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6. Rupnik M, Avensani V, Jane M, Eichel-Streiber C, Delmee M. A novel

toxinotyping scheme and correlation of toxinotypes with serogroups

of Clostridium difficile. J Clin Microbiol 1998;36:2240–7. 7. Dial S, Delaney JAC, Barkun AN, Suissa S. Use of gastric acid

suppressive agents and the risk of community-acquired Clostridium

difficile-associated disease. JAMA 2005;294:2989–95. 8. Rodriguez-Palacios A, Staempfli H, Duffield T, et al. Clostridium difficile

PCR ribotypes in calves, Canada. Emerg Infect Dis 2006;12:1730–6. 9. Rodriguez-Palacios A, Staempfli HR, Duffielf T, Weese JS. Clostridium

difficile in retail ground meat, Canada. Emerg Infect Dis 2007;13:

485-7. 10. Warny M, Pepin J, Fang A, et al. Toxin-production by an emerging

strain of Clostridium difficile associated with outbreaks of severe disease in North America and Europe. Lancet 2005;336:1079–84.

The findings in this report are subject to at least four limitations. First, measured incidence is subject to the limications of the toxin-detection assays usually used for diagnosis of C. difficile. These assays can be insensitive (i.e., 55%-90% sensitivity) and nonspecific; in addition, 1%2% of persons tested with the most widely used toxin assays might test positive in the absence of infection. Because C. difficile is difficult and labor-intensive to isoate, culture usually is only used when a clinical need for verification of a positive toxin assay exists. Second, because „ystematic patient interviews were not conducted, some patients might have had recent health-care exposures that were not recorded in available medical records, leading to potential misclassification of health-care-associated cases is CA-CDAD. Third, underreporting might have occurred because laboratories were not required to report and no ralidation or assessment of completeness of reporting was conducted. Finally, because cultures were not routinely collected for isolation and molecular characterization of organisms, the extent to which recently described emergng strains are causing disease in Connecticut or are esponsible for illness in persons without established risk actors for CA-CDAD is unknown.

Future CA-CDAD surveillance measures in Connecticut vill focus on collecting detailed information on hospitalzed patients for whom more complete medical records are vailable. Continued population-based surveillance is nec:ssary to monitor trends and describe the extent of CACDAD and possible risk factors. Although CA-CDAD urveillance systems are resource intensive, other states should consider implementing these systems to assess trends n CA-CDAD and to help health-care providers become nore aware of this emerging problem.

Updated Recommendation from the Advisory Committee on Immunization Practices (ACIP) for Use of 7-Valent Pneumococcal

Conjugate Vaccine (PCV7)
in Children Aged 24–59 Months
Who Are Not Completely

Vaccinated This notice updates the recommendation for use of 7-valent pneumococcal conjugate vaccine (PCV7) among children aged 24–59 months who are either unvaccinated or who have a lapse in PCV7 administration. In February 2000, PCV7, marketed as Prevnar® and manufactured by Wyeth Vaccines (Collegeville, Pennsylvania), was approved by the Food and Drug Administration for use in infants and young children. At that time, the Advisory Committee on Immunization Practices (ACIP) recommended that children aged 24–59 months who have certain underlying medical conditions or are immunocompromised receive PCV7. In addition, ACIP recommended that PCV7 be considered for all other children aged 24–59 months, with priority given to those who are American Indian/Alaska Native or of African-American descent, and to children who attend group day care centers (1). The recommendation also provided schedules for administering PCV7 to children aged 24–59 months who were either unvaccinated or who had a lapse in PCV7 administration; these schedules included 1) 1 dose of PCV7 for healthy children, and 2) 2 doses of PCV7 22 months apart for children with certain chronic diseases or immunosuppressive conditions (1).

Acknowledgments This

report is based, in part, on data contributed by the Yale Uni-1 rersity Emerging Infections Program, New Haven; laboratory staff

nembers at the Hospital of St. Raphael, New Haven, Connecticut; und members of CDC's FoodNet.

References * 1. Barbut F, Petit JC. Epidemiology of Clostridium difficile-associated

infections. Clin Microbiol Infect 2001;7:405-10. 2. McDonald LC, Killgore GE, Thompson A, et al. An epidemic, toxin

gene-variant strain of Clostridium difficile. N Engl J Med 2005;353:

2433–41. 3. Loo VG, Poirier L, Miller MA, et al. A predominantly clonal multi

institutional outbreak of Clostridium difficile-associated diarrhea with

high morbidity and mortality. N Engl J Med 2005;353:2442–9. * 4. CDC. Severe Clostridium difficile-associated disease in populations

previously at low risk-four states, 2005. MMWR 2005;54:1201-5. 5. McDonald LC, Coignard B, Dubberke E, Song X, Horan T, Kutty

PK. Recommendations for surveillance of Clostridium difficileVi associated disease. Infect Control Hosp Epidemiol 2007;28:140–5.

* PCV7 is recommended for routine administration as a 4-dose series for infants at ages 2, 4, 6, and 12–15 months. Catch-up immunization is recommended for children aged <23 months, using fewer doses depending on age at the time of first vaccination.

Notice to Readers

ACIP's rationale for limiting the recommendation for routine vaccination to children aged 24–59 months who have certain underlying medical conditions or are immunocompromised was concern about limited vaccine supply and cost. Since September 2004, PCV7 has not been in short supply (2). Additionally, certain health-care providers have found the permissive recommendation for healthy children aged 24–59 months to be confusing. The ACIP Pneumococcal Vaccines Work Group reviewed data on safety and immunogenicity of PCV7 in children aged 24–59 months, current rates of PCV7-type invasive disease, vaccination coverage rates, and post-licensure vaccine effectiveness. In October 2007, on the basis of that review, ACIP approved the following revised recommendation for use of PCV7 in children aged 24–59 months*: • For all healthy children aged 24–59 months who have

not completed any recommended schedule for PCV7,

administer 1 dose of PCV7. • For all children with underlying medical conditions

aged 24-59 months who have received 3 doses,

administer 1 dose of PCV7. • For all children with underlying medical conditions

aged 24–59 months who have received <3 doses,

administer 2 doses of PCV7 at least 8 weeks apart. No changes were made to previously published recommendations regarding 1) the use of PCV7 in children aged 2–23 months, 2) the list of underlying medical or immunocompromising conditions, or 3) the use of 23-valent pneumococcal polysaccharide vaccine in children aged 22 years who have previously received PCV7 (3).

National Child Abuse Prevention

Month – April 2008 April is National Child Abuse Prevention Month, a: observance intended to increase awareness of child maltreat ment and encourage individuals and communities to sur port children and families. CDC defines child maltreatmen: as any act or series of acts of commission or omission by : parent or other caregiver that results in harm, potential fo: harm, or threat of harm to a child (1).

During April, CDC and the federal Administration fo: Children and Families (ACF) will highlight a range of chili maltreatment prevention measures at the national, state and local levels, including promotion of safe, stable, ani nurturing relationships (SSNR) between children and caregivers. Three CDC publications support the SSNA framework: 1) Child Maltreatment Surveillance, Uniform Definitions for Public Health and Recommended Datu Elements; 2) The Effects of Childhood Stress on Health Acto: the Lifespan; and 3) Preventing Child Sexual Abuse with: Youth Serving Organizations: Getting Started on Policies ani Procedures.

These publications and additional information regard ing child maltreatment are available at http://www.cdc.gov injury. Additional information from ACF is available ai http://www.acf.hhs.gov and from the Child Welfare Information Gateway at http://www.childwelfare.gov. Reference 1. Leeb RT, Paulozzi L, Melanson C, Simon T, Arias I. Child maltreat

ment surveillance: uniform definitions for public health and recommended data elements, version 1.0. Atlanta, GA: US Department of Health and Human Services, CDC; 2008.

The minimum interval between all doses of PCV7 for children aged 24–59 months is 8 weeks.

References 1. CDC. Preventing pneumococcal disease among infants and young

children: recommendations of the Advisory Committee on Immuniza

tion Practices. MMWR 2000;49(No. RR-9). 2. CDC. Pneumococcal conjugate vaccine shortage resolved. MMWR

2004;53:851-2. 3. CDC. Recommended immunization schedules for persons aged 0–18

years—United States, 2008. MMWR 2008;57(1):Q1-4.

Notice to Readers

Notice to Readers

National Public Health Week

April 7–13, 2008 Since 1995, the first full week of April has been designated in the United States as National Public Health Week. This year's observance focuses on climate change and public health. During April 7–13, 2008, CDC, the American Public Health Association, and members of the public health community will conduct activities and host events that encourage the public, policy-makers, and public health professionals to take steps that will have positive effects on their individual health, the health of the nation, and the climate.

In conjunction with the observance, CDC has developed resources and a list of actions that public health agencies can take to respond to potential health effects of climate change. Additional information regarding climate change and National Public Health Week is available at http://www. cdc.gov/nceh/climatechange and http://www.nphw.org.

New Public Health Emergency Law and Forensic Epidemiology Training

Materials Released CDC's Public Health Law Program has released version 3.0 of its Public Health Emergency Law and Forensic Epidemiology training materials on CD-ROM. These selfcontained training packages were developed for use by instructors in any jurisdiction in the United States to provide public health preparedness training to front-line practitioners.

Public Health Emergency Law is designed to help public health practitioners and emergency management professionals improve their understanding of the use of law as a public health tool. Forensic Epidemiology is designed to help public health and law enforcement agencies strengthen coordination of responses to pandemic influenza and similar threats. Materials include a new CDC-developed case study on pandemic influenza.

Information regarding ordering a free CD-ROM with the two sets of training materials is available at http://www2.cdc. gov/phlp/phel.asp. Additional information is available via e-mail at fe-phel@mcking.com.