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Summary of Notifiable Diseases, United States, 1997Foreword MMWR Summary of Notifiable Diseases, United States, 1997 This publication contains summary tables of the official statistics for the reported occurrence of nationally notifiable diseases in the United States for 1997. These statistics are collected and compiled from reports to the National Notifiable Diseases Surveillance System (NNDSS), which is operated by CDC in collaboration with the Council of State and Territorial Epidemiologists (CSTE). Because the dates of onset or diagnosis for notifiable diseases are not always reported, these surveillance data are presented by the week they were reported to CDC by public health officials in state and territorial health departments. These data are finalized and published in the MMWR Summary of Notifiable Diseases, United States for use by state and local health departments; schools of medicine and public health; communications media; local, state, and federal agencies; and other agencies or persons interested in following the trends of reportable diseases in the United States. The annual publication of the Summary also documents which diseases are considered national priorities for notification and the annual number of cases of such diseases. The Highlights section presents information on selected nationally notifiable and non-notifiable diseases to provide a context in which to interpret surveillance and disease-trend data and to provide further information on the epidemiology and prevention of selected diseases. Part 1 contains information regarding morbidity for each of the diseases considered nationally notifiable during 1997. The tables provide the number of cases of notifiable diseases reported to CDC for 1997, as well as the distribution of cases by month and geographic location and by patient's age, sex, race, and Hispanic ethnicity. The data are final totals as of July 25, 1998, unless otherwise noted. Because no cases of anthrax or yellow fever were reported in the United States during 1997, these nationally notifiable diseases do not appear in the tables in Part 1. Nationally notifiable diseases that are reportable in fewer than 40 states also do not appear in these tables. In all tables, leprosy is listed as Hansen disease, and tickborne typhus fever is listed as Rocky Mountain spotted fever (RMSF). Part 2 contains graphs and maps. These graphs and maps depict summary data for many of the notifiable diseases described in tabular form in Part Part 3 contains tables that list the number of cases of notifiable diseases reported to CDC since 1966. It also includes a table enumerating deaths associated with specified notifiable diseases reported to the National Center for Health Statistics, CDC during 1987-1996. Background As of January 1, 1997, 52 infectious diseases were designated as notifiable at the national level. 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. This section briefly summarizes the history of the reporting of nationally notifiable diseases in the United States. In 1878, Congress authorized the U.S. Marine Hospital Service (i.e., the forerunner of the Public Health Service {PHS}) to collect morbidity reports regarding cholera, smallpox, plague, and yellow fever from U.S. consuls overseas. The intention was to use this information to institute quarantine measures to prevent the introduction and spread of these diseases into the United States. In 1879, a specific Congressional appropriation was made for the collection and publication of reports of these notifiable diseases. Congress expanded the authority for weekly reporting and publication of these reports in 1893 to include data from states and municipal authorities. To increase the uniformity of the data, Congress enacted a law in 1902 directing the Surgeon General to provide forms for the collection and compilation of data and for the publication of reports at the national level. In 1912, state and territorial health authorities -- in conjunction with PHS -- recommended immediate telegraphic reporting of five infectious diseases and the monthly reporting, by letter, of 10 additional diseases. The first annual summary of The Notifiable Diseases in 1912 included reports of 10 diseases from 19 states, the District of Columbia, and Hawaii. By 1928, all states, the District of Columbia, Hawaii, and Puerto Rico were participating in national reporting of 29 specified diseases. At their annual meeting in 1950, state and territorial health officers authorized the Conference of State and Territorial Epidemiologists (CSTE), whose purpose was to determine which diseases should be reported to PHS. In 1961, CDC assumed responsibility for the collection and publication of data concerning nationally notifiable diseases. The list of nationally notifiable diseases is revised periodically. For example, a disease might be added to the list as a new pathogen emerges, or a disease might be deleted as its incidence declines. Public health officials at state health departments and CDC continue to collaborate in determining which diseases should be nationally notifiable. CSTE, with input from CDC, makes recommendations annually for additions and deletions. However, reporting of nationally notifiable diseases to CDC by the states is voluntary. Reporting currently is mandated (i.e., by legislation or regulation) only at the state and local level. Thus, the list of diseases considered notifiable varies slightly by state. All states generally report the internationally quarantinable diseases (i.e., cholera, plague, and yellow fever) in compliance with the World Health Organization's International Health Regulations. The list of 52 infectious diseases designated as notifiable at the national level during 1997 is as follows: Table_A Data Sources Provisional data concerning the reported occurrence of notifiable diseases are published weekly in MMWR. After each reporting year, staff in state health departments finalize reports of cases for that year with local or county health departments and reconcile the data with reports previously sent to CDC throughout the year. These data are compiled in final form in this summary. Notifiable disease reports (which are published in the annual MMWR Summary of Notifiable Diseases only after approval by the appropriate epidemiologist from each submitting state or territory) are the authoritative and archival counts of cases. Data published in MMWR Surveillance Summaries or other surveillance reports produced by CDC programs, which are useful for detailed epidemiologic analyses, may not agree exactly with data reported in the annual Summary of Notifiable Diseases because of differences in the timing of reports, the source of the data, and the case definitions. Data in this summary were derived primarily from reports transmitted to the Division of Public Health Surveillance and Informatics, Epidemiology Program Office, CDC, by the 50 state, two city, and five territorial health departments through the National Electronic Telecommunications System for Surveillance (NETSS). (More information regarding NETSS and notifiable diseases, including case definitions for these conditions, is available on the Internet at http://www.cdc.gov/epo/phs.htm.) Final data for other diseases are from the surveillance program records of the following CDC programs (requests for further information regarding these data should be directed to the source specified): National Center for Health Statistics (NCHS) Office of Vital and Health Statistics Systems (deaths from selected notifiable diseases) National Center for Infectious Diseases (NCID) Division of Bacterial and Mycotic Diseases (toxic-shock syndrome and laboratory data regarding botulism, Escherichia coli O157:H7, Salmonella, and Shigella) Division of Vector-Borne Infectious Diseases (laboratory data regarding arboviral encephalitis) Division of Viral and Rickettsial Diseases (animal rabies) National Center for HIV, STD, and TB Prevention (NCHSTP) Division of HIV/AIDS Prevention -- Surveillance and Epidemiology (acquired immunodeficiency syndrome {AIDS}) Division of Sexually Transmitted Diseases Prevention (chancroid, chlamydia, gonorrhea, and syphilis) Division of Tuberculosis Elimination (tuberculosis) National Immunization Program (NIP) Epidemiology and Surveillance Division (poliomyelitis) Disease totals for the United States, unless otherwise stated, do not include data for American Samoa, Guam, Puerto Rico, the Virgin Islands, or the Commonwealth of the Northern Mariana Islands (CNMI). Disease totals from American Samoa were unavailable for 1997. Population estimates for states are based on the July 1, 1997, post-censal estimates made by the U.S. Department of Commerce, Economics and Statistics Administration, Bureau of the Census, Population Division, Population Branch, Press Release PLL91. Population estimates for territories are 1997 estimates from the Bureau of the Census, Press Releases CB98-54 and CB98-80. Rates in this summary were based on data for the U.S. total-resident population. However, population data from states in which diseases were not notifiable or disease data were not available were excluded from rate calculations. Interpreting Data The data reported in this summary are useful for analyzing disease trends and determining relative disease burdens. However, these data must be interpreted in light of reporting practices. Some diseases that cause severe clinical illness (e.g., plague and rabies), if diagnosed by a clinician, are most likely reported accurately. However, persons who have diseases that are clinically mild and infrequently associated with serious consequences (e.g., salmonellosis) might not seek medical care from a health-care provider. Even if these less severe diseases are diagnosed, they are less likely to be reported. The degree of completeness of reporting also is influenced by the diagnostic facilities available; the control measures in effect; the public awareness of a specific disease; and the interests, resources, and priorities of state and local officials responsible for disease control and public health surveillance. Finally, factors such as changes in the case definitions for public health surveillance, the introduction of new diagnostic tests, or the discovery of new disease entities can cause changes in disease reporting that are independent of the true incidence of disease. Public health surveillance data are published for selected racial and ethnic population groups because these variables can be risk markers for certain notifiable diseases. Risk markers can identify potential risk factors for investigation in future studies. Data regarding race and ethnicity also can be used to identify populations to target for prevention efforts. However, one also must use caution when drawing conclusions from reported data relating to race and ethnicity. Among certain races and ethnicities, there are likely to be differential patterns of access to health care, interest in seeking health care, and detection of disease that would lead to data not representative of disease incidence in these populations. In addition, not all data concerning race and ethnicity are collected uniformly for all diseases. For example, the Division of HIV/AIDS Prevention -- Surveillance and Epidemiology and the Division of Sexually Transmitted Diseases Prevention in the National Center for HIV, STD, and TB Prevention (NCHSTP) collect information regarding race and ethnicity using a single variable. A person's racial and ethnic background is reported as either American Indian/Alaska Native, Asian/Pacific Islander, Black non-Hispanic, White non-Hispanic, or Hispanic. Additionally, although the recommended standard for classifying a person's race or ethnicity is based on self-reporting, this procedure might not always be followed. Highlights for 1997 The Highlights section presents information on the public health importance of selected nationally notifiable and non-notifiable diseases, including a) domestic and international disease outbreaks; b) active surveillance findings; c) changes in data reporting practices; d) the impact of prevention programs; e) the emergence of antimicrobial resistance; and f) changes in immunization policies. This information is intended to provide a context in which to interpret surveillance and disease-trend data and to provide further information on the epidemiology and prevention of selected diseases. Highlights for Selected Nationally Notifiable Diseases Arboviral Encephalitis The 1997 national total of 127 confirmed or probable California serogroup viral encephalitis cases (all of which were La Crosse encephalitis cases) is the fourth largest yearly total of such cases reported since 1964. The 73 case reports from West Virginia (57% of the national total) represent that state's largest total and an increase of 11% over its 1996 total. Much of the increase in reports from West Virginia may be attributable to this state's recent implementation of an active surveillance system for this disease. La Crosse encephalitis is endemic in the eastern United States, where it is associated with exposure to deciduous forests and Aedes triseriatus (the eastern treehole mosquito). A summertime/autumnal outbreak of St. Louis encephalitis in central Florida accounted for nine of the 13 cases reported nationally in 1997. The last major epidemic of St. Louis encephalitis in the United States (223 cases and 11 deaths) occurred in Florida in 1990. St. Louis encephalitis affects persons in portions of both the eastern and western United States. In Florida, the primary mosquito vector of St. Louis encephalitis virus is Culex nigripalpus. Fourteen cases of eastern equine encephalitis among humans were reported in 1997 from the South (12 cases), New England (one case), and the Upper Midwest (one case). Eastern equine encephalitis virus is typically transmitted to humans by various Aedes mosquito species. No cases of western equine encephalitis among humans have been reported nationally since 1994. The primary mosquito vector of western equine encephalitis virus in the western United States is Culex tarsalis. Cryptosporidium National reporting for cryptosporidiosis began in 1995 with 2,972 cases reported from 27 states. During 1996, as cryptosporidiosis became a reportable disease in an increased number of states, 2,426 cases were reported from 42 states. In 1997, a total of 2,566 cases were reported from 45 states. Because the diagnosis of cryptosporidiosis is often not considered, and because laboratories do not routinely test for Cryptosporidium infection, cryptosporidiosis continues to be underdiagnosed and underreported. Diphtheria Four cases of diphtheria were reported in the United States in 1997; two persons, both with localized mild illness, had culture-confirmed diphtheria. One confirmed case was caused by infection with a toxigenic strain of Corynebacterium diphtheriae, and was reported from a known endemic focus in South Dakota (MMWR 1997;46:506-10); one case caused by nontoxigenic C. diphtheriae was reported from Oregon. Two probable cases were reported from Nevada. Both case-patients had acute membranous pharyngitis; oropharyngeal specimens were positive for diphtheria toxin by polymerase chain reaction, but bacterial cultures of these specimens were negative. In 1997, more than 7,000 cases of diphtheria were reported in an ongoing diphtheria epidemic in the New Independent States of the former Soviet Union. No importations were reported in the United States. Haemophilus Influenzae (Invasive Disease) In 1997, a total of 260 cases of Haemophilus influenzae (Hi) invasive disease among children aged less than 5 years were reported. (Data were provided by the National Immunization Program and were based on date of onset, not MMWR week.) An estimated 20,000 cases of Haemophilus influenzae type b (Hib) invasive disease among children occurred annually prior to Hib vaccine licensure in 1987. (JAMA 1993;269:221-6) The dramatic decline is attributed to the widespread administration of the Hib vaccine to preschool-aged children. Of the 260 cases, 201 (77%) isolates were serotyped, and 82 (41%) of the isolates for which serotype was known were type b. Of the 82 cases of Hib invasive disease reported in children aged less than 5 years, 42 (51%) were aged less than 6 months, which is too young to have completed a three-dose primary Hib vaccination. However, 27 (68%) of the 40 children who were old enough (aged greater than or equal to 6 months) to have completed a three-dose primary series before they developed Hib invasive disease were incompletely vaccinated or their vaccination status was unknown. These cases might have been prevented with age-appropriate vaccination. Hantavirus Pulmonary Syndrome In 1997, a total of 21 cases of Hantavirus pulmonary syndrome (HPS) were reported. HPS is a pan-American viral zoonosis caused by Sin Nombre virus and other New World hantaviruses, which in the United States, include Bayou virus, Black Creek Canal virus, and New York-1 virus. The identified rodent reservoirs for Sin Nombre, New York-1, Black Creek Canal, and Bayou viruses are, respectively, Peromyscus maniculatus (deer mouse), Peromyscus leucopus (white-footed mouse), Sigmodon hispidus (cotton rat), and Oryzomys palustris (rice rat). Cases of HPS have been found in the continental United States, Canada, Argentina, Brazil, Chile, Paraguay, and Uruguay. As of March 31, 1998, national surveillance for HPS has identified 179 confirmed cases in 29 states (case-fatality ratio = 44.7%). Hemolytic Uremic Syndrome Post-diarrheal hemolytic uremic syndrome (HUS) is a life-threatening illness characterized by hemolytic anemia, thrombocytopenia, and renal injury. Nearly all cases in the United States are caused by infection with Shiga toxin-producing Escherichia coli, with serotype O157:H7 being predominant. In 1997, the second year of national reporting, 20 states reported 93 cases of post-diarrheal HUS to CDC. By comparison, 18 states reported 104 cases in 1996. The median age of patients was 4 years (range: 1-89 years), with females accounting for 62% of patients overall. Illness was seasonal, with 50% of cases occurring during July through September. Hepatitis A In 1996, the Advisory Committee on Immunization Practices (ACIP) issued recommendations for the prevention of hepatitis A through active or passive immunization (MMWR 1996;45{No. RR-15}). The report provides recommendations for use of the hepatitis A vaccines (i.e., HAVRIX , manufactured by SmithKline Beecham Biologicals, and VAQTA , manufactured by Merck & Company, Inc.). For communities with high rates of hepatitis A and periodic outbreaks (peak rates: 700 reported cases per 100,000 population), routine vaccination of children aged 2 years and catch-up vaccination of older children is recommended. To control outbreaks in communities with intermediate rates of hepatitis A (i.e., 50-200 reported cases per 100,000 population), vaccination programs targeting subpopulations with the highest rates of disease may be considered. In these communities, ongoing routine vaccination of young children should be implemented to prevent future outbreaks. Hepatitis C Hepatitis C virus (HCV) infection is the most common bloodborne infection in the United States. Based on data from the CDC Sentinel Counties Study of Viral Hepatitis, it is estimated that as many as 180,000 new HCV infections occurred each year during the 1980s. Since 1989, the annual number of new infections has declined by 80%. However, in 1996, data from the third National Health and Nutrition Examination Survey, conducted from 1988 through 1994, indicated that approximately 4 million Americans (1.8%) are infected with HCV. Many of these chronically infected persons might not be aware of their infection or be clinically ill, because symptoms of hepatitis C-related chronic liver disease might not develop for 10-20 years after infection. However, such persons can infect others and are at risk for chronic liver disease or other HCV-related chronic diseases. Cirrhosis develops in 10%-20% of persons with HCV-related chronic hepatitis during the first two decades after infection, and 8,000-12,000 persons die from HCV-related chronic liver disease each year. CDC recently published new guidelines for HCV prevention and control (MMWR 1998;47{No. RR-19}). HIV Infection in Children and Infants In 1997, reports based on AIDS surveillance data indicated substantial declines in perinatally acquired AIDS, reflecting declining perinatal HIV transmission. HIV surveillance data indicated that the increasing use of zidovudine was temporally associated with this substantial decline in perinatally acquired AIDS (MMWR 1997;46:1086-92). These data demonstrate success in nationwide efforts to implement Public Health Service guidelines for use of zidovudine to reduce perinatal HIV transmission (MMWR 1994;43{No. RR-11}); MMWR 1998;47{No. RR-2}) and routine, voluntary prenatal HIV testing (MMWR 1995;44{No. RR-7}). States that conduct surveillance of perinatally exposed and infected children can evaluate the impact of the guidelines more completely and document resources needed to care for perinatally exposed infants. In 1997, a total of 30 states conducted surveillance of HIV infection in children, reporting 258 HIV-infected children who had not progressed to AIDS and 200 children who had AIDS. These states also received 2,238 new reports of perinatally exposed children who required follow up with health-care providers to determine their HIV infection status. Measles A total of 138 laboratory-confirmed cases of measles were reported to CDC in 1997, which is the lowest number of measles cases reported in one year and is less than half the previous record low. Of the 138 cases reported, 57 (41%) were international importations, and exposure to these cases resulted in 17 (12%) additional cases. Thus, 74 (54%) cases were associated with importation. An additional seven cases had virologic evidence suggesting an imported measles virus. Fifty-four (41%) measles patients were aged less than 5 years, 39 (28%) were aged 5-19 years, and 42 (30%) were aged greater than or equal to 20 years. Thirty-two patients (23%) reported having been vaccinated; seven (5%) received two doses. A total of 13 outbreaks were reported, with the largest involving eight cases. In 1997, no confirmed measles cases were reported from 21 states, and fewer than five cases were reported from 20 states and the District of Columbia. Plague In 1997, four plague cases among humans were reported in the United States (two cases in California, one in Arizona, and one in Colorado). One case was fatal and, like two fatal cases that occurred in 1996, septicemic plague was diagnosed postmortem. Each of these cases, which occurred in plague-endemic areas, illustrates the need for health-care providers to maintain a high level of awareness about the risks of human plague. Of the 350 cases reported in the United States from 1970 through 1997, approximately 80% were reported from the southwestern states of New Mexico, Arizona, and Colorado; 9% were reported from California; and nine other western states reported limited numbers of cases. Plague also occurs in animal populations in four other western states that have not reported cases among humans, including Kansas, where Yersinia pestis-infected prairie dog fleas were identified in 1997. This is the first report of plague in an animal in Kansas since 1950; however, a nearby county in Oklahoma experienced one case among a person in 1991, and other Great Plains states have reported epizootic activity in recent years (MMWR 1994;43:242-6). Internationally, outbreaks of rat-associated plague occurred in the port city of Mahajanga, Madagascar from 1995 through 1997. These are the first port-related outbreaks to be reported from that country in decades. Researchers reported the first case of multidrug-resistant Y. pestis in 1997. This isolate, which was obtained in 1995 from a case in Madagascar, contained a plasmid that conferred resistance to antibiotics commonly prescribed for plague treatment or prophylaxis (e.g., streptomycin, chloramphenicol, and tetracycline) (N Engl J Med 1997;337:677-80, 702-4). Poliomyelitis In 1997, the Advisory Committee on Immunization Practices (ACIP) recommended a change in routine childhood vaccination policy for polio in the United States. The previously recommended schedule of four doses of attenuated oral poliovirus vaccine (OPV) was changed to a sequential schedule of two doses of inactivated poliovirus vaccine (IPV) followed by two doses of OPV for routine vaccination of children. Since 1980, a total of 147 cases have been reported, of which 139 were associated with the use of OPV. The last imported case was reported in 1993. Streptococcal Disease, Invasive, Group A According to reports from active surveillance programs in five states (i.e., California, Connecticut, Georgia, Minnesota, and Oregon), the incidence of invasive group A streptococcal disease during 1997 was 4.1 cases/100,000 population; disease incidence ranged from 2.2 to 5.1 cases/100,000 population among the surveillance areas. Streptococcal toxic shock syndrome and necrotizing fasciitis accounted for approximately 6.9% and 7.7% of invasive cases, respectively. Overall case-fatality among patients with invasive group A streptococcal disease was 13%; case-fatality rates were higher among patients with streptococcal toxic shock syndrome and necrotizing fasciitis (43% and 21%, respectively). Risk factors for invasive group A streptococcal disease include elderly age, HIV infection, diabetes, cancer, alcohol abuse, and varicella infection. Streptococcus pneumoniae, Drug-Resistant The proportion of drug-resistant Streptococcus pneumoniae isolates continues to increase, according to reports from active surveillance programs in seven states (i.e., California, Connecticut, Georgia, Maryland, Minnesota, Oregon, and Tennessee). During 1997, approximately 26% of pneumococcal isolates obtained from sterile sites were no longer susceptible to penicillin (mean inhibitory concentration {MIC} greater than or equal to 0.1 ug/mL). In 1997, the proportion of all isolates with high-level penicillin resistance (MIC greater than or equal to 2 ug/mL), increased from 12% in 1996 to 14.4%; a total of 7.2% of isolates had MICs greater than or equal to 4 ug/mL compared with 5.4% in 1996. The resistant proportion varied widely by geographic region. To limit the contribution of unnecessary antimicrobial use to the spread of drug-resistant S. pneumoniae, CDC and the American Academy of Pediatrics issued recommendations for judicious use of antimicrobial agents for upper-respiratory-tract infections among children (Pediatrics 1998;101{suppl}). Educational materials concerning the principles of judicious antimicrobial use can be obtained by calling the National Center for Infectious Diseases at (404) 639-4702 for an order form. Tetanus Fifty cases of tetanus were reported in 1997. During 1995-1997, an average annual incidence of 41 cases were reported, the lowest ever reported since national tetanus surveillance began in 1947. The average annual incidence of 0.15 cases per million population represents a slight decline from the incidence of 0.2 cases per million population reported during 1991-1994. Highlights for Selected Non-Notifiable Diseases Cyclosporiasis In 1997, several outbreaks of cyclosporiasis associated with various types of fresh produce (e.g., raspberries, mesclun lettuce, and basil) occurred in the United States. In the largest outbreak, which was associated with consumption of fresh raspberries, 41 clusters with a total of 762 cases (25% were laboratory confirmed) were reported by 13 states, the District of Columbia, and one province in Canada. Dengue Fifty-six laboratory-positive cases of dengue were imported into the United States in 1997 and diagnosed at the CDC Dengue Branch. This number represents a 30% increase from the number of laboratory-confirmed cases reported in 1996 (n=43). Similarly, the total number of dengue and dengue hemorrhagic fever (DHF) cases reported by Pan American Health Organization member countries in 1997 (n=364,945) was 46% higher than the 1996 total (n=250,707). Autochthonous dengue cases (n=3) were documented in south Texas again in 1997, underscoring the risk of dengue transmission in southern gulf coast states where mosquito vectors occur. After a 15-year absence, dengue cases were reported from Cuba in 1997. The municipality of Santiago de Cuba experienced an outbreak with 2,946 laboratory-diagnosed cases and 205 DHF cases, which resulted in 12 deaths. HIV Infection in Adults In June 1997, HIV-infection reporting for adults (i.e., persons aged greater than or equal to 13 years) was added to the list of nationally notifiable diseases at a Council of State and Territorial Epidemiologists (CSTE) meeting. During 1997, reports based on acquired immunodeficiency syndrome (AIDS) surveillance data highlighted substantial declines in AIDS incidence and deaths. As a result of improvements in treatment and care of persons infected with the human immunodeficiency virus (HIV), surveillance of AIDS alone no longer accurately reflects the magnitude or direction of the epidemic. Data concerning persons in whom HIV infection is diagnosed before AIDS is diagnosed are needed to determine populations that could benefit from prevention and treatment services. CSTE recommends that all states and territories implement confidential HIV infection reporting based on methods that provide accurate and representative data for all persons confidentially diagnosed with HIV infection. Influenza A (H5N1) In May 1997, the first known case of disease among humans caused by influenza A (H5N1) virus occurred in a previously healthy 3-year-old child in Hong Kong; this child died from his illness. An additional 17 cases (including five deaths) were detected in November and December 1997. All cases occurred coincident with outbreaks of highly pathogenic avian influenza A (H5N1) virus among poultry. At the end of December, Hong Kong authorities initiated the slaughter of all chickens in Hong Kong and, since then, no additional cases of influenza A (H5N1) virus have been detected among humans despite enhanced surveillance. The pandemic potential of influenza A (H5N1) viruses remains unknown. No cases of H5N1 infection were reported in the United States. Tularemia Tularemia was removed from the nationally notifiable disease list in 1995. However, as of January 1998, a total of 36 states maintained tularemia as a notifiable condition. Based on a telephone survey of state departments of health conducted from 1995 through 1997, a total of 313 cases of tularemia were reported by 43 states (119 cases in 1995, 89 cases in 1996, and 105 cases in 1997). Of these, 155 (49%) were reported from Missouri, Oklahoma, Kansas, and Arkansas. Vancomycin-Resistant Enterococci (VRE) The magnitude and impact of vancomycin-resistant enterococci (VRE) in the United States are demonstrated by CDC's National Nosocomial Infections Surveillance (NNIS) system, which includes more than 275 U.S. hospitals. Additional data are available on the Internet at http://www.cdc.gov/ncidod/hip/Surveill/surveill.htm. During 1989-1997, the percentage of enterococci resistant to vancomycin isolated from patients in intensive care units with nosocomial infections increased from 0.4% to 23.2% (Table Table_B). The percentage of VRE isolated from patients in noncritical care units with nosocomial infections increased from 0.3% to 15.4%. PART 1: Summaries of Notifiable Diseases in the United States EXPLANATION OF SYMBOLS USED IN TABLES, GRAPHS, AND MAPS Data not available..............................................NA Report of disease is not required in that jurisdiction (not notifiable) .............................................NN No reported cases ............................................. -- Table_C NOTIFIABLE DISEASES -- Summary of reported cases, by month, United States, 1997 Table_D1 NOTIFIABLE DISEASES -- Reported cases, by geographic division and area, United States, 1997 Table_D2 NOTIFIABLE DISEASES -- Reported cases, by geographic division and area, United States, 1997 (continued) Table_D3 NOTIFIABLE DISEASES -- Reported cases, by geographic division and area, United States, 1997 (continued) Table_D4 NOTIFIABLE DISEASES -- Reported cases, by geographic division and area, United States, 1997 (continued) Table_D5 NOTIFIABLE DISEASES -- Reported cases, by geographic division and area, United States, 1997 (continued) Table_D6 NOTIFIABLE DISEASES -- Reported cases, by geographic division and area, United States, 1997 (continued) Table_E NOTIFIABLE DISEASES -- Summary of reported cases, by age group, United States, 1997 Table_F NOTIFIABLE DISEASES -- Summary of reported cases, by sex, United States, 1997 Table_G NOTIFIABLE DISEASES -- Summary of reported cases, by race, United States, 1997 Table_H NOTIFIABLE DISEASES -- Summary of reported cases, by ethnicity, United States, 1997 PART 2: Graphs and Maps for Selected Notifiable Diseases in the United States EXPLANATION OF SYMBOLS USED IN TABLES, GRAPHS, AND MAPS Data not available..............................................NA Report of disease is not required in that jurisdiction (not notifiable) .............................................NN Figure_1 ACQUIRED IMMUNODEFICIENCY SYNDROME (AIDS) -- reported cases per 100,000 population, United States and Puerto Rico, 1997 Figure_2 ACQUIRED IMMUNODEFICIENCY SYNDROME (AIDS) -- reported cases by quarter, United States, 1986-1997 Figure_3 ACQUIRED IMMUNODEFICIENCY SYNDROME (AIDS) -- reported pediatric cases, United States and Puerto Rico, 1997 Figure_4 ARBOVIRAL INFECTIONS (of the central nervous system) -- reported laboratory- confirmed cases caused by California serogroup viruses, by month of onset, United States, 1988- 1997 Figure_5 ARBOVIRAL INFECTIONS (of the central nervous system) -- reported laboratory- confirmed cases caused by eastern equine encephalitis virus, by month of onset, United States, 1988-1997 Figure_6 ARBOVIRAL INFECTIONS (of the central nervous system) -- reported laboratory- confirmed cases caused by St. Louis encephalitis virus, by month of onset, United States, 1988- 1997 Figure_7 ARBOVIRAL INFECTIONS (of the central nervous system) -- reported laboratory- confirmed cases caused by western equine encephalitis virus, by month of onset, United States, 1988-1997 Figure_8 BOTULISM (foodborne) -- by year, United States, 1977-1997 Figure_9 BOTULISM (infant) -- by year, United States, 1977-1997 Figure_10 BRUCELLOSIS -- by year, United States, 1967-1997 Figure_11 CHLAMYDIA -- reported cases among women per 100,000 population, United States, 1997 Figure_12 CHOLERA -- reported cases, United States and territories, 1997 Figure_13 CRYPTOSPORIDIOSIS -- reported cases per 100,000 population, United States and territories, 1997 Figure_14 DIPHTHERIA -- by year, United States, 1967-1997 Figure_15 ESCHERICHIA COLI O157:H7 -- reported cases, United States and territories, 1997 Figure_16 ESCHERICHIA COLI O157:H7 -- reported isolates, United States, 1997 Figure_17 GONORRHEA -- reported cases per 100,000 population, United States, 1997 Figure_18 GONORRHEA -- by sex, United States, 1982-1997 Figure_19 GONORRHEA -- by race and ethnicity, United States, 1982- 1997 Figure_20 HAEMOPHILUS INFLUENZAE (Invasive Disease) -- by age group, United States, 1991-1997 Figure_21 HANSEN DISEASE (Leprosy) -- by year, United States, 1967- 1997 Figure_22 HEPATITIS -- by year, United States, 1967-1997 Figure_23 HEPATITIS A -- reported cases per 100,000 population, United States and territories, 1997 Figure_24 HEPATITIS B -- reported cases per 100,000 population, United States and territories, 1997 Figure_25 LEGIONELLOSIS -- by year, United States, 1982-1997 Figure_26 LYME DISEASE -- reported cases, United States, 1997 Figure_27 MALARIA -- by year, United States, 1967-1997 Figure_28 MEASLES (Rubeola) -- by year, United States, 1962-1997 Figure_29 MENINGOCOCCAL DISEASE -- by year, United States, 1967-1997 Figure_30 MUMPS -- by year, United States, 1972-1997 Figure_31 PERTUSSIS (Whooping Cough) -- by year, United States, 1967- 1997 Figure_32 PERTUSSIS (Whooping Cough) -- by age group, United States, 1997 Figure_33 PLAGUE -- among humans, by year, United States, 1967-1997 Figure_34 POLIOMYELITIS (paralytic) -- by year, United States, 1967- 1997 Figure_35 PSITTACOSIS -- by year, United States, 1967-1997 Figure_36 RABIES -- wild and domestic animals, by year, United States and Puerto Rico, 1967-1997 Figure_37 ROCKY MOUNTAIN SPOTTED FEVER (RMSF) -- by year, United States, 1967-1997 Figure_38 RUBELLA (German Measles) -- by year, United States, 1967- 1997 Figure_39 SALMONELLOSIS (excluding Typhoid Fever) -- by year, United States, 1967-1997 Figure_40 SALMONELLA -- serotype of isolate by year, United States, 1972-1997 Figure_41 SHIGELLOSIS -- by year, United States, 1967-1997 Figure_42 SHIGELLA -- species of isolate by year, United States, 1972-1997 Figure_43 SYPHILIS (Primary and Secondary) -- reported cases per 100,000 population, United States, 1997 Figure_44 SYPHILIS (Primary and Secondary) -- by sex, United States, 1982-1997 Figure_45 SYPHILIS (Primary and Secondary) -- by race and ethnicity, United States, 1982-1997 Figure_46 CONGENITAL SYPHILIS -- among infants aged <1 year, United States, 1967-1997 Figure_47 TETANUS -- by year, United States, 1967-1997 Figure_48 TOXIC-SHOCK SYNDROME (TSS) -- by quarter, United States, 1982-1997 Figure_49 TRICHINOSIS -- by year, United States, 1967-1997 Figure_50 TUBERCULOSIS -- reported cases per 100,000 population, United States and territories, 1997 Figure_51 TUBERCULOSIS -- by year, United States, 1977-1997 Figure_52 TUBERCULOSIS -- by year, among U.S.- and foreign-born persons, United States, 1986-1997 Figure_53 TYPHOID FEVER -- by year, United States, 1967-1997 Figure_54 VARICELLA (Chickenpox) -- reported cases per 100, 000 population, United States and territories, 1997 PART 3: Historical Summary Tables EXPLANATION OF SYMBOLS USED IN TABLES, GRAPHS, AND MAPS No reported cases ............................................. -- Table_1 NOTIFIABLE DISEASES -- Summary of reported cases per 100,000 population, United States, 1988-1997 Table_2 NOTIFIABLE DISEASES -- Summary of reported cases, United States, 1990-1997 Table_3 NOTIFIABLE DISEASES -- Summary of reported cases, United States, 1982-1989 Table_4 NOTIFIABLE DISEASES -- Summary of reported cases, United States, 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