Publication of the Bureau of Epidemiology & Disease Control Services

January/February 2003, Vol. 17, No. 1

Smallpox: What Physicians Need to Know
By Dr. Peter Kelly

Smallpox and vaccination against
smallpox is all over the news. The
federal government, fearing terrorists
may have access to variola, asked the
states to submit plans for vaccinating
public health workers and selected
hospital staff prior to the occurrence of
a smallpox case.
Arizona has developed a plan and
it is under review at the Centers for
Disease Control and Prevention. This
article will review some basic information regarding smallpox, vaccination
to protect against smallpox, and
Arizona’s plan for vaccinating health
care workers.

Initially a few minute macules are seen
usually on the face. Careful inspection
at this time also shows some pharyngeal lesions. Over the next three weeks
the rash progresses in a consecutive
manner through papules, vesicles, pustules and eschars. The rash is distributed throughout the body but is most
evident on the face and extremities
(including the palms and soles) with
relative sparing of the trunk. The skin
lesions contain variola so care must be
taken to avoid direct contact and to
dispose of bedding and garments in a
safe way.
Smallpox is a life threatening disease with a mortality rate of approximately 30% in a non-vaccinated population. Treatment of cases is supportive since there is currently no available anti-variola drug. Control of
smallpox depends on prevention by
isolation of cases and by vaccination
of case contacts. Naturally occurring
smallpox was eliminated in 1978 due
to a World Health Organization case
finding and vaccination program.
There has not been a case of smallpox
diagnosed since the world was
declared smallpox free in 1980.
Variola isolates are known to exist in
laboratories in the United States and
Russia. National security experts suspect that variola isolates may be in the
hands of terrorists.

Smallpox: The Disease
Smallpox is a dreaded viral infection caused by variola. The organism
is a large DNA orthopoxvirus that
infects only humans and is spread by
the respiratory route with prolonged,
close, personal contact. After an incubation period of approximately 12
days an illness characterized by abrupt
onset, fever and prostration begins.
Within 3 to 4 days a rash appears signaling the blood borne spread of the
virus to the skin and other organs.
Vivid images of the rash and all the
information than you can read are
available on the CDC web site,
www.cdc.gov.
The distribution and progression of
the rash is diagnostic of smallpox.

Key Points
by Dr. Bob England, State Epidemiologist

• There is no smallpox on earth. Fears
that certain rogue nations have access
to the virus from stockpiles believed
to exist in labs have led to development of vaccination plans.
• The vaccine has a high rate of
uncomfortable side effects and has
uncommon but significant risks.
Therefore, as long as there are no
smallpox cases or known real threat,
we must err on the side of safety in
our use of the vaccine.
• As horrible as the disease is, it is very
controllable. There are reasons that it
was eradicated 25 years ago, and
these same reasons will allow it to be
controlled now. These include:
1. Transmission is primarily by droplet
spread and is limited to face-to-face
and household contacts. This allows
people to be identified who may have
been exposed around each case.
2. The vaccine works even a few days
after exposure to prevent disease,
offering protection to persons even
after they have been exposed.
3. This is the only major infectious
disease that gives a few days warning
BEFORE it becomes contagious!
During the prodromal phase,
persons feel quite ill and everyone
develops a fever, but shedding of
virus doesn’t begin until a few days
later with the development of rash in

Continued on page 2

Continued on page 2

Visit the ADHS Web site at www.hs.state.az.us
New CDC
Hand Hygiene
Guidelines
Page 3
January/February 2003

Naegleria
fowleri Meningitis
Cases
Page 4

Teen Pregnancy
Rate Drops
Page 5

Drinking water
regulations
Page 5

Child Fatality
Review
Page 6

Summary Chart
of Reportable
Diseases
Page 7
Prevention Bulletin

1

Smallpox Continued
Smallpox: The Vaccine
Vaccination against smallpox
began in England in the final years of
the 18th century. Edward Jenner, a
rural physician, showed that inoculation of material from the skin lesion of
a person with cowpox protected
against smallpox infection. His technique spread quickly through out
England, Europe and North America.
By the late 19th century vaccination
was a common practice and cases of
smallpox became less frequent.
The vaccine used in the United
States in modern times is a live vaccinia virus. Vaccinia is an
orthopoxvirus as is variola but the
organisms are separate species.
Immunity induced by vaccination
with vaccinia is mediated by both B
and T cells and full protection lasts for
about 10 years. Immunization not
only protects the individuals but also
prevents transmission of disease.
Once the world was smallpox free
routine vaccination was discontinued.
Thus, for practical purposes now the
people of the United States are a nonimmune population and re-introduction of variola would be a public
health emergency.
Vaccination with live vaccinia,
while generally safe, is not an innocuous procedure. The virus causes a
local, usually self limited infection
which can produce a vigorous inflammatory response. (See Fig. 1 for a normal vaccine site reaction.) One third
of the persons recently vaccinated

developed symptoms such as fever,
swollen upper arms and axillary
adenopathy. More serious but very
infrequent adverse effects include vaccinia encephalitis, progressive vaccinia, eczema vaccinatum, and generalized vaccinia. Altogether, these
adverse events are expected to occur
in ~ 1/1000 vaccinations. A full
description and images of both local
reactions and adverse effects can be
found on the CDC web site. There are
some principle contraindications to
vaccination. See Table 1.

Arizona’s Smallpox Plan
State and county public health
officials have worked collaboratively
over the past year to develop a coordinated response to a bioterrorism
event such as a recurrence of smallpox. The Arizona Department of
Health Services has submitted both
pre- and post-event plans to CDC.
In accordance with federal guidance, Arizona’s pre- event plan for
smallpox calls for offering vaccination
to public health system smallpox
response teams who would investigate
any suspect case and initiate an investigation. In addition, vaccination will
be offered to health care smallpox
teams in hospitals throughout the state
where suspect cases of smallpox
would be diagnosed and treated.
Vaccination is VOLUNTARY. No
person is compelled to be vaccinated.
Any person in either public health or
hospital health care who has a contra-

Table 1

Principle Contra-indications to Smallpox Vaccination
Some people are at greater risk for serious side effects from the smallpox vaccine.
Individuals who have any of the following conditions, or live with someone who does,
should NOT get the smallpox vaccine unless they have been exposed to the smallpox
virus:
• Eczema or atopic dermatitis. (This is true even if the condition is not currently
active, mild or experienced as a child.)
• Skin conditions such as burns, chickenpox, shingles, impetigo, herpes, severe
acne, or psoriasis. (People with any of these conditions should not get the vaccine
until they have completely healed.)
• Weakened immune system. (Cancer treatment, an organ transplant, HIV, or medications to treat autoimmune disorders and other illnesses can weaken the
immune system.)
• Pregnancy or plans to become pregnant within one month of vaccination.

Key Points – Continued from page 1
the mouth and throat. This allows
identified contacts to be observed
and if necessary, isolated, before
they could infect anyone else.
• The Arizona post-event vaccination
strategy is to quickly identify cases,
find their contacts, vaccinate the
contacts, watch the contacts and isolate them at the first sign of illness.
To do this, a cadre of pre-vaccinated
public health workers is needed to
interview and intervene with cases,
as well as a team of health care
workers able to step in and care for
the first case(s).
Importantly, this cadre of workers is
NOT being vaccinated to protect them
“just-in-case” they encounter a case of
smallpox. Rather, these persons are
being asked to voluntarily be prepared
on an immediate basis to respond to
known or suspected cases. Any health
care workers who might incidentally be
the first to come into contact with a case
will be vaccinated after-the-fact, just as
will all other contacts. Thus, we are not
seeking to vaccinate large numbers of
individuals in this first phase of our plan.
Dr. Bob England, State Epidemiologist

indication should not be vaccinated
even if they volunteer. Vaccination of
public health personnel and other key
health care workers has not yet
occurred in Arizona and will not
begin before late January. The availability of vaccine and its use awaits
Federal and state policy decisions.
Dr. Peter Kelly is an infectious disease specialist
with the Department. He can be reached at
602.230.5860 or pckelly@hs.state.az.us.
Figure 1

Source: The Centers for Disease Control and Prevention

2

Prevention Bulletin

January/February 2003

CDC Releases New Hand Hygiene
Guidelines for Health Care Settings
by Clare Kioski

The new hand hygiene guidelines
from the Centers for Disease Control
and Prevention (CDC) for health care
facilities recommend the use of alcohol-based hand rubs before and after
each patient contact as the preferred
method of hand decontamination in
health care settings. Handwashing
with soap and water is recommended
when the workers’ hands are visibly
soiled. The rationale for these guidelines is to improve adherence by
health care personnel to hand
hygiene and thus reduce overall
infection rates in health care facilities
and more importantly the transmission of antimicrobial resistant organisms. These guidelines are for all
healthcare facilities, not just hospitals
and long term care facilities. The
guidelines are not intended for use in
food processing or food service establishments or for community settings.
Problems with adherence by
health care providers to recommended hand washing have been reported
in over 30 studies in the last 20 years.
However, more recent data suggest
that health care personnel may be
more inclined to use alcohol-based
hand rubs. These take less time and
are more convenient to use, are more
effective in reducing the number of
bacteria on the hands than handwashing with soap and water and are
less likely to cause skin irritation. An
ICU nurse could possibly gain an
extra hour in an eight-hour shift by
using an alcohol-based hand rub.

January/February 2003

The current recommendations
are evidence-based and include:
• Handwashing with regular soap
and water to remove unsightly
debris;
• Using an alcohol based hand rub
to reduce bacterial counts;
• And, using gloves in accordance
with Standard Precautions when
contact with blood/body fluids is
anticipated.
Other recommendations include:
• Not wearing artificial nails or
extenders when having direct contact with patients at high risk of
acquiring infections.
• Providing healthcare workers with
hand lotions and creams to minimize the occurrence of irritant
contact dermatitis associated with
hand antisepsis or handwashing.
• Decontaminating the hands after
contact with a patient’s intact skin
(e.g., when taking a pulse or blood
pressure, lifting a patient).
Alcohol has been used as an antiseptic for 60-70 years and there is no
evidence that bacteria are becoming
more resistant to alcohol.
The guidelines can be found at
the CDC’s website at:
www.cdc.gov/mmwr/PDF/rr/rr5116.pdf.
For a two-page summary of the recommendations, contact Clare Kioski
at the number below.
Clare Kioski is an epidemiologist and the antimicrobial surveillance and prevention coordinator
for the Department. She can be reached at
602.230.5927 or ckioski@hs.state.az.us.

Source: CDC. Guideline for Hand Hygiene in
Health-Care Settings: Recommendations of the
Healthcare Infection Control Practices Advisory
Committee and the HICPAC/SHEA/APIC/IDSA
Hand Hygiene Task Force. MMWR 2002;51(No.
RR-16):1-56.

Noteworthy...
ADHS Reports First Flu
Cases of the Season
At the time of this writing, Arizona
has its first seven lab-confirmed flu
cases of the 2002-2003 season.
Four of these culture-confirmed
cases were typed as influenza B, and
three as influenza A. One of each has
been subtyped and both are strains
that are covered by this year’s vaccine.
Subtyping of the others is pending.
Influenza vaccine remains available throughout Arizona. For information regarding influenza vaccination
sites, please contact the Flu Shot
Hotline, Community Information and
Referral, 602.263.8856 in Maricopa
County, 1.800.352.3792 outside of
Maricopa County, website address
http://www.cirs.org/seasonal-flu.html.
For national influenza information,
please visit the Centers for Disease
Control and Prevention’s influenza
website at: http://www.cdc.gov/ncidod/diseases/flu/fluvirus.htm. For further information regarding influenza
in Arizona, please contact the Arizona
Department of Health Services’
Infectious Disease Epidemiology
Section at 602.230.5932, and the
Arizona Immunization Program
Office at 602.230.5852.

MMR vaccine
and autism
In the past few years there have
been some reports suggesting an
association between the measles,
mumps and rubella (MMR) vaccine
and autism. Most of the evidence
suggestive of a link has been based
on case-series, cross-sectional studies
and ecologic studies. Many larger
studies and reviews of data have
failed to detect any association. Most
recently, however, a population-based
study conducted in Denmark provided
strong evidence against the hypothesis
that MMR vaccination causes autism.
(N Engl J Med 2002; 347:1477-82).

Prevention Bulletin

3

Rarity, Complexity Confound
Naegleria fowleri Meningitis Cases
This is a tale of a very rare disease and a possibly unprecedented
source of infection that is told with a
lot of uncertainty.
In October, two nearly simultaneous cases of meningitis due to
Naegleria fowleri occurred in 5 yearold children living in the northwest
metro Phoenix area. This type of
amoebic meningitis is extremely rare
(less than 200 known cases worldwide, ever) and is nearly always fatal,
as it was in both of these tragic cases.
A thorough investigation was begun
by the Maricopa County Department
of Public Health (MCDPH), with
assistance from the Maricopa County
Environmental Services Department
(MCESD), from ADHS and from the
Centers for Disease Control and
Prevention (CDC).

Once before in recorded history,
in Australia during the 1970s, a community water supply was implicated
in causing human infections with
Naegleria fowleri. In this instance,
the water source was surface water,
which would be expected to harbor
the organism, yet was delivered
unchlorinated. When routine chlorination was instituted, human cases
stopped.

Particular test results have
conflicted between private
and public health labs, and
testing continues, but at least
some tests from locations in
the water distribution system
have revealed the presence
of Naegleria fowleri.

The Perplexing Parasite
Naegleria fowleri is a widespread
environmental parasitic amoeba that
only rarely infects humans, virtually
always those who swim in unchlorinated natural bodies of fresh water,
such as stagnant ponds or swimming
holes. In humans, when water
containing the amoeba enters the
nose, the amoeba can pass through
the nasal mucosa, up the olfactory
nerve, directly penetrate the brain
and cause meningoencephalitis. It is
very rarely infectious, however, as
demonstrated by the fact that even
when individuals have been infected
by swimming in such water, tens of
thousands of others may have swum
in the same water without ill effect.
It is a difficult organism to culture
from environmental samples,
requiring lengthy and labor-intensive
techniques that seem to require as
much art as science, with the
potential for both false-negative and
false-positive results (the latter due to
cross-reaction with other amoeba
during some confirmatory testing
techniques). The CDC remains the
best provider of reliable confirmation
of the presence of the organism.
4

Prevention Bulletin

In our investigation, to our surprise, there was no history of exposure to natural bodies of fresh water
in either child. The only link of any
sort that could be established
between these children was that they
both were consumers of unchlorinated water supplied by the same water
company. Unlike the situation in
Australia, however, the water source
was groundwater, which is not
always required to be chlorinated per
existing regulations (see inset for
drinking water facts).
Although we did not initially
expect to find this organism in water
distributed from a groundwater
source, chlorination of the water system was begun due to positive coliform test results. Based on the history in Australia, this would have been
sufficient to prevent further infection
with the amoeba even if it were present. The community that had been
receiving this water was nevertheless
understandably distressed. They had
lost two children and we could not
provide them with answers as to why
it happened.

By Dr. Bob England

Unanswered Questions
Remain
Particular test results have conflicted between private and public
health labs, and testing continues,
but at least some tests from locations
in the water distribution system have
revealed the presence of Naegleria
fowleri. Based on initial results, the
water system was taken offline for
thorough cleaning and installation of
a modern chlorination system.
Still, questions remain. How
were the children infected? Certainly
children submerge their faces in tap
water and might get water up their
noses during bathing or other activities, and this was the case for these
two children, but would the concentration of this amoeba in tap water
have been enough to expect two
children to get infected this way?
After all, many thousands of persons
swim and submerge their faces in
natural bodies of fresh water, which
one would expect to have much
higher concentrations of the organism, without becoming ill.
Could the groundwater itself contain the organism? At least initially,
we were laboring under the assumption that deep well water was relatively pristine. If not from the
groundwater, how could a break in a
line or other problem result in
enough contamination to infect two
people with this relatively poorly
infectious organism, without overwhelming evidence of other contamination?
Does it even mean anything that
we’ve found the organism in this
water system? After all, we also
found it in another system’s wellhead that we were using as a “control” (a system that has long been
chlorinated already so presents no
risk). Does this mean that the organism is frequently present in other
water systems? If so, how much is
Continued on page 5
January/February 2003

Naegleria fowleri Meningitis - Continued from page 4

too much for a water system? If it is widespread, does
that imply that we must chlorinate more frequently?

Chlorination Assures Safety
Since the amoeba in question is a parasite that
requires the presence of other bacteria to multiply, total
and fecal coliform testing can be used as a general
screen for contamination. If there is no bacterial contamination, presumably the amoeba cannot be present
to any significant degree. We have urged private water
companies and labs to continue to rely on this testing,
and to test more frequently than required if there is any
concern.
Federal, state and local agencies have been working
to develop the sort of long-term research studies that
would answer some of these questions. In the meantime, based on the information gained from the outbreak in Australia, we know that the people being
served by the original water system in question are safe,
because they are now receiving chlorinated water.
There is no reason to believe that any other water systems are not safe, because they are either chlorinated or
have adequate negative coliform tests. And we will support the sort of long-term studies needed to determine
whether there is anything else that can be done to make
this extraordinarily rare disease even more rare. The
bottom line, however, is that we may never understand
exactly how this happened.
Dr. Bob England is the State Epidemiologist for the Department and can
be reached at 602.230.5823 or benglan@hs.state.az.us.

Drinking Water Regulations
• The federal Safe Drinking Water Act regulates Arizona’s
public drinking water supply. The law covers
all water systems that serve more than 25 people. It does not cover private wells. The
EPA sets the health-based standards that
must be met by water systems.
• Drinking water that comes from surface
water sources must be properly treated
and chlorinated before it is delivered. Drinking water
from groundwater sources does not need to be chlorinated if bacterial sampling demonstrates that the well is free
of harmful bacteria. Well water that contains coliform
bacteria must be chlorinated before delivery.
• Water suppliers are required to prepare annual reports for
their customers. The reports include information on
detected contaminants, possible health effects, and the
water’s source. Patients who ask about their water quality
can be referred to their water system operator, who must
provide them with an annual report.
• Approximately 95% of Arizona residents receive water
from regulated drinking water systems. Patients with private wells should test their well water annually for the
presence of coliform bacteria and nitrates. Private well
owners should also test at least once for metals and
organic contaminants. The ADHS Office of
Environmental Health can help interpret your patient’s private well sampling results at 1.800.367.6412.

Arizona’s Teen Pregnancy Rate Continues To Decline
Arizona’s teen pregnancy rate
continued its downward trend in
2001, dropping nine percent from the
previous year and 29 percent from the
decade’s high point in 1994, according to new data released by the
Arizona Department of Health
Services.
The latest data provide encouraging news to those behind Arizona’s
“abstinence until marriage” campaign.
“Young people are getting the
message about acting responsibly,”
said Catherine Eden, Director of the
Arizona Department of Health
Services. “This trend is not only making a positive impact on teens, but it’s
also improving the overall health of
our state.
The pregnancy rate for teenagers
15 to 19 years old in 2001 was 72
pregnancies per 1,000 females, nine
percent lower than in 2000 and 29.4
January/February 2003

percent lower than in 1994 when it
reached the decade’s peak of 102
pregnancies per 1,000 girls.
The pregnancy rate for older
teenagers (18 and 19) reached a
record low in 2001, down 8.4 percent
from the previous year, while the
pregnancy rate for teens age 15 to 17
declined even more steeply in 2001,
dropping 10 percent from 2000 and
34 percent from 1994.
Eden cautioned that there is still
much more work to be done, noting
that 21 percent of teenagers who
already had one child gave birth to
another child in 2001.
Arizona launched an aggressive
effort four years ago to reduce the
state’s teen pregnancy through a program that combines an educational
component and a public awareness
campaign. The current ad campaign
encourages teens to think about the

dangers of sexually transmitted diseases, while a Web site (www.sexcanwait.com) provides an interactive
resource for Arizona youth.
The continuing reduction in
Arizona’s birth rate mirrors a national
trend and suggests that teens are less
inclined to engage in casual sex, and
more likely to give serious thought to
the benefits of abstinence until marriage. Other factors could include
increased awareness of sexually transmitted diseases and an increased use
of contraceptives.
The data are contained in the
newly published Teenage Pregnancy,
Arizona, 1991-2001, produced by the
Arizona Department of Health
Services’ Bureau of Public Health
Statistics.
The full report is available on the
Web at www.hs.state.az.us/plan/tp.htm.

Prevention Bulletin

5

Violence Related Childhood Deaths
Increase Dramatically in 2001

Preventable Childhood Deaths
In 2001, there were 1,051 fatalities that occurred in Arizona among
infants and children under age 18.
The Arizona Child Fatality Review
Team reviewed 969 of these fatalities
and determined that a total of 247
fatalities, or nearly 26 percent of all
childhood deaths, could have been
prevented through such preventive
practices as the use of automobile
seat belts, locked storage of guns, and
secured pool fences. Of special note,
approximately 50% of the deaths of
children aged one through 17 could
have been prevented [Figure 1].
Leading Categories of
Preventable Deaths
Motor vehicle accidents remained
the leading cause of preventable
deaths for children in 2001.
Approximately 40 percent of all childhood preventable deaths were due to
motor vehicle accidents.
Unintentional injuries were the second leading cause of preventable
deaths, followed by deaths related to
violence, medical conditions, and
SIDS risk factors [Figure 2]. Within
the category of unintentional injuries,
drowning was the most frequent,
accounting for 35 preventable deaths
followed by 18 deaths from suffocation/choking, 12 from smoke inhalation/burns, 5 from gun shot wounds,
5 from falls and head injury, 4 from
poisoning, and one death each from
exposure, lacerations and electrocution. Thirteen of these deaths were
the result of residential fires.

makers, and the public. Because of
the increased numbers of childhood
death from violence, recommendations include: enacting laws requiring
all guns sold in Arizona to have a
locking device and enforcing the
existing state law prohibiting persons
under age 18 from possessing a
firearm; ensuring funding for
adequate behavioral health services;
and supporting gang prevention
initiatives and conflict resolution
training for youth.

Links to the 2002 and 2001 Child
Fatality Review Team Report and
information describing the Arizona
Child Fatality Review Program and
may be found on the Internet at:
http://www.hs.state.az.us/cfhs/azcf/in
dex.htm
For additional information, contact Robert
Schackner, Director, Child Fatality Review
Program at (602) 542-1875 or
rschack@hs.state.az.us.

Figure 1

Percentage of Preventable Deaths Among Children
Age 1 to 17 in Arizona, 2001

60
47.8%

50

50.7%
46.3%

48.1%

40
Percentage

Violence-related childhood deaths
in Arizona increased by 58 percent in
2001 according to the annual report
of the Arizona Child Fatality Review
Team. Seventy-six children died from
homicide, suicide and child abuse in
2001 compared to 48 in 2000.

by Robert Schackner

30
20.5%

20
10
0

1.9%

Neonates Postneonates 1-4 Years

5-9 Years 10-14 Years 15-17 Years
Figure 2

Preventable Arizona Childhood Deaths by Category, 2001
Medical Condition/
Prematurity
SIDS Risk
7.7%
Factors
4.5%
Violence Related
15.0%

Undetermined
0.4%

Unintentional injuries
(other than motor vehicle crashes)

33.2%

Motor Vehicle Crashes
39.3%

Report Recommendations
The report includes recommendations for elected officials, other policy
6

Prevention Bulletin

January/February 2003

SUMMARY OF SELECTED REPORTABLE DISEASES
Year to Date (January - November, 2002)1
Jan - Nov
2002

Jan - Nov
2001

5 Year Median
Jan - Nov

5 (3)
0
1
179 (88)
0 (0)

9 (5)
1
2
370 (157)
0 (0)

6 (3)
1
5
73 (41)
1 (0)

586
35
14
534
357

584
30
9
628
399

542
37
15
742
553

272
204
960
3
4207

376
143
1386
9
3180

659
169
*
19
*

681
260
29
31

708
162
49
18

589
167
38
41

13613
3401
172 (14)

13383
3636
158 (30)

11392
3802
175 (26)

9 (0)
869

10 (3)
661

10 (1)
690

1
0
135

1
0
128

3
1
78

2490
205
479
469
226 (156)
14

1773
209
483
518
178 (154)
13

1566
197
483
389
321 (184)
13

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-acute2
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 Poisoning3
1
2
*
3

Data are provisional and reflect case reports during this period except Lead Poisoning which is 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.

January/February 2003

Prevention Bulletin

7

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Arizona Department of Health Services
Public Information Office
1740 West Adams
Phoenix, AZ 85007
602.364.1201 • Fax 602.364.0844
Janet Napolitano, Governor
Catherine R. Eden, Ph.D., Director ADHS
Lee A. Bland, Chief, Bureau of Epidemiology
and Disease Control Services
Editorial Board
Bob England, M.D., M.P.H., State Epidemiologist
Victorio Vaz, D.V.M., Ph.D.
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: Bob England, Will Humble, Peter Kelly,
Emma Viera Negron, Robert Schackner
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).

FBI lauds Arizona’s Public Health Response to Anthrax
The Federal Bureau of
Investigation recently praised
Governor Jane Dee Hull and the
Arizona Department of Health
Services for the state’s cooperation
and rapid response during last year’s
anthrax scare.
“During the anthrax scare, the
Arizona State Health Laboratory
proved to be a full and essential partner in the war on terrorism. The protocols developed by the lab, in cooperation with the FBI’s Phoenix office,
today serve as a model for jurisdictions across the country,” said Special
Agent In Charge Charlene B.
Thornton, head of the Phoenix office
of the FBI.
During the 2001 anthrax scare,
employees at the Department’s
Arizona State Health Laboratory
worked around the clock for weeks,
testing more than 1,100 samples submitted by the FBI and other law
enforcement agencies. All of the samples were negative for anthrax.
8

Prevention Bulletin

In a December ceremony at the
Governor’s Office in Phoenix, Special
Agent In Charge Charlene B.
Thornton presented a special agency
award to Governor Hull and Arizona
Department of Health Services
Director Catherine R. Eden. She also
presented individual awards to
Wesley Press, Arizona State Health
Laboratory Bureau Chief; William
Slanta, Assistant Bureau Chief; Powell
Gammill, State Lab Section Manager
of Epidemic Detection; Elisabeth
Lawaczeck, Disease Specialist; and
David Engelthaler, head of the ADHS
Office of Bioterrorism and Epidemic
Preparedness.
The awards cited the ADHS
employees’ “outstanding assistance to
the FBI in connection with its investigative efforts.”
“Your cooperation was of
immeasurable help to our representatives,” the award, signed by FBI
Director Robert S. Mueller III, states.
“I share their gratitude for your sup-

port, which assisted them in carrying
out their responsibilities. You can take
pride in the role you played in the
success achieved, and my associates
and I congratulate you on a job well
done.”
ADHS Director Eden said, “I am
proud that the FBI has cited Arizona
as a national model for cooperation
and response during this difficult
time.”

CORRECTION
The contact information for
the Valley Fever Center for
Excellence at the University of
Arizona was printed incorrectly in
the November/December issue
of Prevention Bulletin. The Center
can be contacted at
520.629.4777 or
www.arl.arizona.edu/vfce.
January/February 2003