CDC and state and local public health authorities have been investigating cases of bioterrorism-related anthrax. This report updates findings as of October 31, and includes interim guidelines for the clinical evaluation of persons with possible anthrax. A total of 21 cases (16 confirmed and five suspected) of bioterrorismrelated anthrax have been reported among persons who worked in the District of Columbia, Florida, New Jersey, and New York City (Figure 1). Until the source of these intentional exposures is eliminated, clinicians and laboratorians should be alert for clinical evidence of Bacillus anthracis infection. Epidemiologic investigation of these cases and surveillance to detect new cases of bioterrorism-associated anthrax continues.To date, the investigations in New York City have identified one confirmed inhalational case and six (three confirmed and three suspected) cutaneous anthrax cases; the confirmed inhalational and one suspected cutaneous case have been identified since the last report (1 ). The six cutaneous cases were associated with four media companies (A-D); the most recent suspected cutaneous case is associated with company D. The most#
infiltrate and a small pleural effusion. She was started on multidrug therapy, including ciprofloxacin, which was changed to azithromycin after 24 hours. On admission, she was febrile and tachycardic. She had an elevated white blood cell (WBC) count of 11,000 with 14% bands. A CT scan on October 19 showed a right pleural effusion, perihilar consolidation, and mediastinal adenopathy. She subsequently had two thoracenteses that produced serosanguinous pleural fluid and a bronchoscopy that showed grossly edematous bronchi. Both pleural fluid and bronchial biopsy were positive for B. anthracis by IHC stain.
On October 17, a 51-year-old woman developed a large pimple on her forehead with erythema and swelling. On October 18, the lesion enlarged, was slightly painful, nonpruritic, and drained a small amount of yellowish fluid. She sought medical care, cervical and preauricular lymphadenopathy was noted on physical examination, and she was treated with ciprofloxacin. The lesion progressed and ulcerated. On October 22, she presented to an emergency department and was admitted with a diagnosis of cellulitis. On admission, she was afebrile with normal vital signs and had a swollen right face and eyelid and enlarged right anterior cervical nodes. Intravenous ciprofloxacin for cutaneous anthrax was started. On October 24, the ulcer was biopsied and debrided. Biopsy specimens were positive for B. anthracis by PCR and IHC. The patient improved and was discharged on October 27 on oral ciprofloxacin. The patient worked as a bookkeeper and reported receiving no unusual or powder-containing mail at home or work. She had made no visits to any post offices in several months.

# District of Columbia
To date, investigations in the District of Columbia, Maryland, and Virginia have confirmed inhalational anthrax in four persons who worked at one postal facility in the District of Columbia. An additional case of inhalational anthrax has been confirmed in a 59-year-old postal worker in a U.S. State Department mail sorting facility that receives mail from the District of Columbia postal facility associated with the previous four cases. The patient presented to an emergency department on October 24 with temperature of 100.8 F (38 C), sweats, myalgia, chest discomfort, mild cough, nausea, vomiting, diarrhea, and abdominal pain. A chest radiograph initially was interpreted as normal but on further review indicated mediastinal widening. A CT scan showed mediastinal lymphadenopathy, hemorrhagic mediastinitis, small bilateral pleural effusions, and a small pericardial effusion. Blood cultures grew B. anthracis. The patient is receiving ciprofloxacin, rifampin, and penicillin.

# Florida
To date, the investigation in Florida has identified two confirmed inhalational cases. No new cases have been identified since the last report (1 ).

# Clinical Presentation of Inhalational and Cutaneous Cases

# Inhalational anthrax
To date, CDC has identified 10 patients with confirmed or suspected inhalational anthrax associated with bioterrorism. All but the most recent patients were postal workers (six), mail handlers or sorters (two), or a journalist who were known to or believed to have processed, handled, or received letters containing B. anthracis spores. The hospital employee with inhalational anthrax did not process mail but might have carried mail to other parts of the facility. Preliminary environmental testing of the patient's work area and home was negative for B. anthracis. The investigation is ongoing.

# MMWR November 2, 2001
The median age of the 10 patients with inhalational anthrax was 56 years (range: 43-73 years); seven were men. The incubation period from the time of exposure to onset of symptoms when known (seven) was 7 days (range: 5-11 days).
The initial illness in these patients was characterized by fever (nine) and/or sweats/ chills (six) (Figure 2). Severe fatigue or malaise was present in eight and minimal or nonproductive cough in nine, including one with blood-tinged sputum. Eight patients reported chest discomfort or pleuritic pain. Abdominal pain or nausea or vomiting occurred in five, and five reported chest heaviness. Other symptoms included shortness of breath (seven), headache (five), myalgias (four), and sore throat (two).
On initial presentation, total WBC count was normal or slightly elevated (7.5-13.3 x 10 3 /cumm); however, elevation in the percentage of neutrophils or band forms was frequently noted. None of the patients had a low WBC count or lymphocytosis when initially evaluated. Chest radiograph was abnormal in all patients, but in two an initial reading was interpreted as within normal limits. Mediastinal changes including mediastinal widening, paratracheal fullness, hilar fullness, and mediastinal lymphadenopathy were noted in all eight patients who had CT scans. Mediastinal widening may be subtle, and careful review of the chest radiograph by a radiologist may be necessary. Pleural effusions were present in seven patients and were a feature of the two patients who did not have mediastinal changes on chest radiograph or did not have a CT scan. Pleural effusions often were large and hemorrhagic, reaccumulated, and required repeated thoracentesis or chest tubes. Pulmonary infiltrates were observed in four patients and were multilobar in three. Blood cultures grew B. anthracis in seven patients and in all who had not received antimicrobials. Diagnosis in the patients with negative cultures was confirmed by bronchial or pleural biopsy and specific IHC staining, by PCR of material from a sterile site, or by a fourfold rise in IgG to the protective antigen.
To date, six of 10 patients with inhalational anthrax have survived. Among those whose condition was recognized early, all remain alive and two have been discharged from the hospital. Prompt recognition of the early features of inhalational anthrax is important in settings of known or suspected exposure.

# Cutaneous anthrax
Eleven patients with cutaneous anthrax have been identified in the current outbreak. Patients with cutaneous anthrax were mail handlers or sorters (four), employees of or visitors to media companies (six), and one bookkeeper. The mean incubation period for cutaneous anthrax was 5 days (range: 1-10 days) based on estimates from the postmark of letters and assumptions of dates of exposures with known positive letters or suspect letters (Figure 3).
Lesions occurred on the forearm, neck, chest, and fingers (two). Lesions were painless but accompanied by a tingling sensation or pruritis. Diagnosis was established by biopsy or culture.   (1 ). A fourth case occurred in a mail handler at a facility not previously linked to cases but that receives mail from a facility at which cases have occurred previously. Two new cases have no discernable epidemiologic link with anthrax cases previously reported or sites that are associated with known cases. These new cases suggest that anthrax exposure has occurred or is continuing to occur through means that cannot be ascribed to known contaminated letters or the paths these letters took through the mail service.
The public health response to these new anthrax cases will evolve based on ongoing epidemiologic and criminal investigations.
Because exposures are being intentionally perpetrated, public health authorities must be vigilant for the appearance of new cases in previously unaffected populations. Prompt data sharing between law enforcement and public health authorities is essential.
Since September 11, 2001, state and local health departments have been responding to many reports of potential bioterrorist threats including letters containing powder, suspicious packages, and potential dispersal devices. During September 11-October 17, 40 state and territorial health officials who responded to a CDC telephone survey estimated that 7,000 reports had been received at their health departments, approximately 4,800 required phone follow-up, and 1,050 reports led to testing of suspicious materials at a public health laboratory (CDC, unpublished data, 2001). In comparison, the number of anthrax threats reported to federal authorities during 1996-2000 did not exceed 180 reported threats per year (Federal Bureau of Investigation, unpublished data, 2001). Therefore, although only four areas have identified cases of bioterrorism-associated anthrax, health departments throughout the nation are responding to public concerns, bioterrorism hoaxes, and threats.
CDC is working with state and local health departments and the U.S. Postal Service to develop standardized guidelines for identifying populations that should receive antimicrobial prophylaxis for prevention of inhalational anthrax. Current challenges include identifying factors that promote the aeresolization of B. anthracis in mail-handling facilities and assessing the risk for anthrax in environments contaminated with B. anthracis spores. Safe levels of B. anthracis spore contamination in occupational settings must be defined to determine the need for clean-up of contaminated facilities. The current antimicrobial prophylaxis recommendations address the prevention of inhalational anthrax, but CDC also is evaluating measures to prevent cutaneous anthrax.
Postexposure prophylaxis with a recommended antimicrobial agent for the prescribed period of time can prevent inhalational anthrax. In the case of a known contaminated letter sent to the office of a U.S. Senator, antimicrobial prophylaxis was administered to persons from the area of exposure and first-responders to the incident (1 ). To date, there have been no cases of anthrax, even among those who had the greatest exposure. Antimicrobial prophylaxis had been recommended for the U.S. State Department mail handler with anthrax, but the worker had not started treatment before the onset of illness. Public health response must include prompt initiation of prophylaxis for exposed persons and systems to promote adherence to a full 60-day regimen.

# MMWR November 2, 2001
Update: Investigation of Anthrax -Continued Previous guidelines recommended ciprofloxacin for antimicrobial prophylaxis until antimicrobial susceptibility test data was available (3 ). Isolates involved in the current bioterrorism attacks have been susceptible to ciprofloxacin, doxycycline, and several other antimicrobial agents. Considerations for choosing an antimicrobial agent include effectiveness, resistance, side effects, and cost. No evidence demonstrates that ciprofloxacin is more or less effective than doxycycline for antimicrobial prophylaxis to B. anthracis. Widespread use of any antimicrobial will promote resistance. Many common pathogens are already resistant to tetracyclines such as doxycycline. However, fluoroquinolone resistance is not yet common in these same organisms. To preserve the effectiveness of fluoroquinolone against other infections, use of doxycycline for prevention of B. anthracis infection among populations at risk may be preferable. However, the selection of the antimicrobial agent for an individual patient should be based on sideeffect profiles, history of reactions, and the clinical setting.
CDC and state and local public health agencies continue to mobilize epidemiologic, laboratory, and other staff to identify and investigate acts of bioterrorism. Cases of bioterrorism-associated anthrax continue to occur and new risk populations may be identified. Until the cause of these acts are removed, public health authorities and clinicians should remain alert for cases of anthrax.

# Major Cardiovascular Disease (CVD) During 1997-1999 and Major CVD Hospital Discharge Rates in 1997 Among Women with Diabetes -United States
Cardiovascular disease (CVD) is the leading cause of death among all women (1 ) and the risk for death from CVD among women with diabetes is two to four times higher than that for women without diabetes (2 ). The excess risk for death as the result of CVD among persons with diabetes is better understood than the excess risk for CVD morbidity (2 ). To estimate national CVD prevalence and CVD hospital use among women with diabetes, CDC and the Agency for Health Care Research and Quality (AHRQ) analyzed data from the 1997-1999 National Health Interview Survey (NHIS) and the 1997 Nationwide Inpatient Sample (NIS). Findings indicate that the age-adjusted prevalence of major CVD for women with diabetes is twice that for women without diabetes and that the ageadjusted major CVD hospital discharge rate for women with diabetes is almost four times the rate for women without diabetes. These findings underscore the need to reduce risk factors associated with CVD among all women with diabetes through focused public health and clinical efforts.
The prevalence of CVD among women aged >18 years by diabetes status was obtained from a 3-year average of the estimates from the 1997-1999 NHIS, an ongoing nationally representative survey providing information on the health of the noninstitutionalized U.S. civilian population. Respondents were asked whether they had ever been told by a doctor or other health-care provider that they had hypertension, coronary heart disease, angina, heart attack, other kinds of heart conditions or heart disease, stroke, or diabetes. Major CVD was defined as one or more positive responses to the six CVD condition questions, and diabetes was defined as a positive response to the diabetes question.
The number of major CVD hospital discharges was estimated from the 1997 NIS, a stratified probability sample of hospitals in 22 states. Discharges from the 22 states represented approximately 60% of all discharges in the United States. Sample data were weighted using the American Hospital Association Annual Survey of Hospitals to approximate discharges from all U.S. acute-care community hospitals. Analysis was restricted to major CVD discharges (e.g., ischemic heart disease, hypertensive disease, rheumatic heart disease, and stroke) having an International Classification of Disease, Ninth Revision, Clinical Modification (ICD-9-CM) code of 390-448 as the first-listed diagnosis. Diabetes-related discharges were identified as those with an ICD-9 code of 250 as a secondary diagnosis. Major CVD discharge rates were calculated for the U.S. female population aged >18 years with and without diabetes by dividing the number of major CVD discharges estimated from NIS by the estimated number of women with and without diabetes obtained using 1997 NHIS data. Rate ratios and rate differences were calculated for both major CVD prevalence and hospital discharge rates by comparing rates for women with diabetes with those for women without diabetes. SUDAAN was used to calculate all estimates and their standard errors because of the complex sample designs of NIS and NHIS.
Major CVD rates were age-adjusted to the 2000 U.S. standard population (3 ). Trends were assessed by age for major CVD prevalence and for hospital discharge rates, rate ratios, and rate differences. The difference between age-adjusted major CVD prevalence and hospital discharge rates by diabetes status across all racial/ethnic categories was assessed using z-tests; a t-test in SUDAAN was used to assess the difference in age-adjusted major CVD prevalence and hospital discharge rates by race/ethnicity, comparing non-Hispanic whites, non-Hispanic blacks, and Hispanics. Other racial/ethnic groups were not included because sample size was too small for meaningful analysis.
During 1997-1999, 72% (95% confidence interval =+1.8%) of all women with diabetes self-reported having major CVD (Figure 1). The most common CVD condition was hypertension (64%; 95% CI=1.8%) followed by other heart disease or conditions (19%; 95% CI=+1.5%), coronary heart disease (12%; 95% CI=+1.2%), heart attack (11%; 95% CI=+1.3%), angina (10%; 95% CI=+1.1%), and stroke (8%; 95% CI=+1.0%) (Figure 1).
The prevalence of major CVD increased with age for women with diabetes from 40.5% (95% CI=+4.9%) for women aged 18-44 years to 85.1% (95% CI=+3.0%) for women aged >75 years (p75 years (p=0.09). Although rate differences were greatest among women aged 45-64 years and lowest among women aged >75 years, no significant trend by age was found (p=0.27) (Table 1).  During 1997, 772,346 of all major CVD hospital discharges (28%) had diabetes as a secondary diagnosis (Table 2). Hospital discharge rates for major CVD among women with diabetes increased from 22.9 per 1,000 (95% CI=+4.5) for the youngest age group to 332.7 per 1,000 (95% CI=+54.3) for the oldest age group (p=0.0004) (Table 2). The ageadjusted major CVD hospital discharge rate for women with diabetes was 3.8 times that of women without diabetes (Table 2). No significant difference was found among racial/ ethnic groups for major CVD hospital discharge rates among women with diabetes. The rate ratio comparing major CVD hospital discharges in women with diabetes with those without diabetes decreased with age from 11.8 per 1,000 (95% CI=+2.4) in the youngest age group to 2.4 per 1,000 (95% CI=+0.4) in the oldest (p=0.04). Rate differences increased with age from 20.9 per 1,000 (95% CI=+4.4) in the youngest to 196.5 per 1,000 (95% CI=+55.2) in the oldest (p=0.02) (Table 2). Editorial Note: This report indicates that 72% of U.S. women with diabetes self-reported having major CVD. Major CVD prevalence is twice as common and major CVD hospitalizations are nearly four times as common among women with diabetes compared with women without diabetes. These findings are consistent with mortality studies documenting that women with diabetes are at much higher risk for death as a result of major CVD than women without diabetes (2 ).
Clinical trials indicate that antihypertensive treatment (4 ), aspirin use (5 ), and lipidlowering therapies (6 ) prevent or delay cardiovascular events. Epidemiologic evidence suggests that the risk for major CVD might be reduced through glycemic control (7 ) and the promotion of healthy lifestyles, including weight reduction/obesity prevention,

# MMWR November 2, 2001
Major Cardiovascular Disease -Continued increased physical activity, smoking cessation/prevention, and improved diet (7 ). Primary prevention of diabetes, a risk factor for major CVD, also can prevent major CVD. The Diabetes Prevention Program, a clinical trial examining the effect of intensive lifestyle intervention on the occurrence of type 2 diabetes in high-risk populations, concluded that improved diet, weight loss, and increased physical activity prevented or delayed the onset of diabetes among adults with impaired glucose tolerance (8 ). Despite the efficacy of prevention strategies for major CVD, a large proportion of persons with diabetes have uncontrolled blood pressure (9 ), dyslipidemia (9 ), and hyperglycemia (9 ) and do not take aspirin (5 ). Additional research is needed to learn how to improve the process and outcomes of care among persons with diabetes. A concerted effort among health-care providers, public health officials, members of community-based organizations, and patients and their families will be necessary to reduce major CVD among persons with diabetes.
The high rate of major CVD among women with diabetes of all ages indicates that strategies for CVD risk reduction should be offered to all women with diabetes. Rate differences in hospital discharges increased with age, indicating that the effects of successful CVD prevention efforts should increase with age for women with diabetes.
The findings in this study are subject to at least six limitations. First, NHIS data on history of diabetes and major CVD are self-reported; however, studies comparing selfreported with physician-reported medical history data have found no difference in the prevalence of diabetes, and self-reported prevalence rates for CVD and hypertension were only slightly higher than physician-reported rates (10 ). Second, because NHIS excludes the institutionalized population, the number of persons with major CVD and diabetes is underestimated. Third, because NIS data represent hospital discharges and not individual persons, patients with multiple CVD hospitalizations within 1 year were counted multiple times; this might have resulted in an overestimation of hospital discharge rates. Fourth, by not including data from long-term and federal hospitals, NIS underestimates major CVD hospitalizations. Fifth, race/ethnicity is missing for approximately 20% of hospital discharges in NIS; four states that contribute to NIS provided no information on race/ethnicity, and one state provided race/ethnicity for approximately 25% of discharges. Therefore, race/ethnicity rates might be underreported and might be biased if disease patterns vary differentially across the reporting and nonreporting states. Finally, because the NIS sample comprised only 22 states, these data might be biased and might differ from estimates of the National Hospital Discharge Sample . However, in 1997, both data sources produced similar estimates of discharges with diabetes as the primary diagnosis (AHRQ, unpublished data, 2000).
CDC has published Diabetes and Women's Health Across the Life Stages: A Public Health Perspective that addresses the need for more research to gain a better understanding of the excess risk for major CVD among women with diabetes and to identify modifiable behavior and other determinants that can be used to develop effective interventions. The National Institutes of Health and CDC also have implemented the National Diabetes Education Program that includes public and private partners in the treatment and outcome of persons with diabetes; this program promotes early diagnosis to reduce morbidity and mortality associated with diabetes. CDC supports diabetes control programs in every state and, in 1998, initiated support for cardiovascular health promotion, disease prevention, and control programs. Since 1999, CDC has supported REACH 2010 (Racial and Ethnic Approaches to Community Health) to eliminate racial/ethnic disparities in numerous health areas, including diabetes and CVD. Additional information on diabetes is available at .

# Hospital Discharge Rates for Nontraumatic Lower Extremity Amputation by Diabetes Status -United States, 1997
Lower extremity amputation (LEA) is a costly and disabling procedure that disproportionately affects persons with diabetes (1,2 ). One of the national health objectives for 2000 was to reduce the LEA rate from a 1991 baseline of approximately eight per 1,000 persons with diabetes to a target of approximately five per 1,000 persons with diabetes. Review of 1996 data indicated an LEA rate of approximately 11. To estimate the national rates of hospital discharges for LEA among persons with and without diabetes and to assess the excess risk for LEA among persons with diabetes, CDC and the Agency for Healthcare Research and Quality (AHRQ) analyzed data from the 1997 Nationwide Inpatient Sample (NIS) and the 1997 National Health Interview Survey (NHIS). This report summarizes the findings of the analysis, which indicated that the age-adjusted rates of hospital discharges among persons with LEA who had diabetes were 28 times that of those without diabetes. This higher rate underscores the need to increase efforts to prevent risk factors (e.g., peripheral vascular disease, neuropathy, and infection) that result in LEA among persons with diabetes.
Hospital discharges were estimated from NIS, a stratified probability sample of hospitals in 22 states. Discharges from these states represented approximately 60% of all discharges in the United States. Sample data were weighted using the American Hospital Association Annual Survey of Hospitals to approximate discharges from all U.S. acute-care community hospitals. LEA discharges were defined using International Classification of Disease, Ninth Revision, Clinical Modification (ICD-9-CM ) codes 84.10-84.19 (traumatic LEA codes 895-897 were excluded). Diabetes-related LEA discharges were identified as discharges that included ICD-9-CM code 250 as one of the listed discharge diagnoses. LEA hospital discharge rates were calculated for populations with and without diabetes. Estimates of the number of persons with and without diabetes were obtained from the 1997 NHIS, an ongoing, nationally representative survey providing information about the health of the noninstitutionalized U.S. civilian population (3 ). SUDAAN was used to calculate estimates and 95% confidence intervals (CIs) of NIS and NHIS data. The 2000 U.S. standard population was used to adjust LEA rates by age. The rate ratio was calculated by dividing the LEA rate for persons with diabetes by the rate for persons without diabetes. The rate difference was defined as the difference in LEA rates between the two populations. The significance of trends by age was assessed for LEA rates, rate ratios, and rate differences, and t-tests in SUDAAN were used to determine the significance of the difference in mean age by diabetes status and the ageadjusted rate differences by sex and race. Z-tests were used to assess the difference between age-adjusted rates by diabetes status among all sex and race groups.
In 1997, 131,218 hospital discharges had an LEA discharge diagnosis code; 87,720 (67%) of these were related to diabetes (Table 1). Among persons with diabetes, 66.7% of LEA hospitalizations were paid by Medicare and an additional 8.1% were paid by Medicaid. Among persons with diabetes, approximately 52% of amputations occurred at or below the foot, and among persons without diabetes, approximately 70% occurred between the ankle and the knee or higher. Patients with diabetes-related LEA hospital discharges had a mean age of 66 years (95% CI=+0.3 years), and the mean age of LEA discharges not related to diabetes was 71 years (95% CI=+0.7 years) (p75 years, respectively. Rate differences ranged from 3.4 to 13.8 per 1,000 persons in those aged 75 years, respectively.
The age-adjusted LEA rate for persons with diabetes (5.5 per 1,000 persons with diabetes) was 28 (95% CI=24-31) times that of persons without diabetes (0.2 per 1,000 persons without diabetes). Regardless of diabetes status, these rates were higher for men than women (p<0.0001) and higher for non-Hispanic blacks than Hispanics or non-Hispanic whites (p<0.05) (Figure 1). Age-adjusted LEA rates were much higher for persons with diabetes for both sexes and all racial/ethnic populations (p<0.0001). Editorial Note: The findings in this report indicate that LEAs occur at a much higher rate among persons with diabetes and that diabetes causes approximately 67% of LEAs. Among persons with diabetes, LEA rates were highest among men, non-Hispanic blacks, and the elderly. These findings indicate that LEAs might increase as the U.S. population ages and as the prevalence of diabetes increases. Because approximately 75% of LEA hospitalizations are paid by Medicare or Medicaid, the increase in prevalence will place a large financial burden on these public health systems. Among persons with diabetes, LEAs result from the single or combined effects of peripheral vascular disease, peripheral neuropathy, and infection (1,4 ). Foot deformities and ulcers occurring as a consequence of neuropathy and/or peripheral vascular disease, minor trauma, and poor foot care also might contribute to LEAs (1,5 ).
The findings in this study are subject to at least five limitations. First, because NIS data represent hospital discharges and not individual persons, patients with multiple amputations within 1 year were counted multiple times; this might have resulted in an overestimation of hospital discharge rates. Second, because NIS data do not include LEAs that occurred in federal hospitals and outpatient settings, the analysis underestimates the total number of LEA discharges that occurred nationally. Third, because NHIS is representative of the noninstitutionalized civilian population, the total population with or without diabetes was underestimated. Fourth, race/ethnicity data are missing for approximately 20% of the hospital discharges in NIS data; four states contributing to NIS provided no race/ethnicity data and one state provided race/ethnicity information for approximately 25% of discharges. Therefore, race/ethnicity-specific rates are underreported and may be biased if race/ethnicity disease patterns vary across reporting and nonreporting states. Finally, because the NIS sample was constructed from only 22 states, these data might be biased and might differ from estimates of the National Hospital Discharge Sample (NHDS). However, in 1997, both data sources produced similar estimates of discharges with diabetes as the primary diagnosis (AHRQ, unpublished data, 2000). Numbers for other racial/ethnic groups were too small for meaningful analysis.

# MMWR November 2, 2001
Nontraumatic Lower Extremity Amputation -Continued Serious foot conditions or LEA can be decreased by 44%-85% in persons with diabetes (5 ). Proper footware can lower abnormal pressure and protect the foot from calluses and ulcers, precursors of LEA (6 ). Education intervention, multidisciplinary care, and insurance coverage for therapeutic shoes are effective in reducing diabetes-related LEA (2 ). Interventions also include early detection of feet at risk through regular foot examination, knowledge of foot hygiene, nonweight-bearing exercise, and provider education on screening examinations for high-risk foot conditions (6,7 ). Good glycemic control can reduce the development of neuropathy, a high-risk condition for LEA (8,9 ).
Because no nationally representative data on lower extremity disease and its risk factors exist, in 1999, CDC and the National Heart, Lung, and Blood Institute of the National Institutes of Health added to the National Health and Nutrition Examination Survey a lower extremity disease examination component for peripheral vascular disease, peripheral neuropathy, and foot deformities, ulcers, and amputations. This component will allow national estimates of the extent of lower extremity disease and identification of its risk factors. It also will increase an understanding of racial/ethnic differences in lower extremity disease and provide information to clinicians and public health providers to develop preventive care and community-based interventions. Materials designed to make good foot care an essential part of diabetes care among health-care providers and persons with diabetes are available at .

# Weekly Update: West Nile Virus Activity -United States, October 24-30, 2001
The following report summarizes West Nile virus (WNV) surveillance data reported to CDC through ArboNET and verified by states and other jurisdictions as of October 30, 2001.
During the week of October 24-30, no human cases of WNV encephalitis or meningitis were reported. During the same period, WNV infections were reported in 200 crows, 43 other birds, and eight horses. A total of 11 WNV-positive mosquito pools were reported in five states (Georgia, Kentucky, New Jersey, Ohio, and Virginia).
During 2001, a total of 37 human cases of WNV encephalitis or meningitis have been reported in Florida (ten), Maryland (six), New Jersey (six), New York (six), Connecticut (five), Pennsylvania (three), and Georgia (one); one death occurred in Georgia. Among these 37 cases, 20 (54%) were in men; the median age was 69 years (range: 36-81 years); and dates of illness onset ranged from July 13 to October 7. A total of 3,996 crows and 1,437 other birds with WNV infection were reported from 25 states and the District of Columbia (Figure 1); 159 WNV infections in other animals (all horses) were reported from 13 states (Alabama, Connecticut, Florida, Georgia, Kentucky, Louisiana, Massachusetts, Mississippi, New York, North Carolina, Pennsylvania, Tennessee, and Virginia); and 736 WNV-positive mosquito pools were reported from 15 states (Connecticut, Florida, Georgia, Illinois, Kentucky, Maryland, Massachusetts, Michigan, New Hampshire, New Jersey, New York, Ohio, Pennsylvania, Rhode Island, and Virginia).
Additional information about WNV activity is available at  and .

# FIGURE 1. Areas reporting West Nile virus (WNV) activity -

# Notice to Readers

# Updated Recommendations for Antimicrobial Prophylaxis Among Asymptomatic Pregnant Women After Exposure to Bacillus anthracis
The antimicrobial of choice for initial prophylactic therapy among asymptomatic pregnant women exposed to Bacillus anthracis is ciprofloxacin, 500 mg twice a day for 60 days. In instances in which the specific B. anthracis strain has been shown to be penicillinsensitive, prophylactic therapy with amoxicillin, 500 mg three times a day for 60 days, may be considered. Isolates of B. anthracis implicated in the current bioterrorist attacks are susceptible to penicillin in laboratory tests, but may contain penicillinase activity (2 ). Pencillins are not recommended for treatment of anthrax, where such penicillinase activity may decrease their effectiveness. However, penicillins are likely to be effective for preventing anthrax, a setting where relatively few organisms are present. Doxycycline should be used with caution in asymptomatic pregnant women and only when contraindications are indicated to the use of other appropriate antimicrobial drugs.
Pregnant women are likely to be among the increasing number of persons receiving antimicrobial prophylaxis for exposure to B. anthracis. Clinicians, public health officials, and women who are candidates for treatment should weigh the possible risks and benefits to the mother and fetus when choosing an antimicrobial for postexposure anthrax prophylaxis. Women who become pregnant while taking antimicrobial prophylaxis should continue the medication and consult a health-care provider or public health official to discuss these issues.
No formal clinical studies of ciprofloxacin have been performed during pregnancy. Based on limited human information, ciprofloxacin use during pregnancy is unlikely to be associated with a high risk for structural malformations in fetal development. Data on ciprofloxacin use during pregnancy from the Teratogen Information System indicate that therapeutic doses during pregnancy are unlikely to pose a substantial teratogenic risk, but data are insufficient to determine that there is no risk (1 ). Doxycycline is a tetracycline antimicrobial. Potential dangers of tetracyclines to fetal development include risk for dental staining of the primary teeth and concern about possible depressed bone growth and defective dental enamel. Rarely, hepatic necrosis has been reported in pregnant women using tetracyclines. Penicillins generally are considered safe for use during pregnancy and are not associated with an increased risk for fetal malformation. Pregnant women should be advised that congenital malformations occur in approximately 2%-3% of births, even in the absence of known teratogenic exposure.
Additional information about the treatment of anthrax infection is available at .

# MMWR 961
Notices to Readers -Continued

# Notice to Readers

# Interim Recommendations for Protecting Workers from Exposure to Bacillus anthracis in Work Sites in which Mail is Handled or Processed
CDC has developed interim recommendations to assist personnel responsible for occupational health and safety in developing a comprehensive program to reduce potential cutaneous or inhalational exposures to Bacillus anthracis spores among workers in work sites in which mail is handled or processed. Such work sites include post offices, mail distribution/handling centers, bulk mail centers, air mail facilities, priority mail processing centers, public and private mail rooms, and other settings in which workers are responsible for handling and processing mail. The recommendations are based on the limited information available on methods to avoid infection and on the effectiveness of various prevention strategies. These recommendations will be updated as new informat on becomes available.
The recommendations are divided into the following hierarchical categories describing measures that should be implemented in distribution/handling centers to prevent potential exposures to B. anthracis spores:
- Engineering controls to prevent or capture aerosolized spores - Administrative controls to limit the number of persons potentially exposed to spores - Housekeeping controls to further reduce the spread of spores - Personal protective equipment for workers to prevent cutaneous and inhalational exposure to spores These control measures should be selected on the basis of an initial work site evaluation that focuses on determining which processes, operations, jobs, or tasks would be most likely to result in an exposure if a contaminated envelope or package enters the work site. The complete interim recommendations are available at .

# Notice to Readers

# National Diabetes Awareness Month -November 2001
November is National Diabetes Awareness Month. During 1998 in the United States, an estimated 15.7 million persons had diabetes (1 ). From 1990 to 2000, an increase of 49% occurred in the prevalence of diagnosed diabetes and gestational diabetes in U.S. adults (2 ); however, lifestyle changes, including weight control and regular physical activity can prevent or delay the onset of type 2 diabetes, even in high-risk persons (3 ).
During November, 59 state and territorial diabetes control programs, other partners, and CDC will highlight activities that increase awareness of the Initiative on Diabetes and Women's Health and of the need for persons with diabetes to receive influenza and pneumococcal vaccines. Persons with diabetes should receive pneumococcal and annual influenza vaccinations because they are more likely than persons without diabetes to die from complications of influenza and pneumonia (4 ). In 1997, only half of adults with diabetes received an annual influenza vaccination, and one third received a pneumococcal vaccine (5 ). Perspective, is the first major publication to address the unique and serious impact diabetes has on women throughout life and to address the public health implications of these issues (6 ). The publication presents 1) trends in risk factors for diabetes and its complications during adolescence; 2) the increased risk for offspring to develop diabetes associated with intrauterine exposure to hyperglycemia; 3) the effect of menopause on health status; and 4) the increase in poverty and disability for older women.
Additional information about diabetes is available from CDC, telephone (877) 232-3422, e-mail diabetes@cdc.gov, and from .
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