In 2008, a total of 12,898 incident tuberculosis (TB) cases were reported in the United States; the TB rate declined 3.8% from 2007 to 4.2 cases per 100,000 population, the lowest rate recorded since national reporting began in 1953. This report summarizes provisional 2008 data from the National TB Surveillance System and describes trends since 1993. Despite this overall improvement, progress has slowed in recent years; the average annual percentage decline in the TB rate decreased from 7.3% per year during 1993-2000 to 3.8% during 2000-2008.- Foreign-born persons and racial/ethnic minorities continued to bear a disproportionate burden of TB disease in the United States. In 2008, the TB rate in foreignborn persons in the United States was 10 times higher than in U.S.-born persons. TB rates among Hispanics and blacks were nearly eight times higher than among non-Hispanic whites, and rates among Asians were nearly 23 times higher than among non-Hispanic whites. In 2008, among persons with TB whose country of origin was known, approximately 95% of Asians, 76% of Hispanics, 32% of blacks, and 18% of#
whites were foreign born. Among U.S.-born racial and ethnic groups, the greatest racial disparity in TB rates was for U.S.born blacks, whose rate was seven times higher than the rate for U.S.-born whites. Intensified efforts are needed to address the slowing decline in TB incidence and the persistent disparities that exist between U.S.-born and foreign-born persons and between whites and minorities in the United States.
Health departments in the 50 states and the District of Columbia (DC) electronically report to CDC verified TB cases that meet the CDC/Council of State and Territorial Epidemiologists case definition.  Reports include the patient's race, ethnicity (i.e., Hispanic or non-Hispanic), treatment information, and, whenever available, drug-susceptibility test results. CDC calculates national and state TB rates overall and by racial/ethnic group using current U.S. Census population estimates. U.S. Census annual estimates were used to calculate the national TB rate and the percentage change from 2007 to 2008. Population denominators used to calculate TB rates and percentage changes over time according to national origin (U.S.-born versus foreign-born persons) were from the U.S. Census Current Population Survey. A U.S.-born person was defined as someone born in the United States or its associated jurisdictions or someone born in a foreign country but having at least one U.S.-born parent. Persons not meeting this definition were classified as foreign born. For 2008, patients with unknown origin of birth represented 0.6% (74 of 12,898) of total cases. For this report, persons identified as white, black, Asian, American Indian/Alaska Native, native Hawaiian or other Pacific Islander, or of multiple races were all classified as non-Hispanic. Persons identified as Hispanic might be of any race.
In 2008, TB rates in the 51 reporting areas ranged from 0.5 (North Dakota) to 9.6 (Hawaii) cases per 100,000 population (median: 3.0 cases per 100,000 population) (Figure 1). Thirtythree states and DC had lower rates in 2008 than in 2007; however, 17 states had higher rates. Four states (California, Florida, New York, and Texas) reported more than 500 cases each for 2008, a decline from seven states with at least 500 cases in 2006 and five states in 2007. Combined, these four states accounted for approximately half (49.2% ) of all TB cases in 2008.
Among U.S.-born persons, the number and rate of TB cases continued to decline in 2008. The number of TB cases in U.S.-born persons (5,283 ) declined 3.9% compared with 2007 and 69.7% compared with 1993 (Figure 2). In 2008, the TB rate among U.S.-born persons was 2.0 per 100,000 population,  TB rate cutoff points were based on terciles: 18 states had TB case rates of 4.0 (range: 4.02-9.63) per 100,000. DC 4.0  Editorial Note: In 2008, the number of TB cases and annual TB rate reached all-time lows in the United States. After the resurgence of TB during 1985-1992, the annual TB rate has steadily decreased. However, since 2000, the pace of that decline has slowed. To hasten the decline of TB in the United States, intensified efforts are required to address the disproportionately high rates of TB that persist among foreign-born persons and racial/ethnic minorities. The proportion of TB cases contributed by foreign-born persons has increased each year since 1993. This is a reflection of high rates of TB in countries of origin for U.S. immigrants. To help address this, in 2007, CDC issued revised technical instructions for TB screening and treatment among persons applying for immigration to the United States (3). The revision included instructions for 1) more comprehensive diagnostic testing among applicants (e.g., cultures and drug-susceptibility testing for persons with suspected TB); 2) the administration of directly observed therapy overseas, before entry into the United States; and 3) targeted tuberculin skin testing (before entry into the United States) of children from high-incidence countries and contacts of persons known to have TB. In addition, CDC continues to work with international partners, including the Stop TB Partnership, to strengthen TB control in countries with high TB incidence. For example, to facilitate patient referral and treatment among persons who cross the U.S.-Mexico border, bilateral initiatives (e.g., CureTB) are improving coordination of TB care between U.S. TB programs and Mexican counterparts. Modeling has suggested that U.S.-funded expansion of the directly observed treatment (short course) strategy in selected high-incidence countries (e.g., Mexico) might be a cost-saving approach to reducing TB-related morbidity and mortality among U.S. immigrants (4).
The proportion of TB cases that are multidrug resistant has remained approximately 1% of culture-positive cases since 1997; however, MDR TB has continued to disproportionately affect foreign-born persons in the United States. CDC continues to provide technical assistance to domestic and international partners to increase detection of MDR TB and improve access to second-line TB drugs (5).   In 2008, TB rates declined for all racial/ethnic minorities, yet among the U.S. born, blacks continue to experience a disproportionately high rate of TB. CDC's TB Epidemiologic Studies Consortium currently is conducting studies to understand how to reduce TB in blacks effectively, including a study to identify barriers to treatment adherence for latent TB infection and TB disease and a study examining the determinants of early diagnosis, prevention, and treatment of TB.
The findings in this report are subject to at least two limitations. First, the analysis was based on provisional 2008 data that are subject to change. This applies to TB case counts and HIV testing results data, both of which were incomplete. Additional data might change the results marginally. Second, population denominator data were drawn from multiple U.S. census sources and are subject to periodic adjustment. CDC's annual TB surveillance summary, due to be published in fall 2009, will provide updated data.
To ensure that TB rates decline further in the United States, especially among foreign-born persons and minority populations, TB prevention and control capacity should be increased (6)(7)(8). Additional capacity should be used to 1) improve case management and contact investigations; 2) intensify outreach, testing, and treatment of high-risk and hard-to-reach populations; 3) enhance treatment and diagnostic tools; 4) increase scientific research to better understand TB transmission; and 5) continue collaboration with other nations to reduce TB globally. FSM comprises four states and more than 600 islands spread across 1 million square miles in the western Pacific Ocean. Half of the population of 108,000 lives in Chuuk, the largest state (2). TB is endemic in Chuuk, where 70 cases of TB were recorded in 2007. The 2007 incidence rate (127 TB cases per 100,000) is 29 times higher than the 2007 U.S. rate (3).

# Two Simultaneous

# Limited transportation hinders access to the only hospital in
Chuuk, which provides chest radiography and smear microscopy services to help diagnose TB. Culture confirmation, drug-susceptibility testing, and genotyping were not available routinely for TB cases in FSM until January 2006, when referral laboratories in Hawaii and California began to offer these services. Before 2008, the state's geography, combined with limited TB program staffing, precluded active case-finding via routine contact investigations or the administration of DOT, a cornerstone of TB treatment that improves completion of therapy and prevents the emergence of drug resistance. Before July 2008, TB patients were identified as they showed signs or symptoms of TB disease at the local clinic or hospital; all received self-administered therapy. FSM's National TB Program has an annual budget of $170,000, and second-line drugs for treating MDR TB were not available because of funding constraints.
In June 2007, pulmonary TB was diagnosed in a Chuuk resident aged 37 years. Sputum-smear microscopy detected acid-fast bacilli, and a chest radiograph showed lung cavitation, both indicators of contagiousness. In November 2007, drug-susceptibility test results confirmed multidrug resistance. The patient did not have access to second-line drugs and died. During December 2007-June 2008, four additional patients with MDR TB disease came to the local clinic or hospital. None of the four patients were treated with second-line drugs; three died, including a child aged 2 years. In May 2008, FSM authorities requested CDC assistance because of the 80% fatality rate and evidence of recent MDR TB transmission.
A confirmed case was defined as laboratory-confirmed MDR TB disease in a Chuuk resident during January 2006-June 2008. A suspected case of MDR TB disease was defined as exposure (based on intensity and duration of contact) to a patient with confirmed TB and clinical findings of TB disease (i.e., laboratory confirmation pending). Patients (or proxies for deceased patients) were interviewed and laboratory and medical records reviewed.
The July 2008 investigation focused on the initial five confirmed MDR TB cases. All patients were born in Chuuk; their median age was 16 years (range: 2-37 years), and four were female. None of the patients had a history of TB disease or treatment with TB drugs. All five patients had pulmonary TB, two with cavitation on chest radiograph and hemoptysis. None of the four patients who died before the investigation had been tested for human immunodeficiency virus (HIV) infection; the surviving patient had a negative HIV test result in July 2008. Two distinct clusters, associated with two different villages, were identified based on genotypes and drug-susceptibility patterns (Figure).
In the first cluster of three cases, Mycobacterium tuberculosis isolates had a matching genotype and resistance to five drugs: isoniazid, rifampin, pyrazinamide, ethambutol, and streptomycin. This drug-susceptibility pattern had not been seen in Chuuk since routine drug-susceptibility testing became available in January 2006. The index patient in this cluster had worked during 1987-2000 in the garment industry in the Commonwealth of the Northern Mariana Islands (Saipan), which employs migrants from Southeast Asian countries (4) where MDR TB is common (5).
In the second cluster of two cases, the isolates had a matching genotype and resistance to three drugs: isoniazid, rifampin, and ethionamide. The two patients were cousins whose extended family included five persons who previously had TB disease with isolates genotypically matched to those of the outbreak patients. However, the earlier isolates had resistance to isoniazid and ethionamide only. These five previous cases of non-MDR TB were diagnosed from January 2006, when genotyping became routinely available in Chuuk, to October 2007. Household caregivers reported that the five patients had self-administered therapy inconsistently or incompletely.
During investigations of the five initial cases of MDR TB disease, a standardized clinical examination, chest radiography, and tuberculin skin testing were used to evaluate contacts for TB disease and latent TB infection (6). The 205 named contacts, of whom 163 (80%) were household members and 42 (20%) were health-care workers, had a median age of 20 years (range: 4 months-62 years), and 117 (57%) were female. During July 1, 2008-March 13, 2009, three additional MDR TB cases were confirmed among household members (Figure ), including a household contact aged 4 years who in November 2008 died of meningitis later confirmed to be caused by MDR TB. Based on history of household exposure to a patient with confirmed TB and clinical findings (e.g., chest radiography consistent with TB disease), 13 other suspected cases of MDR TB disease were identified; all 13 patients began treatment based on the drug-susceptibility results of the respective source case (Table ). Although fewer than one third of the contacts were aged <15 years (60 of 205), they accounted for more than half of the suspected and confirmed MDR TB cases since July 2008 (nine of 16). Latent TB infection was diagnosed in 124 (60%) contacts, although many of the adults were probably infected before this documented emergence of MDR TB in Chuuk. Among contacts aged <15 years, 20 (33%) of 60 had latent TB infection. All household contacts with latent TB infection have begun receiving second-line drugs based on the drug-susceptibility results of the respective source case (1,7).
Multiple  (9) have resulted in the following actions: 1) a consistent supply of fluoroquinolones, aminoglycosides, and other second-line drugs was procured; 2) Chuuk State Hospital added a separate ward for inpatient treatment of patients with TB; 3) TB program staff members received on-site training on providing DOT and conducting contact investigations; 4) nine new outreach workers were hired to administer DOT, and three vehicles were acquired to help workers investigate contacts; 5) the hospital laboratory was equipped for processing specimens for smear microscopy daily and shipping specimens for culture and drug-susceptibility testing weekly. For 2008, the improved case-detection capacity increased the recorded TB incidence to 204 cases per 100,000 persons. The Chuuk TB program is consulting with U.S. MDR TB experts by telephone and e-mail for assistance with complex treatment decisions, and implementing measures to prevent the selection of drug-resistant strains and reduce all TB transmission. Editorial Note: These two clusters of MDR TB represent two distinct outbreaks and illustrate two mechanisms for the emergence of drug resistance. In the first outbreak, the index patient had not been treated previously for TB and probably became infected with a MDR TB strain before returning to Chuuk in 2000 from Saipan; this case illustrates primary (i.e., initial) drug resistance. In the second outbreak, lack of DOT for the five family members with TB disease initially resistant to only isoniazid and ethionamide probably led to secondary (i.e., acquired) rifampin resistance. At least one of these five previous patients thus acquired multidrug resistance and transmitted MDR TB to the index case in the second outbreak.
The emergence and transmission of MDR TB in these outbreaks were caused by the inability to follow standard TB control practices or to provide appropriate drugs. The findings also highlight the vulnerability of pediatric contacts and the challenges of diagnosing and treating MDR TB in resource-limited settings. Laboratory capacity and access to second-line TB drugs are fundamental to controlling MDR TB (1), and finding and curing all persons with TB is critical for interrupting transmission (8). Contact investigations enable active case-finding and early identification of recently infected contacts at highest risk for developing TB disease. Infection control practices (e.g., isolating contagious patients initially during treatment and wearing appropriate personal protective equipment) can prevent transmission of susceptible and drug-resistant TB, and are particularly important in congregate settings such as clinics, hospitals, and prisons. Uniform DOT for patients with TB disease prevents acquired drug resistance (5) and, where feasible, DOT should be offered for contacts with latent TB infection as well.
The measures implemented in response to the MDR TB outbreaks in Chuuk have reflected all five aspects of the WHO global response plan for drug-resistant TB (10), which calls for augmenting the public health infrastructure to control TB, strengthening laboratory services for early diagnosis, improving surveillance to better understand drug resistance, implementing infection control to prevent transmission, and enhancing management of drug-resistant TB cases to reach the Global Plan to Stop TB 2006-2015 goals.  Tangible progress in treating and preventing the spread of TB has been made in Chuuk as recommendations from the investigation have been implemented.
In 2008, an estimated 500,000 persons in the world developed MDR TB, largely as a result of inadequate TB control activities (5). In many countries where TB is endemic, ongoing transmission of multiple strains of MDR TB probably will be discovered as access to laboratory services improves (10). The challenge of primary drug resistance is likely to be exacerbated further by the increasing numbers of migratory and displaced populations (4). Many developing countries provide free firstline TB drugs through TB control programs. However, effective and sustainable mechanisms for access to expensive second-line TB drugs are needed for timely treatment of patients with drug-resistant TB. The multiagency response to the MDR TB outbreaks in Chuuk is a good example of the coordinated efforts that are needed to control MDR TB in many developing countries. As in Chuuk, a concerted focus on improving access to enhanced laboratory services and second-line TB drugs, and building local capacity for finding, diagnosing, and curing all forms of TB is necessary to address the global threat of MDR TB.

# Guidance for Control of Infections with Carbapenem-Resistant or Carbapenemase-Producing Enterobacteriaceae in Acute Care Facilities
Infection with carbapenem-resistant Enterobacteriaceae (CRE) or carbapenemase-producing Enterobacteriaceae is emerging as an important challenge in health-care settings (1). Currently, carbapenem-resistant Klebsiella pneumoniae (CRKP) is the species of CRE most commonly encountered in the United States. CRKP is resistant to almost all available antimicrobial agents, and infections with CRKP have been associated with high rates of morbidity and mortality, particularly among persons with prolonged hospitalization and those who are critically ill and exposed to invasive devices (e.g., ventilators or central venous catheters). This report provides updated recommendations from CDC and the Healthcare Infection Control Practices Advisory Committee (HICPAC) for the control of CRE or carbapenemase-producing Enterobacteriaceae in acute care (inpatient) facilities. For all acute care facilities, CDC and HICPAC recommend an aggressive infection control strategy, including managing all patients with CRE using contact precautions and implementing Clinical and Laboratory Standards Institute (CLSI) guidelines for detection of carbapenemase production. In areas where CRE are not endemic, acute care facilities should 1) review microbiology records for the preceding 6-12 months to determine whether CRE have been recovered at the facility, 2) if the review finds previously unrecognized CRE, perform a point prevalence culture survey in high-risk units to look for other cases of CRE, and 3) perform active surveillance cultures of patients with epidemiologic links to persons from whom CRE have been recovered. In areas where CRE are endemic, an increased likelihood exists for imporation of CRE, and facilities should consider additional strategies to reduce rates of CRE (2). Acute care facilities should review these recommendations and implement appropriate strategies to limit the spread of these pathogens.
For CRKP, the most important mechanism of resistance is the production of a carbapenemase enzyme, bla kpc . The gene that encodes the bla kpc enzyme is carried on a mobile piece of genetic material (transposon), which increases the risk for dissemination. Since first described in North Carolina in 1999, CRKP has been identified in 24 states and is recovered routinely in certain hospitals in New York and New Jersey (3). Analysis of 2007 data regarding health-care-associated infections reported to CDC indicated that 8% of all Klebsiella isolates were CRKP, compared with fewer than 1% in 2000 (CDC, unpublished data, 2008). CRKP poses significant treatment challenges, and CRKP infections have been associated with increased mortality, length of stay, and increased cost (4). The emergence and spread of CRKP and other types of CRE is another in a series of worrisome public health developments regarding antimicrobial resistance among gram-negative bacteria and underscores the immediate need for aggressive detection and control strategies (5).
A difficulty in detecting CRE is the fact that some strains that harbor bla kpc have minimal inhibitory concentrations (MICs) that are elevated but still within the susceptible range for carbapenems. Because these strains are susceptible to carbapenems, they are not identified as potential clinical or infection control risks using current susceptibility testing guidelines. To address this challenge, in January 2009, CLSI published a recommendation that carbapenem-susceptible Enterobacteriaceae with elevated MICs or reduced disk diffusion zone sizes be tested for the presence of carbapenemases using the modified Hodge test (MHT) (6). The MHT is a phenotypic test used to detect carbapenemases in isolates demonstrating elevated but susceptible carbapenem MICs and has demonstrated sensitivity and specificity exceeding 90% in identifying carbapenemase-producing Enterobacteriaceae (6). If the MHT reveals the presence of a carbapenemase, CLSI recommends that a comment be added to the microbiology report to inform clinicians and infection preventionists. Because treatment information on MHT-positive, carbapenem-susceptible isolates is limited, CLSI guidelines do not recommend any changes regarding the reporting of susceptibility results themselves. Strains of Enterobacteriaceae that test intermediate or resistant to carbapenems should be reported as such and do not need to be subjected to the MHT.
Patients with unrecognized CRKP colonization have served as reservoirs for transmission during health-care-associated outbreaks (7). For example, during an outbreak of 39 cases of CRKP infection in a hospital in Puerto Rico in 2008, in addition to a review of infection control practices, active surveillance cultures were performed on patients in the same units as persons with confirmed CRKP infection. Cultures performed on 30 patients in the intensive care unit revealed two colonized patients who were not previously known to harbor CRKP and were not placed in contact precautions (CDC, unpublished data, 2008). Control of the outbreak was hindered by lack of compliance with infection control practices. Health-care personnel adherence to recommendations for gown and glove use was low (62%) at the hospital, and appropriate hand hygiene (i.e., hand washing or using a waterless alcohol-based hand rub before and after patient contact) was observed in only 48% of patient encounters. The hospital eventually was able to control the outbreak through enhanced infection control compliance, patient cohorting, and weekly perirectal surveillance cultures of patients in the outbreak units until no new cases were identified.
Experience from the outbreak in Puerto Rico and elsewhere (notably Israel) suggests that early detection through use of targeted surveillance and introduction of strict infection control measures (including reinforcement of hand hygiene and contact precautions) can help control the spread of CRKP (7). Other recent reports have demonstrated that microbiologic surveillance for CRKP can be accomplished using brothbased culture techniques that are widely available and also by in-house prepared molecular techniques and a commercial chromogenic agar (4,7-9); however, the latter two methods are not currently approved by the Food and Drug Administration. The screening tests used in several studies were performed on rectal or perirectal swabs; limited data indicate that surveillance screening of stool specimens, rectal swabs, or perirectal swabs might produce higher yield than testing of other body sites (e.g., nares or skin) (9).

# CDC and HICPAC Recommendations
In light of the clinical and infection control challenges posed by CRE and advances in the ability to detect these pathogens, CDC and HICPAC have developed new guidance for CRE infection prevention and control in an effort to limit the further emergence of these organisms (Box). These recommendations are based on strategies outlined in the 2006 HICPAC guidelines for management of multidrug-resistant organisms in health-care settings (2).
All patients colonized or infected with CRE or carbapenemase-producing Enterobacteriaceae should be placed on contact precautions. Acute care facilities should establish a protocol, in conjunction with CLSI guidelines, to detect nonsusceptibility and carbapenemase production in Enterobacteriaceae, particularly Klebsiella spp. and Escherichia coli, and immediately alert epidemiology and infection control staff members if identified. All acute care facilities should review microbiology records for the preceding 6-12 months to ensure that previously unrecognized CRE cases have not occurred. If previously unrecognized cases are identified, facilities should conduct a point prevalence survey (a single round of active surveillance cultures) in units with patients at high risk (e.g., intensive care units, units where previous cases have been identified, and units where many patients are exposed to broad-spectrum antimicrobials) to identify any additional patients colonized with carbapenemresistant or carbapenemase-producing Klebsiella spp. and E. coli. The recommended surveillance culture methodology is aimed at detecting carbapenem resistance or carbapenemase production in Klebsiella spp. and E. coli only, because 1) this method facilitates performing the test in the microbiology laboratory without the use of molecular methods and 2) these organisms represent the majority of CRE encountered in the United States. When a case of hospital-associated CRE is identified, facilities should conduct a single round of active surveillance testing of patients with epidemiologic links to the CRE case (e.g., those patients in the same unit or patients who have been cared for by the same health-care personnel).
The goal of active surveillance is to identify undetected carriers of carbapenem-resistant or carbapenemase-producing Klebsiella spp. and E. coli. Identification of other cases among patients with epidemiologic links to persons with confirmed infection suggests patient-to-patient transmission (7); in such instances, infection prevention measures should be vigorously reinforced, and surveillance cultures repeated periodically (e.g., weekly) until no new cases are identified. Situations where periodic point prevalence surveys repeatedly fail to identify other colonized patients suggest that infection control measures at the facility are effective in controlling transmission.
In such instances, consideration should be given to halting active surveillance cultures in response to clinical cases and replacing them with periodic point prevalence surveys in units with patients at high risk to ensure that carbapenem-resistant or carbapenemase-producing Klebsiella spp. and E. coli do not reemerge.
Because the prevalence of CRE is low in the majority of U.S. hospitals, routine microbiologic surveillance of persons admitted, such as that performed in some facilities to detect carriage of methicillin-resistant Staphylococcus aureus, is not recommended. However, in some areas of the United States, notably New York City, CRE are routinely recovered, including from many patients who are admitted from the community. In these settings, point prevalence surveys in response to detected clinical cases might be less useful in controlling transmission of CRE. Facilities in regions where CRE are endemic should monitor clinical cases of CRE and implement the intensified (i.e., Tier 2) infection control strategies outlined in the 2006 HICPAC guidelines if rates of CRE are not decreasing (2). The challenges to hospitals of allocating additional resources to prevent and control CRE are balanced by the fact that an aggressive infection control strategy, such as that recommended in this report, offers an opportunity to limit the impact of these problematic pathogens while CRE prevalence remains low in most U.S. hospitals.

# Infection Prevention and Control
- All acute care facilities should implement contact precautions for patients colonized or infected with carbapenemresistant Enterobacteriaceae (CRE) or carbapenemase-producing Enterobacteriaceae. No recommendation can be made regarding when to discontinue contact precautions.

# Laboratory
- Clinical microbiology laboratories should follow Clinical and Laboratory Standards Institute guidelines for susceptibility testing (1) and establish a protocol for detection of carbapenemase production (e.g., performance of the modified Hodge test).
- Clinical microbiology laboratories should establish systems to ensure prompt notification of infection prevention staff of all Enterobacteriaceae isolates that are nonsusceptible to carbapenems or Klebsiella spp. or Escherichia coli isolates that test positive for a carbapenemase.

# Surveillance
- All acute care facilities should review clinical culture results for the preceding 6-12 months to determine whether previously unrecognized CRE have been present in the facility.
-If this review identifies previously unrecognized CRE, a point prevalence survey (a single round of active surveillance cultures) should be performed to look for CRE in high-risk units (e.g., intensive care units, units where previous cases have been identified, and units where many patients are exposed to broad-spectrum antimicrobials).
-If this review does not identify previously unrecognized CRE, monitoring for clinical infections should be continued.
- If CRE or carbapenemase-producing Klebsiella spp. or E. coli are detected from one or more clinical cultures OR if the point prevalence survey reveals unrecognized colonization, the facility should investigate for possible transmission by:
-Conducting active surveillance testing of patients with epidemiologic links to a patient with CRE infection (e.g., patients in the same unit or who have been cared for by the same health-care personnel).
 Continue active surveillance periodically (e.g., weekly) until no new cases of colonization or infection suggesting cross-transmission are identified.
 If transmission of CRE is not identified after repeated active surveillance testing, consider altering the surveillance strategy by performing periodic point prevalence surveys in high-risk units.
-In areas where CRE are endemic, an increased likelihood exists for importation of CRE, and the procedures outlined might not be sufficient to prevent transmission. Facilities in such areas should monitor clinical cases and consider additional strategies to reduce rates of CRE as described in the 2006 Tier 2 guidelines for management of multidrug-resistant organisms in health-care settings (2). Recommendations for rate calculations have been described previously (3).

# Notice to Readers

# World Water Day -March 22, 2009
Each year on March 22, World Water Day attracts international attention to the need to conserve and develop water resources. Shared Waters-Shared Opportunities, the theme for World Water Day 2009, focuses on issues associated with 263 lakes and river basins that cross the borders of two or more countries.
Worldwide, nearly one third of those 263 water basins are shared by three or more countries, and 19 are shared by five or more countries (1). Despite the complexity of these boundaries, hundreds of successful international transboundary agreements have been negotiated. The United Nations Educational, Scientific and Cultural Organization (UNESCO), the United Nations Economic Commission for Europe, and other organizations are working to ensure the peaceful collaboration of countries who share water systems (1).
Many countries lack resources to provide their inhabitants with safe drinking water and adequate sanitation. Approximately 880 million people still lack access to improved sources of drinking water (2), leaving them at risk for water-, sanitation-, and hygiene-related diseases. Worldwide, 1.6 million deaths per year result from unsafe water, poor sanitation, and lack of hygiene (3). Most of these deaths occur among children aged <5 years. The ongoing cholera epidemic in Zimbabwe (4), which has affected approximately 91,000 persons and caused more than 4,000 deaths (5) since it began in August 2008, is an example of the health risks of waterborne diseases, although most cases and fatalities resulting from waterborne diseases are never reported.

# Notice to Readers

# State Reportable Condition Assessment Results
The Council of State and Territorial Epidemiologists (CSTE) recently completed work on an assessment that captured information regarding which public health conditions were reportable by clinicians, laboratories, hospitals, or other public health reporters, as mandated by law or regulation in 50 U.S. states, four U.S. territories, and two autonomous reporting jurisdictions (New York City and the District of Columbia). A total of 255 conditions, including infectious conditions and noninfectious conditions (e.g., injuries, cancer, and workrelated conditions) were included in the assessment. Results for both the 2008 and 2007 assessments are available, using a web query tool, at / publichealthinformatics/statereportableconditionsqueryresults/tabid/261/default.aspx.
Feedback concerning the 2008 assessment or the web query tool should be directed to CSTE via e-mail (ldwyer@cste.org). Subject matter experts at CDC or local or state health departments who are interested in helping CSTE develop requirements for the 2009 assessment may also notify CSTE at the same e-mail address.      Calculated by summing the incidence counts for the current week, the 2 weeks preceding the current week, and the 2 weeks following the current week, for a total of 5 preceding years. Additional information is available at .  Not notifiable in all states. Data from states where the condition is not notifiable are excluded from this table, except starting in 2007 for the domestic arboviral diseases and influenza-associated pediatric mortality, and in 2003 for SARS-CoV. Reporting exceptions are available at .  Includes both neuroinvasive and nonneuroinvasive. Updated weekly from reports to the Division of Vector-Borne Infectious Diseases, National Center for Zoonotic, Vector-Borne, and Enteric Diseases (ArboNET Surveillance). Data for West Nile virus are available in Table II.  The names of the reporting categories changed in 2008 as a result of revisions to the case definitions. Cases reported prior to 2008 were reported in the categories: Ehrlichiosis, human monocytic (analogous to E. chaffeensis); Ehrlichiosis, human granulocytic (analogous to Anaplasma phagocytophilum), and Ehrlichiosis, unspecified, or other agent (which included cases unable to be clearly placed in other categories, as well as possible cases of E. ewingii).   Data for H. influenzae (all ages, all serotypes) are available in Table II.   Updated monthly from reports to the Division of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention. Implementation of HIV reporting influences the number of cases reported. Updates of pediatric HIV data have been temporarily suspended until upgrading of the national HIV/AIDS surveillance data management system is completed. Data for HIV/AIDS, when available, are displayed in Table IV

# QuickStats
- 1 0 - - 1 1 - SARS-CoV  ,  - - - - - - - - Smallpox  - - - - - - - - Streptococcal