MMWR 2012

Morbidity and Mortality Weekly Report
Weekly / Vol. 61 / No. 10
March 16, 2012
Reducing Bloodstream Infections in

an Outpatient Hemodialysis Center
New Jersey, 20082011
National Kidney Month

March 2012
March is designated National Kidney Month to raise
awareness about kidney disease prevention and early
detection. In 2010, kidney disease was the eighth leading
cause of death in the United States (1). Approximately 20
million U.S. adults aged 20 years have chronic kidney
disease (CKD), and most of them are unaware of their
condition (2,3). If left untreated, CKD can lead to kidney
failure, requiring dialysis or transplantation for survival
(2,4). Among persons on hemodialysis because of kidney
failure, the leading causes of hospitalization are cardiovascular disease and infection (4).
CDC, in collaboration with partner agencies and organizations, has created the National Chronic Kidney Disease Fact
Sheet 2010 (2) and is establishing a national CKD surveillance
system to document and monitor the burden of CKD in the
United States. Diabetes and high blood pressure are major risk
factors for CKD, but controlling diabetes and blood pressure
can prevent or delay CKD and improve health outcomes (2).
Information about kidney disease prevention and control
is available at http://www.nkdep.nih.gov. Information about
CDCs Chronic Kidney Disease Initiative is available at http://
www.cdc.gov/diabetes/projects/kidney.htm.
References
1. Murphy SL, Xu JQ, Kochanek KD. Deaths: preliminary data for
2010. Natl Vital Stat Rep 2012;60(4).
2. CDC. National chronic kidney disease fact sheet 2010. Atlanta, GA:
US Department of Health and Human Services, CDC; 2010.
Available at http://www.cdc.gov/diabetes/pubs/factsheets/kidney.htm.
Accessed March 5, 2012.
3. Plantinga LC, Boulware LE, Coresh J, et al. Patient awareness of
chronic kidney disease: trends and predictors. Arch Intern Med
2008;168:226875.
4. US Renal Data System. USRDS 2011 annual data report: atlas of
chronic kidney disease and end-stage renal disease in the United
States. Bethesda, MD: National Institutes of Health, National
Institute of Diabetes and Digestive and Kidney Diseases; 2011.
Available at http://www.usrds.org/adr.aspx. Accessed March 5, 2012.
Patients undergoing hemodialysis are at risk for bloodstream

infections (BSIs), and preventing these infections in this highrisk population is a national priority (1). During 2008, an
estimated 37,000 BSIs related to central lines occurred among
hemodialysis patients in the United States. This is almost as
many as the estimated 41,000 central lineassociated BSIs that
occurred during 2009 among patients in critical-care units
and wards of acute-care hospitals. In 2009, to decrease BSI
incidence in a New Jersey outpatient hemodialysis center, a
package of interventions was instituted, beginning with participation in a national collaborative BSI prevention program
and augmented by a social and behavioral change process to
enlist staff members in infection prevention. Rates of BSIs
related to the patients vascular access (i.e., access-related BSIs
[ARBs]) were evaluated in the preintervention and postintervention periods. The incidence of all ARBs decreased from
2.04 per 100 patient-months preintervention to 0.75 (p=0.03)
after initiating program interventions and to 0.24 (p<0.01)
after adding a behavioral change intervention. Only one ARB
occurred during the last 12 postintervention months. At this
hemodialysis facility, participating in a collaborative prevention
program along with implementation of a behavioral change
strategy was associated with a large decrease in ARBs. Other
outpatient hemodialysis facilities also might reduce ARBs by
adopting similar approaches to prevention.
To address BSI prevention in outpatient hemodialysis centers, CDC established the CDC Hemodialysis BSI Prevention
Collaborative in mid-2009. As part of this effort, member
INSIDE
174 Tickborne Relapsing Fever in a Mother and
Newborn Child Colorado, 2011
177 Announcements
179 QuickStats
U.S. Department of Health and Human Services

Centers for Disease Control and Prevention
hemodialysis centers report BSIs to the National Healthcare

Safety Network and adopt a uniform package of BSI prevention interventions.* Participating facilities also can implement
a positive deviance approach to social and behavioral change
to engage staff members in these efforts and thereby improve
adherence to recommended interventions. A premise of positive deviance is that in most communities or organizations,
uncommon (deviant) practices of persons or groups within
the organization can yield better (positive) results (e.g., better
adherence to recommended practices) than traditional practices
of their peers who have access to the same resources (2). The
process helps members of an organization identify, generate,
and diffuse positive deviant practices.
The dialysis unit at AtlantiCare Regional Medical Center
is a 12-station, hospital-based outpatient hemodialysis center
serving patients in Atlantic City, New Jersey, and the surrounding region. Several interventions already were in place
to reduce BSIs before introduction of the prevention program
and positive deviance; despite this, BSI incidence remained
above facility goals. The facility joined the collaborative in
September 2009 and during the next 3 months worked to
implement the collaboratives prevention program interventions, which included, in addition to dialysis event surveillance,
1) observation of catheter care and vascular access care, 2) use
* Additional information is available at http://www.cdc.gov/dialysis/collaborative/
index.html.
Additional information is available at http://www.positivedeviance.org.
of chlorhexidine for skin antisepsis, 3) auditing of hand hygiene

adherence, 4) patient education and engagement, 5) catheter
use reduction programs, and 6) staff member education and
competency testing. Program members also participated in
monthly telephone conferences and yearly face-to-face meetings that served as a forum for presenting infection prevention
topics, sharing best practices, and problem solving.
The positive deviance process was introduced to leaders
from the medical center and dialysis center in early 2010. Two
identical kick-off sessions were held in August 2010 to orient
dialysis staff members and support personnel to positive deviance. After the kick-off sessions, discovery and action dialogue
sessions were held (3). These sessions were designed to tap the
expertise of front-line staff members, identify positive deviant
practices and their potential use, and encourage staff members
to take personal responsibility for BSI prevention. For example,
one nurse used a mnemonic device to achieve near-perfect hand
hygiene compliance, which she taught to the other nurses. To
assess and promote the progress of initiatives developed by
staff members during these discussions, follow-up activities
were built into regular staff meetings.
ARBs were measured using Dialysis Event surveillance in the
National Healthcare Safety Network. An ARB was defined as
a positive blood culture attributed to either the vascular access
or an unknown source and collected from a hemodialysis outpatient or from a maintenance hemodialysis patient within 1
day after a hospital admission. Infection rates were reported as
events per 100 patient-months and were sequenced for analysis
The MMWR series of publications is published by the Office of Surveillance, Epidemiology, and Laboratory Services, Centers for Disease Control and Prevention (CDC),
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Suggested citation: Centers for Disease Control and Prevention. [Article title]. MMWR 2012;61:[inclusive page numbers].
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170
MMWR/March 16, 2012/Vol. 61/No. 10
into three periods: 1) preintervention (January 2008August

2009), 2) participation in the prevention program (September
2009July 2010), and 3) participation in the program with
positive deviance (August 2010December 2011). Trends
in infection rates over the three periods were analyzed with
Poisson regression using the three periods as indicator variables.
Two interrupted time series models using Poisson regression
were used to evaluate the effect of the two main interventions
(i.e., participation in the prevention program and implementation of positive deviance) on ARBs (4). The first modeled
the preprevention program rate trend, the rate change
immediately after joining the program, and the difference
between preprevention program and program rate trends.
The second modeled the same rates but also modeled the rate
change immediately after implementing positive deviance and
the difference between the prepositive deviance and positive
deviance rate trends. Using the Durbin-Watson statistic, neither model appeared to demonstrate autocorrelation (i.e., no
significant correlation of adjacent monthly outcomes within
each model). To assess adherence to interventions, process
measures were monitored for five infection prevention practice
categories at least eight times per month. A z-test comparing
proportions was performed to determine whether adherence
differed with each process measure category before and after
implementation of positive deviance.
ARB incidence rates were reported for the preintervention,
prevention program, and program with positive deviance periods (Table 1) and compared (Figure). The comparison revealed
a significant decrease in ARB from the preintervention to the
second postintervention period (2.04 per 100 patient-months
to 0.24 per 100 patient-months [p<0.01]). For the model
using enrollment in the prevention program as the intervention point, monthly ARB incidence did not change before
the intervention (incidence rate ratio [IRR] = 1.00, p=0.94);
at the time of the intervention, the slope of the postintervention monthly ARB incidence did not change significantly, but
the IRR suggested a more downward trend compared with
the preintervention period (IRR = 0.91, p=0.08); and the
ARB incidence postintervention decreased approximately 9%
per month (IRR = 0.91, p=0.045). For the model that used
What is known on this topic?

In 2008, an estimated 37,000 bloodstream infections (BSIs)
related to central lines occurred among hemodialysis patients in
the United States. Despite national decreases in BSIs in other
health-care settings, the incidence of these infections in dialysis
settings does not appear to be decreasing.
What is added by this report?
At one dialysis center, participation in the CDC Hemodialysis BSI
Prevention Collaborative, use of collaborative interventions, and
introduction of a social and behavioral change process (positive
deviance) were associated with significant reductions in BSIs
that were related to the patients vascular access.
What are the implications for public health practice?
Health-careassociated infections, including BSIs, are an
ongoing hazard for patients who receive their care primarily as
outpatients. Based on the success at this facility and the success
of similar programs in other health-care settings, the approach
described in this report might be effective in other outpatient
dialysis facilities to prevent BSIs.
enrollment in the prevention program and positive deviance as

two different intervention points, none of the changes reached
statistical significance; however, a decreasing trend occurred
in the ARB incidence after prevention program enrollment
(IRR = 0.85, p=0.25), which continued downward at nearly the
same rate after the addition of positive deviance (IRR = 1.06,
p=0.75) (Figure). Changes in adherence rates for the five
process measure categories were tracked over the pre and
postpositive deviance periods (Table 2).
Reported by
Gemma Downham, MPH, Erin Jones, Pamela Peterson, MBA,

M. Yaser Mourad, MD, AtlantiCare Regional Medical Center,
New Jersey. Curt Lindberg, DMan, Billings Clinic, Montana.
Priti R. Patel, MD, Alexander J. Kallen, MD, Div of Healthcare
Quality Promotion, National Center for Emerging and Zoonotic
Diseases, CDC. Corresponding contributor: Gemma Downham,
gemma.downham@atlanticare.org, 609-748-7010.
TABLE 1. Incidence rates of all vascular access-related bloodstream infections in an outpatient hemodialysis center across the preintervention
and two postintervention periods New Jersey, 20082011
Period
Preintervention
(Jan 2008Aug 2009)
Prevention program
(Sep 2009Jul 2010)
Prevention program and positive deviance
(Aug 2010Dec 2011)
Patient
months
Access-related
bloodstream
infections
Incidence rate
(per 100
patient-months)
Incidence rate
ratio
p-value
1,518
31
2.04
Referent
Referent
799
0.75
0.37
0.03
1,268
0.24
0.12
<0.01
171
FIGURE. Actual access-related bloodstream infection (ARB) incidence per 100 patient-months at an outpatient hemodialysis center and predicted
ARB incidence using enrollment in the CDC Hemodialysis BSI Prevention Collaborative (collaborative enrollment) (September 2009) as the
intervention, and predicted ARB incidence using collaborative enrollment (September 2009) and addition of a social and behavioral change
process (positive deviance initiation) (August 2010) as separate interventions New Jersey, 20082011
4.5
Collaborative enrollment
Collaborative enrollment and positive deviance
4.0
Enroll in
collaborative
ARB per 100 patient-months
3.5
3.0
Initiate positive
deviance
2.5
2.0
1.5
1.0
0.5
0
Jan
Mar May
Jul
Sep Nov
2008
Jan Mar
May
Jul
Sep Nov
Jan Mar May
2009
Jul
2010
Sep Nov
Jan Mar May
Jul
Sep
Nov
2011
Month and year
Editorial Note
At this outpatient hemodialysis center, use of a package of

interventions, combined with a behavioral change intervention (positive deviance), was associated with a decline in
ARB incidence. Only one ARB was identified in the final 12
months of the intervention period that included more than
1,200 patient-months. Adherence to process measures that
are markers for important infection prevention practices was
high and improved after implementation of positive deviance.
These results demonstrate the utility of a collaborative prevention program that promotes important prevention practices
to decrease BSIs in hemodialysis settings and the potential
for a behavioral change strategy, such as positive deviance, to
increase adherence to prevention strategies.
BSIs are potentially life-threatening infections sometimes
associated with the provision of health care. Preventing these
infections is a priority; however, prevention efforts have focused
primarily on acute-care facilities. Some patients who receive
their care primarily as outpatients, including maintenance
hemodialysis patients, also are at risk for BSIs. Nationally, the
172
number of BSIs among hemodialysis patients is substantial.

Since 1993, hospitalizations for bacteremia or septicemia have
increased 40% among hemodialysis patients (5). This increase
occurred while the number of BSIs declined in intensive-care
units of acute-care hospitals (1).
Preventing BSIs can be a challenge in outpatient hemodialysis settings. However, a number of interventions have been
recommended for prevention, particularly among hemodialysis
patients with central lines (>20% of hemodialysis patients)
(68). The members of this prevention program worked
together to identify a package of evidence-based interventions
that could be implemented in dialysis centers to prevent BSIs
and to develop solutions to the challenges of implementation
and sustainability. A similar collaborative approach has been
used successfully in intensive-care units to decrease the incidence
of central lineassociated BSIs (9). Effective BSI prevention
programs such as this include implementation of evidence-based
practices, endorsement by facility leaders, and empowerment of
frontline health-care personnel to intercede on behalf of patients
when infection control breaches are observed.
TABLE 2. Process measure adherence rates in an outpatient hemodialysis center across two postintervention periods New Jersey,
20082011
Period
Collaborative only
Process measure
Equipment handling
General practice
Medication administration
Isolation precautions
Dialysis initiation and
termination procedures
Collaborative and positive deviance
No.*
(%)
No.*
(%)
p-value
236/245
(96)
378/380
(99)
0.005
1,166/1,190
(98)
1,538/1,546
(99)
<0.001
333/344
(97)
267/269
(99)
0.040
84/88
(95)
26/29
(90)
0.240
458/490
(93)
328/332
(99)
<0.001
* Number of observations in which successful practice was observed / total number of observations.
Included equipment storage and segregation of clean and dirty equipment.
Included use of personal protective equipment and disinfection of the treatment station.
Potentially contributing to this dialysis centers success was

the use of positive deviance to improve adherence to recommended practices and infection prevention principles. Use
of positive deviance or similar interventions has resulted in
reductions in health-careassociated infections in other settings
(10). The significant increases in compliance with infection
prevention processes at this facility suggest that positive deviance helped improve staff member attention to important
infection control practices.
The findings in this report are subject to at least three
limitations. First, results are based on the experience of one
dialysis center and might not be generalizable to other centers.
Second, each intervention period included only a few months,
which diminished the power of the interrupted time series
model to detect statistically significant differences. Finally,
this evaluation is observational. Because no control group was
included, the interventions implemented in this study cannot
be attributed definitively as the cause of the decrease in ARBs.
Prevention of health-careassociated infections, such as
ARBs among hemodialysis patients, is a public health priority.
Prevention efforts at this outpatient hemodialysis center were
improved by including strategies for engaging staff members in
the infection control process and by collaborating with other
facilities to discover practices that can help overcome barriers
to prevention. Other outpatient hemodialysis facilities might
consider similar approaches to BSI prevention.
References
1. CDC. Vital signs: central lineassociated bloodstream infections
United States, 2001, 2008, and 2009. MMWR 2011;60:2438.
2. Marsh DR, Schroeder DG, Dearden KA, et al. The power of positive
deviance. BMJ 2004;329:11779.
3. Lindberg C, Norstrand P, Munger M, et al. Letting go, gaining control:
positive deviance and MRSA prevention. Clinical Leader 2009;2:607.
4. Wagner AK, Soumerai SB, Zhang F, Ross-Degnan D. Segmented
regression analysis of interrupted time series studies in medication use
research. J Clin Pharm Ther 2002;27:299309.
5. US Renal Data System. USRDS 2011 annual data report: atlas of chronic
kidney disease and end-stage renal disease in the United States. Bethesda,
MD: National Institutes of Health, National Institute of Diabetes and
Digestive and Kidney Diseases; 2011. Available at http://www.usrds.
org/adr.aspx. Accessed March 5, 2012.
6. National Kidney Foundation. KDOQI clinical practice guidelines and
clinical practice recommendations for 2006 updates: hemodialysis
adequacy, peritoneal dialysis adequacy and vascular access. Am J Kidney
Dis 2006;48(Suppl 1).
7. OGrady NP, Alexander M, Burns LM, et al. Guideline for the prevention
of intravascular catheter-related infections. Clin Infect Dis 2011;
52:e16293.
8. Mid-Atlantic Renal Coalition. 2010 Fistula First Breakthrough Initiative
annual report. Lake Success, NY: IPRO ESRD Network of New York;
2011. Available at http://www.fistulafirst.org. Accessed February 29, 2012.
9. CDC. Reduction in central lineassociated bloodstream infections
among patients in intensive care unitsPennsylvania, April 2001March
2005. MMWR 2005;54:10136.
10. Ellingson K, Muder RR, Jain R, et al. Sustained reduction in the clinical
incidence of methicillin-resistant Staphylococcus aureus colonization or
infection associated with a multifaceted infection control intervention.
Infect Control Hosp Epidemiol 2011;32:18.
173
Tickborne Relapsing Fever in a Mother and Newborn Child Colorado, 2011

Tickborne relapsing fever (TBRF) is a bacterial infection
caused by certain species of Borrelia spirochetes and transmitted through the bite of Ornithodoros ticks. Clinical illness is
characterized by relapsing fever, myalgias, and malaise. On
May 10, 2011, CDC and the Colorado Department of Public
Health and Environment were notified of two patients with
TBRF: a young woman and her newborn child. This report
summarizes the clinical course of these patients and emphasizes
the importance of considering a diagnosis of TBRF among
patients with compatible clinical symptoms and residence or
travel in a TBRF-endemic area. Pregnant women and neonates
are at increased risk for TBRF-associated complications and
require prompt diagnosis and treatment for optimal clinical
outcomes. Public health follow-up of reported TBRF cases
should include a search for persons sharing an exposure with
the patient and environmental investigation with remediation
measures to prevent additional infections.
On May 2, 2011, a previously healthy woman aged 24 years
sought treatment at a local emergency department in Colorado
after 1 week of fever, nausea, headache, stiff neck, and occasional
blurred vision. Approximately 20 hours earlier, she had delivered
a newborn (at 39 weeks gestation) in a mountain cabin, without
medical attendance. She had received limited prenatal care.
Delivery was notable for amniotic fluid discoloration consistent
with meconium. Physical examination revealed an ill-appearing
and afebrile woman with hypotension (blood pressure:
70/40 mmHg). Gynecologic examination was unremarkable.
A complete blood count revealed an elevated white blood cell
count of 18,000/L (normal: 4,50010,000/L), a decreased
hematocrit of 30% (normal: 37%47%), and a decreased
platelet count of 42,000/L (normal: 130,000400,000/L).
Blood chemistries were remarkable for an elevated creatinine of
1.6 mg/dL (normal: 0.61.3 mg/dL), elevated aspartate aminotransferase of 61 IU/L (normal: 1537 IU/L), and elevated
alkaline phosphatase of 422 IU/L (normal: 50136 IU/L).
She was admitted and treated empirically using intravenous
piperacillin with tazobactam for postpartum sepsis and fluid
resuscitation for hypotension. Antibiotics were changed to oral
amoxicillin after 48 hours. A blood culture drawn at admission
revealed no growth, and the patient remained afebrile during
hospitalization. Because of worsening anemia, she was transfused with packed red blood cells on May 3. Her condition
improved, and she was discharged on May 5.
The newborn female accompanied her mother to the emergency department on May 2. Although physical examination
was normal, the newborn was admitted for observation. An
initial complete blood count was unremarkable, and blood
174
culture collected at admission had no growth after 5 days.

The patient developed neonatal jaundice on May 4 and
remained hospitalized. On May 7, she became febrile with a
temperature of 101.2F (38.4C) and had a platelet count of
34,000/L (normal: 130,000400,000/L). Blood chemistries
revealed an elevated alkaline phosphatase of 196 IU/L (normal:
50136 IU/L) and a decreased albumin of 2.4 g/dL (normal:
3.45.0 g/dL). Treatment for sepsis was initiated with administration of gentamicin, ampicillin, and acyclovir. Subsequently,
her platelet count decreased further to 14,000/L. A review of
the peripheral blood smear to evaluate the newborns thrombocytopenia incidentally revealed spirochetes consistent with
TBRF (Figure). A 10-day course of intravenous penicillin-G
and platelet transfusions for progressive thrombocytopenia
were initiated. The newborn recovered and was discharged on
May 20. Because of the newborns spirochetemia, the mother
was presumptively treated for TBRF with doxycycline.
Blood and serum samples from the mother and her newborn
were tested by CDCs Bacterial Diseases Branch, Fort Collins,
Colorado. Presence of spirochetes was visually confirmed from
the newborns blood smear prepared May 7; a whole blood
sample collected the same day yielded evidence of relapsing
fever Borrelia species by polymerase chain reaction. Sequencing
of polymerase chain reaction targets revealed 100% match to
Borrelia hermsii. Testing of the newborns serum also obtained
FIGURE. Stained thin smear of a newborns peripheral blood, showing
the presence of numerous spirochetes (indicated by black arrows)
at 63X magnification Colorado, 2011
Photo/CDC
May 7 did not detect B. hermsii antibodies by either enzyme

immunoassay (EIA) or immunoglobulin M (IgM) and immunoglobulin G (IgG) Western immunoblots. A sample collected
from the newborn 3 days later had equivocal results by EIA
and three bands visible on IgM immunoblot and one band
visible on IgG immunoblot. Serum collected from the mother
on May 13 produced a positive B. hermsii EIA, >10 bands by
IgM immunoblot, and 10 bands by IgG immunoblot. The
mothers clinical history and dominant IgM antibody response
supported acute maternal B. hermsii infection acquired during
the weeks preceding delivery; the limited antibody response by
the newborn also supported a diagnosis of acute TBRF infection.
The mother was not employed and had moved from a
densely populated urban area in Colorado to the previously
vacant cabin 18 days before delivery. This rural Colorado
cabin was situated near the base of a mountain range within
a juniper and pion tree forest at an approximate elevation
of 8,800 feet. The single-room structure lacked electricity
and running water. An environmental assessment indicated
no ongoing rodent activity, and no ticks were recovered. The
cabin owner declined to permit access to internal wall spaces
to search for rodent nests.
Reported by
Elisabeth W. Lawaczeck, DVM, Colorado Dept of Public Health

and Environment. Paul S. Mead, MD, Martin E. Schriefer, PhD,
Div of Vector-Borne Diseases, National Center for Emerging and
Zoonotic Infectious Diseases; Meghan E. Brett, MD, Jeffrey T.
McCollum, DVM, EIS officers, CDC. Corresponding
contributor: Jeffrey T. McCollum, jmccollum@cdc.gov,
303-692-2745.
Editorial Note
B. hermsii is the most frequent cause of TBRF in the United

States. This spirochete is transmitted to humans by the soft tick
Ornithodoros hermsi, which usually is associated with the nests
of chipmunks and other wild rodents (1). Unlike hard ticks,
O. hermsi transmit spirochetes through a brief (<30 minutes
duration) and painless nocturnal bite. Humans typically are
exposed to these ticks during an overnight stay in rodentinfested dwellings at elevations >2,000 feet.
After an average incubation period of 7 days (range: 218
days), TBRF symptoms include fever, headache, myalgias,
nausea, and chills with a median duration of 3 days (range: 27
days) alternating with afebrile periods of a median duration of 7
days (range: 414 days) (1). Febrile periods can recur 10 times
without treatment. Moderate to severe thrombocytopenia is
typical during acute TBRF illness (1). As occurred in the newborns illness, spirochetes are not detected by automated blood
cell counts but can be observed on direct examination of stained
(Wrights or Giemsa) blood smears, with sensitivity approaching

70% during febrile episodes (2). Blood smears most often reveal
spirochetes during acute infection and before antibiotic treatment. Alternatively, serologic testing for TBRF can be used for
diagnosis but is not widely available. Antibiotics recommended
for treatment include penicillin, doxycycline, and erythromycin.
Patients with TBRF infection should be monitored for 2 hours
after initial antibiotic dose for a Jarisch-Herxheimer reaction, an
acute worsening of symptoms that can be life-threatening.* One
case series documented such reactions among 54% of patients,
demonstrating that this reaction is common (3).
TBRF infection can pose serious risks for mothers and
neonates. Only 12 TBRF infections among pregnant women
have ever been reported in the United States, including the
one in this report (1,39). Among these cases, serious maternal
complications of TBRF infection have been documented and
include adult respiratory distress syndrome, Jarisch-Herxheimer
reaction, and precipitous or premature delivery (46). Among
newborns born to these TBRF-infected mothers, six (55%) of
11 had a documented perinatal TBRF infection; two (33%)
died despite treatment. Potential routes of perinatal TBRF
infection include transplacental transmission or acquisition
during delivery; however, studies have been limited.
The findings in this report are subject to at least two limitations. First, transmission route for the newborn was not determined, but possibilities include transplacental, during birth,
or during residence in the cabin. Second, the cabin remains
the most likely site of exposure for the mother on the basis of
arrival date and acute nature of her illness; however, no rodent
nests or ticks were identified within the structure to provide
more substantial evidence.
TBRF should be considered a potential diagnosis among
febrile patients who reside in or have traveled to the western
United States, especially those inhabiting rustic housing. Cases
should be reported immediately to public health officials to
facilitate identification of other potentially exposed persons
and to evaluate and treat those persons for TBRF infection.
Additionally, TBRF is a reportable disease in 12 western U.S.
states. An environmental investigation should be undertaken
to search for rodent nests. Reinfection and additional TBRF
illnesses can occur in housing previously linked to TBRF cases
(10). Remediation efforts should include rodent-proofing and
treatment of structures with pesticides (particularly crack- and
crevice-type) by pest control specialists to reduce risk for continued tick exposure.
* A Jarisch-Herxheimer reaction is characterized by hypotension, tachycardia, chills,
rigors, diaphoresis, and elevated body temperature and can occur after initial antibiotic
therapy for infections caused by spirochetes, including relapsing fever (1).
One woman with TBRF infection elected to terminate her pregnancy.
Arizona, California, Colorado, Idaho, Montana, Nevada, New Mexico, North
Dakota, Oregon, Texas, Utah, and Washington.
175
What is already known on this topic?

Tickborne relapsing fever (TBRF) is a spirochetal infection
transmitted to humans through the bites of soft ticks. TBRF
infection is endemic to the western United States and often
acquired by patients lodging in rodent-infested rustic dwellings
at elevations >2,000 feet.
What is added by this report?
This report describes the sixth reported case of acute neonatal
TBRF infection associated with maternal TBRF illness in the
United States. It highlights the incidental diagnosis of two TBRF
infections, indicating that TBRF might not be considered initially
for clinically compatible illnesses even in TBRF-endemic areas.
What are the implications for public health practice?
TBRF should be considered among the differential diagnoses of
patients with unexplained or recurrent fever, especially those
with a history of travel or residence in areas where TBRF is
endemic. Pregnant women and neonates are at increased risk
for severe TBRF illness and require prompt diagnosis and
treatment for optimal clinical outcomes. Public health follow-up
of reported TBRF cases should include a search for additional
illnesses and environmental assessment with remediation
measures to prevent further infections or reinfection.
176
Acknowledgments
Local clinicians and clinical laboratories; local health department
personnel; Ken Gershman, MD, Communicable Disease
Epidemiology Program, Colorado Dept of Public Health and
Environment. Christopher Sexton, John Young, Bacterial Diseases
Branch Laboratory, Div of Vector-Borne Diseases; Kris Bisgard,
DVM, EIS Field Assignments Branch, Scientific Education and
Professional Development Program Office, CDC.
References
1. Dworkin MS, Schwan TG, Anderson DE Jr. Tick-borne relapsing fever
in North America. Med Clin North Am 2002;86:41733, viiiix.
2. Southern PM Jr, Sanford JP. Relapsing fever: a clinical and microbiological
review. Medicine 1969;48:12949.
3. Dworkin MS, Anderson DE Jr, Schwan TG, et al. Tick-borne relapsing
fever in the northwestern United States and southwestern Canada. Clin
Infect Dis 1998;26:12231.
4. Davis RD, Burke JP, Wright LJ. Relapsing fever associated with ARDS
in a parturient woman. A case report and review of the literature. Chest
1992;102:6302.
5. Guggenheim JN, Haverkamp AD. Tick-borne relapsing fever during
pregnancy: a case report. J Reprod Med 2005;50:7279.
6. Fuchs PC, Oyama AA. Neonatal relapsing fever due to transplacental
transmission of Borrelia. JAMA 1969;208:6902.
7. Morrison SK, Parsons L. Relapsing fever: report of three cases, one in a
six day old infant. JAMA 1941;116:2201.
8. Steenbarger JR. Congenital tick-borne relapsing fever: report of a case
with first documentation of transplacental transmission. Birth Defects
Orig Artic Ser 1982;18(3 Pt A):3945.
9. Malison MD. Relapsing fever. JAMA 1979;241:281920.
10. Wynns HL. The epidemiology of relapsing fever. In: In: Moulton FR,
ed. A symposium on relapsing fever in the Americas. Washington, DC:
American Association for the Advancement of Science; 1942.
Announcements
National Poison Prevention Week, 50th
Anniversary March 1824, 2012
This year commemorates the 50th anniversary of National
Poison Prevention Week (NPPW), which will be observed
March 1824. Each year, the observance of NPPW is organized by the Poison Prevention Week Council, a coalition of
partners working to raise awareness about poison prevention
across wide-ranging disciplines.*
Since passage of the Poison Prevention Packaging Act
in 1970, the child-resistant packaging required on many
medicines and toxic substances has saved hundreds of lives
(1). However, child poisoning, particularly from medicines,
remains a public health problem. Each year, approximately
60,000 emergency department visits and half a million calls
to poison control centers are made because young children
have gotten into medicines (2,3). A CDC-led public-private
partnership, PROTECT, has developed the Up and Away and
Out of Sight program to remind a new generation of caregivers
about the importance of safe medicine storage.
NPPW also serves to focus attention on the substantial
increase in the number of poisoning deaths among youths and
adults during the past decade. In 2008, poisoning became the
leading cause of injury-related death in the United States (4).
Nearly 90% of poisoning deaths involved drugs, and approximately half of those involved prescription medications. Of
the prescription medication overdose deaths, 74% involved
opioid analgesics (5). NPPW provides a reminder of the many
opportunities available for reversing these trends (2,6).
Additional information about carbon monoxide poisoning, lead poisoning, and other unintentional poisonings is
available from CDC at http://www.cdc.gov/co/default.htm,
http://www.cdc.gov/nceh/lead, and http://www.cdc.gov/
homeandrecreationalsafety/poisoning/index.html, respectively.
Additional poison prevention information is available at http://
poisonhelp.hrsa.gov. The national Poison Help line can be
reached toll-free by dialing 1-800-222-1222.
* Additional information available at http://www.poisonprevention.org.
Additional information available at http://www.cdc.gov/medicationsafety/
protect/protect_initiative.html and http://www.upandaway.org.
References
1. Rodgers G. The safety effects of child-resistant packaging for oral
prescription drugs: two decades of experience. JAMA 1996;275:16615.
2. Budnitz DS, Salis S. Preventing medication overdoses in young children:
an opportunity for harm elimination. Pediatrics 2011;127:e15979.
3. Bronstein AC, Spyker DA, Cantilena LR Jr, Green JL, Rumack BH, Dart
RC. 2010 annual report of the American Association of Poison Control
Centers National Poison Data System (NPDS): 28th annual report. Clin
Toxicol (Phila) 2011;49:91041.
4. Warner M, Chen LH, Makuc DM, Anderson RN, Minio AM. Drug
poisoning deaths in the United States, 19802008. NCHS data brief, no.
81. Hyattsville, MD: US Department of Health and Human Services,
National Center for Health Statistics, CDC; 2011. Available at http://
www.cdc.gov/nchs/data/databriefs/db81.htm. Accessed March 6, 2012.
5. CDC. Vital Signs: overdoses of prescription opioid pain relieversUnited
States, 19992008. MMWR 2011;60:148792.
6. CDC. Policy impact: prescription painkiller overdoses. Atlanta, GA: US
Department of Health and Human Services, CDC; 2011. Available at
http://www.cdc.gov/homeandrecreationalsafety/rxbrief/index.html.
Accessed March 6, 2012.
World Water Day March 22, 2012

World Water Day, sponsored by the United Nations, has
been observed on March 22 each year since 1993. This year,
World Water Day focuses on the link between water use and
food production, in conjunction with its theme, Water and
Food Security: The World is Thirsty Because We are Hungry.
Food production accounts for 70% of all water use, more
than the amount needed for domestic and industrial use
combined. The average person drinks approximately 2.5 liters
of water a day, whereas 15,000 liters of water are required to
produce 1 kilogram (2.2 pounds) of beef. As the world population continues to grow, the demand for fresh water needed
for food production will continue to increase, placing a strain
on the worlds fresh water supply.*
Since 1990, the number of persons able to access improved
drinking water and sanitation resources has increased by 2 billion and 1.8 billion respectively (1). Despite these gains, hundreds of millions still lack access to these essential resources (1).
CDCs global water, sanitation, and hygiene (WASH) program
provides expertise and interventions to increase global access
to safe water, adequate sanitation, and improved hygiene.
* Additional information available at http://www.unwater.org/worldwaterday/
index.html.
Additional information available at http://www.cdc.gov/healthywater/global.
Reference
1. United Nations Childrens Fund (UNICEF), World Health Organization.
Progress on drinking water and sanitation: 2012 update. New York, NY:
UNICEF, World Health Organization; 2012. Available at http://www.
who.int/water_sanitation_health/publications/2012/jmp_report/en/
index.html. Accessed March 13, 2012.
177
Announcements
Epidemiology in Action Course
CDC and Rollins School of Public Health at Emory
University will cosponsor the course, Epidemiology in Action,
June 1122, 2012, at Emory University in Atlanta, Georgia.
This course is designed for state and local public health
professionals.
The course emphasizes practical application of epidemiology
to public health problems and consists of lectures, workshops,
classroom exercises (including actual epidemiologic problems),
and roundtable discussions. Topics scheduled for presentation
include descriptive epidemiology and biostatistics, analytic
epidemiology, epidemic investigations, public health surveillance, surveys and sampling, and Epi Info training, along with
discussions of selected prevalent diseases. Tuition is charged.
Additional information and applications are available by
mail (Emory University, Hubert Department of Global Health
[Attn: Pia Valeriano], 1518 Clifton Rd. NE, CNR Bldg.,
Rm. 7038, Atlanta, GA 30322), telephone (404-727-3485),
fax (404-727-4590), Internet (http://www.sph.emory.edu/
epicourses), or e-mail (pvaleri@emory.edu).
CDC Launches National Tobacco Education

Campaign
Many smokers do not fully understand the health risks of
smoking and underestimate their personal risk (1). Media
campaigns are an evidence-based strategy to educate the public
regarding the harms of tobacco use, prevent smoking initiation,
promote and facilitate cessation, and change social norms on
the acceptability of tobacco use (2,3). Media campaigns that
have strong negative messages regarding health effects, that use
testimonials, or that address the impact of smoking on others
have been demonstrated to be effective (24). Smokers who
report being exposed to advertisements that are more highly
emotional and include personal testimonials have been shown
to be more likely to have quit smoking at follow-up (3), and
graphic television advertisements have been associated with
increased call volume to telephone quitlines (5).
On March 15, 2012, CDC launched a 12-week national
education campaign on the dangers of tobacco use. This
campaign, Tips from Former Smokers, profiles real persons who are living with the significant adverse health effects
of smoking-related diseases, such as stomas, paralysis from
stroke, lung removal, heart attack, and limb amputations.
The multimedia campaign will include advertisements that
will be placed nationally via television, radio, newspapers,
magazines, the Internet, billboards, bus stops, and movie theaters. Advertisements will include a prompt for smokers to call
800-QUIT-NOW for free help to quit. Additional information
is available at http://www.cdc.gov/tobacco.
References
1. Weinstein ND, Marcus SE, Moser RP. Smokers unrealistic optimism
about their risk. Tob Control 2005;14:559.
2. National Cancer Institute. The role of the media in promoting and
reducing tobacco use. Tobacco control monograph no. 19. Bethesda, MD:
US Department of Health and Human Services, National Institutes of
Health, National Cancer Institute; 2008.
3. Wakefield M, Loken B, Hornik RC. Use of mass media campaigns to
change health behaviour. Lancet 2010;376:126171.
4. US Department of Health and Human Services. Preventing tobacco use
among youth and young adults: a report of the Surgeon General. Atlanta,
GA: US Department of Health and Human Services, CDC; 2012.
5. Farrelly MC, Davis KC, Nonnemaker JM, Kamyab K, Jackson C.
Promoting calls to a quitline: quantifying the influence of message theme,
strong negative emotions and graphic images in television advertisements.
Tob Control 2011;20:27984.
178
QuickStats
FROM THE NATIONAL CENTER FOR HEALTH STATISTICS
Percentage of Hospitalizations, by Expected Payment Source* and

Hospital Locality National Hospital Discharge Survey, United States, 2009
60
Metropolitan counties
Nonmetropolitan counties
50
Percentage
40
30
20
10
0
Medicare
Medicaid
Private insurance
Other
Expected payment source

* Expected payment source is the type of program or insurance that, on admission to the hospital, was expected
to be the principal payer for the hospital stay.
Counties where hospitals are located were classified as metropolitan or nonmetropolitan using June 2003
U.S. Office of Management and Budget standards based on the 2000 Census.
95% confidence interval.
In 2009, Medicare was expected to pay for 51% of U.S. hospitalizations in nonmetropolitan counties and 40% of hospitalizations
in metropolitan counties. Private insurance was the expected source of payment for 32% of hospitalizations in metropolitan
counties, compared with 24% of hospitalizations in nonmetropolitan counties.
Source: National Hospital Discharge Survey data (2009). Available at http://www.cdc.gov/nchs/nhds.htm.
Reported by: Margaret J. Hall, PhD, mhall@cdc.gov, 301-458-4252; Maria F. Owings, PhD.
179
Notifiable Diseases and Mortality Tables

TABLE I. Provisional cases of infrequently reported notifiable diseases (<1,000 cases reported during the preceding year) United States, week ending
March 10, 2012 (10th week)*
Current
week
Disease
Anthrax

Arboviral diseases , :
California serogroup virus disease
Eastern equine encephalitis virus disease
Powassan virus disease
St. Louis encephalitis virus disease
Western equine encephalitis virus disease
Babesiosis
Botulism, total
foodborne
infant
other (wound and unspecified)
Brucellosis
Chancroid
Cholera
Cyclosporiasis
Diphtheria
Haemophilus influenzae,** invasive disease (age <5 yrs):
serotype b
nonserotype b
unknown serotype
Hansen disease
Hantavirus pulmonary syndrome
Hemolytic uremic syndrome, postdiarrheal

,
Influenza-associated pediatric mortality
Listeriosis
Measles
Meningococcal disease, invasive:
A, C, Y, and W-135
serogroup B
other serogroup
unknown serogroup
Novel influenza A virus infections***
Plague
Poliomyelitis, paralytic
Polio virus Infection, nonparalytic
Psittacosis
Q fever, total
acute
chronic
Rabies, human
Rubella
Rubella, congenital syndrome
SARS-CoV
Smallpox
Streptococcal toxic-shock syndrome
Syphilis, congenital (age <1 yr)

Tetanus
Toxic-shock syndrome (staphylococcal)

Trichinellosis
Tularemia
Typhoid fever
Vancomycin-intermediate Staphylococcus aureus
Vancomycin-resistant Staphylococcus aureus
Vibriosis (noncholera Vibrio species infections)

Viral hemorrhagic fever
Yellow fever
Cum
2012
Total cases reported for previous years

2011
2010
2009
2008
2007
2
1
1
12
17
3
12
2
13
4
0
2
0
2
0
2
1
0
1
134
4
16
6
752
135
13
91
31
81
28
36
154
75
10
8
10
NN
112
7
80
25
115
24
13
179
55
4
6
12
NN
118
10
83
25
115
28
10
141
62
4
2
13
NN
145
17
109
19
80
25
5
139
55
4
7
9
NN
144
32
85
27
131
23
7
93
1
1
3
1
3
27
41
9
2
9
5
68
25
1
5
5
2
0
3
5
10
3
11
115
254
51
23
219
118
840
216
23
200
223
98
20
266
61
821
63
35
236
178
103
20
242
358
851
71
30
244
163
80
18
330
90
759
140
22
199
180
101
32
292
77
808
43
1
1
3
1
16
7
2
72
12
9
3
27
5
11
2
1
42
6
33
9
4
1
12
0
0
0
2
1
0
5
8
0
2
0
0
7
1
0
4
197
121
19
391
8
2
2
117
94
23
2
4
142
288
12
81
11
141
378
67
783
280
301
135
174
12
23
406
482
4 43,774
2
8
4
9
131
113
106
93
25
20
2
4
5
3
142
161
377
423
26
18
82
74
7
13
124
93
467
397
91
78
2
1
846
789
1
NN
330
188
38
616
2
3
8
120
106
14
2
16
157
431
19
71
39
123
449
63
588
NN
325
167
35
550
4
7
12
171
1
12
132
430
28
92
5
137
434
37
2
549
NN
See Table 1 footnotes on next page.
ND-128
5-year
weekly
average
States reporting cases

during current week (No.)
NY (1), MD (1)
OH (1)
AK (1)
NYC (1)
FL (1)
NC (1)
NY (2), CA (1)
FL (1)
NE (1), MD (1), FL (1), TX (1), HI (1)
MD (1)
NY (2), NC (1)
NY (1), OH (1), MD (1)

GA (1)
FL (1)
TABLE I. (Continued) Provisional cases of infrequently reported notifiable diseases (<1,000 cases reported during the preceding year) United States, week
ending March 10, 2012 (10th week)*
: No reported cases. N: Not reportable. NN: Not Nationally Notifiable. Cum: Cumulative year-to-date counts.
* Case counts for reporting year 2011 and 2012 are provisional and subject to change. For further information on interpretation of these data, see http://www.cdc.gov/osels/ph_surveillance/
nndss/phs/files/ProvisionalNationa%20NotifiableDiseasesSurveillanceData20100927.pdf.
Calculated by summing the incidence counts for the current week, the 2 weeks preceding the current week, and the 2 weeks following the current week, for a total of 5 preceding years.
Additional information is available at http://www.cdc.gov/osels/ph_surveillance/nndss/phs/files/5yearweeklyaverage.pdf.
Not reportable in all states. Data from states where the condition is not reportable are excluded from this table except starting in 2007 for the arboviral diseases, STD data, TB data, and
influenza-associated pediatric mortality, and in 2003 for SARS-CoV. Reporting exceptions are available at http://www.cdc.gov/osels/ph_surveillance/nndss/phs/infdis.htm.
Includes both neuroinvasive and nonneuroinvasive. Updated weekly from reports to the Division of Vector-Borne Infectious Diseases, National Center for Zoonotic, Vector-Borne, and
Enteric Diseases (ArboNET Surveillance). Data for West Nile virus are available in Table II.
** Data for H. influenzae (all ages, all serotypes) are available in Table II.
Updated weekly from reports to the Influenza Division, National Center for Immunization and Respiratory Diseases. Since October 2, 2011, five influenza-associated pediatric deaths
occurring during the 2011-12 influenza season have been reported.
The one measles case reported for the current week was imported.
Data for meningococcal disease (all serogroups) are available in Table II.
*** CDC discontinued reporting of individual confirmed and probable cases of 2009 pandemic influenza A (H1N1) virus infections on July 24, 2009. During 2009, four cases of human infection
with novel influenza A viruses, different from the 2009 pandemic influenza A (H1N1) strain, were reported to CDC. The four cases of novel influenza A virus infection reported to CDC
during 2010, and the eight cases reported during 2011, were identified as swine influenza A (H3N2) virus and are unrelated to the 2009 pandemic influenza A (H1N1) virus. Total case
counts are provided by the Influenza Division, National Center for Immunization and Respiratory Diseases (NCIRD).
No rubella cases were reported for the current week.
Updated weekly from reports to the Division of STD Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention.
There were no cases of viral hemorrhagic fever reported during the current week. See Table II for dengue hemorrhagic fever.
FIGURE I. Selected notifiable disease reports, United States, comparison of provisional 4-week
totals March 10, 2012, with historical data
DISEASE
DECREASE
INCREASE
CASES CURRENT
4 WEEKS
Giardiasis
443
Hepatitis A, acute
60
Hepatitis B, acute
115
Hepatitis C, acute
49
Legionellosis
71
Measles
Meningococcal disease
18
Mumps
Pertussis
710
0.03125 0.0625
0.125
0.25
0.5
Ratio (Log scale)*

Beyond historical limits
* Ratio of current 4-week total to mean of 15 4-week totals (from previous, comparable, and subsequent 4-week
periods for the past 5 years). The point where the hatched area begins is based on the mean and two standard
deviations of these 4-week totals.
Notifiable Disease Data Team and 122 Cities Mortality Data Team
Jennifer Ward
Willie J. Anderson
Rosaline Dhara
Pearl C. Sharp
Deborah A. Adams
Lenee Blanton
Diana Harris Onweh
Michael S. Wodajo
ND-129
TABLE II. Provisional cases of selected notifiable diseases, United States, weeks ending March 10, 2012, and March 12, 2011 (10th week)*
Chlamydia trachomatis infection
Reporting area
United States
New England
Connecticut
Maine
Massachusetts
New Hampshire
Rhode Island
Vermont
Mid. Atlantic
New Jersey
New York (Upstate)
New York City
Pennsylvania
E.N. Central
Illinois
Indiana
Michigan
Ohio
Wisconsin
W.N. Central
Iowa
Kansas
Minnesota
Missouri
Nebraska
North Dakota
South Dakota
S. Atlantic
Delaware
District of Columbia
Florida
Georgia
Maryland
North Carolina
South Carolina
Virginia
West Virginia
E.S. Central
Alabama
Kentucky
Mississippi
Tennessee
W.S. Central
Arkansas
Louisiana
Oklahoma
Texas
Mountain
Arizona
Colorado
Idaho
Montana
Nevada
New Mexico
Utah
Wyoming
Pacific
Alaska
California
Hawaii
Oregon
Washington
Territories
American Samoa
C.N.M.I.
Guam
Puerto Rico
U.S. Virgin Islands
Current
week
Previous 52 weeks
Coccidioidomycosis
Med
Max
Cum
2012
Cum
2011
Current
week
11,288
637
56
505
1
16
59
1,761
116
775
292
578
1,218
29
196
597
228
168
27
27
4,244
43
874
690
221
833
666
917
1,093
281
488
324
470
358
112
573
62
248
242
21
1,265
51
748
466
26,847
898
240
59
427
58
80
27
3,155
539
717
1,012
1,043
4,207
1,221
571
930
1,029
466
1,494
211
206
316
526
124
45
62
5,468
85
111
1,505
1,101
484
991
532
665
81
1,924
551
325
419
604
3,272
317
354
103
2,368
1,698
546
402
90
68
207
220
136
29
4,032
109
3,071
114
280
434
30,781
1,593
869
101
860
90
187
66
4,080
898
2,009
1,315
1,598
4,691
1,475
731
1,210
1,180
561
1,819
439
281
407
759
213
76
89
7,518
182
217
1,696
1,563
769
1,688
1,344
1,778
146
2,804
1,566
557
792
822
4,311
439
1,071
675
3,108
2,412
784
846
274
91
285
336
190
67
5,436
152
4,501
142
412
612
203,700
5,916
583
3,733
315
1,025
260
28,015
4,488
6,259
7,125
10,143
31,058
6,513
4,639
8,310
7,727
3,869
3,663
2,063
114
923
5
558
51,395
722
1,151
13,951
9,866
2,370
9,041
5,877
7,549
868
18,758
4,275
3,060
5,417
6,006
24,766
3,321
1,566
883
18,996
13,874
4,027
3,261
653
738
1,595
2,182
1,310
108
26,255
1,083
18,731
360
2,581
3,500
262,900
7,651
954
592
4,230
605
984
286
31,723
4,653
6,271
10,909
9,890
43,322
12,420
5,823
10,355
10,192
4,532
14,628
2,126
1,945
3,318
4,960
1,155
429
695
54,659
850
1,111
14,406
8,746
4,702
9,718
6,838
7,403
885
17,890
5,297
2,066
4,656
5,871
33,034
3,022
3,943
2,372
23,697
17,631
5,269
4,926
733
663
2,162
2,124
1,341
413
42,362
1,215
32,971
1,182
2,494
4,500
6
109
16
26
348
27
1,009
147
1,075
146
Previous 52 weeks
Cryptosporidiosis
Med
Max
Cum
2012
Cum
2011
Current
week
12
N
N
N
N
N
N
N
N
N
N
N
N
N
1
N
N
1
N
N
N
N
N
N
N
N
N
N
4
N
N
N
4
7
N
7
N
N
N
404
0
0
0
0
0
0
0
0
0
0
0
0
1
0
0
1
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
307
303
0
0
0
2
1
0
0
93
0
93
0
0
0
588
1
0
0
0
1
0
0
0
0
0
0
0
5
0
0
3
2
0
2
0
0
0
0
2
0
0
2
0
0
0
0
2
0
0
0
0
0
0
0
0
0
1
0
1
0
0
460
457
0
0
0
5
4
4
2
172
0
172
0
0
0
2,618
N
N
N
N
N
N
N
10
N
N
6
4
N
N
N
N
N
1
N
N
1
N
N
N
N
N
N
N
N
N
N
2,183
2,151
N
N
N
23
2
5
2
424
N
424
N
N
N
4,316
N
N
N
N
N
N
N
8
N
N
4
4
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
2
N
2
N
N
3,344
3,296
N
N
N
18
19
8
3
962
N
962
N
N
N
0
0
0
0
0
0
Previous 52 weeks
Med
Max
Cum
2012
Cum
2011
51
1
1
2
2
14
13
1
4
3
1
11
7
1
2
5
1
4
5
3
2
2
1
3
134
6
1
1
2
1
0
1
15
1
4
1
9
33
3
3
7
11
8
15
5
0
0
5
2
0
2
22
0
0
8
5
1
0
2
2
0
8
2
2
1
2
9
0
1
2
6
10
1
2
1
1
0
2
1
0
9
0
6
0
2
1
399
22
9
4
8
5
1
5
44
4
16
6
27
148
26
14
14
95
65
85
19
11
0
61
12
12
13
61
4
1
17
12
7
46
6
8
5
25
7
17
4
6
44
2
9
6
40
29
4
11
9
6
2
9
5
3
23
3
16
1
8
17
792
36
5
4
15
5
7
79
1
15
14
49
197
13
12
44
91
37
68
22
4
22
9
11
181
6
83
36
22
16
17
1
51
21
4
8
18
64
3
13
13
35
56
2
5
12
13
2
16
3
3
60
48
2
4
6
957
50
10
7
23
6
1
3
128
9
30
14
75
206
22
31
41
62
50
105
45
27
24
9
206
2
3
82
48
14
21
23
13
33
16
8
3
6
50
2
6
9
33
93
4
27
9
8
2
26
8
9
86
3
43
30
10
0
0
0
0
0
0
C.N.M.I.: Commonwealth of Northern Mariana Islands.

U: Unavailable. : No reported cases. N: Not reportable. NN: Not Nationally Notifiable. Cum: Cumulative year-to-date counts. Med: Median. Max: Maximum.
nndss/phs/files/ProvisionalNationa%20NotifiableDiseasesSurveillanceData20100927.pdf. Data for TB are displayed in Table IV, which appears quarterly.
ND-130
TABLE II. (Continued) Provisional cases of selected notifiable diseases, United States, weeks ending March 10, 2012, and March 12, 2011 (10th week)*
Dengue Virus Infection
Dengue Fever
Reporting area
Current
week
Previous 52 weeks
Med
Max
Dengue Hemorrhagic Fever

Cum
2012
Cum
2011
Current
week
Previous 52 weeks
Med
Max
Cum
2012
Cum
2011
United States
New England
Connecticut
Maine
Massachusetts
New Hampshire
Rhode Island
Vermont
Mid. Atlantic
New Jersey
New York (Upstate)
New York City
Pennsylvania
E.N. Central
Illinois
Indiana
Michigan
Ohio
Wisconsin
W.N. Central
Iowa
Kansas
Minnesota
Missouri
Nebraska
North Dakota
South Dakota
S. Atlantic
Delaware
Florida
Georgia
Maryland
North Carolina
South Carolina
Virginia
West Virginia
E.S. Central
Alabama
Kentucky
Mississippi
Tennessee
W.S. Central
Arkansas
Louisiana
Oklahoma
Texas
Mountain
Arizona
Colorado
Idaho
Montana
Nevada
New Mexico
Utah
Wyoming
Pacific
Alaska
California
Hawaii
Oregon
Washington
2
0
0
0
0
0
0
0
1
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
1
0
0
1
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
17
1
0
0
0
0
0
1
6
0
2
4
2
2
1
1
2
1
1
2
1
1
1
0
0
1
0
9
2
0
7
1
2
1
1
1
0
3
1
1
0
2
2
0
1
0
1
1
1
0
0
0
1
1
1
0
4
0
2
1
0
1
44
2
1
1
13
1
7
5
5
1
1
1
2
1
5
1
1
1
2
1
11
3
5
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
1
0
0
0
0
0
0
0
0
0
0
0
0
1
1
0
0
0
0
0
0
0
0
0
0
0
0
1
0
0
0
0
0
0
0
1
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Territories
American Samoa
C.N.M.I.
Guam
Puerto Rico
U.S. Virgin Islands
0
9
0
0
83
0
179
0
0
0
0
3
0

Dengue Fever includes cases that meet criteria for Dengue Fever with hemorrhage, other clinical and unknown case classifications.
DHF includes cases that meet criteria for dengue shock syndrome (DSS), a more severe form of DHF.
ND-131
Ehrlichiosis/Anaplasmosis
Anaplasma phagocytophilum
Ehrlichia chaffeensis
Reporting area
United States
New England
Connecticut
Maine
Massachusetts
New Hampshire
Rhode Island
Vermont
Current Previous 52 weeks

week
Med
Max
Cum
2012
Cum
2011
Current
week
Previous 52 weeks
Med
Max
Cum
2012
Undetermined
Cum
2011
Current
week
Previous 52 weeks
Med
Max
Cum
2012
Cum
2011
Pacific
Alaska
California
Hawaii
Oregon
Washington
N
N
N
N
N
9
0
0
0
0
0
0
0
1
0
0
0
0
0
0
0
0
0
0
1
0
0
0
1
0
0
0
4
0
0
0
0
0
0
0
1
0
1
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
90
1
0
1
0
1
1
0
5
0
4
2
0
5
4
0
2
1
0
16
0
2
0
16
1
0
1
33
2
0
3
3
3
17
1
13
1
8
2
3
1
5
30
13
0
25
1
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
16
1
1
N
12
N
2
6
1
1
N
N
N
N
N
12
2
1
1
N
8
1
N
1
1
3
2
N
N
N
N
N
N
N
N
N
N
16
3
0
0
1
0
0
0
6
0
3
1
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
1
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
58
28
0
3
18
5
15
1
43
0
43
5
1
2
2
0
0
1
1
6
0
1
1
5
1
0
1
8
1
0
3
2
2
6
0
3
0
2
1
0
1
1
3
3
0
1
2
0
0
0
0
0
0
0
0
0
1
0
0
0
1
0
21
4
13
10
3
1
1
1
1
N
N
N
N
N
23
15
1
1
13
2
1
1
2
1
1
N
N
N
N
N
N
N
N
N
N
2
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
8
1
0
0
0
1
1
0
2
0
2
0
0
6
1
4
2
1
1
6
0
1
0
6
1
0
0
2
0
0
0
1
1
0
1
1
1
3
0
0
0
3
0
0
0
0
0
1
1
0
0
0
0
0
1
0
2
0
2
0
0
0
1
1
N
N
N
N
N
1
N
1
N
2
1
1
N
N
N
N
N
Territories
American Samoa
C.N.M.I.
Guam
Puerto Rico
U.S. Virgin Islands
N
N
0
0
0
0
0
0
N
N
N
N
N
N
0
0
0
0
0
0
N
N
N
N
N
N
0
0
0
0
0
0
N
N
N
N
Mid. Atlantic
New Jersey
New York (Upstate)
New York City
Pennsylvania
E.N. Central
Illinois
Indiana
Michigan
Ohio
Wisconsin
W.N. Central
Iowa
Kansas
Minnesota
Missouri
Nebraska
North Dakota
South Dakota
S. Atlantic
Delaware
Florida
Georgia
Maryland
North Carolina
South Carolina
Virginia
West Virginia
E.S. Central
Alabama
Kentucky
Mississippi
Tennessee
W.S. Central
Arkansas
Louisiana
Oklahoma
Texas
Mountain
Arizona
Colorado
Idaho
Montana
Nevada
New Mexico
Utah
Wyoming

Cumulative total E. ewingii cases reported for year 2011 = 13, and 0 case reports for 2012.
ND-132
Giardiasis
Reporting area
United States
New England
Connecticut
Maine
Massachusetts
New Hampshire
Rhode Island
Vermont
Mid. Atlantic
New Jersey
New York (Upstate)
New York City
Pennsylvania
E.N. Central
Illinois
Indiana
Michigan
Ohio
Wisconsin
W.N. Central
Iowa
Kansas
Minnesota
Missouri
Nebraska
North Dakota
South Dakota
S. Atlantic
Delaware
Florida
Georgia
Maryland
North Carolina
South Carolina
Virginia
West Virginia
E.S. Central
Alabama
Kentucky
Mississippi
Tennessee
W.S. Central
Arkansas
Louisiana
Oklahoma
Texas
Mountain
Arizona
Colorado
Idaho
Montana
Nevada
New Mexico
Utah
Wyoming
Pacific
Alaska
California
Hawaii
Oregon
Washington
Territories
American Samoa
C.N.M.I.
Guam
Puerto Rico
U.S. Virgin Islands
Haemophilus influenzae, invasive

All ages, all serotypes
Gonorrhea
Current Previous 52 weeks Cum

week
Med Max
2012
Cum
2011

week
Med
Max
Cum
2012
Cum
2011
Current
week
Previous 52 weeks
Med
Max
Cum
2012
Cum
2011
110
6
4
1
24
13
4
7
17
1
4
12
10
5
2
3
27
10
2
6
N
5
4
2
2
N
N
N
1
1
N
4
19
13
2
4
276
26
4
3
12
2
0
3
55
0
20
18
15
51
11
5
11
16
8
18
4
2
0
6
3
0
1
53
0
1
23
13
6
0
2
5
0
3
3
0
0
0
5
3
2
0
0
22
2
7
3
2
1
1
3
0
47
2
32
0
6
6
453
64
10
10
29
8
10
19
91
14
50
30
30
92
20
13
22
30
21
50
15
9
0
17
11
12
8
116
3
5
69
51
15
0
8
17
8
8
8
0
0
0
15
8
10
0
0
41
6
23
9
5
4
6
9
2
187
7
52
4
20
150
1,897
113
24
15
47
7
9
11
370
126
147
97
343
51
25
98
124
45
139
39
13
51
27
9
420
3
2
166
140
51
N
23
35
30
30
N
N
N
42
15
27
N
105
11
39
15
8
10
6
10
6
335
12
226
2
53
42
2,594
249
50
17
125
15
12
30
560
69
159
178
154
458
104
61
95
128
70
174
43
20
59
37
15
459
6
9
225
89
57
N
19
54
24
24
N
N
N
36
14
22
N
201
25
55
33
7
20
15
37
9
433
11
294
5
84
39
2,519
63
10
40
1
7
5
414
41
165
62
146
310
9
46
157
61
37
9
9
1,027
13
239
157
56
225
195
142
299
67
145
87
129
100
29
32
1
28
3
236
6
181
49
6,013
107
43
5
47
2
7
0
736
147
117
236
271
1,084
310
135
236
313
92
313
36
42
44
149
26
5
11
1,500
15
38
374
322
119
318
152
127
14
531
168
81
116
151
865
87
103
30
591
208
90
40
2
1
37
35
6
0
637
18
520
12
27
50
6,817
178
91
18
80
8
35
6
1,019
217
400
315
492
1,292
409
172
375
403
118
383
110
65
62
204
52
14
20
1,956
35
105
473
456
185
548
421
353
29
789
408
151
242
256
1,173
138
255
196
828
324
128
77
15
5
57
73
10
3
758
31
621
24
60
79
47,882
609
69
403
21
102
14
6,891
1,225
1,136
1,643
2,887
7,694
1,519
1,095
2,085
2,168
827
665
361
35
195
74
13,326
157
427
3,435
2,681
646
2,760
1,625
1,479
116
4,984
1,177
727
1,497
1,583
6,375
914
453
225
4,783
1,759
770
374
3
20
239
294
55
4
5,579
127
4,809
34
212
397
59,008
1,089
542
33
420
23
66
5
7,101
1,233
935
2,431
2,502
11,362
3,139
1,519
2,676
3,192
836
2,857
375
367
403
1,338
218
42
114
14,581
200
418
3,632
2,642
1,192
3,298
1,880
1,142
177
4,774
1,586
547
1,228
1,413
8,627
909
1,136
770
5,812
2,065
705
491
28
15
455
310
45
16
6,552
180
5,431
138
237
566
21
1
1
3
1
6
2
1
66
4
1
0
2
0
0
0
16
2
3
4
5
11
3
2
1
4
1
2
0
0
0
1
0
0
0
15
0
0
4
2
2
1
1
2
0
4
1
1
0
2
2
0
1
1
0
5
1
1
0
0
0
1
0
0
4
0
1
0
1
0
114
9
5
2
7
2
2
2
31
6
16
9
15
22
11
6
5
7
5
9
1
2
0
5
2
6
1
31
2
1
12
6
6
7
5
8
5
12
3
4
3
8
10
3
4
9
1
10
5
3
2
1
2
3
3
1
9
3
5
3
6
1
597
39
13
7
16
2
1
137
6
35
44
52
72
2
13
12
38
7
23
15
5
163
44
25
21
20
23
20
10
47
11
13
6
17
35
6
11
18
50
15
4
4
2
5
13
6
1
31
2
9
5
15
689
46
11
5
23
3
3
1
130
27
23
26
54
121
37
15
18
36
15
22
11
9
171
1
54
40
18
19
15
24
37
12
8
3
14
39
7
20
12
78
34
18
3
2
4
12
5
45
6
14
6
19
0
1
0
0
8
0
19
0
6
2
0
14
10
38
6
69
29
0
0
0
0
0
0

Data for H. influenzae (age <5 yrs for serotype b, nonserotype b, and unknown serotype) are available in Table I.
ND-133
Hepatitis (viral, acute), by type
A
Reporting area
United States
New England
Connecticut
Maine
Massachusetts
New Hampshire
Rhode Island
Vermont

week
Med
Max
B
Cum
2012
Cum
2011
Current
week
Previous 52 weeks
Med
Max
Cum
2012
Cum
2011
Current
week
Previous 52 weeks
Med
Max
Cum
2012
Cum
2011
Pacific
Alaska
California
Hawaii
Oregon
Washington
14
1
1
1
23
1
0
0
0
0
0
0
4
1
1
1
1
4
1
0
1
0
0
1
0
0
0
0
0
0
0
4
0
0
1
1
0
0
0
0
0
1
0
0
0
0
3
0
0
0
3
1
0
0
0
0
0
0
0
0
3
0
3
0
0
0
43
5
3
2
3
0
1
2
8
3
4
4
5
7
5
1
6
2
1
7
1
1
7
3
1
0
0
11
1
0
8
5
4
3
2
3
2
6
2
2
1
5
7
2
2
2
7
5
2
2
1
0
3
1
1
1
12
1
9
2
2
4
188
3
3
34
1
13
9
11
25
6
2
14
1
2
12
7
4
39
1
18
6
4
4
1
4
1
4
2
2
29
2
27
18
6
4
4
3
1
24
14
2
2
6
232
15
5
1
5
2
2
45
7
6
17
15
44
9
7
14
12
2
10
1
1
4
2
2
44
1
16
13
3
4
2
5
2
1
2
14
13
16
4
6
1
3
1
39
33
1
1
4
33
2
5
1
1
11
7
2
3
2
2
2
49
1
0
0
0
0
0
0
5
1
1
1
2
6
1
1
1
1
1
2
0
0
0
1
0
0
0
13
0
0
4
2
1
1
1
1
0
10
2
3
1
4
6
1
0
1
3
1
0
0
0
0
0
0
0
0
3
0
2
0
0
0
104
8
2
2
6
1
0
0
11
4
4
5
4
37
3
4
6
30
3
9
1
2
7
4
2
0
0
57
2
0
7
7
5
8
3
6
43
21
6
10
4
10
15
4
2
9
12
4
3
2
0
0
3
2
1
0
9
1
6
1
4
4
412
3
1
2
41
14
8
9
10
54
1
6
11
32
4
19
1
16
2
130
3
43
20
15
11
8
11
19
90
12
30
7
41
43
7
6
6
24
11
1
10
21
10
2
5
4
536
21
5
1
14
1
U
58
11
10
20
17
85
20
12
23
24
6
19
2
3
9
4
1
131
37
29
11
27
8
19
93
17
32
7
37
55
9
13
12
21
27
6
6
2
8
2
3
47
1
35
2
7
2
17
N
U
4
U
U
4
1
1
2
U
21
1
0
0
0
0
0
0
2
0
1
0
1
3
0
0
2
0
0
0
0
0
0
0
0
0
0
5
0
0
1
1
1
1
0
0
0
4
0
2
0
2
1
0
0
1
0
1
0
0
0
0
0
0
0
0
2
0
1
0
0
0
42
5
4
3
2
0
0
1
5
2
4
1
4
8
2
5
5
1
1
4
0
1
2
0
1
0
0
14
0
0
5
3
3
7
1
3
7
10
3
8
0
5
5
0
1
4
4
5
0
2
1
3
2
2
2
1
10
0
5
0
2
9
175
3
3
N
U
24
2
9
13
23
1
4
17
1
51
U
22
3
4
8
4
10
36
2
14
U
20
8
1
7
10
U
18
U
8
U
7
3
173
17
12
3
1
N
U
1
14
7
2
5
30
1
21
7
36
U
8
10
4
10
33
1
17
U
15
16
4
7
5
15
U
4
5
1
1
2
2
12
U
6
U
4
2
Territories
American Samoa
C.N.M.I.
Guam
Puerto Rico
U.S. Virgin Islands
0
0
0
2
3
0
6
2
1
0
0
3
3
0
22
4
0
0
0
1
0
0
9
N
Mid. Atlantic
New Jersey
New York (Upstate)
New York City
Pennsylvania
E.N. Central
Illinois
Indiana
Michigan
Ohio
Wisconsin
W.N. Central
Iowa
Kansas
Minnesota
Missouri
Nebraska
North Dakota
South Dakota
S. Atlantic
Delaware
Florida
Georgia
Maryland
North Carolina
South Carolina
Virginia
West Virginia
E.S. Central
Alabama
Kentucky
Mississippi
Tennessee
W.S. Central
Arkansas
Louisiana
Oklahoma
Texas
Mountain
Arizona
Colorado
Idaho
Montana
Nevada
New Mexico
Utah
Wyoming

ND-134
Legionellosis
Reporting area
United States
New England
Connecticut
Maine
Massachusetts
New Hampshire
Rhode Island
Vermont

week
Med
Max
Lyme disease
Cum
2012
Cum
2011
Current
week
Previous 52 weeks
Malaria
Med
Max
Cum
2012
Cum
2011
Current
week
Previous 52 weeks
Med
Max
Cum
2012
Cum
2011
Pacific
Alaska
California
Hawaii
Oregon
Washington
23
3
5
72
4
1
0
3
0
0
0
18
2
6
3
5
14
2
2
2
7
0
1
0
0
0
1
0
0
0
11
0
0
4
1
2
1
0
1
0
2
0
1
0
1
3
0
0
0
2
2
1
0
0
0
0
0
0
0
5
0
4
0
0
0
183
40
11
3
24
3
9
2
92
16
27
17
43
51
11
8
15
34
1
8
2
2
0
5
2
1
1
30
4
3
13
4
15
7
5
8
5
11
2
4
3
8
8
2
2
3
7
9
4
4
1
1
2
2
2
2
17
0
11
2
3
13
328
14
5
1
4
87
4
27
20
36
69
8
12
9
40
73
4
1
35
6
11
5
4
7
8
2
2
4
17
16
12
4
1
1
2
1
42
35
392
29
5
2
16
2
2
2
101
25
28
22
26
78
10
14
16
38
7
1
1
1
53
1
27
4
8
7
1
5
14
3
4
2
5
18
1
7
1
9
22
6
7
1
1
1
5
1
70
63
1
1
5
125
110
63
22
25
15
2
1
551
85
38
12
10
10
1
6
352
159
57
10
116
28
1
1
1
1
25
1
0
0
0
0
0
0
0
66
13
0
3
0
20
0
0
18
0
1
0
0
0
0
1
0
0
0
1
1
0
0
0
0
0
0
0
0
3
0
1
0
0
0
2,210
506
236
67
106
90
31
70
1,235
543
220
42
536
351
21
12
13
6
309
16
13
2
0
2
2
9
2
180
48
3
8
5
115
13
6
75
20
5
2
1
1
4
6
0
1
0
6
5
4
1
2
3
1
2
1
1
8
3
7
0
2
5
2,001
150
49
43
16
14
6
22
1,534
855
150
2
527
24
1
3
3
6
11
3
1
270
68
1
23
5
106
1
3
55
8
1
1
6
1
1
1
11
1
10
N
2,001
509
198
40
175
71
6
19
1,039
367
83
92
497
127
6
1
3
117
2
1
304
82
3
10
1
116
6
1
82
3
4
3
1
5
5
3
1
1
1
3
N
5
28
1
0
0
0
0
0
0
6
0
1
4
1
3
1
0
0
0
0
1
0
0
0
0
0
0
0
9
0
0
2
1
2
0
0
1
0
1
0
0
0
0
1
0
0
0
1
1
0
0
0
0
0
0
0
0
3
0
2
0
0
0
56
7
2
2
6
1
2
1
12
2
4
11
5
10
5
2
4
4
2
5
3
2
0
2
1
0
1
27
3
2
6
6
17
7
1
8
1
4
3
2
1
3
11
1
1
3
9
5
4
3
1
1
2
1
1
0
11
1
7
1
4
2
133
6
1
20
2
14
4
15
2
3
2
7
1
7
1
3
52
1
16
6
15
1
3
10
4
2
7
1
20
1
18
219
15
1
11
1
2
54
6
7
33
8
22
8
2
3
8
1
5
3
1
74
3
16
11
21
8
15
3
1
1
1
7
1
6
13
3
5
3
2
26
2
18
4
2
Territories
American Samoa
C.N.M.I.
Guam
Puerto Rico
U.S. Virgin Islands
0
0
0
0
2
0
0
0
0
0
0
0
0
0
0
0
1
0
Mid. Atlantic
New Jersey
New York (Upstate)
New York City
Pennsylvania
E.N. Central
Illinois
Indiana
Michigan
Ohio
Wisconsin
W.N. Central
Iowa
Kansas
Minnesota
Missouri
Nebraska
North Dakota
South Dakota
S. Atlantic
Delaware
Florida
Georgia
Maryland
North Carolina
South Carolina
Virginia
West Virginia
E.S. Central
Alabama
Kentucky
Mississippi
Tennessee
W.S. Central
Arkansas
Louisiana
Oklahoma
Texas
Mountain
Arizona
Colorado
Idaho
Montana
Nevada
New Mexico
Utah
Wyoming

ND-135
Meningococcal disease, invasive
All serogroups
Reporting area
United States
New England
Connecticut
Maine
Massachusetts
New Hampshire
Rhode Island
Vermont

week
Med
Max
Mumps
Cum
2012
Cum
2011
Current
week
Previous 52 weeks
Pertussis
Med
Max
Cum
2012
Cum
2011
Current
week
Previous 52 weeks
Med
Max
Cum
2012
Cum
2011
Pacific
Alaska
California
Hawaii
Oregon
Washington
12
0
0
0
0
0
0
0
2
0
0
0
0
2
0
0
0
0
0
1
0
0
0
0
0
0
0
2
0
0
1
0
0
0
0
0
0
0
0
0
0
0
1
0
0
0
0
1
0
0
0
0
0
0
0
0
2
0
2
0
0
0
27
3
1
1
2
1
1
3
5
2
3
2
2
6
3
2
2
2
2
3
1
1
0
2
2
1
1
8
1
1
5
1
2
2
1
2
3
3
2
2
1
1
5
2
2
2
2
4
1
1
1
2
1
1
1
0
11
1
8
1
4
3
97
1
16
2
4
4
6
9
1
2
5
1
6
4
1
16
11
1
3
1
1
1
1
6
7
1
1
2
2
1
33
22
2
8
1
182
7
1
1
5
24
2
7
8
7
24
9
3
3
6
3
13
4
1
4
3
1
26
8
2
2
7
3
4
9
5
1
3
17
4
3
2
8
14
4
3
3
48
1
34
2
8
3
6
0
0
0
0
0
0
0
0
0
0
0
0
1
1
0
0
0
0
0
0
0
0
0
0
0
0
1
0
0
0
0
0
0
0
0
0
0
0
0
0
0
1
0
0
0
1
0
0
0
0
0
0
0
0
0
1
0
0
0
0
0
21
2
0
2
1
0
2
1
7
1
3
6
1
12
10
2
2
2
1
3
2
1
1
2
1
3
0
4
0
1
2
2
1
2
1
4
1
1
1
0
1
1
4
2
0
2
4
2
0
1
2
1
0
1
1
1
11
1
11
1
1
1
28
1
2
2
1
1
1
6
3
75
1
8
7
1
16
8
1
6
1
6
3
1
3
1
33
33
1
2
3
191
1
57
41
16
23
2
19
2
3
10
1
1
3
1
2
17
17
77
1
1
1
2
72
320
17
1
3
4
2
0
1
47
4
19
4
13
72
21
4
10
12
17
22
4
2
0
8
1
0
0
27
0
0
6
2
2
3
2
7
0
9
2
3
1
2
19
1
0
0
18
40
14
7
3
1
0
4
7
0
57
0
31
2
5
13
867
33
7
19
10
13
10
18
189
12
142
42
32
220
123
21
38
22
91
119
10
8
110
33
5
16
7
55
5
2
17
7
10
20
9
25
15
19
11
10
4
7
116
8
3
11
108
91
63
25
12
32
5
24
17
3
273
3
68
10
23
219
3,296
166
5
25
24
11
17
84
713
29
374
67
243
909
129
20
116
136
508
233
45
35
127
7
16
3
243
8
1
82
11
33
13
13
60
22
95
19
38
14
24
138
3
2
133
349
159
60
18
22
10
23
54
3
450
14
56
41
41
298
3,398
103
15
28
42
9
8
1
315
32
87
196
786
146
70
227
246
97
169
45
24
72
23
3
2
347
6
1
64
54
32
71
40
79
101
26
44
5
26
157
8
8
3
138
518
211
113
25
44
7
36
80
2
902
13
776
8
48
57
Territories
American Samoa
C.N.M.I.
Guam
Puerto Rico
U.S. Virgin Islands
0
0
0
0
0
0
1
0
0
3
2
0
2
0
0
4
2
0
24
1
Mid. Atlantic
New Jersey
New York (Upstate)
New York City
Pennsylvania
E.N. Central
Illinois
Indiana
Michigan
Ohio
Wisconsin
W.N. Central
Iowa
Kansas
Minnesota
Missouri
Nebraska
North Dakota
South Dakota
S. Atlantic
Delaware
Florida
Georgia
Maryland
North Carolina
South Carolina
Virginia
West Virginia
E.S. Central
Alabama
Kentucky
Mississippi
Tennessee
W.S. Central
Arkansas
Louisiana
Oklahoma
Texas
Mountain
Arizona
Colorado
Idaho
Montana
Nevada
New Mexico
Utah
Wyoming

Data for meningococcal disease, invasive caused by serogroups A, C, Y, and W-135; serogroup B; other serogroup; and unknown serogroup are available in Table I.
ND-136
Rabies, animal
Reporting area
United States
New England
Connecticut
Maine
Massachusetts
New Hampshire
Rhode Island
Vermont

week
Med
Max
Shiga toxin-producing E. coli (STEC)
Salmonellosis
Cum
2012
Cum
2011
Current
week
Previous 52 weeks
Med
Max
Cum
2012
Cum
2011
Current
week
Previous 52 weeks
Med
Max
Cum
2012
Cum
2011
Pacific
Alaska
California
Hawaii
Oregon
Washington
28
3
1
1
7
11
N
10
1
2
1
1
4
1
N
80
6
3
1
0
0
0
0
15
0
7
0
8
2
0
0
1
1
0
1
0
0
0
0
0
0
0
19
0
0
0
0
7
0
0
11
0
3
2
0
0
1
22
0
0
0
19
1
0
0
0
0
0
0
0
0
4
0
4
0
0
0
123
16
10
6
0
3
6
3
36
0
20
3
21
20
6
7
6
5
0
8
0
4
0
4
3
4
0
48
0
0
13
0
13
0
0
27
30
11
7
2
1
4
55
10
0
21
44
4
0
0
1
0
3
4
2
0
14
2
13
0
2
0
436
65
28
18
7
6
6
84
40
44
3
2
1
N
17
146
21
41
N
76
8
14
11
3
78
14
7
57
18
N
18
11
3
8
550
19
4
4
2
2
7
124
41
2
81
8
4
3
1
N
7
249
120
45
N
84
25
14
1
10
99
4
3
92
19
9
6
241
4
2
1
1
31
25
6
7
3
4
6
1
3
2
105
58
5
17
17
1
7
11
1
4
6
38
1
10
27
1
38
1
20
4
13
900
37
8
2
19
3
1
1
96
21
25
19
31
89
27
8
15
20
12
39
8
8
0
15
4
0
3
276
2
1
107
43
19
34
27
20
0
64
18
11
22
15
135
13
14
13
94
46
14
9
2
2
3
6
6
1
94
1
70
6
6
10
1,917
107
30
7
44
8
62
8
209
48
67
44
114
185
80
27
42
46
46
99
19
27
0
42
13
15
10
741
12
6
203
139
46
251
71
54
18
190
70
30
66
51
257
52
44
31
165
93
35
23
8
10
7
22
15
9
173
6
141
14
12
44
4,075
121
36
10
46
9
7
13
440
58
132
116
134
355
109
25
82
107
32
206
40
54
82
20
10
1,403
11
608
167
123
269
110
107
8
275
70
45
74
86
512
32
79
60
341
217
88
34
10
13
14
27
26
5
546
12
396
22
43
73
4,787
225
67
20
104
19
8
7
515
108
97
139
171
556
196
55
93
138
74
233
64
40
90
22
17
1,335
18
6
510
256
99
207
108
131
330
101
60
66
103
505
59
76
46
324
370
125
85
34
7
27
41
44
7
718
10
559
62
51
36
21
1
4
94
3
1
0
1
0
0
0
10
2
3
2
3
16
4
2
3
3
3
11
2
2
0
5
1
0
1
12
0
0
3
2
1
2
0
2
0
4
1
1
0
1
10
1
0
1
7
11
2
3
1
1
1
1
1
0
9
0
5
0
2
2
209
13
4
3
9
3
2
3
34
7
13
6
16
54
14
10
19
9
21
40
15
8
0
32
7
4
4
32
2
1
9
8
4
26
4
8
2
18
15
5
4
11
66
6
1
10
66
27
6
9
8
4
7
3
7
7
28
1
14
2
11
22
359
11
6
44
2
13
10
19
61
9
4
33
15
48
7
5
23
8
5
80
2
1
34
6
7
16
4
10
25
10
5
5
5
26
3
6
17
26
5
4
3
1
4
4
2
3
38
14
11
13
427
17
7
1
2
6
1
68
22
14
10
22
91
17
15
19
21
19
34
9
7
9
8
1
75
2
1
14
14
11
18
4
11
23
2
7
4
10
35
2
2
4
27
51
11
17
6
3
3
5
6
33
19
7
7
Territories
American Samoa
C.N.M.I.
Guam
Puerto Rico
U.S. Virgin Islands
0
1
0
0
6
0
13
0
7
0
2
21
0
4
68
0
0
0
0
0
0
Mid. Atlantic
New Jersey
New York (Upstate)
New York City
Pennsylvania
E.N. Central
Illinois
Indiana
Michigan
Ohio
Wisconsin
W.N. Central
Iowa
Kansas
Minnesota
Missouri
Nebraska
North Dakota
South Dakota
S. Atlantic
Delaware
Florida
Georgia
Maryland
North Carolina
South Carolina
Virginia
West Virginia
E.S. Central
Alabama
Kentucky
Mississippi
Tennessee
W.S. Central
Arkansas
Louisiana
Oklahoma
Texas
Mountain
Arizona
Colorado
Idaho
Montana
Nevada
New Mexico
Utah
Wyoming

Includes E. coli O157:H7; Shiga toxin-positive, serogroup non-O157; and Shiga toxin-positive, not serogrouped.
ND-137
Spotted Fever Rickettsiosis (including RMSF)
Shigellosis
Reporting area
Current
week
Previous 52 weeks
Med
Max
Confirmed
Cum
2012
Cum
2011
Current
week
Previous 52 weeks
Med
Max
Probable
Cum
2012
Cum
2011
Current
week
Previous 52 weeks
Med
Max
Cum
2012
Cum
2011
United States
New England
Connecticut
Maine
Massachusetts
New Hampshire
Rhode Island
Vermont
Mid. Atlantic
New Jersey
New York (Upstate)
New York City
Pennsylvania
E.N. Central
Illinois
Indiana
Michigan
Ohio
Wisconsin
W.N. Central
Iowa
Kansas
Minnesota
Missouri
Nebraska
North Dakota
South Dakota
S. Atlantic
Delaware
Florida
Georgia
Maryland
North Carolina
South Carolina
Virginia
West Virginia
E.S. Central
Alabama
Kentucky
Mississippi
Tennessee
W.S. Central
Arkansas
Louisiana
Oklahoma
Texas
Mountain
Arizona
Colorado
Idaho
Montana
Nevada
New Mexico
Utah
Wyoming
Pacific
Alaska
California
Hawaii
Oregon
Washington
81
2
7
1
6
29
19
6
4
8
3
5
19
2
4
13
10
261
4
1
0
3
0
0
0
29
7
7
8
2
16
4
1
4
6
0
5
0
1
0
3
0
0
0
75
0
0
49
13
2
3
1
2
0
21
5
6
5
4
54
2
4
4
43
12
6
1
0
1
0
2
1
0
18
0
13
0
1
1
381
21
4
8
20
1
3
1
88
39
41
29
13
41
16
6
11
27
0
18
3
8
0
14
2
0
2
134
2
5
98
26
10
19
54
7
2
51
21
22
24
11
142
7
21
28
112
41
27
8
3
15
4
6
4
1
44
2
41
3
4
11
1,699
13
5
289
71
102
100
16
205
13
5
40
147
53
5
28
17
3
401
1
236
103
30
16
3
12
265
59
120
58
28
312
12
27
75
198
42
27
2
2
3
1
6
1
119
3
98
1
10
7
1,546
31
6
1
22
2
113
23
21
48
21
124
43
11
26
44
82
4
20
55
2
1
521
5
323
86
20
58
12
17
94
41
10
17
26
235
4
28
17
186
135
41
17
5
25
6
35
6
211
1
176
17
9
8
3
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
2
0
0
0
1
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
13
1
0
0
0
1
0
0
2
0
1
0
2
2
1
1
1
2
0
4
0
0
0
2
3
1
1
8
1
1
1
8
1
4
2
1
0
2
1
1
0
2
3
3
0
1
1
3
3
0
0
0
0
0
0
0
2
0
2
0
0
0
19
4
1
12
11
2
N
2
N
11
2
1
1
1
6
6
3
1
31
0
0
0
0
0
0
0
1
0
0
0
0
2
1
1
0
0
0
4
0
0
0
4
0
0
0
7
0
0
0
0
0
0
0
4
0
4
1
0
0
4
3
2
0
0
0
1
0
0
0
0
0
0
0
0
0
0
0
0
0
0
137
1
0
1
1
1
1
0
7
0
3
3
3
10
4
5
1
2
0
24
2
0
0
22
1
0
0
57
4
1
2
0
3
49
2
14
1
25
8
2
2
20
52
52
2
25
4
7
6
1
2
1
1
0
1
2
1
0
1
0
0
0
88
10
1
2
7
6
3
1
33
4
4
5
1
14
15
5
1
9
8
5
1
2
7
3
2
N
2
N
55
1
2
1
4
3
8
1
18
1
1
9
1
5
9
3
2
4
1
1
11
11
Territories
American Samoa
C.N.M.I.
Guam
Puerto Rico
U.S. Virgin Islands
0
0
0
0
1
0
N
N
0
0
0
0
0
0
N
N
N
N
N
N
0
0
0
0
0
0
N
N
N
N

Illnesses with similar clinical presentation that result from Spotted fever group rickettsia infections are reported as Spotted fever rickettsioses. Rocky Mountain spotted fever (RMSF) caused
by Rickettsia rickettsii, is the most common and well-known spotted fever.
ND-138
Streptococcus pneumoniae, invasive disease
All ages
Reporting area
United States
New England
Connecticut
Maine
Massachusetts
New Hampshire
Rhode Island
Vermont
Mid. Atlantic
New Jersey
New York (Upstate)
New York City
Pennsylvania
E.N. Central
Illinois
Indiana
Michigan
Ohio
Wisconsin
W.N. Central
Iowa
Kansas
Minnesota
Missouri
Nebraska
North Dakota
South Dakota
S. Atlantic
Delaware
Florida
Georgia
Maryland
North Carolina
South Carolina
Virginia
West Virginia
E.S. Central
Alabama
Kentucky
Mississippi
Tennessee
W.S. Central
Arkansas
Louisiana
Oklahoma
Texas
Mountain
Arizona
Colorado
Idaho
Montana
Nevada
New Mexico
Utah
Wyoming
Pacific
Alaska
California
Hawaii
Oregon
Washington
Territories
American Samoa
C.N.M.I.
Guam
Puerto Rico
U.S. Virgin Islands

week
Med
Max
Age <5
Cum
2012
Cum
2011
Current
week
Previous 52 weeks
Syphilis, primary and secondary
Med
Max
Cum
2012
Cum
2011
Current
week
Previous 52 weeks
Med
Max
Cum
2012
Cum
2011
255
4
3
34
29
5
N
53
N
4
46
3
2
N
N
N
2
N
87
2
29
19
18
N
16
N
3
22
N
2
N
20
48
4
N
44
3
N
N
N
2
1
2
1
N
1
N
N
264
13
6
2
0
1
1
1
31
12
2
12
0
63
0
14
13
27
9
3
0
0
0
0
2
0
0
65
1
0
21
19
9
0
8
0
2
23
0
4
0
19
32
4
2
0
25
25
12
8
0
0
0
4
1
0
2
2
0
0
0
0
526
31
20
8
3
6
5
6
68
26
37
25
0
122
0
36
26
42
23
28
0
0
0
0
8
25
0
143
5
5
48
35
25
0
22
0
48
45
0
12
0
42
154
14
14
0
140
69
33
22
0
0
0
13
7
3
9
9
0
1
0
0
3,023
124
54
23
5
14
11
17
470
104
245
121
N
649
N
101
130
320
98
41
N
N
N
41
N
816
12
1
277
250
94
N
128
N
54
244
N
50
N
194
380
47
39
N
294
276
176
44
N
N
N
51
5
23
22
N
1
N
N
4,086
216
100
28
7
35
36
10
441
218
17
206
N
808
N
213
159
330
106
38
N
N
N
38
N
1,145
21
16
464
313
175
N
156
N
354
N
64
N
290
477
64
77
N
336
564
281
134
N
N
N
85
57
7
43
42
N
1
N
N
16
N
2
N
N
1
2
5
N
N
N
1
1
N
N
N
21
1
0
0
0
0
0
0
2
0
1
0
0
3
0
1
1
1
0
0
0
0
0
0
0
0
0
5
0
0
2
1
1
0
0
0
0
2
0
0
0
1
3
0
0
0
3
2
1
0
0
0
0
0
0
0
0
0
0
0
0
0
43
4
3
1
2
1
1
2
11
4
10
9
0
10
0
4
2
7
2
2
0
0
0
0
2
1
0
15
0
1
8
6
3
0
3
0
4
4
0
3
0
4
10
3
2
0
10
8
3
4
0
0
0
2
1
0
2
2
0
1
0
0
202
6
2
1
2
1
23
8
11
4
N
36
3
8
16
9
3
N
N
60
1
20
21
8
N
4
6
12
N
1
11
34
5
3
26
20
12
4
N
N
4
8
8
N
N
N
249
8
2
1
3
1
1
22
12
10
N
43
12
10
16
5
2
N
N
74
2
37
20
10
N
5
19
N
5
14
40
8
5
27
39
18
5
N
N
7
9
2
2
N
N
N
64
4
2
1
1
1
4
3
1
30
2
10
6
4
4
4
1
1
2
2
2
1
11
269
7
0
0
5
0
0
0
29
3
3
14
7
31
12
3
4
7
1
5
0
0
2
2
0
0
0
68
0
3
24
13
8
8
4
4
0
15
4
2
3
5
37
4
7
1
23
12
5
2
0
0
2
1
0
0
57
0
46
0
4
5
307
23
12
2
10
3
7
2
48
11
12
24
17
49
24
8
12
17
6
13
3
4
8
8
2
1
0
86
4
9
36
47
20
21
11
13
2
31
10
8
22
11
51
15
25
6
38
20
11
6
4
1
9
4
2
0
76
2
64
3
14
12
1,840
67
4
45
5
13
200
8
26
86
80
135
52
29
15
35
4
5
4
542
7
33
198
98
52
72
41
41
90
16
18
25
31
323
52
17
13
241
57
20
13
3
11
7
3
421
3
358
28
32
2,523
74
13
2
45
4
8
2
319
36
29
184
70
333
141
36
57
88
11
80
4
4
34
35
3
594
4
36
228
66
78
86
52
44
131
42
19
25
45
305
31
49
9
216
119
44
24
4
4
25
14
4
568
449
1
41
77
0
0
0
0
0
0
0
0
0
0
0
0
0
5
0
0
15
0
33
41

Includes drug resistant and susceptible cases of invasive Streptococcus pneumoniae disease among children <5 years and among all ages. Case definition: Isolation of S. pneumoniae from
a normally sterile body site (e.g., blood or cerebrospinal fluid).
ND-139
West Nile virus disease
Varicella (chickenpox)
Reporting area
United States
New England
Connecticut
Maine
Massachusetts
New Hampshire
Rhode Island
Vermont
Mid. Atlantic
New Jersey
New York (Upstate)
New York City
Pennsylvania
E.N. Central
Illinois
Indiana
Michigan
Ohio
Wisconsin
W.N. Central
Iowa
Kansas
Minnesota
Missouri
Nebraska
North Dakota
South Dakota
S. Atlantic
Delaware
Florida
Georgia
Maryland
North Carolina
South Carolina
Virginia
West Virginia
E.S. Central
Alabama
Kentucky
Mississippi
Tennessee
W.S. Central
Arkansas
Louisiana
Oklahoma
Texas
Mountain
Arizona
Colorado
Idaho
Montana
Nevada
New Mexico
Utah
Wyoming
Pacific
Alaska
California
Hawaii
Oregon
Washington
Territories
American Samoa
C.N.M.I.
Guam
Puerto Rico
U.S. Virgin Islands
Current
week
Previous 52 weeks
Nonneuroinvasive
Neuroinvasive
Cum
2012
Cum
2011
Med
Max
180
9
2
5
18
8
N
10
32
1
4
27
37
32
N
N
N
11
10
N
1
N
49
N
49
24
16
N
3
N
4
1
N
N
293
21
5
4
9
2
0
2
55
34
0
0
20
63
15
5
18
21
0
13
0
7
0
4
0
0
1
35
0
0
16
0
0
0
0
10
5
5
5
0
0
0
56
4
1
0
48
23
9
6
0
2
0
1
4
0
2
1
0
0
0
0
414
54
20
11
18
10
6
9
80
70
0
0
44
118
38
20
45
47
1
32
0
21
1
18
3
7
6
66
2
2
38
0
0
0
9
27
32
15
14
0
3
0
199
27
6
0
193
68
50
32
0
7
0
8
15
1
9
4
4
4
0
0
2,362
155
35
40
47
3
30
462
286
N
176
568
129
70
160
209
124
N
85
32
3
4
269
1
173
N
N
N
66
29
53
48
N
5
N
485
16
10
N
459
226
49
79
N
11
N
29
56
2
20
9
5
6
N
N
2,815
231
53
42
79
22
9
26
297
108
N
189
764
176
60
254
273
1
141
N
74
55
7
1
4
380
3
4
200
N
N
N
69
104
60
56
N
4
N
455
59
19
N
377
441
144
118
N
74
N
13
89
3
46
20
14
12
N
N
2
8
0
4
21
0
27
6
84
Current
week
Previous 52 weeks
Cum
2012
Cum
2011
Med
Max
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
63
3
2
0
2
0
1
1
11
1
5
4
2
13
6
2
7
3
1
9
2
1
1
2
4
1
0
12
1
3
4
4
5
1
0
2
1
11
2
2
5
3
4
1
1
1
3
11
7
2
1
1
4
1
1
1
18
0
18
0
0
0
0
0
0
0
0
0
Current
week
Previous 52 weeks
Cum
2012
Cum
2011
Med
Max
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
33
1
1
0
1
0
0
0
6
2
4
1
1
7
5
1
2
3
1
7
2
0
1
2
3
1
1
6
0
3
2
1
3
0
0
1
0
5
0
1
4
1
3
0
2
0
3
5
4
2
1
0
2
0
1
1
8
0
8
0
0
0
0
0
0
0
0
0

Updated weekly from reports to the Division of Vector-Borne Infectious Diseases, National Center for Zoonotic, Vector-Borne, and Enteric Diseases (ArboNET Surveillance). Data for California
serogroup, eastern equine, Powassan, St. Louis, and western equine diseases are available in Table I.
Not reportable in all states. Data from states where the condition is not reportable are excluded from this table, except starting in 2007 for the domestic arboviral diseases and influenzaassociated pediatric mortality, and in 2003 for SARS-CoV. Reporting exceptions are available at http://www.cdc.gov/osels/ph_surveillance/nndss/phs/infdis.htm.
ND-140
TABLE III. Deaths in 122 U.S. cities,* week ending March 10, 2012 (10th week)
All causes, by age (years)
Reporting area
All
Ages
New England
Boston, MA
Bridgeport, CT
Cambridge, MA
Fall River, MA
Hartford, CT
Lowell, MA
Lynn, MA
New Bedford, MA
New Haven, CT
Providence, RI
Somerville, MA
Springfield, MA
Waterbury, CT
Worcester, MA
Mid. Atlantic
Albany, NY
Allentown, PA
Buffalo, NY
Camden, NJ
Elizabeth, NJ
Erie, PA
Jersey City, NJ
New York City, NY
Newark, NJ
Paterson, NJ
Philadelphia, PA
Pittsburgh, PA
Reading, PA
Rochester, NY
Schenectady, NY
Scranton, PA
Syracuse, NY
Trenton, NJ
Utica, NY
Yonkers, NY
E.N. Central
Akron, OH
Canton, OH
Chicago, IL
Cincinnati, OH
Cleveland, OH
Columbus, OH
Dayton, OH
Detroit, MI
Evansville, IN
Fort Wayne, IN
Gary, IN
Grand Rapids, MI
Indianapolis, IN
Lansing, MI
Milwaukee, WI
Peoria, IL
Rockford, IL
South Bend, IN
Toledo, OH
Youngstown, OH
W.N. Central
Des Moines, IA
Duluth, MN
Kansas City, KS
Kansas City, MO
Lincoln, NE
Minneapolis, MN
Omaha, NE
St. Louis, MO
St. Paul, MN
Wichita, KS
531
142
33
15
29
U
25
4
29
46
67
38
34
69
2,255
47
33
86
31
22
52
19
998
48
24
561
52
40
81
26
26
59
19
10
21
2,136
54
30
273
92
288
233
146
168
56
80
14
54
201
38
84
58
70
56
96
45
665
58
25
36
69
60
61
91
133
52
80
65
369
90
23
13
22
U
18
1
24
30
58
25
23
42
1,571
30
27
55
18
14
37
14
711
27
16
357
42
34
62
24
21
44
13
8
17
1,451
36
21
176
60
202
159
103
103
36
61
8
34
136
28
56
43
53
39
63
34
426
46
17
26
32
48
40
67
60
38
52
All causes, by age (years)

P&I
4564
2544
124
<1
Total
122
41
7
2
4
U
7
2
4
10
9
7
11
18
487
13
3
22
10
6
14
3
222
10
3
134
7
3
12
2
4
10
4
2
3
499
16
8
66
19
60
58
37
45
18
14
5
14
47
5
18
7
14
16
24
8
156
9
5
7
13
11
12
20
45
12
22
23
7
2
2
U
5
124
3
2
5
46
7
3
43
1
1
6
1
3
1
1
112
1
1
14
9
17
9
5
14
5
13
3
7
5
1
3
3
57
3
1
2
20
1
5
3
17
7
3
1
1
1
1
40
1
1
9
4
2
14
2
2
2
1
45
11
2
7
3
1
2
2
1
1
4
2
3
2
1
3
16
1
4
2
1
6
1
1
10
1
1
U
3
33
1
3
3
2
10
13
29
1
6
2
2
4
2
1
4
1
56
16
6
2
1
U
1
3
6
5
4
2
10
117
2
3
7
1
43
3
33
9
4
2
3
1
1
1
1
152
7
2
15
10
16
7
14
11
4
4
6
18
5
8
7
4
6
6
2
47
1
4
3
2
3
6
11
2
6
9
Reporting area
(Continued)
All
Ages
S. Atlantic
Atlanta, GA
Baltimore, MD
Charlotte, NC
Jacksonville, FL
Miami, FL
Norfolk, VA
Richmond, VA
Savannah, GA
St. Petersburg, FL
Tampa, FL
Washington, D.C.
Wilmington, DE
E.S. Central
Birmingham, AL
Chattanooga, TN
Knoxville, TN
Lexington, KY
Memphis, TN
Mobile, AL
Montgomery, AL
Nashville, TN
W.S. Central
Austin, TX
Baton Rouge, LA
Corpus Christi, TX
Dallas, TX
El Paso, TX
Fort Worth, TX
Houston, TX
Little Rock, AR
New Orleans, LA
San Antonio, TX
Shreveport, LA
Tulsa, OK
Mountain
Albuquerque, NM
Boise, ID
Colorado Springs, CO
Denver, CO
Las Vegas, NV
Ogden, UT
Phoenix, AZ
Pueblo, CO
Salt Lake City, UT
Tucson, AZ
Pacific
Berkeley, CA
Fresno, CA
Glendale, CA
Honolulu, HI
Long Beach, CA
Los Angeles, CA
Pasadena, CA
Portland, OR
Sacramento, CA
San Diego, CA
San Francisco, CA
San Jose, CA
Santa Cruz, CA
Seattle, WA
Spokane, WA
Tacoma, WA
945
181
128
108
7
97
52
51
64
52
98
96
11
936
203
93
109
53
186
79
44
169
1,173
77
70
51
220
116
U
132
89
U
241
64
113
1,193
125
57
71
114
273
39
173
36
135
170
1,819
12
150
21
78
77
282
22
125
225
180
127
214
22
118
58
108
11,653
Total
4564
2544
124
<1
P&I
Total
579
96
80
70
4
56
31
29
44
37
64
59
9
634
131
73
85
40
114
48
28
115
765
52
40
35
146
78
U
79
60
U
157
41
77
820
88
42
55
74
191
29
97
29
92
123
1,291
5
110
15
56
56
196
17
92
157
125
85
161
18
76
45
77
231
45
37
26
3
27
13
10
14
9
22
24
1
223
45
18
16
8
55
26
14
41
237
16
12
9
51
29
U
5
20
U
59
13
23
251
20
14
11
33
53
8
47
6
25
34
389
4
29
6
19
17
67
5
29
55
36
28
33
2
29
9
21
77
19
6
9
10
7
7
4
2
6
6
1
54
18
1
5
5
14
1
1
9
85
6
12
3
7
6
U
19
6
U
15
3
8
83
9
4
7
21
1
17
1
14
9
74
1
5
2
2
12
3
6
9
8
11
1
7
2
5
24
7
3
1
2
2
3
14
4
1
2
2
2
1
2
50
1
5
2
7
1
U
21
1
U
6
5
1
24
5
1
6
1
6
1
4
35
1
1
4
2
5
4
5
1
4
1
5
30
12
4
1
1
2
1
1
4
4
11
5
1
2
2
35
2
1
2
8
2
U
8
2
U
4
2
4
13
3
30
2
4
1
3
1
5
5
2
4
2
1
64
7
9
6
1
6
1
3
4
7
8
11
1
73
17
2
10
5
17
6
3
13
69
7
2
6
9
7
U
6
5
U
15
4
8
93
13
6
2
7
26
1
11
6
12
9
184
13
2
11
7
48
4
10
16
20
11
26
5
1
4
6
7,906
2,595
689
255
199
855
65
U: Unavailable. : No reported cases.

* Mortality data in this table are voluntarily reported from 122 cities in the United States, most of which have populations of >100,000. A death is reported by the place of its occurrence and
by the week that the death certificate was filed. Fetal deaths are not included.
Pneumonia and influenza.
Because of changes in reporting methods in this Pennsylvania city, these numbers are partial counts for the current week. Complete counts will be available in 4 to 6 weeks.
Total includes unknown ages.
ND-141
The Morbidity and Mortality Weekly Report (MMWR) Series is prepared by the Centers for Disease Control and Prevention (CDC) and is available free
of charge in electronic format. To receive an electronic copy each week, visit MMWRs free subscription page at http://www.cdc.gov/mmwr/mmwrsubscribe.
html. Paper copy subscriptions are available through the Superintendent of Documents, U.S. Government Printing Office, Washington, DC 20402;
telephone 202-512-1800.
Data presented by the Notifiable Disease Data Team and 122 Cities Mortality Data Team in the weekly MMWR are provisional, based on weekly reports
to CDC by state health departments. Address all inquiries about the MMWR Series, including material to be considered for publication, to Editor,
MMWR Series, Mailstop E-90, CDC, 1600 Clifton Rd., N.E., Atlanta, GA 30333 or to mmwrq@cdc.gov.
All material in the MMWR Series is in the public domain and may be used and reprinted without permission; citation as to source, however, is appreciated.
Use of trade names and commercial sources is for identification only and does not imply endorsement by the U.S. Department of Health and Human Services.
References to non-CDC sites on the Internet are provided as a service to MMWR readers and do not constitute or imply endorsement of these organizations
or their programs by CDC or the U.S. Department of Health and Human Services. CDC is not responsible for the content of these sites. URL addresses
listed in MMWR were current as of the date of publication.
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Morbidity and Mortality Weekly Report

Weekly / Vol. 61 / No. 10

March 16, 2012

Reducing Bloodstream Infections in

National Kidney Month

Patients undergoing hemodialysis are at risk for bloodstream

U.S. Department of Health and Human Services

Morbidity and Mortality Weekly Report

hemodialysis centers report BSIs to the National Healthcare

of chlorhexidine for skin antisepsis, 3) auditing of hand hygiene

Centers for Disease Control and Prevention

Thomas R. Frieden, MD, MPH, Director

MMWR Editorial and Production Staff

Ronald L. Moolenaar, MD, MPH, Editor, MMWR Series

MMWR Editorial Board

William L. Roper, MD, MPH, Chapel Hill, NC, Chairman

MMWR/March 16, 2012/Vol. 61/No. 10

Morbidity and Mortality Weekly Report

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What is known on this topic?

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MMWR/March 16, 2012/Vol. 61/No. 10

Morbidity and Mortality Weekly Report

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MMWR/March 16, 2012/Vol. 61/No. 10

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