Publication of the Bureau of Epidemiology & Disease Control Services May/June 2002, Vol. 16, No. 3 Rabid Animals and Post-Exposure Prophylaxis A total of 129 animals tested positive for rabies in Arizona in 2001, compared to 101 in 2000, and 56 for the previous 10 years’ annual average. Figure 1 shows the number and distribution of animal rabies cases throughout the State in 1991 and 2001. These cases provide an indication of the primary animal reservoirs for rabies but do not reflect the true extent of rabies infection among wild or domesticated animals due to the passive nature of the surveillance and the lack of animal population estimates. All of the 129 rabid animal cases reported in 2001 were in wildlife. Rabies in skunks and bats accounted for 46% (59) and 43% (55) of all cases, respectively. In addition to a record number of animals testing positive for rabies, 2001 was characterized by three distinct epizootics involving skunks in Pima and Santa Cruz counties, foxes in the Sedona area, and a very unusual rabies epizootic in skunks in the Flagstaff area. The latter represented the first documented rabies cases in a terrestrial animal in the Flagstaff area. Monoclonal antibody typing and genetic sequencing revealed that insectivorous bats were the source of rabies in the Flagstaff skunk population. A major public health initiative was implemented to prevent the permanent establishment of rabies in the skunk population that included a program to trap, vaccinate and release skunks, enhanced rabies surveillance, public education on rabies prevention, pet vaccination campaigns, and rabies quarantine. Over 200 skunks were vaccinated, eartagged and released. A total of 19 skunks tested positive for rabies from January through July 2001. No new cases of skunk rabies have since been identified. The epidemiology of rabies in the United States has changed considerably over the last 50 years. The establishment of effective rabies prevention and control strategies throughout the country have successfully reduced human rabies deaths to a few cases per year. The last human rabies case in Arizona occurred in 1981. The source of rabies also has shifted from domestic animals to wildlife. Successful rabies prevention and control programs continue to rely upon animal control programs, vaccination of companion animals, timely animal rabies surveillance, comprehensive exposure assessment, vaccination of persons at high risk for rabies exposure, well trained public health laboratory staff to accurately test specimens positive for rabies, and continued on page 6 FIGURE 1 Visit the ADHS Web site at www.hs.state.az.us 2001-2002 Influenza Season Peaked in February Page 2 1 Prevention Bulletin Adults Not Reaching Recommended Physical Activity Levels Page 3 County Communicable Disease Summary Page 4 & 5 May/June 2002 2001- 02 Influenza Season Peaked in February by Susan Goodykoontz The 2001/2002 influenza season officially began in Arizona in November 2001 when the first cases of influenza were detected. The number of cases peaked in early February, 2002 and began to decline by mid-March. At its peak, reference laboratories in the state were reporting approximately 40 positive specimens per week. Hospital emergency rooms and primary care clinics also reported increases in the number of patients presenting with influenza-like illness (ILI) during the same period. Several separate influenza outbreaks were reported in Maricopa, Pima, and Yavapai counties. The majority of influenza isolates collected through March were influenza A, and all that were sub-typed were H3N2 (Fig. 1). However, the proportion of influenza B isolates began increasing in March and became the predominant strain by mid-April. Six of the B isolates were typed B/Victoria and all were from children less than 15 years old. Based on surveillance data, the influenza vaccine administered for the 2001/2002 season should provide good protection against all circulating A influenza viruses but not the B/Victoria strain. The influenza season was relatively mild compared to previous seasons. Influenza in Arizona typically peaks in late December or REMINDER: In preparation for the 2002-03 influenza season, vaccine manufacturers encourage providers to submit their influenza vaccine orders as early as possible. The following vaccine manufacturers are currently receiving orders: Aventis, Evans, and Wyeth. Please contact the Arizona Immunization Program Office with any questions regarding influenza vaccine at 602.230.5852. For questions regarding influenza activity in Arizona, please contact the Infectious Disease Epidemiology Section at 602.230.5932. 2 Prevention Bulletin early January but did not peak this season until February. The season usually lasts through April, although sporadic cases may be reported in May and June. Nationwide, influenza activity appears to have peaked during the week ending February 23, 2002, which is 4 to 8 weeks later than the previous two seasons. The Centers for Disease Control and Prevention (CDC) have characterized 391 influenza isolates collected in the United States since September 30. The majority (71%) of the isolates were influenza A (H3N2) viruses, which were well matched antigenically by the A (H3N2) strain in the current vaccine. Influenza A (H1) viruses accounted for 4% and influenza B viruses for 25%. Of the 14 A (H1) viruses characterized by CDC, five were A (H1N1) and nine were A (H1N2). The influenza A (H1) viruses were also similar antigenically to the current vaccine strain, A/New Caledonia/20/99 (H1N1). The newly isolated A (H1N2) viruses appear to have resulted from rearrangement of the genes of currently co-circulating influenza A (H1N1) and A (H3N2) subtypes. The (H1N2) viruses were only identified in Wisconsin, Texas, and Nevada. According to the CDC, the current vaccine should provide good protection against this new strain and no evidence exists that would suggest A (H1N2) viruses are causing more severe illness than other influenza A viruses. Two antigenically distinct lineages of influenza B viruses are currently circulating worldwide: B/Yamagata/16/88 and B/Victoria/2/87. B/Yamagata viruses have circulated widely since 1990. The B component of the current influenza vaccine belongs to this lineage. However, the B/Victoria viruses had not been identified outside of Asia since 1991. Of the 53 B/Yamagata lineage viruses characterized this season in the United States, 22 were similar to the vaccine strain (B/Sichuan/379/99) but 31 demonstrated reduced titers to ferret antiserum produced against the same strain. 2002-2003 Influenza Vaccine The emergence of B/Victoria lineage influenza viruses around the world led to the recommendation of including it in the vaccine for the 2002/2003 season. The FDA’s Vaccine and Related Biological Products Advisory Committee recommended the following composition for the next season’s vaccine: A/New Caledonia/ 20/99-like (H1N1); A/Moscow/10/99like (H3N2); and B/Hong Kong/330/2001-like. Source: MMWR 2002, 51 (13):276-9. Other flurelated information can be found at www.cdc.gov. Susan Goodykoontz is an epidemiologist and state flu surveillance coordinator for the Department. She can be reached at 602.230.5949 or sgoody@hs.state.az.us. FIGURE 1 May/June 2002 60% of American Adults Not Reaching Recommended Physical Activity Levels By Tammy Ball, M.S., CHES Editor’s Note: In the November/December 2001 issue of Prevention Bulletin, Dr. Tim Flood presented a perspective of the major causes of death of Arizonans. As a follow-up, Prevention Bulletin will present a series of six articles examining the status of various behavioral risk factors and how these factors may affect the rates of chronic diseases in Arizona. This is the 3rd article in this series. Percent Arizona, the Arizona Department of Survey (BRFS), during the latter half of the 1990's, 38% of adults in Arizona did Health Services used the new BRFS physical activity questions to conduct a not engage in any leisure time physical activity. Compared to the first half of the Point-In-Time survey in 2000. In-depth analysis provides information on the decade this has worsened by nearly 14 proportion of people who engage in no percentage points (Fig. 1). activity at all (inactive), those that To combat this problem, public Figure 1 engage in some activity, but not enough health officials now (active, but insufficient), and those that recommend a “lifestyle” 70 No Leisure Time Physical Activity engage in enough activity to meet the approach to physical Arizona, 1990 - 2000 60 Surgeon General’s recommendations activity. This approach is (sufficiently active). In contrast to previdesigned to inform the 50 ous BRFS findings that did not include public about the health 40 lifestyle activity, 61% of Arizonans benefits of engaging in engage in enough physical activity to other forms of physical 30 meet the Surgeon General’s recommenactivity, not just exercise. 20 dations (Fig. 2). It is likely that the 2003 Examples of lifestyle BRFS, which will inquire about lifestyle activities include; house10 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 activities, will find similar results. work, yard work, Years In summary, Arizonans should climbing stairs, and engage in a wide-variety of physical walking briskly. Since 1984, the BRFS To encourage Americans to activities on a regular basis. “Lifestyle” has collected data on various health participate in regular physical activity, activities are important in maintaining behaviors and has assisted in the the Surgeon General has released a and improving planning, implementation, report on Physical Activity and Health. Physical Activity of Arizonans health. and evaluation of health The report not only summarized the Previous data promotion and disease numerous benefits of regular physical on physical activity prevention programs. Although, the activity, it also recommended an levels did not BRFS has obtained information on accumulation of 30 minutes or more of include lifestyle leisure-time physical activity, it moderate-intensity physical activity on activities as part did not include “lifestyle” most, preferably all, days of the week. of the total activities. Hopefully, Arizonans After this innovative report was released, may not be as inactive as amount of many organizations reiterated the physical activity. previously thought. benefits of regular physical activity. The It is uncertain if It is important to include National Institutes of Health, the Centers lifestyle activities when the 2003 BRFS for Disease Control and Prevention, the questions will quantifying physical activity American College of Sports Medicine, drastically change levels because a large portion of and the American Heart Association our current the total amount of physical activity Figure 2 have concluded that regular physical understanding of physical may be attributable to these activities. activity is associated with reduced rates activity levels. Preliminary results from For example, a recent study found that of heart disease, blood pressure, women spend proportionally more time the State of Arizona show that Arizonans diabetes, osteoporosis, colon cancer, are more active than previously thought. caring for the home than they do in anxiety, and depression. Physical activity “leisure” time activities. To better However, even with the changed also assists in weight maintenance, aids definitions, many Arizonans still need to quantify physical activity and obtain in the management of osteoarthritis, data on a wider variety of activities, a be encouraged to achieve the recommendimproves self-esteem, builds morale, and new set of BRFS physical activity ed amount of daily physical activity. improves overall quality of life. questions has been developed and will U.S. DHHS. (1996) Physical Activity and Health: A Report of the Surgeon Despite these benefits, more than be included in the new 2003 survey. The General. Atlanta, GA: Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion. 1996. 60% of adults in the United States do new survey should aid researchers in Brownson, C Ross, Deborah A. Jones, Michael Pratt, Curtis Blanton, and Gregory not achieve the recommended amount assessing the utility of the “lifestyle” Heath. Measuring physical activity with the behavioral risk factor surveillance of regular physical activity, and 25% are approach and offer insight into the system. Medicine and Science in Sports & Exercise 2000; 32: 1913-1918. not active at all.1 Physical inactivity is actual activity levels of Americans. Tammy Ball is the Program Manager for Physical especially startling in Arizona. In order to obtain better baseline Activity at the Department. She can be reached According to the Behavioral Risk Factor activity data specifically for the state of at 602.364.2402 or tball@hs.state.az.us. 1 2 3 Prevention Bulletin May/June 2002 Communicable Disease Summary January 1, 2001 - December 31, 2001 – Provisional Data Confirmed Cases Reported in 2001 by County of Residence DISEASE Apache Cochise Coconino AIDS Amebiasis Botulism Botulism, Infant Brucellosis Campylobacteriosis Cholera Chlamydia Coccidioidomycosis Colorado Tick Fever Cryptosporidiosis Dengue E. coli O157:H7 Ehrlichiosis Encephalitis, SLE Encephalitis, other Giardiasis Gonorrhea Haemophilus influenzae Hansen Disease Hanta Pulmonary Syndrome Hepatitis A Hepatitis B Hepatitis B (non-acute)1 Hepatitis C Hepatitis C (non-acute)2 Hepatitis D Hepatitis E Hepatitis Non-A-B Herpes – genital HIV infection* Legionellosis Leptospirosis Listeriosis Lyme Disease Malaria Measles Meningitis-Aseptic Meningococcal Mumps Pertussis Plague 4 Prevention Bulletin Gila Graham Greenlee La Paz Maricopa Mohave Navajo Pima Pinal 33 404 1 1 66 6 8 144 4 2 15 6 2 53 403 9 1 1 1 36 <5 5 115 13 1 9 <5 4 73 5 1 5 7 - 2 - 3 - 1 - - - 8 - 4 1 1 2 2 - 24 - 11 - 50 22 <5 1 8 - 155 6 5 2 - 77 21 <5 2 1 - 0 - <5 3 27 7 2 386 16 1 1 4 318 8963 1715 7 1 20 1 9 208 2830 8 1 9 161 24 1 2 13 14 <5 21 469 5 11 86 - - 40 - 5 - 1 - 18 - - - 2 - 196 114 7 1 1 5 2 3 - 8 4 - - 868 1 13 - 36 3 - 48 1 <5 - 3 3 - 32 5 <5 1 1 - 3431 650 470 11 8 2 14 1 193 15 1 144 - 208 27 <5 1 1 2 21 - 9 1 - 113 21 3 1 134 10 2699 368 408 84 1 5 2 23 4 749 63 Yearly Totals Santa Yavapai Yuma Unknown 2001 Cruz <5 3 7 70 2 1 2 10 13 3 25 150 8 1 2 1 9 15 3 - - 1 - 73 33 12 4 34 - 16 4 164 - 35 - 119 1 10 1 1 1 - 943 169 108 4 2 3 3 4 195 - 684 3 38 16 2 7 - <5 1 1 4 301 11 1 1 2 23 2000 1999 1 1 5 1 - 566 29 1 2 6 635 0 14357 2302 0 11 1 30 1 1 16 267 3923 491 39 0 1 1 619 0 12610 1917 0 10 3 56 1 0 3 313 4136 884 23 0 0 1 594 2 12061 1812 0 16 2 35 0 0 8 255 4273 1 - 81 1 53 0 63 0 6 4 60 2 1 1 1 409 164 4 467 215 2 700 138 3 - 17 - 26 - 6 - 1196 9 1126 1043 21 49 4 1 <5 1 1 - 278 5 6 1 2 3 - 205 1 14 <5 1 - 66 6 - 6339 6390 4798 5 19 21 0 0 0 0 1 0 975 1132 1173 629 561 755 21 11 7 0 0 0 10 20 19 3 2 3 19 11 7 1 0 1 206 163 155 20 33 44 1 6 1 381 108 75 0 1 0 May/June 2002 Communicable Disease Summary January 1, 2001 - December 31, 2001 – Provisional Data Confirmed Cases Reported in 2001 by County of Residence DISEASE Apache Cochise Coconino Q Fever Relapsing Fever, Tick Reye Syndrome Rocky Mountain Spotted Fever Rubella Congenital Rubella Syndrome Salmonellosis Salmonella paratyphi A Salmonella paratyphi B Shigellosis StreptococcalGroup A StreptococcalGroup B3 Streptococcus pneumoniae Syphilis P/S SyphilisCongenital Tetanus Toxic Shock Syndrome Tuberculosis Tularemia Typhoid Fever Vibrio infection Vancomycin Resistant Enterococci (VRE) Yersiniosis Gila Graham Greenlee La Paz Maricopa Mohave Navajo Pima Pinal Yearly Totals Santa Yavapai Yuma Unknown 2001 Cruz 2000 1999 - - - - - - - - - - - - - - - - 0 0 0 - - 2 - - - - - 1 - - - - - - - - 3 1 0 0 0 0 - - - - - - - - - - - - - - - - 0 0 0 1 1 13 21 8 32 6 2 1 2 376 10 12 164 37 6 19 20 17 0 733 0 784 2 908 - - - - - - - - 1 - 1 - - - - - 2 4 1 20 9 16 6 - - - 254 3 15 3 94 37 7 3 15 4 3 483 7 574 5 600 3 3 6 - 1 - 1 135 6 1 24 7 - - - - 187 235 260 - 1 2 - - - - 44 1 1 4 1 1 - - - 55 42 43 13 3 13 0 30 0 7 0 3 0 0 478 148 37 0 19 4 143 22 30 0 5 0 6 0 1 0 - 782 180 811 189 820 212 1 - 0 - 0 - 0 - 0 - 0 - 0 - 28 1 0 - 1 - 0 - 1 - 0 - 0 - 1 - - 32 1 26 0 21 0 15 1 - 3 - 9 1 3 - 1 - - - 7 - 45 1 1 11 - 4 - - 22 - - - 6 - - - 163 1 5 - 0 289 1 2 7 0 261 1 4 3 0 262 2 2 5 5 - 9 - 14 - 5 - 2 - 1 - 3 - 610 2 29 - 11 - 118 2 32 - 1 14 - 12 - 2 - 867 5 1084 1024 4 6 Source: ADHS/OIDS/IDES, 04/15/02 Notes: Only incident cases are reported. Strepococcus pneumoniae is lab reportable only. Haemophilus influenzae, Meningococcal, Strepococcal Group B and Strepococcus pneumoniae include invasive diseases only. Non-resident cases have been excluded. One case of Salmonella paratyphi C was reported in 1998. 1 The non-acute hepatitis B case count includes individuals with a positive HBsAg or HbeAg test alone and may include some acutely infected individuals. These counts reflect the year reported or tested and not the date infected. Case counts are not available before 1997. 2 The non-acute hepatitis C case count includes individuals with a positive screening test alone and may include falsely positive individuals. Known risk factors such as intravenous drug use increases the likelihood of these screening tests to be true positives. These counts reflect the year reported or tested and not the date infected. Case counts are not available before 1997. 3 Invasive disease in infants under 30 days of age. * 5 To protect patient confidentiality, <5 is used to designate a county with fewer than five cases. Prevention Bulletin May/June 2002 Rabid Animals and Post-Exposure Prophylaxis continued from page 1 post-exposure prophylaxis (PEP) when warranted. Although rabies among humans is rare in the United States, the number of persons receiving postexposure prophylaxis annually is estimated at 40,000. At least 15 persons in Arizona are known to have received PEP following exposure to laboratory confirmed rabid animals in 2001. However, a recent incident illustrates how a case of rabies in a pet can result in extensive public health efforts to ensure that human disease does not occur. In April, over 70 persons were identified as having a significant exposure to a puppy that was part of an adoption fair at a pet store in Tucson. The puppy became ill a few days after the adoption fair and tested positive for rabies. All persons with significant exposure were started on PEP. Although the cost varies, a course of rabies immunoglobulins and five doses of vaccine given over a four- week period can easily exceed $1,500. Testing animals for rabies when warranted can prevent unnecessary PEP if the animal tests negative for rabies. Rabies virus transmission only occurs when the virus is introduced into open wounds or mucous membranes through a bite or direct contact with virus-containing saliva. However, unrecognized exposure to rabies, particularly bat-associated variants, continues to pose a challenge to the prevention of rabies in humans. The majority of recent human rabies cases in the United States did not report a known history of an animal bite. Physicians should evaluate each potential exposure to rabies and, if necessary, consult with county and state public health officials for assistance in making an informed exposure assessment. For more information contact the Arizona Department of Health Services at 602.230.5820. Welcome Kip Beardsley, M.P.H. is the new Office Chief for the Department of Health Services’ HIV Program. Kip was formerly the Project Coordinator for the Southwest Washington Health District Gay Health Promotion Program in Vancouver, Washington. Prior to his two years in that position, Kip was with the State of Oregon Health Division Drug Assistance Program. Kip has a Masters degree in Public Health from the University of Washington and an undergraduate degree from Portland State University. The mission of the Office is to prevent further transmission of all STDs, including HIV, and to increase the quality of life among those already infected through education, prevention, monitoring, treatment and services. The office conducts disease surveillance activities, primary and secondary prevention initiatives and public health research. Kip can be reached at 602.230.5822 or kbeards@hs.state.az.us. ❍ Change of Address/Name ❍ Delete my name from your mailing list ❍ I received more than one copy Please include your mailing label with all requests for changes. Fax changes to 602.230.5959 PRSRT STD US Postage PAID Phoenix, AZ Permit No. 957 Arizona Department of Health Services Public Information Office 3815 North Black Canyon Hwy. Phoenix, AZ 85015 602.230.5901 • Fax 602.230.5959 Jane Dee Hull, Governor Catherine R. Eden, Ph.D., Director ADHS Lee A. Bland, Chief, Bureau of Epidemiology and Disease Control Services Editorial Board Victorio Vaz, D.V.M., Ph.D., Acting State Epidemiologist Tim Flood, M.D. Kathy Fredrickson, M.P.H. Will Humble, M.P.H. Ken Komatsu, M.P.H. Cheryl McRill, M.D., M.P.H. Wesley Press, M.S. Emma N. Viera, M.P.H. Managing Editor: Courtney Casillas e-mail: ccasill@hs.state.az.us Contributors: Tammy Ball, Susan Goodykoontz, Mira Leslie, Craig Levy, Victorio Vaz This publication is supported by the Preventive Health and Health Services Block Grant from the Centers for Disease Control and Prevention (CDC). Its contents do not necessarily represent the views of the CDC. If you need this publication in alternative format, please contact the ADHS Public Information Office at 602.230-5901 or 1.800.367.8939 (State TDD/TTY Relay). 6 Prevention Bulletin May/June 2002