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⚫ 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 4 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.

Injuries - Continued

and abrasions, and the proportion of "repeaters" in the slider population, who had already successfully avoided injury and would be somewhat familiar with the course, may have increased substantially during the season. These protective considerations could have caused the early decline, but they were still applicable when rates rose again in late August.

Whether the larger number of cases among females indicates a higher injury rate for that sex is uncertain. Studies of swimming pool and other aquatic injuries have found higher risks among males (4) attributed to greater risk-taking behavior by males (5). The prominence of older persons among fracture victims suggests that larger body size and/or mass may be significant risk factors for severe injury. To minimize risk, it may be necessary to make special considerations for sliders of greater size, weight, and age in the design and/or admission guidelines for water slide rides.

References

1. Department of Health and Human Services. Suggested health and safety guidelines for recreational water slide flumes. Atlanta, Georgia: Centers for Disease Control, 1981.

2. Weiner RI. Large water slide safety problems and implications, past-present-future. Paper presented at American Water Slide Association meeting, Kansas City, Mo., Nov. 21, 1982.

3. National Injury Information Clearinghouse, U.S. Consumer Product Safety Commission, Washington, D.C., 1982. Unpublished data.

4. CDC. Aquatic deaths and injuries-United States. MMWR 1982;31:417-9.

5. Davis HF, et al. The 1990 objectives for the nation for injury prevention: a progress review. Public Health Reports 1984;99:9-24.

International Notes

Salmonellosis Associated with Cheese Consumption - Canada

Several hundred cases of salmonellosis caused by Salmonella typhimurium phage type 10 have been reported from Prince Edward Island, Newfoundland, New Brunswick, and Ontario, Canada, in recent months. These cases have been traced to eating cheese produced by Amalgamated Dairies, Ltd. (ADL) of Summerside, Prince Edward Island. Several different types of cheese, including colby, cheddar, mozzarella, and farmer's cheese, may have been contaminated. The cheeses, which were sold under many different labels, have been recalled in Canada. The brands packaged by ADL that have been recalled are Tyne Valley, Clover Cream, and ADL. In addition, mild and medium cheddar cheese bearing the registration number 1413 (Canada Packers Inc., Toronto, Canada) of the brand names Maple Leaf, Calbeck, Co-op., I.G.A., N & D, and Western Family have been recalled. Mild cheddar cheese bearing the registration number 1557 (Winchester Cheese, Inc., Winchester, Canada) of the brand names J. M. Schneider, Loblaws (including No Name and No Frills), Dutch Boy, Super Value, Quick Save, Dairy Pride, Zehrs, and Sunspun have also been recalled.

To date, CDC is not aware of any distribution of the cheeses in the United States, but it is possible that U.S. citizens have been infected by eating cheese in Canada or by bringing cheese back to the United States. Consumers are advised to discard the product or to return it to the place of purchase.

Reported by Health Protection Br, Health and Welfare, Canada; Emergency and Epidemiology Operations Br, U.S. Food and Drug Administration; Enteric Diseases Br, Div of Bacterial Diseases, Center for Infectious Diseases, CDC.

Editorial Note: CDC's Enteric Diseases Branch, Center for Infectious Diseases, (404) 329-3753, would appreciate reports of any cases or outbreaks of salmonellosis in U.S. citizens associated with eating these cheeses. Reports should go through state and local health departments.

Current Trends

Enterovirus Surveillance

United States, 1984

Reports received from state virology laboratories for enterovirus isolates identified through May 1984 show echovirus 9 (38 isolates) to be the most commonly reported type of nonpolio enteroviruses thus far this year. The three next most common types are echovirus 7 (20 isolates), echovirus 30 (15 isolates), and coxsackievirus A9 (13 isolates). Coxsackievirus B5, the most common enterovirus type isolated in 1983, is being identified less frequently so far this year (seven isolates reported). One hundred eleven (73.5%) of 151 nonpolio enteroviruses identified in 1984 have been reported from the South Atlantic, West South Central, and Pacific regions.

Reported by Respective State Virology Laboratory Directors; Respiratory and Enterovirus Br, Div of Viral Diseases, Center for Infectious Diseases, CDC.

Editorial Note: A retrospective study of CDC's enterovirus surveillance data from 1970 to 1982 showed that southern and coastal regions in the United States report enterovirus isolates significantly earlier than the rest of the nation and that an enterovirus type isolated four or more times from these regions during March, April, and May is likely to be among the 10 most commonly reported types for the remainder of the year. Reports from March, April, and May received to date suggest that echoviruses 7 and 9 and coxsackieviruses A9, B4, and B5 will be common isolates this year (Table 2). Echovirus 30 was frequently isolated only in January and February.

TABLE 2. Nonpolio enteroviruses-selected regions and United States, March-May 1984

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From 1973 through 1983, 2,575 cases of malaria were reported among U.S. citizens who were infected while traveling abroad. This was 33% of all imported cases reported during this period-the majority occurring among foreign nationals. Of the cases among U.S. citizens, 849 (33%) had been infected with Plasmodium falciparum. During this period, the number of P. falciparum infections among U.S. travelers rose almost sevenfold from 21 cases in 1973 to 139 in 1983. The increase has been especially marked among U.S. travelers who visited east Africa: in 1973-1974 only nine cases occurred among such travelers, compared with 88 cases in 1982-1983 (a nearly 10-fold increase). Infections with P. falciparum malaria in non

Malaria - Continued

immune individuals can be extremely serious and potentially fatal: 31 deaths from malaria occurred among the 849 patients with P. falciparum infections, for a case-fatality ratio of 4%.

In 1982-1983, more than half of all P. falciparum cases in the United States were imported from five countries: Kenya (61 cases), Haiti (26), Tanzania (19), Nigeria (15), and Ghana (10); 167 (68%) of the 247 P. falciparum infections among U.S. travelers were acquired in Africa. Attack rates for certain years can be estimated for Kenya, Ghana, and Haiti based on the number of U.S. travelers to those countries as provided by the World Tourism Organization in Madrid. The estimated number of malaria infections in U.S. travelers to Kenya increased from 21.2 per 100,000 travelers in 1977 to 83.3/100,000 in 1982; for Ghana, the estimated number of malaria infections was 104.4/100,000 U.S. visitors in 1977-1978; for Haiti, the number was 19.2/100,000 in 1982.

Importation of malaria is not only a problem in the United States. For instance, the number of imported cases of malaria into Great Britain increased from 100 in 1970 to 1,471 in 1982. Between 1970 and 1980, 88% of the P. falciparum infections reported in Great Britain originated in Africa (1).

Travelers who acquire malaria generally do not take appropriate chemoprophylaxis. For example, only 8% of the U.S. travelers who acquired P. falciparum malaria in west Africa or Haiti between 1981 and 1983 had histories of having taken chloroquine chemoprophylaxis during their travels. Reduced efficacy of chemoprophylaxis may also factor in the increased importation of malaria from certain areas, especially east Africa: the percentage of patients who reportedly had used chloroquine as chemoprophylaxis while traveling in east Africa increased from 22% in 1977 to 76% in 1983. This trend has been reviewed recently by CDC and has necessitated changes in recommendations for chemoprophylaxis for U.S. travelers to defined areas of east Africa (2).

Reported by Malaria Br, Div of Parasitic Diseases, Center for Infectious Diseases, CDC.

Editorial Note: The risk of malaria to travelers can be reduced through adequate use of effective chemoprophylactic drugs. This requires that travelers to malarious countries be adequately informed about malaria risks and malaria chemoprophylaxis and that they be motivated to adhere to recommendations. Information about health risks and chemoprophylaxis is provided through official publications from CDC (3,4) and the World Health Organization (5). Little is known, however, about traveler awareness of the risk in malarious areas, about the advice, if any, they receive about chemoprophylaxis and from which sources, and whether some categories of travelers (e.g., missionaries, Peace Corps volunteers) may be better informed than other groups (e.g., tourists, business travelers). Because of the large number of U.S. international travelers and the great diversity in the U.S. travel industry, efficient dissemination of information to help protect the health of the traveling public is difficult.

In increasing areas of the world, chloroquine can no longer be considered an effective drug to prevent P. falciparum malaria. Chloroquine-resistant P. falciparum is known to exist in the following countries: Bolivia, Burma, Burundi, Colombia, Comoros, Ecuador, French Guyana, Kampuchea, Kenya, Laos, Madagascar, Malaysia, Papua New Guinea, Rwanda, Solomon Islands, Surinam, Tanzania, Thailand, Uganda, Vanuatu, Venezuela, Vietnam, and in parts of Bangladesh, Brazil, China, India, Malawi, Mozambique, Panama, Peru, the Philippines, Sudan, Zaire, and Zambia. Weekly use of the combination drug, pyrimethamine-sulfadoxine (Fansidar®), in addition to weekly use of chloroquine, is recommended by CDC for travelers to these areas (5).

An update of CDC's recommendations (2) regarding chemoprophylaxis will be published soon as an MMWR Supplement, "Prevention of Malaria in Travelers, 1984."

Malaria - Continued

References

1. Bruce-Chwatt LJ. Imported malaria: an uninvited guest. Br Med Bull 1982;38:179-92.
2. CDC. Update: chloroquine-resistant Plasmodium falciparum—Africa. MMWR 1983;32:437.
3. CDC. Prevention of malaria in travelers, 1982. MMWR Supplement 1982;31:1S-28S.

4. CDC. Health information for international travel, 1983. Atlanta, Georgia: Centers for Disease Control, 1983; HHS publication no. (CDC) 83-8280.

5. World Health Organization. Vaccination certificate requirements for international travel and health advice to travellers. Geneva, Switzerland: World Health Organization, 1983.

Notice to Readers

Availability of CDC-NIH Biosafety Manual

The CDC-National Institutes of Health (NIH) publication, Biosafety in Microbiological and Biomedical Laboratories is now available. The publication describes standard and special microbiologic practices, safety equipment, and facilities that constitute biosafety levels 1-4, which are recommended when working with infectious disease agents in various laboratory settings, e.g., clinical, public health, research, or industry. These recommendations are advisory; as such, they are intended to provide a voluntary guide or code of practice, as well as a goal for upgrading current operations and practices. This publication may also be of use in the construction of new microbiologic or biomedical laboratory facilities or in the renovation of existing facilities.

Laboratory activities with infectious agents are categorized into one of four "Biosafety Levels," depending on the assessed infection risks of laboratory personnel conducting manipulations of infectious materials or cultures typical of those performed in microbiology laboratories.

Agent summary statements, citing published or documented cases of laboratoryassociated infections, known and potential laboratory hazards, and recommended precautions, are provided for a variety of indigenous and exotic agents that are known or highpotential infection risks.

The appendices describe biologic safety cabinets and their performance characteristics, immunoprophylaxis, requirements for importation and interstate shipment of human pathogens and related materials and provide a list of animal pathogens whose importation, possession, or use is restricted by the U.S. Department of Agriculture.

The manual is available from the Superintendent of Documents, U.S. Government Printing Office, Washington, D.C. 20402, Stock No. 0170230016-1, Price: $4.00, and the National Technical Information Service, U.S. Department of Commerce, 5285 Port Royal Road, Springfield, Virginia 22161, Stock No. PB84-206879, Price: $13.00 paper, $4.50 microfiche.

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