1966. Three other persons were scratched by
the cat, two of whom also received bites on the wrist and
forearm. The cat was destroyed later that day and the
head submitted to the Animal D,0--.--.- Research Institute
of the Department of Agriculture for examination. On the
following day when the laboratory reported the presence
of Negri bodies in the brain of the cat, antirabies therapy
was begun immediately on the child and other exposed
persons. Each received 14 daily inoculations of Semple
vaccine which was distributed by the Ontario Department
of Health.


Approximately 80 days following the attack by the
rabid cat, the child showed symptoms of encephalitis
which progressed to death. Examination of her brain
showed the presence of Negri bodies.
The last recorded death from rabies in Ontario in
which Semple type vaccine was used occurred 40 years
ago in a child who was attacked and bitten on the face by
a rabid dog. A course of 21 doses of vaccine was admin-
istered but the child died from rabies on the 25th post-
biting day.

(Abstracted from Epidemiological Bulletin, Department of
National Health and Welfare, Ottawa, Canada, Vol. 11,
No. 2, February 1967).


150


MAY 13, 1967






Morbidity and Mortality Weekly Report


EPIDEMIOLOGIC NOTES AND REPORTS
MEASLES Louisiano


Meansls iativit has been widespread throughout
Louisiana during the first 4 months of 1967. Notification
hy physicians has boon sporadic, but an official system
of nweasles reporting by school absenteeism has indicated
(thait 7 .11 eases have occurred in 44 of the (il parishes.
The distribution of cases by parish is shown in Figure 1.
Epidemnic control has boen initiated in several
schools. one of (he largest being in Rapides Parish in
central Loui-iana. Around the end of February and begin-
ning of March, Iapides reported 4 to 28 cases a week.
In\ l Migation sho e il that these cases were distributed
throughout the school system. A survley of school children
hb letters to the parents rioealed o\er6,000 susceptihles.
\ partish-Mide measles campaign waas conducted March 15
through 17 liy lle HRalides Parish Health Unit and the
:pildemiology Section of the Louisiana State Board of
IHealth. The school-by-school program inas carried out lby


mobile teams using jet injectors. Preschool children were
inm cited to the school in their action of the parish.
Approximately 10,)000 vaccinations were given in thel 3-
day campaign. There have been no reported cases since
the campaign.
A similar program was carried ot d(luring tlhe fourth
week in March in \Aoyelles Parish. Around 5,0()(00 tac-
cinations were given to preschoolers and first and second
graders.
Eight parishes. Tangipahoa, East and Weost Feliciana,
St. Helena Grant, St. James. St. John. and Vernon com-
pleted "End Measles" campaigns in April and May in
association with the Vaccination Assistance Immunization
['.... in Louisiana. Campaigns for Ilaton Rouge and
New Orleans are in the planning stage.
(Reportcd by Dr. John A. Trautman,. Chief', lEpidi'miolo~y
Section, Louisiana State Board of Health.)


Figure 1
MEASLES IN LOUISIANA, BY PARISH BASED ON SCHOOL ABSENTEEISM
January-April 1967


MAY 13, 196(7





Morbidity and Mortality Weekly Report


RECOMMENDATION OF THE PUBLIC HEALTH SERVICE ADVISORY
COMMITTEE ON IMMUNIZATION PRACTICES


The Public Health Service Advisory Committee on Immunization Practices meeting
on February 17, 1967, issued the following recommendations on rabies prophy-
laxis for the United States.



RABIES PROPHYLAXIS


Introduction
Although cases of rabies in humans are rare in the United
States, thousands of persons receive rabies prophylaxis
each year. The following approach to prevention is based
on a contemporary interpretation of both the risk of infec-
tion and the efficacy of treatment and incorporates the
basic concepts of the WHO Expert Committee on Rabies (1).
The problem of whether or not to immunize those
bitten or scratched by animals suspected of being rabid is
a perplexing one for physicians. All available methods of
systemic treatment are complicated by numerous instances
of adverse reactions, a few of which have resulted in
death or permanent disability. Furthermore, the decision
must be made immediately because the likelihood that
any prophylactic measure will contribute to the prevention
of rabies diminishes rapidly as the interval between ex-
posure and treatment increases.
The acceptable evidence for efficacy of both active
and passive immunization following exposure is derived
largely from experimental studies in animals. Because
rabies on occasion has developed in humans who received
antirabies prophylaxis, the value of treatment has been
questioned. However, evidence from laboratory and field
experience in many areas of the world indicates post-
exposure prophylaxis can be highly effective when appro-
priately used.

Status of Rabies in the United States
The incidence of rabies in humans has declined from an
average of 22 cases per year in 1946 through 1950, to 1
case per year in 1963 through 1966. Rabies in domestic
animals has diminished similarly. In 1946, there were
more than 8,000 cases of rabies in dogs, compared with
412 in 1966. Thus, the likelihood of humans' being ex-
posed to rabies by domestic animals has decreased greatly,
although bites bydogs and cats continue to be responsible
for the overwhelming majority of antirabies treatments.
In contrast, the disease in wildlife -especially
skunks, foxes, and bats- has become increasingly promi-
nent in recent years, accounting for more than 70 percent
of all reported cases of animal rabies in 1966. During that
year, only four States were reportedly free of wildlife
rabies. Wild animals constitute the most important source


of infection for both domestic animals and man in the
United States today.

Status of Antirabies Treatment in the United States
More than 30,000 people receive post-exposure anti-
rabies treatment each year. However, there is no informa-
tion regarding the number of persons actually exposed to
rabid animals.
Nervous tissue origin rabies vaccine of the Semple
type (NTV) was used almost exclusively in the United
States until 1957, when the duck embryo origin vaccine
(DEV) was licensed. More than 75 percent of those who
received rabies prophylaxis in the United States in 1965
were given DEV.
There has been remarkable variation in the rate of
adverse reactions associated with NTV. In the United
States, it is generally accepted that one individual among
4,000 to 8,000 persons receiving NTV antirabies treat-
ment develops neurologic complications. Death has been
attributed to NTV in a ratio of one to every 35,000
persons treated.
Neurologic complications associated with DEV have
been reported for one of every 25,000 persons treated. One
possibly related death has occurred among some I17... Iii
who have received DEV since its introduction.



Rationale of Treatment
Every exposure to possible rabies infection must be in-
dividually evaluated. In the United States, the following
factors should be considered before specific antirabies
treatment is initiated:
Species of biting animal involved
Carnivorous animals (especially skunks, foxes,
coyotes, raccoons, dogs, and cats) and bats are more
likely to be infective than other animals. Bites of
rodents seldom, if ever, require specific antirabies
prophylaxis.
Circumstances of the biting incident
An unprovoked attack is more likely to mean that the
animal is rabid. (Bites during attempts to feed or
handle an '%pp.r.nrid, healthy animal should generally
be regarded as provoked).


152


MAY 13, 1967





Morbidity and Mortality Weekly Report


Extent and location of bite wound
The likelihood that rabies will result from a bite
varies w ith its extent and location. For convenience
in approaching management, two categories of ex-
posure are widely accepted:
Severe: Multiple or deep puncture wounds, and any
bites on the head, face, neck, hands, or fingers.
Mild: Scratches, lacerations, or single bites on
areas of the body other than the head. face, neck.
hands,.., I,... Open woounds, such as abrasions,
which are suspected of being contaminated with
saliva also belong in this category.
Vaccination status of the biting animal
An adult animal immunized properly with one or more
doses of rabies vaccine has only a minimal chance
of developing rabies and transmitting the virus.
Presence of rabies in the region
If adequate laboratory and field records indicate that
there is no rabies infection in a domestic species
within a given region, local health officials may he
justified in taking this into consideration in any
recommendations concerning antirabies treatment
following a bite by that species.

Management of Biting Animals
A dog or cat that whites a human should be captured.
confined, ande observed by a veterinarian for at least 5
days, preferably 7 to 10. Any illness in the animal should
be reported immediately to the local health department. If
the animal dies, the head should be removed and shipped
under refrigeration to a qualified laboratory for exami-
nation. Because clinical signs of rabies in a wild animal
cannot be reliably interpreted, the animal should be killed
at once and its brain examined for evidence of rabies.


Local Treatment of Wounds
Immediate and thorough local treatment of all bite wounds
and scratches is perhaps the most effective means of pre-
\ rn in. rabies. Experimentally, the incidence of rabies in
animals can be markedly reduced by local therapy alone.
First-aid treatment to be carried out immediately
Copious flushing with water alone, soap and water,
or detergent and water.
Treatment by or under direction of a physician
1. Thorough fiu-hir,- and cleansing of the wound
with soap solution. Quaternary ammonium com-
pounds may also be used.*
2. If antirabies serum is indicated, a portion of the
total dose should be thoroughly infiltrated around
the wound. As in all instances in which horse
serum is used, a careful history should be taken
and tests for hypersensitivity performed (2).

*All traces of soap should be removed before quaternary am-
monium compounds are applied because soap neutralizes
their activity.


3. Tetanus prophylaxis and measures to control
bacterial infections as indicated.
4. Suturing of wound or other form of primary clo-
sure is not adi i ed.


Post-exposure Prophylaxis
Active Immunization
Rabies Vaccine Preparations
Duck Embryo Vaccine (DEV)
Prepared from embryonated duck eggs infected
with a fixed virus and inactivated with beta-
propiolactone.
Nervous Tissue Vaccine (NTV)
Prepared from rabbit brain infected with a fixed
virus and inactivated by phenol at 37"C. (Srniple
type) or inactivated by ultraviolet irradiation.
Antigenicity of Vaccines
Antigenicity of NTV is often higher than that of
DEV when tested in experimental animals. How-
ever, all lots of both vaccines must pass minimum
potency tests established by the Division of
Biologics Standards, National Institutes of Health.
There is evidence that the serum antibody response
in humans is detectable earlier following DEV
vaccination, but the eventual level of response is
frequently higher with NTV.
Effectiveness of Vaccines in Humans
In the United States, comparative effectiveness of
vaccines'can only be judged by frequencies of
failure to prevent disease. During the years 1957
through 1967 when both vaccines were available.
there were 6 rabies deaths among the 117,700
NTV-treated persons (1:1-' 1..In1 and 7 deaths
among the 172,000 treated with DEV ( 1 1 ,.i)
Reactions
Erythema, pruritis, pain, and tenderness at the
site of inoculation are common with both DEV and
NTV. Systemic responses, including low grade
fever, or rarely shock, may occasionally occur
late in the course of therapy with either vaccine.
usually after five to eight doses. In rare instances,
serious reactions have occurred after the first
dose of DEV or NTV. particularly in persons pre-
viously sensitized with vaccines containing avian
or rabbit brain tissue.
As described previously, neuroparalytic re-
actions occur rarely with DEV. They are con-
siderably more frequent following NTV, especially
after repeated courses of treatment with this
preparation.
Choice of Vaccine
Rates of treatment failures with the two vaccines
are not significantly different; therefore, the


MAY 13, 19t17


153





Morbidity and Mortality Weekly Report


lower frequency of central nervous system re-
action with DEV makes it preferable to NTV.

Schedule for Vaccine Use
Primary Course
At least 14 single, daily injections of vaccine
in the dose recommended by the manufacturer.
These should be given subcutaneously in the
abdomen, lower back, or lateral aspect of
thighs; rotation of sites is recommended.
For severe exposures, 21 doses of vaccine
are recommended. These may be given as 21
daily injections or 14 doses during the first 7
days(either two separate injections ora double
dose), the remaining doses given singly during
the next 7 days.
Booster Immunization
Two booster doses, one 10 days and the other
at least 20days after completion of the primary
course. The two booster doses are particularly
important if antirabies serum was used in the
initial therapy.

Precautions
When rabies vaccine must be given to a person
with a history of hypersensitivity, especially to
avian or rabbit tissues, antihistaminic drugs
should be used. Epinephrine is helpful in those of
the anaphylactoid type. If serious allergic mani-
festations preclude continuation of prophylaxis
with one vaccine, the other may be used.
When meningeal or neuroparalytic reactions
develop. vaccine treatment should be discontinued
altogether. Corticotrophin or corticosteroids are
used for such complications.

Passive Immunization
Hyperimmune serum has proved effective in preventing
rabies. Its use in combination with vaccine is con-
sidered- the best post-exposure prophylaxis. However.
the only preparation of antirabies serum now avail-
able in the United States is of equine origin. Because
horse serum induces allergic reaction in at least
20 percent of those receiving it, its use must be
limited.

It is recommended for most exposures classified
as severe, and for all bites by rabid animals, wild
carnivores, and bats. When indicated, antirabies
serum should he used r..- r.il. -- of the interval
between exposure and treatment.

The dose recommended is 1000 units (one vial)
per 40 pounds of body weight. A portion of the anti-
serum is used to infiltrate the wound, and the re-
mainder administered intramuscularly. As previously


noted, a careful history must be obtained and appro-
priate tests for hypersensitivity performed.*


Pre-exposure Immunization
The relatively low frequency of reactions to DEV has
made it more practical to offer pre-exposure immunization
to persons in high-risk groups: veterinarians, animal
!, r.i,-r- certain laboratory workers, and personnel
stationed in areas of the world where rabies is a constant
threat. Others whose vocational or avocational pursuits
result in frequent exposures to dogs, cats, foxes, skunks,
or bats should also be considered for pre-exposure pro-
phylaxis.
Two 1.0 ml injections of DEV given subcutaneously
in the deltoid area 1 month apart should be followed by a
third dose 6 to 7 months after the second dose. This series
of three injections can be expected to produce neutralizing
arii .ii, in 80 to 90 percent of vaccinees 1 month after
the third dose.

If more rapid immunization is desirable, three 1.0 ml
injections of DEV may be given at weekly intervals with
a fourth dose 3 months later. This schedule elicits an
antibody response in about 80 percent of the vaccinees.
All those receiving the pre-exposure vaccination
should have their serum tested for neutralizing antibody 3
to 4 weeks after the last injection. Tests for rabies anti-
body can be arranged with or through state health depart-
ment laboratories. If no antibody is detectable, booster
doses should be given until a response is demonstrated.
Persons with continuing exposure should receive 1.0 ml
boosters every 2 to 3 years.

When an immunized individual with previously demon-
strated antibody is exposed to rabies, it is suggested that
for a mild exposure, one booster dose of vaccine be
given, and for a severe exposure, five daily doses of
vaccine plus a booster dose 20 days later. If it is not
known whether an exposed person had antibody, the
complete post-exposure antirabies treatment should be
given.



References
(1)Technical Report Series No. 321, WHO Expert Committee on
Rabies, Fifth Report, 1966.
(2)Recommendation of the Public Health Service Advisory Com-
mittee on Immunization Practices: Diphtheria, Tetanus, and
Pertussis Vaccines-Tetanus Prophylaxis in Wound Manage-
ment, morbidity and Mortality Weekly Report, Vol. 15, No. 48,
week ending December 3, 1966.



*A useful guide for use of animal serum is included in the rec-
ommendation for tetanus prophylaxis in wound management
prepared h- the PHS Advisory Committee on Immunization
Practices --


154


MAY 13, 1967






Morbidity and Mortality Weekly Report


CHECKLIST OF TREATMENTS FOR ANIMAL BITES
(See Text for Details)



1. Flush Wound Immediately (First Aid).

2. Thorough Wound Cleansing Under Medical Supervision.

3. Antirabies Serum and/or Vaccine as Indicated.

4. Tetanus Prophylaxis and Antibacterial Treatment when Required.

5. No Sutures or Wound Closure Advised.










GUIDE FOR POST-EXPOSURE ANTIRABIES PROPHYLAXIS


ITh," foll ring j recoumcndationsl ar intended only a. a jiuide. They nmay be modified according to knowledge
of the species of biting animal and circumstances surrounding the citing incident


Biting Animal Treatment

Exposure
Species Status at Time of Attack Exposure
No Lesion Mild* Severe*

healthy none nonel S1
signs suggestive of rallies none V2 SV
Dog or Cat
escaped or unknown none S+V

rabid none SX S+V


Skunk. Fox. Iac- regard as rabid in
none S+V S+V
coon, Coyote, Bat unprovoked attack


Other consider individually-see Rationale of Treatment in text


Code: *
v-
s
S2-


See definitions in text.
iablies Vaccine
Antirabies Serum
lBegin vaccine at first sign of rabies in biting dog or cat during holding period (preferably 7-10 days).
Discontinue vaccine if biting dog or cat is healthy 5 days after exposure, or if acceptable laboratory negativity has been
demonstrated in animal killed at time of attack. If observed animal dies after 5 days and brain is positive, resume trtet-
ment.


MAY 13. 1967


155






156 Morbidity and Mortality Weekly Report


CASES OF SPECIFIED NOTIFIABLE DISEASES: UNITED STATES

FOR WEEKS ENDED

MAY 13, 1967 AND MAY 14, 1966 (19th WEEK)


ENCEPHALITIS HEPATITIS

ASEPTIC Primary
AREA MENINGITIS BlMCELL.S)ISIPIITHERIA including Post- Serum Infectious
unsp. cases Infectious
1967 1966 1967 1967 1967 1966 1967 1967 1966 1967 1966
UNITED STATES... 36 33 9 1 33 21 28 43 25 771 660

NEW ENGLAND.......... 5 1 1 37 39
Maine............... 1 8
New Hampshire...... 3
Vermont............ 2 1
Massachusetts...... 17 14
Rhode Island....... 3 1 1 3 9
Connecticut........ 2 11 7

MIDDLE ATLANTIC...... 2 4 4 9 25 12 113 116
New York City...... 2 1 2 10 6 34 30
New York, up-State. 2 3 1 29 35
New Jersey.......... 1 2 6 12 4 22 21
Pennsylvania....... 1 1 1 28 30

EAST NORTH CENTRAL... 1 5 6 1 9 1 121 127
Ohio............... 2 4 1 28 33
Indiana............. 9 5
Illinois........... 1 2 1 7 1 30 17
Michigan........... 1 2 51 68
Wisconsin.......... 3 4

WEST NORTH CENTRAL... I 1 2 2 1 86 32
Minnesota.......... 1 2 1 13 7
Iowa............... 9 13
Missouri........... -- 59 9
North Dakota....... 1
South Dakota....... 2
Nebraska........... 2 -
Kansas............. 2 3

SOUTH ATLANTIC ...... 1 4 7 1 3 3 2 3 82 57
Delaware........... 2 2 2
Maryland............ 1 1 1 17 12
Dist. of Columbia.. 1 -
Virginia........... 7 1 1 1 1 32 5
West Virginia...... 1 2 1 5
North Carolina..... 1 1 8 4
South Carolina..... 1 7
Georgia............ 6 10
Florida............ 1 1 1 14 12

EAST SOUTH CENTRAL... 6 1 1 5 1 2 56 49
Kentucky........... 27 19
Tennessee.......... 1 1 1 5 1 15 20
Alabama............ 2 8 4
Mississippi........ 5 6 6

WEST SOUTH CENTRAL... 14 8 1 5 1 1 82 61
Arkansas........... 2 9
Louisiana.......... 1 1 1 3 8 14
Oklahoma............ 4
Texas.............. 13 7 1 2 1 1 68 38

MOUNTAIN............. 2 1 40 26
Montana............ 3 1
Idaho............... 1 3
Wyoming.............. 1 1
Colorado........... 1 16 4
New Mexico......... 6 6
Arizona.............. 2 11 9
Utah............... 2 2
Nevada.............-

PACIFIC.............. 12 9 8 3 9 16 6 154 153
Washington......... 1 1 15 10
Oregon............... 1 2 18 14
California......... 11 8 3 3 8 14 6 121 126
Alaska.............. 2
Hawaii............. 4 1

Puerto Rico 16 20







Morbidity and Mortality Weekly Report 157


CASES OF SPECIFIED NOTIFIABLE DISEASES: UNITED STATES

FOR WEEKS ENDED

MAY 13, 1967 AND MAY 14, 1966 (19th WEEK) CONTINUED



MALARIA MEASLES (Rubeola) MENINGOCOCCAL INFECTIONS, POLIOMYELITIS RUBELLA
TOTAL
AREA -rl r I. '

1967 1967 1967 1966 1967 1967 1966 1967 1967 1967 1967
UNITED STATES... 27 2,257 44,454 142,413 50 1,114 1,887 5 2,128

NEW ENGLAND.......... 34 554 1,610 2 49 82 251
Maine .............. 140 170 1 3 7 22
New Hampshire...... 2 71 34 2 7 16
Vermont............ 1 36 209 3 30
Massachusetts...... 22 209 608 23 33 118
Rhode Island....... 7 38 66 1 3 7 9
Connecticut......... 2 60 523 18 25 56

MIDDLE ATLANTIC...... 1 96 1,495 15,473 6 170 209 2 69
New York City...... 1 16 260 7,585 2 28 33 1 34
New York, Up-State. 25 344 1,779 1 42 59 34
New Jersey.......... 26 362 1,607 1 67 57 -
Pennsylvania....... 29 529 4,502 2 33 60 1 1

EAST NORTH CENTRAL... 2 217 3,631 52,159 11 129 282 365
Ohio............... 68 639 4,981 6 50 77 22
Indiana............. 2 14 428 3,639 1 16 48 25
Illinois........... 30 588 9,856 2 27 54 53
Michigan........... 57 771 8,880 2 27 74 149
Wisconsin........... 48 1,205 24,803 9 29 116

WEST NORTH CENTRAL... 4 78 1,938 6,696 3 48 104 175
Minnesota.......... 1 2 94 1,475 2 11 25 2
Iowa................ 41 501 3,915 1 10 15 138
Missouri........... 4 139 383 11 43 5
North Dakota....... 24 693 850 4 13
South Dakota....... 46 4 6 3 -
Nebraska............. 6 464 69 8 7 17
Kansas.............. 3 1 1 NN 2 7 -

SOUTH ATLANTIC....... 9 365 5,142 10,920 11 216 304 1 94
Delaware........... 3 35 157 5 3 1
Maryland............ 3 88 1,629 1 27 30 1 15
Dist. of Columbia.. 12 346 1 7 7 -
Virginia........... 2 121 1,615 1,182 1 19 40 9
West Virginia...... 65 972 3,943 16 10 19
North Carolina..... 5 8 768 204 2 45 72 -
South Carolina..... 66 418 498 1 20 40 -
Georgia............. 2 23 213 33 44 -
Florida............. 99 1,211 2,748 5 44 58 50

EAST SOUTH CENTRAL... 153 4,283 15,651 5 104 171 226
Kentucky........... 19 1,092 4,176 29 70 167
Tennessee.......... 58 1,459 9,396 3 44 51 58
Alabama............ 63 1,113 1,295 1 19 38 1
Mississippi........ 13 619 784 1 12 12 -

WEST SOUTH CENTRAL... 5 406 14,788 17,582 4 165 278 2 2
Arkansas........... 1 8 1,359 730 19 16 -
Louisiana.......... 13 117 75 4 63 108 -
Oklahoma........... 4 7 3,257 393 10 13 1
Texas.............. 378 10,055 16,384 73 141 1 2

MOUNTAIN ............. 1 198 3,373 8,386 21 67 140
Montana............ 1 238 1,261 4 12
Idaho............... 9 328 844 1 5 -
Wyoming.............. 21 100 3 -
Colorado............ 1 88 967 832 10 36 60
New Mexico......... 12 490 837 3 9 -
Arizona............. 63 786 4,174 2 8 67
Utah............... 18 279 305 3 1
Nevada............. 7 264 33 2 2 -

PACIFIC.............. 5 710 9,250 13,936 8 212 390 806
Washington......... 3 314 4,395 2,398 1 21 27 141
Oregon.............. 94 1,232 968 1 18 26 25
California.......... 2 280 3,419 10,406 6 164 319 564
Alaska.............. 15 112 79 8 15 45
Hawaii.............. 1 7- 7 92 85 1 3 31
Puerto Rico........... 1 81 1,526 1,806 8 4 -






158 Morbidity and Mortality Weekly Report


CASES OF SPECIFIED NOTIFIABLE DISEASES: UNITED STATES

FOR WEEKS ENDED

MAY 13, 1967 AND MAY 14, 1967 (19th WEEK) CONTINUED


STREPTOCOCCAL TYPHUS FEVER
SORE THROAT & TETANUS TULAREMIA TYPHOID TICK-BORNE RAIS IN
AREA SCARLET FEVER (Rky. Mt. Spotted) ANIMALS
1967 1967 Cum. 1967 Cum. 1967 Cum. 1967 Cum. 1967 Cum.
1967 1967 1967 1967 1967

UNITED STATES... 10,452 1 54 5 54 2 117 3 26 92 1,697

NEW ENGLAND.......... 1,806 1 1 42
Maine.............. 85 1 10
New Hampshire...... 51 25
Vermont............ 36 -- 7
Massachusetts...... 423 -
Rhode Island....... 100
Connecticut........ 1,111

MIDDLE ATLANTIC...... 494 5 14 32
New York City...... 26 3 9
New York, Up-State. 431 1 3 23
New Jersey......... NN I -
Pennsylvania....... 37 1 1 9

EAST NORTH CENTRAL... 981 2 2 8 10 1 4 17 148
Ohio ............... 250 4 1 3 8 71
Indiana............ 146 1 1 1 22
Illinois........... 200 2 2 7 I 4 25
Michigan........... 254 4 1 5
Wisconsin.......... 131 1 3 25

WEST NORTH CENTRAL... 579 1 10 2 27 369
Minnesota.......... 18 1 3 71
Iowa............... 210 1 2 4 41
Missouri........... 30 3 3 81
North Dakota....... 205 4 63
South Dakota....... 27 1 50
Nebraska........... 60 4 26
Kansas............. 29 6 8 37

SOUTH ATLANTIC....... 1,152 1 13 7 1 16 10 9 232
Delaware........... 10
Maryland ........... 228 1 2
Dist. of Columbia.. 3 1
Virginia........... 400 1 4 2 2 3 123
West Virginia...... 309 1 I1 -- 1 39
North Carolina..... 11 4 2 7 1
South Carolina..... 20 2 -3 -
Georgia............ 9 1 3 1 1 5 46
Florida ........... 162 4 1 4 23

EAST SOUTH CENTRAL... 1,224 14 1 7 12 1 4 13 397
Kentucky........... 110 1 4 2 2 75
Tennessee ......... 857 7 4 4 1 2 10 291
Alabama............. 102 5 4 1 29
Mississippi........ 155 2 1 2 2

WEST SOUTH CENTRAL... 982 11 12 17 2 19 332
Arkansas........... 1 3 1 3 2 53
Louiiana .......... 2 1 2 11 30
Oklahoma............ 131 6 2 7 87
Texas.............. 848 7 3 3 10 162

MOUNTAIN............. 1,890 7 15 3 2 44
Montana ............ 63 1- 1
Idaho ............. 117 -
Wyoming............ 19 2 -
Colorado........... 1,024 1 11 3 5
New Mexico......... 299 1 10
Arizona............ 187 3 1 29
Utah............... 181 3 -
Nevada..............- -

'ACIFIC .............. 1,344 8 2 3 1 30 1 3 4 101
W1i ing ton........ 340 2 2 -
reon........59 1
Cailif"rnia......... 835 6 1 1 27 1 3 4 100
A!aska ............. 39 -
w~ii ............. 71 2 3 -

Puerto Rico.......... 1 1 4 4 16













DEATHS IN 122 UNITED STATES CITIES FOR WEEK ENDED MAY 13, 1967


(By place of occurrence and week of filing certificate. Excludes fetal deaths)


Area


NEW ENGIAND:
B st on, Mass.--------
Bridgeport, Co nn.-----
Cambridgi, Mass .----
Fall Rivcr, Mass.-----
l.art frd, Conn.-------
Lowell, Mass.---------
Lynn, Mass.-----------
New Bedford, Mass.----
New Haven, Conn.------
Providence, R. I.-----
Somerville, Mass.-----
Springfield, Mass.----
Watr bury, Conn.------
Worcester, Mass.------

MIDDLE ATLANTIC:
Albany, N. Y.---------
Allentown, Pa.--------
Buffalo, N. Y.--------
Camden, N. J.---------
Elizabeth, N. J.------
Erie, Pa.-------------
Jersey City, N. J.----
Newark, N. J.---------
New York City, N. Y.--
Paterson, N. J.-------
Philadelphia, Pa.-----
Pittsburgh, Pa.-------
Reading, Pa.-----------
Rochester, N. Y.------
Schenectady, N. Y.----
Scranton, Pa.---------
Syracuse, N. Y.-------
Trenton, N. J.--------
Utica, N. Y.----------
Yonkers, N. Y.--------

EAST NORTH CENTRAL:
Akron, Ohio-----------
Canton, Ohio----------
Chicago, Ill.----------
Cincinnati, Ohio------
Cleveland, Ohio-------
Columbus, Ohio--------
Dayton, Ohio----------
Detroit, Mich.--------
Evansville, Ind.-------
Flint, Mich.-----------
Fort Wayne, Ind.------
Gary, Ind.------------
Grand Rapids, Mich.---
Indianapolis, Ind.----
Madison, Wis.---------
Milwaukee, Wis.-------
Peoria, I.-----------
Rockford, Ill.--------
South Bend, Ind.------
Toledo, Ohio----------
Youngstown, Ohio------

WEST NORTH CENTRAL:
Des Moines, Iowa------
Duluth, Minn.---------
Kansas City, Kans.----
Kansas City, Mo.------
Lincoln, Nebr.--------
Minneapolis, Minn.----
Omaha, Nebr.----------
St. Louis, Mo.--------
St. Paul, Minn.-------
Wichita, Kans.--------


A :


-- I- .... .1n .


65 years and
and over Ill gena
All Ages


1 year
All
Causes


Area


All i 5 years
Ages and over


I I I .


767
251
43
31
23
58
25
30
27
50
66
15
54
37
57

3,437
50
36
170
36
34
36
70
96
1,683
34
541
193
41
126
37
40
70
63
37
44

2,642
67
31
781
164
221
122
76
328
49
33
57
50
54
175
42
127
47
24
29
99
66

832
64
29
36
136
23
111
85
242
54
52


492
161
24
22
14
32
16
19
17
23
45
7
40
26
46

2,054
27
27
100
23
20
25
43
47
1,003
16
324
96
26
86
26
23
47
38
28
29

1,501
48
22
424
90
134
68
39
181
27
15
36
30
36
100
23
80
25
16
16
58
33

515
53
16
19
90
14
67
51
136
35
34


*Estimate based on average percent of divisional total.


SOUTH ATLANTIC:
Atlanta, Ga.------------
Baltimore, Md.---------
Charlotte, N. C.-------
Jacksonville, Fla.----
Miami, Fla.-------------
Norfolk, Va.-----------
Richmond, Va.-----------
Savannah, Ga.----------
St. Petersburg, Fla.---
Tampa, Fla.------------
Washington, D. C.------
Wilmington, Del.-------

EAST SOUTH CENTRAL:
Birmingham, Ala.-------
Chattanooga, Tenn.-----
Knoxville, Tenn.-------
Louisville, Ky.--------
Memphis, Tenn.---------
Mobile, Ala.-----------
Montgomery, A4a.-------
Nashville, Tenn.-------

WEST SOUTH CENTRAL:
Austin, Tex.-----------
Baton Rouge, La.-------
Corpus Christi, Tex.---
Dallas, Tex.-----------
El Paso, Tex.-----------
Fort Worth, Tex.-------
Houston, Tex.----------
Little Rock, Ark.------
New Orleans, La.--------
Oklahoma City, Okla.---
San Antonio, Tex.------
Shreveport, La.--------
Tulsa, Okla.-----------

MOUNTAIN:
Albuquerque, N. Mex.---
Colorado Springs, Cole.
Denver, Colo.----------
Ogden, Utah------------
Phoenix, Ariz.---------
Pueblo, Colo.----------
Salt Lake City, Utah---
Tucson, Ariz.----------

PACIFIC:
Berkeley, Calif.-------
Fresno, Calif.---------
Glendale, Calif.-------
Honolulu, Hawaii-------
Long Beach, Calif.-----
Los Angeles, Calif.----
Oakland, Calif.--------
Pasadena, Calif.-------
Portland, Oreg.--------
Sacramento, Calif.-----
San Diego, Calif.------
San Francisco, Calif.--
San Jose, Calif.-------
Seattle, Wash.---------
Spokane, Wash.---------
Tacoma, Wash.----------


1,025
131
227
32
46
72
52
81
28
69
70
188
29

648
98
44
43
116
161
49
37
100

1,119
45
35
35
152
43
77
194
51
165
66
130
45
81

427
55
12
110
18
114
17
55
46

1,637
19
63
36
43
91
477
102
35
113
69
104
193
40
153
56
43


and
Influenza
All Ages


1 year
All
Causes


Total 12,534 7,201 412 592

Cumulative Totals
including reported corrections for previous weeks

All Causes, All Ages ------------------------- 244,145
All Causes, Age 65 and over------------------- 141,132
Pneumonia and Influenza, All Ages------------- 9,604
All Causes, Under 1 Year of Age--------------- 12,217


Week No.


Mo 'Iriidit and Ml'Iorlalit W c eklh I eporl






160 Morbidity and M





CURRENT TRENDS
INFLUENZA 1967-Pinal County, Arizona


Influenza B has been isolated from 4 of 12 throat-
swab specimens taken during the recent respiratory
disease outbreak in Arizona (MMWR, Vol. 16, No. 17).
This virus appears to be antigenically similar to strains
circulating during the 1965-66 season, but full laboratory
characterization has not yet been completed by the Lab-
oratory Improvement Program, NCDC.
(Reported by the Respiratory Diseases Unit, Epidem-
iology Program, NCDC.)



INTERNATIONAL NOTES
QUARANTINE MEASURES


Immunization Information for International Travel
1965-66 edition-Public Health Service Publication No. 384


1. Saudi Arabia Section 2 Measles -p. 16

Delete all information and any subsequent changes and
insert:
"Live attenuated measles virus vaccine is recom-
mended for international travel for all persons who
have neither had measles nor been vaccinated
previously."



2. Section 5 Asia, Saudi Arabia p. 55

Delete note under cholera and any subsequent changes
and insert:
"Cholera-From May 1, 1967, until October 4, 1967,
all arrivals from Afghanistan, Bahrain, Brunei,
Burma, Cambodia, Ceylon, Hong Kong, India,
Indonesia, Iran. Iraq, Malaysia, Nepal, Pakistan,
Philippines, Thailand. Karakalpak and Uzbek
(USSR), and Viet-Nam are required to possess a
valid certificate of vaccination or revaccination
against cholera and a certificate of a negative
stool culture within 7 days prior to departure for
Saudi Arabia. In addition, from October 4, 1967,
through March 29, 1968, all arrivals from these
countries must possess a certificate showing that
they had stayed in a cholera-free area 5 days prior
to their arrival in Saudi Arabia."


oral


-ty weekly report MAY 13. 1967,
uNIVERSITy OF FLORIDA

II II I I I I 111111 11111111111111I III II 11111
3 1262 08864 2250

THE MORBIDITY AND MORTALITY WEEKLY REPORT. WITH A CIRCULA-
TION OF 17.000. IS PUBLISHED AT THE NATIONAL COMMUNICABLE
DISEASE CENTER. ATLANTA, GEORGIA.
DIRECTOR. NATIONAL COMMUNICABLE DISEASE CENTER
DAVID J. SENCER, M.D.
CHIEF. EPIDEMIOLOGY PROGRAM A.D. LANGMUIR, M.D.
ACTING CHIEF. STATISTICS SECTION IDA L. SHERMAN, M.S.

IN ADDITION TO THE ESTABLISHED PROCEDURES FOR REPORTING
MORBIDITY AND MORTALITY, THE NATIONAL COMMUNICABLE DISEASE
CENTER WELCOMES ACCOUNTS OF INTERESTING OUTBREAKS OR CASE
INVESTIGATIONS WHICH ARE OF CURRENT INTEREST TO HEALTH
OFFICIALS AND WHICH ARE DIRECTLY RELATED TO THE CONTROL OF
COMMUNICABLE DISEASES. SUCH COMMUNICATIONS SHOULD BE
ADDRESSED TO:
THE EDITOR
MORBIDITY AND MORTALITY WEEKLY REPORT
NATIONAL COMMUNICABLE DISEASE CENTER
ATLANTA, GEORGIA 30333
NOTE: THE DATA IN THIS REPORT ARE PROVISIONAL AND ARE
BASED ON WEEKLY TELEGRAMS TO THE NCDC BY THE INDIVIDUAL
STATE HEALTH DEPARTMENTS. THE REPORTING WEEK CONCLUDES
ON SATURDAY; COMPILED DATA ON A NATIONAL BASIS ARE RELEASED
ON THE SUCCEEDING FRIDAY.


Dl I 3F 'L d
S .J D.E NT E DEPO






L U.S. DEPOSITORY


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