World No Tobacco Day - May 31, 2011 Cigarette Package Health Warnings and Interest in Quitting Smoking - 14 Countries, 2008-2010

Morbidity and Mortality Weekly Report
Weekly / Vol. 60 / No. 20 May 27, 2011
World No Tobacco Day May 31, 2011

Tobacco use is the leading preventable cause of death; this year approximately 5 million persons worldwide will die from tobacco-related heart attacks, strokes, cancers, and other diseases (1). Sponsored by the World Health Organization (WHO), World No Tobacco Day is observed every year on May 31. This year, World No Tobacco Day highlights the WHO Framework Convention on Tobacco Control (WHO FCTC) (1). Adopted as a resolution at WHOs 1996 World Health Assembly, WHO FCTC took effect in 2005 and is maintained by the United Nations. A total of 172 countries have adopted the treaty (2), making WHO FCTC one of the most widely embraced evidence-based treaties in United Nations history. WHO FCTC urges all countries to ratify the treaty, fully implement its provisions, and adopt its guidelines (1), and WHO provides country-level assistance for implementing effective tobacco control measures (3). CDC has supported this effort by working with partners to provide technical assistance and infrastructure support for the creation of sustainable surveillance systems (the Global Adult Tobacco Survey and the Global Youth Tobacco Survey). Additional information is available at http://www.who.int/fctc/en/ index.html.
References
1. World Health Organization. WHO Framework Convention on Tobacco Control. Geneva, Switzerland: World Health Organization; 2011. Available at http://www.who.int/tobacco/wntd/2011/ announcement/en/index.html. Accessed May 19, 2011. 2. World Health Organization. Parties to the WHO Framework Convention on Tobacco Control. Geneva, Switzerland: World Health Organization; 2011. Available at http://www.who.int/fctc/ signatories_parties/en/index.html. Accessed May 19, 2011. 3. World Health Organization. WHO report on the global tobacco epidemic, 2008: the MPOWER package. Geneva, Switzerland: World Health Organization; 2011. Available at http://www.who.int/tobacco/ mpower/2008/en/index.html. Accessed May 19, 2011.
Cigarette Package Health Warnings and Interest in Quitting Smoking 14 Countries, 20082010
The World Health Organization (WHO) Framework Convention on Tobacco Control (FCTC) requires health warnings on tobacco product packages sold in countries that ratified the WHO FCTC treaty (1). These warnings are expected to 1) describe the harmful effects of tobacco use; 2) be approved by the appropriate national authority; 3) appear on at least 30%, and ideally 50% or more, of the packages principal display areas; 4) be large, clear, visible, and legible in the countrys principal language(s); 5) have multiple, rotating messages; and 6) preferably use pictures or pictograms. To assess the effects of cigarette package health warnings on interest in quitting smoking among smokers of manufactured cigarettes aged 15 years, this report examines 20082010 data from the Global Adult Tobacco Survey (GATS) in 14 WHO FCTC countries. Among men, the prevalence of manufactured cigarette smoking ranged from 9.6% in India to 59.3% in Russia. Among men in 12 of the countries and women in seven countries, >90% of smokers INSIDE
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reported noticing a package warning in the previous 30 days. The percentage of smokers thinking about quitting because of the warnings was >50% in six countries and >25% in men and women in all countries except Poland. WHO has identified providing tobacco health information, including graphic health warnings on tobacco packages, as a powerful best buy in combating noncommunicable disease (2). Implementing effective warning labels as a component of a comprehensive approach can help decrease tobacco use and its many health consequences. GATS is a nationally representative household survey conducted among persons aged 15 years using a standardized questionnaire, sample design, data collection method, and analysis protocol to obtain measures on key tobacco control indicators and ensure comparability across countries.* GATS was conducted once in each of the 14 countries during 20082010 by national governments, ministries of health, survey-implementing agencies, and international partners. In each country, a multistage cluster sample design is used, with households selected proportional to population size. Data are weighted to reflect the noninstitutionalized population aged 15 years in each country. For this analysis, current smokers of manufactured cigarettes were asked whether they had noticed
* Additional information and GATS country reports are available at http://www. cdc.gov/tobacco/global/gats. Respondents who reported currently smoking manufactured (i.e., commercial) cigarettes on a daily or less than daily basis. The term smokers in this report refers to current smokers of manufactured cigarettes. Smokers of other tobacco products, such as bidis, kreteks, hand-rolled cigarettes, cigars, pipes, and waterpipes who did not also smoke manufactured cigarettes are not included in this analysis.
health warnings on a cigarette package in the previous 30 days, and whether the label led them to think about quitting smoking. Responses were analyzed by sex and, within sex strata, by age and education level using bivariate analysis within individual countries. Differences in response estimates were considered statistically significant if 95% confidence intervals did not overlap. Overall response rates ranged from 65.1% in Poland to 97.7% in Russia. The health warnings on cigarette packages in each country at the time GATS was conducted were described according to WHO FCTC guidelines (3,4). All GATS countries had warning labels on cigarette packages describing harmful effects of smoking at the time their survey was conducted. Four of the 14 countries (Brazil, Egypt, Thailand, and Uruguay) had pictorial warnings. A fifth country, India, introduced pictorial warnings in 2009, and had both text and pictorial warnings in circulation when GATS was conducted (Table 1). In all 14 countries, men were more likely to be cigarette smokers than women. Among men, prevalence of smoking ranged from 9.6% in India to 59.3% in Russia (Table 2). Among women, prevalence of smoking was <25% in all countries and <2% in Bangladesh, China, Egypt, India, Thailand, and Vietnam.
In the last 30 days, did you notice any health warnings on cigarette packages?
and In the last 30 days, have warning labels on cigarette packages led you to think about quitting?
The MMWR series of publications is published by the Office of Surveillance, Epidemiology, and Laboratory Services, Centers for Disease Control and Prevention (CDC), U.S. Department of Health and Human Services, Atlanta, GA 30333. Suggested citation: Centers for Disease Control and Prevention. [Article title]. MMWR 2011;60:[inclusive page numbers]. Thomas R. Frieden, MD, MPH, Director Harold W. Jaffe, MD, MA, Associate Director for Science James W. Stephens, PhD, Director, Office of Science Quality Stephen B. Thacker, MD, MSc, Deputy Director for Surveillance, Epidemiology, and Laboratory Services Stephanie Zaza, MD, MPH, Director, Epidemiology and Analysis Program Office Ronald L. Moolenaar, MD, MPH, Editor, MMWR Series Martha F. Boyd, Lead Visual Information Specialist John S. Moran, MD, MPH, Deputy Editor, MMWR Series Malbea A. LaPete, Julia C. Martinroe, Robert A. Gunn, MD, MPH, Associate Editor, MMWR Series Stephen R. Spriggs, Terraye M. Starr Teresa F. Rutledge, Managing Editor, MMWR Series Visual Information Specialists Douglas W. Weatherwax, Lead Technical Writer-Editor Quang M. Doan, MBA, Phyllis H. King Donald G. Meadows, MA, Jude C. Rutledge, Writer-Editors Information Technology Specialists William L. Roper, MD, MPH, Chapel Hill, NC, Chairman Virginia A. Caine, MD, Indianapolis, IN Patricia Quinlisk, MD, MPH, Des Moines, IA Jonathan E. Fielding, MD, MPH, MBA, Los Angeles, CA Patrick L. Remington, MD, MPH, Madison, WI David W. Fleming, MD, Seattle, WA Barbara K. Rimer, DrPH, Chapel Hill, NC William E. Halperin, MD, DrPH, MPH, Newark, NJ John V. Rullan, MD, MPH, San Juan, PR King K. Holmes, MD, PhD, Seattle, WA William Schaffner, MD, Nashville, TN Deborah Holtzman, PhD, Atlanta, GA Anne Schuchat, MD, Atlanta, GA John K. Iglehart, Bethesda, MD Dixie E. Snider, MD, MPH, Atlanta, GA Dennis G. Maki, MD, Madison, WI John W. Ward, MD, Atlanta, GA
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In all countries except India (78.4%) and Mexico (83.5%), >90% of men reported noticing a health warning on a cigarette package (Table 2). Among women, the percentage who noticed
warnings was 75% in all countries except China (60.1%) and India (18.9%), and >90% in seven countries. In Bangladesh
TABLE 1. Characteristics of health warning labels on cigarette packages Global Adult Tobacco Survey (GATS), 14 countries, 20082010
Law mandates font style, size and color Yes Yes Yes Yes Yes No No Yes Yes Yes Yes Yes Yes Yes Percentage of front/back covered by health warning 30/30 0/100 30/30 50/50 40/0 30/100 30/0 30/40 4/4 50/50 30/40 30/30 50/50 30/30 Rotating warnings/ number of warnings approved by law Yes/6 Yes/10 Yes/2 Yes/4 Yes/2 No Yes/4 Yes/16 Yes/2 Yes/9 Yes/16 Yes/7 Yes/6 Yes/2
Country Bangladesh Brazil China Egypt India Mexico Philippines Poland Russia Thailand Turkey Ukraine Uruguay Vietnam
Year(s) survey conducted 2009 2008 2010 2009 20092010 2009 2009 20092010 2009 2009 2008 2010 2009 2010
Warnings appear on each package Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes
Warning describes harmful effects Yes Yes Yes Yes Yes No Yes Yes Yes Yes Yes Yes Yes Yes
Warning label is in principal language(s) Yes Yes Yes/No* Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes
Law mandates specific warnings Yes Yes Yes Yes Yes No Yes Yes Yes Yes Yes Yes Yes Yes
Warnings include a picture or pictogram No Yes No Yes Yes/No No No No No Yes No No Yes No
Sources: Pan American Health Organization. Tobacco control report for the Region of the Americas. Washington, DC: World Health Organization, Pan American Health Organization; 2011. Available at http://new.paho.org/hq/index.php?option=com_content&task=view&id=4457&Itemid=1231&lang=en. World Health Organization. WHO report on the global tobacco epidemic, 2009: implementing smoke-free environments. Appendix V: country profiles. Geneva, Switzerland: World Health Organization. Available at http://www.who.int/tobacco/mpower/2009/Appendix_V-table_1.pdf. * Chinas warning is in Mandarin on the front and in English on the back. India mandated pictorial warnings on packages sold after May 31, 2009, but older packages still were in circulation when GATS was conducted.
TABLE 2. Percentage of current smokers of manufactured cigarettes aged 15 years who noticed health warning labels on cigarette packages and percentage who, as a result, were thinking about quitting smoking, by selected characteristics Global Adult Tobacco Survey (GATS), 14 countries, 20082010*
Bangladesh Men Characteristic % current manufactured cigarette smokers % who noticed health warning labels in past 30 days Age group (yrs) 1524 2564 65 Education No formal education/Less than primary Completed primary/Less than secondary Completed secondary/Completed high school Completed college/university or above % thinking about quitting smoking among those who noticed warning Age group (yrs) 1524 2564 65 Education No formal education/Less than primary Completed primary/Less than secondary Completed secondary/Completed high school Completed college/university or above See table footnotes on page 649. (4,468) % (95% CI) 28.3 91.3 (26.330.4) (89.193.1) Women (5,161) % (95% CI) 0.2 (0.10.4) DS DS Men (18,039) % (95% CI) 17.7 92.4 (17.018.4) (91.293.5) Brazil Women (21,386) % (95% CI) 11.1 (10.611.7) 91.8 (90.493.0) Men (6,603) % (95% CI) 50.5 (48.252.8) 90.3 (85.293.8) % 1.9 60.1 China Women (6,751) (95% CI) (1.52.6) (44.473.9)
93.4 92.0 69.2 85.3 98.3 99.3 95.7 74.1
(85.997.0) (89.893.7) (50.483.2) (81.588.4) (96.699.2) (97.099.8) (88.798.4) (69.977.9)
DS DS NR DS DS NR NR DS
DS DS NR DS DS NR NR DS
92.5 93.3 81.5 NA NA NA NA 71.8
(89.095.0) (92.094.3) (74.487.0) NA NA NA NA (69.873.8)
93.4 (88.796.2) 92.2 (90.793.5) 82.1 (73.888.3) NA NA NA NA NA NA NA NA
91.3 (73.397.5) 91.6 (87.294.6) 69.8 (57.279.9) 65.4 88.8 92.9 98.1 (56.973.0) (84.692.0) (85.296.7) (94.999.3)
DS 61.7 45.9 30.6 69.6 77.5 DS 42.5
DS (44.676.3) (27.565.4) (17.947.3) (48.784.6) (42.094.2) DS (32.053.6)
76.6 (74.278.8)
36.5 (31.342.0)
71.3 75.0 71.6 75.9 72.8 72.9 66.9
(60.480.2) (70.778.8) (52.085.4) (70.880.3) (65.978.8) (61.482.0) (49.580.6)
DS DS NR DS DS NR NR
DS DS NR DS DS NR NR
73.5 71.7 67.5 NA NA NA NA
(68.677.8) (69.474.0) (58.375.5) NA NA NA NA
74.9 (67.681.0) 77.1 (74.579.5) 71.8 (62.179.8) NA NA NA NA NA NA NA NA
37.6 (25.351.7) 36.2 (31.541.1) 37.9 (29.547.0) 35.4 42.7 36.4 27.7 (27.244.6) (35.050.7) (30.243.1) (20.935.8)
DS 37.6 DS DS DS 41.1 DS
DS (26.550.1) DS DS DS (25.259.2) DS
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TABLE 2. (Continued) Percentage of current smokers of manufactured cigarettes aged 15 years who noticed health warning labels on cigarette packages and percentage who, as a result, were thinking about quitting smoking, by selected characteristics Global Adult Tobacco Survey (GATS), 14 countries, 20082010*
Egypt Men Characteristic % current manufactured cigarette smokers % who noticed health warning labels in past 30 days Age group (yrs) 1524 2564 65 Education No formal education/Less than primary Completed primary/Less than secondary Completed secondary/Completed high school Completed college/university or above % thinking about quitting smoking among those who noticed warning Age group (yrs) 1524 2564 65 Education No formal education/Less than primary Completed primary/Less than secondary Completed secondary/Completed high school Completed college/university or above See table footnotes on page 649. (10,062) % (95% CI) 31.7 (30.533.0) 98.6 (97.999.0) Women (10,862) % (95% CI) 0.2 DS (0.10.4) DS Men (33,767) % (95% CI) 9.6 (9.010.3) 78.4 (75.980.7) India Women (35,529) % (95% CI) 0.5 (0.40.7) 18.9 (12.028.4) Men (6,160) % (95% CI) 24.5 83.5 (22.826.2) (80.686.0) % 7.5 87.6 Mexico Women (7,457) (95% CI) (6.48.8) (83.091.1)
98.4 (95.499.4) 98.7 (98.099.1) 98.1 (94.599.3) 98.5 98.3 98.6 99.1 (97.199.2) (95.199.4) (97.699.2) (97.699.6)
DS DS NR DS DS DS DS DS
DS DS NR DS DS DS DS DS
81.2 (75.286.0) 78.2 (75.480.8) 68.2 (57.277.5) 65.4 80.0 87.7 89.2 (60.370.1) (75.883.5) (83.591.0) (84.792.5)
36.9 (9.476.7) 21.1 (12.832.9) 8.3 (3.219.8) 13.8 (8.122.7) 49.3 (21.777.4) 44.8 (13.680.8) DS DS 76.1 (58.188.0)
86.6 82.7 73.3 69.2 81.2 88.6 82.0 37.3
(82.190.1) (79.385.6) (63.381.4) (61.276.1) (75.685.7) (85.691.1) (67.490.9) (33.541.3)
90.8 86.4 DS 64.4 82.8 91.9 93.9 42.6
(79.496.2) (79.691.2) DS (46.878.8) (67.991.6) (87.394.9) (76.298.7) (35.849.7)
45.1 (42.747.5)
53.7 (50.656.8)
44.6 (38.051.4) 45.9 (43.248.5) 35.3 (27.344.3) 44.8 43.6 47.7 37.2 (40.649.0) (36.850.6) (44.251.2) (31.143.8)
DS DS NR DS DS DS DS
DS DS NR DS DS DS DS
68.0 (60.474.7) 50.3 (47.153.5) 45.0 (33.357.2) 52.8 53.8 56.0 51.3 (46.259.2) (48.658.8) (50.261.6) (43.459.1)
DS DS 72.1 (51.586.3) DS DS 84.2 (66.493.4) 61.1 (21.490.0) 73.6 (49.089.0) DS DS
36.3 38.4 27.3 45.7 38.9 36.9 25.0
(30.342.7) (33.443.7) (17.440.1) (35.756.0) (32.046.3) (31.942.1) (15.437.8)
33.5 46.0 DS 32.6 56.9 36.9 53.8
(22.047.3) (38.653.7) DS (19.948.6) (44.868.3) (29.245.3) (32.673.8)
Philippines Men Characteristic % current manufactured cigarette smokers % who noticed health warning labels in past 30 days Age group (yrs) 1524 2564 65 Education No formal education/Less than primary Completed primary/Less than secondary Completed secondary/Completed high school Completed college/university or above % thinking about quitting smoking among those who noticed warning Age group (yrs) 1524 2564 65 Education No formal education/Less than primary Completed primary/Less than secondary Completed secondary/Completed high school Completed college/university or above See table footnotes on page 649. (4,740) % (95% CI) 46.6 (44.748.6) 91.8 (89.993.3) Women (4,961) % (95% CI) 7.5 (6.58.5) 84.2 (78.888.4) Men (3,867) % (95% CI) 35.1 (33.237.1) 97.0 (95.897.9) Poland Women (3,973) % (95% CI) 22.9 (21.424.5) 96.9 (95.497.9) Men (6,217) % (95% CI) 59.3 94.6 (57.661.0) (93.195.8) % 21.4 94.7 Russia Women (5,189) (95% CI) (19.323.5) (92.196.5)
93.4 (88.996.2) 92.0 (89.993.7) 76.3 (62.786.1) 80.5 92.1 97.4 98.6 (75.284.8) (87.595.0) (96.098.3) (96.699.4)
95.9 (87.398.8) 86.8 (81.291.0) 55.9 (36.174.0) 72.4 84.4 92.7 98.0 (62.180.7) (66.793.6) (84.896.7) (92.099.5)
95.7 (90.198.1) 97.4 (96.098.3) 96.0 (90.498.4) DS DS 96.5 (91.998.5) 97.1 (95.698.0) 98.2 (94.399.4) 16.1 (13.619.1)
97.6 (92.699.3) 96.9 (95.298.0) 95.3 (72.899.4) DS DS 93.1 (84.797.0) 97.5 (95.998.5) 96.3 (90.298.7) 21.7 (18.425.5)
95.7 94.7 90.7 DS 90.0 95.3 93.0 33.6
(92.997.5) (93.195.9) (81.495.6) DS (79.795.4) (93.796.5) (89.395.5) (30.736.6)
93.5 95.9 DS NR DS 95.1 95.1 33.9
(87.296.9) (93.097.6) DS NR DS (92.296.9) (91.197.3) (29.239.1)
41.7 (38.844.7)
44.6 (37.052.4)
44.9 (38.551.5) 40.7 (37.643.9) 40.3 (27.754.2) 35.8 37.5 45.6 46.5 (30.341.8) (31.044.6) (41.549.8) (40.452.7)
45.6 (25.367.5) 44.4 (35.853.4) 43.9 (23.067.1) 44.8 51.8 44.5 34.1 (30.460.0) (33.070.0) (33.656.0) (19.752.2)
12.6 (7.620.1) 16.2 (13.419.5) 23.2 (14.834.4) DS DS 26.5 (19.534.9) 15.8 (12.919.2) 7.9 (3.516.9)
15.4 (8.626.0) 22.5 (18.826.8) 25.5 (12.944.1) DS DS 37.9 (28.848.0) 21.0 (17.225.4) 15.6 (9.125.4)
37.5 32.5 35.5 DS 35.7 34.7 30.1
(31.643.8) (29.535.7) (26.945.1) DS (22.751.2) (31.537.9) (25.435.1)
35.6 33.7 DS NR DS 38.2 26.9
(26.645.7) (28.639.2) DS NR DS (33.143.6) (18.737.2)
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Thailand Men Characteristic % current manufactured cigarette smokers % who noticed health warning labels in past 30 days Age group (yrs) 1524 2564 65 Education No formal education/Less than primary Completed primary/Less than secondary Completed secondary/Completed high school Completed college/university or above % thinking about quitting smoking among those who noticed warning Age group (yrs) 1524 2564 65 Education No formal education/Less than primary Completed primary/Less than secondary Completed secondary/Completed high school Completed college/university or above See table footnotes below. (10,052) % (95% CI) 29.6 99.2 (28.131.1) (98.899.5) Women (10,514) % (95% CI) 1.1 (0.91.4) 98.0 (95.299.2) Men (4,269) % (95% CI) 45.8 (43.747.9) 95.3 (93.696.6) Turkey Women (4,761) % (95% CI) 14.9 (13.816.2) 94.3 (91.096.4) % 49.5 96.6 Men (4,076) (95% CI) (47.551.4) (95.397.5) % Ukraine Women (4,082) (95% CI)
11.1 (9.812.5) 96.8 (91.698.8)
99.8 (99.2100.0) 99.1 (98.699.4) 96.5 (89.998.8) 98.2 99.3 99.6 98.7 71.4 (96.899.0) (98.399.7) (99.199.8) (94.399.7) (68.174.5)
DS DS 99.2 (96.599.8) DS DS 97.1 (88.899.3) 97.1 (88.199.4) 99.1 (93.899.9) DS DS 66.1 (56.574.6)
93.9 (88.996.7) 95.9 (94.197.2) 89.2 (78.994.9) 90.9 95.1 96.7 93.8 (82.995.3) (92.996.7) (94.098.2) (85.697.5)
96.0 (87.998.7) 94.0 (90.196.4) DS DS 71.5 98.7 95.5 96.3 (55.183.7) (96.699.5) (89.498.2) (88.698.9)
98.5 96.6 90.9 DS 89.4 96.8 98.4 58.9
(96.299.4) (95.297.6) (85.294.6) DS (80.994.4) (95.597.7) (95.499.4) (55.262.5)
92.5 (65.598.8) 98.0 (95.699.1) NR NR DS DS DS DS 98.0 (95.399.2) 98.8 (94.799.7) 63.9 (57.469.9)
48.8 (45.552.1)
49.5 (45.054.1)
69.4 72.5 59.5 72.3 73.8 70.7 63.9
(60.577.0) (69.375.4) (48.469.7) (66.977.1) (68.178.8) (66.075.0) (54.972.0)
DS DS 70.5 (60.678.7) DS DS 77.6 (64.986.6) 81.5 (66.290.9) 53.4 (36.269.9) DS DS
42.5 (34.750.7) 50.1 (46.553.7) 53.1 (39.766.0) 46.5 53.3 44.5 41.7 (35.058.5) (49.157.5) (39.449.6) (33.350.7)
52.2 (39.864.3) 49.4 (44.354.4) DS DS 54.1 52.7 49.6 28.8 (39.767.8) (46.359.1) (42.656.7) (18.641.8)
56.3 59.8 55.7 DS 50.6 59.4 58.8
(47.165.0) (56.163.3) (46.264.8) DS (37.863.3) (55.863.0) (49.667.4)
51.0 (32.868.9) 67.3 (61.073.1) NR NR DS DS DS DS 62.6 (55.169.5) 72.9 (62.281.4)
Uruguay Men Characteristic % current manufactured cigarette smokers % who noticed health warning labels in past 30 days Age group (yrs) 1524 2564 65 Education No formal education/Less than primary Completed primary/Less than secondary Completed secondary/Completed high school Completed college/university or above % thinking about quitting smoking among those who noticed warning Age group (yrs) 1524 2564 65 Education No formal education/Less than primary Completed primary/Less than secondary Completed secondary/Completed high school Completed college/university or above % 24.3 97.1 98.1 97.6 80.9 87.3 96.2 99.4 100.0 39.3 (2,634) (95% CI) (22.026.7) (94.598.5) (87.499.7) (94.699.0) (52.194.3) (72.694.7) (90.098.6) (96.799.9) (88.7100.0) (33.645.4) Women (2,947) % (95% CI) 18.6 97.2 98.0 97.2 94.4 90.9 98.3 97.0 99.1 47.9 (16.920.4) (94.398.6) (92.299.5) (93.398.8) (82.498.4) (75.397.0) (95.699.3) (91.099.0) (93.799.9) (42.653.3) % 39.1 96.1 97.7 95.9 95.2 89.9 96.7 98.0 99.1 73.1 Men (4,356) (95% CI) (37.041.2) (94.897.1) (94.399.1) (94.397.0) (86.498.4) (84.793.5) (94.498.0) (96.698.9) (96.299.8) (70.375.8) % 1.0 75.0 DS 76.7 DS 70.9 DS DS DS 61.1 Vietnam Women (5,569) (95% CI) (0.61.5) (53.488.7) DS (54.290.1) DS (49.985.6) DS DS DS (42.177.2)
50.1 36.8 13.9 46.7 44.5 33.9 37.3
(37.962.2) (30.743.2) (5.132.5) (29.264.9) (35.454.0) (26.242.5) (22.055.6)
60.2 45.0 45.8 68.7 63.9 37.3 33.3
(46.372.7) (38.951.1) (28.464.2) (47.584.1) (54.472.4) (30.844.3) (20.549.1)
72.1 73.5 70.0 66.5 72.9 75.7 74.0
(63.379.6) (70.576.3) (59.578.8) (59.872.6) (67.477.7) (71.879.3) (66.780.2)
DS 68.0 DS 48.1 DS DS DS
DS (48.282.9) DS (27.569.2) DS DS DS
Abbreviations: CI = confidence interval; DS = data suppressed because cell size <30; NR = no reported cases; NA = Not applicable (GATS countries have varying educational systems. Based on the questionnaire categories used in each country, four approximately comparable categories of education were created. However, Brazils educational categories could not be coded in this fashion). * Results presented in this report differ from those presented in previously published GATS fact sheets or country reports (available at http://www.cdc.gov/tobacco/global) because of differing age and education category breakdowns and because this report includes only respondents who reported being current smokers of manufactured cigarettes. Also, in this report, the percentage who thought about quitting was calculated only among those who noticed labels. Number sampled.
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What is already known on this topic? Warning the public about the dangers of tobacco is one of the key strategies in the World Health Organizations MPOWER package to combat tobacco use. What is added by this report? For the first time, data from all 14 Global Adult Tobacco Survey (GATS) countries are available. In these countries, the prevalence of smoking manufactured cigarettes varies widely and is more common among men. The majority of smokers noticed package warning labels. Among smokers who noticed a health warning, the percentage thinking about quitting because of the warning was >50% in six GATS countries. What are the implications for public health practice? Strong health warning labels on cigarette packages are effective in motivating smokers to consider quitting. These findings emphasize the importance of using warnings that are effective in communicating the risks of smoking to all cigarette smokers.
Editorial Note
and Egypt, not enough women reported current smoking to calculate this percentage. Smokers aged 65 years were less likely to notice warnings in Bangladesh (men), Brazil (men and women), Mexico (men), Philippines (men and women), Thailand (men), and Ukraine (men) (Table 2). Smokers who had not completed primary school education were less likely to have noticed warnings in Bangladesh (men), China (men and women), India (men), Mexico (women), Philippines (men and women), Turkey (women), and Vietnam (men) (Table 2). Among smokers who noticed a package warning, the percentage thinking about quitting because of the warning was >50% in six GATS countries (Bangladesh, Brazil, India, Thailand, Ukraine, and Vietnam) and >25% for men and women in all countries except one (Poland). Older male smokers were less likely to think about quitting in India and Uruguay; no other age group differences were noted.
Reported by
Roberta B. Caixeta, Adriana Blanco, Pan American Health Organization; Heba Fouad, Eastern Mediterranean Regional Office; Rula N. Khoury, European Regional Office; Dhirendra N. Sinha, Southeast Asian Regional Office; James Rarick, Western Pacific Regional Office; Edouard Tursan dEspaignet, Douglas Bettcher, Tobacco Free Initiative, World Health Organization. GATS Collaborative Group. Sara A. Mirza, Rachel B. Kaufmann, Linda J. Andes, Glenda Blutcher-Nelson, Jason Hsia, Samira Asma, Terry Pechacek, Office on Smoking and Health, CDC. Corresponding contributor: Sara A. Mirza, CDC, [email protected], 770-488-6389.
This report is the first to provide survey results from all 14 countries that participated in GATS during 20082010. In these countries, the prevalence of smoking manufactured cigarettes varied widely and was more common among men. Warning the public about the dangers of tobacco is one of the strategies in WHOs MPOWER package to combat the tobacco epidemic (3). Most of these countries had met the minimum WHO FCTC health warning label criteria for cigarette packages at the time GATS was conducted. The majority of smokers noticed the health warnings, and in most countries >25% who noticed the warnings said they were led to think about quitting. These results indicate that package warnings can be effective for various populations and settings, including countries in which cigarette smoking prevalence currently is low. To be effective, cigarette package warnings must capture smokers attention and educate them about the health effects of tobacco use (5). The WHO FCTC guidelines provide parameters to accomplish these objectives by emphasizing features that increase the salience of warnings (1,4). Prominent, pictorial warnings have been found to be the most effective in communicating the harms of smoking in several studies (4,6). Smokers who perceive a greater health risk from smoking are more likely to think about quitting and to quit successfully (6). Further, evidence indicates that warnings are more likely to be effective if they elicit strong emotions, such as fear, seem personally relevant, and increase confidence in the ability to quit (4,7). For example, a comparative analysis of responses to labels in Brazil, Mexico, and Uruguay found that the Brazilian warnings depicting human suffering had the strongest impact on thinking about quitting (8). Rotating warnings also is important because the impact of an individual label will decrease over time (5). Thus, a warning that is small in total size or font size, has been in circulation for a long time, or lacks informational content that generates an emotional response likely will not have the strongest possible impact. Graphic warnings have the potential to reach those who do not notice or read text-only warnings; they also have the potential to better evoke emotional responses, increase knowledge of health risks, and reinforce motivations to quit smoking (9). Therefore, the WHO FCTC guidelines strongly encourage the use of graphic warnings (5). Low education level and older age were associated with not noticing warnings in some countries; virtually all of these countries had text-only warnings. Women were less likely to notice warnings than men in India, China, and Vietnam, countries where cigarette smoking prevalence is very low among women. These findings emphasize the importance of using warnings that are effective in communicating the risks of smoking to all cigarette smokers and using other
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evidence-based tobacco control measures that reach populations that are not frequently exposed to cigarette packages. Warnings were more effective at getting smokers to think about quitting in some countries than in others. Brazil and Thailand, countries with numerous prominent and graphic pictorial warnings in rotation, had among the highest prevalences of smokers thinking about quitting because of the warnings; these warnings received WHOs highest rating (3). However, reported thinking about quitting smoking also was relatively high in Bangladesh and Vietnam, where warnings covered less of the package and were text-only. The reasons for these findings are not immediately clear but might relate to the relative importance of package warnings among other contextual factors such as smokers baseline knowledge about health risks, level of interest in quitting, and level of tobacco dependence, as well as concurrent tobacco control efforts and social norms surrounding tobacco use (7). Further research might be helpful in elucidating these factors and in determining the extent to which thinking about quitting because of warnings leads to quit attempts in GATS countries. The findings in this report are subject to at least five limitations. First, all data were self reported, and social norms (e.g., unacceptability in some countries of women smoking) might have affected responses. Second, the education categories used in Brazil are not comparable to the categories used in this analysis, so Brazils data were not evaluated for differences in prevalence by education. Third, this analysis included only smokers of manufactured cigarettes; however, other tobacco products (e.g., bidis, kreteks, hand-rolled cigarettes, waterpipes, and smokeless tobacco) are commonly used in India and other GATS countries. Fourth, the prevalence of smoking among women is low in some countries, so analyzing or interpreting results on the impact of package warnings among women was not possible. Finally, GATS was not designed to evaluate the effectiveness of individual health warning labels, and its core questions did not distinguish between the different labels in circulation in a country. After GATS was conducted, Mexico, Philippines, Turkey, and Ukraine passed legislation requiring pictorial warning labels, and Thailand and Uruguay increased the size of their warnings. Worldwide, a majority of countries now have warnings on cigarette packages, but their features and strength vary (7). As of 2010, approximately 30 countries had pictorial warning labels covering at least 50% of the package (7), and additional countries were developing such labels. Future GATS will allow tracking of progress toward key tobacco use and control indicators. Smokers view their cigarette packages
Pictorial health warning labels currently in use are available at http://www.who.
every time they remove a cigarette; therefore, the cigarette package represents a powerful vehicle to deliver health warnings directly to smokers. Nonsmokers and former smokers also can be discouraged from smoking by viewing comprehensive warnings (7). WHO has identified price increases; smoke-free policies; bans on tobacco advertising, promotion, and sponsorship; and providing tobacco health information via mass media campaigns and graphic health warnings to the public as tobacco best buys** because they can reduce tobacco initiation, help to prevent progression from initiation to addiction, increase cessation, decrease consumption, and change social norms (2). Providing information about the dangers of using tobacco products with package warnings is a simple and cost-effective strategy to motivate quit attempts, thus helping to prevent the life-threatening effects of tobacco use (9,10).
** A best buy is an intervention that is not only highly cost-effective but also inexpensive, feasible, and culturally acceptable to implement.
Acknowledgment David Hammond, Univ of Waterloo, Ontario, Canada. References

1. World Health Organization. WHO Framework Convention on Tobacco Control. Geneva, Switzerland: World Health Organization; 2005. Available at http://www.who.int/fctc/en. Accessed May 22, 2011. 2. World Health Organization. Global status report on noncommunicable diseases, 2010. Geneva, Switzerland: World Health Organization; 2011. Available at http://www.who.int/nmh/publications/ncd_report2010/ en/index.html. Accessed May 22, 2011. 3. World Health Organization. WHO report on the global tobacco epidemic, 2009: implementing smoke-free environments. Geneva, Switzerland: World Health Organization; 2009. Available at http://www.who.int/ tobacco/mpower/2009/en/index.html. Accessed May 22, 2011. 4. World Health Organization. Conference of the Parties to the WHO Framework Convention on Tobacco Control, third session. Geneva, Switzerland: World Health Organization; 2009. Available at http://apps.who. int/gb/fctc/pdf/cop3/fctc_cop3_rec1-en.pdf. Accessed May 22, 2011. 5. US Department of Health and Human Services, Food and Drug Administration. Required warnings for cigarette packages and advertisements. Federal Register 2010;75:6952465. 6. Hammond D, Fong GT, McNeill A, Borland R, Cummings MK. Effectiveness of cigarette warning labels in informing smokers about the risks of smoking: findings from the International Tobacco Control (ITC) Four Country Survey. Tobacco Control, 2006;15(Suppl III):iii1925. 7. Hammond D. Health warning messages on tobacco products: a review. Tob Control 2011. In press. 8. Thrasher JF, Villalobos V, Szklo A, et al. Assessing the impact of cigarette package health warning labels: a cross-country comparison in Brazil, Uruguay and Mexico. Salud Publica Mex 2010;52(Suppl 2):S20615. 9. Hammond D, Fong GT, Borland R, Cummings KM, McNeill A, Driezen P. Communicating risk to smokers: the impact of health warnings on cigarette packages. Am J Prev Med 2007;32:2029. 10. Borland R, Yong H, Wilson N, et al. How reactions to cigarette packet health warnings influence quitting: findings from the ITC four-country survey. Addiction 2009;104:66975.
int/tobacco/healthwarningsdatabase/en/index.html.
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651
Human Jamestown Canyon Virus Infection Montana, 2009

Jamestown Canyon virus (JCV) is a mosquito-borne zoonotic pathogen belonging to the California serogroup of bunyaviruses. Although JCV is widely distributed throughout temperate North America, reports of human JCV infection in the United States are rare. This is the first report of human JCV infection detected in Montana, one of only 15 cases reported in the United States since 2004, when JCV became reportable. On May 26, 2009, a man aged 51 years with no travel history outside of Montana went to a local emergency department immediately following onset of fever, severe frontal headache, dizziness, left-sided numbness, and tingling. His blood pressure was elevated. Stroke was ruled out, oxygen was administered, medication was prescribed for hypertension, and the patient was sent home. One week later, the patient visited his primarycare physician complaining of continued neurologic symptoms consistent with acute febrile encephalitis and recent mosquito bites. Although West Nile virus (WNV) disease was diagnosed based on detection of WNV-immunoglobulin M (IgM) and G (IgG) antibodies, subsequent testing indicated that the WNV antibodies were from a past infection and that his illness was caused by JCV. The final diagnosis of JCV infection was based on positive JCV-specific IgM enzyme-linked immunosorbent assay (ELISA) results and a fourfold rise in paired sample JCV plaque reduction neutralization test (PRNT) titers. This finding represents a previously unrecognized risk for JCV infection in Montana; clinicians should consider JCV infection when assessing patients for suspected arboviral infections. carotid Doppler test showed no evidence of abnormal arterial blood flow. A lumbar puncture performed on June 11 showed clear, colorless cerebrospinal fluid with no leukocytes or erythrocytes, and bacterial culture showed no growth at 72 hours; no tests for virus were performed. The patient was referred to and visited a neurologist on July 6. The neurologist found no evidence of stroke, diagnosed a complex migraine, and prescribed medication for headache management. The patients symptoms gradually improved, and he reported no residual symptoms 6 months after illness onset. On visiting his primary-care physician and during interviews conducted by the local health department and Montana Department of Public Health and Human Services (DPHHS), the patient reported recent exposure to mosquitoes while working outdoors around his home, which was located in a rural area of Montana. An acute-phase serum sample collected on June 2 (1 week after symptom onset) tested positive for WNV-specific IgM and IgG by ELISA at the Montana Public Health Laboratory (MTPHL). These laboratory results, in combination with the patients symptoms and history of recent mosquito bites, supported a presumptive diagnosis of WNV disease. The acute sample was then sent to CDCs arbovirus diagnostic laboratory (CDC-ADL) in Fort Collins, Colorado, to confirm the diagnosis by PRNT. Testing at CDC-ADL was positive for WNV-specific IgM and IgG antibodies, with a neutralizing titer of 320. Testing also was positive for St. Louis encephalitis virus (SLEV)-specific IgG antibodies, but a negative SLEV-specific IgM antibody test and a neutralizing titer of 10 suggested cross-reactive flaviviral antibodies. An initial convalescent serum sample drawn on June 11 (16 days after symptom onset) also tested positive for WNV-specific IgM and IgG by ELISA at MTPHL but was not available for testing at CDC-ADL. However, another convalescent serum sample was obtained on December 1 (189 days after symptom onset) and was tested at CDC-ADL. Results indicated persistence of WNV-specific IgM and IgG antibodies and stable neutralizing titers (Table). Because the stable titers suggested a previously acquired WNV infection (>6 months before illness onset), WNV avidity testing was obtained from the Viral Zoonoses Section, National Microbiology Laboratory, Public Health Agency of Canada (NML-PHAC), in Winnipeg, Manitoba, Canada. Testing found high-avidity WNV IgG, strongly suggesting that the WNV antibodies were from a past WNV infection (1). In addition to WNV testing, CDC-ADL tested the acute specimen collected on June 2 for antibodies against other
Case Report
On May 26, 2009, a previously healthy man aged 51 years with no travel history outside of Montana went to a local emergency department immediately following onset of fever, severe acute frontal headache, dizziness, left-sided numbness, and tingling. No other symptoms were noted. Results of a physical examination were normal, except for an elevated blood pressure of 214/119 mmHg. Blood chemistries and cardiac enzyme tests were within normal limits, except for an elevated glucose of 130 mg/dL (normal: 70110 mg/dL). Results of an electrocardiogram, magnetic resonance imaging, and computed tomography scan of the brain were normal. Oxygen was administered to the patient, telmisartan was prescribed for hypertension, and he was sent home. A week later, on June 2, the patient visited his primary-care physician complaining of fever, persistent headache, and new onset of muscle pain and weakness. The physician considered the patients symptoms to be consistent with a neurologic illness and evaluated the patient further for a possible stroke or arboviral infection. A
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arboviruses. Results were equivocal for IgM and IgG antibodies against La Crosse virus (LACV) by ELISA. Neutralizing titers of 40 against LACV and 80 against JCV suggested a possible recent infection with a California serogroup virus (Table). Follow-up testing on the day 189 sample was negative for LACV IgM antibodies by ELISA, but showed a twofold increase in LACV neutralizing titers and a fourfold increase in JCV titers. These results suggested that the patients infection most likely was JCV. To confirm the diagnosis, samples were sent to NML-PHAC for testing with their recently developed IgM ELISA assays incorporating JCV antigen. Patient sera obtained June 11 and December 1 were positive for JCVspecific IgM antibodies (Table). The presence of JCV-specific IgM and the fourfold diagnostic rise in JCV-neutralizing antibody titers confirmed the diagnosis of JCV infection. This finding indicated that JCV is present in Montana and that a risk for human infection exists.
Reported by
TABLE. Diagnostic test results for three serum samples used to confirm a case of human Jamestown Canyon virus infection Montana, 2009.
Acute phase serum 6/2/2009 (7 days post onset) Positive Positive 320 ND Negative Positive 10 Equivocal Equivocal 40 ND 80 Convalescent phase serum 6/11/2009 (16 days post onset) Positive Positive ND High ND ND ND ND ND ND Positive ND 12/1/2009 (189 days post onset) Positive Positive 320 High Negative Positive 10 Negative Indeterminate 80 Positive 320
Test* WNV IgM ELISA IgG ELISA PRNT IgG avidity SLEV IgM MIA IgG ELISA PRNT LACV IgM ELISA IgG ELISA PRNT JCV IgM ELISA PRNT
Jennifer Lowell, PhD, Communicable Disease Epidemiology Program, Denise P. Higgins, Laboratory Svcs Bur, Montana Dept of Public Health and Human Svcs. Michael Drebot, PhD, Kai Makowski, Viral Zoonoses, National Microbiology Laboratory, Public Health Agency of Canada. J. Erin Staples, MD, Div of Vector-Borne Diseases, National Center for Emerging and Zoonotic Infectious Diseases, CDC. Corresponding contributor: Jennifer Lowell, [email protected], 406-444-0273.
Editorial Note
Abbreviations: ELISA = enzyme-linked immunosorbent assay; IgG = immunoglobulin G; IgM = immunoglobulin M; JCV = Jamestown Canyon virus; LACV = LaCrosse virus; MIA = microsphere-based immunoassay; ND = not done; PRNT = plaque reduction neutralization test; SLEV = St. Louis encephalitis virus; WNV = West Nile virus. * Results of testing of the acute phase serum for Western equine encephalitis virus IgM and IgG were negative.
Arthropod-borne viruses (i.e., arboviruses) are transmitted to humans primarily through bites from infected mosquitoes or ticks. Most arboviruses of public health importance belong to one of three virus genera: Flavivirus, Alphavirus, and Bunyavirus. Human cases caused by the following domestic arboviruses are nationally reportable to CDC: West Nile, St. Louis encephalitis, Powassan, eastern equine encephalitis, western equine encephalitis, and California serogroup viruses (i.e., La Crosse, Jamestown Canyon, California encephalitis, Keystone, snowshoe hare, and trivittatus). JCV is distributed throughout temperate North America, where it circulates primarily between deer and various mosquito species (24). Despite its wide geographic range, only 15 human JCV infections (mean: <3 per year) have been reported in the United States since 2004, when JCV became a reportable condition, and those have originated predominantly from the midwestern and northeastern states. JCV infections initially were described in the early 1970s to cause a mild febrile illness in humans (5). Serosurveys in Connecticut and New York have shown evidence of JCV infection in up to 12% of the population (3,6). Despite descriptions of mild illness caused
by JCV, at least 11 subsequent cases with moderate-to-severe meningoencephalitis have been described; 10 in the early 1980s and one in 2001 (3,6). A retrospective study of patients with central nervous system manifestations and serologic findings for California serogroup viruses during 19711981 confirmed that 41 of 53 patients (77%) had antibodies to JCV, indicating that JCV originally was underdiagnosed in these patients (7). In comparison with clinical illness caused by LACV, JCV has been described as affecting adults and is more likely to cause meningitis (6,7). Furthermore, while seasonal distribution of LACV infections in humans generally occurs in August, JCV infections can occur earlier, in May and June, and continue through the end of summer, likely because the seasonal distribution of mosquito vectors differs for each virus (8). Although the Montana patient with JCV infection was suspected to have an acute WNV infection, human cases of WNV infection in Montana typically are not reported until late July, with the majority of cases occurring in late August and early September. The onset of illness for this patient was during late spring, which is consistent with approximately 40% of recognized human JCV infections. The differences in the seasonal distribution of these diseases likely are related to the mosquito species that transmit the viruses. Mosquitoes belonging to snow-melt Aedes species are common vectors of JCV, emerge early in spring, and are distributed throughout Montana (3,9).
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What is already known on this topic? Jamestown Canyon virus (JCV) circulates widely in North America, primarily between deer and various mosquito species. Reports of human JCV infections in the United States have been rare and are confined primarily to the midwestern and northeastern states. JCVs nonspecific clinical presentation and the limited availability of sensitive tests for JCV might contribute to many human infections going undetected. What is added by this report? This first reported human case of JCV in Montana suggests that the geographic distribution of human JCV infection is wider than previously recognized, and that increased JCV surveillance is needed to determine whether mosquito-borne arboviruses other than West Nile virus (WNV) pose a substantial risk to humans in the region. What are the implications for public health practice? Clinicians should consider JCV infection in differential diagnoses when an arboviral infection is suspected to be causing a febrile neurologic illness, but WNV testing is inconclusive. Improved and timely arboviral disease diagnostics will aid clinicians in making patient-care and management decisions, help public health professionals perform accurate epidemiologic investigations and target preventive measures, and provide a better understanding of arboviral disease distribution in the United States.
differentiate between arboviral infections, especially within the California serogroup. Initial diagnostic tests in this case included testing for several arboviral diseases. However, the lack of a readily available diagnostic test specific to JCV delayed the diagnosis and led the clinician to consider noninfectious causes of illness. For the patient, the delayed diagnosis resulted in unnecessary medical procedures, including a carotid Doppler ultrasound, plus several hours of travel, and lost work to seek additional medical evaluation from a specialist. Clinically, patient care might not have differed significantly; however, supportive care, including headache management and patient prognosis, would have been established more quickly. Treatment for JCV infection typically includes supportive care and management of complications, such as relieving increased intracranial pressure. This case underscores the importance of Montana clinicians considering JCV infection in patients with a febrile neurologic illness when an arboviral infection is suspected and WNV testing is inconclusive. Improved and timely diagnosis will aid clinicians in making patient-care and management decisions, help public health professionals perform accurate epidemiologic investigations and implement preventive measures, and provide a better understanding of California serogroup virus distribution.
Acknowledgments Local clinicians; health department personnel; Elton Mosher, Bonnie Barnard, Communicable Disease Epidemiology Program, Montana Dept of Public Health and Human Svcs; Montana Public Health Laboratory. Viral Zoonoses Section, National Microbiology Laboratory, Public Health Agency of Canada. Laboratory personnel, Arboviral Diseases Br, Div of Vector-Borne Diseases, CDC. References
1. Levett PN, Sonnenberg K, Sidaway F, et al. Use of immunoglobulin G avidity assays for differentiation of primary from previous infections with West Nile virus. J Clin Microbiol 2005;43:58735. 2. Andreadis TG, Anderson JF, Armstrong PM, Main AJ. Isolations of Jamestown Canyon virus (Bunyaviridae: Orthobunyavirus) from fieldcollected mosquitoes (Diptera: Culicidae) in Connecticut, USA: a ten-year analysis, 19972006. Vector Borne Zoonotic Dis 2008;8:17588. 3. Armstrong PM, Andreadis TG. Genetic relationships of Jamestown Canyon virus strains infecting mosquitoes collected in Connecticut. Am J Trop Med Hyg 2007;77:115762. 4. Wood DM, Dang PT, Ellis RA. The insects and arachnids of Canada, part 6. Hull, QC, Canada: Canadian Government Publishing Centre; 1979. Agriculture Canada publication no. 1696. 5. Thompson WH, Gundersen CB. La Crosse encephalitis: occurrence of disease and control in a suburban area. In: Calisher CH and Thompson WH, eds. California serogroup viruses. New York, NY: Alan R Liss; 1983:22536. 6. Deibel R, Grimstad PR, Mahdy MS, Artsob H, Calisher CH. Jamestown Canyon virus: the etiologic agent of an emerging human disease? In: Calisher CH and Thompson WH, eds. California serogroup viruses. New York, NY: Alan R Liss; 1983:31325.
Vertical transmission of JCV in mosquitoes, overwintering of the virus in mosquito eggs, and larval maturation in temporary ponds produced by melting snow increase the likelihood of human JCV transmission in the spring (10). Detection of JCV previously has relied on cross-reactive antibodies in the LACV-specific ELISA (6,7). Testing of the acute serum sample for this case yielded equivocal anti-LACV IgM results, with a slightly higher neutralizing antibody titer against JCV than LACV. The titers against JCV and LACV were not different enough to determine the etiology. Although the convalescent sample confirmed a fourfold rise in JCV-neutralizing antibody titers, testing of paired acute and convalescent samples using a JCV antigenspecific ELISA was necessary to confirm JCV IgM positive results. The discordant anti-LACV and JCV IgM results suggested that cross-reactivity between LACV and JCV antibodies in the LACV-specific ELISA was incomplete, and that sole reliance on the LACV-specific ELISA to detect JCV can lead to missed JCV infections. In response to this, CDC has developed a JCV-specific IgM ELISA. Currently, testing is available only at CDC on request. As more information about the distribution and frequency of JCV infections and disease is known, testing might be expanded to include regional or state laboratories. The availability of this test will enable clinicians and public health officials to quickly
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7. Srihongse S, Grayson MA, Deibel R. California serogroup viruses in New York State: the role of subtypes in human infections. Am J Trop Med Hyg 1984;33:121827. 8. Grimstad PR. California group virus disease. In: Monath TP, ed. The arboviruses: epidemiology and ecology. Vol. 2. Boca Raton, FL: CRC Press; 1988:99136.
9. West DF, Black WC. Breeding structure of three snow pool Aedes mosquito species in northern Colorado. Heredity 1998;81:37180. 10. Murdock CC, Olival KJ, Perkins SL. Molecular identification of host feeding patterns of snow-melt mosquitoes (Diptera: Culicidae): potential implications for the transmission ecology of Jamestown Canyon virus. J Med Entomol 2010;47:2269.
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Contribution of Occupational Physical Activity Toward Meeting Recommended Physical Activity Guidelines United States, 2007
Regular physical activity helps maintain healthy weight and reduces the likelihood of developing chronic diseases. The 2008 Physical Activity Guidelines for Americans (1) are derived from the most recent scientific review of physical activity health benefits and do not differentiate among physical activity for leisure, transportation, work, or other purposes. To examine the potential influence of occupational physical activity on meeting minimum weekly aerobic physical activity guidelines, the Washington State Department of Health (WADOH) analyzed demographic patterns in physical activity levels with and without consideration of occupational physical activity using 2007 Behavioral Risk Factor Surveillance System (BRFSS) data. This report describes the results of that analysis, which indicated that, approximately two thirds (64.3%) of U.S. adults met minimum physical activity guidelines through nonoccupational physical activity. When occupational physical activity (defined as reported work activity of mostly walking or heavy labor) was considered, an additional 6.5% of adults likely met the guidelines. The increase was greatest for Hispanic men (14.4%) and men with less than a high school education (15.9%). Public health agencies conducting surveillance of population physical activity levels also should consider including occupational physical activity, which will help to identify demographic groups for targeted programs that increase physical activity. BRFSS is a state-based, random-digitdialed telephone survey of the noninstitutionalized, U.S. civilian adult population. The Council of American Survey Research Organizations (CASRO) median response rate for the 2007 BRFSS survey was 50.6%. Among 430,912 respondents, complete occupational and nonoccupational physical activity data were available for 386,397 respondents from 50 states and the District of Columbia. BRFSS collects data on frequency and duration of nonoccupational physical activity, which includes leisure, transportation (e.g., walking), and maintaining a home. WADOH computed the products of activity frequency (days per week) and duration (minutes per day) for moderate-intensity and vigorousintensity activities. Consistent with the guidelines, WADOH classified respondents as having met guidelines if they reported weekly nonoccupational physical activity of 150 minutes of moderate-intensity activity (e.g., brisk walking or gardening), 75 minutes of vigorous-intensity activity (e.g., running or heavy yard work), or a combination of moderate-intensity and vigorous-intensity activity (with vigorous-intensity activity minutes multiplied by two) totaling 150 minutes. BRFSS does not collect data on occupational physical activity frequency and duration; instead, respondents who indicate employment are asked whether their activity at work is mostly standing or sitting, mostly walking, or mostly heavy labor or physically demanding work.* For this analysis, respondents who did not meet guidelines through nonoccupational physical activity were coded as meeting the guidelines if they reported mostly walking or mostly heavy labor or physically demanding work (Figure). WADOH computed age-adjusted prevalence of meeting physical activity guidelines by selected demographic characteristics and calculated age-adjusted prevalence ratios (PRs) for meeting guidelines by fitting two sets of Poisson regressions in which the outcome measures were meeting recommendations (in the first set through nonoccupational activity and in the second set through either nonoccupational or occupational activity). Each Poisson regression contained age and, except for the analysis in which age was the only predictor, an additional predictor variable: race/ethnicity, annual household income, or education. All analyses were stratified by sex and conducted using statistical software that accounted for the complex sampling design.
* Regarding occupational physical activity, respondents were asked the following: When you are at work, which of the following best describes what you do? Would you say 1) mostly sitting or standing; 2) mostly walking; or 3) mostly heavy labor or physically demanding work? Responses of dont know/not sure and a respondents refusal to respond (refused) also were included. Additional information available at http://www.cdc.gov/brfss/questionnaires/pdfques/2007brfss.pdf.
FIGURE. Classification for meeting 2008 physical activity guidelines*

Nonoccupational physical activity
150 min/week moderate 75 min/week vigorous 150 min/week equivalent combination Yes Meets guidelines
No
Occupational physical activity
Mostly walking Mostly heavy labor Yes
* For respondents who meet the 2008 Physical Activity Guidelines for Americans recommendation for aerobic physical activity through nonoccupational physical activity alone or through either occupational or nonoccupational physical activity.
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Approximately two thirds (68.5%) of men met guidelines through nonoccupational physical activity. When occupational physical activity levels also were considered, the proportion meeting guidelines increased from 68.5% to 76.3% (Table 1); 14.8% (95% confidence interval [CI] = 14.4%15.3%) of men reported mostly walking, and 14.3% (CI = 13.9%14.7%) reported mostly heavy labor at work. For women, the proportion increased from 60.4% to 65.7% (Table 2); 12.7% (CI = 12.4%13.0%) of women reported mostly walking, and 3.4% (CI = 3.3%3.6%) of women reported mostly heavy labor at work. Hispanic men and men with less than a high school education exhibited the greatest absolute gains in the proportion meeting guidelines when occupational physical activity was included (from 60.6% to 75.0% and from 55.7% to 71.6%, respectively). Among Hispanic men, 24.3% (CI = 22.6%26.2%) reported mostly walking, and 15.0%
(CI = 13.5%16.5%) reported mostly heavy labor at work; among men with less than a high school education 21.2% (CI = 19.4%23.2%) reported mostly walking, and 18.4% (CI = 16.8% 20.0%) reported mostly heavy labor. Hispanic men had a lower prevalence of meeting guidelines through nonoccupational physical activity compared with non-Hispanic white men (PR = 0.85) (Table 1). However, when occupational physical activity was included, the PR was attenuated (i.e., it approached 1.0; PR = 0.97). Similarly, men with less than a high school education had lower prevalence of meeting physical activity guidelines through nonoccupational physical activity compared with men with a college degree (PR = 0.75). When occupational physical activity was included, the PR was attenuated (PR = 0.93). Similar patterns in attenuation of PRs were noted when comparing men with reported annual household incomes of $35,000 with those
TABLE 1. Prevalence of men meeting 2008 physical activity guidelines, by occupational/nonoccupational activity* and demographic characteristics Behavioral Risk Factor Surveillance System, United States, 2007
Nonoccupational Characteristic Overall Age group (yrs) 1824 2534 3544 4554 5564 65 Race/Ethnicity American Indian/Alaska Native, non-Hispanic Asian, non-Hispanic Black, non-Hispanic Hispanic Native Hawaiian/Other Pacific Islander, non-Hispanic White, non-Hispanic Annual household income <$25,000 $25,000$34,999 $35,000$49,999 $50,000$74,999 $75,000 Education <High school High school graduate Some college College graduate Sample size 144,930 144,930 6,070 14,287 23,322 30,973 31,489 38,789 142,371 2,354 2,455 8,801 8,572 571 119,618 131,907 28,790 15,992 22,137 24,335 40,653 144,727 13,893 42,208 35,391 53,235 % 68.5 78.3 73.6 70.3 68.2 63.5 57.5 72.3 61.4 63.0 60.6 70.6 71.2 57.3 63.6 68.5 73.4 76.1 55.7 65.9 68.7 73.5 95% CI 68.069.1 76.180.4 72.175.1 69.171.4 67.169.2 62.464.6 56.558.5 68.675.7 57.265.4 61.164.9 58.362.8 60.878.8 70.771.7 55.858.7 61.865.4 67.169.9 72.274.6 75.177.0 53.757.7 64.966.8 67.669.8 72.574.6 PR** 1.36 1.28 1.22 1.19 1.10 1.00 1.02 0.86 0.89 0.85 0.95 1.00 0.75 0.84 0.89 0.96 1.00 0.75 0.88 0.92 1.00 95% CI 1.321.41 1.251.32 1.191.25 1.161.21 1.081.13 Referent 0.971.17 0.800.92 0.870.92 0.820.88 0.771.17 Referent 0.730.78 0.810.86 0.870.92 0.940.98 Referent 0.730.78 0.870.90 0.900.94 Referent Occupational or nonoccupational % 95% CI PR 1.46 1.41 1.35 1.30 1.18 1.00 1.01 0.86 0.91 0.97 1.03 1.00 0.85 0.94 0.98 1.00 1.00 0.93 0.98 0.98 1.00 95% CI 1.42 1.50 1.381.45 1.331.38 1.281.33 1.161.21 Referent 0.971.05 0.810.91 0.890.93 0.951.00 0.951.11 Referent 0.830.87 0.920.96 0.971.00 0.991.02 Referent 0.900.95 0.971.00 0.971.00 Referent % increase 7.8 8.1 10.2 9.9 9.0 6.6 1.8 5.7 5.4 7.2 14.4 9.6 6.5 10.6 12.1 10.4 7.3 4.2 15.9 10.5 7.7 3.5 76.3 75.976.8 86.4 83.8 80.2 77.2 70.1 59.3 78.0 66.8 70.2 75.0 80.2 77.7 67.9 75.7 78.9 80.7 80.3 71.6 76.4 76.4 77.0 84.588.1 82.585.0 79.281.1 76.378.1 69.171.1 58.360.2 74.681.0 62.770.7 68.571.9 72.977.0 72.486.2 77.378.2 66.669.1 74.277.0 77.780.0 79.681.7 79.581.1 69.973.2 75.677.2 75.477.3 76.078.0
Abbreviations: CI = confidence interval; PR = prevalence ratio. * Respondents who meet the 2008 Physical Activity Guidelines for Americans recommendation for aerobic physical activity through nonoccupational physical activity alone or through either occupational or nonoccupational physical activity. Prevalence estimates, except those by age group, were age-adjusted to the 2000 U.S. standard population by using the following six age groups: 1824, 2534, 3544, 4554, 5564, and 65 years. Weekly activities outside of work, including leisure, household chores, and transportation, totaling 150 minutes of moderate-intensity physical activity or 75 minutes of vigorous-intensity physical activity or an equivalent combination of moderate and vigorous physical activity. Includes 1) occupational physical activity of mostly walking or heavy labor among respondents who did not meet guidelines through nonoccupational physical activity or 2) weekly activities outside of work, including leisure, household chores, and transportation, totaling 150 minutes of moderate-intensity physical activity or 75 minutes of vigorous-intensity physical activity or an equivalent combination of moderate and vigorous physical activity. ** Prevalence ratio estimated from Poisson regression and adjusted for age, except where age was the only predictor, using the following six age groups: 1824, 2534, 3544, 4554, 5564, and 65 years.
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with reported annual household incomes of $75,000. Among women, inclusion of occupational physical activity minimally changed the age-adjusted PRs for meeting physical activity guidelines by education, race/ethnicity, or annual household income categories (Table 2).
Reported by
Lillian Bensley, PhD, Juliet VanEenwyk, PhD, Office of Epidemiology, Washington State Dept of Health. Myduc Ta, PhD, EIS Officer, CDC. Corresponding contributor: Lillian Bensley, Washington State Dept of Health, 360-236-4248, [email protected].
Editorial Note
As expected, findings from this report provide evidence for a modest contribution of occupational physical activity toward successfully meeting minimum physical activity guidelines
among U.S. adults, with a larger impact for some subpopulations than others. National Health Interview Survey (NHIS) data from 1990 and earlier revealed that approximately half of respondents classified as sedentary in leisure time reported 1 hour of strenuous occupational activity daily; that report indicated that assessing only leisure activity might underestimate physical activity (2). Recent analyses from NHIS are not available because questions regarding the amount of jobrelated physical activity have not been asked since 1990. The findings presented in this report are consistent with reports of Hispanic persons expending more energy at work than persons of other racial/ethnic groups (3). In addition, education and income are strong predictors of leisure-time physical activity, and they remain important predictors of total activity, even though including occupational activity attenuates the association between education and physical activity for men.
TABLE 2. Prevalence of women meeting 2008 physical activity guidelines by occupational/nonoccupational activity* and demographic characteristics Behavioral Risk Factor Surveillance System, United States, 2007
Nonoccupational Characteristic Overall Age group (yrs) 1824 2534 3544 4554 5564 65 Race/Ethnicity American Indian/Alaska Native, non-Hispanic Asian, non-Hispanic Black, non-Hispanic Hispanic Native Hawaiian/Other Pacific Islander, non-Hispanic White, non-Hispanic Annual household income <$25,000 $25,000$34,999 $35,000$49,999 $50,000$74,999 $75,000 Education <High school High school graduate Some college College graduate Sample size 241,467 241,467 8,137 26,403 38,767 49,712 48,782 69,666 237,994 3,536 3,621 19,943 15,801 869 194,224 207,560 63,905 26,870 33,503 34,278 49,004 241,134 23,765 74,256 66,858 76,255 % 95% CI PR** 1.47 1.40 1.38 1.34 1.22 1.00 0.94 0.77 0.80 0.88 1.03 1.00 0.71 0.81 0.89 0.91 1.00 0.72 0.84 0.92 1.00 95% CI 1.431.52 1.371.43 1.351.41 1.321.37 1.191.25 Referent 0.881.01 0.720.83 0.780.82 0.850.91 0.911.16 Referent 0.700.73 0.790.83 0.870.90 0.900.93 Referent 0.690.74 0.830.86 0.900.93 Referent 60.4 60.060.9 68.1 64.9 63.8 63.8 56.5 46.3 59.6 49.5 50.4 56.0 69.0 63.3 51.0 57.2 62.7 64.9 70.8 48.8 56.8 61.5 66.9 66.369.9 63.866.0 62.964.7 62.964.7 55.657.3 45.647.0 55.963.3 45.853.3 49.151.7 54.357.7 61.775.6 62.963.8 49.952.0 55.958.6 61.663.8 63.866.0 69.871.7 47.050.5 56.057.6 60.762.2 66.167.7 Occupational or nonoccupational % 95% CI PR 1.57 1.50 1.49 1.45 1.29 1.00 0.96 0.81 0.85 0.93 1.03 1.00 0.78 0.88 0.93 0.94 1.00 95% CI 1.521.61 1.471.54 1.461.52 1.421.47 1.271.32 Referent 0.911.02 0.760.87 0.830.87 0.900.95 0.931.15 Referent 0.760.79 0.860.90 0.910.95 0.920.96 Referent % increase 5.3 6.1 6.3 6.6 4.7 4.7 1.1 5.4 5.8 7.2 7.2 5.0 4.6 6.8 7.3 5.8 4.7 3.5 7.1 6.5 5.2 3.8 65.7 65.366.1 74.2 71.2 70.4 68.5 61.2 47.4 65.0 55.3 57.6 63.2 74.0 67.9 57.8 64.5 68.5 69.6 74.3 55.9 63.3 66.7 70.7 72.475.8 70.172.2 69.671.3 67.769.3 60.362.1 46.648.1 61.668.2 51.559.0 56.358.8 61.664.9 67.180.0 67.468.3 56.858.8 63.365.8 67.569.6 68.570.6 73.475.2 54.357.6 62.564.1 66.067.5 69.971.5
0.77 0.750.80 0.89 0.880.90 0.94 0.930.96 1.00 Referent
Abbreviations: CI = confidence interval; PR = prevalence ratio. * Respondents who meet the 2008 Physical Activity Guidelines for Americans recommendation for aerobic physical activity through nonoccupational physical activity alone or through either occupational or nonoccupational physical activity. Prevalence estimates, except those by age group, were age-adjusted to the 2000 U.S. standard population by using the following six age groups: 1824, 2534, 3544, 4554, 5564, and 65 years. Weekly activities outside of work, including leisure, household chores, and transportation, totaling 150 minutes of moderate-intensity physical activity or 75 minutes of vigorous-intensity physical activity or an equivalent combination of moderate and vigorous physical activity. Includes 1) occupational physical activity of mostly walking or heavy labor among respondents who did not meet guidelines through nonoccupational physical activity or 2) weekly activities outside of work, including leisure, household chores, and transportation, totaling 150 minutes of moderate-intensity physical activity or 75 minutes of vigorous-intensity physical activity or an equivalent combination of moderate and vigorous physical activity. ** Prevalence ratio estimated from Poisson regression and adjusted for age, except where age was the only predictor, using the following six age groups: 1824, 2534, 3544, 4554, 5564, and 65 years.
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What is already known on this topic? Prevalence estimates of physical activity predominately focus on nonoccupational physical activity; however, physical activity at work also can contribute to levels of physical activity sufficient to meet physical activity recommendations. What is added by this report? This report is the first to provide estimates based on national surveillance data of the potential contribution of occupational physical activity toward meeting physical activity guidelines described in the 2008 Physical Activity Guidelines for Americans; when occupational physical activity was considered, an estimated additional 6.5% of adults overall very likely met the guidelines, and, for some groups, an estimated additional 14%16% met the guidelines. What are the implications for public health practice? Pending evaluation of the usefulness of collecting information on occupational physical activity frequency and duration, consideration of occupational physical activity in the monitoring of population physical activity levels can help to identify demographic groups for targeted programs to increase physical activity.
Although the BRFSS occupational physical activity question has been reported as valid and reliable for classifying physical activities at work (46), the question does not quantify the intensity or duration of continuous occupational physical activity. For this report, the analysis assumed that mostly walking included moderate-intensity activity in 10-minute intervals for 150 minutes per week and mostly heavy labor included vigorous-intensity activity in 10-minute intervals for 75 minutes per week. If the actual time spent in activity of sufficient intensity is less than this, then the effect of occupational physical activity on meeting the minimum aerobic activity guidelines will be overestimated. Relative to a standard work week of 40 hours, these assumptions seem reasonable. Also, a variety of occupational walking activities are in the moderate range, and a variety of heavy labor activities are in the vigorous range, based on comparisons of energy need while performing a task to energy need at rest (5,7). However, a more detailed assessment of occupational physical activities would be needed to confirm these assumptions. The findings in this report are subject to at least three limitations. First, because the duration of mostly walking or heavy physical labor is unavailable, it was not possible to assess whether respondents who did not meet guidelines through nonoccupational activity alone might meet guidelines through the combination of occupational and nonoccupational physical activity. As such, the proportions of persons meeting guidelines might have been underestimated. Second, BRFSS excludes persons in households without landline telephones. Finally, the 2007 BRFSS survey had a low CASRO response rate. These
latter two factors can lead to bias, especially if physical activity patterns differ between those with and without landline telephones and between respondents and nonrespondents. The directions of these potential biases are unknown. As one of the 10 leading health indicators in the United States (8), physical activity is monitored at state and national levels to provide information for public health program planning, implementation, and evaluation. The state of Washington has used combined occupational and nonoccupational physical activity data as part of its assessment to target communities for policy and environmental changes. Debate about the health benefits of physical activity at work is ongoing, but the current guidelines do not distinguish between occupational and nonoccupational physical activity. Thus, public health surveillance that includes both occupational and nonoccupational physical activity more accurately describes whether persons meet guidelines than surveillance that includes only nonoccupational physical activity. Because demographic groups vary in amounts of physical activity at work (9), surveillance that includes both occupational and nonoccupational physical activity can be used to target groups that could derive health benefits by being more physically active.
Acknowledgments State BRFSS coordinators. Eric M. Ossiander, PhD, Office of Epidemiology, Washington State Dept of Health. Fleetwood Loustalot, PhD, Div for Heart Disease and Stroke Prevention, National Center for Chronic Disease Prevention and Health Promotion, Sheryl B. Lyss, MD, Betsy L. Cadwell, MSPH, Div of Applied Sciences, Scientific Education and Professional Development Program Office, CDC. References
1. US Department of Health and Human Services. 2008 physical activity guidelines for Americans. Hyattsville, MD: US Department of Health and Human Services; 2008. Available at http://www.health.gov/ paguidelines/guidelines/default.aspx. Accessed July 6, 2010. 2. CDC. Prevalence of leisure-time and occupational physical activity among employed adults in the United States, 1990. MMWR 2000;49:4204. 3. Ham SA, Yore MM, Kruger J, Heath GW, Moeti R. Physical activity patterns among Latinos in the United States: putting the pieces together. Prev Chronic Dis 2007;4:113. 4. Yore MM, Bowles Hr, Ainsworth BE, et al. Single versus multiple item questions on occupational physical activity. J Phys Act Health 2006;1:10211. 5. Reis JP, Dubose KD, Ainsworth BE, et al. Reliability and validity of the occupational physical activity questionnaire. Med Sci Sports Exerc 2005;37:207583. 6. Evenson KR, McGinn AP. Testretest reliability of adult surveillance measures for physical activity and inactivity. Am J Prev Med 2005;28:4708. 7. Pate RR, Pratt M, Blair SN, et al. Physical activity and public health: a recommendation from the Centers for Disease Control and Prevention and the American College of Sports Medicine. JAMA 1995;273:4027.
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8. US Department of Health and Human Services. Healthy people 2010 (conference ed, in 2 vols). Washington, DC: US Department of Health and Human Services; 2000. Available at http://www.health.gov/healthypeople.
9. Marquez DX, Neighbors CJ, Bustamante EE. Leisure time and occupational physical activity among racial or ethnic minorities. Med Sci Sports Exerc 2010;42:108693.
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Recommendations for Use of a Booster Dose of Inactivated Vero Cell Culture-Derived Japanese Encephalitis Vaccine Advisory Committee on Immunization Practices, 2011
Japanese encephalitis (JE) virus, a mosquito-borne flavivirus, is an important cause of encephalitis in Asia with a case fatality rate of 20%30% and neurologic or psychiatric sequelae in 30%50% of survivors (1). Travelers to JE-endemic countries and laboratory personnel who work with infectious JE virus are at potential risk for JE virus infection. In 2010, CDCs Advisory Committee on Immunization Practices (ACIP) updated recommendations for prevention of JE. The updated recommendations included information on use of a new inactivated, Vero cell culturederived JE vaccine (JE-VC [manufactured as Ixiaro]) that was licensed in the United States in 2009. Data on the need for and timing of booster doses with JE-VC were not available when the vaccine was licensed. This report summarizes new data on the persistence of neutralizing antibodies following primary vaccination with JE-VC and the safety and immunogenicity of a booster dose of JE-VC. The report also provides updated guidance to health-care personnel regarding use of a booster dose of JE-VC for U.S. travelers and laboratory personnel. ACIP recommends that if the primary series of JE-VC was administered >1 year previously, a booster dose may be given before potential JE virus exposure. Additional JE-VC study data have become available since the vaccines licensure. The ACIP JE Vaccines Workgroup reviewed JE-VC clinical trial data on the persistence of neutralizing antibodies following primary vaccination with JE-VC and the safety and immunogenicity of a booster dose of JE-VC. These were primarily from published, peer-reviewed studies; however, unpublished data also were considered. FDA approved an update to the prescribing information for JE-VC in September 2010. No previous guidelines have been given on booster doses with JE-VC. At the February 2011 ACIP meeting, the workgroup presented data supporting use of a booster dose and proposed recommendations for a booster dose. ACIP approved the booster dose recommendations at the meeting.
Persistence of protective neutralizing antibodies after primary vaccination with JE-VC

Three clinical trials have provided data on persistence of protective neutralizing antibodies after a primary 2-dose series of JE-VC. In JE vaccine clinical trials, JE virus neutralizing antibody levels measured by plaque reduction neutralization test (PRNT) can be used as a surrogate for protection. A 50% PRNT (PRNT50) titer of 10 is accepted as an immunologic correlate of protection from JE in humans (3). In a study performed in central Europe (Austria, Germany, and Romania) to evaluate persistence of neutralizing antibodies among subjects who received 2 doses of JE-VC, 95% (172 of 181), 83% (151 of 181), 82% (148 of 181) and 85% (129 of 152) had protective antibodies at 6 months, 12 months, 24 months, and 36 months after receiving the first dose, respectively (Table 1) (46). A study that used similar methods but was performed in western and northern Europe (Germany and Northern Ireland) found that among adults receiving 2 doses of JE-VC, seroprotection rates were 83% (96 of 116) at 6 months, 58% (67 of 116) at 12 months, and 48% (56 of 116) at 24 months after their first vaccination (Table 1) (7). The manufacturer suggested that the different seroprotection rates in the two populations may have resulted from differences in prior vaccination against tick-borne encephalitis (TBE) virus, a related flavivirus. An estimated 75% of subjects in the first study might have received prior TBE vaccine compared with none of the subjects in the second study. A higher JE virus neutralizing antibody response after the first dose of JE-VC previously had been found in subjects with preexisting TBE
Background
For most travelers to Asia, the risk for JE is very low but varies based on destination, duration, season, and activities (2). ACIP recommends JE vaccine for travelers who plan to spend a month or longer in JE-endemic areas during the JE virus transmission season. JE vaccine should be considered for short-term travelers (<1 month) if they plan to travel outside of an urban area and have an itinerary or activities that will increase the risk of JE virus exposure. JE vaccine also is recommended for laboratory personnel with a potential for exposure to infectious JE virus (1). In 2009, the Food and Drug Administration (FDA) licensed JE-VC for use in persons aged 17 years. JE-VC is manufactured by Intercell Biomedical (Livingston, United Kingdom) and is distributed in the United States by Novartis Vaccines (Cambridge, Massachusetts). JE-VC is administered in a 2-dose primary series at 0 and 28 days. Another JE vaccine, an inactivated mouse brainderived vaccine (JE-VAX [JE-MB]), has been licensed in the U.S since 1992. However, JE-MB is no longer being produced and remaining doses expire in May 2011.
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antibodies compared with those without TBE antibodies (8). In a third clinical trial, conducted in Austria and Germany, at 15 months after the first dose of a 2-dose JE-VC immunization series, 69% (137 of 198) of subjects had a protective neutralizing antibody titer (Table 1) (9).
Safety and immunogenicity of a booster dose of JE-VC

Two clinical trials have provided data on the response to a booster dose of JE-VC. In a study conducted in Austria and Germany, 198 adults aged 18 years who had received a 2-dose primary series of JE-VC were administered a booster dose 15 months after the first dose (9). The percentage of subjects with a protective neutralizing antibody titer increased from 69% (137 of 198) on Day 0 before the booster dose to 100% (198 of 198) at Day 28 after the booster dose. Protective titers were found in 98% (194 of 197) at 6 months and 98% (191 of 194) at 12 months after the booster dose (Table 2). The geometric mean titer (GMT) before the booster was 23 and increased 40-fold to 900 at Day 28 after the booster dose. GMTs were 487 and 361 at 6 and 12 months after the booster, respectively (Table 2). During the 7 days following the booster dose, local adverse events were reported in subject diaries by 31% (60 of 195) of subjects. The most frequent local reactions were
tenderness in 19% (37 of 193) and pain in 13% (25 of 195) (Table 3). Systemic adverse events were reported by 23% (44 of 190) of subjects within 7 days of the booster dose. The most commonly reported systemic reactions were headache in 11% (21 of 194) and fatigue in 10% (18 of 188) (6). No serious adverse events were reported during the 28 days following the booster dose. In a second study, a booster dose administered to 40 subjects who had received primary immunization but no longer had protective neutralizing antibody titers resulted in protective titers in all subjects when the booster was administered at 11 months (n = 16) or 23 months (n = 24) after the first dose (7). GMTs at 1 month after the booster increased to 676 and to 2,496 in the groups administered the dose at 11 months and 23 months after the first dose, respectively. Among the 16 subjects who received the booster dose at 11 months, all still had seroprotective titers 13 months later.
Guidelines for use of a booster dose of JE-VC

ACIP recommends that if the primary series of JE-VC was administered >1 year previously, a booster dose may be given before potential JE virus exposure. ACIP recommendations should be consulted for information on prevention of JE and settings in which JE vaccine is recommended, can be
TABLE 1. Number and percentage of subjects with a protective Japanese encephalitis (JE) virus neutralizing antibody titer (10) and geometric mean titers (GMT) at month 6, 12, 15, 24, and 36 after dose 1 of a 2-dose primary series of inactivated Vero cell culturederived JE vaccine (JE-VC [manufactured as Ixiaro])
Months after the first dose of a 2-dose primary series of JE-VC 6 mos Study site Austria, Germany, Romania* [N = 181] Germany, Northern Ireland** [N = 116] Austria, Germany [N = 198] Austria, Germany, Romania* [N = 181] Germany, Northern Ireland** [N = 116] Austria, Germany [N = 198] No. 172 96 GMT 84 47 (%) (95) (83) (95% CI) (7198) (3759) No. 151 67 GMT 41 18 12 mos (%) (83) (58) (95% CI) (3449) (1423) No. 137 GMT 23 15 mos (%) (69) (95% CI) (1927) No. 148 56 GMT 44 16 24 mos (%) (82) (48) (95% CI) (3753) (1321) No. 129 GMT 44 36 mos (%) (85) (95% CI) (3753)
Abbreviation: CI = confidence interval. * Source: Schuller E, Jilma B, Voicu V, et al. Long-term immunogenicity of the new Vero cell-derived, inactivated Japanese encephalitis virus vaccine IC51: six and 12 month results of a multicenter follow-up phase 3 study. Vaccine 2008;26:43826. Source: European Medicines Agency. Annex 1: summary of product characteristics. Available at http://www.ema.europa.eu/docs/en_GB/document_library/ EPAR_-_Product_Information/human/000963/WC500037287.pdf. Source: Dubischar-Kastner K. Data supporting the use of a booster dose of Ixiaro. Presentation to Advisory Committee on Immunization Practices (ACIP), February 23, 2011, Atlanta, GA. Available at http://www.cdc.gov/vaccines/recs/acip/downloads/mtg-slides-feb11/03-2-jev-booster.pdf. n = 152 ** Source: Dubischar-Kastner K, Eder S, Buerger V, et al. Long-term immunity and immune response to a booster dose following vaccination with the inactivated Japanese encephalitis vaccine Ixiaro, IC51. Vaccine 2010;28:5197202. Source: Eder S, Dubischar-Kastner K, Firbas C, et al. Long term immunity following a booster dose of the inactivated Japanese encephalitis vaccine Ixiaro, IC51. Vaccine 2011;29:260712.
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TABLE 2. Number and percentage of subjects with a protective Japanese encephalitis virus neutralizing antibody titer (10) and the geometric mean titers (GMT) prior to and at day 28, month 6, and month 12 after a booster dose of inactivated Vero cell culturederived Japanese encephalitis vaccine (JE-VC [manufactured as Ixiaro]) administered 15 months after dose 1 of a 2-dose primary JE-VC series
Time after administration of the booster dose of JE-VC 0 days (N = 198) Study site Austria, Germany* [N = 198] No. 137 GMT 23 (%) (69) (95% CI) (1927) 28 days (N = 198) No 198 GMT 900 (%) (100) (95% CI) (7421091) 6 months (n = 197) No 194 GMT 487 (%) (98) (95% CI) (391608) 12 months (n = 194) No 191 GMT 361 (%) (98) (95% CI) (295444)
Abbreviation: CI = confidence interval. * Source: Eder S, Dubischar-Kastner K, Firbas C, et al. Long term immunity following a booster dose of the inactivated Japanese encephalitis vaccine Ixiaro, IC51. Vaccine 2011;29:260712.
TABLE 3. Number and percentage of local and systemic adverse events occurring within 7 days after a booster dose of inactivated Vero cell culturederived Japanese encephalitis vaccine (JE-VC [manufactured as Ixiaro]) administered 15 months after dose 1 of a 2-dose primary JE-VC series
Adverse events Local adverse events Tenderness Pain Induration Erythema Edema Any Systemic adverse events Headache Fatigue Myalgia Fever Any No./Total subjects 37/193 25/195 18/194 12/193 4/194 60/195 21/194 18/188 13/194 8/195 44/190 (%) (19) (13) (9) (6) (2) (31) (11) (10) (7) (4) (23)
Reported by
Susan L. Hills, MBBS, Marc Fischer, MD, Div of Vector-Borne Diseases, National Center for Emerging and Zoonotic Infectious Diseases, CDC. Corresponding contributor: Susan L. Hills, CDC, [email protected], 970-221-6400.
References
1. CDC. Japanese encephalitis vaccines: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR 2010;59 (No. RR-1). 2. Shlim DR, Solomon T. Japanese encephalitis vaccine for travelers: exploring the limits of risk. Clin Infect Dis 2002;35:1838. 3. Hombach J, Solomon T, Kurane I, Jacobson J, Wood D. Report on a WHO consultation on immunological endpoints for evaluation of new Japanese encephalitis vaccines. Vaccine 2005;23:520511. 4. Schuller E, Jilma B, Voicu V, et al. Long-term immunogenicity of the new Vero cell-derived, inactivated Japanese encephalitis virus vaccine IC51: six and 12 month results of a multicenter follow-up phase 3 study. Vaccine 2008;26:43826. 5. European Medicines Agency. Annex 1: summary of product characteristics. Available at http://www.ema.europa.eu/docs/en_GB/document_library/ EPAR_-_Product_Information/human/000963/WC500037287.pdf. Accessed May 22, 2011. 6. Dubischar-Kastner K. Data supporting the use of a booster dose of Ixiaro. Presentation to Advisory Committee on Immunization Practices (ACIP), February 23, 2011, Atlanta, GA. Available at http://www.cdc.gov/vaccines/recs/acip/downloads/mtg-slides-feb11/03-2-jev-booster.pdf. Accessed May 22, 2011. 7. Dubischar-Kastner K, Eder S, Buerger V, et al. Long-term immunity and immune response to a booster dose following vaccination with the inactivated Japanese encephalitis vaccine Ixiaro, IC51. Vaccine 2010;28:5197202. 8. Schuller E, Klade CS, Heinz FX, et al. Effect of pre-existing anti-tickborne encephalitis virus immunity on neutralising antibody response to the Vero cell-derived, inactivated Japanese encephalitis virus vaccine candidate IC51. Vaccine 2008;26:61516. 9. Eder S, Dubischar-Kastner K, Firbas C, et al. Long term immunity following a booster dose of the inactivated Japanese encephalitis vaccine Ixiaro, IC51. Vaccine 2011;29:260712.
Sources: Eder S, Dubischar-Kastner K, Firbas C, et al. Long term immunity following a booster dose of the inactivated Japanese encephalitis vaccine Ixiaro, IC51. Vaccine 2011;29:260712. Dubischar-Kastner K. Data supporting the use of a booster dose of Ixiaro. Presentation to Advisory Committee on Immunization Practices (ACIP), February 23, 2011, Atlanta, GA. Available at http://www.cdc.gov/vaccines/recs/acip/ downloads/mtg-slides-feb11/03-2-jev-booster.pdf.
considered, or is not recommended (1). Data on the response to a booster dose administered >2 years after the primary series of JE-VC are not available. Data on the need for and timing of additional booster doses also are not available. No data exist on the use of JE-VC as a booster dose after a primary series with inactivated mouse brain-derived JE vaccine (JE-MB [manufactured as JE-Vax]). Adults aged 17 years who have received JE-MB previously and require further vaccination against JE virus should receive a 2-dose primary series of JE-VC. ACIP will review any additional data that are made available. Recommendations will be updated as needed.
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Update on Japanese Encephalitis Vaccine for Children United States, May 2011
Inactivated mouse brainderived Japanese encephalitis (JE) vaccine (JE-MB [manufactured as JE-Vax]), the only JE vaccine that is licensed for use in children in the United States, is no longer available. This notice provides updated information regarding options for obtaining JE vaccine for U.S. children. In 2009, the Food and Drug Administration (FDA) approved an inactivated Vero cell culture-derived JE vaccine (JE-VC [manufactured as Ixiaro]) for use in adults aged 17 years. One pediatric dose-ranging study has been completed among 60 children aged 1235 months in India (48 children received JE-VC, and 12 children received another inactivated mouse brainderived JE vaccine [manufactured as JenceVac]) (6). A safety and immunogenicity study is ongoing among approximately 1,900 children aged 2 months17 years in the Philippines, and a safety and immunogenicity bridging study has been initiated in the United States and other nonendemic countries with a targeted enrollment of approximately 100 children. Despite these ongoing studies, it likely will be several years before JE-VC is licensed in the United States for use in children. JE-VC product information is available online from FDA at http://www.fda.gov/biologicsbloodvaccines/vaccines/ approvedproducts/ucm179132.htm.
JE among U.S. travelers

JE virus is the leading cause of vaccine-preventable encephalitis in Asia and the western Pacific. For most travelers to Asia, the risk for JE is low but varies on the basis of destination, duration, season, and activities. During the past 4 decades, 17 cases of JE have been reported among U.S. travelers and expatriates, including three cases among U.S. children aged <18 years (1,2). JE is a severe disease; 20%30% of patients die, and 30%50% of survivors have neurologic or psychiatric sequelae (3).
Recommendations for prevention of JE among travelers

The Advisory Committee on Immunization Practices (ACIP) recommends that all travelers, including children, take precautions to avoid mosquito bites to reduce the risk for JE and other vector-borne infectious diseases (3). These precautions include using insect repellent, permethrin-impregnated clothing, and bed nets, and staying in accommodations with screened or air-conditioned rooms. Additional information on protection against mosquitoes and other arthropods is available in CDCs Health Information for International Travel (Yellow Book) (4). For some travelers who will be in a high-risk setting on the basis of season, location, duration, and activities, JE vaccine can reduce the risk for disease further (3).
Current options for obtaining JE vaccine for U.S. children

For U.S. health-care providers interested in obtaining JE vaccine for pediatric patients they judge to be at risk, current options include 1) enroll children in the ongoing clinical trial, 2) administer JE-VC off-label, or 3) receive JE vaccine at an international travelers health clinic in Asia. The ongoing pediatric safety and immunogenicity trial with JE-VC is enrolling children aged 2 months17 years at five U.S. sites (trial identifier NCT01047839). The study is open-label, and all enrollees receive 2 doses of JE-VC administered 28 days apart. A third study visit is required at 56 days after the first dose of vaccine. Additional information about the clinical trial is available online from the National Institutes of Health at http://clinicaltrials.gov/ct2/show/nct01047839. In addition, a list of U.S. clinical trial sites and contact information is available online from CDC at http://www.cdc.gov/ncidod/dvbid/ jencephalitis/children.htm. JE-VC is FDA-licensed for use in adults aged 17 years. However, a health-care provider may choose to administer the vaccine off-label in children aged <17 years. Data from the one completed pediatric study have been published (6). Additional information about the use of JE-VC in children is available from Novartis Medical Communications by telephone (877-683-4732) or e-mail ([email protected]). Several JE vaccines are manufactured and available for pediatric use in Asia but are not licensed in the United States.
JE vaccine for U.S. children

JE-MB has been licensed in the United States since 1992 for use in adults and children aged 1 year. JE-MB has been associated with serious, but rare, allergic and neurologic adverse events (3). During 20022009, a total of 848,571 doses of JE-MB were distributed in the United States (mean: 106,071 doses per year), of which 534,330 (63%) doses were distributed to military health-care providers (5). During this period, an estimated 2,0003,000 doses of JE-MB were distributed for use in U.S. children each year (Sanofi Pasteur, unpublished data, 2011). However, JE-MB is no longer being produced, and all remaining doses expire in May 2011.
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Vaccines available at international travelers health clinics in Asia include another inactivated mouse brainderived JE vaccine manufactured in South Korea, live attenuated SA 14-14-2 vaccine manufactured in China, or another Vero cell culturederived JE vaccine manufactured in Japan. The recommended number of doses and schedule varies by vaccine and country. A partial list of international travelers health clinics in Asia that administer JE vaccines to children is available online from CDC at http://www.cdc.gov/ncidod/dvbid/jencephalitis/ children.htm.
References
1. Hills SL, Griggs AC, Fischer M. Japanese encephalitis in travelers from non-endemic countries, 19732008. Am J Trop Med Hyg 2010;82:9306. 2. CDC. Japanese encephalitis in two childrenUnited States, 2010. MMWR 2011;60:2768. 3. CDC. Japanese encephalitis vaccines: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR 2010;59 (No. RR-1). 4. CDC. Health information for international travel, 2010. Atlanta, GA: US Department of Health and Human Services, CDC; 2009. Available at http://wwwnc.cdc.gov/travel/yellowbook/2010/table-of-contents.htm. Accessed May 19, 2011. 5. Lindsey NP, Staples JE, Jones J, et al. Adverse event reports following Japanese encephalitis vaccination in the U.S., 20002009. Vaccine 2010; 29:5864. 6. Kaltenbck A, Dubischar-Kastner K, Schuller E, Datla M, Klade CS, Kishore TS. Immunogenicity and safety of Ixiaro (IC51) in a phase II study in healthy Indian children between 1 and 3 years of age. Vaccine 2010;28:8349.
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Measles United States, JanuaryMay 20, 2011

On May 24, this report was posted as an MMWR Early Release on the MMWR website (http://www.cdc.gov/mmwr). Measles is a highly contagious, acute viral illness that can lead to serious complications and death. Endemic or sustained measles transmission has not occurred in the United States since the late 1990s, despite continued importations (1). During 20012008, a median of 56 (range: 37140) measles cases were reported to CDC annually (2); during the first 19 weeks of 2011, 118 cases of measles were reported, the highest number reported for this period since 1996. Of the 118 cases, 105 (89%) were associated with importation from other countries, including 46 importations (34 among U.S. residents traveling abroad and 12 among foreign visitors). Among those 46 cases, 40 (87%) were importations from the World Health Organization (WHO) European and South-East Asia regions. Of the 118, 105 (89%) patients were unvaccinated. Forty-seven (40%) patients were hospitalized and nine had pneumonia. The increased number of measles importations into the United States this year underscores the importance of vaccination to prevent measles and its complications. Measles cases are reported by state health departments to CDC, and confirmed cases are reported via the National Notifiable Disease Surveillance System (NNDSS) using standard case definitions (3). Cases are considered internationally imported if at least some of the exposure period (721 days before rash onset) occurred outside the United States and rash occurred within 21 days of entry into the United States, with no known exposure to measles in the United States during that time. Import-associated cases include 1) internationally imported cases; 2) cases that are related epidemiologically to imported cases; and 3) imported virus cases for which an epidemiologic link has not been identified but the viral genotype detected suggests recent importation.* Laboratory confirmation of measles is made by detection in serum of measles-specific immunoglobulin M antibodies, isolation of measles virus, or detection of measles virus RNA by nucleic acid amplification in an appropriate clinical specimen (e.g., nasopharyngeal/oropharyngeal swabs, nasal aspirates, throat washes, or urine). For this report, persons with reported unknown or undocumented vaccination status are considered unvaccinated. An outbreak of measles is defined as a chain of transmission with three or more confirmed cases. During January 1May 20, 2011, a total of 118 cases were reported from 23 states and New York City (Figure 1), the
* Additional information is available at http://www.cdc.gov/osels/ph_surveillance/ nndss/casedef/measles_2010.htm.
highest reported number for the same period since 1996 (Figure 2). Patients ranged in age from 3 months to 68 years; 18 (15%) were aged <12 months, 24 (20%) were aged 14 years, 23 (19%) were aged 519 years, and 53 (45%) were aged 20 years. Measles was laboratory-confirmed in 105 (89%) cases, and measles virus RNA was detected in 52 (44%) cases. Among the 118 cases, 105 (89%) were import-associated, of which 46 (44%) were importations from at least 15 countries (Table), 49 (47%) were import-linked, and 10 (10%) were imported virus cases. The source of 13 cases not import-associated could not be determined. Among the 46 imported cases, most were among persons who acquired the disease in the WHO European Region (20) or South-East Asia Region (20), and 34 (74%) occurred in U.S. residents traveling abroad. Of the 118 cases, 47 (40%) resulted in hospitalization. Nine patients had pneumonia, but none had encephalitis and none died. All but one hospitalized patient were unvaccinated. The vaccinated patient reported having received 1 dose of measlescontaining vaccine and was hospitalized for observation only. Hospitalization rates were highest among infants and children aged <5 years (52%), but rates also were high among children and adults aged 5 years (33%). Unvaccinated persons accounted for 105 (89%) of the 118 cases. Among the 45 U.S. residents aged 12 months19 years who acquired measles, 39 (87%) were unvaccinated, including 24 whose parents claimed a religious or personal exemption and eight who missed opportunities for vaccination. Among the 42 U.S. residents aged 20 years who acquired measles, 35 (83%) were unvaccinated, including six who declined vaccination because of philosophical objections to vaccination. Of the
FIGURE 1. Distribution and origin of reported measles cases (N = 118) United States, January 1May 20, 2011
! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! !! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! !
Import associated Unknown source
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FIGURE 2. Cumulative number of measles cases reported, by month of rash onset United States, 20012011
160 140 20022010 (excluding 2008) 2001 2008 2011
TABLE. Countries where measles was acquired, by World Health Organization (WHO) region United States, JanuaryMay 20, 2011
WHO region African Eastern Mediterranean European No. of cases 2 2 20 Country Kenya Nigeria Pakistan Jordan France France/United Kingdom France/Italy/Spain/Germany Italy Poland Romania Spain United Kingdom Dominican Republic India Indonesia Philippines Philippines/Vietnam/Singapore/ Malaysia China No. of cases 1 1 1 1 11 1* 1* 1 1 1 1 3 1 14 1 4 1* 1
No. of cases (cumulative)
120 100 80 60 40 20 0
Jan Feb Mar Apr May Jun
Jul
Aug Sep Oct Nov Dec
Americas South-East Asia
1 20
Month
33 U.S. residents who were vaccine-eligible and had traveled abroad, 30 were unvaccinated and one had received only 1 of the 2 recommended doses. Nine outbreaks accounted for 58 (49%) of the 118 cases. The median outbreak size was four cases (range: 321). In six outbreaks, the index case acquired measles abroad; the source of the other three outbreaks could not be determined. Transmission occurred in households, child care centers, shelters, schools, emergency departments, and at a large community event. The largest outbreak occurred among 21 persons in a Minnesota population in which many children were unvaccinated because of parental concerns about the safety of measles, mumps, and rubella (MMR) vaccine. That outbreak resulted in exposure to many persons and infection of at least seven infants too young to receive MMR vaccine (4).
Reported by
Western Pacific
* Patient had visited more than one country where measles are endemic during the incubation period, and exposure could have occurred in any of the countries listed. Although the patient acquired measles in the Dominican Republic, the likely source of infection was a French tourist with measles who stayed in an adjacent room at the same resort at the same time as the patient. The genotype identified in this patient was D4, a genotype commonly circulating in France.
Div of Viral Diseases, National Center for Immunization and Respiratory Diseases, CDC. Corresponding contributor: Huong McLean, [email protected], 404-639-7714.
Editorial Note
As a result of high vaccination coverage, measles elimination (i.e., the absence of endemic transmission) was achieved in the United States in the late 1990s (1) and likely in the rest of the Americas since the early 2000s (5). However, as long as measles remains endemic in the rest of the world, importations into the Western Hemisphere will continue. The unusually large number of importations into the United States in the first 19 weeks of 2011 is related to recent increases in measles in countries visited by U.S. travelers. The most frequent sources of importation in 2011 were countries in the
WHO European Region, which has accounted for the majority of measles importations in the United States since 2005 (2), and the South-East Asia Region. This year, 33 countries in the WHO European Region have reported an increase in measles. France, the source of most of the importations from the European Region, is experiencing a large outbreak, with approximately 10,000 cases reported during the first 4 months of 2011, including 12 cases of encephalitis, a complication that often results in permanent neurologic sequelae, 360 cases of severe measles pneumonia, and six measles-related deaths (6). Measles can be severe and is highly infectious; following exposure, up to 90% of susceptible persons develop measles. Measles can lead to life-threatening complications. During 19891991, a resurgence of measles in the United States resulted in >100 deaths among >55,000 cases reported, reminding U.S. residents of the potential severity of measles, even in the era of modern medical care (7). In the years that followed, the United States witnessed the return of subacute sclerosing panencephalitis among U.S. children, a rare, fatal neurologic complication of measles that had all but disappeared after measles vaccine was introduced in the 1960s (8). Children and adults who remain unvaccinated and develop measles also put others in their community at risk. For infants too young for routine vaccination (age <12 months) and persons with medical conditions that contraindicate measles
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What is already known on this topic? Measles, mumps, and rubella (MMR) vaccine is highly effective in preventing measles and its complications. Sustained measles transmission was eliminated from the United States in the late 1990s, but the disease remains common in many countries globally, and cases of measles are imported into the United States regularly. What is added by this report? During the first 19 weeks of 2011, 118 cases of measles were reported in the United States, the highest number for the same period in any year since 1996, and hospitalization rates were high (40%). Importations accounted for 46 (40%) cases, including 34 (74%) cases among U.S. residents who had recently traveled abroad, among 105 import-associated cases. What are the implications for public health practice? High 2-dose MMR vaccine coverage is critical for decreasing the risk for reestablishment of endemic measles transmission after importation of measles into the United States. Before any international travel, infants aged 611 months should receive 1 dose of MMR vaccine and persons aged 12 months should receive 2 doses of MMR vaccine at least 28 days apart or have other evidence of immunity to measles.
MMR vaccine is safe and highly effective in preventing measles and its complications. MMR vaccine is recommended routinely for all children at age 1215 months, with a second dose at age 46 years. For adults with no evidence of immunity to measles, 1 dose of MMR vaccine is recommended unless the adult is in a high-risk group (i.e., health care personnel, international travelers, or students at post-high school educational institutions), in which case, 2 doses of MMR vaccine are recommended. Measles is endemic in many countries, and exposures might occur in airports and in countries of travel. All travelers aged 6 months are eligible to receive MMR vaccine and should be vaccinated before travel (10). Maintaining high immunization rates with MMR vaccine is the cornerstone of outbreak prevention.
Documented receipt of 2 doses of live measles virus-containing vaccine, labora-
tory evidence of immunity, documentation of physician-diagnosed measles, or birth before 1957.
Acknowledgments The findings in this report are based, in part, on contributions by Mary McCauley and Paul Chenoweth, National Center for Immunization and Respiratory Diseases, CDC. References
1. Katz SL, Hinman AR. Summary and conclusions: measles elimination meeting, 1617 March 2000. J Infect Dis 2004;189(Suppl 1):S437. 2. Parker Fiebelkorn A, Redd SB, Gallagher K, et al. Measles in the United States during the postelimination era. J Infect Dis 2010;202:15208. 3. CDC. Manual for the surveillance of vaccine-preventable diseases. 4th ed. Atlanta, GA: US Department of Health and Human Services, CDC; 2009. Available at http://www.cdc.gov/vaccines/pubs/surv-manual/ default.htm. Accessed May 20, 2011. 4. CDC. Measles outbreakHennepin County, Minnesota, February March 2011. MMWR 2011;60:421. 5. World Health Organization. Global elimination of measlesreport by the Secretariate, 16 April 2009. Available at http://apps.who.int/gb/ ebwha/pdf_files/EB125/B125_4-en.pdf. Accessed May 20, 2011. 6. Institut de Veille Sanitaire. Epidmie de rougeole en France; Actualisation des donnes au 20 mai 2011. Available at http://www. invs.sante.fr/surveillance/rougeole/Point_rougeole_200511.pdf. Accessed May 23, 2011. 7. Gindler J, Tinker S, Markowitz L, et al. Acute measles mortality in the United States, 19872002. J Infect Dis 2004;189(Suppl 1):S6977. 8. Bellini WJ, Rota JS, Lowe LE, et al. Subacute sclerosing panencephalitis: more cases of this fatal disease are prevented by measles immunization than was previously recognized. J Infect Dis 2005;192:168693. 9. Editorial team. Measles once again endemic in the United Kingdom. Eurosurveillance 2008;13. Available at http://www.eurosurveillance.org/ viewarticle.aspx?articleId=18919. Accessed May 20, 2011. 10. Watson JC, Hadler SC, Dykewicz CA, Reef S, Phillips L. Measles, mumps, and rubellavaccine use and strategies for elimination of measles, rubella, and congenital rubella syndrome and control of mumps: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR 1998;47(No. RR-8).
immunization, the risk for measles complications is particularly high. These persons depend on high MMR vaccination coverage among those around them to protect them from exposure. In the United States this year, infants aged <12 months accounted for 15% of cases and 15% of hospitalizations. In Europe in recent years, measles has been fatal for several children and adolescents, including some who could not be vaccinated because they were immune compromised. Rapid control efforts by state and local public health agencies, which are both time intensive and costly, have been a key factor in limiting the size of outbreaks and preventing the spread of measles into communities with increased numbers of unvaccinated persons. Nonetheless, maintenance of high 2-dose MMR vaccination coverage is the most critical factor for sustaining elimination. For measles, even a small decrease in coverage can increase the risk for large outbreaks and endemic transmission, as occurred in the United Kingdom in the past decade (9). Because of ongoing importations of measles to the United States, health-care providers should suspect measles in persons with a febrile rash illness and clinically compatible symptoms (e.g., cough, coryza, and/or conjunctivitis) who have recently traveled abroad or have had contact with travelers. Providers should isolate and report suspected measles cases immediately to their local health department and obtain specimens for measles testing, including viral specimens for confirmation and genotyping.
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Announcement
Preventive Medicine Residency and Fellowship Applications Deadline September 15, 2011
The Preventive Medicine Residency and Fellowship (PMR/F) programs are accepting applications from physicians for the residency and from veterinarians, dentists, nurses, physician assistants, and international medical graduates for the fellowship. Applicants with public health and applied epidemiologic practice experience who seek to become preventive medicine and population health specialists and public health leaders are encouraged to apply. The PMR/F prepares clinicians for leadership roles in public health at international, federal, state, and local levels through instruction and supervised practical experiences focused on translating epidemiology to public health practice, management, and policy and program development. Development of leadership and management competency is emphasized. Residents and fellows conduct their training at a CDC location or in a state or local health department. PMR/F alumni occupy many leadership positions at CDC, at state and local health departments, in academia, and in private-sector agencies. Completion of the residency, which is accredited by the Accreditation Council for Graduate Medical Education for 24 months of training, qualifies graduates to apply for certification by the American Board of Preventive Medicine (ABPM) in Public Health and General Preventive Medicine. Select candidates can be considered for 1 year of residency training that also should qualify for application for ABPM certification. Training for PMF clinicians also is 1 year. Applications are being accepted for the class that begins in midJune 2012. Applications must be submitted online by September 15, 2011, and supporting documents must be received in the PMR/F office by that same day. Additional information regarding the programs, eligibility criteria, and application process is available at http://www.cdc.gov/prevmed, by telephone at 404-498-6140, or by e-mail at [email protected].
Notice to Readers
Updated N Indicators for the Year 2010 in National Notifiable Diseases Surveillance System Tables
The 2010 Council of State and Territorial Epidemiologists (CSTE) State Reportable Conditions Assessment (2010 SRCA) has collected data from 55 reporting jurisdictions (50 U.S. states, the District of Columbia, New York City, and three territories [American Samoa, Guam, and Puerto Rico]) to determine which of the nationally notifiable conditions (NNC) were reportable in each reporting jurisdiction in 2010. The 2010 SRCA gathered information regarding whether the condition is 1) explicitly reportable (i.e., listed as a specific disease or as a category of diseases on reportable disease lists), 2) implicitly reportable (i.e., included in a general category of the reportable disease list, such as rare diseases of public health importance), or 3) not reportable within each jurisdiction. Only conditions that were explicitly reportable were considered reportable based on the 2010 SRCA methodology. Results of the 2010 SRCA will be used to indicate whether each NNC is or is not reportable for the specified period and reporting jurisdiction. NNC that are not reportable are noted with an N indicator (for not reportable) in the MMWR Table II weekly update (Provisional cases of selected notifiable diseases, United States) and in the MMWR Summary of Notifiable DiseasesUnited States, 2010. This notation will allow readers to distinguish whether 1) no cases were reported even though the condition is reportable or 2) no cases were reported because the condition is not reportable. The 2010 SRCA data collection and validation concluded in April 2011; results will be used to populate the N indicators for National Notifiable Diseases Surveillance System (NNDSS) data in the 2011 MMWR tables for the current week and for both the 2010 and 2011 cumulative year columns. The 2011 NNDSS data displayed in the MMWR weekly provisional tables will reflect reporting requirements gathered from the 2010 SRCA until 2011 SRCA official results are available.
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Erratum
Vol. 60, No. RR-3
In the MMWR Recommendations and Reports Updated Norovirus Outbreak Management and Disease Prevention Guidelines, an error occurred on page 9. The second sentence under the heading Environmental Specimens should read: If a food or a water source is strongly suspected as the source of an outbreak, a sample should be obtained as early as possible with respect to the time of exposure, and CDC or FDA should be contacted for further guidance on testing. Food samples should be stored frozen at -4F (-20C), and water samples should be stored refrigerated or chilled on ice at 39F (4C).
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QuickStats
from the national center for health statistics
Percentage of Adults Aged 2064 Years with Hypertension Whose Condition Was Undiagnosed,* by Health Insurance Status and Age Group National Health and Nutrition Examination Survey, United States, 20052008
80 70 60 50 40 30 20 10 0 2064 2039 4064
Private insurance Public insurance No insurance
Percentage
Age group (yrs)

* Hypertension was defined as systolic blood pressure 140 mmHg or diastolic blood pressure 90 mmHg or currently taking medication to lower blood pressure, based on positive responses to the following questions: Because of your high blood pressure/hypertension have you ever been told to take prescribed medicine? and Are you now taking a prescribed medicine? Undiagnosed hypertension was a finding of hypertension and a negative response to the following question: Have you ever been told by a doctor or other health professional that you had hypertension, also called high blood pressure? Health insurance coverage is at the time of interview.Public coverage includes Medicaid, Childrens Health Insurance Program (CHIP) state-sponsored or other government-sponsored health plan, Medicare (disability), or military health plan (TRICARE, VA, or CHAMP-VA). Persons with both public and private insurance coverage were included in the private coverage category only. 95% confidence interval.
During 20052008, among U.S. adults aged 2064 years with hypertension, 40% of those with no health insurance had hypertension that was undiagnosed, compared with 21% of those with private insurance and 16% of those with public insurance. In the 2039 years and 4064 years age groups, undiagnosed hypertension also was more common among persons with no health insurance compared with those with private or public insurance.
Sources: National Health and Nutrition Examination Survey, 20052008 data. Available at http://www.cdc.gov/nchs/nhanes.htm. Schober SE, Makuc DM, Zhang C, Kennedy-Stephenson J, Burt V. Health insurance affects diagnosis and control of hypercholesterolemia and hypertension among adults aged 2064: United States, 20052008. NCHS data brief no. 57. Hyattsville, MD: US Department of Health and Human Services, CDC, National Center for Health Statistics; 2011. Available at http://www.cdc.gov/nchs/data/databriefs/db57.pdf.
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Notifiable Diseases and Mortality Tables

TABLE I. Provisional cases of infrequently reported notifiable diseases (<1,000 cases reported during the preceding year) United States, week ending May 21, 2011 (20th week)*
Disease Anthrax Arboviral diseases , : California serogroup virus disease Eastern equine encephalitis virus disease Powassan virus disease St. Louis encephalitis virus disease Western equine encephalitis virus disease Babesiosis Botulism, total foodborne infant other (wound and unspecified) Brucellosis Chancroid Cholera Cyclosporiasis Diphtheria Haemophilus influenzae,** invasive disease (age <5 yrs): serotype b nonserotype b unknown serotype Hansen disease Hantavirus pulmonary syndrome Hemolytic uremic syndrome, postdiarrheal , Influenza-associated pediatric mortality Listeriosis Measles Meningococcal disease, invasive: A, C, Y, and W-135 serogroup B other serogroup unknown serogroup Novel influenza A virus infections*** Plague Poliomyelitis, paralytic Polio virus Infection, nonparalytic Psittacosis Q fever, total acute chronic Rabies, human Rubella Rubella, congenital syndrome SARS-CoV Smallpox Streptococcal toxic-shock syndrome Syphilis, congenital (age <1 yr) Tetanus Toxic-shock syndrome (staphylococcal) Trichinellosis Tularemia Typhoid fever Vancomycin-intermediate Staphylococcus aureus Vancomycin-resistant Staphylococcus aureus Vibriosis (noncholera Vibrio species infections) Viral hemorrhagic fever Yellow fever See Table 1 footnotes on next page. Current week 3 1 2 2 1 3 1 1 1 2 2 2 1 5 2 1 1 4 1 4 Cum 2011 13 26 4 18 4 19 11 17 40 2 44 99 20 6 27 101 148 83 74 46 4 202 1 1 23 13 10 1 53 56 2 35 6 8 124 21 108 5-year weekly average 0 0 0 1 2 0 1 0 3 0 0 2 0 4 4 1 1 4 2 11 3 6 3 1 10 0 0 0 3 2 0 0 4 6 0 1 0 3 7 1 7 Total cases reported f or previous years 2010 75 10 8 10 NN 107 7 75 25 117 30 12 180 23 198 223 70 20 259 61 818 64 276 133 11 414 4 2 4 133 108 25 2 7 159 363 11 81 7 124 466 91 2 847 1 2009 1 55 4 6 12 NN 118 10 83 25 115 28 10 141 35 236 178 103 20 242 358 851 71 301 174 23 482 43,774 8 1 9 113 93 20 4 3 2 161 423 18 74 13 93 397 78 1 789 NN 2008 62 4 2 13 NN 145 17 109 19 80 25 5 139 30 244 163 80 18 330 90 759 140 330 188 38 616 2 3 8 120 106 14 2 16 157 431 19 71 39 123 449 63 588 NN 2007 1 55 4 7 9 NN 144 32 85 27 131 23 7 93 22 199 180 101 32 292 77 808 43 325 167 35 550 4 7 12 171 1 12 132 430 28 92 5 137 434 37 2 549 NN 2006 1 67 8 1 10 NN 165 20 97 48 121 33 9 137 29 175 179 66 40 288 43 884 55 318 193 32 651 NN 17 NN 21 169 3 11 1 125 349 41 101 15 95 353 6 1 NN NN States reporting cases during current week (No.)
NY (1) PA (1), VA (1) FL (1), CA (1) CA (1) NY (1), TX (2)
GA (1) PA (1)
TN (1) MD (1), CO (1) FL (1), CA (1) OH (1), NE (1) WA (1) PA (1), VA (1), AZ (1), CA (2)
NY (1), OH (1)
NE (1) ME (1) TX (1), CO (1), CA (2) FL (1) FL (4)
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TABLE I. (Continued) Provisional cases of infrequently reported notifiable diseases (<1,000 cases reported during the preceding year) United States, week ending May 21, 2011 (20th week)*
: No reported cases. N: Not reportable. NN: Not Nationally Notifiable. Cum: Cumulative year-to-date counts. * Case counts for reporting years 2010 and 2011 are provisional and subject to change. For further information on interpretation of these data, see http://www.cdc.gov/osels/ph_surveillance/ nndss/phs/files/ProvisionalNationa%20NotifiableDiseasesSurveillanceData20100927.pdf. Calculated by summing the incidence counts for the current week, the 2 weeks preceding the current week, and the 2 weeks following the current week, for a total of 5 preceding years. Additional information is available at http://www.cdc.gov/osels/ph_surveillance/nndss/phs/files/5yearweeklyaverage.pdf. Not reportable in all states. Data from states where the condition is not reportable are excluded from this table except starting in 2007 for the arboviral diseases, STD data, TB data, and influenza-associated pediatric mortality, and in 2003 for SARS-CoV. Reporting exceptions are available at http://www.cdc.gov/osels/ph_surveillance/nndss/phs/infdis.htm. Includes both neuroinvasive and nonneuroinvasive. Updated weekly from reports to the Division of Vector-Borne Infectious Diseases, National Center for Zoonotic, Vector-Borne, and Enteric Diseases (ArboNET Surveillance). Data for West Nile virus are available in Table II. ** Data for H. influenzae (all ages, all serotypes) are available in Table II. Updated weekly from reports to the Influenza Division, National Center for Immunization and Respiratory Diseases. Since October 3, 2010, 105 influenza-associated pediatric deaths occurring during the 2010-11 influenza season have been reported. Of the two measles cases reported for the current week, one was imported and one was indigenous. Data for meningococcal disease (all serogroups) are available in Table II. *** CDC discontinued reporting of individual confirmed and probable cases of 2009 pandemic influenza A (H1N1) virus infections on July 24, 2009. During 2009, four cases of human infection with novel influenza A viruses, different from the 2009 pandemic influenza A (H1N1) strain, were reported to CDC. The four cases of novel influenza A virus infection reported to CDC during 2010, and the one case reported during 2011, were identified as swine influenza A (H3N2) virus and are unrelated to the 2009 pandemic influenza A (H1N1) virus. Total case counts for 2009 were provided by the Influenza Division, National Center for Immunization and Respiratory Diseases (NCIRD). No rubella cases were reported for the current week. Updated weekly from reports to the Division of STD Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention. There was one case of viral hemorrhagic fever reported during week 12 of 2010. The one case report was confirmed as lassa fever. See Table II for dengue hemorrhagic fever.
FIGURE I. Selected notifiable disease reports, United States, comparison of provisional 4-week totals May 21, 2011, with historical data
DISEASE Giardiasis Hepatitis A, acute Hepatitis B, acute Hepatitis C, acute Legionellosis Measles Meningococcal disease Mumps Pertussis 0.0625 0.125 0.25 0.5 1 2 4 8 DECREASE INCREASE CASES CURRENT 4 WEEKS 549 51 57 37 72 25 38 18 586
Ratio (Log scale)* Beyond historical limits
* Ratio of current 4-week total to mean of 15 4-week totals (from previous, comparable, and subsequent 4-week periods for the past 5 years). The point where the hatched area begins is based on the mean and two standard deviations of these 4-week totals.
Notifiable Disease Data Team and 122 Cities Mortality Data Team Willie J. Anderson Deborah A. Adams Rosaline Dhara Michael S. Wodajo Pearl C. Sharp Lenee Blanton
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TABLE II. Provisional cases of selected notifiable diseases, United States, weeks ending May 21, 2011, and May 22, 2010 (20th week)*
Chlamydia trachomatis infection Reporting area United States New England Connecticut Maine Massachusetts New Hampshire Rhode Island Vermont Mid. Atlantic New Jersey New York (Upstate) New York City Pennsylvania E.N. Central Illinois Indiana Michigan Ohio Wisconsin W.N. Central Iowa Kansas Minnesota Missouri Nebraska North Dakota South Dakota S. Atlantic Delaware District of Columbia Florida Georgia Maryland North Carolina South Carolina Virginia West Virginia E.S. Central Alabama Kentucky Mississippi Tennessee W.S. Central Arkansas Louisiana Oklahoma Texas Mountain Arizona Colorado Idaho Montana Nevada New Mexico Utah Wyoming Pacific Alaska California Hawaii Oregon Washington Territories American Samoa C.N.M.I. Guam Puerto Rico U.S. Virgin Islands Current week 15,504 643 558 59 26 1,576 183 668 190 535 1,126 151 592 211 172 467 16 25 426 4,978 63 105 737 678 486 1,446 735 669 59 1,383 344 478 308 253 2,759 322 747 313 1,377 722 153 413 152 4 1,850 1,282 260 308 119 Previous 52 weeks Med 25,440 841 234 55 404 53 67 26 3,309 492 710 1,163 949 3,971 1,108 447 942 1,000 453 1,411 203 187 292 521 98 42 63 5,007 83 105 1,466 825 485 756 517 658 75 1,820 548 268 394 590 3,296 303 368 233 2,350 1,665 519 413 66 64 193 195 129 39 3,802 116 2,921 108 235 412 0 9 105 14 Max 31,173 2,043 1,557 100 860 112 154 84 5,068 684 2,099 2,612 1,183 7,039 1,320 3,376 1,398 1,136 557 1,610 240 287 354 771 218 90 93 6,194 220 180 1,706 2,416 1,125 1,436 946 970 122 3,314 1,552 2,352 780 795 4,723 440 1,052 1,371 3,107 2,154 678 849 199 85 380 1,183 175 90 6,559 157 5,763 141 524 520 0 44 353 25 Cum 2011 479,022 15,548 2,620 1,137 8,458 1,132 1,620 581 62,480 8,357 13,664 20,963 19,496 68,263 12,201 11,032 18,497 18,164 8,369 26,895 3,896 3,721 4,625 10,674 2,181 571 1,227 100,075 1,735 1,947 28,556 14,809 8,459 18,022 11,017 13,922 1,608 35,599 10,406 5,976 7,898 11,319 61,249 6,309 3,030 4,556 47,354 32,332 9,288 10,096 1,019 1,271 4,100 3,751 2,110 697 76,581 2,158 58,931 1,762 5,295 8,435 189 2,399 220 Cum 2010 492,436 14,763 3,387 957 7,827 787 1,347 458 64,904 10,174 12,355 24,418 17,957 77,638 23,058 5,955 20,045 19,877 8,703 28,123 4,236 3,757 6,033 10,074 1,995 814 1,214 99,144 1,657 2,051 28,672 18,114 8,553 17,149 9,831 11,672 1,445 34,129 9,191 5,911 8,725 10,302 69,397 6,008 11,442 5,076 46,871 32,066 10,449 7,370 1,467 1,204 3,907 4,221 2,622 826 72,272 2,408 54,317 2,460 4,750 8,337 78 2,499 207 Current week 73 1 1 61 59 2 11 11 Coccidioidomycosis Previous 52 weeks Med 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Max 569 1 0 0 0 1 0 0 0 0 0 0 0 3 0 0 3 3 0 1 0 0 0 0 1 0 0 1 0 0 0 0 1 0 0 0 0 0 0 0 0 0 1 0 1 0 0 424 419 0 0 1 4 4 2 2 145 0 145 0 1 0 0 0 0 0 Cum 2011 5,622 1 1 16 9 7 1 1 1 1 1 1 4,231 4,167 1 34 23 3 3 1,371 1,370 1 Cum 2010 NN NN NN NN NN NN NN NN NN NN NN NN NN NN NN NN NN NN NN NN NN NN NN NN NN NN NN NN NN NN NN NN NN NN NN NN NN NN NN NN NN NN NN NN NN NN NN NN NN NN NN NN NN NN NN NN NN NN NN NN NN NN NN NN NN NN NN Current week 49 8 2 6 11 3 6 2 8 1 7 11 4 4 3 1 1 3 3 3 1 2 4 2 2 N N Cryptosporidiosis Previous 52 weeks Med 122 6 0 0 3 1 0 1 14 1 3 2 8 29 2 3 5 7 9 15 4 1 3 3 3 0 1 18 0 0 6 5 1 0 2 2 0 4 1 1 0 1 8 0 0 1 4 10 1 2 2 1 0 2 1 0 12 0 7 0 4 1 0 0 0 0 Max 369 21 16 7 9 3 2 5 38 4 13 6 26 130 21 10 18 24 65 99 25 6 22 29 26 9 6 52 1 1 19 11 3 16 8 9 5 19 13 6 2 5 33 3 6 8 24 30 3 10 7 5 7 12 5 3 27 3 19 0 13 9 0 0 0 0 Cum 2011 1,444 73 16 2 32 9 1 13 218 9 48 22 139 340 3 36 73 125 103 105 16 6 36 40 7 273 2 3 80 90 17 23 31 20 7 51 7 19 8 17 68 5 10 53 151 9 45 30 20 3 29 9 6 165 4 94 64 3 N N Cum 2010 2,205 198 77 22 44 27 8 20 223 9 47 21 146 560 78 86 110 126 160 342 73 29 115 51 39 3 32 335 2 2 133 110 12 24 17 29 6 73 28 23 4 18 108 13 16 17 62 184 13 47 31 23 5 31 23 11 182 2 106 1 51 22 N N
C.N.M.I.: Commonwealth of Northern Mariana Islands. U: Unavailable. : No reported cases. N: Not reportable. NN: Not Nationally Notifiable. Cum: Cumulative year-to-date counts. Med: Median. Max: Maximum. * Case counts for reporting year 2010 and 2011 are provisional and subject to change. For further information on interpretation of these data, see http://www.cdc.gov/osels/ph_surveillance/ nndss/phs/files/ProvisionalNationa%20NotifiableDiseasesSurveillanceData20100927.pdf. Data for TB are displayed in Table IV, which appears quarterly. Contains data reported through the National Electronic Disease Surveillance System (NEDSS).
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TABLE II. (Continued) Provisional cases of selected notifiable diseases, United States, weeks ending May 21, 2011, and May 22, 2010 (20th week)*
Dengue Virus Infection Dengue Fever Reporting area United States New England Connecticut Maine Massachusetts New Hampshire Rhode Island Vermont Mid. Atlantic New Jersey New York (Upstate) New York City Pennsylvania E.N. Central Illinois Indiana Michigan Ohio Wisconsin W.N. Central Iowa Kansas Minnesota Missouri Nebraska North Dakota South Dakota S. Atlantic Delaware District of Columbia Florida Georgia Maryland North Carolina South Carolina Virginia West Virginia E.S. Central Alabama Kentucky Mississippi Tennessee W.S. Central Arkansas Louisiana Oklahoma Texas Mountain Arizona Colorado Idaho Montana Nevada New Mexico Utah Wyoming Pacific Alaska California Hawaii Oregon Washington Territories American Samoa C.N.M.I. Guam Puerto Rico U.S. Virgin Islands Current week Previous 52 weeks Med 5 0 0 0 0 0 0 0 1 0 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 2 0 0 2 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 88 0 Max 47 3 0 2 0 0 1 1 22 0 5 17 3 7 3 2 2 2 2 6 0 1 1 0 6 0 0 18 0 0 14 0 0 2 3 3 1 2 2 0 0 1 1 0 0 1 1 2 2 0 0 0 1 0 0 0 7 0 5 0 0 2 0 0 550 0 Cum 2011 25 7 7 4 1 1 2 9 8 1 1 1 4 1 3 191 Cum 2010 98 3 3 36 5 25 6 12 4 2 1 5 8 7 1 29 27 2 2 1 1 8 5 3 2,035 Current week Dengue Hemorrhagic Fever Previous 52 weeks Med 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 2 0 Max 2 0 0 0 0 0 0 0 1 0 1 1 0 1 0 0 0 0 1 1 0 0 0 0 0 0 1 1 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 20 0 Cum 2011 1 Cum 2010 3 2 1 1 1 1 53
C.N.M.I.: Commonwealth of Northern Mariana Islands. U: Unavailable. : No reported cases. N: Not reportable. NN: Not Nationally Notifiable. Cum: Cumulative year-to-date counts. Med: Median. Max: Maximum. * Case counts for reporting year 2010 and 2011 are provisional and subject to change. For further information on interpretation of these data, see http://www.cdc.gov/osels/ph_surveillance/ nndss/phs/files/ProvisionalNationa%20NotifiableDiseasesSurveillanceData20100927.pdf. Data for TB are displayed in Table IV, which appears quarterly. Dengue Fever includes cases that meet criteria for Dengue Fever with hemorrhage, other clinical and unknown case classifications. DHF includes cases that meet criteria for dengue shock syndrome (DSS), a more severe form of DHF. Contains data reported through the National Electronic Disease Surveillance System (NEDSS).
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Ehrlichiosis/Anaplasmosis Ehrlichia chaffeensis Reporting area United States New England Connecticut Maine Massachusetts New Hampshire Rhode Island Vermont Mid. Atlantic New Jersey New York (Upstate) New York City Pennsylvania E.N. Central Illinois Indiana Michigan Ohio Wisconsin W.N. Central Iowa Kansas Minnesota Missouri Nebraska North Dakota South Dakota S. Atlantic Delaware District of Columbia Florida Georgia Maryland North Carolina South Carolina Virginia West Virginia E.S. Central Alabama Kentucky Mississippi Tennessee W.S. Central Arkansas Louisiana Oklahoma Texas Mountain Arizona Colorado Idaho Montana Nevada New Mexico Utah Wyoming Pacific Alaska California Hawaii Oregon Washington Territories American Samoa C.N.M.I. Guam Puerto Rico U.S. Virgin Islands Current Previous 52 weeks week Med Max 6 1 1 1 1 1 N 1 N 2 1 N 1 1 1 N N N N N N N N N N 7 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 3 0 0 0 0 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 109 2 0 1 0 1 1 0 8 6 7 2 1 4 2 0 1 3 2 13 0 2 12 13 1 0 0 18 3 0 2 2 3 13 2 8 1 11 3 2 1 7 87 5 0 82 1 0 0 0 0 0 0 0 0 0 1 0 1 0 0 0 0 0 0 0 Cum 2011 48 2 1 1 5 3 2 2 1 1 12 N 1 11 N 22 4 N 4 1 2 6 5 5 2 3 N N N N N N N N N N Cum 2010 109 2 2 20 15 4 1 12 6 6 15 N 15 N 43 4 N 2 9 4 19 5 9 1 1 7 7 1 5 1 N N N N N 1 N 1 N N N N Current week 5 1 1 1 1 1 1 1 N 1 N N 1 1 N N N N N N N N N N Anaplasma phagocytophilum Previous 52 weeks Med 21 1 0 0 0 0 0 0 5 1 3 0 0 5 0 0 0 0 4 4 0 0 4 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Max 145 10 6 2 0 2 6 1 17 7 14 3 1 45 2 0 0 1 45 77 0 1 75 2 0 0 0 7 1 0 1 1 2 4 1 2 0 2 2 0 1 2 9 2 0 7 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Cum 2011 24 2 1 1 5 5 2 1 1 4 N 1 3 N 7 N 1 1 5 4 2 2 N N N N N N N N N N Cum 2010 186 18 5 4 5 4 20 14 6 65 65 74 N 74 N 8 1 N 4 1 2 1 1 N N N N N N N N N N Current week N N N N N N N N N N N N N N Undetermined Previous 52 weeks Med 1 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Max 13 1 0 0 0 1 0 0 2 1 2 0 1 6 2 3 1 0 3 11 0 0 11 3 0 0 0 1 0 0 0 1 1 0 0 1 0 2 0 1 1 1 1 0 0 0 1 1 1 0 0 0 0 0 0 0 1 0 1 0 0 0 0 0 0 0 Cum 2011 9 1 1 3 1 1 1 1 N 1 N N 1 N 1 2 2 N N N N N 1 N 1 N N N N Cum 2010 15 1 1 8 7 1 N N N 4 N 1 3 N N N N N 2 N 2 N N N N
C.N.M.I.: Commonwealth of Northern Mariana Islands. U: Unavailable. : No reported cases. N: Not reportable. NN: Not Nationally Notifiable. Cum: Cumulative year-to-date counts. Med: Median. Max: Maximum. * Case counts for reporting year 2010 and 2011 are provisional and subject to change. For further information on interpretation of these data, see http://www.cdc.gov/osels/ph_surveillance/ nndss/phs/files/ProvisionalNationa%20NotifiableDiseasesSurveillanceData20100927.pdf. Data for TB are displayed in Table IV, which appears quarterly. Cumulative total E. ewingii cases reported for year 2010 = 10, and 2 cases reported for 2011. Contains data reported through the National Electronic Disease Surveillance System (NEDSS).
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Giardiasis Reporting area United States New England Connecticut Maine Massachusetts New Hampshire Rhode Island Vermont Mid. Atlantic New Jersey New York (Upstate) New York City Pennsylvania E.N. Central Illinois Indiana Michigan Ohio Wisconsin W.N. Central Iowa Kansas Minnesota Missouri Nebraska North Dakota South Dakota S. Atlantic Delaware District of Columbia Florida Georgia Maryland North Carolina South Carolina Virginia West Virginia E.S. Central Alabama Kentucky Mississippi Tennessee W.S. Central Arkansas Louisiana Oklahoma Texas Mountain Arizona Colorado Idaho Montana Nevada New Mexico Utah Wyoming Pacific Alaska California Hawaii Oregon Washington Territories American Samoa C.N.M.I. Guam Puerto Rico U.S. Virgin Islands Current Previous 52 weeks Cum week Med Max 2011 134 5 1 1 3 29 13 6 10 17 1 16 8 2 1 5 31 18 6 2 N 5 2 2 N N N N 13 7 4 1 1 29 17 2 10 341 28 5 3 14 2 1 3 61 7 22 17 15 52 10 5 11 17 9 32 5 3 11 8 4 0 1 70 0 1 36 14 4 0 2 8 0 4 4 0 0 0 5 2 3 0 0 29 3 12 4 1 2 2 5 1 51 2 33 1 8 9 0 0 0 0 542 55 12 11 25 10 7 10 106 22 72 30 27 94 32 11 25 29 35 73 12 10 33 26 9 6 5 127 5 5 75 51 11 0 9 32 8 11 11 0 0 0 17 9 12 5 0 58 8 27 9 6 11 6 13 5 129 6 68 4 20 57 0 1 8 0 4,714 361 61 37 176 24 7 56 929 45 329 293 262 760 126 79 168 283 104 311 78 27 119 66 21 971 7 9 422 327 74 N 35 83 14 53 53 N N N 64 34 30 N 383 43 179 49 15 27 18 40 12 882 22 595 13 152 100 8 Cum 2010 6,709 563 107 66 237 66 23 64 1,133 158 387 321 267 1,175 272 138 248 320 197 698 101 81 262 133 75 8 38 1,317 10 17 687 265 125 N 45 155 13 57 57 N N N 132 37 55 40 N 620 53 261 85 50 23 30 98 20 1,014 36 619 23 190 146 1 29 Gonorrhea Current Previous 52 weeks week Med Max 3,465 76 71 2 3 389 43 109 28 209 294 23 165 64 42 117 3 2 112 1,276 13 38 231 216 92 339 213 125 9 361 100 120 72 69 602 85 177 79 261 82 24 33 25 268 239 7 22 5 5,914 101 41 3 49 3 6 0 708 116 111 235 259 1,051 297 117 248 325 97 293 36 40 38 143 22 3 10 1,427 17 39 383 277 133 266 155 121 14 495 161 73 116 142 861 99 112 79 598 191 64 49 2 1 33 27 4 1 628 21 520 14 22 59 0 0 6 3 7,485 206 150 7 80 7 15 17 1,121 172 271 497 365 2,091 369 1,018 490 383 130 363 57 62 62 181 49 11 20 1,879 48 70 486 891 246 596 257 189 26 1,007 403 712 216 194 1,664 138 509 332 867 255 92 92 14 5 103 98 10 4 807 34 695 26 40 86 0 5 12 7 Cum 2011 105,013 1,781 680 60 858 47 120 16 13,381 2,190 2,073 4,345 4,773 17,808 3,046 2,867 4,642 5,589 1,664 5,430 696 697 615 2,736 432 54 200 26,242 361 718 7,177 4,375 2,109 5,916 3,099 2,154 333 9,380 3,119 1,553 2,053 2,655 15,247 1,883 835 1,292 11,237 3,587 1,240 863 42 28 779 550 66 19 12,157 376 9,991 236 479 1,075 6 139 44 Cum 2010 112,609 1,941 894 80 789 61 106 11 12,785 2,124 1,916 4,498 4,247 20,696 5,584 1,655 5,489 6,180 1,788 5,365 664 752 829 2,500 429 66 125 29,106 386 740 7,586 5,908 2,390 5,668 2,957 3,285 186 9,106 2,699 1,480 2,371 2,556 18,542 1,735 3,176 1,449 12,182 3,551 1,233 1,000 41 46 689 395 134 13 11,517 561 9,302 254 396 1,004 5 106 37 Haemophilus influenzae, invasive All ages, all serotypes Current week 43 11 1 2 8 4 1 3 5 5 14 6 4 3 1 1 1 2 2 4 2 1 1 2 2 Previous 52 weeks Med 58 3 0 0 2 0 0 0 11 2 3 2 4 10 3 1 1 2 1 4 0 0 1 1 0 0 0 15 0 0 5 3 1 2 1 1 0 3 1 1 0 1 3 0 0 1 0 5 2 1 0 0 0 1 0 0 3 0 0 0 1 0 0 0 0 0 Max 141 9 6 2 6 2 2 3 32 7 18 5 11 19 9 7 4 6 5 9 0 2 5 5 3 2 0 28 1 0 12 7 5 9 5 8 9 10 4 4 2 4 26 3 4 19 4 12 6 5 2 1 2 4 3 1 10 2 6 2 6 2 0 0 0 0 Cum 2011 1,213 65 6 9 37 8 3 2 237 34 61 44 98 214 56 34 27 67 30 46 4 25 16 1 315 1 118 66 23 38 24 45 77 25 13 5 34 60 13 22 24 1 124 55 26 7 2 8 20 6 75 9 12 11 42 1 Cum 2010 1,283 75 12 3 43 7 7 3 248 40 66 44 98 196 64 41 15 50 26 85 1 10 32 32 5 5 314 3 84 72 21 43 44 39 8 77 8 14 6 49 60 9 15 31 5 158 62 39 7 1 5 21 18 5 70 12 13 11 30 4 1
C.N.M.I.: Commonwealth of Northern Mariana Islands. U: Unavailable. : No reported cases. N: Not reportable. NN: Not Nationally Notifiable. Cum: Cumulative year-to-date counts. Med: Median. Max: Maximum. * Case counts for reporting year 2010 and 2011 are provisional and subject to change. For further information on interpretation of these data, see http://www.cdc.gov/osels/ph_surveillance/ nndss/phs/files/ProvisionalNationa%20NotifiableDiseasesSurveillanceData20100927.pdf. Data for TB are displayed in Table IV, which appears quarterly. Data for H. influenzae (age <5 yrs for serotype b, nonserotype b, and unknown serotype) are available in Table I. Contains data reported through the National Electronic Disease Surveillance System (NEDSS).
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Hepatitis (viral, acute), by type A Reporting area United States New England Connecticut Maine Massachusetts New Hampshire Rhode Island Vermont Mid. Atlantic New Jersey New York (Upstate) New York City Pennsylvania E.N. Central Illinois Indiana Michigan Ohio Wisconsin W.N. Central Iowa Kansas Minnesota Missouri Nebraska North Dakota South Dakota S. Atlantic Delaware District of Columbia Florida Georgia Maryland North Carolina South Carolina Virginia West Virginia E.S. Central Alabama Kentucky Mississippi Tennessee W.S. Central Arkansas Louisiana Oklahoma Texas Mountain Arizona Colorado Idaho Montana Nevada New Mexico Utah Wyoming Pacific Alaska California Hawaii Oregon Washington Territories American Samoa C.N.M.I. Guam Puerto Rico U.S. Virgin Islands Current Previous 52 weeks week Med Max 12 3 3 1 1 3 1 1 1 1 1 4 4 28 1 0 0 0 0 0 0 4 1 1 1 1 4 1 0 1 1 0 1 0 0 0 0 0 0 0 5 0 0 2 1 0 0 0 1 0 0 0 0 0 0 2 0 0 0 2 2 0 0 0 0 0 0 0 0 6 0 5 0 0 0 0 0 0 0 74 6 4 1 5 1 1 1 12 4 4 6 3 9 3 3 5 5 2 25 3 2 22 1 4 3 2 14 1 0 7 4 2 4 1 6 5 6 2 6 1 2 15 1 1 4 11 8 4 2 2 1 3 1 2 3 15 1 15 2 1 2 0 5 2 0 Cum 2011 420 12 5 1 3 1 2 68 7 20 23 18 65 10 8 23 22 2 15 1 3 2 4 3 2 85 1 34 23 8 8 3 8 8 2 2 4 30 1 1 28 29 7 8 4 2 4 3 1 108 1 93 4 3 7 8 2 Cum 2010 607 52 12 3 32 5 94 27 21 26 20 81 24 9 25 14 9 21 4 7 1 7 2 132 5 1 44 14 11 25 16 15 1 17 4 9 1 3 51 4 47 67 31 16 4 4 6 3 3 92 73 4 8 7 10 8 Current week 9 1 1 U 3 1 2 4 3 1 1 1 Med 60 0 0 0 0 0 0 0 5 1 1 1 1 7 2 1 2 1 1 2 0 0 0 2 0 0 0 15 0 0 4 2 1 2 1 2 0 8 1 3 1 3 9 1 1 2 4 2 0 0 0 0 1 0 0 0 5 0 3 0 1 1 0 1 0 0 B Previous 52 weeks Max 165 4 3 2 3 1 0 1 11 5 9 4 3 23 7 6 5 16 3 16 1 2 15 3 3 0 1 33 2 0 11 8 4 16 4 7 18 14 4 8 3 8 65 4 4 14 45 7 2 5 1 0 3 2 1 1 25 1 22 1 3 4 0 8 2 0 Cum 2011 810 20 6 5 8 1 U 100 23 18 27 32 105 24 12 34 25 10 48 4 5 2 30 6 1 231 78 38 22 55 12 26 143 33 45 10 55 85 15 18 16 36 29 9 3 2 12 2 1 49 2 22 4 14 7 28 1 Cum 2010 1,188 28 8 8 7 4 U 1 125 36 18 38 33 191 44 28 52 45 22 51 10 3 2 27 9 341 15 3 116 72 31 29 19 32 24 116 26 37 12 41 174 25 21 25 103 54 12 14 4 16 2 6 108 1 74 3 18 12 18 10 Current week 8 N U 1 1 2 U 1 1 1 U 1 2 U 1 1 2 U U 2 N Med 17 1 0 0 0 0 0 0 1 0 1 0 0 2 0 0 1 0 0 0 0 0 0 0 0 0 0 4 0 0 1 1 0 1 0 0 0 3 0 2 0 1 2 0 0 1 0 1 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 C Previous 52 weeks Max 36 4 4 2 1 0 0 1 6 4 4 1 2 9 1 4 6 1 1 6 0 1 6 1 1 0 1 8 0 0 5 3 2 4 1 2 5 8 1 6 0 5 11 0 2 10 3 4 0 3 2 1 2 1 2 0 9 0 4 0 3 5 0 7 0 0 Cum 2011 333 18 12 3 1 N U 2 25 15 10 79 1 29 46 2 1 3 2 1 68 U 20 12 12 19 5 58 3 27 U 28 36 4 19 13 18 U 2 7 1 6 2 28 U 13 U 7 8 10 N Cum 2010 293 24 11 2 11 N U 34 7 16 1 10 35 13 17 3 2 6 3 2 1 69 U 2 20 8 9 18 6 6 52 1 36 U 15 23 9 14 24 U 7 6 1 7 3 26 U 11 U 8 7 19 N
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Legionellosis Reporting area United States New England Connecticut Maine Massachusetts New Hampshire Rhode Island Vermont Mid. Atlantic New Jersey New York (Upstate) New York City Pennsylvania E.N. Central Illinois Indiana Michigan Ohio Wisconsin W.N. Central Iowa Kansas Minnesota Missouri Nebraska North Dakota South Dakota S. Atlantic Delaware District of Columbia Florida Georgia Maryland North Carolina South Carolina Virginia West Virginia E.S. Central Alabama Kentucky Mississippi Tennessee W.S. Central Arkansas Louisiana Oklahoma Texas Mountain Arizona Colorado Idaho Montana Nevada New Mexico Utah Wyoming Pacific Alaska California Hawaii Oregon Washington Territories American Samoa C.N.M.I. Guam Puerto Rico U.S. Virgin Islands Current Previous 52 weeks week Med Max 18 5 3 1 1 2 2 5 2 2 1 4 1 3 1 1 1 1 N 61 4 0 0 2 0 0 0 15 2 5 2 5 11 2 1 2 4 0 2 0 0 0 1 0 0 0 9 0 0 3 1 2 1 0 1 0 2 0 0 0 1 3 0 0 0 2 2 1 0 0 0 0 0 0 0 5 0 4 0 0 0 0 0 0 0 126 16 6 3 10 5 4 2 53 18 19 17 19 42 15 4 20 15 5 9 2 2 8 4 2 1 2 27 3 4 9 4 6 7 2 9 3 10 2 4 3 6 13 2 3 3 11 10 7 2 1 1 2 2 2 2 21 2 15 1 3 6 0 1 0 0 Cum 2011 600 28 2 3 17 2 1 3 134 1 59 25 49 111 12 13 23 63 13 2 2 8 1 117 2 54 3 19 21 4 14 35 6 8 3 18 21 6 1 14 29 11 3 1 7 2 4 1 112 100 1 3 8 N Cum 2010 790 45 10 2 24 3 5 1 182 31 46 38 67 154 24 21 28 61 20 27 2 3 9 6 2 2 3 156 5 7 57 25 32 12 2 14 2 37 4 8 2 23 32 4 1 3 24 57 17 14 1 11 2 10 2 100 91 2 7 N Current week 154 115 27 88 3 1 2 32 5 10 17 4 4 N N N Lyme disease Previous 52 weeks Med 361 105 34 10 23 15 1 3 149 42 36 9 57 26 1 0 1 0 22 13 0 0 11 0 0 0 0 57 10 1 1 0 18 1 0 17 0 0 0 0 0 0 1 0 0 0 1 0 0 0 0 0 0 0 0 0 3 0 2 0 0 0 0 0 0 0 Max 1,828 503 213 62 223 69 40 28 662 234 159 31 279 373 18 7 14 9 345 188 10 1 181 1 2 10 1 178 33 5 8 2 104 9 3 82 29 4 2 1 0 4 29 0 1 0 29 3 1 1 2 1 1 2 1 0 11 1 9 0 3 4 0 0 0 0 Cum 2011 2,965 467 203 64 94 83 4 19 1,628 387 271 2 968 202 4 3 5 6 184 4 2 1 1 582 169 6 15 1 214 13 3 161 9 5 4 11 11 3 2 1 59 41 N 18 N N Cum 2010 5,914 2,209 872 136 752 388 23 38 2,063 902 386 179 596 474 15 19 5 6 429 207 13 5 186 3 852 215 8 20 3 398 30 13 151 14 14 1 13 26 26 4 2 1 1 65 1 38 N 25 1 N N Current week 16 6 1 1 4 1 1 3 1 2 1 1 1 1 4 3 1 Med 30 1 0 0 0 0 0 0 9 1 1 5 1 3 1 0 0 1 0 1 0 0 0 0 0 0 0 7 0 0 2 1 1 0 0 1 0 0 0 0 0 0 1 0 0 0 1 1 0 0 0 0 0 0 0 0 4 0 2 0 0 0 0 0 0 0 Malaria Previous 52 weeks Max 114 20 20 1 4 2 4 1 22 6 6 13 3 9 6 2 4 5 2 45 2 2 45 3 1 1 2 41 1 2 7 7 21 13 1 5 1 3 1 1 2 2 18 1 1 1 17 4 3 3 1 1 2 1 0 0 10 2 10 1 3 5 0 0 0 0 Cum 2011 349 13 1 9 1 2 84 8 12 45 19 41 15 2 7 16 1 3 2 1 109 2 5 31 23 21 9 18 8 2 4 1 1 16 1 2 13 18 7 5 1 3 2 57 2 42 2 5 6 Cum 2010 463 28 2 21 1 3 1 145 28 26 67 24 41 19 4 4 13 1 21 6 3 3 3 6 135 2 5 45 21 23 18 1 20 6 1 2 3 26 1 1 3 21 19 7 6 1 2 3 42 2 28 1 4 7 4
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Meningococcal disease, invasive All serogroups Reporting area United States New England Connecticut Maine Massachusetts New Hampshire Rhode Island Vermont Mid. Atlantic New Jersey New York (Upstate) New York City Pennsylvania E.N. Central Illinois Indiana Michigan Ohio Wisconsin W.N. Central Iowa Kansas Minnesota Missouri Nebraska North Dakota South Dakota S. Atlantic Delaware District of Columbia Florida Georgia Maryland North Carolina South Carolina Virginia West Virginia E.S. Central Alabama Kentucky Mississippi Tennessee W.S. Central Arkansas Louisiana Oklahoma Texas Mountain Arizona Colorado Idaho Montana Nevada New Mexico Utah Wyoming Pacific Alaska California Hawaii Oregon Washington Territories American Samoa C.N.M.I. Guam Puerto Rico U.S. Virgin Islands Current Previous 52 weeks week Med Max 8 1 1 1 1 1 1 1 1 1 1 3 2 1 15 0 0 0 0 0 0 0 1 0 0 0 0 2 0 0 0 0 0 1 0 0 0 0 0 0 0 2 0 0 1 0 0 0 0 0 0 1 0 0 0 0 1 0 0 0 1 1 0 0 0 0 0 0 0 0 3 0 2 0 1 0 0 0 0 0 53 4 1 1 2 1 1 3 5 1 4 3 2 6 3 2 4 2 2 4 1 2 2 2 2 1 1 7 1 1 5 2 1 3 1 2 1 3 1 2 1 2 12 1 2 2 10 6 2 4 1 2 1 1 1 1 26 1 17 1 3 8 0 0 0 0 Cum 2011 326 19 3 3 9 1 3 30 7 13 10 40 11 6 5 13 5 24 6 2 8 6 1 1 57 1 24 4 5 10 4 9 14 7 2 5 27 6 5 4 12 25 8 2 3 3 3 1 5 90 1 62 3 16 8 Cum 2010 359 6 1 2 3 35 10 6 9 10 63 13 15 8 16 11 22 5 1 2 10 4 69 36 5 2 9 5 11 1 19 4 8 2 5 42 5 11 12 14 24 7 6 3 1 4 2 1 79 1 49 1 14 14 Current week 4 1 1 1 1 1 1 1 1 Med 12 0 0 0 0 0 0 0 4 1 0 0 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 2 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 3 0 0 Mumps Previous 52 weeks Max 217 2 0 1 2 2 0 0 209 11 5 201 16 7 3 1 1 5 1 7 7 1 4 3 1 1 1 4 0 1 2 2 1 2 1 2 0 2 2 1 1 1 15 1 2 1 14 4 1 1 1 0 1 2 1 1 5 1 4 1 1 2 0 32 1 0 Cum 2011 136 1 1 15 8 3 4 37 23 6 8 15 3 3 1 6 1 1 9 2 1 4 2 4 1 2 1 40 1 39 2 1 1 13 1 7 2 3 12 Cum 2010 1,576 16 11 1 4 1,375 269 627 465 14 32 10 2 12 7 1 58 21 3 3 8 22 1 31 2 6 1 7 5 3 5 2 6 4 2 31 1 3 27 7 2 5 20 1 13 1 1 4 293 Current week 183 2 2 13 4 9 14 5 9 109 108 1 8 4 2 1 1 1 1 18 1 17 10 1 7 1 1 8 1 7 Med 548 10 1 1 5 0 0 0 39 3 12 1 20 113 22 11 30 33 13 36 11 2 0 7 4 0 0 38 0 0 6 4 2 3 6 7 0 12 3 3 1 3 51 2 1 1 42 43 13 13 2 2 0 2 6 0 146 0 128 1 5 9 0 0 0 0 Pertussis Previous 52 weeks Max 2,925 24 8 8 13 3 7 4 125 10 81 19 70 198 52 26 57 80 26 501 36 9 469 43 13 30 2 106 4 2 28 13 6 35 25 41 41 35 8 16 10 11 297 18 3 92 187 100 29 63 15 16 7 11 16 2 1,710 6 1,569 6 12 131 0 14 1 0 Cum 2011 4,917 128 17 44 48 15 3 1 466 39 137 7 283 1,191 212 77 411 373 118 359 56 29 108 109 35 20 2 479 10 2 107 71 36 94 52 107 135 43 40 5 47 375 19 10 17 329 800 315 291 33 52 12 47 48 2 984 14 768 14 85 103 31 1 Cum 2010 4,959 112 18 5 79 3 4 3 251 51 84 7 109 1,214 207 172 352 413 70 395 151 57 5 135 30 17 485 3 84 74 50 130 84 53 7 310 83 118 21 88 1,090 57 16 5 1,012 425 164 50 55 8 4 32 108 4 677 11 493 22 98 53 1
C.N.M.I.: Commonwealth of Northern Mariana Islands. U: Unavailable. : No reported cases. N: Not reportable. NN: Not Nationally Notifiable. Cum: Cumulative year-to-date counts. Med: Median. Max: Maximum. * Case counts for reporting year 2010 and 2011 are provisional and subject to change. For further information on interpretation of these data, see http://www.cdc.gov/osels/ph_surveillance/ nndss/phs/files/ProvisionalNationa%20NotifiableDiseasesSurveillanceData20100927.pdf. Data for TB are displayed in Table IV, which appears quarterly. Data for meningococcal disease, invasive caused by serogroups A, C, Y, and W-135; serogroup B; other serogroup; and unknown serogroup are available in Table I. Contains data reported through the National Electronic Disease Surveillance System (NEDSS).
680
MMWR / May 27, 2011 / Vol. 60 / No. 20
Rabies, animal Reporting area United States New England Connecticut Maine Massachusetts New Hampshire Rhode Island Vermont Mid. Atlantic New Jersey New York (Upstate) New York City Pennsylvania E.N. Central Illinois Indiana Michigan Ohio Wisconsin W.N. Central Iowa Kansas Minnesota Missouri Nebraska North Dakota South Dakota S. Atlantic Delaware District of Columbia Florida Georgia Maryland North Carolina South Carolina Virginia West Virginia E.S. Central Alabama Kentucky Mississippi Tennessee W.S. Central Arkansas Louisiana Oklahoma Texas Mountain Arizona Colorado Idaho Montana Nevada New Mexico Utah Wyoming Pacific Alaska California Hawaii Oregon Washington Territories American Samoa C.N.M.I. Guam Puerto Rico U.S. Virgin Islands Current Previous 52 weeks week Med Max 48 4 3 1 8 8 4 1 3 N 31 10 N 21 1 1 N N N 61 4 0 1 0 0 0 1 16 0 8 0 6 2 1 0 1 0 0 3 0 1 0 0 1 0 0 19 0 0 0 0 6 0 0 12 0 3 1 0 0 1 11 0 0 0 11 1 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 167 18 14 3 0 6 4 3 33 0 19 4 17 27 11 0 5 12 0 40 3 4 34 6 3 6 0 37 0 0 29 0 14 0 0 27 7 7 7 4 0 4 54 10 0 30 30 5 2 0 2 0 2 2 3 4 14 2 12 0 2 14 0 0 2 0 Cum 2011 684 37 18 5 2 12 100 100 25 5 8 12 N 26 12 10 4 390 41 112 N 237 45 29 3 13 45 33 12 3 N N 3 13 9 4 N 10 Cum 2010 1,591 107 54 25 4 5 19 415 171 118 126 35 15 14 6 N 85 6 24 13 17 22 3 472 121 144 N 178 29 76 35 3 38 333 11 4 318 17 N 1 N 4 12 51 11 36 4 N 21 Current week 410 2 1 1 44 24 1 19 27 4 23 21 3 3 12 3 170 81 29 17 34 9 21 7 8 6 31 13 11 7 25 1 11 3 2 8 69 47 2 20 Salmonellosis Previous 52 weeks Med 975 29 0 3 18 3 2 1 92 21 25 21 31 85 29 13 14 24 11 48 9 7 9 15 4 0 3 261 3 1 108 43 18 26 25 21 1 57 20 11 17 18 145 13 19 12 95 48 16 10 3 1 4 5 5 1 115 1 81 6 8 16 0 0 5 0 Max 1,810 160 138 8 52 12 17 5 217 57 63 53 80 265 124 62 49 47 57 121 34 19 30 43 13 13 17 624 11 7 226 142 54 241 99 68 14 176 52 32 66 53 515 43 52 95 381 113 43 24 9 6 21 19 17 8 288 4 232 13 20 42 1 3 21 0 Cum 2011 9,730 445 138 43 204 35 10 15 1,087 79 302 279 427 1,062 335 109 173 334 111 574 134 91 250 57 42 2,817 33 10 1,191 492 225 410 197 240 19 599 175 114 111 199 1,007 149 141 127 590 681 227 167 54 29 61 57 65 21 1,458 23 1,088 102 112 133 6 22 Cum 2010 12,100 1,006 491 30 367 57 43 18 1,479 279 341 353 506 1,614 545 187 253 409 220 748 109 106 228 199 58 6 42 2,825 30 36 1,315 409 258 317 193 204 63 618 184 120 136 178 1,210 92 288 116 714 842 255 196 49 33 67 92 132 18 1,758 29 1,191 108 232 198 1 1 194 Shiga toxin-producing E. coli (STEC) Current week 52 2 2 2 2 4 2 2 25 11 3 4 7 2 1 1 3 1 2 6 1 1 3 1 8 4 1 3 Previous 52 weeks Med 102 2 0 0 1 0 0 0 10 2 4 1 3 11 2 3 2 2 2 14 2 1 4 4 1 0 0 17 0 0 6 2 2 2 0 3 0 5 1 1 0 2 7 1 0 1 5 10 1 3 2 1 0 1 2 0 12 0 7 0 2 3 0 0 0 0 Max 258 18 18 3 9 3 1 2 30 9 12 6 13 48 9 10 7 11 16 49 16 5 20 12 6 10 4 31 2 2 15 7 8 10 4 9 4 22 4 6 12 7 144 4 2 48 95 33 14 21 7 3 6 6 8 3 46 1 36 3 11 20 0 0 0 0 Cum 2011 1,107 36 18 3 5 8 2 115 15 37 18 45 139 11 27 36 43 22 112 27 18 47 17 3 304 3 1 142 32 32 39 9 45 1 62 13 9 4 36 67 8 3 10 46 119 27 15 24 8 14 12 17 2 153 109 2 21 21 Cum 2010 1,125 96 60 3 23 8 2 115 28 40 10 37 191 38 22 54 36 41 175 26 15 41 67 18 8 163 1 3 56 20 21 13 6 40 3 53 14 7 7 25 58 13 6 2 37 138 23 47 13 15 9 14 13 4 136 1 62 14 12 47
C.N.M.I.: Commonwealth of Northern Mariana Islands. U: Unavailable. : No reported cases. N: Not reportable. NN: Not Nationally Notifiable. Cum: Cumulative year-to-date counts. Med: Median. Max: Maximum. * Case counts for reporting year 2010 and 2011 are provisional and subject to change. For further information on interpretation of these data, see http://www.cdc.gov/osels/ph_surveillance/ nndss/phs/files/ProvisionalNationa%20NotifiableDiseasesSurveillanceData20100927.pdf. Data for TB are displayed in Table IV, which appears quarterly. Includes E. coli O157:H7; Shiga toxin-positive, serogroup non-O157; and Shiga toxin-positive, not serogrouped. Contains data reported through the National Electronic Disease Surveillance System (NEDSS).
MMWR / May 27, 2011 / Vol. 60 / No. 20
681
Spotted Fever Rickettsiosis (including RMSF) Shigellosis Reporting area United States New England Connecticut Maine Massachusetts New Hampshire Rhode Island Vermont Mid. Atlantic New Jersey New York (Upstate) New York City Pennsylvania E.N. Central Illinois Indiana Michigan Ohio Wisconsin W.N. Central Iowa Kansas Minnesota Missouri Nebraska North Dakota South Dakota S. Atlantic Delaware District of Columbia Florida Georgia Maryland North Carolina South Carolina Virginia West Virginia E.S. Central Alabama Kentucky Mississippi Tennessee W.S. Central Arkansas Louisiana Oklahoma Texas Mountain Arizona Colorado Idaho Montana Nevada New Mexico Utah Wyoming Pacific Alaska California Hawaii Oregon Washington Territories American Samoa C.N.M.I. Guam Puerto Rico U.S. Virgin Islands Current week 169 1 1 6 6 3 3 104 81 16 3 3 1 4 1 3 35 1 5 29 5 1 2 1 1 11 8 1 2 Previous 52 weeks Med 273 4 0 0 2 0 0 0 17 4 3 5 5 19 7 1 4 5 0 17 1 4 0 10 0 0 0 61 0 0 31 14 2 3 1 2 0 14 5 2 1 4 55 2 5 3 44 17 7 2 0 0 0 3 1 0 23 0 19 1 1 1 1 0 0 0 Max 741 17 13 3 16 2 4 1 74 16 15 14 56 37 20 5 10 18 4 81 4 12 4 65 10 0 2 122 2 3 63 26 8 36 5 8 66 29 15 19 5 14 502 7 13 160 338 32 19 8 3 15 6 10 4 0 63 1 59 4 4 22 1 1 1 0 Cum 2011 3,067 62 13 5 42 2 178 24 40 79 35 197 56 25 44 72 139 7 24 104 3 1 1,129 6 805 159 33 79 15 30 2 165 61 28 36 40 598 23 49 39 487 264 66 33 7 88 7 46 16 1 335 1 256 26 25 27 1 1 Cum 2010 4,991 153 69 3 69 4 7 1 675 130 65 125 355 817 560 22 85 109 41 1,105 22 106 17 945 11 4 694 30 15 239 249 41 52 28 39 1 256 34 111 13 98 749 15 85 121 528 209 113 23 7 4 11 41 10 333 265 22 22 24 1 1 Current week N N N N N Med 2 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Confirmed Previous 52 weeks Max 10 0 0 0 0 0 0 0 1 0 1 0 1 1 1 1 0 0 0 2 0 0 0 2 1 0 0 7 0 1 1 6 1 3 1 2 0 3 1 1 0 2 7 2 0 4 1 5 4 1 0 1 0 0 0 0 2 0 2 0 0 1 0 0 0 0 Cum 2011 20 2 2 2 2 10 1 1 4 1 1 2 6 6 N N N N N Cum 2010 24 1 1 1 1 14 1 1 10 2 5 4 1 1 1 2 N 2 N N N N Current week 10 5 5 4 2 2 1 1 N N N N N Med 26 0 0 0 0 0 0 0 1 0 0 0 0 1 0 0 0 0 0 4 0 0 0 4 0 0 0 6 0 0 0 0 0 2 0 2 0 5 1 0 0 4 2 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Probable Previous 52 weeks Max 237 1 0 1 0 1 1 0 7 5 3 2 3 10 5 5 1 2 1 17 1 0 2 17 1 1 0 59 3 0 2 0 5 47 2 12 0 30 9 0 4 20 227 28 1 194 5 7 7 1 1 1 0 0 1 1 1 0 0 0 1 0 0 0 0 0 Cum 2011 149 1 1 5 1 2 2 6 3 1 2 32 1 31 39 5 2 5 12 4 11 41 11 30 4 1 2 1 21 21 N N N N N Cum 2010 211 1 1 13 10 2 1 21 11 6 3 1 43 2 40 1 66 5 4 8 36 3 10 47 7 3 37 17 5 8 4 3 1 1 1 N N N N N
C.N.M.I.: Commonwealth of Northern Mariana Islands. U: Unavailable. : No reported cases. N: Not reportable. NN: Not Nationally Notifiable. Cum: Cumulative year-to-date counts. Med: Median. Max: Maximum. * Case counts for reporting year 2010 and 2011 are provisional and subject to change. For further information on interpretation of these data, see http://www.cdc.gov/osels/ph_surveillance/ nndss/phs/files/ProvisionalNationa%20NotifiableDiseasesSurveillanceData20100927.pdf. Data for TB are displayed in Table IV, which appears quarterly. Illnesses with similar clinical presentation that result from Spotted fever group rickettsia infections are reported as Spotted fever rickettsioses. Rocky Mountain spotted fever (RMSF) caused by Rickettsia rickettsii, is the most common and well-known spotted fever. Contains data reported through the National Electronic Disease Surveillance System (NEDSS).
682
MMWR / May 27, 2011 / Vol. 60 / No. 20
Streptococcus pneumoniae, invasive disease All ages Reporting area United States New England Connecticut Maine Massachusetts New Hampshire Rhode Island Vermont Mid. Atlantic New Jersey New York (Upstate) New York City Pennsylvania E.N. Central Illinois Indiana Michigan Ohio Wisconsin W.N. Central Iowa Kansas Minnesota Missouri Nebraska North Dakota South Dakota S. Atlantic Delaware District of Columbia Florida Georgia Maryland North Carolina South Carolina Virginia West Virginia E.S. Central Alabama Kentucky Mississippi Tennessee W.S. Central Arkansas Louisiana Oklahoma Texas Mountain Arizona Colorado Idaho Montana Nevada New Mexico Utah Wyoming Pacific Alaska California Hawaii Oregon Washington Territories American Samoa C.N.M.I. Guam Puerto Rico U.S. Virgin Islands Current Previous 52 weeks week Med Max 196 3 1 2 7 3 4 N 49 N 2 10 36 1 3 N N N 3 N 33 22 2 9 N N 10 N N N 10 74 4 N 70 17 3 12 N N N 2 N N N N 261 11 0 2 0 2 0 1 19 2 2 13 0 62 0 9 14 25 9 7 0 0 4 0 2 0 0 70 1 1 24 14 9 0 8 0 0 20 0 0 0 20 32 3 3 0 26 31 12 10 0 0 0 3 4 0 2 2 0 0 0 0 0 0 0 0 986 79 49 13 5 8 36 6 75 7 10 42 0 108 0 29 29 45 24 41 0 0 24 0 9 14 0 173 6 4 68 54 32 0 25 0 14 40 0 0 0 36 377 27 11 0 333 75 43 23 0 0 0 13 8 15 24 11 0 3 0 0 0 0 0 0 Cum 2011 6,084 176 7 58 14 51 8 38 400 39 41 320 N 1,502 N 279 336 667 220 62 N N N 62 N 1,554 28 26 756 206 286 N 252 N 471 N N N 471 959 123 97 N 739 891 437 244 N N N 132 63 15 69 68 N 1 N N N Cum 2010 7,670 405 186 64 44 64 8 39 507 66 84 357 N 1,607 N 356 365 635 251 429 N N 340 N 66 23 N 2,223 19 48 830 731 257 N 284 N 54 556 N N N 556 909 91 55 N 763 969 484 272 N N N 89 114 10 65 65 N N N N Current week 12 2 2 N 1 N 1 N N N N 2 2 N N 1 N N N 1 5 N 5 1 1 N N N N N N N Med 24 1 0 0 0 0 0 0 3 1 1 0 0 4 0 0 1 2 0 1 0 0 1 0 0 0 0 7 0 0 3 2 1 0 1 0 0 1 0 0 0 1 4 0 0 0 3 3 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Age <5 Previous 52 weeks Max 123 5 3 1 3 1 3 1 27 5 9 14 0 12 0 4 4 7 3 5 0 0 5 1 1 1 0 25 1 1 13 7 4 0 3 0 6 4 0 0 0 4 38 3 2 0 27 8 5 3 0 0 0 2 3 1 5 2 0 0 0 0 0 0 0 0 Cum 2011 458 18 6 2 6 1 3 53 21 23 9 N 85 N 13 20 44 8 4 N N N 4 N 116 3 67 17 14 N 15 N 26 N N N 26 88 10 8 N 70 63 29 15 N N N 9 10 5 5 N N N N Cum 2010 959 61 21 5 31 3 1 103 32 62 9 N 145 N 31 46 49 19 59 N N 50 N 9 N 267 7 104 83 31 N 32 N 10 56 N N N 56 115 11 15 N 89 137 61 40 N N N 13 21 2 16 16 N N N N Syphilis, primary and secondary Current week 82 1 1 10 5 2 3 27 1 2 3 3 5 4 6 3 12 2 3 6 1 18 5 2 2 9 4 2 1 1 10 6 4 3 Previous 52 weeks Med 252 9 1 0 5 0 0 0 30 4 2 14 7 29 14 3 4 9 1 7 0 0 3 2 0 0 0 63 0 3 23 11 8 7 3 4 0 14 3 3 3 5 37 3 8 1 23 12 4 2 0 0 2 1 0 0 52 0 42 0 1 6 0 0 4 0 Max 354 19 8 3 14 3 4 2 46 10 20 29 16 56 23 14 10 21 3 18 3 3 10 9 2 0 1 166 4 8 44 118 17 19 10 16 2 39 11 16 16 11 71 10 36 6 33 24 9 8 2 2 9 4 5 0 66 1 57 5 7 13 0 0 15 0 Cum 2011 4,078 139 18 8 87 12 10 4 471 67 68 207 129 317 52 49 72 128 16 110 5 5 45 53 2 1,109 5 71 405 152 169 141 80 86 227 41 43 50 93 598 70 108 21 399 196 71 44 3 1 51 21 5 911 742 5 37 127 82 Cum 2010 4,962 175 36 14 108 6 9 2 646 94 36 371 145 735 369 54 114 178 20 102 6 6 24 62 4 1,134 3 52 408 224 88 192 52 112 3 349 111 43 80 115 744 102 151 34 457 199 80 48 2 34 10 25 878 2 750 16 26 84 81
C.N.M.I.: Commonwealth of Northern Mariana Islands. U: Unavailable. : No reported cases. N: Not reportable. NN: Not Nationally Notifiable. Cum: Cumulative year-to-date counts. Med: Median. Max: Maximum. * Case counts for reporting year 2010 and 2011 are provisional and subject to change. For further information on interpretation of these data, see http://www.cdc.gov/osels/ph_surveillance/ nndss/phs/files/ProvisionalNationa%20NotifiableDiseasesSurveillanceData20100927.pdf. Data for TB are displayed in Table IV, which appears quarterly. Includes drug resistant and susceptible cases of invasive Streptococcus pneumoniae disease among children <5 years and among all ages. Case definition: Isolation of S. pneumoniae from a normally sterile body site (e.g., blood or cerebrospinal fluid). Contains data reported through the National Electronic Disease Surveillance System (NEDSS).
MMWR / May 27, 2011 / Vol. 60 / No. 20
683
West Nile virus disease Varicella (chickenpox) Reporting area United States New England Connecticut Maine Massachusetts New Hampshire Rhode Island Vermont Mid. Atlantic New Jersey New York (Upstate) New York City Pennsylvania E.N. Central Illinois Indiana Michigan Ohio Wisconsin W.N. Central Iowa Kansas Minnesota Missouri Nebraska North Dakota South Dakota S. Atlantic Delaware District of Columbia Florida Georgia Maryland North Carolina South Carolina Virginia West Virginia E.S. Central Alabama Kentucky Mississippi Tennessee W.S. Central Arkansas Louisiana Oklahoma Texas Mountain Arizona Colorado Idaho Montana Nevada New Mexico Utah Wyoming Pacific Alaska California Hawaii Oregon Washington Territories American Samoa C.N.M.I. Guam Puerto Rico U.S. Virgin Islands Current week 172 2 2 34 N 34 49 6 5 13 25 N 28 20 N N N 8 6 6 N N 48 N 48 5 5 N N N N N Previous 52 weeks Med 239 19 5 4 5 2 0 2 27 8 0 0 18 69 18 5 21 21 4 11 0 2 0 7 0 0 1 32 0 0 15 0 0 0 0 9 4 6 5 0 0 0 42 3 1 0 37 15 0 6 0 2 0 1 4 0 3 1 0 1 0 0 0 0 5 0 Max 584 46 15 16 17 9 4 13 62 23 0 0 41 153 41 19 43 58 22 35 0 8 0 24 5 10 7 99 4 3 57 0 0 0 6 29 23 15 14 0 3 0 258 17 5 0 247 50 0 31 0 28 0 8 26 3 22 5 19 4 0 0 0 4 30 0 Cum 2011 4,575 336 91 88 103 9 6 39 529 132 N 397 1,403 358 109 436 499 1 172 N 53 90 1 16 12 629 4 8 440 N N N 177 140 132 N 8 N 948 82 18 N 848 339 123 N 84 N 18 107 7 79 24 35 20 N N N 16 50 Cum 2010 7,341 454 133 98 119 57 11 36 756 284 N 1 471 2,631 660 236 807 671 257 395 N 178 183 1 23 10 1,030 13 8 533 N N N 71 202 203 144 142 N 2 N 1,315 108 34 N 1,173 570 203 N 101 N 53 203 10 46 18 13 15 N N N 8 185 Current week Neuroinvasive Previous 52 weeks Med 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Max 71 3 2 0 2 1 0 0 19 3 9 7 3 15 10 2 6 1 0 7 1 1 1 1 3 2 2 6 0 1 3 1 3 0 1 1 0 1 1 1 1 1 16 3 3 1 15 18 13 5 0 0 0 6 1 1 8 0 8 0 0 1 0 0 0 0 Cum 2011 Cum 2010 1 1 1 Current week Nonneuroinvasive Previous 52 weeks Med 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Max 53 2 2 0 1 0 0 0 13 6 7 4 3 7 4 2 1 1 1 11 2 3 3 0 7 2 3 4 0 1 1 3 2 0 0 1 0 3 1 1 2 2 3 1 1 0 2 15 9 11 1 0 1 2 1 1 6 0 6 0 0 1 0 0 0 0 Cum 2011 Cum 2010 7 3 2 1 3 3 1 1
C.N.M.I.: Commonwealth of Northern Mariana Islands. U: Unavailable. : No reported cases. N: Not reportable. NN: Not Nationally Notifiable. Cum: Cumulative year-to-date counts. Med: Median. Max: Maximum. * Case counts for reporting year 2010 and 2011 are provisional and subject to change. For further information on interpretation of these data, see http://www.cdc.gov/osels/ph_surveillance/ nndss/phs/files/ProvisionalNationa%20NotifiableDiseasesSurveillanceData20100927.pdf. Data for TB are displayed in Table IV, which appears quarterly. Updated weekly from reports to the Division of Vector-Borne Infectious Diseases, National Center for Zoonotic, Vector-Borne, and Enteric Diseases (ArboNET Surveillance). Data for California serogroup, eastern equine, Powassan, St. Louis, and western equine diseases are available in Table I. Not reportable in all states. Data from states where the condition is not reportable are excluded from this table, except starting in 2007 for the domestic arboviral diseases and influenzaassociated pediatric mortality, and in 2003 for SARS-CoV. Reporting exceptions are available at http://www.cdc.gov/osels/ph_surveillance/nndss/phs/infdis.htm. Contains data reported through the National Electronic Disease Surveillance System (NEDSS).
684
MMWR / May 27, 2011 / Vol. 60 / No. 20
TABLE III. Deaths in 122 U.S. cities,* week ending May 21, 2011 (20th week)
All causes, by age (years) Reporting area New England Boston, MA Bridgeport, CT Cambridge, MA Fall River, MA Hartford, CT Lowell, MA Lynn, MA New Bedford, MA New Haven, CT Providence, RI Somerville, MA Springfield, MA Waterbury, CT Worcester, MA Mid. Atlantic Albany, NY Allentown, PA Buffalo, NY Camden, NJ Elizabeth, NJ Erie, PA Jersey City, NJ New York City, NY Newark, NJ Paterson, NJ Philadelphia, PA Pittsburgh, PA Reading, PA Rochester, NY Schenectady, NY Scranton, PA Syracuse, NY Trenton, NJ Utica, NY Yonkers, NY E.N. Central Akron, OH Canton, OH Chicago, IL Cincinnati, OH Cleveland, OH Columbus, OH Dayton, OH Detroit, MI Evansville, IN Fort Wayne, IN Gary, IN Grand Rapids, MI Indianapolis, IN Lansing, MI Milwaukee, WI Peoria, IL Rockford, IL South Bend, IN Toledo, OH Youngstown, OH W.N. Central Des Moines, IA Duluth, MN Kansas City, KS Kansas City, MO Lincoln, NE Minneapolis, MN Omaha, NE St. Louis, MO St. Paul, MN Wichita, KS All Ages 446 103 30 19 16 53 20 6 25 34 53 4 21 24 38 2,043 46 26 88 19 20 56 12 1,023 24 8 419 36 24 68 23 31 68 24 18 10 2,056 51 35 226 84 280 210 128 171 48 52 11 62 209 57 77 63 65 66 90 71 527 60 30 29 62 47 67 83 12 47 90 65 315 63 19 16 14 37 12 6 23 21 42 3 14 18 27 1,383 29 26 52 13 10 45 9 710 10 5 255 25 15 45 18 26 49 17 15 9 1,385 25 28 141 56 205 131 100 97 35 36 5 46 126 45 48 47 40 45 68 61 349 39 23 12 39 36 33 67 6 35 59 4564 90 32 6 2 1 10 6 2 7 7 1 4 5 7 460 13 21 3 8 10 1 232 11 3 103 9 4 15 3 4 12 5 2 1 473 14 6 56 15 63 60 24 47 7 13 1 7 57 11 17 12 21 15 19 8 128 15 7 12 18 7 20 11 5 11 22 2544 24 7 3 1 2 2 3 3 3 117 2 8 1 1 1 2 50 3 33 2 5 1 2 5 1 120 5 1 24 4 9 14 1 18 5 1 5 3 16 3 2 4 2 3 26 4 4 5 2 5 2 4 124 5 1 2 1 1 39 4 1 15 13 1 1 2 1 1 37 2 5 3 2 1 1 5 2 4 4 1 3 1 3 11 2 5 1 1 2 <1 12 1 2 1 3 1 3 1 44 2 3 1 1 16 15 6 41 5 6 1 4 2 4 1 2 6 6 1 1 2 13 1 2 4 2 1 3 Total 47 11 3 5 1 3 2 1 2 3 6 1 4 5 99 4 5 5 1 4 4 1 38 2 19 5 2 1 1 1 4 1 1 154 3 5 14 6 25 11 11 6 4 4 1 11 23 6 2 5 2 4 11 49 6 5 3 4 5 8 10 3 5 P&I Reporting area (Continued) S. Atlantic Atlanta, GA Baltimore, MD Charlotte, NC Jacksonville, FL Miami, FL Norfolk, VA Richmond, VA Savannah, GA St. Petersburg, FL Tampa, FL Washington, D.C. Wilmington, DE E.S. Central Birmingham, AL Chattanooga, TN Knoxville, TN Lexington, KY Memphis, TN Mobile, AL Montgomery, AL Nashville, TN W.S. Central Austin, TX Baton Rouge, LA Corpus Christi, TX Dallas, TX El Paso, TX Fort Worth, TX Houston, TX Little Rock, AR New Orleans, LA San Antonio, TX Shreveport, LA Tulsa, OK Mountain Albuquerque, NM Boise, ID Colorado Springs, CO Denver, CO Las Vegas, NV Ogden, UT Phoenix, AZ Pueblo, CO Salt Lake City, UT Tucson, AZ Pacific Berkeley, CA Fresno, CA Glendale, CA Honolulu, HI Long Beach, CA Los Angeles, CA Pasadena, CA Portland, OR Sacramento, CA San Diego, CA San Francisco, CA San Jose, CA Santa Cruz, CA Seattle, WA Spokane, WA Tacoma, WA Total All Ages 1,182 143 148 135 173 101 41 60 48 43 178 100 12 934 219 93 110 100 150 81 39 142 1,254 84 64 57 218 82 U 181 90 U 290 81 107 1,054 162 70 68 82 300 23 U 45 121 183 1,636 13 120 34 48 81 241 35 106 195 164 108 182 21 116 64 108 11,132 All causes, by age (years) 65 739 86 86 100 110 58 27 38 31 27 113 54 9 582 143 58 71 63 83 56 23 85 819 53 46 36 121 63 U 118 57 U 182 64 79 708 99 56 39 51 197 16 U 33 92 125 1,143 8 88 29 34 48 153 27 74 125 127 74 128 13 87 54 74 7,423 4564 301 36 46 24 45 28 8 15 10 11 43 32 3 254 51 26 28 30 51 16 11 41 295 21 10 17 77 14 U 36 20 U 69 13 18 235 36 9 16 21 78 3 U 10 19 43 359 3 19 4 12 26 62 7 24 55 26 27 37 5 19 9 24 2,595 2544 84 15 8 7 12 10 4 4 3 13 8 58 11 8 9 5 10 5 4 6 84 8 6 2 13 4 U 12 9 U 23 2 5 63 19 1 8 6 14 2 U 1 4 8 83 11 1 2 5 20 7 7 3 5 11 2 5 1 3 659 124 34 3 5 3 2 3 4 3 1 1 5 4 20 11 1 2 3 3 28 1 2 2 4 U 5 2 U 9 1 2 26 3 2 5 2 5 2 U 1 3 3 28 2 1 5 3 2 1 4 1 3 6 228 <1 24 3 3 1 4 2 2 2 1 4 2 20 3 2 2 4 1 1 7 28 1 3 1 U 10 2 U 7 1 3 19 5 2 2 5 U 3 2 23 2 1 1 1 1 5 6 1 2 2 1 224 P&I Total 106 8 17 24 14 7 2 6 7 11 10 47 11 5 8 11 3 3 6 90 4 5 17 10 U 16 U 26 5 7 68 16 3 4 9 16 3 U 1 6 10 159 1 6 9 7 8 27 2 8 20 15 19 20 2 1 8 6 819
U: Unavailable. : No reported cases. * Mortality data in this table are voluntarily reported from 122 cities in the United States, most of which have populations of >100,000. 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. Because of changes in reporting methods in this Pennsylvania city, these numbers are partial counts for the current week. Complete counts will be available in 4 to 6 weeks. Total includes unknown ages.
MMWR / May 27, 2011 / Vol. 60 / No. 20
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The Morbidity and Mortality Weekly Report (MMWR) Series is prepared by the Centers for Disease Control and Prevention (CDC) and is available free of charge in electronic format. To receive an electronic copy each week, visit MMWRs free subscription page at http://www.cdc.gov/mmwr/mmwrsubscribe. html. Paper copy subscriptions are available through the Superintendent of Documents, U.S. Government Printing Office, Washington, DC 20402; telephone 202-512-1800. Data presented by the Notifiable Disease Data Team and 122 Cities Mortality Data Team in the weekly MMWR are provisional, based on weekly reports to CDC by state health departments. Address all inquiries about the MMWR Series, including material to be considered for publication, to Editor, MMWR Series, Mailstop E-90, CDC, 1600 Clifton Rd., N.E., Atlanta, GA 30333 or to [email protected]. All material in the MMWR Series is in the public domain and may be used and reprinted without permission; citation as to source, however, is appreciated. Use of trade names and commercial sources is for identification only and does not imply endorsement by the U.S. Department of Health and Human Services. References to non-CDC sites on the Internet are provided as a service to MMWR readers and do not constitute or imply endorsement of these organizations or their programs by CDC or the U.S. Department of Health and Human Services. CDC is not responsible for the content of these sites. URL addresses listed in MMWR were current as of the date of publication.
U.S. Government Printing Office: 2011-723-011/21051 Region IV ISSN: 0149-2195

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Morbidity and Mortality Weekly Report

Weekly / Vol. 60 / No. 20 May 27, 2011