West Nile Virus Activity—United States, August 21-28, 2002, and Illinois, January 1–August 27, 2002 FREE

MMWR. 2002;51:764-766

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This report summarizes West Nile virus (WNV) surveillance data reported to CDC through ArboNET and by states and other jurisdictions as of 7:30 AM Mountain Daylight Time, August 28, 2002, and highlights WNV activity in Illinois.

During the reporting period of August 21-28, a total of 210 laboratory-positive human cases of WNV-associated illness were reported from Illinois (n = 55), Mississippi (n = 36), Louisiana (n = 24), Ohio (n = 22), Missouri (n = 16), Michigan (n = 15), Texas (n = 13), Georgia (n = six), New York (n = four), Alabama (n = three), South Dakota (n = three), Indiana (n = two), Kentucky (n = two), Oklahoma (n = two), Tennessee (n = two), Wisconsin (n =two), Maryland (n = one), Nebraska (n = one), and Virginia (n = one). During this period, Georgia, Maryland, Michigan, Nebraska, Oklahoma, South Dakota, Virginia, and Wisconsin reported their first human cases for 2002. During the same period, WNV infections were reported in 674 dead crows, 305 other dead birds, 581 horses, and 386 mosquito pools. During this period, WNV activity was reported for the first time ever in Montana and New Mexico.

During 2002, a total of 480 human cases with laboratory evidence of recent WNV infection have been reported from Louisiana (n = 171), Mississippi (n = 91), Illinois (n = 71), Texas (n = 38), Missouri (n = 25), Ohio (n = 24), Michigan (n = 15), Alabama (n = eight), Georgia (n = six), Indiana (n = six), New York (n = five), Tennessee (n = four), Kentucky (n = three), South Dakota (n = three), Oklahoma (n = two), Wisconsin (n = two), the District of Columbia (n = one), Florida (n = one), Maryland (n = one), Massachusetts (n = one), Nebraska (n = one), and Virginia (n = one). Among the patients with available data, the median age was 51 years (range: 9 months–98 years), 237 (54%) were male, and the dates of illness onset ranged from June 10 to August 25. In addition, 2,590 dead crows and 1,872 other dead birds with WNV infection were reported from 41 states, New York City, and the District of Columbia; 837 WNV infections in mammals (all but one in horses) have been reported from 25 states (Alabama, Arkansas, Colorado, Florida, Georgia, Iowa, Illinois, Kansas, Kentucky, Louisiana, Minnesota, Mississippi, Montana, Nebraska, New Mexico, New York, North Dakota, Ohio, Oklahoma, South Dakota, Tennessee, Texas, Vermont, Virginia, and Wyoming). During 2002, WNV seroconversions have been reported in 96 sentinel chicken flocks from Florida, Nebraska, Pennsylvania, and New York City; 1,491 WNV-positive mosquito pools have been reported from 18 states (Alabama, Connecticut, Georgia, Illinois, Indiana, Kentucky, Maryland, Massachusetts, Mississippi, Nebraska, New Hampshire, New Jersey, New York, Ohio, Pennsylvania, South Dakota, Texas, and Virginia), New York City, and the District of Columbia.

In 2002, a total of 71 persons with laboratory evidence of WNV were reported through August 27, 2002; 44 cases were laboratory confirmed and 27 were probable. Four cases were fatal; all four patients presented with encephalitis.

The 71 patients had a median age of 49 years (range: 2-92 years); 47% were male. The median age for 32 patients with either aseptic meningitis or encephalitis and a known age was 51 years (range: 18-92 years). Patients who died ranged in age from 67 to 92 years.

Initial clinical data indicate that 20 patients presented with aseptic meningitis and 17 presented with encephalitis. Nine patients presented with WNV-associated fever. The 25 remaining cases are under investigation. Dates of illness onset ranged from July 14 through August 20.

Of Illinois' 102 counties, 92 (90 %) have reported WNV activity (positive animal, mosquito, or human cases). Human cases have occurred among persons in nine counties, with 51 (72 %) cases reported from Cook County, the most populated area of the state. The attack rate during January 1–August 27 was 0.6 per 100,000 for the state population, and 1.0 for Cook County.

Of the 709 crows and blue jays tested, 439 (62%) have tested positive for WNV by the immunohistochemistry test; the first bird tested positive on May 15. Sixty-two horses have tested laboratory positive. These horses had specimens collected during July 19–August 23 from 18 counties. Mosquito pools began testing positive on July 11, and 236 mosquito pools have been reported to the Illinois Department of Public Health (IDPH) as positive through August 16.

IDPH has provided regular updates on WNV on its Web site (http://www.idph.state.il.us). Information on submission of specimens and clinical information on WNV has been provided to local health departments, infection control practitioners, infectious disease physicians, and hospital laboratories. Special reminders have been sent to schools and campgrounds asking them to inform students, spectators, and campers about mosquito repellents and other protective measures. IDPH has conducted vector control consultations and trainings on larviciding. Prevention messages emphasize the need for personal protective measures and removing containers of standing water around residences.

Additional information about WNV activity is available at http://www.cdc.gov/ncidod/dvbid/westnile/index.htm and http://cindi.usgs.gov/hazard/event/west_nile/west_nile.html.

MMWR. 2002;51:790-791

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This report summarizes West Nile virus (WNV) surveillance data reported to CDC through ArboNET and by states and other jurisdictions as of 7:00 AM Mountain Daylight Time, September 4, 2002.

During the reporting period of August 29–September 4, a total of 257 laboratory-positive human cases of WNV-associated illness were reported from Illinois (n = 94), Louisiana (n = 34), Ohio (n = 16), Tennessee (n = 15), Michigan (n = 14), Mississippi (n = 13), Missouri (n = 12), New York (n = eight), Kentucky (n = seven), Alabama (n = five), Texas (n = five), Indiana (n = four), North Dakota (n = four), South Dakota (n = four), Wisconsin (n = four), Arkansas (n = three), Minnesota (n = three), Nebraska (n = three), Virginia (n = two), Connecticut (n = one), Florida (n = one), Iowa (n = one), Maryland (n = one), Massachusetts (n = one), Pennsylvania (n = one), and South Carolina (n = one). During this period, Arkansas, Connecticut, Iowa, Minnesota, North Dakota, Pennsylvania, and South Carolina reported their first human cases for 2002. During the same period, WNV infections were reported in 653 dead crows, 360 other dead birds, 322 horses, and 456 mosquito pools.

During 2002, a total of 737 human cases with laboratory evidence of recent WNV infection have been reported from Louisiana (n = 205), Illinois (n = 165), Mississippi (n = 104), Texas (n = 43), Ohio (n = 40), Missouri (n = 37), Michigan (n = 29), Tennessee (n = 19), Alabama (n = 13), New York (n = 13), Indiana (n = 10), Kentucky (n = 10), South Dakota (n = seven), Georgia (n = six), Wisconsin (n = six), Nebraska (n = four), North Dakota (n = four), Arkansas (n = three), Minnesota (n = three), Virginia (n = three), Florida (n = two), Maryland (n = two), Massachusetts (n = two), Oklahoma (n = two), Connecticut (n = one), the District of Columbia (n = one), Iowa (n = one), Pennsylvania (n = one), and South Carolina (n = one). Among the patients with available data, the median age was 52 years (range: 9 months–98 years); 341 (57%) were male, and the dates of illness onset ranged from June 10 to August 28. A total of 35 human deaths have been reported. The median age of decedents was 76 years (range: 48-94 years); 20 (57%) deaths were among men. In addition, 3,243 dead crows and 2,232 other dead birds with WNV infection were reported from 39 states, New York City, and the District of Columbia; 1,159 WNV infections in mammals (all but one in horses) have been reported from 27 states (Alabama, Arkansas, Colorado, Florida, Georgia, Illinois, Indiana, Iowa, Kansas, Kentucky, Louisiana, Minnesota, Mississippi, Montana, Nebraska, New Mexico, New York, North Dakota, Ohio, Oklahoma, Pennsylvania, South Dakota, Tennessee, Texas, Vermont, Virginia, and Wyoming). During 2002, WNV seroconversions have been reported in 99 sentinel chicken flocks from Florida, Nebraska, Pennsylvania, and New York City; 1,947 WNV-positive mosquito pools have been reported from 18 states (Alabama, Connecticut, Georgia, Illinois, Indiana, Kentucky, Maryland, Massachusetts, Mississippi, Nebraska, New Hampshire, New Jersey, New York, Ohio, Pennsylvania, South Dakota, Texas, and Virginia), New York City, and the District of Columbia.

Additional information about WNV activity is available at http://www.cdc.gov/ncidod/dvbid/westnile/index.htm and http://cindi.usgs.gov/hazard/event/west_nile/west_nile.html.

MMWR. 2002;51:790

On August 23, 2002, the Georgia Division of Public Health (GDPH) and CDC were notified of two cases of unexplained fever and encephalitis in recipients of organ transplants from a common donor. An investigation has identified illness in two other recipients from the same donor: one with encephalopathy and the other with febrile illness. CDC, the Food and Drug Administration, GDPH, and the Florida Department of Health are conducting the investigation. This cluster could possibly represent the first recognized transmission of West Nile virus (WNV) by organ donation.

On August 1, four organs were recovered from a single donor and subsequently transplanted into four persons. The donor had been previously healthy before a fatal injury. Before death, the organ donor received numerous transfusions of blood products. Testing performed at CDC with polymerase chain reaction (PCR) during this investigation revealed the presence of WNV in donor serum collected before organ procurement. Of the four organ recipients, three met the case definition for WNV encephalitis. Testing is pending on the fourth recipient.

A recipient of one of the donor kidneys developed a febrile illness 13 days after transplant which progressed to encephalitis requiring transient mechanical ventilation; the patient's clinical condition is improving. Cerebrospinal fluid (CSF) was positive for WNV IgM antibody. A second kidney recipient had a febrile illness 17 days after transplant progressing to fatal encephalitis. Brain tissues obtained at autopsy were strongly positive for WNV by quantitative PCR and also were positive by flavivirus specific immunohistochemical staining. A third patient who received a heart transplant had ataxia 8 days following transplant; the patient later became unresponsive and required mechanical ventilation. WNV IgM antibody testing of the patient's CSF and serum at the Florida Department of Health Bureau of Laboratories was strongly positive. This patient's mental status has improved, and the patient no longer requires ventilatory support. A fourth patient who underwent liver transplantation had fever, cough, and malaise 7 days following transplant; the patient had no clinical evidence of encephalitis. The patient's symptoms resolved, allowing discharge from the hospital. Laboratory evaluation of serum for WNV is in progress.

WNV infection in organ transplant recipients has not been reported previously, and the risk for transmission of WNV through donated organs is not known. Three of the four organ recipients had encephalitis; typically, one in 150 WNV infections results in encephalitis or meningitis. It is unknown whether immunosuppressed persons, such as organ transplant recipients, are at increased risk for severe WNV-related disease following infection. Similarly, it is unknown if the route of transmission increased the risk for encephalitis in these organ transplant recipients.

The organ donor might have become infected from a mosquito bite or from blood products received following the fatal injury. On the basis of preliminary results from this investigation, clinicians should be aware of the possibility of WNV infection in organ transplant recipients and patients receiving blood transfusions. Clinicians who suspect WNV infection can obtain rapid testing through state and local health departments. Public health officials have initiated precautionary measures including a withdrawal and testing of any remaining blood products from blood donors whose blood product was given to the organ donor. Donors of blood given to the organ donor and other recipients of blood from these donors are being contacted for West Nile virus testing. This is the first report of possible transmission of WNV by organ transplantation. Current data are insufficient to warrant changes to organ or blood donor screening and testing practices or the clinical use of donated organs and blood.

Florida Dept of Health. Georgia Div of Public Health. Center for Biologics Evaluation and Research, Food and Drug Administration. Div of Healthcare Quality Promotion, Div of Vector-Borne Infectious Diseases, National Center for Infectious Diseases, CDC.

MMWR. 2002;51:781-784

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Asthma is a chronic condition that affects approximately 14 million persons in the United States and is characterized by airway inflammation, reversible airway obstruction, and airway hyperresponsiveness to a variety of triggers.¹ Both environmental and psychological factors can trigger asthma exacerbations,^2-4 and a seasonal increase in asthma morbidity occurs in the fall.⁵ This report summarizes the results of a telephone survey conducted among Manhattan residents 5-9 weeks following the September 11, 2001, terrorist attacks on the World Trade Center (WTC) in lower Manhattan in New York City. The findings indicate that among the 13% of adult respondents with asthma, 27% reported experiencing more severe asthma symptoms after September 11. Although a normal seasonal increase in asthma severity was expected, increased severity was reported more commonly among asthmatics reporting psychological distress associated with the attacks and/or difficulty breathing because of smoke and debris during the attacks. Persons with asthma and their clinicians should be aware of the role environmental and psychological factors might play in worsening asthma after disasters.

The study data were collected as part of a survey focused primarily on the psychological impact of the attacks.⁶ Telephone interviews were conducted during October 16-November 15, through a random-digit-dialed sample of persons aged ≥18 years living south of 110th Street in Manhattan. Households were screened for geographic eligibility, and an adult with the most recent birthday was selected to be interviewed. Sample weights based on the number of telephones and adults in each household were applied to adjust for varying probabilities of being interviewed. The response rate was 64.3%. A total of 1,008 persons were interviewed, of whom 20 were excluded from the analysis because of missing weight variables. Psychological factors, including life-stressors,* depression, and risk for post-traumatic stress disorder (PTSD), were assessed by using questions documented previously.⁷

Among participants, 134 (13.4%) reported having been told previously by a doctor that they had asthma; 75 (58.2%) of those with diagnosed asthma were women. The median age of the 134 participants with asthma was 36 years (range: 18-78 years); 86 (70.7%) were non-Hispanic whites, 66 (64.8%) had an annual household income of ≥$40,000, and 99 (72.2%) had a college or graduate degree. Of the 134 persons with asthma, 17 (12.1%) reported that they lived or were present south of Canal Street (i.e., 15 blocks north of the WTC site) at the time of the attacks.

Of the 134 respondents with diagnosed asthma, 34 (27.0%) reported worsening of asthma symptoms after the September 11 terrorist attacks, defined as having moderate to severe symptoms during the weeks since September 11 compared with having none to mild symptoms during the 4 weeks before September 11. Persons with asthma reporting worsening symptoms were more likely than those not reporting worsening symptoms to report unscheduled visits to a health-care provider (28% versus 5%; p = 0.02) for asthma after September 11.

Bivariate analyses showed that an increased severity of asthma symptoms since September 11 was significantly more likely to be reported by respondents who (1) had difficulty breathing because of smoke and debris during the attacks, (2) had two or more life stressors during the 12 months before the attacks, (3) experienced a peri-event panic attack (i.e., an event that occurred at the time of or shortly after the attacks), (4) had depression during the preceding month, or (5) had symptoms of PTSD related to the attacks during the preceding month. Persons with asthma who lived or were present south of Canal Street on September 11 were more likely than others to report increased asthma symptoms; however, the association was not statistically significant.

Separate multivariate logistic regression models were used that included life stressors during the preceding 12 months, peri-event panic attack, PTSD, and depression and that controlled for age, sex, race/ethnicity, income, and difficulty breathing because of smoke and debris. Having two or more life stressors during the 12 months before the attacks (odds ratio [OR] = 4.4; 95% confidence interval [CI] = 1.4-14.2) remained significantly associated with an increase in asthma severity after September 11; difficulty breathing because of smoke and debris also was a significant predictor of worsening asthma after September 11 (OR = 7.0; 95% CI = 2.3-21.3). Although peri-event panic attack (OR = 2.4; 95% CI = 0.8-.4), PTSD (OR = 3.6; 95% CI = 0.6-0.9), and depression (OR = 2.9; 95% CI = 0.9-9.8) also were associated with increased severity in asthma symptoms, the relation was not statistically significant.

J Fagan, PhD, S Galea, MD, J Ahern, MPH, S Bonner, PhD, D Vlahov, PhD, Center for Urban Epidemiologic Studies, New York Academy of Medicine, New York City. Div of Environmental Hazards and Health Effects, National Center for Environmental Health, CDC.

Particulate matter and other constituents of smoke can trigger asthma.⁸ Persons with asthma who reported difficulty breathing because of smoke and debris during the September 11 attacks might have been particularly sensitive to smoke from the fires that burned at the WTC site for several weeks. Psychological stress also can worsen asthma,² and PTSD has been associated with an increase in respiratory symptoms⁹ and with asthma. Even accounting for the impact of smoke and debris on asthma symptoms, adults with asthma who had two or more life stressors before September 11 (a risk factor for PTSD) were more likely to experience worsening of asthma after the attacks.

The findings in this report are subject to at least four limitations. First, no objective measures are available to validate the self-reported worsening of asthma symptoms in this population. Second, because of its cross-sectional design, this study could not establish a temporal or causal relation between worsening of asthma symptoms and psychological symptoms. Third, some selection bias cannot be ruled out; those with health problems might have been more or less likely to participate in the survey than others. Finally, because asthma severity usually increases in the fall,⁵ these data cannot be used to quantify the absolute impact on persons with asthma of environmental and psychological factors related to the September 11 terrorist attacks.

Despite these limitations, the survey data suggest that both the environmental and psychological sequelae of the September 11 attacks contributed to increasing symptoms experienced by some persons with asthma during the weeks following the attacks. Persons with asthma and their clinicians should be aware of the role these factors might play in worsening asthma after disasters.

References: 9 available

*Include death of a close family member; serious illness or injury; change in marital status, family, or work situation; or emotional problems.

MMWR. 2002;51:784-786

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To measure the psychological and emotional effects of the September 11, 2001, terrorist attacks on the World Trade Center (WTC), Connecticut, New Jersey, and New York added a terrorism module to their ongoing Behavioral Risk Factor Surveillance System (BRFSS). This report summarizes the results of the survey, which suggest widespread psychological and emotional effects in all segments of the three states' populations. The findings underscore the importance of collaboration among public health professionals to address the physical and emotional needs of persons affected by the September 11 attacks.

BRFSS is a random-digit-dialed telephone survey of the noninstitutionalized U.S. population aged ≥18 years.^1,2 The terrorism module consisted of 17 questions which asked respondents whether they were victims of the terrorist attacks, attended a memorial or funeral service after the attacks, were employed or missed work after the attacks, increased their consumption of tobacco and/or alcohol following the attacks, or watched more media coverage following the attacks. The survey was conducted during October 11–December 31. A total of 3,512 respondents completed the module in the three states (1,774 in Connecticut, 638 in New Jersey, and 1,100 in New York). SAS and SUDAAN were used in the analyses to account for the complex sampling design.

Of the 3,512 participants, approximately 50% participated in religious or community memorial services, and 13% attended a funeral or a memorial service for an acquaintance, relative, or community member. Three fourths (75%) of respondents reported having problems attributed to the attacks. Nearly half (48%) of respondents reported that they experienced anger after the attacks. Approximately 12% of respondents with problems reported getting help. Family members (36%) and friends or neighbors (31%) were the main source for help. Approximately 3% of alcohol drinkers reported increased alcohol consumption, 21% of smokers reported an increase in smoking, and 1% of nonsmokers reported that they started to smoke after the attacks.

The impact of the attacks varied by sex, age group, educational level, and race/ethnicity. Compared with men, women were more likely to have participated in a religious or community memorial service (55.1% [95% confidence interval (CI) = 54.2%-55.9%] versus 43.0% [95% CI = 41.7%-44.3%]) and to get help with the problems they experienced (15.3% [95% CI = 13.0%-17.6%] versus 8.8% [95% CI = 7.9%-9.6%]). Men were more likely than women to drink more alcohol (4.2% [95% CI = 3.4%-4.9%] versus 2.4% [95% CI = 2.1%-2.6%]), and women smokers were more likely than men to smoke more as a result of the attacks (27.1% [95% CI = 23.9%-30.3%] versus 14.8% [95% CI = 12.3%-17.3%]).

Approximately 27% of respondents who were working at the time of the attacks missed work afterwards. The major reason for missing work was transportation problem (51%). Approximately 21% of workers had to be evacuated on the day of the attacks. Approximately 80% of respondents reported watching more media coverage than usual on television or through the Internet. Approximately 3% of respondents reported that they were victims of the attacks, 7% had relatives who were victims, and 14% had friends who were victims. In Connecticut, New Jersey, and New York, 4%, 17%, and 35% of the respondents, respectively, reported being in New York City during the attacks.

TA Melnik, DrPH, CT Baker, Bur of Chronic Disease Epidemiology and Surveillance, New York State Dept of Health. ML Adams, MPH, Connecticut Dept of Health. K O'Dowd, PhD, New Jersey Dept of Health and Senior Svcs. AH Mokdad, PhD, DW Brown, MSPH, W Murphy, WH Giles, MD, VS Bales, MPH, Div of Adult and Community Health, National Center for Chronic Disease Prevention and Health Promotion, CDC.

The findings in this report document the widespread emotional and psychological effects among residents of three states following the September 11 attacks and indicate that some persons sought help to cope with the catastrophic events. Although this survey inquired about the short-term effects of the attacks, the findings suggest the need to consider the long-term emotional and psychological health of the affected population. The flexible design of BRFSS allows states to add questions to their ongoing surveys to address changing situations and crises, such as the WTC attacks.

The findings in this report are subject to at least four limitations. First, the survey design excluded persons without a telephone, which primarily includes persons of low socioeconomic status. Second, the survey excluded persons who were not yet able to discuss their emotional response to the attacks. Third, the survey did not measure the severity and duration of emotional and psychological problems of the respondents. Finally, the survey might have excluded persons who had moved from the area after the attacks.

Public health professionals should consider the emotional and psychological well-being of persons after traumatic events. The results of community-based surveys can help target programs designed to help residents deal with the aftermath of terrorist attacks. In response to national disasters, several programs have been implemented successfully to provide immediate medical care and to prevent the spread of infections and disease; however, the long-term emotional pain and suffering associated with disasters also needs to be considered in response planning. State and federal agencies should prepare programs to address the emotional and psychological health of persons, and these programs should be integrated with other disaster-preparedness plans.

References: 2 available

MMWR. 2002;51:710

CDC and Emory University's Rollins School of Public Health will cosponsor a course, "Epidemiology in Action," from November 12-22, 2002, at CDC and Emory University campuses. The course is designed for state and local public health professionals.

The course emphasizes the practical application of epidemiology to public health problems and will consist of lectures, workshops, classroom exercises (including actual epidemiologic problems), and roundtable discussions. Topics covered include descriptive epidemiology and biostatistics, analytic epidemiology, epidemic investigations, public health surveillance, surveys and sampling, Epi Info 2000 (Windows® version) training, and discussions of selected prevalent diseases. There is a tuition charge.

Deadline for application is October 1, 2002. Additional information and applications are available from Emory University, International Health Dept. (PIA), 1518 Clifton Road, N.E., Room 746, Atlanta, Georgia 30322; telephone (404) 727-3485; fax (404) 727-4590; or from http://www.sph.emory.edu/EPICOURSES; or e-mail pvaleri@sph.emory.edu.