ATW1H%ASUACAD.BITNET@oac.ucla.edu (Dr David Dodell) (09/05/89)
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to-door vaccination teams in high-risk communities have administered an
additional 2000 doses of vaccine. Hospital emergency department vaccination
clinics have been set up in four locations.
Reported by: RM Krieg, PhD, RW Biek, MD, CR Catania, JW Masterson, MPH,
Chicago Dept of Health; R March, Immunization Program, RJ Martin, DVM, Div of
Infectious Diseases, Illinois Dept of Public Health. Div of Immunization,
Center for Prevention Svcs, CDC.
Editorial Note: This outbreak is similar to others among inner-city
populations in the United States in that it involves primarily unvaccinated
black and Hispanic preschool-aged children (1-3). The Chicago Department of
Health has implemented aggressive outbreak strategies directed toward reaching
the highest-risk group, i.e., unvaccinated preschool-aged children. Such
children are also likely to be a reservoir for transmitting virus to other age
groups. As part of the extensive outbreak-control efforts, children are being
vaccinated in emergency departments. Provision of vaccine to inner-city
children who use these facilities for their primary source of health care
should help to increase vaccination levels in patients who receive sporadic
health care and may reduce the transmission of measles in emergency department
settings.
References
1. CDC. Measles--Dade County, Florida. MMWR 1987;36:45-8.
2. CDC. Measles--Los Angeles County, California, 1988. MMWR 1989;38:49-52,57.
3. Markowitz LE, Preblud SR, Orenstein WA, et al. Patterns of transmission in
measles outbreaks in the United States, 1985-1986. N Engl J Med 1989;320:75-
85.
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Volume 2, Number 32 September 4, 1989
Current Trends
National Mortality Followback Survey: Characteristics of Persons Who
Died from Diseases of the Heart -- United States, 1986
The National Mortality Followback Survey (NMFS) is a periodic survey
conducted by CDC's National Center for Health Statistics and is designed to
collect detailed information not otherwise available on a sample of decedents.
This report describes the health and financial status of persons who died from
heart disease in 1986 and illustrates the usefulness of the NMFS in addressing
public health issues such as the financial burden of chronic disease.
The 1986 NMFS is a stratified random sample of 18,733 (approximately 1%)
deaths from all causes among U.S. residents greater than or equal to 25 years
of age (1). Of these, 6665 were reported as dying from heart disease. Next of
kin or others familiar with the decedent's lifestyle were asked to provide
information concerning use of medical and other care facilities in the last
year of the decedent's life; sources of payment of medical care; impairments
in daily activities; medical conditions; health practices and behaviors;
social and economic characteristics; and the identity of all health facilities
in which the decedent stayed during the last year of life.
Diseases of the heart (International Classification of Diseases, Ninth
Revision 390-398, 402, 404-429) are the most common cause of death in the
United States. In 1986, 765,490 deaths (36% of all deaths in the United
States) were reported to have resulted from heart disease (1), compared with
an estimated 759,431 deaths based on the above sample.
Financial Status
At death, based on estimates from the NMFS, 67,650 (18%) men and 13,240
(5%) women who died from heart disease were employed (Table 1). In the last
year of life, women were more likely than men to have had low family income:
53% of women with less than $9000 compared with 35% of men, and 16% of women
with greater than or equal to $25,000 compared with 21% of men.
Reported family income reflects the combined resources of all members of
the family unit. Therefore, decedent living arrangements had a direct bearing
on family income. Thirty-two percent of women who died from heart disease
reportedly lived alone or with unrelated persons in the last year of life. An
additional 22% had lived in a nursing home, other health-care facility, or
institution during this time. By contrast, less than 20% of men lived alone or
with unrelated persons, and 8% lived in institutional settings before death.
One measure of decedents' financial status was the total value of their
assets (e.g., home, cash, stocks, bonds, cars, jewelry, and business
interests) at death. Women were more likely to have had assets less than
$5000; 23% of women had no assets (Table 1). Women (24%) were less likely than
men (35%) to have had assets greater than or equal to $50,000 at death.
Health Status
In addition to heart disease, many decedents had other serious health
problems, including high blood pressure, stroke, angina pectoris, diabetes,
cancer, asthma, and other lung conditions (Table 2). Except for angina
pectoris and other lung conditions, women were more likely to have had these
health problems.
More women (45%) than men (27%) were reported to have received help from
others or used special equipment in performing activities of daily living
(e.g., walking, eating, bathing, dressing, or using the toilet) (Table 2).
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Volume 2, Number 32 September 4, 1989
Forty-five percent of women and 33% of men also received help with home
medical care (e.g., taking medicines or pills, receiving injections, having
bandages changed, and receiving nursing care). Health-Care Use and Sources of
Payment
The 1986 NMFS assessed whether the decedent had been an overnight patient
in a health facility during the last year of life. A larger proportion of
women than men used hospitals or nursing homes, other health-care facilities,
and home hospice care.
Medicare was reported as the major health payment source for approximately
half the decedents (Table 2). For women, the next most frequently reported
payment source was self/family (14%) or private insurance/health maintenance
organizations (HMOs) (14%). In comparison, 12% of men used their own or their
family's funds and 23% used private insurance/HMOs. An estimated 42% of women
and 46% of men spent less than $500 for their medical care. Eighteen percent
of women and 11% of men spent greater than or equal to $5000 of their own
money.
Reported by: Office of Vital and Health Statistics Systems, National Center
for Health Statistics, CDC.
Editorial Note: Mortality followback surveys collect information not typically
available from death certificates and therefore enable investigators to learn
more about the characteristics of decedents and the circumstances of their
death. The 1986 NMFS is the fifth mortality followback survey conducted by
NCHS; the previous four, conducted in the 1960s, were less comprehensive than
the 1986 survey.
At least two caveats apply to interpretation of the 1986 NMFS data.
First, because these data are national estimates based on a sample survey,
they are subject to respondent and sampling errors. Second, although 82% of
the respondents who com pleted the NMFS questionnaire were close relatives
(e.g., spouse, parent, sibling, or adult child) of the decedent, insufficient
recall or knowledge about details of the decedent's life may have reduced the
accuracy of the replies to certain questions.
The finding that women were more likely to be in "poor health," living
without family support, or with fewer financial resources reflects in part the
differences in age and marital status at death among persons dying from heart
disease. Approximately 70% of women (in contrast to less than 50% of men) were
aged greater than or equal to 75 years when they died; moreover, three times
more women than men were widowed.
These findings can aid in addressing the health-care needs of those with
chronic disease. Other NMFS survey data can be used in addressing other public
health issues.
Reference
1. NCHS. Vital statistics of the United States, 1986. Vol II--Mortality, pt A.
Hyattsville, Maryland: US Department of Health and Human Services, Public
Health Service, 1988; DHHS publication no. (PHS)88-1122.
Health InfoCom Network News Page 13
Volume 2, Number 32 September 4, 1989
Rabies Surveillance,United States, 1988
U.S. Department of Health and Human Services
Public Health Service
Centers For Disease Control
Atlanta, Georgia 30333
The MMWR series of publications is published by the Epidemiology Program
Office, Centers for Disease Control, Public Health Service, U.S. Department
of Health and Human Services, Atlanta, Georgia 30333.
SUGGESTED CITATIONS
General: Centers for Disease Control. CDC Surveillance Summaries,
August 1989. MMWR 1989;38(No. SS-1).
Specific: Centers for Disease Control. Rabies Surveillance, United
States, 1988. In: CDC Surveillance Summaries, August 1989. MMWR 1989;38
(No. SS-1):(inclusive page numbers).
Centers for Disease Control Walter R. Dowdle, Ph.D.
Acting Director
Center for Infectious Diseases Frederick A. Murphy, D.V.M., Ph.D.
Director
Division of Viral Diseases Brian Mahy, Ph.D., Sc.D.
Director
Viral and Rickettsial Zoonoses Branch Kenneth L. Herrmann, M.D.
Acting Chief
George M. Baer, D.V.M.
Pamela A. Yager
Jean S. Smith, M.S.
The production of this report as an MMWR serial publication was
coordinated in:
Epidemiology Program Office Stephen B. Thacker, M.D., M.Sc.
Director
Richard A. Goodman, M.D., M.P.H.
Editor, MMWR Series
Editorial Services R. Elliott Churchill, M.A.
Chief
Ann Penner Usey
Writer-Editor
Mary T. Vaughan
Visual Information Specialist
Ruth C. Greenberg
Editorial Assistant
Copies can be purchased from Superintendent of Documents, U.S. Government
Printing Office, Washington, D.C. 20402-9371. Telephone: (202) 783-3238.
Rabies Surveillance, United States, 1988
Thomas R. Eng, V.M.D., M.P.H.
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Volume 2, Number 32 September 4, 1989
Tedd A. Hamaker, D.V.M.
James G. Dobbins, Ph.D.
Tony C. Tong, M.S.
Joyce H. Bryson
Paul F. Pinsky, M.P.H.
Division of Viral Diseases Center for Infectious Diseases
Summary
The primary purpose of the annual report on rabies surveillance is to assist
local and state public health officials in the planning of rabies control
programs and to guide health professionals in evaluating the need for rabies
postexposure prophylaxis in patients who are exposed to animals that may be
rabid. In 1988, a total of 4,724 cases of animal rabies were reported by 47
states, the District of Columbia, and Puerto Rico, similar to the total
(4,729) for 1987. No human cases of rabies were reported.
The South Atlantic, South Central, North Central, and Middle Atlantic
states reported 81% of the cases. Pennsylvania, Texas, California, Maryland,
and Virginia each reported over 300 rabid animals. Delaware (61 cases), New
Mexico (15), Alaska (34), Connecticut (8), and South Carolina (127) each
reported an increase in animal rabies cases greater than or equal to 100% in
1988 compared with 1987. Smaller but significant increases also were reported
from Florida (66% increase), Pennsylvania (68%), and Georgia (40%).
Eighty-eight percent of rabies cases were in wild animals, and 12% were in
domestic animals. Skunks, raccoons, and bats accounted for 82% of all rabid
animals. Cats became the most commonly reported domestic species for the first
time since reporting to CDC began in 1960.
The most effective methods of reducing the number of people exposed to
rabies are to educate the public to avoid unfamiliar, especially wild, animals
and to vaccinate susceptible pets against rabies. Rabies vaccination programs
should target cats as well as dogs. Two cases of imported canine rabies
emphasized the need to educate travelers of the risk of canine rabies in
developing countries. Caution should be used when pets are imported from these
countries.
INTRODUCTION
Since the 1950s, canine vaccination and programs on stray-dog control have
dramatically decreased rabies in domestic animals (Figure 1) and people. For
example, in the 1950s, an average of 11 persons (range: 4-20) died of rabies
every year in the United States, and all were exposed to rabies by contact
with native animals (Figure 2). In contrast, from 1980 through 1988, an
average of one person (range: 0-3) per year acquired rabies, and 73% of these
persons were exposed to rabies by contact with animals outside the United
States.
The number of rabid wild animals exceeded that of domestic species in 1960
and increased dramatically during the late 1970s and early 1980s (Figure 1).
Whether the case count represented an actual increase in the incidence of
rabies in wildlife or an increased testing of wildlife is unclear; however, at
least four major epizootics in wild animals have been documented. The increase
in the late 1970s was a result of two epizootics of rabies in skunks, one
centered in the North Central and one in South Central states (Figure 3). Two
separate epizootics occurred in raccoons in West Virginia and Virginia. One
began in Florida, Georgia, Alabama, and South Carolina, and the other, which
began in 1977, eventually spread to several other Middle Atlantic and South
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Volume 2, Number 32 September 4, 1989
Atlantic states (1). Since 1980, the most commonly reported rabid wild animals
have been skunks, raccoons, bats, and foxes.
An increase in rabies in domestic animals was also observed in the early
1980s, probably as a result of the increase in rabid wildlife (Figure 4).
Since 1980, the most commonly reported rabid domestic animals have been cats,
cattle, and dogs.
On the basis of reaction patterns to a panel of monoclonal antibodies
against the rabies virus, virus isolates from rabid animals can be grouped
into ecotypes (2). Accordingly, five major distinct ecotypes of the rabies
virus exist in animals in the United States (Figure 5). In each of these
areas, the virus ecotype circulates in the main reservoir of the area but
occasionally extends to other species.
Because of Canada and Mexico's proximity to the United States, data from
these countries are included in a separate section of this report.
METHODS
All cases of animal rabies reported to CDC had been diagnosed by state or
territorial health department laboratories. Suspected rabid animals were
submitted for a variety of reasons to health department laboratories by local
health officials, veterinarians, animal-control officers, and the public.
Almost all diagnoses of animal rabies were based on a positive result on
direct fluorescent-antibody testing of brain tissue. Rabies virus isolation in
mice or in tissue culture (e.g., neuroblastoma cells) was sometimes used to
confirm fluorescent-antibody tests. In addition, virus isolates were
occasionally sent to CDC for ecotype analysis with the use of monoclonal
antibody techniques (2).
Most state and territorial health departments reported cases of animal
rabies by sending a monthly summary of cases stratified by species and county
of origin. Some states submitted these data as part of the Electronic
Surveillance Project (ESP), a CDC computerized surveillance network. The
accuracy of all data was confirmed.
Data were stratified by species and by the state in which the animal was
captured. Data from 1988 were compared with surveillance data from 1987 (3).
For the geographic distribution of cases, states were grouped into eight
divisions.
Data from Canada were obtained from the Animal Health Division, Canadian
Department of Agriculture. Data from Mexico were obtained from the Direccion
General de Medicina Preventiva, Secretaria de Salud. Interpretation of Data
Surveillance data should be interpreted with an understanding of the
general and area-specific limitations of the surveillance system. All
laboratory-confirmed cases of animal rabies are reported to CDC, but not all
rabid animals are submitted to state health departments. Incidence rates
cannot be calculated from rabies surveillance data because the animal
populations are unknown. Therefore, the number of reported cases should be
considered only a crude estimate of the risk of rabies in an animal species
from a particular area.
Decisions on the management of patients or animals exposed to rabies
should be made in consultation with appropriate local and state health
officials. The decision of whether to use rabies postexposure prophylaxis in a
patient exposed to rabies by contact with a suspected rabid animal that is
unavailable for testing depends on 1) the circumstances of the exposure and 2)
the species-specific risk of rabies in that area (4).
Detecting the true distribution of rabies in an area depends on the
sensitivity of the surveillance system. The sensitivity of animal rabies
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Volume 2, Number 32 September 4, 1989
surveillance varies among states because state health department laboratories
have different criteria for accepting a specimen for testing. For example,
many laboratories will test only those animals to which persons or domestic
animals have been exposed. Many rabid animals, especially wildlife, never
expose a human being or domestic animal and, therefore, remain undetected. In
addition, the sensitivity of the surveillance system may vary within a state.
For example, the number of examinations of animals may vary among counties
because of availability of local animal-control services and transportation to
state laboratories. Finally, the proportion of reported cases by species may
not reflect the true distribution of rabies in animals, since certain animals
are more likely to be captured for testing. For example, dogs are more likely
to be captured and tested than wild animals such as bats.
RESULTS
Rabies in the United States and Its Territories
In 1988, a total of 4,724 cases of animal rabies were reported by 47
states, the District of Columbia, and Puerto Rico (Figure 6, Table 1). This
total is essentially the same as in 1987 (4,729). No human cases of rabies
were reported.
The South Atlantic, South Central, North Central, and Middle Atlantic
states reported 81% of the cases (Figure 7). Pennsylvania, Texas, California,
Maryland, and Virginia reported the most cases, each reporting at least 300
rabid animals (Table 1). Delaware (61 cases), New Mexico (15), Alaska (34),
Connecticut (8), and South Carolina (127) each reported an increase in animal
rabies cases greater than or equal to 100% in 1988 compared with 1987 (Table
1). Smaller increases also were reported from Florida (66% increase),
Pennsylvania (68%), and Georgia (40%). Rhode Island (no cases) was the only
state to report greater than or equal to 100% decrease in rabid animals.
Rabies was relatively rare in New England and absent in the U.S.
territories except for Puerto Rico. Although Hawaii, Rhode Island, and Vermont
did not report any cases in 1988, Hawaii is the only state considered to be
free of rabies. Puerto Rico reported 73 cases of animal rabies in 1988; 71%
were rabid mongooses. The other U.S. territories of Guam, the Virgin Islands,
American Samoa, and the Commonwealth of the Northern Mariana Islands are
rabies-free areas (5).
The distribution of rabid animals by species was similar to that in 1987.
Eighty-eight percent of cases were in wild animals, and 12% were in domestic
animals (Figure 8). Skunks, raccoons, and bats accounted for 82% of all rabid
animals. The only notable increase was in rabid foxes. In domestic animals,
the most notable change from the previous year was that the number of rabid
cats exceeded that of rabid cattle and became the most commonly reported
domestic species for the first time since reporting to CDC began in 1960.
Although rabid animals were reported throughout the year, several species
appeared to have seasonal peaks. Distinct peaks of activity in rabid skunks
and cattle occurred in March and April, with the increase in rabid skunks
preceding that of rabid cattle by approximately 1 month (Figures 9, 10). Most
rabid bats and cats were reported during the summer and fall months. The
number of rabid raccoons peaked in the spring and fall.
Rabies in Wild Animals
As in 1987, wild animals accounted for 88% of all rabid animals. Skunks
were the most frequently reported rabid species in the United States,
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Volume 2, Number 32 September 4, 1989
accounting for 38% of all rabid animals, followed by raccoons (31%), bats
(14%), and foxes (4%) (Figure 8). Rabies in wildlife species was reported from
all states except Hawaii and several states in New England (Table 1). Skunks.
Skunks were the most commonly reported rabid animal, although there was a
12% decrease in cases compared with 1987 and a 25% decrease compared with 1986
(3). The distribution of cases (Figure 11) was similar to that of 1987 with
the South Central states, North Central states, and California reporting 73%
of cases. Delaware (7 cases), New Mexico (6), South Carolina (10), and Indiana
(26) reported greater than or equal to 100% increase in rabid skunks compared
with 1987 (3). Raccoons.
Reports of rabid raccoons increased 12% in 1988 compared with 1987;
raccoons were the second most commonly reported rabid animal. Of 1,465 cases,
99% were reported from states involved in one of the two raccoon epizootics
(Figure 12, Table 1). The "mid-Atlantic" epizootic, involving the Middle
Atlantic and South Atlantic states of Delaware, Maryland, Pennsylvania,
Virginia, West Virginia, and the District of Columbia, reported 65% of all
rabid raccoons, and the other "southeastern" epizootic, involving the South
Central and South Atlantic states of Alabama, Florida, Georgia, and South
Carolina (hereafter referred to as the "southeastern states"), reported 34%.
The 498 cases reported in the southeastern states represent a 50% increase
from 1987. There was virtually no change in the number of rabid raccoons
reported from the mid-Atlantic epizootic. Although all of the southeastern
states reported an increase in rabid raccoons, Florida and Georgia reported
the greatest increase (79% and 43%, respectively). In the mid-Atlantic
epizootic, cases occurred predominantly in southeastern Pennsylvania and
northern Delaware (Figure 13). In addition, the outbreak spread south into
southeastern Virginia.
Bats.
Bats were the third most commonly reported species, accounting for 14% of
all rabid animals (Table 1). There was only a 1% increase compared with 1987.
Bats were the most widespread rabid animal, and rabies from bats was reported
from 42 states (Figure 14). Ten states did not report any rabid animals except
for bats. Eighty-eight percent of rabid animals from New England were bats.
Foxes.
Although the proportion of rabies in foxes (4%) was low compared with that
in other wild animals, foxes accounted for one of the largest increases (53%)
in wildlife species in 1988 (Table 1). This increase was mainly a result of a
357% increase in rabid foxes in Alaska. The distribution of rabid foxes was
otherwise similar to that of rabid skunks (Figures 15, 11). Other wild
animals.
Mongooses accounted for most of the other wild animals, and their
distribution was limited to Puerto Rico. Although the number of rabid rodents
doubled in 1988, rodents accounted for less than 1% of all rabid animals. Of
the 22 rabid groundhogs reported, all were from states involved in the mid-
Atlantic epizootic.
Rabies in Domestic Animals
There were 550 cases of rabies in domestic animals in 1988, a 2% decrease
from 1987 (Table 1). Rabies in domestic animals was usually reported only from
states with large numbers of rabid terrestrial wild animals. For example, the
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Volume 2, Number 32 September 4, 1989
North Central and South Central states accounted for 62% of rabies in domestic
animals (Table 1). The most commonly reported rabid domestic animals were
cats, cattle, and dogs. Cats.
Cats accounted for the greatest proportion (35%) of rabies in domestic
animals for the first time. The 192 rabid cats represented a 16% increase from
1987. States that experienced an increase in cases greater than or equal to
100% compared with 1987 included Pennsylvania, Maryland, South Carolina, and
Florida (3). The distribution of rabid cats was similar to that of rabid
skunks and raccoons (Figures 11, 12, 16). The South Atlantic, North Central,
South Central, and Middle Atlantic states accounted for 90% of all cases.
Cattle.
Thirty-one percent of rabid domestic animals were cattle. The number of
cases reported in 1988 (171) was similar to that reported in 1987. The North
Central, South Central, and Middle Atlantic states reported 88% of all cases.
Except for the absence of cases in the South Atlantic states, the distribution
of rabid cattle was similar to that of rabid cats (Figures 16, 17).
Dogs.
Dogs accounted for 23% of all rabid domestic animals. There were 128 cases
of rabies in dogs reported in 1988, a 25% decrease from 1987. No substantial
increases occurred in any state. The distribution of rabid dogs was also
similar to that of the other domestic animals (Figures 16-18). The South
Central, North Central, and South Atlantic states reported 84% of all cases.
In 1988, an outbreak of rabies in dogs and coyotes occurred in two Texas
counties in the Lower Rio Grande Valley that had been free of rabies since
1970 (6). Monoclonal antibody studies indicated that the epizootic virus
ecotype was identical to that found in Mexican dogs. Imported canine rabies.
In 1988, two dogs adopted in Mexico as pets were imported into the United
States and subsequently developed rabies within several weeks of arrival. The
first incident involved a young New Hampshire girl who adopted an unimmunized
puppy while visiting Mexico (7). This adoption resulted in the treatment of 17
exposed persons. The second dog, a puppy that was too young for immunization,
was brought into the United States by a family in Texas.
Other domestic animals.
Other domestic species, such as horses, mules, sheep, goats, and swine,
collectively accounted for 11% of rabid domestic animals. Seventy-three
percent were horses or mules. Although there was more than a twofold increase
in rabid swine, only seven rabid swine were reported. Rabies in Canada and
Mexico
Canada reported 2,284 laboratory-confirmed and 129 clinically diagnosed
cases of animal rabies in 1988, an 18% decrease from 1987. The most commonly
reported rabid animals were foxes (45% of all cases), skunks (28%), cattle
(14%), cats (4%), and dogs (3%); 76% of cases were reported from Ontario.
Mexico reported 74 human rabies deaths in 1988, a 21% increase from 1987.
Ninety-two percent of the decedents had been bitten by rabid dogs. A total of
8,468 cases in animals were diagnosed clinically, and an additional 4,834
cases were diagnosed by laboratory testing. Dogs accounted for 93% of rabid
animals; cats, for 2%; and bats, for 2%; 2% of the animals were of other
species. Rabid animals were found in all areas in the country.
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Volume 2, Number 32 September 4, 1989
DISCUSSION
The most effective methods of reducing the number of people exposed to
rabies are to educate the public to avoid unfamiliar, especially wild, animals
and to vaccinate susceptible pets against rabies. Although domestic animals
account for only 12% of all rabid animals, they account for 64% of all
exposures requiring rabies treatment (8). Given that cats are now the most
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