# Weekly January 30, 2009/Vol. 58/ No. 3



# department ofhealth andhumanservices Centers for Disease Control and Prevention 

# Morbidity and Mortality Weekly Report www.cdc.gov/mmwr 

# Assisted Reproductive Technology and Trends in Low Birthweight — Massachusetts, 1997–2004 Low birthweight (LBW) (<2,500 g) is an important cause of infant morbidity and mortality (1). The rate of LBW has been steadily increasing in the United States. In 2005, the most recent year for which data are available, LBW represented 8.2% of all births, the highest level reported in the past 4 decades (2 ). The use of assisted reproductive technology(ART)* has been associated with LBW (3,4 ). Research in 1999 indicated that, in Massachusetts during 1989–1996, the rate of LBW increased, paralleling the national trend, and an increasing percentage of LBW infants were born to mothers aged>35 years and to mothers with moreeducation.†

# These findings suggested that a proportion of LBW births might be attributable to infertility treatment; however, at that time, no information was available from birth certificate records to examine whether ART was associated with the increasing rates of LBW. To investigate the role of ART, the Massachusetts Department of Public Health (MDPH) and CDC linked birth certificate records to ART records for the years 1997–2004 (the most recent data available). This report summarizes the results of that analysis, which indicated that, on average, 2% of births during the period resulted from ART; however, 7% of LBW births resulted from ART. The rate of LBW increased during this period among non-ART singletons (from 4.8% to 5.1%), accounting for an additional 407 LBW infants, and among ART singletons (from 6.4% to 8.2%), accounting for an additional 59 LBW infants. Although ART contributes disproportionately to LBW, only a small percentage of the excess LBW births in Massachusetts are explained by ART; therefore, other causes for the increase in LBW should be examined.

The analysis was conducted by merging birth certificate records and ART records for 1997–2004. After all births in Massachusetts, information for birth certificate records is abstracted by hospital staff and sent to the Massachusetts Registry of Vital Records and Statistics. All clinics that perform ART report standardized data without personal identifiers for every ART procedure to CDC, as mandated by the Federal Fertility Clinic Success Rate and CertificationAct.§ 

# For this analysis, investigators linked birth certificate records with live-birth ART records in 2-year intervals (5). Birth certificate records and ART records were included based on mother’s residence in Massachusetts. A deterministic linkage was performed using maternal and infant dates of birth and plurality. Questions regarding duplicate matches were resolved using postal code of residence. A total of 13,025 ART records were linked to a birth certificate record, representing 83% of

*ART includes infertility treatments in which both eggs and sperm are handled

in a laboratory for the purpose of establishing a pregnancy. Procedures include in vitro fertilization, gamete intrafallopian transfer, zygote intrafallopian transfer, embryo cryopreservation, and surrogate birth. †

### Additional information available at http://www.cdc.gov/mmwr/preview/

mmwrhtml/00056908.htm. INSIDE 

## 52 Methicillin-ResistantStaphylococcus aureusAmong Players on a High School Football Team — New York City, 2007 55 Children with Elevated Blood Lead Levels Related to Home Renovation, Repair, and Painting Activities — New York State, 2006–2007 58 Invasive Haemophilus influenzae Type B Disease in Five Young Children — Minnesota, 2008 60 Notice to Readers 62 QuickStats §

### Fertility Clinic Success Rate and Certification Act of 1992 (FCSRCA), Public

Law 102–493, October 24, 1992. Additional information available athttp:// www.popline.org/docs/1270/087273.htmland http://wwwn.cdc.gov/dls/art/ fcsrca.aspx.

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

David W. Fleming, MD, Seattle, WA William E. Halperin, MD, DrPH, MPH, Newark, NJ Margaret A. Hamburg, MD, Washington, DC

King K. Holmes, MD, PhD, Seattle, WA Deborah Holtzman, PhD, Atlanta, GA John K. Iglehart, Bethesda, MD Dennis G. Maki, MD, Madison, WI Sue Mallonee, MPH, Oklahoma City, OK 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 

## TheMMWR series of publications is published by the Coordinating Center for Health Information and Service, 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 2009;58:[inclusive page numbers]. Centers for Disease Control and Prevention Richard E. Besser, MD ( Acting )Director Tanja Popovic, MD, PhD Chief Science Officer James W. Stephens, PhD Associate Director for Science

Steven L. Solomon, MD Director, Coordinating Center for Health Information and Service Jay M. Bernhardt, PhD, MPH Director, National Center for Health Marketing Katherine L. Daniel, PhD Deputy Director, National Center for Health Marketing Editorial and Production Staff Frederic E. Shaw, MD, JD

Editor,MMWR Series Susan F. Davis, MD ( Acting )Assistant Editor,MMWR Series Robert A. Gunn, MD, MPH Associate Editor,MMWR Series Teresa F. Rutledge Managing Editor,MMWRSeries Douglas W. Weatherwax Lead Technical Writer-Editor

Donald G. Meadows, MA Jude C. Rutledge

Writers-Editors Martha F. Boyd Lead Visual Information Specialist Malbea A. LaPete Stephen R. Spriggs Visual Information Specialists Kim L. Bright, MBA Quang M. Doan, MBA Phyllis H. King Information Technology Specialists 

## 50 **MMWR** January 30, 2009 

# eligible ART births. These were defined as Massachusetts ART births. ART records not linked to birth certificate records (n = 2,684 [17% of eligible ART births]) were excluded. During 1997–2004, a total of 713 births (0.1% of birth records) occurred in which use of ART was recorded on the birth certificate but the births were not linked to a Massachusetts livebirth ART record. These births were excluded because whether they reflected mothers who had undergone ART procedures in another state or were simply missed by the linkage could not be established. All other births were defined as non-ART births.

Gestational age at birth was obtained from the clinical estimate in weeks recorded on the birth certificate record. Births were excluded if the gestational age was not deemed realistic or not consistent with viability (i.e., <24 weeks [n = 1,329 (0.2%)] or >43 weeks [n = 5,229 (0.8%)]). Birthweight was obtained from the birth certificate record. Birthweight was missing for 203 infants (0.03%). Therefore, for the study period, a total of 636,349 births (98.8% of all birth certificate records) were included in the analysis, 623,434 non-ART (98%) and 12,915 ART (2%) births.

LBW percentages were calculated for births overall and by ART status and plurality. The population attributable risk percentage (PAR%) for LBW resulting from ART was calculated for each 2-year period. The Cochrane-Armitage test for trend was used to test for changes over time.

During 1997–2004 in Massachusetts, the percentage of births resulting from ART ranged from 1.8% to 2.3% (Table 1). During this period, 7.0% of all LBW births were attributable to ART (PAR% range: 5.9%–8.1%). From 1997–1998 to 2003–2004, the percentage of LBW among all infants increased from 6.8% to 7.5% (p-value for trend <0.0001) (Table 2). The percentage of LBW births increased among non-ART births overall (from 6.3% to 7.0%; p-value for trend <0.0001) and among non-ART singleton births (from 4.8% to 5.1%; p-value for trend <0.0001). Among ART singleton births, the percentage of LBW births also increased (from 6.4% to 8.2%; p-value for trend = 0.03). After adjusting for the change in the distribution of births by plurality from 1997 to 2004, 407 additional LBW non-ART singleton births and 59 additional LBW ART singleton births occurred during 2003–2004 compared with 1997–1998. The percentage of LBW births did not increase among twin births or among triplet and higher order multiple births. Reported by:BB Cohen, PhD, Z Zhang, MD, A Nannini, PhD, Massachusetts Dept of Public Health. SL Farr, PhD, JE Anderson, PhD, DJ Jamieson, MD, M Macaluso, MD, Div of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion; NK Tepper, MD, EIS Officer, CDC. 

# Editorial Note:In 1996, Massachusetts introduced a question on its birth certificate form regarding the use of fertility

## Vol. 58 / No. 3 **MMWR 51** 



# assistance; however, this item has only 30% sensitivity for ARTtreatment.¶

# Linking birth certificate records with ART records provides a more sensitive measure of use of ART than birth certificate records alone. Using linked records, the analysis in this report determined that, during 1997–2004 in Massachusetts, although ART accounted for 2% of all births, approximately 7% of LBW births were attributable to ART. However, LBW in Massachusetts increased among both ART and non-ART singletons, and only a small part of the increase in LBW might be explained by ART.

Despite substantial improvements in the United States in infant survival and outcomes, a steady increase in the rate of LBW has occurred. During 1984–2005, the rate of LBW in the United States increased 22%, from 6.7% to 8.2% of all births (2 ). The rate of LBW among all singletons also increased 7% since 2000, from 6.0% to 6.4% (2 ). Although the contribution of ART to national rates of LBW is not known, these results from one state are important to consider in the context of increasing rates of LBW nationwide.

Certain factors increase the risk for LBW, such as prematurity, congenital abnormalities, maternal hypertension and diabetes, maternal smoking and drug use, infections, placental abnormalities, socioeconomic factors, and multiple gestations (6,7 ). LBW also has been associated with ART, but a large part of the elevated risk for LBW among ART births has been attributed to an increased incidence of multiple gestations (3). ART also has been associated with LBW among singleton births. However, for those births, the etiology is less clear; studies have shown potential effects stemming from the treatment itself and from underlying infertility (3). Other factors might be contributing to the increase among non-ART births, such as an increase in delayed childbearing (7 ) or iatrogenic preterm delivery (8).

The findings in this report are subject to at least four limitations. First, ART births might have been misclassified as non-ART births if they were not linked to an ART record. However, given the 83% linkage rate of ART records, potential underestimation of ART births would not substantially affect results. Second, some births might have been misclassified as Massachusetts ART births if they were missing residency information but involved mothers who underwent ART in Massachusetts and delivered in one of three neighboring states. Third, the reliability of information from birth records is variable. However, birthweight from birth certificate records has been shown to have high accuracy when compared with medical records (9 ). Finally, births occurring at <24 weeks’ gestation, the conventional limit of infant viability, were not included in the analysis. Although these births tend to be LBW, they represented only 0.2% of eligible birth records. ¶

### Zhang Z, Schieve L, Macaluso M, Cohen B, Nannini A, Wright V. Evaluation

of assisted reproductive technology reporting on the Massachusetts birth certificates. Presented at the 12th Annual Maternal and Child Health Epidemiology Conference, December 6–8, 2006, Atlanta, GA. 

## TABLE 1. Percentage of all births resulting from assisted reproductive technology (ART) and population attributable risk percentage **(PAR%) of low birthweight (LBW)* attributable to ART,****†**

## by 2-year period — Massachusetts, 1997–2004 **Year 1997–1998**  **1999–2000 2001–2002**  **2003–2004 Total**  Births from ART (%) 1.8 2.3 1.9 2.2 **2.0** PAR% LBW attributable to ART 7.1 8.1 5.9 6.9 **7.0** *Less than 2,500 g. †

### PAR% = [(Incidence LBWTotal

### - Incidence LBWNon-ART

### ) / Incidence LBWTotal

### ] x 100. For example, during 1997–1998, PAR% = [(6.76 – 6.28) / 6.76] x 100 = 7.10 

## TABLE 2. Number and percentage of low birthweight (LBW) births,* by 2-year period, plurality, and assisted reproductive technology **(ART) status — Massachusetts, 1997–2004 Type of birth**  **and plurality Total**  **no. of births for**  **all years Year**  **p-value for trend** **† 1997–1998**  **1999–2000 2001–2002**  **2003–2004 Total no.**  **of births LBW births**  **Total no. of births**  **LBW births Total no.**  **of births LBW births**  **Total no. of births**  **LBW births No.**  **(%) No.**  **(%) No.**  **(%) No.**  **(%) All births**  **636,349 160,054**  **10,819 (6.8)**  **158,554 10,714**  **(6.8) 160,484**  **11,497 (7.2)**  **157,257 11,832**  **(7.5) <0.0001**  **Non ART births 623,434**  157,142 9,861 (6.3) 154,956 9,630 (6.2) 157,489 10,616 (6.7) 153,847 10,768 (7.0) <0.0001 Singleton **602,259** 152,276 7,343 (4.8) 150,437 7,300 (4.9) 151,514 7,551 (5.0) 148,032 7,615 (5.1) <0.0001 Twin **20,135** 4,610 2,285 (49.6) 4,360 2,189 (50.2) 5,675 2,783 (49.0) 5,490 2,848 (51.9) 0.06 Triplet and higher **1,040** 256 233 (91.0) 159 141 (88.7) 300 282 (94.0) 325 305 (93.9) 0.07 **ART births 12,915**  2,912 958 (32.9) 3,598 1,084 (30.1) 2,995 881 (29.4) 3,410 1,064 (31.2) 0.17 Singleton **6,615** 1,428 92 (6.4) 1,795 118 (6.6) 1,575 118 (7.5) 1,817 148 (8.2) 0.03 Twin **5,534** 1,211 614 (50.7) 1,613 791 (49.0) 1,268 618 (48.7) 1,442 775 (53.7) 0.10 Triplet and higher **766** 273 252 (92.3) 190 175 (92.1) 152 145 (95.4) 151 141 (93.4) 0.41 * Less than 2,500 g. † By Cochrane-Armitage test.

## 52 **MMWR** January 30, 2009 

# The excess LBW births in Massachusetts during 1997–2004 is largely not explained by ART, although ART disproportionately contributed to the overall prevalence of LBW. Future LBW research and prevention efforts are needed and should include 1) determining the risk factors that contribute to increasing rates of LBW among non-ART births, and 2) investigating additional risk factors and etiologies for LBW among ART singleton births. Additionally, further reducing rates of multiple gestation resulting from ART, as recommended by the Society for Assisted Reproductive Technology and the American Society for Reproductive Medicine (10 ), and making clinicians more aware of the elevated risk for LBW among ART births also might reduce this outcome among ART births. Acknowledgments 

## The findings in this report are based, in part, on contributions by the Society for Assisted Reproductive Technology. References

1. Kramer MS, Barros FC, Demissie K, Liu S, Kiely J, Joseph KS. Does

reducing infant mortality depend on preventing low birthweight? An analysis of temporal trends in the Americas. Paediatr Perinat Epidemiol 2005;19:445–51. 2.Martin JA, Hamilton BE, Sutton PD, et al. Births: final data for 2005.

Natl Vital Stat Rep 2007;56(6). 3. Schieve LA, Cohen B, Nannini A, et al. A population-based study

of maternal and perinatal outcomes associated with assisted reproductive technology in Massachusetts. Matern Child Health J 2007;11:517–25. 4. Schieve LA, Meikle SF, Ferre C, Peterson HB, Jeng G, Wilcox LS. Low

and very low birth weight in infants conceived with use of assisted reproductive technology. N Engl J Med 2002;346:731–7. 5. Sunderam S, Schieve LA, Cohen B, et al. Linking birth and infant

death records with assisted reproductive technology data: Massachusetts, 1997–1998. Matern Child Health J 2006;10:115–25. 6. Cunningham FG, Hauth JC, Leveno KJ, Gilstrap L, Bloom SL,

Wenstrom KD, eds. Williams obstetrics. 22nd ed. New York, NY: McGraw-Hill; 2005. 7.Tough SC, Newburn-Cook C, Johnston DW, Svenson LW, Rose S,

Belik J. Delayed childbearing and its impact on population rate changes in lower birth weight, multiple birth, and preterm delivery. Pediatrics 2002;109:399–403. 8.Yoder BA, Gordon MC, Barth WH Jr. Late-preterm birth: does the

changing obstetric paradigm alter the epidemiology of respiratory complications? Obstet Gynecol 2008;111:814–22. 9. DiGiuseppe DL, Aron DC, Ranbom L, Harper DL, Rosenthal GE.

Reliability of birth certificate data: a multi-hospital comparison to medical records information. Matern Child Health J 2002;6:169–79. 10. Practice Committee of Society for Assisted Reproductive Technology; Practice Committee of American Society for Reproductive Medicine. Guidelines on number of embryos transferred. Fertil Steril 2008;90(5 Suppl):S163–4. 

# Methicillin-Resistant Staphylococcus aureusAmong Players on a High School Football Team — New York City, 2007 On September 12, 2007, the New York City Department of Health and Mental Hygiene (DOHMH) was notified of threeplayers on a Brooklyn high school football team with cultureconfirmed methicillin-resistantStaphylococcus aureus(MRSA) skin and soft tissue infections (SSTIs). During August 19–24, the team had attended a preseason football training camp, where all 59 players on the team lived together in the school gymnasium. An investigation by DOHMH revealed four culture-confirmed and two suspected cases of MRSA among 51 players interviewed (11.8% attack rate). Of the six cases, three involved abscesses that required incision and drainage. The risk for MRSA infection was higher among those who shared towels during the training camp than among those who did not (relative risk [RR] = 8.2). In addition, the six players with MRSA infections had a mean body mass index (BMI) that was significantly higher than the mean for those who were not infected. Multivariable logistic modeling determined that sharing towels during camp (adjusted odds ratio [AOR] = 15.7) and higher BMI (AOR = 1.4) were associated independently with MRSA infection. Similar outbreaks have been reported among football teams in which inadequate hygiene, combined with skin injuries and living in close quarters, contributed to the spread of MRSA infection. Such outbreaks might be prevented by better educating players and coaches regarding SSTIs and by better promoting proper player hygiene, particularly during training camps.

Initial investigation by DOHMH began on September 12. Investigators learned that all 59 players had attended a preseason training camp during August 19–24. The players had lived together in the school gymnasium, slept on cots in close proximity to each other, and showered in the school locker room, usually only once at the end of the day. The school had supplied antibacterial soap in pump dispensers in the showers; however, several players brought their own soap. Players supplied their own towels. Players reported that they usually left their towels on their cots or on the floor when not in use. The school offered a daily laundry service for uniforms and towels during the camp; however, most players did not have their towels washed and wore their uniforms two or three times between launderings. Players often remained in sweat-soaked clothes between the morning and afternoon practices. The school did not have whirlpools or hot tubs.

Investigators hypothesized that sharing facilities and equipment, previous skin injuries, player position, inadequate player

## Vol. 58 / No. 3 **MMWR 53**  

# hygiene, and having a higher BMI might be risk factors linked to MRSA infections (1–3). To find additional cases, identify risk factors for infection, and implement infection control measures, DOHMH conducted face-to-face interviews on September 14 with 51 of the 59 players, using a close-ended questionnaire; the eight remaining players could not be contacted. In addition, a DOHMH physician further examined the five players reported by the school nurse as potentially infected.

A confirmed MRSA case was defined as a clinically compatible SSTI with a positive MRSA culture in a team member during August 5–September 14, a period ranging from 2 weeks before to 3 weeks after the end of the training camp. A suspected MRSA case was defined as a clinically compatible SSTI or systemic infection with no culture confirmation. Date of symptom onset was defined as the date an infected player reported first noticing an infected wound.

Among the 51 players interviewed, four confirmed and two suspected MRSA cases were identified (11.8% attack rate). Molecular typing with pulsed-field gel electrophoresis revealed that three of the confirmed cases were USA300, a strain usually considered to be a community-associated MRSA. An isolate from the fourth player with confirmed MRSA was not available for typing. Symptom onsets ranged from August 24, the last day of training camp, to September 6, a total of 13 days after the camp (Figure 1).

In the four confirmed cases, infections initially appeared as a blister on the ankle, calf, hip, or instep. One suspected case involved impetigo on the upper arm; the other suspected case involved impetigo on the arms and eyebrow. Three players reported their wounds to the school nurse or a physician only after blisters had developed into infections requiring medical attention. The six players with confirmed or suspected MRSA infections were referred to their personal physicians for treatment. Three of the players had abscesses that required incision and drainage. Three of the players with confirmed cases were treated with Bactrim and doxycycline, clindamycin and mupirocin, and Bactrim and mupirocin, respectively. One of the players with suspected MRSA infection was treated with ciprofloxacin. Antibiotics used to treat the remaining two players were unknown.

Interviews with the players revealed that 33 (65%) had sustained at least one cut, abrasion, or turf burn during the preseason camp or regular season. The players reported that, unless the skin injuries were severe, they had cleaned, dressed, or bandaged them by themselves. No players reported sharing towels or soap during the regular season, because players went home after practice to shower. However, 10 (20%) had shared towels and six (12%) had shared soap during training camp, when the players showered on site.

In a retrospective cohort analysis, after combining confirmed and suspected MRSA cases, bivariate RRs and their 95% confidence intervals (CIs) were calculated to identify risk factors associated with infection. Multivariable logistic regression was used to evaluate the independent association of multiple risk factors, including BMI, which was modeled as a continuous variable because the small number of cases did not allow for tests based on BMI categories (i.e., normal, overweight, and obese).

Sharing towels during training camp significantly increased the risk for MRSA infection (RR = 8.2) (Table). Sharing protective pads, sharing soap, showering less than once a day, having more than one skin injury, and washing uniforms less than once a day were not significant risk factors for infection. Playing at lineman or linebacker and wide receiver or **FIGURE 1.****Number* of culture-confirmed and suspected cases of methicillin-resistant**Staphylococcus aureus**(MRSA) infection †**  

## among players on a high school football team, by date of symptom onset — New York City, 2007

19 20 21 22 23 24 25 26 27 28 29 30 31 1 2 3 4 5 6 7 8 9 10 11 12 13 14 0 1 2 3 

## Preseason training camp No. of cases



## Aug 

## Dayand month Culture-confirmed Suspected

Sep First day of regular season

*N = 6. †

### A confirmed MRSA case was defined as a clinically compatible skin and soft tissue infection (SSTI) with a positive MRSA culture in a team member during

August 5–September 14, a period ranging from 2 weeks before to 3 weeks after the end of the training camp. A suspected MRSA case was defined as a clinically compatible SSTI or systemic infection with no culture confirmation.

## 54 **MMWR** January 30, 2009 

# cornerback positions (previously shown to be potential risk factors in football MRSA outbreaks [2,4]) also were not significant risk factors (Table).

The six players with MRSA infection had a mean BMI of 29.1 (CI = 24.7–33.3), which was significantly higher by t-test (t = 2.56; p=0.014) than the mean BMI of 23.8 (CI = 22.8–25.0) for the 45 players without infection. Using CDC’s child and teen BMI-for-age weight statuscategories,* five of the six (83%) players with MRSA infection could be classified as overweight or obese, compared with 20 of the 45 (44%) players without infection (Figure 2). A bivariate analysis using logistic regression revealed that higher BMI was associated with higher risk for infection (OR = 1.3 per unit increase in BMI; CI = 1.1–1.7). A multivariable logistic model confirmed that both sharing towels during training camp (AOR = 15.7; CI = 1.5–167.4) and BMI (AOR = 1.4; CI = 1.1–1.9) were associated independently with MRSA infection. Reported by:P Kellner, MPH, A Yeung, MPH, HA Cook, MPH, J Kornblum, PhD, M Wong, MPH, F Eniola, MPH, D Weiss, MD, New York City Dept of Health and Mental Hygiene. HP Nair, PhD, EIS Officer, CDC. 

# Editorial Note:Since 2000, outbreaks of MRSA SSTIs have been reported among players on high school, college, and professional football teams with attack rates similar to those described in this report (1–4 ). Despite education efforts by CDC and state and local health departments, MRSA infections continue to be a problem among football players. A 2007 CDC survey of high school athletic trainers revealed that 53% had treated MRSA infections in football players (1). The results of this investigation suggest that sharing of towels among players at a preseason training camp was associated with MRSA infection, a risk factor previously linked to football-related MRSA outbreaks (1–3). These results are also consistent with three previous reports that identified MRSA infections in football teams temporally linked to training camps ( 2–4 ), which might be a setting that increases risk behaviors for infection (4 ). Living in close quarters for an extended period, a potential risk factor identified in other settings (5 ), might have further contributed to the outbreak.

The results also indicated that higher BMI among team players was associated with higher risk for MRSA infection, independent of sharing towels. These results are consistent with those of two other football-related outbreaks (5 ) and published reports linking higher BMI with a range of infections, including skin infections (6 ). The possibility that higher BMI is confounded by player positions (e.g., lineman) involving heavier players and more frequent contact is not supported by the data, which found no differences by player position. Evaluating player position in general is statistically problematic because sample sizes vary substantially by position on most football rosters.

The findings in this report are subject to at least two limitations. First, the small number of cases reduced the precision of the point estimates, as reflected in the wide CIs. Second, because players were not interviewed until 3 weeks after the first reported symptom onsets, they might not have been able to accurately recall events, leading to misclassification of players by risk factor.

High school football programs might be able to reduce the risk for MRSA outbreaks by improving their procedures and facilities to promote optimal player hygiene, particularly during training camps. Improvements might include providing a towel service and collecting used towels from players on a daily basis. Skin injuries should be monitored closely by coaches *Additional information available at http://www.cdc.gov/nccdphp/dnpa/

healthyweight/assessing/bmi/childrens_bmi/about_childrens_bmi.htm. 

## TABLE. Association between exposure to risk factors and culture-confirmed or suspected cases of methicillin-resistant Staphylococcus aureus**(MRSA)** **infection* in players on a high school football team — New York City, 2007** **Players exposed Players not exposed**  **Relative risk**  **(95% CI †** 

### ) **Risk factor Cases**  **Total Attack rate**  **(%) Cases**  **Total Attack rate**  **(%)** Sharing towels during training camp 4 10 (40) 2 41 (5) 8.2 (1.7–38.6) Sharing soap during training camp 2 6 (33) 4 45 (9) 3.8 (0.9–16.2) Sharing protective pads during training camp 0 4 — 6 47 (13) — — Showering less than once a day during training camp 0 2 — 6 49 (12) — — Having more than one skin injury during training camp 3 18 (17) 2 26 (8) 2.2 (0.4–11.7) Washing uniforms less than once a day during training camp 5 45 (11) 1 6 (17) 0.7 (0.1–4.8) Playing at lineman or linebacker 2 17 (12) 4 34 (12) 1.0 (0.2–4.9) Playing at wide receiver or cornerback 1 23 (4) 5 28 (18) 0.2 (0.03–1.9) *A confirmed MRSA case was defined as a clinically compatible skin and soft tissue infection (SSTI) with a positive MRSA culture in a team member during August 5–September 14, a period ranging from 2 weeks before to 3 weeks after the end of the training camp. A suspected MRSA case was defined as a clinically compatible SSTI or systemic infection with no culture confirmation. †

### Confidence interval.

## Vol. 58 / No. 3 **MMWR 55** 



# and trainers, rather than by players alone. Living arrangements might be modified so that players are not living in close quarters for extended periods. Education on SSTI identification, prevention, and intervention might be included as a standard component of football training camps. Acknowledgments 

## This report is based, in part, on contributions by M Marx, PhD, J Nguyen, MPH, M Layton, MD, Bur of Communicable Disease; L Thorpe, PhD, K Konty, PhD, Div of Epidemiology; T Matte, MD, Div of Environmental Surveillance and Policy, New York City Dept of Health and Mental Hygiene. J Magri, MD, Office of Workforce and Career Development, CDC. References 1. Brinsley-Rainisch K, Goding A, Sinkowitz-Cochran R, Pearson M,

Hageman J, the National Athletic Trainers’ Association. MRSA infections in athletics: perceptions and practices of certified athletic trainers [Poster]. Presented at the Society for Healthcare Epidemiology of America 17th Annual Meeting, Baltimore MD; April 15, 2007. 2. Begier EM, Frenette K, Barrett NL, et al. A high-morbidity outbreak

of methicillin-resistantStaphylococcus aureus among players on a college football team, facilitated by cosmetic body shaving and turf burns. Clin Infect Dis 2004;39:1446–53. 3. Romano R, Lu D, Holtom P, et al. Outbreak of community-acquired

methicillin-resistant Staphylococcus aureus skin infections among a collegiate football team. J Athl Train 2006;41:141–5. 4. Kazakova SV, Hageman JC, Matava M, et al. A clone of methicillinresistantStaphylococcus aureus among professional football players. N Engl J Med 2005;352:468–75. 5. Campbell KM, Vaughn AF, Russell KL, et al. Risk factors for communityassociated methicillin-resistant Staphylococcus aureus infections in an outbreak of disease among military trainees in San Diego, California, in 2002. J Clin Microbiol 2004;42:4050–3. 6. Falagas M, Kompoti M. Obesity and infection. Lancet Infect Dis

2006;6:438–46. 

# Children with Elevated Blood Lead Levels Related to Home Renovation, Repair, and Painting Activities — New York State, 2006–2007 Although blood lead levels (BLLs) >10μg/dL are associated with adverse behavioral and developmental outcomes, and environmental and medical interventions are recommended at >20μg/dL, no level is considered safe (1,2 ). A 1997 analysis conducted by the New York State Department of Health (NYSDOH) indicated that home renovation, repair, and painting (RRP) activities were important sources of lead exposure among children with BLLs>20μg/dL in New York state (excluding New York City) during 1993–1994 (3). Subsequently, local health departments in New York state began to routinely collect information about RRP activities when investigating children’s home environments for lead sources. This report updates the 1997 analysis with data from environmental investigations conducted during 2006–2007 in New York state (excluding New York City) for 972 children with BLLs >20μg/dL. RRP activities were identified as the probable source of lead exposure in 139 (14%) of the 972 children. Resident owners or tenants performed 66% of the RRP work, which often included sanding and scraping (42%), removal of painted materials or structures (29%), and other activities (29%) that can release particles of lead-based paint. RRP activities continued to be an important source of lead exposure during 2006–2007. Children living in housing **FIGURE 2. Number of players on a high school football team** * **categorized as overweight/obese or normal, based on body mass index (BMI),** **†**

## by case status regarding methicillin-resistant Staphylococcus aureus**(MRSA) infection — New York City, 2007**

*N = 51. †

### Using CDC’s child and teen BMI-for-age weight status categories, persons

with a BMI equal to or greater than the 85th percentile are categorized as overweight or obese. Additional information available at http://www. cdc.gov/nccdphp/dnpa/healthyweight/assessing/bmi/childrens_bmi/ about_childrens_bmi.htm. §

### Includes both confirmed and suspected cases of MRSA infection. A confirmed MRSA case was defined as a clinically compatible skin and soft tissue infection (SSTI) with a positive MRSA culture in a team member during August 5–September 14, a period ranging from 2 weeks before to 3 weeks after the end of the training camp. A suspected MRSA case was defined as a clinically compatible SSTI or systemic infection with no culture confirmation. 

## 16 18 20 22 24 26 28 30 32 34 36 38 § BMI 

## Noninfected players Cases (infected players)

Overweight/Obese Normal 

## BMI category

## 56 **MMWR** January 30, 2009 

# built before 1978 (when lead-based paint was banned from residential use) that are undergoing RRP activities should be considered at high risk for elevated BLLs, and appropriate precautions should be taken to prevent exposure.

Since 1993, New York stateregulations* have required BLL testing for all children at ages 1 and 2 years. In 2007, 83% of children were tested at least once before age 3 years, but only 41% were tested at ages 1 and 2 years (NYSDOH, unpublished data, 2008). Regulations also require laboratories to report all BLLs to NYSDOH, which then provides results to respective local health departments. For all children reported with BLLs >20μg/dL, local health departments are required to conduct environmental investigations to determine potential sources of exposure and recommend actions to reduce or eliminate exposures following CDC guidelines (1,2). Investigations include questioning about any activities that might have disturbed lead-based paint, including RRP activities, inspection of the home and household items for evidence of cracked or peeling paint, and water testing. If available, paint chips are tested for lead.

During 2006–2007, local health departments conducted environmental investigations for all 972 children reported in New York state with BLLs >20μg/dL. In January 2008, NYSDOH abstracted data from local health department records to identify investigations in which RRP activities were determined to be the most likely source of lead exposure and in which no other source of exposure was identified. RRP activities were considered the most likely source if an activity occurred that might have generated dust or paint chips that could have been inhaled or ingested. Lead-based paint that was intact and in good condition was not considered a source of exposure. For each case, abstracted data included 1) child’s age, 2) blood test date, 3) BLL, 4) address and approximate age of dwelling, 5) activities that might have disturbed paint, and 6) identity of person who performed the RRP work.

The results indicated that, during 2006–2007, the elevated BLLs of 139 (14%) of the 972 children with BLLs>20μg/dL were related to RRP activities (Table). Among the 139 children, 63 (45%) had BLLs of 20–24μg/dL, 24 (17%) had BLLs of 25–29μg/dL, and 52 (38%) had BLLs ≥30μg/dL. Most of the children (71%) were aged 1–2 years, and 25% were aged 3–5 years. The 139 children resided in 131 homes; eight homes had two children per home, and all other homes had only one child. All but one of the homes were built before 1978. Of 131 homes in which environmental investigations were conducted, 56 (43%) were identified as urban, 36 (28%) as suburban, and 39 (30%) as rural. Reported by:EM Franko, DrPH, JM Palome, New York State Dept of Health. MJ Brown, ScD, CM Kennedy, DrPH, Lead Poisoning Prevention Br, Div of Environmental Hazards and Health Effects, National Center for Environmental Health; LV Moore, PhD, EIS Officer, CDC. 

# Editorial Note:In the United States, median BLLs in children aged <5 years have declined 89% from 1976–1980 to 2003–2004 (4). This decline is largely a result of the phaseout of leaded gasoline and efforts by federal, state, and local agencies to limit lead paint hazards in housing. The latter has resulted in a decline in housing units with lead paint hazards from 64 million to 38 million during 1990–2000 (4 ). The decline in the prevalence of elevated BLLs over time has been most pronounced among children belonging to high-risk groups, especially non-Hispanic black children (5 ). However, an estimated 250,000 children remain at risk for exposure to**TABLE. Number and percentage of children with elevated blood lead levels (BLL** **> 20** μ**g/dL) related to home renovation, repair, and painting (RRP) activities, by selected characteristics — New**  **York (excluding New York City), 1993–1994 and 2006–2007 1993–1994**  **2006–2007 Characteristic**  **No. (%)**  **No. (%)**  No. of children with BLL related to RRP activities 320 (6.9)* 139 (14.3)* BLL (μg/dL)

20–24 117 (36.6) 63 (45.3) 25–29 76 (23.8) 24 (17.3) 30–39 87 (27.2) 30 (21.6) >40 40 (12.5) 22 (15.8) Age (yrs)

<1 29 (9.1) 4 (2.9) 1–2 163 (50.9) 98 (70.5) 3–5 88 (27.5) 35 (25.2) >6 9 (2.8) 2 (1.4) Unknown 31 (9.7) 0 — Area of home

Suburban 120 (37.5) 36† 

### (27.5) Rural 101 (31.6) 39† 

### (29.8) Urban 60 (18.8) 56† 

### (42.8) Unknown 39 (12.2) 0†



### — Types of RRP activity

Scraping and/or sanding 155 (48.4) 58 (41.7) Painted component removal 41 (12.8) 40 (28.8) Chemical stripping 32 (10.0) 0 — Hand-held heat guns/torches 17 (5.3) 1 (0.7) Exterior blasting 5 (1.6) 0 — Multiple activities 47 (14.7) 21 (15.1) Unknown 23 (7.2) 19 (13.7) Work performed by

Resident owner/tenant 187 (58.4) 92 (66.2) Contractor 42 (13.1) 9 (6.5) Other 73 (22.8) 17 (12.2) Multiple persons 0 — 3 (2.2) Unknown 18 (5.6) 18 (13.0) *Of a total of 4,608 environmental investigations conducted during 1993–

1994 and 972 conducted during 2006–2007. †

### RRP activities occurred at 131 homes and involved 139 children who had

BLLs>20μg/dL.



### *Title 10 NYCRR Part 67, available at http://www.health.state.ny.us/

environmental/lead/laws_and_regulations/chapter_2_subpart_67.htm.

## Vol. 58 / No. 3 **MMWR 57**  

# harmful lead levels in the United States (4 ). Children living inhousing undergoing RRP and built before 1978, when leadbased paint was banned from residential use, and particularly those built before 1950, when concentrations of lead in paint were higher (6 ), are now at high risk for elevated BLLs. This is of particular concern in New York state, where both the number (3,309,770) and proportion (43%) of housing units built before 1950 are greater than in any other state (7 ). The assessment described in this report showed that RRP activities were an important source of lead exposure among children with BLLs>20μg/dL during 2006–2007 in New York state. Of 972 children investigated for BLLs>20μg/dL during 2006–2007, 139 (14%) were traceable to RRP. Among the 131 homes linked to RRP-related lead exposures, all but one were built before 1978. Young children in homes built before 1978 are known to be a high-risk group for lead exposure (5 ), and these findings indicate RRP activities are an important source of lead exposure in this group.

NYSDOH used methods identical to ones used for this analysis to assess the role of RRP in elevated BLLs during 1993–1994, except that the majority of 2006–2007 records were electronic. During 1993–1994, the total number of children reported with BLLs >20μg/dL related to RRP was 320, and these children made up 7% of all children detected with BLLs>20μg/dL, compared with 139 children and 14% of such cases during 2006–2007. Thus, although the absolute number of RRP-related cases dropped substantially between the two periods, the relative burden of these cases on the state’s lead screening and treatment efforts increased.

The increase in the relative burden of RRP-related cases might signal a shift in populations at risk for lead exposure in New York state. Additional analyses and follow-up studies are needed to better characterize this possible shift.

The findings in this study are subject to at least two limitations. First, any incomplete reporting of children with BLLs >20μg/dL by laboratories might result in an underestimation of the number of children exposed to lead. Second, RRP activities also might be an important lead exposure source among children with lower BLLs (<20μg/dL) who were not included in this study. Although not required by regulation, several local health departments conducted environmental investigations for children with BLLs <20μg/dL during 2006–2007. Children identified with BLLs <20 μg/dL were similar in characteristics to those in this analyses, and RRP activities were the most probable source of lead exposure for 71 (40%) of 178 children (NYSDOH, unpublished data, 2008).

Contractors performed a small percentage (6.5%) of RRP work related to elevated BLLs in New York state during 2006–2007. Resident owners or tenants performed 66% of this work. To help prevent lead contamination when contractors perform RRP projects, the U.S. Environmental Protection Agency issued regulations in March 2008 that will require all renovators in the United States that work on certain types of housing or child-occupied facilities to be certified and follow specific work practices as of April 2010 (8). To address the risk from RRP by owners and do-it-yourselfers, more public outreach and education is needed to raise awareness of potential lead-exposure hazards from RRP and to ensure protective measures that safely contain dust and paint chips. In New York, state and local health departments have implemented education programs on RRP activities and lead-safe work practices for contractors and do-it-yourselfers.†



# Persons who remove lead-based paint should follow recommendations of the U.S. Department of Housing and Urban Development and the U.S. Environmental Protection Agency to protect children from lead exposure (9,10 ). These recommendations include 1) relocate occupants during paint removal, and exclude children and pregnant women from the work area; 2) isolate work areas from other areas of the house; 3) avoid practices that create lead dust or fumes; 4) perform a full cleanup after work is completed; and 5) consider monitoring BLLs in persons who live or work in the dwelling. References

1. CDC. Preventing lead poisoning in young children: a statement by the Centers

for Disease Control and Prevention. Atlanta, GA: CDC; 2005. Available at http://www.cdc.gov/nceh/lead/publications/prevleadpoisoning.pdf . 2. CDC. Managing elevated blood lead levels among young children:

recommendations from the Advisory Committee on Childhood Lead Poisoning Prevention. Atlanta, GA: CDC; 2002. Available at http:// www.cdc.gov/nceh/lead/casemanagement/casemanage_main.htm. 3. CDC. Children with elevated blood lead levels attributed to home

renovation and remodeling activities—New York, 1993–1994. MMWR 1997;45:1120–3. 4. US Environmental Protection Agency. America’s children and the environment. Measure B1: lead in the blood of children. Washington, DC: US Environmental Protection Agency; 2008. Available athttp://www. epa.gov/envirohealth/children/body_burdens/b1-graph.htm. 5.Jones R, Homa D, Meyer P, et al. Trends in blood lead levels and

blood lead testing among U.S. children aged 1 to 5 years: 1998–2004. Pediatrics. In press 2009. 6. US Department of Housing and Urban Development. Putting the pieces

together: controlling lead hazards in the nation’s housing. Lead-Based Paint Hazard Reduction and Financing Task Force. Washington, DC: US Department of Housing and Urban Development; 1995. 7. US Census Bureau. Census 2000 summary file 3 (SF 3), table H34 year

structure built, all states. Washington, DC: US Census Bureau; 2000. Available athttp://factfinder.census.gov . 8. US Environmental Protection Agency. 40 CFR part 745. Lead; renovation,

repair, and painting program; lead hazard information pamphlet; notice of availability; final rule. Federal Register 2008;73(78). Available athttp:// www.epa.gov/fedrgstr/EPA-TOX/2008/April/Day-22/t8141.pdf .

†

### Available athttp://www.health.state.ny.us/environmental/lead.

## 58 **MMWR** January 30, 2009 9. US Department of Housing and Urban Development. Guidelines

for the evaluation and control of lead-based paint hazards in housing. Washington, DC: US Department of Housing and Urban Development; 1995. Available athttp://www.hud.gov/offices/lead/lbp/ hudguidelines. 10. US Environmental Protection Agency. Reducing lead hazards when remodeling your home. Washington, DC: US Environmental Protection Agency; 1997. 

# Invasive Haemophilus influenzae Type B Disease in Five Young Children — Minnesota, 2008 On January 23, this report was posted as anMMWR Early Release on the MMWR website (http://www.cdc.gov/ mmwr).

In 2008, five children aged <5 years were reported to the Minnesota Department of Health (MDH) with invasive Haemophilus influenzaetype b (Hib) disease; one died. Only one of the children had completed the primary Hib immunization series; three had received no doses of Hib-containing vaccine (1). The five Hib cases are the largest number among children aged <5 years reported from Minnesota since 1992. The cases occurred during a Hib vaccine recall and continuing nationwide shortage that began in December 2007. The recall of certain lots of the two Hib-containing vaccines manufactured by Merck & Co., Inc. (West Point, Pennsylvania) and cessation of production of both vaccines left only one manufacturer of Hib vaccine in the United States (Sanofi Pasteur, Swiftwater, Pennsylvania) (2,3). In response, CDC recommended that health-care providers defer the routine 12–15 month booster dose for children not at increased risk for Hib disease (2,3). CDC also emphasized that all children should complete the primary series with available Hib-containing vaccines. However, Minnesota vaccination data indicate that primary Hib series coverage was lower during 2008 than coverage with other vaccines administered at the same ages and lower than Hib coverage in previous years. Increases in Hib cases like the one in Minnesota do not appear to have occurred in other states. The increase highlights the need to ensure that all children complete the primary Hib immunization series. Additional investigation to better elucidate the factors that led to these cases is being conducted by MDH and CDC.

Minnesota conducts surveillance for invasiveH. influenzae disease as part of the Active Bacterial Core surveillance system of CDC’s Emerging Infections Program (4 ). A Hib case is defined as isolation ofH. influenzae from a normally sterile sitein a resident of the state. Merck products are both Hib PRPOMP* vaccines, for which a primary series consists of 2 doses at 2 and 4 months. Sanofi Pasteur products are Hib PRP-TT† 

# vaccines, for which a primary series consists of a 3-dose primary series at 2, 4, and 6 months. For both Hib vaccine series, a routine booster is recommended at age 12–15 months

During 2008 in Minnesota, five children aged 5 months to 3 years were reported with invasive Hib disease; one died (Table). The patients resided in five different counties in Minnesota and had no known relationship to each other. Three patients had received no vaccinations because of parent or guardian deferral or refusal. One child was aged 5 months and had received 2 doses of Hib PRP-TT vaccine in accordance with the primary series schedule. Another child had received 2 doses of Hib PRP-OMP vaccine,but no booster dose, per CDC recommendations during the shortage. Subsequent to Hib infection, this child was diagnosed with hypogammaglobulinemia. None of the five were enrolled in group child care. The five cases in 2008 were the most reported for 1 year from Minnesota since 1992, when 10 cases were reported (Figure 1).

Although the recall and cessation of production of Merck Hib-containing vaccines in December 2007 resulted in a nationwide Hib vaccine shortage, supply of the remaining two products manufactured by Sanofi Pasteur is adequate for all infants to complete the 3-dose primary vaccine series. However, in February 2008 the Minnesota Vaccines for Children program began receiving reports from vaccine providers regarding shortages of vaccine in their offices. In response, MDH advised providers to ensure completion of the primary series as recommended whenever possible and to track and recall infants who had not completed the primary series so that they could be vaccinated as soon as doses were available. On January 13, MDH examined 2008 vaccination coverage data in the Minnesota Immunization Information Connection (MIIC), Minnesota’s immunization registry. Data were reviewed for 25,699 children born between November 1, 2007 and March 31, 2008 (Figure 2). Among children aged 7 months, 3-dose primary Hib series coverage was 46.5%, which is lower than the age-appropriate coverage for children who had received pneumococcal conjugate or diphtheria and tetanus toxoids and acellular pertussis (DTaP) vaccination. In contrast, data from the 2007 National Immunization Survey, conducted prior to the shortage, showed that Hib vaccination coverage among children in Minnesota aged 19 months to 35 months was high and did not differ from the national average, suggesting that coverage has declined as a result of the shortage.

*Capsular polysaccharide polyribosomal phosphate (PRP)–outer membrane

protein (OMP). †

### PRP-tetanus toxoid.

## Vol. 58 / No. 3 **MMWR 59** 

Reported by:J Rainbow, MPH, R Danila, PhD, L Bahta, K White, MPH, K Ehresmann, MPH, R Lynfield, MD, Minnesota Dept of Health. F Coronado, MD, A Cohn, MD, T Clark, MD, N Messonnier, MD, Div of Bacterial Diseases, J Santoli, MD, L Rodewald, MD,Immunization Svcs Div, National Center for Immunization and Respiratory Diseases; M Jackson, PhD, S Lowther, PhD, EIS officers, CDC. 

# Editorial Note:Before development of Hib conjugate vaccines, Hib was the most common cause of bacterial meningitis in children aged <5 years. Since implementation of the Hib conjugate vaccine immunization program in the United States in the early 1990s, the incidence of Hib disease has declined from a peak of 41 cases per 100,000 children aged <5 years in 1987 to approximately 0.11 cases per 100,000 in 2007 (3,5 ). As with other bacterial diseases in which acquisition of carriage is necessary for development of invasive disease, reductions in asymptomatic carriage and transmission are substantial contributors to the reduction in Hib disease achieved through vaccination programs (6

–8). This herd immunity provided by high vaccination coverage provides additional protection both for fully vaccinated and undervaccinated persons (6

–8). Three of the five Hib cases in Minnesota occurred in children who had not been vaccinated. One case occurred in a child who was too young to complete the primary series, and a fifth case occurred in a child with an immunodeficiency. Given the prolonged booster dose deferral and reduced primary series coverage in the state, the increase in the number of Hib cases likely reflects increasing carriage and transmission affecting those with suboptimal primary series vaccination coverage, or a weakening of herd immunity. None of the children failed to receive vaccine because of the vaccine shortage. However, MDH is planning evaluations to describe the extent of Hib carriage in the affected communities and understand reasons why some children are not vaccinated. While the shortage continues, completion of the primary series in all children is essential to safeguard individual protection as well as to strengthen herd immunity.

The current Hib vaccine supply in the United States is sufficient to ensure completion of the primary series for all children, but not yet to resume the booster dose. However, vaccine **TABLE. Characteristics of five reported cases of invasive**Haemophilus influenzae**type b (Hib) disease* in persons aged <5 years** **— Minnesota, 2008 Patient**  **Month of illness onset**  **Patient age at illness onset**  **Clinical syndrome †**  

### Outcome **Hib vaccination status** 1 January 15 mos Meningitis Survived 2 doses at 2 and 5 months (PRP-OMP)§ 

### 2 February 3 yrs Pneumonia Survived 0 doses 3 November 7 mos Meningitis Died 0 doses 4 November 5 mos Meningitis Survived 2 doses at 2 and 4 months (PRP-TT)¶ 

### 5 December 20 mos Epiglottitis Survived 0 doses *Defined as isolation ofH. influenzaefrom a normally sterile site in a Minnesota resident. †

### One patient had meningitis with subdural abscess. §

### Hib vaccine, capsular polysaccharide polyribosomal phosphate (PRP)–outer membrane protein (OMP), 2-dose primary series. ¶

### Hib vaccine, PRP-tetanus toxoid, 3-dose primary series. 

## FIGURE 1.**Number of reported cases of invasive**Haemophilus influenzae**type b (Hib) disease in persons aged <5 years — Minnesota, 1992–2008** 

0 2 4 6 8 10 12

1992 1994 1996 1998 2000 2002 2004 2006 2008 

## Year No. of cases



### 0 20 40 60 80 100



## Hib DTaP PCV 

## Vaccine type Percentage 

## Dose 1 Dose 2 Dose 3 

## FIGURE 2.**Percentage of infants* who, by age 7 months, had** **received 1, 2, and 3 doses of**Haemophilus influenzae**type b (Hib) conjugate vaccine, diphtheria and tetanus toxoids and**  **acellular pertussis (DTaP) vaccine, and pneumococcal con****** **jugate vaccine (PCV) — Minnesota Immunization Information Connection, 2008** 

*Born during November 1, 2007–March 31, 2008; N = 25,699.

## 60 **MMWR** January 30, 2009 

# shortages are difficult to manage. Health-care providers must maintain sufficient stocks on hand for every child brought for vaccination each day. During shortages, local supply/demand mismatches can occur, resulting in missed doses (9,10 ). Hib vaccine supply problems can be further complicated because the primary series for the recalled products consists of 2 doses, but the primary series for the available products consists of 3 doses. Regardless of brand or product used, full vaccination with the primary series of Hib vaccine by age 7 months is critical to protect children from disease. Providers who have questions regarding Hib vaccine supply needed to complete the primary vaccine series should contact their state health departments. Combination products may be used for any or all doses of the Hib primary series. Further, if combination vaccines are the only vaccines available to providers, a combination product should be used to complete the primary Hib series, even when this results in receipt of additional doses of another antigen. In response to the findings described in this report, MDH is working with vaccination providers and other partners to resolve any local supply problems. As the vaccine supply resolves, MDH will expedite resumption of the booster dose in communities where Hib cases have been reported.

Invasive Hib disease in children aged <5 years is a nationally notifiable condition. Health-care providers should promptly report all suspected cases of Hib to their local health department. CDC routinely analyzes national surveillance data for invasive Hib disease in children aged <5 years. As of January 13, 2009, no other increases in Hib cases in children aged <5 years had been reported from other states or territories. CDC is working with health departments to identify areas of suboptimal primary Hib series coverage that might lead to increased transmission and disease. Prompt recognition and reporting of Hib cases is important both in understanding the impact of the Hib vaccine shortage and in guiding recommendations for resuming routine booster vaccination and catch-up of undervaccinated children. Acknowledgments 

## This report is based, in part, on contributions by S Jawahir, S Ersted, L Triden, J Harper, MS, K Como-Sabetti, MPH, Minnesota Dept of Health. References

1. CDC.Haemophilus b conjugate vaccines for prevention ofHaemophilus influenzae type b disease among infants and children two months of age and older: recommendations of the ACIP. MMWR 1991;40(No. RR-1). 2. CDC. Interim recommendations for the use ofHaemophilus influenzae type b (Hib) conjugate vaccines related to the recall of certain lots of Hib-containing vaccines (PedvaxHIB and Comvax). MMWR 2007;56:1318–20. 3. CDC. Continued shortage ofHaemophilus influenzae type b (Hib) conjugate vaccines and potential implications for Hib surveillance—United States, 2008. MMWR 2008;57:1252–5. 4. Schuchat A, Hilger T, Zell E, et al. Active bacterial core surveillance of the emerging infections program network. Emerg Infect Dis 2001;7:92–9. 5. CDC. Progress toward elimination ofHaemophilus influenzaetype b disease among infants and children—United States, 1987–1993. MMWR 1994;43:144–8. 6.Whitney CG, Farley MM, Hadler J, et al. Decline in invasive pneumococcal disease after the introduction of protein-polysaccharide conjugate vaccine. N Engl J Med 2003;348:1737–46. 7. Gray SJ, Trotter CL, Ramsay ME, et al. Epidemiology of meningococcal

disease in England and Wales 1993/94 to 2003/04: contribution and experiences of the Meningococcal Reference Unit. J Med Microbiol 2006;55:887–96. 8. Oh SY, Griffiths D, John T, et al. School-aged children: a reservoir for

continued circulation ofHaemophilus influenzae type b in the United Kingdom. J Infect Dis 2008;197:1275–81. 9. Freed GL, Davis MM, Clark SJ. Variation in public and private supply of pneumococcal conjugate vaccine during a shortage. JAMA 2003;289:575–8. 10. Stokley S, Santoli JM, Willis B, Kelley V, Vargas-Rosales A, Rodewald LE. Impact of vaccine shortages on immunization programs and providers. Am J Prev Med 2004;26:15–21. 

# Notice to Readers 

# American Heart Month — February 2009

As part of American Heart Month, February 6 is National Wear Red Day, a day when persons across the United States wear red to show their support for women’s heart disease awareness. Heart disease is the leading cause of death in the United States for both men and women, with women accounting for nearly half of those deaths (1).

In 2006, 7.9 million persons in the United States reported ever having a heart attack (1). The major signs of a heart attack are chest pain or discomfort; pain in the arm or shoulder; pain in the jaw, neck or back; shortness of breath; and feeling weak, light-headed, or faint. Although the most commonly experienced symptom of a heart attack for both men and women is chest pain or discomfort, women are more likely than men to experience other symptoms, such as shortness of breath, pain in the back or jaw, or nausea (2 ). Women also are more likely than men to delay seeking emergency treatment for a heart attack. Receiving immediate treatment substantially increases the chance of surviving a heart attack (2 ). Additional information on women and heart disease prevention is available at http://www.cdc.gov/women/heart. Information on National Wear Red Day activities is available at http://www.nhlbi.nih.gov/health/hearttruth/wrd/index.htm. Information on CDC’s heart disease programs is available at http://www.cdc.gov/dhdsp.

## Vol. 58 / No. 3 **MMWR 61**  References 1.American Heart Association. Heart disease and stroke statistics—2009

update. Dallas, TX: American Heart Association; 2009. Available athttp:// circ.ahajournals.org/cgi/reprint/117/4/e25. 2.National Institutes of Health; National Heart, Lung, and Blood Institute.

Women and heart attack. Available at http://www.nhlbi.nih.gov/actin- time/haws/women.htm. 

# Erratum: Vol. 57, No. 53 In the report, “Racial/Ethnic Differences in the Birth Prevalence of Spina Bifida — United States, 1995–2005,” an error occurred in the second sentence of the Editorial Note. The sentence should have read: “The previous study revealed that from October 1995–December 1996 (before the folic acid fortification mandate) to October 1998–December 1999 (after theJanuary 1998mandate deadline), the prevalence of spina bifida decreased from 2.62 to 2.02 per 10,000 live births, a decrease of 22.9% (3).”

## 62 **MMWR** January 30, 2009 

# QuickStats

from the national center for health statistics 

# Percentage of Adults Aged**> 18 Years Who Had Ever Been Tested for Human** 

**Immunodeficiency Virus (HIV),* by Age Group and Sex — National Health** **Interview Survey, United States, 2007 †** 

* Based on responses to the following question: “Except for tests you may have

had as part of blood donations, have you ever been tested for HIV?” Persons who refused to respond or who answered “Don’t know” (approximately 5% of respondents combined) were not included. † 

### Estimates are based on household interviews of a sample of the civilian,

noninstitutionalized U.S. population. §

### 95% confidence interval. In 2007, overall, 36.6% of adults aged >18 years reported ever being tested for HIV. For both men and women, the percentage of persons who ever had an HIV test was highest among adults aged 25–34 years and 35–44 years and lowest among adults aged>65 years. The percentages who had ever had an HIV test were higher for women than men in age groups 35–44 years and below, not significantly different for men and women at ages 45–64 years, and higher for men than women at ages>65 years. **SOURCE:**Heyman KM, Schiller JS, Barnes P. Early release of selected estimates based on data from the 2007 National Health Interview Survey. Hyattsville, MD: US Department of Health and Human Services, CDC, National Center for Health Statistics; 2008. Available at http://www.cdc.gov/nchs/about/major/nhis/released200806.htm. 0 20 30 40 50 60 70

>18 18–24 25–34 35–44 45–64 >65 

## Age group (yrs) Percentage 

### Male Female §

10 

### Overall

## Vol. 58 / No. 3 **MMWR 63**  **TABLE I. Provisional cases of infrequently reported notifiable diseases (<1,000 cases reported during the preceding year) — United States, week ending January 24, 2009 (3rd week)** * **Disease Current**  **week Cum**  **2009 5-year**  **weekly average** **† Total cases reported**  **for previous years States reporting cases**  **during current week (No.) 2008**  **2007 2006**  **2005 2004**  Anthrax — — — — 1 1 — — Botulism:

foodborne — — 0 14 32 20 19 16 infant — — 1 99 85 97 85 87 other (wound and unspecified) — 2 0 21 27 48 31 30 Brucellosis — 1 1 80 131 121 120 114 Chancroid — — 0 28 23 33 17 30 Cholera — — 0 2 7 9 8 6 Cyclosporiasis§ 2 3 2 130 93 137 543 160 FL (2) Diphtheria — — — — — — — — Domestic arboviral diseases§,¶:

California serogroup — — — 40 55 67 80 112 eastern equine — — — 3 4 8 21 6 Powassan — — — 1 7 1 1 1 St. Louis — — 0 10 9 10 13 12 western equine — — — — — — — — Ehrlichiosis/Anaplasmosis§,**:

Ehrlichia chaffeensis 1 6 2 863 828 578 506 338 TN (1) Ehrlichia ewingii — — — 9 — — — — Anaplasma phagocytophilum — — 1 546 834 646 786 537 undetermined — — 0 71 337 231 112 59 Haemophilus influenzae,†† invasive disease (age <5 yrs): serotype b — 1 0 28 22 29 9 19 nonserotype b 2 6 3 175 199 175 135 135 MN (1), OK (1) unknown serotype 4 16 4 188 180 179 217 177 NY (1), GA (1), FL (1), AZ (1) Hansen disease§ 1 1 1 72 101 66 87 105 CA (1) Hantavirus pulmonary syndrome§

— — 0 16 32 40 26 24 Hemolytic uremic syndrome, postdiarrheal§

— 4 1 243 292 288 221 200 Hepatitis C viral, acute 6 26 13 847 845 766 652 720 VT (1), NY (1), MI (1), WI (1), WA (1), CA (1) HIV infection, pediatric (age <13 years)§§

— — 3 — — — 380 436 Influenza-associated pediatric mortality§,¶¶

— 2 1 90 77 43 45 — Listeriosis 5 21 11 687 808 884 896 753 VT (1), PA (1), OH (2), CO (1) Measles*** — 1 0 134 43 55 66 37 Meningococcal disease, invasive†††:

A, C, Y, and W-135 — 2 5 306 325 318 297 — serogroup B 1 1 3 161 167 193 156 — MN (1) other serogroup — — 1 31 35 32 27 — unknown serogroup 5 22 17 595 550 651 765 — PA (1), OH (3), WA (1) Mumps 3 12 9 400 800 6,584 314 258 NE (1), MD (1), NC (1) Novel influenza A virus infections — — — 2 4 N N N Plague — — 0 1 7 17 8 3 Poliomyelitis, paralytic — — — — — — 1 — Polio virus infection, nonparalytic§

— — — — — N N N Psittacosis§

— — 0 10 12 21 16 12 Q fever total§,§§§: — 1 1 94 171 169 136 70

acute — 1 0 82 — — — — chronic — — — 12 — — — — Rabies, human — — 0 1 1 3 2 7 Rubella¶¶¶

— 1 0 17 12 11 11 10 Rubella, congenital syndrome — — — — — 1 1 — SARS-CoV§,  — — — — — — — — Smallpox§

— — — — — — — — Streptococcal toxic-shock syndrome§

— 1 3 133 132 125 129 132 Syphilis, congenital (age <1 yr) — — 7 244 430 349 329 353 Tetanus — 1 0 16 28 41 27 34 Toxic-shock syndrome (staphylococcal)§ 1 4 1 70 92 101 90 95 CO (1) Trichinellosis 1 1 0 37 5 15 16 5 CO (1) Tularemia — 1 0 110 137 95 154 134 Typhoid fever — 12 6 401 434 353 324 322 Vancomycin-intermediateStaphylococcus aureus§ 1 3 0 36 37 6 2 — OH (1) Vancomycin-resistantStaphylococcus aureus§

— — — — 2 1 3 1 Vibriosis (noncholera Vibriospecies infections)§ 1 11 1 452 549 N N N FL (1) Yellow fever — — — — — — — — See Table I footnotes on next page.

## 64 ** MMWR** January 30, 2009 **TABLE I. (**Continued**) Provisional cases of infrequently reported notifiable diseases (<1,000 cases reported during the preceding year) — United States, week ending January 24, 2009 (3rd week)** * —: No reported cases. N: Not notifiable. Cum: Cumulative year-to-date counts.

* Incidence data for reporting year 2008 and 2009 are provisional, whereas data for 2004, 2005, 2006, and 2007 are finalized. † Calculated by summing the incidence counts for the current week, the 2 weeks preceding the current week, and the 2 weeks following the current week, for a total of

5 preceding years. Additional information is available athttp://www.cdc.gov/epo/dphsi/phs/files/5yearweeklyaverage.pdf. § Not notifiable in all states. Data from states where the condition is not notifiable are excluded from this table, except starting in 2007 for the domestic arboviral diseases and

influenza-associated pediatric mortality, and in 2003 for SARS-CoV. Reporting exceptions are available athttp://www.cdc.gov/epo/dphsi/phs/infdis.htm. ¶ Includes both neuroinvasive and nonneuroinvasive. Updated weekly from reports to the Division of Vector-Borne Infectious Diseases, National Center for Zoonotic, VectorBorne, and Enteric Diseases (ArboNET Surveillance). Data for West Nile virus are available in Table II. ** The names of the reporting categories changed in 2008 as a result of revisions to the case definitions. Cases reported prior to 2008 were reported in the categories: Ehrlichiosis,

human monocytic (analogous toE. chaffeensis); Ehrlichiosis, human granulocytic (analogous toAnaplasma phagocytophilum), and Ehrlichiosis, unspecified, or other agent (which included cases unable to be clearly placed in other categories, as well as possible cases ofE. ewingii). †† Data forH. influenzae(all ages, all serotypes) are available in Table II. §§ Updated monthly from reports to the Division of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention. Implementation of HIV reporting

influences the number of cases reported. Updates of pediatric HIV data have been temporarily suspended until upgrading of the national HIV/AIDS surveillance data management system is completed. Data for HIV/AIDS, when available, are displayed in Table IV, which appears quarterly. ¶¶ Updated weekly from reports to the Influenza Division, National Center for Immunization and Respiratory Diseases. Two influenza-associated pediatric deaths occurring during

the 2008-09 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. §§§ In 2008, Q fever acute and chronic reporting categories were recognized as a result of revisions to the Q fever case definition. Prior to that time, case counts were not differentiated with respect to acute and chronic Q fever cases. ¶¶¶ No rubella cases were reported for the current week. **** Updated weekly from reports to the Division of Viral and Rickettsial Diseases, National Center for Zoonotic, Vector-Borne, and Enteric Diseases.

* 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. 

## F**igure I.** **Selected notifiable disease reports, United States, comparison of provisional 4-week totals** **January 24, 2009, with historical data** 

Notifiable Disease Data Team and 122 Cities Mortality Data Team Patsy A. Hall Deborah A. Adams Rosaline Dhara Willie J. Anderson Michael S. Wodajo Lenee Blanton Pearl C. Sharp Ratio (Log scale)* DISEASE

4 2 1 0.5 0.25 Beyond historical limits DECREASE INCREASE CASES CURRENT 4 WEEKS

425 52 102 42 78

1 26 12 415 Hepatitis A, acute Hepatitis B, acute Hepatitis C, acute Legionellosis Measles Mumps Pertussis Giardiasis

Meningococcal disease

## Vol. 58 / No. 3 **MMWR 65**  **TABLE II. Provisional cases of selected notifiable diseases, United States, weeks ending January 24, 2009, and January 19, 2008 (3rd week)** * **Reporting area Chlamydia** **† Coccidiodomycosis**  **Cryptosporidiosis Current**  **week Previous**  **52 weeks Cum**  **2009 Cum**  **2008 Current**  **week Previous**  **52 weeks Cum**  **2009 Cum**  **2008 Current**  **week Previous**  **52 week Cum**  **2009 Cum**  **2008 Med**  **Max Med**  **Max Med**  **Max United States**  9,437 21,611 25,238 37,778 54,771 93 122 322 354 585 40 103 433 112 203 **New England** 354 707 1,053 1,322 1,613 — 0 1 — — — 5 20 3 46

Connecticut — 210 473 — 186 N 0 0 N N — 0 2 2 38 Maine§ 51 51 72 175 146 N 0 0 N N — 0 6 1 — Massachusetts 204 327 623 818 1,027 N 0 0 N N — 1 9 — 5 New Hampshire 19 41 64 81 115 — 0 1 — — — 1 4 — 3 Rhode Island§ 59 55 208 176 130 — 0 0 — — — 0 3 — — Vermont§ 21 16 52 72 9 N 0 0 N N — 1 7 — — **Mid. Atlantic** 1,877 2,760 5,091 6,261 5,992 — 0 0 — — 5 12 34 18 24

New Jersey — 430 576 269 1,230 N 0 0 N N — 0 2 — 2 New York (Upstate) 426 532 1,857 851 384 N 0 0 N N 4 4 17 8 1 New York City 1,100 1,047 3,412 3,584 2,094 N 0 0 N N — 2 6 3 7 Pennsylvania 351 803 1,078 1,557 2,284 N 0 0 N N 1 5 15 7 14 **E.N. Central** 1,165 3,502 4,285 4,081 10,546 — 1 3 1 3 6 25 126 20 43

Illinois 85 1,071 1,407 642 3,306 N 0 0 N N — 2 13 — 5 Indiana 235 377 713 836 1,071 N 0 0 N N 1 3 12 1 1 Michigan 649 826 1,226 2,221 2,472 — 0 3 — 2 — 5 13 1 14 Ohio — 796 1,261 — 2,487 — 0 2 1 1 5 6 59 14 15 Wisconsin 196 315 615 382 1,210 N 0 0 N N — 9 46 4 8 **W.N. Central** 400 1,269 1,696 2,275 3,306 — 0 2 — — 3 16 68 9 13

Iowa — 174 239 346 484 N 0 0 N N — 4 30 — 6 Kansas 23 181 529 339 213 N 0 0 N N — 1 8 — — Minnesota — 264 339 101 891 — 0 0 — — 3 4 15 3 — Missouri 231 484 566 1,097 1,263 — 0 2 — — — 3 13 3 2 Nebraska§ 87 83 244 210 186 N 0 0 N N — 2 8 2 3 North Dakota — 35 58 3 125 N 0 0 N N — 0 2 — 1 South Dakota 59 55 85 179 144 N 0 0 N N — 1 9 1 1 **S. Atlantic** 1,887 3,643 6,329 7,837 8,785 — 0 1 — — 15 17 47 39 37

Delaware 103 69 150 292 179 — 0 1 — — — 0 2 — 1 District of Columbia — 127 201 239 405 — 0 0 — — — 0 2 — 1 Florida 906 1,368 1,571 3,542 3,461 N 0 0 N N 8 7 35 16 16 Georgia 4 523 1,307 83 1,153 N 0 0 N N 5 4 13 12 10 Maryland§ 280 444 693 1,255 891 — 0 1 — — 2 1 4 3 — North Carolina — 0 1,208 — 7 N 0 0 N N — 0 16 5 — South Carolina§ 95 478 3,042 937 1,520 N 0 0 N N — 1 4 1 5 Virginia§ 472 621 1,059 1,361 1,024 N 0 0 N N — 1 4 1 1 West Virginia 27 60 102 128 145 N 0 0 N N — 0 3 1 3 **E.S. Central** 636 1,571 2,302 3,642 4,042 — 0 0 — — — 2 9 2 8

Alabama§

— 441 547 206 1,422 N 0 0 N N — 1 6 1 5 Kentucky 219 245 373 859 650 N 0 0 N N — 0 4 — 2 Mississippi 417 408 1,048 1,436 581 N 0 0 N N — 0 2 — 1 Tennessee§

— 535 792 1,141 1,389 N 0 0 N N — 1 6 1 — **W.S. Central** 589 2,781 3,530 1,970 7,491 — 0 1 — — 1 6 164 1 2

Arkansas§ 321 276 455 922 715 N 0 0 N N — 0 7 — 1 Louisiana 200 417 775 852 807 — 0 1 — — — 1 5 — — Oklahoma 68 142 391 196 714 N 0 0 N N 1 1 16 1 1 Texas§

— 1,934 2,343 — 5,255 N 0 0 N N — 3 149 — — **Mountain** 536 1,261 1,806 2,501 3,524 65 88 182 254 302 1 8 37 5 15

Arizona 336 470 650 1,022 1,065 65 86 181 253 294 — 1 9 1 3 Colorado 133 266 578 795 830 N 0 0 N N — 1 12 — 3 Idaho§ 28 63 314 34 151 N 0 0 N N 1 1 5 2 5 Montana§

— 58 87 45 178 N 0 0 N N — 1 3 1 1 Nevada§

— 176 415 277 650 — 0 6 1 2 — 0 1 — — New Mexico§

— 132 455 194 308 — 0 3 — 3 — 1 23 1 3 Utah — 104 253 49 331 — 0 2 — 3 — 0 6 — — Wyoming§ 39 31 58 85 11 — 0 1 — — — 0 4 — — **Pacific** 1,993 3,698 4,460 7,889 9,472 28 33 159 99 280 9 8 20 15 15

Alaska 103 85 178 223 143 N 0 0 N N 1 0 1 1 — California 1,409 2,878 3,307 6,221 7,168 28 33 159 99 280 5 5 14 9 11 Hawaii 46 104 164 208 266 N 0 0 N N — 0 1 — — Oregon§ 185 186 631 404 553 N 0 0 N N 1 1 4 3 4 Washington 250 404 527 833 1,342 N 0 0 N N 2 1 12 2 — American Samoa — 0 20 — — N 0 0 N N N 0 0 N N C.N.M.I. — — — — — — — — — — — — — — — Guam — 4 24 — 1 — 0 0 — — — 0 0 — — Puerto Rico 102 117 333 308 132 N 0 0 N N N 0 0 N N U.S. Virgin Islands — 13 23 — 26 — 0 0 — — — 0 0 — — C.N.M.I.: Commonwealth of Northern Mariana Islands. U: Unavailable. —: No reported cases. N: Not notifiable. Cum: Cumulative year-to-date counts. Med: Median. Max: Maximum. * Incidence data for reporting year 2008 and 2009 are provisional. Data for HIV/AIDS, AIDS, and TB, when available, are displayed in Table IV, which appears quarterly. †Chlamydia refers to genital infections caused byChlamydia trachomatis. §Contains data reported through the National Electronic Disease Surveillance System (NEDSS).

## 66 **MMWR** January 30, 2009 **TABLE II. (**Continued **) Provisional cases of selected notifiable diseases, United States, weeks ending January 24, 2009, and January 19, 2008 (3rd week)** *

**Reporting area Giardiasis**  **Gonorrhea** Haemophilus influenzae**, invasive All ages, all serotypes** **† Current**  **week Previous**  **52 weeks Cum**  **2009 Cum**  **2008 Current**  **week Previous**  **52 weeks Cum**  **2009 Cum**  **2008 Current**  **week Previous**  **52 weeks Cum**  **2009 Cum**  **2008 Med**  **Max Med**  **Max Med**  **Max United States**  129 303 590 430 714 2,100 5,883 6,818 9,498 16,993 30 46 81 105 189 **New England** 2 24 49 16 74 44 97 171 131 245 1 2 8 2 13

Connecticut — 5 14 — 23 — 50 129 — 41 — 0 7 — — Maine§ 2 3 12 8 2 1 2 6 4 3 1 0 2 2 1 Massachusetts — 8 17 — 26 34 38 69 108 173 — 0 5 — 9 New Hampshire — 2 11 2 10 — 2 6 4 3 — 0 1 — 1 Rhode Island§

— 1 8 — 6 8 5 13 13 25 — 0 7 — — Vermont§

— 3 13 6 7 1 0 3 2 — — 0 3 — 2 **Mid. Atlantic** 27 60 108 89 136 391 619 987 1,399 1,327 2 10 18 22 32

New Jersey — 6 14 — 31 — 97 167 85 378 — 1 7 — 8 New York (Upstate) 16 21 51 35 23 93 117 407 218 92 2 3 13 8 7 New York City 3 16 29 29 39 220 191 633 698 259 — 2 6 2 4 Pennsylvania 8 15 46 25 43 78 213 268 398 598 — 4 9 12 13 **E.N. Central** 21 48 88 64 136 398 1,195 1,650 1,513 4,138 1 7 17 15 31

Illinois — 11 32 3 41 20 362 485 251 1,276 — 2 7 1 15 Indiana N 0 0 N N 85 147 284 322 512 — 1 12 3 — Michigan 2 12 22 12 25 225 306 657 812 975 — 0 2 1 2 Ohio 16 17 31 44 48 — 274 531 — 1,033 1 2 6 10 11 Wisconsin 3 8 20 5 22 68 80 176 128 342 — 0 2 — 3 **W.N. Central** 6 28 143 37 49 110 316 425 642 912 3 3 15 9 12

Iowa — 6 18 — 17 — 29 50 46 99 — 0 1 — 1 Kansas — 3 11 — 5 8 41 130 103 57 — 0 3 — — Minnesota — 0 106 — 1 — 54 92 13 222 3 0 10 3 — Missouri 2 8 22 21 16 67 149 193 386 453 — 1 6 5 9 Nebraska§ 3 4 10 11 5 28 26 47 61 63 — 0 2 1 2 North Dakota — 0 3 — 1 — 2 6 — 9 — 0 3 — — South Dakota 1 2 10 5 4 7 8 20 33 9 — 0 0 — — **S. Atlantic** 36 54 88 109 126 451 1,250 2,007 2,276 3,382 14 12 25 37 53

Delaware — 1 3 1 3 16 19 44 46 68 — 0 2 — 1 District of Columbia — 1 5 — 1 — 53 101 127 131 — 0 2 — — Florida 22 24 57 78 55 258 445 522 1,095 1,308 7 3 9 18 8 Georgia — 9 27 — 31 1 193 455 30 454 2 2 8 8 21 Maryland§ 6 5 12 12 10 76 118 212 317 342 3 1 6 5 12 North Carolina N 0 0 N N — 0 831 — — — 1 9 3 1 South Carolina§

— 2 6 4 6 31 180 829 299 612 — 1 7 — 4 Virginia§ 7 7 19 13 17 64 182 486 333 433 — 1 7 — 5 West Virginia 1 1 5 1 3 5 14 26 29 34 2 0 3 3 1 **E.S. Central** 1 8 22 3 13 193 544 837 1,230 1,649 1 3 8 3 11

Alabama§

— 4 12 — 8 — 169 218 67 642 — 0 2 1 2 Kentucky N 0 0 N N 76 89 153 293 282 — 0 1 — — Mississippi N 0 0 N N 117 140 401 469 225 — 0 2 — 1 Tennessee§ 1 3 13 3 5 — 163 297 401 500 1 2 6 2 8 **W.S. Central** 4 7 20 9 9 192 927 1,297 672 2,867 2 2 8 2 4

Arkansas§ 1 2 8 1 3 83 87 167 268 243 — 0 2 — — Louisiana — 2 10 1 4 86 169 317 332 430 — 0 1 — — Oklahoma 3 3 9 7 2 23 50 124 72 319 2 1 7 2 4 Texas§ N 0 0 N N — 616 729 — 1,875 — 0 2 — — **Mountain** 13 27 62 32 65 65 203 337 286 637 6 5 14 11 26

Arizona 3 3 8 9 8 34 63 93 123 173 4 2 11 8 10 Colorado 9 10 27 9 23 29 57 99 109 144 2 1 5 2 4 Idaho§ 1 3 14 7 3 — 3 13 — 11 — 0 4 — — Montana§

— 1 9 6 2 — 2 7 — 3 — 0 1 — 1 Nevada§

— 1 8 — 5 — 36 129 31 182 — 0 2 — 2 New Mexico§

— 1 7 1 7 — 22 47 19 99 — 0 4 — 3 Utah — 6 18 — 14 — 9 20 2 23 — 1 5 1 6 Wyoming§

— 0 3 — 3 2 2 9 2 2 — 0 2 — — **Pacific** 19 53 112 71 106 256 601 759 1,349 1,836 — 2 6 4 7

Alaska — 2 10 4 2 17 10 18 42 19 — 0 2 1 — California 13 35 56 53 80 178 494 633 1,118 1,515 — 0 3 — 1 Hawaii — 1 4 1 1 5 11 22 24 34 — 0 2 2 — Oregon§ 2 8 18 9 21 28 22 48 54 89 — 1 4 1 6 Washington 4 8 70 4 2 28 57 90 111 179 — 0 2 — — American Samoa — 0 0 — — — 0 1 — — — 0 0 — — C.N.M.I. — — — — — — — — — — — — — — — Guam — 0 0 — — — 1 15 — 1 — 0 0 — — Puerto Rico — 2 13 — 1 2 5 25 6 8 — 0 0 — — U.S. Virgin Islands — 0 0 — — — 2 6 — 6 N 0 0 N N C.N.M.I.: Commonwealth of Northern Mariana Islands. U: Unavailable. —: No reported cases. N: Not notifiable. Cum: Cumulative year-to-date counts. Med: Median. Max: Maximum. * Incidence data for reporting year 2008 and 2009 are provisional. † Data forH. 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).

## Vol. 58 / No. 3 **MMWR 67**  **TABLE II. (**Continued **) Provisional cases of selected notifiable diseases, United States, weeks ending January 24, 2009, and January 19, 2008 (3rd week)** *

**Reporting area Hepatitis (viral, acute), by type** **† Legionellosis**  **A B**  **Current week**  **Previous 52 weeks**  **Cum 2009**  **Cum 2008**  **Current week**  **Previous 52 weeks**  **Cum 2009**  **Cum 2008**  **Current week**  **Previous 52 weeks**  **Cum 2009**  **Cum 2008**  **Med Max**  **Med Max**  **Med Max**  **United States** 14 44 76 58 126 14 67 93 112 189 27 44 145 97 111 **New England** — 1 7 — 6 — 1 7 1 2 2 2 16 2 2

Connecticut — 0 4 — 1 — 0 7 1 — 2 0 5 2 — Maine§

— 0 2 — 1 — 0 2 — 1 — 0 2 — — Massachusetts — 0 5 — 3 — 0 1 — 1 — 0 2 — — New Hampshire — 0 2 — — — 0 2 — — — 0 5 — — Rhode Island§

— 0 2 — 1 — 0 1 — — — 0 14 — — Vermont§

— 0 1 — — — 0 1 — — — 0 1 — 2 **Mid. Atlantic** 2 5 12 6 24 3 8 14 7 31 9 14 59 25 27

New Jersey — 1 4 — 6 — 2 7 — 15 — 1 8 — 7 New York (Upstate) 1 1 4 2 4 3 1 6 5 — 4 5 19 11 2 New York City — 2 6 1 8 — 1 6 — 4 — 2 12 1 5 Pennsylvania 1 1 6 3 6 — 2 8 2 12 5 6 33 13 13 **E.N. Central** — 6 16 11 17 2 8 15 25 22 4 9 40 21 36

Illinois — 2 10 2 5 — 3 6 — 4 — 1 10 — 8 Indiana — 0 4 — — — 1 4 — — — 1 6 1 — Michigan — 2 7 4 8 — 2 6 5 6 — 2 16 3 11 Ohio — 1 4 5 2 2 2 12 20 10 4 3 18 17 16 Wisconsin — 0 2 — 2 — 0 1 — 2 — 0 3 — 1 **W.N. Central** — 4 16 2 15 1 2 7 7 5 — 2 9 — 3

Iowa — 1 7 — 7 — 0 2 — — — 0 2 — 1 Kansas — 0 3 — 1 — 0 3 — 1 — 0 1 — — Minnesota — 0 8 — 1 — 0 4 — — — 0 4 — — Missouri — 1 3 2 1 1 1 4 6 4 — 1 7 — — Nebraska§

— 0 5 — 4 — 0 2 1 — — 0 4 — 2 North Dakota — 0 0 — — — 0 1 — — — 0 0 — — South Dakota — 0 1 — 1 — 0 0 — — — 0 1 — — **S. Atlantic** 4 7 14 18 20 2 17 34 31 65 6 8 22 27 21

Delaware — 0 1 — — — 0 1 — 3 — 0 2 — — District of Columbia U 0 0 U U U 0 0 U U — 0 2 — 1 Florida 4 2 8 10 11 1 6 12 12 16 5 3 7 11 9 Georgia — 1 4 3 3 — 3 8 10 8 — 0 4 4 2 Maryland§

— 1 4 5 4 1 2 4 1 6 1 2 10 6 5 North Carolina — 0 9 — — — 0 17 7 16 — 0 7 6 1 South Carolina§

— 0 3 — — — 1 4 — 9 — 0 2 — 1 Virginia§

— 1 5 — 2 — 2 7 1 3 — 1 4 — 1 West Virginia — 0 1 — — — 1 4 — 4 — 0 3 — 1 **E.S. Central** — 1 9 3 2 — 7 13 8 16 — 2 10 5 6

Alabama§

— 0 2 1 — — 2 6 2 5 — 0 2 — — Kentucky — 0 3 — 2 — 2 5 1 5 — 1 4 1 5 Mississippi — 0 2 1 — — 1 3 1 — — 0 1 — — Tennessee§

— 0 6 1 — — 3 8 4 6 — 1 5 4 1 **W.S. Central** — 4 12 — 5 2 13 23 9 11 — 1 9 1 2

Arkansas§

— 0 1 — — — 0 4 — — — 0 2 — — Louisiana — 0 1 — 1 — 1 4 1 4 — 0 2 1 — Oklahoma — 0 3 — — 2 2 8 3 — — 0 6 — — Texas§

— 4 11 — 4 — 8 19 5 7 — 1 5 — 2 **Mountain** 5 4 12 8 8 — 4 12 1 12 4 2 8 10 5

Arizona 4 2 11 7 4 — 1 5 — 7 3 0 3 8 1 Colorado 1 0 3 1 2 — 0 3 — 2 — 0 2 — 2 Idaho§

— 0 3 — — — 0 2 — — — 0 1 — — Montana§

— 0 1 — — — 0 1 — — — 0 1 — — Nevada§

— 0 3 — — — 0 3 — 1 1 0 2 2 1 New Mexico§

— 0 3 — 2 — 0 2 — 1 — 0 1 — — Utah — 0 2 — — — 0 3 1 1 — 0 2 — 1 Wyoming§

— 0 1 — — — 0 1 — — — 0 0 — — **Pacific** 3 9 24 10 29 4 6 29 23 25 2 4 10 6 9

Alaska — 0 1 — — — 0 2 1 — — 0 1 — — California 3 7 24 10 25 4 5 19 21 21 2 3 8 6 8 Hawaii — 0 2 — 1 — 0 1 — 1 — 0 1 — — Oregon§

— 0 3 — 3 — 1 3 1 3 — 0 2 — 1 Washington — 1 5 — — — 1 10 — — — 0 3 — — American Samoa — 0 0 — — — 0 0 — — N 0 0 N N C.N.M.I. — — — — — — — — — — — — — — — Guam — 0 0 — — — 0 0 — — — 0 0 — — Puerto Rico — 0 2 1 — — 0 5 — 3 — 0 1 — — U.S. Virgin Islands — 0 0 — — — 0 0 — — — 0 0 — — C.N.M.I.: Commonwealth of Northern Mariana Islands. U: Unavailable. —: No reported cases. N: Not notifiable. Cum: Cumulative year-to-date counts. Med: Median. Max: Maximum. * Incidence data for reporting year 2008 and 2009 are provisional. † Data for acute hepatitis C, viral are available in Table I. §Contains data reported through the National Electronic Disease Surveillance System (NEDSS).

## 68 **MMWR** January 30, 2009 **TABLE II. (**Continued **) Provisional cases of selected notifiable diseases, United States, weeks ending January 24, 2009, and January 19, 2008 (3rd week)** *

**Reporting area Lyme disease**  **Malaria Meningococcal disease, invasive** **† All serotypes**  **Current week**  **Previous 52 weeks**  **Cum 2009**  **Cum 2008**  **Current week**  **Previous 52 weeks**  **Cum 2009**  **Cum 2008**  **Current week**  **Previous 52 weeks**  **Cum 2009**  **Cum 2008**  **Med Max**  **Med Max**  **Med Max**  **United States** 37 445 1,454 160 392 9 21 44 24 43 6 19 47 25 47 **New England** — 44 260 10 64 — 0 6 — 2 — 0 3 — 3

Connecticut — 0 0 — — — 0 3 — — — 0 1 — — Maine§

— 3 73 — — — 0 1 — — — 0 1 — — Massachusetts — 10 114 — 45 — 0 2 — 2 — 0 3 — 3 New Hampshire — 13 141 3 18 — 0 2 — — — 0 0 — — Rhode Island§

— 0 0 — — — 0 1 — — — 0 0 — — Vermont§

— 4 40 7 1 — 0 1 — — — 0 0 — — **Mid. Atlantic** 12 250 1,004 53 214 2 4 14 2 9 1 2 6 2 4

New Jersey — 31 211 — 71 — 0 0 — — — 0 2 — 2 New York (Upstate) 7 99 702 13 8 2 0 5 2 — — 0 3 — 1 New York City — 0 4 — 5 — 3 10 — 7 — 0 2 1 — Pennsylvania 5 93 532 40 130 — 1 3 — 2 1 1 5 1 1 **E.N. Central** 6 11 146 13 25 — 2 7 2 14 3 3 9 6 11

Illinois — 0 12 — 2 — 1 5 — 9 — 1 5 — 7 Indiana — 0 8 — — — 0 2 — — — 0 4 — — Michigan — 1 10 1 2 — 0 2 — 2 — 0 3 — 2 Ohio — 1 5 1 1 — 0 3 2 3 3 1 4 6 1 Wisconsin 6 9 129 11 20 — 0 3 — — — 0 2 — 1 **W.N. Central** — 8 156 — 1 1 1 10 1 — 1 2 8 3 3

Iowa — 1 8 — 1 — 0 3 — — — 0 3 — 1 Kansas — 0 1 — — — 0 2 — — — 0 2 — 1 Minnesota — 4 152 — — 1 0 8 1 — 1 0 7 1 — Missouri — 0 1 — — — 0 3 — — — 0 3 2 1 Nebraska§

— 0 2 — — — 0 2 — — — 0 1 — — North Dakota — 0 1 — — — 0 0 — — — 0 1 — — South Dakota — 0 1 — — — 0 0 — — — 0 1 — — **S. Atlantic** 13 63 219 67 80 5 4 15 9 10 — 3 10 7 8

Delaware 4 12 37 11 23 — 0 1 1 — — 0 1 — — District of Columbia — 2 11 — 3 — 0 2 — — — 0 0 — — Florida 2 2 10 8 1 4 1 7 4 3 — 1 3 3 4 Georgia — 0 3 — — — 1 5 — 3 — 0 2 1 1 Maryland§ 6 28 158 41 45 1 1 7 1 4 — 0 4 — — North Carolina — 0 7 — — — 0 7 2 — — 0 3 2 — South Carolina§

— 0 2 2 — — 0 1 — — — 0 3 — 3 Virginia§ 1 13 53 5 7 — 1 3 1 — — 0 2 1 — West Virginia — 1 11 — 1 — 0 0 — — — 0 1 — — **E.S. Central** — 1 5 1 — 1 0 2 1 2 — 1 6 — 5

Alabama§

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

— 0 3 1 — 1 0 2 1 — — 0 3 — 2 **W.S. Central** — 2 8 — — — 1 11 — — — 2 7 — 3

Arkansas§

— 0 0 — — — 0 0 — — — 0 2 — — Louisiana — 0 1 — — — 0 1 — — — 0 3 — 2 Oklahoma — 0 0 — — — 0 2 — — — 0 3 — 1 Texas§

— 2 8 — — — 1 11 — — — 1 5 — — **Mountain** 1 0 16 2 — — 0 3 — 2 — 1 4 2 4

Arizona — 0 2 — — — 0 2 — 1 — 0 2 — — Colorado 1 0 1 1 — — 0 1 — 1 — 0 1 — — Idaho§

— 0 1 — — — 0 1 — — — 0 1 1 — Montana§

— 0 16 — — — 0 0 — — — 0 1 — — Nevada§

— 0 2 — — — 0 3 — — — 0 1 1 1 New Mexico§

— 0 2 — — — 0 1 — — — 0 1 — — Utah — 0 1 1 — — 0 1 — — — 0 1 — 3 Wyoming§

— 0 1 — — — 0 0 — — — 0 1 — — **Pacific** 5 4 13 14 8 — 3 10 9 4 1 5 19 5 6

Alaska — 0 2 — — — 0 2 — — — 0 2 1 — California 5 3 8 13 8 — 2 8 8 3 — 3 19 2 4 Hawaii N 0 0 N N — 0 1 — — — 0 1 — — Oregon§

— 1 3 1 — — 0 2 1 1 — 1 3 1 2 Washington — 0 9 — — — 0 7 — — 1 0 5 1 — American Samoa N 0 0 N N — 0 0 — — — 0 0 — — C.N.M.I. — — — — — — — — — — — — — — — Guam — 0 0 — — — 0 2 — — — 0 0 — — Puerto Rico N 0 0 N N — 0 1 1 — — 0 1 — — U.S. Virgin Islands N 0 0 N N — 0 0 — — — 0 0 — — C.N.M.I.: Commonwealth of Northern Mariana Islands. U: Unavailable. —: No reported cases. N: Not notifiable. Cum: Cumulative year-to-date counts. Med: Median. Max: Maximum. * Incidence data for reporting year 2008 and 2009 are provisional. † 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).

## Vol. 58 / No. 3 **MMWR 69**  **TABLE II. (**Continued **) Provisional cases of selected notifiable diseases, United States, weeks ending January 24, 2009, and January 19, 2008 (3rd week)** * **Reporting area Pertussis**  **Rabies, animal Rocky Mountain spotted fever**  **Current week**  **Previous 52 weeks**  **Cum 2009**  **Cum 2008**  **Current week**  **Previous 52 weeks**  **Cum 2009**  **Cum 2008**  **Current week**  **Previous 52 weeks**  **Cum 2009**  **Cum 2008**  **Med Max**  **Med Max**  **Med Max**  **United States** 92 184 403 323 361 16 103 168 66 263 3 32 145 22 8 **New England** — 9 32 2 81 1 7 20 7 7 — 0 2 — —

Connecticut — 0 4 — 7 1 4 17 4 — — 0 0 — — Maine†

— 0 5 1 1 — 1 5 1 1 N 0 0 N N Massachusetts — 7 24 — 71 N 0 0 N N — 0 1 — — New Hampshire — 1 4 1 1 — 0 3 — 3 — 0 1 — — Rhode Island†

— 1 7 — — N 0 0 N N — 0 2 — — Vermont†

— 0 2 — 1 — 1 6 2 3 — 0 0 — — **Mid. Atlantic** 9 18 38 35 52 4 33 67 12 52 — 1 6 — 2

New Jersey — 1 6 — 6 — 0 0 — — — 0 2 — 1 New York (Upstate) 2 7 28 6 6 4 9 20 12 16 — 0 5 — — New York City — 0 5 — 8 — 0 2 — 2 — 0 2 — 1 Pennsylvania 7 8 31 29 32 — 21 52 — 34 — 0 2 — — **E.N. Central** 19 33 189 84 71 — 3 28 1 1 — 2 15 — 1

Illinois — 7 43 6 10 — 1 21 1 1 — 1 11 — 1 Indiana — 1 27 2 — — 0 2 — — — 0 3 — — Michigan 1 6 14 13 6 — 0 8 — — — 0 1 — — Ohio 18 10 176 62 47 — 1 7 — — — 0 4 — — Wisconsin — 2 7 1 8 N 0 0 N N — 0 1 — — **W.N. Central** 21 17 118 101 45 — 3 13 — — 1 4 32 1 1

Iowa — 3 21 — 7 — 0 5 — — — 0 2 — — Kansas — 1 13 — 2 — 0 0 — — — 0 0 — — Minnesota — 2 26 — — — 0 10 — — — 0 0 — — Missouri 13 6 50 89 30 — 1 8 — — 1 4 31 1 1 Nebraska† 7 2 33 11 4 — 0 0 — — — 0 4 — — North Dakota — 0 1 — — — 0 7 — — — 0 0 — — South Dakota 1 0 7 1 2 — 0 2 — — — 0 1 — — **S. Atlantic** 25 17 44 63 35 11 34 88 34 184 2 13 71 20 3

Delaware 1 0 3 2 — — 0 0 — — — 0 5 — — District of Columbia — 0 1 — 2 — 0 0 — — — 0 2 — — Florida 7 6 20 27 4 4 0 37 7 100 — 0 3 — — Georgia — 1 8 — 2 — 5 42 — 13 — 1 8 — 1 Maryland† 1 2 8 7 9 — 8 17 6 23 1 1 7 2 1 North Carolina 16 0 15 19 10 7 9 16 11 19 — 3 55 16 1 South Carolina†

— 2 11 8 3 — 0 0 — — — 1 9 — — Virginia†

— 3 12 — 5 — 11 24 9 29 1 2 15 2 — West Virginia — 0 2 — — — 1 9 1 — — 0 1 — — **E.S. Central** — 8 29 12 18 — 3 7 4 7 — 3 23 — —

Alabama†

— 1 5 1 4 — 0 0 — — — 1 8 — — Kentucky — 2 11 8 2 — 0 4 4 1 — 0 1 — — Mississippi — 2 5 1 11 — 0 1 — 1 — 0 3 — — Tennessee†

— 2 14 2 1 — 2 6 — 5 — 2 19 — — **W.S. Central** 6 30 157 7 4 — 1 11 2 3 — 2 41 1 —

Arkansas†

— 1 20 — 2 — 0 6 1 3 — 0 14 1 — Louisiana — 1 7 — — — 0 0 — — — 0 1 — — Oklahoma 1 0 21 1 — — 0 10 1 — — 0 26 — — Texas† 5 26 150 6 2 — 0 1 — — — 1 6 — — **Mountain** 8 15 34 12 38 — 1 8 — 2 — 1 3 — 1

Arizona — 3 10 1 9 N 0 0 N N — 0 2 — — Colorado 6 3 7 6 16 — 0 0 — — — 0 1 — — Idaho† 2 1 5 4 — — 0 0 — — — 0 1 — — Montana†

— 1 11 — 3 — 0 2 — — — 0 1 — — Nevada†

— 0 7 — 1 — 0 4 — — — 0 2 — — New Mexico†

— 1 8 — — — 0 3 — 2 — 0 1 — 1 Utah — 4 17 1 7 — 0 6 — — — 0 1 — — Wyoming†

— 0 2 — 2 — 0 3 — — — 0 2 — — **Pacific** 4 25 82 7 17 — 3 13 6 7 — 0 1 — —

Alaska 3 3 21 6 8 — 0 4 2 4 N 0 0 N N California — 8 23 — — — 3 12 4 3 — 0 1 — — Hawaii — 0 2 — 2 — 0 0 — — N 0 0 N N Oregon†

— 3 10 — 7 — 0 3 — — — 0 1 — — Washington 1 6 62 1 — — 0 0 — — N 0 0 N N American Samoa — 0 0 — — N 0 0 N N N 0 0 N N C.N.M.I. — — — — — — — — — — — — — — — Guam — 0 0 — — — 0 0 — — N 0 0 N N Puerto Rico — 0 0 — — — 1 5 — 1 N 0 0 N N U.S. Virgin Islands — 0 0 — — N 0 0 N N N 0 0 N N C.N.M.I.: Commonwealth of Northern Mariana Islands. U: Unavailable. —: No reported cases. N: Not notifiable. Cum: Cumulative year-to-date counts. Med: Median. Max: Maximum. * Incidence data for reporting year 2008 and 2009 are provisional. †Contains data reported through the National Electronic Disease Surveillance System (NEDSS).

## 70 **MMWR** January 30, 2009 **TABLE II. (**Continued **) Provisional cases of selected notifiable diseases, United States, weeks ending January 24, 2009, and January 19, 2008 (3rd week)** * **Reporting area Salmonellosis**  **Shiga toxin-producing E. coli (STEC) †**  **Shigellosis Current**  **week Previous**  **52 weeks Cum**  **2009 Cum**  **2008 Current**  **week Previous**  **52 weeks Cum**  **2009 Cum**  **2008 Current**  **week Previous**  **52 weeks Cum**  **2009 Cum**  **2008 Med**  **Max Med**  **Max Med**  **Max United States**  308 889 1,489 1,189 1,968 9 82 251 80 135 122 431 611 635 761 **New England** 1 17 63 20 552 — 3 14 1 51 — 2 7 — 44

Connecticut — 0 11 11 484 — 0 1 1 44 — 0 0 — 38 Maine§ 1 3 8 7 2 — 0 3 — 1 — 0 6 — — Massachusetts — 12 52 — 52 — 0 11 — 5 — 1 5 — 5 New Hampshire — 2 10 1 7 — 1 3 — 1 — 0 1 — 1 Rhode Island§

— 2 9 — 3 — 0 3 — — — 0 1 — — Vermont§

— 1 7 1 4 — 0 3 — — — 0 2 — — **Mid. Atlantic** 28 88 177 111 209 1 6 192 4 14 5 44 96 38 58

New Jersey — 12 30 — 56 — 0 3 — 3 — 12 38 3 28 New York (Upstate) 14 26 60 29 24 1 3 188 3 3 3 11 35 5 3 New York City 1 20 53 23 61 — 1 5 1 6 — 13 35 19 18 Pennsylvania 13 27 78 59 68 — 1 8 — 2 2 4 23 11 9 **E.N. Central** 40 93 194 134 211 — 11 74 4 16 44 74 121 169 181

Illinois — 25 72 3 70 — 1 10 — — — 19 35 5 75 Indiana 3 9 53 5 4 — 1 14 — — — 10 39 1 39 Michigan 5 17 38 26 55 — 2 43 1 5 1 3 20 14 2 Ohio 32 26 65 88 48 — 3 17 2 4 39 42 80 136 47 Wisconsin — 14 50 12 34 — 4 20 1 7 4 7 33 13 18 **W.N. Central** 21 49 151 62 77 4 12 59 13 5 4 17 40 7 30

Iowa — 8 16 — 17 — 2 21 — 3 — 3 12 — 4 Kansas — 7 31 3 8 — 1 7 1 — — 1 5 1 — Minnesota 17 13 70 17 1 4 3 21 4 — 3 5 25 3 — Missouri 3 14 48 31 38 — 2 11 6 2 — 3 14 2 17 Nebraska§ 1 4 13 6 12 — 2 29 2 — 1 0 3 1 — North Dakota — 0 7 — — — 0 1 — — — 0 5 — — South Dakota — 3 9 5 1 — 1 4 — — — 0 9 — 9 **S. Atlantic** 98 245 457 464 422 2 14 50 34 19 16 58 100 117 161

Delaware 1 2 9 1 4 — 0 2 — 1 — 0 1 1 — District of Columbia — 1 4 — 4 — 0 1 — 1 — 0 3 — 1 Florida 53 97 174 201 254 — 2 11 12 10 5 14 34 31 71 Georgia 15 43 86 45 40 — 1 7 2 — 4 20 48 23 54 Maryland§ 13 13 36 32 33 1 2 10 7 1 2 2 8 13 3 North Carolina — 24 106 143 1 — 1 19 12 — — 3 27 32 — South Carolina§ 1 18 55 16 37 — 0 4 — 1 — 8 32 5 25 Virginia§ 13 19 42 23 28 1 3 25 1 1 5 4 35 12 7 West Virginia 2 3 6 3 21 — 0 3 — 4 — 0 3 — — **E.S. Central** 8 58 138 61 123 1 5 21 5 10 5 34 67 24 137

Alabama§

— 15 47 25 43 — 1 17 1 3 — 7 18 2 30 Kentucky — 9 18 15 22 — 1 7 — 2 — 3 24 3 21 Mississippi — 14 57 — 27 — 0 2 — 1 — 4 18 — 51 Tennessee§ 8 14 60 21 31 1 2 7 4 4 5 17 46 19 35 **W.S. Central** 18 135 265 36 67 — 6 27 — 5 24 93 215 174 42

Arkansas§ 10 11 40 14 11 — 1 3 — — — 11 27 3 2 Louisiana 3 17 50 9 28 — 0 1 — — 1 11 25 4 12 Oklahoma 5 14 36 8 6 — 1 19 — — 3 3 11 8 6 Texas§

— 91 179 5 22 — 5 12 — 5 20 64 188 159 22 **Mountain** 30 59 110 70 113 — 10 39 2 11 11 21 53 54 36

Arizona 13 19 45 33 33 — 1 5 2 1 7 12 34 38 18 Colorado 13 12 43 13 26 — 3 18 — 2 4 2 11 4 10 Idaho§ 3 3 14 10 6 — 2 15 — 1 — 0 2 — — Montana§

— 2 8 3 2 — 0 3 — 3 — 0 1 — — Nevada§ 1 3 9 11 11 — 0 2 — — — 4 13 10 4 New Mexico§

— 6 33 — 23 — 1 6 — 3 — 1 10 2 3 Utah — 6 19 — 5 — 1 9 — 1 — 1 3 — — Wyoming§

— 1 4 — 7 — 0 1 — — — 0 1 — 1 **Pacific** 64 112 521 231 194 1 10 51 17 4 13 28 82 52 72

Alaska 2 1 4 4 3 — 0 1 — 1 — 0 1 1 — California 51 81 507 194 153 1 6 39 16 3 12 26 74 46 63 Hawaii 1 4 15 13 18 — 0 2 1 — — 1 3 — 3 Oregon§ 2 7 20 12 20 — 1 8 — — — 1 10 4 6 Washington 8 12 124 8 — — 2 36 — — 1 1 24 1 — American Samoa — 0 1 — 1 — 0 0 — — — 0 0 — 1 C.N.M.I. — — — — — — — — — — — — — — — Guam — 0 2 — — — 0 0 — — — 0 3 — — Puerto Rico 1 9 29 3 25 — 0 1 — — — 0 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 notifiable. Cum: Cumulative year-to-date counts. Med: Median. Max: Maximum. * Incidence data for reporting year 2008 and 2009 are provisional. † IncludesE. 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).

## Vol. 58 / No. 3 **MMWR 71**  **TABLE II. (**Continued **) Provisional cases of selected notifiable diseases, United States, weeks ending January 24, 2009, and January 19, 2008 (3rd week)** *

**Reporting area Streptococcal diseases, invasive, group A**  Streptococcus pneumoniae,**invasive disease, nondrug resistant †**  **Age <5 years Current**  **week Previous**  **52 weeks Cum**  **2009 Cum**  **2008 Current**  **week Previous**  **52 weeks Cum**  **2009 Cum**  **2008 Med**  **Max Med**  **Max United States**  56 84 181 209 306 20 33 55 57 127 **New England** — 4 31 1 18 1 1 11 1 8

Connecticut — 0 26 — — — 0 11 — — Maine§

— 0 3 — 1 — 0 1 — — Massachusetts — 1 8 — 15 — 0 4 — 6 New Hampshire — 0 2 1 2 — 0 1 — 2 Rhode Island§

— 0 9 — — — 0 2 — — Vermont§

— 0 3 — — 1 0 1 1 — **Mid. Atlantic** 14 17 43 31 73 1 3 15 4 25

New Jersey — 2 11 — 16 — 1 4 — 5 New York (Upstate) 8 6 17 12 17 1 2 15 4 8 New York City — 4 10 4 17 — 0 5 — 12 Pennsylvania 6 6 16 15 23 N 0 2 N N **E.N. Central** 11 15 42 43 54 1 5 15 10 24

Illinois — 5 16 7 16 — 1 5 — 7 Indiana 3 2 9 3 5 — 0 5 — — Michigan 3 3 10 8 14 — 1 5 2 8 Ohio 5 5 14 24 16 1 1 4 8 6 Wisconsin — 1 10 1 3 — 0 4 — 3 **W.N. Central** 1 5 39 10 10 2 2 11 5 8

Iowa — 0 0 — — — 0 0 — — Kansas — 0 5 1 1 — 0 3 1 1 Minnesota — 0 35 — — 2 0 9 2 — Missouri — 2 10 3 8 — 1 2 2 5 Nebraska§

— 1 3 4 — — 0 1 — 2 North Dakota — 0 3 — — — 0 2 — — South Dakota 1 0 2 2 1 — 0 1 — — **S. Atlantic** 20 21 37 77 74 9 6 16 22 29

Delaware 1 0 2 2 — — 0 0 — — District of Columbia — 0 4 — 2 — 0 1 — — Florida 6 5 10 19 24 3 1 4 5 4 Georgia 8 4 14 24 14 5 1 4 8 4 Maryland§ 2 3 8 11 18 — 1 4 5 11 North Carolina — 2 10 5 2 N 0 0 N N South Carolina§ 2 1 5 9 5 1 1 6 4 5 Virginia§ 1 3 9 5 7 — 0 6 — 5 West Virginia — 0 3 2 2 — 0 1 — — **E.S. Central** 1 3 9 9 8 1 2 6 1 1

Alabama§ N 0 0 N N N 0 0 N N Kentucky — 1 3 — 2 N 0 0 N N Mississippi N 0 0 N N — 0 3 — 1 Tennessee§ 1 3 6 9 6 1 1 5 1 — **W.S. Central** 4 9 28 19 10 1 5 16 6 7

Arkansas§

— 0 2 — — — 0 2 1 2 Louisiana — 0 2 — 1 1 0 3 4 1 Oklahoma 3 2 8 14 3 — 1 3 — 1 Texas§ 1 6 25 5 6 — 3 13 1 3 **Mountain** 4 9 20 12 50 3 4 11 7 24

Arizona 1 3 9 8 15 1 2 7 5 15 Colorado 3 2 8 3 13 2 1 4 2 5 Idaho§

— 0 2 — 1 — 0 1 — 1 Montana§ N 0 0 N N — 0 1 — — Nevada§

— 0 1 — 2 N 0 0 N N New Mexico§

— 1 8 1 13 — 0 3 — 1 Utah — 1 4 — 6 — 0 4 — 2 Wyoming§

— 0 2 — — — 0 1 — — **Pacific** 1 3 8 7 9 1 0 2 1 1

Alaska 1 1 4 2 1 N 0 0 N N California — 0 0 — — N 0 0 N N Hawaii — 2 8 5 8 1 0 2 1 1 Oregon§ N 0 0 N N N 0 0 N N Washington N 0 0 N N N 0 0 N N American Samoa — 0 12 — — N 0 0 N N C.N.M.I. — — — — — — — — — — Guam — 0 0 — — — 0 0 — — Puerto Rico N 0 0 N N N 0 0 N N U.S. Virgin Islands — 0 0 — — N 0 0 N N C.N.M.I.: Commonwealth of Northern Mariana Islands. U: Unavailable. —: No reported cases. N: Not notifiable. Cum: Cumulative year-to-date counts. Med: Median. Max: Maximum. * Incidence data for reporting year 2008 and 2009 are provisional. † Includes cases of invasive pneumococcal disease, in children aged <5 years, caused byS. pneumoniae, which is susceptible or for which susceptibility testing is not available

(NNDSS event code 11717). §Contains data reported through the National Electronic Disease Surveillance System (NEDSS).

## 72 **MMWR** January 30, 2009 **TABLE II. (**Continued **) Provisional cases of selected notifiable diseases, United States, weeks ending January 24, 2009, and January 19, 2008 (3rd week)** *

**Reporting area** Streptococcus pneumoniae**, invasive disease, drug resistant †**  **Syphilis, primary and secondary All ages**  **Aged <5 years Current**  **week Previous**  **52 weeks Cum**  **2009 Cum**  **2008 Current**  **week Previous**  **52 weeks Cum**  **2009 Cum**  **2008 Current**  **week Previous**  **52 weeks Cum**  **2009 Cum**  **2008 Med**  **Max Med**  **Max Med**  **Max United States**  31 52 105 150 290 1 8 23 10 31 93 242 303 390 633 **New England** 1 1 48 2 5 — 0 5 — — 4 5 14 12 15

Connecticut — 0 48 — — — 0 5 — — — 0 3 — — Maine§

— 0 2 — 2 — 0 1 — — — 0 2 — — Massachusetts — 0 0 — — — 0 0 — — 3 4 11 9 12 New Hampshire — 0 0 — — — 0 0 — — 1 0 2 3 1 Rhode Island§

— 0 2 — 2 — 0 1 — — — 0 5 — 2 Vermont§ 1 0 2 2 1 — 0 1 — — — 0 2 — — **Mid. Atlantic** 3 4 13 4 22 — 0 2 — 1 30 32 52 87 93

New Jersey — 0 0 — — — 0 0 — — — 4 10 5 11 New York (Upstate) 1 1 5 1 3 — 0 1 — — 1 3 7 1 1 New York City — 1 6 — 7 — 0 0 — — 28 20 36 72 57 Pennsylvania 2 1 9 3 12 — 0 2 — 1 1 5 12 9 24 **E.N. Central** 5 12 41 32 83 — 2 7 2 13 15 23 38 46 69

Illinois — 0 7 — 31 — 0 2 — 7 2 7 19 6 29 Indiana — 2 31 — 12 — 0 5 — — 2 3 10 4 4 Michigan — 0 3 2 4 — 0 1 — 1 6 3 21 15 10 Ohio 5 7 18 30 36 — 1 4 2 5 4 6 15 19 23 Wisconsin — 0 0 — — — 0 0 — — 1 1 4 2 3 **W.N. Central** — 2 9 5 23 — 0 2 — 1 2 8 14 10 26

Iowa — 0 0 — — — 0 0 — — — 0 2 — — Kansas — 1 5 — 7 — 0 1 — 1 — 0 5 — — Minnesota — 0 0 — — — 0 0 — — — 2 6 1 5 Missouri — 1 5 5 16 — 0 1 — — 2 4 10 9 21 Nebraska§

— 0 0 — — — 0 0 — — — 0 2 — — North Dakota — 0 0 — — — 0 0 — — — 0 0 — — South Dakota — 0 1 — — — 0 1 — — — 0 1 — — **S. Atlantic** 21 21 53 86 121 1 3 13 6 10 26 55 106 127 90

Delaware — 0 1 — — — 0 0 — — — 0 4 2 — District of Columbia — 0 3 — 3 — 0 1 — — — 2 9 14 6 Florida 17 13 30 62 74 — 2 12 5 8 6 19 37 55 51 Georgia 4 6 23 21 38 1 1 5 1 2 — 13 51 — 3 Maryland§

— 0 2 1 1 — 0 1 — — 5 7 14 11 12 North Carolina N 0 0 N N N 0 0 N N 14 5 19 32 6 South Carolina§

— 0 0 — — — 0 0 — — 1 2 6 3 4 Virginia§ N 0 0 N N N 0 0 N N — 5 16 10 8 West Virginia — 1 9 2 5 — 0 2 — — — 0 1 — — **E.S. Central** 1 5 20 13 23 — 1 4 1 2 6 21 37 36 54

Alabama§ N 0 0 N N N 0 0 N N — 8 17 9 25 Kentucky — 1 6 6 6 — 0 2 1 — 2 1 10 5 4 Mississippi — 0 2 — — — 0 1 — — 4 3 19 5 5 Tennessee§ 1 3 18 7 17 — 0 3 — 2 — 8 19 17 20 **W.S. Central** — 2 7 6 8 — 0 2 1 2 4 42 63 29 116

Arkansas§

— 0 4 5 — — 0 1 1 — 3 2 19 19 4 Louisiana — 1 6 1 8 — 0 1 — 2 1 10 31 7 25 Oklahoma N 0 0 N N N 0 0 N N — 1 5 3 10 Texas§

— 0 0 — — — 0 0 — — — 26 47 — 77 **Mountain** — 2 14 — 4 — 0 4 — 1 — 9 16 6 28

Arizona — 0 0 — — — 0 0 — — — 5 13 — 13 Colorado — 0 0 — — — 0 0 — — — 1 7 3 6 Idaho§ N 0 1 N N N 0 1 N N — 0 2 — — Montana§

— 0 1 — — — 0 0 — — — 0 7 — — Nevada§ N 0 1 N N N 0 0 N N — 1 6 1 5 New Mexico§

— 0 1 — — — 0 0 — — — 1 4 2 4 Utah — 1 13 — 4 — 0 4 — 1 — 0 2 — — Wyoming§

— 0 1 — — — 0 0 — — — 0 1 — — **Pacific** — 0 1 2 1 — 0 1 — 1 6 44 64 37 142

Alaska N 0 0 N N N 0 0 N N — 0 1 — — California N 0 0 N N N 0 0 N N 4 40 58 27 124 Hawaii — 0 1 2 1 — 0 1 — 1 — 0 3 4 3 Oregon§ N 0 0 N N N 0 0 N N 2 0 3 2 2 Washington N 0 0 N N N 0 0 N N — 3 9 4 13 American Samoa N 0 0 N N N 0 0 N N — 0 0 — — C.N.M.I. — — — — — — — — — — — — — — — Guam — 0 0 — — — 0 0 — — — 0 0 — — Puerto Rico — 0 0 — — — 0 0 — — 1 3 11 4 1 U.S. Virgin Islands — 0 0 — — — 0 0 — — — 0 0 — — C.N.M.I.: Commonwealth of Northern Mariana Islands. U: Unavailable. —: No reported cases. N: Not notifiable. Cum: Cumulative year-to-date counts. Med: Median. Max: Maximum. * Incidence data for reporting year 2008 and 2009 are provisional. † Includes cases of invasive pneumococcal disease caused by drug-resistantS. pneumoniae(DRSP) (NNDSS event code 11720). §Contains data reported through the National Electronic Disease Surveillance System (NEDSS).

## Vol. 58 / No. 3 **MMWR 73**  **TABLE II. (**Continued **) Provisional cases of selected notifiable diseases, United States, weeks ending January 24, 2009, and January 19, 2008 (3rd week)** * **West Nile virus disease †**  **Reporting area Varicella (chickenpox)**  **Neuroinvasive Nonneuroinvasive** **§ Current**  **week Previous**  **52 weeks Cum**  **2009 Cum**  **2008 Current**  **week Previous**  **52 weeks Cum**  **2009 Cum**  **2008 Current**  **week Previous**  **52 weeks Cum**  **2009 Cum**  **2008 Med**  **Max Med**  **Max Med**  **Max United States**  251 505 1,001 787 1,367 — 1 76 — — — 1 73 — 1 **New England** — 10 22 16 39 — 0 2 — — — 0 1 — —

Connecticut — 0 0 — — — 0 2 — — — 0 1 — — Maine¶

— 0 0 — — — 0 0 — — — 0 0 — — Massachusetts — 0 1 — — — 0 0 — — — 0 0 — — New Hampshire — 5 13 11 21 — 0 0 — — — 0 0 — — Rhode Island¶

— 0 0 — — — 0 1 — — — 0 0 — — Vermont¶

— 4 17 5 18 — 0 0 — — — 0 0 — — **Mid. Atlantic** 37 43 81 100 184 — 0 8 — — — 0 4 — —

New Jersey N 0 0 N N — 0 1 — — — 0 1 — — New York (Upstate) N 0 0 N N — 0 5 — — — 0 2 — — New York City N 0 0 N N — 0 2 — — — 0 2 — — Pennsylvania 37 43 81 100 184 — 0 2 — — — 0 1 — — **E.N. Central** 56 135 312 284 457 — 0 8 — — — 0 3 — —

Illinois 4 23 66 38 11 — 0 4 — — — 0 2 — — Indiana — 0 0 — — — 0 1 — — — 0 1 — — Michigan 11 55 116 75 226 — 0 4 — — — 0 2 — — Ohio 38 46 106 164 220 — 0 3 — — — 0 1 — — Wisconsin 3 4 50 7 — — 0 2 — — — 0 1 — — **W.N. Central** 37 21 71 68 70 — 0 6 — — — 0 21 — —

Iowa N 0 0 N N — 0 2 — — — 0 1 — — Kansas — 6 40 2 26 — 0 2 — — — 0 3 — — Minnesota — 0 0 — — — 0 2 — — — 0 4 — — Missouri 37 9 51 66 43 — 0 3 — — — 0 1 — — Nebraska¶ N 0 0 N N — 0 1 — — — 0 8 — — North Dakota — 0 39 — — — 0 2 — — — 0 11 — — South Dakota — 0 5 — 1 — 0 5 — — — 0 6 — — **S. Atlantic** 47 86 173 101 244 — 0 3 — — — 0 3 — —

Delaware — 1 5 — — — 0 0 — — — 0 1 — — District of Columbia — 0 3 — 4 — 0 0 — — — 0 0 — — Florida 34 29 87 78 53 — 0 2 — — — 0 0 — — Georgia N 0 0 N N — 0 1 — — — 0 1 — — Maryland¶ N 0 0 N N — 0 2 — — — 0 2 — — North Carolina N 0 0 N N — 0 0 — — — 0 0 — — South Carolina¶

— 13 67 1 43 — 0 0 — — — 0 1 — — Virginia¶

— 20 81 — 72 — 0 0 — — — 0 1 — — West Virginia 13 11 33 22 72 — 0 1 — — — 0 0 — — **E.S. Central** 4 17 101 16 52 — 0 7 — — — 0 8 — 1

Alabama¶ 4 17 101 16 52 — 0 3 — — — 0 3 — — Kentucky N 0 0 N N — 0 1 — — — 0 0 — — Mississippi — 0 2 — — — 0 4 — — — 0 7 — — Tennessee¶ N 0 0 N N — 0 2 — — — 0 3 — 1 **W.S. Central** 51 113 435 150 158 — 0 8 — — — 0 7 — —

Arkansas¶

— 9 55 — 19 — 0 1 — — — 0 1 — — Louisiana — 1 10 2 5 — 0 3 — — — 0 5 — — Oklahoma N 0 0 N N — 0 1 — — — 0 1 — — Texas¶ 51 107 422 148 134 — 0 6 — — — 0 4 — — **Mountain** 16 39 90 42 154 — 0 12 — — — 0 22 — —

Arizona — 0 0 — — — 0 10 — — — 0 8 — — Colorado 16 14 44 16 68 — 0 4 — — — 0 10 — — Idaho¶ N 0 0 N N — 0 1 — — — 0 6 — — Montana¶

— 5 27 21 24 — 0 0 — — — 0 2 — — Nevada¶ N 0 0 N N — 0 2 — — — 0 3 — — New Mexico¶

— 3 18 5 18 — 0 2 — — — 0 1 — — Utah — 11 55 — 43 — 0 2 — — — 0 5 — — Wyoming¶

— 0 4 — 1 — 0 0 — — — 0 2 — — **Pacific** 3 2 8 10 9 — 0 38 — — — 0 23 — —

Alaska 3 1 6 9 2 — 0 0 — — — 0 0 — — California — 0 0 — — — 0 37 — — — 0 19 — — Hawaii — 1 5 1 7 — 0 0 — — — 0 0 — — Oregon¶ N 0 0 N N — 0 2 — — — 0 4 — — Washington N 0 0 N N — 0 1 — — — 0 1 — — American Samoa N 0 0 N N — 0 0 — — — 0 0 — — C.N.M.I. — — — — — — — — — — — — — — — Guam — 1 17 — 4 — 0 0 — — — 0 0 — — Puerto Rico 2 7 20 5 24 — 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 notifiable. Cum: Cumulative year-to-date counts. Med: Median. Max: Maximum. * Incidence data for reporting year 2008 and 2009 are provisional. † 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 notifiable in all states. Data from states where the condition is not notifiable are excluded from this table, except starting in 2007 for the domestic arboviral diseases and

influenza-associated pediatric mortality, and in 2003 for SARS-CoV. Reporting exceptions are available athttp://www.cdc.gov/epo/dphsi/phs/infdis.htm. ¶Contains data reported through the National Electronic Disease Surveillance System (NEDSS).

## 74 **MMWR** January 30, 2009 **TABLE III. Deaths in 122 U.S. cities,* week ending****January 24, 2009 (3rd week) Reporting area**  **All causes, by age (years) P&I** **† Total**  **Reporting area 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**  481 355 89 25 7 5 40 **S. Atlantic** 1,238 804 304 68 30 32 72

Boston, MA 147 98 28 15 3 3 12 Atlanta, GA 59 22 14 5 — 18 3 Bridgeport, CT 32 26 4 — 1 1 3 Baltimore, MD 177 105 55 10 3 4 11 Cambridge, MA 14 13 1 — — — 2 Charlotte, NC 87 67 10 7 3 — 6 Fall River, MA 29 24 4 1 — — 3 Jacksonville, FL 146 98 38 9 1 — 12 Hartford, CT 36 25 8 2 1 — 1 Miami, FL 75 52 12 7 4 — 2 Lowell, MA 20 13 6 — 1 — 3 Norfolk, VA 58 38 11 3 4 2 6 Lynn, MA 6 4 2 — — — 1 Richmond, VA 215 133 64 10 4 4 13 New Bedford, MA 24 16 7 1 — — 2 Savannah, GA 64 46 14 2 — 2 4 New Haven, CT U U U U U U U St. Petersburg, FL 50 34 10 2 4 — 3 Providence, RI 50 41 9 — — — — Tampa, FL 218 155 51 7 4 1 11 Somerville, MA 5 5 — — — — — Washington, D.C. 77 44 23 6 3 1 1 Springfield, MA 31 21 4 4 1 1 4 Wilmington, DE 12 10 2 — — — — Waterbury, CT 25 22 3 — — — 1 **E.S. Central** 962 619 237 64 20 21 76 Worcester, MA 62 47 13 2 — — 8 Birmingham, AL 204 139 44 14 4 3 19 **Mid. Atlantic** 2,169 1,505 467 102 24 71 135 Chattanooga, TN 76 46 19 6 3 2 7

Albany, NY 55 32 16 3 1 3 5 Knoxville, TN 104 68 27 8 — 1 4 Allentown, PA 30 21 6 2 1 — 2 Lexington, KY 79 58 14 3 2 2 6 Buffalo, NY 91 70 12 5 1 3 10 Memphis, TN 203 132 57 8 3 3 18 Camden, NJ 23 14 5 3 1 — — Mobile, AL 112 66 27 8 5 5 7 Elizabeth, NJ 26 18 7 1 — — 1 Montgomery, AL 33 22 7 3 1 — 5 Erie, PA 51 40 10 1 — — 4 Nashville, TN 151 88 42 14 2 5 10 Jersey City, NJ 15 8 5 1 — 1 1 **W.S. Central** 1,277 849 288 80 32 28 56 New York City, NY 1,125 803 247 45 11 19 60 Austin, TX 96 63 20 5 3 5 6 Newark, NJ 51 29 13 5 3 1 2 Baton Rouge, LA U U U U U U U Paterson, NJ 15 8 6 1 — — 4 Corpus Christi, TX 70 48 20 2 — — 6 Philadelphia, PA 272 151 58 19 4 40 22 Dallas, TX 235 150 49 19 10 7 7 Pittsburgh, PA§ 46 30 12 4 — — 3 El Paso, TX 103 79 18 4 1 1 4 Reading, PA 35 28 5 1 — 1 1 Fort Worth, TX — — — — — — — Rochester, NY 154 118 27 5 1 3 17 Houston, TX 412 251 107 33 12 9 11 Schenectady, NY 24 20 3 1 — — — Little Rock, AR 82 46 22 7 4 3 2 Scranton, PA 39 31 5 2 1 — 1 New Orleans, LA U U U U U U U Syracuse, NY 53 39 13 1 — — 1 San Antonio, TX U U U U U U U Trenton, NJ 19 15 3 1 — — — Shreveport, LA 89 64 20 4 — 1 8 Utica, NY 22 13 9 — — — 1 Tulsa, OK 190 148 32 6 2 2 12 Yonkers, NY 23 17 5 1 — — — **Mountain** 911 609 208 62 20 12 68 **E.N. Central** 2,245 1,500 533 132 39 41 152 Albuquerque, NM U U U U U U U

Akron, OH 64 39 18 4 1 2 — Boise, ID 52 42 8 2 — — 8 Canton, OH 43 34 9 — — — 4 Colorado Springs, CO 87 57 14 8 7 1 4 Chicago, IL 366 234 93 27 8 4 21 Denver, CO 88 52 26 7 1 2 8 Cincinnati, OH 80 51 19 5 — 5 10 Las Vegas, NV 217 148 53 12 1 3 25 Cleveland, OH 203 138 46 13 5 1 6 Ogden, UT 40 29 8 2 — 1 4 Columbus, OH 176 108 44 13 2 9 19 Phoenix, AZ 125 76 30 14 3 2 9 Dayton, OH 157 115 26 9 6 1 19 Pueblo, CO 34 23 9 1 1 — 1 Detroit, MI 177 80 69 18 5 5 6 Salt Lake City, UT 122 80 26 9 5 2 3 Evansville, IN 55 43 10 2 — — 7 Tucson, AZ 146 102 34 7 2 1 6 Fort Wayne, IN 81 58 16 4 1 2 8 **Pacific** 1,828 1,301 380 83 38 25 195 Gary, IN 20 8 7 1 3 1 1 Berkeley, CA 14 12 2 — — — 1 Grand Rapids, MI 57 43 13 — — 1 2 Fresno, CA 151 104 34 8 3 2 18 Indianapolis, IN 246 176 55 6 3 6 17 Glendale, CA 34 27 6 1 — — 6 Lansing, MI 71 53 18 — — — 3 Honolulu, HI 96 66 27 1 1 1 8 Milwaukee, WI 119 80 23 15 1 — 7 Long Beach, CA 68 37 25 5 — 1 8 Peoria, IL 56 39 12 3 1 1 5 Los Angeles, CA 245 165 46 15 13 6 34 Rockford, IL 70 55 10 3 1 1 5 Pasadena, CA 22 19 2 — — 1 1 South Bend, IN 41 26 7 4 2 2 2 Portland, OR 146 95 38 10 2 — 10 Toledo, OH 113 83 27 3 — — 3 Sacramento, CA 197 147 38 8 2 2 28 Youngstown, OH 50 37 11 2 — — 7 San Diego, CA 147 114 22 6 4 1 12 **W.N. Central** 658 417 170 32 18 21 59 San Francisco, CA 116 83 24 6 — 3 15

Des Moines, IA 170 113 42 8 2 5 14 San Jose, CA 280 215 45 9 8 3 37 Duluth, MN 43 22 15 3 2 1 4 Santa Cruz, CA 37 30 4 2 1 — 3 Kansas City, KS 8 3 2 1 1 1 1 Seattle, WA 107 73 26 3 2 3 6 Kansas City, MO 88 61 19 — 5 3 5 Spokane, WA 61 44 12 3 1 1 5 Lincoln, NE 56 42 10 3 1 — 1 Tacoma, WA 107 70 29 6 1 1 3 Minneapolis, MN 45 23 16 4 — 2 6 **Total ¶**  **11,769 7,959**  **2,676 648**  **228 256**  **853** Omaha, NE 111 66 30 6 6 3 17 St. Louis, MO 49 33 9 3 — 4 3 St. Paul, MN 58 32 21 4 — 1 5 Wichita, KS 30 22 6 — 1 1 3 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.

## MMWR 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, send an e-mail message to listserv@listserv.cdc.gov. The body content should read SUBscribe mmwr-toc. Electronic copy also is available from CDC’s Internet server athttp://www.cdc.gov/mmwror from CDC’s file transfer protocol server at ftp://ftp.cdc.gov/pub/publications/mmwr .Paper copy subscriptions are available through the Superintendent of Documents, U.S. Government Printing Office, Washington, DC 20402; telephone 202-512-1800. Data in the weeklyMMWR are provisional, based on weekly reports to CDC by state health departments. The reporting week concludes at close of business on Friday; compiled data on a national basis are officially released to the public on the following Friday. Data are compiled in the National Center for Public Health Informatics, Division of Integrated Surveillance Systems and Services. 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 theMMWRSeries 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 toMMWRreaders 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. 

## 76 **January 30, 2009**

U.S. Government Printing Office: 2009-523-019/41152 Region IV ISSN: 0149-2195