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:
AA00010654:00164

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


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

HEALTH SERVICES AND MENTAL HEALTH A~D'MNI,'T


EPIDEMIOLOGIC NOTES AND REPORTS
INFLUENZA United States 1968

Since November 23, 196,. documented outbreaks of
A,'Hong Kong,68 influenza or A2 influenza have been
reported from Connecticut. Illinois, Maryland, Missouri,
and New York City.
In Connecticut, an outbreak of A2'Hong Kong,'68
influenza, documented by viral isolates, began at a uni-
versity on November 17. Although secondary isolated
cases of A2 Hong Kong, 6S influenza were reported in a
nearby college, there has been no increase in absenteeism
rates in public schools or industries.
In Illinois, in a Veterans Administration hospital.
influenza cases have occurred in several wards. A2 in-


Vol. 17, No. 48


WEEKLY

REPORT


Week Ending

j. ember 30, 1968




3IC HEAWF SERVICE


Ep Iderto olo o Ill ir \ ,) NTENTS
Influen a I .r 'ly. t ,\ '., ./
Clostrndium h i
(Californ:r. .. ... .
Me z. les Pht .ielphia . .......
Seombrotd Fi Poisoning Ne\ York (it .
Trivalent Botulinun Antioxin . .
Survtilla nce Sunmmary
IRotuii-m Unlitfd State, 1899! -1967 ...
International Not's
Smallpox Survtsellance in f.ri<.a ............


. 1 16

!1Ii


fluenza viruses were isolated from 10 cases. and to date.
three of these haxe been confirmed as \A Hlong Kong Uis-
like viruses Scattered isolated cases of A2 II.. Kong (i
influenza have also been confirmed in other area- of the
state.
('Continued o10 paye 4";')


TABLE I. CASES OF SPECIFIED NOTIFIABLE DISEASES: UNITED STATES
(Cumulative totals include revised and delayed reports through previous weeks)
48th WEEK ENDED) CUMULATIVE, FIRST 48 WEEKS
MEDIAN
DISEASE November 30, December 2, 1963- 1967 MEDIAN
1968 1967 1968 1967 1963 1917
Aseptic meningitis ...................... 64 56 47 4.124 2,841 2,003
Brucellosis ............................ 10 7 7 217 235 235
Diphtheria .............................. 3 24 2 218 187 187
Encephalitis, primary:
Arthropod-borne & unspecified ......... 22 17 1,324 1,487
Encephalitis, post-infectious ............. 1 9 439 711 -
Hepatitis, serum ........................ 97 85 75 4,286 2,127
Hepatitis. infectious ..................... 834 766 42,180 35,614
Malaria ................................. 54 46 1 2.200 1,936 97
Measles rubeolaa) ........................ 212 248 2,272 21.441 60.732 253.379
Meningococcal infections, total ........... 37 35 41 2,359 1.991 2,559
Civilian .............................. 37 35 2.166 1,868
Military ... ........... ............ 193 123
Mumps .................................. 1.918 -- 140,086 -
Poliomyelitis, total ..................... 2 4 55 43 96
Paralytic .................. ........... 3 55 32 89
Rubella (German measles) ............... 286 262 46.987 42.657 -
Streptococcal sore throat & scarlet fever.... 9.216 8,873 8,194 392.711 409.582 360.761
Tetanus ............................... 1 6 6 152 209 254
Tularemia ....................... ........ 1 1 3 166 157 230
Typhoid fever .......................... 8 4 8 373 382 422
Typhus, tick-borne (Rky. Mt. spotted fever) 3 1 1 276 297 245
Rabies in animals ............. ....... 1 48 61 69 3,117 3,931 3.931

TABLE II. NOTIFIABLE DISEASES OF LOW FREQUENCY
Cum. Cum.
Anthrax: .... ....................................... 3 Rabies in man: ..... ........ 1
Botulism: .......................................... 7 Rubella. Congenital Syndrome: ... ... 5
Leptospirosis: Pla.-4, Tenn.-l ....................... 53 Trichinosis: NYC-1 ............. ........ ...... 60
P league: ............ .... ............ ............ 3 T yphus, m utr ne: .. .... ....... .30
Psittacosis: ...................................... 40











In Maryland, an outbreak of a febrile respiratory ill-
ness with an attack rate of 20 percent occurred in a
school. Because of this outbreak, school was closed
early for Thanksgiving vacation on November 22. Three
of four throat cultures were positive for A2 influenza;
further typing is underway.
In Missouri, an outbreak of an influenza-like illness
began in a military installation on November 22. To date,


NOVEMBER 30, 1968


approximately 100 cases of influenza have occurred, and
direct fluorescent antibody studies on sera from three
patients have been positive for influenza A2. An A2/Hong
Kong/68-like virus was isolated from a patient in another
part of Missouri.
New York City reported scattered outbreaks of in-
fluenza-like illness, and an A2 influenza virus was iso-
lated. Further typing of this virus is in progress. Although


Figure 1
MORTALITY IN 122 UNITED STATES CITIES


ALL CAUSES
ALL AGES


ALL CAUSES
AGE 65 AND OVER


PNEUMONIA-INFLUENZA
ALL AGES


ALL CAUSES AGE UNDER I



41if^


Morbidity and Mortality Weekly Report


INFLUENZA (Continued from front page)


WEER NO 4 12 6 i2 24 28 2 36 4044 48 2 8 22 2024 32 6 4 44 4 52 4 8 12 2 24 2 32 36 40 4 4 2
WK ENOE.D 28 25 25 22 0 17 15 12 9 7 4 2 0 274 2 23 20 18 13 07 5 2 30 2 25 22 22 19 I7 14 12 9 6 4 1 29 27
MONTH JFM A M 1 0 J S O N a 0 F D J M M J S O N 0
96 1968 1969












industries in New York ('ity are reporting febrile respira-
tory illness in emploesee, absenteeinsm rates have not
increased.
During the past week, Montana, Texas. Ohio, and the
District of Columbia have reported isolated outbreaks of
influenza-like illness. These are currently being investi-
gated.
Since September 2, a total of 25 states and the Dis-
trict of Columbia and Puerto Rico have reported some form


of influenza acting ity (F'igure 3). Dociiienenld oiibrak- ol
A2. Long Kong '(i iInfluenza or ..\ inllurenia \,i, r. porlld
in Alaska, Puerto Rico, California. Colorado. I tli. '1enn-
sylvania, New Jersey, (onnecticut, Mary'land. North Caro-
lina, \ % -lI~.ir .,..,. Missouri. Illinois. and N\e York (it>
Outbreaks of an influenza-like illness were reported from
Montana, Arizona, Texas, Ohio, and the District of (olum-
bia. In addition, Texas, Ohio, and the District of Columbia
(Cont inued o n pdiyc c 4.")


Figure 2

PNEUMONIA-INFLUENZA DEATHS IN 122 UNITED STATES CITIES


ALL CITIES


EPIDEMIC THRESHOLD
EXPECTED NUMBER


WEEK NO 40 44 48 52 4 8 12 16 20 24 28 2 36 40 44 48 52 4 8 12 16 20 24 28 32 3640 44 48 52 4 8 12 16 20 24 28 32 36
WK ENOED 8 5 3 1 28 25 25 22 20 17 5 12 9 7 4 2 30 27 24 23 20 18 15 3 10 7 5 2 30 Z8 25 2222 9 17 14 i2 9 6
MONTH O N 0 J F M A M J J A S 0 N 0 J F M A M J J A S 0 N D F M A M J A S
196611967 196711968 196811969

150
WN. CENTRAL 20 E N CENTRAL 15 NEW ENGLAND
125 tO CITIES 21 CITIES 14 CITIES
200 100
00
150 75
75



2 5 50 25

SWEEK NO 40 44 48 52 4 8 12 16 20 24 28 32 40 44 48 52 4 8 12 6 20 24 28 2 40 44 48 52 4 8 12 16 20 24 28 32 36
S 1968 1 969 1968 C 1969 1968 1969

MOUNTAIN ES CENTRAL MIDDLE ATLANTIC
I MOUNTAIN I E.S CENTRAL i MIDDLE ATLANTIC


250

200




50
Ai_ 'D


,30 20 CITIES


WEEK NO 40 44 48 52 4 8 12 16 20 24 28 32 40 44 48 52 4 8 12 16 20 24 28 32 40 44 48 52 4 8 12 16 20 24 2 32 36
1968 1969 1968 11969 1968 11969
S01 2000
=0r~ I 00


SOUTH ATLANTIC
12 CITIES


50 50 -50



WEEK NO 40 44 48 52 4 8 12 16 20 24 28 32 40 4 48 52 4 8 12 20 24 28 32 40 44 48 52 4 M 12 6 20 24 28 32 6
19681969 1968| 1969 1968 1969


NOVEMBER 30, 1968


Morbidity and Mortality Weekly Report


8 CITIES


8 CITIES


75



25


PACIFIC
16 CITIES


W S CENTRAL
13 CITIES


-~ilrro






Morbidity and Mortality Weekly Report


NOVEMBER 30, 1968


INFLUENZA (Continued from page 443)


also reported laboratory documentation of isolated cases
of A2. Hong Kong 6,6 influenza. Although no major out-
breaks of influenza have occurred in Oregon, Hawaii,
Minnesota, lowa, \isconsin. Michigan, Georgia, Alabama,
and Virginia, these states have reported sporadic cases
of A2, Hong Kong,'68 influenza, documented by serologic
evidence or viral isolations.
As illustrated in Figure 1, since the beginning of the
current influenza season, there has been no sustained
excess mortality reported from 122 U.S. cities. In addi-
tion. the geographic divisions with the exception of the
Mountain Division have shown no significant increase in
pneumonia-influenza deaths (Figure 2).
Editor's Note:
As contributors and readers of the Morbidity and
Mortality Weekly Report know, individuals submitting data
used in each article are identified. However, because of
space limitations and the high priority of the influenza
summary, in this issue. individuals responsible for this
information have not been identified. The information was
reported by the following state and local health depart-
ments: Alabama. Alaska, Arizona. California. Cleveland,


Figure 3
INCIDENCE OF INFLUENZA AND INFLUENZA-LIKE
DISEASE BY STATE AS REPORTED TO NCDC
SEPTEMBER 2, 1968 DECEMBER 4, 1968


0 ......... .....
0 -


Colorado, Connecticut, District of Columbia, Georgia,
Hawaii, Illinois, Iowa, Maryland, Michigan, Minnesota,
Missouri, Montana, New Jersey, New York City, North
Carolina, Ohio, Oregon. Pennsylvania, Puerto Rico, Texas,
Utah, Virginia, Washington, and Wisconsin.


*


TRIVALENT BOTULINUS ANTITOXIN


Recently. a new trivalent antitoxin containing anti-
toxins A, B, and E (CONNAUGHT) was licensed for use
in the United States. This and other combinations of
type specific antisera are available from NCDC on re-
quest. Day and night telephone coverage has been es-
tablished at the following numbers:
Area Code 404 633-3311
404 634-2561
Patients with illness diagnosed clinically as botu-
lism should immediately receive the trivalent antitoxin
preparation (CONNAU'GHT) until laboratory tests deter-


mine which toxin is responsible. Monovalent and biva-
lent preparations should be reserved for use after spe-
cific toxins have been demonstrated in the laboratory.
Because types A and B as well as E toxins can con-
taminate marine products and because plant products
can be contaminated with type E, the toxin type can not
be determined by history alone; laboratory tests are
essential.
In addition to providing type specific antisera on
request, the NCDC also provides assistance in epidemic
investigation and laboratory diagnostic services.


SURVEILLANCE SUMMARY
BOTULISM United States 1899-1967


During the years 1S99-1967, 640 outbreaks of botu-
lhsm with 1,669 cases and 948 deathswere recorded in the
t'nited States: 163 of these outbreaks occurred between
195)0-1967. Of the 640 outbreaks. 21.6 percent were due to
('/lotrit iun, botuliut um, type A, 5.3 percent to type B, 2.7
percent to type E. and 0.3 percent to type F; in 70.1 per-
cent. the type was not determined. In recent years, cases
due to ty pe E ha\( increased in frequency, while cases
dute to ty pes and B have declined (Figure 4). From
1960 1967. type E accounted for most cases reported by
-pecific typr followed by ty pes B. and F. respectively.
The proportion of diagnosed cases in which the toxin type
was undetermined has remained high: 76 percent of cases


during the period 1950-1959 were due to unknown toxin
types compared with 53 percent during 1960-1967.
During the period 1899-1949. the death-to-case ratio
in botulism cases remained at levels above 60 percent.
Since about 1950, the death-to-case ratio has declined
(Figure 5). This decline is undoubtedly due to improve-
ments in intensive care of acute respiratory failure and
probably from the beneficial effects of C. botulinum anti-
toxins. The decline in death-to-case ratios has been
greater for types A and B botulism than for type E. During
the period 1960-1967. type E had the highest death-to-case
ratio that was more than twice as high as for type A and
four times as high as for type B. The specific age-to-case


444







NOVEMBER 30, 1968


30(

-J
I-
o 20C
H-


100


Morbidity and Mortality Weekly Report


Figure 4
CASES OF BOTULISM, BY TYPE IN 10-YEAR PERIODS
1899-1967


1890 1900 1910 1920


Figure 5 Figure 6
CASES AND DEATHS DUE TO BOTULISM AGE SPECIFIC BOTULISM CASE* FATALITY RATES
BY 10-YEAR PERIODS 100- 1962-1967
1899-1967

.....FS u 80"
-a-- o (X) = TOTAL NUMBER IN AGE GROUP
|0 OET WITH BOTULISM


S 899 1900- 909 9I C .919 1920 1929 1930 939 1940- 9 9 191 959 6 96

fatality ratio was significantly higher for adults than for
children from 1962-1967, during Nhich time data x\ere
collected on 9h cases reported by age (Figure 6). This is
probably a dose-related phenomenon rather than an inher-
ent resistance of the young. since children are often more
fastidious in their eating habits than adults.
Although outbreaks were reported from 44 states, flNe
western states (California. V\ashington. Colorado. Oregon.
and New Mexico) accounted for more than one-half of all
reported outbreaks (Figure 7). There wa- also a correla-
tion between the toxin type of hotulism reported and the
geographic area reporting it. Of the 18:9 t pe A outbreak-
recorded from 1S99-1967. 1.2i (91 percent) were in states
west of the Mississippi Ri\er. California. Vashington,
New\ Mexico. and Oregon accounted for 43. 12. h. and 7
percent, respectivel y of type A outbreaks. Twenty- ix
states, most of them in the East. haxe nexer reported t peo
A outbreaks. Of the 34 type B outbreaks. -2-3 xere reported
from eastern states: Nexi York ranked first in Itpe B out-
breaks by reporting 10 of these. Of the type E outbreaks.


I-- (15)
40-


a 20 -
a (24
(10)
0-9 10-19 20-29 30-39 40-49 50-59 60
*98 TOTAL CASES AGE


most occurred in Alaska or the Great Lakes area. How-
ever. California did report one type E outbreak and New
York one type A outbreak. Alaska has nexer reported
types A or B. These regional distributions are in keeping
with the known distribution of spores revealed in sur\ e-
of soil samples conducted in 192-'.1 1966.' and 1966.''
Since 1910. the source of most outbreaks of botulism
\as home-canned or pre-er ed foods. A smaller number
hale been ascribed to commercially preso-r\d foods. The
sources of many outbreaks haie remained unknown. I until
a fewo years ago. outbreaks of botulism for which toxin
types were determined were most frequently. caused hb
type A or B toxin and were usually associated with a inrc--
tion of home-canneid \eetables. fruit-, or meat products.
Botulism due to t ype E toxin \\as not recognized as a
major problem until 1963 when 3 ( case- of this ty pe w ere
reported in 2 outbreaks traced to comnuercially preserved
fi.h products. Of the 17 outbreaks of Itpe E. 16F were
traced to fish or fish products and one to a nonnariner







Morbidity and Mortality Weekly Report


NOVEMBER 30, 1968


BOTULISM (Continued from page 445)


28
ic


218 44

4 8
28


5 3 -



' 2 o 9 3

S


7 2
'__ a 3 7 2 /
4

r-zc" J
*y


TOTAL 640 OUTBREAKS (O1E OUTBREAK $S COUNTED
AS OCCURMNG IN THREE STATES


product, mushrooms. In addition to these 16 outbreaks of
type E associated with fish. fi\e outbreaks traced to fish
or fish products were due to type A. and 2 to type B. One


Figure 7
OUTBREAKS* OF BOTULISM
1899-1967

- ..2. ,


EPIDEMIOLOGIC NOTES AND REPORTS
CLOSTRIDIUM BOTULINUM, TYPE A -
Los Angeles, California


Several da:. after eating a sandwich of chopped
chicken li\er on October 17. 196b. a 3-y.ear-old man in
Los Angeles. (California. developed diplopia. dysphagia.
difficultI in opening his e-es. and weakness of the limbs.
On October 212. he was ho-pitalized. Re-piratory arrest
followed, and a tracheo-lomry w as performed and he was
placed on a respirator. A lumbar puncture revealed normal
cerehrospinal fluid. iihen the history of inestin a chick-
en liter -andwich that had a bad taste was elicited, a
diaignosis of boitulism as made. At the present time,
although the patient has shown slight improvement. he
-till requires constant a-sistance for respiration.
Laloratory -ltudies of the leftover chicken li-er
rexialed ('Costid m bo htinim. type A toxin. No toxin
xa.- detected in the patient's serum obtained on October 23.
The commercial -ource for the chopped chicken lixer
wa- in\estirated. IT \\as found that the chopped chicken
lier- are prepared from frozen stock. They are boiled for
20 minutes and then blended with onions, chicken skin.
ets. and seasoning. The resultant mixture is packed in a
alas- jar and immersed for 1 hour in a 1 0lF. water bath
for pasteurization During this process the internal tem-
perature of the jars does not exceed 15 5F. After cooling


at room temperature, the jars are refrigerated at 42 F..
awaiting distribution. The canned chicken liter has been
recalled from distribution.

iReported by James ( V1.D.. Head. General Epidemi-
oogey Section, Bureau of Communicable Diseases. Cali-
foria State Department of Public Health: Iciiro Kamei,
V.)., Chief. Division of Acute Disease Control. and C.A.
Lao rence, Ph.D.. Director. Bureau of Laboratories. Los
Angeles County Department of Public Health: and an EIS
Officer.)

Editorial Note:
It is not unusual that type A toxin was not found in
the patient's serum since 9 days had elapsed after inges-
tion of the contaminated vehiclee and since, of all the
botulinum toxins. type A appears to ha\e the greatest
tissue affinity. Prodromal gastrointestinal symptoms \were
notably absent in this case which is consistent \with the
behavior of type A toxin. Gastrointestinal disturbances
are seen more commonly with types B and E. This is the
second case of C. botulinum type A involving canned
chicken liver reported to the NCDC during the past 5
years.


MEASLES Philadelphia


Between Septemner I and Noxember 16. 196h. 44
ca- of rnea-Iles were reported from Philadelphia: 24 of
which were a-sociated with an elementary school out-


break. This outbreak w\as discovered following the in\es-
tigation of a case reported on No\ember 6 in a 6-year-old
Negro boy. School attendance records for grades 1-4 in


446


outbreak of type F was reported; it was traced to home-
prepared venison jerky (MMWR, Vol. 15. Nos. 41 and 42).
(Reported by Enteric Diseases Unit, Bacterial Diseases
Section. Epidemiology Program, and the Anaerobic Bac-
teriology Laboratory, Laboratory Program, \CDC.)

A copy of the original report from which these data were
derived is available on request from:
National Communicable Disease Center
Atlanta, Georgia 30333
Attn: Chief, Enteric Diseases Unit
Bacterial Diseases Section
Epidemiology Program

References:
1Meer, K. F., and Dubovsky, B. J.: The distribution of the
spores of B. botulinus in the United States. IV. J Infect Dis,
31:559-594, 1922.
2Bott. T. L. Deffner JS.. McCoy. E.. and Foster, E. M.:
Clostridium botulinum typi E in fish from the Great Lakes.
J Bact. 91:919-924. 1966.
3Ekiund. M. W.. and Poysky. F.: Incidence of Clostrididum
bot ulnurt type E from the Pacific Coast of the United States.
Proceedings of the Fifth International Symposium on Food
Microb iorogy Moscor, July 1966. p. 49. Edited by Ingran, M.
ani R -rts. T. A., Chapman and Haii, Limited. London.


----











this boy's school aore reviewooed and \isits to homes of
children who had 4 or more conseculi\e days of absentee-
ism %ere conducted. A total of 15 measles cases since
the opening of school on September 6 were uncovered
(Table 1). An additional nine measles cases were dis
co ered in preschool siblings of school age cases.
Because a school child could not be identified as the
index case. further epidemiologic investigation of pre-

Table 1
Measles Attack Rates by Grade in a Philadelphia
Elementary School, September 6 November 16, 1968

Attack Kate
Grade Enrollment Measles Cases- t
(Percent)

1 52 S 15
2 35 5 14
3 29 1 3
4 44 1 2

Total 160 15 11


school children wka undertaken. \flitr po-ilb e\plo-ure
to measles in a hospital outpaient ci nic.I a 1 e ar ld
boy developed me asle on Siptember 9 111- 4I ear old
is ter. following 4 d(la of cough. coryza, and fever, d
%eloped a raih on September 2- which lareid unl l Sepi
member 30. On Seprtmbei r 29!. thl- girl attend d ;i church
service with another of her brother- and sa witi h iiimembr-
of his first grade class of the intolled -hool. althoughh
these class members \were exposed late in rhi. Lrl'- ill
neo-, -,he may hate been the source of mea-le- introduc-
lion for the school.
Cases of neasles hate boon relporteld amonr -rudlei-
in at least four other schools in thi- area of Philadelph-ia.
These cases are present l, heing inae-tigatnd.

(Reported by Alfred S. Bogurki, l.I)., .1P.II.. dlrrttr.
Division of Epidemiology. Leirii 1). Polk. i.).. .PI'.1 ..
Deputy Healt/h ('om0misio0ier for ('ommuniMty lHealt/ Sirr-
iceC. aind oid Faris, 11.I.. I.P.l., DiVision of Epidemi-
ology, City of Philadelphia, Department of Public IHetal/t
and an EIS Officer.)


INTERNATIONAL NOTES
SMALLPOX SURVEILLANCE IN AFRICA'


Through October 31 in 1968, 54,135 cases of small-
pox were reported from the world's endemic area- to the
World Health Organization, approximately one-half the
number of cases recorded during the same period in 1967.
Of these. 17.1 percent were reported from Africa.
At present in Africa, smallpox is not a widespread
disease: rather, it is concentrated in certain geographic
foci. Fixe endemic areas are readily definable: in West
and Central Africa 1) Sierra Leone-Guinea and 2) Nige-
ria-Niger-Dahoimey-Togo: and in East and Southern Africa
- 3) Ethiopia, 4) Democratic Republic of the Congo. and
5) Mozambique. Adjacent countries, often periodically free
of smallpox, are repeat-edll reinfected from these, endemic
areas.
In \est and Central Africa. an active eradication pro-
gram has been underway for the past 2 years. Since Janu-
ary 1. 1967, ox(r 60.000.000 vaccinationss have been given
in this area which has a population of 116,000.000. In the
endemic areas, prompt case In\estigation and epidemic
control measures are being performed whenever a case is
reported. Results of these efforts are -hown in the signif-
icant reduction of smallpo\ cases over the past year
(Figure b). To date in 196h. 4,556 cases of smallpox haxe
been reported compared with 9.724 cases in 1967. a reduc-
tion of 53.1 percent. Every country except Togo has re-
corded foeer cases this year than last.
For 1968, lho\wexr. in Eastern and Southern Africa,
reported smallpox cases are already 50 percent greater
than in 1967. If present trends continue, about 7.000 cases
x\ill be reported for the year. This approximates the num-


Figure 8
SMALLPOX CASES BY MONTH
* WEST AND CENTRAL AFRICA 1966-1968


iOOk


5 0---


her of cases observed during most years of the past dec-
ade but is considerably more than the 4,450 cases report-
ed in 1967, a record lox year. Information regarding the
progress of smallpox eradication efforts in Eastern and
Southern Africa is incomplete since most of these coun-
tries are just beginning or have only recently begun \ac-
cination programs.
(Reported by the Smallpox Eradication Proyram. \'CD.)

HPference:
lWorld Health Organization reekly Epidemiologai Rte cr.,
- t5 :- 75-57 9.


NOVEMBER 30, 1968


Morbidity and Mortality Weekly Report


aoo


1,o00o


1o1


I-i







448 Morbidity and Mortality Weekly Report


TABLE III. CASES OF SPECIFIED NOTIFIABLE DISEASES: UNITED STATES

FOR WEEKS ENDED

NOVEMBER 30, 1968 AND DECEMBER 2, 1968 (48th WEEK)


ENCEPHALITIS HEPATITIS
ASEPTIC Primary
AREA MENINGITIS BRI I OsIS DFPIITIIERIk including Post- MALARIA
AREA MENINGITIS including Infectious Serum Infectious MALARIA
unsp. cases
S 1968 1967 1968 1968 1968 1967 1968 1968 1968 1967 1968
UNITED STATES... 64 56 10 3 22 17 1 97 834 766 54

NEW ENGLAND.......... 1 2 5 1 15 57 38 1
Maine ............1 1 2 -
New Hampshire.* .... 1
Vermont........ .. -
Massachusetts...... 1 1 2 4 34 12 1
Rhode Island ....... 1 8 2 -
Connecticut........ 2 1 11 13 22 -

MIDDLE ATLANTIC...... 13 12 1 1 42 153 102 4
New York City...... 4 3 1 26 64 37 -
New York, up-State. 2 1 7 23 14 1
New Jersey......... 5 5 5 25 22 -
Pennsylvania....... 4 2 4 41 29 3

EAST NORTH CENTRAL... 7 5 7 2 2 142 128 2
Ohio............... 2 4 1 61 25 -
Indiana............ 8 12 -
Illinois........... 2 1 1 18 37 2
Michigan........... 5 1 2 1 1 46 39 -
Wisconsin.......... 1 1 9 15 -

WEST NORTH CENTRAL... 1 1 1 1 25 53 2
Minnesota.......... 1 15 17 -
Iowa............... 1 1 4 16 -
Missouri............ 1 12 2
North Dakota....... 1 2 -
South Dakota....... -
Nebraska............ 3 -
Kansas............. 2 6 -

SOUTH ATLANTIC....... 8 12 5 2 88 94 24
Delaware ........... 1 5 -
Maryland........... 1 2 15 13
Dist. of Columbia.* 1 4 -
Virginia............... 1 1 1 14 10 -
West Virginia...... 2 7 13 -
North Carolina..... 1 2 7 3 11
South Carolina.... 7 1 -
Georgia............. 17 34 10
Florida........... 6 6 3 20 11 3

EAST SOUTH CENTRAL... 8 2 2 1 51 57 2
Kentucky........... 4 29 19 2
Tennessee.......... 4 2 1 12 20 -
Alabama........... 2 6 2 -
Mississippi......... 4 16 -

WEST SOUTH CENTRAL... 4 3 1 2 3 1 32 76 4
Arkansas........... 1 9 -
Louisiana. t........ 1 1 1 7 18 3
Oklahoma........... 1 2 1 6 1
Texas.............. 4 2 1 24 43

MOUNTAIN............ 1 1 1 1 53 24 2
Montana............ 1 7
Idaho.............. 1
Wyoming ........... 1 2
Colorado............. 1 1 25 2
New Mexico.......... 14 2
Arizona............ 3 -
Utah............... 1 8 11 -
Nevada ............ 2 -

PACIFIC............. 21 23 4 6 5 33 233 194 13
Washington.......... 1 1 17 20
Oregon ......- 20 12 1
California......... 20 21 4 5 5 33 192 161 4
Alaska............. -
Hawaii............ 2 4 1 8

Puerto Rico. ......... 46 22

*Delayed reports: Aseptic meningitis: D.C. 7, La. delete 2
Encephalitis, primary: N.H. 1, D.C. 5, La. 1
Hepatitis, infectious: Me. 3








Morbidity and Mortality Weekly Report 449


TABLE Il. CASES OF SPECIFIED NOTIFIABLE DISEASES: UNITED STATES

FOR WEEKS ENDED

NOVEMBER 30, 1968 AND DECEMBER 2, 1967 (48th WEEK) CONTINUED


MEASLES (Rubeola) MENINGOCOCCAL INFECTIONS, MUMPS POLIOMYELITIS RUBELLA
TOTAL
AREA Total Paralytic
AREA Cumulative Cumulative Total Paralytic

I' in r .. I I 1 .1 "E .


NEW ENGLAND........... 26 1,245 923 2 137 80 339 21
Maine.............. 38 262 6 3 38 2
New Hampshire* .. 141 77 8 3 1
Vermont........... 1 3 34 1 1 34
Massachusetts.*.... 3 379 391 1 72 36 137 1 8
Rhode Island....... 16 39 62 9 6 64 2
Connecticut........ 6 645 97 1 41 31 65 9

MIDDLE ATLANTIC...... 60 4,533 2,483 3 423 329 59 1 18
New York City...... 27 2,342 508 86 60 32 8
New York, Up-State. 13 1,337 630 72 81 NN 1 4
New Jersey......... 16 689 575 146 106 27 6
Pennsylvania...... 4 165 770 3 119 82 NN -

EAST NORTH CENTRAL... 35 4,082 6,028 7 294 277 470 9 73
Ohio............... 5 320 1,177 1 82 92 51 2 8
Indiana............. 5 709 647 1 40 31 44 2 17
Illinois........... 6 1,410 1,162 1 64 61 16 2 6
Michigan........... 4 317 1,006 4 88 72 77 3 29
Wisconsin.......... 15 1,326 2,036 20 21 282 13

WEST NORTH CENTRAL... 2 409 2,944 126 93 381 3 18
Minnesota.......... 18 135 29 21 7 3
Iowa............... 108 775 10 19 172 1 13
Missouri ........... 81 340 41 18 130 2
North Dakota....... 138 886 4 3 58 -
South Dakota....... 4 58 5 7 NN
Nebraska............ 2 50 656 9 15 7 2
Kansas............. 10 94 28 10 7 -

SOUTH ATLANTIC....... 37 1,645 7,214 11 474 388 114 3 25
Delaware............ 1 18 50 3 12 8 2 3
Maryland........... 103 174 40 55 16 5
Dist. of Columbia.. 6 24 17 15 1 -- 1
Virginia........... 319 2,254 44 43 7 3
West Virginia...... 312 1,457 13 37 54 1 9
North Carolina..... 25 317 926 3 94 80 NN I
South Carolina..... 3 22 512 61 32 13 -
Georgia.............. 4 42 3 93 57 -
Florida............. 8 544 1,775 2 100 61 21 4

EAST SOUTH CENTRAL... 503 5,460 1 209 156 48 1 7
Kentucky............. 103 1,428 94 45 27 I -
Tennessee.......... 64 2,002 1 64 68 21 5
Alabama............ 95 1,354 27 29 -
Mississippi......... 241 676 24 14 -

WEST SOUTH CENTRAL... 25 5,155 18,005 5 336 252 52 24 14
Arkansas........... 2 1,404 20 40 -
Louisiana........... 25 156 94 98 -
Oklahoma ............ 128 3,359 2 55 18 2 2 2
Texas.............. 25 5,000 13,086 3 167 96 50 21 12

MOUNTAIN............. 2 1,058 4,848 2 43 40 70 1 29
Montana............ 58 328 6 5 18 6
Idaho............... 21 395 11 3 1
Wyoming............ 54 202 3 1
Colorado............ 1 521 1,617 1 13 13 29 11
New Mexico......... 143 606 1 5 3
Arizona............ 233 1,048 1 5 6 17 1 3
Utah............... 21 383 1 4 2 9
Nevada.............. 1 7 269 3 3

PACIFIC .............. 25 2,811 12,827 6 317 376 385 12 81
Washington.......... 5 588 5,623 3 50 37 168 1 41
Oregon............ 5 577 1,698 25 30 3 7
California........ 15 1,600 5,183 3 225 294 197 1 31
Alaska............. 11 141 3 i 11 -
Hawaii............. 35 182 14 4 6 2

Puerto Rico.......... 3 488 2,236 -20 15 30

*DlAyved reports: MInlos: Ma dlt .l
M'ningococtal inf-ctions: N.H. 1
Mumps: C<,l1t.252







450 Morbidity and Mortality Weekly Report


TABLE III. CASES OF SPECIFIED NOTIFIABLE DISEi .-S: UNITED STATES

FOR WEEKS ENDED

NOVEMBER 30, 1968 AND DECEMBER 2, 1967 (48th WEEK) CONTINUED


STREPTOCOCCAL TYPHUS FEVER
SORE THROAT & TETANUS TULAREMIA TYPHOID TICK-BORNE RABIES IN
AREA SCARLET FEVER (Rky. Mt. Spotted) ANIMALS
Cum. Cum. Cum. Cum. Cum.
1968 1968 1968 1968 1968 1968 1968 1968 1968 1968 1968
UNITED STATES... 9,216 1 152 1 166 8 373 3 276 48 3,117

NEW ENGLAND........... 1,398 4 47 13 1 74
Maine.*............ 16 2 55
New Hampshire...... 26 1 1 2
Vermont............ 20 47 11
Massachusetts...... 239 1 7 1 5
Rhode Island....... 148 -
Connecticut........ 949 2 3 1

MIDDLE ATLANTIC...... 228 19 10 1 35 22 1 51
New York City...... 6 11 1 18
New York, Up-State. 192 4 7 8 5 41
New Jersey........ NN 1 4 7
Pennsylvania....... 30 3 3 5 10 1 10

EAST NORTH CENTRAL... 574 16 11 47 9 1 279
Ohio............... 134 2 1 19 7 92
Indiana............ 90 2 1 7 90
Illinois........... 63 8 8 19 2 38
Michigan........... 150 3 1 1 17
Wisconsin.......... 137 1 2 42

WEST NORTH CENTRAL... 335 15 16 1 39 9 12 772
Minnesota.......... 44 2 2 4 246
Iowa ............... 94 4 2 1 119
Missouri........... 1 5 7 26 3 1 111
North Dakota....... 61 6 126
South Dakota....... 24 1 3 2 4 97
Nebraska........... 58 3 1 1 4 1 27
Kansas.............. 53 5 3 1 46

SOUTH ATLANTIC....... 877 32 12 1 62 1 142 9 382
Delaware........... 5 1
Maryland............. 148 3 9 18 6
Dist. of Columbia.. 2 1 2
Virginia........... 231 4 3 10 44 2 131
West Virginia...... 183 2 2 49
North Carolina..... 14 2 3 4 39 12
South Carolina..... 72 4 3 9
Georgia............ 5 3 4 15 1 27 4 77
Florida............. 219 12 2 1 20 3 3 104

EAST SOUTH CENTRAL... 959 15 9 2 46 2 57 9 665
Kentucky........... 122 I 2 10 10 6 351
Tennessee.......... 674 6 5 2 21 1 39 3 282
Alabama............ 66 5 2 1 5 25
Mississippi........ 97 3 2 13 3 7

WEST SOUTH CENTRAL... 518 1 30 1 48 51 30 12 482
Arkansas........... 16 5 15 18 6 1 62
Louisiana.......... 14 10 7 6 1 1 46
Oklahoma............ 50 9 15 14 1 120
Texas.............. 438 1 15 1 17 12 9 9 254

MOUNTAIN............. 2,264 1 9 2 21 5 2 89
Montana ............ 50 -
Idaho.............. 92 -
Wyoming.. ......... 192 1 1 3
Colorado............ 1,625 3 2 5 4 4
New Mexico.......... 119 8 1 39
Arizona ........... 78 1 6 1 39
Utah............... 105 5 1
Nevada ............. 3 1 3

PACIFIC .............. 2,063 20 4 1 59 1 2 323
Washington.......... 1,240 1 2 2
Oregon............. 75 1 5 6
California ......... 592 18 3 1 52 1 2 315
Alaska............. 5 -
Hawaii............. 151 -

Puerto Rico.......... 6 12 1 5 20

*Delayed reports: SST: Me. 15, Wyo. 8
Rabies in animals: Ariz. 1







Morbidity and Mortality Weekil Report 451






Week No. TABLE IV. DEATHS IN 122 UNITED STATES CITIES FOR WEEK ENDED NOVEMBER 30, 1968

48 (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 1 year Area All 65 years Ianflu a yAl
Ages and over InfluenzAges 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.--------


719
224
40
32
28
68
35
22
23
28
63
13
47
41
55

2,954
45
24
129
44
24
41
72
59
1,556
27
401
135
57
96
32
36
78
35
33
30

2,409
64
38
748
129
231
130
67
323
38
52
29
42
37
120
12
88
42
32
33
97
57

802
49
33
29
131
18
111
64
241
62
64


424
118
22
18
20
50
19
14
16
19
39
9
27
21
32

1,781
28
18
85
19
16
25
46
29
903
18
246
80
44
63
26
22
50
20
26
17

1,355
41
20
387
73
122
75
35
182
30
28
18
26
21
71
6
58
25
15
21
62
39

472
31
17
17
74
15
65
45
136
42
30


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.----------


1,064
121
212
39
77
79
54
79
33
57
54
211
48

503
74
20
28
105
107
52
27
90

875
31
28
16
136
20
61
136
40
162
53
82
54
56

487
31
50
137
23
124
15
51
56

1,396
17
45
36
46
79
374
47
43
147
50
94
136
47
151
52
32


Total 11,209 6,445 446 517


Cumulative Totals
including reported corrections for


previous weeks


All Causes, All Ages ------------------------- 607,798
All Causes, Age 65 and over------------------- 349,212
Pneumonia and Influenza, All Ages------------ 23,964
All Causes, Under 1 Year of Age--------------- 28,765








Morbidity and Mortality Weekly Report


EPIDEMIOLOGIC NOTES AND REPORTS

SCOMBROID FISH POISONING New York City

Recently, two outbreaks of scombroid fish poisoning
occurred in New York City. The first outbreak occurred on
July 10. 196s, along members of two families. Of a total
of nine persons, eight became ill with symptoms charac-
terized by' generalized flushing, urticaria, conjunc'tiitis,
nausea, headache, abdominal cramps, and diarrhea. The
incubation period was less than 30 minutes and duration
of illness from 1 to 4 hours. The patients improved with
antihistamine treatment.
Food histories implicated fresh tuna fish as the ve-
hicle of infection. The tuna fish was purchased from a
fish market, and then washed, salted, and refrigerated.
Later the same day, It was fried and eaten. Routine labora-
tory cultures of left-oxer fish including tests for Proteus
species were negative. Hosweer. the fish was noted to be
honeycombed a sign of advanced decomposition and
had a histamine level of 425.5 nig per 100 gim.*
The second outbreak occurred on October 4, 1968,
among members of two families. Of six persons eating
the meal, five subsequently became ill with symptoms
characterized by rash. palpitations, nausea, abdominal
cramps, and diarrhea. The incubation period was 20-30
minutes and duration of illness from 2 to 6 hours. The
patients were treated with antiltii tamines.
Food histories again implicated fresh tuna fish as the
vehicle. The tuna fish was caught off-shore by a private
fisherman 4 days prior to the dinner. The fish was re-
frigerated intact for the first 24 hours. In attempting to
clean the fish the following (day, 111iir ., was encountered
in removing the head. To facilitate dressing, the fish was
placed in a hath tub of hot water for 24 hours. The fish
was then cut, cooked, and eaten. No fish remained for
laboratory examination.
(Reported by 'arol Schachner. M.D., Epidemiologist, and
Tibor Fodor, lV.)., ohef, rirsion of Epidemiology and
Diagnosis. New York City Department of Health.)
Editorial Note:
Scomhroid fish poisoning occurs in scombroid fish
such as tuna. mackerel, bonito, albicore, and skipjack.
This form of ichthyosarcotoxism. which is associated with
inadequate refrigeration or decomposition of fish, is thought
to be due to the release of histamine or a histamine-like
substance called saurine. These chemical products are
released when contaminating or naturally present bacteria
such as Proteus species act on the histadine substrate
in the fish skin. 1.2

Referencers:
Kawabata. T., l-ihizaka. K., and Miura, T.: Studies on altergy-
lhke foodd poisoninS associated with putrefaction of marine
produIct. Ja Ji M SI, and Biol S,(6):1487-528, 1955.
-Hlal tead,.t B. .: 'PIisonous fish-like vertebrates. In Conference
on Shellfi. h Tom oloh, u\ 1957. U.S. Dt-iprtment of Health,
Education, and \`elf,re, Puhlie Health Serviwe, ,ashington,
1). C., 1957. pp. 37-76.

*A level of 50 imlrc-rrams per 100 ml is evidence of advanced
decomposition for tuna fish. In freshly caught tuna fish, the
amount of hsi.lamine i" virutally zero.


<'
NOVEMBER 30, 1968

-. o
0~(


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,
CHIEF. STATISTICS SECTION IDA L. SHERMAN, M.S.
EDITOR MICHAEL B. GREGG, M.D.

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
NATIONAL COMMUNICABLE DISEASE CENTER
ATLANTA, GEORGIA 30333
ATTN: THE EDITOR
MORBIDITY AND MORTALITY WEEKLY REPORT

NOTE- THE DATE IN THIS REPORT ARE PROVISIONAL AND ARE
BASED ON WEEKLY TELEGRAMS TO THE NCDC BY THE INDIVIDUAL
STATE HEALTH DEPARTMENTS. THE REPORTING WEEK CONCLUDES
AT CLOSE OF BUSINESS ON FRIDAY. COMPILED DATA ON A NATIONAL
BASIS ARE RELEASED ON THE SUCCEEDING FRIDAY.


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