Publication of the Division of Public Health Services

Table of Contents
West Nile Virus
Update
Page 3
Fluoridation in Arizona
Water
Page 4
The State Epi's Corner
Page 5
Disease Reporting Chart
Page 6
Noteworthy

Page 7

A Look at Norovirus
Page 8

Visit the ADHS
Web site at
www.azdhs.gov

May/June 2006, Vol. 20, No. 3

Remember, It’s Hot Out There!
By Don Herrington

Why do you need to remember it’s hot? It is
quite obvious and doesn’t require that you remember it, right? Of course, but what people often forget
is that heat related illnesses can occur before a person realizes they are in danger. Constant monitoring and an awareness of the causes, symptoms, and
preventative measures can reduce or eliminate the
possibility of a heat related illness occurring.

Heat Related Illnesses
and Symptoms
Common heat-related illnesses are: heat
stroke, heat exhaustion, heat cramps, heat rash,
and sunburn. The Centers for Disease Control and
Prevention along with the Arizona Department of
Health Services offers the following information on
these illnesses and symptoms.
Heat Rash is a skin irritation caused by sweating
during hot, humid weather. It can occur at any age, but is most common in young children.
It appears as a cluster of red pimples or small blisters. It is more likely to occur on the neck
and chest, in the groin, under the breasts, and in elbow creases.
Heat Cramps are muscular pains and spasms due to overexertion and an early warning
that the body is having trouble cooling.
Heat exhaustion is a milder form of heat-related illness that can develop after several
days of exposure to high temperatures and inadequate or unbalanced replacement of fluids.
It is the body’s response to an excessive loss of the water and salt contained in sweat. Those
most prone to heat exhaustion are elderly people, people with high blood pressure, and
people working or exercising in a hot environment. Heat exhaustion is exhibited by heavy
sweating, paleness, cramps, weakness, and skin being cool & moist. Heat exhaustion can
become heat stroke if warning signs ignored.
Heat stroke occurs when the body is unable to regulate its temperature. The body’s
temperature rises rapidly, the sweating mechanism fails, and the body is unable to cool
down. Body temperature may rise to 106°F or higher within 10 to 15 minutes. Heat stroke
can cause death or permanent disability if emergency treatment is not provided. Warning
signs or symptoms of heat stroke vary but may include an extremely high body temperature
(above 103°F, orally), red, hot, and dry skin (no sweating), a rapid, strong pulse, throbbing
headache, dizziness, nausea, confusion, and unconsciousness.
Sunburn should be avoided because it damages the skin. Although the discomfort is usually minor and healing often occurs in about a week, a more severe sunburn may require
medical attention. Symptoms of sunburn are well known: the skin becomes red, painful,
Continued on page 2

May/June 2006

1

Remember, It’s Hot Out There!
and abnormally warm after sun exposure. Chronic sun burns can lead to
an increased risk of developing skin
cancer.

Preventative Measures

At Risk Populations

Heat Advisories and
Heat Warnings

•

•
•

•
•

•

•
•
•

For people ages 65+, excessive
heat ranked 5th among accidental
deaths (1992-2002). Medical and
Health experts report that elderly
are often less likely to sense or
respond to changes in heat.
People with heart disease or high
blood pressure.
People taking certain medication for depressions, insomnia, or
poor circulation may be adversely
affected by heat. Medications
(such as those described in the
table to the right) may make a
person more prone to adverse
health effects.
People who are overweight may
be at risk because of a tendency
to retain body heat.
People who overexert themselves
during work or exercise may
become dehydrated and susceptible to heat sickness.
Infants and small children are
sensitive to heat and rely on others to regulate their environments
and provide adequate liquid.
People who use illicit drugs such
as cocaine, amphetamines, and
methamphetamines.
Homeless people.
Migrants.

May/June 2006

continued from page 1

Preventative measures include
drinking plenty of water, wearing
appropriate clothing, using liberal
amounts of sunscreen, pacing yourself during strenuous activities, staying cool indoors, scheduling outdoor
activities carefully, and monitoring
those at high risk. People can also
prevent heat related illness through
better acclimating to the climate by
limiting physical activity until they
do acclimate, allowing several days
before vigorously exercising in a hot
climate while traveling, and being
aware that a sudden onset of heat can
trigger heat illness.

To assist Arizona residents,
the Arizona Department of Health
Services has developed a heat plan
which can be accessed at www.
azdhs.gov/phs/oeh/pdf/heatplan506.
pdf . The plan is tied to
National Weather Service
Advisories and Warnings,
which can be accessed at
http://www.wrh.noaa.gov/psr/.
The advisories and warnings
are divided into three categories, Heat Advisories, Excessive
Heat Watches and Excessive
Heat Warnings.
Heat advisories make
recommendations to counties to prepare to initiate
emergency response plans,
drafts heat health alert messages for the public, notifies
the Department of Education,
Behavioral Health Authorities,
Licensed Care Facilities, and
sends heat and other health
alerts to various groups via
the Health Alert Network (HAN) and
to hospital emergency departments
statewide via the EMSystem.
Excessive Heat Watches make
recommendations to counties
to begin implementing emergency
response plans, notifies affected

Tribal/Regional Behavioral Health
Associations to increase outreach
efforts and contact outreach teams
as applicable, and informs T/RBHAs
that conditions are likely to result in
a life–threatening heat emergency
within the next 24 to 48 hours. The
Excessive Heat Watch encourages
county health departments to activate their agency’s Heat Emergency
Response plan and increase surveillance efforts pertaining to heat-related
deaths and injuries.
Excessive Heat Warnings makes
recommendations to counties to
initiate emergency response plans,
notifies affected T/RBHAs to initiate
outreach efforts and use clinic staff to
assist with welfare checks for clients
who may be at risk of severe health
impacts due to extreme heat. The
work is done in conjunction with
local providers to advise area hospitals of the excessive heat warning and
urge them to consider the extreme
weather conditions when discharging
patients.
Under the Excessive Heat
Warning, ADHS staff will coordinate actions when there are any
reports of a facility exceeding
temperatures or experiencing air
conditioning operational issues,
and T/RBHA will assist in relocation of residents if needed. The
ADHS Licensing Services group
will serve in any capacity necessary to assist consumers and providers of health care and child
care in licensed facilities during
a response to extreme heat.
Additionally, ADHS will coordinate with partners to provide
Crisis Intervention Specialists
and behavioral health screening
at cooling stations, hydration
centers, emergency shelters or
other locations established by
the city or county as a result of the
emergency.
The heat of summer can be deadly, but taking proper precautions can
reduce the danger and make for a
more enjoyable summer season.
2

West Nile Virus
Another mosquito season is
underway in Arizona, and state and
local health officials have initiated
surveillance efforts to detect and
monitor arbovirus activity. Once
again, field staff will be trapping mosquitoes, and laboratory staff will be
testing mosquitoes, sick horses, dead
birds and chicken blood samples.
This year, 2006, will be our fourth
year dealing with West Nile virus
(WNV) in Arizona. WNV is now
considered to be endemic in the area.
Last year, 113 human cases were
reported in Arizona, of which 61 were
classified as West Nile fever, 23 were
encephalitis, 22 were meningitis, and
seven were acute flaccid paralysis.
This represents a 71 percent decrease
from the previous year, 2004, when
391 cases were reported.
WNV is a reportable condition
in Arizona by both physicians and
laboratories. Ordering appropriate
diagnostic tests and reporting cases of
arboviral disease is a vital part of the
surveillance program. Surveillance
data helps health officials to identify areas/communities at higher
risk for disease and helps them to
prioritize and target vector control
efforts. Laboratory testing is available through commercial laboratories.
If necessary, it can also be done at
the Arizona State Health Laboratory
(ASHL). The ASHL currently performs
an IgM capture ELISA for WNV and
St. Louis encephalitis (SLE). Testing
can be performed on serum or CSF.
Specimens can be sent to:

Arizona State Health Laboratory
May/June 2006

By Craig Levy

Arizona State Health Laboratory
Attn: Virology
250 North 17th Avenue
Phoenix, Arizona 85007
The following information must
accompany specimens: patient name,
age or date of birth, onset of symptoms, specimen collection date, primary symptoms/clinical picture and
contact information for submitting
physician.

•

The incubation period is thought
to range from 3 to 14 days in
immunocompetent individuals,
and up to 21 days after organ
transplantation.

•

The most significant risk factor for
developing severe neurological
disease is advanced age.

•

In recent outbreaks, symptoms
occurring among patients hospitalized with severe disease
included fever, weakness, gastrointestinal symptoms and change
in mental status; also reported
were severe muscle weakness and
flaccid paralysis, maculopapular
or morbilliform rash involving
neck, trunk, arms or legs, ataxia
and extrapyramidal signs, cranial
nerve abnormalities, myelitis,
optic neuritis, polyradiculitis and
seizures.

Clinical Suspicion
•

WNV, or other arboviral diseases
such as St. Louis encephalitis,
should be strongly considered in
persons who develop unexplained
encephalitis or meningitis in summer or early fall.

•

The local presence of WNV enzootic activity or other human cases
should further raise suspicion.

•

Contact your local health department to report suspect cases and
inquire about laboratory testing.

Clinical Features of WNV
Infections
•

Approximately 70-80% of WNV
infections are clinically inapparent.

•

Approximately 20% of those
infected develop a West Nile
fever. West Nile fever can range
from mild to severe. West Nile
fever can be characterized by sudden onset of fever often accompanied by one or more
of the following: malaise,
headache, anorexia, nausea, vomiting, eye pain,
myalgia, maculopapular
rash or lymphadenopathy.
Some symptoms may persist from days to months.
• Approximately 1%
of infections will result
in neurological disease
such as meningitis
and/or encephalitis.

Laboratory Findings
Among Patients in Recent
Outbreaks
•

Total leukocyte counts in peripheral blood were mostly normal or
elevated, with lymphocytopenia
and anemia also occurring.

•

Examination of the cerebrospinal
fluid (CSF) showed pleocytosis,
usually with a predominance of
lymphocytes.

Also noteworthy: recent studies
(www.jem.org/cgi/doi/10.1084/
jem.20051970) indicate that the
CCR5∆32 genotype, a defective
CCR5 allele shown to be associated
with resistance to HIV, may play
an opposite role in WNV infection.
Thus, CCR5-blocking agents now
under development for the treatment
of HIV/AIDS could render patients
more susceptible to WNV disease.

3

Fluoridation in Arizona Water
By Joyce Flieger BSDH, MPH

Fluoridation Facts1:
•

•

•

•

Fluoridation of community water
supplies is the single most effective health measure to prevent
dental decay. Throughout more
than 60 years of research and
practical experience, the overwhelming weight of credible scientific evidence has consistently
indicated that fluoridation of
community water supplies is safe.
The Centers for Disease and
Prevention has proclaimed community water fluoridation (along
with vaccination and infectious
disease control) as one of ten
great public health achievements
of the 20th century.
Studies prove water fluoridation continues to be effective in
reducing dental decay by 2040%, even in an era with widespread availability of fluoride
from other sources, such as fluoride toothpaste.
Community water fluoridation
benefits everyone, especially
those without access to regular
dental care. It is the most
efficient way to prevent one of
the most common childhood
diseases- dental decay (5 times
as common as asthma and 7
times as common as hay fever in
5-17-year-olds). Without fluoridation, there would be many more
than the estimated 51 million
school hours lost per year in this
country because of dental-related
illnesses.

•

Community water fluoridation is
the adjustment of fluoride that
occurs naturally in water to optimal levels to protect oral health.

•

Information on other community
systems may be obtained by calling the water company serving
that area.

•

Water that has been fortified with
fluoride is similar to fortifying salt
with iodine, milk with vitamin D
and orange juice with vitamin C.

*Many non-adjusted systems have naturally
occurring levels that are optimal.

•

Be aware of misinformation on
the Internet and other junk science related to water fluoridation.

•

The American Dental Association
maintains Fluoride and
Fluoridation Web pages at www.
ada.org/goto/fluoride.

Fluoridation Facts: Arizona2
Arizona communities that adjust fluoride to the level that prevents tooth
decay: *
Bisbee
Peoria
Chandler
Phoenix
Gilbert
Tempe (since 1965)
Glendale
Yuma
Mesa
•

Nearly all of the metropolitan
Phoenix area, with the exception
of Avondale, has enough fluoride
to prevent tooth decay.

•

Flagstaff’s municipal water supply
does not have enough fluoride to
prevent tooth decay.

•

Tucson’s municipal water supply
has variable levels, most of which
are below the range to prevent
tooth decay.

Bottled Drinking
Water Facts
Bottled drinking water rarely contains enough fluoride. Although
fluoride has no taste or smell, the
reverse osmosis process used to filter
the water removes it. Some dentists
have anecdotally reported a rise in
tooth decay in their patients and they
blame the lack of fluoride in bottled
water and high intake of sports
drinks.
American Dental Association Council on Access
Prevention and Interprofessional Relations.
Fluoridation Facts. Chicago IL,2005
1

Arizona Department of Health Services, Office of
Oral Health data.
2

Joyce Flieger BSDH, MPH is ADHS Office Chief
for Office of Oral Health.

Communicable Disease Statistics
Monthly and year-to-date statistical summaries for selected reportable infectious diseases can be found
on our website at: http://www.azdhs.gov/phs/oids/stats/index.htm.
These summaries are updated monthly to reflect the most up-to-date data. All data contained in these
reports are provisional.
Other reports and publications of the Office of Infectious Disease Services can be referenced through:
http://www.azdhs.gov/phs/oids/reports.htm.
May/June 2006

4

Disease Surveillance Anemia
Any health
care provider who
diagnoses, treats, or
detects a case or suspect case of a communicable disease
listed on the Arizona
Communicable
Disease Rules (R96-202, see enclosed
David Engelthaler,
list) is required by
State Epidemiologist
law to report it to the
local public health
department(1) within the specified amount of time. I hope this
doesn’t come as a surprise to any reader, as this often overlooked regulation has profound impact on Public Health.
Infectious disease reporting is the lifeblood of Public
Health and disease control. By reporting infectious diseases,
the medical practitioner also becomes a public health practitioner. Public Health efforts to assess burden of disease and
its distribution and monitor trends for purposes of disease
prevention and control hinge upon this reporting. Success
stories like the elimination of smallpox and the eradication of
diseases like polio from the U.S. are due in large part to the
strong connection between health care and public health.
However, national studies show us that less than 10%
of reportable diseases are actually reported to Public Health
by health care providers(2), and the majority of acute communicable diseases are not reported within one incubation
period(3). Unfortunately, this is true for health care provider
reports of infectious diseases in Arizona (unpublished data).
Most data on infectious diseases in Arizona is coming only
from clinical laboratories, which typically have no useful
information about the patients themselves. Without the critical patient information, little to no epidemiology can be performed, leading to inappropriate analyses and interventions.
In turn, we, in Public Health, have not made reporting
easy for the provider, especially the private practice physician. The 1940’s style paper-based surveillance system
doesn’t cut it anymore. Public Health has also done a poor
job of getting information back to providers. We realize that
this is a give and take, and we’ve concentrated more on the
“taking” than the “giving”.
Recent paradigm shifts in electronic information management in health care and public health should help us to
bridge the gaps.

Major components of the Roadmap include:

The Arizona Health-e Connection Roadmap

1.
2.

As health care is grappling with the coming age of electronic heath records, Arizona is in the forefront of embracing this technological advancement for the improvement of
medical care through the secure and appropriate sharing
of patients’ medical information between providers. The
Arizona Health-e Connection Roadmap was recently developed by an alliance of Arizona’s private and public sector
leaders in health care, information technology, policy, and
public health(4).
May/June 2006

•

Encouraging health information technology adoption
among health care providers;

•

Identifying key infrastructure components that enable
providers to securely exchange health information;

•

Implementing both regional and centralized initiatives;

•

Developing a not-for-profit, public-private governance
organization with representation from all major stakeholders groups to provide leadership implementing the
Roadmap; and,

•

Creating a funding structure that is value-driven and
self-sustaining with many costs borne by those receiving
benefit.

MEDSIS - Electronic Disease Surveillance

The Arizona Department of Health Services has recently
developed, and is now implementing, the Arizona electronic
disease surveillance system - known as MEDSIS(5). This
secure, Internet-based system allows for state and local public health to share a unified data system that also connects to
hospitals, labs, and soon clinics and private practice offices.
When complete, this system will allow for two way flow of
information between public health and health care, essentially changing the face of public health practice in Arizona.
As a result, MEDSIS promises to improve the accuracy, completeness, and timeliness of disease reporting to state and
local health departments thereby improving the quality and
utility of the information provided back to the provider.
With these two concurrent strategies, Arizona is on a
trajectory to true electronic health information exchange.
This will provide for better informed public health and health
care systems, achieving better personal and population
health. This mission is more important now than ever before,
with the backdrop of emerging infections, bioterrorism and
other public heath threats.
In the meantime, we will look for more effective ways to
get disease-related information back to the providers. This
information is developed from the data, the surveillance system lifeblood, provided by the front-line practitioners. We
can ill-afford the public health surveillance anemia caused
by under-reporting. Please continue to do your public health
duty, and we will try to do ours.

3.

4.
5.

http://www.azdhs.gov/phs/oids/contacts.htm#L
Doyle, et al. 2002.Completeness of Notifiable Infectious Disease Reporting in
the United States: An Analytical Literature Review. Am J Epid 155 (9):866-874
(http://aje.oxfordjournals.org/cgi/reprint/155/9/866)
Jajosky and Groseclose. 2004. Evaluation of reporting timeliness of public
health surveillance systems for infectious diseases. BMC Public Health 2004,
4:29 (http://www.biomedcentral.com/1471-2458/4/29)
http://www.azgita.gov/tech_news/2006/Arizona%20Healthe%20Connection%20Roadmap.pdf
http://www.azdhs.gov/medsis/

See Chart on Page 6
5

Reporting Requirements for a Health Care Provider or an
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��� Institution
� ������ ����
�� �� Facility
Administrator
a Health Care
or��������
Correctional
������������� �� � ������ ���� ����������� �� ������������ ��������

�*,O
�
�
�
�
�
�*,O

Amebiasis
Anthrax
Aseptic meningitis: viral
Basidiobolomycosis
Botulism
Brucellosis
Campylobacteriosis

�
�
�*,O
�
�
�*,O
�

Hantavirus infection
Hemolytic uremic syndrome
Hepatitis A
Hepatitis B and D
Hepatitis C
Hepatitis E
Herpes genitalis

�

Chancroid

�

HIV infection and related disease

�
�*
�
�
O
�
�*,O

��������� infection, genital
Cholera
Coccidioidomycosis (valley fever)
Colorado tick fever
Conjunctivitis: acute
Creutzfeldt-Jakob disease
Cryptosporidiosis

�
�
�
�
�
�
�

Kawasaki syndrome
Legionellosis (Legionnaires’ disease)
Leptospirosis
Listeriosis
Lyme disease
Lymphocytic choriomeningitis
Malaria

�
�
�
O

���������� infection
Cysticercosis
Dengue
Diarrhea, nausea, or vomiting

�
�
�
�

Measles (rubeola)
Meningococcal invasive disease
Mumps
Pertussis (whooping cough)

�
�
�

Diphtheria
Ehrlichiosis
Emerging or exotic disease

�
�
�

Plague
Poliomyelitis
Psittacosis (ornithosis)

�

Encephalitis, viral or parasitic

�

Q fever

�
�
�*,O
�
�

Enterohemorrhagic ����������� ����
Enterotoxigenic ����������� ����
Giardiasis
Gonorrhea
����������� ����������: invasive
disease
Hansen’s disease (Leprosy)

�
�
�
�
�*

Rabies in a human
Relapsing fever (borreliosis)
Reye syndrome
Rocky Mountain spotted fever
Rubella (German measles)

Salmonellosis
Scabies
Severe acute respiratory syndrome
Shigellosis
Smallpox
Streptococcal Group A: Invasive disease
Streptococcal Group B: Invasive disease
in infants younger than 90 days of age
�
������������� ����������
(pneumococcal invasive disease)
�
Syphilis
�*,O Taeniasis
�
Tetanus
�
Toxic shock syndrome
�
Trichinosis
�
Tuberculosis
�
Tuberculosis infection in a child
younger than 6 (positive test result)
�
Tularemia
�
Typhoid fever
�
Typhus fever
�
Unexplained death with a history of
fever
�
Vaccinia-related adverse event
�
Vancomycin-resistant ������������ spp.
�
Vancomycin-resistant or Vancomycinintermediate �������������� ������
�
Vancomycin-resistant ��������������
�����������
�
Varicella (chickenpox)
�*,O ������ infection
�
Viral hemorrhagic fever
�
West Nile virus infection
�
Yellow fever

�

Rubella syndrome, congenital

�*,O Yersiniosis

�

�*,O
O
�
�*,O
�
�
�

����
� Submit a report by telephone or through an electronic reporting system authorized by the Department within 24
hours after a case or suspect case is diagnosed, treated, or detected or an occurrence is detected.
*

If a case or suspect case is a food handler or works in a child care establishment or a health care institution, instead
of reporting within the general reporting deadline, submit a report within 24 hours after the case or suspect case is
diagnosed, treated, or detected.

�

Submit a report within one working day after a case or suspect case is diagnosed, treated, or detected.

� Submit a report within five working days after a case or suspect case is diagnosed, treated, or detected.
O

May/June 2006

Submit a report within 24 hours after detecting an outbreak.

6

First Case of
Lymphogranuloma
Venerum (LGV) in AZ
In March 2006 Arizona’s first
confirmed case of Lymphogranuloma
venereum (LGV) was reported in
Maricopa County. The male patient
reported multiple unprotected, anonymous sexual encounters with other
men at a commercial sex venue in
Maricopa County within 60 days
prior to diagnosis and was co-infected
with syphilis. The patient denied
travel within the previous 60 days.
LGV is a systemic, sexually
transmitted disease (STD) caused
by a type of Chlamydia trachomatis that is endemic in Africa, India,
southeast Asia, South America and
the Caribbean[1]. Recent outbreaks
of LGV proctitis have been reported
among men who have sex with men
(MSM) in the European Union[2].
Sporadic cases of LGV in the U.S.
have been diagnosed among HIVinfected MSM[3]. Symptoms of LGV
include mucoid / purulent anal discharge, rectal bleeding, constipation,
inguinal / femoral lymphadenopathy (buboes), genital or rectal ulcer
or papule, anal spasms, and / or
tenesmus[4]. LGV is of concern due
to the ulcerative nature of the lesions
that facilitate transmission and acquisition of HIV and other STDs.
Clinicians seeing patients with
these symptoms should contact their
county health department or the
ADHS STD Program at 602.364.4666
for guidance on specimen collection, specimen shipment, and partner
notification. The Centers for Disease
Control and Prevention (CDC) is
assisting state and local health departments in identifying patients with
LGV in cities across the United States.
Specimens are submitted to CDC’s
chlamydia laboratory for testing
through the Arizona STD Program.
For updated information on the diagnosis of LGV visit the CDC Division
May/June 2006

of STD Prevention’s website at www.
cdc.gov/std/lgv.
1. Holmes, King. Sexually Transmitted Diseases. McGrawHill Companies Inc. New York, NY. 1999:423-30.
2. Centers for Disease Control and Prevention.
Lymphogranuloma Venereum Among Men Who Have Sex
with Men --- Netherlands, 2003--2004. MMWR. 2004:
53(42);985-988
3. “Dear Colleague Letter to California STD Controllers,”
December 20, 2004 - Dr. Gail Bolan, California Dept. of
Health Services available at http://www.stdhivtraining.
org/pdf/STD_Controllers_Letter_12.20.04.pdf
4. Division of STD Prevention, Centers for Disease Control
and Prevention, LGV Information Sheet available at
http://www.cdc.gov/std/lgv/LGVInfo_v16.pdf
5. Centers for Disease Control and Prevention. Sexually
Transmitted Diseases treatment guidelines 2002. MMWR
2002;51 (no. RR-6):18-9.

Hantavirus Pulmonary
Syndrome Update
Eight cases of Hantavirus
Pulmonary Syndrome (HPS) have
already been reported in Arizona
in 2006, including two cases in
Maricopa County and six case in
Northern Arizona. 50% of these
cases were fatal. Having eight cases
early in the year raises concerns of
increased incidence in 2006. To date,
52 cases of HPS have been reported
in Arizona since 1992.
Sin Nombre virus (SNV) is the
specific hantavirus responsible for the
majority of HPS cases reported in the
U.S. SNV is carried by deer mice and
other related species, which excrete
the virus in their urine, droppings and
saliva. People can become infected
by inhaling aerosolized virus, and
this commonly occurs when people
disturb rodent contaminated dust or
rodent nests during cleaning activities.
People living, working or recreating in
rural areas are at greater risk for expo-

John Good

sure due to the presence of wild mice.
People should be especially cautious
when entering/opening cabins and
trailers that have been closed-up during the winter. Appropriate prevention
measures to take to reduce risk can be
found at http://www.cdc.gov/ncidod/
diseases/hanta/hps/noframes/FAQ.htm.
The incubation period for HPS is
a few days to six weeks. Prodromal
symptoms commonly include fever
(usually 101º degrees F or greater),
myalgias, abdominal pain, cough,
nausea and vomiting. Flu-like symptoms are followed in 1-10 days by
rapid onset of respiratory distress.
Pharyngitis, otitis, sinusitis, rhinorrhea, and rash are rarely seen in HPS
cases. Clinical findings commonly
include leukocytosis with left shift.
Lymphocyte count may be normal,
but significant morphologic abnormalities by lymphoid cells are evident. At least 10% of lymphocytes
are either immunoblasts or plasma
cells. The platelet count is usually
less than 150,000. Patients with HPS
will most often require admission to
the ICU along with hemodynamic
monitoring.
Serologic testing for HPS is available at the Arizona State Health
Laboratory (ASHL). Please call your
county health department or the
Vector-Borne & Zoonotic Diseases
(VBZD) Program at (602) 364-4562
to discuss and arrange for laboratory
testing. Collect blood specimens
in a plain red top 10 ml tube. Do
not use a tube with serum separator.
The State Laboratory will centrifuge
the blood to separate serum and clot.
Specimens should be sent to:
Arizona State Health Laboratory
Attn: Serology
250 North 17th Avenue
Phoenix, Arizona 85007
For more information, contact
the ADHS, Vector-Borne & Zoonotic
Diseases Program staff at (602) 3644562, or visit our website at www.
azdhs.gov.
7

A Look at Norovirus
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
David Engelthaler,
Joyce Flieger,
Don Herrington
Will Humble M.P.H.,
Craig Levy
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).

Norovirus is a frequent cause of viral gastroenteritis in Arizona and across the U.S. Also
known as “Norwalk-like virus”, it is an RNA
virus belonging to the Caliciviridea family
that causes acute gastroenteritis in humans.
Caliciviruses are the most common cause of
viral gastroenteritis in the U.S. and are estimated to cause 23 million cases each year.
There are five genogroups of noroviruses
which are further subclassified into more
then 25 genetic clusters. They are capable of
surviving high chlorine concentration, freezing and heating up to 60 degrees. Disease
affects all ages and occurs year round, with
peaks in the winter months.
Symptoms of norovirus commonly include
nausea, vomiting, abdominal cramps and
loose, watery diarrhea. Vomiting is more
prevalent in children while diarrhea is more
prevalent in adults. The incubation period
is 12 to 48 hours, and the illness usually
lasts only 12 to 60 hours with no long term
effects. One complication which can be
fatal if ignored or undetected is dehydration.

Figure A: Norovirus Outbreaks by Setting/
Location, Arizona 2005

Figure B: Reported Gastroenteritis
Outbreaks, Arizona, 2005 (N=51 outbreaks)

The major mode of transmission of norovirus
is by the ingestion of fecally contaminated
food or water. Several factors facilitate the
spread of infection: a low infectious dose of
By Ayesha Bashir MD, MPH
less then 100 viral particles; viral shedding
in the stool for up to two weeks; the ability
of the virus to survive in the environment for
extended periods of time; and the short term
human immunity against the virus. Norovirus
outbreaks often occur in congregate settings,
such as cruise ships, daycares or long termcare facilities and gatherings. The settings for
the norovirus outbreaks confirmed in 2005 in
Arizona are shown in Fig. A (provisional data).
Six (31%) of the 19 outbreaks occurred in long
term-care facilities.

Norovirus in Arizona

May/June 2006

By Ayesha Bashir MD, MPH

Of the 51 outbreaks of gastroenteritis reported
to Arizona health departments in 2005, 37%
were confirmed to be norovirus as shown in Fig.
B (provisional data). An additional 39% were
of unknown or suspected viral etiology; many
of these may have been caused by norovirus
but could not be confirmed. While individual
norovirus cases are not reportable in Arizona,
outbreaks of nausea, vomiting and diarrhea are.
Local health agencies initiate an investigation in
response to these reported outbreaks to identify
potential common exposures among the cases,
collect specimens for laboratory testing and recommend measures for disease control. Lab testing for norovirus outbreaks is conducted at the
Arizona State Laboratory, and is most commonly
done by reverse-transcriptase polymerase chain
reaction (RT-PCR), which may be followed by

sequencing analysis to confirm outbreak strains
or linked cases.
There are several reasons why norovirus is
not more commonly detected and diagnosed.
Oftentimes, cases of norovirus may occur sporadically and either not necessitate a visit to
a health care provider, or not be reported and
diagnosed as norovirus if the event involves only
single cases. Even if several people do become
ill and the outbreak is reported, it can be difficult
to collect specimens in a timely manner and
obtain positive lab results on those specimens,
all contributing to the challenges of confirming
outbreaks of nausea, vomiting or diarrhea as
norovirus.
To report an outbreak of nausea, vomiting or
diarrhea and discuss testing of specimens,
please contact your local health department.
Noroviruses are the most common cause of
acute gastroenteritis. The key to the control
and prevention of not only norovirus but also
other gastroenteritis is hand wash, hand wash,
hand wash and applying infection control in the
appropriate settings.
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