TABLE III. (Cont'd.) Cases of specified notifiable diseases, United States, weeks ending January 30, 1988 and January 31, 1987 (4th Week)

*Mortality data in this table are voluntarily reported from 121 cities in the United states, most of which have populations of 100,000 or 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.

††Total includes unknown ages.

§ Data not available. Figures are estimates based on average of past 4 weeks.

In the past, fresh sperm has been routinely recommended for use in artificial insemination and may still be appropriate when semen is from a donor in a mutually monogamous marriage/relationship with the recipient. However, it is now considered prudent to freeze samples from all other donors and store them in that state for a minimum of 6 months. Before frozen semen is used for artificial insemination, a blood sample taken at the time the semen was collected and a second blood sample taken aminimum of 6 months later should be tested for HIV antibody. Responsible medical personnel must be certain that the blood samples are from the same donor, and the donor's identity must be assured. Frozen semen should be used only if both of the tests are negative. These special safeguards should be observed in addition to the preliminary precautions that the donor had 1) no history of risk factors for HIV infection and 2) a physical examination, properly documented by a licensed physician at the time of donation, that showed no obvious evidence of HIV infection.

The American Fertility Society has already modified its guidelines in accordance with these recommendations (10), and these revised guidelines have been accepted by the American College of Obstetricians and Gynecologists. The American Association of Tissue Banks is in the process of similarly revising its standards (personal communication).

References

1. Centers for Disease Control. Testing donors of organs, tissues, and semen for antibody to human T-lymphotropic virus type III/lymphadenopathy-associated virus. MMWR 1985; 34:294.

2. Stewart GJ, Tyler JPP, Cunningham AL, et al. Transmission of human T-cell lymphotropic virus type III (HTLV-III) by artificial insemination by donor. Lancet 1985;2:581-4.

3. Mascola L, Guinan ME. Screening to reduce transmission of sexually transmitted diseases in semen used for artificial insemination. New Engl J Med 1986;314:1354-9.

4. Berry WR, Gottesfeld RL, Alter HJ, Vierling JM. Transmission of hepatitis B virus by artificial insemination. JAMA 1987;257:1079-81.

5. Clarke JA. HIV transmission and skin grafts [Letter]. Lancet 1987;1:983.

6. Centers for Disease Control. Human immunodeficiency virus infection transmitted from an organ donor screened for HIV antibody- North Carolina. MMWR 1987;36:306-8,314-5.

7. American Medical Association. Prevention and control of acquired immunodeficiency syndrome: an interim report [Board of Trustees report YY]. JAMA 1987;258:2097-103.

8. American Association of Tissue Banks. Standards for tissue banking. Arlington, Virginia: American Association of Tissue Banks, 1987.

9. American Fertility Society. New guidelines for the use of semen donor insemination: 1986. Fertil Steril 1986;46(suppl 2).

10. American Fertility Society. Revised new guidelines for the use of semen-donor insemination. Fertil Steril 1988;49:211.

Epidemiologic Notes and Reports

Acute Respiratory Illness Among Cruise-Ship Passengers Asia

In late October 1987, influenza A(H3N2) was isolated from a throat culture specimen collected from an 83-year-old woman in Los Angeles County, California. The patient had been hospitalized with pneumonia and congestive heart failure 1 day after returning from a 19-day tour and cruise in Asia. When interviewed in November, the woman said many tourists had been ill with an acute respiratory illness (ARI)

Respiratory Illness - Continued

while aboard the cruise ship. The patient's physician became ill with an ARI 36 hours after examining the woman. Influenza A(H3N2) virus was also isolated from his throat culture.

The tour group convened in Hong Kong on October 7 and toured the city for 2 days before boarding a cruise ship on October 9. The ship departed the following day and visited Shanghai, People's Republic of China (PRC), on October 13-14; Pusan, Korea, on October 17; and Yantai and Qinhuandao, PRC, on October 19 and 20, respectively. The tour group disembarked at Qinhuandao for an overland journey and a 3-day visit in Beijing before returning to the United States by air.

A telephone survey was conducted to determine the impact of ARI among the cruise-ship passengers. There were 427 passengers (median age, 66 years): 222 were residents of California, 201 were residents of 31 other states and the District of Columbia, three were from foreign countries, and the residence of one was not identified. Between November 21 and December 15, attempts were made to contact each of the 423 U.S. residents by telephone. A standard questionnaire was administered to the 277 (65%) persons who were interviewed; 19 persons (5%) refused to be interviewed; and 127 (30%) could not be reached.

One hundred four (38%) of the persons interviewed reported an ARI during the period October 1-30. Symptoms for 94 of these persons included fever or feverishness with either cough or sore throat; 10 persons reported cough, sore throat, and myalgias. The peak of the outbreak occurred on October 20 (Figure 1), 6 days after the ship's visit to Shanghai and 3 days after the visit to Pusan, Korea. Seven passengers (2.5%) reported that they were diagnosed by a physician as having pneumonia after their return home; five (71%) of the seven were hospitalized. No deaths were reported.

To determine the potential for secondary spread in the community, passengers were asked to identify nontourist contacts who had onset of an ARI within 3 days of the tourist's return home. Ten (36%) of the 28 households with a tourist who reported FIGURE 1. Acute respiratory illness among cruise-ship passengers, by date of onset of symptoms October 1-28, 1987

24

late onset of symptoms* reported that at least one nontourist contact had become ill. Two (5%) of the 42 households without a patient with late onset of symptoms reported contacts who had become ill (relative risk = 7.5, 95% confidence interval 2.3 to 24.5).

=

Data from persons over 64 years of age were analyzed separately because this age group is considered to be at increased risk for complications following influenza infection (1). To decrease this risk, the Immunization Practices Advisory Committee (ACIP) recommends that all persons over 64 receive influenza vaccine annually (1). In calculating vaccine efficacy, investigators assumed that 1) all cases of ARI were due to influenza and 2) risk factors for influenza-related complications were similar for the vaccinated and unvaccinated groups. The attack rate among the 36 tourists who were over 64 years of age and had received the 1987-88 influenza vaccine in August or September 1987 was 36%; the rate was 37% among the 127 unvaccinated travelers in this age group. Duration of illness, defined as the number of days before patients felt that they had returned to their normal level of health, did not differ significantly between the two groups. The mean duration was 19.3 days for the vaccinated group and 21.9 days for the unvaccinated group (t test 0.62, p<0.40). The hospitalization rate was the same (3%) among the vaccinated and unvaccinated passengers in this age-group.

=

Antigenic analysis of the isolates from the two culture-confirmed index cases was performed by reciprocal hemagglutination-inhibition tests with sera taken from infected ferrets during the convalescent stage of illness. The results indicate that the isolates are type A(H3N2) variants similar to influenza viruses isolated in Asian and Pacific countries since April 1987 (2).

Reported by: CD Berlingberg, MD, FH Kahn, MD, Los Angeles; LY Chun, MPH, JM Cruz, G Gellert, MD, MP Giles, MS, L Mascola, MD, FJ Sorvillo, MPH, M Tormey, MPH, SH Waterman, MD, Los Angeles County Dept of Health Svcs; RA Murray, DrPH, KH Acree, MDCM, MPH, JD, Acting State Epidemiologist, California Dept of Health Svcs. Office of the Director, Influenza Br, Div of Viral Diseases, Center for Infectious Diseases, CDC.

Editorial Note: This is the second outbreak of ARI among U.S. tourists who have traveled aboard cruise ships in the Pacific Basin during the last 6 months. The previous outbreak was also identified following reports of a traveler who was acutely ill upon returning from a trip and for whom influenza A (H3N2) infection was confirmed (3). The extent of illness among nontourist household contacts in the present outbreak suggests that an infectious agent that is transmitted from person to person was responsible. The following evidence suggests that influenza virus was involved: 1) influenza A(H3N2) was isolated from a tourist and her physician, 2) viruses from these index cases were antigenically similar to strains present in Hong Kong (4) and Shanghai during September 1987 (Health and Antiepidemic Station, Shanghai, PRC, unpublished data) and 3) the sharp peak in the epidemic curve and high attack rates are typically seen in influenza outbreaks in partially closed settings, including military vessels (5,6), aircraft (7,8), and institutions (9).

Most tourists with ARI had onset of illness in late October and were ill either during the flight home to the United States or within 3 days of returning home. Although the duration of illness following influenza infection for persons over 64 years of age may be longer than the 5-7 days usually experienced by younger adults (10), the longer *Less than 4 days before the end of the tour or within 3 days of returning home.