Summary of Notifiable Diseases --- United States, 2008

Highlights for 2008

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).

AIDS

Since 1981, confidential name-based AIDS surveillance has been the cornerstone of national, state, and local efforts to monitor the scope and impact of the human immunodeficiency virus (HIV) epidemic. The data have multiple uses, including the development of policy to help prevent and control AIDS. However, because of the introduction of therapies that effectively slow the progression of HIV infection, AIDS data no longer adequately represent the populations affected by the epidemic. By helping public health practitioners understand the epidemic at an earlier stage, combined HIV and AIDS data better represent the overall impact of HIV. As of April 2008, all 50 states, the District of Columbia, and five U.S. territories had implemented confidential name-based HIV surveillance into their AIDS surveillance systems; names or other personal identifying information are not reported to CDC.

Botulism

Botulism is a severe paralytic illness caused by toxins produced by 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 botulism) (1). CDC maintains intensive surveillance for cases of botulism in the United States with a 24 hour/7 day a week consultation service. Health-care providers should report suspected botulism cases immediately to their state health departments; all states maintain 24-hour telephone services for reporting of botulism and other public health emergencies. Additional emergency consultation is available from the CDC botulism duty officer via the CDC Emergency Operations Center, telephone 660-488-7100. In 2008, cases were attributed to foodborne botulism, wound botulism, infant botulism, and unknown forms of botulism.

1. Sobel J. Botulism. Clin Infect Dis 2005;41:1167--73.

Brucellosis

The incidence of brucellosis in the United States increased from 2003 until 2007. The number of reported cases in 2008 decreased 36.0% from the previous year. Overall, the demographic characteristics of persons with brucellosis remained stable. For patients for whom ethnicity was identified, 62.3% were Hispanic. The majority of cases were reported in the Southwest.

In the U.S. animal population, brucellosis eradication efforts continue. In 2008, the U.S. Department of Agriculture declared Texas a brucellosis Class Free state. Montana was reclassified as a Class A state following the report of a second brucellosis-affected herd within 2 years (1). In total, 49 states and three territories were classified as brucellosis Class Free states at the end of 2008 (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.

Risk factors associated with brucellosis include the consumption of unpasteurized milk or soft cheeses. The risk for brucellosis from domestic dairy products is low. Unpasteurized dairy products from countries with endemic brucellosis remains a source of brucellosis for immigrants and travelers. Hunters are at an elevated risk for contracting brucellosis from the carcass or meat of infected animals. In addition, exposure to Brucella spp. can occur in diagnostic and research laboratories because of the potential for aerosol transmission (2). For the same reason, biosafety level 3 practices, containment, and equipment are recommended for laboratory manipulation of isolates (3). In the event of an exposure, postexposure prophylaxis can effectively prevent illness (4). CDC provides recommendations for laboratory exposures and can assist with the serologic monitoring of laboratory workers who are affected.

1. Donch DA, Gertonson AA, Rhyan JH, Gilsdorf MJ. Status report---fiscal year 2007 cooperative state-federal Brucellosis Eradication Program. Washington, DC: US Department of Agriculture; 2008. Available at http://www.aphis.usda.gov/animal_health/animal_diseases/brucellosis/downloads/yearly_rpt.pdf.
2. CDC. Bioterrorism agents/diseases, by category. Atlanta, GA: US Department of Health and Human Services, CDC; 2006. Available at http://www.bt.cdc.gov/agent/agentlist-category.asp#adef.
3. CDC, National Institutes of Health. Biosafety in microbiological and biomedical laboratories (BMBL). 5th ed. Washington, DC: US Department of Health and Human Services, CDC, National Institutes of Health; 2007. Available at http://www.cy118119.com/OD/OHS/biosfty/bmbl5/bmbl_5th_edition.pdf.
4. CDC. Laboratory-acquired brucellosis---Indiana and Minnesota, 2006. MMWR 2008;57:39--42.

Cholera

Cases of cholera continue to be rare in the United States. Cases reported in 2008 were fewer than the average number of cases per year reported during 2003--2007 (mean: 6.8) (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 (2,3). The single patient with domestic exposure in 2008 ate crab harvested from the U.S. Gulf Coast. Other serogroups of toxin-producing Vibrio cholerae (e.g., O141 and O75) also have caused severe diarrhea in patients who have a history of consumption of seafood from the Gulf Coast (4).

1. 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.
2. Gaffga NH, Tauxe RV, Mintz ED. Cholera: a new homeland in Africa. Am J Trop Med Hyg 2007;77:705--13.
3. Mintz ED, Guerrant RL. A lion in our village -- the unconscionable tragedy of cholera in Africa. New Engl J Med 2009;360:1061--3.
4. Tobin-D'Angelo M, Smith AR, Bulens SN, et al. Severe diarrhea caused by cholera toxin--producing Vibrio cholerae serogroup O75 infections acquired in the southeastern United States. Clin Infect Dis 2008;47:1035--40.

Coccidioidomycosis

Coccidioidomycosis is a common cause of community-acquired fungal pneumonia in disease-endemic areas of the southwest United States; however, clinical suspicion and laboratory testing occur infrequently (1). Fungal conidia survive in the soil and are propagated in an airborne manner, particularly when soil is disrupted. In the southwest United States, alkaline soil and climate support coccidioidomycosis growth and propagation. In recent years, strategies to model the effects of climate on disease incidence have begun, which include linking changes in incidence to climatic change, particularly in the region where the disease is endemic (2--4).

Case counts decreased for the first time in a decade during 2007. In 2008, reported coccidioidomycosis cases in the United States decreased again, primarily because of fewer reports received from the disease-endemic states of California and, to a lesser extent, Arizona. Case counts decreased even after the case definition revision implemented by the Council of State and Territorial Epidemiologists in 2007 included less stringent diagnostic criteria.

In 2009, certain laboratories in Arizona, where approximately 60% of coccidioidomycosis cases in the United States occur, modified their reporting criteria to include all cases with a positive enzyme immunoassay without confirmation by immunodiffusion assay. As a result, case counts in Arizona might increase during 2009; however, such an increase can be attributed to a less stringent case definition.

1. Valdivia L, Nix D, Wright M, et al. Coccidioidomycosis as a common cause of community-acquired pneumonia. Emerg Infect Dis 2006;12:958--62.
2. Park B, Sigel K, Vaz V, et al. An epidemic of coccidioidomycosis in Arizona associated with climatic changes, 1998--2001. J Infect Dis 2005;191:1981--7.
3. Comrie AC. Climate factors influencing coccidioidomycosis seasonality and outbreaks. Environ Health Perspect 2005;113:688--92.
4. Kolivras KN, Comrie AC. Modeling valley fever (coccidioidomycosis) incidence on the basis of climate condition. Int J Biometeorol 2003;47:87--101.

Cryptosporidiosis

The number of cryptosporidiosis cases reported to CDC increased during 2005--2007. Despite a decrease in the number of cases reported in 2008, cryptosporidiosis incidence was approximately threefold greater compared with 2004.

As in previous years, cryptosporidiosis case reports were influenced by outbreaks, particularly those associated with treated recreational water. Although cryptosporidiosis affects persons in all age groups, the number of reported cases occurred more frequently among children aged 1--9 years. A tenfold increase in transmission of cryptosporidiosis occurred during summer through early fall, coinciding with increased use of recreational water by younger children, which is a known risk factor for cryptosporidiosis. Cryptosporidium oocysts can be detected routinely in treated recreational water (1). Contamination of, and the subsequent transmission through, recreational water is facilitated by the substantial number of Cryptosporidium oocysts that can be shed by a single person; the extended time that oocysts can be shed (2); the low infectious dose (3); the resistance of Cryptosporidium oocysts to chlorine (4); and the prevalence of improper pool maintenance (i.e., insufficient disinfection, filtration, and recirculation of water), particularly of children's wading pools (5). The application of molecular epidemiology (i.e., genotyping and subtyping Cryptosporidium specimens) to clinical and environmental samples has demonstrated potential to expand our knowledge of Cryptosporidium epidemiology (6). In 2008, CDC partnered with state and local health professionals to release Cryptosporidiosis Outbreak and Response Evaluation (CORE) guidelines (http://www.cy118119.com/crypto/resources/core_guidelines.pdf) that health departments, aquatic facilities, and child care programs can implement to reduce the risk of community-wide spread.

1. Shields JM, Gleim ER, Beach MJ. Prevalence of Cryptosporidium spp. and Giardia intestinalis in swimming pools, Atlanta, Georgia. Emerg Infect Dis 2008;14:948--50.
2. 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.
3. 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.
4. Shields JM, Hill VR, Arrowood MJ, Beach MJ. Inactivation of Cryptosporidium parvum under chlorinated recreational water conditions. J Water Health. 2008;6:513--20.
5. CDC. Surveillance data from swimming pool inspections---selected states and counties, United States, May--September 2002. MMWR 2003;52:513--6.
6. Xiao L. Molecular epidemiology of cryptosporidiosis: an update. Exp Parasitol 2009 April 7 [Epub ahead of print].

Domestic Arboviral, Neuroinvasive and Nonneuroinvasive
(West Nile virus disease)

During 2008, West Nile virus (WNV) disease cases were reported from 45 states and the District of Columbia, including 27 counties that had not reported cases previously. Nationally, the reported incidence of West Nile neuroinvasive disease (WNND) was 0.2 cases per 100,000 population, which is lower than that reported in the previous 4 years during 2004--2007 (median: 0.4, range: 0.4-0.5). The highest incidence of WNND continued to occur in western and central states.

In 2008, CDC, the Food and Drug Administration (FDA), and state health departments investigated an increase in false-positive test results obtained with a commercially available WNV test kit (1). The investigation revealed that one particular kit lot was the source of the false-positive results, and that lot was recalled. Among specimens that tested positive using the implicated kit lot that were retested at CDC, 72% were determined to be false-positive results. A higher false-positive percentage was found among patients without evidence of neuroinvasive disease (77%) than patients with evidence of neuroinvasive disease (47%). Commercially available WNV test kits should be used to determine a presumptive diagnosis of WNV neuroinvasive disease. These kits should not be used to test specimens from persons without compatible illness, and any positive result should be confirmed by additional testing at a state health department or CDC. Considering the large proportion of false-positives, CDC recommended that state health departments not classify patients as having WNV disease if the only laboratory evidence was from the recalled kit lot. States have since reevaluated affected cases to arrive at the final WNV disease totals for 2008.

1. CDC. False-positive results with a commercially available West Nile Virus immunoglobulin M assay---United States, 2008. MMWR 2009;58:458--60.

Ehrlichiosis and Anaplasmosis

Case definitions for these diseases were modified beginning in 2008 (1) to include a separate designation for Ehrlichia ewingii for better assessment and enumeration of these cases. Four categories of ehrlichiosis and anaplasmosis were reportable during 2008: 1) Ehrlichia chaffeensis, 2) Ehrlichia ewingii, 3) Anaplasma phagocytophilum, and 4) Human ehrlichiosis/anaplasmosis - undetermined. Infection caused by E. chaffeensis was reported primarily from the lower Midwest and the Southeast, reflecting the range of the primary tick vector species (Amblyomma americanum). Infection caused by A. phagocytophilum was reported primarily from the upper Midwest and coastal New England, reflecting both the range of the primary tick vector species (Ixodes scapularis) and preferred animal hosts for tick feeding. Four central U.S. states and Delaware reported nine confirmed cases of E. ewingii infection. The category "Human ehrlichiosis/anaplasmosis - undetermined" includes cases for which a specific etiologic agent could not be identified using available serologic tests. The high number of "Human ehrlichiosis/anaplasmosis - undetermined" cases reported from some northern states (2) reflects state-specific classifications based on indistinguishable antigenic cross-reactivity or situations in which physicians, confused regarding the likely causative agent, ordered single or inappropriate tests (e.g., ordering only ehrlichiosis tests in a region where anaplasmosis would be expected to predominate).

During 2008, cases attributed to E. chaffeensis and A. phagocytophilum increased by 16% and 21%, respectively. Reported ehrlichiosis and anaplasmosis cases have increased every year since this group of diseases became notifiable in 1999. Increases in reported cases might be the result of several factors, including ecological changes influencing disease transmission, changes in diagnostic approaches that alter detection rates, or changes in surveillance and reporting. Changes in the case definition that became effective in January 2008 (1) also might have altered how cases were classified.

1. Council of State and Territorial Epidemiologists. Revision of the surveillance case definitions for Ehrlichiosis. Position statement 07-ID-03. Atlanta, GA: Council of State and Territorial Epidemiologists; 2007. Available at http://www.cste.org/position%20statements/searchbyyear2007final.asp.
2. CDC. Anaplasmosis and Ehrlichiosis--- Maine, 2008. MMWR 2009; 58:1033--6.

Hansen Disease (Leprosy)

The number of cases of Hansen disease (HD) reported in the United States peaked in 1985 and decreased until 2006. The number of reported cases increased in 2007 and decreased 26.6% in 2008. Cases were reported from 19 states and one territory; 70% of cases were reported from California, Florida, Hawaii, Texas, and New York City. HD is not highly transmissible; cases appear to be related predominantly to immigration from areas in which the disease is endemic. Information on 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 6.3% of all persons infected with E. coli O157:H7, but 15.3% of children aged < 5 years, progress to HUS (2). During 2008, as usual, most reported cases occurred among children aged 1--4 years.

1. 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.
2. Gould L, Demma L, Jones TF, et al. Hemolytic uremic syndrome and death in persons with Escherichia coli O157:H7 infection, Foodborne Diseases Active Surveillance Network Sites, 2000--2006. Clin Infect Dis 2009;49:1480--5.

HIV Infection

As of April 2008, all 50 states, the District of Columbia, and five U.S. dependent areas have laws or regulations requiring confidential name-based reporting for human immunodeficiency virus (HIV) infection, in addition to reporting persons with AIDS. In 2008, CDC published a revised surveillance case definition for HIV infection that includes AIDS and incorporates the HIV infection classification (1). Laboratory-confirmed evidence of HIV infection is now required to meet the surveillance case definition for HIV infection, including stage 3 HIV infection, i.e., AIDS.

In 2002, CDC initiated a system to monitor HIV incidence; in 2003 this system was expanded. On the basis of extrapolations for the 22 states with HIV incidence surveillance, the estimated number of new HIV infections for the United States in 2006 was 56,300 (2).

1. CDC. Revised surveillance case definitions for HIV infection among adults, adolescents and children aged <18 months and for HIV infection and AIDS among children aged 18 months to <13 years---United States, 2008. MMWR 2008;57(No. RR-10).
2. Hall HI, Song, R, Rhodes P, et al. Estimation of HIV incidence in the United States. JAMA 2008;300:520--9.

Influenza-Associated Pediatric Mortality

In June 2004, the Council of State and Territorial Epidemiologists added influenza-associated pediatric mortality (i.e., among persons aged <18 years) to the list of conditions reportable to the National Notifiable Diseases Surveillance System. Cumulative year-to-date incidence is published each week in MMWR Table I for low-incidence nationally notifiable diseases.

A total of 90 cases of influenza-associated pediatric deaths were reported to CDC during 2008. Pediatric deaths reported during 2008 occurred during the 2006--07, 2007--08, and 2008--09 influenza seasons. In 2008, the median age at death was 5.6 years (range: 29 days--17.9 years). A total of 10 children (11%) were aged <6 months; 14 (16%) were aged 6--23 months; 19 (21%) were aged 24--59 months; and 47 (52%) were aged >5 years. Among all pediatric deaths reported in 2008, 56 (62%) children died after being admitted to the hospital, whereas 34 (38%) died in the emergency room or outside the hospital. Information on underlying or chronic medical conditions was reported for 82 children: 47 (57%) children had one or more underlying or chronic medical conditions, placing them at increased risk for influenza-associated complications. Fifty-one of the 90 children had specimens collected for bacterial culture from normally sterile sites and 15 (29%) were positive. Staphylococcus aureus was the most frequently reported bacterial pathogen in 2008 and was found in 13 (87%) of the 15 children with co-infections. Nine of the Staphylococcus isolates were methicillin-resistant and the remaining four were sensitive to methicillin. Of the 65 children aged >6 months for whom the vaccination status was known, nine had been vaccinated against influenza according to the 2008 Advisory Committee on Immunization Practices recommendations (1). Continued surveillance of influenza-related mortality is important to monitor the effects of influenza and the possible effect of interventions in children.

1. CDC. Prevention and control of influenza: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR 2008; 57(No. RR-7):1--60.

Listeriosis

Listeriosis is a rare but severe infection caused by Listeria monocytogenes; it 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 2008, most cases occurred among persons aged ≥65 years.

Molecular subtyping of L. monocytogenes isolates and sharing 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 2008, the incidence of listeriosis in FoodNet/active surveillance sites was 0.29 cases per 100,000 population, representing a decrease of 36% compared with 1996--1998; however, the 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 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.cy118119.com/national/surveillance/listeria_surveillance.html. Rapid analysis of surveillance data will allow identification of possible food sources of outbreaks.

1. 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.
2. 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.
3. CDC. Preliminary FoodNet data on the incidence of infection with pathogens transmitted commonly through food---10 states, 2008. MMWR 2009;58:333--7.
4. Outbreak of Listeria monocytogenes Infections associated with pasteurized milk from a local dairy---Massachusetts, 2007. MMWR 2008;57:1097--1100.

Lyme Disease

In January 2008, a CSTE-approved revised national surveillance case definition was implemented. The purpose of the revision was to permit states and territories to report confirmed and probable cases of Lyme disease to the National Notifiable Diseases Surveillance System in accordance with the 2007 CSTE position statement template, update the criteria for laboratory evidence of infection to reflect current testing practices, and provide measures to assess the public health surveillance burden. Because of the modifications to the classification of a confirmed case and criteria for laboratory evidence and addition of probable cases to the total case count, the total and confirmed case counts from 2008 are not directly comparable to total case counts reported in previous years. The revised surveillance case definition can be accessed at http://www.cy118119.com/ncphi/disss/nndss/casedef/lyme_disease_2008.htm.

Measles

As in recent years, the majority (125) of confirmed measles cases in 2008 were import-associated (1). Twenty-five cases were internationally imported, including 13 in U.S. residents who had acquired measles while traveling abroad and 12 in non-U.S. residents who had acquired the disease abroad before traveling to the United States. Importations came from 12 countries, many of which are within the WHO European Region. Other import-associated cases included 29 cases with a direct link to an imported case, 22 imported virus cases (i.e., cases that cannot be linked epidemiologically to an imported case, but for which imported virus has been isolated), and 49 cases with link to virus-only cases. The sources of infection for the remaining 15 cases were classified as unknown because no link to importation was found.

Of the 127 U.S. residents with measles in 2008, 7 were vaccinated, 21 had unknown vaccination histories, and 99 were not vaccinated. Of the 99 cases in unvaccinated U.S. residents: 67% were among persons unvaccinated because of their personal or religious beliefs. Fourteen cases occurred among children unvaccinated because of missed opportunity, delayed vaccination, or unknown reasons. This group included mostly children aged 12--15 months, who had not been vaccinated, or older toddlers whose parents delayed vaccination but did not state any religious or personal objections to vaccination. Seventeen cases occurred in children too young to be vaccinated routinely, although two infants, aged 6 and 9 months, were traveling internationally and thus should have been vaccinated according to vaccination recommendations of the Advisory Committee for Immunization Practices (2). One case occurred in a person who was born before 1957, and therefore was considered to have evidence of immunity because of birth year (2).

Although still low, the number of measles cases reported during 2008 was the highest since 1996. The increase was not the result of a greater number of imported cases, but was the result of greater viral transmission after importation into the United States. The import-linked cases occurred largely among school-aged children who were eligible for vaccination but whose parents chose not to have them vaccinated (3). One study reported an increase in the number of vaccine exemptions among U.S. children who attend school in states that allow philosophical exemptions (4). In 2008, 41% of measles cases occurred among school-aged children and adolescents (aged 5--19 years). Seventeen children, including five aged <15 months, were hospitalized.

Nine outbreaks occurred in seven states, all with viral or epidemiologic evidence of an imported source. These outbreaks accounted for 74% of all cases. In four outbreaks, 50% of cases occurred among persons unvaccinated because of personal beliefs. Two such outbreaks involved home-schooled populations (3). In one 12-case outbreak among children with personal belief exemptions, 70 children exposed to a measles case were placed on voluntary home quarantine because parents declined vaccination or because they were too young to be vaccinated (5). In another outbreak, the majority of infections were acquired in hospitals or emergency rooms. This outbreak lasted over 2 months and 6 generations of spread. This outbreak included a case in an unvaccinated health-care worker who was infected in a hospital (6).

Although the elimination of endemic measles in the United States has been achieved, and population immunity remains high (7), outbreaks can occur when measles is introduced into susceptible groups, often at substantial cost to control (8). Measles can be prevented by adhering to recommendations for vaccinations, including guidelines for travelers (2, 9).

1. 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.
2. CDC. Measles, mumps, and rubella---vaccine use and strategies for elimination of measles, rubella, congenital rubella syndrome and control of mumps: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR 1998;47(No. RR-8).
3. CDC. Measles--- United States, January--July 2008. MMWR 2008;57:893--6.
4. Omer SB, Pan WKY, Halsey NA, et al. Nonmedical exemptions school immunization requirements: secular trends and association to state policies with pertussis incidence. JAMA 2006;296:1757--63.
5. CDC. Outbreak of measles---San Diego, California, January--February 2008. MMWR 2008;57:203--6.
6. Measles---United States, January 1--April 25, 2008. MMWR 2008;57:494--8.
7. Hutchins SS, Bellini W, Coronado V, et al. Population immunity to measles in the United States. J Infect Dis 2004:189(Suppl 1):S91--7.
8. 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.
9. CDC. Preventable measles among U.S. residents, 2001--2004. MMWR 2005:54:817--20.

Mumps

Since mumps vaccine licensure in 1967, the number of cases of mumps in the United States declined steadily until 2006, when the largest mumps outbreak in >20 years occurred, with >6,000 reported cases (1--4). Following the resurgence of mumps in 2006, reported cases declined towards pre-resurgence levels with 800 cases in 2007 and 454 cases in 2008 (5). In response to the 2006 outbreak, the Advisory Committee on Immunization Practices (ACIP) updated criteria for mumps immunity and mumps vaccination recommendations (5). In 2007, the Council of State and Territorial Epidemiologists revised the mumps case definition by extending the case definition to include cases with mumps symptoms other than parotitis, by adding mumps virus nucleic acid detection to the laboratory criteria, and by making several changes to the case classification system (6). The revised case definition has been in effect since January 1, 2008.

In 2008, after a review of scientific evidence, ACIP, the Healthcare Infection Control Practices Advisory Committee, and the American Academy of Pediatrics recommended reducing, from 9 to 5 days, the period of isolation for persons with mumps in both health-care and community settings. All three groups now recommend a 5-day period of isolation after onset of parotitis, both for isolation of persons with mumps in either community or health-care settings and for use of standard precautions and droplet precautions. Among the rationale cited for these recommendations is the substantial reduction in viral secretion 5 days after onset of parotitis and the likelihood that much transmission in community settings occurs from persons with asymptomatic infection and, among persons with symptomatic disease, before the onset of parotitis. Postexposure recommendations remain unchanged. Health-care personnel with no evidence of mumps immunity who are exposed to patients with mumps should be excluded from duty from the 12th day after first exposure through the 26th day after last exposure (7--8).

1. CDC. Mumps epidemic---Iowa, 2006. MMWR 2006;55:366--8.
2. CDC. Update: multistate outbreak of mumps---United States, January 1--May 2, 2006. MMWR 2006;55:559--63.
3. CDC. Update: mumps activity---United States, January 1--October 7, 2006. MMWR 2006;55:1152--3.
4. Dayan G, Quinlisk P, Parker, A, et al. Recent resurgence of mumps in the United States. N Engl J Med 2008;358:1580--9.
5. Barskey AE, Glasser, JW, LeBaron CW.  Mumps resurgence in the United States:  A historical perspective on unexpected elements. Vaccine 2009;27:6186--95.
6. CDC. Updated recommendations of the Advisory Committee on Immunization Practices (ACIP) for the control and elimination of mumps. MMWR 2006;55:629--30.
7. Council of State and Territorial Epidemiologists. Revision of the surveillance case definition for mumps 07-ID-02. Available at http://www.cste.org/PS/2007ps/2007psfinal/ID/07-ID-02.pdf.
8. CDC. Updated recommendations for isolation of persons with mumps. MMWR 2008;57:1103--5.

Pertussis

Although the incidence of reported pertussis has declined in the United States following the 2004 peak (8.9 per 100,000), overall incidence increased slightly during 2007 and 2008 (3.62 and 4.18 cases per 100,000, respectively). Infants aged <6 months, who are at greatest risk for severe disease and death, continued to have the highest reported rate of pertussis (79.41 per 100,000). However, adolescents (aged 10--19 years) and adults (aged >20 years) accounted for nearly half of reported cases in 2008, and the contribution of cases in persons aged 5--9 years appears to be increasing in comparison with previous years (20% of cases in 2008, 13% of cases in 2007, 10% in 2006). Adolescents and adults are critical age groups as they are thought to be a source of transmission of pertussis to young infants who are too young to be completely vaccinated. In 2005, a combined tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis vaccine (Tdap) was recommended for use among adolescents and adults (1,2). Although Tdap coverage among adolescents aged 13--17 years has increased from 10.8% in 2006 to 40.8% in 2008, the direct impact of Tdap is still unknown (3,4). Continued monitoring of disease trends through national surveillance will be important to assess both the direct impact of Tdap among target vaccine age groups and the indirect effects of vaccination on infants.

1. CDC. Preventing tetanus, diphtheria, and pertussis among adolescents; use of tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis vaccines: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR 2006;55(No. RR-3).
2. CDC. Preventing tetanus, diphtheria, and pertussis among adults: use of tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccine: recommendations of the Advisory Committee on Immunization Practices (ACIP) and Recommendation of ACIP, supported by the Healthcare Infection Control Practices Advisory Committee (HICPAC), for use of Tdap among health-care personnel. MMWR 2006;55 (No. RR-17).
3. CDC. Vaccination coverage among adolescents aged 13--17 years-- United States, 2006. MMWR 2007;56:885--8.
4. CDC. Vaccination coverage among adolescents aged 13--17 years---United States, 2008. MMWR 2009;58:997--1001.

Psittacosis

Psittacosis is a respiratory infection caused by the bacterium Chlamydophila psittaci. Once referred to as "parrot fever", psittacosis occurs through exposure to the feces, respiratory secretions, plumage, or tissues of infected birds and can lead to severe respiratory compromise in a minority of cases. In 2008, the incidence of reported cases of psittacosis continued to be low. Because of the recent development of improved molecular diagnostics for the detection of C. psittaci (1), a revised position statement by the Council of State and Territorial Epidemiologists and case definition for psittacosis is anticipated. Additional information about psittacosis and case reporting tools can be found at http://www.nasphv.org/documentsCompendiaPsittacosis.html.

1. Mitchell SL, Wolff BJ, Thacker WL, et al. Genotyping of Chlamydophila psittaci by real time PCR and high resolution melt analysis. J Clin Microbiol 2008;47:175--81.

Q Fever

The case definition for Q fever was modified beginning in 2008 (1) to include a separate designation for acute and chronic infection and to restrict designation of cases diagnosed by use of indirect immunofluorescent antibody assays to those minimally exhibiting IgG antibody titers ≥1:128. Among cases reported in 2008, 88% were identified as acute infection, whereas 12% were the result of chronic Q fever infection. In 2008, cases remained distributed across the United States, in keeping with the consideration that Q fever is considered enzootic in ruminants (sheep, goats, and cattle) throughout the country.

During 2008, cases of Q fever reported decreased by 30% from those reported for 2007, the largest decrease since reporting of cases of Q fever was initiated in 2000. This decrease likely reflects the more stringent case classification criteria in effect during 2008 (1) compared with the previous year. Although few human cases are reported annually, Q fever is believed to be substantially underreported because of its nonspecific presentation and the failure of physicians to suspect infection and request appropriate diagnostic tests.

1. Council of State and Territorial Epidemiologists. Revision of the surveillance case definitions for Q fever. Position statement 07-ID-04. Atlanta, GA: Council of State and Territorial Epidemiologists; 2007. Available at http://www.cste.org/position%20statements/searchbyyear2007final.asp.

Rabies

During 2008, two cases of human rabies were reported in the United States: an imported case from Mexico and an indigenous case in a 55-year-old male from Missouri. Epidemiologic investigations of these cases implicated bat rabies virus variants in both cases. The case from Mexico marked the first imported case of rabies reported as a rabies virus variant not associated with dogs in the origin country (1). During 2008, the majority (93%) of 6,841 animal rabies cases in the United States were reported in wild animal species. Overall, a 3% decrease in rabies cases was reported in animals in 2008 compared with 2007. In the United States, five groups of animals are recognized as reservoirs 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) (2). A skunk rabies virus variant associated with spillover and adaptation of a big brown bat rabies virus was reported in Flagstaff, Arizona after nearly 2 years with no cases after wildlife vaccination campaigns were implemented in the area.

Reported cases of rabies in domestic animals remain low (7% of reported rabid animals) in part because of high vaccination rates and the elimination of dog-to-dog transmission, which was last reported in 2004. One case of canine rabies imported in a dog from Iraq was reported during 2008 (3). This case illustrates the continued challenge for the United States to remain canine rabies free. Public health education programs should target travelers and health-care providers regarding rabies prevention measures and the potential risk of rabies exposure in countries where the disease is endemic in domestic animals. In the United States, cats remained the most commonly reported domestic animal with rabies during 2008 (62% of reported rabid domestic animals).

Vaccination programs to control rabies in wild carnivores are ongoing through the distribution of baits containing an oral rabies vaccine in the eastern United States and Texas. Oral rabies vaccination programs in the eastern United States are targeted at preventing the westward spread of the raccoon rabies virus variant whereas programs in Texas are being maintained as a barrier to prevent the reintroduction of canine rabies from Mexico and to eliminate gray fox rabies.

1. Velasco-Villa A, Messenger SL, Orciari LA, et al. New rabies virus variant in a Mexican immigrant. Emerg Infect Dis 2008;14:1906--8.
2. Blanton JD, Robertson K, Palmer D, Rupprecht CE. Rabies surveillance in the United States during 2008. J Am Vet Med Assoc 2009; 235:676--89.
3. CDC. Rabies in a dog imported from Iraq---New Jersey, June 2008. MMWR 2008;57:1076--8.

Rocky Mountain Spotted Fever

The case definition for Rocky Mountain Spotted Fever (RMSF) was modified beginning in 2008 (1) to include more detailed classification criteria for serologic assays, including enzyme-linked immunosorbent assays and use of IgM antibody tests. During 2008, RMSF cases increased 15% over those reported in 2007. Cases reported in 2008 were distributed across the United States, reflecting the endemic status of RMSF and the widespread ranges of the primary tick vectors (primarily Dermacentor variabilis and Dermacentor andersoni) responsible for transmission. RMSF cases associated with transmission by Rhipicephalus sanguineus, first reported in 2004 (2), continued to be reported from Arizona during 2008.

The reporting years 2005--2008 reflect a trend toward stabilized numbers of reported RMSF cases. However, RMSF case reports have increased more than 300% during the past decade. This increase might be the result of several factors, including ecological changes influencing disease transmission, changes in diagnostic approaches that alter detection rates, or changes in surveillance and reporting. Changes in the case definition in 2004 and a further revision of the case definition beginning in 2008 (1) also might have altered how cases were classified.

1. Council of State and Territorial Epidemiologists. Revision of the surveillance case definitions for Rocky Mountain spotted fever. Position statement 07-ID-05. Atlanta, GA: Council of State and Territorial Epidemiologists; 2007. Available at http://www.cste.org/position%20statements/searchbyyear2007final.asp.
2. L Demma, Traeger M, Nicholson W, et al. Rocky Mountain spotted fever from an unexpected tick vector in Arizona. New Engl J Med 2005;353:587--94.

Salmonellosis

During 2008, as in previous years, the age group with the highest incidence of salmonellosis was children aged <5 years. Salmonella enterica serotype Typhimurium and S. enterica serotype Enteritidis have been the most frequently isolated serotypes since 1996 (1). The epidemiology of Salmonella has been changing during the past decade. Salmonella serotype Typhimurium has decreased in incidence, whereas the 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 antimicrobial 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; therefore, in 2005, the Council of State and Territorial Epidemiologists adopted a position statement for serotype-specific reporting of laboratory-confirmed salmonellosis cases (3). Increasing evidence indicates that infections with certain serotypes of Salmonella are more likely to be invasive and lead to poor outcomes than infections with other serotypes. Such findings have implications for better understanding the public health importance and pathogencity of salmonellosis (4).

1. CDC. Salmonella Surveillance summary, 2006. Atlanta, Georgia: U.S. Department of Health and Human Services, CDC; 2008. Available at http://www.cy118119.com/nationalsurveillance/salmonella_surveillance.html.
2. CDC. National Antimicrobial Resistance Monitoring System for Enteric Bacteria (NARMS): 2006 human isolates final report. Atlanta, Georgia: U.S. Department of Health and Human Services, CDC; 2009.
3. Council of State and Territorial Epidemiologists. Position statement 05-ID-09. Serotype specific national reporting for salmonellosis. Atlanta, GA: Council of State and Territorial Epidemiologists; 2005. Available at http://www.cste.org/PS/2005pdf/final2005/05-ID-09final.pdf.
4. Jones TF, Ingram LA, Cieslak PR, et al. Salmonellosis outcomes differ substantially by serotype. J Infect Dis 2008;198:109--14.

Shiga Toxin-Producing Escherichia coli (STEC)

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. In 2006, the nationally notifiable diseases case definition designation was changed from EHEC to STEC, and serotype-specific reporting was implemented (2). Diagnosis solely on the basis of detection of Shiga toxin does not protect public health sufficiently; characterizing STEC isolates by serogroup and, for E. coli O157, also by pulsed-field gel electrophoresis pattern is important to detect, investigate, and control outbreaks. Stool specimens from patients with community-acquired diarrhea should be submitted to clinical laboratories for routine testing, should be cultured for O157 STEC, and tested with an assay that detects Shiga toxins (3). This simultaneous approach has several advantages. First, it enables rapid detection of Shiga toxin-related illness, including that caused by non-O157 STEC, which are not readily identified in culture. Second, it permits rapid identification of O157 STEC, the serogroup most strongly associated with the development of hemolytic uremic syndrome (HUS); quickly identifying O157 STEC infections might facilitate measures to prevent HUS and speed the identification of outbreaks. Third, culturing enables isolation of STEC, which can then be characterized by serogroup and pulsed-field gel electrophoresis pattern to facilitate outbreak detection and investigation. All STEC isolates and enrichment broths from Shiga toxin-positive specimens that do not yield STEC O157 should be forwarded to state or local public health laboratories for further testing.

Healthy cattle, which harbor the organism as part of the bowel flora, are the main animal reservoir of STEC. Most reported outbreaks are caused by contaminated food or water. During 2004, a substantial decline in reported O157:H7 STEC cases led to an incidence measured in the Foodborne Diseases Active Surveillance System (FoodNet) that met the Healthy People 2010 goal of <1.0 cases/100,000 population; since then, the incidence has increased (4).

1. Mead PS, Griffin PM. Escherichia coli O157:H7. Lancet 1998;352:1207--12.
2. 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. Atlanta, GA: Council of State and Territorial Epidemiologists; 2005. Available at http://www.cste.org/position%20statements/searchbyyear2005.asp.
3. CDC. Recommendations for diagnosis of shiga toxin-producing Escherichia coli infections by clinical laboratories, 2009. MMWR 2009;58(RR12):1--14.
4. CDC. Preliminary FoodNet data on the incidence of infection with pathogens transmitted commonly through food, 10 sites---United States, 2004. MMWR 2005; 54:352--6.

Shigellosis

During 1978--2003, shigellosis cases reported to CDC exceeded 17,000 in nearly every year. 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, decreased slightly in 2006, increased to approximately 20,000 in 2007, and to approximately 22,000 in 2008. Shigella sonnei infections continue to account for >75% of shigellosis in the United States (1). Most cases occur among young children, and large day care-associated outbreaks are common and difficult to control (2). Some cases of shigellosis are acquired during international travel (3,4). In addition to spreading 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 (5).

1. 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.
2. Arvelo W, Hinkle J, Nguyen TA, et al. Transmission risk factors and treatment of pediatric shigellosis during a large daycare center-associated outbreak of multidrug resistant Shigella sonnei. Pediatr Infect Dis J 2009;11:976--80
3. 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 2008;136:577--603.
4. 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 Hispanola. Am J Trop Med Hyg 2007;76:1163--5.
5. CDC. National Antimicrobial Resistance Monitoring System for enteric bacteria (NARMS): Human isolates final report, 2006. Atlanta, GA: US Department of Health and Human Services, CDC; 2009. Available at http://www.cy118119.com/narms.

Syphilis, Primary and Secondary

The rate of primary and secondary (P&S) syphilis in the United States declined 90% during 1990--2000. However, the rate of P&S syphilis has increased each year since 2001, mostly in men, but also in women for the past 4 years. In 2008, a total of 13,500 cases of P&S syphilis were reported to CDC. (1) This is the highest number of reported cases since 1995 and corresponds to a rate of 4.5 cases per 100,000 population, an 18% increase from 2007. Since 2001, the rate of P&S syphilis has increased 114%. On the basis of information from 44 states and Washington, D.C. in 2008, 63% of reported P&S syphilis cases in the United States occurred among men who have sex with men (MSM). Although the majority of U.S. syphilis cases have occurred among MSM, syphilis among heterosexuals is an emerging problem as reflected in a 88% increase in women since 2004 (1).

1. CDC. Sexually Transmitted Disease Surveillance, 2008. Atlanta, GA: U.S. Department of Health and Human Services; November 2009.

Trichinellosis

In November 2008, an outbreak of trichinellosis occurred in Humboldt County, California, among several families who participated in a cultural ceremony. At least 34 persons attended the event, at which they shared a meal of bear meat that was hunted by one of the family members. Case-patients recalled eating both raw and undercooked bear meat; 30 confirmed cases were reported to CDC.

This is the eighth outbreak and the largest attributed to bear meat reported to CDC in the past 10 years (1,2); it highlights the continued need for public health prevention messages aimed at consumers of wild game meat in general and for targeted prevention messages for certain cultural groups whose customs put them at risk for Trichinella infection in particular.

Proper cooking of meat dishes, especially dishes prepared with some types of game meats, will prevent trichinellosis. Meat products, including sausages or other prepared dishes, should be cooked to internal temperatures of at least 170° F or until juices run clear. Some species of Trichinella are resistant to freezing, so freezing might not be an effective prevention measure (3).

1. Kennedy ED, Hall RL, Montgomery SP, Pyburn DG, Jones JL. Trichinellosis surveillance---United States, 2002--2007. In: Surveillance Summaries, December 4, 2009. MMWR 2009;58 (No. SS-9).
2. Roy SL, Lopez AS, Schantz PM. Trichinellosis surveillance---United States, 1997--2001. In: Surveillance Summaries, July 25, 2003. MMWR 2003;52(No. SS-6).
3. Hill DE, Gamble HR, Zarlenga DS, Coss C, Finnigan J. Trichinella native in a black bear from Plymouth, New Hampshire. Vet Parasitol 2005;132:143--6.

Typhoid Fever

Recommendations indicate that travelers to countries in which typhoid fever is endemic should be vaccinated with either of two effective vaccines available in the United States. Despite these recommendations, approximately 75% of all cases of typhoid fever reported in the United States from 1999 through 2006 occurred among persons who reported international travel during the preceding month and who had not been vaccinated (1). Persons visiting friends and relatives in South Asia appear to be at particular risk, even during short visits (1,2). Certain recent illnesses have been caused by ciprofloxacin-resistant isolates (1). Salmonella serotype Typhi strains with decreased susceptibility to ciprofloxacin are isolated with increasing frequency, and infected persons might require treatment with alternative antimicrobial agents (3). Although the number of S. Typhi infections in the United States has been decreasing slowly, the number of infections attributed to Salmonella serotype Paratyphi A, which causes an illness indistinguishable from that caused by S. Typhi, has been increasing. In a cross-sectional laboratory-based surveillance study conducted by CDC, 80% of patients with paratyphoid fever acquired their infections in South Asia, and 75% were infected with nalidixic acid-resistant strains, indicating decreased susceptibility to ciprofloxacin. A vaccine for paratyphoid fever is needed (4).

1. Lynch MF, Blanton EM, Bulens S, et al. Typhoid fever in the United States, 1999--2006. JAMA 2009;302:898--9
2. Steinberg EB, Bishop RB, Dempsey AF, et al. Typhoid fever in travelers: who should be targeted for prevention? Clin Infect Dis 2004;39:186--91.
3. Crump JA, Ram PK, Gupta SK, Miller MA, Mintz ED. Review article: part I. analysis of data gaps pertaining to Salmonella enterica serotype Typhi infections in low and medium human development index countries, 1984--2005. Epidemiol Infect 2008;136:436-48.
4. Gupta SK, Medalla F, Omondi MW, et al. Laboratory-based surveillance of paratyphoid fever in the United States: travel and antimicrobial resistance. Clin Infect Dis 2007;46:1656--63.

Varicella (Chickenpox) Deaths

Varicella-related deaths have declined dramatically since the prevaccine era; during 2003--2005 the national annual average of varicella-related deaths was 16 (1) compared with 100--150 deaths during 1990--1994 (2,3). In 1999, varicella-related deaths became reportable to CDC (4) and an average of five deaths (range: 0--9 deaths) has been reported annually to CDC since then (1). The two varicella-related deaths reported in 2008 highlight important aspects of continued progress towards varicella disease control and prevention.

Both varicella-related deaths occurred in adult females aged 41 and 72 years; both were born outside of the United States, had underlying chronic conditions that were not contraindications for vaccination, and had no history of varicella disease or vaccination. Assessing evidence of immunity to varicella is important in determining who should be vaccinated. One of the criteria for evidence of immunity is birth in the United States before 1980 (5). Both of the reported deaths that occurred in adults in 2008 were in persons born outside of the United States. Both women had been assessed as susceptible to varicella during previous health-care visits. Vaccination was recommended to both women at the time of assessment but one refused it and vaccine was not available for the second woman at a follow-up visit. These deaths highlight the importance of assessing immune status among foreign-born persons and emphasize the need for vaccination if they are determined to be susceptible.

1. CDC. Summary of Notifiable Diseases---United States, 2007. MMWR 2007;56(No. 53).
2. Nguyen HQ, Jumaan AO, Seward JF. Decline in mortality due to varicella after implementation of varicella vaccination in the United States. N Engl J Med 2005;352:450--8.
3. Preblud SR. Age-specific risk of varicella complications. Pediatrics 1981;68:14--7.
4. Council of State and Territorial Epidemiologists. CSTE position statement 1998-ID-10: inclusion of varicella-related deaths in the National Public Health Surveillance System (NPHSS). Available at http://www.cste.org/ps/1998/1998-id-10.htm.
5. CDC. Prevention of varicella: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR 2007;56 (No. RR-4).

Vibriosis

Vibriosis became a nationally notifiable disease in January 2007 (1). Cholera, which is caused by infection with toxigenic Vibrio cholerae O1 and O139, has been nationally notifiable for several years. Infections attributable to other Vibrio species (vibriosis), especially V. parahaemolyticus and V. vulnificus, are a substantial public health burden. Infections are either foodborne or associated with wounds exposed to waters containing Vibrio species. During 2008, the majority of cases occurred in persons aged 40--64 years. In addition to reporting through the National Notifiable Diseases Surveillance System, CDC requests that states collect information on the standard surveillance form for cholera and other Vibrio illness surveillance (available at http://www.cy118119.com/nationalsurveillance/cholera_vibrio_surveillance.html).

1. Council of State and Territorial Epidemiologists. National reporting for non-cholera Vibrio infections (vibriosis). Position statement 06-ID-05. Atlanta, GA: Council of State and Territorial Epidemiologists; 2006. Available at http://www.cste.org/position%20statements/searchbyyear2006.

PART 1

Summaries of Notifiable Diseases in the United States, 2008

Abbreviations and Symbols Used in Tables

U Data not available.

N Not reportable (i.e., report of disease is not required in that jurisdiction).

--- No reported cases.

Notes: Rates <0.01 after rounding are listed as 0.

Data in the MMWR Summary of Notifiable Diseases --- United States, 2008 might not match data in other CDC surveillance reports because of differences in the timing of reports, the source of the data, and the use of different case definitions.