CENTER FOR DISEASE CONTROL September 1, 1978 / VWll / Nch$5 <*

MORBIDITY AND MORTALITY WEEKLY REPORT

International Notes

England 1^' Crg/Current Trends'f" /,Measles — Unit '

321 Q Fever - New Y

ACIP Recommenda

327 Meningococcal Polysaci

Vaccines

International Notes

Laboratory-Associated Smallpox — England

England has reported a case of laboratory-associated smallpox. This is the first small

pox case reported in the world since October 26, 1977, when a case occurred in Somalia.

The patient is a 40-year-old female medical photographer employed at Birmingham

Medical School; her office is located on the floor above the Department of Virology,

where work on variola viruses is done. She developed fever on August 11 and rash 2 days

later. She was hospitalized on August 24; the same day she was transferred to a small

pox infectious disease hospital.

Electron microscopy (EM) was positive for pox virus on August 25; on August 27,

variola major virus was isolated.

Thirty-nine close and 196 casual contacts of the patient have been identified. Three

f contacts who have become ill have been admitted to isolation as a precautionary measure.

EM results on one such contact, who had rash and fever, showed Herpes virus. As of

August 30, all other contacts are well.

One contact, a 20-year-old British woman, traveled to North Dakota on August 18.

When it was learned that her co-worker had smallpox, state and local health officials

were notified, and CDC dispatched a medical epidemiologist to the farm where she is

staying. She is afebrile and has no symptoms. She had been vaccinated 5 years ago.

Daily surveillance is being maintained by local health authorities.

As of August 30, the patient is still hospitalized but improving. She has a confluent

rash on her face and discrete lesions on her extremeties. The medical school labora

tory has been closed.

Reported by PA Hyzler, MD, National Health Div, Dept of Health and Social Security, London;

K Mosser, State Epidemiologist, North Dakota State Dept of Health; Bur of Smallpox Eradication,

CDC.

Editorial Note: This patient was presumably infected by airborne transmission of vari

ola virus from the smallpox laboratory on the ground floor to the patient's normal

work area on the first floor. The ability of variola virus to transmit from 1 floor to

another via external air currents has been previously documented in a hospital out

break of smallpox in Meschede, Germany (/). Investigation will be required to iden

tify the specific safety breakdown in the Birmingham laboratory.

As smallpox laboratories hold the only known reservoir of smallpox virus, the World

Health Organization (WHO) has urged that storage of the reference virus strains be

restricted to the 5 WHO Pox Virus Reference Centers (2). Since 1975, 62 of 76 labora

tories with known variola virus have destroyed or transferred their virus stocks. The

Birmingham incident emphasizes the continuing risk of laboratory-acquired infection

and the need to ensure maximum security at every facility holding the virus.

U.S. DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE / PUBLIC HEALTH SERVICE

September 1, 1978

Smallpox — Continued

The British contact now in the United States is not believed to be at risk of devel

oping smallpox because her exposure to the case occurred 2-3 days before the patient

had become infectious and 21 days have elapsed since exposure—more than the maxi

mum expected incubation period. U.S. and British vaccination requirements for inter

national travelers remain unchanged {3). However, Malta and Jamaica are now requiring

valid vaccination certificates for anyone who has been in Birmingham in the previous

14 days.

References

1. Wehrle PF, Posch J, Richter KH, Henderson DA: An airborne outbreak of smallpox in a German

hospital and its significance with respect to other recent outbreaks in Europe. Bull WHO 43:669-

679,1970

2. WHO: Laboratories retaining variola virus. Weekly Epidemiological Record 53:221-222, 1978

3. MMWR 27:295, 1978

Current Trends

Measles - United States, 1978

During the first 33 weeks of 1978, 22,546 cases of measles were reported to CDC-

a 57.1% decrease from the same period in 1977 (/). Twenty-six states have reported no

measles for at least a 1-month period. The incidence of measles this year is 15.8% greater

than the equivalent period in 1974, when the fewest number of cases was reported

(Figure 1).

Five states—Maine, Michigan, Virginia, West Virginia, and Wisconsin—have each re

ported a measles incidence rate greater than 100 cases per 100,000 population less than

FIGU14,000-I

3.500-

3000-

2,500-

« 2,000-<

1.500-

1,000-

500-

0

RE1. Reported measles cases, by week.

A

A f \/ V \

United States,

\

1974,1977, 1978

-- I974

- 1977

— I978

345 6 7 8 9 10 II 12 13 14 15 16 17 18 19 2021 22 23 24 25 36 27 28 29 30 31 32 33 34 35 36 37 38 J9 40 41 42 43 44 4546 47 48495051 52

September 1,1978 MMWR 321

Measles — Continued

18 years of age.* These stdtes, which together account for 10.3% of the U.S. population

of this age, have reported 60.9% of the nation's measles cases this year.

Reported by Immunization Div, Bur of State Services, CDC.

Editorial Note: Data collected prior to the introduction of measles vaccine suggest

that only about 10% of measles cases occurring in the United States at that time were

reported to local health officials. Although it is generally felt that reporting efficiency

has improved somewhat since then, it is clear that a significant amount of underreporting

still exists. Since there is variation from area to area in the methodology (and probably

the sensitivity) of the current measles surveillance system, incidence rate data must be

interpreted with some caution. Nonetheless, it is reasonable to assume that prolonged

absence of reported cases in a particular state probably indicates little or no measles

transmission. Preliminary indications from the 5 high-incidence states that a large number

of cases are occurring in junior and senior high school students highlight the need to

assess immunization status of children of all ages and to provide immunization to those

not known to be protected.

Reference

1.MMWR 27:252, 1978

1976 population data

Epidemiologic Notes and Reports

Q Fever — New York

On May 25, 1978, the Suffolk County Department of Health Services was informed

by an infection control nurse at the Brookhaven Memorial Hospital that 2 days earlier

a 27-year-old man had been admitted with a 4-day history of fever to 104 F (40 C),

severe headache, chills, malaise, and vomiting. This patient had visited West Africa in

April and was an employee of an exotic bird and reptile importing company in Deer

Park, New York. Within 1 week, 3 other employees of that company were admitted to

the same hospital with similar symptoms. One had a non-productive cough. All were

treated with oral tetracycline with rapid resolution of their symptoms and complete

recovery.

These 4 persons had all been involved in unpacking and deticking a shipment of

approximately 500 ball pythons (Python regius), which were imported on May 3 from

Accra, Ghana. Examination of the hemolymph of 5 ticks removed from these snakes

indicated that all contained numerous bacteria, both bacillary and coccoid forms, and

that 2 contained rickettsiae which were not further characterized. Three types of ticks

were identified, namely, Amblyomma nuttalli, Aponomma latum, and Aponomma

flavomaculaturn.

Paired serum samples examined by the New York State Department of Health Labora

tory revealed rising titers against the Q fever antigen by complement fixation. Serum

specimens from the 4 hospitalized patients, tested at Rocky Mountain Laboratory,

National Institutes of Health (NIH), by microimmunofluorescence, showed confirma

tory rises in titers to Q fever.

Seven other persons were identified who had been in contact with the pythons, ticks

from the pythons, or excreta of ticks or pythons. Of thpse, 5 had had febrile illnesses

3 0001 00128 1270

322 MMWR September 1, 1978

Q Fever — Continued

with similar, but somewhat milder, symptoms than the hospitalized group. Four of the

5 had been seen by their family physicians and had received oral tetracycline. The fifth

did not see a physician. Serologic tests in 4 of these individuals confirmed a recent Q

fever infection in one and probable Q fever infections in 2 others.

Samples of python blood, spleen and liver, as well as 15 live ticks and 5 frozen ticks

removed from the pythons, were processed for attempted isolation of organisms; all

were negative.

The county health department has been informed that 420 of the pythons have been

sold to retailers all over the United States. The distribution list is unavailable at this time.

Reported by S Kim, MD, Patchogue, New York; S Guirgis, PhD, D Harris, MD, MPH, T Keelan, RN,

MPH, M Mayer, MD, MPH, M Zaki, MD, DrPH, Suffolk County Dept of Health Services; L Steinert,

RN, BS, Brookhaven Memorial Hospital; J Benach, PhD, D White, MS, DO Lyman, MD, State Epi

demiologist, New York State Dept of Health; R Ormsbee, PhD, Rocky Mountain Laboratory, Nation

al Institute of Allergy and Infectious Diseases, NIH; Viral Diseases Div, Bur of Epidemiology, CDC.

Editorial Note: Q fever is an acute, systemic disease caused by Coxiella burneti. Charac

terized by the abrupt onset of headache, myalgia, chills and fever, it is usually a self-

limited illness of 1-3 weeks duration. Pneumonia and hepatitis are frequent manifesta

tions (7), and endocarditis has been reported (2). Patients with Q fever, as opposed to

those with other rickettsial diseases, do not develop Weil-Felix agglutinins and virtually

never have an accompanying rash. The treatment of choice is tetracycline or chloram-

phenicol.

(Continued on page 327)

TABLE 1. Summary -- cases of specified notifiable diseases. United States

[Cumulative totals include revised and delayed reports through previous weeks.]

DISEASE

Aseptic meningitis

Brucellosis

Chickenpox

Diphtheria

Encephalitis: Primary (arthropod-borne & unspec.)

Post-infectious

Hepatitis, Viral: Type B

Type A

Type unspecified

Malaria

Measles (rubeola)

Meningococcal infections: Total

Civilian

Military

Mumps

Pertussis

Rubella (German measles)

Tetanus

Tuberculosis

Tularemia

Typhoid fever

Typhus fever, tick borne (Rky. Mt. spotted)

Venereal diseases:

Gonorrhea: Civilian

Military

Syphilis, primary & secondary: Civilian

Military

Rabies in animals

34th WEEK ENDING

August 26, | August 27,1978

346

3

321

3

32

11

285

562

200

8

91

32

32—

106

54

65

3

568

1

10

44

21,662

428

477

5

31

1977*

2 06

14

217

1

53

3

304

612

169

15

103

16

15

1

106

97

49

3

644

4

a

53

2 0,445

602

444

2

54

J tar ni A IUMtUIAN

1973-1977**

131

6

263

1

53

6

273

I 673f

14

103

16

15

-

269

49

3

644

3

6

32

20,750

604

463

2

59

iCUMULATIVE, FIRST 34 WEEKS

August 26,

1978

2,706

100

121,877

57

490

137

9,561

18,535

5,832

449

22,637

1.702

1,682

20

13,015

1,235

14,908

53

19,677

69

284

743

640,068

16,321

13,687

187

2,001

August 27,

1977*

2,491

150

159,902

60

5 54

148

10,765

20,196

5,763

354

52,6 00

1,226

1,217

9

15,730

865

18,428

45

19,779

102

231

884

635,797

17,679

13,455

192

1,992

TABLE II. Notifiable diseases of low frequency. United States

Anthrax (N.Dak. 1)

Botulism

Congenital rubella syndrome (Mich. 1)

Leprosy (Tex. I.Calif. 5)

Leptospirosis

Plague

re used to

CUM. 1978

5 Polion

55

22 Psittac

104 Rabies

39 Trichi

6 Typht

uDdate last vear's w

yelitis: Total

Paraly

osis (La. 1)

in man

losis (NYC 2)

s fever, flea bor

'eklv and cumu

tic

ne (endemic, muri

lative totals.

le)

MEDIAN

1973-1977**

1,835

150

144,519

126

592

196

7,511

1 22,856j

268

23,999

1,022

999

23

43,881

14,654

57

20,574

92

245

612

633,797

19,504

15,873

229

1,931

CUM. 1978

1

1

74

—

40

26

September 1, 1978

TABLE III (Cont.'d). Cases of specified notifiable diseases. United States, weeks ending

August 26,1978, and August 27, 1977 (34th week)

REPORTING AREA

UNITED STATES

NEW ENGLAND

Maine

N.H.t

Vt

Mass.

R.I.

Conn.

MID. ATLANTIC

Upstate N.Y.

N.Y. City

N.J.

Pa.

E.N. CENTRAL

Ohio

lnd.t

III.

Mich.

Wis.

W.N. CENTRAL

Minn.

Iowa

Mo.

N. Dak.

S.Dak.

Nebr.

Kara.

S. ATLANTIC

Del.

Md.

D.C

Va.

W. Va.

NX.

S.C.

Ga.

Fla.t

E.S. CENTRAL

Ky.

Tenn.

Ala.

Miss.

W.a CENTRAL

Ark.

La.

Okla.

Tex.

MOUNTAIN

Mont

MEASLES (RUBEOLA)

1971

91

2

—

—

_

2—

-

7

3

3

1

-

38-

5

T

24

2

_

—

—

-

—

—

—

-

19

1

4

-

2

2

—

_

—

10

2

_

—

2

_

_

_

-

-

_

_

CUM.

1978

22,637

1,968

1,314

46

25

253

8

322

2,147

1,363

335

74

355

9,867

475

187

628

7,124

1,453

378

34

52

11

191

—

i

95

4,827

7

50

—

2,80!i

1.032

116

1S6

17

604

1,379

118

956

89

216

1,009

u

341

13

639

247

105

CUM.

1977*

52,600

2,482

170

510

292

623

64

823

8, 305

3,787

710

195

3,613

11,128

1,842

4,302

1,66 0

525

2,399

9,437

2,620

4,267

1,038

23

67

214

1.208

4,517

22

371

14

2,701

222

62

14 7

764

214

1,969

1, 182

672

77

38

2.062

29

74

55

1,904

2,506

1,160

MENINGOCOCCAL INFECTIONS

1971

32

1

-

—

_

_

-

1

4

-

2

1

1

2

2

-

-

—

-

_

-

-

-

-

-

-

-

6

-

2

-

-

-

-

_

1

3

2

1

1

-

8

-

6

-

2

I

1

CUM.

1978

1,702

86

6

8

2

27

17

26

301

103

69

52

77

153

57

29

7

49

11

56

14

5

2 3

3

2

-

9

424

15

27

1

52

0

82

24

47

16 7

136

2d

iZ

42

34

269

li.

114

16

117

3b

2

CUM.

1977*

1.22o

52

3

3

5

17

1

23

162

36

44

37

45

134

44

9

34

35

12

54

19

8

16

1

4

1

5

2 68

19

18

—

23

9

62

28

44

85

132

26

33

49

24

215

11

83

10

114

30

2

1978

106

2

1

-

-

-

1

7

1

3

1

2

43

22

1

5

3

12

3

1

-

1

1

-

-

-

14

4

-

-

1

1

1

1

1

5

6

_

1

1

4

14

1

-

-

li

1 I

-

MUMPS

CUM.

1978

13.015

718

485

13

5

85

32

98

593

198

137

131

127

5,211

693

302

1,651

1,344

1,021

1,893

1%

120

1,154

li

6

21

560

741

53

65

1

133

165

66

16

65

177

1,108

iai

445

407

75

1,645

562

61

4

*93

394

141

PERTUSSIS

1978

54

3

-

-

_

3

-

-

a

4

2

—

2

10

1

4

-

-

5

2

-

-

-

-

1

1

-

4

-

-

-

-

-

—

1

2

1

3

1

2

-

-

4

1

-

I

2

13

-

RUBELLA

1971

65

5

—

1_

4

—

-

9

I

4

2

2

19

1

4

-

6

8

_

-

-

-

-

—

-

-

13

I

-

-

4

5

—

-

-

3

2

—

2

—

-

2

-

—

-

2

4

-

CUM.

1978

14.908

729

148

101

27

215

42

196

2,971

515

122

1,598

736

6,839

1,257

566

422

3,072

1,522

655

128

52

97

81

111

34

152

1,002

35

7

1

238

333

178

28

5

177

494

128

198

21

147

905

5b

483

11

353

199

17

TETANUS

CUM.

1978

53

1

-

-

1

-

-

3

1

-

—

2

2

1

1

-

-

-

6

1

-

-

-

1

-

4

11

-

2

1

-

2

1

-

6

3

2

-

—

1

14

1

1

3

9

1

-

tussis: N.H. +2; Rubella: Gu

Guam +2; Men. inf.: Fla. -1. Mumps: Ind. —1, Guam +4; Pe

September 1,1978

TABLE III (Cont.'d). Cases of specified notifiable diseases. United States, weeks ending

August 26,1978, and August 27, 1977 (34th week)

REPORTING AREA

TUBERCULOSIS

1978

UNITED STATES 568

NEW ENGLAND

Maine t

N.H.

Vtt

Mass.

R.I.

Conn.

MID. ATLANTIC

Upstate N.Y.

N.Y. Cityt

N.J.

Pat

E.N. CENTRAL

Ohio

IndT

III.

Mich.t

Wis.

W.N. CENTRAL

Minn.

Iowa

Mo.

N. Dak.

S. Dak.

Nebr.

Kam.t

& ATLANTIC

Del.t

k Md.t

1 D.C." Va.

W. Va.

N.C.t

S.C.

Ga.

Flat

E.S. CENTRAL

Ky.

Tenn.

Ala

Miss.

W.S. CENTRAL

Ark.t

La.

Okla.

Tex.t

MOUNTAIN

Mont.

Idaho

Wyo.

Colo.t

N. Mex.

Ariz.

Utah

Nev.

PACIFIC

Wash.t

Oreg.

Calif.

Alaska

Hawaii

Guamt

P.R.

V.I.

19

-

—

1

13

1

«♦

95

It

31

19

37

108

za

10

42

33

3

12

i

'♦

2

1

2

-

-

117

3

23

2

12

ZZ

6

—

41

65

20

17

19

9

56

U

5

12

29

5

-

2

-

—

-

2

-

1

91

Nm

2

86

-

3

NA

2

-

CUM.

1978

19,677

649

45

13

29

378

45

139

3,349

49 7

1,208

814

S30

3,055

560

351

1,146

86 3

135

640

120

74

266

30

55

12

83

4,233

36

651

218

455

148

656

384

572

1,113

1,830

409

561

442

418

2,314

251

400

235

1,42 6

569

42

24

13

53

90

272

26

49

3,038

145

128

2.34S

46

370

37

25 5

4

TULA

REMIA

CUM.

1978

69

_

-

-

—

-

-

-

3

2

I

-

-

1

1

-

-

-

-

15

-

-

-

-

-

2

7

-

4

-

3

-

-

-

-

-

5

2

J

-

-

32

21

5

3

3

4

-

2

1

-

-

-

1

-

2

-

-

2

-

_

-

—

TVPHOIO

FEVER

1978

10

1

-

—

—

1

—

-

_

-

-

—

-

1

-

-

-

1

-

_

-

-

—

—

—

-

-

2

—

2

—

—

—

—

—

—

-

_

-

-

—

-

3

3

—

-

-

2

1

—

—

-

-

1

—

-

1

-

-

—

NA

-

—

CUM.

1978

284

40

-

5

1

Zi

4

7

32

7

17

4

4

21

7

-

4

10

-

12

4

2

4

-

-

-

2

39

1

8

1

5

2

2

4

3

13

7

2

3

1

1

34

5

3

2

24

17

2

5

-

3

2

3

1

1

82

6

1

68

-

7

_

1

2

TYPHUS FEVER

(Tick-borne)

(RMSF)

1978

44

2

-

-

-

1

-

1

2

-

-

2

-

1

1

-

—

-

-

1

-

-

-

-

-

1

-

23

-

8

-

6

- —

5

-

4

-

7

3

4

—

-

6

1

-

5

-

2

-

-

—

2

-

-

-

-

_

-

-

-

-

NA

-

-

CUM.

1978

743

14

-

—

—

5

1

8

43

24

2

10

7

22

16

1

5

—

-

22

—

-

13

1

2

2

4

416

5

99

-

88

9

137

44

35

-

138

37

89

6

6

77

12

1

45

19

8

2

2

1

2

—

—

—

I

3

-

z

I

-

-

_

-

—

21

1

3

1

1

5

1

1

1

2

1

3

3

1978

,662

550

31

26

13

251

31

198

,1127

391

719

121

596

,4 36

,092

97

,180

839

223

998

182

87

5 37

19

22

73

78

.347

129

807

366

606

67

6J8

422

,103

,239

,864

366

633

601

2 64

,862

168

621

291

,782

d66

36

40

22

235

-

358

52

123

.912

3 82

216

,17a

91

45

NA

53

2

VENERF.AL DISEASES (C

GONORRHEA

CUM.

1978

640,068

16,661

1,242

774

387

7,385

1,182

5,691

67,913

11,551

26,203

12,358

17,801

96,637

25,260

9,701

30,664

22,356

8.656

32,187

5,565

3,571

14,027

588

1,123

2,413

4,900

156,565

2 ,209

19,947

10,286

15,056

2,175

22,360

15,245

30,132

39,155

55,097

6,990

20,317

15,975

11,815

87 ,674

6,416

14,423

8 ,231

5a,604

24,103

1,377

935

568

6,683

3,310

6 ,382

1 .306

3,542

103,231

b,277

7 ,166

82,685

3,235

1 ,868

119

1 ,496

140

CUM.

1S77*

635,797

16,809

1,237

661

440

7,149

1,369

5,953

64,646

11,109

25,330

11,120

17,039

99,460

25,920

8,923

32,634

22,901

9,0d2

33,446

6,106

3,841

13,908

642

989

2,912

5,0-»8

158,136

2,144

19,839

10,316

16,530

2,141

23,338

14,499

30,725

38,634

56,642

7,588

22,878

15,457

10,719

80,080

6,351

11,674

7,631

54.424

25,857

1,325

1,215

642

6, 758

3,789

7,282

1,459

3,387

100,719

7,5 99

6,942

80,776

3,291

2,111

144

2, 127

137

viiian)

SYPHILIS (Pri

1978

477

9

-

—

_

6

-

3

51

6

27

13

5

45

19

1

22

2

1

14

2

4

6

-

-

2

-

133

_

6

12

15

2

16

8

34

40

26

7

12

6

I

87_

32

1

54

10-

1

—

6

3-

_

-

102

NA

4

98

_

-

NA

11_

CUM.

1978

13,687

384

7

5

3

235

16

US

1,801

139

1,254

207

201

1.49S

288

93

932

141

45

331

129

48

10

2

2

11

49

3,616

6

273

277

307

12

372

187

891

1,291

710

93

246

119

252

2,182

49

478

61

1,594

2 76

7

9

8

85

63

61

11

32

2,888

118

94

2,642

7

27

318

12

SSec.)

EuS1977*

13,455

551

16

3

6

393

7

126

1,872

180

1,177

244

271

1,424

334

107

745

167

71

296

88

28

112

3

3

24

38

3,789

18

243

396

372

3

524

161

805

1,262

481

58

148

97

178

1,908

46

463

53

1,346

289

4

7

2

87

65

108

5

11

2,845

158

83

2,561

18

25

1

369

7

RABIESIn

Animals)

CUM.

1978

2,001

73

61

2

1

6

—

3

69

50

11

8

119

11

8

39

5

56

419

134

86

49

68

56

4

22

277

1

_

7

a

8

66

17b

11

98

53

20

25

633

99

12

133

389

57

11

_

19

13

12

2

256

6

242

8

23

lived for 1977 are not shown b

ing delayed reports will be reflected in next week

Pa. -1, Del. +I.C0I0. +1; RMSF: N.C. -3, GC: Gu

but are used to update last year's v

eflected in next week's cumulative totals: TB: NYC +14, Mich. -2, Kans. -1 Md. -7 Fla -1 Wash +43 Gua

SF: N.C. -3, GC: Guam +13; Syphilis: Ark. -1, Tex. -1; An. Rabies: Maine+1, Vt.+1, Ind. +1.

September 1,1978

TABLE IV. Deaths in 121 U.S. cities,* week ending

August 26,1978 (34th week)

ALL CAUSES. BY AGE (YEARS)

REPORTING AREA

Bridgeport. Conn.

Cambridge, Mass.

Fall River, Mass.

Hartford, Conn.

Lowell. Mass.

Lynn, Mass.

New Bedford, Mass.

New Haven, Conn.

Springfield, M

Waterbury, Conn.

Worcester, Mass.

MID. ATLANTIC

Albany, N.Y.

Allentown, Pa

Buffalo, N.Y.

Camden, N.J.

Elizabeth. N.J.

Jersey City, N.J.

Newark. N.J.

N.Y. City. N.Y.

Paterson, N.J.

Philadelphia. Pa.

Pittsburgh. Pa

Reading, Pa

Rochester. N.Y.

Schenectady. N.Y.

ton. Pa

Syracuse. N.Y.

Trenton. N.J.

. N.Y.

Yonkers. N.Y.

REPORTING AREA

24 S. ATLANTIC

5 Atlanta, Ga

4 Baltimore. Md.

I Charlotte. N.C.

Jacksonville, Ft

1 Norfolk. Va

1 Richmond. Va.

1 Savannah, Ga

St. Petersburg, Fla

5 Tampa, Fla

I Washington, D.C.

E.S. CENTRAL

Birmingha

131 Chattanoc

2 Knoxville, T

1 Louisville. Ky

7 Memphis. Tr

- Mobile. Ala

1 Montgomery, Ala

- Nashville, Tenn.

57 W.S. CENTRAL5 Austin, Tex.

3 ° Baton Rouge. La2 Corpus Christi. Te

EIP

Fort Worth, Tex.

1 New Orle~ San Anto.Mu,

? Shreveport, La

Tulsa. Okla.

ALL CAUSES. BY AGE (YEARS)

>65 45-64 2544

976 533

139 65

211 110

2M«

96

28

22

Li49

5

17

P&l**

TOTAL

34

5

6

EN. CENTRAL

Akron. Ohio

Canton. Ohio

Chicago. III.

Cincinnati, Ohio

Cleveland, Ohio

Dayton, Ohio

Detroit, Mich,

lie. Ind.

Fort Wayne, Ind.

Gary, Ind.

Grand Rapids. Mich.

Indianapolis. Ind.

Madi—

,171 1,305

37 19

33 24

494 299

145 87

178 114

140 78

105 67

Peoria, III.

Rockford. III.

South Bend. Ind.

Toledo. Ohio

Youngstown, Ohil

W.N. CENTRAL

Des Moines, Iowa

Duluth, Minn.

Kansas City, Kans.

"—as City, Mo.

oln, Nebr.

Omaha, Nebr.

St. Louis, Mo.

St. Paul. Minn.

•Mortality data in this table

reported by the place of it!

"Pneumonia and influenza

MOUNTAIN

Albuquerque, N. Mex

Colo. Springs, Colo.

Denver, Colo.

Las Vegas, Nev.

Ogden, Utah

Phoenix, Ariz.

Pueblo. Colo.

Salt Lake City. Utah

Tucson. Ariz.

PACIFIC

Berkeley. Calif.

Fresno. Calif.

Glendale, Calif.

Honolulu, Hawaii

Long Beach, Calif.

Los Angeles. Calif.

Oakland. Calif.

Pasadena, Calif.

Portland. Oreg.

Sacramento, Calif.

San Diego. Calif.

San Francisco. Calif.

San Jose, Calif.

Seattle, Wash.

Spok

10.662 6,483 2,537 71S

10,866 6,521 2,794 713

nost of which have populations of 100,000 or

September 1, 1978

Q Fever — Continued

Since the first described outbreak in this country in 1946 (3), numerous outbreaks

usually associated with cattle, sheep, and goats have been investigated. Various species

of ticks (including A. nuttalli) carry the rickettsial organisms, but man is usually infected

by inhaling aerosolized particles containing C. burneti.

Reptiles have rarely been documented as potential hosts for C. burneti (4). Never

theless, physicians seeing patients with a compatible illness and a history of ownership

of pythons or other exotic pets should consider Q fever in their differential diagnosis,

obtain suitable acute and convalescent blood specimens for serologic diagnosis, and

report the illness to local and state health authorities.

References

1. Hoeprich PD (ed): Infectious Diseases: A Modern Treatise of Infectious Processes. New York,

Harper and Row, 1977, pp 288-289

2. Freeman G, Hodson ME: Q fever endocarditis treated with trimethoprim and sulphamethoxasole.

Br Med J 1:419-420, 1972

3. Irons JV, Topping WH, Shepard CC, Cox HR: Outbreak of Q fever in the United States. Public

Health Rep 61:784-785, 1946

4. Tendeiro J: Nota previa sobre febre Q. Gaz Med Portuguesa 5:645-649, 1952

Recommendation of the Public Health Service

Advisory Committee on Immunization Practices

Meningococcal Polysaccharide Vaccines

INTRODUCTION

Polysaccharide vaccines against diseases caused by Neisseria meningitidis serogroups A

and C are now licensed in the United States. They are prepared as monovalent and as

bivalent antigens. The purpose of this statement is to summarize available information

on these antigens and to offer general guidance regarding their role in the control of epi

demics of meningococcal disease in the civilian population of the United States.

MENtNGOCOCCAL DISEASE

Meningococcal disease is endemic in the United States and throughout the world. It

caused serious epidemics approximately every 10 years from 1900 to 1945 in this coun

try. The fact that it also regularly caused outbreaks among military recruits was a catalyst

for the development of serogroup-specific vaccines.

During the last decade an estimated 3,000-6,000 cases a year of meningococcal disease

occurred in the United States. From 1964 to 1968 and since 1972, the serogroup most

often isolated from patients has been serogroup B. From 1969 through 1971 serogroup

C was most common in the civilian and military populations. Serogroup A was only

rarely identified until the occurrence recently of small outbreaks in several cities of the

Pacific Northwest. In 1971 the Armed Forces began administering serogroup C meningo

coccal polysaccharide vaccine routinely to all recruits. Since then, the incidence of men

ingococcal disease in the military has declined sharply, and serogroup C disease has been

virtually eliminated in that population.

Sulfa-sensitive serogroup B strains currently cause the majority of U.S. cases. Highest

attack rates are in infants. Serogroup C strains account for about one-third of cases. Al

though the highest age-specific attack rate for serogroup C is also in infants, about 70% of

serogroup C cases occur in persons over 2 years old. More than two-thirds of all meningo

coccal disease occurs in patients less than 20 years old.

September 1, 1978

Meningococcal Vaccine — Continued

In recent years meningococcal disease in civilians has occurred primarily as single iso

lated cases or, infrequently, as small, localized clusters. Secondary cases occur more fre

quently in household contacts than in the general population, and appropriate antibiotic

prophylaxis has been the principal means of reducing the risk for immediate contacts

of cases.

MENINGOCOCCAL VACCINES

Three meningococcal polysaccharide vaccines, monovalent A, monovalent C, and

bivalent A-C vaccine,* are licensed for selective use in the United States. These vaccines

are chemically defined antigens consisting of purified bacterial capsular polysaccharide,

each inducing specific serogroup immunity. The duration of immunity conferred by each

vaccine is unknown.

Serogroup A vaccine was evaluated in 62,000 Egyptian schoolchildren 6-15 years old

and appeared to be highly effective and not to induce any serious side effects. When used

to control an outbreak in Brazil, it appeared to be effective in all age groups beyond the

first year of life. Further confirmation of effectiveness was found in children of ages 3

months-5 years in a vaccine trial carried out in Finland. Serogroup A vaccine has also

been used to control outbreaks in the United States in Portland, Seattle, Anchorage, and

Fairbanks.

Serogroup C vaccine has been given routinely to American military recruits since

October 1971. More than 500,000 young adults have been vaccinated without significant

adverse reactions. Serogroup C vaccine has been studied in infants, preschool and school-

age children, and adults. It elicited antibody in all age groups, although older children and

young adults had the highest levels. Serogroup C vaccine does not appear to be effective

in children less than 2 years of age.

VACCINE USAGE

General Recommendations

Routinely vaccinating civilians with meningococcal polysaccharide vaccines is not

recommended because of insufficient evidence of its value when the risk of infection is

low. The serogroup-specific monovalent vaccines should be used, however, to control out

breaks of meningococcal disease caused by N. meningitidis serogroup A or C.

Vaccine may be of benefit for some travelers planning to visit countries recognized as

having epidemic meningococcal disease. Although cases among Americans traveling in

such areas are rare, prolonged contact with the local populace could enhance the risk of

infection and make vaccination a reasonable precaution.

Vaccination should be considered an adjunct to antibiotic chemoprophylaxis for

household contacts of meningococcal disease cases caused by serogroups A or C. This is

because half the secondary family cases occur more than 5 days after the primary case-

long enough to yield potential benefit from vaccination if the antibiotic chemoprophy

laxis has not been successful.

Primary Immunization

For both adults and children, vaccine is administered parenterally as a single dose in

the volume specified by the manufacturer.

PRECAUTIONS AND CONTRAINDICATIONS

Reactions

Adverse reactions to meningococcal vaccine are infrequent and mild, consisting princi

pally of localized erythema lasting for 1-2 days.

'Official names: Meningococcal Polysaccharide Vaccine, Group A; or , Group C; or , Groups A & C

0345 4September 1,197? ■ ' **IMWR II 329

Meningococcal Vaccine — Continued \\ HI I 11 11 I I Ml3 0001 00128 1270

Pregnancy

The safety of meningococcal vaccines in pregnant women has not been established. On

theoretical grounds, it is prudent not to use them unless there is a substantial risk of in

fection.

EPIDEMIC CONTROL

In an epidemic of meningococcal disease due to serogroups A or C, the population at

risk should be identified. It should be delineated by neighborhood, census tract, or other

reasonable boundary. If there is ample vaccine, all residents in that area should be vac

cinated. If not, persons expected or known to be at highest risk of disease by virtue of

age, socioeconomic status, or area of residence should receive priority vaccination.

SELECTED BIBLIOGRAPHY

Artenstein MS, Winter PE, Gold R, et at: Immunoprophylaxis of meningococcal infection. Milit

Med 139:91-95, 1974

Peltola H, Makela PH, Kayhty H, et al: Clinical efficacy of meningococcus group A capsular poly-

saccharide vaccine in children three months to five years of age. N Engl J Med 297:686-691, 1977

Wahdan MH, Rizk F, el-Akkad AM, et al: A controlled field trial of a serogroup A meningococcal

polysaccharide vaccine. Bull WHO 48:667-673, 1973

Revision of MMWR 24:381-382, 1975

The Morbidity and Mortality Weekly Report, circulation 78,750, is published by the Center for

Disease Control, Atlanta, Georgia. The data in this report are provisional, based on weekly tele

graphs to CDC by state health departments. The reporting week concludes at close of business on

Friday; compiled data on a national basis are officially released to the public on the succeeding Friday.The editor welcomes accounts of interesting cases, outbreaks, environmental hazards, or other

public health problems of current interest to health officials. Send reports to: Center for Disease

Control, Attn: Editor, Morbidity and Mortality Weekly Report, Atlanta, Georgia 30333.

Send mailing list additions, deletions, and address changes to: Center for Disease Control, Attn:

Distribution Services, GSO, 1 SB-36, Atlanta, Georgia 30333. When requesting changes be sure to

give your former address, including zip code and mailing list code number, or send an old address label.

September 1, 1978

U.S. DEPARTMENT OF HEALTH, EDUCATION. AND WELFARE

PUBLIC HEALTH SERVICE / CENTER FOR DISEASE CONTROL

ATLANTA, GEORGIA 30333 OFFICIAL BUSINESS

Director, Center for Disease Control

William H. Foege, M.D.

Director, Bureau of Epidemiology

Philip S. Brachman, M.D.

Editor

Michael B. Gregg, M.D.

Managing Editor

Anne D. Mather, M.A.

Chief, MMWR Statistical Activity

Dennis J. Bregman, M.S.

Postage and Fees Paid

U.S. Department of HEW

HEW 396

Creighton University

Health Sciences Library

2500 California Street

Omaha, NE 68178

421X3

HEW Publication No. (CDC) 78-8017 Redistribution using indicia is illegal.