Publication of the Division of Public Health Services

November/December 2004, Vol. 18, No. 6

Influenza and Influenza Vaccine
by Karen Lewis, M.D.

As we begin the influenza vaccination season, one of the two manufacturers of influenza vaccine for the
United States announced that it is
unable to distribute any influenza
vaccine this year. Chiron Corporation
of the United Kingdom had its license
to manufacture Fluvirin® suspended
for three months, due to problems
with Serratia contamination of some
of its lots.

cine (LAIV--FluMist®).
In 2002, about 92 million doses
of influenza vaccine were produced,
79 million doses were sold, and 12
million went unused. In 2003, about
85 million doses were produced, and
due to increased demand, almost all
of the doses were used.

Indications
Yearly in the U.S. approximately
36,000 people die from influenza and
over 200,000 are hospitalized. The
elderly, people with chronic medical
conditions, very young children, and
pregnant women are at the highest
risk for serious complications if they
get influenza. Due to the decreased
supply of vaccine, prioritization needs
to be given to these people at highest
risk for complications and death.
Another way of protecting these
high-risk people is by giving vaccine
to those who care for them, such as
health care workers and parents and

Vaccine Supply History
The vaccine supply for the U.S.
was estimated at 100 million doses
for the 2004-2005 season. Chiron
Corporation was to have provided
approximately half of this supply.
Aventis Pasteur, Inc. is the remaining
provider for inactivated influenza vaccine for the U.S., producing almost
54 million doses of Fluzone®.
Additionally, MedImmune has produced approximately 1.1 million
doses of live attenuated influenza vacSUMMARY

Amantadine Rimantadine
(Symmetrel®) (Flumadine®)

Oseltamivir
(Tamiflu®)

Zanamivir
(Relenza®)

Works for Influenza A

Yes

Yes

Yes

Yes

Works for Influenza B

No

No

Yes

Yes

Mode

Oral

Oral

Oral

Inhaled

Treatment

> 1 y.o.

> 13 y.o.

> 1 y.o.

> 7 y.o.

Length of Treatment

3-5 days

3-5 days

5 days

5 days

Prophylaxis

> 1 y.o.

> 1 y.o.

> 13 y.o.

Not licensed

caretakers of infants.
The Arizona Department of
Health Services supports the Centers
for Disease Control and Prevention’s
recommendations to prioritize the following groups to receive inactivated
influenza vaccine (shots) this season:
• children aged 6–23 months;
• adults aged 65 years and older;
• persons aged 2–64 years with
underlying chronic medical conditions (e.g. asthma, chronic lung
or heart disease, chronic metabolic diseases including diabetes,
hemoglobinopathies, immunodeficiency, renal disease)
• women who will be pregnant
during the influenza season;
• residents of nursing homes and
long-term care facilities;
• children aged 6 months–18 years
on chronic aspirin therapy;
• out-of-home caregivers and
household contacts of children
aged less than 6 months;
• health-care workers involved in
direct patient care.
Because it is important to prioritize the influenza shots (inactivated
vaccine) for high-risk people, live
attenuated influenza vaccine
(FluMist®) is an excellent alternate for
healthy people between the ages 5 to
Continued on page 2

Visit the ADHS Web site at www.hs.state.az.us
Substance
Abuse Links
Page 2

November/December 2004

HIV Trends
Found in MSM
Populations
Page 3

Co-infection
with Hep C &
HIV
Page 4

November is
Communicable
Hepatitis C
Disease
Awareness Month
Summary
Page 5
Page 7

HIV/Syphilis
Co-infection
Common
Page 8
Prevention Bulletin

1

Influenza and Influenza Vaccine
continued from page 1

49 years old who want to be vaccinated. This includes healthy parents and caretakers of infants less
than 6 months of age.
Infants have just as high of risk
of hospitalization as do the elderly, yet inactivated vaccine is not
approved under
age 6 months.
Therefore, it is important to give
influenza vaccine to parents and
caretakers of children less than 6
months old.
Health care workers under the
age of 50 can also receive FluMist®
if they do not care for immunosuppressed patients during the time
when they require protective
isolation. Anyone who has
received an FluMist® should not
have contact with severely
immunosuppressed patients for
senen days after immunization.

Antiviral Medicines
With a shortage of influenza
vaccines this winter, physicians
should consider antiviral medicines
for treatment and prophylaxis. They
can speed recovery and decrease
the severity of influenza if started
within 48 hours of becoming ill.
The choice of antiviral medicines depends on what strain of
influenza is circulating.
Amantadine (Symmetrel®) and
Rimantadine (Flumadine®) are
effective only against influenza A.
Oseltamivir (Tamiflu®) and
Zanamivir (Relenza®) are effective
against both influenza A and B, but
are more expensive.
When influenza A is known to
be circulating in a community,
Amantadine and Rimantadine are
the empiric drugs of choice. When
influenza B is known to be circulating, Oseltamivir or Zanamivir
should be used until the precise
strain can be identified.
Amantadine, Rimantadine, and
Oseltamivir are taken orally. All
three are also available in a liquid
form. Zanamivir is delivered by an
inhaler. The use of antiviral medi2

Prevention Bulletin

cines should be avoided in pregnant women.
All four antiviral medicines are
approved for treatment for influenza, but the ages differ. Amantadine
and Oseltamivir are approved for
treatment of people over 1 year of
age, and Rimantadine is approved
for treating influenza in people >
13 years of age. Since Zanamivir
has to be given by an inhaler, it
cannot be used in young children,
so it is approved for people > 7
years of age.
Treatment with Amantadine
and Rimantadine should be
stopped when clinically warranted,
usually within 3 to 5 days of treatment, or within 24 to 48 hours
after the disappearance of symptoms. Treatment with both
Oseltamivir and Zanamivir is recommended for five days.
Three of the antivirals are
approved for use as prophylaxis:
Amantadine, Rimantadine, and
Oseltamivir. Amantadine and
Rimantadine are approved for people > 1 year of age. Oseltamivir is
approved for people > 13 years of
age, Zanamivir is only approved
for treatment of influenza.
Prophylaxis involves prescribing antivirals to susceptible highrisk patients when influenza is circulating in the community.
Prophylaxis can be given for the
entire duration of the outbreak.
Another use is in patients who
have been immunized late in the
season, and the vaccine will not be
effective in preventing disease for
two to three weeks. Antiviral medicines can then be given for two to
three weeks after vaccination.
For more information about
antiviral dosing, side effects, and
dose adjustments, please refer to
Morbidity and Mortality Weekly
Report, May 28, 2004, at http://
www.cdc.gov/mmwr/preview/
mmwrhtml/rr5306a1.htm
Karen Lewis is Medical Director, Bureau of
Epidemiology and Disease Control, and can be
reached at lewisk@azdhs.gov, 602.364.3574.

Substance Abuse Linked
to Stressful Environments
for Pregnant and Post
Partum Women
Lisa Shumaker

Women with small children and substance abuse problems are more likely to
live in stressful environments including situations like physical or sexual abuse, limited
financial and social support, homelessness,
legal problems, and major health problems.
Their children are at greater risk of abuse,
neglect, and development of behavioral
health problems. Treatment of pregnant
women and women with small children is
particularly challenging because of cooccurring health care needs and the need to
provide safety and security for children.
Medical providers can help women
with substance abuse problems by referring
them to programs designed to meet their
unique needs and by coordinating their
medical care with behavioral health
providers.
The Division of Behavioral Health sponsors several specialty programs for pregnant
and parenting women with small children.
For example, the Center for Hope is a
housing and recovery program for homeless, substance abusing women and their
children. The services provided include
gender-specific, comprehensive familyfocused therapy, parenting skills, life skills,
job skills, and educational opportunities.
Other specialty programs for mothers in
recovery include the following:

Central and Northern Arizona
Native American Connections:
602.424.2060
Elba House: 602.276.4288
New Arizona Family, Inc.:
602.553.7300
Casa de Amigas: 602.265.9987
Center for Hope: 480.831.7566

Southern Arizona
CODAC Behavioral Health Services:
520.327.4505
Las Amigas: 520.882.5898
The Haven: 520.623.4590
Amity Foundation: 520.749.5980
Lisa Shumaker is Manager of Prevention, Division of
Behavioral Health Services, and can be reached at
shumakl@azdhs.gov, 602.364.4593.
November/December 2004

HIV Trends Found in MSM Populations
By: S. Robert Bailey, Kelli M. Donley

The Arizona Department of Health Services’ Office of HIV/AIDS has developed current (2002) estimates of risk group
populations, i.e. men-who-have-sex-with-men (MSM), Injection Drug Users, and High Risk Heterosexuals. Based upon
these population estimates and reported cases of HIV infection through 2002, 9% of MSM in Arizona across all age
groups, and 22% aged 35-49 are estimated to be currently infected with HIV. These are crude estimates and consider
only reported cases. According to the CDC, reported cases constitute 70% of the actual number of infections, suggesting
Figure 1
that actual rates may be higher.
In addition, the distribution of HIV/AIDS reports
Prevalence and New Case Rates per 100 MSM by Age,
among racial and ethnic groups is noteworthy. Although
Arizona, 2004
Blacks are just 3.2% of the state’s population total, they
25.00
are 7.6% of new HIV/AIDS cases. A Black MSM is more
than twice as likely to be infected with HIV/AIDS in
20.00
Arizona than a White MSM. On the other hand,
Hispanics constitute 27.1% of the state population, yet
15.00
make up just 14.1% of new HIV/AIDS cases.
Figure 1 describes the epidemic among MSM by age
10.00
category. While prevalent cases peak at age 40-44, the
highest new case rates are reported among those aged
30-39. This divergence in mean ages of new cases and
5.00
prevalence is influenced by the availability of effective
anti-retroviral therapy since 1996. Persons with
0.00
HIV/AIDS are living longer after diagnosis due to
13 - 19
20 - 29
30 - 39
40 - 49
50 - 59
60 +
anti-retroviral therapy.
Prevalence Rate per 100 MSM

New Case rate per 100 MSM

Rocky Mountain Spotted Fever on the Rise in Arizona
by Craig Levy

Until recently, cases of Rocky
Mountain Spotted Fever (RMSF) were
rare in Arizona. Only four cases were
reported between 1990 and 2001,
and three of these had out-of-state
travel/exposure histories. Since 2002,
eight cases of RMSF have been reported, including six cases (so far) in
2004. Two cases in young children
were fatal. All of the recent patients
reside in the White Mountain Region
of eastern Arizona.
RMSF is a tick-borne disease
caused by the bacterium Rickettsia
rickettsii. RMSF transmission is seasonal with most cases reported from April
through September. Tick bites are
reported in approximately 60% of
cases. Incubation period is five to ten
days after a tick bite. Early symptoms
may include fever, severe headache,
muscle pain, nausea, vomiting, and
lack of appetite. Rash often appears
two to five days after onset and may
be macular and/or petechial. Rash
usually appears on extremities first
(especially wrists and forearms),
November/December 2004

before becoming more generalized
(rash may include palms and soles). In
some cases rash may appear late or
not at all (~10-15% of cases).
Abnormal laboratory findings may
include thrombocytopenia, hyponatremia, or elevated liver enzymes.
Severe manifestations can include disseminated intravascular coagulopathy
(DIC), encephalitis, pneumonitis and
skin necrosis.
Because of the rise in RMSF incidence in Arizona, it should be considered in the differential diagnosis of
compatible illnesses in patients who
reside in, or visit, the White
Mountains and the surrounding area.
History of tick-bite is significant, however, absence of known tick-bite does
not rule-out the possibility of RMSF.
Any attached ticks should be saved
and sent to the ADHS Vector-Borne
and Zoonotic Diseases Program for
species identification (see phone
number and address at end). RMSF is
a reportable condition in Arizona.
Suspected cases should be reported to

local health officials. Serologic testing
for RMSF is available at the Arizona
State Health Laboratory. Paired sera
collected 2 to 4 weeks apart would be
needed to confirm or rule-out RMSF
infection.
RMSF is a severe and potentially
life threatening disease. Treatment
with appropriate antibiotics (e.g.,
doxycycline) should be promptly
initiated when RMSF is suspected.
The decision to treat should not be
delayed while waiting for positive
laboratory results.
For more information on RMSF,
contact ADHS staff at 602.364.4562.
Tick specimens can be sent to:
Arizona Department of Health Services,
Vector-Borne and
Zoonotic Diseases Program,
150 North 18th Avenue,
Suite 140,
Phoenix, Arizona 85007.
Craig Levy, M.S., is Manager, Vector-Borne and
Zoonotic Diseases’ Program, and can be
reached at levyc@azdhs.gov, 602.364.4562.

Prevention Bulletin

3

Co-infection with Hepatitis C and HIV
Leads to Faster Disease Progression
By S. Robert Bailey, Kelli M. Donley, Michele Humphreys, Julie Karcis

Arizonans who are infected with
HIV are 12 times more likely to be
infected with hepatitis C than the general population. Of nearly 10,000
Arizonans currently reported with
HIV, 830 are also hepatitis C positive.
Co-infection is of concern because it
has shown to lead to faster progression of both diseases.
Of particular concern are infected
men-who-have-sex-with-men, or
MSM. Of those co-infected, there is a
cohort of MSM who report no intravenous drug use (IDU). These men
may have become infected with hepatitis C from sexual acts that resulted in
significant blood exchange with their
partner.
Of the 830 Arizonans co-infected,
388 are MSM, 183 of which do not
report IDU. In other words, 22% of
co-infected Arizonans are MSM with
no reported IDU.
The prevalence of HIV in Arizona
is estimated to be 180 people per
100,000, the prevalence for hepatitis
C is 700 per 100,000. Hepatitis C has
been traditionally considered a blood
borne disease and is currently transmitted via sharing of injection equipment by injection drug users. This
matches Arizona data, where 66% of
those co-infected with HIV and hepatitis C report IDU activity. In contrast,
of those infected solely with HIV, 22%
report IDU activity.
According to the Centers for
Disease Control and Prevention
(CDC), rapid liver disease progression
is common among those co-infected.
In 1999, the rapid progression of hepatitis C symptoms in co-infected
patients pushed the United States
Public Health Service to list the disease as an opportunistic infection for
HIV patients – although hepatitis C is
not considered an AIDS-defining illness. The recommendations include
regularly testing HIV-infected patients
for hepatitis C. Hospital records
nationally show hepatitis C-related
liver disease is a significant cause of
4

Prevention Bulletin

hospital admissions and death for
those infected with HIV.

The prevalence of HIV in
Arizona is estimated at 180
people per 100,000, the
prevalence for hepatitis C
is 700 per 100,000.
Dual treatment of the viruses is
complex. Highly Active Anti-Retroviral
Therapy (HAART) is the life-extending
prophylactic treatment for HIV/AIDS.
CDC officials report this treatment has
no influence on the hepatitis C virus;
however, those co-infected may have
increased liver toxicity. Two different
treatments are used in the United
States to treat chronic hepatitis C
infection – monotherapy and combination therapy. The research continues
on which treatment is more effective
for HIV/hepatitis C co-infected
patients.
Other health issues to consider
when treating co-infected patients
include alcohol and injection and
non-injection drug use. Both HAART
and the hepatitis C interferon treatment can be negatively influenced by
alcohol and drug use; alcohol abstinence is required. Some patients may
need to demonstrate a 6-month abstinence from alcohol before being
prescribed interferon treatment.
Considering intravenous drug use is a
common mode of transmission for
both HIV and hepatitis C transmission;
a 6-month abstinence from use is also
required before treatment. CDC recommends that health care workers
pay particular attention to these
patients and watch for warning signs
of drug abuse. Substance abuse therapists should be contacted for both
alcohol and intravenous drug use
patients when necessary. Co-infected
patients may also show signs of
depression. Health care workers are
encouraged to keep this concern in

mind and have mental health specialists available for consultation.
Hepatitis C infection can be prevented among HIV patients.
Recommendations to prevent coinfection include discontinuing intravenous drug use, not sharing personal
items that may contain trace amounts
of blood, such as toothbrushes or
razors, and not engaging in risky sexual activity, such as having unprotected
sex. The CDC MSM Information
Center recommends, “comprehensive
STD prevention services care for
MSM, including testing for HIV,
syphilis, gonorrhea, and clamydia at
least annually, and vaccination against
hepatitis A and B.” The CDC and the
Arizona Department of Health
Services strongly recommend these
vaccinations for the MSM population
and sent a letter to public health programs and private providers in 2002
encouraging their participation in the
vaccination campaign. For more information about the STD treatment
guidelines for MSM, visit:
www.cdc.gov/ncidod/diseases/hepatitis/msm.
S. Robert Baily is an Epidemiologist for ADHS and
can be reached at baileys@azdhs.gov, 602.364.3596.
Kelli M. Donley is an Intern with the Office of
HIV/AIDS and can be reached at
donleyk@azdhs.gov., 602.364.3881.
Julie Karcis, R.N., M.S.N., is an Epidemiologist, STD
Control Program, and can be reached at
karcisj@azdhs.gov, 602.364.4761.
Michele Humphreys is Tribal Prepareness
Coordinator, Office of Public Health Emergency
Preparedness and Response, and can be reached at
humphrm@azdhs.gov, 602.364.3655.
References:
Brook, M.G. (2002). Sexually Acquired Hepatitis. Sexually Transmitted
Infection. 78(4):235-40.
Centers for Disease Control and Prevention. (2001). Frequently Asked
Questions and Answers About Coinfection with HIV and Hepatitis C Virus.
As reviewed June 7, 2004 from: www.cdc.gov/hiv/pubs/facts/HIVHCV_Coinfection.htm.
Centers for Disease Control and Prevention. (2002). Frequently Asked
Questions about STD Treatment Guidelines recommendations for MSM. As
reviewed September 23, 2004 from: www.cdc.gov/ncidod/diseases/hepatitis/msm
Diamond, C., Theide, H., Perdue, T., Secura G.M., Valleroy, L., Mackellar, D.,
Corey L. (2003). Viral Hepatitis Among Young Men Who Have Sex With Men:
Prevalence of Infection, Risk Behaviors, and Vaccination. Sexually Transmitted
Disease. 30(5):425-32.
Flecher, S. (2003). Sexual Transmission of Hepatitis C and Early Intervention.
Journal of Associated Nurses for AIDS Care. 14(5 Suppl):87S-94S.
Saxton, P.J., Hughes A.J., Robinson, E.M. (2002). Sexually Transmitted
Diseases and Hepatitis In a National Sample of Men Who Have Sex with Men
in New Zealand. New Zealand Journal of Medicine. 115(1158):U106.

November/December 2004

November is Hepatitis C Awareness Month
by Judy Norton

The Centers for Disease Control
Overall, the Hepatitis C Program
and Prevention (CDC) estimate that
is responsible for disease surveil3.9 million people (1.8% of the populance, and prevention activities such
lation) are infected with the hepaas harm reduction, edutitis C virus (HCV) nationwide;
cation to persons
of these, approximately 2.7
living with hepatitis
More than
million are thought to be
C, limited provi44,000 case
chronically infected.
sion of hepatitis
reports of non-acute A and B vacBased on the above
data, HCV infection is
cine to those
hepatitis C were
the most common blood
received by the state who are not
borne viral infection in
insured and
Hepatitis C Program cannot afford to
the United States. To
since its inception. pay for the vacraise awareness about
hepatitis C in Arizona,
cine, and public
Governor Janet Napolitano
education. Seminars
has declared November as
and workshops can also
“Hepatitis C Awareness Month.”
be arranged for health care
The incidence of hepatitis C has been
providers. HCV-infected persons are
declining in the U.S. since the midcounseled on the risks of alcohol con1980s. However, the magnitude of
sumption and other drug use. They
the chronically infected persons is of
are encouraged to be followed-up by
concern. Because it may take 10
a physician and are told of the imporyears or more to develop the disease,
tance of being vaccinated against
most of the chronically infected do
hepatitis A and hepatitis B. Lastly,
not exhibit signs of the disease, and
educational materials and information
thus are not aware of their infection.
on local resources is provided.
Besides spreading HCV to others,
Preliminary data from a sixthe undiagnosed and the nonmonth pilot project “Love Your Liver
informed infected persons are at risk
and Live Longer,” (n=1,000 HCV posfor cirrhosis and liver cancer. More
itive patients) indicates some of the
than 44,000 case reports of non-acute
areas that need to be addressed:
hepatitis C were received by the
• Injecting drug users continue to
state Hepatitis C Program since its
be at the highest risk for HCV
inception.
infection.
The national recommendations
for prevention and control of HCV
• Nearly half of those interviewed
infection issued in 1998 [CDC recomclaimed to be unaware of their
mendations for prevention and conHCV status despite a HCV positrol of HCV infection and HCV-relattive test (EIA and/or confirmatory
ed chronic diseases MMWR 1998;
test) up to two months earlier. We
four (RR:19)] rely primarily on pricannot rule out that some of
mary prevention activities to reduce
them may have been informed
HCV transmission. To address the secabout the test results, but did not
ondary prevention needs, the Arizona
recall or did not understand
program was re-structured to include
the implications of being HCVhealth educators who offer education
positive.
and counseling to HCV-infected per• Similarly, these patients were not
sons. The education includes measaware of alcohol use as a risk
ures that should be taken to minimize
factor for cirrhosis. The majority
progression to severe liver disease
of interviewees claimed that they
and, at the same time, reduce
would follow their doctor’s
transmission to others.
advice about not drinking.
November/December 2004

Healthcare providers are encouraged to test patients with a history of
injecting illegal drugs, patients who
received a blood transfusion or an
organ transplant before July 1992,
patients with persistently abnormal
ALT levels, hemophiliacs who
received clotting factors before 1987,
and patients who were ever on
chronic hemodialysis for HCV.
Others at risk include health care
workers after a percutaneous or
mucosal exposure to HCV-positive
blood and children born to
HCV-positive women.
If you would like health education materials or an in-service at your
site, please call the county health
department or the state program at
602.364.3658. State program staff
can provide in-service trainings or
help you arrange a more intensive
2-day Hepatitis C Train the Trainer
course in the community. Please let
us know if you would like to have
other information included in the
client education packet or information to the patient to ensure they
understand important elements in the
prevention and control of HCV.
Additionally, the Arizona Hepatitis
C Coalition offers an opportunity for
professional networking and continuing education on hepatitis C-related
issues. The mission of the Coalition
is to mobilize resources for prevention and management of hepatitis C
infection and its consequences by
advocating, advising, educating and
supporting Arizona’s communities.
Contact the Hepatitis C Program for
more information on the Coalition at
602.364.3658 or 1.800.496.9660.
Additional information and a
calendar of upcoming events and
training opportunities can be found at
http://www.azdhs.gov/phs/oids/hepc/i
ndex.htm.

Judy Norton is Manager, Hepatitis C Program,
and can be reached at nortonj@azdhs.gov,
602.364.3658.

Prevention Bulletin

5

Flu Notes
Options for Controlling
Influenza This Year
Influenza is associated with
approximately 36,000 deaths and
more than 200,000 hospitalizations
each year in the United States. The
primary tool used to reduce the
annual burden of disease associated
with influenza in the U.S. is
immunoprophylaxis with inactivated
vaccine (killed virus) and live, attenuated vaccine. Thus, the current vaccine shortage for the 2004-05
influenza season dictates that (1) the
limited available vaccine be prioritized and (2) other adjunct options
considered. Antiviral drugs for
chemoprophylaxis or treatment of
influenza are not a substitute for vaccination, yet can be useful, particularly in the current situation.
Vaccine Supply: In 2002, about
80 of the 92 million doses of influenza vaccine available were used in the
U.S. In 2003, almost all of the 85
million doses available were used
due to increased demand. The supply projection for 2004 was 100 million doses. However, due to problems with contamination of some
lots, Chiron Corporation, the manufacturer of Fluvirin®, had its license
suspended for three months. This
action is expected to reduce the
national supply of vaccine for the
2004-05 in half, because Chiron and
Aventis Pasteur, Inc. are the only two
influenza vaccine suppliers to the
U.S. Additionally, MedImmune produces a smaller amount of live,
attenuated vaccine.
Who Should Get the Inactivated
Vaccine: With the vaccine shortage,
it is imperative to target the current
limited supply of vaccine to the elderly, children 6 through 23 months of
age, persons with chronic health
conditions, such as asthma and diabetes, and people with weakened
immune systems. Individuals, who
are in close contact with these highrisk groups, should also receive the
vaccine. Available vaccine should be
given to persons in these groups on a
6

Prevention Bulletin

by Victorio Vaz, Ph.D.

first-come, first-served basis. Children
aged less than 9 years who have not
been previously vaccinated require
two doses of vaccine, but the available vaccine should not be used to
ensure a second dose. For more
information please visit the Arizona
Department of Health Services’ web
site at http://www.azdhs.gov/flu.
Who Should Get Live Attenuated
Vaccine: Additionally, the live vaccine FluMist®, if available, should be
considered for healthy persons who
are aged 5 to 49 years, are not pregnant and/or fall into one of the highrisk groups, including health-care
workers (except those who care for
severely immunocompromised
patients in special care units), and
persons caring for children aged less
than 6 months. For more information
go to http://www.cdc.gov/flu.
Antiviral Medications: Centers
for Disease Control and Prevention
interim recommendations for the
2004-05 season can be found at
http://www.cdc.gov/flu/professionals/t
reatment/0405antiviralguide.htm.
Amantadine or rimantadine are recommended for chemoprophylaxis
and oseltamivir or zanamivir for
treatment. Again, people who fall
into high-risk groups and any person
experiencing a potentially life threatening influenza-related illness should
be given priority and treated with
antiviral medications. Persons at high
risk for serious complications of
influenza and who are within the first
two days of illness onset should be
treated with antiviral medications.
(Pregnant women should consult
their primary provider regarding use
of influenza antiviral medications.)
Please note that rimantadine is not
approved for treatment of children
aged less than 13 years. These children should receive amantadine and
oseltamivir (children aged 1 to 12
years), or zanamivir (children aged 7
to 12 years).
Victorio Vaz, Ph.D., Chief, Office of Infectious
Disease Services, can be reached at
vazv@azdhs.gov, 602.364.4564.

Missed Opportunities to
Prevent Congenital Syphilis
by Ashraf Lasee, M.P.H., Dr. P.H.

Arizona had 29 cases of congenital
syphilis (CS) reported in 2003. This
translates into 31.9 cases per 100,000
live births (LBs), the highest case rate
nationwide. Additionally, while rates
nationwide have declined from
14.5/100,000 LBs in 2000 to 10.3 in
2003, case rates in Arizona have
remained high and relatively stable
during the same timeframe (31.8 in
2000 and 31.9 in 2003). More importantly, CS case rates nationwide have
paralleled the reduction in primary and
secondary (P&S) syphilis among
women. Of concern is the lack of
decline in CS case rates in Arizona
despite a decrease in P&S syphilis rates
among women.
CS results in a heavy disease burden that can be prevented provided
the mother is diagnosed and treated
before the infant has been irreversibly
affected. Lack of prenatal care, late or
limited prenatal care and maternal use
of illicit drugs have been associated
with CS according to earlier national
reports. In Arizona, most missed
opportunities to prevent CS appear to
be due to either failure to access prenatal care or failure to be screened for
syphilis at the first visit or the third
trimester. From 1998 to 2002, approximately 60% of the mothers who gave
birth to a CS child in Arizona reported
receiving no prenatal care.
We welcome any help that clinicians can provide in raising awareness
of the risk of syphilis. The Centers for
Disease Control and Prevention recommends syphilis testing for all
women during the early stages of pregnancy and a subsequent test in the
third trimester among women at high
risk and women in areas where
syphilis prevalence is high. Women
who deliver a stillborn infant after 20
weeks’ gestation should also be tested.
Emergency departments, jails, prisons
and other settings offer an opportunity
for syphilis screening among women
who otherwise may not seek or have
access to prenatal care.
Ashraf Lasee, M.P.H., Dr. P.H., Manager - STD
Control Program, and can be reached at
laseea@azdhs.gov, 602.364.3661.
November/December 2004

SUMMARY OF SELECTED REPORTABLE DISEASES
Year to Date (January - September, 2004)1, 2
Jan - Sept
2004

Jan - Sept
2003

5 Year Median
Jan - Sept

VACCINE PREVENTABLE DISEASES:
Haemophilus influenzae, serotype b invasive disease (<5 years of age)
Measles
Mumps
Pertussis (<12 years of age)
Rubella (Congenital Rubella Syndrome)
FOODBORNE DISEASES:
Campylobacteriosis
E.coli O157:H7
Listeriosis
Salmonellosis
Shigellosis

0 (0)
0
1
107 (59)
0 (0)

9 (6)
1
0
100 (63)
0 (0)

4 (3)
1
1
59 (36)
0 (0)

620
21
6
543
297

651
28
10
535
393

495
28
11
535
356

223
197
1,009
0
N/A

214
215
819
7
7,054 (2,892)

319
148
819
9
5,149 (2,803)

493
176
33
11

543
183
27
25

609
166
27
25

12,138
2,883
133 (33)

10,177
2,806
148 (16)

10, 177
2,941
148 (16)

17 (2)
984

6 (1)
721

8 (1)
721

1
0
90

0
0
57

1
0
75

2,772
158
411
337
273 (246)

1,866
158
345
342
223 (200)

1,466
158
349
353
259 (200)

VIRAL HEPATITIDES:
Hepatitis A
Hepatitis B: acute
Hepatitis B: non-acute3
Hepatitis C: acute
Hepatitis C: non-acute3 (confirmed to date)
INVASIVE DISEASES:
Streptococcus pneumoniae
Streptococcus Group A
Streptococcus Group B in infants <30 days of age
Meningococcal Infection
SEXUALLY TRANSMITTED DISEASES:
Chlamydia
Gonorrhea
P/S Syphilis (Congenital Syphilis)
DRUG-RESISTANT BACTERIA:
TB isolates resistant to at least INH (resistant to at least INH & Rifampin)
Vancomycin resistant Enterococci isolates
VECTOR-BORNE & ZOONOTIC DISEASES:
Hantavirus Pulmonary Syndrome
Plague
Animals with Rabies4
ALSO OF INTEREST IN ARIZONA:
Coccidioidomycosis
Tuberculosis
HIV
AIDS
Lead Poisoning (<16 years of age)
1
2
3
4

Data are provisional and reflect case reports during this period except Lead Poisoning which is by date of diagnosis.
These counts reflect the year reported or tested and not the date infected.
Case counts for non-acute Hepatitis B and C are not available before 1998.
Based on animals submitted for rabies testing.

November/December 2004

Prevention Bulletin

7

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Arizona Department of Health Services
Public Information Office
150 North 18th Avenue
Phoenix, AZ 85007

Please include your mailing label with all
requests for changes. Fax changes to
602.364.3266 or call 602.364.3860

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Phoenix, AZ
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Janet Napolitano, Governor
Catherine R. Eden, Ph.D., Director ADHS
Rose Conner, Assistant Director, Public Health Services
Contributors
S. Robert Bailey, Kelli M. Donley, Michele Humphreys,
Julie Karcis, Ashraf Lasee, M.P.H., Dr. P.H.
Craig Levy, Karen Lewis, M.D., Judy Norton,
Lisa Shumaker, M.A., Victorio Vaz, D.V.M., Ph.D.
Managing Editor: Mary Ehlert, M.S., ABC
e-mail: ehlertm@azdhs.gov
Assistant to Mary Ehlert: Jennifer Slater

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 602.364.1201 or 1.800.367.8939 (State TDD/TTY Relay).

Study Finds HIV/Syphilis Co-infection Common
By Kelli M. Donley, S. Robert Bailey, Julie Karcis

A recent study at the Arizona
Department of Health Services has
identified 687 cases of individuals
who have histories of infection with
HIV and syphilis during their lifetime.
These cases occur among 16,149 persons reported with syphilis, and
17,208 persons reported with HIV
infection from 1981 through 2003.
Using the HIV diagnosis as a baseline,
“concurrent infection” (those who
became infected with syphilis while
HIV positive) was established
in 58% (n=399) of this group. Among
persons in the “concurrent infection”
group, 19 had multiple concurrent
syphilis infections. Considering only
primary, secondary and early latent
syphilis cases, at least 16% (n=64) of
HIV/syphilis “concurrent infection”
cases demonstrate certain syphilis
infection after HIV diagnosis.
The race/ethnicity among “concurrent infection” of HIV/syphilis is
not substantially different from that
of HIV alone.
8

Prevention Bulletin

Based on this study, persons with
a syphilis diagnosis are at least 14
times more likely to be HIV positive
than the general population of
Arizona (0.0247 compared to 0.0017
for the general population). An
apparent increasing trend in syphilis
diagnosis among HIV positive persons
has been observed since 1998.
The Centers for Disease Control
and Prevention (CDC) reported 6,862
cases of syphilis nationally in 2002,
a 12.4% increase from 2001. Men
having sex with men have had the
largest increase in reported syphilis.
Hall Klausner and Bolan report the
resurgence of syphilis is in part due to
increased anonymous sexual contact,
reduced condom use, increased use
of methamphetamine and sildenafil
(Viagra®) and increased use of the
Internet for meeting sexual partners.
Patients who test positive for HIV
or syphilis should be tested for other
sexually transmitted diseases. A positive HIV or syphilis test should be

considered a “sentinel event” in the
patient’s clinical history. Sexual
behaviors, injection drug use, and
medical history should be well documented. Persons testing positive for
HIV can be referred to the Prevention
for Positives Program, which began
doing prevention case management
in 2004. This initiative works with
HIV positive persons to reduce
ongoing risk behaviors.
Contact Scott Davies at the
Southern Arizona Aids Foundation in
Pima County 520.628.7223;
Scott Haverstock at Body Positive in
Maricopa County 602.307.5330; or
Gerry Garvey with the Yavapai
County Health Department
928.522.7891.
References:
Hall, C.S., Klausner, J.D., Bolan, G. A. (2004). Managing Syphilis in the
HIV-Infected Patient. Current Infectious Disease Reports. 6:72-81.
http://www.dph.sf.ca.us/sfcityclinic/providers/HallsyphHIVreview2004.pdf
MMWR: 2/23/2001 / 50(07); 117-120.
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5007a2.htm
ADHS HIV/AIDS 2004 Annual Report:
http://www.hs.state.az.us/phs/hiv/stats_reports.htm

November/December 2004