Publication of the Division of Public Health Services

September/October 2005, Vol. 19, No. 5

Community-acquired Pneumonia
Peter C. Kelly, M.D., F.A.C.P.

Respiratory tract infections are a
common cause of illness. Most of
these infections are mild, self-limited
and do not require professional medical care. Some individuals will have
signs and symptoms of a lower respiratory tract infection (also known as
acute bronchitis) such as cough, sputum production, and fever. A smaller
group of people will have symptoms
of a lower respiratory tract infection
accompanied by rales on auscultation
of the chest and /or an infiltrate on
chest radiograph. This later group has
an infection of the lung parenchyma
known as pneumonia. Pneumonia
has many different causes most of
which are microorganisms. In fact the
microorganisms causing pneumonia
are very diverse ranging from viruses
to bacteria and fungi. The diversity of
causes challenges physicians to make
an accurate diagnosis so that appropriate treatment can be given.
A practical approach to managing
pneumonia is to classify cases according to the circumstances of the patient
at the time the disease was acquired.
Some of the categories include pneumonia acquired in the community by
overtly normal people, pneumonia
acquired in the hospital or nursing
home setting, and pneumonia among
immunocompromised hosts. This article will focus on community-acquired
pneumonia in normal hosts.

Community-acquired
Pneumonia, the Big Picture

Parameters that Define
Severe Pneumonia(3,5)

The estimated annual case load of
community-acquired pneumonia in
the United States is 4 million. These
cases result in 600,000 hospitalizations at a cost of $23 billion.(1)
Mortality rates vary widely from a
low of 5.1% for hospitalized and
ambulatory patients to a high of
36.5% for patients requiring intensive
care.(2) Community-acquired pneumonia occurs in patients of all ages but
is frequent in people from their midfifties to late sixties.(3)

Any single parameter defines severe
pneumonia.

Microorganisms Causing
Community-acquired
Pneumonia

5. An increase in the size of the pulmonary infiltrate of up to 50% in
the first 48 hours.

Many different microorganisms
cause community-acquired pneumonia. Among patients requiring
hospitalization Streptococcus pneumoniae is the most frequently
identified pathogen but accounts for
only ~ 20% of cases. Other bacteria
recognized as causative agents are
Haemophilus influenzae,
Staphylococcus aureus, Mycoplasma
pneumoniae, and several different
enteric gram negative rods. In addition there are organisms that occur
infrequently when nation wide data
are surveyed but can be frequent
causes in specific locations. Examples
include Legionella species, Coxiella

1. Greater than 30 breaths per
minute on admission
2. A ratio of arterial oxygen tension
to fractional inspired oxygen of
less than 250
3. The need for mechanical
ventilation
4. Bilateral or multilobar involvement
on chest radiograph

6. Systolic blood pressure <90
mmHg
7. Diastolic blood pressure < 60
mmHg
8. The need for vasopressors for
more than four hours
9. A urine output of < 20mL/hour or
a total output of < 80mL over 4
hours
10. Acute renal failure
burnetii, and Chlamydia psittaci. One
of the most common findings in many
studies is that no pathogen is identified.
continued on page 2

Visit the ADHS Web site at www.azdhs.gov
Flu Vaccine Risk
Groups & Your
Practice
Page 3
September/October 2005

Unsafe Behaviors
and STDs Predict
HIV Increase
Page 4

Dengue Fever
Page 5

Communicable
Disease Summary
Page 7

Hepatitis C:
Acute vs. Chronic
Infections
Page 8
Prevention Bulletin

1

Community-acquired Pneumonia
In Arizona we
have two organisms
that deserve
consideration. In the
desert counties
(Maricopa, Pima, and
Pinal) Coccidiodes
immitis, a fungal
organism found in the
soil and aerosolized
by wind or by working in the soil, can
cause communityacquired pneumonia.
In recent years the
number of cases of
coccidioidomycosis
has steadily increased
(See Figure 1) due in
part to increased population but also
due in part to other unidentified factors. In view of the increasing cases
physicians should strongly consider
ordering a coccidioidal serology and
fungal sputum culture on cases of
community-acquired pneumonia,
especially if symptoms persist for two
weeks or longer. In the northeastern
part of the state the Sin Nombre Virus
can cause a severe pulmonary illness
(Hantavirus Pulmonary Syndrome)
preceded by abdominal pain. The
virus is shed in the urine of deer mice
and humans acquire infection via
aerosols.
Viral pathogens can cause community-acquired pneumonia and are
frequent in mild cases not requiring
hospitalization. The principal causes
are Influenza A and B, Respiratory
syncytial virus (RSV), Parainfluenza
virus and Adenovirus. Influenza and
RSV are seasonal pathogens with
clustering in the fall and winter
months. Mycoplasma pneumoniae is
the most frequently established diagnosis in out-patient pneumonias, and
accounts for ~20% of cases.
Given the diversity of causes of
community-acquired pneumonia it is
not necessary or desirable to order
diagnostic tests for each possible
microorganism. Testing can be tailored to the circumstances of the
case. For patients admitted to the hos2

Prevention Bulletin

continued from page 1
Figure 1

pital, two pretreatment blood cultures,
an expectorated deep-cough sputum
for Gram stain and culture and a coccidiodal serology is sufficient. Mild
cases not requiring hospitalization
can be evaluated for Mycoplasma
pneumoniae, and seasonal viruses
such as Influenza and RSV. If a
specific organism is suspected on
clinical grounds, then tests for that
agent can be ordered.

Severe Community-acquired
Pneumonia(3)
Ten percent of communityacquired pneumonia cases can be
severely ill and benefit from intensive
care. Criteria for identifying these
patients are listed in the box on
page 1. S. pneumoniae and L.
pneumophilia are the organisms most
commonly found in severe cases.
Mortality rates for severe pneumonia
range from 20 to 53%. Clinical factors
independently associated with death
are tachypnea (>30 breaths/minute),
diastolic blood pressure < 60 mmHg
and blood urea nitrogen >
7mmol/liter.

Treatment of Communityacquired Pneumonia
In clinical practice, treatment
decisions are frequently made before
the results of diagnostic tests are available. A detailed discussion of empiric
antibiotic selection is beyond the
scope of this article and can be found

in the published guidelines of the
Infectious Diseases Society of
America(4) or the American Thoracic
Society(5). The initially prescribed
antibiotics can be modified when a
specific cause is identified. In patients
that do not respond to empiric therapy additional diagnostic testing based
clinical findings should be undertaken
prior to broadening the antibiotic regimen. In our state, the frequency of
coccidioidomycosis should prompt
physicians to order coccidioidal serology early in the course of communityacquired pneumonia.
References:
(1) Bartlett JG, Mundy LM. Community-acquired
pneumonia. N Engl J Med 1995; 333:1618-1624.
(2) Fine MJ, Smith MA, Carson CA, et al. Prognosis
and outcomes of patients with communityacquired pneumonia: A meta-analysis. JAMA
1996; 275: 134-141.
(3) Donowitz, GR, Mandell GL. Acute Pneumonia.
In Mandell GL, Bennett JE, Dolin R,eds Principles
and Practice Infectious Diseases, 6th
ed.Philadelphia: Elsevier; 2005: 819-845.
(4) Mandell LA, Bartlett JG, Dowell SF, et al. Update
of practice guidelines for the management of
community-acquired pneumonia in immunocompetent adults. Clin Infect Dis. 2003; 37: 14051433.
(5) Niederman MS, Mandell LA, Anzueto A, et al.
Guidelines for the management of adults with
community-acquired pneumonia: Diagnosis,
assessment of severity, and antimicrobial therapy
and prevention. Am J Resp Crit Care Med. 2001;
163: 1730-1754.

Dr. Peter Kelly is a physician consultant at
ADHS and can be reached at
kellypc@azdhs.gov.
September/October 2005

Flu Vaccine Risk Groups & Your Practice
by Will Humble
Table 1
The United States has
had either shortages or
Priority Group
Estimated AZ Pop.
Estimated US Pop.
delays of inactivated
1. A Persons > 65 w/co-morbidity
364,000
18,200,000
influenza vaccine during
Residents of Long Term Care Facilities
34,000
1,700,000
three of the last five
influenza seasons. Delays
Sub-total
398,000
19,900,000
in delivery of influenza
vaccine or vaccine short1. B Persons 2-64 w/co-morbidity
848,000
42,400,000
ages are likely in future
Persons > 65
354,000
17,700,000
years as well because of
Children 6-23 mos.
120,000
6,000,000
inherent time constraints in
Pregnant women
80,000
4,000,000
manufacturing the vaccine
Sub-total
1,402,000
70,100,000
and uncertainties regarding
vaccine supply.
1. C Health care personnel
140,000
7,000,000
Vaccination will conClose contacts of children < 6 mos.
100,000
5,000,000
tinue to be prioritized on
the basis of risk for serious
Sub-total
240,000
12,000,000
influenza-associated complications during periods of 2
Household contacts of high risk persons
1,406,000
70,300,000
inactivated influenza
Healthy persons 50 - 64
354,000
17,700,000
vaccine shortfall. In years
Sub-total
1,760,000
88,000,000
when there is an adequate
supply, nationwide media
3
Healthy Persons 2-49
2,110,000
105,500,000
campaigns will use the
tiered groupings to encourTotal
5,900,000
295,000,000
age people to get their flu
shots. The CDC published
teleconferences, print media outreach, clinician education,
an article in their August 5, 2005 Morbidity and Mortality
and web based advertising.
Weekly Reports that identifies the vaccination priority
The media outreach plan will have three phases that
groups http://www.cdc.gov/mmwr/.
will
encourage different risk groups to get their influenza
The CDC determined the priority groups, ranked in
vaccine at different times. Phase I will be in October and
three tiers, on the basis of influenza-associated mortality
will encourage persons in Tier 1 (highest risk) to seek a flu
and hospitalization rates. In years when there is an
shot. Phase II will encourage persons in Tier 2 (medium
influenza vaccine shortfall, persons in Tier 1 should be
risk) to get their shot. The final Phase will be implemented
vaccinated preferentially, followed by persons in Tier 2,
then persons in Tier 3. Table 1 displays a description of the if there are adequate supplies and will encourage lower
risk persons aged 2 to 49 years without medical problems
tiered groups and an estimate of the number of people in
to get their shot.
each category in Arizona.
The CDC website continues to post regular updates
The CDC will be using the new tiered risk grouping in
and downloadable influenza prevention materials for
their nationwide media campaign this year to increase the
public's awareness of this year's immunization recommen- healthcare providers at http://www.cdc.gov/flu/.
dations. The media plan will include radio and TV public
Will Humble is Deputy Assistant Director of Public Health Preparedness,
and can be reached at 602.364.3855 or humblew@azdhs.gov.
service announcements, video news releases, radio tours,

Arizona's “Evergreen” Pandemic Flu Plan
A pandemic influenza is inevitable. The ADHS has created this Pandemic Influenza Response Plan to promote an
effective and coordinated response throughout the pandemic in order to lessen the impact of the influenza pandemic.
Healthcare providers will be important partners with the Federal State and Local government when the next influenza
pandemic arrives.
The Arizona plan is on the ADHS website at: www.azdhs.gov. This is an “evergreen” document that is updated as
suggestions and recommendations are made. You can provide recommendations to improve the plan by e-mailing
Will Humble at humblew@azdhs.gov.
September/October 2005

Prevention Bulletin

3

Unsafe Behaviors and STDs Predict HIV Increase
by Melanie Taylor, M.D., M.P.H., and S. Robert Bailey, M.S.

An analysis of sexually transmitted disease (STD), Hepatitis C (HepC),
and HIV/AIDS surveillance reports
made to the Arizona Department of
Health Services from 1998-2003
reveal prevailing patterns of co-morbidity in Arizona. Because common
modes of transmission exist between
these diseases co-morbidity analyses
can support and direct recommendations for testing. Using disease
reports, epidemiologists constructed a
lifetime diagnosis history of STDs ,
HepC, and HIV for persons reported
with one of these diseases during
1998-2003. Significant morbidity
overlaps among the disease groups
was observed.
The reported co-morbidity reflects
the number of persons in
each disease group
also having any
lifetime reported diagnosis
within any of
the other
disease
groups. Most
noteworthy is
the fact that
nearly 15% of
those reported
with HIV/AIDS
have also been
reported with an STD
or HepC. Compared
with prevalent
disease rates
in the Arizona
population,
persons reported
with Hep C are
nearly 12 times
more likely to
have been
diagnosed with
HIV; persons
reported with
Gonorrhea
are more
than 9 times
as likely to
have been
diagnosed
4

Prevention Bulletin

with HIV; persons reported with
Syphilis are nearly 13 times more
likely to have been diagnosed with
HIV infection.
It has long been understood that
the presence of an STD facilitates the
transmission of HIV, and that STDs
themselves are an indicator of unsafe
sexual practices conducive to HIV
infection. Current Centers for
Disease Control and Prevention
(CDC) recommendations include HIV
testing for all persons who seek testing or treatment for STDs. The U.S.
Preventative Services Task Force has
recently released updated recommendations for HIV testing among other
risk groups.

Among HIV-infected persons STD
testing (syphilis, gonorrhea, chlamydia) is recommended yearly and
every 3-6-months for persons engaging in unsafe sexual activities such as
having sex with anonymous partners,
drug use (methamphetamine, Viagra,
ecstasy, cocaine), prostitution, and
meeting partners at commercial sex
venues such as bathhouses, sex clubs
and adult bookstores. Hep C testing is
recommended for all persons at the
initial visit for HIV primary care. For
HIV-infected persons reporting ongoing injection drug use, ADHS recommends ongoing annual Hep C testing.

continued on page 5

September/October 2005

Unsafe Behaviors

cont. from pg. 4

In addition to these co-morbidity data,
other data, such as methamphetamine
positivity rates among arrestees, reported
patterns of drug use among persons with
HIV, and patterns of risk behavior reported among men who have sex with men
support a general picture of resurgent
risk taking behaviors. Together these data
suggest that a significant proportion of
HIV infected persons are continuing to
engage in behaviors that promote HIV,
and STD transmission.
For this reason, providers should collect comprehensive sexual and drug-use
histories from their patients and use this
information to guide HIV and STD testing. Collection of comprehensive sexual
histories should be ongoing with patients
reporting current high-risk behaviors.
Providers should encourage and support
practices (such as condom use) that can
significantly reduce the risk of acquisition or transmission of disease.
References:
1.
2.
3.

4.

5.

6.

7.

8.

Sexually Transmitted Diseases included in this analysis
were Chlamydia, Gonorrhea, Herpes, and Syphilis.
Hepatitis C reports included acute and chronic infections,
but more than 99% of reports were chronic infections.
Fleming DT, Wasserheit JN. From epidemiological synergy to public health policy and practice: the contribution of other sexually transmitted diseases to sexual
transmission of HIV infection. Sex Transm Inf.
1999;75:3-17.
Centers for Disease Control and Prevention. Sexually
Transmitted Disease Treatment Guidelines 2002.
MMWR. 2002;51:1-78.
U.S. Preventative Serives Task Force. Screening for HIV:
Recommendations Statement. Annals of Internal
Medicine. 2005;143;32-37.
Centers for Disease Control and Prevention.
Incorporating HIV Prevention into the medical care of
persons living with HIV: recommendations of CDC, the
Health Resources and Services Administration, the
National Institutes of Health, and the HIV Medicine
Association of the Infectious Disease Society of America.
MMWR. 2003;52:1-32. http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5212a1.htm.
Centers for Disease Control and Prevention. Guidelines
for preventing opportunistic infections among HIV infected persons. MMWR 2002;51:1-46. www.cdc.gov/mmwr/
preview/mmwrhtml/rr5108a1.htm
2003 Tucson Rapid Assessment Response and Evaluation
(RARE) Project on high-risk behaviors of MSM; 2005
Community Needs Assessment for Ryan White Title I as
reported in Arizona Republic, ('Drug use 'Huge' with HIV
Victims, 8/13/2005, Cohen, Mitchell); 2003 Arrestee
Drug Abuse Monitoring for Methamphetamine in
Phoenix available at (http://www.ojp.usdoj.gov/nij/adam/
ADAM2003.pdf) shows an increase in Methamphetamine
positive testing among male arrestees from 17% to 38%
between 2000 and 2003.

Melanie Taylor and S. Robert Bailey are STD
Epidemiologists and can be reached at
baileys@azdhs.gov or taylorm@azdhs.gov.

September/October 2005

Dengue Fever
Dengue is an arboviral disease
caused by a flavivirus for which
there are four serotypes 1, 2, 3,
and 4. Dengue is endemic to
most tropical and subtropical
regions of the world, and an estimated 50-100 million infections
occur annually. Dengue is transmitted by mosquito bites, and is
not transmitted person-toperson. Incubation period is 3-14 days. Classic
dengue is characterized by
sudden onset, high
fever, severe frontal
headache, backache,
myalgia, arthralgia,
nausea, vomiting and rash.
The rash, which is usually
maculopapular, appears
3-4 days after onset of fever.
The acute phase may last up to a
week, with a prolonged convalescence characterized by weakness,
malaise, and anorexia. Classic
dengue can be treated with bed
rest, fluids, and antipyretics; however, aspirin is contraindicated.
Dengue hemorrhagic fever
(DHF) and dengue shock syndrome (DSS) are more severe forms
of this disease. DHF is characterized by fever, thrombocytopenia,
hemorrhage, and capillary leak
syndrome (manifested as hemoconcentration, hypoalbuminemia,
or pleural effusion). Skin manifestations can occur such as petechiae, purpura, or ecchymoses.
Other hemorrhagic symptoms may
include epistaxis, bleeding gums,
hematemesis, and melena. DSS
may include the above in addition
to hypotension and shock.

by Craig Levy

The primary mosquito vectors
are Aedes aegypti (“yellow fever
mosquito”) and Aedes albopictus
(“Asian tiger mosquito”). Aedes
aegypti mosquitoes are prevalent
in many southern and central
Arizona communities. Aedes
aegypti mosquitoes have also been
reported as far north as the Verde
Valley area of Yavapai County.
This mosquito breeds in back
yard containers and has a tendency to bite around the feet
and ankles. The potential
exists for autocthonous
transmission of dengue
due to the widespread
presence of vectors in
Arizona, and with people
traveling from endemic
areas. Infected travelers can serve
as reservoirs for local transmission.
Dengue is a reportable disease
in Arizona. Health care workers
should consider dengue in the differential diagnosis of patients with
compatible symptoms, especially if
there is recent travel to tropical
countries. Suspected cases should
be reported to your local health
department, or ADHS at the number listed below. Serologic testing
is available through ADHS State
Health Laboratory. Paired sera can
be submitted to:
Arizona State Health Laboratory
Attn: Serology
250 North 17th Avenue
Phoenix, Arizona 85007.
For more information, contact
the ADHS-VBZD staff at
602.364.4562.
Craig Levy is the ADHS Vector-Borne
Disease Program Manager and can be
reached at levyce@azdhs.gov.

Save the Date – November 17 - 18
The 12th Annual Immunization Conference will be held November 17
and 18 at the Mesa Convention Center. Keynote speakers include two
medical epidemiologists from the National Immunization Program at the
Centers for Disease Control and Prevention (CDC). Attendees can earn
8.75 hours of Category 1 CMEs through Phoenix Children's Hospital. The
registration form is available at www.azdhs.gov/phs/immun/conf.htm or
call Michelle Gonazales at 602.364.3635.
Prevention Bulletin

5

Noteworthy
Increase in Reported Cases
of Enterohemorrhagic
Escherichia coli
The Arizona Department of Health
Services (ADHS) has noted an increase
in reported cases of Enterohemorrhagic
Escherichia coli (EHEC) in 2005. As of
August 16, 2005, 26 cases of EHEC
have been reported in Arizona compared to 12 cases reported for the
same period in 2004.
EHEC is the primary cause of
hemolytic uremic syndrome (HUS)
and occurs more frequently in young
children and the elderly. Risk of progression to HUS varies by serotype,
but approximately 8% of E. coli
O157:H7 cases develop this syndrome. It is important to note that
severe abdominal cramping and
bloody diarrhea is only accompanied
by fever in less than one third of
cases. County and the state health
departments have not received any
reports of HUS in 2005.
E. coli is transmitted primarily
through food contaminated with ruminant feces; however, direct transmission from person-to-person does occur
in families and other institutions.
Outbreaks have been associated with
undercooked beef, unpasteurized milk,
apple cider, raw vegetables, petting
zoos, and recreational water.
Contact with ruminants, such as cattle,
goats, and sheep, has become an
increasingly recognized source of
EHEC cases nationally. In 2004, a
large outbreak of E. coli O157 associated with a petting zoo was reported in
North Carolina, with over 100 cases
identified. Two of the 26 reported
cases of E. coli O157 in Arizona in
2005 had a common exposure to animals.
Isolation of E. coli from a stool
specimen remains the gold standard
for diagnosis of EHEC. However,
identification of Shiga-toxin using

Enzyme Immunoassay (EIA) and PCR
is becoming more widely available.
Treatment for EHEC is usually entirely
supportive. There is still debate as to
whether antimicrobial therapy is safe
for all cases. Some studies have
identified a higher risk of developing
HUS if treated with antimicrobials.
However, a large scale randomized
trial evaluating the risks and benefits
of antimicrobial therapy is needed.
E. coli infection should be considered in cases of gastroenteritis accompanied by bloody diarrhea and with
a history of animal contact and/or
other risk factors. ADHS reminds
providers to:
• Report all cases of
Enterohemorrhagic E. coli and
HUS to your local health department within 24 hours of diagnosis
(per Arizona Administrative Code
R-9-6-202).
• Collect stool cultures on cases of
bloody and/or severe diarrhea.
• Avoid the use of antimicrobial
therapy in patients with EHEC
infection.
Additional information on
Enterohemorrhagic E. coli and HUS
can be found on the CDC website or
by calling the Infectious Disease
Epidemiology Program at 602.364.
3676.

Pertussis Outbreak Update:
Back to School May Increase
Transmission

decreasing, school has just started and
the case load is expected to increase.
Thankfully, we have a few great tools
to help lessen the severity of the current outbreak and hopefully help prevent future outbreaks: Tdap booster
vaccines for adolescents and adults
(Boostrix® for patients 10-18 years of
age and Adacel® for patients 11-65
years of age). Please recommend
these boosters to your eligible patient
population, especially those that have
close contacts with infants (adolescent
siblings, new mothers, caregivers,
etc.). ADHS also continues to
recommend the use of the accelerated
immunization schedule for infants
until 12/31/05. For more information
on these recommendations and
pertussis in general please visit the
ADHS Pertussis Website at www.
azdhs.gov/phs/oids/epi/pertussis.htm.

Arizona Valley Fever
Awareness Week
November 14-21, 2005
Current Schedule of Events
For further listings and updates, go to
http://www.vfce.arizona.edu/
Tuesday 12:00 - 1:00 p.m.
Demo Pappagianis M.D. PhD.
“The historical importance of Valley
Fever to the Southwest.” Tenth Annual
VFCE Farness Lecture as the University
of Arizona College of Public Health
Grad Rounds. Arizona Health
Sciences Center, Tucson Arizona.
2:00 - 4:30 p.m. state-wide poster
session of current research into Valley
Fever. University of Arizona Student
Union. Jointly sponsored by the VFCE
and the Bio5 Institute, University of
Arizona, Tucson Arizona.

Arizona is continuing to see above
average rates of pertussis activity,
throughout the state. As of the time of
this printing, 737 cases have been
reported, which represents of 390%
above the 5-year median (2000-2004)
for this time frame, and includes four- Friday Noon-1:00 p.m.
Telemedicine Lecture:
teen of Arizona's fifteen counties. And
while the number of new cases report- “Coccidioidomycosis for Arizona
Physicians.”
ed per week currently appears to be

Prevention Bulletin Going Only Electronic Starting January 2006
This is the second to the last paper issue of the Prevention Bulletin. The January/February issue and
beyond will only be available in electronic format. We can send you future issues electronically if you e-mail
Wendy Snyder at snyderw@azdhs.gov with your e-mail address. Future issues will also be posted on our
website at www.azdhs.gov.
6

Prevention Bulletin

September/October 2005

SUMMARY OF SELECTED REPORTABLE DISEASES
Year to Date (January - August, 2005)1, 2
Jan - Aug
2005

Jan - Aug
2004

5 Year Median
Jan - Aug

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

1 (0)
1
0
737 (358)
0 (0)

0 (0)
0
1
151 (96)
0 (0)

4 (3)
0
1
151 (93)
0 (0)

646
27
5
448
249

529
15
6
455
267

469
25
7
435
277

134
265
766
0
5,239 (2,589)

190
155
809
1
7,238 (2,529)

223
155
775
7
5,972 (2,546)

489
184
37
953
33

473
170
32
N/A
10

590
169
25
N/A
22

12,547
2,790
101 (12)

11,103
2,592
118 (27)

9,598
2,592
130 (17)

11 (0)
1,365

15 (2)
881

6 (0)
712

5
0
29
122

1
0
356
66

1
0
N/A
66

1,989
147
510
355

2,334
137
327
327

1,634
132
309
320

VIRAL HEPATITIDES:
Hepatitis A
Hepatitis B: acute
Hepatitis B: non-acute
Hepatitis C: acute
Hepatitis C: non-acute (confirmed to date)
INVASIVE DISEASES:
Streptococcus pneumoniae
Streptococcus Group A
Streptococcus Group B in infants <90 days of age
Methicillin-resistant Staphylococcus aureus 3
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
West Nile virus Infection
Animals with Rabies4
ALSO OF INTEREST IN ARIZONA:
Coccidioidomycosis
Tuberculosis
HIV
AIDS
1
2
3
4

Data are provisional and reflect case reports during this period.
These counts reflect the year reported or tested and not the date infected.
MRSA was not reportable before October 2004.
Based on animals submitted for rabies testing.
Data compiled by Offices of Infectious Disease and Office of HIV/AIDS Services

September/October 2005

Prevention Bulletin

7

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Permit No. 957

Arizona Department of Health Services
Public Information Office
150 North 18th Avenue
Phoenix, AZ 85007
Janet Napolitano, Governor
Susan Gerard, Director ADHS
Niki O’Keeffe, Assistant Director, Public Health Services
Contributors
S. Robert Bailey, M.S., Will Humble, Peter C. Kelly, M.D.,
F.A.C.P., Craig Levy, Melanie Taylor, M.D., M.P.H.,
the Office of Infectious Disease Services,
the Arizona Immunization Program Office
and the Office of HIV/AIDS Services
Managing Editor: Mary Ehlert, M.S., ABC
e-mail: ehlertm@azdhs.gov
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).

Hepatitis C: Acute vs. Chronic Infections
For the past five years (20002004), there were 17 acute hepatitis
C virus (HCV) infections reported in
Arizona; yet, 42,780 chronic infections were reported during the same
period of time. These data emphasize that despite significant decreases in newly acquired HCV infections, the pool of those previously
infected is enormous, approximately
4 million persons in the United
States. Due to the long lag of time
between infection and chronic
disease, the true burden of disease
is yet to come. More importantly,
many of the HCV-infected persons
are unaware of their HCV status and
thus, do not take the take the
adequate measures to spread the
infection to others and at the same
time minimize further damage to
their liver.
HCV, sexually transmitted
diseases (STD) and HIV/AIDS share
some common modes of transmis8

Prevention Bulletin

sion; thus, persons seeking
HIV/AIDS/STD treatment are likely
to be at risk for HCV too. Thus,
offering viral hepatitis services in
HIV and STD clinic settings
provides a unique opportunity to
integrate viral hepatitis services into
existing clinics. Furthermore,
offering hepatitis A and B immunization and education services to
those at risk for hepatitis C can help
address the HCV burden of disease.
The Arizona Department of
Health Services' (ADHS) Hepatitis C
Program can help you with
presentations, patient brochures and
patient education via phone. You
can access more HCV information
at www.cdc.gov or by contacting
the ADHS program at
602.364.3658. November 2005 is
Hepatitis C Awareness Month! Visit
our website at www.azdhs.gov for
updates to our November Events
Calendar.

Hepatitis C Risk Assessment
• Blood transfusion or organ transplant before 1992
• Injected street drugs, vitamins or
steroids, even just one time
• Snorted or smoked street drugs,
even just one time
• Veteran of the armed forces
• Received medical care outside of
the United States
• Had multiple sex partners (> 5
partners in a year, > 10 partners in
a lifetime)
• Received hemodialysis
• Tattoos or body piercings from an
unsterile environment
• Been in prison
• Current or past unexplained liver
disease
• Current or past unexplained
abnormal liver function tests
September/October 2005