CENTERS FOR DISEASE CONTROL

December 11, 1987 I Vol. 36 / No. 48

785
795

Tuberculosis and Acquired

Immunodeficiency Syndrome - New
York City
ACIP: Poliomyelitis Prevention:
Enhanced-Potency Inactivated
Poliomyelitis V
Supplem

iiij>t..

MORBIDITY AND MORTALITY WEEKLY REPORT

Epidemiologic Notes and Reports

Tuberculosis and Acquired Immunodeficiency Synd

In recent years, reported tu bercu losis (TB) cases in New York City (NYC) h ave
i n creased su bsta nti a l ly, in l arge part rel ated to coexisting h u m a n i m m u nodeficiency
virus (H IV) a nd Mycobacterium tuberculosis i nfecti o n . From 1984 to 1986, reported TB
cases i ncreased by 36%, or 593 cases (from 1,630 to 2,223 cases) (Fig ure 1), a
numerica l i ncrease greater t h a n that for a ny state or any other city i n t h e nati on. By
compariso n , duri ng t h e sa me peri od, reported cases for the entire nation i ncreased
2%, or 513 (from 22,255 to 22,768).
Beca use the i ncreased TB morbidity in NYC was co ncurre_ n t with the acqu ired
imm u nodeficiency syndrome (AI DS) e pidemic a nd was co ncentrated in the gro u p
with 80% o f a l l NYC A I DS patients (ma l es 20-49 years o f age) , a speci a l study wa
conducted to eva l u ate the hypot h esi s that i n creased TB morbidity m i g ht be related to
AIDS. The NYC TB registry for 1979 thro u g h 1985 and t h e NYC A I DS reg i stry for 1981
thro u g h 1985 were matched.* To deter m i n e differences in cl i n ica l , de mo gra p h ic, a nd
behavi oral c haracteri stics of pers o ns with o n e or both di seases, patients with both TB
a nd AIDS (TB/AI DS) were compared with AIDS pati e nts without TB a nd with TB
patie nts without AI DS. O n ly adu lts a nd adolescents (perso ns 13 years of age or o lder
at d i a g nosis) were com pared becau se no pediatric patients with both diseases were
identified.
TB/ AIDS Patients
The 261 patients common to both-registri es constituted 2% of the 11;231 adult a nd
adolescent TB patie nts reported to the NYC TB reg i stry fro m 1979 thro u g h 1985 a nd
5% of the 4,892 adu lt a nd ado l escent AIDS patie nts reported to the NYC AIDS registry
from 1981 thro u g h 1985. Eig hty-seven percent (226) of these 261 patients were m a l e;
52% (136) were black; 29% (76) were Hispan i c; a nd 19% (49) were n o n-Hispa n ic wh ite.
The med i a n age for diag nosis of both TB and A I DS was 34 years.
*These time i ntervals were ch ose n because A I DS was fi rst recognized nationally in 1981 and
because it was noted that the diag nosis of tuberculosis often preceded the diag n osis of AIDS by
months or years.
A notice regarding cha nges in tel epho n e numbers th roug hout the Centers for Disease
Contro l a n d the Agency for Toxic Substa nces a n d Disease Registry appears on page 800.

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES I PUBLIC HEALTH SERVICE

3 0001 00085 8599

December 11, 1987

MMWR

786
TB and AIDS

Continued

The date on wh ich t h e fi rst M. tuberculosis-positive s pecimen was ta ken was

ava i l a b le fo r 258 TB/AI DS patie nts. Fo r th ese patients, TB h ad been diag nosed a
med i a n of 2 mo nths before AIDS diag nosis (ra ng e: 94 months befo re AIDS diagnosis
to 28 months after A I DS diagn osis). Fo r 65% of the patie nts, TB was diagnosed wit h i n
6 months before o r after AI DS diagnosis.
Adult and Adolescent AIDS Patients With and Without TB
TB/AI DS patients a nd AIDS patients with out TB were simi l a r in medi a n age at A I DS
diag nosis (34 compa red with 36 yea rs) a nd in g ender. Howeve r, TB/AI DS patie nts
were more li kely to be n o n-Haiti a n black, H aitia n , and Hispa n ic t h a n AIDS patients
without TB (Ta b l e 1). In addition, TB/AI DS patients repo rted i ntravenous (IV) drug
a buse mo re f req uently a nd h omosex u a l/bisex u a l activity a l o n e l ess freq uently than
patients with AI DS a l one. Among non-H a iti a n-b l ack IV drug a b u se rs, the percentage
of TB/AI DS patients (10%) was more than twice that amo n g both th ose with a h is
tory of h omosexual/bisex u a l behavior (4%) a nd those with neither risk facto r (4%)
(Ta ble 2). Amon g non-Hi spa n ic-wh ite IV drug abu sers, the percentage of TB/AIDS
patients (5%) was more than twice that among both t h ose with a h i sto ry of
homosex u a l/bisex u a l behavi o r (2%) and th ose with neither risk factor (0%) . Amon g
H is pa n ic IV dru g abusers, the perce ntag e o f TB/AI DS patients (8%) w a s h ig her than
that amo n g those with a h i sto ry of h omosexu a l/ b i sex u a l behavior (5%) a nd more t h a n
twice t h at amo ng t h o s e w i t h neither risk facto r (3%). T h u s , wh e n the data o n AIDS
patie nts was adjusted for race/et h n icity, th ose A I DS patients w h o were IV drug
a bu sers were sig nificantly more l i kely to deve l o p tu berculosis than those who we re
n ot (Ma ntei-Haen szel x2
18 7, p <0.0001) .
Adult and Adolescent TB Patients With and Without AIDS
TB/AI DS patients were you ng er (medi a n age at TB diagnosis: 34 years compared
with 44 yea rs) a nd more li kely to be ma l e than TB pati e nts with out AI DS. In additio n ,
they were more l i ke l y at T B diag nosis to h ave more t h a n o n e site of disease,
extra p u lmo n a ry TB, a nd a no nreactive tu bercu l i n ski n test (Ta b l e 3) . TB/AIDS patients
with a p u lmo n ary s ite of disease we re l ess l i kely to have cavitary disease.
=

FIGURE 1. Reported tuberculosis cases, by year - New York City, 1981-1986

2,500

2,000

(/)

1,500

1,000
500

1981

1982

1983

1984
YEAR

1985

1986

787

MMWR

Vol. 36/ No. 48

TB and AIDS - Continued

Reported by: RL Stoneburner, MD, MPH, MM Ruiz, MD, JA Milberg, MPH, S Schultz, MD, A
Vennema, MD, New York City Dept of Health; DL Morse, MD, MS, State Epidemiologist, New
York State Dept of Health. AIDS Program, Center for Infectious Diseases; Div of Tuberculosis
Control, Center for Prevention Svcs, CDC.

Editorial Note: The data f rom t h i s study, as wel l as oth e r evi de n ce p resented bel ow,
suggest that h uma n immu nodefici e n cy virus (H IV) i nfectio n is c a u s i n g a resu rgence
of TB i n NYC. Th ree f i n d i ng s f rom t h i s study s u p p o rt t h e hypothesis that A I DS i s
associated with t h e o bse rved i nc rease i n TB morbid ity. Fi rst, t h e i n c rease i n TB cases
was concentrated in the sex and age g ro u p co nta i n i n g the majo rity of NYC A I DS
pat i e nts (males 20-49 yea rs of age). Seco n d , a rel ative ly h i g h p roportion of A I DS
patie nts (5%) a lso h a d cl i n i ca l ly a ctive TB. Th i rd, among patie nts with both d i seases,
TB d i ag n oses c l u stered in time a ro u n d the AIDS d i a g n oses.
Perh aps the stro ngest evi dence to date for a causal associ ati o n between TB a n d
HI V i nfection comes f rom a stu dy amo n g a coh ort o f 5191V d rug a b u se rs i n NYC w h o
TABLE 1 . Adult and adolescent AIDS patients with T B (TB/AIDS) and without TB, by
race/ethnicity and AIDS risk factor - New York City, 1981-1985
AIDS Only
(n=4,631)

TB/AIDS
(n=261)
Characteristics

No.

(%)

No.

(%)

Race/Eth n icity
Bl ack, N o n-Ha itian

107

(41)

1,279

(28)

Haitian

29

(11)

119

(3)

Hispa n i c

76

(29)

1,077

(23)

Wh ite, N o n-H ispa nic

49

(19)

2,113

(46)

43

(1)

Other/Un known
Risk Factor

127

(49)

1,303

(28)

Hom osexual ity/Bisexuality

81

(31)

2,709

(58)

Both of Above

22

(8)

265

(6)

Oth er

31

(12)

354

(8)

IV Drug Abuse

TABLE 2. Intravenous (IV) drug abuse and homose ality/bisexuality among adult
and adolescent AIDS patients* with TB (TB/AIDS) and without TB, by race/ethnicity
and AIDS risk factor - New York City, 1981-1985
IV Drug Abuse
TB/AIDS
Cases

AIDS
Cases

No.

Black,
Non-Haitian

669

70

White,
Non-Hispanic

191

Hispanic

555

1,415

123

Race/Ethnicity

Total

Homo/Bisexuality
TB/AIDS
Cases

Both Factors
TB/AIDS
Cases

No.

(%)

12

(12)

107

(4)

107

(4)

61

(0)

74

(8)

88

(3)

282

22

(8)

256

(3)

No.

(4)

101

36

(2)

23

(5)

80

(3)

No.

(10)

509

21

(5)

1,803

44

(8)

436

(9)

2,748

Cases

(%)

(%)

(%)

TB/AIDS
AIDS
Cases

AIDS
Cases

AIDS
Cases

Neither Factor

*Excludes 148 Haiti a n AIDS patients, 29 of whom also had TB, a n d 43 patients with oth er o r
unknown race/eth n icity, none of w h o m also had TB.

MMWR

788
TB and AIDS

December 11, 1987

Continued

we re foll owed from 1984 t h ro u g h 1986 ( 1 ). I n t h i s g ro u p, 12 of the 279 p e rsons with

serol o g i c evi dence of H IV i nfection o r c l i nical AIDS d eveloped TB, whereas n o ne of
the 240 H IV-negative perso ns deve l o ped TB (p
0.0005, Fischer's exact test).
Oth er evi de nce that H IV i nfection a n d AIDS may be responsi b l e fo r the resu rg ence
of TB i n NYC i n cludes the fact that NYC, the a rea with the l a rgest i nc rease i n TB i n the
nation, h a s a lso rep o rted more AIDS cases t h a n a ny oth e r a rea i n the n ation. The
nearly 600 additi o n a l TB cases i n 1986 (compa red with 1984) exceeds the i ncrease in
the enti re n ation as a wh o l e. Thro u g h 1986, 7,891 patie nts with AI DS, o r 27% of the
natio n's cumu l ative reported cases (29,121), we re NYC reside nts. Data a l so i n d i cate
that the g reatest i nc reases in TB in NYC occu rred in a reas of the city with a h i g h
i ncide nce o f AIDS.
Data suggest that H IV i nfection i n the a bsence of A I DS i s associated with i nc reased
TB mo rbid ity (New York City Depa rtme nt of Health, u n pu b l i s hed data) . In t h i s study,
58 ma l es who we re 25-44 yea rs of age and did not have AIDS but were hospita l ized
for suspected TBt consented to H IV a nti body test i n g . Th i rty-o n e (53%) of them were
HIV positive.
Previously p u b l ished stu di es have l i n ked TB to A I DS i n F l o ri d a (2-3 ), Newa rk (4 ),
Co n necticut (5 ), a n d S a n Fra ncisco ( 6 ) . I ncreased TB mo rbid ity h a s been associ ated
with H IV i nfection in Dade Cou nty, Florida (7 ). Of 71 consecutive TB patients seen at
=

tAll 58 patients were later found positive for M. tuberculosis.

TABLE 3. Adult and adolescent TB patients with AIDS (TB/AIDS) and without AIDS,
by demographic group and clinical characteristics of TB
New York City, 1979-1985
-

TB/AIDS
(n=261)

TB Only
(n=1 0,9 70)

No.

(%)

No.

226

(87)

7,351

(67)

35

(13)

3,619

(33)

244

(93)

6,219

(57)

17

(7)

4,751

(43)

Multipl e*

62

(24)

415

(4)

One, Extrapul monary

58

(22)

1,741

(16)

141

(54)

8,814

(80)

N o nreactive

50

(58)

792

(18)

Reactive

36

(42)

3,686

(82)

Characteristics at TB Diagnosis

(%)

Sex
Male
Fe male
Age 20-49 Years
Yes
No
Disease Sites

One, Pul m onary

Tubercul i n Ski n Testt

Chest X-ray
Normal
Abnormal, N o ncavitary
Abnormal, Cavitary

13

(8)

269

(3)

131

(80)

5,410

(66)

20

(12)

2,576

(31)

*I ncludes at l east one extrapul monary site.

tl ncludes only patients with known tubercul i n ski n test results.
I ncludes only those with pul monary d i sease a n d known ch est X-ray results.

MMWR

Vol. 36 I No. 48
TB and AIDS

789

Continued

the Dade Cou nty P u b l i c H ea lth Depa rtment, 31% (22) we re H IV positive. Two of these
22 patients met the former CDC su rve i l l a nce c rite ria for A I DS ; ten (45%) of the 22 had
extra pulmo n a ry TB a n d wou ld t h us meet the revi sed CDC su rve i l l a nce case defi niti o n
f o r A I D S ( 8 ).
The re a re two poss i b l e mec h a n i sms by which the immu nodefici ency caused by
H I V infection may i nc rease the risk of tu bercu losis. H IV-rel ated immunodeficiency
cou ld i ncrease suscept i b i l ity to new i nfection a n d permit that i nfection to ra p i d ly
p rog ress to c l i n i ca l ly a p pa rent d i sease, or it may a l l ow a p reviously l atent tu bercu lous
infection to p rog ress to c l i n i ca l ly a pp a re nt d i sease. Alth o u g h the cl i n i cal a n d rad i o
g ra p h ic evi de nce of tuberculosi s i n AIDS patients is often simi l a r to the patte rn
observed in non immu nod eficient pati e nts with p rima ry o r recently acq u i red infecti o n,
the clusteri ng of TB d i a g noses a ro u n d the time of the AIDS d i a g noses s u g gests that
most tu bercu losis i n pati ents with AIDS resu lts from reactivati o n of a p reviously
acq u i red l atent i nfectio n . The p resent a n n u a l risk of new tu bercu l o us infection i n the
U n ited States is too low to account-for the h ig h i ncidence of tu bercu losis amo n g AIDS
pati ents. Th us, most tubercu losi s i n AI DS pati ents i s p robably d u e to the reactivati o n
o f l atent i nfections.
The reg i stry match i n dicates that TB/AIDS pati ents in NYC a re p redom i n a ntly IV
d ru g a busers . Fifty-seve n pe rcent of t h e TB/AI DS patients in this stu dy we re IV drug
abuse rs, whe reas 34% of A I DS patients without TB h a d this risk facto r. Th e n umber of
repo rted TB patients in NYC who a re IV drug a busers is c u r rently u n known. There a re
a n estimated 200,000 IV d rug abuse rs i n NYC, 30,000 of whom a re e n ro l led i n
methadone treatment p rog rams. These estimates, a lo n g with t h e fact that 12 TB cases
devel o ped in a coh o rt of 519 IV drug a busers, that IV d rug a buse i s the most common
risk facto r amo ng TB/AI DS patients, a n d that NYC had 600 mo re cases in 1986 t h a n it
had i n 1984, suggest that many u n reported or u n i dentified TB cases may be occu rri n g
a n n u a l ly among H IV-positive IV d rug a buse rs. Identifyi ng tubercu l i n-positive IV d ru g
abusers a n d g iv i ng them isoniazid p reve ntive the ra py, rega rd l ess o f t h e i r a g e , may
prevent TB amo ng this g ro u p.
The reg istry match a l so i nd i cates that most TB/AI DS patie nts i n NYC a re membe rs
of raci a l a n d eth n i c mino riti es. Eig hty-one percent of the TB/AIDS patie nts were black
(incl u d i n g H a itian) o r H ispa n ic, whereas 53% of AIDS patients without TB a n d 68% of
TB patients without A I DS (50% black and 18% H i spanic) belonged to these g ro u ps.
Patients with AI DS o r H IV i nfection who a l so develop TB often have cl i n ical
f i n d i ng s that a re d iffe rent from those of TB patie nts without immu nodeficiency (2-8 ),
and a h i g h i ndex of suspicion a n d special d i a g n osti c stu d i es a re often needed to
esta b l i s h th e d i a g n osis of TB in t h ese pati ents (9 ). H IV-infected persons who have
active TB s h o ul d be t reated i n acco rd a nce with recently p u b l i s h ed g u i d e l i nes (9 ).
HIV test i n g of a l l TB patients sho u l d be co nsidered beca use of the impl i cati ons of
H IV seropositivity for pati e nt ma nagement ( 10 ) . There is some evidence t h at TB
pati e nts with H IV i nfection do not respond to sta n d a rd the ra p i es as wel l as pati e nts
without H IV i nfecti o n . Some repo rts have suggested a h i g h e r i n ci dence of adverse
drug reactions ( 6 ) and a h i g h e r treatment-fa i l u re rate d u ri n g thera py (4 ). Therefore,
CDC a n d the America n Thoracic Society have recommended a more a g g ressive
a p p roach to treatment of TB in H IV-i nfected patients (9, 71 ) . Treatment shou l d i n itia l ly
i nclude at l east th ree of the d ru g s ava i l a b l e fo r treatment of TB, s h o u l d co nti n u e for
Multiple disease sites, extrapul monary i nvo lvem ent, l oss of tubercul i n ski n reactivity, and,
among patients with pul monary d i sease, no ncavitary ch est X-rays.

December 11, 1987

MMWR

790
TB and AIDS

Continued

a m i n imum of 9 months, a n d s h o u l d l a st for at least 6 months after t h e patient

becomes negative forM. tuberculosis. H IV-i nfected p ati e nts with tu berculosis s h o u l d
receive f req uent a n d ca reful mo n ito r i n g for adverse d ru g effects d u ri n g thera py a n d
s h o u l d be periodica l ly eva l u ated fo r s i g n s o f rela pse afte r t h e ra py i s com p l ete. To
p revent th e t ra nsmission of H IV, persons bei n g tested for H IV i nfection s h o u l d be
cou nseled in acco rda nce with cu rrent recommen dations ( 12 ) .
I ncreases i n TB mo rbid ity may occu r i n oth e r a reas as the p reva lence of HIV
i nc reases in these a reas. H ealth depa rtments s h o u l d con d u ct su rveys of t h e p reva
l e nce of H IV i nfection among TB patie nts in thei r j u risdictions. CDC is c u r rently
worki n g with h ea lth departments in 30 metropol ita n a reas to p l a n and implement
such su rveys.

(Continued on page

795)

TABLE I. Summary - cases of specified notifiable diseases, United States

48th Week Ending
Disease

Acquired Immunodeficiency Syndrome (AIDS)

Aseptic meningitis
Encephalitis: Primary (arthropod-borne
& unspec)
Post-infectious
Civilian
Gonorrhea:
Military
Type A
Hepatitis:
Type B
Non A, Non B
Unspecified
Legionellosis
Leprosy
Malaria
Measles: Total*
Indigenous
Imported
Meningococcal infections: Total
Civilian
Military
Mumps
Pertussis
Rubella (German measles)
Syphilis (Primary & Secondary): Civilian
Military
Toxic Shock syndrome
Tuberculosis
Tularemia
Typhoid Fever
Typhus fever, tick-borne (RMSF)
Rabies, animal

Dec. 5,
1987
828
154

11
2
13,569
209
465
442
28
63
7
4
10
9
9
38
38
206
51
5
644
3
6
429
1
19
2
68

Nov. 29,
1986
75
164
16
15,056
237
439
412
43
59
9
4
15
29
28
1
36
36
179
38
3
571
5
8
261
4
2
54

Median
1982-1986
N
222
22
1
15,532
240
455
486
N
,,
N
4
14
15
N
N
46
46
67
38
8
521
3
N
499
3
4
4
87

Cumulative, 48th Week Ending

Dec. 5,
1987
18,853
10,477
1,190
92
708,207
15,000
22,526
23,300
2,656
2,871
804
182
794
3,554
3,134
420
2,636
2,635
1
11,758
2,314
325
33,171
145
302
19,634
182
327
578
4,308

Nov. 29,
1986
12,187
10,083
1,128
98
821,053
15,563
21,042
23,737
3,245
4,031
756
236
1,045
5,919
5,615
304
2,282
2,280
2
4,911
3,903
505
25,010
152
330
20,097
153
298
731
5,041

Median
1982-1986
N
9,631
1,220
98
821,053
19,545
21,042
23,737
N
5,297
N
221
951
2,516
N
N
2,461
2,457
7
3,044
2,174
707
25,709
271
N
20,097
239
354
821
5,041

TABLE II. Notifiable diseases of low frequency, United States

Cum. 1987
Anthrax
Botulism: Foodborne (N.Y. City 2)
Infant
Other
Brucellosis (Mass. 1; Calif.2)
Cholera
Congenital rubella syndrome
Congenital syphilis, ages < 1 year
Diphtheria

,
12
44
2
103
4
5
127
3

Cum. 1987
Leptospirosis (Calif. 1; Hawaii 1)
Plague (Ariz. 1)
Poliomyelitis, Paralytic
Psittacosis (Md. 1)
Rabies, human
Tetanus (Calif.1)
Trichinosis
Typhus fever, flea-borne (endemic, murine)

*There were no cases of internationally Imported measles reported for th1s week.

36
11
76
37
33
34

Vol. 36 I No. 48

MMWR

791

TABLE Ill. Cases of specified notifiable diseases, United States, weeks ending

December 5, 1987 and November 29, 1986 (48th Week)

Reporting Area

UNITED STATES

AIDS

Aseptic
Meningitis

Encephalitis
Pnmary
.

Cum.
1987

1987

Cum.
1987

18,853

154

Cum.
1987

1,190

92

43

799
27
29
14
456
60
213

MID. ATLANTIC
Upstate N.Y.
N.Y. City
N.J.
Pa.

5,401
663
2,849
1,317
572

19
6
7
3
3

134
48
12
10
64

E.N. CENTRAL
Ohio
Ind.
Ill.
Mich.
Wis.

1,235
279
102

25
9
7

345
155
53
25
76

W.N. CENTRAL
Minn.
Iowa
Mo.
N. Oak.
S. Oak.
Nebr.
Kans.
S. ATLANTIC
Del.
Md.
D.C.
Va.
W.Va.
N.C.
S.C.
Ga.
Fla.
E.S. CENTRAL
Ky.
Tenn.
Ala.
Miss.
W.S. CENTRAL
Ark.
La.
Okla.
Tex.
MOUNTAIN
Mont.
Idaho
Wyo.
Colo.
N. Mex.
Ariz.
Utah
Nev.
PACIFIC
Wash.
Oreg.
Calif.
Alaska
Hawaii
Guam
P.R.
V.I.
Pac. Trust Terr.
Amer. Samoa
N: Not notifiable

4
2
1

210
96

5
1
3
2

26
1
1
14

281
43
65
142
31

60
31
12
17

1,934
45

31
1

306
96
1,487

2
4
24

552
6
10
3
205
45
168

12

1
16
4
2

5
22
6

110,584
15,428
59,422
15,133
20,601

142,830
17,246
82,811
18,130
24,643

36
22
3
10
1

72
11
24
28
9

20

108,429
24,859
8,789
31,217
34,605
8,959

110,514
27,344
11,380
25,340
34,655
11,543

17
3
3
4
7

46
10
6
3
27

28,547
4,255
2,791
15,231
261
561
1,877
3,571

35,216
5,084
3,603
17,429
289
720
2,603
5,488

15

7
3

212,539
3,483
25,081
15,870
17,475
2,053
32,829
17,943
35,232
62,573

13

24

185,794
3,167
21,420
12,395
13,555
1,297
27,962
14,192
33,135
58,671

1
5

53,462
5,359
18,830
16,755
12,518

65,480
7,214
24,793
19,225
14,248

79,845
9,007
13,158
8,634
49,046

95,137
9,020
16,230
10,917
58,970

63
13
1
21
28

26
4
35

18,492
517
635
399
4,190
2,016
6,288
595
3,852

24,035
633
800
500
6,208
2,556
7,783
1,029
4,526

99

21

100,994
8,140
3,708
86,828
1,547
771

115,095
8,476
5,051
98,190
2,437
1,193

179

201

1,763
268
351
76

2,237
254
444
53

7
3

4
13
6

34
1
7

4
2

1
3

25
1
6

129

17

U: Unavailable

182

375
203
7,736
2,003
11,089

21
4

3
158

63

35

145
11

28

442

32

1987

23

39
76

1987

465

73

1
42
5
18
1
5

Cum.
1987

1987

20,207
789
530
246
7,983
1,710
8,949

38
54

145
2
28
26
89

1987

Unspecified

821,053

10
9
160
7
19

Leprosy

NA,NB

22,060
654

13
1
1

10
1
1

Legionellosis

708,207

85
51

23

I
1

1987

4
2
5
17
3
12

3,226
28
406
419
218
20
166
72
457
1,440

Cum.
1988

36

423
110
25
220
2
2
18
46

5,002
317
153
4,445
14
73

Hepatitis (Viral), by type

Gonorrhea
(Civilian)

Cum.
1987

NEW ENGLAND
Maine
N.H.
Vt.
Mass.
R.I.
Conn.

548

Post-infactious

20

1
3
1

1
11

70
1
31

1
13
9
8
6
18
3
7
5

3
70
5

10

9
14

1
4
7

52
14
192
43
32
111
6

15

2
12

8
1

6
4

103
19
22
61
1

10

28
4
1

23

1
130
6
1
100
23

48

December 11, 1987

MMWR

792

TABLE Ill. (Cont'd.) Cases of specified notifiable diseases, United States, weeks ending

December 5, 1987 and November 29, 1986 (48th Week)

Reporting Area

UNITED STATES

Malaria

Measles (Rubeola)
Indigenous

Cum.
1987

1987

794

NEW ENGLAND
Maine
N.H.
Vt.
Mass.
R.I.
Conn.

53
2
2

MID. ATLANTIC
Upstate N.Y.
N.Y. City
N.J.
Pa.

109
33
23
27
26

22
8
19
3
1
2

Cum.
1987

Imported*

1987

Cum.
1987

325

159
2
82
3
42
6
24

2
1

264
109
10
75
70

9
6

282
162
13
20
87

202
125
10
20
47

12
10
1
1

37
27
5
5

6,388
113
934
2,616
1,053
1,672

236
74
17
17
49
79

389
166
35
39
35
111

37

77
1

27
9
1

67
8
1

1,414
781
446
33
6
90
4
54

136
13
58
34
12
3
1
15

1,345
48
19
22
5
14
10
1,227

300

310
5
19

754
227
164

52
50
119

41
26
79
18
132
67

341
118
34
67
122

1,088
10
38
679
75
286

401
134
42
98
102
25

34

340
49
134
32
25

11

1
99

107
30
5
31
1
3
6
31

859
1
35
2
60
2
4
301
93
361

436
7
43
10
67
5
52
39
88
125

70
6
56
2
6

138
24
61
44
9

99
50
49

1,374
273
1,039
61
N

723
283
4
39

34
2
9
N
8

1,268
293
665
N
294

28

397

177
21
23
24
109

330
8
1

86
4
6

231
7
7

10
38
258
13
2

30
7
26
9
4

643
168
12
434

732
78
35
602
7
10

208
19

22
20

188
1

158
32
9

13

2
2
9
103

E.S. CENTRAL
Ky.
Tenn.
Ala.
Miss.

15
3
1
5
6

W.S. CENTRAL
Ark.
La.
Okla.
Tex.

53
1
1
5
46

3
441

MOUNTAIN
Mont.
Idaho
Wyo.
Colo.
N. Mex.
Ariz.
Utah
Nev.

41

480

Guam
P.R.
V.I.
Pac. Trust Terr.
Amer. Samoa

3,903

161
28
39
4
55
5
30

1,763
101
727
909
26

28
8
6
8

1
4

444

127

305
26
6
267
3
3

2,314

57
14
19
7
17

W.N. CENTRAL
Minn.
Iowa
Mo.
N. Oak.
S. Oak.
Nebr.
Kans.

5
311
35

832
34
21
777

2
771

19
1
2
4
9
1
1
1
114
11
81
17
1
4

29
5
36

10
1

13
6
N
7

30
N
170
12
5
459
62
N
374

16
5
12
20
5
7

*For measles only, imported cases includes both out-of-state and international importations.
t
1
lnternational
0ut-of-state
U: Unavailable

N: Not notifiable

2
1

30
1
80
40
30
19
40
60

N
5

Cum.
1986

528
27
446
32
23

11
23

51

36
2
9

Cum.
1987

60
1
11
7
23
2
16

218
13
20
18
108
14
45

11,758

2,636

102
15
39
1
6

Rubella

1987

103
13
43

18

PACIFIC
Wash.
Oreg.
Calif.
Alaska
Hawaii

206

5,919

187
29
143

3
2
13
2
17
1
3

1987

Cum.
1987

Cum.
1987

420

25
4

6
5
33

Cum.
1987

163

360
1

P ertussis

Mumps

Cum.
1986

119
3
61
11
27
1
16

51
13
7
7
18
6

139
3
33
19
25
2
13

Men ingococcal
Infections

3,134

E.N. CENTRAL
Ohio
Ind.
Ill.
Mich.
Wis.

S. ATLANTIC
Del.
Md.
D.C.
Va.
W.Va.
N.C.
S.C.
Ga.
Fla.

( Total

23
42
47
2
15
24

1
27

Cum.
1986

1987

505

1
1
4
2
1

14
1
1
1
1

10
18
2
3
1
1

2
8

11

11

3
2
1

4
4

49
5
18
25
1

304
13
50
163
78

250
20
15
126
89

11
2

71
1

203
6
65
5
67
12
38
10

273
20
46
4
66
26
65
42
4

25

635
98
71
225
5
236

'482
149
14
297
5
20

20

19

5
4
8
1
1

70
24
2

5
10

2
15
3

215
2
2
139
2
70

258
17
4
231

4
62

Vol. 36/ No. 48

MMWR

793

TABLE Ill. (Cont'd.) Cases of specified notifiable diseases, United States, weeks ending

December 5, 1987 and November 29,1986 (48th Week)

Reporting Area

UNITED STATES

Syphilis (Civilian)
( P rimary & Secondary)
Cum.
1987

Toxicshock
Syndrome

Tularemia

Typhoid
Fever

Typhus Fever
(Tick-borne)
(RMSF)

Rabies,
Animal

Cum.
1986

Cum.
1987

Cum.
1987

Cum.
1987

Cum.
1987

182

4,308

Tuberculosis

Cum.
1986

1987

Cum.
1987

33,171

25,010

19,634

20,097

327

578

586
1
3

589
22
18
15
324
58
152

631
34
30
16
347
42
162

32
1

NEW ENGLAND
Maine
N.H.
Vt.
Mass.
R.I.
Conn.

282
12
284

458
19
13
9
246
19
152

MID. ATLANTIC
Upstate N.Y.
N.Y. City
N.J.
Pa.

6,001
232
4,446
666
657

3,506
183
1,958
610
755

3,599
477
1,771
639
712

3,974
577
2,078
673
646

43
9
13
21

25
11
5
1
8

377
54

E.N. CENTRAL
Ohio
Ind.
Ill.
Mich.
Wis.

810
101
56
408
188
57

808
117
103
370
176
42

2,184
389
220
981
504
90

2,367
419
258
1,027
561
102

35
11
5
11
5
3

38
22
1
7
5
3

152
17
17
44
28
46

W.N. CENTRAL
Minn.
Iowa
Mo.
N. Dak.
S. Dak.
Nebr.
Kans.

171
20
26
78
1
11
15
20

201
31
9
104
6
9
12
30

568
112
38
308
14
24
25
47

584
136
44
289
10
28
15
62

11
5
2
3

53

911
224
256
54
104
219
16
38

11,639
66
579
383
308
13
670
668
1,556
7,396

7,568
53
423
274
318
20
490

4,025
45
281
152
342
115
581
515

34

646
1,391
3,953

4,218
39
362
145
403
96
534
431
760
1,448

668
1,326

2
13

E.S. CENTRAL
Ky.
Tenn.
Ala.
Miss.

1,764
23
699
465
577

1,667
65
575
485
542

1,775
396
544
509
326

1,776
403
516
557
300

8
3
1
1
3

W.S. CENTRAL
Ark.
La.
Okla.
Tex.

4,164
233
855
148
2,928

4,868
244
845
139
3,640

2,305
277
285
224
1,519

2,545
349
391
235
1,570

72
38
3
28
3

659
9
5
3
115
54
284
23
166

578
7
14
4
126
68
233
18
108

479
16
17

506
27
23

16

40
94
255
25
32

68
92
230
31
35

7,377

5,356
168
107
5,047

3,917
227
121
3,323
64
182

3,689
199
117
3,154
55
164

26
278
2
152
3

34
305
1
88
5

S. ATLANTIC
Del.
Md.
D.C.
Va.
W.Va.
N.C.
S.C.
Ga.
Fla.

MOUNTAIN
Mont.
Idaho
Wyo.
Colo.
N. Mex.
Ariz.
Utah
Nev.
PACIFIC
Wash.
Oreg.
Calif.
Alaska
Hawaii
Guam
P.R.
V.I.
Pac. Trust Terr.
Amer. Samoa
U: Unavailable

129
280
6,950
4
14
2
832
9
222
2

34
1
808
1
262

1
19
3
8

64
4
40
1
9
3
7

1
18
1
3
30

4
2
9

222
2
46
22

1,240
424
42
343
70
8
57

4
2
1
1

98
13
58
15
12

298
133
81
77
7

30
2

117
12

571
119

4
24

87
18

13
32
407

16

13
11

349
159
9
72
7
3
78
7
14

403

11
4

5
2
1

15
308

197
99

12
4

1
3

7
80
33
29
3

122
8
2
104

399
4

67
20
1

794

December 11, 1987

MMWR

TABLE IV. Deaths in 121 U.S. cities,* week ending

December 5, 1987 (48th Week)

Reporting Area

All Causes, By Age (Years)

1 /gs 1 1 1 1 1
65

4564 2544

P&l

1-24

<1

21
7
1

20
11
1

3
3
1
1
1
1

709
204
59
30
37
51
39
19
35
62
39
7
48
34
45

514
139
47
25
29
29
28
13
27
43
34
4
38
19
39

112
35
5
4
6
10
6
4
6
12
4
2
5
9
4

42
12
5
1
2
6
2
1
1
4

3,246
65
23
151
43
14
51
67
1,720
100
20
406
109
35
133
25
62
104
54
27
37

2,125
51
19
109
35
12
41
41
1,072
49
9
253
83
27
107
20
48
69
36
18
26

668
12
2
32
3
2
6
8
375
27
7
85
20
6
15
5
10
25
12
7
9

310
1
2
8
2

58

85
1

1
2

1
1

2
13
197
18
4
35
3
1
6

1
2
29
2

1
3
47
4

11
1
1
4

22
2

2
7
6
2
1

2
2

2,602
E.N. CENTRAL
Akron, Ohio
35
55
Canton, Ohio
564
Chicago, Ill.
135
Cincinnati, Ohio
177
Cleveland, Ohio
128
Columbus, Ohio
155
Dayton, Ohio
299
Detroit, Mich.
Evansville, Ind.
63
82
Fort Wayne, Ind.
30
Gary, Ind.
64
Grand Rapids, Mich.
189
Indianapolis, Ind.
40
Madison, Wis.
161
Milwaukee, Wis.
81
Peoria, Ill.
65
Rockford, Ill.
South Bend, Ind.
54
1oledo, Ohio
129
96
Youngstown, Ohio

1,753
22
46
362
98
100
81
102
165
49
63
19
47
129
29
123
56
47
37
106
72

531
11
5
125
25
50
22
34
70
10
12
4
12
44
7
30
17
12
10
15
16

164
1
1
45
5
12
14
6
34
3
4
4
2
9
2
3
6
3
2
4
4

76
1
3
10
1
9
7
9
18

1,034
128
34
43
107
34
263
111
142
85
87

727
98
26
28
68
26
182
79
85
64
71

193
19
6
10
24
5
54
22
35
11
7

61
7
1
4
7
1
12
4
14
8
3

22
2

NEW ENGLAND
Boston, Mass.
Bridgeport, Conn.
Cambridge, Mass.
Fall River, Mass.
Hartford, Conn.
Lowell, Mass.
Lynn, Mass.
New Bedford, Mass.
New Haven, Conn.
Providence, R.I.
Somerville, Mass.
Springfield, Mass.
Waterbury, Conn.
Worcester, Mass.
MID. ATLANTIC
Albany, N.Y.
Allentown, Pa.
Buffalo, N.Y.
Camden, N.J.
Elizabeth, N.J.
Erie, Pa.t
Jersey City, N.J.
N.Y. City, N.Y.
Newark, N.J.
Paterson, N.J.
Philadelphia, Pa.
Pittsburgh, Pa.t
Reading, Pa.
Rochester, N.Y.
Schenectady, N.Y.
Scranton, Pa.t
Syracuse, N.Y.
Trenton, N.J.
Utica, N.Y.
Yonkers, N.Y.

W.N. CENTRAL
Des Moines, Iowa
Duluth, Minn.
Kansas City, Kans.
Kansas City, Mo.
Lincoln, Nebr.
Minneapolis, Minn.
Omaha, Nebr.
St. Louis, Mo.
St. Paul, Minn.
Wichita, Kans.

1
2
4
1

,
2

2
1

2
1
3
1
2
3
1
2
2
1

1
5
1
6
3
3
1

77

22
6
6
3
4
12
1
1
2
6
2
2
2
3
2
3
31
2
1
3
1
9
3
5
2
5

Total

R.eporting

All Causes, By Age (Years)

Area

As I

;..&5

1 1 1 1
45-84 25-44

1-24

P&J

<1

Total

53 S. ATLANTIC
1,152
21 Atlanta, Ga.
135
4 Baltimore, Md.
164
1 Charlotte, N.C.
61

Jacksonville, Fla.
143
2 Miami. Fla.
90
6 Norfolk, Va.
61
2 Richmond, Va.
86
2 Savannah, Ga.
53
3 St. Petersburg, Fla.
76
3 Tampa, Fla.
73
Washington, D.C.
191
4 Wilmington, Del.
19
2
746
3 E.S. CENTRAL
103
Birmingham, Ala.
145 Chattanooga, Tenn.
48
1 Knoxville, Tenn.
68
1 Louisville, Ky.
88
8 Memphis, Tenn.
180
Mobile, Ala.
71
59
Montgomery, Ala.
2 Nashville, Tenn.
129
2
1,487
65 W.S. CENTRAL
77
3 Austin, Tex.
Baton Rouge, La.
37
57
Corpus
Christi,
Tex.
22
Dallas,
Tex.
198
6
68
9 El Paso, Tex.
110
7 Fort Worth, Tex
308
4 Houston, Tex.
91
4 Little Rock, Ark.
143
4 New Orleans, La.
201
San
Antonio,
Tex.
2
66
2 Shreveport, La.
131
3 Tulsa, Okla.

727
88
96
38
95
45
40
60
41
66
46
99
13

236
26
46
13
29
20
12
16
7
4
14
49

105
13
15
3
14
16
3
5
3
3
7
22
1

29
6
2
3
3
2
2
2

494
65
32
54
59
122
36
41
85

170
27
10
10
21
35
22
14
31

48
7
3
3
5
14
9
4
3

17
2

911
48
21
33
113
45
73
176
59
70
128
46
99

313
18
8
14
39
14
22
74
18
25
48
11
22

141
4
4
5
26
7
3
34
4
30
16
2
6

74
4
3
3
10
1
6
13
5
18
5
3
3

4
4
1

16
5
10

753
111
52
140
103
23
119
27
49
129

515
72
39
103
68
15
87
18
23
90

130
19
7
25
22
4
14
5
13
21

61
15
5
6
7
1
5
3
6
13

24
3
1
4
5
2
1
1
5
2

23
2

34
2
9
3
4
1
7
3

1,548
17
77
25
60
38
430
47
25
89
150
112
136
145
112
37
48

371
4
23
4
12
12
99
15
5
20
42
24
33
42
21
8
7

180
1
6
3
6
7
70
4

75
1
4

65

2
2
27
2

6
12
20
24
12
5
3
1

2
8
7
6
8
5
1

2
3
5
1
1
4
7
6
10
7
12
3

10
6
17
4
3
5
16
13
7
14
7
6
3

13,977H 9,314 2,724 1,112

396

412

683

96

MOUNTAIN
Albuquerque, N. Mex.
Colo. Springs, Colo.
Denver, Colo.
Las Vegas, Nev.
Ogden, Utah
Phoenix, Ariz.
Pueblo, Colo.
Salt Lake City, Utah
Tucson, Ariz.

8
16
8
2
3
10
4
3
4 PACIFIC
2,248
1 Berkeley, Calif.
23
5 Fresno, Calif.
114
3 Glendale, Calif.
32
2 Honolulu, Hawaii
82
13 Long Beach, Calif.
62
3 Los Angeles Calif.
639
3 Oakland, Calif.
69
3 Pasadena. Calif.
31
3 Portland, Oreg.
121
2 Sacramento, Calif.
219
170
69 San Diego, Calif.
209
7 San Francisco, Calif.
214
San Jose, Calif.
155
Seattle,
Wash.
5
52
9 Spokane, Wash.
Tacoma,
Wash.
56
7
23
7
1
1
9

TOTAL

1
1
7

1
1
6

46
2
5
4
2
7
4
3
2
2
2
13

44
6
4
3
6

17
2
3

53
5
3
10
6
14
3
4
8

48
3
1
2
10
1
6
11
5

68
3
5
1
7
4
4
7
6

2
3
4

2
1
1
12
2
3

4
3
4
1
7
6

5
121
3
7

*Mortality data in this table are voluntarily reported from 121 cities in the United states, most of which have populations of 100,000 or
more. A death is reported by the place of its occurrence and by the week that the death certificate was filed. Fetal deaths are not
included.
**Pneumonia and influenza.
tBecause of changes in reporting methods in these 3 Pennsylvania cities, these numbers are partial counts for the current week.
Complete counts will be available in 4 to 6 weeks.
ttTotal includes unknown ages.
Data not available. Figures are estimates based on average of past 4 weeks.

Vol. 36 I No. 48

MMWR

795

TB and AIDS - Continued

References

1. Sto neburner R L, Des J arl ais D, M i lberg J, Fried man SR, Sothera n J L. Evidence for a causal
association between H IV i nfection a nd i ncreasi ng tuberculosis i ncidence in N ew York City.
Presented at the th ird i nte rnatio nal conference o n acquired i m munodeficiency syn d rome
(AIDS), Washi ngto n, DC, J une 1-5, 1987.
2. Pitch e n i k AE, Cole C, Russe l l BW, Fischl MA, Spira T J, Sni der DE J r. Tuberculosis, atypical
mycobacteriosis, a n d the acquired i m munodeficiency syn d rome among H a itian and non
Haitian patients i n south Florida. Ann Intern Med 1984;101 :641-5.
3. Centers for Disease Co ntrol. Tuberculosis a n d acquired i m munodeficiency syn d rome
Florida. M MWR 1986;35:587-90.
4. Sundera m G, McDonald RJ, M a n iatis T, Oleske J, Kapi la R, Reich m a n LB. Tuberculosis as a
m a n ifestatio n of the acquired i m munodeficiency syn d rome (AIDS). J AMA 1986;256:362-6.
5. Centers for Disease Control. Tuberculosis a n d AIDS - Connecticut. M MWR 1987;36:133-5.
6. Cha isson RE, Schecter GF, Theuer CP, Rutherford GW, Echen berg DF, Hopewell PC.
Tuberculosis in patients with the acquired i m munodeficie ncy syndrome: cl i n ical features,
respo nse to therapy, a n d surviva l . Am Rev Respir Dis 1987;136:570-4.
7. Pitc h e n i k AE, Burr J, Suarez M, Fertel D, Go nza lez G, Moas C. Human T-cell lymphotropic
virus-Ill (HTLV-111) seropositivity a n d related disease a mong 71 consecutive patients in whom
tuberculosis was d i a g n osed: a prospective study. Am Rev Respir Dis 1987;135:875-9.
8. Centers for Disease Control. Revision of the CDC surve i l l a nce case defi n ition for acquired
i m munodefici ency sy ndrome. M M WR 1987;36(suppl 1S).
9. Centers for Disease Control. Diag nosis a n d ma nagement of mycobacte rial i nfection a n d
disease i n persons with h u m a n T-lymphotropic virus type I ll/lymphaden opathy-associated
vi rus i nfection. M MWR 1986;35:448-52.
10. Centers for Disease Control. Public Health Service guidel i nes for counseli ng a n d a nti body
testing to prevent HIV i nfecti o n and AIDS. M MWR 1987;36:509-15.
11. American Thoracic Soci ety, Centers for Disease Co ntrol. Mycobacterioses and the acquired
i m m unodeficiency syndrome. Am Rev Respi r Dis 1987;136:492-6.
12. Centers fo r Disease Control. Additional reco mmend ations to reduce sexual a n d d rug
abuse-related tra nsm issi on of hum a n T-lymphotropic vi rus type I l l/lymph adenopathy
associated vi rus. M MWR 1986;35:152-5.

Recommendations of the Immunization

Practices Advisory Committee (ACIP)
Poliomyelitis Prevention: Enhanced-Potency Inactivated Poliomyelitis
Vaccine - Supplementary Statement

The s u p p l ementa ry statement p rovi des i nformati o n on a n d recomme ndations for

the use of i nactivated pol iovi rus vacc i n e (I PV) of e n h a nced poten cy.* The Immuniza
tion Practices Advisory Committee (ACI P) bel i eves th at, in the U n ited States, po l i o
immu n ization s h o u l d rely p rima ri ly on ora l po l i ovi rus vacc i n e (OPV), with sel ected
use of e n h a n ced-potency I PV as specified in t h i s document. However, t h i s su bject
shou l d be revi ewed on a conti n u i ng basis, a n d an extensive rev i ew of po l i o vacci nes
a n d potentia l vaccine pol icies wi l l ta ke place d u ri n g 1988. General recommendati ons
o n pol i omye l itis p reventi o n , i nclud i ng the u se of a n d sch e d u les for OPV, a refou n d in
the c u r re nt ACI P recomme ndations ( 1 ) .
Introduction
Conventionai/PV. I PV was i ntrod u ced i n the U n ited States i n 1955 a n d was used
widely u nti l O PV became ava i l a b l e d u ri n g the period 1961-1964. The reafter, the use of
I PV ra p i d l y decl i ned to a l evel of less t h a n 1% of a l l p o l i o vacci ne d i stri buted a n nu a l ly
in the U n ited States .
*Pol iovirus Vaccine Inactivated, which is manufactured by Connaug ht Laboratories Ltd., wi ll be
distri buted by Connaug ht Laboratories I nc. beg i n n ing in M arch 1988.

796

MMWR

December 11, 1987

Poliomyelitis - Continued

In recent U .S. stu d ies, th ree doses of I PV a d m i n i stered i n the fi rst yea r of l ife
p roduced a nti bod i es to pol i ovi rus se rotypes 1, 2, a n d 3 i n 87%, 97%, a n d 95% of
recipients, respectively. M o re t h a n 99% of ch i l d re n com pl eti ng the fou r-dose pri m a ry
series by 18 months of age prod uced a nt i bodies to a l l th ree se rotypes (2 )
Enhanced-Potency IPV. A method of prod uci n g a more potent I PV with g reate r
a ntigenic content was deve l o ped i n 1978 a n d l ed to the newly l i censed I PV, wh ich i s
p roduced i n h u m a n d i p l o i d ce l l s ( 3 ) . Resu lts o f stu d i es fro m seve ra l cou ntries h ave
i n di cated that a red uced n u m be r of doses of I PV p rod uced with t h i s tec h n i q u e can
i m m u n ize c h i l d ren satisfacto rily (4-6 ) . A c l i n ica l tria l of two prepa rations of
e n h a nced-potency I PV was co m p l eted i n the U n ited States i n 1984 ( 7 ) . C h i l d ren
received th ree doses of o n e of the e n h a nced-potency I PVs at 2, 4, and 18 m o nths of
age. I n spite of the p rese nce of matern a l a nti bod i es i n the majo rity of the i nfa nts at the
time of the fi rst dose, 99%- 1 00% of the c h i l d re n we re s e ropositive fo r a l l t h ree
pol iovirus types at 6 m o nths of age (2 months after thei r seco nd dose) . The
percentage of sero positive ch i l d re n did n ot rise o r fa l l s i g n ifi cantly d u ri n g the
14-m onth pe riod fo l l owi n g the seco nd dose, a resu lt that co nfi rms that seroco nver
s i o n h a d occu rred i n a l m ost a l l c h i l d re n . F u rth erm o re, geometric mean tite rs i n
creased 5- to 10-fo l d fo l l owi n g both the seco nd a nd th i rd doses. Co nclu sive stu dies
a re not yet ava i l a b l e conce r n i n g a nti body persistence fol lowi ng t h ree doses of the
e n h a nced-pote ncy I PV to be made ava i l a b l e i n the U n ited States. Howeve r, u n pu b
l i shed stu d i es of a n I PV with lower a ntigen content h ave s hown 100% seropositivity
5 yea rs after the th i rd dose (2 ) .
The effect of e n h a nced-pote ncy I PV on the circu lati o n of pol i ovi rus in a co m m u n ity
has not yet been dete rm i n ed, but it is l i ke l y to be at l east as good as that seen with
conventio n a l I PV. In a recent study of pol i ovirus excretion fo l l ow i n g type 1 vacci ne
vi rus c h a l l e n g e after the t h i rd dose of e n h a n ced-potency I PV, the decrease i n
excretio n was a t least as g reat a s that after co nvent i o n a i i PV, but sti l l s i g n ifica ntly less
than that fou n d after t h ree doses of O PV (8 ) .
Vaccine Usage
Indications. Pe rso n s with a co n g e n ita l i m m u n e deficiency d i sease, such as
aga m m m a g l o bu l i n e m i a ; a n acq u i red i m m u n e deficiency d isease, such as acq u i red
i m m u n odefici ency syn d ro m e (AI DS) ; or an a lte red i m m u n e status as a resu lt of oth e r
d i seases o r i m m u nosu p pressive t h e ra py a re at i ncreased risk for pa ra lysis a ssociated
with O PV. Therefore, if pol io i m m u n ization i s i n d icated, these persons a n d thei r
house h o l d m e m be rs a n d oth e r cl ose contacts s h o u l d receive I PV rath e r than O PV.
Althoug h a p rotective i m m u n e respo nse fo l l owi n g recei pt of e n h a nced-potency IPV
can not be assu red, some protection may be p rovided to t h e i m m u noco m p ro m i sed
patient. Ava i l a b l e data on ch i l d re n p reviously d i a g nosed with asy m pto matic h u m a n
i m m u nodeficiency vi rus ( H I V) i nfection do not suggest that t h ey a re a t i nc reased risk
of adve rse conseque nces from OPV. H owever, fo r such persons, use of I PV rather
than O PV i s p ru de nt si nce fa m i ly m e m be rs m ay be i m m u noco m p ro m i sed beca use of
AIDS o r H IV i nfection a n d m ay be at i nc reased risk fo r pa ra lys i s fro m contact with an
OPV vi rus.
Routi ne p ri ma ry p o l i ovi ru s vacci nation of adu lts (ge nera l l y those 18 yea rs of age o r
older) resi d i ng i n t h e U n ited States i s not reco m m e nded. Ad u lts a t i n creased r i s k of
exposu re to either vacc i n e or wi l d pol iovirus ( 1 ) s h o u l d receive polio vacci n ation i n
acco rda nce with th e sched u l e p rescri bed o n pag e 797.
.

Vol. 36 I No. 48

MMWR

797

Poliomyelitis - Continued

In households w h e re p o l i o vacc i n e is to be a d m i n i ste red to i m m u n o l og ica l ly

normal c h i l d ren, ACI P reco m mends g iv i n g O PV reg a rd less of t h e po l i ovi rus-vacci n e
statu s o f a d u lt h o us eh o l d contacts ( 1 ). T h e overa l l risk o f vacc i ne-associ ated p a ra lyti c
d isease i n i m m u nolog ica l l y normal contacts of O PV recipients i s one c a s e p e r 5.5
m i l l io n doses of O PV d i stri buted (9 ). As an a lternative, a d u lt contacts ca n fi rst
co m p l ete th e i r p ri m a ry series of p o l i o vacci ne as deta i l ed in the sched u l e be l ow, if
there is stro n g ass u ra nce that su bseq uent i m m u n ization of the ch i l d wi l l not be
jeopard ized or u n d u ly d e l ayed .
Schedules. The p ri m a ry series fo r e n h a n ced-potency I PV co nsists of t h ree 0.5-m l
doses a d m i n i stered su bcuta neously. The i nterval betwee n the fi rst two doses s h o u l d
b e a t least 4 weeks, b u t p refera b l y 8 weeks. T h e th i rd dose shou l d fol l ow i n at l east 6
months, but p refe ra b l y nearer to 12 mo nths. A p ri m a ry series ca n be sta rted as early
as 6 weeks of age, but p referably at 2 m o nths of age. Alth o u g h stu d i es h ave n ot been
conducted, young c h i l d re n shou l d receive t h e t h i rd dose a l o n g with d i phtheria,
teta n u s, p ertussis vaccine (DTP) a n d measles, m u m ps, ru bella vaccine ( M M R) at 15
months of a g e, if possi b l e.
A p ri m a ry series of po l i o vacci n e usua l l y consists of e n h a n ced-potency I PV alone
o r O PV a l o ne. However, a co m b i nati o n of both vacci nes tota l l i ng th ree doses and
sepa rated by a ppro p ri ate i nterva l s constitutes a p ri m a ry series. If e n h a n ced-potency
I PV is a d m i n i stered to perso ns with a p reviously i nco m plete series of co nventi o n a l
I PV, a fi n a l tota l of fo u r doses of po l i o vacci n e is n ecessa ry fo r a prima ry seri es.
Al l c h i l d re n who received a p r i m a ry series of e n h a nced-potency I PV or of a
com b i n ation of po l i o vacci nes shou l d be g ive n a booster dose befo re ente ring schoo l ,
u n less the fi n a l dose o f the p r i m a ry series w a s a d m i n i ste red on o r after the fou rth
b i rthday. The need fo r routi nely a d m i n i steri n g additional doses is u n known at t h i s
ti me.
For u n vacci nated adu lts at i ncreased risk of ex posu re to pol iovi rus, a p r i m a ry
series of e n h a nced-pote ncy I PV is recom mended. Wh i l e the respo nses of a d u lts to a
pri m a ry series have not been stu d i ed , the reco m m ended sch e d u l e fo r a d u lts is two
doses g iven at a 1- to 2-m onth i nterval a n d a t h i rd dose g iven 6 to 12 m o nths l ater. If
less t h a n 3 m o nths but more than 2 m o nths a re ava i l a bl e befo re protection is needed,
th ree doses of e n h a n ced-pote ncy I PV s h o u l d be g iven at least 1 m o nth a pa rt.
Li kewi se, if o n l y 1 to 2 m o nths a re ava i l a ble, two doses of e n h a n ced-potency I PV
s hou l d be g iven at least 1 m o nth a p a rt. If less t h a n 1 m o nth i s ava i l able, a s i n g l e d ose
of eit h e r O PV or e n h a n ced-potency I PV is reco m m e n ded.
Ad u lts who a re at i ncreased risk of exposu re a n d h ave h a d 1) at l east o n e dose of
O PV, 2) fewe r t h a n t h ree doses of conventio n a l I PV, or 3) a com bi nation of
conve nti o n a i i PV a n d O PV tota l l i n g fewe r than th ree doses should receive at least o ne
dose of OPV or e n h a nced-potency I PV. Additiona l doses n eeded to co m p l ete a
p ri ma ry series s h o ul d be g iven if t i m e perm its.
Adu lts who a re at i n creased risk of exposu re a n d who have p reviously co m p l eted
a p ri m a ry series with a ny one o r com bi nation of p o l io vacci nes can be g iven a dose
of OPV o r e n h a nced-potency I PV.
Side Effects and Adverse Reactions. Ava i la ble data i n d icate that t h e rate of adverse
reactions in the kid ney cel l s of m o n keys receiving e n h a n ced-pote ncy I PV a re low a n d
that the reacti ons a re not diffe re nt from th ose fol lowi n g a d m i n istrati on of a p lacebo.
The recently l i censed h u m a n d i ploid cel l-derived vacc i ne was not co m p a red to a
placebo. Rates of loca l a dverse events fo l lowi n g its use a re s i m i l a r to rates fou n d i n

798

MMWR

December 11, 1987

Poliomyelitis - Continued

contro l led stud i es u s i n g vaccine de rived fro m the kid ney cel l s of m o n keys. The re is no
evi de nce that co nventio n a i i PV causes a ny serious side effects. Consequently, seri ous
side effects a re not expected to occ u r with e n h a nced-potency I PV. Th i s concl usion can
be confi rmed only with postma rket i n g s u rvei l l a n ce. Pa rents of c h i l d ren receivi n g the
vacci ne, older vacci ne reci p i e nts, a n d h e a lth-ca re p rovi ders a re e n co u ra g ed to report
a l l adverse events occu rri n g wit h i n 4 weeks of recei pt of e n h a n ced-pote n cy I PV to the
m a n u factu rer a n d to l ocal o r state h ea lth de p a rtments. The i nfo rmation wi l l be
forwa rded to the a pp ropriate federal agency.t
Precautions and Contraindications. Vacci n e a d m i n i stration s h o u l d not be post
poned beca use of m i n o r i l l n esses, such as m i ld u p pe r-respi rato ry i nfections. Gen er
a l ly, h owever, persons with severe feb ri l e i l l n esses shou l d not be vacci n ated u nti l
t h ey h ave recovered.
The e n h a nced-potency I PV may conta i n t ra ce a m o u nts of streptomyc i n a n d
neomyci n. Person s who h ave had a n a phylactic reactions t o topica l l y o r syste m i ca l l y
a d m i n i stered streptom yc i n a n d n eo myci n s h o u l d n ot receive e n h anced-poten cy I PV.
There is no convi nci n g evi de n ce docu m e nti n g adverse effects of co nvent i o n a l I PV
on t h e p re g n a nt wom a n o r deve l o p i n g fetus. Data o n a dverse events fol lowi n g use of
e n h a nced-potency I PV a re not ava i l a bl e . On theoretical g rou nds, it is p ru dent to avoid
vacci nati n g preg n a nt wom e n. However, if a p re g n a nt wom a n needs i m mediate
p rotection a g a i nst po l i o myel itis, O PV is reco m m e n ded.
References

1. I m munization Practices Advisory Com m ittee. Po lio myelitis preve ntion. M MWR 1982;
31 : 22-26,31-34.
2. Bernier RH. I m proved i n activated po l iovi rus vacci n e : an update. Ped I nfect Dis 1986 ; 5 : 289-92.
3. von Seefried A, Chun J H, G rant JA, Letve nuk L, Pearso n EW. I n activated pol iovi rus vacci ne
a n d test deve lopment at Con naug ht Labo ratories Ltd. Rev I nfect Dis 1984 ; 6(suppl 2):S345-9.
4. van Wezel AL, van Steen is G, H a n n i k CA, Cohen H. N ew approach to the production of
concentrated a n d purified i nactivated po l i o a n d ra bies tissue culture vacci nes. Dev Bioi Sta nd
1978;41: 159-68.
5. Sa l k J, Stoeckel P, van Wezel AL, Lapi nlei mu K, van Steenis G. Antig en content of i nactivated
pol iovirus vaccine fo r use in a o ne- o r two-dose reg imen. Ann Cl i n Res 1 982 ;14: 204-1 2.
6. Simoes EA, Pad m i n i B, Ste i n h off M C, J a d h av M, J o h n TJ. Antibody response of i nfants to two
doses of i nactivated poliovi rus vaccine of e n ha nced potency. Am J Dis C h i l d 1985;139:977-80.
7. McBean AM , Thoms M L, J oh nson R H , et al. A compa rison of the serologic responses to oral
and i njecta ble trivalent pol i ovi rus vacci nes. Rev I nfect Dis 1984; 6(suppl 2) : S552-5.
8. O no rato I, M od l i n J, Bernier R, M cBea n M, Thoms M L. I ntesti n a l i m munity i n duced by
enha nced-potency i n activated po lio vacci ne a n d oral pol io vacci ne [Abstract]. I n : Progra m
a n d a bstracts o f t h e i nterscience conference on a ntim icrobial age nts a n d chemoth erapy.
Washi ngto n , DC: America n Society for M icro bio logy, 1987.
9. N kowa ne B M , Wassilak SGF, Orenste i n WA, et al. Vacci ne-associated paralytic pol iomyel i
tis - U n ited States: 1973 throug h 1984. JAMA 1 987; 257: 1335-40.
tcenter for Biologi cs Evaluation a n d Research, Food a n d Drug Ad m i n istration, or the Centers for
Disease Contro l .

Vol. 36 , No. 48
M MW R

I\\IUI\II\1lmOOM\\ \l
8599
3 000 1 00085

FIGURE I. Reported measles cases - United States, Weeks 44-47, 1987

1888 CASES REPORTED

0 NO REPORTED CASES

199

800

MMWR

December 11, 1987

WE'RE CHANGING
Effective December 1 4, 1 987, CDC/ATSDR will be
changing telephone numbers as follows:
Current Numbers

New Numbers

320, 321 , 329-XXXX

262 or 264-XXXX
452-XXXX
454-4300 thru 454-4799
728-XXXX or 454-0700 thru
454-0899
All FTS Prefixes {236)

639-XXXX
842-XXXX
488-XXXX
488-XXXX

Total Change
Unchanged

Recorded Messa es Will Provide New Numbers

The Morbidity and Mortality Weekly Report i s prepared by the Centers for Disease Control, Atlanta,
Georgia, and available on a paid subscription basis from the Superintendent of Documents, U .S. Government
Printing Office, Washington, D.C.

20402, (202) 783-3238.

The data i n this report are provisional, based on weekly reports to CDC b y state health departments. The
reporting week concludes at close of business on Friday; compiled data on a national basis are officially
released to the public o n the succeeding Friday. The editor welcomes accounts of interesting cases,
outbrea ks, environmental hazards, or other public health problems of current interest to health officials. Such
reports a n d any other matters pertaining to editorial o r other textual considerations should be addressed to :
Editor, Morbidity and Mortality Weekly Report, Centers for Disease Control, Atlanta, Georg ia

30333.

Director, Centers fo r Disease Control

James 0. Mason. M . D . , Dr.P. H .

Ed itor
M ichael B. Gregg, M . D.

Di rector, Epidemiology Program Office

Carl W. Tyler, J r., M . D.

Managing Editor
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Penalty for Private Use $300

6 8 l l 8 C R E 8 3 8 6 46
YJ
S C I ENC E S
C R E I GH T ON U N I V Hl T H
L l BR A RY .
S
2 8 T H & BU RT S T R E E T
6 8 17 8
O M A HA , NE
.

H H S P u b l ication No. (CDC) 88-8017

Redistri buti o n usi ng i ndicia is i l l eg a l .