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Arthritis Program Continued signed into law in 1984, gave the Department of Health the authority to establish a network of regional arthritis centers and to appoint two advisory bodies. The 25-member Missouri Arthritis Advisory Board was formed and charged with making recommendations to the Department of Health on the statewide arthritis plan and with assisting in issuing guidelines for the services provided by the regional arthritis centers. A separate Program Review Committee was created to select regional centers. Eight regional arthritis centers were selected from applications from healthcare institutions, and funds were awarded to seven by contract in the fall of 1985 (2).

During their first 2 years, the regional arthritis centers educated 2,600 health professionals and reached 4,600 persons through public education sessions. Also, over 1,000 persons with arthritis attended specially tailored programs, such as an aquatic exercise program and a self-help course taught in Spanish for the Kansas City Hispanic population. Two centers established newsletters and a WATS line. Television presentations have also been developed. Activities within each region have involved the collaboration of private physicians, the Arthritis Foundation, local hospitals, and other resources to maximize the impact of the programs in the community (3).

Because the regional and national data available on attitudes and knowledge concerning arthritis and care-seeking behaviors are limited, a statewide telephone survey was conducted in early 1987. The goals were to determine specific beliefs and levels of awareness about arthritis among the general public to better focus program efforts (4). The Media Research Bureau of the University of Missouri School of Journalism administered a survey of 2,533 households. The major findings from the survey were 1) arthritis symptoms are severe before persons seek care; 2) the causes of arthritis are misunderstood; 3) the public has limited knowledge of specific arthritis diagnoses, types of effective treatments, and available sources for optimal care; 4) programs and advertisements on television and articles in newspapers and magazines are the most likely and effective mechanisms for changing knowledge and attitudes about arthritis (4).

Funding for the Missouri Arthritis Program began in October 1985. State funding has been augmented with Federal Preventive Health and Health Services Block Grant monies. Further information may be obtained by contacting Marsha Dubbert, R.N., Bureau of Chronic Diseases, Missouri Department of Health, Box 570, Jefferson City, Missouri 65102; telephone, (314) 751-6252. Reported by: BH Singsen, MD, GC Sharp, MD, Health Sciences Center, Univ of Missouri; DM Markenson, MS, RG Harmon, MD, HD Donnell, Jr, MD, MPH, State Epidemiologist, Missouri Dept of Health. Div of Chronic Disease Control, Center for Environmental Health and Injury Control, CDC. Editorial Note: Arthritis, one of the most common and disabling disorders, is not a single disease but a manifestation of more than a hundred diseases. According to the 1980 National Health Interview Survey, approximately 37 million people in the United States consider that they have arthritis (5). Extrapolation from the U.S. Health and Nutrition Examination Survey I indicates that 33% of the adult population has clinical evidence of joint swelling, tenderness, limitation of movement, or pain during movement (6).

The disabling effects of arthritis can be forestalled either by preventing musculoskeletal impairment or by preventing impairment from becoming a disability. The goal of state arthritis programs is to make optimal diagnostic, treatment, educational

Arthritis Program Continued and rehabilitation services accessible to all individuals with arthritis and musculoskeletal diseases.

In a survey conducted by the Association of State and Territorial Health Officials in February 1987, 10 of the 49 state and territorial health agencies with formal written health plans cited arthritis as part of this plan. According to the survey, seven state chronic disease units included arthritis in their activities (7). References 1. Missouri Task Force on Arthritis. Report of the Missouri Task Force on Arthritis. Vol 1-3.

Columbia, Missouri: University of Missouri Multipurpose Arthritis Center, 1980. 2. Hazelwood SE, Singsen BH, Sharp GC, Oliver CL, Hall PJ. Methods to implement a state-wide

arthritis program (Abstract). Arthritis Rheum 1986;29:S159. 3. Hazelwood S, Singsen B, Sharp G, Markenson D, Oliver C, Hall P. A state-wide Regional

Arthritis Center (RAC) Program (Abstract). Arthritis Rheum 1987;30:S194. 4. Singsen B, Sylvester J, Markenson D, et al. Arthritis knowledge and attitudes in the Missouri

statewide survey. Arthritis Rheum (in press). 5. McDuffie FC, Felts WR Jr, Hochberg MC, et al. In: Amler RW, Dull HB, eds. Closing the gap:

the burden of unnecessary illness. New York: Oxford University Press, 1987:19-28. 6. Cunningham LS, Kelsey JL. Epidemiology of musculoskeletal impairments and associated

disability. Am J Public Health 1984;74:574-9. 7. Centers for Disease Control. Survey of chronic disease activities in state and territorial health

agencies. MMWR 1987;36:565-8.

International Notes

Korean Hemorrhagic Fever

Fourteen cases of Korean hemorrhagic fever (KHF) were identified among 3,754 U.S. Marines who participated in a joint U.S.-Korean military training exercise in the Republic of Korea (ROK) from late September to mid-November 1986. Ten individuals were hospitalized; two of these died. Cases were confirmed by serologic testing and by postdeployment screening of serum from 2,053 of the participants.

Korean hemorrhagic fever occurs frequently among rural civilians and Korean military personnel. However, in recent years, fewer than 10 cases have been recognized annually among U.S. troops. The Marine units participating in the military exercise were from camps in Okinawa, Japan, where KHF has not been reported. In addition, KHF had not been previously reported in association with this exercise, which is held annually, even though most of the training takes place northeast of Seoul in an area where the disease is endemic. There was nothing unusual about the exercise, except that it occurred approximately 1 month earlier than those held in previous years. The weather was milder; conditions were warm, dry, and dusty until early November.

Most (1,969) of the U.S. force was quartered in tents at Uncheon Base Camp, within the perimeter of a permanent ROK Army garrison camp southwest of Uncheon. Another 1,105 Marines were at Watkins Range, about 2 km northwest of Uncheon Base Camp. The remaining 680 troops were engaged in aviation activities at various locations distant from the base camp.

Hemorrhagic Fever Continued

The patient with the index case became ill on October 26. The other patients had onsets of illness throughout the ensuing 51 days (Figure 1). The last patient identified became ill on December 17, 38 days following his departure from Korea. The 10 hospitalized patients initially had nonspecific flu-like illnesses. The four nonhospitalized patients had a variety of symptoms. Prominent findings on admission included fever (100%), fatigue (100%), headache (90%), conjunctival injection (90%), thrombocytopenia (100%), and proteinuria (100%).

The overall attack rate was 4.6/1,000 among the total group of soldiers deployed in the Uncheon area (14/3,074) and 7.0/1,000 among the group that was screened (14/1,985). Cases occurred in several different units, but 13 of the 14 were among the 1,969 persons housed at Uncheon Base Camp. One was among the 1,105 persons housed at Watkins Range (rate ratio = 7.3; 95% confidence interval, 0.96 to 55.7). At least 10 of the patients lived in tents pitched along the periphery of the camp in an area near high grass and scrub brush. Six of the 14 patients (43%), including the two who died, were from a single engineer company of 118 men and women. All of the affected persons in this company were assigned to two of the three company platoons (attack rates, 54/1,000 and 94/1,000).

All of the soldiers who had been tested for antibody completed a questionnaire within 2 months of their return from Korea. In addition, 11 of the 12 surviving patients were interviewed. No temporal clustering by unit, field exercise area, environment, or work-related factors could be identified as risk factors for infection.

FIGURE 1. Cases of Korean hemorrhagic fever among U.S. Marines participating in a military exercise,* by date of onset of symptoms - Republic of Korea, OctoberDecember 1986

Nonhospitalized Cases
Hospitalized Casos
Fatal Cases

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Cases

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DEC

Onset *Personnel were billeted at Uncheon Base Camp from October 6-November 12; field training took place October 7-27; the field exercise took place November 1-8; and redeployment was from November 12-December 1.

Hemorrhagic Fever Continued

Fifteen persons with IgM antibody titers >1:3,000 were identified by an enzymelinked immunosorbent assay (ELISA) specific for hantaviruses. Thirteen were confirmed by indirect immunofluorescence assay (IFA) (>1:128) and plaque-reduction neutralization (PRN) (>1:20). The fourteenth case was diagnosed by IFA and PRN alone. Neutralization tests distinguished Apodemus-associated (Hantaan) virus from urban rat-associated (Seoul) virus. All sera that had been confirmed as positive yielded titers at least fourfold higher against prototype Hantaan virus than against Seoul virus.

Approximately 150 cases of KHF were reported among ROK military forces between September and December 1986. Nine cases of KHF were identified among ROK troops stationed in the Uncheon area during the time of the exercise. Two of these occurred among the approximately 1,500 ROK Marines participating with the U.S. forces. Differential neutralization revealed Apodemus-associated infection in these patients as well. Reported by: CDR E Pon, LCDR B Merrell, LCDR R Thomas, US Navy Environmental Preventive Medicine Unit #6, Pearl Harbor, Hawaii. LT A Corwin, Consolidated Preventive Medicine Svc, US Naval Hospital, Okinawa, Japan. MAJ B Diniega, MAJ K McKee, Walter Reed Army Institute of Research, Washington, DC. LTC T Ksiazek, US Army Medical Research Institute of Infectious Diseases, Fort Detrick, Maryland. H-W Lee, Korea Univ Medical College, Seoul, Korea.* Special Pathogens Br, Div of Viral Diseases, Center for Infectious Diseases, CDC. Editorial Note: Hemorrhagic fever with renal syndrome (HERS), sometimes known as Korean hemorrhagic fever, is a viral infection acquired from rodents, principally the species Apodemus agrarius, Rattus rattus, and Clethrionomys glariolus. Human infections are widespread, particularly in Asia north of the Himalayas. For example, in the People's Republic of China, HFRS is responsible for over 100,000 reported cases annually, with the reported incidence increasing rapidly in the last few years ( 1 ). This increase may be the result of recent changes in agricultural practices, which may have altered rodent populations. The disease is undoubtedly ancient, but was first recognized independently and reported in the 1930s in Scandinavia and in Manchuria during the Japanese campaign (2). Most of the early recognized outbreaks were associated with military maneuvers, especially where troops had bivouacked in the open or had been involved in trench warfare. During the Korean conflict, at least 3,000 United Nations troops were affected (3,4). The prototype virus was isolated in 1978 and named after the Hantaan river in Korea (5).

The group of closely related viruses causing HFRS have recently been classified as the genus Hantavirus, forming a subgroup of the family Bunyaviridae (6). The virus is usually acquired directly from rodents, in which it establishes a silent but persistent infection. In these rodents, the virus is detected primarily in the lung and kidney, where it is able to persist in the presence of serum antibodies. Large quantities of virus are excreted throughout life. Humans may become infected through minor cuts and abrasions contaminated with rodent urine or feces, but evidence also suggests that aerosol infection may occur where virus contamination is heavy. Infections have also been reported among laboratory personnel in the Soviet Union, Japan, Scandinavia, and Belgium. Most of these have been associated with handling of infected wild or laboratory rodents (2,7).

Both the epidemiologic characteristics of outbreaks of human disease and the severity of the infection may be determined by the rodent host. A. agrarius, the major *The views of the authors do not purport to reflect the position of the U.S. Department of the Army or the U.S. Department of Defense.

Hemorrhagic Fever Continued host in Asia, is found mainly in rural areas, particularly in the eastern Soviet Union, mainland China, and Korea, where its habits are increasingly peridomestic. The Apodemus-associated hantaviruses probably cause the most severe human disease, with mortality rates currently reported between 3% and 7% (1). Rattus-associated disease is apparently less severe, and asymptomatic infections may be more common than with Apodemus-associated disease (8). Human infections from R. rattus are reported from some inner cities in Asia and probably occur also in rural areas where infestation with both R. rattus and A. agrarius is common. Although infected rats have been detected in Western cities, associated human disease has yet to be described (9). Nephropathia epidemica, which was first described in Scandinavia, is now known to be due to infection with a strain of Hantavirus that infects voles (Clethrionomys species) (10). It has become apparent recently that infected voles and human disease occur throughout Western Europe (11). Nephropathia

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TABLE II. Notifiable diseases of low frequency, United States

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*One of the 46 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.

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