Publication of the Division of Public Health Services

Table of Contents
Hepatitis Awareness
Month
Page 3
What's New In Newborn
Screening
Page 4
The State Epi's Corner
Page 6
Noteworthy

Page 7

The Impact Of An
Influenza Pandemic
In Arizona? Page 8
Kids Learning Sun Safety
in School Page 9

Visit the ADHS
Web site at
www.azdhs.gov

March/April 2006, Vol. 20, No. 2

The Challenge Of
Tuberculosis Screening
By Karen Lewis, M.D.
State Tuberculosis Control Officer

Tuberculosis (TB) has changed in the United States in the last 50 years. In 1953 there
were 84,304 cases of TB, and 19,707 deaths from TB. In 2005, there were only 14,093
cases of TB. In addition, deaths due to TB had fallen to fewer than 800 a year, AZ has seen
a similiar trend. This is due to effective antibiotics and good public health interventions.
However, TB remains a problem throughout the world. It is estimated that 1/3 of the
world’s population is infected with TB. About 10% of those infected will develop active
TB sometime in their lifetime. Since TB control continues to improve in the U.S., it is not
surprising that now more than half of TB cases in this country are in people born in another
country.

Screening tests for Latent TB Infection
Effective TB control requires timely diagnosis of active TB disease and proper treatment
of those with latent tuberculosis infection (LTBI). Screening for of LTBI is done in two ways:
tuberculin skin testing (TST) (1,2) or blood assays for Mycobacterium tuberculosis such as the
QuantiFERON®-TB Gold (QFT-G) test (3).
The preferred TST for diagnosing LTBI is the intradermal method of placing 0.1 ml of 5
tuberculin units (TU) of PPD into the volar surface of the forearm, and recording how many
millimeters of induration are present 48-72 hours later. Multiple puncture tests (such as the
tine test) or PPD strengths of 1 TU or 250 TU are not sufficiently accurate and should not
be used.
The purpose of tuberculin screening programs for TB is to indentify and treat LTBI in
persons at high risk for TB, i.e., recently infected people, infected people at increased risk
for progression to active TB disease, and people whose employment may put them at risk
for TB infection (such as health care workers).
Screening of low risk persons is discouraged because it diverts resources from activities
of higher priority. Also, a substantial proportion of tuberculin test positive persons from low
risk populations may have false positive skin tests.

Cut-off Levels for TST
Three cut-off levels are used for defining a positive TST. For people with no risk factor
for TB, a positive TST is when the induration is > 15 mm.
A skin test of > 5 mm is positive for people who: 1) Are recent contacts of an infectious
TB patient, 2) Have fibrotic changes on chest Xray consistent with prior TB, or 3) Are immunosuppressed because of disease (e.g. HIV) or drugs (e.g. organ transplants or systemic corticosteroids).
A TST of > 10 mm is positive in people who have clinical conditions that increase their
risk for progressing to active TB disease. These clinical conditions include children < 4 years
old, children exposed to high risk adults, silicosis, diabetes mellitus, chronic renal failure,
Continued on page 2

March/April 2006

1

The Challenge Of Tuberculosis Screening
leukemia, lymphoma, carcinoma
of the head or neck and lung, gastrectomy, jejunoileal bypass, or
weight loss of > 10% ideal body
weight.
The TST cut-off of > 10 mm
also applies to people who have
an increased probability of recent
infection, such as recent immigrants from high prevalence
countries, injection drug users, or
residents and employees of highrisk congregate settings such as jails,
prisons, nursing homes, hospitals,
and homeless shelters.

Health Care Workers
and TST
Routine TSTs are not recommended for people at low risk for
LTBI. However, when health care
workers are tested on entry to a work
site where risk for exposure to TB is
anticipated, the higher cut-off of > 15
mm is recommended for the initial
TST interpretation.
Subsequently, health care workers with negative TST reactions who
undergo repeated skin testing will
then have a lower cut-off point. In
these people, an increase in reaction size of > 10 mm within a period
of 2 years should be considered a
skin-test conversion indicating recent
infection with M. tuberculosis.

QuantiFERON®-TB Gold
(QFT-G)
QFT-G is a new aid in diagnosing both LTBI and active TB disease.
QFT-G is an enzyme-linked immunosorbent assay (ELISA) test that detects
the release of interferon-gamma in
fresh heparinized whole blood. The
blood is incubated with synthetic
peptides that simulate two proteins
found in M. tuberculosis and pathogenic M. bovis but which are absent
in BCG vaccine. These proteins are
early secretory antigenic target-6
(ESAT-6) and culture filtrate protein10 (CFP-10).
Results QFT-G testing are reported as positive, negative, or indeterMarch/April 2006

continued from page 1

Exclude Active TB before
Treating for LTBI

minate. Positive means the M. tuberculosis infection is likely. Negative
means that M. tuberculosis infection
is unlikely but cannot be excluded,
especially when illness is consistent
with TB disease or the person has an
increased likelihood of progression to
TB disease. Indeterminate means that
the results cannot be interpreted, due
to the controls either showing a low
mitogen response or a high background interferon level.
The CDC states that QFT-G can
be used in all circumstances in which
the TST is currently used (including
contact investigations, evaluation
of recent immigrants who have had
BCG vaccination, and TB screening
of health-care workers for M. tuberculosis). Advantages of QFT-G over
the TST include a single patient visit,
decreased staff time, and the results
not being affected by reader bias or
previous BCG vaccine.
A disadvantage of QFT-G is that
blood samples must be processed
within 12 hours after collection
while white blood cells are still
viable. In addition, its sensitivity
in immunocompromised patients,
diabetes, chronic renal failure, or in
children younger than 17 years old
has not yet been determined.
Before QFT-G testing is done,
arrangements should be made with
a qualified laboratory (and courier
service, if needed) to ensure prompt
and proper processing of the blood.
At least one laboratory in Arizona is
currently offering QFT-G, and others
are discussing implementation in the
future.

A diagnosis of LTBI requires
first excluding TB disease by medical evaluation. Patients who have
a positive TST or positive QFT-G
should be checked for signs and
symptoms suggestive of TB disease
and should receive a chest Xray.
The clinical screening and
chest Xray should always be done
before starting any TB medicines.
If evidence of active TB infection is
found on the chest Xray, the patient
has active pulmonary TB, not LTBI.
Sputum cultures should be obtained,
and four effective TB medicines
should be started pending culture
results.
Remember: Using only one TB
drug in the face of active TB disease
can lead to the development of drug
resistance within just a few weeks.
If active TB disease is excluded
by clinical and radiologic exam,
patients with LTBI should be started
on preventive therapy. Isoniazid
(INH) is given for 9 months. An
alternate regimen for LTBI is Rifampin
given for 4 months.
Previously there had been a recommendation of rifampin plus pyrazinamide as an alternate treatment
for LTBI. This is no longer recommended because of the risk of serious
hepatotoxicity with using these two
drugs for preventive therapy.(4)
References
(1) MMWR Targeted Tuberculin Testing and Treatment
of Latent Tuberculosis Infection. June 9, 2000; Vol 49
(No. RR-6) www.cdc.gov/mmwr/preview/mmwrhtml/
rr5417a1.htm
(2) MMWR Guidelines for Preventing the Transmission
of Mycobacterium tuberculosis in Health-Care Settings,
2005. December 30, 2005; Vol 54 (No. RR-17) www.
cdc.gov/mmwr/preview/mmwrhtml/rr4906a1.htm
(3) MMWR Guidelines for Using the QuantiFERON®TB Gold Test for Detecing Mycobacterium tuberculosis
Infection, United States. December 16, 1005; Vol 54
(No. RR-15)
(4) MMWR Update: Adverse Event Data and Revised
American Thoracic Society/CDC Recommendations
Against the Use of Rifampin and Pyrazinamide for
Treatment of Latent Tuberculosis Infection-United
States, 2003. August 8, 2003. Vol. 52(31); 735-739
www.cdc.gov/mmwr/preview/mmwrhtml/mm5231a4.htm

2

HEPATITIS AWARENESS MONTH

May 2006 - Screening, Education And Vaccination
By Judy Norton, Millie Blackstone, RN, MPH, & Ayesha Bashir MD, MPH

May is Hepatitis Awareness
Month: The main viral hepatitides in
the United States continue to be A, B
and C. In 2005, there were 195 cases
of hepatitis A reported in Arizona
compared to 0 cases of hepatitis C
and 389 cases of hepatitis B; however, there were 8,034 cases of nonacute hepatitis C and 1,027 cases
of non-acute hepatitis B reported in
2005 (provisional numbers). Even
though the number of new hepatitis
C infections has been decreasing
considerably nationwide due to better blood screening tests, hepatitis C
continues to represent the most common chronic bloodborne infection in
the United States.
Hepatitis A and Hepatitis B vaccines have been partially responsible
for the success in their control; unfortunately, there is no vaccine available for hepatitis C. Additionally, the
long term consequences of hepatitis
C (e.g., chronic liver disease) may
not become apparent for 20 or more
years; thus, many of those infected
are not aware of their infection status
and do not take the necessary measures to avoid spreading the virus to
others and to minimize the risk of
developing serious liver disease.
High-risk behaviors include:
• Shared needles use to injects
drugs or for tattoos/piercing;
• Health care workers exposed to
blood;
• Organ transplant recipients
before 1992;
VIRUS
Transmission Type
Chronic Form?
Risk factors for epatocellular
carcinoma, cirrhosis, liver failure
Vaccination?
Treatment?
Passive Immunization?

March/April 2006

•
•
•
•

Recipients of clotting factors
before 1987;
Long-tem kidney dialysis
patients;
Sexual activity to some extent;
Child born to a hepatitis C
positive mother.

OF SPECIAL NOTE
Recent immigrants from
high risk counties such as
Asia may be at increased risk of
hepatitis B and should be
screened and vaccinated.

NEW PERINATAL HEPATITIS
B RECOMMENDATIONS:
The Advisory Committee on
Immunization Practices (ACIP) recommends implementation specific
strategies to improve identification
and eliminate transmission of hepatitis B virus (HBV) to infants born to
HBsAg positive mothers and mothers with unknown HBsAg status at
the time of delivery. These strategies
regarding HBV include:
• Implementation of delivery hospital policies and procedures;
• Case-management programs,
Laws and regulations to ensure
administration of appropriate
post-exposure immunoprophylaxis to these infants beginning at
birth; and,
• Administration of a birth dose
of hepatitis B vaccine to medically stable infants who weigh ≥
2000 grams and who are born to

HBsAg-negative mothers.
The ACIP also recommends
improving vaccine coverage of children and adolescents who were not
previously vaccinated. This includes:
• Implementing immunization
record reviews for all children
aged 11-12 years of age and children/adolescents under 19 years
of age who were born in countries with an intermediate or high
endemic rate of HBV,
• Adopt hepatitis B vaccine requirement for school entry, and
• Vaccinate all un-vaccinated adolescents in settings that provide
health care services to persons in
this age group.
Health education materials,
information about disease reporting, and resources are available at
ADHS. For more information about
hepatitis A and hepatitis B contact
The Office of Infectious Disease
Services at 602.364.3676. For information regarding perinatal hepatitis
B, contact the Immunization Program
Office at 602.364.3638. For more
information about hepatitis C contact the Hepatitis C Program at
602.364.3658. You can also check
our web site at www.azdhs.gov.
By Judy Norton, Program Manager for Hepatitis
C; Millie Blackstone, RN, MPH, Perinatal
Hepatitis B Coordinator; and Ayesha Bashir MD,
MPH, Infectious Disease Epidemiology

HEPATITIS A
Fecal/oral
No

HEPATITIS B
Blood and body fluid
Yes

HEPATITIS C
Blood and body fluid
Yes

No
Yes; 2 doses – 6 mo.apart
No
Yes, within 2
weeks of exposure

Yes
Yes; series of three
Yes, but not curative
Yes, In in conjunction
with vaccine

Yes
No
Yes, but not curative
No; management with
supportive care, screening
those with high risk
behaviors, and offering
both hepatitis A and B
vaccine and education.
3

What’s New in Newborn Screening?
By Jan Kerrigan and Elaine Carr

Newborn screening has long
been recognized as an essential, lifesaving, and effective public health
service. Through newborn screening in Arizona last year, more than
80 babies were identified to have
serious genetic disorders and were
helped to access the services they
needed. This valuable service is
about to become even more so.
Providers will be able to offer
parents of newborns an extra measure of protection as the Arizona
Department of Health Services
(ADHS) Newborn Screening Program
begins expansion of the newborn
screening panel, increasing from
8 to 28 disorders (see Table 1). In
addition to expanding the number of
disorders identified by bloodspot testing, the ADHS will begin providing
follow up services for newborns and
infants who do not pass the hearing
screen done at birth. New legislation
requires all providers who perform
newborn hearing screens (and sub-

sequent hearing tests) to
submit the test results to
the ADHS, and the ADHS
to encourage families of
children with possible
hearing loss to access
appropriate evaluations,
services, and early intervention.
The bloodspot screen
expansion begins in
late April 2006 with the
initial addition of three
disorders. Other disorders
will be added periodically over the
next year (see Table 2). By July 2007,
results will be reported for all 28 disorders, including cystic fibrosis. The
twenty-eight disorders recommended
by the Arizona Newborn Screening
Advisory Committee and selected
for the expansion are the same as
those recommended by the American
Academy of Pediatrics, March of
Dimes, American College of Medical
Genetics, and the Health Resources

TABLE I. THE EXPANDED NEWBORN SCREENING
PANEL OF DISORDERS
Amino Acid Metabolism Disorders
Phenylketonuria* (PKU)
Maple syrup urine disease*
Homocystinuria*
Citrullinemia
Tyrosinemia type I
Argininosuccinic acidemia
Fatty Acid Oxidation Disorders
Medium chain acyl-CoA
dehydrogenase deficiency (MCADD)
Very long-chain acyl-CoA
dehydrogenase deficiency
Long-chain L-3-OH acyl-CoA
dehydrogenase deficiency
Trifunctional protein deficiency
Carnitine uptake defect
Organic Acid Disorders
Isovaleric acidemia
Glutaric acidemia type I
3-OH 3-CH3 glutaric aciduria

March/April 2006

Multiple carboxylase deficiency
Methylmalonic acidemia
Methylmalonic acidemia (mutase
deficiency)
3-Methylcrotonyl-CoA carboxylase
deficiency
Propionic acidemia
Beta-ketothiolase deficiency
Hemoglobin Disorders
Hb S/Beta-thalassemia
Hb S/C disease
Sickle cell anemia*
Other Disorders
Congenital hypothyroidism*
Congenital adrenal hyperplasia*
Biotinidase deficiency*
Galactosemia*
Hearing Loss
Cystic Fibrosis
*Current disorders tested by ADHS

and Services Administration.
Arizonans benefit because treatable,
disabling or life-threatening, genetic
disorders can be identified in babies
who otherwise may seem perfectly
healthy at birth. Early treatment can
prevent or minimize the irreversible
symptoms of damage that, in the
past, often occurred before diagnosis
could be made.
Expansion of the newborn
screen is primarily possible because
of the availability of Tandem Mass
Spectrometry (MS/MS), a laboratory methodology that improves and
consolidates metabolic screening
processes. This method incorporates
an acylcarnitine profile, enabling
the addition of fatty acid oxidation
disorders (e.g., medium-chain acylCoA dehydrogenase [MCAD] deficiency) and organic acid disorders
to the newborn screening panel. The
Arizona State Laboratory has three
MS/MS instruments able to distinguish and measure scores of analytes
indicating possible presence of disease. The Arizona State Laboratory
is completing validation testing for
many of the disorders that will be
screened, and testing will continue
for the next year. Some disorders are
identified with other methodology
but the MS/MS offers a huge breakthrough in newborn screening. MS/
MS uniquely lends itself to the rapid
testing and high volume necessary
for Arizona’s growing birth rate.
continued on page 5
4

What’s New in Newborn Screening?
A critical piece of Arizona’s
comprehensive newborn screening
program is still the collection of a
satisfactory specimen, with complete
and accurate information on the
specimen card. Screening continues
to be performed from small samples
of blood placed on a filter paper collection kit between 24 and 72 hours
of age or before the baby leaves the
hospital. A second newborn screen
is collected at five to ten days of age,
or at the time of the first doctor visit.
Because there is no perfect point in

time for optimum identification of
all of the disorders in the expanded
panel, it is more important than ever
to ensure babies have two newborn
screens.
Should test results indicate a suspicion of one of the newly screened
disorders during the expansion
period, the provider ordering the
newborn screen will be notified by a
genetic specialist contracted by the
ADHS. The specialist will offer help
to providers for initial patient management and referral, if necessary.
Fact sheets for providers
on each of the disorders
of newborn screening are
being developed nationally and will be tailored
with Arizona-specific
information. Additional
educational materials
are being developed for
families. Please check our
website http://www.azdhs.
gov/phs/owch/newbrnscrn.

TABLE II. NEWBORN
SCREENING EXPANSION
SCHEDULE
By May 2006
• Results will be reported for the currently
screened disorders plus Citrullinemia,
Tyrosinemia, and Argininosuccinic acidemia
• Pilot testing for Fatty Acid Oxidation and
Organic Acid disorders will begin
• The ADHS will provide follow-up services to encourage families of infants who
have not passed the newborn hearing
screen, to access appropriate screening,
evaluation or intervention
• The newborn screening fee will increase
from $20 per screen to $30 for the first
screen, and $40 for the second screen
By September 2006
• Results will be reported for 27 disorders
• Pilot testing for cystic fibrosis will begin
By July 2007
• Results will be reported for 28 disorders,
including Cystic Fibrosis
March/April 2006

continued from page 4

htm periodically as we add this and
other important information, or contact the Newborn Screening Program
602.364.1409 or 1.800.548.8381.
A partnership plan with the Arizona
Chapter of the American Academy of
Pediatrics and Arizona Chapter of the
March of Dimes is also being developed to promote and offer education
about newborn screening.
For more information about
the changes in newborn screening
or education opportunities, please
call the ADHS Newborn Screening
Program at 602.364.1409 or
1.800.548.8381 or visit our website
at http://www.azdhs.gov/phs/owch/
newbrnscrn.htm.
For helpful additional electronic
references, see Table 3.
Jan Kerrigan, RN, is the Newborn Screening
Program Manager, Arizona Department of
Health Services, Office of Women’s and
Children’s Health, and can be reached at
602.364.1410

TABLE III. ELECTRONIC REFERENCES
March of Dimes
An excellent description of the 28
disorders and hearing loss is provided. http://www.marchofdimes.
com/professionals/14332_1200.
asp
National Newborn Screening and
Genetics Resource Center
Offers national and state newborn
screening information, and links
to all relevant sites.
http://genes-r-us.uthscsa.edu/

Mountain States Genetics
Foundation Newborn Screening
Practitioner’s Manual
This web site also has additional
links to parent resources.
http://www.mostgene.org/

Save Babies Through Screening
Foundation
Resource Library and information
for families http://www.savebabies.org/
Sickle Cell Disease Association of
America
Provider and lay information,
links, and library
http://sicklecelldisease.org/
Arizona Department of Health
Services
Information about the Arizona
Newborn Screening Program,
information for families, providers, submitters, and links to relevant sites.
http://www.azdhs.gov/phs/owch/
newbrnscrn.htm.

5

And Now, For The Disease Forecast …
As we know,
changes in climate
can have significant impact human
health in a variety
of ways, from infectious disease to
environmental exposures. In Arizona,
David Engelthaler,
we see a close tie
State Epidemiologist
between climate,
the environment and
human diseases. This year, we will possibly see increases
in several infectious diseases in Arizona because of climate dynamics over the past few years. Here are some of
them:

Coccidioidomycosis or “Valley Fever”

Coccidioidomycosis (Cocci) is a fungal disease that is
highly endemic in Arizona, with Maricopa County being
the hotspot for the world. The fungus grows in desert soils
and spores are release into the air following soil disruption.
Recent studies have shown associations between coccidioidomycosis and climate changes. Some of these
studies suggest that previous rainfall (even up to four
years out) can affect disease burden today. It is believed
that cocci risk increases after a certain period of rainfall,
followed by a certain period of drought, as this helps
to increase cocci fungal spore production in soils in
Arizona’s deserts. The recent rain/drought cycle appears
not to be an exception, as we have been experiencing
the largest recorded increase of cocci cases on record
in Arizona (Jan-Mar 2006, n = 1732; 5-yr mean = 648).
We also know that reported cases are only a fraction of
actual cases in the community. Recent studies in Arizona
suggest that upwards of 30% of patients with communityacquired pneumonia (CAP) in cocci-endemic areas are
serologically positive for cocci, and that very few ambulatory CAP cases are actually ever tested for cocci.
The Forecast: At this point the dramatic increase in
cocci cases has not tapered off and may continue well
into 2006.
Action: Test for cocci on all ambulatory patients with
CAP!

Hantavirus Pulmonary Syndrome (HPS)

HPS is primarily caused by Sin Nombre Virus, a
hantavirus shed by wild deer mice throughout much
of the North America, with most cases occurring in the
American Southwest. It is not surprising that climate
would affect this disease, and again the heavy rainfall followed by significant drought dynamic has been hypothesized to be associated with increased human cases. This
holds true for this past year as well. In fact, in the past 18
months, Arizona has had more cases of HPS than in any
March/April 2006

previous time period since the original outbreak in 199394. Unlike cocci, HPS is a rare disease (48 cases total
found in Arizona since 1992). However, it still remains
highly fatal, killing about one-third of its victims. The one
encouraging sign we have seen is that the earlier cases are
recognized, the better their chances of survival.
The Forecast: While cases continue to be rare, we will
possibly see more cases in Arizona due to the tremendous
rainfall and increases in rodent populations early last year.
Action: Suspect HPS for any patient with fever, tachypnea and tachycardia along with a history of significant
mouse exposure, especially in rural and urban fringe
areas. Following the flu-like prodrome (3-5 days), patients
start to exhibit the classical HPS picture: atypical lymphocytes, a significant bandemia, and thrombocytopenia
in the setting of pulmonary edema. If HPS is suspected,
please immediately contact local or state health officials.

Plague

Plague is another disease highly associated with
climate and the environment due to its flea-rodent/vector-host lifecycle. Humans are typically infected after
exposure to infected fleas or rodents, typically in the high
country above 4500 ft in the Southwest. Again, plague is
a very rare disease, but it can be highly fatal if not treated
in time. Fatal cases sometimes go undiagnosed until after
death, as treating physicians don’t automatically consider
plague in the differential diagnosis. The current model
suggests that when precipitation in the preceding year’s
late winter and early summer is above average, followed
by mild temperatures in the current year’s spring there is
increase risk for human cases.
The Forecast: We had the necessary winter precipitation and rodent population increases last year, as well as
above average August precipitation. If milder temperatures maintain throughout April, we may see an increase
in human cases this year in the Southwest.
Action: Patients with fever and a painful, swollen,
regional lymph node (bubo), accompanied with a history
of exposure to rodents or rabbits, or their fleas, in areas
above 4500ft. elevation, should automatically lead to suspicion of plague (or tularemia, which may have multiple
lymph node swelling). As with HPS, suspect plague cases
should be immediately reported to local or state health
officials.
These diseases represent some of the most prevalent
and rare infectious diseases in Arizona, but they are all
tied to the environment. Seasonal weather changes may
have expected yearly effects on disease risk (e.g., increase
rain during the summer monsoons increases mosquito
production and West Nile Fever risk). But climate changes tend to be associated with peaks and valleys between
years. There have been numerous studies associating climate changes and disease incident fluctuations, but such
continued on page 8
6

Epi Corner continued from page 6
studies are not able to fully account for the complexities of disease dynamics and, therefore, should be
interpreted with caution. The recent climatic events in
Arizona, however, maybe the stars aligning for a few disease peaks this year.

CDC’s Advisory Committee
Recommends Expanded
Influenza Vaccinations
for Children
On February 23, 2006
the Advisory Committee on
Immunization Practices (ACIP) to
the Centers for Disease Control and
Prevention (CDC) recommended
an expansion of routine influenza
vaccination for children. With the
expansion, the recommended influenza vaccination age will be from
6 months to up to 5 years old. The
previous recommendation was for
children 6 months to 23 months old.
The new recommendation expands
that recommendation to also cover
children from 2 years to up to 5
years old.
The committee also recommended expanding routine vaccination for household contacts (anyone
who spends a significant amount of
time in the home) and out-of-home
caregivers of children 24-59 months
old. The previous recommendation
had been for household contacts
and caregivers for children 6 months
to 23 months old.
Otherwise healthy children are
at increased risk for requiring influenza-related medical care and rates
of medial outpatient visits for influenza-related illnesses are high in all
childhood ages. Children 24 months
to 59 months old with influenza are
nearly as likely to require visits to
healthcare providers and emergency
rooms as children 6 months to 23
months old. Approximately 5.3
March/April 2006

Resources:
Park, et al. 2005. An epidemic of coccidioidomycosis in Arizona associated with climatic changes, 1998-2001. JID. 191:1981-7.
Kolivras, et al, 2003. Modeling valley fever incidence on the basis of climate conditions. Int J
Biometeorol. 47:87-101.
Enscore, et al. 2002 Modeling relationships between climate and the frequency of human
plague cases in the southwestern United States, 1960-1997. Am J trop Med Hyg. 66:186-96.
Engelthaler, et al. 1999 Climatic and environmental patterns associated with hantavirus pulmonary syndrome, Four Corners region, United States, EID. 5:87-94.
Galgiani. 2006. Personal communication.

million children and 11.4 million
healthy household contacts or caregivers for these children will also be
covered by the new recommendation Vaccination of all children who
have certain chronic medical conditions such as asthma, diabetes, kidney disease or weakened immune
systems continues to be strongly
recommended by ACIP. Children
younger than nine years who will
be receiving the influenza vaccine
for the first time should receive two
doses.

Don’t forget to order your influenza vaccine early as one concern
is whether vaccine supply will be
adequate when additional children
are going to be vaccinated!

Arizona Celebrating Success
During National Infant
Immunization Week (NIIW)
National Infant Immunization
Week (NIIW) is April 22-29th.
Arizona has been invited to showcase the border activities within the
state. The Director of the National
Immunization Program, Dr. Anne
Schuchat, will be traveling to
Yuma, Tucson, and Phoenix during
the week as a featured speaker at
events.
The Arizona Immunization
Conference will be held for one day
on April 27th this year. Please mark
your calendars for this event!

Influenza vaccine manufacturers have indicated that they plan to
produce between 100 million and
120 million doses of influenza vaccine for the 2006-07 influenza season. The 2006-07 influenza vaccine
will include two new strains, an
A/Wisconsin/67/2005 (H3N2)-like
virus and a B/Malaysia/2506/2004like virus; the A/New Caledonia/20/
99(H1N1)-like virus strain from the
2005-2006 season will remain in
the upcoming vaccine.*
*Note: Exerpt from the CDC Office
of Communication – Media Relations
dated February 23, 2006

The New Health Care
and EMS Checklists Are On
the HHS Website
Home Health Care Services
Checklist
http://www.pandemicflu.gov/plan/
healthcare.html
Medical Offices and Clinics
Checklist
http://www.pandemicflu.gov/plan/
medical.html
Emergency Medical Service and
Medical Transport Checklist
http://www.pandemicflu.gov/plan/
emgncymedical.html
7

What Would Be The Impact
Of An Influenza Pandemic
Be In Arizona?
by Will Humble

An especially severe influenza pandemic could lead to high
levels of illness, death, social disruption, and economic loss in
Arizona. Everyday life would be disrupted because so many people
in so many places become seriously ill at the same time. Impacts
can range from school and business closings to the interruption of
basic services such as public transportation and food delivery.
A substantial percentage of Arizona’s population will require
some form of medical care. Health care facilities would likely be
overwhelmed, creating a shortage of hospital staff, beds, ventilators
and other supplies. Surge capacity at non-traditional sites such as
schools may need to be created to cope with demand.
The need for vaccine is likely to outstrip supply and the supply
of antiviral drugs is also likely to be inadequate early in a pandemic.
Difficult decisions will need to be made regarding who gets antiviral
drugs and vaccines.
The State of Arizona has created an Influenza Pandemic
Response Plan to promote an effective response throughout an influenza pandemic. While a pandemic response is primarily a public
health response, many agencies, organizations, and private institutions will need to work in a coordinated and collaborative manner
to ensure an effective overall response in Arizona. The report and
a series of useful influenza pandemic preparedness checklists are
posted at www.azdhs.gov/pandemicflu.
The Arizona Influenza Pandemic Response Plan consists of an
introductory summary and a series of detailed Supplements. The
heart of the Arizona Influenza Pandemic Response Plan is the
Response Activity Supplements. These Supplements are subject-area
specific and provide very detailed planning and response activities.

PANDEMIC DEATH
TOLLS SINCE 1900
1918-1919
U.S
500,000+
Worldwide 40,000,000+
1957-1958
U.S.
70,000+
Worldwide
1-2,000,000
1968-1969
U.S.
34,000+
Worldwide
700,000+
March/April 2006

The Response Activity
Supplements are subject to
change and will be updated with changes in planning assumptions, response
capacities, or information
on potential pandemic
strains and subsequent disease.
The ADHS will be continually soliciting input on
this plan through a series
of Regional Pandemic
Influenza Coordinating
committee meetings that
will be held throughout
2006. You can contact
your local health department to get involved in
your county’s response
plan.

Patients Worried About Avian
Flu and Pandemic Flu?
As the Avian influenza A virus H5N1
in poultry and wild birds has been spreading recently to a long list of countries in
Asia, Europe, Africa, and the Near East, and
further human cases are reported, concern
among the public is growing. Your patients
may ask you questions about both pandemic flu and avian flu. Educating your
patients on the difference between seasonal
flu, pandemic flu, and Avian flu may help
reassure them. The following websites and
hotlines may useful for such education:
For more information on avian and
pandemic flu:
1) U.S. Department of Health and Humans
Services webpage on pandemic flu: www.
pandemicflu.gov
2) Arizona Department of Health Services
website with frequently asked questions
about pandemic flu: www.azdhs.gov/phs/
oids/epi/pandemic_flu.htm
2) The Centers for Disease Control and
Prevention (CDC) webpage on avian flu:
www.cdc.gov/flu/avian/index.htm
3) The World Health Organization (WHO)
on avian flu: www.who.int/csr/disease/
avian_influenza/en
4) Arizona Department of Agriculture
(ADA) website: www.azda.gov/Main/
Avian%20Influenza.htm
5) U.S. Department of Agriculture (USDA)
website: www.usda.gov/birdflu
6) World Organization of Animal Health
(referred to as OIE): www.oie.int/eng/
AVIAN_INFLUENZA/home.htm
For more information on avian and
pandemic flu via phone:
Arizona Public Health Hotline,
with bilingual recorded information:
1.800.314.9243 or in metro Phoenix
602.364.4500
Arizona Department of Agriculture
Livestock and Poultry Hotline Number
with recorded information on avian flu and
other animal diseases: 1.888.742.5334
USDA recorded information on
food safety on the USDA Meat and
Poultry Hotline: 1.888-MPHotline
(1.888.674.6854), TTY: 1.800.256.7072

8

Kids Learning Sun Safety in School
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 Dir.,
Public Health Services
Contributors:
Ayesha Bashir MD, MPH,
Millie Blackstone, RN, MPH,
Elaine Carr,
Lani Clark,
David Engelthaler,
Will Humble M.P.H.,
Jan Kerrigan,
Karen Lewis, M.D.,
Sharon McKenna,
Judy Norton,
The Office of Infectious
Disease Services,
The Arizona Immunization
Program Office,
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).

Arizona children are learning how to protect themselves from the sun,
thanks to a new law aimed at combating rising skin cancer rates.
In a state where sunshine is plentiful and the risk of skin cancer is
considerably greater than in other parts of the country, sun safety education is especially important.
One in five Arizonans are likely to develop skin cancer and since
80 percent of a person’s lifetime exposure to the sun occurs before the
age of 18, childhood intervention is crucial to preventing the disease.
The law, passed in August 2005, requires sun safety education in all
public and charter elementary and middle schools. Free materials and items
are given to educators and free school assemblies are also available. More than half a million
students are learning simple ways to reduce their sun exposure and protect their skin in order to
develop habits to last a lifetime.

Here are ways to “Limit the Sun but Not the Fun!”
Cover Up!

Wear long sleeves and pants to
protect your skin when playing
or working outdoors. Darker colors and fabric with a tight weave
provide the most protection.

Use Sunscreen Every Day!

Even on cloudy days, the sun’s rays can damage your skin. Wear sunscreen
with a Sun Protection Factor (SPF)
of 15 or higher. Apply 15 minutes
before going outside and reapply every 2 ½ hours or sooner if
perspiring or engaging in water
activities.

Wear a Hat and Lip Balm!

A hat with a wide brim offers good protection for your scalp, ears, face
and the back of your neck. The
bigger the brim, the better the
protection. Protect lips with
SPF 15 balm.

Wear Sunglasses!

Sunglasses reduce sun exposure that can
damage your eyes and lead to
cataracts. Check the label and
choose sunglasses that block at
least 90% of UV-A and UV-B
rays.

Limit Time in the Midday Sun!

Limit your outdoor activities when
the sun’s ultraviolet rays are the
strongest and most damaging (10
a.m. to 4 p.m.).

March/April 2006

Seek Cover!

peak UV.

Find something fun that doesn’t
involve the direct sun. Look for
shade under a tree, a ramada or
find an indoor activity inside a
gym, library or classroom during

Check the daily UV Index!

Did you know you can check the intensity of
the sun’s rays every day? The ultraviolet or UV index is a way of measuring
the sun’s radiation level. The scale is
from 1 to 10. The higher the UV, the
more careful you should be. A day
with a UV rating of 10 requires more
protection than a day with a rating
of 1. Click on the SunWise website
below to find your school’s daily UV.

Avoid Sun Lamps and Tanning
Booths!

These artificial sources of UV light
can cause as much damage as the
sun’s UV rays. Remember, there is
no such thing as a safe tan. To get
a tan, skin damage has to occur!

Visit the Arizona Department of Health
Services website for FREE sun safety activities
and more at: www.azdhs.gov/phs/sunwise.
Contact Sharon McKenna at 602.364.3143,
800.367.6412 or e-mail: mckenns@azdhs.gov
to learn about SunWise.

9