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January 20, 1995 / Vol. 44/ No. 2 Dengue Type 3 Infection Race-Specific Differences in Influenza Vaccination Levels Among Medicare Beneficiaries — United States, 1993 Type B Botulism Associated with Roasted Eggplant in Oil — Italy, 1993 Adult Blood Lead Epidemiology and Surveillance — United States Multistate Outbreak of Viral Gastroenteritis Associated with Consumption : of Oysters — Apalachicola Bay, Florida, MORBIDITAYN D MORTALITY WEEKLY REPORT = December 1994-January 1995 Notices to Readers International Notes Dengue Type 3 Infection — Nicaragua and Panama, October-November 1994 The geographic range and incidence of dengue virus activity in the Americas substantially increased from 1980 to 1994. During this period, all dengue activity in the Americas was associated with dengue serotypes 1, 2, and 4 (DEN-1, DEN-2, and DEN- 4). On November 25, 1994, the Ministry of Health of Nicaragua announced the isolation of dengue type 3 (DEN-3) from two children hospitalized with minor hemorrhagic manifestations in Managua. Subsequently, DEN-3 virus was isolated from two persons with dengue fever in Panama. These cases represent the first isolation of DEN-3 from autochthonous cases in the Americas since 1977. This report describes these cases and dengue activity in Nicaragua and Panama and summarizes public health activities to control dengue fever in the Americas. On October 22, 1994, a 5-year-old boy was hospitalized in Managua with symptoms of classic dengue fever (i.e., fever, vomiting, and rash). On October 23, a 10-year-old girl from Managua was hospitalized with similar symptoms. Both children had an un- eventful clinical course and recovered. DEN-3 virus was isolated and reiso!ated (for confirmation) from blood samples from both patients by the Pedro Kouri Institute of Tropical Medicine in Havana. Serologic analyses confirmed that both were primary dengue infections. DEN-3 virus also was isolated from Blood samples of two patients with symptoms of dengue fever in Panama by the Gorgas Memorial Laboratory in Panama City. The first case occurred in the province of Chiriqui (sample collected on October 11) and the second, in the province of Panama (sample collected on November 14). Genetic typing of the initial DEN-3 isolate from Panama at CDC indicated the virus belongs to the Sri Lanka/india genotype, which caused major dengue hemorrhagic fever (DHF) epidemics in Sri Lanka and India during 1989-1992. During 1994, a countrywide dengue epidemic occurred in Nicaragua (1994 estimated population: 4,300,000). A total of 20,469 dengue cases (4.8 per 1000 population) was reported: the attack rate was highest in the province of Leon (11.9 cases per 1000); the largest number of cases (7631; attack rate: 6.4 per 1000) was reported in Managua. The National Diagnostic and Reference Center documented probable dengue infection U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES / Public Health Service 22 MMWR January 20, 1995 Dengue — Continued (i.e., presence of antiflavivirus immunoglobulin M) in patients from 15 (83%) of the 18 health-care regions. Of the 20,469 reported cases, 1247 (6.1%) had hemorrhagic manifestations; 900 (4.4%) patients were hospitalized. Reviews of medical records at two hospitals indicated that 35 (5.2%) of 676 hospitalized patients met the diagnostic criteria for dengue hemorrhagic fever (DHF). Six cases of suspected DHF were fatal. In October and November, as the result of increased dengue transmission in Mana- gua, the Ministry of Health initiated a multifaceted response to control Aedes aegypti, the mosquito vector of dengue. This response included ultralow-volume application of insecticides (deltamethrin or cypermethrin); indoor application of mosquito larvi- cide (temephos [Abate®*]); and a national, community-based campaign to eliminate mosquito production sites. These activities were supported by efforts to educate the community. By the end of November, the weekly number of reported cases decreased substantially. In late November, an international team sponsored by the Pan American Health Organization (PAHO) traveled to Nicaragua to reinforce laboratory diagnostic capabilities, obtain epidemiologic information, evaluate the severity of disease pro- duced by DEN-3, and assist national authorities in their efforts to control the outbreak. An outbreak of dengue, which began in July 1994, also occurred in Panama; DEN-1 was the predominant virus serotype isolated. As of December 28, a total of 716 laboratory-diagnosed cases originating from eight of the 13 provinces (attack rate: 27.4 per 100,000 persons) had been reported. Reported by: M Palacio, JJ Amador, F Acevedo, J de los Reyes, A Ramirez, A Gonzalez, G Hu- elva, Ministry of Health, Managua; R Jiménez, Hospital La Mascota, F Ruiz, Hospital Manolo Morales, Managua; R Cuadra, Hospital Escuela, Leén, Nicaragua. MG Guzmén, G Kouri, M Soler, M Alvarez, R Rodriguez, Pedro Kouri Institute of Tropical Medicine, E Martinez, Hospital William Soler, Havana. E Quiroz, V Bayard, C Cai...0s, MO Vasquez, Ministry of Health, Panama. Div of Communicable Disease Prevention and Control, Pan American Health Organization, Washing- ton, DC, and Nicaragua. Dengue Br, Div of Vector-Borne Infectious Diseases, National Center for Infectious Diseases, CDC. Editorial Note: Dengue fever is an acute, mosquito-transmitted viral disease charac- terized by fever, headache, arthralgia, myalgia, rash, nausea, and vomiting. Infections are caused by any of the four virus serotypes. Although most dengue infections result in relatively mild illness, some can produce DHF. Based on the World Health Organiza- tion case definition (17), a case of DHF must meet the following criteria: 1) fever, 2) minor or major hemorrhagic manifestations, 3) thrombocytopenia (<100,000/mm%), and 4) objective evidence of increased capillary permeability (e.g., hem oconcentration {hematocrit increased by >20%l], pleural effusions [evidenced by chest radiography or other imaging method], or hypoproteinemia). A case of dengue shock syndrome (DSS) must meet all the criteria for DHF plus hypotension or narrow pulse pressure (<20 mm Hg); the fatality rate for patients with DSS can be as high as 44% (2). In 1994, outbreaks of dengue were reported from Brazil, Costa Rica, Dominican Re- public, Haiti, Mexico, Puerto Rico, and Venezuela. In Nicaragua, an outbreak in 1992 was localized in Leén province and associated with DEN-2 and DEN-4 viruses; an outbreak in June and July 1993 was focused in Leén and adjacent Chinandega province, but no virus was isolated. A limited outbreak of DEN-2 (14 laboratory-confirmed *Use of trade names and commercial sources is for identification only and does not imply endorsement by the Public Health Service or the U.S. Department of Health and Human Services. Vol. 44 / No. 2 MMWR 23 Dengue — Continued cases) occurred in Panama City in 1993 and was the first recorded outbreak of dengue in Panama since 1942. DEN-3 was first isolated in the Americas (in Puerto Rico) in 1963 (3) and subsequently caused epidemics in Jamaica and the eastern Caribbean during that year (4). Although DEN-3 has been isolated from international travelers returning to the Americas from other geographic regions (5), this serotype was last isolated in the region (in Puerto Rico) in 1977 (6). The identification of autochthonous transmission of DEN-3 in two countries in the Americas (Nicaragua and Panama) in 1994 has impor- tant implications for public health because most residents of urban areas in the American tropics are susceptible to this serotype. In particular, all persons in the American tropics who are aged <16 years (approximately one third of the population of Latin America) and all persons living in Ae. aegypti-infested areas who were not infected with DEN-3 during 1963-1978 are at risk for infection with this virus. The ap- pearance of DEN-3 also may increase the risk for DHF resulting from secondary, heterotypic infection (7) or from the introduction of a particularly virulent genotype of DEN-3 (8). The international response to the outbreak in Nicaragua was specified by a contingency plan developed by health agencies in 1993 to address the potential for reintroduction of DEN-3 into the Americas. This plan highlighted the importance of effective, laboratory-based surveillance programs for dengue and DHF in the Ameri- cas. Because of increased DEN-3 activity in other regions and repeated detection of DEN-3 in travelers returning to the Americas, PAHO alerted member countries of these events during April-May 1994 and recommended actions to follow after the identification of an autochthonous case of DEN-3. These actions include prompt investigation to define the magnitude and distribution of the DEN-3 virus in the country and, if the distribution is determined to be limited and circumscribed, efforts to eradicate mos- quitoes in the affected area. PAHO recently published a document for the prevention and control of dengue in the Americas (9), which includes a detailed emergency plan for the control of epidemic dengue and DHF. During 1992-1994, these guidelines were presented by PAHO to national representatives of Ae. aegypti-infested countries in the Americas. In addition, during 1994, PAHO teams reviewed national dengue-control programs in selected countries and assisted national authorities in preparing or updating contingency plans for outbreaks. Health-care providers should consider dengue in the differential diagnosis of all patients who have symptoms compatible with dengue and who reside in or have vis- ited any tropical areas. When dengue is suspected, the patient's blood pressure, hematocrit, and platelet count should be monitored for evidence of hypotension, hemoconcentration, and thrombocytopenia. Acetaminophen products are recommended for management of fever because of the anticoagulant properties of acetyl- salicylic acid (i.e., aspirin). Acute- and convalescent-phase serum samples should be obtained for viral isolation and serodiagnosis. Suspected dengue cases should be reported to the state or territorial health department; the report should include a clinical summary, dates of onset of illness and blood collection, and other epidemiologic information (e.g., a detailed travel history with dates and location of travel). Serum samples should be sent for confirmation through state health department laboratories to CDC’s Dengue Branch, Division of Vector- 24 MMWR January 20, 1995 Dengue — Continued Borne Infectious Diseases, National Center for Infectious Diseases, 2 Calle Casia, San Juan, PR 00921-3200; telephone (809) 766-5181; fax (809) 766-6596. References 1.World Health Organization. Dengue hemorrhagic fever: diagnosis, treatment, and control. Geneva: World Health Organization, 1986. . Tassniyom S, Vasanawathana S, Chirawatkul A, Rojanasuphot S. Failure of high-dose methyl- prednisolone in established dengue shock syndrome: a placebo-controlled, double-blind study. Pediatrics 1993;92:111-5. . Russell PK, Buescher EL, McCown JM, Ordofiez J. Recovery of dengue viruses from patients during epidemics in Puerto Rico and East Pakistan. Am J Trop Med Hyg 1966;15:573-9. . Ehrenkranz NJ, Ventura AK, Cuadrado RR, Pond WL, Porter JE. Pandemic dengue in Caribbean countries and the southern United States: past, present, and potential problems. N Engi J Med 197 1;285: 1460-9. . Rigau-Pérez JG, Gubler DJ, Vorndam AV, Clark GG. Dengue surveillance—United States, 1986- 1992. in: CDC surveillance summaries (July). MMWR 1994;43(no. SS-2):7-19. . Gubler DJ. Dengue and dengue hemorrhagic fever in the Americas. P R Health Sci J 1987;6: 107-11. . Halstead SB. Pathogenesis of dengue: challenges to molecular biology. Science 1988;239: 476-81. . Lanciotti RS, Lewis JG, Gubler DJ, Trent DW. Molecular evolution and epidemiology of DEN-3 virus. J Gen Virol 1994;75:65-75. . Pan American Health Organization. Dengue and dengue hemorrhagic fever in the Americas: guidelines for prevention and control of dengue and dengue hemorrhagic fever in the Ameri- cas. Washington, DC: Pan American Health Organization, 1994; scientific publication no. 548. Health Objectives for the Nation Race-Specific Differences in Influenza Vaccination Levels Among Medicare Beneficiaries — United States, 1993 One national health objective for the year 2000 is to provide annual influenza vaccination to 60% of all noninstitutionalized, high-risk populations in the United States, (objective 20.11) (7). Since May 1, 1993, Medicare has reimbursed providers for the cost of influenza vaccine; reimbursement for the administration of the vaccine also has been provided for beneficiaries with part B coverage, which allows them to re- ceive the vaccine without a copayment and without having to meet the annual deductible amount for part B reimbursement. Approximately 96% of all persons aged 265 years in the United States have Medicare part B coverage (Health Care Financing Administration [HCFA], unpublished data, 1994). To characterize patterns of vaccine use by Medicare beneficiaries, HCFA and CDC estimated influenza vaccine use by Medicare beneficiaries during September—-December 1993. Because of disparities in vaccine use by race, this analysis focused on race-specific differences between blacks and whites. This report presents the findings of that analysis. Claims submitted for services provided during September 1-December 31, 1993, and paid by Medicare were used to identify persons who received influenza vaccine. The percentage of beneficiaries who received Medicare-paid vaccinations was calcu- lated using the HCFA 1993 denominator file for beneficiaries aged >65 years for the United States and for each state and county, by sex, 10-year age group, and race Vol. 44 / No. 2 MMWR 25 Influenza Vaccination Levels — Continued (white and black [data for racial groups other than whites and blacks are grouped together in the Medicare claims data system and were not analyzed separately]) (Tables 1 and 2). Medicare claims are not submitted by managed-care plans; therefore, beneficiaries who are members of such plans (approximately 6% of the Medicare population) were excluded from the analysis. Because 1993 was the first year influenza vaccination was reimbursed by Medicare, approximately 10%-20% of Medicare beneficiaries may have been vaccinated in 1993 and not had claims filed with Medi- care (CDC, unpublished data, 1994). During 1993, a total of 9,831,884 (35%) beneficiaries received Medicare-reimbursed influenza vaccinations. However, the vaccination rate for blacks (17%) was less than half that for whites (37%) (Table 1). Among whites, the vaccination rate for women aged 285 years (30%) was lower than that for women aged 65-84 years by approximately eight percentage points and lower than that for men aged 285 years by TABLE 1. Number and rate of influenza vaccinations paid for by Medicare part B, by recipient age, sex, and race — United States, 1993 Race*/Sex/ No. non-HMOt No. Medicare-paid Medicare-paid Age group (yrs) part B enrollees influenza vaccinations vaccination rate 5,483,480 1,883,175 34% 3,404,559 1,367,802 40% 844,735 291,706 35% 9,732,774 3,542,683 36% 6,882,485 2,556,524 37% 5,561,678 2,136,587 38% 2,256,534 684,299 30% 14,700,697 5,377,410 37% 12,365,965 4,439,699 36% 8,966,237 3,504,389 39% 3,101,269 976,005 31% 24,433,471 8,920,093 37% 456,776 64,127 14% 251,261 43,612 17% 68,566 10,990 16% 776,603 118,729 15% 655,873 118,960 18% 467,096 92,067 20% 187,636 31,590 17% 1,310,605 242,617 19% 1,112,649 183,087 16% 718,357 135,679 19% 256,202 42,580 17% 2,087,208 361,346 17% *Data for racial groups other than whites and blacks are grouped together in the Medicare claims data system and were not analyzed separately. tHealth maintenance organization. 26 MMWR January 20, 1995 Influenza Vaccination Levels — Continued TABLE 2. Rates of influenza vaccination paid for by Medicare, by state and race* of recipient — United States, 1993 Race State i Total State i Black Totalt Alabama 35 Montana 48 Alaska 16 Nebraska 45 Arizona! 42 Nevada 23 Arkansas 44 New Hampshire California’ 26 New Jersey’ 26 Colorado 46 New Mexico Connecticut 35 New York Delaware 30 North Carolina District of North Dakota Columbia 20 Ohio Florida 40 Oklahoma Georgia 33 Oregon Hawaii 36 Pennsylvania Idaho Rhode Island ilinois South Carolina’ Indiana South Dakota lowa Tennessee Kansas Texas Kentucky Utah Louisiana Vermont Maine Virginia Maryland Washington Massachusetts West Virginia Michigan Wisconsin Minnesota Wyoming Mississippi 27 Missouri 36 Total *Data for racial groups other than whites and blacks are grouped together in the Medicare claims data system and were not analyzed separately. tincludes persons in all racial groups and persons of unknown race. SAfter the mailing of the original estimates from the Medicare claims data to the 63 federal vaccination grant programs, California and South Carolina reported 473,062 and 23,322 influenza vaccinations administered to persons aged >65 years, respectively, which were not billed to Medicare in 1993. Arizona estimated that an additional 40,000 persons received vaccine that was not billed to Medicare, and New Jersey estimated 80.000-100,000 doses were not billed. This additional information is not reflected in the table. approximately five percentage points (p<0.01 for both comparisons). Among blacks, vaccination rates varied 1%-3% between different age-sex groups (Table 1). Coverage rates for Medicare-reimbursed influenza vaccination ranged from 16% (Alaska) to 49% (lowa) (Table 2). Vaccination levels were >40% in 20 (40%) of the 50 states and in the District of Columbia. In 33 (66%) states and in the District of Co- lumbia, vaccination rates for blacks were below 60% of the rates for whites. Vaccination rates for blacks were at least 60% of the rates for whites in 17 states*; in these states, the total black population aged >65 years with Medicare part B coverage was 65,515 (3% of the national black population that has Medicare part B coverage). *A laska, Connecticut, Hawaii, Idaho, Kentucky, Maine, Minnesota, Montana, Nevada, New Hampshire, North Dakota, Rhode Island, South Dakota, Vermont, West Virginia, Wisconsin, and Wyoming. Vol. 44 / No. 2 Influenza Vaccination Levels — Continued Reported by: AM McBean, MD, Univ of Minnesota School of Public Health, Minneapolis. JD Babish, MPH, Office of Research and Demonstrations, Health Care Financing Administration. Adult Vaccine Preventable Disease Br, National Immunization Program, CDC. Editorial Note: The findings in this report are consistent with previous surveys that have documented lower influenza vaccination coverage among blacks than whites. For example, based on the 1991 National Health Interview Survey, among all persons aged >65 years, 41% had been vaccinated; however, within this age group, blacks were less likely than whites to have been vaccinated (27% and 43%, respectively) (2). Findings from the Medicare Current Beneficiary Survey (September—December 1992) indicated that, for noninstitutionalized beneficiaries, the vaccination rate during winter 1991-92 was 48% overall but 29% among blacks and 50% among whites (Office of the Actuary, HCFA, unpublished data, 1994). These variations may reflect differences in factors such as socioeconomic status, access to medical care, and prevalence of specific risks. The finding in this report that >40% of beneficiaries in 20 states and the District of Columbia had received vaccine indicates that, in these areas, substantial progress has been made toward achieving the national health objective for the year 2000 (1,3). Because the wide variations in state-specific vaccination levels (Table 2) also have been documented for Medicare-reimbursed pneumococcal vaccination claims (4), analysis of these variations may assist in planning programs for increasing vaccine coverage. Because not all providers submitted claims to Medicare for reimbursement, the rates for Medicare-reimbursed influenza vaccination claims in this report are lower than those based on other national surveys. However, failure to submit claims to Medicare in 1993 for influenza vaccination services is not known to have differentialiy affected claims submitted for vaccinations administered to black beneficiaries com- pared with white beneficiaries. In the future, reporting may be enhanced through communication with public and private providers; the use of simplified billing proce- dures; and helping public-sector providers, visiting nurse groups, and others obtain Medicare provider numbers (5). HCFA is collaborating with a coalition representing approximately 160 community organizations to identify strategies to improve coverage in 1995. In addition, as part of HCFA’s Consumer Information Strategy (6), demographic- and county-specific vaccination rates for 1993 (7) were provided to health-care providers; consumer-based organizations; local, state, and other federal agencies; and Medicare beneficiaries. This information should assist in increasing beneficiary use of influenza vaccine and addresses consumer and provider concerns about the risks for influenza and the effec- tiveness and safety of influenza vaccine (8-10). The county-specific vaccination rates also may assist programs receiving federal childhood vaccination grants to improve influenza vaccination coverage. References 1. Public Health Service. Healthy people 2000: national health promotion and disease prevention objectives. Washington, DC: US Department of Health and Human Services, Public Health Service, 1991:122-3; DHHS publication no. (PHS)91-50213. 2. Heath KA, Strikas RA, Stevenson J, Williams WW. Influenza and pneumococcal vaccination among older adults: results of the 1991 National Health Interview Survey [Abstract]. In: Pro- gram and abstracts of the CDC Epidemic Intelligence Service 43rd annual conference. Atlanta: US Department of Health and Human Services, Public Health Service, CDC, 1994:33. (Continued on page 33) 28 MMWR January 20, 1995 FIGURE |. Notifiable disease reports, comparison of 4-week totals ending Jan- uary 14, 1995, with historical data — United States CASES CURRENT DISEASE DECREASE INCREASE 4 WEEKS Aseptic Meningitis 272 Encephalitis, Primary 35 Hepatitis A 1,229 Hepatitis B 428 Hepatitis, Non-A, Non-B Hepatitis, Unspecified Legionellosis Malaria Measles, Total* Meningococcal Infections Mumps Pertussis Rabies, Animal Rubella 0.0625 0.125 0.25 0.5 1 Ratio (Log Scale)’ BEYOND HISTORICAL LIMITS *The large apparent decrease in the number of reported cases of measles (total) reflects dramatic fluctuations in the historical baseline. Ratio of current 4-week total to mean of 15 4-week totals (from previous, comparable, and subsequent 4-week periods for the past 5 years). The point where the hatched area begins is based on the mean and two standard deviations of these 4-week totals. TABLE |. Summary — cases of specified notifiable diseases, United States, cumulative, week ending January 14, 1995 (2nd Week) Cum. 1995 Anthrax - Plague Aseptic Meningitis Poliomyelitis, Paralytic’ Brucellosis Psittacosis Cholera - Rabies, human Congenital rubella syndrome - Rocky Mountain Spotted Fever Diphtheria - Syphilis, congenital, age < 1 year® Encephalitis, primary Tetanus Encephalitis, post-infectious Toxic shock syndrome H. philus inf e Trichinosis Hansen Disease - Tularemia Hepatitis, unspecified Typhoid fever Leptospirosis *Of 34 cases of known age, 8 (24%) were reported among children less than 5 years of age. "Updated quarterly from reports to the Division of Sexually Transmitted Diseases and HIV Prevention, National Center for Prevention Services. First quarter data not yet available. -! NO reported cases Vol. 44 / No. 2 MMWR 29 TABLE Il. Cases of selected notifiable diseases, United States, weeks ending January 14, 1995, and January 15, 1994 (2nd Week) Hepatitis (Viral), by type Reporting Area B NA,NB Legionellosis 1995 1995 1994 1995 1994 1995 1994 UNITED STATES 97 340 32 154 17 57 154 - 7 - 1 1 " MID. ATLANTIC Upstate N.Y. N.Y. City N.J. 1 Pa. 1 E.N. CENTRAL 2 ‘] Ohi 6 9 4 5 1 W.N. CENTRAL 5 inn. 3 ~ _ wo, ~5 WNQae-eWse -: 4 ~ _o- @> MOUNTAIN Mont. Idaho Wyo. Colo. N. Mex. Ariz. Utah Nev. wawn‘8 n8.8 , PACIFIC Alaska Hawaii Vi. Amer. Samoa C.N.M.1. N: Not notifiable U: Unaveilable -: No reported cases C.N.M.1.: Commonweaith of Northern Mariana Islands *Updated monthly to the Division of HIV/AIDS, National Center for infectious Diseases. 30 MMWR January 20, 1995 TABLE Ii. (Cont’d.) Cases of selected notifiabie diseases, United States, weeks ending January 14, 1995, and January 15, 1994 (2nd Week) Measles (Rubeola) Reperting fees Lyme Indigenous | Imported* Totai Infections Cum. Cum. | Cum. | Cum. | Cum. | Cum. 1995 | 1995 | 1995 | 1995 | 1995 | 1994 | 1995 1994 UNITED STATES - 4 - 4 1 57 153 NEW ENGLAND - 2 - - 2 - 4 MID. ATLANTIC Upstate N.Y. E.N. CENTRAL Ohio Ind wm. Mich. Wis W.N. CENTRAL Minn w, E.S. CENTRAL Ky. a Tenn Ala. Miss Ww W.S. CENTRAL S2—1 SN ONWe MOUNTAIN ont Idaho Wyo Colo N. Mex Ariz. Utah Nev PACIFIC Wash Oreg Calif Alaska Hawaii Amer. Samoa - - . ° ° . C.N.M.1. . : . 1 2 i 4 9 *For imported measies, cases include only those resulting from importation from other countries. N: Not notifiable U: Unavailable : NO reported cases