Publication of the Bureau of Epidemiology & Disease Control Services

July/August 2002, Vol. 16, No. 4

Sun Protection at School – A Call for Action
By Will Humble, M.P.H.

A cross-sectional study
published in the June issue of
Pediatrics [www.pediatrics.org]
found that only a third of more
than 10,000 children surveyed
said they routinely used sunscreen during the previous
summer.
Eighty-three percent (83%)
of children had at least one
sunburn during the previous
summer, and 36% had three or
more sunburns. Half of those
that had a sunburn last summer said it was worth it to get
the tan that followed.
The study found that the
preference for tanned skin,
having many friends who were
tanned, and belief in the worth
of burning to get a tan, were
associated with limited sunscreen use and more frequent
sunburns.
The bottom line: Kids are
still seeking tans - and not
using sunscreen - despite
warnings about the dangers of
skin cancer.
Changing childhood attitudes and behaviors about the
importance of sun protection
begins with sun safety awareness in pre-school and early
elementary school. Wagging

your finger at teenagers and
telling them, “you ought to
wear sunscreen” has very little
effect.
Elementary schools can
play a major role in protecting
children and adolescents from
UV exposure by instituting
shade-friendly policies, making environmental changes,
and conducting educational
programs that reduce skin
cancer risks.
The U. S. Centers for
Disease Control and
Prevention (CDC) has recently
published specific and detailed
guidelines for school programs
to prevent skin cancer. The
CDC report outlines recommendations for sun policy
changes, environmental
changes, education programs,
family involvement, professional development, and
evaluation.
The full report is published
on the CDC website at:
http://www.cdc.gov/
mmwr/preview/mmwrhtml/rr5
104a1.htm.
Will Humble is the Chief of the Office of
Environmental Health at the Bureau of
Epidemiology and Disease Control and
can be reached at 602.230.5941 or
whumble@hs.state.as.us.

Specific Sun Protection
Recommendations For Schools
• Include sun safety in the
general school health program.
• Encourage students and staff to wear hats
and sun-protective clothing during recess,
lunch breaks, and P.E.
• Encourage parents to apply sunscreen to
children before coming to school.
• Consider the construction of shade structures
and the planting of shade trees in playground
areas and school common grounds.

Visit the ADHS Web site at www.hs.state.az.us
Keys to
Arthritis Pain
Relief
Page 2
July/August 2002

West Nile
Virus Threat
Page 3

Increase in
Invasive Group A
Streptococcal
Disease Page 4

Child
Drownings
Page 5

Suicide - 8th
Leading Cause
of Death in AZ
Page 6

Summary Chart
of Reportable
Diseases
Page 7
Prevention Bulletin

1

Proper Management, Physical Activity —
Keys to Arthritis Pain Relief
Arthritis and other rheumatic
conditions currently affect more
than a million people in Arizona at
an annual cost of approximately
one billion dollars. Managing
chronic disease can often be frustrating for patients and physicians;
however, proper management,
physical activity, and medical interventions can have a tremendous
effect on people’s qualities of life
and enable them to live healthier
lives with less pain and disability.
In 2001, the Arizona
Department of Health Services’
Arthritis Program conducted interviews with physicians and people
with arthritis, as well as four focus
groups composed of people with
arthritis.
One of the more significant
findings from these interviews was
that people with arthritis felt a
strong incentive not to self-identify
as having arthritis because of the
fear of stigmatization by society or
their friends and family. One focus
group participant described the stigma by commenting, “Someone with
arthritis is older, female, Anglo,
weak, and dependent. She is crippled and moody.” Such personal
beliefs make it difficult to reach
this population with public health
messages.
ARTHRITIS RESOURCES
IN ARIZONA

People in pain do
not want to see themselves as having
arthritis, so they ignore
the public health messages. However, interviews also indicated
that people are receptive to hearing messages about arthritis
and how to manage
their disease when they
visit their doctor.
Recommendations
by their doctor to
engage in self-management of their disease
are highly valued by patients. One
very successful self-management
program is the Arthritis Self-Help
Course, available through the
Arthritis Foundation. This course is
clinically proven to reduce arthritis
pain by 20% and to reduce arthritis
related doctor visits by 40%.
One focus group participant
stated “Just the fact that it [Arthritis
Self-Help Course] was prescribed or
recommended by my doctor, and
handed to me [as a written prescription] by my doctor, I would
go.” Unfortunately, this resource is
underutilized because of a general
lack of knowledge of its existence.

Figure 2

Arthritis Foundation (Phoenix)
602-264-7679
1-800-477-7679
www.arthritis.org
Arthritis Foundation (Tucson)
520-917-7070
1-800-444-5426
www.arthritis.org
ADHS Arthritis Program
602-542-7200
2

Prevention Bulletin

by Patrick Mause
Figure 1

0

5

10

15

The Arthritis Program is currently
working on two initiatives aimed
at improving the quality of information provided to arthritis patients.
One initiative is “Physical Activity The Arthritis Pain Reliever” that
utilizes materials developed by
the Centers for Disease Control
and Prevention and the Arthritis
Foundation to promote physical
activity.
The other initiative is to aggressively promote the six week
Arthritis Self-Help Course by providing physicians with brochures
that describe the course and
includes a gift certificate for $10 off
the cost of the course that generally
runs between $25-$40. The
gift certificate appears on the
back of the brochure and
includes a space where the
physician can write the
patient’s name. By personalizing the course brochure with
the patient’s name, it will
hopefully link the course recommendation psychologically
to that of a prescription and
result in greater patient
participation and compliance.
For information on these
two initiatives, or to request
materials, please contact the
ADHS Arthritis Program at
(602) 542-7200.
July/August 2002

West Nile Virus —
An Emerging Public Health Threat in Arizona?
By Craig Levy and William Slanta

The West Nile virus (WNV)
had not been documented in the
Western Hemisphere until 1999.
However, the virus survived its
first winter and is rapidly
spreading across the United
States. WNV has been detected
in humans, birds, mosquito
pools, sentinel chickens and
other animals. Although not yet
detected in Arizona, the arrival
of WNV is expected to occur
this year. Because of Arizona’s
history of sporadic cases of
arboviruses such as St. Louis
encephalitis (SLE) and western
equine encephalitis (WEE) it is
important to now include WNV
into our routine seasonal
arbovirus surveillance.
The national WNV surveillance program is a cooperative
effort conducted from May through
October involving county and state
health departments, the Centers for
Disease Control and Prevention,
university staff, and pest abatement
districts.
The surveillance program consists
of five focus areas:
(1) human surveillance for arboviral encephalitis through serologic tests,
(2) mosquito surveillance for
arboviruses,
(3) sentinel chicken flock surveillance for serologic conversion
through blood samples collected twice-per-month,
(4) veterinary surveillance for
equines exhibiting neurologic
symptoms compatible with
WNV, and
(5) dead bird surveillance for
pathologic changes associated
with the WNV.
The objectives of the surveillance program are to detect and
July/August 2002

respond to outbreaks of arboviruses, determine incidence and monitor trends, assess human risk, and
issue alerts and implement mosquito control measures as necessary.
The laboratory testing of mosquito samples, blood from sentinel
chicken flocks, and human sera is
performed at the Arizona State
Health Laboratory. Molecular analytical procedures using polymerase
chain reaction (PCR) for the identification of SLE, WEE and WNV will
be used for mosquito samples.
The use of PCR allows the State
Lab to phase out mouse inoculation
and increase the capacity to test
mosquito samples while at the
same time reducing the turn around
time. The sentinel chicken flock
surveillance for arboviruses was initiated in Arizona in 2000 with three
flocks and has now expanded to 15
flocks. In 2001, a total of 28 chickens in Maricopa and Yuma counties
seroconverted: 24 for SLE and 11
for WEE.
The State Lab tested 18 patients
diagnosed with viral encephalitis

for arboviruses in 2001. One case
of SLE was confirmed in a
Maricopa County child in
September and an arboviral infection was ruled out as the cause of
encephalitis in 17 other cases.
Reporting of encephalitis is
required in Arizona and prompt
reporting of cases is necessary for
a timely public health investigation and response. To report
encephalitis cases, contact your
local health department or the
Arizona Department of Health
Services’ Vector-Borne and
Zoonotic Diseases staff at (602)
230-5932.
Serum samples of all encephalitis cases should be submitted to
the State Lab for arbovirus testing.
Blood should be collected in a
red top tube or serum separator
and shipped to: Arizona State
Health Laboratory; Attn:
Serology/Arbovirus Testing; 1520
West Adams, Phoenix, Arizona
85007. Convalescent specimens
collected 2-4 weeks after the acute
specimens are essential to definitely
confirm or rule out arbovirus infection, as early specimens are often
seronegative up to eight days.
Horses with neurologic disease
are tested for WNV and WEE at the
National Veterinary Services
Laboratory in Ames, Iowa. Dead
birds meeting WNV surveillance
criteria are tested at the University
of Arizona Veterinary Diagnostic
Laboratory in Tucson. For more
information on arboviruses in
Arizona, contact the ADHS staff at
(602) 230-5932.
Craig Levy is the manager of the
Department’s Vector-Borne and Zoonotic
Diseases Section and can be reached at
602.230.5918 or clevy@hs.state.az.us.
William Slanta is the Health Services Assistant
Bureau Chief at the State Health Laboratory.
He can be reached at 602.542.6128 or wslanta@hs.state.az.us.

Prevention Bulletin

3

Increase in Invasive Group A
Streptococcal Disease in 2002
By Clare Kioski, M.P.H.

A total of 154 cases of invasive Group A
Streptococcal disease have been reported to the
Arizona Department of Health Services through the
first 5 months of 2002. This represents a 31% and
44% increase in the number of cases during the
same time periods in 2000 and 2001, respectively
(Figure 1).
Of 74 patients with known outcomes, thirteen
(18%) died and of 82 cases with known race/ethnicity, thirteen (16%) were Native Americans. Eight cases
of necrotizing fasciitis and 16 cases of Streptococcal
Toxic Shock Syndrome were reported.
Eleven cases were reported in children less than 5
years of age, but no cases have been associated with
varicella. None of the cases were related. The
Centers for Disease Control and Prevention does not
recommend antimicrobial prophylaxis of the household members of cases1.
After early childhood, the risk of invasive Group A
Streptococcal disease increases dramatically with age.
The disease rate for the 70+ age group is approximately six times greater than that of the 10-19 year
old group (Figure 2).
If you have any questions, please contact Clare
Kioski, Epidemiology Specialist, at (602)230-5927 or
ckioski@hs.state.az.us.

Figure 1
Number of Reported Cases of Invasive Group A Streptococcal
Disease in Arizona by Month of Onset, 2000-2002*

Figure 2
Rate of Invasive Group A Streptococcal in Arizona by Age.
Jan-May, 2000-2002*

Clare Kioski is an infectious disease epidemiologist at the Bureau of
Epidemiology and Disease Control. She can be reached at
602.230.5927 or ckioski@hs.state.az.us.

REFERENCES:
1. Prevention of Invasive Group A Streptococcal Disease among
Household Contacts of Case-Patients: Is Prophylaxis Warranted?
The Working Group on Prevention of Invasive Group A
Streptococcal Infections. JAMA. 279(15):1206-10, 1998 Apr 15.

Roof Rats Negative for Hantavirus, Plague and Tularemia
The presence
of roof rats
Rattus rattus
in an East
Phoenix neighborhood was first
identified in late December 2001.
Fortunately, these rats are not native
to Arizona. Following weeks of surveillance activity by the Maricopa

4

Prevention Bulletin

County Vector Control staff including the monitoring of complaints,
trapping of rats, and mapping roof
rat sightings, the distribution of roof
rats was found to span a 16 square
mile area. Evidence suggests that
the roof rats were thriving on the
abundant citrus fruits in the area.
Recommended control efforts
including the reduction/removal of

the rat’s food source and placement
of anticoagulant baits appear to
have been effective in reducing the
roof rat population.
However, eradication of the
roof rat population entirely may be
extremely difficult. The good news
is that all rats tested have been negative for fleas, plague, hantavirus
and tularemia.

July/August 2002

Report ‘Em! It’s the Law
By Cheryl McRill, M.D.

The ability of the public health
system to recognize and respond to
the occurrence of communicable diseases depends on prompt and complete reporting by all health care
providers. Arizona Administrative
Code specifically requires that “a
physician or an administrator of a
health care facility, or authorized representative, shall submit a communicable disease report of a case or a
suspect case” of certain communicable diseases to the local health department. However, a recent study by the
Arizona Department of Health
Services showed that the actual rate of
reporting of selected reportable diseases varied from 42% for invasive
Haemophilus influenza to 100% for
typhoid fever. Only a little over half
of invasive meningococcal infections
were reported!
Failure to report required
reportable diseases represents a

potential threat to the public’s health.
Reporting is a responsibility that
should not be overlooked or taken
lightly despite busy and demanding
physician schedules. Health care
providers who would like a list of
reportable diseases and a supply of
communicable disease report forms
should call 602.230.5932.
Questions about reporting
requirements may be directed to Dr.
Cheryl McRill at 602.230.5820.
Physicians who fail to report will be
sent a friendly reminder letter the first
time this occurs. If necessary, a second reminder letter will be sent.
Subsequent failure to report will be
referred to the Arizona Board of
Medical Examiners or the Arizona
Board of Osteopathic Examiners.
Dr. Cheryl McRill is the Chief Medical Officer for
the Arizona Department of Health Services. She
can be reached at 602.230.5820 or
cmcrill@hs.state.az.us.

Child Drownings Persist
in Central Arizona
The latest data concerning child
drownings in Maricopa County
reveal that 27 children age 4 years or
less drowned in 2001. Little change
in the drowning rate is noted when
the 2001 data are compared to 1990
because of a dramatic increase in the
drowning rate during the last 3 years.
Most of the drowning incidents continue to occur during the summer
months in backyard swimming
Figure 1

July/August 2002

By Tim Flood, M.D.

pools. Health care workers can continue to educate parents about the
risk of drowning during this summer
season, and to be aware of the need
to maintain constant supervision of
children if there is a pool or any
body of water present.
Dr. Tim Flood is Medical Director for the
Bureau of Public Health Statistics. He can be
reached at 602.542.7331 or
tflood@hs.state.az.us.

Arizona Vaccine Shortages
Slowly Improving
Physicians should be receiving
more supplies of vaccines that were
in short supply just in time to begin
back-to-school shots.
State health officials received
about 50 percent of the ordered
tetanus-diphtheria vaccine in June,
and anticipate private health care
providers will begin seeing their
orders arrive throughout the summer.
“We are pleased that the vaccine is
coming in and that the shortage
appears to be ending,” said Kathy
Fredrickson, chief of the ADHS
immunization program. “Some children will likely be able to receive the
tetanus-diphtheria booster shot
deferred last fall.”
However, Fredrickson said, the
school entry immunization waiver for
the tetanus-diphtheria booster is still
in place until June 2003 in order to
allow health care providers to “catchup” their patients. “We want to make
sure everyone has enough time to get
their vaccine supply and for parents
to get the message that this vaccine is
now available. Students will not be
denied entry to school if they do not
have the tetanus-diphtheria booster,”
Fredrickson said.
Last summer, the Centers for
Disease Control and Prevention recommended national deferral of routine tetanus-diphtheria booster vaccination of both children age 7 and
older and adults to assure vaccine
availability for wound management
and other high priority indications.
There is a continued shortage of
Diphtheria/Tetanus/Pertussis
(DTaP/DTP) vaccine given to young
children. ADHS has recommended
the deferral of the fourth dose, which
is usually given at 12-18 months of
age, until DTaP supplies increase.
Child care centers have provided
waivers for this required dose.
For more information about
school immunization requirements,
contact the immunization coordinator
at your local county health department or the ADHS Immunization
Program Office at (602) 230-5852.
Prevention Bulletin

5

Suicide - The 8th Leading
Cause of Death in Arizona

By Sheila Sjolander, MSW

Suicide, the act of taking one’s
emerging early in life often persists,
For both women and men, rates
own life, ranks 8th among the leadrecurs, and continues into adultof major depression are highest
ing causes of death in Arizona and
hood. Early onset of depression
among the separated or divorced
accounts for 2% of all deaths. Each
may predict more severe illness in
and lowest among the married.
year an average of 800 people die
adult life.
Suicide rates are also highest
from suicide in Arizona and an
More women (12 percent) than
among separated, divorced, and
average of 2,600 persons
men (7 percent) are
widowed people.
are admitted to hospiaffected by a depresImproved recognition, treattals because of suisive illness each
ment, and prevention of depression
cide attempts. For
year and approxare critical to improving the quality
Over the past
the past decade,
imately
20
perof life for thousands of Arizonans
decade, the suicide
the rate of death
cent
of
and preventing needless death.
rate in young people
from suicide has
women have
has increased
Sheila Sjolander is Manager of the Planning,
been higher in
at least one
Education, and Partnerships Section, Office of
dramatically
nationwide
Arizona than
episode of
Women and Children's Health. She can be
and suicide is now one
that of the
depression
reached at 602.364.1469 or
of the three leading
ssjolan@hs.state.us.az.
United States.
that should be
causes of death among
The reasons
treated someyouth 19 and younger
for suicide are
time during
REFERENCES
often unclear, maktheir life. The
in Arizona.
Arizona Department of Health Services.
ing prevention of suichildbearing years
Adolescent Suicide and Attempted Suicide in
cide especially difficult.
are marked by the
Arizona 2000. May 2001.
However, research has
highest rates of depresArizona Department of Health Services. Injury
shown that nearly all people who
sion, followed by the years prior to
Mortality Among Arizona Residents, 1990-2000.
commit suicide have a diagnosable
menopause.
Mrela C. Arizona Suicide Mortality Arizona,
mental or substance abuse disorder.
Although Arizona men have
1989-1999. ADHS. Rates described above are
Suicide rates increase with age
much higher rates of suicide than
adjusted to the 1940 standard.
and are highest among Arizonans
women, women have higher rates
National Institute of Mental Health, Department
aged 65 and older. In studies of
of suicide attempts. Factors that
of Health and Human Services. Depression
older adults who committed suimay contribute to depression are
Research at the National Institute of Mental
cide, nearly all had major depresnot well understood but are
Health Fact Sheet, May 2000.
sion. The suicide rate among peobelieved to include genetics, brain
National Institute of Mental Health, Department
ple ages 65 and older was signifibiochemistry, stressors, and other
of Health and Human Services. Depression:
What Every Woman Should Know, 2000.
cantly higher in Arizona than the
psychological and social factors.
U.S., with a rate of 23.2 per
100,000 compared to the U.S. rate
of 15.9 per 100,000 in 1999.
Figure 1
Although older people have
higher rates of completed suicides,
Suicide Rates, Arizona and U.S.
teenagers 15-19 have the highest
1990-1999
rates of suicide attempts in Arizona.
Depression in children and adolescents is associated with an
increased risk of suicidal behaviors.
Over the past decade, the suicide rate in young people has
increased dramatically nationwide
and suicide is now one of the three
leading causes of death among
youth 19 and younger in Arizona.
There is evidence that depression
6

Prevention Bulletin

July/August 2002

SUMMARY OF SELECTED REPORTABLE DISEASES
(January - May, 2002)1
Jan - May
2002

Jan - May
2001

5 Year Median
Jan - May

2 (1)
0
0
33 (22)
0 (0)

5 (1)
0
1
265 (100)
0 (0)

4 (1)
0
3
29 (20)
1 (0)

237
5
8
245
107

196
10
5
223
149

168
10
5
220
149

160
82
411
2
1437

193
75
481
8
1264

371
75
*
11
*

480
166
10
18

503
86
21
12

405
86
14
26

6138
1459
93 (6)

5944
1662
51 (11)

5297
1662
71 (11)

N/A
374

3 (0)
308

1 (0)
324

1
0
72

1
0
68

1
0
18

1441
20
51
40
109 (96)
15

601
29
147
166
103 (81)
7

601
25
345
404
206 (104)
5

VACCINE PREVENTABLE DISEASES:
Haemophilus influenzae, serotype b invasive disease (<5 years of age)
Measles
Mumps
Pertussis (<12 years of age)
Rubella (Congenital Rubella Syndrome)
FOODBORNE DISEASES:
Campylobacteriosis
E.coli O157:H7
Listeriosis
Salmonellosis
Shigellosis
VIRAL HEPATITIDES:
Hepatitis A
Hepatitis B
Hepatitis B: non-acute2
Hepatitis C
Hepatitis C: non-acute3
INVASIVE DISEASES:
Streptococcus pneumoniae
Streptococcus Group A
Streptococcus Group B in infants <30 days of age
Meningococcal Infection
SEXUALLY TRANSMITTED DISEASES:
Chlamydia
Gonorrhea
P/S Syphilis (Congenital Syphilis)
DRUG-RESISTANT BACTERIA:
TB isolates resistant to at least INH (resistant to at least INH & Rifampin)
Vancomycin resistant Enterococci isolates
VECTOR-BORNE & ZOONOTIC DISEASES:
Hantavirus Pulmonary Syndrome
Plague
Animals with Rabies
ALSO OF INTEREST IN ARIZONA:
Coccidioidomycosis
Tuberculosis
HIV
AIDS
Lead Poisoning (<16 years of age)
Pesticide Poisoning4
1
2
*
4

Data are provisional and reflect case reports during this period except HIV, AIDS, and Lead Poisoning which are by date of diagnosis.
These counts reflect the year reported or tested and not the date infected.
Case counts for non-acute Hepatitis B and C are not available before 1998.
Not all reports will be confirmed as meeting the case definition for pesticide poisoning upon further investigation.

July/August 2002

Prevention Bulletin

7

Noteworthy...

Women’s Health
The National Women’s
Health Information Center
(NWHIC) is the country’s largest
noncommercial information
center on women’s health and
provides a gateway to all of the
other federal health agencies
and to a variety of other online
women’s health information
resources. NWHIC can be
found at www.4woman.gov.
Another valuable resource is
the Regional Women’s Health
Coordinators (RWHCs) in each
of the 10 regions of the
Department of Health and
Human Services. The RWHCs
support and coordinate women’s
health efforts such as research,
education of public and health
professionals and programs in

health care service delivery.
They are a great source of information about women’s health
issues nationally and specific to
their region. The Region IX
(Arizona, California, Hawaii,
Nevada, and six jurisdictions in
the Pacific Basin) Coordinator is
Kay A. Strawder, J.D., M.S.W.
For more information, go to
http://www.4woman.gov/owh/
reg/9/index.htm.
Locally, the Department’s
Office of Women’s and
Children’s Health provides information on specific health topics
and support for innovative programs addressing the health
needs of women across different
ages, cultures, and races/ethnicities. The Office can be reached
at 602.364.1419 or on the Web
at www.hs.state.az.us.

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Arizona Department of Health Services
Public Information Office
3815 North Black Canyon Hwy.
Phoenix, AZ 85015
602.230.5901 • Fax 602.230.5959
Jane Dee Hull, Governor
Catherine R. Eden, Ph.D., Director ADHS
Lee A. Bland, Chief, Bureau of Epidemiology
and Disease Control Services
Editorial Board
Victorio Vaz, D.V.M., Ph.D., Acting State Epidemiologist
Tim Flood, M.D.
Kathy Fredrickson, M.P.H.
Will Humble, M.P.H.
Ken Komatsu, M.P.H.
Cheryl McRill, M.D.
Wesley Press, M.S.
Emma N. Viera, M.P.H.
Managing Editor: Courtney Casillas
e-mail: ccasill@hs.state.az.us
Contributors: Tim Flood, Will Humble, Clare Kioski,
Craig Levy, Patrick Mause, Cheryl McRill
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 602.230.5901 or 1.800.367.8939 (State TDD/TTY Relay).

8

Prevention Bulletin

July/August 2002