Morbidity and Mortality Weekly Report

Weekly / Vol. 59 / No. 36 September 17, 2010

Balamuthia mandrillaris Transmitted Through Organ Transplantation —

Mississippi, 2009

On December 14, 2009, a physician in Mississippi contacted prescribed antivirals; his symptoms resolved without hospitaliza-
CDC to report possible transplant-transmitted encephalitis in tion. On November 3, the boy had sudden onset of headache
two kidney transplant recipients who shared the same organ and seizures and was hospitalized (Table 1). Cerebrospinal
donor. Histopathologic testing of donor autopsy brain tissue fluid (CSF) demonstrated lymphocytic pleocytosis (170 white
at CDC showed amebae, and subsequent testing of specimens blood cells/mm3) and normal protein (29 mg/dL); magnetic
from the donor and the two kidney recipients confirmed resonance imaging (MRI) of the brain showed numerous small
transmission by transplantation of Balamuthia granulomatous enhancing lesions and edema (Table 2). An extensive search
amebic encephalitis (GAE), a rare disease caused by Balamuthia for viral, bacterial, and fungal etiologies of encephalitis was
mandrillaris, a free-living ameba found in soil (1). One kidney unrevealing. His clinical presentation, CSF findings, and MRI
recipient, a woman aged 31 years, died; the other recipient, were thought to be most consistent with a diagnosis of ADEM,
a man aged 27 years, survived with neurologic sequelae. an immune-mediated encephalitis that can follow influenza or
Recipients of the heart and liver from the same donor received other infections. He was treated symptomatically and discharged
preemptive therapy and have shown no signs of infection. The on November 6.
donor, a previously healthy boy aged 4 years, was presumed to The boy was readmitted on November 10 with recurrent
have died from acute disseminated encephalomyelitis (ADEM), seizures. MRI of the brain demonstrated progression of several
an autoimmune neurologic disease, after infection with influ- of the enhancing lesions; CSF again demonstrated lymphocytic
enza A. An investigation was conducted by the state health pleocytosis (150 cells/mm3) and normal protein (44 mg/dL)
departments in Mississippi, Kentucky, Florida, and Alabama (Table 2). He was treated for presumed worsening ADEM
and CDC to characterize the cases, elucidate possible exposures with intravenous corticosteroids and immunoglobulin. He
in the donor, and develop recommendations for early detec- developed subarachnoid hemorrhage and brain stem hernia-
tion and prevention. This is the first reported transmission tion on November 18 and was pronounced brain dead the next
of Balamuthia by organ transplantation. Clinicians should day. His heart, liver, and kidneys were transplanted into four
be aware of Balamuthia infection as a potentially fatal cause recipients at three different transplant centers on November 20.
of encephalitis. Organ procurement organizations (OPOs) On December 16, histopathologic examination of the donor’s
and transplant centers should be aware of the potential for
Balamuthia infection in donors with encephalitis of uncertain
etiology, and OPOs should communicate this elevated risk for INSIDE
infection to transplant centers so they can make an informed
1171 National, State, and Local Area Vaccination
risk assessment in the decision to accept an organ. Coverage Among Children Aged 19–35 Months —
United States, 2009
Organ Donor 1178 CDC Grand Rounds: Radiological and Nuclear
The organ donor, a boy aged 4 years from Kentucky, was Preparedness
living with relatives in Mississippi in October 2009, when he 1182 Notes from the Field
developed a transient febrile illness. He was diagnosed with 1183 Announcements
influenza A infection by rapid influenza test on October 25 and 1185 QuickStats

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Disease Control and Prevention
www.cdc.gov/mmwr
 MMWR Morbidity and Mortality Weekly Report

brain tissue at CDC revealed the presence of abundant intensive-care unit. MRI of the brain demonstrated
amebae morphologically suggestive of Balamuthia numerous ring-enhancing lesions. CSF initially
(Figure); empiric treatment for both kidney recipients showed a normal white blood cell count (3 cells/mm3)
was initiated later that day, in consultation with CDC. and elevated protein (75 mg/dL); however, another
On December 17, immunohistochemical and indirect specimen collected on December 15 revealed a neu-
immunofluorescent stains (Figure) revealed antigens trophilic pleocytosis (507 cells/mm3) and increased
of free-living amebae in the donor’s brain tissue; protein (142 mg/dL) (Table 2). On December 16,
polymerase chain reaction (PCR) results confirmed she underwent brain biopsy. On December 18,
Balamuthia infection. histopathologic examination of the brain tissue at
CDC revealed amebae; immunohistochemical stains
Kidney Recipient A detected antigens of free-living amebae, and PCR
Kidney recipient A, a woman aged 31 years, confirmed Balamuthia infection. She was treated with
underwent transplantation for end-stage renal dis- pentamidine, sulfadiazine, flucytosine, fluconazole,
ease resulting from hypertension and diabetes. On and azithromycin. Miltefosine, an antileishmanial
December 10, post-transplant day (PTD) 20, she and antineoplastic agent, was added on December 25
reported onset of right leg twitching and neck spasms, under an emergency investigational new drug (IND)
numbness, headache, nausea, and seeing flashing protocol. Despite several weeks of intensive care, she
lights (Table 1). She was evaluated in an emergency deteriorated neurologically and died on February 3
department, where she was treated with benzodi- (PTD 75).
azepines and discharged with muscle relaxants; no
neuroimaging or lumbar puncture was performed. Kidney Recipient B
On December 12, she was found unresponsive at Kidney recipient B, a man aged 27 years, under-
home and taken back to the emergency depart- went transplantation for end-stage renal disease
ment, where she had a generalized seizure and was resulting from focal segmental glomerulosclerosis.
admitted; the next day, she was transferred to the On December 10 (PTD 20), he had sudden onset

The MMWR series of publications is published by the Office of Surveillance, Epidemiology, and Laboratory Services, Centers for Disease
Control and Prevention (CDC), U.S. Department of Health and Human Services, Atlanta, GA 30333.
Suggested citation: Centers for Disease Control and Prevention. [Article title]. MMWR 2010;59:[inclusive page numbers].
Centers for Disease Control and Prevention
Thomas R. Frieden, MD, MPH, Director
Harold W. Jaffe, MD, MA, Associate Director for Science
James W. Stephens, PhD, Office of the Associate Director for Science
Stephen B. Thacker, MD, MSc, Deputy Director for Surveillance, Epidemiology, and Laboratory Services

MMWR Editorial and Production Staff

Ronald L. Moolenaar, MD, MPH, Editor, MMWR Series
John S. Moran, MD, MPH, Deputy Editor, MMWR Series Martha F. Boyd, Lead Visual Information Specialist
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Teresa F. Rutledge, Managing Editor, MMWR Series Visual Information Specialists
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Donald G. Meadows, MA, Jude C. Rutledge, Writer-Editors Information Technology Specialists

MMWR Editorial Board

William L. Roper, MD, MPH, Chapel Hill, NC, Chairman
Virginia A. Caine, MD, Indianapolis, IN Patricia Quinlisk, MD, MPH, Des Moines, IA
Jonathan E. Fielding, MD, MPH, MBA, Los Angeles, CA Patrick L. Remington, MD, MPH, Madison, WI
David W. Fleming, MD, Seattle, WA Barbara K. Rimer, DrPH, Chapel Hill, NC
William E. Halperin, MD, DrPH, MPH, Newark, NJ John V. Rullan, MD, MPH, San Juan, PR
King K. Holmes, MD, PhD, Seattle, WA William Schaffner, MD, Nashville, TN
Deborah Holtzman, PhD, Atlanta, GA Anne Schuchat, MD, Atlanta, GA
John K. Iglehart, Bethesda, MD Dixie E. Snider, MD, MPH, Atlanta, GA
Dennis G. Maki, MD, Madison, WI John W. Ward, MD, Atlanta, GA

1166 MMWR / September 17, 2010 / Vol. 59 / No. 36

 MMWR Morbidity and Mortality Weekly Report

TABLE 1. Timeline of events involving transmission of Balamuthia infection from an organ donor to two kidney recipients — Mississippi, 2009–2010
Date Donor Kidney recipient A Kidney recipient B
2009
November 3 Hospitalized with headaches and seizures.
November 5 Initial brain MRI performed.
November 6 Discharged from hospital.
November 10 Hospitalized after recurrence of seizures.
November 18 Developed subarachnoid hemorrhage and
brain stem herniation.
November 19 Pronounced brain dead.
November 20 Heart, liver, and kidneys transplanted into Received kidney from donor. Received kidney from donor.
four recipients.
December 10 Onset of right leg twitching and neck spasms, Onset of severe headache and vomiting.
numbness, headache, nausea, and seeing
flashing lights.
December 11 Onset of altered mental status and seizures.
Hospitalized.
December 12 Found unresponsive at home. Hospitalized.
December 13 Admitted to intensive-care unit. Admitted to intensive-care unit. Initial brain
MRI performed.
December 15 Initial brain MRI performed.
December 16 Histopathologic examination of brain tissue Underwent brain biopsy. Started on multiple Started on multiple drug regimen.
at CDC revealed amebae suggestive of drug regimen.
Balamuthia.
December 17 Balamuthia infection confirmed by PCR. Amebae seen on brain histopathlolgy at CDC.
December 18 Balamuthia infection confirmed by PCR of brain
tissue at CDC.

2010
January 5 Balamuthia infection confirmed by PCR on CSF
specimen drawn December 29.
February 2 Balamuthia infection cultured from CSF
specimen drawn December 29.
February 3 Died after 7 weeks of intensive care.
April 28 Discharged to a rehabilitation facility.
June 11 Discharged home with neurologic sequelae.
Abbreviations: MRI = magnetic resonance imaging; PCR = polymerase chain reaction; CSF = cerebrospinal fluid.

of severe headache and vomiting and was examined kidney recipient A, including miltefosine obtained
at a local emergency department early the next under IND. Balamuthia infection was confirmed by
morning, where he was diagnosed with sinusitis and PCR and culture on a CSF specimen drawn December
discharged on amoxicillin-clavulanic acid (Table 1). 29. After 2 months in a coma, the man had a slow
Later that day, he developed altered mental status but significant recovery of cognitive and motor func-
and seizures and was admitted to a regional hospital. tion and was discharged to a rehabilitation facility on
A lumbar puncture was performed; CSF demon- April 28 (PTD 159). He was discharged home June
strated 1 white blood cell/mm3 and slightly elevated 11. His neurologic sequelae included residual right
protein (69 mg/dL) (Table 2). On December 13, arm paralysis, bilateral leg weakness, and intermittent
he was transferred to the intensive-care unit at the vision loss; however, he performed most activities of
same hospital as kidney recipient A. CSF that day daily living independently.
revealed mild pleocytosis (19 cells/mm3) and slightly
increased protein (74 mg/dL). MRI of the brain Heart Recipient
showed numerous ring-enhancing lesions. The man The heart recipient, a boy aged 2 years, underwent
was treated with the same combination of drugs as transplantation for restrictive cardiomyopathy. When the

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 MMWR Morbidity and Mortality Weekly Report

TABLE 2. Demographic, clinical, and laboratory features of cases involving transmission of Balamuthia infection from an organ donor to two
kidney recipients — Mississippi, 2009–2010
Initial lumbar puncture (LP) Mode
results (2nd LP results) of initial
Time from Balamuthia
Race/ transplant to Neuroimaging GAE Preliminary
Patient Age/Sex Ethnicity symptom onset Initial clinical symptoms WBC* Protein† Glucose§ results diagnosis diagnosis Outcome
Donor 4 yrs/male White, N/A Personality changes, loss of 170 29 49 Multiple focal Autopsy ADEM Death
non- appetite, muscle twitching, (150) (44) (46) enhancing
Hispanic headache, seizure lesions
Kidney 31 yrs/female Black, 20 days Paresthesias, muscle spasms, 3 75 114 Multiple large PCR of brain Muscle Death
recipient A non- headache, nausea, altered (507) (142) (67) ring-enhancing biopsy spasms
Hispanic mental status, seizure lesions
Kidney 27 yrs/male Black, 20 days Headache, nausea, altered 1 69 77 Ring-enhancing PCR and Sinusitis Survived,
recipient B non- mental status, seizure (19) (74) (62) lesions culture of but with
Hispanic CSF neurologic
sequelae¶

Abbreviations: GAE = granulomatous amebic encephalitis; ADEM = acute disseminated encephalomyelitis; PCR = polymerase chain reaction; CSF = cerebrospinal fluid.
* White blood cells per mm3; normal range: 0–5 (aged >12 yrs), 0–20 (aged 1–4 yrs).
† mg/dL; normal range: 12–60.
§ mg/dL; normal range: 40–70.
¶ Including intermittent hemianopsia, bilateral leg weakness, and right arm paralysis.

kidney recipients were diagnosed with Balamuthia GAE, Approximately 4 months before his first seizure, the
the boy was asymptomatic. On December 17 (PTD 27), boy had become more irritable and emotionally labile.
he was hospitalized for evaluation. MRI of the brain was His family also noted regression of toilet training and
normal, and testing of CSF, serum, and endomyocardial an infrequent, sporadic tremor of the right hand that
tissue at CDC showed no evidence of Balamuthia infec- began at about the same time. He had no history of
tion. The boy was treated for presumed Balamuthia expo- immunocompromising conditions. No medical evalu-
sure with a 6-week course of intravenous pentamidine, ation of family members was conducted.
azithromycin, and fluconazole, followed by 5 weeks of
Reported by
oral azithromycin. He remains well.
S Schlessinger, MD, Mississippi Organ Recovery Agency,
Liver Recipient Flowood; K Kokko, MD, J Fratkin, MD, F Butt, MD,
The liver recipient, a boy aged 7 years, underwent A Hawxby, MD, M Todaro, PharmD, H Henderson,
transplantation for end-stage liver disease resulting from MD, A Seawright, DNP, C Parker, MD, Univ of
alpha-1-antitrypsin deficiency. The boy was asymptom- Mississippi Medical Center; P Byers, MD, Mississippi
atic when the kidney recipients were diagnosed with Dept of Health. R Gonzalez-Peralta, MD, L Kayler,
Balamuthia GAE, and he was hospitalized for evaluation MD, L Fauerbach, R Lawrence, MD, A Haafiz,
on December 17. MRI of the boy’s brain was normal, and MD, Shands Hospital, Univ of Florida; D Stanek,
testing of CSF, serum, and liver tissue at CDC showed DVM, R Hammond, Florida Dept of Health. D Thor-
no evidence of Balamuthia infection. He was treated for oughman, PhD, Kentucky Dept for Public Health.
presumed Balamuthia exposure with a 1-month course T Pippen, S Johnson, Alabama Dept of Public Health.
of intravenous pentamidine, fluconazole, azithromycin, W Mahle, MD, G Lyon III, MD, K Laporte, K Kanter,
and sulfadiazine. He remains well. MD, Children’s Healthcare of Atlanta, Emory Univ,
Atlanta; M Ivey, MPH, K Arnold, MD, S Lance,
Public Health Investigation DVM, Georgia Div of Public Health. E Navarro-
Interviews with the donor’s family revealed that Almario, Food and Drug Admin. E Farnon, MD,
he had lived in Kentucky, Florida, and Mississippi M Kuehnert, MD, Div of Healthcare Quality Promo-
during the 2 years before his death. He frequently tion; W Shieh, MD, C Paddock, MD, S Zaki, MD,
played outdoors and had soil exposure in all of these C Drew, DVM, A Schmitz, DVM, J Sejvar, MD, Div of
locations. He occasionally played in a wading pool; High-Consequence Pathogens and Pathology; R Sriram,
the water supply for drinking and recreation in Florida PhD, G Visvesvara, PhD, M Beach, PhD, J Yoder,
was untreated well water. No environmental sampling MPH, S Roy, MD, Div of Foodborne, Waterborne, and
was performed because Balamuthia is thought to be Environmental Diseases, National Center for Emerg-
ubiquitous in the environment. ing and Zoonotic Infectious Diseases; Y Qvarnstrom,

1168 MMWR / September 17, 2010 / Vol. 59 / No. 36

 MMWR Morbidity and Mortality Weekly Report

PhD, R Bandea, PhD, A daSilva, PhD, E Bosserman, FIGURE. Organ donor brain tissue revealing amebae suggestive of Balamuthia
MPH, Div of Parasitic Diseases and Malaria, Center (indicated by arrows) (A), and immunohistochemical staining showing anti-
gens (red) of free-living amebae (B)*
for Global Health; P Budge, MD, E Lutterloh, MD,
EIS officers, CDC. A B

Editorial Note
This report is the first to describe transmis-
sion of Balamuthia through organ transplantation.
However, a second cluster of patients with transplant-
transmitted Balamuthia was confirmed at CDC
on August 27, 2010 (2). Balamuthia infection is
extremely rare, with fewer than 200 human cases rec-
ognized worldwide since Balamuthia was found to be Photomicrographs/CDC
* Original magnifications: 158x (A), 100x (B).
a human pathogen in 1990 (3,4). The true magnitude
of disease caused by Balamuthia is unknown because
Balamuthia GAE often is misdiagnosed as other sulfadiazine, fluconazole or amphotericin B, azithro-
neurologic diseases (1,3). Once infection progresses mycin or clarithromycin, and miltefosine (3,8).
to encephalitis, it is almost always fatal. Infection However, optimal therapy has not been determined.
occurs in both immunocompromised and otherwise Optimal preemptive therapy for asymptomatic
healthy persons, and often in children, although cases recipients after transplant of an infected organ also
have occurred in patients across the age spectrum (5). is unknown. Miltefosine is active against Balamuthia
Because of the rarity of Balamuthia GAE, risk fac- in vitro and was recently used with success in com-
tors are poorly defined, but might include exposure bination therapy for Balamuthia GAE in Peru (9).
to soil or stagnant water, young age, and Hispanic Miltefosine is not marketed in the United States but
ethnicity (3). can be available through single patient IND.*
Balamuthia has been isolated from soil and dust Balamuthia is one of several agents of severe or
and is thought to be present worldwide (6). Routes fatal encephalitis (e.g., West Nile virus, lymphocytic
of infection might include exposure of mucous mem- choriomeningitis virus, and rabies virus) that have
branes or nonintact skin to cysts or trophozoites in soil. been transmitted through organ transplantation
Balamuthia has not been isolated from water, but water in recent years (10). Organ donors are screened to
also might serve as a vehicle for infection (1). Cutaneous identify infectious risks in accordance with policies
lesions have preceded Balamuthia GAE in some cases, set by the Organ Procurement and Transplantation
primarily those reported in South America (7). These Network,† which is overseen by the United Network
lesions often are on the central face, suggesting nasal for Organ Sharing through a contract with the Health
exposure; but they also have been reported on the Resources and Services Administration. However, the
extremities. Extension to the brain might occur through number of pathogens screened is limited and creating
hematogenous spread or by direct extension through standards that eliminate all risk for infectious disease
the nasal cavity or sinuses (1). Why some patients transmission is not feasible. Therefore, physicians and
develop cutaneous lesions before onset of neurologic organ procurement organizations should be aware
disease and others do not is unknown. In a series of of the possibility of transmitting Balamuthia and
10 Balamuthia cases in California, common signs and other potentially fatal infections from donors with
symptoms of Balamuthia GAE were headache, altered encephalitis of uncertain etiology, even after testing for
mental status, and cranial nerve abnormalities (3). usual agents of encephalitis has shown negative results
Although the incubation period for Balamuthia GAE (10). Balamuthia infection should be considered in
has been postulated as ranging from weeks to 2 years, patients who might have an infectious encephalitis,
the two kidney recipients in this report had onset of * For information regarding a single patient IND for miltefosine,
symptoms only 20 days after transplantation. contact the Food and Drug Administration’s Division of Special
Successful treatment of Balamuthia GAE has Pathogen and Transplant Products at 301-796-1600 (1-888-INFO-
FDA after hours).
been reported in some, but not all, patients admin- † Additional information available at http://optn.transplant.hrsa.gov/
istered a combination of flucytosine, pentamidine, policiesandbylaws/policies.asp.

MMWR / September 17, 2010 / Vol. 59 / No. 36 1169

 MMWR Morbidity and Mortality Weekly Report

with encephalitis of uncertain etiology, and OPOs

What is already known on this topic?
should communicate this elevated risk for infection to
Balamuthia madrillaris is a free-living ameba found in transplant centers so they can make an informed risk
soil worldwide that causes skin lesions and Balamuthia
granulomatous amebic encephalitis (GAE), a rare
assessment in the decision to accept an organ.§
central nervous system infection that usually is fatal;
because of its rarity, Balamuthia GAE is likely to be § Additional information available at http://www.cdc.gov/
misdiagnosed as another neurologic disease. balamuthia.
What is added by this report?
References
This is the first report of Balamuthia madrillaris 1. Visvesvara GS, Moura H, Schuster FL. Pathogenic and
transmission through organ transplantation; two of opportunistic free-living amoebae: Acanthamoeba spp.,
four recipients from an organ donor thought to have Balamuthia mandrillaris, Naegleria fowleri, and Sappinia
a noninfectious encephalitis developed GAE 20 days diploidea. FEMS Immunol Med Microbiol 2007;50:1–26.
after transplantation, one of whom died. 2. CDC. Transplant-transmitted Balamuthia mandrillaris—
Arizona, 2010. MMWR 2010;59:1182.
What are the implications for public health practice?
3. CDC. Balamuthia amebic encephalitis—California, 1999–
Organ procurement organizations (OPOs) and trans- 2007. MMWR 2008;57:768–71.
plant centers should be aware of the potential for 4. Visvesvara GS, Martinez AJ, Schuster FL, et al. Leptomyxid
Balamuthia infection in donors with encephalitis of ameba, a new agent of amebic meningoencephalitis in humans
uncertain etiology, and OPOs should communicate and animals. J Clin Microbiol 1990;28:2750–6.
this elevated risk for infection to transplant centers 5. Cary LC, Maul E, Potter C, et al. Balamuthia mandrillaris
so they can make an informed risk assessment in the meningoencephalitis: survival of a pediatric patient. Pediatrics
2010;125:e699–703.
decision to accept an organ.
6. Niyyati M, Lorenzo-Morales J, Rezaeian M, et al. Isolation
of Balamuthia mandrillaris from urban dust, free of known
infectious involvement. Parasitol Res 2009;106:279–81.
particularly those with elevated CSF protein, CSF 7. Bravo F, Sanchez MR. New and re-emerging cutaneous
pleocytosis (white blood cells >5/mm3), and enhanc- infectious diseases in Latin America and other geographic
ing lesions on MRI (3). areas. Dermatol Clin 2003;21:655–68, viii.
Clinicians should be aware of Balamuthia as a 8. Jung S, Schelper RL, Visvesvara GS, Chang HT. Balamuthia
mandrillaris meningoencephalitis in an immunocompetent
cause of skin lesions and encephalitis and should patient: an unusual clinical course and a favorable outcome.
report all suspected cases of transplant-transmitted Arch Pathol Lab Med 2004;128:466–8.
infection to public health departments and organ 9. Martinez DY, Seas C, Bravo F, et al. Successful treatment of
Balamuthia mandrillaris amoebic infection with extensive
procurement organizations to enable prompt evalua- neurological and cutaneous involvement. Clin Infect Dis
tion and treatment of all recipients from an infected 2010;51:e7–11.
donor. OPOs and transplant centers should be aware 10. Kotton C. Zoonoses in solid-organ and hematopoietic stem
cell transplant recipients. Clin Inf Dis 2007;44:857–66.
of the potential for Balamuthia infection in donors

1170 MMWR / September 17, 2010 / Vol. 59 / No. 36

 MMWR Morbidity and Mortality Weekly Report

National, State, and Local Area Vaccination Coverage Among

Children Aged 19–35 Months — United States, 2009

Since 1994, the National Immunization Survey the population of children aged 19–35 months, with
(NIS) has been collecting data to monitor child- adjustments for households with multiple telephone
hood immunization coverage. This report describes lines, household nonresponse, and exclusion of house-
the 2009 NIS coverage estimates for children born holds without landline telephones.† During 2009, the
during January 2006–July 2008 and focuses on the household response rate§ was 63.9%; a total of 17,313
more recently recommended vaccines (i.e., hepatitis children with provider-reported vaccination records
B [HepB] vaccine birth dose, hepatitis A vaccine were included in this report, representing 70.7% of
[HepA], pneumococcal conjugate vaccine [PCV], and all children with completed household interviews.
rotavirus vaccine) for children aged 19–35 months. Because the number of Hib¶ and rotavirus** vaccine
The most recent NIS data indicate that vaccination doses required differs according to manufacturer,
coverage increased in 2009 compared with 2008 for coverage estimates for these vaccines now take into
HepB birth dose (from 55.3% to 60.8%) and HepA account the brand of vaccine used. Logistic regression
(from 40.4% to 46.6%), but coverage for PCV (≥4 was used to examine differences among racial/ethnic
doses) remained stable (80.4%). Full coverage for groups, controlling for poverty status. Statistical analy-
rotavirus vaccine was 43.9% among children born ses were conducted using t-tests based on weighted
within 2 years of licensure (1). Coverage for poliovi- data and accounting for the complex survey design.
rus (92.8%), measles, mumps, and rubella (MMR) All tests with p<0.05 were regarded as statistically
(90.0%), hepatitis B (HepB) (92.4%), and varicella significant.
(VAR) (89.6%) vaccines continued to be at or near During 2009, national coverage with the first
the national health objective of 90%, although cover- dose of HepB within 3 days of birth (birth dose)
age for MMR and HepB vaccines decreased slightly
in 2009. The percentage of children who have not † Since the inception of NIS in 1994, its methodology has undergone
received any vaccines remained low (<1%). Parents several revisions. A report of revisions implemented during
1994–2002 that includes a description of the sampling design,
and primary-care providers continued to ensure response rates, and the precision of key monitoring statistics is
that children were vaccinated, in spite of interim available at http://www.cdc.gov/nchs/data/series/sr_02/sr02_138.
recommendations to suspend the booster dose of pdf. NIS conducts quarterly surveys in each state and local area
to produce annual estimates within each area. For 2009, the U.S.
Haemophilus influenzae type b vaccine (Hib) because Virgin Islands survey was conducted only for the second quarter
of a national shortage, and heightened public aware- for annual estimates. National estimates exclude the territory of
ness of controversies in vaccine safety (2,3). the U.S. Virgin Islands.
§ The Council of American Survey Research Organization (CASRO)
To estimate coverage for all age-eligible children, household response rate, calculated as the product of the resolution
NIS uses a quarterly, random-digit–dialed sample rate (percentage of the total telephone numbers called that were
of telephone numbers for the 50 states and selected classified as either nonworking, nonresidential, or residential),
screening completion rate (percentage of known households that
urban areas and territories,* followed by a mail survey were successfully screened for the presence of age-eligible children),
of the children’s vaccination providers to collect vac- and the interview completion rate (percentage of households with
one or more age-eligible children that completed the household
cination information. Data were weighted to represent survey). Additional information is available at http://www.casro.
org/codeofstandards.cfm.
* The 13 local areas separately sampled for the 2009 NIS included six ¶ Coverage for Hib vaccine for the primary series was based on receipt
areas that receive federal immunization grant funds and are included of ≥2 or ≥3 doses, depending on product type received. The Merck
in the NIS sample every year (District of Columbia; Chicago, Hib vaccines require a 2-dose primary series with doses at ages 2
Illinois; New York, New York; Philadelphia County, Pennsylvania; months and 4 months, and the Sanofi Pasteur Hib vaccines require
Bexar County, Texas; and Houston, Texas); six previously sampled a 3-dose primary series with doses at ages 2, 4, and 6 months.
areas (Los Angeles County, California; Marion County, Indiana; Coverage for the full series, which includes the primary series and
Baltimore, Maryland; Dallas County, Texas; El Paso County, Texas; a booster dose, was based on receipt of ≥3 or ≥4 doses, depending
and eastern/western counties, Washington); and one area sampled on product type received. Both Merck and Sanofi Pasteur Hib
for the first time (Lake County, Indiana). Local areas sampled in vaccines require a booster dose at age 12–15 months.
the NIS might change yearly as state immunization programs target ** Coverage for rotavirus vaccine was based on ≥2 or ≥3 doses,
local assessments where they are most needed. For the first time, the depending on product type received (≥2 doses for Rotarix [RV1],
U.S. Virgin Islands (including St. Croix, St. Thomas, St. John, and licensed in April 2008, and ≥3 doses for RotaTeq [RV5], licensed
Water Island) was included in the NIS sample. in February 2006).

MMWR / September 17, 2010 / Vol. 59 / No. 36 1171

 MMWR Morbidity and Mortality Weekly Report

increased to 60.8% from 55.3% in 2008, the largest from 61.4% in the eastern/western counties of
increase observed for the birth dose in the past 5 years Washington to 73.5% in Los Angeles, California. The
(Table 1); by state, coverage ranged from 22.8% in percentage of children aged 19–35 months receiving
Vermont to 80.7% in Michigan (Table 2). Coverage no vaccinations remained at 0.6%.
with ≥2 doses of HepA vaccine increased from 40.4% Coverage differed by race/ethnicity.§§ Among
in 2008 to 46.6% in 2009. Coverage ranged from the more recently recommended vaccines, PCV
19.3% in Maine to 63.2% in North Dakota. Coverage and rotavirus coverage was lower among black and
with ≥4 doses PCV at the national level changed little multiracial children than among white children
(from 80.1% to 80.4%), but increased significantly (Table 3). Coverage for PCV also was lower among
in Illinois (from 76.2% to 82.9%), Mississippi (from Asian children. Coverage for HepA was lower among
74.7% to 85.0%), Nevada (from 63.6% to 75.1%), black children and American Indian/Alaska Native
and Wyoming (from 69.2% to 82.3%). Across all children than among white children. Except for
states, PCV coverage ranged from 67.5% in Missouri rotavirus coverage among black children, these dif-
to 90.7% in Connecticut. Coverage for rotavirus ferences persisted after controlling for poverty status.
vaccine was 43.9% nationally, similar to previous HepB birth dose coverage was higher among Hispanic
coverage reports for newly recommended vaccines, children than among white children. For vaccines with
and varied widely by state, from 20.9% in Washington longer-standing recommendations, differences were
to 71.2% in Rhode Island. Rotavirus vaccine coverage observed for diphtheria, tetanus toxoid, and acellular
increased from 8.0% among children born during pertussis (DTaP) vaccine. Compared with coverage
January–June 2006 to 60.0% among children born among white children, coverage was lower for black
January–June 2008. For children born between those children for ≥3 and ≥4 DTaP doses and lower for
periods, estimated coverage ranged from 34.8% for Hispanic children for ≥4 doses only. The difference
children born July–December 2006, to 49.0% for in coverage between white and black children for ≥4
children born January–June 2007, to 53.4% for doses remained statistically significant after control-
children born July–December 2007. ling for poverty status.
The seven-vaccine series (i.e., 4:3:1:3:3:1:4) Coverage also differed by poverty status.¶¶
reported in the 2009 NIS added ≥4 doses of PCV to Coverage for HepB birth dose was higher among chil-
the combined 4:3:1:3:3:1†† series reported in previ- dren living below poverty level than for those living
ous years. Because of changes in measurement of the at or above poverty level (by 3.8 percentage points).
Hib vaccine and the vaccine shortage that occurred Among children living below poverty level, coverage
from December 2007 to September 2009 (2), state was lower for ≥4 doses of PCV (by 8.4 percentage
coverage estimates included in this report were based points) and rotavirus vaccine (by 9.4 percentage
on the series that excludes Hib. Using this modified points) than for other children. Among the longer-
seven-vaccine series (minus Hib), coverage remained standing recommendations, coverage for ≥4 doses of
stable in 2009 (70.5%) compared with 2008 (70.6%) DTaP also was lower (by 5.6 percentage points).
(Table 1). In 2009, modified series coverage ranged
§§ Race
from 56.2% in Missouri to 78.1% in Iowa (Table was self-reported. Persons identified as white, black, Asian,
or American Indian/Alaska Native are all non-Hispanic. Persons
2). Significant increases were observed in Wyoming identified as Hispanic might be of any race. Children identified
(69.6% versus 58.9%), Idaho (70.5% versus 60.4%), as multiracial selected more than one race category.
¶¶ Poverty status categorizes income into 1) at or above the poverty
Oklahoma (66.3% versus 57.4%), Nevada (62.6%
level and 2) below the poverty level. Poverty level was based on
versus 55.2%), and North Dakota (77.0% versus 2008 U.S. Census poverty thresholds, available at http://www.
69.1%). Among the 13 local areas, coverage ranged census.gov/hhes/www/poverty.html.

Reported by
††
The combined 4:3:1:3:3:1 series includes ≥4 doses of diphtheria,
tetanus toxoid, and cellular pertussis vaccine, which can include KG Wooten, MA, M Kolasa, MPH, JA Singleton MS,
diphtheria and tetanus toxoid vaccine or diphtheria, tetanus toxoid, A Shefer, MD, Immunization Svcs Div, National Center
and pertussis vaccine (DTaP), ≥3 doses of poliovirus vaccine; ≥1
doses of MMR vaccine; ≥3 doses of Hib vaccine; ≥3 doses of HepB
for Immunization and Respiratory Diseases, CDC.
vaccine; and ≥1 doses of VAR vaccine.

1172 MMWR / September 17, 2010 / Vol. 59 / No. 36

 MMWR Morbidity and Mortality Weekly Report

TABLE 1. Estimated vaccination coverage among children aged 19–35 months, by selected vaccines and dosages — National
Immunization Survey, United States, 2005–2009*
2005 2006 2007 2008 2009
Vaccine % (95% CI) % (95% CI) % (95% CI) % (95% CI) % (95% CI)
DTP/DT/DTaP
≥3 doses 96.1 (±0.5) 95.8 (±0.5) 95.5 (±0.5) 96.2 (±0.5) 95.0 (±0.6)
≥4 doses 85.7 (±0.9) 85.2 (±0.9) 84.5 (±0.9) 84.6 (±1.0) 83.9 (±1.0)
Poliovirus 91.7 (±0.7) 92.8 (±0.6) 92.6 (±0.7) 93.6 (±0.6) 92.8 (±0.7)
MMR ≥1 doses 91.5 (±0.7) 92.3 (±0.6) 92.3 (±0.7) 92.1 (±0.7) 90.0 (±0.8)
Hib†
>3 doses 93.9 (±0.6) 93.4 (±0.6) 92.9 (±0.7) 90.9 (±0.7) 83.6 (±1.0)
Primary series N/A N/A N/A N/A 92.1 (±0.8)
Full series N/A N/A N/A N/A 54.8 (±1.4)
Hepatitis B
≥3 doses 92.9 (±0.6) 93.3 (±0.6) 92.7 (±0.7) 93.5 (±0.7) 92.4 (±0.7)
1 dose by 3 days (birth)§ 49.6 (±1.2) 50.1 (±1.1) 53.2 (±1.3) 55.3 (±1.3) 60.8 (±1.3)
Varicella ≥1 doses 87.9 (±0.8) 89.2 (±0.7) 90.0 (±0.7) 90.7 (±0.7) 89.6 (±0.8)
PCV
≥3 doses 82.8 (±1.0) 86.9 (±0.8) 90.0 (±1.0) 92.8 (±0.6) 92.6 (±0.7)
≥4 doses 53.7 (±1.3) 68.4 (±1.1) 75.3 (±1.3) 80.1 (±1.1) 80.4 (±1.2)
Hepatitis A (≥2 doses)¶ N/A N/A N/A 40.4 (±1.2) 46.6 (±1.4)
Rotavirus** N/A N/A N/A N/A 43.9 (±1.4)
Combined series
4:3:1:3:3:1†† 76.1 (±1.1) 76.9 (±1.0) 77.4 (±1.1) 76.1 (±1.1) 69.9 (±1.2)
4:3:1:3:3:1 with Hib excluded 76.6 (±1.1) 77.6 (±1.0) 78.3 (±1.1) 78.7 (±1.1) 77.5 (±1.1)
4:3:1:3:3:1:4§§ 47.2 (±1.3) 60.1 (±1.2) 66.5 (±1.3) 68.4 (±1.2) 63.6 (±1.2)
4:3:1:3:3:1:4 with Hib excluded 47.3 (±1.3) 60.4 (±1.2) 67.0 (±1.3) 70.6 (±1.2) 70.5 (±1.2)
Children who received no 0.4 (±0.1) 0.4 (±0.1) 0.6 (±0.1) 0.6 (±0.2) 0.6 (±0.1)
vaccinations
Abbreviations: CI = confidence interval; DTP/DT/DTaP = diphtheria, tetanus toxoids and pertussis vaccines, diphtheria and tetanus toxoids,
and diphtheria, tetanus toxoids and acellular pertussis vaccine; Hib = Haemophilus influenzae type b vaccine; MMR = measles, mumps,
and rubella vaccine; N/A = not available; PCV = pneumococcal conjugate vaccine.
* For 2005, includes children born during February 2002–July 2004; for 2006, children born during January 2003–June 2005; for 2007, children
born during January 2004–July 2006; for 2008, children born during January 2005–June 2007; and for 2009, children born during January
2006–July 2008.
† Primary series: receipt of >2 or >3 doses, depending on product type received. Full series: receipt of >3 or >4 doses, depending on product
type received (primary series and booster dose). Hib coverage for primary or full series not available until 2009.
§ Hepatitis B vaccine administered between birth and age 3 days.
¶ Hepatitis A vaccine coverage not available before 2008.
** Rotavirus vaccine includes >2 or >3 doses, depending on product type received (≥2 doses for Rotarix [RV1] and ≥3 doses for RotaTeq
[RV5]). Estimates of rotavirus vaccine coverage not available before 2009.
†† 4:3:1:3:3:1 Series, referred to as routine, includes >4 doses of DTP/DT/DTaP, >3 doses of poliovirus vaccine, >1 doses of measles-containing
vaccine, >3 doses of Hib vaccine, >3 doses of hepatitis B vaccine, and >1 doses of varicella vaccine.
§§ 4:3:1:3:3:1:4 Series, referred to as routine, includes >4 doses of DTP/DT/DTaP, >3 doses of poliovirus vaccine, and >1 doses of measles-
containing vaccine, >3 doses of Hib vaccine, >3 doses of hepatitis B vaccine, >1 doses of varicella vaccine, and >4 doses of PCV.

Editorial Note the ability of immunization programs at state and local

NIS is the only population-based survey to provide levels to incorporate newly recommended vaccines
national, state, local area, and territorial estimates while sustaining coverage at or above national target
of provider-reported vaccination coverage among levels for most longer-standing recommended vac-
children aged 19–35 months in the United States. cines. Careful monitoring of uptake of new vaccines
Coverage levels for poliovirus, MMR, HepB, and overall and in subpopulations (e.g., by race/ethnicity
VAR continued to hold at or above 90%, the national and geographically) will be important to ensure that
health objective for specific vaccines. PCV, first rec- all children are protected adequately against vaccine-
ommended in 2000, has now reached coverage levels preventable diseases.
comparable to those for DTaP, a vaccine also requiring The Hib shortage and interim recommendation
4 doses but with longer-standing recommendations. to suspend the booster dose for healthy children (2)
For the more recently recommended vaccines, cover- occurred during a period when 70% of the children
age for the birth dose of the HepB series and the full in the 2009 NIS would have been eligible for the
series of HepA increased. These findings demonstrate booster dose of Hib vaccine. Not surprisingly, Hib
vaccine coverage measured by receipt of ≥3 doses

MMWR / September 17, 2010 / Vol. 59 / No. 36 1173

 MMWR Morbidity and Mortality Weekly Report

TABLE 2. Estimated vaccination coverage for vaccination series (modified)* and selected individual vaccines among children aged 19–35 months, by
state and local area — National Immunization Survey, United States, 2009†
Vaccine series
MMR (≥1 doses) PCV (≥4 doses) Hep B (birth)§ HepA (≥2 doses)¶ Rotavirus** (modified)
State/Area % (95% CI) % (95% CI) % (95% CI) % (95% CI) % (95% CI) % (95% CI)
United States 90.0 (±0.8) 80.4 (±1.1) 60.8 (±1.3) 46.6 (±1.4) 43.9 (±1.4) 70.5 (±1.2)
Alabama 95.4 (±2.9) 73.3 (±9.2) 68.1 (±7.0) 43.6 (±8.0) 50.8 (±8.4) 63.9 (±8.9)
Alaska 85.2 (±5.8) 73.2 (±7.3) 65.4 (±7.6) 45.9 (±8.2) 32.3 (±7.4) 56.6 (±8.3)
Arizona 90.8 (±3.6) 77.8 (±5.6) 77.6 (±5.7) 51.9 (±6.8) 39.8 (±6.5) 66.4 (±6.5)
Arkansas 81.8 (±6.0) 69.2 (±6.8) 70.7 (±6.7) 25.1 (±5.7) 27.3 (±5.8) 61.5 (±6.9)
California 89.8 (±3.7) 79.8 (±5.1) 49.8 (±6.3) 51.5 (±6.3) 43.9 (±6.1) 72.2 (±5.5)
Los Angeles County 88.9 (±5.4) 79.4 (±6.7) 51.5 (±8.1) 51.7 (±8.0) 51.5 (±8.1) 73.5 (±7.2)
Rest of state 90.1 (±4.7) 79.9 (±6.5) 49.1 (±8.1) 51.5 (±8.0) 41.1 (±7.8) 71.7 (±7.1)
Colorado 83.6 (±7.0) 77.5 (±7.6) 52.5 (±8.8) 38.9 (±8.5) 44.8 (±8.8) 66.1 (±8.4)
Connecticut 93.7 (±3.3) 90.7 (±5.4) 46.8 (±9.6) 46.9 (±9.8) 46.4 (±9.6) 76.0 (±7.7)
Delaware 90.2 (±4.2) 81.6 (±5.9) 62.8 (±7.4) 52.3 (±7.3) 56.4 (±7.4) 69.2 (±6.8)
District of Columbia 91.2 (±4.5) 77.6 (±7.1) 67.9 (±6.8) 54.1 (±7.2) 39.3 (±7.1) 63.8 (±7.5)
Florida 91.2 (±3.8) 79.5 (±5.5) 47.8 (±6.8) 44.6 (±6.6) 36.4 (±6.5) 68.7 (±6.1)
Georgia 91.3 (±4.2) 79.4 (±5.9) 71.2 (±6.6) 58.1 (±7.1) 48.5 (±7.1) 73.1 (±6.5)
Hawaii 86.7 (±5.3) 80.7 (±5.9) 65.4 (±7.3) 47.1 (±7.7) 39.4 (±7.5) 71.0 (±6.9)
Idaho 88.1 (±4.8) 82.5 (±6.0) 70.3 (±7.1) 37.3 (±7.5) 30.3 (±7.2) 70.5 (±7.0)
Illinois 88.2 (±3.9) 82.9 (±4.6) 58.6 (±5.7) 38.0 (±5.5) 37.9 (±5.4) 72.8 (±5.2)
City of Chicago 90.4 (±4.0) 84.7 (±5.0) 69.8 (±7.1) 47.2 (±7.5) 39.9 (±7.1) 71.4 (±6.9)
Rest of state 87.5 (±5.1) 82.3 (±5.9) 54.7 (±7.3) 34.8 (±6.8) 37.2 (±6.8) 73.2 (±6.6)
Indiana 86.6 (±4.6) 78.6 (±5.6) 74.8 (±5.4) 46.1 (±6.5) 50.8 (±6.5) 67.3 (±6.3)
Lake County 82.7 (±6.4) 75.5 (±7.3) 69.9 (±7.6) 22.6 (±6.8) 33.4 (±7.4) 61.5 (±8.0)
Marion County 87.4 (±5.0) 81.0 (±6.0) 77.4 (±6.0) 45.1 (±7.3) 44.3 (±7.3) 69.5 (±6.9)
Rest of state 86.8 (±6.1) 78.4 (±7.4) 74.8 (±7.0) 48.8 (±8.5) 54.2 (±8.5) 67.4 (±8.2)
Iowa 93.2 (±3.8) 83.8 (±5.3) 46.7 (±7.2) 47.8 (±7.0) 51.1 (±7.1) 78.1 (±6.0)
Kansas 92.5 (±4.6) 78.6 (±7.4) 72.6 (±7.7) 43.8 (±8.5) 39.7 (±8.1) 71.7 (±8.0)
Kentucky 88.9 (±3.8) 75.2 (±5.4) 76.6 (±5.0) 37.9 (±5.7) 45.3 (±5.8) 67.5 (±5.7)
Louisiana 94.4 (±3.0) 81.6 (±5.9) 63.0 (±6.9) 52.2 (±7.4) 50.9 (±7.4) 74.9 (±6.5)
Maine 91.4 (±3.9) 82.5 (±5.2) 68.6 (±6.2) 19.3 (±5.2) 28.5 (±6.3) 72.3 (±6.1)
Maryland 89.7 (±5.2) 83.4 (±6.7) 67.6 (±7.8) 44.9 (±8.1) 44.5 (±7.9) 77.9 (±7.0)
City of Baltimore 91.0 (±4.4) 80.1 (±6.5) 67.8 (±7.0) 46.1 (±7.3) 37.5 (±6.7) 70.4 (±7.0)
Rest of state 89.5 (±5.9) 83.9 (±7.6) 67.6 (±8.9) 44.7 (±9.1) 45.5 (±9.0) 79.0 (±7.9)
Massachusetts 93.7 (±3.2) 86.0 (±5.3) 62.5 (±6.8) 47.1 (±7.1) 45.2 (±7.0) 76.0 (±6.3)
Michigan 90.9 (±5.1) 87.0 (±4.3) 80.7 (±6.1) 43.2 (±7.4) 46.0 (±7.4) 76.5 (±6.4)
Minnesota 93.6 (±3.0) 83.8 (±5.7) 34.1 (±6.2) 49.4 (±6.6) 50.1 (±6.6) 71.6 (±6.3)
Mississippi 91.6 (±3.3) 85.0 (±4.3) 68.0 (±6.2) 41.3 (±6.6) 43.4 (±6.5) 75.2 (±5.4)
Missouri 88.8 (±5.0) 67.5 (±6.9) 59.9 (±6.7) 33.6 (±6.5) 46.9 (±7.1) 56.2 (±7.0)
Montana 87.2 (±5.0) 74.6 (±6.7) 65.2 (±7.2) 31.1 (±7.0) 30.7 (±6.8) 61.7 (±7.5)
Nebraska 93.6 (±3.1) 79.2 (±6.5) 45.4 (±7.4) 52.7 (±7.3) 62.3 (±7.4) 65.4 (±7.3)
Nevada 86.3 (±4.6) 75.1 (±5.7) 72.3 (±5.8) 49.1 (±6.8) 34.4 (±6.4) 62.6 (±6.5)
New Hampshire 92.0 (±3.8) 85.8 (±5.2) 63.7 (±7.1) 49.7 (±7.4) 54.8 (±7.5) 73.3 (±6.5)
New Jersey 86.9 (±4.3) 79.6 (±6.0) 39.0 (±6.1) 34.5 (±6.0) 42.4 (±6.3) 67.2 (±6.4)
New Mexico 89.1 (±4.1) 79.9 (±5.4) 51.2 (±6.8) 40.8 (±6.5) 43.6 (±6.6) 70.2 (±6.4)
New York 90.3 (±3.2) 80.1 (±4.3) 48.6 (±5.4) 34.6 (±5.2) 39.5 (±5.3) 67.2 (±5.0)
City of New York 91.9 (±4.4) 77.2 (±6.5) 41.1 (±7.8) 35.0 (±7.4) 38.6 (±7.7) 67.5 (±7.2)
Rest of state 88.7 (±4.5) 82.9 (±5.5) 55.8 (±7.4) 34.2 (±7.3) 40.4 (±7.3) 67.0 (±6.8)
North Carolina 92.9 (±4.0) 84.0 (±5.8) 76.6 (±6.7) 47.5 (±7.7) 41.1 (±7.4) 76.7 (±6.5)
North Dakota 94.4 (±3.2) 84.0 (±5.5) 78.3 (±6.0) 63.2 (±7.0) 62.6 (±7.1) 77.0 (±6.2)
Ohio 89.4 (±4.2) 82.1 (±5.3) 63.6 (±7.5) 46.7 (±7.4) 48.9 (±7.4) 72.4 (±6.2)
Oklahoma 94.2 (±2.7) 74.0 (±6.1) 66.0 (±6.3) 59.0 (±6.5) 33.4 (±6.3) 66.3 (±6.5)
Oregon 88.1 (±4.3) 81.9 (±5.3) 59.4 (±6.7) 49.5 (±6.6) 31.6 (±6.0) 69.9 (±6.2)
Pennsylvania 89.3 (±4.4) 82.6 (±4.7) 69.1 (±5.8) 52.0 (±6.1) 59.0 (±6.1) 69.4 (±5.9)
Philadelphia County 90.7 (±4.0) 77.6 (±6.0) 72.2 (±6.6) 50.0 (±6.8) 52.6 (±7.2) 68.5 (±6.7)
Rest of state 89.1 (±5.1) 83.6 (±5.5) 68.5 (±6.7) 52.4 (±7.1) 60.2 (±7.1) 69.6 (±6.9)
Rhode Island 90.8 (±4.2) 83.6 (±6.5) 69.5 (±7.3) 55.5 (±7.8) 71.2 (±7.3) 69.7 (±7.5)
South Carolina 86.9 (±4.9) 79.7 (±5.9) 62.5 (±6.8) 43.9 (±6.8) 42.5 (±6.7) 70.9 (±6.4)
South Dakota 92.8 (±3.5) 80.6 (±5.9) 53.0 (±7.2) 43.0 (±7.2) 38.6 (±7.0) 69.6 (±6.7)
Tennessee 94.7 (±2.7) 81.2 (±5.3) 49.7 (±6.7) 47.3 (±6.7) 53.1 (±6.8) 72.5 (±5.9)
See Table 2 footnotes on next page.

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 MMWR Morbidity and Mortality Weekly Report

TABLE 2. (Continued) Estimated vaccination coverage for vaccination series (modified)* and selected individual vaccines among children aged
19–35 months, by state and local area — National Immunization Survey, United States, 2009†
Vaccine series
MMR (≥1 doses) PCV (≥4 doses) Hep B (birth)§ HepA (≥2 doses)¶ Rotavirus** (modified)
State/Area % (95% CI) % (95% CI) % (95% CI) % (95% CI) % (95% CI) % (95% CI)
Texas 88.5 (±3.2) 80.8 (±4.2) 69.8 (±4.8) 55.0 (±5.5) 45.8 (±5.4) 71.3 (±5.0)
Bexar County 87.6 (±5.6) 76.3 (±7.4) 58.3 (±7.5) 51.2 (±8.0) 49.9 (±8.0) 65.4 (±7.8)
City of Houston 86.9 (±4.9) 75.7 (±6.8) 62.3 (±7.9) 57.3 (±7.9) 46.6 (±8.4) 67.9 (±7.4)
Dallas County 84.9 (±6.1) 78.0 (±7.1) 70.5 (±7.0) 46.4 (±8.2) 47.4 (±8.1) 69.7 (±7.8)
El Paso County 87.1 (±4.4) 72.7 (±5.7) 71.5 (±5.8) 56.6 (±6.2) 56.5 (±6.3) 63.9 (±6.1)
Rest of state 89.5 (±4.6) 83.1 (±6.0) 72.1 (±7.0) 56.5 (±8.1) 44.5 (±7.9) 73.3 (±7.2)
Utah 91.3 (±4.1) 79.2 (±5.9) 77.8 (±6.1) 51.3 (±7.2) 43.6 (±7.4) 69.3 (±6.9)
Vermont 91.9 (±3.2) 80.9 (±5.0) 22.8 (±5.1) 43.4 (±6.2) 34.5 (±5.8) 59.9 (±6.1)
Virginia 85.8 (±6.8) 76.4 (±7.9) 60.8 (±7.9) 37.8 (±7.5) 53.1 (±8.1) 68.6 (±8.0)
Washington 90.8 (±3.0) 82.2 (±4.1) 70.1 (±5.4) 52.3 (±5.9) 20.9 (±4.7) 64.9 (±5.7)
Eastern/Western Washington 87.8 (±4.4) 72.9 (±6.0) 73.0 (+6.1) 41.1 (±6.4) 25.5 (±5.5) 61.4 (±6.5)
Rest of state 92.1 (±3.8) 86.2 (±5.2) 68.8 (±7.3) 57.1 (±7.8) 18.9 (±6.3) 66.4 (±7.6)
West Virginia 89.2 (±5.7) 74.4 (±7.5) 53.7 (±8.2) 51.7 (±8.1) 40.9 (±7.9) 60.9 (±8.0)
Wisconsin 94.4 (±2.7) 86.9 (±4.7) 63.1 (±6.6) 52.5 (±6.6) 46.7 (±6.8) 75.9 (±6.0)
Wyoming 91.3 (±3.6) 82.3 (±5.1) 61.2 (±6.8) 32.2 (±6.3) 34.7 (±6.3) 69.6 (±6.5)
U.S. Virgin Islands 71.2 (±6.4) 46.5 (±7.1) 81.8 (±5.5) 15.9 (±5.5) 5.6 —†† 37.0 (±6.8)
Abbreviations: CI = confidence interval; DTP/DT/DTaP = diphtheria, tetanus toxoids and pertussis vaccines, diphtheria and tetanus toxoids, and diphtheria, tetanus
toxoids, and acellular pertussis vaccine; HepB = hepatitis B vaccine; Hib = Haemophilus influenzae type b vaccine; MMR = measles, mumps, and rubella vaccine; PCV =
pneumococcal conjugate vaccine.
* Includes ≥4 doses of DTP/DT/DTaP, ≥3 doses of poliovirus vaccine, ≥1 doses of any measles-containing vaccine, ≥3 doses of HepB, ≥1 doses of varicella vaccine,
and ≥4 doses of PCV; Hib vaccine is excluded.
† Children in the 2009 National Immunization Survey were born during January 2006–July 2008.
§ ≥1 doses of HepB vaccine administered between birth and age 3 days.
¶ ≥2 doses hepatitis A vaccine and measured among children aged 19–35 months.
** ≥2 or ≥3 doses of rotavirus vaccine, depending on product type received (≥2 doses for Rotarix [RV1] and ≥3 doses for RotaTeq [RV5]).
†† The asymmetric CI of 3.1–10.0 is reported instead of the confidence width.

dropped from 90.9% in 2008 to 83.6% in 2009, and reached 60.0% among children born during
in part because of the shortage and interim recom- January–June 2008; overall vaccination coverage for
mendation. Starting in 2009, coverage estimates are rotavirus likely will continue to increase.
reported based on a more accurate measurement of The Vaccines for Children program,*** a federal
Hib vaccination status that takes into account vac- entitlement program that provides vaccine at no cost
cine product type (Hib vaccine products vary in the for eligible children, has been effective in reducing
number of recommended doses) (2). Concerns that potential gaps in coverage levels resulting from poverty
providers were not vaccinating children adequately status; however, some gaps persist that reflect other
with the primary series during the shortage and barriers that must be addressed. Race/ethnicity was
temporary suspension of the booster vaccine proved associated with vaccination status in the 2009 NIS
unfounded; nationally, 92.1% of eligible children data, independent of poverty status, for HepA, 4
completed the primary series for Hib. doses of PCV, and 4 doses of DTaP. In the 2008 NIS
Since the 2006 introduction of live rotavirus vac- data, racial/ethnic disparities for 4 doses of PCV and
cine, hospitalizations for gastroenteritis during the 4 doses of DTaP were observed but did not persist
rotavirus season have declined markedly, beginning in after controlling for poverty status (5). Associations
2007, as have emergency department and physician of race/ethnicity and poverty with vaccination status
office visits for gastroenteritis (4). NIS estimates of will continue to be monitored, and further research
rotavirus coverage in this report reflect early vaccina- will explore reasons for disparities.
tions, primarily among children born during the first State variation in vaccine coverage persists year
2 years of licensure of rotavirus vaccine. Analysis by to year. Many factors that potentially could affect
birth cohort of the 2009 NIS showed rotavirus vacci-
nation for the full vaccine series has increased steadily *** Additional information on the Vaccines for Children program is
available at http://www.cdc.gov/vaccines/programs/vfc/default.htm.

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 MMWR Morbidity and Mortality Weekly Report

TABLE 3. Estimated vaccination coverage among children aged 19–35 months, by selected vaccines and dosages by race/ethnicity* and poverty
level† — National Immunization Survey, United States, 2009§
Race/Ethnicity Poverty level
American
White, Black, Indian/ Alaska Multiracial,
non-Hispanic non-Hispanic Hispanic Native Asian non-Hispanic Below At or above
Vaccine % (95% CI) % (95% CI) % (95% CI) % (95% CI) % (95% CI) % (95% CI) % (95% CI) % (95% CI)
DTP/DT/DTaP
≥3 doses 95.6 (±0.6) 93.3 (±2.0)¶ 94.6 (±1.6) 94.5 (±4.8) 95.9 (±2.4) 95.9 (±2.4) 94.1 (±1.2) 95.6 (±0.7)
≥4 doses 85.8 (±1.1) 78.6 (±3.1)¶ 82.9 (±2.5)¶ 82.1 (±8.1) 86.6 (±5.5) 81.8 (±4.1) 80.1 (±2.3)** 85.7 (±1.1)
Poliovirus 93.3 (±0.8) 90.9 (±2.3) 92.5 (±1.8) 92.2 (±5.5) 94.0 (±3.4) 92.8 (±3.0) 92.0 (±1.5) 93.3 (±0.8)
MMR ≥1 doses 90.8 (±0.9) 88.3 (±2.7) 89.3 (±2.0) 94.9 (±3.1)¶ 90.7 (±4.3) 88.5 (±3.8) 88.8 (±1.8) 90.6 (±0.9)
Hib††
≥3 doses 82.9 (±1.2) 80.4 (±3.1) 86.4 (±2.2)¶ 88.3 (±5.9) 81.4 (±6.4) 83.7 (±4.0) 82.0 (±2.1) 84.3 (±1.1)
Primary series 92.6 (±0.8) 91.0 (±2.2) 92.3 (±1.8) 91.8 (±5.2) 86.5 (±5.6)¶ 91.9 (±2.6) 90.1 (±1.7)** 93.1 (±0.8)
Full series 55.3 (±1.6) 51.2 (±3.7) 55.4 (±3.3) 62.5 (±3.1) 54.6 (±8.8) 53.7 (±5.9) 51.4 (±3.0)** 56.5 (±1.5)
Hepatitis B
≥3 doses 92.3 (±0.9) 91.6 (±2.2) 92.6 (±1.7) 92.5 (±5.2) 93.1 (±3.2) 93.3 (±2.6) 92.3 (±1.4) 92.7 (±0.9)
1 dose by 3 days (birth)§§ 58.8 (±1.6) 61.7 (±3.7) 64.7 (±3.1)¶ N/A¶¶ 53.3 (±9.2) 60.7 (±5.9) 63.2 (±2.9)** 59.4 (±1.5)
Varicella ≥1 doses 89.2 (±1.0) 88.2 (±2.7) 90.7 (±1.9) 89.2 (±6.3) 89.5 (±5.3) 90.6 (±3.1) 89.0 (±1.8) 90.2 (±0.9)
PCV
≥3 doses 93.2 (±0.8) 91.5 (±2.2) 92.7 (±1.7) 94.4 (±4.3) 88.5 (±5.0) 91.1 (±3.0) 91.2 (±1.5) 93.5 (±0.8)
≥4 doses 83.4 (±1.2) 73.2 (±3.4)¶ 80.6 (±2.5) 76.2 (±9.2) 72.5 (±9.5)¶ 73.1 (±5.7)¶ 74.8 (±2.6)** 83.2 (±1.1)
Hepatitis A (≥2 doses) 46.2 (±1.6) 41.3 (±3.7)¶ 49.3 (±3.3) 33.2 (±9.8)¶ 50.9 (±9.1) 47.8 (±5.9) 47.3 (±3.0) 46.2 (±1.5)
Rotavirus*** 46.4 (±1.6) 38.0 (±3.6)¶ 43.7 (±3.2) N/A¶¶ 41.7 (±8.6) 38.4 (±5.6)¶ 37.7 (±2.8)** 47.1 (±1.5)
Combined series
4:3:1:3:3:1††† 69.2 (±1.5) 66.6 (±3.5) 72.8 (±2.8)¶ 73.4 (±9.4) 69.9 (±7.4) 67.1 (±5.2) 68.4 (±2.6) 70.4 (±1.3)
4:3:1:3:3:1 with Hib 78.1 (±1.3) 73.7 (±3.3) 78.2 (±2.7) 76.6 (±9.0) 80.3 (±6.2) 74.8 (±4.8) 75.5 (±2.4) 78.5 (±1.2)
excluded
4:3:1:3:3:1:4§§§ 64.1 (±1.5) 58.2 (±3.7)¶ 67.1 (±3.0) N/A¶¶ 55.0 (±8.9) 57.2 (±5.8) 60.7 (±2.8)** 64.8 (±1.4)
4:3:1:3:3:1:4 with Hib 72.4 (±1.4) 64.3 (±3.6)¶ 72.0 (±2.9) N/A¶¶ 62.5 (±9.1)¶ 63.4 (±5.8)¶ 66.9 (±2.7)** 72.1 (±1.4)
excluded
Abbreviations: CI = confidence interval; DTP/DT/DTaP = diphtheria, tetanus toxoids and pertussis vaccines, diphtheria and tetanus toxoids, and diphtheria, tetanus
toxoids and acellular pertussis vaccine; Hib = Haemophilus influenzae type b vaccine; MMR = measles, mumps, and rubella vaccine; N/A = not available; PCV = pneu-
mococcal conjugate vaccine.
* Native Hawaiian or other Pacific Islanders were not included in the table because of small sample sizes.
† Poverty level was determined for all children. Children were classified as below poverty if their total family income was less than the poverty threshold specified
for the applicable family size, and number of children aged <18 years. All others were classified as at or above poverty. Poverty thresholds reflect yearly changes
in the Consumer Price Index. Thresholds and guidelines available at http://www.census.gov/hhes/www/poverty.html.
§ Children in the 2009 National Immunization Survey were born during January 2006–July 2008.
¶ Estimates are statistically significant at p<0.05. White, non-Hispanic children were the reference group.
** Estimates are statistically significant at p<0.05. Children living at or above poverty were the reference group.
†† Primary series: receipt of ≥2 or ≥3 doses, depending on product type received; full series: primary series and booster dose includes receipt of ≥3 or ≥4 doses
depending on product type received.
§§ Hepatitis B vaccine administered between birth and age 3 days.
¶¶
Estimate not available if the unweighted sample size for the numerator was <30 or CI half width / estimate >0.5 of CI half width >10.
*** Includes ≥2 or ≥3 doses, depending on product type received (≥2 doses for Rotarix [RV1], ≥3 doses for RotaTeq [RV5]).
†††
4:3:1:3:3:1 series includes ≥4 doses of DTP/DT/DTaP, ≥3 doses of poliovirus vaccine, ≥1 doses of any measles-containing vaccine, ≥3 doses of Hib vaccine, ≥3 doses
of hepatitis B vaccine, and ≥1 doses of varicella vaccine.
§§§
4:3:1:3:3:1:4 series includes ≥4 doses of DTP/DT/DTaP, ≥3 doses of poliovirus vaccine, ≥1 doses of any measles-containing vaccine, ≥3 doses of Hib vaccine, ≥3
doses of hepatitis B vaccine, ≥1 doses of varicella vaccine, and ≥4 doses of PCV.

vaccination coverage rates vary across states. Such fac- observed differences in vaccination coverage is unclear.
tors include population characteristics, health system Further work is needed to understand factors that most
characteristics, state policies (e.g., child care vaccina- strongly influence vaccination coverage and to identify
tion requirements), vaccine financing policies that best practices among states.
might affect speed with which new vaccine recom- The findings in this report are subject to at
mendations can be adopted and the degree to which least three limitations. First, NIS is a landline-
underinsured children can receive publicly purchased based telephone survey, and statistical adjustments
vaccine, reimbursement of providers for immuniza- might not fully compensate for nonresponse and
tion services, and immunization program activities households without landline or only cellular tele-
(6–8). How these various factors interact to influence phones. Vaccination coverage estimates that include

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 MMWR Morbidity and Mortality Weekly Report

vaccines continue to increase. CDC encourages the

What is already known on this topic?
use of evidence-based methods of improving coverage,
By estimating vaccination coverage among U.S. children which include parent and provider reminders, reduc-
aged 19–35 months, the National Immunization Survey
(NIS) is used to monitor efforts to reduce the burden and
ing out-of-pocket costs, increasing access to vaccina-
prevent a resurgence of vaccine-preventable diseases. tion, and multicomponent interventions that include
What is added by this report?
education (10). Research is under way to understand
barriers to implementing proven methods of improving
The 2009 NIS findings demonstrate 1) the ability of
state and local immunization programs to incorpo- coverage and identify approaches to promoting more
rate newly recommended vaccines while sustaining widespread implementation.
coverage at or above national target levels for most
longer-standing recommended vaccines, and 2) the
References
existence of racial/ethnic disparities in coverage for 1. CDC. Reduction in rotavirus after vaccine introduction—
some vaccines, independent of poverty status. United States, 2000–2009. MMWR 2009;48:1146–9.
2. CDC. Changes in measurement of Haemophilus influenzae
What are the implications for public health practice? serotype b (Hib) vaccination coverage—National
Continued partnerships among national, state, local, Immunization Survey, United States, 2009. MMWR
private, and public entities are needed to sustain cov- 2010;59:1069–72.
3. Chatterjee A, O’Keefe C. Current controversies in the
erage levels, increase coverage with the more recently
USA regarding vaccine safety. Expert Rev Vaccines
recommended vaccines, implement targeted vaccina- 2010;9:497–502.
tion programs to address disparities in coverage, and 4. Curns AT, Steiner CA, Barrett M, Hunter K, Wilson E,
support research to explore reasons for disparities Parashar UD. Reduction in acute gastroenteritis hospitalizations
and understand barriers to implementing proven among US children after introduction of rotavirus vaccine:
methods to improve coverage. analysis of hospital discharge data from 18 US states. J Infect
Dis 2010;201:1607–10.
5. CDC. National, state, and local area vaccination coverage
nonlandline households might be lower than NIS among children aged 19–35 months—United States, 2008.
estimates (9). Second, underestimates of vaccination MMWR 2009;58:921–6.
6. Groom H, Kennedy A, Evans V, Fasano N. Qualitative
coverage might have resulted from the exclusive use analysis of immunization programs with most improved
of provider-reported vaccination histories because childhood vaccination coverage from 2001 to 2004. J Public
completeness of these records is unknown. Finally, Health Manag Pract 2010;16:E1–8.
7. Lee GM, Santoli JM, Hannan C, et al. Gaps in vaccine
although national coverage estimates are precise, financing for underinsured children in the United States.
annual estimates and trends for state and local areas JAMA 2007;298:638–43.
should be interpreted with caution because of smaller 8. Coleman MS, Lindley MC, Ekong J, Rodewald L. Net
sample sizes and wider confidence intervals. financial gain or loss from vaccination in pediatric medical
practices. Pediatrics 2009;124:S472–91.
Achieving and maintaining high vaccination cover- 9. Barron M, Wooten K, Taylor B. Comparing vaccination
age levels is important to reduce the burden of vaccine- estimates from four survey designs: vaccination estimates
preventable diseases and prevent a resurgence of these from RDD, RDD+Cell, ABS, and area probability sampling.
Presented at the 2010 Joint Statistical Meetings; July
diseases in the United States, particularly in undervac- 31–August 5, 2010; Vancouver, British Columbia, Canada.
cinated populations. Continued partnerships among 10. Task Force on Community Preventive Ser vices.
national, state, local, private, and public entities are Recommendations regarding interventions to improve
vaccination coverage in children, adolescents, and adults.
needed to sustain vaccination coverage levels and ensure Am J Prev Med 2000;18(1S):92–6.
that coverage levels for the more recently recommended

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 MMWR Morbidity and Mortality Weekly Report

CDC Grand Rounds: Radiological and Nuclear Preparedness

Radiological and nuclear disasters are infrequent, BOX 1. Spectrum of potential public health roles in a radio-
but when they occur, they result in large and demon- logical or nuclear emergency*
strable health burdens. Several scenarios can result
in the public’s exposure to radiation. For example, • Identify radiological agent or cause.
radiation sources used in health care or other indus- • Determine radiological exposure and
tries can be lost or misused. Incidents in the nuclear contamination.
power industry, such as those at Chernobyl and Three • Provide medical and public guidance on
Mile Island, require significant public health response. radiological-protective actions and medical
In addition, radiological terrorism can involve the management.
use of a radiological dispersal device (RDD) or an • Conduct environmental and human surveil-
improvised nuclear device (IND). State and local lance for potential radiological contamina-
health agencies are expected to perform essential tion or exposure.
public health functions in response to any of these • Conduct epidemiologic investigations, if
emergencies (1,2) (Box 1). needed.
Recent events illustrate that the public health • Conduct radiological monitoring and screen-
sector will be essential in a radiological or nuclear ing (environment and persons).
response. For example, in August 2004, the day • Conduct radiological sampling and labora-
before the Republican National Convention, the New tory testing.
York City Department of Health and Mental Health • Coordinate requests, receipt, and distri-
(DOHMH) responded to a radiation incident at a bution of Strategic National Stockpile, if
mid-town Manhattan post office. A radiation source needed.
failed to retract into its protective shielding, resulting • Undertake mitigation and recovery.
in dangerously high radiation levels near the radiation
source. Police and fire departments evacuated the * Additional information available at http://www.bt.cdc.gov/
radiation/glossary.asp.
building and closed off nearby streets. The DOHMH
response included conducting extensive environmen-
tal surveys outside and throughout the building,
assisting with shielding the source, conducting press When Aleksander Litvinenko died in London
conferences, providing approximately 2,000 copies of in 2006 from poisoning with the radioisotope
fact sheets to residents in nearby buildings, and con- polonium-210, public health agencies in the United
ducting dose estimates for the contractor and postal States were affected. Polonium was spread to many
service employees. It took over 24 hours to remove places in London, potentially contaminating thousands
the radiation source safely. The public’s maximal risk of persons, including foreign visitors. In the United
for exposure was less than that received from a single Kingdom, approximately 8,000 persons contacted
chest radiograph because of their distance from the public health authorities, and citizens from 52 countries
radiation source. potentially were involved, including 160 U.S. citizens.
Approximately 20 U.S. state and local public health
agencies worked with CDC to notify involved citizens
This is another in a series of occasional MMWR and to coordinate laboratory testing.
reports titled CDC Grand Rounds. These reports These events demonstrate that 1) radiological inci-
are based on grand rounds presentations at CDC dents can happen at any time and any place, 2) state
on high-profile issues in public health science, prac- and local health agencies are involved in response and
tice, and policy. Information about CDC Grand communication concerning health effects of radiation, 3)
Rounds is available at http://www.cdc.gov/about/ communication needs arise even when there is no public
grand-rounds. risk, 4) responses require coordination with multiple
agencies, and 5) planning requires multiagency input.

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 MMWR Morbidity and Mortality Weekly Report

Current Capability of States and Localities health surveillance, epidemiology, laboratory analyses
State and local capabilities to respond effectively to of biologic samples, and health physics. Some states can
radiological or nuclear incidents vary greatly: 31 states handle events involving a small number of casualties,
with commercial nuclear power plants are required to such as an industrial incident, but all states are likely
have detailed response plans and drills, but only for to face major challenges in dealing with a large mass-
designated zones around their power plants. Some casualty event, such as detonation of an RDD or an
major metropolitan areas that are considered high- IND. In these events, persons might be contaminated
probability terrorist targets (e.g., Los Angeles and both on the body (external contamination) and in the
New York City) have done extensive planning. Other body (internal contamination). An IND event also
regions have made modest planning efforts. Each state will expose thousands of persons to strong gamma rays
has one or more radiation control programs. In 35 without external or internal contamination. External
states, these programs are in the state public health radioactive contamination can be assessed with readily
department; in the other states, this expertise is else- available radiation survey meters. Internal contamina-
where, often in state environmental departments. tion by strong gamma emitters can be detected by
whole body counters, radiation meters, or bioassays.
Enhancing Overall Public Health Capacity Internal contamination by most alpha and beta emit-
for Response ters requires a urine bioassay. Additionally, medical
Public health authorities at all levels must under- countermeasures might be required for either internal
stand the extent of their responsibilities in radiologi- contamination (such as Prussian blue) or external high-
cal emergencies, and they must prioritize emergency dose exposure (such as filgrastim) or both (3), and it
planning appropriately. Enhancing public health will be the responsibility of public health authorities to
expertise on radiological agents is paramount for provide access to the Strategic National Stockpile and
appropriate planning, drilling, and responding to recommendations on medical countermeasure use.
radiological and nuclear incidents (Box 1). CDC has developed a guidance document to help
The pre-event phase of planning includes 1) identify- state and local authorities evaluate their emergency
ing preexisting radiation sources to establish a baseline, response plans and prioritize allocation of existing
2) developing and coordinating multiagency response resources. CDC and state and local partners are
plans, and 3) conducting training and exercises. These developing data collection and reporting tools for
actions require strong alliances among public health epidemiology, surveillance, and registry needs, as
entities, radiation control programs, subject matter well as developing guidance for using readily available
experts, and emergency response agencies. handheld instruments for internal monitoring (4).
In the initial hours of an event, environmental char- Public health issues to be addressed during the
acterization is critical for identifying persons and places recovery phase (days to months after the event begins)
likely to be contaminated and for driving protective and clean-up process require engagement of many
actions. The capabilities of the Integrated Modeling and stakeholders. These issues include 1) safe management
Atmospheric Assessment Center* can help initially to and identification of human remains (5), 2) complete
define the contaminated areas (via atmospheric plume identification of types and levels of contamination
modeling), identify potential evacuation routes, and present (i.e., chemical, biologic, and radioactive), 3)
assist with initial protective action guidance, such as the intended use of the restored area (e.g., residential,
recommendations for sheltering in place versus evacua- school, industrial, or tourism), 4) selection of the
tion. Real-time environmental monitoring data should remedial action most cost-effective and acceptable to
be used to verify the atmospheric modeling results and the community, and 5) establishment of a post-event
guide decision-making as quickly as such monitoring acceptable level of residual radioactivity based on a
data become available. pre-event background level of radioactivity.
During the hours to days after an event begins, Throughout all phases of a radiological or nuclear
besides the ongoing environmental monitoring, event, public health authorities must ensure the safety
public health response elements fall under the rubric and health of the potentially large number of emer-
of population monitoring, which draws upon public gency responders, health-care workers, and recovery
workers involved in the response. Many of these
* Additional information available at https://imaacweb.llnl.gov/web. workers will have very little experience in radiological

MMWR / September 17, 2010 / Vol. 59 / No. 36 1179

 MMWR Morbidity and Mortality Weekly Report

and nuclear safety and health. Responders should be BOX 2. CDC radionuclide screen*
trained to recognize the acute health effects of high-
dose radiation, the long-term risk for cancer that can Step 1. Screen for the presence of any
result from low-dose radiation, and the protective radionuclides:
principles of time, distance, and shielding (3). Because • Identifies presence of alpha-, beta-, or
personal protective equipment (PPE) does not protect gamma-emitting radionuclides.
responders from external gamma radiation exposure, • Results for the first 100 samples in 8
responders must rely instead on monitoring equip- hours.
ment to alert them to such exposures and help gauge • Throughput: alpha or beta, 300 samples per
the appropriate time and distance allowed for work day; gamma, 3,000 samples per day.
near a radiation source. PPE can, however, protect Step 2. Identify and quantify specific
the responder from internal or external radionuclide radionuclides:
contamination. The need for such equipment will • Goal: 22 radionuclides (current capability:
vary, depending on the type of radiological or nuclear eight radionuclides).
event. CDC’s National Institute for Occupational • Specific radionuclide assays.
Safety and Health (NIOSH) and other organizations • Throughput: 300 samples per day.
have prepared guidance in the selection of appropriate Sample requirement:
PPE for radioactive environments (6). • 70 mL of urine (spot sample).
Finally, at all times, public health authorities must • All methods in accordance with Clinical
provide the public with information on how to protect Laboratory Improvement Amendments
themselves. The communication needs during any (CLIA) regulations.
radiological event, regardless of size, should not be
underestimated. * Additional information available at http://www.bt.cdc.gov/
radiation/glossary.asp.
Enhancing Laboratory Expertise and
Capacity for Response Response Network (Radiological) at 10 or more state
According to recent surveys by the Association of public health laboratories needs to be established once
Public Health Laboratories and the Conference of resources become available. The effort should include
Radiation Control Program Directors, state public equipment, personnel, supplies, training, technology
health laboratories currently have no rapid methods transfer, and ongoing performance evaluation.
for analyzing clinical samples (7). Such bioassays
are critical for 1) defining baseline contamination, Ensuring Strong Partnerships in All Phases
2) identifying persons with post-event internal con- of Response
tamination, 3) estimating radiation dose, 4) directing In an emergency setting, the public health system
short- and long-term medical care, and 5) support- has the flexibility to reach from federal to state to local
ing epidemiologic assessments. In response to this authorities to ensure that the health system response
shortage, CDC is developing rapid urine bioassays to is integrated with a broader national response to an
detect 22 radionuclides; these bioassays will include event (including responses related to transporta-
both traditional radiation counting technologies and tion, commerce, agriculture, and the environment).
mass spectrometry analytical methods (Box 2).† To National planners must develop broad partnerships to
develope the needed surge capacity, a Laboratory integrate radiological and nuclear preparedness into
† Bioassays are analytical technologies that detect the type and amount overall national preparedness, including 1) develop-
of radionuclides in a urine sample to determine the amount of ing a national concept of operations (CONOPS) for
internal radionuclide contamination that a person has received during post-event monitoring of exposed persons and vali-
a radiological or nuclear incident. Traditional counting technologies
include liquid scintillation counting to detect alpha- and beta- dating that concept with stakeholders, 2) defining the
emitting radionuclides, alpha spectrometry to detect alpha-emitting resources needed to meet monitoring needs, and 3)
radionuclides, and gamma spectrometry to detect gamma-emitting
radionuclides in urine. Mass spectrometry technologies detect the actual
using the CONOPS to drive interagency collabora-
number of radionuclide atoms instead of the alpha, beta, or gamma tions with partners, including the Federal Radiological
emissions. Additional information, including a glossary of terms, is Preparedness Coordinating Committee, the U.S.
available at http://www.bt.cdc.gov/radiation/glossary.asp.

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 MMWR Morbidity and Mortality Weekly Report

Department of Defense, the U.S. Department of References

Energy, the U.S. Environmental Protection Agency, 1. US Department of Homeland Security. National response
the Food and Drug Administration, and the U.S. framework, January 2008. Washington, DC: US Department
of Homeland Security, Federal Emergency Management
Department of Agriculture. Agency; 2008. Available at http://www.fema.gov/pdf/
Radiological preparedness activities can be funded emergency/nrf/nrf-core.pdf. Accessed September 9, 2010.
through various mechanisms, including the U.S. 2. CDC. Radiation emergencies. Atlanta, GA: US Department of
Health and Human Services, CDC; 2010. Available at http://
Department of Homeland Security’s Urban Areas emergency.cdc.gov/radiation. Accessed September 9, 2010.
Security Initiative Grants, CDC’s Public Health 3. National Institutes of Health, National Library of Medicine.
Preparedness Grants, the U.S. Department of Health Radiation Event Medical Management (REMM). Available at
and Human Services’ Health Preparedness Program, http://remm.nlm.gov. Accessed September 9, 2010.
4. CDC. Population monitoring in radiation emergencies: a
and professional organizations such as the Conference guide for state and local public health planners. Atlanta, GA:
of Radiation Control Program Directors. Funding US Department of Health and Human Services, CDC; 2007.
and planning resources also might be available from Available at http://emergency.cdc.gov/radiation/pdf/population-
monitoring-guide.pdf. Accessed September 9, 2010.
neighboring regional or state programs. 5. CDC. Guidelines for handling decedents contaminated
Finally, radiological response planning should be with radioactive materials. Atlanta, GA: US Department
part of all-hazards preparedness. Real-life and exercise of Health and Human Services, CDC; 2007. Available at
http://emergency.cdc.gov/radiation/pdf/radiation-decedent-
experience can be used to strengthen coordination guidelines.pdf. Accessed September 9, 2010.
and performance and to define gaps that can be filled 6. CDC. Attention emergency responders: guidance on
through corrective actions. emergency responder personal protective equipment (PPE) for
response to CBRN terrorism incidents. Cincinnati, OH: US
Reported by Department of Health and Human Services, CDC, National
Institute for Occupational Safety and Health; 2008. Available
S Deitchman, MD, C Miller, PhD, RL Jones, PhD, at http://www.cdc.gov/niosh/docs/2008-132/pdfs/2008-132.
RC Whitcomb Jr, PhD, JB Nemhauser, MD, National pdf. Accessed September 9, 2010.
Center for Environmental Health; J Halpin, MD, 7. Association of Public Health Laboratories. 2009 APHL All-
Hazards Laboratory Preparedness Survey data. Silver Spring,
National Institute for Occupational Safety and Health; MD: Association of Public Health Laboratories; 2010. Available
D Sosin, MD, Office of Public Health Preparedness and at http://www.aphl.org/aphlprograms/ep/ahr/documents/
Response; T Popovic, MD, PhD, Office of the Director, aphlallhazwhitepaperepr.pdf. Accessed September 14, 2010.
CDC. K Uranek, MD, New York City Dept of Health
and Mental Hygiene, New York.

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 MMWR Morbidity and Mortality Weekly Report

Notes from the Field

Transplant-Transmitted Balamuthia This is the second confirmed cluster of transplant-
mandrillaris — Arizona, 2010 transmitted Balamuthia granulomatous amebic
encephalitis (GAE). The first occurred in 2009 in
On August 23, 2010, CDC was notified regarding
two recipients of kidneys from a common donor
two organ transplant recipients in Arizona who had
(1). Balamuthia GAE is a rare and frequently fatal
encephalitis with multiple ring-enhancing lesions
disease caused by B. mandrillaris, a free-living ameba
revealed by cerebral magnetic resonance imaging. The
found in soil (2,3). Persons of Hispanic ethnicity
common organ donor, a Hispanic male landscaper
might be disproportionately affected (2,3). Patients
aged 27 years, had died in Arizona from a presumed
can have skin lesions months to years before having
stroke on July 21. He had a large skin lesion for
encephalitis symptoms. No optimal treatment has
approximately 6 months on his back that he had
been identified; among patients treated with com-
attributed to an insect bite. The ill recipients, a male
bination antimicrobial therapy, few have survived
liver recipient aged 56 years, and a male recipient of
(1–3). Amebic encephalitis might be more common
a kidney and pancreas aged 24 years, received organ
than previously thought and underdiagnosed among
transplants on July 22. In addition, two other recipi-
organ donors with encephalitis of uncertain etiology
ents received organs from this donor: an adult male
or other neurologic conditions.*
heart recipient received his transplant in California on
July 22, and an adult male kidney recipient received * Additional information available at http://www.cdc.gov/
his transplant in Utah on July 23. balamuthia.
On August 8, the liver recipient had onset of Reported by
diplopia and difficulty walking; he was hospitalized on Arizona Dept of Health Svcs. Div of Healthcare Quality
August 9 and died on August 17. The kidney-pancreas Promotion, Div of High-Consequence Pathogens and
recipient had onset of headache, nausea, and vomiting Pathology, Div of Foodborne, Waterborne, and Envi-
on August 15 and was hospitalized the same day. A ronmental Diseases, National Center for Emerging and
brain biopsy, performed on August 23, demonstrated Zoonotic Infectious Diseases; Div of Parasitic Diseases
amebic encephalitis on histopathologic examination; and Malaria, Center for Global Health; C Mbaeyi,
empiric therapy was initiated on August 24. On August BDS, EIS Officer, CDC.
26, Balamuthia mandrillaris antigens were identified
in the brain biopsy from the kidney-pancreas recipi- References
ent and in postmortem brain and liver tissue from the 1. CDC. Balamuthia mandrillaris transmitted through
organ transplantation—Mississippi, 2009. MMWR
liver recipient, using immunohistochemical staining. 2010;59:1165–70.
B. mandrillaris DNA was detected in the brain tissue 2. Schuster FL, Visvesvara GS. Balamuthia mandrillaris. In:
from both patients by real-time polymerase chain reac- Emerging protozoan pathogens. Khan NA, ed. London,
tion on August 27. The kidney-pancreas recipient died England: Taylor and Francis Group; 2008:71–118.
3. Schuster FL, Yagi S, Gavali S, et al. Under the radar: Balamuthia
on August 30. The heart and kidney recipients, who amebic encephalitis. Clin Infect Dis 2009;48:879–87.
have been asymptomatic, were placed on preemptive
therapy on August 26.

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 MMWR Morbidity and Mortality Weekly Report

Announcements
National Child Passenger Safety Week — Environmental Microbiology: Control
September 19–25, 2010 of Foodborne and Waterborne Diseases
Motor vehicle crashes are a leading cause of death Course — January 5–8 and 10, 2011
and injury among children. National Child Passenger CDC and Emory University's Rollins School
Safety Week, September 19–25, 2010, highlights the of Public Health will cosponsor a 4.5-day course,
importance of ensuring that all child passengers ride in Environmental Microbiology: Control of Foodborne
correctly installed, age- and size-appropriate restraints. and Waterborne Diseases, January 5–8 and 10, 2011,
Although most children use child safety seats or at Emory University, Rollins School of Public Health in
seat belts, results from CDC’s Second Injury Control Atlanta, Georgia. This course on surveillance of food-
and Risk Survey (ICARIS-2), a nationally representa- borne and waterborne diseases is designed for public
tive survey conducted from July 23, 2001, through health practitioners and persons interested in the safety of
February 7, 2003, estimated that approximately food and water. The course will provide a broad overview
600,000 U.S. children aged ≤12 years rode unre- of the major foodborne and waterborne diseases.
strained at least some of the time during a 30-day Course attendees will learn how information
period. In addition, an estimated 8 million children from surveillance is used to improve public health
aged ≤7 years used only adult seat belts during the policy and practice to safeguard food and water.
same period, despite their increased risk for abdomi- Course discussion will focus on the microorganisms
nal, spinal cord, and brain injuries from poor-fitting and chemical agents responsible for food and water-
seat belts (1,2). The National Highway Traffic Safety transmitted diseases, including pathogenesis, clinical
Administration (NHTSA) and CDC recommend the manifestations, reservoirs, modes of transmission, and
use of appropriate car or booster seats up to at least surveillance systems. Transport, survival, and fate of
age 8 years or 57 inches tall (3,4). Greater effort is pathogens in the environment, indicator organisms
needed to ensure that parents correctly restrain their as surrogates for pathogens, and the removal and
children on every trip. inactivation of pathogens and indicators by water and
Information about National Child Passenger Safety wastewater treatment processes also will be discussed.
Week activities and child passenger safety is available Additional topics covered during the course will
from NHTSA at http://www.nhtsa.gov/Safety/CPS include the public health impact of quality assurance
and from CDC at http://www.cdc.gov/motorvehi- programs, such as hazard analysis and critical control
clesafety/child_passenger_safety/childseat-spot.html. points, in controlling foodborne and waterborne dis-
References eases in industrialized and developing countries.
1. Greenspan AI, Dellinger AM, Chen J. Restraint use and seating
This course is offered to Emory University stu-
position among children less than 13 years of age: is it still a dents and to public health professionals. Continuing
problem? J Safety Res 2010;41:183–5. Education credit is available. Tuition will be charged.
2. Winston FK, Durbin DR, Kallan MJ, Moll EK. The danger The application deadline is December 5, 2010, or
of premature graduation to seat belts for young children.
Pediatrics 2000;105:1179–83. until all slots have been filled. Additional informa-
3. National Highway Traffic Safety Administration. Child safety. tion and applications are available by mail (Emory
4 easy steps to protect our children. Washington, DC: National University, Hubert Department of Global Health
Highway Traffic Safety Administration; 2010. Available at
http://www.nhtsa.gov/Safety/CPS. Accessed September 8, [Attn: Pia], 1518 Clifton Rd. NE, CNR Bldg., Rm.
2010. 7038, Atlanta, GA 30322); telephone (404-727-
4. CDC. Protect the ones you love: road traffic injuries. Atlanta, 3485); fax (404-727-4590); Internet (http://www.
GA: US Department of Health and Human Services, CDC;
2010. Available at http://www.cdc.gov/safechild/road_traffic_
sph.emory.edu/epicourses), or e-mail (pvaleri@emory.
injuries. Accessed September 8, 2010. edu).

MMWR / September 17, 2010 / Vol. 59 / No. 36 1183

 MMWR Morbidity and Mortality Weekly Report

Errata
Vol. 59, No. RR-9 Vol. 59, No. 20 
In the report “Use of World Health Organization In the report “FDA Licensure of Bivalent
and CDC Growth Charts for Children Aged 0–59 Human Papillomavirus Vaccine (HPV2, Cervarix)
Months in the United States,” errors occurred in for Use in Females and Updated HPV Vaccination
Figures 4 and 5 on pages 10 and 11. The y axis of Recommendations from the Advisory Committee on
each figure should read Length (cm). Immunization Practices (ACIP),” the second footnote
under Table 2 should read as follows: “Phase III trial.
According to protocol efficacy analysis included
females aged 15 through 25 years who received all 3
vaccine doses, were seronegative at day 1 and HPV
DNA negative at day 1 through month 6 for the
respective HPV type, and had normal or low grade
cytology at day 1, with case counting beginning 1 day
after third vaccine dose; mean duration of follow-up
post third vaccine dose: 34.9 months.”

1184 MMWR / September 17, 2010 / Vol. 59 / No. 36

 MMWR Morbidity and Mortality Weekly Report

QuickStats
from the national center for health statistics

Life Expectancy at Birth, by Race* and Sex — United States, 1970–2007

85

80

75
Life expectancy (yrs)

70

65

60 White female
Black female
White male
55 Black male
Overall

0
1970 1973 1976 1979 1982 1985 1988 1991 1994 1997 2000 2003 2006

Year

* Includes Hispanics and non-Hispanics.

During 1970–2007, life expectancy at birth in the United States demonstrated a long-term increasing trend for the total popula-
tion, for both males and females, and for the black and white populations. In 2007, the disparities in life expectancy for males
compared with females and for blacks compared with whites were the smallest ever recorded. Life expectancy at birth was
highest for white females (80.8 years), followed by black females (76.8), white males (75.9), and black males (70.0).
Source: Xu J, Kochanek KD, Murphy SL, Tejada-Vera B. Deaths: final data for 2007. Natl Vital Stat Rep 2010;58(19). Available at http://www.cdc.
gov/nchs/data/nvsr/nvsr58/nvsr58_19.pdf.

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 MMWR Morbidity and Mortality Weekly Report

Notifiable Diseases and Mortality Tables

TABLE I. Provisional cases of infrequently reported notifiable diseases (<1,000 cases reported during the preceding year) — United States, week ending
September 11, 2010 (36th week)*
Total cases reported
5-year
for previous years
Current Cum weekly States reporting cases
Disease week 2010 average† 2009 2008 2007 2006 2005 during current week (No.)
Anthrax — — 0 1 — 1 1 —
Botulism, total — 59 3 118 145 144 165 135
foodborne — 5 1 10 17 32 20 19
infant — 42 2 83 109 85 97 85
other (wound and unspecified) — 12 1 25 19 27 48 31
Brucellosis 3 85 2 115 80 131 121 120 NY (1), FL (2)
Chancroid 1 32 0 28 25 23 33 17 TX (1)
Cholera — 5 0 10 5 7 9 8
§
Cyclosporiasis 2 130 2 141 139 93 137 543 FL (1), OK (1)
Diphtheria — — — — — — — —
§¶
Domestic arboviral diseases , :
California serogroup virus disease — 25 4 55 62 55 67 80
Eastern equine encephalitis virus disease — 10 1 4 4 4 8 21
Powassan virus disease — 2 0 6 2 7 1 1
St. Louis encephalitis virus disease — 3 1 12 13 9 10 13
Western equine encephalitis virus disease — — — — — — — —
Haemophilus influenzae,** invasive disease (age <5 yrs):
serotype b — 10 0 35 30 22 29 9
nonserotype b — 129 2 236 244 199 175 135
unknown serotype — 154 2 178 163 180 179 217
Hansen disease§ — 29 2 103 80 101 66 87
§
Hantavirus pulmonary syndrome — 15 1 20 18 32 40 26
§
Hemolytic uremic syndrome, postdiarrheal 2 130 8 242 330 292 288 221 NE (1), MD (1)
††
HIV infection, pediatric (age <13 yrs) — — 1 — — — — 380
§ §§
Influenza-associated pediatric mortality , — 56 1 358 90 77 43 45
Listeriosis 10 530 23 851 759 808 884 896 PA (1), OH (1), FL (3), WA (1), CA (4)
¶¶
Measles — 49 1 71 140 43 55 66
Meningococcal disease, invasive***:
A, C, Y, and W-135 — 175 4 301 330 325 318 297
serogroup B 1 79 2 174 188 167 193 156 TX (1)
other serogroup — 7 0 23 38 35 32 27
unknown serogroup 3 268 8 482 616 550 651 765 FL (3)
Mumps 7 2,333 15 1,991 454 800 6,584 314 MI (1), TX (6)
†††
Novel influenza A virus infections — 1 0 43,774 2 4 NN NN
Plague — 1 0 8 3 7 17 8
Poliomyelitis, paralytic — — — 1 — — — 1
§
Polio virus Infection, nonparalytic — — — — — — NN NN
§
Psittacosis — 4 0 9 8 12 21 16
§ §§§
Q fever, total , 2 80 3 114 120 171 169 136
acute 2 62 1 94 106 — — — CA (2)
chronic — 18 0 20 14 — — —
Rabies, human — — 0 4 2 1 3 2
¶¶¶
Rubella — 5 0 3 16 12 11 11
Rubella, congenital syndrome — — — 2 — — 1 1
SARS-CoV§,**** — — — — — — — —
Smallpox§ — — — — — — — —
§
Streptococcal toxic-shock syndrome 1 123 1 161 157 132 125 129 CT (1)
††††
Syphilis, congenital (age <1 yr) — 136 9 423 431 430 349 329
Tetanus — 5 1 18 19 28 41 27
§
Toxic-shock syndrome (staphylococcal) 1 58 2 74 71 92 101 90 MI (1)
Trichinellosis — 2 0 13 39 5 15 16
Tularemia 2 68 3 93 123 137 95 154 IN (1), WA (1)
Typhoid fever 1 255 13 397 449 434 353 324 CA (1)
§
Vancomycin-intermediate Staphylococcus aureus 2 64 1 78 63 37 6 2 MO (2)
§
Vancomycin-resistant Staphylococcus aureus — 1 — 1 — 2 1 3
§
Vibriosis (noncholera Vibrio species infections) 27 493 15 789 588 549 NN NN OH (1), MD (4), VA (1), GA (3), FL (2), WA (11), CA (5)
Viral hemorrhagic fever§§§§ — 1 — NN NN NN NN NN
Yellow fever — — — — — — — —

See Table I footnotes on next page.

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 MMWR Morbidity and Mortality Weekly Report

TABLE I. (Continued) Provisional cases of infrequently reported notifiable diseases (<1,000 cases reported during the preceding year) — United States, week
ending September 11, 2010 (36th week)*
—: No reported cases. N: Not reportable. NN: Not Nationally Notifiable Cum: Cumulative year-to-date counts.
* Incidence data for reporting years 2009 and 2010 are provisional, whereas data for 2005 through 2008 are finalized.
† Calculated by summing the incidence counts for the current week, the 2 weeks preceding the current week, and the 2 weeks following the current week, for a total of 5 preceding years.
Additional information is available at http://www.cdc.gov/ncphi/disss/nndss/phs/files/5yearweeklyaverage.pdf.
§ Not reportable in all states. Data from states where the condition is not reportable are excluded from this table except starting in 2007 for the domestic arboviral diseases, STD data, TB
data, and influenza-associated pediatric mortality, and in 2003 for SARS-CoV. Reporting exceptions are available at http://www.cdc.gov/ncphi/disss/nndss/phs/infdis.htm.
¶ Includes both neuroinvasive and nonneuroinvasive. Updated weekly from reports to the Division of Vector-Borne Infectious Diseases, National Center for Zoonotic, Vector-Borne, and
Enteric Diseases (ArboNET Surveillance). Data for West Nile virus are available in Table II.
** Data for H. influenzae (all ages, all serotypes) are available in Table II.
††
Updated monthly from reports to the Division of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention. Implementation of HIV reporting influences
the number of cases reported. Updates of pediatric HIV data have been temporarily suspended until upgrading of the national HIV/AIDS surveillance data management system is
completed. Data for HIV/AIDS, when available, are displayed in Table IV, which appears quarterly.
§§
Updated weekly from reports to the Influenza Division, National Center for Immunization and Respiratory Diseases. Since April 26, 2009, a total of 286 influenza-associated pediatric
deaths associated with 2009 influenza A (H1N1) virus infection have been reported. Since August 30, 2009, a total of 281 influenza-associated pediatric deaths occurring during the
2009–10 influenza season have been reported. A total of 133 influenza-associated pediatric deaths occurring during the 2008-09 influenza season have been reported.
¶¶
No measles cases were reported for the current week.
*** Data for meningococcal disease (all serogroups) are available in Table II.
††† CDC discontinued reporting of individual confirmed and probable cases of 2009 pandemic influenza A (H1N1) virus infections on July 24, 2009. During 2009, three cases of novel
influenza A virus infections, unrelated to the 2009 pandemic influenza A (H1N1) virus, were reported to CDC. The one case of novel influenza A virus infection reported to CDC during
2010 was identified as swine influenza A (H3N2) virus and is unrelated to pandemic influenza A (H1N1) virus. Total case count for 2009 was provided by the Influenza Division, National
Center for Immunization and Respiratory Diseases (NCIRD).
§§§
In 2009, Q fever acute and chronic reporting categories were recognized as a result of revisions to the Q fever case definition. Prior to that time, case counts were not differentiated with
respect to acute and chronic Q fever cases.
¶¶¶ No rubella cases were reported for the current week.
**** Updated weekly from reports to the Division of Viral and Rickettsial Diseases, National Center for Zoonotic, Vector-Borne, and Enteric Diseases.
†††† Updated weekly from reports to the Division of STD Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention.
§§§§ There was one case of viral hemorrhagic fever reported during week 12. The one case report was confirmed as lassa fever. See Table II for dengue hemorrhagic fever.

FIGURE I. Selected notifiable disease reports, United States, comparison of provisional 4-week
totals September 11, 2010, with historical data

CASES CURRENT
DISEASE DECREASE INCREASE 4 WEEKS

Giardiasis 946

Hepatitis A, acute 81

Hepatitis B, acute 134

Hepatitis C, acute 40

Legionellosis 180

Measles 8

Meningococcal disease 25

Mumps 20

Pertussis 1,119

0.25 0.5 1 2 4

Ratio (Log scale)*

Beyond historical limits

* Ratio of current 4-week total to mean of 15 4-week totals (from previous, comparable, and subsequent 4-week periods for the
past 5 years). The point where the hatched area begins is based on the mean and two standard deviations of these 4-week
totals.

Notifiable Disease Data Team and 122 Cities Mortality Data Team
Patsy A. Hall-Baker
Deborah A. Adams Rosaline Dhara
Willie J. Anderson Pearl C. Sharp
Michael S. Wodajo Lenee Blanton

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 MMWR Morbidity and Mortality Weekly Report

TABLE II. Provisional cases of selected notifiable diseases, United States, weeks ending September 11, 2010, and September 12, 2009 (36th week)*
Chlamydia trachomatis infection Cryptosporidiosis

Current Previous 52 weeks Cum Cum Current Previous 52 weeks Cum Cum
Reporting area week Med Max 2010 2009 week Med Max 2010 2009
United States 10,836 22,757 26,114 793,792 869,576 127 122 272 5,032 5,026
New England 581 740 1,396 26,889 27,981 3 8 60 309 326
Connecticut — 221 736 6,617 7,977 — 0 54 54 38
Maine† 67 50 75 1,764 1,683 1 1 7 61 36
Massachusetts 352 396 638 13,664 13,453 — 3 10 91 134
New Hampshire 60 40 116 1,636 1,487 1 1 5 42 61
Rhode Island† 95 65 120 2,377 2,578 — 0 8 9 8
Vermont† 7 23 63 831 803 1 1 9 52 49
Mid. Atlantic 2,119 3,199 4,619 115,761 108,699 16 15 37 564 566
New Jersey — 455 698 16,750 17,051 — 0 3 — 41
New York (Upstate) 517 674 2,530 23,435 20,955 9 3 16 149 143
New York City 1,103 1,194 2,144 43,345 40,425 — 1 5 52 65
Pennsylvania 499 890 1,091 32,231 30,268 7 9 26 363 317
E.N. Central 688 3,511 4,413 118,534 140,380 24 30 101 1,308 1,230
Illinois 11 840 1,322 24,746 42,895 — 3 15 136 116
Indiana — 336 786 12,781 16,483 — 4 10 133 206
Michigan 431 892 1,417 33,272 32,258 — 5 15 233 196
Ohio 82 964 1,077 33,455 34,067 15 7 24 326 285
Wisconsin 164 405 494 14,280 14,677 9 10 47 480 427
W.N. Central 342 1,330 1,592 45,959 49,668 35 24 61 902 746
Iowa 4 186 293 6,753 6,823 — 4 20 218 159
Kansas 17 187 235 6,502 7,618 — 2 9 100 73
Minnesota — 273 337 9,380 10,051 — 2 30 98 190
Missouri 181 489 606 16,811 18,128 19 4 24 253 141
Nebraska† 123 93 237 3,372 3,774 16 2 16 151 77
North Dakota — 33 93 1,083 1,171 — 0 18 16 7
South Dakota 17 60 82 2,058 2,103 — 2 7 66 99
S. Atlantic 3,216 4,499 5,681 157,071 177,111 15 19 51 720 755
Delaware 76 85 156 2,906 3,285 — 0 2 5 6
District of Columbia 94 97 177 3,386 4,938 — 0 1 2 5
Florida 709 1,402 1,661 51,089 51,825 8 8 24 270 270
Georgia 376 395 1,323 12,198 28,470 — 5 31 216 262
Maryland† 64 454 1,031 15,735 15,644 2 1 3 29 32
North Carolina 688 797 1,562 28,993 29,392 2 1 12 55 78
South Carolina† 515 523 692 18,678 19,213 3 1 8 62 43
Virginia† 603 594 902 21,531 21,787 — 2 8 69 49
West Virginia 91 68 137 2,555 2,557 — 0 2 12 10
E.S. Central 398 1,694 2,415 60,285 66,108 — 4 15 187 152
Alabama† 233 481 665 17,626 18,950 — 1 8 80 47
Kentucky — 290 642 10,563 9,190 — 1 6 56 40
Mississippi — 389 780 12,622 16,928 — 0 3 10 15
Tennessee† 165 572 732 19,474 21,040 — 1 5 41 50
W.S. Central 1,669 2,857 4,578 103,173 113,874 8 8 39 254 367
Arkansas† 297 238 402 7,552 10,017 3 1 4 25 36
Louisiana — 0 1,055 2,922 20,378 — 1 5 34 37
Oklahoma 221 261 1,376 11,051 10,154 — 1 9 61 83
Texas† 1,151 2,220 3,201 81,648 73,325 5 4 30 134 211
Mountain 375 1,432 2,081 47,495 54,226 12 10 23 372 402
Arizona 175 457 713 13,370 18,077 2 0 3 25 25
Colorado 9 380 709 12,365 12,406 5 2 8 98 106
Idaho† 4 64 191 2,184 2,563 — 2 6 63 64
Montana† — 58 75 2,031 2,108 3 1 4 36 44
Nevada† — 175 337 6,564 7,191 — 0 2 15 15
New Mexico† 163 172 453 5,465 6,221 — 2 8 72 103
Utah 8 117 175 4,146 4,317 2 1 4 50 30
Wyoming† 16 38 78 1,370 1,343 — 0 2 13 15
Pacific 1,448 3,439 5,350 118,625 131,529 14 12 28 416 482
Alaska — 107 147 4,002 3,717 — 0 1 2 5
California 1,158 2,736 4,406 95,946 100,735 9 8 19 239 275
Hawaii — 112 158 3,833 4,270 — 0 0 — 1
Oregon — 0 468 1,367 7,592 3 2 9 115 146
Washington 290 393 497 13,477 15,215 2 1 8 60 55
Territories
American Samoa — 0 0 — — N 0 0 N N
C.N.M.I. — — — — — — — — — —
Guam — 4 31 179 269 — 0 0 — —
Puerto Rico 56 95 265 3,650 5,273 N 0 0 N N
U.S. Virgin Islands — 10 29 323 371 — 0 0 — —
C.N.M.I.: Commonwealth of Northern Mariana Islands.
U: Unavailable. —: No reported cases. N: Not reportable. NN: Not Nationally Notifiable. Cum: Cumulative year-to-date counts. Med: Median. Max: Maximum.
* Incidence data for reporting years 2009 and 2010 are provisional. Data for HIV/AIDS, AIDS, and TB, when available, are displayed in Table IV, which appears quarterly.
† Contains data reported through the National Electronic Disease Surveillance System (NEDSS).

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 MMWR Morbidity and Mortality Weekly Report

TABLE II. (Continued) Provisional cases of selected notifiable diseases, United States, weeks ending September 11, 2010, and September 12, 2009 (36th week)*
Dengue Virus Infection
Dengue Fever† Dengue Hemorrhagic Fever§

Current Previous 52 weeks Cum Cum Current Previous 52 weeks Cum Cum
Reporting area week Med Max 2010 2009 week Med Max 2010 2009
United States — 3 24 270 NN — 0 1 2 NN
New England — 0 2 4 NN — 0 0 — NN
Connecticut — 0 0 — NN — 0 0 — NN
Maine¶ — 0 2 3 NN — 0 0 — NN
Massachusetts — 0 0 — NN — 0 0 — NN
New Hampshire — 0 0 — NN — 0 0 — NN
Rhode Island¶ — 0 0 — NN — 0 0 — NN
Vermont¶ — 0 1 1 NN — 0 0 — NN
Mid. Atlantic — 0 9 73 NN — 0 0 — NN
New Jersey — 0 0 — NN — 0 0 — NN
New York (Upstate) — 0 0 — NN — 0 0 — NN
New York City — 0 7 62 NN — 0 0 — NN
Pennsylvania — 0 2 11 NN — 0 0 — NN
E.N. Central — 0 2 22 NN — 0 0 — NN
Illinois — 0 0 — NN — 0 0 — NN
Indiana — 0 2 7 NN — 0 0 — NN
Michigan — 0 1 4 NN — 0 0 — NN
Ohio — 0 2 8 NN — 0 0 — NN
Wisconsin — 0 1 3 NN — 0 0 — NN
W.N. Central — 0 3 14 NN — 0 0 — NN
Iowa — 0 1 1 NN — 0 0 — NN
Kansas — 0 0 — NN — 0 0 — NN
Minnesota — 0 2 10 NN — 0 0 — NN
Missouri — 0 1 3 NN — 0 0 — NN
Nebraska¶ — 0 0 — NN — 0 0 — NN
North Dakota — 0 0 — NN — 0 0 — NN
South Dakota — 0 0 — NN — 0 0 — NN
S. Atlantic — 1 15 137 NN — 0 1 1 NN
Delaware — 0 0 — NN — 0 0 — NN
District of Columbia — 0 0 — NN — 0 0 — NN
Florida — 1 14 119 NN — 0 1 1 NN
Georgia — 0 2 7 NN — 0 0 — NN
Maryland¶ — 0 0 — NN — 0 0 — NN
North Carolina — 0 1 1 NN — 0 0 — NN
South Carolina¶ — 0 3 8 NN — 0 0 — NN
Virginia¶ — 0 0 — NN — 0 0 — NN
West Virginia — 0 1 2 NN — 0 0 — NN
E.S. Central — 0 1 1 NN — 0 0 — NN
Alabama¶ — 0 0 — NN — 0 0 — NN
Kentucky — 0 0 — NN — 0 0 — NN
Mississippi — 0 0 — NN — 0 0 — NN
Tennessee¶ — 0 1 1 NN — 0 0 — NN
W.S. Central — 0 1 1 NN — 0 1 1 NN
Arkansas¶ — 0 0 — NN — 0 1 1 NN
Louisiana — 0 0 — NN — 0 0 — NN
Oklahoma — 0 1 1 NN — 0 0 — NN
Texas¶ — 0 0 — NN — 0 0 — NN
Mountain — 0 1 9 NN — 0 0 — NN
Arizona — 0 1 2 NN — 0 0 — NN
Colorado — 0 0 — NN — 0 0 — NN
Idaho¶ — 0 0 — NN — 0 0 — NN
Montana¶ — 0 1 2 NN — 0 0 — NN
Nevada¶ — 0 1 4 NN — 0 0 — NN
New Mexico¶ — 0 1 1 NN — 0 0 — NN
Utah — 0 0 — NN — 0 0 — NN
Wyoming¶ — 0 0 — NN — 0 0 — NN
Pacific — 0 2 9 NN — 0 0 — NN
Alaska — 0 0 — NN — 0 0 — NN
California — 0 1 4 NN — 0 0 — NN
Hawaii — 0 0 — NN — 0 0 — NN
Oregon — 0 0 — NN — 0 0 — NN
Washington — 0 2 5 NN — 0 0 — NN
Territories
American Samoa — 0 0 — NN — 0 0 — NN
C.N.M.I. — — — — NN — — — — NN
Guam — 0 0 — NN — 0 0 — NN
Puerto Rico — 84 481 5,798 NN — 0 3 28 NN
U.S. Virgin Islands — 0 0 — NN — 0 0 — NN
C.N.M.I.: Commonwealth of Northern Mariana Islands.
U: Unavailable. —: No reported cases. N: Not reportable. NN: Not Nationally Notifiable. Cum: Cumulative year-to-date counts. Med: Median. Max: Maximum.
* Incidence data for reporting years 2009 and 2010 are provisional.
† Dengue Fever includes cases that meet criteria for Dengue Fever with hemorrhage, other clinical, and unknown case classifications.
§ DHF includes cases that meet criteria for dengue shock syndrome (DSS), a more severe form of DHF.
¶ Contains data reported through the National Electronic Disease Surveillance System (NEDSS).

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 MMWR Morbidity and Mortality Weekly Report

TABLE II. (Continued) Provisional cases of selected notifiable diseases, United States, weeks ending September 11, 2010, and September 12, 2009 (36th week)*
Ehrlichiosis/Anaplasmosis†
Ehrlichia chaffeensis Anaplasma phagocytophilum Undetermined

Current Previous 52 weeks Cum Cum Current

Previous 52 weeks
Cum Cum Current
Previous 52 weeks
Cum Cum
Reporting area week Med Max 2010 2009 week Med Max 2010 2009 week Med Max 2010 2009
United States 9 11 181 451 711 8 13 309 454 679 1 2 35 73 141
New England — 0 3 3 38 — 1 17 51 202 — 0 2 7 2
Connecticut — 0 0 — — — 0 13 18 2 — 0 2 5 —
Maine§ — 0 1 2 3 — 0 2 13 12 — 0 0 — —
Massachusetts — 0 0 — 9 — 0 4 — 82 — 0 0 — —
New Hampshire — 0 1 1 3 — 0 3 8 15 — 0 1 2 1
Rhode Island§ — 0 2 — 22 — 0 7 12 91 — 0 0 — 1
Vermont§ — 0 0 — 1 — 0 0 — — — 0 0 — —
Mid. Atlantic 4 1 15 37 128 5 3 17 143 209 1 0 2 4 40
New Jersey — 0 6 — 75 — 0 2 1 60 — 0 0 — —
New York (Upstate) 4 1 15 22 35 5 3 17 139 144 1 0 1 4 4
New York City — 0 3 14 7 — 0 1 3 4 — 0 0 — 1
Pennsylvania — 0 5 1 11 — 0 1 — 1 — 0 1 — 35
E.N. Central — 0 4 22 74 — 2 27 188 241 — 1 4 41 61
Illinois — 0 2 10 32 — 0 1 1 6 — 0 2 3 3
Indiana — 0 0 — — — 0 0 — — — 0 3 23 33
Michigan — 0 1 1 4 — 0 0 — — — 0 1 2 —
Ohio — 0 3 5 10 — 0 1 1 1 — 0 0 — 2
Wisconsin — 0 3 6 28 — 2 27 186 234 — 0 3 13 23
W.N. Central 1 2 13 108 133 — 0 261 8 7 — 0 30 11 16
Iowa — 0 0 — — — 0 0 — — — 0 0 — —
Kansas — 0 1 6 6 — 0 0 — 1 — 0 0 — —
Minnesota — 0 6 — 1 — 0 261 — 3 — 0 30 — 3
Missouri 1 1 13 101 124 — 0 3 8 2 — 0 3 11 13
Nebraska§ — 0 1 1 2 — 0 0 — 1 — 0 0 — —
North Dakota — 0 0 — — — 0 0 — — — 0 0 — —
South Dakota — 0 0 — — — 0 0 — — — 0 0 — —
S. Atlantic 3 4 19 194 200 3 0 7 46 14 — 0 1 3 2
Delaware — 0 3 16 16 — 0 1 4 2 — 0 0 — —
District of Columbia — 0 0 — — — 0 0 — — — 0 0 — —
Florida — 0 2 8 8 1 0 1 3 3 — 0 0 — —
Georgia — 0 4 15 17 — 0 1 1 1 — 0 1 1 —
Maryland§ — 0 3 18 33 — 0 2 11 3 — 0 1 2 —
North Carolina 2 1 13 75 53 1 0 4 17 3 — 0 0 — —
South Carolina§ — 0 2 3 8 — 0 0 — — — 0 0 — —
Virginia§ 1 1 13 59 64 1 0 2 10 2 — 0 0 — 2
West Virginia — 0 0 — 1 — 0 0 — — — 0 1 — —
E.S. Central 1 1 10 69 106 — 0 2 16 3 — 0 2 6 20
Alabama§ — 0 3 10 6 — 0 2 7 1 — 0 0 — —
Kentucky — 0 2 10 9 — 0 0 — — — 0 0 — —
Mississippi — 0 1 3 6 — 0 1 1 — — 0 0 — —
Tennessee§ 1 1 10 46 85 — 0 2 8 2 — 0 2 6 20
W.S. Central — 0 141 17 29 — 0 23 2 1 — 0 1 1 —
Arkansas§ — 0 34 2 4 — 0 6 — — — 0 0 — —
Louisiana — 0 1 1 — — 0 0 — — — 0 0 — —
Oklahoma — 0 105 11 23 — 0 16 2 1 — 0 0 — —
Texas§ — 0 2 3 2 — 0 1 — — — 0 1 1 —
Mountain — 0 0 — — — 0 0 — — — 0 1 — —
Arizona — 0 0 — — — 0 0 — — — 0 1 — —
Colorado — 0 0 — — — 0 0 — — — 0 0 — —
Idaho§ — 0 0 — — — 0 0 — — — 0 0 — —
Montana§ — 0 0 — — — 0 0 — — — 0 0 — —
Nevada§ — 0 0 — — — 0 0 — — — 0 0 — —
New Mexico§ — 0 0 — — — 0 0 — — — 0 0 — —
Utah — 0 0 — — — 0 0 — — — 0 0 — —
Wyoming§ — 0 0 — — — 0 0 — — — 0 0 — —
Pacific — 0 1 1 3 — 0 0 — 2 — 0 1 — —
Alaska — 0 0 — — — 0 0 — — — 0 0 — —
California — 0 1 1 3 — 0 0 — 2 — 0 1 — —
Hawaii — 0 0 — — — 0 0 — — — 0 0 — —
Oregon — 0 0 — — — 0 0 — — — 0 0 — —
Washington — 0 0 — — — 0 0 — — — 0 0 — —
Territories
American Samoa — 0 0 — — — 0 0 — — — 0 0 — —
C.N.M.I. — — — — — — — — — — — — — — —
Guam — 0 0 — — — 0 0 — — — 0 0 — —
Puerto Rico — 0 0 — — — 0 0 — — — 0 0 — —
U.S. Virgin Islands — 0 0 — — — 0 0 — — — 0 0 — —
C.N.M.I.: Commonwealth of Northern Mariana Islands.
U: Unavailable. —: No reported cases. N: Not reportable. NN: Not Nationally Notifiable. Cum: Cumulative year-to-date counts. Med: Median. Max: Maximum.
* Incidence data for reporting years 2009 and 2010 are provisional.
† Cumulative total E. ewingii cases reported for year 2010 = 10.
§ Contains data reported through the National Electronic Disease Surveillance System (NEDSS).

1190 MMWR / September 17, 2010 / Vol. 59 / No. 36

 MMWR Morbidity and Mortality Weekly Report

TABLE II. (Continued) Provisional cases of selected notifiable diseases, United States, weeks ending September 11, 2010, and September 12, 2009 (36th week)*
Haemophilus influenzae, invasive†
Giardiasis Gonorrhea All ages, all serotypes
Current Previous 52 weeks Cum Cum Current Previous 52 weeks Cum Cum Current Previous 52 weeks Cum Cum
Reporting area week Med Max 2010 2009 week Med Max 2010 2009 week Med Max 2010 2009
United States 223 341 666 11,824 12,613 2,594 5,386 6,656 185,128 211,317 11 59 171 2,022 2,101
New England 16 31 65 993 1,152 69 101 196 3,557 3,329 — 3 21 113 142
Connecticut — 5 15 187 203 — 45 169 1,556 1,530 — 0 15 25 41
Maine§ 12 4 11 145 157 1 3 11 124 95 — 0 2 9 16
Massachusetts — 13 33 393 494 57 42 72 1,540 1,356 — 2 8 58 68
New Hampshire — 3 9 102 144 1 3 7 105 77 — 0 2 8 7
Rhode Island§ — 1 7 35 39 10 5 13 187 241 — 0 1 7 6
Vermont§ 4 4 14 131 115 — 0 17 45 30 — 0 1 6 4
Mid. Atlantic 39 61 112 2,036 2,295 467 672 941 23,844 21,613 — 11 34 398 414
New Jersey — 6 15 192 305 — 98 151 3,552 3,311 — 2 7 58 96
New York (Upstate) 21 23 84 764 844 97 104 422 3,793 3,881 — 3 20 106 101
New York City 9 16 31 585 578 249 226 394 8,369 7,582 — 2 6 80 49
Pennsylvania 9 15 37 495 568 121 217 290 8,130 6,839 — 4 9 154 168
E.N. Central 23 52 92 1,841 1,982 179 971 1,536 32,203 44,782 2 9 20 344 328
Illinois — 11 20 368 437 4 189 441 5,656 14,334 — 2 9 97 125
Indiana — 6 14 191 191 — 91 216 3,578 5,335 — 1 6 65 57
Michigan 1 13 25 447 454 90 247 502 9,294 10,370 — 0 4 25 17
Ohio 19 16 28 577 553 42 315 372 10,576 11,081 2 2 6 85 76
Wisconsin 3 7 22 258 347 43 92 154 3,099 3,662 — 2 5 72 53
W.N. Central 15 26 165 987 1,148 104 273 367 9,324 10,473 2 3 24 119 119
Iowa 4 5 11 202 219 1 32 53 1,140 1,190 — 0 1 1 —
Kansas — 4 8 151 112 2 39 83 1,336 1,805 — 0 2 12 13
Minnesota — 0 135 136 250 — 41 64 1,298 1,622 — 0 17 25 40
Missouri 8 8 15 267 371 67 122 172 4,445 4,577 2 1 6 57 43
Nebraska§ 3 4 9 159 121 31 22 50 792 948 — 0 2 15 18
North Dakota — 0 8 16 8 — 2 11 76 88 — 0 4 9 5
South Dakota — 1 10 56 67 3 6 16 237 243 — 0 0 — —
S. Atlantic 44 75 143 2,594 2,468 930 1,296 1,651 45,557 52,739 6 14 27 543 575
Delaware — 0 5 23 18 10 18 34 665 655 — 0 1 5 3
District of Columbia — 1 4 23 46 38 38 65 1,304 1,927 — 0 1 2 2
Florida 35 39 87 1,435 1,316 255 376 466 13,778 15,052 2 3 9 130 178
Georgia — 13 51 485 505 123 148 494 4,263 9,541 — 3 9 131 111
Maryland§ 2 6 12 189 188 16 132 237 4,540 4,234 1 1 6 44 68
North Carolina N 0 0 N N 225 254 596 9,679 10,083 3 2 9 93 68
South Carolina§ 1 3 9 104 71 159 153 230 5,625 5,961 — 2 7 65 55
Virginia§ 6 8 36 312 292 93 163 271 5,355 4,920 — 2 4 57 66
West Virginia — 0 5 23 32 11 8 20 348 366 — 0 5 16 24
E.S. Central — 6 22 171 282 100 473 700 16,404 19,094 1 3 12 122 133
Alabama§ — 4 8 119 141 59 140 217 5,148 5,394 — 0 3 20 33
Kentucky N 0 0 N N — 76 156 2,745 2,668 — 0 2 24 19
Mississippi N 0 0 N N — 111 216 3,526 5,297 — 0 2 10 7
Tennessee§ — 2 18 52 141 41 148 195 4,985 5,735 1 2 10 68 74
W.S. Central 8 8 18 251 346 432 771 1,227 27,491 33,280 — 2 20 92 88
Arkansas§ 5 2 9 81 96 55 73 139 2,297 3,094 — 0 3 12 15
Louisiana 1 3 9 105 138 — 0 343 910 6,625 — 0 3 17 16
Oklahoma 2 2 7 65 112 78 80 359 3,200 3,226 — 1 15 56 54
Texas§ N 0 0 N N 299 573 962 21,084 20,335 — 0 2 7 3
Mountain 19 30 53 1,101 1,150 34 168 266 5,602 6,381 — 5 15 213 188
Arizona 2 3 7 101 142 13 57 109 1,562 2,136 — 2 10 80 61
Colorado 12 13 27 489 344 5 52 127 1,761 1,870 — 1 5 65 53
Idaho§ — 4 9 132 131 — 2 6 61 76 — 0 2 12 3
Montana§ 2 2 11 75 91 — 2 6 78 53 — 0 1 2 1
Nevada§ — 1 10 65 80 — 29 94 1,177 1,256 — 0 2 5 14
New Mexico§ — 1 5 61 96 16 20 41 716 735 — 1 5 28 26
Utah 3 5 12 154 219 — 7 15 222 204 — 0 4 16 27
Wyoming§ — 1 5 24 47 — 1 4 25 51 — 0 2 5 3
Pacific 59 53 133 1,850 1,790 279 579 795 21,146 19,626 — 2 9 78 114
Alaska — 2 7 67 73 — 23 37 859 664 — 0 2 16 13
California 29 33 61 1,167 1,180 238 482 699 17,963 16,152 — 0 4 12 39
Hawaii 2 0 4 21 14 — 13 24 475 434 — 0 2 5 26
Oregon 13 9 15 316 272 — 0 43 106 763 — 1 5 41 33
Washington 15 8 75 279 251 41 48 66 1,743 1,613 — 0 4 4 3
Territories
American Samoa — 0 0 — — — 0 0 — — — 0 0 — —
C.N.M.I. — — — — — — — — — — — — — — —
Guam — 0 1 2 3 — 0 4 20 16 — 0 0 — —
Puerto Rico — 0 7 18 119 3 5 14 182 173 — 0 1 1 4
U.S. Virgin Islands — 0 0 — — — 2 7 78 93 — 0 0 — —
C.N.M.I.: Commonwealth of Northern Mariana Islands.
U: Unavailable. —: No reported cases. N: Not reportable. NN: Not Nationally Notifiable. Cum: Cumulative year-to-date counts. Med: Median. Max: Maximum.
* Incidence data for reporting years 2009 and 2010 are provisional.
† Data for H. influenzae (age <5 yrs for serotype b, nonserotype b, and unknown serotype) are available in Table I.
§ Contains data reported through the National Electronic Disease Surveillance System (NEDSS).

MMWR / September 17, 2010 / Vol. 59 / No. 36 1191

 MMWR Morbidity and Mortality Weekly Report

TABLE II. (Continued) Provisional cases of selected notifiable diseases, United States, weeks ending September 11, 2010, and September 12, 2009 (36th week)*
Hepatitis (viral, acute), by type
A B C
Current Previous 52 weeks Cum Cum Current
Previous 52 weeks
Cum Cum Current
Previous 52 weeks
Cum Cum
Reporting area week Med Max 2010 2009 week Med Max 2010 2009 week Med Max 2010 2009
United States 20 30 69 1,028 1,394 31 59 204 2,056 2,304 7 15 44 572 515
New England 1 2 5 70 79 — 1 5 39 40 — 1 4 24 48
Connecticut 1 0 3 22 17 — 0 2 13 11 — 0 3 17 37
Maine† — 0 1 7 1 — 0 2 11 9 — 0 1 — 1
Massachusetts — 1 4 34 49 — 0 2 8 16 — 0 1 7 9
New Hampshire — 0 1 1 6 — 0 2 5 4 N 0 0 N N
Rhode Island† — 0 4 6 4 U 0 0 U U U 0 0 U U
Vermont† — 0 0 — 2 — 0 1 2 — — 0 0 — 1
Mid. Atlantic 3 4 10 133 197 1 5 10 208 245 2 2 6 75 70
New Jersey — 0 3 11 54 — 1 5 51 74 — 0 2 7 4
New York (Upstate) 1 1 3 39 35 1 1 6 38 39 2 1 4 45 34
New York City 1 1 4 47 61 — 2 4 62 48 — 0 1 — 4
Pennsylvania 1 1 6 36 47 — 1 5 57 84 — 0 3 23 28
E.N. Central 1 4 8 134 221 — 8 14 296 321 1 2 8 101 66
Illinois — 1 3 28 103 — 2 6 61 84 — 0 1 1 4
Indiana — 0 2 15 15 — 1 5 40 50 — 0 2 20 13
Michigan — 1 4 41 51 — 2 6 83 99 1 1 6 66 23
Ohio 1 0 5 28 30 — 2 6 79 70 — 0 1 8 23
Wisconsin — 0 3 22 22 — 1 3 33 18 — 0 1 6 3
W.N. Central — 1 12 51 81 — 2 15 76 96 — 0 11 17 9
Iowa — 0 3 5 26 — 0 2 11 26 — 0 4 1 3
Kansas — 0 2 10 7 — 0 2 4 5 — 0 0 — 1
Minnesota — 0 12 13 14 — 0 13 6 17 — 0 9 9 2
Missouri — 0 2 15 14 — 1 3 44 32 — 0 1 5 —
Nebraska† — 0 4 8 17 — 0 2 10 14 — 0 1 2 2
North Dakota — 0 1 — — — 0 0 — — — 0 1 — —
South Dakota — 0 0 — 3 — 0 1 1 2 — 0 0 — 1
S. Atlantic 9 8 14 251 298 16 16 40 610 637 — 4 7 124 120
Delaware — 0 1 6 3 — 0 2 19 23 U 0 0 U U
District of Columbia — 0 1 1 1 — 0 1 3 9 — 0 1 2 1
Florida 6 3 8 96 128 12 6 11 218 210 — 1 4 41 30
Georgia — 1 3 28 34 — 3 7 103 106 — 0 2 6 29
Maryland† 2 0 4 20 32 — 1 6 42 55 — 0 2 18 17
North Carolina — 0 5 41 33 — 1 15 65 82 — 1 3 33 16
South Carolina† — 1 4 22 42 — 1 4 39 39 — 0 0 — 1
Virginia† 1 1 6 35 24 — 2 14 74 65 — 0 2 10 7
West Virginia — 0 2 2 1 4 0 14 47 48 — 0 5 14 19
E.S. Central — 1 3 30 31 3 7 13 238 231 2 3 7 98 67
Alabama† — 0 1 5 7 — 1 5 43 67 — 0 2 5 5
Kentucky — 0 2 13 7 — 2 7 82 55 1 2 5 67 40
Mississippi — 0 1 2 8 — 1 3 24 21 U 0 0 U U
Tennessee† — 0 2 10 9 3 3 7 89 88 1 1 4 26 22
W.S. Central 1 2 19 81 136 6 10 109 300 397 — 1 14 51 41
Arkansas† — 0 3 — 7 — 1 4 32 50 — 0 1 — 1
Louisiana — 0 2 6 4 — 1 5 32 48 — 0 1 4 6
Oklahoma — 0 3 — 3 5 1 19 66 71 — 0 12 18 10
Texas† 1 2 18 75 122 1 5 87 170 228 — 1 3 29 24
Mountain — 3 8 110 112 — 2 8 85 100 — 1 5 35 36
Arizona — 1 5 50 46 — 0 2 22 36 U 0 0 U U
Colorado — 1 3 25 38 — 0 3 19 19 — 0 2 6 23
Idaho† — 0 2 6 3 — 0 1 6 9 — 0 2 8 2
Montana† — 0 1 4 5 — 0 1 1 — — 0 0 — 1
Nevada† — 0 2 11 8 — 0 3 29 23 — 0 1 3 2
New Mexico† — 0 1 3 7 — 0 1 3 5 — 0 2 8 5
Utah — 0 2 8 3 — 0 1 5 4 — 0 2 10 3
Wyoming† — 0 3 3 2 — 0 0 — 4 — 0 0 — —
Pacific 5 5 16 168 239 5 6 20 204 237 2 1 6 47 58
Alaska — 0 1 1 2 — 0 1 2 2 U 0 2 U U
California 4 4 15 137 188 3 4 17 141 168 — 0 4 21 30
Hawaii — 0 2 1 8 1 0 1 1 5 U 0 0 U U
Oregon — 0 2 14 10 — 1 4 30 29 — 0 3 9 15
Washington 1 0 2 15 31 1 1 4 30 33 2 0 6 17 13
Territories
American Samoa — 0 0 — — — 0 0 — — — 0 0 — —
C.N.M.I. — — — — — — — — — — — — — — —
Guam — 0 6 14 4 — 1 6 30 48 — 0 6 25 33
Puerto Rico — 0 1 3 20 — 0 5 10 21 — 0 0 — —
U.S. Virgin Islands — 0 0 — — — 0 0 — — — 0 0 — —
C.N.M.I.: Commonwealth of Northern Mariana Islands.
U: Unavailable. —: No reported cases. N: Not reportable. NN: Not Nationally Notifiable. Cum: Cumulative year-to-date counts. Med: Median. Max: Maximum.
* Incidence data for reporting years 2009 and 2010 are provisional.
† Contains data reported through the National Electronic Disease Surveillance System (NEDSS).

1192 MMWR / September 17, 2010 / Vol. 59 / No. 36

 MMWR Morbidity and Mortality Weekly Report

TABLE II. (Continued) Provisional cases of selected notifiable diseases, United States, weeks ending September 11, 2010, and September 12, 2009 (36th week)*
Legionellosis Lyme disease Malaria
Current Previous 52 weeks Cum Cum Current
Previous 52 weeks
Cum Cum Current
Previous 52 weeks
Cum Cum
Reporting area week Med Max 2010 2009 week Med Max 2010 2009 week Med Max 2010 2009
United States 41 59 111 1,995 2,274 220 425 2,336 17,759 29,225 18 24 89 904 989
New England 5 3 10 127 151 63 123 376 4,931 10,286 — 1 4 44 43
Connecticut 4 0 3 29 42 4 40 191 1,863 3,545 — 0 1 1 5
Maine† — 0 1 7 6 58 12 76 478 609 — 0 1 5 2
Massachusetts — 1 7 67 77 — 39 127 1,460 4,486 — 1 3 30 27
New Hampshire — 0 3 11 10 1 21 59 859 1,125 — 0 1 2 3
Rhode Island† — 0 3 5 10 — 0 11 36 197 — 0 1 4 3
Vermont† 1 0 2 8 6 — 4 26 235 324 — 0 1 2 3
Mid. Atlantic 16 16 44 492 835 115 180 643 8,647 12,633 3 7 14 235 286
New Jersey — 2 11 47 157 — 43 167 2,028 4,232 — 0 4 1 74
New York (Upstate) 9 5 19 172 247 72 55 577 2,114 2,873 2 1 4 51 36
New York City — 2 12 80 168 — 1 31 11 817 — 4 9 144 133
Pennsylvania 7 6 16 193 263 43 75 359 4,494 4,711 1 1 3 39 43
E.N. Central 2 12 33 449 483 1 21 130 1,282 2,535 — 2 9 95 140
Illinois — 2 10 75 82 — 1 11 70 123 — 1 7 33 59
Indiana 1 2 6 69 41 — 1 7 59 71 — 0 2 7 20
Michigan — 3 18 104 101 1 1 14 79 78 — 0 4 19 21
Ohio 1 4 12 158 200 — 0 5 21 34 — 0 5 31 31
Wisconsin — 1 11 43 59 — 18 113 1,053 2,229 — 0 1 5 9
W.N. Central — 2 19 80 83 — 3 1,395 91 193 2 1 11 48 44
Iowa — 0 2 11 20 — 0 10 66 101 — 0 1 8 10
Kansas — 0 2 6 5 — 0 1 6 17 — 0 2 7 6
Minnesota — 0 16 23 8 — 0 1,380 — 68 — 0 11 3 13
Missouri — 0 4 24 39 — 0 1 1 3 2 0 3 15 9
Nebraska† — 0 2 8 9 — 0 2 9 3 — 0 2 13 5
North Dakota — 0 1 4 1 — 0 15 8 — — 0 1 — —
South Dakota — 0 1 4 1 — 0 1 1 1 — 0 2 2 1
S. Atlantic 14 11 25 366 345 36 58 157 2,537 3,254 3 6 36 245 259
Delaware — 0 3 12 12 — 12 31 486 784 — 0 1 2 4
District of Columbia — 0 4 12 15 — 0 4 18 46 — 0 3 7 11
Florida 2 4 10 126 112 6 2 11 63 51 2 2 7 90 69
Georgia — 1 4 32 33 — 0 2 8 36 — 0 2 3 57
Maryland† 6 3 12 79 89 8 28 73 1,054 1,617 — 1 19 58 56
North Carolina 4 1 7 40 40 — 1 9 67 74 — 0 13 33 20
South Carolina† — 0 2 10 6 — 1 3 26 25 — 0 1 3 3
Virginia† 2 1 6 46 32 22 14 79 733 522 1 1 5 48 37
West Virginia — 0 3 9 6 — 0 33 82 99 — 0 2 1 2
E.S. Central — 2 10 92 92 — 1 4 33 26 — 0 3 21 28
Alabama† — 0 2 10 12 — 0 1 1 2 — 0 1 4 8
Kentucky — 0 4 19 37 — 0 1 2 1 — 0 3 5 8
Mississippi — 0 3 9 4 — 0 0 — — — 0 2 2 3
Tennessee† — 1 6 54 39 — 1 4 30 23 — 0 2 10 9
W.S. Central — 3 14 95 75 2 3 44 63 139 1 1 31 56 44
Arkansas† — 0 2 11 5 — 0 0 — — — 0 1 1 3
Louisiana — 0 3 5 7 — 0 1 1 — — 0 1 1 5
Oklahoma — 0 4 11 3 — 0 2 — — 1 0 1 5 1
Texas† — 2 10 68 60 2 3 42 62 139 — 1 30 49 35
Mountain — 3 10 110 89 — 0 3 16 47 2 1 3 43 43
Arizona — 1 5 35 34 — 0 1 3 4 — 0 2 19 8
Colorado — 1 5 25 13 — 0 1 2 1 2 0 1 14 24
Idaho† — 0 1 3 3 — 0 1 5 13 — 0 1 1 2
Montana† — 0 1 4 5 — 0 1 1 3 — 0 1 2 5
Nevada† — 0 2 18 11 — 0 1 — 12 — 0 1 3 —
New Mexico† — 0 2 6 3 — 0 1 3 4 — 0 1 1 —
Utah — 0 3 15 19 — 0 1 2 8 — 0 1 3 4
Wyoming† — 0 2 4 1 — 0 1 — 2 — 0 0 — —
Pacific 4 5 19 184 121 3 4 10 159 112 7 3 19 117 102
Alaska — 0 2 2 1 — 0 1 4 5 — 0 1 2 2
California 4 3 19 157 94 2 3 8 108 70 2 2 13 81 76
Hawaii — 0 1 1 1 N 0 0 N N — 0 1 1 1
Oregon — 0 3 9 10 1 1 3 40 30 — 0 1 7 10
Washington — 0 4 15 15 — 0 3 7 7 5 0 5 26 13
Territories
American Samoa — 0 0 — — N 0 0 N N — 0 0 — —
C.N.M.I. — — — — — — — — — — — — — — —
Guam — 0 0 — — — 0 0 — — — 0 0 — —
Puerto Rico — 0 1 — 1 N 0 0 N N — 0 1 1 4
U.S. Virgin Islands — 0 0 — — — 0 0 — — — 0 0 — —
C.N.M.I.: Commonwealth of Northern Mariana Islands.
U: Unavailable. —: No reported cases. N: Not reportable. NN: Not Nationally Notifiable. Cum: Cumulative year-to-date counts. Med: Median. Max: Maximum.
* Incidence data for reporting years 2009 and 2010 are provisional.
† Contains data reported through the National Electronic Disease Surveillance System (NEDSS).

MMWR / September 17, 2010 / Vol. 59 / No. 36 1193

 MMWR Morbidity and Mortality Weekly Report

TABLE II. (Continued) Provisional cases of selected notifiable diseases, United States, weeks ending September 11, 2010, and September 12, 2009 (36th week)*
Meningococcal disease, invasive†
All groups Pertussis Rabies, animal
Current Previous 52 weeks Cum Cum Current
Previous 52 weeks
Cum Cum Current
Previous 52 weeks
Cum Cum
Reporting area week Med Max 2010 2009 week Med Max 2010 2009 week Med Max 2010 2009
United States 4 16 43 529 679 199 291 1,756 11,466 10,947 31 72 145 2,457 3,744
New England — 0 2 13 24 1 7 19 269 486 3 4 24 168 243
Connecticut — 0 2 2 3 — 1 8 70 35 — 0 22 59 101
Maine§ — 0 1 3 3 — 0 5 26 71 1 1 4 44 39
Massachusetts — 0 1 3 12 — 4 10 135 283 — 0 0 — —
New Hampshire — 0 1 — 1 — 0 3 9 62 — 0 5 11 25
Rhode Island§ — 0 0 — 4 1 0 8 21 26 — 0 2 14 35
Vermont§ — 0 1 5 1 — 0 3 8 9 2 1 5 40 43
Mid. Atlantic — 1 4 44 76 21 21 63 862 841 12 17 41 747 433
New Jersey — 0 2 9 13 — 3 8 68 172 — 0 0 — —
New York (Upstate) — 0 3 9 17 11 7 27 318 139 12 9 22 379 320
New York City — 0 2 11 13 — 0 11 44 59 — 1 12 105 13
Pennsylvania — 0 2 15 33 10 8 39 432 471 — 5 24 263 100
E.N. Central — 3 8 93 119 38 69 143 2,903 2,255 9 2 38 251 192
Illinois — 0 4 17 31 — 11 28 457 505 6 1 22 153 72
Indiana — 0 3 21 26 — 9 26 371 256 — 0 0 — 25
Michigan — 0 2 13 18 6 23 45 814 570 1 1 5 56 55
Ohio — 1 2 23 26 32 20 69 1,019 792 2 0 12 42 40
Wisconsin — 0 2 19 18 — 5 12 242 132 — 0 0 — —
W.N. Central — 1 6 38 52 47 27 627 1,267 1,636 1 5 16 189 295
Iowa — 0 3 8 7 — 6 24 273 164 — 0 2 7 25
Kansas — 0 2 6 9 — 3 9 98 183 — 1 4 47 61
Minnesota — 0 2 2 10 38 0 601 463 336 — 1 9 26 43
Missouri — 0 3 16 18 1 8 25 245 796 — 1 6 56 52
Nebraska§ — 0 2 5 5 8 2 10 131 111 1 1 4 43 68
North Dakota — 0 1 1 1 — 0 30 32 17 — 0 7 10 4
South Dakota — 0 2 — 2 — 1 5 25 29 — 0 2 — 42
S. Atlantic 3 3 7 105 125 25 26 75 1,015 1,221 — 23 85 756 1,576
Delaware — 0 1 1 2 — 0 4 9 10 — 0 0 — —
District of Columbia — 0 0 — — — 0 1 4 4 — 0 0 — —
Florida 3 1 5 48 40 11 5 28 230 399 — 0 72 72 161
Georgia — 0 2 9 24 — 3 16 145 187 — 0 13 — 297
Maryland§ — 0 1 5 8 — 2 8 78 104 — 6 15 247 287
North Carolina — 0 2 14 24 — 1 32 124 149 — 0 15 — 353
South Carolina§ — 0 1 9 11 10 5 19 253 199 — 0 0 — —
Virginia§ — 0 2 17 11 3 5 15 136 145 — 10 26 384 393
West Virginia — 0 2 2 5 1 0 7 36 24 — 1 6 53 85
E.S. Central — 1 4 27 23 — 14 25 501 630 4 3 7 120 110
Alabama§ — 0 2 5 6 — 4 8 146 242 2 0 4 38 —
Kentucky — 0 2 12 4 — 4 13 162 188 1 0 4 16 37
Mississippi — 0 1 3 3 — 1 6 45 53 — 0 1 1 4
Tennessee§ — 0 2 7 10 — 4 10 148 147 1 2 4 65 69
W.S. Central 1 1 9 59 62 29 58 753 1,948 2,265 2 1 40 60 621
Arkansas§ — 0 2 5 5 1 4 29 118 265 — 0 10 20 28
Louisiana — 0 4 12 13 — 1 4 22 129 — 0 0 — —
Oklahoma — 0 7 14 6 8 0 41 39 37 2 0 30 40 21
Texas§ 1 0 7 28 38 20 50 681 1,769 1,834 — 0 30 — 572
Mountain — 1 6 42 50 11 21 41 760 701 — 1 8 46 80
Arizona — 0 2 11 12 1 6 14 240 174 — 0 5 — —
Colorado — 0 4 13 15 9 3 13 142 178 — 0 0 — —
Idaho§ — 0 1 5 6 1 2 19 121 64 — 0 2 5 4
Montana§ — 0 1 1 5 — 1 8 35 25 — 0 3 12 24
Nevada§ — 0 1 8 4 — 0 7 19 19 — 0 1 4 5
New Mexico§ — 0 1 3 3 — 1 8 59 52 — 0 3 9 20
Utah — 0 1 1 1 — 4 10 138 167 — 0 2 2 8
Wyoming§ — 0 1 — 4 — 0 1 6 22 — 0 3 14 19
Pacific — 3 16 108 148 27 33 186 1,941 912 — 3 12 120 194
Alaska — 0 1 1 6 — 0 6 26 34 — 0 2 11 11
California — 1 13 70 95 2 22 162 1,414 439 — 2 12 99 172
Hawaii — 0 1 1 5 — 0 6 29 30 — 0 0 — —
Oregon — 1 3 24 29 2 5 15 243 207 — 0 2 10 11
Washington — 0 7 12 13 23 4 24 229 202 — 0 0 — —
Territories
American Samoa — 0 0 — — — 0 0 — — N 0 0 N N
C.N.M.I. — — — — — — — — — — — — — — —
Guam — 0 0 — — — 0 2 — — — 0 0 — —
Puerto Rico — 0 1 — — — 0 0 — 1 — 1 3 32 28
U.S. Virgin Islands — 0 0 — — — 0 0 — — — 0 0 — —
C.N.M.I.: Commonwealth of Northern Mariana Islands.
U: Unavailable. —: No reported cases. N: Not reportable. NN: Not Nationally Notifiable. Cum: Cumulative year-to-date counts. Med: Median. Max: Maximum.
* Incidence data for reporting years 2009 and 2010 are provisional.
† Data for meningococcal disease, invasive caused by serogroups A, C, Y, and W-135; serogroup B; other serogroup; and unknown serogroup are available in Table I.
§ Contains data reported through the National Electronic Disease Surveillance System (NEDSS).

1194 MMWR / September 17, 2010 / Vol. 59 / No. 36

 MMWR Morbidity and Mortality Weekly Report

TABLE II. (Continued) Provisional cases of selected notifiable diseases, United States, weeks ending September 11, 2010, and September 12, 2009 (36th week)*
Salmonellosis Shiga toxin-producing E. coli (STEC)† Shigellosis
Current Previous 52 weeks Cum Cum Current
Previous 52 weeks
Cum Cum Current
Previous 52 weeks
Cum Cum
Reporting area week Med Max 2010 2009 week Med Max 2010 2009 week Med Max 2010 2009
United States 819 889 1,602 31,078 32,576 50 80 198 3,014 3,186 148 251 527 9,058 11,374
New England 2 29 346 1,489 1,752 2 3 38 140 194 — 5 44 214 273
Connecticut — 0 329 329 430 — 0 38 38 67 — 0 37 37 43
Maine§ 2 2 7 84 95 2 0 2 14 14 — 0 2 5 3
Massachusetts — 20 42 807 858 — 2 8 59 68 — 4 15 156 189
New Hampshire — 3 10 124 219 — 0 2 17 25 — 0 2 6 16
Rhode Island§ — 2 17 97 97 — 0 26 2 1 — 0 3 9 17
Vermont§ — 1 5 48 53 — 0 2 10 19 — 0 1 1 5
Mid. Atlantic 59 96 174 3,636 3,899 6 8 26 348 312 17 34 61 1,156 2,176
New Jersey — 15 39 445 843 — 1 4 36 78 — 6 17 200 473
New York (Upstate) 29 24 78 979 893 5 3 15 138 96 11 4 19 162 159
New York City 9 25 55 924 891 — 1 6 51 46 — 7 13 214 332
Pennsylvania 21 29 77 1,288 1,272 1 2 13 123 92 6 17 35 580 1,212
E.N. Central 33 80 231 3,514 3,843 4 12 35 493 563 8 25 235 1,189 2,063
Illinois — 26 112 1,171 1,082 — 2 8 76 133 — 9 228 646 482
Indiana — 10 53 369 458 — 1 8 67 72 — 1 5 31 56
Michigan 2 15 41 627 728 3 2 16 123 104 1 4 9 165 175
Ohio 31 24 47 974 1,054 1 2 11 112 101 7 6 23 236 933
Wisconsin — 10 40 373 521 — 3 9 115 153 — 4 14 111 417
W.N. Central 20 45 94 1,696 1,972 4 10 39 444 560 17 48 88 1,676 682
Iowa 2 7 35 370 314 — 2 15 121 131 — 1 5 40 46
Kansas — 7 18 300 299 — 1 6 48 47 — 4 14 184 162
Minnesota — 4 32 178 429 — 1 14 31 147 — 0 6 14 59
Missouri 11 12 44 558 458 3 3 27 175 100 16 42 75 1,406 385
Nebraska§ 7 4 13 174 280 1 1 6 51 70 1 0 4 27 23
North Dakota — 0 39 27 35 — 0 7 — 4 — 0 5 — 3
South Dakota — 2 6 89 157 — 0 4 18 61 — 0 2 5 4
S. Atlantic 339 267 545 8,975 8,686 8 13 30 470 462 23 40 85 1,576 1,744
Delaware 1 3 10 115 83 — 0 2 4 11 — 1 10 37 80
District of Columbia — 2 4 52 68 — 0 1 5 2 — 0 4 20 18
Florida 168 126 277 3,785 3,676 7 4 13 161 113 10 13 49 697 312
Georgia 80 40 126 1,563 1,605 — 1 15 69 53 6 13 25 476 459
Maryland§ 22 15 47 708 545 1 2 6 63 64 3 2 8 85 307
North Carolina 18 30 144 1,043 1,229 — 1 7 44 77 2 2 17 117 324
South Carolina§ 33 20 76 878 624 — 0 3 16 23 2 1 5 50 94
Virginia§ 17 18 68 698 698 — 2 15 94 100 — 2 15 93 144
West Virginia — 3 16 133 158 — 0 5 14 19 — 0 2 1 6
E.S. Central 23 51 135 2,180 2,105 — 4 11 168 157 4 12 40 474 605
Alabama§ — 15 42 529 580 — 1 4 36 39 — 3 10 104 113
Kentucky 7 8 29 363 342 — 1 6 38 55 1 4 28 181 143
Mississippi 6 14 60 687 629 — 0 2 11 6 1 1 4 29 36
Tennessee§ 10 14 45 601 554 — 2 8 83 57 2 4 11 160 313
W.S. Central 126 114 547 3,491 3,708 6 5 68 185 212 32 47 251 1,587 2,146
Arkansas§ 38 10 36 455 413 1 1 5 40 27 — 1 9 38 238
Louisiana 1 19 45 696 768 — 0 2 11 20 — 3 10 153 146
Oklahoma 26 10 46 404 434 — 0 27 15 23 7 6 96 200 197
Texas§ 61 72 477 1,936 2,093 5 3 41 119 142 25 35 144 1,196 1,565
Mountain 24 48 103 1,842 2,206 4 9 29 388 411 7 15 39 495 839
Arizona 5 18 41 602 737 — 1 5 40 47 3 8 25 259 609
Colorado 13 11 23 421 465 2 2 18 144 126 3 2 6 82 67
Idaho§ 3 3 9 111 133 2 1 7 52 60 — 0 3 18 6
Montana§ — 2 7 67 84 — 0 5 28 26 — 0 1 6 11
Nevada§ — 4 20 202 190 — 0 5 23 21 — 0 7 21 49
New Mexico§ — 5 15 195 283 — 1 4 30 29 — 2 9 80 80
Utah 3 5 18 212 244 — 1 7 60 92 1 0 4 29 15
Wyoming§ — 1 9 32 70 — 0 2 11 10 — 0 2 — 2
Pacific 193 115 299 4,255 4,405 16 10 46 378 315 40 20 64 691 846
Alaska — 1 5 61 54 — 0 1 1 1 — 0 2 1 2
California 138 84 227 3,198 3,274 7 5 35 162 167 32 16 51 567 673
Hawaii 6 4 14 120 241 — 0 4 18 4 — 0 3 11 31
Oregon 6 8 48 391 324 2 2 11 69 47 — 1 4 37 40
Washington 43 14 61 485 512 7 3 19 128 96 8 2 22 75 100
Territories
American Samoa — 1 1 2 — — 0 0 — — — 0 1 1 3
C.N.M.I. — — — — — — — — — — — — — — —
Guam — 0 2 4 9 — 0 0 — — — 0 3 1 7
Puerto Rico — 5 39 131 369 — 0 0 — — — 0 1 — 10
U.S. Virgin Islands — 0 0 — — — 0 0 — — — 0 0 — —
C.N.M.I.: Commonwealth of Northern Mariana Islands.
U: Unavailable. —: No reported cases. N: Not reportable. NN: Not Nationally Notifiable. Cum: Cumulative year-to-date counts. Med: Median. Max: Maximum.
* Incidence data for reporting years 2009 and 2010 are provisional.
† Includes E. coli O157:H7; Shiga toxin-positive, serogroup non-O157; and Shiga toxin-positive, not serogrouped.
§ Contains data reported through the National Electronic Disease Surveillance System (NEDSS).

MMWR / September 17, 2010 / Vol. 59 / No. 36 1195

 MMWR Morbidity and Mortality Weekly Report

TABLE II. (Continued) Provisional cases of selected notifiable diseases, United States, weeks ending September 11, 2010, and September 12, 2009 (36th week)*
Spotted Fever Rickettsiosis (including RMSF)†
Confirmed Probable

Current Previous 52 weeks Cum Cum Current Previous 52 weeks Cum Cum
Reporting area week Med Max 2010 2009 week Med Max 2010 2009
United States 1 2 14 111 119 14 16 421 987 1,095
New England — 0 0 — 2 — 0 1 1 9
Connecticut — 0 0 — — — 0 0 — —
Maine§ — 0 0 — — — 0 1 1 4
Massachusetts — 0 0 — 1 — 0 1 — 5
New Hampshire — 0 0 — — — 0 1 — —
Rhode Island§ — 0 0 — — — 0 0 — —
Vermont§ — 0 0 — 1 — 0 0 — —
Mid. Atlantic 1 0 2 15 10 1 1 4 41 80
New Jersey — 0 0 — 2 — 0 3 — 51
New York (Upstate) 1 0 1 2 — 1 0 3 11 11
New York City — 0 1 1 1 — 0 4 20 6
Pennsylvania — 0 2 12 7 — 0 1 10 12
E.N. Central — 0 1 4 8 1 1 8 64 75
Illinois — 0 1 2 1 — 0 5 19 45
Indiana — 0 1 2 3 1 0 5 34 9
Michigan — 0 1 — 3 — 0 2 3 1
Ohio — 0 0 — — — 0 2 7 16
Wisconsin — 0 0 — 1 — 0 1 1 4
W.N. Central — 0 3 14 16 6 2 20 211 232
Iowa — 0 0 — 1 — 0 1 3 4
Kansas — 0 1 2 1 — 0 0 — —
Minnesota — 0 1 — 1 — 0 1 — 1
Missouri — 0 3 11 6 6 2 19 203 223
Nebraska§ — 0 1 1 7 — 0 1 4 4
North Dakota — 0 0 — — — 0 1 1 —
South Dakota — 0 0 — — — 0 0 — —
S. Atlantic — 1 10 54 57 4 5 59 337 332
Delaware — 0 1 1 — — 0 3 15 16
District of Columbia — 0 0 — — — 0 1 — —
Florida — 0 1 2 — — 0 1 7 4
Georgia — 0 6 33 46 — 0 0 — —
Maryland§ — 0 1 2 2 — 0 4 29 32
North Carolina — 0 3 11 6 3 1 48 186 217
South Carolina§ — 0 1 1 3 — 0 2 10 15
Virginia§ — 0 2 4 — 1 1 10 90 46
West Virginia — 0 0 — — — 0 0 — 2
E.S. Central — 0 3 14 7 2 3 28 271 225
Alabama§ — 0 1 4 3 — 1 8 51 53
Kentucky — 0 2 6 1 — 0 0 — —
Mississippi — 0 0 — — — 0 2 7 9
Tennessee§ — 0 2 4 3 2 3 20 213 163
W.S. Central — 0 3 1 6 — 1 408 54 119
Arkansas§ — 0 1 — — — 0 110 20 62
Louisiana — 0 0 — — — 0 1 2 2
Oklahoma — 0 2 — 5 — 0 287 17 39
Texas§ — 0 1 1 1 — 0 11 15 16
Mountain — 0 2 2 12 — 0 2 7 23
Arizona — 0 2 — 6 — 0 1 2 11
Colorado — 0 0 — 1 — 0 0 — —
Idaho§ — 0 0 — — — 0 1 2 1
Montana§ — 0 1 2 4 — 0 1 1 6
Nevada§ — 0 0 — — — 0 0 — 1
New Mexico§ — 0 0 — — — 0 1 1 1
Utah — 0 0 — — — 0 1 1 1
Wyoming§ — 0 0 — 1 — 0 0 — 2
Pacific — 0 2 7 1 — 0 1 1 —
Alaska N 0 0 N N N 0 0 N N
California — 0 2 6 1 — 0 0 — —
Hawaii N 0 0 N N N 0 0 N N
Oregon — 0 1 1 — — 0 1 1 —
Washington — 0 0 — — — 0 0 — —
Territories
American Samoa N 0 0 N N N 0 0 N N
C.N.M.I. — — — — — — — — — —
Guam N 0 0 N N N 0 0 N N
Puerto Rico N 0 0 N N N 0 0 N N
U.S. Virgin Islands — 0 0 — — — 0 0 — —
C.N.M.I.: Commonwealth of Northern Mariana Islands.
U: Unavailable. —: No reported cases. N: Not reportable. NN: Not Nationally Notifiable. Cum: Cumulative year-to-date counts. Med: Median. Max: Maximum.
* Incidence data for reporting years 2009 and 2010 are provisional.
† Illnesses with similar clinical presentation that result from Spotted fever group rickettsia infections are reported as Spotted fever rickettsioses. Rocky Mountain spotted fever (RMSF) caused
by Rickettsia rickettsii, is the most common and well-known spotted fever.
§ Contains data reported through the National Electronic Disease Surveillance System (NEDSS).

1196 MMWR / September 17, 2010 / Vol. 59 / No. 36

 MMWR Morbidity and Mortality Weekly Report

TABLE II. (Continued) Provisional cases of selected notifiable diseases, United States, weeks ending September 11, 2010, and September 12, 2009 (36th week)*
Streptococcus pneumoniae,† invasive disease
All ages Age <5 Syphilis, primary and secondary
Current Previous 52 weeks Cum Cum Current
Previous 52 weeks
Cum Cum Current
Previous 52 weeks
Cum Cum
Reporting area week Med Max 2010 2009 week Med Max 2010 2009 week Med Max 2010 2009
United States 58 188 492 10,090 2,121 6 50 156 1,571 1,633 70 235 413 7,866 9,800
New England — 7 99 564 38 — 1 24 74 50 2 7 22 299 227
Connecticut — 0 92 254 — — 0 22 24 — — 1 10 58 43
Maine§ — 1 6 87 10 — 0 2 7 4 — 0 3 16 2
Massachusetts — 0 5 53 3 — 1 4 35 35 2 5 14 181 159
New Hampshire — 0 7 59 — — 0 2 3 8 — 0 1 14 13
Rhode Island§ — 0 34 53 14 — 0 2 2 1 — 0 4 28 10
Vermont§ — 1 6 58 11 — 0 1 3 2 — 0 2 2 —
Mid. Atlantic 3 14 54 867 128 — 7 48 245 211 13 33 45 1,167 1,247
New Jersey — 1 8 76 — — 1 5 39 36 — 4 12 152 162
New York (Upstate) — 3 12 114 51 — 3 19 83 93 3 2 11 97 85
New York City 1 4 25 328 8 — 1 24 83 69 9 18 31 676 768
Pennsylvania 2 6 22 349 69 — 0 5 40 13 1 7 16 242 232
E.N. Central 4 31 98 2,032 479 — 8 18 254 271 2 27 46 883 1,082
Illinois — 1 7 70 — — 2 5 63 42 2 12 23 313 522
Indiana — 7 23 417 187 — 1 6 35 57 — 3 13 120 115
Michigan 1 7 27 480 20 — 2 6 57 50 — 3 12 146 171
Ohio 2 14 49 837 272 — 2 6 68 93 — 8 13 276 239
Wisconsin 1 5 22 228 — — 1 4 31 29 — 1 3 28 35
W.N. Central — 8 182 584 139 — 2 12 104 134 2 5 12 206 222
Iowa — 0 0 — — — 0 0 — — — 0 2 9 17
Kansas — 1 7 72 47 — 0 2 11 15 — 0 3 11 22
Minnesota — 0 179 287 34 — 0 10 44 60 — 1 9 78 50
Missouri — 2 9 81 49 — 0 3 28 37 1 3 8 102 125
Nebraska§ — 1 7 91 — — 0 2 12 10 1 0 1 6 5
North Dakota — 0 11 39 7 — 0 1 2 4 — 0 1 — 3
South Dakota — 0 3 14 2 — 0 2 7 8 — 0 0 — —
S. Atlantic 20 40 144 2,356 958 — 12 28 392 389 19 56 218 1,895 2,349
Delaware — 0 3 27 15 — 0 2 — — — 0 2 4 23
District of Columbia — 0 4 21 17 — 0 2 7 3 2 2 8 94 128
Florida 11 18 89 1,084 561 — 3 18 146 140 1 19 32 673 729
Georgia 6 10 28 388 275 — 4 12 105 99 3 11 167 371 558
Maryland§ 2 5 25 341 4 — 1 6 39 60 3 6 11 191 203
North Carolina — 0 0 — — — 0 0 — — 7 7 31 259 390
South Carolina§ 1 5 25 365 — — 1 4 40 35 2 2 7 102 89
Virginia§ — 0 4 41 — — 1 4 39 34 1 4 22 198 225
West Virginia — 1 21 89 86 — 0 4 16 18 — 0 2 3 4
E.S. Central 6 17 50 882 204 1 2 8 84 104 — 18 39 617 812
Alabama§ — 0 0 — — — 0 0 — — — 5 12 164 319
Kentucky — 2 16 132 55 — 0 2 10 7 — 2 13 90 47
Mississippi — 1 6 41 36 — 0 2 8 18 — 5 17 148 152
Tennessee§ 6 12 44 709 113 1 2 7 66 79 — 6 17 215 294
W.S. Central 16 17 90 1,299 88 3 6 41 209 243 21 34 71 1,076 1,983
Arkansas§ 3 2 9 122 41 — 0 3 11 32 4 3 14 111 163
Louisiana — 1 8 58 47 — 0 3 18 19 — 0 23 64 577
Oklahoma — 0 5 36 — — 1 5 36 43 — 1 6 52 61
Texas§ 13 13 82 1,083 — 3 3 34 144 149 17 25 42 849 1,182
Mountain 6 20 82 1,289 84 2 5 12 181 207 2 9 20 304 375
Arizona 2 7 51 598 — 1 2 7 78 93 — 3 7 92 178
Colorado 4 6 20 380 — 1 1 4 51 30 — 2 5 76 69
Idaho§ — 0 2 11 — — 0 2 5 7 — 0 1 2 3
Montana§ — 0 2 13 — — 0 1 1 — — 0 1 1 —
Nevada§ — 1 4 54 34 — 0 1 5 7 — 1 10 70 64
New Mexico§ — 2 9 114 — — 0 4 14 24 2 1 4 32 37
Utah — 2 9 110 41 — 1 4 24 45 — 1 4 31 21
Wyoming§ — 0 1 9 9 — 0 1 3 1 — 0 0 — 3
Pacific 3 4 14 217 3 — 0 7 28 24 9 39 60 1,419 1,503
Alaska — 1 9 83 — — 0 5 18 15 — 0 1 1 —
California 3 2 12 134 — — 0 2 10 — 4 36 55 1,250 1,334
Hawaii — 0 0 — 3 — 0 1 — 9 — 0 3 25 25
Oregon — 0 0 — — — 0 0 — — — 0 5 6 41
Washington — 0 0 — — — 0 0 — — 5 3 10 137 103
Territories
American Samoa — 0 0 — — — 0 0 — — — 0 0 — —
C.N.M.I. — — — — — — — — — — — — — — —
Guam — 0 0 — — — 0 0 — — — 0 0 — —
Puerto Rico — 0 0 — — — 0 0 — — 3 4 16 161 160
U.S. Virgin Islands — 0 0 — — — 0 0 — — — 0 0 — —
C.N.M.I.: Commonwealth of Northern Mariana Islands.
U: Unavailable. —: No reported cases. N: Not reportable. NN: Not Nationally Notifiable. Cum: Cumulative year-to-date counts. Med: Median. Max: Maximum.
* Incidence data for reporting years 2009 and 2010 are provisional.
† Includes drug resistant and susceptible cases of invasive Streptococcus pneumoniae disease among children <5 years and among all ages. Case definition: Isolation of S. pneumoniae from
a normally sterile body site (e.g., blood or cerebrospinal fluid).
§ Contains data reported through the National Electronic Disease Surveillance System (NEDSS).

MMWR / September 17, 2010 / Vol. 59 / No. 36 1197

 MMWR Morbidity and Mortality Weekly Report

TABLE II. (Continued) Provisional cases of selected notifiable diseases, United States, weeks ending September 11, 2010, and September 12, 2009 (36th week)*
West Nile virus disease†
Varicella (chickenpox)§ Neuroinvasive Nonneuroinvasive¶
Previous 52 weeks Previous 52 weeks Previous 52 weeks
Current Cum Cum Current Cum Cum Current Cum Cum
Reporting area week Med Max 2010 2009 week Med Max 2010 2009 week Med Max 2010 2009
United States 102 326 547 9,903 15,212 — 0 41 217 325 — 1 26 164 288
New England 4 15 36 469 754 — 0 3 8 — — 0 2 2 —
Connecticut 3 6 20 220 364 — 0 2 5 — — 0 2 2 —
Maine§ — 3 15 130 139 — 0 0 — — — 0 0 — —
Massachusetts — 0 1 — 3 — 0 2 3 — — 0 0 — —
New Hampshire — 2 8 88 147 — 0 0 — — — 0 0 — —
Rhode Island§ 1 1 12 19 25 — 0 0 — — — 0 0 — —
Vermont§ — 0 10 12 76 — 0 0 — — — 0 0 — —
Mid. Atlantic 11 33 66 1,107 1,477 — 0 12 52 5 — 0 4 18 1
New Jersey — 9 30 394 307 — 0 2 6 3 — 0 1 1 —
New York (Upstate) N 0 0 N N — 0 7 26 1 — 0 4 12 1
New York City — 0 0 — — — 0 4 19 1 — 0 4 5 —
Pennsylvania 11 22 52 713 1,170 — 0 1 1 — — 0 0 — —
E.N. Central 21 108 176 3,288 4,726 — 0 5 11 8 — 0 3 6 4
Illinois 3 26 49 851 1,137 — 0 1 1 5 — 0 0 — —
Indiana§ — 5 35 303 352 — 0 0 — 2 — 0 2 3 2
Michigan 6 35 62 999 1,344 — 0 4 9 — — 0 1 1 —
Ohio 11 28 56 910 1,448 — 0 1 1 — — 0 1 1 2
Wisconsin 1 7 21 225 445 — 0 0 — 1 — 0 1 1 —
W.N. Central 1 15 40 536 1,004 — 0 7 19 23 — 0 7 37 61
Iowa N 0 0 N N — 0 1 1 — — 0 1 1 5
Kansas§ 1 6 22 207 423 — 0 0 — 4 — 0 2 5 7
Minnesota — 0 0 — — — 0 1 3 1 — 0 1 — 1
Missouri — 7 23 277 483 — 0 1 3 3 — 0 1 — —
Nebraska§ N 0 0 N N — 0 3 7 9 — 0 3 12 34
North Dakota — 0 26 31 57 — 0 2 2 — — 0 1 5 1
South Dakota — 0 7 21 41 — 0 1 3 6 — 0 3 14 13
S. Atlantic 37 37 99 1,524 1,907 — 0 3 11 13 — 0 1 4 2
Delaware§ — 0 4 17 11 — 0 0 — — — 0 0 — —
District of Columbia — 0 4 15 26 — 0 0 — 2 — 0 0 — —
Florida§ 19 15 57 756 936 — 0 2 3 1 — 0 0 — 1
Georgia N 0 0 N N — 0 1 3 3 — 0 1 3 —
Maryland§ N 0 0 N N — 0 2 5 — — 0 1 1 1
North Carolina N 0 0 N N — 0 0 — — — 0 0 — —
South Carolina§ — 0 35 75 93 — 0 0 — 3 — 0 0 — —
Virginia§ 1 11 34 338 525 — 0 1 — 4 — 0 0 — —
West Virginia 17 8 26 323 316 — 0 0 — — — 0 0 — —
E.S. Central 4 6 28 209 401 — 0 5 3 29 — 0 3 5 21
Alabama§ 4 6 27 202 398 — 0 1 1 — — 0 1 2 —
Kentucky N 0 0 N N — 0 1 — 2 — 0 0 — —
Mississippi — 0 2 7 3 — 0 3 2 25 — 0 2 3 17
Tennessee§ N 0 0 N N — 0 2 — 2 — 0 1 — 4
W.S. Central 18 56 285 1,989 3,844 — 0 9 28 104 — 0 3 11 30
Arkansas§ — 3 32 122 390 — 0 3 3 6 — 0 0 — —
Louisiana — 1 5 40 109 — 0 2 6 9 — 0 1 6 9
Oklahoma N 0 0 N N — 0 2 — 5 — 0 0 — 2
Texas§ 18 48 272 1,827 3,345 — 0 8 19 84 — 0 2 5 19
Mountain 6 22 37 744 1,013 — 0 10 64 73 — 0 10 64 112
Arizona — 0 0 — — — 0 10 50 12 — 0 9 32 5
Colorado§ 3 8 20 296 386 — 0 4 10 32 — 0 6 27 61
Idaho§ N 0 0 N N — 0 0 — 9 — 0 4 — 27
Montana§ 2 3 17 157 123 — 0 0 — 2 — 0 1 — 3
Nevada§ N 0 0 N N — 0 0 — 7 — 0 0 — 5
New Mexico§ — 2 8 81 96 — 0 1 3 6 — 0 2 3 2
Utah 1 6 22 197 408 — 0 1 — 1 — 0 0 — 1
Wyoming§ — 0 3 13 — — 0 1 1 4 — 0 1 2 8
Pacific — 1 5 37 86 — 0 10 21 70 — 0 4 17 57
Alaska — 0 5 30 52 — 0 0 — — — 0 0 — —
California — 0 0 — — — 0 8 21 45 — 0 4 17 36
Hawaii — 0 2 7 34 — 0 0 — — — 0 0 — —
Oregon N 0 0 N N — 0 0 — 1 — 0 1 — 9
Washington N 0 0 N N — 0 2 — 24 — 0 0 — 12
Territories
American Samoa N 0 0 N N — 0 0 — — — 0 0 — —
C.N.M.I. — — — — — — — — — — — — — — —
Guam — 0 3 12 17 — 0 0 — — — 0 0 — —
Puerto Rico — 5 30 188 406 — 0 0 — — — 0 0 — —
U.S. Virgin Islands — 0 0 — — — 0 0 — — — 0 0 — —
C.N.M.I.: Commonwealth of Northern Mariana Islands.
U: Unavailable. —: No reported cases. N: Not reportable. NN: Not Nationally Notifiable. Cum: Cumulative year-to-date counts. Med: Median. Max: Maximum.
* Incidence data for reporting years 2009 and 2010 are provisional. Data for HIV/AIDS, AIDS, and TB, when available, are displayed in Table IV, which appears quarterly.
† Updated weekly from reports to the Division of Vector-Borne Infectious Diseases, National Center for Zoonotic, Vector-Borne, and Enteric Diseases (ArboNET Surveillance). Data for California
serogroup, eastern equine, Powassan, St. Louis, and western equine diseases are available in Table I.
§ Contains data reported through the National Electronic Disease Surveillance System (NEDSS).
¶ Not reportable in all states. Data from states where the condition is not reportable are excluded from this table, except starting in 2007 for the domestic arboviral diseases and influenza-
associated pediatric mortality, and in 2003 for SARS-CoV. Reporting exceptions are available at http://www.cdc.gov/ncphi/disss/nndss/phs/infdis.htm.

1198 MMWR / September 17, 2010 / Vol. 59 / No. 36

 MMWR Morbidity and Mortality Weekly Report

TABLE III. Deaths in 122 U.S. cities,* week ending September 11, 2010 (36th week)
All causes, by age (years) All causes, by age (years)
All P&I† All P&I†
Reporting area Ages ≥65 45–64 25–44 1–24 <1 Total Reporting area Ages ≥65 45–64 25–44 1–24 <1 Total

New England 468 336 85 27 11 6 45 S. Atlantic 1,083 687 281 65 28 22 61

Boston, MA 140 93 28 11 6 2 18 Atlanta, GA 122 81 27 9 4 1 5
Bridgeport, CT 36 29 6 1 — — 2 Baltimore, MD 119 61 43 8 4 3 12
Cambridge, MA 16 12 4 — — — — Charlotte, NC 118 76 30 5 1 6 7
Fall River, MA 23 18 3 2 — — 1 Jacksonville, FL 140 87 42 9 2 — 6
Hartford, CT 37 29 6 1 1 — 3 Miami, FL 159 106 34 11 5 3 7
Lowell, MA 29 22 4 1 2 — 3 Norfolk, VA 40 30 10 — — — 2
Lynn, MA 8 6 2 — — — 1 Richmond, VA 44 27 10 2 — 5 2
New Bedford, MA 13 7 4 2 — — 1 Savannah, GA 38 27 7 2 1 1 4
New Haven, CT 27 20 4 3 — — 3 St. Petersburg, FL 42 25 10 4 2 1 1
Providence, RI 53 40 7 2 — 1 3 Tampa, FL 164 110 42 4 6 2 8
Somerville, MA 4 1 1 2 — — — Washington, D.C. 89 51 25 10 3 — 6
Springfield, MA 28 20 3 2 1 2 2 Wilmington, DE 8 6 1 1 — — 1
Waterbury, CT 17 11 5 — 1 — 3 E.S. Central 687 450 182 32 13 10 45
Worcester, MA 37 28 8 — — 1 5 Birmingham, AL 141 82 50 4 2 3 7
Mid. Atlantic 1,601 1,068 391 77 31 34 75 Chattanooga, TN 78 62 14 2 — — 5
Albany, NY 37 22 9 2 1 3 — Knoxville, TN 76 46 24 3 2 1 3
Allentown, PA 15 9 5 — — 1 — Lexington, KY 33 22 9 — — 2 1
Buffalo, NY 79 58 15 3 1 2 4 Memphis, TN 122 74 34 10 3 1 12
Camden, NJ 23 13 9 — 1 — 1 Mobile, AL 73 60 9 2 2 — 4
Elizabeth, NJ 17 13 4 — — — 2 Montgomery, AL 34 23 9 1 1 — 4
Erie, PA 46 33 6 5 2 — 4 Nashville, TN 130 81 33 10 3 3 9
Jersey City, NJ 18 10 7 — 1 — 2 W.S. Central 1,223 771 286 94 46 23 53
New York City, NY 869 598 212 34 16 9 36 Austin, TX 90 50 24 10 1 5 3
Newark, NJ 26 10 12 2 1 1 1 Baton Rouge, LA 75 47 14 4 8 2 —
Paterson, NJ 15 6 2 1 — 6 1 Corpus Christi, TX 46 36 7 2 — 1 3
Philadelphia, PA 191 99 57 19 5 11 4 Dallas, TX 162 97 41 14 7 3 3
Pittsburgh, PA§ 37 22 10 4 1 — 5 El Paso, TX 92 62 21 5 4 — 2
Reading, PA 30 22 4 4 — — 6 Fort Worth, TX U U U U U U U
Rochester, NY 40 22 15 1 1 1 3 Houston, TX 316 189 83 30 8 3 14
Schenectady, NY 13 12 1 — — — — Little Rock, AR 38 25 8 3 1 1 —
Scranton, PA 24 21 3 — — — 1 New Orleans, LA U U U U U U U
Syracuse, NY 63 52 10 — 1 — 4 San Antonio, TX 218 153 41 16 5 3 20
Trenton, NJ 28 21 6 1 — — — Shreveport, LA 74 41 18 6 7 2 —
Utica, NY 15 13 1 1 — — 1 Tulsa, OK 112 71 29 4 5 3 8
Yonkers, NY 15 12 3 — — — — Mountain 915 586 217 67 21 23 51
E.N. Central 1,697 1,111 414 115 29 27 88 Albuquerque, NM 94 60 29 2 1 2 9
Akron, OH 45 24 16 4 1 — 4 Boise, ID 42 32 5 5 — — 2
Canton, OH 35 17 14 2 1 1 4 Colorado Springs, CO 77 44 25 6 1 1 1
Chicago, IL 220 136 47 30 6 1 13 Denver, CO 62 37 17 4 1 3 2
Cincinnati, OH 66 44 17 3 — 2 7 Las Vegas, NV 242 144 64 23 6 4 18
Cleveland, OH 194 122 51 12 4 5 4 Ogden, UT 36 29 5 2 — — 1
Columbus, OH 126 83 31 6 3 3 6 Phoenix, AZ 152 85 35 16 6 10 8
Dayton, OH 94 66 23 3 — 2 9 Pueblo, CO 32 24 7 — 1 — 1
Detroit, MI 147 71 53 16 4 2 3 Salt Lake City, UT 115 80 21 8 4 2 4
Evansville, IN 41 28 13 — — — 4 Tucson, AZ 63 51 9 1 1 1 5
Fort Wayne, IN 59 43 13 2 1 — 2 Pacific 1,349 916 281 79 34 38 128
Gary, IN 15 10 4 1 — — 2 Berkeley, CA 18 11 4 — — 3 1
Grand Rapids, MI 38 29 6 2 — 1 3 Fresno, CA 104 68 24 5 4 3 12
Indianapolis, IN 190 127 50 6 3 4 7 Glendale, CA 39 33 6 — — — 6
Lansing, MI 52 34 13 3 1 1 4 Honolulu, HI 41 31 3 5 — 2 4
Milwaukee, WI 81 58 15 5 2 1 5 Long Beach, CA 62 35 17 3 3 4 6
Peoria, IL 46 36 6 3 — 1 — Los Angeles, CA 178 110 44 14 8 2 18
Rockford, IL 61 44 12 5 — — 1 Pasadena, CA 20 15 4 1 — — 2
South Bend, IN 44 28 7 6 2 1 3 Portland, OR 85 61 14 8 1 1 7
Toledo, OH 77 56 13 6 1 1 3 Sacramento, CA 160 105 34 13 5 3 13
Youngstown, OH 66 55 10 — — 1 4 San Diego, CA 133 83 26 9 2 13 15
W.N. Central 634 403 171 29 18 13 26 San Francisco, CA 109 75 23 5 3 2 14
Des Moines, IA 54 41 11 2 — — 2 San Jose, CA 149 110 36 2 — 1 12
Duluth, MN 23 13 9 1 — — — Santa Cruz, CA 18 16 1 1 — — 2
Kansas City, KS 69 39 22 5 3 — 1 Seattle, WA 89 62 20 5 1 1 7
Kansas City, MO 59 39 12 4 2 2 3 Spokane, WA 50 38 5 2 3 2 6
Lincoln, NE 51 38 8 2 3 — — Tacoma, WA 94 63 20 6 4 1 3
Minneapolis, MN 58 32 18 1 4 3 3 Total¶ 9,657 6,328 2,308 585 231 196 572
Omaha, NE 55 38 12 2 2 1 7
St. Louis, MO 37 17 14 3 — 3 1
St. Paul, MN 42 30 11 — — 1 6
Wichita, KS 186 116 54 9 4 3 3
U: Unavailable. —: No reported cases.
* Mortality data in this table are voluntarily reported from 122 cities in the United States, most of which have populations of >100,000. A death is reported by the place of its occurrence and
by the week that the death certificate was filed. Fetal deaths are not included.
† Pneumonia and influenza.
§ Because of changes in reporting methods in this Pennsylvania city, these numbers are partial counts for the current week. Complete counts will be available in 4 to 6 weeks.
¶ Total includes unknown ages.

MMWR / September 17, 2010 / Vol. 59 / No. 36 1199

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