Approximately 28,000 organ transplants were performed in the United States in 2007 (1). When infections are transmitted from donors, the implications can be serious for multiple recipients (2-4). Tuberculosis (TB), a known infectious disease complication associated with organ transplantation, occurs in an estimated 0.35%-6.5% of organ recipients in the United States and Europe posttransplantation (2). In 2007, the Oklahoma State Department of Health identified Mycobacterium tuberculosis in an organ donor 3 weeks after the donor's death. This report summarizes results of the subsequent investigation, which determined that disseminated TB occurred in two of three transplant recipients from this donor, and one recipient died. Genotypes of the donor and recipient TB isolates were identical, consistent with transmission of TB by organ transplantation. To reduce the risk for TB transmission associated with organ transplantation, organ recovery personnel should consider risk factors for TB when assessing all potential donors. In addition, clinicians should recognize that transplant recipients with TB might have unusual signs or symptoms. When transmission is suspected, investigation of potential donor-transmitted TB requires rapid communication among physicians, transplant centers, organ procurement organizations (OPOs), and public health authorities.#
Editorial Note: The majority of TB cases among organ transplant recipients are caused by activation of latent tuberculosis infection (LTBI) in the recipient once immunosuppressive medications are started to prevent organ rejection; a minority are attributed to donor transmission. In one international study, 4% of TB infections in recipients were considered donor derived (2). In this case report, genotyping supported the conclusion that transmission of TB occurred by organ transplantation to two recipients from a common donor. Although organ procurement protocols were followed, pretransplantation screening did not identify TB in the donor.
In the United States, all potential organ donors are screened to prevent transmission of infectious diseases, including TB, by organ transplantation. Minimum standards for donor eligibility are defined by United Network for Organ Sharing (UNOS), a nonprofit, private organization under government contract with the Health Resources and Services Administration to coordinate U.S. transplant activities (5). To evaluate eligibility, 1) the donor's medical record is reviewed for specific conditions (such as known active TB), 2) a medical and social history is conducted with next of kin (or other suitable person familiar with the donor), and 3) selected laboratory testing (such as testing for human immunodeficiency virus, hepatitis, and good organ function) and a chest radiograph are performed. No standard assessment is conducted to determine specifically whether the potential donor is at risk for having previously undiagnosed TB or LTBI. Although the screening process might uncover symptoms or risk factors for TB or LTBI, no further investigation or diagnostic testing is required. For all patients who are eligible by UNOS definitions, each OPO devises its own process for donor acceptance. The donor's medical and social history obtained by the OPO is made available for review by transplant center clinicians to independently assess risk for transmission of infection before accepting the organs for transplantation. The completeness and accuracy of this background information is variable, however, because often such information is obtained secondhand by interview of persons familiar with the donor.
Early recognition of posttransplantation TB in the recipient is critical for successful treatment. The incidence of TB among organ recipients is as much as 74 times that of the general population (2). In addition, 49% of U.S. transplant recipients with TB have disseminated disease, and 38% die (2). Extrapulmonary and disseminated diseases are common, leading to atypical signs that might not be easily recognized as TB if unsuspected by the clinician. In transplant patients, TB should be considered in the differential diagnosis of persistent fever, pneumonia, meningitis, septic arthritis, pyelonephritis, septicemia, graft rejection, or bone marrow suppression. Clinicians should recognize that the presence of an unusual constellation of symptoms, particularly during the first few weeks after transplantation, raises the possibility of donor-transmitted infection or activation of LTBI. Even with a high index of suspicion, TB in an organ recipient can be challenging to diagnose: 75%-80% of organ recipients who developed TB had a false-negative pretransplantation TST (6), and in this immunosuppressed population, symptoms of TB might be attributed to other potential complications, including organ rejection or other infectious diseases.
Diagnosis of TB in an organ recipient, in the absence of clear risk factors or other evidence from pretransplantation screening, should prompt investigation of possible transmission from the donor. Other recipients from a common donor might be at risk and should be evaluated for TB. When transplantation-transmitted TB is suspected, healthcare providers should alert the associated OPO, tissue bank, and public health authorities.
To prevent TB transmission by transplantation, specific policies can be established to improve recognition of disease in donors. In 2004, the American Society of Transplantation developed guidelines to assist in pretransplantation screening of potential organ donors and recipients (6,7). These recommendations are not mandatory standards and, therefore, are not necessarily incorporated into OPO standard operating procedures. OPOs can enhance their pretransplantation screening protocols by incorporating these guidelines to identify risk factors for unrecognized TB in the donor. If risk factors are found, further mycobacterial testing and radiologic assessment is warranted. For risk factor assessment, OPOs should obtain donor history of symptoms consistent with active TB, past diagnosis of TB infection (active or latent), homelessness, excess alcohol or injection-drug use, incarceration, recent exposure to persons with active TB, or travel to areas where TB is endemic. Complete donor medical and social histories should be provided to transplant centers.
Regardless of risk factor assessment, testing for M. tuberculosis (e.g., AFB smear or mycobacterial culture) whenever clinical specimens for routine bacterial testing are obtained from donors can help ensure detection of unrecognized TB. In addition, routine retention of samples of donor tissues and serum from organ procurement (or from autopsy) that are suitable for laboratory evaluation can aid subsequent transmission investigations. Genotyping and other relatedness testing of isolates can help establish or rule out transmission links between donor and recipients, as demonstrated in this report. OPOs also should follow up on results of all tests pending at the time of organ donation and notify transplant centers immediately of any results that might have implications for recipients. Because not all disease transmission through transplantation can be prevented, rapid recognition is critical to facilitate appropriate treatment, minimize complications, enhance patient safety, and improve public health.  (1).- Approximately 19% of child maltreatment fatalities occurred among infants (i.e., persons aged <1 year) (1), and homicide statistics suggest that fatality risk might be greatest in the first week of life (2). However, the risk for nonfatal maltreatment among infants has not been examined previously at the national level. To determine the extent of nonfatal infant maltreatment in the United States, CDC and the federal Administration for Children and Families (ACF) analyzed data collected in fiscal year 2006 (the most recent data available) from the National Child Abuse and Neglect Data System (NCANDS). This report summarizes the results of that analysis, which indicated that, in fiscal year 2006, a total of 91,278 infants aged <1 year (rate: 23.2 per 1,000 population) experienced nonfatal maltreatment, including 29,881 (32.7%) who were aged <1 week. Neglect was the maltreatment category cited for 68.5% of infants aged <1 week, but NCANDS data did not permit further characterization of the nature of this neglect. Developing effective measures to prevent maltreatment of infants aged <1 week will require more detailed characterization of neglect in this age group.
NCANDS is a national data collection and analysis system created in response to the federal Child Abuse Prevention and Treatment Act.  Data have been collected annually from states and reported since 1993. States submit caselevel data as child-specific records for each report of alleged child maltreatment for which a completed investigation or assessment by a CPS agency has been made during the reporting period. Individual CPS agencies are responsible for determining the type of maltreatment and outcome of the maltreatment investigation based on state and federal laws. However, no standardized definitions of maltreatment are used consistently by all states; therefore, each state maps its own classification of maltreatment onto NCANDS definitions  before sending the final data file to NCANDS. Once a state submits its data to NCANDS, a technical validation review is conducted by a staff supervised by the ACF Children's Bureau to assess the internal consistency of the data and to identify probable causes for missing data. States are requested to make corrections as needed.
In fiscal year 2006, 49 states, the District of Columbia, and Puerto Rico provided case-level data to NCANDS. For this report, data from five states (Alaska, Maryland, North Dakota, Pennsylvania, and Vermont) were not available for analysis. Only data regarding victims with a CPS agency disposition of substantiated maltreatment issued during fiscal year 2006 were analyzed. Among the approximately 3.6 million children aged <18 years who were subjects of maltreatment investigations in fiscal year 2006, maltreatment was substantiated by CPS agencies in approximately 905,000 (25.1%) children. Substantiated maltreatment data were analyzed for victims aged <1 year by the age of the infant victim at the time of first report, sex, race/ ethnicity, type of maltreatment, and source of the report.
A total of 91,278 unique victims of substantiated maltreatment were identified in CPS agency dispositions in fiscal year 2006 among infants aged <1 year, an annual rate of 23.2 per 1,000 population. A total of 47,117 (51.6%) victims were male. By race/ethnicity, 39,768 (43.6%) infant victims were white; 23,008 (25.2%) were black or African American; 17,582 (19.3%) were Hispanic; 1,141 (1.3%) were American Indian or Alaska Native; and 583 (0.6%) were Asian.  Multiple race/ethnicity was identified for 2,874 (3.1%) of the infant victims, and 6,322 (6.9%) were of unknown race/ethnicity. Among the 91,278 infant victims of substantiated maltreatment, 35,455 (38.8%) were aged <1 month (Figure 1). Of these, 29,881 (84.3%) were aged <1 week (Figure 2). Among maltreated infants aged <1 week, 20,472 (68.5%) were categorized as victims of neglect (including deprivation of necessities or medical neglect), and 3,957 (13.2%) as victims of physical abuse (Table ).    This report is the first published national analysis of substantiated nonfatal maltreatment of infants, using NCANDS data. Although the results demonstrate a concentration of maltreatment and neglect at age <1 week, NCANDS data cannot be used to determine the etiology of the infant maltreatment and neglect because NCANDS reports are limited to broad categories and do not provide specific information about diagnoses or the circumstances of the maltreatment. The concentration of reports of neglect in the first few days of life and the preponderance of reports from medical professionals during the same period suggest that neglect often was identified at birth. One hypothesis for the concentration of maltreatment and neglect reports in the first few days of life is that the majority of reports resulted from maternal or newborn drug tests. Although tracking of prenatal substance exposure and hospital postnatal toxicology-screening practices vary among states and within states, positive maternal or neonatal drug test results routinely are reported to CPS agencies as child neglect (3). Additional research is needed to clearly define the causes of substantiated neglect and maltreatment among newborns and to determine the best strategies for intervention.
The percentage of substantiated reports categorized as physical abuse among infants aged <1 week (13.2%) is similar to the percentage among maltreated children of all ages (16%) (1). Physical abuse is defined by CDC and NCANDS as the intentional use of physical force by a parent or caregiver against a child that results in, or has the potential to result in, physical injury. Physical abuse includes beating, kicking, biting, burning, shaking, or otherwise harming a child. Although the act is intentional, the consequence might be intentional or unintentional (i.e., resulting from overdiscipline or physical punishment) (1,4). One type of physical abuse, shaken baby syndrome/ abusive head trauma (SBS/AHT) (5), is a cause of severe physical injury and death in infants, occurring in 21.0-32.2 infants aged <1 year per 100,000 population. More detailed study of contextual information is needed to determine the causes of physical abuse in infants reported to NCANDS and to develop additional prevention strategies.
Few studies have examined rates and risk factors for maltreatment in infants aged <1 year, and risk for nonfatal maltreatment among infants has not been examined previously at the national level in the United States. A study by the Public Health Agency of Canada provided nationallevel data for that country (excluding the province of Quebec) and reported incidence in 2003 of substantiated nonfatal maltreatment among infants aged <1 year of 27.3 per 1,000 population for females and 29.1 for males, similar to the rates described in this report. Also similar to this study, the Canadian study found that neglect was the most common form of substantiated maltreatment for children aged <3 years; the Canadian study did not determine the most common form of maltreatment among infants aged <1 year.
The findings in this report are subject to at least two other limitations, in addition to the lack of specific information about maltreatment circumstances. First, underreporting or delayed reporting might influence the findings. Both mandated reporters and the public might lack sufficient knowledge or training that supports reporting possible child maltreatment (6,7). To assist health-care professionals in better reporting child maltreatment, CDC developed uniform definitions and recommended data elements to promote and improve consistency of child maltreatment reporting and serve as a technical reference for the collection of data (4). Second, data collection and reporting practices vary among states, and data from certain states were not available for analysis.
CDC supports a range of research, early intervention, and prevention programs at the national, state, and local levels. These efforts include a focus on developing child-maltreatment tracking programs in state health departments and promotion of positive parenting and prevention of child maltreatment through a framework of safe, stable, and nurturing relationships between children and caregivers.   Similarly, ACF supports a range of prevention and intervention programs, including programs to identify and serve substance-exposed newborns and reduce variation in the policies and procedures related to prenatal substance exposure. Reframing neglect as a series of missed opportunities for prevention and emphasizing safe, stable, and nurturing relationships can highlight opportunities for prevention that might otherwise be missed. For example, approximately 84% of pregnant women in the United States receive some prenatal care, and approximately 99% of infants are born in medical settings ( 8), these setting provide an opportunity for medical professionals to detect and manage early risk for maltreatment (e.g., maternal substance abuse) that can impair or interfere with child-caregiver relationships.
Serious injury resulting from physical abuse of infants can be decreased by efforts focusing on reduction of SBS/ AHT through in-hospital programs aimed at parents of newborns. These programs have produced a substantial reduction in reported SBS/AHT in localized areas ( 9), and CDC is supporting research to evaluate the replicability of these results in diverse settings. In addition, home-visitation and parent-training programs (10), particularly those that 1) begin during pregnancy, 2) provide social support to parents, and 3) teach parents about developmentally appropriate infant behavior and age-appropriate disciplinary communication skills, have been determined to reduce risk for child maltreatment.

# Surveillance for Community-Associated Clostridium difficile -Connecticut, 2006
Clostridium difficile is a well-known cause of hospitalacquired infectious diarrhea and is associated with increased health-care costs, prolonged hospitalizations, and increased patient morbidity. Previous antimicrobial use, especially use of clindamycin or ciprofloxacin, is the primary risk factor for development of C. difficile-associated diarrhea (CDAD) because it disrupts normal bowel flora and promotes C. difficile overgrowth (1). Historically, CDAD has been associated with elderly hospital in-patients or longterm-care facility (LTCF) residents. Since 2000, a strain of C. difficile that has been identified as North American pulsed-field type 1 (NAP1) and produces an extra toxin (binary toxin) and increased amounts of toxins A and B has caused increased morbidity and mortality among hospitalized patients (2,3). During 2005, related strains caused severe disease in generally healthy persons in the community at a rate of 7.6 cases per 100,000 population, suggesting that traditional risk factors for C. difficile might not always be factors in development of community-associated CDAD (CA-CDAD) (4). Cases of CA-CDAD are not nationally reportable, and population-based data at a statewide level have not been reported previously. In 2006, the Connecticut Department of Public Health (DPH) implemented a statewide surveillance system to assess the burden of CA-CDAD and to determine the descriptive epidemiology, trends, and risk factors for this disease. This report describes that surveillance system and summarizes results from the first year of surveillance. The findings indicated the presence of occasionally severe CDAD among healthy persons living in the community, including persons with no established risk factors for infection. Clinicians should consider a diagnosis of CA-CDAD in outpatients with severe diarrhea, even in the absence of established risk factors. In addition, continued surveillance is needed to determine trends in occurrence and whether more toxigenic strains are having an increasing impact in the community and in the hospital setting.
On January 1, 2006, CA-CDAD was added to the list of conditions reportable by Connecticut health-care providers. A case of CA-CDAD was defined as a positive C. difficile toxin assay for a person with gastrointestinal symptoms and no known previous overnight hospitalizations or LTCF stays during the 3 months preceding specimen collection, collected from an outpatient or within 48 hours of hospital admission (5). DPH staff members contacted hospital infection-control practitioners at Connecticut's 32 acute-care hospitals by telephone, informed them about the new reporting requirements, and asked them to review positive laboratory results to identify cases. Laboratories were not required to report to DPH. Physicians were informed by a special mailing. In May 2006, all hospitals were sent a letter summarizing initial findings and reminding physicians and infection-control practitioners about the reporting requirements. In addition, hospitals that did not initially report cases were recontacted by telephone and reminded of the reporting requirements. DPH staff members contacted treating physicians to confirm case status and collect patient information, including demographics, symptoms, select medical history, and possible risk factors. When necessary, DPH staff members reviewed medical records or conducted patient interviews. However, systematic patient interviews to verify absence of a recent stay in a health-care setting were not conducted.
Incidence rates were calculated using the number of confirmed cases reported among Connecticut residents and 2005 U.S. Census state population estimates. Differences in proportions and tests for trend by age group were evaluated using the chi-square test and chi-square test for trend; multivariate logistic regression analysis was conducted. A separate 3-month pilot study was conducted during 2006 by FoodNet,- Emerging Infections Program sites,  and CDC to collect specimens from patients with CA-CDAD for culture for C. difficile and to characterize the isolates by toxinotyping and detection of binary toxin and deletions in the tcdC gene (6). As part of this study, in Connecticut, all toxin-positive stool specimens from confirmed CA-CDAD patients at three hospital laboratories were collected and cultured.
A total of 456 possible cases, determined on the basis of tests conducted on outpatients or within 2 days of hospitalization, were reported during 2006; 241 (53%) were subsequently confirmed as meeting the case definition. Of the 215 cases that were not confirmed, 159 (74%) occurred in persons who had an LTCF stay or hospitalization during the preceding 3 months, 50 (23%) occurred in per- sons for whom insufficient medical information was available to enable confirmation; and six (5 years increased with age; females had nearly twice the incidence of males. Rates were higher during the spring and summer months than during the fall and winter months (Table 1).
A total of 28 (88%) of 32 acute-care hospitals reported at least one case of CA-CDAD (range: 1-26 cases). Among the 241 cases, 110 (46%) were in patients who required hospitalization for CA-CDAD, mainly for diagnosis and treatment of dehydration or colitis; 13 (12%) were in patients who required an intensive-care unit stay, two (2%) were in patients who had both toxic megacolon and a colectomy, and two (2%) were in patients who died of complications related to C. difficile infection. The median length of stay among hospitalized patients was 4 days (range: 1-39 days). Among all patients for whom follow-up information was available, 29% had an inpatient health-care exposure (defined as overnight hospitalization or LTCF stay during the >3 to 12 months preceding illness or day surgery during the 12 months preceding illness), 67% had an underlying medical condition, and 68% had taken an antimicrobial during the 3 months preceding symptom onset (Table 2). When CA-CDAD patients requiring hospitalization were compared with those managed as outpatients, independent predictors of hospitalization by multivariate analysis included age of >65 years (p = 0.001), fever (p = 0.001), and inpatient health-care exposure during the >3 to 12 months preceding illness (p = 0.04).
A total of 59 (25%) patients had no underlying conditions and no inpatient health-care exposures during the 12 months preceding illness. Compared with all other patients, this group was younger (63% versus 23% were aged <45 years ), less likely to be hospitalized for their CA-CDAD illness (36% versus 52% ), and more likely to report bloody diarrhea (37% versus 19% ). In addition, 35 (59%) patients received an antimicrobial during the 3 months preceding symptom onset, 21 (36%) took no antimicrobial, and three (5%) patients had no information on antimicrobial use available.
Twelve C. difficile isolates were recovered from toxinpositive stool specimens and were characterized at CDC. Eight (67%) had binary toxin genes similar to the epidemic NAP1 strain, and three (25%) were identified as NAP1.
Coinfection with a second pathogen appeared to be rare. A review of the FoodNet enteric pathogen surveillance database in Connecticut indicated that five (2%) of the 241 patients with CA-CDAD also had a stool-culture positive result for another reportable enteric pathogen from a specimen collected on the same day or within 1 day of the toxin-positive C. difficile sample: Salmonella (one patient), Campylobacter (three), and Escherichia coli O157:H7 (one). Editorial Note: The findings in this report demonstrate that CA-CDAD is an important and geographically widespread health problem among Connecticut outpatients, a population previously thought to be at low risk for this disease. Although interest in CA-CDAD has grown in recent years, this report describes the first attempt to define population-based incidence of this disease at the state level. The CA-CDAD incidence in Connecticut in 2006 (6.9 per 100,000 population) was similar to that found in Philadelphia in 2005 (7.6 per 100,000 population) using a similar case definition. Both of these rates were considerably lower than that found in the United Kingdom (UK) in 2004 (22.0 per 100,000 population), despite the fact the UK study used a more restrictive case definition in which persons with hospitalization during the 12 months preceding illness onset were excluded (4,7).
The findings in this report highlight the importance of increasing age (with the attendant underlying health problems and increased use of the health-care system) and antibiotic exposure in the development of CDAD. However, one fourth of all CA-CDAD cases were in persons who lacked established predisposing risk factors for CDAD, including advanced age, an underlying health condition, and a health-care exposure during the 12 months preceding illness. Moreover, similar to what was observed in the community studies conducted in Philadelphia and the UK, 32% of patients had no recent exposure to antimicrobials. Approximately 9% of all cases were in patients who had none of these factors. These findings emphasize the need for continued study of this disease to identify additional risk factors for exposure to C. difficile and for development of disease.
The ability of C. difficile to form spores is thought to be a key feature in enabling the bacteria to persist in patients and the physical environment for long periods, thereby facilitating its transmission. C. difficile is transmitted through the fecal-oral route. Postulated risk factors for acquiring C. difficile in the community include contact with a contaminated health-care environment, contact with persons who are infected with and shedding C. difficile (person-to-person transmission), and ingestion of contaminated food.
Studies have shown C. difficile to be a pathogen or colonizer of calves, pigs, and humans (8,9). The recent detection of the NAP1 strain of C. difficile in retail ground beef is cause for concern (9). This hyper-toxin-producing strain has been reported as a cause of serious outbreaks of healthcare-associated disease in humans in North America and Europe (10) and was found among a small subset of specimens from CA-CDAD cases in Connecticut. Further studies are needed to determine whether C. difficile is transmitted via the food chain and the relative importance of such transmission in human CDAD.
The findings in this report are subject to at least four limitations. First, measured incidence is subject to the limitations of the toxin-detection assays usually used for diagnosis of C. difficile. These assays can be insensitive (i.e., 65%-90% sensitivity) and nonspecific; in addition, 1%-2% of persons tested with the most widely used toxin assays might test positive in the absence of infection. Because C. difficile is difficult and labor-intensive to isolate, culture usually is only used when a clinical need for verification of a positive toxin assay exists. Second, because systematic patient interviews were not conducted, some patients might have had recent health-care exposures that were not recorded in available medical records, leading to potential misclassification of health-care-associated cases as CA-CDAD. Third, underreporting might have occurred because laboratories were not required to report and no validation or assessment of completeness of reporting was conducted. Finally, because cultures were not routinely collected for isolation and molecular characterization of organisms, the extent to which recently described emerging strains are causing disease in Connecticut or are responsible for illness in persons without established risk factors for CA-CDAD is unknown.
Future CA-CDAD surveillance measures in Connecticut will focus on collecting detailed information on hospitalized patients for whom more complete medical records are available. Continued population-based surveillance is necessary to monitor trends and describe the extent of CA-CDAD and possible risk factors. Although CA-CDAD surveillance systems are resource intensive, other states should consider implementing these systems to assess trends in CA-CDAD and to help health-care providers become more aware of this emerging problem.

# Updated Recommendation from the Advisory Committee on Immunization Practices (ACIP) for Use of 7-Valent Pneumococcal Conjugate Vaccine (PCV7) in Children Aged 24-59 Months Who Are Not Completely Vaccinated
This notice updates the recommendation for use of 7-valent pneumococcal conjugate vaccine (PCV7) among children aged 24-59 months who are either unvaccinated or who have a lapse in PCV7 administration.- In February 2000, PCV7, marketed as Prevnar  and manufactured by Wyeth Vaccines (Collegeville, Pennsylvania), was approved by the Food and Drug Administration for use in infants and young children. At that time, the Advisory Committee on Immunization Practices (ACIP) recommended that children aged 24-59 months who have certain underlying medical conditions or are immunocompromised receive PCV7. In addition, ACIP recommended that PCV7 be considered for all other children aged 24-59 months, with priority given to those who are American Indian/Alaska Native or of African-American descent, and to children who attend group day care centers (1). The recommendation also provided schedules for administering PCV7 to children aged 24-59 months who were either unvaccinated or who had a lapse in PCV7 administration; these schedules included 1) 1 dose of PCV7 for healthy children, and 2) 2 doses of PCV7 >2 months apart for children with certain chronic diseases or immunosuppressive conditions (1).

# MMWR April 4, 2008
ACIP's rationale for limiting the recommendation for routine vaccination to children aged 24-59 months who have certain underlying medical conditions or are immunocompromised was concern about limited vaccine supply and cost. Since September 2004, PCV7 has not been in short supply (2). Additionally, certain health-care providers have found the permissive recommendation for healthy children aged 24-59 months to be confusing. The ACIP Pneumococcal Vaccines Work Group reviewed data on safety and immunogenicity of PCV7 in children aged 24-59 months, current rates of PCV7-type invasive disease, vaccination coverage rates, and post-licensure vaccine effectiveness. In October 2007, on the basis of that review, ACIP approved the following revised recommendation for use of PCV7 in children aged 24-59 months  :
- For all healthy children aged 24-59 months who have not completed any recommended schedule for PCV7, administer 1 dose of PCV7. - For all children with underlying medical conditions aged 24-59 months who have received 3 doses, administer 1 dose of PCV7. - For all children with underlying medical conditions aged 24-59 months who have received 2 years who have previously received PCV7 (3).

# Notice to Readers

# National Child Abuse Prevention Month -April 2008
April is National Child Abuse Prevention Month, an observance intended to increase awareness of child maltreatment and encourage individuals and communities to support children and families. CDC defines child maltreatment as any act or series of acts of commission or omission by a parent or other caregiver that results in harm, potential for harm, or threat of harm to a child (1).
During These publications and additional information regarding child maltreatment are available at / injury. Additional information from ACF is available at  and from the Child Welfare Information Gateway at .

# Notice to Readers

# National Public Health Week -April 7-13, 2008
Since 1995, the first full week of April has been designated in the United States as National Public Health Week. This year's observance focuses on climate change and public health. During April 7-13, 2008, CDC, the American Public Health Association, and members of the public health community will conduct activities and host events that encourage the public, policy-makers, and public health professionals to take steps that will have positive effects on their individual health, the health of the nation, and the climate.
In conjunction with the observance, CDC has developed resources and a list of actions that public health agencies can take to respond to potential health effects of climate change. Additional information regarding climate change and National Public Health Week is available at . cdc.gov/nceh/climatechange and . Public Health Emergency Law is designed to help public health practitioners and emergency management professionals improve their understanding of the use of law as a public health tool. Forensic Epidemiology is designed to help public health and law enforcement agencies strengthen coordination of responses to pandemic influenza and similar threats. Materials include a new CDC-developed case study on pandemic influenza.

# Notice to Readers

# New Public Health Emergency Law and Forensic Epidemiology
Information regarding ordering a free CD-ROM with the two sets of training materials is available at . gov/phlp/phel.asp. Additional information is available via e-mail at fe-phel@mcking.com.

# MMWR April 4, 2008
QuickStats from the national center for health statistics from the national center for health statistics from the national center for health statistics from the national center for health statistics from the national center for health statistics Life Expectancy Ranking- at Birth,  by Sex -Selected Countries and Territories, 2004   - Rankings are from the highest to lowest female life expectancy at birth.  Life expectancy at birth represents the average number of years that a group of infants would live if the infants were to experience throughout life the age-specific death rates present at birth.  Countries and territories were selected based on quality of data, high life expectancy, and a population of at least 1 million population. Differences in life expectancy reflect differences in reporting methods, which can vary by country, and actual differences in mortality rates.  Most recent data available. Data for Ireland and Italy are for 2003.
In 2004, life expectancy at birth ranged from a low of 59.1 years for the Russian male population to a high of 85.6 years for the female population of Japan. In the United States, life expectancy for men (75.2 years) ranked 25th out of 37 countries and territories and 23rd for women (80.4 years). Japan and Hong Kong were the countries with the highest life expectancy, whereas the countries of Eastern Europe (e.g., Russian Federation, Romania, and Bulgaria) reported the lowest life expectancy.

# SOURCES:
2 0 4 2 1 3 - 0 1 2 4 1 0 2 6 2 North Dakota - 0 0 - - - 0 1 - - - 0 0 - - South Dakota - 0 1 1 2 - 0 1 - 3 - 0 1 1 1 S.
1 0 2 8 1 - 0 1 1 3 - 0 1 1 1 Montana  - 0 2 - - - 0 1 - - - 0 1 2 - Nevada  - 0 1 - 4 - 1 3 8 1 2 - 0 2 2 2 New Mexico  - 0 2 5 1 - 0 2 2 4 - 0 1 1 2 Utah - 0 2 2 2 - 0 2 2 3 - 0 3 4 3 Wyoming  - 0 1 2 1 - 0 1 - - - 0 1 - 2