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Vol. 57 / No. 13

MMWR

343

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).

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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.

Quick Stats

FROM THE NATIONAL CENTER FOR HEALTH STATISTICS

Life Expectancy Ranking* at Birth,t by Sex - Selected Countries

and Territories, 2004$11

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85.6
84.7
83.8
83.7
83.7
83.0
82.7
82.6
82.5
82.3
82.3
823
82.2
82.1
82.0
81.7
81.5
81.5
81.4
81.4

78.6

79.0 76.7

78.6 77 2 78.1 78.4 77.8 76.8

77.5 75.3 741

77.9

Japan
Hong Kong

France
Switzerland

Spain
Australia
Sweden
Canada

Italy
Puerto Rico

Norway
Finland

Israel
Austria
Singapore
New Zealand

Greece

Belgium
Netherlands

Germany
England & Wales

Portugal
Northern Ireland

Ireland
Costa Rica

Chile
United States
Denmark

Cuba
Scotland

Poland
Czech Republic

Slovakia
Hungary
Bulgaria

Romania
Russian Federation

81.1

81.0
80.8
80.7
80.7
80.6
80.4
79.9
79.8
79.3
79.2
79.0
77.8
76.9
76.3
75.6

72.4

76.4
77.1

77.5
75.6
76.6
75.7
76.9

76.8 74.5 76.0 76.4 75 8 74.0 75.2 75.2 75.4

74.2 70.7

72.6 70.3 68.6 69.1 68.3

59.1

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* Rankings are from the highest to lowest female life expectancy at birth.
+ Life expectancy at birth represents the average number of years that a group of infants would live if the

infants were to experience throughout life the age-specific death rates present at birth.
$ Countries and territories were selected based on quality of data, high life expectancy, and a population
of at least 1 million population. Differences in life expectancy reflect differences in reporting methods,
which can vary by country, and actual differences in mortality rates.
a Most recent data available. Data for Ireland and Italy are for 2003.

In 2004, life expectancy at birth ranged from a low of 59.1 years for the Russian male population to a high of 85.6 years for the female population of Japan. In the United States, life expectancy for men (75.2 years) ranked 25th out of 37 countries and territories and 23rd for women (80.4 years). Japan and Hong Kong were the countries with the highest life expectancy, whereas the countries of Eastern Europe (e.g., Russian Federation, Romania, and Bulgaria) reported the lowest life expectancy. SOURCES: Organisation for Economic Co-operation and Development. OECD health data 2007: statistics and indicators for 30 countries. Paris, France: Organisation for Economic Co-operation and Development; 2008. Available at http://www. oecd.org/health/healthdata. CDC. Health, United States, 2007. With chartbook on trends in the health of Americans. Hyattsville, MD: US Department of Health and Human Services, CDC, National Center for Health Statistics; 2007. Available at http://www.cdc.gov/nchs/ data/hus/hus07.pdf.

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45

ABLE I. Provisional cases of infrequently reported notifiable diseases (<1,000 cases reported during the preceding year) United States, leek ending March 29, 2008 (13th Week)*

5-year Current Cum weekly

Total cases reported for previous years isease

week 2008 averaget 2007 2006 2005 2004 2003 States reporting cases during current week (No.) nthrax otulism: foodborne

1
0 26 20 19 16

20 infant

13

1

83 97 85 87 76 other (wound & unspecified)

0

24 48 31 30 33 rucellosis

10

128 121 120 114 104 hancroid

13

30 33 17 30 54 holera

7
9
8
6

2 yclosporiasis

16

91 137 543 160 75 FL (2) iphtheria

1 omestic arboviral diseases $1; California serogroup

44

67 80 112 108 eastern equine

21

14 Powassan

1
1
1

1 St. Louis

7
10
13
12

41
western equine
hrlichiosis/Anaplasmosiss. **:
Ehrlichia chaffeensis

22

2
734

578 506 338 321 Ehrlichia ewingii

1 Anaplasma phagocytophilum

2 730 646 786 537 362 undetermined

1

162 231 112 59 44
'aemophilus influenzae, tt
invasive disease (age <5 yrs):
serotype b

1
8
0
23 29

9

19 32 MN (1) nonserotype b

1
34
3 174 175 135 135 117

NV (1) unknown serotype

58

190 179 217 177 227 OH (1), NC (1), TN (1), AZ (1) ansen diseases

16

73 66 87 105 95 antavirus pulmonary syndromes

2
0 32 40 26

24

26 emolytic uremic syndrome, postdiarrheals

14

2 276 288 221 200 178 CO (1) epatitis C viral, acute

5 135 17 847 766 652 720 1,102 MO (1), KS (1), TX (2), WA (1) IV infection, pediatric (age <13 yrs)$$

4

380 436 504 ifluenza-associated pediatric mortalitys. om

6 59
76 43

N CT (1), MN (2), TX (1), AZ (1), NV (1) isteriosis

99

10 783 884 896 753 696 FL (5) leasles***

7

1
42
55
66
37

56
leningococcal disease, invasivettt:
A, C, Y, & W-135

1
69
8 305 318 297

MN (1) serogroup B

3 42
149 193 156

NY (2), MN (1) other serogroup

11

31 32 27 unknown serogroup 14 169 19 581 651 765

NY (1), OH (1), FL (1), CO (1), CA (10) Aumps 7 140 67 777 6,584 314

231 TN (1), NV (1), CA (5) lovel influenza A virus infections

N N N lague

17
8
3

1 Poliomyelitis, paralytic

1 Poliovirus infection, nonparalytics

N
N
N

N sittacosis

1
11 21

16
12

12 2 fever::$$ total:

10

190 169 136 70 71 acute

7 chronic

3 Rabies, human

3
2
7

2 Rubella

2

11
11
10

7

PA (1) Rubella, congenital syndrome

1

1 SARS-CoVS**

8 - No reported cases. N: Not notifiable. Cum: Cumulative year-to-date counts.

Incidence data for reporting years 2007 and 2008 are provisional, whereas data for 2003, 2004, 2005, and 2006 are finalized. * Calculated by summing the incidence counts for the current week, the 2 weeks preceding the current week, and the 2 weeks following the current week, for a total of 5 preceding years. Additional information is available at http://www.cdc.gov/epo/dphsi/phs/files/5yearweeklyaverage.pdf. Not notifiable in all states. Data from states where the condition is not notifiable are excluded from this table, except in 2007 and 2008 for the domestic arboviral diseases and influenza-associated pediatric mortality, and in 2003 for SARS-COV. Reporting exceptions are available at http://www.cdc.gov/epo/dphsi/phs/infdis.htm. Includes both neuroinvasive and nonneuroinvasive. Updated weekly from reports to the Division of Vector-Borne Infectious Diseases, National Center for Zoonotic, VectorBorne, and Enteric Diseases (ArboNET Surveillance). Data for West Nile virus are available in Table II. The names of the reporting categories changed in 2008 as a result of revisions to the case definitions. Cases reported prior to 2008 were reported in the categories: Ehrlichiosis, human monocytic (analogous to E. chaffeensis); Ehrlichiosis, human granulocytic (analogous to Anaplasma phagocytophilum), and Ehrlichiosis, unspecified, or

other agent (which included cases unable to be clearly placed in other categories, as well as possible cases of E. ewingi). # Data for H. influenzae (all ages, all serotypes) are available in Table II. $$ Updated monthly from reports to the Division of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention. Implementation of HIV reporting

influences the number of cases reported. Updates of pediatric HIV data have been temporarily suspended until upgrading of the national HIV/AIDS surveillance data

management system is completed. Data for HIV/AIDS, when available, are displayed in Table IV, which appears quarterly. 1 Updated weekly from reports to the Influenza Division, National Center for Immunization and Respiratory Diseases. Fifty-nine cases occurring during the 2007–08 influenza

season have been reported.

No measles cases were reported for the current week. 1 Data for meningococcal disease (all serogroups) are available in Table II. $$$ in 2008, Q fever acute and chronic reporting categories were recognized as a result of revisions to the Q fever case definition. Prior to that time, case counts were not

differentiated with respect to acute and chronic Q fever cases. * The one rubella case reported for the current week was unknown.

* Updated weekly from reports to the Division of Viral and Rickettsial Diseases, National Center for Zoonotic, Vector-Borne, and Enteric Diseases.

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