### 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 cur rent editorial note.**  **Reprinted below is the report published April 24, 1992, which first descr ibed** **the need for information on the economic and social impact of disease- and injury prevention strategies, followed by a cont**  **emporary 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 pub**  **lished 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 c**  **ost 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 e fficacious**  **and effective strategies to reduce morbidity and pre mature 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 w**  **ill highl ight the knowledge base regarding a** **specific prevention strategy and will address related considerations, including effi cacy, 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 hea lth officials and policy-makers at all levels require a scientific**  **framework for assessing the effectiveness of disease and injury prevention as a basis**  **for estab lishing 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 Effec tiveness 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 descr**  **ibe examples of how prevention e ffectiveness**  **can be assessed. Because public health programs sometimes may begin to implement preventive** **measures before appropriate assessments are completed, gaps may exist in knowl edge of the e** **fficacy, effecti veness, safety, or ec**  **onomic i mpact of specific prevention**  **strategies. The series of reports in MMWR**  **(weekly) will chara cterize 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 communiti es; 2) sug**  **gest approaches suitable for adaptation to public hea**  **lth practice; and 3) encourage further examination of these topics and stimulate additio**  **nal 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. Pub**  **lic 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 interven** **tions, intermediate impacts, and health outcomes, synthetic analyses can be devel oped 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**  **path ways. 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 c**  **ommunities with di ffering**  **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 hea**  **lth. Recommendations for comparable methods for decision modeling and analysis and eco**  **nomic evaluation in public health are now available (**  **12,13 ). These standards for analysis assure policymakers that studies con**  **ducted in accordance with these principles are reliable and comparable. The need to spend limi**  **ted health-care resources more efficiently is generally ac cepted. Managed-care and public health partners now routinely explore the broadest**  **range of communi ty-based intervention strategies to improve the health of the popu**  **lations they serve. The tools of prevention effectiveness provide decision-makers with critical information necessary for improving decision-making to weigh along with eth**  **ics, feasibility, and the distribution of costs and benefits to different populations. For**  **example, policy discussions on the fortification of food with fo lic 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 supplemen tation, or with no intervention (**  **14 ).**  **Since 1992, CDC has increased substantially its capab ility in prevention effective**  **ness through courses, postdoctoral fellowships, routine use of economic evaluations (cost-effectiveness and cost-bene** **fit 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. P**  **revention effective ness has become a**  **core science for public health, but additional efforts are required to clarify un**  **derstanding of how prevention effectiveness**  **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 com**  **plete, and comparable information on cost-effectiveness needs to be available to**

**users. 1997 Editorial Note by Steven M Teutsch, MD, MPH, Office of the D**  **irector, Division of Pr evention**  **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 f ocus: 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 de**  **cision 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. Cost effectiveness 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 nued**  **Influenza activity in the United States increased from mid-No 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 col laborating laborator**  **ies 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 i nfluenza 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 Janu**  **ary 18. The number of inf luenza 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 infl **uenza 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 lab**  **oratory-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 phy**  **sicians 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 Janu**  **ary 18. The percentage of deaths attributed to pn**  **eumo nia and influenza (P&I) ex**  **ceeded 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 anti**  **gens. 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, Epidemiol ogy, 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 morbid**  **ity and mortality, particularly among the el derly, than have seasons**  **during which influenza A(H1N1) or influenza type B vir**  **uses predominated ( 1,2**  **). When influenza strains included in vaccines are closely matched with circulating strains, influenza vac**  **cine 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 regres sion 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, influ enza vaccine may be only 30%–40% effective in preventing ILI among nursin**  **g-home residents; however, among such groups, influenza vaccine may be 50%–60% effective**  **in preventing pneumonia and hospitali zation 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 vacci**  **nated groups. Nursing homes and other facilities providing care for persons at risk for influenza-associated complications should consider using the antiviral agents**  **aman tadine 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**  **empha sizes the importance of continued surveillance to detect changes in the relative pro**  **portions of circulating influenza virus ty pes or subtyp**  **es. 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 riman tadine 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, tel**  **ephone (404) 33 2-4551, 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 — Conti **nued** 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 chil**  **dren 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) pro gress toward global eradication of poliomyelitis has reduced the risk for importation**  **of wild poliovirus into the United States ( 3** **), and 3) vaccine-associated paralytic polio myelitis (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 depart ments reported to CDC** **133 confirmed cases of paralytic poliomyelitis. Of these, 125 (94%) cases were associ ated with administration of OPV (annual mean: eight VAPP cases) (Figure 1); six cases**  **(only one of which occurred after 1986) were classified as im ported; 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 nor**mal 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 vac**  **cinees), and 30 (24%) among immunologically**  **compromised OPV recipients or con tacts 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 admini**  **stration 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 (7 0%) 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 recipi ents, 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 administra**  **tion 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 t**  **hrough 1994. The number of cases among all vaccine recipi**  **ents 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 c ontacts declined signifi**  **cantly, 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 im munologi** **cally normal first-dose recipients was one case to the 1.4 million first doses distrib uted. For all first-dose recipients (i**  **mmunologically 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 mi**  **llion 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 k**  **nown, 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 immunologi**  **cally 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 al low additional time for di**  **agnosis of immunodeficiency (which contraindicates receipt of OPV) and enable prevention of**  **some VAPP cases among i mmunodefici**  **ent 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. Al**  **though 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 par**  **ents and adult close contacts of vaccinees without i mmunity to pol**  **iovirus, particularly in areas where compliance with these requirements is high (**  **8 ). However, other re**  **ports 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 suscep tible 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 di**  **agnosed cases contributes to incomplete surveillance (**  **6 ). Any suspected**  **case of paralytic poliomyelitis must be reported immedi ately to state or local health**  **authorities ( 10** **). A clinical case definition for reporting cases of paralytic poliomyeli** **tis* was adopted by the** **Council of State and Territorial Epidemiologists in 1990. Con**  **firmed 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 un known 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 polio myelitis (i.e., patients with acute paralytic manifestations), and information about** **clinical diagnosis and reporting of cases is available from CDC’s National Immuniza tion Program, telephone (404) 639-8255.**  **Laboratory studies, especially attempted poliovirus isola**  **tion, 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 en teroviral typing should be considered for**  all**patients with acute flaccid paralysis un less an alternative diagnosis is apparent. Intratypic differentiation must be performed** **to determine whether a poliovirus isolate is vaccine-related or wild type. The En terovirus 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 ship**  **ment of clinical specimens is avail able from this laboratory, tel**  **ephone (4 04) 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—recommen**  **dations 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 polio**  **myelitis 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 para**  **lytic 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 nued**  **Contaminated whirlpool spas have been reported as a source of legionellosis. This**  **report describes the preliminary findings of an o ngoing 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 con** **tacted the Office of Epidemiology, VDH, about a hospital (hospital A) report that 15 pa tients had been admitted during October 12–13 with**  **unexplained pneumo nia. On** **October 21, another hospital (hospital B), located approximately 15 miles from hospi tal 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] an**  **tigen 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 col**  **lected 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 pn**  **eumo nia 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 anti**  **gen, 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, case**  **patients 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 confir**  **med 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 follow ing the case-control study). A history of having visited a large h**  **ome-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 c ommunity,**  **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 test**  **ing 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 sub typing and arbitrarily primed polymerase chain reaction, to the sputum isolates cul**  **tured 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 en**  **vironmental 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 out**  **breaks have documented aerosol transmission of Legionella** **from contaminated cool ing 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 occu**  **rring disease attributable to these sources has not**  **yet been determined. In contrast with other spa- or whirlpool-assoc**  **iated 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. Al**  **though most community-wide outbreaks of legionellosis have resulted**  **from transmission from an**  **outdoor source (e.g., c ooling 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 investiga**  **tion 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 isol ates, suggesting this case was not**  **related to the outbreak. Although the source of the outbreak was removed before the inv** **estigation 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 regul**  **arly changed or decontaminated. In response to a recent outbreak of Legion**  **naires 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 regard ing 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 Legion naires’ 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 Legion**  **naires’ 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 rec**  **ommendations 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 — Conti **nued** 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 Janu ary 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 Pas senger Safety Awareness**  **Week is a time to enhance activities focusing on child passenger safety. Additional information about materials to s**  **upport 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 Ad ministration, 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 I mmunization Initia** **tive (CII), CDC publishes quarterly a tabular summary of the number of cases of na tionally 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 Telecommunica**  **tions 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 vac**  **cination 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, pediat ric** * **§**

**-** 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 Div ision of Viral and Rick** **etts ial**  **Diseases, National Center for Infe ctious D**  **iseases (NCID). §**  **Updated monthly to the Division of HIV/AIDS Prevention, National Center for HIV, STD, and TB Prev ention**  **(NCHSTP), last update December**  **24, 1996. ¶**  **Updated quarterly from reports to the Div ision 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**

**2 1**  **0.5 0.25**  **0.125 0.0625**  **0.03125**

***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 C enter for HIV, S** **TD, and TB Prevention, last update De cember 24, 1996.**  **† National Electronic Telecommunications System for**  **Surveillance. §**  **Public Health Laboratory Information System.**

Reporting Area AIDS* Chlamydia Escherichia coli O157:H7
Gonorrhea Hepatitis C/NA,NB NETSS † PHLIS §

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: Unav ailable -: 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 a mong children aged <5 years, ser** **otype 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 Pertu ssis 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, Co nn. 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 Evansv**  **ille, 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, T**  **ex. 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 Pasade**  **na, 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 C ruz, 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 † Total All Ages All Causes, By Age (Years) Reporting Area P&I † Total All 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 95The Morbidity and Mortality Weekly Report (MMWR) Series is prepared by the Centers for Disease Control and Prevent ion (CDC) and is available free of charge in electronic format and on a paid subscription basis for paper copy. To receive an electronic copy on Friday of each week, send an e-mail message to lists@list.cdc.gov

. The body content should read subscribe mmwr-toc

. Electronic copy also is available from CDC’s World-Wide Web server at http://www.cdc.gov/ or from CDC’s file transfer protocol server at ftp.cdc.gov

. To subscribe for paper copy, contact Superintendent of Documents, U.S. Government Printing 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 to be considered for publication, to: Editor, MMWR Series, Mailstop C-08, CDC, 1600 Clifton Rd., N.E., Atlanta, GA 30333; telephone (404) 332-4555. 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, E pidemiology 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. F oster, M.A.**  **Writers-Editors, MMWR**  **(weekly) David C. Johnson**  **Darlene D. Rumph Person Teresa F. Rutledge**  **Caran R. Wilbanks**

✩ U.S. Government Printing Office: 1997-5 32-228/47056 Region IV 96 MMWR January 31, 1997