Weekly / Vol. 60 / No. 50 December 23, 2011

U.S. Department of Health and Human Services

Centers for Disease Control and Prevention

Morbidity and Mortality Weekly Report

On September 29, 2011, the United Network for Organ 

Sharing notified CDC of two patients who tested positive for 

hepatitis C virus (HCV) infection approximately 6 months 

after receiving kidney transplants from a deceased donor. 

Before transplantation, the donor had tested negative for HCV 

antibody by the organ procurement organization. Tissue also 

was procured from the donor for possible transplantation. The 

tissue bank performed an HCV antibody test on the donor’s 

serum specimen that was negative and nucleic acid testing 

(NAT) that was positive, but misread as negative. Retesting 

of the donor specimen during the investigation confirmed 

the NAT results as positive. Donated tissue included 43 

musculoskeletal grafts and one cardiopulmonary patch, which 

were distributed to health-care facilities in several states. An 

investigation was initiated to 1) identify potential sources of 

the donor’s infection, 2) document the mode of transmission 

to the organ recipients, and 3) ensure timely notification 

of the implanting surgeons and testing of tissue recipients. 

Implantation of infected HCV tissue occurred after recognition 

of new HCV infection in the organ transplant recipients, highlighting the need for rapid communication between transplant 

centers, organ procurement organizations, tissue banks, and 

public health authorities regarding suspected transplantation 

transmission events. 

Donor Investigation 

The donor, a middle-aged man in Kentucky, sustained a 

traumatic brain injury in March 2011 in an all-terrain vehicular incident and died 2 days later. His medical history was 

significant for schizophrenia, substance abuse, and a 5-month 

incarceration approximately 10 years before his death. The 

donor had no known history of intravenous drug use or other 

hepatitis risk factors, according to his father at the time of organ 

procurement; however, further investigation revealed that the 

donor’s father had limited contact with his son during the 

year before his death and was unfamiliar with recent personal 

habits or behaviors. 

Policies of the Organ Procurement and Transplantation Network 

(OPTN), the oversight entity for solid organs in the United States, 

require testing for HCV by antibody only, whereas the Food and 

Drug Administration (FDA), which regulates human cells, tissues, and cellular and tissue-based products, requires screening 

of donated tissue for HCV by both antibody and NAT (1). The 

donor’s HCV antibody tested negative on both organ and tissue 

donor screening, but misreading of the reaction wells on testing 

led to an incorrectly reported negative HCV NAT result. Once 

this error was identified, repeat NAT was performed at the tissue 

bank and confirmed that the donor was HCV-positive at the time 

of donation. During the donor’s final hospital stay in March, he 

received six units of blood products. Pretransfusion serum from 

the donor was not available for analysis. Testing of posttransfusion 

stored serum at CDC on October 28 confirmed by NAT that 

the donor was HCV-positive with genotype 1a and a viral load 

of >69,000,000 IU/mL. Blood traceback investigation of the six 

associated blood donors to the infected donor is ongoing, and all 

remaining units from these donations have been quarantined. 

Organ Transplant Investigation 

In March 2011, three organs (two kidneys and the liver) 

from the donor were transplanted into three recipients at a 

local hospital in Kentucky (Figure). Both kidney recipients had 

Transmission of Hepatitis C Virus Through Transplanted Organs and Tissue — 

Kentucky and Massachusetts, 2011 

INSIDE

1701 Food Safety Epidemiology Capacity in State Health 

Departments — United States, 2010 

1705 Recommendations on the Use of Quadrivalent 

Human Papillomavirus Vaccine in Males — Advisory 

Committee on Immunization Practices (ACIP), 2011 

1709 Use of Hepatitis B Vaccination for Adults with 

Diabetes Mellitus: Recommendations of the Advisory 

Committee on Immunization Practices (ACIP) 

1712 QuickStats
Morbidity and Mortality Weekly Report

1698 MMWR / December 23, 2011 / Vol. 60 / No. 50

The MMWR series 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

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James W. Stephens, PhD, Director, Office of Science Quality

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Stephanie Zaza, MD, MPH, Director, Epidemiology and Analysis Program Office

MMWR Editorial and Production Staff

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Visual Information Specialists

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Information Technology Specialists

MMWR Editorial Board

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Virginia A. Caine, MD, Indianapolis, IN

Matthew L. Boulton, MD, MPH, Ann Arbor, MI

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

Timothy F. Jones, MD, Nashville, TN

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

tested negative for hepatitis C before transplant, whereas the 

liver recipient had a previous diagnosis of hepatitis C. 

First kidney recipient. On July 26, 2011, the recipient of the 

first kidney, a man aged 41 years, was noted to have elevated liver 

enzymes (aspartate aminotransferase [AST]: 161 U/L; alanine 

aminotransaminase [ALT]: 217 U/L). HCV antibody testing 

conducted August 22 was negative. Liver function tests continued to be elevated, and HCV NAT performed September 19 

was positive. 

Second kidney recipient. The recipient of the second kidney, 

a woman aged 46 years, was noted to have elevated liver function 

tests on August 25 (AST: 206 U/L, ALT: 221 U/L); HCV NAT 

was positive September 21. 

Liver recipient. The liver recipient, a man aged 51 years, 

had a history of chronic infection with HCV, genotype 1a, 

before transplant. Liver function testing on September 7 was 

unchanged from his baseline (AST: 46 U/L, ALT: 55 U/L). 

At CDC, serum specimens were tested for HCV RNA. 

Serum collected after organ transplantation from all three 

recipients tested positive for HCV by NAT at CDC, and all 

three HCV strains were confirmed to be genotype 1a. 

Tissue Transplant Investigation 

On September 29, the organ procurement organization 

notified the tissue bank of the apparent HCV transmission 

to the kidney and liver recipients. The tissue bank informed 

health-care facilities, and a voluntary recall was begun on 

September 30. The tissue bank had distributed 43 musculoskeletal grafts and one cardiopulmonary patch to health-care 

facilities, but names and contact information for surgeons 

who implanted these tissues were not uniformly available at 

the time of recall. CDC telephone notification of all surgeons 

and requests for testing of all patients was completed on 

October 27. 

The cardiopulmonary patch, the only nonmusculoskeletal 

tissue distributed, had been treated with antibiotics by the 

tissue bank according to protocol and was implanted by a 

health-care facility in Massachusetts on September 26. After the 

health-care facility was notified, the recipient underwent testing. Hepatitis C antibody was negative, but NAT was positive 

at 82,000 IU/mL; the recipient’s ALT was normal (12 U/L). 

The 43 distributed musculoskeletal grafts were treated chemically and by irradiation at the tissue bank, according to protocol. Fifteen of the musculoskeletal tissues were implanted; the 

remaining 28 were returned to the tissue bank. The 15 recipients 

of musculoskeletal tissues were recommended to receive HCV 

serologic testing and NAT immediately and again 6 months 

from the time of tissue implantation. As of December 16, initial 

test results from 14 of the musculoskeletal tissue recipients were 

known, and all were negative based on HCV NAT. 

Molecular Characterization of HCV Strains 

To determine the genetic relatedness among the HCV strains 

obtained from the donor, the two kidney recipients, the liver 
Morbidity and Mortality Weekly Report

MMWR / December 23, 2011 / Vol. 60 / No. 50 1699

recipient, and the cardiopulmonary patch recipient, maximum 

likelihood phylogenetic trees were created (2). These analyses 

showed that two specimens from the donor and the three specimens from the kidney recipients and cardiopulmonary patch 

recipient shared identical NS5b sequences; the liver recipient 

did not share these sequences, indicating previous infection. 

Quasispecies analysis was performed on the specimens that 

shared identical NS5b sequences (3). The E1-HVR1 quasispecies sequences from the donor, the two kidney recipients, 

and the cardiopulmonary patch recipient clustered in a single 

group, indicating their close genetic relatedness consistent with 

a common source of HCV transmission. The donor and the 

two kidney recipients and one cardiopulmonary patch recipient 

had from two to 10 distinct E1-HVR1 sequences that shared 

from 99.7% to 100% similarity with each other. 

Reported by 

Michael R. Marvin, MD, Melissa Steele, Univ of Louisville/Jewish 

Hospital; Sharon K. Green, Magoffin County Health Dept, 

Kentucky; Doug Thoroughman, PhD, Tennis J. Sugg, MPH, Kraig 

E. Humbaugh, MD, Kentucky Dept for Public Health. Louise E. 

Vaz, MD, Sandra K Burchett, MD, Kristin Moffitt, MD, 

Children’s Hospital, Boston, Massachusetts. Carrie F. Nielsen, 

PhD, Scott D. Holmberg, MD, Jan Drobeniuc, MD, Yury 

Khudyakov, PhD, Div of Viral Hepatitis, National Center for 

HIV/AIDS, Viral Hepatitis, STD, and TB; Matthew J. 

Kuehnert, MD, Susan N. Hocevar, MD, Div of Healthcare 

Quality Promotion, National Center for Emerging and Zoonotic 

Infectious Diseases; Reena Mahajan, MD, EIS officer, CDC. 

Corresponding contributor: Reena Mahajan, rmahajan@cdc.gov, 

404-718-8563. 

Editorial Note 

The transmission of HCV associated with transplanted 

organs and minimally processed tissue has been described 

previously, but this is the first recognized HCV transmission 

via a cardiopulmonary patch (4). Although correct reading 

of tissue donor NAT screening results would have prevented 

transmission through the tissue patch, the organ recipients still 

would have become infected because current OPTN policies 

for organ donor screening only require HCV serologic testing 

(1). Furthermore, positive organ donor NAT screening likely 

would have resulted in quarantine of potentially infected tissue. 

Use of NAT, in addition to anti-HCV serologic testing, has 

been proposed to decrease the risk for transmitting undetected 

HCV infection. However, no one test can uniformly detect all 

infections, either because of false-negative tests resulting from 

the window period, or assay-related issues, or, as described in 

this report, because of human error.

Kentucky donor test results: negative for HCV 

antibody by OPO testing and negative for 

HCV NAT by tissue bank testing

Transplant center reports 

positive HCV in kidney 

recipients to OPO

OPO reports events to UNOS and 

noties tissue bank; UNOS noties CDC

Tissue bank retests 

stored donor specimen 

and conrms donor 

was HCV NAT positive 

CDC conrms donor specimen 

HCV NAT positive; blood bank 

follow-up initiated

March

2011

July

26

Nov

7 Aug Sep Oct

22 25 19 22 26 28 29 30 5 7 27

Liver and two kidneys transplanted 

in Kentucky recipients

Second kidney recipient 

tests positive for HCV NAT 

Second kidney recipient 

has elevated liver enzymes 

Cardiopulmonary patch recipient 

tests HCV NAT positive

First kidney 

recipient has 

elevated liver 

enzymes 

First kidney 

recipient tests 

negative for 

HCV antibody

First kidney 

recipient tests 

positive for 

HCV NAT 

Cardiopulmonary 

patch implanted in 

Massachusetts 

recipient

Tissue bank issues 

recall and notication 

of facilities 

All surgeons 

notied by CDC 

FIGURE. Investigation timeline after initial report of transmission of hepatitis C virus (HCV) from an organ and tissue donor — Kentucky and 

Massachusetts, 2011

Abbreviations: OPO = organ procurement organization; NAT = nucleic acid testing; UNOS = United Network for Organ Sharing.
Morbidity and Mortality Weekly Report 

1700 MMWR / December 23, 2011 / Vol. 60 / No. 50

Without information regarding a donor’s behavioral risk 

factors, the assay selection and sensitivity of pretransplantation 

testing is critical. The incidence of HCV infection not detected 

by serologic screening for anti-HCV antibody varies from 

1 in 5,000 for normal-risk patients to 1 in 1,000 for patients at 

high risk (5). The window period (i.e., the time from exposure 

to detectable HCV antibody) has a mean of 65–70 days; this 

period is shortened to 3–5 days with use of NAT (6). A transplant 

facility’s decision to use an organ is based on the organ procurement organization’s assessment of the donor’s risk status and on 

test results (5). Multiple factors, including the urgent need for 

a potentially life-saving transplant and informed consent of the 

transplant candidate must be considered when determining 

whether benefits of transplantation outweigh the risk for transmitting HCV. The U.S. Public Health Service recently drafted 

guidelines recommending testing of all organ donors with NAT 

for HCV regardless of risk status (7). Even if test results are not 

available at the time of transplantation, results still can be used 

afterward to guide recipient evaluation and treatment. 

The diagnosis of HCV infection in two recipients of kidneys 

from the same donor should raise immediate suspicion of donorderived infection and reporting to OPTN and to local and state 

health departments as required by policy. Reporting to local 

and state health departments also should occur because acute 

HCV infection is a nationally notifiable disease. Reporting of 

suspected new diagnoses in organ recipients, including to tissue 

banks, should occur without delay, because such diagnoses might 

have implications for tissues that have not yet been transplanted. 

The events in this report demonstrate the importance of timely 

communication once a transplant transmission is suspected and 

the difficulty of tracking tissue to the patient or provider level 

should a potential transmission be recognized after tissue has been 

distributed. Although FDA requires that the tissue bank track the 

distribution of tissues down to the institutional level, no government 

regulations require tracking tissue to the patient level; hospitals are 

asked voluntarily to return a record, often a postcard, to the tissue 

bank to notify them of implantation of the tissue. Many health-care 

facilities have a mechanism to track tissue to the patient, although 

approaches are not standardized (8). Systems that facilitate real-time 

notification of possible disease transmission to tissue banks, organ 

procurement organizations, and other transplant centers do not 

exist, and development is hindered by the lack of standardized tissue 

nomenclature and identification standards (9,10). 

This investigation reveals several areas in which current detection and notification might be improved to prevent similar future 

transplant transmission events, including: 1) consideration of the 

use of HCV NAT for organ donors; 2) use of algorithms or other 

procedures to ensure accurate reading of test results and reduce 

human error; and 3) timely feedback of possible disease transmission in organ or tissue recipients to organ procurement organizations, tissue banks, public health authorities, and regulators. 

References 

1. Health Resources and Services Administration. Minimum procurement 

standards for an Organ Procurement Organization (OPO). Rockville, 

MD: Health Resources and Services Administration; 2011. Available at 

http://optn.transplant.hrsa.gov/policiesandbylaws2/policies/pdfs/

policy_2.pdf. Accessed December 19, 2011. 

2. Felsentein J. Evolutionary trees from DNA sequences: a maximum 

likelihood approach. J Mol Evol 1981;17:368–76. 

3. Ramachandran S, Xia GL, Ganova-Raeva LM, Nainan OV, Khudyakov Y. 

End-point limiting-dilution real-time PCR assay for evaluation of 

hepatitis C virus quasispecies in serum: performance under optimal and 

suboptimal conditions. J Virol Methods 2008;151:217–24. 

4. Tugwell BD, Patel PR, Williams IT, et al. Transmission of hepatitis C 

virus to several organ and tissue recipients from an antibody-negative 

donor. Ann Intern Med 2005;143:648–54. 

5. Ellingson K, Seem D, Nowicki M, Strong DM, Kuehnert MJ, Organ 

Procurement Organization Nucleic Acid Testing Yield Project Team. 

Estimated risk of human immunodeficiency virus and hepatitis C virus 

infection among potential organ donors from 17 organ procurement 

organizations in the United States. Am J Transplant 2011;11:1201–8. 

6. Kleinman SH, Lelie N, Busch MP. Infectivity of human immunodeficiency 

virus-1, hepatitis C virus, and hepatitis B virus and risk of transmission 

by transfusion. Transfusion 2009;49:2454–89. 

7. Draft PHS guideline for reducing transmission of human immunodeficiency 

virus (HIV), hepatitis B virus (HBV), and hepatitis C virus (HCV) through 

solid organ transplantation. Available at http://www.regulations.gov. 

Enter: ID = CDC-2011-0011. Accessed December 19, 2011. 

8. Kuehnert MJ, Yorita KL, Holman RC, Strong DM; AABB Tissue Task 

Force. Human tissue oversight in hospitals: an AABB survey. Transfusion 

2007;47:194–200. 

9. Strong DM, Seem D, Taylor G, Parker J, Stewart D, Kuehnert MJ. Development 

of a transplantation transmission sentinel network to improve safety and 

traceability of organ and tissues. Cell Tissue Bank 2010;11:335–43. 

10. Brubaker S, Wilson D. Coding and traceability: cells and tissues in North 

America. Cell Tissue Bank 2010;11:379–89. 

What is already known on this topic? 

Hepatitis C virus (HCV) transmission from antibody-negative organ 

donors has been documented previously; nucleic acid testing 

(NAT) is required for tissue donors but not for organ donors. 

What is added by this report? 

A donor transmitted HCV to two kidney recipients and one 

tissue recipient because of a negative antibody test (a result of 

the window period) and an incorrectly read HCV NAT result. 

Implantation of infected tissue occurred after recognition of the 

infected organ transplant recipients, highlighting the need for 

more rapid methods to recognize and communicate information on suspected transplantation transmission. 

What are the implications for public health practice? 

HCV antibody testing alone might not be adequate to detect 

disease in organ donors with acute infection or in recipients 

who are immunosuppressed. A real-time system for notification 

of disease clusters in transplant recipients is needed to prevent 

further use of tissue that tests positive for HCV or other 

infections. Suspected disease transmission through organ and 

tissue transplantation should be reported by clinicians to 

appropriate oversight organizations and public health authorities without delay. 
Morbidity and Mortality Weekly Report

MMWR / December 23, 2011 / Vol. 60 / No. 50 1701

In 2002, the Council of State and Territorial Epidemiologists 

(CSTE) conducted its first national food safety epidemiology 

capacity assessment (1), which provided the basis for development of minimum performance standards to guide state 

and local foodborne disease control programs. During April 

2010, CSTE sent states a follow-up, web-based questionnaire 

to gather information about food safety–related workforce 

training and education, epidemiology and laboratory capacity, 

and information technology (IT) to support surveillance. This 

report summarizes the results of the assessment, which found 

that in 2010, states reported a need for 304 more full-time 

equivalent (FTE) employees working in food safety to reach 

full program capacity, with the greatest demand for master’s 

degree–level epidemiologists (50% of demand). Barriers to 

investigating foodborne outbreaks reported most often by 

states included delayed notification of the outbreak (reported 

by 41 states), lack of a sufficient number of foodborne safety 

staff members (29 states), lower prioritization of investigations 

(27 states), lack of ability to pay overtime (20 states), and 

lack of adequate epidemiology expertise (12 states). Strategies 

should be developed to increase the number of food safety staff 

members and enhance their training opportunities, address 

gaps in IT, and improve the relationship between state and 

local health departments and federal agencies collaborating 

on responses to foodborne disease outbreaks. 

The main objectives of the food safety epidemiology capacity assessment were to count and characterize the food safety 

workforce in local, regional, and state health departments and 

to measure and evaluate core capacity to detect, investigate, 

and respond to foodborne diseases and outbreaks. After pilot 

testing, CSTE made the assessment available online to all states 

during April 2010. The assessment was sent to the state epidemiologist and the lead foodborne disease epidemiologist in each 

state, with a suggestion for the latter to serve as respondent. All 

50 states participated, but not every state answered all questions. Capacity was defined for participants using a qualitative 

scale,* as validated in previous CSTE assessments (2–4). 

In 2010, a total of 787 FTEs were working as foodborne 

disease epidemiologists in state, regional, and local health 

departments in the United States. Of these, 616.5 (78%) 

had an epidemiology-related degree or had completed some 

coursework in epidemiology; 170.5 (22%) had only on-the-job 

training or no formal epidemiology training (Table). Formal 

education in epidemiology was highest at the state level, 

where most (73%) foodborne disease epidemiologists had an 

epidemiology degree. The proportion of personnel working 

as foodborne epidemiologists who had a nursing degree was 

substantially higher at the local level (19%) than at the regional 

(5%) or state (4%) level. States reported the need for an additional 304 FTEs to reach full program capacity, with the greatest demand (50% of need) for master’s-level epidemiologists. 

The number of respondents with substantial-to-full capacity 

to use electronic laboratory reporting for foodborne diseases by 

laboratory type was highest for public health laboratories and 

lower for other laboratory types (i.e., hospital-based, reference, 

and other clinical). Forty-three states reported using a National 

Electronic Diseases Surveillance System–compliant database for 

maintaining enteric illness cases. Forty-two states reported using 

an electronic database housed at the state health department for 

outbreak investigations; 13 states used an electronic database at 

the local level. All respondents used CDC’s electronic Foodborne 

Outbreak Reporting System and National Outbreak Reporting 

System for reporting. Most states electronically recorded multiple 

variables related to cases of enteric illness, including laboratory 

results (49 states), epidemiologic risk factors (44), clinical symptoms (42), travel history (42), environmental exposures (42), 

food history (35), and food purchasing locales (30), as separate 

elements of their enteric illness case files. 

State capacity for completing tasks related to the investigation of sporadic cases of enteric illness caused by Salmonella and 

Escherichia coli O157 varied. Nearly all (49) states entered case 

data electronically for both pathogens; other tasks were generally 

more likely to be completed for E. coli O157 than for Salmonella, 

including collection of isolates (48 and 46 states, respectively), 

pulsed-field gel electrophoresis analysis (48 and 42), analysis of 

aggregate data (46 and 45), comparison of case classification to 

standard case definition (49 and 44), interview of patients (47 

and 39), and more intensive questionnaire review (42 and 38). 

Although states investigate foodborne disease outbreaks 

caused by numerous pathogens, they were more likely to investigate outbreaks associated with some pathogens than others. 

For specific pathogens, a history of investigating >75% of 

outbreaks was reported by the highest proportion of states for 

E. coli (86% of states), followed by Listeria (81%), Salmonella

(78%), Campylobacter (73%), other foodborne pathogens 

(68%), and norovirus (55%). Conversely, a small but substantial proportion of states reported investigating <25% of 

outbreaks caused by these same pathogens: Campylobacter 

Food Safety Epidemiology Capacity in State Health Departments — 

United States, 2010 

*None means that none of the activity, knowledge, or resources described within 

the question were met; minimal capacity = 1%–24%, partial capacity = 

25%–49%, substantial capacity = 50%–74%, almost full capacity = 75%–99%, 

and full capacity = 100% of the activity, knowledge, or resources described 

within the question were met. 
Morbidity and Mortality Weekly Report 

1702 MMWR / December 23, 2011 / Vol. 60 / No. 50

(16% of states), Listeria (13%), E. coli (10%), norovirus (7%) 

and Salmonella (4%) (Figure 1). 

States were more likely to obtain stool specimens than food 

samples as part of foodborne outbreak investigations. Relatively 

few states reported always collecting either stool specimens 

(five states) or food (one state) samples associated with foodborne disease outbreaks; 33 states collected stool specimens in 

50%–99% of outbreaks, and 36 states collected food samples 

in <50% of outbreaks. Thirty-nine states reported having 

performed 1–10 tracebacks of commercial products during 

the past 3 years; relatively few (seven states) had conducted 

≥11 tracebacks, and three states completed no tracebacks of 

commercial products during that period. 

All respondents reported barriers to investigating foodborne 

or enteric outbreaks. Barriers reported as either moderate 

or substantial by states included delayed notification of the 

outbreak (reported by 41 states), lack of sufficient number of 

foodborne safety staff members (29), lower prioritization of 

investigations (27), lack of ability to pay overtime (20), lack of 

adequate epidemiology expertise (12), difficulties working with 

in-state agencies (eight), constraints related to administrative 

support (eight), and difficulties working with other state or 

federal agencies (five) (Figure 2). 

In 2009, the Council to Improve Foodborne Outbreak 

Response (CIFOR) distributed to all states its Guidelines for 

Foodborne Disease Outbreak Response (5), which was intended to 

improve outbreak response. Among the states, 47 plan to read 

the document, 39 plan to distribute it, and 29 plan to review 

their practices against the recommendations in the Guidelines 

and the performance indicators therein. Few states reported 

plans to implement or incorporate the Guidelines into practice 

in the immediate future (27%). 

TABLE. Level of education or training of food safety epidemiologists, by level of government — United States, 2010*

Level of education/training†

State Region/District Local Total FTEs needed to reach full capacity

No. (%) No. (%) No. (%) No. (%) No. (% increase)

Doctoral degree 14.0 (6) 7.5 (4) 8.5 (2) 30.0 (4) 25.5 (85)

Professional background 25.5 (11) 9.0 (5) 18.0 (5) 52.5 (7) 28.0 (53)

Master’s degree 93.5 (39) 54.0 (32) 60.5 (16) 208.0 (26) 152.5 (73)

Bachelor’s degree 15.5 (6) 11.0 (7) 13.0 (3) 39.5 (5) 26.0 (66)

Nursing degree 29.0 (12) 37.0 (22) 151.0 (40) 217.0 (28) 47.5 (22)

Some coursework 25.0 (10) 11.5 (7) 33.0 (9) 69.5 (9) 14.0 (20)

On-the-job training 23.5 (10) 29.0 (17) 44.0 (12) 96.5 (12) 10.5 (11)

No formal training in epidemiology 14.0 (6) 10.0 (6) 50.0 (13) 74.0 (9) 0.0 —

Total 240.0 (100) 169.0 (100) 378.0 (100) 787.0 (100) 304.0 (38)

Abbreviation: FTE = full-time equivalent employee.

* Based on responses to an April 2010 web-based survey of state health departments by the Council of State and Territorial Epidemiologists.

† Doctoral degree = PhD, DrPH, or other doctoral degree in epidemiology; professional background = MD, DO, DVM, or DDS with a dual degree in epidemiology; 

master’s degree = MPH, MSPH, MS, or other master’s degree in epidemiology; bachelor’s degree = BA, BS, or other bachelor’s degree in epidemiology; nursing 

degree = RN, BSN, or other nursing designation; some coursework = completion of some coursework in epidemiology; on-the-job training = receipt of any type of 

on-the-job training in epidemiology.

45

40

35

30

25

20

15

10

5

0

No. of states

Pathogen

Salmonella Campylobacter Listeria Norovirus Other 

pathogens

Escherichia coli

O157

0%–24%

25%–74%

75%–100%

FIGURE 1. Number of states investigating outbreaks of specific pathogens by proportion 

of outbreaks investigated — United States, 2010

* Based on responses to an April 2010 web-based survey of state health departments by the Council 

of State and Territorial Epidemiologists.

Reported by 

Matthew L. Boulton, MD, Univ of Michigan, 

School of Public Health and School of 

Medicine, Ann Arbor, Michigan. Lauren D. 

Rosenberg, MPA, Council of State and 

Territorial Epidemiologists, Atlanta, Georgia. 

Corresponding contributor: Matthew L. 

B o u l t o n , m b o u l t o n @ u m i c h . e d u , 

734-936-1623. 

Editorial Note 

Ensuring adequate epidemiology capacity 

in foodborne disease programs is essential for 

the timely detection, investigation, control, 

and prevention of foodborne disease outbreaks. Although national foodborne disease 
Morbidity and Mortality Weekly Report

MMWR / December 23, 2011 / Vol. 60 / No. 50 1703

epidemiology and surveillance capacity has increased since the 

previous CSTE assessment (1), critical gaps remain. Levels of 

formal epidemiology education among foodborne disease epidemiologists, especially at the local level, were lower than those 

of the national epidemiology workforce. Foodborne diseases 

personnel at the local level, compared with those at state and 

regional/district levels, were less likely to have an epidemiology 

degree and more likely to have only on-the-job-training or no 

formal training in epidemiology (6,7); previous assessments 

show this to be particularly true of nurses working as epidemiologists (8). States have a substantial need for additional 

FTEs, especially those with a master’s degree in epidemiology, 

to reach full capacity in foodborne diseases program capacity 

at the state, local, and regional/district levels. Many of the 

specific activities assessed in this study directly rely on having 

enough trained or competent personnel on hand to perform 

them (e.g., conducting commercial tracebacks and collection 

of stool and food specimens). Insufficient workforce capacity 

hinders the ability to conduct these activities and, therefore, 

reduces the quality and quantity of foodborne investigations 

carried out by states. 

Widespread use of electronic surveillance systems by states 

has increased the desirability and feasibility of electronic 

laboratory-based reporting and the potential for improving 

the timeliness of infectious disease reporting and response. 

However, improvement and investment in public health IT 

infrastructure is needed to respond adequately to foodborne 

disease outbreaks. Improvements have resulted from several 

years of federal preparedness funding targeting states’ development of electronic surveillance and reporting systems. Despite 

these improvements, many states report that they lack core 

capacity, which has directly affected their ability to investigate and control outbreaks of foodborne diseases and enteric 

illnesses. Data elements considered essential to routine surveillance for foodborne diseases are collected inconsistently across 

states and some, such as food purchasing locale, are collected by 

few. States also lack adequate IT infrastructure, based on their 

reported lack of timely notification as the single most common 

barrier to completion of foodborne disease investigations. 

The findings in this report are subject to at least two limitations. 

First, state-level epidemiologists estimated current epidemiology 

capacity at regional/district and local levels. The methods 

used by responding states to estimate their own capacity were 

subjective and likely varied. Second, not all responding states 

answered every question. However, these findings still provide 

useful insight into foodborne disease epidemiology capacity 

at state and local levels. 

FIGURE 2. Number of states reporting selected barriers to investigation of enteric illness outbreaks during the past 3 years — United States, 2010*

* Based on responses to an April 2010 web-based survey of state health departments by the Council of State and Territorial Epidemiologists.

† Response = 49 states; response to all other barrier questions = 50 states.

Minimal barrier

Not a barrier

Moderate or substantial barrier

45

40

35

30

25

20

15

10

5

0

No. of states

Delayed 

notication

Lack of

adequate 

sta

Low priority/

competing

priorities†

Lack of 

ability to 

pay

overtime†

Lack of

epidemiology

expertise

Diculty of

specimen

transport

Lack of

statistical

support†

Diculty

working with

partners

in-state

Lack of 

laboratory

capacity/

capability

Travel 

policy 

constraints

Diculty 

working

with other

states/federal

partners

Barrier

†
Morbidity and Mortality Weekly Report 

1704 MMWR / December 23, 2011 / Vol. 60 / No. 50

CSTE recommends an increase in the number of personnel 

working in foodborne disease epidemiology and surveillance 

in state and local health departments, and enhanced training opportunities, including use of the CSTE/CDC applied 

epidemiology competencies (6) and the CIFOR Guidelines 

for Foodborne Disease Outbreak Response (5). Increased investment in IT also is needed to realize greater improvements in 

foodborne disease outbreak capacity. 

Acknowledgments 

The 2009–2010 Food Safety Epidemiology Capacity Assessment 

workgroup: Roberta Hammond, Tim Jones, C.P. Kanwat, Bill Keene, 

Bela Matyas, Julie Schlegel, Don Sharp. 

What is already known on this topic? 

Ensuring the safety of the food supply has become a national 

public health priority, and considerable resources at the federal, 

state, and local government levels have been directed at 

improving national food safety capacity. 

What is added by this report? 

Data from this assessment indicate that overall foodborne 

disease epidemiology capacity needs to improve to achieve full 

capacity to detect, investigate, and respond to foodborne 

disease outbreaks. 

What are the implications for public health practice? 

Agencies at the federal, state, and local levels should work 

together to improve capacity through increased staffing levels, 

enhanced training opportunities, and increased investment in 

health information technology. 

References 

1. Council of State and Territorial Epidemiologists. National assessment of 

epidemiologic capacity in food safety programs: findings and 

recommendations, September 2002. Atlanta, GA: Council of State and 

Territorial Epidemiologists; 2002. Available at http://www.cste.org/

pdffiles/fsreportfinal.pdf. Accessed April 28, 2011. 

2. Council of State and Territorial Epidemiologists. 2009 national assessment 

of epidemiology capacity: findings and recommendations, 2009. Atlanta, 

GA: Council of State and Territorial Epidemiologists; 2009. Available at 

http://www.cste.org/2009eca.pdf. Accessed April 27, 2011. 

3. Council of State and Territorial Epidemiologists. 2006 national assessment 

of epidemiologic capacity: findings and recommendations. Atlanta, GA: 

Council of State and Territorial Epidemiologists; 2006. Available at http://

www.cste.org/pdffiles/2007/2006csteecafinalfulldocument.pdf. Accessed 

April 27, 2011. 

4. Council of State and Territorial Epidemiologists. 2004 national assessment 

of epidemiologic capacity: findings and recommendations. Atlanta, GA: 

Council of State and Territorial Epidemiologists; 2004. Available at http://

www.cste.org/dnn/LinkClick.aspx?fileticket=AY1F5brMfy0%3d&tabid

=175&mid=716. Accessed April 27, 2011. 

5. Council to Improve Foodborne Outbreak Response (CIFOR). Guidelines 

for foodborne disease outbreak response. Atlanta, GA: Council of State 

and Territorial Epidemiologists; 2009. Available at http://www.cste.org/

dnn/programsandactivities/infectiousdiseases/cifortoolkitandguidelines/

tabid/207/default.aspx.Accessed December 16, 2011. 

6. Council of State and Territorial Epidemiologists. CDC/CSTE 

Competencies for applied epidemiologists in governmental public health 

agencies, 2008. Atlanta, GA: Council of State and Territorial 

Epidemiologists; 2008. Available at http://www.cste.org/dnn/

programsandactivities/workforcedevelopment/competencies/tabid/174/

default.aspx. Accessed October 13, 2011. 

7. Boulton ML, Lemmings J, Beck AJ. Assessment of epidemiology capacity 

in state health departments, 2001–2006. J Public Health Manag Pract 

2009;15:328–36. 

8. Boulton ML, Hadler J, Beck AJ, Ferland L, Lichtveld M. Assessment of 

epidemiology capacity in state health departments, 2004–2009, Public 

Health Rep 2011;126:84–93. 

9. Council of State and Territorial Epidemiologists. 2010 food safety 

epidemiology capacity assessment. Atlanta, GA: Council of State and 

Territorial Epidemiologists; 2010. Available at http://www.cste.org/

webpdfs/fseca.pdf. Accessed April 27, 2011. 
Morbidity and Mortality Weekly Report

MMWR / December 23, 2011 / Vol. 60 / No. 50 1705

Recommendations on the Use of Quadrivalent Human Papillomavirus Vaccine 

in Males — Advisory Committee on Immunization Practices (ACIP), 2011 

On October 25, 2011, the Advisory Committee on Immunization 

Practices (ACIP) recommended routine use of quadrivalent 

human papillomavirus (HPV) vaccine (HPV4; Gardasil, Merck 

& Co. Inc.) in males aged 11 or 12 years. ACIP also recommended vaccination with HPV4 for males aged 13 through 

21 years who have not been vaccinated previously or who 

have not completed the 3-dose series; males aged 22 through 

26 years may be vaccinated. These recommendations replace 

the October 2009 ACIP guidance that HPV4 may be given to 

males aged 9 through 26 years (1). For these recommendations, 

ACIP considered information on vaccine efficacy (including 

data available since October 2009, on prevention of grade 2 

or 3 anal intraepithelial neoplasia [AIN2/3], a precursor of 

anal cancer), vaccine safety, estimates of disease and cancer 

resulting from HPV, cost-effectiveness, and programmatic considerations. The evidence for HPV4 vaccination of males was 

evaluated using Grading of Recommendations, Assessment, 

Development, and Evaluation (GRADE) methods (2). 

Background of HPV Vaccination Program in the 

United States 

HPV4 is directed against HPV types 6, 11, 16, and 18, and 

was licensed by the Food and Drug Administration (FDA) for 

use in females in June 2006. Bivalent HPV vaccine (HPV2; 

Cervarix, GlaxoSmithKline) is directed against HPV 16 and 

18, and was licensed for use in females in October 2009. 

ACIP recommends either vaccine for routine use in females 

aged 11 or 12 years (3). In 2009, HPV4 was licensed for use 

in males for prevention of genital warts; in December 2010, 

FDA added prevention of anal cancer in males and females as 

an indication for use (4). Since 2006, HPV vaccine coverage in 

females has increased but remains low. In 2010, coverage with 

at least 1 dose among females aged 13 through 17 years was 

48.7%, and 3-dose coverage was 32.0% (5). Coverage with at 

least 1 dose among males aged 13 through 17 years was <2%. 

Burden of Disease and Cancer in Males 

HPV-associated cancers in males include some anal, penile, 

and oropharyngeal cancers caused primarily by HPV 16 (6–9). 

An estimated 22,000 HPV 16- and 18-associated cancers occur 

annually in the United States, including an estimated 7,000 

HPV 16- and 18-associated cancers in males (9). Data from 

U.S. cancer registries have shown increases in the incidence 

of oropharyngeal and anal cancers in men (8,9); an evaluation 

of data from 1973–2007 found increases of 1% per year for 

oropharyngeal cancers and 3% per year for anal cancers (9). 

Nononcogenic HPV types, primarily 6 and 11, cause >90% 

of genital warts (condylomata) and most cases of recurrent 

respiratory papillomatosis. Approximately 250,000 cases of 

genital warts occur each year in the United States among sexually active males (10,11). 

Efficacy 

In a phase III efficacy trial, HPV4 had high efficacy for prevention of genital warts among 4,055 males aged 16 through 

26 years. Exclusion criteria included history of genital warts, 

history of genital lesions possibly HPV-related, and less than 

one or more than five lifetime sex partners. Among those who 

received all 3 vaccine doses and were seronegative at day 1 

and DNA-negative day 1 through month 7 to the respective 

HPV type (per protocol population), efficacy for prevention 

of HPV 6-, 11-, 16-, and 18-related genital warts was 89.3% 

(95% confidence interval [CI] = 65.3%–97.9%); efficacy for 

HPV 6- and 11-related genital warts was similar. Efficacy for 

prevention of HPV 6-, 11-, 16- and 18-related genital warts 

among males who received at least 1 vaccine dose, regardless 

of baseline infection or serology (intent to treat population), 

was 68.1% (CI = 48.8%–80.7%) (4). No efficacy was observed 

among males who were infected with the respective HPV 

type at baseline. Although grade 1, 2, and 3 penile/perineal/

perianal intraepithelial neoplasias were evaluated, too few were 

observed, and efficacy was not demonstrated (4). 

A substudy of the phase III efficacy trial included 598 

men who have sex with men (MSM), aged 16 through 26 

years; outcomes were genital warts; AIN grades 1, 2, or 3 

(AIN1/2/3); and AIN2/3. Per protocol efficacy for prevention of HPV 6-, 11-, 16-, and 18-related genital warts was 

88.1% (CI = 13.9%–99.7%) (Carlos Sattler, MD, Merck, 

personal communication, August 2011). Per protocol efficacy 

for prevention of HPV 6-, 11-, 16-, 18- related AIN1/2/3 

was 77.5% (CI = 39.6%–93.3%), and against AIN2/3 was 

74.9% (CI = 8.8%–95.4%) (Table) (4). In the intent to treat 

population, efficacy for prevention of HPV 6-, 11-, 16-, 

and 18-related AIN1/2/3 was 50.3% (CI = 25.7%–67.2%), 

and prevention of HPV 6-, 11-, 16-, and 18-related AIN2/3 

was 54.2% (CI = 18.0%–75.3%) (4). In the intent to treat 

population, efficacy for prevention of any HPV type-related 

AIN2/3 was 24.3% (CI = -13.8%–50.0%) (4). No studies have 

evaluated the efficacy of HPV4 for prevention of recurrent 

respiratory papillomatosis or oropharyngeal cancer. 

The efficacy of HPV4 for prevention of HPV-related precancerous lesions and disease is supported further by studies 
Morbidity and Mortality Weekly Report 

1706 MMWR / December 23, 2011 / Vol. 60 / No. 50

among females. In three trials, HPV4 had high efficacy (>98%) 

for prevention of HPV 6-, 11-, 16-, and 18-related grade 2 or 3 

cervical intraepithelial neoplasia (CIN2/3) or adenocarcinoma 

in situ (AIS), grade 2 or 3 vulvar intraepithelial neoplasia 

(VIN2/3), and grade 2 or 3 vaginal intraepithelial neoplasia 

(VaIN2/3) (12). 

Immunogenicity 

Data on immunogenicity in males are available from the 

phase III trial conducted among males aged 16 through 

26 years and from bridging immunogenicity studies conducted 

among males aged 9 through 15 years (4). Seroconversion was 

high for all four HPV vaccine types and postvaccination antibody titers were significantly higher in males aged 9 through 

15 years compared with males aged 16 through 26 years (4). 

Data from a follow-up study of 500 boys who were in an 

immunogenicity study showed no cases of persistent infection or disease related to any of the four HPV vaccine types 

during 6 years of follow-up (13). The high efficacy found in 

the clinical trials in females and males to date has not allowed 

identification of a minimum protective antibody titer. 

Safety 

Clinical trial data in approximately 5,300 males found that 

the most common adverse events were mild or moderate, and 

were most commonly injection-site reactions (4). Headache 

and fever were the most commonly reported systemic adverse 

events in vaccine recipients and controls (4). Since licensure, 

at least 40 million doses of HPV4 have been distributed in the 

United States through September 2011. National postlicensure 

safety data indicate that HPV4 adverse events were similar to 

those from prelicensure trials (14). Postlicensure safety data 

from the Vaccine Safety Datalink study, including data from 

>600,000 HPV4 doses administered, showed no statistically 

significant increased risk for the outcomes studied, including 

Guillain-Barré syndrome, stroke, venous thromboembolism, 

appendicitis, seizures, syncope, allergic reactions, and anaphylaxis (15). Postlicensure safety data from a manufacturersponsored study found no increased risk for outcomes such as 

anaphylaxis and venous thromboembolism; however, persons 

who were vaccinated with HPV4 were more likely to faint on 

the day they were vaccinated than another period in which 

vaccine was not administered (16). ACIP recommends that 

vaccination providers should consider observing patients for 

15 minutes after all vaccinations, including HPV vaccination. 

Cost-Effectiveness 

The cost-effectiveness* of male vaccination is sensitive to a 

range of assumptions, such as vaccine efficacy, vaccine coverage of females, the range of health outcomes included, and the 

effect of HPV-associated diseases on quality of life (17–20). 

Adding male vaccination to female-only vaccination becomes 

more cost-effective when all HPV-associated health outcomes 

are included in the model and vaccine coverage of females is 

low (e.g., 3-dose vaccine coverage <50% by age 12 years). 

Adding male vaccination to female-only vaccination becomes 

less cost-effective when considering scenarios such as only 

the health outcomes for which evidence of vaccine efficacy is 

available, when vaccine coverage of females is high (such as 

3-dose vaccine coverage >70% by age 12 years), if vaccinated 

males have mostly vaccinated sex partners, and when male 

vaccination is compared with a strategy of increased vaccine 

coverage of females (20). At the current vaccine price, adding 

male vaccination at age 12 years to a female-only vaccination 

TABLE. Efficacy of quadrivalent HPV vaccine for prevention of HPV 6-, 11-, 16-, and 18-related genital warts, AIN1/2/3, or AIN 2/3, per protocol,* 

in males aged 16 through 26 years†

Condition

Control Vaccine Vaccine efficacy

No. Cases No. Cases % (95% CI)

Genital warts 1,404 28 1,394 3 89.3 (65.3–97.9)

AIN1/2/3§ 208 24 194 5 77.5 (39.6–93.3)

AIN2/3§ 208 13 194 3 74.9 (8.8–95.4)

Abbreviations: HPV = human papillomavirus; AIN = anal intraepithelial neoplasia; CI = confidence interval.

Source: Food and Drug Administration. Highlights of prescribing information. Gardasil (human papillomavirus quadrivalent [types 6, 11, 16 and 18]). Available at 

http://www.fda.gov/downloads/biologicsbloodvaccines/vaccines/approvedproducts/ucm111263.pdf.

* Per protocol population included males who received all 3 vaccine doses, were seronegative at day 1 and DNA negative at day 1 through month 7 to the respective 

HPV type, with case counting beginning after month 7. 

† Participants were enrolled from North America, South America, Europe, Australia, and Asia; median duration of follow-up was 2.3 years for the study in all males and 

2.6 years for the study in men who have sex with men (MSM).

§ Efficacy for AIN studied in MSM.

*By charter, when considering recommendations for use of a vaccine, ACIP 

members’ deliberations should include consideration of vaccine efficacy, as well 

as cost-benefit and risk-benefit analyses. No predefined threshold for costeffectiveness is considered. To ensure that economic data presented to ACIP 

and its working groups are uniform in presentation, understandable, and of 

the highest quality, lead economists and the Health Economics Research Group 

at CDC developed Guidance for Health Economics Studies Presented to the ACIP, 

available at http://www.cdc.gov/vaccines/recs/acip/economic-studies.htm. The 

guidance specifically mandates technical review of any economic study that is 

presented to ACIP. 
Morbidity and Mortality Weekly Report

MMWR / December 23, 2011 / Vol. 60 / No. 50 1707

strategy would cost approximately $20,000–$40,000 per 

quality-adjusted life year (QALY) in the more favorable 

scenarios and approximately $75,000 to >$250,000 per QALY 

in less favorable scenarios (18–20). Vaccination of adult males 

becomes less cost-effective as age at vaccination increases, and 

models suggest the cost per QALY gained by vaccinating males 

>21 years would be approximately 2–4 times that of vaccinating males aged <18 years (21). 

Special Populations 

MSM are at higher risk for conditions associated with HPV 

types 6, 11, 16, and 18 than are heterosexual men; diseases 

and cancers that have a higher incidence among MSM include 

AIN, anal cancers, and genital warts (22,23). HPV4 clinical 

trial data demonstrated high efficacy for prevention of genital 

warts, AIN1/2/3, and AIN2/3 (4). HPV4 is not licensed for 

males aged >26 years, and no information is available on the 

efficacy for prevention of outcomes in MSM aged >26 years. 

A cost-effectiveness analysis estimated <$50,000 per QALY 

for vaccination of MSM through age 26 years, using various 

assumptions (24). 

Persons infected with the human immunodeficiency virus 

(HIV) also have a high burden of HPV-associated outcomes. 

Genital warts are more common and more difficult to treat in 

HIV-infected persons (25). AIN and anal cancer are common 

in HIV-infected MSM, and data suggest that effective antiretroviral therapy has not reduced the burden of anal cancer (26). 

One small trial in HIV-infected boys and girls found HPV4 to 

be safe and immunogenic (27), as did a study in HIV-infected 

men (28). Antibody titers to vaccine types 6 and 18 were lower 

in HIV-infected children than those observed in age-matched 

HIV-uninfected children; the clinical significance of this is 

not known (27). Ongoing studies will evaluate the efficacy 

and duration of immune response in HIV-infected persons. 

GRADE 

Data on HPV4 for males were reviewed according to 

GRADE methods (2). Factors considered in determining the 

recommendation included benefits and harms, evidence type, 

values and preferences, and health economic analysis.†

Rationale 

Although the largest number of HPV-associated cancers 

occur in women (approximately 15,000 HPV 16- and 

18-associated cancers each year), an estimated 7,000 HPV 

16- and 18-associated cancers occur each year in men in the 

United States. These include anal, oropharyngeal, and penile 

cancers. HPV4 has high efficacy for prevention of genital warts, 

AIN1/2/3, and AIN2/3 in males. HPV4 also has high efficacy 

for prevention of genital warts, CIN1/2/3 or AIS, CIN2/3, 

VIN2/3, and VaIN2/3 in females. Although data show HPV4 

prevents various outcomes, no data are available on the efficacy 

for prevention of oropharyngeal or penile cancers. Vaccination 

of males would provide direct benefits and likely would reduce 

HPV 6, 11, 16, and 18 transmission, and resulting infection, 

disease, and cancers in females (through herd immunity). 

However, no clinical efficacy data demonstrating that HPV4 

prevents HPV transmission are available. 

Because HPV4 is prophylactic, it would be most effective 

when given before exposure to HPV through sexual contact. 

The recommendation for vaccination at ages 11 or 12 years 

is supported by data from the efficacy trial, demonstrating 

highest efficacy in males who had no evidence of previous or 

current HPV vaccine type infection, data on sexual behavior 

in the United States, and immunogenicity studies showing higher antibody titers after vaccination of males at ages 

9 through 15 years compared with those aged 16 through 

26 years. Other vaccines are recommended at age 11 or 12 

years, including HPV vaccine for females. The population level 

benefits decrease with increasing age at vaccination, especially 

after age 21 years. 

Recommendations 

ACIP recommends routine vaccination of males aged 11 or 

12 years with HPV4 administered as a 3-dose series (recommendation category: A, evidence type: 2§). The vaccination 

series can be started beginning at age 9 years. Vaccination with 

HPV4 is recommended for males aged 13 through 21 years who 

have not been vaccinated previously or who have not completed 

the 3-dose series. Males aged 22 through 26 years may be vaccinated. Recommendations for administration and precautions 

are unchanged from previous recommendations (1).

Recommendations for Special Populations 

HPV4 is not a live vaccine and can be administered to 

persons who are immunocompromised as a result of infection (including HIV), disease, or medications. The immune 

response and vaccine efficacy might be less than that in immunocompetent persons. For immunocompromised males, ACIP 

recommends routine vaccination with HPV4 as for all males, 

and vaccination through age 26 years for those who have not 

been vaccinated previously or who have not completed the 

3-dose series. 

†Additional information is available at http://www.cdc.gov/vaccines/recs/acip/

grade/table-refs.htm. 

§Recommendation category A: recommendation that applies to all persons in an 

age or risk-based group. Evidence type 2: randomized controlled trials with 

important limitations or exceptionally strong evidence from observational studies. 
Morbidity and Mortality Weekly Report 

1708 MMWR / December 23, 2011 / Vol. 60 / No. 50

MSM are at higher risk for infection with HPV types 6, 11, 

16, and 18 and associated conditions, including genital warts 

and anal cancer. For MSM, ACIP recommends routine vaccination with HPV4 as for all males, and vaccination through 

age 26 years for those who have not been vaccinated previously 

or who have not completed the 3-dose series. 

Reported by 

Eileen F. Dunne, MD, Lauri E. Markowitz, MD, Harrell 

Chesson, PhD, Div of STD Prevention, National Center for HIV/

AIDS, Viral Hepatitis, STD and TB Prevention; C. Robinette 

Curtis, MD, Immunization Svcs Div, National Center for 

Immunizations and Respiratory Diseases; Mona Saraiya, MD, 

Div of Cancer Prevention and Control, National Center for 

Chronic Disease Prevention and Health Promotion; Julianne Gee, 

MPH, Div of Healthcare Quality Promotion, Elizabeth R. Unger, 

PhD, MD, Div of High-Consequence Pathogens and Pathology, 

National Center for Emerging and Zoonotic Infectious 

Diseases, CDC. Corresponding contributor: Eileen F. Dunne, 

edunne@cdc.gov, 404-639-6184. 

References 

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Committee on Immunization Practices (ACIP). MMWR 

2010;59:630–2. 

2. Ahmed F, Temte JL, Campos-Outcalt D, Schünemann HJ; ACIP 

Evidence Based Recommendations Work Group (EBRWG). Methods 

for developing evidence-based recommendations by the Advisory 

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Disease Control and Prevention (CDC). Vaccine 2011;29:9171–6. 

3. CDC. FDA licensure of bivalent human papillomavirus vaccine (HPV2, 

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recommendations from the Advisory Committee on Immunization 

Practices (ACIP). MMWR 2010;59:626–9. 

4. Food and Drug Administration. Highlights of prescribing information. 

Gardasil (human papillomavirus quadrivalent [types 6, 11, 16 and 18]). 

Silver Spring, MD: Food and Drug Administration; 2011. Available at 

http://www.fda.gov/downloads/biologicsbloodvaccines/vaccines/

approvedproducts/ucm111263.pdf. Accessed December 13, 2011. 

5. CDC. National and state vaccination coverage among adolescents aged 

13 through 17 years—United States, 2010. MMWR 2011;60:1117–23. 

6. Joseph DA, Miller JW, Wu X, et al. Understanding the burden of human 

papillomavirus-associated anal cancers in the U.S. Cancer 2008;113(10 

Suppl):2892–900. 

7. Gillison ML, Chaturvedi AK, Lowy DR. HPV Prophylactic vaccines 

and the potential prevention of noncervical cancers in both men and 

women. Cancer 2008;113(10 Suppl):3036–46. 

8. Chaturvedi AK, Engels EA, Pfeiffer RM, et al. Human papillomavirus 

and rising oropharyngeal cancer incidence in the United States. J Clin 

Oncol 2011;29:4294–301. 

9. Saraiya M. Burden of HPV-associated cancers in the United States. 

Presentation before the Advisory Committee on Immunization Practices 

(ACIP), February 24, 2011. Atlanta, GA: US Department of Health 

and Human Services, CDC; 2011. Available at http://www.cdc.gov/

vaccines/recs/acip/downloads/mtg-slides-feb11/11-2-hpv-rela-cancer.

pdf. Accessed November 21 2011. 

10. Hu D, Goldie S. The economic burden of noncervical human 

papillomavirus disease in the United States. Am J Obstet Gynecol 

2008;198:500–7. 

11. Hoy T, Singhal PK, Willey VJ, Insinga RP. Assessing incidence and 

economic burden of genital warts with data from a US commercially 

insured population. Curr Med Res Opin 2009;25:2343–51. 

12. Kjaer SK, Sigurdsson K, Iversen OE, et al. A pooled analysis of continued 

prophylactic efficacy of quadrivalent human papillomavirus (types 

6/11/16/18) vaccine against high-grade cervical and external genital 

lesions. Cancer Prev Res (Phila) 2009;2:868–78. 

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Clinical Workshop, September 17–22, 2011, Berlin, Germany. 

14. Slade BA, Leidel L, Vellozzi C, et al. Postlicensure safety surveillance for 

quadrivalent human papillomavirus recombinant vaccine. JAMA 

2009;302:750–7. 

15. Gee J, Naleway A, Shui I, et al. Monitoring the safety of quadrivalent 

human papillomavirus vaccine: Findings from the Vaccine Safety 

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16. Velicer C. Post-licensure safety study of quadrivalent human 

papillomavirus vaccine among 189,629 females. Atlanta, GA: US 

Department of Health and Human Services, CDC; 2011. Presentation 

before the Advisory Committee on Immunization Practices (ACIP), 

October 25, 2011. Available at http://www.cdc.gov/VACCINes/recs/

acip/downloads/mtg-slides-oct11/03-HPV-CVelicer.pdf. Accessed 

November 21, 2011. 

17. Brisson M, Van de Velde N, Boily MC. Economic evaluation of human 

papillomavirus vaccination in developed countries. Public Health 

Genomics 2009;12:343–51. 

18. Kim JJ, Goldie SJ. Cost effectiveness analysis of including boys in a 

human papillomavirus vaccination programme in the United States. 

BMJ 2009;339:b3884. 

19. Elbasha EH, Dasbach EJ. Impact of vaccinating boys and men against 

HPV in the United States. Vaccine 2010;28:6858–67. 

20. Chesson HW, Ekwueme DU, Saraiya M, Dunne EF, Markowitz LE. 

The cost-effectiveness of male HPV vaccination in the United States. 

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21. Chesson HW. HPV vaccine cost-effectiveness: updates and review. 

Presentation before the Advisory Committee on Immunization Practices 

(ACIP), June 22, 2011. Atlanta, GA: US Department of Health and 

Human Services, CDC; 2011. Available at http://www.cdc.gov/vaccines/

recs/acip/downloads/mtg-slides-jun11/07-5-hpv-cost-effect.pdf. 

Accessed December 15, 2011. 

22. Jin F, Prestage GP, Kippax SC, et al. Risk factors for genital and anal 

warts in a prospective cohort of HIV-negative homosexual men: the 

HIM study. Sex Transm Dis 2007;34:488–93. 

23. Chin-Hong PV, Palefsky JM. Natural history and clinical management 

of anal human papillomavirus disease in men and women infected with 

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24. Kim JJ. Targeted human papillomavirus vaccination of men who have 

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25. CDC. Sexually transmitted diseases treatment guidelines, 2010. MMWR 

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26. Simard EP, Pfeiffer RM, Engels EA. Spectrum of cancer risk late after 

AIDS onset in the United States. Arch Intern Med 2010;170:

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27. Levin MJ, Moscicki AB, Song LY, et al; IMPAACT P1047 Protocol 

Team. Safety and immunogenicity of a quadrivalent human 

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Morbidity and Mortality Weekly Report

MMWR / December 23, 2011 / Vol. 60 / No. 50 1709

Hepatitis B virus (HBV) causes acute and chronic infection of the 

liver leading to substantial morbidity and mortality. In the United 

States, since 1996, a total of 29 outbreaks of HBV infection in 

one or multiple long-term–care (LTC) facilities, including nursing 

homes and assisted-living facilities, were reported to CDC; of these, 

25 involved adults with diabetes receiving assisted blood glucose 

monitoring (1; CDC, unpublished data, 2011). These outbreaks 

prompted the Hepatitis Vaccines Work Group of the Advisory 

Committee on Immunization Practices (ACIP) to evaluate the 

risk for HBV infection among all adults with diagnosed diabetes. 

The Work Group reviewed HBV infection–related morbidity 

and mortality and the effectiveness of implementing infection 

prevention and control measures. The strength of scientific evidence regarding protection was evaluated using the Grading of 

Recommendations, Assessment, Development, and Evaluation 

(GRADE) methodology,* and safety, values, and cost-effectiveness 

were incorporated into a recommendation using the GRADE 

system. Based on the Work Group findings, on October 25, 2011, 

ACIP recommended that all previously unvaccinated adults aged 

19 through 59 years with diabetes mellitus (type 1 and type 2) be 

vaccinated against hepatitis B as soon as possible after a diagnosis of 

diabetes is made (recommendation category A). Data on the risk for 

hepatitis B among adults aged ≥60 years are less robust. Therefore, 

ACIP recommended that unvaccinated adults aged ≥60 years with 

diabetes may be vaccinated at the discretion of the treating clinician 

after assessing their risk and the likelihood of an adequate immune 

response to vaccination (recommendation category B). This report 

summarizes these recommendations and provides the rationale 

used by ACIP to inform their decision making. 

Risk for HBV Infection 

An estimate of the risk for HBV infection for adults with 

diabetes living in LTC facilities was not available; continuing 

outbreaks suggest that it might be substantial. The population 

risk for HBV infection among adults with diagnosed diabetes was estimated from 865 confirmed cases of acute HBV 

infection reported during 2009–2010 from eight Emerging 

Infections Program (EIP) sites constituting approximately 

17% of the U.S. population. The analysis was restricted to 

persons aged ≥23 years because of high rates of vaccination 

among younger persons. In multivariate analyses that considered persons without hepatitis B–related risk behaviors (i.e., 

injection-drug use, male sex with a male, and sex with multiple 

partners), persons aged 23 through 59 years with diabetes had 

2.1 (95% confidence interval [CI] = 1.6–2.8) times the odds 

of developing acute hepatitis B as those without diabetes; 

the odds were 1.5 (CI = 0.9–2.5) times as likely for persons 

aged ≥60 years. The annual incidence of reported cases of 

acute HBV infection among adults with diabetes was 1.8 per 

100,000 (CI = 1.5–2.2) (2). Acute HBV infection incidence 

is underestimated; an additional 10.5 new cases of infection 

likely occurred for each reported, confirmed case (3). 

Data for the period 1999–2010 from the National Health and 

Nutrition Examination Survey (NHANES), a nationally representative sample of the noninstitutionalized U.S. population, 

indicated a 60% (p<0.001) higher seroprevalence of antibody 

to hepatitis B core antigen (indicative of past or present HBV 

infection) overall among persons aged ≥18 years with diagnosed 

diabetes compared with those without diabetes. Stratified by 

age, the estimated prevalence ratios were 1.7 (CI = 1.3–2.2) for 

persons aged 18 through 59 years and 1.3 (CI = 1.0–1.6) for 

those aged ≥60 years (CDC, unpublished data, 2011). 

Morbidity and Mortality 

The severity of acute HBV infection among adults ranges from 

asymptomatic to fulminant hepatitis. National viral hepatitis 

surveillance data indicate that of the 3,371 acute HBV infections reported in 2009, 47% of the 2,126 infections for which 

information was available resulted in hospitalization, and 1% of 

the 1,900 infections for which information was available were 

fatal (3). Data from EIP for the period 2009–2010 indicated 

a higher case-fatality rate among acute HBV–infected persons 

with diagnosed diabetes compared with those without diabetes, 

although the difference was not statistically significant (5% versus 

2%, p=0.127) (2). Acute HBV infection progresses to chronic 

infection in approximately 5% of otherwise healthy adults (4), 

but is believed to be greater among older adults with diabetes (5). 

In the United States, an estimated 700,000 to 1.4 million persons 

are infected with HBV (3). Because chronic HBV infection can 

persist for decades, persons with chronic HBV infection are the 

Use of Hepatitis B Vaccination for Adults with Diabetes Mellitus: 

Recommendations of the Advisory Committee on Immunization Practices (ACIP) 

*Recommendation category A: a recommendation that applies to all persons in an 

age or risk-based group. Recommendation category B: a recommendation for 

individual clinical decision making. Evidence type 1: randomized controlled 

trials, or overwhelming evidence from observational studies. Evidence type 2:

randomized controlled trials with important limitations, or exceptionally strong 

evidence from observational studies. Evidence type 3: observational studies, or 

randomized controlled trials with notable limitations. Evidence type 4: clinical 

experience and observations, observational studies with important limitations, 

or randomized controlled trials with several major limitations. Source: Ahmed 

F, Temte JL, Campos-Outcalt D, Schünemann HJ; for the ACIP Evidence 

Based Recommendations Work Group (EBRWG). Methods for developing 

evidence-based recommendations by the Advisory Committee on Immunization 

Practices (ACIP) of the U.S. Centers for Disease Control and Prevention (CDC). 

Vaccine 2011;29:9171–6. Additional information about the GRADE 

methodology related to this policy is available at http://www.cdc.gov/vaccines/

recs/acip/grade/table-refs.htm. 
Morbidity and Mortality Weekly Report 

1710 MMWR / December 23, 2011 / Vol. 60 / No. 50

reservoir for continuing HBV transmission. Chronic HBV infection is associated with high morbidity and mortality, leading to 

cirrhosis and liver cancer in ≥15% of affected adults (5). 

Diabetes is associated with nonalcoholic fatty liver disease, including its most severe form, nonalcoholic steatohepatitis. A study of 

veterans without HBV infection indicated that adults with diabetes 

have approximately twice the risk for chronic nonalcoholic liver 

disease and hepatocellular carcinoma as those without diabetes (6). 

Infection Control 

HBV is highly infectious and environmentally stable (5); HBV 

can be transmitted by medical equipment that is contaminated 

with blood that is not visible to the unaided eye. Percutaneous 

exposures to HBV occur as a result of assisted monitoring of 

blood glucose (7) and other procedures involving instruments 

or parenteral treatments shared between persons. Lapses in 

infection control during assisted blood glucose monitoring that 

have led to HBV transmission include multipatient use of finger 

stick devices designed for single-patient use and inadequate 

disinfection and cleaning of blood glucose monitors between 

patients. Breaches have been documented in various settings, 

including LTC facilities, hospitals, community health centers, 

ambulatory surgical centers, private offices, homes, and health 

fairs (7; CDC, unpublished data, 2011). Initiatives are ongoing 

to encourage improvement in the design and labeling of devices 

used in diabetes monitoring and care, and for greater oversight 

and training of staff responsible for providing diabetes care.†

Infection control guidelines for safe blood glucose monitoring 

have been available since 1990, and guidelines targeting LTC 

settings were published in 2005 (8). Since 1982, hepatitis B 

vaccination has been recommended for health-care personnel, 

including personnel exposed to blood in LTC settings, in conjunction with meticulous attention to infection control practice 

(5,8). In addition, a recommendation for hepatitis B vaccination 

exists for persons beginning hemodialysis (5). 

Hepatitis B Vaccine 

Two single-antigen recombinant hepatitis B vaccines, 

Recombivax HB (Merck & Co., Inc.) and Engerix-B 

(GlaxoSmithKline Biologicals), and one combination hepatitis A and hepatitis B vaccine, Twinrix (GlaxoSmithKline 

Biologicals), are available in the United States. Hepatitis B vaccines have been used in the United States since 1982. Extensive 

data support their safety in all age groups (5). 

Hepatitis B vaccination usually consists of 3 doses of vaccine administered intramuscularly at 0, 1, and 6 months; other 

schedules are available. At younger ages, the immune response to 

vaccine is similar among adults with and without diabetes. The 

proportion of adults who achieve seroprotection (≥10 mIU/mL 

antibody to hepatitis B surface antigen [anti-HBs]) after receipt 

of the 3-dose vaccine series decreases with age, obesity, smoking, 

immunosuppression, and comorbid conditions including diabetes. 

When the antibody responses among older adults with and without diabetes are compared, the response might be reduced among 

those with diabetes. A synthesis of available literature suggests a 

protective response is achieved after completion of the hepatitis 

B vaccine series in ≥90%, 80%, 65%, and <40% of adults with 

diabetes lacking comorbid conditions aged ≤40 years, 41 through 

59 years, 60 through 69 years, and ≥70 years, respectively (CDC, 

unpublished data, 2011). Revaccination with 1–3 additional doses 

of hepatitis B vaccine safely increases the proportion of adults who 

achieve a protective level of anti-HBs (≥10 mIU/mL) (5). The 

duration of protection against symptomatic and chronic HBV 

infection lasts >22 years among healthy vaccine responders (9); 

duration of immunity among persons with diabetes is unknown. 

Cost-Effectiveness 

The Hepatitis Vaccines Work Group developed economic 

models that yielded age-stratified calculations (base case) of the 

incremental cost per quality-adjusted life-year (QALY) saved 

based on vaccinating adults with diabetes against hepatitis B.§

The estimated cost per QALY saved was $75,100 for persons aged 

20 through 59 years but increased substantially with increasing 

age. From a lifetime perspective, a one-time vaccination program 

consisting of a 3-dose series of hepatitis B vaccine, covering 10% 

of unvaccinated U.S. adults with diagnosed diabetes aged 20 

through 59 years (or approximately 528,047 persons) would be 

expected to prevent 4271 HBV infections, 467 hospitalizations, 

256 chronic cases, 33 cases of hepatocellular carcinoma, 13 liver 

transplants, and 130 deaths. Postvaccination serologic testing and 

revaccination would add considerable cost, with limited increase 

in disease protection (CDC, unpublished data, 2011). 

ACIP Recommendations 

On the basis of available information about HBV risk, morbidity and mortality, available vaccines, age at diagnosis of diabetes, 

and cost-effectiveness, ACIP recommends the following: 

†Additional information available at http://www.cdc.gov/injectionsafety/

meetings/stickingwsafety52010.html. 

§The Charter of ACIP states that, when considering recommendations for use 

of a vaccine, ACIP members’ deliberations should include consideration of 

vaccine efficacy as well as cost-benefit and risk-benefit analyses. No predefined 

threshold for cost-effectiveness is considered. To ensure that economic data 

presented to the Committee and its Working Groups are uniform in 

presentation, understandable, and of the highest quality, lead economists and 

the Health Economics Research Group at CDC developed Guidance for Health 

Economics Studies Presented to the Advisory Committee on Immunization Practices 

(ACIP), available at http://www.cdc.gov/vaccines/recs/acip/economic-studies.

htm. The guidance specifically mandates technical review of any economic 

study that is presented to ACIP. 
Morbidity and Mortality Weekly Report

MMWR / December 23, 2011 / Vol. 60 / No. 50 1711

•	 HepatitisBvaccinationshouldbe administeredtounvaccinated

adults with diabetes mellitus who are aged 19 through 59 years 

(recommendation category A; evidence type 2). 

•	 Hepatitis B vaccination may be administered at the

discretion of the treating clinician to unvaccinated adults 

with diabetes mellitus who are aged ≥60 years 

(recommendation category B; evidence type 2). 

Remarks 

Continued efforts are needed to increase adherence to recommended infection control practice. Shared use of bloodcontaminated equipment increases the risk for exposure to 

bloodborne pathogens, including hepatitis C virus, human 

immunodeficiency virus, and HBV, which is highly infectious. 

Administration of the hepatitis B vaccine series should 

be completed as soon as feasible after diabetes is diagnosed. 

Available data do not confirm an advantage to any specific 

hepatitis B vaccine, dosage, or approved schedule for adults 

with diabetes. No serologic testing or additional hepatitis B 

vaccination is recommended for adults who received a complete series of hepatitis B vaccinations at any time in the past. 

The hepatitis B vaccination series can be given safely to 

persons of any age, but current hepatitis B vaccines are less 

efficacious and less cost-effective among older adults. Evidence 

for the extent of increased risk for acute HBV infection among 

persons with diabetes who are aged ≥60 years is less strong than 

for younger persons with diabetes. In 2008, the median age of 

diabetes diagnosis was 53 years; two thirds of adult diabetes 

diagnoses were made before age 60 years.¶

Decisions to vaccinate adults with diabetes who are aged ≥60 

years of age should incorporate consideration of the patient’s 

likelihood of acquiring HBV infection, including the risk posed 

by an increased need for assisted blood-glucose monitoring in 

LTC facilities, the likelihood of experiencing chronic sequelae if 

infected with HBV, and the declining immunologic responses 

to vaccines that are associated with frailty, a geriatric syndrome 

characterized by decreased physiologic reserve and increased 

vulnerability, leading to early mortality in older adults (10). 

Hepatitis B vaccine may be administered during health-care 

visits scheduled for other purposes as long as minimum intervals 

between doses are observed; there is no maximum interval between 

doses that makes the hepatitis B vaccination series ineffective. 

Reported by 

Mark H. Sawyer, MD, Univ of California San Diego and Rady 

Children’s Hospital, San Diego, California. Thomas J. Hoerger, 

PhD, RTI International, Research Triangle Park, North Carolina. 

Trudy V. Murphy, MD, Sarah F. Schillie, MD, Dale Hu, MD, 

Philip R. Spradling, MD, Kathy K. Byrd, MD, Jian Xing, PhD, 

Meredith L. Reilly, MPH, Rania A. Tohme, MD, 

Anne Moorman, MPH, Emily A. Smith, MPH, Brittney N. 

Baack, MPH, Ruth B. Jiles, PhD, Monina Klevens, DDS, 

John W. Ward, MD, Div of Viral Hepatitis, National Center for 

HIV, Viral Hepatitis, STD, and TB Prevention; Henry S. Kahn, 

MD, Div of Diabetes Translation, National Center for Chronic 

Disease Prevention and Health Promotion; Fangjun Zhou, PhD, 

Immunization Svcs Div, National Center for Immunization and 

Respiratory Diseases, CDC. Corresponding contributor:

Trudy V. Murphy, tvmurphy@cdc.gov, 404-639-8845. 

Acknowledgments 

John S. Wittenborn, RTI International, Research Triangle Park, 

North Carolina. Nicola D. Thompson, PhD, Joseph F. Perz, PhD, 

Div of Healthcare Quality Promotion, National Center for Emerging 

and Zoonotic Infectious Diseases; Rachel J. Wilson, Div of Viral 

Hepatitis, National Center for HIV, Viral Hepatitis, STD, and 

TB Prevention; Nilka Ríos Burrows, MPH, Pamela Allweiss, MD, 

Div of Diabetes Translation, National Center for Chronic Disease 

Prevention and Health Promotion, CDC. 

References 

1. Thompson ND, Perz JF. Eliminating the blood: ongoing outbreaks of 

hepatitis B virus infection and the need for innovative glucose monitoring 

technologies. J Diabetes Sci Technol 2009;3:283–8. 

2. Reilly ML, Poissant T, Vonderwahl CW, Gerard K, Murphy TV. 

Incidence of acute hepatitis B among adults with and without diabetes, 

2009–2010. Presented at the 49th Annual Meeting of the Infectious 

Disease Society of America and the HIV Medicine Association; Boston, 

MA, October 20–23, 2011. 

3. CDC. Viral hepatitis surveillance—United States, 2009. Atlanta, GA: 

US Department of Health and Human Services; 2011. Available at 

http://www.cdc.gov/hepatitis/statistics/2009surveillance/index.htm. 

Accessed December 15, 2011. 

4. Hyams KC. Risks of chronicity following acute hepatitis B virus 

infection: a review. Clin Infect Dis 1995;20:992–1000. 

5. CDC. A comprehensive immunization strategy to eliminate transmission

of hepatitis B virus infection in the United States. Recommendations 

of the Advisory Committee on Immunization Practices (ACIP) part II: 

immunization of adults. MMWR 2006;55(No. RR-16). 

6. El-Serag HB, Tran T, Everhart JE. Diabetes increases the risk of chronic 

liver disease and hepatocellular carcinoma. Gastroenterology 

2004;126:460–8. 

7. Klonoff DC, Perz JF. Assisted monitoring of blood glucose: special safety 

needs for a new paradigm in testing glucose. J Diabetes Science Technol 

2010;4:1027–31. 

8. CDC. Transmission of hepatitis B virus among persons undergoing 

blood glucose monitoring in long-term–care facilities—Mississippi, 

North Carolina, and Los Angeles County, California, 2003–2004. 

MMWR 2005;54:220–3. 

9. Leuridan E, Van Damme P. Hepatitis B and the need for a booster dose. 

Clin Infect Dis 2011;53:68–75. 

10. Yao X, Hamilton RG, Weng NP, et al. Frailty is associated with 

impairment of vaccine-induced antibody response and increase in postvaccination influenza infection in community-dwelling older adults. 

Vaccine 2011;29:5015–21. ¶Additional information available at http://www.cdc.gov/diabetes/statistics/age/

fig1.htm. 
Morbidity and Mortality Weekly Report 

1712 MMWR / December 23, 2011 / Vol. 60 / No. 50

* Employed adults are persons who had worked at a job or business any time in the 12 months before the 

interview (either full-time or part-time). 

† Adults were defined as having current asthma if they answered “yes” to the following two questions: “Have 

you ever been told by a doctor or other health professional that you had asthma?” “Do you still have asthma?” 

§ Adults were defined as having a skin condition if they answered “yes” to the following question: “During the 

past 12 months, have you had dermatitis, eczema, or any other red, inflamed skin rash?” 

¶ Adults were defined as having carpal tunnel syndrome if they answered “yes” to the following two questions: 

“Have you ever been told by a doctor or other health professional that you have a condition affecting the 

wrist and hand called carpal tunnel syndrome?” and “During the past 12 months, have you had carpal tunnel 

syndrome?” 

** Asthma was considered work-related if a doctor or other health professional had told the adult that it “was 

probably caused by your work,” “was probably made worse by your work,” or “was ever made worse by any 

job you have ever had.” Skin condition and carpal tunnel syndrome were considered work-related if a doctor 

or other health professional had told the adult that the condition “was probably work-related.” 

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

and are derived from the National Health Interview Survey sample adult component. Asthma, skin condition, 

and carpal tunnel syndrome were the only three conditions for which participants were asked if a doctor or 

health professional had told them the condition was probably work-related.

§§ 95% confidence interval. 

In 2010, among employed adults aged 18–64 years who currently had asthma, 6.7% had been told their current asthma was workrelated. Among employed adults who had a skin condition, 5.8% had been told their skin condition was work-related. Among 

employed adults who had carpal tunnel syndrome, 69.4% had been told their carpal tunnel syndrome was work-related. Men 

(61.1%) were less likely than women (73.2%) to have been told their carpal tunnel syndrome was work-related. No significant 

differences by sex for either work-related current asthma or skin conditions were observed. 

Source: National Health Interview Survey, 2010 data. Available at http://www.cdc.gov/nchs/nhis.htm. 

0

10

20

30

40

50

60

70

Percentage

Total

Men

Women

Asthma Skin condition

Condition

Carpal tunnel syndrome

§§

80

QuickStats

FROM THE NATIONAL CENTER FOR HEALTH STATISTICS

Percentage of Employed Adults* Aged 18–64 Years with Current Asthma,†

Skin Condition,§ or Carpal Tunnel Syndrome¶ Who Were Told Their Condition 

Was Work-Related,** by Sex — National Health Interview Survey, 2010††
Morbidity and Mortality Weekly Report

MMWR / December 23, 2011 / Vol. 60 / No. 50 1713

TABLE I. Provisional cases of infrequently reported notifiable diseases (<1,000 cases reported during the preceding year) — United States, week ending 

December 17, 2011 (50th week)*

Disease

Current 

week

Cum 

2011

5-year 

weekly 

average†

Total cases reported for previous years

States reporting cases 

2010 2009 2008 2007 2006 during current week (No.)

Anthrax — 1 0 — 1 — 1 1

Arboviral diseases§, ¶

:

California serogroup virus disease — 125 0 75 55 62 55 67

Eastern equine encephalitis virus disease — 4 — 10 4 4 4 8

Powassan virus disease — 14 0 8 6 2 7 1

St. Louis encephalitis virus disease — 5 0 10 12 13 9 10

Western equine encephalitis virus disease — — — — — — — —

Babesiosis 2 622 0 NN NN NN NN NN NY (2)

Botulism, total 1 106 4 112 118 145 144 165

foodborne — 8 1 7 10 17 32 20

infant 1 68 3 80 83 109 85 97 NV (1)

other (wound and unspecified) — 30 1 25 25 19 27 48

Brucellosis — 75 3 115 115 80 131 121

Chancroid — 27 1 24 28 25 23 33

Cholera — 29 0 13 10 5 7 9

Cyclosporiasis§ 1 140 1 179 141 139 93 137 FL (1)

Diphtheria — — — — — — — —

Haemophilus influenzae,

** invasive disease (age <5 yrs):

serotype b — 7 1 23 35 30 22 29

nonserotype b — 102 6 200 236 244 199 175

unknown serotype 4 226 5 223 178 163 180 179 PA (2), OH (1), MO (1)

Hansen disease§ 2 48 1 98 103 80 101 66 FL (2)

Hantavirus pulmonary syndrome§ — 20 1 20 20 18 32 40

Hemolytic uremic syndrome, postdiarrheal§ — 200 7 266 242 330 292 288

Influenza-associated pediatric mortality§,

†† — 118 2 61 358 90 77 43

Listeriosis 8 729 19 821 851 759 808 884 NY (2), PA (2), FL (1), WA (1), CA (2)

Measles§§ — 210 1 63 71 140 43 55

Meningococcal disease, invasive¶¶:

A, C, Y, and W-135 — 175 8 280 301 330 325 318

serogroup B — 99 5 135 174 188 167 193

other serogroup — 12 0 12 23 38 35 32

unknown serogroup 2 357 12 406 482 616 550 651 TN (1), CO (1)

Novel influenza A virus infections*** — 8 0 4 43,774 2 4 NN

Plague — 2 — 2 8 3 7 17

Poliomyelitis, paralytic — — 0 — 1 — — —

Polio virus Infection, nonparalytic§ — — — — — — — NN

Psittacosis§ — 2 0 4 9 8 12 21

Q fever, total§ 2 104 3 131 113 120 171 169

acute 1 77 2 106 93 106 — — TX (1)

chronic 1 27 1 25 20 14 — — TX (1)

Rabies, human — 2 0 2 4 2 1 3

Rubella††† — 5 0 5 3 16 12 11

Rubella, congenital syndrome — — — — 2 — — 1

SARS-CoV§ — — — — — — — —

Smallpox§ — — — — — — — —

Streptococcal toxic-shock syndrome§ 4 106 4 142 161 157 132 125 NY (2), NC (2)

Syphilis, congenital (age <1 yr)§§§ — 229 8 377 423 431 430 349

Tetanus — 9 1 26 18 19 28 41

Toxic-shock syndrome (staphylococcal)§ — 69 2 82 74 71 92 101

Trichinellosis — 9 0 7 13 39 5 15

Tularemia — 136 2 124 93 123 137 95

Typhoid fever — 305 9 467 397 449 434 353

Vancomycin-intermediate Staphylococcus aureus§ — 61 1 91 78 63 37 6

Vancomycin-resistant Staphylococcus aureus§ — — 0 2 1 — 2 1

Vibriosis (noncholera Vibrio species infections)§ 8 707 10 846 789 588 549 NN FL (2), TX (1), AZ (1), CA (4)

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 

1714 MMWR / December 23, 2011 / Vol. 60 / No. 50

Notifiable Disease Data Team and 122 Cities Mortality Data Team

Jennifer Ward Deborah A. Adams

Willie J. Anderson Lenee Blanton

Rosaline Dhara Diana Harris Onweh

Pearl C. Sharp Michael S. Wodajo

* 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 December 17, 2011, with historical data

0.125 0.25 1 2 4

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

550

35

77

35

133

1

14

13

610

0.5

TABLE I. (Continued) Provisional cases of infrequently reported notifiable diseases (<1,000 cases reported during the preceding year) — United States, week 

ending December 17, 2011 (50th week)*

—: No reported cases. N: Not reportable. NN: Not Nationally Notifiable. Cum: Cumulative year-to-date counts.

* Case counts for reporting year 2011 are provisional and subject to change. For further information on interpretation of these data, see http://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 at http://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 at http://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 2, 2011, no influenza-associated pediatric deaths 

occurring during the 2011-12 influenza season have been reported. §§ No measles cases were reported for the current week. ¶¶ 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 eight cases 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 are 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

MMWR / December 23, 2011 / Vol. 60 / No. 50 1715

TABLE II. Provisional cases of selected notifiable diseases, United States, weeks ending December 17, 2011, and December 18, 2010 (50th week)*

Reporting area

Chlamydia trachomatis infection 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 

Med Max Med Max Med Max 2010

United States 12,532 26,502 31,142 1,272,762 1,254,968 104 382 579 18,696 NN 43 129 388 7,939 8,663

New England 657 871 2,043 42,691 40,497 — 0 1 1 NN — 7 22 369 478

Connecticut — 227 1,557 10,107 10,843 — 0 0 — NN — 1 9 68 77

Maine† 54 58 98 2,916 2,496 — 0 0 — NN — 1 4 47 92

Massachusetts 409 433 860 21,611 20,243 — 0 0 — NN — 3 8 152 165

New Hampshire 4 57 90 2,725 2,374 — 0 1 1 NN — 1 5 61 57

Rhode Island† 137 78 154 3,919 3,320 — 0 0 — NN — 0 1 1 18

Vermont† 53 27 84 1,413 1,221 — 0 0 — NN — 0 5 40 69

Mid. Atlantic 2,144 3,235 3,953 159,099 166,873 — 0 1 6 NN 10 15 41 809 840

New Jersey 154 538 1,003 26,687 25,428 — 0 0 — NN — 0 1 — 51

New York (Upstate) 904 713 2,099 34,844 33,387 — 0 0 — NN 5 4 15 218 213

New York City 278 1,103 1,329 48,325 62,170 — 0 0 — NN — 1 6 83 103

Pennsylvania 808 976 1,236 49,243 45,888 — 0 1 6 NN 5 9 26 508 473

E.N. Central 1,229 4,049 7,039 193,825 201,156 3 1 5 52 NN 9 32 143 2,395 2,360

Illinois 25 1,103 1,326 49,660 58,785 — 0 0 — NN — 3 26 205 331

Indiana 252 536 3,376 27,296 22,375 — 0 0 — NN — 4 14 180 279

Michigan 627 952 1,429 47,003 47,970 2 0 3 33 NN 1 6 14 330 314

Ohio 169 1,013 1,124 48,082 49,520 1 0 3 19 NN 8 11 95 1,082 458

Wisconsin 156 463 553 21,784 22,506 — 0 0 — NN — 8 61 598 978

W.N. Central 218 1,472 1,782 70,782 70,043 — 0 2 6 NN 1 17 87 1,228 1,825

Iowa 28 211 253 10,290 10,257 — 0 0 — NN — 6 19 342 390

Kansas 17 208 288 10,068 9,333 — 0 0 — NN — 0 11 41 106

Minnesota — 287 381 13,180 14,913 — 0 0 — NN — 0 4 — 391

Missouri — 529 759 26,034 25,240 — 0 0 — NN 1 5 63 502 544

Nebraska† 139 113 218 6,142 4,924 — 0 2 6 NN — 2 12 173 258

North Dakota 2 40 77 1,891 2,283 — 0 0 — NN — 0 12 28 31

South Dakota 32 63 93 3,177 3,093 — 0 0 — NN — 2 13 142 105

S. Atlantic 4,804 5,375 7,367 271,989 249,086 — 0 2 5 NN 10 21 37 1,085 1,041

Delaware 148 85 134 4,232 4,271 — 0 0 — NN — 0 1 7 9

District of Columbia 4 107 190 5,304 5,423 — 0 0 — NN — 0 1 5 8

Florida 847 1,494 1,698 73,036 72,671 — 0 0 — NN 7 8 17 423 393

Georgia 893 1,018 2,384 49,826 42,218 — 0 0 — NN 2 5 11 258 261

Maryland† — 473 1,125 23,545 24,438 — 0 2 5 NN — 1 6 64 39

North Carolina 1,288 971 1,688 50,232 40,407 — 0 0 — NN — 0 23 62 94

South Carolina† 626 526 946 27,933 25,783 — 0 0 — NN — 2 8 126 118

Virginia† 917 659 1,576 33,766 30,112 — 0 0 — NN 1 2 8 124 100

West Virginia 81 81 121 4,115 3,763 — 0 0 — NN — 0 5 16 19

E.S. Central 1,134 1,896 3,314 92,009 88,219 — 0 0 — NN 1 7 25 424 341

Alabama† 594 546 1,566 28,008 26,050 — 0 0 — NN 1 2 7 127 180

Kentucky 298 301 2,352 15,992 13,902 — 0 0 — NN — 1 17 164 83

Mississippi — 392 696 18,580 20,678 — 0 0 — NN — 1 4 45 24

Tennessee† 242 600 754 29,429 27,589 — 0 0 — NN — 2 6 88 54

W.S. Central 715 3,386 4,329 166,314 172,517 — 0 1 8 NN 6 8 62 527 513

Arkansas† 305 309 440 15,429 14,984 — 0 0 — NN — 0 2 25 33

Louisiana 311 412 1,071 22,316 27,952 — 0 1 8 NN 1 0 9 47 66

Oklahoma 99 173 850 9,190 13,408 — 0 0 — NN 2 1 34 83 86

Texas† — 2,426 3,137 119,379 116,173 — 0 0 — NN 3 5 37 372 328

Mountain 169 1,751 2,279 85,349 80,298 91 295 459 14,636 NN 2 11 30 569 592

Arizona — 547 773 27,386 25,963 89 292 456 14,470 NN — 1 4 42 38

Colorado — 421 847 22,065 19,039 — 0 0 — NN — 2 12 146 132

Idaho† 5 81 235 4,081 3,987 — 0 0 — NN 1 2 9 104 105

Montana† 61 64 87 3,273 2,981 — 0 2 5 NN 1 1 6 75 49

Nevada† 29 204 380 9,990 9,386 2 2 5 97 NN — 0 2 14 38

New Mexico† — 200 1,183 10,235 10,421 — 0 4 46 NN — 3 9 122 131

Utah 51 131 190 6,541 6,482 — 0 2 15 NN — 1 5 41 71

Wyoming† 23 36 67 1,778 2,039 — 0 2 3 NN — 0 5 25 28

Pacific 1,462 3,964 6,559 190,704 186,279 10 83 145 3,982 NN 4 11 21 533 673

Alaska 4 110 157 5,381 5,864 — 0 0 — NN — 0 3 14 6

California 887 2,973 5,763 145,775 142,281 10 82 145 3,975 NN 2 6 15 317 362

Hawaii — 109 141 5,444 5,840 — 0 0 — NN — 0 1 1 1

Oregon 204 277 412 13,390 11,693 — 0 1 7 NN — 2 8 126 215

Washington 367 434 672 20,714 20,601 — 0 0 — NN 2 1 9 75 89

Territories

American Samoa — 0 0 — — — 0 0 — NN N 0 0 N N

C.N.M.I. — — — — — — — — — NN — — — — —

Guam — 14 44 189 905 — 0 0 — NN — 0 0 — —

Puerto Rico — 104 349 5,010 5,816 — 0 0 — NN N 0 0 N N

U.S. Virgin Islands — 16 27 642 566 — 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 2011 are provisional and subject to change. For further information on interpretation of these data, see http://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 

1716 MMWR / December 23, 2011 / Vol. 60 / No. 50

TABLE II. (Continued) Provisional cases of selected notifiable diseases, United States, weeks ending December 17, 2011, and December 18, 2010 (50th 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 

Med Max Med Max 2010

United States — 3 16 203 684 — 0 1 2 10

New England — 0 1 2 10 — 0 0 — —

Connecticut — 0 0 — — — 0 0 — —

Maine** — 0 0 — 6 — 0 0 — —

Massachusetts — 0 0 — — — 0 0 — —

New Hampshire — 0 0 — — — 0 0 — —

Rhode Island** — 0 0 — 1 — 0 0 — —

Vermont** — 0 1 2 3 — 0 0 — —

Mid. Atlantic — 1 6 56 222 — 0 0 — 5

New Jersey — 0 0 — 29 — 0 0 — —

New York (Upstate) — 0 1 — 31 — 0 0 — 2

New York City — 0 4 40 141 — 0 0 — 3

Pennsylvania — 0 2 16 21 — 0 0 — —

E.N. Central — 0 2 14 67 — 0 1 1 1

Illinois — 0 2 4 21 — 0 1 1 —

Indiana — 0 1 2 14 — 0 0 — —

Michigan — 0 1 2 9 — 0 0 — —

Ohio — 0 1 2 16 — 0 0 — —

Wisconsin — 0 2 4 7 — 0 0 — 1

W.N. Central — 0 2 11 33 — 0 0 — 1

Iowa — 0 1 3 2 — 0 0 — —

Kansas — 0 1 1 4 — 0 0 — —

Minnesota — 0 1 5 14 — 0 0 — —

Missouri — 0 1 1 5 — 0 0 — —

Nebraska** — 0 0 — 7 — 0 0 — —

North Dakota — 0 1 1 1 — 0 0 — —

South Dakota — 0 0 — — — 0 0 — 1

S. Atlantic — 1 8 81 237 — 0 1 1 2

Delaware — 0 2 2 — — 0 0 — —

District of Columbia — 0 0 — — — 0 0 — —

Florida — 1 7 61 188 — 0 0 — 2

Georgia — 0 1 3 12 — 0 0 — —

Maryland** — 0 2 5 — — 0 0 — —

North Carolina — 0 1 2 8 — 0 0 — —

South Carolina** — 0 1 1 13 — 0 0 — —

Virginia** — 0 1 7 14 — 0 1 1 —

West Virginia — 0 0 — 2 — 0 0 — —

E.S. Central — 0 3 8 7 — 0 0 — —

Alabama** — 0 1 2 4 — 0 0 — —

Kentucky — 0 1 3 2 — 0 0 — —

Mississippi — 0 0 — — — 0 0 — —

Tennessee** — 0 2 3 1 — 0 0 — —

W.S. Central — 0 2 9 28 — 0 0 — 1

Arkansas** — 0 0 — — — 0 0 — 1

Louisiana — 0 1 3 4 — 0 0 — —

Oklahoma — 0 0 — 5 — 0 0 — —

Texas** — 0 1 6 19 — 0 0 — —

Mountain — 0 1 4 24 — 0 0 — —

Arizona — 0 1 2 12 — 0 0 — —

Colorado — 0 0 — — — 0 0 — —

Idaho** — 0 0 — 3 — 0 0 — —

Montana** — 0 0 — 4 — 0 0 — —

Nevada** — 0 1 1 4 — 0 0 — —

New Mexico** — 0 0 — 1 — 0 0 — —

Utah — 0 1 1 — — 0 0 — —

Wyoming** — 0 0 — — — 0 0 — —

Pacific — 0 4 18 56 — 0 0 — —

Alaska — 0 0 — 1 — 0 0 — —

California — 0 2 5 36 — 0 0 — —

Hawaii — 0 4 5 — — 0 0 — —

Oregon — 0 0 — — — 0 0 — —

Washington — 0 1 8 19 — 0 0 — —

Territories

American Samoa — 0 0 — — — 0 0 — —

C.N.M.I. — — — — — — — — — —

Guam — 0 0 — — — 0 0 — —

Puerto Rico — 23 82 1,361 10,586 — 0 3 30 237

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 2011 are provisional and subject to change. For further information on interpretation of these data, see http://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).

§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

MMWR / December 23, 2011 / Vol. 60 / No. 50 1717

TABLE II. (Continued) Provisional cases of selected notifiable diseases, United States, weeks ending December 17, 2011, and December 18, 2010 (50th 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 

Med Max Med Max Med Max 2010

United States 4 7 109 677 629 20 13 57 772 1,726 — 2 13 105 90

New England — 0 1 4 8 2 3 28 272 117 — 0 1 2 2

Connecticut — 0 0 — — — 0 2 — 41 — 0 0 — —

Maine§ — 0 1 1 4 — 0 3 23 17 — 0 0 — —

Massachusetts — 0 0 — — — 1 18 172 — — 0 0 — —

New Hampshire — 0 1 2 3 — 0 4 22 20 — 0 1 1 2

Rhode Island§ — 0 1 1 1 1 0 15 47 37 — 0 1 1 —

Vermont§ — 0 0 — — 1 0 1 8 2 — 0 0 — —

Mid. Atlantic — 1 7 58 84 15 5 31 353 274 — 0 2 10 15

New Jersey — 0 1 — 51 — 0 2 — 74 — 0 0 — 1

New York (Upstate) — 0 7 47 26 15 3 27 299 188 — 0 2 10 11

New York City — 0 2 11 5 — 0 5 50 11 — 0 0 — —

Pennsylvania — 0 0 — 2 — 0 1 4 1 — 0 0 — 3

E.N. Central — 0 5 31 44 1 0 3 21 510 — 1 5 44 45

Illinois — 0 4 21 16 — 0 2 9 9 — 0 1 2 3

Indiana — 0 0 — — — 0 0 — — — 0 3 34 15

Michigan — 0 2 4 2 — 0 0 — 4 — 0 2 5 —

Ohio — 0 1 6 7 1 0 1 9 2 — 0 1 1 —

Wisconsin — 0 0 — 19 — 0 3 3 495 — 0 1 2 27

W.N. Central — 1 19 159 120 — 0 8 33 733 — 0 11 15 10

Iowa N 0 0 N N N 0 0 N N N 0 0 N N

Kansas — 0 2 5 6 — 0 0 — 1 — 0 1 1 —

Minnesota — 0 12 — — — 0 1 1 720 — 0 11 — —

Missouri — 1 19 152 112 — 0 7 29 12 — 0 7 13 10

Nebraska§ — 0 1 1 2 — 0 1 1 — — 0 1 1 —

North Dakota N 0 0 N N N 0 0 N N N 0 0 N N

South Dakota — 0 1 1 — — 0 1 2 — — 0 0 — —

S. Atlantic 1 2 33 240 251 2 1 8 66 64 — 0 2 13 6

Delaware — 0 2 15 17 — 0 1 1 4 — 0 0 — —

District of Columbia N 0 0 N N N 0 0 N N N 0 0 N N

Florida — 0 3 15 8 — 0 3 10 3 — 0 0 — —

Georgia — 0 3 18 20 — 0 2 9 1 — 0 1 2 1

Maryland§ — 0 3 28 22 — 0 2 6 15 — 0 1 1 2

North Carolina — 0 17 66 99 — 0 6 20 28 — 0 0 — —

South Carolina§ — 0 1 2 5 — 0 0 — 1 — 0 1 1 —

Virginia§ 1 1 13 96 77 2 0 3 20 12 — 0 1 8 3

West Virginia — 0 0 — 3 — 0 0 — — — 0 1 1 —

E.S. Central — 1 8 73 87 — 0 2 16 20 — 0 3 14 9

Alabama§ — 0 2 4 11 — 0 1 4 7 N 0 0 N N

Kentucky — 0 3 13 16 — 0 0 — — — 0 0 — 1

Mississippi — 0 1 3 3 — 0 1 1 2 — 0 0 — 1

Tennessee§ — 0 5 53 57 — 0 2 11 11 — 0 3 14 7

W.S. Central 3 0 87 112 33 — 0 9 8 8 — 0 0 — 1

Arkansas§ 1 0 13 51 14 — 0 3 6 4 — 0 0 — —

Louisiana — 0 0 — 1 — 0 0 — — — 0 0 — —

Oklahoma 2 0 82 59 15 — 0 7 2 2 — 0 0 — —

Texas§ — 0 1 2 3 — 0 1 — 2 — 0 0 — 1

Mountain — 0 0 — — — 0 0 — — — 0 1 5 —

Arizona — 0 0 — — — 0 0 — — — 0 1 4 —

Colorado N 0 0 N N N 0 0 N N N 0 0 N N

Idaho§ N 0 0 N N N 0 0 N N N 0 0 N N

Montana§ N 0 0 N N N 0 0 N N N 0 0 N N

Nevada§ N 0 0 N N N 0 0 N N N 0 0 N N

New Mexico§ N 0 0 N N N 0 0 N N N 0 0 N N

Utah — 0 0 — — — 0 0 — — — 0 1 1 —

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

Pacific — 0 1 — 2 — 0 1 3 — — 0 1 2 2

Alaska N 0 0 N N N 0 0 N N N 0 0 N N

California — 0 1 — 2 — 0 0 — — — 0 1 2 2

Hawaii N 0 0 N N N 0 0 N N N 0 0 N N

Oregon — 0 0 — — — 0 1 3 — — 0 0 — —

Washington — 0 0 — — — 0 0 — — — 0 0 — —

Territories

American Samoa N 0 0 N N N 0 0 N N N 0 0 N N

C.N.M.I. — — — — — — — — — — — — — — —

Guam N 0 0 N N N 0 0 N N N 0 0 N N

Puerto Rico N 0 0 N N 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 2011 are provisional and subject to change. For further information on interpretation of these data, see http://www.cdc.gov/osels/ph_surveillance/nndss/

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

† Cumulative total E. ewingii cases reported for year 2011 = 13. § Contains data reported through the National Electronic Disease Surveillance System (NEDSS).
Morbidity and Mortality Weekly Report 

1718 MMWR / December 23, 2011 / Vol. 60 / No. 50

TABLE II. (Continued) Provisional cases of selected notifiable diseases, United States, weeks ending December 17, 2011, and December 18, 2010 (50th 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 

Med Max Med Max Med Max 2010

United States 148 281 445 14,299 19,083 2,978 5,982 7,484 291,262 297,339 34 64 141 3,036 2,942

New England 2 27 64 1,478 1,629 73 106 206 5,196 5,381 — 4 12 209 189

Connecticut — 4 10 216 285 — 45 150 2,184 2,386 — 1 5 50 44

Maine§ 1 3 10 170 220 12 5 17 249 152 — 0 2 25 13

Massachusetts — 13 29 701 709 26 47 80 2,264 2,363 — 2 6 102 93

New Hampshire — 2 8 115 153 — 2 7 121 149 — 0 2 15 12

Rhode Island§ — 1 10 66 80 35 6 16 331 273 — 0 2 10 13

Vermont§ 1 3 19 210 182 — 0 8 47 58 — 0 2 7 14

Mid. Atlantic 42 54 103 2,731 3,258 473 738 916 37,113 35,702 11 14 32 697 562

New Jersey — 0 10 — 465 45 148 232 7,440 5,721 — 2 6 104 103

New York (Upstate) 30 20 72 1,146 1,140 143 114 271 5,708 5,524 4 3 18 171 152

New York City 7 16 29 818 901 67 242 314 11,119 12,067 2 3 7 167 93

Pennsylvania 5 16 29 767 752 218 255 361 12,846 12,390 5 5 11 255 214

E.N. Central 9 47 78 2,276 3,210 323 1,033 2,091 51,039 55,760 8 11 22 537 487

Illinois — 10 19 439 678 6 280 359 12,847 15,253 1 3 11 151 167

Indiana — 4 11 189 389 53 129 1,018 6,544 6,397 — 2 7 90 100

Michigan 1 10 21 491 683 183 240 499 12,207 13,229 1 1 4 67 33

Ohio 8 16 30 755 842 47 315 398 15,127 15,964 6 3 7 164 118

Wisconsin — 8 18 402 618 34 89 118 4,314 4,917 — 1 5 65 69

W.N. Central 7 21 50 1,068 2,058 31 306 372 14,912 14,486 2 2 10 146 219

Iowa 2 4 15 262 278 4 37 54 1,846 1,747 — 0 1 3 1

Kansas — 2 8 94 204 — 42 57 2,018 2,006 — 0 2 19 23

Minnesota — 0 13 — 821 — 38 56 1,820 2,064 — 0 5 — 75

Missouri 4 8 23 403 413 — 150 204 7,245 6,876 2 1 5 83 82

Nebraska§ — 3 11 166 214 25 24 51 1,249 1,147 — 0 2 26 26

North Dakota — 0 12 38 31 — 4 8 185 193 — 0 6 14 12

South Dakota 1 1 8 105 97 2 11 20 549 453 — 0 1 1 —

S. Atlantic 33 51 98 2,594 3,862 1,266 1,486 1,927 73,147 73,554 3 14 31 688 737

Delaware 1 0 3 33 34 20 15 31 781 957 — 0 2 5 5

District of Columbia — 0 3 31 55 — 38 98 1,924 2,033 — 0 0 — 6

Florida 26 23 50 1,193 2,067 207 378 462 18,903 19,595 — 5 12 218 185

Georgia — 10 51 645 785 294 311 874 15,134 14,791 1 2 7 122 158

Maryland§ 5 6 13 297 258 — 120 203 5,603 7,044 1 2 5 91 68

North Carolina N 0 0 N N 400 323 548 16,040 13,542 — 1 7 74 123

South Carolina§ — 2 8 111 142 170 152 257 7,938 7,769 — 1 5 70 80

Virginia§ 1 5 32 262 474 165 111 352 6,051 7,270 1 1 8 91 82

West Virginia — 0 8 22 47 10 17 29 773 553 — 0 9 17 30

E.S. Central 1 3 9 160 216 323 515 1,007 25,225 24,116 2 3 12 199 174

Alabama§ 1 3 9 160 216 174 162 408 8,583 7,616 — 1 4 47 30

Kentucky N 0 0 N N 70 77 712 4,374 3,612 1 1 4 41 36

Mississippi N 0 0 N N — 113 191 5,062 5,944 1 0 3 19 15

Tennessee§ N 0 0 N N 79 145 224 7,206 6,944 — 2 5 92 93

W.S. Central 2 5 15 250 382 211 885 1,181 43,241 48,066 5 2 26 140 136

Arkansas§ 1 2 9 117 129 86 89 138 4,523 4,602 1 0 3 31 18

Louisiana 1 2 10 133 191 98 136 313 6,486 8,585 — 1 4 45 29

Oklahoma — 0 0 — 62 27 51 254 2,658 4,101 4 1 19 62 81

Texas§ N 0 0 N N — 589 839 29,574 30,778 — 0 4 2 8

Mountain 24 25 45 1,292 1,719 6 207 289 10,361 9,168 1 5 12 251 294

Arizona 2 3 6 123 161 — 80 131 4,240 3,124 — 1 6 84 108

Colorado 14 11 25 618 680 — 41 89 2,114 2,683 1 1 5 64 81

Idaho§ 4 3 9 158 208 1 2 13 128 136 — 0 2 21 18

Montana§ 3 2 5 79 107 — 1 4 79 99 — 0 1 3 2

Nevada§ 1 1 7 74 104 3 39 103 1,900 1,668 — 0 2 17 10

New Mexico§ — 2 6 90 103 — 33 98 1,605 1,118 — 1 4 42 40

Utah — 3 9 128 303 2 5 10 255 303 — 0 3 18 29

Wyoming§ — 0 5 22 53 — 0 3 40 37 — 0 1 2 6

Pacific 28 47 128 2,450 2,749 272 628 791 31,028 31,106 2 3 9 169 144

Alaska — 2 7 95 95 — 20 31 938 1,250 — 0 3 25 25

California 17 33 67 1,619 1,668 201 518 695 25,608 25,316 1 1 5 44 26

Hawaii 1 0 4 34 54 — 13 24 628 727 1 0 3 26 20

Oregon 4 7 20 347 477 23 27 60 1,386 1,026 — 1 6 71 64

Washington 6 7 57 355 455 48 50 79 2,468 2,787 — 0 1 3 9

Territories

American Samoa — 0 0 — — — 0 0 — — — 0 0 — —

C.N.M.I. — — — — — — — — — — — — — — —

Guam — 0 0 — 3 — 0 5 6 99 — 0 0 — —

Puerto Rico — 0 4 38 92 — 6 14 312 301 — 0 0 — 1

U.S. Virgin Islands — 0 0 — — — 2 10 113 132 — 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 2011 are provisional and subject to change. For further information on interpretation of these data, see http://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

MMWR / December 23, 2011 / Vol. 60 / No. 50 1719

TABLE II. (Continued) Provisional cases of selected notifiable diseases, United States, weeks ending December 17, 2011, and December 18, 2010 (50th 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 

Med Max Med Max Med Max 2010

United States 6 22 74 1,096 1,574 30 47 167 2,399 3,155 12 18 39 960 799

New England — 1 5 67 93 — 1 8 76 54 — 1 5 60 54

Connecticut — 0 3 19 28 — 0 4 16 22 — 0 5 40 37

Maine† — 0 2 6 7 — 0 2 8 13 — 0 2 4 2

Massachusetts — 0 3 31 48 — 1 6 49 12 — 0 2 11 13

New Hampshire — 0 1 — 1 — 0 1 3 5 N 0 0 N N

Rhode Island† — 0 1 5 9 U 0 0 U U U 0 0 U U

Vermont† — 0 2 6 — — 0 0 — 2 — 0 1 5 2

Mid. Atlantic 1 3 7 163 269 3 5 11 207 272 3 1 5 84 101

New Jersey — 0 2 — 73 — 0 2 — 74 — 0 0 — 28

New York (Upstate) 1 1 4 46 56 2 1 9 54 50 1 1 4 48 44

New York City — 1 5 62 88 — 1 5 78 79 — 0 0 — 3

Pennsylvania — 1 3 55 52 1 2 4 75 69 2 0 4 36 26

E.N. Central 1 3 8 174 202 1 6 37 316 466 2 2 8 134 92

Illinois — 1 4 53 48 — 1 6 59 128 — 0 2 7 1

Indiana — 0 3 12 12 — 1 3 57 71 — 0 5 55 27

Michigan 1 1 6 64 73 1 1 6 80 119 2 1 4 64 45

Ohio — 1 3 39 47 — 1 30 89 94 — 0 1 6 9

Wisconsin — 0 1 6 22 — 0 3 31 54 — 0 1 2 10

W.N. Central — 1 25 39 75 — 2 16 123 114 — 0 6 8 20

Iowa — 0 1 8 11 — 0 1 10 14 — 0 0 — —

Kansas — 0 2 3 11 — 0 2 12 11 — 0 1 3 2

Minnesota — 0 22 9 15 — 0 15 9 8 — 0 6 2 10

Missouri — 0 1 12 20 — 2 5 79 67 — 0 0 — 6

Nebraska† — 0 1 5 14 — 0 3 12 12 — 0 1 3 2

North Dakota — 0 1 — 3 — 0 0 — — — 0 0 — —

South Dakota — 0 2 2 1 — 0 1 1 2 — 0 0 — —

S. Atlantic 1 4 12 227 332 12 12 56 668 872 6 4 11 231 182

Delaware — 0 1 2 7 — 0 2 13 24 U 0 0 U U

District of Columbia — 0 0 — 1 — 0 0 — 3 — 0 0 — 2

Florida 1 1 7 79 137 7 4 7 199 290 1 1 3 56 55

Georgia — 1 5 48 37 — 2 7 113 163 — 0 3 33 32

Maryland† — 0 4 25 22 2 1 4 58 66 1 0 3 35 24

North Carolina — 0 3 27 45 2 2 12 106 108 4 1 7 60 39

South Carolina† — 0 2 10 26 — 1 3 32 58 — 0 1 1 1

Virginia† — 0 3 28 49 1 1 6 68 90 — 0 3 20 12

West Virginia — 0 5 8 8 — 0 43 79 70 — 0 6 26 17

E.S. Central — 1 6 47 48 7 10 15 459 370 1 4 10 215 157

Alabama† — 0 2 7 8 1 2 6 109 65 — 0 3 18 7

Kentucky — 0 2 10 26 2 3 7 136 132 — 2 7 121 106

Mississippi — 0 1 7 2 — 1 4 44 33 U 0 0 U U

Tennessee† — 0 5 23 12 4 4 8 170 140 1 1 5 76 44

W.S. Central 1 3 15 128 141 3 6 67 296 553 — 2 11 83 68

Arkansas† — 0 1 1 2 — 1 4 48 62 — 0 0 — 1

Louisiana — 0 2 5 11 — 1 4 34 51 — 0 2 5 4

Oklahoma — 0 4 3 2 1 1 16 82 97 — 1 10 47 31

Texas† 1 2 11 119 126 2 3 45 132 343 — 0 3 31 32

Mountain — 1 5 57 140 1 1 4 73 133 — 1 5 62 64

Arizona — 0 2 16 61 — 0 3 16 26 U 0 0 U U

Colorado — 0 2 18 35 — 0 2 15 44 — 0 3 17 19

Idaho† — 0 1 6 7 — 0 1 2 6 — 0 2 10 11

Montana† — 0 1 2 4 — 0 0 — — — 0 1 3 3

Nevada† — 0 3 5 14 1 0 3 27 41 — 0 2 10 7

New Mexico† — 0 1 5 5 — 0 2 8 5 — 0 2 12 14

Utah — 0 2 3 10 — 0 1 5 8 — 0 2 8 10

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

Pacific 2 3 13 194 274 3 3 25 181 321 — 2 12 83 61

Alaska — 0 1 2 5 — 0 1 4 5 U 0 0 U U

California 1 3 12 151 225 — 2 22 114 227 — 1 4 38 27

Hawaii — 0 2 8 7 — 0 1 6 6 U 0 0 U U

Oregon — 0 2 9 17 2 0 4 31 40 — 0 3 13 15

Washington 1 0 4 24 20 1 0 4 26 43 — 0 5 32 19

Territories

American Samoa — 0 0 — — — 0 0 — — — 0 0 — —

C.N.M.I. — — — — — — — — — — — — — — —

Guam — 0 5 8 7 — 2 8 28 77 — 0 3 10 61

Puerto Rico — 0 1 7 20 — 0 2 8 28 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 2011 are provisional and subject to change. For further information on interpretation of these data, see http://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 

1720 MMWR / December 23, 2011 / Vol. 60 / No. 50

TABLE II. (Continued) Provisional cases of selected notifiable diseases, United States, weeks ending December 17, 2011, and December 18, 2010 (50th 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 

Med Max Med Max Med Max 2010

United States 29 56 160 3,550 3,225 175 323 1,470 23,045 29,538 7 25 114 1,309 1,641

New England — 5 39 390 264 1 76 493 6,743 8,838 — 2 20 87 102

Connecticut — 1 10 74 53 — 30 227 2,606 3,033 — 0 20 12 2

Maine† — 0 3 18 11 — 13 66 911 709 — 0 2 6 6

Massachusetts — 3 24 235 127 — 19 106 1,354 3,255 — 1 6 56 71

New Hampshire — 0 3 24 22 — 15 86 1,131 1,313 — 0 1 2 5

Rhode Island† — 0 9 28 42 — 1 31 147 181 — 0 2 5 15

Vermont† — 0 2 11 9 1 6 67 594 347 — 0 1 6 3

Mid. Atlantic 9 14 72 1,052 916 150 143 741 11,048 10,677 — 6 13 303 503

New Jersey — 0 2 — 148 — 0 34 — 3,657 — 0 2 — 102

New York (Upstate) 7 5 27 371 286 56 50 213 3,664 2,540 — 1 4 50 75

New York City — 3 14 200 161 — 1 12 110 720 — 4 10 198 268

Pennsylvania 2 5 37 481 321 94 90 516 7,274 3,760 — 1 5 55 58

E.N. Central 5 11 51 791 669 1 15 163 1,521 3,811 — 3 10 151 161

Illinois — 1 11 121 145 — 1 18 164 135 — 1 5 55 60

Indiana — 2 7 109 55 — 1 15 100 78 — 0 2 9 15

Michigan 1 3 15 188 178 1 1 12 107 94 — 0 4 32 31

Ohio 4 6 34 372 229 — 1 6 51 41 — 1 4 41 41

Wisconsin — 0 1 1 62 — 12 121 1,099 3,463 — 0 2 14 14

W.N. Central — 1 8 79 122 — 1 15 136 2,085 — 1 45 56 70

Iowa — 0 2 11 15 — 0 12 82 85 — 0 3 22 14

Kansas — 0 2 11 12 — 0 2 13 10 — 0 2 9 13

Minnesota — 0 4 — 35 — 0 3 — 1,954 — 0 45 — 3

Missouri — 1 5 47 37 — 0 2 8 4 — 0 2 20 21

Nebraska† — 0 1 6 9 — 0 2 8 8 — 0 1 4 15

North Dakota — 0 1 2 5 — 0 10 21 23 — 0 0 — 1

South Dakota — 0 1 2 9 — 0 2 4 1 — 0 1 1 3

S. Atlantic 6 10 29 569 540 18 54 172 3,337 3,766 3 8 24 425 438

Delaware — 0 4 24 17 — 12 48 804 644 — 0 3 7 2

District of Columbia — 0 3 9 18 — 0 3 31 41 — 0 1 5 13

Florida 3 3 13 180 164 5 2 7 126 80 2 2 6 100 131

Georgia — 1 3 41 63 — 0 5 25 10 — 1 5 73 69

Maryland† 1 2 14 128 110 9 19 114 1,231 1,611 1 2 14 125 99

North Carolina 1 1 7 77 62 — 0 12 70 80 — 0 6 38 52

South Carolina† — 0 5 22 16 — 0 6 33 29 — 0 1 6 6

Virginia† 1 1 7 82 76 4 16 76 940 1,151 — 1 8 71 63

West Virginia — 0 2 6 14 — 0 14 77 120 — 0 0 — 3

E.S. Central 2 2 11 163 132 1 1 5 61 43 — 0 4 35 31

Alabama† — 0 2 26 22 1 0 2 22 2 — 0 3 6 9

Kentucky — 1 4 47 27 — 0 1 2 5 — 0 2 9 8

Mississippi — 0 3 13 12 — 0 1 3 — — 0 1 1 2

Tennessee† 2 1 8 77 71 — 0 4 34 36 — 0 3 19 12

W.S. Central 1 2 13 130 168 2 1 29 52 112 1 0 18 31 95

Arkansas† — 0 2 14 19 — 0 0 — — — 0 1 5 4

Louisiana — 0 3 18 11 — 0 1 1 3 — 0 1 1 5

Oklahoma — 0 3 9 13 — 0 0 — — 1 0 1 6 5

Texas† 1 2 11 89 125 2 1 29 51 109 — 0 17 19 81

Mountain — 2 8 103 168 — 0 4 42 28 1 1 5 62 65

Arizona — 1 4 42 64 — 0 2 11 2 — 0 4 22 28

Colorado — 0 1 6 31 — 0 1 1 3 1 0 3 22 21

Idaho† — 0 1 8 8 — 0 2 4 9 — 0 1 2 3

Montana† — 0 1 1 4 — 0 3 11 4 — 0 1 2 3

Nevada† — 0 2 16 20 — 0 1 4 2 — 0 2 8 6

New Mexico† — 0 2 11 9 — 0 2 5 5 — 0 1 3 1

Utah — 0 2 15 24 — 0 1 4 3 — 0 1 3 3

Wyoming† — 0 2 4 8 — 0 1 2 — — 0 0 — —

Pacific 6 5 21 273 246 2 2 11 105 178 2 3 11 159 176

Alaska — 0 0 — 2 — 0 2 12 7 — 0 2 5 5

California 5 4 15 229 202 — 1 9 64 118 2 2 8 108 115

Hawaii — 0 2 3 2 N 0 0 N N — 0 1 8 4

Oregon — 0 3 19 16 — 0 2 12 39 — 0 4 17 14

Washington 1 0 6 22 24 2 0 6 17 14 — 0 3 21 38

Territories

American Samoa N 0 0 N N N 0 0 N N — 0 1 1 —

C.N.M.I. — — — — — — — — — — — — — — —

Guam — 0 0 — 1 — 0 0 — — — 0 0 — —

Puerto Rico — 0 0 — 2 N 0 0 N N — 0 0 — 5

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 2011 are provisional and subject to change. For further information on interpretation of these data, see http://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 / December 23, 2011 / Vol. 60 / No. 50 1721

TABLE II. (Continued) Provisional cases of selected notifiable diseases, United States, weeks ending December 17, 2011, and December 18, 2010 (50th 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 

Med Max Med Max Med Max 2010

United States 2 12 53 643 761 4 7 47 337 2,547 168 287 2,925 14,249 23,983

New England — 0 3 29 21 — 0 2 10 25 3 14 32 700 507

Connecticut — 0 1 3 3 — 0 0 — 11 — 1 5 56 105

Maine§ — 0 1 5 5 — 0 2 2 2 2 3 19 199 51

Massachusetts — 0 2 14 7 — 0 1 4 9 — 4 10 222 274

New Hampshire — 0 1 1 — — 0 0 — 3 1 2 13 143 20

Rhode Island§ — 0 1 1 1 — 0 2 3 — — 0 4 28 40

Vermont§ — 0 3 5 5 — 0 1 1 — — 0 10 52 17

Mid. Atlantic — 1 5 70 77 — 1 23 48 2,115 54 31 112 1,731 1,801

New Jersey — 0 1 — 21 — 0 2 10 353 — 3 10 168 164

New York (Upstate) — 0 4 22 12 — 0 3 11 663 42 12 81 756 610

New York City — 0 3 28 18 — 0 22 24 1,039 — 2 41 150 85

Pennsylvania — 0 2 20 26 — 0 8 3 60 12 12 40 657 942

E.N. Central — 2 6 94 127 1 2 6 85 79 28 65 129 3,120 5,512

Illinois — 0 3 28 23 — 1 5 54 29 — 17 49 883 1,001

Indiana — 0 2 19 29 — 0 1 1 4 — 4 18 243 729

Michigan — 0 2 11 22 — 0 2 11 18 6 12 41 632 1,497

Ohio — 0 2 23 32 1 0 2 15 23 19 13 45 733 1,738

Wisconsin — 0 2 13 21 — 0 1 4 5 3 12 26 629 547

W.N. Central — 1 3 51 57 — 0 4 32 81 10 20 501 1,117 2,384

Iowa — 0 1 14 10 — 0 1 5 38 — 4 15 194 670

Kansas — 0 1 4 8 — 0 1 4 4 — 2 8 87 177

Minnesota — 0 1 — 8 — 0 4 1 4 — 0 469 326 662

Missouri — 0 3 18 23 — 0 3 12 10 10 6 26 378 589

Nebraska§ — 0 2 11 6 — 0 1 6 23 — 1 7 51 206

North Dakota — 0 1 1 2 — 0 3 4 — — 0 10 51 51

South Dakota — 0 1 3 — — 0 0 — 2 — 0 7 30 29

S. Atlantic — 2 8 125 129 — 0 4 36 56 15 26 106 1,340 1,854

Delaware — 0 1 1 1 — 0 0 — — 1 0 5 23 14

District of Columbia — 0 1 1 1 — 0 0 — 3 — 0 2 6 15

Florida — 1 5 49 58 — 0 2 10 8 4 6 17 309 307

Georgia — 0 1 14 12 — 0 2 5 5 1 3 8 167 238

Maryland§ — 0 1 13 9 — 0 1 2 11 — 2 8 114 135

North Carolina — 0 3 15 13 — 0 2 9 10 8 2 35 177 337

South Carolina§ — 0 1 9 12 — 0 1 1 4 1 2 25 140 363

Virginia§ — 0 2 16 21 — 0 4 9 13 — 6 41 341 320

West Virginia — 0 3 7 2 — 0 0 — 2 — 0 41 63 125

E.S. Central 1 0 3 26 43 — 0 1 5 10 8 9 25 439 822

Alabama§ — 0 2 10 8 — 0 1 1 6 — 2 11 129 200

Kentucky — 0 2 5 17 — 0 0 — 1 3 3 16 164 291

Mississippi — 0 1 3 5 — 0 1 3 — 1 0 3 41 105

Tennessee§ 1 0 2 8 13 — 0 1 1 3 4 2 10 105 226

W.S. Central — 1 12 57 86 3 1 15 67 117 9 20 297 895 2,982

Arkansas§ — 0 2 12 6 — 0 2 3 5 — 1 16 58 226

Louisiana — 0 2 12 15 — 0 0 — 8 — 0 3 17 46

Oklahoma — 0 2 10 16 — 0 2 4 — — 0 92 52 91

Texas§ — 0 10 23 49 3 1 14 60 104 9 18 187 768 2,619

Mountain 1 1 4 47 55 — 0 2 8 20 28 37 79 1,932 1,826

Arizona — 0 1 11 13 — 0 0 — 5 — 13 28 656 516

Colorado 1 0 1 10 21 — 0 1 3 7 22 8 31 424 487

Idaho§ — 0 1 7 5 — 0 2 2 1 6 2 12 179 185

Montana§ — 0 2 4 2 — 0 0 — — — 1 32 130 113

Nevada§ — 0 1 5 8 — 0 0 — 1 — 0 5 31 38

New Mexico§ — 0 1 2 3 — 0 1 2 2 — 3 23 249 143

Utah — 0 2 8 1 — 0 0 — 3 — 5 16 254 332

Wyoming§ — 0 1 — 2 — 0 1 1 1 — 0 1 9 12

Pacific — 3 26 144 166 — 0 11 46 44 13 61 1,710 2,975 6,295

Alaska — 0 1 3 1 — 0 1 1 1 — 0 4 25 41

California — 2 17 100 110 — 0 11 37 29 4 37 1,569 1,940 5,462

Hawaii — 0 1 4 1 — 0 1 2 4 2 1 9 92 64

Oregon — 0 3 22 31 — 0 1 4 3 3 5 23 295 276

Washington — 0 8 15 23 — 0 1 2 7 4 11 131 623 452

Territories

American Samoa — 0 0 — — — 0 0 — — — 0 0 — —

C.N.M.I. — — — — — — — — — — — — — — —

Guam — 0 0 — — — 1 3 12 484 — 2 14 31 3

Puerto Rico — 0 0 — 2 — 0 1 1 1 — 0 1 2 4

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 2011 are provisional and subject to change. For further information on interpretation of these data, see http://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 

1722 MMWR / December 23, 2011 / Vol. 60 / No. 50

TABLE II. (Continued) Provisional cases of selected notifiable diseases, United States, weeks ending December 17, 2011, and December 18, 2010 (50th week)*

Reporting area

Rabies, animal Salmonellosis Shiga toxin-producing E. 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 

Med Max Med Max Med Max 2010

United States 19 57 119 2,863 4,172 396 856 1,816 44,660 52,475 41 89 264 4,832 5,154

New England 2 4 16 253 301 5 36 107 2,028 2,306 — 3 13 209 209

Connecticut — 2 10 121 142 — 8 30 445 491 — 1 4 53 60

Maine§ — 1 6 63 62 — 2 8 127 128 — 0 3 29 21

Massachusetts — 0 0 — — — 19 44 1,041 1,266 — 1 9 80 82

New Hampshire 2 0 3 20 17 1 3 8 159 171 — 0 3 24 21

Rhode Island§ — 0 6 25 29 4 1 62 181 170 — 0 2 7 3

Vermont§ — 0 2 24 51 — 1 8 75 80 — 0 3 16 22

Mid. Atlantic 5 15 35 810 1,028 32 72 169 4,218 5,705 5 8 30 484 559

New Jersey — 0 0 — — — 0 15 — 1,176 — 0 2 — 125

New York (Upstate) 5 7 20 361 485 18 25 67 1,356 1,388 5 3 12 213 196

New York City — 0 3 9 145 — 19 42 1,085 1,288 — 1 6 89 79

Pennsylvania — 8 21 440 398 14 30 111 1,777 1,853 — 3 18 182 159

E.N. Central — 2 17 180 228 22 83 157 4,208 5,736 2 14 49 842 797

Illinois — 0 6 50 114 — 27 80 1,527 1,942 — 4 14 215 152

Indiana — 0 7 26 — — 7 19 351 755 — 1 8 86 139

Michigan — 1 6 57 68 8 14 42 814 918 — 3 19 179 152

Ohio — 1 5 47 46 14 21 46 1,162 1,286 2 3 10 180 135

Wisconsin N 0 0 N N — 7 45 354 835 — 2 20 182 219

W.N. Central 1 1 40 78 241 14 40 103 2,245 2,942 5 11 40 725 895

Iowa — 0 0 — 27 1 9 19 441 520 — 2 15 183 170

Kansas — 0 4 31 59 — 8 28 443 426 — 1 8 104 76

Minnesota — 0 34 — 25 — 0 6 — 700 — 0 2 — 287

Missouri 1 0 0 1 63 13 16 46 933 821 5 5 32 292 233

Nebraska§ — 0 3 33 51 — 4 13 232 243 — 1 7 95 77

North Dakota — 0 6 13 16 — 0 15 41 51 — 0 4 13 17

South Dakota — 0 0 — — — 3 10 155 181 — 1 4 38 35

S. Atlantic 6 15 93 1,023 1,113 167 267 722 14,191 15,450 8 12 28 645 721

Delaware — 0 0 — — — 2 11 164 175 — 0 2 15 6

District of Columbia — 0 0 — — — 1 5 52 91 — 0 1 3 9

Florida — 0 84 117 121 105 107 203 5,732 6,124 5 3 15 150 217

Georgia — 0 0 — — 15 40 127 2,361 2,750 — 2 8 116 98

Maryland§ — 5 13 247 358 14 18 42 931 1,064 3 1 6 59 106

North Carolina — 0 0 — — 21 31 251 2,270 2,271 — 2 11 120 97

South Carolina§ N 0 0 N N 6 26 70 1,481 1,675 — 0 4 15 24

Virginia§ 6 11 27 578 557 6 21 68 1,155 1,123 — 3 9 164 139

West Virginia — 0 30 81 77 — 0 14 45 177 — 0 2 3 25

E.S. Central 1 3 11 170 169 18 61 190 4,075 3,898 1 5 18 263 267

Alabama§ 1 2 7 81 69 7 18 70 1,199 1,038 — 0 15 71 55

Kentucky — 0 2 16 21 — 10 30 569 583 — 1 5 67 70

Mississippi — 0 1 1 — 3 21 66 1,315 1,203 — 0 4 24 30

Tennessee§ — 1 6 72 79 8 16 52 992 1,074 1 1 11 101 112

W.S. Central 3 1 31 112 826 56 118 515 6,371 7,217 2 9 151 418 367

Arkansas§ 3 0 10 57 34 10 14 53 842 763 — 1 6 60 48

Louisiana — 0 0 — — 5 14 44 971 1,342 — 0 1 12 20

Oklahoma — 0 21 55 42 14 12 95 713 651 1 1 55 71 49

Texas§ — 0 12 — 750 27 83 381 3,845 4,461 1 6 95 275 250

Mountain 1 0 4 42 66 25 44 93 2,381 2,834 3 10 26 532 668

Arizona N 0 0 N N 13 14 34 775 978 1 2 7 81 98

Colorado — 0 0 — — 9 10 24 528 561 1 2 7 106 219

Idaho§ — 0 1 6 11 — 3 8 141 162 — 2 8 116 108

Montana§ N 0 0 N N 2 2 10 124 94 1 0 5 39 41

Nevada§ — 0 2 16 8 1 3 8 158 302 — 0 7 39 41

New Mexico§ 1 0 2 13 13 — 5 22 309 333 — 1 3 41 49

Utah — 0 2 7 10 — 5 15 291 342 — 1 7 85 93

Wyoming§ — 0 0 — 24 — 1 9 55 62 — 0 7 25 19

Pacific — 3 15 195 200 57 100 288 4,943 6,387 15 15 46 714 671

Alaska — 0 2 12 12 — 1 6 52 79 — 0 1 4 2

California — 3 12 169 171 32 74 232 3,777 4,767 6 9 36 442 310

Hawaii — 0 0 — — 3 7 14 332 318 — 0 2 9 28

Oregon — 0 1 14 17 1 5 12 251 501 1 1 11 101 115

Washington — 0 14 — — 21 9 42 531 722 8 2 13 158 216

Territories

American Samoa N 0 0 N N — 0 0 — 2 — 0 0 — —

C.N.M.I. — — — — — — — — — — — — — — —

Guam — 0 0 — — — 0 3 6 11 — 0 0 — —

Puerto Rico — 0 6 38 41 3 3 12 193 604 — 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 2011 are provisional and subject to change. For further information on interpretation of these data, see http://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

MMWR / December 23, 2011 / Vol. 60 / No. 50 1723

TABLE II. (Continued) Provisional cases of selected notifiable diseases, United States, weeks ending December 17, 2011, and December 18, 2010 (50th 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 

Med Max Med Max Med Max 2010

United States 165 233 742 11,244 13,765 3 3 15 202 145 9 26 245 1,952 1,570

New England — 5 21 261 316 — 0 1 1 — — 0 1 8 5

Connecticut — 0 4 37 69 — 0 0 — — — 0 0 — —

Maine§ — 0 8 32 8 — 0 0 — — — 0 1 1 2

Massachusetts — 3 20 175 208 — 0 0 — — — 0 1 4 —

New Hampshire — 0 1 3 14 — 0 1 1 — — 0 1 1 1

Rhode Island§ — 0 3 8 16 — 0 0 — — — 0 1 2 2

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

Mid. Atlantic 20 14 74 809 1,558 1 0 2 20 2 3 1 4 59 101

New Jersey — 0 3 — 367 — 0 0 — 1 — 0 1 — 59

New York (Upstate) 18 5 20 322 218 1 0 1 5 1 2 0 1 10 17

New York City 2 6 27 369 294 — 0 0 — — — 0 3 29 11

Pennsylvania — 2 56 118 679 — 0 2 15 — 1 0 3 20 14

E.N. Central 7 14 40 716 1,516 1 0 2 9 3 — 2 9 113 77

Illinois — 4 16 204 828 — 0 1 2 2 — 1 4 47 34

Indiana§ — 1 4 45 62 — 0 1 2 1 — 0 4 46 20

Michigan 1 3 10 169 251 1 0 1 2 — — 0 1 2 1

Ohio 6 4 27 298 302 — 0 2 3 — — 0 2 18 15

Wisconsin — 0 1 — 73 — 0 0 — — — 0 0 — 7

W.N. Central 1 5 18 288 2,042 — 0 4 27 13 1 4 29 346 275

Iowa — 0 4 20 55 — 0 0 — — — 0 2 7 5

Kansas§ — 1 6 60 291 — 0 0 — — — 0 0 — —

Minnesota — 0 2 — 66 — 0 0 — — — 0 2 — —

Missouri 1 3 14 188 1,567 — 0 3 19 10 1 4 29 334 267

Nebraska§ — 0 2 14 56 — 0 3 5 3 — 0 1 5 2

North Dakota — 0 0 — — — 0 1 2 — — 0 0 — 1

South Dakota — 0 2 6 7 — 0 1 1 — — 0 0 — —

S. Atlantic 65 73 134 3,691 2,657 1 1 8 104 82 3 6 55 550 503

Delaware§ — 0 2 6 39 — 0 1 1 1 — 0 4 18 21

District of Columbia — 0 5 20 34 — 0 1 1 1 — 0 1 3 —

Florida§ 49 50 98 2,575 1,135 — 0 1 3 3 1 0 2 13 11

Georgia 10 10 24 567 777 — 1 6 65 57 — 0 0 — —

Maryland§ 2 1 7 98 129 1 0 1 4 — — 0 2 30 49

North Carolina 1 3 19 205 237 — 0 4 15 15 — 0 49 264 269

South Carolina§ 1 1 52 117 69 — 0 2 11 1 — 0 2 21 19

Virginia§ 2 2 8 99 133 — 0 1 4 4 2 3 14 197 134

West Virginia — 0 5 4 104 — 0 0 — — — 0 1 4 —

E.S. Central 3 17 46 930 770 — 0 2 14 20 2 4 25 334 403

Alabama§ 1 5 21 285 229 — 0 1 5 5 1 1 8 73 78

Kentucky — 3 22 227 221 — 0 1 3 6 — 0 1 1 —

Mississippi 1 4 24 228 58 — 0 0 — 1 — 0 2 12 25

Tennessee§ 1 4 11 190 262 — 0 2 6 8 1 3 20 248 300

W.S. Central 41 52 503 2,711 2,852 — 0 8 11 7 — 2 235 485 185

Arkansas§ 2 2 7 78 77 — 0 3 6 2 — 0 50 416 130

Louisiana 3 5 21 277 287 — 0 0 — — — 0 2 7 3

Oklahoma 8 2 161 207 254 — 0 5 3 3 — 0 202 43 26

Texas§ 28 42 338 2,149 2,234 — 0 1 2 2 — 0 5 19 26

Mountain 10 15 42 794 836 — 0 4 15 12 — 1 7 57 20

Arizona 6 5 27 369 459 — 0 4 15 9 — 0 6 40 8

Colorado§ 1 1 8 99 96 — 0 0 — 1 — 0 1 2 1

Idaho§ — 0 3 16 23 — 0 0 — — — 0 1 1 5

Montana§ 1 1 15 123 9 — 0 0 — 2 — 0 1 1 1

Nevada§ 2 0 4 33 48 — 0 0 — — — 0 1 2 —

New Mexico§ — 2 7 105 154 — 0 0 — — — 0 0 — 1

Utah — 1 4 47 47 — 0 0 — — — 0 1 1 3

Wyoming§ — 0 1 2 — — 0 0 — — — 0 2 10 1

Pacific 18 20 63 1,044 1,218 — 0 2 1 6 — 0 0 — 1

Alaska — 0 2 5 2 N 0 0 N N N 0 0 N N

California 6 16 59 859 1,002 — 0 1 1 6 — 0 0 — —

Hawaii — 1 3 44 46 N 0 0 N N N 0 0 N N

Oregon 2 1 4 44 58 — 0 0 — — — 0 0 — 1

Washington 10 1 6 92 110 — 0 1 — — — 0 0 — —

Territories

American Samoa — 0 1 1 4 N 0 0 N N N 0 0 N N

C.N.M.I. — — — — — — — — — — — — — — —

Guam — 0 1 1 5 N 0 0 N N N 0 0 N N

Puerto Rico — 0 1 — 6 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 2011 are provisional and subject to change. For further information on interpretation of these data, see http://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 

1724 MMWR / December 23, 2011 / Vol. 60 / No. 50

TABLE II. (Continued) Provisional cases of selected notifiable diseases, United States, weeks ending December 17, 2011, and December 18, 2010 (50th 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 

Med Max Med Max Med Max 2010

United States 154 241 937 12,202 15,052 17 24 118 1,149 2,019 69 262 363 12,325 13,213

New England 3 13 79 678 851 — 1 5 45 100 1 7 16 356 463

Connecticut — 6 49 282 340 — 0 3 10 27 — 0 5 41 93

Maine§ 2 2 13 124 116 — 0 1 4 10 — 0 2 12 31

Massachusetts — 1 3 35 67 — 0 2 18 44 — 5 10 237 277

New Hampshire — 2 8 97 129 — 0 1 5 5 — 0 3 18 22

Rhode Island§ — 1 6 73 117 — 0 1 2 8 — 0 7 39 37

Vermont§ 1 1 6 67 82 — 0 2 6 6 1 0 2 9 3

Mid. Atlantic 8 14 81 691 1,576 2 1 27 75 232 11 31 53 1,474 1,636

New Jersey — 0 29 — 705 — 0 4 — 58 — 5 13 212 235

New York (Upstate) 3 1 10 83 144 2 1 9 46 110 5 3 20 181 124

New York City 5 11 42 608 727 — 0 14 29 64 2 15 30 725 921

Pennsylvania N 0 0 N N N 0 0 N N 4 6 15 356 356

E.N. Central 45 61 115 2,897 3,123 5 5 13 240 358 — 30 47 1,429 1,839

Illinois N 0 0 N N — 1 6 73 95 — 12 24 584 880

Indiana 1 13 33 648 733 — 1 3 32 55 — 3 8 153 169

Michigan 3 14 26 631 710 — 1 3 34 80 — 5 12 243 227

Ohio 35 26 44 1,207 1,175 3 2 7 80 94 — 8 17 398 514

Wisconsin 6 8 24 411 505 2 0 3 21 34 — 1 5 51 49

W.N. Central — 2 33 162 829 — 1 4 64 153 1 6 13 278 346

Iowa N 0 0 N N N 0 0 N N — 0 3 18 18

Kansas N 0 0 N N N 0 0 N N — 0 4 24 19

Minnesota — 0 17 — 620 — 0 1 — 85 — 2 8 109 145

Missouri N 0 0 N N — 0 4 36 39 — 2 6 117 147

Nebraska§ — 2 9 108 136 — 0 2 12 16 1 0 2 9 10

North Dakota — 0 25 54 73 — 0 1 2 2 — 0 1 1 3

South Dakota N 0 0 N N — 0 2 14 11 — 0 0 — 4

S. Atlantic 44 66 170 3,524 4,000 5 6 25 325 540 34 68 178 3,268 3,072

Delaware — 1 6 47 40 — 0 1 — — 4 0 4 24 5

District of Columbia — 1 4 44 75 — 0 1 5 9 2 3 8 152 132

Florida 26 22 68 1,265 1,401 3 3 13 127 188 5 24 36 1,151 1,157

Georgia 11 20 54 980 1,364 1 2 5 83 159 14 14 130 734 663

Maryland§ 7 9 33 524 506 1 1 3 41 52 — 8 20 417 308

North Carolina N 0 0 N N N 0 0 N N 4 8 19 366 383

South Carolina§ — 7 25 408 493 — 0 3 28 55 4 4 11 215 144

Virginia§ N 0 0 N N — 0 3 27 55 1 4 12 207 274

West Virginia — 0 48 256 121 — 0 6 14 22 — 0 1 2 6

E.S. Central 10 18 37 867 1,028 2 1 4 70 111 5 14 34 720 858

Alabama§ N 0 0 N N N 0 0 N N 1 4 11 201 249

Kentucky N 0 0 N N N 0 0 N N 4 2 16 120 122

Mississippi N 0 0 N N — 0 2 11 17 — 3 14 167 214

Tennessee§ 10 18 37 867 1,028 2 1 4 59 94 — 5 11 232 273

W.S. Central 25 31 368 1,709 1,843 3 4 38 197 287 6 35 50 1,711 2,030

Arkansas§ 6 4 26 212 164 1 0 3 14 18 4 3 10 181 203

Louisiana — 2 11 157 137 — 0 2 16 27 2 6 25 366 537

Oklahoma N 0 0 N N 1 1 8 36 46 — 1 4 50 88

Texas§ 19 24 333 1,340 1,542 1 2 27 131 196 — 23 37 1,114 1,202

Mountain 19 27 72 1,528 1,693 — 3 8 118 221 — 11 20 541 599

Arizona 11 12 45 714 772 — 1 5 53 97 — 5 10 226 218

Colorado 8 9 23 489 519 — 0 4 33 63 — 2 6 104 137

Idaho§ N 0 0 N N — 0 1 5 8 — 0 4 12 4

Montana§ N 0 0 N N N 0 0 N N — 0 1 4 3

Nevada§ N 0 0 N N N 0 0 N N — 2 9 127 124

New Mexico§ — 4 13 225 157 — 0 2 15 17 — 1 4 57 51

Utah — 1 8 77 216 — 0 3 12 32 — 0 2 11 62

Wyoming§ — 0 3 23 29 — 0 0 — 4 — 0 0 — —

Pacific — 3 11 146 109 — 0 2 15 17 11 53 74 2,548 2,370

Alaska — 2 11 139 105 — 0 1 11 17 — 0 1 3 3

California N 0 0 N N N 0 0 N N 6 42 62 2,077 2,006

Hawaii — 0 1 7 4 — 0 1 4 — — 0 2 11 35

Oregon N 0 0 N N N 0 0 N N 2 4 14 185 70

Washington N 0 0 N N N 0 0 N N 3 5 11 272 256

Territories

American Samoa N 0 0 N N — 0 0 — — — 0 0 — —

C.N.M.I. — — — — — — — — — — — — — — —

Guam — 0 0 — — — 0 0 — — — 0 0 — —

Puerto Rico — 0 0 — — — 0 0 — — — 4 14 232 215

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 2011 are provisional and subject to change. For further information on interpretation of these data, see http://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

MMWR / December 23, 2011 / Vol. 60 / No. 50 1725

TABLE II. (Continued) Provisional cases of selected notifiable diseases, United States, weeks ending December 17, 2011, and December 18, 2010 (50th 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 

Med Max Med Max Med Max 2010

United States 147 256 364 11,542 14,856 — 0 59 460 629 — 0 32 222 392

New England 4 23 50 1,149 1,127 — 0 3 14 14 — 0 1 2 5

Connecticut 2 5 16 283 315 — 0 2 8 7 — 0 1 1 4

Maine¶ — 4 11 201 237 — 0 0 — — — 0 0 — —

Massachusetts — 9 18 429 253 — 0 2 4 6 — 0 1 1 1

New Hampshire — 1 7 102 156 — 0 0 — 1 — 0 0 — —

Rhode Island¶ — 0 6 34 46 — 0 1 1 — — 0 0 — —

Vermont¶ 2 1 9 100 120 — 0 1 1 — — 0 0 — —

Mid. Atlantic 15 19 42 963 1,685 — 0 11 34 123 — 0 6 22 63

New Jersey — 0 9 — 559 — 0 1 2 15 — 0 2 5 15

New York (Upstate) N 0 0 N N — 0 5 18 56 — 0 4 14 30

New York City — 0 0 — — — 0 4 9 33 — 0 1 2 9

Pennsylvania 15 19 39 963 1,126 — 0 2 5 19 — 0 1 1 9

E.N. Central 49 63 110 2,965 4,793 — 0 13 73 80 — 0 6 27 30

Illinois 1 14 31 713 1,183 — 0 6 22 45 — 0 5 12 16

Indiana¶ 11 5 20 268 355 — 0 2 7 6 — 0 1 2 7

Michigan 16 18 43 970 1,435 — 0 7 32 25 — 0 1 1 4

Ohio 21 21 58 1,012 1,311 — 0 3 10 4 — 0 3 11 1

Wisconsin — 0 13 2 509 — 0 1 2 — — 0 1 1 2

W.N. Central — 21 64 702 979 — 0 9 31 32 — 0 7 29 75

Iowa N 0 0 N N — 0 2 5 5 — 0 2 4 4

Kansas¶ — 15 61 403 372 — 0 1 4 4 — 0 0 — 15

Minnesota — 0 1 1 — — 0 1 1 4 — 0 1 1 4

Missouri — 3 24 200 474 — 0 2 6 3 — 0 2 4 —

Nebraska¶ — 0 2 7 25 — 0 4 14 10 — 0 3 15 29

North Dakota — 0 10 36 49 — 0 1 1 2 — 0 1 3 7

South Dakota — 1 6 55 59 — 0 0 — 4 — 0 1 2 16

S. Atlantic 10 32 65 1,674 2,049 — 0 10 52 38 — 0 7 28 22

Delaware¶ — 0 1 8 39 — 0 1 1 — — 0 0 — —

District of Columbia — 0 2 12 20 — 0 1 3 3 — 0 5 11 3

Florida¶ 7 17 38 837 952 — 0 5 20 9 — 0 2 3 3

Georgia N 0 0 N N — 0 2 7 4 — 0 1 5 9

Maryland¶ N 0 0 N N — 0 5 10 17 — 0 3 9 6

North Carolina N 0 0 N N — 0 1 2 — — 0 0 — —

South Carolina¶ — 0 9 12 77 — 0 0 — 1 — 0 0 — —

Virginia¶ 3 8 26 437 529 — 0 2 8 4 — 0 0 — 1

West Virginia — 5 32 368 432 — 0 1 1 — — 0 0 — —

E.S. Central 5 5 15 258 298 — 0 11 55 8 — 0 5 25 10

Alabama¶ 4 5 14 245 289 — 0 2 5 1 — 0 0 — 2

Kentucky N 0 0 N N — 0 2 4 2 — 0 1 1 1

Mississippi 1 0 3 13 9 — 0 5 30 3 — 0 4 22 5

Tennessee¶ N 0 0 N N — 0 3 16 2 — 0 1 2 2

W.S. Central 49 48 258 2,609 2,769 — 0 4 26 104 — 0 3 11 20

Arkansas¶ — 5 20 292 192 — 0 1 1 6 — 0 0 — 1

Louisiana — 1 6 75 89 — 0 1 6 20 — 0 2 4 7

Oklahoma N 0 0 N N — 0 0 — 1 — 0 0 — —

Texas¶ 49 43 247 2,242 2,488 — 0 3 19 77 — 0 3 7 12

Mountain 15 18 65 1,089 1,035 — 0 10 65 157 — 0 5 33 127

Arizona — 4 50 418 — — 0 6 43 107 — 0 4 19 60

Colorado¶ 12 4 31 279 399 — 0 2 2 26 — 0 2 5 55

Idaho¶ N 0 0 N N — 0 1 1 — — 0 1 1 1

Montana¶ 1 2 28 133 188 — 0 1 1 — — 0 0 — —

Nevada¶ N 0 0 N N — 0 4 12 — — 0 2 4 2

New Mexico¶ 2 1 4 43 95 — 0 1 4 21 — 0 0 — 4

Utah — 3 26 204 332 — 0 1 1 1 — 0 1 2 1

Wyoming¶ — 0 1 12 21 — 0 1 1 2 — 0 1 2 4

Pacific — 3 9 133 121 — 0 18 110 73 — 0 7 45 40

Alaska — 1 4 64 48 — 0 0 — — — 0 0 — —

California — 0 4 29 35 — 0 18 110 72 — 0 7 45 39

Hawaii — 1 4 40 38 — 0 0 — — — 0 0 — —

Oregon N 0 0 N N — 0 0 — — — 0 0 — —

Washington N 0 0 N N — 0 0 — 1 — 0 0 — 1

Territories

American Samoa N 0 0 N N — 0 0 — — — 0 0 — —

C.N.M.I. — — — — — — — — — — — — — — —

Guam — 2 4 16 28 — 0 0 — — — 0 0 — —

Puerto Rico — 4 14 179 619 — 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 2011 are provisional and subject to change. For further information on interpretation of these data, see http://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 at http://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 

1726 MMWR / December 23, 2011 / Vol. 60 / No. 50

TABLE III. Deaths in 122 U.S. cities,* week ending December 17, 2011 (50th 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 498 340 111 28 13 6 36 S. Atlantic 1,137 696 303 79 32 27 56

Boston, MA 135 85 34 7 7 2 13 Atlanta, GA 154 74 60 11 5 4 6

Bridgeport, CT 28 21 5 1 — 1 1 Baltimore, MD 173 83 62 16 7 5 9

Cambridge, MA 16 10 5 — 1 — — Charlotte, NC 138 87 31 11 7 2 8

Fall River, MA 24 20 3 1 — — 4 Jacksonville, FL 21 17 3 1 — — 1

Hartford, CT 47 28 15 2 1 1 1 Miami, FL 102 70 19 9 2 2 6

Lowell, MA 20 15 5 — — — 2 Norfolk, VA 52 33 9 4 3 3 6

Lynn, MA 4 3 — — 1 — — Richmond, VA 65 36 18 7 3 1 —

New Bedford, MA 23 16 5 1 1 — 1 Savannah, GA 55 36 12 6 — 1 1

New Haven, CT 37 21 8 6 1 1 — St. Petersburg, FL 57 41 11 2 2 1 4

Providence, RI 43 30 5 7 1 — 2 Tampa, FL 203 143 47 5 1 7 11

Somerville, MA 4 3 1 — — — — Washington, D.C. 103 65 28 7 2 1 3

Springfield, MA 30 20 9 1 — — 4 Wilmington, DE 14 11 3 — — — 1

Waterbury, CT 35 29 5 1 — — 1 E.S. Central 976 631 245 53 24 23 82

Worcester, MA 52 39 11 1 — 1 7 Birmingham, AL 193 126 47 8 4 8 15

Mid. Atlantic 2,149 1,485 495 102 39 28 81 Chattanooga, TN 118 83 26 5 3 1 7

Albany, NY 62 46 12 1 1 2 1 Knoxville, TN 110 84 24 2 — — 16

Allentown, PA 21 16 4 1 — — 3 Lexington, KY 71 46 15 7 1 2 4

Buffalo, NY 81 59 18 4 — — 4 Memphis, TN 175 95 59 10 5 6 18

Camden, NJ 22 12 7 — 2 1 — Mobile, AL 125 81 30 8 5 1 9

Elizabeth, NJ 19 9 10 — — — 2 Montgomery, AL 43 28 9 3 1 2 2

Erie, PA 53 43 8 2 — — 3 Nashville, TN 141 88 35 10 5 3 11

Jersey City, NJ 15 8 5 2 — — 1 W.S. Central 1,249 798 311 78 30 27 64

New York City, NY 1,168 811 262 53 25 17 38 Austin, TX 92 61 25 4 2 — 6

Newark, NJ 49 27 13 8 1 — 1 Baton Rouge, LA 64 44 15 4 1 — —

Paterson, NJ U U U U U U U Corpus Christi, TX 65 35 18 9 3 — 5

Philadelphia, PA 357 214 106 21 9 7 11 Dallas, TX 242 151 62 19 5 3 11

Pittsburgh, PA§ 32 24 6 1 1 — 1 El Paso, TX 83 64 13 5 1 — 3

Reading, PA 36 28 7 1 — — — Fort Worth, TX U U U U U U U

Rochester, NY 67 51 13 2 — 1 5 Houston, TX 92 53 23 4 3 8 4

Schenectady, NY 22 18 4 — — — 4 Little Rock, AR 73 47 19 3 — 3 4

Scranton, PA 28 23 2 3 — — 1 New Orleans, LA U U U U U U U

Syracuse, NY 77 61 14 2 — — 3 San Antonio, TX 288 180 77 16 10 5 20

Trenton, NJ 13 11 2 — — — 1 Shreveport, LA 114 65 32 7 3 7 1

Utica, NY 10 9 — 1 — — 1 Tulsa, OK 136 98 27 7 2 1 10

Yonkers, NY 17 15 2 — — — 1 Mountain 1,194 839 247 61 25 21 76

E.N. Central 2,198 1,454 534 113 51 46 142 Albuquerque, NM 89 64 16 3 6 — 9

Akron, OH 69 46 19 2 — 2 9 Boise, ID 56 42 11 1 1 1 4

Canton, OH 41 24 15 1 — 1 3 Colorado Springs, CO 71 50 14 2 2 3 —

Chicago, IL 245 162 52 17 12 2 22 Denver, CO 91 63 18 6 1 3 5

Cincinnati, OH 73 44 22 2 2 3 6 Las Vegas, NV 314 225 66 12 7 4 18

Cleveland, OH 247 171 52 11 8 5 15 Ogden, UT 24 16 4 4 — — 2

Columbus, OH 365 242 84 24 6 9 25 Phoenix, AZ 180 120 43 9 2 6 13

Dayton, OH 135 97 27 6 2 3 10 Pueblo, CO 48 26 16 6 — — 2

Detroit, MI 193 94 69 21 4 5 — Salt Lake City, UT 124 85 26 9 4 — 13

Evansville, IN 48 29 18 1 — — 3 Tucson, AZ 197 148 33 9 2 4 10

Fort Wayne, IN 68 46 14 5 3 — 4 Pacific 1,834 1,308 376 93 33 23 181

Gary, IN 11 7 3 — 1 — — Berkeley, CA 9 6 3 — — — 1

Grand Rapids, MI 67 54 10 1 — 2 6 Fresno, CA 132 82 29 11 7 3 23

Indianapolis, IN 188 122 50 5 5 6 12 Glendale, CA 27 21 5 1 — — 7

Lansing, MI 70 55 14 1 — — 5 Honolulu, HI 69 51 12 3 — 3 6

Milwaukee, WI 99 59 29 6 2 3 7 Long Beach, CA 70 49 14 3 3 1 9

Peoria, IL 47 32 10 2 — 3 2 Los Angeles, CA 292 208 60 16 4 4 41

Rockford, IL 42 29 10 1 2 — 2 Pasadena, CA 25 20 3 2 — — 2

South Bend, IN 42 29 8 2 1 2 4 Portland, OR 143 94 36 8 3 1 6

Toledo, OH 76 58 13 2 3 — 5 Sacramento, CA 203 146 48 6 1 2 17

Youngstown, OH 72 54 15 3 — — 2 San Diego, CA 201 149 36 11 3 2 8

W.N. Central 744 456 201 55 17 15 46 San Francisco, CA 118 86 23 8 — 1 13

Des Moines, IA 101 67 26 6 1 1 4 San Jose, CA 198 146 30 12 7 3 23

Duluth, MN 32 24 7 1 — — 1 Santa Cruz, CA 46 37 7 1 1 — 5

Kansas City, KS 24 16 6 1 1 — 1 Seattle, WA 111 73 29 5 1 3 6

Kansas City, MO 106 64 29 9 1 3 3 Spokane, WA 68 56 10 1 1 — 3

Lincoln, NE 42 30 9 2 1 — — Tacoma, WA 122 84 31 5 2 — 11

Minneapolis, MN 65 38 19 5 1 2 8 Total¶ 11,979 8,007 2,823 662 264 216 764

Omaha, NE 83 53 19 8 1 2 9

St. Louis, MO 151 70 55 15 8 3 10

St. Paul, MN 62 35 17 6 2 2 2

Wichita, KS 78 59 14 2 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: 2012-523-043/21096 Region IV ISSN: 0149-2195

The Morbidity and Mortality Weekly Report (MMWR) Series is prepared by the Centers for Disease Control and Prevention (CDC) and is available free 

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