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Morbidity and Mortality U. S. DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE PUBLIC HEALTH SERVICE Prepared by the IhCMUNICAB:LE DISEAEi] For release March 27, 1964 ATLANTA, GEORGIA 30333 Vol. 13, No. 12 PROVISIONAL INFORMATION ON SELECTED NOTIFIABLE DISEASES IN THE UNITED STATES AND ON DEATHS IN SELECTED CITIES FOR WEEK ENDED MARCH 21,1964 RUBELLA On the basis of r Health Departments in, a nationwide epidemic to be in progress A ri late last fall in the n observed only during appears to have spread the exception of Minn a marked rise in rep< creases were observed East North Central ai Atlantic, East Souti. Mountain areas. Labor agent in specimens fr polished in New York C reports from several local and Stare other areas, the diagnosis has been made on the basis of the various regions of the country, clinical characteristics of the illness. of rubella (German measles) appears Rubella is optionally reported on an annual basis to se in reported cases was first noted the Communicable Disease Center by several States. northeast, with peak incidence being Statistics from 25 States and the District of Columbia for the past few weeks. The outbreak the past 10 years are summarized in the graph, page 94 , d rapidly to the south and west. With which demonstrates the recent pattern of occurrence. The esota, all States queried have noted similarity of the patterns observed in the various geo- orted rubella cases. In general, in- graphic areas to that seen for the nation as a whole is of 1 in January in the Mid-Atlantic and interest. The Pacific Stares (Washington and Oregon) areas, and in February in the South demonstrate a curve similar in shape to that observed in Central, West South Central, and other areas, rent one-year shift to the actor) identification of the eliologic right. A si a rved previously in pat- om typical cases has been accom- terns of i occurrence. ity, Philadelphia, and Cleveland; in ase aurn o page 95) Table 1. CASES OF SPECIFIED NOTIFIABLE SEAES UNITED ST os unlopg 5 tCumulative totals include revised and delayea re nrougn previous we w 12th Week Ended \ Cumulat ve. /trst 12 Weeks Disease March 21, March 23, Median Median 1964 1963 1959 1963 4 64 1963 1959 1963 Aseptic meningitis ................ 28 14 --- 312 268 -- Brucellosis ....................... 6 11 11 84 76 117 Diphtheria ........................ 2 10 6 3 81 193 Encephalitis, primary infectious.. 27 2 363 1 -- Encephalitis, post-infectious ..... 14 2. -124 Hepatitis, infectious including serum hepatitis ................ 935 908 908 11,285 12,960 12,960 Measles .......................... 16,892 14,746 15,519 108,045 129,117 136,645 Heningococcal infections .......... 66 57 57 679 691 685 Poliomyelitis, Total .............. 3 1 8 16 37 99 Paralytic ......................... 3 1 5 13 32 57 Nonparalytic ................... --- 3 2 --- Unspecified ................... --- 3 --- Streptococcal Sore Throat and Scarlet fever .................. 11,062 11,199 --- 127,578 120,080 - Tetanus ........................... 2 5 --- 44 42 --- Tularemia ........................ 2 1 --- 68 48 --- Typhoid fever .............. ........ 5 11 9 75 74 99 Rabies in Animals ................. 112 90 95 928 785 923 Table 2. NOTIFIABLE DISEASES OF LOW FREQUENCY Cum. Cum. Anthrax: 1 Psittacosis: Mich. 1, Calif. 1 9 Botulism: 6 Rabies in Man: Leptospirosis: 5 Smallpox: Malaria: N.Y. UP-State 1, Calif. 1 21 Typhus- Plague: Murine: 2 _Rky Mt. Spotted: 3 634-5131 60/9 15/1iv; o9 Morbidity and Mortality Weekly Report RUBELLA UNITED STATES, 1953-1962 ANNUAL TOTALS 26 REPORTING STATES CASES j / / I / / I / Pacific States East North Central States United States (26 States) -United States (26 States) 1953 YEAR \ \ \ ''-- \aa Morbidity and Mortality Weekly Report The clinical characteristics of the disease now oc- curring have varied somewhat within the spectrum of signs and symptoms classically described for rubella. The most frequently described as maculopapular, beginning first on the face and neck, with rapid progression to trunk, arms, hands, legs, and feet. Cervical, occipital, and post- auricular lymphadenopathy has been a prominent feature in reported cases; while most patients have experienced mild fever, the maximum level has nor been impressive. In some areas, arthralgia resembling that of rheumatoid arthritis has been nored. In general, the disease lasts 3-7 days and has been symptomatically mild. Most of the victims are children of school age, but cases have also occurred among pre-school children, as well as adults, although with a lower order of frequency. Prophylaxis with gamma globulin has been used widely in the first trimester of pregnancy and in a few instances physicians have elected to perform therapeutic abortion of pregnant females who experienced the disease. Current epidemiologic reports of rubella from several States are included in this issue. Thus far in 1964, 8417 cases of rubella are reported. For the comparable period of 1963, 1605 cases were reported. The following graph depicts rubella cases for each of the first 12 weeks of 1963 and 1964. CASES 1,500. 400 00 soo. 200 100 REPORTED RUBELLA MASSACHUSETTS, 1963-1964 BY WEEK 1963 ,---. _..- .-N. -- 1 2 3 4 5 6 7 8 9 10 HI 12 WEEK NEW ENGLAND Massachusetts Reports of rubella cases are about 5 times greater than for the comparable period of 1963, one of Massachu- setts' high years for this disease. Rubella cases reported in Massachusetts during the past 11 years are shown in the graph below: RUBELLA MASSACHUSE T TS, 1953-1963 ANNUAL TOTALS CASES 15,000 10,000 / 5,000. 2.,000. 1.000 1953 54 55 56 '57 '58 59 60 '61 62 '63 YEAR The illness has affected large numbers of teenagers and adults, as well as school children. The epidemic appears concentrated in the eastern re- gion of the state; considerably fewer cases are reported in the Berkshire (western) area. There is no normal in- crease in school absenteeism, nor is there an unusual de- mand for gamma globulin. Clinically, the rash is more extensive in individual cases than seen in past epidemics, and is accompanied by the usual adenopathy; arthralgia is not an uncommon symptom, according to Dr. Louis Weinstein. The arthral- gia is noted particularly in adolescent females, affecting the proximal interphalangeal joints, and occasionally the large joints, resembling rheumatoid arthritis. It appears usually as the rash disappears, and may persist for as long as one week. (Reported by Nicholas J. Fiumara, M. D., M.P.H.. Director, Communicable Diseases Massachusetts Department of Public Health, and Louis Weinstein, M. D., Professor of Medicine, Tufts University School of Medicine). Rhode Island Thus far in 1964, Rhode Island has recorded 50 per- cent more cases of rubella than were reported during the entire year, 1963. The epidemic began in late December, and has mushroomed since. Whereas cases are occurring throughout the state, reporting is heaviest in Warwick, i Morbidity and Mortality Weekly Report Cranston and Providence. A graph of the reported rubella cases in Rhode Island for this year, 1963 and 1958 (the last epidemic year) is shown: REPORTED RUBELLA RHODE ISLAND, 1958, 1963-1964 SY MONTH J F M A M J A 'S 0 D MONTH The disease appears to altect school age children, 6-10, primarily, but cases in university and college popu- lations have accounted for about 8 percent of the state's total. The demand for gamma globulin, specifically re- quested for known rubella contacts, has increased marked- ly. In February, 1963, 45 vials were requested for rubella contacts; 644 vials were dispensed this February. More than 600 vials were requested through March 20, compared with 126 for the entire month of March, 1963. (Reported by James Bowes, M. D., Chief. Divirson of Epidemiology, Rhode Island State Health Department). MIDDLE ATLANTIC New York City Rubella cases are reported at about 17 times the num- ber for the comparable period one year ago, and the 1964 totals through March 20 almost equal the total number of cases (8,888) reported for 1955, the last epidemic year in New York City. Case reports increased last April, May and June, then declined to normal. The epidemic began in late fall, and case reports jumped markedly in January. A table comparing January-March, 1963-1964 follows: 1964 1963 January 1441 67 February 3296 103 March 325* 340 *Through March 20 only 8562* 510 Rubella virus was isolated from throat swabs of 8 cases of typical rubella in New York City by Dr. Robert Green and his associates at New York University School of Medicine by the interference technique in African green monkey kidney cultures. The virus was also isolated from nasopharyngeal secretions in some cases as early as 7 days prior to the appearance of the rash and as late as 14 days after resolution of the rash. Rubella virus was demonstrated also in 3 fetuses obtained from therapeutic abortions performed 8 to 28 days after illness in the mother. One patient had received gamma globulin the day of exposure, but she experienced clinical illness 20 days later. (Reported by Dr. Harold T. Fuerst. Director, Bureau of Preventable Disease Ner York City Department of Health; Robert H. Green, M.D Associate Professor of Medicine, Michael R. Balsama, M.D.. Instructor in Medicine. loan P. Grles, Research Associate Professor of Pediatrics, Saul Krugman, M.D.. Professor of Pediatrics, and George Myrick. M.D., Professor of Medicine, New. York Unrversrty.) New York State Reporting of rubella cases has shown a marked in- crease each month since November. The following table compares the cases reported from November to February during the past 3 years. (Figures exclude New York City). 1963-1964 1962-1963 1961-1962 Nov. 135 58 54 D.c. 264 91 81 Jan. 1202 214 143 Feb. 3855 400 247 Although increased numbers of cases are reported throughout New York State, about 40 percent of February's cases occurred in Nassau County. The southern and eastern regions of the Stare also report large numbers of rubella cases. The rubella outbreak has led to increased demands for gamma globulin for exposed expectant mothers. (Reported by Robert M. Albrecht, M.D., Director, Epidemi- ology Division. New York Slate Department of Health). CASta *kch *0O 041l Morbidity and Mortality Weekly Report Pennsylvania EAST NORTH CENTRAL Large numbers of cases of an exanthamatous disease have been reported from several areas in Pennsylvania. An interfering agent, presumably rubella virus, .was isolated from 4 patients by the interference technique in primary African green monkey kidney tissue cultures at the Virus Diagnostic Laboratory, Children's Hospital, Philadelphia, the reference laboratory for the Department of Health, Commonwealth of Pennsylvania. In Allegheny County rubella is epidemic, with more than 300 cases per week reported during March. The total number of cases reported thus far in 1964 has already ex- ceeded the total reported for all of 1963, as shown in the following table listing the total cases reported annually since 1961: 1964 1963 1962 1961 Total Cases 1425* 1202 650 571 "through March 13 only. A minor epidemic was noted during the spring of 1963, resulting in 258 cases 'reported for March of that year. April was the peak month last year, with 358 cases re- ported. This year's epidemic affects elementary school children primarily. The outbreak began in the highest socioeconomic area of the county and has spread con- centrically from southwest to southeast. At present, few cases are reported north of the Ohio river. At the Uni- versity of Pittsburgh, an outbreak of the disease has been observed among students. During the Christmas vacations, two students were exposed to German measles outside the county, and came down with the illness following return to school. Roommates of these two students subse- quently developed the illness, followed in turn by 115 other classmates. Gamma globulin distribution specifically for rubella has increased about 700 percent over that observed in pre- ceding years but, 'to date, .only one case of the illness has been reported in a pregnant woman. (Reported b\ Ailliam D. Schrack, Jr., M.D.. D.P.H., Direc- tor of Communicable Diseases, Pennsylvania Department of Health; g erner Henle, M.D., Director of Laboratories, and Ronald Altman, M.D., Virus Diagnostic Laboratory, Children's Hospital, Philadelphia; and Edwin Brown, M.D., Chief, Division o(Disease Control, and Herbert R. Domke, M.D., Health Oflicer, Allegheny County Health Department). Ohio An increase in the frequency of reported cases of rubella was noted first in Ohio in December 1963; reports have skyrocketed since. A table comparing cases reported during the period November through March with a similar period last year demonstrates this sharp rise: 1963 1964 1962 1964 November 38 32 December 283 71 January 315 145 February 788 467 March 1,940* 623 *1st 3 weeks only. Although the illness has affected school age children primarily, about one percent of Ohio State University stu- dents have experienced rubella during this outbreak. From 6 clinical cases, an interfering agent, presum- ably rubella virus, was isolated by the ECHO 11 inter- ference technique in primary African green monkey kidney tissue cultures, 'according to Dr. Fred Heggie. Rubella virus was serologically identified by Dr. Heggie, in specimens from a Cleveland nursing instructor whose clinical illness was accompanied by neutralizing titer rise from less than 1:2 to greater than 1:16. This patient experienced marked arthralgia in her hands. One of the other clinical cases from which an interfering agent was isolated occurred in a Lorraine County student, 50 percent of whose schoolmates developed clinical rubella within a two-week period. Further laboratory work in- volving tissue cultures of 47 throat swabs from Lorraine County cases or known contacts have failed to reveal evi- dence of enterovirus infection, including ECHO, Cox- sackie B, and polio virus, according to Dr. Martha Lepow, Cleveland Metropolitan General Hospital. (Reported by Dr. Harold A. Decker, M.P.H., Division of Communicable Diseases, Ohio State Department of Health; Fred Heggie, M.D., Research Fellow in Pediatrics and Preventive Medicine, Western Reserve University; and Dr. Martha Lepow, Cleveland Metropolitan General Hos- pital). Morbidity and Mortaliyv weekly Report WEST NORTH CENTRAL Illinois Illln,.i has an S. percent increase in reported rubella cases for January 1 March 1%', 1I,4, as compared with the same period of 1963. This increase is noted :hroughour the rlartL, but especially in Kane, Lake, LaSalle, Lop.in, McLean. Piatn, Warren, and Henry Counties. These coun- ties have reported more cases for the first 12 weeks of 11,4- than for the entire year 106 (see map below). Cook, Macon, and 'innebago Counties also have reported high incidences of rubella this year. Minnesota Rubella, which is not a reportable disease in Minne- sota, does not appear to be unusually prevalent this year. In Minneapolis, 116 cases were reported to date, com- pared with 102 for the comparable period of 1963. A one to 3 percent increase in school absenteeism was noted earlier this month in St. Paul, where mumps and atypical rashes were noted. Viral studies from students at Carleton College, where an exanthematous disease occurred, have not identified a specific etiologic agent. Although the State does not supply gamma globulin for pregnant females with known exposure to rubella, there has been no increase in calls concerning gamma globulin. (Reported by D. S. Fllemring. M.DI., Director, Division of Disease Prevention and Control, Minnesota Department r of Health.) SOUTH ATLANTIC Maryland More than twice as many cases are reported thus far in 1964 than during the entire year, 1963, in Maryland. Approximately 90 percent of this year's cases are re- ported from 6 counties, and over 50 percent of these are from the city of Baltimore and Balrimore and Prince Georges Counties. In Baltimore County, about 15-20 percent of the 3400 students in 2 schools checked were affected. Adults in the same families and older schools teachers also experienced the same clinical illness. The disease is characterized by a mild rash spreading from the face over the trunk, a mild fever to 1010, post auricular and post occipital lymphadenoparhy and has an equal sex and school grade distribution. (Reported by John H. Janney, M.D., Acting Chief, Divi- sion of Fpidemioloug, Mar land ltate Department of Health.) North Carolina The disease is considered to be underreported in Illinois on the basis of requests for gamma globulin for pregnant females exposed to rubella. (Reported by Norman 1. Rose. M.D C(/'ii Bureau of Fp-. demiology, Illinois Departnmrit of Public Hiuall, . Clinical rubella or rubella-like illness is prevalent in North Carolina, a spot check within that State indi- cates. Rubella is not an officially reported disease in North Carolina. At least 3 cities are affected. The out- break began in mid-February, and continues strong in REPORTED RUBELLA OUTBREAKS 0 -14 TOyLS CCeo #"I o WRCESUEO Oate 4I4 -- ,: Morbidity and Mortality Weekly Report some areas while tapering in others. Physicians in most communities have diagnosed rubella clinically, but other physicians prefer the diagnosis of "viral exanthem." Raleigh has experienced the epidemic for the past 6 weeks; it appears to be continuing. The illness is char- acterized by the rash; many victims also have post- auricular nodes and sore throat. There has been a high absenteeism rare in school students. Greensboro has been affected for 4 weeks. Chief victims are elementary school children, but University of North Carolina student nurses and some 50-and 60-year olds were noted to have the same disease. The 'rash lasts 3 days; in some it is noted to fade, then return for another day. The illness is definitely not erythema in- fectiosum, according to the physicians. In Asheville, a similar illness has occurred during the past 4 weeks, but physicians have not diagnosed it as rubella. Many victims have experienced arthritis; occasional cases of encephalitis have been observed. Camp Lejeune doctors have noted typical rubella at that Marine base. (Reported b% Fred T. Foard, M.D., Director of Epidemi- ology, and Jacob Koomen, M.D., M.P.H., Assistant Sec- retary and State Health Director, North Carolina State Board of Health.) Georgia In the metropolitan Atlanta area physicians report a marked increase in incidence of a rash disease similar in rrost patients to rubella. In Dekalb County a telephone survey of public school principals was performed to de- termine the extent of "rash disease" in the community. Although average daily attendance was not significantly different from 1963, it was found that a large percentage of absenteeism was attributed to this rash disease. Fifteen of 20 elementary schools reported the presence of the illness. Principals in these schools estimated ap- proximately 75 percent of their absenteeism was secondary to this disease. In these elementary schools 26 teachers (all females) were affected. Among high schools surveyed four of six had rash illness among the pupils but it was considered to be causing less than 10 percent of absenteeism at present. Four high school teachers had contracted the rash illness. Scattered outbreaks were reported to have occurred before February 1964 but the disease first became apparent in the community during the week of February 23. Elementary and high schools were affected simul- taneously. County health department records of gamma globulin administered to pregnant women for possible rubella exposures indicated a marked increase during that same week. Week of Onset of Rash Illness in DeKalb County Elementary Schools and Number of Doses of Gamma Globulin Administered by the Health Department to Pregnant Women for Possible Rubella Exposure Week Starting Before 2/2 2/2 2/9 2/16 2/23 3/1 3/8 3/15 Schools Affected 3 1 0 0 4 3 7 ? Gamma Globulin Administration 1 0 0 1 6 8 7 9 In most elementary schools the disease first appeared in the lower grades Eight of 14 elementary schools re- ported either the first or second grades to be first affected. Elementary School Grades First Affected by Rash Illness, DeKolb County, Georgia The estimated duration of illness as reported by the school principals generally varied from two to five days for both pupils and teachers. Among Negro patients dura- tion of illness was 9 days to 2 weeks in several cases. The three colleges in the area have had only scat- tered cases prior to spring vacation. (Reported by Dr. W. J. Murphy, Director, Epidemiologic Investigations Branch, Georgia Department of Public Health, Dr. T. O. Vinson, Director of Public Health, DeKalb-Rockdale District, Dr. Marion S. Dressier, DeKalb County Health Department). EAST SOUTH CENTRAL Kentucky About 60 percent more rubella cases are reported thus far in 1964 in Kentucky. For the first 12 weeks of 1964, 730 cases were reported; 461 cases were reported for the comparable period a year ago. The outbreak is scattered throughout the entire State, although not every county has reported increased numbers. The cases are reported in school and pre-school age children primarily. The demand for gamma globulin is the greatest ever in the State. (Reported by ]. Clifford Todd, M.P.H., State Epidemiolo- gist, Kentucky Department of Health.) Morbidity and Mortality Weekly Report Tennessee RubtL lil1 is reported in at least 6 counties, predomi- nantly in eastern Tennessee. Most severely hit is Roane (Counri. population 1O,'12), 35 miles west of Knoxville. The illnt.e appeared first in late January and peaked during the last 2 weeks in February In Roane County the outbreak boosted absenteeism to 20 percent, resulting in the lo-.ing of 6 schools; all but one have reopened. The illness" is concentrated in the elementary school group; infrequent cases occur in pre-school and adult ige groups. (linicall%, it is characterized by a pruritic maculo- papular rash, accompanied by mild fever and palpebral conjunctivitis, as well as post-Lervical, post-occipital and post-auricular lymphadenopathy. No other unusual adenopathy and no splenomegaly are observed. The rash ,haracterisricall. is noted first on the face and neck, with progression to the hands and feet; resolution occurs in the same sequence. The duration of illness usually is 2-4 days, during which time the patients are only mildly symptomatic. Several children have reported one or 2 recurrences within a 4 week period. The disease has not been reported in Memphis or western counties. None of the other areas involved has been affected as severely as Roane County. 1', poitrd by Cecil B. Tucker, M.D., M.P.H., Director, Pereentable Diseases, Tennessee Department of Public Health.) To date, no apparent increase in rubella cases has been noted in the Shreveport metropolitan area in western (Reported by C. T. Caraway, D.V.M.. M P.H.. Assistant Chief. Fpidrem, ,li.\ Section, Louisiana Stair Bruard of lHealthI. MOUNTAIN Colorado Rubella became epidemics in Colorado in late Janu- ary. The total number reported through the 11th week ( '30 cases)exceedsthe total for 1963 (1219 cases). A graph of Colorado's reported cases since 1947 is shown on the opposite page. In 1959, rubella cases increased in March, so the 2 epidemics are not as yet comparable. (Reported by Cecil S. Molloban, M.D., M.P.H., Chief of Epidemiolog). Colorado State Department of Public Health.) PACIFIC Washington Rubella does not appear to be epidemic in the State of Washington. Case reports are slightly higher than one year ago, but are not comparable to the peak year, 1959, when 10,625 cases were reported. (Reported by Ernest A. Ager, M.D.. Chief. Communicable Disease Control, Washington State Department of Health). WEST SOUTH CENTRAL Louisiana The 3 parish metropolitan New Orleans area has noted a sharp increase in the occurrence of rubella cases, which started apparently during the week ended February 1-. While rubella is not a reportable disease in Louisiana, practicing pediatricians estimate the present outbreak to be more extensive than any observed in the past 2 decades. The State Health Department has noted a brisk in- crease in requests for gamma globulin. During March, 196 342 cc. of the substance were dispensed, whereas, already to date this month, 984 cc. were distributed. Demands for the serum remain heavy. The great bulk of of this increase is believed due to requests for rubella proprh laxis in pregnant females, since hepatitis case reponing is about the same as last year. (Gamma globulin requests characteristically are primarily for prophylaxis of these 2 diseases.i 4 INFLUENZA Pneumonia and influenza deaths in 12 reporting reporting cities in the Pacific Coast region increased only slightly during the past week (90 deaths reported as compared to 88 during the previous week). This figure has remained above the epidemic threshold during the past 5 consecutive weeks, however. Pneumonia and influenza deaths in 108 cities representing the country as a whole were below threshold during the past week. Regions other than the Pacific Coast have shown no sustained elevations. 100ll 101 Morbidity and Mortality Weekly Report REPORTED RUBELLA COLORADO, 1947-1963 CASES 3,600 3,000 2,000. 1,500. 1,000. 600. 200. 1947 '48 '49 '50 '51 '52 '53 '54 '55 '56 '57 '58 '59 '60 '61 '62 '63 YEAR California Oregon During the past week, serologic evidence of in- fluenza A2 virus infection was obtained in 12 sporadic cases, representing widely separated areas in northern California. To date, a total of 34 serologically confirmed cases have been reported from 10 counties all but two of these counties lying in the northern part of the State. (In addition to the 12 confirmed cases reported this week, a total of 22 cases were confirmed serologically in two recent institutional outbreaks. See MMWR, Vol. 13, p. 86.) No clearcut community-wide epidemics observed in the Stare thus far this year, although several areas in north- ern California have noted an increasing incidence of influenza-like disease during recent weeks, accompanied in some instances by moderately elevated school absen- teeism. This trend has been observed in several commu- nities in Humboldt County, as well as in the San Fran- cisco Bay area. (Reported b) Phil:p K. Condit, M.D.. Chief. Bureaz of Communicable Discoa Sltte Depart rent of Health, Berkeley, Calilornit., A total of 4,224 cases of influenza-like disease were reported to State health officials in Portland during the past week. Benton, Josephine, and Umatilla counties were the areas showing greatest increase in case reports during this period. The Portland metropolitan area has experienced only mild involvement to date. Serologic studies performed at the Oregon State laboratories have thus far implicated influenza A, virus in 8 cases seen during recent outbreaks. (Reported hb Dr Grant Skinner, Director, Epidermiology Section, State Board ol Health, Portland. Oregon.) WASHINGTON Recently described outbreaks of influenza-like dis- ease are currently subsiding in most affected areas in the State. i Reported b\ Ernest A. .4ger. M.D.. Chief. Ditision o/ Epider.olog~. State Department of Health, 01rmpia, H a shi.gti.,n. I *1 r 1 Morbidity and Mortality Weekly Report ENCEPHALITIS A total of 51 cases of post infectious encephalitis were reported during February (See table right ). This compares with 29 cases reported for January (See MMWR. Vol. 13, p. 46). Mumps was the chief inciting cause, accounting for 19 cases I"6 percent) in February. In January, mumps cases totalled 22 (88 percent). Reports of unspecified post infectious encephalitis are included in the category of primary encephalitis. The monthIl summary lists only chose cases for which an eriology has been specified, either at the time of the report to CDC, or by later communication. REPORTED CASES OF POST-INFECTIOUS ENCEPHALITIS FOR FEBRUARY 4 Weeks Ending 2 6, 2 15, 2 22. 2'29 INCITING CAUSE German REPORTING AREA Mumps Chickenpox Measles Measles Pertussis NEW ENGLAND Massoachusetts 1 MIDDLE ATLANTIC New York Up-State 4 I 2 Pennsylvania 2 EAST NORTH CENTRAL Ohio 3 1 1 Illinois 9 3 Michigan 3 SOUTH ATLANTIC Florida I EAST SOUTH CENTRAL Tennessee 1 WEST SOUTH CENTRAL Arkansas 1 MOUNTAIN Wyoming 1 ________ ____ PACIFIC Washington 3 1 Oregon 2 Calilornia 8 I 1 U. S. TOTAL 39 3 6 2 (States not reporting case not listed) SUMMARY OF DEATHS AMONG PERSONS 65 YEARS AND OVER IN 108 U.S. CITIES The weekly average number of deaths among persons 65 years and over in 108 cities for the four-week period ending March 21 was b,826 as compared with an expected weekly average of 7,0'0. DEATHS at AGE 65 and OC Average Number per Week toOr, -T NUMBER OF .500'- DEATS Pniod No - Week Ending 2.'29 3'7 3,14 3.'21 4 Week Total Weekly Average Observed 6,883 6.912 6,837 6,671 27,303 6.826 Expected 7,107 7,087 7,060 7,026 28,280 7,070 Excess 224 -175 -223 -355 -977 -244 ER in 108 U.S. CITIES by Four Week Periods T I. NFLLUENZA A PLACE OF OCCun i **C LA-- L O_ MO*S -- 1 FffECE rlf OCO jR W *CA At EDt now .r EirnrW uCI 102 (See table, page 107) SUMMARY OF REPORTED CASES OF INFECTIOUS SYPHILIS FEBRUARY 1964 FEBRUARY 1963 CASES OF PRIMARY AND SECONDARY SYPHILIS: By Reporting Area February 1964 and February 1963 Provisional Data Cumulative Cumulative Reporting Area February Jan Feb Reporting Area February Jan Feb 1964 1963 1964 1963 1964 1963 1964 1963 NEW ENGLAND............... 39 32 82 75 EAST SOUTH CENTRAL........ 114 109 227 221 Maine.................... 1 1 Kentucky................. 13 12 19 21 New Hampshire ............ 2 1 3 2 Tennessee................ 44 33 72 70 Vermont.................. Alabama ................. 51 47 120 102 Massachusetts............ 22 13 53 37 Mississippi.............. 6 17 16 28 Rhode Island............. 2 1 4 3 Connecticut.............. 13 16 22 32 WEST SOUTH CENTRAL........ 231 214 410 459 Arkansas................. 18 10 32 30 MIDDLE ATLANTIC............ 490 455 881 984 Louisiana ............... 50 56 99 105 Upstate New York......... 55 39 112 85 Oklahoma................. 8 13 17 37 New York City............ 294 268 504 574 Texas.................... L55 135 262 287 Pa. (Excl. Phila.) ....... 11 10 23 24 Philadelphia.............. 35 62 56 126 MOUNTAIN.................. 46 48 95 86 eew Jersey............... 95 76 186 175 Montana.................. 1 1 - Idaho...................... 1 3 - EAST NORTH CENTRAL......... 187 146 384 302 Wyoming................. 5 3 5 3 Ohio..................... 55 34 107 61 Colorado................. 5 1 12 Indiana.................. 3 3 15 9 New Mexico............... 26 10 50 18 Downstate Illinois....... 16 11 26 21 Arizona................ 12 23 25 39 Chicago .................. 69 66 137 149 Utah ................... 4 3 Michigan ................. 39 29 91 56 Nevada................... 1 7 6 11 Wisconsin..................... 5 3 8 6 PACIFIC................... 206 187 449 393 WEST NORTH CENTRAL........ 64 33 115 68 Washington............... 3 13 11 30 Minnesota................ 17 4 24 13 Oregon................... 9 2 17 7 Iowa..................... 1 3 6 3 California............... 191 168 414 350 Missouri................. 32 13 52 26 Alaska................... 1 1 3 2 North Dakota............. Hawaii ................. 2 3 4 4 South Dakota.............. 4 2 13 5 Nebraska ................. 9 6 15 10 U. S. TOTAL............... 1,943 1,631 3,756 3,527 Kansas .................... 1 5 5 11 ... TERRITORIES............... 68 53 133 109 SOUTH ATLANTIC............ 566 407 1,113 939 Puerto Rico............. 66 52 129 105 Delaware................. 9 3 21 13 Virgin Islands........... 2 1 4 4 Maryland ................. 42 42 80 90 District of Columbia..... 49 52 95 115 Virginia................. 15 26 51 51 West Virginia............ 3 3 4 6 North Carolina........... 94 48 161 138 Note: Cumulative Totals include revised and delayed reports South Carolina........... 98 53 146 114 through previous months. Georgia.................. 98 58 185 155 Florida................... 158 122 370 257 104 lMorbidilt and Mlorlalily Weekly Report Tablic CASES OF SPECIFIED NOTIFIABLE DISEASES. UNITED STATES FOR WEEKS ENDED MARCH 21, 1964 AND MARCH 21. 1963 ( 12rh WEEK) Encephalitis Aseptic Meningitis Primary Post-Inf. Poliomyelitis, Total Cases Poliomyelitis, Paralytic Area Cumulative Cumulative 1964 1963 1964 1964 1964 1963 1964 1963 1964 1963 1964 1963 UNITED STATES... 28 14 27 14 3 1 16 37 3 1 13 32 EW ENGAND............. . Maine ............ - New Hampshire...... - Vermont ............ - Massachusetts....... -- Rhode Island....... - Connecticut ........ . MIDDLE ATLANTIC...... I 1 7 3 1 4 5 1 4 5 New York City .. .... 3 1 1 I- - New York, Up-State. 1 2 2 4 2 4 New Jersey.......... 4 1 - Pennsylvania ....... 1 l I 1 EAST NORTH CENTRAL... 5 3 3 3 1 9 1 7 Ohio ............... 1 1 2 1 Indiana............ 2 - Illinois........... I I 2 1 5 1 4 Michigan........... 3 1 2 2 Wisconsin .......... - WEST NORTH CENTRAL... 2 5 1 1 Minnesota.......... 2 5 1 - Iowa ........ ..... - Missouri............ - North Dakota ....... - South Dakota ....... - Nebraska ........... - Kansas............. - SOUTH ATLANTIC....... 1 2 3 1 9 3 1 6 2 Delaware ........... Maryland........... . Dist. of Columbia.. - Virginia ........... . West Virginia...... - North Carolina..... .- I 1 4 2 1 1 2 South Carolina...... 1 1 Georgla............ 1 1 1 - Florida............ 2 3 3 EAST SOUTH CENTRAL... 7 1 1 - Kentucky.......... 5 - Tennessee.......... 2 - Alabama............. - Mississippi........ . WEST SOUTH CENTRAL... 3 1 9 9 Arkansas........... - Louisiana.......... - Oklahoma........... . Texas.............. 3 1 - MOUNTAIN.............. 2 1 1 1 1 1 Montana............ - Idaho ................ - Wyoming............ - Colorado........... 1 I 1 1 i New Mexico......... - Arizona............. - Utah..... ........ - Nevada............... PACIFIC...... ....... 6 7 6 1 7 1 1 6 Washington........ 1 - Oregon............. 2 1 - California.......... 6 7 5 4 1 1 5 1 1 4 Alaska............. - Hawa i ............. - Puerto Rico 2 2 2 2 Morbidity and Mortality Weekly Report 105 Table 3 CASES OF SPECIFIED NOTIFIABLE DISEASES UNITED STATES FOR WEEKS ENDED MARCH 21, 1964 AND MARCH 23. 1963 ( 121h WEEK) Continued Infectious Hepatitis Brucellosis Diphtheria including Serum Hepatitis Typhoid Fever Area Under 20 years Age Cum. Cum. Total 20 years and over Unknown Cumulative Cum. 1964 1966 1964 1964 1964 1964 1964 1964 1964 1963 1964 1964 UNITED STATES... 6 84 2 43 935 474 412 49 11,285 12,960 5 75 NEW ENGLAND........... 1 83 37 44 2 1,298 1,642 6 Maine .............. 27 9 18 466 753 - New Hampshire...... 3 1 2 117 110 - Vermont............. 19 14 3 2 159 23 Massachusetts...... 1 11 4 7 241 493 3 Rhode Island........ 9 4 5 56 37 3 Connecticut........ 14 5 9 259 226 MIDDLE ATLANTIC...... 1 4 216 97 119 2,511 2,518 11 New York City...... 1 52 15 37 363 283 2 New York, Up-Stare. 84 46 38 1,143 1,157 3 New Jersey......... -- 2 36 7 29 400 383 Pennsylvania....... 1 1 44 29 15 605 695 6 EAST NORTH CENTRAL... 1 13 6 158 88 66 4 1,664 2,062 3 16 Ohio............... 36 16 18 2 457 615 2 13 Indiana............ 1 10 5 5 137 174 1 2 Illinois........... 10 6 40 21 19 258 436 I Michigan.......... 63 39 24 723 726 Wisconsin.......... 1 2 9 7 2 89 111 - WEST NORTH CENTRAL... 1 45 8 62 31 19 12 715 561 2 9 Minnesota........... 2 1 11 6 4 1 52 102 - Iowa............... 1 21 2 1 1 106 92 1 3 Missouri........... 4 25 9 12 4 179 240 1 2 North Dakota....... 1 32 11 - South Dakota....... 8 3 1 2 78 15 1 Nebraska........... 8 1 I 17 41 - Kansas............. 1 7 20 14 6 251 60 3 SOUTH ATLANTIC....... 2 6 1 10 82 47 32 3 1,082 1,393 16 Delaware............ 14 21 - Maryland............ 15 6 9 196 152 - Dist. of Columbia.. 3 1 2 22 49 - Virginia........... 2 10 6 3 1 162 316 2 West Virginia...... 24 21 1 2 204 203 - North Carolina..... 1 10 7 3 203 378 9 South Carolina..... 1 3 2 1 1 36 61 1 Georgia............. 2 2 5 4 1 3 24 48 Florida............ 1 2 14 4 10 221 165 4 EAST SOUTH CENTRAL... 1 3 1 4 52 38 14 760 1,307 9 Kentucky............. 13 10 3 342 395 4 Tennessee........... 1 19 13 6 254 489 4 Alabama............. 1 2 2 12 10 2 107 209 1 Mississippi........ 1 1 1 8 5 3 57 214 - WEST SOUTH CENTRAL.. 4 5 87 49 35 3 799 848 4 Arkansas........... 10 7 3 99 111 1 Louisiana.......... 1 2 10 8 2 150 139 - Oklahoma........... I 4 2 2 47 51 3 Texas.............. 1 3 63 32 28 3 503 547 - MOUNTAIN ............ 7 48 18 6 24 764 961 - Montana............ 3 1 1 1 66 150 Idaho............... 3 3 58 145 Wyoming............. 2 2 31 9 - Colorado............ 19 8 4 7 220 205 - New Mexico......... 1 9 7 2 133 116 - Arizona............ 11 11 162 216 - Utah............... 5 1 1 71 111 - Nevada.............. 23 9 - PACIFIC.............. I 5 5 147 69 77 1 1,692 1,668 4 Washington......... 5 14 5 9 179 273 Oregon............. 6 3 3 176 249 California......... 5 123 60 63 1,239 1.099 4 Alaska ............. 1 1 56 38 - Hawaii............. 3 1 2 42 9 Puerto Rico 2 3 12 9 3 129 139 5 106 Morbidilt and Mortality Weekly Report Table 3 CASES OF SPECIFIED NOTIFIABLE DISEASES. UNITED STATES FOR WEEKS ENDED MARCH 21. 1964 AND MARCH 23. 1963 ( 12Ih WEEK) Conranucd Streptococcal Meningococcal Sore Throat and Rabies in Measles Meningitis Scarlet Fever Tetanus Tularemia Animals Area Cumulative Cum. Cum. Cum. 1964 1964 1964 1963 1964 1963 1964 1964 1964 1964 1964 1964 UNITED STATES... 16,892 66 619 691 11,062 11,199 2 44 2 68 112 928 NEW ENGLAND......... 1,144 3 21 50 1,331 1,276 1 Maine.............. 50 1 2 9 42 39 - New Hampshire...... 47 2 12 3 1 Vermont............ 58 1 16 45 - Massachusetts...... 786 2 10 20 168 174 - Rhode Island....... 71 2 6 217 79 - Connecticut........ 132 7 12 876 936 - MIDDLE ATLANTIC..... 2,386 5 68 93 742 806 1 20 New York City...... 752 1 10 10 47 52 - New York, Up-State. 616 4 25 30 444 385 1 19 New Jersey......... 506 14 15 94 188 - Pennsylvania....... 512 19 38 157 181 1 EAST NORTH CENTRAL... 5,110 9 111 117 2,023 1,444 1 5 7 7 87 Ohio................ 1,246 3 36 31 626 311 1 1 5 44 Indiana............ 1,562 3 16 16 246 113 1 1 1 7 Illinois........... 641 2 24 18 185 208 2 4 1 12 Michigan........... 944 1 29 36 575 373 1 1 9 Wisconsin.......... 717 6 16 391 439 1 15 WEST NORTH CENTRAL... 609 9 35 40 497 371 2 21 39 290 Minnesota.......... 21 1 8 8 43 40 1 11 87 lowa............... 378 2 1 120 109 1 14 95 Missouri........... 72 8 17 19 159 16 2 13 12 62 North Dakota ..... 131 3 1 96 170 15 South Dakota....... 2 59 2 18 Nebraska........... 7 1 8 1 8 Kansas.............. NN 4 1 20 35 6 5 SOUTH ATLANTIC........ 1,938 12 157 146 1,072 881 17 10 17 167 Delaware............ 30 2 1 12 7 - Maryland........... 144 12 23 68 47 1 Dist. of Columbia.. 28 1 4 3 11 -- - Virginia........... 518 1 13 36 296 297 1 3 12 121 West Virginia...... 269 13 9 440 257 7 North Carolina..... 42 26 24 42 53 7 1 2 South Carolina..... 190 3 18 10 66 35 2 - Georgia............ 10 14 8 9 33 6 1 16 Florida............. 707 7 55 32 128 152 6 4 21 EAST SOUTH CENTRAL... 1,933 7 55 52 1,438 1,416 1 6 1 16 12 150 Kentucky............ 532 2 10 16 166 52 1 1 20 Tennessee.......... 1,059 1 25 25 1,212 1,251 1 3 1 11 11 127 Alabama............ 28 1 10 7 11 57 3 3 3 Mississippi........ 314 3 10 4 49 56 1 WEST SOUTH CENTRAL... 97 6 53 71 439 1,061 7 10 24 147 Arkansas........... 42 4 5 6 10 I 1 3 38 Louisiana.......... 13 4 46 24 6 6 3 4 15 Oklahoma........... 42 3 15 70 25 9 4 14 Texas.............. 27 357 1,020 3 13 80 MOUNTAIN.............. 968 3 32 23 1,982 2,464 2 1 4 9 37 Hontana............ 179 98 50 1 - Idaho............... 75 I 89 202 - Wyoming........... 3 1 1 20 92 1 1- - Colorado............ 282 7 5 1,058 1,283 -- - New Mexico......... 32 3 16 2 319 445 1 3 20 Arizona............ 266 2 5 142 262 6 17 Utah............... 36 1 9 256 130 1 2 Nevada............. 95 4 1 - PACIFIC.............. 2,707 14 147 99 1,538 1,480 5 3 29 Washington......... 926 13 11 329 647 - Oregon............. 301 5 4 44 26 - California......... 1,407 12 122 79 995 731 5 3 29 Alaska ............. 64 1 3 4 113 58 - Hawaii............. 9 1 4 1 57 18 - Puerto Rico 301 8 10 2 2 16 2 Morbidity and Morallity Weekly Heport T.ibh 4 (D) TOTAL DEATHS AMON( PERSONS (5 YEARS AND OV'R IN REPORTING (I1TIIS (Tables 4(A), 4(B), 4(C), and 4(D) will be published in sequence covering a four-week period.)o 107 Area For weeks ending Area For weeks ending 2/29 3/7 3/14 3/21 2/29 3/7 3/14 3/21 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, I11............. 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............ 134 28 16 23 40 11 22 15 29 42 3 31 20 35 11 21 80 26 22 25 29 53 1,024 17 312 106 41 67 16 26 50 18 17 14 36 19 389 119 Ill 62 58 184 26 21 27 14 35 89 24 84 20 16 21 53 42 40 14 19 107 12 83 42 173 37 45 166 20 18 21 19 17 19 16 21 37 8 25 18 48 24 19 83 30 25 29 47 44 1,016 29 333 101 42 68 14 31 39 16 20 16 37 32 407 104 148 87 47 191 20 22 15 14 31 82 17 80 14 19 31 72 31 38 16 26 79 25 76 54 113 45 44 137 19 15 19 22 15 24 20 30 44 9 31 17 40 18 18 88 25 13 26 39 46 1,020 16 336 101 33 79 15 43 44 31 21 13 34 24 384 98 94 56 57 182 25 26 23 18 36 83 15 102 23 18 21 62 31 34 17 19 73 15 72 43 144 48 33 NOTE: All deaths by place ol occurrence. 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, Cclo ............. 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.......... Porcland, Oreg............ Sacramento, Calif ........ San Diego, Calif......... San Francisco, Calif..... San Jose, Calif.......... Seattle, Wash ............ Spokane, Wash............ Tacoma, Wash............. 58 131 13 43 41 26 53 22 75 46 105 22 47 36 22 59 83 31 20 62 26 15 11 67 11 44 113 38 109 42 59 28 26 10 12 92 13 68 7 25 40 19 21 39 14 35 288 49 23 105 36 60 121 22 87 34 23 55 151 23 57 61 30 62 26 75 47 96 14 57 31 17 74 54 26 18 58 20 9 15 74 26 26 75 26 98 52 67 38 43 20 15 71 11 52 6 24 36 16 30 36 19 49 322 57 21 68 43 47 114 28 100 34 34 62 138 21 20 44 16 51 18 65 38 88 23 55 27 19 80 69 28 17 51 19 18 12 78 19 34 94 33 88 35 52 25 40 21 9 72 13 64 5 30 27 11 22 44 20 44 355 73 22 103 56 51 133 34 89 39 29 San Juan, P.R.............. 11 8 10 (---) oCurrent Week Mortality for 108 Selected Cities 4(A) Total Mortality, all ages.................... 11,942 4(B) Pneumonia-Influenza Deaths, all ages........ 554 4(C) Total Deaths under 1 Year of Age............. 784 4(D) Total Deaths, Persons 65 years and over..... 6,671 *Estimate based on average percent of divisional total. Totals for previous weeks include reported corrections. Morbidity and Mortality Weekly Report INTERNATIONAL NOTES QUARANTINE MEASURES Immunization Information for International Travel 1963-64 Edition Public Health Service Publication No. 384 The following information should be added to the list of Yellow Fever Vaccination Centers in Section 6: Page 69 City: Santa Ana, California Center: Clinic Hours: Fee: Orange County Health Department Wednesday, 2:00 p.m. No In addition to the established procedures for reporting morbidity and mortality, the Communicable Disease Center welcomes accounts of interesting outbreaks or cases. Such accounts should be addressed to: Lawrence K. Alrmon. M.D., Editor Morbidity and Mortality Weekly Report Communicable Disease Center Atlanta, Georgia 30333 NoHes: Themu provisional dae are bored on weekly telegraml te e Croa* ni. cabe Dioelre Center by rkh Individual Stoae health departments. Symbols- Dane nor aevlable oQuauity ere Procedure for conucllftJn of vraous mortality curve. mer e oeblanld from Srotirtics Section, Comminncable Disease Cnfter, Public Neelsh Service, U. S. Deporrteni of Healhk, Education, and Welfare, Atlmure, Cmrloe JOJn3. The following correction should be added to the list of Yellow Fever Vaccination Centers in Section 6: Page 73 City: Albuquerque, New Mexico Center: Lovelace Clinic 4800 Gibson Blvd., S.E. Telephone 265-1211 Ext. 362 Clinic Hours: UNIV Or cL IB SDOC MENTS DEPT U S DEPOSITORY Friday, 2:00 p.m. Fee: The Morbidity and Mortality Weekly Report, with a circulation of 10,800 is published by the Communicable Disease Center, Atlanta, Georgia. Chef, Communicable Disease Center Chief. Epidemiology Branch Chief, Statistics Section Asst. Chief, Statistics Section Chief, Surveillance Section Edrtor, MMWR James L. Goddard, M.D. A. D. Langmuir, M.D R. E. Serfling, Ph.D. I. L. Sherman, M.S. D. A. Henderson, M.D. L. K. 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