Particulate matter and other constituents of smoke can trigger asthma (8). Persons with asthma who reported difficulty breathing because of smoke and debris during the September 11 attacks might have been particularly sensitive to smoke from the fires that burned at the WTC site for several weeks. Psychological stress also can worsen asthma (2), and PTSD has been associated with an increase in respiratory symptoms (9) and with asthma. Even accounting for the impact of smoke and debris on asthma symptoms, adults with asthma who had two or more life stressors before September 11 (a risk factor for PTSD) were more likely to experience worsening of asthma after the attacks. Vol. 51 / No. 35 MMWR 783 - Number of respondents who had ever been told by a doctor that they had asthma. Numbers might not add up to 134 because of missing values. Sample weights based on number of telephones and adults in each household applied to adjust for varying probabilities of being interviewed.  Odds ratio.  Confidence interval.  Numbers for other racial/ethnic groups were too small for meaningful analysis.  15 blocks north of WTC site.   Include death of a close family member; serious illness or injury; change in marital status, family, or work situation; or emotional problems.#
Asthma is a chronic condition that affects approximately 14 million persons in the United States and is characterized by airway inflammation, reversible airway obstruction, and airway hyperresponsiveness to a variety of triggers (1). Both environmental and psychological factors can trigger asthma exacerbations (2)(3)(4), and a seasonal increase in asthma morbidity occurs in the fall (5). This report summarizes the results of a telephone survey conducted among Manhattan residents 5-9 weeks following the September 11, 2001, terrorist attacks on the World Trade Center (WTC) in lower Manhattan in New York City. The findings indicate that among the 13% of adult respondents with asthma, 27% reported experiencing more severe asthma symptoms after September 11. Although a normal seasonal increase in asthma severity was expected, increased severity was reported more commonly among asthmatics reporting psychological distress associated with the attacks and/or difficulty breathing because of smoke and debris during the attacks. Persons with asthma and their clinicians should be aware of the role environmental and psychological factors might play in worsening asthma after disasters.
The study data were collected as part of a survey focused primarily on the psychological impact of the attacks (6). Telephone interviews were conducted during October 16-November 15, through a random-digit-dialed sample of persons aged >18 years living south of 110th Street in Manhattan. Households were screened for geographic eligibility, and an adult with the most recent birthday was selected to be interviewed. Sample weights based on the number of telephones and adults in each household were applied to adjust for varying probabilities of being interviewed. The response rate was 64.3%. A total of 1,008 persons were interviewed, of whom 20 were excluded from the analysis because of missing weight variables. Psychological factors, including life-stressors*, depression, and risk for post-traumatic stress disorder (PTSD), were assessed by using questions documented previously (7).
Among participants, 134 (13.4%) reported having been told previously by a doctor that they had asthma; 75 (58.2%) of those with diagnosed asthma were women. The median age of the 134 participants with asthma was 36 years (range: 18-78 years); 86 (70.7%) were non-Hispanic whites, 66 (64.8%) had an annual household income of >$40,000, and 99 (72.2%) had a college or graduate degree. Of the 134 persons with asthma, 17 (12.1%) reported that they lived or were present south of Canal Street (i.e., 15 blocks north of the WTC site) at the time of the attacks.
Of the 134 respondents with diagnosed asthma, 34 (27.0%) reported worsening of asthma symptoms after the September 11 terrorist attacks, defined as having moderate to severe symptoms during the weeks since September 11 compared with having none to mild symptoms during the 4 weeks before - Include death of a close family member; serious illness or injury; change in marital status, family, or work situation; or emotional problems. September 11. Persons with asthma reporting worsening symptoms were more likely than those not reporting worsening symptoms to report unscheduled visits to a health-care provider (28% versus 5%; p=0.02) for asthma after September 11. Bivariate analyses showed that an increased severity of asthma symptoms since September 11 was significantly more likely to be reported by respondents who 1) had difficulty breathing because of smoke and debris during the attacks, 2) had two or more life stressors during the 12 months before the attacks, 3) experienced a peri-event panic attack (i.e., an event that occurred at the time of or shortly after the attacks), 4) had depression during the preceding month, or 5) had symptoms of PTSD related to the attacks during the preceding month (Table ). Persons with asthma who lived or were present south of Canal Street on September 11 were more likely than others to report increased asthma symptoms; however, the association was not statistically significant.
Separate multivariate logistic regression models were used that included life stressors during the preceding 12 months, peri-event panic attack, PTSD, and depression and that controlled for age, sex, race/ethnicity, income, and difficulty breathing because of smoke and debris. Having two or more life stressors during the 12 months before the attacks (odds ratio =4.4; 95% confidence interval =1.4-14.2) remained significantly associated with an increase in asthma severity after September 11; difficulty breathing because of smoke and debris also was a significant predictor of worsening asthma after September 11 (OR=7.0; 95% CI=2. 3-21.3). Although peri-event panic attack (OR=2.4; 95% CI=0.8-7.4), PTSD (OR=3.6; 95% CI=0.6-20.9), and depression (OR=2.9; 95% CI=0.9-9.8) also were associated with increased severity in asthma symptoms, the relation was not statistically significant.
The findings in this report are subject to at least four limitations. First, no objective measures are available to validate the self-reported worsening of asthma symptoms in this population. Second, because of its cross-sectional design, this study could not establish a temporal or causal relation between worsening of asthma symptoms and psychological symptoms. Third, some selection bias cannot be ruled out; those with health problems might have been more or less likely to participate in the survey than others. Finally, because asthma severity usually increases in the fall (5), these data cannot be used to quantify the absolute impact on persons with asthma of environmental and psychological factors related to the September 11 terrorist attacks.
Despite these limitations, the survey data suggest that both the environmental and psychological sequelae of the September 11 attacks contributed to increasing symptoms experienced by some persons with asthma during the weeks following the attacks. Persons with asthma and their clinicians should be aware of the role these factors might play in worsening asthma after disasters. To measure the psychological and emotional effects of the September 11, 2001, terrorist attacks on the World Trade Center (WTC), Connecticut, New Jersey, and New York added a terrorism module to their ongoing Behavioral Risk Factor Surveillance System (BRFSS). This report summarizes the results of the survey, which suggest widespread psychological and emotional effects in all segments of the three states' populations. The findings underscore the importance of collaboration among public health professionals to address the physical and emotional needs of persons affected by the September 11 attacks.
BRFSS is a random-digit-dialed telephone survey of the noninstitutionalized U.S. population aged >18 years (1,2). The terrorism module consisted of 17 questions which asked respondents whether they were victims of the terrorist attacks, attended a memorial or funeral service after the attacks, were employed or missed work after the attacks, increased their consumption of tobacco and/or alcohol following the attacks, or watched more media coverage following the attacks. The survey was conducted during October 11-December 31. A total of 3,512 respondents completed the module in the three states (1,774 in Connecticut,638 in New Jersey, and 1,100 in New York). SAS and SUDAAN were used in the analyses to account for the complex sampling design.
Of the 3,512 participants, approximately 50% participated in religious or community memorial services, and 13% attended a funeral or a memorial service for an acquaintance, relative, or community member (Table ). Three fourths (75%) of respondents reported having problems attributed to the attacks. Nearly half (48%) of respondents reported that they experienced anger after the attacks. Approximately 12% of respondents with problems reported getting help. Family members (36%) and friends or neighbors (31%) were the main source for help. Approximately 3% of alcohol drinkers reported increased alcohol consumption, 21% of smokers reported an increase in smoking, and 1% of nonsmokers reported that they started to smoke after the attacks.
The impact of the attacks varied by sex, age group, educational level, and race/ethnicity. Compared with men, women were more likely to have participated in a religious or community memorial service (55.1%  versus 43.0% ) and to get help with the problems they experienced (15.3%  versus 8.8% ). Men were more likely than women to drink more alcohol (4.2%  versus 2.4% ), and women smokers were more likely than men to smoke more as a result of the attacks (27.1%  versus 14.8% ).
Approximately 27% of respondents who were working at the time of the attacks missed work afterwards. The major reason for missing work was transportation problem (51%). Approximately 21% of workers had to be evacuated on the day of the attacks. Approximately 80% of respondents reported watching more media coverage than usual on television or through the Internet. Approximately 3% of respondents reported that they were victims of the attacks, 7% had relatives who were victims, and 14% had friends who were victims. In Connecticut, New Jersey, and New York, 4%, 17%, and 35% of the respondents, respectively, reported being in New York City during the attacks. Editorial Note: The findings in this report document the widespread emotional and psychological effects among residents of three states following the September 11 attacks and indicate that some persons sought help to cope with the catastrophic events. Although this survey inquired about the shortterm effects of the attacks, the findings suggest the need to consider the long-term emotional and psychological health of the affected population. The flexible design of BRFSS allows states to add questions to their ongoing surveys to address changing situations and crises, such as the WTC attacks.
The findings in this report are subject to at least four limitations. First, the survey design excluded persons without a telephone, which primarily includes persons of low socioeconomic status. Second, the survey excluded persons who were not yet able to discuss their emotional response to the attacks. Third, the survey did not measure the severity and duration of emotional and psychological problems of the respondents. Finally, the survey might have excluded persons who had moved from the area after the attacks.
Public health professionals should consider the emotional and psychological well-being of persons after traumatic events. The results of community-based surveys can help target programs designed to help residents deal with the aftermath of terrorist attacks. In response to national disasters, several programs have been implemented successfully to provide immediate medical care and to prevent the spread of infections and disease; however, the long-term emotional pain and suffering associated with disasters also needs to be considered in response planning. State and federal agencies should prepare programs to address the emotional and psychological health of persons, and these programs should be integrated with other disaster-preparedness plans.

# Occupational Health Guidelines for Remediation Workers at Bacillus anthracis-Contaminated Sites -United States, 2001-2002
Remediation workers involved in clean up and decontamination are potentially exposed to Bacillus anthracis spores while working in contaminated buildings along the paths of letters implicated in bioterrorism-related anthrax. Federal guidelines and Occupational Safety and Health Administration (OSHA) regulations for hazardous waste operations and hazardous material response workers (HAZWOPER) (1,2) provide information about surveillance for hazardous exposures, the use of personal protective equipment (PPE) and clothing, and a generic medical program but do not address anthrax specifically. CDC has developed the following guidelines to provide medical protection for current and future workers responsible for making B. anthracis-contaminated buildings safe for others to enter and occupy. This information will benefit medical directors and consultants who design and supervise medical components of the OSHA-required health and safety plan (HASP), health-care providers who implement these programs for onsite workers or who care for workers offsite, and site health and safety officers who coordinate onsite programs.

# HAZWOPER Guidelines and Regulations
A medical program for remediation workers should be part of a site-specific HASP that also includes 1) environmental surveillance of health hazards; 2) engineering and administrative controls and use of PPE; 3) training about exposures, potential adverse health events, and preventive measures; and 4) an emergency response plan (1,2). The medical program should be designed and administered by a licensed physician in conjunction with the site health and safety officer. The administering physician should be knowledgeable about all of the relevant areas of occupational medicine (e.g., toxicology, industrial hygiene, medical screening, and occupational health surveillance) (3) and should be able to interpret information about potential exposures, PPE, work schedules, work practices, and relevant regulations. Because work sites might be remote from the home base, health-care providers implementing the program should be selected for accessibility to workers, access to diagnostic resources and a reliable system for hospital referral, and the ability to conduct aroundthe-clock coverage for work-related medical care. Baseline medical evaluations should identify pre-existing conditions affecting a worker's fitness for duty, ability to use PPE safely, and susceptibility to adverse work-related health outcomes. Periodic evaluations should be scheduled to detect symptoms and signs related to workplace exposures and to reassess fitness for duty. Active surveillance for exposure incidents (e.g., PPE breaches) and adverse health outcomes should determine the need for additional evaluations. Exit evaluations should identify changes from the person's baseline and any new risk factors.
Selection of specific PPE should be based on an assessment of potential exposures and activities; the highest level of protection (i.e., level A) might be required (4). Examining physicians should be familiar with the physical requirements and limitations imposed on workers by the selected PPE (e.g., water-impermeable, chemical-resistant suits prevent evaporative cooling and contribute to dehydration and heat stress; facepieces might aggravate claustrophobia; respirator air-flow resistance and the weight of self-contained breathing apparatuses  might aggravate respiratory and heart conditions; and PPE materials might contribute to skin problems).
When notifying the employer of a worker's fitness for duty, health-care providers should maintain confidentiality of medical information according to ethical and legal requirements. Workers should be notified of the results of their own evaluations.

# Medical Measures to Prevent Anthrax
Despite the use of PPE, remediation workers are at risk for exposure to B. anthracis spores because spores might be reaerosolized (R. E. McCleer, CDC, personal communication, 2002), PPE is not 100% protective (5), individual work practices might lead to exposure (5), breaches in PPE and environmental controls might occur, and some breaches might go unrecognized. Neither the infective dose for development of inhalational anthrax nor the level of exposure to B. anthracis during remediation activities has been characterized adequately. Because of these uncertainties and because anthrax is potentially fatal, workers entering B. anthraciscontaminated sites should be vaccinated adequately with anthrax vaccine or protected with antibiotic prophylaxis. This recommendation also applies to workers entering areas that already have been remediated but have not yet been cleared for general occupancy. The use of medical measures for preventing anthrax does not eliminate requirements for use of PPE when entering uncleared areas. The initial medical evaluation should screen for contraindications to anthrax vaccine or antibiotic use, and periodic evaluations should monitor for adverse effects (Table ). Workers should be educated about possible adverse effects and antibiotic interactions with food and drugs.
To prevent anthrax, CDC has recommended 60 days of antibiotic prophylaxis after exposure to B. anthracis (6). Unvaccinated remediation workers should begin antibiotic prophylaxis at the time of their first entry and continue until at least 60 days after last entry into a contaminated area.
Remediation workers with repeated entries into contaminated sites over a prolonged period of time require antibiotic coverage for considerably longer than the 60 days recommended for persons with a one-time exposure. Some remediation workers have been treated with antibiotics for >6 months, and remediation projects are not yet complete. Prolonged antibiotic use might cause side effects (frequently mild but occasionally severe) and might also result in the development of resistant microorganisms. Although supplies for civilian use remain severely limited, CDC recommends anthrax vaccine adsorbed (BioThrax TM , formerly known as AVA, BioPort Inc, Lansing, Michigan) for workers who will be making repeated entries into known contaminated areas and is making BioThrax TM available to workers meeting these criteria. This ultimately will reduce the need for antibiotic prophylaxis and associated side effects for vaccinated persons. The recommended pre-exposure course of BioThrax TM is 6 doses (at 0, 2, and 4 weeks and at 6, 12, and 18 months) with annual boosters (7). If BioThrax TM is administered while the risk for exposure continues, CDC recommends concomitant antibiotic prophylaxis throughout the period of risk for exposure and for 60 days after the risk for exposure has ended unless the 6-dose initial series has been completed and annual boosters are up to date.

# Anthrax-Related Medical Monitoring and Follow-up
No validated methods exist for monitoring a person's exposure to B. anthracis. Nasal swabs and serology might be useful as epidemiologic tools but are not appropriate for medical surveillance of potentially exposed individual workers. Results of these tests should not be used to assess individual exposure or to make decisions about antibiotic prophylaxis (8).
Inhalational exposure to a high dose of B. anthracis spores might result in rapid death. Therefore, in the absence of PPE, exposure to aerosolized powder known or strongly suspected to be contaminated with B. anthracis spores should be treated as a medical emergency (i.e., requiring prompt initiation of antibiotic prophylaxis). Fully vaccinated workers wearing appropriate PPE would not require antibiotic prophylaxis unless they had a breach in their PPE that allowed inhalation of ambient air, for example, a disruption of their respiratory protection. All workers should be trained to recognize and report exposure incidents and early symptoms and signs of anthrax, understand the importance of immediate medical attention, and know how to access emergency medical care. Medical follow-up should be provided as long as the risk for anthrax exists, whether the worker is onsite, off duty (including vacation or holiday), or no longer working at the remediation site. Because remediation work is transient and the workforce highly mobile, special arrangements are necessary for following workers after they leave the worksite.

# Summary
Despite the apparently low disease rate from exposure, protection for remediation workers at B. anthracis-contaminated sites is warranted because inhalational anthrax is rapidly progressive and highly fatal, PPE does not guarantee 100% protection, and the risk for developing disease cannot be characterized adequately. The guidelines described here go beyond HAZWOPER requirements and include recommendations for treating inhalation exposure to B. anthracis spores as a medical emergency, medical follow-up as long as the risk for anthrax persists or a worker is receiving antibiotic prophylaxis, accommodation of a mobile workforce, and assurance that workers understand the need for immediate medical attention should symptoms of anthrax occur. Completion of the 6-dose series of anthrax vaccine followed by annual booster doses will decrease the reliance on antibiotics for the prevention of anthrax. Measures to protect workers must include both medical measures (i.e., vaccination, antibiotic prophylaxis, or a combination of both) and measures to prevent exposure (e.g., PPE and environmental controls).

# Notice to Readers

# Protecting Building Environments from Airborne Chemical, Biologic, or Radiologic Attacks
In November 2001, following the discovery that letters containing Bacillus anthracis had been mailed to targeted locations in the United States, the Secretary of the U.S. Department of Health and Human Services requested site assessments of an array of public-and private-sector buildings by a team of engineers and scientists from CDC's National Institute for Occupational Safety and Health (NIOSH). In November 2001, this team assessed six buildings, including a large hospital and medical research facility, a museum, a transportation building, two large office buildings, and an office/laboratory building. In January 2002, additional building assessments were conducted at CDC campuses in Atlanta and, in April 2002, at a large, urban transportation facility. A total of 59 buildings were evaluated during this 5-month period.
The primary goal of these assessments was to determine the vulnerability of building air environments, including heating, ventilation, and air-conditioning (HVAC) systems, to a terrorist attack with chemical, biologic, and radiologic (CBR) agents and to develop cost-effective prevention and control strategies. At each facility, CDC investigators performed onsite evaluations to assess the building's vulnerability to CBR attack from internal and external sources. The investigators also reviewed security and safety plans at each facility. Facility owners received confidential reports identifying observed vulnerabilities and possible remedial options. Collectively, the field observations and prevention recommendations from the building assessments were combined with input from government and industry experts to identify general guidance that encourages building owners, facility managers, and engineers to review design, operational, and security procedures at their own facilities.
The recommendations include measures that can transform buildings into less attractive targets by increasing the difficulty of introducing a CBR agent, increasing the ability to detect terrorists before they carry out an intended release, and incorporating plans and procedures to mitigate the effects of a CBR release. These recommendations are presented in the recently completed NIOSH guidelines (1), which address physical security, airflow and filtration, maintenance, program administration, and staff training. The guidelines recommend that building owners and managers first understand their buildings' systems by conducting walk-through inspections of the HVAC, fire protection, life-safety, and other systems. Security measures should be adopted for air intakes and return-air grills, and access to building operation systems and building design information should be restricted. The guidelines also recommend that the emergency capabilities of the systems' operational controls should be assessed, filter efficiency should be evaluated closely, buildings' emergency plans should be updated, and preventive maintenance procedures should be adopted. The guidelines also caution against detrimental actions, such as permanently sealing outdoor air intakes.
The recommendations are intended for building owners, managers, and maintenance personnel responsible for public, private, and government buildings, including hospitals, laboratories, offices, retail facilities, schools, transportation facilities, and public venues. The recommendations do not address single-family or low-occupancy residences or higher-risk facilities such as industrial or military facilities, subway systems, or law-enforcement facilities. Copies of these recommendations are available at  or by telephone, 800-356-4674.

# MMWR September 6, 2002
Public Health Dispatch

# West Nile Virus Infection in Organ Donor and Transplant Recipients -Georgia and Florida, 2002
On August 23, 2002, the Georgia Division of Public Health (GDPH) and CDC were notified of two cases of unexplained fever and encephalitis in recipients of organ transplants from a common donor. An investigation has identified illness in two other recipients from the same donor: one with encephalopathy and the other with febrile illness. CDC, the Food and Drug Administration, GDPH, and the Florida Department of Health are conducting the investigation. This cluster could possibly represent the first recognized transmission of West Nile virus (WNV) by organ donation.
On August 1, four organs were recovered from a single donor and subsequently transplanted into four persons. The donor had been previously healthy before a fatal injury. Before death, the organ donor received numerous transfusions of blood products. Testing performed at CDC with polymerase chain reaction (PCR) during this investigation revealed the presence of WNV in donor serum collected before organ procurement. Of the four organ recipients, three met the case definition for WNV encephalitis. Testing is pending on the fourth recipient.
A recipient of one of the donor kidneys developed a febrile illness 13 days after transplant which progressed to encephalitis requiring transient mechanical ventilation; the patient's clinical condition is improving. Cerebrospinal fluid (CSF) was positive for WNV IgM antibody. A second kidney recipient had a febrile illness 17 days after transplant progressing to fatal encephalitis. Brain tissues obtained at autopsy were strongly positive for WNV by quantitative PCR and also were positive by flavivirus specific immunohistochemical staining. A third patient who received a heart transplant had ataxia 8 days following transplant; the patient later became unresponsive and required mechanical ventilation. WNV IgM antibody testing of the patient's CSF and serum at the Florida Department of Health Bureau of Laboratories was strongly positive. This patient's mental status has improved, and the patient no longer requires ventilatory support. A fourth patient who underwent liver transplantation had fever, cough, and malaise 7 days following transplant; the patient had no clinical evidence of encephalitis. The patient's symptoms resolved, allowing discharge from the hospital. Laboratory evaluation of serum for WNV is in progress.
WNV infection in organ transplant recipients has not been reported previously, and the risk for transmission of WNV through donated organs is not known. Three of the four organ recipients had encephalitis; typically, one in 150 WNV infections results in encephalitis or meningitis. It is unknown whether immunosuppressed persons, such as organ transplant recipients, are at increased risk for severe WNV-related disease following infection. Similarly, it is unknown if the route of transmission increased the risk for encephalitis in these organ transplant recipients.
The organ donor might have become infected from a mosquito bite or from blood products received following the fatal injury. On the basis of preliminary results from this investigation, clinicians should be aware of the possibility of WNV infection in organ transplant recipients and patients receiving blood transfusions. Clinicians who suspect WNV infection can obtain rapid testing through state and local health departments. Public health officials have initiated precautionary measures including a withdrawal and testing of any remaining blood products from blood donors whose blood product was given to the organ donor. Donors of blood given to the organ donor and other recipients of blood from these donors are being contacted for West Nile virus testing. This is the first report of possible transmission of WNV by organ transplantation. Current data are insufficient to warrant changes to organ or blood donor screening and testing practices or the clinical use of donated organs and blood. During the reporting period of August 29-September 4, a total of 257 laboratory-positive human cases of WNV-associated illness were reported from Illinois (n=94), Louisiana (n=34), Ohio (n=16), Tennessee (n=15), Michigan (n=14), Mississippi (n=13), Missouri (n=12), New York (n=eight), Kentucky (n=seven), Alabama (n=five), Texas (n=five), Indiana (n=four), North Dakota (n=four), South Dakota (n=four), Wisconsin (n=four), Arkansas (n= three), Minnesota (n= three), Nebraska (n=three), Virginia (n=two), Connecticut (n=one), Florida (n=one), Iowa (n=one), Maryland (n=one), Massachusetts (n=one), Pennsylvania (n=one), and South Carolina (n=one). During this period, Arkansas, Connecticut, Iowa, Minnesota,
North Dakota, Pennsylvania, and South Carolina reported their first human cases for 2002. During the same period, WNV infections were reported in 653 dead crows, 360 other dead birds, 322 horses, and 456 mosquito pools.
During 2002, a total of 737 human cases with laboratory evidence of recent WNV infection have been reported from Louisiana (n=205), Illinois (n=165), Mississippi (n=104), Texas (n=43), Ohio (n=40), Missouri (n=37), Michigan (n=29), Tennessee (n=19), Alabama (n=13), New York (n=13), Indiana (n=10), Kentucky (n=10), South Dakota (n=seven), Georgia (n=six), Wisconsin (n=six), Nebraska (n=four), North Dakota (n=four), Arkansas (n=three), Minnesota (n=three), Virginia (n=three), Florida (n=two), Maryland (n=two), Massachusetts (n=two), Oklahoma (n=two), Connecticut (n=one), the District of Columbia (n=one), Iowa (n=one), Pennsylvania (n=one), and South Carolina (n=one) (Figure ). Among the patients with available data, the median age was 52 years (range: 9 months-98 years); 341 (57%) were male, and the dates of illness onset ranged from June 10 to August 28. A total of 35 human deaths have been reported. The median age of decedents was 76 years (range: 48-94 years); 20 (57%) deaths were among men. In addition, 3,243 dead crows and 2,232 other dead birds with WNV infection were reported from 39 states, New York City, and the District of Columbia; 1,159 WNV infections in mammals (all but one in horses) have been reported from 27 states (Alabama, Arkansas, Colorado, Florida, Georgia, Illinois, Indiana, Iowa, Kansas, Kentucky, Louisiana, Minnesota, Mississippi, Montana, Nebraska, New Mexico, New York, North Dakota, Ohio, Oklahoma, Pennsylvania, South Dakota, Tennessee, Texas, Vermont, Virginia, and Wyoming). During 2002, WNV seroconversions have been reported in 99 sentinel chicken flocks from Florida, Nebraska, Pennsylvania, and New York City; 1,947 WNV-positive mosquito pools have been reported from 18 states (Alabama, Connecticut, Georgia, Illinois, Indiana, Kentucky, Maryland, Massachusetts, Mississippi, Nebraska, New Hampshire, New Jersey, New York, Ohio, Pennsylvania, South Dakota, Texas, and Virginia), New York City, and the District of Columbia.
Additional information about WNV activity is available at  and / west_nile.html.
- W.S. CENTRAL - -. 7 1 - 2,318 2,371 4 2 - - Tenn. - - 99 6,220 6,769 24 31 - - Ala. - - 122 6,509 7,028 14 26 1 - Miss. - - - 4,269 5,362 5 2 -