depar depar depar depar department of health and human ser tment of health and human ser tment of health and human ser tment of health and human ser tment of health and human services vices vices vices vices#
When first evaluated at WRAMC, the 22 patients had a median of three (range: one to nine) skin lesions, which ranged from 3 mm to 40 mm in diameter. Higher proportions of the lesions were located on the upper (39%) or lower (32%) extremities than on the trunk/back (16%) or face/neck (13%). Typically, the lesions were painless, had enlarged slowly, and ultimately had central ulceration, often covered with eschar and surrounded by an erythematous, indurated border (Figure 2). Regional lymph nodes (e.g., epitrochlear, axillary, and inguinal), if palpable, usually were <1 cm in diameter. None of the patients had systemic symptoms.
In 17 (77%) of the 22 cases, parasites were noted on lightmicroscopic examination of tissue. Of the 19 patients who had tissue cultured for parasites, 14 (74%) had positive cultures, of which 13 (93%) had sufficient organisms for species identification by isoenzyme electrophoresis. All nine of the 13 patients whose cultures had been tested as of October 20, 2003, were infected with Leishmania major. Additional evidence that 21 (95%) of the 22 patients had CL was obtained by testing tissue with an investigational, fluorogenic, genusspecific polymerase chain reaction (PCR) assay developed and conducted by staff of WRAMC and Walter Reed Army Institute of Research (Silver Spring, Maryland) (6).
Since 1978, military personnel with potential cases of leishmaniasis have been referred to WRAMC for evaluation and therapy with the pentavalent antimonial compound sodium stibogluconate (Pentostam  , The Wellcome Foundation, United Kingdom). Although treatment of cases of CL with pentavalent antimonial compounds has been considered the standard of care for over half a century (1), these compounds Editorial Note: Leishmaniasis is a vector-borne parasitic disease endemic in parts of the tropics, subtropics, and Southern Europe. The World Health Organization estimates that 1.5 million cases of CL and 500,000 cases of visceral leishmaniasis (VL) occur each year (1).
Both cutaneous and visceral infection can remain asymptomatic or be associated with mild, nonspecific, and nonprogressive symptoms (1). Clinical manifestations, if they develop, typically are first noted weeks to months after exposure. The skin lesions of CL, which can be chronic and disfiguring, typically evolve from papules to nodules to ulcerative lesions but can persist as nodules or plaques (1). Host (e.g., immune status) and parasite (e.g., species and strain) characteristics affect the natural history and the ease and importance of diagnosing and treating cases of CL. Although both L. major and L. tropica are common etiologic agents of CL in Afghanistan, Iraq, and Kuwait (1,7,8), which species has caused a particular case of CL depends on such factors as the geographic area and ecologic setting of exposure and the species of the sand-fly vector. VL is more prevalent in Iraq (8) than in Afghanistan or Kuwait. Manifestations of cases of advanced VL include fever, cachexia, hepatosplenomegaly, pancytopenia, and hypergammaglobulinemia; such cases can be fatal if not treated appropriately and quickly (1).
No FDA-approved vaccines or prophylactic medications to prevent leishmaniasis are available (1). Control measures against vectors or reservoir hosts of infection might be effective in particular settings (1,8,9). Personal protective measures to decrease risk for infection include avoiding, if possible, areas where leishmaniasis is endemic, particularly from dusk through dawn; using permethrin-treated bed nets and clothing; minimizing the amount of exposed skin; and applying insect repellents containing 30%-35% DEET (lower percentages for children) to exposed skin.
Transmission of leishmanial parasites through blood transfusion has not been reported in the United States. However, as a precautionary measure, the Armed Services Blood Program Office of the Department of Defense (DoD) (Falls Church, Virginia) and the American Association of Blood Banks (AABB) (Bethesda, Maryland) are implementing policies to defer prospective blood donors who have been in Iraq from donating blood for 12 months after the last date they left Iraq. Additional information about these deferral policies is available from DoD at / downloads/prevmed/leishmanAug03.pdf and from AABB at .
In Operations Desert Storm and Shield during 1990-1991, among approximately 697,000 deployed military personnel, WRAMC identified 12 cases of so-called viscerotropic leishmaniasis caused by L. tropica (a syndrome associated with visceral infection but not necessarily the classic clinical manifestations of VL) and 20 cases of CL (3,10;WRAMC, unpublished data, 2003). During August 2002-September 2003, WRAMC identified 22 cases of CL among personnel participating in Operations Iraqi and Enduring Freedom. The apparent decline in numbers of cases of CL with self-reported onset of lesions during July-August 2003 (Figure 1) could reflect delays in persons seeking medical evaluation for skin lesions that might not cause concern initially. U.S. personnel in Iraq have reported being bitten by sand flies (some persons have received >100 bites in a single night), and up to 2% of female phlebotomine sand flies collected in Iraq were infected with leishmanial parasites. As of October 21, WRAMC had identified nine more cases of CL in addition to the 22 cases described in this report. WRAMC is evaluating additional potential cases of CL in deployed personnel, and the number of confirmed cases probably will continue to increase.
U.S. health-care providers should consider the possibility of CL in persons with chronic skin lesions who were deployed to Southwest/Central Asia or who were in other areas where leishmaniasis is endemic and that of VL in such persons with persistent, febrile illnesses, especially if associated with other manifestations suggestive of VL (e.g., splenomegaly and pancytopenia) (1,4,8,10). Information about diagnosing and treating CL and VL has been published (1,5). Both WRAMC and CDC provide diagnostic services and the antileishmanial compound sodium stibogluconate. For treatment of health-care beneficiaries of the military, health-care providers should contact WRAMC, telephone 202-782-6740. For treatment of civilians, providers should contact CDC's Drug Service, telephone 404-639-3670.

# Infant Health Among Puerto Ricans -Puerto Rico and U.S. Mainland, 1989-2000
Although the overall U.S. infant mortality rate (IMR) declined dramatically during the 1900s, striking racial/ethnic disparities in infant mortality remain (1,2). Infant health disparities associated with maternal place of birth also exist within some racial/ethnic populations (3,4). Eliminating disparities in infant health is crucial to achieving the 2010 national health objective of reducing the infant death rate to 4.5 per 1,000 live births (objective 16-1c) (5). Hispanics comprise the largest racial/ethnic minority population in the United States. Among U.S. Hispanics, considerable heterogeneity exists in infant health, with the poorest outcomes reported among Puerto Rican infants (6). This report compares trends during the previous decade in IMRs and major determinants of these rates such as low birthweight (LBW), preterm delivery (PTD), and selected maternal characteristics among infants born to Puerto Rican women on the U.S. mainland (50 states and the District of Columbia) with corresponding trends among infants born in Puerto Rico. The findings indicate that despite having lower prevalence of selected maternal risk factors, Puerto Rico-born infants are at greater risk for LBW, PTD, and infant death than mainland-born Puerto Rican infants. This report also highlights a persistent disparity in IMRs and an emerging disparity in LBW and PTD rates between Puerto Rico-born infants and mainland-born Puerto Rican infants. Future research should focus on identifying factors responsible for these disparities to improve infant health in Puerto Rico.
Linked birth/infant death files for the 50 states, the District of Columbia, and Puerto Rico for 1989-1991 and 1998-2000 were used to assess IMR trends. Natality files for 1990-2000 were used to examine trends in rates of LBW (<2,500 g), know what matters.

# Dispatch
up-to-the-minute: adj 1 : extending up to the immediate present, including the very latest information; see also MMWR. PTD (<37 weeks' gestation), and selected maternal characteristics among live-born infants. Analyses were limited to infants born to Puerto Rican women (i.e., those born in Puerto Rico, those born on the mainland to Puerto Rico-born mothers, or those born on the mainland to mothers who reported being of Puerto Rican ethnicity). Infants born in Puerto Rico to women not born either in Puerto Rico or on the mainland were excluded. Four subpopulations of Puerto Rican infants were examined initially: infants born in Puerto Rico to Puerto Rico-born mothers, infants born in Puerto Rico to mainlandborn mothers, infants born on the mainland to Puerto Ricoborn mothers, and infants born on the mainland to mainland-born mothers of Puerto Rican ethnicity. However, because maternal place of birth was not associated substantially with infant health outcomes, data are shown for Puerto Rico-born and mainland-born infants without regard to maternal place of birth. Chi square tests were used to compare differences in the prevalence of infant and maternal characteristics and differences in IMRs among the groups.

# Low Birthweight and Preterm Delivery
In 1990, Puerto Rico-born infants were 1.03 times more likely to be of LBW than mainland-born infants, and in 2000, this disparity increased to 1.2 (Figure). From 1990 to 2000, the LBW rate for Puerto Rico-born infants increased 18.0%, from 9.2% to 10.9%; for mainland-born infants, the LBW rate increased 3.7%, from 8.9% to 9.3%. Similar differences in LBW rate increases were observed when analyses were restricted to full-term and singleton births. The increase in the LBW rate among Puerto Rico-born infants was associated predominantly with an increase in the percentage of infants with an intermediate LBW (ILBW; 1,500-2,499 g); however, a small increase also was observed in the percentage with a very low birthweight (VLBW; <1,500 g) (Table 1). In 2000, Puerto Rico-born infants were less likely than mainlandborn infants to be of VLBW (ratio = 0.7) but more likely to be of ILBW (ratio = 1.3) (Table 1).
In 1990, Puerto Rico-born infants were less likely than mainland-born infants to be born preterm (ratio = 0.9) (Figure ). From 1990 to 2000, the PTD rate among Puerto Rico-born infants increased 29.3% (from 11.6% to 15.0%), and that among mainland-born infants increased 0.9% (from 13.3% to 13.4%). As a result, in 2000, Puerto Rico-born infants were 1.1 times more likely than mainland-born infants to be born preterm. Similar differences in PTD rates were observed when analyses were limited to singleton births. The increase in the PTD rate among Puerto Rico-born infants was attributable primarily to an increase in the rate of moderately preterm births (32-36 weeks' gestation), although the rate of very preterm births (<32 weeks' gestation) also increased slightly (Table 1).
In 2000, despite higher rates of LBW and PTD among Puerto Rico-born infants, their mothers were less likely than mothers of mainland-born infants to report selected maternal risk factors, including receiving late/no prenatal care, having <12 years of education, not being married, having plural births, and using tobacco (Table 1). The prevalence of first trimester prenatal care and the percentage of mothers aged <19 years at their infant's birth were similar for the two groups (Table 1). The prevalence of these maternal characteristics did not differ by maternal place of birth.

# Infant Mortality
From 1989-1991 to 1998-2000, the combined IMR for Puerto Rico-born and mainland-born infants declined approximately 24%. The 1989-1991 IMR for Puerto  (6), risk factors such as maternal tobacco use might be reported less completely in Puerto Rico than on the mainland. Second, because Hispanic origin is not recorded on birth certificates in Puerto Rico, this study was based on records for infants born either in Puerto Rico or on the mainland; mainland-born infants were defined as having Puerto Rican ethnicity if their mothers were born in Puerto Rico or reported being Puerto Rican.
This report highlights a continuing disparity in infant mortality rates and an emerging disparity in LBW and PTD rates between Puerto Rico-born infants and infants born on the mainland to Puerto Rican mothers. These differences should be considered in the planning and implementation of efforts to reduce IMRs among Puerto Ricans. The higher birthweightand gestational age-specific IMRs in Puerto Rico contribute more to the overall higher IMR in Puerto Rico than do the differences in birthweight and gestational age distributions between Puerto Rico-and mainland-born infants (8). Efforts to reduce IMR in Puerto Rico should focus on reducing mortality rates among LBW and preterm infants, perhaps by examining existing perinatal services. Additional opportunities might exist for lowering the overall IMR if the underlying causes of the increases in the prevalence of LBW and PTD can be identified and prevented. Improving infant health in Puerto Ricans will most likely require interventions at the individual, provider, and health-care system levels.

# West Nile Virus Infection Among Turkey Breeder Farm Workers -Wisconsin, 2002
In 2002, Wisconsin public health officials were notified of two cases of febrile illness in workers at a commercial turkey breeder farm (farm A) in county A. The Wisconsin Division of Public Health (WDPH) initiated an investigation that found a high prevalence of West Nile virus (WNV) antibody among farm A workers and turkeys. An associated high incidence of febrile illness among farm A workers also was observed. This report summarizes the results of this investigation, which indicate possible nonmosquito transmission among birds and subsequent infection of humans at farm A. Because the mode of transmission in this outbreak is unknown, turkey handlers should take appropriate precautions, including use of DEETcontaining mosquito repellents, protective clothing and gloves, respiratory protection, and proper hand hygiene. Suspected occupationally acquired WNV infections should be reported immediately to local and state health departments.
During November 2002, WDPH and the Wisconsin State Laboratory of Hygiene (WSLH) confirmed that two ill residents of county A had been infected with WNV. Before these reports, only one human WNV infection had been reported in this county. Both persons worked at farm A and had febrile illness with rash during late September-early October. These human illnesses occurred after a suspected fowl pox outbreak among farm A turkeys in September. Workers were concerned the pox outbreak might be associated with their illnesses.
Farm A is one of six turkey breeder farms in county A owned by a company that also operates nonbreeder farms and a turkey meat processing plant in county A. The five other turkey breeder farms are located within 10 miles of farm A, and multiple private residences are within a quarter mile. In February 2003, county and state public health staff, in collaboration with the company, identified workers at the six turkey breeder farms, the nonbreeder farms, and the plant, and requested their consent to participate in a serosurvey. Serum samples were collected from participating workers (N = 93) to identify persons infected recently. A questionnaire was administered to identify persons who had a febrile illness during August-October 2002. Serum samples also were collected from residents (N = 14) who lived within a quarter mile of farm A. All serum samples were tested for WNV-specific IgM antibody at WSLH (1). IgM-positive specimens were confirmed by plaque-reduction neutralization tests at CDC (2). Of 107 total participants, 10 (9%) were seropositive. Of approximately 90 workers at the six breeder farms, 57 (63%) participated; of these, 10 (18%) were infected recently with WNV (Table ). None of the meat processing workers or other area residents was infected. Of 11 persons who worked exclusively at farm A, six (55%) were WNV IgM-positive, compared with two (25%) of eight who worked at both farm A and other breeder farms and two (5%) of 38 who worked only at other breeder farms. Of the 10 IgM-positive workers, six (60%) reported febrile headaches during August-October (all occurring during the last week of September), compared with seven (7%) of 97 IgM-negative persons sampled (p = 0.0002 by Fisher exact test). All six IgMpositive persons who reported febrile headache had worked at farm A. All six noted a skin rash, and one had meningoencephalitis and was hospitalized; no deaths occurred. Reported mosquito exposures and bites were similar for IgM-positive (nine  and eight  of 10, respectively) and IgMnegative workers (67  and 54  of 79, respectively). Only one (2%) of 57 breeder farm workers reported using insect repellent while working.
Farm A includes two breeder bird barns and a juvenile flock barn. The breeder barns separate uncaged females from male turkeys with a solid plywood wall. The sides of the barns housing the female turkeys are covered with 1 in. x 1 in. mesh wire fencing and plastic curtains that can be adjusted to lower the temperature during warm months.
Serum from farm A turkeys and turkeys from the nearest breeder farm were collected in late January 2003. The farm A flock sampled was the group of birds housed in the juvenile flock barn from mid-June to early December 2002, at which time this flock was moved to a breeder barn on farm A to replace a flock slaughtered in November. The flock sampled on the nearby farm was a breeder flock also in place in Editorial Note: The investigation described in this report found that workers at farm A had a higher incidence of febrile illness and prevalence of WNV antibodies than workers at other breeder and nonbreeder farms, workers at a turkey meat processing facility, or persons who lived on or near the affected farm and who did not work in the turkey barns. The mode of transmission to these workers is unknown. Although the majority of human WNV infections are mosquito-borne, transmission by less typical routes might have occurred, including percutaneous (e.g., exposure of broken skin or mucosa to infected turkey feces or serous exudates from duallyinfected pox lesions), fecal-oral, or respiratory (e.g., exposure to aerosolized infected turkey feces). The WNV seroprevalence (96%) among female turkeys on farm A was high. However, experimental evidence suggests that turkeys develop insufficient levels of WNV viremia to contribute to a bird-mosquito-bird amplification cycle (3). Although WNV was detected in the feces of these turkeys, no oropharyngeal shedding or transmission to cage mates was observed (3). Nonvector-borne WNV transmission has been demonstrated experimentally among rodents and among certain bird species other than turkeys (4,5). Once WNV was introduced to female turkeys at farm A (presumably by mosquitoes), widespread transmission within that flock might have taken place by fecal-oral, respiratory, or another atypical (e.g., percutaneous exposure associated with pecking behavior or vaccination) route. In addition, other unique conditions at farm A, including possible co-infection with an avian pox virus, might have resulted in higher WNV viremias or infectious materials with higher WNV titers than laboratory studies have suggested.
Despite uncertainty over the mode(s) of transmission, epidemiologic evidence suggests that this outbreak was related to occupational exposure. Occupationally acquired WNV infections have been reported previously among laboratory or field workers who experienced a known percutaneous injury or aerosol exposure while working with high concentrations of WNV in cell culture or infected animal tissues (6)(7)(8)(9). In this investigation, no such exposure was documented. Because the mode of transmission in this outbreak is unknown, turkey handlers should 1) take personal protective measures, including wearing protective clothing and using mosquito repellents (e.g., those containing DEET on skin and clothing and those containing permethrin on clothing), as recommended for outdoor workers; 2) wear gloves; and 3) wash hands frequently. In addition, respiratory protection has been recommended for reducing other exposures to workers in turkey barns (10). Respiratory protection should be selected and used in accordance with the Occupational Safety and Health Administration (OSHA) respiratory protection standard (Title 29 CFR 1910.134).
Workers should receive training that reinforces awareness of potential occupational hazards and risks and stresses the importance of timely reporting of all injuries and illnesses of suspected occupational origin. Health-care workers should inquire about a patient's outdoor exposure and occupation when a human WNV infection is suspected or identified and consider WNV as a possible etiology among turkey farm workers with febrile headache or rash, meningitis, encephalitis, or other severe neurologic illness, especially when WNV illnesses exist among co-workers or birds. Suspected occupationally acquired WNV infections should be reported immediately to local and state health departments.
The investigation of turkey breeder farm workers in county A is ongoing. In addition, further studies are needed to determine the factors involved in this outbreak, to better define the occupational risk for WNV infections, and to assess appropriate personal protective measures. On the basis of recommendations from public health staff, the company has made mosquito repellent containing 30% DEET available at farm A and other turkey breeder farms. Recommendations that were outlined previously in place at the company farms include protective clothing, frequent hand washing, and an OSHArequired respiratory protection program. Gloves and safety glasses also are available to workers.

# Public Health and Aging

# Nonfatal Injuries Among Older Adults Treated in Hospital Emergency Departments -United States, 2001
Because injuries generally are considered a problem of the young, injuries among older adults (i.e., persons aged >65 years) have received little attention. However, injuries are the eighth leading cause of death among older adults in the United States (1). In 2001, approximately 2.7 million older adults were treated for nonfatal injuries in hospital emergency departments (EDs); the majority of these injuries were the result of falls (1). To characterize nonfatal injuries among older adults, CDC analyzed data from the National Electronic Injury Surveillance System-All Injury Program (NEISS-AIP). This report summarizes the results of that analysis, which indicate differences in type and mechanism of injury by sex, suggesting that prevention programs should be designed and tailored differently for men and women.
NEISS-AIP is operated by the U.S. Consumer Product Safety Commission and collects data about initial visits for all (MMWR on line) cdc.gov/mmwr Online types and causes of injuries treated in U.S. EDs, drawing from a nationally representative sample of 66 hospitals selected as a stratified probability sample of hospitals in the United States. Data from these cases are weighted by the inverse of the probability of selection to produce national estimates (2). For this report, annualized estimates were calculated on the basis of weighted data for 36,752 nonfatal injuries among older adults treated in EDs during January-December 2001. U.S. Census Bureau population estimates for 2001 were used to calculate injury rates (3). A direct variance estimation procedure was used to calculate 95% confidence intervals and to account for the complex sample design (2). All nonfatal injuries were classified according to the mechanism of injury (e.g., fall, struck by/against, or motor vehicle crash), diagnosis, primary body part injured, disposition, location of injury, and intent. The diagnosis and intent of the injury were classified according to the most severe injury (4). Injuries of unknown intent were grouped with those classified as unintentional.
During 2001, an estimated 935,556 men and 1,731,640 women aged >65 years were treated in EDs for nonfatal injuries. The overall injury rate per 100,000 persons was higher among women (8,466 per 100,000 persons) than among men (6,404). Injury rates increased with age, to 15,272 for women aged >85 years and 11,547 for men aged >85 years. Nearly all injuries (99%) were classified as unintentional/unknown intent (Table ).
Overall, falls resulted in the highest rates of injury (4,684 per 100,000 persons) and were the most common mechanism of injury, accounting for 62% of all nonfatal injury ED visits in this population. The injury rate from falls was higher among women (5,659) than men (3,319). However, the injury rates for women were lower with certain other types of injuries, such as being struck by/against (588 versus 617), occupying a motor vehicle (525 versus 540), and being cut or pierced (243 versus 488) (Table ).
The greatest number of nonfatal injuries among older adults were diagnosed as fractures (26%), followed by contusions/ abrasions (23%), lacerations (17%), strains/sprains (13%), and internal injuries (5%). Diagnoses varied by sex. Fractures of all parts of the body were more common among women than men (30% versus 19%), and lacerations were more common among men than women (22% versus 14%). The parts of the body affected most were the head/neck (25%) and arms/hands (22%). The majority (82%) of older adults were treated and released; 16% were hospitalized. The ratio of patients treated/ released to those hospitalized was lower among women (4.7:1) than men (5.9:1), suggesting women were more often hospitalized after a nonfatal injury. The most common (47%) location for nonfatal injuries was the home (Table ). Editorial Note: Falls remain the leading cause of both nonfatal and fatal injury among older adults aged >65 years in the United States (1). The findings in this report, which indicate that falls were the most common reason for injury-related ED visits among persons aged >65 years, are consistent with previous studies indicating that approximately 40% of older adults living in community settings (e.g., in private residences or minimally assisted environments) fall each year (5).
In this study, 82% of persons aged >65 years were treated and released following injury, compared with 95% of persons aged <65 years. Older adults were more than three times more likely (1,217 per 100,000 persons) to be hospitalized than persons aged <65 years (353) (1).
The findings in this report are subject to at least five limitations. First, NEISS-AIP provides national estimates and does not allow for estimates by region, state, or local jurisdiction. Second, injury outcomes are specific to ED visits and do not include subsequent outcomes. Third, NEISS-AIP data reflect only those injuries that were severe enough to require treatment in an ED. Fourth, in cases with multiple injuries, only data regarding the most severe injury are recorded. Finally, data for intent are classified on the basis of information contained in the medical record. Injuries for which intent cannot be determined conclusively from the ED record are grouped with unintentional injuries.
The findings in this report can form the basis for targeting prevention efforts to different populations of older adults. For example, exercise can reduce the risk for fall among older adults by 15% (6). Because women are more likely to sustain fallrelated injuries, exercise can be an especially important preventive measure for this population. Data from NEISS-AIP can continue to be a source for monitoring trends, evaluating interventions, and characterizing nonfatal injuries among persons aged >65 years.  (n = four), New Mexico (n = four), North Dakota (n = four), Alabama (n = three), Ohio (n = three), Indiana (n = two), Missouri (n = two), Montana (n = two), New Jersey (n = two), Delaware (n = one), Illinois (n = one), Kansas (n = one), Kentucky (n = one), Louisiana (n = one), Michigan (n = one), Mississippi (n = one), Tennessee (n = one), and Virginia (n = one). A total of 682 presumptive West Nile viremic blood donors have been reported to ArboNET. Of these, 596 (87%) were reported from the following nine western and midwestern states: Colorado, Kansas, Nebraska, New Mexico, North Dakota, Oklahoma, South Dakota, Texas, and Wyoming. Of the 529 donors for whom data were reported completely, six subsequently had meningoencephalitis, and 76 subsequently had West Nile fever.
In addition, 10,453 dead birds with WNV infection have been reported from 42 states, the District of Columbia, and New York City; 3,270 WNV infections in horses, 16 WNV infections in dogs, 14 infections in squirrels, and 24 infections in unidentified

# Human WNV disease and animal WNV activity
Animal WNV activity only one. In addition, seropositivity was reported from one other unidentified animal species. A total of 6,667 WNV-positive mosquito pools have been reported from 38 states, the District of Columbia, and New York City.
Additional information about WNV activity is available from CDC at / index.htm and .

# Notice to Readers

# Guidelines for Maintaining and Managing the Vaccine Cold Chain
In February 2002, the Advisory Committee on Immunization Practices (ACIP) and American Academy of Family Physicians (AAFP) released their revised General Recommendations on Immunization (1), which included recommendations on the storage and handling of immunobiologics. Because of increased concern over the potential for errors with the vaccine cold chain (i.e., maintaining proper vaccine temperatures during storage and handling to preserve potency), this notice advises vaccine providers of the importance of proper cold chain management practices. This report describes proper storage units and storage temperatures, outlines appropriate temperature-monitoring practices, and recommends steps for evaluating a temperature-monitoring program. The success of efforts against vaccine-preventable diseases is attributable in part to proper storage and handling of vaccines. Exposure of vaccines to temperatures outside the recommended ranges can affect potency adversely, thereby reducing protection from vaccine-preventable diseases (1). Good practices to maintain proper vaccine storage and handling can ensure that the full benefit of immunization is realized.

# Recommended Storage Temperatures
The majority of commonly recommended vaccines require storage temperatures of 35F-46F (2C-8C) and must not be exposed to freezing temperatures. Introduction of varicella vaccine in 1995 and of live attenuated influenza vaccine (LAIV) more recently increased the complexity of vaccine storage. Both varicella vaccine and LAIV must be stored in a continuously frozen state <5F (-15C) with no freeze-thaw cycles (Table 1). In recent years, instances of improper vaccine storage have been reported. An estimated 17%-37% of providers expose vaccines to improper storage temperatures, and refrigerator temperatures are more commonly kept too cold than too warm (2,3).
Freezing temperatures can irreversibly reduce the potency of vaccines required to be stored at 35F-46F (2C-8C). Certain freeze-sensitive vaccines contain an aluminum adjuvant that precipitates when exposed to freezing temperatures. This results in loss of the adjuvant effect and vaccine potency (4). Physical changes are not always apparent after exposure to freezing temperatures and visible signs of freezing are not necessary to result in a decrease in vaccine potency.
Although the potency of the majority of vaccines can be affected adversely by storage temperatures that are too warm,  these effects are usually more gradual, predictable, and smaller in magnitude than losses from temperatures that are too cold. In contrast, varicella vaccine and LAIV are required to be stored in continuously frozen states and lose potency when stored above the recommended temperature range.

# Vaccine Storage Requirements
Vaccine storage units must be selected carefully and used properly. A combination refrigerator/freezer unit sold for home use is acceptable for vaccine storage if the refrigerator and freezer compartments each have a separate door. However, vaccines should not be stored near the cold air outlet from the freezer to the refrigerator. Many combination units cool the refrigerator compartment by using air from the freezer compartment. In these units, the freezer thermostat controls freezer temperature while the refrigerator thermostat controls the volume of freezer temperature air entering the refrigerator. This can result in different temperature zones within the refrigerator.
Refrigerators without freezers and stand-alone freezers usually perform better at maintaining the precise temperatures required for vaccine storage, and such single-purpose units sold for home use are less expensive alternatives to medical specialty equipment. Any refrigerator or freezer used for vaccine storage must maintain the required temperature range year-round, be large enough to hold the year's largest inventory, and be dedicated to storage of biologics (i.e., food or beverages should not be stored in vaccine storage units). In addition, vaccines should be stored centrally in the refrigerator or freezer, not in the door or on the bottom of the storage unit, and sufficiently away from walls to allow air to circulate.

# Temperature Monitoring
Proper temperature monitoring is key to proper cold chain management. Thermometers should be placed in a central location in the storage unit, adjacent to the vaccine. Temperatures should be read and documented twice each day, once when the office or clinic opens and once at the end of the day. Temperature logs should be kept on file for >3 years, unless state statutes or rules require a longer period. Immediate action must be taken to correct storage temperatures that are outside the recommended ranges. Mishandled vaccines should not be administered.
One person should be assigned primary responsibility for maintaining temperature logs, along with one backup person. Temperature logs should be reviewed by the backup person at least weekly. All staff members working with vaccines should be familiar with proper temperature monitoring.
Different types of thermometers can be used, including standard fluid-filled, min-max, and continuous chart recorder thermometers (Table 2). Standard fluid-filled thermometers are the simplest and least expensive products, but some models might perform poorly. Product temperature thermometers (i.e., those encased in biosafe liquids) might reflect vaccine temperature more accurately. Min-max thermometers monitor the temperature range. Continuous chart recorder thermometers monitor temperature range and duration and can be recalibrated at specified intervals. All thermometers used for monitoring vaccine storage temperatures should be calibrated and certified by an appropriate agency (e.g., National Institute of Standards and Technology). In addition, temperature indicators (e.g., Freeze Watch TM  or ColdMark TM ) can be considered as a backup monitoring system (5); however, such indicators should not be used as a substitute for twice daily temperature readings and documentation.
All medical care providers who administer vaccines should evaluate their cold chain maintenance and management to ensure that 1) designated personnel and backup personnel have written duties and are trained in vaccine storage and handling; 2) accurate thermometers are placed properly in all vaccine storage units and any limitations of the storage system are fully known; 3) vaccines are placed properly within the refrigerator or freezer in which proper temperatures are maintained; 4) temperature logs are reviewed for completeness and any deviations from recommended temperature ranges; 5) any outof-range temperatures prompt immediate action to fix the problem, with results of these actions documented; 6) any vaccines exposed to out-of-range temperatures are marked "do not use" and isolated physically; 7) when a problem is discovered, the exposed vaccine is maintained at proper temperatures while state or local health departments, or the vaccine manufacturers, are contacted for guidance; and 8) written emergency retrieval and storage procedures are in place in case of equipment failures or power outages. Around-the-clock monitoring systems might be considered to alert staff to afterhours emergencies, particularly if large vaccine inventories are maintained.
Additional information on vaccine storage and handling is available from the Immunization Action Coalition at http:// www.immunize.org/izpractices/index.htm. Links to state and local health departments are available at / other.htm. Especially detailed guidelines from the Commonwealth of Australia on vaccine storage and handling, vaccine storage units, temperature monitoring, and stability of vaccines at different temperatures (6)

# Notice to Readers

# International Conference on Emerging Infectious Diseases
CDC's National Center for Infectious Diseases, the Council of State and Territorial Epidemiologists, the American Society for Microbiology, and the World Health Organization will cosponsor the International Conference on Emerging Infectious Diseases February 29-March 3, 2004, at the Marriott Marquis Hotel in Atlanta, Georgia. The conference will explore the most current research, surveillance, and prevention and control programs addressing all aspects of emerging infectious diseases. Attendance is limited to 2,500 participants.
The conference will include general and plenary sessions, symposia, panels of speakers, presentations on emerging infections activities, oral and poster presentations, and exhibits. The deadline for abstract submission for presentations is November 14, 2003. Information about submitting abstracts is available at . Abstracts should address new, reemerging, or drug-resistant infectious diseases that affect human health. The deadline for late-breaker abstracts is January 16, 2004.
Registration information is available at  and at  and by e-mail at meetinginfo@asmusa.org or at dsy1@cdc.gov.

# Errata: Vol. 52, No. 40
In the article, "Cigarette Smoking Among Adults -United States, 2001," an error occurred in the table on page 955. Total prevalence for persons with 0-12 yrs (no diploma) of education was reported to be 28.4% (95% CI +1.4). The correct prevalence for this population should have been 27.5% (95% CI +1.4).
In the article, "Recommended Adult Immunization Schedule -United States, 2003-2004," on page 968, an incorrect volume number was given for the fourth reference. The reference should read, "4. CDC. Prevention of pneumococcal disease: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR 1997;46(No. RR-8)."

# Errata: Vol. 52, No. RR-10
In the MMWR Recommendations and Reports, "Guidelines for Environmental Infection Control in Health-Care Facilities: Recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee (HICPAC)," On page 10, in Figure 1, the third bullet under the footnote should read as follows:
"- air volume differential >125 cfm supply versus exhaust." On page 11, in Figure 2, the label "Neutral anteroom" should read "anteroom." Also, the first, second, and seventh bullets under the footnote should read as follows: "- pressure differential of 2.5 Pa (0.01-in. water gauge) measured at the door between patient room and anteroom;
- air volume differential >125 cfm, depending on anteroom airflow direction (i.e., pressurized versus depressurized);
- anteroom airflow patterns (i.e., anteroom is pressurized in top and middle panels, and depressurized in bottom panel)."
On page 12, in Figure 3, the third bullet under the footnote should read as follows:
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- No measles or rubella cases were reported for the current 4-week period yielding a ratio for week 42 of zero (0).  Ratio of current 4-week total to mean of 15 4-week totals (from previous, comparable, and subsequent 4-week periods for the past 5 years). The point where the hatched area begins is based on the mean and two standard deviations of these 4-week totals.
U: Unavailable.
-:No reported cases. - Mortality data in this table are voluntarily reported from 122 cities in the United States, most of which have populations of >100,000. 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.  Total includes unknown ages.