# Weekly / Vol. 60 / No. 17 May 6, 2011

U.S. Department of Health and Human Services Centers for Disease Control and Prevention 

# Morbidity and Mortality Weekly Report

Hepatitis C virus (HCV) infection is a major cause of liver disease and hepatocellular carcinoma in the United States (1,2 ). Of the estimated 2.7–3.9 million persons with active HCV infection, most were born during 1945–1964 and likely were infected during the 1970s and 1980s, before the advent of prevention measures (3). Nationwide, rates of acute, symptomatic HCV infection declined during 1992–2005 and then began to level (4 ). Declines also were observed in rates of newly reported HCV infection in Massachusetts. Although these declines were evident among reported cases overall in Massachusetts during 2002–2006, an increase was observed among cases in the 15–24 year age group. In response to this increase, the Massachusetts Department of Public Health (MDPH) launched a surveillance initiative to collect more detailed information on cases reported during 2007–2009 among this younger age group and to examine the data for trends through 2009. This report describes results of both efforts, which revealed continued increases in rates of newly reported HCV infection among persons aged 15–24 years. These cases were reported from all areas of the state, occurred predominantly among non-Hispanic white persons, and were equally distributed among males and females. Of cases with available risk data, injection drug use (IDU) was the most common risk factor for HCV transmission. The increase in case reports appears to represent an epidemic of HCV infection related to IDU among new populations of INSIDE 542 Fatal Injuries Among Grounds Maintenance Workers —United States, 2003–2008 547 Vital Signs: Asthma Prevalence, Disease Characteristics, and Self-Management Education — UnitedStates, 2001–2009 553 Announcements 555 QuickStats 

# Hepatitis Awareness Month — May 2011 This month marks the 16th anniversary of Hepatitis Awareness Month in the United States. Viral hepatitis, particularly infection with hepatitis B virus (HBV) or hepatitis C virus (HCV), is a major cause of morbidity and mortality. This issue ofMMWR includes a report that focuses on a recent trend in HCV infection.

The report shows an increase in cases of HCV infection during 2002–2009 among adolescents and young adults aged 15–24 years in Massachusetts and highlights the fundamental role of surveillance in identifying emerging patterns of transmission and developing appropriate public health response. The Massachusetts cases were reported from all areas of the state, primarily among non-Hispanic whites. Injection drug use (IDU) was the most common risk factor for HCV transmission, and the increase in case reports suggests an epidemic of HCV infection related to IDU in this age group in Massachusetts.

In 2010, the Institute of Medicine (IOM) of the National Academies of Sciences issued a report on viral hepatitis outlining recommendations for the prevention and control of HBV and HCV infection, including improvement in public health surveillance for viral hepatitis and viral hepatitis screening linked with prevention and care (1). In response to the IOM report, the U.S. Department of Health and Human Services is developing a comprehensive viral hepatitis action plan that will set forth strategies to improve viral hepatitis prevention, care, and treatment in the United States. Additional information regarding viral hepatitis is available from CDC at http://www.cdc.gov/hepatitis. Reference 1.Institute of Medicine. Hepatitis and liver cancer: a national strategy

for prevention and control of hepatitis B and C. Washington, DC: National Academies Press; 2010. Available athttp://www.nap.edu/ openbook.php?record_id=12793&page=1. Accessed April 28, 2011. 

# Hepatitis C Virus Infection Among Adolescents and Young Adults — Massachusetts, 2002–2009

### TheMMWRseries of publications is published by the Office of Surveillance, Epidemiology, and Laboratory Services, Centers for Disease Control and Prevention (CDC), U.S. Department of Health and Human Services, Atlanta, GA 30333. Suggested citation:Centers for Disease Control and Prevention. [Article title]. MMWR 2011;60:[inclusive page numbers]. 

## Centers for Disease Control and Prevention Thomas R. Frieden, MD, MPH,Director Harold W. Jaffe, MD, MA,Associate Director for Science James W. Stephens, PhD,Office of the Associate Director for Science Stephen B. Thacker, MD, MSc,Deputy Director for Surveillance, Epidemiology, and Laboratory Services Stephanie Zaza, MD, MPH,Director, Epidemiology and Analysis Program Office 

## MMWR Editorial and Production Staff Ronald L. Moolenaar, MD, MPH,Editor,MMWRSeries John S. Moran, MD, MPH,Deputy Editor,MMWRSeries Robert A. Gunn, MD, MPH,Associate Editor,MMWRSeries Teresa F. Rutledge,Managing Editor,MMWRSeries Douglas W. Weatherwax,Lead Technical Writer-Editor Donald G. Meadows, MA, Jude C. Rutledge,Writer-Editors Martha F. Boyd,Lead Visual Information Specialist Malbea A. LaPete, Julia C. Martinroe, Stephen R. Spriggs, Terraye M. Starr Visual Information Specialists Quang M. Doan, MBA, Phyllis H. King Information Technology Specialists 

## MMWR Editorial Board William L. Roper, MD, MPH, Chapel Hill, NC, Chairman Virginia A. Caine, MD, Indianapolis, IN Jonathan E. Fielding, MD, MPH, MBA, Los Angeles, CA David W. Fleming, MD, Seattle, WA William E. Halperin, MD, DrPH, MPH, Newark, NJ King K. Holmes, MD, PhD, Seattle, WA Deborah Holtzman, PhD, Atlanta, GA John K. Iglehart, Bethesda, MD Dennis G. Maki, MD, Madison, WI Patricia Quinlisk, MD, MPH, Des Moines, IA Patrick L. Remington, MD, MPH, Madison, WI

Barbara K. Rimer, DrPH, Chapel Hill, NC John V. Rullan, MD, MPH, San Juan, PR

William Schaffner, MD, Nashville, TN

Anne Schuchat, MD, Atlanta, GA Dixie E. Snider, MD, MPH, Atlanta, GA John W. Ward, MD, Atlanta, GA 

## Morbidity and Mortality Weekly Report

538 MMWR / May 6, 2011 / Vol. 60 / No. 17 

# adolescents and young adults in Massachusetts. The findings indicate the need for enhanced surveillance of HCV infection and intensified hepatitis C prevention efforts targeting adolescents and young adults.

MDPH currently uses an electronic data system for disease surveillance. All positive laboratory results indicating HCV infection are reportable to MDPH. A positive laboratory result on a previously unreported case prompts a case report form to be sent to the health-care provider (e.g., clinician) ordering the test. This one-page form collects information on demographics, symptoms, and risk history. In accordance with CDC case definitions, HCV infection cases are classified as either confirmed (i.e., positive by an anti-HCV antibody assay with a nucleic acid test [NAT] result confirming active infection) or probable (i.e., positive antibody test result with confirmatory NAT either not conducted or not reported to MDPH). For this analysis, all confirmed and probable cases of HCV infection were included.

In 2006, anecdotal information received from communitybased partners about HCV infection cases among adolescents and young adults prompted a review of state surveillance data. Although an overall decline in rates of newly reported HCV infection (from 181 to 128 cases per 100,000 population) was observed during 2002–2006, an increase (from 65 to 102 cases per 100,000 population) was observed among persons aged 15–24 years. At the time, 75% of 2005 surveillance reports for cases among persons in this age group lacked risk history; therefore, the sources of infection were unknown. Beginning in 2007, MDPH sent HCV infection case report forms (CRFs) to reporting clinicians to collect additional information when a report of newly identified HCV antibody (anti-HCV) positivity among persons aged 15–24 years was received. Clinicians also were sent reminders to fill out CRFs if more than 30 days had passed from the date the form was sent and a completed form had not yet been received by MDPH.

During 2002–2009, rates of newly reported HCV infection (confirmed and probable) among persons aged 15–24 years increased from 65 to 113 cases per 100,000 population (Figure 1). The number of confirmed cases of HCV infection reported in Massachusetts was further examined by age and compared for the years 2002 and 2009 (Figure 2). The data shifted from a unimodal age distribution in 2002 to a bimodal age distribution in 2009, with the latter showing substantially more reports of HCV infection among adolescents and young adults compared with the earlier period.

During 2007–2009, MDPH received 1,925 reports of new cases of HCV infection among persons aged 15–24 years. Of these, 1,026 (53%) were classified as confirmed cases of HCV infection; the remainder were classified as probable. Although some clustering of cases was observed in urban areas, cases were reported from all areas of the state, including large metropolitan areas, suburban areas of Boston, smaller cities, and rural areas. Cases occurred with nearly the same frequency among men and women.

Of the 1,925 CRFs sent to reporting sources for completion, 1,448 (75%) were returned to MDPH, providing details of 802 confirmed and 646 probable cases. Of those returned, 252

## Morbidity and Mortality Weekly Report

MMWR / May 6, 2011 / Vol. 60 / No. 17 539 

# (17%) CRFs did not have sufficient information to assess risk, and of these, 148 (59%) contained no risk data.

Of the total 1,448 CRFs returned, 1,357 (94%) included information on race. Of these, 1,052 (78%) indicated cases among persons who were white, 37 (3%) who were black, and 21 (2%) who were Asian; four indicated cases among persons who were American Indian/Alaska Native, and two indicated cases among persons who were Native Hawaiian or other Pacific Islanders. Ninety-four CRFs indicated cases in persons reported as being of unknown race, and 147 indicated “other” or multiple race categories. Of 1,154 (80%) cases with ethnicity information, 98 (8%) were among persons identified as Hispanic. Eight percent of the 1,448 cases with completed CRFs were among persons who were homeless or incarcerated. By far, the most common risk identified was IDU. Of 1,196 cases with a reported risk history, 860 (72%) were in persons who reported current or past IDU; of these, 719 (84%) reported injecting drugs during the preceding 12 months. In addition, 445 (34%) reported some history of intranasal drug use. All but 34 of the cases for which intranasal drug use was listed also indicated IDU. Of the 719 cases for which IDU during the preceding 12 months was reported, 615 (85%) were among persons who reported heroin use, 220 (29%) cocaine use, seven (1%) methamphetamine use, and 31 (4%) use of other drugs, including opiates other than heroin (categories are not mutually exclusive because more than one drug could be reported). Additional commonly reported potential exposures included “other” blood exposures (24%) (further detail is missing for most cases for which this was reported; for those cases with this information included, a majority of “other” exposures listed were related to IDU), tattoos (23%), and a history of incarceration (20%); however, most cases involving these exposures were among persons who also were exposed through IDU. Reported by 

# Shauna Onofrey, MPH, Daniel Church, MPH, Patricia Kludt, MPH, Alfred DeMaria, MD, Kevin Cranston, MDiv, Massachusetts Dept of Public Health. Geoff A. Beckett, MPH, Scott D. Holmberg, MD, John W. Ward, MD, Deborah Holtzman, PhD, Div of Viral Hepatitis, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, CDC.**Corresponding contributor:** Deborah Holtzman, CDC, 404-718-8555, dholtzman@cdc.gov . 0 20 40 60 80 100 120 140 160 180 200

2002 2003 2004 2005 2006 2007 2008 2009Rate per 100,000 population



## Year All other age groups Ages 15–24 yrs 

## FIGURE 1. Rates of newly reported cases of hepatitis C virus infection (confirmed and probable) among persons aged 15–24 years and among all other age groups — Massachusetts, 2002–2009

0 1 2 3 4 5

0 1 2 3 4 5

10 20 30 40 50 60 70 80 90 10 20 30 40 50 60 70 80 90% of total cases reported for year% of total cases reported for year 

## 2002* 2009† 

### Male Female Male Female



## Age (yrs) Age (yrs) FIGURE 2. Age distribution of newly reported confirmed cases of hepatitis C virus infection — Massachusetts, 2002 and 2009

*N = 6,281; excludes 35 cases with missing age or sex information. †

### N = 3,904; excludes 346 cases with missing age or sex information.

## Morbidity and Mortality Weekly Report

540 MMWR / May 6, 2011 / Vol. 60 / No. 17 

## Editorial Note 

# The Massachusetts surveillance data indicate an increase in HCV infection cases among adolescents and young adultsduring 2002–2009. These cases were primarily among nonHispanic white residents in urban, suburban, and rural communities. Although calculating an incidence rate from the surveillance data or determining the duration of infection for persons who tested positive for anti-HCV antibody is not possible, the findings suggest that most persons aged 15–24 years with HCV infection likely acquired their infections within a few years of being tested and reported. Although similar increases in human immunodeficiency virus (HIV) infection were not identified for this age group, increases in reports of HCV infection among injection drug users might be a harbinger of increases in IDU-associated HIV.

Other states have indicated similar increases in HCV infection among adolescents and young adults. For example, in 2008, New York reported an increase in HCV infection among persons aged <30 years in suburban Buffalo (5). Since that time, surveillance data have indicated continued transmission and possibly new activity in other areas of New York (Elena Rizzo, New York State Department of Health, personal communication, 2011).

During the period when increases in HCV infection were being observed, Massachusetts experienced a concomitant increase in heroin use among adolescents and young adults. Data from MDPH-funded substance abuse programs showed a rise in the percentage of admissions (for all drug use) among persons aged 15–24 years, from 19% in 2002 to 23% in 2008.* Furthermore, the percentage of program clients who reported needle use when admitted increased from 29% in 2002 to 38% in 2008 among persons aged 15–24 years, whereas the percentage among all other age groups during this same period remained relatively constant at approximately 30%. Although the occurrence of IDU-associated HCV infection has been documented for decades, the recent epidemic in reported cases among adolescents and young adults and its apparent association with increases in drug injection and sharing of injection equipment in this population is a disturbing trend. Law enforcement data suggest this trend might be occurring in other states. During 2002–2009, the estimated average annual number of heroin initiates in the United States increased from 100,000 to 180,000.†

# Law enforcement reporting from the Great Lakes, Mid-Atlantic, New England, New York/New Jersey, Southeast, and West Central regions also suggests that heroin use is increasing, particularly among younger users.§



# Addressing the epidemic of HCV infection among adolescents and young adults presents unique challenges in terms of education, outreach, and other interventions. Studies have shown that the incidence of HCV infection among injection drug users aged <30 years ranges from 10 to 37 cases per 100 person-years (6,7 ). Moreover, among adolescents and young adults who inject drugs, HCV positivity has been associated with duration and frequency of injection (6 ). Adolescents and young adults might be more likely to share drug equipment because of the nature of their social networks, which are characterized by trust and sharing (6 ). The nature of these interactions must be taken into account when developing educational materials. Adolescents and young adults are likely to have participated in other risky behaviors before initiation of injecting and might have multiple physical, mental, and emotional health needs (8 ). The recent Institute of Medicine report on viral hepatitis and liver cancer noted that younger injection drug users might be at highest risk for seroconversion in the years immediately following initiation of injection practices (2 ). The findings in this report are subject to at least four limitations. First, the surveillance data only include information for persons who have access to and obtain serologic testing and thus might underrepresent the number of persons with HCV infection. This also might explain, in part, the demographic patterns that were observed. Second, efforts by MDPH to raise awareness of the increase in case rates among this age group might have contributed to an increase in testing and reporting of cases after 2007. Although data were not available to ascertain whether this actually occurred, and if so, what the

* Additional information available athttp://www.mass.gov/dph/masschip.



## What is already known on this topic? In the United States, hepatitis C virus (HCV) infection is an important cause of morbidity and mortality, especially in its chronic form. Persons who inject drugs are at greatest risk for HCV infection. What is added by this report? The Massachusetts surveillance data indicate an increase in cases of HCV infection among adolescents and young adults (i.e., persons aged 15–24 years) during 2002–2009. The increase in case reports appears to represent an epidemic of HCV infection related to injection drug use in this age group. What are the implications for public health practice? This report highlights the essential role of surveillance for HCV infection and reporting of all laboratory tests positive for HCV, along with the collection of case data sufficient to assess disease burden and transmission patterns. This report also strongly indicates the need for expanded and intensified hepatitis C prevention efforts targeting adolescents and young adults.

†

### Additional information available at http://oas.samhsa.gov/nsduh/ 2k9nsduh/2k9resultsp.pdf . §

### Additional information available athttp://www.justice.gov/ndic/pubs38/38661/

index.htm.

## Morbidity and Mortality Weekly Report

MMWR / May 6, 2011 / Vol. 60 / No. 17 541 

# magnitude of such an effect might have been, increases in the case rate among adolescents and young adults in Massachusetts were evident in the years before 2007 and, in fact, were more pronounced. In addition, recent research on injection drug users showed that, although persons aged 18–24 years had the highest rate of being tested for HIV, they had the lowest rate of HCV testing despite national recommendations for counseling and screening of injection drug users (9,10 ). Third, differences by county of residence could not be determined because of infrequent recording of residence information on laboratory results not accompanied with a matching CRF. Finally, differences in testing and reporting by county might also exist. Further studies are needed to better characterize the population groups that are at increased risk and those persons who are infected with HCV. Health-care providers need to be encouraged to ask about risks for HCV infection, especially IDU, and to screen patients at risk.

One important outcome of this study is that CDC, in collaboration with state and local health departments, is examining HCV surveillance data to determine whether similar trends are occurring in other reporting areas. In addition, MDPH and CDC are conducting an in-depth investigation of the causes of HCV transmission among adolescents and young adults in Massachusetts to recommend and implement targeted prevention measures.

This report highlights the important role of surveillance for HCV infection and reporting of all laboratory tests positive for HCV, along with the capacity to collect data of sufficient quality for meaningful analysis of trends in transmission and disease. By 2010, 43 states (including Massachusetts) and the District of Columbia required reporting of all laboratory tests indicative of HCV infections.¶

# However, despite the laboratory reporting requirement, most states have limited resources dedicated to surveillance of viral hepatitis and lack capacity to investigate reported cases and forward reliable data to CDC for national reporting. The Institute of Medicine noted this deficiency in public health surveillance as a major weakness in the prevention of viral hepatitis and liver cancer and recommended federal assistance for states to effectively conduct surveillance for all forms of hepatitis C (2 ). This report also strongly indicates the need for expanded and intensified hepatitis C prevention efforts targeting adolescents and young adults. The Institute of Medicine notes that multicomponent, comprehensive risk reduction programs are likely to be the most successful at addressing HCV infection prevention needs of persons who use illicit drugs. Some interventions that could be implemented include access to sterile syringes and drug preparation equipment through syringe exchange services, expanded school-based education that includes viral hepatitis prevention messages, expanded harm reduction programs directed toward young drug users, entry to drug treatment for young injection drug users, and access to comprehensive health services that include HCV testing and linkage to care. Acknowledgments

This report is based, in part, on contributions by Massachusetts local health departments. References

1.Wise M, Bialek S, Finelli L, Bell BP, Sorvillo F. Changing trends in

hepatitis C-related mortality in the United States, 1995–2004. Hepatol 2008;47:1128–31. 2.Institute of Medicine. Hepatitis and liver cancer: a national strategy for

prevention and control of hepatitis B and C. Washington, DC: National Academies Press; 2010. 3.Armstrong GL, Wasley A, Simard EP, McQuillan GM, Kuhnert WL,

Alter MJ. The prevalence of hepatitis C virus infection in the United States, 1999 through 2002. Ann Intern Med 2006;144:705–14. 4.CDC. Surveillance for acute viral hepatitis—United States, 2005.

MMWR 2007;56(No. SS-3). 5.CDC. Use of enhanced surveillance for hepatitis C virus infection to

detect a cluster among young injection-drug users—New York, November 2004–April 2007. MMWR 2008;57:517–21. 6.Miller CL, Johnston C, Spittal PM, et al. Opportunities for prevention:

hepatitis C prevalence and incidence in a cohort of young injection drug users. Hepatol 2002;36:737–42. 7.Hahn JA, Page-Schafer K, Lum PJ, et al. Hepatitis C virus seroconversion among young injection drug users: relationships and risks. J Infect Dis 2002;186:1558–64. 8.Fuller CM, Vlahov D, Arria AM, Ompad DC, Garfein R, Strathdee

SA. Factors associated with adolescent initiation of injection drug use. Public Health Rep 2001;116:136–45. 9.CDC. Recommendations for prevention and control of hepatitis C virus

(HCV) infection and HCV-related chronic disease. MMWR 1998;47(No. RR-19). 10.CDC. HIV-associated behaviors among injecting-drug users—23 cities, United States, May 2005–February 2006. MMWR 2009;58:329–32. ¶

### Additional information available athttp://www.cste.org/dnn/programsand

activities/publichealthinformatics/statereportableconditionsqueryresults/ tabid/261/default.aspx.

## Morbidity and Mortality Weekly Report

542 MMWR / May 6, 2011 / Vol. 60 / No. 17



# A total of 1,142 grounds maintenance workers (GMWs) were fatally injured at work during 2003–2008, an average of 190 each year. GMWs accounted for 3.4% of all occupational fatalities, and 31% of those GMWs were Hispanic or Latino. Approximately 83% of the Hispanic or Latino GMWs who died were born outside the United States. In 2008, approximately 1.52 million persons were employed as GMWs, constituting 1.0% of the U.S. workforce (1). During 2003–2007, an average of 13.3 per 100,000 employed GMWs died each year, compared with an overall rate of 4.0 fatalities per 100,000 U.S. workers.The rate of on-the-job fatal injuries among GMWs has remained elevated relative to other workers for >20 years (2,3). This report characterizes events leading to GMW fatalities and differences in fatality characteristics across demographic groups among GMWs, based on an evaluation of 2003–2008 data from the U.S. Department of Labor’s Bureau of Labor Statistics (BLS) Census of Fatal Occupational Injuries (CFOI) program. The report also identifies workplace interventions that might reduce the incidence of fatal injuries. Major events leading to GMW occupational fatalities included transportation incidents (31%), contact with objects and equipment (25%), falls (23%), and traumatic acute exposures to harmful substances or environments (e.g., electrocution and drowning) (16%). To reduce the incidence of such fatalities, employers, trade and worker associations, and policy makers should focus on effective, targeted workplace safety interventions such as frequent hazard identification and training for specific hazards. Diversity among the populations of workers requires use of culture- and language-appropriate training techniques as part of comprehensive injury and illness prevention programs.

Annual data for 2003–2008 on occupational fatalities resulting from traumatic injuries were obtained from CFOI, a national surveillance system for work-related traumatic injury deaths maintained by BLS. Occupations in CFOI were classified using the 2000 Standard Occupational Classification (SOC) system. Cases were defined as all fatalities among persons classified as either GMWs (SOC 37-301) or first-line supervisors/managers of landscaping, lawn service, and groundskeeping workers (SOC 37-1012).* Case characteristics, such as events, were coded by CFOI using the Occupational Injury and Illness Classification System. Industries were classified by CFOI using the 2002 North American Industry Classification System (NAICS). The CFOI program uses multiple source documents, an average of almost four unique documents per case, to identify and describe all fatal occupational injuries in the United States. Common source documents include death certificates, media reports, Occupational Safety and Health Administration (OSHA) reports, coroner/medical examiner reports, and workers’ compensation reports. For a fatality to be included in CFOI, the decedent must have been employed at the time of the event, engaged in a legal work activity, and present at the site of the incident as a job requirement. Fatalities that occur during a person’s normal commute to or from work are excluded from CFOI counts (4 ). An average of 13.3 per 100,000 employed GMWs died each year as a result of injuries on the job, compared with an overall rate of 4.0 fatalities per 100,000 U.S. workers during 2003–2007†

# ; a total of 1,142 GMWs died during 2003–2008 (Table 1). Among those, 901 (79%) were employed in the private-sector landscaping services industry (NAICS 56173). Another 43 fatalities were incurred by GMWs employed by private-sector golf courses and country clubs (NAICS 71391). Among the 70 GMWs fatally injured while working for a government entity, most (54) were working for a local government.

In 172 instances (15% of deaths) during this period, GMWs were struck by a falling tree or limb and died.§

# Another 145 GMWs (13%) were killed after falling from or falling because of a tree (e.g., knocked off a ladder by a falling branch), almost all of whom were involved in tree-care tasks. Highway transportation incidents while on the job accounted for 122 fatalities (11%). Nonhighway vehicle overturns were responsible for 102 (9%) deaths during the 6 years. The majority of these involved riding lawnmowers or tractors. Contact with overhead power lines caused 97 (8%) fatalities, of which 27 (2%) resulted from a cutting hand tool contacting a power line. In addition, 34 (3%) workers drowned. Distributions of these events varied across the GMW occupations (Table 2).

Approximately 99% of the fatally injured 1,142 GMWs were males. Approximately 27% of the fatally injured GMWs were self-employed, compared with 20% of all fatally injured U.S. workers during the same period. Fatally injured GMWs 

# Fatal Injuries Among Grounds Maintenance Workers — United States, 2003–2008

*GMWs are further defined as persons working in the following occupations,

based on the 2000 SOC system: first-line supervisors/managers of landscaping, lawn service, and groundskeeping workers (SOC 37-1012); landscaping and groundskeeping workers (SOC 37-3011); pesticide handlers, sprayers, and applicators, vegetation (SOC 37-3012); tree trimmers and pruners (SOC 37-3013); and grounds maintenance workers, all other (SOC 37-3019). †

### Fatal injury rates were calculated for 2003–2007, rather than 2003–2008, because CFOI changed its method for calculating fatal injury rates in 2008. These fatal injury rates are employment-based. Fatal injury rates currently published by CFOI are hours-based. Additional information is available at http://www.bls.gov/iif/oshnotice10.htm. §

### Additional information on fatalities in tree-care operations is available athttp://

www.cdc.gov/mmwr/preview/mmwrhtml/mm5815a2.htm.

## Morbidity and Mortality Weekly Report

MMWR / May 6, 2011 / Vol. 60 / No. 17 543 

# tended to be younger than all fatally injured U.S. workers; 44 (4%) were aged <20 years, and 174 (15%) of GMWs were aged <25 years when they died. For the entire United States, workers aged <25 years accounted for fewer than 10% of fatal work-related traumatic injuries.

Hispanic or Latino workers constituted approximately 36% of GMWs (1) and approximately 31% of fatally injured GMWs. The average age at death for all Hispanic and Latino GMW fatalities was 35.6 years, compared with age 45.0 years for GMW fatalities among persons of other races/ethnicities. In nearly five of every six fatalities involving a Hispanic or Latino worker, the worker was born in a country other than the United States, particularly Mexico (218), Guatemala (33), and El Salvador (19). Although foreign-born Hispanic or Latino TABLE 1. Fatal occupational injuries among grounds maintenance workers,* by selected characteristics — United States, 2003–2008† 

### Characteristic All grounds maintenance workers % of total Hispanic or Latino grounds maintenance workers % of total Total fatal occupational injuries 1,142 (100) 356 (100) Employee status Wage and salary§ 

### 836 (73) 296 (83) Self-employed¶ 

### 306 (27) 60 (17) Sex

Male 1,130 (99) 354 (99) Female 12 (1) — — Age group (yrs) <16 4 (<1) — — 16–17 7 (1) 4 (1) 18–19 33 (3) 17 (5) 20–24 130 (11) 64 (18) 25–34 209 (18) 98 (28) 35–44 261 (23) 79 (22) 45–54 256 (22) 57 (16) 55–64 149 (13) 28 (8)

≥65 93 (8) 7 (2) Race/Ethnicity** White, non-Hispanic 620 (54) — — Black, non-Hispanic 129 (11) — — Hispanic or Latino 356 (31) 356 (100) Asian, Native Hawaiian or other Pacific Islander, non-Hispanic 24 (2) — — U.S. born Yes 802 (70) 61 (17) No 340 (30) 295 (83) Event†† 

### Transportation incidents 355 (31) 125 (35)

Highway 122 (11) 56 (16) Nonhighway 155 (14) 36 (10)

Overturned 102 (9) 20 (6) Pedestrian struck by vehicle, mobile equipment 67 (6) 31 (9) Contact with objects and equipment 290 (25) 76 (21) Struck by object or equipment 223 (20) 49 (14)

Struck by falling object or equipment 186 (16) 46 (13)

Struck by falling tree/branch§§ 

### 172 (15) 41 (12) Caught in or compressed by equipment or objects 52 (5) 17 (5) Falls 259 (23) 60 (17) Falls to a lower level 247 (22) 56 (16)

Fall from or because of tree§§ 

### 145 (13) 33 (9) Exposure to harmful substances or environments 180 (16) 76 (21) Contact with electric current 109 (10) 41 (12)

Contact with overhead power lines 97 (8) 33 (9) Drowning, submersion 34 (3) 23 (6) Assaults and violent acts 48 (4) 15 (4)

Homicides 19 (2) 8 (2) Suicides 26 (2) 6 (2) Occupation¶¶



### First-line supervisors/managers 186 (16) 35 (10) Landscaping and groundskeeping workers 559 (49) 235 (66) Pesticide handlers, sprayers, and applicators, vegetation 5 (<1) — — Tree trimmers and pruners 377 (33) 85 (24) Grounds maintenance workers, all other 15 (1) — — See table footnotes on page 544.

## Morbidity and Mortality Weekly Report

544 MMWR / May 6, 2011 / Vol. 60 / No. 17 

# workers accounted for 26% of fatalities among GMWs, they accounted for 22 of the 34 (65%) work-related drownings in this occupational group.

Approximately half (568 deaths) of the GMW fatalities occurred in seven states: California (137), Florida (136), Texas (91), Virginia (56), North Carolina (52), Georgia (49), and Ohio (47) (Figure). A total of 463 (41%) of the GMW fatalities occurred at private residences. Reported by 

# Stephen Pegula, MS, Bur of Labor Statistics, US Dept of Labor. David F. Utterback, PhD, Div of Surveillance, Hazard Evaluations, and Field Studies, National Institute for Occupational Safety and Health, CDC. **Corresponding contributor:** David F. Utterback, CDC, 513-841-4492,dutterback@cdc.gov . Editorial Note 

# GMWs typically are employed as intermittent labor at private residences, recreational facilities, public buildings, parksand cemeteries, and other locations. Most GMWs work yearround and many change work locations throughout the day. GMWs complete tasks such as lawn care, landscape installation and maintenance, and tree care and removal. In the course of this work, GMWs frequently operate on- and off-road vehicles, and often use heavy equipment and various types of machinery and power tools. GMWs frequently work at heights and along busy streets and highways (5 ). Weather-related hazards can change throughout the day and across the seasons. As a result, GMWs are likely to encounter wet ground surfaces, especially TABLE 1. (Continued) Fatal occupational injuries among grounds maintenance workers,* by selected characteristics — United States, 2003–2008† 

### Characteristic All grounds maintenance workers % of total Hispanic or Latino grounds maintenance workers % of total Industry***

Private industry 1,072 (94) 351 (99) Landscaping services 901 (79) 297 (83) Golf courses and country clubs 43 (4) 14 (4) Government 70 (6) 5 (1)

Federal 3 (<1) — — State 13 (1) — — Local 54 (5) 4 (1) Sources:U.S. Department of Labor, Bureau of Labor Statistics, Census of Fatal Occupational Injuries, and data from state, New York City, District of Columbia, and federal agencies.

* Includes, as coded in the 2000 Standard Occupational Classification (SOC) system, first-line supervisors/managers of landscaping, lawn service, and groundskeeping

workers (SOC 37-1012) and grounds maintenance workers (SOC 37-3011, 37-3012, 37-3013, and 37-3019). † Data for all years are revised and final. Totals for major categories might include subcategories not shown separately. Fatality counts exclude illness-related deaths

unless precipitated by an injury event. § 

### Might include volunteers and workers receiving other types of compensation. ¶ 

### Includes self-employed workers, owners of unincorporated businesses or farms, paid and unpaid family workers, and might include some owners of incorporated

businesses or members of partnerships. ** Persons identified as Hispanic or Latino might be of any race. The race categories shown exclude data for Hispanics and Latinos. †† 

### Coded per the Occupational Injury and Illness Classification System (OIICS). §§ 

### Data for this event were compiled using the Event and Source or Secondary Source categories in OIICS. ¶¶ 

### Coded per the 2000 SOC system. ***Coded per the 2002 North American Industry Classification System. 

## TABLE 2. Fatal occupational injuries (N = 1,142) among grounds maintenance workers, by specified occupation and event — United States, 2003–2008* Occupation†

### /Event§ 

### Total fatal occupational

injuries % of total Landscaping and groundskeeping workers 559 (49)

Highway incident 81 (7) Nonhighway overturned mower/tractor¶ 

### 63 (6) Struck by falling tree or limb¶ 

### 47 (4) Drowning 32 (3) Fall from or because of tree¶ 

### 23 (2) Contact with overhead powerlines 20 (2) Fall from ladder 19 (2) Tree trimmers and pruners 377 (33)

Struck by falling tree or limb¶ 

### 96 (8) Fall from or because of tree¶ 

### 91 (8) Contact with overhead powerlines 64 (6) Fall from nonmoving vehicle 31 (3) First-line supervisors/managers** 186 (16)

Highway incident 27 (2) Struck by falling tree or limb¶ 

### 26 (2) Fall from or because of tree¶ 

### 17 (1) Fall from nonmoving vehicle 12 (1) Contact with overhead powerlines 12 (1) Caught in or compressed by equipment or

objects 12 (1) All other grounds maintenance workers 20 (2) Sources:U.S. Department of Labor, Bureau of Labor Statistics, Census of Fatal Occupational Injuries, and data from state, New York City, District of Columbia, and federal agencies. *Data for all years are revised and final. Totals for major categories might include subcategories not shown separately. †

### Coded per the 2000 Standard Occupational Classification (SOC) system. §

### Coded per the Occupational Injury and Illness Classification System (OIICS). ¶ 

### Data for this event were compiled using the Event and Source or Secondary

Source categories in OIICS. **Includes SOC 37-1012 first-line supervisors/managers of landscaping, lawn

service, and groundskeeping workers as coded per the 2000 SOC system.

## Morbidity and Mortality Weekly Report

MMWR / May 6, 2011 / Vol. 60 / No. 17 545 

## What is already known on this topic? Grounds maintenance workers (GMWs) experience elevated rates of fatal occupational injuries; however, previous reports examined the landscaping industry rather than the GMW occupation group. What is added by this report? Nearly one third (31%) of fatally injured GMWs were Hispanic or Latino, and five out of six of these workers were born outside the United States. Nearly one third (31%) of fatal occupational injuries were transportation-related, and almost all (99%) of fatally injured GMWs were male. Fatally injured Hispanic or Latino GMWs were 9.4 years younger at death than the remaining GMWs fatalities. What are the implications for public health practice? GMW employers should tailor injury and illness prevention programs to specific hazards and worker demographics, to include worksite hazard identification and language and literacy-level appropriate training. Oversight agencies should increase outreach and enforcement activities in states where GMW workplace fatalities are more prevalent. 

# early in the day, which can reduce traction, and heat stress is a common hazard during summer in many regions.¶



# Wide-ranging injury prevention strategies that emphasize intervention for specific hazards and tasks (Table 2), focus on key worker groups, and are language and literacy-level appropriate are needed to reduce fatalities among GMWs. CDC’s National Institute for Occupational Safety and Health (NIOSH) and its partners previously have recommended specific types of training and comprehensive safety and health programs for grounds maintenance operations (6,7 ). These programs should provide formal training to workers to ensure proper use of personal protective equipment (e.g., fall protection gear and seat belts). Some GMWs specialize in specific tasks (e.g., tree care), so they encounter a more limited, although severe, set of hazards. However, nearly all GMWs are on crews that might engage in a large variety of tasks over the course of a day and week. Worksite hazard identification should be completed by knowledgeable persons at the beginning of each day and before work begins at other sites throughout the day.

The frequently changing and mobile nature of groundskeeping work makes it difficult to train crews effectively. GMW employers and supervisors should use tailgate or toolbox safety training techniques** and repeat and reinforce safety topics regularly. Topics should be specific to the work tasks, location, and season. Training might include tree care, trimming, and removal, and safe operation and maintenance of all vehicles in use, such as riding lawnmowers, tractors, trucks, and other highway vehicles. All hazards (e.g., overhead power lines, tree work, bodies of water, unstable and slippery ground surfaces, steep grades, trenches, and roadway traffic) must be identified at all worksites and appropriate safety training provided.

The findings in this report are subject to at least three limitations. First, workers with other occupational titles might have died while performing similar operations and tasks, such as roadside maintenance. Second, inclusion of cases is dependent on identification of work-relatedness. Such determinations can be difficult for certain types of incidents, such as those on private property. Finally, the Current Population Survey (1) is a monthly household survey that might underreport employment for some workers, such as those without telephone access or permanent addresses or those who are undocumented. Underestimates of the workforce would result in overestimation of the fatality rates in this report.

Small businesses, which are common employers of GMWs ( 2

), often do not have the resources to employ occupational safety professionals, and their owners and supervisors might lack the knowledge, skills, and resources to identify safety hazards and to develop safe work practices. NIOSH and OSHA have developed guides for small businesses that identify government and other sources of information (8,9 ). Trade associations also are useful sources of health and safety information that is specific to the landscape services industry (6 ). FIGURE. Fatal occupational injuries (N = 1,142) among grounds maintenance workers,* as a percentage of all occupational fatalities† 

## — United States, 2003–2008

Source:U.S. Department of Labor, Bureau of Labor Statistics. *Includes 2000 Standard Occupational Classification codes 37-1012, 37-3011,

37-3012, 37-3013, and 37-3019. †

### For the entire United States, fatal occupational injuries to grounds maintenance

workers accounted for 3.4% of all fatal occupational injuries during 2003–2008. >5.00 3.51–5.00 2.01–3.50 0–2.00 No data available



### **Brief, on-site training modules that remind workers about specific hazards and proper use of equipment. ¶

### During 2003–2008, job-related exposure to environmental heat caused the

deaths of 12 GMWs, including eight who were Hispanic or Latino.

## Morbidity and Mortality Weekly Report

546 MMWR / May 6, 2011 / Vol. 60 / No. 17 

## References 1.Bureau of Labor Statistics. Current Population Survey. Washington, DC:

US Department of Labor, Bureau of Labor Statistics; 2008. Available at ftp://ftp.bls.gov/pub/special.requests/lf/aa2008/pdf/cpsaat11.pdf. Accessed April 26, 2011. 2.Poulin Buckley J, Sestito J, Hunting KL. Fatalities in the landscape and

horticultural services industry, 1992–2001. Am J Ind Med 2008; 51:701–13. 3.Wiatrowski WJ. Fatalities in the ornamental shrub and tree services

industry. Washington, DC: US Department of Labor, Bureau of Labor Statistics; 2005. Available at http://www.bls.gov/opub/cwc/ sh20050719ar01p1.htm. Accessed May 2, 2011. 4.Bureau of Labor Statistics. Occupational safety and health statistics. In:

Bureau of Labor Statistics handbook of methods. Washington, DC: US Department of Labor, Bureau of Labor Statistics; 2010. Available athttp:// www.bls.gov/opub/hom/homch9_a.htm. Accessed April 28, 2011. 5.Bureau of Labor Statistics. Grounds maintenance workers. In:

Occupational outlook handbook, 2010–11 edition. Washington, DC: US Department of Labor, Bureau of Labor Statistics; 2010. Available at http://www.bls.gov/oco/ocos172.htm. Accessed April 28, 2011. 6.CDC. Fatal injuries among landscape services workers. Cincinnati, OH: US Department Health and Human Services, CDC, National Institute for Occupational Safety and Health; 2008. Available athttp://www.cdc. gov/niosh/docs/2008-144/pdfs/2008-144.pdf . Accessed April 28, 2011. 7.CDC. Work-related fatalities associated with tree care operations—United

States, 1992–2007. MMWR 2009;58:389–93. 8.CDC. Safety and health resource guide for small business. Cincinnati, OH:

US Department of Health and Human Services, CDC, National Institute for Occupational Safety and Health; 2003. Available athttp://www.cdc. gov/niosh/docs/2003-100/default.html. Accessed April 28, 2011. 9.Occupational Safety and Health Administration. Small business handbook. Washington, DC: US Department of Labor, Occupational Safety and Health Administration; 2005. Available at http://osha.gov/ Publications/smallbusiness/small-business.pdf . Accessed April 28, 2011.

## Morbidity and Mortality Weekly Report

MMWR / May 6, 2011 / Vol. 60 / No. 17 547 

# Abstract Background:Most persons with asthma can be symptom-free if they receive appropriate medical care, use inhaled corticosteroids when prescribed, and modify their environment to reduce or eliminate exposure to allergens and irritants. This report reviews recent progress in managing asthma and reducing its prevalence in the United States. Methods:CDC analyzed asthma data from the 2001–2009 National Health Interview Survey concerning children and adults, and from the 2001, 2005, and 2009 state-based Behavioral Risk Factor Surveillance System concerning adults. Results:Among persons of all ages, the prevalence of asthma increased from 7.3% (20.3 million persons) in 2001 to 8.2% (24.6 million persons) in 2009, a 12.3% increase. Prevalence among children (persons aged <18 years) was 9.6%, and was highest among poor children (13.5%) and among non-Hispanic black children (17.0%). Prevalence among adults was 7.7%, and was greatest in women (9.7%) and in adults who were poor (10.6%). More uninsured persons with asthma than insured could not afford to buy prescription medications (40.3% versus 11.5%), and fewer uninsured persons reported seeing or talking with a primary-care physician (58.8% versus 85.6%) or specialist (19.5% versus 36.9%). Among persons with asthma, 34.2% reported being given a written asthma action plan, and 68.1% had been taught the appropriate response to symptoms of an asthma attack. Only about one third of children or adults were using long-term control medicine such as inhaled corticosteroids at the time of the survey. Conclusions and Comment:Persons with asthma need to have access to health care and appropriate medications and use them. They also need to learn self-management skills and practice evidence-based interventions that reduce environmental risk factors. 

# Vital Signs: Asthma Prevalence, Disease Characteristics, and Self-Management Education — United States, 2001–2009

Introduction

Asthma is a chronic respiratory disease that affects persons of all ages and is characterized by episodic and reversible attacks of wheezing, chest tightness, shortness of breath, and coughing (1). Although asthma cannot be cured at present, symptoms can be controlled with appropriate medical treatment, self-management education, and by avoiding exposure to environmental allergens and irritants that can trigger an attack (1,2). The most current evidencebased guidelines for the diagnosis and management of asthma were developed by an expert panel commissioned by the National Asthma Education and Prevention Program (NAEPP), coordinated by the National Heart, Lung, and Blood Institute of the National Institutes of Health (NIH) ( 2

). The NAEPP guidelines focus on four key components of asthma care to improve the quality of care and health outcomes of persons with asthma: 1) assessment and monitoring, 2) patient education, 3) control of factors contributing to asthma severity, and 4) medical treatment. These guidelines indicated that, among other long-term control medications for asthma, inhaled corticosteroids were the most potent and consistently effective long-term control medication ( 2

). In the United States, national survey data indicate persistent demographic differences in asthma prevalence, with rates disproportionately greater among children, women, blacks, and those reporting income below the federal poverty level (FPL) (3–6 ). Although most persons with asthma can be free of symptoms with appropriate management, poor asthma control continues to be associated with increased emergency department visits, hospitalizations, and medical costs (2,7 ). The estimated total cost of asthma to society, including medical expenses ($50.1 billion per year), loss of productivity resulting from missed school or work days ($3.8 billion per year), and premature death ($2.1 billion per year) was $56 billion (2009 dollars) in 2007; a $3 billion (5.7%) increase from 2002. Medical expenses associated with asthma were $3,259 per person per year during 2002–2007 (7 ). This report updates U.S. asthma prevalence estimates and describes trends, disease characteristics, and self-management education status among persons who have asthma. On May 3, this report was posted as anMMWR Early Release on theMMWRwebsite ( http://www.cdc.gov/mmwr ).

## Morbidity and Mortality Weekly Report

548 MMWR / May 6, 2011 / Vol. 60 / No. 17 

# Methods

Data from the 2001–2009 National Health Interview Surveys (NHIS) were used to assess trends in asthma prevalence; details of the survey methodology are described elsewhere (8). Respondents were considered to have current asthma if they answered “yes” to both of the following questions: “Have you ever been told by a doctor or other health professional that [you/your child] had asthma?” and “Do [you/your child] still have asthma?” (4,5 ). Data from the 2009 NHIS were used to estimate asthma prevalence by age, sex, race/ethnicity, income status, and U.S. Bureau of the Census geographic region. Data from the NHIS 2008 core survey were used to estimate asthma attack prevalence (the percentage of persons with at least one asthma attack in the preceding 12 months). Data from the NHIS 2008 asthma supplement were used to estimate the status of health, health insurance, and asthma self-management education among children (aged <18 years) and adults (aged ≥18 years). Data concerning children were obtained from an adult in the home who served as a proxy.

Data from the 2001, 2005, and 2009 Behavioral Risk Factor Surveillance System (BRFSS) surveys were used to estimate the state-specific asthma prevalence for adults; dissimilar question wording and weighting methodology precluded estimating prevalence from BRFSS for children (9 ). For the 2009 landline BRFSS sample, the median response rate was 52.5% (10 ). Statistical software was used to account for the complex sample design, fit trends over time, and evaluate when changes in trends occurred. Data were weighted to either the state (BRFSS) or U.S. population (NHIS). Estimates for trend analysis were age-adjusted to the standard year 2000 population. Statistical significance was assumed if p<0.05 (by a nondirectional, two-tailed z-test). 

# Results

During 2001–2009, the proportion of persons of all ages with asthma in the United States increased significantly (12.3%), from 7.3% (20.3 million persons) to 8.2% (24.6 million persons). A rising trend in asthma prevalence was observed across all demographic groups studied (Figure 1). Prevalence increased significantly during 2001–2009 for children (8.7% to 9.6%), adults (6.9% to 7.7%), males (6.3% to 7.1%), females (8.3% to 9.2%), whites (7.2% to 7.8%), blacks (8.4% to 10.8%), and Hispanics (5.8% to 6.4%). Significant differences in prevalence by age, sex, and race/ethnicity persisted over the observed period (Figure 1). In examining subgroups, a rising trend in asthma prevalence was observed for non-Hispanic black children (11.4% to 17.0%), non-Hispanic white women (8.9% to 10.1%), and non-Hispanic black men (4.7% to 6.4%). In 2009, asthma prevalence was greater among children than adults (9.6% versus 7.7%), and was especially high among boys (11.3%) and nonHispanic black children (17.0%). Prevalence among adults was greatest for women (9.7%) and adults who were poor (10.6%) (Table 1). In 2008, at least one half (52.6 %) of persons who had asthma reported having had an asthma attack in the preceding 12 months. A greater proportion of children were reported to have had an asthma attack than adults (57.2% versus 50.7%) in the preceding 12 months. A greater proportion of persons who had asthma reported being in fair or poor health (21.8%) than those who did not have asthma (9.3%). A greater proportion of persons who had an asthma attack reported being in fair or poor health (24.8%) than those who did not have an attack (17.9%) (Table 2).

In 2008, 41.8% (4.6 million) of persons who reported having an asthma attack missed ≥1 days of school or work because of asthma in the preceding 12 months. Persons with an asthma attack missed an average of 4.5 days of school or work per year, with 26.0% (3.2 million persons) reporting emergency department or urgent care center visits and 7.0% (850,183 persons) reporting having been admitted to a hospital. Thus, 13.6% (or nearly one in seven) of persons with asthma had an asthma attack that required urgent outpatient care.

Most persons with asthma had health insurance (89.0%) and had taken quick-relief inhaler prescription medicine (64.4%; 15 million persons) during the past 3 months. Long-term control (oral or inhaler) prescription medicine use, including use of corticosteroids at the time of the survey, was 33.5% (7.8 million persons). However, compared with those who had health insurance in the preceding 12 months, nearly four times the number of the uninsured persons with asthma were unable to buy prescription medication (40.3% versus 11.5%) and fewer reported seeing or talking with a primary care physician (58.8% versus 85.6%) or specialist (19.5% versus 36.9%) in the preceding 12 months.

Nearly 60% of persons who had asthma had been taught to recognize early signs and symptoms of an asthma attack, and 68.1% had been taught the appropriate response to it. However, fewer persons with asthma reported having a written action plan (34.2%), taking a class to learn how to manage their asthma (12.2%), or being taught how to use a peak flow meter (a portable device used to measure a person’s ability to exhale) (42.2%). Approximately half (49.3%) of respondents with asthma had been advised to change conditions in their home, school, or work environments to reduce exposure to asthma triggers. More children with asthma and/or their caregivers had been taught how to recognize the early signs and symptoms of an asthma attack (72.1%), how to respond to an attack (78.3%), and how to use a peak flow meter (49.4%), compared with adults with asthma (54.8%, 63.8%, and 39.2%, respectively). Likewise, more children with asthma and/or their

## Morbidity and Mortality Weekly Report

MMWR / May 6, 2011 / Vol. 60 / No. 17 549 

## Age group and sex 10 9 8 7 6 5 4 3 2 1 0 Total Adults (aged ≥18 yrs) Male 

## Year 2001 2002 2003 2004 2005 2006 2007 2008 2009 2001 2002 2003 2004 2005 2006 2007 2008 2009 10 9 8 7 6 5 4 3 2 1 0 11Prevalence (%)Prevalence (%)



## Race/Ethnicity Year Female Children (aged <18 yrs) White Black Other race Hispanic 

## FIGURE 1. Current asthma prevalence,* by age group,†

## sex, and race/ethnicity — National Health Interview Survey, United States, 2001–2009

*Includes persons who answered “yes” to the questions: “Have you ever been told by a doctor or other health professional that [you/your child] had asthma?” and

“Do [you/your child] still have asthma?” †

### Age-adjusted to the 2000 U.S. population, except age-group–specific estimates. 

## TABLE 1. Prevalence of current asthma* among children and adults,†

## by selected characteristics — National Health Interview Survey, United States, 2009 Characteristic Total (N = 38,815) Children (n = 11,129) Adults (n = 27,686) No. in sample (%§

### ) (95% CI)§ 

### No. in sample (%§

### ) (95% CI)§ 

### No. in sample (%§

### ) (95% CI)§ 

### Total 38,815 (8.2) (7.8–8.6) 11,129 (9.6) (8.9–10.4) 27,686 (7.7) (7.3–8.1) Sex

Male 17,881 (7.0) (6.5–7.6) 5,640 (11.3) (10.2–12.5) 12,241 (5.5) (5.0–6.1) Female 20,934 (9.3) (8.8–9.9) 5,489 (7.9) (7.0–8.9) 15,445 (9.7) (9.1–10.3) Race/Ethnicity White, non-Hispanic 20,915 (8.1) (7.7–8.6) 4,816 (8.5) (7.6–9.5) 16,099 (8.1) (7.6–8.6) Black , non-Hispanic 6,138 (11.1) (9.9–12.4) 1,791 (17.0) (14.5–19.9) 4,347 (8.7) (7.5–10.1) Hispanic 8,579 (6.3) (5.6–7.1) 3,420 (7.7) (6.5–9.2) 5,159 (5.5) (4.7–6.4) Other race¶ 

### 3,183 (7.5) (6.2–9.0) 1,102 (9.6 ) (7.5–12.2) 2,081 (6.6) (5.3–8.4) Poverty threshold**

Poor 6,898 (11.6) (10.6–12.7) 2,307 (13.5 ) (11.6–15.5) 4,591 (10.6) (9.5–11.7) Near poor 8,293 (8.5) (7.8–9.4) 2,595 (9.5 ) (7.9–11.3) 5,698 (8.1) (7.3–9.1) Not poor 23,624 (7.3) (6.9–7.8) 6,227 (8.3) (7.5–9.1) 17,397 (7.0) (6.6–7.6) Region††



### Northeast 6,426 (9.3) (8.4–10.3) 1,828 (11.1) (9.5–13.0) 4,598 (8.7) (7.8–9.9) Midwest 8,528 (8.8) (8.0–9.6) 2,289 (10.9 ) (9.2–12.8) 6,239 (8.1) (7.3–9.0) South 14,163 (7.5) (6.9–8.1) 4,024 (9.8 ) (8.7–11.0) 10,139 (6.8) (6.2–7.4) West 9,698 (7.7) (7.0–8.5) 2,988 (7.1) (6.0–8.5) 6,710 (7.9) (7.0–8.8) Abbreviation:CI = confidence interval. *Includes persons who answered “yes” to the questions: “Have you ever been told by a doctor or other health professional that [you/your child] had asthma?” and

“Do [you/your child] still have asthma?” †

### Children aged <18 years; adults aged ≥18 years. §

### Weighted estimates. ¶ 

### Includes American Indian/Alaska Native, Asian, Native Hawaiian/other Pacific Islander, and persons of multiple races. **Poor = household income below the federal poverty level (FPL), near poor = 100% to <200% of the FPL, and nonpoor = ≥200% of the FPL. ††

### U.S. Census Bureau regions. Additional information available athttp://www.census.gov/geo/www/us_regdiv.pdf .

## Morbidity and Mortality Weekly Report

550 MMWR / May 6, 2011 / Vol. 60 / No. 17 

# caregivers had received an asthma action plan (44.3%), and followed “most or all” advice about changing things in their home, school, or work environments (81.2%), compared with adults (29.9% and 51.6%, respectively) (Table 2).

Asthma prevalence among adults varied across states, ranging from 5.3% to 9.5% (median: 7.3%) in 2001, 5.9% to 10.7% (median: 8.0%) in 2005, and 6.3% to 11.1% (median: 8.8%) in 2009. Prevalence increased significantly from 2001 to 2009 in 22 states* and the District of Columbia (Figure 2). By U.S. Census Bureau region,†

# asthma prevalence was higher in the Northeast (9.3%) and Midwest (8.8%) than in the West (7.7%) and South (7.5%) (Table 1). 

# Conclusions and Comment The prevalence and number of persons with asthma have increased since 2001, and demographic differences among population subgroups persist despite improvements in outdoor air quality and decreases in cigarette smoking and secondhand smoke exposure (11–13). Although probable causes for the increase in asthma are unclear, CDC’s top priority is getting people to manage their asthma better. Asthma has been more prevalent among children than adults, women than men, and blacks than whites since 2001. Similar to findings in previous studies (3–6 ), in 2009, asthma was more prevalent among children, women, non-Hispanic blacks, the poor, and in the Northeast and Midwest. The cause of this variation remains unclear and might be the result of characteristics associated with asthma development and disease duration that were not examined in this study, including genetic predisposition, history TABLE 2. Disease characteristics and self-management education status among children and adults* with current asthma†

## — National Health Interview Survey, United States, 2008 Characteristic Total (N = 2,421) Children (n = 806) Adults (n = 1,615) No. (%§

### ) (95% CI)§ 

### No. (%§

### ) (95% CI)§ 

### No. (%§

### ) (95% CI)§ 

### Asthma attack 2,409 (52.6) (50.2–55.1) 804 (57.2) (52.9–61.4) 1,605 (50.7) (47.8–53.6)

Missed ≥1 school or work days¶

### ** 1,143 (41.8) (38.4–45.2) 427 (59.1) (52.5–65.4) 716 (32.7) (28.6–37.1) Missed days¶

### ** (mean) 1,143 (4.5) (3.1–6.0) 427 (3.8) (2.9–4.6) 716 (5.0) (2.9–7.0) ED/UC visit¶ 

### 1,264 (26.0) (23.3–28.9) 448 (32.5) (27.4–38.1) 816 (22.8) (19.5–26.5) Hospitalized¶ 

### 1,267 (7.0) (5.4–8.9) 448 (8.0) (5.2–12.3) 819 (6.5) (4.7–8.7) Fair/Poor health (%) 2,420 (21.8) (20.0–23.6) 806 (6.4) (4.8–8.4) 1,614 (28.3) (25.9–30.9)

No asthma attack 1,142 (17.9) (15.6–20.5) 356 (3.9) (2.4–6.3) 786 (23.1) (20.0–26.6) Asthma attack 1,266 (24.8) (22.2–27.6) 448 (8.2) (5.8–11.6) 818 (32.8) (29.1–36.8) Health insurance — insured 2,166 (89.0) (87.1–90.7) 752 (93.9) (91.4–95.7) 1,414 (87.0) (84.6–89.0)

Cannot afford prescription medicine 261 (11.5) (9.9–13.3) 47 (5.4) (3.8–7.7) 214 (14.3) (12.1–16.8) Seen/Talked to a specialist physician 780 (36.9) (34.4–39.4) 176 (22.6) (19.1–26.5) 604 (43.5) (40.5–46.7) Seen/Talked to a primary-care physician 1,821 (85.6) (83.8–87.2) 669 (90.9) (88.2–93.1) 1,152 (83.1) (80.7–85.3) Health insurance — uninsured 250 (11.0) (9.3–12.9) 52 (6.1) (4.3–8.6) 198 (13.0) (11.0–15.4)

Cannot afford prescription medicine 106 (40.3) (33.2–47.7) 9 (14.0)†† 

### (6.7–27.0)†† 

### 97 (45.4) (37.2–53.8) Seen/Talked to a specialist physician 43 (19.5) (14.1–26.3) 7 (17.1)†† 

### (6.1–39.7)†† 

### 36 (20.0) (14.1–27.5) Seen/Talked to a primary-care physician 142 (58.8) (50.5–66.6) 37 (78.7) (63.5–88.7) 105 (54.8) (45.3–63.9) Prescription asthma medicine use

Quick-relief inhaler during preceding 3 mos 2,421 (64.4) (62.1–66.7) 806 (59.4) (54.9–63.7) 1,615 (66.6) (63.8–69.2) Long-term control medicine (oral or inhaler) at the time of

survey 2,421 (33.5) (31.1–35.9) 806 (31.3) (27.5–35.3) 1,615 (34.4) (31.6–37.4) Self-management education§§



### Given an action plan 2,383 (34.2) (31.8–36.8) 789 (44.3) (40.0–48.8) 1,594 (29.9) (27.2–32.8) Taken a class to learn how to manage their asthma 2,411 (12.2) (10.7–13.8) 801 (12.5) (10.0–15.7) 1,610 (12.0) (10.3–13.9) Taught to recognize early signs and symptoms of an asthma

attack 2,402 (59.9) (57.3–62.5) 800 (72.1) (68.1–75.8) 1,602 (54.8) (51.5–58.0) Taught to respond to an asthma attack 2,404 (68.1) (65.6–70.6) 800 (78.3) (74.2–82.0) 1,604 (63.8) (60.8–66.8) Taught how to use a peak flow meter 2,388 (42.2) (39.7–44.7) 791 (49.4) (45.1–53.6) 1,597 (39.2) (36.2–42.2) Given advice on environment control 2,407 (49.3) (46.6–52.0) 800 (50.6) (45.9–55.2) 1,607 (48.8) (45.6–51.9) Followed “most or all” advice about environment 1,164 (60.7) (57.1–64.2) 397 (81.2) (76.2–85.3) 767 (51.6) (47.0–56.2) Abbreviation:CI = confidence interval; ED/UC = emergency department/urgent care. *Children aged <18 years; adults aged ≥18 years. †Includes persons who answered “yes” to the questions, “Have you ever been told by a doctor or other health professional that [you/your child] had asthma?” and

“Do [you/your child] still have asthma?” §

### Weighted estimates. ¶ 

### Related questions were asked among persons who had an asthma attack during the previous 12 months. **Calculated for those who go to child care, preschool, school, or work at home or outside. ††

### Estimates are not reliable because of small sample size. §§

### Ever been educated.



### *Arizona, Connecticut, Hawaii, Indiana, Kentucky, Maryland, Massachusetts,

Mississippi, Nebraska, New Hampshire, New Jersey, New Mexico, New York, North Carolina, North Dakota, Ohio, Oklahoma, Oregon, Pennsylvania, South Dakota, Washington, and Wisconsin. †

### Additional information available athttp://www.census.gov/geo/www/us_regdiv.

pdf .

## Morbidity and Mortality Weekly Report

MMWR / May 6, 2011 / Vol. 60 / No. 17 551 

# of atopy (a genetic tendency to develop an allergic reaction), health risk factors (e.g., smoking, obesity), earlier diagnosis, socioeconomic status (e.g., education or occupation), and exposure to environmental allergens or irritants (e.g., mold, tobacco smoke, secondhand smoke exposure, pet dander, outdoor air pollution, and any upper respiratory infection, such as influenza or common cold) (1–3,5,6 ). In particular, obesity and exposure to tobacco smoke each have been associated with increased asthma severity (14,15 ). More detailed analytic investigation of these risk factors might help characterize subpopulations and identify those in greatest need of targeted prevention efforts.

Approximately half of persons with asthma in the United States reported having an asthma attack in the preceding 12 months. Those who had attacks had a higher proportion of missed school or work days, emergency department and urgent care visits, and reported fair or poor health. A greater percentage of persons with asthma reported having health-care insurance than persons without asthma. However, among persons with asthma, more of the uninsured were unable to buy prescription medication and fewer reported seeing or talking to a specialist or primary care physician about their asthma. This is a particular concern, given the value of inhaled corticosteroids in the management of adults and children with persistent asthma.

Key Points

•	 In2009,theprevalenceofasthmaincreasedto7.7%

among adults, 9.6% among all children, and 17.0% among black, non-Hispanic children. •	 In2008, approximatelyhalfofpersonswithasthma

reported having had at least one asthma attack during the preceding 12 months. •	 Medicalexpensesassociatedwithasthmaamountedto

$3,259 per person per year during 2002–2007. •	 Good control ofasthmaincludes self-management

training, appropriate use of inhaled corticosteroids to prevent symptoms and attacks, and avoidance of environmental allergens and irritants. However, only approximately one third of persons with asthma had been given an asthma action plan as recommended and approximately half had been advised to change their environment. •	 More uninsured than insuredpersonswith asthma

reported not being able to buy prescription medications (40.3% versus 11.5%). DC

DC

DC 

## 2001

2005

2009

5% to <7% 7%to<8% 8% to <9% ≥9% 

## FIGURE 2. Current asthma prevalence among adults — Behavioral Risk Factor Surveillance System, United States, 2001, 2005, and 2009*

*Cut-off points are the approximate quartiles of the state-specific prevalence

of asthma among adults during 2001, 2005, and 2009.

## Morbidity and Mortality Weekly Report

552 MMWR / May 6, 2011 / Vol. 60 / No. 17



# Asthma health outcomes can be improved by addressing gaps in health-care coverage and access, and by supporting preventive measures. In particular, patient education concerning self-management of the disease and its attacks is key. It is one of the four key components of effective asthma management listed in the NIH guidelines that were developed by NAEPP (2

). Even so, such recommended educational activities were not reported widely and did not meet theHealthy People 2010 targets for objectives 24-6 and 24-7 (6,16 ). For example, the NAEPP expert panel recommends that every person with asthma have an asthma action plan, yet only one third of adults and children reported having such a plan. An asthma action plan is a written form developed by health-care providers to address the specific needs and circumstances of an individual patient. The plan describes 1) how to monitor symptoms, 2) when to change the amount or type of medication, 3) how to identify and avoid exposure to allergens and irritants, 4) how to recognize worsening asthma symptoms, and 5) when to take action, such as calling the physician for advice or going to the emergency department ( 2

). Although multitrigger/multicomponent homebased environmental interventions are known to improve asthma symptoms (median decrease of 21 days with symptoms per year) and to reduce missed days of school among children (median decrease of 12 days per year), only half of children/caregivers were advised to change conditions at school, home, or work to reduce environmental triggers (17 ). The findings in this report are subject to at least onelimitation. NHIS and BRFSS data are based on adult selfreport or adult proxy response for children; therefore, the findings might be biased as a result of inaccurate recall or the social desirability of providing positive responses.

The findings suggest the need for coordinated efforts at the local, state, and national levels to develop programs that empower persons with asthma to better control and manage their asthma. Health-care providers and public health officials should continue to address gaps in access to care and to support preventive measures that can improve asthma health outcomes by promoting appropriate medical care, asthma self-management education, and evidence-based interventions to reduce modifiable risk factors (e.g., environmental irritants and allergens) for asthma. Actions to expand reimbursement for asthma education and environmental control services might further improve the application of asthma self-management strategies. Reported by 

# Hatice S. Zahran, MD, Cathy Bailey, MS, Paul Garbe, DVM, Div of Environmental Hazards and Health Effects, National Center for Environmental Health, CDC.**Contributing correspondent:** Hatice S. Zahran, CDC, 770-488-1509,hzahran@cdc.gov . Acknowledgments This report is based, in part, on contributions by M King, PhD, E Herman, MD, Div of Environmental Hazards and Health Effects, National Center for Environmental Health; and survey coordinators for the Behavioral Risk Factor Surveillance System and the National Health Interview Survey, National Center Health Statistics, CDC. References 1.Kliegman RM, Behrman RE, Jenson HB, Stanton BF. Nelson textbook

of pediatrics. 18th ed. Philadelphia, PA: Saunders Elsevier; 2007. 2.National Institutes of Health, National Heart, Lung, and Blood Institute.

Expert panel report 3: guidelines for the diagnosis and management of asthma. Bethesda, MD: US Department of Health and Human Services, National Institutes of Health, National Heart, Lung, and Blood Institute; 2007. Available athttp://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.pdf . Accessed April 7, 2011. 3.CDC. CDC health disparities and inequalities report—United States,

2001. MMWR 2011;60(Suppl). 4.CDC. National Health Interview Survey (NHIS) data: 2008 lifetime

and current asthma. Atlanta, GA: US Department of Health and Human Services, CDC; 2010. Available athttp://www.cdc.gov/asthma/nhis/08/ data.htm. Accessed April 7, 2011. 5.CDC. National surveillance for asthma—United States, 1980–2004.

MMWR 2007;56(No. SS-8). 6.Akinbami LJ, Moorman JE, Liu X. Asthma prevalence, health care use,

and mortality: United States, 2005–2009. National health statistics reports no. 32. Hyattsville, MD: National Center for Health Statistics; 2011. 7.Barnett SBL, Nurmagambetov TA. Costs of asthma in the United States:

2002–2007. J Allergy Clin Immunol 2011;127:145–52. 8.National Center for Health Statistics. National Health Interview Survey

(NHIS) 2009 data release. Atlanta, GA: US Department of Health and Human Services, CDC, National Center for Health Statistics; 2010. Available athttp://www.cdc.gov/nchs/nhis/nhis_2009_data_release.htm. Accessed April 7, 2011. 9.CDC. BRFSS [Behavioral Risk Factor Surveillance System] annual survey

data. Atlanta, Georgia: US Department of Health and Human Services, CDC; 2009. Available athttp://www.cdc.gov/brfss. Accessed December 28, 2010. 10.CDC. 2009 Behavioral Risk Factor Surveillance System summary data quality report. Atlanta, Georgia: US Department of Health and Human Services, CDC; 2011. Available athttp://www.cdc.gov/brfss/technical_ infodata/quality.htm. Accessed March 16, 2011. 11.Environmental Protection Agency. Air quality trends. Washington, DC: Environmental Protection Agency; 2011. Available athttp://www.epa. gov/airtrends/aqtrends.html#airquality . Accessed April 27, 2011. 12.CDC. Cigarette smoking—United States, 1965–2008. MMWR 2011;60:109–13. 13.CDC. Vital signs: nonsmokers' exposure to secondhand smoke—United States, 1999–2008. MMWR 2010;59:1141–6. 14.Dixon, AE, Holguin F, Sood A, et al. An official American Thoracic Society workshop report: obesity and asthma. Proc Am Thorac Soc 2010;7:325–35. 15.US Department of Health and Human Services. The health consequences of involuntary exposure to tobacco smoke: a report of the Surgeon General. Atlanta GA, 2006. 16.US Department of Health and Human Services. Healthy people 2010: understanding and improving health. 2nd ed. Washington, DC: US Government Printing Office; 2000. 17.Task Force on Community Prevention Services. Asthma control: home-based multi-trigger, multicomponent environmental interventions. In: Task Force on Community Prevention Services. The guide to community preventive services. New York, NY: Oxford University Press; 2005. Available athttp:// www.thecommunityguide.org/asthma/multicomponent.html. Accessed April 7, 2011.

## Morbidity and Mortality Weekly Report

MMWR / May 6, 2011 / Vol. 60 / No. 17 553 

# Hepatitis Single Topic Conference — June 4–5, 2011

Registration is still open for the Hepatitis Single Topic Conference, Chronic Viral Hepatitis: Strategies to Improve Effectiveness of Screening and Treatment, to be held June 4–5, 2011, at the Emory Conference Center in Atlanta, Georgia. Deadline for registration is May 6, 2011. However, late registration will be accepted, and participants also will be permitted to register at the conference.

Cosponsored by CDC and the American Association for the Study of Liver Disease, the Hepatitis Single Topic Conference will cover current and novel approaches to viral hepatitis testing, referral to care, and clinical management. Participants also will learn about the epidemiology of chronic hepatitis B and hepatitis C, the role of community engagement and education in viral hepatitis prevention and care, models of care that optimize patient acceptance and adherence to care and treatment, and options for clinical monitoring and therapy. The conference will be of interest to hepatologists, gastroenterologists, primary-care physicians, health-care managers, insurers, public health professionals, policy makers, industry representatives, patient advocate organizations, and any other health professional seeking to expand awareness regarding viral hepatitis prevention and treatment.

No continuing education credits will be provided for this conference. Additional information regarding the conference and registration is available athttp://www.aasld.org/conferences/ meetings/pages/hepatitissingletopicconference.aspx. 

# National Women’s Health Week — May 8–14, 2011

In 2007, the life expectancy for women in the United States reached 80.4 years, a 0.2-year increase from 2006 (1). The top five leading causes of death for U.S. females in 2006 were diseases of the heart, malignant neoplasms, cerebrovascular diseases, chronic lower respiratory diseases, and Alzheimer’s disease (2 ). Beginning May 8, 2011 (Mother’s Day), the 12th annual National Women’s Health Week encourages women to make health a top priority and to take simple steps to achieve a longer, healthier, happier life. With a theme of “It’s Your Time,” the week-long celebration brings together communities, businesses, government, health organizations, and other groups across the United States to promote women’s health. Regular physical activity, healthful eating, healthy weight maintenance, quitting tobacco use, managing stress, protecting themselves from injury, and periodic check-ups are a few of the many actions that can lead to safer and healthier lives (3). CDC promotes and advances the health and safety of women through development, implementation, and support of research, disease surveillance, and national, state, and local disease prevention and health promotion programs. Through numerous partnerships and programs, CDC works to improve women’s health in areas such as reproductive health, sexually transmitted infections, breast and cervical cancer screening, gynecologic cancers, occupational safety and health, immunizations, birth defects prevention, heart disease, and violence against women.

Additional information about women’s health is available athttp://www.cdc.gov/women. Additional information about National Women’s Health Week is available athttp://www. womenshealth.gov/whw .References 1.Xu JQ, Kochanek KD, Murphy SL, Tejada-Vera B. Deaths: final data for

2007. Natl Vital Stat Rep 2010;58(19). 2.Heron M. Deaths: leading causes for 2006. Natl Vital Stat Rep

2010;58(14). 3.CDC. Tips for a safe and healthy life. Atlanta, GA: US Department of

Health and Human Services, CDC; 2006. Available athttp://www.cdc. gov/family/tips/index.htm. Accessed May 3, 2011. 

# Healthy Vision Month — May 2011

May is Healthy Vision Month. Because vision impairment affects all communities across the nation, CDC’s Vision Health Initiative, in collaboration with the National Eye Institute, encourages all persons in the United States to make vision a health priority.

In the United States, approximately 25.2 million adults have self-reported vision impairment; of these, approximately 6.5 million are aged ≥65 years, 15.0 million are women, and 5.8 million are black or Hispanic (1). Many adults at high risk for serious vision loss do not receive needed eye care. Data from the 2002 National Health Interview Survey indicate that approximately 5 million high-risk adults could not afford glasses when needed, and only 42% had dilated eye examinations in the preceding year (2 ). Early detection and timely treatment of conditions that cause visual impairment can delay eye disease progression and prevent vision loss. Recommended eye care differs by age and risk factors; however, most persons should have periodic, comprehensive, dilated eye examinations as recommended by their eye-care providers (3). Additional information on Healthy Vision Month, the Vision Health Initiative, and strategies for prevention and control of common eye diseases is available athttp://www.cdc.gov/visionhealthandhttp://www.nei.nih. gov/healthyeyes. 

# Announcements

## Morbidity and Mortality Weekly Report

554 MMWR / May 6, 2011 / Vol. 60 / No. 17 

## References 1. Pleis JR, Lucas JW, Ward BW. Summary health statistics for U.S. adults:

National Health Interview Survey, 2008. Vital Health Stat 2009;10(242). 2. Zhang X, Saaddine JB, Lee PP, et al. Eye care in the United States: do we

deliver to high-risk people who can benefit most from it? Arch Ophthalmol 2007;125:411–8. 3. American Academy of Ophthalmology Preferred Practice Patterns

Committee. Preferred practice pattern guidelines. Comprehensive adult medical eye evaluation. San Francisco, CA: American Academy of Ophthalmology; 2010. Available athttp://www.aao.org/ppp. Accessed May 2, 2011. 

# Launch of Decade of Action for Global Road Safety — May 11, 2011

Road traffic injuries are the leading cause of death among persons aged 15–29 years and the ninth leading cause of death overall in the world, resulting in 1.3 million deaths and 50 million nonfatal injuries each year (1). Without new and sustained commitment to preventing traffic injuries, the number of deaths is expected to increase by 65% over the next 20 years (2

). A recent World Health Organization report summarized the magnitude of the problem and the impact these injuries will have on global public health and development (3).

On March 2, 2010, the United Nations adopted a resolution calling for a Decade of Action for Global Road Safety, with a goal of reducing by 50% the projected increase in road traffic deaths by 2020. The official launch of the Decade of Action begins May 11, 2011. Governments, international agencies, organizations, and private companies are encouraged to hold events in conjunction with the launch and to register their events athttp://www.who.int/roadsafety/decade_of_action/ launch/planned_events/en/index.html. Additional information is available athttp://www.decadeofaction.org. References 1.World Health Organization. Global status report on road safety 2009.

Geneva, Switzerland: World Health Organization; 2009. Available at http://www.who.int/violence_injury_prevention/road_safety_ status/2009/en. Accessed April 28, 2011. 2.Kopits E, Cropper M. Policy research working paper no. 3035. Washington,

DC: The World Bank; 2003. Available athttp://econ.worldbank.org. Accessed April 28, 2011. 3.Peden M, Scurfield R, Sleet DA, et al, eds. World report on road traffic

injury prevention. Geneva, Switzerland: World Health Organization; 2011. Available athttp://www.who.int/violence_injury_prevention/publications/ road_traffic/world_report/en/index.html. Accessed April 28, 2011. 

# Amyotrophic Lateral Sclerosis (ALS) Awareness Month — May 2011

May is Amyotrophic Lateral Sclerosis (ALS) Awareness Month. ALS, also known as Lou Gehrig’s disease, is a progressive, fatal, neurodegenerative disorder of the upper and lower motor neurons. Persons with ALS (PALS) usually die within 2–5 years of diagnosis.

In 2008, the National ALS Registry Act was signed into law, allowing for creation of a national ALS registry to better understand the incidence, prevalence, and potential risk factors for ALS. In October 2010, the Agency for Toxic Substances and Disease Registry (ATSDR) launched the National ALS Registry to collect, manage, and analyze data about PALS. This registry uses data from national databases, including those maintained by the Centers for Medicare and Medicaid Services and the Department of Veterans Affairs, and information provided by participating PALS through a secure web portal. The web portal also contains brief risk-factor surveys that allow PALS to provide additional information about their illness to help researchers gain a better understanding of who gets ALS.

Approximately 16,000 PALS were identified in the national databases for persons receiving care at any time during 2001– 2005. Since October 2010, PALS from all 50 states, Puerto Rico, and the U.S. Virgin Islands have registered in the National ALS Registry. When sufficient data have been gathered from the secure web portal and merged with the national databases to provide a representative picture of PALS in the United States, ATSDR will make summary data and de-identified datasets available to interested scientists and researchers. ATSDR also is collaborating with the ALS Association (ALSA), Muscular Dystrophy Association ALS Division, and other organizations to make all PALS aware of the self-registration portion of the National ALS Registry. Health-care professionals who interact with PALS also are encouraged to visit the web portal at http://www.cdc.gov/alsto learn more and educate their patients about the National ALS Registry. 

# Announcements

## Morbidity and Mortality Weekly Report

MMWR / May 6, 2011 / Vol. 60 / No. 17 555 *Emotional or behavioral difficulties of children were based on parents’ responses to the following question:

“Overall, do you think that [child] has any difficulties in one or more of the following areas: emotions, concentration, behavior, or being able to get along with other people?” Response options were 1) “no”; 2) “yes, minor difficulties”; 3) “yes, definite difficulties”; and 4) “yes, severe difficulties.” Children whose parents responded “yes, definite difficulties” or “yes, severe difficulties” were defined as having serious emotional or behavioral difficulties. †

### Family income group is based on family income and family size using the U.S. Census Bureau poverty thresholds. Family income was imputed when information was missing, using multiple imputation methodology. §

### Estimates are based on household interviews of a sample of the U.S. civilian noninstitutionalized population.

Denominators for each category exclude persons for whom data were missing. ¶

### 95% confidence interval. 

## During 2004–2009, approximately 5.1% of all U.S. children aged 4–17 years were reported by parents as having serious emotional or behavioral difficulties. Across all age groups, poor children (i.e., those living in families with incomes <100% of the poverty level) more often were reported to have serious emotional or behavioral difficulties compared with the most affluent children (i.e., those living in families with incomes ≥400% of the poverty level). For example, among children aged 11–14 years, approximately 9.3% of poor children were reported by parents to have serious difficulties, compared with 3.5% of the most affluent children. Source:National Health Interview Survey, 2004–2009. Available athttp://www.cdc.gov/nhis.htm. 

### 0 2 4 6 8 10 12

4–7 8–10 11–14 15–17 

## Age group(yrs)Percentage 

### <100% of poverty level 100%–199% of poverty level 200%–399% of poverty level ≥400% of poverty level

¶ 

# QuickStats fromthenationalcenterforhealthstatistics 

# Percentage of Children with Serious Emotional or Behavioral Difficulties,* by Age Group and Family Income Group†

# — National Health Interview Survey,§ 

# United States, 2004–2009

## Morbidity and Mortality Weekly Report

556 MMWR / May 6, 2011 / Vol. 60 / No. 17 TABLE I. Provisional cases of infrequently reported notifiable diseases (<1,000 cases reported during the preceding year) — United States, week ending April 30, 2011 (17th week)* Disease Current week Cum 2011 5-year weekly average† Total cases reportedfor previous years States reporting cases during current week (No.) 2010 2009 2008 2007 2006 Anthrax — — — — 1 — 1 1 Arboviral diseases§,¶:

California serogroup virus disease — — — 75 55 62 55 67 Eastern equine encephalitis virus disease — — — 10 4 4 4 8 Powassan virus disease — — 0 8 6 2 7 1 St. Louis encephalitis virus disease — — 0 10 12 13 9 10 Western equine encephalitis virus disease — — — — — — — — Babesiosis — 9 1 NN NN NN NN NN Botulism, total — 20 2 112 118 145 144 165 foodborne — 2 0 7 10 17 32 20 infant — 14 1 80 83 109 85 97 other (wound and unspecified) — 4 1 25 25 19 27 48 Brucellosis — 13 3 117 115 80 131 121 Chancroid — 7 1 29 28 25 23 33 Cholera — 16 0 12 10 5 7 9 Cyclosporiasis§ 1 30 1 174 141 139 93 137 FL (1) Diphtheria — — — — — — — — Haemophilus influenzae,**invasive disease (age <5 yrs):

serotype b — 1 0 23 35 30 22 29 nonserotype b — 35 5 192 236 244 199 175 unknown serotype 3 88 3 231 178 163 180 179 NY (1), OH (1), FL (1) Hansen disease§

— 15 2 69 103 80 101 66 Hantavirus pulmonary syndrome§

— 5 0 20 20 18 32 40 Hemolytic uremic syndrome, postdiarrheal§ 3 21 4 253 242 330 292 288 MO (1), TN (1), CA (1) Influenza-associated pediatric mortality§,†† 3 96 2 61 358 90 77 43 MI (1), NC (1), WI (1) Listeriosis 4 121 12 785 851 759 808 884 CA (4) Measles§§ 2 53 3 61 71 140 43 55 TX (1), CA (1) Meningococcal disease, invasive¶¶:

A, C, Y, and W-135 — 60 6 271 301 330 325 318 serogroup B 1 40 3 124 174 188 167 193 MD (1) other serogroup — 4 1 10 23 38 35 32 unknown serogroup 16 170 11 400 482 616 550 651 PA (1), OH (1), NC (1), FL (2), OR (1), CA (10) Novel influenza A virus infections*** — 1 0 4 43,774 2 4 NN Plague — 1 0 2 8 3 7 17 Poliomyelitis, paralytic — — — — 1 — — — Polio virus Infection, nonparalytic§

— — — — — — — NN Psittacosis§

— 1 0 4 9 8 12 21 Q fever, total§ 2 17 3 119 113 120 171 169

acute 1 8 1 97 93 106 — — FL (1) chronic 1 9 0 22 20 14 — — TX (1) Rabies, human — — — 2 4 2 1 3 Rubella†††

— 1 0 6 3 16 12 11 Rubella, congenital syndrome — — 0 — 2 — — 1 SARS-CoV§

— — — — — — — — Smallpox§

— — — — — — — — Streptococcal toxic-shock syndrome§ 2 45 4 165 161 157 132 125 NY (2) Syphilis, congenital (age <1 yr)§§§

— 45 7 309 423 431 430 349 Tetanus — 1 0 10 18 19 28 41 Toxic-shock syndrome (staphylococcal)§

— 28 1 77 74 71 92 101 Trichinellosis 1 6 0 6 13 39 5 15 FL (1) Tularemia 1 6 1 114 93 123 137 95 OK (1) Typhoid fever 3 98 7 443 397 449 434 353 FL (1), CA (2) Vancomycin-intermediateStaphylococcus aureus§ 1 19 1 81 78 63 37 6 NY (1) Vancomycin-resistantStaphylococcus aureus§

— — — 2 1 — 2 1 Vibriosis (noncholeraVibriospecies infections)§ 15 76 5 820 789 588 549 NN FL (12), AZ (1), CA (2) Viral hemorrhagic fever¶¶¶

— — — 1 NN NN NN NN Yellow fever — — — — — — — — See Table 1 footnotes on next page. 

# Notifiable Diseases and Mortality Tables

## Morbidity and Mortality Weekly Report

MMWR / May 6, 2011 / Vol. 60 / No. 17 557 

## Notifiable Disease Data Team and 122 Cities Mortality Data Team Willie J. Anderson Deborah A. Adams Rosaline Dhara Willie J. Anderson Pearl C. Sharp Michael S. Wodajo Lenee Blanton *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. 

## FIGURE I. Selected notifiable disease reports, United States, comparison of provisional 4-week totals April 30, 2011, with historical data

4 2 0.125 0.0625 1 Beyond historical limits DISEASE

Ratio (Log scale)* DECREASE INCREASE CASES CURRENT 4 WEEKS Hepatitis A, acute Hepatitis B, acute Hepatitis C, acute Legionellosis Measles Mumps Pertussis Giardiasis

Meningococcal disease 626 45 72 43 76 10 43 14 499 0.25 0.5 

### TABLE I. (Continued) Provisional cases of infrequently reported notifiable diseases (<1,000 cases reported during the preceding year) — United States, week ending April 30, 2011 (17th week)* —: No reported cases. N: Not reportable. NN: Not Nationally Notifiable. Cum: Cumulative year-to-date counts.

*Case counts for reporting years 2010 and 2011 are provisional and subject to change. For further information on interpretation of these data, seehttp://www.cdc.gov/osels/ph_surveillance/

nndss/phs/files/ProvisionalNationa%20NotifiableDiseasesSurveillanceData20100927.pdf . †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 athttp://www.cdc.gov/osels/ph_surveillance/nndss/phs/files/5yearweeklyaverage.pdf . § Not reportable in all states. Data from states where the condition is not reportable are excluded from this table except starting in 2007 for the arboviral diseases, STD data, TB data, and

influenza-associated pediatric mortality, and in 2003 for SARS-CoV. Reporting exceptions are available athttp://www.cdc.gov/osels/ph_surveillance/nndss/phs/infdis.htm. ¶ 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. ** Data for H. influenzae (all ages, all serotypes) are available in Table II. †† Updated weekly from reports to the Influenza Division, National Center for Immunization and Respiratory Diseases. Since October 3, 2010, 100 influenza-associated pediatric deaths

occurring during the 2010-11 influenza season have been reported. §§Of the two measles cases reported for the current week, one was imported, and one was indigenous. ¶¶ Data for meningococcal disease (all serogroups) are available in Table II. ***CDC discontinued reporting of individual confirmed and probable cases of 2009 pandemic influenza A (H1N1) virus infections on July 24, 2009. During 2009, four cases of human infection with novel influenza A viruses, different from the 2009 pandemic influenza A (H1N1) strain, were reported to CDC. The four cases of novel influenza A virus infection reported to CDC during 2010, and the one case reported during 2011, were identified as swine influenza A (H3N2) virus and are unrelated to the 2009 pandemic influenza A (H1N1) virus. Total case counts for 2009 were provided by the Influenza Division, National Center for Immunization and Respiratory Diseases (NCIRD). ††† No rubella cases were reported for the current week. §§§ Updated weekly from reports to the Division of STD Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention. ¶¶¶There was one case of viral hemorrhagic fever reported during week 12 of 2010. The one case report was confirmed as lassa fever. See Table II for dengue hemorrhagic fever.

## Morbidity and Mortality Weekly Report

558 MMWR / May 6, 2011 / Vol. 60 / No. 17 TABLE II. Provisional cases of selected notifiable diseases, United States, weeks ending April 30, 2011, and May 1, 2010 (17th week)* Reporting area Chlamydia trachomatisinfection Coccidioidomycosis Cryptosporidiosis Current week Previous 52 weeks Cum 2011 Cum 2010 Current week Previous 52 weeks Cum 2011 Cum 2010 Current week Previous 52 weeks Cum 2011 Cum 2010 Med Max Med Max Med Max United States 13,968 24,872 29,896 404,394 409,075 144 0 506 4,384 NN 29 123 376 1,160 1,861 New England 866 806 2,044 13,802 12,222 — 0 1 1 NN — 6 19 67 176

Connecticut 274 171 1,558 2,386 2,727 N 0 0 N NN — 0 13 13 77 Maine†

— 56 100 951 809 N 0 0 N NN — 1 7 2 16 Massachusetts 439 405 872 7,486 6,530 N 0 0 N NN — 3 9 32 38 New Hampshire 37 53 112 974 612 — 0 1 1 NN — 1 3 9 22 Rhode Island† 92 70 154 1,503 1,136 — 0 0 — NN — 0 2 1 7 Vermont† 24 26 84 502 408 N 0 0 N NN — 1 5 10 16 Mid. Atlantic 1,737 3,353 5,178 52,839 54,918 — 0 0 — NN 8 15 38 180 187

New Jersey 228 498 697 7,005 8,559 N 0 0 N NN — 0 4 9 6 New York (Upstate) 706 708 2,028 11,453 10,284 N 0 0 N NN 2 4 13 37 37 New York City 169 1,173 2,773 17,893 20,666 N 0 0 N NN — 2 6 18 18 Pennsylvania 634 954 1,181 16,488 15,409 N 0 0 N NN 6 8 26 116 126 E.N. Central 848 3,778 6,416 57,448 64,134 — 0 3 15 NN 4 28 130 255 465

Illinois 15 959 1,093 12,201 17,749 N 0 0 N NN — 3 21 3 68 Indiana — 428 2,965 8,332 4,942 N 0 0 N NN — 3 10 24 73 Michigan 550 934 1,400 15,577 17,219 — 0 3 8 NN 1 5 18 60 99 Ohio 150 991 1,134 14,725 16,876 — 0 3 7 NN 3 7 24 95 108 Wisconsin 133 428 518 6,613 7,348 N 0 0 N NN — 9 65 73 117 W.N. Central 373 1,406 1,592 22,107 24,026 — 0 0 — NN 2 18 104 88 292

Iowa 21 202 240 3,221 3,657 N 0 0 N NN — 4 25 13 63 Kansas 13 188 287 3,000 3,253 N 0 0 N NN — 2 9 14 29 Minnesota — 290 354 3,855 5,163 — 0 0 — NN — 4 22 — 98 Missouri 319 512 769 8,861 8,538 — 0 0 — NN 2 3 29 31 42 Nebraska†

— 97 218 1,769 1,695 N 0 0 N NN — 3 26 25 30 North Dakota — 41 91 332 693 N 0 0 N NN — 0 9 — 2 South Dakota 20 62 93 1,069 1,027 N 0 0 N NN — 1 6 5 28 S. Atlantic 3,344 4,825 6,195 81,675 81,047 — 0 0 — NN 2 19 39 233 288

Delaware 69 84 220 1,490 1,411 — 0 0 — NN — 0 1 2 1 District of Columbia 92 99 158 1,628 1,669 — 0 0 — NN — 0 1 3 2 Florida 648 1,462 1,706 23,712 24,190 N 0 0 N NN 1 7 19 68 115 Georgia 553 678 2,303 12,776 12,800 N 0 0 N NN — 5 11 72 92 Maryland† 458 499 1,106 6,926 7,191 — 0 0 — NN — 1 3 13 9 North Carolina — 720 1,436 12,342 14,246 N 0 0 N NN — 0 12 23 26 South Carolina† 947 530 847 9,358 8,546 N 0 0 N NN — 2 8 29 14 Virginia† 515 658 970 12,006 9,806 N 0 0 N NN 1 2 9 17 24 West Virginia 62 76 124 1,437 1,188 N 0 0 N NN — 0 5 6 5 E.S. Central 1,106 1,790 3,314 29,321 27,079 — 0 0 — NN 3 4 19 41 62

Alabama† 395 548 1,549 8,978 7,578 N 0 0 N NN — 2 13 7 22 Kentucky 441 267 2,352 4,676 5,028 N 0 0 N NN 2 1 6 15 22 Mississippi — 388 780 6,356 5,912 N 0 0 N NN — 0 2 6 4 Tennessee† 270 591 797 9,311 8,561 N 0 0 N NN 1 1 5 13 14 W.S. Central 2,980 3,235 4,623 56,849 57,017 — 0 1 1 NN 1 8 31 47 89

Arkansas† 346 305 440 5,399 5,068 N 0 0 N NN — 0 3 5 13 Louisiana 538 396 790 7,181 8,154 — 0 1 1 NN — 1 6 8 12 Oklahoma 205 237 1,372 3,845 4,178 N 0 0 N NN — 1 8 — 12 Texas† 1,891 2,340 3,109 40,424 39,617 N 0 0 N NN 1 4 24 34 52 Mountain 629 1,526 2,222 23,008 27,007 66 0 423 3,221 NN 2 10 30 112 154

Arizona 114 498 657 3,092 8,770 65 0 418 3,169 NN — 1 3 7 10 Colorado — 339 876 8,124 6,228 N 0 0 N NN — 2 6 30 41 Idaho† 1 70 199 1,019 1,184 N 0 0 N NN 2 2 7 23 27 Montana† 76 64 83 1,145 1,010 N 0 0 N NN — 1 4 11 16 Nevada† 199 193 380 3,514 3,210 1 0 4 28 NN — 0 7 2 5 New Mexico† 166 196 1,253 3,382 3,684 — 0 4 18 NN — 2 12 25 29 Utah 49 129 175 2,110 2,245 — 0 2 3 NN — 1 5 9 19 Wyoming† 24 42 90 622 676 — 0 2 3 NN — 0 2 5 7 Pacific 2,085 3,791 5,526 67,345 61,625 78 0 105 1,146 NN 7 12 29 137 148

Alaska — 118 156 1,795 2,034 N 0 0 N NN — 0 3 4 2 California 1,625 2,863 4,717 49,440 46,351 78 0 105 1,146 NN 6 7 18 77 87 Hawaii — 108 158 1,315 2,042 N 0 0 N NN — 0 0 — 1 Oregon 179 218 496 4,421 4,129 N 0 0 N NN 1 4 13 54 41 Washington 281 424 891 10,374 7,069 N 0 0 N NN — 1 7 2 17 Territories

American Samoa — 0 0 — — N 0 0 N NN N 0 0 N NN C.N.M.I. — — — — — — — — — NN — — — — — Guam — 9 44 189 64 — 0 0 — NN — 0 0 — — Puerto Rico — 104 251 1,731 2,114 N 0 0 N NN N 0 0 N NN U.S. Virgin Islands — 14 29 220 147 — 0 0 — NN — 0 0 — — C.N.M.I.: Commonwealth of Northern Mariana Islands. U: Unavailable. —: No reported cases. N: Not reportable. NN: Not Nationally Notifiable. Cum: Cumulative year-to-date counts. Med: Median. Max: Maximum. *Case counts for reporting year 2010 and 2011 are provisional and subject to change. For further information on interpretation of these data, seehttp://www.cdc.gov/osels/ph_surveillance/

nndss/phs/files/ProvisionalNationa%20NotifiableDiseasesSurveillanceData20100927.pdf . Data for TB are displayed in Table IV, which appears quarterly. †Contains data reported through the National Electronic Disease Surveillance System (NEDSS).

## Morbidity and Mortality Weekly Report

MMWR / May 6, 2011 / Vol. 60 / No. 17 559 TABLE II. (Continued) Provisional cases of selected notifiable diseases, United States, weeks ending April 30, 2011, and May 1, 2010 (17th week)* Reporting area Dengue Virus Infection Dengue Fever† Dengue Hemorrhagic Fever§ Current week Previous 52 weeks Cum 2011 Cum 2010 Current week Previous 52 weeks Cum 2011 Cum 2010 Med Max Med Max United States — 6 52 20 89 — 0 2 — 2 New England — 0 3 — 3 — 0 0 — —

Connecticut — 0 0 — — — 0 0 — — Maine¶

— 0 2 — 3 — 0 0 — — Massachusetts — 0 0 — — — 0 0 — — New Hampshire — 0 0 — — — 0 0 — — Rhode Island¶

— 0 1 — — — 0 0 — — Vermont¶

— 0 1 — — — 0 0 — — Mid. Atlantic — 2 25 7 34 — 0 1 — 2

New Jersey — 0 5 — 3 — 0 0 — — New York (Upstate) — 0 5 — 5 — 0 1 — 1 New York City — 1 17 — 20 — 0 1 — 1 Pennsylvania — 0 3 7 6 — 0 0 — — E.N. Central — 1 7 2 12 — 0 1 — —

Illinois — 0 3 — 4 — 0 0 — — Indiana — 0 2 1 2 — 0 0 — — Michigan — 0 2 — 1 — 0 0 — — Ohio — 0 2 — 5 — 0 0 — — Wisconsin — 0 2 1 — — 0 1 — — W.N. Central — 0 6 — 8 — 0 1 — —

Iowa — 0 1 — — — 0 0 — — Kansas — 0 1 — — — 0 0 — — Minnesota — 0 2 — 7 — 0 0 — — Missouri — 0 0 — — — 0 0 — — Nebraska¶

— 0 6 — — — 0 0 — — North Dakota — 0 0 — 1 — 0 0 — — South Dakota — 0 0 — — — 0 1 — — S. Atlantic — 2 19 6 20 — 0 1 — —

Delaware — 0 0 — — — 0 0 — — District of Columbia — 0 0 — — — 0 0 — — Florida — 2 14 5 17 — 0 1 — — Georgia — 0 2 — 1 — 0 0 — — Maryland¶

— 0 0 — — — 0 0 — — North Carolina — 0 2 1 — — 0 0 — — South Carolina¶

— 0 3 — — — 0 0 — — Virginia¶

— 0 3 — 2 — 0 0 — — West Virginia — 0 1 — — — 0 0 — — E.S. Central — 0 2 — — — 0 0 — —

Alabama¶

— 0 2 — — — 0 0 — — Kentucky — 0 1 — — — 0 0 — — Mississippi — 0 0 — — — 0 0 — — Tennessee¶

— 0 1 — — — 0 0 — — W.S. Central — 0 1 — — — 0 1 — —

Arkansas¶

— 0 0 — — — 0 1 — — Louisiana — 0 0 — — — 0 0 — — Oklahoma — 0 1 — — — 0 0 — — Texas¶

— 0 1 — — — 0 0 — — Mountain — 0 2 1 3 — 0 0 — —

Arizona — 0 2 1 1 — 0 0 — — Colorado — 0 0 — — — 0 0 — — Idaho¶

— 0 1 — — — 0 0 — — Montana¶

— 0 1 — — — 0 0 — — Nevada¶

— 0 1 — 1 — 0 0 — — New Mexico¶

— 0 0 — 1 — 0 0 — — Utah — 0 0 — — — 0 0 — — Wyoming¶

— 0 0 — — — 0 0 — — Pacific — 0 7 4 9 — 0 0 — —

Alaska — 0 0 — 1 — 0 0 — — California — 0 5 1 5 — 0 0 — — Hawaii — 0 0 — — — 0 0 — — Oregon — 0 0 — — — 0 0 — — Washington — 0 2 3 3 — 0 0 — — Territories

American Samoa — 0 0 — — — 0 0 — — C.N.M.I. — — — — — — — — — — Guam — 0 0 — — — 0 0 — — Puerto Rico — 104 550 191 1,726 — 2 20 1 46 U.S. Virgin Islands — 0 0 — — — 0 0 — — C.N.M.I.: Commonwealth of Northern Mariana Islands. U: Unavailable. —: No reported cases. N: Not reportable. NN: Not Nationally Notifiable. Cum: Cumulative year-to-date counts. Med: Median. Max: Maximum. *Case counts for reporting year 2010 and 2011 are provisional and subject to change. For further information on interpretation of these data, seehttp://www.cdc.gov/osels/ph_surveillance/

nndss/phs/files/ProvisionalNationa%20NotifiableDiseasesSurveillanceData20100927.pdf . Data for TB are displayed in Table IV, which appears quarterly. †Dengue Fever includes cases that meet criteria for Dengue Fever with hemorrhage, other clinical and unknown case classifications. §DHF includes cases that meet criteria for dengue shock syndrome (DSS), a more severe form of DHF. ¶Contains data reported through the National Electronic Disease Surveillance System (NEDSS).

## Morbidity and Mortality Weekly Report

560 MMWR / May 6, 2011 / Vol. 60 / No. 17 TABLE II. (Continued) Provisional cases of selected notifiable diseases, United States, weeks ending April 30, 2011, and May 1, 2010 (17th week)*

Reporting area Ehrlichiosis/Anaplasmosis† Ehrlichia chaffeensis Anaplasma phagocytophilum Undetermined Current week Previous 52 weeks Cum 2011 Cum 2010 Current week Previous 52 weeks Cum 2011 Cum 2010 Current week Previous 52 weeks Cum 2011 Cum 2010 Med Max Med Max Med Max United States 3 8 79 23 65 1 18 132 10 78 — 1 13 5 8 New England — 0 2 — 1 — 1 7 1 9 — 0 1 — —

Connecticut — 0 0 — — — 0 6 — — — 0 0 — — Maine§

— 0 1 — 1 — 0 2 1 4 — 0 0 — — Massachusetts — 0 0 — — — 0 0 — — — 0 0 — — New Hampshire — 0 1 — — — 0 2 — 2 — 0 1 — — Rhode Island§

— 0 1 — — — 0 6 — 3 — 0 0 — — Vermont§

— 0 0 — — — 0 0 — — — 0 0 — — Mid. Atlantic 2 0 10 3 8 — 4 15 3 2 — 0 1 1 1

New Jersey — 0 0 — — — 0 0 — 1 — 0 0 — — New York (Upstate) 2 0 10 2 4 — 4 15 3 1 — 0 1 1 1 New York City — 0 3 1 3 — 0 2 — — — 0 0 — — Pennsylvania — 0 0 — 1 — 0 0 — — — 0 0 — — E.N. Central — 0 4 2 7 — 4 41 — 28 — 0 7 2 5

Illinois — 0 2 1 3 — 0 2 — — — 0 2 1 — Indiana — 0 0 — — — 0 0 — — — 0 3 1 5 Michigan — 0 1 — — — 0 0 — — — 0 1 — — Ohio — 0 3 1 — — 0 1 — — — 0 0 — — Wisconsin — 0 1 — 4 — 3 41 — 28 — 0 4 — — W.N. Central — 1 13 2 6 — 5 74 — 32 — 0 11 — —

Iowa — 0 0 — — — 0 0 — — — 0 0 — — Kansas — 0 1 — — — 0 0 — — — 0 0 — — Minnesota — 0 0 — — — 5 73 — 32 — 0 11 — — Missouri — 1 13 2 6 — 0 2 — — — 0 3 — — Nebraska§

— 0 1 — — — 0 0 — — — 0 0 — — North Dakota — 0 0 — — — 0 0 — — — 0 0 — — South Dakota — 0 0 — — — 0 0 — — — 0 0 — — S. Atlantic 1 3 18 15 36 1 1 7 5 6 — 0 1 — —

Delaware — 0 3 2 3 — 0 1 — — — 0 0 — — District of Columbia — 0 0 — — — 0 0 — — — 0 0 — — Florida — 0 2 2 2 — 0 1 — — — 0 0 — — Georgia — 0 4 1 3 — 0 1 — — — 0 1 — — Maryland§

— 0 3 2 4 — 0 2 — 3 — 0 1 — — North Carolina 1 1 13 6 23 1 0 4 5 2 — 0 0 — — South Carolina§

— 0 2 — — — 0 1 — — — 0 0 — — Virginia§

— 1 8 2 1 — 0 2 — 1 — 0 1 — — West Virginia — 0 1 — — — 0 0 — — — 0 0 — — E.S. Central — 0 11 1 4 — 0 2 1 1 — 0 2 1 2

Alabama§

— 0 3 — 1 — 0 2 1 — — 0 0 — — Kentucky — 0 2 — — — 0 0 — — — 0 0 — — Mississippi — 0 1 — — — 0 1 — — — 0 1 — — Tennessee§

— 0 7 1 3 — 0 2 — 1 — 0 1 1 2 W.S. Central — 0 66 — 2 — 0 7 — — — 0 1 — —

Arkansas§

— 0 5 — — — 0 2 — — — 0 0 — — Louisiana — 0 0 — 1 — 0 0 — — — 0 0 — — Oklahoma — 0 61 — — — 0 5 — — — 0 0 — — Texas§

— 0 1 — 1 — 0 1 — — — 0 1 — — Mountain — 0 0 — — — 0 0 — — — 0 1 1 —

Arizona — 0 0 — — — 0 0 — — — 0 1 1 — Colorado — 0 0 — — — 0 0 — — — 0 0 — — Idaho§

— 0 0 — — — 0 0 — — — 0 0 — — Montana§

— 0 0 — — — 0 0 — — — 0 0 — — Nevada§

— 0 0 — — — 0 0 — — — 0 0 — — New Mexico§

— 0 0 — — — 0 0 — — — 0 0 — — Utah — 0 0 — — — 0 0 — — — 0 0 — — Wyoming§

— 0 0 — — — 0 0 — — — 0 0 — — Pacific — 0 1 — 1 — 0 0 — — — 0 1 — —

Alaska — 0 0 — — — 0 0 — — — 0 0 — — California — 0 1 — 1 — 0 0 — — — 0 1 — — Hawaii — 0 0 — — — 0 0 — — — 0 0 — — Oregon — 0 0 — — — 0 0 — — — 0 0 — — Washington — 0 0 — — — 0 0 — — — 0 0 — — Territories

American Samoa — 0 0 — — — 0 0 — — — 0 0 — — C.N.M.I. — — — — — — — — — — — — — — — Guam — 0 0 — — — 0 0 — — — 0 0 — — Puerto Rico — 0 0 — — — 0 0 — — — 0 0 — — U.S. Virgin Islands — 0 0 — — — 0 0 — — — 0 0 — — C.N.M.I.: Commonwealth of Northern Mariana Islands. U: Unavailable. —: No reported cases. N: Not reportable. NN: Not Nationally Notifiable. Cum: Cumulative year-to-date counts. Med: Median. Max: Maximum. *Case counts for reporting year 2010 and 2011 are provisional and subject to change. For further information on interpretation of these data, seehttp://www.cdc.gov/osels/ph_surveillance/

nndss/phs/files/ProvisionalNationa%20NotifiableDiseasesSurveillanceData20100927.pdf . Data for TB are displayed in Table IV, which appears quarterly. †Cumulative totalE. ewingiicases reported for year 2010 = 11, and 1 case reported for 2011. §Contains data reported through the National Electronic Disease Surveillance System (NEDSS).

## Morbidity and Mortality Weekly Report

MMWR / May 6, 2011 / Vol. 60 / No. 17 561 TABLE II. (Continued) Provisional cases of selected notifiable diseases, United States, weeks ending April 30, 2011, and May 1, 2010 (17th week)* Reporting area Giardiasis Gonorrhea Haemophilus influenzae, invasive† All ages, all serotypes Current week Previous 52 weeks Cum 2011 Cum 2010 Current week Previous 52 weeks Cum 2011 Cum 2010 Current week Previous 52 weeks Cum 2011 Cum 2010 Med Max Med Max Med Max United States 114 332 533 3,941 5,575 3,033 5,798 6,574 88,935 92,516 22 59 132 998 1,125 New England 1 25 54 280 390 95 102 206 1,590 1,544 — 3 9 55 51

Connecticut — 3 12 — 1 50 39 169 606 664 — 0 6 — — Maine§ 1 3 11 33 60 — 2 7 51 74 — 0 2 8 2 Massachusetts — 14 25 176 202 30 51 82 764 652 — 2 6 37 36 New Hampshire — 2 10 20 53 5 3 7 40 51 — 0 1 5 6 Rhode Island§

— 1 7 7 22 8 5 15 119 92 — 0 2 3 6 Vermont§

— 4 10 44 52 2 0 17 10 11 — 0 3 2 1 Mid. Atlantic 21 60 106 786 950 332 718 1,165 11,258 10,818 6 11 26 198 227

New Jersey — 3 18 35 134 42 117 173 1,788 1,785 — 2 5 34 34 New York (Upstate) 10 23 58 280 323 93 110 260 1,738 1,599 2 3 15 48 58 New York City 6 17 33 251 258 46 237 535 3,753 3,833 — 2 5 38 46 Pennsylvania 5 15 27 220 235 151 264 366 3,979 3,601 4 4 11 78 89 E.N. Central 17 51 91 621 970 256 1,041 1,985 15,121 16,926 1 10 20 168 186

Illinois — 10 32 98 234 7 245 328 3,046 4,137 — 3 9 45 52 Indiana — 5 11 55 121 — 113 1,000 2,272 1,390 — 1 7 19 35 Michigan 5 11 25 136 209 159 250 489 3,959 4,715 — 1 4 25 13 Ohio 11 17 29 243 268 53 317 383 4,511 5,234 1 2 6 56 40 Wisconsin 1 8 34 89 138 37 95 156 1,333 1,450 — 1 5 23 46 W.N. Central 8 34 73 293 586 108 289 364 4,448 4,565 1 4 9 33 71

Iowa 1 5 12 68 81 2 35 57 580 565 — 0 0 — 1 Kansas — 3 10 38 65 3 40 62 533 631 — 0 2 2 7 Minnesota — 13 33 — 224 — 37 62 489 731 — 1 5 — 25 Missouri 4 8 26 109 107 103 142 181 2,285 2,119 — 1 5 17 30 Nebraska§ 2 4 9 57 69 — 23 49 357 356 1 0 3 13 3 North Dakota — 0 5 — 6 — 3 11 32 57 — 0 2 1 5 South Dakota 1 2 5 21 34 — 10 20 172 106 — 0 0 — — S. Atlantic 27 72 121 818 1,100 865 1,376 1,808 21,348 23,347 12 14 26 262 276

Delaware — 0 5 7 9 18 17 48 320 321 — 0 1 1 3 District of Columbia — 0 5 7 13 26 35 66 596 637 — 0 1 — — Florida 15 39 75 370 561 208 378 486 5,950 6,383 4 4 12 100 76 Georgia 8 13 48 267 230 172 230 704 3,727 4,000 — 3 7 50 63 Maryland§ 1 4 11 62 107 106 133 243 1,806 2,005 1 1 5 21 19 North Carolina N 0 0 N N — 248 596 4,222 4,537 7 2 9 31 39 South Carolina§

— 2 9 29 36 231 154 261 2,615 2,508 — 1 5 23 38 Virginia§ 2 8 32 63 131 90 122 189 1,817 2,790 — 1 7 36 32 West Virginia 1 0 8 13 13 14 14 26 295 166 — 0 9 — 6 E.S. Central 1 4 11 43 92 293 484 1,007 7,658 7,250 — 3 10 58 66

Alabama§ 1 4 11 41 50 131 162 403 2,650 2,217 — 1 4 20 7 Kentucky N 0 0 N N 107 71 712 1,214 1,277 — 1 4 12 12 Mississippi N 0 0 N N — 113 216 1,618 1,632 — 0 2 4 6 Tennessee§

— 0 3 2 42 55 144 194 2,176 2,124 — 1 4 22 41 W.S. Central 3 6 14 53 115 713 873 1,624 14,394 15,216 1 2 26 54 54

Arkansas§ 2 2 7 29 31 103 98 138 1,613 1,453 1 0 3 13 10 Louisiana 1 2 8 24 51 131 111 469 1,940 2,216 — 0 4 21 12 Oklahoma — 0 5 — 33 59 80 332 1,132 1,206 — 1 19 19 28 Texas§ N 0 0 N N 420 600 866 9,709 10,341 — 0 4 1 4 Mountain 4 30 57 322 531 64 184 230 2,592 2,983 — 5 12 104 144

Arizona 1 3 8 38 47 19 57 83 550 1,041 — 2 6 47 59 Colorado — 12 27 138 222 — 50 93 725 844 — 1 5 21 34 Idaho§ 2 4 9 42 72 — 2 14 42 34 — 0 2 4 7 Montana§

— 1 6 10 45 — 1 5 25 42 — 0 1 2 1 Nevada§

— 2 11 26 17 31 34 103 692 574 — 0 2 8 5 New Mexico§

— 2 6 17 24 10 27 100 477 327 — 1 4 16 18 Utah 1 5 13 40 85 4 5 15 66 109 — 0 3 6 15 Wyoming§

— 0 5 11 19 — 1 4 15 12 — 0 1 — 5 Pacific 32 51 132 725 841 307 641 809 10,526 9,867 1 3 20 66 50

Alaska — 2 6 19 32 — 21 36 301 490 — 0 2 8 10 California 28 32 57 493 525 263 521 684 8,308 7,972 — 0 16 9 — Hawaii — 1 4 10 20 — 13 26 178 220 — 0 2 10 10 Oregon 4 8 20 123 170 13 21 40 400 353 1 1 6 38 27 Washington — 8 71 80 94 31 61 115 1,339 832 — 0 2 1 3 Territories

American Samoa — 0 0 — — — 0 0 — — — 0 0 — — C.N.M.I. — — — — — — — — — — — — — — — Guam — 0 1 — 1 — 0 5 6 4 — 0 0 — — Puerto Rico — 0 8 8 27 — 6 14 114 80 — 0 0 — 1 U.S. Virgin Islands — 0 0 — — — 3 7 44 27 — 0 0 — — C.N.M.I.: Commonwealth of Northern Mariana Islands. U: Unavailable. —: No reported cases. N: Not reportable. NN: Not Nationally Notifiable. Cum: Cumulative year-to-date counts. Med: Median. Max: Maximum. *Case counts for reporting year 2010 and 2011 are provisional and subject to change. For further information on interpretation of these data, seehttp://www.cdc.gov/osels/ph_surveillance/

nndss/phs/files/ProvisionalNationa%20NotifiableDiseasesSurveillanceData20100927.pdf . Data for TB are displayed in Table IV, which appears quarterly. †Data for H. influenzae (age <5 yrs for serotype b, nonserotype b, and unknown serotype) are available in Table I. §Contains data reported through the National Electronic Disease Surveillance System (NEDSS).

## Morbidity and Mortality Weekly Report

562 MMWR / May 6, 2011 / Vol. 60 / No. 17 TABLE II. (Continued) Provisional cases of selected notifiable diseases, United States, weeks ending April 30, 2011, and May 1, 2010 (17th week)* Hepatitis (viral, acute), by type Reporting area A B C Current week Previous 52 weeks Cum 2011 Cum 2010 Current week Previous 52 weeks Cum 2011 Cum 2010 Current week Previous 52 weeks Cum 2011 Cum 2010 Med Max Med Max Med Max United States 6 27 66 336 499 16 60 158 678 1,028 10 16 35 260 258 New England — 1 6 12 34 — 0 4 13 24 — 0 4 7 22

Connecticut — 0 4 5 — — 0 2 2 6 — 0 4 3 11 Maine†

— 0 1 1 2 — 0 1 2 8 — 0 2 2 — Massachusetts — 0 5 3 27 — 0 3 8 5 — 0 1 1 11 New Hampshire — 0 1 — — — 0 1 1 4 N 0 0 N N Rhode Island†

— 0 1 1 5 U 0 0 U U U 0 0 U U Vermont†

— 0 1 2 — — 0 1 — 1 — 0 1 1 — Mid. Atlantic — 4 10 52 67 2 5 10 71 100 1 1 5 22 31

New Jersey — 0 1 2 9 — 1 5 11 27 — 0 2 — 7 New York (Upstate) — 1 4 12 16 1 1 8 14 13 1 1 4 14 13 New York City — 1 7 21 24 — 1 4 20 33 — 0 1 — — Pennsylvania — 1 3 17 18 1 2 5 26 27 — 0 3 8 11 E.N. Central — 4 9 55 83 — 8 23 93 187 2 2 6 57 25

Illinois — 1 3 10 20 — 2 7 21 39 — 0 1 1 — Indiana — 0 3 7 9 — 1 6 8 27 — 0 4 20 9 Michigan — 1 5 19 23 — 2 5 31 45 2 1 5 34 11 Ohio — 1 5 18 11 — 1 16 24 39 — 0 1 2 3 Wisconsin — 0 1 1 20 — 1 5 9 37 — 0 2 — 2 W.N. Central — 1 23 14 21 — 2 16 39 42 — 0 6 2 5

Iowa — 0 3 1 4 — 0 1 4 8 — 0 0 — — Kansas — 0 2 2 7 — 0 1 3 2 — 0 1 — — Minnesota — 0 22 2 1 — 0 15 1 2 — 0 6 — 3 Missouri — 0 2 4 7 — 1 3 25 22 — 0 1 — 2 Nebraska†

— 0 4 3 2 — 0 3 5 8 — 0 1 2 — North Dakota — 0 3 — — — 0 0 — — — 0 0 — — South Dakota — 0 2 2 — — 0 1 1 — — 0 0 — — S. Atlantic 5 5 14 70 108 7 16 33 200 278 2 4 8 57 61

Delaware — 0 1 1 4 — 0 2 — 12 U 0 0 U U District of Columbia — 0 0 — 1 — 0 1 — 2 — 0 0 — 2 Florida 2 2 7 27 36 3 5 11 68 95 1 1 5 17 15 Georgia — 1 4 17 10 1 2 8 31 57 — 0 3 9 6 Maryland†

— 0 3 9 7 — 1 4 18 27 — 1 3 11 10 North Carolina 3 0 4 7 21 2 2 16 47 28 1 1 4 16 17 South Carolina†

— 0 1 2 16 — 1 4 10 13 — 0 1 — — Virginia†

— 1 6 7 12 1 2 7 26 25 — 0 2 4 5 West Virginia — 0 5 — 1 — 0 18 — 19 — 0 5 — 6 E.S. Central — 0 6 7 15 4 8 14 131 99 3 3 8 47 47

Alabama†

— 0 2 — 4 — 1 4 29 22 — 0 1 3 1 Kentucky — 0 6 2 7 1 3 8 43 32 — 2 6 22 34 Mississippi — 0 1 2 1 — 1 3 9 9 U 0 0 U U Tennessee†

— 0 2 3 3 3 3 8 50 36 3 1 5 22 12 W.S. Central 1 2 15 22 44 2 9 63 72 148 2 2 12 29 19

Arkansas†

— 0 1 — — — 1 4 12 17 — 0 0 — — Louisiana — 0 2 1 3 — 1 4 14 20 — 0 2 4 2 Oklahoma — 0 4 1 — 1 2 14 16 19 1 1 11 16 7 Texas† 1 2 11 20 41 1 4 45 30 92 1 0 3 9 10 Mountain — 2 8 20 52 — 2 7 23 49 — 1 4 14 23

Arizona — 0 4 5 23 — 0 2 6 15 U 0 0 U U Colorado — 0 2 6 12 — 0 5 1 11 — 0 3 1 7 Idaho†

— 0 2 3 2 — 0 1 2 3 — 0 2 6 5 Montana†

— 0 1 2 3 — 0 0 — — — 0 1 1 — Nevada†

— 0 2 1 6 — 1 3 12 12 — 0 2 4 1 New Mexico†

— 0 1 2 3 — 0 1 1 2 — 0 1 2 7 Utah — 0 2 — 3 — 0 1 1 6 — 0 2 — 3 Wyoming†

— 0 3 1 — — 0 1 — — — 0 0 — — Pacific — 5 16 84 75 1 4 23 36 101 — 1 8 25 25

Alaska — 0 1 1 — — 0 1 2 1 U 0 0 U U California — 4 16 72 58 1 3 18 15 74 — 0 4 12 10 Hawaii — 0 1 2 4 — 0 1 2 2 U 0 0 U U Oregon — 0 1 2 8 — 1 3 11 15 — 0 3 7 8 Washington — 0 2 7 5 — 1 5 6 9 — 0 5 6 7 Territories

American Samoa — 0 0 — — — 0 0 — — — 0 0 — — C.N.M.I. — — — — — — — — — — — — — — — Guam — 0 5 8 7 — 1 8 28 16 — 0 7 10 12 Puerto Rico — 0 2 2 5 — 0 2 1 8 — 0 0 — — U.S. Virgin Islands — 0 0 — — — 0 0 — — — 0 0 — — C.N.M.I.: Commonwealth of Northern Mariana Islands. U: Unavailable. —: No reported cases. N: Not reportable. NN: Not Nationally Notifiable. Cum: Cumulative year-to-date counts. Med: Median. Max: Maximum. *Case counts for reporting year 2010 and 2011 are provisional and subject to change. For further information on interpretation of these data, seehttp://www.cdc.gov/osels/ph_surveillance/

nndss/phs/files/ProvisionalNationa%20NotifiableDiseasesSurveillanceData20100927.pdf . Data for TB are displayed in Table IV, which appears quarterly. †Contains data reported through the National Electronic Disease Surveillance System (NEDSS).

## Morbidity and Mortality Weekly Report

MMWR / May 6, 2011 / Vol. 60 / No. 17 563 TABLE II. (Continued) Provisional cases of selected notifiable diseases, United States, weeks ending April 30, 2011, and May 1, 2010 (17th week)* Reporting area Legionellosis Lyme disease Malaria Current week Previous 52 weeks Cum 2011 Cum 2010 Current week Previous 52 weeks Cum 2011 Cum 2010 Current week Previous 52 weeks Cum 2011 Cum 2010 Med Max Med Max Med Max United States 15 58 122 512 667 52 411 1,677 2,091 4,786 10 27 101 283 363 New England — 4 16 25 30 — 111 503 243 1,590 — 1 11 13 22

Connecticut — 0 6 — — — 39 213 — 647 — 0 11 — — Maine†

— 0 3 3 1 — 11 62 55 78 — 0 1 1 1 Massachusetts — 2 10 17 21 — 33 223 94 536 — 1 4 9 17 New Hampshire — 0 5 2 2 — 18 69 71 284 — 0 2 1 1 Rhode Island†

— 0 4 1 5 — 1 40 4 18 — 0 4 — 2 Vermont†

— 0 2 2 1 — 4 28 19 27 — 0 1 2 1 Mid. Atlantic 3 13 48 115 143 36 180 737 1,263 2,148 1 7 18 73 89

New Jersey — 0 11 1 23 — 38 220 304 675 — 0 2 8 1 New York (Upstate) — 5 19 51 37 20 36 159 204 293 1 1 6 11 20 New York City — 2 17 22 33 — 1 10 2 47 — 4 14 43 50 Pennsylvania 3 5 19 41 50 16 92 386 753 1,133 — 1 3 11 18 E.N. Central 2 11 44 96 159 — 25 330 37 243 1 3 9 31 39

Illinois — 2 15 10 20 — 1 18 4 10 — 1 6 8 19 Indiana — 1 6 10 31 — 0 7 1 14 — 0 2 2 4 Michigan — 3 20 21 26 — 1 14 4 3 — 0 4 6 4 Ohio 2 4 15 55 53 — 0 9 6 6 1 1 5 14 11 Wisconsin — 0 5 — 29 — 21 302 22 210 — 0 2 1 1 W.N. Central — 2 9 10 23 — 1 11 3 9 — 1 45 2 21

Iowa — 0 2 2 2 — 1 10 1 5 — 0 2 — 6 Kansas — 0 2 1 3 — 0 1 1 3 — 0 2 1 3 Minnesota — 0 8 — 6 — 0 0 — — — 0 45 — 3 Missouri — 0 4 6 5 — 0 1 — — — 0 3 — 3 Nebraska†

— 0 2 — 2 — 0 2 1 1 — 0 1 1 6 North Dakota — 0 1 — 2 — 0 5 — — — 0 1 — — South Dakota — 0 2 1 3 — 0 1 — — — 0 2 — — S. Atlantic 7 10 27 96 125 13 58 179 475 706 7 7 44 91 117

Delaware — 0 3 2 4 1 10 33 127 177 — 0 1 1 1 District of Columbia — 0 4 — 2 — 0 4 4 4 — 0 2 3 5 Florida 1 3 9 45 50 1 1 8 20 16 1 2 7 27 38 Georgia — 1 4 3 18 — 0 2 1 2 4 1 7 17 18 Maryland† 2 2 6 16 25 4 20 106 180 322 1 1 24 17 18 North Carolina 3 1 7 15 11 3 0 9 13 42 1 0 13 9 20 South Carolina†

— 0 2 3 2 — 0 3 1 13 — 0 1 — 1 Virginia† 1 1 9 12 11 4 18 82 129 120 — 1 5 17 16 West Virginia — 0 3 — 2 — 0 29 — 10 — 0 1 — — E.S. Central 1 2 10 21 25 — 0 4 7 11 — 0 3 5 5

Alabama†

— 0 2 4 3 — 0 2 3 — — 0 1 1 1 Kentucky — 0 4 5 8 — 0 1 — 1 — 0 1 2 2 Mississippi — 0 3 2 2 — 0 0 — — — 0 2 1 — Tennessee† 1 1 6 10 12 — 0 4 4 10 — 0 2 1 2 W.S. Central — 3 11 19 24 1 1 29 8 22 — 1 18 14 20

Arkansas†

— 0 2 — 2 — 0 0 — — — 0 1 — 1 Louisiana — 0 3 6 1 — 0 1 — — — 0 1 — 1 Oklahoma — 0 3 1 — — 0 0 — — — 0 1 2 2 Texas†

— 2 11 12 21 1 1 29 8 22 — 1 17 12 16 Mountain — 2 10 25 48 — 0 3 3 3 — 1 4 13 17

Arizona — 1 7 9 12 — 0 1 2 — — 0 3 4 6 Colorado — 0 2 2 12 — 0 1 — — — 0 3 4 6 Idaho†

— 0 1 1 — — 0 2 — 1 — 0 1 — — Montana†

— 0 1 — 1 — 0 1 — — — 0 1 — — Nevada†

— 0 2 6 10 — 0 1 — — — 0 2 3 2 New Mexico†

— 0 2 2 2 — 0 2 1 1 — 0 1 2 — Utah — 0 2 4 9 — 0 1 — 1 — 0 0 — 3 Wyoming†

— 0 2 1 2 — 0 0 — — — 0 0 — — Pacific 2 5 15 105 90 2 3 11 52 54 1 4 10 41 33

Alaska — 0 2 — — — 0 1 — 1 — 0 2 2 2 California 1 4 14 93 81 2 2 8 35 31 1 2 9 31 22 Hawaii — 0 1 1 — N 0 0 N N — 0 1 — 1 Oregon 1 0 3 3 2 — 0 3 17 22 — 0 3 3 3 Washington — 0 5 8 7 — 0 3 — — — 0 5 5 5 Territories

American Samoa — 0 0 — — N 0 0 N N — 0 0 — — C.N.M.I. — — — — — — — — — — — — — — — Guam — 0 1 — — — 0 0 — — — 0 0 — — Puerto Rico — 0 0 — — N 0 0 N N — 0 1 — 3 U.S. Virgin Islands — 0 0 — — — 0 0 — — — 0 0 — — C.N.M.I.: Commonwealth of Northern Mariana Islands. U: Unavailable. —: No reported cases. N: Not reportable. NN: Not Nationally Notifiable. Cum: Cumulative year-to-date counts. Med: Median. Max: Maximum. *Case counts for reporting year 2010 and 2011 are provisional and subject to change. For further information on interpretation of these data, seehttp://www.cdc.gov/osels/ph_surveillance/

nndss/phs/files/ProvisionalNationa%20NotifiableDiseasesSurveillanceData20100927.pdf . Data for TB are displayed in Table IV, which appears quarterly. †Contains data reported through the National Electronic Disease Surveillance System (NEDSS).

## Morbidity and Mortality Weekly Report

564 MMWR / May 6, 2011 / Vol. 60 / No. 17 TABLE II. (Continued) Provisional cases of selected notifiable diseases, United States, weeks ending April 30, 2011, and May 1, 2010 (17th week)* Reporting area Meningococcal disease, invasive† All serogroups Mumps Pertussis Current week Previous 52 weeks Cum 2011 Cum 2010 Current week Previous 52 weeks Cum 2011 Cum 2010 Current week Previous 52 weeks Cum 2011 Cum 2010 Med Max Med Max Med Max United States 17 14 39 274 315 9 13 219 106 1,189 203 549 2,220 4,150 4,017 New England — 0 3 14 4 — 0 2 1 15 2 10 24 111 92

Connecticut — 0 1 1 — — 0 1 — 10 — 1 8 — 16 Maine§

— 0 1 3 — — 0 1 — 1 2 1 8 44 5 Massachusetts — 0 2 9 2 — 0 2 1 4 — 5 13 48 63 New Hampshire — 0 0 — — — 0 2 — — — 0 3 15 2 Rhode Island§

— 0 1 — — — 0 0 — — — 0 7 3 3 Vermont§

— 0 1 1 2 — 0 0 — — — 0 4 1 3 Mid. Atlantic 1 1 5 27 29 1 4 209 11 1,033 12 38 122 406 207

New Jersey — 0 1 — 9 — 1 11 5 254 — 2 9 11 38 New York (Upstate) — 0 4 7 4 1 0 11 2 610 1 13 85 130 71 New York City — 0 3 11 8 — 0 201 4 156 — 0 12 7 3 Pennsylvania 1 0 2 9 8 — 0 16 — 13 11 20 70 258 95 E.N. Central 1 2 6 33 59 — 1 7 23 35 27 114 194 1,044 988

Illinois — 0 3 10 8 — 1 2 11 8 — 22 52 169 152 Indiana — 0 2 4 15 — 0 1 — 2 — 12 26 68 127 Michigan — 0 4 3 7 — 0 1 4 11 7 32 57 358 272 Ohio 1 1 2 12 14 — 0 5 8 5 20 34 80 343 330 Wisconsin — 0 2 4 15 — 0 2 — 9 — 12 24 106 107 W.N. Central — 1 4 19 18 — 0 14 12 41 4 37 430 219 320

Iowa — 0 1 5 5 — 0 7 1 13 — 12 36 48 105 Kansas — 0 2 1 1 — 0 1 3 2 — 2 9 23 51 Minnesota — 0 2 — 2 — 0 4 — 3 — 0 408 — — Missouri — 0 2 8 8 — 0 3 6 6 1 7 43 99 125 Nebraska§

— 0 2 3 2 — 0 5 1 17 3 4 13 34 23 North Dakota — 0 1 1 — — 0 1 1 — — 0 30 13 — South Dakota — 0 1 1 — — 0 1 — — — 0 2 2 16 S. Atlantic 4 2 6 47 65 2 0 4 6 29 13 38 103 433 420

Delaware — 0 1 1 — — 0 0 — — — 0 4 6 — District of Columbia — 0 0 — — — 0 0 — 2 — 0 2 1 3 Florida 2 1 3 18 32 — 0 2 2 5 5 6 28 98 64 Georgia — 0 2 3 4 — 0 2 1 1 — 5 13 64 64 Maryland§ 1 0 1 4 2 — 0 1 — 6 3 2 6 34 46 North Carolina 1 0 3 9 10 2 0 2 2 5 3 3 35 89 127 South Carolina§

— 0 1 4 5 — 0 1 — 3 — 6 25 44 70 Virginia§

— 0 2 8 11 — 0 2 1 5 2 7 39 97 39 West Virginia — 0 1 — 1 — 0 0 — 2 — 0 41 — 7 E.S. Central — 1 3 11 17 — 0 2 3 4 — 13 35 116 274

Alabama§

— 0 1 6 4 — 0 2 1 2 — 4 8 33 72 Kentucky — 0 2 — 6 — 0 1 — — — 4 16 39 103 Mississippi — 0 1 2 2 — 0 1 2 — — 1 10 5 19 Tennessee§

— 0 2 3 5 — 0 1 — 2 — 3 11 39 80 W.S. Central — 1 12 24 37 2 2 15 38 21 17 54 293 312 942

Arkansas§

— 0 1 6 4 — 0 1 — 1 — 2 17 17 50 Louisiana — 0 1 5 9 — 0 2 — 2 — 1 3 10 11 Oklahoma — 0 2 4 12 — 0 1 1 — — 1 92 17 3 Texas§

— 1 10 9 12 2 2 14 37 18 17 45 187 268 878 Mountain — 1 6 23 23 — 0 4 1 5 1 42 99 672 356

Arizona — 0 2 8 7 — 0 1 — 1 1 12 29 243 144 Colorado — 0 4 1 5 — 0 1 — 4 — 13 63 253 38 Idaho§

— 0 1 3 3 — 0 1 — — — 3 15 30 44 Montana§

— 0 2 2 1 — 0 0 — — — 2 16 46 5 Nevada§

— 0 1 3 4 — 0 1 — — — 0 7 8 2 New Mexico§

— 0 1 1 2 — 0 2 1 — — 2 11 42 32 Utah — 0 1 5 1 — 0 1 — — — 6 16 48 88 Wyoming§

— 0 1 — — — 0 1 — — — 0 2 2 3 Pacific 11 3 15 76 63 4 0 18 11 6 127 150 1,101 837 418

Alaska — 0 1 — — — 0 1 1 1 — 0 6 14 11 California 10 2 10 54 46 4 0 18 5 1 127 130 959 656 269 Hawaii — 0 1 2 1 — 0 1 2 1 — 1 6 9 18 Oregon 1 1 3 15 12 — 0 1 3 1 — 5 12 65 82 Washington — 0 4 5 4 — 0 2 — 2 — 10 132 93 38 Territories

American Samoa — 0 0 — — — 0 0 — — — 0 0 — — C.N.M.I. — — — — — — — — — — — — — — — Guam — 0 0 — — — 1 15 14 13 — 0 14 31 — Puerto Rico — 0 0 — — — 0 1 — — — 0 1 1 — U.S. Virgin Islands — 0 0 — — — 0 0 — — — 0 0 — — C.N.M.I.: Commonwealth of Northern Mariana Islands. U: Unavailable. —: No reported cases. N: Not reportable. NN: Not Nationally Notifiable. Cum: Cumulative year-to-date counts. Med: Median. Max: Maximum. *Case counts for reporting year 2010 and 2011 are provisional and subject to change. For further information on interpretation of these data, seehttp://www.cdc.gov/osels/ph_surveillance/

nndss/phs/files/ProvisionalNationa%20NotifiableDiseasesSurveillanceData20100927.pdf . Data for TB are displayed in Table IV, which appears quarterly. †Data for meningococcal disease, invasive caused by serogroups A, C, Y, and W-135; serogroup B; other serogroup; and unknown serogroup are available in Table I. §Contains data reported through the National Electronic Disease Surveillance System (NEDSS).

## Morbidity and Mortality Weekly Report

MMWR / May 6, 2011 / Vol. 60 / No. 17 565 TABLE II. (Continued) Provisional cases of selected notifiable diseases, United States, weeks ending April 30, 2011, and May 1, 2010 (17th week)* Reporting area Rabies, animal Salmonellosis Shiga toxin-producingE. coli(STEC)† Current week Previous 52 weeks Cum 2011 Cum 2010 Current week Previous 52 weeks Cum 2011 Cum 2010 Current week Previous 52 weeks Cum 2011 Cum 2010 Med Max Med Max Med Max United States 22 53 146 521 1,026 295 956 1,805 7,635 9,853 44 99 246 866 898 New England — 4 18 26 72 — 32 110 378 910 1 2 13 23 89

Connecticut — 2 11 — 28 — 0 88 88 490 — 0 9 9 60 Maine§

— 1 3 12 20 — 3 8 36 23 1 0 3 3 1 Massachusetts — 0 0 — — — 21 52 204 299 — 1 9 5 18 New Hampshire — 0 6 4 4 — 3 12 28 49 — 0 2 6 8 Rhode Island§

— 0 4 2 3 — 2 17 10 37 — 0 1 — — Vermont§

— 1 3 8 17 — 1 5 12 12 — 0 2 — 2 Mid. Atlantic 9 16 33 81 341 40 95 218 828 1,156 4 9 32 95 104

New Jersey — 0 0 — — — 12 57 73 208 — 1 9 11 22 New York (Upstate) 9 8 19 81 141 26 26 63 236 246 2 4 12 33 33 New York City — 0 4 — 91 1 23 56 213 296 — 1 7 14 11 Pennsylvania — 6 17 — 109 13 29 81 306 406 2 3 13 37 38 E.N. Central 2 2 27 15 15 19 91 253 805 1,199 11 12 44 116 169

Illinois — 1 11 4 7 — 35 124 240 397 — 2 9 10 28 Indiana — 0 0 — — — 13 62 58 153 — 2 10 17 15 Michigan — 1 5 5 5 3 14 49 146 208 5 3 9 34 54 Ohio 2 0 12 6 3 16 23 47 264 302 6 2 11 35 25 Wisconsin — 0 0 — — — 10 48 97 139 — 3 17 20 47 W.N. Central 2 3 36 22 70 14 49 123 436 606 3 16 50 77 113

Iowa — 0 3 — 6 1 9 34 105 82 — 2 16 19 20 Kansas — 1 4 10 22 — 7 18 61 88 — 1 5 14 10 Minnesota — 0 34 — 12 — 12 33 — 183 — 5 21 — 37 Missouri — 0 6 — 11 11 15 43 192 160 3 4 28 29 28 Nebraska§ 2 1 4 8 16 2 4 13 39 46 — 1 6 13 12 North Dakota — 0 3 4 3 — 0 13 — 8 — 0 10 — — South Dakota — 0 0 — — — 3 17 39 39 — 0 4 2 6 S. Atlantic 9 20 38 279 408 114 262 619 2,167 2,483 8 16 31 235 135

Delaware — 0 0 — — — 3 11 26 27 — 0 2 3 1 District of Columbia — 0 0 — — — 1 6 7 25 — 0 1 1 2 Florida — 0 27 38 121 78 108 226 944 1,082 6 6 15 113 51 Georgia — 0 0 — — 8 43 142 375 316 — 1 7 22 18 Maryland§

— 6 15 78 121 13 18 57 169 207 1 2 9 28 18 North Carolina — 0 0 — — — 23 240 289 459 — 2 10 29 11 South Carolina§

— 0 0 — — 2 25 99 140 159 — 0 4 7 4 Virginia§ 9 12 25 163 141 12 21 68 198 152 1 3 9 31 28 West Virginia — 0 7 — 25 1 1 14 19 56 — 0 4 1 2 E.S. Central — 3 7 43 47 14 57 176 490 474 4 5 22 52 42

Alabama§

— 1 7 27 11 2 20 52 141 150 — 1 4 11 11 Kentucky — 0 4 3 2 5 11 32 95 90 — 1 6 7 4 Mississippi — 0 0 — — — 18 66 97 88 — 0 12 3 4 Tennessee§

— 1 4 13 34 7 17 53 157 146 4 2 7 31 23 W.S. Central — 0 30 37 11 30 140 505 815 953 4 8 135 61 39

Arkansas§

— 0 10 27 7 5 13 43 109 64 — 1 5 7 6 Louisiana — 0 0 — — 1 19 49 116 227 — 0 2 3 4 Oklahoma — 0 30 10 4 11 12 95 95 79 2 1 40 9 1 Texas§

— 0 0 — — 13 95 381 495 583 2 5 95 42 28 Mountain — 1 7 5 17 6 52 113 548 679 3 11 33 94 112

Arizona — 0 0 — — 2 16 43 183 223 — 1 14 24 21 Colorado — 0 0 — — — 10 24 123 161 — 3 21 9 36 Idaho§

— 0 2 — 1 2 3 9 48 39 1 2 7 17 11 Montana§

— 0 3 2 — — 1 6 19 25 — 0 3 2 12 Nevada§

— 0 2 — — 2 5 22 47 43 1 0 6 13 5 New Mexico§

— 0 2 3 4 — 5 19 45 77 — 1 6 10 11 Utah — 0 2 — — — 5 17 65 94 1 2 8 17 13 Wyoming§

— 0 4 — 12 — 1 8 18 17 — 0 3 2 3 Pacific — 1 13 13 45 58 116 291 1,168 1,393 6 12 52 113 95

Alaska — 0 2 9 10 — 1 4 21 22 — 0 1 — 1 California — 0 12 — 31 48 79 217 876 976 6 6 32 80 54 Hawaii — 0 0 — — 8 6 14 85 88 — 0 3 1 14 Oregon — 0 2 4 4 2 8 20 86 202 — 2 11 16 10 Washington — 0 0 — — — 15 71 100 105 — 3 18 16 16 Territories

American Samoa N 0 0 N N — 0 1 — 1 — 0 0 — — C.N.M.I. — — — — — — — — — — — — — — — Guam — 0 0 — — — 0 3 6 — — 0 0 — — Puerto Rico — 0 2 7 19 — 6 21 15 170 — 0 0 — — U.S. Virgin Islands — 0 0 — — — 0 0 — — — 0 0 — — C.N.M.I.: Commonwealth of Northern Mariana Islands. U: Unavailable. —: No reported cases. N: Not reportable. NN: Not Nationally Notifiable. Cum: Cumulative year-to-date counts. Med: Median. Max: Maximum. *Case counts for reporting year 2010 and 2011 are provisional and subject to change. For further information on interpretation of these data, seehttp://www.cdc.gov/osels/ph_surveillance/

nndss/phs/files/ProvisionalNationa%20NotifiableDiseasesSurveillanceData20100927.pdf . Data for TB are displayed in Table IV, which appears quarterly. †Includes E. coli O157:H7; Shiga toxin-positive, serogroup non-O157; and Shiga toxin-positive, not serogrouped. §Contains data reported through the National Electronic Disease Surveillance System (NEDSS).

## Morbidity and Mortality Weekly Report

566 MMWR / May 6, 2011 / Vol. 60 / No. 17 TABLE II. (Continued) Provisional cases of selected notifiable diseases, United States, weeks ending April 30, 2011, and May 1, 2010 (17th week)* Spotted Fever Rickettsiosis (including RMSF)† Reporting area Shigellosis Confirmed Probable Current week Previous 52 weeks Cum 2011 Cum 2010 Current week Previous 52 weeks Cum 2011 Cum 2010 Current week Previous 52 weeks Cum 2011 Cum 2010 Med Max Med Max Med Max United States 113 279 629 2,470 4,134 — 2 10 16 15 4 28 196 92 139 New England — 4 17 56 143 — 0 0 — — — 0 1 1 1

Connecticut — 0 8 8 69 — 0 0 — — — 0 0 — — Maine§

— 0 3 5 3 — 0 0 — — — 0 1 — 1 Massachusetts — 3 16 42 60 — 0 0 — — — 0 0 — — New Hampshire — 0 2 — 4 — 0 0 — — — 0 1 — — Rhode Island§

— 0 4 — 6 — 0 0 — — — 0 1 1 — Vermont§

— 0 1 1 1 — 0 0 — — — 0 0 — — Mid. Atlantic 2 22 70 159 569 — 0 1 1 — — 1 4 4 8

New Jersey — 4 16 24 102 — 0 0 — — — 0 0 — — New York (Upstate) 1 3 15 34 49 — 0 1 — — — 0 3 1 1 New York City 1 5 14 71 101 — 0 1 — — — 0 4 2 7 Pennsylvania — 7 55 30 317 — 0 1 1 — — 0 3 1 — E.N. Central 5 20 45 162 804 — 0 1 — — — 1 10 4 9

Illinois — 7 20 51 532 — 0 1 — — — 0 5 1 4 Indiana§

— 1 3 15 18 — 0 1 — — — 0 5 — 4 Michigan 1 4 10 39 71 — 0 0 — — — 0 1 1 — Ohio 4 5 18 57 76 — 0 0 — — — 0 2 2 — Wisconsin — 1 21 — 107 — 0 0 — — — 0 1 — 1 W.N. Central 2 18 81 103 869 — 0 2 2 — — 4 17 17 18

Iowa — 1 4 5 16 — 0 0 — — — 0 1 1 1 Kansas§

— 4 13 21 65 — 0 1 — — — 0 0 — — Minnesota — 1 4 — 12 — 0 0 — — — 0 2 — — Missouri 2 10 65 73 767 — 0 2 2 — — 4 17 16 17 Nebraska§

— 1 10 3 6 — 0 1 — — — 0 1 — — North Dakota — 0 0 — — — 0 0 — — — 0 1 — — South Dakota — 0 2 1 3 — 0 0 — — — 0 0 — — S. Atlantic 48 59 122 878 535 — 1 7 7 10 1 6 60 24 71

Delaware§

— 0 2 — 29 — 0 0 — 1 — 0 3 2 5 District of Columbia — 0 3 6 10 — 0 1 1 — — 0 0 — — Florida§ 41 30 63 619 189 — 0 1 1 — — 0 2 1 2 Georgia 4 16 27 124 184 — 0 6 2 5 — 0 0 — — Maryland§ 2 2 8 28 31 — 0 1 1 1 1 0 5 2 7 North Carolina — 3 36 63 42 — 0 3 1 3 — 2 48 12 51 South Carolina§

— 1 5 11 25 — 0 1 1 — — 0 2 1 2 Virginia§ 1 2 8 25 24 — 0 2 — — — 2 12 6 4 West Virginia — 0 66 2 1 — 0 0 — — — 0 0 — — E.S. Central 3 15 40 133 169 — 0 3 — 3 3 5 29 23 21

Alabama§ 1 5 14 53 24 — 0 1 — — — 1 8 7 4 Kentucky — 2 28 16 55 — 0 2 — 2 — 0 0 — — Mississippi 1 1 7 26 10 — 0 0 — — — 0 4 — 1 Tennessee§ 1 4 14 38 80 — 0 2 — 1 3 4 20 16 16 W.S. Central 40 54 387 461 603 — 0 7 — 1 — 2 186 3 10

Arkansas§ 1 1 6 12 14 — 0 2 — — — 1 29 1 4 Louisiana — 5 13 41 64 — 0 0 — — — 0 1 — — Oklahoma 2 3 46 31 95 — 0 4 — — — 0 152 1 2 Texas§ 37 44 337 377 430 — 0 1 — 1 — 0 5 1 4 Mountain 3 17 32 220 171 — 0 5 6 — — 0 7 16 1

Arizona 2 7 19 51 94 — 0 4 6 — — 0 7 16 — Colorado§

— 2 8 29 20 — 0 1 — — — 0 1 — — Idaho§

— 0 3 7 4 — 0 0 — — — 0 1 — — Montana§

— 0 15 74 4 — 0 1 — — — 0 1 — — Nevada§

— 0 6 6 9 — 0 0 — — — 0 0 — — New Mexico§

— 3 10 37 30 — 0 0 — — — 0 0 — 1 Utah 1 1 4 16 10 — 0 0 — — — 0 1 — — Wyoming§

— 0 0 — — — 0 0 — — — 0 1 — — Pacific 10 22 73 298 271 — 0 2 — 1 — 0 1 — —

Alaska — 0 1 1 — N 0 0 N N N 0 0 N N California 10 19 58 232 216 — 0 2 — 1 — 0 0 — — Hawaii — 1 4 23 20 N 0 0 N N N 0 0 N N Oregon — 1 4 23 22 — 0 0 — — — 0 1 — — Washington — 2 17 19 13 — 0 0 — — — 0 0 — — Territories

American Samoa — 1 1 1 — N 0 0 N N N 0 0 N N C.N.M.I. — — — — — — — — — — — — — — — Guam — 0 1 1 — N 0 0 N N N 0 0 N N Puerto Rico — 0 1 — 1 N 0 0 N N N 0 0 N N U.S. Virgin Islands — 0 0 — — — 0 0 — — — 0 0 — — C.N.M.I.: Commonwealth of Northern Mariana Islands. U: Unavailable. —: No reported cases. N: Not reportable. NN: Not Nationally Notifiable. Cum: Cumulative year-to-date counts. Med: Median. Max: Maximum. *Case counts for reporting year 2010 and 2011 are provisional and subject to change. For further information on interpretation of these data, seehttp://www.cdc.gov/osels/ph_surveillance/

nndss/phs/files/ProvisionalNationa%20NotifiableDiseasesSurveillanceData20100927.pdf . Data for TB are displayed in Table IV, which appears quarterly. †Illnesses with similar clinical presentation that result from Spotted fever group rickettsia infections are reported as Spotted fever rickettsioses. Rocky Mountain spotted fever (RMSF) caused

by Rickettsia rickettsii, is the most common and well-known spotted fever. §Contains data reported through the National Electronic Disease Surveillance System (NEDSS).

## Morbidity and Mortality Weekly Report

MMWR / May 6, 2011 / Vol. 60 / No. 17 567 TABLE II. (Continued) Provisional cases of selected notifiable diseases, United States, weeks ending April 30, 2011, and May 1, 2010 (17th week)* Streptococcus pneumoniae,†invasive disease Reporting area All ages Age <5 Syphilis, primary and secondary Current week Previous 52 weeks Cum 2011 Cum 2010 Current week Previous 52 weeks Cum 2011 Cum 2010 Current week Previous 52 weeks Cum 2011 Cum 2010 Med Max Med Max Med Max United States 159 298 915 5,645 7,005 11 32 109 492 1,041 92 252 352 3,353 4,170 New England — 7 68 92 192 — 1 4 11 35 3 9 20 125 141

Connecticut — 0 46 — — — 0 3 — — — 1 8 17 25 Maine§

— 2 13 46 54 — 0 1 2 4 — 0 3 7 13 Massachusetts — 1 5 14 40 — 0 3 6 27 3 5 15 77 89 New Hampshire — 0 3 — 54 — 0 0 — 3 — 0 3 10 5 Rhode Island§

— 1 36 8 7 — 0 3 — — — 1 4 10 7 Vermont§

— 1 5 24 37 — 0 1 3 1 — 0 2 4 2 Mid. Atlantic 23 31 60 616 498 2 5 19 70 131 10 30 46 371 570

New Jersey — 1 8 30 48 — 1 5 17 23 1 4 10 51 81 New York (Upstate) 3 2 11 33 68 1 1 9 19 51 5 2 18 61 26 New York City 9 14 33 288 173 — 1 14 9 32 1 13 29 154 332 Pennsylvania 11 12 24 265 209 1 1 5 25 25 3 7 16 105 131 E.N. Central 49 60 105 1,250 1,386 7 5 12 94 176 1 28 53 274 634

Illinois — 1 6 25 49 — 1 4 25 43 — 11 25 52 320 Indiana — 9 28 199 316 — 0 4 7 28 — 3 14 38 53 Michigan 8 13 29 278 316 — 1 4 16 44 — 4 9 59 96 Ohio 35 25 45 570 557 7 2 4 38 43 1 9 22 114 146 Wisconsin 6 8 22 178 148 — 0 4 8 18 — 1 3 11 19 W.N. Central 2 15 36 162 477 — 2 7 26 85 — 7 18 99 94

Iowa — 0 0 — — — 0 0 — — — 0 3 3 5 Kansas — 2 6 32 50 — 0 2 2 8 — 0 3 6 7 Minnesota — 6 24 — 291 — 1 5 — 44 — 3 10 40 21 Missouri — 2 10 77 52 — 1 4 21 19 — 2 9 48 58 Nebraska§ 2 2 9 53 58 — 0 1 3 8 — 0 2 2 3 North Dakota — 0 11 — 14 — 0 1 — — — 0 0 — — South Dakota — 0 2 — 12 — 0 2 — 6 — 0 1 — — S. Atlantic 41 71 171 1,399 1,999 1 8 25 120 268 34 62 172 915 955

Delaware — 1 6 27 13 — 0 1 — — — 0 4 4 3 District of Columbia — 0 2 5 15 — 0 2 1 3 6 3 15 58 48 Florida 20 26 68 696 748 1 3 13 61 97 4 23 44 330 346 Georgia 3 16 53 167 663 — 2 7 15 77 — 12 127 122 164 Maryland§ 14 10 32 262 222 — 1 4 12 29 5 8 16 145 76 North Carolina — 0 0 — — — 0 0 — — 10 6 19 116 167 South Carolina§ 4 7 25 223 262 — 1 4 12 29 — 3 10 63 45 Virginia§

— 1 4 19 28 — 1 4 19 26 9 4 16 77 103 West Virginia — 0 14 — 48 — 0 6 — 7 — 0 2 — 3 E.S. Central 9 24 45 489 605 — 2 6 32 58 6 15 39 167 279

Alabama§

— 0 0 — — — 0 0 — — 1 4 11 33 89 Kentucky 1 4 11 73 76 — 0 3 10 5 4 2 16 34 29 Mississippi — 1 8 4 32 — 0 2 — 6 — 3 16 31 63 Tennessee§ 8 19 36 412 497 — 1 4 22 47 1 5 11 69 98 W.S. Central 25 31 366 683 812 1 4 38 72 138 26 37 71 504 617

Arkansas§ 7 4 23 111 74 — 0 3 10 10 10 3 10 58 83 Louisiana — 2 10 91 50 — 0 2 8 16 6 8 36 88 123 Oklahoma 1 0 8 15 29 1 0 8 15 29 — 1 6 14 27 Texas§ 17 25 333 466 659 — 3 27 39 83 10 23 33 344 384 Mountain 8 33 75 813 912 — 3 8 58 132 4 12 24 114 163

Arizona 6 11 43 383 443 — 1 5 26 59 — 4 9 7 65 Colorado — 10 23 188 233 — 1 3 9 34 — 2 8 35 43 Idaho§

— 0 2 4 6 — 0 2 3 2 — 0 2 3 2 Montana§

— 0 2 4 7 — 0 1 — — — 0 2 1 — Nevada§

— 2 8 49 34 — 0 1 3 4 4 2 9 45 26 New Mexico§

— 3 13 109 79 — 0 2 7 12 — 1 4 18 8 Utah — 4 8 63 101 — 0 3 10 19 — 1 5 5 19 Wyoming§ 2 0 15 13 9 — 0 1 — 2 — 0 0 — — Pacific 2 6 24 141 124 — 0 5 9 18 8 50 65 784 717

Alaska — 2 11 51 55 — 0 2 3 14 — 0 1 — 2 California 2 3 23 89 69 — 0 5 6 4 2 41 57 622 609 Hawaii — 0 3 1 — — 0 0 — — — 0 5 4 13 Oregon — 0 0 — — — 0 0 — — 1 1 7 31 20 Washington — 0 0 — — — 0 0 — — 5 6 14 127 73 Territories

American Samoa — 0 0 — — — 0 0 — — — 0 0 — — C.N.M.I. — — — — — — — — — — — — — — — Guam — 0 0 — — — 0 0 — — — 0 0 — — Puerto Rico — 0 0 — — — 0 0 — — — 4 15 65 65 U.S. Virgin Islands — 0 0 — — — 0 0 — — — 0 0 — — C.N.M.I.: Commonwealth of Northern Mariana Islands. U: Unavailable. —: No reported cases. N: Not reportable. NN: Not Nationally Notifiable. Cum: Cumulative year-to-date counts. Med: Median. Max: Maximum. *Case counts for reporting year 2010 and 2011 are provisional and subject to change. For further information on interpretation of these data, seehttp://www.cdc.gov/osels/ph_surveillance/

nndss/phs/files/ProvisionalNationa%20NotifiableDiseasesSurveillanceData20100927.pdf . Data for TB are displayed in Table IV, which appears quarterly. †Includes drug resistant and susceptible cases of invasive Streptococcus pneumoniae disease among children <5 years and among all ages. Case definition: Isolation of S. pneumoniae from

a normally sterile body site (e.g., blood or cerebrospinal fluid). §Contains data reported through the National Electronic Disease Surveillance System (NEDSS).

## Morbidity and Mortality Weekly Report

568 MMWR / May 6, 2011 / Vol. 60 / No. 17 TABLE II. (Continued) Provisional cases of selected notifiable diseases, United States, weeks ending April 30, 2011, and May 1, 2010 (17th week)* West Nile virus disease† Reporting area Varicella (chickenpox) Neuroinvasive Nonneuroinvasive§ Current week Previous 52 weeks Cum 2011 Cum 2010 Current week Previous 52 weeks Cum 2011 Cum 2010 Current week Previous 52 weeks Cum 2011 Cum 2010 Med Max Med Max Med Max United States 157 240 575 3,686 5,975 — 1 71 — 1 — 0 53 — 3 New England — 18 46 227 353 — 0 3 — — — 0 2 — —

Connecticut — 3 20 — 90 — 0 2 — — — 0 2 — — Maine¶

— 5 16 75 81 — 0 0 — — — 0 0 — — Massachusetts — 5 17 103 94 — 0 2 — — — 0 1 — — New Hampshire — 2 9 9 47 — 0 1 — — — 0 0 — — Rhode Island¶

— 0 4 6 9 — 0 0 — — — 0 0 — — Vermont¶

— 2 13 34 32 — 0 0 — — — 0 0 — — Mid. Atlantic 16 26 62 417 629 — 0 19 — — — 0 13 — —

New Jersey — 6 23 104 226 — 0 3 — — — 0 6 — — New York (Upstate) N 0 0 N N — 0 9 — — — 0 7 — — New York City — 0 0 — 1 — 0 7 — — — 0 4 — — Pennsylvania 16 19 41 313 402 — 0 3 — — — 0 3 — — E.N. Central 48 71 154 1,191 2,139 — 0 15 — — — 0 7 — —

Illinois 8 18 43 291 563 — 0 10 — — — 0 4 — — Indiana¶ 1 5 19 97 207 — 0 2 — — — 0 2 — — Michigan 10 24 43 377 689 — 0 6 — — — 0 1 — — Ohio 29 21 58 425 539 — 0 1 — — — 0 1 — — Wisconsin — 5 20 1 141 — 0 0 — — — 0 1 — — W.N. Central 2 10 35 77 329 — 0 7 — — — 0 11 — 1

Iowa N 0 0 N N — 0 1 — — — 0 2 — — Kansas¶ 1 2 18 47 156 — 0 1 — — — 0 3 — 1 Minnesota — 0 0 — — — 0 1 — — — 0 3 — — Missouri — 7 24 10 144 — 0 1 — — — 0 0 — — Nebraska¶ N 0 0 N N — 0 3 — — — 0 7 — — North Dakota — 0 10 11 20 — 0 2 — — — 0 2 — — South Dakota 1 1 7 9 9 — 0 2 — — — 0 3 — — S. Atlantic 21 33 100 520 780 — 0 6 — — — 0 4 — 2

Delaware¶

— 0 4 3 11 — 0 0 — — — 0 0 — — District of Columbia — 0 2 5 6 — 0 1 — — — 0 1 — — Florida¶ 18 15 57 368 397 — 0 3 — — — 0 1 — — Georgia N 0 0 N N — 0 1 — — — 0 3 — 2 Maryland¶ N 0 0 N N — 0 3 — — — 0 2 — — North Carolina N 0 0 N N — 0 0 — — — 0 0 — — South Carolina¶

— 0 7 — 58 — 0 1 — — — 0 0 — — Virginia¶ 3 10 29 144 154 — 0 1 — — — 0 1 — — West Virginia — 5 26 — 154 — 0 0 — — — 0 0 — — E.S. Central 1 6 22 103 93 — 0 1 — 1 — 0 3 — —

Alabama¶ 1 5 22 98 92 — 0 1 — — — 0 1 — — Kentucky N 0 0 N N — 0 1 — — — 0 1 — — Mississippi — 0 3 5 1 — 0 1 — 1 — 0 2 — — Tennessee¶ N 0 0 N N — 0 1 — — — 0 2 — — W.S. Central 68 39 258 759 1,133 — 0 16 — — — 0 3 — —

Arkansas¶

— 2 17 67 89 — 0 3 — — — 0 1 — — Louisiana — 1 4 13 27 — 0 3 — — — 0 1 — — Oklahoma N 0 0 N N — 0 1 — — — 0 0 — — Texas¶ 68 37 247 679 1,017 — 0 15 — — — 0 2 — — Mountain — 16 50 318 488 — 0 18 — — — 0 15 — —

Arizona — 0 0 — — — 0 13 — — — 0 9 — — Colorado¶

— 6 31 111 174 — 0 5 — — — 0 11 — — Idaho¶ N 0 0 N N — 0 0 — — — 0 1 — — Montana¶

— 3 28 82 84 — 0 0 — — — 0 0 — — Nevada¶ N 0 0 N N — 0 0 — — — 0 1 — — New Mexico¶

— 1 8 13 41 — 0 6 — — — 0 2 — — Utah — 5 26 107 183 — 0 1 — — — 0 1 — — Wyoming¶

— 0 3 5 6 — 0 1 — — — 0 1 — — Pacific 1 2 20 74 31 — 0 8 — — — 0 6 — —

Alaska — 1 5 22 15 — 0 0 — — — 0 0 — — California — 0 17 35 2 — 0 8 — — — 0 6 — — Hawaii 1 1 4 17 14 — 0 0 — — — 0 0 — — Oregon N 0 0 N N — 0 0 — — — 0 0 — — Washington N 0 0 N N — 0 1 — — — 0 1 — — Territories

American Samoa N 0 0 N N — 0 0 — — — 0 0 — — C.N.M.I. — — — — — — — — — — — — — — — Guam — 0 4 16 6 — 0 0 — — — 0 0 — — Puerto Rico — 7 30 49 157 — 0 0 — — — 0 0 — — U.S. Virgin Islands — 0 0 — — — 0 0 — — — 0 0 — — C.N.M.I.: Commonwealth of Northern Mariana Islands. U: Unavailable. —: No reported cases. N: Not reportable. NN: Not Nationally Notifiable. Cum: Cumulative year-to-date counts. Med: Median. Max: Maximum. *Case counts for reporting year 2010 and 2011 are provisional and subject to change. For further information on interpretation of these data, seehttp://www.cdc.gov/osels/ph_surveillance/

nndss/phs/files/ProvisionalNationa%20NotifiableDiseasesSurveillanceData20100927.pdf . Data for TB are displayed in Table IV, which appears quarterly. †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 California

serogroup, eastern equine, Powassan, St. Louis, and western equine diseases are available in Table I. §Not reportable in all states. Data from states where the condition is not reportable are excluded from this table, except starting in 2007 for the domestic arboviral diseases and influenzaassociated pediatric mortality, and in 2003 for SARS-CoV. Reporting exceptions are available athttp://www.cdc.gov/osels/ph_surveillance/nndss/phs/infdis.htm. ¶Contains data reported through the National Electronic Disease Surveillance System (NEDSS).

## Morbidity and Mortality Weekly Report

MMWR / May 6, 2011 / Vol. 60 / No. 17 569 TABLE III. Deaths in 122 U.S. cities,* week ending April 30, 2011 (17th week) Reporting area All causes, by age (years) P&I† Total Reporting area (Continued ) All causes, by age (years) P&I† Total All Ages ≥65 45–64 25–44 1–24 <1 All Ages ≥65 45–64 25–44 1–24 <1 New England 555 388 119 22 13 13 50 S. Atlantic 1,198 782 287 61 37 31 80

Boston, MA 129 84 29 7 6 3 12 Atlanta, GA 154 102 28 13 6 5 11 Bridgeport, CT 27 23 4 — — — 2 Baltimore, MD 121 73 32 9 2 5 11 Cambridge, MA 8 6 1 1 — — 3 Charlotte, NC 127 96 24 2 3 2 10 Fall River, MA 29 24 3 1 1 — 4 Jacksonville, FL 158 102 41 9 4 2 12 Hartford, CT 60 40 14 4 1 1 6 Miami, FL 145 95 38 7 3 2 9 Lowell, MA 34 23 7 4 — — — Norfolk, VA 44 24 13 — 5 2 — Lynn, MA 8 4 3 1 — — — Richmond, VA 62 35 20 3 2 2 3 New Bedford, MA 19 14 4 1 — — — Savannah, GA 50 31 16 2 — 1 3 New Haven, CT 26 15 8 — 2 1 6 St. Petersburg, FL 57 39 8 2 5 3 4 Providence, RI 73 52 20 — 1 — 2 Tampa, FL 184 132 38 7 3 4 12 Somerville, MA 4 1 1 1 1 — — Washington, D.C. 82 44 26 5 4 3 4 Springfield, MA 51 36 7 2 1 5 2 Wilmington, DE 14 9 3 2 — — 1 Waterbury, CT 38 29 9 — — — 5 E.S. Central 828 525 217 57 15 14 60 Worcester, MA 49 37 9 — — 3 8 Birmingham, AL 152 94 37 13 3 5 2 Mid. Atlantic 1,936 1,331 438 108 27 32 111 Chattanooga, TN 77 44 26 7 — — 9

Albany, NY 46 31 10 3 — 2 5 Knoxville, TN 109 77 21 6 4 1 10 Allentown, PA 28 22 4 2 — — 2 Lexington, KY 58 36 13 7 — 2 — Buffalo, NY 85 59 21 2 1 2 8 Memphis, TN 204 127 60 12 4 1 22 Camden, NJ 30 14 10 3 — 3 4 Mobile, AL 61 40 12 4 3 2 2 Elizabeth, NJ 17 14 3 — — — 2 Montgomery, AL 25 16 8 1 — — 4 Erie, PA 32 27 4 1 — — 2 Nashville, TN 142 91 40 7 1 3 11 Jersey City, NJ 8 5 2 1 — — — W.S. Central 1,103 719 257 72 29 26 76 New York City, NY 984 686 215 60 12 11 38 Austin, TX 81 50 22 4 2 3 13 Newark, NJ 30 14 11 3 1 1 3 Baton Rouge, LA 71 40 15 10 5 1 — Paterson, NJ 27 14 6 5 1 1 6 Corpus Christi, TX 56 38 15 3 — — 7 Philadelphia, PA 302 191 84 12 8 7 12 Dallas, TX 169 88 58 14 2 7 9 Pittsburgh, PA§ 42 27 13 1 — 1 2 El Paso, TX 99 76 16 2 3 2 4 Reading, PA 45 34 9 1 — 1 3 Fort Worth, TX U U U U U U U Rochester, NY 58 43 11 3 — 1 5 Houston, TX 157 102 29 11 5 10 11 Schenectady, NY 22 16 3 3 — — 2 Little Rock, AR 81 53 20 5 2 1 — Scranton, PA 29 24 3 2 — — 2 New Orleans, LA U U U U U U U Syracuse, NY 105 79 19 4 3 — 13 San Antonio, TX 232 163 47 15 7 — 16 Trenton, NJ 11 6 4 — — 1 — Shreveport, LA 37 28 8 1 — — 3 Utica, NY 18 15 2 — 1 — 2 Tulsa, OK 120 81 27 7 3 2 13 Yonkers, NY 17 10 4 2 — 1 — Mountain 956 654 212 63 20 7 69 E.N. Central 1,833 1,203 453 109 38 30 110 Albuquerque, NM 144 105 25 10 3 1 18

Akron, OH 48 31 11 3 1 2 5 Boise, ID 60 46 11 3 — — 5 Canton, OH 47 37 10 — — — 3 Colorado Springs, CO 81 55 14 8 4 — 4 Chicago, IL 212 139 48 21 4 — 19 Denver, CO 80 49 22 7 1 1 4 Cincinnati, OH 84 45 26 6 3 4 5 Las Vegas, NV 283 191 70 16 4 2 25 Cleveland, OH 261 176 63 15 3 4 12 Ogden, UT 29 20 7 1 1 — 3 Columbus, OH 51 31 15 2 1 2 4 Phoenix, AZ U U U U U U U Dayton, OH 129 85 31 8 3 2 4 Pueblo, CO 30 22 6 2 — — 3 Detroit, MI 192 101 68 13 7 3 9 Salt Lake City, UT 111 75 23 7 5 1 4 Evansville, IN 47 37 8 1 1 — 1 Tucson, AZ 138 91 34 9 2 2 3 Fort Wayne, IN 73 52 15 4 1 1 1 Pacific 1,789 1,243 383 99 36 28 162 Gary, IN 10 8 2 — — — — Berkeley, CA 23 14 9 — — — — Grand Rapids, MI 48 29 9 6 — 4 6 Fresno, CA 120 83 27 7 3 — 13 Indianapolis, IN 217 144 52 15 4 2 15 Glendale, CA 46 38 6 1 1 — 9 Lansing, MI 50 29 15 2 1 3 4 Honolulu, HI 71 49 17 2 — 3 6 Milwaukee, WI 93 60 25 4 3 1 1 Long Beach, CA 67 42 17 6 1 1 9 Peoria, IL 40 34 5 — 1 — 4 Los Angeles, CA 285 179 64 27 11 4 21 Rockford, IL 51 27 19 4 1 — 1 Pasadena, CA 27 23 4 — — — 2 South Bend, IN 45 36 5 3 1 — 4 Portland, OR 119 87 22 4 3 3 15 Toledo, OH 73 46 20 2 3 2 9 Sacramento, CA 213 149 47 9 4 4 18 Youngstown, OH 62 56 6 — — — 3 San Diego, CA 165 110 37 14 3 1 22 W.N. Central 628 425 138 35 9 19 60 San Francisco, CA 108 80 24 3 — 1 15

Des Moines, IA 73 51 15 6 — 1 9 San Jose, CA 201 153 32 7 4 5 15 Duluth, MN 40 27 9 3 1 — 6 Santa Cruz, CA 35 24 7 3 1 — 1 Kansas City, KS 25 16 8 — — 1 1 Seattle, WA 129 86 29 6 3 5 7 Kansas City, MO 81 44 22 8 2 5 7 Spokane, WA 69 49 14 5 — 1 4 Lincoln, NE 42 29 9 3 1 — 4 Tacoma, WA 111 77 27 5 2 — 5 Minneapolis, MN 79 57 11 5 3 2 9 Total¶ 10,826 7,270 2,504 626 224 200 778 Omaha, NE 119 87 23 4 1 4 11 St. Louis, MO 39 22 11 1 — 4 1 St. Paul, MN 49 36 11 2 — — 4 Wichita, KS 81 56 19 3 1 2 8 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.

## U.S. Government Printing Office: 2011-723-011/21047 Region IV ISSN: 0149-2195 TheMorbidity and Mortality Weekly Report (MMWR)Series is prepared by the Centers for Disease Control and Prevention (CDC) and is available free of charge in electronic format. To receive an electronic copy each week, visit MMWR’s free subscription page athttp://www.cdc.gov/mmwr/mmwrsubscribe. html . Paper copy subscriptions are available through the Superintendent of Documents, U.S. Government Printing Office, Washington, DC 20402; telephone 202-512-1800. Data presented by the Notifiable Disease Data Team and 122 Cities Mortality Data Team in the weeklyMMWR are provisional, based on weekly reports to CDC by state health departments. Address all inquiries about theMMWR Series, including material to be considered for publication, to Editor, MMWR Series, Mailstop E-90, CDC, 1600 Clifton Rd., N.E., Atlanta, GA 30333 or tommwrq@cdc.gov . All material in theMMWR Series is in the public domain and may be used and reprinted without permission; citation as to source, however, is appreciated. Use of trade names and commercial sources is for identification only and does not imply endorsement by the U.S. Department of Health and Human Services. References to non-CDC sites on the Internet are provided as a service toMMWR readers and do not constitute or imply endorsement of these organizations or their programs by CDC or the U.S. Department of Health and Human Services. CDC is not responsible for the content of these sites. URL addresses listed inMMWR were current as of the date of publication. Morbidity and Mortality Weekly Report