Morbidity and mortality

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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:
AA00010654:00163

Related Items

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

Full Text


NATIONAL COMMUNICABLE DISEASE CENTER
NATIONAL COMMUNICABLE DISEASE CENTER


U.S. DEPARTMENT OF HEALTH, EDUCATION, AND WEN

HEALTH SERVICES AND MENTAL HEALTH ADMINISTF


INTERNATIONAL NOTES
INFLUENZA
The outbreak of influenza in the Manila area (MMWR,
Vol. 17, No. 36) appears to be subsiding (Table 1). One
index of the magnitude of the epidemic is that absenteeism
among Philippine residents who are employed by the
United States Agency for International Development was
three times greater at the end of August than it was at the
end of July. Cases and deaths from pneumonia in Manila
(Table 2) were substantially increased during weeks 33-35
of 1968 over the 5-year median (1963-67). The clinical syn-
drome has been typical of influenza: 4 to 5-day illness char-
acterized by malaise, fever, cough, headache, and myalgia.
The International Influenza Center for the Americas
confirmed 10 viruses, isolated from the epidemic in Manila,


. 17, No. 38


EEKLY

PORT


k Ending
mber 21, 1968




HEALTH SERVICE


CONTENTS
International Notes
Influenza ........ .. .... ... ....... 345
Epidemiologic Notes and Reports
Outbreak of California Encephalitis -
Southwestern Kentucky . . 346
Meningococcal and ECHO-9 Meningitis -
Manatee County, Florida ... . .. ..347
Murine Typhus, Baltimore Maryland . .... 348
Clostridium botulinum Type B due to Home-cooked
Chicken St. Joseph, Michigan . .... 348
Food Poisoning Morton, Mississippi . ... 348
Measles Terrebonne Parish, Louisiana ... 349
Arsine Gas Poisoning New Jersey . ... 350
Malaria ... . . .. 351
Current Trends
California Encephalitis United States .... 346
Morbidity Reporting . . ..... 356

as similar to the A2/Hong Kong/68 strains; 10 paired
sera had rises in titer to an A2/Hong Kong/68 strain
(Continued on page 346)


TABLE I. CASES OF SPECIFIED NOTIFIABLE DISEASES: UNITED STATES
(Cumulative totals include revised and delayed reports through previous weeks)
38thWEEK ENDEDAN CUMULATIVE, FIRST 38 WEEKS
MEDIAN
DISEASE September 21, September 23, 1963 1967 MEDIAN
1968 1967 1968 1967 1963 1967
Aseptic meningitis ..................... 295 128 94 2,871 2,034 1,431
Brucellosis ............................ 5 4 6 158 188 192
Diphtheria............................... 5 2 3 137 90 142
Encephalitis, primary:
Arthropod-borne & unspecified ........... 61 39 929 1,178 ---
Encephalitis, post-infectious ............. 8 14 381 651 -
Hepatitis, serum ........................ 116 59 7 3,154 1,577
Hepatitis, infectious ..................... 1,051 708 32,312 27,744
Malaria ................................ 72 32 3 1,650 1,434 72
Measles(rubeola) ....................... 130 204 554 19,798 58,049 240,837
Meningococcal infections, total ........... 29 24 30 2,060 1,703 2,078
Civilian .............................. 28 23 1,880 1,589
Military ............................... 1 1 180 114
Mumps ................................. 609 -- 125,661
Poliomyelitis, total ................... .. 1 2 41 26 71
Paralytic ............................. 1 2 41 22 67
Rubella (German measles) ............... 215 146 44,116 40,022 -
Streptococcal sore throat & scarlet fever.... 5,727 5,350 4;705 310,971 334,172 299,858
Tetanus ............................... 5 8 6 116 163 186
Tularemia ............................... 2 3 6 144 134 190
Typhoid fever .......................... 13 8 9 276 307 303
Typhus, tick-borne (Rky. Mt. spotted fever) 9 14 5 246 276 211
Rabies in animals ....................... 55 90 85 2.599 3.302 3.302

TABLE II. NOTIFIABLE DISEASES OF LOW FREQUENCY
Cum. Cum.
Anthrax: ........................................... 3 Rabies in man: ...................................... -
Botulism: ......................................... 4 Rubella, Congenital Syndrome: ......................... 5
Leptospirosis: .................. ................... 30 Trichinosis: ...................................... 47
Plague: ........................ .............. .... 2 Typhus, murine: Md.-1 .............................. 23
Psittacosis: ...................................... 35


6---






Morbidity and Mortality Weekly Report


SEPTEMBER 21, 1968


INFLUENZA (Continued from front page)

Table 1
Weekly Cases of Influenza-like Illness Reported
From Public Health Facilities in Greater Manila (Approx. 1.5 million pop.)

Week Number
Year
27 28 29 30 31 32 33 34 35 36 37 38 39 40

1965 65 46 42 54 50 61 46 32 47 43 44 22 52 35
1966 44 40 42 78 46 58 87 174 96 167 119 254 243 107
1967 46 29 69 130 57 85 152 250 255 251 214 230 140 144
1968 53 48 46 65 59 162 1,882 20,346 11,285 5,812


Table 2
Pneumonia Cases and Deaths in Manila
(Cases/Deaths)


Week Number
Year
31 32 33 34 35 36

Median
1963-67 86/46 100/48 111/38 119/45 124/48 159/56
1968 98/53 111/43 155/64 242/76 206/97 158/67


when tested by the .. ...~ii luinri,. n ;rnhi,; i I-.n technique.
In previous years influenza in the Philippines had
seasonal peaks in August and September. The last severe
epidemic of influenza was recorded in 1957 with the first
appearance of the A2 strains.
A widespread outbreak of influenza has also been
reported from the Northern Territory of Australia. Three
virus isolates from this outbreak were similar to A2/Hong
h._.nr r.- strains. \lhlr .gh there has also been a single
isolation of virus similar to the A2/Hong Kong/68 strains
in Melbourne, Australia, only sporadic cases of respiratory


illness have occurred in that area. Sydney,Melbourne, and
Perth had extensive A2 epidemics in June and July. These
were caused by strains more closely related to earlier A2
viruses than to the A2/Hong Kong 68 strains.
In addition to the recently reported A2 outbreak-, the
first type B outbreak recognized in Trinidad has been re-
ported. On July 19, 1968, the first influenza B isolate
was obtained. Since the beginning of August an additional
31 isolates have been recovered from children and a few
adults.
(Reported by J.J. Dizon, M.D., M.P.H., Chief, Disease
Intelligence, Disease Intelligence Center, Department of
H .. .'i Manila, Philippines; Dr. Espiritu-Campos, Depart-
ment of Microbiology, University of the P'4..1ppin', In-
stitute of Hygiene; Elmer Z. Dahl, Colonel, MC, USAF,
Commander of the Fifth Epidemiological Flight, Manila,
Philippines; M.F. Warburton, Ph.D., Controller, WHO
Influenza Center, Melbourne, Australia; Andries H.Jonkers,
Ph.D., Acting Director, Trinidad Regional Virus Laboratory,
University of the West Indies; and Respiratory Virus In-
fections Unit, Laboratory Program, and Respiratory Viral
Diseases Unit, Epidemiology Program, NCDC.)


EPIDEMIOLOGIC NOTES AND REPORTS
OUTBREAK OF CALIFORNIA ENCEPHALITIS Southwestern Kentucky


During August and September 1968 a total of 10 per-
sons in Trigg and Calloway Counties in southwestern
Kentucky were hospitalized with a clinical diagnosis of
encephalitis or aseptic meningitis. The patients, ranging
in age from 14 to 40 years, presented with a clinical his-
tory of fever, chills, headache, and \...r.ii;pf All recovered
uneventfully in 4-10 days. The patients with the exception
of one pair of siblings were unrelated to each other. Other
than the -.lli,.-. all but one patient denied any knowl-
edge of similar illnesses in family, friends, or acquaint-
ances. No common exposure could be determined.
Acute and convalescent sera from two patients demon-
strated a fourfold or greater rise in titer to California en-
cephalitis antigen. Other sera are now being processed.


A survey of physicians in a 20-county area in western
Kentucky revealed 12 additional cases of similar illnesses
in Trigg and Calloway Counties and two cases in adjacent
Graves County. Intensive surveillance is continuing in
this 20-county area which is near Saline County, Illinois,
the site of the recent outbreak of St. Louis encephalitis
(MMIR. Vol. 17, No. 37).

(Reported by C. Hernandez, M.D., M.P.H., Director, Divi-
sion of Epidemiology, B. F. Brown, M.D., M.P.H., Director,
Division of Laboratory Services, J. W. Skaggs, D.V.M.,
M.P.H., Acting Director, Office of Communicable Diseases,
and Wallace Guerrant, Field I '*.'.'.'.. i Unit, Kentucky
State Health Department; and EIS Officers.)


CURRENT TRENDS
CALIFORNIA ENCEPHALITIS United States


In addition to the cases reported from Kentucky, there
have been case reports of California encephalitis from five


other states in the summer and fall of 1968. On the basis
of serologic data, Arkansas, Iowa, and Wisconsin each


346


Weekly Reported










reported one confirmed case, while Minnesota reported two
and Ohio four cases. On the basis of clinical data and
serologic tests on a single serum specimen, one presump-
tive case was reported from Minnesota and five from Wis-
consin.

(Reported by Bryant S. Swindoll, M.D., M.P.H., Director,
Division of Chronic Disease Control, Arkansas State Board
of Health; Arnold M. Reeve, M.D., M.P.H., Chief, Preven-


347


tive Medical Service, Iowa State Department of Health;
D. S. Fleming, M.D., M.P.H., Director, Division of Disease
Prevention and Control, Minnesota Department of Health;
Calvin B. Spencer, M.D., Acting Chief, Bureau of Preveln-
tive Medicine, Ohio Department of Health; and H. Grant
Skinner, M.D., Chief, Section of Communicable Disease
Control, Wisconsin Division of Health; and Wayne Thomp-
son, D.V.M., Zoonoses Research Laboratory, University
of Wisconsin.)


EPIDEMIOLOGIC NOTES AND REPORTS
MENINGOCOCCAL AND ECHO-9 MENINGITIS Manatee County, Florida


From May 7.to.June 4, 1968, the Manatee County Health
Department, Florida, serving a population of 80,000, was
notified of 15 cases of meningitis, including one death. A
detailed investigation confirmed five cases of meningo-
coccal meningitis, eight cases of viral meningitis, and
two viral illnesses occurring in six families.
The first case was diagnosed as fulminant menin-
gococcemia by autopsy on May 7 (Figure 1 Town A). On
May 22, 2 weeks later, a second case of meningococcal
meningitis, documented by positive cerebral spinal fluid
(CSF) culture, occurred in a child in the S. family who
rode a church bus with the first case. Over the following
7 days, five siblings (cases 3, 4, 5, 6, 7) of the second
case developed viral meningitis. Of these five siblings,
three had ECHO-9 isolates in their stools. Two additional
cases (8, 9 in the W. family) of ECHO-9 meningitis, docu-
mented by a fourfold rise in neutralizing antibody, occurred
in next door playmates of the S. family on May 24 and
May 26. Another case of ECHO-9 meningitis (case 10),
documented by an ECHO-9 isolate in his stool and a four-
fold antibody rise, occurred on May 28 in a 17-month-old
male. This boy's grandmother drove the school bus and
worked in the school cafeteria where the S. and W. chil-
dren attended school.
A third case (11) of presumptive meningococcal men-
ingitis, documented by positive CSF smear with negative
culture, occurred on May 28 in a 6-year-old male who lived
in another town several miles away (Figure 1 Town B).
This patient had been on polycillin for 1 week prior to the
spinal tap. No epidemiologic link could be established
with the earlier cases of meningococcal or viral meningitis.
Two of his brothers (cases 12, 13) had viral illnesses
characterized by febrile headaches without stiff necks.
Although no CSF or stool cultures were obtained, throat
cultures were negative for bacterial pathogens. Serologic
data are pending. On May 31, 3 days later, the next door
playmate (case 14) of case 10 developed meningococcal
meningitis following a 7-day illness characterized by
fever, headache, vomiting, and a measles-like rash. Al-
though she had been on antibiotics for 1 week, examina-
tion of the CSF revealed gram-negative diplococci on
smear with a negative culture. On June 3, her father (case 15)
developed meningococcal meningitis documented by posi-
tive CSF. blood, and throat cultures.


Figure 1
MENINGOCOCCAL MENINGITIS, ECHO-9
MENINGITIS, AND VIRAL ILLNESS
MANATEE COUNTY, FLORIDA
MAY 7 TO JUNE 5, 1968


4 TOWN A
TOWN A
2-


4I
TOWN B
2

%
7 21 22 23 24 25 26 27 28 29 30 31 I 2 3 4 5
MAY JUNE


ONSET

MENINGOCOCCAL MENINGITIS 0 VIRAL ILLNESS
] ECHO-9 MENINGITIS Q = ASSIGNED CASE NUMBER

In summary, two families had cases of meningococcal
meningitis occurring at the same time as a viral illness
and/or ECHO-9 meningitis. Three cases (2, 11, 14) had
prodromal symptoms of headache and fever for 4-7 days
prior to the onset of meningococcal meningitis. Case 14
had a measles-like rash 2 days prior to the onset of menin-
geal signs, and case 2 had a dual infection with Neisseria
meningitidis and ECHO-9.
Therefore, simultaneous outbreaks of meningococcal
and ECHO-9 meningitis have been confirmed. Although no
conclusions as to a causal relationship between these
two outbreaks can be made at the present time, further
studies are underway to evaluate this possibility.
(Reported by Irving Hall, M.D., Pediatrician, Manatee
County; George Dame, M.D., Director, Manatee County
Health Department; Elsie Buff, M.S., Chief Virologist,
Charles Hartwig, Ph.D., Director, Tampa Regional Labora-
tory, James O. Bond, M.D., D.P.H., Director, Encephalitis
Research Center, Nathan J. Schneider, Ph.D., Director,
Laboratories, and E. Charlton Prather, M.D., M.P.H.,
Director, Division of Epidemiology, Florida State Board of
Health, and an EIS Officer.)


SEPTEMBER 21, 1968


Morbidity and Mortality Weekly Report


o

6






Morbidity and Mortality Weekly Report


MURINE TYPHUS Baltimore, Maryland


Murine typhus was diagnosed in a 27-year-old chief
mate of a German freighter which docked in Baltimore,
Maryland, on August 21, 1968. While the ship was on route
from Mazatlan. Mexico, on August 19. the man became ill
with fever. severe headache, and backache. On August 21,
the man reported to a hospital; a urinary infection was
diagnosed and he was given sulfa drugs but was not hos-
pitalized. His symptoms persisted, and he returned to the
hospital on August 26; again he was not admitted but was
told that he had influenza. The man went to a private
physician on August 29; because a malaria smear was
negative and a white blood cell count was 13,h00, he was
hospitalized. On admission the patient had albuminuria,
and during the hospital course, he developed a bibasilar
pneumonitis.
Serologic studies revealed an OX19 titer of 1:320 on
August 20 and 1:1250 on September 3. Complement fixation
titers to murine typhus were 1:32 on September 3 and 1:128
on September 9. a fourfold rise. A fluorescent lnili,,..*. test
to murine typhus on September 9 had a titer of 1:80, and the
diagnosis of murine typhus was made. There was no rise
in titer to Rocky Mountain spotted fever or Q Fever. Titers
to epidemic typhus are in progress.


The patient was treated with tetracycline for 10 days
and became afebrile after the third day of treatment. He
was discharged on September 10 and returned to Germany.
The patient reported a large rat population on the
docks in Mazatlan: however, he did not note any increased
flea population. He made several visits to shore while the
ship was docked. He also reported that two crew members
had been hospitalized in Mazatlan with fever and gas-
troenteritis.

(Reported by John B. MacGibbon, M.D., Baltimore, Mary-
land: John H. Janney, M.D., Chief, Division of Communi-
cable Diseases, and J.M. Joseph, Ph.D., Chief, Division
of Virology, Bureau of Laboratories, Maryland State Health
Department; and two EIS Officers.)

Editorial Note:
Because the average incubation period for murine
typhus is 12 days, the patient probably contracted typhus
by contact with an infected flea while the ship was docked
at Mazatlan. Although it is possible that he contracted
the disease while traveling from Mazatlan to Baltimore,
the investigators found a good level of sanitation aboard
the ship.


CLOSTRIDIUM BOTULINUM TYPE B DUE TO HOME-COOKED CHICKEN St. Joseph, Michigan


An elderly couple, each 78 years old, developed botu-
lism after eating leftover chicken. The chicken had been
frozen until July 16 when it was stewed in a broth con-
taining rice. It was described as "tasty" when served
the same day. Leftovers were placed in a covered, plastic
container and stored in a cellar-way where the temperature
was later recorded at 75F. It was warmed and served at
lunch the next day when it was noted to taste "moldy."
At noon on July 18 the chicken was again heated and
served: the wife ate more than the husband who complained
that it tasted "slimmy." A doctor was seen by the couple
about 7:30 a.m. on July 20 because of visual and bulbar
symptoms and impending respiratory failure. The wife's
symptoms were more severe than the husband's; rh,., were
both hospitalized and treated with Clostridium botulinum
type AB antitoxin. She died about 24 hours later; he made
an uneventful recovery.
Laboratory examination showed C. botulinum type B
toxin in the serum from both the husband and wife and in
the leftover chicken. The wife's serum contained 20 mouse
LD50 doses/ml and the husband's, 10-20 mouse LD50
doses ml. In addition, Clostridium botulinum type B was
isolated from the chicken.
(Reported by C. E. Baggerly, D.O., Practicing Osteopath,
Buchanan, Michigan; Robert P. Locey, M.D., Health Offi-


cer, Berrien County Health Department; Donald B. Coohon,
D.Y.M., Public Health Veterinarian, George Agate, M.D.,
M.S.P.H., Chief, Division of Epidemiology, and William W.
Ferguson, Ph.D., Chief, Division of Microbiology, Michi-
gan Department of Public Health; and the Anaerobic Bac-
teriology Laboratory, Bacterial Reference Unit, Bacteriol-
ogy Section, Laboratory Program, NCDC.)
Editorial Note:
Botulism resulting from the ingestion of poultry is
quite rare in the United States. Of 640 reported outbreaks
which occurred from 1899-1967 only one, also type B, was
attributed to poultry. This is in agreement with the low
incidence of Clostridium botulinum spores in raw meats in
the United States and Canada.1 Nevertheless, C. botulinum
spores might well contaminate raw poultry, and it is possi-
ble that the heat resistant spores could survive normal
cooking. In this outbreak storage of the leftover chicken
in broth at room temperature undoubtedly permitted spores
to germinate. This made possible the production of toxin;
reheating on 2 subsequent days was obviously inadequate
to inactivate all the toxin present.
Reference:
lIngram, M. and Roberts, T. A.: Botulism 1966, Chapman and
Hall, Ltd., London, 1967, pp. 34-37. Based on the Proceedings
of the Fifth International Symposium on Food Microbiology,
Moscow, July 1966.


FOOD POISONING Morton, Mississippi


An outbreak of food poisoning occurred on Septem-
ber 1-' 1968, in Morton, Mississippi, among students who
ate their noon meal in the cafeteria of a consolidated pub-


lic school with grades 1-12. Of the school's total enroll-
ment of 1,409 pupils, 88.1 percent (1,241) ate the suspect
lunch, resulting in 406 cases of illness characterized by


SEPTEMBER 21, 1968










nausea, vomiting, prostration, and less frequently diarrhea.
The mean attack rate was 32.7 percent with children in the
lower grades appearing to be at greater risk (Table 3).
The epidemic curve demonstrates the short incubation
period and common source nature of the illness (Figure 2).

Table 3
Attack Rate by Grade, Morton, Mississippi
September 12, 1968

Children in Number
Grades Attack Rate
Each Grade Ill

1 130 59 45.4
2 119 54 45.4
3 120 47 39.2
4 111 43 38.7
5 97 44 45.4
6 91 34 37.4
7 107 38 35.5
8 111 36 32.4
9 101 15 14.9
10 85 14 16.5
11 90 14 14.5
12 79 8 10.2

Total 1,241 406 32.7

Of the items on the menu the greatest disparity in
attack rates between those who ate and those who did not
eat the specified food was for tuna fish salad, the in-
criminated vehicle (Table 4). Except for chopped eggs
prepared by hand the previous day, all other ingredients
of the salad were mixed just prior to serving. Cultures of
the tuna fish salad served grew abundant Staphylococcus
aureus. All other ingredients, including canned tuna and
other foods on the menu, were culture negative.

Table 4
Food Histories of Students Eating School Lunch

Number persons who Number who did NOT
ATE specified food eat specified food
Food Items Not Attack Not Attack
Ill Il Total Rate Ill Total Rate
Percent Ill Percent
Tuna Fish
Salad 383 380 763 50.3 25 453 478 5.2
Butter Beans 231 298 529 43.8 179 533 712 25.1
Jello 248 338 586 42.5 148 507 655 22.6
Vanilla Wafer 266 359 625 42.6 167 449 616 26.7
Milk 333 512 845 39.5 59 337 396 14.9
Ice Cream 190 354 544 35.0 225 472 697 32.4

Although no apparent pustular skin lesions were de-
tected on food handlers in the cafeteria, nose and/or
throat cultures on nine of 11 food handlers grew S. aureus.


349


Figure 2
FOOD POISONING IN PUBLIC SCHOOL
MORTON, MISSISSIPPI SEPTEMBER 12, 1968


200.


170-

160-

150-

140-

130.

120-


U)
11-
C-,
L 100
0

S90-

z


I 2 3 4 5 6 7 8 9 10
ONSET- HOURS AFTER NOON MEAL


Phage typing and enterotoxin producing ability of all
staphylococcal isolates as well as enterotoxin assay of
the incriminated tuna fish salad are in progress.
(Reported by D. L. Blakey, M.D., M.P.H., Director, Divi-
sion of Preventable Disease Control, Richard H. Andrews,
1.S., Director, Division of Public Health Laboratories,
and S. L. Moore, M.D., M.P.H., Director and Personnel
Officer, Division of County Health Work, Mississippi State
Board of Health; and an EIS Officer.)


MEASLES Terrebonne Parish, Louisiana


On September 2, 1968, a 7-year-old girl was admitted
to a hospital in New Orleans, Louisiana, with clinical
measles and associated mild encephalitis from which she


subsequently recovered. Epidemiologic investigation in a
relatively isolated area of Terrebonne Parish revealed a
(Continued on page 350)


SEPTEMBER 21, 1968


Morbidity and Mortality Weekly Report






Morbidity and Mortality Weekly Report


SEPTEMBER 21, 1968


MEASLES (Continued from page 349)


total of 21 related cases and traced cases to June when
the first case occurred in a day care center for retarded
children (Figure 3). Cases had continued at a low rate
because of the pupils' limited social contact. At the end
of July a normal child was exposed at Bible School to a
retarded child, and she subsequently exposed four siblings,
one friend, and five cousins including the presenting
case. Nonehad been immunized lilhouhl a community-wide
measles program was held in December 1967.
Emergency vaccine supplies were obtained from NCDC
and an intensified community immunization program was
conducted during the week of September 9. As a result of
this investigation, surveillance for measles in special
institutions will be added to the present school reporting
system in Louisiana.

(Reported by Charles T. Caraway, D.V.M., M.P.H., ( ,.r
Section of Epidemiology, Louisiana State Department of
Health; and an EIS Officer.)


Figure 3
MEASLES CASES BY WEEK OF ONSET
TERREBONNE PARISH, LOUISIANA
JUNE 29 SEPT. 14, 1968


_1 7


291 6
JUN


13 20 27 | 3 10 17
JUL. AUG.
WEEK ENDING


ARSINE GAS POISONING New Jersey


On May 29, 1968, three workers in a chemical plant
in New Jersey developed nausea, vomiting, abdominal
pain. and hematuria within 1 hour after cleaning a large
vat containing several arsenic compounds. The workers'
symptoms were compatible with those caused by the in-
halation of arsine gas (AsH,).
The first case, a 44-year-old male, was exposed to
the arsine fumes for approximately 5 minutes. Within 1
hour he had onset of weakness, blurred vision, headache,
nausea, vomiting, epigastric pain, and hematuria. He was
hospitalized the following tlay. When the history of ex-
posure to arsenic was obtained, he was transferred to an-
other hospital. On admission, he was found to have icterus,
dusky tan skin, and a tender abdomen. His admission
hemoglobin was 7.8 gm percent. He was treated by manni-
tol diuresis and received two exchange transfusions of 5
and 10 units of blood, respectively. Neurologic studies,
urine output, and EKG and bone marrow biopsies were
normal. At the present time, the patient is ambulatory and
is in satisfactory condition. Kidney and liver function
tests have returned to normal; however, the patient con-
tinues to be anemic.
The second case, a 31-year-old male, was exposed to
the arsine fumes for approximately 30 minutes; 15 minutes
after exposure, he developed hematuria and then the onset
of nausea, vomiting, myalgia, and headache. He received
symptomatic medication that evening, but did not improve.
Examination on May 30 revealed icteric sclera and a ten-
der abdomen; arsenic poisoning was diagnosed and the
patient was hospitalized. On admission the patient had
dusky brown skin and a blood pressure of 158/80 with a
pulse of 66. His initial laboratory tests included a hemo-
globin of 11.7 gm percent which decreased to 8.0 gm per-


cent over the next 2 weeks, a bilirubin of 13.6 mgm, and a
plasma free hemoglobin of 2,180 mgm/100cc (normal is
less than 5 mgm/100cc). Initial treatment included an ex-
change transfusion with 14 units of blood, six doses of
200 mg BAL every 4 hours, and peritoneal dialysis. His
subsequent hospital course was complicated by high fever,
pneumonia, persistent oliguria with azotemia, hyperkalemia,
and mental aberration with hyperreflexia. Repeated trans-
fusions, peritoneal dialysis, and ion exchange resins were
employed, resulting in diuresis on June 20. Despite the
return to normal of liver and kidney functions, the patient
remains anemic.
The third case, a 44-year-old male, was believed to
be exposed to a more concentrated volume of gas than the
second case. He immediately became symptomatic with
weakness, headache, nausea, frequent and severe vomit-
ing, and right upper quadrant pain. He received sympto-
matic treatment that evening but continued to be ill and
on May 20 was hospitalized. On admission he was dis-
oriented and had a blood pressure of 100/60, pulse of
120/min, and respirations of 28/min. He had yellow sclera
and his skin was greyish brown. He was diffusely tender
throughout the abdomen, particularly in the right upper
quadrant. His admission hemoglobin was 5.9 gm percent
and his plasma free hemoglobin was 2,500 mgm/100 cc.
The patient's course was similar to that of the second
case with anuria, azotemia, hyperkalemia, and mental
agitation. Treatment with BAL, blood transfusions, peri-
toneal lI.Il'. -, and ion exchange resin, resulted in diuresis
by the third week of his hospital stay. After discharge from
the hospital the patient complained of weakness in his
legs. Liver function returned to normal, but his kidney
function remains impaired.


350


MASS IMMUNIZATION


T II


311 7 14
SEP


O I, ,-I I I I --










(Reported by Norman Plummer, M.D., Coordinator, Pesti-
cides Program, Division of Environmental Health, and
Arthur DePalma, M.D., Pesticides Project, New Jersey
State Department of Health; and the Pesticides Program,
Food and Drug Administration, Atlanta, Georgia.)
Editorial Note:
The legs of the aluminum ladder which was used to
enter the vat were actually in contact with the arsenic
compounds in the vat. The following chemical reactions
probably occurred. NaAsO2 + H20 NaOH + HAsO2
3NaOH + Al -, NaA103 + 3H
6H + HAsO3 2H20 + AsH3


Although arsine gas (AsH3) has a distinct garlic odor,
the three patients could not remember smelling this odor.
A possible explanation for this is that sodium arsenite
(NaAsO2), also present in the vat, has a strong odor and
may have masked the arsine gas odor.
Hematuria, cephalgia, jaundice, and abdominal pain,
commonly seen in arsine gas poisonings, are caused by
the acute hemolytic crisis resulting from arsine inhala-
tion. The persistence of nausea and vomiting in the pa-
tients was probably caused by the effects of arsine gas,
the systemic effects of arsenic, and the azotemia which
the patients developed.


MALARIA


Recently, two cases of malaria due to Plasmodium
falciparum were reported to NCDC.

Case No. 1: San Antonio, Texas
On June 27, 1968, while on duty in Vietnam, a 41-
year-old American serviceman developed chills, fever,
blurred vision, and generalized weakness. He returned to
his home in the United States on June 28, having received
emergency leave because of illness in his family. His
chills and fever persisted, and on July 1, he sought med-
ical attention at a nearby military hospital. On physical
examination, his temperature was'103F.; he was drowsy,
moderately confused, and appeared somewhat toxic; his
liver and spleen were enlarged and tender. Initial iab-
oratory studies showed a hematocrit of 43 percent, a BUN
of 32 mg percent, a CO2 of 19 meq per liter, and a bili-
rubin of 3.8 mg percent. A urinalysis was normal. Peri-
pheral blood smears showed that approximately 50 percent
of the red cells were parasitized with Plasmodium falci-
parum.
The patient was treated with intravenous quinine sul-
fate and oral chloroquine phosphate. Because of progressive
signs of cerebral involvement, he was also treated with
dexamethasone, 6 mg intramuscularly every 6 hours. On
July 2 his platelet count was 5,000; the prothrombin time,
partial thromboplastin time, and fibrinogen level were
normal, and there were no petechiae or signs of blood
loss. Because the thrombocytopenia suggested dissemi-
nated intravascular coagulation, he was treated with intra-
venous heparin, 50 mg every 4 hours. He also developed
hemoglobinemia and hemogloginuria, associated with a
decline in hematocrit to 30 percent. Although he was treated
by forcing fluids and with mannitol and diuretics, he
became oliguric and azotemic. On July 3 his platelet count
was still 5,000 and his hematocrit had decreased to 26
percent; he received four units of packed cells and 12
units of platelets. Also on July 3 he had a grand mal sei-
zure. necessitating treatment with diphenylhydantoin. On
July 4 he began to show signs of improvement; his tem-
perature returned to normal, and his mental status improved
slightly; his BUN stabilized at 150 mg percent, and his
urine output increased to 100-150 cc per hour. Peripheral
blood smears at this time showed a 10 to 15 percent par-


asitemia. By July 5 the platelet count had ri ien to 25,000
and the hematocrit was stable at 32 percent. On July 6,
however, he again became febrile and a chest film showed
bilateral pulmonary infiltrates. His sputum contained both
gram negative positive organisms as well as leukocytes.
Blood cultures were drawn, and he was started on ceph-
alosphorin and sodium colistimethate. However, he de-
veloped progressive respiratory insufficiency, and despite
a tracheostomy, he died on July 7, the seventh hospital
day. The blood cultures drawn on July 6 subsequently
grew Staphylococcus aureus and Pseudomonas aeruginosa.
On postmortem examination, the lungs showed an
acute necrotizing confluent bronchopneumonia with pul-
monary edema and congestion. The kidneys showed focal
acute inflammation and necrosis with occasional colonies
of gram positive cocci; hemoglobin casts were found in
the distal tubules. The brain showed multiple small foci of
acute inflammation, one of which contained gram positive
organisms; in addition, focal perivascular hemorrhage with
ischemic necrosis was noted. The heart showed focal
acute myocarditis. There was marked hyperplasia of both
myeloid and erythroid elements in the bone marrow. P.
falciparum parasites were not detected in any tissues, but
malaria pigment was found in virtually every organ. Post-
mortem cultures of the lungs grew S. aureus and Ps. aeru-
ginosa.
(Reported by Charles L. Hedberg, Colonel, MC, Acting
Chief, Department of Medicine, Brooke Army Medical Cen-
ter, Ft. Sam Houston, Texas; and M.S. Dickerson, M.D.,
Director, Communicable Disease Division, Texas State
Department of Health.)

Case No. 2: Minneapolis, Minnesota
On July 13, 1968, following an untreated illness of 8
days duration, a 25-year-old American woman in Minnea-
polis, Minnesota, died. On July 14, postmortem examination
revealed a normally proportioned Caucasian female with
slightly icteric skin. The liver and spleen were enlarged
and slate grey in color, and the brain appeared slightly
congested and edematous.On microscopic examination, the
capillaries of all organs were found to contain red cells
parasitized with Plasmodium falciparum. Hemoglobin casts
(Continued on page 356)


SEPTEMBER 21, 1968


Morbidity and Mortality Weekly Report







352 llorbidit) and Mortality Weekly Report


TABLE 111. CASES OF SPECIFIED NOTIFIABLE DISEASES: UNITED STATES

FOR WEEKS ENDED

SEPTEMBER 21, 1968 AND SEPTEMBER 23, 1967 (38th WEEK)

ENCEPHALITIS HEPATITIS
ASEPTIC Primary
AREA MENINBITS Ill ( OSIS DIPTHERIA including Post- MALARIA
AREA MENINGITIS including Infectious Serum Infectious MA
unsp. cases
1968 1967 1968 1968 1968 1967 1968 1968 1968 1967 1968


UNITED STATES... 295 128 5 5 61 39 8 116 1,051 708 72

NEW ENGLAND.......... 12 2 1 1 2 67 50
Maine ............. 2
New Hampshire...... -
Vermont............. 13
Massachusetts...... 1 1 23 22
Rhode Island ....... 3 1 11 6
Connecticut........ 9 1 2 20 20

MIDDLE ATLANTIC...... 67 9 6 9 49 168 112 9
New York City...... 24 3 2 37 67 43
New York, t.r-r,t. 6 4 6 36 17
New Jersey.t....... 26 3 1 5 47 24 5
Pennsylvania ...... 11 3 1 7 1 18 28 4

EAST NORTH CENTRAL... 59 7 27 15 3 140 80
Ohio................ 13 2 18 15 1 29 26
Indiana............ 9 5
Illinois............ 5 2 4 35 15
Michigan........... 40 3 5 2 67 33
Wisconsin.......... 1 1

WEST NORTH CENTRAL... 13 5 2 5 1 2 2 58 45 1
Minnesota.......... 9 5 1 1 2 2 16 11 -
lowa.*.............. 4 3 -- 11 8
Missouri........... 1 21 23 1
North Dakota....... -
South Dakota...... I
Nebraska ........... 4
Kansas............. 4 3

SOUTH ATLANTIC....... 18 42 2 2 1 97 81 17
Delaware........... 4 12 1
Maryland............ 1 32 1 12 17 1
Dist. of Columbia.. -
Virginia........... 6 1 11 7
West Virginia...... 5 1 1 8 9 -
North Carolina..... 4 7 2 1 19 7 7
South Carolina..... 2 3 5 -
Georgia............ 17 10 7
Florida............ 1 23 14 1

EAST SOUTH CENTRAL... 17 24 4 4 2 1 55 42 1
Kentucky........... 5 13 1 21 14 1
Tennessee .......... 6 2 2 1 1 18 7
Alabama............ 3 4 7 8
Mississippi........ 3 9 2 9 13

WEST SOUTH CENTRAL... 8 5 1 1 1 6 77 75
Arkansas........... -- 7 7 -
Louisiana.......... 4 2 1 3 16 15
Oklahoma........... 8 2
Texas.............. 3 3 1 1 3 46 51

MOUNTAIN ............. 4 1 1 59 30 7
Montana............ 2 8 4
Idaho............... I -- 3 1
Wyoming............ -
Colorado........... 1 1 33 8 5
New Mexico......... 4 4 1
Arizona........... 7 4 1
Utah............... 4 9
Nevada.............

PACIFIC.............. 97 33 1 14 10 2 56 330 193 37
Washington.......... 2 30 8 1
Oregon.1........... 14 1 16 6 1
California......... 79 32 1 13 10 2 56 280 177 4
Alaska............. 2 3 1 -
Hawaii............. I 1 31


Puert Rio ....... 21 49

*Delayed reports: Aseptic meningitis: Ore. 1
Encephalitis, primary: Pa. delete 1
Hepatitis infectious: Me. 3, P.R. 4
Malaria: N.J. 2, Iowa 1


~








Morbidity and Mortality Weekly Report 353


TABLE III. CASES OF SPECIFIED NOTIFIABLE DISEASES: UNITED STATES

FOR WEEKS ENDED

SEPTEMBER 21, 1968 AND SEPTEMBER 23, 1967 (38th WEEK) CONTINUED


MEASLES (Rubeola) MENINGOCOCCAL INFECTIONS, MUMPS POLIOMYELITIS RUBELLA
TOTAL
AREA Cumulative Cumulative Total Paralytic
Cum.
1968 1968 1967 1968 1968 1967 1968 1968 1968 1968 1968
UNITED STATES... 130 19,798 58,049 29 2,060 1,703 609 1 1 41 215

NEW ENGLAND............ 5 1,162 848 121 68 76 1 32
Maine.............. 37 239 6 3 3
New Hampshire...... 141 74 7 2 2 -
Vermont............ 2 34 1 1 12 1
Massachusetts...... 1 366 349 63 32 36 1 12
Rhode Island....... 5 62 9 4 10 5
Connecticut........ 4 611 90 35 26 16 11

MIDDLE ATLANTIC...... 23 4,114 2,276 8 371 280 14 25
New York City...... 20 2,130 464 2 75 49 16
New York, Up-State. 1,218 587 3 67 68 NN 8
New Jersey.......... 3 639 490 128 93 14 1
Pennsylvania....... 127 735 3 101 70 NN -

EAST NORTH CENTRAL... 31 3,811 5,501 6 251 231 186 1 71
Ohio................ 2 296 1,150 3 67 80 7 5
Indiana............. 4 676 597 35 23 18 11
Illinois........... 5 1,369 979 2 56 55 11 1 7
Michigan........... 6 272 937 1 73 56 30 28
Wisconsin.......... 14 1,198 1,838 20 17 120 20

WEST NORTH CENTRAL... 1 385 2,868 3 111 73 54 2 15
Minnesota.......... 16 134 26 18 1 -
Iowa................ 1 99 749 1 7 14 48 12
Missouri........... 81 333 2 37 15 1 2 3
North Dakota....... 134 870 3 1 -
South Dakota....... 4 54 5 6 NN -
Nebraska........... 41 635 6 13 4 -
Kansas............. 10 93 27 6

SOUTH ATLANTIC....... 8 1,515 6,898 2 412 329 35 1 1 3 13
Delaware............ 16 46 8 6 2
Maryland............ 4 100 161 34 43 7 2
Dist. of Columbia?. 6 22 14 10 1
Virginia........... 1 302 2,191 1 36 40 2 -
West Virginia...... 1 289 1,390 11 26 13 1 1 1 2
North Carolina..... 282 853 1 77 70 NN 1
South Carolina..... 12 511 56 29 -
Georgia ............ 4 36 85 49 -
Florida............. 2 504 1,688 91 56 13 7

EAST SOUTH CENTRAL... 4 496 5,213 2 187 129 40 2 7
Kentucky............ 100 1,337 1 85 35 7 1
Tennessee.......... 62 1,880 54 55 31 5
Alabama............ 94 1,329 26 26 1 1 2
Mississippi........ 4 240 667 1 22 13 1 -

WEST SOUTH CENTRAL... 27 4,806 17,439 3 308 222 45 21 16
Arkansas........... 2 1,404 20 31 1 -
Louisiana.......... 2 155 1 89 88 -
Oklahoma........... 6 123 3,351 50 16 1 2
Texas............... 21 4,679 12,529 2 149 87 43 19 16

MOUNTAIN.............. 14 994 4,672 1 32 32 51 9
Montana............ 1 59 287 1 5 1 9 2
Idaho.............. 21 385 11 3 4 1
Wyoming............. 51 181 1 -
Colorado*........... 501 1,569 10 13 11 2
New Mexico.......... 10 112 586 3 4 3
Arizona*........... 3 224 1,019 2 4 17 1
Utah................ 21 376 1 4 6 -
Nevada............. 5 269 3 3 -

PACIFIC.............. 17 2,515 12,334 4 267 339 108 11 27
Washington.......... 13 533 5,439 1 39 29 1 8
Oregon*............. 2 525 1,609 21 27 10 9
California.......... 2 1,420 4,975 3 193 269 89 10 5
Alaska.............. 2 140 2 10 5 5
Hawaii............. 35 171 12 4 4 -

Puerto Rico........... 5 412 2,126 1 20 12 23 3

*Delayed reports: Measles: Colo. delete 1, Ariz. delete 1, Ore. delete 3
Poliomyelitis, paralytic: D.C. 1
Rubella: Ore. 3







354 Morbidit- and Mortality Weekly Report


TABLE III. CASES OF SPECIFIED NOTIFIABLE DISEASES: UNITED STATES

FOR WEEKS ENDED

SEPTEMBER 21, 1968 AND SEPTEMBER 23, 1967 (38th WEEK) CONTINUED


STRlITOCOCCAL TYPHUS FEVER
SORt THROAT & TETANUS TULAREMIA TYPHOID TICK-BORNE RABIES IN
AREA SCARLET FEVER (Rky. Mt. Spotted) ANIMALS
Cum. Cum. Cu;. Cupi. Cum.
1_968 1968 1968 1968 1 196 1968 1968 68 1968 1968 1968 1968
UNITED STATES... 5,727 5 116 2 144 13 276 9 246 55 2,599

NEW ENGLAND........... 640 2 46 1 8 1 70
aine ............. 2 53
New Hampshire...... 26 1 2
Ver- t ............. 11 46 11
Massachusetts...... 97 1 1 4 1 3
Rhode Island....... 39
Conneticut........ 465 1 3 1

MIDDLE ATLANTIC...... 119 2 15 7 21 18 1 40
New Yurk City...... 4 2 8 10 -
New York, Up-Statc. 101 4 7 4 4 1 33
New Jersey......... NN 4 6
Pennsylvania....... 14 3 3 8 7

EAST NORTH CENTRAL... 415 10 8 1 36 8 7 249
Ohio............... 53 1 1 14 6 86
Indiana............ 92 2 1 3 3 80
Illinois.......... 57 5 5 18 2 1 35
Michigan .......... 100 2 1 13
Wiconsin......... 113 1 1 2 35

WEST NORTH CENTRAL... 240 1 9 13 1 31 9 9 633
Minne-ta .......... 28 2 5 195
1 1wa............... 94 3 1 1 2 105
Missouri........... 7 2 7 1 24 3 2 92
North Dakota....... 46 102
Sourb D.ikot ....... 14 3 1 4 79
Nebraska............ 45 1 2 3 1 25
Kansas............ 6 3 2 35

SOUTH ATLANTIC....... 620 25 1 10 54 7 134 6 296
Delaware ........... 2 -
Maryland.......... 118 3 9 1 15 5
Dist. of Columbia.. 28 2 1 1
Virginia........... 204 4 2 9 42 1 108
West Virginia...... 137 2 2 2 34
North Carolina... 11 2 2 2 3 37 11
South Carolina..... 31 3 3 1 9 -
Georgia............ 4 1 4 14 26 4 53
Florida............. 85 9 2 16 3 1 84

EAST SOUTH CENTRAL... 1,055 1 15 8 2 31 1 46 12 561
Kentucky........... 132 1 1 6 10 7 285
Tennessee.......... 778 1 6 5 16 1 31 5 253
Alabama............ 57 5 2 2 3 22
Mississippi....... 88 3 2 7 2 1

WEST SOUTH CENTRAL... 572 1 22 1 43 4 36 1 24 5 424
Arkansas........... 15 4 14 2 7 5 54
Louisiana.......... 3 1 9 6 1 6 2 40
Oklahoma............ 45 8 12 1 12 117
Texas.................. 509 9 1 15 1 11 7 3 213

MOUNTAIN ............. 1,161 7 1 15 5 3 74
Montana............ 19 -
Idaho............... 89 1 -
Wyoming............. 33 1 1 3
Colorado............ 749 3 2 4 3
New Mexico......... 135 1 8 1 31
Arizona ............ 90 3 2 36
Utah................ 46 3 -
Nevada............... 1 1

PACIFIC.............. 905 18 2 3 44 1 12 252
Washington......... 250 1 2 2
Oregon............. 42 1 1 5 6
California......... 386 16 1 3 37 1 12 244
Alaska ............ 81 -
Hawaii............ 146 -

Puerto Rico.......... 10 8 I 3 17

*Delayed reports: SST: Me. 6







Morbidity and Mortality Weekly Report






Week No. TABLE IV. DEATHS IN 122 UNITED STATES CITIES FOR WEEK ENDED SEPTEMBER 21, 1968
38


355


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

All Causes Pneumonia Under All Causes Pneumonia Under

Area All 65 years and y Area All 65 years Iand z year
Ages and over Influenza All Ages and over Influenza All
All Ages Causes All Ages Causes


NEW ENGLAND:
Boston, Mass.----------
Bridgeport, Conn.-----
Cambridge, Mass.-------
Fall River, Mass.----
Hartford, Conn.-------
Lowell, Mass.---------
Lynn, Mass.------------
New Bedford, Mass.---
New Haven, Conn.------
Providence, R. I.---
Somerville, Mass.----
Springfield, Mass.----
Waterbury, 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, Ill.----------
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.--------


695
197
39
24
20
65
28
19
22
62
66
12
48
25
68

3,109
48
51
150
43
39
37
50
70
1,552
37
406
175
59
-134
31
43
84
53
26
21

2,555
73
37
749
173
196
119
73
319
43
55
63
20
56
160
30
119
33
32
45
110
50

868
77
27
60
125
26
123
76
226
68
60


407
113
21
11
15
28
16
11
16
37
41
9
30
12
47

1,792
27
36
88
25
26
21
37
32
913
22
205
86
39
75
19
26
53
29
19
14

1,398
37
25
374
94
95
62
46
169
26
31
45
11
36
78
19
81
22
23
27
67
30

527
57
20
38
77
19
68
45
127
46
30


*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, Ala.-------
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, Colo.
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.----------


1,161
130
252
51
62
119
59
68
52
71
66
197
34

665
101
56
46
136
144
45
47
90

1,141
33
29
23
158
40
74
192
87
157
83
134
58
73

427
48
33
107
18
77
25
58
61

1,629
17
39
28
42
80
601
85
40
108
59
83
186
41
137
44
39


Total 12,250 6,950 393 646

Cumulative Totals
including reported corrections for previous weeks

All Causes, All Ages ------------------------ 484,836
All Causes, Age 65 and over------------------- 279,520
Pneumonia and Influenza, All Ages ----------- 19,635
All Causes, Under 1 Year of Age--------------- 22,877










0



--e
==O




iC4


MALARIA (Continuetd from page 351)

were found in the renal tubules, and vacuolar degeneration
wias noted in the proximal tubular cells. The bone marrow
showed marked erythroid hyperplasia. The heart and lungs
were normal.
The woman had no history of previous malaria attacks
and had not received blood transfusions. She and her hus-
band had lied in Sierra Leone from September 1967 until
June .5, 1968. and then had returned to the United -1 i -
arrim ing in San Francisco on July 5. During their return
journey they had visitedd several countries in southeast
Asia, including Thailand. While abroad, the woman had
not used malaria chemroprophlaxis. On July 5 she com-
plained of dizzy spells and by July 10 appeared febrile
and intermittently delirious. Because of her religious
beliefs, she had not sought medical attention.

(Reported by Calvin Bandt, M.D., Hennepin County Med-
ical Examiner's Office, Minneapolis, Minnesota; Fred G.
Gunlaugson, M.D., Director, Bureau of Disease Prevention
and Control, Minneapolis C ; Health Department; and D.S.
Fleming, M.D., Director, Division of Disease Prevention
and Control, Minnesota State Health Department.)


Editorial Note:
The time between the onset of the woman's illness
and her departure from Sierra Leone was 20 days. Since
the usual incubation period for mosquito-transmitted fal-
ciparum malaria is 12 days, she almost certainly acquired
her infection during her return journey, probably in south-
east Asia.













CURRENT TRENDS
MORBIDITY REPORTING


The "Manual of Procedures for National Morbidity
Reporting and Surveillance of Communicable Diseases"
has recently been revised and is available on request from:

National Communicable Disease Center
Atlanta, Georgia 30333

Attn: Acting Chief, Statistics Section
Epidemiology Pro r ni

The manual describes procedures by which data are col-
lected for the "Morbidity and Mortality Weekly Report"
and the "Annual Supplement" to the \IM I R. includes in-
structions for submitting surveillance forms on individual
cases of diseases under national surveillance, and ex-
hibits current surveillance forms used by various programs
of the NCDC.


356


THE MORBIDITY AND MORTALITY WEEKLY REPORT, WITH A CIRCULA-
TION OF 17,000, IS ...L --. THE NATIONAL COMMUNICABLE
DISEASE CENTER, A1 L -.r if -
DIRECTOR, NATIONAL COMMUNICABLE i *r TER
L I_ J. SENCER, M.D.
CHIEF, EPIDEMIOLOGY PROGRAM L LANGMUIR. M.D.
ACTING CHIEF. STATISTICS SECTION IDA L. SHERMAN, M.S.
EDITOR MICHAEL B GREGG, MD.

IN ADDITION TO THE ESTABLISHED PROCEDURES FOR REPORTING
MORBIDITY -u'i rM,.i TALITY, THE NATIONAL COMMUNICABLE DISEASE
CENTER t'-. '"CFL ACCOUNTSOF 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:
NATIONAL .:rJM 6.,N : & ELi DISEASE CENTER
ATLANTA, "t: 'J :,
ATTN: THE EDITOR
MORBIDITY AND MORTALITY WEEKLY REPORT

NOTE: THE DATA IN THIS REPORT ARE PROVISIONAL AND ARE
BASED ON WEEKLY TELEGRAMS TO I:-, BY THE NDi .DUAL
STATE HEALTI- I. -rI TM'. '.T ,. THE r:F.:*,r, WEEK :.G .:LjD.3
ON SATURDAYi : i ,iL C.' & i ON A NATIONAL BASIS ARE RELEASED
ON THE SUCCEEDING FRIDAY









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LI u? LjIl TOI'


SEPTEMBER 21, 1968


Morbidity and Mortality Weekly Report