As part of its commemoration of CDC’s 50th anniversary, MMWR is reprinting

selected MMWR articles of historical interest to public health, accompanied by a current editorial note.

Reprinted below is the report published April 24, 1992, which first described

the need for information on the economic and social impact of disease- and injuryprevention strategies, followed by a contemporary editorial note.

Effectiveness in Disease and Injury Prevention

Public Health Focus:

Effectiveness of Disease and Injury Prevention

Prevention — Continued Public health practice is based on scientifically sound strategies for improving the

quality of life and reducing morbidity and premature mortality. To maximize the health

benefits of available resources, public health decision-makers require information on

the effectiveness, as well as the economic and social impact, of disease and injury

prevention strategies (1 ). This report introduces a monthly series of articles to be published in MMWR (weekly) that highlight prevention effectiveness.

The development of prevention technology begins with researchers in the basic

public health and biomedical sciences identifying potentially effective technologies

that can be used to reduce unnecessary morbidity and premature mortality. Applied

research under carefully controlled conditions may then determine whether such

techniques are efficacious (e.g., the effect of smoking cessation on lung cancer). As

these techniques are applied at the community level, their impact and cost can be

assessed first in demonstration settings and then in routine community settings, and

improvements in techniques can then be incorporated into prevention strategies.

Important considerations in the assessment of disease and injury prevention

strategies (i.e., the scientific method for evaluating the effectiveness of prevention

strategies) include

• identification of efficacious and effective strategies to reduce morbidity and premature mortality and improve the quality of life;

• characterization of the social, legal, and ethical impact of these strategies;

• estimation of the economic impact of prevention strategies;

TM

January 31, 1997 / Vol. 46 / No. 4

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES / Public Health Service

73 Public Health Focus: Effectiveness

of Disease and Injury Prevention

76 Update: Influenza Activity —

United States, 1996–97 Season

79 Paralytic Poliomyelitis —United States,

1980–1994

83 Legionnaires Disease Associated

with a Whirlpool Spa Display — 

Virginia, September–October, 1996

87 Child Passenger Safety Awareness

Week — February 9–15, 1997

88 Quarterly Immunization Table
• determination of optimal methods for implementing those strategies; and

• evaluation of the health impact of prevention programs.

Each report in the monthly series will highlight the knowledge base regarding a

specific prevention strategy and will address related considerations, including efficacy, effectiveness, safety, and economic factors. Topics have been selected based on

their inclusion in the national health objectives for the year 2000 (2 ), CDC and other

public health program efforts, and the availability of data. In particular, the reports will

present specific examples of disease and injury prevention strategies and illustrate

approaches to evaluating the effectiveness of such strategies.

Reported by: Office of Program Planning and Evaluation, Office of the Director; Office of the

Director, Epidemiology Program Office, CDC.

Editorial Note: Public health officials and policy-makers at all levels require a scientific

framework for assessing the effectiveness of disease and injury prevention as a basis

for establishing priorities, selecting prevention strategies, and allocating resources.

The success of prevention activities can be defined by whether they delay or avert

morbidity and mortality. However, the ability to evaluate objectively many prevention

techniques with randomized controlled trials is often limited by fiscal, ethical, or other

constraints. The MMWR Recommendations and Reports issue, “A Framework for

Assessing the Effectiveness of Disease and Injury Prevention” (1 ), focuses on the

challenges of assessment that arise as a consequence of these constraints. Reports in

the MMWR (weekly) series will describe examples of how prevention effectiveness

can be assessed.

Because public health programs sometimes may begin to implement preventive

measures before appropriate assessments are completed, gaps may exist in knowledge of the efficacy, effectiveness, safety, or economic impact of specific prevention

strategies. The series of reports in MMWR (weekly) will characterize many of these

gaps and describe how they have been addressed. In addition, the reports in this

series are intended to 1) provide decision-makers with information about the potential

impact of these interventions on the health of their communities; 2) suggest

approaches suitable for adaptation to public health practice; and 3) encourage further

examination of these topics and stimulate additional systematic efforts by public

health professionals to assess and enhance the effectiveness of public health

programs.

References

1. CDC. A framework for assessing the effectiveness of disease and injury prevention. MMWR

1992;41(no. RR-3).

2. Public Health Service. Healthy people 2000: national health promotion and disease prevention

objectives—full report, with commentary. Washington, DC: US Department of Health and

Human Services, Public Health Service, 1991; DHHS publication no. (PHS)91-50212.

Editorial Note—1997: Since the initiation of the series of articles (1–7 ) and publication

of the MMWR Recommendations and Reports (8 ) on prevention effectiveness, the

concepts have been institutionalized as a public health science at CDC and many other

organizations in the public health community. Public health programs traditionally

have been accountable for their effectiveness and have had to exist within resource

constraints. Choices among competing priorities and intervention strategies have

been and will continue to be made regardless of the information available. Prevention

effectiveness integrates the best available information into the value of those choices.

74 MMWR January 31, 1997

Prevention — Continued
The prevention-effectiveness initiative has helped to catalyze the integration of the

principles of evidence-based medicine (9 ) into public health. A central feature of this

approach is the focus on health outcomes. By examining the links between interventions, intermediate impacts, and health outcomes, synthetic analyses can be developed as tools to assist in selecting the best intervention strategies. These tools assist

in clarifying the objectives, the strategies available to achieve those objectives, the

logic of the causal pathways, and the evidence that supports the links in those pathways. In addition to facilitating understanding of problems and potential solutions,

these tools provide a basis for developing practice guidelines (10 ) and, in the future,

adapting those guidelines to communities with differing demographics, risk profiles,

and health concerns (11 ).

Public health uses clinical interventions as well as behavioral, environmental, and

social approaches. Many of the prevention-effectiveness methods that have been

applied in the clinical arena (e.g., decision analyses and economic evaluations as

applied to technology assessments, outcomes research, and health services research)

needed to be adapted to public health. Recommendations for comparable methods

for decision modeling and analysis and economic evaluation in public health are now

available (12,13 ). These standards for analysis assure policymakers that studies conducted in accordance with these principles are reliable and comparable.

The need to spend limited health-care resources more efficiently is generally accepted. Managed-care and public health partners now routinely explore the broadest

range of community-based intervention strategies to improve the health of the populations they serve. The tools of prevention effectiveness provide decision-makers with

critical information necessary for improving decision-making to weigh along with ethics, feasibility, and the distribution of costs and benefits to different populations. For

example, policy discussions on the fortification of food with folic acid to reduce neural

tube defects used economic evaluations to compare the costs, benefits, and hazards

associated with fortifying foods with different levels of folic acid, with diet supplementation, or with no intervention (14 ).

Since 1992, CDC has increased substantially its capability in prevention effectiveness through courses, postdoctoral fellowships, routine use of economic evaluations

(cost-effectiveness and cost-benefit and cost-utility analyses), and the development of

comparable methodologies (11 ). For example, a recent study of the cost-effectiveness

of antibiotics for the treatment of chlamydia cervicitis (15 ) led to a negotiated public

health price for a single-dose formulation of azithromycin suitable for administration

in clinics. Prevention effectiveness has become a core science for public health,

but additional efforts are required to clarify understanding of how preventioneffectiveness studies can be better used by decision-makers. Methods for measuring

outcomes (such as quality-adjusted life-years and benefits estimation for cost-benefit

analyses) and resource allocation need to be refined. Finally, improved, more complete, and comparable information on cost-effectiveness needs to be available to

users.

1997 Editorial Note by Steven M Teutsch, MD, MPH, Office of the Director, Division of Prevention

Research and Analytic Methods (proposed), Epidemiology Program Office, CDC.

References

1. CDC. Public health focus: fluoridation of community water systems. MMWR 1992;41:

372–5,381.

Vol. 46 / No. 4 MMWR 75

Prevention — Continued
2. CDC. Public health focus: mammography. MMWR 1992;41:454–9.

3. CDC. Public health focus: effectiveness of smoking-control strategies—United States. MMWR

1992;41:645–7,653.

4. CDC. Public health focus: surveillance, prevention, and control of nosocomial infections.

MMWR 1992;41:783–7.

5. CDC. Public health focus: effectiveness of rollover protective structures for preventing injuries

associated with agricultural tractors. MMWR 1993;42:57–9.

6. CDC. Public health focus: prevention of blindness associated with diabetic retinopathy. MMWR

1993;42:191–5.

7. CDC. Public health focus: physical activity and the prevention of coronary heart disease.

MMWR 1993;42:669–72.

8. Teutsch SM. A framework for assessing the effectiveness of disease and injury prevention.

MMWR 1992;41(no. RR-3).

9. Field MJ, Lohr KN, eds. Clinical practice guidelines: directions for a new program. Washington,

DC: National Academy Press, 1990.

10. CDC. CDC guidelines: improving the quality. Atlanta, Georgia: US Department of Health and

Human Services, Public Health Service, CDC, 1996.

11. Gold MR, McKay KI, Teutsch SM, Haddix AC. Assessing outcomes in population health: moving

the field forward. Am J Prev Med 1997 (in press).

12. Haddix AC, Teutsch SM, Shaffer PA, Duñet DO, eds. Prevention effectiveness: a guide to decision analysis and economic evaluation. New York, New York: Oxford University Press, 1996.

13. Gold MR, Siegel JE, Russell LB, Weinstein M. Cost effectiveness in health and medicine. New

York, New York: Oxford University Press, 1996.

14. Kelly AE, Haddix AC, Scanlon KS, Helmick CG, Mulinare J. Cost-effectiveness of strategies

to prevent neural tube defects. In: Gold MR, Siegel JE, Russell LB, Weinstein MC, eds. Costeffectiveness in health and medicine. New York, New York: Oxford University Press, 1996:

313–48.

15. Haddix AC, Hillis SD, Kassler WJ. The cost-effectiveness of azithromycin for Chlamydia

trachomatis infections in women. Sex Transm Dis 1995;22:274–80.

Prevention — Continued

Update: Influenza Activity —

United States, 1996–97 Season

Influenza Activity — Conti Influenza activity in the United States increased from mid-No nued vember through

December 1996, peaked during December 22, 1996–January 4, 1997, and began to

decline during January 5–18. Laboratory-confirmed influenza type A and/or type B has

been reported in all states this season. This report summarizes influenza surveillance

data from September 29, 1996, through January 18, 1997.

As of January 18, World Health Organization collaborating laboratories in the

United States had tested 20,754 specimens for respiratory viruses, and 4063 (20%)

were positive for influenza. Of these isolates, 3959 (97%) were influenza type A, and

104 (3%) were influenza type B. The number of influenza isolates and percentage of

specimens positive for influenza increased steadily during November and December.

During the weeks ending December 28 and January 4, 31% of specimens tested were

positive for influenza; however, the percentage positive for influenza declined to

25% during the week ending January 11 and to 18% during the week ending January 18. The number of influenza type B isolates increased each week during December

and accounted for 68 (5%) of 1376 isolates reported during December 29–January 18.

Although influenza type B viruses have been isolated in all nine regions of the United

States, 51 (49%) of the 104 influenza type B isolates reported this season were from

the Pacific region.

76 MMWR January 31, 1997

Prevention — Continued
State and territorial epidemiologists first reported regional influenza activity* for

the week ending October 19, 1996. During each of the subsequent 4 weeks, one or two

states reported regional activity. Widespread activity was first reported during the

week ending November 23 (week 47) from two states (Colorado and Pennsylvania),

and the number of states reporting regional activity during week 47 increased to

seven. The number of states reporting regional or widespread activity increased

during December and peaked at 38 during the week ending January 4, then declined

to 31 during the week ending January 18. Most laboratory-confirmed influenza

outbreaks reported by states to CDC have occurred among elderly nursing-home

residents, although some reported outbreaks have been among children and young

adults.

During the week ending December 7, the percentage of visits to U.S. sentinel physicians for influenza-like illness (ILI) increased above baseline levels (0–3%) for the first

time this season and ranged from 5% to 7% through the week ending January 4. The

percentage of patient visits for ILI returned to baseline levels (3%) during the week

ending January 11 and remained at baseline levels (2%) during the week ending January 18. The percentage of deaths attributed to pneumonia and influenza (P&I) exceeded the epidemic threshold† for the first time this season during the week ending

December 14 and has continued to increase each week through the week ending

January 18. During the week ending January 18, 8.6% of deaths were attributed to P&I,

which is above the epidemic threshold of 7.2% for the week.

The trivalent vaccine prepared for the 1996–97 influenza season contains A/Texas/

36/91-like (H1N1), A/Wuhan/359/95-like (H3N2), and B/Beijing/184/93-like viral antigens. U.S. manufacturers used A/Nanchang/933/95(H3N2) and B/Harbin/07/94

viruses for the A/Wuhan/359/95-like and B/Beijing/184/93-like antigens, respectively,

because of their growth properties. All 105 influenza A(H3N2) isolates antigenically

characterized by CDC were closely related to A/Wuhan/359/95 and A/Nanchang/933/95

(Table 1). The five antigenically characterized influenza B isolates were B/Beijing/

184/93-like.

Reported by: Participating state and territorial epidemiologists and state public health laboratory

directors. World Health Organization collaborating laboratories. Sentinel Physicians Influenza

Surveillance System. Influenza Br, and WHO Collaborating Center for Surveillance, Epidemiology, and Control of Influenza, Div of Viral and Rickettsial Diseases, National Center for Infectious

Diseases, CDC.

Editorial Note: The pattern of influenza activity during mid-November 1996–January

18, 1997, has been consistent with previous influenza seasons dominated by influenza

A(H3N2) viruses. Since the emergence of influenza A(H3N2) viruses in 1968, seasons

during which these viruses predominate have been associated with higher morbidity and mortality, particularly among the elderly, than have seasons during which

influenza A(H1N1) or influenza type B viruses predominated (1,2 ). When influenza

strains included in vaccines are closely matched with circulating strains, influenza vaccine is approximately 70% effective in preventing ILI in healthy adults aged <65 years.

*Levels of activity are 1) no activity; 2) sporadic—sporadically occurring influenza-like illness

(ILI) or culture-confirmed influenza, with no outbreaks detected; 3) regional—outbreaks of ILI

or culture-confirmed influenza in counties with a combined population of <50% of the state’s

total population; and 4) widespread—outbreaks of ILI or culture-confirmed influenza in counties

with a combined population of ≥50% of the state’s total population.

†The epidemic threshold is 1.645 standard deviations above the seasonal baseline. The expected

seasonal baseline is projected using a robust regression procedure in which a periodic regression model is applied to observed percentages of deaths from P&I since 1983.

Vol. 46 / No. 4 MMWR 77

Influenza Activity — Continued
Because of decreased immunologic response among persons aged ≥65 years, influenza vaccine may be only 30%–40% effective in preventing ILI among nursing-home

residents; however, among such groups, influenza vaccine may be 50%–60% effective

in preventing pneumonia and hospitalization and 80% effective in preventing death

(3 ).

Despite the close match between influenza vaccine strains and strains circulating

during the current season, the potential remains for influenza outbreaks among vaccinated groups. Nursing homes and other facilities providing care for persons at risk for

influenza-associated complications should consider using the antiviral agents amantadine hydrochloride or rimantadine hydrochloride for prophylaxis and/or treatment

during institutional outbreaks of influenza type A (3 ).

The increase in the proportion of influenza type B viruses in recent weeks emphasizes the importance of continued surveillance to detect changes in the relative proportions of circulating influenza virus types or subtypes. Influenza virus types or

subtypes that were not predominant during the early part of the season often increase

in number toward the end of the season. Current surveillance data indicate circulation

of both influenza type A and influenza type B viruses. Because amantadine and rimantadine are effective only against influenza type A viruses, the use of rapid diagnostic

testing for influenza type A can be useful in guiding decisions regarding management

of cases of influenza and responses to outbreaks.

Influenza surveillance data are updated weekly and are available through the CDC

voice information system, telephone (404) 332-4551, or the fax information system,

telephone (404) 332-4565, by requesting document no. 361100.

References

1. Lui KL, Kendal AP. Impact of influenza epidemics on mortality in the United States from October

1972 to May 1985. Am J Public Health 1987;77:712–6.

2. Noble GR. Epidemiological and clinical aspects of influenza. In: Beare AS, ed. Basic and applied

research. Boca Raton, Florida: CRC Press, 1982:11–50.

3. ACIP. Prevention and control of influenza: recommendations of the Advisory Committee on

Immunization Practices (ACIP). MMWR 1996;45(no. RR-5).

Influenza Activity — Continued

TABLE 1. Hemagglutination-inhibition titers of influenza type A(H3N2) viruses with

serum specimens from infected ferrets*

Viral antigen

Ferret antiserum

A/Johannesburg/33/94 A/Wuhan/359/95 A/Nanchang/933/95

Reference antigens

A/Johannesburg/33/94 640 40 40

A/Wuhan/359/95 80 1280 1280

A/Nanchang/933/95 80 1280 1280

Recent isolates

A/New York/37/96 160 1280 1280

A/Minnesota/01/96 80 640 1280

A/Texas/09/96 80 640 1280

A/Indiana/02/96 160 1280 1280

A/Washington/07/96 40 640 1280

A/California/11/96 80 1280 1280

*A fourfold difference in hemagglutination-inhibition titers between two viruses is usually

indicative of antigenic variation between viruses.

78 MMWR January 31, 1997

Influenza Activity — Continued
Paralytic Poliomyelitis — United States, 1980–1994

Paralytic Poliomyelitis — Continued The Advisory Committee on Immunization Practices (ACIP) recently recommended

a sequential vaccination schedule of two doses of inactivated poliovirus vaccine (IPV)

followed by two doses of oral poliovirus vaccine (OPV) for routine vaccination of children in the United States (1 ). ACIP revised its recommendation for routine poliovirus

vaccination for three reasons: 1) paralytic poliomyelitis attributable to indigenously

acquired wild poliovirus has not occurred in the United States since 1979 (2 ), 2) progress toward global eradication of poliomyelitis has reduced the risk for importation

of wild poliovirus into the United States (3 ), and 3) vaccine-associated paralytic poliomyelitis (VAPP) continues to occur. ACIP has recommended that implementation of

this new vaccination schedule begin in early 1997. This report summarizes both the

epidemiology of paralytic poliomyelitis in the United States reported during 1980–

1994 and provisional reports for 1995–1996 and updates the estimated risk for VAPP.

These findings indicate that the overall estimated risk for VAPP has remained

constant.

Epidemiology

During 1980–1994, state and territorial health departments reported to CDC

133 confirmed cases of paralytic poliomyelitis. Of these, 125 (94%) cases were associated with administration of OPV (annual mean: eight VAPP cases) (Figure 1); six cases

(only one of which occurred after 1986) were classified as imported; and two

were classified as indeterminate (no poliovirus was isolated from samples obtained

from the patients, and these persons had no history of recent vaccination or direct

contact with a vaccine recipient). Of the 125 VAPP cases, 49 (39%) occurred among

1960 1965 1970 1975 1980 1985 1990

Year

Vaccine-Associated

Total

3000

2500

1000

300

100

80

60

40

20

 0

Cases

*Excluding imported cases.

FIGURE 1. Total number of reported paralytic poliomyelitis cases* and number of

reported vaccine-associated cases — United States, 1960–1994

Vol. 46 / No. 4 MMWR 79
immunologically normal recipients of OPV, 46 (37%) among immunologically normal contacts of OPV recipients (including six cases among persons from whom

vaccine-like poliovirus was isolated but who had no history of direct contact with vaccinees), and 30 (24%) among immunologically compromised OPV recipients or contacts of OPV recipients. Provisional reports include an additional six confirmed cases

for 1995 and one confirmed case for 1996.

During 1980–1994, of the 125 VAPP cases, 97 (78%) were associated with administration of the first or second dose of OPV. Of the 49 cases among immunologically

normal OPV recipients (Table 1), 45 (92%) were associated with administration of the

first or second dose of OPV, and 41 (91%) of these were among persons aged <1 year.

Of the 46 cases among immunologically normal contacts, 32 (70%) were associated

with the first or second dose of OPV, and 26 (81%) of these occurred among persons

aged ≥20 years. Of the 23 cases among immunologically compromised vaccine recipients, 15 (65%) were associated with administration of the first or second dose of OPV,

and 12 (80%) of these were among persons aged <1 year. Of the seven cases among

immunologically compromised contacts, five (71%) were associated with administration of the first or second dose, and four (80%) of these occurred among persons aged

≥20 years. Of the immunologically compromised vaccine recipients with VAPP, none

had immunodeficiency diagnosed before onset of paralysis. Of the seven persons

with cases of VAPP during 1995–1996, five were OPV recipients, and all of these were

aged <1 year.

To analyze temporal trends, cases of VAPP among OPV recipients and contacts

were grouped by 3-year intervals from 1980 through 1994. The number of cases

among all vaccine recipients occurring during each 3-year period remained relatively

constant (range: 13–16, p=0.71), and there were no substantial temporal changes in

the number of cases among immunologically normal recipients (p=0.18). However,

from 1980–1982 to 1992–1994, the number of cases among contacts declined significantly, from 15 to four (p=0.01) (Table 1).

TABLE 1. Number of cases of vaccine-associated paralytic poliomyelitis (VAPP) among

recipients of oral poliovirus vaccine (OPV) and contacts of OPV recipients, by 3-year

groupings — United States, 1980–1994

Category

VAPP cases

1980–1982 1983–1985 1986–1988 1989–1991 1992–1994* Total

Recipients

Immunologically normal 10 12 11 8 8 49

Immunologically

compromised 3 2 5 8 5 23

Total 13 14 16 16 13 72

Contacts

Immunologically normal 14 12 9 7 4 46

Immunologically

compromised 1 2 2 2 0 7

Total 15 14 11 9 4 53

Total 28 28 27 25 17 125

*Because of late reporting, the number of cases during this period may be incomplete.

80 MMWR January 31, 1997

Paralytic Poliomyelitis — Continued
Estimated Risks for VAPP

Based on the distribution of an estimated 303 million total doses of OPV during

1980–1994, the overall risk (as measured by a ratio) for VAPP during this period was

one case to the 2.4 million doses distributed; for children receiving their first doses of

OPV, the ratio was one case to the 750,000 children. Assuming that all 57.8 million

children born during 1980–1994 received a first dose of OPV, the ratio for immunologically normal first-dose recipients was one case to the 1.4 million first doses distributed. For all first-dose recipients (immunologically normal or compromised), the ratio

was one case to the 1.2 million first doses distributed. Based on all doses distributed,

the ratio for recipients was one case to the 6.2 million doses distributed.

Samples for poliovirus isolation were obtained from 110 (88%) of the 125 persons

with VAPP; of these, poliovirus was isolated from the samples from 89 (81%) persons.

Of the 109 cases for which the date of sample collection was known, poliovirus was

isolated from 83 (85%) of the 98 samples obtained ≤15 days after onset of paralysis

and from five (46%) of the 11 samples obtained >15 days after onset of paralysis.

Cases were reported to CDC a median of 47 days (range: 1 day–13 years) after onset

of paralysis.

Reported by: Child Vaccine Preventable Disease Br, Epidemiology and Surveillance Div, National

Immunization Program, CDC.

Editorial Note: The new sequential IPV/OPV poliovirus vaccination schedule is

expected to reduce the incidence of VAPP while maintaining individual and population

immunity against polioviruses at the high levels necessary to prevent polio outbreaks

if wild poliovirus is reintroduced into the United States. Use of IPV as the first two

doses of the sequential vaccination schedule should induce high levels of protective

antibodies among immunologically normal vaccine recipients by the time the first

dose of OPV is administered at age 12–18 months, thereby eliminating 95% of VAPP

cases among these children (4 ). In addition, the number of contact cases may

decrease because of reduced transmission (attributed to some IPV-induced immunity

of pharyngeal mucosa and, to a lesser degree, of intestinal mucosa) of vaccine virus

from persons given OPV after receipt of two doses of IPV. Delaying administration of

the first dose of OPV until age 12 months may allow additional time for diagnosis of

immunodeficiency (which contraindicates receipt of OPV) and enable prevention of

some VAPP cases among immunodeficient recipients (4,5 ).

The overall estimated risk for VAPP in the United States has remained relatively

constant since 1965 (2,6,7 ); however, the findings in this report suggest that the risk

for VAPP among contacts of OPV recipients has decreased since 1980. Because of

reporting delays, the data for recent years may not be complete, and additional years

of observation are required to confirm this trend. Although reasons for the decline

have not been firmly established, enforcement of state vaccination requirements for

school entry beginning in the late 1960s may have decreased the proportion of parents and adult close contacts of vaccinees without immunity to poliovirus, particularly

in areas where compliance with these requirements is high (8 ). However, other reports suggest that the prevalence of poliovirus susceptibility among young adults did

not change during this period: for example, data from a national serosurvey of U.S.

Army recruits born during 1954–1972 indicated that 12.5%–13.0% were susceptible to

poliovirus type 3, and that no statistically significant decline in the percentage susceptible occurred among recruits born after 1966 (9 ).

Vol. 46 / No. 4 MMWR 81

Paralytic Poliomyelitis — Continued
Enhanced surveillance for paralytic poliomyelitis (whether vaccine- or wild

poliovirus-associated) is necessary to monitor the impact of the change in the routine

poliovirus vaccination policy. The completeness of reporting for diagnosed paralytic

poliomyelitis in the United States has been estimated at 81%. Misdiagnosis or failure

to report diagnosed cases contributes to incomplete surveillance (6 ). Any suspected

case of paralytic poliomyelitis must be reported immediately to state or local health

authorities (10 ). A clinical case definition for reporting cases of paralytic poliomyelitis* was adopted by the Council of State and Territorial Epidemiologists in 1990. Confirmed cases are those that meet the clinical case definition and in which the patient

has a neurologic deficit 60 days after onset of initial symptoms, has died, or has unknown follow-up status. Experts at state and local health departments and at CDC are

available for consultation about patients who have suspected cases of paralytic poliomyelitis (i.e., patients with acute paralytic manifestations), and information about

clinical diagnosis and reporting of cases is available from CDC’s National Immunization Program, telephone (404) 639-8255.

Laboratory studies, especially attempted poliovirus isolation, are critical for ruling

out or confirming paralytic poliomyelitis. Specimens for virus isolation (e.g., stool,

throat swab, and cerebrospinal fluid) and serologic testing must be obtained in a

timely manner. At least two stool specimens and two throat swabs should be obtained

as early as possible in the course of illness (optimally within 15 days of onset) from

patients who are suspected to have polio. Cultures for enterovirus followed by enteroviral typing should be considered for all patients with acute flaccid paralysis unless an alternative diagnosis is apparent. Intratypic differentiation must be performed

to determine whether a poliovirus isolate is vaccine-related or wild type. The Enterovirus Laboratory of CDC’s National Center for Infectious Diseases is the national

reference laboratory for polioviruses in the United States and the only laboratory that

performs this procedure on a routine basis. Information about collection and shipment of clinical specimens is available from this laboratory, telephone (404) 639-2749.

References

1. ACIP. Poliomyelitis prevention in the United States: introduction of a sequential vaccination

schedule of inactivated poliovirus vaccine followed by oral poliovirus vaccine—recommendations of the Advisory Committee on Immunization Practices. MMWR 1997;46(no. RR-3).

2. CDC. Poliomyelitis—United States, 1975–1984. MMWR 1986;35:180–2.

3. CDC. Certification of poliomyelitis eradication—the Americas, 1994. MMWR 1994;43:720–2.

4. Miller MA, Sutter RW, Strebel PM, Hadler SC. Cost-effectiveness of incorporating inactivated

poliovirus vaccine into the routine childhood immunization schedule. JAMA 1996;276:967–71.

5. Prevots DR, Sutter RW, Quick L, Izurieta H, Strebel PM. Vaccine-associated paralytic poliomyelitis in the United States, 1980–1994: current risk and potential impact of proposed

sequential schedule of IPV followed by OPV [Abstract]. In: Program and abstracts of the 36th

Interscience Conference on Antimicrobial Agents and Chemotherapy. New Orleans, Louisiana:

American Society for Microbiology, 1996:179.

6. Prevots DR, Sutter RW, Strebel PM, Weibel RE, Cochi SL. Completeness of reporting for paralytic poliomyelitis, United States, 1980 through 1991: implications for estimating the risk of

vaccine-associated disease. Arch Pediatr Adolesc Med 1994;148:479–85.

7. Strebel PM, Sutter RW, Cochi SL, et al. Epidemiology of poliomyelitis in the United States

one decade after the last reported case of indigenous wild virus-associated disease. Clin Infect

Dis 1992;14:568–79.

*Acute onset of flaccid paralysis in one or more limbs with decreased or absent tendon reflexes

in the affected limbs without other apparent cause and without sensory or cognitive loss (as

reported by a physician).

82 MMWR January 31, 1997

Paralytic Poliomyelitis — Continued
8. Orenstein WA, Wassilak SGF, Deforest A, et al. Seroprevalence of poliovirus antibodies among

Massachusetts schoolchildren. In: Program and abstracts of the 28th Interscience Conference

on Antimicrobial Agents and Chemotherapy [Abstract]. Washington, DC: American Society

for Microbiology, 1988:198.

9. Kelley PW, Petruccelli BP, Stehr-Green P, Erickson RL, Mason CJ. The susceptibility of young

adult Americans to vaccine-preventable infections: a national serosurvey of US Army recruits.

JAMA 1991;266:2724–9.

10. CDC. Mandatory reporting of infectious diseases by clinicians. MMWR 1990;39(no. RR-9):1–17.

Paralytic Poliomyelitis — Continued

Legionnaires Disease Associated with a Whirlpool Spa Display — 

Virginia, September–October, 1996

Legionnaires Disease — Conti Contaminated whirlpool spas have been reported as a source of legionellosis. This nued

report describes the preliminary findings of an ongoing investigation by the Virginia

Department of Health (VDH) and CDC of a recent outbreak of Legionnaires disease in

Virginia, which implicated a whirlpool spa display at a retail store as the source of

infection.

On October 15, 1996, a district health department in southwestern Virginia contacted the Office of Epidemiology, VDH, about a hospital (hospital A) report that 15 patients had been admitted during October 12–13 with unexplained pneumonia. On

October 21, another hospital (hospital B), located approximately 15 miles from hospital A, reported its pneumonia census to be higher than expected for the first 2 weeks

of October. On October 23, the district health department was informed about three

area residents with legionellosis (with Legionella pneumophila serogroup 1 [Lp1] antigen detected in urine); one was a patient at hospital A, and two were patients at

hospitals outside the jurisdiction of the health department.

To identify all outbreak-associated cases, investigators reviewed medical records

and laboratory reports of admissions to the three hospitals for pneumonia during

September 1–November 12. Hospital personnel and area health-care providers collected and submitted specimens from patients with pneumonia, including serum for

the determination of acute Lp1 antibody titers (to be followed by convalescent titers);

sputum, when possible, for Legionella culture; and urine to detect Lp1 antigens.

A case of Legionnaires disease was defined as pneumonia in an area resident

with onset of illness during September 1–November 12 with Lp1 identified by culture

of sputum, antigen assay of urine, or fourfold rise in serum antibody titers. Based on

the review of records, 23 cases eventually were identified, including 15 by urine antigen, seven by serology, and three by sputum culture; two were identified by urine

antigen and sputum culture. Of the 23 case-patients, 22 were hospitalized, and two

died. The mean age of case-patients was 65 years (range: 42–86 years), and most (17)

were male. Although patients had onsets of illness during September 29–October 22,

most (18 [78%]) had onsets during October 8–14 (Figure 1).

To identify potential exposures associated with Legionnaires disease, casepatients were asked about their activities during the 2 weeks before onset of illness.

Based on these interviews, a questionnaire was developed and a case-control study

was initiated on November 2 to assess potential risk factors for and exposures related

to infection. Three controls were selected for each confirmed case by using office

records of the primary-care physicians of the case-patients; controls were matched by

Vol. 46 / No. 4 MMWR 83

Paralytic Poliomyelitis — Continued
age (within 10 years), sex, and underlying medical conditions. All case-patients and

controls were asked whether, during the 2 weeks before onset of illness, they had

visited any of 14 retail and manufacturing sites. 

Of the 23 cases, 15 were included in the case-control study (one person died before

the case-contol study was initiated and had no available exposure history, and seven

patients were identified after convalescent serum became available 2 months following the case-control study). A history of having visited a large home-improvement

center during the 2 weeks before onset of illness was reported by 14 (93%) of the

15 cases, compared with 12 (27%) of the 45 controls (matched odds ratio [MOR]=23.3;

95% confidence interval [CI]=3.0–182). Of the 13 case-patients and 12 controls who

had visited the store and for whom there was a detailed in-store exposure history,

cumulative duration of total store visits averaged 79 minutes for cases, compared

with 29 minutes for controls (F-test p<0.01); in addition, 10 (77%) case-patients

reported spending time in the area surrounding the spas during their visits to the

store, compared with three (25%) of the 12 controls (MOR=5.5; 95% CI=0.7–256). Four

of these case-patients and one of the controls reported only “walking by” the spa. No

other activity, including drinking from the store’s water fountains or visiting the

14 other locations in the community, was associated with illness. 

22 24 26 28 30 2 4 6 8 10 12 14 16 18 20 22 24

0

5

10

15

Cases

 Whirlpool Spas Drained

September October

Date

*Pneumonia in an area resident with onset of illness during September–November 12 with

Legionella pneumophila serogroup 1 identified by culture of sputum, antigen assay of urine,

or fourfold rise in serum antibody titers.

†n=23.

FIGURE 1. Number of cases of Legionnaires disease*, by date of onset — Virginia,

September–October 1996†

84 MMWR January 31, 1997

Legionnaires Disease — Continued
Samples were collected and cultured for the presence of Legionella from water

sources in the home-improvement center, including a whirlpool spa basin, spa filters,

a greenhouse sprinkler system, a decorative fish pond and fountain, potable water

fountains, urinals, and hot and cold water taps in the store’s restrooms. In addition to

these potential sources, a second whirlpool spa had been sold, drained on October 9,

and removed from the store floor on October 11. Three filters were available for testing from the two spas. One of these filters was from the purchased spa, and the other

two had been used in the spa that was in operation until October 28, but that had been

drained and out of service during October 9–17. Lp1 was isolated from the filter from

the purchased spa; that isolate was an exact match, by monoclonal antibody subtyping and arbitrarily primed polymerase chain reaction, to the sputum isolates cultured from two of the cases. A third isolate from the case-patient that did not visit the

home-improvement center had a different monoclonal antibody pattern. All other environmental sources, including the other two filters, tested negative.

Reported by: J Hershey, MD, B Burrus, V Marcussen, J Notter, K Watson, R Wolford,

RE Shaffner III, New River Health District; Carilion Giles Memorial Hospital, Pearisburg; Carilion

Radford Community Hospital, Radford; Columbia Lewis Gale Hospital, Salem; Columbia

Montgomery Regional Hospital, Blacksburg; Department of Veterans Affairs Medical Center,

Salem; E Barrett, DMD, D Woolard, MPH, L Branch, R Hackler, B Rouse, L Gibson, S Jenkins,

VMD, J Rullan, MD, G Miller, Jr, MD, State Epidemiologist, Virginia Dept of Health; S Curran,

Div of Consolidated Laboratory Svcs, Richmond, Virginia. Laboratory Corporation of America.

Childhood and Respiratory Diseases Br, Div of Bacterial and Mycotic Diseases, National Center

for Infectious Diseases; State Br, Div of Applied Public Health Training (proposed), Epidemiology

Program Office, CDC.

Editorial Note: Approximately 10,000–15,000 cases of Legionnaires disease occur

each year in the United States; most occur sporadically (1 ). Investigations of outbreaks have documented aerosol transmission of Legionella from contaminated cooling towers and evaporative condensers (2,3 ), showers (4 ), decorative fountains (5 ),

humidifiers (6 ), respiratory therapy equipment (7 ), and whirlpool spas (8 ). However,

the proportion of sporadically occurring disease attributable to these sources has not

yet been determined.

In contrast with other spa- or whirlpool-associated outbreaks, in this outbreak,

none of the case-patients actually entered the water. Instead, all were most likely

exposed by walking by or spending time in the area surrounding the spa. Although

most community-wide outbreaks of legionellosis have resulted from transmission

from an outdoor source (e.g., cooling towers), this report underscores the potential for

such outbreaks in association with contaminated indoor sources.

Even though the epidemiologic findings of the case-control study indicated that the

source of the outbreak was located in a home-improvement center, the laboratory

findings were critical in identifying the exact source of exposure within the store.

Case-patients were more likely than controls to have reported exposure to the spas,

but the difference was not statistically significant. By matching the two clinical Lp1

isolates to the isolate from the purchased spa, molecular epidemiologic typing helped

link the spa to illness.

Enhanced surveillance during investigations of legionellosis outbreaks may result

in the detection of some sporadically occurring cases. For example, in the investigation of this outbreak, one case-patient did not report visiting the home-improvement

center. However, the sputum Lp1 isolate from this patient did not match that of the

Vol. 46 / No. 4 MMWR 85

Legionnaires Disease — Continued
whirlpool spa filter or the other available clinical isolates, suggesting this case was not

related to the outbreak.

Although the source of the outbreak was removed before the investigation was

initiated, cases continued to occur. However, all of these cases, except the case not

related to the outbreak, occurred within the normal incubation period for Legionnaires

disease (i.e., 2–10 days) following removal of the source.

Following the investigation, VDH recommended that whirlpool spas being used

as displays be regularly inspected and maintained with biocides and that filters be

regularly changed or decontaminated. In response to a recent outbreak of Legionnaires disease on a cruise ship (8 ), CDC developed guidelines for the maintenance of

whirlpool spas on cruise ships (9 ). Based on the findings of this investigation, CDC is

assessing these guildelines to determine whether modifications are necessary regarding use of land-based whirlpool spas, including those that are being operated while on

display.

References

1. Marston BJ, Lipman HB, Breiman RF. Surveillance for Legionnaires’ disease: risk factors for

morbidity and mortality. Arch Intern Med 1994;154:2417–22.

2. Dondero TJ Jr, Rendtorff RC, Mallison GF, et al. An outbreak of Legionnaires’ disease associated

with a contaminated air-conditioning cooling tower. N Engl J Med 1980;302:365–70.

3. Breiman RF, Cozen W, Fields BS, et al. Role of air sampling in the investigation of an outbreak

of Legionnaires’ disease associated with exposure to aerosols from an evaporative condenser.

J Infect Dis 1990;161:1257–61.

4. Breiman RF, Fields BS, Spika JS, Sanden GN, Volmer L, Meier A. Association of shower use

with Legionnaires’ disease: possible role of amoebae. JAMA 1990;263:2924–6.

5. Fenstersheib MD, Miller M, Diggins C, et al. Outbreak of Pontiac fever due to Legionella anisa.

Lancet 1990;336:35–7.

6. Mahoney FJ, Hoge CW, Farley TA, et al. Community wide outbreak of Legionnaires’ disease

associated with a grocery store mist machine. J Infect Dis 1992;165:736–9.

7. Mastro TD, Fields BS, Breiman RF, Campbell J, Plikaytis BD, Spika JS. Nosocomial Legionnaires’ disease and use of medication nebulizers. J Infect Dis 1991;163:667–71.

8. Jernigan DB, Hofmann J, Cetron MS, et al. Outbreak of Legionnaires’ disease among cruise

ship passengers exposed to a contaminated whirlpool spa. Lancet 1996;347:494–9.

9. National Center for Environmental Health/National Center for Infectious Diseases. Final recommendations to minimize transmission of Legionnaires’ disease from whirlpool spas on

cruise ships. Atlanta, Georgia: US Department of Health and Human Services, Public Health

Service, CDC, 1996.

Legionnaires Disease — Continued

86 MMWR January 31, 1997

Legionnaires Disease — Continued
Child Passenger Safety Awareness Week — February 9–15, 1997

February 9–15 is National Child Passenger Safety Awareness Week. As of January 29, 1997, a total of 35 children have died as a result of injuries associated with

deployment of air bags in motor-vehicle crashes. Hundreds more children aged

<5 years die each year because they are not buckled into a child-safety seat or the

child-safety seat is misused; approximately 80,000 more are seriously injured (1 ).

Most of these fatalities and injuries are preventable but require the combined

effort of increased public education, improved child passenger safety laws, and

strong enforcement of these laws. National Child Passenger Safety Awareness

Week is a time to enhance activities focusing on child passenger safety. Additional

information about materials to support such activities is available from the Office

of Communications and Outreach, National Highway Traffic Safety Administration

(NHTSA), 400 Seventh St., S.W., NTS-20, Washington, DC 20590; fax (202) 493-

2062; or the NHTSA World Wide Web site at http://www.nhtsa.dot.gov.

Reference

1. National Highway Traffic Safety Administration. Traffic safety facts, 1995: alcohol.

Washington, DC: US Department of Transportation, National Highway Traffic Safety Administration, National Center for Statistics and Analysis, Research, and Development, 1996.

Vol. 46 / No. 4 MMWR 87
Quarterly Immunization Table

To track progress toward achieving the goals of the Childhood Immunization Initiative (CII), CDC publishes quarterly a tabular summary of the number of cases of nationally notifiable diseases preventable by routine childhood vaccination reported

during the previous quarter and year-to-date (provisional data). In addition, the table

compares provisional data with final data for the previous year and highlights the

number of reported cases among children aged <5 years, who are the primary focus

of CII. Data in the table are reported through the National Electronic Telecommunications System for Surveillance (NETSS).

Number of reported cases of nationally notifiable diseases preventable by routine

childhood vaccination — United States, October–December 1996 and 1995–1996*

Disease

 No. cases,

 October–

 December

 1996

 Total cases 

January–December 

 No. cases among 

children aged <5 years†

January–December

1995 1996 1995 1996 

Congenital rubella

syndrome 1 6 2 6 2

Diphtheria 0 0 1 0 0

Haemophilus influenzae§ 321 1180 1078 290 277

Hepatitis B¶ 2666 10,805 10,167 81 78

Measles 39 310 494 107 114

Mumps 167 906 666 165 142

Pertussis 2860 5137 6911 2733 3097

Poliomyelitis, paralytic** 0 6 1 4 1

Rubella 15 128 210 9 15

Tetanus 8 41 28 2 0

 *Data for 1995 are final and for 1996 are provisional.

†For 1995 and 1996, age data were available for ≥94% of cases, except for 1996 age data for

measles, which were available for 89% of cases.

§Invasive disease; H. influenzae serotype is not routinely reported to the National Notifiable

Diseases Surveillance System. Of 277 cases among children aged <5 years, serotype was

reported for 95 cases, and of those, 31 were type b, the only serotype of H. influenzae

preventable by vaccination.

¶Because most hepatitis B virus infections among infants and children aged <5 years are

asymptomatic (although likely to become chronic), acute disease surveillance does not

reflect the incidence of this problem in this age group or the effectiveness of hepatitis B vaccination in infants.

**Five suspected cases with onset in 1996 have been reported to date. One additional

suspected case with onset in 1995 is under investigation.

88 MMWR January 31, 1997
FIGURE I. Selected notifiable disease reports, comparison of provisional 4-week totals

ending January 25, 1997, with historical data — United States

Anthrax - Plague -

Brucellosis 1 Poliomyelitis, paralytic -

Cholera - Psittacosis 1

Congenital rubella syndrome 3 Rabies, human -

Cryptosporidiosis* 44 Rocky Mountain spotted fever (RMSF) 3

Diphtheria - Streptococcal disease, invasive Group A 29

Encephalitis: California* - Streptococcal toxic-shock syndrome* 2

eastern equine* - Syphilis, congenital¶ -

St. Louis* - Tetanus 1

western equine* - Toxic-shock syndrome 8

Hansen Disease 6 Trichinosis 2

Hantavirus pulmonary syndrome*† - Typhoid fever 10

Hemolytic uremic syndrome, post-diarrheal* - Yellow fever -

HIV infection, pediatric*§ -

Cum. 1997 Cum. 1997

TABLE I. Summary — provisional cases of selected notifiable diseases,

United States, cumulative, week ending January 25, 1997 (4th Week)

-: no reported cases

*Not notifiable in all states.

† Updated weekly from reports to the Division of Viral and Rickettsial Diseases, National Center for Infectious Diseases (NCID). §Updated monthly to the Division of HIV/AIDS Prevention, National Center for HIV, STD, and TB Prevention (NCHSTP), last

update December 24, 1996. ¶Updated quarterly from reports to the Division of STD Prevention, NCHSTP.

DISEASE DECREASE INCREASE CASES CURRENT

4 WEEKS

Ratio (Log Scale)*

AAAA AAAA

AAAA

AA

AA

AA Beyond Historical Limits

4

737

231

96

41

29

1

161

6

186

282

2

Hepatitis A

Hepatitis B

Hepatitis, C/Non-A, Non-B

Legionellosis

Malaria

Measles, Total

Meningococcal Infections

Mumps

Pertussis

Rabies, Animal

Rubella

0.03125 0.0625 0.125 0.25 0.5 1 2

*Ratio of current 4-week total to mean of 15 4-week totals (from previous, comparable, and

subsequent 4-week periods for the past 5 years). The point where the hatched area begins is

based on the mean and two standard deviations of these 4-week totals.

Vol. 46 / No. 4 MMWR 89
TABLE II. Provisional cases of selected notifiable diseases, United States,

weeks ending January 25, 1997, and January 27, 1996 (4th Week)

UNITED STATES - 3,215 14,482 23,077 54 - 13,066 24,215 102 183

NEW ENGLAND - 196 932 1,213 4 - 366 593 - 2

Maine - - - - - - - 3 - -

N.H. - 2 10 41 - - 3 7 - -

Vt. - - 14 37 - - 1 11 - 2

Mass. - 133 545 478 4 - 182 245 - -

R.I. - 9 151 142 - - 45 44 - -

Conn. - 52 212 515 - - 135 283 - -

MID. ATLANTIC - 1,193 1,060 421 - - 653 2,051 2 5

Upstate N.Y. - 155 N N - - - - - 3

N.Y. City - 697 - - - - - 1,012 - 1

N.J. - 204 480 421 - - 252 254 - -

Pa. - 137 580 - N - 401 785 2 1

E.N. CENTRAL - 272 2,611 5,526 5 - 2,517 4,779 43 31

Ohio - 66 863 1,177 3 - 704 1,008 3 1

Ind. - - 286 - - - 312 621 1 -

Ill. - 155 765 1,884 - - 425 1,517 - 8

Mich. - 36 641 1,667 2 - 1,015 1,210 39 22

Wis. - 15 56 798 N - 61 423 - -

W.N. CENTRAL - 74 1,304 2,299 10 - 542 1,084 2 4

Minn. - 20 - 562 7 - U - - -

Iowa - - 383 1 3 - 67 - 2 -

Mo. - 51 611 848 - - 384 782 - 4

N. Dak. - - 83 37 - - 6 - - -

S. Dak. - 2 49 52 - - 9 6 - -

Nebr. - - 17 432 - - 2 66 - -

Kans. - 1 161 367 - - 74 230 - -

S. ATLANTIC - 124 3,087 2,282 4 - 5,752 7,822 9 6

Del. - 32 - - - - 91 124 - -

Md. - 67 382 215 - - 741 1,207 3 -

D.C. - 2 N N - - 391 360 - -

Va. - 1 755 836 N - 622 604 - -

W. Va. - 7 - - N - 39 45 - 3

N.C. - 1 - - 2 - 1,222 1,210 4 1

S.C. - - 18 - - - 869 1,176 2 1

Ga. - 9 591 - 2 - 687 2,012 U -

Fla. - 5 1,341 1,231 - - 1,090 1,084 - 1

E.S. CENTRAL - 147 1,163 1,976 6 - 1,363 2,334 12 47

Ky. - 38 447 505 5 - 335 328 - -

Tenn. - 56 153 781 - - 133 783 - 47

Ala. - 35 563 685 - - 895 1,106 1 -

Miss. - 18 - 5 1 - - 117 11 -

W.S. CENTRAL - 399 822 2,814 1 - 955 2,759 3 28

Ark. - 19 84 74 1 - 170 344 - -

La. - 19 401 - - - 483 344 1 1

Okla. - 1 337 307 - - 302 243 - 25

Tex. - 360 - 2,433 - - - 1,828 2 2

MOUNTAIN - 111 1,158 810 14 - 315 645 25 50

Mont. - 2 22 - - - 4 2 2 2

Idaho - 1 90 87 - - 11 5 6 8

Wyo. - - 37 51 - - 3 5 10 10

Colo. - 53 - - 9 - - 163 4 7

N. Mex. - 1 321 292 3 - 78 81 1 16

Ariz. - 36 525 63 N - 188 313 2 4

Utah - 17 97 107 1 - 9 28 - 3

Nev. - 1 66 210 1 - 22 48 - -

PACIFIC - 699 2,345 5,736 10 - 603 2,148 6 10

Wash. - 64 572 705 - - 150 221 - -

Oreg. - 48 - 350 2 - - 9 1 2

Calif. - 577 1,620 4,555 8 - 385 1,838 - 7

Alaska - 3 95 27 - - 42 43 - 1

Hawaii - 7 58 99 N - 26 37 5 -

Guam - - - 26 N - - 13 - -

P.R. - - N N 1 U 40 - - 5

V.I. - 1 N N N U - - - -

Amer. Samoa - - - - N U - - - -

C.N.M.I. - - N N N U - 5 - -

N: Not notifiable U: Unavailable -: no reported cases C.N.M.I.: Commonwealth of Northern Mariana Islands

*Updated monthly to the Division of HIV/AIDS Prevention, National Center for HIV, STD, and TB Prevention, last update December 24, 1996. †National Electronic Telecommunications System for Surveillance.

§Public Health Laboratory Information System. 

Reporting Area

AIDS* Chlamydia

Escherichia

coli O157:H7

Gonorrhea

Hepatitis

NETSS† PHLIS§ C/NA,NB

Cum.

1997

Cum.

1996

Cum.

1997

Cum.

1996

Cum.

1997

Cum.

1997

Cum.

1997

Cum.

1996

Cum.

1997

Cum.

1996

90 MMWR January 31, 1997
TABLE II. (Cont’d.) Provisional cases of selected notifiable diseases, United States,

weeks ending January 25, 1997, and January 27, 1996 (4th Week)

UNITED STATES 42 56 96 163 51 64 376 849 413 785 317

NEW ENGLAND 2 1 3 3 - 3 10 15 9 12 31

Maine - - - - - - - - - 1 1

N.H. - - 1 - - - - - - - -

Vt. 1 - 1 - - 1 - - - - 9

Mass. 1 - - - - 2 3 6 3 2 3

R.I. - 1 1 3 - - - - 1 4 -

Conn. N N - - - - 7 9 5 5 18

MID. ATLANTIC 6 7 66 142 6 15 5 18 30 30 84

Upstate N.Y. - - - 1 - - - - - - 62

N.Y. City - - 1 67 4 5 - 7 12 7 -

N.J. 1 3 13 27 1 9 1 4 5 10 6

Pa. 5 4 52 47 1 1 4 7 13 13 16

E.N. CENTRAL 16 25 3 1 6 8 32 152 64 153 1

Ohio 12 10 2 1 1 - 13 64 33 14 -

Ind. - 5 1 - - - 9 25 7 11 1

Ill. - 2 - - - 3 6 44 24 128 -

Mich. 4 8 - - 5 3 - - - - -

Wis. - - U U - 2 4 19 - - -

W.N. CENTRAL - 3 - 2 - 1 7 36 9 11 28

Minn. - - - - - - - 4 7 2 2

Iowa - - - - - - - - - 3 20

Mo. - 2 - 1 - 1 7 24 1 3 1

N. Dak. - - - - - - - - 1 - 4

S. Dak. - - - - - - - - - - -

Nebr. - 1 - - - - - 3 - - -

Kans. - - - 1 - - - 5 - 3 1

S. ATLANTIC 9 6 14 9 10 12 191 213 39 35 161

Del. 1 - - 2 1 2 2 4 - 2 2

Md. 7 1 13 7 1 2 33 22 6 - 32

D.C. 1 - - - 1 1 6 6 6 - 1

Va. - 1 - - 1 3 19 31 - 1 18

W. Va. - 1 - - - - - - 3 4 3

N.C. - 3 1 - 1 2 50 48 9 11 73

S.C. - - - - 1 - 37 33 15 17 2

Ga. - - - - 2 1 24 55 - - 14

Fla. - - - - 2 1 20 14 - - 16

E.S. CENTRAL 2 6 7 5 - - 72 238 24 63 4

Ky. - 3 - 2 - - 11 19 - 3 2

Tenn. - 1 - 3 - - 11 65 5 21 -

Ala. 1 - - - - - 50 44 19 19 2

Miss. 1 2 7 - - - - 110 - 20 -

W.S. CENTRAL - - - - - - 51 112 - 14 5

Ark. - - - - - - 2 16 - 3 -

La. - - - - - - 38 21 - - -

Okla. - - - - - - 11 1 - 11 5

Tex. - - - - - - - 74 - - -

MOUNTAIN 5 4 - - 4 5 4 16 10 26 1

Mont. - - - - 1 - - - - - -

Idaho - - - - - - - - - 1 -

Wyo. - - - - - - - - 1 - -

Colo. 2 2 - - 3 3 - 5 1 14 -

N. Mex. - - - - - 1 - - 2 - -

Ariz. 1 1 - - - - 4 9 4 11 1

Utah 2 - - - - 1 - - - - -

Nev. - 1 - - - - - 2 2 - -

PACIFIC 2 4 3 1 25 20 4 49 228 441 2

Wash. - - - - - - - - 7 14 -

Oreg. - - 1 1 2 2 - 1 - 8 -

Calif. 2 4 2 - 23 18 4 48 199 402 2

Alaska - - - - - - - - 4 10 -

Hawaii - - - - - - - - 18 7 -

Guam - - - - - - - 2 - - -

P.R. - - - - 1 - 11 5 - - 1

V.I. - - - - - - - - - - -

Amer. Samoa - - - - - - - - - - -

C.N.M.I. - - - - - - - - - - -

N: Not notifiable U: Unavailable -: no reported cases

Reporting Area

Legionellosis

Lyme

Disease Malaria

Syphilis

(Primary & Secondary) Tuberculosis

Rabies,

Animal

Cum.

1997

Cum.

1996

Cum.

1997

Cum.

1996

Cum.

1997

Cum.

1996

Cum.

1997

Cum.

1996

Cum.

1997

Cum.

1996

Cum.

1997

Vol. 46 / No. 4 MMWR 91
TABLE III. Provisional cases of selected notifiable diseases preventable by vaccination,

United States, weeks ending January 25, 1997,

and January 27, 1996 (4th Week)

UNITED STATES 58 90 1,101 1,629 327 510 1 1 - - 1 1

NEW ENGLAND 2 4 23 12 4 14 - - - - - -

Maine - - 1 2 - - - - - - - -

N.H. 1 4 1 1 - - - - - - - -

Vt. - - 2 - - - - - - - - -

Mass. 1 - 5 2 2 1 - - - - - -

R.I. - - 1 2 - 1 - - - - - -

Conn. - - 13 5 2 12 - - - - - -

MID. ATLANTIC 10 12 85 93 50 66 - - - - - -

Upstate N.Y. - 1 - 2 - 4 - - - - - -

N.Y. City 4 1 37 59 24 37 - - - - - -

N.J. 4 8 30 19 21 16 - - - - - -

Pa. 2 2 18 13 5 9 - - - - - -

E.N. CENTRAL 8 15 89 169 51 79 - - - - - -

Ohio 8 13 40 65 5 9 - - - - - -

Ind. - - 15 10 4 3 - - - - - -

Ill. - 2 - 46 - 31 - - - - - -

Mich. - - 34 25 42 26 - - - - - -

Wis. - - - 23 - 10 U - U - - -

W.N. CENTRAL - 5 50 131 14 34 - - - - - -

Minn. - - 1 - - 1 - - - - - -

Iowa - 3 12 31 10 5 - - - - - -

Mo. - 2 18 65 1 22 - - - - - -

N. Dak. - - - 1 - - - - - - - -

S. Dak. - - 1 6 - - - - - - - -

Nebr. - - - 18 1 3 - - - - - -

Kans. - - 18 10 2 3 - - - - - -

S. ATLANTIC 15 10 74 50 29 72 - - - - - -

Del. - - 4 1 1 - - - - - - -

Md. 6 1 36 17 14 20 - - - - - -

D.C. 2 - 1 1 1 1 - - - - - -

Va. 1 - 12 3 - 4 - - - - - -

W. Va. - - 1 2 1 3 - - - - - -

N.C. 4 2 7 12 8 36 - - - - - -

S.C. - - 2 6 2 4 - - - - - -

Ga. 1 7 1 - - - - - - - - -

Fla. 1 - 10 8 2 4 - - - - - -

E.S. CENTRAL 1 3 22 79 17 57 - - - - - -

Ky. 1 - - 4 - 6 - - - - - -

Tenn. - 2 - 45 - 47 - - - - - -

Ala. - 1 6 7 1 4 - - - - - -

Miss. - - 16 23 16 U - - - - - -

W.S. CENTRAL 2 4 85 187 4 11 - - - - - -

Ark. - - 11 31 3 4 - - - - - -

La. - - - 3 - 1 - - - - - -

Okla. 2 4 67 139 - 6 - - - - - -

Tex. - - 7 14 1 - - - - - - -

MOUNTAIN 4 7 266 248 73 70 - - - - - -

Mont. - - 6 5 - - - - - - - -

Idaho - 1 19 37 - 10 - - - - - -

Wyo. - - 2 1 1 - - - - - - -

Colo. 2 1 64 17 24 11 - - - - - -

N. Mex. - 2 17 45 27 25 - - - - - -

Ariz. 2 1 99 55 13 9 - - - - - -

Utah - 1 49 63 6 10 - - - - - -

Nev. - 1 10 25 2 5 - - - - - -

PACIFIC 16 30 407 660 85 107 1 1 - - 1 1

Wash. - - 4 11 - 3 - - - - - -

Oreg. 5 2 43 123 12 8 - - - - - -

Calif. 9 27 348 518 71 96 1 1 - - 1 -

Alaska - - 3 1 - - - - - - - -

Hawaii 2 1 9 7 2 - - - - - - 1

Guam - - - 1 - - U - U - - -

P.R. - - 5 10 6 10 - - - - - -

V.I. - - - - - - U - U - - -

Amer. Samoa - - - - - - U - U - - -

C.N.M.I. - 8 - 1 - 3 U - U - - -

N: Not notifiable U: Unavailable -: no reported cases

*Of 8 cases among children aged <5 years, serotype was reported for 2 and of those, 0 were type b. †For imported measles, cases include only those resulting from importation from other countries.

Reporting Area

H. influenzae,

invasive

Hepatitis (Viral), by type Measles (Rubeola)

A B Indigenous Imported† Total

Cum.

1997*

Cum.

1996

Cum.

1997

Cum.

1996

Cum.

1997

Cum.

1996 1997

Cum.

1997 1997

Cum.

1997

Cum.

1997

Cum.

1996

92 MMWR January 31, 1997
UNITED STATES 208 319 4 8 27 61 228 87 2 2 9

NEW ENGLAND 18 16 - - - 20 53 9 - - -

Maine - 3 - - - - 3 1 - - -

N.H. 2 1 - - - 12 18 1 - - -

Vt. - 1 - - - 8 31 2 - - -

Mass. 12 2 - - - - 1 5 - - -

R.I. - 3 - - - - - - - - -

Conn. 4 6 - - - - - - - - -

MID. ATLANTIC 14 26 - - 4 1 1 4 - - -

Upstate N.Y. - 2 - - 1 - - 3 - - -

N.Y. City 4 5 - - - - - - - - -

N.J. 5 10 - - 2 - - 1 - - -

Pa. 5 9 - - 1 1 1 - - - -

E.N. CENTRAL 28 52 - - 9 2 5 29 - - -

Ohio 23 25 - - 5 - - 14 - - -

Ind. 3 3 - - - - - - - - -

Ill. - 15 - - 1 - - 2 - - -

Mich. 2 2 - - 3 2 5 4 - - -

Wis. - 7 U - - U - 9 U - -

W.N. CENTRAL 12 36 - - 2 2 7 2 - - -

Minn. - - - - - - - - - - -

Iowa 9 7 - - - 2 6 - - - -

Mo. 1 20 - - - - - 2 - - -

N. Dak. - - - - 2 - - - - - -

S. Dak. 1 2 - - - - 1 - - - -

Nebr. - 4 - - - - - - - - -

Kans. 1 3 - - - - - - - - -

S. ATLANTIC 45 41 - - 2 6 11 5 - - -

Del. 2 1 - - - - - - - - -

Md. 4 6 - - 1 6 11 4 - - -

D.C. 1 2 - - - - - - - - -

Va. 2 3 - - - - - - - - -

W. Va. 1 - - - - - - - - - -

N.C. 6 6 - - - - - - - - -

S.C. 13 8 - - 1 - - - - - -

Ga. 10 13 - - - - - 1 - - -

Fla. 6 2 - - - - - - - - -

E.S. CENTRAL 13 24 - 2 1 2 3 7 - - -

Ky. - 6 - - - - - 5 - - -

Tenn. - 6 - - - - - 1 - - -

Ala. 9 10 - - 1 - 1 1 - - -

Miss. 4 2 - 2 - 2 2 - - - N

W.S. CENTRAL 5 28 - - 1 - 1 1 - - -

Ark. 3 5 - - - - - 1 - - -

La. - 6 - - 1 - - - - - -

Okla. 1 2 - - - - - - - - -

Tex. 1 15 - - - - 1 - - - -

MOUNTAIN 16 24 2 2 2 7 98 16 2 2 -

Mont. 1 - - - - - - - - - -

Idaho 1 2 - - - - 70 - - - -

Wyo. - - - - - - 1 - - - -

Colo. 1 3 1 1 - 5 18 - - - -

N. Mex. 3 7 N N N 2 5 7 - - -

Ariz. 7 8 - - - - 4 - 2 2 -

Utah 2 1 1 1 - - - - - - -

Nev. 1 3 - - 2 - - 9 - - -

PACIFIC 57 72 2 4 6 21 49 14 - - 9

Wash. 7 3 - - - 1 1 1 - - -

Oreg. 23 16 - - - - 2 12 - - -

Calif. 27 51 1 1 5 20 45 - - - 9

Alaska - 1 - - - - 1 - - - -

Hawaii - 1 1 3 1 - - 1 - - -

Guam - 1 U - 1 U - - U - -

P.R. - - - - - - - - - - -

V.I. - - U - - U - - U - -

Amer. Samoa - - U - - U - - U - -

C.N.M.I. - - U - - U - - U - -

N: Not notifiable U: Unavailable -: no reported cases

TABLE III. (Cont’d.) Provisional cases of selected notifiable diseases preventable

by vaccination, United States, weeks ending January 25, 1997,

and January 27, 1996 (4th Week)

Reporting Area

Meningococcal

Disease Mumps Pertussis Rubella

Cum.

1997

Cum.

1996 1997

Cum.

1997

Cum.

1996 1997

Cum.

1997

Cum.

1996 1997

Cum.

1997

Cum.

1996

Vol. 46 / No. 4 MMWR 93
NEW ENGLAND 633 475 100 36 9 13 61

Boston, Mass. 152 95 32 11 4 10 21

Bridgeport, Conn. 44 35 7 1 1 - 3

Cambridge, Mass. 18 15 3 - - - 2

Fall River, Mass. 33 31 2 - - - 3

Hartford, Conn. 65 47 8 9 1 - 3

Lowell, Mass. 34 31 3 - - - 4

Lynn, Mass. 22 19 2 - - 1 2

New Bedford, Mass. 32 24 7 1 - - 1

New Haven, Conn. 45 35 4 3 1 2 3

Providence, R.I. 65 51 8 5 1 - 4

Somerville, Mass. 5 4 - 1 - - 1

Springfield, Mass. 41 33 5 3 - - 8

Waterbury, Conn. 12 9 3 - - - -

Worcester, Mass. 65 46 16 2 1 - 6

MID. ATLANTIC 2,630 1,872 471 204 42 38 187

Albany, N.Y. 67 49 8 4 3 3 4

Allentown, Pa. 20 17 2 1 - - -

Buffalo, N.Y. 73 53 14 3 3 - 6

Camden, N.J. 37 23 9 2 1 2 3

Elizabeth, N.J. 15 11 3 1 - - -

Erie, Pa.§ 38 31 5 2 - - 3

Jersey City, N.J. 59 42 12 4 1 - 4

New York City, N.Y. 1,363 972 247 107 15 22 74

Newark, N.J. 80 31 20 20 5 2 4

Paterson, N.J. 26 18 4 4 - - 2

Philadelphia, Pa. 400 274 75 34 11 5 35

Pittsburgh, Pa.§ 66 53 10 2 - 1 9

Reading, Pa. 12 10 2 - - - 7

Rochester, N.Y. 153 109 29 10 2 3 14

Schenectady, N.Y. 22 19 2 1 - - 1

Scranton, Pa.§ 47 41 5 - 1 - 2

Syracuse, N.Y. 72 54 16 2 - - 13

Trenton, N.J. 46 36 7 3 - - 5

Utica, N.Y. 34 29 1 4 - - 1

Yonkers, N.Y. U U U U U U U

E.N. CENTRAL 2,453 1,710 462 166 44 71 203

Akron, Ohio 49 39 4 5 - 1 -

Canton, Ohio 38 20 16 - 1 1 4

Chicago, Ill. 529 316 118 56 10 29 50

Cincinnati, Ohio 225 158 36 19 5 7 24

Cleveland, Ohio 158 109 27 10 3 9 5

Columbus, Ohio 247 171 52 15 8 1 27

Dayton, Ohio 120 98 18 2 1 1 29

Detroit, Mich. 237 153 57 18 8 1 12

Evansville, Ind. 56 42 10 3 - 1 2

Fort Wayne, Ind. 71 53 11 3 1 3 9

Gary, Ind. U U U U U U U

Grand Rapids, Mich. 51 42 6 1 - 2 5

Indianapolis, Ind. 164 111 32 10 5 6 1

Lansing, Mich. 57 38 13 5 - 1 4

Milwaukee, Wis. 120 87 26 3 - 4 7

Peoria, Ill. 59 49 7 2 1 - 1

Rockford, Ill. 64 49 8 4 - 3 2

South Bend, Ind. 47 38 5 4 - - 3

Toledo, Ohio 93 77 10 4 1 1 17

Youngstown, Ohio 68 60 6 2 - - 1

W.N. CENTRAL 880 643 136 53 19 14 73

Des Moines, Iowa U U U U U U U

Duluth, Minn. 35 31 4 - - - 1

Kansas City, Kans. 48 30 13 4 1 - 1

Kansas City, Mo. 143 91 21 11 1 4 14

Lincoln, Nebr. 47 36 7 2 2 - 4

Minneapolis, Minn. 171 129 19 15 7 1 19

Omaha, Nebr. 124 91 25 2 4 2 11

St. Louis, Mo. 124 89 21 10 1 3 8

St. Paul, Minn. 78 68 5 2 1 2 5

Wichita, Kans. 110 78 21 7 2 2 10

S. ATLANTIC 1,384 930 252 144 34 24 112

Atlanta, Ga. 143 98 28 14 2 1 10

Baltimore, Md. 289 181 64 34 5 5 31

Charlotte, N.C. 131 89 25 10 4 3 14

Jacksonville, Fla. 135 96 26 13 - - 5

Miami, Fla. 107 74 18 14 1 - 2

Norfolk, Va. 59 49 4 4 2 - 6

Richmond, Va. U U U U U U U

Savannah, Ga. 55 46 5 1 - 3 9

St. Petersburg, Fla. 66 50 12 2 1 1 6

Tampa, Fla. 185 128 34 16 5 2 22

Washington, D.C. 195 103 36 33 14 9 7

Wilmington, Del. 19 16 - 3 - - -

E.S. CENTRAL 591 423 106 37 15 9 59

Birmingham, Ala. 39 21 5 8 4 - 1

Chattanooga, Tenn. 100 79 14 5 - 2 18

Knoxville, Tenn. 120 86 20 10 3 1 19

Lexington, Ky. 48 34 10 2 2 - 3

Memphis, Tenn. U U U U U U U

Mobile, Ala. 49 39 8 2 - - -

Montgomery, Ala. 55 46 7 1 1 - 7

Nashville, Tenn. 180 118 42 9 5 6 11

W.S. CENTRAL 1,592 1,025 344 135 57 31 126

Austin, Tex. 101 65 23 10 2 1 4

Baton Rouge, La. 54 33 12 4 3 2 3

Corpus Christi, Tex. 63 39 15 4 2 3 2

Dallas, Tex. 232 139 60 24 5 4 11

El Paso, Tex. 91 60 16 8 4 3 10

Ft. Worth, Tex. 132 88 20 13 9 2 9

Houston, Tex. 439 277 89 40 23 10 42

Little Rock, Ark. 72 49 13 7 1 2 3

New Orleans, La. 43 25 13 2 2 1 -

San Antonio, Tex. 158 104 35 16 1 2 18

Shreveport, La. 64 42 18 3 1 - 5

Tulsa, Okla. 143 104 30 4 4 1 19

MOUNTAIN 1,210 861 213 84 28 24 135

Albuquerque, N.M. 120 85 21 12 1 1 3

Boise, Idaho 43 35 7 1 - - 2

Colo. Springs, Colo. 60 42 9 4 2 3 5

Denver, Colo. 123 85 26 7 2 3 24

Las Vegas, Nev. 305 206 67 18 8 6 25

Ogden, Utah 31 26 3 1 - 1 5

Phoenix, Ariz. 191 122 29 23 9 8 17

Pueblo, Colo. 42 35 5 1 - 1 6

Salt Lake City, Utah 113 82 20 7 3 1 17

Tucson, Ariz. 182 143 26 10 3 - 31

PACIFIC 1,690 1,243 280 113 31 23 203

Berkeley, Calif. 19 14 2 1 1 1 4

Fresno, Calif. 127 85 26 10 3 3 13

Glendale, Calif. 17 13 4 - - - 2

Honolulu, Hawaii 83 67 10 5 - 1 15

Long Beach, Calif. 112 86 20 5 1 - 29

Los Angeles, Calif. 323 229 55 27 10 2 14

Pasadena, Calif. 36 25 3 5 - 3 2

Portland, Oreg. 162 127 24 9 2 - 17

Sacramento, Calif. U U U U U U U

San Diego, Calif. 127 88 24 10 2 3 18

San Francisco, Calif. 136 94 26 12 2 2 30

San Jose, Calif. 239 186 35 9 6 3 30

Santa Cruz, Calif. 40 33 5 1 1 - 9

Seattle, Wash. 133 93 25 10 3 2 8

Spokane, Wash. 66 51 7 5 - 3 9

Tacoma, Wash. 70 52 14 4 - - 3

TOTAL 13,063¶ 9,182 2,364 972 279 247 1,159

Reporting Area >65 45-64 25-44 1-24 <1

P&I†

All Total

Ages

All Causes, By Age (Years)

Reporting Area

P&I†

All Total

Ages

All Causes, By Age (Years)

>65 45-64 25-44 1-24 <1

U: Unavailable -: no reported cases

*Mortality data in this table are voluntarily reported from 122 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 3 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.

TABLE IV. Deaths in 122 U.S. cities,* week ending

January 25, 1997 (4th Week)

94 MMWR January 31, 1997
Contributors to the Production of the MMWR (Weekly)

Weekly Notifiable Disease Morbidity Data and 122 Cities Mortality Data

Denise Koo, M.D., M.P.H.

Deborah A. Adams

Timothy M. Copeland

Patsy A. Hall

Carol M. Knowles

Sarah H. Landis

Myra A. Montalbano

Desktop Publishing and Graphics Support

Morie M. Higgins

Peter M. Jenkins

Vol. 46 / No. 4 MMWR 95
The Morbidity and Mortality Weekly Report (MMWR) Series is prepared by the Centers for Disease Control

and Prevention (CDC) and is available free of charge in electronic format and on a paid subscription basis

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Office, Washington, DC 20402; telephone (202) 512-1800.

Data in the weekly MMWR 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 national basis are officially

released to the public on the following Friday. Address inquiries about the MMWR Series, including material

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All material in the MMWR Series is in the public domain and may be used and reprinted without

permission; citation as to source, however, is appreciated.

Director, Centers for Disease Control 

and Prevention

David Satcher, M.D., Ph.D.

Deputy Director, Centers for Disease Control

and Prevention

Claire V. Broome, M.D.

Director, Epidemiology Program Office

Stephen B. Thacker, M.D., M.Sc.

Editor, MMWR Series

Richard A. Goodman, M.D., M.P.H.

Managing Editor, MMWR (weekly)

Karen L. Foster, M.A.

Writers-Editors, MMWR (weekly)

David C. Johnson

Darlene D. Rumph Person

Teresa F. Rutledge

Caran R. Wilbanks

✩U.S. Government Printing Office: 1997-532-228/47056 Region IV

96 MMWR January 31, 1997