Summary of Notifiable Diseases --- United States, 2006
Please note:
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Prepared by
Scott J.N. McNabb,PhD
Ruth Ann Jajosky, DMD
Patsy A. Hall-Baker, Annual Summary Coordinator
Deborah A. Adams
Pearl Sharp
Carol Worsham
Willie J. Anderson
J. Javier Aponte
Gerald F. Jones
David A. Nitschke
Araceli Rey, MPH
Michael S. Wodajo
Division of Integrated Surveillance Systems and Services,
National Center for Public Health Informatics,
Coordinating Center for Health Information and Service, CDC
Preface
The Summary of Notifiable Diseases --- United States, 2006
contains the official statistics, in tabular and graphic form, for the
reported occurrence of nationally notifiable infectious diseases in the
United States for 2006. Unless otherwise noted, the data are final
totals for 2006 reported as of June 30, 2007. These statistics are
collected and compiled from reports sent by state and territorial health
departments to the National Notifiable Diseases Surveillance System (NNDSS),
which is operated by CDC in collaboration with the Council of State and
Territorial Epidemiologists (CSTE). The Summary is available at
http://www.cdc.gov/mmwr/summary.html. This site also includes
publications from previous years.
The Highlights section presents noteworthy epidemiologic and prevention
information for 2006 for selected diseases and additional information to
aid in the interpretation of surveillance and disease-trend data. Part 1
contains tables showing incidence data for the nationally notifiable
infectious diseases during 2006.* The tables provide the number of cases
reported to CDC for 2006 as well as the distribution of cases by month,
geographic location, and the patient's demographic characteristics (age,
sex, race, and ethnicity). Part 2 contains graphs and maps that depict
summary data for certain notifiable infectious diseases described in
tabular form in Part 1. Part 3 contains tables that list the number of
cases of notifiable diseases reported to CDC since 1975. This section
also includes a table enumerating deaths associated with specified
notifiable diseases reported to CDC's National Center for Health
Statistics (NCHS) during 2002--2004. The Selected Reading section
presents general and disease-specific references for notifiable
infectious diseases. These references provide additional information on
surveillance and epidemiologic concerns, diagnostic concerns, and
disease-control activities.
Comments and suggestions from readers are welcome. To increase the
usefulness of future editions, comments about the current report and
descriptions of how information is or could be used are invited.
Comments should be sent to Public Health Surveillance Team --- NNDSS,
Division of Integrated Surveillance Systems and Services, National
Center for Public Health Informatics at soib@cdc.gov.
Background
The infectious diseases designated as notifiable at the national level
during 2006 are listed on page 5. A notifiable disease is one for which
regular, frequent, and timely information regarding individual cases is
considered necessary for the prevention and control of the disease. A
brief history of the reporting of nationally notifiable infectious
diseases in the United States is available at
http://www.cdc.gov/epo/dphsi/nndsshis.htm. In 1961, CDC assumed
responsibility for the collection and publication of data on nationally
notifiable diseases. NNDSS is neither a single surveillance system nor a
method of reporting. Certain NNDSS data are reported to CDC through
separate surveillance information systems and through different
reporting mechanisms; however, these data are aggregated and compiled
for publication purposes.
Notifiable disease reporting at the local level protects the public's
health by ensuring the proper identification and follow-up of cases.
Public health workers ensure that persons who are already ill receive
appropriate treatment; trace contacts who need vaccines, treatment,
quarantine, or education; investigate and halt outbreaks; eliminate
environmental hazards; and close premises where spread has occurred.
Surveillance of notifiable conditions helps public health authorities to
monitor the impact of notifiable conditions, measure disease trends,
assess the effectiveness of control and prevention measures, identify
populations or geographic areas at high risk, allocate resources
appropriately, formulate prevention strategies, and develop public
health policies. Monitoring surveillance data enables public health
authorities to detect sudden changes in disease occurrence and
distribution, detect changes in health-care practices, develop and
implement public health programs and interventions, and contribute data
to monitor global trends.
The list of nationally notifiable infectious diseases is revised
periodically. A disease might be added to the list as a new pathogen
emerges, or a disease might be deleted as its incidence declines. Public
health officials at state and territorial health departments and CDC
collaborate in determining which diseases should be nationally
notifiable. CSTE, with input from CDC, makes recommendations annually
for additions and deletions. Although disease reporting is mandated by
legislation or regulation at the state and local levels, state reporting
to CDC is voluntary. Reporting completeness of notifiable diseases is
highly variable and related to the condition or disease being reported (1).
The list of diseases considered notifiable varies by state and year.
Current and historic national public health surveillance case
definitions used for classifying and enumerating cases consistently
across reporting jurisdictions are available at
http://www.cdc.gov/epo/dphsi/nndsshis.htm.
Revised International Health Regulations
In May 2005, the World Health Assembly adopted revised International
Health regulations (IHR) (2) that went into effect in the United
States on July 18, 2007. This international legal instrument governs the
role of the World Health Organization (WHO) and its member countries,
including the United States, in identifying, responding to and sharing
information about Public Health Emergencies of International Concern
(PHEIC). A PHEIC is an extraordinary event that 1) constitutes a public
health risk to other countries through international spread of disease,
and 2) potentially requires a coordinated international response.
The IHR are designed to prevent and protect against the international
spread of diseases while minimizing the effect on world travel and
trade. Countries that have adopted these rules have a much broader
responsibility to detect, respond to, and report public health
emergencies that potentially require a coordinated international
response in addition to taking preventive measures. The IHR will help
countries work together to identify, respond to, and share information
about public health emergencies of international concern.
The revised IHR represent a conceptual shift from a predefined disease
list to a framework of reporting and responding to events on the basis
of an assessment of public health criteria, including seriousness,
unexpectedness, and international travel and trade implications. PHEIC
are events that fall within those criteria (further defined in a
decision algorithm in Annex 2 of the revised IHR). Four conditions
always constitute a PHEIC and do not require the use of the IHR decision
instrument in Annex 2: Severe Acute Respiratory Syndrome (SARS),
smallpox, poliomyelitis caused by wild-type poliovirus, and human
influenza caused by a new subtype. Any other event requires the use of
the decision algorithm in Annex 2 of the IHR to determine if it is a
potential PHEIC. Examples of events that require the use of the decision
instrument include, but are not limited to, cholera, pneumonic plague,
yellow fever, West Nile fever, viral hemorrhagic fevers, and
meningococcal disease. Other biologic, chemical, or radiologic events
might fit the decision algorithm and also must be reportable to WHO. All
WHO member states are required to notify WHO of a potential PHEIC. WHO
makes the final determination about the existence of a PHEIC.
Health-care providers in the United States are required to report
diseases, conditions, or outbreaks as determined by local, state, or
territorial law and regulation, and as outlined in each state's list of
reportable conditions. All health-care providers should work with their
local, state, and territorial health agencies to identify and report
events that might constitute a potential PHEIC occurring in their
location. U.S. State and Territorial Departments of Health have agreed
to report information about a potential PHEIC to the most relevant
federal agency responsible for the event. In the case of human disease,
the U.S. State or Territorial Departments of Health will notify CDC
rapidly through existing formal and informal reporting mechanisms (3).
CDC will further analyze the event based on the decision algorithm in
Annex 2 of the IHR and notify the U.S. Department of Health and Human
Services (DHHS) Secretary's Operations Center (SOC), as appropriate.
DHHS has the lead role in carrying out the IHR, in cooperation with
multiple federal departments and agencies. The HHS SOC is the central
body for the United States responsible for reporting potential events to
the WHO. The United States has 48 hours to assess the risk of the
reported event. If authorities determine that a potential PHEIC exists,
the WHO member country has 24 hours to report the event to the WHO.
An IHR decision algorithm in Annex 2 has been developed to help countries
determine whether an event should be reported. If any two of the
following four questions can be answered in the affirmative, then a
determination should be made that a potential PHEIC exists and WHO
should be notified:
Is the public health impact of the event serious?
Is the event unusual or unexpected?
Is there a significant risk of international spread?
Is there a significant risk of international travel or trade
restrictions?
At its annual meeting in June 2007, the Council of State and
Territorial Epidemiologists (CSTE) approved a position statement to
support the implementation of the 2005 IHR in the United States (3).
CSTE also approved a position statement in support of the 2005 IHR
adding initial detections of novel influenza A virus infections to the
list of nationally notifiable diseases reportable to NNDSS, beginning in
January 2007 (4).
Doyle TJ, Glynn MK, Groseclose LS. Completeness of notifiable
infectious disease reporting in the United States: an analytical
literature review. Am J Epidemiol 2002;155:866--74.
* No cases of diphtheria, neuroinvasive or nonneuroinvasive western
equine encephalitis virus disease, paralytic poliomyelitis, severe acute
respiratory syndrome--associated coronavirus (SARS-CoV), smallpox,
yellow fever, or varicella deaths were reported in the United States in
2006; these conditions do not appear in the tables in Part 1. For
certain other nationally notifiable diseases, incidence data were
reported to CDC but are not included in the tables or graphs of this
Summary. Data on chronic hepatitis B and hepatitis C virus
infection (past or present) are not included because they are undergoing
data quality review. CDC is upgrading its national surveillance data
management system for human immunodeficiency virus (HIV) and acquired
immunodeficiency syndrome (AIDS). During this transition, CDC is not
updating AIDS or HIV infection surveillance data. Therefore, no updates
are provided for HIV and AIDS data in this
Summary.
Infectious Diseases
Designated as Notifiable at the National Level During 2006
Acquired immunodeficiency syndrome (AIDS)�
Lyme disease
Anthrax
Malaria
Botulism
Measles
foodborne
Meningococcal disease, invasive�
infant
Mumps
other (wound and unspecified)
Pertussis
Brucellosis
Plague
Chancroid
Poliomyelitis, paralytic
Chlamydia trachomatis, genital infection
Psittacosis
Cholera
Q fever
Coccidioidomycosis
Rabies
Cryptosporidiosis
animal
Cyclosporiasis
human
Diphtheria
Rocky Mountain spotted fever
Domestic arboviral diseases, neuroinvasive and
nonneuroinvasive
Rubella
California serogroup virus disease
Rubella, congenital syndrome
eastern equine encephalitis virus disease
Salmonellosis
Powassan virus disease
Severe acute respiratory syndrome--associated coronavirus (SARS-CoV)
disease
� The 2005 CSTE position statement approving changes to
the AIDS case definition for adults and adolescents aged
>13 years is pending final review and publication in MMWR.
� In accord with position statements approved by CSTE in
2005, the national surveillance case definitions for hepatitis C virus
infection (past or present), legionellosis, and meningococcal disease
were revised.
� Beginning in 2006, STEC replaced the Enterohemorrhagic
Escherichia coli infection category that was previously
nationally notifiable.
Data Sources
Provisional data concerning the reported occurrence of nationally
notifiable infectious diseases are published weekly in MMWR.
After each reporting year, staff in state and territorial health
departments finalize reports of cases for that year with local or county
health departments and reconcile the data with reports previously sent
to CDC throughout the year. Notifiable disease reports are the
authoritative and archival counts of cases. They are approved by the
appropriate chief epidemiologist from each submitting state or territory
before being compiled and published in the
Summary.
Data in the Summary are derived primarily from reports
transmitted to CDC from health departments in the 50 states, five
territories (American Samoa, the Commonwealth of the Northern Mariana
Islands, Guam, Puerto Rico, and the U.S. Virgin Islands), New York City,
and the District of Columbia. Data were reported for
MMWR weeks 1--52, which correspond to the period for the week
ending January 7, 2006, through the week ending December 30, 2006. More
information regarding infectious notifiable diseases, including case
definitions, is available at
http://www.cdc.gov/epo/dphsi/phs.htm. Policies for reporting
notifiable disease cases can vary by disease or reporting jurisdiction.
The case-status categories used to determine which cases reported to
NNDSS are published, by disease or condition, and are listed in the
print criteria column of the 2006 NNDSS event code list (available at
http://www.cdc.gov/epo/dphsi/phs/files/NNDSSeventcodelistJanuary2007.pdf).
Final data for certain diseases are derived from the surveillance
records of the CDC programs listed below. Requests for further
information regarding these data should be directed to the appropriate
program.
Coordinating Center for Health Information and Service
National Center for Health Statistics (NCHS)
Office of Vital and Health Statistics Systems (deaths from selected
notifiable diseases)
Coordinating Center for Infectious Diseases
National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention
(NCHHSTP)
Division of HIV/AIDS Prevention (AIDS and HIV infection)
Division of STD Prevention (chancroid; Chlamydia trachomatis,
genital infection; gonorrhea; and syphilis)
Division of Tuberculosis Elimination (tuberculosis)
National Center for Immunization and Respiratory Diseases
Influenza Division (influenza-associated pediatric mortality)
Division of Viral Diseases (poliomyelitis, varicella deaths, and
SARS-CoV)
National Center for Zoonotic, Vector-Borne, and Enteric Diseases
Division of Vector-Borne Infectious Diseases (arboviral diseases)
Division of Viral and Rickettsial Diseases (animal rabies)
Population estimates for the states are from the NCHS bridged-race
estimates of the July 1, 2000--July 1, 2005 U.S. resident population
from the vintage 2005 postcensal series by year, county, age, sex, race,
and Hispanic origin, prepared under a collaborative arrangement with the
U.S. Census Bureau. This data set was released on August 16, 2005, and
is available at
http://www.cdc.gov/nchs/about/major/dvs/popbridge/popbridge.htm.
Populations for territories are 2005 estimates from the U.S. Census
Bureau International Data Base Data Access--Display Mode, available at
http://www.census.gov/ipc/www/idb/summaries.html. The choice of
population denominators for incidence reported in MMWR is based
on 1) the availability of census population data at the time of
preparation for publication and 2) the desire for consistent use of the
same population data to compute incidence reported by different CDC
programs. Incidence in the Summary is calculated as the number of
reported cases for each disease or condition divided by either the U.S.
resident population for the specified demographic population or the
total U.S. residential population, multiplied by 100,000. When a
nationally notifiable disease is associated with a specific age
restriction, the same age restriction is applied to the population in
the denominator of the incidence calculation. In addition, population
data from states in which the disease or condition was not notifiable or
was not available were excluded from incidence calculations. Unless
otherwise stated, disease totals for the United States do not include
data for American Samoa, Guam, Puerto Rico, the Commonwealth of the
Northern Mariana Islands, or the U.S. Virgin Islands.
Interpreting Data
Incidence data in the Summary are presented by the date of
report to CDC as determined by the
MMWR week and year assigned by the state or territorial health
department, except for the domestic arboviral diseases, which are
presented by date of diagnosis. Data are reported by the state in which
the patient resided at the time of diagnosis. For certain nationally
notifiable infectious diseases, surveillance data are reported
independently to different CDC programs. Thus, surveillance data
reported by other CDC programs might vary from data reported in the
Summary because of differences in 1) the date used to aggregate
data (e.g., date of report or date of disease occurrence), 2) the timing
of reports, 3) the source of the data, 4) surveillance case definitions,
and 5) policies regarding case jurisdiction (i.e., which state should
report the case to CDC).
Data reported in the Summary are useful for analyzing disease
trends and determining relative disease burdens. However, reporting
practices affect how these data should be interpreted. Disease reporting
is likely incomplete, and completeness might vary depending on the
disease. The degree of completeness of data reporting might be
influenced by the diagnostic facilities available; control measures in
effect; public awareness of a specific disease; and the interests,
resources, and priorities of state and local officials responsible for
disease control and public health surveillance. Finally, factors such as
changes in methods for public health surveillance, introduction of new
diagnostic tests, or discovery of new disease entities can cause changes
in disease reporting that are independent of the true incidence of
disease.
Public health surveillance data are published for selected
racial/ethnic populations because these variables can be risk markers
for certain notifiable diseases. Race and ethnicity data also can be
used to highlight populations for focused prevention efforts. However,
caution must be used when drawing conclusions from reported race and
ethnicity data. Different racial/ethnic populations might have different
patterns of access to health care, potentially resulting in data that
are not representative of actual disease incidence among specific
racial/ethnic populations. Surveillance data reported to NNDSS are in
either individual case-specific form or summary form (i.e., aggregated
data for a group of cases). Summary data often lack demographic
information (e.g., race); therefore, the demographic-specific rates
presented in the
Summary might be underestimated.
In addition, not all race and ethnicity data are collected uniformly
for all diseases. For example, certain disease programs collect data on
race and ethnicity using one or two variables, based on the 1977
standards for collecting such data issued by the Office of Management
and the Budget (OMB). However, beginning in 2003, certain CDC programs,
such as the tuberculosis program, implemented OMB's 1997 revised
standards for collecting such data; these programs collect data on
multiple races per person using multiple race variables. In addition,
although the recommended standard for classifying a person's race or
ethnicity is based on self-reporting, this procedure might not always be
followed.
Transition in NNDSS Data Collection and
Reporting
Before 1990, data were reported to CDC as cumulative counts rather
than individual case reports. In 1990, states began electronically
capturing and reporting individual case reports (without personal
identifiers) to CDC using the National Electronic Telecommunication
System for Surveillance (NETSS). In 2001, CDC launched the National
Electronic Disease Surveillance System (NEDSS), now a component of the
Public Health Information Network (http://www.cdc.gov/phin),
to promote the use of data and information system standards that advance
the development of efficient, integrated, and interoperable surveillance
information systems at the local, state, and federal level. One of the
objectives of NEDSS is to improve the accuracy, completeness, and
timeliness of disease reporting at the local, state, and national level
(5). CDC has developed the NEDSS Base System (NBS), a public
health surveillance information system that can be used by states that
do not wish to develop their own NEDSS-based systems. NBS can capture
data that already are in electronic form (e.g., electronic laboratory
results, which are needed for case confirmation) rather than requiring
that these data be entered manually as in the NETSS application. In
2006, NBS was used by 16 states to transmit nationally notifiable
infectious diseases to CDC. Additional information concerning NEDSS is
available at http://www.cdc.gov/NEDSS.
5. National Electronic Disease Surveillance System Working Group.
National Electronic Disease Surveillance System (NEDSS): a
standards-based approach to connect public health and clinical medicine.
J Public Health Manag Pract 2001;7:43--50.
Highlights for 2006
Below are summary highlights for certain national notifiable
diseases. Highlights are intended to assist in the interpretation of
major occurrences that affect disease incidence or surveillance trends
(e.g., outbreaks, vaccine licensure, or policy changes).
Anthrax
In February 2006, the first naturally-occurring case of inhalation
anthrax in the United States since 1976 occurred in a New York City
resident. His exposure to Bacillus anthracis spores was
determined to be the result of making traditional African drums using
hard-dried animal hides that were contaminated with spores (1).
The patient recovered with treatment (2). A subsequent,
unrelated, fatal case of inhalation anthrax occurred in July 2006 in
Scotland; exposure was suspected to result from the playing of
traditional African drums. In both cases, the animal hides were
suspected to originate from west Africa. These events demonstrate a
previously unrecognized risk for serious illness and death from
inhalation anthrax resulting from the making and playing of animal-skin
drums.
Naturally occurring anthrax epizootics in animal populations continue
to be reported in the United States annually. In 2006, epizootics were
reported in four states, affecting livestock in Minnesota, North Dakota,
and South Dakota and livestock and wildlife in Texas.
Walsh JJ, Pesik N, Quinn CP, et al. A case of naturally acquired
inhalation anthrax: clinical care and analyses of anti-protective
antigen immunoglobulin G and lethal factor. Clin Infect Dis
2007;44:968--71.
Arboviral, Neuroninvasive and
Nonneuroinvasive (West Nile Virus)
During 2006, for the second consecutive year, West Nile virus (WNV)
activity was detected in all 48 contiguous states; in one state
(Washington), human cases were reported for the first time (1).
Cases of WNV disease in humans were reported from 731 counties in 43
states and the District of Columbia. Of these cases, 35% were West Nile
neuroinvasive disease (WNND), 61% were uncomplicated fever, and 4% were
clinically unspecified. Of the cases with WNND, 12% were fatal. The
number of WNND cases reported was the highest since 2003; approximately
10% of these cases were from Idaho, which previously had reported very
few cases. Since WNV was first recognized in the United States in 1999,
a median of 1,229 (mean:1,238; range:19--2,946) WNND cases have been
reported annually.
Botulism is a severe paralytic illness caused by the toxins of
Clostridium botulinum. Exposure to toxin can occur by ingestion
(foodborne botulism) or by in situ production from C. botulinum
colonization of a wound (wound botulism) or the gastrointestinal tract
(infant botulism and adult intestinal colonization of botulism) (1).
In addition to the National Notifiable Diseases Surveillance System, CDC
maintains intensive surveillance for cases of botulism in the United
States. In 2006, cases were attributed to foodborne botulism, wound
botulism, and infant botulism.
Sobel J. Botulism. Clin Infect Dis 2005;41:1167--73.
Brucellosis
In 2006, two cattle herds in one state were reported by the U.S.
Department of Agriculture (USDA) to be affected by brucellosis. USDA has
designated 48 states and three territories as being free of cattle
brucellosis, with one state regaining and another state losing
Brucellosis Class Free state status (1). Brucella abortus
remains enzootic in elk and bison in the greater Yellowstone National
Park area, and
Brucella suis is enzootic in feral swine in the southeast. Hunters
exposed to these animals might be at increased risk for infection. Human
cases can occur among immigrants and travelers returning from countries
with endemic brucellosis and are associated with consumption of
unpasteurized milk or soft cheeses. Pathogenic Brucella species
are considered category B biologic threat agents because of a high
potential for aerosol transmission (2). For the same reason,
biosafety level 3 practices, containment, and equipment are recommended
for laboratory manipulation of isolates (3).
CDC, National Institutes of Health. Biosafety in microbiological
and biomedical laboratories (BMBL). 4th ed. Washington, DC: US
Department of Health and Human Services, CDC, National Institutes of
Health; 1999. Available at
http://www.cdc.gov/OD/OHS/biosfty/bmbl4/bmbl4toc.htm.
Cholera
Cases of cholera continue to be rare in the United States. The number
of cases reported in 2006 was slightly higher than the average number of
cases per year reported during 2001--2005 (4.6) (1). Foreign
travel continues to be the primary source of illness for cholera in the
United States. Cholera remains a global threat to health, particularly
in areas with poor access to improved water and sanitation, such as
sub-Saharan Africa (2). All patients with domestic exposure had
consumed seafood (3). Crabs harvested from the U.S. Gulf Coast
continue to be a common source of cholera, especially during warmer
months, when environmental conditions favor the growth and survival of
Vibrio species in marine water.
Steinberg EB, Greene KD, Bopp CA, Cameron DN, Wells JG, Mintz ED.
Cholera in the United States, 1995--2000: trends at the end of the
twentieth century. J Infect Dis 2001;184:799--802.
Gaffga NH, Tauxe RV, Mintz ED. Cholera: a new homeland in Africa.
Am J Trop Med Hyg 2007;77:705--13.
Brunkard JM, et al. Cholera, crabs, and Katrina: Is cholera
increasing in southern Louisiana? [Abstract]. Presented at the 45th
annual meeting of the Infectious Disease Society of America, San Diego,
CA; October 4--7, 2007.
Cryptosporidiosis
In 2006, the number of cryptosporidiosis cases continued to increase.
This follows a dramatic increase in the number of cases in 2005. The
reasons for this increase are unclear but might reflect changes in
jurisdictional reporting patterns; increased testing for
Cryptosporidium
following the introduction of nitazoxanide, the first licensed treatment for
the disease (1); or a real increase in infection and disease
caused by
Cryptosporidium. This drug introduction might have affected clinical
practice by increasing the likelihood of health-care providers
requesting
Cryptosporidium testing, leading to an increase in subsequent
case reports.
Although cryptosporidiosis is widespread geographically in the United
States, a higher incidence is reported by northern states (2).
However, this observation is difficult to interpret because of
differences in cryptosporidiosis surveillance systems and reporting
among states.
As in previous years, cryptosporidiosis case reports were clearly
influenced by cryptosporidiosis outbreaks. Although cryptosporidiosis
affects persons in all age groups, the number of reported cases was
highest among children aged 1--9 years. A tenfold increase in
transmission of cryptosporidiosis occurred during summer through early
fall compared with winter, coinciding with increased use of recreational
water by younger children, which is a known risk factor for
cryptosporidiosis. Transmission through recreational water is
facilitated by the substantial number of
Cryptosporidium oocysts that can be shed by a single person; the
extended periods of time that oocysts can be shed (3); the low
infectious dose (4); the resistance of
Cryptosporidium oocysts to chlorine (5); and the prevalence of
improper pool maintenance (i.e., insufficient disinfection, filtration,
and recirculation of water), particularly of children's wading pools (6).
Fox LM, Saravolatz LD. Nitazoxanide: a new thiazolide
antiparasitic agent. Clin Infect Dis 2005;40:1173--80.
Chappell CL, Okhuysen PC, Sterling CR, DuPont HL.
Cryptosporidium parvum: intensity of infection and oocyst excretion
patterns in healthy volunteers. J Infect Dis 1996;173:232--6.
DuPont HL, Chappell CL, Sterling CR, Okhuysen PC, Rose JB,
Jakubowski W. The infectivity of Cryptosporidium parvum in healthy volunteers. N Engl J Med
1995;332:855--9.
Korich DG, Mead JR, Madore MS, Sinclair NA, Sterling CR. Effects
of ozone, chlorine dioxide, chlorine, and monochloramine on Cryptosporidium parvum occyst viability. Appl Environ Microbiol
1990;56:1423--8.
Human monocytic ehrlichiosis and human granulocytic ehrlichiosis (now
known as human [granulocytic] anaplasmosis) are emerging tick-borne
diseases that became nationally notifiable in 1999. Because
identification and reporting of these diseases remain incomplete, areas
shown in the maps on pages 49--50 of this summary might not be
definitive predictors for overall distribution or regional prevalence.
Increases in numbers of reported cases of human rickettsial infections
might result from several factors, including but not limited to
increases in vector tick populations, increases in human-tick contact as
a result of encroachment into tick habitat through suburban/rural
recreational activities and housing construction; changes in case
definitions, case report forms, and laboratory tests; and increased use
of active surveillance methods to supplement previously passive
surveillance methods as a result of increased resource availability and
perception of high case density in newly surveyed areas.
The pathogen responsible for human granulocytic ehrlichiosis, genus
Ehrlichia, has been reclassified and now belongs to the genus
Anaplasma. Diseases resulting from infection with Ehrlichia
chaffeensis, Anaplasma phagocytophilum (formerly Ehrlichia
phagocytophila), and other pathogens (comprising
Ehrlichia ewingii and undifferentiated species) have been referred to
respectively by the acronyms "HME," "HGE," and "Ehrlichiosis
(unspecified or other agent)." The case definitions for these diseases
have been modified by a resolution adopted at the June 2007 meeting of
the Council of State and Territorial Epidemiologists; the new category
names and the new case definitions became effective January 1, 2008 (1).
In 2006, rates of gonorrhea in the United States increased for the
second consecutive year (1). Increases in gonorrhea rates in
eight western states during 2000--2005 have been described previously (2).
Increases in quinolone-resistant Neisseria gonorrhoeae in 2006
led to changes in national guidelines that now limit the recommended
treatment of gonorrhea to a single class of drugs, the cephalosporins (3).
The combination of increases in gonorrhea morbidity with increases in
resistance and decreased treatment options have increased the need for
better understanding of the epidemiology of gonorrhea.
CDC. Sexually transmitted disease surveillance, 2006. Atlanta, GA:
US Department of Health and Human Services, CDC; 2007. Available at
http://www.cdc.gov/std/stats/toc2006.htm.
Before the introduction of effective vaccines,
Haemophilus influenzae type b (Hib) was the leading cause of bacterial
meningitis and other invasive bacterial disease among children aged <5
years. Incidence of invasive Hib disease began to decline dramatically
in the late 1980s, coincident with licensure of conjugate Hib vaccines;
incidence has declined >99% compared with the prevaccine era (1).
During 2006, approximately 8% of all cases of invasive
Haemophilus influenzae (Hi) disease reported among children aged
<5 years were attributed to Hib, reflecting successful delivery of
highly effective conjugate Hib vaccines to children beginning at age 2
months (2). Nevertheless, for approximately 50% of reported
cases, serotype information was either unknown or missing, and some of
these also might be Hib cases. Accurate laboratory information is
essential to correctly identify the serotype of the causative Hi isolate
and to assess progress toward elimination of Hib invasive disease (3).
Schuchat A, Rosentein Messonnier N. From pandemic suspect to the
postvaccine era: the Haemophilus influenzae story. Clin Infect Dis 2007;44:817--9
LaClaire LL, Tondella ML, Beall DS, et al. Identification of
Haemophilus influenzae serotypes by standard slide agglutination
serotyping and PCR-based capsule typing. J Clin Microbiol
2003;41:393--6.
Hansen Disease (Leprosy)
The number of cases of Hansen disease (HD) reported in the United
States peaked at 361 in 1985 and has declined since 1988. In 2006, cases
were reported from 20 states and two territories. HD is not highly
transmissible; cases appear to be related predominantly to immigration.
HD outpatient clinics operated under the guidance and direction of the
U.S. Department of Health and Human Services, Health Resources and
Services Administration exist in Phoenix, Arizona; Los Angeles,
Martinez, and San Diego, California; Miami, Florida; Chicago, Illinois;
Baton Rouge, Louisiana; Boston, Massachusetts; New York City, New York;
San Juan, Puerto Rico; Austin, Dallas, Harlingen, Houston, and San
Antonio, Texas; and Seattle, Washington. Services provided to HD
patients include diagnosis, treatment, follow-up of patients and
contacts, disability prevention and monitoring, education, and a
referral system for HD health-care services. Approximately 6,500 person
in the United States are living with HD. Additional information
regarding access to clinical care is available at
http://www.hrsa.gov/hansens.
Hemolytic Uremic Syndrome, Postdiarrheal
Hemolytic uremic syndrome (HUS) is characterized by the triad of
hemolytic anemia, thrombocytopenia, and renal insufficiency. The most
common etiology of HUS in the United States is infection with Shiga
toxin-producing Escherichia coli, principally
E. coli O157:H7 (1). Approximately 8% of persons infected with E.
coli O157:H7 progress to HUS (2). During 2006, the majority of
reported cases occurred among children aged <5 years.
Banatvala N, Griffin PM, Greene KD, et al. The United States
prospective hemolytic uremic syndrome study: microbiologic, serologic,
clinical, and epidemiologic findings. J Infect Dis 2001;183:1063--70.
Slutsker L, Ries AA, Maloney K, et al. A nationwide case-control
study of Escherichia coli O157:H7 infection in the United States. J
Infect Dis 1998;177:962--6.
Influenza-Associated Pediatric Mortality
An early and severe influenza season during 2003--2004 was associated
with deaths in children in multiple states, prompting CDC to request
that all state, territorial, and local health departments report
laboratory confirmed influenza-associated pediatric deaths in children
aged <18 years (1,2). During the 2003--04 influenza season, 153
pediatric influenza-associated deaths were reported to CDC by 40 state
health departments (3). In June 2004, the Council of State and
Territorial Epidemiologists added influenza-associated pediatric
mortality to the list of conditions reportable to the National
Notifiable Diseases Surveillance System (NNDSS) (4). Cumulative
year-to-date incidence data are published each week in
MMWR Table I for low-incidence nationally notifiable diseases.
During 2006, a total of 43 influenza-associated pediatric deaths were
reported to CDC. The median age at death was 4 years (range: 28 days--17
years): seven children (16%) were aged <6 months; 12 (28%) were aged
6--23 months; five (12%) were aged 24--59 months; and 19 (44%) were aged
>5 years. In 2006, approximately half of all influenza-associated
pediatric deaths occurred in the inpatient setting; a slight increase
occurred in the number of children who died in the emergency room or
outside the hospital compared with 2005 (22 and 17, respectively).
Twenty (47%) children had one or more underlying or chronic condition,
and 21 (53%) were previously healthy. The more common chronic conditions
reported included moderate to severe developmental delay (n = 8),
neuromuscular disorders (n = 5), chronic pulmonary disease (n = 5),
seizure disorder (n = 4), and asthma (n = 4). Bacterial coinfections
were confirmed in seven children. Pathogens cultured were
Staphylococcus aureus, sensitivity not done; Staphylococcus
aureus, methicillin-sensitive; Streptococcus viridans; Group
A Streptococcus; Pseudomonas aeruginosa, and one infection with
an unidentified gram-negative bacteria. Of the six (14%) children who
received
>1 dose of influenza vaccine before the onset of illness during the
2005--06 season, only three were fully vaccinated. The current
recommendations of the Advisory Committee on Immunization Practices
highlight the importance of administering 2 doses of influenza vaccine
for previously unvaccinated children aged 6 months--<9years (5).
Continued surveillance of severe influenza-related mortality is
important to monitor the impact of influenza and the possible effects of
interventions in children.
During 2005--2006, nationwide legionellosis case counts increased for
the second year in a row. In 2005, in collaboration with CDC, the
Council for State and Territorial Epidemiologists adopted a position
statement to improve reporting of travel-associated legionellosis (1);
this might have resulted in an increase in case reporting. Nearly all
regions of the United States, with the exception of the West North
Central area, reported more cases in 2006 than in 2005. Other possible
explanations for the increase include an actual increase in disease
incidence or increased use of
Legionella diagnostic tests.
Council of State and Territorial Epidemiologists. Strengthening
surveillance for travel-associated legionellosis and revised case
definitions for legionellosis. Position statement 05-ID-01. Available at
http://www.cste.org/position%20statements/searchbyyear2005.asp.
Listeriosis
Listeriosis is a rare but severe infection caused by Listeria
monocytogenes that has been a nationally notifiable disease since
2000. Listeriosis is primarily foodborne and occurs most frequently
among persons who are older, pregnant, or immunocompromised. During
2005, the majority of reported cases occurred among persons aged >65
years.
Molecular subtyping of L. monocytogenes isolates and sharing
of that information through PulseNet has enhanced the ability of public
health officials to detect and investigate outbreaks. Recent outbreaks
have been linked to ready-to-eat deli meat (1) and unpasteurized
cheese (2). During 2006, the incidence of listeriosis in FoodNet
active surveillance sites was 0.3 cases per 100,000 population,
representing a decrease of 34% compared with 1996--1998; however,
incidence remained higher than at its lowest point in 2002 (3).
All clinical isolates should be submitted to state public health
laboratories for pulsed-field gel electrophoresis (PFGE) pattern
determination, and all persons with listeriosis should be interviewed by
a public health official or health-care provider using a standard
Listeria case form (available at
http://www.cdc.gov/nationalsurveillance/ListeriaCaseReportFormOMB0920-0004.pdf).
Rapid analysis of surveillance data will allow identification of
possible food sources of outbreaks.
Gottlieb SL, Newbern EC, Griffin PM et al. Multistate outbreak of listeriosis linked to turkey deli meat and subsequent changes in US
regulatory policy. Clin Infect Dis 2006;42:29--36.
MacDonald PDM, Whitwam RE, Boggs JD et al. Outbreak of listeriosis
among Mexican immigrants caused by illicitly produced Mexican-style
cheese. Clin Infect Dis 2005;40:677--82.
In 2006, the Council of State and Territorial Epidemiologists (CSTE)
approved a modified case classification for measles, simultaneously with
those for rubella and congenital rubella syndrome (1). Because
measles is no longer endemic in the United States, its future
epidemiology in the U.S. will reflect its global epidemiology. The
modification of the case classification clearly identifies the origin of
each case and will help define the impact of imported cases on the
epidemiology of measles in the United States.
As in recent years, 95% of confirmed measles cases reported during
2006 were import-associated. Of these, 31 cases were internationally
imported, 20 resulted from exposure to persons with imported infections,
and in one case, virologic evidence indicated an imported source. The
sources for the remaining three cases were classified as unknown because
no link to importation was detected. Nearly half of all cases occurred
among adults aged 20--39 years, and 20% occurred in adults aged >40
years. Four outbreaks occurred during 2006 (size range: 3--18 cases),
all from imported sources. Three imported cases occurred in each of two
outbreaks, with no secondary transmission. In another outbreak; one
imported case and two secondary cases occurred in an immigrant
community. In the fourth outbreak, 18 cases occurred among persons aged
25--46 years, most of whom had unknown vaccination histories. The
primary exposure setting for this outbreak was a large office building
and nearby businesses. Five case-patients were foreign born, including
the index case-patient, who had arrived in the United States 9 days
before onset of symptoms.
Measles can be prevented by adhering to recommendations for
vaccination, including guidelines for travelers (2,3). Although
the elimination of endemic measles in the United States has been
achieved, and population immunity remains high (4), an outbreak
can occur when measles is introduced into a susceptible group, often at
significant cost to control (5).
Council of State and Territorial Epidemiologists. Revision of
measles, rubella, and congenital rubella syndrome case classifications
as part of elimination goals in the United States. Position statement
2006-ID-16. Available at http://www.cste.org/position%20statements/searchbyyear2006.asp.
Hutchins SS, Bellini W, Coronado V, et al. Population immunity to
measles in the United States. J Infect Dis 2004;189(Suppl 1):S91--S97.
Parker AA, Staggs W, Dayan G, et al. Implications of a 2005
measles outbreak in Indiana for sustained elimination of measles in the
United States. N Engl J Med 2006;355:447--55.
Meningococcal Disease, Invasive
Neisseria meningitidis is a leading cause of bacterial
meningitis and sepsis in the United States. Rates of meningococcal
disease are highest among infants, with a second peak at age 18 years (1).
The proportion of cases caused by each serogroup of N. meningitidis
varies by age group. Among adolescents aged 11--19 years, 75% of cases
are caused by serogroups contained in the tetravalent (A,C,Y,W-135)
meningococcal conjugate vaccine ([MCV4] Menactra� (Sanofi
Pasteur, Swiftwater, Pennsylvania). The majority of cases in infants are
caused by serogroup B, for which no vaccine is licensed in the United
States.
MCV4 is licensed for persons aged 2--55 years. In 2007, CDC's
Advisory Committee on Immunization Practices revised recommendations for
routine use of MCV4 to include children aged 11--12 years at the
preadolescent vaccination visit and adolescents aged 13--18 years at the
earliest opportunity (2). MCV4 also is recommended for college
freshmen living in dormitories and other populations aged 2--55 years at
increased risk for meningococcal disease (1). Further reductions
in meningococcal disease could be achieved with the development of an
effective serogroup B vaccine.
CDC. Use of quadrivalent meningococcal conjugate vaccine (MCV4) in
children aged 2--10 years at increased risk for invasive meningococcal
disease: recommendation of the Advisory Committee on Immunization
Practices (ACIP). MMWR. In press.
Mumps
Since vaccine licensure in 1967, the number of cases of mumps in the
United States has declined steadily. Since 2001, an average of 265 mumps
cases (range: 231--293 cases) has been reported each year (1).
However, in 2006, the largest mumps outbreak in >20 years occurred, with
>5,000 cases reported (1--3). The outbreak began in Iowa in
December 2005, peaked in April 2006, and declined to lower levels of
reporting during summer 2006 (3). The majority of cases occurred
during March--May, 2006 (3). The outbreak was primarily focal in
geographic distribution; 84% of cases were reported by six contiguous
midwestern states (Illinois, Iowa, Kansas, Nebraska, South Dakota, and
Wisconsin) (3). In contrast to the childhood age range
traditionally associated with mumps disease, young adults aged 18--24
years were the age group most highly affected (1--3). In 2006, a
total of 63% of reported cases occurred in females; previously, no
gender differences in case rates had been reported (3).
In response to the outbreak, the Advisory Committee on Immunization
Practices (ACIP) updated criteria for mumps immunity and mumps
vaccination recommendations (4). Acceptable presumptive evidence
of immunity to mumps includes one of the following: 1) documentation of
adequate vaccination, 2) laboratory evidence of immunity, 3) birth
before 1957, or 4) documentation of physician-diagnosed mumps.
Documentation of adequate vaccination now requires 2 doses of a live
mumps virus vaccine for school-aged children (grades K--12) and adults
at high risk (i.e., persons who work in health-care facilities,
international travelers, and students at post--high school educational
institutions). Health-care workers born before 1957 without other
evidence of immunity should now consider 1 dose of live mumps vaccine.
During an outbreak, a second dose of live mumps vaccine should be
considered for children aged 1--4 years and adults at low risk if
affected by the outbreak; health-care workers born before 1957 without
other evidence of immunity should strongly consider 2 doses of live
mumps vaccine.
In 2006, incidence of reported pertussis decreased to 5.35 cases per
100,000 population after peaking during 2004--2005 at 8.9 per 100,000.
Infants aged <6 months, who are too young to be fully vaccinated, had
the highest reported rate of pertussis (84.21 per 100,000 population),
but adolescents aged 10--19 years and adults aged >20 years contributed
the greatest number of reported cases. Adolescents and adults might be a
source of transmission of pertussis to young infants who are at higher
risk for severe disease and death and are recommended to be vaccinated
with tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis
vaccine (Tdap) (1,2). In 2006, coverage with Tdap in adolescents
aged 13--17 years was 10.8%, compared with 49.4% coverage with tetanus
and diphtheria toxoids vaccine (Td) (3). The decrease in reported
pertussis incidence in 2006 is unlikely to be related to use of Tdap and
is more likely related to the cyclical nature of disease.
The number of human plague cases reported in 2006 was the greatest
number since 1994 and was fourfold higher than the average for the
preceding 5 years. Six cases were classified as primary septicemic
plague, approximately twice the usual frequency of this disease
manifestation. Nearly half of the cases reported in 2006 were from New
Mexico (n = 8); two of these cases were fatal. Although factors
governing the occurrence of plague are incompletely understood, the
disease appears to fluctuate naturally in response to climactic factors.
Poliomyelitis, Paralytic and Polio Virus
Infections
In 2006, the Council of State and Territorial Epidemiologists (CSTE)
recommended revision of the surveillance case definition for paralytic
poliomyelitis to include nonparalytic poliovirus infection and the
addition of non-paralytic poliovirus infection to the list of nationally
notifiable diseases reported through the National Notifiable Diseases
Surveillance System (1). These changes resulted from the
identification in 2005 of a type 1 vaccine-derived poliovirus (VDPV)
infection among unvaccinated Minnesota Amish children who were not
paralyzed (2). Public health officials should remain alert that
paralytic poliomyelitis or poliovirus infections might occur in
high-risk (i.e., unvaccinated or undervaccinated) populations and should
report any detected poliovirus infections attributed to either wild or
vaccine-derived polioviruses and any paralytic poliomyelitis cases.
Council of State and Territorial Epidemiologists. Inclusion of
poliovirus infection reporting in the National Notifiable Diseases
Surveillance System. Position statement 2006-ID-15. Available at: http://www.cste.org/position%20statements/searchbyyear2006.asp.
Psittacosis is an avian zoonosis with a spectrum of disease that
ranges from a mild influenza-like illness to severe pneumonia with
multiorgan involvement. Case reports of psittacosis in 2006 increased
slightly compared with the previous four years. Further information
regarding diagnosis, treatment, and prevention of psittacosis is
available at
http://www.avma.org/pubhlth/psittacosis.asp.
Rabies
During 2006, the majority (92%) of animal rabies cases were reported
in wild animal species. Overall an 8.2% increase in rabies cases was
reported in animals compared with 2005 (1). In the United States
five animal species are recognized as reservoir species for various
rabies virus variants over defined geographic regions: raccoons (eastern
United States), bats (various species, all U.S. states except Hawaii),
skunks (North Central United States, South Central United States, and
California), foxes (Alaska, Arizona, and Texas), and mongoose (Puerto
Rico). During 2006, bats became the second most reported species with
rabies.
Reported cases of rabies in domestic animals remain low in part
because of high vaccination rates. Dog-to-dog transmission has not been
reported in 2 years, making the United States free of the canine rabies
virus variant in 2006. As in the past decade, cats were the most
commonly reported domestic animal with rabies during 2006.
Vaccination programs to control rabies in wild carnivores were
ongoing through the distribution of baits containing an oral rabies
vaccine in the Eastern United States and Texas. Oral rabies vaccination
programs in Texas are being maintained as a barrier to prevent the
reintroduction of canine rabies from Mexico. Oral rabies vaccination
programs are also being conducted in the Eastern United States to
attempt to stop the westward spread of the raccoon rabies virus variant.
Active surveillance conducted by the U. S. Department of Agriculture
(USDA) to monitor oral rabies vaccination programs were further enhanced
by the deployment of the Direct Rapid Immunohistochemical Test (DRIT)
which USDA began implementing in the last half of 2005 after receiving
training on its use at CDC. This test is used for screening the large
number of samples collected by USDA in the field, reducing the burden on
state laboratories and allowing for faster processing of surveillance
samples (2).
Three cases of human rabies were identified during 2006: one in a
male aged 16 years from Texas, one in a female aged 10 years from
Indiana, and one in a male aged 11 years from California. The cases in
Texas and Indiana were attributable to bat-associated rabies virus
variants; free-tailed bat and sliver-haired bat respectively. The case
in California was associated with a canine variant from the Philippines.
The patient had recently immigrated from the Philippines where an
exposure to a dog was noted approximately 2 years before onset of rabies
(2).
Blanton JD, Hanlon CA, Ruprrecht CE. Rabies surveillance in the
United States during 2006. J Am Vet Med Assoc 2007;231:540--56.
Lembo T, Niezgoda M, Hamir AN, et al. Evaluation of a direct,
rapid immunohistochemical test for rabies diagnosis. Emerg Infect Dis
2006;12:310--3.
Salmonellosis
During 2006, as in previous years, the majority of reported cases
occurred among persons aged <5 years. Since 1993, the most frequently
reported isolates have been
Salmonella enterica serotype Typhimurium and S. enterica serotype
Enteritidis (1). The epidemiology of
Salmonella has been changing over the past decade.
Salmonella serotype Typhimurium has decreased in incidence, while
incidence of serotypes Newport, Mississippi, and Javiana have increased.
Specific control programs might have led to the reduction of serotype
Enteritidis infections, which have been associated with the consumption
of internally contaminated eggs. Rates of antibiotic resistance among
several serotypes have been increasing; a substantial proportion of
serotypes Typhimurium and Newport isolates are resistant to multiple
drugs (2).
The epidemiology of Salmonella infections is based on serotype
characterization; in 2005, the Council of State and Territorial
Epidemiologists adopted a position statement for serotype-specific
reporting of laboratory-confirmed salmonellosis cases (3).
However, reporting through the National Notifiable Diseases Surveillance
System (NNDSS) does not include serotype; serotypes for Salmonella
isolates are reported through the Public Health Laboratory Information
System (PHLIS). The National Electronic Disease Surveillance System
(NEDSS) or compatible systems eventually will replace PHLIS; users of
NEDSS or compatible systems should report serotype in NEDSS.
CDC. National Antimicrobial Resistance Monitoring System for
enteric bacteria (NARMS): 2004 human isolates, final report. Atlanta,
GA: US Department of Health and Human Services, CDC; 2006.
Escherichia coli O157:H7 has been nationally notifiable since
1994 (1). National surveillance for all Shiga toxin-producing
E. coli (STEC), under the name enterohemorrhagic E. coli
(EHEC), began in 2001. As of January 1, 2006, the nationally notifiable
diseases case definition designation changed from EHEC to STEC, and
serotype-specific reporting was implemented (2). Because
diagnosis solely on the basis of detection of Shiga toxin does not
sufficiently protect the public's health, characterizing STEC isolates
by serotype and pulsed-field gel electrophoresis (PFGE) patterns is
critical to detect, investigate, and control outbreaks. Screening of
stool specimens by clinical diagnostic laboratories for Shiga toxin by
enzyme immunoassay, subsequent bacterial culture using sorbitol
MacConkey agar (SMAC), and forwarding enrichment broths from Shiga
toxin-positive specimens that do not yield STEC O157 to state or local
public health laboratories are important for public health surveillance
of STEC infections (3).
Healthy cattle, which harbor the organism as part of the bowel flora,
are the main animal reservoir of STEC. The majority of reported
outbreaks are caused by contaminated food or water. The substantial
decline in cases reported during 2002--2003 coincided with industry and
regulatory control activities and with a decrease in the contamination
of ground beef (4). However, during 2005--2006, incidence of
human STEC infections increased. Reasons for the increases are not
known. Three large multistate outbreaks of E. coli O157
infections during fall 2006 caused by contaminated spinach and lettuce
suggest that produce that is consumed raw is an important source of STEC
infection (5,6).
Council of State and Territorial Epidemiologists. Revision of the Enterohemorrhagic Escherichia coli (EHEC) condition name to Shiga toxin-producing Escherichia coli (STEC) and adoption of serotype specific national
reporting for STEC. Position statement 05-ID-07. Available at http://www.cste.org/position%20statements/searchbyyear2005.asp.
Naugle AL, Holt KG, Levine P, Eckel R. 2005 Food Safety and
Inspection Service regulatory testing program for Escherichia coli O157:H7 in raw ground beef. J Food Prot
2005;68:462--8.
CDC. Multistate outbreak of E. coli infections linked to
Taco Bell. Atlanta, GA: US Department of Health and Human Services, CDC;
2006. Available at http://www.cdc.gov/ecoli/2006/december/index.htm.
Shigellosis
During 1978--2003, the number of shigellosis cases reported to CDC
consistently exceeded 17,000. The approximately 14,000 cases of
shigellosis reported to CDC in 2004 represented an all-time low. This
number increased to approximately 16,000 in 2005 and decreased slightly
in 2006.
Shigella sonnei infections continue to account for >75% of shigellosis in
the United States (1). Certain cases of shigellosis are acquired
during international travel (2,3). In addition to spread from one
person to another,
shigellae can be transmitted through contaminated foods, sexual contact,
and water used for drinking or recreational purposes (1).
Resistance to ampicillin and trimethoprim-sulfamethoxazole among S.
sonnei strains in the United States remains common (4).
Gupta A, Polyak CS, Bishop RD, Sobel J, Mintz ED.
Laboratory-confirmed shigellosis in the United States, 1989--2002:
epidemiologic trends and patterns. Clin Infect Dis 2004;38:1372--7.
Ram PK, Crump JA, Gupta SK, Miller MA, Mintz, ED. Review article:
part II. Analysis of data gaps pertaining to Shigella infections in low and medium human development index
countries, 1984--2005. Epidemiol Infect. In press.
Gupta SK, Strockbine N, Omondi M, Hise K, Fair MA, Mintz ED. Short
report: emergence of shiga toxin 1 genes within Shigella dysenteriae Type 4 isolates from travelers returning
from the island of Hispa�ola. Am J Trop Med Hyg 2007;76:1163--5.
CDC. National Antimicrobial Resistance Monitoring System (NARMS):
enteric bacteria. Atlanta, GA: US Department of Health and Human
Services, CDC; 2007. Available at http://www.cdc.gov/narms.
Streptococcus pneumoniae, invasive
disease
In 1994, the Council of State and Territorial Epidemiologists (CSTE)
adopted a position statement making drug-resistant Streptococcus
pneumoniae (DRSP) invasive disease a nationally notifiable disease (1).
In 2000, in anticipation of the routine introduction of the 7-valent
pneumococcal conjugate vaccine (PCV7) (2), CSTE made invasive
pneumococcal disease (IPD) among children aged <5 years nationally
notifiable (3). Consequently, the National Notifiable Diseases
Surveillance System (NNDSS) had two event codes for reporting IPD that
were not mutually exclusive: DRSP among persons of all ages and IPD
among children aged <5 years.
To avoid submissions of duplicate reports, CSTE modified the case
classification of DRSP and IPD in 2006. Under the modified case
definition, which became effective in January 2007, cases with isolates
causing IPD from children aged <5 years for whom antibacterial
susceptibilities are available and determined to be DRSP should be
reported only as DRSP, and cases with isolates causing IPD from children
aged <5 years who are susceptible or for which susceptibilities are not
available should be reported only as IPD in children aged <5 years (4).
Only susceptible IPD episodes among children aged <5 years are reported
in this Summary. In 2006, for the first time after several years
of increasing case counts, the number of cases of pneumococcal disease
in both reportable categories declined. The initial increases in
reported cases likely represented improvements in surveillance and
possibly duplicate reporting of DRSP and IPD cases during the first few
years after the adoption of the 2000 position statement. Other data
sources have demonstrated substantial declines in the incidence of IPD
and DRSP among children and adults after introduction of PCV7 (5,6).
Although PCV7 has been recommended for use in children since 2000,
recommendations for use of the 23-valent pneumococcal polysaccharide
vaccine for adults aged >65 years and for older children and adults with
underlying illnesses were updated in 1997 (7). Cases of
susceptible IPD among persons aged >5 years are not nationally
notifiable.
States are encouraged to evaluate their own pneumococcal disease
surveillance programs (8). CSTE also has recommended that
technology for pneumococcal serotyping using polymerase chain reaction
(PCR) (9) should be shared with state public health laboratories
to improve surveillance for vaccine- and nonvaccine-preventable IPD
among children aged <5 years (4). PCR is used by the majority of
state public health laboratories to detect a variety of infectious
diseases; therefore, this technology should allow most, if not all,
state health departments to enhance surveillance for vaccine-preventable
IPD. With better data, public health officials will be able to assess
the burden of vaccine-preventable IPD and to evaluate current PCV7
immunization programs.
Council of State and Territorial Epidemiologists. National
surveillance for drug-resistant Streptococcus pneumoniae (DRSP) invasive diseases. Position
statement 1994-NSC-10. Available at http://www.cste.org/ps/1994/1994-nsc-10.htm.
Council of State and Territorial Epidemiologists. Surveillance for
invasive pneumococcal disease in children less than five years of age.
Position statement 2000-ID-6. Available at http://www.cste.org/ps/2000/2000-id-06.htm.
Council of State and Territorial Epidemiologists. Enhancing local,
state and territorial-based surveillance for invasive pneumococcal
disease in children less than five years of age. Position statement
06-ID-14. Available at http://www.cste.org/position%20statements/searchbyyear2006.asp.
Kyaw MH, Lynfield R, Schaffner W, et al. Effect of introduction of
the pneumococcal conjugate vaccine on drug-resistant Streptococcus pneumoniae. N Engl J Med 2006;354:1455--63.
In 2006, primary and secondary (P&S) syphilis cases reported to CDC
increased for the sixth consecutive year (1). During 2005--2006,
the number of P&S syphilis cases reported to CDC increased 11.8%.
Overall increases in rates during 2001--2006 were observed primarily
among men (2). However, after decreasing during 2001--2004, the
rate of primary and secondary syphilis among women increased, from 0.8
cases per 100,000 population in 2004 to 1.0 cases per 100,000 population
in 2006. During 2005--2006, P&S syphilis increased among persons of all
races and ethnicities.
In 2005, CDC requested that all state health departments report the
sex of partners of persons with syphilis. In 2006, of all P&S syphilis
cases reported from the 30 areas (29 states and Washington, D.C.) for
which complete data were available, 64% occurred among men who have sex
with men (3).
Although the majority of cases of syphilis in the United States occur
among men who have sex with men, recent increases in the number of cases
reported among women suggest that heterosexually transmitted syphilis
might be an emerging problem. In collaboration with partners throughout
the United States, CDC updated the Syphilis Elimination Plan for
2005--2010 and is now working to implement it (4). Collaboration
with multiple organizations, public health professionals, the private
medical community, and other partners is essential for the successful
elimination of syphilis in the United States.
CDC. Sexually transmitted disease surveillance, 2006. Atlanta, GA:
US Department of Health and Human Services, CDC; 2007. Available at http://www.cdc.gov/std/stats/toc2006.htm.
Heffelfinger JD, Swint EB, Berman SM, Weinstock HS. Trends in
primary and secondary syphilis among men who have sex with men in the
United States. Am J Public Health 2007;97:1076--83.
Beltrami JF, Weinstock H.S. Primary and secondary syphilis among
men who have sex with men in the United States, 2005 [Abstract O-069].
Program and abstracts of the 17th biennial meeting of the International
Society for Sexually Transmitted Diseases Research; July 29--August 1,
2006; Seattle, Washington.
CDC. The national plan to eliminate syphilis from the United
States. Atlanta, GA: US Department of Health and Human Services, CDC;
2006.
Tetanus
In 2006, incidence of reported tetanus and case fatality continued to
be low. No neonatal cases were reported. The majority of cases occurred
among persons aged 25--59 years and those aged >60 years. Mortality from
tetanus was associated with diabetes, intravenous drug use, and advanced
age, especially in the setting of unknown vaccination status.
Typhoid Fever
Despite recommendations that travelers to countries in which typhoid
fever is endemic should be vaccinated with either of two effective
vaccines available in the United States, approximately three fourths of
all cases occur among persons who reported international travel during
the preceding month and were not immunized. Persons visiting South Asia
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