Morbidity and Mortality Weekly Report
Weekly August 9, 2002 / Vol. 51 / No. 31
West Nile Virus Activity United States, July 31August 7, 2002, and Louisiana, January 1August 7, 2002
This report summarizes West Nile virus (WNV) surveillance data reported to CDC through ArboNET and by states and other jurisdictions as of August 7, 2002.
FIGURE 1. Areas reporting West Nile virus (WNV) activity United States, 2002*

United States

During the reporting period of July 31August 7, a total of 68 laboratory-positive human cases of WNV-associated illness were reported from Louisiana (n=40), Mississippi (n=23), Texas (n=four), and Illinois (n=one). During the same period, WNV infections were reported in 447 dead crows, 263 other dead birds, 42 horses, and 183 mosquito pools. During 2002, a total of 112 human cases with laboratory evidence of recent WNV infection have been reported from Louisiana (n=71), Mississippi (n=28), Texas (n=12), and Illinois (n=one). Five deaths have been reported, all from Louisiana. Among the 98 cases with available data, 59 (60%) occurred among men; the median age was 55 years (range: 388 years), and the dates of illness onset ranged from June 10 to July 29. In addition, 1,076 dead crows and 827 other dead birds with WNV infection were reported from 34 states, New York City, and the District of Columbia (Figure 1); 87 WNV infections in horses have been reported from 12 states (Alabama, Florida, Georgia, Illinois, Kentucky, Louisiana, Minnesota, Mississippi, North Dakota, South Dakota, Tennessee, and Texas). During 2002, WNV seroconversions have been reported in 52 sentinel chicken flocks from Florida, Nebraska, and Pennsylvania; and 425 WNV-positive mosquito pools have been reported from 12 states (Alabama, Georgia, Illinois, Indiana, Massachusetts, Mississippi, New Jersey, Ohio, Pennsylvania, South Dakota, Texas, and Virginia), New York City, and the District of Columbia.

District of Columbia

Recent human WNV infection and animal WNV activity Animal WNV activity only

* As of August 7, 2002.

INSIDE
Outbreak of Salmonella Serotype Javiana Infections Orlando, Florida, June 2002 Childhood Lead Poisoning Associated with Tamarind Candy and Folk Remedies California, 19992000 Human Rabies California, 2002 Outbreak of Tularemia Among Commercially Distributed Prairie Dogs, 2002 Notices to Readers
Centers for Disease Control and Prevention
SAFER HEALTHIER PEOPLE HEALTHIER

August 9, 2002

Louisiana
The MMWR series of publications is published by the Epidemiology Program Office, Centers for Disease Control and Prevention (CDC), U.S. Department of Health and Human Services, Atlanta, GA 30333.
SUGGESTED CITATION Centers for Disease Control and Prevention. [Article Title]. MMWR 2002;51:[inclusive page numbers].
Julie L. Gerberding, M.D., M.P.H. Director David W. Fleming, M.D. Deputy Director for Science and Public Health Dixie E. Snider, Jr., M.D., M.P.H. Associate Director for Science
Epidemiology Program Office
Stephen B. Thacker, M.D., M.Sc. Director
Office of Scientific and Health Communications
John W. Ward, M.D. Director Editor, MMWR Series David C. Johnson Acting Managing Editor, MMWR (Weekly) Jude C. Rutledge Teresa F. Rutledge Jeffrey D. Sokolow, M.A. Writers/Editors, MMWR (Weekly) Lynda G. Cupell Malbea A. Heilman Beverly J. Holland Visual Information Specialists Quang M. Doan Erica R. Shaver Information Technology Specialists
Division of Public Health Surveillance and Informatics
During January 1August 7, Louisiana Office of Public Health (LOPH) has identified 71 laboratory-positive human cases of WNV. Clinically, 55 patients presented with WNVassociated meningoencephalitis (including five fatalities) and nine with WNV-associated fever. The clinical presentations of seven patients have not been ascertained. Of the 71 cases, 38 (54%) occurred in males. Patients ranged in age from 13 to 88 years (median: 55 years). Decedents ranged in age from 53 to 83 years (median: 75 years). Patients resided in 13 different Louisiana parishes including the southeast (Ascension, East Baton Rouge, East Feliciana, Jefferson, Livingston, Orleans, St. Tammany, Tangipahoa, Washington, West Baton Rouge), southwest (Allen and Calcasieu), and north (Ouachita) regions of the state (Figure 2). LOPH, with the assistance of CDC, has initiated a hospital-based, active surveillance system for viral encephalitis and meningitis. In addition, the incidence of WNV-associated fever in the community is being investigated through intensive evaluation of febrile patients with symptoms compatible with WNV-associated fever who consult physicians and hospitals. A clinical case-series has been established, and entomological and avian studies are under way. Surveillance for WNV has been ongoing in Louisiana since spring 2000 and involves testing of dead birds, sick horses, mosquito pools, and sentinel chicken flocks. The increase in dead bird collections during the last week of May 2002 triggered the intensification of mosquito-control activities, including warnings to mosquito-control district staff and communities. The Louisiana Department of Health and Hospitals also created a website (http://www.FightTheBiteLouisiana.com) to provide the public with information about personal protective measures. A related media campaign was launched durFIGURE 2. Number of West Nile virus cases in humans, by parish Louisiana, January 1August 7, 2002

Shreveport 1

Notifiable Disease Morbidity and 122 Cities Mortality Data Robert F. Fagan Deborah A. Adams Felicia J. Connor Lateka Dammond Patsy A. Hall Pearl C. Sharp

Baton Rouge 1 3

Slidell

New Orleans

Vol. 51 / No. 31
ing the third week of June. Mosquito surveillance has guided vector-control activities, including larviciding of potential breeding sites and ultra-low volume applications of insecticide against adult mosquitoes. Additional information about WNV activity is available at http://www.cdc.gov/ncidod/dvbid/westnile/index.htm and http://cindi.usgs.gov/hazard/event/west_nile/west_nile.html.
Outbreak of Salmonella Serotype Javiana Infections Orlando, Florida, June 2002
On July 16, 2002, the Minnesota Department of Health identified two cases of Salmonella serotype Javiana infections among persons who had attended the 2002 U.S. Transplant Games held at theme park A in Orlando, Florida, during June 2529. Isolates from both patients were indistinguishable by pulsed field gel electrophoresis (PFGE). The U.S. Transplant Games is a 4-day athletic competition among recipients of solid organ transplants (i.e., heart, liver, kidney, lung, and pancreas) and bone marrow transplants. Approximately 6,000 persons from the United States and five other countries, including 1,500 transplant-recipient athletes, participated in the games. This report summarizes the results of an ongoing epidemiologic and laboratory investigation that has identified 141 ill persons in 32 states who attended the games. For case ascertainment and investigation purposes, a webbased survey was distributed electronically on July 20 to 1,100 attendees with known e-mail addresses, including athletes, donors, family members, and transplant professionals. Anonymous e-mail addresses for these persons were obtained from the organizers of the games. A case was defined as fever or diarrhea with onset during June 25July 7 in a person who visited Orlando. A total of 369 (34%) persons responded by August 1; of these, 296 (80%) responded by July 22. Ninetyfour (25%) persons reported that at least one household member had an illness that met the case definition, representing 141 ill persons. For each of the 369 households, detailed information was collected for one person who was selected on the basis of birth date. Among these persons, 82 (22%) reported illness. The median age of ill respondents was 47 years (range: 471 years); 48 (59%) were transplant recipients, and 43 (52%) were receiving immunosuppressive therapy. Dates of illness onset ranged from June 26 to July 7. Predominant symptoms included diarrhea (93%), abdominal pain (79%), and fever (51%). Three (4%) respondents were hospitalized.

All survey respondents were asked about places they stayed, events they attended, and foods they ate while in Orlando. Fifty-one (66%) ill persons stayed at resorts located in theme park A during their time in Orlando, and 75 (91%) reported eating food items at establishments located in theme park A. On July 31, a second web-based survey containing questions about potentially suspect food items available in theme park A was distributed electronically to the 369 persons who responded to the first survey. Ill persons were asked about specific foods eaten during the 3 days before illness onset, and well persons were asked about the middle 3 days of the games (June 2628). By August 2, a total of 222 (60%) persons had responded to the second survey; 41 had been ill. Univariate analysis demonstrated that ill persons were significantly more likely to report eating foods containing diced Roma tomatoes than were well persons (44% of ill versus 14% of well persons; adjusted odds ratio=4.3; 95% confidence interval=2.19.1). Preliminary microbiologic evaluation indicates fecal coliform contamination of the diced tomatoes. To identify other potential cases of S. Javiana, the PFGE pattern for the outbreak strain was posted on PulseNet, the National Molecular Subtyping Network for Foodborne Disease Surveillance. A total of 18 additional infections caused by S. Javiana with an indistinguishable PFGE pattern were identified in nine states (Illinois, Massachusetts, Michigan, Minnesota, New Hampshire, North Carolina, Pennsylvania, Tennessee, and Virginia). Of 16 patients who were interviewed, one was a games participant, and 12 others had visited theme park A during the last week of June but did not attend the games. Dates of illness onset ranged from June 24 to July 8. State and local health departments are investigating additional cases to establish epidemiologic links to the outbreak.
Reported by: B Toth, MPH, Orange County Health Dept, Orlando; D Bodager, MPA, RM Hammond, PhD, Florida Dept of Health. S Stenzel, JK Adams, Minnesota Dept of Health. T Kass-Hout, MD, RM Hoekstra, PhD, PS Mead, MD, Div of Bacterial and Mycotic Diseases, National Center for Infectious Diseases; P Srikantiah, MD, EIS Officer, CDC.
Editorial Note: Salmonellosis causes an estimated 1.4 million illnesses each year in the United States (1). S. Javiana is the fifth most common Salmonella serotype in the United States and accounted for 3.4% of Salmonella isolates reported to CDC during 2001 (CDC, unpublished data, 2002). The majority of persons infected with Salmonella have diarrhea, fever, and abdominal cramps 1272 hours after exposure. The illness usually lasts 47 days, and the majority of persons recover without treatment. Persons with impaired immune systems are at increased risk for having a more severe illness, atypical symptoms, and complications of infection. Among organ transplant recipients,

salmonellosis is associated strongly with antirejection therapy (2), and febrile illness with bacteremia is a more common presentation (3). Organ transplant patients are at increased risk for focal manifestations of illness including meningitis, urinary tract infections, abscesses of soft tissues, septic arthritis, osteomyelitis, and vascular infections, including infections of vascular grafts (46). Recurrence of nontyphoidal salmonellosis is common among this population and might occur in up to 35% of renal transplant recipients (2,3). Physicians caring for recipients of solid organ and bone marrow transplants should be aware of possible exposure to S. Javiana at the 2002 U.S. Transplant Games and should consider obtaining cultures (i.e., stool, blood, and urine) from ill patients with this exposure. The optimal therapy for Salmonella infection in transplant recipients is not known (4). However, because of the increased susceptibility to infection and the potential for complications, physicians might consider empiric antimicrobial therapy in transplant recipients with suspected salmonellosis from whom appropriate cultures have been obtained. The strain of S. Javiana responsible for this outbreak is susceptible to several commonly used antimicrobials, including trimethoprim-sulfamethoxazole, ciprofloxacin, and ceftriaxone. Physicians should report culture-confirmed cases of salmonellosis to their local health department. The use of a web-based survey in this investigation allowed a substantial number of persons who were dispersed geographically to be asked about potential exposures in a relatively short period of time. Twelve culture-confirmed cases of S. Javiana among visitors to theme park A who did not attend the games were identified through PulseNet, indicating that the number of ill persons in this outbreak is probably much larger than what has been identified in the surveyed Transplant Games population. The combination of molecular subtyping, web-based technology, and routine public health surveillance facilitated the outbreak investigation. The findings in this report are subject to at least two limitations. First, a web-based investigation limited responses to only those attendees with known e-mail addresses and Internet access. Second, although responses were received from both well and ill persons, households with ill persons might have been more likely to respond to a web-based survey. Therefore, it is difficult to calculate an accurate attack rate among attendees of the games. Preliminary findings of the epidemiologic investigation have implicated fresh, pre-packaged diced Roma tomatoes supplied to theme park A as the probable vehicle for this outbreak. Efforts are under way to identify the source of these tomatoes and possible routes of contamination. Tomatoes are not a

commonly recognized vehicle for Salmonella, and no evidence exists for widespread contamination of tomatoes available for purchase. However, tomatoes have been implicated in at least one previous outbreak of S. Javiana infections (7), and cut surfaces of tomatoes and other fresh fruits and vegetables can support the growth of Salmonella and other enteric pathogens (8,9). Produce is recognized increasingly as a source of Salmonella infections in the United States, and consumers should wash tomatoes and other produce items thoroughly before eating. The Food and Drug Administration guidelines for safe produce-handling practices are available at http:// www.cfsan.fda.gov/~lrd/tpproduc.html.

Acknowledgments

This report is based on data contributed by R Baker, MS, Florida Dept of Health. C Langkop, MSPH, Illinois Dept of Public Health. T LaPorte, MS, Massachusetts Dept of Public Health. S Bidol, MPH, Michigan Dept of Community Health. L Anderson, MD, New Hampshire Dept of Health and Human Svcs. P Jenkins, North Carolina Dept of Health and Human Svcs. J Murphy, DVM, Virginia Dept of Health.
References 1. Mead PS, Slutsker L, Dietz V, et al. Food-related illness and death in the United States. Emerg Infect Dis 1999;5:60725. 2. Dhar JM, al-Khader AA, al-Sulaiman M, al-Hasani MK. Non-typhoid Salmonella in renal transplant recipients: a report of twenty cases and review of the literature. Q J Med 1991;78:23550. 3. Rubin RH. Gastrointestinal infectious disease complications following transplantation and their differentiation from immunosuppressantinduced gastrointestinal toxicities. Clin Transpl 2001;15:1122. 4. Huang JY, Huang CC, Lai MK, Chu SH, Chuang CK. Salmonella infection in renal transplant recipients. Transplant Proc 1994;26:2147. 5. Patel R, Paya CV. Infections in solid-organ transplant recipients. Clin Microbiol Rev 1997;10:86124. 6. Ramos JM, Garcia-Corbeira P, Aguado JM, Plaza JJ, Soriano F. Nontyphoid Salmonella extraintestinal infections in renal transplant recipients. Nephron 1995;71:48990. 7. Hedberg CW, Angulo FJ, White KE, et al. Outbreaks of salmonellosis associated with eating uncooked tomatoes: implications for public health. Epidemiol Infect 1999;122:38593. 8. Zhuang RY, Beuchat LR, Angulo FJ. Fate of Salmonella Montevideo on and in raw tomatoes as affected by temperature and treatment with chlorine. Appl Environ Microbiol 1995;61:212731. 9. Asplund K, Nurmi E. The growth of Salmonellae in tomatoes. Int J Food Microbiol 1991;13:17781.

Childhood Lead Poisoning Associated with Tamarind Candy and Folk Remedies California, 19992000
Lead poisoning affects children adversely worldwide. In the United States, elevated blood lead levels (BLLs) (>10 g/dL)
result primarily from exposure to lead-based paint or from associated lead-contaminated dust and soil; however, other sources of lead exposure, including folk remedies, Mexican terra cotta pottery, and certain imported candies, also have been associated with elevated BLLs in children (1). This report describes five cases in California of lead poisoning from atypical sources. Health-care providers should be aware of the potential hazards of certain food products, and community members should be educated about potential sources of lead poisoning for children.

Case Reports

Cases 1 and 2. In March 1999, two Hispanic children residing in Stanislaus County in the Central Valley, a boy aged 4 years and his sister aged 6 years, were identified during routine screening by Californias Child Health and Disability Prevention (CHDP) Program. The boy had a BLL of 88.0 g/dL and the girl a BLL of 69.0 g/dL. Both children underwent chelation therapy. Their parents had not traveled recently outside the United States but had used greta, a Mexican folk remedy (taken commonly for stomachache or intestinal illness) that usually contains high levels of lead. No pottery in the home tested positive for lead, and tests on paint and dust from their home did not indicate high lead levels. Greta powder collected from the familys home had 770,000 parts per million (ppm) of lead, and miniblinds on the windows of the home tested positive for lead by swab. Imported candies, including Dulmex-brand Bolirindo lollipops, which were identified later to be contaminated with lead, were found in the home. Case 3. In May 2000, a Hispanic boy aged 4 years residing in Fresno County was identified during routine CHDP screening with a BLL of 26 g/dL. His family had moved to California recently from Oaxaca, Mexico, where they had used a ceramic bean pot and water jug regularly. An environmental investigation did not reveal high lead levels in dust, paint, or soil, but tests on imported candies collected from the home revealed a candy wrapper with a lead level of 16,000 ppm. The childs BLL had decreased to 13.2 g/dL by February 2002. Case 4. In June 2000, a Hispanic boy aged 2 years residing in Orange County was identified through routine screening as having a BLL of 26 g/dL. The familys house was built in 1963 and had been renovated during early 2000. Tests on soil, paint, and dust in and around the childs home did not reveal high lead levels. The child had been given greta and azarcon (a folk remedy that usually contains substantial amounts of lead) and had eaten various imported tamarind fruit candies purchased routinely by his family in Mexico. High lead levels were found in one of the three brands

References 1. CDC. Preventing lead poisoning in young children: a statement by the Centers for Disease Control, October 1991. Atlanta, Georgia: U.S. Department of Health and Human Services, Public Health Service, CDC, 1991. 2. CDC. Lead poisoning associated with imported candy and powdered food coloringCalifornia and Michigan. MMWR 1998;47:10413. 3. Fuortes L, Bauer E. Lead contamination of imported candy wrappers. Vet Hum Toxicol 2000;42:412. 4. Lynch RA, Boatright DT, Moss SK. Lead-contaminated imported tamarind candy and childrens blood lead levels. Public Health Rep 2000;115:53743. 5. Wu TN, Yang GY, Shen CY, Liou SH. Lead contamination of candy: an example of crisis management in public health. Lancet 1995;346:14378. 6. CDC. Guidelines for the management of elevated blood lead levels among young children. Atlanta, Georgia: U.S. Department of Health and Human Services, Public Health Service, CDC, 2002.
Human Rabies California, 2002
On March 31, 2002, a man aged 28 years residing in Glenn County, California, died from rabies encephalitis caused by a rabies virus variant associated with the Mexican free-tailed bat (Tadarida brasiliensis) (Figure). This report summarizes the investigation by the Glenn County Health Department (GCHD) and the California Department of Health Services (CDHS). Persons who observe abnormal behavior in any wildlife species should contact animal control or animal rescue agencies immediately and should avoid approaching or handling these animals. On March 18, the patient sought medical care at the emergency department (ED) of a medical center with symptoms including headache, jaw pain, photophobia, agitation, dizziness, numbness, nausea, and vomiting. He was treated for dehydration, administered analgesics, and discharged. On the following day, the patient returned to the ED with increasing headache, pain, agitation, tingling of the head and legs, nausea, and vomiting. The patient was hospitalized later that evening, and treatment was initiated with ceftriaxone. A computerized tomography scan performed on March 19 was unremarkable, except for right-sided ethmoid sinusitis. Lumbar punctures were performed on March 19 and March 22 and yielded normal results. Laboratory results from serum specimens obtained on March 28 indicated hyponatremia of 131 meq/L (normal: 136145 meq/L), decreased uric acid of 1.5 mg/dL (normal: 2.58.0 mg/dL), creatine phosphokinase of 236 units/ml (normal: 2590 units/ml), and a white blood cell count of 11,500/uL (normal: 3,7009,400/uL). Blood and cerebrospinal fluid bacterial cultures were negative. The
FIGURE. Mexican free-tailed bat (Tadarida brasiliensis)

Photo/CDC

patients condition continued to deteriorate with symptoms of a rapidly progressive encephalopathy. He had fever, incoherent speech, increased agitation, and copious salivation. The patient became comatose on March 27 and was placed on ventilatory support; support was withdrawn on March 31, and the patient died. On March 27, rabies was suspected, and samples, including serum, corneal impressions, a nuchal biopsy, and saliva, were collected and sent to the CDHS Viral and Rickettsial Disease Laboratory (VRDL). No rabies virusspecific antibody was detected in the serum, and the direct fluorescent antibody (DFA) test on corneal impressions was inconclusive. On March 29, additional samples of serum and corneal impressions were collected and showed that the corneal impressions were positive for rabies virusspecific antigen by DFA and that the saliva sample was positive for rabies virus RNA by reverse transcription polymerase chain reaction (RT-PCR). The nuchal biopsy was negative by DFA. Rabies was diagnosed presumptively pending confirmation by CDC. Serum samples also were collected on March 30 and 31. The diagnosis was confirmed by CDC on April 1, with a saliva sample positive by RT-PCR. The virus was identified by genetic sequence analysis as a variant associated with the Mexican free-tailed bat. Rabies virusspecific antibody was detected at VRDL by indirect immunofluorescent antibody test in the serum samples from March 30 and 31. Histopathology results of brain tissue obtained from the autopsy showed lymphocytic infiltration of the meninges and perivascular areas within the brain parenchyma. Eosinophilic inclusions consistent with Negri bodies were found primarily in the brainstem. These features were consistent with a diagnosis of rabies viral encephalitis. The patients family reported that he had killed a bat in his house on March 10, although he had denied having any direct contact. The family also reported numerous bats in the home environment. An investigation of the patients home by GCHD revealed a bat colony in the attic of the house. A bat that appeared ill was found inside the living spaces of the house on March 31 and was submitted for rabies testing and species identification. The bat was identified as a Mexican free-tailed bat; it was negative for rabies by DFA. Four household members, two other family members, and 12 social contacts received postexposure prophylaxis (PEP) because of possible exposure to the patient through saliva. In addition, 28 health-care workers who had contact with the patient also received PEP.

This report is based on data contributed by D Schnurr, PhD, R Devlin, MT, S Honarmand, E Tu, A Hewitt, E Yeh, C Kohlmeier, A Wong, D Constantine, DVM, Viral and Rickettsial Disease Laboratory; M Jay, DVM, B Sun, DVM, Div of Communicable Disease Control, California Dept of Health Svcs; D Galvon, MD, G Norton, D Holm, Glenn County Health Dept, Willows; M Lundberg, MD, T Baptista, Butte County Health Dept, Oroville; S Forner, MD, E ORegan, MD, Enloe Medical Center; L Wong, MD, Path Sciences Medical Group, Chico, California. C Hanlon, VMD, L Orciari, MS, M Niezgoda, MS, J Smith, MS, Div of Viral and Rickettsial Diseases, National Center for Infectious Diseases, CDC.
References 1. Krebs JW, Mondul AM, Rupprecht CE, Childs JE. Rabies surveillance in the United States during 2000. J Am Vet Med Assoc 2001;219:168799. 2. Wilkins KT. Tadarida brasiliensis. Mammalian Species 1989;331:110. 3. Gibbons RV. Cryptogenic rabies, bats, and the question of aerosol transmission. Ann Emerg Med 2002;39:52836. 4. CDC. Human rabies preventionUnited States, 1999: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR 1999;48(No. RR-1).

Public Health Dispatch

Outbreak of Tularemia Among Commercially Distributed Prairie Dogs, 2002
Tularemia has been identified recently as the cause of a die-off in captured wild prairie dogs (Cynomys ludovicianus) (Figure) at a commercial exotic animal distributor in Texas. The Texas Department of Health and CDC immediately notified all state health departments and are investigating the outbreak.
FIGURE. Black-tailed prairie dogs (Cynomys ludovicianus)
Until shipments were halted on August 1, 2002, approximately 250 of an estimated 3,600 prairie dogs that passed through the Texas facility had died. The sick animals were believed to be part of a single shipment of prairie dogs that were caught in South Dakota starting on May 18 and shipped to the Texas distributor on June 16. All prairie dogs that were shipped by the Texas facility after June 16 or by the South Dakota trader after May 18 are being recalled. Potentially infected prairie dogs were distributed to wholesalers, retailers, and persons in Arkansas, Florida, Illinois, Michigan, Mississippi, Nevada, Ohio, Texas, Washington, and West Virginia and exported to Belgium, the Czech Republic, Japan, The Netherlands, and Thailand. States and countries that received shipments of potentially infected animals have been notified. Unusually high numbers of sick or dead prairie dogs were reported from Texas and the Czech Republic. Tularemia is caused by infection with Francisella tularensis. The incubation time in humans is normally 26 days but can be 114 days. The disease usually begins suddenly with high fever, chills, head and muscle aches, and a feeling of weakness. Chest discomfort and a dry cough are common. Other symptoms might appear depending on how the infection is acquired. For example, if the bacteria enter through a break in the skin, an ulcer will usually develop at the site of entry, accompanied by regional lymphadenopathy. In the United States, humans usually acquire tularemia by handling wild rabbits (e.g., while skinning the animal) or by being bitten by infective ticks and certain flies (e.g., deer flies and horse flies). Two known F. tularensis biotypes exist in the United States. Type A is more virulent than type B, but both can result in severe and sometimes fatal illness. F. tularensis recovered from the sick prairie dogs was type B. Adults who have handled sick or dead prairie dogs from the suspected shipments in the last 2 weeks are being advised to take doxycycline (100 mg twice daily for 14 days) or ciprofloxacin (500 mg twice daily for 14 days). Because these drugs have a higher risk for side effects in children, children who are considered at risk should not take antibiotics but have their temperature monitored for 14 days. Persons who have been in contact with prairie dogs during the preceding 2 weeks and who have fever and other symptoms suggesting tularemia should see their physician. Preferred drugs for treatment of tularemia are gentamicin and streptomycin. To report human tularemia cases that might be associated with prairie dog exposure or to inquire about shipment of potentially infected prairie dogs, state health departments should contact CDCs Division of Vector-borne Infectious Diseases, telephone 970-221-6400, fax 970-221-6476, e-mail ncidprairiedoginquiries@cdc.gov.

(Continued on page 699)

FIGURE I. Selected notifiable disease reports, United States, comparison of provisional 4-week totals ending August 3, 2002, with historical data

DISEASE

Hepatitis A, Acute Hepatitis B, Acute Hepatitis C; Non-A, Non-B, Acute Legionellosis Measles, Total Meningococcal Infections Mumps Pertussis Rubella *

DECREASE

INCREASE

CASES CURRENT 4 WEEKS

0.03125 0.0625 0.125 0.25 0.5

Ratio (Log Scale)

Beyond Historical Limits
* No rubella cases were reported for the current 4-week period yielding a ratio for week 31 of zero (0). 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.
TABLE I. Summary of provisional cases of selected notifiable diseases, United States, cumulative, week ending August 3, 2002 (31st Week)*

Cum. 2002

Anthrax Botulism: foodborne infant other (wound & unspecified) -

Cum. 2001

4 Encephalitis: West Nile Hansen disease (leprosy) Hantavirus pulmonary syndrome Hemolytic uremic syndrome, postdiarrheal HIV infection, pediatric Plague Poliomyelitis, paralytic Psittacosis Q fever Rabies, human Streptococcal toxic-shock syndrome Tetanus Toxic-shock syndrome Trichinosis Tularemia Yellow fever
Brucellosis Chancroid Cholera Cyclosporiasis Diphtheria Ehrlichiosis: human granulocytic (HGE) human monocytic (HME) other and unspecified Encephalitis: California serogroup viral eastern equine Powassan St. Louis western equine -:No reported cases. * Incidence data for reporting year 2001 and 2002 are provisional and cumulative (year-to-date). Not notifiable in all states. Updated monthly from reports to the Division of HIV/AIDS Prevention Surveillance and Epidemiology, National Center for HIV, STD, and TB Prevention (NCHSTP). Last update July 28, 2002.
TABLE II. Provisional cases of selected notifiable diseases, United States, weeks ending August 3, 2002, and August 4, 2001 (31st Week)*

Escherichia coli Shiga Toxin Positive, O157:H7 Serogroup non-O157 Cum. Cum. Cum. Cum. 2002 2001
1,N 25 N U 1,N N 1 U U 3 N U N U U
AIDS Reporting Area UNITED STATES NEW ENGLAND Maine N.H. Vt. Mass. R.I. Conn. MID. ATLANTIC Upstate N.Y. N.Y. City N.J. Pa. E.N. CENTRAL Ohio Ind. Ill. Mich. Wis. W.N. CENTRAL Minn. Iowa Mo. N. Dak. S. Dak. Nebr. Kans. S. ATLANTIC Del. Md. D.C. Va. W. Va. N.C. S.C. Ga. Fla. E.S. CENTRAL Ky. Tenn. Ala. Miss. W.S. CENTRAL Ark. La. Okla. Tex. MOUNTAIN Mont. Idaho Wyo. Colo. N. Mex. Ariz. Utah Nev. PACIFIC Wash. Oreg. Calif. Alaska Hawaii Guam P.R. V.I. Amer. Samoa C.N.M.I. Cum. 2002 24,713 1,370 5,3,1,080 2,347 1,41 7,1,1,160 3,111 1,275 2,1,3,216 2,U 2 Cum. 2001 23,6,3,338 1,1,7,852 3,160 1,263 2,1,2,119 2,U U
Chlamydia Cum. Cum. 435,265 15,6,277 1,631 5,095 43,874 9,738 16,956 4,157 13,023 76,351 19,572 9,560 18,911 18,855 9,453 24,321 5,523 2,765 8,1,196 1,857 3,905 83,225 1,557 8,657 1,908 9,422 1,345 14,614 7,355 15,586 22,781 29,358 5,060 9,470 8,506 6,322 62,840 3,893 11,112 6,240 41,595 27,054 1,309 1,8,232 3,234 8,789 1,280 2,237 72,977 8,327 4,052 55,999 2,089 2,510 1,U 122 449,014 12,5,038 1,660 4,373 48,329 7,861 17,929 7,607 14,932 82,761 21,432 9,125 25,076 17,528 9,600 22,733 4,620 2,742 8,969 2,054 3,582 87,248 1,697 8,983 1,958 11,423 1,392 12,897 9,220 18,281 21,397 29,492 5,213 8,898 8,175 7,206 63,591 4,589 10,635 6,429 41,938 26,422 1,231 1,7,641 3,442 8,2,866 75,521 8,084 4,307 59,207 1,623 2,1,U U
Cryptosporidiosis Cum. Cum. 1,U 1,U 3 U U
N: Not notifiable. U: Unavailable. -: No reported cases. C.N.M.I.: Commonwealth of Northern Mariana Islands. * Incidence data for reporting year 2001 and 2002 are provisional and cumulative (year-to-date). Chlamydia refers to genital infections caused by C. trachomatis. Updated monthly from reports to the Division of HIV/AIDS Prevention Surveillance and Epidemiology, National Center for HIV, STD, and TB Prevention. Last update July 28, 2002.
TABLE II. (Continued) Provisional cases of selected notifiable diseases, United States, weeks ending August 3, 2002, and August 4, 2001 (31st Week)*
Haemophilus influenzae, Invasive Age <5 Years All Ages, Serotype All Serotypes B Cum. Cum. Cum. Cum. 15 17

U 1 U U 1 U 4 U U

Reporting Area UNITED STATES NEW ENGLAND Maine N.H. Vt. Mass. R.I. Conn. MID. ATLANTIC Upstate N.Y. N.Y. City N.J. Pa. E.N. CENTRAL Ohio Ind. Ill. Mich. Wis. W.N. CENTRAL Minn. Iowa Mo. N. Dak. S. Dak. Nebr. Kans. S. ATLANTIC Del. Md. D.C. Va. W. Va. N.C. S.C. Ga. Fla. E.S. CENTRAL Ky. Tenn. Ala. Miss. W.S. CENTRAL Ark. La. Okla. Tex. MOUNTAIN Mont. Idaho Wyo. Colo. N. Mex. Ariz. Utah Nev. PACIFIC Wash. Oreg. Calif. Alaska Hawaii Guam P.R. V.I. Amer. Samoa C.N.M.I.
Escherichia coli Shiga Toxin Positive, Not Serogrouped Cum. Cum. 24 7

1 N U 2 N 1 U U

Giardiasis Cum. 2002 8,1,309 1,87 1,11 U -
Gonorrhea Cum. Cum. 183,766 206,398 4,1,1,673 19,883 4,942 6,926 2,982 5,033 36,623 10,504 4,158 10,225 8,361 3,375 9,532 1,4,1,603 48,4,835 1,590 5,9,799 4,424 8,603 11,877 16,806 2,052 5,439 5,539 3,776 27,734 2,205 6,896 2,665 15,968 5,1,2,690 15,090 1,12,25 U 12 3,1,1,361 23,840 4,753 7,453 4,281 7,353 42,663 11,672 3,859 13,601 10,117 3,414 9,567 1,4,1,564 54,5,163 1,727 6,10,314 6,841 9,942 12,162 18,957 2,028 5,871 6,356 4,702 31,231 2,870 7,421 2,974 17,966 6,1,2,1,024 16,460 1,13,U U
N: Not notifiable. U: Unavailable. - : No reported cases. * Incidence data for reporting year 2001 and 2002 are provisional and cumulative (year-to-date).
Haemophilus influenzae, Invasive
Age <5 Years Non-Serotype B Cum. Cum. 1 Unknown Serotype Cum. Cum. A Cum. 2002 4,55 1,29 1,Cum. 2001 5,107 1,51 1,75 1,109 U U Cum. 2002 3,61 U 32 Hepatitis (Viral, Acute), By Type B Cum. 2001 4,U U C; Non-A, Non-B Cum. Cum. 1,41 U 2,1 U U
Reporting Area UNITED STATES NEW ENGLAND Maine N.H. Vt. Mass. R.I. Conn. MID. ATLANTIC Upstate N.Y. N.Y. City N.J. Pa. E.N. CENTRAL Ohio Ind. Ill. Mich. Wis. W.N. CENTRAL Minn. Iowa Mo. N. Dak. S. Dak. Nebr. Kans. S. ATLANTIC Del. Md. D.C. Va. W. Va. N.C. S.C. Ga. Fla. E.S. CENTRAL Ky. Tenn. Ala. Miss. W.S. CENTRAL Ark. La. Okla. Tex. MOUNTAIN Mont. Idaho Wyo. Colo. N. Mex. Ariz. Utah Nev. PACIFIC Wash. Oreg. Calif. Alaska Hawaii
Guam P.R. V.I. Amer. Samoa U U U U U C.N.M.I. U U N: Not notifiable. U: Unavailable. -: No reported cases. * Incidence data for reporting year 2001 and 2002 are provisional and cumulative (year-to-date).
Legionellosis Cum. Cum. N 3 N 42 U 14 N 6 N U U Listeriosis Cum. Cum. 1 U 3 U U Lyme Disease Cum. Cum. 5,287 7,3,705 2,181 1,U N N U 2,197 1,241 4,056 1,1,536 1,2 N N U U Malaria Cum. Cum. 6 U U U Measles Total Cum. 1 U Cum. 6 U U
N: Not notifiable. U: Unavailable. -: No reported cases. * Incidence data for reporting year 2001 and 2002 are provisional and cumulative (year-to-date). Of 13 cases reported, four were indigenous and nine were imported from another country. Of 90 cases reported, 42 were indigenous and 48 were imported from another country.