Att C ACE Morbidity and Mortality Weekly Report Article

Morbidity and Mortality Weekly Report
Weekly / Vol. 60 / No. 28

July 22, 2011

World Hepatitis Day —
July 28, 2011
July 28, 2011, marks the first official World Hepatitis
Day established by the World Health Organization
(WHO). CDC joins with WHO in calling for a renewed
commitment against a largely silent but persistent
epidemic. Worldwide, nearly 500 million persons are living
with chronic hepatitis B virus or hepatitis C virus (HCV)
infections, and these infections cause approximately
1 million deaths annually (1); most persons with chronic
viral hepatitis are unaware of their infections. Effective
tools are available to prevent infection with viral hepatitis,
including hepatitis B vaccination, surveillance, education,
screening, and treatment; the challenge is to build the
capacity to extend these interventions globally. In 2010,
the World Health Assembly passed a resolution urging
greater control of viral hepatitis (2).
In Europe, HCV infection outbreaks and rising
incidence have been observed among men who have sex
with men (MSM) with human immunodeficiency virus
(HIV) infection. This issue of MMWR includes a report on
sexual transmission of HCV among HIV-infected MSM
in New York City. The findings emphasize the importance
of HCV screening among these men, which allows for
preventive care and treatment.
In the United States, World Hepatitis Day will be
observed July 28 at a White House event. Information
regarding the webcast of this event will be available at
http://www.cdc.gov/hepatitis.

Sexual Transmission of Hepatitis C
Virus Among HIV-Infected Men Who
Have Sex with Men — New York City,
2005–2010
In the United States, an estimated 3.2 million persons
are living with hepatitis C virus (HCV) infection (1). HCV
transmission occurs primarily through percutaneous exposure
to blood, and persons who inject drugs are at greatest risk for
infection. The role of sexual transmission of HCV has not
been well defined. However, reports over the past decade,
mainly from Europe, have implicated sexual transmission of
HCV among human immunodeficiency virus (HIV)–infected
men who have sex with men (MSM). In late 2005, two HIVinfected MSM, each with acute HCV infection that was
suspected to have been acquired sexually, were evaluated at
Mount Sinai Medical Center in New York City, prompting
Mount Sinai to request referrals of similar patients (2).
During 2005–2010, a total of 74 HIV-infected MSM with
recently acquired HCV infection and no reported history
of injection-drug use were evaluated. To examine the role of
sexual transmission, a matched case-control study and viral
analysis were conducted. Results from the case-control study
showed that high-risk sexual behavior was the most likely
mode of transmission among these men. Phylogenetic analyses
revealed five clusters of closely related HCV variants, suggesting
networks of transmission among these men. The findings
underscore the importance of screening HIV-infected MSM for
HCV, particularly those engaged in high-risk sexual behavior.
INSIDE

References
1. Hu DJ, Bower WA, Ward JW. Viral hepatitis. In: Morse S, Moreland
AA, Holmes KK, eds. Atlas of sexually transmitted diseases and
AIDS. London, England: Elsevier; 2010:203–29.
2. World Health Organization. Viral hepatitis. Geneva, Switzerland:
World Health Organization; 2010. Available at http://apps.who.int/
gb/ebwha/pdf_files/wha63/a63_r18-en.pdf. Accessed July 6, 2011.

951 Chlorine Gas Exposure at a Metal Recycling Facility
— California, 2010
955 Severe Hearing Impairment Among Military
Veterans — United States, 2010
959 Announcement
960 QuickStats

U.S. Department of Health and Human Services
Centers for Disease Control and Prevention

Morbidity and Mortality Weekly Report

For this study, a case-patient was defined as an HIV-infected
MSM examined at Mount Sinai during October 2005–
December 2010 who had 1) a newly elevated alanine transferase
(ALT) level, 2) a newly positive HCV-antibody test result, and
3) no other evident cause of the newly elevated ALT level.
To the extent possible, positive HCV-antibody results were
confirmed by HCV RNA testing. If no record was found of
a previous negative HCV-antibody test, a finding of jaundice
or an ALT elevation of more than 15-fold above the upper
limit of normal (i.e., >450 U/L) also was required. To assess
whether patients might have had a previous positive HCV test
result unknown to the referring physicians, the date of the first
positive HCV-antibody test of a subset of patients (24 men)
was confirmed by the New York City Department of Health
and Mental Hygiene through review of the hepatitis registry
of HCV surveillance data. Providers of primary care to HIVinfected MSM in New York City (who, as part of care, routinely
obtain ALT levels on their patients during HIV monitoring
visits) were contacted by the lead investigator and asked to refer
patients with newly elevated ALT levels to Mount Sinai as soon
as possible. Reminders were provided periodically throughout
the study period. A total of 35 HIV-care providers contributed
information on their patients to this study.

Characteristics of Case-Patients
During October 2005–December 2010, Mount Sinai evaluated 74 HIV-infected MSM who reported no injection-drug

use and had newly elevated ALT levels and a positive HCV
antibody test result; 73 of 74 also had documented HCV
viremia. Median age of the 74 patients was 39 years; 41 were
non-Hispanic white, 14 non-Hispanic black, 18 Hispanic,
and one Asian (Table 1). Median CD4+ cell count for the
patients was 483 cells/µL (range: 66–1,258 cells/µL). Sixty
patients (81%) were asymptomatic, and new HCV infection
was detected solely because of new ALT elevation; 14 (19%)
had jaundice at presentation. Median peak ALT level was 665
U/L (range: 72–5,291 U/L). No other cause for the patients’
elevated ALT levels was found (e.g., no new infection with
hepatitis A or B virus and no new drug therapy). Of the 74
patients, 65 (91%) had a previous negative HCV-antibody
test result before detection of hepatitis (median: 12 months;
range: 0–110 months).

Case-Control Study
To assess the role of sexual transmission of HCV, a matched
case-control study was conducted beginning in July 2007.
HIV-infected MSM examined at Mount Sinai during July
2007–December 2010 who were within 12 months of clinical
onset of HCV infection and who reported no injection-drug
use were recruited as case-patients. For each case-patient, 1–10
controls (i.e., HIV-infected MSM who did not have HCV
infection, reported no injection-drug use, and matched by
age [±5 years] and race/ethnicity) were recruited by Mount
Sinai staff members from among the practices that referred

The MMWR series of publications is published by the Office of Surveillance, Epidemiology, and Laboratory Services, Centers for Disease Control and Prevention (CDC),
U.S. Department of Health and Human Services, Atlanta, GA 30333.
Suggested citation: Centers for Disease Control and Prevention. [Article title]. MMWR 2011;60:[inclusive page numbers].

Centers for Disease Control and Prevention

Thomas R. Frieden, MD, MPH, Director
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James W. Stephens, PhD, Director, Office of Science Quality
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Stephanie Zaza, MD, MPH, Director, Epidemiology and Analysis Program Office

MMWR Editorial and Production Staff

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MMWR Editorial Board

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

946

MMWR / July 22, 2011 / Vol. 60 / No. 28

Morbidity and Mortality Weekly Report

TABLE 1. Characteristics of MSM with HIV and recent HCV coinfection
(N = 74) — New York City, 2005–2010
Characteristic
Age (median) (yrs)
Race/Ethnicity
White, non-Hispanic (No. [%])
Black, non-Hispanic (No. [%])
Hispanic (No. [%])
Asian, non-Hispanic (No. [%])
CD4 count (median) (cells/µL)
Duration of HIV infection (median) (yrs)
Receipt of antiretroviral drug therapy (No. [%])
HIV viral load <400 copies/mL (No. [%])
No previous HCV-positive serology (No. [%])
Seroconversion interval* (median) (mos) (N = 65)
Presence of jaundice on presentation (No. [%])
Peak ALT (median) (U/L)
Peak HCV viral load (log10 IU/mL)
HCV genotype (N = 72)
1a (No. [%])
1b (No. [%])
2b (No. [%])
3a (No. [%])

Result
39 (23–63)
41
(55)
14
(19)
18
(24)
1
(1)
483 (66–1,258)
8 (0–23)
55
(74)
50
(68)
9 (12)
12 (0–110)
14
(19)
665 (72–5,291)
6.68 (<0.7–8.0)
65
4
2
1

(90)
(6)
(3)
(1)

Abbreviations: MSM = men who have sex with men; HIV = human immunodeficiency virus; HCV = hepatitis C virus; ALT: alanine aminotransferase.
* Interval between last negative and first positive HCV antibody test.

case-patients during the enrollment period. In all, 22 casepatients and 53 control subjects were enrolled in the study.
All participants were asked to complete self-administered
questionnaires regarding their sexual practices and drug-use
behaviors during the 12 months preceding diagnosis (for casepatients) or preceding the questionnaire (for matched controls).
To conduct a matched analysis, a conditional logistic regression
of each variable (i.e., sexual practice or drug use behavior)
was performed. Those variables that had a p value of ≤0.20 in
the univariable analysis, as well as those previously associated
with sexual transmission (3), were entered into a model and
analyzed using multivariable conditional logistic regression
(i.e., forward, backward, and stepwise) to determine which
variables were independently associated with HCV infection.
Univariable results. Univariable analyses indicated that the
HIV-infected MSM newly infected with HCV (case-patients)
were significantly more likely than the HIV-infected MSM
without HCV infection (matched controls) to have had
receptive (matched odds ratio [mOR] = 24.87) or insertive
(mOR = 2.62) anal intercourse with no condom and with
ejaculation, practiced receptive (mOR = 10.08) or insertive
(mOR = 7.90) fisting, used sex toys (mOR = 4.38), engaged
in group sex (mOR = 19.28), engaged in sex while high
on drugs (mOR = 11.37), previously had syphilis (mOR =
8.80) or gonorrhea (mOR = 5.02), and had sex while high

on methamphetamine (mOR = 26.80) (Table 2). Because
three variables (receptive anal intercourse, no condom, no
ejaculation; sex while high on gamma hydroxybutyrate [GHB];
and sex while high on ketamine) yielded undefined ORs, the
data were analyzed further using exact conditional logistic
regression. Results showed that case-patients were significantly
more likely than controls to report receptive anal intercourse
with no condom and no ejaculation (mOR = 24.26) and sex
while high on GHB (mOR = 16.34).
Multivariable results. Results from the multivariable
analyses showed that receptive anal intercourse with no
condom and with ejaculation of the partner (adjusted odds
ratio [AOR] = 23.00) and sex while high on methamphetamine
(AOR = 28.56) were both significantly related to acquiring
HCV infection. Of all the practices and behaviors, having sex
while using methamphetamine was most strongly associated
with HCV infection (Table 2).

Results of Phylogenetic Analyses
Polymerase chain reaction and sequencing of a 470 base-pair
region of NS5B from HCV strains recovered from 50 of the
74 men were conducted using methods described previously
(4). Forty-seven of the 50 were genotype 1a, and three were
genotype 1b. A maximum-likelihood phylogenetic tree was
then created (5).* These analyses identified five clusters of
closely related HCV variants from 26 (55%) of the 47 men
with genotype 1a infections.
* Available at http://www.cdc.gov/hepatitis/resources/professionals/pdfs/msm_
hcv_ns5b-sequence_tree.pdf.

What is already known on this topic?
Infection with hepatitis C virus (HCV) is a major cause of
morbidity, and, if left untreated, can lead to chronic liver disease
and death. HCV transmission occurs primarily through
percutaneous exposure to blood (injection-drug users are at
greatest risk), but the role of sexual transmission has not been
well defined.
What is added by this report?
Sexual transmission was found to be the most likely mode of
transmission of HCV among human immunodeficiency virus
(HIV)–infected men who have sex with men (MSM) in this study
in New York City.
What are the implications for public health practice?
These findings, and those elsewhere, suggest that sexual
transmission of HCV can occur undetected among HIV-infected
MSM in the absence of injection-drug use. Health-care providers
should consider HCV testing for HIV-infected MSM with high-risk
sexual behaviors or concomitant ulcerative sexually transmitted
diseases (e.g., syphilis and herpes simplex virus).

MMWR / July 22, 2011 / Vol. 60 / No. 28

947

Morbidity and Mortality Weekly Report

TABLE 2. Odds ratios for comparison of case-patients (HIV-infected MSM with HCV infection) and controls (HIV-infected MSM without HCV
infection), by sexual practice and drug use behavior, using conditional logistic regression — New York City, 2007–2010
Case-patients
(n = 22)
Characteristic

Controls*
(n = 53)

Univariable analysis

No.

(%)

No.

(%)

OR

(95% CI)

p value

Receptive anal intercourse, with condom
Yes
No

16
6

(73)
(27)

26
26

(50)
(50)

1.68

(0.57–4.96)

0.35

Receptive anal intercourse, no condom, no ejaculation
Yes
No

22 (100)
0
—

21
32

(40)
(60)

Receptive anal intercourse, no condom, with ejaculation
Yes
No

19
3

(86)
(14)

12
41

(23)
(77)

24.87

(3.18–194.55)

Insertive anal intercourse, with condom
Yes
No

13
9

(59)
(41)

24
29

(45)
(55)

1.34

(0.48–3.78)

0.58

Insertive anal intercourse, no condom, no ejaculation
Yes
No

17
5

(77)
(23)

18
35

(34)
(66)

8.13

(1.76–37.55)

0.007

Insertive anal intercourse, no condom, with ejaculation
Yes
No

13
9

(59)
(41)

14
39

(26)
(74)

2.62

(1.00–6.87)

0.05

Receptive fisting
Yes
No

8
14

(36)
(64)

3
50

(6)
(94)

10.08

(2.03–50.02)

0.005

Insertive fisting
Yes
No

8
14

(36)
(64)

3
50

(6)
(94)

7.90

(1.96–31.84)

0.004

Use of sex toys
Yes
No

12
10

(55)
(45)

13
40

(25)
(75)

4.38

(1.35–14.26)

0.01

Group sex
Yes
No

20
2

(91)
(9)

18
35

(34)
(66)

19.28

(2.51–148.23)

0.005

Previously had syphilis
Yes
No

11
11

(50)
(50)

9
43

(17)
(83)

8.80

(1.88–41.05)

0.006

Previously had gonorrhea
Yes
No

15
7

(68)
(32)

17
35

(33)
(67)

5.02

(1.40–18.05)

0.01

Multivariable analysis
AOR

(95% CI)

p value

23.00

(2.17–243.84)

0.009

ND†

0.002

See table footnotes on page 949.

Reported by

Daniel S. Fierer, MD, Stephanie H. Factor, MD, Alison J. Uriel,
MBBS, Damaris C. Carriero, MS, Douglas T. Dieterich, MD,
Michael P. Mullen, MD, Arielle Klepper, Wouter van Seggelen,
MSc, Kathryn Childs, MBBS, Andrea D. Branch, PhD, Dept of
Medicine, Mount Sinai School of Medicine, New York, New York.
Deborah Holtzman, PhD, John W. Ward, MD, Yury Khudyakov,
PhD, Scott D. Holmberg, MD, Div of Viral Hepatitis, National
Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention,
CDC. Corresponding contributor: Deborah Holtzman,
[email protected], 404-718-8555.
Editorial Note

This report suggests high-risk sexual behavior as a cause
of HCV transmission among HIV-infected MSM in New
York City. Unprotected receptive anal intercourse with
ejaculation and sex while high on methamphetamine were the
948

MMWR / July 22, 2011 / Vol. 60 / No. 28

most important predictors of HCV infection. Results from
phylogenetic analyses suggest networks of HCV transmission
among these men. The findings of high-risk sex, concurrent
noninjection-drug use, and phylogenetic clustering are similar
to those observed among cohorts of HIV-infected MSM with
HCV infection in Northern Europe and Australia (4). A
notable finding from this study and those in other countries
is the association of noninjection, recreational drug use (e.g.,
methamphetamine use) with the acquisition of HCV infection.
Sexual transmission of HCV is considered to be an inefficient
and rare mode of transmission (6). However, concurrent HIV
infection results in increased HCV RNA levels (viral load)
(7), which are thought to increase infectiousness of HCV
acquired through sexual contact. Of further concern among
persons who are coinfected is that HIV accelerates HCV disease
progression, even in its early stages (2). End-stage liver disease
and hepatocellular carcinoma, both usually resulting from

Morbidity and Mortality Weekly Report

TABLE 2. (Continued) Odds ratios for comparison of case-patients (HIV-infected MSM with HCV infection) and controls (HIV-infected MSM without HCV infection), by sexual practice
and drug use behavior, using conditional logistic regression — New York City, 2007–2010
Case-patients
(n = 22)
Characteristic

Controls*
(n = 53)

Univariable analysis

No.

(%)

No.

(%)

OR

(95% CI)

p value

Sex while high on drugs
Yes
No

17
4

(81)
(19)

14
38

(27)
(73)

11.37

(2.51–51.52)

0.002

Sex while high on cocaine
Yes
No

3
19

(14)
(86)

4
49

(8)
(92)

1.32

(0.27–6.50)

0.74

Sex while high on GHB
Yes
No

7
15

(32)
(68)

0
—
53 (100)

ND†

Sex while high on ketamine
Yes
No

2
20

(9)
(91)

0
—
53 (100)

ND†

Sex while high on ecstasy
Yes
No

4
18

(18)
(82)

2
51

(4)
(96)

2.89

(0.52–16.12)

0.23

Sex while high on marijuana
Yes
No

8
14

(36)
(64)

8
45

(15)
(85)

3.10

(0.84–11.51)

0.09

Sex while high on methamphetamine
Yes
No

13
9

(59)
(41)

2
51

(4)
(96)

26.80

(3.30–217.77)

0.002

Sex while drunk
Yes
No

13
9

(59)
(41)

19
33

(37)
(63)

0.18

(0.67–7.04)

Multivariable analysis
AOR

(95% CI)

p value

28.56

(1.84–443.03)

0.02

0.19

Abbreviations: HIV = human immunodeficiency virus; MSM = men who have sex with men; HCV = hepatitis C virus; OR = odds ratio; CI = confidence interval; AOR = adjusted odds ratio;
ND = not defined; GHB = gamma hydroxybutyrate.
* Controls matched for age (±5 yrs) and race/ethnicity.
† Because each of these variables yielded undefined ORs, the data were further analyzed using exact conditional logistic regression. Univariable results were as follows: receptive anal
intercourse, no condom, no ejaculation (OR = 24.26 [95% CI = 4.13–∞], p<0.0001); sex while high on GHB (OR = 16.34 [95% CI = 2.39–∞], p=0.002); sex while high on ketamine (OR = 4.38 [95%
CI = 0.38–∞], p=0.222). All variables were further tested in a model using exact conditional logistic regression; however, none of the three variables exhibited significant independent effects
on acquiring HCV infection in the multivariable analysis. The multivariable results from the exact conditional procedure were the same as those from the conditional procedure (i.e., only
receptive anal intercourse, no condom, with ejaculation and sex while high on methamphetamine exhibited significant independent effects on acquiring HCV infection).

chronic HCV infection, are now leading causes of death not
attributable to acquired immunodeficiency syndrome (AIDS)
among HIV-infected persons in the United States (8).
The findings in this report are subject to at least three
limitations. First, recall of events such as ejaculation by
sex partner up to 12 months before HCV diagnosis can be
imperfect. For example, the findings should not be interpreted
to definitively exclude acquisition of HCV by some men
through unprotected receptive anal intercourse without
ejaculation, even though this variable did not exert a significant
independent effect on HCV infection in the multivariable
analysis. Second, refusal to acknowledge injection-drug use is
not uncommon, and other types of stigmatizing risk behavior
also might be underreported. Such social desirability bias
was addressed by using a self-administered questionnaire and
assuring each patient that his responses would not be shared
with his primary-care provider. Finally, study investigators
relied on patient referrals from HIV-care providers outside
Mount Sinai, and referral bias might have occurred; however,
the number of referring providers was fairly sizable (n = 35).

Sexual transmission of HCV among HIV-infected MSM is
more widespread than this one study demonstrates. A recent
U.S. report described HCV-antibody seroconversions among
HIV-infected MSM without a history of injection-drug use
(9). A recent European report that examined a group of
studies, primarily from Europe, found substantial increases,
particularly during 2002–2007, in the incidence of HCV
infection among HIV-infected MSM, demonstrating just
how serious the epidemic has become among these men (10).
Hepatitis C should be added to the list of infections spread
among HIV-infected MSM who have sex with HCV-infected
partners. HIV-infected patients should be counseled and
reminded that unprotected sex between HIV-infected partners
can transmit other infections, including HCV. In addition to
HCV screening for MSM newly diagnosed with HIV, routine
HCV screening using both ALT and antibody testing should
be considered for HIV-infected MSM, particularly those with
high-risk sexual behaviors or concomitant ulcerative sexually
transmitted diseases (e.g., syphilis and herpes simplex virus).†
† Based

on CDC’s Sexually Transmitted Diseases Treatment Guidelines, 2010,
available at http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5912a1.htm.

MMWR / July 22, 2011 / Vol. 60 / No. 28

949

Morbidity and Mortality Weekly Report

Finally, newly diagnosed HCV infections among HIV-infected
MSM should be reported to state and local health authorities.
References
1. Armstrong GL, Wasley A, Simard EP, McQuillan GM, Kuhnert WL,
Alter MJ. The prevalence of hepatitis C virus infection in the United
States, 1999 through 2002. Ann Intern Med 2006;144:705–14.
2. Fierer DS, Uriel AJ, Carriero DC, et al. Liver fibrosis during an outbreak
of acute hepatitis C virus infection in HIV-infected men: a prospective
cohort study. J Infect Dis 2008;198:683–6.
3. Danta M, Brown D, Bhagani S, et al. Recent epidemic of acute hepatitis
C virus in HIV-positive men who have sex with men linked to high-risk
sexual behaviours. AIDS 2007;21:983–91.
4. van de Laar T, Pybus O, Bruisten S, et al. Evidence of a large, international
network of HCV transmission in HIV-positive men who have sex with
men. Gastroenterology 2009;136:1609–17.

950

MMWR / July 22, 2011 / Vol. 60 / No. 28

5. Felsentein J. Evolutionary trees from DNA sequences: a maximum
likelihood approach. J Mol Evol 1981;17:368–76.
6. Tohme RA, Holmberg SD. Is sexual contact a major mode of hepatitis
C virus transmission? Hepatol 2010;52:1497–505.
7. Matthews-Greer JM, Cladito GC, Adley SD, et al. Comparison of
hepatitis C viral loads in patients with or without human immuno­
deficiency virus. Clin Diagn Lab Immunol 2001;8:690–4.
8. Palella FJ Jr, Baker RK, Moorman AC, et al. Mortality in the highly
active antiretroviral therapy era: changing causes of death and disease in
the HIV outpatient study. J Acquir Immune Defic Syndr 2006;43:​
35–41.
9. Taylor LE, Holubar M, Wu K, et al. Incident hepatitis C virus infection
among US HIV-infected men enrolled in clinical trials. Clin Infect Dis
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among HIV-positive MSM: incidence estimates from 1990 to 2007.
AIDS 2011;25:1083–91.

Morbidity and Mortality Weekly Report

Chlorine Gas Exposure at a Metal Recycling Facility — California, 2010
On June 8, 2010, chlorine gas was released from a ruptured,
1-ton, low-pressure tank being recycled at a California metal
recycling facility. A total of 23 persons, including employees,
customers, and workers at nearby businesses, were treated for
the effects of the fumes at seven area hospitals. Chlorine is a
corrosive, greenish-yellow gas that is heavier than air and can
cause severe respiratory damage; it is used widely in water
purification, sewage treatment, and disinfectant washes for
foods. Following the incident, the Agency for Toxic Substances
and Disease Registry (ATSDR) and CDC collaborated with
the California Department of Public Health (CDPH) on
an Assessment of Chemical Exposures (ACE) to determine
1) the circumstances surrounding those exposed during the
chlorine gas release, 2) health effects associated with exposures,
and 3) recommendations for preventing recurrences. This
report describes the chlorine gas release in California and
summarizes the results of the ACE investigation. Of 29 persons
potentially exposed to chlorine gas, 27 were interviewed to
collect information regarding their exposures. In addition,
information regarding acute health effects and symptoms was
abstracted from medical records. At the time of the chlorine
gas release, 15 persons were outdoors, and 13 were exposed
for >30 minutes before they were decontaminated. Twentythree persons reported experiencing one or more upper or

lower respiratory tract symptoms within 24 hours of exposure;
six persons were hospitalized for 1–11 days. Based on these
findings, CDPH issued a statewide alert to all recycling facilities
on how to handle containers with potential hazardous waste.
The chlorine gas release occurred at 2:44 p.m. at a metal
recycling facility located in an industrial area. A worker used
an excavator to cut into a 1-ton, low-pressure tank that was
unlabeled, reportedly empty, and sold to the facility as scrap
metal. When punctured, the tank produced an explosive release
of a greenish-yellow cloud of gas. The release occurred outdoors
in an open work area and affected 29 persons who were at or
near the recycling facility (Figure). Of the 16 workers at the
recycling facility, the majority were outdoors at the time of the
release. Most followed a planned evacuation route, exiting the
facility through the main gate and meeting in an open field
across the street in an evacuation area that was downwind from
the tank (Figure).
When emergency medical services and fire department
personnel arrived at the scene, they set up a decontamination
area 200 yards north of the facility, where the majority of exposed
persons were decontaminated by rinsing with water. Twentytwo of those exposed were then transported by ambulance (one
person self-transported) to seven local hospitals where some
were decontaminated again by removing clothing and washing

FIGURE. Schematic of chlorine gas release at a metal recycling facility, which resulted in 23 persons seeking hospital treatment and six being
hospitalized — California, 2010
Decontamination
area

Vacant field

Vacant field

Recycling
facility

Evacuation area

Release site

Business A

Covered work area

Office

Non-hospitalized
person

Hospitalized
person

Road

Business B

Railroad
Fence

MMWR / July 22, 2011 / Vol. 60 / No. 28

951

Morbidity and Mortality Weekly Report

with soap and water. At 5:58 p.m., local hazardous materials
team members identified the gas as chlorine and measured a
concentration of 328 ppm near the tank.
ATSDR and CDC arrived in California on June 14 to assist
CDPH with the ACE investigation. The ACE program, which
is part of the National Toxic Substance Incidents Program,
provides assistance to state and local health departments for
rapid assessments after large-scale toxic substance releases.
Of the 29 persons identified as potentially exposed during
the release, 16 were workers at the facility, and 13 were
either customers or in businesses located across the street
and downwind from the tank. Twenty-seven persons were
interviewed (in English and Spanish), and information was
collected regarding demographics, exposure characteristics,
acute health effects, medical history, occupational history,
and health services use. Two persons were not available at
the time of interviews. Medical charts were obtained and
abstracted for the 23 persons treated at area hospitals, six of
whom were admitted. One of the six hospitalized persons was
not interviewed.
Twenty-seven (93%) of the 29 potentially exposed persons
were aged >18 years; average age was 40 years, with a range of
2–77 years. Of the 27 interviewed, 20 (74%) were Hispanic;
21 (78%) were male, and 18 (67%) had at least a high school
education. Fifteen (56%) persons were outdoors at the time
of the chlorine gas release, and 24 (89%) reported smelling an
odor (Table 1). A total of 22 (82%) had been decontaminated
(either by rinsing with water, removing clothing, or washing
with soap and water), and 13 (48%) said they were exposed to
chlorine gas for >30 minutes before being decontaminated. Five
(19%) said they were exposed for <30 minutes, and nine (33%)
either did not know how long or did not answer the question.
Twenty-three (85%) of the 27 persons interviewed reported
experiencing acute health effects within 24 hours of the chlorine
gas release (Table 2). The most common symptoms reported
were coughing (22 persons, 82%); difficulty breathing/feeling
out of breath (22, 82%); headache (21, 78%); and burning of
the nose, throat, or lungs (20, 74%).
Among the 27 interviewed, five persons (19%) reported
preexisting high blood pressure, four (15%) reported diabetes,
and three (11%) reported allergies (11%); eight (30%) reported
current smoking. None of the 27 reported any preexisting
respiratory conditions (e.g., asthma or chronic obstructive
pulmonary disease) that might have placed them at greater
risk from the chlorine exposure.
Of the 23 exposed persons who received care at seven area
hospitals, 17 (74%) were treated and discharged from the
emergency department, and six (26%) were hospitalized.
Five (83%) of the six hospitalized patients worked at the
recycling facility. Among those who received medical care,

952

MMWR / July 22, 2011 / Vol. 60 / No. 28

TABLE 1. Circumstances surrounding chlorine gas exposure reported
by 27 persons who were interviewed — California, 2010
Circumstance
Exposure time*
<30 min
≥30 min
Don’t know/Missing
Location
Indoors
Outdoors
Don’t know/Missing
Distance from release site
≤100 yards
>100 yards
Don’t know/Missing
Smelled odor
Yes
No
Don’t know/Missing
Odor type
Strong
Mild
Don’t know/Missing
In gas cloud
Yes
No
Don’t know/Missing
Evacuated area
Yes
No
Don’t know/Missing
Sheltered in place
Yes
No
Don’t know/Missing
Decontaminated
Yes
No

No.

(%)

5
13
9

(19)
(48)
(33)

10
15
2

(37)
(56)
(7)

10
15
2

(37)
(56)
(7)

24
2
1

(89)
(7)
(4)

23
—
4

(85)
—
(15)

15
9
3

(56)
(33)
11

25
1
1

(93)
(4)
(4)

1
25
1

(4)
(93)
(4)

22
5

(82)
(19)

* Exposure time = (time decontaminated) – (time of chlorine gas release).

TABLE 2. Health effects experienced by 27 persons within 24 hours
of chlorine gas exposure — California, 2010
Health effect
Illness within 24 hrs
Yes
No
Symptoms within 24 hrs*
Coughing
Difficulty breathing/feeling out of breath
Headache
Burning nose, throat, or lungs
Increased congestion or mucous
Dizziness/lightheadedness
Eye irritation/pain/burning
Runny nose
Wheezing in chest
Chest tightness or pain/angina
Nausea
Skin irritation/pain/burning

No.

(%)

23
4

(85)
(15)

22
22
21
20
19
18
18
18
17
16
16
8

(82)
(82)
(78)
(74)
(70)
(67)
(67)
(67)
(63)
(59)
(59)
(30)

* Affected persons were asked about each symptom separately. The number
responding “yes” for each symptom is shown.

Morbidity and Mortality Weekly Report

What is already known on this topic?
Exposure to chlorine, which is used in numerous industrial
processes and for water treatment, can cause severe respiratory
damage, depending on the concentration.
What is added by this report?
In June 2010 in California, chlorine gas was released from a tank
sold as scrap metal; 23 persons were treated for the effects of
the fumes, including six who were hospitalized for 1–11 days.
What are the implications for public health practice?
Health officials should urge metal recycling facilities to 1) only
accept containers that are cut open, dry, or without a valve or
plug; 2) treat closed containers as potential hazardous waste; and
3) develop and practice a hazardous gas release evacuation plan.

four had an oxygen saturation level <95% recorded in the
emergency department. Five persons had an arterial blood
gas measurement when they first reached a hospital, and their
partial pressure of oxygen values ranged from 62 to 78 mmHg
(reference range: 80–100 mmHg) (1).
Among those who were discharged from the emergency
department, three received oxygen, and nine were prescribed
nebulized β2-agonists. All six of those hospitalized were
prescribed nebulized β2-agonists; five received oxygen, three
were given steroids (oral or intravenous), and two were treated
with antibiotics. Most of the hospitalized patients were released
after 1–4 days. However, one recycling facility worker was
hospitalized for 11 days and required mechanical ventilation
for 2 days.
Reported by

Kate Kelsey, MPH, Rachel Roisman, MD, Richard Kreutzer, MD,
Barbara Materna, PhD, California Dept of Public Health. Mary
Anne Duncan, DVM, Maureen Orr, MS, Ayana Anderson, MPH,
Perri Ruckart, MPH, Jeffery Henry, Div of Health Studies, Yulia
Iossifova, MD, PhD; Div of Toxicology and Environmental
Medicine, Agency for Toxic Substances and Disease Registry. Rizwan
Riyaz, MD, Div of Environmental Hazards and Health Effects,
National Center for Environmental Health; Ekta Choudhary, PhD,
EIS Officer, CDC. Corresponding contri­butor: Ekta Choudhary,
[email protected].
Editorial Note

The incident described in this report demonstrates the
risk for unintentional release of a hazardous substance at
a metal recycling facility. During 2001–2009, ATSDR’s
Hazardous Substance Emergency Events Surveillance (HSEES)
program received reports of 21 incidents in nine participating
states involving a tank that contained a hazardous substance.

In 2009, a total of 230 chlorine release events were reported
to HSEES, of which 81 resulted in injuries (2). In California,
which is not an HSEES participating state, an earlier chlorine
gas release occurred in February 2010 at another scrap metal
recycling facility. In that incident, a 1-ton tank being moved
by a crane was punctured, and chlorine gas released, resulting
in hospitalization of five workers for respiratory symptoms (3).
Chlorine, in its various forms, is used in chemical and
plastic manufacturing, textile and paper bleaching, and
water purification (4). Chlorine is a respiratory irritant and
can produce symptoms ranging from mild ocular and upper
respiratory irritation to severe inflammation of bronchoalveolar
tissues, which can lead to death (5). The symptoms caused by
chlorine depend on the concentration to which a person is
exposed. In the incident described in this report, the symptoms
experienced were consistent with those reported in previous
community exposures (6–10). Although the number of
exposed persons was smaller in this incident, the proportion
hospitalized was higher (21%) than in incidents reported
previously in Pennsylvania (8%) (7) and South Carolina (12%)
(10). However, unlike those earlier incidents, which occurred
near highly populated areas and involved greater amounts of
chlorine gas, no fatalities occurred in California.
As a result of the June 2010 incident in California, the
CDPH Division of Environmental and Occupational Disease
Control, Emergency Planning and Preparedness Team
produced a Chemical Release Alert, which was mailed to
approximately 1,200 recycling facilities in the state. The alert
urged facilities to 1) only accept containers that are cut open,
dry, or without a valve or plug; 2) treat all closed containers
as potential hazardous waste; and 3) develop and practice an
evacuation plan, including training workers to stay upwind
when evacuating after a hazardous gas release (3).
Acknowledgments
Tulare County Dept of Public Health; Visalia Fire Dept HAZMAT
Team; City of Tulare Fire Rescue; Div of Occupational Safety and
Health, California Dept of Industrial Relations; Fresno County Dept
of Public Health; Emergency Planning and Preparedness Team, Div of
Environmental and Occupational Disease Control, California Dept
of Public Health. Norys Guerra, Melissa Smith, D. Kevin Horton,
Anne Sowell, Div of Health Studies, Agency for Toxic Substances
and Disease Registry; Joshua Schier, Div of Environmental Hazards
and Health Effects, National Center for Environmental Health;
Outbreak Management System Team, National Center for Public
Health Informatics, CDC.
References
1. Fischbach FT, Dunning MB. A manual of laboratory and diagnostic
tests. Philadelphia, PA: Lippincott Williams & Wilkins, 2009:973.

MMWR / July 22, 2011 / Vol. 60 / No. 28

953

Morbidity and Mortality Weekly Report

2. Agency for Toxic Substance and Disease Registry. Hazardous Substance
Emergency Events Surveillance. Atlanta, GA: US Department of Health
and Human Services, Agency for Toxic Substances and Disease Registry;
2008–2009. Available at http://www.atsdr.cdc.gov/hs/hsees/public_use_
file.html. Accessed July 19, 2011.
3. Emergency Planning and Preparedness Team, Division of Environmental
and Occupational Disease Control, California Department of Public
Health. Chemical release alert: chlorine gas release at two scrap recycling
facilities. Sacramento, California: California Department of Public
Health; 2010. Available at http://www.cdph.ca.gov/programs/ohb/
documents/chlorinereleasealert.pdf or at [Spanish] http://www.cdph.
ca.gov/programs/ohb/documents/chlorinereleasealertspan.pdf. Accessed
July 15, 2011.
4. Winder C. The toxicology of chlorine. Environ Res 2001;85:105–14.
5. Agency for Toxic Substances and Disease Registry. Toxicological profile
for chlorine. Atlanta, GA: US Department of Health and Human
Services, Agency for Toxic Substances and Disease Registry; 2004.

954

MMWR / July 22, 2011 / Vol. 60 / No. 28

6. Guloglu C, Kara IH, Erten PG. Acute accidental exposure to chlorine
gas in the Southeast of Turkey: a study of 106 cases. Environ Res 2002;​
88:89–93.
7. Hedges JR, Morrissey WL. Acute chlorine gas exposure. JACEP 1979;8:​
59–63.
8. Jones RN, Hughes JM, Glindmeyer H, Weill H. Lung function after
acute chlorine exposure. Am Rev Respir Dis 1986;134:1190–5.
9. Mohan A, Kumar SN, Rao MH, Bollineni S, Manohar IC. Acute
accidental exposure to chlorine gas: clinical presentation, pulmonary
functions and outcomes. Indian J Chest Dis Allied Sci 2010;52:​
149–52.
10. Wenck MA, Van Sickle D, Drociuk D, et al. Rapid assessment of exposure
to chlorine released from a train derailment and resulting health impact.
Public Health Rep 2007;122:784–92.

Morbidity and Mortality Weekly Report

Severe Hearing Impairment Among Military Veterans — United States, 2010
A substantial proportion of hearing loss in the United
States is attributable to employment-related exposure to
noise (1). Among military veterans, the most common
service-connected disabilities are hearing impairments (2),
suggesting that occupational noise exposure during military
service might cause more veterans to have hearing loss than
nonveterans. However, a recent analysis of data from the
1993–1995 Epidemiology of Hearing Loss Study did not
find significant differences between the two groups (3). To
further investigate hearing loss among veterans, specifically
the prevalence of severe hearing impairment (SHI), data from
the 2010 Annual Social and Economic Supplement (ASEC)
to the Current Population Survey (CPS) were analyzed. This
report describes the results of those analyses, which indicated
that the prevalence of SHI among veterans was significantly
greater than among nonveterans. Veterans were 30% more
likely to have SHI than nonveterans after adjusting for age
and current occupation, and veterans who served in the United
States or overseas during September 2001–March 2010, the
era of overseas contingency operations (including Operations
Enduring Freedom and Iraqi Freedom), were four times more
likely than nonveterans to have SHI. These findings suggest
a need for increased emphasis on improving military hearing
conservation programs (HCPs) and on hearing loss surveillance
in military and veterans’ health systems.
CPS is a monthly national survey of 57,000 households
conducted by the Bureau of the Census for the Bureau of
Labor Statistics. CPS obtains information on employment,
demographics and other characteristics of the civilian,
noninstitutionalized population aged ≥16 years. ASEC is
conducted each year in conjunction with the March survey to
collect additional data on work experience, income, noncash
benefits, and migration. Data on all sample household
members are collected from a single respondent by trained
interviewers using a standardized questionnaire during
in-person or telephone interviews. The combined 2010 CPSASEC response rate was 85.9% (4). For this report, data on
151,995 persons aged ≥17 years were analyzed to produce
population-weighted estimates of SHI prevalence for the
total population and various demographic and occupational
subgroups by veteran status and period of most recent military
service (before September 2001 versus September 2001–March
2010). Veteran status was defined as ever having served on
active duty in the armed forces. SHI was identified based on
self or proxy report of being deaf or having “serious difficulty
hearing” (4). Prevalence ratios, adjusted for the effect of

demographic and occupational* factors, were produced using
multivariable Poisson regression. Two regression models were
used. The first, model A, treated the independent variable,
veteran status, as dichotomous, and was used to compare all
veterans with nonveterans. The second, model B, included
three categories for the independent variable and was used to
compare veterans who served before and after September 2001
with nonveterans separately.
In 2010, 8.9% of the U.S. population aged ≥17 years were
veterans, but only 0.7% of the population had served after
September 2001. The prevalence of SHI among nonveterans
was 2.5%. Among all veterans, the prevalence was 10.4%;
among veterans who served after September 2001, the
prevalence was 3.9% (Table  1).† The prevalence of SHI
increased with age for veterans and nonveterans.
Among nonveterans, men and women reported similar
prevalences of SHI (2.3% and 2.5%, respectively). Female
veterans, however, had a significantly lower prevalence of
SHI than male veterans (4.0% versus 10.9%; p<0.05), but
a significantly higher prevalence than either male or female
nonveterans. Among nonveterans and veterans alike, nonHispanic blacks reported the lowest SHI prevalence of all
racial/ethnic groups and non-Hispanic whites the highest. The
prevalence of SHI was significantly higher for veterans than
for nonveterans in all occupational categories (p<0.05) except
farming, fishing, and forestry, and in production occupations.§
Small sample sizes limited the ability to compare subgroups
for veterans who served after September 2001.
In the multivariable analysis, increasing age was positively
associated with SHI, as was working in certain occupational
categories (Table 2) and unemployment or nonparticipation in
the labor force, relative to working in management, business,
and financial occupations. Female sex and race/ethnicity
other than non-Hispanic white were significantly negatively
associated with SHI (p<0.05). Controlling for demographic
factors and occupation, all veterans were 30% more likely to
have SHI than nonveterans in model A (adjusted prevalence
ratio = 1.3). In model B, veterans who served after September
2001 were four times more likely than nonveterans to have
SHI (adjusted prevalence ratio = 4.0) (Table 2).
* Current occupation was defined based on the 11 major groupings of census
occupation codes used in the CPS-ASEC. The CPS-ASEC uses 2002 census
occupation codes, which, in turn, are based on the 2000 standard occupational
classification (SOC) codes.
† Bivariate analyses not age-standardized.
§ Production occupations include assemblers and fabricators; plant and system
operators; machinists and machine operators; and food processing, metal,
plastic, printing, textile, apparel, furnishing, and wood workers.

MMWR / July 22, 2011 / Vol. 60 / No. 28

955

Morbidity and Mortality Weekly Report

TABLE 1. Percentage of persons aged ≥17 years reporting severe hearing impairment (SHI), by veteran status and selected characteristics —
Current Population Survey, United States, 2010
Veterans
Nonveterans
No.*

% with SHI†

(95% CI)

No.*

% with SHI†

(95% CI)

212,237

2.5

(2.3–2.6)

20,634

10.4

(9.8–11.0)

1,696

3.9

(2.6–5.8)

33,463
39,425
38,142
41,128
30,334
29,745

0.4
0.5
1.0
1.5
3.0
10.0

(0.4–0.5)
(0.4–0.6)
(0.8–1.1)
(1.3–1.7)
(2.7–3.3)
(9.4–10.6)

197
1,286
2,051
3,186
5,045
8,869

0.8
2.0
1.8
3.9
8.2
17.4

(0.1–4.9)
(1.2–3.5)
(1.1–2.8)
(3.0–5.0)
(7.1–9.5)
(16.2–18.6)

197
869
257
257
111
4

0.8
2.8
3.7
4.4
17.8
0.0

(0.1–4.9)
(1.6–4.9)
(1.4–9.7)
(1.7–11.3)
(8.4–33.7)
—

93,494
118,743

2.3
2.5

(2.2–2.5)
(2.4–2.7)

19,141
1,493

10.9
4.0

(10.3–11.6)
(2.7–5.7)

1,397
299

4.3
2.5

(2.8–6.3)
(0.8–7.1)

141,442
24,804
31,513
14,479

2.9
1.5
1.6
1.8

(2.7–3.0)
(1.3–1.7)
(1.4–1.8)
(1.5–2.1)

16,825
2,056
1,107
645

11.3
4.6
8.3
8.8

(10.6–12.0)
(3.5–5.8)
(6.5–10.7)
(6.7–11.5)

1,155
262
203
77

4.8
0.8
3.1
4.0

(3.0–7.5)
(0.1–4.8)
(0.9–10.5)
(1.0–14.8)

20,401
30,665
25,854
16,305
18,876
1,119
8,394
4,682
8,299
8,301
11
69,328

1.0
0.9
1.0
1.1
1.0
1.6
1.3
1.3
1.7
1.3
0.0
5.3

(0.8–1.2)
(0.8–1.1)
(0.8–1.1)
(0.9–1.4)
(0.8–1.2)
(0.8–3.1)
(1.0–1.6)
(0.9–2.0)
(1.3–2.2)
(0.9–1.7)
—
(5.0–5.6)

1,936
1,911
1,439
935
874
41
861
776
790
1,053
29
9,989

4.7
3.7
4.0
4.0
5.2
9.0
5.5
5.4
3.2
5.0
5.1
16.7

(3.4–6.5)
(2.6–5.2)
(2.8–5.7)
(2.5–6.3)
(3.3–8.2)
(1.2–45.1)
(3.4–8.8)
(3.3–8.9)
(1.9–5.1)
(3.2–7.7)
(0.7–30.4)
(15.6–17.9)

212
254
271
88
146
4
99
91
101
119
27
285

2.3
2.6
2.3
0.0
5.0
0.0
3.4
6.1
4.4
2.7
5.5
8.4

(0.7–7.7)
(0.8–8.6)
(0.7–7.2)
—
(1.8–13.0)
—
(0.4–23.7)
(2.1–16.4)
(1.0–17.4)
(0.4–17.5)
(0.7–32.3)
(4.5–15.1)

Characteristic
Total
Age group (yrs)
17–24
25–34
35–44
45–54
55–64
≥65
Sex
Male
Female
Race/Ethnicity
White, non-Hispanic
Black, non-Hispanic
Hispanic
Other, non-Hispanic
Current occupation
Management, business, and financial
Professional and related
Service
Sales and related
Office and administrative support
Farming, fishing, and forestry
Construction and extraction
Installation, maintenance, and repair
Production§
Transportation and material moving
Other
Unemployed or not in labor force

September 2001–2010
service period

All service periods

No.* % with SHI†

(95% CI)

Abbreviation: CI: confidence interval.
* Estimated population, in thousands.
† Bivariate analyses not age-standardized.
§ Production occupations include assemblers and fabricators; plant and system operators; machinists and machine operators; and food processing, metal, plastic,
printing, textile, apparel, furnishing, and wood workers.

Reported by

Matthew R. Groenewold, PhD, Sangwoo Tak, ScD, Elizabeth
Masterson, MPH, Div of Surveillance, Hazard Evaluations and
Field Studies, National Institute for Occupational Safety and
Health, CDC. Corresponding contributor: Matthew Groenewold,
[email protected], 513-841-4329.
Editorial Note

Military service can entail harmful exposure to high-intensity
noise from firearms, explosives, jet engines, machinery, and
other sources during combat operations, training, or in the
course of general job duties. Such exposures can cause or
contribute to hearing impairments, including hearing loss,
if adequate hearing protection is not available and properly
used (2,5). The findings in this report indicate that prior
military service is associated with increased prevalence of SHI,
independent of demographic factors and current occupation.

956

MMWR / July 22, 2011 / Vol. 60 / No. 28

For veterans who served after September 2001, the prevalence
is even higher than for other veterans.
Noise-induced hearing loss is a permanent disability,
although the impairment sometimes can be rehabilitated
with hearing aids. Since 1978, the Department of Defense
(DoD) policy has required each of the armed services to have
in place HCPs incorporating noise hazard identification,
safety signs and labels, noise mitigation, education and
training, audiometric surveillance, and program evaluation
(2). However, a 2005 Institute of Medicine report identified
certain shortcomings in military HCPs (5). Between 10%
and 18% of service members enrolled in military HCPs had
standard threshold shifts in hearing,¶ a prevalence two to
five times higher than would be considered acceptable in a
¶ A standard threshold shift is a change of 10 dB or more in the average hearing

thresholds at 2,000, 3,000, and 4,000 Hz in comparison with a baseline
audiogram.

Morbidity and Mortality Weekly Report

civilian, industrial HCPs (5). A more recent report
from the Government Accountability Office (GAO)
Model A
Model B
also concluded that improvements in military HCPs
Characteristic
APR (95% CI)
APR
(95% CI)
would lead to improved outcomes (2). For its part,
†
DoD has acknowledged the increase in sequelae from
Age
1.1
(1.1–1.1)
1.1
(1.1–1.1)
Sex
auditory injuries among service members and the
Male
Referent
Referent
need for improvements to military HCPs, and has
Female
0.6
(0.6–0.7)
0.6
(0.6–0.7)
concurred with the GAO’s recommendations (2).
Race/Ethnicity
Beyond the effect of SHI on the well-being of
White, non-Hispanic
Referent
Referent
Black, non-Hispanic
0.6
(0.6–0.7)
0.6
(0.6–0.7)
individual veterans, higher rates of SHI are costly
Hispanic
0.9
(0.8–1.0)
0.9
(0.8–1.0)
to the nation because of increased use of medical
Other, non-Hispanic
0.8
(0.7–1.0)
0.8
(0.7–1.0)
services and disability payments. According to
Current occupation
Management, business, and financial
Referent
Referent
the Department of Veterans Affairs (VA), hearing
Professional and related
1.0
(0.8–1.3)
1.0
(0.8–1.3)
impairments have been the most common type of
Service
1.3
(1.1–1.7)
1.3
(1.1–1.7)
service-connected disability since 2005, and the
Sales and related
1.3
(1.0–1.7)
1.3
(1.0–1.7)
Office and administrative support
1.3
(1.0–1.7)
1.3
(1.0–1.7)
number of veterans being awarded compensation for
Farming, fishing, and forestry
1.9
(1.0–3.9)
1.9
(1.0–3.9)
hearing impairment has continued to grow each year.
Construction and extraction
1.5
(1.2–2.0)
1.5
(1.2–2.0)
Installation, maintenance, and repair
1.5
(1.1–2.2)
1.5
(1.0–2.2)
In fiscal year 2009, the VA paid approximately $1.1
Production§
1.7
(1.3–2.2)
1.7
(1.3–2.2)
billion to compensate 1.2 million veterans who filed
Transportation and material moving
1.4
(1.0–2.0)
1.4
(1.0–2.0)
claims for service-connected hearing impairments
Other
4.9 (0.4–54.4)
2.0
(0.2–21.4)
Unemployed or not in labor force
2.5
(2.1–3.0)
2.5
(2.1–3.0)
(6,7).
Veteran
The findings in this report are subject to at
Yes
1.3
(1.2–1.5)
—
least
six limitations. First, ascertainment of SHI
No
Referent
—
was
based
on self or proxy report by the survey
Period of military service
September 2001–2010
—
4.0
(2.7–6.0)
household respondent and was not validated by
Before September 2001
—
1.3
(1.2–1.4)
audiometric testing. Although self report has been
None
—
Referent
found to have acceptable sensitivity and specificity
Abbreviation: CI = confidence interval.
compared with audiometric measurement of hearing
* Prevalence ratios statistically adjusted for the effects of all other variables in the table.
† Prevalence ratio associated with a 1-year increase in age.
loss in past studies (8), proxy report has not been
§ Production occupations include assemblers and fabricators; plant and system operators;
similarly validated. This could have resulted in some
machinists and machine operators; and food processing, metal, plastic, printing, textile,
apparel, furnishing, and wood workers.
misclassification errors. Second, although physical
requirements for military service ensured that SHI
was not present in the exposed group before entering military
What is already known on this topic?
service, the specific cause of subsequent hearing impairment was
Military service entails hazardous exposure to high-intensity
not determined. Third, these analyses assume equal incidence
noise. Hearing impairments are the most common types of
of age-related hearing loss and other hearing loss unrelated
service-connected disability for which veterans are being
to noise among veterans and nonveterans. This assumption
compensated by the Department of Veterans Affairs.
most likely resulted in underestimation of prevalence ratios.
What is added by this report?
Persons with congenital deafness and hearing loss resulting
The prevalence of severe hearing impairment (SHI) among
from childhood infections or other nonservice-related causes
veterans is significantly greater than among nonveterans. After
were not excluded from the reference group. Fourth, although
adjusting for age and current occupation, veterans are 30%
attempts were made to adjust for current occupation and
more likely to have SHI than nonveterans, and veterans who
demographic characteristics, data on past occupations and on
served after September 2001 are four times more likely than
nonveterans to have SHI.
recreational and other nonoccupational noise exposures (e.g.,
hunting or listening to loud music) were not available. To the
What are the implications for public health?
extent such factors were differentially distributed between
Improvements in military hearing conservation programs and
increased emphasis on hearing loss surveillance in military and
veterans and nonveterans, adjustments might have been
veterans’ health systems will be needed to reduce the prevalence
insufficient to control for all potential confounding factors.
of disability caused by hearing impairments among veterans.
Fifth, because data on length of service were unavailable,
TABLE 2. Adjusted prevalence ratios (APRs)* for severe hearing impairment among
persons aged ≥17 years — Current Population Survey, United States, 2010

MMWR / July 22, 2011 / Vol. 60 / No. 28

957

Morbidity and Mortality Weekly Report

adjustments for duration of exposure were not possible. Finally,
the cross-sectional nature of these analyses precludes making
direct causal inferences.
Noise-induced hearing loss is preventable. The observed
association of SHI with military service, and particularly
with service in the United States or overseas after September
2001, underscores the need for improved HCPs in the various
service branches and the importance of hearing loss surveillance
in military and VA health systems. The study results also
suggest a need for further research to identify possible causes
for the increased prevalence of SHI among veterans with
service after September 2001. Increased exposure to combat
and its attendant uncontrolled noise hazards is a potential
hypothesis, but data on specific exposures during military
service were unavailable in the CPS-ASEC. In 2008, serious
auditory injuries sustained by service members in Operations
Enduring Freedom and Iraqi Freedom led Congress to mandate
that DoD create a Hearing Center of Excellence to improve
hearing loss prevention and treatment and to establish an
electronic registry to track and share information with the VA
on military personnel with hearing loss.** DoD is finishing
plans for the center and the registry (2). GAO also has made
specific recommendations to DoD for improvement of military
HCPs (2).
** Duncan Hunter National Defense Authorization Act for Fiscal Year 2009,
Pub. L. No. 110-417, Sect. 721, 122 Stat. 4506 (2008).

958

MMWR / July 22, 2011 / Vol. 60 / No. 28

References
1. Tak S, Calvert GM. Hearing difficulty attributable to employment by
industry and occupation: An analysis of the National Health Interview
Survey—United States, 1997 to 2003. J Occup Environ Med 2008;50:​
46–56.
2. US Government Accountability Office. Hearing loss prevention:
improvements to DOD hearing conservation programs could lead to
better outcomes. Washington, DC: US Government Accountability
Office; 2011. Available at http://www.gao.gov/new.items/d11114.pdf.
Accessed July 20, 2011.
3. Wilson RH, Noe CM, Cruickshanks KJ, et al. Prevalence and degree of
hearing loss among males in Beaver Dam cohort: comparison of veterans
and nonveterans. J Rehabil Res Dev 2010;47:505–20.
4. US Census Bureau. Current population survey, 2010 annual social
and economic (ASEC) supplement. Washington, DC: US Census
Bureau; 2010. Available at http://www.census.gov/apsd/techdoc/cps/
cpsmar10.pdf. Accessed July 15, 2011.
5. Committee on Noise-Induced Hearing Loss and Tinnitus Associated
with Military Service from World War II to the Present. Noise and
military service: implications for hearing loss and tinnitus. Humes LE,
Joellenbeck LM, Durch JS, eds. Washington, DC: The National
Academies Press; 2004.
6. National Center for Rehabilitative Auditory Research. Calendar year 2009
annual report. Portland, OR: Department of Veterans Affairs,
Rehabilitation Research and Development; 2010.
7. Veterans Benefits Administration. Annual benefits report, fiscal year 2009.
Washington, DC: US Department of Veterans Affairs; 2010. Available at
http://www.vba.va.gov/reports/abr/2009_abr.pdf. Accessed July 15, 2011.
8. Sindhusake D, Mitchell P, Smith W, et al. Validation of self-reported
hearing loss: the Blue Mountain hearing study. Int J Audiol 2006;45:​
309–17.

Morbidity and Mortality Weekly Report

Announcement

Errata

Epidemic Intelligence Service Application
Deadline — September 1, 2011

Vol 60, No. 27

Applications are now being accepted for CDC’s July 2012–
June 2014 Epidemic Intelligence Service (EIS) program. EIS
is a 2-year, postgraduate program of service and on-the-job
training for health professionals interested in the practice
of epidemiology. Each year, EIS provides approximately
80 persons from around the world opportunities to gain
hands-on experience in epidemiology at CDC or state or local
health departments. EIS officers, often called CDC’s “disease
detectives,” have gone on to assume leadership positions at
CDC and other public health agencies. The EIS experience
also is useful for health professionals who would like to gain a
population-based perspective on public health practice.
Persons with a strong interest in applied epidemiology who
meet at least one of the following qualifications may apply to
EIS: 1) physicians with ≥1 year of clinical training; 2) persons
with a doctoral degree in epidemiology, biostatistics, social
or behavioral sciences, natural sciences, or nutrition sciences;
3) dentists, physician assistants, or nurses with a master of
public health (MPH) or equivalent degree; 4) veterinarians
with an MPH or equivalent degree or relevant public health
experience.
The deadline for submitting applications for the July 2012–
June 2014 EIS program is September 1, 2011. Information
regarding the new EIS online application and program details
is available at http://www.cdc.gov/eis/applynow.html; by
telephone (404-498-6110); or via e-mail ([email protected]).

In the report, “Illnesses associated with exposure to methyl
bromide-fumigated produce—California, 2010,” errors
occurred on pages 923 and 924. On page 923, in the second
full paragraph of the second column, the fifth sentence should
read as follows: “Assuming first-order elimination kinetics and
a 12-day half-life for inorganic bromide, his serum bromide
was estimated to have been 5.87 mg/dL on March 13, his last
day working in cold storage.” On page 924, first full paragraph
of the 1st column, the fourth sentence should read as follows:
“After learning that patient A had similar symptoms, a serum
bromide test was obtained on March 20, 2010, that showed a
bromide level of 1.5 mg/dL, which was estimated to have been a
level of 8.5 mg/dL on patient B’s last work day (February 18).”

MMWR / July 22, 2011 / Vol. 60 / No. 28

959

Morbidity and Mortality Weekly Report

QuickStats
FROM THE NATIONAL CENTER FOR HEALTH STATISTICS

Percentage of Adults Aged ≥18 Years Who Ever Received a Diagnosis
of Diabetes,* by Race/Ethnicity and Hispanic Subpopulation† —
National Health Interview Survey, United States, 2009§
25

Percentage

20
15
10

¶

5
0
White,
nonHispanic

Black,
nonHispanic

Hispanic

Mexican

Puerto
Rican

Cuban

Central
or South
American

Other
Hispanic

Race/Ethnicity and Hispanic subpopulation
* Respondents were asked if they had ever been told by a doctor or other health professional that they had
diabetes or sugar diabetes (female respondents were instructed to exclude pregnancy-related diabetes).
Responses from persons who said they had “borderline” diabetes were treated as unknown with respect to
diabetes. Unknowns were not included in the denominators when calculating percentages.
† Persons of Hispanic origin might be of any race or combination of races.
§ Estimates are based on household interviews of a sample of the U.S. civilian, noninstitutionalized population.
Estimates are age adjusted using the projected 2000 U.S. standard population as the standard population
and using four age groups: 18–44 years, 45–64 years, 65–74 years, and ≥75 years.
¶ 95% confidence interval.

During 2009, non-Hispanic black adults (13.2%) were almost twice as likely as non-Hispanic white adults (7.7%) to have been told
by a doctor or other health professional that they had diabetes. The prevalence of diagnosed diabetes also was higher among
Hispanic adults (12.3%) than among non-Hispanic white adults. Among Hispanic subpopulations, Mexican adults (13.8%) and
Puerto Rican adults (16.7%) were more likely to have been told by a doctor or other health professional that they had diabetes
compared with Central or South American adults (7.3%).
Source: National Health Interview Survey, 2009 data. Available at http://www.cdc.gov/nchs/nhis.htm.

960

MMWR / July 22, 2011 / Vol. 60 / No. 28

Morbidity and Mortality Weekly Report

Notifiable Diseases and Mortality Tables
TABLE I. Provisional cases of infrequently reported notifiable diseases (<1,000 cases reported during the preceding year) — United States, week ending
July 16, 2011 (28th 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

Current
week

Cum
2011

5-year
weekly
average†

Total cases reported f​ or previous years
2010

2009

2008

2007

2006

—

—

—

—

1

—

1

1

—
—
—
—
—
21
1
—
1
—
2
—
—
4
—

2
—
2
—
—
95
45
5
34
6
37
12
24
67
—

3
0
0
0
—
3
3
0
2
0
2
1
0
6
—

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
—

67
8
1
10
—
NN
165
20
97
48
121
33
9
137
—

—
—
5
1
—
2
1
2
2

4
60
145
23
10
55
110
231
136

0
4
3
2
1
7
1
20
1

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

29
175
179
66
40
288
43
884
55

1
—
—
7
—
—
—
—
—
—
—
—
—
—
—
—
—
3
—
—
—
—
—
1
—
—
9
—
—

110
54
5
256
1
1
—
—
1
35
23
12
1
3
—
—
—
74
75
4
42
7
43
185
27
—
222
—
—

5
3
0
9
0
0
—
—
0
3
2
0
0
0
—
—
—
2
8
0
2
0
5
8
1
—
16
—
—

280
135
12
406
4
2
—
—
4
131
106
25
2
5
—
—
—
148
377
10
82
7
124
468
91
2
848
1
—

301
174
23
482
43,774
8
1
—
9
113
93
20
4
3
2
—
—
161
423
18
74
13
93
397
78
1
789
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
—

318
193
32
651
NN
17
—
NN
21
169
—
—
3
11
1
—
—
125
349
41
101
15
95
353
6
1
NN
NN
—

States reporting cases
during current week (No.)

RI (2), NY (16), PA (3)

TX (1)
CA (2)

NY (1), FL (2), TX (1)

OH (2), MD (1), FL (1), HI (1)
FL (1)
FL (1), TN (1)
VA (1)
NY (1), KY (1)
NY (1), PA (1)
NY (1)

NY (2), MD (1), FL (3), CA (1)

NY (3)

FL (1)

GA (1), FL (6), TX (1), CA (1)

See Table 1 footnotes on next page.

MMWR / July 22, 2011 / Vol. 60 / No. 28

961

Morbidity and Mortality Weekly Report

TABLE I. (Continued) Provisional cases of infrequently reported notifiable diseases (<1,000 cases reported during the preceding year) — United States, week
ending July 16, 2011 (28th week)*
—: No reported cases.  N: Not reportable.  NN: Not Nationally Notifiable.  Cum: Cumulative year-to-date counts.
* Case counts for reporting years 2010 and 2011 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 3, 2010, 114 influenza-associated pediatric deaths
occurring during the 2010-11 influenza season have been reported.
§§ The two measles cases reported for the current week were 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 one case reported in 2011 were identified as swine influenza A (H3N2) virus and are unrelated to the 2009 pandemic influenza A (H1N1) virus. Total case counts for
2009 were 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 was one case of viral hemorrhagic fever reported during week 12 of 2010. The one case report was confirmed as lassa fever. See Table II for dengue hemorrhagic fever.

FIGURE I. Selected notifiable disease reports, United States, comparison of provisional 4-week
totals July 16, 2011, with historical data
DISEASE

DECREASE

INCREASE

CASES CURRENT
4 WEEKS

Giardiasis

570

Hepatitis A, acute

40

Hepatitis B, acute

71

Hepatitis C, acute

36

Legionellosis

144

Measles

7

Meningococcal disease

21

Mumps

5

Pertussis

329
0.0625

0.125

0.25

0.5

1

2

4

Ratio (Log scale)*
Beyond historical limits

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

Notifiable Disease Data Team and 122 Cities Mortality Data Team

Jennifer Ward, MS
Deborah A. Adams Rosaline Dhara
Willie J. Anderson Pearl C. Sharp
Lenee Blanton Michael S. Wodajo

962

MMWR / July 22, 2011 / Vol. 60 / No. 28

Morbidity and Mortality Weekly Report

TABLE II. Provisional cases of selected notifiable diseases, United States, weeks ending July 16, 2011, and July 17, 2010 (28th week)*
Coccidioidomycosis

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

Cum
2011

Cum
2010

31,142
2,043
1,557
100
860
81
154
84
5,069
684
2,099
2,612
1,231
7,039
1,320
3,376
1,397
1,134
559
1,643
240
287
361
766
218
90
93
6,539
220
180
1,706
2,384
1,125
1,477
946
970
121
3,314
1,566
2,352
614
795
4,723
440
1,052
1,371
3,107
2,155
697
848
199
83
380
1,183
175
90
6,559
157
5,763
138
524
522

669,718
22,909
4,918
1,659
11,815
1,528
2,204
785
84,199
11,522
18,966
26,724
26,987
100,850
23,853
13,660
25,143
26,506
11,688
35,618
5,424
5,216
5,596
13,680
3,275
664
1,763
144,822
2,320
2,542
40,265
27,505
11,450
25,109
14,958
18,475
2,198
49,497
14,340
8,568
10,832
15,757
85,240
8,494
6,949
5,319
64,478
43,715
12,531
12,584
1,403
1,761
5,763
5,326
3,380
967
102,868
2,909
78,682
2,521
7,329
11,427

686,384
21,168
5,199
1,332
10,863
1,216
1,883
675
89,591
14,048
17,195
33,485
24,863
107,907
31,968
9,985
26,617
27,212
12,125
38,414
5,683
5,227
8,224
13,661
2,761
1,201
1,657
139,084
2,287
2,847
39,996
23,483
12,728
25,437
14,034
16,346
1,926
49,005
13,651
8,550
11,922
14,882
95,928
8,267
15,110
7,048
65,503
44,480
14,521
10,378
2,051
1,606
5,410
5,887
3,524
1,103
100,807
3,312
76,658
3,332
6,208
11,297

0
—
81
349
27

—
—
189
3,351
328

—
—
545
3,367
315

Med

Max

10,304
794
—
65
571
48
75
35
1,587
58
683
200
646
1,122
15
206
468
306
127
121
17
11
U
—
74
—
19
3,475
69
—
657
611
421
980
—
682
55
994
—
207
568
219
—
—
—
—
—
594
111
210
—
45
178
48
—
2
1,617
—
1,388
—
229
—

25,725
847
228
57
403
53
70
26
3,321
479
712
1,145
953
4,001
1,110
455
946
1,000
472
1,437
208
190
289
524
102
39
65
5,111
83
105
1,490
930
460
756
523
662
78
1,826
542
268
392
586
3,294
311
343
226
2,369
1,680
514
408
61
62
197
194
131
38
3,758
115
2,884
109
255
430

—
—
—
82
—

0
—
4
105
14

Current
week

Previous 52 weeks

Cryptosporidiosis

Med

Max

Cum
2011

Cum
2010

83
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
U
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
48
48
—
—
—
—
—
—
—
35
—
35
—
—
—

86
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
60
58
0
0
0
1
0
0
0
20
0
20
0
0
0

567
1
0
0
0
1
0
0
1
0
0
0
1
3
0
0
3
3
0
1
0
0
0
0
1
0
0
2
0
0
0
0
2
0
0
0
0
0
0
0
0
0
1
0
1
0
0
432
427
0
0
1
4
4
2
2
142
0
142
0
1
0

8,794
1
—
—
—
1
—
—
3
—
—
—
3
26
—
—
16
10
—
2
—
—
—
—
2
—
—
3
—
—
—
—
3
—
—
—
—
—
—
—
—
—
1
—
1
—
—
6,931
6,841
—
—
2
48
31
6
3
1,827
—
1,826
—
1
—

NN
NN
NN
NN
NN
NN
NN
NN
NN
NN
NN
NN
NN
NN
NN
NN
NN
NN
NN
NN
NN
NN
NN
NN
NN
NN
NN
NN
NN
NN
NN
NN
NN
NN
NN
NN
NN
NN
NN
NN
NN
NN
NN
NN
NN
NN
NN
NN
NN
NN
NN
NN
NN
NN
NN
NN
NN
NN
NN
NN
NN
NN

—
—
—
—
—

0
—
0
0
0

0
—
0
0
0

—
—
—
—
—

NN
NN
NN
NN
NN

Current
week

Previous 52 weeks
Med

Max

Cum
2011

Cum
2010

88
—
—
—
—
—
—
—
20
—
4
—
16
13
—
—
—
13
—
15
—
—
U
6
6
3
—
14
1
—
5
5
—
—
—
3
—
3
—
1
—
2
5
—
1
—
4
12
—
7
5
—
—
—
—
—
6
—
6
—
—
—

95
4
0
0
2
1
0
1
14
1
4
2
8
23
1
4
5
8
8
10
2
0
1
3
3
0
0
18
0
0
6
5
1
0
2
1
0
4
1
1
0
1
6
0
0
0
4
10
1
2
1
1
0
3
1
0
11
0
6
0
3
0

374
29
24
7
9
3
2
5
38
4
13
6
26
137
21
15
18
24
65
99
25
6
22
29
26
9
4
53
1
1
19
11
6
17
8
5
5
19
13
6
2
5
33
3
9
8
24
30
3
10
7
5
7
12
5
3
27
3
19
0
13
9

2,275
96
24
3
32
17
1
19
368
18
76
32
242
520
5
44
117
206
148
192
27
3
—
66
69
16
11
422
4
4
107
144
33
36
51
31
12
83
9
24
16
34
127
8
23
—
96
244
15
73
36
32
3
52
23
10
223
7
144
—
68
4

3,522
267
77
32
77
36
11
34
356
14
69
38
235
935
106
142
165
193
329
598
132
51
174
108
64
12
57
516
4
2
192
154
20
47
34
57
6
106
40
35
7
24
173
16
20
41
96
264
16
66
47
30
8
49
34
14
307
2
174
1
91
39

N
—
—
N
—

0
—
0
0
0

0
—
0
0
0

N
—
—
N
—

N
—
—
N
—

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.
* Case counts for reporting year 2010 and 2011 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. Data for TB are displayed in Table IV, which appears quarterly.
† Contains data reported through the National Electronic Disease Surveillance System (NEDSS).

MMWR / July 22, 2011 / Vol. 60 / No. 28

963

Morbidity and Mortality Weekly Report

TABLE II. (Continued) Provisional cases of selected notifiable diseases, United States, weeks ending July 16, 2011, and July 17, 2010 (28th week)*
Dengue Virus Infection†
Dengue Fever§
Reporting area

Current
week

Previous 52 weeks
Med

Dengue Hemorrhagic Fever¶
Cum ​
2011

Max

Cum ​
2010

Current
week

Previous 52 weeks
Med

Max

Cum ​
2011

Cum ​
2010

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

—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
U
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—

3
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
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

55
3
0
2
0
0
1
1
25
5
5
17
3
7
3
2
2
2
2
6
1
1
1
1
6
0
0
19
0
0
13
2
0
2
3
3
1
2
2
1
0
0
4
0
2
1
2
2
2
0
1
1
1
0
1
0
7
0
5
0
0
2

44
1
—
—
—
—
—
1
19
—
—
10
9
4
1
1
—
—
2
—
—
—
—
—
—
—
—
11
—
—
10
—
—
1
—
—
—
—
—
—
—
—
—
—
—
—
—
3
2
—
—
—
—
—
1
—
6
—
2
—
—
4

248
4
—
3
—
—
—
1
71
8
11
43
9
18
4
4
3
5
2
16
1
2
9
3
—
1
—
96
—
—
78
6
—
—
5
5
2
1
—
—
—
1
13
—
1
1
11
7
2
—
1
2
1
1
—
—
22
1
17
—
—
4

—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
U
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—

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

2
0
0
0
0
0
0
0
1
0
1
1
0
1
0
0
0
0
1
1
0
0
0
0
0
0
1
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

—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—

4
—
—
—
—
—
—
—
2
—
1
1
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
1
—
—
1
—
—
—
—
—
—
—
—
—
—
—
1
1
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—

Territories
American Samoa
C.N.M.I.
Guam
Puerto Rico
U.S. Virgin Islands

—
—
—
—
—

0
—
0
32
0

0
—
0
550
0

—
—
—
299
—

—
—
—
4,308
—

—
—
—
—
—

0
—
0
0
0

0
—
0
20
0

—
—
—
1
—

—
—
—
96
—

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.
* Case counts for reporting year 2010 and 2011 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. Data for TB are displayed in Table IV, which appears quarterly.
† Updated weekly from reports to the Division of Vector-Borne Infectious Diseases, National Center for Zoonotic, Vector-Borne, and Enteric Diseases (ArboNET Surveillance).
§ Dengue Fever includes cases that meet criteria for Dengue Fever with hemorrhage, other clinical and unknown case classifications.
¶ DHF includes cases that meet criteria for dengue shock syndrome (DSS), a more severe form of DHF.
** Contains data reported through the National Electronic Disease Surveillance System (NEDSS).

964

MMWR / July 22, 2011 / Vol. 60 / No. 28

Morbidity and Mortality Weekly Report

TABLE II. (Continued) Provisional cases of selected notifiable diseases, United States, weeks ending July 16, 2011, and July 17, 2010 (28th week)*
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
2011

Cum
2010

Current
week

Previous 52 weeks
Med

Max

Cum
2011

Undetermined
Cum
2010

Current
week

Previous 52 weeks
Med

Max

Cum
2011

Cum
2010

Pacific
Alaska
California
Hawaii
Oregon
Washington

21
—
—
—
—
—
—
—
5
—
5
—
—
—
—
—
—
—
—
4
N
—
U
4
—
N
—
4
—
N
1
—
2
—
—
1
—
3
—
—
—
3
5
5
—
—
—
—
—
N
N
N
N
N
—
—
—
N
—
N
—
—

6
0
0
0
0
0
0
0
1
0
0
0
0
0
0
0
0
0
0
1
0
0
0
0
0
0
0
3
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

109
2
0
1
0
1
1
0
7
2
7
1
1
4
2
0
1
3
1
13
0
1
12
13
1
0
0
18
2
0
3
3
2
13
1
8
1
11
3
2
1
7
87
5
0
82
1
0
0
0
0
0
0
0
0
0
1
0
1
0
0
0

232
3
—
1
—
1
1
—
23
—
20
3
—
10
6
—
1
3
—
75
N
2
—
73
—
N
—
84
12
N
11
8
12
15
—
26
—
31
—
7
—
24
6
6
—
—
—
—
—
N
N
N
N
N
—
—
—
N
—
N
—
—

326
3
—
2
—
1
—
—
51
37
10
3
1
25
10
—
—
2
13
73
N
5
—
68
—
N
—
116
11
N
6
15
13
35
3
32
1
44
6
8
1
29
13
—
1
10
2
—
—
N
N
N
N
N
—
—
1
N
1
N
—
—

18
5
—
—
—
—
4
1
13
—
13
—
—
—
—
—
—
—
—
—
N
—
U
—
—
N
—
—
—
N
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
N
N
N
N
N
—
—
—
N
—
N
—
—

15
1
0
0
0
0
0
0
4
0
3
0
0
1
0
0
0
0
1
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
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0

89
8
6
2
0
3
6
1
20
3
18
5
1
24
2
0
1
1
23
45
0
0
44
3
0
0
0
4
1
0
1
1
1
4
1
1
0
2
2
0
1
2
9
2
0
7
1
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0

161
27
—
7
—
7
11
2
87
—
73
14
—
7
2
—
—
2
3
14
N
—
1
13
—
N
—
19
1
N
3
5
1
7
—
2
—
7
3
—
—
4
—
—
—
—
—
—
—
N
N
N
N
N
—
—
—
N
—
N
—
—

1,094
56
22
12
—
8
13
1
112
47
59
6
—
347
2
—
2
—
343
534
N
1
526
7
—
N
—
35
4
N
1
1
12
11
—
6
—
10
4
—
1
5
—
—
—
—
—
—
—
N
N
N
N
N
—
—
—
N
—
N
—
—

1
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
N
—
U
—
—
N
—
—
—
N
—
—
—
—
—
—
—
1
N
—
—
1
—
—
—
—
—
—
—
N
N
N
N
N
—
—
—
N
—
N
—
—

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
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
2
0
1
4
1
3
1
1
3
11
0
0
11
7
1
0
1
1
0
0
0
1
1
0
0
1
0
1
0
0
0
1
1
0
0
0
1
1
1
0
0
0
0
0
0
0
1
0
1
0
0
0

40
1
—
—
—
1
—
—
3
—
3
—
—
16
2
11
1
1
1
13
N
—
—
11
1
N
1
1
—
N
—
1
—
—
—
—
—
3
N
—
—
3
—
—
—
—
—
2
2
N
N
N
N
N
—
—
1
N
1
N
—
—

52
2
—
—
—
2
—
—
7
1
4
—
2
28
3
11
—
—
14
5
N
—
—
5
—
N
—
1
—
N
—
1
—
—
—
—
—
7
N
1
1
5
—
—
—
—
—
—
—
N
N
N
N
N
—
—
2
N
2
N
—
—

Territories
American Samoa
C.N.M.I.
Guam
Puerto Rico
U.S. Virgin Islands

N
—
N
N
—

0
—
0
0
0

0
—
0
0
0

N
—
N
N
—

N
—
N
N
—

N
—
N
N
—

0
—
0
0
0

0
—
0
0
0

N
—
N
N
—

N
—
N
N
—

N
—
N
N
—

0
—
0
0
0

0
—
0
0
0

N
—
N
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
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§

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.
* Case counts for reporting year 2010 and 2011 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. Data for TB are displayed in Table IV, which appears quarterly.
† Cumulative total E. ewingii cases reported for year 2010 = 10, and 6 cases reported for 2011.
§ Contains data reported through the National Electronic Disease Surveillance System (NEDSS).

MMWR / July 22, 2011 / Vol. 60 / No. 28

965

Morbidity and Mortality Weekly Report

TABLE II. (Continued) Provisional cases of selected notifiable diseases, United States, weeks ending July 16, 2011, and July 17, 2010 (28th week)*
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
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

Haemophilus influenzae, invasive†
All ages, all serotypes

Gonorrhea

Current Previous 52 weeks Cum
week
Med Max
2011

Cum
2010

Current Previous 52 weeks
week
Med
Max

Cum
2011

Cum
2010

Current
week

Previous 52 weeks
Med

Max

Cum
2011

Cum
2010

161
1
—
1
—
—
—
—
33
—
20
3
10
25
—
—
1
23
1
18
3
—
U
8
2
2
3
33
—
—
16
10
5
N
—
2
—
1
1
N
N
N
4
3
1
—
N
13
1
10
—
1
—
1
—
—
33
—
33
—
—
—

291
24
5
3
11
2
1
3
60
8
21
17
16
50
9
6
10
16
8
26
5
2
5
8
4
0
1
60
1
1
25
14
4
0
2
8
0
4
4
0
0
0
5
2
3
0
0
27
3
12
4
1
2
2
4
0
49
2
32
0
7
9

549
55
12
11
25
7
7
10
106
22
72
30
27
99
31
14
25
29
35
73
12
10
33
26
9
12
5
127
5
5
75
51
10
0
9
32
8
11
11
0
0
0
17
9
12
5
0
58
8
27
9
6
11
5
13
5
129
7
68
4
20
57

6,757
477
103
60
176
39
29
70
1,378
128
463
433
354
1,077
185
119
220
393
160
485
122
40
—
178
91
21
33
1,366
17
16
577
430
120
N
53
131
22
85
85
N
N
N
99
54
45
—
N
594
63
285
69
28
35
32
68
14
1,196
39
839
14
156
148

9,496
820
148
93
351
99
38
91
1,580
220
533
451
376
1,639
368
203
348
428
292
983
145
119
361
189
108
11
50
1,914
15
31
1,020
376
163
N
66
227
16
87
87
N
N
N
191
55
80
56
N
880
76
371
110
60
30
54
153
26
1,402
51
869
31
249
202

2,337
82
—
6
55
5
16
—
291
23
88
46
134
384
6
52
173
115
38
28
9
1
U
—
16
—
2
988
9
—
202
190
83
351
—
145
8
283
—
65
176
42
—
—
—
—
—
96
32
15
—
—
44
5
—
—
185
—
176
—
9
—

5,805
101
43
3
48
3
5
0
716
116
113
238
263
1,048
285
113
244
321
99
297
38
39
38
144
23
3
12
1,471
17
37
382
315
123
257
155
116
14
495
160
71
116
140
863
101
94
66
596
185
64
46
2
1
33
28
4
0
626
20
513
13
23
59

7,484
206
150
7
80
7
15
8
1,121
172
271
497
364
2,091
369
1,018
490
383
130
363
57
57
62
181
49
9
20
1,862
48
70
486
874
246
468
257
185
26
1,007
414
712
197
194
1,664
138
509
332
867
253
95
84
14
5
103
98
9
3
807
34
695
26
40
86

148,956
2,702
1,135
95
1,208
71
167
26
18,207
2,925
2,910
5,643
6,729
26,186
5,859
3,292
6,369
8,286
2,380
7,296
975
985
744
3,614
630
61
287
38,686
455
920
10,236
8,398
2,807
8,228
4,228
2,989
425
13,147
4,308
2,305
2,840
3,694
21,514
2,571
1,858
1,562
15,523
4,972
1,742
1,089
48
37
1,080
833
121
22
16,246
489
13,356
328
646
1,427

159,638
2,863
1,334
104
1,185
76
133
31
18,062
2,992
2,738
6,253
6,079
29,166
8,009
2,804
7,308
8,550
2,495
7,546
882
1,112
1,133
3,506
635
106
172
41,344
516
1,116
10,687
8,098
3,629
8,486
4,270
4,297
245
13,206
3,999
2,178
3,288
3,741
25,770
2,448
4,331
2,082
16,909
5,056
1,737
1,418
55
62
972
596
195
21
16,625
732
13,551
373
538
1,431

31
1
—
—
—
—
1
—
8
—
3
3
2
6
—
—
—
6
—
—
—
—
U
—
—
—
—
8
—
—
3
1
3
1
—
—
—
2
—
—
—
2
—
—
—
—
—
3
—
1
2
—
—
—
—
—
3
—
—
1
2
—

63
4
1
0
1
0
0
0
12
2
3
2
4
11
3
2
1
3
1
4
0
0
0
1
0
0
0
15
0
0
5
3
1
2
1
2
0
3
1
0
0
1
2
0
0
1
0
5
2
1
0
0
0
1
0
0
3
0
0
0
1
0

141
12
6
2
6
2
2
3
32
7
18
6
11
19
9
7
4
7
5
10
0
2
5
5
3
6
1
30
2
0
12
7
4
9
5
8
9
11
4
4
3
5
26
3
4
19
4
12
6
5
2
1
2
4
3
1
10
2
6
3
6
2

1,823
105
33
14
37
9
8
4
399
65
103
80
151
329
95
57
35
100
42
88
—
12
—
45
21
9
1
442
3
—
148
87
45
49
38
63
9
122
38
17
11
56
73
19
27
26
1
162
62
40
11
2
12
23
11
1
103
12
18
16
55
2

1,768
101
21
8
53
7
8
4
335
57
89
55
134
287
97
60
21
70
39
123
1
13
45
45
11
8
—
451
5
—
112
109
34
73
56
50
12
108
19
20
9
60
86
14
19
47
6
194
73
56
11
2
5
22
20
5
83
14
15
13
37
4

—
—
—
—
—

0
—
0
1
0

0
—
1
7
0

—
—
—
13
—

—
—
2
44
—

—
—
—
6
—

0
—
0
6
2

0
—
17
12
7

—
—
6
187
49

—
—
49
154
73

—
—
—
—
—

0
—
0
0
0

0
—
0
0
0

—
—
—
—
—

—
—
—
1
—

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.
* Case counts for reporting year 2010 and 2011 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. Data for TB are displayed in Table IV, which appears quarterly.
† Data for H. influenzae (age <5 yrs for serotype b, nonserotype b, and unknown serotype) are available in Table I.
§ Contains data reported through the National Electronic Disease Surveillance System (NEDSS).

966

MMWR / July 22, 2011 / Vol. 60 / No. 28

Morbidity and Mortality Weekly Report

TABLE II. (Continued) Provisional cases of selected notifiable diseases, United States, weeks ending July 16, 2011, and July 17, 2010 (28th week)*
Hepatitis (viral, acute), by type
A
Reporting area
United States
New England
Connecticut
Maine†
Massachusetts
New Hampshire
Rhode Island†
Vermont†

Current Previous 52 weeks
week
Med
Max

B
Cum
2011

Cum
2010

Current
week

Previous 52 weeks

C

Med

Max

Cum
2011

Cum
2010

Current
week

Previous 52 weeks
Med

Max

Cum
2011

Cum
2010

Pacific
Alaska
California
Hawaii
Oregon
Washington

10
2
—
—
—
—
—
2
1
—
—
—
1
—
—
—
—
—
—
—
—
—
U
—
—
—
—
5
—
—
1
1
1
1
—
1
—
—
—
—
—
—
1
—
—
—
1
—
—
—
—
—
—
—
—
—
1
—
1
—
—
—

22
0
0
0
0
0
0
0
4
1
1
1
1
3
1
0
1
1
0
1
0
0
0
0
0
0
0
5
0
0
2
1
0
0
0
1
0
0
0
0
0
0
2
0
0
0
2
2
0
0
0
0
0
0
0
0
4
0
2
0
0
0

74
6
4
1
5
1
1
1
12
4
4
6
3
9
3
3
5
5
2
25
3
2
22
1
4
3
2
14
1
0
7
4
2
4
2
4
5
6
2
6
1
5
15
1
1
4
11
5
2
2
1
1
3
1
2
1
15
1
15
2
2
5

534
15
5
1
3
—
2
4
101
11
25
36
29
92
16
10
40
23
3
17
2
3
2
5
3
—
2
118
1
—
40
28
12
13
5
14
5
25
1
5
3
16
54
—
2
1
51
39
9
14
5
2
4
3
—
2
73
2
46
5
5
15

816
62
15
5
35
—
7
—
134
40
27
38
29
95
26
10
33
17
9
27
4
8
1
11
3
—
—
182
5
1
65
21
13
31
19
26
1
22
5
9
1
7
74
—
5
1
68
96
44
23
6
4
7
3
6
3
124
1
95
5
11
12

12
—
—
—
—
—
U
—
1
—
—
—
1
1
—
—
1
—
—
—
—
—
U
—
—
—
—
6
—
—
2
1
1
1
—
1
—
1
1
—
—
—
1
—
—
—
1
2
—
2
—
—
—
—
—
—
—
—
—
—
—
—

57
0
0
0
0
0
0
0
5
1
1
1
1
6
2
1
2
1
0
2
0
0
0
2
0
0
0
14
0
0
4
2
1
2
1
1
0
8
1
3
1
3
8
1
1
1
4
2
0
0
0
0
0
0
0
0
4
0
2
0
1
1

167
5
4
2
3
1
0
0
11
4
9
5
4
34
6
6
5
30
3
16
1
2
15
5
3
0
1
33
1
0
11
8
4
16
4
7
18
14
4
8
3
8
67
4
4
16
45
7
3
5
1
0
3
2
1
1
25
1
22
1
3
4

1,168
21
7
5
8
1
U
—
135
26
24
43
42
170
36
18
48
55
13
66
6
7
2
42
8
—
1
321
—
—
110
45
27
67
18
35
19
203
42
60
21
80
138
22
23
25
68
49
11
12
2
—
18
5
1
—
65
4
23
5
20
13

1,676
34
10
10
8
4
U
2
168
48
26
50
44
280
71
37
74
66
32
65
10
4
2
39
9
—
1
457
18
3
158
99
36
35
31
46
31
180
35
56
19
70
265
37
28
43
157
71
15
19
4
—
23
3
7
—
156
1
104
3
26
22

10
1
—
—
—
N
U
1
2
—
1
—
1
—
—
—
—
—
—
—
—
—
U
—
—
—
—
3
U
—
—
—
—
1
1
1
—
2
—
—
U
2
1
—
—
—
1
—
U
—
—
—
—
—
—
—
1
U
1
U
—
—

17
1
0
0
0
0
0
0
1
0
0
0
0
3
0
0
1
0
0
0
0
0
0
0
0
0
0
4
0
0
1
0
0
1
0
0
0
3
0
2
0
1
2
0
0
1
0
1
0
0
0
0
0
0
0
0
1
0
0
0
0
0

39
4
3
2
1
0
0
1
6
4
4
1
2
12
1
5
7
1
1
6
0
1
6
1
1
0
0
11
0
0
5
3
2
7
1
2
5
8
1
6
0
5
11
0
2
10
3
4
0
3
2
1
2
1
2
1
12
1
4
0
3
5

488
25
15
5
1
N
U
4
40
—
25
—
15
100
2
37
56
4
1
2
—
2
—
—
—
—
—
117
U
—
29
16
19
34
1
9
9
91
7
38
U
46
45
—
5
21
19
34
U
12
6
2
7
4
1
2
34
U
12
U
10
12

425
35
21
2
12
N
U
—
55
13
26
2
14
52
—
18
25
6
3
7
—
—
3
2
2
—
—
91
U
2
25
12
14
24
—
8
6
76
3
52
U
21
40
1
1
13
25
32
U
8
7
—
3
9
5
—
37
U
17
U
9
11

Territories
American Samoa
C.N.M.I.
Guam
Puerto Rico
U.S. Virgin Islands

—
—
—
—
—

0
—
0
0
0

0
—
5
2
0

—
—
8
3
—

—
—
4
10
—

—
—
—
—
—

0
—
0
0
0

0
—
8
3
0

—
—
28
6
—

—
—
48
13
—

—
—
—
N
—

0
—
0
0
0

0
—
8
0
0

—
—
10
N
—

—
—
40
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
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†

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.
* Case counts for reporting year 2010 and 2011 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. Data for TB are displayed in Table IV, which appears quarterly.
† Contains data reported through the National Electronic Disease Surveillance System (NEDSS).

MMWR / July 22, 2011 / Vol. 60 / No. 28

967

Morbidity and Mortality Weekly Report

TABLE II. (Continued) Provisional cases of selected notifiable diseases, United States, weeks ending July 16, 2011, and July 17, 2010 (28th week)*
Legionellosis
Reporting area
United States
New England
Connecticut
Maine†
Massachusetts
New Hampshire
Rhode Island†
Vermont†

Current Previous 52 weeks
week
Med
Max

Lyme disease

Cum
2011

Cum
2010

Current
week

Previous 52 weeks
Med

Max

Malaria
Cum
2011

Cum
2010

Current
week

Previous 52 weeks
Med

Max

Cum
2011

Cum
2010

Pacific
Alaska
California
Hawaii
Oregon
Washington

63
—
—
—
—
—
—
—
11
—
6
—
5
31
—
2
2
27
—
2
—
—
U
1
1
—
—
5
—
—
4
—
—
1
—
—
—
4
—
—
—
4
3
—
—
—
3
—
—
—
—
—
—
—
—
—
7
—
7
—
—
—

49
3
1
0
1
0
0
0
14
2
5
3
5
9
1
1
2
4
0
2
0
0
0
1
0
0
0
9
0
0
3
1
1
1
0
1
0
2
0
0
0
1
3
0
0
0
2
2
1
0
0
0
0
0
0
0
5
0
4
0
0
0

128
16
6
3
10
5
4
2
53
18
19
17
19
44
12
5
20
34
5
9
2
2
8
5
1
1
2
22
1
3
9
4
6
6
2
9
2
10
2
4
3
8
13
2
3
2
11
10
7
2
1
1
2
2
2
2
21
0
15
1
2
6

1,168
47
15
3
17
3
5
4
291
24
105
49
113
273
22
36
51
163
1
39
5
4
—
27
1
1
1
201
3
8
76
14
31
32
5
27
5
75
10
13
9
43
50
4
8
2
36
45
15
4
4
—
8
4
9
1
147
—
133
1
4
9

1,491
97
16
4
56
5
12
4
353
58
104
61
130
314
81
27
59
115
32
61
5
6
18
21
5
2
4
287
10
13
85
36
63
31
7
33
9
71
7
13
9
42
68
11
4
7
46
94
28
18
2
4
16
5
16
5
146
2
124
1
8
11

697
43
—
—
—
—
27
16
576
148
202
—
226
1
—
—
—
1
—
—
—
—
U
—
—
—
—
76
6
—
7
—
19
—
—
44
—
—
—
—
—
—
—
—
—
—
—
1
—
—
—
1
—
—
—
—
—
—
—
N
—
—

334
74
34
10
11
13
1
4
146
43
35
1
61
21
1
0
1
1
17
3
0
0
2
0
0
0
0
57
10
0
1
0
17
0
0
19
0
0
0
0
0
0
1
0
0
0
1
0
0
0
0
0
0
0
0
0
3
0
2
0
0
0

1,575
401
151
62
173
43
40
28
868
482
168
30
307
224
9
7
14
9
201
171
5
1
164
1
2
10
0
178
32
5
8
1
103
9
3
76
29
3
2
1
0
3
29
0
1
0
29
3
1
1
2
1
1
1
1
0
11
1
9
0
3
4

9,286
1,386
745
133
94
260
47
107
6,021
2,236
1,130
11
2,644
443
37
23
19
19
345
26
19
3
—
—
4
—
—
1,294
336
9
44
5
430
23
6
421
20
19
7
—
—
12
18
—
—
—
18
7
3
1
—
1
—
1
1
—
72
1
53
N
18
—

16,836
5,270
1,873
229
2,185
790
41
152
5,690
2,302
1,050
366
1,972
2,476
89
56
37
12
2,282
1,383
62
9
1,302
2
5
2
1
1,833
423
18
31
8
817
34
21
466
15
29
—
2
—
27
49
—
—
—
49
13
2
—
4
1
—
4
2
—
93
4
58
N
26
5

21
1
—
—
—
—
—
1
1
—
—
—
1
5
—
—
1
4
—
—
—
—
U
—
—
—
—
10
—
—
3
—
1
—
—
6
—
1
—
1
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
3
—
3
—
—
—

26
1
0
0
0
0
0
0
8
1
1
4
1
3
1
0
0
1
0
1
0
0
0
0
0
0
0
7
0
0
2
1
1
0
0
1
0
1
0
0
0
0
1
0
0
0
1
1
0
0
0
0
0
0
0
0
4
0
2
0
0
0

114
20
20
1
5
2
4
1
22
6
6
13
4
9
6
2
4
5
2
45
2
2
45
3
1
1
1
41
1
1
7
7
21
13
1
4
1
3
1
1
2
2
18
1
1
1
17
4
4
3
1
1
2
1
0
0
10
2
10
1
3
5

557
20
1
2
9
2
2
4
124
8
22
66
28
66
21
5
13
23
4
7
3
2
—
—
2
—
—
198
4
5
52
37
44
17
1
38
—
14
3
5
1
5
21
2
—
2
17
32
14
12
1
—
3
2
—
—
75
3
55
2
5
10

746
55
2
5
39
1
6
2
243
62
35
112
34
79
31
7
15
21
5
28
7
3
3
4
9
—
2
191
2
9
59
34
31
18
3
35
—
14
3
3
—
8
42
2
2
3
35
29
13
9
—
1
3
—
3
—
65
2
38
2
6
17

Territories
American Samoa
C.N.M.I.
Guam
Puerto Rico
U.S. Virgin Islands

N
—
—
—
—

0
—
0
0
0

0
—
1
1
0

N
—
—
—
—

N
—
—
1
—

N
—
—
N
—

0
—
0
0
0

0
—
0
0
0

N
—
—
N
—

N
—
—
N
—

—
—
—
—
—

0
—
0
0
0

0
—
0
1
0

—
—
—
—
—

—
—
—
4
—

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†

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.
* Case counts for reporting year 2010 and 2011 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. Data for TB are displayed in Table IV, which appears quarterly.
† Contains data reported through the National Electronic Disease Surveillance System (NEDSS).

968

MMWR / July 22, 2011 / Vol. 60 / No. 28

Morbidity and Mortality Weekly Report

TABLE II. (Continued) Provisional cases of selected notifiable diseases, United States, weeks ending July 16, 2011, and July 17, 2010 (28th week)*
Meningococcal disease, invasive† ​
All serogroups
Reporting area
United States
New England
Connecticut
Maine§
Massachusetts
New Hampshire
Rhode Island§
Vermont§

Current Previous 52 weeks
week
Med
Max

Cum
2011

Mumps

Cum
2010

Current
week

Previous 52 weeks
Med

Max

Pertussis
Cum
2011

Cum
2010

Current
week

Previous 52 weeks
Med

Max

Cum
2011

Cum
2010

Pacific
Alaska
California
Hawaii
Oregon
Washington

8
—
—
—
—
—
—
—
3
—
3
—
—
—
—
—
—
—
—
—
—
—
U
—
—
—
—
4
—
—
3
—
1
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
1
—
1
—
—
—

14
0
0
0
0
0
0
0
1
0
0
0
0
2
0
0
0
1
0
1
0
0
0
0
0
0
0
2
0
0
1
0
0
0
0
0
0
1
0
0
0
0
1
0
0
0
0
1
0
0
0
0
0
0
0
0
4
0
2
0
0
0

53
4
1
1
2
1
1
3
6
1
4
3
2
7
3
2
4
2
2
4
1
1
2
2
2
1
1
8
1
1
5
2
1
3
1
2
1
3
2
1
1
2
12
1
2
2
10
4
1
2
1
2
1
1
2
1
26
1
17
1
3
8

425
20
3
3
9
1
—
4
49
3
16
17
13
54
16
7
5
18
8
27
6
2
—
9
7
1
2
82
1
—
35
8
8
12
7
9
2
19
9
1
2
7
32
7
6
5
14
33
8
8
3
3
3
1
7
—
109
2
76
3
16
12

482
11
1
3
2
—
—
5
48
15
9
12
12
80
17
19
11
18
15
35
8
4
3
14
5
1
—
86
—
—
43
6
4
9
7
15
2
24
4
10
3
7
56
5
12
14
25
40
10
13
5
1
7
3
1
—
102
1
62
1
23
15

1
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
1
—
—
U
—
1
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—

9
0
0
0
0
0
0
0
2
1
0
0
0
1
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
1
0
0
0
1
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0

47
2
0
1
2
0
0
0
23
6
3
22
16
7
3
1
1
5
1
4
1
1
4
3
1
3
1
4
0
1
2
2
1
2
1
2
0
1
1
0
1
1
15
1
2
1
14
4
1
1
1
0
1
2
1
1
3
1
3
1
1
1

151
1
—
—
1
—
—
—
20
9
3
8
—
39
25
—
5
9
—
21
4
3
1
6
3
4
—
10
—
—
2
1
1
4
—
2
—
3
1
—
2
—
44
1
—
1
42
4
—
3
—
—
—
1
—
—
9
1
3
2
3
—

2,263
20
11
1
5
3
—
—
1,997
316
649
1,015
17
37
12
3
14
7
1
75
36
4
3
8
23
—
1
38
—
2
8
2
8
5
3
8
2
9
6
1
—
2
45
4
4
—
37
12
4
6
—
—
—
—
2
—
30
1
20
2
1
6

79
1
—
—
—
—
1
—
15
—
7
—
8
14
—
—
1
13
—
10
—
3
U
2
—
5
—
18
—
—
9
2
—
—
—
7
—
2
2
—
—
—
11
—
1
—
10
8
—
4
4
—
—
—
—
—
—
—
—
—
—
—

380
9
1
2
4
1
0
0
38
2
12
0
18
106
18
10
29
31
12
34
7
2
0
6
3
0
0
35
0
0
6
4
2
3
4
7
1
11
3
3
1
3
31
2
0
0
28
42
14
10
2
2
0
3
4
0
103
0
96
1
5
11

2,925
24
8
8
13
5
4
4
125
10
81
19
70
198
50
26
57
80
26
501
36
9
469
43
13
30
2
106
2
2
15
13
6
35
25
41
41
35
11
16
10
11
297
18
3
92
187
100
29
63
15
16
5
11
16
2
1,710
6
1,569
7
11
131

6,434
180
21
67
48
29
9
6
674
54
223
27
370
1,425
317
95
408
441
164
523
83
50
171
150
37
29
3
711
12
3
153
91
42
109
76
180
45
189
80
45
9
55
492
32
11
17
432
879
359
259
59
74
15
60
49
4
1,361
16
1,030
29
115
171

8,804
205
33
18
129
5
17
3
523
79
194
38
212
2,054
382
333
563
642
134
653
243
93
24
205
64
—
24
774
7
4
146
112
60
164
181
89
11
414
120
139
38
117
1,568
93
23
17
1,435
648
218
80
87
32
17
39
169
6
1,965
17
1,639
41
163
105

Territories
American Samoa
C.N.M.I.
Guam
Puerto Rico
U.S. Virgin Islands

—
—
—
—
—

0
—
0
0
0

0
—
0
1
0

—
—
—
—
—

—
—
—
1
—

—
—
—
—
—

0
—
3
0
0

0
—
15
1
0

—
—
12
1
—

—
—
392
—
—

—
—
—
—
—

0
—
0
0
0

0
—
14
1
0

—
—
31
2
—

—
—
1
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
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§

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.
* Case counts for reporting year 2010 and 2011 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. Data for TB are displayed in Table IV, which appears quarterly.
† Data for meningococcal disease, invasive caused by serogroups A, C, Y, and W-135; serogroup B; other serogroup; and unknown serogroup are available in Table I.
§ Contains data reported through the National Electronic Disease Surveillance System (NEDSS).

MMWR / July 22, 2011 / Vol. 60 / No. 28

969

Morbidity and Mortality Weekly Report

TABLE II. (Continued) Provisional cases of selected notifiable diseases, United States, weeks ending July 16, 2011, and July 17, 2010 (28th week)*
Rabies, animal
Reporting area
United States
New England
Connecticut
Maine§
Massachusetts
New Hampshire
Rhode Island§
Vermont§

Current Previous 52 weeks
week
Med
Max

Shiga toxin-producing E. coli (STEC)†

Salmonellosis

Cum
2011

Cum
2010

Current
week

Previous 52 weeks
Med

Max

Cum
2011

Cum
2010

Current
week

Previous 52 weeks
Med

Max

Cum
2011

Cum
2010

Pacific
Alaska
California
Hawaii
Oregon
Washington

36
1
—
1
—
—
—
—
10
—
10
—
—
—
—
—
—
—
N
2
—
—
U
—
1
1
—
23
—
—
—
—
6
—
N
17
—
—
—
—
—
—
—
—
—
—
—
—
N
—
—
N
—
—
—
—
—
—
—
—
—
—

60
4
0
1
0
0
0
1
14
0
7
0
8
2
1
0
1
0
0
2
0
1
0
0
1
0
0
19
0
0
0
0
6
0
0
11
0
2
1
0
0
1
6
0
0
0
0
0
0
0
0
0
0
0
0
0
2
0
0
0
0
0

172
18
8
3
0
6
3
3
33
0
19
4
17
27
11
3
4
12
0
40
3
4
34
6
3
6
0
53
0
0
29
0
14
0
0
27
30
7
7
2
1
4
54
10
0
30
30
5
0
0
2
0
2
2
3
4
15
2
10
0
2
14

1,242
63
—
30
—
9
9
15
337
—
161
7
169
60
17
4
19
20
N
45
—
18
—
—
19
8
—
597
—
—
54
—
163
—
N
325
55
66
44
8
1
13
53
41
—
12
—
8
N
—
—
N
2
4
2
—
13
9
—
—
4
—

2,277
143
67
32
—
4
12
28
596
—
262
130
204
102
47
—
33
22
N
138
11
38
17
36
30
6
—
643
—
—
121
—
195
—
N
286
41
107
44
11
—
52
431
13
—
7
411
29
N
—
2
N
2
7
2
16
88
11
68
—
9
—

703
6
—
3
—
1
—
2
68
—
32
2
34
34
—
—
2
32
—
35
1
6
U
23
3
2
—
307
1
—
160
40
20
38
32
16
—
65
15
16
8
26
123
27
4
—
92
18
4
10
3
—
—
1
—
—
47
—
39
8
—
—

854
25
0
2
15
3
2
1
92
15
25
21
32
84
27
10
13
21
11
46
9
7
1
16
4
0
3
262
3
1
107
40
18
30
30
20
0
60
18
9
21
18
114
14
16
10
84
47
14
10
3
1
4
6
6
1
103
1
77
6
7
13

1,812
209
187
8
52
12
62
5
217
57
63
53
80
203
61
43
49
42
50
121
34
18
30
43
13
15
17
624
11
7
226
142
54
241
99
68
14
175
52
32
65
53
515
43
52
95
381
113
43
24
9
6
21
19
17
8
288
5
232
13
20
42

17,821
662
187
62
204
75
108
26
2,119
256
561
509
793
1,903
624
192
315
544
228
1,012
221
161
—
416
109
22
83
5,168
63
26
2,121
883
376
720
500
443
36
1,353
367
198
406
382
2,170
272
293
164
1,441
1,099
328
268
78
52
86
108
150
29
2,335
35
1,786
168
115
231

21,590
1,440
491
64
636
107
111
31
2,646
545
600
611
890
3,035
1,060
388
444
692
451
1,346
254
200
374
324
104
14
76
5,082
62
53
2,244
913
436
477
409
395
93
1,329
346
245
373
365
2,442
237
572
225
1,408
1,338
435
289
80
54
127
138
187
28
2,932
44
2,065
169
314
340

76
2
—
1
—
—
—
1
9
—
8
—
1
1
—
—
1
—
—
14
—
—
U
10
4
—
—
18
—
—
9
—
1
3
1
4
—
7
2
—
—
5
6
—
—
—
6
12
2
6
3
—
—
1
—
—
7
—
4
—
3
—

93
2
0
0
0
0
0
0
9
2
3
1
3
11
2
2
2
2
1
13
2
1
1
4
1
0
1
19
0
0
6
2
2
2
0
3
0
5
1
1
0
3
8
1
0
0
6
11
2
3
3
1
0
1
1
0
13
0
8
0
2
2

264
27
27
3
9
3
1
2
30
9
12
6
10
48
9
10
7
11
16
49
16
7
20
14
5
10
4
31
2
1
15
7
8
10
4
9
5
22
16
6
12
12
151
4
2
55
95
33
14
21
7
4
6
6
8
3
46
1
36
3
11
20

2,131
64
27
14
5
13
1
4
221
33
77
35
76
250
46
51
55
73
25
292
67
45
—
109
48
6
17
476
8
3
202
49
46
56
15
90
7
159
47
17
11
84
149
19
6
12
112
255
47
61
49
19
17
21
30
11
265
—
176
4
37
48

2,193
130
60
6
42
14
2
6
230
51
73
25
81
372
80
61
76
62
93
429
87
40
131
118
38
3
12
304
3
6
94
44
42
25
15
67
8
117
27
21
10
59
120
28
10
9
73
251
31
91
26
24
11
16
40
12
240
1
106
17
37
79

Territories
American Samoa
C.N.M.I.
Guam
Puerto Rico
U.S. Virgin Islands

N
—
—
—
—

0
—
0
0
0

0
—
0
6
0

N
—
—
20
—

N
—
—
26
—

—
—
—
—
—

0
—
0
6
0

0
—
3
25
0

—
—
6
49
—

2
—
6
301
—

—
—
—
—
—

0
—
0
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
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§

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.
* Case counts for reporting year 2010 and 2011 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. Data for TB are displayed in Table IV, which appears quarterly.
† Includes E. coli O157:H7; Shiga toxin-positive, serogroup non-O157; and Shiga toxin-positive, not serogrouped.
§ Contains data reported through the National Electronic Disease Surveillance System (NEDSS).

970

MMWR / July 22, 2011 / Vol. 60 / No. 28

Morbidity and Mortality Weekly Report

TABLE II. (Continued) Provisional cases of selected notifiable diseases, United States, weeks ending July 16, 2011, and July 17, 2010 (28th week)*
Spotted Fever Rickettsiosis (including RMSF)†
Shigellosis
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

Confirmed
Cum
2011

Cum
2010

Med

Max

178
—
—
—
—
—
—
—
5
—
4
1
—
17
—
—
—
17
—
6
—
2
U
4
—
—
—
70
—
—
57
8
—
4
1
—
—
7
—
3
3
1
51
1
2
—
48
9
6
3
—
—
—
—
—
—
13
—
13
—
—
—

258
3
0
0
2
0
0
0
14
3
3
5
4
17
6
1
4
5
0
14
0
3
0
7
0
0
0
66
0
0
36
13
2
3
1
2
0
13
5
1
2
4
57
2
5
2
46
17
7
2
0
1
0
3
1
0
23
0
18
1
1
2

742
20
18
4
14
2
4
1
74
16
18
14
56
37
20
4
9
27
4
52
4
12
4
41
10
0
2
132
1
3
99
26
7
36
5
8
66
29
15
6
7
14
503
7
13
161
338
32
19
7
3
15
6
10
4
1
63
2
59
3
4
22

5,218
83
18
16
42
1
4
2
304
40
97
113
54
367
77
32
76
182
—
184
8
33
—
134
5
—
4
1,958
1
7
1,419
284
46
123
27
47
4
290
102
34
72
82
1,200
33
96
40
1,031
361
112
43
12
104
10
55
24
1
471
3
369
30
26
43

7,276
214
69
3
126
5
10
1
985
232
89
175
489
1,018
626
31
137
178
46
1,538
32
162
29
1,291
20
—
4
1,091
35
18
419
385
63
74
37
59
1
404
78
168
22
136
1,223
25
137
155
906
337
182
45
12
4
17
59
18
—
466
—
368
31
33
34

—
—
—
—
—

1
—
0
0
0

1
—
1
1
0

1
—
1
—
—

1
—
5
3
—

Current
week

Previous 52 weeks

Probable
Cum
2011

Cum
2010

Med

Max

5
—
—
—
—
—
—
—
2
—
—
—
2
—
—
—
—
—
—
1
—
—
U
1
—
—
—
—
—
—
—
—
—
—
—
—
—
2
—
—
—
2
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
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
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

11
0
0
0
0
0
0
0
1
0
0
0
1
1
1
1
0
1
0
4
0
0
0
2
3
0
0
6
1
1
1
3
1
4
1
2
0
3
1
0
1
2
8
2
0
5
1
5
4
1
0
0
0
0
0
0
2
0
2
0
0
1

57
—
—
—
—
—
—
—
6
—
—
—
6
1
—
—
—
1
—
8
—
—
—
5
3
—
—
31
1
1
3
15
2
5
3
1
—
5
—
—
1
4
—
—
—
—
—
6
6
—
—
—
—
—
—
—
—
N
—
N
—
—

77
—
—
—
—
—
—
—
2
1
1
—
—
1
—
1
—
—
—
7
—
—
—
5
2
—
—
49
1
—
2
39
—
6
—
1
—
11
1
6
—
4
1
—
—
—
1
2
—
—
—
2
—
—
—
—
4
N
4
N
—
—

N
—
N
N
—

0
—
0
0
0

0
—
0
0
0

N
—
N
N
—

N
—
N
N
—

Current
week

Previous 52 weeks

Cum
2011

Cum
2010

Med

Max

31
—
—
—
—
—
—
—
—
—
—
—
—
2
—
2
—
—
—
10
—
—
U
9
1
—
—
8
—
—
1
—
2
—
—
5
—
3
—
—
—
3
7
7
—
—
—
1
—
—
1
—
—
—
—
—
—
N
—
N
—
—

23
0
0
0
0
0
0
0
1
0
0
0
0
1
0
0
0
0
0
4
0
0
0
4
0
0
0
6
0
0
0
0
0
1
0
2
0
5
1
0
0
4
1
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0

245
1
0
1
0
1
1
0
5
3
3
2
2
5
2
3
1
2
1
23
1
0
2
23
1
1
0
59
2
0
2
0
5
47
2
12
1
26
6
0
4
20
235
28
1
202
5
7
7
1
1
0
0
0
1
1
0
0
0
0
0
0

515
2
—
—
—
1
1
—
12
—
2
5
5
34
15
14
—
5
—
136
1
—
—
134
1
—
—
154
9
—
4
—
10
73
11
45
2
115
24
—
1
90
36
28
2
4
2
26
20
2
1
—
—
—
—
3
—
N
—
N
—
—

639
1
—
1
—
—
—
—
50
34
3
7
6
49
24
15
1
6
3
132
3
—
—
127
1
1
—
173
11
—
6
—
27
76
7
46
—
193
36
—
13
144
36
12
1
13
10
4
—
—
1
1
—
1
1
—
1
N
—
N
1
—

N
—
N
N
—

0
—
0
0
0

0
—
0
0
0

N
—
N
N
—

N
—
N
N
—

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.
* Case counts for reporting year 2010 and 2011 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. Data for TB are displayed in Table IV, which appears quarterly.
† Illnesses with similar clinical presentation that result from Spotted fever group rickettsia infections are reported as Spotted fever rickettsioses. Rocky Mountain spotted fever (RMSF) caused
by Rickettsia rickettsii, is the most common and well-known spotted fever.
§ Contains data reported through the National Electronic Disease Surveillance System (NEDSS).

MMWR / July 22, 2011 / Vol. 60 / No. 28

971

Morbidity and Mortality Weekly Report

TABLE II. (Continued) Provisional cases of selected notifiable diseases, United States, weeks ending July 16, 2011, and July 17, 2010 (28th week)*
Streptococcus pneumoniae,† invasive disease
All ages
Reporting area

Current Previous 52 weeks
week
Med
Max

Age <5
Cum
2011

Cum
2010

Current
week

Previous 52 weeks
Med

Max

Syphilis, primary and secondary
Cum
2011

Cum
2010

Current
week

Previous 52 weeks
Med

Max

Cum
2011

Cum
2010

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

92
3
—
—
—
—
—
3
1
—
1
—
N
16
N
—
4
11
1
1
N
N
U
N
1
—
N
32
—
—
5
17
10
N
—
N
—
7
N
N
N
7
22
—
1
N
21
10
7
2
N
N
N
1
—
—
—
—
N
—
N
N

287
11
0
2
0
2
1
1
23
6
2
14
0
65
0
15
15
26
9
5
0
0
1
0
2
0
0
70
1
1
23
20
9
0
8
0
1
19
0
0
0
19
31
3
3
0
26
32
12
11
0
0
0
3
3
0
3
2
0
0
0
0

937
79
49
13
3
8
36
6
81
29
10
42
0
110
0
32
29
45
24
35
0
0
24
0
9
18
0
170
6
3
68
54
32
0
25
0
48
36
0
0
0
36
368
26
11
0
333
72
45
23
0
0
0
13
8
15
11
11
0
3
0
0

8,165
260
8
82
14
68
39
49
597
128
56
413
N
1,926
N
399
437
806
284
93
N
N
—
N
75
18
N
2,292
33
28
897
574
337
N
298
N
125
586
N
N
N
586
1,171
146
104
N
921
1,140
539
352
N
N
N
158
72
19
100
99
N
1
N
N

9,744
530
232
80
52
75
35
56
1,013
451
101
461
N
1,993
N
451
456
771
315
515
N
N
387
N
87
41
N
2,640
23
52
979
838
338
N
336
N
74
673
N
N
N
673
1,163
112
63
N
988
1,150
566
333
N
N
N
110
131
10
67
67
N
—
N
N

5
—
—
—
—
—
—
—
—
—
—
—
N
1
N
—
—
1
—
—
N
N
U
N
—
—
N
1
—
—
—
—
1
N
—
N
—
2
N
N
N
2
1
—
—
N
1
—
—
—
N
N
N
—
—
—
—
—
N
—
N
N

23
1
0
0
0
0
0
0
3
1
1
0
0
4
0
1
1
2
0
1
0
0
0
0
0
0
0
6
0
0
3
2
1
0
1
0
0
1
0
0
0
1
4
0
0
0
3
3
1
1
0
0
0
0
0
0
0
0
0
0
0
0

101
5
3
1
3
1
3
2
27
4
9
14
0
10
0
4
4
7
3
5
0
0
5
0
1
1
0
22
1
1
13
7
4
0
3
0
6
4
0
0
0
4
30
3
2
0
27
8
5
4
0
0
0
2
3
1
2
2
0
0
0
0

622
26
6
3
6
5
1
5
79
26
31
22
N
109
N
17
24
56
12
4
N
N
—
N
4
—
N
167
—
4
80
41
19
N
18
N
5
37
N
N
N
37
107
12
9
N
86
85
39
25
N
N
N
10
11
—
8
8
N
—
N
N

1,192
69
20
5
36
4
1
3
154
39
77
38
N
177
N
35
56
60
26
70
N
N
57
N
11
2
N
328
—
7
132
99
38
N
37
N
15
65
N
N
N
65
154
11
16
N
127
160
75
46
N
N
N
13
24
2
15
15
N
—
N
N

45
3
—
—
2
—
1
—
7
—
2
1
4
1
—
—
—
1
—
—
—
—
U
—
—
—
—
19
—
—
—
—
6
12
—
1
—
4
—
—
2
2
—
—
—
—
—
2
—
—
—
—
2
—
—
—
9
—
8
—
1
—

259
8
1
0
5
0
0
0
31
4
3
15
7
31
14
4
4
9
1
7
0
0
3
2
0
0
0
64
0
3
22
11
8
7
4
4
0
15
4
2
3
5
35
3
7
1
23
12
4
2
0
0
3
1
0
0
52
0
41
0
1
6

363
19
8
3
14
3
7
2
46
10
20
31
13
56
23
14
10
21
4
18
3
3
10
9
2
1
1
178
4
8
44
130
17
19
10
16
2
34
11
16
16
11
71
10
36
6
33
23
9
8
2
1
9
4
4
0
66
1
57
5
7
13

6,198
207
32
10
124
12
24
5
730
101
98
353
178
722
305
86
99
209
23
140
11
9
56
59
5
—
—
1,588
12
99
568
258
223
195
111
120
2
363
93
58
77
135
867
97
175
25
570
283
101
61
4
3
77
32
5
—
1,298
1
1,071
7
49
170

6,982
242
47
14
150
11
18
2
892
129
66
492
205
1,030
507
84
143
270
26
156
12
10
50
79
5
—
—
1,581
3
76
560
336
140
242
73
148
3
461
133
71
103
154
1,067
135
219
54
659
315
119
71
2
2
53
23
45
—
1,238
3
1,053
22
32
128

Territories
American Samoa
C.N.M.I.
Guam
Puerto Rico
U.S. Virgin Islands

N
—
—
—
—

0
—
0
0
0

0
—
0
0
0

N
—
—
—
—

N
—
—
—
—

N
—
—
—
—

0
—
0
0
0

0
—
0
0
0

N
—
—
—
—

N
—
—
—
—

—
—
—
4
—

0
—
0
4
0

0
—
0
13
0

—
—
—
134
—

—
—
—
123
—

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.
* Case counts for reporting year 2010 and 2011 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. Data for TB are displayed in Table IV, which appears quarterly.
† Includes drug resistant and susceptible cases of invasive Streptococcus pneumoniae disease among children <5 years and among all ages. Case definition: Isolation of S. pneumoniae from
a normally sterile body site (e.g., blood or cerebrospinal fluid).
§ Contains data reported through the National Electronic Disease Surveillance System (NEDSS).

972

MMWR / July 22, 2011 / Vol. 60 / No. 28

Morbidity and Mortality Weekly Report

TABLE II. (Continued) Provisional cases of selected notifiable diseases, United States, weeks ending July 16, 2011, and July 17, 2010 (28th week)*
West Nile virus disease†
Varicella (chickenpox)
Reporting area

Current
week

Previous 52 weeks
Med

Max

Nonneuroinvasive§

Neuroinvasive

Cum
2011

Cum
2010

Current
week

Previous 52 weeks
Med

Max

Cum
2011

Cum
2010

Current
week

Previous 52 weeks
Med

Max

Cum
2011

Cum
2010

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

74
3
—
—
—
—
—
3
20
5
N
—
15
12
—
1
2
9
—
—
N
—
U
—
—
—
—
13
—
—
10
N
N
N
—
3
—
—
—
N
—
N
24
—
—
N
24
1
—
1
N
—
N
—
—
—
1
—
—
1
N
N

252
17
5
5
3
1
0
2
31
9
0
0
18
68
18
4
20
20
1
12
0
4
0
5
0
0
1
36
0
0
15
0
0
0
0
9
7
5
5
0
0
0
44
3
2
0
38
13
0
5
0
2
0
1
4
0
2
1
0
1
0
0

367
46
16
16
17
9
5
10
57
50
0
0
41
118
31
18
38
58
22
42
0
15
0
24
5
10
7
64
3
2
38
0
0
0
8
25
32
15
14
0
3
0
258
17
5
0
247
50
0
31
0
28
0
8
26
3
6
5
3
4
0
0

6,477
456
147
115
103
9
18
64
999
457
N
—
542
1,719
435
131
558
594
1
210
N
65
—
100
3
23
19
1,056
5
12
530
N
N
N
11
257
241
167
158
N
9
N
1,419
119
48
N
1,252
388
—
150
N
92
N
23
116
7
63
30
6
27
N
N

9,379
642
195
114
174
77
18
64
1,036
376
N
—
660
3,133
778
234
963
834
324
489
N
210
—
230
5
29
15
1,356
19
15
668
N
N
N
74
319
261
185
178
N
7
N
1,775
125
47
N
1,603
694
—
249
N
148
N
68
216
13
69
27
21
21
N
N

—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
U
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—

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

71
3
2
0
2
1
0
0
19
3
9
7
3
15
10
2
6
1
0
7
1
1
1
1
3
2
2
6
0
1
3
1
3
0
1
1
0
1
0
1
1
1
16
3
3
1
15
18
13
5
0
0
0
6
1
1
8
0
8
0
0
1

4
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
1
—
—
—
—
—
—
1
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
1
—
—
—
1
2
2
—
—
—
—
—
—
—
—
—
—
—
—
—

49
—
—
—
—
—
—
—
2
—
1
1
—
1
—
—
—
1
—
—
—
—
—
—
—
—
—
1
—
—
—
—
1
—
—
—
—
2
1
—
1
—
5
—
3
—
2
31
30
1
—
—
—
—
—
—
7
—
7
—
—
—

—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
U
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—

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

53
2
2
0
1
0
0
0
13
6
7
4
3
7
4
2
1
1
1
11
2
3
3
0
7
2
3
4
0
1
1
3
2
0
0
1
0
3
1
1
2
2
3
1
1
0
2
15
9
11
1
0
1
2
1
1
6
0
6
0
0
1

5
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
1
—
—
1
—
1
—
—
—
1
3
2
—
—
—
—
—
—
1
—
—
—
—
—
—

65
1
1
—
—
—
—
—
2
—
2
—
—
1
—
—
—
—
1
17
—
4
—
—
6
2
5
3
—
—
—
3
—
—
—
—
—
1
1
—
—
—
1
—
—
—
1
32
21
9
—
—
1
—
—
1
7
—
7
—
—
—

Territories
American Samoa
C.N.M.I.
Guam
Puerto Rico
U.S. Virgin Islands

N
—
—
—
—

0
—
0
6
0

0
—
4
28
0

N
—
16
70
—

N
—
17
364
—

—
—
—
—
—

0
—
0
0
0

0
—
0
0
0

—
—
—
—
—

—
—
—
—
—

—
—
—
—
—

0
—
0
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.
* Case counts for reporting year 2010 and 2011 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. Data for TB are displayed in Table IV, which appears quarterly.
† Updated weekly from reports to the Division of Vector-Borne Infectious Diseases, National Center for Zoonotic, Vector-Borne, and Enteric Diseases (ArboNET Surveillance). Data for California
serogroup, eastern equine, Powassan, St. Louis, and western equine diseases are available in Table I.
§ 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.
¶ Contains data reported through the National Electronic Disease Surveillance System (NEDSS).

MMWR / July 22, 2011 / Vol. 60 / No. 28

973

Morbidity and Mortality Weekly Report

TABLE III. Deaths in 122 U.S. cities,* week ending July 16, 2011 (28th week)
All causes, by age (years)
Reporting area
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

All ​
Ages
530
139
38
25
27
53
27
8
18
27
61
—
33
18
56
1,850
44
26
69
24
21
42
20
1,008
39
23
221
26
34
91
30
28
48
25
14
17
2,049
61
34
205
73
275
216
147
161
64
69
8
72
186
42
93
52
62
51
113
65
392
10
U
19
115
54
U
88
18
U
88

≥65
360
81
28
15
21
34
24
5
16
16
44
—
22
16
38
1,249
33
21
49
18
13
29
16
693
8
18
124
19
23
64
22
21
38
18
11
11
1,382
43
25
146
37
205
152
108
82
42
38
4
43
125
27
53
38
45
41
77
51
246
7
U
8
66
42
U
54
10
U
59

All causes, by age (years)
P&I†

45–64

25–44

1–24

<1

Total

117
41
7
8
3
13
3
3
2
6
12
—
8
1
10
425
7
5
16
3
8
10
3
228
11
2
66
6
8
20
6
5
9
6
2
4
467
12
7
45
26
54
45
25
48
19
21
3
18
47
11
25
8
10
6
26
11
100
2
U
8
35
10
U
21
3
U
21

33
10
3
2
3
2
—
—
—
4
3
—
1
1
4
114
—
—
1
2
—
2
1
57
13
2
21
1
2
5
1
1
1
1
1
2
123
3
2
8
7
10
14
9
16
3
6
1
8
5
2
10
3
4
2
8
2
31
1
U
2
8
2
U
8
5
U
5

12
4
—
—
—
4
—
—
—
1
—
—
1
—
2
43
2
—
2
1
—
1
—
21
6
—
7
—
1
1
—
1
—
—
—
—
36
3
—
6
1
4
1
5
6
—
2
—
2
2
—
2
—
1
—
1
—
12
—
U
—
6
—
U
4
—
U
2

8
3
—
—
—
—
—
—
—
—
2
—
1
—
2
19
2
—
1
—
—
—
—
9
1
1
3
—
—
1
1
—
—
—
—
—
41
—
—
—
2
2
4
—
9
—
2
—
1
7
2
3
3
2
2
1
1
3
—
U
1
—
—
U
1
—
U
1

41
14
1
4
1
6
1
—
3
3
3
—
2
—
3
86
1
—
6
1
—
6
—
48
—
—
11
1
—
5
2
1
3
—
1
—
132
4
4
11
2
13
18
5
8
3
4
—
5
8
3
11
9
2
5
12
5
37
10
U
4
9
1
U
4
2
U
7

Reporting area
(Continued)
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
Total¶

All ​
Ages

≥65

45–64

25–44

1–24

<1

P&I†
Total

1,126
154
136
125
101
118
58
69
65
51
152
88
9
897
194
97
97
60
183
73
37
156
1,299
72
65
64
220
133
U
212
77
U
245
34
177
1,159
134
71
74
74
278
40
156
36
124
172
1,688
13
124
31
77
66
262
19
126
190
167
108
179
21
96
72
137

686
86
74
84
58
83
33
39
46
33
95
49
6
591
119
76
70
40
108
51
26
101
788
43
42
37
125
95
U
102
46
U
162
22
114
749
78
48
53
43
177
30
99
22
82
117
1,150
7
83
24
51
47
166
18
90
128
112
76
125
16
64
48
95

297
46
42
30
32
25
8
21
15
12
40
24
2
208
46
11
15
15
60
14
10
37
339
20
10
22
67
28
U
51
24
U
60
6
51
276
37
15
13
21
77
5
37
10
20
41
381
3
28
7
16
14
59
—
25
50
40
27
40
3
22
16
31

85
10
10
9
6
6
13
5
2
5
10
8
1
56
14
8
6
3
12
4
—
9
108
7
9
2
14
5
U
35
5
U
16
6
9
78
14
4
7
6
11
2
9
2
16
7
85
2
6
—
5
2
16
1
7
8
6
5
9
1
6
6
5

37
7
8
1
1
1
3
3
1
—
6
6
—
20
8
1
1
1
2
2
—
5
38
1
3
—
7
4
U
13
2
U
6
—
2
37
3
3
1
3
8
2
6
2
5
4
34
—
3
—
3
—
7
—
3
2
3
—
3
1
3
—
6

21
5
2
1
4
3
1
1
1
1
1
1
—
22
7
1
5
1
1
2
1
4
25
1
1
3
6
1
U
11
—
U
1
—
1
14
2
1
—
1
5
1
3
—
1
—
38
1
4
—
2
3
14
—
1
2
6
—
2
—
1
2
—

60
8
13
3
8
5
2
3
6
3
8
1
—
71
17
10
7
1
26
—
—
10
62
7
—
5
6
3
U
15
—
U
15
—
11
56
6
5
5
3
15
5
8
2
4
3
140
3
10
7
4
8
20
4
4
16
11
12
17
1
3
11
9

10,990

7,201

2,610

713

269

191

685

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.

974

MMWR / July 22, 2011 / Vol. 60 / No. 28

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