CENTERS FOR DISEASE CONTROL January 25, 1991 / Vol. 40 / No. 3 Mortality Attributable to HIV Infection/ AIDS — United States, 1981-1990 Update: Influenza Activity — United States, 1990-91 Laboratory-Acquired Meningococcemia — California and Massachusetts MORBIDITY AND MORTALITY WEEKLY REPORT Current Trends Mortality Attributable to HIV Infection/AIDS — United States, 1981-1990 From 1981 through 1990, 100,777 deaths among persons with acquired immuno- deficiency syndrome (AIDS) were reported to CDC by local, state, and territorial health departments; almost one third (31,196) of these deaths were reported during 1990.* During the 1980s, AIDS emerged as a leading cause of death among young adults in the United States. By 1988," human immunodeficiency virus (HIV) infection/AIDS had become the third leading cause of death among men 25-44 years of age and, by 1989, was estimated to be second, surpassing heart disease, cancer, suicide, and homicide (Figure 1). In 1988, HIV infection/AIDS ranked eighth among causes of death among women 25-44 years of age (Figure 2); in 1991, based on current trends, HIV infection/AIDS is likely to rank among the five leading causes of death in this population (7 ). Most deaths from AIDS have occurred among homosexual/bisexual men (men who have had sex with other men) (59%) and among women and heterosexual men who are intravenous-drug users (21%) (Table 1). Nearly three fourths of deaths occurred among persons 25-44 years of age. Although most deaths occurred among whites, death rates have been highest for blacks and Hispanics. During 1990, the number of reported deaths (national AIDS surveillance) per 100,000 population was 29.3 for blacks (non-Hispanic), 22.2 for Hispanics, 8.7 for whites (non-Hispanic), 2.8 for Asian/Pacific Islanders, and 2.8 for American Indians/Alaskan Natives. As a percentage of all deaths, HIV infection/AIDS mortality has been greatest among persons 25-44 years of age. In 1989, among persons in this age group, HIV infection/AIDS accounted for 14% and 4% of all deaths among men and women, respectively; these proportions were more similar for white men and black men (14% and 16%, respectively) than for white women and black women (2% and 9%, respectively) (2). *Single copies of this article will be available free until January 25, 1992, from the National AIDS Information Clearinghouse, P.O. Box 6003, Rockville, MD 20850; telephone (800) 458-5231. 'The most recent year for which national vital statistics data are available to compare rankings of HIV infection/AIDS with other causes of death by age and sex. Vital statistics data in this report represent deaths for which HIV infection or AIDS was designated as the underlying cause of death. U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES / PUBLIC HEALTH SERVICE 42 January 25, 1991 HIV Infection/AIDS — Continued Reported by: Local, state, and territorial health departments. Div of HIV/AIDS, Center for Infectious Diseases; Div of Vital Statistics, National Center for Health Statistics, CDC. Editorial Note: From 1981, when AIDS was first recognized, through 1990, more than 100,000 persons in the United States have died from AIDS. The impact of AIDS has been greatest among men 25-44 years of age, contributing substantially to the overall increase in deaths among this group during the 1980s (3); in addition, AIDS is becoming a leading cause of death among women. FIGURE 1. Leading causes of death among men 25-44 years of age — United States, 1981-—1989* 100.04 Unintentional Injuries ererrrr Heart Disease ————e ma o e@g e-=e- =e- =—e - S=ell ememmeeet eHNIeeVo/pAllIaDs Sm s -,f ere Suicide — - Homicide Chronic Liver Disease and Cirrhosis —_———_ = Cerebrovascular Disease PD1poe0epa0rut, lh0as0t 0i on =Pan eumSoen iae e | and Influenza ganany Fm ’ — Diabetes Mell 1981 1982 1983 1984 1985 1986 1987 1988 1989 Gubaceames: Year *National vital statistics. Final data for 1981-1988; provisional data for HIV infection/AIDS for 1989. FIGURE 2. Leading causes of death among women 25-44 years of age — United States, 1980—1989* 100.0 5 Neoplasms Unintentional oe ee ee ee er eT Tt Injuries se eseeeeer OMe e ee ee eee ee eee eeeee sees eeeeeeee Heart Disease —_—_— i - = ” 7 Suicide SS oe Homicide = ee ee es ees es _— - Cerebrovascular OR ee rs ee ee Pasas @ ? Chronic Liver Disease and Cirrhosis —_—_—_— = HIV/AIDS ee PD1poe0epa0rut, lh0as0t 0i on Diabetes Mellitus nr es eee Pneumonia » _and Influenza 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 — eee Year *National vital statistics. Final data for 1980-1988; provisional data for HIV infection/AIDS for 1989. Vol. 40 / No. 3 HIV Infection/AIDS — Continued The impact of AIDS on mortality patterns has been greater in certain areas of the United States than in others. For example, in San Francisco, Los Angeles, and New York City, HIV infection/AIDS is the leading cause of death among young adult men. In both New York State and New Jersey, HIV infection/AIDS is the leading cause of death among black women 15-44 years of age; in New Jersey, the number of deaths among this population from HIV infection/AIDS in 1988 was nearly equal to the TABLE 1. Characteristics of persons who have died from AIDS — United States, 1981-1990 Characteristic No. (%) Total (100.0) HIV exposure group Homosexual/Bisexual men ( 59.1) Intravenous-drug users Women and heterosexual men ( 21.0) Homosexual/Bisexual men ( 6.8) Persons with hemophilia Adult/Adolescent 0.9) Child 0.1) Transfusion recipient Adult/Adolescent 2.8) Child 0.1) Heterosexual contact 3.6) Persons born in countries where HIV infection occurs primarily through heterosexual contact 1.2) Perinatal 1.2) No identified risk 3.3) Race/Ethnicity White, non-Hispanic 55.1) Black, non-Hispanic 28.4) Hispanic 15.7) Asian/Pacific Islander 0.6) American Indian/Alaskan Native 0.1) Unspecified 0.2) Age at death (yrs) <5 1.1) 5-14 0.3) 15-24 3.2) 25-34 36.1) 37.3) 14.1) 7.3) Unspecified 0.3) Sex Male ( 90.0) Female ( 10.0) Unspecified ( <0.1) Source: National AIDS surveillance. 44 January 25, 1991 HIV Infection/AIDS — Cont.:aued number of deaths from the second and third leading causes combined (cancer and unintentional injuries) (7; CDC, unpublished data). In some locations, HIV infection/ AIDS has become a major cause of death among young children; in New York State in 1988, HIV infection/AIDS was the leading cause of death among Hispanic children 1—4 years of age, and the second leading cause of death among black children 1-4 years of age, exceeding deaths from unintentional injuries among Hispanic children and from all other infectious diseases among both groups (4). Surveillance for AIDS cannot identify deaths among persons in whom HIV infection or HlV-related illness has not been diagnosed; however, AIDS surveillance does identify most deaths among persons diagnosed as having HIV infection. From July 1986 through June 1987, 3001 death certificates listing diagnoses that indicate HIV infection/AIDS were filed in New York City; of the deaths registered by these certificates, 85% were among persons who met the CDC AIDS surveillance case definition, 6% among persons who would have met the definition if HIV serology results had been available, and 9% among HIV-infected persons with illnesses or conditions not included in the AIDS surveillance definition (5). When the effects of underdiagnosis and underreporting are considered, AIDS surveillance identifies 70%-90% of HIV-infection—related deaths and, therefore, provides a minimum esti- mate of HIV-infection—related mortality (3; CDC, unpublished data). In addition to mortality statistics, measures of the public health impact of HIV infection/AIDS include morbidity, disability, and health-care costs. For example, the HIV infection/AIDS epidemic is straining the resources of public hospitals (6 ); in 1989, private insurers paid more than an estimated one billion dollars for reimbursement of AIDS-related claims for life and health insurance, an increase of 71% from 1988 (7). An estimated one million persons in the United States are infected with HIV (8 ); of these, an estimated 165,000—215,000 will die during 1991—1993 (8 ). The impact of HIV infection/AIDS on mortality in the mid-1990s to late 1990s and early 2000s will depend on present efforts to prevent and treat HIV infection. References . Chu SY, Buehler JW, Berkelman RL. Impact of the human immunodeficiency virus epidemic on mortality in women of reproductive age, United States. JAMA 1990;264:225-9. . NCHS. Births, marriages, divorces, and deaths for 1989. Hyattsville, Maryland: US Depart- ment of Health and Human Services, Public Health Service, CDC, 1990. (Monthly vital statistics report; vol 38, no. 12). . Buehler JW, Devine OJ, Berkelman RL, Chevarley F. Impact of the human immunodeficiency virus epidemic on mortality trends in young men, United States. Am J Public Health 1990;80: 1080-6. . Chu SY, Buehler JW, Oxtoby MJ, et al. Impact of the human immunodeficiency virus epi- demic on mortality in children, United States. Pediatrics 1991 (in press). . Hindin RH, Thomas P, Nicholas A, et al. Evaluating completeness of New York City’s case registry [Abstract]. V International Conference on AIDS. Montreal, June 4-9, 1989:110. . Andrulis DP, Weslowski VB, Gage LS. The 1987 US hospital AIDS survey. JAMA 1989;262: 784-94. . Carroll W. AlDS-related claims survey: claims paid in 1989. Washington, DC: American Council of Life Insurance/Health Insurance Association of America, Sept. 1989. . CDC. HIV prevalence estimates and AIDS case proje tions for the United States: report based on a workshop. MMWR 1990;39(no. RR-16):30. Vol. 40 / No. 3 MMWR Update: Influenza Activity — United States, 1990-91 During December 1990 (weeks 48-52) and January 1991 (weeks 1 and 2), influenza and influenza-like illness activity were higher in the United States than in previous weeks (Table 1). As of January 18, >95% of the approximately 125 influenza virus isolates reported to CDC have been influenza B. Deaths associated with pneumonia and influenza are at levels expected for this time of year. During December, a small number of outbreaks of influenza-like illnesses were reported in schools and colleges in the northeastern United States. Through Jan- uary 18, there have been no reports of outbreaks in chronic-care facilities or nursing homes. Reported by: State and territorial health department epidemiologists and state public health laboratory directors. WHO Collaborating Laboratories. Sentinel Physicians Influenza Surveil- lance System of the American Academy of Family Practice. Epidemiology Office and Influenza Br, Div of Viral and Rickettsial Diseases, Center for Infectious Diseases, CDC. Editorial Note: During the 1989-90 influenza season, widespread influenza out- breaks occurred during December 1989, and influenza A(H3N2) was the predominant virus isolated. Although influenza B has been the predominant virus isolated this season, culturing for influenza viruses remains important in the evaluation of respiratory illnesses in high-risk persons, especially those in group living situations, because amantadine may be useful in treatment and prophylaxis if influenza A is identified (7). Amantadine is effective against influenza A but not against influenza B. Parents and health-care workers should consult a physician before administering aspirin to children with influenza and influenza-like illness because its use may increase the risk for Reye syndrome (2). TABLE 1. influenza and influenza-like illness (IL!)* activity’ — October 1990—January 1991 % Patients No. states reporting activity Week with ILI® Sporadic Regional Widespread 40-46 3.5 4-10 0 0 47 4.7 g 48 4.4 14 49 4.6 11 50 4.7 16 51 5.7 16 52 6.8 16 1 5.9 17 2 - 18 8 *IIlness with fever (temperature >100 F [>37.8 C]) and cough, myalgia, or sore throat. "Levels of activity are: 1) sporadic—sporadically occurring influenza-like illness or culture- confirmed influenza, with no outbreaks detected; 2) regiona/— outbreaks of influenza-like illness or culture-confirmed influenza in counties having a combined population of <50% of the state’s total population; 3) widespread—outbreaks of influenza-like illness or culture-confirmed influenza in counties having a combined population of =50% of the state’s total population. ’Approximately 150 physicians in 48 states report number of patients seen and number of patients with IL! each week. 46 January 25, 1991 Influenza Activity — Continued References 1. ACIP. Prevention and control of influenza. MMWR 1990;39(no. RR-7). 2. Hurwitz ES, Barrett MJ, Bregman D, et al. Public Health Service Study of Reye’s Syndrome and Medications: report of the main study. JAMA 1987;257:1905—11. Laboratory-Acquired Meningococcemia — California and Massachusetts Although Neisseria meningitidis is commonly isolated in clinical laboratories, laboratory-acquired infection is rare (7). This report describes two fatal cases of meningococcal infection in laboratory workers; both of these cases probably were laboratory acquired. Case 1. On March 8, 1988, a clinical laboratory bacteriologist in California became ill with influenza-like symptoms and nausea. During the next 24 hours, she developed fever, myalgias, arthralgias, diarrhea, skin lesions, and confusion. Her husband informed ambulance personnel that she had had a mishap in the laboratory approx- imately 1 week earlier with a type of organism that causes meningitis. When hospitalized at 10 p.m. on March 9, she was hypotensive with numerous petechial and purpuric lesions on her face, neck, trunk, and extremities; she died 6 hours later. The final autopsy diagnosis was “clinical acute intractable shock, consistent with acute meningococcemia.” Blood cultures and cerebrospinal fluid studies were negative. Serum was positive by a bivalent (groups C and W135) latex agglutination test for N. meningitidis. A throat culture grew N. meningitidis. No mishap had been reported at the hospital laboratory where the patient worked, nor could the patient’s co-workers recall any episode; no additional information regarding a mishap could be discovered. During the previous 3 months, the patient worked with only one known WN. meningitidis isolate, which was obtained from the blood of a patient with acute meningitis and cultured by the affected laboratory worker 5—6 days before onset of her symptoms. Both the workplace isolate and the laboratory worker’s nasopharyngeal isolate were identified as N. meningitidis serogroup C by the Microbial Diseases Laboratory of the California Department of Health Services. CDC performed isoenzyme testing on the laboratory worker's nasopharyngeal isolate, the workplace isolate, and 14 other unrelated but recently isolated group C strains from throughout northern California. The isoenzyme type of the laboratory worker's isolate and the workplace isolate were identical and rare. They differed from the 14 northern California isolates (p<0.01, Fisher’s exact test) and from a collection of 256 group C meningococci isolated between 1986 and 1989 (p<0.01, Fisher’s exact test). Case 2. On the morning of September 6, 1988, a microbiology technician at a teaching hospital in Massachusetts presented to the hospital’s employee health clinic with a history of several days of rhinorrhea, sore throat, and myalgias. She was sent home at 1 p.m. with a diagnosis of viral syndrome. Twelve hours later, she presented to the emergency room semiresponsive, hypotensive, dyspneic, and with petechial Vol. 40 / No. 3 Meningococcemia — Continued and purpuric skin lesions. A gram stain of the buffy coat of her blood showed gram negative diplococci. Despite antibiotic therapy, she died 6% hours later. Blood cultures grew N. meningitidis group B. For several days before her hospitalization the patient had been working in the bacteriology laboratory at the teaching hospital despite her upper respiratory infec- tion symptoms. The laboratory had not isolated N. meningitidis during the 3 weeks before the patient's illness. On September 3 and 4, the patient worked in the bacteriology laboratory of another hospital. She had been observed using gloves to subculture an N. meningitidis isolate, and she had extensive rhinorrhea. Both the workplace isolate and the patient's blood culture isolate were identified as N. meningitidis serogroup B. lsoenzyme testing performed by CDC on the patient's blood isolate, the workplace isolate, and nine other unrelated but recently isolated group B strains from Massachusetts demonstrated that the isoenzyme pattern of the patient and workplace isolate were identical. They differed from the nine other Massachusetts group B isolates (p<0.02, Fisher’s exact test). Reported by: KK Takata, BG Hinton, MD, Sacramento County Health Dept; SB Werner, MD, Infectious Disease Br, Preventive Medical Svcs Div; GW Rutherford, MD, State Epidemiologist, California Dept of Health Svcs. SM Lett, MD, Bur of Communicable Disease Control, Center for Disease Control, Massachusetts Dept of Public Health. Biosafety Br, Office of Health and Safety; Meningitis and Special Pathogens Br, Div of Bacterial and Mycotic Diseases, Center for Infectious Diseases, CDC. Editorial Note: Laboratory-acquired infection with N. meningitidis is rare. Three previous case reports describe infections in persons working in research laboratories who handled meningococcal organisms frequently and in large volumes (1,2 ); two of these occurred before the availability of effective vaccines and antibiotic therapy. Although N. meningitidis was never isolated from the blood of the laboratory worker in California, other evidence supports the conclusion that she had laboratory- acquired meningococcal infection. The worker in Massachusetts may have been at increased risk for meningococcal infection; several studies suggest that concurrent viral infection increases the risk of developing invasive meningococcal infection (3-5 ). These cases represent the first reports of meningococcal infection acquired in the clinical laboratory setting. Although laboratory workers frequently handle specimens and cultures containing meningococci, the laboratory workers probably are not at increased risk of infection when standard microbiologic practices are followed. Meningococci may be present in specimens of pharyngeal exudates, cerebrospinal fluid, blood, and saliva. Laboratory workers may be exposed to organisms by inoc- ulation, ingestion, and droplet or aerosol exposure of the mucous membranes. Guidelines for laboratory workers who handle meningococci include use of protec- tive gloves and laboratory coats and decontamination of all infectious wastes (6). A class Il biological safety cabinet should be used when mechanical manipulations that have high aerosol potential are performed. Work involving high concentrations or large quantities of organisms should be performed in a biosafety level 3 laboratory; laboratory workers in this setting should be immunized with the tetravalent menin- gococcal polysaccharide vaccine that includes serogroups A, C, Y, and W135 but does not include serogroup B, currently the most common serogroup in the United States. In the event of any incident or exposure involving meningococci, workers should seek prompt medical attention. Persons with percutaneous exposure to meningococci should receive chemoprophylaxis with penicillin; those with mucosal exposure should be treated with rifampin (7). (Continued on page 55) MMWR January 25, 1991 FIGURE |. Notifiable disease reports, comparison of 4-week totals ending January 19, 1991, with historical data — United States DISEASE DECREASE INCREASE Aseptic Meningitis Encephalitis, Primary Hepatitis A Hepatitis B Hepatitis, Non—A, Non—B Hepatitis, Unspecified Legionellosis Malaria Measles, Total Meningoco<cal Infections Mumps Pertussis Rabies, Animal Rubella rr T T 0.125 0.25 0.5 1 Ratio(Log Scale)* BEYOND HISTORICAL LIMITS *Ratio of current 4-week total to mean of 15 4-week totals (from comparable, previous, and subsequent 4-week periods for past 5 years). TABLE |. Summary — cases of specified notifiable diseases, United States, cumulative, week ending January 19, 1991 (3rd Week) Cum. 1991 Cum. 1991 AIDS 1,757 Plague Anthrax Poliomyelitis, Paralytic* - Botulism: Foodborne - Psittacosis 1 Infant Rabies, human - Other - Syphilis: civilian 1,672 Brucellosis military 2 Cholera - Syphilis, congenital, age 1 year Congenital rubella syndrome : Tetanus : Diphtheria - Toxic shock syndrome 17 Encephalitis, post-infectious Trichinosis 1 Gonorrhea: civilian Tuberculosis military Tularemia Leprosy Typhoid fever Leptospirosis Typhus fever, tickborne (RMSF) Measles: imported indigenous *No cases of suspected poliomyelitis have been reported in 1991; none of the 6 suspected cases in 1990 have been confirmed to date. Five of the 13 suspected cases in 1989 were confirmed and all were vaccine associated. Vol. 40 / No. 3 MMWR TABLE Il. Cases of specified notifiable diseases, United States, weeks ending January 19, 1991, and January 20, 1990 (3rd Week) Ascptis Encephalitis Hepatitis (Viral), by type Reporting Area AIDS | Megniitins- Pri. mary SPeocstti.oinn-s G(oCniiovvirilr ihane)a B NA.NB Un oe i- Leglioosnise l- C1u9m91. Cum. C1u99m1 C1u9m9.1 C1u99m1 C1u9m9.0 . | C1u99m1 C1u9m9.1 C1u9m9.1 C1u9m9.1 UNITED STATES 1,757 23 1 24,485 37,839 141 38 39 MNaEiWn e ENGLAND 1316 21 - 1,0005 71 3 5 1 402 MID. ATLANTIC Upstate N.Y E.N. CENTRAL Ohio Ind Wt Mich Wis W.N. CENTRAL S. ATLANTIC Del Md D.C E.S. CENTRAL Ky Tenn Ala Miss eW-nBwO NW— W.S. CENTRAL Ark MOUNTAIN Mont Idaho Wyo Colo N. Mex -_ Ariz Utah Nev PACIFIC Wash Oreg Calif Alaska wbe Hawaii @N1 NNWS,O O Amer. Samoa C.N.M.1 N: Not notifiable U: Unavailable C.N.M.1.: Commonwealth of the Northern Mariana Islands 50 MMWR January 25, 1991 TABLE Il. (Cont’d.) Cases of specified notifiable diseases, United States, weeks ending January 19, 1991, and January 20, 1990 (3rd Week) Reporting Area Malaria Indi- genoMuesa sles i(mRpuobretoelda*) Total | i9n Mfeenctiino-n s Mumps Pertussis Rubella C19u91m_| "87 |C 1u99m1 | 997] C1u9m9.3 || C 1u99m0 | C1u99m1 1997 |C 1u99m1 |" 99" |C 1u9m9.7 || C 1u99m0 1991| CS uom.o t | C1u9m9.0 MUNaNEiIWnT eE DE NGSLTAANTEDS 334 40 86 5 6175 646 45 1021 301 75 15310 3 8 19 1 MID. ATLANTIC Upstate N.Y N.Y. City N.J Pa E.N. CENTRAL Ohio Ind WW Mich Wis W.N. CENTRAL S. ATLANTIC Del Md D.C E.S. CENTRAL Ky Tenn Ala Miss W.S. CENTRAL Ark la Okla Tex MOUNTAIN Mont Idaho Wyo Colo N. Mex Ariz Utah Nev PACIFIC Wash Oreg Calif Alaska Hawaii ~-—@OoZnw Amer. Samoa C.N.M.I ce¢c,.cc¢ N“:F orN omte ansolteifsi abolnel y, imUp:o rtUenda vacialsaebsl e includ"eIsn tebrontaht ioounta-lo f-stat‘eO uta-nodf -sitnatteer national importations.