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:
AA00010654:00172

Related Items

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


This item is only available as the following downloads:


Full Text

F9L
I


NATIONAL COMMUNICABLE DISEASE CENTER


caCd


Vol. 18, No. 22

WE[ F .Y



For

Week Ending


U.S. DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE / PUBLIC HEALTH SERVICE HEALTH
DATE OF RELEASE: JUNE 6, 1969 ATLANTA, GEORGIA


INTERNATIONAL NOTES
OUTBREAK OF PARATYPHOID FEVER Linz, Austria

An epidemic of paratyphoid fever due to Salmonella
schottmilleri has been reported from Austria. As of June
3, a total of 907 infections, in both symptomatic and
asymptomatic persons, were reported, of which 293 have
been confirmed. ',.n.pion.- were reported as mild and there
were no deaths. The earliest cases were recognized be-
tween May8 and 10 with rapid increases of reported cases
thereafter. The peak of the outbreak was reached on May
17 when 147 cases were reported. A 30 to 35 percent
secondary attack rate was recorded among close house-
hold contacts, especially children, of the cases.
The focus of the epidemic was Linz (a city approxi-
mately 95 miles west of Vienna), although cases were
widely scattered throughout upper Austria. The outbreak
began immediately after an annual fair in Linz from April


International Notes
Outbreak of Paratyphoid e- Linz, Austria 185
Epidemiologic Notes and
Case of Group A '.1 ,..a -
Fort Benni .L .. .r,. \ : 186
Outbreak of .I. I.t, .,11,n. .
Infections w artue, \ t., ,r'' ... 186
Outbreak of Shigellosis Fr.- ll. .. 187
Malaria Outbreak on Board a Merchant Vessel ....... .188
A Fatal Case of Malaria .................. 188
Follow-up Botulism Tarrant County. Texa.s ....... 196
Recommendations of the Public Health Servict Advisory
Committee on Immunization Practices -
Yellow Fever Vaccine .................... 189
Surveillance Summary
Viral Hepatitis United States . . 190


27 through May 4. a period which was unseasonah.y warm.
Most of the patients had attended the fair and gave a his-
tory of eating ice cream. The implicated ice cream vendor
at the fair also had a shop in Waldhausen (a village approx-
(Continued on page 186)


TABLE I. CASES OF SPECIFIED NOTIFIABLE DISEASES: UNITED STATES
(Cumulative totals include revised and delayed reports through previous weeks)
22nd WEEK ENDED CUMULATIVE, FIRST 22 WEEKS
DISEASE MEDIAN
DISMay 31, June 1, 1964- 1968 MEDIAN
1969 1968 1969 1968 1964 1968
Aseptic meningitis ...................... .23 33 27 598 640 630
Brucellosis ............................ 8 3 3 59 63 97
Diphtheria.............................. 1 17 4 63 84 78
Encephalitis, primary:
Arthropod-borne & unspecified ........... 19 14 26 427 351 541
Encephalitis, post-infectious ............. 9 10 23 127 242 378
Hepatitis, serum ........................ 78 73 2,197 1,694 17
Hepatitis, infectious .................... 787 821 543 20186 18593 7.890
Malaria ................................ 47 37 4 1,110 898 119
Measles rubeolaa) .................. ..... 625 708 5.919 15.126 15.229 162.223
Meningococcal infections, total .......... 58 32 41 1,828 1.473 1,473
Civilian ............................... 55 24 1.650 1.327
Military ............................... 3 3 178 146
Mumps ................................. 2,176 3.368 -53.995 105,987
Poliomyelitis, total ..................... 1 1 2 21 13
Paralytic ............ ................ 1 1 2 21 11
Rubella (German measles) ............... 2,215 1,695 37,195 34,577
Streptococcal sore throat & scarlet fever.... 6.357 7,880 6.795 235,006 232,984 232.984
Tetanus ............................... 3 6 6 49 52 66
Tularemia................................ 2 10 3 53 77 77
Typhoid fever .......................... 9 5 5 119 107 134
Typhus, tick-borne (Rky. Mt. spotted fever) 28 13 8 74 46 32
Rabies in animals ....................... 49 52 1 76 1.636 1.658 1 967

TABLE II. NOTIFIABLE DISEASES OF LOW FREQUENCY


Cum. Cum.
Anthrax: ........................................... 2 Rabies in man: ...................................... 1
Botulism: .......................................... 10 Rubella congenital syndrome: ......................... 5
Leptospirosis: La.-2 ................................ 23 Trichinosis: Mich.-., Ohio-5 .......................... 38
Plague: ............................................ Typhus, marine: ..... .............................. 6
Psittacosis: ....................................... 13


. / /. /







Morbidity and Mortality Weekly Report


PARATYPHOID FEVER (Continued from front page)


imatel 32 miles east of Linz). where additional cases
occurred in persons who had not been to Linz hut who
had eaten ice cream at this shop. Investigation revealed
that the ice cream xendor w\as clinically ill and S. schott-
miilliri \ as isolated from him. 1\hether the \endor or con-
taminated water used to rinse ice cream equipment and
container-s \xa the source of infection is not known.
New%-paper coverage of the outbreak prompted many
persons to -uspeci that they had been infected and to
pre-ent themsel`s- for examination to the local health
official-. Identified excretors of the salmonella organism
were excluded from food handling occupations and other
occupations heree the possibility of further transmissions
exi-ted. Fi\e food handling establishments uere closed
because of positive cultures among employees. The iim-
mediate outbreak control measures taken hlb the Austrian
health authorities appear to ha e ended an\ general threat
of infection.


(Reported by Dr. Franz Bauhofer, Chief. Division of Pub-
lic Health, Federal Ministry of Social Affairs. Republic
of Austria, Vienna, and Dr. Franz Poddany, M.O.C.,
USPIIS Visa Examining Unit, Vienna; and the Foreign
Quarantine Program, NCDC.)
Editorial Comment:
Inquiries concerning the advisability of immuniza-
tion with typhoid-paratyphoid \accine have been made
both in the United States and abroad by persons traveling
to Austria. Immunization has not been recommended. Sal-
monella paratyphi A and B antigens of the combined
typhoid-paratyphoid vaccine have not been demonstrated
to be effectivein preventing paratyphoid fevers. The U.S.
Public Health Service Advisory Committee on Immuniza-
tion Practices (MM\\WR. Vol. 15. No. 29) did not recom-
mend use of the combined typhoid and paratyphoid vac-
cine because of the lack of demonstrated efficacy and
increased likelihood of vaccine reactions.


EPIDEMIOLOGIC NOTES AND REPORTS
CASE OF GROUP A MENINGOCOCCEMIA Fort Benning, Georgia


The first i.,. A r meningococcal organism reported
from within the I'nited States to NCDC since early 1967
was recentl i-oIolated from a -oldier at Fort Benning.
The soldier xax- not a recruit and had served in the armi
since Jul\ 19(7. He was tran-ferred to Fort Benning on
March 19. 19fi9. after a tour of dut\ in Korea. He remained
on the hbae working in a spare parts -upply room of a
Con-truction Engineer company. He took no leaxe during
the ensuing 7 weeks. On the evening of M\la 4, he com-
plained of upper re-piratory symptoms and fever and was
seen at the pott hospital where the feoer was confirmed.
He was admitted for obser action and within several hours
developed headache and multiple petechiae. A clinical
diagnosis of mfningococcemia was made and the patient
wa- treated with large volumes of intravenous fluids and
high doses of intravenous penicillin. He made an un-
eventful recovery.. Subsequent\ an organism was isolated
from an admission blood culture which xa- identified as
\Nisseria mrniJigittiis. Group .. which was highly sensi-
tite( to sulfadiazine. being inhibited by a concentration
of 0.1 ig per ml (0.01 nig percent).
A nasophar ngeal culture survey of 122 members of
the soldier's companyy was conducted on May '27. V. imen-
ingitidis was isolated from 31 members of the company.
Howvecer, none of the isolates belonged to Serogroup A.
Fourteen of the organisms belonged to Serogroup IB. nine
to Serogroup C. file to Serogroup Y (Boshard), one to


Serogroup 29E. and two organisms could not be typed.
Large recruit populations enter Fort Benning, and
since last fall 34 cases of meningococcal infections have
been diagnosed there. Routine culture sur\eys are con-
ducted monthly at Fort Benning. A routine monthly culture
sur\ey conducted on May 12 revealed that newly arriving
recruits had the same prevalence of positive throat cul-
tures as trainees already in the sixth week of training.
Serogrouping has been performed on 16 isolates oh-
tained since Jan. 1, 1969: 11 belonged to Serogroup C.
three to Serogroup B. one to Serogroup Y. and one organism
could not be typed.
There hate been no Group A sulfonamide resistant
organisms from the United States ever received by NCDC
although sulfonamide resistant Group A meningococcal
disease has been reported from North Africa.

(Reported by Lt. Col. Charles Webb. Chief, Preventive
medicine Activities, IEDDAC, Fort Benning, Georgia;
Col. J. R. Gauld, Prerentive medicine Division, Office
of the Surgeon General of the Army, Washington, D.C.;
Malcolm Artenstein, M.D.. Chief, Department of Bacterial
Diseases, Walter Reed Army Institute of Research; and
the Bacterial Reference Lnit and Bacterial Immunology
Unit. Laboratory Division. and the Special Pathogens
Section. Bacterial Diseases Branch, Epidemiology Pro-
gram, 'CDC.)


OUTBREAK OF METHICILLIN-RESISTANT STAPHYLOCOCCAL INFECTIONS
Seattle, Washington


Between Dec. 2.i. 19(th. and Feb. 21. 1969. six pa-
tients at the Harlorxei \lMedical Center in Seattle were
infected and or colonized with a methicillin-resistant


strain of Staphylococcus a'ircus, phage type b4. The in-
dex case. a 92- ear-old man with pneumonia, was ad-
mitted to the hospital from a nursing home on December 25.


MAY 31, 1969






Morbidity and Mortality Weekly Report


Methicillin-re- isltant S. aureus was isolated from cultures
of his sputumr and urine and from a deculbitus ulcer. Fol-
low ing therapy with cephalothin. his sputum and urine he-
came negative, but the decuhitus ulcer remained positive
until his discharge from the hospital on January 31. Two
other patients developed fatal staphylococcal pneumonia
caused bh this strain. Another patient developed a post-
operative wound abscess with the organisms on February
17 following a cholhc ystectomy. During the outbreak.
anterior nasal culture surveys of personnel and patients
from the same wards revealed two other asymptomatic
patientcarriers of the methicillin-resistant staphylococcal
strain. None of the five subsequently infected persons
had direct contact with the index case. Other surveys dur-
ing the outbreak failed to detect a carrier of this strain
among hospital personnel.
Culture surveys were also conducted at the nursing
home from which the index case had been admitted. Two
additional patient carriers were detected, but no carriers
were found among personnel. No contact could he estab-
lished between the index case and these carriers.
Since the hospitalized patients had not shared the
same room and the hospital personnel were not colonized
with this strain, it is presumed that indirect contact
spread occurred between patients, probably \ia hands of
personnel. No new infections have been noted at the
hospital since February 21.
Prior to this outbreak, only one methicillin-resistant
S. aureus strain had ever been isolated at this hospital.
This strain differed from that associated with the present
outbreak and was isolated in February 1968 from a patient
with staphylococcal endocarditis who was referred from
another hospital.
(Reported by Harry N. Beaty, M.D., Division of Infectious


Disease, and Htarold Luws, M.1.. Vledical I r, !or,r II,rr-
borricr Medical ('enter. S,'Nltle, 0Dn lid l. I'P,, 1, r .
1.l).. lHealth Officerr, 'Kiny ', it,,/, anI li,/r t 1. yr .. .
MI.D., C.P.l., Chief, lbiisior n f t Epid.rmi ,,liii, i i -.,i-
tnii Stater Drpartmntcl of llril/th.
Editorial Comment:
Since its introduction into clinical use in li;(,
methicillin has been widely\ us offectl\e in the treatment of patients with -l cxri infer-
tions, especially bactrenitm caused l) p(en ic llin-r-i)-laint
S. oureus. Strains of S. aurerus re-itsani t ito mtcthi lli n
and similar penicillinase-re-iri-ant ponicillin- alppear,-d
soon after its general clinical us-e began. Nosocomial in-
fections caused by such strains ha\e( noiw been reported
from Australia and many European countries, and iia izabhl
and increasing proportion of staphylococical infecltin-
in hospitalized patients within these countrie- (lup to I21
percent)l are presently caused hy nilthliillin-re- i-lant
strains. However, prior to a report of I clinicall\ in-
fected, hospitalized patients in 19(hs. t cases had been reported froni the United Staties.-
The strains associated with these ho-pital-acquirrtd
infections have been predominantly phage group III, as i
the outbreak reported above. and are characterized b.i
resistance to multiple antibiotics: they are often u---
ceptible only to a few, relatively toxic, antimicrohial-.
It is likely that infections caused by such strains will be-
come of increasing importance in the United States.
References:
ISiboni, K., and Poulsen, E.D.: The Dominine, of M-thi ilim-
Resistant Staphylococ)(l in a Co Bull, 15(6):161-165. 196S.
B13rrett, F. F., McGh(; e, R. F.. .nd FinlA.nd, M.: i in-th
Rtisttnt Staphyloroccus aurciis at Boston (I \ II ( p .ii. .i
Eng J ,ed, 79:441-44S, 191S.


OUTBREAK OF SHIGELLOSIS Prineville, Oregon


During March and April 1969. 31 of 36 residents in
seven houses of a new housing development near Prine-
ville became ill with acute febrile gastroenteritis (Fig-
ure 1). The illnesses lasted from 1 to 7 days (median 3
days) and were characterized by diarrhea (97 percent).
fever (71 percent), nausea (65 percent), cramps (48 per-
cent). headache (45 percent). vomiting (42 percent). and
myalgia (19 percent). One man required hospitalization.
Shigella sonnei was cultured from the stools of four per-
sons with acute diarrhea, eight convalescent persons,
and two of six visitors to the area.
Figure 1
FEBRILE GASTROENTERITIS, PRINEVILLE, OREGON, 1969
O ss o++++ v emeTins o+

'0




-- H -_ .
!N


The epidemic curve was compatible with a common
source outbreak, and the epidemiologic investigation sug-
gested the water supply as the vehicle of infection. after r
for the residents of all seen houses came from a common
well, 30 feet in depth, and sealed with cement grout to a
depth of 20 feet. The soil strata showed 1 to 3 foel of
top soil and then mixed clay and gravel to a depth of s3
feet. Sewage disposal was provided by individual house-
hold septic tanks. On April 23 water from the well was
cultured and grew S. sonnei and coliform organism-. \l-
though fluorescein dye and sodium chloride tracer tech-
niques were used, the presumed contaminating link be-
tween sewage and the will could not he demonstrated.
The primary control measure employed was the drilling
of a new deep well for the housing development.
Because of contact with the affected area and re-
ports of similar illnesses in persons residing in houses
contingent to these seven houses, a random -ample sur-
tey of 252 housing units was conducted on \May 6 and 7.
Approximately 15 percent of the sampled population had
experienced diarrheal illness between January 1 and lMas 7.
({Cuontinmin on paye 1SS)


MAY 31, 1969


u.-C.


wa,


D-TE O. O.SeT







Morbidity and Mortality Weekly Report


SH!GELLOSIS (Continued from page 187)


No statistically significant difference in the incidence of
diarrheal illness could be demonstrated between persons
having private wells and those receiving their water from
the chlorinated municipal water supply. Twenty-two stool
cultures obtained from persons recently ill with diarrhea
in the survey population were all negative for enteric
bacterial I' ali.. -r,-


(Reported by Gatlin Brandon, M.S., M.P.H., Director,
Oregon State Public Health Laboratory; Ken Ashbaker,
District Sanitary Engineer, Oregon State Board of Health;
Dick Clark, Sanitarian, and Helenmarr Wimp, Public Health
Nurse, Crook County Health Department; Enteric Diseases
Section, Bacterial Diseases Branch, and Statistics Sec-
tion, Epidemiology Program, NCDC; and an EIS Officer.)


MALARIA OUTBREAK ON BOARD A MERCHANT VESSEL


On April 4, 1969, while on board a ship in the At-
lantic, a 30-year-old Ghanian merchant seaman developed
chills, fever, headache, and abdominal pain. His symptoms
persisted and when the ship arrived in Newark, New Jersey.
on April 7, he was hospitalized. Plasmodium falciparum
trophozoites were identified in his peripheral blood, and
following chloroquine treatment, he recovered. During the
4 weeks prior to his illness, his ship had visited ports in
Senegal. the Ivory (:oast, and Ghana.
On April 10, the ship traveled to Philadelphia, and
on April ,I, the day of departure for Galveston, Texas,
sera and blood smears were obtained from 37 crew mem-
bers, all of whom were native West Africans, and from the
captain and his wife. who were British. None of the 39
individuals were ill. The captain's daughter and the re-
maining nine crew members were not available for inter-
viewing or blood sampling.
Four of the 37 crewman had asexual malaria parasites
in their blood smears; in two of these, the species were
P. falciparum and in the other two, the Plasmodium spe-
cies could not be identified; gametocytes were not seen.


The sera were analyzed for malaria antibodies using the in-
direct fluorescent antibody technique. Sera from the captain
and his wife were negative, but all 37 crewmen had high
titers to at least one of the four human Plasmodium antigens.
On April 25, the ship arrived in Galveston. On April
26, the vessel was sprayed with DDT and all crew mem-
bers were treated with chloroquine. As of May 9, when
the ship left American waters, no further illness has
developed among the 50 persons on board.
(Reported by Alfred B. Giordano, Acting Chief Inspector,
and Angelo Storino, Sanitary Inspector, Contagious Dis-
eases Bureau, and Aaron II. Haskin, M.D., M.P.H., Health
Officer, Newark City Health Department; Ronald Altman,
41.D., Director, Preventable Diseases Bureau, New Jersey
State Health Department; Sylvan M. Fish, M.D., Consult-
ant, Communicable Disease Control Section, Division of
Epidemiology, Philadelphia City Health Department; C. D.
Bienrenu, Foreign Quarantine Inspector, Galveston, Texas,
and Norman G. Craig, Supervisory Quarantine Inspector,
Staten Island, New York, and the Foreign Quarantine Pro-
gram, NCDC; and two EIS Officers.)


A FATAL CASE OF MALARIA


On March 26. 1968, while on board a ship in the mid-
Atlantic. a 21-year-old American seaman developed weak-
ness. chills, and fever. His ship had departed from a West
African port several days previously. He was treated with
aspirin but continued to feel feverish and weak. On March
30, he developed headache, severe diarrhea, abdominal
cramps, and dyspnea; his temperature was 103.6 F. He
was treated with tetracycline and later penicillin but con-
tinued to have daily temperatures as high as 106F.; his
diarrhea persisted and he became extremely weak. On
April 5, his ship arrived in the United States and he was
hospitalized. Physical examination revealed an exceed-
ingly thirsty, agitated, dehydrated, hypotensive white
male with diarrhea, tachycardia, and a temperature of
100F. The tip of his spleen was palpable and he had
marked weaknes. of the extremities. The hematocrit was
62 percent and the white cell count was 5,800: no malaria
parasite, were noted in the initial examination of the ad-
mission blood -mear. The BUN was 42 mg percent, sodium
124 nme per liter, potassium 3.2 meq per liter, chloride
s3 meq per liter, and carbon dioxide 16 meq per liter. A
lumbar puncture was normal. He was treated with in-
travenous fluids and belladonna. Twenty-four hours later
he had not improved: another blood smear was obtained at


this time and numerous Plasmodium falciparum parasites
were identified. Chloroquine therapy was immediately
instituted, but very shortly thereafter, the patient's temp-
erature rose to 1080F. and he died.
Postmortem examination revealed malaria parasites
and malaria pigment in red cells throughout the body. The
heart showed interstitial edema and hyaline degeneration;
there was pulmonary edema; the central nervous system
neurons showed anoxic changes. In addition, there was
marked congestion of the intestinal mucosa. A review of
the blood smears obtained on the day of the patient's hos-
pitalization revealed P. falciparum parasites.

(Reported by Henry E. Harris, Senior Surgeon, U.S. Pub-
lic Health Service Hospital, Staten Island; and Howard B.
Shookhoff, M.D., Chief, Tropical Disease Division, Bureau
of Preeentable Disease, New York City Health Department.)

Editorial Comment:
Seamen continue to have the highest malaria case
fatality ratio for any occupational group in the United
States. As in this case, seamen with falciparum malaria
frequently become ill at sea and do not receive treatment
until many days later, when serious complications have
developed.


MAY 31, 1969






MAY 31, 1969


INTRODUCTION
At present, cases of yellow fever are reported from
only Africa and South America. Two forms of yellow foeer
- urban and jungle are distinguishable epidemiologically.
Clinically and etiologically, they are identical.
Urban yellow fever is an epidemic viral disease of
man transmitted from infected to susceptible persons hy a
vector, the Ar.des aegypti mosquito. With the elimination
of A. aeqypti, urban yellow fever has disappeared from
previously epidemic foci.
Jungle yellow fever is an enzootic viral disease
transmitted among non-human hosts by a variety of mosquito
vectors. It is currently observed only in the jungles of
South America and Africa, but in the past has extended
into parts of Central America as well. Human cases occur
by chance. The disease can ostensibly disappear from an
area for years and then reappear. Delineation of areas
affected depends upon accurate diagnosis and prompt re-
porting of all cases.
Urban yellow fexer can be prevented by eradicating
A. aeyypti mosquitoes. Jungle yellow fever can be pre-
vented in humans only by immunization. Because infec-
tion is from a non-human reservoir, prevention of human
cases require-s vaccination of all persons at risk.


YELLOW FEVER VACCINE
Yellow fever vaccine is a live. attenuated xirus prep-
aration made from one of two strains of virus: 17D and
Dakar (French neurotropic). The Dakar strain has been
associated with a significant (0.5 percent) incidence of
meningoencephalitic reactions and is not recommended.
The 17D strain has caused no significant complications.
Licensed vaccine available in the United States is
prepared from the 17D strain, which is grown in chick
embryo inoculated with a fixed passage level seed virus.
The vaccine is freeze-dried supernate of centrifuged em-
bryo homogenate.
Vaccine should be stored at the temperature recom-
mended by the manufacturer until it is reconstituted by the
addition of sterile physiologic saline. Unused vaccine
should be discarded within approximately 1 hour of re-
constitution.


RECOMMENDATIONS OF VACCINE USE
Vaccination against yellow fever is recommended for:
1) Persons 6 months of age or older traveling or
living in areas where yellow fever infection ex-
ists (currently Africa and South America; see
Vaccination for International Travel).

2) Laboratory personnel who might be exposed to
virulent yellow fever virus.


Vaccination for International Travel
To he acceptable for purposes of international travel.
yellow fever vaccines must be approved by the world d
Health Organization and administered at a Yellow Fe' er
Vaccination Center listed with i1HO. Vaccines -houlti
have an International Certificate of Vaccination filled in.
signed, and validated with the stamp of the (Center where
the vaccination is administered.(Yellow Fo'er Vaccina-
tion ('Centers in the United States are de>ignaird by the
Foreign Quarantine Program of the Public Heal th Sert ice*).
Vaccination for international travel may he required
under circumstances other than those included in these
recommendations. A number of courtin e, in \frica and
South America require evidence of \accination from all
entering travelers; some may waie the requirement for
travelers coming from non-infec re d areas and saying les
than 2 weeks. These requirements ma. change. -o that
travelers should seek current information from health
departments and travel agencies.
Some countries require an individual, even if only in
transit, to have a valid International Certificate of \acci-
nation if he has been in countries either known or thought
to harbor yellow fever virus. This applies particularly to
travelers to South and Southeast Asia by way of the Atlantic.

Vaccination Schedule
Primary Vaccination: A single subcutaneou- injet-
tion of 0.5 ml. of reconstituted vaccine for hoth adults
and children.
Revoccination: Yellow fever immunity following \ac-
cination with 17D strain virus has been shown to persist
for more than 10 years: the International Sanitary Regula-
tions do not require revaccination more frequently than
every 10 years.


Reactions
The few reactions to 17D yellow fever vaccine that
occur are generally mild. Five to ten percent of xaccinees
have mild headache, myalgia, low-grade fever. or other
minor symptoms 5-10 days after vaccination. Symptoms
cause less than 0.2 percent to curtail regular activities.
Only two cases of encephalitis have been reported in the
United States, for more than ;34 million doses of vaccine
distributed.
Because yellow fever vaccine is prepared from chick
embryos. it may induce reactions of varying degree- of
severity in individuals hypersensitive to eggs. Experience
*For a i nt of such centers, Inmunirn actionn f inf rmunat for
Internal iort al Travel. PIIt Puhtihc: ion No. S, ;t.t tilil from
the Supt. of Document., U.S. (io. rnme nt Printinw Off il
washingtoni D.C. 20 0I2 t 10 ti 'nt .'
(('antini!, i 0i, i':,L 190


Morbidity and Mortality Weekly Report


RECOMMENDATION OF THE PUBLIC HEALTH SERVICE
ADVISORY COMMITTEE ON IMMUNIZATION PRACTICES

YELLOW FEVER VACCINE







Morbidity and Mortality Weekly Report


YELLOW FEVER VACCINE (Continued from page 189)


in the Armed Forces suggests that allergy severe enough
to preclude vaccination is very uncommon and occurs only
in those \%ho are actually unable to eat eggs.


Precautions and Contraindications
Pregnancy: Although specific information is not
available concerning adverse effects of yellow fever vac-
cine on the developing fetus, it is prudent on theoretical
grounds to aioid r accinating pregnant women.
Altered Immune States: Yellow fever vaccine virus
infection might lie potentiated by severe underlying dis-
eases. such as leukemia. lymphoma. or generalized malig-
nancy. and bh lomiered resistance. such as from therapy
with steroids. alkylating drugs, antimetabolites. or radia-
tion: therefore. vaccinationn of such patients should be
a oided.
Allergy: Documented hypersensitivity to eggs can be
contraindication to vaccination. In making the decision to
vaccinate despite a hi-tory of egg allergy, a physician
must weigh three factor-: (1) the nature of the history and
of the reported h persen-iti ity. (2) the relative risk of
exposure to iI low fe-er. and (3). in the case of inter-
national trarxI. the po--ible inconvenience from disrupted
trax il plan-.
If international quarantine regulations are the onlI
reason to xaccinate a patient hypersen-itixe to eggs.
effort- -hould first hbe made to obtain a waixer. A physi-
cian's letter which clearly -tates the contraindication to
\actcination ha:- been acceptable to some go\ernmients.
(Ideally. it -hould he written under hi- letterhead and
hear the iuthenicating stamp used by health departments
and official immunization center- to alidate International
C(e rtificate- of \ vaccination ) Becau-e thi- is not uniformly


true. however, it is prudent for the traveler to obtain
specific and authoritative advice from the country or
countries he plans to visit. Their embassies or con-
sulates may be contacted. Subsequent waiver of require-
ments should be documented by appropriate letters.


Simultaneous Administration of Live Virus Vaccines
There are obvious practical ad antages to administer-
ing two or more live virus vaccines simultaneously. Data
from specific investigations are not yet sufficient to
develop comprehensive recommendations on simultaneous
use. but a summary of current experience, attitudes, and
practices provide useful guidance.
It has been generally recommended that live virus
vaccines be given at least 1 month apart whenever possible
- the rationale for this being that more frequent and
severe adverse reactions as well as diminished antibody
responses otherwise might result. Field observations in-
dicate. however, that with simultaneous administration of
certain live virus vaccines, results of this type have been
minimal or absent. (For example. the third dose of tri talent
oral polio\irus vaccine, which is recommended during the
-econd year of life. is commonly gi\en at the same time
as smallpox \accination without evident disadvantage.)
If the theoretically desirable 1-month interval is not
feasible, as with the threat of concurrent exposures or
disruption of immunization programs. the vaccines should
preferably he given on the same day at different sites
for parenteral products. An internal of about 2 days to 2
weeks should be avoided because interference between
the vaccinee viruses is most likely then.

May 1969


SURVEILLANCE SUMMARY
VIRAL HEPATITIS United States
Fall and Winter Quarters, Epidemiologic Year 1969


In the I'nimrd State- during the fall quarter of epi-
demiologic Yorr" (EY) 1969 (September 29, 196h. through
December 2n. 196i). there \\ere 13.693 cases of viral
hepatiti- (infectiou- and serum) reported for an incidence
rate of 6.9 ca-e- per 100,000 population. This was a 25
percent incroea-e o\r the rate of 5.5 (10(.04 cases) for
the fall quarter of the previous epidemiologic year. Of the
nine geographic division, -sexen had rate increase- with
the East South Central and Hoest South Central Divisions
being the only exceptions (Table 1). Increases ranged
from 11 percent in the h cst North Central Dixision to 73
percent in theta N \i England Dixision.
Serum hepatitis in the fall quarter of EY 1969 con-
tinued its progre--sile increase noted since it became a
separately reportable disease in July 1966. During the
fall quarter of EY 1969. 1.420 cases were reported. whichh
is almost twice that of the corresponding quarter of EY
19 s. \Ithough each di i-ion experienced an increase in


the number of reported cases of serum hepatitis during the
fall quarter, the Middle Atlantic and Pacific Divisions
exhibited the major increases due to contributions from
Nex York City and California in their respect\ e divisions.
In the winter quarter (December 29, 1968-March 29,
1969) of epidemiologic year 1969, there were 13.200 cases
of viral hepatitis reported for an incidence of 6.6 cases
per 100.000 population (Table 2). This represents a 12
percent increase o\er the rate of 5.9 (11.707 cases) for
the corresponding quarter of the previous year. However.
for the first time since July 1952, when hepatitis morbidity
data were first reported to the NCDC. the winter quarter
exhibited a decline in incidence from the previous fall
quarter. Six of the nine geographic divisions experienced
rate increases ranging from only 2 percent in the Mountain
to 103 percent in the New England Division, which again
had the highest rate increase. As in the fall quarter, the
(Continued on page 196)


MAY 31. 1969







Morbidity and Mortality Weekly Report


Table 1
Reported Cases and Incidence of Viral Hepatitis by Geographic Divisions, Fall Quarters EY* 1969 and 1968


Geographic
Division



IUnited States
Ner England
Middle Atlantic
East North Central
\est North Central
South Atlantic
East South Central
\est South 'Central
Mountain
Pacific


Fall Quarter
Oct. 1, 1967 Dec. :0, 1967


Fall Quarter
Sept. 29, 196h Dec'. 2r, 196S,


Infectious Sntruim Totli Rit, le* Infectious Serum Total IRate++ t ay


10,045)
1i 5 4
1,707
1,571)
I.5th!)
5S7
1,01S
7.14
934
157
02.555


1O,M(O)
10,s04
1 69
1,971


1,04s
752
960
459
2,93 5


12,273:
72h
2,129
1,909
637
1,375
719
?)35
543
3,39


1,420
h4l
19,t
63
15
hs
17
31
20
(!<)h


13.693
Sh12
2,6( 3
2 ,f;23
1,972
652
1,4.163
7:1 (
S66
563
006


Ch
Quait
Fall


+2,Sh9
+343
+:155

+ l5
115
-16
-94
+101
+1,071


Geographic
Division


unitedd States
New England
Middle Atlantic
East North Central
\\est North Central
South Atlantic
East South Central
W est South Central
Mountain
Pacific


l\inter Quarter
Dec. :1. 1967 March 30, 196S8


_---_-- ( Cases
Infectious Serum

10.792 91to 1
422 29
1,514 276
1,819 26
71O5 10
1,002 31
933 5
1,0201 15
509 6
2,868 514


Total Rate*

1,707 5.9
451 4.0
1.790 4.9
1,b45 4.7
715 4.5
1,036 3.5
93: 7.2
1.035 5.4
515 6.6
3,382 13.4


\inter Quarter
Dec. 29, 196i March 29. 19i69


Infectious


11.,)00
s56

2,002
505
1,164
S45
994
521
3,028
8,1125


Cases

Serum Total


1.300
69
501
101
17
59
4
20
13
516


13,200
925
2,,4S6
2,1013

1,223
h49
1,0141
534
3,544


'* .e pP.r 10(1.001 population n liba .d on C.S. Censu. mldl-aear i:


Change from ) inter
Quarter E1 I196) to
winter Quarter E' 1969

Cas, PercoinI hang-


+1.193
+474
+69 196

-S19


-21
+19
+1612


+10



+;7


-10
-2
+2
+4


MAY :1, 1969


ang from Fall
rte(r EY 1l96S to
Quarter EY 19(i9
PercenT C hi a,
in tatr


F' Ii rn i loz N' ar
*IRate p 1r 100,000 population l),,a d cn I.S. Cen( u mid-year estimates July 1, 1967, andI July Ii, 19 i .




Table 2
Reported Cases and Incidence of Viral Hepatitis by Geographic Divisions, Winter Quarters EY 1969 and 1968


LIL


timatc, July 1. t1967. ,ond July 1. 1965.


7


L 1 -_








192 Morbidity and Mortality Weekly Report


TABLE 111. CASES OF SPECIFIED NOTIFIABLE DISEASES: UNITED STATES

FOR WEEKS ENDED

MAY 31, 1969 AND JUNE 1, 1968 (22nd WEEK)


ASEPTIC ENCEPHALITIS HEPATITIS
MENIN- BRUCEL- )PIITHERIA Primary including Post- MALARIA
AREA CITIS LOSIS unsp. cases I tious Serum Infectious
Cum.
1969 1969 1969 1969 1968 1969 1969 1969 1968 1969 1969
UNITED STATES... 23 8 1 19 14 9 78 787 821 47 1,110

NEW ENGLAND.......... 1 1 3 1 54 37 39
Maine.....t........ 3 2
New Hampshire...... 1 2
Vermont ........... 4 -
Massachusetts...... 2 19 15 30
Rhode Island........ 1 -- 19 10 1
Connecticut ........ 1 1 11 9 4

MIDDLE ATLANTIC...... 8 1 1 3 20 112 105 9 126
New York City...... 2 14 42 34 9
New York, up-State. 1 2 20 18 22
New Jersey.......... 6 3 18 30 2 44
Pennsylvania....... 1 3 1 32 23 7 51

EAST NORTH CENTRAL... 1 10 4 16 134 199 2 94
Ohio............... 7 2 2 25 44 10
Indiana........... 1 9 12 7
Illinois........... 1 4 41 26 46
Michigan........... 1 1 2 10 49 109 2 3u
Wisconsin.......... 10 8 1

WEST NORTH CENTRAL... 1 2 1 34 30 4 77
Minnesota.......... 1 1 10 4 7
Iowa............... 2 5 5 5
Missouri........... o 10 3 23
North Dakota ....... 2
South Dakota....... 3
Nebraska........... 1 3 3
Kansas ............. 12 4 37

SOUTH ATLANTIC ....... 3 3 3 2 10 103 84 10 356
Delaware........... 1 4 2
Maryland........... 3 9 o 10
Dist. of Columbia.. 1
Virginia........... 1 5 9 1 15
West Virginia...... I 1 1 4 -
North Carolina ..... 1 1 20 5 7 162
South Carolina..... 4 2 29
Georgia............ 1 i 19 39 119
Florida............ 3 1 3 1 5 44 13 18

EAST SOUTH CENTRAL... I 1 1 2 47 54 32
Kentucky........... 12 26 20
Tennessee............ 1 1 1 15 15
Alabama........... 2 8 2 6
Mississippi........ 12 11 -

WEST SOUTH CENTRAL ... 2 3 80 73 2 32
Arkansas........... 1 2 5
Louisiana.......... 2 2 23 14 2 24
Oklahoma........... 2 16 3
Texas.............. 1 54 41 -

MOUNTAIN .............- 2 1 2 24 42 4 76
Montana............ 2 3 10 -
Idaho .............. .. 2
Wyoming ............ 1 1 1 -
Colorado .......... 7 16 4 68
New Mexico ......... 3 3 4
Arizona............ ..- 2 5 4 1
Utah............... 5 8 1
Nevada..........

PACIFIC.............. 8 3 1 2 1 3 24 199 197 16 276
Washington........... 2 1 18 27 5
Oregon.............. 1 12 7 6
California......... 3 3 2 1 3 24 167 163 8 215
Alaska ............. 1 1- -
Hawaii .............. 1 1 8 51

Puerto Rice..* ....... --- --- ---- .- __ --- 21 -- 1
*Delayed reports: Hepatitis, infectious: Me. 1, P.R. 2








Morbidity and Mortality Weekly Report 193


TABLE III. CASES OF SPECIFIED NOTIFIABLE DISEASES: UNITED STATES

FOR WEEKS ENDED

MAY 31, 1969 AND JUNE 1, 1968 (22nd WEEK) CONTINUED


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

UNITED STATES... 625 15,126 15,229 58 1,828 1,473 2,176 2 2,215

NEW ENGLAND.......... 31 739 775 2 59 75 274 160
Maine. ......*...... -4 30 5 6 16 -- 9
New Hampshire...... 6 216 113 1 7 3 -- 3
Vermont............ 2 1 1 1 -- 7
Massachusetts...... 9 139 229 1 27 33 117 53
Rhode Island....... 9 1 1 5 7 25 -- 9
Connecticut........ 16 369 401 21 21 112 79

MIDDLE ATLANTIC...... 247 5,443 2,525 15 286 247 187 -101
New York City...... 157 3,761 1,043 2 51 47 127 42
New York, Up-State. 18 466 971 1 46 40 NN -- 24
New Jersey.......... 24 602 424 7 126 90 60 23
Pennsylvania........ 48 614 87 5 63 70 IN -- 1

EAST NORTH CENTRAL... 79 1,552 3,173 11 241 163 512 -- 637
Ohio................ 19 251 252 3 83 44 65 57
Indiana .....*...... 5 436 564 2 29 19 57 -96
Illinois ........... 24 288 1,201 39 39 99 -165
Michigan........... 10 146 202 6 74 48 107 176
Wisionsin.......... 21 431 954 16 13 184 143

WEST NORTH CENTRAL... 24 426 317 3 96 76 120 112
Minnesota.......... 2 13 1 17 17 9 4
Iowa............... 13 270 77 1 11 5 73 92
Missouri............ 1 19 73 1 44 26 12 4
North Dakota....... 1 7 109 3 3 4
South Dakota....... 1 4 1 4 NN -
Nebraska............ 9 123 33 9 6 14 6
Kansas............. 4 8 14 15 9 2

SOUTH ATLANTIC....... 53 2,075 1,135 8 324 312 193 340
Delaware............ 14 263 11 4 4 1 1
Maryland............ 1 31 72 1 31 21 8 17
Dist. of Columbiaf. 1 6 9 11 1 4
Virginia........... 854 228 1 37 22 20 90
West Virginia...... 156 181 14 7 O0 87
North Carolina..... 17 196 261 4 55 62 NN -
South Carolina..... 3 100 12 1 47 54 7 3
Georgia............ 1 3 56 58 -
Florida............ 18 473 361 1 71 73 96 144

EAST SOUTH CENTRAL... 4 77 386 4 108 128 55 148
Kentucky............ 4 43 87 38 48 9 67
Tennessee.......... 15 53 1 40 44 41 75
Alabama........... 1 62 17 18 1 3
Mississippi........ 18 184 3 13 18 4 3

WEST SOUTH CENTRAL... 119 3,482 4,057 9 258 255 260 2 151
Arkansas... ....... 29 2 27 15 -
Louisiana.. ....... 3 103 2 70 67
Oklahoma........... 3 119 105 1 25 48 60 38
Texas............... 113 3,231 3,948 8 136 125 200 2 113

MOUNTAIN............. 27 512 776 34 24 66 112
Montana............. 8 57 4 2 4 -
Idaho............... 1 48 12 6 10 7 1
Wyoming ........... 48 3
Colorado........... 4 104 390 6 7 9 55
New Mexico......... 2 176 77 6 12 16
Arizona............ 20 172 168 8 1 34 37
Utah............... 3 19 2 1 -
Nevada............. 1 5 2 3

PACIFIC............... 41 820 2,085 6 422 193 509 448
Washington........... 53 488 50 32 144 80
Oregon............... 5 172 404 10 16 3 49
California.......... 36 565 1,158 6 343 135 277 278
Alaska............. 11 1 11 71 25
Hawaii............. 19 34 8 10 14 1

Puerto Rico.............-- 654 302 --- 13 17
*Delayed reports: Measles: Mass. delete 8, D.C. delete 1, Ark. 13
Meningococcal infections: Ind. delete 1, La. delete 1
Mumps: Me. 9
Rubella: Me. 34








194 Morbidity and Mortality Weekly Report


TABLE III CASES OF SPECIFIED NOTIFIABLE DISEASES: UNITED STATES

FOR WEEKS ENDED

MAY 31, 1969 AND JUNE 1, 1968 (22nd WEEK) CONTINUED


STREPTOCOCCAL TYPHUS FEVER
TYPHOID RABIES IN
SORE THROAT & TETANUS TULAREMIA TICK-BORNE I
AREA SCARLET FEVER 'EK (Rky. Mt. Spotted)IMALS
Cum. .
1969_ 196 11969 169 69 9 1969 9 1969 1969 1969 1469 1969
-- I I. 11 .. l"j

NEW ENGLAND......... 1,274 4 2 1 b
Maine....*,......... 1 4
New Hampshire ...... 1
Vermont............ 1 4 -- 1
Massachusetts...... 182 1 -
Rhode Island....... 71
Connecticut......... 1 ,00 1 1

MIDDLE ATLANTIC ...... 529 1 7 2 12 1 4 5 52
New York City...... 44 1 5 1 6
New York, Up-State. 462 2 1 4 5 49
New Jersey .........
Pennsylvania ....... 23 2 1 4 3

EAST NORTH CENTRAL... f30 7 1 4 1 4 101
Ohio............... 66 6 2 3
Indiana............. I' 1 1 2
Illinois............ 1 3 5 1 2 1- 1 is
Michigan ........... 71 2 3 2
Wisconsin .......... 9h -- 1 23

EST NORTH CENTRAL... 143 2 6 4 1 11 289
Minnesta ......... 9 1 2 74
Iowa................ 38 39
Missouri........... 14 3 2 1 91
North Dakta....... 48 37
South Dak3ra....... 16 13
Nebraska ....... ... 9 -- 1 1 9
Kansas. .......... 9 2 3 -- 5 2b

OUTH ATLNTIC ....... 732 1 I( 3 19 1b 35 7 469
Delaware........... 9 1 I _
Maryland.......... ... 137 1 3 4
Dist. of Columbia.. 2 I -
Virginia ........... 1 9 1 1 7 7 2 250
West Virginia...... 11 1 2 1 3 3 73
North Carolina..... 4 1 5 3 5 13 4
South Carolina .... 1 2 1 2 2
Georgia. ............ 5 2 2 7 3B
Florida............ 188 5 4 2 104

EAST SOUTH CENTRAL... 821 4 1 12 2 t, 6 272
Kentucky.......... 47 2 2 1 2 150
Tennessee .......... 64 2 7 8 2 14 4 93
Alabaa ............ 11 1 29
Mississippi..... 1 1 1 2

WEST SOUTH CENTRAL... 340 1 13 1 17 5 11 7 220
Arkansas........... 1 8 1 3 17
Luisana .......... 5 13
Oklaho-a........... 53 1 4 6 1 36
Texas............ .. 2 6 I 7 1 9 2 6 154

MO NTAIN......... ...... I 3 17 1 5 4 71

Ida'o .............. 1 1 -
Montana............ 12.

Wyoming............ 2 5 40
Colorado........... 727 2 1 5 2
sF6 Mexico......... 1h 5 I 8
ArizonaT ............ 28 2 3 3 17
tah. ............. :5 4 1
eviada .............1 3

PACIFIC....... ....... 81 1 1 1 26 2 1 2 4 1 56
shi ,n ..... .. 617 1 1 1 -
Ore ............. 7
California ......... --- 1 5 1 19 1 4 15l
Alaka. ............. 25 .. 1
a.ai .......... 72 -

urrt : Rai ........... --- 2 12
Selave< re7rt: IST: : 'e. j, l.ans. 1-1








Morbidity and Mortality Weekly Report 195






Week No. TABLE IV. DEATHS IN 122 UNITED) STATES CIlIES FOR WEEK ENDI)EI MAY 31, 1969

22 (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 yArea All 65 years and
Ages and over Influenza Alland 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, lowa------
Duluth, Minn.---------
Kansas City, Kans.----
Kansas City, Mo.------
Lincoln, Nebr.--------
Minneapolis, Minn.----
Omaha, Nebr.----------.
St. Louis, Mo.--------
St. Paul, Minn.-------
Wichita, Kans.----.---


672
207
39
28
25
51
39
15
32
40
59
11
49
29
48

2,925
31
39
134
30
33
43
61
67
1 ,445
32
499
144
47
103
14
36
75
41
25
26

2,444
55
49
780
121
149
104
72
356
30
52
33
24
50
164
14
139
44
24
37
95
52

735
48
14
37
120
18
110
62
212
45
69


391
101
27
15
19
31
25
12
24
1"
29
9
30
14
36

1 ,700
18
25
72
15
17
28
31
34
862
17
285
76
31
62
8
22
44
24
13
16

1 ,395
29
30
439
79
79
46
35
197
22
28
22
11
35
89
5
94
28
11
24
60
32

446
34
10
25
64
16
76
36
118
26
41


*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 ,049
118
245
41
64
81
43
77
24
90
66
160
40

602
98
42
29
97
145
45
39
107

1 ,065
34
22
25
203
44
76
197
30
151
68
1UU
56
53

428
30
23
114
19
117
13
57
55

1 ,356
13
41
id
47
88
356
63
31
151
52
94
179
35
99
47
42


Total 11,276 6,459 J4 522

Cumulative Totals
including reported corrections for previous weeks

All Causes, All Ages ------------------------- 290,754
All Causes, Age 65 and over------------------- 173,474
Pneumonia and Influenza, All Ages------------- 1b,413
All Causes, Under 1 Year of Age--------------- 13,540












Morbidity and Mortality Weekly Report


VIRAL HEPATITIS (Continued from page 190)

East South Central and West South Central Dixisions ex-
hibited rate decreases; in addition, the West North Cen-
tral had a decrease in rate of 27 percent.
The number of cases reported as serum hepatitis
(1.300) for the winter quarter of epidemiologic year 1969
was significantly higher than the 915 cases reported dur-
ing the corresponding quarter of the previous year. How-
ever. this was the first quarter since July 1966 that the
number of cases did not exceed that of the proceeding
quarter (1,420 cases, Table 1).
The pattern of viral hepatitis during the fall and
winter quarters of EY 1969 can be seen in relation to
previous years in Figure 2. Although a general upward
trend in incidence has occurred since EY 1967. this up-
swing has not been as marked as that experienced prior
to the 1961 epidemic peak. It is not possible to predict
when or if a peak year in hepatitis morbidity comparable
to 1961 will occur.
(Reported by the Hepatitis Section, Viral Diseases Branch,
Epidemiology Program, NCDC.)
*Morbicdity data are ..ummarized in Itrms of at n "epliemiologic
year" ihich for h<,pratilis begins with the 27th ieek of the
cahlndar ycar.


EPIDEMIOLOGIC NOTES AND REPORTS
FOLLOW-UP BOTULISM Torrant County, Texas


On March 31. 1969, in Tarrant County, a 25-year-old
man became ill and subsequently developed typical symp-
toms and signs of botulism (MMIR. Vol. 1.8 No. 14). De-
spite treatment with trivalent (A. B. and E) Clostridium
botulinum antitoxin on April 4. he expired on April 9 with
complicating severe pneumonia and respiratory failure.
Type A botulism toxin was demonstrated in a pretreatment
sample of the patient's serum using the mouse protection
test. The isolation from the patient's feces of C. botulinum
organisms which produced type A toxin in vitro provided
corroborative evidence.
During the epidemiologic investigation of the case
b\ local officials over 90 food items were collected for
testing in the laboratory. Neither (. botulinum organisms
nor toxin could ie found in any specimens. Alil ,. "i.. ih no
source for this fatal case of botulism could be found, no
subsequent cases dtevloped in Texas during the ensuing
6 weeks.
(Reported by Staff. Tarrant County Health Department:
11. S. Dickerson, 1.D.. Chief, Communicable Disease
Serrices, a.nd J. V. Irons, Sc.)., Director of Laboratories,
Texas State i)Dpartment of lHealth: Anaerobic Bacteriology
Laboratory. Bacterial Reference I nit, Laboratory Di) i-
siol,. \CD(*: land ti EIS O/fficcr.)


ERRATUM, Vol. 18, No. 21, p. 178
In the article "Smallpox" in Table 1, under the coun-
try of Chad, under weeks- 12. 14, and 15, and under total
to date 1969. the numbers 1, 10. 1. and 12 should he
changed to 0. No cases of smallpox have been reported
from Chad during, 1969.


THE MORBIDITY AND MORTALITY WEEKLY REPORT. WITH A CIRCULA-
TION OF 18,500 IS PUBLISHED AT THE NATIONAL COMMUNICABLE
DISEASE CENTER, ATLANTA, GEORGIA.
DIRECTOR, NATIONAL COMMUNICABLE DISEASE CENTER
DAVID J. SENCER, M.D.
CHIEF. EPIDEMIOLOGY PROGRAM A. 0. LANGMUIR, M.D.
EDITOR MICHAEL B. GREGG. M.D.
MANAGING EDITOR PRISCILLA B. HOLMAN
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
ATTN: THE EDITOR
MORBIDITY AND MORTALITY WEEKLY REPORT
ATLANTA, GEORGIA 30333

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


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