Jul 16, 1990 - International Notes. Earthquake .... Epidemiology Program Office, CDC. Editorial ... In addition, in response to a request from the. Philippine ...... 365. E.N. CENTRAL. 2,145. 1,131. 49. 1,417. 1,441. 1. 22. 36. 109. Ohio. 362. 88.
CENTERS FOR DISEASE CO NTROL
A u g u s t 3 1 , 1 9 9 0 / V o l. 3 9 / N o . 3 4 573 577
579 586 587
MORBIDITY A N D MORTALITY WEEKLY REPORT
589
Earthquake Disaster - Luzon, Philippines Nursing Home Outbreaks of Invasive Group A Streptococcal Infections - Illinois, Kansas, North Carolina, and Texas Common Source Outbreak of Relapsing Fever — California Football-Related Spinal Cord Injuries Among High School Players — Louisiana, 1989 Update: EMS Associated with Ingestion of LT - United States, through August 24, 1990 Analysis of LT for the Etiology of EMS
International Notes Earthquake D isaster — Luzon, Philippines At 4:30 p.m. on July 16, 1990, an earthquake measuring 7.7 on the Richter scale struck northern and central Luzon Island in the Philippines, resulting in substantial morbidity and mortality and widespread damage. Among the areas severely affected were the mountain city of Baguio; the coastal areas in La Union; Dagupan city in Pangasinan; and the central plain area —primarily Cabanatuan city in Nueva Ecija and mountainous Nueva Viscaya. Buildings in Baguio and Cabanatuan suffered extensive structural failure, and buildings in the coastal areas in La Union and in Dagupan suffered foundation failure or the effects of liquefaction*. This report summarizes preliminary data gathered by Philippine Field Epidemiology Training Program (FETP) teams on the damage, deaths, and injuries sustained in the four areas. Baguio The city of Baguio (1989 population: 154,000) covers 49 square kilometers (30 square miles) in the Cordillera mountains. Baguio is a major tourist destination and the principal trade and educational center in the Cordillera region. Twenty-eight buildings and 132 residences in the city were damaged or destroyed. Three hotels were totally destroyed. Two schools were severely damaged, trapping students and faculty members. A factory building collapsed and burned with workers trapped inside. For the first 48 hours after the earthquake, the city was isolated from the rest of the country. Electric, water, and communication lines were destroyed. The city was inaccessible by land because of landslides and inaccessible by air, except to helicopters, because of damage at the airport. Food and fuel were scarce. Because hospital buildings were damaged, patients were relocated under tents set up in open spaces in front of hospitals. Damage to homes and the occurrence of many aftershocks caused most residents to set up camps in open spaces in the city. Three days after the earthquake, a main road leading to the city was cleared to enable delivery of supplies. During the first 48 hours, rescue teams consisted of local volunteers, mainly miners and cadets from a military school in the city, who worked with their hands and *A change in the soil from a firm material into a viscous semiliquid material that resembles quicksand.
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES / PUBLIC HEALTH SERVICE
574
MMWR
August 31, 1990
Earthquake Disaster — Continued
with picks and shovels. Foreign rescue teams with sophisticated equipment and dogs trained for rescue were able to reach the area after 48 hours. The FETP team estimated that 1084 earthquake-related casualties occurred: 695 injured survivors and 389 fatalities (case-fatality rate: 36%). The estimated injury rate was 703 per 100,000 population; the estimated death rate was 252 per 100,000. The FETP team conducted a case-control study to identify risk factors for earthquake-related injuries. The study included 150 cases (surviving and deceased casualties) and 305 controls.f Casualties ranged in age from 3 months to 70 years (mean: 25 years); 51% were male. Eighty-four (56%) casualties were at home when the earthquake struck; 19 (13%), in school; 11 (7%), in a street; and 36 (24%), in other places. The majority (74%) of casualties were inside a building during the earthquake. The 150 casualties sustained a total of 235 injuries (average: 1.6 injuries per person). The three most common injuries were contusion (35%), fracture (14%), and laceration (12%). The most common causes of injury were being hit by falling objects (37%), being crushed or pinned by heavy objects (29%), and falling (7%). Based on preliminary analysis, cases and controls were similar in age and sex distribution. Similar proportions of cases and controls were inside (74% and 80%, respectively) and outside (26% and 20%, respectively) buildings during the earth quake. For persons who were inside a building, risk factors included building height, type of building material, and the floor level the person was on. Persons inside buildings with seven or more floors were 35 times more likely to be injured (odds ratio [OR] = 34.7; 95% confidence interval [Cl] = 8.1-306.9). Persons inside buildings constructed of concrete or mixed materials were three times more likely to sustain injuries (OR = 3.4; 95% Cl = 1.1—13.5) than were those inside wooden buildings. Persons at middle levels of multistory buildings were twice as likely to be injured as those at the top or bottom levels (OR = 2.3; 95% Cl = 1.3-4.2). Cabanatuan Cabanatuan (population: 176,053) is a major city in the central plain of Luzon. The city has many concrete buildings, mostly three stories high. The highest structure, a six-floor school, was the only building in Cabanatuan that collapsed during the earthquake. A total of 363 casualties (including 274 [75%] persons, primarily students, trapped in the collapsed school) were reported in Cabanatuan; 154 (42%) died. The death and injury rates were 87 and 206 per 100,000 population, respectively. Dagupan Dagupan (population: 112,850) is a commercial city located along the coast of Lingayen Gulf. Approximately 150 concrete buildings were located in the commercial hub; most of these were less than five stories high. Approximately 90 (60%) buildings in the city were damaged, and approximately 20 collapsed. Some structures sus tained damage because liquefaction caused buildings to sink as much as 1 meter (39 inches). Because the earthquake caused a decrease in the elevation of the city, several areas were flooded. Of 64 casualties, 47 survived and 17 died. The injury and death rates were 57 and 15 per 100,000 population, respectively. Most injuries were sustained during stam fA case was any casualty (injured or dead) resulting directly from the earthquake or aftershocks. For injured persons, information was obtained from the patients, when possible, or from other survivors; for infants and young children, from their parents or guardians; and for decedents, from survivors or from rescuers. Controls were noninjured family members or noninjured persons in refugee centers.
Vol. 39 / No. 34
MMWR
575
Earthquake Disaster — Continued
pedes at a university building and a theater. Fourteen (82%) of the deaths occurred among women. La Union In La Union, a coastal province located in the northwestern part of Luzon, five municipalities (combined population: 132,208) were affected: Agoo, Aringay, Caba, Santo Tomas, and Tubao. Principal occupations are farming and fishing. The houses are constructed of wood, concrete, or light materials; most buildings are concrete and are less than four stories high. A total of 2387 families were dislocated when two coastal barangays (i.e., a large neighborhood or barrio) sank. Many buildings col lapsed or were otherwise severely damaged. Of 493 casualties, 32 died. The injury and death rates were 349 and 24 per 100,000 population, respectively. Patterns of Damage The earthquake caused different patterns of damage in different parts of Luzon Island. The mountain resort of Baguio was most severely affected, probably because it had the highest population density and many tall concrete buildings, which were more susceptible to seismic damage. Because all routes of communication, roads, and airport access were severed for several days, relief efforts were also the most difficult there. Relief efforts were further hampered by daily drenching, cold rains. Because Baguio is home to a large mining company and a military academy, experienced miners and other disciplined volunteers played a crucial role in early rescue efforts. Rescue teams arriving from Manila and elsewhere in Luzon were able to decrease mortality from major injuries. Surgeons, anesthesiologists, and special ized equipment and supplies were brought to the area, and victims were promptly treated. Patients requiring specialized care (e.g., hemodialysis) not available in the disaster area were airlifted to tertiary hospitals in metropolitan Manila. Outside of Baguio, destruction tended to be more diffuse. Damage was caused by landslides in the mountains and settling in coastal areas. Relief efforts in these areas were prompt and successful, partly because the areas remained accessible. Reported by: MC Roces, MD, Nl Pastor; MD, IL Gopez, MD, MCL Quizon, MD, RU Rayrayf MD, RR Gavino, MD, ES Salva, MD, MB Brizueia, MD, FC Diza, MD, EV Falcon, MD, JM Lopez, MD, MEG Miranda, DVM, RA Sadang, MD, NS Zacarias, MD, M M Dayrit, MD, Field E pidem iology Training Program, Philippines. Div o f Environm ental Hazards and Health Effects, Center for Environm ental Health and Injury Control; Global Epidemic Intelligence Svc, Div o f Field Svcs, Epidem iology Program Office, CDC.
Editorial Note: As in previous earthquake disasters, the most important relief work in the Philippines was done by survivors during the first 48 hours after the shock ( 1,2). Because earthquake relief efforts may be hampered by a lack of accurate data (3,4 ), the Department of Health (DOH) deployed teams of FETP epidemiologists within 24 hours to each site to provide accurate estimates of casualties, damage, and needs. Because Baguio was accessible only by air, setting priorities for relief shipments was vital. Daily reports were provided for local disaster coordinators and to head quarters in Manila. Information gathering was possible but was constrained by the lack of telephones, power, and transportation and by general confusion. On July 19, 3 days after the earthquake, the priority of relief efforts shifted from treatment of injuries to public health concerns. For example, numerous broken pipes completely disrupted water systems, limiting the availability of potable water, and refugees who camped in open areas had no adequate toilet facilities. Early efforts at providing potable water by giving refugees chlorine granules were unsuccessful.
576
MMWR
August 31, 1990
Earthquake Disaster — Continued
Most potable water was distributed from fire engines, and DOH sanitarians chlori nated the water before it was distributed. Surveys of refugee areas showed few latrines; these had to be dug by the DOH. Although national disaster plans had worked well in typhoons and floods, their effectiveness was undermined by the unprecedented demands caused by the earth quake. High-level government officials, such as cabinet secretaries and agency heads, were quickly assigned to manage emergency relief in different areas. Important factors contributing to the risk for death after the collapse of buildings include entrapment, the severity of injuries, length of time victims can survive without medical attention, and time to rescue and medical treatment (5 -7 ). Earthquake drills are important, particularly in relation to appropriate occupant behavior at the time of an earthquake (8). Deaths and injuries caused by stampedes in schools underlined the need for earthquake drills. A widespread public expectation was that epidemics of communicable diseases would follow the earthquake. However, sentinel surveillance sites established in each of the earthquake areas did not detect increases in diarrhea, measles, or other diseases, confirming experiences after previous earthquakes (5). This information was released to the press frequently and helped to quell rumors, a major concern in the second and third weeks following the earthquake. In addition, reliable epidemi ologic data permitted relief managers to avoid displacing important relief goods with unnecessary medicines (sorting and storing large quantities of inappropriate medi cines has been a problem after other recent earthquakes [70]). Many nations contributed effectively to the successful relief effort. The most useful international relief was low-technology assistance, such as tents, blankets, and food. Teams equipped with high-technology equipment to detect survivors arrived after most of the survivors had already been extricated. A team from Singapore remained for several weeks to provide a range of services, including medical care and cooking; these services were particularly useful. In addition, in response to a request from the Philippine FETP, the government of Mexico provided information based on its experience with the recent earthquake in Mexico; this information aided the Philip pines in its public health response. Future international relief efforts should focus more on problems that arise in the days after earthquakes. In Baguio, these needs were 1) engineers to establish whether buildings are habitable and to help reestablish water and communication lines, 2) volunteers to help remove corpses from the wreckage, 3) psychologists and psychiatrists to attend to the psychological problems of helplessness, depression, and anger in survivors and rescuers, and 4) tents and food. References 1. Noji ER. The 1988 earthquake in Soviet Armenia: implications for earthquake preparedness. Disasters 1989;13:255-62. 2. de Bruycker M, Greco D, Annino I, et al. The 1980 earthquake in southern Italy: rescue of trapped victims and mortality. Bull WHO 1983;61:1021-5. 3. Lechat MF. Disasters and public health. Bull WHO 1979;57:11-7. 4. Foege WH. Public health aspects of disaster management. In: Last JM, ed. Public health and preventive medicine. 12th ed. Norwalk, Connecticut: Appleton-Century-Crofts, 1986:187984. 5. Noji EK, Kelen GD, Armenian HK, Oganessian A, Jones NP, Silvertson KT. The 1988 earthquake in Soviet Armenia: a case study. Ann Emerg Med 1990;19:891-7. 6. Glass Rl, Urrutia JJ, Sibony S, et al. Earthquake injuries related to housing in a Guatemalan village. Science 1977;197:638-43.
Vol. 39 / No. 34
MMWR
577
Earthquake Disaster — Continued 7. Noji EK, Armenian HK, Oganessian AP. Case control study of injuries due to earthquake in Soviet Armenia. Ann Emerg Med 1990;19:449. 8. de Bruycker M, Greco D, Lechat MF. The 1980 earthquake in Southern Italy: morbidity and mortality. Int J Epidemiol 1985;14:113-7. 9. Anonymous. The risk of disease outbreaks after natural disasters. WHO Chronicle 1979; 33:214-6. 10. Autier P, Ferir M-C, Hairapetien A, et al. Drug supply in the aftermath of the 1988 Armenian earthquake. Lancet 1990;335:1388-90.
Epidemiologic Notes and Reports Nursing H om e O utbreaks of Invasive G roup A Streptococcal Infections — Illinois, Kansas, N o rth Carolina, and Texas During the winter of 1989-90, outbreaks of invasive group A streptococcal infec tions in one nursing home each in Illinois, Kansas, North Carolina, and Texas were reported to CDC. This report summarizes the clinical, laboratory, and epidemiologic features of these outbreaks. A total of 18 residents had invasive disease, and 10 (56%) died. Clinical features of infection included fever, altered mental status, and symptoms referable to the specific focus of infection. Eight patients had pneumonia with cough and respiratory distress; seven had cutaneous infections (usually at the site of a pre-existing skin lesion); two had sinusitis; and three had no apparent focus for infection. Serious complications included necrotizing fasciitis requiring debridement or amputation, renal failure, and adult respiratory distress syndrome (ARDS). Several patients had illnesses consistent with streptococcal toxic shock-like syndrome ( 1 ). Documented group A streptococcal infection in nursing home staff was rare; two nurses had culture-confirmed pharyn gitis, and one, pneumonia. Isolates from patients from each of the outbreaks were typed at CDC. Two outbreaks were caused by M-nontypeable, T-11/12 strains; one, by M-1, T-1; and one, by M-29, T-nontypeable strains. In all four nursing homes, culture surveys of all residents and staff were performed to evaluate throat and wound carriage of group A streptococci. Eleven (4%) of 312 residents and four (1%) of 297 staff had asymptom atic pharyngeal carriage. At each nursing home, the pharyngeal and invasive isolates were the same serotype. No wound swab cultures were positive. In one nursing home, a case-control investigation was conducted to determine risk factors for infection. This study suggested person-to-person spread of infection between close contacts, with statistically significant clustering of case-patients by room. No other risk factors were identified. In three nursing homes, prophylactic antimicrobial therapy was instituted after the survey of residents and staff was completed. In two, full courses of therapy were given to all residents and staff; in the third, therapy was discontinued when all surveillance cultures were reported as negative. In the fourth nursing home, antimi crobial therapy was given only to those who were culture positive. No further cases of infection occurred after these interventions. Reported by: JL Hansen, JP Paulissen, MD, AL Larson, MPH, Du Page County Health Dept; B Solon, C Langkop, BJ Francis, MD, State Epidem iologist, Illinois Dept o f Public Health. P Gladbach, M ercy Hospital, C Lipe, Arkhaven Nursing Home, Ft. Scott; C Wood, MD, State Epidemiologist, Kansas Dept o f Health and Environment. M Fiorelli, MD, D Williams, Halifax;
578
MMWR
August 31, 1990
Streptococcal Infections — Continued A Atamura, MD, Univ o f North Carolina School o f Medicine, Chapel H ill; RA M erriweather, MD, Communicable Disease Control, North Carolina Dept o f Human Resources. B Gray; M Averill, MD, Nursing Home Care Unit, JW Smith, MD, Veterans' A dm inistration M edical Center, CE Haley, MD, Dallas County Health Dept; DM Simpson, MD, State Epidem iologist, Texas Dept o f Health. Respiratory Diseases Br, Div o f Bacterial and M ycotic Diseases and Hospital Infections Program, Center fo r Infectious Diseases, CDC.
Editorial Note: Residents of nursing homes are at increased risk for many infectious diseases. Outbreaks of infection in this setting are facilitated by the close contact of persons who are highly susceptible to infection because of their ages and underlying illnesses. In addition, knowledge of infection-control practices by nursing home personnel and the ability to isolate or cohort patients in a nursing home are often limited ( 2 ). In recent years, invasive group A streptococcal infections have occurred more commonly throughout the United States ( 1,3). Recent population-based studies have established an incidence of 4-5 cases per 100,000 persons (CDC, unpublished data). The risk for streptococcal bacteremia and the case-fatality rate are highest in the elderly (4,5). Additional outbreaks in nursing homes are possible because of the increasing rate of severe group A streptococcal infections, the propensity of this organism to cause disease in the elderly, and the ability of this organism to spread by the person-to-person route. These four nursing home outbreaks shared several features: 1) a cutaneous or respiratory focus of infection in most patients, 2) high case-fatality rates, 3) uncom mon pharyngeal carriage among residents and staff, 4) lack of documentation of carriage in skin lesions not showing evidence of an acute cellulitis, and 5) apparent person-to-person spread between close contacts. Two other reported nursing home outbreaks were characterized by similar features (6,7). Although specific guidelines for controlling group A streptococcal infections in nursing homes have not been published, the CDC guidelines for isolation precautions in hospitals should be applied to these settings ( 8 ). Isolation of patients until 24 hours of effective antimicrobial therapy has been completed is important. The role of culture surveys and antimicrobial prophylaxis is unclear; because the streptococcal carriage rate is low, treatment of all patients and staff probably is unnecessary. However, throat cultures could be obtained from all nursing home residents and staff followed by institution of antimicrobial therapy; when culture results are available, a course of therapy could be completed only by those who are culture positive or who have symptoms consistent with streptococcal infection. Penicillin is the recommended antimicrobial for treating group A streptococcal infections; erythromycin is recom mended for penicillin-allergic persons. The development of more effective approaches to the control of invasive group A streptococcal infections in nursing home residents and in other settings requires additional information about clusters of this disease. Descriptions of clusters of two or more cases of invasive group A streptococcal infections may be reported to CDC's Respiratory Diseases Branch, Division of Bacterial and Mycotic Diseases, Center for Infectious Diseases, through state health departments. Serotyping of isolates from clusters and case report forms are available from CDC. References 1. Stevens DL, Tanner MH, Winship J, et al. Severe group A streptococcal infections associated with a toxic shock-like syndrome and scarlet fever toxin A. N Engl J Med 1989;321:1—8. 2. Garibaldi RA, Brodine S, Matsumiya A. Infections among patients in nursing homes: policies, prevalence, problems. N Engl J Med 1981;305:731-5.
Vol. 39 / No. 34
579
MMWR
Streptococcal Infections — Continued 3. CDC. Group A beta-hemolytic streptococcal bacteremia —Colorado, 1989. MMWR 1990;39: 3-11. 4. Francis J, Warren RE. Streptococcus pyogenes bacteremia in Cambridge —a review of 67 episodes. Quart J Med 1988;256:603-13. 5. Bibler MR, Rouan GW. Cryptogenic group A streptococcal bacteremia: experience at an urban general hospital and review of the literature. Rev Infect Dis 1986;8:941-51. 6. Ruben FL, Norden CW, Heisler B, Korica Y. An outbreak of Streptococcus pyogenes infections in a nursing home. Ann Intern Med 1984;101:494-6. 7. Reid Rl, Briggs RS, Seal DV, Pearsom AD. Virulent Streptococcus pyogenes: outbreak and spread within a geriatric unit. J Infect 1983;6:219-25. 8. Garner JS, Simmons BP. Guideline for isolation precautions in hospitals. Infect Control 1983;4(suppl): 245-325.
C om m on Source O u tb reak of Relapsing Fever — California In August and September 1989, six persons who had each at different times spent the night in the same cabin at Big Bear Lake, San Bernardino County, California, developed sudden onset of high fever with severe headache, prostration, nausea, and vomiting. Four patients were initially considered to have viral gastroenteritis and received no antibiotic therapy. When fevers recurred, relapsing fever was suspected and confirmed serologically in two of these patients. Two of the four patients were treated with tetracycline and recovered. Two recovered without treatment after three relapses. The fifth patient, an elderly woman, was admitted to intensive care with septic shock. Laboratory findings included spirochetes visible in a Giemsa-stained smear of peripheral blood, neutrophilic pleocytosis of the cerebrospinal fluid, peripheral leukocytosis, thrombocytopenia, and hypophosphatemia. She was treated with intravenous doxycycline and developed a probable Jarisch-Herxheimer reaction before recovering fully. For the sixth patient, the suspected diagnosis of relapsing fever was confirmed by the identification of spirochetes in a thick blood smear. This patient was treated promptly with tetracycline and recovered rapidly. The Santa Barbara and San Bernardino county health departments were advised of the outbreak and conducted an epidemiologic and environmental investigation of the Big Bear Lake area and the cabin used by each of the six patients. The investigators noted a large population of California ground squirrels and chipmunks and the widespread practice by visitors of feeding these animals. Inhabited ground-squirrel burrows were found under the cabin. The cabin was fumigated to kill vectors (ticks). No other cabins were known to be associated with illness. In the spring of 1990, educational literature about relapsing fever and prevention of the disease was distributed to cabin owners in the Big Bear Lake area. Reported by: WC Koonce, MD, S Abbott, MD, S Hosea, MD, E Hunt, MD, W M orton-Sm ith, MD, Santa Barbara; L Harris, Santa Barbara County Dept o f Health; San Bernardino County Depts o f Public Health and Environm ental Health, California. Bacterial Zoonoses Br, Div o f Vector-Borne Infectious Diseases, Center fo r Infectious Diseases, CDC.
Editorial Note: In the United States, relapsing fever results from infection by the spirochetes Borrelia herm sii and B. turicatae. The disease, which occurs in the western United States, is transmitted to humans principally by the bites of the infected ticks Ornithodoros herm si and 0. turicata but possibly also by O. parked (Continued on page 585)
August 31, 1990
MMWR
580
FIGURE I. Notifiable disease reports, comparison of 4-week totals ending August 25, 1990, with historical data — United States DISEASE
DECREASE
INCREASE
CASES CURRENT 4 WEEKS
Aseptic Meningitis
1,092
Encephalitis, Primary
67
Hepatitis A
1,945
Hepatitis B
1,510
Hepatitis, Non-A, Non-B
205
Hepatitis, Unspecified
102
Legionellosis
134
Malaria
82
Measles, Total
1,030
Meningococcal Infections
106
Mumps
254
Pertussis
381
Rabies, Animal
301 103
Rubella
---------------1
r
0.25
0.5
1
2
4
Ratio(Log S c a le )* Ratio
[xxi B«y°nd ^ ^ Historical Umits
*Ratio of current 4-week total to mean of 15 4-week totals (from comparable, previous, and subsequent 4-week periods for past 5 years).
TABLE I. Summary - cases of specified notifiable diseases, United States, cumulative, week ending August 25,1990 (34th Week) Cum. 1990 AIDS Anthrax Botulism: Foodborne Infant Other Brucellosis Cholera Congenital rubella syndrome Diphtheria Encephalitis, post-infectious Gonorrhea: civilian military Leprosy Leptospirosis Measles: imported indigenous
27,283 -
9 39 6 47 3 3 2 65 430,230 5,921 139 29 969 18,016
Cum. 1990 Plague Poliomyelitis, Paralytic* Psittacosis Rabies, human Syphilis: civilian military Syphilis, congenital, age < 1 year Tetanus Toxic shock syndrome Trichinosis Tuberculosis Tularemia Typhoid fever Typhus fever, tickborne (RMSF)
1 -
77 1 31,180 166 685 35 214 19 13,926 81 263 383
*Three cases of suspected poliomyelitis have been reported in 1990; five of 13 suspected cases in 1989 were confirmed and all were vaccine-associated.
Vol. 39 / No. 34
MMWR
581
TABLE II. Cases of specified notifiable diseases, United States, weeks ending August 25, 1990, and August 26, 1989 (34th Week)
Cum. 1990
Aseptic Menin gitis Cum. 1990
AIDS Reporting Area
UNITED STATES
Encephalitis Post-in fectious Cum. Cum. 1990 1990
Primary
Gonorrhea (Civilian)
Hepatitis (Viral), by type NA,NB Unspeci B fied Cum. Cum. Cum. Cum. 1990 1990 1990 1990 A
Legionellosis
Leprosy
Cum. 1990
Cum. 1990
Cum. 1990
Cum. 1989
430,230
446,733
18,650
13,161
1,422
1,091
759
139
12,107 129 119 38 5,021 755 6,045
12,809 177 115 44 4,968 939 6,566
381 6 6 4 263 39 63
704 25 29 37 442 31 140
46 4 4 4 24
44 1 2
33 3 4 5 15 6
9
8 1
58,889 8,894 25,160 9,736 15,099
66,547 10,165 26,923 9,781 19,678
2,652 736 347 251 1,318
1,844 480 494 428 442
156 44 23 33 56
79 20 42
240 90 50 43 57
17 1 12 3 1
27,283
4,659
469
NEW ENGLAND Maine N.H. Vt. Mass. R.l. Conn.
1,013 40 53 10 566 53 291
174 6 16 17 56 55 24
17 3
MID. ATLANTIC Upstate N.Y. N.Y. City N.J. Pa.
8,462 1,035 5,002 1,618 807
459 241 98
4 1 1
120
35 29 3 1 2
E.N. CENTRAL Ohio Ind. III. Mich. Wis.
1,881 440 176 747 368 150
846 187 123 150 356 30
117 34 2 38 38 5
11 3 6 2
82,041 24,973 7,240 26,099 18,781 4,948
79,954 20,511 5,638 26,124 20,796 6,885
1,433 141 85 706 259 242
1,566 284 286 300 449 247
114 44 5 31 24 10
68 10 14 15 29
171 61 30 8 52 20
2
633 120 25 360 2 2 29 95
212 12 25 119 9 5 16 26
38 11 5 5
1 1
22,202 2,759 1,638 13,420 55 144 1,156 3,030
19,785 2,178 1,653 12,023 93 167 890 2,781
1,076 156 210 336 10 144 64 156
594 76 46 366 4 5 23 74
95 21 8 42 2 3 4 15
25
38
1
3
6 5
1 -
5,650 65 560 484 501 39 408 233 772 2,588
982 28 119 2 157 33 88 12 194 349
105 3 14
123,506 2,013 13,988 8,657 11,412 751 18,964 9,672 27,206 30,843
121,105 2,005 13,661 8,117 9,990 926 18,374 11,019 23,272 33,741
2,245 89 784 12 186 15 501 29 243 386
2,524 68 363 28 163 59 704 401 295 443
217 6 31 4 32 4 82 13 7 38
169 1 9
121 6 49
3
124 4
9 3 15 15 14 10
665 113 211 144 197
418 101 66 174 77
39 15 18 6
1
37,510 3,930 11,274 13,166 9,140
35,043 3,365 11,610 11,194 8,874
257 65 122 69 1
1,004 346 544 109 5
105 36 53 14 2
4 3 1
46 18 16 12 -
2,975 140 457 148 2,230
446 8 62 40 336
23 1 6 2 14
6
43,598 5,725 8,071 3,994 25,808
46,784 5,465 9,905 4,067 27,347
1,924 348 131 375 1,070
1,341 55 206 107 973
62 6 3 19 34
175 13 7 17 138
38 7 12 13 6
737 10 19 2 219 70 232 68 117
231 3 7 1 52 10 113 24 21
17
2
3,053 88 59 44 199 605 1,496 326 236
1,003 49 60 12 107 131 354 73 217
139 5 8 5 31 9 53 18 10
29 2 3
2
9,374 129 125 62 2,090 910 3,664 293 2,101
85 4
7 2 4
8,274 116 88 101 1,634 810 3,521 272 1,732
PACIFIC Wash. Oreg. Calif. Alaska Hawaii
5,267 437 192 4,524 22 92
891
78 6
21 1
745 84 62
67 4 1
19
42,103 3,448 1,683 35,948 691 333
55,332 4,325 2,033 48,019 626 329
5,629 938 579 3,913 137 62
2,581 396 278 1,815 42 50
488 83 37 356 3 9
442 20 7 409 1 5
Guam P.R. V.l. Amer. Samoa C.N.M.I.
1 1,004 10
2 45
-
6
1 192 8
1
-
9 113 1 26 10
8 19
-
111 725 454 32 68
.
-
149 460 249 49 148
W.N. CENTRAL Minn. Iowa Mo. N. Dak. S. Dak. Nebr. Kans. S. ATLANTIC Del. Md. D.C. Va. W. Va. N.C. S.C. Ga. Fla. E.S. CENTRAL Ky. Tenn. Ala. Miss. W.S. CENTRAL Ark. La. Okla. Tex. MOUNTAIN Mont. Idaho Wyo. Colo. N. Mex. Ariz. Utah Nev.
N: Not notifiable
65
2 6 1 5
2
2 7 8
1
-
35 19 23 1 4 6
2
1 15
1
5 1
-
1 3 -
U: Unavailable
19
-
1
10
2
-
39 2 -
-
17
-
.
2 19 1
4 23 . -
5
.
8 7 16
1 30 5 31 5 9
.
1 . .
1 .
30 -
30
5 2 9 3 5 43 11
75 4
31
60
1
11 .
.
.
.
.
-
9
15
C.N.M.I.: Commonwealth of the Northern Mariana Islands
.
1 1 -
-
10 4
582
MMWR
August 31, 1990
TABLE II. (Cont'd.) Cases of specified notifiable diseases, United States, weeks ending August 25, 1990, and August 26, 1989 (34th Week) Malaria Reporting Area Cum. 1990
1990
Cum. 1990
Cum. 1989
Menin gococcal Infections Cum. 1990
101
969
11,258
1,704
24 2 8 1 7 3 3
312 11 3 45 41 212
128 10 6 10 60 12 30
150 110 21 10 9
906 138 89 422 257
251 93 36 58 64
2
3,201 549 319 1,242 348 743
143 3 1 10 125 4
3,629 743 78 2,288 307 213
233 73 23 62 54 21
1
770 314 25 96
13 3 1
638 16 9 367
Measles (Rubeola) Indigenous Cum. 1990 1990
740
104
18,016
NEW ENGLAND Maine N.H. Vt. Mass. R.I. Conn.
61 1 4 5 32 5 14
. -
236 27 17 27 165
MID. ATLANTIC Upstate N.Y. N.Y. City N.J. Pa.
157 31 51 54 21
.
E.N. CENTRAL Ohio Ind. III. Mich. Wis.
44 5 2 19 14 4
1 1 -
W.N. CENTRAL Minn. Iowa Mo. N. Dak. S. Dak. Nebr. Kans.
10 1 2 6 -
UNITED STATES
1
-
-
-
976 200 226 188 362
154 3 43 10 39 2 10 15 32
2
E.S. CENTRAL Ky. Tenn. Ala. Miss.
15 2 8 5 -
-
W.S. CENTRAL Ark. La. Okla. Tex.
37 2 2 8 25
52 52
3,975 12 10 175 3,778
MOUNTAIN Mont. Idaho Wyo. Colo. N. Mex. Ariz. Utah Nev.
18 1 3
49
796
PACIFIC Wash. Oreg. Calif. Alaska Hawaii Guam P.R. V.l. Amer. Samoa C.N.M.I.
-
244 17 12 210 2 3
834 8 193 15 72 6 9 4 81 446
99
98§ 1§
147 31 70 20 26 1
1§
16
2 3 8 1
1 1S
15 97 223
S. ATLANTIC Del. Md. D.C. Va. W. Va. N.C. S.C. Ga. Fla.
2
Imported*
48 1 -
*
3 2
U
35 ■
U
u
89 81 274 126 210 7,081 202 168 6,625 78 8 U 808 21 190 ■
Mumps
Pertussis
1990
Cum. 1990
53
. -
2
Rubella
1990
Cum. 1990
Cum. 1989
1990
Cum. 1990
Cum. 1989
3,791
98
2,175
2,194
6
776
288
36
9
8 1 11 5 11
5 4 . -
266 10 36 6 197 2 15
258 9 5 6 214 11 13
247 105
46 8
62 80
38
395 276 . 21 98
110 43 3 25 39
445 128 83 97 60 77
303 45 18 100 30 110
31 1
108 17 15 60 2 1 4 9
157 36 13 97 2 1 5 3
14 9 4
180 5 47 14 15 14 39 5 24 17
197 1 26
18
9
2 1 1
2
14
6
11 7
1 -
386 89 16 116 126 39
2 -
111 7 16 50
3 . . .
. 2
3 35
1 2 4
4 -
8 1
113 133
58 11 1 23 1 2 5 15
307 3 18 7 2 15 201 61
541 39 76 35 21 51 168 3 2 146
308 3 35 11 40 13 44 21 54 87
26 . 12 . 12 2 -
1,573 4 908 32 90 40 220 45 82 152
2 -
99 32 36 29 2
2
84
110
2 -
210 32 132 46 -
1 1
47 13 24
45 59 6
152 1 93 49 9
87 28 59
3,109 5 9 106 2,989
114 16 26 15 57
6 2 3
589 133 101 105 250
7 5
87 8 19 32 28
91 1 10 11 42 12 12
372 13 2
53 10 5
5
2
17 6 4 5 6
1 1
3
73 31 137 113 3
299 1 142 2 21 N 110 8 15
152 69 44 33 2 4
1,541 51 28 1,435 1 29
460 59 53 336 8 4
466 41 N 407 4 14
16 13 3
1
2 466 4
3 7 7 19 8
U
3 U U
Total
.
1
1 N 4 9 N 7 2 U
9 .
U
u
*For measles only, imported cases includes both out-of-state and international importations. N: Not notifiable U: Unavailable international 5Out-of-state
. .
4
-
.
2
-
2 1 3 6 6
11 10 1
18 9 3
6 4 1 1
29 12 15 2 24 3 . 19 1 1 6 1 4
1 1
24 20 40 26 60
.
. 1
3
2
3
2
219 18 13 41 147
66 3
36
188 26 36
498 29 65
105 13 49
63 15 34 10 4
43 21 326 13 1
4
396 101 44 217 4 30
300 120 7 166
1 62
7
5 1 30 35 1 32 -]
30 1 8
1
520
141
10 500
2 118
10
21
-
U 6
u u
8 1 1
4
7 u
4
-
u
-
-
MMWR
Vol. 39 / No. 34
583
TABLE II. (Cont'd.) Cases of specified notifiable diseases, United States, weeks ending August 25, 1990, and August 26, 1989 (34th Week) Reporting Area
UNITED STATES
Cum. 1990
Cum. 1989
Toxicshock Syndrome Cum. 1990
Syphilis (Civilian) (Primary & Secondary)
Tula remia
Typhoid Fever
Cum. 1989
Cum. 1990
Cum. 1990
Typhus Fever (Tick-borne) (RMSF) Cum. 1990
Tuberculosis Cum. 1990
Rabies, Animal Cum. 1990
31,180
27,931
214
13,926
13,699
81
263
383
2,747
NEW ENGLAND Maine N.H. Vt. Mass. R.l. Conn.
1,158 5 40 1 453 12 647
1,101 8 10
16 5 1
340
2
21
337 21 725
8 1 1
2
20 1
16 . . 15 . 1
4
3 7 185 43 102
363 12 17 7 183 42 102
MID. ATLANTIC Upstate N.Y. N.Y. City N.J. Pa.
6,375 569 2,966 1,039 1,801
5,735 590 2,536 882 1,727
22 8 5
3,547 281 2,231 579 456
2,635 212 1,443 522 458
1
66 13 36 14 3
17 8 . 6 3
638 79
E.N. CENTRAL Ohio Ind. III. Mich. Wis.
2,145 362 56 866 645 216
1,131 88 43 519 380 101
49 17 1 7 24
1,417 236 120 725 276 60
1,441 257 133 655 311 85
1 1
36 28 1 . 7
-
22 5 1 11 4 1
109 5 4 21 31 48
322 61 42 166 1 1 9 42
215 32 22 112 3 1 17 28
23 1 5 8
355 70 28 167 11 18 16 45
30
3
3 6
364 66 40 175 14 9 14 46
435 159 17 19 61 139 4 36
S. ATLANTIC Del. Md. D.C. Va. W. Va. N.C. S.C. Ga. Fla.
10,236 123 759 690 563 57 1,161 664 2,635 3,584
10,225 110 509 608 347 11 671 560 2,590 4,819
20 1 1 1 2 . 10 2 1 2
2,796 24 214 98 246 49 361 311 468 1,025
2,916 30 233 132 232 52 350 338 458 1,091
3
E.S. CENTRAL Ky. Tenn. Ala. Miss.
2,882 57 1,209 865 751
1,852 39 821 565 427
12 2 7 3
1,064 268 277 336 183
1,106 267 315 320 204
7 1 6
2 1
-
1
W.S. CENTRAL Ark. La. Okla. Tex.
4,752 356 1,150 159 3,087
3,767 242 885 63 2,577
11
1,798 229 150 125 1,294
1,614 165 212 145 1,092
24 17 . 7 -
8
1 7 3
557 6 26 29 403 8 85
408 1 1 3 55 21 162 12 153
24 2 2 7 3 7 3 -
329 22 9 3 14 78 146 18 39
300 11 20 -
2,753 229 95 2,411 10 8
3,497 292 161 3,032 3 9
37 4 32
2,271 182 86 1,848 29 126
2,969 158 95 2,557 43 116
3 1
2 204 3
4 376 8
29 66 4 11 40
54 200 4 4 17
.
W.N. CENTRAL Minn. Iowa Mo. N. Dak. S. Dak. Nebr. Kans.
MOUNTAIN Mont. Idaho Wyo. Colo. N. Mex. Ariz. Utah Nev. PACIFIC Wash. Oreg. Calif. Alaska Hawaii Guam P.R. V.l. Amer. Samoa C.N.M.I. U: Unavailable
-
-
-
3
7
9
-
1 -
21 54 138 26 30
-
-
1
-
3
42 . 27
-
-
3 3 2
-
2 1 12
-
22
31 8 . 2
2
2
194 365
146 1 14 . 15 . 73 34 9
769 16 283 . 132 29 4 94 148 63
53 6 40 7 -
122 34 27 61 -
. 2 6
55 12 1 39 3
333 37 18 97 181
10
18 . .
10 4 .
3 2 3
-
139 34 2 43 9 6 25 6 14
1 . 1 1 -
2 1 1 17
-
16 2
1 1 1 3
2 92 3 4 81
2 4 . . . -
8
198
1 2 . 5
1 175 22
. . .
33 . .
-
-
.
1 4
MMWR
584
August 31, 1990
TABLE III. Deaths in 121 U.S. c ities / week ending August 25, 1990 (34th Week) All Causes, By Age (Years) Reporting Area
NEW ENGLAND Boston, Mass. Bridgeport, Conn. Cambridge, Mass. Fall River, Mass. Hartford, Conn. Lowell, Mass. Lynn, Mass. New Bedford, Mass. New Haven, Conn. Providence, R.l. Somerville, Mass. Springfield, Mass. Waterbury, Conn. Worcester, Mass.
All Ages
>65 45-64 25-44 1-24
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