persons who commit suicide later in the cluster. There is also research evidence that exposure to a suicide that was not part of a cluster may lead certain persons to take their own lives (5,6). Thus, it is prudent for a community faced with a suicide cluster to make every effort to anticipate and prevent additional suicides among susceptible individuals. In some circumstances, a community may want to consider implementing a suicide response plan before a cluster has begun. Many of the suicide clusters of which CDC is aware have been preceded by one or more deaths due to injuries (either intentional or unintentional) among teenagers or young adults in the community. For example, in the New Jersey cluster, the multiple simultaneous suicides occurred after four traumatic deaths among persons 15-24 years of age in a 9-month period. In other clusters, the first suicide of the cluster had been recognized at the time by school officials or others as being particularly stressful for many students and young adults. Both of these situations suggest the possibility of anticipating and thus preventing such clusters. In November 1987, the New Jersey Department of Health and CDC cosponsored a workshop on community responses to suicide clusters. Participants included individuals who had played key roles in community responses to nine suicide clusters, including the New Jersey cluster. These persons represented different sectors, including local government, school systems, and crisis centers; the medical community; mental health organizations; university research programs; and state and federal public health agencies. Also participating at that workshop were representatives from the National Institutes of Mental Health, the Indian Health Service, the American Association of Suicidology, and the Association of State and Territorial Health Officials. Based on ideas from this workshop, recommendations are being developed for a plan that community leaders could implement to prevent or contain suicide clusters. These recommendations will be published in an MMWR supplement later in the year. References 1. Coleman L. Suicide clusters. Boston: Faber and Faber, 1987. 2. Robbins D, Conroy RC. A cluster of adolescent suicide attempts: is suicide contagious? J Adolesc Health Care 1983;3:253-5. 3. Davidson L, Gould MS. Contagion as a risk factor for youth suicide. In: US Department of Health and Human Services. Report of the Secretary's Task Force on Youth Suicide. Vol. 2: Risk factors for youth suicide. Washington, DC: US Government Printing Office (in press). 4. Gould MS, Wallenstein S, Kleinman M. A study of time-space clustering of suicide: final report. Atlanta, Georgia: Centers for Disease Control, September 11, 1987; contract no. RFP 200-85-0834 (P). 5. Phillips DP, Carstensen LL. Clustering of teenage suicides after television news stories about suicide. N Engl J Med 1986;315:685-9. 6. Gould MS, Shaffer D. The impact of suicide in television movies: evidence of imitation. N Engl J Med 1986;315:690-4. Current Trends Rabies Vaccine, Adsorbed: A New Rabies Vaccine for Use in Humans Rabies Vaccine, Adsorbed (RVA, Michigan Department of Public Health), a new cell culture-derived rabies vaccine for use in humans, was licensed on March 18, 1988, for both preexposure and postexposure prophylaxis. The Biologics Products Program, Michigan Department of Public Health, developed, produces, and distributes the vaccine. RVA is currently available only to residents of the state of Michigan, but plans are being developed for out-of-state distribution. The vaccine is prepared from the Kissling strain of rabies virus adapted to a diploid cell line of the fetal rhesus lung (1). The virus is inactivated with B-propiolactone and concentrated by adsorption to aluminum phosphate (AIPO4). AIPO may also serve as an adjuvant. 4 RVA differs from the rabies vaccine currently available in the United States, the human diploid cell rabies vaccine (HDCV) produced by Merieux Institute, Inc. A different virus strain, cell line, and concentration process are used in making RVA, and, because RVA is adsorbed to AIPO4, it is liquid rather than lyophilized. After preexposure (2), simulated postexposure (3), and booster vaccination (4), acceptable levels of rabies-neutralizing antibody have been found in over 99% of 3,000 persons tested. The recommended timing of vaccinations with RVA is identical to that of vaccinations with HDCV. Preexposure vaccination consists of three 1-mL doses, one dose to be administered intramuscularly (IM) in the deltoid area on days 0, 7, and 28. Preexposure booster doses of RVA (one 1-mL IM dose) should be administered according to previous guidelines (5). In contrast to HDCV (6), the antibody response and side effects after intradermal administration of RVA have not been studied. RVA should not be used intradermally. Postexposure vaccination of individuals who have not previously been immunized consists of five 1.0-mL doses of RVA, one dose to be administered IM in the deltoid (IM in the anterior lateral thigh for infants) on days 0, 3, 7, 14, and 28. At the same time that the first 1-mL dose of RVA is administered on day 0, rabies immune globulin (RIG) 20 IU/kg is administered as a separate injection. Up to half of the RIG is infiltrated around the site of the bite, if feasible; the rest is administered IM in the gluteal area (for infants, IM in the anterior lateral thigh). Rabies vaccine and RIG should never be administered into the same limb. If exposed to rabies, persons who were previously vaccinated with HDCV or RVA (preexposure or postexposure) and persons who were immunized with other rabies vaccines and who had a documented neutralizing antibody response after vaccination should receive only two 1-mL IM booster doses of RVA, one on day 0 and one on day 3. Testing to document primary seroconversion is recommended only for persons whose immune system is suppressed by a disease or medication. Reactions after primary vaccination with RVA appear similar in nature and frequency to those observed with HDCV. They include local reactions (pain and redness or swelling at the injection site) in 85%-90% of volunteers receiving RVA and mild systemic reactions (fever, nausea, and arthralgia) in 10%. Physicians and other health-care providers are urged to report any other type of reactions to either RVA or HDCV to the manufacturer or the Food and Drug Administration on CDC form 55.19 9/82 (formerly CDC form 4.650), which is available from state and local health departments. The use of preexposure booster doses of HDCV has been limited because approximately 6% of individuals who receive both primary and booster vaccinations with HDCV develop a serum sickness like an allergic reaction (7,8). These reactions are thought to be due to the presence of a small amount of human serum albumin that has been rendered allergenic by the ẞ-propiolactone used in making HDCV (9,10). Human serum albumin is not a component of the medium used to grow the rabies virus for RVA and, therefore, is not present when ẞ-propiolactone is added to inactivate the virus. However, systemic allergic reactions have also occurred in four persons after they received booster doses of RVA, for a rate of <1%. Reported by: Biologics Products Program, Michigan Dept of Public Health. Quinnan GV, MD, Fitzgerald EA, PhD, Center for Biologics Evaluation and Research, Food and Drug Administration. Viral and Rickettsial Zoonoses Br, Div of Viral Diseases, Center for Infectious Diseases, CDC. TABLE II. Notifiable diseases of low frequency, United States 1 3 19 11 18 87 142 142 968 1,239 1,239 Because AIDS cases are not received weekly from all reporting areas, comparison of weekly figures may be misleading. 'One of the 25 reported cases for this week was imported from a foreign country or can be directly traceable to a known internationally imported case within two generations. |