Syphilis (Civilian) TABLE III. (Cont'd.) Cases of specified notifiable diseases, United States, weeks ending February 20, 1988 and February 21, 1987 (7th Week) Reporting Area Syndrome (RMSF) *Mortality data in this table are voluntarily reported from 121 cities in the United states, most of which have populations of 100,000 of more. A death is reported by the place of its occurrence and by the week that the death certificate was filed. Fetal deaths are not included. **Pneumonia and influenza. † Because of changes in reporting methods in these 3 Pennsylvania cities, these numbers are partial counts for the current week Complete counts will be available in 4 to 6 weeks. tal includes unknown ages. a not available. Figures are estimates based on average of past 4 weeks. A follow-up examination 4 months later showed a partial return of function in the lower left leg. The child was able to walk with a slight limp. Reflexes were present, but they were slightly weaker in the left leg than in the right. There was some atrophy in the left calf. These and other clinical findings were indicative of a lower motor neuron process, such as paralytic poliomyelitis, in the lower left leg. Stool specimens obtained on October 5, 6, and 8 all grew enterovirus 71 (EV71). Cerebrospinal fluid was not cultured for virus. Sera obtained on October 3, 4, 6, and 29 (7, 8, 10, and 33 days after onset of illness) all showed low but constant titers to the three serotypes of poliovirus (range 1:40 to 1:120), as would be expected for a child who had received three OPV vaccinations. The titers to EV71 were 1:720, 1:1,280, and 1:720 for the first, third, and fourth serum specimens, respectively. Reported by: RR Hanson, MD, Univ Medical Center; H Myers, MD, Voice of Calvary Family Health Center, Jackson; FE Thompson, MD, State Epidemiologist, Mississippi State Dept of Health. Div of Field Svcs, Epidemiology Program Office; Div of Viral Diseases, Center for Infectious Diseases, CDC. Editorial Note: While flaccid paralysis is most often associated with poliovirus infection, several nonpolio enteroviruses, including EV71, have also been associated with paralytic disease. The etiology of this case is likely to be EV71 infection for three reasons. First, the serologic results were consistent with those expected for an 18-month-old child who had received three doses of OPV and had developed an antibody response to all three serotypes. Second, EV71 was the only virus isolated from the specimens under conditions in which poliovirus, if present, would have been isolated. Third, the antibody titers to EV71 were very high, as would be expected with a recent infection. EV71 is unique among the nonpolio enteroviruses in its ability to occasionally cause outbreaks of severe central nervous system (CNS) disease including encephalitis and polio-like paralysis (1). EV71 was first described in 1974 from cases of CNS disease, including fatal encephalitis, occurring in California from 1969 to 1973 (2). To date, the virus has principally been associated with outbreaks of hand, foot, and mouth disease (HFMD), upper respiratory symptoms, meningitis, encephalitis, and flaccid paralysis very similar to that associated with poliovirus infection (2-8). The clinical symptoms associated with any particular outbreak have varied widely. In California prior to 1973, in Australia in 1972 (3), and in Sweden in 1973 (4), meningitis was the predominant severe illness associated with outbreaks of EV71. In Japan in 1973 and 1978 (5,6), HFMD was the predominant syndrome, although CNS infections were frequently observed. In Bulgaria in 1975 (7), 21% of about 700 patients with laboratory-confirmed EV71 infection developed paralysis, and 44 patients died. Fatal encephalitis occurred among patients in an outbreak of EV71 infection in Hungary in 1978 (8). In the United States, a cluster of 12 laboratory-confirmed cases in the Rochester, New York, area in 1977 included two cases of transient polio-like paralysis (9). While isolates of EV71 have been identified sporadically in the United States, extensive spread of the virus has not been observed. The enterovirus surveillance system at CDC received 49 reports of EV71 isolates from 1977 through 1987. Fifteen of these occurred in 1977; 11, in 1979; and 8, in 1987. No other year had more than four reported isolates. However, in the last 6 months, the Enterovirus Laboratory at CDC has received and characterized ten additional EV71 isolates including four from Alaska, two from Oklahoma, and four from Pennsylvania, bringing the total for 1987 to 18. Surveillance data on EV71 is probably not a sensitive measure of its presence because of the inability of most diagnostic virology laboratories to isolate or characterize the virus. EV71 infection can be diagnosed by isolation or serologic studies. A variety of human and primate cell lines, including primary rhesus monkey kidney cells, diploid human lung fibroblast cells, rhabdomyosarcoma cells, and Vero cells, can be used to isolate EV71. Growth of this virus is often slow compared to other enteroviruses, and multiple blind passages are often required to isolate it. Once isolated, the virus can readily be adapted to a wide variety of human and primate cells. Identification of an isolate is complicated by the absence of antisera to EV71 in the common enterovirus typing pools and by the limited availability of type-specific antisera. Clinicians are encouraged to report suspected cases of paralytic illness due to enteroviruses to their local and state or territorial health departments. Enterovirus isolates from these cases can be sent through the local and state or territorial laboratories to the Division of Viral Diseases, Center for Infectious Diseases, CDC, for typing. References 1. Melnick JL. Enterovirus type 71 infections: a varied clinical pattern sometimes mimicking paralytic poliomyelitis. Rev Infect Dis 1984;6(Suppl 2):S387-90. 2. Schmidt NJ, Lennette EH, Ho HH. An apparently new enterovirus isolated from patients with disease of the central nervous system. J Infect Dis 1974;129:304-9. 3. Kennett ML, Birch CJ, Lewis FA, Yung AP, Locarnini SA, Gust ID. Enterovirus type 71 infection in Melbourne. Bull WHO 1974;51:609-15. 4. Blomberg J, Lycke E, Ahlfors K, Johnsson T, Wolontis S, von Zeipel G. New enterovirus type associated with epidemic of aseptic meningitis and/or hand, foot, and mouth disease [Letter]. Lancet 1974;2:112. 5. Tagaya I, Takayama R, Hagiwara A. A large-scale epidemic of hand, foot and mouth disease associated with enterovirus 71 infection in Japan in 1978. Jpn J Med Sci Biol 1981;34:191-6. 6. Ishimaru Y, Nakano S, Yamaoka K, Takami S. Outbreaks of hand, foot, and mouth disease by enterovirus 71. High incidence of complication disorders of central nervous system. Arch Dis Child 1980;55:583-8. 7. Shindarov LM, Chumakov MP, Voroshilova MK, et al. Epidemiological, clinical, and pathomorphological characteristics of epidemic poliomyelitis-like disease caused by enterovirus 71. J Hyg Epidemiol Microbiol Immunol 1979;23:284-95. 8. World Health Organization. Virus diseases surveillance. Wkly Epidem Rec 1979;54:57. 9. Chonmaitree T, Menegus MA, Schervish-Swierkosz EM, Schwalenstocker E. Enterovirus 71 infection: report of an outbreak with two cases of paralysis and a review of the literature. Pediatrics 1981;67:489-93. Current Trends Vessel Sanitation Scores The Centers for Disease Control (CDC) established the Vessel Sanitation Program in 1975 as a cooperative activity with the cruise ship industry. The goals of the program were to achieve and maintain a level of sanitation on passenger vessels that would lower the risk of gastrointestinal disease outbreaks and provide a healthy environment. To meet these goals, CDC began inspecting all passenger cruise ships that had foreign itineraries and arrived at ports under U.S. control. Between 1975 and 1985, CDC conducted three types of inspections: semiannual, follow-up, and "other." All inspections were unannounced and were conducted upon a ship's arrival in port. Inspectors rated cruise ships on water quality, food preparation and handling, potential for contamination of food, general cleanliness, methods of food storage, and repair of food service equipment. If a vessel failed a semiannual inspection, CDC conducted one or more follow-up inspections, depending on the itinerary of the cruise ship. "Other" inspections were conducted for special purposes, such as investigating a specific item (e.g., shipboard water chlorination levels) or a gastrointestinal disease outbreak. From the program's inception through 1985, CDC conducted nearly 1,800 inspections of 172 vessels. In the first months of the program, ships received a simple pass or fail rating. Beginning in late 1975, however, CDC assigned a numerical score based on the same detailed criteria. Scores ranged from 1 to 100 points; 86 or above was considered satisfactory. The data collected during these inspections indicate major changes since 1975: the number of cruises per year and the number of passenger days per year have increased, while the number of diarrheal disease outbreaks per 10 million passenger days has decreased (Figure 1). To assess the effectiveness of the Vessel Sanitation Program, CDC reviewed inspection data from 905 semiannual inspections performed from 1975-1985. The semiannual inspections are thought to best represent shipboard conditions because they were all complete inspections. Some inspections during the early years, although unannounced and rated, were not complete. A cruise ship was considered to have experienced an outbreak if at least 3% of passengers or crew sought medical attention for diarrhea from the ship's physician and if CDC was notified and initiated an investigation. Cruises with fewer than 100 passengers and cruises of less than 3 days or more than 15 days were excluded, as |