Page images
PDF
EPUB

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,

[merged small][ocr errors][merged small][merged small][subsumed][merged small][ocr errors][subsumed][merged small][merged small][merged small][merged small][merged small]

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.

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,

[merged small][merged small][merged small][merged small][merged small][merged small][ocr errors][merged small][merged small][subsumed][merged small][ocr errors][merged small][merged small]
[ocr errors]

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, Iowa, Kansas, Minnesota, Missouri, Montana, North Dakota, South Carolina, South Dakota, Tennessee, Texas, Wisconsin, and Wyoming.

TABLE I. Summary

(Continued on page 9) 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
18
55

47 Unspecified

20
35
60
20
35

60 Legionellosis

4
22

4
22

7 Leprosy

5

5 Malaria

19
9

19

9 Measles: Total*

35

35

8 Indigenous

35

35

7 Imported

1 Meningococcal infections

59
41

59 Mumps

75
46

75 Pertussis

26
26

26 Rubella (German measles)

3

3 Syphilis (Primary & Secondary): Civilian

433
698
354
433
698

354
Military
2

2 Toxic Shock syndrome

2
3

2

3 Tuberculosis

87
218
213

87
218

213 Tularemia

2
2

2 Typhoid Fever

4
3

4 Typhus fever, tick-borne (RMSF)

4

4 Rabies, animal

22
67
53
22
67

53

[ocr errors]
[ocr errors]
[ocr errors]
[ocr errors]
[ocr errors]
[ocr errors]

-งงงง

[ocr errors]

TABLE II. Notifiable diseases of low frequency, United States

Cum. 1988

Cum. 1988

1

Anthrax
Botulism: Foodborne

Infant

Other
Brucellosis (Calif. 1)
Cholera
Congenital rubella syndrome
Congenital syphilis, ages <1 year
Diphtheria

Leptospirosis (Hawaii 1)
Plague
Poliomyelitis, Paralytic
Psittacosis
Rabies, human
Tetanus
Trichinosis

"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.

« PreviousContinue »