Community acquired Pneumonia

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					 Publication of the Division of Public Health Services           September/October 2005, Vol. 19, No. 5

                  Community-acquired Pneumonia
                                                                                                              Peter C. Kelly, M.D., F.A.C.P.
     Respiratory tract infections are a             Community-acquired                                Parameters that Define
common cause of illness. Most of                    Pneumonia, the Big Picture                         Severe Pneumonia(3,5)
these infections are mild, self-limited                  The estimated annual case load of
and do not require professional med-                                                             Any single parameter defines severe
                                                    community-acquired pneumonia in              pneumonia.
ical care. Some individuals will have               the United States is 4 million. These
signs and symptoms of a lower respi-                cases result in 600,000 hospitaliza-         1. Greater than 30 breaths per
ratory tract infection (also known as               tions at a cost of $23 billion.(1)              minute on admission
acute bronchitis) such as cough, spu-               Mortality rates vary widely from a           2. A ratio of arterial oxygen tension
tum production, and fever. A smaller                low of 5.1% for hospitalized and                to fractional inspired oxygen of
group of people will have symptoms                  ambulatory patients to a high of                less than 250
of a lower respiratory tract infection              36.5% for patients requiring intensive
accompanied by rales on auscultation                                                             3. The need for mechanical
                                                    care.(2) Community-acquired pneumo-
of the chest and /or an infiltrate on                                                                ventilation
                                                    nia occurs in patients of all ages but
chest radiograph. This later group has              is frequent in people from their mid-        4. Bilateral or multilobar involvement
an infection of the lung parenchyma                 fifties to late sixties.(3)                      on chest radiograph
known as pneumonia. Pneumonia
has many different causes most of                   Microorganisms Causing                       5. An increase in the size of the pul-
which are microorganisms. In fact the               Community-acquired                              monary infiltrate of up to 50% in
microorganisms causing pneumonia                                                                    the first 48 hours.
are very diverse ranging from viruses                    Many different microorganisms           6. Systolic blood pressure <90
to bacteria and fungi. The diversity of             cause community-acquired pneumo-                mmHg
causes challenges physicians to make                nia. Among patients requiring                7. Diastolic blood pressure < 60
an accurate diagnosis so that appro-                hospitalization Streptococcus pneu-             mmHg
priate treatment can be given.                      moniae is the most frequently
     A practical approach to managing               identified pathogen but accounts for          8. The need for vasopressors for
pneumonia is to classify cases accord-              only ~ 20% of cases. Other bacteria             more than four hours
ing to the circumstances of the patient             recognized as causative agents are           9. A urine output of < 20mL/hour or
at the time the disease was acquired.               Haemophilus influenzae,                          a total output of < 80mL over 4
Some of the categories include pneu-                Staphylococcus aureus, Mycoplasma               hours
monia acquired in the community by                  pneumoniae, and several different
overtly normal people, pneumonia                                                                 10. Acute renal failure
                                                    enteric gram negative rods. In addi-
acquired in the hospital or nursing                 tion there are organisms that occur
home setting, and pneumonia among                                                                burnetii, and Chlamydia psittaci. One
                                                    infrequently when nation wide data
immunocompromised hosts. This arti-                                                              of the most common findings in many
                                                    are surveyed but can be frequent
cle will focus on community-acquired                                                             studies is that no pathogen is identi-
                                                    causes in specific locations. Examples
pneumonia in normal hosts.                                                                       fied.
                                                    include Legionella species, Coxiella                                continued on page 2

                                                    Visit the ADHS Web site at
                                    Flu Vaccine Risk     Unsafe Behaviors       Dengue Fever         Communicable        Hepatitis C:
                                    Groups & Your        and STDs Predict          Page 5           Disease Summary    Acute vs. Chronic
                                        Practice           HIV Increase                                  Page 7           Infections
                                         Page 3               Page 4                                                        Page 8

September/October 2005                                                                                                     Prevention Bulletin   1
     Community-acquired Pneumonia                                                 continued from page 1

                                                                                                                                     Figure 1
         In Arizona we
    have two organisms
    that deserve
    consideration. In the
    desert counties
    (Maricopa, Pima, and
    Pinal) Coccidiodes
    immitis, a fungal
    organism found in the
    soil and aerosolized
    by wind or by work-
    ing in the soil, can
    cause community-
    acquired pneumonia.
    In recent years the
    number of cases of
    has steadily increased
    (See Figure 1) due in                     pital, two pretreatment blood cultures,      in the published guidelines of the
    part to increased population but also     an expectorated deep-cough sputum            Infectious Diseases Society of
    due in part to other unidentified fac-     for Gram stain and culture and a coc-        America(4) or the American Thoracic
    tors. In view of the increasing cases     cidiodal serology is sufficient. Mild         Society(5). The initially prescribed
    physicians should strongly consider       cases not requiring hospitalization          antibiotics can be modified when a
    ordering a coccidioidal serology and      can be evaluated for Mycoplasma              specific cause is identified. In patients
    fungal sputum culture on cases of         pneumoniae, and seasonal viruses             that do not respond to empiric thera-
    community-acquired pneumonia,             such as Influenza and RSV. If a               py additional diagnostic testing based
    especially if symptoms persist for two    specific organism is suspected on             clinical findings should be undertaken
    weeks or longer. In the northeastern      clinical grounds, then tests for that        prior to broadening the antibiotic reg-
    part of the state the Sin Nombre Virus    agent can be ordered.                        imen. In our state, the frequency of
    can cause a severe pulmonary illness                                                   coccidioidomycosis should prompt
    (Hantavirus Pulmonary Syndrome)           Severe Community-acquired                    physicians to order coccidioidal serol-
    preceded by abdominal pain. The           Pneumonia(3)                                 ogy early in the course of community-
    virus is shed in the urine of deer mice       Ten percent of community-                acquired pneumonia.
    and humans acquire infection via          acquired pneumonia cases can be
    aerosols.                                 severely ill and benefit from intensive       References:
         Viral pathogens can cause com-       care. Criteria for identifying these         (1) Bartlett JG, Mundy LM. Community-acquired
    munity-acquired pneumonia and are         patients are listed in the box on                pneumonia. N Engl J Med 1995; 333:1618-1624.
    frequent in mild cases not requiring      page 1. S. pneumoniae and L.                 (2) Fine MJ, Smith MA, Carson CA, et al. Prognosis
    hospitalization. The principal causes     pneumophilia are the organisms most              and outcomes of patients with community-
                                                                                               acquired pneumonia: A meta-analysis. JAMA
    are Influenza A and B, Respiratory         commonly found in severe cases.                  1996; 275: 134-141.
    syncytial virus (RSV), Parainfluenza       Mortality rates for severe pneumonia         (3) Donowitz, GR, Mandell GL. Acute Pneumonia.
    virus and Adenovirus. Influenza and        range from 20 to 53%. Clinical factors           In Mandell GL, Bennett JE, Dolin R,eds Principles
                                                                                               and Practice Infectious Diseases, 6th
    RSV are seasonal pathogens with           independently associated with death              ed.Philadelphia: Elsevier; 2005: 819-845.
    clustering in the fall and winter         are tachypnea (>30 breaths/minute),          (4) Mandell LA, Bartlett JG, Dowell SF, et al. Update
    months. Mycoplasma pneumoniae is          diastolic blood pressure < 60 mmHg               of practice guidelines for the management of
    the most frequently established diag-     and blood urea nitrogen >                        community-acquired pneumonia in immunocom-
                                                                                               petent adults. Clin Infect Dis. 2003; 37: 1405-
    nosis in out-patient pneumonias, and      7mmol/liter.                                     1433.
    accounts for ~20% of cases.
         Given the diversity of causes of
                                              Treatment of Community-                      (5) Niederman MS, Mandell LA, Anzueto A, et al.
                                                                                               Guidelines for the management of adults with
    community-acquired pneumonia it is        acquired Pneumonia                               community-acquired pneumonia: Diagnosis,
                                                  In clinical practice, treatment              assessment of severity, and antimicrobial therapy
    not necessary or desirable to order                                                        and prevention. Am J Resp Crit Care Med. 2001;
    diagnostic tests for each possible        decisions are frequently made before             163: 1730-1754.
    microorganism. Testing can be tai-        the results of diagnostic tests are avail-
    lored to the circumstances of the         able. A detailed discussion of empiric       Dr. Peter Kelly is a physician consultant at
                                              antibiotic selection is beyond the           ADHS and can be reached at
    case. For patients admitted to the hos-                                      
                                              scope of this article and can be found
2    Prevention Bulletin                                                                                              September/October 2005
     Flu Vaccine Risk Groups & Your Practice
                                                                                                                           by Will Humble
     The United States has         Table 1
had either shortages or                Priority Group                              Estimated AZ Pop.           Estimated US Pop.
delays of inactivated
influenza vaccine during          1. A Persons > 65 w/co-morbidity                              364,000                        18,200,000
three of the last five                  Residents of Long Term Care Facilities                    34,000                         1,700,000
influenza seasons. Delays
                                       Sub-total                                               398,000                       19,900,000
in delivery of influenza
vaccine or vaccine short-        1. B Persons 2-64 w/co-morbidity                              848,000                        42,400,000
ages are likely in future              Persons > 65                                            354,000                        17,700,000
years as well because of               Children 6-23 mos.                                      120,000                          6,000,000
inherent time constraints in           Pregnant women                                            80,000                         4,000,000
manufacturing the vaccine
and uncertainties regarding            Sub-total                                             1,402,000                       70,100,000
vaccine supply.
     Vaccination will con-       1. C Health care personnel                                    140,000                          7,000,000
                                       Close contacts of children < 6 mos.                     100,000                          5,000,000
tinue to be prioritized on
the basis of risk for serious          Sub-total                                               240,000                       12,000,000
influenza-associated com-
plications during periods of 2         Household contacts of high risk persons               1,406,000                        70,300,000
inactivated influenza                   Healthy persons 50 - 64                                 354,000                        17,700,000
vaccine shortfall. In years
when there is an adequate              Sub-total                                             1,760,000                       88,000,000
supply, nationwide media
campaigns will use the           3     Healthy Persons 2-49                                  2,110,000                       105,500,000
tiered groupings to encour-
                                       Total                                                 5,900,000                       295,000,000
age people to get their flu
shots. The CDC published
an article in their August 5, 2005 Morbidity and Mortality          teleconferences, print media outreach, clinician education,
Weekly Reports that identifies the vaccination priority              and web based advertising.
groups                                         The media outreach plan will have three phases that
     The CDC determined the priority groups, ranked in              will encourage different risk groups to get their influenza
three tiers, on the basis of influenza-associated mortality          vaccine at different times. Phase I will be in October and
and hospitalization rates. In years when there is an                will encourage persons in Tier 1 (highest risk) to seek a flu
influenza vaccine shortfall, persons in Tier 1 should be             shot. Phase II will encourage persons in Tier 2 (medium
vaccinated preferentially, followed by persons in Tier 2,           risk) to get their shot. The final Phase will be implemented
then persons in Tier 3. Table 1 displays a description of the if there are adequate supplies and will encourage lower
tiered groups and an estimate of the number of people in            risk persons aged 2 to 49 years without medical problems
each category in Arizona.                                           to get their shot.
     The CDC will be using the new tiered risk grouping in               The CDC website continues to post regular updates
their nationwide media campaign this year to increase the           and downloadable influenza prevention materials for
public's awareness of this year's immunization recommen- healthcare providers at
dations. The media plan will include radio and TV public            Will Humble is Deputy Assistant Director of Public Health Preparedness,
service announcements, video news releases, radio tours,            and can be reached at 602.364.3855 or

                                  Arizona's “Evergreen” Pandemic Flu Plan
 A pandemic influenza is inevitable. The ADHS has created this Pandemic Influenza Response Plan to promote an
 effective and coordinated response throughout the pandemic in order to lessen the impact of the influenza pandemic.
 Healthcare providers will be important partners with the Federal State and Local government when the next influenza
 pandemic arrives.
 The Arizona plan is on the ADHS website at: This is an “evergreen” document that is updated as
 suggestions and recommendations are made. You can provide recommendations to improve the plan by e-mailing
 Will Humble at

September/October 2005                                                                                                    Prevention Bulletin   3
      Unsafe Behaviors and STDs Predict HIV Increase
                                                                        by Melanie Taylor, M.D., M.P.H., and S. Robert Bailey, M.S.
         An analysis of sexually transmit-   with HIV; persons reported with                Among HIV-infected persons STD
    ted disease (STD), Hepatitis C (HepC),   Syphilis are nearly 13 times more         testing (syphilis, gonorrhea, chlamy-
    and HIV/AIDS surveillance reports        likely to have been diagnosed with        dia) is recommended yearly and
    made to the Arizona Department of        HIV infection.                            every 3-6-months for persons engag-
    Health Services from 1998-2003                It has long been understood that     ing in unsafe sexual activities such as
    reveal prevailing patterns of co-mor-    the presence of an STD facilitates the    having sex with anonymous partners,
    bidity in Arizona. Because common        transmission of HIV, and that STDs        drug use (methamphetamine, Viagra,
    modes of transmission exist between      themselves are an indicator of unsafe     ecstasy, cocaine), prostitution, and
    these diseases co-morbidity analyses     sexual practices conducive to HIV         meeting partners at commercial sex
    can support and direct recommenda-       infection. Current Centers for            venues such as bathhouses, sex clubs
    tions for testing. Using disease         Disease Control and Prevention            and adult bookstores. Hep C testing is
    reports, epidemiologists constructed a   (CDC) recommendations include HIV         recommended for all persons at the
    lifetime diagnosis history of STDs ,     testing for all persons who seek test-    initial visit for HIV primary care. For
    HepC, and HIV for persons reported       ing or treatment for STDs. The U.S.       HIV-infected persons reporting ongo-
    with one of these diseases during        Preventative Services Task Force has      ing injection drug use, ADHS recom-
    1998-2003. Significant morbidity          recently released updated recommen-       mends ongoing annual Hep C testing.
    overlaps among the disease groups        dations for HIV testing among other
    was observed.                            risk groups.
         The reported co-morbidity reflects                                                                      continued on page 5
    the number of persons in
    each disease group
    also having any
    lifetime report-
    ed diagnosis
    within any of
    the other
    groups. Most
    noteworthy is
    the fact that
    nearly 15% of
    those reported
    with HIV/AIDS
    have also been
    reported with an STD
    or HepC. Compared
    with prevalent
    disease rates
    in the Arizona
    persons reported
    with Hep C are
    nearly 12 times
    more likely to
    have been
    diagnosed with
    HIV; persons
    reported with
    are more
    than 9 times
    as likely to
    have been

4    Prevention Bulletin                                                                                     September/October 2005
Unsafe Behaviors                            cont. from pg. 4       Dengue Fever                                                  by Craig Levy

In addition to these co-morbidity data,                                Dengue is an arboviral disease        The primary mosquito vectors
other data, such as methamphetamine                               caused by a flavivirus for which       are Aedes aegypti (“yellow fever
positivity rates among arrestees, reported                        there are four serotypes 1, 2, 3,     mosquito”) and Aedes albopictus
patterns of drug use among persons with                           and 4. Dengue is endemic to           (“Asian tiger mosquito”). Aedes
HIV, and patterns of risk behavior report-                        most tropical and subtropical         aegypti mosquitoes are prevalent
ed among men who have sex with men                                regions of the world, and an esti-    in many southern and central
support a general picture of resurgent                            mated 50-100 million infections       Arizona communities. Aedes
risk taking behaviors. Together these data                        occur annually. Dengue is trans-      aegypti mosquitoes have also been
suggest that a significant proportion of                           mitted by mosquito bites, and is      reported as far north as the Verde
HIV infected persons are continuing to                            not transmitted person-to-             Valley area of Yavapai County.
engage in behaviors that promote HIV,                             person. Incubation peri-                This mosquito breeds in back
and STD transmission.                                             od is 3-14 days. Classic                 yard containers and has a ten-
     For this reason, providers should col-                       dengue is characterized by                 dency to bite around the feet
lect comprehensive sexual and drug-use                            sudden onset, high                            and ankles. The potential
histories from their patients and use this                        fever, severe frontal                             exists for autocthonous
information to guide HIV and STD test-                            headache, backache,                               transmission of dengue
ing. Collection of comprehensive sexual                           myalgia, arthralgia,                              due to the widespread
histories should be ongoing with patients                         nausea, vomiting and rash.                      presence of vectors in
reporting current high-risk behaviors.                            The rash, which is usually                      Arizona, and with people
Providers should encourage and support                            maculopapular, appears                          traveling from endemic
practices (such as condom use) that can                           3-4 days after onset of fever.        areas. Infected travelers can serve
significantly reduce the risk of acquisi-                          The acute phase may last up to a      as reservoirs for local transmission.
tion or transmission of disease.                                  week, with a prolonged convales-           Dengue is a reportable disease
                                                                  cence characterized by weakness,      in Arizona. Health care workers
References:                                                       malaise, and anorexia. Classic        should consider dengue in the dif-
1.   Sexually Transmitted Diseases included in this analysis      dengue can be treated with bed        ferential diagnosis of patients with
     were Chlamydia, Gonorrhea, Herpes, and Syphilis.
                                                                  rest, fluids, and antipyretics; how-   compatible symptoms, especially if
2.   Hepatitis C reports included acute and chronic infections,
     but more than 99% of reports were chronic infections.        ever, aspirin is contraindicated.     there is recent travel to tropical
3.   Fleming DT, Wasserheit JN. From epidemiological syn-              Dengue hemorrhagic fever         countries. Suspected cases should
     ergy to public health policy and practice: the contribu-     (DHF) and dengue shock syn-           be reported to your local health
     tion of other sexually transmitted diseases to sexual
     transmission of HIV infection. Sex Transm Inf.               drome (DSS) are more severe forms     department, or ADHS at the num-
     1999;75:3-17.                                                of this disease. DHF is character-    ber listed below. Serologic testing
4.   Centers for Disease Control and Prevention. Sexually
     Transmitted Disease Treatment Guidelines 2002.
                                                                  ized by fever, thrombocytopenia,      is available through ADHS State
     MMWR. 2002;51:1-78.                                          hemorrhage, and capillary leak        Health Laboratory. Paired sera can
5.   U.S. Preventative Serives Task Force. Screening for HIV:     syndrome (manifested as hemo-         be submitted to:
     Recommendations Statement. Annals of Internal
     Medicine. 2005;143;32-37.                                    concentration, hypoalbuminemia,       Arizona State Health Laboratory
6.   Centers for Disease Control and Prevention.                  or pleural effusion). Skin manifes-   Attn: Serology
     Incorporating HIV Prevention into the medical care of        tations can occur such as petechi-    250 North 17th Avenue
     persons living with HIV: recommendations of CDC, the
     Health Resources and Services Administration, the            ae, purpura, or ecchymoses.           Phoenix, Arizona 85007.
     National Institutes of Health, and the HIV Medicine          Other hemorrhagic symptoms may             For more information, contact
     Association of the Infectious Disease Society of America.
     MMWR. 2003;52:1-32.             include epistaxis, bleeding gums,     the ADHS-VBZD staff at
     view/mmwrhtml/rr5212a1.htm.                                  hematemesis, and melena. DSS          602.364.4562.
7.   Centers for Disease Control and Prevention. Guidelines       may include the above in addition
     for preventing opportunistic infections among HIV infect-                                          Craig Levy is the ADHS Vector-Borne
     ed persons. MMWR 2002;51:1-46.             to hypotension and shock.             Disease Program Manager and can be
     preview/mmwrhtml/rr5108a1.htm                                                                      reached at
8.   2003 Tucson Rapid Assessment Response and Evaluation
     (RARE) Project on high-risk behaviors of MSM; 2005
     Community Needs Assessment for Ryan White Title I as
     reported in Arizona Republic, ('Drug use 'Huge' with HIV
     Victims, 8/13/2005, Cohen, Mitchell); 2003 Arrestee          Save the Date – November 17 - 18
     Drug Abuse Monitoring for Methamphetamine in
     Phoenix available at (     The 12th Annual Immunization Conference will be held November 17
     ADAM2003.pdf) shows an increase in Methamphetamine           and 18 at the Mesa Convention Center. Keynote speakers include two
     positive testing among male arrestees from 17% to 38%
     between 2000 and 2003.                                       medical epidemiologists from the National Immunization Program at the
                                                                  Centers for Disease Control and Prevention (CDC). Attendees can earn
Melanie Taylor and S. Robert Bailey are STD                       8.75 hours of Category 1 CMEs through Phoenix Children's Hospital. The
Epidemiologists and can be reached at
                                                                  registration form is available at or or
                                                                  call Michelle Gonazales at 602.364.3635.

September/October 2005                                                                                                          Prevention Bulletin   5
    Increase in Reported Cases                Enzyme Immunoassay (EIA) and PCR           decreasing, school has just started and
    of Enterohemorrhagic                      is becoming more widely available.         the case load is expected to increase.
    Escherichia coli                          Treatment for EHEC is usually entirely     Thankfully, we have a few great tools
         The Arizona Department of Health     supportive. There is still debate as to    to help lessen the severity of the cur-
    Services (ADHS) has noted an increase     whether antimicrobial therapy is safe      rent outbreak and hopefully help pre-
    in reported cases of Enterohemorrhagic    for all cases. Some studies have           vent future outbreaks: Tdap booster
    Escherichia coli (EHEC) in 2005. As of    identified a higher risk of developing      vaccines for adolescents and adults
    August 16, 2005, 26 cases of EHEC         HUS if treated with antimicrobials.        (Boostrix® for patients 10-18 years of
    have been reported in Arizona com-        However, a large scale randomized          age and Adacel® for patients 11-65
    pared to 12 cases reported for the        trial evaluating the risks and benefits     years of age). Please recommend
    same period in 2004.                      of antimicrobial therapy is needed.        these boosters to your eligible patient
         EHEC is the primary cause of              E. coli infection should be consid-   population, especially those that have
    hemolytic uremic syndrome (HUS)           ered in cases of gastroenteritis accom-    close contacts with infants (adolescent
    and occurs more frequently in young       panied by bloody diarrhea and with         siblings, new mothers, caregivers,
    children and the elderly. Risk of pro-    a history of animal contact and/or         etc.). ADHS also continues to
    gression to HUS varies by serotype,       other risk factors. ADHS reminds           recommend the use of the accelerated
    but approximately 8% of E. coli           providers to:                              immunization schedule for infants
    O157:H7 cases develop this syn-           • Report all cases of                      until 12/31/05. For more information
    drome. It is important to note that            Enterohemorrhagic E. coli and         on these recommendations and
    severe abdominal cramping and                  HUS to your local health depart-      pertussis in general please visit the
    bloody diarrhea is only accompanied            ment within 24 hours of diagnosis     ADHS Pertussis Website at www.
    by fever in less than one third of             (per Arizona Administrative Code
    cases. County and the state health             R-9-6-202).
    departments have not received any         • Collect stool cultures on cases of       Arizona Valley Fever
    reports of HUS in 2005.                        bloody and/or severe diarrhea.
                                                                                         Awareness Week
         E. coli is transmitted primarily     • Avoid the use of antimicrobial
    through food contaminated with rumi-                                                 November 14-21, 2005
                                                   therapy in patients with EHEC
    nant feces; however, direct transmis-                                                Current Schedule of Events
    sion from person-to-person does occur                                                For further listings and updates, go to
                                                   Additional information on   
    in families and other institutions.       Enterohemorrhagic E. coli and HUS
    Outbreaks have been associated with                                                  Tuesday 12:00 - 1:00 p.m.
                                              can be found on the CDC website or
    undercooked beef, unpasteurized milk,                                                    Demo Pappagianis M.D. PhD.
                                              by calling the Infectious Disease
    apple cider, raw vegetables, petting                                                 “The historical importance of Valley
                                              Epidemiology Program at 602.364.
    zoos, and recreational water.                                                        Fever to the Southwest.” Tenth Annual
    Contact with ruminants, such as cattle,                                              VFCE Farness Lecture as the University
    goats, and sheep, has become an                                                      of Arizona College of Public Health
    increasingly recognized source of         Pertussis Outbreak Update:                 Grad Rounds. Arizona Health
    EHEC cases nationally. In 2004, a         Back to School May Increase                Sciences Center, Tucson Arizona.
    large outbreak of E. coli O157 associ-    Transmission                                   2:00 - 4:30 p.m. state-wide poster
    ated with a petting zoo was reported in        Arizona is continuing to see above    session of current research into Valley
    North Carolina, with over 100 cases       average rates of pertussis activity,       Fever. University of Arizona Student
    identified. Two of the 26 reported         throughout the state. As of the time of    Union. Jointly sponsored by the VFCE
    cases of E. coli O157 in Arizona in       this printing, 737 cases have been         and the Bio5 Institute, University of
    2005 had a common exposure to ani-        reported, which represents of 390%         Arizona, Tucson Arizona.
    mals.                                     above the 5-year median (2000-2004)
         Isolation of E. coli from a stool    for this time frame, and includes four- Friday Noon-1:00 p.m.
    specimen remains the gold standard        teen of Arizona's fifteen counties. And      Telemedicine Lecture:
    for diagnosis of EHEC. However,           while the number of new cases report- “Coccidioidomycosis for Arizona
    identification of Shiga-toxin using        ed per week currently appears to be     Physicians.”

                    Prevention Bulletin Going Only Electronic Starting January 2006
       This is the second to the last paper issue of the Prevention Bulletin. The January/February issue and
    beyond will only be available in electronic format. We can send you future issues electronically if you e-mail
    Wendy Snyder at with your e-mail address. Future issues will also be posted on our
    website at
6    Prevention Bulletin                                                                                     September/October 2005
                                                      Year to Date (January - August, 2005)1, 2

                                                                                                             Jan - Aug              Jan - Aug      5 Year Median
                                                                                                               2005                   2004            Jan - Aug
Haemophilus influenzae, serotype b invasive disease (<5 years of age)                                                1 (0)                 0 (0)             4 (3)
Measles                                                                                                                1                     0                 0
Mumps                                                                                                                  0                     1                 1
Pertussis (confirmed)                                                                                           737 (358)               151 (96)          151 (93)
Rubella (Congenital Rubella Syndrome)                                                                               0 (0)                 0 (0)             0 (0)
Campylobacteriosis                                                                                                    646                   529                469
E.coli O157:H7                                                                                                         27                    15                 25
Listeriosis                                                                                                             5                     6                  7
Salmonellosis                                                                                                         448                   455                435
Shigellosis                                                                                                           249                   267                277
Hepatitis A                                                                                                        134                      190              223
Hepatitis B: acute                                                                                                 265                      155              155
Hepatitis B: non-acute                                                                                             766                      809              775
Hepatitis C: acute                                                                                                   0                        1                7
Hepatitis C: non-acute (confirmed to date)                                                                 5,239 (2,589)            7,238 (2,529)    5,972 (2,546)
Streptococcus pneumoniae                                                                                              489                   473                590
Streptococcus Group A                                                                                                 184                   170                169
Streptococcus Group B in infants <90 days of age                                                                       37                    32                 25
Methicillin-resistant Staphylococcus aureus 3                                                                         953                   N/A                N/A
Meningococcal Infection                                                                                                33                    10                 22
Chlamydia                                                                                                        12,547                 11,103             9,598
Gonorrhea                                                                                                         2,790                  2,592             2,592
P/S Syphilis (Congenital Syphilis)                                                                              101 (12)               118 (27)          130 (17)
TB isolates resistant to at least INH (resistant to at least INH & Rifampin)                                       11 (0)                 15 (2)              6 (0)
Vancomycin resistant Enterococci isolates                                                                          1,365                   881                712
Hantavirus Pulmonary Syndrome                                                                                           5                     1                  1
Plague                                                                                                                  0                     0                  0
West Nile virus Infection                                                                                              29                   356                N/A
Animals with Rabies4                                                                                                  122                    66                 66
Coccidioidomycosis                                                                                                 1,989                  2,334              1,634
Tuberculosis                                                                                                         147                    137                132
HIV                                                                                                                  510                    327                309
AIDS                                                                                                                 355                    327                320
   1   Data are provisional and reflect case reports during this period.
   2   These counts reflect the year reported or tested and not the date infected.
   3   MRSA was not reportable before October 2004.
   4   Based on animals submitted for rabies testing.

                                                    Data compiled by Offices of Infectious Disease and Office of HIV/AIDS Services

September/October 2005                                                                                                                             Prevention Bulletin   7
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               Arizona Department of Health Services
                       Public Information Office
                       150 North 18th Avenue
                         Phoenix, AZ 85007

                      Janet Napolitano, Governor
                     Susan Gerard, Director ADHS
        Niki O’Keeffe, Assistant Director, Public Health Services

       S. Robert Bailey, M.S., Will Humble, Peter C. Kelly, M.D.,
           F.A.C.P., Craig Levy, Melanie Taylor, M.D., M.P.H.,
                the Office of Infectious Disease Services,
               the Arizona Immunization Program Office
                   and the Office of HIV/AIDS Services

                 Managing Editor: Mary Ehlert, M.S., ABC

     This publication is supported by the Preventive Health and Health Services Block
            Grant from the Centers for Disease Control and Prevention (CDC).
             Its contents do not necessarily represent the views of the CDC.
    If you need this publication in alternative format, please contact the ADHS Public
      Information Office at 602.364.1201 or 1.800.367.8939 (State TDD/TTY Relay).

          Hepatitis C: Acute vs. Chronic Infections
        For the past five years (2000-                                sion; thus, persons seeking                        Hepatitis C Risk Assessment
    2004), there were 17 acute hepatitis                             HIV/AIDS/STD treatment are likely
    C virus (HCV) infections reported in                             to be at risk for HCV too. Thus,                  • Blood transfusion or organ trans-
    Arizona; yet, 42,780 chronic infec-                              offering viral hepatitis services in                plant before 1992
    tions were reported during the same                              HIV and STD clinic settings                       • Injected street drugs, vitamins or
    period of time. These data empha-                                provides a unique opportunity to                    steroids, even just one time
    size that despite significant decreas-                            integrate viral hepatitis services into           • Snorted or smoked street drugs,
    es in newly acquired HCV infec-                                  existing clinics. Furthermore,                      even just one time
    tions, the pool of those previously                              offering hepatitis A and B immu-
    infected is enormous, approximately                              nization and education services to                • Veteran of the armed forces
    4 million persons in the United                                  those at risk for hepatitis C can help            • Received medical care outside of
    States. Due to the long lag of time                              address the HCV burden of disease.                  the United States
    between infection and chronic                                        The Arizona Department of                     • Had multiple sex partners (> 5
    disease, the true burden of disease                              Health Services' (ADHS) Hepatitis C                 partners in a year, > 10 partners in
    is yet to come. More importantly,                                Program can help you with                           a lifetime)
    many of the HCV-infected persons                                 presentations, patient brochures and
    are unaware of their HCV status and                                                                                • Received hemodialysis
                                                                     patient education via phone. You
    thus, do not take the take the                                   can access more HCV information                   • Tattoos or body piercings from an
    adequate measures to spread the                                  at or by contacting                     unsterile environment
    infection to others and at the same                              the ADHS program at                               • Been in prison
    time minimize further damage to                                  602.364.3658. November 2005 is                    • Current or past unexplained liver
    their liver.                                                     Hepatitis C Awareness Month! Visit
        HCV, sexually transmitted                                    our website at for
    diseases (STD) and HIV/AIDS share                                updates to our November Events                    • Current or past unexplained
    some common modes of transmis-                                   Calendar.                                           abnormal liver function tests

8   Prevention Bulletin                                                                                                                    September/October 2005

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Description: Community acquired Pneumonia