# 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

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

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

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

## MMWR Editorial Board William L. Roper, MD, MPH, Chapel Hill, NC, Chairman Virginia A. Caine, MD, Indianapolis, IN 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

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# 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.

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# 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 kidneysfrom 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

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# 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 bySalmonella 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 forE. coli O157 than forSalmonella, 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 byListeria (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.

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# (16% of states),Listeria(13%),E. coli(10%), norovirus (7%) andSalmonella(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 itsGuidelines 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 theGuidelines and the performance indicators therein. Few states reported plans to implement or incorporate theGuidelines 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 0No. 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

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# 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 0No. 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 †

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# 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 CIFORGuidelines 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 T erritorial 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 T erritorial 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 T erritorial 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 T erritorial 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 T erritorial 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

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# 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

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# 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 wellas 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 developedGuidance 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

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# 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

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# 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 1.CDC. FDA licensure of quadrivalent human papillomavirus vaccine

(HPV4, Gardasil) for use in males and guidance from the Advisory Committee on Immunization Practices (ACIP). MMWR 2010;59:630–2. 2.Ahmed F, T emte JL, Campos-Outcalt D, Schünemann HJ; 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. 3.CDC. FDA licensure of bivalent human papillomavirus vaccine (HPV2,

Cervarix) for use in females and updated HPV vaccination 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. 13.Ferris D. A long-term extension study of Gardasil in adolescents. O-18.05. Proceedings of the 27th International Papillomavirus Conference and 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 Datalink. Vaccine 2011;29;8279–84. 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. Vaccine 2011;29:8443–50. 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 human immunodeficiency virus. Clin Infect Dis 2002;35:1127–34. 24.Kim JJ. Targeted human papillomavirus vaccination of men who have sex with men in the USA: a cost-effectiveness modelling analysis. Lancet Infect Dis 2010;10:845–52. 25.CDC. Sexually transmitted diseases treatment guidelines, 2010. MMWR 2010;59(No. RR-12). 26.Simard EP, Pfeiffer RM, Engels EA. Spectrum of cancer risk late after AIDS onset in the United States. Arch Intern Med 2010;170: 1337–45. 27.Levin MJ, Moscicki AB, Song L Y, et al; IMPAACT P1047 Protocol Team. Safety and immunogenicity of a quadrivalent human papillomavirus (types 6, 11, 16, and 18) vaccine in HIV-infected children 7 to 12 years old. J Acquir Immune Defic Syndr 2010;55:197–204. 28.Wilkin T, Lee JY, Lensing SY, et al. Safety and immunogenicity of the quadrivalent human papillomavirus vaccine in HIV-1-infected men. J Infect Dis 2010;202:1246–53.

## Morbidity and Mortality Weekly Report

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# 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

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# 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 developedGuidance 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 

# •	 HepatitisBvaccinationshouldbeadministeredtounvaccinated

adults with diabetes mellitus who are aged 19 through 59 years (recommendation category A; evidence type 2). •	 HepatitisBvaccinationmaybeadministeredatthe

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 withimpairment 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 70Percentage 

### 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 reportedfor previous years States reporting cases during current week (No.) 2010 2009 2008 2007 2006 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-intermediateStaphylococcus aureus§

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

— — 0 2 1 — 2 1 Vibriosis (noncholeraVibriospecies 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. W odajo *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

4 2 0.25 0.125 1 Beyond historical limits DISEASE

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

Meningococcal disease 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 trachomatisinfection Coccidioidomycosis Cryptosporidiosis Current week Previous 52 weeks Cum 2011 Cum 2010 Current week Previous 52 weeks Cum 2011 Cum 2010 Current week Previous 52 weeks Cum 2011 Cum 2010 Med Max Med Max Med Max United States 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 2010 Med Max Med Max 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 2010 Med Max Med Max Med Max 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 totalE. ewingiicases 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 2010 Med Max Med Max Med Max 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 2010 Med Max Med Max Med Max 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 2010 Med Max Med Max Med Max 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 2010 Med Max Med Max Med Max 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-producingE. coli(STEC)† Current week Previous 52 weeks Cum 2011 Cum 2010 Current week Previous 52 weeks Cum 2011 Cum 2010 Current week Previous 52 weeks Cum 2011 Cum 2010 Med Max Med Max Med Max United States 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 2010 Med Max Med Max Med Max 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 2010 Med Max Med Max Med Max 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 2010 Med Max Med Max Med Max 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 TheMorbidity and Mortality Weekly Report (MMWR)Series is prepared by the Centers for Disease Control and Prevention (CDC) and is available free of charge in electronic format. To receive an electronic copy each week, visitMMWR’ s free subscription page athttp://www.cdc.gov/mmwr/mmwrsubscribe. html . Paper copy subscriptions are available through the Superintendent of Documents, U.S. Government Printing Office, Washington, DC 20402; telephone 202-512-1800. Data presented by the Notifiable Disease Data Team and 122 Cities Mortality Data Team in the weeklyMMWR are provisional, based on weekly reports to CDC by state health departments. Address all inquiries about theMMWR Series, including material to be considered for publication, to Editor, MMWR Series, Mailstop E-90, CDC, 1600 Clifton Rd., N.E., Atlanta, GA 30333 or tommwrq@cdc.gov. All material in theMMWR Series is in the public domain and may be used and reprinted without permission; citation as to source, however, is appreciated. Use of trade names and commercial sources is for identification only and does not imply endorsement by the U.S. Department of Health and Human Services. References to non-CDC sites on the Internet are provided as a service toMMWR readers and do not constitute or imply endorsement of these organizations or their programs by CDC or the U.S. Department of Health and Human Services. CDC is not responsible for the content of these sites. URL addresses listed inMMWR were current as of the date of publication. Morbidity and Mortality Weekly Report