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CENTERS FOR DISEASE CONTROL

January 15, 1988 / Vol. 37 / No. 1

WMWR

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States

11 9157

in Nool

here. 1988 2.2

Connecticut Public He: No.1-24

1 thyme Disease:- Connecticut
3 Suspected Nosocomial Influenza Cases

in an Intensive Care Unit LIC HEALTH

9 Prevalence of Overweight in PUBLIC HEALTH RA

Behavioral Risk Fac

RA

11
BIDITY AND MORTALITY WEEKLY REPORT

The Univer: - 4157
DUDLIC UEMELSV.37

WIOMIS
Lyme Disease

Library
From 1984 through 1986, CDC received an average of 1,500 reports of Lyme
disease annually, making it the most common tick-borne disease reported to CDC.
The disease takes its name from Lyme, Connecticut, where the full spectrum of illness
was first described in 1975. To further study the incidence of disease among its
residents, Connecticut conducted a laboratory-based program of surveillance for
Lyme disease from July 1, 1984, to March 1, 1986.

Indirect immunofluorescence antibody (IFA) and enzyme-linked immunosorbent assays (ELISA) were used to detect antibodies to Borrelia burgdorferi, the spirochete that causes the disease. Serologic testing was offered to Connecticut physicians without cost for all residents with suspected Lyme disease if the serum was accompanied by a case report form. Residents who, in 1984 or 1985, had onset of erythema migrans* and/or neurologic, cardiac, or arthritic manifestations characteristic of Lyme disease and a positive serologic test (IFA >1:128 or ELISA >1:160 with a polyvalent conjugate) were included in the study.

Thirty-seven percent of the 3,098 patients reported met the criteria for inclusion in the study (460 in 1984 and 689 in 1985). In 1985, the first complete year of reporting, 66% of the patients studied had onset of symptoms from June through August. Twenty-four percent more patients had onset of symptoms from July through December 1985, than from July through December 1984 (492 compared with 397). Serologic testing was equally available during these time periods.

The incidence of Lyme disease for all Connecticut residents in 1985 was 22/100,000. Town-specific incidences ranged from zero to 1,156/100,000. Towns with the highest incidences were in southern Connecticut, east of the Connecticut River.

Fifty-one percent of patients with Lyme disease were male, and all but one of the 372 patients with known race reported in 1984 were white. Racial information was not gathered in 1985. Age-specific incidence was tabulated by 5-year age groups for patients reported in 1985. The incidence ranged from 11/100,000 for persons aged 20 to 24 years, to 39/100,000 for those aged 5 to 9 years (Figure 1).

Overall, 83% of the patients studied had erythema migrans; 24% had arthritis; 8% had neurologic manifestations; and 2% had cardiac involvement. For those with arthritis, affected joints were the knee (89%), hip (9%), shoulder (9%), ankle (7%), and elbow (2%). In 1985, persons under 20 years of age were 1.6 times more likely to have *A distinctive skin lesion that characterizes the first stage of the disease. *Neurologic and cardiac manifestations characterize the second stage of the disease, and arthritic manifestations, the third. These later stages can occur weeks or years after the initial tick bite and without evidence of an earlier skin lesion.

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES / PUBLIC HEALTH SERVICE

US meaningy IAN 28.1984

Lyme Disease Continued arthritis than persons over 20 (7/100,000 compared with 4/100,000), while both groups were equally likely to develop erythema migrans (13/100,000). Seventy-nine percent of patients with arthritis did not report antecedent erythema migrans. Sixty-one percent of patients with erythema migrans reported a tick bite within 30 days of illness.

Sera received before July 1, 1985, (1,447 samples) were tested by IFA; sera received later (1,579 samples) were tested by ELISA; and 72 patients were reported without a request for serologic testing. For those with erythema migrans, the overall sensitivity of serology was 30% by IFA and 24% by ELISA. When the serum sample had been obtained 21 days or more after onset of symptoms, the sensitivity of the IFA increased to 45% and that of the ELISA, to 32%. Reported by: LA Magnarelli, PhD, Connecticut Agricultural Experiment Station, New Haven; RW Ryan, PhD, RC Tilton, PhD, Univ of Connecticut School of Medicine; JA Hardin, MD, Yale Univ School of Medicine; DC Niejadlik, MD, Middlesex Memorial Hospital, Middletown; AH Sweeney, MPH, ML Cartter, MD, PJ Checko, MPH, PA Mshar, HC Chaski, MPH, JL Hadler, MD, MPH, State Epidemiologist, Connecticut State Dept of Health Svcs. AC Steere, MD, Tufts Univ School of Medicine, Boston, Massachusetts. Meningitis and Special Pathogens Br, Center for Infectious Diseases; Div of Field Svcs, Epidemiology Program Office, CDC. Editorial Note: This study demonstrates the impact of Lyme disease in an endemic area. A comparison of the results with those of a 1977 study (1) reveals an increase of 163% in the incidence of Lyme disease in the eight towns reporting cases in 1977 and shows that, by the mid-1980s, the disease had spread inland from the coastal areas.

Serologic testing for Lyme disease has increased considerably in Connecticut. To trace these changes in testing, the state health department recently compared the annual number of immunoglobulin or IgG-specific serologic tests for Lyme disease ordered by Connecticut physicians from January 1984 through August 1987. The number and results of these tests varied by year as follows: 2,492 in 1984 (30% positivity), 3,770 in 1985 (20% positivity), 5,175 in 1986 (24% positivity), and 6,420 through August of 1987 (14% positivity). This increase may reflect an actual increase in the incidence of Lyme disease or in the recognition of the disease by physicians. It may also reflect the increased availability of the laboratory test or its overuse, FIGURE 1. Lyme disease incidence, by age group · Connecticut, 1985

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Lyme Disease Continued especially during the early stage of the disease, when the test is likely to be negative (2-4).

The diagnosis of early Lyme disease remains primarily clinical, and physicians should be aware of the limitations of current tests. Sensitivities of the IFA and the ELISA are relatively low during stage one (2-4), and the antibody response can be curtailed or aborted by early treatment with antibiotics (3). In contrast, some research laboratories have reported sensitivities >95% for tests of patients with stage two or three Lyme disease (2,4,5). Test specificities approaching 100% have also been reported (2,6); however, considerable variability may occur among laboratories because the tests are not standardized and are difficult to perform. The sensitivities and lack of standardization of the tests preclude their use alone for routine disease reporting and reinforce the need to develop a reliable and practical case definition for surveillance that is not dependent on serologic test results.

Lyme disease is a problem of increasing national and international concern that merits continual and improved surveillance. Clinical studies to further define complications of the disease and to evaluate treatment regimens are needed. Public health education can help alert people to the symptoms of Lyme disease and to the importance of avoiding tick bites. The development of other effective primary preventive measures, particularly vector control, is essential. References 1. Steere AC, Broderick TF, Malawista SE. Erythema chronicum migrans and Lyme arthritis:

epidemiologic evidence for a tick vector. Am J Epidemiol 1978;108:312-21. 2. Craft JE, Grodzicki RL, Steere AC. Antibody response in Lyme disease: evaluation of

diagnostic tests. J Infect Dis 1984;149:789-95. 3. Shrestha M, Grodzicki RL, Steere AC. Diagnosing early Lyme disease. Am J Med

1985;78:235-40. 4. Wilkinson HW. Immunodiagnostic tests for Lyme disease. Yale J Biol Med 1984;57:567-72. 5. Craft JE, Grodzicki RL, Shrestha M, Fischer DK, Garcia-Blanco M, Steere AC. The antibody

response in Lyme disease. Yale J Biol Med 1984;57:561-5. 6. Magnarelli LA, Anderson JF, Johnson RC. Cross-reactivity in serological tests for Lyme

disease and other spirochetal infections. J Infect Dis 1987;156:183-8.

Suspected Nosocomial Influenza Cases in an Intensive Care Unit Georgia. During November 1987, CDC received reports of three patients and one nurse with suspected influenza infections in a 15-bed medical-surgical intensive care unit (MSICU). The index case occurred in a 71-year-old female with diabetes mellitus who was admitted to the MSICU on October 29 and subsequently required mechanical ventilation. Influenza A was identified by fluorescent antibody (FA) staining of tissue culture cells inoculated with an endotracheal aspirate collected on November 11. The patient died on November 14, and influenza virus was identified in lung tissue collected postmortem. The second patient, an intubated 60-year-old woman with chronic obstructive lung disease, had been hospitalized since October 26. Influenza A was identified by FA staining of cell culture inoculation of a lung biopsy specimen obtained on November 23. The same procedure was used to identify influenza A in an endotracheal aspirate specimen collected on November 26 from an intubated 76-year-old man who had been hospitalized since September 28. Further investigation revealed that a nurse who had cared for all three patients was absent from work during the last week of November because of an influenza-like illness. Neither the three patients nor the nurse had received the 1987-88 influenza vaccine. Isolates were not available for confirmation and subtype identification.

Influenza Continued

Other reports. For the report week ending January 2, four states* reported regional outbreaks of influenza-like illness. Fifteen states have reported isolates of influenza A(H3N2), which is the predominant subtype so far this season. Influenza A, subtype pending, has been reported from Hawaii, Louisiana, Utah, and Washington. Reported by: P Patterson, D Smith, RK Sikes, DVM, MPH, State Epidemiologist, Georgia Dept of Human Resources. Univ Hygienic Laboratory, Univ of lowa. Participating State and Territorial Epidemiologists and State Laboratory Directors. WHO Collaborating Center for Influenza, Influenza Br, Div of Viral Diseases, Center for Infectious Diseases, CDC. Editorial Note: In the past, hospital laboratories have had to send specimens to reference laboratories for virus isolation and identification. Now, many hospital laboratories are able to rapidly identify influenza A or B viruses by using monoclonal antibodies for typing virus antigens produced in cell culture. Results can usually be obtained within 24 to 72 hours after inoculation of the specimen. *Alabama, South Dakota, Utah, and Wisconsin. *California, Colorado, Florida, lowa, Kansas, Minnesota, Missouri, Montana, North Dakota, South Carolina, South Dakota, Tennessee, Texas, Wisconsin, and Wyoming.

(Continued on page 9) TABLE I. Summary cases of specified notifiable diseases, United States

1st Week Ending

Cumulative, 1st Week Ending
Disease

Jan. 9, Jan. 10, Median Jan. 9, Jan. 10, Median
1988
1987 1983-1987 1988

1987 1983-1987 Acquired Immunodeficiency Syndrome (AIDS)

400
263

97
400
263

97 Aseptic meningitis

54
117
74
54
117

74
Encephalitis: Primary (arthropod-borne
& unspec)

6
21
15

6
21

15
Post-infectious

1

1
1

1 Gonorrhea: Civilian

10,586 18,006 13,471 10,586 18,006 13,471
Military

147
474
250
147
474

250 Hepatitis: Type A

241
265
276
241
265

276
Type B

174
335
335
174
335

335
Non A, Non B

18
55
47

55
Unspecified

20

60
20
35

60 Legionellosis

22
7
4
22

7 Leprosy

5 Malaria

6
19
9
6
19

9 Measles: Total

9
35
8

35

8
Indigenous

8
35
7
8
35

7
Imported

1
1

1 Meningococcal infections

36
59
41
36
59

41 Mumps

58
75
46
58
75

46 Pertussis

22
26
26
22
26

26 Rubella (German measles)

1
3
6
1
3

6 Syphilis (Primary & Secondary): Civilian

433
698
354
433
698

354
Military

1
2
2
1
2

2 Toxic Shock syndrome

2
3
7
2
3

7 Tuberculosis

87

213

87
218

213 Tularemia

2
2

2.

2 Typhoid fever

4
3
1
4

3 Typhus fever, tick-borne (RMSF)

4
1

4

1 Rabies, animal

22
67
53
22
67

53

18

35

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TABLE II. Notifiable diseases of low frequency, United States

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Anthrax

Leptospirosis (Hawaii 1)

1 Botulism: Foodborne

Plague
Infant

Poliomyelitis, Paralytic
Other

Psittacosis
Brucellosis (Calif. 1)

1

Rabies, human Cholera

Tetanus
Congenital rubella syndrome

Trichinosis
Congenital syphilis, ages <1 year
Diphtheria

One of the 9 reported cases for this week were imported from a foreign country or can be directly traceable to a known
internationally imported case within two generations.

TABLE III. Cases of specified notifiable diseases, United States, weeks ending

January 9, 1988 and January 10, 1987 (1st Week)

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NEW ENGLAND
Maine
NH.
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R.I.
Conn.

366
10
14

5
100

40 197

622
12
5

5
213

74 313

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