Publication of the Division of Public Health Services

November/December 2005, Vol. 19, No. 6

Get On Your Toes Before an Influenza Pandemic Starts
By Will Humble, M.P.H.

Health care providers will play a
critical role during all phases of an
influenza pandemic in Arizona and
throughout the world. As health care
providers you will play a critical role
in initial case identification, reporting
and surveillance, community infection
control, antiviral distribution, vaccine
administration, and health care system
management.

Getting Ahead of the Game

Your role during a pandemic is
critical, and getting ahead and staying
informed will be the key to improving
your effectiveness. Clinical guidelines,
case definitions, procedures for
screening and reporting, infection
control, laboratory testing, antiviral
regimens, and the availability of
antivirals and vaccine will change
rapidly during the course of a
pandemic. Clinicians will need to
regularly consult updates on case
definitions, screening, laboratory
testing, and treatment guidelines for
pandemic influenza and be prepared
to report pandemic influenza cases
or fatalities as requested by your
local health department. In addition,
clinicians should be on the alert and
report atypical cases, breakthrough
infections while on prophylaxis, or any
other abnormal cases throughout the
duration of the pandemic to public
health agencies.
Getting up to speed on these things
before a pandemic starts will give you

a head start on the current clinical
and public health recommendations.
This will allow you to be better able to
make informed decisions about patient
management and more effectively
participate in early surveillance,
community infection control, and
vaccine and antiviral distribution.
The federal pandemic influenza
website provides a nice information
hub for you to stay informed at
www.pandemicflu.gov.

Early Detection of Cases

The first thing that you will be
asked to participate in is early
surveillance. Health care providers
will be in the best position to detect
an index case of pandemic influenza
in a community. Early identification
of cases is critical because rapid
identification and isolation of initial
cases may help slow the spread of
influenza within a community if
prompt and effective isolation and
quarantine measures are taken.
Since a new pandemic strain of
influenza is very unlikely to originate in
Arizona, taking and closely examining
the travel history of patients with
symptoms of influenza will be the key
to finding early cases.
Right now, the likelihood of novel
influenza virus infection is very low in
a returned traveler from Southeast Asia
who has severe respiratory disease or
influenza-like illness. However, if local
person-to-person transmission of a new

influenza virus strain is confirmed at
some point in the future, the potential
for new-strain influenza virus infection
will be higher in a patient with an
epidemiologic link to an affected area.
Your local health department can
be helpful in determining whether a
sick patient with a travel history to an
affected area might be an index case.
In order to increase your chances
of finding early cases, you will need to
stay up-to-date with the latest clinical
and epidemiological information
from around the world. Up to date
information for clinicians will be
posted at www.cdc.gov to help you
find early cases. The World Health
Organization also has updated
information at: www.who.int/en/.

Get Involved

ADHS is currently in the process
of revising and updating Arizona’s
Pandemic Influenza Preparedness Plan,
which is posted at: http://www.azdhs.
gov/phs/oids/epi/pandemic_flu.htm.
In February, the Department will
be organizing an interdisciplinary
Pandemic Influenza Coordinating
Committee to improve the plan and to
bring critical partners into the mix. If
you would like to participate in the
Committee please contact Will Humble
at humblew@azdhs.gov.
Will Humble, MPH is the Chief of Public
Health Preparedness and can be reached at
humblew@azdhs.gov

Visit the ADHS Web site at www.azdhs.gov

Special Collector's Edition

This is the last hard copy issue of Prevention Bulletin. The Prevention Bulletin is going all
electronic. Future issues will be available on the ADHS website at www.azdhs.gov under the
Prevention Bulletin heading. Simply fill out and return the the card insert to receive the link for
future issues.
November/December 2005

Prevention Bulletin

1

Antiviral Medications
Although recent media attention has focused on avian influenza,
patients in the United States are at
much higher risk this winter from the
regular winter outbreak of human
influenza.
Antiviral medicines are very
useful for the treatment and prevention of influenza. By learning how
to use antivirals for influenza, health
care providers can benefit their
patients every winter, as well as
preparing for pandemic influenza.
Human influenza is caused
by influenza A and influenza B.
Influenza outbreaks in North America
come every winter, and start as early
as November or as late as February.
There is also variability as to which
strain of influenza A or B circulates
each year. The current avian influenza in southeast Asia is an influenza
A (H5N1).

Treatment

The greatest benefit occurs when
antivirals are given within the first
48 hours of symptoms. Therefore,
providers should start antivirals when
rapid testing or clinical suspicion
suggests that the patient’s illness is
either influenza A or B.
Treatment with Amantadine
or Rimantadine is given for 3-5
days, or until the patient is afebrile for 1-2 days. Amantadine is
approved for treatment in ages ≥ 1
year old; Rimantadine is approved
for treatment in ages ≥ 13 years
old. Treatment with Oseltamir
and Zanamivir is given for 5 days.
Oseltamivir is approved for use
in ages ≥ 1 year old; Zanamivir is
approved for treatment in ages ≥ 7
years old. [See tables 1& 2]

by Karen Lewis,M.D.

influenza is already circulating in
the community, they can still be vaccinated. However, at the same time,
an antiviral can be prescribed for two
weeks, in order to protect against
influenza during the 2 weeks that
antibodies are developing to the vaccine.
Amantadine and rimantadine are
licensed for prophylaxis in ages ≥ 1
year old, and oseltamivir is licensed
for prophylaxis in ages ≥ 13 years
old. Zanamivir is not licensed for
prophylaxis. [See tables 1 & 2]

Priority Groups

Recommendations for antiviral
use depend on the supply in the
community. When there is a shortage of antiviral medications, antiviral
use should be focused on specific
priority groups.
Treatment priority groups are: 1)
Prophylaxis
People with a potentially life-threatInfluenza antivirals are used to
ening influenza-related illness, and 2)
Antivirals
prevent influenza in several ways
People at high risk for serious comThere are four antivirals for
ways. They can be prescribed to
plications of influenza and who are
influenza that are licensed in the
people who have been exposed to
within the first 2 days of illness onset.
United States: two are amantadanes,
someone
with
influenza.
They
are
Prophylaxis priority groups are:
and two are neuraminidase inhibiusually
prescribed
for
seven
days,
1)
All
residents and workers durtors. The amantadanes’ spectrum
although
when
used
in
an
instituing
an
institutional outbreak, and 2)
is limited to influenza A, whereas
tional
outbreak,
they
can
be
given
for
People
at high risk of serious influenneuraminidase inhibitors are effective
za
complications
if they are exposed
a
longer
period
of
time.
against both influenza A and influto
a
known
or
suspected
case of
Antivirals
can
be
given
to
highenza B.
influenza.
risk
people
who
are
unable
to
receive
The amantadanes are Amantadine
an influenza vaccine (e.g. in egg
(Symmetrel®) and Rimantadine
allergy). This prophylaxis should be Where Antiviral Supply
(Flumadine®). They are both given
timed for use during the 6-8 weeks in Is Sufficient
orally. The neuraminidase inhibiWhen there is enough local supwinter when influenza is circulating
tors are Oseltamivir (Tamiflu®) and
ply
of
antivirals, treatment can be
in
a
community.
Zanamivir (Relenza®). Oseltamivir is
given
to
adults and children > 1 years
A third use for antivirals is when
given orally, whereas Zanamivir
old who have influenza infection, but
high-risk patients are late for getis given by an inhaler.
ting their influenza shot. If a patient who are not at high risk for serious
Antivirals will shorten the
complications.
has not received vaccination until
course of influenza when
given within the first
Table 1: Characteristics of Antiviral Medications
1-2 days of sympAmantadine
Rimantadine
Oseltamivir
Zanamivir
toms. They can also
(Symmetrel®)
(Flumadine®)
(Tamiflu®)
(Relenza®)
be used as prophylaxis against influenza.
Effective for
Yes
Yes
Yes
Yes
Antivirals should be
Influenza A
avoided in pregnant
Effective for
No
No
Yes
Yes
women unless the
Influenza B
benefit outweighs the
Mode
Oral
Oral
Oral
Inhaled
risk.
Treatment
≥ 1 y.o.
≥ 13 y.o.
≥ 1 y.o.
≥ 7 y.o.
Prophylaxis
≥ 1 y.o.
≥ 1 y.o.
≥ 13 y.o.
Not licensed
2

Prevention Bulletin

November/December 2005

Antiviral Medications
In addition, prophylaxis can be offered
during the time that
influenza viruses are
circulating in the community (usually for 6-8
weeks) to the following
people: 1) Persons at
high risk of serious complications who have not
been able to get vaccinated, 2) Persons at high
risk of complications but
who have not had time
to mount an adequate
immune response, 3)
People with immunosuppressive conditions
who are not expected to
mount an adequate antibody response to influenza vaccine, and 4) Health
care workers with direct
patient care responsibilities who have not been
vaccinated.

Empiric Antiviral
Choices

The proper selection of amantadanes or
neuraminidase inhibitors depends on the circulating viruses in the
community. In general,
amantadanes are used for
empiric prophylaxis, and
neuraminidase inhibitors are used for empiric
therapy. However, if
influenza A is the only
strain known to be in
circulation, amantadanes

are an excellent empiric
treatment choice.
If a person has close
exposure to a patient with
documented influenza
B infection, oseltamivir
would be the drug of
choice for prophylaxis,
since neither amantadine nor rimantadine are
effective against influenza B. Conversely, if a
patient has been started
a neuraminidase inhibitor (either oseltamivir or
zanamavir) for treatment
of a presumed influenza
infection, and testing
shows it to be influenza
A, then either amantadine
or rimantadine would
currently be the drugs of
choice for treatment.

Side Effects & Dosing
Influenza antiviral
medications are usually well tolerated. Side
effects of Amantadine can
include dry mouth, trouble concentrating, insomnia, and lowered seizure
threshold. The dose
should be decreased in
people over 65 years old,
in renal insufficiency, and
when people are having
side effects. Rimantadine
side effects are similar but
less common. The daily
dose for both Amantadine
and Rimantadine is the
same for treatment and

prophylaxis: in adults
it is 100 mg BID, and in
children it is 5 mg/kg/day
in two divided doses.
Side effects of
Oseltamivir can include
nausea and vomiting. The
daily dose for adults is 75
mg twice a day for treatment, and 75 mg once
a day for prophylaxis.
Pediatric dosing depends
on the child’s weight [i.e.
For treatment: 60 mg BID
for >23-40 kg; 45 mg BID
for >15-23 kg; 30 mg BID
for ≤ 15 kg].
Zanamivir can
cause bronchospasm.
Zanamivir inhalation is
given twice a day for
treatment of influenza (it
is not licensed for prophylaxis).

Additional
Information

For more detailed
information about antiviral medications, see:
www.cdc.gov/flu/professionals/treatment orwww.
azdhs.gov/flu/pdf/fluantiviralclinicianfactsheet.doc
Karen Lewis is the Medical
Director , Bureau of
Epidemiology and Disease
Control and can be reached
at lewisk@azdhs.gov or
602.364.4562.

Table 2: Length of Antiviral Treatment and Chemoprophylaxis
Chemoprophylaxis
Medicine
Amantadine
Rimantadine
Oseltamivir
Zanamivir

Treatment After
3-5 days*
5 days

exposure
7 days

After
vaccine
2 weeks

Children needing
2 vaccines**

6 weeks

Institutional
outbreak
Until
outbreak
is over

* Until afebrile 1-2 days
**Children < 9 years receiving influenza vaccine for the 1st time need 2 doses to achieve optimal efficacy

November/December 2005

Imported VaccineAssociated Paralytic
Poliomyelitis –
Arizona, 2005
Reported by: Infectious Disease
Epidemiology Section, ADHS; Yavapai
County Department of Community
Health Services; and the Centers for
Disease Control and Prevention.

Case Report:

In March 2005, a 22-year old
Arizona woman developed paralytic poliomyelitis while traveling
in Latin America. She was taking part in a university-sponsored
study abroad program in Costa
Rica and living with a local family for about 1 month when she
visited Colombia for 3 days. On
March 3, two days after returning
to Costa Rica, she reported having
a sore throat, neck and back pain.
Over the next 24 hours, her symptoms worsened to include fever
and headache. She was treated
at a local hospital for a kidney
infection. On March 6, she experienced acute leg weakness and
was hospitalized locally and soon
transferred to a hospital in San
Jose, Costa Rica. On March 9,
she was emergently transported
by air from San Jose, Costa Rica
to Phoenix, Arizona for further
evaluation.
Upon admission to a hospital
in Arizona, she had bilateral areflexic lower extremity weakness
and respiratory failure requiring intubation. Cerebrospinal
fluid (CSF) studies on March 9
showed pleocytosis and elevated
protein with normal glucose
levels. Electrodiagnostic studies
displayed reduced compound
muscle action potentials (CMAPs)
and normal sensory nerve action
potentials (SNAPs), and widespread denervation, consistent
with a severe, asymmetric process
involving anterior horn cells or
motor axons. MRI of the cervical
and thoracic spine demonstrated
signal abnormality in the anterior
continued on page 8
Prevention Bulletin

3

Pertussis: The Outbreak and the Future
As a health care practitioner in
the state, you know that Arizona
had a state-wide pertussis outbreak
this year. This is the first time that
such a state-wide outbreak had been
recorded in Arizona. Typically we
have local or regional outbreaks
which tend to occur every three
to five years. In the past we have
had relatively few effective tools to
respond to pertussis outbreaks, primarily accelerating the immunization
schedule and increasing surveillance
and prophylaxis. This year we were
able to expand our toolkit, with two
new vaccines, and hopefully made a
greater and lasting impact.
In April and early May of 2005,
the Arizona Department of Health
Services (ADHS) received reports
from several counties of increase
pertussis activity, including in middle
schools and high schools. Earlier in
the spring, Pima County had declared
a county-wide outbreak because of
increased local activity. On May 19,
2005 ADHS declared a state-wide
outbreak, identifying above-average
level activity in more than half of
Arizona’s fifteen counties.
In order to respond to the outbreak, the Department took the following steps:
• requested that local health department increase surveillance for
more cases and enhance the use
of prophylaxis;
• requested that pediatricians accelerate the childhood immunization
schedule;
• increased public awareness
through media and marketing
campaigns;
• provided recommendations to
health care providers on limiting
the spread of illness in birthing
facilities.
These are the standard public
health responses to pertussis outbreaks and primarily focus efforts on
infants and children.
The overall effectiveness of these
actions is unknown, but is probably
limited. While the youngest children
are the most at risk to serious illness,
4

Prevention Bulletin

by David Engelthaler, State Epidemiologist
60

Date of Onset of Reported Cases

50

Probable
Confirmed
40

30

20

10

0

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 42 43

MMWR Week

Data in epidemiological curve represent cases reported to ADHS with onset date, tracked by CDC’s
MMWR week. Suspect cases under investigation are not shown.
(11/04/2005 data; n=782)

it may be the adults and adolescents
that keep an outbreak going, and
probably keep pertussis endemic in
a community. This is due to the fact
that there have been no vaccines
available for this population and
adolescents and adults have little lasting immunity from their childhood
vaccinations. Therefore, while morbidity is not high in adolescents and
adults, they are acting as the reservoir
for continual re-infection into the
pediatric population.
That paradigm all changed this
year. In May of 2005, a new acellular

pertussis vaccine (Tdap – Boostrix ®)
was approved for immunization of
adolescents (10-18 years old). This
new vaccine, along with a booster
approved in June 2005 for both adolescents and adults (Tdap- Adacel®),
provided tools to attack pertussis at
its source. To that end, the Governor
signed an Executive Order to allow
the purchase of the new booster vaccines for the outbreak response. This
was the first such effort nation-wide.
These vaccine were purchased
and supplied to the county health
departments for use in adolescents
November/December 2005

Pertussis

David Engelthaler is the State
Epidemiologist and can be reached at
602.364.3297 or engeltd@azdhs.gov .
November/December 2005

by S. Robert Bailey and Melanie Taylor, MD, MPH
Minority populations in Arizona, particularly non-Hispanic Blacks are disproportionately affected by sexually transmitted diseases (STDs) and HIV/AIDS. These
disparities are observed regardless of geographic region of the state, behavioral risk
group, gender or age. Heightened awareness of these disparities is needed in order
to foster increased opportunities for STD/
HIV screening, diagnosis, treatment and
prevention in minority populations at-risk.
Current HIV surveillance data (19992004) demonstrate that non-Hispanic
Blacks in Arizona are 3.3 times more likely
than non-Hispanic Whites to have HIV
infection, and 4.5 times more likely to
be newly diagnosed with HIV. The rate
of HIV diagnosis among non-Hispanic
Black women is rising, while rates among
women of all other racial/ethnic groups
remain relatively stable (Figure 1). During
2003 and 2004 the number of emergent HIV diagnoses among non-Hispanic
Black women (3.1% of the population
of women, 33.3% of new cases) was
greater than the number among either
non-Hispanic White women (62.0% of
the population of women, 29.6% of new
cases), or Hispanic women (27.8% of
the population of women, 29.2% of new
cases).
During 1999-2004, the rates of syphilis and gonorrhea declined considerably
among non-Hispanic Blacks. However,
during 2004, the rates of syphilis and
gonorrhea among non-Hispanic Blacks
were 5 and 12 times greater than for
non-Hispanic Whites respectively. Rates
of syphilis, gonorrhea, and chlamydia
have increased among Native Americans
between 2003-2004. Chlamydia rates

Rate per 100,000

and adults who had an infant in the
house or who were infant caretakers. Health care providers were
also urged to provide these boosters
to patients that fit this targeted category. In order to help determine
the effectiveness of this campaign
the Department decided to conduct
an evaluation study, which is still
underway.
On October 11, 2005, the
Department officially declared an
end to the state-wide outbreak, as
activity levels had decreased back
to endemic levels in most counties.
In the end, Arizona had the most
cases seen in at least a decade (n =
874) and had widespread activity
across the state. While measuring
the effectiveness of preventing cases
is difficult, these new weapons to
fight pertussis may have helped
lessen the severity of the outbreak.
These new boosters should also
help limit or prevent future outbreaks as well. This can only be
done with the help of Arizona’s
health care practitioners. We must
continue on with our vigilance, and
the best way to do this is to follow
the recent ACIP recommendations:
• Adolescents 11-12 be given
Tdap instead of the Td booster
• Adolescents 13-18 who missed
the booster
• Adolescents who received Td
more than 5 years ago
• Adults 19-64 who have not
received Td in 10 years (exception is for those with close contact to infants <12 months; a 2
year interval between Td and
Tdap is acceptable)
By following these guidelines,
and quickly responding to suspect
outbreaks, hopefully we can make
this the last state-wide outbreak
of pertussis, and some day make
pertussis go the way of the other
vaccine-preventable childhood diseases.

Racial Disparities Among HIV/AIDS and
STD Diagnoses in Arizona, 1999-2004
reflect significant racial disparities among
non-Hispanic Blacks, Hispanics, and
Native Americans as compared to nonHispanic Whites and Asians.
Increased provider and community
awareness of racial disparities in STD/
HIV diagnoses can help in the identification and referral of populations at
risk. Current CDC guidelines recommend
chlamydia screening of all sexually active
women between the ages of 15-25 years
of age regardless of symptoms [1]. Testing
for HIV is recommended for all persons
who seek evaluation and treatment for
any STDs[2]. Other STD/HIV screening
should target individuals engaging in highrisk sexual behaviors that include but are
not limited to sex with multiple partners,
unprotected sex, prior history of an STD,
prior incarceration, sex with an infected
partner, and current or previous history
of drug use. Providers should endeavor
to collect sexual risk assessments in order
to guide STD and HIV testing. Patient
education regarding the consistent and
correct use of condoms can assist in the
prevention of HIV and STDs. Adherence
to STD/HIV screening recommendations
is important for providers and community
organizations delivering care and support
services to minority populations at risk.
1. Centers for Disease Control and Prevention.
Screening tests to detect Chlamydia trachomatis
and Neisseria gonorrheae infections 2002.MMWR
2002;51 (No. RR-15): pp 37.
2. Centers for Disease Control and Prevention.
Sexually transmitted diseases treatment guidelines
2002. MMWR 2002;51 (No. RR-6). Pp 2.

S. Robert Bailey, MSPh is an Epidemiologist in
the Office of HIV/AIDS and can be reached at
baileys@azdhs.
FIg.1: Emergent HIV/AIDS Among Women
gov or
602.364.3596,
by Race/Ethnicity, Arizona, 1999-2004
and Melanie
Taylor, MD,
MPH is a
Medical
White*
Epidemiologist
in the Office
Black*
of Infectious
Hispanic
Disease Services
Asian
and can be
reached at
Native Am
taylorm@azdhs.
gov or
602.364.4565.

Prevention Bulletin

5

Noteworthy
Mexican-Style Soft
Cheese Advisory

The Arizona Department of Health
Services recommends that consumers do not eat any type of raw milk
by Bob Gomez, R.S., M.P.H.
soft cheese. Pregnant women are
The U.S. Food and Drug
about 20 times more likely than
Administration (FDA) recently issued a other healthy adults to get listeriosis.
health advisory for certain types of soft Infections during pregnancy can lead
cheese made from raw (unpasteurto miscarriage, stillbirth, premature
ized) milk. The advisory warned that
delivery, or infection of the newborn.
certain types of raw milk soft cheese
In addition to avoiding consumpcould cause serious infections includ- tion of raw milk and products made
ing, listeriosis, brucellosis, salmonelfrom raw milk, the Centers for Disease
losis, and tuberculosis, particularly in
Control and Prevention (CDC) have
high-risk groups including, pregnant
provided these general recommendawomen, newborns, older adults, and
tions to reduce the risk for listeriosis:
people with weakened immune sys• Thoroughly cook raw food from
tems. Bacteria can contaminate foods
animal sources,
and without adequate pasteurization,
the bacteria can survive and multiply. • Separate raw meat, poultry and
seafood from vegetables and
Listeriosis is the emerging infection
ready-to-eat foods,
of concern with raw milk soft cheese.
An estimated 2,500 persons become
• Wash hands and food contact surill with listeriosis each year in the
faces after handling raw foods,
United States and of these, 500 die.
Symptoms include fever, muscle ache, • Properly refrigerate perishable
foods.
and sometimes nausea or diarrhea. If
Additional CDC recommendations
the infection spreads, headache, stiff
for persons at high risk:
neck, confusion, loss of balance, or
convulsions may occur. The incuba• Do not eat hot dogs, deli meats,
tion period ranges from 3 – 70 days.
or luncheon meats unless they are
Raw milk soft cheese from Mexico
reheated until steaming hot.
and Central American countries
• Avoid getting fluid from hot dog
presents the most concern. These
packages on other foods, utensils,
cheeses are typically made from raw
and food contact surfaces, and
milk in non-commercial settings with
wash hands after handling hot
questionable sanitary conditions and
dogs, deli meats, and luncheon
are transported to the United States
meats.
in personal luggage and belongings. Non-commercial quantities
• Do not eat soft cheeses such as
of this cheese can be transported
feta, Brie, Camembert, blue veined
across the border without any restriccheeses or Mexican-style cheeses
tions. The FDA is currently looking at
unless they have labels that clearly
tighter restrictions on non-commercial
state they are made from pasteurentries. In addition, personal domesized milk.
tic production of this cheese in the
• Do not eat refrigerated pates or
United States is on the rise. Common
meat spreads. Canned and shelfMexican-style raw milk soft cheese
stable pates and meat spreads may
including queso blanco, queso fresco,
be eaten.
and Panela are very popular among
• Do not eat refrigerated smoked
the Hispanic community. Arizona
seafood unless it is an ingredient
County Health Department inspectors
in a cooked dish, such as a cashave observed these cheeses being
serole. Canned and shelf-stable
sold at flea markets, door-to-door, in
smoked seafoods may be eaten.
shopping center parking lots, and out
of personal vehicles. Although perBob Gomez, R.S., M.P.H., is the ADHS program
sonal production and consumption
manager for the Food Safety and Environmental
is legal, commercial activity is illegal
Services Section.
and prohibited.
6

Prevention Bulletin

Pneumococcal Vaccination
Promotion in Arizona

Infections with bacterial pathogens such as Streptococcus pneumoniae, are the main cause of severe
illnesses and deaths associated with
influenza in the high risk groups.
Pneumococcal vaccines, administered
to high-risk groups of the population,
can significantly reduce the incidence of this secondary infection and
reduce illness and death from with
influenza. Increasing pneumococcal
vaccine coverage in high-risk groups
can reduce the public health impact
of the annual flu season as well as the
impact of an influenza pandemic.
The adult pneumococcal vaccine was first licensed in 1977 and
administered primarily to adults 65
and older and persons >2 years of age
with specific chronic illnesses (Brand
name is Pneumovax®). One dose is
recommended for adults after the 65th
birthday. Approximately 65% of the
adults Arizonans age 65+ have had a
pneumococcal immunization.
The pediatric pneumococcal vaccine was first licensed in 2000 (Brand
name Prevnar®). This vaccine is
for children <24 months of age and
children age 24-59 months with a
high-risk medical condition. The recommended vaccination schedule is 4
doses administered at 2, 4, 6, and 12
months of age. Approximately 73%
of Arizona’s 2 year old children have
received at least 3 doses of the childhood pneumococcal vaccine.
Vaccinating your patients with the
pneumococcal vaccine will save lives
during normal influenza seasons as
well as better prepare your patients in
advance of an influenza pandemic.

Thank you to
Health Care Providers

It will be very difficult for the AriIt
would be very difficult for the Arizona
Department of Health Services to
present its monthly summary of selected reportable diseases without receiving Communicable Disease Report
(CDR) forms from providers. Disease
reporting by health care providers
enables us to capture any unusual pattern in morbidity trends. ADHS appreciates your efforts and teamwork.
November/December 2005

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

Jan - Oct
2004

5 Year Median
Jan - Oct

VACCINE PREVENTABLE DISEASES:
Haemophilus influenzae, serotype b invasive disease (<5 years of age)
Measles
Mumps
Pertussis (confirmed)
Rubella (Congenital Rubella Syndrome)

1 (0)
1
0
869 (434)
0 (0)

0 (0)
0
2
201 (118)
0 (0)

4 (3)
0
2
201 (106)
0 (0)

761
35
10
565
422

685
21
7
570
339

620
35
12
570
417

187
324
951
0
6,681 (3,662)

222
216
1,026
1
8,836 (3,144)

268
204
793
7
7,715 (3,406)

544
223
43
1,232
34

548
197
38
N/A
11

651
197
33
N/A
26

14,995
3,323
153 (22)

13,592
3,268
138 (35)

12,103
3,268
160 (24)

12 (0)
1,665

16 (2)
1,083

9 (1)
841

5
0
103
158

1
0
387
105

1
0
N/A
105

2,594
178
637
478

2,992
167
401
433

2,116
174
370
421

FOODBORNE DISEASES:
Campylobacteriosis
E.coli O157:H7
Listeriosis
Salmonellosis
Shigellosis

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

November/December 2005

Prevention Bulletin

7

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Arizona Department of Health Services
Public Information Office
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Phoenix, AZ 85007
Janet Napolitano, Governor
Susan Gerard, Director ADHS
Niki O’Keeffe, Assistant Director, Public Health Services
Contributors
S. Robert Bailey, M.S., David Engelthaler,
Will Humble M.P.H., Bob Gomez, R.S., M.P.H.,
Karen Lewis, M.D., 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
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e-mail: ehlertm@azdhs.gov
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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
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Imported Vaccine-Associated Paralytic Poliomyelitis
cord, indicative of anterior horn cell
involvement. Serologic results for antibodies specific for West Nile and dengue
viruses were negative. Stool specimens
collected on March 20 were positive
for Sabin strain polio virus types 2 and
3 at the CDC polio reference laboratory; no other enteroviruses were identified. The results of serologic tests for all
3 serotypes were greater than 1:10 for
both acute and convalescent specimens.
Sixty days after the onset of weakness,
she had residual weakness of both legs.
According to the new epidemiologic
and laboratory classification of paralytic
poliomyelitis cases, this case is classified
as imported vaccine-related poliovirus
with onset of illness within 30 days
before entry into the United States.
The patient had no history of vaccination with either oral polio vaccine (OPV)
or inactivated polio vaccine (IPV). The
Costa Rican family household that she
lived with had young children, ages ~6
months, 3 years, 7 years, and 8 years,
although the exposure history provides
8

Prevention Bulletin

no clear epidemiological link to an oral
polio vaccine (OPV) recipient. The case
had no underlying medical or immunocompromising conditions.

Implications:

Cases of paralytic poliomyelitis
are now rare in the United States due
to the success of the U.S. childhood
immunization program and the global
Polio Eradication Initiative (PEI). In the
United States, the last cases of paralytic
poliomyelitis caused by indigenous and
imported wild polioviruses occurred in
1979 and 1993, respectively. Since the
early 1960s, when trivalent oral polio
vaccine (OPV) became the vaccine of
choice for the childhood immunization
program, about 8-10 VAPP cases have
occurred annually. To reduce the risk
of VAPP, the United States switched to
a sequential inactivated polio vaccine
(IPV)--OPV schedule (1997) and then
to an all-IPV schedule (2000). This
policy change resulted in elimination
of VAPP in the U. S. (1). Prior to this

continued from page 3

report, the last VAPP case occurred in
1999. High polio vaccine coverage
rates have been maintained among
children 19-35 months with the transition from OPV to IPV. In 2004, 92%
of children in this age group received
3 doses of IPV as part of the routine
infant and child immunization schedule (NIS).
Polio vaccination is already recommended for persons traveling to polioendemic countries. However, this case
may lead to a change in vaccine recommendations for travelers to countries
routinely using OPV.
**This article is adapted from a
submission to CDC’s MMWR.

References
1. Alexander LN, Seward JF, Santibanez
TA, et al. Vaccine Policy Changes and
Epidemiology of Poliomyelitis in the
United States. JAMA 2004; 292:16961701.
November/December 2005