
Following is the final electronic text from the Morbidity and Mortality Weekly
Report (MMWR), vol. 44, no. 17, dated May 5, 1995.  The MMWR is published by
the U.S. Department of Health and Human Services, Public Health Service,
Centers for Disease Control and Prevention (CDC), Atlanta, Georgia.
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CONTENTS OF THIS ISSUE:
Pages/Title
    329
        National Arthritis Month - May 1995
    329-334
        Prevalence and Impact of Arthritis Among Women --
        United States, 1989-1991
    335-337
        Trends in Length of Stay for Hospital Deliveries --
        United States, 1970-1992
    337, 343-347
        Deaths from Melanoma -- United States, 1973-1992
    347-350
        Reptile-Associated Salmonellosis -- Selected States,
        1994-1995
    351
        Monthly Immunization Table
--------------------------------------------------------------

National Arthritis Month - May 1995

    May is National Arthritis Month. During this month, nationwide
educational activities are planned to increase awareness of arthritis.
Additional information about arthritis and addresses of local chapters are
available from the Arthritis Foundation, P.O. Box 7669, Atlanta, GA 30357;
telephone (800) 283-7800 or (404) 872-7100.


Prevalence and Impact of Arthritis Among Women --
United States, 1989-1991

     Arthritis and other rheumatic conditions are among the most prevalent
chronic conditions in the United States, affecting approximately 38 million
persons (1). The self-reported prevalence of arthritis is greater among women
than among men, and for women aged greater than 45 years, arthritis is the
leading cause of activity limitation (1,2). This report uses data from the
National Health Interview Survey (NHIS) to provide estimates of the prevalence
and impact of arthritis among women aged greater than or equal to 15 years
during 1989-1991, compares the prevalence estimates of arthritis to other
chronic conditions affecting women during 1989-1991, and projects the
prevalence of arthritis among women in 2020.

Prevalence and Impact Estimates
     The NHIS is an annual national probability sample of the U.S. civilian,
noninstitutionalized population (3). Estimates of the prevalence of arthritis
were based on a one-sixth random sample of women aged greater than or equal to
15 years during 1989-1991 (n=24,201 of 145,832) who answered questions about
the presence of any musculoskeletal condition during the preceding 12 months
and details about these conditions. Each condition was assigned a code from
the International Classification of Diseases, Ninth Revision, Clinical
Modification (ICD-9-CM). This analysis used the definition of arthritis, which
included arthritis and other rheumatic conditions,* developed by the National
Arthritis Data Workgroup (1). These data were weighted to provide average
annual prevalence estimates.
     Arthritis impact, defined as activity limitation caused by arthritis, was
estimated using all women aged greater than or equal to 15 years participating
in NHIS. Respondents were asked whether they were limited in working,
housekeeping, or performing other activities as a result of health
condition(s) and the condition(s) they considered to be responsible for these
activity limitations. Data from women who attributed their activity limitation
to arthritis were weighted to provide average annual prevalence estimates of
the impact of arthritis among women aged greater than or equal to 15 years
during 1989-1991.
     An estimated 22.8 million (22.7%) women self-reported arthritis during
1989-1991 (Table 1). The prevalence of self-reported arthritis increased
directly with age and was 8.6% for women aged 15-44 years, 33.5% for women
aged 45-64 years, and 55.8% for women aged greater than or equal to 65 years.
Rates were higher for women who were overweight (body mass index [BMI] greater
than or equal to 27.3 [28.9%]), had less than or equal to 11 years of
education (30.0%), and resided in households with an annual income less than
$20,000 (29.9%).
     An estimated 4.6 million (4.6%) women reported arthritis as a major or
contributing cause of activity limitation during 1989-1991 (Table 1). Activity
limitation associated with arthritis increased directly with age and was 1.0%
for women aged 15-44 years, 6.4% for women aged 45-64 years, and 14.2% for
women aged greater than or equal to 65 years. Age-adjusted rates of activity
limitation were higher for blacks (6.5%) and American Indians/Alaskan Natives
(6.9%) than for whites (4.2%). Age-adjusted rates of activity limitation for
women who were overweight were nearly twofold greater than for those who were
not, and nearly threefold greater for women who resided in a household with an
annual income less than $10,000 per year than for those who resided in a
household with an annual income greater than or equal to $35,000.

Comparison With Other Chronic Conditions Affecting Women
     Average annual prevalence estimates of other chronic conditions affecting
women were based on a one-sixth random sample of women who answered questions,
on separate condition lists, regarding the presence of impairments;
respiratory conditions; circulatory conditions; and selected conditions of the
genitourinary, endocrine, and nervous systems. These data were weighted to
provide average annual prevalence estimates of other chronic conditions among
women aged greater than or equal to 15 years during 1989-1991. Average annual
prevalence estimates of activity limitation caused by these chronic conditions
were determined as they were for arthritis.
     Arthritis was the most common self-reported chronic condition affecting
women (Table 2), ranking ahead of self-reported hypertension (8.1 million),
ischemic heart disease (3.7 million), and other chronic conditions, including
breast cancer and malignancy of the female reproductive tract (e.g., ovarian,
endometrial, and cervical cancer). Among the conditions reported responsible
for activity limitations, women most frequently mentioned arthritis (4.6
million), followed by orthopedic deformity (3.0 million) and ischemic heart
disease (1.3 million).

Projections for 2020
     Arthritis among women aged greater than or equal to 15 years was
projected to 2020 by applying the average annual arthritis prevalence rate for
1989-1991, stratified by age and race to the relevant U.S. population
projected by the Bureau of the Census (4).
     From 1989-1991 to 2020, the prevalence of self-reported arthritis among
women aged greater than or equal to 15 years is projected to increase from
22.8 million (22.7%) to 35.9 million (26.7%).

Reported by: Statistics Br, and Aging Studies Br, Div of Chronic Disease
Control and Community Intervention, National Center for Chronic Disease
Prevention and Health Promotion, CDC.

Editorial Note: The findings in this report indicate that during 1989-1991,
arthritis was the most common self-reported chronic condition and cause of
activity limitation among women aged greater than or equal to 15 years. By
2020, an estimated 36 million women may be affected by arthritis--primarily
reflecting the increasing average age of the U.S. population.
     The analysis in this report also documents higher prevalences of
self-reported arthritis and related activity limitation among older women,
overweight women, and women with lower income and education levels. Older age
and overweight are commonly recognized risk factors for arthritis. The
cross-sectional analysis in this report precluded determination of whether
overweight precedes or results from arthritis; however, overweight has been
established as a risk factor for osteoarthritis of the knee (5). In addition,
low socioeconomic status, for which income and education may be markers, has
been associated with increased prevalence, mortality, and disability among
persons with arthritis and other rheumatic conditions (6,7). Although
prevalence rates for self-reported arthritis among blacks and American
Indians/Alaskan Natives were similar to those among whites, activity
limitation was more prevalent among both of these groups. Reasons for the
increased activity limitation among blacks and American Indians/Alaskan
Natives have not been determined but might reflect sociocultural differences
or access to health care.
     Diseases considered to have particularly important public health
ramifications for women include those that affect only women (e.g.,
endometrial, ovarian, and cervical cancers); are more prevalent among women
(e.g., breast cancer and osteoporosis); are more prevalent overall (e.g.,
hypertension, diabetes, and cardiovascular disease); have different risk
factors for women (e.g., menopause and cardiovascular disease or smoking and
pregnancy); or require different interventions for women (e.g., infertility)
(8). Although the prevalence of arthritis is approximately 60% greater among
women than men (1), the public health importance of arthritis among women has
not been emphasized previously.
     The NHIS data enables a more accurate estimate of the prevalence and
impact of arthritis than alternative data sources (e.g., Medicare, health
maintenance organization databases, and hospital discharge data) because many
persons with arthritis do not visit physicians for their condition. However,
these self-reported conditions and the ICD-9-CM codes assigned to them have
not been validated.
     In addition to limitations in understanding the epidemiology of
self-reported arthritis among women, the relation of arthritis to other
chronic conditions among women has not been well characterized. To assist in
reducing the public health impact of arthritis among women, priorities in the
assessment of this problem include determining frequencies of the different
types of arthritis and their natural histories among women, estimating more
accurately the economic and societal burden of this condition in women, and
evaluating the effectiveness of interventions, including supervised exercise
programs, weight loss, and self-education courses (5,9,10). Additional
strategies public health agencies and health-care providers can consider to
reduce the impact of arthritis among women include 1) promoting primary
prevention of arthritis through weight reduction and prevention of sports- or
occupational-related joint injury and 2) encouraging early detection and
appropriate management of women with arthritis through use of medical and
physical therapy, exercise, and established educational programs such as the
Arthritis Self-Management Course (9,10).

References
1. CDC. Arthritis prevalence and activity limitations--United States, 1990.
MMWR 1994;43:433-8.
2. Verbrugge LM, Patrick DL. Seven chronic conditions: their impact on U.S.
adults' activity levels and use of medical services. Am J Public Health
1995;85:173-82.
3. Massey JT, Moore TF, Parsons VL, Tadros W. Design and estimation for the
National Health Interview Survey, 1985-1994. Vital Health Stat 1989;2:1-5.
4. Day JC. Population projections of the United States, by age, sex, race, and
Hispanic origin: 1993 to 2050. Washington, DC: US Department of Commerce,
Bureau of the Census, 1993. (Current population reports; series P25, no.
1104).
5. Felson DT, Zhang Y, Anthony JM, Naimark A, Anderson JJ. Weight loss reduces
the risk for symptomatic knee osteoarthritis in women: the Framingham Study.
Ann Intern Med 1992;116:535-9.
6. Leigh JP, Fries JF. Occupation, income, and education, as independent
covariates of arthritis in four national probability samples. Arthritis Rheum
1991;34:984-94.
7. Badley EM, Ibanez D. Socioeconomic risk factors and musculoskeletal
disability. J Rheumatol 1994;21:515-22.
8. Merritt DH, Kirchstein RL. Women's health: report of the public health task
force on women's health issues. Vol II. Washington, DC: US Department of
Health and Human Services, Public Health Service, 1987; DHHS publication no.
(PHS)88-50506.
9. Kovar PA, Allegrante JP, MacKenzie CR, Peterson MGE, Gutin B, Charlson ME.
Supervised fitness walking in patients with osteoarthritis of the knee: a
randomized, controlled trial. Ann Intern Med 1992;116:529-34.
10. Lorig KR, Mazonson PD, Holman HR. Evidence suggesting that health
education for self-management in patients with chronic arthritis has sustained
health benefits while reducing health care costs. Arthritis Rheum 1993;36:439-45.

* ICD-9-CM codes 95.6, 95.7, 98.5, 99.3, 136.1, 274, 277.2, 287.0, 344.6,
353.0, 354.0, 355.5, 357.1, 390, 391, 437.4, 443.0, 446, 447.6, 696.0, 710-716, 719.0, 719.2-719.9, 720-721, 725-727, 728.0-728.3, 728.6-728.9, 729.0-729.1, and 729.4.


Trends in Length of Stay for Hospital Deliveries --
United States, 1970-1992

     Obstetric delivery is the most frequent cause of hospital admission in
the United States, reflecting the approximately 4 million births in this
country each year (1). Because of steadily increasing hospital costs, overall
lengths of hospital stay have declined. To assess national trends in length of
stay for hospital deliveries, data were analyzed from CDC's National Hospital
Discharge Survey (NHDS) from 1970 through 1992, by method of delivery. This
report summarizes the results of the analysis.
     Since 1965, the NHDS has collected data from U.S. nonfederal, short-stay
hospitals. Each year, approximately 200,000 inpatient records are selected
from approximately 400 hospitals; data are weighted to represent all
hospitalizations nationally (2,3). Selected patient information (e.g., medical
diagnoses and surgical procedures) is abstracted from each record. For this
analysis, the NHDS provided information about mother's age and race/ethnicity;
method of payment; and the hospital's ownership, size, and location. Estimates
for average length of stay were derived from the 20,000-33,000 deliveries each
year among all records sampled. Hospital stays of less than 24 hours were
recoded as 0 days; these hospitalizations accounted for less than 1% of all
deliveries and were relatively constant by year (i.e., 0.3% in 1970 to 0.7% in
1992). The proportion of all deliveries that occurred outside of hospitals
also was stable from 1975 (0.9%) to 1990 (1.1%) (4).
     In 1970, the average length of stay for all hospital deliveries was 4.1
days (median: 4 days). By 1992, the average had decreased by 37% to 2.6 days
(median: 2.0 days). The average length of stay for women who gave birth
vaginally decreased by 46% (from 3.9 to 2.1 days) and for those who gave birth
by cesarean section by 49% (from 7.8 to 4.0 days) (Figure 1). The decrease in
the average length of stay for all deliveries was smaller than that for either
method because the percentage of deliveries by cesarean section increased from
5.5% to 23.5% during this period (5).
     The average length of stay also was analyzed by mother's age (less than
20, 20-29, 30-39, and greater than 39 years), race (white or black)*, hospital
location (Northeast, Midwest, South, or West regions), hospital ownership
(proprietary, government, or nonprofit), and hospital size (less than 100,
100-299, 300-499, and greater than 499 beds). From 1970 through 1992, the
average length of stay decreased similarly for all these groups; decreases
ranged from 39% to 52% for vaginal deliveries and from 38% to 53% for cesarean
deliveries. NHDS began collecting information about method of payment (i.e.,
Blue Cross/Blue Shield**, other private insurance, Medicaid, and self-paying)
in 1977. From 1977 through 1992, the average length of stay decreased for
these payment groups; decreases ranged from 35% to 38% for vaginal deliveries
and from 32% to 47% for cesarean deliveries.

Reported by: Div of Reproductive Health, National Center for Chronic Disease
Prevention and Health Promotion; Prevention Effectiveness Activity,
Epidemiology Program Office, CDC.

Editorial Note: The length of stay associated with hospital deliveries
steadily decreased during 1970-1992. Early hospital discharge results in
reduced health-care costs and enables mothers to return home sooner with their
newborns. However, careful postpartum follow-up is necessary to ensure prompt
diagnosis and treatment of any maternal or neonatal complications. Early
discharge should not preclude efforts traditionally conducted during
postpartum hospitalization to educate women about breastfeeding, family
planning, care of their newborn, and other topics important for new mothers.
     The optimal length of stay for uncomplicated deliveries reflects several
factors, including the presence of others in the home who can support the
mother after discharge, the mother's awareness of complications, and access to
health-care services. Guidelines published by the American Academy of
Pediatrics and the American College of Obstetricians and Gynecologists suggest
that, when there have been no complications, the duration of postpartum
hospital stays range from an average of 48 hours for vaginal delivery to an
average of 96 hours for cesarean birth (excluding the day of delivery) (6). In
addition, specific criteria should be met for a woman to be discharged early,
especially within 24 hours of delivery.
     One potential limitation of the analysis in this report is that data from
the NHDS on length of stay does not distinguish the postpartum period from the
rest of the hospitalization. Therefore, this analysis could not determine
whether the decrease in the average length of stay resulted from a shorter
antepartum stay or postpartum stay. However, since 1970, most of the efforts
to decrease length of stay for hospital deliveries has been directed toward
the postpartum period.
     Since 1970, the rate of health-care costs has increased more rapidly than
that of general inflation; efforts to decrease hospital health-care costs by
reducing length of stay will probably intensify. Most studies have not
detected an increased rate of morbidity in association with early postpartum
discharge (7-9). However, these studies--which were conducted among carefully
selected women at low risk for postpartum complications--documented rates of
complications of up to 14% among women and 11% among their infants (7). In
addition, home visits by nurse practitioners after discharge (a practice not
routinely used by health-care providers) ensured prompt diagnosis and
treatment of postpartum complications. These findings underscore the need to
ensure adequate follow-up care for women and infants and to maintain the
educational activities traditionally provided during postpartum
hospitalization. The prevalence of complications also should be monitored to
accurately determine the costs and benefits of early postpartum discharge.

References
1. Agency for Health Care Policy and Research. The national bill for diseases
treated in U.S. hospitals, 1987. Washington, DC: US Department of Health and
Human Services, Public Health Service, 1994. (Provider studies research note
no. 19).
2. National Center for Health Statistics. 1985 Summary: National Hospital
Discharge Survey. Hyattsville, Maryland: US Department of Health and Human
Services, Public Health Service, 1986; DHHS publication no. (PHS)86-1250.
(Advance data no. 127).
3. Graves EJ. 1990 Summary: National Hospital Discharge Survey. Hyattsville,
Maryland: US Department of Health and Human Services, Public Health Service,
CDC, 1992; DHHS publication no. (PHS)92-1250. (Advance data no. 210).
4. NCHS. Advance report of final natality statistics, 1992. Hyattsville,
Maryland: US Department of Health and Human Services, Public Health Service,
CDC, 1994. (Monthly vital statistics report; vol 43, no. 17, suppl).
5. CDC. Rates of cesarean delivery--United States, 1991. MMWR 1993;42:285-9.
6. American Academy of Pediatrics/American College of Obstetricians and
Gynecologists. Guidelines for perinatal care. 3rd ed. Washington, DC: American
College of Obstetricians and Gynecologists, 1992:105-8.
7. Welt SI, Cole JS, Myers MS, Sholes DM Jr, Jelovsek FR. Feasibility of
postpartum rapid hospital discharge: a study from a community hospital
population. Am J Perinatol 1993;10:384-7.
8. Brooten D, Roncoli M, Finkler S, Arnold L, Cohen A, Mennuti M. A randomized
trial of early hospital discharge and home follow-up of women having cesarean
birth. Obstet Gynecol 1994;84:832-8.
9. Norr KF, Nacion K. Outcomes of postpartum early discharge, 1960-1986: a
comparative review. Birth 1987;14:135-41.

* Numbers from other racial/ethnic groups were too small for reliable
analysis.
** 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.



Deaths from Melanoma -- United States, 1973-1992

     Approximately three fourths of all skin cancer-associated deaths are
caused by melanoma. During 1973-1991, the incidence of melanoma increased
approximately 4% each year (1). In addition, the incidence of melanoma is
increasing faster than that of any other cancer (2). To characterize the
distribution of deaths from melanoma in the United States, CDC analyzed
national mortality data for 1973 through 1992. This report summarizes the
results of that analysis.
     Decedents for whom the underlying cause of death was melanoma
(International Classification of Diseases, Adapted, Ninth Revision, codes
172.0-172.9) were identified from public-use, mortality data tapes from 1973
through 1992 (3). The denominators for rate calculations were derived from
U.S. census population estimates (4,5). Rates were directly standardized to
the age distribution of the 1970 U.S. population and were analyzed by state,
age group, sex, year, and race. To increase the precision of the rates
presented, race was characterized as white and all other races because
approximately 98% of deaths from melanoma occurred among whites.
     From 1973 through 1992, the overall percentage increase in the rate of
deaths from melanoma (34.1%) was the third highest of all cancers; for males,
the percentage increase for melanoma (47.9%) was the highest for all cancers
(6). During the same period, the increase in the rate of deaths from melanoma
was greater for white males than for other racial and sex groups (Figure 1).
In 1992, the rate of deaths from melanoma was 5.9 times higher for whites than
for all other races (2.5 and 0.4 per 100,000 population, respectively), and
2.1 times higher for males than females (3.1 and 1.5, respectively).
     To increase statistical precision, the rate of deaths from melanoma by
state was aggregated for 1988-1992. In every state, the rate of deaths from
melanoma was substantially higher for whites than for persons of all other
races. For whites, the age-adjusted death rate by state ranged from 2.2 to 5.0
per 100,000 population for males and 0.8 to 2.3 for females (Table 1). Most
states that are in the two highest death rate quartiles are not in the lower
U.S. latitudes where sun exposure is generally more intense (Figure 2).
     During 1973-1975 and 1990-1992, death rates were highest for white men
aged greater than or equal to 50 years (Figure 3). The death rate increased
more with age for males than for females during 1990-1992.

Reported by: Div of Cancer Prevention and Control, National Center for Chronic
Disease Prevention and Health Promotion, CDC.

Editorial Note: The findings in this report indicate that the rate of deaths
from melanoma was higher for whites than persons of all other races--a finding
consistent with the more common occurrence of melanoma among persons with
lightly pigmented skin (2) and an incidence among whites that is more than 10
times higher than that for blacks (1). Based on estimates by the American
Cancer Society, during 1995 an estimated 34,100 new cases of melanoma will be
diagnosed and 7200 deaths will be caused by melanoma (1). The likelihood of
survival of melanoma is substantially greater if the disease is detected early
and treated (2). Early detection of thin lesions is associated with improved
prognosis and treatment outcome than is detection of thicker, later stage
tumors (2).
     Risk factors (2,7,8) for melanoma related to ultraviolet radiation
exposure include a history of sunburn or sun sensitivity, a tendency to
freckle, the presence of lightly pigmented skin, blue eyes, and blond or red
hair. Other risk factors include a family or personal history of melanoma and
the presence of a large number of moles or any atypical moles. Sources for
exposure to ultraviolet radiation include sunlight and artificial light (e.g.,
tanning booths), both of which can cause acute sunburn. The increased risk
among persons who sustain intermittent, acute sunburn at an early age (i.e.,
less than 18 years) underscores the need for initiating prevention measures
early in childhood (9).
     Adults, particularly older men in whom rates of deaths from melanoma are
highest, should be encouraged to perform periodic skin self-examination or be
examined by a family member (2) to monitor location, size, and color of a
pigmented lesion or mole. The "ABCD approach" can be used to assess pigmented
lesions and represents mole asymmetry ("A"), border irregularity ("B"),
nonuniform color (i.e., pigmentation) ("C"), and diameter greater than 6 mm
("D") (1,2,8).
     Recommendations for preventing melanoma should emphasize reduction of
direct exposure to the sun when sunburn is most likely to occur, especially
from 10 a.m. to 3 p.m. Specific measures include wearing a broad-brimmed hat
and clothes that protect sun-exposed areas, seeking shade when outdoors, using
a sunscreen of sun protection factor greater than or equal to 15 that provides
protection against ultraviolet radiation A and ultraviolet radiation B, and
referring to the daily Ultraviolet Index* rating provided by the National
Weather Service and others when planning outdoor activities.
     In 1994, CDC implemented a program to assist in achievement of the
national health objectives for the year 2000 for preventing skin cancer (10).
Elements of the CDC program include funding support for state health
departments to develop and implement prevention projects aimed at parents and
caregivers of young children; enhancing prevention messages for the public;
initiating the development of school health curriculum guidelines; enhancing
Ultraviolet Index public health messages; and developing a public and
professional education plan for skin cancer prevention.
    May is Melanoma/Skin Cancer Detection and Prevention Month. Additional
information is available from the American Academy of Dermatology, 930 North
Meacham Road, Schaumburg, IL 60173-4965.

References
1. American Cancer Society. Cancer facts and figures, 1995. Atlanta: American
Cancer Society, 1995; publication no. 5008.95.
2. Koh HK. Cutaneous melanoma. N Engl J Med 1991;325:171-82.
3. NCHS. Vital statistics mortality data, underlying cause of death, 1973-1992
[Machine-readable public-use data tapes]. Hyattsville, Maryland: US Department
of Health and Human Services, Public Health Service, CDC, 1973-1992.
4. Bureau of the Census. 1970-1989 Intercensal population estimates by race,
sex, and age [Machine-readable data files]. Washington, DC: US Department of
Commerce, Bureau of the Census, nd.
5. Irwin R. 1990-1992 Postcensal population estimates by race, sex, and age
[Machine-readable data files]. Alexandria, Virginia: Demo-Detail, 1993.
6. Ries LAG, Miller BA, Hankey BF, Kosary CL, Harras A, Edwards BK, eds. SEER
cancer statistics review, 1973-1991: tables and graphs. Bethesda, Maryland: US
Department of Health and Human Services, Public Health Service, National
Institutes of Health, National Cancer Institute, 1994; publication no.
(NIH)94-2789.
7. Hartman AM, Goldstein AM. Melanoma of the skin. In: Miller BA, Ries LAG,
Hankey BF, et al., eds. SEER cancer statistics review, 1973-1990. Bethesda,
Maryland: US Department of Health and Human Services, Public Health Service,
National Institutes of Health, National Cancer Institute, 1993; publication
no. (NIH)93-2789.
8. Marks R, Hill D, eds. The public health approach to melanoma control:
prevention and early detection. Geneva: International Union Against Cancer,
1992.
9. Wiley HE. Ways to protect children from sun damage. The Skin Cancer
Foundation Journal 1994;12:41,98.
10. Public Health Service. Healthy people 2000: national health promotion and
disease prevention objectives. Washington, DC: US Department of Health and
Human Services, Public Health Service, 1991; DHHS publication no.
(PHS)91-50213.

* The Ultraviolet Index, provided by the National Weather Service, is
broadcast by television and print media in 58 U.S. cities and provides
information on the intensity of the sun's rays during the solar noon hour. The
index ranges from 0 to 10+ with greater than or equal to 10 indicating the
most intense sunlight.


Reptile-Associated Salmonellosis -- Selected States, 1994-1995

     During 1994-1995, health departments in 13 states reported to CDC persons
infected with unusual Salmonella serotypes in which the patients had direct or
indirect contact with reptiles (i.e., lizards, snakes, or turtles). In many of
those cases, the same serotype of Salmonella was isolated from patients and
from reptiles with which they had had contact or a common contact. For some
cases, infection resulted in invasive illness, such as sepsis and meningitis.
This report summarizes clinical and epidemiologic information for six of these
cases.
     Connecticut. During January 1995, a 40-year-old man was hospitalized
because of an acute illness characterized by constipation, lower back pain,
chills, and fever. He reported having taken ranitidine and an antacid for
symptoms of heartburn before onset of mild diarrhea 3 days before
hospitalization. A blood culture yielded Salmonella serotype Wassenaar. A
magnetic resonance image scan of the right sacrum suggested osteomyelitis.
Ciprofloxacin therapy was initiated for presumed Salmonella osteomyelitis, and
he was discharged after 14 days. All household contacts were asymptomatic. The
family had purchased two iguanas (Iguana iguana) in October 1994; although the
patient denied directly handling the iguanas, he reported having recently
cleaned their aquarium. Stool samples obtained from both iguanas yielded
Salmonella Wassenaar.
     New Jersey. During September 1994, a 5-month-old girl was hospitalized
because of an acute illness including vomiting, lethargy, and fever; on
admission, she had a bulging fontanelle and stiff neck. Blood cultures and
cerebrospinal fluid yielded Salmonella serotype Rubislaw. She was treated with
intravenous ceftazidime for Salmonella sepsis and meningitis and discharged
from the hospital after 10 days. Other members of the family were
asymptomatic. The infant routinely was fed infant formula. Although the family
did not own a reptile, the infant frequently stayed at a babysitter's house
where an iguana was kept. Culture of a stool sample from the iguana yielded
Salmonella Rubislaw. The infant was reported to have not touched the iguana;
however, the iguana frequently was handled by the babysitter and other members
of the babysitter's family. All members of the babysitter's family were
asymptomatic, but stool cultures from two members, including a child who had
frequently played with and fed the infant, yielded Salmonella Rubislaw.
     New York. In December 1994, a 45-year-old man infected with human
immunodeficiency virus was hospitalized because of weakness, nausea, vomiting,
and diarrhea. His CD4+ T-lymphocyte count was less than 50 cells/uL. Cultures
from blood and sputum samples yielded Salmonella serotype IIIa 41:z subscript
4 z subscript 23:- (S. subspecies Arizonae). He owned corn snakes and, until
shortly before onset of illness, had worked at a pet store where he handled
reptiles frequently. Salmonella sepsis was diagnosed, and he was treated with
oral ciprofloxacin.
     North Carolina. During December 1994, a 2-day-old boy born 8 weeks
prematurely developed respiratory difficulties, had pneumothorax diagnosed,
and was transferred to a referral hospital. Blood obtained at birth for
culture had been negative, but a culture of blood obtained 9 days later
because of an elevated white blood cell count yielded Salmonella serotype
Kintambo. He was treated with intravenous ampicillin for Salmonella sepsis and
was discharged from the hospital after 30 days. Eleven days after the positive
culture was collected, Salmonella Kintambo was cultured from a blood sample
obtained from a 12-day-old acutely ill boy who was born at 28 weeks' gestation
and had shared a room at the referral hospital with the first infant. The
second infant was treated with intravenous cefotaxime for Salmonella sepsis
and was discharged after 44 days. Both infants had been in the hospital
continuously from birth until onset of illness. The mother of the first infant
reported having had a diarrheal illness 4 days before the birth of the infant;
she frequently handled a savanna monitor lizard (Varanus exanthemapicus) that
the family had purchased in September 1994 and kept in a cage in the kitchen.
Culture of a stool sample from the lizard yielded Salmonella Kintambo. The
second family did not own a reptile.
     Ohio. During January 1994, a 6-week-old boy was hospitalized because of
diarrhea, stiff neck, and fever; culture of samples of blood and cerebrospinal
fluid yielded Salmonella serotype Stanley. The infant was treated with
intravenous cefotaxime for Salmonella sepsis and meningitis and discharged
from the hospital after 56 days. He had been fed only formula and had not
attended a child-care facility; household contacts were asymptomatic. The
family had purchased a 4-inch water turtle in April 1993. A culture of stool
from the turtle yielded Salmonella Stanley. Although the infant had not had
contact with the turtle, other family members had had direct contact, and the
turtle's food and water bowls were washed in the kitchen sink.
     Pennsylvania. During October 1994, a 21-day-old girl was hospitalized
because of an illness including vomiting, bloody diarrhea, and fever. She
received empirical treatment with intravenous ampicillin. A culture of stool
yielded Salmonella serotype Poona; she was discharged from the hospital after
11 days. Other members of the family were asymptomatic. The infant had been
fed infant formula and had not attended a child-care center. The family owned
an iguana, and culture of a stool sample from the iguana yielded Salmonella
Poona. Although the infant did not have contact with the iguana, the iguana
was handled frequently by her mother and other members of the family.
     Additional investigations. In addition to the six states in this report,
seven other states (California, Colorado, Florida, Illinois, Minnesota,
Oregon, and Utah) have reported recent isolation of the same Salmonella
serotype from samples obtained from patients and reptiles with which they had
been in contact or associated. Several of these states issued press releases
about the risk for acquiring salmonellosis from reptiles. In addition, some
states have issued health alerts to pet stores to warn owners and prospective
owners about the risks for salmonellosis associated with contact with reptiles
and to provide instructions about proper handling of reptiles; store owners
have been asked to post the alert and provide copies to all persons purchasing
a reptile.

Reported by: JW Weinstein, MD, EG Seltzer, MD, Yale Univ School of Medicine,
New Haven; RS Nelson, DVM, JL Hadler, MD, State Epidemiologist, Connecticut
Dept of Public Health and Addiction Svcs. SM Paul, MD, FE Sorhage, VMD, Div of
Epidemiology, Environmental and Occupational Health Svcs; K Pilot, S Matluck,
Public Health and Environmental Laboratories; K Spitalny, MD, State
Epidemiologist, New Jersey State Dept of Health. M Gupta, MD, J Misage, G
Balzano, T Root, G Birkhead, MD, DL Morse, MD, State Epidemiologist, New York
State Dept of Health. A Kopelman, MD, S Engelke, MD, L Jones, Pitt County
Memorial Hospital, Greenville; L Latour, PhD, P Perry, Wilson County Health
Dept, Wilson; B Jenkins, State Laboratory of Public Health, J-M Maillard, MD,
JN MacCormack, MD, State Epidemiologist, North Carolina Dept of Environment,
Health, and Natural Resources. C Richards, P Fruth, Defiance County Health
Dept, Defiance; S Hufford, MD, B Dick, MPH, Toledo Hospital; M Bundesen, Bur
of Public Health Laboratories, EP Salehi, MPH, Infectious Disease Epidemiology
Unit, TJ Halpin, MD, State Epidemiologist, Ohio Dept of Health. P Lurie, MD, M
Deasy, K Mihelcic, JT Rankin, Jr, DVM, State Epidemiologist, Pennsylvania Dept
of Health. Foodborne and Diarrheal Diseases Br, Div of Bacterial and Mycotic
Diseases, National Center for Infectious Diseases; Div of Field Epidemiology,
Epidemiology Program Office, CDC.

Editorial Note: For most of the cases described in this report, the
identification of rare Salmonella serotypes in persons who had no other
apparent exposures was linked to direct or indirect contact with a pet reptile
from which the same serotype was isolated. In addition, these cases are
consistent with previous reports indicating that direct contact with a reptile
is not necessary for transmission of Salmonella (1,2). This report also
illustrates the severe complications of Salmonella infection that can occur in
young children, immunocompromised persons, and infants during the peripartum
period.
     Reptiles are popular as pets in the United States: an estimated 7.3
million pet reptiles are owned by approximately 3% of households (G. Mitchell,
Pet Industry Joint Advisory Council, personal communication, 1995). Because
the most popular reptiles species will not breed if closely confined, most
reptiles are captured in the wild and imported. The number of reptiles
imported into the United States has increased dramatically since 1986 and
primarily reflects importation of iguanas (27,806 in 1986 to 798,405 in 1993)
(M. Albert, Fish and Wildlife Service, U.S. Department of the Interior,
personal communication, June, 1994).
     A high proportion of reptiles are asymptomatic carriers of Salmonella.
Fecal carriage rates can be more than 90% (3); attempts to eliminate
Salmonella carriage in reptiles with antibiotics have been unsuccessful and
have led to increased antibiotic resistance (1,4). A wide variety of
Salmonella serotypes has been isolated from reptiles, including many that
rarely are isolated from other animals (reptile-associated serotypes).
Reptiles can become infected through transovarial transmission or direct
contact with other infected reptiles or contaminated reptile feces. High rates
of fecal carriage of Salmonella can be related to the eating of feces by
hatchlings--a typical behavior for iguanas and other lizards--which can
establish normal intestinal flora for hindgut fermentation (5).
     During the early 1970s, small pet turtles were an important source of
Salmonella infection in the United States; an estimated 4% of families owned
turtles, and 14% of salmonellosis cases were attributed to exposure to turtles
(6). In 1975, the Food and Drug Administration prohibited the distribution and
sale of turtles with a carapace less than 4 inches; many states prohibited the
sale of such turtles. These measures resulted in the prevention of an
estimated 100,000 cases of salmonellosis annually (6). However, since 1986,
the popularity of iguanas and other reptiles that can transmit infection to
humans has been paralleled by an increased incidence of Salmonella infections
caused by reptile-associated serotypes (7).
     Because young children are at increased risk for reptile-associated
salmonellosis and severe complications (e.g., septicemia and meningitis) (7-9), reducing exposure of infants or children aged less than 5 years to
reptiles is particularly important. The risks for transmission of Salmonella
from reptiles to humans can be reduced by avoiding direct and indirect contact
with reptiles (see box).
(BOX)

Recommendations for Preventing Transmission of Salmonella From Reptiles to
Humans
o Persons at increased risk for infection or serious complications of
salmonellosis (e.g., pregnant women, children aged less than 5 years, and
immunocompromised persons such as persons with AIDS) should avoid contact with
reptiles.
o Reptiles should not be kept in child-care centers and may not be
appropriate pets in households in which persons at increased risk for
infection reside.
o Veterinarians and pet store owners should provide information to potential
purchasers and owners of reptiles about the increased risk of acquiring
salmonellosis from reptiles.
o Veterinarians and operators of pet stores should advise reptile owners
always to wash their hands after handling reptiles and reptile cages.
o To prevent contamination of food-preparation areas (e.g., kitchens) and
other selected sites, reptiles should be kept out of these areas in
particular, kitchen sinks should not be used to bathe reptiles or to wash
reptile dishes, cages, or aquariums.


References
1. CDC. Iguana-associated salmonellosis--Indiana, 1990. MMWR 1992;41:38-9.
2. CDC. Lizard-associated salmonellosis--Utah. MMWR 1992;41:610-1.
3. Chiodini RJ, Sundberg JP. Salmonellosis in reptiles: a review. Am J
Epidemiol 1981;113:494-9.
4. Shane SM, Gilbert R, Harrington KS. Salmonella colonization in commercial
pet turtles (Pseudemys scripta elegans). Epidemiol Infect 1990;105:307-16.
5. Troyer K. Transfer of fermentative microbes between generations in
herbivorous lizard. Science 1982;216:540-2.
6. Cohen ML, Potter M, Pollard R, Feldman RA. Turtle-associated salmonellosis
in the United States: effect of public health action, 1970 to 1976. JAMA
1980;243:1247-9.
7. Cieslak PR, Angulo FJ, Dueger EL, Maloney EK, Swerdlow DL. Leapin' lizards:
a jump in the incidence of reptile-associated salmonellosis [Abstract]. In:
Program and abstracts of the 34th Interscience Conference on Antimicrobial
Agents and Chemotherapy. Washington, DC: American Society for Microbiology,
1994.
8. Ackman D, Drabkin P, Birkhead B, Cieslak P. Reptile-associated
salmonellosis: a case-control study [Abstract]. In: Program and abstracts of
the 34th Interscience Conference on Antimicrobial Agents and Chemotherapy.
Washington, DC: American Society for Microbiology, 1994.
9. Dalton C, Hoffman R, Pape J. Iguana-associated salmonellosis in children.
Pediatr Infect Dis J 1995;14:319-20.


Monthly Immunization Table

     To track progress toward achieving the goals of the Childhood
Immunization Initiative (CII), CDC publishes monthly a tabular summary of the
number of cases of all diseases preventable by routine childhood vaccination
reported during the previous month and year-to-date (provisional data). In
addition, the table compares provisional data with final data for the previous
year and highlights the number of reported cases among children aged less than
5 years, who are the primary focus of CII. Data in the table are derived from
CDC's National Notifiable Diseases Surveillance System.
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Director, Centers for Disease Control and Prevention
     David Satcher, M.D., Ph.D.
Deputy Director, Centers for Disease Control and Prevention
     Claire V. Broome, M.D.
Director, Epidemiology Program Office
     Stephen B. Thacker, M.D., M.Sc.
Editor, MMWR Series
     Richard A. Goodman, M.D., M.P.H.
Managing Editor, MMWR (weekly)
     Karen L. Foster, M.A.
Writers-Editors, MMWR (weekly)
     David C. Johnson         Darlene D. Rumph-Person
     Patricia A. McGee        Caran R. Wilbanks
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