HICNet Medical News Digest      Sun, 19 Dec 1993        Volume 06 : Issue 56

Today's Topics:

  [MMWR 17 Dec 93] Viral Gastroenteritis Related to Consumption Oysters
  [MMWR] HIV Transmission Between Two Brothers with Hemophilia
  [MMWR] Resurgence of Pertussis
  [MMWR] Estimates Future Global Tuberculosis Morbidity/Mortality
  [MMWR] Approval Haemophilus influenzae vaccine for children/infants
  Epidemological Bulletin from Institute of Tropical Medicine

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Date: Sun, 19 Dec 93 22:39:44 MST
From: mednews (HICNet Medical News)
To: hicnews
Subject: [MMWR 17 Dec 93] Viral Gastroenteritis Related to Consumption Oysters
Message-ID: <XkDuec1w165w@stat.com>

                        Epidemiologic Notes and Reports

                 Multistate Outbreak of Viral Gastroenteritis
                     Related to Consumption of Oysters --
          Louisiana, Maryland, Mississippi, and North Carolina, 1993

     On November 17, 1993, the state health departments of Louisiana,
Maryland, and Mississippi notified CDC of several outbreaks of gastroenteritis
occurring in their states since November 12. Preliminary epidemiologic
investigations identified consumption of oysters as the primary risk factor
for illness. On November 16, the Louisiana Department of Health and Hospitals
(LDHH) had identified the Grand Pass and Cabbage Reef harvesting areas off the
Louisiana coast as the source of oysters associated with outbreaks in
Louisiana and Mississippi. Tagged oysters associated with outbreaks in
Maryland were traced to the same oyster beds. The oysters harvested from these
areas had been distributed throughout the United States. On November 18 and
19, the LDHH and CDC notified state epidemiologists of the potential for
oyster-associated illness; outbreaks of oyster-associated gastroenteritis
subsequently were identified in Florida and North Carolina. Collaborative
investigations by state health officials, the Food and Drug Administration
(FDA), and CDC were initiated to determine the magnitude and characteristics
of the multistate outbreak, identify the etiologic agent, and trace the
oysters. This report summarizes the preliminary findings of the ongoing
investigation.*
     As of December 2, the investigation had identified 23 separate clusters
of ill persons in four states. These clusters have accounted for acute
gastroenteritis in at least 180 persons who consumed oysters in a variety of
settings, ranging from an individual family meal to a 3-day festival attended
by 19,000 persons. Similar clinical features of gastroenteritis predominated
in all clusters. In Maryland, where 90 ill persons were identified, clinical
features included diarrhea (83 [92%]), vomiting (64 [71%]), nausea (60 [67%]),
abdominal cramps (55 [61%]), and fever (40 [44%]). For ill persons from
Louisiana, Maryland, and Mississippi, the median incubation period was 34
hours (n=146 persons), and median duration of illness was 37 hours (n=137).
     Raw or steamed oysters were the only food associated with illness; attack
rates among the 23 groups ranged from 43% to 100%. Oysters from 20 of 23
outbreaks were traced to the implicated harvest area; oysters or their tags
were not available from the other three clusters. Three persons were
hospitalized, and at least four cases of secondary transmission have been
reported. In one Maryland cluster, associated with a 3-day event beginning on
November 12, primary cases first occurred on November 13; secondary cases
first occurred on November 18 (Figure 1).
     Stool specimens were examined by electron microscopy (EM) and reverse
transcription-polymerase chain reaction (RT-PCR) methods. Small round
structured viruses or Norwalk-like viruses were detected by EM and confirmed
by RT-PCR in 13 of 26 stool specimens from ill persons in Louisiana, Maryland,
Mississippi, and North Carolina. Oysters associated with several of the
outbreaks are being analyzed for the presence of Norwalk-like viruses by RT-
PCR.
     In addition to the notification of state and territorial epidemiologists
by LDHH and CDC on November 18 and 19, four public health measures were
implemented to prevent further outbreaks associated with the contaminated
oysters. First, on November 16, LDHH implemented National Shellfish Sanitation
Program (NSSP) procedures for shellfish harvesting closures and recall
procedures for oysters from the implicated harvest area (1). Second, on
November 18, public health officials in Maryland, North Carolina, and Virginia
initiated investigations to identify, detain, and recall all Grand Pass and
Cabbage Reef oysters harvested during November 9-11 that had reached the
retail markets in their states. Third, on November 23, FDA issued a statement
advising consumers that all oysters harvested before November 16 from the
Grand Pass and Cabbage Reef areas should not be consumed. Fourth, on November
24, CDC issued a follow-up memorandum to all state and territorial
epidemiologists and public health laboratory directors alerting them to the
outbreaks and instructing appropriate handling of laboratory specimens if
additional outbreaks are suspected.
     The continuing investigation in Louisiana, Maryland, Mississippi, and
North Carolina includes efforts to trace contaminated oysters from the
implicated harvest area through large distributors to retailers and consumers.

Reported by: C Conrad, Seafood Sanitation Program; K Hemphill, Molluscan
Shellfish Program; S Wilson, L McFarland, DrPh, State Epidemiologist, Office
of Public Health, Louisiana Dept of Health and Hospitals. K Coulbourne, Talbot
County Health Dept, Easton; S Qarni, MD, Baltimore County Health Dept,
Baltimore; S Poster, Harford County Health Dept, Bel Air; C Groves, MS, C
Slemp, MD, E Butler, D Matuszak, MD, D Dwyer, MD, E Israel, MD, State
Epidemiologist, Maryland State Dept of Health and Mental Hygiene. J Cirino,
Bureau of Marine Resources; D Cumberland, L Pollack, MD, B Brackin, MPH, M
Currier, MD, State Epidemiologist, Mississippi State Dept of Health. H Morris,
Beaufort County Health Dept, Washington; M Bissett, S Evans, Craven County
Health Dept, New Bern; B Respess, Pitt County Health Dept, Greenville; B
Jenkins, J Maillard, MD, R Meriwether, MD, JN MacCormack, MD, State
Epidemiologist, North Carolina Dept of Environment, Health, and Natural
Resources. B Creasy, J Veazey, K Calci, S Rippey, PhD, G Hoskin, Food and Drug
Administration. Div of Field Epidemiology, Epidemiology Program Office; Viral
Gastroenteritis Section, Respiratory and Enteric Viruses Br, Div of Viral and
Rickettsial Diseases, National Center for Infectious Diseases, CDC.

Editorial Note: Because oysters from the beds implicated in this outbreak were
shipped to at least 14 states,** public health officials, health-care
providers, and the public should be informed of the possibility that
consumption of oysters from these beds may be associated with clusters and
isolated cases of acute gastroenteritis in their states. The cases of
gastrointestinal illnesses identified by this investigation were recognized
because they occurred as part of discrete clusters; however, it is likely that
many isolated cases occurred but were not recognized or reported. For example,
a previous study of persons who attended a national convention in Louisiana
determined that the risk for acute gastroenteritis was higher among persons
who consumed raw shellfish than among those who did not, even though no
"outbreaks" were identified (2).
     Oysters can be traced to their harvest beds because of the regulation
requiring sacks of oysters to carry a tag identifying their harvest date and
the bed from which they were harvested (1). In this multistate outbreak, these
tags facilitated the rapid identification and closing of contaminated beds,
provided the link for illness occurring simultaneously in several states, and
enabled a product recall.
     Investigations of shellfish-associated outbreaks of gastroenteritis have
implicated a variety of pathogens, including Vibrio species, Salmonella typhi,
Campylobacter species, hepatitis A, and Norwalk-like viruses. For most
reported outbreaks, however, an etiologic agent is not identified; these
outbreaks may be of viral origin (3). Gastrointestinal illness associated with
the consumption of virally contaminated oysters characteristically is self-
limited and not life-threatening. However, the likelihood of more severe
disease may be increased for persons who are immunocompromised or have other
chronic problems (e.g., alcoholism; hepatic, gastrointestinal, or hematologic
disorders; cancer; diabetes; or kidney disease).
     The etiology of this multistate outbreak was determined rapidly because
specimens were collected and handled appropriately and new PCR-based assays
were available (4,5). To enable examination of specimens for viral agents in
such outbreaks, the following methods are recommended: 1) collection of large-
volume stool specimens in clean, dry containers during the first 48 hours of
illness and storage at 39 F (4 C) and2) collection of acute- (within 1 week of
onset of illness) and convalescent-phase (3-4 weeks after onset) serum
specimens.
     FDA, NSSP, and the Interstate Shellfish Sanitation Conference have
developed guidelines to protect consumers by controlling the harvesting,
handling, and processing of shellfish products (6). Additional efforts are
required to develop new assays for screening for viral pathogens in these
products before distribution to consumers and to evaluate the effectiveness of
various food-preparation practices in decreasing the risk for infection
associated with the consumption of molluscan shellfish.

References

1. Office of Seafood, Shellfish Sanitation Branch, Food and Drug
Administration. National Shellfish Sanitation Program manual of operations:
part II, 1992 revision. Washington, DC: US Department of Health and Human
Services, Public Health Service, Food and Drug Administration, 1992.

2. Lowry PW, McFarland LM, Peltier BH, et al. Vibrio gastroenteritis in
Louisiana: a prospective study among attendees of a scientific congress in New
Orleans. J Infect Dis 1989;160:978-84.

3. Morse DL, Guzewich JJ, Hanrahan JP, et al. Widespread outbreaks of clam-and
oyster-associated gastroenteritis: role of Norwalk virus. N Engl J Med
1986;314:678-81.

4. CDC. Recommendations for collection of laboratory specimens associated with
outbreaks of gastroenteritis. MMWR 1990;39(no. RR-14).

5. Jiang X, Wang J, Graham DY, Estes MK. Detection of Norwalk virus in stool
by polymerase chain reaction. J Clin Microbiol 1992;30:2529-34.

6. Ahmed FE, ed. Seafood safety. Washington, DC: National Academy Press, 1991.

*Because the outbreaks in Florida have been linked to consumption of oysters
from harvest areas other than the Louisiana coast, those outbreaks are not
included in this report.

**Alabama, California, Florida, Illinois, Louisiana, Maryland, Mississippi,
Missouri, New Jersey, North Carolina, South Carolina, Tennessee, Texas, and
Virginia.




------------------------------

Date: Sun, 19 Dec 93 22:40:48 MST
From: mednews (HICNet Medical News)
To: hicnews
Subject: [MMWR] HIV Transmission Between Two Brothers with Hemophilia
Message-ID: <PmDuec2w165w@stat.com>

                        Epidemiologic Notes and Reports

                               HIV Transmission
                Between Two Adolescent Brothers With Hemophilia
     In July 1992, the National Hemophilia Foundation and CDC received a
report from a hemophilia-treatment center of a 19-year-old man with hemophilia
(patient 2) who recently had seroconverted for antibody to human
immunodeficiency virus (HIV). This report summarizes the findings of an
investigation by CDC and state and local public health officials, which
determined he was infected with a strain of HIV nearly identical to that in
his previously infected older brother (patient 1).*

                                Case Summaries

     Patient 1, who has severe factor VIII deficiency (hemophilia A), before
1985, received factor VIII concentrate made from plasma that was neither
screened for HIV antibody nor heat-treated. Review of medical records
indicated that in 1983 he had an episode of pharyngitis and diffuse lymph node
enlargement compatible with an acute retroviral syndrome. In 1985, when first
tested, HIV antibody was detected in his serum. His CD4+ T-lymphocyte count
ranged from 400 to 550 cells/uL during 1987-1991 but declined to 110 cells/uL
in 1992.
     Patient 2 also received unscreened factor VIII concentrate before 1985 to
treat severe hemophilia A. Since 1985, however, he had received only screened
and heat-treated factor concentrate, and beginning in 1988, he received only
concentrate that was heat-treated and monoclonally purified. HIV-antibody
tests performed annually during November 1985-April 1989 were negative. When
his serum was next tested in January 1992, HIV antibody was detected. A stored
plasma specimen drawn in April 1991 also contained HIV antibody. His CD4+ T-
lymphocyte count was 1102 cells/uL in 1985, 846 cells/uL and 500 cells/uL as
measured from the same specimen in two different laboratories in 1987, and 70
cells/uL and 120 cells/uL at two different times in 1992.
     The brothers have two uncles with hemophilia and HIV infection; one uncle
visited their home daily to weekly but did not live with them. This uncle was
HIV-seropositive when first tested in 1985.

                              Laboratory Findings

     Nucleotide sequencing of HIV-1 DNA indicated that the viral strains
present in both brothers were genetically similar. Proviral DNA from
peripheral blood mononuclear cells obtained from each brother and from the
uncle with whom they had frequent contact was amplified by polymerase chain
reaction. DNA fragments encompassing 345 nucleotides of the V3 and flanking
regions of the gene encoding the HIV-1 envelope glycoprotein (gp120) were
sequenced after cloning into M13 vectors. Genetic analysis indicated that two
variants, or quasi-species, were present in both brothers. Variant A was the
predominant species (15 of 21 clones) in patient 1 and the minor species (one
of 20 clones) in patient 2, with an average intravariant nucleotide divergence
of 1.8% between the two brothers. Variant B was the minor species in patient 1
(six of 21 clones) and the predominant species in patient 2 (19 of 20 clones),
with an average intravariant nucleotide diversity of 3.5% in the B variants
between the two brothers. The average nucleotide difference between variants A
and B in the two brothers was 6.2%. Only one HIV variant was present in the
uncle; that variant differed from variant A by 10.2% and variant B by 10.8%.

                          Epidemiologic Investigation

     Information concerning factor concentrate administration during the
period in which patient 2 most likely was infected (October 1988 [6 months
before his last negative HIV-antibody test] through April 1991) was obtained
by review of medical records and interviews with the two brothers. During this
period, patient 1 received factor concentrate infusions at home approximately
10 times per year and patient 2 approximately five times per year. Each
brother reported always self-administering infusions and never receiving
assistance from anyone else, including the other brother. They reported
routinely administering their infusions at different times of the day and in
different locations in their home. On the infrequent days when both received
infusions on the same day, they reportedly never administered factor
concentrates in the same room at the same time and never used each other's
infusion equipment. Contaminated needles and other infusion equipment used
were reportedly kept in one puncture-resistant container.
     Both brothers recalled sharing a razor on one occasion, most likely
during 1988, when they both cut themselves and bled slightly while shaving.
They did not recall which brother used the razor first. Patient 2 was not
aware of any other contact with his brother's blood or bloody body fluids. In
October 1988, patient 1 had bleeding hemorrhoids; however, his blood
reportedly never soaked through his clothing and never contaminated his
sheets, toilet seats, or other environmental surfaces.
     From October 1988 through April 1991, the two brothers were not
hospitalized at the same time and made no visits to the dentist, emergency
department, or outpatient clinic on the same day. Neither brother reported
receiving tattoos, acupuncture, or injections other than factor concentrates
nor recalled having had a needlestick injury or open skin lesions. During this
period, the two brothers shared a bedroom and routinely slept in the same bed
at night. Their mother and sister also lived in the household; the sister
tested negative for HIV antibody, and the mother declined to be tested.
     The brothers denied having had sex with any common sex partners or with
each other. In 1990, patient 2 had unprotected sexual contact with two women;
one tested negative for HIV antibody in 1992, and the other could not be
located. During 1989 and 1990, patient 2 had acute gastrointestinal bleeding
and received transfusions of six units of red blood cells from seronegative
donors later determined not to be infected with HIV.

Reported by: A Brownstein, MPH, National Hemophilia Foundation, New York City.
W Fricke, MD, Center for Biologics Evaluation and Research, Food and Drug
Administration. Div of HIV/AIDS, National Center for Infectious Diseases, CDC.

Editorial Note: The laboratory and epidemiologic findings from this
investigation indicate that patient 2 became infected with an HIV strain that
had previously infected his older brother. The presence in each brother of two
variants of HIV, each with DNA sequence concordance similar to that reported
for other infections known to be epidemiologically related (1-3), strongly
supports the hypothesis that their infections are related. However, the more
than 3-year interval between seroconversion in the two brothers strongly
suggests that the brothers were not infected by the same source (e.g.,
contaminated clotting factor concentrate administered in 1985 or earlier).
     Although this investigation was unable to determine precisely how patient
2 became infected with HIV, transmission most likely occurred during the
reported blood contact (i.e., the episode of razor-sharing) or other blood
contact that went unrecognized or unreported. Factors accounting for an
increased likelihood of blood contact included possible bleeding related to
hemophilia or its treatment, the presence of used needles in the home, and the
close physical contact between the brothers. However, it is also possible that
transmission occurred through an exposure, such as sexual contact, that was
not identified by the investigation. The limited ability of the brothers to
recall events 2-3 years earlier and the inability of the investigators to
independently confirm information provided by the brothers made determining
the precise mode of transmission difficult.
     Seventeen previous studies in the United States and Europe have examined
the prevalence of HIV infection among nonsexual, nonneedlesharing household
contacts of persons with HIV infection; none of the 1167 contacts who were
followed for more than 1700 person-years in these studies were infected (95%
confidence interval for the rate of transmission=0-0.2 infections per 100
person-years) (4). However, HIV has been transmitted in households in which
opportunities existed for percutaneous, skin, or mucous-membrane contact with
HIV-infected blood. This report is the second documented instance of HIV
transmission between siblings with hemophilia; the first report documented
opportunities for percutaneous blood exposure associated with intravenous
infusions (2). Cases of HIV transmission also have been reported in households
in which needles were shared for medical injections at home (5), cutaneous
exposure to blood occurred during home health care (6,7), and there was
presumed but undocumented blood contact between young children (3).
     The findings in this report re-emphasize the need for precautions to
prevent contact with blood in households and other settings--especially those
in which health care is provided. Adherence to guidelines for preventing blood
exposure in health-care and other settings (8-10) may reduce the risk for
blood contact and transmission of bloodborne pathogens even in homes and other
settings in which the risk is already extremely low.

References

 1. Ou C-Y, Ciesielski CA, Myers G, et al. Molecular epidemiology of HIV
transmission in a dental practice. Science 1992;256:1165-71.

 2. CDC. HIV infection in two brothers receiving intravenous therapy for
hemophilia. MMWR 1992;41:228-31.

 3. Fitzgibbon JE, Gaur S, Frenkel LD, Laraque F, Edlin BR, Dubin DT.
Transmission of human immunodeficiency virus type 1 with a zidovudine
resistance mutation between two children. N Engl J Med 1993;329:1835-41.

 4. Simonds RJ, Chanock S. Medical issues related to caring for HIV-infected
children in and out of the home. Pediatr Infect Dis J 1993;12:845-52.

 5. Koenig RE, Gautier T, Levy JA. Unusual intrafamilial transmission of human
immunodeficiency virus. Lancet 1986;2:627.

 6. Grint P, McEvoy M. Two associated cases of the acquired immunodeficiency
syndrome (AIDS). Communicable Disease Report 1985;42:4.

 7. CDC. Apparent transmission of human T-lymphotrophic virus type
III/lymphadenopathy-associated virus from a child to a mother providing health
care. MMWR 1986;35:76-9.

 8. CDC. Recommendations for prevention of HIV transmission in health-care
settings. MMWR 1987;36(suppl 2S).

 9. CDC. Update: universal precautions for prevention of transmission of human
immunodeficiency virus, hepatitis B virus, and other bloodborne pathogens in
health-care settings. MMWR 1988;37:377-82,387-8.

10. Simonds RJ, Rogers MF. HIV transmission--bringing home the message
[Editorial]. N Engl J Med 1993;329:1883-5.

*Single copies of this report will be available free until December 17, 1994,
from the CDC National AIDS Clearinghouse, P.O. Box 6003, Rockville, MD 20849-
6003; telephone (800) 458-5231.




------------------------------

Date: Sun, 19 Dec 93 22:43:18 MST
From: mednews (HICNet Medical News)
To: hicnews
Subject: [MMWR] Resurgence of Pertussis
Message-ID: <uqDuec3w165w@stat.com>

                                Current Trends

                Resurgence of Pertussis -- United States, 1993

     From January 3 through December 4, 1993 (weeks 1-48), 5457 pertussis
cases were reported to CDC--an 82% increase over the number reported during
the same period in 1992 (3004) and the highest annual number of cases reported
since 1967 (Figure 1). Compared with 1992, the number of reported pertussis
cases increased in 35 states, especially those in the New England, middle-
Atlantic, North Central, and Mountain regions (Figure 2). During 1993, large
outbreaks have occurred in Chicago and Cincinnati. This report summarizes
epidemiologic characteristics of pertussis cases reported through December 4,
1993.

                                Characteristics

     Of 4989 persons with pertussis for whom age was known, 2218 (44.4%) were
infants (i.e., aged less than 1 year); 1031 (20.7%), aged 1-4 years; 563
(11.3%), aged 5-9 years; and 1177 (23.6%), aged greater than or equal to 10
years. Of 1976 infants for whom age in months was reported, 1555 (78.7%) were
aged less than 6 months and 421 (21.3%), aged 6-11 months.

                     Vaccination Status and Complications

     Supplemental reports about vaccination status and complications were
available for 744 (13.6%) cases. Of 596 persons for whom vaccination status
was known, 368 (61.7%) had received fewer than three doses of diphtheria and
tetanus toxoids and pertussis vaccine (DTP)*. Of 207 children aged 7 months-4
years who were "age-eligible" to have received three doses of DTP, 33 (15.9%)
had received no doses, and 97 (46.9%) had received fewer than three doses. Of
infants with pertussis for whom data on disease severity were available, 212
(65.2%) of 325 had been hospitalized, 45 (15.8%) of 285 had had pneumonia
confirmed radiographically, and five (1.6%) of 305 had had seizures resulting
from pertussis. Of the 5457 persons with pertussis, seven died.

                                   Outbreaks

     Chicago. From July 1 through October 30, a total of 226 persons with
suspected cases of pertussis were reported to the Chicago Department of
Health. Of these, 70 (31.0%) persons tested culture-positive for Bordetella
pertussis; an additional 96 (42.5%) persons met the CDC clinical case
definition for pertussis** during outbreaks. Of the remaining 60 cases, 29
(48.3%) did not meet the clinical case definition, and 31 (51.7%) are still
under investigation. Of the 166 persons whose illness met the case definition
or who had culture-confirmed pertussis, the median age was 9 months (range:
less than 1 month-35 years). Most (127 [76.5%]) of these cases were reported
by a single pediatric teaching hospital, and 70 (42.2%) persons were
hospitalized (median hospital stay: 5 days). Of 111 persons aged greater than
2 months with pertussis for whom previous vaccination history was available,
52 (46.8%) were not up-to-date with DTP vaccinations. Of 61 persons with
pertussis aged 7 months-4 years, 30 (49.2%) had received fewer than three
doses of DTP, and six (10.0%) had received no doses.
     Cincinnati. From July 1 through October 30, a total of 285 suspected
cases of pertussis were reported to the Cincinnati Health Department: 164
(57.5%) cases were culture-confirmed; 102 (35.8%) occurred in infants. Nearly
all (265 [93.0%]) cases were reported by a single large teaching hospital, and
95 (33.3%) persons were hospitalized. Measures to control this epidemic
included introduction of an accelerated DTP vaccination schedule (doses given
at 1, 2, and 3 months of age) for infants. Investigation of this outbreak is
ongoing.

Reported by: J Wilhelm, MD, T Kenyon, MD, E Mihalek, K Brusealas, Chicago Dept
of Health; S Shulman, MD, E Bergman, Children's Memorial Hospital, Chicago; R
Daum, MD, Wyler Children's Hospital, Chicago; BJ Francis, MD, State
Epidemiologist, D Robinson, Illinois Dept of Public Health. M Adcock, PhD, J
Daniels, MD, V Wells, MD, Cincinnati Health Dept; C Christie, MD, S Reising,
PhD, Children's Hospital Medical Center, Cincinnati; TJ Halpin, MD, State
Epidemiologist, Ohio Dept of Health. R Finger, MD, State Epidemiologist, Dept
of Health Svcs, Kentucky Cabinet for Human Resources. National Immunization
Program, CDC.

Editorial Note: Based on the number of pertussis cases reported through
December 4, the projected total number of cases for 1993 will be the highest
reported since 1967. Since 1976 (when the lowest number of pertussis cases
[1010] was reported), the number of reported cases in peak years has steadily
increased (Figure 1); in 1990 (the last peak year), 4570 cases were reported.
Despite the recent resurgence in pertussis, the number of cases reported in
1993 represents a more than 96% decline from the annual number reported during
the prevaccine era (i.e., before 1948).
     Complications associated with pertussis may be severe, especially among
infants. Rates of complications among infants during 1993 have been similar to
those reported during 1980-1989, when 69% were hospitalized, 22% developed
pneumonia, 3% had seizures, 1% had pertussis encephalopathy, and 0.6% died
(2). The two groups currently at greatest risk for severe complications are
infants aged less than 6 months (the age by which children are recommended to
have received three doses of DTP) and preschool-aged children who are
undervaccinated. The finding that approximately 50% of preschool-aged children
with pertussis in 1993 were undervaccinated underscores the importance of
timely vaccination of children according to the recommendations of the
Advisory Committee on Immunization Practices (ACIP)***. During outbreaks
involving primarily young infants, introduction of an accelerated DTP
vaccination schedule (doses given at ages 6, 10, and 14 weeks) should be
considered; for preschool-aged children, receipt of three or more doses is
highly protective against severe disease caused by pertussis (4).
     Pertussis incidence is usually characterized by a cyclical pattern, with
peaks occurring at 3- to 4-year intervals; the increase in reported cases in
1993 coincides with the expected cyclical peak. However, the total number of
reported cases has increased in each successive peak year since 1977 (Figure
1); reasons for this resurgence of pertussis are unclear. Vaccination coverage
with three or more doses of DTP among children aged 2 years has remained
relatively stable but low (approximately 70%) since 1962 (CDC, unpublished
data). Furthermore, the proportion of reported pertussis cases among children
aged 1-4 years has not increased during 1980-1993. These observations suggest
that the recent increase in pertussis incidence is related neither to a
decrease in vaccination coverage nor to a substantive reduction in DTP vaccine
efficacy.
     As the incidence of pertussis has increased, the proportion of reported
cases among persons aged greater than or equal to 10 years has increased--from
15.1% during 1977-1979 to 19.8% during 1980-1989 and 26.9% during 1992-1993.
Adolescents and young adults play an important role in transmitting pertussis
to susceptible infants because vaccination-induced immunity to pertussis wanes
with increasing age (beginning approximately 4 years after the last dose) (5-
8). In addition, pertussis among adolescents and adults is often atypical and
is frequently not diagnosed (9).
     In addition to prevention through vaccination, control of pertussis and
interruption of transmission requires prompt recognition of disease by health-
care providers and timely administration of effective antimicrobials (i.e.,
erythromycin or trimethoprim-sulfamethoxazole) to persons with pertussis and
their close contacts (8). Health-care providers should consider the diagnosis
of pertussis in persons of all age groups who develop a cough lasting more
than 7 days. Because only 10% of pertussis cases are reported (10),
surveillance must be enhanced. In addition, all cases should be investigated
promptly. In the future, introduction of new acellular pertussis vaccines for
use in adolescents or young adults may potentially reduce the disease burden
in these age groups and among young children.

References

 1. Medical Research Council. The prevention of whooping cough by vaccination.
Brit M J 1951;1:1463-71.

 2. Farizo KM, Cochi SL, Zell ER, Brink EW, Wassilak SG, Patriarca PA.
Epidemiological features of pertussis in the United States, 1980-1989. Clin
Infect Dis 1992;14:708-19.

 3. ACIP. Diphtheria, tetanus, and pertussis: recommendations for vaccine use
and other preventive measures--recommendations of the Immunization Practices
Advisory Committee (ACIP). MMWR 1991;40(no. RR-10).

 4. Onorato I, Wassilak SG, Meade B. Efficacy of whole-cell pertussis vaccine
in preschool children in the United States. JAMA 1992;267:2745-9.

 5. Lambert HJ. Epidemiology of a small pertussis outbreak in Kent County,
Michigan. Public Health Rep 1965;80:365-9.

 6. Jenkinson D. Duration of effectiveness of pertussis vaccine: evidence from
a 10-year community study. BMJ 1988;296:612-4.

 7. Bass JW, Stephenson SR. The return of pertussis. Pediatr Infect Dis J
1987;6:141-4.

 8. Biellik RJ, Patriarca PA, Mullen JR, et al. Risk factors for community-and
household-acquired pertussis during a large-scale outbreak in central
Wisconsin. J Infect Dis 1988;157:1134-41.

 9. Herwaldt LA. Pertussis in adults: what physicians need to know. Arch
Intern Med 1991;151:1510-2.

10. Sutter RW, Cochi SL. Pertussis hospitalizations and mortality in the
United States, 1985-1988: evaluation of the completeness of national
reporting. JAMA 1992;267:386-91.

*Three doses of DTP is the minimum number required for effective protection
against pertussis (1).

**Cough illness lasting greater than or equal to 14 days without other
apparent cause.

***DTP at ages 2, 4, 6, and 15 months, with an additional dose at age 4 6
years (3). Diphtheria and tetanus toxoids and acellular pertussis (DTaP)
vaccine may be used for the fourth and fifth doses in the series, beginning at
15 months of age.




------------------------------

Date: Sun, 19 Dec 93 22:44:03 MST
From: mednews (HICNet Medical News)
To: hicnews
Subject: [MMWR] Estimates Future Global Tuberculosis Morbidity/Mortality
Message-ID: <5RDuec4w165w@stat.com>

                              International Notes

        Estimates of Future Global Tuberculosis Morbidity and Mortality

     Tuberculosis (TB) is the leading cause of death associated with
infectious diseases globally. The incidence of TB is expected to increase
substantially worldwide during the next 10 years because of the interaction
between the TB and human immunodeficiency virus (HIV) epidemics. This report
uses TB notification data (i.e., cases reported to the ministries of health
and collected by the World Health Organization [WHO]) to estimate the future
global public health impact of TB and assesses the present and future
contribution of HIV infection to TB.

                                   Morbidity

     The incidence of TB in 1990 was calculated for each WHO region by first
estimating the incidence in some of the most populated countries in each
region for which notification data were considered reliable (i.e., the data
were provided by programs with established surveillance systems) (1). For
countries without reliable notification data, annual risk of infection was
used to estimate incidence (2). Incidence estimates were then applied to the
populations in subregions and then used in calculating regional totals. For
projections of future TB incidence, regional age-specific incidence rates for
1990 were first derived by applying regional data on the age distribution of
reported cases to the estimated crude incidence rates. Based on the assumption
that future age-specific trends will remain stable, trends in regional
reporting rates during 1985-1990 were applied to the 1990 regional age-
specific incidence rates to derive such rates for 1995, 2000, and 2005. These
rates were subsequently applied to regional age-specific population
projections (3,4).
     During 1990, an estimated 7.5 million incident cases of TB occurred
worldwide (Table 1). Approximately 4.9 million cases (66%) occurred in the
Southeast Asian and Western Pacific regions; India (2.1 million), China (1.3
million), and Indonesia (0.4 million) accounted for the largest number of
cases. By 2005, the incidence of TB may increase to 11.9 million cases per
year--an increase of 58% over 1990. Demographic factors (e.g., population
growth and changes in the age structure of populations) will account for 77%
of the predicted increase in incidence; epidemiologic factors (e.g., changes
in incidence rates associated with the HIV epidemic) will account for 23%. For
example, incidence rates for Africa may increase by 10 additional cases per
100,000 population per year during 1990-2005, primarily because of the HIV
epidemic. In the Southeast Asian, Western Pacific, Eastern Mediterranean, and
American regions, age-specific incidence rates are expected to decline during
1990-2005; in comparison, age-specific rates in Eastern Europe, Western
Europe, and other industrialized countries may remain stable. However, because
of population growth, the total number of new cases in these regions will
continue to increase.

                                 HIV Infection

     The estimated impact of HIV infection on TB incidence was based on
reported HIV seroprevalence data among patients with TB (5), assumed changes
in HIV seroprevalence by region through 2000, and the estimation that 95% of
HIV-associated TB cases are attributable to HIV infection (4). For 1990, an
estimated 4.2% of all incident TB cases were attributable to HIV infection.
This proportion may increase to 8.4% in 1995 and to 13.8% by 2000, when more
than 1.4 million cases will be attributable to HIV infection (4). During 1990-
1999, an estimated 88.2 million persons will develop TB; 8 million of those
cases will be attributable to HIV infection (4).

                                   Mortality

     Estimates of TB deaths for 1990 were derived using 1) published case-
fatality rates of 7% for industrialized countries (6), 2) estimated case-
fatality rates of 15% for Eastern Europe, 3) an estimated case-fatality rate
of 20% for Central and South America, and 4) the assumption that all cases
reported to WHO were treated and that 5% of treated cases were not reported
for other regions. Based on these considerations, an estimated 40%-50% of new
cases were treated in 1990; assuming a case-fatality rate of 55% for persons
not receiving treatment and 15% for those receiving treatment, the overall
case-fatality rates for other regions ranged from 35% to 40%. In estimating
future mortality, the proportion of persons with cases treated was assumed to
remain at the 1990 level. The number of TB deaths associated with HIV
infection were estimated by applying these same case-fatality rates to the
estimates of HIV-attributable cases.
     For 1990, an estimated 2.5 million deaths occurred from TB, of which
116,000 were associated with HIV infection (Table 2). In 2000, an estimated
3.5 million TB deaths will occur (39% more than in 1990), and approximately
0.5 million will be associated with HIV infection. Almost half of these HIV-
associated deaths will occur in sub-Saharan Africa. During 1990-1999, an
estimated 30 million persons will die from TB; approximately 3 million of
those deaths will be associated with HIV infection. In Southeast Asia, 12.3
million deaths from TB will occur during the decade, of which approximately 1
million will be associated with HIV infection. Nearly 6 million TB deaths are
projected in sub-Saharan Africa, of which approximately 1.5 million will be
associated with HIV infection.

Reported by: PJ Dolin, PhD, Imperial Cancer Research Fund, Cancer Epidemiology
Unit, Radcliffe Infirmary, Univ of Oxford, Oxford, United Kingdom. MC
Raviglione, MD, A Kochi, MD, Tuberculosis Program, World Health Organization,
Geneva.

Editorial Note: The estimates of current TB incidence in this report, which
are based primarily on notification data, are similar to those produced by
other methods and document the substantial public health burden of TB in
developing countries (7,8). Moreover, because TB cases are generally
underreported, estimates of incidence based on notification data are likely
conservative. Similarly, estimates of TB mortality should be considered to be
conservative (8): earlier estimates used a case-fatality rate of 50% for HIV-
associated cases, while the current estimate did not assume that mortality was
different between HIV-positive and HIV-negative persons. Because TB mortality
is highly related to case finding and treatment, projections beyond 2000 were
not made.
     The use of short-course therapy in well-managed national TB programs has
reduced TB-associated morbidity, even under the most adverse circumstances
(e.g., in countries with high prevalences of HIV infection) (9). The use of
this intervention for persons with smear-positive TB is also among the most
cost-effective health interventions available (10). The potential benefits of
these and other strategies for TB control should be evaluated by those
countries most severely affected by TB and by donor countries and
organizations that invest in health-care programs in countries with high rates
of TB.

References

 1. World Health Organization. Tuberculosis notification update, July 1992.
Geneva: World Health Organization, Division of Communicable Diseases,
Tuberculosis Program, 1992; publication no. WHO/TB/92.169.

 2. Cauthen GM, Pio A, Ten Dam HG. Annual risk of tuberculosis infection.
Geneva: World Health Organization, Tuberculosis Program, 1988; publication no.
WHO/TB/88.154.

 3. United Nations. Global estimates and projections of population by sex and
age, 1988 revision. New York: United Nations, 1989; publication no.
ST/ESA/SER.R/93.

 4. Dolin PJ, Raviglione MC, Kochi A. A review of current epidemiological data
and estimations of current and future incidence and mortality from
tuberculosis. Geneva: World Health Organization, Tuberculosis Program, 1993
(in press).

 5. Narain JP, Raviglione MC, Kochi A. HIV-associated tuberculosis in
developing countries: epidemiology and strategies for prevention. Tuber Lung
Dis 1992;3:311-21.

 6. Raviglione MC, Sudre P, Rieder HL, Spinaci S, Kochi A. Secular trends of
tuberculosis in Western Europe. Bull World Health Organ 1993;71:297-306.

 7. Murray CJ. Health sector priorities review: tuberculosis. In: Jamison DT,
Mosley WH, eds. Disease control priorities in developing countries. New York:
Oxford University Press, 1993.

 8. Sudre P, Ten Dam G, Kochi A. Tuberculosis: a global overview of the
situation today. Bull World Health Organ 1992;70:149-59.

 9. Styblo K. The impact of HIV infection on the global epidemiology of
tuberculosis. Bull Int Union Tuberc Lung Dis 1991;66:27-32.

10. Murray CJL, DeJonghe E, Chum HJ, Nyangulu DS, Salomao A, Styblo K. Cost
effectiveness of chemotherapy for pulmonary tuberculosis in three sub-Saharan
African countries. Lancet 1991;338:1305-8.




------------------------------

Date: Sun, 19 Dec 93 22:44:45 MST
From: mednews (HICNet Medical News)
To: hicnews
Subject: [MMWR] Approval Haemophilus influenzae vaccine for children/infants
Message-ID: <aTDuec5w165w@stat.com>

                     Food and Drug Administration Approval
           of Use of Haemophilus influenzae Type b Conjugate Vaccine
            Reconstituted with Diphtheria-Tetanus-Pertussis Vaccine
                           for Infants and Children

     Haemophilus influenzae type b (Hib) conjugate vaccines have been
recommended for use in infants since 1990, and their routine use in infant
vaccination has contributed to the substantial decline in the incidence of Hib
disease in the United States (1-3). Vaccines against diphtheria, tetanus, and
pertussis during infancy and childhood have been administered routinely in the
United States since the late 1940s and have been associated with a more than
90% reduction in morbidity and mortality caused by infection with these
organisms. Because of the increasing number of vaccines now routinely
recommended for infants, a high priority has been placed on the development of
combined vaccines that allow simultaneous administration with fewer separate
injections. One product combining Hib conjugate vaccine with diphtheria and
tetanus toxoids and whole-cell pertussis vaccine had been licensed by the Food
and Drug Administration (FDA) (4).
     On November 18, 1993, the FDA approved the reconstitution of the
previously licensed Hib conjugate vaccine (tetanus toxoid conjugate) (PRP-T),
with a previously licensed diphtheria and tetanus toxoids and whole-cell
pertussis vaccine (DTP), allowing simultaneous vaccination for Hib disease,
diphtheria, tetanus, and pertussis in a single injection. PRP-T, manufactured
by Pasteur Merieux Serums and Vaccines and distributed by Connaught
Laboratories, Inc. (CLI) (Swiftwater, Pennsylvania) as ActHIB (trademark)*,
and by SmithKline Beecham (Philadelphia) as OmniHIB (trademark), is now
licensed to be reconstituted with DTP manufactured by CLI. ActHIB (trademark)
is distributed as 10 single-dose vials of lyophilized PRP-T, packaged together
with a multidose vial of CLI DTP for reconstitution. Other licensed
formulations of DTP have not been approved by FDA for reconstitution of PRP-T
vaccine and may not be used for that purpose.
     PRP-T reconstituted with CLI DTP has been licensed for use in children
aged 2 months-5 years for protection against diphtheria, tetanus, pertussis,
and Hib disease. Previously unvaccinated younger children should receive doses
of the PRP-T-CLI DTP combination at ages 2, 4, 6, and 15-18 months. Based on
comparable antibody responses to each of the components of the vaccine, PRP-T
reconstituted with CLI DTP is expected to provide protection against Hib
disease, as well as diphtheria, tetanus, and pertussis, equivalent to that of
already licensed formulations of other DTP and Hib conjugate vaccines.
     The Advisory Committee on Immunization Practices (ACIP) recommends that
all infants receive a primary series of one of the licensed Hib conjugate
vaccines beginning at age 2 months and a booster dose at age 12-15 months (5).
The ACIP also recommends that all infants receive a four-dose primary series
of diphtheria and tetanus toxoids and pertussis vaccine at ages 2, 4, 6, and
15 months and a booster dose at age 4-6 years (6-8).

Reported by: Office of Vaccines Research and Review, Center for Biologics
Evaluation and Research, Food and Drug Administration. Childhood and
Respiratory Diseases Br, Div of Bacterial and Mycotic Diseases, National
Center for Infectious Diseases; National Immunization Program, CDC.

References

1. Adams WG, Deaver KA, Cochi SL, et al. Decline of childhood Haemophilus
influenzae type b (Hib) disease in the Hib vaccine era. JAMA 1993;269:221-6.

2. Broadhurst LE, Erickson RL, Keiley PW. Decrease in invasive Haemophilus
influenzae disease in U.S. Army children, 1984 through 1991. JAMA
1993;269:227-31.

3. Murphy TV, White KE, Pastor P, et al. Declining incidence of Haemophilus
influenzae type b disease since introduction of vaccination. JAMA
1993;269:246-8.

4. CDC. FDA approval of use of a new Haemophilus b conjugate vaccine and a
combined diphtheria-tetanus-pertussis and Haemophilus b conjugate vaccine for
infants and children. MMWR 1993;42:296-8.

5. ACIP. Recommendations for use of Haemophilus b conjugate vaccines and a
combined diphtheria, tetanus, pertussis, and Haemophilus b vaccine:
recommendations of the Advisory Committee on Immunization Practices (ACIP).
MMWR 1993;42(no. RR-13).

6. ACIP. Diphtheria, tetanus, and pertussis: recommendations for vaccine use
and other preventive measures--recommendations of the Immunization Practices
Advisory Committee (ACIP). MMWR 1991;40(no. RR-10).

7. ACIP. Pertussis vaccination: acellular pertussis vaccine for reinforcing
and booster use--supplementary ACIP statement. Recommendations of the
Immunization Practices Advisory Committee (ACIP). MMWR 1992;41(no. RR-1).

8. ACIP. Pertussis vaccination: acellular pertussis vaccine for the fourth and
fifth doses of the DTP series--update to supplementary ACIP statement.
Recommendations of the Advisory Committee on Immunization Practices (ACIP).
MMWR 1992;41(no. RR-15).

*Use of trade names and commercial sources is for identification only and does
not imply endorsement by the Public Health Service or the U.S. Department of
Health and Human Services.




------------------------------

Date: Sun, 19 Dec 93 22:45:21 MST
From: mednews (HICNet Medical News)
To: hicnews
Subject: Epidemological Bulletin from Institute of Tropical Medicine
Message-ID: <auDuec6w165w@stat.com>

IPK - EPIDEMIOLOGICAL BULLETIN               Vol 3e / No.46
                                             Date: 11/20/93


Institute of Tropical Medicine "Pedro Kouri"
National Epidemiology Office
Ministry of Public Health
------------------------------------------------------------------

Cuba. Cases and Cumulative of selected notifiable diseases. Week
ending 11/20/93. (46th week)
-------------------------------------------------------------------

DISEASES            IN THIS WEEK   CUMULATIVE          RATES+
                    1992 1993      1992      1993      1992 1993
------------------------------------------------------------------
 TYPHOID FEVER      *    1         46        179       0.4  1.8
 TUBERCULOSIS       15   10        501       573       5.2  5.9
 HANSEN DISEASE     5    7         259       161       2.7  1.6
 PERTUSSIS          *    *         1         11        0.0  0.1
 SCARLET FEVER      8    3         565       332       5.9  3.4
 TETANUS            *    *         2         *         0.0  *
 ASEPTIC MEN.       61   77        3750      2935      39.2 30.3
 BACTERIAL MEN.     30   22        1611      1019      16.8 10.5
 VARICELLA          316  193       102305    39551   1071.3 409.3
 VIRAL HEPATITIS    553  220       29047     13537    304.1 140.0
 MALARIA            *    *         11        15        0.1  0.1
 LEPTOSPIROSIS      51   26        508       667       5.3  6.9
 MENINGOCOCCAL D.   *    1         130       66        1.3  0.6
 SYPHILIS           209  226       9664      8115     101.2 83.9
 GONORRHEA          507  399       23354     16831    244.5 174.1
 ACUMINATA COND.    57   39        2194      1669      22.9 17.2
 MEASLES            1    *         10        3         0.1  0.0
 RUBELLA            *    *         6         5         0.0  0.0
 MUMPS              *    *         3         2         0.0  0.0
 ACUTE AMEB. D.     16   3         701       1434      7.3  15.0
------------------------------------------------------------------
 Source:  1992, MND (Written Report) EIG-IPK.
          1993, MND (Phone Report) EIG-IPK.

          * Means 0 reported case.
          + Period adjusted rate.


Medical Consultations of Acute Diarrhoeal Diseases by age groups.
Cases and Cumulative. Week ending 11/20/93 (46th week).
------------------------------------------------------------------
               IN THIS WEEK                       CUMULATIVE
 AGE           CASES               MEDIAN         1992      1993
 GROUPS        1992      1993      (1986-1992)
------------------------------------------------------------------
 <1            2652      3243      3593           174995   144799
 1 - 4         3144      3922      3235           197339   179427
 5 - 14        1986      2072      2117           126727   130331
 15 - 64       6306      7196      6306           446868   450294
 > 65          749       856       612            45812    46453
------------------------------------------------------------------
 Source:  MND (Phone Report).


Acute Respiratory Infections. Cuba, Weekly Index by age groups.
Week ending 11/20/93 (46th week)
-------------------------------------------------------
 AGE           WEEKLY         EPIDEMIC       EPIDEMIC
 GROUPS        INDEX          INDEX          THRESHOLD
-------------------------------------------------------
 < 1           439            619            734
 1 - 4         282            347            431
 5 - 14        82             96             121
 15 - 64       27             36             46
 > 65          23             28             35
 ALL AGES      59             75             87
-------------------------------------------------------
 Source:  MND (Phone Report). Index x 10000 inhabitants.


Notified Outbreaks. Week 11/18/93 - 11/24/93.
-----------------------------------------------------------------
DISEASES       NUMBER OF OUTBREAKS      CASES          PROVINCES
-----------------------------------------------------------------
 F.T.D.             5              88        VILLA CLARA 3/32



                        SANT.CUBA 2/56
-----------------------------------------------------------------
 Source:  DIS.


Meningococcal Disease. Cuba. More important indexes. Week ending
11/24/93.
-------------------------------------------------------------------

AGE       MORBIDITY                MORTALITY
LETHALITY
 GROUPS   CASES     RATES          DEATHS    RATES     RATES
          1992 1993 1992 1993      1992 1993 1992 1993 1992 1993
------------------------------------------------------------------
 0-5      85   36   8.5  3.7       15   8    1.5  0.8  17.6 21.6
 6-14     14   8    1.1  0.6       2    1    0.1  0.0  14.2 12.5
 >15      31   21   0.4  0.2       10   9    0.1  0.1  32.2 42.8
 ALL AGES 130  66   1.3  0.6       27   18   0.2  0.1  20.7 27.6
------------------------------------------------------------------
 Source:            DIS, EIG-IPK
          Cumulative and period adjusted rate x 100000 inhabitants.

          Lethality expressed as percentage.


_________________________________________________________________
This bulletin was prepared with the 64% of provinces-days- information. The
provinces: Villa Clara, Cienfuegos, Sancti Spiritus, Camaguey, Granma and
Santiago de Cuba have contributed with the 100% provinces-days-information.

The offered indexes are provisionals and were taken from the daily report of
the Direct Information System (DIS) remitted by Provincial Centers of Hygiene
and Epidemiology, from the weekly phone report of Mandatory Notifiable
Diseases (MND) remitted by National Statistics Division of the Ministry of
Public Health, and from the Reference Laboratories of the Institute of
Tropical Medicine "Pedro Kouri".
_________________________________________________________________

This is the weekly IPK-Epidemiological Bulletin emitted via Electronic Mail.
The numbering plan agree with the IPK- Epidemiological Bulletin edited by
Institute of Tropical Medicine "Pedro Kouri" and it is an abbreviated version.


IPK - EPIDEMIOLOGICAL BULLETIN               Vol 3e / No.47
                                             Date: 11/27/93


Institute of Tropical Medicine "Pedro Kouri"
National Epidemiology Office
Ministry of Public Health
------------------------------------------------------------------

Cuba. Cases and Cumulative of selected notifiable diseases. Week
ending 11/27/93. (47th week)
-------------------------------------------------------------------
DISEASES            IN THIS WEEK   CUMULATIVE          RATES+
                    1992 1993      1992      1993      1992 1993
------------------------------------------------------------------
 TYPHOID FEVER      *    28        46        207       0.4  2.1
 TUBERCULOSIS       10   7         511       580       5.2  5.8
 HANSEN DISEASE     3    1         262       162       2.6  1.6
 PERTUSSIS          *    *         1         11        0.0  0.1
 SCARLET FEVER      7    2         572       334       5.8  3.3
 TETANUS            1    *         3         *         0.0  *
 ASEPTIC MEN.       61   121       3811      3056     39.0  30.9
 BACTERIAL MEN.     35   33        1646      1052     16.8  10.6
 VARICELLA          370  158       102675    39709  1052.4  402.2
 VIRAL HEPATITIS    543  223       29590     13760   303.3  139.3
 MALARIA            *    *         11        15        0.1  0.1
 LEPTOSPIROSIS      8    33        516       700       5.2  7.0
 MENINGOCOCCAL D.   8    *         138       66        1.3  0.6
 SYPHILIS           283  194       9947      8309    101.9  83.9
 GONORRHEA          436  368       23790     17199   243.8  174.2
 ACUMINATA COND.    40   42        2234      1711     22.8  17.3
 MEASLES            1    *         11        3         0.1  0.0
 RUBELLA            *    *         6         5         0.0  0.0
 MUMPS              *    *         3         2         0.0  0.0
 ACUTE AMEB. D.     25   6         726       1440      7.4  14.7
------------------------------------------------------------------
 Source:  1992, MND (Written Report) EIG-IPK.
          1993, MND (Phone Report) EIG-IPK.

          * Means 0 reported case.
          + Period adjusted rate.


Medical Consultations of Acute Diarrhoeal Diseases by age groups.
Cases and Cumulative. Week ending 11/27/93 (47th week).
------------------------------------------------------------------
               IN THIS WEEK                       CUMULATIVE
 AGE           CASES               MEDIAN         1992      1993
 GROUPS        1992      1993      (1986-1992)
------------------------------------------------------------------
 <1            2667      3096      3663           177662   147895
 1 - 4         3262      3814      3470           200601   183241
 5 - 14        2087      2890      2206           128824   133221
 15 - 64       6340      7263      6340           453208   457557
 > 65          726       818       626            46538    47271
------------------------------------------------------------------
 Source:  MND (Phone Report).


Acute Respiratory Infections. Cuba, Weekly Index by age groups.
Week ending 11/27/93 (47th week)
-------------------------------------------------------
 AGE           WEEKLY         EPIDEMIC       EPIDEMIC
 GROUPS        INDEX          INDEX          THRESHOLD
-------------------------------------------------------
 < 1           390            620            734
 1 - 4         245            345            428
 5 - 14        77             96             121
 15 - 64       25             36             46
 > 65          22             28             36
 ALL AGES      53             75             86
-------------------------------------------------------
 Source:  MND (Phone Report). Index x 10000 inhabitants.


Notified Outbreaks. Week 11/25/93 - 12/01/93.
-----------------------------------------------------------------
DISEASES       NUMBER OF OUTBREAKS      CASES          PROVINCES
-----------------------------------------------------------------
 F.T.D.             2              209       PINAR DEL RIO 1/10
                                             CAMAGUEY 1/199
------------------------------------------------------------------
 VIRAL HEPATITIS    1              8         CIUDAD HABANA
-----------------------------------------------------------------
 Source:  DIS.


Meningococcal Disease. Cuba. More important indexes. Week ending
12/01/93.
-------------------------------------------------------------------
AGE       MORBIDITY                MORTALITY           LETHALITY
 GROUPS   CASES     RATES          DEATHS    RATES     RATES
          1992 1993 1992 1993      1992 1993 1992 1993 1992 1993
------------------------------------------------------------------
 0-5      91   37   9.0  3.6       17   8    1.6  0.7  18.6 21.6
 6-14     14   8    1.1  0.6       2    1    0.1  0.0  14.2 12.5
 >15      33   21   0.4  0.2       12   9    0.1  0.1  36.3 42.8
 ALL AGES 138  66   1.3  0.6       31   18   0.3  0.1  22.4 27.2
------------------------------------------------------------------
 Source:  DIS, EIG-IPK
          Cumulative and period adjusted rate x 100000 inhabitants.
          Lethality expressed as percentage.


_________________________________________________________________
This bulletin was prepared with the 67% of provinces-days-information. The
provinces: Ciudad de La Habana, Villa Clara, Cienfuegos, Sancti Spiritus,
Camaguey, Granma and Guantanamo have contributed with the 100% provinces-days-
information.

The offered indexes are provisionals and were taken from the daily report of
the Direct Information System (DIS) remitted by Provincial Centers of Hygiene
and Epidemiology, from the weekly phone report of Mandatory Notifiable
Diseases (MND) remitted by National Statistics Division of the Ministry of
Public Health, and from the Reference Laboratories of the Institute of
Tropical Medicine "Pedro Kouri".
_________________________________________________________________

IPK - EPIDEMIOLOGICAL BULLETIN               Vol 3e / No.47
                                             Date: 12/04/93

Institute of Tropical Medicine "Pedro Kouri"
National Epidemiology Office
Ministry of Public Health
------------------------------------------------------------------

Cuba. Cases and Cumulative of selected notifiable diseases. Week
ending 12/04/93. (48th week)
-------------------------------------------------------------------
DISEASES            IN THIS WEEK   CUMULATIVE          RATES+
                    1992 1993      1992      1993      1992 1993
------------------------------------------------------------------
 TYPHOID FEVER      *    *         46        207       0.4  2.0
 TUBERCULOSIS       27   12        535       592       5.3  5.8
 HANSEN DISEASE     11   3         274       165       2.7  1.6
 PERTUSSIS          *    *         1         11        0.0  0.1
 SCARLET FEVER      10   2         582       336       5.8  3.3
 TETANUS            *    *         3         2         0.0  0.0
 ASEPTIC MEN.       75   89        3886      3145     39.0  31.2
 BACTERIAL MEN.     38   26        1629      1078     16.3  10.6
 VARICELLA          352  209       103027    39918  1034.2  395.9
 VIRAL HEPATITIS    441  253       30031     14013   301.4  139.0
 MALARIA            *    *         11        8         0.1  0.0
 LEPTOSPIROSIS      52   44        568       744       5.7  7.3
 MENINGOCOCCAL D.   1    *         139       66        1.3  0.6
 SYPHILIS           219  167       10166     8476    102.0  84.0
 GONORRHEA          495  366       24283     17565   243.7  174.2
 ACUMINATA COND.    35   40        2269      1751     22.7  17.3
 MEASLES            *    *         11        *         0.1  *
 RUBELLA            *    *         6         *         0.0  *
 MUMPS              *    *         3         1         0.0  0.0
 ACUTE AMEB. D.     42   6         768       1446      7.7  14.3
------------------------------------------------------------------
 Source:  1992, MND (Written Report) EIG-IPK.
          1993, MND (Phone Report) EIG-IPK.

          * Means 0 reported case.
          + Period adjusted rate.


Medical Consultations of Acute Diarrhoeal Diseases by age groups.
Cases and Cumulative. Week ending 12/04/93 (48th week).
------------------------------------------------------------------
               IN THIS WEEK                       CUMULATIVE
 AGE           CASES               MEDIAN         1992      1993
 GROUPS        1992      1993      (1986-1992)
------------------------------------------------------------------
 <1            3088      3006      4314           180750   150901
 1 - 4         3573      3811      3682           204174   187052
 5 - 14        2306      2649      2210           131130   135870
 15 - 64       7460      7717      6405           460668   465274
 > 65          833       880       681            47371    48151
------------------------------------------------------------------
 Source:  MND (Phone Report).

Acute Respiratory Infections. Cuba, Weekly Index by age groups.
Week ending 12/04/93 (48th week)
-------------------------------------------------------
 AGE           WEEKLY         EPIDEMIC       EPIDEMIC
 GROUPS        INDEX          INDEX          THRESHOLD
-------------------------------------------------------
 < 1           385            618            732
 1 - 4         247            341            425
 5 - 14        83             95             120
 A5??I?????$???$???H???     36             46
 > 65          24             28             36
 ALL AGES      56             74             85
-------------------------------------------------------
 Source:  MND (Phone Report). Index x 10000 inhabitants.


Notified Outbreaks. Week 12/02/93 - 12/08/93.
--------qm?------------------------------------------------------
DISEASES       NUMBER OF OUTBREAKS      CASES          PROVINCES
-----------------------------------------------------------------
-              -                        -              -
-----------------------------------------------------------------
 Source:  DIS.


Meningococcal Disease. Cuba. More important indexes. Week ending
12/01/93.
-------------------------------------------------------------------
AGE       MORBIDITY                MORTALITY           LETHALITY
 GROUPS   CASES     RATES          DEATHS    RATES     RATES
          1992 1993 1992 1993      1992 1993 1992 1993 1992 1993
------------------------------------------------------------------
 0-5      91   37   8.8  3.5       17   8    1.6  0.7  18.6 21.6
 6-14     14   8    1.0  0.6       2    1    0.2  0.0  14.2 12.5
 >15      34   21   0.4  0.2       13   9    0.1  0.1  38.2 42.8
 ALL AGES 139  66   1.3  0.6       32   18   0.3  0.1  23.0 27.2
------------------------------------------------------------------
 Source:  DIS, EIG-IPK
          Cumulative and period adjusted rate x 100000 inhabitants.
          Lethality expressed as percentage.


_________________________________________________________________
This bulletin was prepared with the 47% of provinces-days-information. The
provinces: Camaguey and Granma have contributed with the 100% provinces-days-
information.

The offered indexes are provisionals and were taken from the daily report of
the Direct Information System (DIS) remitted by Provincial Centers of Hygiene
and Epidemiology, from the weekly phone report of Mandatory Notifiable
Diseases (MND) remitted by National Statistics Division of the Ministry of
Public Health, and from the Reference Laboratories of the Institute of
Tropical Medicine "Pedro Kouri".




------------------------------

End of HICNet Medical News Digest V06 Issue #56
***********************************************


---
Editor, HICNet Medical Newsletter
Internet: david@stat.com                 FAX: +1 (602) 451-6135
Bitnet  : ATW1H@ASUACAD



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