Selected Reportable Communicable Disease Summary State of Oregon. PUBLIC HEALTH DIVISION Office of Disease Prevention and Epidemiology

Selected Reportable Communicable Disease Summary 28 29 State of Oregon PUBLIC HEALTH DIVISION Office of Disease Prevention and Epidemiology

Selected reportable communicable disease summary 28 29 State of Oregon Oregon Public Health Division Office of Disease Prevention and Epidemiology Acute and Communicable Disease Prevention 8 N.E. Oregon Street, Suite 772 Portland, OR 97232 Phone: 971-673-1111 E-mail: ohd.acdp@state.or.us Website: http://oregon.gov/dhs/ph/acd Compiled and prepared by June Bancroft, M.P.H., epidemiologist Leslie Byster, electronic publications specialist December 21 This document can be provided upon request in alternative formats for individuals with disabilities or in a language other than English for people with limited English skills. To request this form in another format or language, contact the program at 971-673-1111.

About surveillance data Oregon law specifies diseases of public health importance that must be reported to local public health authorities by diagnostic laboratories and health care professionals. This report reflects reporting laws in effect for 28 and 29. In general, local public health officials investigate reports of a communicable disease in order to characterize the illness and collect demographic information about the case, to identify possible sources of the infection, and to take steps to prevent further transmission. Basic information about each case is forwarded to the Oregon Public Health Division. In some cases (e.g., Salmonella infection), laboratories are required to forward bacterial isolates to the Oregon State Public Health Laboratory for subtyping. Together, these epidemiologic and laboratory data constitute our communicable disease surveillance system; data from 28 29 and trends from recent years are summarized in this report. But caveat lector! Disease surveillance data have many limitations. First, for most diseases, reported cases represent but a fraction of the true number. The most important reason for this is that many patients especially those with mild disease do not present themselves for medical care. Even if they do, the health care professional may not order a test to identify the causative microorganism. The reader may be scandalized to learn that not every reportable disease gets reported as the law requires. Cases are lost to surveillance along each step of the path from patient to physician to laboratory to public health department; in the case of salmonellosis, for example, reported cases are estimated to account for only about 3% of the true number. Second, cases that do get reported are a skewed sample of the total. More severe illnesses (e.g., meningococcal disease) are more likely to be reported than milder illnesses. Infection with hepatitis A virus is more likely to cause symptoms (and those symptoms are more likely to be severe) in adults than in children. Testing is not random; clinicians are more likely to test stool from children with bloody diarrhea for E. coli O157 than they are to test stool from adults with bloody diarrhea. Health care professionals may be more inclined to report contagious diseases such as tuberculosis where the public health importance of doing so is obvious than they are to report non-contagious diseases such as Lyme disease. Outbreaks of disease or media coverage about a particular disease can greatly increase testing and reporting rates. Population estimates for rate calculations were obtained from the Center for Population Research at Portland State University (www.pdx.edu/prc). Using rates instead of case counts allows for comparisons between populations of different sizes e.g., United States versus Oregon. Rates are usually reported as cases per 1, persons per year. However, if the population in which the rate is calculated is very small (e.g., in frontier counties in Oregon), a case or two might mean the difference between a rate of zero and a very high rate. To compensate 1

for this, some of our maps showing rates by county give an average over multiple years of data or report case counts per county. Even with this aggregation, for some conditions, the number of cases remains small. In addition, the rates presented are not adjusted for age due to the small number of cases in each age group. Incidence is annualized by onset date unless otherwise stated. Case counts include both confirmed and presumptive cases. Also keep in mind that cases are assigned to the county of residence at the time of the report not to the county in which the case received medical care, or the county where the exposure to infection occurred. Even with these limitations, surveillance data are valuable in a variety of ways. They help identify demographic groups at higher risk of illness. They allow analysis of disease trends and identify outbreaks of disease. With this in mind, we present the 28 29 communicable disease summary. We present 22 years of data whenever possible. For most of the diseases, we include the following: figures showing case counts by year for the past 22 years; aggregate case counts by month to demonstrate any seasonal trends; incidence by age and sex; incidence in Oregon compared to national incidence over the past 22 years; and incidence by county. Where appropriate, additional data on subtypes or risk factors are included. At the end of the booklet you will find a tally of disease outbreaks reported in the past year, a summary of enhanced data on gastroenteritis outbreaks, a summary table of statewide case counts over the past 2 years and disease totals by county. We hope that, with all their limitations, you will find these data useful. If you have additional questions, please call our epidemiology staff at 971-673-1111 or e-mail ohd.acdp@state.or.us. Paul R. Cieslak, M.D. Manager, Acute and Communicable Disease Prevention 2

Table of contents AIDS and HIV infection...5 Campylobacteriosis...7 Chlamydiosis...1 Cryptosporidiosis...13 Escherichia coli O157 and other Shiga toxin producing Escherichia coli (STEC) infections...16 Giardiasis...19 Gonorrhea...22 Haemophilus influenzae...24 Hepatitis A...28 Acute hepatitis B...31 Chronic hepatitis B...33 Hepatitis C...35 Legionellosis...39 Listeriosis...41 Lyme disease...43 Malaria...46 Measles...49 Meningococcal disease...51 Mumps...54 Pertussis...55 Rabies...58 Salmonellosis...61 Shigellosis...64 Early syphilis...68 Tuberculosis...7 Tularemia...73 Vibriosis...74 West Nile virus...76 Yersiniosis...78 Disease outbreaks...81 Public health reporting for clinicians...86 Public health reporting for laboratories...88 Selected cases of notifiable diseases by year*, Oregon 199 29...9 Oregon communicable disease case counts by county of residence, 29...91 3

List of contributors June Bancroft, M.P.H. Michelle Barber, M.P.H. Paul Cieslak, M.D. Emilio DeBess, D.V.M., M.P.V.M. Doug Harger, B.S. Bill Keene, Ph.D., M.P.H. Lindsey Lane, M.P.H. Lore Lee R.N., M.P.H. Juventila Liko, M.D., M.P.H. Tasha Poissant, M.P.H. Melissa Powell, M.P.H. Barbara Progulske, D.V.M., M.P.H. Beletshachew Shiferaw, M.D., M.P.H. Sean Schafer, M.D. Graci VanNess, M.P.H. 4

AIDS and HIV infection Human immunodeficiency virus (HIV) is spread by having sex, sharing injection drug equipment, or receiving a transfusion or transplant from an infected person. It can be spread from mother to fetus, to infant at the time of delivery, or by breastfeeding. Rarely, HIV spreads by inadvertent exposure to bodily fluids of an infected person such as a contaminated needle stick in a health care worker. The acquired immunodeficiency syndrome (AIDS) represents the late stage of HIV infection with immune system impairment, marked by low CD4-positive lymphocyte counts and opportunistic or atypical infections. There is no cure for HIV infection, but treatment can prolong life and reduce transmission. HIV infection can be avoided by abstaining from sex outside of a monogamous relationship with an uninfected partner and by not injecting recreational drugs. Using a condom during intercourse and not sharing injection drug equipment also reduce risk of acquiring HIV. A pregnant woman who is infected with HIV can minimize transmission of infection to her fetus by taking medication during pregnancy and refraining from breastfeeding. Caesarean section may also prevent transmission when the mother s infection is not well controlled. As of July 21, 8,467 cases of HIV infection (including cases that had, and cases that had not yet progressed to AIDS) had been diagnosed among Oregon residents between 1981 and 29 and reported to the Oregon HIV/STD/TB Program; 3,466 of these casepatients had died, leaving 5,1 living with HIV infection. Approximately 64% of these infections had progressed to AIDS by the end of 29. In addition, approximately 1,329 people are estimated to be infected, but not yet diagnosed; about 2,1 people with HIV infection who resided in another state at the time of their diagnosis had moved to Oregon by the end of 29. Men accounted for 87% of prevalent cases. Whites accounted for 78%, blacks and/or African Americans, 7%, and Hispanics, 11%. Among men, the five year average annual incidence of new HIV diagnoses was 11.4 cases per 1, whites, 29.6 cases per 1, blacks and/or African Americans and 18.1 per 1, among Hispanics. Among females, these rates were 1.2, 13.5, and 3.1 respectively. During 25 29, 69% of infected men in Oregon acquired their infection by sex with other men, while 9% of men with HIV acknowledged both sex with other men and previous injection drug use, obscuring their most likely transmission mode. Injection drug use was the most likely transmission mode for 6% of males and heterosexual transmission the most likely mode for 3%. Among women with HIV infection, heterosexual transmission was believed to be the most likely mode for 61% and injection drug use for 22%. 5

HIV infection diagnoses in Oregon by sex and year of diagnosis, 1981 29 4 35 Male Female Cases diagnosed per 1, 3 25 2 15 1 5 1981 1983 1985 1987 1989 1991 1993 1995 1997 1999 21 23 25 27 29 New cases of HIV infection by age at diagnosis, Oregon, 29 45 4 Cases diagnosed per 1, 35 3 25 2 15 1 5 12 13 19 2 24 25 29 3 34 35 39 4 44 45 49 5 54 55 59 6 64 65 69 7+ 6

Persons living with HIV or AIDS by county of residence, Oregon, 29 Clatsop Columbia Tillamook Washington Lincoln Polk Benton Yamhill Marion Multnomah Clackamas Linn Hood River Wasco Jefferson Sherman Gilliam Wheeler Morrow Grant Umatilla Union Baker Wallowa Curry Coos Josephine Douglas Lane Jackson Deschutes Klamath Lake Crook Harney Malheur Rate per 1,. 18.7 18.8 42.6 42.7 64.9 65. 17.6 17.7 384.8 Campylobacteriosis Campylobacteriosis is caused by a Gramnegative bacterium. It is characterized by acute onset of diarrhea, vomiting, abdominal pain, fever and malaise. Campylobacteriosis is the most common bacterial enteric infection reported. It is of worldwide epidemiologic importance due to the fecal-oral route of infection and the extensive reservoir of the organism in both wild and domestic animals. Children aged -4 years have the highest rates of illness. Infections occur year-round in Oregon, with peak incidence in the summer months. Campylobacteriosis is not nationally reportable. Rates are highest in Malheur and Harney counties. Most illnesses are sporadic, but outbreaks may be associated with undercooked meat (often chicken), unpasteurized milk, direct contact with animals or non-chlorinated water. Since 1998, eight outbreaks of campylobacteriosis have been investigated: three foodborne, two waterborne, two from animal contact, and one of unknown etiology. Proper food handling and water treatment, along with good hygienic practices (hand washing!) are the keys to prevention. 7

Campylobacteriosis by year: Oregon, 1988 29 12 1 Cases 8 6 4 2 1 9 8 1988 1989 199 1991 1992 Campylobacteriosis by report month: Oregon, 29 29 Median 24 28 1993 1994 1995 1996 1997 1998 1999 2 21 22 23 24 25 26 27 28 29 7 6 Cases 5 4 3 2 1 Jan Feb March April May June July August Sept Oct Nov Dec 8

Incidence of campylobacteriosis by age and sex: Oregon, 29 45 4 Male Female 35 3 Cases/1, 25 2 15 1 5 4 5 9 1 19 2 29 3 39 4 49 5 59 6 69 7 79 8+ Age Incidence of campylobacteriosis: Oregon, 1988 29 4 3 Cases/1, 2 1 1988 199 1992 1994 1996 1998 2 22 24 26 28 Not a nationally notificable disease. 9

Incidence of campylobacteriosis by county of residence: Oregon, 2 29 Clatsop Columbia Tillamook Washington Lincoln Polk Benton Yamhill Marion Multnomah Clackamas Linn Hood River Wasco Jefferson Sherman Gilliam Wheeler Morrow Grant Umatilla Union Baker Wallowa Coos Douglas Lane Deschutes Lake Crook Harney Malheur Rate per 1,..1 14.9 15. 2.7 2.8 26.9 27. 35.4 Curry Josephine Jackson Klamath Chlamydiosis Chlamydia trachomatis is Oregon s most commonly reported infection. In 29, there were 11,497 cases reported for a rate of 33.3 cases per 1, population. Compared to 28 this is an increase of 635 cases (5.8%). The highest rates of infection in 29 were observed in females aged 15-19 followed closely by females aged 2-24. As with gonorrhea and syphilis, chlamydial infections are transmitted by vaginal, rectal and oral sexual contact. Chlamydiosis may be prevented by abstaining from sexual contact or only having sex with one uninfected sex partner. Those who are sexually active outside of a mutually monogamous relationship can lower their risks of infection by using a condom when engaging in sexual activity. Chlamydial infections are likely to be silent, with neither men nor women having symptoms. However, reproductive health complications, especially among women, may lead to infertility and an increased risk of tubal pregnancy. 1

Chlamydiosis by year: Oregon, 1988 29 14 12 1 Cases Cases/1, 8 6 4 2 18 16 14 12 1 8 6 4 2 Incidence of chlamydiosis by age and sex: Oregon, 29 Male Female 1988 1989 199 1991 1992 1993 1994 1995 1996 1997 1998 1999 2 21 Case count by selected age group and sex Male Female 1 14 14 9 15 19 725 3,77 2 24 1221 3,25 25 29 69 1,142 22 23 24 25 26 27 28 29-4 5-9 1-19 2-29 3-39 4-49 5-59 6-69 7-79 8+ Age 11

Incidence of chlamydiosis: Oregon vs. nationwide, 1995 29 45 4 Oregon US 35 3 Cases/1, 25 2 15 1 5 1995 1996 1997 1998 1999 2 21 22 23 24 25 26 27 28 29 Incidence of chlamydiosis by county of residence: Oregon, 2 29 Clatsop Columbia Tillamook Washington Multnomah Hood River Morrow Umatilla Wallowa Yamhill Polk Marion Clackamas Wasco Sherman Gilliam Union Lincoln Benton Linn Jefferson Wheeler Grant Baker Crook Lane Deschutes Rate per 1, Curry Coos Josephine Douglas Jackson Klamath Lake Harney Malheur 32.1 42.3 42.4 117.8 117.9 166.8 166.9 258. 258.1 394.1 12

Cryptosporidiosis Cryptosporidiosis in humans results from infection with protozoal parasites in the genus Cryptosporidium most commonly C. hominis or C. parvum. Symptomatic infections are characterized by watery diarrhea and abdominal cramps. Symptoms typically resolve in one to four weeks in immunocompetent persons. Infections can be difficult to control among the immunocompromised. Studies suggest that the prevalence of cryptosporidiosis among young children, particular those in large child care facilities, is surprisingly high. Many of these infections are asymptomatic. In Oregon the rate of infection with Cryptosporidium has been increasing since 25. In 28, there was a lull in Oregon cases, however, the increase continued in 29. New anitgen tests for Cryptosporidium might be playing a role. In 29, we had a record 22 cases. In 27, the Oregon investigative guidelines were changed to reflect the increasing numbers of cases; previously, investigations were required only for abnormally high case counts. All cases will now be routinely investigated to identify the source of infection. Given the number of asymptomatic and undiagnosed infections, surveillance data can be difficult to interpret. However, these data have been used to identify a number of outbreaks over the years, most commonly associated with child care or water (both drinking and recreational). In 28 no outbreaks were investigated, in 29 one outbreak (15 cases) occurred in a health care setting. Cryptosporidiosis by year: Oregon, 1988 29 25 2 15 Cases 1 5 1988 1989 199 1991 1992 1993 1994 1995 1996 1997 1998 1999 2 13 21 22 23 24 25 26 27 28 29

Cryptosporidiosis by onset month: Oregon, 29 45 4 29 Median 24 28 35 3 Cases 25 2 15 1 5 Jan Feb March April May June July August Sept Oct Nov Dec Incidence of cryptosporidiosis by age and sex: Oregon, 29 14 12 Male Female 1 Cases/1, 8 6 4 2-4 5-9 1-19 2-29 3-39 4-49 5-59 6-69 7-79 8+ Age 14

Incidence of cryptosporidiosis: Oregon vs. nationwide, 1988 29 6 5 Oregon US 4 Cases/1, 3 2 1 1988 199 1992 1994 1996 1998 2 22 24 26 28 Not nationally reportable until 1995. Incidence of cryptosporidiosis by county of residence: Oregon, 2 29 Clatsop Columbia Tillamook Washington Lincoln Polk Benton Yamhill Marion Multnomah Clackamas Linn Hood River Wasco Jefferson Sherman Gilliam Wheeler Morrow Grant Umatilla Union Baker Wallowa Coos Douglas Lane Deschutes Lake Crook Harney Malheur Rate per 1,..8.9 2.1 2.2 4. 4.1 7.1 7.2 21. Curry Josephine Jackson Klamath 15

Escherichia coli O157 and other Shiga toxin producing Escherichia coli (STEC) infections E. coli O157 (O157) has become one of the most feared common causes of infectious diarrhea. Oregon has been the setting for many O157 outbreaks, and investigations of those outbreaks combined with the analysis of other surveillance information have contributed greatly to our understanding of this pathogen. Spread by the fecal-oral route, O157 has a number of animal reservoirs, the most important of which are ruminants, including cattle, goats, sheep, deer and elk. Transmission often occurs from consumption of contaminated food or water, as well as direct person-to-person spread. We identified two O157 outbreaks in 28 and five in 29. These included a nationwide outbreak associated with Nestlé cookie dough, and multi-state outbreaks associated with organic spinach from Washington, a summer camp in Washington, and an Oregon rodeo the latter with most cases among Washington residents. (Notice any theme here?) Mid-to-late summer is the peak season for E. coli O157 infections. The statewide incidence has been more-or-less stable over the past few years. Non-O157 STEC are a small but growing proportion of the problem, with increasing use of Shiga-toxin screening tests driving that trend. For 28 29, 12% of STEC isolates were other than O157, with O26, O121, O111, and O13 leading the pack. 3 E. coli O157 infection by year: Oregon, 1988 29 25 2 Cases 15 1 5 1988 1989 199 1991 1992 1993 1994 1995 1996 1997 1998 1999 2 21 16 22 23 24 25 26 27 28 29

E. coli O157 infection by onset month: Oregon, 29 3 25 29 Median 24 28 2 Cases 15 1 5 Jan Feb March April May June July August Sept Oct Nov Dec Incidence of E. coli O157 infection by age and sex: Oregon, 29 8 7 Male Female 6 Cases/1, 5 4 3 2 1 4 5 9 1 19 2 29 3 39 4 49 5 59 6 69 7 79 8+ Age 17

Incidence of E. coli O157 infection: Oregon vs. nationwide, 1988 29 1 9 Oregon US 8 7 Cases/1, 6 5 4 3 2 1 1988 199 1992 1994 1996 1998 2 22 24 26 28 Not nationally reportable until 1994. Incidence of E. coli O157 infection by county of residence: Oregon, 2 29 Clatsop Columbia Tillamook Washington Multnomah Hood River Morrow Umatilla Wallowa Yamhill Polk Marion Clackamas Wasco Sherman Gilliam Union Lincoln Benton Linn Jefferson Wheeler Grant Baker Crook Lane Deschutes Rate per 1, Curry Coos Josephine Douglas Jackson Klamath Lake Harney Malheur..8.9 2.2 2.3 3.6 3.7 5.1 5.2 8.5 18

Giardiasis Giardia intestinalis, the flagellated protozoan originally named G. lamblia, is the most commonly identified parasitic pathogen in the United States. Children in daycare and their close contacts are at greatest risk, as are backpackers and campers (by drinking unfiltered, untreated water), persons drinking from shallow wells, travelers to diseaseendemic areas, and men who have sex with men. Giardia cysts can be excreted in the stool intermittently for weeks or months, resulting in a protracted period of communicability. Transmission occurs when as few as 1 cysts are ingested through person-to-person or animal-to-person contact, or by ingestion of fecally contaminated water or food. The majority of Giardia infections occur without symptoms. When symptomatic, patients report chronic diarrhea, steatorrhea, abdominal cramps, bloating, frequent loose and pale greasy stools, fatigue, and weight loss. In 29, the reported incidence of giardiasis in Oregon remained nearly twice that of the rest of the United States, with 11.2 cases per 1, population. Fifty-eight percent of 28 29 cases were reported as sporadic or household-associated; one outbreak occurred in a daycare center. Children less than 5 years of age continue to have the highest incidence, with 36 cases/1,. Rates of infection tend to be higher in the summer months with transmission related to outdoor activities in or near untreated water. Prevention depends upon good personal hygiene (hand washing!) and avoiding consumption of fecally contaminated water. Travel warnings on water quality should be heeded. Giardiasis by year: Oregon, 1988 29 16 14 12 1 Cases 8 6 4 2 1988 1989 199 1991 1992 1993 1994 1995 1996 1997 19 1998 1999 2 21 22 23 24 25 26 27 28 29

Giardiasis by onset month: Oregon, 29 7 6 29 Median 24 28 5 4 Cases 3 2 1 Jan Feb March April May June July August Sept Oct Nov Dec Incidence of giardiasis by age and sex: Oregon, 29 45 4 Male Female 35 3 Cases/1, 25 2 15 1 5 4 5 9 1 19 2 29 3 39 4 49 5 59 6 69 7 79 8+ Age 2

Incidence of giardiasis: Oregon vs. nationwide, 1988 29 5 4 Oregon US Cases/1, 3 2 1 1988 199 1992 1994 1996 1998 2 22 24 26 28 Not nationally reportable until 22. Incidence of giardiasis by county of residence: Oregon, 2 29 Clatsop Columbia Tillamook Washington Multnomah Lincoln Polk Benton Yamhill Marion Clackamas Linn Hood River Wasco Jefferson herman Gilliam Wheeler Morrow Grant Umatilla Union Baker Wallowa Curry Coos Josephine Douglas Lane Jackson Deschutes Klamath Lake Crook Harney Malheur Rate per 1,. 4.2 4.3 9.2 9.3 12.5 12.6 17.3 17.4 21.7 21

Gonorrhea Gonorrhea, caused by the Gram-negative bacterium Neisseria gonorrhoeae, is easily transmitted from person to person through vaginal, rectal and oral sexual contact. Gonorrhea can be prevented by abstaining from sexual contact or only having sex with one uninfected sex partner. Those who are sexually active outside of a mutually monogamous relationship can lower their risks of infection by using a condom when engaging in sexual activity. If untreated, gonococcal infections cause a variety of health problems for men, women and infants. The major complications of gonorrhea are infertility and tubal pregnancies among women. Recent sex partners of persons infected with gonorrhea should be evaluated and treated for gonorrhea. The 1,113 gonorrhea cases reported in 29 represent a decrease of 11.5% from the 1,258 cases reported in 28. Gonorrhea by year: Oregon, 1988 29 35 Cases 3 25 2 15 1 5 1988 1989 199 1991 1992 1993 1994 1995 1996 1997 1998 1999 2 21 22 23 24 25 26 27 28 29 22

Incidence of gonorrhea by age and sex: Oregon 29 12 1 Male Female Case count by selected age group and sex Male Female 8 1 14 1 8 15 19 87 159 Cases/1, 6 2 24 152 17 25 29 118 81 4 2 4 5 9 1 19 2 29 3 39 4 49 5 59 6 69 7 79 8+ Age Incidence of gonorrhea: Oregon vs. nationwide, 1988 29 3 25 Oregon US Cases/1, 2 15 1 5 1988 199 1992 1994 1996 1998 2 22 24 26 28 23

Incidence of gonorrhea by county of residence: Oregon, 2 29 Clatsop Columbia Tillamook Washington Multnomah Lincoln Polk Benton Yamhill Marion Clackamas Linn Hood River Wasco Jefferson Sherman Gilliam Wheeler Morrow Grant Umatilla Union Baker Wallowa Curry Coos Josephine Douglas Lane Jackson Deschutes Klamath Lake Crook Harney Malheur Rate per 1,. 2.4 2.5 11. 11. 19.1 19.2 33.2 33.3 96.9 Haemophilus influenzae Until the advent of an effective vaccine against serotype b (Hib) organisms, Haemophilus influenzae (H. influenzae) was the leading cause of bacterial meningitis in children under 5 years of age in Oregon and elsewhere. Today it is well down the listing, with Streptococcus pneumoniae now in the lead. In 28 29, Hib was cultured from sterile body fluids in three persons, all aged >4 years. Appropriate use of conjugate vaccine will help ensure that Hib occurrence remains minimal well into the future. All sterile site H. influenzae isolates must be sent to the Oregon State Public Health Laboratory for additional typing. Concurrent with the decline in serotype b infections is an increase in other serotypes. In 29, 71% of cases were non-typeable, 15% were identified as serotype f, and the remainder were other serotypes. This shift in dominant strains changes the clinical manifestations of illness. From 23 29 Oregon clinical manifestations of Oregon cases included primarily pneumonia (more than 5%), followed by sepsis (35%). Less than 1% of cases had meningitis. Concurrent with the changes in clinical manifestations is a shift in age distribution from infants to older persons. The majority of cases in 28 29 continue to be among those aged 5 and over. Peak incidence occurs in late winter and early spring. Fifty-seven cases were reported in 29. 24

H. influenzae by year: Oregon, 1988 29 16 14 12 Cases 1 8 6 4 2 12 1 1988 1989 199 1991 1992 1993 1994 H. influenzae by onset month: Oregon, 29 29 Median 24 28 1995 1996 1997 1998 1999 2 21 22 23 24 25 26 27 28 29 8 Cases 6 4 2 Jan Feb March April May June July August Sept Oct Nov Dec 25

Incidence of H. influenzae by age and sex: Oregon, 29 2 18 Male Female 16 14 Cases/1, 12 1 8 6 4 2 4 5 9 1 19 2 29 3 39 4 49 5 59 6 69 7 79 8+ Age H. influenzae by year and serotype: Oregon, 2 29 45 4 35 3 Cases 25 2 15 1 5 2 21 22 23 24 25 26 27 28 29 non-typeable b f other type 26

Incidence of H. influenzae: Oregon vs. nationwide, 1988 29 6 5 Oregon US 4 Cases/1, 3 2 1 1988 199 1992 1994 1996 1998 2 22 24 26 28 Not nationally reportable until 1995, only Hib consistently reported by states. Incidence of H. influenzae by county of residence: Oregon, 2 29 Clatsop Columbia Tillamook Washington Multnomah Lincoln Polk Benton Yamhill Marion Clackamas Linn Hood River Wasco Jefferson Sherman Gilliam Wheeler Morrow Grant Umatilla Union Baker Wallowa Curry Coos Josephine Douglas Lane Jackson Deschutes Klamath Lake Crook Harney Malheur Rate per 1,..1.8.9 1.5 1.6 2.3 2.4 3.8 27

Hepatitis A Hepatitis A is a liver disease caused by the hepatitis A virus, which infects humans via fecal-oral transmission. In Oregon, hepatitis A can occur in situations ranging from isolated cases of disease to statewide outbreaks. Good personal hygiene and proper sanitation can help prevent hepatitis A. Vaccines are recommended for long-term prevention of hepatitis A in all Oregon children 1 year of age and older, as well as for adults in highrisk groups. Since licensure of the vaccine in 1995 1996, rates of infection have declined nationally and in Oregon, one of the higher incidence states. In 27, Oregon adopted the CDC case definition; laboratory positive, asymptomatic infections are no longer reportable. Recent changes in post-exposure prophylaxis include vaccination instead of immunoglobulin for immune-competent contacts aged 1-4 years. For those over 4 years of age, or with immune-compromising conditions, immune globulin is still recommended. In 29, Oregon logged 19 cases of acute hepatitis A. No outbreaks were recorded. Twenty-eight (61%) of the 46 cases in 28 29 were acquired by venturing outside of Oregon, often to countries with high rates of hepatitis A. Such persons placing themselves at elevated risk should receive a dose of hepatitis A vaccine as soon as travel is considered. Completion of the hepatitis A vaccination series (administered according to the licensed schedule) is recommended for long-term protection. Hepatitis A by year: Oregon, 1988 29 35 3 25 Cases 2 15 1 5 1988 1989 199 1991 1992 1993 1994 1995 1996 1997 1998 1999 2 21 22 28 23 24 25 26 27 28 29

Hepatitis A by onset month: Oregon, 29 8 29 Median 24 28 6 Cases 4 2 Jan Feb March April May June July August Sept Oct Nov Dec Incidence of hepatitis A by age and sex: Oregon, 29 2 Male Female Cases/1, 1-4 5-9 1-19 2-29 3-39 4-49 5-59 6-69 7-79 Age 8+ 29

Incidence of hepatitis A: Oregon vs. nationwide, 1988 29 18 16 Oregon US 14 12 Cases/1, 1 8 6 4 2 1988 199 1992 1994 1996 1998 2 22 24 26 28 Incidence of hepatitis A by county of residence: Oregon, 2 29 Clatsop Columbia Tillamook Washington Multnomah Hood River Morrow Umatilla Wallowa Yamhill Polk Marion Clackamas Wasco Sherman Gilliam Union Lincoln Benton Linn Jefferson Wheeler Grant Baker Crook Lane Deschutes Rate per 1, Coos Douglas Lake Harney Malheur..6.7 1.4 1.5 2.2 2.3 3.8 3.9 6.7 Curry Josephine Jackson Klamath 3

Acute hepatitis B Hepatitis B is a vaccine-preventable viral disease of the liver that occurs when the virus of an infected person passes (through blood, semen, or saliva) into the blood stream of a non-immune person. Percutaneous or permucosal exposures take place when hypodermic needles are shared; when blood splashes into an eye; during sex; by biting; when improperly sterilized injection devices are used for tattooing, body piercing and acupuncture; and when the baby of a mother who is a hepatitis B carrier is being born. Acute hepatitis B virus infection (diagnosed by the presence in serum of IgM antibody to the hepatitis B core antigen [IgM anti-hbc]) usually, but not always, causes jaundice. Some infections are mild, even asymptomatic, and may go undetected. Hepatitis B has been vaccine-preventable since 1982 and, to promote universal vaccination and hence protection, was added to the recommended childhood immunization schedule in 1992 with the series starting at birth. Acute hepatitis B continues to decline in Oregon a decline that started here after the hepatitis B vaccine was licensed in 1982. Local health departments investigated and reported 46 acute cases in 28, 5 in 29. Seventy-four percent of the cases were male. The number of cases reporting injection drug use continues to decrease; use was reported by 14% of cases in 29 and 29% in 28. Acute hepatitis B by year: Oregon, 1988 29 7 6 Cases 5 4 3 2 1 1988 1989 199 1991 1992 1993 1994 1995 1996 1997 1998 1999 2 21 22 23 24 31 25 26 27 28 29

Incidence of acute hepatitis B by age and sex: Oregon, 29 4 Male Female 3 Cases/1, 2 1-4 5-9 1-19 2-29 3-39 4-49 5-59 6-69 7-79 8+ Age Incidence of acute hepatitis B: Oregon vs nationwide, 1988-29 3 25 Oregon US 2 Cases/1, 15 1 5 1988 199 1992 1994 1996 1998 2 22 24 26 28 32

Incidence of acute hepatitis B by county of residence: Oregon, 2 29 Clatsop Columbia Tillamook Washington Multnomah Lincoln Polk Benton Yamhill Marion Clackamas Linn Hood River Wasco Jefferson Sherman Gilliam Wheeler Morrow Grant Umatilla Union Baker Wallowa Coos Douglas Lane Deschutes Lake Crook Harney Malheur Rate per 1,..4.5 1.3 1.4 2.2 2.3 3.2 3.3 6.3 Curry Josephine Jackson Klamath Chronic hepatitis B Persons with chronic hepatitis B are known as chronic carriers a state of infection defined by the persistence of hepatitis B surface antigen (HBsAg) in the blood for more than six months. The likelihood of becoming a chronic carrier is affected by the age at infection. Fewer than 6% of acutely infected adults in the United States become carriers, compared to 25% (with HBeAgnegative moms) to 9% (with HBeAg-positive moms) of children infected in early childhood or during birth. Perinatal infection can be prevented by prompt administration of hepatitis B immune globulin and initiation of the three-dose hepatitis B vaccination series. This perinatal intervention is widely practiced in the United States all states have federal funding for perinatal hepatitis B prevention programs but not in other parts of the world, particularly Asia and sub- Saharan Africa, where the prevalence of chronic hepatitis B is higher to begin with. Seventy-nine percent of 28 29 reports were from foreign born individuals. Chronic carriers are at greater risk of developing life-threatening diseases (e.g., chronic active hepatitis, cirrhosis or liver cancer) decades later. Carriers will sustain transmission of hepatitis B in the United States until vaccineinduced immunity is nearly universal. Recommendations and strategies to prevent new cases include the following: routinely vaccinating all infants at birth; screening 33

all pregnant women for hepatitis B; administering hepatitis B immune globulin (HBIG) in addition to hepatitis B vaccine to infants born to HBsAg-positive mothers; and ensuring that all infants complete the hepatitis B vaccine series. In 28 29, there were 985 newly reported carriers and, as in the past, they were older than acute cases and close to evenly distributed between men and women. Women, however, are diagnosed earlier than men, perhaps due to pre-natal screening. In 28, seven children 2 years old were reported as chronic carriers, six were born in countries where prevalence of chronic hepatitis B is high. In 29, six children were reported and five were born in high prevalence countries. Chronic carriers are not reportable in many of the U.S. states, so a table comparing Oregon to the rest of the United States is not given. Chronic hepatitis B by year: Oregon, 1988 29 7 6 5 4 Cases Cases/1, 3 2 1 3 25 2 15 1 1988 1989 199 1991 1992 1993 1994 1995 1996 1997 1998 1999 2 21 22 23 24 25 26 27 28 29 Incidence of chronic hepatitis B by age and sex: Oregon, 29 Male Female 5-4 5-9 1-19 2-29 3-39 4-49 5-59 6-69 7-79 8+ Age 34

Incidence of chronic hepatitis B by county of residence: Oregon 2 29 Clatsop Columbia Tillamook Washington Multnomah Hood River Morrow Umatilla Wallowa Yamhill Polk Marion Clackamas Wasco Sherman Gilliam Union Lincoln Benton Linn Jefferson Wheeler Grant Baker Crook Lane Deschutes Rate per 1, Curry Coos Josephine Douglas Jackson Klamath Lake Harney Malheur..6.7 4.5 4.6 7.2 7.3 13.6 13.7 25.3 Hepatitis C Infection with hepatitis C virus (HCV) causes acute and chronic hepatitis C disease. HCV is found in the blood of persons who have the disease. The most common signs and symptoms of hepatitis C include: jaundice, fatigue, dark urine, abdominal pain, loss of appetite and nausea. However, 8% of persons are asymptomatic. Hepatitis C cases are underreported due to the fact that most persons are asymptomatic and that laboratories can not test for acute HCV infection. Hepatitis C can lead to liver damage and sometimes death due to liver breakdown. Nearly 4.1 million people in the United States have been infected with hepatitis C, of whom 3.2 million are chronically infected. Chronic liver disease develops in up to 7% of chronically infected persons. Hepatitis C infection is the leading indication for liver transplant. Currently, 8, to1, people die each year in the United States from hepatitis C. There is no vaccine for hepatitis C. Hepatitis C is spread from one person to another primarily by direct contact with human blood. Most infections are due to illegal injection drug use. The virus can also be transmitted through sexual contact and from infected mothers to their infants at the time of birth. The risk for perinatal HCV transmission is about 4%. If the mother is coinfected with HIV, the risk for perinatal infection increases to about 19%. Since the adoption of routine blood donor screening in 1992, transfusionassociated cases now occur less than one per 2 million units of blood transfused. 35

Acute hepatitis C On average, from 2 29, there were 2 acute hepatitis C cases reported per year in Oregon. In 28 and 29, 33 and 26 cases were reported, respectively. In 69% of the cases, patients were less than 4 years of age, and 42% of all cases were female. Acute hepatitis C by year: Oregon, 1988 29 35 3 25 Cases 2 15 1 5 3 Male Female 1988 1989 199 1991 1992 1993 1994 1995 1996 1997 1998 1999 Acute hepatitis C by age and sex: Oregon, 29 2 21 22 23 24 25 26 27 28 29 2 Cases/1, 1 4 5 9 1 19 2 29 3 39 4 49 5 59 6 69 7 79 8+ Age 36

Incidence of acute hepatitis C by county of residence: Oregon, 2 29 Clatsop Columbia Tillamook Washington Lincoln Polk Benton Yamhill Marion Multnomah Clackamas Linn Hood River Wasco Jefferson Sherman Gilliam Wheeler Morrow Grant Umatilla Union Baker Wallowa Curry Coos Josephine Douglas Lane Jackson Deschutes Klamath Lake Crook Harney Malheur Rate per 1,..1.2.9 1. 1.9 2. 3.3 3.4 8.3 Chronic hepatitis C Chronic hepatitis C was reportable in Oregon as of July 1, 25. In 29, 6,288 chronic hepatitis C cases were reported, down from 7,877 reported in 28. Infection in males (59%) is higher than females, and in those aged 4-6 years (62%). These numbers are likely an underestimate of the true incidence because most infections are asymptomatic and therefore are not diagnosed or reported to public health. Chronic hepatitis C by year: Oregon, 21 29 9 8 7 6 Cases 5 4 3 2 1 21 22 23 24 25 26 27 28 29 Not officially reportable until July 1, 25. 37

Chronic hepatitis C by age and sex: Oregon, 29 7 6 Male Female 5 Cases/1, 4 3 2 1 4 5 9 1 19 2 29 3 39 4 49 5 59 6 69 7 79 8+ Age Incidence of chronic hepatitis C by county of residence: Oregon, 2 29 Clatsop Columbia Tillamook Washington Multnomah Hood River Morrow Umatilla Wallowa Yamhill Polk Marion Clackamas Wasco Sherman Gilliam Union Lincoln Benton Linn Jefferson Wheeler Grant Baker Crook Lane Deschutes Rate per 1, Coos Douglas Lake Harney Malheur 16.8 57.9 58. 96.9 97. 131.2 131.3 183.2 183.3 249.8 Curry Josephine Jackson Klamath 38

Legionellosis Legionellosis is usually an acute respiratory tract infection that begins two to 14 days after exposure to Legionella spp. Signs of the disease can include a high fever, chills and cough, in addition to head and muscle aches. Since symptoms are similar to those seen in other forms of pneumonia, the diagnosis is rarely obvious and can be difficult to make. Available diagnostic tests include direct fluorescent antibody staining, culture, polymerase chain reaction on sputum, and urine antigen detection. Pontiac Fever, a milder illness associated with Legionella bacteria, is characterized by fever and myalgias without pneumonia. It typically occurs a few hours to two days after exposure. Legionella bacteria are found naturally in the environment, usually in water, and grow best in warm conditions such as hot tubs, cooling towers, hot water tanks, large plumbing systems, or the air-conditioning systems of large buildings. Person-to-person transmission does not occur. Risks for infection include older age, smoking, chronic lung disease (like emphysema), renal insufficiency, diabetes and immune deficiency. Death occurs in 1% to 15% of cases: a substantially higher proportion of fatal cases occur during nosocomial outbreaks. Legionellosis became officially reportable in Oregon in 21. In 29, 19 cases of legionellosis were reported among Oregonians, up from 18 cases reported in 28. Thirty-six (97%) of 37 cases were hospitalized and four died. Legionellosis by year: Oregon, 21 29 25 2 15 Cases 1 5 21 22 23 24 25 26 27 28 29 Not officially reportable in Oregon until 21. 39

Incidence of legionellosis: Oregon vs. nationwide, 2 29 1.2 1. Oregon US.8 Cases/1,.6.4.2. 1988 199 1992 1994 1996 1998 2 22 24 26 28 Not nationally reportable until 1995. Incidence of legionellosis by county of residence: Oregon, 2 29 Clatsop Columbia Tillamook Washington Lincoln Polk Benton Yamhill Marion Multnomah Clackamas Linn Hood River Wasco Jefferson Sherman Gilliam Wheeler Morrow Grant Umatilla Union Baker Wallowa Coos Douglas Lane Deschutes Lake Crook Harney Malheur Rate per 1,..1.2.3.4.7.8 1.4 Curry Josephine Jackson Klamath 4

Listeriosis Listeriosis is a bacterial infection that may present as influenza-like illness with high fever, headache and myalgias; as a gastrointestinal illness; or as an invasive disease with sepsis or meningitis. In pregnant women, listeriosis may cause miscarriages or stillbirths. The case fatality rate of invasive listeriosis is as high as 3% in infants infected prenatally and in nonpregnant adults. Most cases of listeriosis are sporadic rather than epidemic. However, several large outbreaks have been associated with consumption of contaminated foods. It is important to track the incidence of this disease to identify such outbreaks, as well as to identify high risk groups. The rate is higher among pregnant women, newborns, the elderly and immunocompromised persons. Cooking food properly is the most important means of prevention. When listerosis is diagnosed, treatment with antibiotics should be instituted promptly. In 28 there were six cases, in 29, 19 cases were reported, a 216% increase compared to 28 and the highest rate (.5 per 1,) reported in 1 years. Twenty-three cases in 28 29 were hospitalized and there were five deaths. Four of these cases were pregnancy-related, one infant died. No outbreak-related cases were reported. Listeriosis by year Oregon, 1988 29 Cases 2 18 16 14 12 1 8 6 4 2 1988 1989 199 1991 1992 1993 1994 1995 1996 1997 1998 1999 2 21 22 23 24 25 26 41 27 28 29

Incidence of listeriosis: Oregon vs. nationwide, 1998 29 2 Oregon US Cases/1, 1 1998 1999 2 21 22 23 24 25 26 27 28 29 Listeriosis by age and sex: Oregon, 2 29 2.5 Male Female 2. Cases/1, 1.5 1..5. 4 5 9 1 19 2 29 3 39 4 49 5 59 6 69 7 79 8+ Age 42

Incidence of listeriosis by county of residence: Oregon, 2 29 Clatsop Columbia Tillamook Washington Lincoln Polk Benton Yamhill Marion Multnomah Clackamas Linn Hood River Wasco Jefferson Sherman Gilliam Wheeler Morrow Grant Umatilla Union Baker Wallowa Coos Douglas Lane Deschutes Lake Crook Harney Malheur Rate per 1,..1.2.3.4.5.6.7 1.3 Curry Josephine Jackson Klamath Lyme disease Lyme disease is a tick-borne zoonotic disease caused by the spirochete Borrelia burgdorferi. The first manifestation in about 6% of patients appears as a red macule or papule (bull s eye) that expands slowly in an annular manner, sometimes with multiple similar lesions. This distinctive skin lesion is called erythema migrans. The incubation period for Lyme disease ranges from three to 32 days after tick exposure; however, the early stages of the illness may be asymptomatic, and the patient may later develop systemic symptoms and rheumatologic, neurologic or cardiac involvement in varying combinations over a period of months to years. Currently, increasing recognition of the disease is redefining enzootic areas for B. burgdorferi; Lyme disease cases have been reported in 47 states, and in Ontario and British Columbia, Canada. Elsewhere, related borrelioses have been found in Europe, the former Soviet Union, China and Japan. In 1997 1998, a tick identification and Borrelia isolation study was conducted by the CDC and the Oregon Department of Human Services in Deschutes, Josephine and Jackson counties. No ticks from Deschutes County were identified as carrying Borrelia in this study. The organism was isolated in 3.5% of Ixodes pacificus ticks tested. During 28 29, 31 confirmed cases and 52 presumptive cases were reported in Oregon. The median age was 42 years. Fifityone (6%) cases were female. Of the cases, 25% were reported in Deschutes, Jackson and Josephine counties. 43

Lyme disease by year: Oregon, 1988 29 Cases 45 4 35 3 25 2 15 1 5 9 8 1988 1989 199 1991 1992 1993 1994 1995 1996 1997 1998 1999 2 21 22 23 24 25 26 27 Lyme disease by onset month: Oregon, 29 29 Median 24 28 28 29 7 6 Cases 5 4 3 2 1 Jan Feb March April May June July August Sept Oct Nov Dec 44

Incidence of Lyme disease by age and sex: Oregon, 2 29 3 Male Female Cases/1, 2 1-4 5-9 1-19 2-29 3-39 4-49 5-59 6-69 7-79 8+ Age Incidence of Lyme disease: Oregon vs. nationwide, 1988 29 15 Oregon US Cases/1, 1 5 1988 199 1992 1994 1996 1998 2 22 24 26 28 45

Incidence of Lyme disease by county of residence*: Oregon, 2 29 *Not necessarily county of acquisition Clatsop Columbia Tillamook Washington Lincoln Polk Benton Yamhill Marion Multnomah Clackamas Linn Hood River Wasco Jefferson Sherman Gilliam Wheeler Morrow Grant Umatilla Union Baker Wallowa Coos Douglas Lane Deschutes Lake Crook Harney Malheur Rate per 1,..1.2.7.8 1.4 1.5 2.7 2.8 5.7 Curry Josephine Jackson Klamath Malaria Worldwide, malaria is one of the most devastating of the communicable diseases, causing perhaps 1 million to 2 million deaths annually, not to mention an enormous burden of disability and medical costs. While transmission has not been documented in Oregon for decades, malaria is reported every year in our state; all cases have resulted from exposures outside the United States. Competent anopheline mosquitoes are resident in Oregon, so limited local transmission remains a theoretical possibility. Oregon rates are similar to the national average. Oregon surveillance data contribute to the national database, which is used to tailor recommendations for prophylaxis and treatment. In 28, four cases were reported, three of which were Plasmodium falciparum (the most severe of the four human parasite species). In 29, Plasmodium vivax (four cases) was most commonly reported. 46

Malaria by year: Oregon, 1988 29 45 4 35 3 Cases 25 2 15 1 5 3 1988 1989 199 1991 1992 1993 1994 1995 1996 1997 1998 1999 2 Incidence of malaria by age and sex: Oregon, 2-29 Male Female 21 22 23 24 25 26 27 28 29 2 Cases/1, 1 4 5 9 1 19 2 29 3 39 4 49 5 59 6 69 7 79 8+ Age 47

Incidence of malaria: Oregon vs. nationwide, 1988 29 2 Oregon US Cases/1, 1 1988 199 1992 1994 1996 1998 2 22 24 26 28 Malaria cases by continent of acquisition: Oregon, 28 29 Caribbean/ Central America 2% Africa 53% Asia/Pacific Islands 27% 48

Measles Measles is an acute, highly communicable viral illness known for its red, blotchy rash that starts on the face and then becomes generalized. The rash is preceded by a febrile prodrome that includes cough, coryza and conjunctivitis, and sometimes photophobia and Koplik spots. Diagnosis is confirmed by the presence of serum IgM antibodies (in a patient who has not recently been immunized). During 1989 1991, a major resurgence of measles occurred in the United States, with more than 55, cases and 12 deaths reported. The resurgence was characterized by an increasing proportion of cases among unvaccinated preschool-aged children. A focus on increasing vaccination among preschool children by following the 1989 recommendation for two doses of MMR vaccine resulted in a dramatic reduction in illness. Endemic measles has been eliminated from the United States, but cases are occasionally imported. In Oregon, two doses of measles vaccination have been required since 1998. In 29, >94% of school-aged children had received two doses of measles-containing vaccine. Since 22, 1 cases have been reported in Oregon; eight of these were imported, and two were linked to imported cases. Most imported cases originated in Asia and Europe and occurred both among Oregon citizens traveling abroad and persons visiting Oregon from other countries. The median age of cases has been 29 (range, 19 49) years. Cases were either unvaccinated (9) or had undocumented vaccination status (1). Though measles is highly infectious, the risk of exposure to measles in Oregon remains low. Sustaining high levels of vaccination is important to limit the spread of measles from imported cases and to prevent it from becoming re-established as an endemic disease in the United States. Measles by year: Oregon, 1988 29 25 2 15 Cases 1 5 1988 1989 199 1991 1992 1993 1994 1995 1996 1997 49 1998 1999 2 21 22 23 24 25 26 27 28 29

Incidence of measles: Oregon vs. nationwide, 1988 29 15 Oregon US 1 Cases/1, 5 1988 199 1992 1994 1996 1998 2 22 24 26 28 Measles by country of importation: 1997 29 Kenya 1% Hong Kong 1% Japan 4% Saudi Arabia 2% Europe 2% 5

Meningococcal disease Reported cases of invasive meningococcal infections, including sepsis and meningitis, have declined from the hyperendemic levels seen in 1993 1997 to those observed prior to the advent of the enzyme-type 5 (ET5) strain of serogroup B. Respiratory secretions and droplets continue to be shared among Oregonians and predispose secondary cases. Meningococcal disease reports remained stable in 28 and 29, with 38 and 39 cases respectively. This is up from the 32 cases reported in 27, at least a 2-year low. Though Oregon s trend is one of decline, we do continue to have higher rates than the nation. In 28 29, the highest majority (52%) of illness in Oregon was once again caused by serogroup B organisms. However, in 29, serogroup Y was a close second with 14 cases compared to 17 group B. December through March shows an increase in meningococcal activity, with the highest rates of disease occurring among infants. Higher rates are also seen in those aged 1 19 years and in persons over 7 years of age. Though a new conjugate vaccine (Menactra) for adolescents and young adults was licensed in 26, this vaccine does not protect against serogroup B disease. Meningococcal disease by year: Oregon, 1988 29 16 Cases 14 12 1 8 6 4 2 51 1988 1989 199 1991 1992 1993 1994 1995 1996 1997 1998 1999 2 21 22 23 24 25 26 27 28 29

Meningococcal disease by onset month: Oregon, 29 14 12 29 Median 24 28 1 8 Cases 6 4 2 Jan Feb March April May June July August Sept Oct Nov Dec Incidence of meningococcal disease by age and sex: Oregon, 29 8 Male Female 6 Cases/1, 4 2 4 5 9 1 19 2 29 3 39 4 49 5 59 6 69 7 79 8+ Age 52

Incidence of meningococcal disease: Oregon vs. nationwide, 1988 29 5 4 Oregon US Cases/1, 3 2 1 1988 199 1992 1994 1996 1998 2 22 24 26 28 Meningococcal disease by serogroup: Oregon, 28 29 other 2% C 12% W135 8% B 52% Y 26% 53

Incidence of meningococcal disease by county of residence: Oregon, 2 29 Clatsop Columbia Tillamook Washington Lincoln Polk Benton Yamhill Marion Multnomah Clackamas Linn Hood River Wasco Jefferson Sherman Gilliam Wheeler Morrow Grant Umatilla Union Baker Wallowa Coos Douglas Lane Deschutes Lake Crook Harney Malheur Rate per 1,..5.6 1.3 1.4 2.1 2.2 3.5 3.6 5.3 Curry Josephine Jackson Klamath Mumps Mumps is an acute viral illness characterized by fever and swelling of the salivary glands, typically the parotids. Transmission is generally airborne through respiratory droplets or through direct contact with nasal secretions. Reporting of this vaccine-preventable viral infection was discontinued in Oregon in 1981. Once an almost universal childhood infection, mumps incidence decreased in the United States with routine childhood vaccination. Mumps reporting was re-established in Oregon July 1, 26, prompted by outbreaks of illness among both vaccinated and unvaccinated persons. No mumps cases were reported in 28, three cases were reported in 29. Because as many as 2% of mumps infections are asymptomatic, and nearly 5% are associated with non-specific or primarily respiratory symptoms (with or without parotitis), mumps infections are significantly underreported. In response to the 26 nationwide mumps outbreak, the Advisory Committee on Immunization Practices (ACIP) updated its recommendations for prevention and control of mumps, with vaccination remaining the cornerstone of prevention. 54