November 16, 2001 / Vol. 50 / No. 45 U.S. DEPARTMENT OF HEALTH & HUMAN SERVICES Coccidioidomycosis in Workers at an Archeologic Site — Dinosaur National Monument, Utah, June–July 2001 Coccidioidomycosis is a fungal infection caused by inhalation of airborne Coccidio- ides immitis spores that are present in the arid soil of the southwestern United States, California, and parts of Central and South America. Infection with C. immitis previously has not been diagnosed in patients outside these areas, except in travelers returning from areas where the disease is endemic (1 ). This report describes an outbreak of coccidioidomycosis in workers at an archeologic site in northeastern Utah during June– July, 2001, and represents the first identification of coccidioidomycosis in northern Utah. Health-care providers should consider coccidioidomycosis in the differential diagnosis for patients with compatible illness who reside in or recently have traveled to this area. Interventions to minimize soil disturbance and dust inhalation can reduce the risk for coccidioidomycosis. Dinosaur National Monument (DNM) encompasses 320 square miles in northeastern Utah and northwestern Colorado; 397,800 persons visited DNM in 2000 (Figure 1). On June 18, 2001, under the direction of National Park Service (NPS) archeologists, six student volunteers and two leaders began work at an archeologic site in DNM. Work included laying stone steps, building a retaining wall, and sifting dirt for artifacts. Peak dust exposure occurred on June 19, the day most sifting occurred. Workers did not wear protective facemasks. During June 29–July 3, all eight team members and two NPS archeologists who had worked at the site sought medical care at a local hospital emer- gency department for respiratory and systemic symptoms. All 10 persons had diffuse pulmonary infiltrates on chest radiographs; eight were hospitalized with pneumonia of unknown etiology. Pending investigation, NPS closed the work site to all visitors and staff, and the TriCounty Health Department alerted the public. On July 2, the TriCounty Health Department, the Utah Department of Health, and CDC initiated an investigation to iden- tify the risk factors, cause, and extent of the outbreak. During July 2–4, a total of 18 persons (the eight team members and 10 archeologists) with potential exposure to dust at the work site in June were interviewed using a stan- dardized questionnaire to determine symptoms and previous activities. Hospital records were reviewed to ascertain clinical information. A case was defined as an illness with onset of at least two selected symptoms (i.e., self-reported fever, difficulty breathing, and cough) after June 18 in a person working at DNM. Illness in 10 persons, including all eight team members and two NPS archeologists, met the case definition. Median age was 17 years (range: 16–29 years). Illness onset occurred during June 28–July 1. The most common symptoms included difficulty 1005 Coccidioidomycosis in Workers at an Archeologic Site 1008 Update: Investigation of Bioterrorism-Related Anthrax 1011 n-Hexane–Related Peripheral Neuropathy Among Automotive Technicians 1013 Weekly Update: West Nile Virus 1014 Update: Interim Recommendations for Antimicrobial Prophylaxis for Children and Breastfeeding Mothers and Treatment of Children with Anthrax 1016 Notices to Readers
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November 16, 2001 / Vol. 50 / No. 45
U.S. DEPARTMENT OF HEALTH & HUMAN SERVICES
Coccidioidomycosis in Workers at an Archeologic Site —Dinosaur National Monument, Utah, June–July 2001
Coccidioidomycosis is a fungal infection caused by inhalation of airborne Coccidio-ides immitis spores that are present in the arid soil of the southwestern United States,California, and parts of Central and South America. Infection with C. immitis previouslyhas not been diagnosed in patients outside these areas, except in travelers returningfrom areas where the disease is endemic (1 ). This report describes an outbreak ofcoccidioidomycosis in workers at an archeologic site in northeastern Utah during June–July, 2001, and represents the first identification of coccidioidomycosis in northern Utah.Health-care providers should consider coccidioidomycosis in the differential diagnosisfor patients with compatible illness who reside in or recently have traveled to this area.Interventions to minimize soil disturbance and dust inhalation can reduce the risk forcoccidioidomycosis.
Dinosaur National Monument (DNM) encompasses 320 square miles in northeasternUtah and northwestern Colorado; 397,800 persons visited DNM in 2000 (Figure 1). OnJune 18, 2001, under the direction of National Park Service (NPS) archeologists, sixstudent volunteers and two leaders began work at an archeologic site in DNM. Workincluded laying stone steps, building a retaining wall, and sifting dirt for artifacts. Peakdust exposure occurred on June 19, the day most sifting occurred. Workers did not wearprotective facemasks. During June 29–July 3, all eight team members and two NPSarcheologists who had worked at the site sought medical care at a local hospital emer-gency department for respiratory and systemic symptoms. All 10 persons had diffusepulmonary infiltrates on chest radiographs; eight were hospitalized with pneumonia ofunknown etiology. Pending investigation, NPS closed the work site to all visitors and staff,and the TriCounty Health Department alerted the public. On July 2, the TriCounty HealthDepartment, the Utah Department of Health, and CDC initiated an investigation to iden-tify the risk factors, cause, and extent of the outbreak.
During July 2–4, a total of 18 persons (the eight team members and 10 archeologists)with potential exposure to dust at the work site in June were interviewed using a stan-dardized questionnaire to determine symptoms and previous activities. Hospital recordswere reviewed to ascertain clinical information. A case was defined as an illness withonset of at least two selected symptoms (i.e., self-reported fever, difficulty breathing, andcough) after June 18 in a person working at DNM.
Illness in 10 persons, including all eight team members and two NPS archeologists,met the case definition. Median age was 17 years (range: 16–29 years). Illness onsetoccurred during June 28–July 1. The most common symptoms included difficulty
1005 Coccidioidomycosis in Workers at anArcheologic Site
1008 Update: Investigation of Bioterrorism-RelatedAnthrax
1013 Weekly Update: West Nile Virus1014 Update: Interim Recommendations for
Antimicrobial Prophylaxis for Children andBreastfeeding Mothers and Treatment ofChildren with Anthrax
1016 Notices to Readers
1006 MMWR November 16, 2001
Coccidioidomycosis — Continued
breathing (10), fever (10), cough (nine), fatigue (eight), shortness of breath (seven),myalgia (six), and generalized skin rash (six). All 10 persons present at the work site onJune 19 had illness that met the case definition, compared with none of the eight who didnot work that day (Fisher exact p-value=0.00002). One ill person had visited the work siteonly on June 19 and had illness onset on June 29.
Results of blood cultures from the hospitalized persons were negative for bacterialpathogens. Initial serologic tests were negative for antibodies to Francisella tularensis,Yersinia pestis, Mycoplasma species, Histoplasma capsulatum, and C. immitis. On fur-ther analysis, using serum specimens concentrated 3–5 fold in an assay that detects IgMantibodies (immunodiffusion tube precipitin), nine of the 10 acute serum specimens frompatients contained IgM antibodies to C. immitis, confirming the diagnosis of acute coccid-ioidomycosis (2 ). All hospitalized patients were treated with fluconazole. The averagelength of hospital stay was 1.5 days.
Because approximately 60% of infections with C. immitis are asymptomatic, aserosurvey of park employees was conducted during August 15–17 to identify otherinfected persons and to guide prevention and control measures (1,3 ). Of the 40 parkemployees participating in the serosurvey, three (7.5%) reported “flu-like illness” sinceJune. None of the 40 had detectable IgM or IgG antibodies to C. immitis. These resultssuggest that infection with C. immitis during the preceding 12 weeks was unlikely (2,4 ).
Investigation of the work site on July 3 revealed a desert environment with the groundcovered with bedonite, a fine, alkaline soil that can provide a conducive environment forC. immitis spores. NPS is working with the U.S. Geological Survey to conduct mycologicstudies of the soil (M. Bultman, personal communication, October 2001).
FIGURE 1. Geographic distribution of Coccidioides immitis and location of coccidioidomy-cosis outbreak — Utah, 2001
Source: U.S. Geological Survey.
Areas Where Disease isKnown to be Endemic
2001 Outbreak
X
Vol. 50 / No. 45 MMWR 1007
Coccidioidomycosis — Continued
On August 24, the state and local health departments jointly recommended that em-ployees minimize soil disturbance and dust inhalation (e.g., watering down the soil andwearing National Institute for Occupational Safety and Health [NIOSH]-approved N95respirators) at the work site to reduce their risk for C. immitis infection. During Septem-ber 24–27, four NPS employees completed work on the retaining wall and steps. Subse-quently, one developed respiratory illness consistent with coccidioidomycosis and labo-ratory evidence of acute infection (IgM and rising titer of IgG to C. immitis).
The site reopened on September 28. NPS guidelines advise DNM visitors to stay onmaintained trails to avoid raising dust or stepping on native soil. Visitors’ risk for infectionwith C. immitis should be minimal because their exposure to inhaled dust is substantiallylower than that experienced by the persons in this outbreak. However, additional mea-sures are being considered to minimize risk for visitors, including warnings to avoid thesite when wind conditions are conducive to dust exposure. Surveillance is ongoing atarea hospitals.Reported by: D Mardo, RA Christensen, N Nielson, MD, S Hutt, MHSA, Ashley Valley MedicalCenter; R Hyun, MD; J Shaffer, MA, TriCounty Health Dept, Vernal; AV Gundlapalli, MD, Univ ofUtah School of Medicine, Salt Lake City; C Barton, G Dowdle, MSPH, S Mottice, PhD, C Brokopp,DrPh, R Rolfs, MD, State Epidemiologist, Utah Dept of Health. D Panebaker, National Park Svc,US Dept of the Interior. Div of Vector-borne Infectious Diseases; Mycotic Diseases Br, Div ofBacterial and Mycotic Diseases, National Center for Infectious Diseases; Epidemiology Pro-gram Office; and EIS officers, CDC.
Editorial Note: DNM is located approximately 200 miles north of the area of Utah whereC. immitis is endemic. Soil disturbances can aerosolize C. immitis spores (arthroconidia)and result in coccidioidomycosis outbreaks (5 ). Other ground-disturbing activities, suchas construction or archeology digs, may increase the risk for infection (3,6 ). A similarpoint-source outbreak of coccidioidomycosis occurred in 1970 among archeologystudents in an area of northern California where C. immitis was not known to be endemic.In both of these outbreaks, a high attack rate of symptomatic infection was reported (7 ).
Symptoms of acute coccidioidomycosis include fever, headache, rash, muscle aches,dry cough, weight loss, and malaise. Most infections are asymptomatic or self-limitedand resolve without antimicrobial treatment in patients with healthy immune systems. Inrare instances, severe lung disease or disseminated infection can develop in patients;susceptibility is higher in immunocompromised persons, pregnant women, and personsof African or Asian descent (8 ).
Because infection with C. immitis results in long-term immunity, the coccidioidin orspherulin skin test, which detects T-cell mediated delayed-type hypersensitivity toC. immitis, is the best method to screen for past infection (3 ). However, the coccidioidinskin test is not available in the United States. Therefore, a serosurvey was used to assessfor subclinical cases of infection in this outbreak. In previous studies of asymptomaticpersons who had positive skin tests, 7% had positive serologies; the time of exposure inthose persons was unknown (4 ). The sensitivity of the serologic test is low for remotepast infection and unknown for recent asymptomatic infection (4 ). Therefore, this inves-tigation was unable to establish the prevalence of previous infection among tested NPSemployees.
In settings where coccidioidomycosis outbreaks have occurred, measures to mini-mize soil disturbance and dust inhalation reduce the risk for inhalation of C. immitisspores (3,6 ). The most recent case indicates an ongoing risk for infection at the siteassociated with this outbreak and the importance of adherence to recommendations for
1008 MMWR November 16, 2001
Coccidioidomycosis — Continued
respiratory protection (e.g., NIOSH-approved N95 respirators that are properly fittedand consistently worn) when dust exposure is unavoidable.
The outbreak in this location indicates that areas where C. immitis is endemic mayextend farther north than previously documented. Surveillance should be continued inthese areas. In addition, health-care providers should be alert for coccidioidomycosiscases in persons who reside in or have traveled to these areas and who may have beenexposed to dust from disturbed soil.References1. CDC. Coccidioidomycosis in travelers returning from Mexico—Pennsylvania, 2000. MMWR
2000;49:1004–6.2. Kaufman L, Kovacs JA, Reiss E. Clinical immunomycology. In: Rose NR, Folds JD, DeMacario
EC, et al, eds. Manual of clinical laboratory immunology. Washington, DC: American Soci-ety for Microbiology, 1997:585–604.
3. Galgiani J. Coccidioides immitis. In: Mandell GL, Bennett JE, Dolin R, eds. Principles andpractice of infectious diseases. Vol 2. Philadelphia, Pennsylvania: Churchill Livingstone,2000:2746–57.
4. Pappagianis D, Zimmer B. Serology of coccidioidomycosis. Clin Microbiol Rev 1990;3:247–68.5. CDC. Coccidioidomycosis following the Northridge earthquake—California, 1994. MMWR
1994;43:194–5.6. Fisher FS, Bultman MW, Pappagianis D. Operational guidelines for geological fieldwork in
areas endemic for coccidioidomycosis (Valley fever) [open-file report 00-348]. Reston,Virginia: US Geological Survey, 2000. Available at <http://geopubs.wr.usgs.gov/open-file/of00-348/of00-348.pdf>. Accessed October 2001.
7. Werner SB, Pappagianis D, Heindl I, Mickel A. An epidemic of coccidioidomycosis amongarchaeology students in northern California. N Engl J Med 1972;286:507–12.
8. Rosenstein NE, Emery KW, Werner SB, et al. Risk factors for severe pulmonary and dissemi-nated coccidioidomycosis: Kern County, California, 1995–1996. Clin Infect Dis 2001;32:708–15.
Update: Investigation of Bioterrorism-Related Anthrax, 2001
This report updates the investigation of bioterrorism-related anthrax and the provi-sion of antimicrobial prophylaxis to exposed persons and highlights CDC assistance toother countries investigating cases of bioterrorism-related anthrax. Since November 7,2001, CDC and state and local public health agencies have identified no new cases ofbioterrorism-related anthrax. As of November 14, a total of 22 cases of anthrax has metthe CDC case definition (1 ); 10 were confirmed inhalational anthrax, and 12 (sevenconfirmed and five suspected) were cutaneous anthrax. Investigation of a case of inhala-tional anthrax in a hospital stock room worker aged 61 years in New York City (NYC)found no evidence of anthrax contamination at the work site or home; the source ofexposure is unknown. Environmental clean-up of contaminated facilities continues, andsurveillance for new cases of bioterrorism-related anthrax is ongoing in Delaware (DE),District of Columbia (DC), Florida (FL), Maryland (MD), New Jersey (NJ), NYC, Pennsyl-vania (PA), Virginia (VA), and other states.
Use of Antimicrobial Prophylaxis
A 60-day course of antibiotics to prevent inhalational anthrax has been recommendedfor persons potentially exposed to Bacillus anthracis aerosols in FL, NJ, NYC, VA,and DC. These recommendations are for persons at risk for inhalational anthrax by1) the presence of an inhalational case at a facility (e.g., media company in FL),
Update: Investigation of Bioterrorism-Related Anthrax — Continued
2) environmental specimens positive for B. anthracis in facilities along the path of acontaminated letter in which aerosolization might have occurred (e.g., postal facilities inNYC), and 3) exposure to an air space known to be contaminated with aerosolizedB. anthracis from an opened letter (e.g., Senate office building in DC). These personsshould receive a full 60-day course of antimicrobial prophylaxis. Specific recommenda-tions by site include:
• Boca Raton, FL—prophylaxis is recommended for employees and visitors whospent >1 hour during August 1–October 6 in the American Media, Inc., building.
• New York City, NY—prophylaxis is recommended for all employees who workedduring October 9–26 on the second and third floors of the south section of theMorgan Central Postal Facility in Manhattan.
• Hamilton Township, NJ—prophylaxis is recommended for all employees andbusiness visitors (i.e., temporary postal workers, vendors, contractors, and any-one in nonpublic work sites) who were in the U.S. Postal Service Route 130Processing and Distribution Center during September 18–October 18.
• Washington, DC (Capitol Hill)—prophylaxis is recommended for persons whowere on the fifth and sixth floors of the southeast wing of the Senate Hart Buildingon October 15, from 9 a.m. to 7 p.m.
• Washington, DC—prophylaxis is recommended for all employees and businessvisitors to the nonpublic mail room of the U.S. Postal Service Processing andDistribution Center at 900 Brentwood Road during October 12–21.
• Sterling, VA—prophylaxis is recommended for all mail room employees andbusiness visitors who were at the Department of State Annex 32 mail roomfacility during October 12–22.
In addition, a 60-day course of antimicrobial prophylaxis is recommended for otherworkers with specified risks for inhalational anthrax. In some areas, local health authori-ties facilitated access to a 60-day course of antimicrobial prophylaxis for persons whohandled mail in facilities from which B. anthracis was isolated but did not have expo-sures for which antimicrobial prophylaxis is recommended (2 ). These persons maychoose or may be directed by local health authorities to discontinue antimicrobial pro-phylaxis before completing a 60-day course.
CDC Assistance to Other Countries
CDC has assisted authorities in other countries investigating cases ofbioterrorism-related anthrax. During October 12–November 13, CDC received 111 re-quests from 66 countries. Of these, 47 (42%) requests were laboratory related; 43 (39%)were general requests for bioterrorism information; 13 (12%) were for environmental oroccupational health guidelines; and eight (7%) were about developing bioterrorism pre-paredness plans. The largest proportion of requests were from Central and South America(26%). Of the 66 countries, 15 (23%) received laboratory assistance, including testing orarrangements for testing of suspected isolates at a CDC-supported laboratory or a refer-ence laboratory in another country. Forty-two (64%) countries received telephone ore-mail consultation regarding specific tests for suspected B. anthracis isolates. CDC hasconfirmed two isolates from outside the United States as B. anthracis. These isolateswere recovered from the outer surface of letters or packages sent in State Departmentpouches to the U.S. Embassy in Peru. These items were processed at the U.S. StateDepartment mail sorting facility where a case of inhalational anthrax had occurred (1 ).No cases of bioterrorism-related anthrax have been confirmed in U.S. Embassy
1010 MMWR November 16, 2001
employees or in persons from other countries. Requests for information regardingbioterrorism-related issues outside the United States should be directed to the Interna-tional Team of CDC’s Emergency Operations Center (telephone, [770] 488-7100, e-mail,[email protected]).Reported by: J Malecki, MD, Palm Beach County Health Dept, West Palm Beach; S Wiersma,MD, State Epidemiologist, Florida Dept of Health. New York City Dept of Health. E Bresnitz, MD,State Epidemiologist, G DiFerdinando, MD, New Jersey Dept of Health and Senior Svcs.P Lurie, MD, K Nalluswami, MD, Pennsylvania Dept of Health. L Hathcock, PhD, State Epidemi-ologist, Delaware Div of Public Health. L Siegel, MD, S Adams, I Walks, MD, J Davies-Coles,PhD, M Richardson, MD, District of Columbia Dept of Health. R Brechner, MD, State Epidemi-ologist, Maryland Dept of Health and Hygiene. R Stroube, MD, State Epidemiologist, VirginiaDept of Health. J Burans, US Naval Research Center Detachment, Lima, Peru. US Dept ofDefense. EIS officers, CDC.
Editorial Note: Since the previous report, all patients with bioterrorism-related anthraxwho were hospitalized have been discharged and continue to recover; no new caseshave been reported. The source of these bioterrorist attacks has not been identified, andadditional cases might occur. Public health authorities, health-care providers, andlaboratorians should remain vigilant for cases of anthrax.
Antimicrobial prophylaxis is indicated to prevent inhalational anthrax after a con-firmed or suspected aerosol exposure. Persons recommended to receive prophylaxisshould complete the 60-day regimen. Public health programs should work with health-care providers and patients to promote completion of antimicrobial prophylaxis and tomonitor the occurrence of adverse events (1 ).
CDC continues to respond to inquiries about anthrax and bioterrorism. The CDC Pub-lic Response Hotline was established to provide the public with information aboutanthrax and other biologic and chemical agents. During November 1–12, CDC receivedapproximately 4,400 calls through the hotline and to the Emergency Operations Center.The hotline is available in English (888-246-2675) and Spanish (888-246-2857). CDC alsoreceives requests for information by e-mail through the Health Alert Network(<[email protected]>), MMWR (<http://www.cdc/gov/mmwr/contact.html>), and otherpublic health communications systems.
Additional information about anthrax is available at <http://www.bt.cdc.gov>. A com-pendium of MMWR reports and recommendations related to anthrax and bioterrorismis available at <http://www.cdc.gov/mmwr>.References1. CDC. Update: Investigation of anthrax associated with intentional exposure and interim
public health guidelines, October 2001. MMWR 2001;50:889–93.2. CDC. Update: Investigation of bioterrorism-related anthrax and adverse events from anti-
microbial prophylaxis. MMWR 2001;50:973–6.
Update: Investigation of Bioterrorism-Related Anthrax — Continued
n-Hexane–Related Peripheral Neuropathy Among Automotive Technicians —California, 1999–2000
Solvents, glues, spray paints, coatings, silicones, and other products contain normal(n-) hexane, a petroleum distillate and simple aliphatic hydrocarbon. n-Hexane is anisomer of hexane and was identified as a peripheral neurotoxin in 1964 (1 ). Since then,many cases of n-hexane–related neurotoxicity have occurred in printing plants, sandalshops, and furniture factories in Asia, Europe, and the United States (2 ). This reportdescribes an investigation of n-hexane–associated peripheral neuropathy in an automo-tive technician, an occupation in which this condition has not been reported, and summa-rizes the results of two other case investigations in the automotive repair industry. Thefindings suggest that solvent manufacturers should avoid using hexane when producingautomotive degreasing products, and automotive technicians should avoid regular con-tact with hexane-based cleaning solvents.
In December 1998, the California Department of Health Services (CDHS) received areport from an occupational-medicine physician of a patient with peripheral neuropathyassociated with occupational exposure to n-hexane at an automotive repair facility. Theindex patient was a 24-year-old male automotive technician who had worked in theindustry during June 1995–April 1997. In January 1997, numbness and tingling devel-oped in his hands and feet then spread proximally to his forearms and waist. In March, aneurologic evaluation revealed bilaterally diminished reflexes of the biceps, patellar, andAchilles’ deep tendon. Vibration and pinprick sensations were reduced from the lowerthird of the forearms and downward from the waist; the result of his Romberg test waspositive. Tests evaluating his metabolic and thyroid function; urinary cadmium, arsenic,lead, and mercury levels; and central nervous system imaging were normal; however,nerve conduction velocity studies revealed a subacute progressive mixed motor-sensory neuropathy with distal nerve involvement. He had reported using from one tonine 15-oz. aerosol cans of brake cleaner per day during the 22 months of his employ-ment. This brake cleaner contained 50%–60% hexane (composed of 20%–80%n-hexane), 20%–30% toluene, and 1%–10% each of methyl ethyl ketone (MEK), acetone,isopropanol, methanol, and mixed xylenes. The technician sprayed the product on brakes,tools, small spills, and engine surfaces. He occasionally used a rag. He reported wearinglatex gloves daily and drinking alcohol occasionally. His condition improved with cessa-tion of n-hexane exposure; however, he continues to have paresthesias in the hands and feet.
To assess the possible occurrence of n-hexane–related peripheral neuropathy atother automotive repair facilities, during 1999, CDHS screened for n-hexane–relatedperipheral neuropathy at a local automotive dealership that used an aerosol productcontaining 1%–5% n-hexane and 2% MEK. This facility was chosen for convenience andthe employees’ willingness to participate. A case of n-hexane–related peripheral neur-opathy was defined as symptoms and results of nerve conduction velocity tests consis-tent with peripheral neuropathy in an automotive technician who had chronic occupa-tional exposure to hexane-containing solvents and no other explanation for peripheralneuropathy. Screening included a medical history, an exposure questionnaire, physicaland neurologic examinations, nerve conduction velocity studies, and neurophysiologictesting for cognitive and motor function, reaction time, and color vision. At CDC’sNational Institute for Occupational Safety and Health (NIOSH), recent exposure ton-hexane was estimated by measuring 2,5-hexanedione (2,5-HD), a urinary metabolite,in acid-hydrolyzed urine samples. Air samples were not tested because managementhad removed the hexane-containing solvent from the facility at the onset of the investigation.
1012 MMWR November 16, 2001
n-Hexane-Related Peripheral Neuropathy — Continued
Six (40%) of 15 technicians from this facility participated in the screening. All partici-pants had worked >20 years as technicians; one met the case definition for n-hexane–related peripheral neuropathy. Three of the six had detectable 2,5-HD levels, which were7.0%, 26.0%, and 6.4% of the biologic exposure index (BEI) of 5 mg 2,5-HD/g creatinine.The BEI is a biomarker that correlates to the American Conference of GovernmentalIndustrial Hygienists’ 8-hour threshold limit value (ACGIH TLV) of 50 ppm (3 ). The expo-sure values identified are considered acceptable by this standard.
During August 2000, CDHS surveyed California neurologists* to identify additionalcases of n-hexane–related peripheral neuropathy and to determine whether exposurehad occurred among persons while working in automotive repair facilities. A total of58 (20%) of 291 neurologists responded to the survey. One automotive technician wasidentified with n-hexane–related peripheral neuropathy. CDHS reviewed the medicalrecords and verified that the technician met the case definition for n-hexane–relatedperipheral neuropathy.
In July 2000, CDHS guidelines were published outlining the diagnosis and manage-ment of n-hexane–related peripheral neuropathy (4 ). The guidelines and notification ofthe identified cases were distributed to the Association of California Neurologists and tomembers of the Association of Occupational and Environmental Clinics. The northernCalifornia district of the International Association of Machinists and the California MotorCar Dealer Association also were notified.Reported by: R Harrison, MD, L Israel, DO, P Larabee, MD, Dept of Medicine, Univ of California,San Francisco; J Cone, MD, C Baker, MPH, M Brewer, R Das, MD, S Brumis, MPH, OccupationalHealth Br, California Dept of Health Svcs; R Bowler, PhD, San Francisco State Univ; MP Wilson,MPH, SK Hammond, PhD, School of Public Health, Univ of California, Berkeley. Div of AppliedResearch and Technology, National Institute for Occupational Safety and Health; and an EISOfficer, CDC.
Editorial Note: The three cases of peripheral neuropathy described in this report arerelated to occupational exposure to n-hexane among automotive technicians. Hexane-containing degreasing products are used in automotive repair facilities and usually aredispensed in an aerosol spray. Inhalation is the primary exposure route. Dermal exposurealso may occur, and latex gloves provide ineffective protection from organic solvents.The neurotoxic effects of n-hexane may be intensified when used with other chemicalsfound in automotive degreasers (e.g., acetone, MEK, and isopropanol) (5 ). Acid-hydrolyzed urinary levels of 2,5-HD, sampled at the end of a shift, correlate with workplaceconcentrations of n-hexane. Because 2,5-HD has a half-life of 13–14 hours, accumulationmay occur during the workweek (6 ).
Chronic n-hexane exposure produces a gradual sensorimotor neuropathy withdemyelinating features. The most common initial complaint is numbness and tingling ofthe toes and fingers; a progressive loss of motor function may develop. Chronic poly-neuropathy with demyelinating features also is associated with other underlying condi-tions. Other causes of peripheral neuropathy should be considered when evaluatingpersons with possible n-hexane–related peripheral neuropathy. Removal from n-hexaneexposure is the only known treatment for n-hexane–related neurotoxicity.
The prognosis for n-hexane neuropathy generally is favorable, but recovery maytake months to years, depending on disease severity. The current Occupational Safetyand Health Administration permissible exposure limit (PEL) for n-hexane, adopted in
*List generated by Dun and Bradstreet directory (June–August 2000). Standard IndustryCode 8011-6107.
Vol. 50 / No. 45 MMWR 1013
n-Hexane–Related Peripheral Neuropathy — Continued
1971, is 500 ppm in air. NIOSH established a recommended PEL of 50 ppm in 1989; thePEL for ACGIH TLV and California are 50 ppm (7 ).
Other cases of n-hexane–related peripheral neuropathy may be occurring in thisindustry, but the nature of these exposures and the extent of illness are unknown. Themethods used to identify the cases in this report were not intended to represent allautomotive repair facilities. An exposure assessment and additional case ascertainmentare in progress. Cases of n-hexane–related neuropathy in the automotive repair industrycould be prevented through reformulation of hexane-containing products and greateruse of aqueous cleaning systems.References1. Yamada S. An occurrence of polyneuritis by n-hexane in the polyethylene laminating plants.
Jpn J Ind Health 1964;6:192.2. Arlien-Soborg P. Solvent neurotoxicology. Boca Raton, Florida: CRC Press, 1992:155–83.3. American Conference of Governmental Industrial Hygienists. 2000 TLVs® and BEIs®: thresh-
old limit values for chemical substances and physical agents and biological exposureindices. Cincinnati, Ohio: American Conference of Governmental Industrial Hygienists, 2000.
4. Hazard Evaluation System and Information Service. Medical guidelines: n-hexane, July2000. Available at <http://www.dhs.ca.gov/ohb/HESIS/nhexane.htm>. Accessed November 2001.
5. Ralston W, Hilderbrand R, Uddin D, Andersen M, Gardier R. Potentiation of 2,5-hexanedioneneurotoxicity by methyl ethyl ketone. Toxicol Appl Pharmacol 1985;81:319–27.
6. Perbellini L, Mozzo P, Brugnone F, Zedde A. Physiologico-mathematical model for studyinghuman exposure to organic solvents: kinetics of blood/tissue n-hexane concentrationsand of 2,5-hexanedione in urine. Br J Ind Med 1986;43:760–8.
7. Lanska DJ. Limitations of occupational air contaminant standards, as exemplified by theneurotoxin n-hexane. J Pub Health Policy 1999;20:441–58.
Weekly Update: West Nile Virus Activity —United States, November 7–13, 2001
The following report summarizes West Nile virus (WNV) surveillance data reported toCDC through ArboNET and verified by states and other jurisdictions as of November 13, 2001.
During the week of November 7–13, three human cases of WNV encephalitis ormeningitis were reported from New York (two) and Louisiana (one). During the sameperiod, WNV infections were reported in 266 crows, 15 other birds, and six horses. A totalof 17 WNV-positive mosquito pools were reported from two jurisdictions (Pennsylvaniaand District of Columbia).
During 2001, a total of 45 human cases of WNV encephalitis or meningitis has beenreported from New York (12), Florida (10), Connecticut (six), Maryland (six), New Jersey(six), Pennsylvania (three), Georgia (one), and Louisiana (one). Among these 45 cases,24 (53%) were in men; the median age was 70 years (range: 36–90 years); dates ofillness onset ranged from July 13 to October 7; three persons died. A total of 4,517 crowsand 1,474 other birds with WNV infection was reported from 26 states and the District ofColumbia (Figure 1); 176 WNV infections in other animals (all horses) were reported from14 states (Alabama, Connecticut, Florida, Georgia, Indiana, Kentucky,Louisiana, Massachusetts, Mississippi, New York, North Carolina, Pennsylvania, Tennes-see, and Virginia). During 2001, 753 WNV-positive mosquito pools were reported from15 states (Connecticut, Florida, Georgia, Illinois, Kentucky, Maryland, Massachusetts,Michigan, New Hampshire, New Jersey, New York, Ohio, Pennsylvania, Rhode Island,and Virginia) and the District of Columbia.
Weekly Update: West Nile Virus Activity — Continued
Additional information about WNV activity is available at <http://www.cdc.gov/ncidod/dvbid/westnile/index.htm> and <http://cindi.usgs.gov/hazard/event/west_nile/west_nile.html>.
Notice to Readers
Update: Interim Recommendations for Antimicrobial Prophylaxisfor Children and Breastfeeding Mothersand Treatment of Children with Anthrax
Ciprofloxacin or doxycycline is recommended for antimicrobial prophylaxis and treat-ment of adults and children with Bacillus anthracis infection associated with the recentbioterrorist attacks in the United States. Amoxicillin is an option for antimicrobial prophy-laxis for children and pregnant women and to complete treatment of cutaneous diseasewhen B. anthracis is susceptible to penicillin, as is the case in the recent attacks (1–3 ).Use of ciprofloxacin or doxycycline might be associated with adverse effects in children(4,5 ), and liquid formulations of these drugs are not widely available. This notice pro-vides further information about prophylaxis and treatment of children and breastfeedingmothers, including the use of amoxicillin.
Ciprofloxacin, doxycycline, and penicillin G procaine have been effective as antimi-crobial prophylaxis for inhalational B. anthracis infection in nonhuman primates and areapproved for this use in humans by the Food and Drug Administration (FDA) (5,6 ).Amoxicillin has not been studied in animal models and is not approved by FDA for the
FIGURE 1. Areas reporting West Nile virus (WNV) activity — United States, 2001*
* As of November 13, 2001.† Mississippi reported WNV infection only in a horse.
Human WNV Encephalitis or Meningitis and Animal WNV Activity
prophylaxis or treatment of anthrax. Other data indicate that B. anthracis strains pro-duce a cephalosporinase and suggest that the strains contain an inducible beta-lactamasethat might decrease the effectiveness of penicillins, especially when a large number oforganisms is present (2 ). In addition, penicillin achieves low intracellular concentrationsthat might be detrimental to its ability to kill germinating spores in macrophages.
Because of these concerns, penicillins (including amoxicillin) are not recommendedfor initial treatment of anthrax, but are likely to be effective for antimicrobial prophylaxisfollowing exposure to B. anthracis, a setting where relatively few organisms areexpected to be present. Therefore, amoxicillin* may be used for the 60-day antimicrobialprophylaxis in infants and children when the isolate involved in the exposure is deter-mined to be susceptible to penicillin. Isolates of B. anthracis implicated in the recentbioterrorist attacks are susceptible to ciprofloxacin, doxycycline, and penicillin (2 ).
Initial treatment of infants and children with inhalational or systemic (including gas-trointestinal or oropharyngeal) anthrax should consist of intravenous ciprofloxacin† ordoxycyline§, plus one or two additional antimicrobial¶ agents. If meningitis is suspected,ciprofloxacin might be more effective than doxycycline because of better central ner-vous system penetration (2 ). Experience with fluoroquinolones other than ciprofloxacinin children is limited.
Ciprofloxacin or doxycycline should be the initial treatment of localized cutaneousanthrax in infants and children. Intravenous therapy with multiple antimicrobial agents isrecommended for cutaneous anthrax with systemic involvement, extensive edema, orlesions on the head or neck (2 ). Whether infants and young children are at increased riskfor systemic dissemination of cutaneous infection is not known; a 7-month-old patientinfected during the recent bioterrorism attacks developed systemic illnessafter onset of cutaneous anthrax (7 ). For young children (e.g. aged <2 years), initialtherapy of cutaneous anthrax should be intravenous, and combination therapy withadditional antimicrobials should be considered.
After clinical improvement following intravenous treatment for inhalational or cuta-neous anthrax, oral therapy with one or two antimicrobial agents (including either cipro-floxacin or doxycycline) may be used to complete the first 14–21 days of treatment forinhalational anthrax or the first 7–10 days for uncomplicated cutaneous anthrax. Theoptimal oral treatment regimen is unknown; some adults with inhalationalanthrax as a result of the recent bioterrorist attacks are receiving ciprofloxacin andrifampin. For both inhalational and cutaneous anthrax in the setting of this bioterroristattack, antimicrobial therapy should be continued for 60 days because of the likelihood ofexposure to aerosolized B. anthracis and the need to protect against persistent sporesthat might germinate in the respiratory tract. Because of potential adverse effects ofprolonged use of ciprofloxacin or doxycycline in children, amoxicillin is an option forcompletion of the remaining 60 days of therapy for persons infected in these bioterroristattacks.
Notices to Readers — Continued
*The recommended dose of amoxicillin is 80 mg/kg/day orally divided every 8 hours (maximum500 mg/dose).
† The recommended dose of ciprofloxacin is 10 mg/kg/dose every 12 hours intravenously(maximum 400 mg/dose) or 15 mg/kg/dose every 12 hours orally (maximum 500 mg/dose).
§ The recommended dose of doxycycline is 2.2 mg/kg/dose every 12 hours intravenously ororally (maximum 100 mg/dose).
¶ Options for additional drugs, based on in vitro sensitivity testing of isolates in the recentattacks, include rifampin, vancomycin, penicillin, ampicillin, chloramphenicol, imipenem,clindamycin, and clarithromycin (2 ).
1016 MMWR November 16, 2001
Because of its known safety for infants, amoxicillin is an option for antimicrobialprophylaxis in breastfeeding mothers when B. anthracis is known to be penicillin-susceptible and no contraindication to maternal amoxicillin use is indicated. The Ameri-can Academy of Pediatrics also considers ciprofloxacin and tetracyclines (which includedoxycycline) to be usually compatible with breastfeeding because the amount of eitherdrug absorbed by infants is small, but little is known about the safety of long-term use (8 ).Mothers concerned about the use of ciprofloxacin or doxycycline for antimicrobial pro-phylaxis should consider expressing and then discarding breast milk so that breastfeedingcan be resumed when antimicrobial prophylaxis is completed. Decisions about antimi-crobial choice and continuation of breastfeeding should be made by the mother and herand the infant’s health-care providers. Consideration should be given to antimicrobialefficacy, safety for the infant, and the benefits of breastfeeding.
Health-care providers prescribing antimicrobial drugs for the prophylaxis or treat-ment of anthrax should be aware of their adverse effects and consult with an infectiousdisease specialist as needed. Additional information about recognition, prophylaxis, andtreatment of anthrax infection is available at <http://www.bt.cdc.gov>.References1. CDC. Update: investigation of anthrax associated with intentional exposure and interim
public health guidelines, October 2001. MMWR 2001;50:889–93.2. CDC. Update: investigation of bioterrorism-related anthrax and interim guidelines for
exposure management and antimicrobial therapy, October 2001. MMWR 2001;50:909–19.3. CDC. Updated recommendations for antimicrobial prophylaxis among asymptomatic preg-
nant women after exposure to Bacillus anthracis. MMWR 2001;50:960.4. Bayer Corporation. Ciprofloxacin®. In: Physicians desk reference. Montvale, New Jersey:
Medical Economics Company, 2000:678–83.5. Food and Drug Administration. Prescription drug products; Doxycycline and Penicillin G
Procaine administration for inhalational anthrax (post-exposure). Federal Register 2001;66:55679.6. Friedlander AM, Welkos SL, Pitt MLM, et al. Postexposure prophylaxis against experimental
inhalation anthrax. J Infect Dis 1993;167:1239–43.7. Roche KJ, Chang MW, Lazarus H. Cutaneous anthrax infection: images in clinical medicine.
N Engl J Med 2001. Available at <http://www.nejm.org>. Accessed November 6, 2001.8. American Academy of Pediatrics Committee on Drugs. The transfer of drugs and other
chemicals into human milk. Pediatrics. 2001;108:776–89.
Notice to Readers
Reducing the Risk for Injury While Traveling for Thanksgiving Holidays
Each year in the United States, motor-vehicle crashes result in approximately 40,000deaths (1 ) and 3.2 million nonfatal injuries (2 ). In 2000 during the Thanksgiving holiday,motor-vehicle crashes killed approximately 500 persons (US Department of Transporta-tion, National Highway Traffic Safety Administration, unpublished data, 2000), and re-sulted in >43,000 hospital emergency department visits (2 ). Following are steps thatmight prevent many of these deaths and injuries:
• Wear safety belts at all times. Safety-belt use is the single most effective meansof reducing fatal and nonfatal injuries in motor-vehicle crashes. Although safetybelts reduce the risk for death by approximately 45%–60%, three out of 10 U.S.adults do not routinely use them. Effective interventions to increase safety-belt
use include safety-belt laws, primary enforcement laws, and enhanced enforcementprograms (3 ).
• Place children in age appropriate restraints. Infants should be placed in rear-facing child safety seats (CSSs) until they are at least age 1 year and 20–22 lbs.Older children, up to 40 lbs., are safest in forward facing convertible CSSs. School-aged children who have outgrown convertible CSSs should be placed in a boosterseat until they fit in a car safety belt alone. Effective interventions to increase CSSuse include child safety seat use laws, communitywide information plusenhanced enforcement campaigns, CSS distribution plus education programs,and incentive plus education programs that reward parents or children forcorrectly using CSSs (4 ).
• Place all children aged <12 years in the back seat. This eliminates the injury riskfor deployed passenger-side airbags and places the child in the safest part of thevehicle in a crash. It is particularly important not to place infants in the front of anairbag. Riding in the back seat is associated with at least a 30% reduction in therisk for fatal injury (5 ).
• Never drink and drive. More than 16,000 (73%) traffic deaths each year areassociated with alcohol use (6 ). Effective interventions to reduce alcohol-impaired driving include 0.08% blood alcohol concentration (BAC) laws, lowerBAC laws for young or inexperienced drivers, minimum legal drinking age laws,sobriety checkpoints, and server intervention programs that involve face-to-faceinstruction and management support (7 ).
Additional information is available at <http://www.cdc.gov/ncipc>.References1. CDC. National Center for Health Statistics. Annual mortality tapes. Hyattsville, Maryland:
US Department of Health and Human Services, 1999.2. CDC. Data from the National Electronic Injury Surveillance System-All Injury Program oper-
ated by the US Consumer Product Safety Commission. Atlanta, Georgia: US Department ofHealth and Human Services, CDC, National Center for Injury Prevention and Control, 2001.
3. Dinh-Zarr TB, Sleet DA, Shults RA, et al. Reviews of evidence regarding interventions toincrease the use of safety belts. Am J Prev Med 2001;21:48–65.
4. Zaza S, Sleet DA, Thompson RS, et al. Reviews of evidence regarding interventions toincrease use of child safety seats. Am J Prev Med 2001;21:31–47.
5. Braver ER, Whitfield R, Ferguson SA. Seating position and children’s risk of dying in motorvehicle crashes. Injury Prev 1998;4:181–7.
6. National Highway Traffic Safety Administration. Traffic safety facts 1999: alcohol. Wash-ington, DC: US Department of Transportation, National Highway Traffic Safety Administra-tion, 2000; publication no. DOT HS 809 086.
7. Shults RA, Elder RW, Sleet DA, et al. Reviews of evidence regarding intervention to reducealcohol-impaired driving. Am J Prev Med 2001;21:66–88.
CDC and Emory University’s Rollins School of Public Health will co-sponsor a course,“Epidemiology in Action: Intermediate Methods” during February 25–March 1, 2002, atEmory University. The course is designed for practicing public health professionals whohave had training and experience in basic applied epidemiology and would like training inadditional quantitative skills related to analysis and interpretation of epidemiologic data.
The course will review the fundamentals of descriptive epidemiology and biostatis-tics, measures of association, normal and binomial distributions, confounding, statisticaltests, stratification, logistic regression, models, and computers as used in epidemiology.Prerequisite is an introductory course in epidemiology, such as Epidemiology in Action,International Course in Applied Epidemiology or any other introductory class. There is atuition charge.
Deadline for applications is January 15. Additional information and applications areavailable from Emory University, International Health Dept.(Pia), 1518 Clifton Road, N.E.,Room 746, Atlanta, GA 30322; telephone (404) 727-3485; fax (404) 727-4590; or [email protected].
Vol. 50 / No. 45 MMWR 1019
FIGURE I. Selected notifiable disease reports, United States, comparison ofprovisional 4-week totals ending November 10, 2001, with historical data
* No rubella cases were reported for the current 4-week period yielding a ratio for week 45 ofzero (0).
† Ratio of current 4-week total to mean of 15 4-week totals (from previous, comparable, andsubsequent 4-week periods for the past 5 years). The point where the hatched area beginsis based on the mean and two standard deviations of these 4-week totals.
TABLE I. Summary of provisional cases of selected notifiable diseases,United States, cumulative, week ending November 10, 2001 (45th Week)*
human monocytic (HME)† 76 Streptococcal disease, invasive, group A 3,208Encephalitis: California serogroup viral† 93 Streptococcal toxic-shock syndrome† 42
-:No reported cases. *Incidence data for reporting year 2001 are provisional and cumulative (year-to-date). † Not notifiable in all states. § Updated monthly from reports to the Division of HIV/AIDS Prevention — Surveillance and Epidemiology, National Center for HIV,
STD, and TB Prevention (NCHSTP). Last updated October 30, 2001. ¶ Updated from reports to the Division of STD Prevention, NCHSTP.
DISEASE DECREASE INCREASECASES CURRENT
4 WEEKS
Ratio (Log Scale)†
Beyond Historical Limits
4210.50.250.125
394
338
51
84
1
63
14
249
0
Hepatitis A
Hepatitis B
Hepatitis C; Non-A, Non-B
Legionellosis
Measles, Total
Mumps
Pertussis
Rubella
Meningococcal Infections
*
0.06250.03125
1020 MMWR November 16, 2001
TABLE II. Provisional cases of selected notifiable diseases, United States,weeks ending November 10, 2001, and November 11, 2000 (45th Week)*
Guam 12 13 - 438 - - N N U UP.R. 1,021 1,133 2,193 U - - 1 6 U UV.I. 2 31 53 - - - - - U UAmer. Samoa 1 - U U U U U U U UC.N.M.I. - - 111 U - U - U U U
N: Not notifiable. U: Unavailable. -: No reported cases. C.N.M.I.: Commonwealth of Northern Mariana Islands.* Incidence data for reporting year 2001 are provisional and cumulative (year-to-date). Incidence data for reporting year 2000 are finalized and
cumulative (year-to-date).† Individual cases can be reported through both the National Electronic Telecommunications System for Surveillance (NETSS) and the Public
Health Laboratory Information System (PHLIS).§ Chlamydia refers to genital infections caused by C. trachomatis.¶ Updated monthly from reports to the Division of HIV/AIDS Prevention — Surveillance and Epidemiology, National Center for HIV, STD, and
TB Prevention. Last updated October 30, 2001.
Vol. 50 / No. 45 MMWR 1021
TABLE II. (Cont’d) Provisional cases of selected notifiable diseases, United States,weeks ending November 10, 2001, and November 11, 2000 (45th Week)*
Reporting Area
N: Not notifiable. U: Unavailable. - : No reported cases.* Incidence data for reporting year 2001 are provisional and cumulative (year-to-date). Incidence data for reporting year 2000 are finalized and
Guam - 2 - - - 24 U UP.R. 4 5 83 71 510 597 U UV.I. - - - - - - U UAmer. Samoa U U U U U U U UC.N.M.I. - U - U 14 U U U
N: Not notifiable. U: Unavailable. -: No reported cases.* Incidence data for reporting year 2001 are provisional and cumulative (year-to-date). Incidence data for reporting year 2000 are finalized and
cumulative (year-to-date).† Individual cases can be reported through both the National Electronic Telecommunications System for Surveillance (NETSS) and the Public
Health Laboratory Information System (PHLIS).
TABLE II. (Cont’d) Provisional cases of selected notifiable diseases, United States,weeks ending November 10, 2001, and November 11, 2000 (45th Week)*
Vol. 50 / No. 45 MMWR 1023
TABLE II. (Cont’d) Provisional cases of selected notifiable diseases, United States,weeks ending November 10, 2001, and November 11, 2000 (45th Week)*
Guam - 36 U U - 3 - 47P.R. 8 33 U U 240 141 76 135V.I. - - U U - - - -Amer. Samoa U U U U U U U UC.N.M.I. 7 U U U 10 U 31 UN: Not notifiable. U: Unavailable. -: No reported cases.* Incidence data for reporting year 2001 are provisional and cumulative (year-to-date). Incidence data for reporting year 2000 are finalized and
cumulative (year-to-date).† Individual cases can be reported through both the National Electronic Telecommunications System for Surveillance (NETSS) and the Public
Health Laboratory Information System (PHLIS).
1024 MMWR November 16, 2001
N: Not notifiable. U: Unavailable. - : No reported cases.* Incidence data for reporting year 2001 are provisional and cumulative (year-to-date). Incidence data for reporting year 2000 are finalized and
cumulative (year-to-date).† For imported measles, cases include only those resulting from importation from other countries.§ Of 240 cases among children aged <5 years, serotype was reported for 117, and of those, 20 were type b.
TABLE III. Provisional cases of selected notifiable diseases preventableby vaccination, United States, weeks ending November 10, 2001,
Guam - 1 - 1 - 10 U - U - - -P.R. 1 4 119 228 173 255 - - - - - 2V.I. - - - - - - U - U - - -Amer. Samoa U U U U U U U U U U U UC.N.M.I. - U - U 32 U U - U - - U
Guam - - U - 14 U - 4 U - 1P.R. 4 9 - - - - 2 9 - - -V.I. - - U - - U - - U - -Amer. Samoa U U U U U U U U U U UC.N.M.I. - U U - U U - U U - U
N: Not notifiable. U: Unavailable. - : No reported cases.* Incidence data for reporting year 2001 are provisional and cumulative (year-to-date). Incidence data for reporting year 2000 are finalized and
cumulative (year-to-date).
1026 MMWR November 16, 2001
TABLE IV. Deaths in 122 U.S. cities,* week endingNovember 10, 2001 (45th Week)
W.N. CENTRAL 644 445 126 45 21 7 49Des Moines, Iowa U U U U U U UDuluth, Minn. U U U U U U UKansas City, Kans. 38 25 7 5 1 - 1Kansas City, Mo. 94 63 17 8 3 3 17Lincoln, Nebr. 44 30 9 4 1 - 4Minneapolis, Minn. 170 126 30 7 6 1 17Omaha, Nebr. 99 72 16 5 4 2 4St. Louis, Mo. 93 54 23 11 4 1 1St. Paul, Minn. U U U U U U UWichita, Kans. 106 75 24 5 2 - 5
U: Unavailable. -:No reported cases.* Mortality data in this table are reported voluntarily from 122 cities in the United States, most of which have populations of >100,000. 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 this Pennsylvania city, these numbers are partial counts for the current week. Complete
counts will be available in 4 to 6 weeks.¶ Total includes unknown ages.
Contributors to the Production of the MMWR (Weekly)
Weekly Notifiable Disease Morbidity Data and 122 Cities Mortality Data
Samuel L. Groseclose, D.V.M., M.P.H.Wayne S. Brathwaite
State Support Team CDC Operations TeamRobert Fagan Carol M. KnowlesJose Aponte Deborah A. AdamsGerald Jones Willie J. AndersonDavid Nitschke Lateka M. DammondScott Noldy Patsy A. HallJim Vaughan Mechele A. HesterCarol A. Worsham Felicia J. Connor
Pearl Sharp
Informatics
T. Demetri Vacalis, Ph.D.
Michele D. Renshaw Erica R. Shaver
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IU.S. Government Printing Office: 2002-733-100/49025 Region IV
Director, Centers for DiseaseControl and Prevention
Jeffrey P. Koplan, M.D., M.P.H.
Deputy Director for Science andPublic Health, Centers for DiseaseControl and Prevention
David W. Fleming, M.D.
Director,Epidemiology Program Office
Stephen B. Thacker, M.D., M.Sc.
Editor, MMWR SeriesJohn W. Ward, M.D.
Acting Managing Editor, MMWR(Weekly)
Teresa F. Rutledge
Writers-Editors, MMWR (Weekly)Jill CraneDavid C. Johnson