Vol19no1 PDF Version

Peer-Reviewed Journal Tracking and Analyzing Disease Trends pages 1188

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Emerging Infectious Diseases www.cdc.gov/eid Vol. 19, No. 1, January 2013
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p. 79
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On the Cover
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Disease incidence rates declined in areas with
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polyomavirus may play a role in tumor
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Organizing and prioritizing data collection
may lead to informed assessment and guide
decision making.

Temperate regions, school-aged children, and
native peoples were particularly susceptible to
the first wave of a novel influenza strain.
Dispatches

January 2013
p. 120
p. 162
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p. 180
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Photos: David Snyder / CDC Foundation

, a bacterial foodborne patho-
gen, can cause meningitis, bacteremia, and complications
during pregnancy. This report summarizes listeriosis out-
breaks reported to the Foodborne Disease Outbreak Sur-
veillance System of the Centers for Disease Control and
Prevention during 19982008. The study period includes
the advent of PulseNet (a national molecular subtyping
network for outbreak detection) in 1998 and the

Initiative (enhanced surveillance for outbreak investigation)
in 2004. Twenty-four confirmed listeriosis outbreaks were
reported during 19982008, resulting in 359 illnesses, 215
hospitalizations, and 38 deaths. Outbreaks earlier in the
study period were generally larger and longer. Serotype
4b caused the largest number of outbreaks and outbreak-
associated cases. Ready-to-eat meats caused more early
outbreaks, and novel vehicles (i.e., sprouts, taco/nacho
salad) were associated with outbreaks later in the study
period. These changes may reflect the effect of PulseNet
and the

Initiative and regulatory initiatives de-
signed to prevent contamination in ready-to-eat meat and
poultry products.
Listeriosis Outbreaks and
Associated Food Vehicles,
United States, 19982008
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Emerging Infectious Diseases www.cdc.gov/eid Vol. 19, No. 1, January 2013 1
Medscape, LLC is pleased to provide online continuing medical education (CME) for this journal article, allowing clinicians the
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R
C P C G E C D G S C T U C F C B V C J W X Y X Z W X [ \ ] H Q J G S Q I O D G S C T U C F C B V C J W X Y X Z W ^
_
C G J O Q O K ` V M C F S Q a C E
Upon completion of this activity, participants will be able to:
Assess the general epidemiology of listeriosis
Analyze the epidemiology of listeriosis in the United States between 1998 and 2008
Distinguish the most common food vehicle for listeriosis during the study period
Evaluate clinical outcomes of listeriosis
b c
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I B G E f A g J h F i G O Y
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Y Technical Writer/Editor, k l 5 8 6 < m 6 n m o 5 p 4 < 7 q > r < > 5 3 > 5 > s r < > p t 7 > q 8 5 u v w 7 l 3 > x s y 8 9 p z 3 m { / | { w 3 >
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California, Irvine. r < > p t 7 > q 8 5 u 2 w 3 8 t 5 > 0 s 5 6 3 { / r { w 3 > ; < > p t 7 > 5 ; m 7 8 5 t 5 } 3 m 4 o < m 3 m p < 3 t 8 5 t 3 4 < 7 m > w < ~ > s
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Author affiliation: Centers for Disease Control and Prevention,
Atlanta, Georgia, USA
DOI: http://dx.doi.org/10.3201/eid1901.120393
SYNOPSIS

2 Emerging Infectious Diseases www.cdc.gov/eid Vol. 19, No. 1, January 2013
Listeriosis Outbreaks, United States, 19982008
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Figure 1. Reported listeriosis outbreaks by single-state or
multistate status and total number of outbreak-associated cases,
Foodborne Disease Outbreak Surveillance System, United States,
19982008 (n = 24 outbreaks). White bar sections indicate single-
state and multistate outbreaks, gray bar sections indicate multistate
outbreaks, and black line indicates total ill.
SYNOPSIS

Table 1. Reported listeriosis outbreaks (n = 24) by year, Foodborne Disease Outbreak Surveillance System, United States, 1998
2008*
Study period,
year Multistate Duration, d
Total no.
cases
No.
hospitalizations
No.
deaths

serotype Food vehicle (reference)
Early
1998 Yes 389 108 101 14 4b Frankfurters ( )
No NA 4 NA NA NA Frankfurters
1999 No NA 6 NA NA NA Unknown
No NA 4 NA NA 1/2a Frankfurters
No NA 5 5 1 NA Deli meat
Yes NA 11 NA NA 1/2a Pt
No NA 2 2 1 NA Deli meat
2000 No 122 13 13 0 4b Mexican-style cheese ( )
Yes 151 30 29 4 1/2a Deli meat ( )
2001 No 3 28 0 0 1/2a Deli meat ( )
2002 Yes 100 54 NA 8 4b Deli meat ( )
2003 No NA 3 NA NA 4b Unknown
No NA 12 12 1 4b Mexican-style cheese
Late
2005 No 32 6 6 0 4b Unknown
No 7 3 3 0 1/2b Grilled chicken
Yes 37 13 13 1 1/2a Deli meat
No 36 12 12 0 4b Mexican-style cheese
2006 No 7 2 1 1 4b Unknown
No 2 2 0 0 1/2b Taco or nacho salad
No 1 3 2 1 4b Cheese
2007 No 163 5 5 3 4b Milk ( )
2008 No 47 5 5 3 1/2a Tuna salad ( )
Yes 351 20 2 0 1/2a Sprouts
Yes 150 8 4 0 1/2a Mexican-style cheese ( )
*NA, no data available.
No listeriosis cases were reported in 2004.
Includes laboratory-confirmed and epidemiologically linked cases.
Table 2. Characteristics of 24 listeriosis outbreaks by implicated food categories, Foodborne Disease Outbreak Surveillance System,
United States, 19982008*
Food category
No.
outbreaks
Total no.
cases
No. (%)
hospitalized
No. deaths
(CFR, %)
Age group, y, no. (%) No. (%)
female
<1 149 >50
Deli meats 6 132 49 (37) 15 (11) NA NA NA 40 (45)
Frankfurters 3 116 101 (87) 14 (12) 0 52 (46) 60 (54) 57 (49)
Other meats 2 14 3 (21) 0 NA NA NA 2 (67)
Mexican-style cheese 4 45 41 (91) 1 (2) 8 (18) 32 (73) 4 (9) 37 (84)
Other dairy products 2 8 7 (88) 4 (50) 1 (13) 1 (13) 6 (75) 4 (50)
Salad/other 3 27 7 (26) 3 (11) 0 7 (26) 20 (74) 16 (59)
Unknown 4 17 7 (41) 1 (6) 0 1 (13) 7 (88) 4 (50)
Overall 24 359 215 (60) 38 (11) 10 (4) 120 (50) 108 (45) 160 (54)
*CFR, case-fatality rate; NA, not available.
Percentages were calculated on the basis of available information on age distribution (17 outbreaks) and sex (19 outbreaks) for 238 and 296 patients,
respectively.

!

" #

Figure 2. Distribution of single-state and multistate outbreaks of
listeriosis, 19982008, Foodborne Disease Outbreak Surveillance
System, United States, 19982008 (n = 24 outbreaks). Dark gray
indicates single-state and multistate outbreaks, and light gray
indicates multistate outbreaks. Values indicate total outbreaks in
each state. The grand total of outbreaks indicated in each state is
>24 because of multistate outbreaks.
Table 3. Characteristics of 24 listeriosis outbreaks by $ % & ' ( ) % * + , - , . / ' , 0 ( - ( & serotype, Foodborne Disease Outbreak Surveillance
System, United States, 19982008*
Serotype No. outbreaks Total no. cases
Median duration, d
(range)
No.
cases/outbreak
No. (%)
hospitalized
No. deaths
(CFR, %)
4b 10 218 68 (1389) 22 152 (70) 28 (13)
1/2a 8 119 99 (3351) 15 53 (45) 8 (7)
1/2b 2 5 5 (27) 3 3 (60) 0
Unknown 4 17 NA 4 7 (41) 2 (12)
*NA, not available.
SYNOPSIS
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2 6 1 O 2 4 C P 8 : B M 8 : 3 4 9 ; < 5 8 9 N 5 9 6 C 2 A B 6 2 C B 9 6 B 6 2 C : 8 2 4 C F 9 N
C P 8 : B 4 C 8 < B 9 4 B 4 9 ; C 7 < 8 2 M 4 D Y j K 1 ; < B 6 ? C P 8 4 C ; 1 3 U 8 < B 9 1 2 6 1 2 C
: 8 2 4 C k 2 1 1 B C B 9 6 2 : : B 4 C 8 < B 9 4 B 4 9 ; C 7 < 8 2 M 4 2 4 4 9 5 B 2 C 8 1 O B C P l 8 m R
B 5 2 6 R 4 C 3 : 8 5 P 8 8 4 8 4 B 6 5 8 C P 8 4 C ; 1 3 U 8 < B 9 1 D S S K Z n 9 U < 8 Q 8 6 C
U 9 4 C U 2 4 C 8 ; < B \ 2 C B 9 6 5 9 6 C 2 A B 6 2 C B 9 6 L B C B 4 6 8 5 8 4 4 2 < 3 C 9 A 2 B 6 R
C 2 B 6 4 C < B 5 C 4 8 U 2 < 2 C B 9 6 9 N U < 8 U 2 4 C 8 ; < B \ 8 1 2 6 1 U 9 4 C U 2 4 C 8 ; < B \ 8 1
1 2 B < 3 U < 9 1 ; 5 C 4 2 6 1 4 C < B 5 C 4 2 6 B C 2 C B 9 6 B 6 C P 8 U 9 4 C U < 9 5 8 4 4 B 6 ?
8 6 Q B < 9 6 A 8 6 C Z
n P 8 9 ; C 7 < 8 2 M 4 2 4 4 9 5 B 2 C 8 1 O B C P l 8 m B 5 2 6 R 4 C 3 : 8 5 P 8 8 4 8
U q I I 1 9 8 4 6 9 C 5 9 : : 8 5 C B 6 R
N 9 < A 2 C B 9 6 9 6 8 C P 6 B 5 B C 3 9 < U < 8 ? 6 2 6 5 3 4 C 2 C ; 4 L 7 ; C 9 C P 8 < 4 ; < R
Q 8 B : : 2 6 5 8 1 2 C 2 B 6 1 B 5 2 C 8 C P 2 C U < 8 ? 6 2 6 C r B 4 U 2 6 B 5 O 9 A 8 6 P 2 Q 8
1 B 4 U < 9 U 9 < C B 9 6 2 C 8 : 3 P B ? P 8 < < 2 C 8 4 9 N : B 4 C 8 < B 9 4 B 4 D s K Z [ 6 Q 8 4 C B ? 2 R
C B 9 6 4 9 N 9 ; C 7 < 8 2 M 4 2 4 4 9 5 B 2 C 8 1 O B C P l 8 m B 5 2 6 R 4 C 3 : 8 5 P 8 8 4 8
P 2 Q 8 B 6 N 9 < A 8 1 < 8 5 9 A A 8 6 1 2 C B 9 6 4 N 9 < U < 8 ? 6 2 6 C O 9 A 8 6 C 9
2 Q 9 B 1 5 9 6 4 ; A U C B 9 6 9 N ; 6 U 2 4 C 8 ; < ; ? @ 1 A B 6 B 4 C < 2 C B 9 6 O B C P ? < 8 2 C 8 < 2 ; C P 9 < B C 3 C 9 U < 8 Q 8 6 C
2 6 1 5 9 6 C < 9 : 9 ; C 7 < 8 2 M 4 9 N : B 4 C 8 < B 9 4 B 4 2 6 1 9 C P 8 < N 9 9 1 7 9 < 6 8 B 6 R
N 8 5 C B 9 6 4 C P < 9 ; ? P A 2 6 1 2 C 9 < 3 U < 8 Q 8 6 C B 9 6 5 9 6 C < 9 : 4 2 6 1 4 2 N 8 C 3
4 C 2 6 1 2 < 1 4 L A 9 < 8 4 C < B 6 ? 8 6 C C 9 9 : 4 N 9 < B 6 4 U 8 5 C B 9 6 2 6 1 5 9 A R
U : B 2 6 5 8 L 2 6 1 2 6 8 6 P 2 6 5 8 1 2 7 B : B C 3 C 9 < 8 A 9 Q 8 5 9 6 C 2 A B 6 2 C 8 1
N 9 9 1 4 N < 9 A C P 8 N 9 9 1 4 ; U U : 3 D 8 Z ? Z L A 2 6 1 2 C 9 < 3 < 8 5 2 : : 4 K Z r 9 O R
8 Q 8 < L 1 2 B < 3 U < 9 1 ; 5 C 4 B A U 9 < C 8 1 N < 9 A 5 9 ; 6 C < B 8 4 O B C P 1 B N N 8 < 8 6 C
< 8 ? ; : 2 C 9 < 3 5 9 6 C < 9 : 4 L P 9 A 8 A 2 1 8 U < 9 1 ; 5 C 4 9 < U < 9 1 ; 5 C 4 A 2 1 8
7 3 ; 6 : B 5 8 6 4 8 1 A 2 6 ; N 2 5 C ; < 8 < 4 L 2 6 1 U < 9 1 ; 5 C 4 5 9 6 C 2 A B 6 2 C 8 1
2 N C 8 < U 2 4 C 8 ; < B \ 2 C B 9 6 5 9 6 C B 6 ; 8 C 9 U 9 4 8 < 8 ? ; : 2 C 9 < 3 2 6 1 8 6 R
N 9 < 5 8 A 8 6 C 5 P 2 : : 8 6 ? 8 4 D Y Y K Z n P 8 < 8 N 9 < 8 L 2 1 1 B C B 9 6 2 : U < 8 Q 8 6 R
C B 9 6 2 6 1 8 1 ; 5 2 C B 9 6 8 N N 9 < C 4 2 < 8 4 C B : : 6 8 8 1 8 1 C 9 8 N N 8 5 C B Q 8 : 3
U < 9 C 8 5 C 4 ; 4 5 8 U C B 7 : 8 U 9 U ; : 2 C B 9 6 4 Z
I 8 Q 8 < 2 : 6 9 Q 8 : N 9 9 1 Q 8 P B 5 : 8 4 L B 6 5 : ; 1 B 6 ? 4 U < 9 ; C 4 2 6 1
C 2 5 9 t 6 2 5 P 9 4 2 : 2 1 L O 8 < 8 B A U : B 5 2 C 8 1 B 6 : B 4 C 8 < B 9 4 B 4 9 ; C 7 < 8 2 M 4
1 8 4 5 < B 7 8 1 B 6 C P B 4 < 8 Q B 8 O Z n P < 8 8 2 1 1 B C B 9 6 2 : 6 9 Q 8 : Q 8 P B 5 : 8
9 ; C 7 < 8 2 M 4 P 2 Q 8 4 B 6 5 8 7 8 8 6 < 8 U 9 < C 8 1 Z [ 6 E X F X L P 9 ? P 8 2 1
5 P 8 8 4 8 O 2 4 2 4 4 9 5 B 2 C 8 1 O B C P u : B 4 C 8 < B 9 4 B 4 5 2 4 8 4 B 6 v 9 ; B 4 B 2 6 2
D Y w K L 2 6 1 5 8 : 8 < 3 B 6 2 1 B 5 8 1 5 P B 5 M 8 6 4 2 : 2 1 O 2 4 2 4 4 9 5 B 2 C 8 1
O B C P 2 6 9 ; C 7 < 8 2 M 9 N F X 5 2 4 8 4 2 A 9 6 ? P 9 4 U B C 2 : B \ 8 1 U 2 C B 8 6 C 4 B 6
n 8 m 2 4 D S j K Z x P 9 : 8 5 2 6 C 2 : 9 ; U 8 N < 9 A 2 4 B 6 ? : 8 N 2 < A O 2 4 2 4 R
4 9 5 B 2 C 8 1 O B C P 2 : 2 < ? 8 L A ; : C B 4 C 2 C 8 9 ; C 7 < 8 2 M D 6 y F k z 5 2 4 8 4 K B 6
E X F F L 2 6 1 5 2 ; 4 8 1 C P 8 A 9 4 C 1 8 2 C P 4 D 6 y J J K N < 9 A 2 6 9 ; C 7 < 8 2 M
9 N N 9 9 1 7 9 < 6 8 B : : 6 8 4 4 B 6 C P 8 { 6 B C 8 1 I C 2 C 8 4 B 6 6 8 2 < : 3 p X 3 8 2 < 4
D T s K Z q ; C 7 < 8 2 M 4 C P 2 C O 8 < 8 : B 6 M 8 1 C 9 N 9 9 1 Q 8 P B 5 : 8 4 O B C P A ; : R
C B U : 8 B 6 ? < 8 1 B 8 6 C 4 2 < 8 6 9 C 8 O 9 < C P 3 7 8 5 2 ; 4 8 B 1 8 6 C B N 3 B 6 ? 2 U 2 < R
C B 5 ; : 2 < B 6 ? < 8 1 B 8 6 C C P 2 C B 4 5 9 6 C 2 A B 6 2 C 8 1 5 2 6 7 8 5 P 2 : : 8 6 ? B 6 ?
D 8 Z ? Z L 5 8 : 8 < 3 B 6 5 P B 5 M 8 6 4 2 : 2 1 L C 2 5 9 t 6 2 5 P 9 4 2 : 2 1 K Z | < 8 Q 8 6 C B 6 ?
_ ` a b c b d e f b g h c h i 5 9 6 C 2 A B 6 2 C B 9 6 9 N N 9 9 1 B 4 1 B N } 5 ; : C ~ C P 8
7 2 5 C 8 < B 2 U < 9 : B N 8 < 2 C 8 ; 6 1 8 < 2 5 B 1 B 5 5 9 6 1 B C B 9 6 4 L P B ? P 4 2 : C 5 9 6 R
5 8 6 C < 2 C B 9 6 4 L 2 6 1 : 9 O C 8 A U 8 < 2 C ; < 8 4 Z x 8 8 m U 8 5 C C P 2 C N ; C ; < 8
9 ; C 7 < 8 2 M B 6 Q 8 4 C B ? 2 C B 9 6 4 O B : : 5 9 6 C B 6 ; 8 C 9 B 1 8 6 C B N 3 6 8 O N 9 9 1
Q 8 P B 5 : 8 4 C P 2 C 5 2 6 C < 2 6 4 A B C _ ` a b c b d e f b g h c h i C 9 P ; A 2 6 4 2 6 1
B 1 8 6 C B N 3 6 8 O 9 U U 9 < C ; 6 B C B 8 4 N 9 < 5 9 6 4 ; A 8 < U < 8 Q 8 6 C B 9 6 8 1 ; 5 2 R
C B 9 6 L B 6 1 ; 4 C < 3 B 6 C 8 < Q 8 6 C B 9 6 4 C 9 < 8 1 ; 5 8 5 9 6 C 2 A B 6 2 C B 9 6 L 2 6 1
< 8 ? ; : 2 C 9 < 3 5 9 6 C < 9 : U 9 : B 5 B 8 4 Z
x 8 N 9 ; 6 1 C P 2 C 4 8 < 9 C 3 U 8 k 7 5 2 ; 4 8 1 A 9 < 8 9 ; C 7 < 8 2 M 4 L
A 9 < 8 9 ; C 7 < 8 2 M R 2 4 4 9 5 B 2 C 8 1 5 2 4 8 4 L 2 6 1 < 8 4 ; : C 8 1 B 6 P B ? P 8 < < 2 C 8 4
Figure 3. Incidence of all cases (per
million) and outbreaks of listeriosis,
19782008, United States. White
bar sections indicate single-state
outbreaks, gray bar sections indicate
multisite outbreaks, and black line
indicates incidence per million. Data
were obtained from the Foodborne
Diseases ActiveSurveillance Network
(FoodNet) and the Foodborne Disease
Outbreak Surveillance System. Data
are as of June 2010.

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The opinions expressed by authors contributing to this
journal do not necessarily reflect the opinions of the Centers for
Disease Control and Prevention or the institutions with which
the authors are affiliated.
We conducted a retrospective, observational, popula-
tion-based study to investigate the effect of staphylococcal
infections on the hospitalization of children in California
during 19852009. Hospitalized children with staphylococ-
cal infections were identified through the California Office
of Statewide Health Planning and Development discharge
database. Infections were categorized as community on-
set, community onset health careassociated, or hospital
onset. Infection incidence was calculated relative to all
children and to those hospitalized in acute-care facilities. A
total of 140,265 records were analyzed. Overall incidence
increased from 49/100,000 population in 1985 to a peak of
83/100,000 in 2006 and dropped to 73/100,000 in 2009.
Staphylococcal infections were associated with longer
hospital stays and higher risk for death relative to all-cause
hospitalizations of children. The number of methicillin-re-
sistant infections increased, and
the number of methicillin-susceptible infections
remained unchanged. Children <3 years of age, Blacks,
and those without private insurance were at higher risk for
hospitalization.
Staphylococcal Infections
in Children, California, USA,
19852009
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RESEARCH
Author affiliation: Stanford University School of Medicine, Stanford,
California, USA
DOI: http://dx.doi.org/10.3201/eid1901.111740 1
Current affiliation: Foodia, San Francisco, California, USA.
Medscape, LLC designates this Journal-based CME activity for a maximum of 1 = > = ? @ = A B C D E F G H I A G D J K C L M N
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passing score and complete the evaluation at O O O P Q R S T U V W R P X Y Z [ \ X ] Y ^ V _ [ R ` S ; (4) view/print certificate.
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Assess temporal trends of staphylococcal infection among hospitalized children
Distinguish risk factors for staphylococcal infection among hospitalized children
Analyze clinical characteristics of staphylococcal infection among hospitalized children
Evaluate the microbiology of staphylococcal infection among hospitalized children.
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Staphylococcal Infections in Children, California

RESEARCH
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Figure 1. Hospitalization trends for children <17 years of age,
California, USA, 19852009. The incidence of hospitalizations and
mean length of stay for children with staphylococcal infection (SI)
are compared with the incidences of hospitalizations for cellulitis
(Diagnosis Related Group [DRG] 279 or Medicare Severity
DRG 602603) and for all-cause hospitalizations of children. The
horizontal line separates the incidence graphs, which are to be
read against the left axis, and the graph for length of stay, which is
read against the right axis.
RESEARCH

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Figure 2. Hospitalization trends for children <17 years of age with staphylococcal infection, California, USA, 19852009. Data are no. of
patients/100,000 population, except as indicated for children <1 year of age. A) Trends by sex. B) Trends by race. C) Trends by age group,
age >1 year. D) Trends for infants (children <364 days of age) compared with trends for children 117 years of age; *number/100,000
children <1 year of age.
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Figure 3. Hospitalization trends for children <17 years of age with
staphylococcal infection (SI), California, USA, 19852009. A)
Population incidence of particular SI-associated diagnoses relative
to the incidence of the same diagnoses in 2000. B) Percentage
of all SI-coded hospitalization records that were further classified
by various types of SI; the classification code has been available
only since 1994. C) Trends for types of SI with cellulitis; available
only since 1994. Data are no. of patients/100,000 population. D)
Trends for types of SI with pneumonia; available only since 1999.
Data are no. of patients/1,000,000 population. E) Trends for types
of SI with septicemia; available only since 1998. Data are no. of
patients/1,000,000 population. MSSA, methicillin-susceptible

; MRSA, methicillin-resistant

.
RESEARCH


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Figure 4. Hospitalization trends for children 1 month to 17 years
of age with infection, by infection onset,
California, USA, 19962009. Data are no. of patients/100,000
population. A) Incidence of methicillin-susceptible . B)
Incidence of methicillin-resistant
RESEARCH

Table 4. Medical conditions associated with community-onset staphylococcal infections in non-neonate children, California, 1996
2009*
Medical condition
Type of infection
All, N = 31,893 MRSA, n = 12,667 MSSA, n = 13,605 Other, n = 3,073
Skin/soft tissue infection
Records with diagnosis, % 71 91 66 36
Cellulitis, % 84 90 80 63
Deaths, no. 1 0 1 0
Mean (SE) LOS, d 4.5 (<0.1) 4.3 (<0.1) 4.6 (<0.1) 5.5 (0.2)
Median (IQR) LOS, d 3 (25) 3 (25) 3 (25) 4 (26)
Sepsis, shock, or bacteremia
Deaths, no. 15 1 6 1
Mean (SE) LOS, d 8.0 (0.2) 10.9 (0.4) 8.3 (0.2) 6.6 (0.3)
Median (IQR) LOS, d 6 (49) 8 (513) 6 (410) 5 (37)
Respiratory infection
Deaths, no. 31 2 19 1
Mean (SE) LOS, d 7.1 (0.1) 6.9 (0.2) 7.3 (0.2) 6.6 (0.3)
Median (IQR) LOS, d 5 (38) 4 (37) 5 (38) 4 (37)
Musculoskeletal infections
Deaths, no. 0 0 0 0
Mean (SE) LOS, d 9.0 (0.1) 11.0 (0.4) 8.4 (0.1) 9.4 (0.7)
Median (IQR) LOS, d 7 (410) 7 (513) 6 (49) 6 (410)
*MRSA, methicillin-resistant ! " # $ % & ' & ' ' ( ) ! ( * + ( ) ; MSSA, methicillin-sensitive , ! ( * + ( ) ; LOS, length of stay in hospital; IQR, interquartile range
A particular staphylococcal type could not be determined for 11% of the records; thus, added together, numbers in the MRSA, MSSA, and Other
staphylococci groups do not equal the number in All types of staphylococcal infection group. Diagnostic groups are not mutually exclusive; therefore,
percentages in columns total >100.
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RESEARCH

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dihydropteroate synthase
(DHPS) mutations have been associated with failure of
sulfa prophylaxis; their effect on the outcome of patients
with
. < 9 8 : 3 ; 0 4 8 8
pneumonia (PCP) remains controversial.
. < 9 8 : 3 ; 0 4 8 8
DHPS polymorphisms and genotypes were
identified in 112 cases of PCP in 110 HIV-infected patients
by using PCR single-strand conformation polymorphism.
Of the 110 patients observed, 21 died; 18 of those deaths
were attributed to PCP. Thirty-three percent of the PCP
cases involved a
. < 9 8 : 3 ; 0 4 8 8
strain that had 1 or both DHPS
mutations. The presence or absence of DHPS mutations
Pneumocystis jirovecii Genotype
Associated with Increased Death
Rate of HIV-infected Patients
with Pneumonia
= > ? @ A @ B C D C E F G F E @ H I @ > J F J F @ K @ F L L @ E J H M @ J G F N O P @ Q Q R H S F T @ B L > U @ V F T @ E @ H A > E R W M F > G G > X F L L F B > G J H
M V F L F Y Y > K @ E V > T Z H @ E D M V F L F Y Y > = [ \ @ ] Z > G
Author affiliations: Hospices Civils de Lyon, Lyon, France (M.
Rabodonirina); Service dHygine, Epidmiologie et Prvention,
Hpital Edouard Herriot, Lyon (L. Vaillant, R.-P. Gillibert, P.
Vanhems); Institut de Veille Sanitaire, Paris, France (L. Vaillant);
Centre Hospitalier Universitaire Vaudois and University of
Lausanne, Lausanne, Switzerland (P. Taff, A. Nahimana, P.M.
Hauser); and Claude Bernard Lyon 1 University, Lyon (P. Vanhems)
Medscape, LLC designates this Journal-based CME activity for a maximum of 1 ^ _ ^ ` a ^ b c d e f g h i j b h e k l d m n o
TM
. Physicians
passing score and complete the evaluation at p p p q r s t u v w x s q y z { | } y ~ z w | s t ; (4) view/print certificate.
s s w u s t w s s v s r s z x z w y t w s s v s r s z
s w z { } s v s u
Distinguish the rate of dihydropteroate synthase (DHPS) mutations among patients with ` e g i n d l n l h g e l l
pneumonia (PCP) in the current study
Analyze patient characteristics associated with a higher rate of DHPS mutations
Assess variables associated with sulfa resistance among cases of PCP in the current study
Evaluate the effects of DHPS mutations on the risk of death among cases of PCP in the current study.

t y z
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y s u Technical Writer/Editor, e h f l f e d l g n l n e c n e n l n g n h e e c _ l c e n g e n c n k l n g n e k g
h e e c d l c l c h e c d l g n l n

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Health Sciences Clinical Professor; Residency Director, Department of Family Medicine, University of
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RESEARCH
had no effect on the PCP mortality rate within 1 month,
whereas type 7 and mechanical ventilation at
PCP diagnosis were associated with an increased risk
of death caused by PCP. Mechanical ventilation at PCP
diagnosis was also associated with an increased risk of
sulfa treatment failure at 5 days.

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Table 1. dihydropteroate synthase genotype distribution according to clinical parameters of 112 cases of
pneumonia in 110 HIV-positive patients from 5 university hospitals in Lyon, France*
Characteristic
DHPS genotype
p value
Wild type, n = 75 M2, n = 17 M3, n = 20
Age at PCP diagnosis, y
140 41 10 14 0.62
4160 31 7 5
6180 3 0 1
Sex
M 62 14 19 0.38
F 13 3 1
Diagnosis year
1993 6 2 0 0.58
1994 24 3 4
1995 20 5 6
1996 25 7 10
CD4 cell count, median cells/PL
050 42 15 11 0.05
51100 17 0 4
>100 10 0 2
First-line treatment
SMX/TMP 59 14 15 0.90
Pentamidine or atovaquone 14 3 5
Others 2 0 0
SMX/TMP allergy
Yes 4 0 3 0.27
No 71 17 17
Corticotherapy at PCP diagnosis
Yes 18 1 3 0.25
No 57 16 17
Mechanical ventilation at PCP diagnosis
Yes 11 0 3 0.26
No 64 17 17
SSCP type 1 3 6 1 <0.001
7 3 0 6
10 2 1 1
Others 30 3 3
Co-infected 37 7 9
Outcome within 1 month
Favorable 61 16 14 0.39
Death attributed to PCP 12 1 5
Death not attributed to PCP 2 0 1
*Data derived from Fishers exact test. DHPS, dihydropteroate synthase; M, mutation; SSCP, single-strand conformation polymorphism; PCP,
pneumonia; SMX/TMP, sulfamethoxazole and trimethoprim.
Data missing for 11 patients.
RESEARCH

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RESEARCH
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Figure. Kaplan-Meier survival plots for 4 variables of 112
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+ ) " # ' ( J $ " " / C * + # & ) & ( $ / > ? # " ? " + & , M ] X P A L " + $ ? " / > E " # <
? % ' + E + C ' $ % ' ( # & ) & ? $ " # + ' ( - " / - & , ' ( $ % & ' E E . ( & # & + ? " ( + &
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J & ( " $ > ? & + E ' J % $ % * - & , ' ! ! & # & ( $ ? * $ % " J & ( ' ) $ # * ' $ + A d . # $ % & #
+ $ . , ' & + " ! 9 : ; < = = : 9 $ > ? & @ ) " . / , % & / ? . ( , & # + $ * ( , ' ( J " !
0 1 2 3 4 5 6 7 8 3 3 - ' # . / & ( ) & * ( , , # . J # & + ' + $ * ( ) & K > ) / ' ( ' ) ' * ( + * ( ,
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e f g h i j k l m n o l h p q
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t u s w s t } { v ~ v w w s ~ } t w z z
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l l l h f l q

RESEARCH

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5 4 4 3 @ A A B C B J E B J M F @ L
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: : 8 8 $ 8 " : E Z < " " Q 3 8 5 8 3 $
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Since 2000 in the United Kingdom, infections caused by
spore-forming bacteria have been associated with increasing
illness and death among persons who inject drugs (PWID).
To assess temporal and geographic trends in these illnesses
(botulism, tetanus, f g h i j k l m l n o p h q r l infections and anthrax),
we compared rates across England and Scotland for 2000
2009. Overall, 295 infections were reported: 1.45 per 1,000
PWID in England and 4.01 per 1,000 PWID in Scotland. The
higher rate in Scotland was mainly attributable to f t p h q r l
infection and anthrax; rates of botulism and tetanus were
comparable in both countries. The temporal and geographic
clustering of cases of f t p h q r l and anthrax into outbreaks
suggests possible contamination of specific heroin batches;
in contrast, the more sporadic nature of tetanus and botulism
cases suggests that these spores might more commonly
exist in the drug supply or local environment although at
varying levels. PWID should be advised about treatment
programs, injecting hygiene, risks, and vaccinations.
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Infections with Spore-forming
Bacteria in Persons Who Inject
Drugs, 20002009

Author affiliations: Health Protection Scotland, Glasgow, Scotland,
UK (N.E. Palmateer, K. Roy, C.N. Ramsay, D.J. Goldberg); Health
Protection Agency, London, UK (V.D. Hope, A. Marongiu, J.M.
White, K.A. Grant, F. Ncube); and London School of Hygiene and
Tropical Medicine, London (V.D. Hope)
RESEARCH

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Infections with Spore-forming Bacteria in PWID
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p u j h z v h j k h m h r n m y s m h v p m f v h i y f j r o q s o
r j g f s t } h m p z g h k p u j n j k v g h g i j s m l { | } ~ w v p u
x m p y z v s n v h l j p v m h g h k g h p u f g w j f j m n g f g x z j
p m p u j n j k v g h g i j m l { | } ~ l f m n p u j m n n y h v p r s g n z j t
w u j f j g s p u j n j k v g h g i j w g s u v i u j f l m f { | } ~ v h l j p j k
w v p u p j p g h y s q s o o r j g f s g z p u m y i u h m p s v i h v g h p z r
s m
l p u j f j m f p j k g s j g p v j h p s g f j h m w h
p m u g j k v j k
l p u j s j k v j k m l x m p y z v s n k v j k
m l p j p g h y s o o k v j k m l v h l j p v m h g h k
k v j k m l g h p u f g

j f p u j k j g k j x j i v h h v h i v h g z n m s p o
s j j f j v h l j p v m h s g y s j k x r s m f j l m f n v h i x g p j f v g w j f j
f j m f p j k g n m h i { | } ~ v h h i z g h k g h k m p z g h k t m l
p u j s j g p v j h p s k v j k u j k v s p f v x y p v m h m l p u j g s j s g f v j k
n g f j k z r x j p w j j h p u j s j m y h p f v j s } h m p z g h k p u j h y n x j f
m l g s j s w g s j j s s v j f j z g p v j p m p u j j s p v n g p j k m y z g p v m h
m l { | } ~ w u j h m n g f j k w v p u h i z g h k t p u v s j j s s
u m w j j f v s n g v h z r g p p f v x y p g x z j p m g h j j s s m l
v h l j p v m h s g h k g h p u f g g s j s } h m h p f g s p f g p j s m l x m p y z v s n
g h k p j p g h y s l m f m p z g h k w j f j z m w j f p u g h g h k m n g f g x z j
w v p u f j s j p v j z r p u m s j l m f h i z g h k
} h p u j h v p j k v h i k m n n v f m x v m z m i v g z p j s p v h i
u g s y s y g z z r x j j h y h g x z j p m m h f n p u j f j s j h j m l p u j s j
x g p j f v g z s j v j s v h s j v j k m f s y f f j h k j f j k u j f m v h
g z p u m y i u v h w g s v s m z g p j k l f m n
s g n z j m l u j f m v h s j v j k v h m p z g h k f g h p j f s
m n n j j f p u j z j s s v p v s i j h j f g z z r f j m i h v j k p u g p p u j
v h l j p v m h s k v s y s s j k u j f j u g j f j s y z p j k l f m n m h p g n v h g p j k
u j f m v h w u v u n v i u p u g j x j m n j m h p g n v h g p j k k y f v h i
f m j s s v h i p f g h s m f p m f s p m f g i j } h p u j h v p j k v h i k m n
m l u j f m v h y s j k m f v i v h g p j s v h l i u g h v s p g h w u j f j
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j h p j f v h i p u j y f m j g h h v m h g h k f j g u v h i p u j h v p j k
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v h l j p v m h v h g k f y i v h j p m f v h m f w g r v h
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h m p u j f s m y f j m l m p j h p v g z m h p g n v h g p v m h v s k f y i
g k y z p j f g h p s y p p v h i g i j h p s w u v u g f j w v k j z r y s j k p m
k v z y p j g h k v h f j g s j p u j x y z m l v z z v v p k f y i s z p u m y i u
n m s p v h l j p v m h s f m x g x z r f j s y z p j k l f m n y s p f j g n x j l m f j v p
f j g u j s p u j j h k y s j f m h p g n v h g p v m h m l u j f m v h s m f j s m h p u j
s m v z j k u g h k s m l y s j f s g h k k v f p r h j j k z j s m y z k x j v h m y z g p j k
k y f v h i p u j v h j p v m h f m j s s u v s n m k j m l v h l j p v m h
f j n g v h s y h f m j h g z p u m y i u s v i h s m l p j p g h y s w j f j m x s j f j k
Table 1. Cases of infection with spore-forming bacteria and rates of infection among PWID, by health region, England and Scotland,
20002009*
Health region
No.
PWID
No. cases (rate/1,000 PWID) Total no. cases
(rate/1,000 PWID, 95%
CI)
Botulism Tetanus

infection Anthrax
England 137,141 139 (1.01) 28 (0.20) 32 (0.23) 0 199 (1.45, 1.221.65)
East of England 9,418 17 (1.81) 0 2 (0.21) 0 19 (2.02, 1.453.04)
East Midlands 11,796 15 (1.27) 4 (0.34) 1 (0.08) 0 20 (1.70, 1.481.91)
London 17,909 28 (1.56) 4 (0.22) 2 (0.11) 0 34 (1.90, 1.422.10)
North East 8,959 6 (0.67) 1 (0.11) 0 0 7 (0.78, 0.660.99)
North West 22,089 14 (0.63) 7 (0.32) 16 (0.72) 0 37 (1.68, 1.471.97)
South East 13,778 9 (0.65) 3 (0.22) 5 (0.36) 0 17 (1.23, 0.951.41)
South West 17,444 23 (1.32) 3 (0.17) 1 (0.06) 0 27 (1.55, 1.381.69)
West Midlands 14,734 4 (0.27) 5 (0.34) 1 (0.07) 0 10 (0.68, 0.590.74)
Yorkshire and the Humber 21,014 23 (1.09) 1 (0.05) 4 (0.19) 0 28 (1.33, 1.231.41)
Scotland 23,933 18 (0.75) 5 (0.21) 60 (2.51) 13 (0.54) 96 (4.01, 3.434.29)
Ayrshire and Arran 2,373 0 0 0 0 0
Borders 201 0 0 0 0 0
Dumfries and Galloway 486 0 1 (2.06) 0 0 1 (2.06, 1.492.70)
Fife 1,270 2 (1.57) 0 2 (1.57) 1 (0.79) 5 (3.94, 3.274.64)
Forth Valley 786 1 (1.27) 0 0 0 1 (1.27, 1.041.52)
Grampian 3,056 6 (1.96) 2 (0.65) 3 (0.98) 0 11 (3.60, 2.834.48)
Greater Glasgow and Clyde 8,862 8 (0.90) 1 (0.11) 50 (5.64) 9 (1.02) 68 (7.67, 5.749.17)
Highland 734 0 0 0 0 0
Lanarkshire 1,649 0 0 2 (1.21) 2 (1.21) 4 (2.43, 1.924.46)
Lothian 3,262 0 1 (0.31) 0 0 1 (0.31, 0.230.40)
Tayside 1,254 1 (0.80) 0 0 1 (0.80) 2 (1.59, 1.261.97)
*PWID, persons who inject drugs.
References .
Regions of mainland Scotland only.
Region not known for 3 of the 60 case-patients who had infection.
RESEARCH

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Figure 1. Annual numbers of cases of botulism, tetanus, 4 5 6 7 8 9 : ; : < =
>
6 ? @ : infection, and anthrax among persons who inject drugs,
England and Scotland, 20002009.
Figure 2. Rates of infection with spore-forming bacteria (4 5 6 7 8 9 : ; : < =
A
6 8 < 5 :
>
< = , 4 B 8 C 8 D
>
: , 4 B
>
6 ? @ : , and E D F : 5 5 < 7 D
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8 G 9 D F : 7 ) among
persons who inject drugs (PWID), by health region, England and
Scotland, 20002009.
Infections with Spore-forming Bacteria in PWID
H I J K L M N L O P Q N R S J T O U J M R H M T V H O J U W S N X X S U J U X R T J N P R N X P Y
O N Z T L R S U R W J H [ U [ \ T U L M X H L K J V T M X U P T P Q T J T P N V N \ U J N L
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RESEARCH

Outbreak detection systems for use with very large
multiple surveillance databases must be suited both to the
data available and to the requirements of full automation.
To inform the development of more effective outbreak
detection algorithms, we analyzed 20 years of data (1991
2011) from a large laboratory surveillance database used
for outbreak detection in England and Wales. The data
relate to 3,303 distinct types of infectious pathogens, with a
frequency range spanning 6 orders of magnitude. Several
hundred organism types were reported each week. We
describe the diversity of seasonal patterns, trends, artifacts,
and extra-Poisson variability to which an effective multiple
laboratory-based outbreak detection system must adjust.
We provide empirical information to guide the selection
of simple statistical models for automated surveillance of
multiple organisms, in the light of the key requirements
of such outbreak detection systems, namely, robustness,
flexibility, and sensitivity.

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Automated Biosurveillance Data
from England and Wales, 19912011
: ; < ; = > ? @ A B C D @ E F G H I ; J K H B G < C L H J G M > = H N O P Q H B O F C I B R A S > D @ T N F Q U C D @ T N V W P H N G F O O C
W P N B U X H @ F C H @ T W > L H T T < Y H N N B @ E O ; @
Author affiliations: Open University, Milton Keynes, UK (D.G. Enki,
A. Noufaily, P.H. Garthwaite, C.P. Farrington); and Health Protection
Agency, London, UK (N.J. Andrews, A. Charlett, C. Lane)
RESEARCH
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o ] [ _ ] ^ h c ] ^ d ` c g ^ c ` ` _ ^ c ] h m m ] j p c ] [
Z [ c ] h m Z [ \ ] ^ _ ` a g c _ ^ o c ` b _ \ ] b c d b m c o ] j _ d _ b p Z
c l ] b _ Z ^ n p i j Z b b _ ^ \ b m c j Z \ Z b m c o ] [ _ ] ^ h c Z b m c g c c j p
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Figure 1. Weekly counts of organisms by date of specimen
collection, England and Wales, 19912011: A) isolates; B) organism
types.
RESEARCH
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! * . " # # 6 7 * ! " * + 4 . # , * + 0 k 5 * . " # + ? E " ( q ? 0 " + $ " 4 * . " + ) . ' * .
. ' 7 * ! " * / " - " . 3 # 6 1 2 - 3 4 # 5 + . ( # 6 . ' * . # ! ) * + " ( , " ( ) ! * . !
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. + $ + 4 3 6 # ! . ' $ " ( ! ( " # + . # " + 4 ! * ( 1 " . ' . ' , * + r . '
, # ! 4 # , , # + . ' # ! ) * + " ( , 0 . ' - ( ( * ! # ! " * . * y # " ( ( # +
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:
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4 * - 4 5 - * . $ 6 ! # , $ * . * / * ( $ # + 1 2 # 6 ! # ! . 0 . ' * + 1 ' +
4 * - 4 5 - * . $ 6 ! # , $ * . * / * ( $ # + 1 2 # 6 ( 4 " , + D # + - " +
& 4 ' + " 4 * - j + $ " 9
:
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Figure 2. Weekly counts for 6 selected organisms, by date of specimen collection, England and Wales, 19912011.
z { | } { ~ } } } | | { | } } ~
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Figure 3. Distributions of mean (A) and SD (B) of weekly counts for
all organisms, England and Wales, 19912011.
RESEARCH
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: 7 / 2 :
Figure 4. A) Distribution of estimated linear trend parameters (units:
per week) for data on 2,250 organisms (excluding 4 organisms with
extreme slopes), England and Wales, 19912011. B) Stacked bar
chart of modal seasonal period for 2,254 organisms. The black
bar sections represent organisms for which the seasonal effect is
statistically significant.
Figure 5. Relationships between mean and variance for data on
organisms collected, England and Wales, 19912011. A) The log
of variance plotted against log of mean for f g h i j k l j m n spp. The full
line is the best fit to the points; the dashed line corresponds to the
quasi-Poisson model; the dotted line corresponds to the Poisson
model. B) Histogram of the slopes of the best-fit lines for 1,001
organisms; the value 1 corresponds to the quasi-Poisson model
(equation 1).
o p p q r o s t s u r t v u w x y z o x q t v { o | w z t } u ~ p u p w q s v o r t y t p x o r t y
s w | t o | t r r o s

t u o z t q y t r s o t o y t s o ~ x t y o o x v ~ v w s u t x w | o x
t o s q r t v w o x o r t v q r z t ~ x x o p t y o s o | o v t o p p q q x o s t y
y q r ~ t o r v w v s v s r ~ ~ ~ v s u t z o r ~ t s w s t w r o x
o s s t r v { ~ s t r v w r t q t p ~ t v { s r t y v { o y v t o v w o x ~ s
w t z o x q o | x t t t r o x p w p x q v ~ w v t t r t w y ~ r t p s
r t x t z o p t s w s u t y t v ~ w w q s | r t o y t s t p s ~ w v v s t v
u t r v s v s t v r w s u t r t o s z o r ~ o s ~ w ~ w r o ~ v
r t q t p { } u ~ p u v s r t s p u t v w z t r w r y t r v w o ~ s q y t
r w
s w
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u t v t v ~ s ~ z ~ s o y v t p ~ p ~ s
w s u t y t s t p s ~ w v v s t v u w q x y r t o ~ | r w o y x p w v s o s
w z t r s u ~ v r o t { v w s u o s s u t v v s t t r w r v } t x x w r | w s u
r o r t o y p w w w r o ~ v v
u t r ~ o r w q s q s r w o
q x s ~ x t w q s | r t o y t s t p s ~ w v v s t ~ v x ~ t x s w | t o r o ~
w o | t r r o p t v ~ y t p r t o v ~ w r y t r w s u t v s o s ~ v s ~ p o x t z ~ y t p t
q y t r ~ ~ s u t
u t p w r r t p s t v v w s u t w r y t r ~ ~ v
o r q o | x w r t ~ w r s o s s u o o p u ~ t z ~ w ~ o x v t v ~ s ~ z ~ s
o y v t p ~ p ~ s x t z t x v { v w s u o s o s s t s ~ w ~ v w p q v t y w s u t
w v s y ~ v p r t o s w r o ~ v v r o p s ~ p t { s u ~ v t o v s u o s
w q s | r t o y t s t p s ~ w t s u w y v q v t y } ~ s u q x s ~ x t v q r z t ~ x x o p t
v v s t v q v s t r w r r w | q v s x o y p w v ~ v s t s x w z t r s u t
r o t w r t q t p ~ t v t t p s t y
w r o x o r t o r s w s u ~ v r o t
v t p w y p w p x q v ~ w ~ v s u o s s u t v v s t o s ~ p p w w t s v
w s u t v s o s ~ v s ~ p o x w q s | r t o y t s t p s ~ w w y t x v q v s | t o | x t s w
p w t o q s w o s ~ p o x x } ~ s u s u t ~ y ~ w v p r o v ~ t v w ~ y ~ z ~ y q o x
y o s o v t r ~ t v { w s o | x v t o v w o x ~ s o y s r t y v { } ~ s u w q s
r t q ~ r ~ ~ s t r z t s ~ w | s u t q v t r
u ~ v t p t v v ~ s o s t v s u t
q v t w v q ~ s o | x t ~ | x t w y t x ~ t z ~ r w t s v { s u w q u
t p t v v ~ z t t ~ | ~ x ~ s p o ~ s v t x p o q v t r w | x t v w w z t r s s ~
p o r t q x | o x o p t t t y v s w | t v s r q p w r t o x t { | t s } t t
s u t y t s o ~ x t y w y t x ~ r t q ~ r t y s w ~ p w r w r o s t v t o v w o x
t t p s v { } u ~ p u ~ v p r q p ~ o x w r v w t w r o ~ v v { } u ~ x t
r t p w ~ ~ s u o s v q p u t t p s v o r t w s r t o s x r t x t z o s w r
o w s u t r v o y y ~ s ~ w { r w | q v s q t r ~ p o x o x w r ~ s u v s u o s
o r t q o r o s t t y s w } w r w r o x x | q s w } t s r t t y o s o
p w q r o s ~ w v o r t t v v t s ~ o x
u ~ r y { w q r o o x v t v r w z ~ y t t ~ r ~ p o x v q w r s w r
s u t q v t w o v ~ x t { r w | q v s o x w r ~ s u o p r w v v s u ~ v r o t w
w r o ~ v v
u t y o s o v q t v s s u o s s u t r t o s o w r ~ s w
w r o ~ v v p o o y t q o s t x s u w q u o r r w t r t p s x | t
r t r t v t s t y | o v s o s ~ v s ~ p o x w y t x ~ } u ~ p u s u t z o r ~ o p t
~ v r w w r s ~ w o x s w s u t t o { v q p u o v s u t q o v ~ w ~ v v w w r
t o s ~ z t | ~ w ~ o x w y t x v
w t ~ r w z t t s } w q x y
t z t r s u t x t v v | t w v v ~ | x t s u r w q u s u t q v t w w r t t t r o x
w y t x v ~ } u ~ p u s u t z o r ~ o p t ~ v r w w r s ~ w o x s w o w } t r w
s u t t o
q p u w r t t t r o x y ~ v s r ~ | q s ~ w v { | o v t y w | ~ r s u
r w p t v v t v { u o z t | t t v s q y ~ t y

q r s u t r ~ z t v s ~ o s ~ w ~ v
} o r r o s t y w r o x ~ p o s ~ w s w v q r z t ~ x x o p t y o s o
u t v t p w p x q v ~ w v o x v t p ~ p o x x s w s u t q v t w
o q s w o s t y | ~ w v q r z t ~ x x o p t o v o v t p w y x ~ t w y t t v t ~
v q w r s w ~ z t v s ~ o s w r x t y w q s | r t o y t s t p s ~ w t s u w y v {
o v ~ x t t s t y ~ x o y o y
o x t v
u q v { } t v t t o
v v s t s u o s t r w r v o y t q o s t x w z t r s u t t s ~ r t r o t w
w r o ~ v v { s w | t v p o t y r w q s ~ t x { r o s u t r s u o w t s u o s
~ v w s ~ ~ t y w r o o r s ~ p q x o r w r o ~ v
t | t x ~ t z t s u o s
~ s t r o s ~ ~ z t v s ~ o s w r x t y o y o q s w o s t y v q r z t ~ x x o p t ~
s u ~ v } o x o v | t v s s w s u t v s r t s u v w t o p u t s u w y
o p u } t t { s u t x o y o y
o x t v y t s t p s ~ w
v v s t o v w r o ~ v v { x ~ v s t y ~ y t p r t o v ~ w r y t r
Figure 6. Relationships between mean and skewness for data
on organisms collected, England and Wales, 19912011. A)
Skewness plotted against log of mean for spp. The full
curve is the best fit to the points; the dashed curve corresponds to
the negative binomial model; the dotted curve corresponds to the
Poisson model. B) Histogram of the parameters corresponding to
the best-fit curves for 1,001 organisms; the value 0.5 corresponds
to the negative binomial model (equation 2).
RESEARCH

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R . U E V @ 1 B W / 7 L F 4 ? B 3 E B L 7 4 > ? 9 1 0 @ . 8 ; E 9 ? E F E B > @ 5 B > 0 1 3 ? X
@ : 0 O 4 ? F F E B X 4 G 1 0 ; : Y F ? X D 4 E F 9 D . Z D ? X D 4 @ 9 4 0 J K L M N [ ? F 4 5 Q R S S \
] . [ E C B 4 0 A 7 A 1 1 0 4 W 7 W 0 5 4 F 6 7 4 > ? 9 1 0 @ . ^ E B > Y 1 1 2 1 G Y ? 1 @ : 0 O 4 ? F F E B X 4 .
/ : 0 F ? B C 9 1 B J A W M N W X E > 4 3 ? X P 0 4 @ @ Q R S S _ .
T . A 4 E > P 8 7 8 F : 9 @ 2 4 0 U 7 < ? 4 9 ` a 7 A X Z E ? C U = 7 / 0 4 @ 4 4 b 8 7 8 D E ; ? 0 1 Z 7 4 9
E F . = 1 1 > c 0 4 F E 9 4 > ? F F B 4 @ @ E B > > 4 E 9 D ? B 9 D 4 K B ? 9 4 > 8 9 E 9 4 @ . d 3 4 0 C e B G 4 X 9
< ? @ . - f f f Q \ N _ S g h R \ . D 9 9 ; N i i > I . > 1 ? . 1 0 C i - S . ] R S - i 4 ? > S \ S \ . f f S \ S R
\ . W > E 2 j L 7 U 1 B C 8 A 7 H k / 0 ? 4 B 8 b . l 0 4 B > @ ? B ? B > ? C 4 B 1 : @ G 1 1 > Y 1 0 B 4
> ? @ 4 E @ 4 @ E B > > 4 E 9 D @ 7 d B C F E B > E B > [ E F 4 @ N - f f R 9 1 R S S S . j : 9 .
R S S R Q \ - N m ] R h T - . D 9 9 ; N i i > I . > 1 ? . 1 0 C i - S . - - ] _ i C : 9 . \ - . _ . m ] R
_ . = E 0 0 ? B C 9 1 B Z P 7 W B > 0 4 V @ n b 7 / 4 E F 4 W < 7 Z E 9 X D ; 1 F 4 A W . W @ 9 E 9 ? @ 9 ? X E F
E F C 1 0 ? 9 D 3 G 1 0 9 D 4 4 E 0 F 5 > 4 9 4 X 9 ? 1 B 1 G 1 : 9 Y 0 4 E 2 @ 1 G ? B G 4 X 9 ? 1 : @
> ? @ 4 E @ 4 . b 6 8 9 E 9 8 1 X 8 4 0 W . - f f _ Q - \ f N \ T g h _ ] . D 9 9 ; N i i > I . > 1 ? .
1 0 C i - S . R ] S g i R f m ] ] ] -
g . A X Z E Y 4 j b 7 j 0 4 4 B D E F C D < 7 j 4 9 9 ? B C Y 5 j 7 ^ 1 F 3 4 @ d 7 Z 1 V > 4 B b .
P 0 4 > ? X 9 ? 1 B 1 G ? B G 4 X 9 ? 1 : @ > ? @ 4 E @ 4 @ N E B 4 I X 4 ; 9 ? 1 B 0 4 ; 1 0 9 ? B C @ 5 @ 9 4 3 . b
A 4 > e B G 1 0 3 E 9 l 4 X D B 1 F . R S S ] Q \ N _ g h g T .
m . ^ : F 9 D W 7 W B > 0 4 V @ n 7 d 9 D 4 F Y 4 0 C 8 7 < 0 4 4 @ 3 E B b 7 = E 4 B @ 4 B < 7 O E B P 4 F 9
[ 7 4 9 E F . P 0 E X 9 ? X E F : @ E C 4 1 G X 1 3 ; : 9 4 0 c @ : ; ; 1 0 9 4 > 1 : 9 Y 0 4 E 2 > 4 9 4 X 9 ? 1 B
? B o O 4 d : 0 1 ; 4 E B X 1 : B 9 0 ? 4 @ . d : 0 1 @ : 0 O 4 ? F F . R S - S Q - \ N ; ? ? N - f _ f m .
f . 8 1 B 4 @ @ 1 B Z 7 / 1 X 2 < . W 0 4 O ? 4 V E B > > ? @ X : @ @ ? 1 B 1 G ; 0 1 @ ; 4 X 9 ? O 4
@ 9 E 9 ? @ 9 ? X E F @ : 0 O 4 ? F F E B X 4 ? B ; : Y F ? X D 4 E F 9 D . b 6 8 9 E 9 8 1 X 8 4 0 W .
R S S ] Q - _ _ N \ h R - . D 9 9 ; N i i > I . > 1 ? . 1 0 C i - S . - - - - i - T _ g c f m \ p . S S R \ _
- S . / : X 2 4 0 ? > C 4 1 : 9 Y 0 4 E 2 > 4 9 4 X 9 ? 1 B N E 0 4 @ 4 E 0 X D @ 5 B 9 D 4 @ ? @ .
b / ? 1 3 4 > e B G 1 0 3 . R S S \ Q ] m N f f h - - ] . D 9 9 ; N i i > I . > 1 ? . 1 0 C i - S . - S - _ i q .
q Y ? . R S S T . - - . S S g
- - . 8 D 3 : 4 F ? j 7 / : 0 2 1 3 ^ . 8 9 E 9 ? @ 9 ? X E F X D E F F 4 B C 4 @ G E X ? B C 4 E 0 F 5 1 : 9 Y 0 4 E 2
> 4 9 4 X 9 ? 1 B ? B Y ? 1 @ : 0 O 4 ? F F E B X 4 . l 4 X D B 1 3 4 9 0 ? X @ . R S - S Q \ R N ] f h \ - . D 9 9 ; N i i
> I . > 1 ? . 1 0 C i - S . - - f m i l d Z ^ . R S - S . S _ - ] T
- R . K B 2 4 F 8 7 = E 0 0 ? B C 9 1 B Z P 7 j E 0 9 D V E ? 9 4 P ^ 7 6 1 Y 4 0 9 @ 1 B Z 7 W B > 0 4 V @
n . 8 9 E 9 ? @ 9 ? X E F 3 4 9 D 1 > @ G 1 0 9 D 4 ; 0 1 @ ; 4 X 9 ? O 4 > 4 9 4 X 9 ? 1 B 1 G ? B G 4 X 9 ? 1 : @
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We analyzed highly pathogenic avian influenza
A(H5N1) viruses isolated from humans infected in Egypt
during 20072011. All analyzed viruses evolved from the
lineage of subtype H5N1 viruses introduced into Egypt in
2006; we found minimal evidence of reassortment and no
exotic introductions. The hemagglutinin genes of the viruses
from 2011 formed a monophyletic group within clade 2.2.1
that also included human viruses from 2009 and 2010 and
contemporary viruses from poultry; this finding is consis-
tent with zoonotic transmission. Although molecular mark-
ers suggestive of decreased susceptibility to antiviral drugs
were detected sporadically in the neuraminidase and matrix
2 proteins, functional neuraminidase inhibition assays did
not identify resistant viruses. No other mutations suggesting
a change in the threat to public health were detected in the
viral proteomes. However, a comparison of representative
subtype H5N1 viruses from 2011 with older subtype H5N1
viruses from Egypt revealed substantial antigenic drift.
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Microevolution of Highly
Pathogenic Avian Influenza A(H5N1)
Viruses Isolated from Humans,
Egypt, 20072011

Author affiliations: US Naval Medical Research Unit No.3, Cairo,
Egypt (M. Younan, E. Elassal, M.A. ElBadry, S. Truelove, A.M.
Gaynor, E. Mohareb, C. Cornelius, G. Pimentel, K. Earhart); Centers
for Disease Control and Prevention, Atlanta, Georgia, USA (M.K.
Poh, T. Davis, P. Rivailler, A.L. Balish, N. Simpson, J. Jones, V.
Deyde, R. Loughlin, I. Perry, L. Gubareva, A.I. Klimov, R.O. Donis);
Cairo University, Cairo (M. Amin); and Ministry of Health and Popu-
lation, Cairo (A. Naguib, A.S. Abdelghani, S. Refaey, A. Kandeel)
These authors contributed equally to this article.
RESEARCH

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Figure 1. Phylogenetic tree of the influenza A(H5) virus
hemagglutinin genes, clade 2.2.1, generated by neighbor-joining
analysis. Subgroups of clade 2.2.1 are indicated on the right.
Bootstrap values (>79) generated from 1,000 neighbor-joining
replicates are shown above branches, and Bayesian posterior
probabilities are shown below the branches at relevant nodes.
Scale bar represents 0.002 nt substitutions per site. Viruses
recommended by the World Health Organization for development
of candidate pandemic vaccines are indicated with a V; viruses
inoculated into ferrets to raise antiserum for hemagglutinin
inhibition assays are indicated with an R. Underlined names
denote 23 human viruses collected in 2011. Sequences used for
full genome analysis in this study are annotated with a dot.
Microevolution of Influenza A(H5N1) Viruses, Egypt
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p s y w { x k
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w y { x j k y ~ h i ~ k j t h y i ~ y x i k v x r v u { | v i j v w k w h i p q r s t

y w t y ~ t u y w k k s y w { x k w k x k z k w j x h } k z v w y j j { x
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u r y q k i k t h j v i v r w h w y ~

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h x { w k w v q v h i w t
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h x { w k w
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v i z

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h x { w

y ~ { x t u k x h i
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h x { w k w ~ x y | u { | v i w v i z
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h i t x v j v z k y x y t u k x
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h i t u k t y s y y q r y ~ t u k s u r y q k i k t h j t x k k y ~ t u k
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h v i h i { k i v q k i k w
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n
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h x { w k w h i p q r s t u v w } k k i x k s y x t k z

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We conducted cross-sectional and longitudinal
studies to determine the distribution of and risk factors
for seropositivity to Nipah virus (NiV) among

and

bats in Peninsular Malaysia.
Neutralizing antibodies against NiV were detected at most
locations surveyed. We observed a consistently higher
NiV risk (odds ratio 3.9) and seroprevalence (32.8%) for

than

(11.1%) bats. A 3-year
longitudinal study of

bats indicated
nonseasonal temporal variation in seroprevalence,
evidence for viral circulation within the study period, and an
overall NiV seroprevalence of 9.8%. The seroprevalence
fluctuated over the study duration between 1% and 20%
and generally decreased during 20042006. Adult bats,
particularly pregnant, with dependent pup and lactating
bats, had a higher prevalence of NiV antibodies than
juveniles. Antibodies in juveniles 6 months2 years of age
suggested viral circulation within the study period.

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Peninsular Malaysia
2 3 4 5 6 5 7 8 9 : ; 5 4 < 5 = > ? 5 7 8 @ @ 5 4 A 5 B B 5 = > C 3 = 5 7 4 5 = A : D E B 7 F 8 = > G 5 8 = 8 H : I 5 < 5 7 > 9 J 8 J I : K 5 7 8 < >
2 4 5 L 8 @ 5 4 2 : A 5 B B 5 = > A M < F D : N 8 F O P > Q 3 < A M R 4 F B > C M B 7 8 = S F B 7 L M < > I : 2 : T 5 8 < > 9 L B 4 5 P 2 : 2 M L 8 >
9 : 9 J 8 J C 5 < 5 O M P P 8 = > U F 7 F L V 5 B J 5 W > 5 = P 7 4 F A F = 8 E 5 X 8 L M B D Y 3 O 3 R 6 ; F B F 5 L Y 4 Z L 3 M E [
Author affiliations: Veterinary Research Institute, Ipoh, Malaysia (S.A.
Rahman, Z.C. Mamat, A.M. Yatim, M.S. Naim, A.A. Jamaluddin);
Universiti Putra Malaysia, Serdang, Malaysia (L. Hassan, A.S.
Suri); EcoHealth Alliance, New York, New York, USA (J.H. Epstein,
T. Hughes, J. Westrum, P. Daszak); Monash University, Serdang,
(S.S. Hassan); and Queensland Primary Industries and Fisheries,
Brisbane, Queensland, Australia (H.E. Field)
1
Members of the Henipavirus Ecology Research Group are listed
on the groups website (www.ecohealthalliance.org/herg).
RESEARCH
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Figure 1. Trapping sites for

and
bats and
seroprevalence of Nipah virus in 8 sites,
Peninsular Malaysia, January 2004
September 2006. Values in the small graphs
indicate number of positive samples.
Nipah Virus Infection among Pteropid Bats

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Table 2. z { | } ~ ~ | bats with Nipah virusneutralizing antibody titers, Peninsular Malaysia, January 2004
October 2006*
Location Sex Age No. SNT titer No. positive % Seroprevalence
(95% CI)
Pulau Pangkor, n = 23 M Adult 13 <8 0 0 (016)
Juvenile 4 <8 0
Pup 0 NA NA
F Adult 4 <8 0
Juvenile 2 <8 0
Pup 0 NA NA
Pulau Perhentian, n = 15 M Adult 2 <8128 0 13.3 (2.539.1)
Juvenile 1 <8 1
Pup 0 NA NA
F Adult 7 <864 1
Juvenile 5 <8 0
Pup 0 NA NA
Pulau Kapas, n = 29 M Adult 7 <8 0 3.3 (0.0118.1)
Juvenile 0 NA NA
Pup 0 NA NA
F Adult 15 <8 1
Juvenile 7 <832 0
Pup 0 NA NA
Pulau Tioman, n = 50 M Adult 27 <8128 6 20 (11.133.2)
Juvenile 4 <8 0
Pup 0 NA NA
F Adult 11 <8256 4
Juvenile 8 <8 0
Pup 0 NA NA
Overall, N = 117 Adult 73 <8256 13 11.1 (6.518.2)
Juvenile 31 NA 0
Pup 0 NA 0
*SNT, serum neutralization test; NA, not applicable (no sample).
Figure 2. Seroprevalence of
Nipah virus among

bats in Pulau
Tioman, Peninsular Malaysia,
January 2004September 2006.
Error bars indicate 95% CIs.
RESEARCH


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RESEARCH

We assessed known risk factors, clinical presentation,
and outcome of invasive pneumococcal disease (IPD) in
children 359 months of age after introduction of the 7-va-
lent pneumococcal conjugate vaccine (PCV7) in England
and Wales. During September 2006March 2010, a total
of 1,342 IPD episodes occurred in 1,332 children; 14.9%
(198/1,332) had comorbidities. Compared with IPD caused
by PCV7 serotypes (44/248; 17.7%), comorbidities were
less common for the extra 3 serotypes in the 10-valent vac-
cine (15/299; 5.0%) but similar to the 3 additional PCV13
serotypes (45/336; 13.4%) and increased for the 11 extra
serotypes in 23-valent polysaccharide vaccine (PPV23)
(39/186; 21.0%) and non-PPV23 serotypes (38/138;
27.5%). Fifty-two (3.9%) cases resulted from PCV7 failure;
9 (0.7%) case-patients had recurrent IPD. Case-fatality rate
was 4.4% (58/1,332) but higher for meningitis (11.0%) and
children with comorbidities (9.1%). Thus, comorbidities were
more prevalent in children with IPD caused by non-PCV13
serotypes and were associated with increased case fatality.

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Author affiliations: Health Protection Services Colindale, London,
UK (S.N. Ladhani, M.P.E. Slack, N.J Andrews, P.A Waight, E. Mill-
er); and Health Protection Agency, Manchester, UK (R. Borrow)
Invasive Pneumococcal Disease
after Routine Pneumococcal
Conjugate Vaccination in Children,
England and Wales
A
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B P Q J E I P Q R F S H / K + T 0 J M B U
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I H + S F V B I W - , J
X B L Y . K K . T J B H / N
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RESEARCH
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introduction, England and Wales, September 4, 2006March 31,
2010. A) Distribution of cases. Black bar sections, bacteremia;
dark gray bar sections, lower respiratory tract infection; light gray
bar sections, meningitis; white bar sections, other. B) Proportion
of serotyped cases caused by PCV7 serotypes in healthy children
(dashed line) and children with comorbidities (solid line). The
prevalences of comorbidity among IPD cases during the 4 time
periods were 13,5%, 17.7%, 17.0%, and 10.7%, and the case-
fatality rates were 5.6%, 4.3%, 4.3%, and 3.0%, respectively. *Data
included for 7 months only. IPD, invasive pneumococcal disease;
PCV7, 7-valent pneumococcal conjugate vaccine.
RESEARCH

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Tick-borne encephalitis (TBE) is a substantial public
health problem in many parts of Europe and Asia. To
assess the effect of increasing TBE vaccination coverage
in Austria, we compared incidence rates over 40 years for
highly TBE-endemic countries of central Europe (Czech
Republic, Slovenia, and Austria). For all 3 countries we
found extensive annual and longer range fluctuations and
shifts in distribution of patient ages, suggesting major
variations in the complex interplay of factors influencing
risk for exposure to TBE virus. The most distinctive effect
was found for Austria, where mass vaccination decreased
incidence to 16% of that of the prevaccination era.
Incidence rates remained high for the nonvaccinated
population. The vaccine was effective for persons in all age
groups. During 20002011 in Austria, 4,000 cases of TBE
were prevented by vaccination.

Vaccination and Tick-borne
Encephalitis, Central Europe

Author affiliations: Medical University of Vienna, Vienna, Austria
(F.X. Heinz, K. Stiasny, H. Holzmann, M. Kundi); National Institute
of Public Health, Ljubljana, Slovenia (M. Grgic-Vitek); National In-
stitute of Public Health, Prague, Czech Republic (B. Kriz); and GfK
Austria Healthcare, Vienna (A. Essl)
RESEARCH
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Vaccination and Tick-borne Encephalitis

Figure 1. Tick-borne encephalitis (TBE) incidence rates (no.
cases/100,000 population), 19722011, central Europe. A) Total
population (black dashed line) and nonvaccinated population
(black solid line) in Austria. The gray line represents the increasing
coverage of vaccination, which started in 1978. B) Comparative
representation of TBE incidence rates in Austria (black line), Czech
Republic (light gray short-dashed line), and Slovenia (dark gray
long-dashed line). The incidence scale for Slovenia (right y-axis)
differs from that of Austria and the Czech Republic (left y-axis). C)
Sliding-window representation of TBE incidence in Austria (black
line), Czech Republic (light gray short-dashed line), and Slovenia
(dark gray long-dashed line) using means of 5-year intervals. The
incidence scale for Slovenia (right y-axis) differs from that of Austria
and the Czech Republic (left y-axis). A color version of this figure is
available online (wwwnc.cdc.gov/EID/article/19/1/12-0458-F1.htm).
RESEARCH
Figure 2. Results of joinpoint analysis of annual incidence rates (no. cases/100,000 population) of tick-borne encephalitis (TBE) in A)
Austria (total population), B) Austria (nonvaccinated population), C) Czech Republic, and D) Slovenia. The lines in each panel represent
the piecewise log-linear relationship between year and incidence. Estimated joinpoints and their 95% CIs are shown.

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during 19901999 (dotted lines; open symbols) and 20002010
(solid lines; closed symbols) in Austria (black and circles), Czech
Republic (light gray and diamonds), and Slovenia (dark gray and
rectangles). The incidence scale for Slovenia (right y-axis) differs
from that of Austria and the Czech Republic (left y-axis). A color
version of this figure is available online (wwwnc.cdc.gov/EID/
article/19/1/12-0458-F3.htm).
RESEARCH


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Tumors of any type are exceedingly rare in raccoons.
High-grade brain tumors, consistently located in the fron-
tal lobes and olfactory tracts, were detected in 10 raccoons
during March 2010May 2012 in California and Oregon,
suggesting an emerging, infectious origin. We have identi-
fied a candidate etiologic agent, dubbed raccoon polyoma-
virus, that was present in the tumor tissue of all affected
animals but not in tissues from 20 unaffected animals.
Southern blot hybridization and rolling circle amplification
showed the episomal viral genome in the tumors. The mul-
tifunctional nuclear protein large T-antigen was detectable
by immunohistochemical analyses in a subset of neoplastic
cells. Raccoon polyomavirus may contribute to the develop-
ment of malignant brain tumors of raccoons.
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E H O A F L E K P N F G P N A T E L @ G S E N L E H F L D K P L A K O L D G H N C E N N E K H G H S
Novel Polyomavirus associated
with Brain Tumors in Free-Ranging
Raccoons, Western United States

Author affiliations: University of California, Davis, Davis, California,
USA (F.N. Dela Cruz, Jr., F. Giannitti, L.W. Woods, P.A. Pesavento);
Blood Systems Research Institute, San Francisco, California, USA
(L. Li, E. Delwart); Louisiana State University, New Orleans, Louisi-
ana, USA (L. Del Valle); and University of California, San Francisco,
San Francisco (E. Delwart)
RESEARCH

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Polyomavirus in Raccoons
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Figure 1. Pathology of raccoon polyomavirusassociated tumors. A) Normal anatomy, head of unaffected raccoon, midsagittal section.
An intact cribriform plate separates the ethmoid turbinates from the olfactory tract. B) Gross pathology, head of raccoon no. 9 (Rac9), left
parasagittal section. The tumor obliterates the left olfactory tract and extends into the left frontal lobe to the level of the midbrain. The tumor
compresses the brain and distorts the cerebellum. The raccoon head in length (crown to nose) is 16 cm. C) Histopathology (hematoxylin and
eosin staining) for Rac5. Marked anisokaryosis and anisocytosis are evident. Original magnification 40. D) Histopathology (hematoxylin
and eosin staining) for Rac10. Shown is a region that has streams of elongated cells. Original magnification 40. Scale bar = 40 mm. E)
Histopathology (hematoxylin and eosin staining) for Rac3. Cell-dense sheets of neoplastic cells are interrupted by vast regions of necrosis.
Original magnification 20. A color version of this figure is available online (wwwnc.cdc.gov/EID/article/19/1/12-1078-F1.htm).
RESEARCH
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Figure 2. Genome organization of RacPyV. The entire dsDNA viral
genome for RacPyV10 comprises 5,015 bp. The viral genome has
a noncoding regulatory region and putative open reading frames for
the late proteins VP1, VP2, and VP3 and the early proteins LT-Ag
and sT-Ag. MCPyV and GorPyV, which are phylogenetic neighbors,
and SV40 are presented for comparison. RacPyV, raccoon
polyomavirus; LT-Ag, large T-antigen; sT-Ag, small T-antigen; VP,
viral protein; MCPyV, Merkel cell polyomavirus; SV40, simian virus
40. GorPyV, gorilla polyomavirus.

Figure 3. Phylogenetic relationship of RacPyV with representative polyomavirus species. Phylogenetic trees were individually generated
on the basis of amino acid sequences of LT-Ag (A), sT-Ag (B), VP1, and VP2 (C, D) by using the neighbor-joining method with p-distance
and 1,000 bootstrap replications. RacPyV, raccoon polyomavirus; LT-Ag, large T-antigen; sT-Ag, small T-antigen; VP, viral protein; GorPyV,
gorilla polyomavirus; ChPyV, chimpanzee polymavirus; MCPyV, Merkel cell polyomavirus; OraPyV, orangutan polyomavirus; JCV, JC
virus; SV40, simian virus 40; MuPyV, murine polyomavirus. The bar represents 5% estimated phylogenetic divergence.
Figure 4. Partial genome sequences (ranging from 2,998 bp in raccoon polyomavirus 6 [RacPyV6] to 4,667 bp in RacPyV9) were obtained
from 4 raccoons that had either undergone prolonged storage (RacPyV9) or were available only as formalin-fixed, paraffin-embedded
tissue (dashed lines, RacPyVs 1, 6, and 7). Gaps in the sequences correspond to regions where amplification reactions failed. The
genomes of RacPyVs 2, 3, 4, 5, 8, and 10 were sequenced in their entirety by using a primer walking method to complete the RacPyV
circular genome. Open circles represent noncoding mutations; the closed circle represents a coding mutation. Horizontal bars indicate
deletions. LT-Ag, large T-antigen; VP, viral protein; NCRR, noncoding regulatory region.
RESEARCH
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Figure 5. Raccoon polyomavirus (RacPyV) is episomal in raccoon
brain tumors as detected by Southern blot hybridization and rolling
circle amplification. A unique KpnI site in viral protein 1 (online
Technical Appendix Figure 2, wwwnc.cdc.gov/EID/pdfs/12-1078-
Techapp.pdf) conserved across the viral genomes was predicted to
linearize circular RacPyV DNA. Genomic DNA was KpnI digested
and probed with a 799-bp probe designed to hybridize to large
T-antigen (online Technical Appendix Figure 3). A) Southern blot
hybridization. DNA digested with KpnI (K) and undigested DNA (U)
and hybridized with RacPyV_LT_Probe1 shows identical banding
patterns in each tumor. In KpnI-digested samples, a single band
appears at 5 kb (closed arrow), which is the expected position for
linearized RacPyV genome. L, DNA ladder; N, DNA extracted from
a raccoon that did not have a brain tumor (i.e., normal raccoon).
B) RCA applied to RacPyV DNA by using random hexamers was
digested with KpnI. Amplification of the circular RacPyV genome
occurred in the same cohort of samples that was successful for the
Southern blot hybridization. L, DNA ladder.

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The effects of influenza on a population are attributable
to the clinical severity of illness and the number of persons
infected, which can vary greatly between seasons or pan-
demics. To create a systematic framework for assessing the
public health effects of an emerging pandemic, we reviewed
data from past influenza seasons and pandemics to charac-
terize severity and transmissibility (based on ranges of these
measures in the United States) and outlined a formal assess-
ment of the potential effects of a novel virus. The assessment
was divided into 2 periods. Because early in a pandemic,
measurement of severity and transmissibility is uncertain, we
used a broad dichotomous scale in the initial assessment to
divide the range of historic values. In the refined assessment,
as more data became available, we categorized those values
more precisely. By organizing and prioritizing data collection,
this approach may inform an evidence-based assessment of
pandemic effects and guide decision making.

Novel Framework for Assessing
Epidemiologic Effects of Influenza
Epidemics and Pandemics

Author affiliation: Centers for Disease Control and Prevention,
Atlanta, Georgia, USA
Figure 1. Estimates of influenza deaths in the 2010 United States
population (308,745,538 persons) across varying values of case-
fatality ratio and the cumulative incidence of infection in the
population. Selected estimated numbers of deaths are indicated with
a black line, across each relevant combination of case-fatality ratio
and cumulative incidence. A color version of this figure is available
online (wwwnc.cdc.gov/EID/article/19/01/12-0124-F1.htm)
RESEARCH

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Framework for Assessing Influenza Epidemics
S T U V W X Y W U Z U [ T W Y [ \ X ] ^ ^ U W _ Y ` a b W [ U c V d U d V e f g S _ \ S \
\ d U \ h \ Y X \ e X U i S T U \ g g U g g c U W S [ V f X _ S d \ W g Y S Y V W S V S T U c V d U
_ U S \ Y X U _ g [ \ X U V j S T U d U k W U _ \ g g U g g c U W S j d \ c U l V d m i l Y S T
g [ \ X U _ h \ X f U g V j g U h U d Y S n \ W _ S d \ W g c Y g g Y e Y X Y S n ^ X V S S U _ \ X V W o
\ W ` p \ ` Y g \ W _ n p \ ` Y g i d U g ^ U [ S Y h U X n q r Y o f d U s t a u U [ \ f g U S T U
U j j U [ S g V j \ W Y W v f U W w \ ^ \ W _ U c Y [ c \ n h \ d n e U S l U U W \ o U
o d V f ^ g i S T U d U k W U _ \ g g U g g c U W S [ V f X _ \ X g V e U [ V W _ f [ S U _
l Y S T \ o U p g S d \ S Y k U _ _ \ S \ V W Y W _ Y [ \ S V d g V j S d \ W g c Y g g Y e Y X Y S n
\ W _ [ X Y W Y [ \ X g U h U d Y S n \ W _ S T U W ^ X V S S U _ e n f g Y W o S T U g \ c U
g [ \ X U \ W _ j d \ c U l V d m q r Y o f d U x t a
y z { | } ~ { z z { z
r V d S T U d U k W U _ \ g g U g g c U W S i l U g [ \ X U _ \ W _ ^ X V S S U _ _ \ S \
j d V c V e S \ Y W U _ j d V c V f d X Y S U d \ S f d U d Y U l j V d x ^ \ W _ U c Y [ g
q i i i t \ W _ s W V W ^ \ W _ U c Y [ Y W v f U W w \ g U \ p
g V W g S T \ S d \ W o U _ Y W S d \ W g c Y g g Y e Y X Y S n \ W _ g U h U d Y S n q i
i \ W _ t q V W X Y W U Z U [ T W Y [ \ X ] ^ ^ U W _ Y ` t a T U W
c f X S Y ^ X U c U \ g f d U g j V d S d \ W g c Y g g Y e Y X Y S n V d g U h U d Y S n l U d U ^ d U g p
U W S i l U f g U _ S T U c U _ Y \ W g [ V d U \ [ d V g g \ X X \ h \ Y X \ e X U c U \ g f d U g a
] o U p g S d \ S Y k U _ _ \ S \ j d V c S T U Y W v f U W w \ ] q t ^ \ W p
_ U c Y [ l U d U \ X g V g Y c Y X \ d X n g [ \ X U _ \ W _ ^ X V S S U _ e n f g Y W o S T U
\ o U [ \ S U o V d Y U g n U \ d g i x n U \ d g i \ W _ n U \ d g a

z { { z
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X n S V e U d U g S d Y [ S U _ S V \ ^ \ d S Y [ f X \ d o U V o d \ ^ T Y [ \ d U \ i c V g S X n
Y W j V [ \ X [ X f g S U d g V j Y W j U [ S Y V W g i \ W _ U ^ Y _ U c Y V X V o Y [ _ \ S \ \ d U
X Y c Y S U _ a Z V d U v U [ S S T U f W [ U d S \ Y W S n Y W U \ d X n _ \ S \ i l U _ Y h Y _ U _
U \ [ T c U \ g f d U V j S d \ W g c Y g g Y e Y X Y S n \ W _ g U h U d Y S n j V d S T U Y W Y p
S Y \ X \ g g U g g c U W S j d \ c U l V d m Y W S V \ _ Y [ T V S V c V f g g [ \ X U [ V d p
d U g ^ V W _ Y W o S V S T U X V l p c V _ U d \ S U \ W _ c V _ U d \ S U p T Y o T U W _ g
V j S T U d \ W o U V j h \ X f U g j d V c S T U X Y S U d \ S f d U d U h Y U l a [ \ X U _
h \ X f U g j V d S T U Y W Y S Y \ X \ g g U g g c U W S \ d U g T V l W Y W Z \ e X U a
U d U [ V o W Y w U _ S T \ S U \ d X n c U \ g f d U g \ d U X Y m U X n S V T \ h U
g f e g S \ W S Y \ X e Y \ g U g a
\ d X n c U \ g f d U g V j S T U S d \ W g c Y g g Y e Y X p
Y S n V j S T U h Y d f g \ d U X Y m U X n S V [ V c U j d V c X \ d o U d d U [ V o W Y w U _
V f S e d U \ m g i l T Y [ T c \ n X U \ _ S V T Y o T U d U g S Y c \ S U g S T \ W l V f X _
U h U W S f \ X X n V [ [ f d Y W S T U l T V X U ^ V ^ f X \ S Y V W a Y m U l Y g U i U \ d X n
Y W _ Y [ \ S V d g V j g U h U d Y S n c \ n e U V h U d U g S Y c \ S U _ Y j g U h U d U Y X X p
W U g g U g \ d U c V d U X Y m U X n S V e U d U [ V o W Y w U _ i \ g l \ g g U U W l V d X _ p
l Y _ U U \ d X n Y W S T U Y W v f U W w \ ] q t ^ \ W _ U c Y [ q i t a
r V d U ` \ c ^ X U i d U ^ V d S g S V S T U U W S U d g j V d Y g U \ g U V W S d V X
\ W _ d U h U W S Y V W q ] S X \ W S \ i ] i ] t V j [ V W k d c U _ [ \ g U g Y W
S T U k d g S j U l l U U m g V j S T U ^ \ W _ U c Y [ Y W _ Y [ \ S U _ \ [ d f _ U
r V j a s q t i p j V X _ T Y o T U d S T \ W Y S l \ g U g S Y c \ S U _ S V
e U j V X X V l Y W o \ _ f g S c U W S j V d f W _ U d _ U S U [ S Y V W q i t a Z V \ [ p
[ V f W S j V d S T Y g e Y \ g Y W U \ d X n c U \ g f d U c U W S g i l U g U S S T U c Y _ p
^ V Y W S V j S T U r Y W S T U Y W Y S Y \ X \ g g U g g c U W S T Y o T U d S T \ W
S T U c Y _ ^ V Y W S Y W S T U d U k W U _ \ g g U g g c U W S a
\ d X n c U \ g f d U g V j S d \ W g c Y g g Y e Y X Y S n l U d U S T U W g [ \ X U _
\ X V W o \ n p \ ` Y g i \ W _ U \ d X n c U \ g f d U g V j [ X Y W Y [ \ X g U h U d Y S n l U d U
g [ \ X U _ \ X V W o \ W ` p \ ` Y g a r d V c S T U [ V c e Y W \ S Y V W V j S T U g U _ Y p
[ T V S V c V f g g [ \ X U g i S T U Y W Y S Y \ X j d \ c U l V d m d U g f X S g Y W x f \ _ p
d \ W S g q r Y o f d U t a W f \ _ d \ W S ] i j V d U ` \ c ^ X U i \ h \ Y X \ e X U Y W p
_ Y [ \ S V d g \ ^ ^ U \ d g Y c Y X \ d S V S T U d \ W o U g U U W Y W \ W W f \ X g U \ g V W \ X
U ^ Y _ U c Y [ g a r V d f \ _ d \ W S u i \ X S T V f o T [ X Y W Y [ \ X g U h U d Y S n Y g Y W
S T U d \ W o U V j S T \ S g U U W Y W g U \ g V W \ X U ^ Y _ U c Y [ g i S T U S d \ W g c Y g p
g Y e Y X Y S n Y g o d U \ S U d \ W _ S T f g V h U d \ X X d \ S U g V j g U h U d U V f S [ V c U g
c \ n e U o d U \ S U d a V W h U d g U X n i Y W f \ _ d \ W S i S d \ W g c Y g g Y e Y X p
Y S n Y g g Y c Y X \ d S V S T \ S V j g U \ g V W \ X U ^ Y _ U c Y [ g i e f S g U h U d Y S n Y g
U ` ^ U [ S U _ S V e U T Y o T U d i \ o \ Y W X U \ _ Y W o S V Y W [ d U \ g U _ U ` ^ U [ S U _
d \ S U g V j g U h U d U V f S [ V c U g i e f S j V d \ _ Y j j U d U W S d U \ g V W a r Y W \ X p
X n i Y W f \ _ d \ W S i e V S T Y W _ Y [ \ S V d g \ d U o d U \ S U d S T \ W U ` ^ U [ S U _
_ f d Y W o \ W W f \ X g U \ g V W \ X U ^ Y _ U c Y [ g a V W g U f U W S X n i d U [ V c p
c U W _ U _ o f Y _ \ W [ U \ W _ Y W S U d h U W S Y V W g _ f d Y W o S T U ^ \ W _ U c Y [
d U g ^ V W g U c \ n e U _ Y j j U d U W S e U S l U U W S T U f \ _ d \ W S g a
Figure 2. Framework for the initial assessment of the effects of an
influenza pandemic.
Figure 3. Framework for the refined assessment of the effects of an
influenza pandemic, with scaled examples of past pandemics and
past influenza seasons. A color version of this figure is available
online (wwwnc.cdc.gov/eid/article/19/1/12-0124-F3.htm).
RESEARCH

Figure 4. Framework for the refined assessment of the effects of an
influenza pandemic, stratified by age group with scaled examples
from the 2009 pandemic. A color version of this figure is available
online (wwwnc.cdc.gov/eid/article/19/1/12-0124-F4.htm).

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D C B 7 9 D 7 ; < C 9 < 7 D : C ; 9 B S L C 9 Q : = 7 A 5 9 B 7 8 C D T 5 9 ; I 7 L 5 J J 6 P 8 A R
: ; 8 5 : C D 5 : : 5 D U L 5 : 7 ; < > V W X Y Z [ H \ ; 9 : = 7 : L 5 9 6 8 C 6 6 C K C J C : P
6 D 5 J 7 ] H K S : L 7 J 5 : C I 7 J P < 7 G C 9 : = 5 : 5 Q 7 Q L ; S A G = ; K 7 D 5 8 7
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6 D 5 J 7 ] E c = ; 6 7 d V \ P 7 5 L 6 ; < 5 Q 7 H = ; G 7 I 7 L H = 5 B J C : : J 7 C J J 9 7 6 6
T 5 9 ; I 7 L 5 J J 6 P 8 A : ; 8 5 : C D 5 : : 5 D U L 5 : 7 ; < N \ W X Y Z [ H > ; 9 : = 7
: L 5 9 6 8 C 6 6 C ; 9 6 D 5 J 7 ] H K S : 8 ; L 7 ; < : = ; 6 7 G = ; K 7 D 5 8 7 C J J B C 7 B
T 5 ^ _ ` ; < ? E N O W X a H b [ H e ; 9 : = 7 D J C 9 C D 5 J 6 7 I 7 L C : P 6 D 5 J 7 ] E
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I 7 J ; A 7 B : ; 6 P 6 : 7 8 5 : C D 5 J J P 5 6 6 7 6 6 : = 7 A ; : 7 9 : C 5 J A ; A S J 5 : C ; 9
7 < < 7 D : 6 ; < 5 9 C 9 o S 7 9 p 5 A 5 9 B 7 8 C D K P D = 5 L 5 D : 7 L C p C 9 Q B 5 : 5 ; 9
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7 A C B 7 8 C ; J ; Q C D B 5 : 5 8 5 P K 7 5 I 5 C J 5 K J 7 5 9 B 7 5 L J P C 9 B C D 5 : ; L 6
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S 6 C 9 Q 5 K L ; 5 B B C D = ; : ; 8 ; S 6 6 D 5 J 7 E s 9 : = 7 L 7 t 9 7 B 5 6 6 7 6 6 8 7 9 : H
5 6 C 9 D L 7 5 6 7 B B 5 : 5 K 7 D ; 8 7 5 I 5 C J 5 K J 7 J 5 : 7 L C 9 5 A 5 9 B 7 8 C D H : = 7
L 5 9 Q 7 6 ; < : L 5 9 6 8 C 6 6 C K C J C : P 5 9 B 6 7 I 7 L C : P 8 7 5 6 S L 7 6 G 7 L 7 8 ; L 7
t 9 7 J P D 5 : 7 Q ; L C p 7 B E
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8 5 P K 7 8 C 6 J 7 5 B C 9 Q C < : = ; 6 7 B 5 : 5 5 L 7 S 9 5 I 5 C J 5 K J 7 ; L 9 ; : L 7 A R
L 7 6 7 9 : 5 : C I 7 7 5 L J P C 9 : = 7 A 5 9 B 7 8 C D H G 7 C 9 D ; L A ; L 5 : 7 B 6 7 I 7 L 5 J
7 A C B 7 8 C ; J ; Q C D 8 7 5 6 S L 7 6 C 9 : ; : = 7 < L 5 8 7 G ; L U H 5 J : = ; S Q = : = 7
^ _ ` L 7 8 5 C 9 6 5 I 5 J S 5 K J 7 8 7 5 6 S L 7 ; < D J C 9 C D 5 J 6 7 I 7 L C : P E r C : =
: = 7 D L 7 5 : C ; 9 ; < 5 6 : 5 9 B 5 L B 6 D 5 J 7 : = 5 : C 9 D J S B 7 6 8 S J : C A J 7 7 A C R
B 7 8 C ; J ; Q C D 8 7 5 6 S L 7 6 H 5 I 5 L C 7 : P ; < B 5 : 5 8 5 P K 7 C 9 D ; L A ; L 5 : 7 B
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C 9 B C D 5 : ; L ; < : L 5 9 6 8 C 6 6 C K C J C : P 5 9 B D J C 9 C D 5 J 6 7 I 7 L C : P E
c = 7 I C 6 S 5 J C p 5 : C ; 9 ; < 7 A C B 7 8 C ; J ; Q C D B 5 : 5 C 9 : = 7 < L 5 8 7 R
G ; L U A L ; I C B 7 6 7 A C B 7 8 C ; J ; Q C 6 : 6 H A S K J C D = 7 5 J : = ; < t D C 5 J 6 H 5 9 B
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RESEARCH

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http://wwwnc.cdc.gov/eid/podcasts.htm
To estimate population attack rates of influenza
A(H1N1)pdm2009 in the Southern Hemisphere during
JuneAugust 2009, we conducted several serologic stud-
ies. We pooled individual-level data from studies using
hemagglutination inhibition assays performed in Australia,
New Zealand, and Singapore. We determined seropositive
proportions (titer >40) for each study region by age-group
and sex in pre- and postpandemic phases, as defined by
jurisdictional notification data. After exclusions, the pooled
database consisted of, 4,414 prepandemic assays and
7,715 postpandemic assays. In the prepandemic phase,
older age groups showed greater seropositive proportions,
with age-standardized, community-based proportions rang-
ing from 3.5% in Singapore to 11.9% in New Zealand. In the
postpandemic phase, seropositive proportions ranged from
17.5% in Singapore to 30.8% in New Zealand, with highest
proportions seen in school-aged children. Pregnancy and
residential care were associated with lower postpandemic
seropositivity, whereas Aboriginal and Torres Strait Islander
Australians and Pacific Peoples of New Zealand had great-
er postpandemic seropositivity.

Seroepidemiologic Effects
of Influenza A(H1N1)pdm09
in Australia, New Zealand,
and Singapore

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RESEARCH
Author affiliations:Melbourne Sleep Disorders Centre, East Mel-
bourne, Victoria, Australia (J.M. Trauer); Environmental Science
and Research, Wallaceville, New Zealand (D. Bandaranayake, Q.S.
Huang); National Centre for Immunisation Research and Surveil-
lance, Westmead, New South Wales, Australia (R. Booy, G. Khan-
daker); National University Health System, Singapore (M.I. Chen);
University of Sydney, Sydney, New South Wales, Australia (M. Cre-
tikos); Communicable Disease Control Directorate, Shenton Park,
Western Australia, Australia (G.K. Dowse); Centre for Infectious
Diseases and Microbiology, Westmead (D.E. Dwyer, J. Kok); CSL
Limited, Parkville, Victoria, Australia (M.E. Greenberg); World Health
Organization Collaborating Centre for Reference and Research in
Influenza, North Melbourne, Victoria, Australia (K.L. Laurie); World
Health Organization, Geneva, Switzerland (V.J. Lee); Melbourne
School of Population Health, Parkville (J. McVernon); Centre for Epi-
demiology and Research, North Sydney, New South Wales, Austra-
lia (S. Walter); and Centre for Disease Control, Tiwi, Northern Terri-
tory, Australia (P.G. Markey)
A list of the groups members can be found at the end of this article.
Influenza A(H1N1)pdm09 in Australia, New Zealand, and Singapore
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h i j k l m n o j j p q l r q n k s o l t r k s k u v w o x y o z y o p p q t l { t r o j p k y o r q p | j k } o r ~ o y s q n k j j } u

o o y o l n o n k s o z t y } u

Table 5. Multivariate logistic regression models comparing specific collections on outcome of seropositivity, with exposures of region,
age group, and sex, in community-based studies of influenza A (H1N1) 2009 in the Southern Hemisphere, winter 2009*
Collections compared
No.
assays
included
Characteristics of model ORs 95% CI for exposure variables
Comp. Ref.
Restrictions to
inclusion Rationale Male sex Age
Comp. group/study
compared with ref.
group/study
K N 493 Residence in NSW;
post; age 1678 y
Stored pathology
specimens survey vs.
survey of blood donors
(NSW)
0.98
(0.651.49);
p = 0.93
0.74
(0.660.84);
p<0.001
1.37
(0.892.09);
p = 0.15
R N 204 Residence in WA;
post
Patients voluntarily
enrolled in RCT vs.
blood donors (WA)
1.05
(0.561.98);
p = 0.88
1.06
(0.861.31);
p = 0.56
1.48
(0.792.79);
p = 0.22
D K 278 Pre; age t58 y Persons in res,care vs.
community control
group (NSW)
0.49
(0.310.79);
p = 0.003
2.79
(2.013.86);
p<0.001
0.34
(0.150.79);
p = 0.01
M K 278 Post; age 1977 y Persons with HIV
infection vs. community
control group (NSW)
1.43
(0.802.57);
p = 0.23
0.74
(0.610.90);
p = 0.003
1.26
(0.662.41);
p = 0.48
Q K 192 Post; age 4388 y Hemo. patients vs.
community control
group (NSW)
0.90
(0.421.95);
p = 0.79
0.91
(0.681.21);
p = 0.50
1.65
(0.753.63);
p = 0.21
J N, R 316 Res. in WA; post ;
age 2145 y
Preg. women vs.
community control
group (WA)
0.72
(0.481.06);
p = 0.10
0.44
(0.240.81);
p = 0.008
C B 1,316 Post; age >21 HCWs vs. community
control group (NZ)
0.92
(0.701.22);
p = 0.56
0.95
(0.881.03);
p = 0.26
1.09
(0.831.42);
p = 0.54
F E 1,080 Post HCWs vs. community
control group
(Singapore)
1.12
(0.741.71);
p = 0.59
0.78
(0.660.93);
p = 0.006
0.65
(0.411.01);
p = 0.06
H E 996 Post; age 2162 y Military personnel vs.
community control
group (Singapore)
1.19
(0.751.88);
p = 0.45
0.71
(0.58 0.85);
p<0.001
0.97
(0.581.60);
p = 0.89
G E 858 Post Res. care group vs.
community control
group (Singapore)
1.38
(0.892.16);
p = 0.15
0.81
(0.680.96);
p= 0.02
0.44
(0.220.90);
p = 0.03
P P 1,689 Post Aboriginal and Torres
Strait Islanders vs.
nonindig. people (NT)
0.95
(0.741.22);
p = 0.68
0.88
(0.820.94);
p<0.001
2.67
(2.083.42);
p<0.001
B B 1,147 Post Maori vs nonindig.
people (NZ)
0.95
(0.731.22);
p = 0.66
0.86
(0.820.91);
p <0.001
1.17
(0.831.64);
p = 0.38
B B 966 Post Pacific Peoples vs.
nonindig. people (NZ)
1.04
(0.781.37);
p = 0.80
0.87
(0.820.92);
p<0.001
1.99
(1.412.82);
p<0.001
*ORs, odds ratios; comp., comparison; ref., referent; NSW, New South Wales; post, postpandemic phase; WA, Western Australia; RCT, randomized
controlled trial; pre, prepandemic phase; res., residence/residential; hemo., hemodialysis; preg., pregnant; HCWs, health care workers; NZ, New
Zealand; NT, Northern Territory; nonindig., nonindigenous.
Age is considered as a continuous variable with OR for each decade of increasing age.
RESEARCH

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Sheep-to-Human
Transmission of
Orf Virus during
Eid al-Adha
Religious Practices,
France

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Five persons in France were infected with Orf virus
after skin wounds were exposed to infected sheep tissues
during Eid al-Adha, the Muslim Feast of Sacrifice. Infec-
tions were confirmed by electron microscopy, PCR, and
sequence analysis. Prevention and control of this underdi-
agnosed disease can be achieved by educating physicians,
slaughterhouse workers, and persons participating in Eid
al-Adha.
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DISPATCHES
Author affiliations: Aix-Marseille University, Marseille, France (A.
Nougairede, N. Salez, L. Ninove, X. de Lamballerie, R.N. Char-
rel); Assistance PubliqueHopitaux de Marseille, Marseille (A. Nou-
gairede, L. Ninove, C. Zandotti, X. de Lamballerie, R.N. Charrel);
Hpital Paul Desbief, Marseille (C. Fossati); AlphaBio Laboratory,
Marseille (S. Cohen-Bacrie); Service Sant, Protection Animales et
Environnement, Marseille (F. Michel); Regional Office of the French
Institute for Public Health Surveillance (Institut de Veille Sanitaire),
Marseille (S. Aboukais); and Bavarian Health and Food Safety Au-
thority, Oberschleiheim, Germany (M. Buttner)
These authors contributed equally to this article.
Sheep-to-Human Transmission of Orf Virus
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Figure 1. Orf virus infection in 5 persons who butchered or prepared lambs as part of a religious practice for Eid al-Adha (the Muslim Feast
of Sacrifice), Marseille, France, 2011. Cutaneous lesions on hands of case-patient 3 (A, B) and case-patient 5 (C) are shown. Negative-
staining electron microscopy of samples from case-patient 3 (D) and case-patient 5 (E, F) show ovoid particles (250 nm long, 150 nm
wide) with a crisscross appearance; the size and appearance of these particles are highly suggestive of parapoxvirus virions.

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; ; [ e ; < C o ; < C H E M [ ] M U e F L : _ ` 9 _ ^ m 9 G _ X s c a :
s : r F K H F C = h < C Q B = F E = F r < K H C < M E K D ? C F A F K H B < K : g C h A B C J = B K h F N H B < K
B K I J \ E K = t u F T v < C ] R O M M B K < B = R r E M B h < C K B E R E K D w F K K F = = F F R _ ` ` X c
_ ` ` s : ; ; [ e ; < C o ; < C H E M [ ] M U e F L : _ ` ` m ^ s s G m s c a :
m : Y F D F C \ E K x e R p J = H B K r R w C F A B K < O R e F U K < M D = ; y R j T E K = < K
S
R
r I F C C U > R F H E M : g e V A B C J = B K h F N H B < K B K N I B M D C F K G N M B K B N E M N I E C E N H F C Z
B = H B N = R H C E K = \ B = = B < K R D B E W K < = H B N \ F H I < D = R E K D h J H J C F H I F C E L F J H B N = :
? F D B E H C O K h F N H Q B = f : _ ` ` k ^ _ m G k X ` c X : I H H L G l l D @ : D < B : < C W l 9 ` : 9 ` b k l
O u V : ` o ` 9 d F d 9 a ` m _ 9 9 o h
k : Y B v R ; F U F C
S
R z I E <
S
R Q E \ < K O P : y r N < K H F K H c o E = F D L E K Z L < @
J K B A F C = E M ? r e E = = E U = h < C L < @ A B C J = D F H F N H B < K : f r M B K ; B N C < o B < M :
_ ` 9 ` ^ X a G _ m a c k m : I H H L G l l D @ : D E = B N M < N E M
E M B W K \ F K H = F E C N I H < < M : f ; < M > B < M : 9 b b ` ^ _ 9 s G X ` d c 9 ` :
b : Y E C ] B K ; p R > M E N ] = I B F M D = y R > C < T K u ? R r I F K K E e R ; N y F H H B W E K ? p R
; N [ B M M B E \
S
R F H E M : r M J = H E M [ E K D r M J = H E M { A F C = B < K _ : ` : > B < B K h < C Z
\ E H B N = : _ ` ` k ^ _ d G _ b X k c a : I H H L G l l D @ : D < B : < C W l 9 ` : 9 ` b d l o B < B K h < C \ E H B N = l
o H \ X ` X
DISPATCHES
Figure 2. Natural history of Orf virus
infection and diagnosis in 5 persons
who butchered or prepared lambs
as part of a religious practice for
Eid al-Adha (the Muslim Feast of
Sacrifice), Marseille, France, 2011.
Arrows indicate events for the first
cluster of cases among 3 related
persons (a brother and sister and
their aunt).
Sheep-to-Human Transmission of Orf Virus
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etymologia
Orf
orf

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DOI: http://dx.doi.org/10.3201/eid1901.ET1901

Schmallenberg
Virus in Culicoides
spp. Biting Midges,
the Netherlands,
2011

! " #
! $
To determine which species of % & ' ( ) * ( + , - biting midges
carry Schmallenberg virus (SBV), we assayed midges col-
lected in the Netherlands during autumn 2011. SBV RNA
was found in % . - ) * / ( ) & - , % . * 0 - * ' , / & - - , 1 - & - / 2 ( ) / * , and
% . ) 3 ( * 4 / , 2 & - . The high proportion of infected midges might
explain the rapid spread of SBV throughout Europe.
5 6 7 8 9 : ; 6 < = > 5 ? ? : 6 @ A B B C D E F ? ; < < : 8 G : 6 9 H 7 6 5 > I D J K L C
; 8 M H : < M 6 N F M G 5 8 = ; H 7 6 5 > M O N F : D 7 ? G 5 > : 6 M 9 6 M 5 P C
> P 6 : ; Q ; E 6 M > > ? 5 E F M O 8 M 6 N F : 6 8 R 5 6 M P : C 7 8 O : E N 7 8 9 6 5 ? 7 8 ; 8 N
< 7 H : > N M E S T U F : D 7 ? G 5 > : 6 M 9 6 M 5 P I O ; ? 7 < = V W X Y Z [ \ ] \ ^ Z _ C 9 : `
8 5 > V W X Y Z [ \ ] W a L 7 8 E < 5 Q : > D F ; ? M 8 Q ; H 7 6 5 > C b S ; G ; 8 : H 7 6 5 > C
D ; N F 5 P : 6 7 H 7 6 5 > C ; 8 Q b 7 8 M H 7 6 5 > T U F : > : H 7 6 5 > : > E ; 5 > : N : 6 ; `
N M < M 9 7 E : O O : E N > 7 8 6 5 ? 7 8 ; 8 N > ; 8 Q ; 6 : ; 6 N F 6 M P M Q ` G M 6 8 : C ; 8 Q
? M > N F ; H : G : : 8 7 > M < ; N : Q 7 8 N F : c < Q d M 6 < Q O 6 M ? ? M > e 5 7 N M : >
; 8 Q f W g \ h i \ ^ _ a > P P T G 7 N 7 8 9 ? 7 Q 9 : > I j L T k : E : 8 N P 6 : < 7 ? 7 8 ; 6 =
> N 5 Q 7 : > 7 8 Q 7 E ; N : N F ; N
B > P : E 7 : > M O f W g \ h i \ ^ _ a ? 7 Q 9 : > ; E N ; >
l
: < Q H : E N M 6 > O M 6 D J K 7 8 R 5 6 M P : I m L T U M Q : N : 6 ? 7 8 : n F 7 E F
f W g \ h i \ ^ _ a ? 7 Q 9 : > P : E 7 : > F ; 6 G M 6 D J K C n : ; 8 ; < = o : Q ? 7 Q 9 : >
E M < < : E N : Q O 6 M ? p < 7 H : > N M E S F M < Q 7 8 9 > 7 8 : ; > N : 6 8 ; 8 Q 8 M 6 N F `
: ; > N : 6 8 P ; 6 N > M O N F : q : N F : 6 < ; 8 Q > T
r "
U F 6 M 5 9 F M 5 N D : P N : ? G : 6 ; 8 Q : ; 6 < = c E N M G : 6 @ A B B C f W s
g \ h i \ ^ _ a > P P T G 7 N 7 8 9 ? 7 Q 9 : > n : 6 : N 6 ; P P : Q ; < ? M > N Q ; 7 < = ; N ;
Q ; 7 6 = 7 8 N F : ? 5 8 7 E 7 P ; < 7 N = M O R 6 ? : < M I : ; > N : 6 8 q : N F : 6 < ; 8 Q > L
G = H ; 6 7 M 5 > ? : N F M Q > C 7 8 E < 5 Q 7 8 9 N F : > N ; 8 Q ; 6 Q c 8 Q : 6 > N : P M M 6 N `
N = P : G < ; E S < 7 9 F N N 6 ; P T t 8 ; Q Q 7 N 7 M 8 C Q 5 6 7 8 9 > : H : 6 ; < Q ; = > 7 8 b 5 `
9 5 > N ; 8 Q D : P N : ? G : 6 @ A B B C f W g \ h i \ ^ _ a > P P T G 7 N 7 8 9 ? 7 Q 9 : >
n : 6 : N 6 ; P P : Q 8 : ; 6 > F : : P u M E S > 7 8 N F : ? 5 8 7 E 7 P ; < 7 N 7 : > M O
J 7 < N F M H : 8 I E : 8 N 6 ; < q : N F : 6 < ; 8 Q > L ; 8 Q v 7 Q Q : 8 ` w 6 : 8 N F :
I 8 M 6 N F : ; > N : 6 8 q : N F : 6 < ; 8 Q > L G = 5 > 7 8 9 N F : c 8 Q : 6 > N : P M M 6 N `
N = P : N 6 ; P ; 8 Q ; Q 6 M P ` N : 8 N E ; 9 : T x ; P N 5 6 : Q ? 7 Q 9 : > n : 6 :
> N M 6 : Q 7 8 y A z : N F ; 8 M < T
{
: ? ; < : ? 7 Q 9 : > n : 6 : E ; N : 9 M 6 7 o : Q ; > 8 5 < < 7 P ; 6 M 5 > C P ; 6 `
M 5 > C 9 6 ; H 7 Q C M 6 O 6 : > F < = G < M M Q O : Q I : 8 9 M 6 9 : Q L I | L } M 8 < =
? 7 Q 9 : > G : < M 8 9 7 8 9 N M N F :
l
6 > N p E ; N : 9 M 6 7 : > n : 6 : ; > > ; = : Q T
U F : ~ C B A A > : < : E N : Q ? 7 Q 9 : > n : 6 : Q 7 H 7 Q : Q 7 8 N M ~ B A > P : E 7 : > `
> P : E 7
l
E P M M < > C B A ? 7 Q 9 : > P : 6 P M M < T 8 Q : 6 ; Q 7 > > : E N 7 8 9 ? 7 `
E 6 M > E M P : C N F : F : ; Q > n : 6 : > : P ; 6 ; N : Q O 6 M ? ; G Q M ? : 8 > G = 5 > :
M O ; > E ; n : 6 : N F : 8 P M M < : Q ; 8 Q ; > > ; = : Q O M 6
D J K C n F : 6 : ; > N F : E M 6 6 : > P M 8 Q 7 8 9 ; G Q M ? : 8 > I ; < > M P M M < : Q L
n : 6 : > N M 6 : Q 7 8 y A z : N F ; 8 M < T
b < < ? 7 Q 9 : > n : 6 : 7 Q : 8 N 7
l
: Q ? M 6 P F M < M 9 7 E ; < < = C G 5 N G : `
E ; 5 > : O : ? ; < : f i a i g _ W a > : 8 > 5 > N 6 7 E N M ? 7 Q 9 : > E ; 8 8 M N G :
> : P ; 6 ; N : Q n 7 N F E M 8
l
Q : 8 E : O 6 M ? f a h i \ h W a ? 7 Q 9 : > C N F : =
n : 6 : P M M < : Q ; 8 Q ; 6 : 6 : O : 6 6 : Q N M M 7 8 N < = ; > N F : f i a i g _ W a
E M ? P < : T U F : 8 5 ? G : 6 M O P M M < > ; > > ; = : Q O M 6 : ; E F > P : E 7 : >
n ; > ; > O M < < M n > f i a i g _ W a E M ? P < : I @ p A L C f h \ i _ ] W a
I B L C f ^ _ W g I B p A L C f W X h Z W a I B A L C ; 8 Q f W g \ h Z s
] \ a I B L T b O N : 6 ; > > ; = > n : 6 : E M 8 Q 5 E N : Q C N F : > P : E 7 : > 7 Q : 8 N 7 N =
M O : ; E F D J K ` P M > 7 N 7 H : ? 7 Q 9 : P M M < n ; > : > N ; G < 7 > F : Q G = 5 > 7 8 9
? M < : E 5 < ; 6 N : E F 8 7 e 5 : > T
c 8 < = n F : 8 ; P M M < M O B A F : ; Q > n ; > O M 5 8 Q D J K P M > 7 `
N 7 H : n ; > N F : E M 6 6 : > P M 8 Q 7 8 9 P M M < M O Q 7 > > : E N : Q ; G Q M ? : 8 >
6 : N 6 7 : H : Q ; 8 Q ; > > ; = : Q T t 8 N F 7 > 7 8 > N ; 8 E : C N F : B A ; G Q M ? : 8 >
n : 6 : ; > > ; = : Q > 7 8 9 < = C > M N F ; N N F : 7 8 Q 7 H 7 Q 5 ; < ; G Q M ? : 8 N F ; N
n ; > D J K ` P M > 7 N 7 H : E M 5 < Q G : 7 Q : 8 N 7
l
: Q ? M < : E 5 < ; 6 < = C N M : > `
N ; G < 7 > F : ; E N < = n F 7 E F M O N F : @ > P : E 7 : > M O N F : f i a i g _ W a
E M ? P < : n ; > 7 8 H M < H : Q ; 8 Q N M E M 8
l
6 ? M 6 6 : O 5 N : N F : ? M 6 P F M `
< M 9 7 E 7 Q : 8 N 7
l
E ; N 7 M 8 > N F ; N F ; Q G : : 8 ? ; Q : O M 6 N F : 6 : ? ; 7 8 7 8 9
f W g \ h i \ ^ _ a > P : E 7 : > T
k q b : N 6 ; E N 7 M 8 n ; > P : 6 O M 6 ? : Q ; E E M 6 Q 7 8 9 N M ; P 6 M N M `
E M < Q : H : < M P : Q G = x c w b ` x R k K b I x : 8 N 6 5 ? H M M 6 c 8 Q : 6 `
o M : S 7 8 w 7 : 6 9 : 8 : : > S 5 8 Q : : 8 b 9 6 M E F : ? 7 : C x : 8 N 6 : Q N 5 Q :
: N Q : k : E F : 6 E F : > K N 6 7 8 ; 7 6 : > : N b 9 6 M E F 7 ? 7 e 5 : > L C J 6 5 > > : < > C
J : < 9 7 5 ? } n F : 6 : ; > C 6 : H : 6 > : N 6 ; 8 > E 6 7 P N 7 M 8 x k I k U ` x k L
n ; > P : 6 O M 6 ? : Q ; E E M 6 Q 7 8 9 N M ; ? : N F M Q 6 : E : 8 N < = Q : H : < M P : Q
N M Q : N : E N N F : > ? ; < < > : 9 ? : 8 N M O D J K I L T U F : k U ` x k E 5 N `
M O O H ; < 5 : O M 6 N F : P M M < : Q F : ; Q > n ; > > : N ; N ; E = E < : N F 6 : > F M < Q
I x L H ; < 5 : M O p T M M < > n 7 N F x p n : 6 : 6 : N : > N : Q ; 8 Q E M 8 `
> 7 Q : 6 : Q P M > 7 N 7 H : n F : 8 E M 8
l
6 ? : Q T k : P M 6 N : Q x H ; < 5 : > O M 6
G < M M Q > ; ? P < : > O 6 M ? 7 8 O : E N : Q E ; N N < : 7 8 : 6 ? ; 8 = C N : > N : Q G =
5 > 7 8 9 N F : > ; ? : k U ` x k C n : 6 : @ p I L ; 8 Q n : 6 : 5 > : Q
; > N F : 9 5 7 Q : O M 6 M 5 6 E F M 7 E : M O E 5 N M O O H ; < 5 : T t O ; > P : E 7
l
E
P M M < M O ? 7 Q 9 : F : ; Q > N : > N : Q P M > 7 N 7 H : C 7 8 Q 7 H 7 Q 5 ; < ; G Q M ? : 8 >
O 6 M ? N F : E M 6 6 : > P M 8 Q 7 8 9 > N M 6 : Q P M M < n : 6 : N : > N : Q > : P ; 6 ; N : < =
G = k U ` x k T
{
M 6 ? M < : E 5 < ; 6 7 Q : 8 N 7
l
E ; N 7 M 8 M O N F : D J K ` P M > `
7 N 7 H : ? 7 Q 9 : > C N F : B D 7 8 N : 6 8 ; < N 6 ; 8 > E 6 7 G : Q > P ; E : 6 B I t U D B L
T D 6 : 9 7 M 8 n ; > ; ? P < 7
l
: Q G = 5 > 7 8 9 N F : ; 8 x 5 <
{
; 8 Q ; 8 `
x 5 < k P 6 7 ? : 6 > : N C ; Q ; P N : Q O 6 M ? x N 6 : ` D M > > ; F : N ; < T I L T U F :
t U D B > : e 5 : 8 E : > M G N ; 7 8 : Q O 6 M ? N F : D J K ` P M > 7 N 7 H : ; G Q M ? : 8 >
n : 6 : 5 > : Q N M Q : H : < M P ; f W g \ h i \ ^ _ a > P P T P F = < M 9 : 8 = I
{
7 9 5 6 : L C
n F 7 E F 7 8 E < 5 Q : > : 8 J ; 8 S > : e 5 : 8 E : > 6 : P 6 : > : 8 N 7 8 9 ; < < > P : `
E 7 : > M O N F : > 5 G 9 : 8 5 > [ Z ] \ \ Z I 7 8 E < 5 Q 7 8 9 f \ \ h i g Z L S 8 M n 8
DISPATCHES
Author affiliations: Central Veterinary Institute, Lelystad, the Neth-
erlands (A.R.W. Elbers, E. van Weezep, E.A. Kooi); Rocca di Cave,
Rome, Italy (R. Meiswinkel); and Utrecht University, Utrecht, the
Netherlands (M.M. Sloet van Oldruitenborgh-Oosterbaan)
Schmallenberg Virus in Biting Midges

Figure. Phylogenetic tree comparing
Schmallenberg viruspositive

spp. biting midge abdomens isolated
in different regions in the Netherlands,
2011, with reference sequences from
Deblauwe et al. ( ). was used
as an outgroup. Bootstrap values are
indicated at the significant nodes. Scale
bar indicates nucleotide substitutions per
site.
Table 1. Schmallenberg virus RNA in
spp. biting midges collected AugustSeptember 2011, the Netherlands
Municipality (Province)
Pools, no. positive/no. tested*

complex

Total
Bilthoven (Utrecht) 0/10 0 0 0 0 0/10
Midden-Drenthe (Drenthe) 0/5 0 1/39 0 0 1/44
Ermelo (Gelderland) 12/215 0/130 1/105 0/105 0/1 13/556
Total 12/230 0/130 2/144 0/105 0/1 14/610
*Tested by reverse transcription PCR.
! " # $ % & ' ( ! ) * + , # $ - . ' ! / 0 / 0 1 2 3 / 3 / 4 3 5 6 3 /
7 3 8 3 * 9 : + ; < 2 3 9 : 8 3 * = > + , * + < : ? < 2 3 @ A / 4 3 5 6 3 / ? : > + , * <
< 2 3 B 6 C 3 / < : 5 D 2 : B , 6 + ; / / * 9 4 B 3 , 0 1 2 3 2 : B , 6 + ; / 7 3 8 3 / 6 < > E
* < 3 , 6 + < 2 3 5 3 + < 3 8 : ? < 2 3 3 4 6 , 3 9 6 5 * 8 3 * ) * + , : ? < 2 3
@ F F
* + 6 9 * B / * < < 2 3 , * 6 8 G 6 + H 8 9 3 B : ) I J K L 2 * , / 3 8 : 5 : + C 3 8 < 3 , < :
M N O
0 1 2 3 B : 7 P Q C * B > 3 / 6 + , 6 5 * < 3 < 2 * < 5 : + 5 3 + < 8 * < 6 : + / : ? < 2 3
C 6 8 > / 6 + 9 : / <
M N O
E 4 : / 6 < 6 C 3 # ! . R ' 9 6 , ; 3 / 7 3 8 3 2 6 ; 2 0
1 2 3 ? * 5 < < 2 * < < 2 3 P Q C * B > 3 / ? : 8 < 2 3 2 3 * , / : ? 9 6 , ; 3 / 9 * < 5 2 3 ,
5 B : / 3 B G 7 6 < 2 < 2 : / 3 ? 8 : 9 < 2 3 * / / : 5 6 * < 3 , * = , : 9 3 + / 8 3 + , 3 8 / 6 <
5 3 8 < * 6 + < 2 * <
M N O
2 * , 8 3 4 B 6 5 * < 3 , < : < 8 * + / 9 6 / / 6 = B 3 B 3 C 3 B / 6 +
< 2 3 / 3 9 6 , ; 3 / * + , / > 4 4 : 8 < / < 2 3 5 : + < 3 + < 6 : + < 2 * < S / 4 3 5 6 3 / : ?
< 2 3 # $ - . ' ! 5 : 9 4 B 3 T ) * B : + ; 7 6 < 2 # $ % & ' ( ! " * 5 < * /
+ * < > 8 * B C 3 5 < : 8 / ? : 8
M N O
0 U 3 / 4 6 < 3 < 2 3 8 3 B * < 6 C 3 B G B * 8 ; 3 + > 9 E
= 3 8 / : ?
M N O
E + 3 ; * < 6 C 3 4 : : B / ) : > 8 V + , 6 + ; / / 2 : > B , + : < = 3 6 + E
< 3 8 4 8 3 < 3 , < : 3 T 5 B > , 3 < 2 3 6 + C : B C 3 9 3 + < : ? : < 2 3 8 / 4 3 5 6 3 / ) / > 5 2
* / # $ R ' W ! . X : 8 # $ & ! Y Z ! ) 6 + V 3 B , < 8 * + / 9 6 / / 6 : + : ?
M N O
0
[
3 5 : + 5 B > , 3 < 2 * < < 2 3 2 6 ; 2 4 8 : 4 : 8 < 6 : + : ?
M N O
E 4 : / 6 < 6 C 3 # ! \
. R ' / 4 4 0 9 6 , ; 3 / * + , < 2 3 9 > B < 6 4 B 3 C 3 5 < : 8 / 4 3 5 6 3 / 5 : > B ,
2 3 B 4 3 T 4 B * 6 + < 2 3 8 * 4 6 , / 4 8 3 * , : ?
M N O
< 2 8 : > ; 2 : > < 9 > 5 2 : ?
H > 8 : 4 3 , > 8 6 + ; S F @ @ 0
] ^ _ ` a b c d e f g d ` h i
j k l m n o p q n r p k s t n o u k o l v w x o o y k z y { k o m | y } ~ | s } m x } l v
k l n k x o v x o y k } } k o v k } } k k o } v x x } l x x v n o
q n y n o o k j k } } k s } x m k s y o l n } y k } k { k
n o y q k y m | y k o x k k s s k o l n o y k o s r x x k n l y x o n o
k o k x | } s r x t y y o n k } } l x l m k y n } l | k } n o n o y n s } n o s }
k x k | y { l k v q n n t n o k l l k o v n o | l m x } } k } k y k } x
k n y l n l y o l m k y k }
m y } } l | r n } x y } } y x o k n o | o k r l m k | l m q y o
y } l r x x o x y n y } v y | s l | k v n o o o x t n l y x o ~ j
x n n o l m k y k l x n l k u k o k n s x k n s l m n o w x o } |
k } v | x k n o w x y } } y x o v | } } k s } v k s y |
s k } y } n t k l k y o n r k y k y x s x y } l n o } k o y x } y k o
l y } l y o l m k k n l k o l x y k y x s x r v w y } y } n o y } n l y x o n o
y n o x } l y } v w k o l n s k l k y o n r o } l y l | l k v n l x j n k o y o k o
o y t k } y l r n o k } k n m w k o l k v k s r } l n y } k } k n m y o l k k } l }
n k o x l y n s k n o y n s y } k n } k } n o } | t k y s s n o k n o k n s r k l k l y x o
} r } l k }
d d d ` ^ d i

DISPATCHES
Table 2. Ct values of Schmallenberg viruspositive
spp. biting midges collected AugustSeptember 2011, the Netherlands*
Pool no.
Pooled heads Individual abdomens
Species identification by
morphologic examination
Ct value Species identification by
DNA sequencing
Ct value
First test Second test First test Second test
95-D
27.88 NA
24.59 NA
501

35.36 34.98

36.45 35.07
9-A

complex 30.44 NA
24.75 NA
18-C

complex 28.24 NA
24.95 NA
32-B

complex 21.84 NA

18.32 NA
259

complex 19.60 NA
18.16 NA
275

complex 20.72 NA
20.39 NA
276

complex 36.02 36.78

36.68 NA
293

complex 20.43 NA No reliable sequence 19.95 NA
294

complex 24.60 NA

sensu stricto 20.06 NA
368

complex 25.21 NA

21.80 NA
385

complex 20.67 NA
20.25 NA
405

complex 23.38 NA

21.64 NA
434

complex 23.68 NA

23.10 NA
*Ct values determined by reverse transcription PCR. All midges were collected from cattle in the Ermelo municipality except no. 95-D, which was collected
from sheep in the Midden-Drente municipality. Ct, cycle threshold; NA, not applicable.
Two abdomens from this pool were positive; Ct values for the second abdomen were 35.75 and 35.37.
Schmallenberg Virus in Biting Midges
! " # $ % & ' ( ) * ! $ + * % , $ - * ! # & + .
) ! / * 0 $ # 1 $ ! * ! - 2 - ! " 3 4 5 6 7 8 6 9 : ; < = : > 6 ? @ = ; 6 ; A & 0 $ B
C
D E F G H I J H H K L D M N J O O " P " * O D Q D D D D O R D F H D . Q D S D E F
) Q T I D T P
E ! " # $ % & * 1 ) 0 0 N / * 0 $ $ U * M ! * 2
N ! * - , ! J V ! M W " * M ) / * 0 $ $ J N * " 1 * - ( ! "
2 - ( B - I X 2 Y ! Z [ \ ] J ' Y ' W $ $ G D E E
D Q ! " # $ % & ( 2 & \ & M N " $ ) * * ! 2 - " 0 * ! ! N * ^ .
* 2 # N M 1 - # / * ! D E L & 0 $ B
C
D E F T G I J F F K Q M N J O O
" P " * O D Q D D D D O R D F H D . Q D S D E F T ) Q T T D E P
D D M ( Y \ ' - (
C
! " # $ % & ( 2 & \ ! U " ! _ & B * .
0 $ $ * ! $ * $ - " # 1 M N " $ " 0 * ! ! N * ^ * 2 # ) / * !
N M 1 - # / * ! ` 0 ! $ - ! " & 0 $ B
C
D E F T G I J D K L M N J O O
" P " * O D Q D D D D O R D F H D . Q D S D E F T ) Q T T T Q P
D T / * ! * # # " V V ! 2 [ * ! ! & ' a V & X - "
\ - X - 0 ! 0 / * 0 $ * $ - * ! # 1 1 * " $ ) - ! * ! M
b ) $ - 0 $ 2 1 N - P Z ' 0 - * 2 * " $ * N J ' N ! * " ] * ! , - (
B Y 2 T Q Q H G D H F J D S S K E
D S * R + $ c / ! " B ! ,
C d
% e - ^ - Y / ! Y * R ! W & V * $ U * ! .
+ - Y 3 4 5 6 7 8 6 9 : ; 7 f 6 8 g ? : = 4 ; $ N ! * - / 2 # ) - 0 ! 0
/ * 0 $ * ! c 0 N B Y 2 T Q Q G D L T J I T T M N J O O " P " * O D Q D D S L O
/ D L T D S I T T .
& " " $ $ # 2 $ N ! " ! 2 J & 1 * ! Y _ c - ) $ N 1 ! #
c N * " 1 * - ( ' * $ * $ b ! * $ * ! ! " * ! $ * 2 $ ' ! - B * ! (
, ! $ * 0 N # _ ! * ! ! h ! * / $ * ( ! " Y $ 2 M ' ! % 0 * ) U
S E i \ . T T D Y & \ - ( $ " M i M - ! " $ G 1 * - J 1 * ! - ) $ j U 0 ! -
Hepatitis E Virus
Genotype 4
Outbreak,
Italy, 2011
k l l m n o p m q r s t u v m w x m y u m z { y t l m | v t u v y w
} v { y u m x ~ q y v u u y w u m s v y m q v m m q y v m l l v w
x m s m u ~ z y q v u u y w m l v ~ u ~ p ~ l v u ~ w
x m q v v m m z { m u m w l q v { y p v q m q v w
m l m q v m n o m y r v m l { v
During 2011, 5 persons in the area of Lazio, Italy were
infected with a monophyletic strain of hepatitis E virus that
showed high sequence homology with isolates from swine
in China. Detection of this genotype in Italy parallels findings
in other countries in Europe, signaling the possible spread
of strains new to Western countries.

~ z s

DISPATCHES
Author affiliations: Lazzaro Spallanzani National Institute for Infectious
Diseases, Rome, Italy (A.R. Garbuglia, P. Scognamiglio, N. Petrosillo,
P. La Scala, E. Girardi, M.R. Capobianchi); Sapienza University,
Rome (C.M. Mastroianni); Santa Maria Goretti Hospital, Latina Italy
(C.M. Mastroianni); Tor Vergata University Polyclinic, Rome (P.
Sordillo); and Local Health Unit ASL Roma H, Rome (D. Gentile)
HEV Genotype 4, Italy

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F z G F O K 9
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F z G G 2 O K 9 M y / 9 , = 3 B / y / 9 , = 3 B / y / 9 , = 3 B / y / 9 , = 3 B / y / 9 , = 3 B /
{ | } ~ } | ~ } ~ } } ~

Figure 1. A) Lazio region of Italy (black). B) Location of 5 cases of hepatitis E virus (HEV) subtype 4d infection involved in an autochthonous
outbreak, MarchApril 2011. (Map source: CartineGeografiche, Catania, Sicily, Italy; www.cartinegeografiche.eu).

DISPATCHES

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L M N O P Q R P S T P U Q V W X Y N O X W P Z X O T O [ \ X N ] ^ N _ Q O ` Q O ` a
, - 6 3 2 6 ?
HEV Genotype 4, Italy
b c d e f g h i j k l i e m
n o p q r s t u q v w v x x o y z w { z s | z } x } z ~ v v s p q o { o o s o { z |
o s z p x o | } z { z p q o } s } r s o
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} r } w v r v { r { o s v z } { v o s p v { p r p p q o ~ v } z w z w r z } r p z } z |
p q o r r } z x r w w r s r s v r p v z s r w s { p v p p o | z } s | o p v z { v { o r { o {
v s z o o } x } v r } } o { o r } q v s p o } o { p { v s w o ~ v } { o ~ z w p v z s
r s r w { v { r s q z { p x r p q z o s v s p o } r p v z s

Figure 2. Phylogenetic trees based on partial open reading frame (ORF) sequences of the hepatitis E virus monophyletic strain involved in
an outbreak in Lazio, Italy, MarchApril 2011. A) ORF1, 172 nt. Sequences from the outbreak in Italy could not be submitted to GenBank,
being <200 nt long; they are available on request from the authors. B) ORF2, 411 nt. The ORF 2 sequence (identical in all 5 patients)
described in this panel was submitted to GenBank (accession no. JX401928). Neighbor-joining trees were built by using MEGA5.1 software
(www.megasoftware.net), applying the Jukes-Cantor p-distance model of nucleotide substitution. Bootstrap values were determined on
1,000 resamplings of the data set; bootstrap values >80 are shown. Reference strains from GenBank are also included in the trees.
Reference viral strains are identified by GenBank accession number, source, country of origin, and respective genotype and subtype. The
avian strain AY535004 was used as outgroup. Triangles indicate sequences recovered during the outbreak in Italy. Scale bars represent
nucleotide substitutions per site.

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DISPATCHES
Characterization
of Full Genome of
Rat Hepatitis E
Virus Strain
from Vietnam
A B C D E F G H D I J B K L C M N M G B O P B K L N Q B R S T N U C R B K
T G N P V H B W X L C M N Y C K Z N P B R S L S M G B P C [ M N K
\ B Q S O Q B R C ] C K ^ C S R C U N A C R H Y C K C D Y _ C R B [ C A C R C ` B
We amplified the complete genome of the rat hepatitis
E virus (HEV) Vietnam strain (V-105) and analyzed the
nucleotide and amino acid sequences. The entire genome
of V-105 shared only 76.8%76.9% nucleotide sequence
identities with rat HEV strains from Germany, which
suggests that V-105 is a new genotype of rat HEV.
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l a b c d e d e f g y z c j f a t ~ l g m e q a z d e o q y e f c f a i e o j f b j ~ s e z
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e q z s j t e q r b e r f y e s t ~ o c i f y e s t t a a i y i c ~ ~ e d f y a i i a d f y
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d o | j } c q f y c q t d | a i a o i a | a b c d e d e f g z c j f a t ~ r a q o d b a f
c q t
e f i a z o r q e a t c f c o o q o d e z t e f a c f a k y y x n
u c d l g m c f { i f d e f o s c d a t i o } v o i c i c d f e q
a i } c q k y x x n e q z a d | a q y i c d l g m f d i c e q f | c h a ~ a a q
e f o s c d a t i o } e s t i c d f e q o d | a i c i a c f o
a i } c q c q t
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q a r a q o d b a o i c d l g m
A G H T [ N Y
| a i c d l g m j f a t e q d | e f f d j t c f e f o s c d a t i o } c

s j q r | o } o r a q c d a o c e s t i c d i o } m e a d q c } y | e z |
c f b o f e d e h a o i i c d l g m u v w ~ i a h a i f a d i c q f z i e b d e o q

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o c } b s e d | a v p d a i } e q j f q o q f d i j z d j i c s i a r e o q o
m p y a f q d | a f e a t z v w e d | b i e } a i u p u
y c q t
c v w c q z | o i k
w w

w w

w

p v l n c f s e q a t d o d | a v p d a i } e q j f
o d | a z v w ~
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c b c q n j f e q r d | e f c q z | o i p z v w c f d | a d a } b s c d a y d | a
{ i f d c q t d | a q a f d a t

u f a i a z c i i e a t o j d e d |
f a d f o
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u p u y
i a f b a z d e h a s
Author affiliations: National Institute of Infectious Diseases, Tokyo,
Japan (T.-C. Li, Y. Ami, Y. Suzaki, W. Takaji); Graduate School of
Medicine, Hokkaido University, Sapporo, Japan (S.P. Yasuda, K.
Yoshimatsu, J. Arikawa); and Osaka University, Osaka, Japan (N.
Takeda)

DISPATCHES
Table 1. Oligonucleotides used in amplifying the complete genome of the rat HEV Vietnam strain, V-105*
Primers Product length, bp
Forward ORF1-F1 (1-21) 5'-GCAACCCCCGATGGAGACCCA-3'
Reverse ORF1-R12 (4149-4171) 5'-GGCGGCCTCGAACTTCTCCTGAA-3'
Forward ORF1-F2 (11-30) 5'-ATGGAGACCCATCAGTATGT-3'
Reverse ORF1-R1 (431-450) 5'-GTGCAAAAGGAAAGATCAGT-3' 440
Forward ORF1-F9 (388-408) 5'-AGCTAACAACATCCGCCGTTG-3'
Reverse ORF1-R10 (2197-2217) 5'-TGGGTTCGGTCGAAGGCCTCT-3' 1,830
Forward ORF1-F16 (2080-2100) 5'-TGCAGCCGTTTATGAGGGAGA-3'
Reverse ORF1-R16 (3055-3075) 5'-CGCCATTCTGTGGGTTCTAGA-3' 996
Forward ORF1-F7 (2990-3009) 5'-GACCCAAGGCAGATCCCTGC-3'
Reverse ORF1-R12 (4149-4171) 5'-GGCGGCCTCGAACTTCTCCTGAA-3' 1,182
Forward ORF1-F18 (3991-4011) 5'-ATTCACCACAGACGAGCCAGT-3'
Reverse ORF2-R21 (5079-5100) 5'-GGTGATAGCCAATTGGTAAGCT-3' 1,110
Forward F13 (4896-4915) 5'-AATAACACTCTGGGCTGTAG-3'
ReverseTX30SXN 5'-GACTAGTTCTAGATCGCGAGCGGCCGCCCTTTTTTTTTTTTTTTTTTTTTTTTTTTTTT-3' 2,092
Forward primer Anchor-1: 5'-CCTCTGAAGGTTCCAGAATCGATAG-3'
Reverse primer ORF1-R14 (276-296) 5'-TAGACCTAGGGTGCGCACCGA-3'
Forward primer Anchor-2: 5'-GAATCGATAGTGAATTCGTG-3'
Reverse primer ORF1-R13 (200-220) 5'-AACACGCTGTACCGGATGCGA-3' 240
*HEV, hepatitis E virus; ORF, open reading frame.
Numbers in a parentheses show the positions of primers corresponding to the entire genome of rat HEV V-105.
Primer designed based on rat HEV (GU345042).
The PCR product was not detected (reverse).

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Figure. Phylogenetic relationships among
genotypes 14, wild boar, rabbit, avian
(bird), and rat hepatitis E virus (HEV)
isolates. The nucleic acid sequence
alignmentwasperformedbyusingClustalX
1.81 (www.clustal.org). The genetic
distance was calculated by the Kimura
2-parameter method. A phylogenetic
tree with 1,000 bootstrap replicates was
generated by the neighbor-joining method,
based on the entire genome (A) and open
reading frame 3 (B) of the genotypes
14, wild boar, rabbit, chicken (avian),
and rat HEV isolates. Scale bar indicates
nucleotide substitutions per site.

indicates isolate used in this study.
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DISPATCHES
Adenovirus
Serotype 14
Infection,
New Brunswick,
Canada, 2011
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q
j k g r h s p g e d k i t m u j k o h v w k r r h l g x m
y
d t p d i g h z d r t g h { m d { l u d {
q
g
We describe 3 culture-proven cases of adenovirus se-
rotype 14 infection in New Brunswick, Canada, during the
summer of 2011. Strains isolated from severely ill patients
were closely related to strains of a genomic variant, ade-
novirus 14p1, circulating in the United States and Ireland.
Physicians in Canada should be aware of this emerging
adenovirus.
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Author affiliations: Centre hospitalier universitaire Dr-Georges-
L.-Dumont, Moncton, New Brunswick, Canada (G. Girouard, R.
Garceau, L. Thibault, Y. Oussedik); and Public Health Agency of
Canada, Winnipeg, Manitoba, Canada (N. Bastien, Y Li)

DISPATCHES
Figure 1. Hematoxylin and eosinstained lung tissue (original
magnification 10) from a patient in New Brunswick, Canada, with a
fatal case of pneumonia caused by adenovirus 14. A) Arrow shows
a patchy area of hemorrhagic consolidation. B) Arrow shows an
area of necrosis.
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Adenovirus Serotype 14 Infection, Canada
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p r s v h | o r m s z r w q o g h p r k w s m j h p j r z n l { k j k | } o h
i h j n r i k o m i { r l l s h j j h j m i k j } s j n h | r h p j n m i k p r | r i k l n s h }
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p r s h t i } s j t r | u m m o q h i | k j h j q k h g h h s
i h n m i o h p

Figure 2. Phylogenetic analysis of human adenovirus 14 (HAdV-14)
isolates from patients in New Brunswick, Canada, 2011. Nucleotide
sequences were determined for the fiber (A), E1A (B), and hexon
(C) genes. The corresponding gene sequences from previously
reported HAdV-14 isolates are also included. Phylogenetic analysis
was performed by using the neighbor-joining method of the MEGA2
program (
). Scale bars indicate nucleotide substitutions per site.
Numbers on branches and at nodes indicate bootstrap proportions.
The GenBank accession numbers for the fiber, E1A, and hexon
genes for HAdV-14 (Canada) RV1360 are JQ815083, JQ815080,
JQ815086, respectively; those for RV1368 are JQ815084,
JQ815081, JQ815087, respectively; and those for RV1370 are
JQ815085, JQ815082, JQ815088, respectively.
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DISPATCHES
Staphylococcus
aureus
Causing Tropical
Pyomyositis,
Amazon Basin, Peru
W X Y Z [ \ ] ^ _ Z Y ` a Z b c Z Y \ d e Z [ [ \ f b g Y \ Z f d h d i [ Z f X b
j [ \ k \ d Y h d f \ l b c X \ l d l m \ ^ n \ f ` ^ Z b
o
X p Z f f d q d _ Y X X ] b r q n Z Y q X _ X ] n p p X b
Z f q s Z f s Z ` X t l
We studied 12 u v w x y z { | } | } } ~ w ~ ~ isolates caus-
ing tropical pyomyositis in the Amazon Basin of Peru. All
isolates were methicillin-susceptible; 11 carried Panton-
Valentine leukocidinencoding genes, and 5 belonged to
multilocus sequence type 25 and possessed an extensive
set of enterotoxins. Our findings suggest sequence type 25
is circulating in tropical areas of South America.

^ d m ] n q

Author affiliations: Universidad Peruana Cayetano Heredia, Lima,
Peru (C. Garca, E. Gotuzzo); Universit Libre de Bruxelles, Brus-
sels, Belgium (M. Hallin, A. Deplano, O. Denis); Hospital Iquitos
Cesar Garayar Garca, Iquitos, Peru (M. Sihuincha); Universit-
eit Leiden, Leiden, the Netherlands (R. De Groot); and Institute of
Tropical Medicine Antwerp, Antwerp, Belgium (J. Jacobs)

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DISPATCHES
Table. Characteristics of patients with tropical pyomyositis caused by methicillin-susceptible , Amazon Basin,
Peru*
Patient
age
Year patient
hospitalized
Body site
involved
isolate

type
Multilocus
ST
Gene
Enterotoxin genes
A
S- F
12 mo 2005 Lower limb t6465
+ ,
3 y 2005 Lower limb t6465 ST121 + ,
6 mo 2009 Upper limb t701
+
12 y 2009 Thorax, lower
limb
t078
+ , , , , ,

, , ,
24 mo 2009 Lower limb t078 ST25 + , , , , ,

, , ,
45 y 2009 Thorax t1778
+
3 y 2009 Abdomen,
upper limb
t701 ST6 +
28 d 2010 Lumbar t164
- , ,
, ,
3 y 2010 Lower limb t078 ST25 + , , , , ,

, , ,
26 y 2010 Abdomen t078 ST25 + , , , , ,

, , ,
4 y 2010 ND t1778 ST1 +
18 mo 2010 Thorax t078 ST25 + , , , , ,

,

*ST, sequence type; , negative; +, positive; ND, no data.
indicates isolates that were randomly selected by type for multilocus sequence typing (MLST). The other isolates were not analyzed by
MLST. Results for those isolates were extrapolated from results for the analyzed isolates of the same type.

Causing Tropical Pyomyositis

!
Use of trade names is for identification only and does not
imply endorsement by the Public Health Service or by the US
Department of Health and Human Services.
Puumala Virus
Infections
Associated with
Cardiovascular
Causes of Death
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We studied the causes of death of patients in Sweden
with diagnoses of hemorrhagic fever with renal syndrome
(HFRS) during 19972009. Cardiovascular disorders were
a common cause of death during acute-phase HFRS and
were the cause of death for >50% of those who died during
the first year after HFRS.
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DISPATCHES
Author affiliations: Ume University, Ume, Sweden (A.-M. Con-
nolly-Andersen, K. Ahlm, C. Ahlm); Swedish Institute for Communi-
cable Disease Control, Solna, Sweden (J. Klingstrm); and Karolin-
ska Institutet, Stockholm, Sweden (J. Klingstrm)
Puumala Virus Infections and Cardiovascular Deaths


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Figure 1. Main causes of death for patients in the acute phase of
hemorrhagic fever with renal syndrome (HFRS), Sweden 1997
2009. Acute phase includes any death within 90 days of HFRS
diagnosis. Data from the HFRS database, Swedish Institute for
Communicable Disease Control, Cause of Death Register, National
Board of Health and Welfare. HFRS, hemorrhagic fever with renal
syndrome; CVD, cardiovascular disease; RD, renal disease; PD,
pulmonary disease; ND, neoplastic disease; GI, gastrointestinal
disease; ID, infectious disease; ED, endocrine disease; CNS,
central nervous system disease.
E F G H I J K L M N O P E Q R S Q N T U T O O E V N T Q N E S W R Q X R R S Y Z [ O T S \
G H I J \ R O R ] ^ R O F _ ] Q M R ] V E S O N \ R ] T Q N E S N S E Q M R ] V E M E ] Q O E F
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T S \ [ E W ] T ^ T ^ N ] _ O R O b R d N O Q T S \ N S V E _ S Q ] N R O X N Q M U T ] a R S _ ` e
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m m m i g m r

DISPATCHES
Figure 2. Main cardiovascular causes of death after the acute phase
of hemorrhagic fever with renal syndrome (HFRS), Sweden 1997
2009. Bars indicate percentage of patients with cardiovascular
diseases during 12-month intervals after HFRS as a main cause
of death is displayed; horizontal line indicates the background
rate of cardiovascular disease (40%) as main cause of death for
the general population in Sweden. Data from the HFRS database,
Swedish Institute for Communicable Disease Control, Cause of
Death Register, National Board of Health and Welfare.
Linezolid
Dependence in
Staphylococcus
epidermidis
Bloodstream
Isolates

We document linezolid dependence among 5 highly
linezolid-resistant (LRSE)
bloodstream isolates that grew substantially faster at 32 g/
mL linezolid presence. These isolates carried the mutations
T2504A and C2534T in multiple 23S rRNA copies and 2
mutations leading to relevant amino acid substitutions in L3
protein. Linezolid dependence could account for increasing
LRSE emergence.
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Author affiliations: University of Thessaly Medical School, Larissa,
Greece (S. Pournaras, E. Ntokou); Tzaneio General Hospital,
Piraeus, Greece (O. Zarkotou, K. Themeli-Digalaki); University of
Athens Medical School, Athens, Greece (K. Ranellou, A. Tsakris);
and University of Patras School of Medicine, Patras, Greece (C.
Stathopoulos)
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DISPATCHES

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f _ i _ W f _ W [ U T a \ Z [ _ T Y Z ` ` U _ f k d [ Z [ U a W T U W [ c _ ` U p a T a k Z \
i ` a [ _ U W h l { W a b W [ a T [ U k d \ Z [ _ ` U p a T a k _ Z T T _ k p \ ] g w c _
Y a d i \ U W V a ^ ` m T ] W [ c _ T U T ^ ` a k i ` _ Y d ` T a ` m k a \ _ Y d \ _ T
Z W f ` U p a T a k _ Z T T _ k p \ ] i a T T U p \ ] Z ^ ^ _ Y [ T [ c _ a j _ ` Z \ \ ` Z [ _ a ^
i ` a [ _ U W T ] W [ c _ T U T U W j U j a x ~ } z g h U W _ e a \ U f k Z ] U W [ _ ` ^ _ ` _ U W
[ c U T U W [ _ ` Z Y [ U a W l [ c d T Z ^ ^ _ Y [ U W V [ c _ ` U p a T a k Z \ Z T T _ k p \ ] Z W f
_ W Z p \ U W V U W [ _ ` Z Y [ U a W T b U [ c i ` _ Y d ` T a ` ^ a ` k T a ^ [ c _ u n T d p d W U [ l
Z T f _ k a W T [ ` Z [ _ f ^ a ` _ ` ] [ c ` a k ] Y U W x ~ z g _ T i _ Y d \ Z [ _ [ c Z [
Figure 1. LRSE isolated from patients with
bloodstream infections, Greece, 2008
2010. Effect of growth under exposure
to linezolid at 128 g/mL is shown for
the 5 highly LRSE: A) A2562[1], B)
E371, C) A2864, D) 217, and E) 6052.
LRSE, linezolid-resistant

Figure 2. LRSE isolated from patients
with bloodstream infections, Greece,
20082010. Effect of growth under
exposure to linezolid at half-MIC is
shown for the 3 low-level LRSE: A)
A2570, B) A1702, and C) A2490;
and at half-MIC for the 2 linezolid-
susceptible control isolates: D) A1521
and E) ATCC 29213. LRSE, linezolid-
resistant

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DISPATCHES
Klebsiella
pneumoniae
Antimicrobial
Drug Resistance,
United States,
19982010
@ A B C C D E F G H I J K L M N D O P Q G L K C R S I T K U V D E P
Q B M N K E R W I X C K E Y P T K R B N K Z [ [ K O P
\
K R F K E K ] ^ A _ _ A E B P @ A ` V K a Y V K P
K L R b G U D W G E R G L
We studied antimicrobial-resistant c d e f g h e d d i j k e l m
n o
k h i e for 19982010 by using data from The Surveillance
Network. Susceptibility results (n = 3,132,354) demonstrat-
ed significant increases in resistance to all antimicrobial
drugs studied, except tetracycline. Cross-resistance among
carbapenem-resistant c p j k e l
n o
k h i e was lower for tetracy-
cline and amikacin.
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Author affiliations: George Washington University, Washington, DC,
USA (G.V. Sanchez); Quest Diagnostics Nichols Institute, Chantilly,
Virginia, USA (R.N. Master, R.B. Clark); and Providence Hospital,
Washington (M. Fyyaz, P. Duvvuri, G. Ekta, J. Bordon)

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DISPATCHES
Table 1. + , - . / 0 - , , 1 2 3 - 4 5 6 3 0 1 - antimicrobial drug resistance among inpatients, by year, United States, 19982010*
Antimicrobial
drug No. 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
Total
change
TET 80,862 14.2 14.7 14.6 13.9 14.2 13 15.6 14.8 15.6 15.2 15.3 16.4 16.7 2.5
AMK 232,933 0.7 0.9 0.8 0.9 1 1.1 2.1 3.7 4.9 4.6 4.9 4.6 4.5 3.8
IPM 259,589 0 0 0 0 0 0 0.3 0.6 0.6 1.5 3.3 3.8 4.3 4.3
GEN 344,597 4.9 4.6 4.6 5.2 5.5 5.6 6.9 8.3 8.4 7.8 8.7 9.1 9.2 4.3
CPM 211,134 2.1 2 2.7 2.3 2.3 2.5 5.1 5.3 5.5 5.8 7.7 7.3 7.7 5.6
TMP/SXT 344,522 10.9 11 10.9 10.4 10.4 10.9 13 15 16.2 16.5 19.4 18.9 19.3 8.4
TZP 250,554 4 5.5 5.4 5.3 5.3 5.6 7.7 8.8 8.4 7.8 10.5 12 12.7 8.7
TOB 289,287 4.6 4.5 4.4 4.8 5.2 5.5 8 9.8 11.9 10.4 13.2 13.2 13.8 9.2
CRO 287,091 1.8 2.7 3.2 2.9 2.6 3.1 5.7 6.9 8.1 8.7 11.1 11.2 12.1 10.3
CIP 306,348 5.5 6.1 6.5 7 7.6 7.9 9.9 11.7 14.4 14.6 17 16.8 16.8 11.3
CAZ 248,004 5.5 6.8 7.9 7.9 7.7 7.8 11.3 13.3 12.3 12.3 15.6 15.2 17.2 11.7
ATM 184,981 7.7 7.7 7.7 7.5 8 7.3 11.2 12.9 12.8 12.8 16.6 16.1 22.2 14.5
*TET, tetracycline; AMK, amikacin; IPM, imipenem; GEN, gentamicin; CPM, cefepime; TMP/SXT, trimethoprim/sulfamethoxazole; TZP,
piperacillin/tazobactam; TOB, tobramycin; CRO, ceftriaxone; CIP, ciprofloxacin; CAZ, ceftazidime; ATM, aztreonam.
Change from 1998 to 2010. p<0.0001 for all antimicrobial agents except tetracycline (p = 0.0745).
Figure 1. 7 8 9 : ; < 9 8 8 = > ? 9 @ A B ? < = 9 antimicrobial drug resistance,
United States, 19982010. ATM, aztreonam; SXT, trimethoprim/
sulfamethoxazole; CAZ, ceftazidime; CIP, ciprofloxacin; TET,
tetracycline; TOB, tobramycin; TZP, piperacillin/tazobactam;
CPM, cefepime; AMK, amikacin; IPM, imipenem. Ceftriaxone and
gentamicin were not included for better data presentation.
C D E F G H I J F K L G
Antimicrobial Drug Resistance
M N O P Q R S M N T R N U M V M O P W X M R Y Z P [ T P Q S M S U R N O Q U W \ ] ^ _ ` a b c _ d e `
M N W [ P S U [ Z f g R O W N O [ P P Q N U Y R O h W i N W j Q Y R N U M V M O P W X M R Y R T Q N U
Z Q j Q Y W k V Q N U l m n o g R N Z Y M V M U Q Z U p Q P R k Q [ U M O W k U M W N S R j R M Y R X Y Q
i W P U P Q R U M N T q r s t u P Q Y R U Q Z M N i Q O U M W N S R Z Z i [ P U p Q P [ P T Q N O f U W
M V k P W j Q k P Q j Q N U M W N Q i i W P U S R N Z U P Q R U V Q N U S U P R U Q T M Q S v
w
[ P S U [ Z f Z R U R p R j Q S U P Q N T U p S R N Z Y M V M U R U M W N S v x p Q
S U P Q N T U p S R P Q U p Q y M Z Q j R P M Q U f W i R N U M V M O P W X M R Y R T Q N U S
M N O Y [ Z Q Z g U p Q N [ V X Q P W i Y R X W P R U W P M Q S P Q k W P U M N T Z R U R g U p Q
N R U M W N R Y Y f P Q k P Q S Q N U R U M j Q T Q W T P R k p M O Z M S U P M X [ U M W N W i U p Q S Q
M N S U M U [ U M W N S g R N Z U p Q Y R P T Q N [ V X Q P W i M S W Y R U Q S v z Q W T P R k p f M S
R O P M U M O R Y O W N S M Z Q P R U M W N y M U p S [ P j Q M Y Y R N O Q W i U p M S W P T R N M S V
X Q O R [ S Q Z M S U P M X [ U M W N W i \ ] ^ _ ` a b c _ d e ` R N U M V M O P W X M R Y
Z P [ T P Q S M S U R N O Q j R P M Q S y M U p M N U p Q { N M U Q Z | U R U Q S l m } o v x p Q
Y M V M U R U M W N S W i U p Q S Q Z R U R M N O Y [ Z Q R Y R O h W i O Q N U P R Y Y R X W P R U W P f
U Q S U M N T R N Z U p Q j R P M Q U f W i U Q S U V Q U p W Z S [ S Q Z v ~ Q O R [ S Q
W i R Y R O h W i q Y M N M O R Y R X W P R U W P f | U R N Z R P Z S N S U M U [ U Q W P

M N U Q P k P Q U M j Q X P Q R h k W M N U S i W P \ ] ^ _ ` a b c _ d e ` R N Z
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Q O Q k U U Q U P R O f O Y M N Q S v q P W S S u P Q S M S U R N O Q R V W N T M V M k Q N Q V u
P Q S M S U R N U \ ] ^ _ ` a b c _ d e ` y R S p M T p i W P O M k P W W R O M N X [ U
Y W y Q P i W P U Q U P R O f O Y M N Q R N Z R V M h R O M N v x p M S Q V Q P T M N T k P W X Y Q V
k P Q S Q N U S R V R W P U p P Q R U U W k [ X Y M O p Q R Y U p R N Z y R P P R N U S Z [ Q
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C 0 0 1 5 8 5 9 K N P 9 8 Q 9 P O 9 N M Q N O 9 O 9 M P L 9 9 M 9 K O 9 L 9
6 / , * 5 9 9 5 N Q L P 9 L K 9 P 9 8 Q 9 M K 9 N 9 9 8 O L 9 9 K M 9 N 9 9 L M
R 0 2 * 1 5 5 N P N 9 8 9 9 P P 9 P L 8 O N 9 L N 9 K M 9 O N 9 Q K 9 Q P
H 4 ; , / + 0 / S 5 M 5 M K N K 9 9 9 9 N K 9 Q P P N P L 9 M 9 N N O O 8 8 9 N N
T U V W X Y Z [ \ Y ] [ ^ _ ` a b X c d ^ e Y Z [ ] [ ^ _ f g h X e i j k Y Z l ] [ ^ _ f m n X o [ o d k Y ] [ p p [ ^ q e Y r i j Y ] e Y Z _ U f V X Y r e k d i ^ Y Z _ s n V X [ Z [ o d ^ d Z _ t U m X ] d u e Y r [ v [ Z d _ t w g X
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Figure 2. Prevalence of antimicrobial cross-resistance among
imipenem-resistant

isolates, United States,
2010. TET, tetracycline; AMK, amikacin; GEN, gentamicin; CPM,
cefepime; SXT, trimethoprim/sulfamethoxazole; CRO, ceftriaxone;
TOB, tobramycin; CIP, ciprofloxacin; TZP, piperacillin/tazobactam;
CAZ, ceftazidime; ATM, aztreonam.

DISPATCHES
The opinions expressed by authors contributing to this
journal do not necessarily reflect the opinions of the Centers for
Disease Control and Prevention or the institutions with which
the authors are affiliated.
West Nile Virus
Infection among
Humans, Texas,
USA, 20022011

We conducted an epidemiologic analysis to document
West Nile virus infections among humans in Texas, USA,
during 20022011. West Nile virus has become endemic
to Texas; the number of reported cases increased every 3
years. Risk for infection was greatest in rural northwestern
Texas, where mosquitoes are the predominant
mosquito species.

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DISPATCHES
Figure 1. Reported cases of West Nile virus infection among
humans, Texas, USA, 20022011. A) Epidemic curve. B) Incidence
(no. cases/100,000 population).

! " # $ % & ' ( ) * " ( + , -
. /

0 1 2 3
WNV Infection among Humans, Texas
4 5 6 5 7 8 9 : ; < ; 6 = 4 > ? @ 8 9 A ? 6 5 6 ; ? 6 ; B 5 C C D = E 5 C > 5 6 ; F G 6 : = ; F H > I
= F B = 9 @ J K L M N O M P Q O A 9 ? R > ; 6 9 = ? 9 F S T U 6 8 5 F ? A ; ? ? ; 9 F 6 9
: > A 5 F ? V W B B 9 8 4 ; F G 6 9 6 : = C ; 6 = 8 5 6 > 8 = 5 F 4 9 > 8 7 8 = C ; A ; F 5 8 D
4 5 6 5 X Y = < = C ; = E = J K L M N O M P Q O A 9 ? R > ; 6 9 = ? A ; G : 6 < = 5 @ 5 B 6 9 8
5 ? ? 9 B ; 5 6 = 4 Y ; 6 : ; F B 8 = 5 ? = 4 Z Z ; F Y = ? 6 = 8 F B 9 A 7 5 8 = 4 Y ; 6 :
= 5 ? 6 = 8 F [ = \ 5 ? X Y : = 8 = J K ] ^ Q _ ] ^ ` a M O b Q M L Q O A 9 ? R > ; 6 9 = ? 5 8 =
6 : = A 9 8 = = ? 6 5 < C ; ? : = 4 ? 7 = B ; = ? V
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q r o s S T T
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A ; C C ; 9 F V W C 6 : 9 > G : 5 6 6 5 B y 8 5 6 = ? 5 F 4 Z Z ? Y = 8 = : ; G : = 8 @ 9 8 7 = 8 I
? 9 F ? ; F 8 > 8 5 C B 9 > F 6 ; = ? X ? 7 = B ; z B 5 C C D ; F F 9 8 6 : Y = ? 6 = 8 F [ = \ 5 ? X
6 : = : ; G : = ? 6 F > A < = 8 ? 9 @ B 5 ? = ? Y = 8 = 8 = 7 9 8 6 = 4 @ 8 9 A A = 6 8 9 I
7 9 C ; 6 5 F B ; 6 ; = ? V
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Figure 2. Average relative risk (RR) for human infection with West
Nile virus, by county, Texas, USA, 20022011. A color version of
this figure is available online (wwwnc.cdc.gov/EID/article/19/1/12-
1135-F2.htm).
Seropositivity for
Influenza A(H1N1)
pdm09 Virus
among Frontline
Health Care
Personnel

! "
# ! $
% " & $
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Seroprevalence of antibodies to influenza A(H1N1)
pdm09 virus among 193 emergency department health care
personnel was similar among 147 nonhealth care person-
nel (odds ratio 1.4, 95% CI 0.82.4). Working in an acute
care setting did not substantially increase risk for virus infec-
tion above risk conferred by community-based exposures.
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M
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V ; 1 + 3 b c 1 - A ` . 8 , - 7 d 3 R 0 . ; = 3 , 8 5 ; V 9 . 5 3 / D c 1 - A ` . 8 , - 7
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+ 3 4 3 0
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M
3 2 1 +
, - 5 0 B 1 7 0 3 . 5 1 H < = I J I @ : 7 / K L
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R , . . ; 1 R - 5 1 : + 1
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9 3 , + . 1 2 , A 3 , - 7 L g j . : 3 4 0 T 4 0 5 9 0 - : 3 + . 1 - . i K b q L 9 3 , + . 1 2
, A 3 < r @ D
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3 : 3 + . 1 - . R 3 + 3 : 3 + 2 1 + / 3 7 2 1 + = > ? , - 7 - 1 - Z
= > ? B 9 6 . 0 - A 3 0 5 ; 3 + , t u . 5 , 5 0 . 5 0 4 N _ 0 . ; 3 + 3 W , 4 5 5 3 . 5 N 1 + a , - - Z
[
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2 , 4 5 1 + . , . . 1 4 0 , 5 3 7 R 0 5 ; . 3 + 1 : 1 . 0 5 0
M
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< : s K D I K @ 1 + ; 9 : 1 5 ; 3 . 0 G 3 7 5 1 B 3 3 W : 1 . 6 + 3 + 0 . C 2 , 4 5 1 + . R 3 + 3
0 - 4 8 6 7 3 7 D H - , 8 9 . 3 . R 3 + 3 : 3 + 2 1 + / 3 7 B 9 6 . 0 - A V H V
M
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L D g . 1 2 5 R , + 3 < V H V ` - . 5 0 5 6 5 3 ` - 4 D N > , + 9 N J > N U V H @ D
DISPATCHES
Author affiliations: North ShoreLong Island Jewish Health
System, New Hyde Park, New York, USA (K. Alagappan, R.A.
Silverman, M.F. Ward, S. De Cicco, M. McCullough, K. Tenner);
Hofstra North ShoreLong Island Jewish School of Medicine,
Hempstead, New York, USA (K. Alagappan, R.A. Silverman,
M.F. Ward); Albert Einstein College of Medicine, Bronx, New
York, USA (K. Alagappan, R.A. Silverman); Feinstein Institute for
Medical Research, Manhasset, New York, USA (K. Alagappan,
R.A. Silverman, M.F Ward, M. Akerman); and Centers for Disease
Control and Prevention, Atlanta, Georgia, USA (K. Hancock, F.S.
Dawood, A. Branch, E. Steward-Clark, J.M. Katz)
Seropositivity for Influenza A(H1N1)pdm09 Virus
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! " #
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& ' ( ) * + , - . / 0 1 2 ' 3 4 5 4 & 6 3 & 7 5 & 8 9 3 : 5 3 ; 4 < = ' > ' ? = 4 & ? : @ A
4 6 = ' B = 6 C D E 6 3 F 6 D > ' 3 ; G 2 H 5 3 > ' 4 & 4 & ? : 5 6 4 F ' > B D = 5 3 ;
G 2 H D 3 : 3 ' 3 I G 2 H 7 D 4 4 5 > 5 E D = & ' & 8 D & < ' = 3 ' 3 I G 2 H
+ . J - . / 0 1 G ' 7 6 C 6 = A 4 ' > 6 4 & ? : 5 6 4 5 : 6 3 & 5 9 6 : : 5 < < 6 = 6 3 F 6 4
5 3 4 6 = ' B = 6 C D E 6 3 F 6 D 4 4 ' F 5 D & 6 : 7 5 & 8 G 2 H = ' E 6 D 3 : K 6 & 7 6 6 3
9 = 4 & I E 5 3 6 D 3 : 4 6 F ' 3 : I E 5 3 6 G 2 H + , A . . 0 1 L E & 8 ' ? ; 8 ' ? = 4 & ? : @
: 5 : 3 ' & 8 D C 6 D : 6 M ? D & 6 B ' 7 6 = & ' : 6 & 6 F & 4 ? F 8 : 5 < < 6 = 6 3 F 6 4 A
7 6 ' K 4 6 = C 6 : D & = 6 3 : & ' 7 D = : 8 5 ; 8 6 = 4 6 = ' B ' 4 5 & 5 C 5 & @ D > ' 3 ;
B 8 @ 4 5 F 5 D 3 B = ' C 5 : 6 = 4 F D = 5 3 ; < ' = F 8 5 E : = 6 3 1
N
6 C 6 = D E 4 & ? : 5 6 4 : ' F ? > 6 3 & 6 : = 6 : ? F & 5 ' 3 5 3 4 B = 6 D : ' <
5 3 O ? 6 3 P D K @ < D F 6 > D 4 Q ? 4 6 D 3 : 8 D 3 : 7 D 4 8 5 3 ; + . R A . S 0 1
T
6 D 4 ? = 6 4 & D Q 6 3 & ' E 5 > 5 & & 8 6 4 B = 6 D : ' < 5 3 < 6 F & 5 ' 3 : ? = 5 3 ;
L + G U V U 0 B : > ) W 5 3 ' ? = 8 ' 4 B 5 & D E 4 5 3 F E ? : 6 : 5 4 ' E D & 5 ' 3 ' D 4 Q 4 A ; E ' C 6 4 A D 3 : ; ' 7 3 4 Z D 3 : 4 & D 3 : D = :
B = 6 F D ? & 5 ' 3 4 4 ? F 8 D 4 8 D 3 : 7 D 4 8 5 3 ; 1 \ 6 : 5 : 3 ' & 6 C D E ? D & 6
& 8 6 6 < < 6 F & ' < & 8 6 4 6 B = 6 F D ? & 5 ' 3 4 ' 3 = 5 4 Q < ' = L + G U V U 0
B : > ) W C 5 = ? 4 5 3 < 6 F & 5 ' 3 K 6 F D ? 4 6 7 6 : 5 : 3 ' & > 6 D 4 ? = 6 G 2 H
D : 8 6 = 6 3 F 6 & ' B = 6 C 6 3 & 5 ' 3 > 6 D 4 ? = 6 4 1 G ' 7 6 C 6 = A 4 6 = ' B ' 4 5 & 5 C 5 & @
< ' = L + G U V U 0 B : > ) W C 5 = ? 4 > 5 ; 8 & 8 D C 6 K 6 6 3 8 5 ; 8 6 = D > ' 3 ;
G 2 H 5 3 ' ? = 4 & ? : @ 5 < & 8 6 4 6 B = 6 C 6 3 & 5 ' 3 4 > 6 D 4 ? = 6 4 7 6 = 6 3 ' &
5 3 B E D F 6 1
]
? = 4 & ? : @ 8 D : 4 6 C 6 = D E E 5 > 5 & D & 5 ' 3 4 1
]
? = F ' 3 & = ' E
; = ' ? B > D @ 3 ' & 8 D C 6 K 6 6 3 = 6 B = 6 4 6 3 & D & 5 C 6 ' < & 8 6 ; 6 3 6 = D E
F ' > > ? 3 5 & @ 1 \ 6 : 5 : 3 ' & D 4 4 6 4 4 < ' = ? 4 6 ' < 5 3 O ? 6 3 P D
D 3 & 5 C 5 = D E > 6 : 5 F D & 5 ' 3 4 D < & 6 = B ' & 6 3 & 5 D E 6 ^ B ' 4 ? = 6 4 D > ' 3 ;
B D = & 5 F 5 B D 3 & 4 1
]
3 & 8 6 K D 4 5 4 ' < ' ? = 4 D > B E 6 4 5 P 6 A 7 6 ' 3 E @
8 D : D : 6 M ? D & 6 B ' 7 6 = & ' : 6 & 6 F & D _ [ * : 5 < < 6 = 6 3 F 6 5 3
4 6 = ' B ' 4 5 & 5 C 5 & @ K 6 & 7 6 6 3 G 2 H D 3 : 3 ' 3 I G 2 H 1 \ 6 : 5 : 3 ' &
8 D C 6 B = 6 B D 3 : 6 > 5 F 4 6 = ? > 4 D > B E 6 4 < = ' > 4 & ? : @ B D = & 5 F 5 B D 3 & 4
& ' 6 C D E ? D & 6 < ' = B = 6 I 6 ^ 5 4 & 5 3 ; F = ' 4 4 I = 6 D F & 5 C 6 D 3 & 5 K ' : 5 6 4
& ' L + G U V U 0 B : > ) W C 5 = ? 4 1 G ' 7 6 C 6 = A 7 6 < ' ? 3 : & 8 D & & 8 D &
' ? = F = 5 & 6 = 5 D < ' = 4 6 = ' B ' 4 5 & 5 C 5 & @ 7 6 = 6 8 5 ; 8 E @ 4 B 6 F 5 9 F < ' =
: 6 & 6 F & 5 ' 3 ' < L + G U V U 0 B : > ) W C 5 = ? 4 5 3 < 6 F & 5 ' 3 1
` a b c d e d f f d g h i d g j k j a e j g l m f n m i h l h d g d g o d i i p l h d q j l n d h a
p r q n j ` j f d a q k j g q p r s k j a e j g l m t j o h l h g j d q q n j u p a q n v n p a j w
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j k j a e j g l m k j o h l h g j

DISPATCHES

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Seropositivity for Influenza A(H1N1)pdm09 Virus
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p W h m Z W r U m U h W [ v k X ` q Y q k X W k h p f e ^ h r _ W o U f q c W ^ e ` q Y f ` W V [ x x
R ` q s ] W [ v W o c r W } ^ X b [ v u u x x [ Y s W V ^ U e ^ X W f U e ] ^ k e S m k V
Human
Gastroenteritis
Outbreak
Associated with
Escherichia
albertii, Japan

Although is an emerging intestinal
pathogen, it has been associated only with sporadic human
infections. In this study, we determined that a human gas-
troenteritis outbreak at a restaurant in Japan had
as the major causative agent.

DISPATCHES
Author affiliations: University of Miyazaki, Miyazaki, Japan (T.
Ooka, Y. Ogura, T. Hayashi); Kumamoto Prefectural Institute of
Public Health and Environmental Science, Kumamoto, Japan (E.
Tokuoka, M. Furukawa, T. Nagamura, S. Harada); and University of
Tokushima, Tokushima, Japan (K. Arisawa)
Human Gastroenteritis Associated with ! " # $ % & ' ( (
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+ : 8 + + : * H I J K L M N ? O O ) + 2 8 3 4 ) : 8 9 3 4 + 3 5 3 4 P 7 G : 3 1 : 3 ) 2 8 2 * F .
3 9 * 4 + 3 Q * 9 3 4 * 4 + * 2 , / 8 + : , 6 * 4 3 1 H I = R K O , 2 * 4 + * 2 , : * 5 , 2 2 : 8 6 3 1
H I = R K O S + : * F , 1 ; ) , - * 4 + * 2 , 1 . + * * - - 8 1 * 5 * 4 + G 8 ) 3 4 + * 6 2 8 + * 9
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: 8 9 9 3 8 2 2 : * 8 8 4 9 8 < 9 , 5 3 4 8 F / 8 3 4 5 , 2 * - 2 * g ; * 4 + F . + : 8 4
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) : , G 4 3 4 + : * , 4 F 3 4 * [ * 1 : 4 3 1 8 F X / / * 4 9 3 s D
t u v w x y z { u v z
0 4 + : 3 ) 6 8 ) + 2 , * 4 + * 2 3 + 3 ) , ; + < 2 * 8 m 7 H I J K L M N ? O O , 2 | ? } ~ _ / , ) _
3 + 3 ] * H I = R K O a b c d e f b c G 8 ) 3 ) , F 8 + * 9 - 2 , 5 ` ^ 3 F F / 8 + 3 * 4 + ) S
< , + : ) + 2 8 3 4 ) G * 2 * 3 ) , F 8 + * 9 - 2 , 5 / 8 + 3 * 4 + ) D [ : ; ) 7 8 F + : , ; 6 :
+ : * 2 * ) / , 4 ) 3 < F * 5 * 8 F , 2 - , , 9 G 8 ) 4 , + 3 9 * 4 + 3 Q * 9 7 3 + G 8 ) 5 , ) +
F 3 m * F . 1 , 4 + 8 5 3 4 8 + * 9 G 3 + : + : * ) * ` 5 3 1 2 , , 2 6 8 4 3 ) 5 ) D [ : *
1 , 4 + 2 3 < ; + 3 , 4 , 2 3 4 ] , F ] * 5 * 4 + , - H I = R K O a b c d e f b c 3 4 + : 3 )
, ; + < 2 * 8 m 3 ) ; 4 m 4 , G 4 < * 1 8 ; ) * + : * 2 * G * 2 * d / 8 + 3 * 4 + ) - 2 , 5
G : , 5 , 4 F . H I = R K O a b c d e f b c G 8 ) 3 ) , F 8 + * 9 8 4 9 < * 1 8 ; ) *
+ : * 2 * G * 2 * 4 , 9 3 - - * 2 * 4 1 * ) 3 4 1 F 3 4 3 1 8 F ) . 5 / + , 5 ) < * + G * * 4
/ * 2 ) , 4 ) 3 4 - * 1 + * 9 G 3 + : H I = R K O a b c d e f b c 8 4 9 / * 2 ) , 4 ) 4 , +
3 4 - * 1 + * 9 A [ 8 < F * ) b 7 ` C D 0 4 1 , 4 + 2 8 ) + 7 H I J K L M N ? O O G 8 ) 3 ) , F 8 + * 9

Figure.

I-digested pulsed-field gel electrophoresis profiles of isolates from fecal specimens collected from patients during an outbreak
of human gastroenteritis associated with

, Japan. Extra bands observed in 2

isolates are indicated by
arrowheads (only 1 or 2 band differences). The 2
O183:H18 and 6

isolates indicated by numbers in boxes were subjected
to multilocus sequence analysis (see text and online Technical Appendix, wwwnc.cdc.gov/EID/pdfs/12-0646-Techapp.pdf). , Shiga
toxin 2d gene;
, enteroaggregative
heat-stable toxin gene;
, intimin gene. Lane M,

serovar Braenderup
strain H9812 (used as a DNA size standard); lanes P1, Party 1; lanes P2, Party 2; lanes KS, kitchen staff.

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P @ e A N H G O w N O @ C O @ O ^ v C e G U A J H P L @ K N e N D @ ^ x D N c @ Q O N A J H P L N J C y C E N ^
L N J C y C E N ^ j C S C D f _ N O Q @ O @ C Q e B N D A @ Q @ O A O N D e U G K @ T C e A @ Q N C U R @ D H d `
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DISPATCHES

! " # $ % & ' ( % ) $ # * # + , - . / $ " 0 $ , 1 2 , 1 $ + # ! %
3 4
# ! 5 6 2 , $ 6 , - 7 2 " ! $ # 8 ! 9 7 : : 0 7 ! # $ 7 - # - 7 " 7 $ " : 8 ! . - 0 %
; < = > ? @ A B = C D E F D @ G H ? @ G D > = I J K
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4 ` a b c d ` a
8 ! - ! $ , : # : , 1
+ " $ 2 ! / " $ 6 8 1 - 7 1 , 1 5 8 " # $ , - ! $ , : %
Novel Epidemic
Clones of Listeria
monocytogenes,
United States,
2011
e f g f h i j i k f l i m n o k p q r s t g u q t v t m
w
t x t g y t g k t g z e j o p x m { q t g | } ~ f g g m h i g o y } f p k t | m
h f o k i v t q m h t t f x m f g | f k k ~ r g k v t m
o l q f t } g f l t m o { q t k m g o l n g i k m
o l q f g p t o k t g v j f k k m f g n t g g f k u m
f k p e x t q t k k f t }
We identified a novel serotype 1/2a outbreak strain and
2 novel epidemic clones of while
investigating a foodborne outbreak of listeriosis associated
with consumption of cantaloupe during 2011 in the United
States. Comparative analyses of strains worldwide are es-
sential to identification of novel outbreak strains and epi-
demic clones.

~ q t e x r p |

Author affiliations: Universit degli Studi di Torino, Turin, Italy (S.
Lomonaco); Accugenix, Newark, Delaware, USA (B. Verghese);
The Pennsylvania State University, University Park, Pennsylvania,
USA (B. Verghese, S. Knabel); Centers for Disease Control and
Prevention, Atlanta, Georgia, USA (P. Gerner-Smidt, C. Tarr, L.
Gladney, L. Joseph, L. Katz, M. Turnsek, M. Frace); Food and Drug
Administration, College Park, Maryland, USA (Y. Chen, E. Brown);
and US Department of Agriculture, Athens, Georgia, USA (R. Mein-
ersmann, M. Berrang)

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DISPATCHES
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f B g h = Z ` f B g h h e i Z G F @ ` j F = F @ H e a k \ \ l
m n o p q r s t u [ @ Z E c v
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z
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a i j | u a k k a e i j e E C G E _ @ Z Y ? = Z F u w x \ a > w x w g h x
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\ k k \ k
~ y z
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\ k k \ \
~ y z
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{ f Y D I J G ? @ a
z
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{ f Y D I J G ? @
z
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z
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{ f Y D I J G ? @
z
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z
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z
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a \ i j | u a k k a e i j e E C G E _ @ Z Y ? = Z F u w f x \ a = w x w g h h x \ \
i j | u a k k e i j e E C G E _ @ Z Y ? = Z F w f x \ a = w x w g h h x \ k
\ k \
~ y z
a k k k B = Z = ` = e b C G Y Y G Z [ E D @ = d w B x \ a = w x w g h h x \
\ k \ a
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a k k k B = Z = ` = e b C G Y Y G Z [ E D @ = d w x \ a = w x w g h h x \

Figure 1. Four
I / 4
I pulsed-
field gel electrophoresis (PFGE)
profiles (identified at the time the
research was performed) displayed
by clinical
isolates (L2624, L2625, L2626, and
L2676) and isolates from food or
environmental samples (LIS0072,
LIS0075, LIS0077, LIS0078, and
LIS0087) associated with the
2011 listeriosis outbreak traced to
cantaloupe. PFGE profiles 3 and 4
differ by 40-kb shift in 1 band in the
AscI pattern, likely related to the loss
or acquisition of the comK prophage,
because the size of this prophage
was 40 kb as calculated by using
the whole genome sequencing data
(not shown).
Novel Epidemic Clones in Listeriosis Outbreak

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Figure 2. Unrooted neighbor-joining tree
computed in MEGA 5.0 (] ^ ) for multivirulence
locus sequence typing) data based on
sequencing of 6 virulence genes, _ ` a b c
d e f g
c
d e f h
, i j
f
c k
f
_ l c and
f d m n
(3) obtained
for the 93 o
d m p q
`
d
j r s
e
s k t
p
s u
q e q m
isolates
compared in this study. Nine cantaloupe-
associated outbreak isolates were from the
Centers for Disease Control and Prevention
(CDC) (GenBank accession nos. JQ407055
JQ407078) and Food and Drug Administration
(FDA) (JX141237JX141275), 23 isolates
from Knabel et al., 2012 (v ), 29 isolates from
Chen et al., 2007 (w ), 29 from Berrang et al.,
2005 and 2010 (x c y ) (JQ946653JQ946836),
and 3 other isolates for which sequence data
were available in GenBank. Squares indicate
reference strains representing the 5 currently
known o z r s
e
s k t
p
s u
q e q m
epidemic clones.
Underlined text indicates CDC and FDA
isolates associated with the isolates from the
2011 cantaloupe-associated outbreak. Circles
indicate strains classified as epidemic clone
(EC)VI. Triangles indicate strains classified
as ECVII. Diamond indicates the novel
outbreak strain.
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DISPATCHES
All material published in Emerging Infectious Diseases is in
the public domain and may be used and reprinted without
special permission; proper citation, however, is required.
Rinderpest Virus
Sequestration
and Use in
Posteradication Era
Z [ \ ] ] ^ [ _ ` a b [ c d \ e f g ` d h i j ` ^ [ k ^ \ l f
j c i b d i m n o b d ` l f o [ ^ d p [ q c b r s f
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m d x [ l y ^ _ ` c b d f ^ d h z \ c { | n } ~ ` \ ~ ~ ` c
After the 2011 declaration of rinderpest disease eradi-
cation, we surveyed 150 countries about rinderpest virus
stocks. Forty-four laboratories in 35 countries held labora-
tory-attenuated strains, field strains, or diagnostic samples.
Vaccine and reagent production and laboratory experiments
continued. Rigorous standards are necessary to ensure that
stocks are kept under safe conditions.

s ` r [ h i

Author affiliations: Royal Veterinary College, London, UK (G. Fourni,
W. Beauvais, B.A. Jones, D.U. Pfeiffer); Food and Agriculture
Organization of the United Nations, Rome, Italy (J. Lubroth,
F. Ambrosini, F. Njeumi); and AusVet Animal Health Services,
Wentworth Falls, New South Wales, Australia (A. Cameron)
DOI: http://doi.dx.org/10.3201/eid1901.120967

DISPATCHES
Figure. Countries and laboratories
holding material containing rinderpest
virus, June 2011. Numbers in
parentheses indicate the potential
number of laboratories or countries
holding a given type of virus
when accounting for incomplete
information. *Reference virus or
specimens as part of a collection for
research or teaching. FAO, Food and
Agriculture Organisation of the United
Nations; OIE, World Organisation for
Animal Health.
Rinderpest Virus Sequestration and Use
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} B ~ B B > < B G

wwwnc.cdc.gov/eid/pages/eCard.htm
LETTERS
Schmallenberg
Virus in Central
Nervous System
of Ruminants

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LETTERS
\ ] ^ _ ` a b c d e a ] f a b ` ] g h c ` ] i b i j k l m c n
` _ a h c o n c ` ] p a c ^ a b ` ] b h c n a n i j q r k ] b s
t
c \ \ c ` ] i b i j o b u b i v b a ` ] i e i ^ w x
y z { | } ~ |

Author affiliations: University of Veterinary
Medicine, Hannover, Germany (K. Hahn,
A. Habierski, V. Herder, P. Wohlsein, F.
Hansmann, W. Baumgrtner); National
Veterinary Laboratory, Arnsberg, Germany
(M. Peters); and Centre for Systems Neuro-
science, Hannover (K. Hahn, V. Herder, F.
Hansmann, W. Baumgrtner)
1
These authors contributed equally to this
article.
| z

Polyomavirus in
Saliva of
HIV-infected
Children, Brazil

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9 0 @ @ x 1 A d i w n ( B B C C x < A ^ ] e n (
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Figure. In situ detection by using Nomarski differential interference contrast microscopy
of Schmallenberg virus mRNA in neurons in the medulla of a neonatal sheep for which
Schmallenberg virus infection was confirmed by real-time quantitative reverse transcription
PCR. Scale bar = 100 m.
LETTERS
D E F G H I J D K L I M N I O K F P J E Q R S T U V W D K J X
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LETTERS
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Author affiliation: Federal University of Rio
of Janeiro, Rio de Janeiro, Brazil
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{ j v t z p j v t q j q ~ n p v g { n e h o { e {
Carbapenem-
hydrolyzing
Oxacillinase-48 and
Oxacillinase-181 in
Canada, 2011

1
These authors contributed equally to this
article.
LETTERS

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Author affiliations: National Microbiology
Laboratory, Winnipeg, Manitoba, Canada
(L.F. Mataseje, D.A. Boyd, M.R. Mulvey);
British Columbia Center for Disease Con-
trol, Vancouver, British Columbia, Canada
(L. Hoang, M. Imperial); Laboratoire de
Sant Publique du Qubec, Sainte-Anne-
de-Bellevue, Quebec, Canada (B. Lefe-
bvre); SMBDJewish General Hospital,
Montreal, Quebec, Canada (M. Miller); Uni-
versity of Toronto, Toronto, Ontario, Canada
(S.M. Poutanen); University Health Net-
work/Mount Sinai Hospital, Toronto (S.M.
Poutanen, B.M. Willey); and Vancouver
General Hospital, Vancouver (D. Roscoe)
n n n j h n s

LETTERS
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Characterization
of Peste des Petits
Ruminants Virus,
Eritrea, 20022011
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LETTERS

! " # $ # % % & ' ' ( )
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Author affiliations: Istituto "G. Caporale,"
Teramo, Italy (G.M. Cosseddu, C. Pinoni, A.
Polci, R. Lelli, F. Monaco); and National Ani-
mal and Plant Health Laboratory, Asmara,
Eritrea (T. Sebhatu)
8 9 :
; < = > ? @ > A B C D E F > A G B > H E = > I I J ? D E K L A > D E
M N
G > I J O K E P G Q J > L R < R S T Q > S B G U I A G Q L I G T ?
T V W J U I J B J U W J I G I U A L X G ? > ? I U Y G A L U > ? B
W A T U W J Z I U V T A G X W A T Y J B B G > [ ? T U G U > ? B Z T ? \
I A T S < ] R J ? ^ G A T S < _ ` ; ` a b ; c _ d d e f b g < h I I W c i i
B j I J O K E C S G l m E H > J J B n
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X G ? > ? I U Y G A L U E C V A G Z > A G H E H L S L O L u E P J Q S > ? Z v E
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Y G A L U E H G J A A > P J T ? J Z @ \ m @ X > ? ? p E u T [ J A w E m L A > A B D E
R L G S S T L ] F E P G Q J > L R E
q
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? > ? I U Y G A L U Q @ > W T S @ X J A > U J Z h > G ? A J > Z I G T ?
> U U > @ < ] ^ G A T S o J I h T B U < _ ` ` _ a ; ` ` c ; g f _ e <
h I I W c i i B j S S | C < = G T p B G I c > L U J A \ V A G J ? B S @ Q G T S T [ G \
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h I I W c i i B j ? o > A G T
D T U U J B B L E n U I G I L I T t T T W A T S > I I G Z T H W J A G X J ? I > S J
B J S S C Q A L x x T J B J S o T S G U J R < D > W T A > S J E ^ G >
D > X W T = T > A G T s k ; ` ` | J A > X T E n I > S @ a J X > G S c
[ < Z T U U J B B L G x U < G I
Figure. Phylogenetic tree showing the genetic relationships between isolates of peste des
petits ruminants virus (PPRV). The tree was constructed on the basis of 255-nt sequences
of the PPRV nucleoprotein gene. Black dots indicate sequences obtained in this study.
Lineages are indicated on the right, and GenBank accession numbers are shown in
parentheses. Analysis was performed by using the MEGA4 software ( ) and neighbor-
joining (maximum composite likelihood) methods. Bootstrap support values >70 are shown
at nodes (1,000 replicates). The scale bar indicates nucleotide substitutions per site.
LETTERS
A Case of Endemic
Syphilis, Iran

Figure. Disfiguring infiltration of the nose, glabella, and forehead with clustered nodules in left
interciliary region of boy with endemic syphilis, Iran, 2010. Photograph byAlirezaAbdolrasouli.
LETTERS

! " # $ % & ' ! $ ( ' ) *
& $ + , ! ' ) - . " ! *
/ $ . 0 $ 1 " + + $ 2 *
$ 3 & 4 $ 5 & 6 $ % " 0
Author affiliations: Imperial College
Healthcare National Health Service Trust,
London, UK (A. Abdolrasouli, A. Croucher);
Imperial College London, London (A.
Abdolrasouli); Marie-Curie Medical
Institute, Tehran, Iran (A. Abdolrasouli, Y.
Hemmati); and London School of Hygiene
and Tropical Medicine, London (D. Mabey)
DOI: http://doi.dx.org/10.3201/eid1901.120756
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Antiretroviral
Therapy
associated
Coccidioidal
Meningitis

All material published in Emerging
Infectious Diseases is in the public
domain and may be used and
reprinted without special permission;
proper citation, however, is required.
LETTERS

Figure. Test results of cerebrospinal fluid and brain tissue in HIV-positive man with signs and
symptoms of meningitis, Atlanta, Georgia, USA, 2011. A) Atypical lymphocytes containing
flower-shaped nuclei (arrows) and coarse chromocenters (arrowhead). Cerebrospinal
fluid processed by Cytospin centrifuge (Thermo Electron Corp., Waltham, MA, USA) and
prepared by Papanicolaou staining. Original magnification 100. B) Gomori methenamine
silver stain of sampled brain tissue showing multiple spherules and endospores of

spp. Original magnification 40.
LETTERS

! " # $ % & ! ' ( ) ' % ! * " + ' $ , (
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Author affiliation: Emory University School
of Medicine, Atlanta, GA, USA
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Concurrent
Tuberculosis
and Influenza,
South Korea

LETTERS

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# $
%
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%

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8
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Table. Case summary of concurrent active pulmonary TB and influenza A(H1N1)pdm09 infection*
Patient
age,
y/sex
Date of
influenza
diagnosis
Underlying
disease
Days from
influenza
to TB
diagnosis
Lymphocyte
count at
initial visit,
cells/L (%)
Specimen/
auramine-
rhodamine
stain result
Specimen/
TB PCR
result
MTB
source
Radiographic
findings
Days
hospitalized
17/F 2009 Sep None 17 NA BAL/+ BAL/+ BAL Patchy
consolidation in
LUL
0
15/M 2009 Sep None 2 380 (7.3) Sputum/+ Sputum/+ Sputu
m
Pneumonic
infiltration in both
upper lobes,
cavitary lesion in
LUL
7
15/F 2009 Oct None 17 NA Sputum/+ Sputum/ Sputu
m
Nodular
infiltration with
cavity in LUL
10
26/M 2009 Nov None 1 1,406 (18.5) Sputum/+ Sputum/+ Sputu
m
Multiple nodules
and cavities in
RUL and RML
6
29/M 2010 Feb None 2 NA Sputum/,
BAL/
BAL/+ Sputu
m,
BAL
Pneumonic
infiltration in RUL
0
68/M 2010 Feb Colon cancer 1 230 (4.9) Sputum/+ NA Sputu
m
Lobar
pneumonia in
RLL
10
24/F 2011 Feb Previous
wedge
resection to
treat
pneumothorax
7 1,433 (37.7) Sputum/,
BAL/+
Sputum/,
BAL/+
BAL Patchy opacity in
left middle lung
zone
0
*All patients survived. TB, tuberculosis; MTB, M N O P Q R O S T U V W X S W Q T U O W Y P Z V Z ; NA, not available; BAL, bronchoalveolar lavage; LUL, left upper lobe; RUL,
right upper lobe; RML, right middle lobe; RLL, right lower lobe.
This patient had a history of 7.5 pack-years of smoking.
LETTERS
[ \ ] ^ _ ` a b c [ d e a f g h h c
i a _ j ^ k l b a \ c
[ a a _ ] a ^ _ m j a _ m c ] ^ n \ _ j h a c
o _ j h a _ p \ q c r h h [ \ _ l b h a _ m c
d _ s i a a [ a a p \ q
Author affiliations: Korea University College
of Medicine, Seoul, South Korea (J.Y. Noh,
W.S. Choi, J.Y. Song, Y.B. Seo, I.S. Kim, H.J.
Cheong, W.J. Kim); Asia Pacific Influenza
Institute, Seoul (J.Y. Noh, W.S. Choi, J.Y.
Song, Y.B. Seo, I.S. Kim, H.J. Cheong, W.J.
Kim); Hallym University College of Medicine,
Chuncheon, South Korea (J. Lee); and
Transgovernmental Enterprise for Pandemic
Influenza in Korea, Seoul (W.J. Kim)
t u v u w u x y u z
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Cronobacter
Infections Not from
Infant Formula,
Taiwan

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Subcutaneous
Infection with
Dirofilaria immitis
Nematode in
Human, France
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LETTERS

Author affiliations: Assistance Publique
Hpitaux de Marseille, Marseille, France
(M. Foissac, M. Million, C. Mary, J.-P.
Dales, R. Piarroux, P. Parola); Aix-Marseille
Universit, Marseille (M. Foissac, M. Mil-
lion, C. Mary, J.-P. Dales, P. Parola); and
Hpital dInstruction des Armes Sainte-
Anne, Toulon, France (J.-B. Souraud)

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Author affiliation: Hospital-Clnica Kennedy,
Universidad de Especialidades Espritu
Santo, Guayaquil, Ecuador
DOI: http://dx.doi.org/eid1901.120432

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Author affiliations: Puerto Rico Department
of Health, San Juan, Puerto Rico (E.
Hassan-Ros, P. Torres, E. Muoz, C.
Matos); and Centers for Disease Control
and Prevention, Atlanta, Georgia, USA (A.J.
Hall, N. Gregoricus, J. Vinj)

Cronobacter
sakazakii
ST4 Strains
and Neonatal
Meningitis,
United States

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Author affiliation: Nottingham Trent
University School of Science and
Technology, Nottingham, UK
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Seroprevalence
of Crimean-Congo
Hemorrhagic Fever
Virus, Bulgaria

LETTERS

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Author affiliations: National Center of Infec-
tious and Parasitic Diseases, Sofia, Bulgar-
ia (I. Christova, T. Gladnishka, E. Tasseva,
N. Kalvatchev); and Aristotle University of
Thessaloniki, Thessaloniki, Greece (K.
Tsergouli, A. Papa)

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LETTERS
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LETTERS

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A B C D C E F D D G B H H B C I J K
L B I M N O F P C Q B D M K R C O S H T O C U I C K
C D V A C W B V T X M H H C U V
Author affiliations Health Resources and
Services Administration, Baton Rouge,
Louisiana, USA (D.L. Williams, R. Sharma,
D. Scollard); Louisiana State University,
Baton Rouge (D.L. Williams, R. Sharma,
D. Scollard); and John A. Burns School of
Medicine, Aiea, Hawaii, USA (T. Hagino)
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Figure. Acid-fast organisms from biopsy specimens of a man with leprosy, United States. Fite-stained sections show numerous acid-fast
bacilli in the initial skin biopsy specimen (A) and in the biopsy specimen taken at relapse, 6 years after completion of treatment (B). Both
specimens demonstrate the clumps of

referred to as globi. In panel B, bacilli can be seen within a cutaneous nerve
(arrows), a finding that is pathognomonic of

. Original specimen magnification 1,000.
LETTERS

RETRACTION
Triple Reassortant Swine Influenza A (H3N2) Virus in Waterfowl

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Author affiliation: College of Veterinary Medicine University of Minnesota, St. Paul, Minnesota, USA
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North Carolina
Museum of Art, Raleigh, purchased with funds from the State of North Carolina
One Rotten Apple Infects All in the Basket

Author affiliation: Centers for Disease Control and Prevention, At-
lanta, Georgia, USA
DOI: http://dx.doi.org/10.3201/eid1901.AC1901
ABOUT THE COVER

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Earning CME Credit
To obtain credit, you should first read the journal article. After reading the article, you should be able to answer the
following, related, multiple-choice questions. To complete the questions (with a minimum 70% passing score) and earn
continuing medical education (CME) credit, please go to s s s t u v w x y z { v t | } ~ | } z v w . Credit cannot be obtained
for tests completed on paper, although you may use the worksheet below to keep a record of your answers. You must
be a registered user on Medscape.org. If you are not registered on Medscape.org, please click on the New Users: Free
Registration link on the left hand side of the website to register. Only one answer is correct for each question. Once you
successfully answer all post-test questions you will be able to view and/or print your certificate. For questions regarding
the content of this activity, contact the accredited provider, CME@medscape.net. For technical assistance, contact CME@
webmd.net. American Medical Associations Physicians Recognition Award (AMA PRA) credits are accepted in the US as
evidence of participation in CME activities. For further information on this award, please refer to http://www.ama-assn.org/
ama/pub/category/2922.html. The AMA has determined that physicians not licensed in the US who participate in this CME
activity are eligible for

. Through agreements that the AMA has made with agencies in some
countries, AMA PRA credit may be acceptable as evidence of participation in CME activities. If you are not licensed in the
US, please complete the questions online, print the certificate and present it to your national medical association for review.
Article Title
Listeriosis Outbreaks and Associated Food
Vehicles, United States, 19982008
CME Questions

A. Infection with

is marked by at least mild
gastrointestinal symptoms among pregnant women
B. There are fewer than 200 cases of listeriosis in the United
States annually
C. The incidence of listeriosis increased from 1996 to 2003
D. The incidence of listeriosis has remained fairly stable since
2003

A. There were 24 confirmed outbreaks between 1998 and 2008
B. Less than one third of patients required hospitalization
C. The median duration of outbreaks was 6 months
D. Listeriosis most commonly affected infants

A. Deli meats
B. Cheese made from unpasteurized milk
C. Frankfurters
D. Sprouts and other vegetables

A. Serotype 1/2a accounted for most outbreaks of listeriosis
B. Serotype 4b was associated with the highest hospitalization
rate
C. Outbreaks recorded later in the study period involved more
cases
D. The number of outbreaks associated with processed meats
increased throughout the study period

Strongly Disagree Strongly Agree
1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5
Earning CME Credit
continuing medical education (CME) credit, please go to . Credit cannot be obtained

Article Title
Staphylococcal Infections in Children, California, USA, 19852009
CME Questions

A. The biggest increase in the incidence of
hospitalizations occurred between 1985 and 2002
B. The biggest increase in the incidence of
hospitalizations occurred between 2006 and 2009
C. Hospitalizations for cellulitis declined between 2002
and 2006
D. The maximum incidence of hospitalization remained
below 100 cases per 100,000 population

A. Female sex
B. African American race
C. Age 14 to 17 years
D. Low family income

A. Excluding neonates, the mean length of hospital stay
was approximately 14 days
B. The length of hospital stay progressively increased
over the entire study period
C. Staphylococcal infection did not independently
increase the risk of mortality
D. African American race was associated with a higher
risk of mortality due to staphylococcal infection

A. Bacteremia was the most common type of infection
B. Rates of infection with methicillin-susceptible

increased substantially from 2000 to 2009
C. Rates of infection with methicillin-resistant

(MRSA) increased substantially from 2000 to 2009
D. MRSA infections were most common among neonates
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continuing medical education (CME) credit, please go to > > > ? @ A B C D E F A ? G H I J K G L H M E N J A O B
. Credit cannot be obtained
P Q P R S P T U V W X Y Z [ \ T Z W ] ^ V _
Article Title
Pneumocystis jirovecii Genotype Associated with Increased
Death Rate of HIV-infected Patients with Pneumonia
CME Questions
`
? a G L E H A C A A O M I E b c d e A E H d G N B @ E M > O f g h i j O M k A D f O G M
E M B E M A > B O E I M G C O C G k l m n o p q r s t u v t w v x q y n r v v
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g E f > E C f g A G A H E N N H E f A G k B O g e B H G F f A H G E f A C e M f g E C A
z h { } @ L f E f O G M C E @ G M I D E C A C G k { | { O M f g A D L H H A M f
C f L B e
A. 4%
B. 33%
C. 74%
D. 83%
? h { @ L f E f O G M C > A H A @ G C f E C C G D O E f A B > O f g > g O D g

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C f L B e
A. CD4 count less than 50 cells/L
B. Age over 40 years
C. Male sex
D. Diagnosis of PCP after 1995
b ? a G L O M O f O E f A f H A E f @ A M f > O f g f H O @ A f g G F H O @ d
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g O D g G k f g A k G N N G > O M I E H O E ~ N A C
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w v x q y n r v v O M f g A D L H H A M f C f L B e
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R ^ Z Y W ^ ^
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D. DHPS M2 mutation
?

g O D g G k f g A k G N N G > O M I E H O E ~ N A C > E C @ G C f
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f g A D L H H A M f C f L B e
A. DHPS M2 mutation
B. DHPS M3 mutation
C.
R ^ Z Y W ^ ^
type 7
D. Older age

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

1 2 3 4 5
NEWS & NOTES
Upcoming Issue
Broadening the Paradigm of Research and Development for
Rift Valley Fever
Eastern Equine Encephalitis in Children, Massachusetts and
New Hampshire, 19702010
Lessons and Challenges for Measles Control from
Unexpected Large Outbreak, Malawi
Nosocomial and Corpse-to-Human Transmission of Nipah
Virus, Bangladesh
Phylogenetic and Ecologic Analyses of Monkeypox Outbreak,
South Sudan
Rift Valley Fever, Sudan, 2007 and 2010
Severe Lower Respiratory Tract Infection in Early Infancy and
Pneumonia Hospitalizations among Children, Kenya
Laboratory-based Surveillance for Hepatitis E Virus Infection,
United States, 20052012
Plague Outbreak in Libya, 2009, Unrelated to Plague in
Algeria
Lessons from the History of Isolation and Quarantine
Avian Influenza Virus among Poultry Workers, Beijing, China
Typhus Group Rickettsiae in Mbeya Region, Southwestern
Tanzania

spp. Infection among Employees at a Poultry
Processing Plant, Virginia, 20082011
Environmental Analysis for Avian Influenza Surveillance in
Wet Markets, Cambodia
Hepatitis E Virus in Pork Liver Sausage, France

Meningoencephalitis, West Africa
Kyasanur Forest Disease, India, 20112012
Genetic Variants of Echovirus 13, Northern India, 2010
Transmission and Maintenance Cycle of

in Rhesus Macaques, China
Complete list of articles in the February issue at
http://www.cdc.gov/eid/upcoming.htm
Upcoming Infectious
Disease Activities

Announcements
To submit an announcement, send an email message to
EIDEditor (eideditor@cdc.gov). Include the date of the
event, the location, the sponsoring organization(s), and
a website that readers may visit or a telephone number
or email address that readers may contact for more
information.
Announcements may be posted on the journal Web
page only, depending on the event date.
Emerging Infectious Diseases www.cdc.gov/eid Vol. 18, No. 12, December 2012 187
Instructions to Authors

To submit a manuscript, access Manuscript Central from
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indicating the proposed category of the article (e.g., Research, Dispatch), verifying the
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For word processing, use MS Word. List the following infor-
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!
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ences. Use of subheadings in the main body of the text is recommended. Photographs
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# $
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%
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Email to eideditor@cdc.gov.
Emerging Infectious Diseases is a peer-reviewed journal established expressly to promote the recognition of new and
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Peer-Reviewed Journal Tracking and Analyzing Disease Trends pages 1188

North Carolina Museum of Art, Raleigh,

8 Emerging Infectious Diseases www.cdc.gov/eid Vol. 19, No. 1, January 2013

14 Emerging Infectious Diseases www.cdc.gov/eid Vol. 19, No. 1, January 2013

50 Emerging Infectious Diseases www.cdc.gov/eid Vol. 19, No. 1, January 2013

Invasive Pneumococcal Disease in Children

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Peer-Reviewed Journal Tracking and Analyzing Disease Trends pages 1188

North Carolina Museum of Art, Raleigh,

8 Emerging Infectious Diseases www.cdc.gov/eid Vol. 19, No. 1, January 2013

14 Emerging Infectious Diseases www.cdc.gov/eid Vol. 19, No. 1, January 2013

50 Emerging Infectious Diseases www.cdc.gov/eid Vol. 19, No. 1, January 2013

Invasive Pneumococcal Disease in Children

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