Recent immigrants and refugees constitute a substantial proportion of malaria cases in the United States, accounting for nearly one in 10 imported malaria cases involving persons with known resident status in 2006 (1). This report describes three cases of Plasmodium falciparum malaria and two cases of Plasmodium ovale malaria that occurred during June 27-October 15, 2007 in King County, Washington. The infec tions were diagnosed in Burundian refugees who had recently arrived in the United States from two refugee camps in Tanza nia. Since 2005, CDC has recommended presumptive malaria treatment with artemisinin-based combination therapy (ACT) (e.g., artemether-lumefantrine) for refugees from sub-Saharan Africa before their departure for the United States (2). Rising levels of resistance to the previous mainstays of treatment, chloroquine and sulfadoxine-pyrimethamine, prompted CDC to make this recommendation. Implementa tion has been delayed in some countries, including Tanzania, where predeparture administration of presumptive ACT for refugees started in July 2007. The cases in this report high light the need for health-care providers who care for recently arrived Burundian and other refugee populations to be vigi lant for malaria, even among refugees previously treated for the disease. Washington state law requires health-care providers, hospi tals, and laboratories to report malaria and certain other con ditions to the local health department.- This report summarizes the findings from five cases reported to the local health department by health-care providers and laboratories (Table ). After these cases were reported, the patients' medical records were obtained from two local hospitals and reviewed to assist in case investigations. Initial investigations were limited to case investigation forms completed by public health officials based on available medical records. *Notifiable conditions. Ch. 246-101, Washington Administrative Code. Available at . Case 1. A female aged 3 years was diagnosed with P. falciparum malaria in May 2007 while in Tanzania. At that time, she was placed on a quinine-based regimen (formula tion, date of administration, and method of administration unknown) and clinically recovered. During an overseas predeparture exam, a requirement for entry into the United States, she received presumptive malaria treatment, with a course of sulfadoxine-pyrimethamine. She arrived in the United States on June 12, 2007, and became ill on June 25, 2007, with fevers, chills, and cough. On June 27, 2007, she was admitted to the local children's hospital. A blood smear revealed 7% hyperparasitemia (>5% = hyperparasitemia) with P. falciparum. Other laboratory findings included anemia, thrombocytopenia, and elevated aspartate aminotransferase. She received oral atovaquone-proguanil, clinically improved, and was discharged July 2, 2007 after 5 days in the hospital. Case 2. A female aged 9 years arrived in the United States on July 23, 2007. Before leaving Tanzania, she received pre sumptive 3-day treatment of twice daily artemether lumefantrine; the last doses were administered on July 19, 2007. She became ill on August 11, 2007, with fever, head ache, malaise, and cough. She was evaluated in the local county hospital emergency department on August 14, 2007. Blood smear (percent parasitemia unknown) and polymerase chain reaction (PCR) test results were positive for P. ovale. Other INSIDE#
In the United States atovaquone-proguanil mefloquine and primaquine chloroquine and primaquine quinidine and clindamycin, followed by atovaquone proguanil quinidine and clindamycin, followed by atovaquone proguanil Editorial Note: CDC recommends presumptive treatment of P. falciparum malaria in United States-bound refugees at high risk for infection rather than waiting for development of symptoms and risking severe complications or death after arrival in the United States (2). To be considered adequate presumptive therapy, the regimen must be completed no sooner than 3 days before departure (2). This approach reduces the risk for malaria-related morbidity and mortality among these refugees. Refugees are typically a medically underserved population with difficulty accessing care, which can lead to delays in diagnosis and treatment. Even if refugees are able to obtain care, health-care providers in the United States might not be familiar with recommended malaria treatment regimens. For example, the patient in case 1 did not receive adequate treatment for severe infection with P. falciparum. Instead, she received oral atovaquone-proguanil, which would have been appropriate for uncomplicated malaria.
The recommended regimens for severe infection with P. falciparum include either intravenous quinidine or artesunate (3). The latter is available from CDC via an investigational new drug protocol. Presumptive predeparture treatment for malaria in a geographically clustered population of refugees, as in a refugee camp, is easier logistically and less costly than treatment of symptomatic cases dispersed throughout the United States after arrival. Presumptive treatment also can reduce the risk for reintroduction of malaria into the United States. Reintroduction is a concern given that the malaria vec tor, the female Anopheles mosquito, is widespread in the United States. A recent malaria outbreak in the Caribbean resulting from reintroduction is an example of this possibility (4). The International Organization for Migration (IOM) is an intergovernmental agency that screens and treats most refugees bound for the United States. This is done at the request of the United States in an effort to reduce the incidence of infectious disease among refugees after they reach the United States. IOM administers presumptive treatment against P. falciparum malaria (and intestinal parasites) to refugees resettling from Tan zania before departure for the United States. In 2005, CDC recommended ACT as presumptive P. falciparum treatment for refugees resettling in the United States from sub-Saharan Africa. However, presumptive P. falciparum malaria treatment using sulfadoxine-pyrimethamine was used for Tanzanian refugees until July 7, 2007. CDC surveillance data indicate that among 1,805 Burundian refugees from Tanzania who resettled to 34 U.S. states during May 4-July 7, 2007, 29 symptomatic cases of malaria were identified in 12 states, including Washington. Twenty-six of these refugees (including the patient in case 1) were infected with P. falciparum alone, and two had mixed infections (P. falciparum and P. ovale or Plasmodium malariae). Speciation was not performed for the remaining case. Twenty-four of the 29 (82%) patients were hospitalized; none died (CDC, unpub lished data). These 29 refugees departed for the United States before July 7, 2007, the date when IOM implemented the CDC recommendations that refugees from Tanzania receive presump tive treatment with 6-dose artemether-lumefantrine within 3 days before departure for the United States. Instead, they all received sulfadoxine-pyrimethamine before departure; high rates of resistance to sulfadoxine-pyrimethamine have been reported (5), but the artemether-lumefantrine regimen has been effective in field settings in Africa (6).
Two of the patients in this report who were infected with P. falciparum, the patients in cases 4 and 5, were resettled to the United States after July 7, 2007, the date when IOM instituted the change to artemether-lumefantrine treatment. These two patients received a complete artemether lumefantrine presumptive treatment course before departure from Tanzania, yet both were diagnosed with P. falciparum after arrival in the United States. Possible explanations include incomplete treatment or nonadherence to the medication regi men (only 3 of 6 doses were directly observed in these two patients, and in the patients in cases 2 and 3), poor medica tion absorption, reinfection after treatment, or treatment dur ing a time in the parasite's lifecycle when it would be unaffected by this regimen. In response to such continuing cases, IOM now directly observes all 6 doses of artemether-lumefantrine treatment and provides milk with each dose to improve absorption.
Current IOM policy targets infection with P. falciparum only. However, cases 2 and 3 in this series involved relapses of P. ovale after arrival in the United States. Infection with P. ovale (or Plasmodium vivax) generally results in less severe disease than infection with P. falciparum. Hypnozoites of P. ovale or P. vivax can remain dormant in the liver for months or years before causing relapse, and primaquine is the only agent available that can eliminate malaria parasites at this stage of their life cycle (7,8). However, predeparture presumptive treatment with primaquine to prevent relapse of P. ovale or P. vivax currently is not recommended because the cost, logis tics of implementing a 14-day medication course, and risk for severe hemolytic anemia in glucose-6-phosphate dehydroge nase (G6PD)-deficient patients outweigh the potential ben efit of avoiding a small number of non-P. falciparum malaria cases.
Up to 10,000 Burundian refugees from Tanzania will have been resettled in the United States during 2007-2008 (9). Health-care providers in the United States caring for refugee populations resettling from malarial regions should remain aware of the possibility of malaria in these groups, regardless of prior treatment.

# Syphilis Testing Algorithms Using Treponemal Tests for Initial Screening -Four Laboratories, New York City, 2005-2006
In the United States, testing for syphilis traditionally has consisted of initial screening with an inexpensive nontreponemal test, then retesting reactive specimens with a more specific, and more expensive, treponemal test. When both test results are reactive, they indicate present or past infection. However, for economic reasons, some high-volume clinical laboratories have begun using automated treponemal tests, such as automated enzyme immunoassays (EIAs) or immunochemoluminescence tests, and have reversed the test ing sequence: first screening with a treponemal test and then retesting reactive results with a nontreponemal test. This approach has introduced complexities in test interpretation that did not exist with the traditional sequence. Specifically, screening with a treponemal test sometimes identifies persons who are reactive to the treponemal test but nonreactive to the nontreponemal test. No formal recommendations exist regard ing how such results derived from this new testing sequence should be interpreted, or how patients with such results should be managed. To begin an assessment of how clinical laborato ries are addressing this concern, CDC reviewed the testing algorithms used and the test interpretations provided in four laboratories in New York City. Substantial variation was found in the testing strategies used, which might lead to confusion about appropriate patient management. A total of 3,664 (3%) of 116,822 specimens had test results (i.e., reactive trepone mal test result and nonreactive nontreponemal test result) that would not have been identified by the traditional testing algorithms, which end testing if the nontreponemal test result is nonreactive. If they have not been previously treated, patients with reactive results from treponemal tests and nonreactive results from nontreponemal tests should be treated for late latent syphilis.
Four New York City laboratories that routinely conduct syphilis testing using EIA treponemal screening tests were able to provide their testing algorithms, test volume, and test results for a convenience sample of specimens. Each labora tory used a slightly different testing algorithm and tested approximately 26,000-130,000 specimens for syphilis per year. CDC reviewed test results from a convenience sample of 116,822 specimens tested at these four laboratories during October 1, 2005-December 1, 2006.
In all four laboratories, no further testing was done on speci mens that were nonreactive with the treponemal screening EIA. In all four laboratories, specimens considered reactive by EIA test were next tested with a rapid plasma reagin (RPR) test. However, the approach to follow-up testing then differed. At two laboratories, specimens that were reactive with EIA and nonreactive with RPR were retested using a different tre ponemal test: Treponema pallidum particle agglutination (TP-PA) or fluorescent treponemal antibody (FTA-ABS). At a third laboratory, specimens that were reactive to both the EIA test and the RPR test were retested using a different tre ponemal test (i.e., FTA-ABS or TP-PA). At the fourth labora tory, no further testing was done after the EIA and RPR tests. Of the 116,822 specimens included in the convenience sample, 6,587 (6%) were initially reactive to the EIA test (Figure). When 6,548 of the EIA-reactive specimens were tested with an RPR test, 2,884 (44%) were reactive and 3,664 (56%) were nonreactive to the RPR test. Further testing with FTA-ABS or TP-PA tests on 2,512 of the specimens reactive to the EIA test but nonreactive to the RPR test found 2,079 (83%) specimens reactive to the second treponemal tests (i.e., FTA-ABS or TP-PA). In addition, the one laboratory that performed TP-PA testing on specimens that were reactive to both the EIA and RPR tests found 78 of 80 (98%) specimens were reactive to the TP-PA test.
One laboratory provided limited interpretation of the vari ous permutations of syphilis test results. The other three labo ratories gave providers an objective summary of the test results (e.g., EIA reactive, RPR reactive, or EIA reactive and RPR nonreactive) with no interpretation. No additional informa tion was available from the four laboratories regarding patient treatment. Editorial Note: In the four New York City laboratories stud ied, reversing the traditional order of screening and confirma tory tests for syphilis resulted in 3,664 (3%) of 116,822 specimens with test results (i.e., reactive treponemal test result and nonreactive nontreponemal test result) that would not have been identified by the traditional testing algorithm. The importance of these test results is unclear because no specific prognostic information exists to guide patient evalua tion and treatment.
Treponemal tests detect antibodies specific to T. pallidum. In addition to T. pallidum pallidum, which causes syphilis, other treponemal subspecies (e.g., pertenue, which causes yaws, and carateum, which causes pinta) also can produce reactive results to treponemal tests, but these subspecies are rare in the United States (1). A reactive treponemal test result indicates that treponemal infection has occurred at some point in the past but cannot distinguish between treated and untreated infections. As such, treponemal tests, such as the T. pallidum EIA test, TP-PA test, and FTA-ABS test, can produce reactive results for life, even after adequate treatment for syphilis.
Nontreponemal tests, such as the RPR test and venereal dis ease research laboratory (VDRL) test, detect antibodies to cardiolipin and are not specific for treponemal infection. Nontreponemal tests are more likely than treponemal tests to produce nonreactive results after treatment; therefore, reac tive results from nontreponemal tests are more reliable indi cators of untreated infection. Quantitative nontreponemal tests also are used to monitor responses to treatment or to indicate new infections. False-positive nontreponemal tests occur in 1%-2% of the U.S. population, and have been associated with multiple conditions, including pregnancy, human immuno deficiency virus (HIV) infection, intravenous drug use, tuberculosis, rickettsial infection, spirochetal infection other than syphilis, bacterial endocarditis, and disorders of immu noglobulin production (2,3). Nontreponemal test results might be falsely negative in longstanding latent infection (4). Both treponemal and nontreponemal tests can produce nonreactive results when the infection has been acquired recently; approxi mately 20% of test results are negative when patients have primary syphilis (4).
The four New York City laboratories in this report used various algorithms to evaluate specimens that were reactive to treponemal tests and nonreactive to nontreponemal tests. The different algorithms might lead to confusion in the interpre tation of test results and, in turn, in the management and treatment of patients. Test results that would not have been identified by the traditional algorithm were obtained for 3% of the specimens tested for syphilis; thus, such results might be expected to occur several thousand times per year in New York City alone.
When results are reactive to both treponemal and RPR tests, persons should be considered to have untreated syphilis unless it is ruled out by treatment history. Persons who were treated in the past are considered to have a new syphilis infection if quantitative testing on an RPR test or another nontreponemal test reveals a four fold or greater increase in titer (health departments maintain registries of past positive tests). When results are reactive to the treponemal test but nonreactive to the RPR test, persons with a history of previous treatment will require no further management. For persons without a history of treatment, a second, different treponemal test should be per formed (5). If the second treponemal test is nonreactive, the clinician may decide that no further evaluation or treatment is indicated, or may choose to perform a third treponemal test to help resolve the discrepancy.
If the second treponemal test is reactive, clinicians should discuss the possibility of infection and offer treatment to patients who have not been previously treated. Unless history or results of a physical examination suggest a recent infection, such patients are unlikely to be infectious and should be treated for late latent infections, even though they do not meet the surveillance case definition (7). Treatment can prevent severe (i.e., tertiary) complications that can result from untreated syphilis, although the probability of such complications occurring without treatment, while unknown, likely is small (6) Treatment also allows patients to report that they have been treated for syphilis if they ever receive similar results from future treponemal screening tests. Public health departments determine their own priorities for partner notification and other prevention activities; however, because late infections are unlikely to be infectious, they would likely be considered low priority for health department intervention activities.
Reversal of the traditional syphilis screening sequence has been driven by economics. For high-volume laboratories, an automated treponemal test can be less expensive than using an RPR test for the initial screening. An important conse quence of this reversal is the identification of a combination of reactive and nonreactive test results that would not other wise have been identified. The clinical interpretation of these results is complicated by the lack of standardized follow-up testing algorithms among the four laboratories, and by the lack of an evidence base with which to judge the merits of each algorithm. Consequently, use of a reversed sequence of syphilis testing might result in overdiagnosis and overtreatment of syphilis in some clinical settings.
The recommendations in this report might not be appro priate in countries with different patterns of seroreactivity, systems of health care, and epidemiology of disease. Further more, additional analyses are needed that further elucidate the use and total costs of these alternative screening approaches for syphilis, given the anticipated increase in use of trepone mal tests for screening in the United States.

# Infection Control Requirements for Dialysis Facilities and Clarification Regarding Guidance on Parenteral Medication Vials
In April 2008, the Centers for Medicare and Medicaid Ser vices (CMS) published in the Federal Register its final rule on

# Conditions for Coverage for End-Stage Renal Disease (ESRD)
Facilities (1). The rule establishes new conditions dialysis facilities must meet to be certified under the Medicare pro gram and is intended to update CMS standards for delivery of quality care to dialysis patients. CDC's 2001 Recommenda tions for Preventing Transmission of Infections among Chronic Hemodialysis Patients (2) have been incorporated by reference into the new CMS conditions for coverage. Thus, effective October 14, 2008, all ESRD facilities are expected to follow the CDC recommendations as a condition for receiving Medi care payment for outpatient dialysis services.
In recent years, outbreak investigations in dialysis and other health-care settings have demonstrated that mishandling of parenteral medication vials can contribute to the risk for hepa titis C virus (HCV) infection and bacterial and other infec tions (3)(4)(5)(6)(7). In 2002, a CDC communication to CMS suggested that reentry into single-use parenteral medication vials (i.e., to administer medication to more than one patient), when performed on a limited basis and under strict condi tions in hemodialysis settings, likely would result in low risk for bacterial infection (8). However, the 2002 communica tion did not address risks for bloodborne viral infections (e.g., HCV and hepatitis B virus infection). This report is intended to clarify and restate CDC's recommendation on parenteral medication to include bloodborne viral infections. The rec ommendations in this report supersede the 2002 CDC com munication to CMS.
To prevent transmission of both bacteria and bloodborne viruses in hemodialysis settings, CDC recommends that all single-use injectable medications and solutions be dedicated for use on a single patient and be entered one time only. Medi cations packaged as multidose should be assigned to a single patient whenever possible. All parenteral medications should be prepared in a clean area separate from potentially contami nated items and surfaces. In hemodialysis settings where envi ronmental surfaces and medical supplies are subjected to frequent blood contamination, medication preparation should occur in a clean area removed from the patient treatment area. Proper infection control practices must be followed during the preparation and administration of injected medications (9). This is consistent with official CDC recommendations for infection control precautions in hemodialysis (2) and other health-care settings (9).
Health departments and other public health partners should be aware of the new CMS conditions for ESRD facilities. All dialysis providers are advised to follow official CDC recom mendations regarding Standard Precautions and infection control in dialysis settings (2,9). Specifically, CDC has recommended the following: "Intravenous medication vials labeled for single use, including erythropoietin, should not be punctured more than once. Once a needle has entered a vial labeled for single use, the sterility of the product can no longer be guaranteed" (2). Additional guidance on safe injection prac tices can be found in the Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Set tings 2007 (9).
Dialysis providers also should be aware of their responsibil ity to report clusters of infections or other adverse events to the appropriate local or state public health authority. Failure to report illness clusters to public health authorities can result in delays in recognition of disease outbreaks ( 10

# Notice to Readers

# Preventive Medicine Residency Application Deadline -October 1, 2008
CDC's Preventive Medicine Residency (PMR) program is accepting applications from physicians with public health and applied epidemiology experience. Application materials must be postmarked by October 1, 2008 for the 12-month program that begins in mid-June 2009.
The PMR prepares physicians for leadership roles in public health at 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. Residents spend the practicum year at CDC or in a state or local health department.
PMR alumni occupy leadership positions at CDC, at state and local health departments, in academia, and in privatesector agencies. Completion of the residency, which is accred ited by the Accreditation Council for Graduate Medical Education for 12 months of practicum training, qualifies graduates to apply for certification by the American Board of Preventive Medicine in Public Health and General Preventive Medicine.
Additional information regarding the residency, eligibility criteria, and application process is available at . cdc.gov/epo/dapht/pmr/pmr.htm or by calling 404-498-6140.

# Erratum: Vol. 57, No. SS-6
In the MMWR Surveillance Summary (Vol. 57, No. SS-6), "Epilepsy Surveillance Among Adults -19 States, Behavioral Risk Factor Surveillance System," 2005, an error occurred on page 1 in the fourth sentence of the second paragraph of the Results/Interpretation. The sentence should read, "Among adults with active epilepsy with recent seizures, 16.1% reported not currently taking their epilepsy medication, and 65.1% reported having had more than one seizure in the past 3 months." 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 Age-Adjusted Death Rates- by Race and Sex -United States, 2006  - Per 100,000 standard population.
 Preliminary data.
In 2006, age-adjusted death rates were higher for males (924.6 per 100,000 population) than females (657.8 per 100,000 population) overall and within black and white populations. By race, death rates were higher for blacks than for whites.                 A death is reported by the place of its occurrence and by the week that the death certificate was filed. Fetal deaths are not included.  Pneumonia and influenza.  Because of changes in reporting methods in this Pennsylvania city, these numbers are partial counts for the current week. Complete counts will be available in 4 to 6 weeks.  Because of Hurricane Katrina, weekly reporting of deaths has been temporarily disrupted.  Total includes unknown ages.
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