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.  "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?"#
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 WHO's 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 / index.html.

# Cigarette Package Health Warnings and Interest in Quitting Smoking -14 Countries, 2008-2010
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 package's principal display areas; 4) be large, clear, visible, and legible in the country's 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 2008-2010 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 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 2008-2010 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 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.     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. This report is the first to provide survey results from all 14 countries that participated in GATS during 2008-2010. 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 WHO's 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 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 Organization's 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. 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 WHO's 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 Brazil's 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 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). 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.

# 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: 70-110 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 patient's symptoms to be consistent with a neurologic illness and evaluated the patient further for a possible stroke or arboviral infection. A 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 patient's 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 patient's symptoms and history of recent mosquito bites, supported a presumptive diagnosis of WNV disease.
The acute sample was then sent to CDC's 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

# Human Jamestown Canyon Virus Infection -Montana, 2009
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 patient's 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.

# Editorial Note
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 (2)(3)(4). 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 1971-1981 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). 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 antigen-specific 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 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.
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. JCV's 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.
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-digit-dialed 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 "don't know/not sure" and a respondent's refusal to respond ("refused") also were included. Additional information available at .

# FIGURE. Classification for meeting 2008 physical activity guidelines*

# Contribution of Occupational Physical Activity Toward Meeting Recommended Physical Activity Guidelines -United States, 2007
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  = 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 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. Although the BRFSS occupational physical activity question has been reported as valid and reliable for classifying physical activities at work (4-6), 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.

# 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. 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, CDC's 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 culture-derived JE vaccine (JE-VC ) 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.

# 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 brain-derived vaccine (JE-VAX ), has been licensed in the U.S since 1992. However, JE-MB is no longer being produced and remaining doses expire in May 2011.
Additional JE-VC study data have become available since the vaccine's 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 (PRNT 50 ) 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) (4-6). 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

# Recommendations for Use of a Booster Dose of Inactivated Vero Cell
Culture-Derived Japanese Encephalitis Vaccine -Advisory Committee on Immunization Practices, 2011 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 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 ). 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.   Inactivated mouse brain-derived Japanese encephalitis (JE) vaccine (JE-MB ), 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.

# 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 culture-derived Japanese encephalitis vaccine (JE-VC ) administered 15 months after dose 1 of a 2-dose primary JE-VC series

# 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 CDC's 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).

# 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 2002-2009, 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 2,000-3,000 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.
In 2009, the Food and Drug Administration (FDA) approved an inactivated Vero cell culture-derived JE vaccine (JE-VC ) for use in adults aged 17 years. One pediatric dose-ranging study has been completed among 60 children aged 12-35 months in India (48 children received JE-VC, and 12 children received another inactivated mouse brain-derived JE vaccine ) (6). A safety and immunogenicity study is ongoing among approximately 1,900 children aged 2 months-17 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 / approvedproducts/ucm179132.htm.

# 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 months-17 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 . In addition, a list of U.S. clinical trial sites and contact information is available online from CDC at / 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 (vaccineinfo.us@novartis.com).
Several JE vaccines are manufactured and available for pediatric use in Asia but are not licensed in the United States.

# Update on Japanese Encephalitis Vaccine for Children -United States, May 2011
Vaccines available at international travelers' health clinics in Asia include another inactivated mouse brain-derived 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 / children.htm.

# On May 24, this report was posted as an MMWR Early Release on the MMWR website ().
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 2001-2008, a median of 56 (range: 37-140) 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 (7-21 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 1-May 20, 2011, a total of 118 cases were reported from 23 states and New York City (Figure 1), the 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 1-4 years, 23 (19%) were aged 5-19 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

# Measles -United States, January-May 20, 2011 FIGURE 1. Distribution and origin of reported measles cases (N = 118) -United States, January 1-May 20, 2011
Import associated Unknown source
- Additional information is available at / nndss/casedef/measles_2010.htm.
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: 3-21). 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

# Div of Viral Diseases, National Center for Immunization and Respiratory Diseases, CDC. Corresponding contributor: Huong
McLean, hmclean@cdc.gov, 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 1989-1991, 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 - 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. MMR vaccine is safe and highly effective in preventing measles and its complications. MMR vaccine is recommended routinely for all children at age 12-15 months, with a second dose at age 4-6 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. 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.
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 6-11 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.

# 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 ) 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 Diseases-United 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.

# 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 mid-June 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 , by telephone at 404-498-6140, or by e-mail at prevmed@cdc.gov.

# 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)." - 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, Children's 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 2005-2008, among U.S. adults aged 20-64 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 20-39 years and 40-64 years age groups, undiagnosed hypertension also was more common among persons with no health insurance compared with those with private or public insurance.
- 0 1 - 1 - 0 1 - - - 0 1 - - Mountain - 0 0 - - - 0 0 - - - 0 1 2 - Arizona - 0 0 - - - 0 0 - - - 0 1 2 - Colorado N 0 0 N N N 0 0 N N N 0 0 N N Idaho  N 0 0 N N N 0 0 N N N 0 0 N N Montana  N 0 0 N N N 0 0 N N N 0 0 N N Nevada  N 0 0 N N N 0 0 N N N 0 0 N N New Mexico  N 0 0 N N N 0 0 N N N 0 0 N N Utah - 0 0 - - - 0 0 - - - 0 0 - - Wyoming  - 0 0 - - - 0 0 - - - 0 0 - - Pacific - 0 1 - 1 - 0 0 - - - 0 1 1 2 Alaska N 0 0 N N N 0 0 N N N 0 0 N N California - 0 1 - 1 - 0 0 - - - 0 1 1 2 Hawaii N 0 0 N N N 0 0 N N N 0 0 N N Oregon - 0 0 - - - 0 0 - - - 0 0 - - Washington - 0 0 - - - 0 0 - - - 0 0 - -

# Territories

# Territories
- Case counts for reporting year 2010 and 2011 are provisional and subject to change. For further information on interpretation of these data, see / 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).                        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 MMWR's free subscription page at . html. Paper copy subscriptions are available through the Superintendent of Documents, U.S. Government Printing Office, Washington, DC 20402; telephone 202-512-1800.
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