(1 figure omitted)
During August 10-November 23, 1998, 33 confirmed*
measles cases were reported to the Anchorage Department of Health and
Human Services and the Alaska Department of Health and Social Services
(ADHSS). Of these, 26 cases were confirmed by positive rubeola IgM
antibody test, and seven met the clinical case definition. This was the
largest outbreak of measles in the United States since
1996.1,2 This report summarizes results of the
epidemiologic investigation conducted by ADHSS and underscores the
importance of second-dose requirements for measles vaccine.
On August 10, a 4-year-old child (index case) visiting from Japan had
rash onset of measles while in Anchorage. The child was hospitalized
for 1 day, and measles was diagnosed by positive rubeola IgM
enzyme-linked immunosorbent assay. No measles virus cultures were
obtained. No cases were reported during the following 3 weeks, when
secondary cases would have been expected. On September 5, 26 days after
onset of the imported case, a 16-year-old high school student developed
measles, confirmed by IgM testing. Subsequently, 15 other students and
one teacher at the same high school developed measles during September
14-October 4; 12 cases were laboratory confirmed. In addition, four
laboratory-confirmed cases and two clinical cases occurred at six other
Anchorage schools; one case-patient attended two schools while
infectious (from 7 days before to 4 days after rash onset). Eight other
confirmed cases occurred among young adults not associated with
schools, and one case occurred in a 2-year-old child.
The 33 case-patients ranged in age from 2 to 28 years (median:
16 years). Twenty-nine case-patients had received at least one dose of
measles-containing vaccine (MCV) at or after age 12 months; one person
with laboratory-confirmed measles had received two appropriately spaced
doses of measles-mumps-rubella vaccine (MMR). No serious complications
or deaths were reported.
At the high school where the 17 cases occurred, based on school
records, only one of 2186 students had not received at least one dose
of MCV before the outbreak; 1057 (49%) had received one dose of MCV,
and 1112 (51%) had received two or more doses. Estimated vaccine
efficacy for two or more doses of MCV was 100%.
Sequence analysis was conducted on the region coding for the COOH
terminus of the nucleoprotein for measles virus cultured from three
outbreak cases. All three isolates had identical sequences and were
classified as genotype D5.3 This strain was almost
identical to wild measles virus strains circulating in Japan in
1998 and was not related to the strain isolated from an outbreak in
Juneau in 1996, the most recent isolate available from
Before 1996, all students attending public and private schools in
Alaska were required to have documentation of a single dose of MCV (or
a valid medical or religious exemption). Beginning in September 1996,
all students entering kindergarten or first grade were required to have
two doses of MCV. As a result, school records indicate that virtually
all students in kindergarten through third grade as of fall 1998 had
received two doses of MMR. However, the proportion of students in
grades 4-12 that had two doses was unknown.
In response to the outbreak, ADHSS issued an emergency order
requiring that all Anchorage schoolchildren have two doses of MCV by
November 16, 1998. Subsequently, the order was expanded to require all
students in the state to have two doses of MCV by January 4, 1999.
Students were vaccinated by their health-care providers and at special
clinics conducted in Anchorage schools. By November 17, 98.6% of
49,346 Anchorage School District students had provided documentation of
two doses of MCV to their schools.
B Chandler, MD, Dept of Health and
Human Svcs, Municipality of Anchorage; Alaska State Virology
Laboratory, Fairbanks; L Wood, MPA, E Funk, MD, M Beller, MD, J
Middaugh, MD, State Epidemiologist, Alaska Dept of Health and Social
Svcs. Measles Virus Section, Respiratory and Enteric Diseases Br, Div
of Viral and Rickettsial Diseases, National Center for Infectious
Diseases; Measles Elimination Activity, Child Vaccine Preventable
Diseases Br, Epidemiology and Surveillance Div, National Immunization
Program; Div of Applied Public Health Training, Epidemiology Program
Office; and an EIS Officer, CDC.
The occurrence of this outbreak primarily in one school, despite
the extremely high one-dose measles vaccine coverage, demonstrates the
importance of school requirements for a second dose of MCV. MCV is
highly effective; <5% of children who receive one dose fail to
develop immunity. However, most children respond to a second dose, and
>99% of persons aged ≥12 months receiving two or more doses at
least 28 days apart develop immunity.
The Advisory Committee on Immunization Practices and the American
Academy of Pediatrics recommend that all students from grades
kindergarten through 12 have two doses of MCV by 2001.5,6
As of the 1998-99 school year, state school requirements for two-dose
measles vaccination have covered approximately 53% of U.S.
schoolchildren (CDC, unpublished data, 1998). The vigorous response by
public health and school officials in Anchorage to this outbreak in
accelerating second-dose measles vaccination among schoolchildren may
have limited the extent of this outbreak and will help prevent future
outbreaks in Alaska schools.
Monitoring of viral genotypes is an important component of
measles surveillance. Genotyping provided evidence that the
Anchorage outbreak was due to importation from Japan; however, no
specimens were obtained from the index case. This underscores the
importance of obtaining throat and urine specimens from suspected
measles cases immediately after rash onset. Although no endemic measles
virus is circulating in the United States, outbreaks may continue to
occur when imported measles virus is introduced into a high-risk
setting (e.g., schools with incomplete second-dose MCV coverage).
References 6 available
*A confirmed case was laboratory confirmed or met the clinical
case definition and was epidemiologically linked to a confirmed case. A
clinical case was defined as an illness characterized by generalized
rash lasting ≥3 days; temperature ≥101 F (≥38.3 C); and either
cough, coryza, or conjunctivitis.
Cigarette smoking is the leading preventable cause
of death in the United States.1 Environmental and policy
interventions, particularly tobacco-control laws and regulations, are
an important means to prevent and reduce tobacco use.2 For
this study, preemptive legislation was defined as legislation that
prevents any local jurisdiction from enacting restrictions that are
more stringent than the state law or restrictions that may vary from
the state law. One of the national health objectives for 2000 is to
reduce to zero the number of states with preemptive smokefree indoor
air laws (objective 3.25)3; a proposed objective for 2010
is to reduce the number of states with any preemptive tobacco-control
laws to zero. To document trends in preemptive tobacco-control
legislation at the state level, CDC identified state preemptive
provisions and their effective dates from June 1982 (the oldest
provision currently in effect) to September 1998. This report
summarizes the results of this analysis, which indicate an increase in
the number of preemptive provisions from 1982 to 1996; no preemptive
provisions in tobacco-control laws have been enacted since 1996.
CDC gathered data about state tobacco-control laws from an online legal
research database to monitor such laws in four primary areas: smokefree
indoor air, minors' access, marketing, and excise taxes. Data included
the preemptive provisions of these laws. For this study, preemptive
provisions are presented in three categories: smokefree indoor air
(applying to restrictions on government or private worksites or
restaurants), minors' access (addressing restrictions on sales to
youth, vending machines, or distribution), and marketing (including
restrictions on tobacco product sampling, display, promotion, or
labeling). A multistep process was used to identify the month and year
the preemptive provisions of these laws took effect. The process
included identifying the history of the law by finding the records of
each state's legislative session in a given year and analyzing the
session laws to determine the effective date of the law's provision.
From 1982 through September 1998, 31 states incorporated
preemptive provisions in their tobacco-control laws. Maine was the only
state to repeal its preemptive provision (on tobacco displays, product
placement, and time of sale) during the study period. Some preemptive
provisions are very narrow. For example, in New York, the state
government has precedence over local government restrictions on the
free distribution of samples of tobacco products. Other provisions are
broad. For example, in Tennessee, minors' access laws preempt local
legislation of all tobacco-control areas.
The number of preemptive provisions included in state tobacco-control
laws increased from 1982 through 1996 but has leveled off since 1996.
The results of a linear regression analyzing the number of preemptive
provisions per law and the years they became effective indicated a
significant increase in the number of provisions from 1993 through
1996. During the 1980s, nine states passed 11 preemptive laws covering
21 provisions. From 1993 to June 1996, 20 states passed 24 preemptive
laws covering 82 different provisions. Since July 1996, no preemptive
tobacco-control laws have been enacted.
Eighteen states preempt at least one provision of smokefree indoor air
restrictions (e.g., government worksites, private worksites, and
restaurants); since 1985, 13 states have preempted smokefree indoor air
laws in all three areas. Except in South Carolina, all preemptive laws
that became effective since 1990 have covered all three areas.
Twenty-one states preempt at least one provision of minors'
access restrictions (e.g., sales to youths, vending machines, and
distribution). Ten states preempt all three components of minors'
access laws. Of 21 states with provisions preempting local minors'
access laws, 76% became effective during July 1993-July 1996.
Seventeen states preempt localities from promulgating their own laws
restricting the marketing of tobacco products. Three states (Illinois,
Michigan, and West Virginia) specifically preempt restrictions on
smokeless tobacco warning labels on billboards; all three of these
preemptive provisions became effective during July 1987-September 1988.
Fourteen states preempt laws on tobacco display, promotion, or
sampling; in 93% of these states, the preemptions became effective
during January 1993-July 1996.
Office on Smoking and Health, National
Center for Chronic Disease Prevention and Health Promotion, CDC.
The findings in this report indicate that most states have preemptive
tobacco-control laws. Of the 30 states with such laws, 18 have
preemptive provisions for smokefree indoor air. As a result,
achievement of the 2000 objective is unlikely.
Tobacco-control policy occurs at the federal, state, and local
level. Laws enacted by higher-level jurisdictions benefit the public
health by implementing widespread standards. Unless they contain
preemptive provisions, legislation at higher levels set minimum
requirements and allow the continued passage and
enforcement of local ordinances that may
establish a greater level of protection of public
health.4-6 However, legislation that preempts lower-level
action removes control from localities by preventing them from enacting
more stringent laws or tailoring laws to address community-specific
issues.4,6,7 In addition, preemptive laws deter debate over
local ordinances; such debate can educate the community about tobacco,
potentially altering social norms about tobacco use.8
Preemptive state laws also can be a barrier to local enforcement
because communities not involved in the decision-making process may be
A 1991 Smokeless Tobacco Council memorandum outlines a strategy to
oppose local ordinances and advance statewide antitobacco bills that
contain preemption clauses.4 In addition, a Tobacco
Institute priority for 1993 was to "encourage and support statewide
legislation preempting local laws, including smoking, advertising,
sales, and vending restrictions".10 A potential reason
for this strategy is the passage of strong tobacco-control laws at the
local level and the logistical difficulties of the tobacco industry to
devote resources toward multiple local jurisdictions.4,7
One limitation of this report is that legislative language is subject
to interpretation. Although a law may have been considered preemptive
by the definition used in this study, it may not have been implemented
as preemptive in a particular state.
Nevertheless, during 1993-1996, the number of tobacco-control
laws with preemptive provisions increased significantly. The 1992
federal Synar Amendment, which required states to enact and enforce
minors' access laws, resulted in the passage of new laws (many of
which included preemptive provisions) in several states. This, coupled
with the Tobacco Institute's 1993 stated priority to promote
tobacco-control laws with preemptive provisions, may have contributed
to this increase. However, since 1996, no preemptive tobacco-control
laws have been passed, possibly because of an increased community
awareness of the potential harmful effects of preemption and a shift in
industry priorities from state to federal restrictions and ongoing
The importance of laws and policies as a component of comprehensive
tobacco-control interventions has resulted in their inclusion in
surveillance efforts. CDC will continue to monitor progress toward
achieving national health objectives for 2000 to reduce tobacco-related
morbidity and mortality.
References 10 available
From early August 1998 through January 6, 1999, at
least 50 illnesses caused by a rare strain of the bacterium
Listeria monocytogenes, serotype 4b, have been reported to CDC
by 11 states. Six adults have died and two pregnant women have had
spontaneous abortions. Reported illness onset dates were during August
2-December 13, 1998. CDC and state and local health departments have
identified the vehicle for transmission as hot dogs and possibly deli
meats produced under many brand names by one manufacturer. This report
updates the investigation of this outbreak.1
On December 22, the manufacturer, Bil Mar Foods, voluntarily recalled
specific production lots of hot dogs and deli meats that might be
contaminated. CDC later isolated the outbreak strain of L.
monocytogenes from an opened and a previously unopened package of
hot dogs manufactured at the company's plant in Zeeland, Michigan. In
addition, a different strain of L. monocytogenes was isolated
from unopened packages of deli meats produced at the same plant.
Recalled products bear the establishment numbers EST P261 or EST 6911.
The establishment number appears on the outer edge of all packages. The
affected products included hot dogs and deli meats with the brand names
Ball Park, Bil Mar, Bryan Bunsize, Bryan 3-lb Club Pack, Grillmaster,
Hygrade, Mr. Turkey, Sara Lee Deli Meat, and Sara Lee Home Roast
brands. Institutions may have received recalled product under other
brand names. Packages for the above brand names that carry other
establishment numbers are not affected by the recall. Other Sara Lee
products that are not meat also are not affected.
Ohio Dept of Health.
New York State Dept of Health; Food Safety Laboratory, Cornell Univ,
New York City Dept of Health. Tennessee Dept of Health. Massachusetts
Dept of Public Health. West Virginia Dept of Health and Human
Resources. Michigan Dept of Community Health. Connecticut Dept of
Public Health. Health Div, Oregon Dept of Human Resources. Vermont Dept
of Health. Div of Public Health, Georgia Dept of Human Resources.
Minnesota Dept of Community Health. Foodborne and Diarrheal Diseases
Br, Div of Bacterial and Mycotic Diseases, National Center for
Infectious Diseases; and EIS officers, CDC.
Healthy persons rarely develop severe illness from Listeria.
The illness primarily occurs in pregnant women, newborns, and persons
with impaired immunity caused by serious illness, such as acquired
immunodeficiency syndrome or cancer. Listeria infections
during pregnancy may cause an influenza-like illness with fever and
chills, and may lead to loss of the fetus. In other persons, early
symptoms can include fever, severe headache, and stiff neck. Illness
can begin 2-8 weeks after eating the contaminated food.
Consumers who have the affected product should not eat it, but
rather should discard it or return it to the point of purchase. The
risk for developing Listeria infection after eating a
contaminated product is low. Persons who have eaten a contaminated
product and do not have any symptoms do not need any special medical
evaluation or treatment, even if they are in high-risk groups. However,
persons in high-risk groups who have eaten the contaminated product,
and within 2 months become ill with fever or influenza-like illness,
should inform their physicians about this exposure. Because of this
long incubation period, cases may continue to occur and be reported for
several weeks after an effective recall.
Consumers who have questions about the recall or the products
involved should contact Bil Mar Foods, telephone (800)
247-8339. Persons who have questions about
Listeria should call their physicians or their local or state
health departments or visit CDC's World-Wide Web site,
questions about meat handling should be directed to the U.S. Department
of Agriculture's Meat and Poultry Hotline, telephone (800) 535-4555,
Monday through Friday from 10 AM to 4 PM eastern
References 1 available.
During August 1996-June 1998, 74 patients at two hospitals in Arizona had cultures positive for Burkholderia
cepacia. Most isolates were from the respiratory tracts of patients
in intensive-care units (ICUs). Because of the large number of B.
cepacia isolates, personnel at both hospitals requested the Arizona
Department of Health Services assist in an investigation. This report
summarizes the results of the investigation.
A case of infection or colonization was defined as a positive
culture for B. cepacia from the respiratory tract of any ICU
patient at these hospitals during August 31, 1996-June 12, 1998
(epidemic period). Hospital microbiology records were reviewed to
identify all isolates of B. cepacia during the pre-epidemic
(January 1, 1994-August 30, 1996) and epidemic periods. Case-patient
medical records, respiratory therapy procedures, and ICU nursing
procedures were reviewed.
A total of 69 patients had positive cultures and had illness that met
the case definition, compared with one ICU patient during the
pre-epidemic period. Case-patients ranged in age from 17 to 87 years
(median: 73 years), and 36 (52%) were male. Case-patients were
admitted to the ICU with various diagnoses. None had medical conditions
associated with infection with B. cepacia (e.g., cystic
fibrosis or chronic granulomatous disease). Hospital clinicians
identified 33 (48%) case-patients as having infections and 36
case-patients as having B. cepacia respiratory tract
All case-patients had been intubated and mechanically ventilated during
their ICU stay. All mechanically ventilated patients had received
routine oral care that included swabbing with an alcohol-free mouthwash
(Kentron Alcohol Free Mouthwash and Gargle™, product #711-04,
manufactured for Kentron Health Care, Inc., Phoenix Cosmetics,
Holbrook, New York). The active ingredient in this product is cetyl
pyridium chloride; the formulation does not contain alcohol. This
product was produced only during 1994-1995 and was distributed
throughout the United States. The extent of use of this product in ICU
patients at other hospitals is unknown.
Cultures of unopened 4-oz. bottles of the mouthwash grew B.
cepacia, Alcaligenes xylosoxidans, and Pseudomonas
fluorescens putida group. B. cepacia isolates from
case-patients and mouthwash were similar by pulsed-field gel
electrophoresis. Other potential reservoirs (e.g., lotion,
povidone-iodine solution, water supplies, and a name-brand mouthwash)
were culture-negative for B. cepacia.
On June 12, the two hospitals discontinued use of the product, and no
further respiratory isolates of B. cepacia have occurred in
their ICU patients. On June 16, the Kentron company initiated a
voluntary recall of this product.
L Matrician, G Ange, S Burns, L Fanning; C Kioski, G
Cage, G Harter, D Reese, D McFall, K Komatsu, R Englund, State
Epidemiologist, Arizona Dept of Health Svcs. Investigation Br, Phoenix
Resident Post, Food and Drug Administration. Hospital Infections
Program, National Center for Infectious Diseases; and an EIS Officer,
B. cepacia (formerly Pseudomonas
cepacia) is a motile aerobic gram-negative bacillus commonly found
in liquid reservoirs and moist environments. B. cepacia is a
well-known nosocomial pathogen that is intrinsically resistant to
aminoglycosides and first- and second-generation cephalosporins; it is
responsible for 0.6% of all ventilator-associated pneumonias
(1; CDC, unpublished data, 1994). Numerous outbreaks of
B. cepacia infection have been reported among cystic fibrosis
patients.1-3 In December 1995, a similar outbreak involving
B. cepacia in respiratory cultures from patients without
cystic fibrosis was traced to intrinsically contaminated alcohol-free
mouthwash prepared by a different manufacturer.4 An
investigation by the Food and Drug Administration (FDA) suggested an
association with the deionization procedure of the water used to
prepare the product (R. Johnson, FDA, personal communication, 1998).
Potential pathogens may be present in low numbers in many
nonsterile products used in hospitals. Mechanically ventilated patients
are vulnerable to pathogens in their mouths and upper airways because
of their inability to maintain the mucociliary and cough mechanisms
that normally protect the lower respiratory tract.5 These
outbreaks of B. cepacia related to mouthwash highlight the
increased risk for respiratory colonization and infection among
patients on ventilators. Hospital surveillance and investigation of
unusual clusters are crucial to promptly identifying unexpected sources
of these pathogens and protecting patients at risk.
Clinicians who detect ventilator-associated pneumonia or
respiratory colonization with B. cepacia associated with the
use of nonalcohol containing mouthwash are encouraged to report such
episodes through local and state health departments to CDC's Hospital
Infections Program, National Center for Infectious Diseases, telephone
(404) 639-6413; fax (404) 639-6459; and to
MEDWATCH, the FDA Medical Products Reporting
Program, telephone (800) 332-1088.
References 5 available
Transmission of Measles Among a Highly Vaccinated
School Population— Anchorage, Alaska, 1998Preemptive State Tobacco-Control Laws—United States, 1982-1998Update: Multistate Outbreak of Listeriosis—United
States, 1998-1999Nosocomial. JAMA. 1999;281(4):315-316. doi:10-1001/pubs.JAMA-ISSN-0098-7484-281-4-jwr0127