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STATISTICAL HANDBOOK ON INFECTIOUS DISEASES

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STATISTICAL HANDBOOK ON INFECTIOUS DISEASES

Sarah B. Watstein and John Jovanovic

An Oryx Book

Greenwood Press Westport, Connecticut London

Library of Congress Cataloging-in-Publication Data Watstein, Sarah. Statistical handbook on infectious diseases / Sarah B. Watstein and John Jovanovic. p. ;cm. Includes bibliographical references and index. ISBN 1-57356-375-7 (alk. paper) 1. Communicable diseases—Statistics—Handbooks, manuals, etc. 2. Epidemiology—Handbooks, manuals, etc. I. Jovanovic, John. II. Title. [DNLM: 1. Communicable Diseases—epidemiology—Handbooks. 2. Vaccination—statistics & numerical data—Handbooks. WC 39 W343s 2002] RA643.W33 2003 614'.07'27—dc21 2002022055 British Library Cataloguing in Publication Data is available. Copyright © 2003

by Sarah B. Watstein and John Jovanovic

All rights reserved. No portion of this book may be reproduced, by any process or technique, without the express written consent of the publisher. Library of Congress Catalog Card Number: 2002022055 ISBN: 1-57356-375-7 First published in 2003 Greenwood Press, 88 Post Road West, Westport, CT 06881 An imprint of Greenwood Publishing Group, Inc. www. greenwood.com Printed in the United States of America

The paper used in this book complies with the Permanent Paper Standard issued by the National Information Standards Organization (Z39.48-1984). 10

9 8 7 6 5 4 3 2 1

Acknowledgements: From John S. Jovanovic and Sarah Barbara Watstein: We would like to thank Eleanora Von Dehsen, our acquiring editor, with thanks for your guidance, support, and most of all, your patience; We would also like to thank the following for helping us ferret out and format information— Louveller Luster, formerly Head, Government Documents, Virginia Commonwealth University, VCU Libraries & Mary Horman, Government Information Specialist, Virginia Commonwealth University, VCU Libraries & Pascal Calarco, Head, Library Information Systems, Virginia Commonwealth University, VCU Libraries Dedication: From John S. Jovanovic To Emily and Ethan, who fill each of my days with joy From Sarah Barbara Watstein To my family and friends, and especially to Dr. R., who believed that there was light at the end of the tunnel

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Contents List of Tables Preface

ix

xix

Introduction

xxi

A. Nationally Notifiable Diseases 1 1. Background 1 2. Surveillance 1 3. Data Sources 2 4. Interpreting Data 3 5. Table Overview 3 6. Notes 5 B. Human Immunodeficiency Virus (HIV) and Acquired Immunodeficiency Syndrome (AIDS) 47 1. Overview 47 2. Definition 47 3. Case Definition and Case Classification 48 4. Symptoms and Pathologies 49 5. Diagnosis 49 6. Transmission 49 7. Treatment 50 8. Surveillance 50 9. Healthy People 52 10. Table Overview 53 11. Notes 54 C. Malaria 81 1. Overview 81 2. Case Definition 81 3. Symptoms and Pathologies 81 4. Diagnosis 82 5. Transmission 82 6. Treatment 82 7. Surveillance 82 8. Table Overview 82 9. Notes 83

D. Sexually Transmitted Diseases 92 1. Overview 92 2. Transmission 92 3. The Diseases 92

4. Surveillance 96 5. Healthy People 97 6. Table Overview 98 7. Notes 101 E. Tuberculosis 144 1. Overview 144 2. Case Definition 144 3. Symptoms and Pathologies 144 4. Diagnosis 145 5. Transmission 145 6. Treatment 145 7. Surveillance 145 8. Table Overview 146 9. Notes 147 F. Foodborne Diseases 175 1. Overview 175 2. Symptoms and Pathologies 175 3. Diagnosis 175 4. Transmission 175 5. Surveillance 176 6. Table Overview 177 7. Notes 177 G. Waterborne Diseases 214 1. Overview 214 2. Symptoms and Courses of Illness 214 3. Diagnosis 214 4. Transmission 214 5. Treatment 214 6. Surveillance 214 7. Table Overview 215 8. Notes 216 H. Infectious Disease Worldwide: Present Issues, Emerging Concerns 223 1. Overview 223 2. Surveillance 224 3. Prevention and Control 224 4. Highlighted Diseases 225 5. Table Overview 226 6. Notes 227

viii

Contents

I. Vaccine-Preventable Diseases 260 1. Overview 260 2. Vaccines 260 3. Selected Vaccine Roster 260 4. Table Overview 263 5. Notes 263 J. Infectious Disease Elimination and Eradication 282 1. Overview 282 2. Disease Control and Elimination 282 3. The Diseases 283 4. Table Overview 285 5. Notes 285

K. Bioterrorism and Biological Warfare 292 1. Overview 292 2. Diagnosis 294 3. Surveillance 296 4. Table Overview 297 5. Notes 297 Appendix: World Health Organization (WHO) Regions 305 Glossary

309

Bibliography Index

319

315

List of Tables A. NATIONALLY NOTIFIABLE DISEASES

A3.4. Hansen Disease (leprosy)—reported cases by year, United States, 1969-1999 A3.5. Hepatitis—reported cases per 100,000 population by year, United States, 1969-1999 A3.6. Hepatitis A—reported cases per 100,000 population, United States and territories, 1999 A3.7. Lyme Disease—reported cases by county, United States, 1998 A3.8. Measles (rubeola)—reported cases (thousands) by year, United States, 1964-1999

1. Historical Trends ALL Reported incidence rates of notifiable diseases per 100,000 population, United States, 1989-1999 A1.2. Reported cases of notifiable diseases, United States, 1992-1999 A 1.3. Reported cases of notifiable diseases, United States, 1984-1991 A1.4. Reported cases of notifiable diseases, United A3.9. States, 1976-1983 A 1.5. Reported cases of notifiable diseases, United States, 1968-1975 A3.10. A1.6. Deaths from selected notifiable diseases, United States, 1989-1998 A3.11. 2. Summary Data A2.1. Reported cases of notifiable diseases, by month, United States, 1999 A2.2. Reported cases of notifiable diseases, by geographic division and area, United States, 1999 A2.3. Reported cases and incidence rates of notifiable diseases, by age group, United States, 1999 A2.4. Reported cases and incidence rates of notifiable diseases, by sex, United States, 1999 A2.5. Reported cases and incidence rates of notifiable diseases, by race, United States, 1999 A2.6. Reported cases and incidence rates of notifiable diseases, by ethnicity, United States, 1999 3. Selected Diseases A3.1. Cholera—reported cases, United States and territories, 1999 A3.2. Diptheria—reported cases by year, United States, 1969-1999 A3.3. Haemophilus Influenzae, invasive disease—reported cases per 100,000 population by age group, United States, 1991-1999

Meningococcal Disease—reported cases per

100,000 population by year, United States, 1969-1999 Mumps—reported cases per 100,000 popula-

tion by year, United States, 1974-1999 Pertussis (whooping cough)—reported cases

per 100,000 population by year, United States,

1969-1999 A3.12. Pertussis (whooping cough)—reported cases

by age group, United States, 1999 A3.13. Plague—among humans, by year, United States, 1969-1999 A3.14. Poliomyelitis (paralytic)—reported cases by

year, United States, 1969-1999 A3.15. Rabies—reported wild and domestic animal cases by year, United States and Puerto Rico,

1969-1999

A3.16. Rubella (German measles)—reported cases per

100,000 population by year, United States, 1969-1999 A3.17. Tetanus—reported cases by year, United States, 1969-1999

A3.18. Typhoid fever—reported cases by year, United

States, 1969-1999 A3.19. Varicella (Chickenpox)—reported cases from

selected U.S. states (n = 7), 1990-1999

x

List of Tables

B. HUMAN IMMUNODEFICIENCY VIRUS (HIV) AND ACQUIRED IMMUNODEFICIENCY SYNDROME (AIDS) 1. Persons Living with HIV/AIDS B1. Persons reported to be living with HIV infection and with AIDS, by area and age group, reported through December 2000 2. HIV Infection B2.1. HIV infection cases, by area and age group, reported through December 2000, from areas with confidential HIV infection reporting B2.2. HIV infection cases in adolescents and adults under age 25, by sex and exposure category, reported through December 2000, from the 34 areas with confidential HIV infection reporting B2.3. HIV infection cases, by age group, exposure category, and sex, reported through December 2000, from the 36 areas with confidential HIV infection reporting B2.4. HIV infection cases, by sex, age at diagnosis and race/ethnicity, reported through December 2000, from the 36 areas with confidential HIV infection reporting B2.5. Male adult/adolescent HIV infection cases, by exposure category and race/ethnicity, reported through December 2000, from the 34 areas with confidential HIV infection reporting B2.6. Female adult/adolescent HIV infection cases by exposure category and race/ethnicity, reported through December 2000, from the 34 areas with confidential HIV infection reporting B2.7. Health care workers with documented and possible occupationally acquired AIDS/HIV infection, by occupation, reported through June 2000, United States 3. AIDS Cases B 3.1. Acquired Immunodeficiency Syndrome— reported cases per 100,000 population, United States, Guam, Puerto Rico, and U.S. Virgin Islands, 1999 B3.2. AIDS cases and annual rates per 100,000 population, by area and age group, reported through December 2000, United States B3.3. AIDS cases and annual rates per 100,000 population, by metropolitan area and age group, reported through December 2000, United States B3.4. AIDS cases by age group, exposure category, and sex, reported through December 2000, United States

B3.5.

AIDS cases by sex, age at diagnosis, and race/ethnicity, reported through December 2000, United States B3.6. Male adult/adolescent AIDS cases, by exposure category and race/ethnicity, reported through December 2000, United States B3.7. Female adult/adolescent AIDS cases, by exposure category and race/ethnicity, reported through December 2000, United States B3.8. AIDS cases in adolescents and adults under age 25, by sex and exposure category, reported through December 2000, United States B3.9. Adult/adolescent AIDS cases by single and multiple exposure categories, reported through December 2000, United States 4. Pediatric HIV and AIDS B4.1. Acquired Immunodeficiency Syndrome— reported pediatric cases, United States, Puerto Rico, and U.S. Virgin Islands, 1999 B4.2. Pediatric HIV infection cases, by exposure category and race/ethnicity, reported through December 2000, from the 36 areas with confidential HIV infection reporting B4.3. Pediatric AIDS cases, by exposure category and race/ethnicity, reported through December 2000, United States 5. Trends B5.1. Acquired Immunodeficiency Syndrome— reported cases, by quarter, United States, 1988-1999 B5.2. Estimated persons living with AIDS, by region of residence and year, 1993 through 1999, United States B5.3. Estimated persons living with AIDS, by sex, exposure category, and year, 1993 through 1999, United States B5.4. Estimated persons living with AIDS, by race/ethnicity and year, 1993 through 1999, United States B5.5.

AIDS cases and deaths, by year and age group,

through December 2000, United States B5.6. Estimated deaths of persons with AIDS, by region of residence and year of death, 1993 through 1999, United States B5.7. Estimated deaths of persons with AIDS, by race/ethnicity and year of death, 1993 through

1999, United States

List of Tables xi

B5.8.

B5.9.

Estimated deaths of persons with AIDS, by age group, sex, exposure category, and year of death, 1993 through 1999, United States Deaths in persons with AIDS by race/ethnicity, age at death, and sex, occurring in 1998 and 1999; and cumulative totals reported through December 2000, United States

C. MALARIA 1. General Surveillance Data C1.1. Malaria—reported cases per 100,000 population, by year, United States, 1968-1998 C1.2. Number of malaria cases in U.S. and foreign civilians and U.S. military personnel—United States, 1968-1997 2. Data by Plasmodium Species C2. Number of malaria cases, by Plasmodium species—United States, 1996 and 1997 3. Area of Acquisition C3.1. Number of malaria cases, by Plasmodium species and area of acquisition—United States, 1996 C3.2. Number of malaria cases, by Plasmodium species and area of acquisition—United States, 1997 4. Imported Malaria Cases by Interval between Arrival in the United States and Onset of Illness C4.1. Number of imported malaria cases, by Plasmodium species and by interval between date of arrival in the country and onset of illness— United States, 1997 C4.2. Number of imported malaria cases in U.S. and foreign civilians, by region of acquisition— United States, 1997 5. Purpose of Travel C5. Number of imported malaria cases in U.S. civilians, by purpose of travel at the time of acquisition—United States, 1997

D. SEXUALLY TRANSMITTED DISEASE 1. Healthy People 2000 Dl. Healthy People 2000 sexually transmitted diseases objective 19.1-19.8 status

2. Summary Data D2.1. Reported cases of sexually transmitted disease by gender and reporting source: United States, 1999 D2.2. Cases of sexually transmitted diseases reported by state health departments and rates per 100,000 civilian population: United States, 1941-1999 3. Chlamydia D3.1. Chlamydia—reported cases, by age, gender, and race/ethnicity: United States, 1996-1999 D3.2. Chlamydia—reported rates per 100,000 population, by age, gender, and race/ethnicity: United States, 1996-1999 D3.3. Chlamydia—reported cases and rates, by state/area, ranked according to rates: United States and outlying areas, 1999 D3.4. Chlamydia—reported cases and rates, by state/area and region listed in alphabetical order: United States and outlying areas, 1995-1999 D3.5. Chlamydia—reported cases among women per 100,000 female population, United States, 1999 D3.6. Chlamydia—Women—reported cases and rates, by state/area listed in alphabetical order: United States and outlying areas, 1995-1999 D3.7. Chlamydia—-Men—reported cases and rates, by state/area listed in alphabetical order: United States and outlying areas, 1995-1999 4. Gonorrhea D4.1. Gonorrhea—rates by region: United States, 1981-1999, and the Healthy People year 2000 objective D4.2. Gonorrhea—reported cases per 100,000 population, United States, 1999 D4.3. Gonorrhea—reported cases and rates, by state/area, ranked according to rates: United States and outlying areas, 1999 D4.4. Gonorrhea—reported cases and rates, by state/area and region listed in alphabetical order: United States and outlying areas, 1995-1999 D4.5. Gonorrhea—reported cases per 100,000 population by sex, United States, 1984-1999 D4.6. Gonorrhea—Women—reported cases and rates, by state/area listed in alphabetical order: United States and outlying areas, 1995-1999

xii

List of Tables

D4.7.

Gonorrhea—Men—reported cases and rates, by state/area listed in alphabetical order: United States and outlying areas, 1995-1999 D4.8. Gonorrhea—reported cases per 100,000 population, by race and ethnicity, United States, 1984-1999 D4.9. Gonorrhea—reported rates per 100,000 population, by age, gender, and race/ethnicity: United States, 1995-1999 D4.10. Gonorrhea—reported cases, by age, gender, and race/ethnicity: United States, 1995-1999 5. Syphilis D5.1. Primary and secondary syphilis—reported rates: United States, 1970-1999, and the Healthy People year 2000 objective D5.2. Syphilis, primary and secondary—reported cases per 100,000 population, United States, 1999 D5.3. Primary and secondary syphilis—reported cases and rates, by state/area, ranked according to rates: United State and outlying areas, 1999 D5.4. Syphilis, primary and secondary—reported cases per 100,000 population by sex, United States, 1984-1999 D5.5. Primary and secondary syphilis—Women—reported cases and rates, by state/area listed in alphabetical order: United States and outlying areas, 1995-1999 D5.6. Primary and secondary syphilis—Men—reported cases and rates, by state/area listed in alphabetical order: United States and outlying areas, 1995-1999 D5.7. All stages of syphilis—reported cases and rates, by state/area listed in alphabetical order: United States and outlying areas, 1995-1999 D5.8. All stages of syphilis—reported cases and rates in selected cities of >200,000 population listed in alphabetical order: United States and outlying areas, 1995-1999 D5.9. Primary and secondary syphilis—reported cases and rates, by state/area and region listed in alphabetical order: United States and outlying areas, 1995-1999 D5.10. Early latent syphilis—reported cases and rates in selected cities of >200,000 population listed in alphabetical order: United States and outlying areas, 1995-1999 D5.11. Late and late latent syphilis—reported cases and rates, by state/area listed in alphabetical

order: United States and outlying areas, 1995-1999 D5.12. Late and late latent syphilis—reported cases and rates in selected cities of >200,000 population listed in alphabetical order: United States and outlying areas, 1995-1999 D5.13. Primary and secondary syphilis—rates, by race and ethnicity: United States, 1981-1999, and the Healthy People year 2000 objective D5.14. Syphilis, primary and secondary—reported cases per 100,000 population, by race and ethnicity, United States, 1984-1999 D5.15. Primary and secondary syphilis—reported cases, by age, gender, and race/ethnicity: United States, 1995-1999 D5.16. Congenital syphilis—rates for infants 1 month's duration), or bronchitis, pneumonitis, or esophagitis; disseminated or extrapulmonary histoplasmosis; chronic intestinal isosporiasis (>1 month's duration); Kaposi's sarcoma; Burkitt's lymphoma (or equivalent term); immunoblastic lymphoma (or equivalent term); primary

lymphoma of the brain; disseminated or extrapulmonary mycobacterium avium complex of M. Kansasii; pulmonary or extrapulmonary Mycobacterium tuberculosis; Pneumocystis carinii pneumonia; recurrent pneumonia; progressive multifocal leukoencephalopathy; recurrent Salmonella septicemia; toxoplasmosis of the brain; and wasting syndrome due to HIV7 In 1993 Centers for Disease Control and Prevention expanded the acquired immunodeficiency syndrome (AIDS) surveillance case definition to include all human immunodeficiency virus (HlV)-infected adolescents and adults aged 13 years or older who have either a) CD4+ T-lymphocyte counts of 75% of cases. b Excludes New York City. c Not included in U.S. totals. Ellipses indicate data not available. Source: Centers for Disease Control and Prevention, U.S. Department of Health and Human Services. National Center for HIV, STD, and TB Prevention, Division of Tuberculosis Elimination. Reported Tuberculosis in the United States, 1999 (Atlanta, GA: CDC, 2000).

E. Tuberculosis 173

Table E5.1. Number and Percentage of Reported TB Cases with HIV Test Results and with HIV Coinfection, by Age Group: United States, 1993-1998

Year 1993 1994 1995 1996 1997 1998

a

25-44 Years Old HIV HIV Test Results3 Positiveb No. (%) No. (%) 4,372 4,432 4,266 4,328 4,106 3,837

(46) (49) (52) (57) (60) (60)

2,786 2,659 2,167 1,856 1.466 1,239

(29) (29) (26) (25) (21) (20)

All Ages HIV Test Results3 No. (%) 7,447 7,869 8,168 8.757 8,715 8,229

(30) (33) (36) (41) (44) (45)

HIV Positive15 No. (%) 3,678 3,588 3,031 2,615 2,084 1,824

(15) (15) (13) (12) (11) (10)

Rhode Island reported HIV test results during 1998. HIV test results were not reported from California. California did provide HIV status for TB cases reported during 1993-1998 in persons also reported with AIDS (i.e., HIV-positive). Includes cases with positive, negative, or indeterminate HIV test results and California cases also reported with AIDS. Percentages based on all reported TB cases, indicates cases with HIV-positive test results and California cases also reported with AIDS. Percentages based on all reported TB cases. Note: Data for all years updated through May 3, 2000. Source: Centers for Disease Control and Prevention, U.S. Department of Health and Human Services. National Center for HIV, STD, and TB Prevention, Division of Tuberculosis Elimination. Reported Tuberculosis in the United States, 1999 (Atlanta, GA: CDC, 2000).

174 Statistical Handbook on Infectious Diseases

Table E5.2. Tuberculosis Cases, Aged 25-44, by HIV Status: 59 Reporting Areas, 1999

Reporting Area

Total Cases

Cases with Information on HIV Status3 No. %

United States

6,078

3,475

57.2

--

80 26 99 32 1,161

73 15 83 25

91.3 57.7 83.8 78.1

11.0

Colorado Connecticut Delaware District of Columbia Florida

26 45 15 30 516

23 32 11 30 444

88.5 71.1 73.3 100.0 86.0

8.7

Georgia Hawaii Idaho Illinois Indiana

251 46 5 295 42

193 3 4 110 13

76.9 6.5 80.0 37.3 31.0

Iowa Kansas Kentucky Louisiana Maine

30 27 58 114 5

12 18 42 101 0

Maryland Massachusetts Michigan Minnesota Mississippi

109 114 112 67 45

89 58 39 44 44

40.0 66.7 72.4 88.6 0.0 81.7 50.9 34.8 65.7 97.8

Missouri Montana Nebraska Nevada New Hampshire

66 1 8 25 8

55 1 2 25 5

83.3 100.0 25.0 100.0 62.5

New Jersey New Mexico New York State0 New York City North Carolina

225 18 143 671 165

North Dakota Ohio Oklahoma Oregon Pennsylvania

0 80 70 38 123 11 107 6 118 594

56.0 66.7 58.7 75.4 90.3 0.0 61.3 41.4 84.2 46.3 27.3 93.5 83.3 79.7 75.4

10 0 114 82 3 40 2

126 12 84 506 149 0 49 29 32 57 3 100 5 94 448 10 0 81 57 3 34 2

100.0 0.0 71.1 69.5 100.0 85.0 100.0

0

0

0.0

-

21 37 67 4

4 35 54 2

19.0 94.6 80.6 50.0

2.9 77.8

Alabama Alaska Arizona Arkansas California

Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming American Samoad Fed. States of Micronesiad Guamd N. Mariana lslandsd Puerto Ricod Republic of Palaud U.S. Virgin lslandsd

Percent of Cases in HIV-Positive Persons'3

-

12.0 8.0

-

43.3 44.1 35.8



0.0

---

24.8

--

21.3

~ ~ 6.8 10.9 0.0

-

16.0



42.5 24.2

— -

12.5

--

35.0 0.0 25.5 30.1 30.0

— —

0.0 5.9 0.0

-

--

includes only those cases with negative, positive, and indeterminate HIV test results. Percentages shown only for reporting areas with information reported for >75% of cases. c Excludes New York City. d Not included in U.S. totals. Ellipses indicate data not available. Source: Centers for Disease Control and Prevention, U.S. Department of Health and Human Services. National Center for HIV, STD, and TB Prevention, Division of Tuberculosis Elimination. Reported Tuberculosis in the United States, 1999 (Atlanta, GA: CDC, 2000).

E Foodborne Diseases OVERVIEW Hardly a day passes without news media coverage of one or another foodborne illness, and now there are new fears, that terrorists may tamper with America's food supply. Many bacteria (e.g., Campylobacter pylori, Escherichia coli 0157:H7, Salmonella enteri-

Before 1992, three exceptions existed to this definition; only one case of botulism, marine-toxin intoxication, or chemical intoxication was required to constitute an FBDO if the etiology for that type of FBDO was confirmed. This definition was changed in 1992; currently, two or more cases are required to constitute an outbreak.

tidis), and viruses (e.g., caliciviruses) cause foodborne illnesses. New pathogens continue to emerge (e.g., Sal-

monella typhimurium DTI04, Salmonella enteritidis phage type 4). Older conditions also continue to reemerge (e.g., salmonellosis from pet reptiles). Resistance of foodborne pathogens to antimicrobial agents is increasing. Some of the more significant illnesses include amebiasis, botulism, cryptosporidiosis, gastroenteritis, giardiasis, listeriosis, Norwalk-like viruses, salmonellosis, and trichinosis. Interest in the role of food and milk in outbreaks of intestinal illness has been the basis for public health action for over half a century. The reporting of foodborne diseases in the United States began over 60 years ago, when state and territorial health officers, concerned about the high morbidity and mortality caused by typhoid fever and infantile diarrhea, recommended cases of "enteric fever" be investigated and reported. The purpose of the investigation and reporting of these cases was to obtain information regarding the role of food, milk and water in outbreaks of intestinal illness as the basis for public health action. Beginning in 1925, the Public Health Service published summaries of outbreaks of gastrointestinal illness attributed to milk. In 1938, it added summaries of outbreaks caused by all foods. These early surveillance efforts led to the enactment of important public health measures (e.g., the Pasteurized Milk Ordinance) that led to decreased incidence of enteric diseases, particularly those transmitted by milk and water.l A foodborne disease outbreak (FBDO) is defined as the occurrence of two or more cases of a similar illness resulting from the ingestion of a common food.

SYMPTOMS AND PATHOLOGIES More than 250 foodborne diseases have been described. Symptoms vary widely depending on etiologic agent. Gastrointestinal symptoms are the most common, such as pain, nausea, vomiting, and serious diarrhea. The development of muscular symptoms often follows, as does fluid volume deficit. Sometimes infections cause no symptoms. Long-term consequences of infection also vary from disease to disease, as do pathologies.

DIAGNOSIS Laboratory or clinical guidelines for confirming an FBDO outbreak vary for bacterial, chemical, parasitic, and viral agents. Outbreaks of unknown etiology are divided into four subgroups according to incubation period of their illness: < 1 hour (probably chemical poisoning), 1-7 hours (probably Staphylococcus aureus or Bacillus cereus food poisoning), 8-14 hours (other agents), and greater than or equal to 15 hours (other agents).

TRANSMISSION Foodborne diseases are caused by the ingestion of contaminated food, with or without subsequent spread from person to person by the fecal-oral route. All persons are at risk; infants, the elderly, and the immuno-

176 Statistical Handbook on Infectious Diseases

compromised are at greatest risk of serious illness and death. Contamination may stem from the consumption of food that has not been cooked sufficiently to kill infection-causing agents, the consumption of unpasteurized milk and juice, and swimming in or drinking sewage-contaminated water. Organisms in diarrheal stools of infected persons can also be passed from one person to another if hygiene or handwashing habits are inadequate. Outbreak investigations are a critical means of identifying new and emerging pathogens as well as maintaining awareness about ongoing problems. However, the pathogen is not identified in many outbreaks because of delayed or incomplete laboratory investigation, inadequate laboratory capacity, or inability to recognize a pathogen as a cause of foodborne disease. Prompt and thorough investigations of foodborne outbreaks aid in the timely identification of etiologic agents and lead to appropriate prevention and control measures. SURVEILLANCE The CDC currently maintains two types of foodborne disease surveillance systems—one "passive," one "active." Under its passive system, begun in 1973, state and local public health departments have primary responsibility for identifying, investigating, and reporting foodborne disease outbreaks (FBDOs). Clinical laboratories report FBDOs to state health departments, which in turn report to CDC. At the regional and national levels, surveillance data provide an indication of the etiologic agents, vehicles of transmission, and contributing factors associated with FBDOs and help direct public health actions to reduce illness and death caused by FBDOs. This passive system has significant limitations. Only a fraction of the most common foodborne illnesses are routinely reported to CDC, because of the complex reporting system. In the mid-1990s the CDC established the Foodborne Diseases Active Surveillance Network (FoodNet), an active surveillance system. Under this system public health officials frequently contact laboratory directors to find new cases of foodborne diseases and report these cases electronically to CDC. In addition, FoodNet is designed to monitor each of the events that occurs along the foodborne diseases pyramid2 and thereby allow more accurate and precise estimates and interpretation of the burden of foodborne diseases over time. FoodNet is a collaborative project of the CDC, the U.S. Department of Agriculture (USDA), the Food and Drug Administration

(FDA), and several states. In 1995, FoodNet surveillance began in five locations: California, Connecticut, Georgia, Minnesota, and Oregon. Each year the surveillance area, or catchment, has expanded, with the inclusion of additional counties or additional sites (New York and Maryland in 1998, Tennessee in 2000, and Colorado in 2001). The total population of the current catchment, as of October 5, 2000, was 25.4 million persons, or 10% of the United States population. Information is being collected on every laboratorydiagnosed case of bacterial pathogens including Campylobacter, Escherichia coli 0157, Listeria monocytogenes, Salmonella, Shigella, Yersinia enterocolitica, and Vibrio and on parasitic organisms including Cryptosporidium and Cyclospora infections among residents of the catchment areas of the nine EIP sites. In addition to collecting laboratory-diagnosed cases of foodborne pathogens, investigators at FoodNet sites began active surveillance for hemolytic uremic syndrome (HUS) (a serious complication off. coli 0157 infection), Guillain-Barre syndrome (a serious complication of Campylobacter infection) and toxoplasmosis. The result is a comprehensive and timely database of foodborne illness in a well-defined population. FoodNet provides a network for responding to new and emerging foodborne diseases of national importance, monitoring the burden of foodborne diseases, and identifying the sources of specific foodborne diseases. Foodborne disease surveillance has served three purposes: (1) disease prevention and control; (2) knowledge of disease causation; and (3) administrative guidance. Resulting prevention and control measures include the early identification and removal of contaminated products from the commercial market, the correction of faulty food-preparation practices in food-service establishments and in the home, and the identification and appropriate treatment of human carriers of foodborne pathogens. Despite the fact that the pathogen is not identified in many outbreaks because of delayed or incomplete laboratory investigation, inadequate laboratory capacity, or inability to recognize a pathogen as a cause of foodborne disease, outbreak investigations are considered a critical means of identifying new and emerging pathogens as well as maintaining awareness about ongoing problems. The information derived from investigations of FBDOs enables assessment of trends over time in the prevalence of outbreaks caused by specific etiologic agents, food vehicles, and common errors in food handling. This information provides the basis for regulatory and other changes to improve food safety. The CDC's system has several limitations. First, the system excludes outbreaks that occur on cruise

F. Foodborne Diseases

ships; outbreaks in which food was eaten outside the United States, even if the illness occurred within the United States; and outbreaks that are traced to water intended for drinking. A second limitation is the classification of outbreaks by only one food vehicle. The CDC also does not include FBDOs in the surveillance system if the route of transmission from the contaminated food to the infected persons is indirect. Finally, there are no standard criteria for classifying a death as being FBDOrelated. This determination is made by the reporting agency. From 1951 through 1960, the National Office of Vital Statistics reviewed reports of outbreaks of foodborne illness and published annual summaries in Public Health Reports. In 1961, CDC—then the Communicable Disease Center—assumed responsibility for publishing reports concerning foodborne illness. During 1961-1965, CDC discontinued publication of annual reviews but reported pertinent statistics and detailed individual investigations in MMWR: Morbidity and Mortality Weekly Report. In 1966, the present system of surveillance of foodborne and waterborne diseases began with the incorporation of all reports of enteric-disease outbreaks attributed to microbial or chemical contamination of food or water into an annual summary. Since 1978, because of increasing interest and activity in waterborne disease surveillance, foodborne and waterborne disease outbreaks have been reported in separate annual summaries. Summaries of foodborne disease outbreaks (FBDOs) have been published for the years 1983-1987, 1988-1992, and 1993-1997.3

TABLE OVERVIEW F1.1-F1.6. Foodborne Diseases by Etiology This suite of tables shows the number of reported foodborne-disease outbreaks, cases, and death by etiology for 1993 through 1997, the most recent data available. The CDC tables do not isolate data for foodborne disease caused by infectious agents. The tables in this section also include outbreaks and cases traced to chemical agents as well. Fl.l provides totals for the 5-year period; F1.2-F1.6 provide totals for each of the 5 years. During 1993-1997, a total of 2,751 outbreaks of foodborne disease were reported. These outbreaks caused a reported 86,058 persons to become ill. Among outbreaks for which the etiology was determined, bacterial pathogens caused the largest percentage of outbreaks (75%) and the largest percentage of cases (86%). Salmonella serotype enteritis accounted for the largest

177

number of outbreaks, cases, and deaths; most of these outbreaks were attributed to eating eggs. F2.1-F2.5. Foodborne Diseases by Etiology and Month of Occurrence The next suite of tables shows the number of reported foodborne-disease outbreaks by etiology and month of occurrence for each of the five years between 1993 and 1997. Again, these tables include data on chemical as well as infectious agents. A large portion of the outbreaks occurred from May through November in each of the years included. F3.1-F3.5. Foodborne Diseases by Place Where Food Was Eaten The focus of the next cluster is the place where food was eaten, such as private residence; delicatessen, cafeteria, or restaurant; school; picnic; church; or camp. Primary residences and delicatessens/ restaurants account for most outbreaks. F4.1-F4.5. Vehicle of Transmission This cluster offers data on the food source of disease, either individual food items (e.g., milk or eggs) or food categories (e.g., ice cream or multitype vehicles). The value of the data is limited because the CDC identifies only one food vehicle per outbreak. F5.1-F5.5. Etiology and Contributing Factors This cluster presents data on outbreaks by etiology and contributing factors, such as improper holding temperatures, inadequate cooking, contaminated equipment, food from unsafe source, or poor personal hygiene, for 1993 through 1997. Improper holding temperature is the largest contributing factor, followed by poor personal hygiene. F6.l-F6.10. Significant Foodborne Diseases The last cluster in this chapter presents maps and graphs on seven significant foodborne diseases: botulism, Cryptosporidiosis, E. coli, hemoloytic uremic syndrome, salmonella, Salmoneilosis, Shigella, Shigellosis and trichinosis. NOTES 1. Sonja J. Olsen et al., "Surveillance for Foodborne-Disease Outbreaks— United States, 1993-1997," Morbidity and Mortality Weekly Report 49, no. SS-1 (March 2000): 2. 2. The burden of foodborne diseases pyramid consists of 7 layers or components—exposures in the general population; person becomes ill; person seeks care; specimen obtained; lab tests for organism; cultureconfirmed case; reported to health department/CDC See http://www. cdc.gov/foodnet/what_is.htm 3. Centers for Disease Control and Prevention, "Foodborne Disease Outbreaks, 5-Year Summary, 1983-1987," MMWR: Morbidity and Mortality Weekly Report 39, no. SS-1 (1990): 15-57; Centers for Disease Control and Prevention, "Surveillance for Foodborne-Disease Outbreaks—United States, 1988-1992," MMWR: Morbidity and Mortality Weekly Report 45, no. SS-5 (1996): 1-66; Centers for Disease Control and Prevention, "Surveillance for Foodborne-Disease Outbreaks— United States, 1993-1997," MMWR: Morbidity and Mortality Weekly Report 49, no. SS-1 (2000): 1-64.

1 78

Statistical Handbook on Infectious Diseases

Table F1.1. Number of Reported Foodborne-Disease Outbreaks, Cases, and Deaths, by Etiology—United States* 1993-1997* Outbreaks Etiology

No.

(%)

Cases

Deaths (%)

No.

( 0.8) ( 0.0) ( 0.6) ( 0.1) ( 3.2) ( 3.8) ( 0.1) ( 37.9) ( 1.8) ( 1.6) ( 0.1) ( 0.0) < 0.0) ( 0.0) ( 0.0) ( 0.7) ( 50.9)

0 0 1 1 0 8 2 13 0 1 0 0 0 0 1 1 28

No.

(%)

Bacterial Bacillus cereus Brucella Campylobacter Clostridiunn botulinum Clostridium perfringens Escherichia coli Listeria monocytogenes Salmonella Shigella Staphylococcus aureus Streptococcus, group A Streptococcus, other Vibrio cholerae Vibrio parahaemolyticus Yersinia enterocolitica Other bacterial Total bacterial

14 1 25 13 57 84 3 357 43 42 1 1 1 5 2 6 655

( 0.5) ( 0.0) ( 0.9) ( 0.5) ( 2.1) ( 3.1) ( 0.1) ( 13.0) ( 1.6) ( 1.5) ( 0.0) ( 0.0) ( 0.0) ( 0.2) < 0.1) ( 0.2) ( 23.8)

691 19 539 56 2,772 3,260 100 32,610 1,555 1,413 122 6 2 40 27 609 43,821

Chemical Ciguatoxin Heavy metals Monosodium glutamate Mushroom poisoning Scombrotoxin Shellfish Other chemical Total chemical

60 4 1 7 69 1 6 148

( 2.2) ( 0.1) ( 0.0) ( 0.3) < 2.5) ( 0.0) ( 0.2) ( 5.4)

205 17 2 21 297 3 31 576

( ( ( ( ( ( ( (

0.2) 0.0) 0.0) 0.0) 0.3) 0.0) 0.0) 0.7)

0 0 0 0 0 0 0 0

( 0.0) ( 0.0) ( 0.0) ( 0.0) ( 0.0) ( 0.0) ( 0.0) ( 0.0)

0.1) 0.1) 0.5) 0.7)

45 19 2,261 2,325

( ( ( (

0.1) 0.0) 2.6) 2.7)

0 0 0 0

( ( ( (

Parasitic Giardia lamblia Trichinella spiralis Other parasitic Total parasitic

4 2 13 19

( ( ( (

( ( ( ( ( ( I ( ( ( ( ( ( ( ( ( (

0.0) 0.0) 3.4) 3.4) 0.0) 27.6) 6.9) 44.8) 0.0) 3.4) 0.0) 0.0) 0.0) 0.0) 3.4) 3.4) 96.6)

0.0) 0.0) 0.0) 0.0)

Viral Hepatitis A Norwalk Other viral Total viral Confirmed etiology Unknown etiology

23 9 24 56 878 1,873

( 0.8) ( 0.3) ( 0.9) ! 2.0) ( 31.9) < 68.1)

729 1,233 2,104 4,066 50,788 35,270

( 0.8) ( 1.4) ( 2.4) I 4.7) ( 59.0) < 41.0)

0 0 0 0 28 1

( 0.0) ( 0.0) ( 0.0) ( 0.0) ( 96.6) ( 3.4)

Total 1993-1997

2,751

(100.0)

86,058

(100.0)

29

(100.0)

"Includes Guam, Puerto Rico, and the U.S. Virgin Islands. 'Totals might vary by < I % from summed components because of rounding. Source: Center for Disease Control and Prevention, U.S. Department of Health and Human Services. MMWR: Morbidity and Mortalit\ Weekl\ Review CDC Surveillance Summaries Surveillance for Foodborne-Disease Outbreaks United States, 1993-1997 49 No. SS-1 (2000). http://www.cdc.gov/mmwr/ PDF/ss/ss4901.pdf.

F. Foodborne Diseases

179

Table F1.2. Number of Reported Foodborne-Disease Outbreaks, Cases, and Deaths, by Etiology—United States? 1993* Outbreaks Etiology

No.

(%)

Bacterial Bacillus cereus Campylobacter Clostridium botulinum Clostridium perfringens Escherichia coli Salmonella Shigella Staphylococcus aureus Streptococcus, other Vibrio parahaemolyticus Other bacterial Total bacterial

4 6 5 15 15 68 9 7 1 1 4

< 0.8) ( 1.2) ( 1.0) ( 3.1) ( 3.1) ( 13.9) ( 1.8) < 1.4) ( 0.2) ( 0.2) ( 0.8)

Chemical Ciguatoxin Heavy metals Mushroom poisoning Scombrotoxin Other chemical Total chemical Parasitic Trichinella spiralis Other parasitic Total parasitic

135

( 27.6)

Deaths

Cases

No.

(%)

188 110 17 534 1,340 7,122 338 355 6 4 388 10,402

< ( ( ( ( ( ( ( < ( ( (

1.1) 0.6) 0.1) 3.1) 7.7) 40.8) 1.9) 2.0) 0.0) 0.0) 2.2) 59.5)

No. 0 0 1 0 5 1 0 1 0 0

(%)

( (

0.0) 0.0)

1

( ( ( ( ( ( ( (

0.0) 55.6) 11.1) 0.0) 11.1) 0.0) 0.0) 11.1)

9

(100.0)

( 11.1)

13 1 1 5 1 21

( ( < ( ( (

2.7) 0.2) 0.2) 1.0) 0.2) 4.3)

44 6 2 21 2 75

( ( ( ( ( (

0.3) 0.0) 0.0) 0.1) 0.0) 0.4)

0 0 0 0 0 0

( ( ( ( ( (

0.0) 0.0) 0.0) 0.0) 0.0) 0.0)

1 1

( ( (

0.2) 0.2) 0.4)

10 6

0.1) 0.0) 0.1)

0 0 0

{ (

0.0) 0.0)

16

( ( (

(

0.0)

81 45 631 757 11,250 6,227

( 0.5) ( 0.3) ( 3.6) ( 4.3) ( 64.4) ( 35.6)

0 0 0 0 9 0

( 0.0) < 0.0) ( 0.0) ( 0.0) (100.0) ( 0.0)

17,477

(100.0)

9

(100.0)

2

Viral Hepatitis A Norwalk Other viral Total viral Confirmed etiology Unknown etiology

168 321

( 1.0) ( 0.2) ( 0.8) I 2.0) ( 34.4) ( 65.6)

Total 1993

489

(100.0)

5 1 4 10

*Includes Guam, Puerto Rico, and the U.S. Virgin Islands. 'Totals might vary by < 1 % from summed components because of rounding. Source: Center for Disease Control and Prevention. U.S. Department of Health and Human Services. MMWR: Morbidity and Mortality Weekly Review CDC Surveillance Summaries Surveillance for Foodborne-Disease Outbreaks United States, 1993-1997 49 No. SS-1 (2000). http://www.cdc.gov/mmwr/ PDF/ss/ss4901.pdf.

180 Statistical Handbook on Infectious Diseases

Table F1.3. Number of Reported Foodborne-Disease Outbreaks, Cases, and Deaths, by Etiology—United States* 1994+

Outbreaks Etiology Bacterial Bacillus cereus

Campylobacter

Clostridium botulinum Clostridium perfringens Escherichia coli

Listeria monocytogenes

Salmonella

Shigella Staphylococcus aureus Vibrio cholerae Yersinia enterocolitica Total bacterial Chemical Ciguatoxin Heavy metals Monosodium glutamate Scombrotoxin Other chemical Total chemical Parasitic Giardia

lamblia

No.

(%)

3 6 3 12 25 3 70 11 13 1 1 148

( 0.5) ( 0.9) ( 0.5) ( 1.8) ( 3.8) ( 0.5) ( 10.7) ( 1.7) ( 2.0) ( 0.2) ( 0.2) ( 22.7)

Deaths

Cases (%)

No.

(%)

( 0.1) ( 0.6) ( 0.2) ( 3.2) ( 5.6) ( 0.6) ( 17.6) ( 3.3) ( 2.6) ( 0.0) ( 0.0) ( 33.8)

0 0 0 0 0 2 1 0 0 0 0 3

( 0.0) ( 0.0) ( 0.0) ( 0.0) ( 0.0) ( 66.7) ( 33.3) ( 0.0) ( 0.0) ( 0.0) ( 0.0) (100.0)

No. 19 97 27 517 902 100 2,858 534 421 2 10 5,487

11 2 1 21 2 37

( ( ( ( ( (

1.7) 0.3) 0.2) 3.2) 0.3) 5.7)

54 8 2 83 14 161

( ( ( ( ( (

0.3) 0.0) 0.0) 0.5) 0.1) 1.0)

0 0 0 0 0 0

( ( ( ( ( (

0.0) 0.0) 0.0) 0.0) 0.0) 0.0)

2

(

0.3)

22

(

0.1)

0

(

0.0)

Viral Hepatitis A Norwalk Other viral Total viral Confirmed etiology Unknown etiology

6 1 3 10 197 456

( 0.9) ( 0.2) ( 0.5) ( 1.6) ( 30.2) ( 69.8)

310 34 268 612 6,282 9,952

( 1.9) ( 0.2) ( 1.7) ( 3.8) ( 38.7) ( 61.3)

0 0 0 0 3 0

( 0.0) ( 0.0) ( 0.0) ( 0.0) (100.0) ( 0.0)

Total 1994

653

(100.0)

16,234

(100.0)

3

(100.0)

^Includes Guam, Puerto Rico, and the U.S. Virgin Islands. totals might vary by < 1 % from summed components because of rounding. Source: Center for Disease Control and Prevention. U.S. Department of Health and Human Services. MMWR: Morbidity and Mortality Weekly Review CDC Surveillance Summaries Surveillance for Foodborne-Disease Outbreaks United States, 1993-1997 49 No. SS-1 (2000). http://www.cdc.gov/mmwr/ PDF/ss/ss4901.pdf.

F Foodborne Diseases

181

Table F1A Number of Reported Foodborne-Disease Outbreaks, Cases, and Deaths, by Etiology—United States? 1995+

Etiology Bacterial Bacillus cereus Campylobacter

Clostridium botulinum Clostridium perfringens

Escherichia coli Salmonella Shigel la Staphylococcus aureus Yersina enterocolitica Other bacterial Total bacterial Chemical Ciguatoxin Heavy metals Scombrotoxin Other chemical Total chemical Parasitic Trichinella

spiralis

No.

(%)

2 6 2 14 25 90 7 6 1 2 155

( 0.3) ( 1.0) ( 0.3) ( 2.2) ( 4.0) ( 14.3) ( 1.1) ( 1.0) ( 0.2) ( 0.3) ( 24.7)

Deaths

Cases

Outbreaks

(%)

No.

(%)

( 0.1) ( 0.7) ( 0.0) ( 2.6) ( 2.2) ( 47.5) ( 1.5) ( 0.4) ( 0.1) ( 1.2) ( 56.3)

0 0 0 0 1 9 0 0 1 0 11

( 0.0) ( 0.0) ( 0.0) ( 0.0) ( 9.1) ( 81.8) ( 0.0) ( 0.0) ( 9.1) ( 0.0) (100.0)

No. 24 127 6 455 393 8,449 259 66 17 221 10,017

10 1 16 2 29

( ( ( ( (

1.6) 0.2) 2.5) 0.3) 4.6)

27 3 91 12 133

( ( ( ( (

0.2) 0.0) 0.5) 0.1) 0.7)

0 0 0 0 0

( ( ( ( (

0.0) 0.0) 0.0) 0.0) 0.0)

1

(

0.2)

9

(

0.1)

0

(

0.0)

Viral Hepatitis A Norwalk Other viral Total viral Confirmed etiology Unknown etiology

4 4 1 9 194 434

( 0.6) ( 0.6) ( 0.2) ( 1.4) ( 30.9) ( 69.1)

38 433 41 512 10,671 7,129

( 0.2) ( 2.4) ( 0.2) ( 2.9) ( 59.9) ( 40.1)

0 0 0 0 11 0

( 0.0) ( 0.0) ( 0.0) ( 0.0) (100.0) ( 0.0)

Total 1995

628

(100.0)

17,800

(100.0)

11

(100.0)

^Includes Guam, Puerto Rico, and the U.S. Virgin Islands. 'Totals might vary by < 1 % from summed components because of rounding. Source: Center for Disease Control and Prevention. U.S. Department of Health and Human Services. MMWR: Morbidity and Mortality Weekly Review CDC Surveillance Summaries Surveillance for Foodborne-Disease Outbreaks United States, 1993-1997 49 no. SS-1 (2000). http://www.cdc.gov/mmwr/ PDF/ss/ss4901.pdf.

182

Statistical Handbook on Infectious Diseases

Table F1.5. Number of Reported Foodborne-Disease Outbreaks, Cases, and Deaths, by Etiology—United States? 1996*

(%)

No.

(%)

( 0.1) ( 0.1) ( 0.4) ( 0.0) ( 4.5) ( 1.4) ( 55.1) ( 0.5) ( 0.8) ( 62.9)

0 0 0 0 0

2 0 0 3

( 0.0) ( 0.0) ( 0.0) < 0.0) ( 0.0) ( 25.0) ( 50.0) ( 0.0) ( 0.0) ( 75.0)

32 10 37 3 3 85

( ( ( ( ( (

0.1) 0.0) 0.2) 0.0) 0.0) 0.4)

0 0 0 0 0 0

( ( ( ( ( (

0.2) 0.4) 0.6)

6 1,582 1,588

( ( (

0.0) 7.0) 7.0)

0 0 0

( 0.0) ( 0.0) ( 0.0)

1.0) 0.6) 0.4) 2.1) 31.7) 68.3)

126 721 573 1,420 17,312 5,295

( ( ( ( ( (

0.6) 3.2) 2.5) 6.3) 76.6) 23.4)

0 0 0 0 3

1

( 0.0) ( 0.0) ( 0.0) ( 0.0) ( 75.0) ( 25.0)

(100.0)

22,607

(100.0)

4

(100.0)

Etiology

No.

Bacterial Bacillus cereus Brucella Campylobacter Clostridium botulinum Clostridium perfringens Escherichia coli Salmonella Sh/gella Staphylococcus aureus Total bacterial

1 1 5 2 10 11 69 6 7 112

( ( ( ( ( ( ( ( ( (

0.2) 0.2) 1.0) 0.4) 2.1) 2.3) 14.5) 1.3) 1.5) 23.5)

22 19 101 4 1,011 325 12,450 109 178 14,219

9 3 12 1 1 26

( ( ( ( ( (

1.9) 0.6) 2.5) 0.2) 0.2) 5.5)

1 2 3

( ( (

Hepatitis A Norwalk Other viral Total viral Confirmed etiology Unknown etiology

5 3 2 10 151 326

( ( ( ( ( (

Total 1996

477

Chemical Ciguatoxin Mushroom poisoning Scombrotoxin Shellfish Other chemical Total chemical Parasitic Giardia lamblia Other parasitic Total parasitic

Deaths

Cases

Outbreaks (%)

No.

1

0.0) 0.0) 0.0) 0.0) 0.0) 0.0)

Viral

*Includes Guam, Puerto Rico, and the U.S. Virgin Islands. Totals might vary by < I % from summed components because of rounding. Source: Center for Disease Control and Prevention. U.S. Department of Health and Human Services. MMWR: Morbidity and Mortality Weekly Review CDC Sun-eillance Summaries Surveillance for Foodborne-Disease Outbreaks United States, 1993-1997 49 no. SS-1 (2000). http://www.cdc.gov/mmwr/ PDF/ss/ss4901.pdf.

F Foodborne Diseases

183

Table F1.6. Number of Reported Foodborne-Disease Outbreaks, Cases, and Deaths, by Etiology—United States* 1997+ Outbreaks Etiology Bacterial Bacillus cereus

Campylobacter

Clostridium perfringens Clostridium

botulinum

Escherichia coli Salmonella

Shigella

Staphylococcus aureus Streptococcus, group A Vibrio parahaemolyticus Total bacterial

No.

(%)

4 2 1 6 8 60 10 9 1 4 105

( 0.8) ( 0.4) ( 0.2) ( 1.2) ( 1.6) ( 11.9) ( 2.0) ( 1.8) ( 0.2) ( 0.8) ( 20.8)

Cases No. 438 104 2 255 300 1,731 315 393 122 36 3,696

Deaths (%)

No.

(%)

( 3.7) ( 0.9) ( 0.0) ( 2.1) ( 2.5) ( 14.5) ( 2.6) ( 3.3) ( 1.0) ( 0.3) (31.0)

0 1 0 0 1 0 0 0 0 0 2

( 0.0) ( 50.0) ( 0.0) ( 0.0) ( 50.0) ( 0.0) ( 0.0) ( 0.0) ( 0.0) ( 0.0) (100.0)

Chemical Ciguatoxin Mushroom poisoning Scombrotoxin Total chemical

17 3 15 35

( ( ( (

3.4) 0.6) 3.0) 6.9)

48 9 65 122

( ( ( (

0.4) 0.1) 0.5) 1.0)

0 0 0 0

( ( ( (

Parasitic Giardia lamblia Other parasitic Total parasitic

1 10 11

( 0.2) ( 2.0) ( 2.2)

17 673 690

( 0.1) ( 5.6) ( 5.8)

0 0 0

( 0.0) ( 0.0) ( 0.0)

Viral Hepatitis A Other viral Total viral Confirmed etiology Unknown etiology

3 14 17 168 336

( 0.6) ( 2.8) ( 3.4) ( 33.3) ( 66.7)

174 591 765 5,273 6,667

( 1.5) ( 4.9) ( 6.4) ( 44.2) ( 55.8)

0 0 0 2 0

( 0.0) ( 0.0) ( 0.0) (100.0) ( 0.0)

Total 1997

504

(100.0)

11,940

(100.0)

2

(100.0)

0.0) 0.0) 0.0) 0.0)

^Includes Guam, Puerto Rico, and the U.S. Virgin Islands. 'Totals might vary by < 1% from summed components because of rounding. Source: Center for Disease Control and Prevention. U.S. Department of Health and Human Services. MMWR: Morbidity and Mortality Weekly Review CDC Surveillance Summaries Surveillance for Foodborne-Disease Outbreaks United States, 1993-1997 49 no. SS-1 (2000). http://www.cdc.gov/mmwr/ PDF/ss/ss4901.pdf.

Table F2.1. Number of Reported Foodborne-Disease Outbreaks, by Etiology and Month of Occurrence—United States* 1993

Month of occurrence | Etiology Bacterial Bacillus cereus Campylobacter

Clostridium botulinum

Clostridium perfringens

Escherichia coli Salmonella Shigella Staphylococcus a u re us Streptococcus, other Vibrio parahaemolyticus Other bacterial Total bacteria!

Jan

— — — — 1 5 1 1

— — — 8

Chemical Ciguatoxin Heavy metals Mushroom poisoning Scombrotoxin Other chemical Total chemical

— — — — — —

Parasitic Trichinella spiral is Other parasitic Total parasitic

— — —

Viral Hepatitis A Norwalk Other viral Total viral Confirmed etiology Unknown etiology

1 1 9 20

Total 1993

29

— —

Feb

— — — 1

— 4

— — — — —

Mar

— — — 4 2 7

— 1

— —

5

1 15

1



— — 2



1

— — —

Apr

May

Jun

Jul

Aug

Sep

Oct

Nov

Dec

1

— —

— — —

2



1 1







__ — __

— — 3 2 4 2

— — —

1

— — 7 1 1



1

— 4 1 2

1 1 4 8

— —

1 13



11

— __ — 8

1 18

1

3

1

— — — —

— — —

— — — —

1

1 4

1



__ 1 1 3 1

— — —

— — —

— — — — —

10

1

3

2

— —

— — — —

— —

3

4

— — — — — —

— — —

— — —



— — — —-

— — — —

2



— — —

— — —

— 1 1

— — —

— — —

__ __ —

1

— — — —

— — — —

— — — —

1

1

— —

— —

1 9 13

— — — — 16 28

15 27

15 39

22

44

42

54

— __

3 15 3 1

25

1

1



1 1 2 1 5

1 9

3

1

2 1

3

1 1

1 1

Total

3

4 6 5 15 15 68 9 7 1 1 4 135

— __ — — 1

— — — — — —

13 1 1 5 1 21

— — —

__ __ —

1 1 2

— —

1 1 4 38

5 1 4 10 168 321

42

489 |

2 1 1 1 4

— 1

— — — 10

1

9 33

1 22 26

1 13 23

29 22

11 22

2 1 2 5 16 30

42

48

36

51

33

46

1

— 2

— __ — — —

^Includes Guam, Puerto Rico, and the U.S. Virgin Islands. Source: Center for Disease Control and Prevention. U.S. Department of Health and Human Services. MMWR: Morbidity and Mortality Weekly Review CDC Surveillance Summaries Surveillance for Foodborne-Disease Outbreaks United States, 1993-1997'49 no. SS-1 (2000). http://www.cdc.gov/mmwr/PDF/ss/ss4901.pdf.

Table F2.2. Number of Reported Foodborne-Disease Outbreaks, by Etiology and Month of Occurrence -United States* 1994 Month of occurrence Etiology Bacterial Bacillus cereus Campylobacter

Clostridium botulinum

Clostridium perfringens Escherichia coli Listeria monocytogenes Salmonella Shigella Staphylococcus aureus Vibrio cholera Yersinia enterocolitica Total bacterial

Chemical Ciguatoxin Heavy metals Monosodium glutamate Scombrotoxin Other chemical Total chemical Parasitic Giardia lamblia Viral Hepatitis A Norwalk Other viral Total viral Confirmed etiology Unknown etiology Total 1994

Jan

Feb

— — —

— — __ —

1 1



2

Mar

— — — 1

Apr

— —

Aug

1





1 1 1

—__ —

Oct

Nov

Dec

Total

1

— — —

— —

— — —



— —

3 6 3 12 25 3 70 11 13 1 1 148

— — —

— —

— — —

— —

— —

12

29

18

18

13

1 14

4

3





— — —





7

3

— — — — — —

2 1

1 2

— — — —







1

1

1

— —

— —

— —

1 20 55

1 33 33

75

66





— — —

— — — —



2

4

7

— — —

— — —

— — —

1







2

2

1 2 3

— —







— — — —



— — — —

1 2

1

Sep

2

— —

3

2

Jul

— —

1 1 1

— — — —

2

Jun

3 1 4 7 1 6 4 3

— — — — — —

1

May

4

1

2

5 17

1 1 2 6 32

7 33

1 10 46

22

38

40

56

1

8

— — 4

— 11 2

— — — 13

5

— 6





2

1

1 1 2 9

— — —

1

1 3 6 3 2

3

5

__ 3 1

— —



16

12

— —

— — —











6

3

5

2

2

11 2 1 21 2 37

2











2

— — — —

1

1

1

— —

— —

— —

— —

20 35

1 25 34

1 17 31

1 20 38

_ — — — 18 36

2 2 16 66

6 1 3 10 197 456

55

59

48

58

54

82

653

3

3

1

4

2

1

— 1

includes Guam, Puerto Rico, and the U.S. Virgin Islands. Source: Center for Disease Control and Prevention. U.S. Department of Health and Human Services. MMWR: Morbidity and Mortality Weekly Review CDC Surveillance Summaries Surveillance for Foodborne-Disease Outbreaks United States, 1993-1997'49 no. SS-1 (2000). http://www.cdc.gov/mmwr/PDF/ss/ss4901.pdf.

Table F2.3. Number of Reported Foodborne-Disease Outbreaks, by Etiology and Month of Occurrence—United States* 1995 Month of occurrence Etiology Bacterial Bacillus cereus Campylobacter

Clostridium botulinum Clostridium perfringens

Escherichia coli Salmonella Shigella Staphylococcus aureus Yersinia enterocolitica Other bacterial Total bacterial

Chemical Ciguatoxin Heavy metals Scombrotoxin Other chemical Total chemical Parasitic Trichinella spiralis

Jan

Feb

Mar

Apr

— — —

— — —

— __ —

— — —





— 4 2

2 1 6 2

— — —

— — —

— — __

— — __ 11

1 12

1

— —

2





— —

— —









__

1

7 1

9

1

1

3 1

5

1

2

1

1



1

7

2

1

2 2 7

__ — —

Jul





— —

— —

1

4 9

— — — __

14

2

6 12 1 2

— —

23

— — —

— — —

— —



1

— 4 19

— — —

1 26

— — — —

— 1 2 8

— 2

— —

4 3 3

1



14

16

11

1

1

1 1 3

— —



















1

— — — —

— — — —

— — — —

1 1

2 2

26 36

64

51

62

59

1 2

1 1 1 2 9

— —

15 36

52



2 1 1

1 15 49

36

1



2

— —— —

47

Dec



— — — —

Total 1995

Nov

1



11 41

Oct





6 30

Sep

1



1 13 34

Aug

— — —

1

1 1 1 3 15 44

_

— — —

Jun

4

Viral Hepatitis A Norwalk Other viral Total viral Confirmed etiology Unknown etiology

1

May

— —

3

4

1 1 3 2

— — 7

1

Total 2 6 2 14 25 90 7 6 1 2 155

2

4

1 2

10 1 16 2 29

__





1

1

— — — —



2

4

— —

29 30

2 20 18

1 19 34

15 45

1 10 37

4 4 1 9 194 434

59

38

53

60

47

628



__ _

1



includes Guam, Puerto Rico, and the U.S. Virgin Islands. Source: Center for Disease Control and Prevention. U.S. Department of Health and Human Services. MMWR: Morbidity and Mortality Weekly Review CDC Surveillance Summaries Surveillance for Foodborne-Disease Outbreaks United States, 1993-1997 49 no. SS-1 (2000). http://www.cdc.gov/mmwr/PDF/ss/ss4901.pdf.

Table F2.4. Number of Reported Food borne-Disease Outbreaks, by Etiology and Month of Occurrence -United States* 1996 Month of occurrence Etiology Bacterial Bacillus cereus Brucella Campylobacter Ctostridium botul'mum Clostridium perfringens Escherichia coli Salmonella Sbigetta Staphyiococcus aureus Total bacterial Chemical Ciguatoxin Mushroom poisoning Scombotoxin Shellfish Other chemical Total chemical

Jan

Feb

Mar

Apr

Total 1996

Jun

Jul

Aug

Sep

Oct

Nov

Dec

Total

3

2

4

5

1 0

1 1 5 2 10 1 1 69 6 7

7

1 1 1 3 1

2

1 1 3 5 2

4

4

2

4

2 7

6

4

12

1

1

1

3 1 1

1

1 5

5

1 3

Parasitic Giardia lamblta Other parasitic Total parasitic Viral Hepatitis A Norwalk Other viral Staphyiococcus aureus Confirmed etiology Unknown etiology

May

1

2 1

1 1

1 1

3 12

18

2 4

3 4

12 1

10 2

U

1 14

1 7

2 9

1

1

1

1

1

1

3 1

1

2

2 1

1

2

5

2

3

3

1 1 2

1 1

3 1

2

7 27

1 1 13 21

2 8 27

34

34

35

7 33

1 1 15 36

19 37

16 27

19 29

11 24

40

51

56

43

48

35

112 9 3 1 2 1 1 2 6 1 2 3

2 2

1

3

1 1

5 3 2 10

12 14

13 30

11 21

151 326

26

43

32

477

*lndjdes Guam, Puerto Ricu, anil ihc U.S. Virgin Islands. Source: Center for Disease Control and Prevention. U.S. Department of Health and Human Services. MMWR: Morbidity and Mortality Weekly Review CDC Surveillance Summaries Surveillance for FooMorne-Disease Outbreaks United States, 199J-199741) No. SS-1 f2(XX», http://www.cdc.gov/mmwr/PDF/ss/ss490l.pdf.

Table F2.5. Number of Reported Foodborne-Disease Outbreaks, by Etiology and Month of Occurrence -United States* 1997 Month of occurrence Etiology

Jan

Feb

Mar

Apr

May

Jun

— — — — — 5 _ 1 — — 6

— — — 1 4 6 _ — — — 11

2 — 3

1 — 3_

Jul

Aug

Sep

— — — — — 5 1 — — 1 7

— 1 — — — 10 3 3 — 1 18

1 — — — — 6

1 —

4

Oct

Nov

Dec

2 — 2 13

— — — — — 211 — — 1 — 3

— — — — — 11 2 2 — — 15

2 — — — 1 — 1 1 — — 5

4 2 1 6 8 60 1 0 9 1 4 105

1 1 -\

6 — 3

— — 2

3 1 —

— — 2

1 7 3 15

1

3

9

4

2

Bacterial Bacillus cereus Campylobacter Clostridium botulinum Clostridium perfringens Escherichia coli Salmonella Shigella Staphylococcus aureus Streptococcus, group A Vibrio parahaemolyticus Total bacterial

— — — 1 — 5 ___ — — — 6

— — 1 — — 5

1 1 — 1 1 3

— — — 6

— — — 7

— — — 3 2 2 1 — — — 8

Chemical Ciguatoxin Mushroom poisoning Scombrotoxin Total chemical

2 1 __ 3

1 —

— — 1

— — _

1

1

Parasitic Giardia lamblia Other parasitic Total parasitic

— — —

— — —

1 1 2

— 2 2

— 4 4 —

— —

— 1 1

— — —

— — —

— 1— 1 —



— 3

1 2



1 1

1 2 3





— 1 1

— 2

5

2

2

Viral Hepatitis A Other viral Total viral Confirmed etiology Unknown etiology

3

— 1 1

3

— 1 1

12 29

8 23

13 37

11 38

15 33

2 17 32

12 16

21 30

22 14

7 31

Total 1997

41

31

50

49

48

49

28

51

36

38

— 1 1

Total

3 5

1 1

1 0 1

2

— 1 1

3 14 17

21 26

9 27

168 336

47

36

504

includes Guam, Puerto Rico, and the U.S. Virgin Islands. Source: Center for Disease Control and Prevention. U.S. Department of Health and Human Serviees. MMWR: Morbidity and Mortality Weekly Review CDC Surveillance Summaries Surveillance for Foodborne-Disease Outbreaks United States. 1993-199749 No. SS-1 (2000). http://www.cdc.gov/mmwr/PDF/ss/ss4901.pdf.

Table F3.1. Number of Reported Foodborne-Disease Outbreaks, by Etiology and Place Where Food was Eaten—United States? 1993 Place where food was eaten

Etiology

Delicatessen, Private cafeteria, or residence restaurant

School

Picnic

Church

Camp

Other

Bacterial Bacillus cereus Campylobacter Clostridium botulinum Clostridium perfringens Escherichia coli Salmonella Shigella Staphylococcus aureus Streptococcus, other Vibrio parahaemo/yt/cus Other bacterial Total bacterial

— — 4 2 1 9 2 — 1 — 1 20

1 4 — 6 4 26 4 1 — — 2 48

— — — — — 2 _ 2 — — — 4

— — — 1 1 — _ — — — — 2

— — — 1 1 4 _ — — — — 6

— — — — — 2 _ — — — — 2

3 2 — 5 8 24 3 47 — — 1 50

Chemical Ciguatoxin Heavy metals Mushroom poisoning Scombrotoxin Other chemical Total chemical

11 — 1 1 — 13

1 — — 4 1 6

— — — — — —

— — — — — —

— — — — — —

— — — — — —

Parasitic Trichinellaspiralis Other parasitic Total parasitic

— 1 1

— — —

— — —

— — —

— — —

Viral Hepatitis A Norwalk Other viral Total viral Confirmed etiology Unknown etiology

— — — — 34 53

2 — — 2 56 168

— — 1 1 5 9

1 — — 1 3 7

Total 1993

87

224

14

10

Known place

Total

1 — 4 132

— — 1 — — 1 _ — — 1 — 3

4 6 5 15 15 68 9 7 1 1 4 135

— 1 — — — 1

12 1 1 5 1 20

1 — — — — 1

13 1 1 5 1 21

— — —

1 — 1

1 1 2

— — —

1 1 2

— — — — 6 8

— — — — 2 3

2 1 3 6 58 68

5 1 4 10 164 316

— — — — 4 5

5 1 4 10 168 321

14

5

480

9

489

126

4 6 4 15 15 67 9

Unknown place

''Includes Guam, Puerto Rico, and the U.S. Virgin Islands. Source: Center for Disease Control and Prevention. U.S. Department of Health and Human Services. MMWR: Morbiditv and Mortality Weekly Review CDC Surveillance Summaries Surveillance for Foodborne-Disease Outbreaks United States, 1993-1997 49 No. SS-1 (2000). http://www.cdc.gov/mmwr/PDF/ss/ss4901.pdf.

Table F3.2. Number of Reported Foodborne-Disease Outbreaks, by Etiology and Place Where Food was Eaten—United Statesf 1994 Place where food was eaten

Etiology

Delicatessen, Private cafeteria, or residence restaurant

Bacterial Bacillus cereus Campy/obacter Clostridium botulinum Clostridium perfringens Escherichia coli Listeria monocytogenes Salmonella Shigella Staphylococcus aureus Vibrio cholera Yersinia enterocolitica Total bacterial

— 1 1 — 82 — 8 3 2 1 1 25

Chemical Ciguatoxin Heavy metals Monosodium gluatamate Scombrotoxin Other chemical Total chemical Parasitic Giardia lamblia Viral Hepatitis A Norwalk Other viral Total viral Confirmed etiology Unknown etiology Total 1994

Picnic

Church

Camp

Other

Known place

Unknown place

Total

— 26 4 3 — — 44

— 1 — 2 1 — 2 2 1 — — 9

— 1 — 1 — — — — — — — 2

— — — — — — 4 — — — — 4

— — — — 2 — 2 — — — — 4

2 — 1 5 9 2 26 2 7 — — 54

3 6 2 12 22 2 68 11 13 1 1 141

— — — — 3 1 2 — — — — 6

3 6 3 12 25 3 70 11 13 1 1 148

8 1 — 6 1 16

2 — 1 11 _ 14

— — — — _ —

— — — — _ —

1 — — — _ 1

— — — — _ —

— 1 — 4 i 6

11 2 1 21 2 37

— — — — — —

11 2 1 21 2 37

1

1











2



2

— 1 1 2 44 86

2









4



_ 2 61 198

_ — 9 20

_ — 2 5

_ — 5 9

_ — 4 4

2 6 66 119

6 1 3 10 191 441

— — 6 15

6 1 3 10 197 456

259

29

7

14

8

185

632

21

653

130

1 3 1 4 2

School

*Indudes Guam, Puerto Rico, and the U.S. Virgin Islands. Source: Center for Disease Control and Prevention. U.S. Department of Health and Human Services. MMWK: Morbidity and Mortality Weekly Review CDC Surveillance Summaries Surveillance for Foodborne-Disease Outbreaks United States, 1993-1997 49 no. SS-1 (2000). http://www.cdc.gov/mmwr/PDF/ss/ss490l.pdf.

Table F3.3. Number of Reported Foodborne-Disease Outbreaks, by Etiology and Place Where Food was Eaten—United States? 1995 Place where food was eaten

Etiology

Delicatessen, Private cafeteria, or residence restaurant

School

Picnic

Church

Other

— 1 — — 3 — — — — _ 4

— 2 — 4 0

2 6 2 14 24

29 27 2 — 2 47

88

Bacterial Bacillus cereus Campylobacter Clostridium botulinum Clostridium perfringens Escherichia coli 8 Salmonella Shigella Staphylococcus aureus Yersinia enterocolitica Other bacterial Total bacterial

1 2 2 1 8 21 — 1 1 _ 37

1 — — 8 3 35 4 2 — _ 53

— — — —

— — — —

— — 1 — _ 1

1 — — — _ 1

— 1 — 1 4 4 2 1 — — _ 9

Chemical Ciguatoxin Heavy metals Scombrotoxin Other chemical

10 — 5 —

— 1 9 i

— — — _

— — — _

— — — _

— — — _

15

11







1







1 _ _ 1

2 _ _ 2

— _ _

54 93

66 222

147

288

Total chemical Parasitic Trichinella spiralis Viral Hepatitis A Norwalk Other viral Total viral Confirmed etiology Unknown etiology Total 1995

Known place

Camp

Unknown place

Total

6 1 2 152

— — — — 1 2 — — — — 3

90 7 6 1 2 155

— — 2 1

10 1 16 2

— — — —

10 1 16 2



3

29



29







1



1

— _ _

— _ _

— _ _

1 3 T

4 3 i

— 1 _

4 4 i

5

8

1 7

1 2

9 7

4 6

55 74

190 411

4 23

194 434

8

3

16

10

129

600

27

628

7

1

2 6 2 14 25

9

*Includes Guam, Puerto Rico, and the U.S. Virgin Islands. Source: Center for Disease Control and Prevention. U.S. Department of Health and Human Services. MMWR: Morbidity and Mortality Weekly Review CDC Surveillance Summaries Surveillance for Foodborne-Disease Outbreaks United States, 1993-1997 49 no. SS-1 (2000). http://www.cdc.gov/mmwr/PDF/ss/ss4901 .pdf.

Table F3.4. Number of Reported Foodborne-Disease Outbreaks, by Etiology and Place Where Food was Eaten—United States; 1996 Place where food was eaten

Etiology Bacterial Bacillus cereus Brucella Campytobacter Clostridium botutinum Clostridium perfringens Escherichia coii Salmonella Shigelta Staphytococcus aureus Total bacterial Chemical Ciguatoxin Mushroom poisoning Scombrotoxin Shellfish Other chemical Total Chemical

Delicatessen, Private cafeteria, or residence restaurant

School

Picnic

Church

Camp

Other

1 2

1

3 3

3

1 1

1

2 3 11

26 4

4

1 39

3 12

1 4

4 2

8 2 2 1

5

1 1 5 2 1 0 3

3

17

65

4

1 28

7 106

2

4

2 18

Knwon place

1 4

9 3 1 2 1 1 26

Ciardia lamblia

1

1

Other parasitic Total parasitic

1 2

1 2

13

1

6

8

2

8

1

Parasitic

Viral Hepatitis A Norwalk Other viral Total viral Confirmed etiology Unknown etiology Total 1996

1

1 1

1 32 76

2 49 149

12 11

5 3

4 5

1 2

198

23

8

9

3

108

1

2 2 2 6 40 69 109

Unknown place

2 4

6

Total 1 1 5 2 1 0 11 69

6

7 112 9 3 1 2 1 1 26

1 1 1

2 3

1

4 3 2 9 143 315

1 8 11

5 3 2 10 151 326

458

19

477

*Ini:iu

Oi

0

0

3

oj

0

"See list of Member States by WHO Region and mortality stratum (pp. 168-169). Estimates for specific causes may not sum to broader causes groupings due to omission of residual categories.

Source: World Health Organization. World Health Report 2000 (Geneva: World Health Organization, 2000). http://www.who.int/whr/2000/en/report.htm.

230

Statistical Handbook on Infectious Diseases

Table H1.2. Burden of Disease in Disability-Adjusted Life Years (DALYs), by Cause, Sex, and Mortality Stratum in WHO Regions.3 Estimates for 2000 AFRICA Mortality stratum High High child, child, < very high high adult adult

SEX

Cause1" Population (000)

Males

Both sexes 6 045 172

Infectious and parasitic diseases Tuberculosis " STDs excluding HI V " Syphilis Chlamydia Gonorrhoea HIV/AIDS Diarrhoea! diseases _Chiidhood diseases Pertussis Poliomyelitis Diphtheria Measjes tetanus Meningitis Hepatitis' Malaria Tropical diseases Trypanosomiasis Chagas disease Schistpsomiasis Leishmaniasis Lymphatic fiiariasis _ Onchocerciasis Leprosy Dengue Japanese encephalitis Trachoma Jntestinal nematode infections Ascariasis Trichuriasis Hookworm disease a

140 176

23.1 2.4' 1.1 5 574' 0.4 6 128' 0.4 3 9 1 9 ' " " 0.3

35792' 15'839"

90392

6.1'

(000) % total 173704 22.7 21829 2.9

5 808 3095' 902" 1 758

44366

1 585 "680" 1713"'" 1 8JO _5549'"" 951 141 433' 426

O.V 0.0' 0.1 0.4' 0.1 0.0 0.0' 0.0

32" 399 25151' 6 369 95' 61' 13 755 4870 : 3011^ 1 400' 19""237" 8271 1013 360 r " 1 037' I 067 4 245 549' 76 : 286 207'

4811 1252" 1 640

0.3 0.1 0.1

2461 636 836

62227' 50380 12768

184 114

"4.2 3.4 0.9'

0.0 O.Ql

27549' 1.9" 9766_ 0.7" 5751 .'"_P,4"

2 739'

0.2"

40213" 12289

"'2.7' 0.8

1 181"

Females 2" 999 800 _ j (000) % total !66473 23.6 13962! 2,0" 10031 1.4 0.8 0.4' 2479^ 0.4' O.L 5 2 2 6 _ 0.7~ 0.2 2 161' 0.3 5.8_ 46026' 6.5 4j 29828 4.2" 2J 229_ 3.6 3,3 0.8 "6398 "" O."9l 0.0 89 0.0 53"" ""' "pj>: 0.0" 13J793 _ 2.0_ L8 0.6_ 4_895: 0.7 ""0.4 2" 7'4pl 0_.4" 0.2 1 339 Ci.2' 2.5" 20 976_ 3.0 1.1 4018 0.6 0.1 572 d"l OX)' 320 O'.O" O.'l" 676 0.1' p.li 744' O.l' 1 304 0.2_ 0.6 O'.f '402' 0.1 0.0' 65 0.0 0.0 147 0.0 0.0 219' "0.0 862 O.L 2 350 0.3 0.3 O.V" "616" " O.V 0.1 803 _ 0.1 'O.l' 890 "0.1

3 045 372

(000) %to(a/

0.1'

0.1'

1829 '"" 0.1

319

939"

p.p:

See list of Member States by WHO Region in Appendix b Estimates for specific causes may not sum to broader causes groupings due to omission of residual categories.

294 OiS (OOP) I

68459 3"'"754l

2 837 1 353 829 655 _ 15605" 8070 " 15396 3'6f2f 16 24'" 93_44" 2400

~6"?i;' 334;

17916 _ 3051" 804 0; 648 222"'

"894'

484 8_ "2 0 212' 289 48 50 "191"

45533 (000)1 14 085^ 6034

THE AMERICAS Mortality stratum Very low Low High child, child, child, high adult very low low adult adult

325 186 I 430 95) I (000) I (OOP) 1 4 7 8 , 7820 20" " 633':

no"

"601

91 16

389 186

57046' ' 13424" "

504'

j_L45"

11 043 _ 2"922 7 '"23 : ""

50'

3351 1 817 837 693

6J)46: _ 1 446*

817"" 444 17 832' "

3012 '_

754 "O'J 724" L73'_ _ 966 395'"' ' 8_ 4 '" 0

232' ' 364_ 70 70' ' 222

L

108"

50 "p' 0

"

23

1838 : '2022

_ '0' "

p;

'

1781 6' 2 _r

2

14'

47_ __ 437; 82 59r \ 83i 51 '701 0 0 7""""' 582" V " 70"" 1 41 0"' " Z8" 0 1 0 15' 0 3 0" 0" 0 P 1 1 " " " ' 549' 3 168 5' 239_1 3 125

71 235 (PPO) 3058 482" 98 4 63 "31 714

882 256

236 1 0 3

'"""17

46 35 " "27 109" _0

?! 9

5 1 2 0 7 0 0

_L?3

27 46 20

H. Infectious Disease Worldwide: Present Issues, Emerging Concerns

231

Table H1.2. (Continued) EASTERN MEDITERRANEAN EUROPE Mortality stratum ' Mortality stratum Low child, ; High child, 1 Very low Low child, I Low child, low adult high adult i child, low adult high adult 'Very low adult

SOUTH-EAST ASIA | WESTERN PACIFIC Mortality stratum Mortality stratum Low child, High child, i Very low Low child, low adult high adult j child, low adult • very low

adult Cause Population (000) 139(171 342SJ4\ 411910 218473 243^92 I 283821 1 241113\ \ 1S43S»\ 1 S3294t

(OOP)

Infectious and parasitic disease Tuberculosis STDs excluding HIV Syphilis Chlamydia Gonorrhoea HIV/AIDS Diarrhoea! diseases Childhood diseases Pertussis Poliomyelitis Diphtheria Measles Tetanus Meningitis Hepatitisc Malaria Tropical diseases Trypanosomiasis Chagas disease Schistosomiasis Leishmaniasis Lymphatic iliariasis Onchocerciasis Leprosy Dengue Japanese encephalitis Trachoma intestinal nematode infections Ascariasis Trichuriasis Hookworm disease Respiratory infections Lower respiratory infections Upper respiratory infections Otitis media

2965 176"""

"m 3'

5I

T 20 :

2__ 815

IL

IL 5

0: ~

"

(OOP)

(OOP)

28 474

1097

"" 2*77_5'

1 150 316"

:_«?.[ 313;

1 784: 8358 6934; 2 204^

16" 16

lOJ

2 882*

7i

1816| 80p' 181 1 898 846 26 " 0: 154 124 473 69* 12; 19

7l" 73 4?' 62

o"

o"* !

43 16 4'

"o*

' "o"

p!

0 71' "" 47" 20' 1 26 J_279' 1*212'

" 28: 40'

" T 108* 248

83[

31 134' 10120 9929

if.

ns"

63; J?2! '__ I ~16s"

is'

307; 109J 66' 63'

i' oj_ _i' i

66' 45! 2

o' o:

" p' "0;

o' " q' d" o' o' p" """ oo* o

"p" _¥

(OOOT

(OOP)

3118 444

(OOO)I

2608 :

9745

"*2pT

""194*1

i q%ii

24 j "*T20'J

fi

1401' 38'"

(000) "

76 637 j

3 063 ~

" 5 981' ';

33* 291.

"_f4427"

35" " _42l'' _ 36:

215 i 1 198J

"^166:!

4

JI63! " "_332!"

63'

__T

6* 252' 6J 206|

142 19

L

"__T o' o" 0 b 1

:

JL _~o"

p ' q" _ o' s" 7

o'

_0_

676

2264

612! 28J 37*

2 182 48* 34'

34*29'" \\'-!

""* Tj " "2,"

r

125

:

o"

_1 J! i

o" o" " " o"' p*"

" _0:* 0

0:'

p" ' "o ' ;

894' 31 ':'•

- 27r

1331

11

4* 1 212J_ * 2391 98 292! 242! 0 0* _3~ 6 233*

"o" o" o' o" I

951;

976 1 599*

442^

46"

119290

_54li

*o"

7' " 25" 22: 24' 469 I14

1

:

194 160: 3456

3 350' * 38'" 69

(OOP)

(OOOI

397 _53

20234

Jsi*"" 1 41," ~8"_

J 932* * 150*51";

if 45"

10279J; 22387 *

3

12 m ~~

" 0: *

!

*6?

_3S"^

5989J

-jl-

T582J

3 rfr ' o"

O**

"p'

_

83** 346*""

*6l' ' _Jp"/ "l 044: " * 123' ' 202 703 ^9005! 28]34' "*528' "

~_jm''

"l"34p

*4 084 2240

462

52 4

1 206 _o " 516 _14 _555 56T 389 2__ " 514 4 472 " O1** ""6

_756 '

" 1 210*** 2562 '

-51 266 1*89

;

_ 3 36 i I_42S~_;

_1 '

zT_

36

T737j"

" 5 272 521

o' "

0^ " 0T "

iL

JD^ " _0_

q-_ * "6* _ __o' 6*

i" 2"""

' 21 381 358'

10'

13*

0

60 9" 403

"o"

6 26 "336 484"

"" T"651 588 799 242 14387

13316 74 I 330

" See list of Member States by WHO Region in Appendix b Estimates for specific causes may not sum to broader causes groupings due to omission of residual categories.

Source: World Health Organization. World Health Report 2000 (Geneva: World Health Organization, 2000). http://www.who.int/whr/2000/en/report.htm.

232

Statistical Handbook on Infectious Diseases

Table H2.1. African Trypanosomiasis, Cases Reported to WHO, Number of Countries Reporting, and Population Screened, 1990-1998 [

1990

1991

1992

1993

1994;

!

Burkina_Faso 7 Burundi_

2 n

1996

19,

1998

!

~~ ~ _ -\A98^ 2,094 __J " ~°j__Z 1L_ 1

Angola^ _ Benin711 Botswana

1995

J^ZTT

2

2^406! i , 7 9 6 T ^ f 2 2 ' 4 7 ^ 6 7 2 6 - '8,29T7 ' " 2^ '""_~_" f^"" _o[ "~o" ' ~~ o'_ """ 0+ _; , _j ___

_L_ _".__

20

J.'IT2..LI_ J8£__ T3.__'" J ^

2

6,610 0

T _ J L ~ _ T "

CcUTieroon I T ~ Jpjl I 1 ^ T ~~^fll^J2!^it Ii[ fj ~" 55 Central African Republic 1 "_jn8l_^_" 535_ 36^ 264 362J ~ 673: ' 434^ 708r 1,069 Chad ^ "Z^^T^^^l 2 ^ "_T?A _""_~_65_ 213r 401; ~"l78_f" " 13V__ 134 27 4 Conger "^ __"1IT1 ^?OJ 703^ Z 1 Ji "418[ 475J ~ 474 " 142J 201 Coterflvoi're' ^ T ~_3^|"T_349 456 ~ ^402 ^_ 404r ~5^' ~\ ~"~~ 18 1 "~ ^ D_em._R^ofJheCqr^o_J"~__7,712] ~5,824^ 7,7"57T"""il,384r 19,34o[ 18/158 19,342^' 25,200^ 27,044 Equatorial Guinea 28^ 30 85; 32 62U 38 46 68; 59 Gabon ~ 1 Z[l _f?i_ 32 18' ~ 94^ 85j 41 ^ 11~p'~" 6

Gambia GhanT __

_

Guinea ~ "" Guinea-Bissau Kenya71 ' 1

'

4

_ ""[I"_

16; _" 2il

^l]

Z

??/

\9a

""~

7

Mair 'i^"_~"_ " I 11 111"LU — T

Mozambique 7_ _^_ _ ^T Niger _ • Nigerja I Rwanda Senegal _ _ Sierra Leone Sudan !" "_" 6f United Rep. of Tanzania^ 180 Togo2 ^ Uganda" Zambia

_""

totaTnoTof"cases

3

I i2 2,667? |

_Z^__

58 466 ?1 2T481

" 13,5To; "12,901

_„!

:

^

2:

I27' — 2

IL 127r

_^4i _

28; 5131

1°1 _

62 ^_303

^ __ ~*L 'T,i26"~ 17770

13,724""

|

;

Mil f

"Jl3^~ 0__~

~47" cT~T

I7!

ii:

693J9"

~56 " 157 422"' " 4 0 0

1^1

^_

_5

: ; 92i'"_" 6 ~

1" °i 3

737" 508

1 __lo"^_ "^Y_ ZI 9 Z 1.89T _ l 7 2 0 0 _ " 1,125 _1,300" 7

17?07T"24,527

24.6067 ""28.955" ""37,221-

_ 57 20

°

J ^194 L_ 677

367T47"

Source: World Health Organization, Department of Communicable Disease Surveillance and Response. WHO Report on Global Surveillance of Epidemicprone Infectious Diseases (2000). http://www.who.inl/emc-documents/surveillance/vvhoedscsrisr2000lc.htmlSenglish.

H. Infectious Disease Worldwide: Present Issues, Emerging Concerns 233

Table H2.2. Cholera, Cases and Total Number of Deaths Reported to WHO, Africa, 1990-1998

Algeria Angola Benin Burkina Faso Burundi Cameroon Cape Verde Central African Republic Chad Comoros Congo Cote d'lvoire Dem. Rep. of the Congo Djibouti Equatorial Guinea Ethiopia Gabon Gambia Ghana Guinea Guinea Bissau Kenya Liberia Libyan Arab Jamahiriya Madagascar Malawi Mali Mauritania Morocco Mozambique Niger Nigeria Rwanda Sao Tome and Principe Senegal Sierra Leone Somalia South Africa Sudan Swaziland Togo Tunisia Uganda United Republic of Tanzania [Zambia Zimbabwe Total no. of cases Total no. of deaths No. of countries reporting

1990

1991

1992

1,293 9,527

1,991 8,590 7,474 537l 3 4,026

82 16

1993

1994

69 3,608 413

10

118 3,443 187

479 1,268

78 648

1996

3,295 203 1,451 2,297 615 12,913

1,306 6,190 425 418 5,796 426

1,094

13,915

^^468j

604 4,066

37 1,949

724 986 10,055

2,937

13,172

228

1,448

3,388 132

13,457

8,088

298

25,193

4,152

7,847 3,238 59,478 679 3

30,802

19,803

804

562 527 128

1995

7,671 530

107

1 2,048

1 5,723 4,534

130 6 462

1J45

3,957 12,374 106

8,739 259 1,322 274

42,672

264 1,059 3 ^~ 3,222 10,285 9,255

16,107

371

10,274

6,814

2,096 4,404 20

2 146

42

3,217

2,281 753

19

47

76,713 2,532 16

3,426 881 126 22,432 2,123

20,555 17,200 91

2,396

91,081 5,291 20

379

7 1,665 287 8,397 482 8,922

78

155,358 13,998 22

34,899 164

443 8,801

15 4,698 6,506 119 1,543 3,420 22

11

38,683 2,288 11

2,421 2,424

1,959 1,709

1 2,267 31,415 15,296 880 764

10

792 6,766 5,385

275

206 1,036 1,067 4,603 133 4,095 22 7,300 3,222

1,345 7,888

9,709 27,904 4

5,072 18,526 11,659 2,039

778

4,993 553

4,160 568

279 5,676 13,154

1998

1,108 58,057 1,122

6 692 732 2,859 10

2,230 3,717

7,830

1997

\

65

3,464 3,220

T

704 2,240

538 1,698

291 1,464 2,172

2,610 40,249 36

161,983 8,128 28

71,081 3,024 26

108,535 6,216 28

118,349 5,853 25

49,514 14,488 171 995" _

2Tl7748 9,856 29

Source: World Health Organization, Department of Communicable Disease Surveillance and Response. WHO Report on Global Surveillance of Epidemicprone Infectious Diseases (2000). http://www.who.int/emc-documents/surveillance/whocdscsrisr20001 c.html#english.

234

Statistical Handbook on Infectious Diseases

Table H2.3. Cholera, Cases and Total Number of Deaths Reported to WHO, the Americas, 1991-1998

1991 Argentina Belize Bolivia Brazil Canada Chile Colombia Costa Rica Ecuador El Salvador French Guiana Guatemala Guyana Honduras Mexico Nicaragua Panama Paraguay Peru Suriname United States of America Venezuela Total no. of cases Total no. of deaths No. of countries reporting

206 1,567" 2

41 11,979 46,320 947

T

3,674

11 2,690 1

1,17V 322,562

26 15 391,220 4,002 16

1992

1993

1994

1995

1996]

1997

1998

553 159 22,260" 30,309 4 " 73 15,129 12 31,870 8,106] 16^ 15,395 576 384 8,162 3,067^ 2,416^

2,080 135" 10,134 59,212 „ 6 32" 230 14"

889 6 2,710" 49,455 2 1 996 38 1,785 11739'

188 | "19"" 2,293 ! 15,915 ! 7

637 2 1,632 2,881

T922; 24 i 2,160 | 2,923 j

474 I 26 T 2,847 4,634 2 1; 4,428 : 19 1,059_j_ 182~^

12 28 466 2,571 2 24 442

5,282

7,970 i

1,568 i

1,263

^970

4,965 4,059 7,821

4,717 I 30' 8,825

708 1,088 ' 2,813

90 2,356 1,283

306 71 1,437

4 4,518 j

3,483

41,717

4

212,642 12 " ~102 2,842 354,089 2,401 21 I

6,833 6,573" 2

30,604 66 4,007 10,712 6,631 42 3 71,448 19 409 209,192" 2,438 21

2

2Z$&7 47

113,684 1,107 17

22,397 19f

85,809 j _ 845 15 |

3

4 1,508 1 65 0

3,724 8

269~j

2,551

15 313

24,643 351 18 |

17,760 225 16

57,106 558 16

Source: World Health Organization, Department of Communicable Disease Surveillance and Response. WHO Report on Global Surveillance of Epidemicprone Infectious Diseases (2000). http://www.who.int/emc-documents/surveillance/whocdscsrisr20001 c.html#english.

H. Infectious Disease Worldwide: Present Issues, Emerging Concerns 235

Table H2.4. Cholera, Cases and Total Number of Deaths Reported to WHO, Asia, 1990-1998

1990 Afghanistan Armenia Azerbaijan Bahrain Bangladesh Bhutan Brunei Darussalam Cambodia China Dem. People's Republic of Korea Georgia Hong Kong SAR India Indonesia Iran (Islamic Republic of) Iraq Israel Japan Jordan Kazakhstan Kuwait Kyrgyzstan Lao People's Dem. Republic Lebanon Maldives Macao SAR Malaysia Mongolia Myanmar Nepal Oman Pakistan Philippines Republic of Korea Saudi Arabia Singapore Syrian Arab Republic Sri Lanka Tajikistan Thailand Turkey Turkmenistan United Arab Emirates Uzbekistan Viet Nam West Bank and Gaza Strip Yemen Total no. of cases Total no. of deaths No. of countries reporting

1991

1992

1993

1994

1995

37,046

38,735

19,903

1996

1997

1998

4,170

10,000 25

9 12 422

494

770 205

1,229 580

2,252 11,717

3,085 34,821

4,190 10,344

740 312

155 1,163

1,197

5 3,583 155 178

5 6,993 6,202 1,880 877

3 6,911 25 97 97

8 30 9,437 3,564 1,347 280

56 4,973 47 15 838

6 3,315

4 4,396

71 7,151

2,177 820

14 2,768 66 1,106

73 2

90

46

89

91

321

89

60

74 1

3

8

5,521 344

4 9,640 3

1,365

720

1,486 177

389

8 1,304

639

25

19

39

270 53

4 1

1 2,071

506

474

995

534

2,209

24 23,888

924 30,648

826 764

1,758 31

421 32

1,296 157

274

245

1,745

12,092 708 5

3,340 34

847 74

1,402 7

605 10

729

113

345 6

34

17

24

41

14

19

19

31

70

121

1 165

430

1,536

26

10 3,487 1

358

52

4,260

55

3,361

1 5,776 103

6,088

566

4

13

90,862 1,809 25

106,100 1,393 26

53,159 1,158 18

10,142 122 13

11,293 196 18

24,212 172 16

4 31,003 628 13

49,791 1,286 16

16,299 372 18

Source: World Health Organization, Department of Communicable Disease Surveillance and Response. WHO Report on Global Surveillance of Epidemicprone Infectious Diseases (2000). http://www.who.int/emc-documents/surveillance/whocdscsrisr2000lc.html#english.

236

Statistical Handbook on Infectious Diseases

Table H2.5. Cholera, Cases and Total Number of Deaths Reported to WHO, Europe, 1990-1998

1990 Albania Andorra Austria Belarus Belgium Czechoslovakia 1 Denmark Estonia Finland France Germany Greece Hungary Italy Netherlands Norway Poland Portugal Republic of Moldova Romania Russian Federation Spain Sweden Switzerland United Kingdom of G.B and N.I. Ukraine Yugoslavia Total no. of cases Total no. of deaths No. of countries reporting 1

1991

1992

1993

1994

1995

1997

1996

1998

626 1 1

2 1

2 2

1

61 1

7

1

11

5 1 1,

2

3

270

1

226 3 1

8

6 49

75

349 2 9

320 9 6

3 6

1 15 23 3

1 ii 5

2 13

18 0 7

73 0 15

1 3 1

3

2

3

2 4 5

1 5 1

12 1

1 9 1

1

1

6

3 2

2 5

T"

1 1 8 80 1,048 1 1 18 813 2 2,630 0 20

1 240 118 9 6' 2 2 10 525

937 0 17

3

2

2 4 2

1 1 1

4

10

13

6

2 18

18 1 6

47 0 10

25 0

I-

6l

Czechoslovakia dissolved on 31 December 1992.

Source: World Health Organization, Department of Communicable Disease Surveillance and Response. WHO Report on Global Surveillance of Epidemicprone Infectious Diseases (2000). http://www.who.int/emc-documents/surveillance/whocdscsrisr2000lc.html#english.

H. Infectious Disease Worldwide: Present Issues, Emerging Concerns 237

Table H2.6. Cholera, Cases and Total Number of Deaths Reported to WHO, Oceania, 1990-1998

1990

1991

2 1

1992

1993

1994

1995

1996

1997

1998

3

5

3 1

5

2 1

2

5 2

1

3

Australia Guam Kiribati Northern Mariana Islands Micronesia (Federated States o Nauru Papua New Guinea New Zealand Samoa Trust Territories of the Pacific1 Tuvalu

27

293

Total no. of cases Total no. of deaths No. of countries reporting

67 1 5

296 8 2

34

3

0

5 0 1

2

2

6 0 3

7 0 2

1

4 0 3

5 0 2

8 0 3

1 The Trust Territories of the Pacific consisted of the Federated States of Micronesia, Marshall Islands, Palau, and the Northern Mariana Islands.

Source: World Health Organization, Department of Communicable Disease Surveillance and Response. WHO Report on Global Surveillance of Epidemicprone Infectious Diseases (2000). http://www.who.int/emc-documents/surveillance/whocdscsrisr2000lc.html#english.

238

Statistical Handbook on Infectious Diseases

Table H2.7. Dengue Fever, Cases Reported to WHO, the Americas, 1990-1998

Anguilla Antigua Aruba Bahamas Barbados Belize Bermuda Bolivia Bonaire Brazil British Virgin Islands Cayman Islands Colombia Costa Rica Cuba Dominica Dominican Republic Ecuador El Salvador French Guiana Grenada Guadeloupe Guatemala Guyana Haiti Honduras Jamaica Martinique Mexico Montserrat Netherlands Antilles Nicaragua Panama Paraguay Puerto Rico Peru St. Kittsand Nevis St. Lucia St. Martin St. Vincent Suriname Trinidad and Tobago Turks and Caicos Islands United States of America Venezuela Virgin Islands (USA) Other Caribbean islands iTotal no. of cases |No. of countries reporting

1990

1991

1992

12 1 0 2 236 2

0 1 0 0 21 0

0 0 0 0 4 0

0 0 40,642 3

0 0 97,209 1

0 0 3,501

17,389 0 0 6 39 2,109 2,381 29 3 12 5,757 3 1,700 9 4 14,485 0

15,103 0 0 12 24 302 1,273 269 1 51 10,968 0 0 5,303 5 0 7,158 0

20,130 25,585 4,612 0 0 0 0 105 138 454 9,015 884 245 569 178 1 1 75 0 1,907 1,286 2 0 0 2,113 2,847 296 0 38 0 8,131 2,899 0

4,137 0 0 9,450 7,858 0 2 0 9 16 526 0 102 10,962 339

1,885 0 0 10,305 714 8 4 0 1 40 36 0 25 6,559 62

4,936 0 0 13,000 1,971 0 0 0 7 24 116 0 68 2,707 48

118,225 157,340 43 42

2]

1993

1994

55

114

0

0

6,915 0

1995

1996

1997

1998

4 56 37 1 976 107 0

1 12 10 0 130 0 0 52

0 9 0 0 199 210 0 223

0 4 126 610 17 0 49

54,453 124,887 175,751 254,942 530,578 0 9 0 0 1 1 0 0 1 27,885 51,059 33,155 14,958 43,855 5,134 13,929 2,307 14,267 2,290 0 3,012 1 293 0 3 7 1,211 64 249 89 3,049 6,607 8,145 284 5,189 4,219 9,658 281 348 790 1,354 164 364 896 851 534 74 5 22 6 156 0 186 0 2,872 3,679 3,980 5,379 1,593 1 0 0 0 42 0 0 0 5,047 11,730 22,218 3,055 27,575 1,884 4 16 46 68 519 0 235 430 44 6,770 17,088 20,687 35,108 23,639 0 75 15 3

8,938 14 0 6,600 897 1 5

20,469 790 0 22,000 1,478 8 0

19,260 3,083 6,765 2,732 27 52

2,792 811 0 4,655 6,395 6 65

7 171 268 0 57 9,059 0 500

2 75 48 0 91 15,046 0 275

224 344 312 0 7 32,280 0

190 677 3,983 0 0 9,180 0

3,126 1,710

13,592 2,717

6,955 1,151 0 14

14,828 988

3 90 1,357 0

112 1,230 2,792

33,654 0

3

0 37,586 0

60,468 80,914 179,187 316,411 276,691 389,917 708,146 42 37 35 39 40 42 35

Source: World Health Organization, Department of Communicable Disease Surveillance and Response. WHO Report on Global Surveillance of Epidemicprone Infectious Diseases (2000). http://www.who.int/emc-documents/surveillance/whocdscsrisr2000lc.html#english.

H. Infectious Disease Worldwide: Present Issues, Emerging Concerns 239

Table H2.8. Dengue Haemorrhagic Fever, Cases Reported to WHO, the Americas, 1990-1998

1990

1991

274

188

I Argentina Aruba Barbados Brazil Belize Bermuda Bolivia Cayman Islands Colombia Costa Rica Cuba Curacao Dominica ^Dominican Republic El Salvador French Guiana Grenada Guadeloupe Guatemala Haiti Honduras Jamaica Martinique Mexico Montserrat Nicaragua Panama Puerto Rico St. Lucia Suriname Trinidad and Tobago Venezuela

3,325

1,980

Total no. of cases No. of countries reporting

3,646 5

2,304 8

1992

1993

1994

1995

24

105

21

1996

1997

2

3 35

1998

89 1 0

J39I

96

493

303

568

1,028 1

1,757

3,330

5,276

205

2

7 1

16

2 0 38

1

4 3 2

1

2

6

14

100 0 1

4

30

11 38 129 1 1 7 1 15 108 3 539

17, 1 6

3 3

176 2 1

19

6

1

0

18

884

15 239

806 3 24

49

68

24

62 1

372

559

97

249

9

8

137

7

1

649

2,884

3,607

5,380

1,680

39 6,300

432 1 133 1 11 189 5,723

1,751 8

3,309 9

4,721 11

8,202 19

4,439 11

10,309 14

12,426 18

Source: World Health Organization, Department of Communicable Disease Surveillance and Response. WHO Report on Global Surveillance of Epidemicprone Infectious Diseases (2000). http://www.who.int/emc-documents/surveillance/whocdscsrisr2000lc.html#english.

240

Statistical Handbook on Infectious Diseases

Table H2.9. Dengue Fever and Dengue Haemorrhagic Fever, Cases Reported to WHO, Asia, 1990-1998 1990 Bangladesh Cambodia China India Indonesia Lao People's Dem. Rep. Malaysia Maldives Myanmar Philippines Saudi Arabia Singapore Sri Lanka Thailand Viet Nam

22,807 60 4,880 0 6,318 588

Total no. of cases No. of countries reporting

7,247 376

1991

1,882 902 6,291 21,120

1992

1993

1994

1995

1996

1997

1998

10,199 6,114 7,847 35,102 7,781 6,543 0 2,477 7,413

1,433 13 16,517 44,650 8,197 14,255 0 1,655 13,614

4,224 647 1,177 30,730 1,536 19,544 0 3,993 12,811

16,216 15 707 71,087 3,755 27,370 2,000 8,978 31,829

837 750 67,017 53,674

1,498 2 7,494 18,783 2,585 3,133 0 11,647 5,603 315 1,216 582 51,688 44,944

2,008 440 59,911 80,447

3,128 1,298 38,109 89,963

4,300 980 99,150 108,000

5,183 800 126,348 150,898

169,019 13

149,490 14

226,282 13

232,832 13

287,092 13

445,186 13

6,628 0 8,055 1,865

4,695 46,095 2,683 17,620 138 5,473 0 1,685 3,980

3,913 359 11,125 17,418 343 5,589 0 2,279 5,715

1,733 1,350 92,002 37,569

2,179 1,048 43,511 111,817

2,878 656 41,125 51,311

174,930 12

205,298 12

178,339 13

Source: World Health Organization, Department of Communicable Disease Surveillance and Response. WHO Report on Global Surveillance of Epidemicprone Infectious Diseases (2000). http://www.who.int/emc-documents/surveillance/whocdscsrisr2000lc.html#english.

H. Infectious Disease Worldwide: Present Issues, Emerging Concerns 241

Table H2.10. Dengue Fever and Dengue Haemorrhagic Fever, Cases Reported to WHO, Oceania, 1990-1998

American Samoa Australia Cook Islands Fiji French Polynesia Guam Kiribati Marshall Islands Micronesia (Fed. States of) Nauru New Caledonia New Zealand Niue Palau Papua New Guinea Samoa Tokelau Tonga Tuvalu Vanuatu Wallis and Futuna Total no. of cases No. of countries reporting

1992

1991

1990

5 1,461

0

46 833

0

1993

1994

a

0 366 5 349 593

6901 0 39 355

0

0 0

92

16

10

1995 246 17 0

61 0 0 0 0 0

0

0

0

1996 0 34 786 27 208

1997 49 43 2

1998

205 1,075

500 24,780

1

20 0 1,820

2

275 154

2,618

163

49

11 0 0

0

°

475

896

115

52

2,506 6

1,485 6

3 0 35 811 113 0

27 0

2,285 13

1,121 15

2 0 8 1

0 0 0 16

0 636 0 278

1,013 3

460

0 131 395

3 279 17

3,812 14

1,121 6

1,598 5

29,210 9

Source: World Health Organization, Department of Communicable Disease Surveillance and Response. WHO Report on Global Surveillance of Epidemicprone Infectious Diseases (2000). http://www.who.int/emc-documents/surveillance/whocdscsrisr2000lc.html#english.

242

Statistical Handbook on Infectious Diseases

Table H2.11. Global Summary of the HIV/AIDS Epidemic, December 2000 People newly infected with HIV in 2000

Total Adults Women Children 90% secondary attack rates among susceptible persons. Measles may be transmitted from 4 days prior to 4 days after rash onset. The incubation period of measles, from exposure to prodrome, averages 10-12 days. From exposure to rash onset averages 14 days. The prodrome lasts 2-4 days. It is characterized by fever, which increases in stepwise fashion, often peaking as high as 103° to 105°; cough, or coryza (runny nose), or conjunctivitis; and Koplik spots. The measles rash is a maculopapular eruption that usually lasts 5-6 days. Other symptoms of measles include anorexia, diarrhea, especially in infants, and generalized lymphadenopathy. Onchocerciasis Onchocerciasis is caused by Onchocerca volvulus, a parasitic worm that lives for up to 14 years in the human body. Each adult female worm, thin but more than Vi meter in length, produces millions of microfilariae (microscopic larvae) that migrate throughout the body and give rise to a variety of symptoms: serious visual impairment, including blindness; rashes, lesions, intense itching, and depigmentation of the skin; lymphadenitis, which results in hanging groins and elephantiasis of the genitals; and general debilitation. Onchocerciasis manifestations begin to occur in infected persons 1 to 3 years after the injection of infective larvae. Microfilariae produced in one person are carried to another by the blackfly. The world's second leading infectious cause of blindness, onchocerciasis is present in 36 countries of Africa, the Arabian peninsula and the Americas. As a public health problem the disease is most closely associated with Africa, where it constitutes a serious obstacle to socioeconomic development. Onchocerciasis is often called "river blindness" because of its most extreme manifestation and because the blackfly vector abounds in fertile riverside areas, which frequently remain uninhabited for fear of infection. Poliomyelitis Poliovirus is a member of the enterovirus subgroup, family Picornaviridae. Person-toperson spread of poliovirus via the fecal-oral route is the most important route of transmission, although the oral-oral route may account for some cases. The incu-

bation period for poliomyelitis is commonly 6-20 days, with a range of from 3 to 35 days. The response to poliovirus infection is highly variable and has been categorized based on the severity of clinical presentation. Up to 95% of all polio infections are inapparent or subclinical without symptoms. Approximately 4%-8% of polio infections consist of a minor, nonspecific illness without clinical or laboratory evidence of central nervous system invasion. This syndrome, known as abortive poliomyelitis, is characterized by complete recovery in less than a week. Nonparalytic aseptic meningitis (symptoms of stiffness of the neck, back, and/or legs), usually following several days after a prodrome similar to that of minor illness, occurs in l%-2% of polio infections. Increased or abnormal sensations can also occur. Typically these symptoms will last from 2 to 10 days, followed by complete recovery. Less than 2% of all polio infections result in flaccid paralysis. Paralytic symptoms generally begin 1-10 days after prodromal (early) symptoms and progress for 2-3 days. Generally, no further paralysis occurs after the temperature returns to normal. Many persons with paralytic poliomyelitis recover completely, and muscle function returns to some degree in most. Patients with weakness or paralysis 12 months after onset will usually be left with permanent residua. Smallpox Variola virus is the etiological agent of smallpox. During the smallpox era, the only known reservoir for the virus was humans; no known animal or insect reservoirs or vectors existed. The most frequent mode of transmission was person to person, spread through direct deposit of infective droplets onto the nasal, oral, or pharyngeal mucosal membranes or the alveoli of the lungs from close, face-to-face contact with an infectious person. Indirect spread (i.e., not requiring face-to-face contact with an infectious person) through fine-particle aerosols or a fomite (any substance that adheres to and transmits infectious material) containing the virus was less common. Symptoms of smallpox begin 12-14 days after exposure. Two to three days before the eruption of the characteristic rash, the victim experiences high fever, malaise, and severe headache and backache. This preemptive stage is followed by the appearance of a maculopapular rash that progresses to papules 1-2 days after the rash appears; the appearance of vesicles, pustules, and scab lesions follow. As the skin lesions heal, the scabs separate and pitted scarring gradually develops. Smallpox patients are most infectious during the first week of the rash, when the oral mucosa lesions ulcerate and release substantial amounts of virus into the saliva. A patient is no longer infectious after all scabs have separated.

J. Infectious Disease Elimination and Eradication

TABLE OVERVIEW J1.1-J1.2. Target Dates and Cost of Eradication The first table in this cluster summarizes the goals and estimated cost of eradication or elimination of the seven diseases targeted by the World Health Organization. The second table summarizes U.S. spending for the eradication of these diseases for fiscal 1997, the latest year for which figures are available. J2.1-J2.7. Diseases Targeted for Elimination or Eradication The tables in this cluster summarize epidemiological data for those diseases targeted for elimination or eradication: Chagas' disease (Trypanosoma cruzi), dracunculiasis, leprosy, measles, and poliomyelitis. International data is not available for lym-

285

phatic filariasis and onchoceriasis. The cluster also includes historical data on smallpox.

NOTES 1. "Final Push for Polio Eradication in Year 2000—Every Child Counts." Dr. Gro Harlem Brundtland, New Delhi, India, 6 January 2000. 2. T.A. Cockburn, "Eradication of Infectious Diseases." Science 133 no. 3458 (Apr. 7, 1961): 1050-1058. 3. F.L. Soper, "Problems to Be Solved if the Eradication of Tuberculosis Is to Be Realized," American Journal of Public Health 52 (1962): 734-745. 4. J.M. Andrews and A.D. Langmuir, "The Philosophy of Disease Eradication," American Journal of Public Health 53 (1963): 1-6. 5. CDC, "Recommendations of the International Task Force for Disease Eradication," Morbidity and Mortality Weekly Report 42, no. RR-16 (1993): 1-38.

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Table J1.1. WHO Estimated Target Dates and Costs for Eradicating or Eliminating Selected Diseases as of December 1997 Disease Dracunculiasis Polio Leprosy Measles Onchocarciasis Changas' disease Lymphatic filariasis

Goal Eradication Eradication I Elimination Eradication Elimination Elimination Elimination

Target date 2011** 2000*** 2000 2010 2010 2010 2030

Estimate cost* ($ million) $40 $1,600 $225 $4,900 $143 $391 $228

These costs represent projected public expenditures by national governments and donor countries for eradication or elimination campaigns. Costs are in 1997 dollars. **WHO expects that all but two countries will be free of dracunculiasis by 2005 ***Certification is expected by 2005 Source: United States General Accounting Office, Infectious Diseases: Soundness of World Health Organization Estimates for Eradication or Elimination (Washington, DC: General Accounting Office, 1998).

Table J1.2. U.S. Spending on Diseases to Be Eradicated or Eliminated, Fiscal Year 1997 Disease Dracunculiasis Polio Leprosy Measles Onchocarciasis Changas' disease Lymphatic filariasis Total

Domestic programs ($ millions)

Overseas programs ($ millions) ($ millions) 0 0.7 230 74.2 20: "0 50 11.7 0 3.5 0 0.4 0 0.6 300 91.1

Total 0.7 $304 $20 $62 $4 $0 $1 391.1

Source: United States General Accounting Office, Infectious Diseases: Soundness of World Health Organization Estimates for Eradication or Elimination. (Washington, DC: General Accounting Office, 1998).

J. Infectious Disease Elimination and Eradication 287 Table J2.1. Human Infection by Trypanosoma cruzi and Reduction of Incidence, Southern Cone Initiative, 1983-1999

Country

A g e group

Infection in

Infection in

Reduction of

(Years)

1983

1999

Incidence

(Rates x 100)

(Rates x 100)

(%)

Argentina

18

4.5

1.2

85.0

Brazil

7-14

18.5

0.17

96.0

Bolivia

1-4

33.9

ND

ND

Chile

0-10

5.4

0.14

99.0

Paraguay

18

9.3

3.9

60.0

Uruguay

6-12

2.5

0.06

99.0

Source: World Health Organization, Chagas (Web site). ttp://www.who.int/ctd/chagas/epidemio.htm.

Table J2.2. Dracunculiasis, Recent Epidemiological Data

Year 1992

1994

1995

1996

1997

16334 4302 Benin 4315 Burkina Faso 11784 8281 6861

2273 6281

1427 3241

855

127 CAR 0 156 Chad Cote d'lvoire 0

72 0

30

1231

640

15 18 149

17 9 127

19* 5 25

23* 34 3

8034

5061

3801

2794

India

1081

Kenya Mali Mauritania Niger Nigeria Togo Uganda Yemen Ethiopia Ghana Senegal Sudan Pakistan TOTAL

0

755 35

371 53

60 23

9 0

16024 1557 32829 183169 8179 126369

12011 5882 25346 75752 10349 42852

5581 5029 18562 39774 5044 10425

4218 1762 13821 16374 2073 4810

2402

562

8* 10* 1* 1254 1414* 485 0 0 0 7* 1* 6* 1099 650* 405 388 379* 214

2956 12282 1626 1455

3030 12590 1762 1374

2700* 13420* 2128* 1061*

0 303

0

106

82 514

62 371

7 451

0

8894

4877

8921

365* 5473* 9027

19

4

0

1993

1998

1999**

Country

Cameroon

1

695* 1898 2227

492 2160

1920 13237 1589

321 0 247

33464

1120 1252 17918 8432

728

815

195

76

2447

2984

53271

64608

118578 43596 47997* 59860

23

2

0

0

0

0

0

0 0

422555 229773 164990 129852 152814 77863 78557* 89966*

* Including imported cases. ** Provisional data, based on reports received through December, 1999. Source: World Health, Organization, Dracunculiasis (Web site). http://www.wHO.int/ctd/dracun/epidemio.htm.

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Table J2.3. Registered Prevalence of Leprosy and Detection Rate in the Top 11 Endemic Countries, Start of 2000a Country India Brazil (b) Myanmar Indonesia Nepal Madagascar Ethiopia(b) Mozambique Congo DR(b) Tanzania Guinea Total

Registered Cases at Prevalence per New cases detected Detection rate per start of 2000 10 000 during 1999 100 000 population 495 073 5.0 537 956 54.3 78 068 4.3 42 055 25.9 28 404 5.9 30 479 62.9 23 156 1.1 17 477 8.3 13 572 5.7 18 693 78.7 7 865 4.7 8 704 51.6 7 764 1.3 4 457 7.4 7 403 3.9 5 488 28.7 5 031 1.0 4 221 8.6 4 701 1.4 5 081 15.4 1 559 2.0 2 475 32.0 672 596 4.1 677 086 41.7

a)The top 11 endemic countries included in the above table have the following characteristics: (i) they have a prevalence of 1 or more than 1 in 10 000 populatiorl, and (ii) the number of prevalent leprosy cases is more than 5 000, or the number of newly detected cases is more than 2 000. b)1999 information Last Update: 14 December 2000 Source: World Health Organization., The most endemic countries in 2000 (Web site), http://www.who.int/lep/13.htm.

Table J2.4. Measles Global Annual Reported Incidence, 1980-1999

Source: World Health Organization, Department of Vaccines and Biologicals, WHO Vaccine Preventable Diseases: Monitoring System 2000 Global Summary (Geneva: World Health Organization, 2000). Available on the Internet at http://www.who.int/vaccines-documents/GlobalSummary/GlobalSummary.pdf.

J. Infectious Disease Elimination and Eradication

289

Table J2.5. Polio Global Annual Reported Incidence, 1980-1999

Source: World Health Organization, Department of Vaccines and Biologicals, WHO Vaccine Preventable Diseases: Monitoring System 2000 Global Summary (Geneva: World Health Organization, 2000). Available on the Internet at http://www.who.int/vaccines-documents/GlobalSummary/GlobalSummary.pdf.

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Statistical Handbook on Infectious Diseases

Table J2.6. Smallpox Cases in the United States, 1920-1950 Year 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950

Number of Cases 102 128 102 787 33 378 30 907 56 591 39 572 33 732 37 600 39 396 42 282 48 907 30 233 11224 6 491 5 371 7 957 7 834 11 673 14 939 9 877 2 795 1 396

865 765 397 346 337l

176 57 ^49"

39

Number of Deaths

498 620 607 126 871 707 376 138 129 137 165 93 38 39 24 25 35 34 48 41 14 12 2 8 9 12 25 5 5 2 0

Source: Jack W. Hopkins, The Eradication of Smallpox: Organizational Learning and Innovation in Health (Boulder: Westview Press, 1989).

J. Infectious Disease Elimination and Eradication 291

Table J2.7. Smallpox Cases Reported in World, by Year, 1920-1979

1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 19381 1939 1940 19411 1942 1943 1944 19451 19461 1947 1948 1949 1950 1951 1952 1953^ 1954 1955 1956 1957 1958 1959

19601 1961 1962 1963 1964 1965 1966 1967 1968 1969

Cases 401,318 303,850 190,159 174,799 186,354 284,845 324,125 327,289 272,529 267,322 360,575 182,829 211,274 328,212 327,373 331,151 263,579 149,184 144,042 186,393 235,820 195,863 124,504 210.3581 407,525 405,833 302,694 163,375 161,893 632,858 426,006 554,756 167,085 94,135 99,232 91,823 96,089 156,652 280,475 96,270 67,148' 90.5551 98,757 133,504 76,198 122,280 92,799 131,6974 80,024 54-202

Source: World Health Organization, The Global Eradication of Smallpox: Final Report of the Global Commission for the Certification of Smallpox Eradication (Geneva): World Health Organization, December 1979.

K. Bioterrorism and Biological Warfare OVERVIEW An intentional attack with a biological agent, bioterrorism is one of the most formidable of the growing roster of emerging infectious diseases. Prior to September 11, 2001, the clandestine release of infectious agents and the specter of biological weapons use were considered little more than theoretical possibilities. On September 11, 2001, however, the United States was attacked with, as President George W. Bush noted, "deliberate and massive cruelty."1 Images of fire, ashes, and bent steel were seen worldwide. The attacks were followed by anthrax mailings over the course of the fall. Today the clandestine release of infectious agents and the specter of biological weapons use constitute a public health threat of enormous magnitude. Today bioterrorism and bioweapons constitute new and increasingly critical policy priorities for public health and medical communities worldwide. Note that as recently as 1998 the U. S. Federal Bureau of Investigation (FBI) issued some statistics that appear to indicate a trend towards greater use of nuclear, biological, and chemical weapons.2 For these reasons, and although surveillance of bioterrorism has only recently begun at the federal level, and that data on this phenomenon are few, this Handbook would be incomplete without discussion of bioterrorism. Discussion includes a review of recent events, definitions of key terms, overview of diagnostic challenges, facts about two critical agents3 that remain in the media spotlight, and concludes with a review of the status of surveillance and prevention. Recent Events Recent events in the United States, Iraq, Japan, and Russia, cast an ominous shadow and are proof that large scale bioterrorism could happen. In the fall of 2001, anthrax mailings in the United States raised the public's awareness of health threats arising from exposure to biological agents. As of November 14, 2001, a total of 22 cases of anthrax has met the Centers for Disease Control and Prevention case definition;4 10 were confirmed inhalational anthrax, and 12 (seven confirmed and five suspected) were cuta-

neous anthrax.5 Confirmed anthrax cases6 include workers at American Media, Inc., Boca Raton, FL; NBC, ABC and CBS in Manhattan; West Trenton, New Jersey post office; Hamilton Township mail center, also in New Jersey; Brentwood mail center in Washington, DC; the Department of State Annex mail center, in Sterling, VA; and the Manhattan Eye, Ear & Throat Hospital. (Further information about anthrax is presented below.) Note too that anthrax contamination had forced the closure of the largest of the United States' Senate's office buildings, the Hart Office Building, for more than three months in the fall and early winter, 2001-2002. After the Gulf War, Iraq was discovered to have a large biological weapons program. In 1995, Iraq confirmed that it had produced, filled, and deployed bombs, rockets, and aircraft spray tanks containing Bacillus anthracis and botulinum toxin. In the same year, the Japanese cult, Aum Shinrikyo, released the nerve gas Sarin in the Tokyo subway. The cult also had plans for biological terrorism, and in its arsenal were large quantities of nutrient media, botulinum toxin, anthrax cultures, and drone aircraft equipped with spray tanks. Members of this group had traveled to Zaire in 1992 to obtain samples of Ebola virus for weapons development. Aum Shinrikyo demonstrated that terrorist groups now exist with resources comparable to those of some governments. Also of recent concern is the status of one of Russia's largest and most sophisticated former bioweapons facilities, called Vector, in Koltsovo, Novosibirsk. Writing in the journal Emerging Infectious Diseases, D. A. Henderson states Through the early 1990s, this was a 4,000-person, 30-building facility with ample biosafety level 4 laboratory facilities, used for the isolation of both specimens and human cases. Situated on an open plain surrounded by electric fences and protected by an elite guard, the facility housed the smallpox virus as well as Ebola, Marburg, and the hemorrhagic

K. Bioterrorism and Biological Warfare 293 fever viruses (e.g., Machupo and Crimean-Congo). A visit in the autumn of 1997 found a half empty facility protected by a handful of guards who had not been paid for months. (P. Jahrling, pers. comm., 1998).7

Key Terms Unlike chemical terrorism, which is immediately obvious, bioterrorism "may appear insidiously, with primary care providers witnessing the first cases."8 An understanding of biological agents is key to understanding the epidemiology of bioterrorism. Specifically, "A biological agent is commonly portrayed as a genetically engineered organism resistant to all known vaccines and drugs, highly contagious, and able to harm thousands of people."9 The Centers for Disease Control and Prevention categorizes biological agents by priority into Category A, B and C.10 High-priority agents include organisms that pose a risk to national security because they can be easily disseminated or transmitted person-to-person; cause high mortality, with potential for major public health impact; might cause public panic and social disruption; and require special action for public health preparedness. Category A agents include variola major (smallpox); Bacillus anthracis (anthrax); Yersinia pestis (plague); Clostribium botulinum toxin (botulism); Francisella tularensis (tularaemia); filoviruses (Ebola hemorrhagic fever and Marburg hemorrhagic fever); and arenaviruses (Lass and Junin [Argenine hemorrhagive fever]). Category B, or second priority agents, include those that are moderately easy to disseminate; cause moderate morbidity and low mortality; and require specific enhancements of CDC's diagnostic capacity and enhanced disease surveillance. Category B agents include Coxiella burnetti (Q fever); Brucella species (brucellosis); Burkholderia mallei (glanders); alphaviruses (Venezuelan encephalomyelitis, eastern and western equine encephalomyelitis); ricin toxin from Ricinus communis (castor beans); Staphylococcus enterotoxin B. A subset of List B agents includes pathogens that are food- or waterborne: Salmonella species; Shigella dysenteriae; Escherichia coli O 157:H7; Vibrio cholerae', and Cryptosporidium parvum. Third highest priority agents include emerging pathogens that could be engineered for mass dissemination in the future because of availability; ease of production and dissemination; and potential for high morbidity and mortality and major health impact. Category C agents include Nipah virus; hantaviruses, tickborne hemorrhagic fever viruses; tickborne encephalitis viruses; yellow fever; and multidrugresistant tuberculosis.

Epidemiologists and others report that biological attacks may not follow an expected pattern. They caution that "a small outbreak of an illness could be an early warning of a more serious attack. . . . " H They advise that "any small or large outbreak of disease should be evaluated as a potential bioterrorist attack."12 Biological warfare—that in which disease-producing microorganisms, toxins, or organic biocides (a substance capable of destroying living organisms) are deliberately used to destroy, injure, or immobilize livestock, vegetation, or human life, is contrasted with chemical warfare—the tactics and technique of conducting warfare by use of toxic chemical agents. Chemical agents that might be used by terrorists range from warfare agents to toxic chemicals commonly used in industry. Categories of chemical agents include nerve agents (tabun, sarin, soman, GF, VX); blood agents (hydrogen cyanide, cyanogen chloride); blister agents (lewisite, ntirogen and sulfur mustards, phosgene oxime); heavy metals (arsenic, lead, mercury); volatile toxins (benzene, chloroform, trihalomethanes); pulmonary agents (phosgene, chlorine, vinyl chloride); incapacitating agents (BZ); pesticides; dioxins, furans, and poly chlorinated biphenyls (PCBs); explosive nitro compounds and oxidizers (ammonium nitrate combined with fuel oil); flammable industrial gases and liquids (gasoline and propane); poison industrial gases, liquids, and solids (cyanides, nitriles); and corrosive industrial acids and bases (nitric acid, sulfuric acids). Note too the phenomena of biocrimes, the illicit use of biological agents by criminals and terrorists. Of concern here are instances in which a perpetrator or perpetrators used, acquired, or threatened to use a biological agent with the intent of inflicting mass casualties to achieve ideological, revenge, or "religious" goals, often hard to understand by laypersons and terrorism experts alike. Of relevance here too is the concept of weapons of mass destruction. The U.S. Department of Defense defines a weapon of mass destruction to include nuclear, biological, and chemical weapons, but the legal definition is different. "The Violent Crime Control and Law Enforcement Act of 1994" defines a weapon of mass destruction to include "any destructive device as defined in section 921" of Title 18 of the U.S. Code. According to section 921, a destructive device is any type of weapon which will, or which may be readily converted to, expel a projectile by the action of an explosive or other propellant, and which has any barrel with a bore of more than one-half inch in diameter; any bomb, grenade, any rocket having a propellant charge of more than four ounces; missile having an explosive or incendiary charge of more

294

Statistical Handbook on Infectious Diseases

than one-quarter ounce; mine; or similar device. To the Federal Bureau of Investigation, then, a weapon of mass destruction is basically any destructive device, including a great many that clearly cannot cause mass destruction and that have nothing to do with nuclear, biological, and chemical weapons cases.

DIAGNOSIS Differential diagnosis of an outbreak is advised as a first course of action. Many epidemiologic clues or indicators may point to the intentional use of a biological agent, including 1) the presence of a large epidemic, with greater case loads than expected, especially in a discrete population. 2) More severe disease than expected for a given pathogen, as well as unusual routes of exposure. 3) A disease that is unusual for a given geographic area, is found outside the normal transmission season, or is impossible to transmit naturally in the absence of the normal vector for transmission. 4) Multiple simultaneous epidemics of different disease. 5) A disease outbreak with zoonotic as well as human consequences, as many of the potential threat agents are pathogenic to animals. 6) Unusual strains or variants of organisms or antimicrobial resistance patterns disparate from those circulating. 7) Higher attack rates in those exposed in certain areas. . . . 8) intelligence that an adversary has access to a particular agent or agents. 9) Claims by a terrorist of the release of a biological agent. 10) Direct evidence of the release of an agent, with findings of equipment, munitions, or tampering.] 3 Of the long list of potential pathogens, D. A. Henderson comments only a handful are reasonably easy to prepare and disperse and can inflict sufficiently severe disease to paralyze a city and perhaps a nation. In April 1994, Anatoliy Vorobyov, A Russian bioweapons expert, presented to a working group of the National Academy of Sciences the conclusions of Russian experts as to the agents most likely to be used. Smallpox headed the list followed closely by anthrax and plague.14

None of these agents has so far effectively been deployed as a biological weapon. However, the magnitude of the problems that would be associated with the release of smallpox and anthrax were vividly demonstrated by two epidemics of smallpox in Europe during the 1970s and by an accidental release of aerosolized anthrax from a Russian bioweapons facility in 1979. In the Media Spotlight: Bacillus anthracis (anthrax) The Centers for Disease Control and Prevention defines a confirmed case of anthrax as (1) a clinically compatible case of cutaneous, inhalational, or gastrointestinal illness that is laboratory confirmed by isolation of B. antracis from an affected tissue or site or (2) other laboratory evidence of B. antracis infection bases on at least two supportive laboratory tests. Cutaneous anthrax is the most common naturally occurring type of infection (>95%) and usually occurs after skin contact with contaminated meat, wool, hides, or leather from infected animals. The incubation period ranges from 1-12 days. The skin infection begins as a small papule, progresses to a vesicle in 1-2 days followed by a necrotic ulcer. The lesion is usually painless, but patients also may have fever, malaise, headache, and regional lymphadenopathy. Most (about 95%) anthrax infections occur when the bacterium enters a cut or abrasion on the skin. Skin infection begins

as a raised bump that resembles a spider bite, but (within 1-2 days) it develops into a vesicle and then a painless ulcer, usually 1-3 cm in diameter, with a characteristic black necrotic (dying) area in the center. Lymph glands in the adjacent area may swell. About 20% of untreated cases of cutaneous anthrax will result in death. Deaths are rare if patients are given appropriate antimicrobial therapy. Early treatment of cutaneous anthrax is usually curative. Patients with cutaneous anthrax have reported case fatality rates of 20% without antibiotic treatment and less than 1% with it.15 Inhalational anthrax is the most lethal form of anthrax. Anthrax spores must be aerosolized in order to cause inhalational anthrax. The number of spores that cause human infection is unknown. The incubation period of inhalational anthrax among humans is unclear, but it is reported to range from 1 to 7 days, possibly ranging up to 60 days. It resembles a viral respiratory illness and initial symptoms include sore throat, mild fever, muscle aches and malaise. These symptoms may progress to respiratory failure and shock with meningitis frequently developing. Early treatment is important for recovery. Although case fatality estimates for inhalational anthrax are based on incomplete information, the rate is extremely high, approximately 75%, even with all possible supportive care including appro-

K. Bioterrorism and Biological Warfare 295

priate antibiotics. Estimates of the impact of the delay in post-exposure prophylaxis are not known.16 Gastrointestinal anthrax usually follows the consumption of raw or undercooked contaminated meat and has an incubation period of 1 to 7 days. It is associated with severe abdominal distress followed by fever and signs of septicemia. The disease can take an oropharyngeal or abdominal form. Involvement of the pharynx is usually characterized by lesions at the base of the tongue, sore throat, dysphagia, fever, and regional lymphadenopathy. Lower bowel inflammation usually causes nausea, loss of appetite, vomiting and fever, followed by abdominal pain, vomiting blood, and bloody diarrhea. As with cutaneous and inhalational anthrax, early treatment is important for recovery. For gastrointestinal anthrax, the case-fatality rate is estimated to be 25%-60% and the effect of early antibiotic treatment on that case-fatality rate is not defined.17 People should watch for the following symptoms: fever (temperature greater than 100 degrees F) and flulike symptoms, and a sore, especially on the face, arms or hands, that starts as a raised bump and develops into a painless ulcer with a black area in the center. The fever may be accompanied by chills or night sweats. Flu-like symptoms include a cough (usually non-productive cough), chest discomfort, shortness of breath, fatigue, muscle aches, sore throat, followed by difficulty swallowing, enlarged lymph nodes, headache, nausea, loss of appetite, abdominal distress, vomiting, or diarrhea. Before 2001, the last case of cutaneous anthrax in the United States occurred in North Dakota in 2000. It was the only case since 1992.18 Note that there is no screening test for anthrax; the only way exposure can be determined is through a public health investigation. Nasal swabs and environmental tests are used to determine the extent of exposure in a given building or workplace; they are not tests to determine whether an individual should be treated. Note too that anthrax is not contagious; the illness cannot be transmitted from person to person. Therefore, there is no need to quarantine individuals suspected of being exposed to anthrax or to immunize or treat contacts of persons ill with anthrax, such as household contacts, friends, or coworkers, unless they also were also exposed to the same source of infection. With regards to prevention, note that a vaccine has been developed for anthrax that is protective against invasive disease; it is currently only recommended for high-risk populations. CDC and academic partners are continuing to support the development of the next generation of anthrax vaccines. The Advisory Committee on Immunization Practices (ACIP) has recommended

anthrax vaccination for the following groups: persons who work directly with the organism in the laboratory; persons who work with imported animal hides or furs in areas where standards are insufficient to prevent exposure to anthrax spores; persons who handle potentially infected animal products in high-incidence areas; and military personnel deployed to areas with high risk for exposure to the organism. The anthrax crisis in the United States in the fall of 2001 precipitated an overwhelming demand from the American public and professionals for up-to-date and accurate information on health threats arising from exposure to biological, chemical, or radiological agents. In response to this demand the Centers for Disease Control and Prevention redesigned its Web site on bioterrorism resources (www.bt.cdc.gov). The redesigned site is the official federal site for medical, laboratory, and public health professionals to reference when providing information to the public and for updates on protocols related to health threats such as anthrax. In response to the mailings, Congress in December 2001 set aside $500 million to help the United States Postal Service, walloped by steep drops in revenue and mail volume, safeguard its customers, employees and the mail itself against bioterrorist attacks. In March of 2002, the Postal Service announced plans to use a highly sophisticated technology—polymerase chain reaction,19 to detect anthrax and other biohazards in the mail virtually as it is being sorted. By the end of September 2002, the Service plans to install the PCR systems at 292 facilities across the country. The Service also plans to spend $245 million to retrofit its high speed sorters, adding a system that will vacuum up air near the mail and feed it through a filter to capture any harmful bacteria. Today, fear of anthrax contamination remains high, fueled in part by the fact that scientists and bioinformatics experts still cannot pinpoint the source of the microbes used in the anthrax mailings. In the Media Spotlight: Variola major (smallpox) Caused by the variola virus, smallpox is spread from one person to another by infected saliva droplets that expose a susceptible person having face-to-face contact with the ill person. Persons with smallpox are most infectious during the first week of illness when the largest amount of virus is present in saliva. However, some risk of transmission lasts until all scabs have fallen off. The incubation period is about 12 days (range: 7 to 17 days) following exposure. Initial symptoms include high fever, fatigue, and head and backaches. A characteristic rash, most prominent on the face, arms, and legs, follows in 2-3 days. The rash starts with flat red lesions that evolve at the same rate. Lesions become

296 Statistical Handbook on Infectious Diseases pus-filled and begin to crust early in the second week. Scabs develop and then separate and fall off after about 3-4 weeks. The majority of patients with smallpox recover, but death occurs in up to 30% of cases. There is no proven treatment for smallpox but research to evaluate new antiviral agents is ongoing. Patients with smallpox can benefit from supportive therapy (intravenous fluids, medicine to control fever or pain, etc.) and antibiotics for secondary bacterial infections that occur. Smallpox infection was eliminated from the world in 1977. Routine vaccination against smallpox ended in 1972. The level of immunity, if any, among persons who were vaccinated before 1972 is uncertain; therefore, these persons are assumed to be susceptive. Vaccination against smallpox is not recommended to prevent the disease in the general public and is therefore not available. In people exposed to smallpox, the vaccine can lessen the severity of or even prevent illness if given within 4 days after exposure. Vaccine against smallpox contains another live virus called vaccinia. The vaccine does not contain smallpox virus. The United States currently has an emergency supply of smallpox vaccine. As of this writing, a debate is underway as to the pros and cons of the resumption of smallpox vaccination. Scientists agree that smallpox vaccine knowledge is lacking among physicians and the public: misinformation about the vaccine is widespread. The first vaccine to be developed (in 1796), the smallpox vaccine is considered to be the most dangerous. Unlike most other immunizations, smallpox vaccine can harm recipients and their contacts. Current guidelines, published in June 2001, do not recommend smallpox vaccine for the public. Vaccination is limited chiefly to laboratory workers directly involved with smallpox virus or its close virological cousins. The limits were based largely on the lack of enough vaccine. At the time, the government had only 15 million doses. But in the wake of the anthrax attacks in the fall 2001, the government expanded its stockpile of smallpox vaccine. Despite the fact that there is no information to suggest that a smallpox attack is likely, there is a tremendous demand for smallpox vaccine, including parents and health-care and other workers who would be the first to respond in an attack.

SURVEILLANCE Formal surveillance for potential bioterrorism agents began in January 1999, when CDC established the Bioterrorism Preparedness and Response Program to

improve the public health ability to detect and respond to biological and chemical terrorism. Members of this program are working with the FBI and other federal agencies to develop an organized response to suspect and confirm biological events. The program focuses on state-level preparedness for early clinical and laboratory detection, which is essential to ensure a prompt response to a bioterrorist attack (e.g., by providing prophylactic medicines or vaccines). Its initial activities are aimed at what are seen as critical agents, as defined in an earlier note. These critical agents and their associated diseases include variola major (smallpox), Bacillus anthracis (anthrax), Yersinia pestis (plague), Francisella tularensis (tularemia), Clostridium botulinum (botulism), and the viral hemorrhagic fevers (e.g., arenaviruses and filoviruses). Several other agents, including ones that cause food and waterborne disease, have been identified but require less broad-based preparedness efforts. An important part of preparedness is defining the natural epidemiology of diseases that can be caused by critical agents, including anthrax and plague, which are nationally notifiable diseases. Prevention The prospect of domestic bioterrorism is of increasing concern to a wide spectrum of individuals nationwide. Today it is generally understood that the United States is vulnerable to both biological and chemical terrorism. Today, too, it is generally understood that biological terrorism is more likely than ever before and far more threatening than either explosives or chemicals. Today we know that preventing or controlling bioterrorism will be extremely difficult. The fact that the detection or interdiction of those intending to use biological weapons is next to impossible poses additional challenges. In the United States today it is widely understood that substantial resources at the federal, state, and local levels are required to mount a credible and meaningful response. Educating the public and policy makers about bioterrorism is required for longerterm solutions, as is the building of a global consensus condemning the use of biological weapons. Today it is probably safe to say that the public health infrastructure is better prepared than it was prior to the fall of 2001 to prevent illness and injury that would result from biological and chemical terrorism, especially a covert terrorist attack. In the United States, preparedness activities and prevention efforts are multifaceted. Federal Emergency Management Agency and the Centers for Disease Control and Prevention occupy center stage in the preparation for a possible bioterrorism threat. In a bioterrorist event, the Department of Health and Human Services has special responsibilities, in-

K. Bioterrorism and Biological Warfare 297

eluding detecting the disease, investigating the outbreak, and providing stockpiled pharmaceuticals and emergency supplies in the large amounts needed. President Bush has named the Federal Emergency Management Agency to coordinate federal response efforts in the event of chemical, biological or nuclear terrorism. The Centers for Disease Control and Prevention has developed a strategic plan to address the deliberate dissemination of biological or chemical agents. The plan contains recommendations to reduce United States' vulnerability to biological and chemical terrorism—preparedness planning, detection and surveillance, laboratory analysis, emergency response, and communication systems.20 Training and research are integral components for achieving these recommendations. The success of the plan hinges on strengthening the relationships between medical and public health professionals and on building new partnerships with emergency management, the military, and law enforcement professionals. Reliable information is undisputedly the key to preparedness: for information on the public health aspects of bioterrorism see the Centers for Disease Control and Prevention's Bioterrorism Preparedness and Response Web site. The site provides information about chemical and biological agents, press releases, training, contacts, and other important information dealing with the public health aspects of bioterrorism, preparedness, and response. As concerns biological agents/diseases, the information provided for selected infectious diseases includes case definition, basic laboratory protocols for the presumptive identification of causative agents, prevention guidelines, and fact sheets or FAQs (frequently asked questions). Additionally, and as regards bioterrorism reports, CDC acknowledges that the ability to recognize a bioterrorism hoax is an important part of preparedness, and has taken steps to educate the public. CDC advises persons that if they are not sure whether a bioterrorism report is true or not, to check with credible sources, such as CDC's Health-Related Hoaxes and Rumors Web Site at http://www.cdc.gov/hoax_rumors.htm. A number of Internet sites are available regarding urban legends and hoaxes, such as the Urban Legend Reference Page at http://www.snopes2.com and the Computer Incident Advisory Committee and Department of Energy's HoaxBusters site at http://hoaxbusters.ciac.org. The HoaxBuster's site also offers a guide for recognizing Internet hoax at http://hoaxbusters.ciac.org/ HBHoaxInfo.html#identify. Efforts in the United States to deal with possible incidents involving bioweapons in the civilian sector

have begun only recently and have made only limited progress. The prospect of global bioterrorism, like that of domestic bioterrorism, is also of increasing concern to a wide spectrum of individuals worldwide. Today the CDC is cooperating with international health organizations like the World Health Organization (WHO) to help authorities in other countries investigate cases of what appear to be bioterrorism-related diseases. Requests for information regarding bioterrorism-related issues outside the United States should be directed to the International Team of CDC's Emergency Operations Center (email, [email protected]). In the event of a suspected or confirmed bioterrorist attack outside the United States, CDC would respond to a request for assistance from the World Health Organization or a International Ministry of Health. CDC's role in an international team responding to a bioterrorist attack would be determined by the specific needs identified by the World Health Organization and the host country or countries.

TABLE OVERVIEW Trends in bioagent cases since 1900 are presented in Table Kl. State supporters of terrorism and nuclear, biological, and chemical programs are presented in Table K2. The U.S. Department of State suspects that all of the countries listed possess biological weapons programs; six possess chemical weapons programs; and four have nuclear weapons programs. Today, anthrax and plague are nationally notifiable diseases. The last case of naturally occurring anthrax in the United States was reported in 1992. Cases of anthrax and plague are shown in Tables K3 and K4. Finally, two tables depict incidences of smallpox, both in the United States and globally, Tables K5 and K6.

NOTES 1. Taken from President George W. Bush's address at a prayer service on Friday, September 14, 2001 at the Washington National Cathedral. 2. "Reno, FBI Head Warn of Terrorism," Associated Press, April 23, 1998, 4:44 A.M. feed; Tim Weiner, "U.S. May Stockpile Medicine for Terrorist Attack," New York Times, April 23, 1998. 3. Critical agents are defined as those that are associated with high case fatality, can be disseminated to a large population, can cause social disruption because of public perception, and require preparedness efforts. 4. Centers for Disease Control and Prevention. "Update: Investigation of Anthrax Associated with Intentional Exposure and Interim Public Health Guidelines." October 2001. MMWR: Morbidity and Mortality Weekly Report 2001, 50:889-93.

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5. Centers for Disease Control and Prevention. "Update: Investigation of Bioterrorism-related anthrax, 2001." November 2001. MMWR: Mobidity and Mortality Weekly Report 2001, 50:1008-1010. 6. Cases were confirmed by the Centers for Disease Control and Prevention. The status of the victims varies; several have died. Other suspected cases remain unconfirmed as of this writing by the CDC. They include workers at the New York Post and a second NBC worker. 7. D. A. Henderson. Bioterrorism as a Public Health Threat. Emerging Infectious Diseases. Vol. 4, no. 3, July-September 1998. 8. J. A. Pavlin. Epidemiology of Bioterrorism. Emerging Infectious Diseases. 9. Ibid. 10. Ibid. 11. Ibid. 12. Ibid. 13. Ibid. 14. D. A. Henderson, Bioterrorism as a Public Health Threat. Emerging Infectious Diseases. Vol. 4, no. 3 (July—September 1998) p. 488-92. 15. Centers for Disease Control and Prevention. Facts about Anthrax. http://www.bt.cdc.gov/DocumentsApp/faqanthrax.asp. Accessed March 13,2002.

16. Ibid. 17. Centers for Disease Control and Prevention. Facts about Anthrax. http://www.bt.cdc.gov/DocumentsApp/faqanthrax.asp. Accessed March 13,2002. 18. To find out more about this case, see "Human Anthrax Associated with an Epizootic Among Livestock—North Dakota, 2000" (MMWR 2000; 5[32]:677). 19. Polymerase chain reaction is a laboratory method used to detect and amplify genetic material from organisms. It can be used to diagnose disease by identifying genetic material (DNA) commonly found in all Bacillus anthracis strains or it can be used to subtype the organism by amplifying specific genetic material and comparing it with known strains of B. anthracis to se if it matches of if it is different. When PCR is used for subtyping (a laboratory process to identify different subtypes of organisms), the amplified genetic material is usually further analyzed by other molecular methods, such as DNA sequencing. 20. Full details may be found in Centers for Disease Control and Prevention. Biological and Chemical Terrorism: Strategic Plan for Preparedness and Response. Recommendations of the CDC Strategic Planning Workgroup. MMWR 2000;49 (No. RR-4).

K. Bioterrorism and Biological Warfare 299

Table K1. Trends in Bioagent Cases, 1900-1999 Other/ Uncertain

Terrorist

Criminal

1990-1999

19

40

94

1980-1989

3

6

0

9

1970-1979

3

2

3

8

1960-1969

0

1

0

1

1950-1959

1

0

0

1

1940-1949

1

0

0

1

1930-1939

0

3

0

3

1920-1929

0

0

0

0

1910-1919

0

3

0

3

1900-1909

0

1

0

1

27

56

97

180

Totals

Total

153

Source: W. Seth Carus, Bioterrorism andBiocrimes: The Illicit Use of Biological Agents Since 1900. Working Paper. Center for Counterprofileration Research, National Defense University, Washington, DC. (February 2001 revision). http://www.ndu.edu/ndu/centercounter/Full_Doc.pdf.

Table K2. State Supporters of Terrorism and NBC Programs

State Supporters of Terrorism

Nuclear Program

CW Program

BW Program

Cuba Iraq Iran Libya North Korea Sudan Syria

None Confirmed Confirmed Confirmed Confirmed None None

None Confirmed Confirmed Confirmed Confirmed Confirmed Confirmed

Confirmed Confirmed Confirmed Confirmed Confirmed Confirmed Confirmed

Source: Robert G. Joseph, and John F. Reichart, Deterrence and Defense in a Nuclear, Biological, and Chemical Environment. Center for Counterproliferation Research, National Defense University, Washington, DC (1999). http://www.ndu.edu/inss/books/017.pdf.

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Table K3. Anthrax Cases in the United States, 1990-1999 Year 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999

Number 0 0 1 0 0 0 0 0 0 0

Source: Center for Disease Control and Prevention. U.S. Department of Health and Human Services. MMWR: Morbidity and Mortality Weekly Review Summary of Notifiable Disease. United States, 1999. 48 no. 53 (2001). http://www.cdc.gov/mmwr/PDF/wk/mm4853.pdf.

Table K4. Reported Cases of Plague, United States, 1980-1999 Year 1999

1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980

Number of Cases

9 9 4 5 9 17 10 13 11 2 4 15 12 10 17 31 40 19 13 18

Source: Center for Disease Control and Prevention. U.S. Department of Health and Human Services. MMWR: Morbidity and Mortality Weekly Review Summary of Notifiable Disease. United States, 7999 48 no. 53 (2001). http://www.cdc.gov/mmwr/PDF/wk/mm4853.pdf.

K. Bioterrorism and Biological Warfare 301

Table K5. Smallpox Cases in the United States, 1920-1950 Year

Number of Cases

Number of Deaths

1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950

102 128 102 787 33 378 30 907 56 591 39 572 33 732 37 600 39 396 42 282 48 907 30 233 11 224 6 491 5 371 7 957 7 834 11 673 14 939 9 877 2 795 1 396 865 765 397 346 337 176 57 49 39

498 620 607 126 871 707 376 138 129 137 165 93 38 39 24 25 35 34 48 41 14 12 2 8 9 12 25 5 5 2 0

Source: Jack W. Hopkins. The Eradication of Smallpox: Organizational Learning and Innovation in Health. Boulder: Westview Press, 1989.

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Table K6. World: Number of Smallpox Cases Reported, by Year, 1920-1979

Year 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961

Number 401 318 303 850 190 159 174 799 186 354 284 845 324 125 327 289 272 529 267 322 360 575 182 829 211 274 328 212 327 373 331 151 263 579 149 184 144 042 186 393 235 820 195 863 124 504 210 358 407 525 405 833 302 694 163 375 161 893 632 858 426 006 554 756 167 085 94 135 99 232 91 823 96 089 156 652 280 475 96 270 67 148 90 555

K. Bioterrorism and Biological Warfare 303

Table K6. (Continued) Year 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979

Number 98 757 133 504 76 198 122 280 92 799 131 697 80 024 54 202 33 706 52 806 65 153 135 859 218 367 19 278 954 3 234 2 0

Source: World Health Organization. The Global Eradication of Smallpox: Final Report of the Global Commission for the Certification of Smallpox Eradication. Geneva, December 1979.

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Appendix: World Health Organization (WHO) Regions AFRICAN REGION (AFR) Algeria Angola Benin Botswana Burkina Faso Burundi Cameroon Cape Verde Central African Republic Chad Comoros Congo Congo, Democratic Republic of the Cote d'lvoire Equatorial Guinea Eritrea Ethiopia Gabon Gambia Ghana Guinea Guinea-Bissau Kenya Lesotho Liberia Madagascar Malawi Mali Mauritania Mauritius Mozambique Namibia Niger Nigeria Rwanda

Sao Tome Senegal Seychelles Sierra Leone South Africa Swaziland Tanzania Togo Uganda Zambia Zimbabwe REGION OF THE AMERICAS (AMR) Antigua and Barbuda Argentina Bahamas Barbados Belize Bolivia Brazil Canada Chile Colombia Costa Rica Cuba Dominica Dominican Republic Ecuador El Salvador Grenada Guatemala Guyana Haiti Honduras Jamaica

306 Appendix: World Health Organization (WHO) Regions

Mexico Nicaragua Panama Paraguay Peru Saint Kitts Saint Lucia Saint Vincent and the Grenadines Suriname Trinidad and Tobago United States of America Uruguay Venezuela EASTERN MEDITERRANEAN REGION (EMR) Afghanistan Bahrain Cyprus Djibouti Egypt Iran Iraq Jordan Kuwait Lebanon Libya Morocco Oman Pakistan Qatar Saudi Arabia Somalia Sudan Syria Tunisia United Arab Emirates Yemen EUROPEAN REGION (EUR) Albania Andorra Armenia Austria Azerbaijan Belarus Belgium Bosnia and Herzegovina Bulgaria

Croatia Czech Republic Denmark Estonia Finland France Georgia Germany Greece Hungary Iceland Ireland Israel Italy Kazakhstan Kyrgyzstan Latvia Lithuania Luxembourg Macedonia, The Former Yugoslav Republic of Malta Monaco Netherlands Norway Poland Portugal Republic Romania Russian Federation San Marino Slovakia Slovenia Spain Sweden Switzerland Tajikistan Turkey Turkmenistan Ukraine United Kingdom Uzbekistan Yugoslavia SOUTH-EAST ASIA REGION (SEAR) Bangladesh Bhutan India Indonesia Maldives Myanmar

Appendix: World Health Organization (WHO) Regions

Nepal Sri Lanka Thailand

WESTERN PACIFIC REGION Australia Brunei Cambodia China Cook Islands Fiji Japan Kiribati Korea, Republic of Laos

Malaysia Marshall Islands Micronesia, Federated States of Mongolia Nauru New Zealand Niue Palau Papua New Guinea Philippines Samoa Singapore Solomon Islands Tonga Tuvalu Vanuatu Viet Nam

307

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Glossary Active reporting. See Passive reporting. Behavioral epidemic. Charles Mackay, in his classic work Extraordinary Popular Delusions and the Madness of Crowds, described what is known as a behavioral epidemic. This phenomenon can be seen in the reactions of impressionable teenagers at a rock concert, and in a different form in movements such as Nazism, when an entire nation is gripped by destructive fanaticism. The huge increase in traffic-related deaths and injury rates during the twentieth century, which has continued into the twentyfirst century, is a behavioral epidemic associated with addiction to high-speed automobiles. Biocrimes. The illicit use of biological agents by criminals and terrorists. Of concern are instances in which a perpetrator or perpetrators used, acquired, or threatened to use a biological agent with the intent of inflicting mass casualties to achieve ideological, revenge, or "religious" goals, often hard to understand by laypersons and terrorism experts alike. See biological agent; biological warfare; bioterrorism; chemical warfare; weapons of mass destruction. Biological agent. "A biological agent is commonly portrayed as a genetically engineered organism resistant to all known vaccines and drugs, highly contagious, and able to harm thousands of people."1 See also biocrimes; biological warfare; bioterrorism; chemical warfare; weapons of mass destruction. Biological warfare. Warfare in which disease-producing microorganisms, toxins, or organic biocides (a substance capable of destroying living organisms) are deliberately used to destroy, injure, or immobilize livestock, vegetation, or human life. See biocrimes; biological agent; bioterrorism; chemical warfare; weapons of mass destruction. Bioterrorism. Unlike chemical terrorism, which is immediately obvious, bioterrorism "may appear insidiously, with primary care providers witnessing the first cases."2 An understanding of biological agents is key to understanding

the epidemiology of bioterrorism. Specifically, "A biological agent is commonly portrayed as a genetically engineered organism resistant to all known vaccines and drugs, highly contagious, and able to harm thousands of people."3 However, epidemiologists and others report that biological attacks may not follow an expected pattern. They caution that "a small outbreak of an illness could be an early warning of a more serious attack."4 They advise that "any small or large outbreak of disease should be evaluated as a potential bioterrorist attack."5 See biocrimes; biological agent; biological warfare; chemical warfare; weapons of mass destruction. Border crosser. Defined, in part, by the Immigration and Naturalization Service as a "nonresident alien entering the United States across the Mexican border for stays of no more than 72 hours." Border crossers may go back and forth across the border many times in a short period. Burden of disease. See disease burden. Case. Within the context of infectious diseases, an episode of a disease in a person meeting the laboratory or clinical criteria for that disease generally as defined in the document "Case Definitions for Infectious Conditions under Public Health Surveillance." For example, a case of tuberculosis is an episode of TB disease in a person meeting the laboratory or clinical criteria for TB as defined in that document. MMWR: Morbidity and Mortality Weekly Report 1997,46, no. RR-10. Case definition. Provide uniform criteria for public health professionals to use when reporting cases of nationally notifiable infectious diseases. Components of case definitions may include clinical description, laboratory criteria for diagnosis, and case classification. Case definitions are intended to be used for identifying and classifying cases, both of which are often done retrospectively, for national reporting purposes. Case definitions serve to increase the specificity of reporting and improve the comparability of diseases reported from different geographic areas. Case definitions are revised as necessary; new case definitions

310

Glossary

are generated as needed. Case definitions are not intended to be used as the sole criteria for establishing clinical diagnoses, determining the standard of care necessary for a particular patient, setting guidelines for quality assurance, or providing standards for reimbursement, nor are they intended to be used for public health action. In October 1990, in collaboration with the Council of State and Territorial Epidemiologists (CSTE), CDC published "Case Definitions for Public Health Surveillance" (MMWR 1990, 39, no. RR-13). The definitions were approved by a full vote of the CSTE membership and also were endorsed for use by the Association of State and Territorial Public Health Laboratory Directors (ASTPHLD). This document was updated in 1997 (MMWR 1997, 46, no.RR-10). Chemical warfare. The tactics and technique of conducting warfare by use of toxic chemical agents. Chemical agents include blistering agents (e.g., distilled mustard, lewistie, mustard gas, nitrogen mustard, phosgene oxime, ethyldichloroarsine, methyldichloroarsine), agents that damage the blood (e.g., arsine, cyanogen chloride, hydrogen chloride, hydrogen cyanide), choking/lung/pulmonary damaging agents (e.g., chlorine, diphosgene, nitrogen oxide, perflurorisobutylene, phosgene, sulfur trioxide-chlororsulfonic acid), agents that cause vomiting (e.g., adamsite, diphenylchloroarsine, diphenylcyanoarsine), nerve agents (e.g., cyclohexyl sarin, GE, sarin, soman, tabun), riot control/tear agents, defoliants, and herbicides. See biocrimes; biological agent; biological warfare; bioterrorism; weapons of mass destruction. Clinically compatible case. In the context of case classification, a clinical syndrome generally compatible with the disease. Common-vehicle epidemic. An epidemic that is due to an agent that is spread on an ongoing basis in a "vehicle" such as food, water, or air. Food-borne common-vehicle epidemics usually cause gastrointestinal disease, and are sometimes perpetuated by a carrier who is a foodhandler. Waterborne epidemics include typhoid, giardia, viral hepatitis A, and many others. The best known airborne common vehicle epidemic is Legionnaire's disease. Notorious blood-borne common vehicle epidemics have occurred since the 1980s in many countries after the blood supply became infected with HIV or Hepatitis C virus. Communicable disease. A disease, the causative organism of which is transmissible from one person to another either directly or indirectly through a carrier or vector. Communicable disease surveillance. See surveillance.

Confirmed case. In the context of case classification, a case that is classified as confirmed for reporting purposes. Counting of a case. The process whereby a reporting area with count authority evaluates verified cases of a specific disease (e.g., assesses for case duplication). These cases are then counted for morbidity in that locality (e.g., state or county) and reported to the Centers for Disease Control and Prevention for national morbidity counting. See verification of a case. DALE. See disability-adjusted life expectancy. DALYs. See disability-adjusted life years. Disability-adjusted life expectancy (DALE). A summary measure of the burden of disability from all causes in a population, DALE is best understood as the expectation of life lived in equivalent full health. Disability-adjusted life years (DALYs). DALYs, along with disability-adjusted life expectancy (DALE), are summary measures of population health. DALYs are a measure of health gaps that state the difference between a population's health and a normative goal of living in full health. Disease. A pathological condition of the body that presents a group of clinical signs and symptoms and laboratory findings peculiar to it and that sets the condition apart as an abnormal entity differing from other normal or pathological body states. The concept of disease may include a condition of illness or suffering not necessarily arising from pathological changes in the body. There is a major distinction between disease and illness in that the former is usually tangible and may even be measured, whereas illness is highly individual and personal, as with pain, suffering, and distress. A person may have a serious disease such as hypertension but have no feeling of pain or suffering and thus no illness. Conversely, a person may be extremely ill, as with hysteria or mental illness, but have no evidence of disease as measured by pathological changes in the body. Disease burden. The impact of a disease or disease condition^) on a given population or populations. Discussions of disease burden have traditionally focused on mortality data and, within this context, on premature death or disability. More recently, the focus has shifted both to the impact of non-fatal outcomes of disease on the overall health status and/or productivity of a given population or populations and to the unseen burden of disease, such as the impact of years lived with disability on the overall health status and/or productivity of a population or populations. Discussions of disease burden often focus on the global burden of disease and generally include both comparisons

Glossary 311 of the burden of disease across many different disease conditions and projections for the future. Disease control. The reduction of disease incidence, prevalence, morbidity, or mortality to a locally acceptable level as a result of deliberate efforts; continued intervention measures are required to maintain the reduction. Control measures usually depend on routine services being instituted and maintained in a long-term perspective. Disease elimination. The reduction to zero of the incidence of a specified disease in a defined geographical area as a result of deliberate efforts; continued intervention measures are required. Disease eradication. Reduction of the worldwide incidence of a disease to zero as a result of deliberate efforts, obviating the necessity for further control measures. The extinction of the disease pathogen. Disease projection. Calculation of the future of disease (incidence, prevalence, etc.). Disease surveillance. The monitoring of disease. Within the context of communicable disease or diseases, the procedure of closely monitoring the contacts of individuals exposed to an infectious disease during the incubation period to prevent the spread of the disease. Surveillance is used in place of quarantine. The surveillance of a communicable disease is fundamental for disease prevention and control. Disease surveillance is used for a variety of purposes, for example, to monitor disease trends; monitor progress toward control objectives; estimate the size of a health problem; detect outbreaks of an infectious disease; evaluate interventions and preventative programs; and identify research needs. See also multi-disease surveillance. Disease trend. The general course or tendency of a disease. Endemic. The constant presence of a disease or infectious agent within a given geographic area. Endemic zone. Areas where there is a potential risk of infection. For example, yellow fever endemic zones in the Americas are areas in which a potential risk of infection exists because of the presence of vectors and animal reservoirs. Some countries consider these zones "infected" areas and require an international certificate of vaccination against yellow fever from travellers arriving from these areas. Epidemic. The occurrence in an area of a disease or illness to an extent greater than expected on the basis of past experience for a given population. In the case of a new disease, such as AIDS, any occurrence may be considered "epidemic." Also, a temporary prevalence of a disease.

Epidemic intelligence. Information on ongoing outbreaks or rumors of outbreaks worldwide. To improve international preparedness for epidemic response, it is essential to actively collect and rapidly verify this information and then to share it with the public health community. Epidemiologically linked case. In the context of case classification, a case in which (a) the patient has had contact with one or more persons who have or had the disease or have been exposed to a point source of infection and (b) transmission of the agent by the usual modes of transmission is plausible. A case may be considered epidemiologically linked to a laboratory-confirmed case if at least one case in the chain of transmission is laboratory confirmed. Health. A condition in which all functions of the body and mind are normally active. The World Health Organization defines health as a state of complete physical, mental, or social well-being and not merely the absence of disease or infirmity. Infection. The state or condition in which the body or part of it is invaded by a pathogenic agent (microorganism or virus) that, under favorable conditions, multiples and produces injurious effects. Localized infection is usually accompanied by inflammation, but inflammation may occur without infection. The symptoms of infection are those of inflammation. The five classical symptoms listed by early medical writers are dolor (pain), calor (heat), rubor (redness), tumor (swelling), and functio laesa (disordered function). Infectious agent. Something that produces infection. Also, something that is capable of being transmitted with or without contact. Infectious disease. Disease resulting from the presence of a pathogenic organism in the body. Specifically, any of the many diseases or illnesses (caused by bacteria or viruses) that can be transmitted from person to person, from animal to animal, or from organism to organism, by direct or indirect contact. The International Statistical Classification of Diseases & Related Health Problems (ICD) defines infectious diseases to include those diseases generally recognized as communicable or transmissible as well as a few diseases of unknown but possibly infectious origin. Laboratory-confirmed case. In the context of case classification, a case that is confirmed by one or more of the laboratory methods listed in the case definition under "Laboratory Criteria for Diagnosis." Although other laboratory methods can be used in clinical diagnosis, only those listed are accepted as laboratory confirmation for national reporting purposes.

312

Glossary

Multi-disease surveillance. A multi-disease approach to communicable disease surveillance that involves looking at all surveillance activities in a country as a common public service. These activities involve similar functions and very often use the same structure, processes, and personnel as disease surveillance. Surveillance is based on collecting only the information that is required to achieve control objectives of diseases. Data requested may differ from disease to disease, and some diseases may have specific information needs. Features of this approach include the following: looks at surveillance as a "common" service; seeks to maintain surveillance and control functions close to one another; recognizes that different diseases may have specialized surveillance needs; uses a functional approach to communicable disease surveillance; exploits opportunities for synergy in carrying out core as well as surveillance support functions; does not require a single system solution; and is best approached by developing and strengthening surveillance networks. Noninfectious conditions. As contrasted with infectious conditions, noninfectious conditions include environmental or occupational conditions, chronic diseases, adverse reproductive health events, and injuries. Notifiable disease. In the United States, a notifiable disease is one for which regular, frequent, and timely information regarding individual cases is considered necessary for the prevention and control of the disease. As of 1999, 55 infectious diseases were designated as notifiable at the national level. Pandemic. A worldwide epidemic affecting an exceptionally high proportion of the global population. Pandemics are contrasted to epidemics, which spread from person to person in a locality where the disease is not permanently prevalent. Parasitic disease. Disease resulting from the growth and development of parasitic organisms (plants and animals) in or upon the body. Passive reporting. The reporting and confirmation of cases seen in health facilities, as contrasted to active case-finding methods, where by cases are actively sought. Point-source epidemic. An epidemic in which a group of people fall ill as a result of a single exposure, typically to an agent in food they have all consumed, e.g., an outbreak of acute food poisoning due to staphylococcal enterotoxin. Prevalence. The number of existing cases of a disease among a total or specified population in a given period of time; usually expressed as a percentage or as the number of cases per thousand, per 10,000, and so on.

Probable case. In the context of case classification, a case that is classified as probable for reporting purposes. Prophylactic. Something that guards against or prevents disease. Prophylaxis. Measures designed to prevent the spread of disease and to preserve health; protective or preventive treatment. Public health. State of health of the population of a particular community as opposed to an individual or personal health. Health services to improve and protect community health, especially preventative medicine, immunization, and sanitation. Quarantine. Any isolation or restriction of movement imposed on apparently well individuals after they have been exposed to an infectious disease in an effort to control its spread. Also, the period of detention at entering a country (originally 40 days). The period of isolation following the onset of contagious disease. The place where individuals are detained for observation. Region of acquisition. The region or country of infection. To track epidemiologic patterns of disease acquisition more effectively, new regional categories are periodically devised. Region of diagnosis. The region or country of diagnosis. Reporting area. Areas responsible for counting and reporting verified cases of a disease to the Centers for Disease Control and Prevention. Currently there are 59 reporting areas: the 50 states, District of Columbia, New York City, American Samoa, Federated States of Micronesia, Guam, Northern Mariana Islands, Puerto Rico, Republic of Palau, and the U.S. Virgin Islands. Subepidemic. The morbidity that occurs within a proportion of the population infected by an epidemic. Supportive or presumptive laboratory results. In the context of case classification, specified laboratory results that are consistent with the diagnosis, yet do not meet the criteria for laboratory confirmation. Surveillance. The ongoing systematic collection, collation, analysis, and interpretation of data and the dissemination of information to those who need to know in order that action may be taken. Within the context of epidemiology, surveillance has been defined as the continuing scrutiny of all aspects of the occurrence and spread of a disease that are pertinent to effective control.6 For this, systematic collection, analysis, interpretation, and dissemination of health data are essential. This includes collecting information about clinical diagnoses, laboratory diagnoses, and mortality, as well as other relevant information needed to detect and track diseases in terms of person,

Glossary 313 place, and time. Surveillance systems must detect new communicable diseases as well as recognize and track diseases that are, or have the potential to become, of major public health importance. Disease surveillance systems may be national, regional, or global and may focus on an individual disease or on multiple diseases. Suspect. A person for whom there is a high index of suspicion (likely to have the disease) for active disease who is currently under evaluation for that disease. For example, in the context of tuberculosis, a person for whom there is a high index of suspicion for active TB (e.g., a known contact to an active TB case or a person with signs/symptoms consistent with TB) who is currently under evaluation for TB disease. Suspected case. In the context of case classification, a case that is classified as suspected for reporting purposes. Universal infection control precautions. Guidelines and procedures to protect health care workers from exposure to infection from blood and other body fluids. Vector-borne epidemics. Epidemics that are spread by insect vectors; vector-borne epidemics include viruses such as dengue and viral encephalitis, which are transmitted by mosquitoes. Verification of a case. The process whereby a case of a disease, after the diagnostic evaluation is complete, is reviewed at the local level (e.g., state or county) by a control official who is familiar with surveillance definitions for that particular disease; if all the criteria for a case are met,

the case is then verified and eligible for counting. See counting of a case. Weapon of mass destruction. The U.S. Department of Defense defines a weapon of mass destruction to include nuclear, biological, and chemical weapons, but the legal definition is different. "The Violent Crime Control and Law Enforcement Act of 1994" defines a weapon of mass destruction to include "any destructive device as defined in section 921" of Title 18 of the U.S. Code. According to section 921, a destructive device is "any gun with a barrel larger than half an inch, any bomb, grenade, any rocket have a propellant charge of more than four ounces." To the FBI, then, a weapon of mass destruction is basically any destructive device, including a great many that clearly cannot cause mass destruction and that have nothing to do with nuclear, biological, and chemical weapons cases. See biocrimes; biological warfare; bioterrorism; chemical warfare.

NOTES 1. J.A. Pavlin. "Epidemiology of Bioterrorism." Emerging Infectious Diseases Journal 5, no. 4 (1999): 528-30. 2. Ibid. 3. Ibid. 4. Ibid. 5. Ibid. 6. J.M. Last, A Dictionary of Epidemiology (New York: Oxford University Press, 1995).

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D. SEXUALLY TRANSMITTED DISEASES Centers for Disease Control and Prevention (CDC), U.S. Department of Health and Human Services. "Chancroid—United States, 1981-1990: Evidence for Underreporting of Cases." CDC Surveillance Summaries. MMWR 41, no. SS-3 (1992): 57-61. Centers for Disease Control and Prevention (CDC), U.S. Department of Health and Human Services. "Chlamydia Trachomatis Genital Infections—United States, 1995." MMWR 46, no. 9 (1997): 193-98. Available on the Internet at http://www.cdc.gov/mmwr/PDF/wk/mm4609.pdf. Accessed Sept. 5, 2001. Centers for Disease Control and Prevention (CDC), U.S. Department of Health and Human Services. "Congenital Syphilis—United States, 1998." MMWR 48, no. 34 (1999): 757-61. Available on the Internet at http:// www.cdc.gov/mmwr/PDF/wk/mm4834.pdf. Accessed Sept. 5, 2001. Centers for Disease Control and Prevention (CDC), U.S. Department of Health and Human Services. "Gonorrhea—United States, 1998." MMWR 49, no. 24 (2000): 538^12. Available on the Internet at http:// www.cdc.gov/mmwr/PDF/wk/mm4924.pdf. Accessed Sept. 5, 2001. Centers for Disease Control and Prevention (CDC), U.S. Department of Health and Human Services. "Primary and Secondary Syphilis—United States, 1998." MMWR 48, no. 39 (1999): 873-78. Available on the Internet at http://www.cdc.gov/mmwr/PDF/wk/mm4839.pdf. Accessed Sept. 5,2001. Division of STD Prevention, Centers for Disease Control and Prevention (CDC), U.S. Department of Health and Human Services. Sexually Transmitted Disease Surveillance 1999. Atlanta, GA: Centers for Disease Control and Prevention (CDC), 2000. Division of STD Prevention, Centers for Disease Control and Prevention (CDC), U.S. Department of Health and Human Services. Sexually Transmitted Disease Surveillance 1999 Supplement: Chlamydia Prevalence Monitoring Project. Atlanta, GA: Centers for Disease Control and Prevention (CDC), November 2000. Available on the Internet at http://www.cdc.gov/nchstp/dstd/Stats_Trends/99Chlamydia.htm. Accessed Sept. 5, 2001.

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E. TUBERCULOSIS Burwen, D.R., A.B. Bloch, L.D. Griffin, CA. Ciesielski, H.A. Stern, and I.M. Onorato. "National Trends in the Occurrence of Tuberculosis and Acquired Immunodeficiency Syndrome." Archives of Internal Medicine 155, no.12 (1995): 1281-86. Cantwell, M.F., D.E. Snider, G.M. Cauthen, and I.M. Onorato. "Epidemiology of Tuberculosis in the United States, 1985 through 1992." Journal of the American Medical Association 272, no. 7 (1994): 535-39. Centers for Disease Control and Prevention (CDC), U.S. Department of Health and Human Services. "Progress toward the Elimination of Tuberculosis—United States, 1998. MMWR 48, no. 33 (1999): 732-36. Available on the Internet at http://www.cdc.gov/mmwr/PDF/wk/mm4833.pdf. Accessed Sept. 5, 2001. Centers for Disease Control and Prevention (CDC), U.S. Department of Health and Human Services. Reported Tuberculosis in the United States, 1999. Atlanta, GA: Centers for Disease Control and Prevention (CDC), 2000. Available on the Internet at http://www.cdc.gov/nchstp/ tb/surv/surv99/surv99.htm. Accessed Sept. 5, 2001. Centers for Disease Control and Prevention (CDC), U.S. Department of Health and Human Services. "Tuberculosis Elimination Revisited: Obstacles, Opportunities, and a Renewed Commitment. Advisory Council for the Elimination of Tuberculosis (ACET). MMWR 48, no. RR-9 (1999). McKenna, M.T., E. McCray, J.L. Jones, I.M. Onorato, and K.G. Castor. "The Fall after the Rise: Tuberculosis in the United States, 1991-1994." American Journal of Public Health 88 (1998): 1059-63. Moore, M., I.M. Onorato, E. McCray, and K.G. Castro. Trends in Drug-Resistant Tuberculosis in the United States, 1993-1996. Journal of the American Medical Association 278, no. 8 (1997): 833-37.

F. FOODBORNE DISEASES Olsen, S.J., et al. "Surveillance for Foodborne-Disease Outbreaks—United States, 1993-1997." CDC Surveillance Summaries. MMWR 49, no. SS1 (2000): 1-7. Tauxe, R.V. "Emerging Foodborne Disease: An Evolving Public Health Challenge." Emerging Infectious Disease 3 (1997): 425-34.

G. WATERBORNE DISEASES Barwick, R.S., et al. "Surveillance for Waterborne-Disease Outbreaks— United States, 1997-1998." CDC Surveillance Summaries. MMWR 49,

Bibliography no. SS-4 (1996). Available on the Internet at http://www.cdc.gov/mmwr/ PDF/ss/ss4501.pdf. Accessed Sept. 5, 2001. Craun, G.F., ed. Waterborne Diseases in the United States. Boca Raton, FL: CRC Press, 1986.

H. INFECTIOUS DISEASE WORLDWIDE: PRESENT ISSUES, EMERGING CONCERNS Burnet, M. Natural History of Infectious Disease. Cambridge, England: Cambridge University Press, 1963. Centers for Disease Control and Prevention (CDC), U.S. Department of Health and Human Services. "Emerging Infectious Diseases." MMWR 42, no. 14 (1993): 257. "Control of Infectious Diseases, 1900-1999." Journal of the American Medical Association 282, no. 11 (1999): 1029. Eckert, E. "Diseased Societies." World and I 13, no. 10 (1998): 166(8). Garrett, L. The Coming Plague: Newly Emerging Diseases in a World out of Balance. New York: Farrar, Straus and Giroux, 1994. Garvey, G. "New or Emerging Infections." In The Columbia University College of Physicians & Surgeons Complete Home Medical Guide, 463. 3rd ed. New York: Crown, 1995. The Global Infectious Disease Threat and Its Implications for the United States. Available on the Internet at http://www.odci.gov/cia/publications/nie/report/nie99-17d.html. Accessed Sept. 5, 2001. Kunin, CM. "Resistance to Antimicrobial Drugs—A Worldwide Calamity." Annals of Internal Medicine 118, no. 7 (1993): 557-61. Lederberg, J., R.E. Shope, and S.C. Oaks, Jr., eds. Emerging Infections: Microbial Threats to Health in the United States. Washington, DC: National Academy Press, 1992. Morse, S.S., ed. Emerging Viruses. New York: Oxford University Press, 1993. Murray, C.J.L., and A.D. Lopez, eds. The Global Burden of Disease: A Comprehensive Assessment of Mortality and Disability from Diseases, Injuries and Risk Factors in 1990 and Projected to 2020. Global Burden of Disease and Injury Series, Vol. 1. Cambridge, MA: Harvard School of Public Health on behalf of the World Health Organization and the World Bank, 1996. Murray, C.J.L., and A.D. Lopez. Global Health Statistics: A Compendium of Incidence, Prevalence, and Mortality Estimates for over 200 Conditions. Cambridge, MA: Harvard School of Public Health on behalf of the World Health Organization and the World Bank, 1996. Murray, C.J.L., and A.D. Lopez. "Progress and Direction in Refining the Global Burden of Disease Approach: Response to Williams." Health Economics 9 (2000): 69-82. Murray, C.J.L., et al. Overall Health System Achievement for 191 Countries. GPE Discussion Paper No. 28. Geneva: WHO, 2000. Orloski, K.A., E.B. Hayes, G.L. Campbell, and D.T. Dennis. Surveillance for Lyme Disease—United States, 1992-1998. CDC Surveillance Summaries. MMWR 49, no. SS-3 (2000): 1-11. Available on the Internet at http://www.cdc.gov/mmwr/PDF/ss/ss4903.pdf. Accessed Sept. 5, 2001. Tandon, A., et al. Measuring Overall Health System Performance for 191 Countries. GPE Discussion Paper No. 30. Geneva: World Health Organization, 2000. World Health Organization (WHO). International Statistical Classification of Diseases & Related Health Problems (ICD). Available on the Internet at http://www.who.int/whosis/icdlO/. Accessed Sept. 5, 2001. World Health Organization (WHO). Report on Infectious Diseases: Overcoming Antimicrobial Resistance. Geneva, Switzerland: World Health Organization, 2000. Available on the Internet at http://www.who.int/ infectious-disease-report/2000/index.html. Accessed on Sept. 5, 2001. World Health Organization (WHO). Report on Infectious Diseases: Removing Obstacles to Healthy Development. Geneva, Switzerland: World Health Organization, 1999. Available on the Internet at http:// www.who.int/infectious-disease-report/index-rpt99.html. Accessed on Sept. 5, 2001.

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I. VACCINE-PREVENTABLE DISEASES Epidemiology and Prevention of Vaccine-Preventable Diseases. 6th ed. Waldorf, MD: Public Health Foundation, 2nd printing, January 2001. Available on the Internet at http://www.cdc.gov/nip/publications/pink/. Accessed Sept. 5, 2001. Fenner, F , et al. Smallpox and Its Eradication. Geneva, Switzerland: World Health Organization, 1988. Plotkin, S.A., and W.A. Orenstein. Vaccines. 3rd ed. Philadelphia, PA: W.B. SaundersCo., 1999.

J. INFECTIOUS DISEASE ELIMINATION AND ERADICATION Centers for Disease Control and Prevention (CDC), U.S. Department of Health and Human Services. "Eradication: Lessons from the Past: Global Disease Elimination and Eradication as Public Health Strategies. MMWR 48, supplement (1999): 16-22. http://www.cdc.gov/mmwr/ PDF/other/suppl48.pdf. Accessed Sept. 5, 2001. Centers for Disease Control and Prevention (CDC), U.S. Department of Health and Human Services. "Recommendations of the International Task Force for Disease Eradication." MMWR 42, no. RR-16 (1993). http://www.cdc.gov/mmwr/PDF/rr/rr4216.pdf.Accessed Sept. 5, 2001. Centers for Disease Control and Prevention (CDC), U.S. Department of Health and Human Services. "Reduced Incidence of Menstrual ToxicShock Syndrome—United States, 1980-1990." MMWR 39, no. 25 (1990): 421-23. Available on the Internet at http://www.cdc.gov/mmwr/ pre vie w/mmwrhtml/00001651.htm. Accessed Sept. 5, 2001. Dowdle, W.R., and R.D. Hopkins, eds. The Eradication of Infectious Diseases: Report of the Dahlem Workshop on the Eradication of Infectious Diseases. Chichester, England: John Wiley & Sons, 1998. The Global Eradication of Smallpox: Final Report of the Global Commission for the Certification of Smallpox Eradication, Geneva, December 1979. Geneva: World Health Organization, 1980. Hinman, A.R., et al. "The Case for Global Eradication of Poliomyelitis." Bulletin of the World Health Organization 65, no. 6 (1987): 835-40. Hopkins, Jack W. The Eradication of Smallpox: Organizational Learning and Innovation in International Health. Boulder: Westview Press, 1989. Mahon, B.E., E.D. Mintz, K.D. Greene, J.G. Wells, and R.V. Tauxe. "Reported Cholera in the United States, 1992-1994: a Reflection of Global Changes in Cholera Epidemiology." Journal of the American Medical Association 276, no. 4 (1996): 307-12. Mintz, E.D., R.V. Tauxe, and M.M. Levine. "The Global Resurgence of Cholera." In N.D. Noah and M. O'Mahony, eds. Communicable Disease Epidemiology and Control 63-104. Chichester, England: John Wiley & Sons, 1998. World Health Organization. "Global Eradication of Poliomyelitis by the Year 2000." Weekly Epidemiological Record 63 (1988): 161-62.

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Journal of the American Medical Association 278, no. 5 (1997): 399-411. Inglesby, T.V., D.T. Dennis, D.A. Henderson, et al. "Plague as a Biological Weapon: Medical and Public Health Management. Working Group on Civilian Biodefense" [Review]. Journal of the American Medical Association 283, no. 17 (2000): 2281-90. Okumura, T., K. Suzuki, A. Fukuda, et al. "Tokyo Subway Sarin Attack: Disaster Management, Part 1: Community Emergency Response." Academic Emergency Medicine 5 (1998): 613-17. Pile, J.C, et al. "Anthrax as a Potential Biological Warfare Agent." Archives of Internal Medicine 158, no. 5 (1998): 429-34. Tucker, J.B. "Chemical/Biological Terrorism: Coping with a New Threat." Politics and the Life Sciences 15 (1996): 167-84.

GLOSSARY Last, J.M. A Dictionary of Epidemiology. New York: Oxford University Press, 1995. Pavlin, J.A. "Epidemiology of Bioterrorism." Emerging Infectious Diseases Journal 5, no. 4 (1999): 528-30.

Index Acquired immunodeficiency syndrome (AIDS), 226; case definition, 48; children with, 47, 48, 49; clinical conditions included, 48; deaths from, 47, 51-52; definition, 47-48; delays in reporting, 52; diagnosis, 49; exposure categories, 52; pathologies, 49; persons living with, 47, 51; reporting delays, 52; subepidemics, 47; surveillance of, 50-52; symptoms, 49; table overview, 53-54; transmission, 49-50; treatment, 50; trends in incidence, 52, 54; and tuberculosis, 144. See also Human immunodeficiency virus (HIV) Addressing Emerging Infectious Disease Threats: A Prevention Strategy for the United States (CDC), 225 Adolescents: and pertussis, 4 Advisory Committee on Immunization Practices (ACIP), 5, 262, 295 African trypanosomiasis, 225 Alphaviruses, 293 Amebiasis, 175 Anthrax, 3, 197, 293, 294-95, 298; cutaneous, 294; gastrointestinal, 294-95; inhalational, 294; mailings of, 292; prevention, 295; symptoms, 295; vaccine, 295 Arenaviruses, 293, 296 Aum Shinrikyo, 292 Bacille Calmette-Guerin (BCG), 262 Bacillus anthracis, 292, 293, 294-95, 296 Biocrimes, 293 Biological agents, 293; categories, 293; definition, 293; diagnosis, 294-96; surveillance, 296-97 Biological warfare, 292-93 Bioterrorism, 292-97; agents, 292. See Biological agents; prevention, 296-97; and Yersinia pestis, 4 Bioterrorism Preparedness and Response Program (CDC), 296; Web site, 297 Blood transfusions: AIDS/HIV, 82; malaria, 49 Bodily fluids, exchange of, 49 Bordetella pertussis, 261-62 Botulism, 175,293,296 Brucella, 293 Brundtland, Gro Harlem, 282 Burkholderia mallei, 293 Campylobacter, 175, 176 CD4+cells, 48 Centers for Disease Control and Prevention (CDC), 1, 48; Addressing Emerging Infectious Disease Threats: A Prevention Strategy for the United States, 225; Bioterrorism Preparedness and Response Program, 296; bioterrorism Web site, 295, 297; HealthRelated Hoaxes and Rumors (Web site), 297; Preventing

Emerging Infectious Diseases: A Strategy for the 21st Century, 224-25; surveillance of emerging diseases, 224 Chagas disease, 283 Chancre, 96; sores, chancroid vs., 93 Chancroid, 92-93; chancre sores vs., 93; and HIV, 93; table overview, 100-101 Chemical agents, 293 Chemical terrorism, 293 Chickenpox. See Varicella Children: with AIDS, 47, 48, 49; and gonorrhea, 94; with haemophilus influenzae, 3; with hepatitis B, 4; and Hib vaccine, 2; with HIV, 51, 52; with pertussis, 4; and syphilis, 95; with tetanus, 5 Chlamydia, 93; and HIV, 93; in New York State, 97; reporting of, 96, 97; surveillance, 97; table overview, 98-99 Chlamydia trachomatis, 95, 96 Chloroquine phosphate, 82 Cholera, 3, 225; vaccine, 260-61 Clostridium: botulinum, 293, 296; tetani, 262 Cold sores, 93 Computer Incident Advisory Committee, 297 Council of State and Territorial Epidemiologists (CSTE), 1,215 Coxiella burnetti, 293 Critical agents: defined, 297 n.3 Cryptosporidiosis, 175 Cryptosporidium, 176, 214; parvum, 293 Cyclospora, 176 Deaths: from AIDS, 47, 51-52 Dengue fever, 225-26 Dengue haemorrhagic fever (DHF), 225-26 Department of Health and Human Services: and bioterrorism, 296-97 Diphtheria, 3; vaccine, 261 Disability-adjusted life years (DALYs), 227 Disseminated gonococcal infection (DGI), 94-95 Division of Emerging and Other Communicable Diseases Surveillance and Control (EMC), 224 Dracunculiasis, 283 Dracunculus medinensis, 283 Drug resistance: infectious diseases, 223-24; tuberculosis, 144 Ebola hemorrhagic fever, 293 Ebola virus, 292 Elephantiasis, 284 EMC. See Division of Emerging and Other Communicable Diseases Surveillance and Control (EMC) Emerging Infections Program (EIP), 224

320

Index

Encephalomyelitis, 293 Enteric fever, 175 Epidemics: defined, xxi Escherichia coli, 175, 176, 214, 293 Federal Emergency Management Agency, 297 Fetus: and HIV, 49; and syphilis, 95 Filariasis, lymphatic, 283-84 Filoviruses, 293, 296 Flaccid paralysis, 284 Flavivirus, 226 Foodborne diseases, 175; diagnosis, 175; outbreaks (FBDOs), 175-77; pathologies, 175; prevention and control, 176; pyramid, 176; surveillance, 176-78; symptoms, 175; table overview, 177; transmission, 175-76 Foodborne Diseases Active Surveillance Network (FoodNet), 176 Francisella tularensis, 293, 296 Gastroenteritis, 175 Genital herpes simplex virus, 93-94; and chancroid, 93; and HIV, 94; table overview, 100-101 Giardia, 175 Giardiasis, 175 Gonococcal Isolate Surveillance Project (GISP), 96 Gonorrhea, 94-95; and children, 94; and donor insemination, 94; pharyngeal, 95; and PID, 94, 95; and prostate, 95; reporting of, 96; surveillance, 97; table overview, 99 Guillain-Barre syndrome, 176 Guinea worm disease, 283 Haemophilus: ducreyi, 92, 100; influenzae, 3; type b (Hib), 3, 261 Hansen disease, 3 Hantaviruses, 293 Hart Office Building: anthrax contamination, 292 Health Plan Employer Data and Information Set (HEDIS), 97 Healthy People 2000, xxii, 98; HIV/AIDS and, 52-53 Healthy People 2010, xxii, 96 Healthy People: The Surgeon Generals Report on Health Promotion and Disease Prevention, xxi Hemolytic uremic syndrome (HUS), 176 Hepatitis A, 4; vaccine, 261 Hepatitis B, 4; vaccine, 261 Hepatitis B virus (HBV), 4 Hepatitis C virus (HCV), 4 Herpes simplex, 93-94 Hib vaccine, 3 HIV See Human immunodeficiency virus (HIV) HIV-1, 48 HIV-2, 48 HIV/AIDS, as a term, 48 HIV/AIDS Surveillance Report, 54 n.12 HoaxBusters (Web site), 297 Human immunodeficiency virus (HIV), 226; and acquired immunodeficiency syndrome (AIDS), 48; and blood transfusions, 49; case definition, 48-49; and chancroid, 93; children with, 51, 52; and chlamydia, 93; classification system, 48^49; diagnosis, 49; exposure categories, 52; and fetus/baby, 49; and genital herpes, 94; and needle injections of drugs, 49; numbers infected, 47; persons living with, 51; and pregnancy, 49; risk factors, 49; surveillance of, 50; and syphilis, 95; table overview, 53-54; transmission, 49; treatment, 50; and tuberculosis, 144. See also Acquired immunodeficiency syndrome (AIDS)

Human papillomavirus (HPV), 95 Immune deficiencies: and tuberculosis, 144 Inactivated poliovirus vaccine (IPV), 4, 262 Infants: with hepatitis B, 4 Infectious diseases: control, 282-83; defined, xxi; drug-resistant, 223-24; elimination, 282-83; emerging, 223, 224; eradication, 282-83; extinction, 282; global surveillance, 224; prevention and control, 224-25; worldwide, 223; table overview, 226-27 International Coordinating Group (ICG) on Vaccine Prevention for Epidemic Meningitis Control, 224 International Statistical Classification of Diseases and Related Health Problems (ICD), xxii Iraq: biological warfare, 292 Isoniazid (INH), 145 Jarisch-Herxheimer reaction, 95 Leprosy, 3, 283 Listeria monocytogenes, 176 Listeriosis, 175 Lyme disease, 4 Lymphatic filariasis, 283-84 Malaria, 81-83; case definition, 81; cerebral, 81; classification, 82; diagnosis, 82; incidence, 81; pathologies, 81-82; quartan, 81; quotidian, 81; surveillance, 81, 82; symptoms, 81-82; table overview, 82-83; tertian, 81; transmission, 82; treatment, 82 Marburg hemorrhagic fever, 293 Mass destruction, weapons of, 293-94 Measles, 4, 284; vaccine, 261 Meningitis, 226; vaccine, 261 Meningococcal disease, 4, 226 Meningoencephalitis, 94 MMWR Summary of Notifiable Diseases, United States, xxii, 2 Morbidity and Mortality Weekly Report (MMWR), 2, 54 n. 12 Morbillivirus, 284 Mumps, 4; vaccine, 261 Mycobacterium: avium, 145; leprae, 284; tuberculosis, 144, 145, 262 Naegleria, 175 National Academy of Science Institute of Medicine, 224 National Center for Infectious Diseases, 224 National Electronic Telecommunications System for Surveillance (NETSS), 2 National Malaria Surveillance System (NMSS), 82 National Notifiable Diseases Surveillance System (NNDSS), 2, 4, 82 Needle injections of drugs: and HIV, 49 Neisseria gonorrhoeae, 94 Newborn: chlamydia passed to, 93; and herpes, 94 Nipah virus, 293 Norwalk-like viruses, 175, 214 Notifiable diseases: history of reporting, 1, 3; surveillance, xxiii, 1-2 Onchocerca volvulus, 284 Onchocerciasis, 284 Ophthalmia: neonatal, 93 Oral poliovirus vaccine (OPV), 4, 262 Outbreak Verification network, WHO, 224

Index Panvisceral infections, 94 Paralysis: flaccid, 284 Paralytic poliomyelitis, 3 Pelvic inflammatory disease (PID), 93; and gonorrhea, 94, 95 Pertussis, 4; and adolescents, 4; vaccine, 4, 261-62 Pharyngeal gonorrhea, 95 Picornaviridae, 284 Plague, 4, 226, 293, 296, 297; vaccine, 262 Plasmodium: falciparum, 81; malariae, 81; ovale, 81; vivax, 81 Pneumonia: neonatal, 93 Polio Eradication Initiative, 282 Poliomyelitis, 284; abortive, 284; eradication, 282; paralytic, 3, 4-5, 284; vaccines, 262 Pregnancy: and chlamydia, 93; and hepatitis B, 4; and HIV, 49; and syphilis, 95; tubal, 93 Preventing Emerging Infectious Diseases: A Strategy for the 21st Century (CDC), 224-25 Primaquine, 82 Promoting Health/Preventing Disease: Objectives for the Nation in 1980, xxi Prostate: and gonorrhea, 95 Pyrazinamide (PZA), 145 Pyrimethamine, 82 Q fever, 293 Quinine, 82 Rabies, 5; human, 3; vaccine, 262 Ricinus communis, 293 Rifampin (RMP), 145 Risk factors, 49 Rocky Mountain spotted fever, 3 Rubella, 5; vaccine, 261 Salmonella, 176, 293; enteritidis, 175; typhi, 5, 263; typhimurium, 175 Salmonellosis, 175 Sarin, 292 Sexual activities: and HIV, 49; and STDs, 92 Sexually transmitted diseases (STDs): case definitions, 97; federally funded control programs, 96-97; fungal, 92; parasitic, 92; preventability, 92; surveillance, 96-97; in teenagers, 92; transmission, 92; trends, 92; viral, 92 Shigella, 176,214,293 Sleeping sickness. See African trypanosomiasis Smallpox, 295-96; eradication, 282, 284; vaccine, 296 Staphylococcus enterotoxin B, 293 Subepidemics, 47 Sulfonamides, 82 Surveillance: AIDS, 50-52; bioterrorism agents, 296-97; chlamydia, 97; foodborne diseases, 176-78; global infectious diseases, 224; gonorrhea, 97; HIV, 50; malaria, 82; notifiable diseases, xxiii, 1-2; sexually transmitted diseases (STDs), 96-97; syphilis, 97; tuberculosis, 144^-6; waterborne diseases, 214-15 Syphilis, 93, 95-96; congenital, 97; effect on fetus, 95; and HIV, 95; and pregnancy, 95; reporting of, 96; stages of, 95-96; surveillance, 97; table overview, 99-100 T cells, 48

321

Teenagers: with STDs, 92 Tetanus, 5; vaccine, 262 Tickborne hemorrhagic fever viruses, 293 Tickborne typhus fever, 3 Toxoplasmosis, 176 Treponema pallidum, 95, 96 Trichinosis, 175 Trichomona vaginalis, 96 Trichomoniasis, 96 Trypanosoma cruzi, 283 Trypanosomiasis, African, 225 Tsetse flies, 225 Tubal pregnancy, 93 Tuberculosis, 144-47; antibiotics, 145; case definition, 144; diagnosis, 144; and HIV/AIDS, 144; and immune deficiencies, 144; incidence, 144; miliary, 144; multidrug resistant (MDR-TB), 144, 294; pathologies, 144; surveillance, 144-46; symptoms, 144; table overview, 146-47; transmission, 144; treatment, 144; vaccine, 262 Tularaemia, 293, 296 Typhoid: vaccine, 263 Typhoid fever, 5 Urban Legend Reference Page, 297 Urethritis, nonspecific, 95 U.S. Environmental Protection Agency (EPA), 214-15 U.S. Federal Bureau of Investigation (FBI), 292 U.S. Marine Hospital Service, 1 Vaccine-associated paralytic poliomyelitis (VAPP), 4-5, 262 Vaccine-preventable diseases, 260-63; table overview, 263 Vaccine Prevention for Epidemic Meningitis Control, International Coordinating Group (ICG) on, 224 Vaccines, 260; access to, 260; anthrax, 295; cholera, 260-61; classes, 260; diphtheria, 261; haemophilus influenza type b (Hib), 261; hepatitis A, 261; hepatitis B, 261; measles, 261; meningitis, 261; mumps, 261; pertussis, 4, 261-62; plague, 262; poliovirus, 262; rabies, 262; roster of, 260-63; rubella, 261; smallpox, 296; tetanus, 262; tuberculosis, 262; typhoid, 263; usage, 263-64; yellow fever, 263 Varicella, 5 Variola major, 295-96 Vector, 292-93 Vibrio, 176; cholera, 225, 260-61, 293 Waterborne diseases, 214-16; diagnosis, 214; outbreaks (WBDOs), 214-15; surveillance, 214-15; symptoms, 214; table overview, 215-16; transmission, 214; treatment, 214 Weapons of mass destruction, 293-94 World Health Organization (WHO): and bioterrorism, 297; on emergence of infectious diseases, 223; global surveillance of infectious diseases, 224; International Health Regulations, 1; International Statistical Classification of Diseases and Related Health Problems (ICD), xxii; monitoring of infectious diseases worldwide, 224; Outbreak Verification network, 224 Yellow fever, 226, 293; vaccine, 263 Yersinia: enterocolitica, 176; pestis, 4, 226, 262, 293, 296

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About the Authors SARAH B. WATSTEIN is Director for Academic User Services and Head of the James Branch Cabell Library at Virginia Commonwealth University. She is the author of The AIDS Dictionary (1998) and AIDS and Women: A Sourcebook (Oryx, 1990). JOHN JOVANOVIC works for the government documents division of the James Branch Cabell Library, specializing in the identification and use of statistical sources.