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TABLE III. (Cont'd.) Cases of specified notifiable diseases, United States, weeks ending

December 8, 1984 and December 10, 1983 (49th Week)

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TABLE IV. Deaths in 121 U.S. cities,' week ending

December 8, 1984 (49th Week Ending)

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EN CENTRAL 2.242
Akron, Ohio

79 Canton, Ohio

50 Chicago, IllI

459 Cincinnati, Cnio 121 Cleveland, Ohio 152 Columbus, Ohio 135 Dayton, Ohio

111 Detroit, Mich. 271 Evansville, Ind

34 Fort Wayne, Ind

47 Gary, Ind

12 Grand Rapids, Mich 70 Indianapolis, Ind 211 Madison, Wis.

25 Milwaukee, Wis. 121 Peoria, III

86 Rockford, III

50 South Bend, Ind 46 Toledo, Ohio

103 Youngstown, Ohio 59

4 4

1,600

65 35 413 80 90 87 77 176 22 32

4 56 127 20 90 48 33 32 71 42

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PACIFIC

1.804 1.320 Berkeley, Calif.

19 17 Fresno, Calif.

76 46 Glendale, Calif. S

18 18
Honolulu, Hawaii

75 56
Long Beach, Calif 96 64
Los Angeles, Calit § 402 366
Oakland, Calif.

70 45
Pasadena, Calif.

25 19 Portland, Oreg

110 74 Sacramento, Calif. 138 101 San Diego, Calif. 171

105 San Francisco, Calif 172 110 San Jose, Calif.

176 123 Seattle, Wash

161 106 Spokane, Wash

51

36 Tacoma, Wash

44 34

tt TOTAL

12.795

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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. Com.

plete counts will be available in 4 to 6 weeks ++ Total includes unknown ages

Datonist available Figures are estimates based on average of past 4 weeks

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Endrin Poisoning - Continued consuming contaminated food (5,6). No endrin was detected 29-31 days after exposure (6). The presence of endrin in 57% of seizure patients tested in Pakistan suggests that endrin was the cause of this most recent outbreak.

Previous outbreaks of endrin poisoning have been associated with consumption of contaminated flour. Bread and rolls from the outbreaks contained 126-180 parts per million of endrin (5,7). The first reported outbreak was in Great Britain, where endrin was spilled on the floor of a box car; 1 month later, bags of flour stacked on the floor of the car became contaminated (8). In the Middle East, over 800 cases of endrin poisoning occurred in four outbreaks after contaminated flour was used in several bakeries (7). The flour had been imported aboard ships that were also transporting endrin. Endrin spilled from the upper decks of the ships onto the sacks of flour. As a result of the investigation, the governments of Qatar and Saudi Arabia required that ships transporting foodstuffs identify the type and location of all toxic chemicals and that the ships be inspected before food was unloaded for delivery (7).

In the Pakistan episode, circumstances of endrin use and food and chemical transport suggest that food products could have been contaminated during transport. Whether further analysis of environmental samples and epidemiologic data can document the source(s) and route(s) of exposure remains to be seen. References 1. Hayes WJ Jr. Clinical handbook on economic poisons. Emergency information for treating poisoning.

Atlanta, Georgia. Public Health Service publication no. 476, revised 1963. 2. Jager KW. Aldrin, dieldrin, endrin and telodrin. An epidemiological and toxicological study of long

term occupational exposure. Amsterdam, The Netherlands: Elsevier Publishing Company, 1970. 3. Hayes WJ Jr, Curley A. Storage and excretion of dieldrin and related compounds. Effect of occupa

tional exposure. Arch Environ Health 1968;16:155-62. 4. Hayes WJ Jr, Dale WE, Burse VW. Chlorinated hydrocarbon pesticides in the fat of people in New Or

leans. Life Sciences 1965;4:1611-5. 5. Coble Y, Hildebrant P, Davis J, Raasch F, Curley A. Acute endrin poisoning. JAMA 1967:202:

489-93. 6. Curley A, Jennings RW, Mann HT, Sedlak V. Measurement of endrin following epidemics of poison

ing. Bull Environmental Contam Toxicol 1970;5:24-9. 7. Weeks DE. Endrin food-poisoning. A report on four outbreaks caused by two separate shipments of

endrin-contaminated flour. Bull WHO 1967:37:499-512. 8. Davies GM, Lewis I. Outbreak of food-poisoning from bread made of chemically contaminated flour.

Br Med J 1956,2:393-8.

Human Salmonella Isolates

United States, 1983

In 1983, 38,881 Salmonella isolates (including Salmonella typhi) from humans were reported to CDC. This represents a 3.2% increase over the 37,683 isolates reported in 1982. During the past 16 years, the number of Salmonella isolates reported to CDC has continued to rise from the 19,659 isolates reported in 1968. The increase was not confined to one state or region. Notable increases over 1982 were seen in: Maryland - 183% increase (442 to 1,251); Vermont-119% increase (73 to 160); Indiana - 105% increase (242 to 497); New Mexico -37% increase (243 to 333); Utah -34% increase (85 to 114); Oklahoma - 33% increase (272 to 361); Alabama - 31% increase (561 to 743); and New York – 27% increase (2,300 to 2,916). The extent to which these increases represent reporting artifacts is unknown.

The 10 most frequently reported isolates comprised 71% of all the isolates reported (Table 1). S. heidelberg increased 42% (2,641 isolates in 1982 to 3,746 isolates in 1983), and S. agona increased 24% (1,125 to 1,396).

Increases were also reported in some less frequently isolated serotypes. S. stanleyville increased from one isolate reported in 1982 to 37 in 1983; 57% of these isolates were report

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Human Salmonella Continued ed by New York state. S. djuju increased from three reported isolates to 24; an outbreak at a catered party in Alabama was partially responsible for this increase. tennessee increased from 59 to 136 reported isolates; increases were reported by Illinois and Virginia. S. braenderup increased from 212 to 324; an outbreak of this serotype was reported in a restaurant in Illinois. Reported isolates of S. havana increased from 71 to 114; an outbreak that occurred in a North Carolina hospital was in part responsible for this increase. S. dublin increased from 126 to 182; 66% of these isolates were reported by California. S. hadar increased from 144 to 325; 40% of these isolates were reported by New Jersey, New York, North Carolina, and Virginia.

Age data were reported for 80% of the isolates. The reported rates of Salmonella isolation were highest for 2- to 4-month-old infants, decreased abruptly among early childhood age groups, and then remained relatively constant through the adult years. The reported rates were slightly higher among males in the under-20-year age groups and slightly higher among females in the 20- to 69-year age groups. This is consistent with reports from previous years. During the past 16 years, the median age of all persons from whom isolates were obtained has increased from a median of 6 years in 1968 to 14 years in 1982 and 1983.

In 1983, 525 S. typhi isolates were reported: 156 were from cases; 26 were from carriers; and the remaining were not designated as to case or carrier status. The carriers' median age was 61; the median age of cases was 25. Reported by Statistical Svcs Activity, Enteric Diseases Br, Div of Bacterial Diseases, Center for Infectious Diseases, CDC. Editorial Note: This report is based on the Salmonella surveillance activity conducted by the Association of State and Territorial Epidemiologists, the Association of State and Territorial Public Health Laboratory Directors, and CDC. It is a passive laboratory-based system that receives weekly reports from the states and the District of Columbia and regular summaries from the U.S. Department of Agriculture. The reports do not distinguish between clinical and subclinical infections or between chronic and convalescent carriers. Many factors affect whether an infection will be reported; however, these data permit comparison with past and future tabulations and have provided information for epidemiologic investigations and a crude index of the effectiveness of various public health measures.

In many of the detected outbreaks, the cause was a relatively uncommon serotype, which points to the importance of serotyping Salmonella. An increase in a common serotype is less likely to be recognized as an outbreak. Recently, however, identification of outbreaks caused by common serotypes has been facilitated by the application of molecular biologic techniques, such as plasmid profile analysis.

Information from epidemiologic investigations during 1983 has added to the understand

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TABLE 1. Salmonella serotypes most frequently isolated from humans United States, 1983

No.

Median age of persons from Serotype

isolates (%)

whom isolates were obtained S. typhimurium

13,172 (33.9) S. heidelberg

3,746 (9.6) S. enteritidis

3,256 (8.4) S. newport

2,071 (5.3) S. agona

1.396 (3.6) S. infantis

1,272 (3.3) S. saint paul

711 (1.8) S. montevideo

658 (1.7) S. Oranienburg

578 (1.5) S. typhi

525 (1.4) Subtotal

27,385 (70.5) Total

38,881 'Includes S. typhimurium var. Copenhagen.

10 yrs.

5 yrs. 24 yrs. 17 yrs. 18 yrs. 18 yrs. 20 yrs. 20 yrs. 22 yrs. 26 yrs.

Human Salmonella – Continued ing of salmonellosis. In early 1983, 18 persons in four midwest states developed salmonellosis. These patients, most of whom had developed severe salmonellosis after taking antimicrobials for other illnesses, were infected with multi-drug-resistant S. newport. The investigation demonstrated that this organism was transmitted by hamburger from a beef herd that had been fed subtherapeutic doses of an antimicrobial for growth promotion (1). This outbreak demonstrated that antimicrobial-resistant bacteria of animal origin can cause serious human disease, especially among persons taking antimicrobials. A second investigation of S. dublin infections in California confirmed the findings of previous studies linking S. dublin to the consumption of certified raw milk (CRM) (2). The risk of contracting S. dublin for California CRM drinkers in 1983 was calculated to be 158 times greater than the California population that did not drink CRM. A third study in Puerto Rico again associated pet turtles with human disease (3). This study of salmonellosis among children under 1 year of age showed that turtles were responsible for 12%-17% of reported infant salmonellosis in Puerto Rico. Although the U.S. Food and Drug Administration banned interstate and intrastate commercial distribution of turtles under 4 inches long in 1975, pet turtles raised in and exported from the United States continue to pose a public health problem. These animals remain inappropriate pets for children. References 1. Holmberg SD, Osterholm MT, Senger KA, Cohen ML. Drug-resistant Salmonella from animals fed an

timicrobials. N Engl J Med 1984;311:617-22. 2. CDC. Salmonella dublin and raw milk consumption - California. MMWR 1984;33:196-8. 3. CDC. Pet-turtle-associated salmonellosis - Puerto Rico. MMWR 1984;33:141-2.

Diphtheria-Tetanus-Pertussis Vaccine Shortage

United States

In the past 6 months, major changes have occurred in the pattern of manufacture and distribution of diphtheria-tetanus-pertussis* (DTP) vaccine in the United States. Now, two of the three U.S. commercial manufacturers (Wyeth and Connaught, Inc.) have stopped distribution of their products. Thus, only one manufacturer (Lederle) now markets DTP vaccine in the United States. Lederle has been increasing its production and expanding its facilities to meet current needs. Careful monitoring of supplies and production schedules previously indicated that national supplies would be adequate. However, some recent lots of Lederle DTP vaccine have failed to meet the manufacturer's requirements for release. Production and testing of this three-component vaccine is complex and requires several months. No new vaccine lots may be available until sometime in February 1985. Comparison of available stocks and the quantity of DTP vaccine now being distributed with the usual national utilization of DTP vaccine indicates that, if current use patterns continue, beginning in January 1985, supplies of DTP vaccine will be very limited, and some areas may be without DTP vaccine. This situation may continue through most of 1985.

To minimize the health impact of this shortage, two major options exist– to reduce the amount of vaccine given in a particular dose and to postpone one or more doses. Because it is impossible to predict the degree of protection conferred by partial doses, this option is not recommended (1). Consequently, consideration has been given to the possibility of postponing one or more doses of the current immunization schedule, which calls for the administration of DTP vaccine at 2, 4, 6, and 18 months of age, with a fifth dose at 4-6 years of age.

With pertussis, there is a significant risk of infection in infancy and early childhood, with 2,463 cases reported in 1983 (51% of them among infants under 1 year old). Additionally, infants are more likely to suffer complications or death from pertussis than are older children. Consequently, it is critical to continue providing protection against pertussis to infants. The *Diphtheria and Tetanus Toxoids and Pertussis Vaccine. Adsorbed.

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