Needs Assessment Following Hurricane Georges—Dominican Republic, 1998Human Rabies— Virginia, 1998Change in Recommendation for Meningococcal Vaccine for TravelersNeeds Assessment Following Hurricane Georges—Dominican Republic, 1998Human Rabies— Virginia, 1998Change in Recommendation for Meningococcal Vaccine for Travelers FREE

MMWR. 1999;48:93-95

Hurricane Georges struck the Carribean Islands in September 1998, causing numerous deaths and extensive damage throughout the region. The Dominican Republic was hardest hit, with approximately 300 deaths; extensive infrastructure damage; and severe agricultural losses, including staple crops of rice, plantain, and cassava. Two months after the hurricane, the American Red Cross (ARC) was asked to provide food to an estimated 170,000 families affected by the storm throughout the country. To assist in directing relief efforts, CDC performed a needs assessment to estimate the food and water availability, sanitation, and medical needs of the hurricane-affected population. This report summarizes the results of that assessment, which indicate that, 2 months after the disaster, 40% of selected families had insufficient food ≥5 days per week and 28% of families reported someone in need of medical attention.

A household survey was performed using a modified cluster-sampling method¹ to select persons from the first 33,000 families identified by the ARC as beneficiaries to receive support. The country was divided geographically into clusters. Using a random number generator, 30 clusters were selected with probability proportional to the number of households within a cluster. One adult family member was interviewed from each of seven selected households within each cluster. A total of 207 interviews were completed, representing 1414 persons. Respondents were asked about availability of food, water, and housing, and medical needs and storm preparation.

Data were analyzed using EpiInfo 6.1.² Frequencies of variables were calculated for the population as a whole. Two groups of beneficiaries were considered by ARC: persons residing in groups in migrant farm worker settlements (i.e., bateys) (35 of 207 households) where baseline conditions were thought to be more harsh, and persons residing in shelters (50 of 207 households) who had been displaced from their homes and resources. Conditions for persons in bateys and shelters were compared with conditions for persons residing in other housing at the time of the survey.

The availability of food decreased dramatically after the hurricane. Respondents from 167 (83%) of 202 households reported insufficient food since the hurricane, compared with 107 (53%) of 202 who reported insufficient food before the storm (p<0.01). Of 202 households, 174 (86%) reported not having enough food ≥1 day per week. Of 201 households, 13 (7%) reported insufficient food for ≥5 days per week before the storm and 59 (29%) of 203 households after the storm. Of 202 households, 70 (35%) reported having enough food in their home for the next 3 days. At the time of the survey, relief services were providing food for 45 (23%) of 207 households; 38 (82%) of these families reported insufficient food despite the support.

Persons residing in batey households reported a higher mean number of days each week with insufficient food than did persons residing in other households before the hurricane (2.7 days compared with 1.9 days) (p<0.01). At the time of the survey, no difference was reported (3.4 days compared with 3.3 days). Of 33 batey households, 10 (30%) reported insufficient food ≥5 days per week, compared with 35 (24%) in the other households (p>0.05). Three fourths of batey households reported needing food; 16 (50%) batey households were relying on relief efforts for food.

Before the hurricane, the need for food was similar between households now housed in shelters and other nonbatey households. After the hurricane, 70% of nonbatey households identified food as a need, with 20 (40%) of 50 shelter households without enough food ≥5 days per week. At the time of the survey, relief efforts provided food for 32% of families in shelters.

At the time of the survey, 47 (28%) of 171 households reported having someone in the home who needed medical attention, and 160 (78%) of 205 households reported someone in the home who needed medication. Since the hurricane, 168 (82%) of 206 households reported an illness in a household member: respiratory illness (99 [59%]), gastrointestinal illness (69 [41%]), chronic illness (30 [18%]), or stress reaction (15 [9%]). In bateys and shelter populations, more families reported gastrointestinal (52% and 54%, respectively) (p<0.01) and respiratory (67% and 66%, respectively) disease than other families (37% [p<0.01] and 56% [p>0.05], respectively), but both were less likely to request medication. Families residing in shelters had the same access to health care than other households (67% compared with 74%) (p=0.4) and a higher self-reported need for health care (48% compared with 20%) (p<0.01).

After the storm, 97 (47%) households had running water. At the time of the survey, 18 (9%) households were relying on river water and 18 (9%) on rainwater. Although 85 (41%) households reported having wells, many reported water as a need. Most (93%) households reported access to a bathroom or latrine.

Dominican Republic Red Cross; American Red Cross International Svcs. National Center for Environmental Health; and EIS officers, CDC.

After a natural disaster, assessments typically are conducted within the first week to 10 days to determine the acute impact on the population.³ This evaluation was conducted 2 months after the storm to identify public health needs that remained after the emergency response to the disaster. Basic subsistence and health-care needs were present 2 months after the hurricane, when relief efforts were decreasing. Because of small sample sizes, comparisons between groups (i.e., batey, shelter, and other populations) should be interpreted with caution.

Following this assessment, recommendations were given to ARC and the Dominican Republic Ministry of Health, emphasizing the need for food, with special consideration of pregnant and lactating women and their newborns. In addition, periodic reassessments were recommended to monitor the effectiveness of follow-up interventions.⁴ Because of the high medical needs and low food availability reported by the shelter families, immediate preventive interventions were recommended.

As a result of these recommendations, ARC's food delivery schedule was accelerated by 1 month because of acute food needs. In addition, the Ministry of Health initiated medical interventions as soon as possible for shelter residents. Periodic needs assessments have been scheduled through November 1999.

References: 4 available

MMWR. 1999;48:95-97

On December 31, 1998, a 29-year-old man in Richmond, Virginia, died from rabies encephalitis caused by a rabies virus variant associated with insectivorous bats. This report summarizes the clinical and epidemiologic investigations by the Virginia Department of Health and CDC.

On December 14, 1998, an inmate at the Nottoway Correctional Center in Nottoway County, Virginia, developed malaise and back pain while working on a roadside clean-up crew. He sought medical care at the prison on December 15, complaining of muscle pains, vomiting, and abdominal cramps, and was treated with acetaminophen. His clinical signs progressed to include persistent right wrist pain, muscle tremors in his right arm, and difficulty walking. On December 18, the patient was sent to a Richmond emergency department, where he had a temperature of 103 F (39.4 C). He initially was alert and oriented but had visual hallucinations. During the next 12 hours, he became increasingly agitated and less oriented. Physical examination revealed anisocoria, increased tone in the right forearm, and hyperesthesia over the entire right side of the body. Intoxication with anticholinergic agents such as pesticides or Jimson weed was considered; however, toxicology studies were negative.

The patient's condition worsened, with hypersalivation, priapism, and wide fluctuations in body temperature and blood pressure. He was intubated and heavily sedated on December 20. Laboratory findings included a white blood cell count of 20,800/µL (normal: 3700-9400/µL), myoglobinuria, and a compensated metabolic anion gap acidosis with renal insufficiency. Peak creatine phosphokinase levels were 130,900 U/L (normal: 50-450 U/L), indicating rhabdomyolysis. Analysis of cerebrospinal fluid (CSF) showed a white blood cell count of 57/µL (normal: 0-5/µL), protein levels of 128 mg/dL (normal: 12-60 mg/dL), and glucose levels of 46 mg/dL (normal: at least two thirds of a concurrent serum glucose value, which was approximately 136 mg/dL). A computed tomography scan of the patient's head revealed no abnormal findings.

A diagnosis of rabies was first considered by the patient's physician on December 20. Samples sent to CDC for testing on December 21 included a nuchal skin biopsy, which tested positive for rabies virus by direct fluorescent antibody test on December 22, and saliva and skin, which were positive by reverse-transcriptase polymerase chain reaction (RT-PCR) assay on December 23. The sequence of the amplified RT-PCR product showed >99.7% DNA homology to a rabies virus variant associated with eastern pipistrelle bats (Pipistrellus subflavus) and silver-haired bats (Lasionycteris noctivagans). Serum and CSF samples obtained December 21 contained rabies virus neutralizing antibody titers of 1:50 and 1:36, respectively, by rapid fluorescent focus inhibition test (RFFIT). A serum sample obtained December 28 showed a rabies virus neutralizing antibody titer of 1:1200 by RFFIT. After the removal of all sedatives, the patient showed no purposeful movement and loss of brainstem reflexes. He died December 31.

Postexposure prophylaxis (PEP) was administered to 48 persons who possibly had contact with the patient's saliva between December 4 (10 days preceding the first clinical signs of illness) and death. Of the 48, 29 were prison inmates who reported possible contact with the patient's saliva, either while caring for him during his illness or through shared cigarettes or drinking and eating utensils. Three family members who visited the patient at the prison on December 6, 15 health-care providers, and the pathologist who conducted the autopsy also received PEP.

Family members, friends, and prison staff reported the patient had not indicated any contact with or bite from an animal in recent months, and prison medical records did not document evidence of a bite or scratch. The patient lived at a work center that housed up to 160 inmates in two separate dormitories. He had worked around the prison on a farm repairing fence lines and feeding cattle, in a paper recycling facility, and along roadsides cleaning up trash and debris. No evidence of bats was found within the prison or on prison grounds, although inmates reported occasionally seeing bats flying near the outdoor lights in the summer. Several stray cats were reported to occasionally approach inmates at the facility; however, the patient was not known to have handled them.

The patient had been incarcerated at Nottoway for approximately 6 weeks after transfer from another correctional unit. At the other correctional facility, the patient worked inside the prison and on a road crew cutting brush and picking up trash along highways. No evidence of bats was found in the prison, and inmates reported that they had never seen bats inside the facility. Prison staff and inmates reported that they did not recall the patient ever being bitten by an animal while working, and that he usually did not handle small animals found by the road crews.

D Robinson, L Thompson, MD, M Epperson, F Dabbs, R Lawman, M Hill, L Trailer, H Hensley, Nottoway Correctional Center, Nottoway County; G Bryan, Chatham Correctional Unit, Pittsylvania County; T Kerkering, MD, F Tortorella, MD, M Wong, MD, M Edmond, MD, M Kohmetscher, MD, L Han, MD, C Subrahman, MD, L Brath, MD, T Miller, MD, Medical College of Virginia, Richmond; C Armstrong, MD, C DeBusk, S Leslie, K Blackenship, J Hawley, Piedmont Health District; J Harris, MD, Central Virginia Health District; S Jenkins, VMD, C Woolard, PhD, R Stroube, MD, State Epidemiologist, Office of Epidemiology, Virginia Dept of Health. Viral and Rickettsial Zoonoses Br, Div of Viral and Rickettsial Diseases, National Center for Infectious Diseases; and an EIS Officer, CDC.

This report describes the only case of human rabies diagnosed in the United States during 1998 and the first case in Virginia since 1953. A definitive history of an animal bite could not be established for this patient, and the most likely explanation is an unrecognized bat bite occurring either at the farm or recycling facility or while the patient was working on a road crew. Because the incubation period for rabies varies from several weeks to several months, he may have contracted rabies before his transfer to Nottoway.

Since 1990, 27 human rabies cases have occurred in the United States (an average of three cases per year).^1- 2 Although 20 (74%) have been attributed to bat-associated variants of the rabies virus, a definitive history of a bat bite was established for only one of these cases. Of the 20 attributed to bat-associated variants, 15 (75%) have been caused by the same eastern pipistrelle/silver-haired bat variant responsible for the death described in this report. Although bat-associated rabies virus variants theoretically can be secondarily transmitted from terrestrial mammals, an unrecognized bat bite is the most likely explanation for these cases.

The reasons for the preponderance of human rabies cases associated with the eastern pipistrelle/silver-haired bat virus variant remain speculative. Epidemiologic findings suggest that it can be transmitted following minor, undetected exposures.¹ Insectivorous bats, such as those implicated in the human rabies deaths in the United States, have small teeth that may not cause an obvious wound in human skin.³ Accordingly, it is important to treat persons for rabies exposure when the possibility of a bat bite cannot be reasonably excluded. In all cases where bat-human contact has occurred, the bat should be collected and tested for rabies if possible. If the bat is not available for rabies testing, the need for PEP should be assessed by public health officials familiar with recent recommendations.⁴

The total of 48 persons who received PEP after contact with the patient described in this report is similar to the mean of 49.8 persons who received PEP after exposures to human rabies cases during 1990-1997.^1,5- 6 Consideration of rabies before the patient's death may have minimized the number of hospital staff that received PEP in this case.

Although this patient did not exhibit classic hydrophobia, other typical clinical signs, such as hypersalivation, hallucinations, priapism, paresthesias, muscle spasms, and autonomic instability occurred. The use of sedatives may have masked hydrophobia in this patient. Medical personnel should consider rabies as a diagnosis in any case presenting with the acute onset and rapid progression of compatible neurologic signs, regardless of whether the patient reports a history of an animal bite. Although early diagnosis cannot save the patient, it may help minimize the number of potential exposures and the need for PEP.

MMWR. 1999;48:104

Because no evidence exists of ongoing epidemics, CDC no longer recommends meningococcal vaccine for travelers to Saudi Arabia, Nepal, India, Mongolia, Kenya, Burundi, and Tanzania. This announcement supersedes the most recent edition of Health Information for International Travel,¹ which recommends meningococcal vaccine for those countries. These new recommendations will be reflected in the next edition of Health Information for International Travel.

Although CDC no longer recommends vaccination, Saudi officials may require that pilgrims and "Umra" performers produce a certificate of vaccination against meningococcal disease issued not more than 3 years and not less than 10 days before arrival in Saudi Arabia. Travelers to Saudi Arabia during pilgrimage months should verify these requirements with a Saudi embassy.

From December through June, vaccination is still recommended for countries in the meningitis belt of Africa.