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Salmonellosis Continued

A review of the method used to prepare the giblet gravy revealed that, 3 days before Thanksgiving, the giblets had been removed from forty-three 22- to 24-pound turkeys, which had been thawed at room temperature for 36 hours before cooking. The giblets were refrigerated, with instructions reportedly given to boil them the day before Thanksgiving at the time the stock was being prepared. However, when each of the 18 foodhandlers was questioned individually, no one admitted to cooking the giblets or recalled seeing the giblets being boiled. The uncooked giblets were ground in a blender and added to a thickened, hot stock mixture. The gravy was not returned to a boil after addition of the ground giblets, so the thickened mixture would not scorch. The mixture was stored on the counter behind the stove at room temperature throughout Thanksgiving Day. Leftover gravy was used for turkey luncheon specials offered November 26 and 27.

Outbreak 2: Seven persons, all of whom were culture-positive for Salmonella serotype heidelberg, became ill after eating at the second restaurant on October 17, 1983. In univariate analysis of the latter outbreak, eating liver pate was associated with illness (p = 0.003). No pate remained for laboratory analysis, since the restaurant had been alerted to the problem by a customer and had stopped making the pate 2 days before the investigation. The pate was prepared October 15. Four 5-pound containers of frozen chicken livers had been defrosted under refrigerated conditions for 4 days before use. They were sauteed in a 20-quart vessel and ground in a food processor. After addition of seasoning and diced boiled eggs, the mixture was poured into a large storage pan and refrigerated. The pate was served in a small crock on the salad bar, which was replenished from the refrigerated storage container as needed from October 16 to October 19. Reported by KF Gensheimer, MD, Maine Dept of Human Svcs; Enteric Diseases Br, Div of Bacterial Diseases, Center for Infectious Diseases, CDC. Editorial Note: Poultry products are a frequent source of Salmonella infections, and reported outbreaks from turkey increase markedly during the Thanksgiving and Christmas holiday seasons (1). Culture surveys of poultry flocks and market poultry have demonstrated that salmonellae may be recovered frequently (2), a fact that is often not known or is overlooked during rushed holiday preparations.

The outbreaks described here were unusual in that they involved giblets that had been stored under refrigeration for several days and that, because they had oxidized, appeared to have been cooked. Domestic and commercial foodhandlers should be aware of the misleading appearance of giblets and other poultry organs that have been refrigerated for prolonged periods. References 1. Horwitz MA, Gangarosa EJ. Foodborne disease outbreaks traced to poultry, United States,

1966-1974. J Milk Food Technol 1976;39:859-63. 2. Zecha BC, McCapes RH, Dungan WM, Holte RJ, Worcester WW, Williams JE. The Dillon Beach

Project - a five-year epidemiological study of naturally occurring salmonella infection in turkeys and their environment. Avian Dis 1977; 21:141-59.

The Morbidity and Mortality Weekly Report is prepared by the Centers for Disease Control, Atlanta, Georgia, and available on a paid subscription basis from the Superintendent of Documents, U.S. Government Printing Office, Washington, D.C. 20402. (202) 783-3238.

The data in this report are provisional, based on weekly reports to CDC by state health departments. The reporting week concludes at close of business on Friday; compiled data on a na. tional basis are officially released to the public on the succeeding Friday.

The editor welcomes accounts of interesting cases, outbreaks, environmental hazards, or other public health problems of current interest to health officials. Such reports and any other mat. ters pertaining to editorial or other textual considerations should be addressed to: ATTN: Editor, Morbidity and Mortality Weekly Report, Centers for Disease Control, Atlanta, Georgia 30333.

Director, Centers for Disease Control

James O. Mason, M.D., Dr.P.H. Director, Epidemiology Program Office

Carl W. Tyler, Jr., M.D.

Editor

Michael B. Gregg, M.D. Assistant Editor

Karen L. Foster, M.A.

U.S. Government Printing Office: 1984.746-149/10022 Region IV

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The second case of human rabies occurring in the United States in 1984 was diagnosed September 21, in Danville, Pennsylvania. The patient, a 12-year-old male resident of Williamsport, Pennsylvania, had no history of exposure to a known rabid animal.

He was in good health until September 14, when he complained of a runny nose and sore throat. He was feverish and had teeth-chattering chills and drenching sweats. Later that day, he refused to eat, choking when he finally attempted to eat, and he was unable to swallow antipyretics. The next day, he felt somewhat better, but he was still unable to eat. On September 16, he complained of being chilly, hungry, and thirsty. The following morning, he suddenly developed muscle spasms and had difficulty breathing. When his mother attempted to take him to the hospital, he tried to run away.

On September 17, at the emergency room of a local hospital, the patient was agitated; his temperature was 39.4 C (103 F); and he appeared dehydrated. Diaphoresis, mydriasis, generalized hyperreflexia, and fasciculations of all muscle groups were noted. The admitting diagnosis was fever with dehydration. Hyperthyroidism, sepsis, and drug intoxication were ruled out shortly after admission. On September 18, after rehydration, he showed no changes. He refused to swallow liquids and expectorated all secretions. The diagnosis of rabies was considered, and contact isolation was instituted. Lumbar puncture was traumatic, revealing 149 white blood cells/mm3 and 17,560 red blood cells/mm3. Cardiac arrhythmias, including premature atrial and ventricular beats, were noted. His extremities became cold, and blood pressure was sometimes difficult to auscultate. He was transferred to a referral center, where physical examination revealed him to be both diaphoretic and shivering, intermittently responsive to commands, and at other times yelling inappropriately and violently. This became particularly marked when cool breezes, such as from an oxygen canula, crossed his face. He frequently gagged and expectorated. Periods of lucidity alternated with hallucinations and disorientation, and he exhibited facial grimaces and fasciculations. A skin biopsy from the nape of the neck performed on September 20 and examined at CDC on September 21 was positive for rabies by immunofluorescent staining. On September 23, the patient became less responsive, failing to follow commands to open his eyes. He was intubated because of expectoration of large amounts of foamy saliva and episodes of respiratory depression. On the morning of September 26, he became almost completely unresponsive, with only occasional grimaces to pain and asymmetric and sluggishly reactive pupils. Chest radiograph revealed consolidation of the left lower lung field and patchy densities in the right lung fields. An episode of bradycardia occurred. Further neurologic deterioration occurred, and the patient died after an episode of asystole on September 29.

US DEPOSITORY DEC 1 4 1984 U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES / PUBLIC HEALTH SERVICE

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Human Rabies Continued

Sera and cerebrospinal fluid from September 20, were negative for rabies neutralizing an- | tibodies using the rapid fluorescent focus inhibition test performed at CDC. The definitive diagnosis was based on the positive fluorescent antibody of the neck biopsy and later isolation of rabies virus from the saliva.

Although the mid-Atlantic raccoon rabies epizootic now involves Pennsylvania, no rabid animals have been found since 1978 in the county where the patient lived. Testing of numerous terrestrial animals, including raccoons, failed to detect any animal rabies. For 1984, only one animal with rabies, a bat, has been reported from those counties adjacent to where the patient lived.

Monoclonal antibody analysis of the rabies virus isolated from the patient's saliva did not reveal the characteristic antigenic patterns found in rabies isolates from raccoons and other terrestrial mammals in the mid-Atlantic states. The similarity between this isolate and those obtained from insectivorous bats common to the eastern United States suggests a bat as the origin of this isolate, but an identical isolate has not been obtained (1). Further analyses and comparison of this isolate with virus isolates from rabid bats in the Pennsylvania area are

under way.

Reported by D Zeidner, MD, A Bowman, J Dennehy, MD, C Hufnal-Miller, MD, R Leipold, MD, T Royer, MD, M Ryan, MD, S Toor, MD, T Martin, MD, Geisinger Medical Center, Danville, J Maksimak, MD, RH Kaiser, MD, G Lattimer, MD, M Hart, C Sinner, Divine Providence Hospital, Williamsport, B Jones, DVM, S Bowen, MD, E Witte, VMD, C Hays, MD, State Epidemiologist, Pennsylvania State Dept of Health; Div of Viral Diseases, Center for Infectious Diseases, CDC. Editorial Note: This patient's classic hydrophobia, aerophobia, and furious behavior resulted in the early suspicion of rabies and early institution of proper isolation measures even in the absence of a history of rabies exposure. Although an exposure history can be identified in most cases of rabies, no exposure has been identified in nine (20%) of the 45 cases occurring in the United States from 1960 to the present (2). This case did not appear to have been acquired from a wild terrestrial mammal, and, to date, no case of human rabies has been associated with the mid-Atlantic raccoon rabies epizootic.

The absence of a known history of exposure, in conjunction with the impending hunting season, resulted in an unprecedented demand for preexposure immunization among many Pennsylvania hunters, trappers, and other outdoors enthusiasts. However, only professional trappers and hunters in rabies-endemic areas who are regularly exposed to potentially rabid animals should receive preexposure prophylaxis; the population at large, including individuals : in rabies epizootic areas, does not require rabies preexposure prophylaxis (3). Sports trappers and hunters are at little risk of an inapparent exposure.

All hunters and trappers in rabies-endemic areas handling animals, such as raccoons, foxes, and skunks, known to be involved in endemic epizootic rabies problems should use care, especially when skinning animals, to avoid exposures (bites and contamination of mucous membranes and open wounds with potentially infectious materials (saliva and brain tissue]). The use of gloves is recommended when wild mammals are handled. Any bite or nonbite exposure should be treated promptly with local-wound care and should be reported to appropriate local or state health officials. The animal head should be maintained at refrigerator temperature (approximately 4 C (39 F]) pending instructions on the need for testing.

Preexposure prophylaxis does not eliminate the need for postexposure prophylaxis. The use of rabies postexposure prophylaxis should be based on individual evaluations of each exposure and examination of the animal that was the source of the exposure after consultation with appropriate local and state health authorities. Rabies in humans is very rare in the United States, with an average of only two cases per year since 1960 (2), and no case has occurred in a person who has received the recommended postexposure treatment.

Human Rabies - Continued References 1. Smith JS, Sumner JW, Roumillat LF, Baer GM, Winkler WG. Antigenic characteristics of isolates as

sociated with a new epizootic of raccoon rabies in the United States. J Infect Dis 1984;149:769-74. 2. Anderson LJ, Nicholson KG, Tauxe RV, Winkler WG. Human rabies in the United States, 1960 to

1979: epidemiology, diagnosis, and prevention. Ann Intern Med 1984;100:728-35. 3. ACIP. Rabies prevention - United States, 1984. MMWR 1984;33:393-402, 407-8.

Current Trends

Paralytic Poliomyelitis – United States, 1982 and 1983

As of June 1984, 21 patients with paralytic poliomyelitis had been reported to CDC with onset of illness in 1982 and 1983.· Nine of the patients had onset in 1982, and 12, in 1983. All 21 cases were classified as vaccine-associated, using both epidemiologic and laboratory classifications (1.2) (Tables 1 and 2). One case occurred in a 22-year-old unimmunized individual with no history of contact with a trivalent oral poliomyelitis vaccine (OPV) recipient before onset of his illness. Although his case was classified epidemiologically as endemic, not vaccine-associated, a vaccine-like poliovirus type 2 was isolated from his stool.

Eight cases occurred among OPV recipients. All were associated with the first OPV dose, and seven were 2 months to 4 months of age, the recommended age for the first OPV dose.

*These reported cases comprise the "Best Available Paralytic Poliomyelitis Case Count," i.e., they are clinically and epidemiologically compatible with poliomyelitis with residual neurologic deficit 60 days after onset of initial symptoms (or death).

TABLE 1. Epidemiologic classifications of paralytic poliomyelitis

I. EPIDEMIC: occurring with epidemiologic linkage to other cases

A Oral poliovirus vaccine (OPV) not received 4-30 days before onset of illness.
B. OPV received 4-30 days before onset of illness.

II. ENDEMIC: occurring without epidemiologic linkage to other cases

A. No history of receiving OPV or of contact with an OPV recipient as defined in B and C below.
B. OPV received 4-30 days before onset of illness.
C. Onset of illness 4-60 days after OPV was fed to a recipient in contact with patient and contact

occurred within 30 days before onset of illness.
1. Household contact - vaccine recipient and patient regularly share the same home for

sleeping
2. Community contact or nonhousehold contact.

III. IMPORTED

Disease develops in U.S. resident who has traveled outside the United States in areas with known endemic or epidemic poliomyelitis.

IV. IMMUNE DEFICIENT

Documented immunodeficiency of any type.

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