ther study and targeted interventions. Vehicles used in and gas extraction are exempt from certain U.S. partment of Transportation hours-of-service regulations. uck drivers and workers in pickup trucks often travel tween oil and gas wells located on rural highways, which en lack firm road shoulders, rumble strips, and, occaonally, pavement. Workers often are on 8- or 12-hour fts, working 7-14 days in a row. Fatigue has been idened as an important risk factor in motor-vehicle crashes ; therefore, a targeted program that addresses fatigue ong workers in this 24-hour industry might reduce otor-vehicle crashes and fatalities. Persons also can reduce ving fatalities by always wearing seatbelts while operator riding in motor vehicles.

Many of the hazards associated with using heavy tools d equipment in this industry were documented in the 70s (10), and being struck by these items remains the cond most common event leading to an occupational ality. The use of mechanized tools to move and manipue heavy pipe can remove workers from potentially injuus environments. These types of controls are becoming ore common on land-based drilling rigs and are consisat with good safety practices because they control a workated hazard at the source.

The findings in this report are subject to at least three itations. First, fatality rates were calculated using an ployment estimate that is different from the standard ployment estimates used by CFOI to calculate occupanal fatality rates. Comparisons of the fatality rates in s report to other CFOI occupational fatality rates should interpreted with caution. Second, the data do not proe detailed information on the worker population at risk 3., the proportion of new workers), which would allow re detailed analyses of risk factors. Finally, because clascation of worker fatalities into industry subsectors is

cording to part 395 of the Code of Federal Regulations title 49 (Transportation gulations), drivers of vehicles that are used exclusively to service oil and gas lls are not required to count waiting time at the well site toward their on-duty

- urs.

limited by the information available, misclassification might have occurred.

Although each company has the ultimate responsibility for the safety of its employees, drilling operations involve many companies working together in an environment with complex machinery and complex levels of supervision. Well operators have significant influence over how work is conducted and authority to establish a culture and process of safety at a site. Improved safety for oil and gas extraction workers requires a dedicated and collaborative effort from all parts of the industry. CDC is supporting this type of effort through 1) development of new worksite selfassessment, training, and communication products that emphasize seatbelt use and fall protection and 2) the activities of the National Occupational Research Agenda Oil and Gas Extraction Sub Council."

References

1. US Department of Labor, Bureau of Labor Statistics. Quarterly Census of Employment and Wages. Washington, DC: US Department of Labor, Bureau of Labor Statistics; 2008. Available at http://data.bls.gov/ labjava/outside.jsp?survey=en.

Available at http://

2. Baker Hughes, Inc. Rig counts. investor.shareholder.com/bhi/rig_counts/rc_index.cfm.

3. US Department of Labor, Bureau of Labor Statistics. All charts, Census of Fatal Occupational Injuries, 2004. Washington, DC: US Department of Labor, Bureau of Labor Statistics; 2006. Available at http://www.bls.gov/iif/oshwc/cfoi/cfch0003.pdf.

4. US Department of Labor, Bureau of Labor Statistics. Injuries, illnesses, and fatalities: Census of Fatal Occupational Injuries (CFOI)— current and revised data. Washington, DC: US Department of Labor, Bureau of Labor Statistics; 2008. Available at http://www.bls.gov/iif/ oshcfoil.htm.

5. US Department of Labor, Bureau of Labor Statistics. Technical note. Washington, DC: US Department of Labor, Bureau of Labor Statistics; 2007. Available at http://www.bls.gov/news.release/cfoi.tn.htm. 6. CDC. The oil and gas extraction industry: recent fatal injury data and areas for action [Abstract]. In: NORA Symposium 2006, Research Makes a Difference. Washington, DC: US Department of Health and Human Services, CDC, National Institute for Occupational Safety and Health; 2006. Available at http://www.cdc.gov/niosh/nora/symp06/ pdfs/norasymposium2006book.pdf.

7. Curlee CK, Broulliard SJ, Marshall ML, Knode TL, Smith SL. Upstream onshore oil and gas fatalities: a review of OSHA's database and strategic direction for reducing fatal incidents. Galveston, TX: Society of Petroleum Engineers, Inc.; 2005. Available at http:// www.spe.org/elibrary/servlet/spepreview?id=SPE-94416-MS.

8. US Department of Labor, Bureau of Labor Statistics. All charts, Census of Fatal Occupational Injuries, 2006. Washington, DC: US Department of Labor, Bureau of Labor Statistics; 2008. Available at http://www.bls.gov/iif/oshwc/cfoi/cfch0005.pdf.

9. MacLean AW, Davies DR, Thiele K. The hazards and prevention of driving while sleepy. Sleep Med Rev 2003;7:507–21. 10. CDC. Comprehensive safety recommendations for land-based oil and gas well drilling. Morgantown, WV: US Department of Health and Human Services, CDC, National Institute for Occupational Safety and Health; 1983. NIOSH publication no. 83-127. Available at http:// www.cdc.gov/niosh/83-127.html.

Additional information available at http://www.cdc.gov/niosh/nora/councils/ mining/oilgas.

Outbreak of Multidrug-Resistant Salmonella enterica serotype Newport Infections Associated with Consumption of Unpasteurized Mexican-Style Aged Cheese Illinois, March 2006-April 2007 During March 2006-April 2007, an outbreak of Salmonella enterica serotype Newport infections occurred predominantly among Hispanics in northeastern Illinois. Samples from 85 patients, one sample of Mexican-style aged cheese (cotija) from a local Hispanic grocery store (grocery store A), and milk from a bulk tank on a local dairy farm tested positive for S. Newport and had indistinguishable pulsed-field gel electrophoresis (PFGE) patterns. This report summarizes the investigation into S. Newport infections associated with this outbreak. The findings emphasize the need for regulatory authorities to ensure that dairy products, including Mexican-style cheese, are manufactured and distributed by inspected sources and highlight the need for culturally targeted education of consumers and grocerystore operators regarding risks associated with consuming unpasteurized dairy products.

On October 9, 2006, public health officials in Kane County, Illinois, notified the Illinois Department of Public Health (IDPH) of 13 cases of S. Newport infection. among Hispanic residents since March 2, 2006. S. Newport is a rare serotype in Kane County; during 2001-2005, five or fewer infections were reported annually. The Kane County Department of Health conducted the initial investigation and contacted IDPH for assistance in determining the source of infection and developing measures to prevent future illness.

By March 1, 2007, local health departments had identified 67 patients who had illnesses compatible with S. Newport infection. Among these, 46 (69%) reported shopping at local Hispanic grocery stores. Three stores with the highest reported shopping frequency (including grocery store A) and the patients' home addresses were mapped using geographic information system software; clustering of cases near the stores was apparent. A hypothesis-generating questionnaire was developed and included questions regarding consumption of various foods, including Mexican-style cheese, unpasteurized milk, and unpasteurized and homemade cheese. The questionnaire was administered beginning March 2, 2007, to patients with onset of illness within the preceding 3 months. Thirteen patients with an onset during December 30, 2006-February 26, 2007, completed the questionnaire. Ten (77%) reported eating Mexican-style

cheese; none reported consuming unpasteurized milk, pasteurized cheese, or homemade cheese 7 days before e set of illness.

Case Definition and Case Finding

A case was defined as diarrheal illness (three or more loos stools within 24 hours) with onset beginning on or af March 2, 2006, and an isolate of S. Newport with a PFG match by at least one enzyme (xbal) in an Illinois reside A memorandum was sent to all local health departmen on November 28 to inform them of the outbreak and er courage prompt reporting to IDPH. Additional cases wer identified by performing PFGE on all S. Newport isola cultures reported to IDPH. Local Illinois health depa ments contacted all identified patients to obtain inform tion regarding demographic characteristics, date of iline onset, clinical presentation, and household contac Patients were asked to report food-consumption and grocer shopping history for the 3 days (one incubation period before illness onset by use of a standardized Illinois salm nellosis case report form.

Eighty-five culture-confirmed cases were identified amon residents of nine counties in northeastern Illinois, w dates of illness onset during March 2, 2006-April 25, 200 (Figure). Patients ranged in age from 9 days to 85 yea (median: 34 years). Forty-five (53%) were male. Seventy six (96%) of 79 patients who reported ethnicity were H panic, and Spanish was the primary language for 40 (78) of 51 patients who reported a primary language. Amo: patients who reported clinical symptoms, 53 (72%) of reported fever, and 43 (59%) of 73 reported bloody dia rhea. Thirty-six (44%) of 82 patients were hospitalize No deaths were reported. Five patient stool isolates we selected randomly and sent to CDC for antibiotic susce tibility testing. All five isolates were resistant to eight an biotics: amoxicillin/clavulanic acid, ampicillin, cefoxiti ceftiofur, chloramphenicol, streptomycin, sulfamethoxazo and tetracycline. This resistance pattern is consistent wit S. Newport multidrug-resistant phenotype Amp (Newport-MDRAmpC) (1).

Case-Control Study

After investigators found improperly labeled cotija chee in grocery store A, a case-control study was initiated a March 21, 2007. Case-patients with the most recent ons of illness were contacted first. Controls were selecte through a reverse telephone directory and matched by ag ethnicity, and city of residence. Twelve case-patients wit onset of illness from November 1, 2006-March 2, 200

Jul 2006

Dec Jan Feb Mar Apr

2006

= 85.

d 27 controls were enrolled. The study included quesns about consumption of four specific types of Mexicanle cheese and purchase of cheese from 10 local Hispanic ocery stores. Interviews were ended on March 23 because press release was issued by the Kane County Department Health to warn the public, specifically members of the spanic community, about the risks of consuming exican-style cheese from unlicensed producers, an action at might have biased responses. A matched-pair analysis s performed; no statistical association was found between ess and cotija or grocery store A (Tables 1 and 2).

Ivironmental Investigation

During March 6-April 5, 2007, local and state public alth food sanitarians inspected Hispanic grocery stores Kane County. On March 9, a sanitarian noticed an properly labeled Mexican-style aged cheese (cotija) in cery store A. The cheese label did not specify the manuturer or distributor; inspectors were unable to determine ether the cheese had been obtained from a licensed

The cotija cheese manufacturer was not identified, so investigators searched for the source of unpasteurized milk used to make the cheese. In 2005, dairy farm A had been suspected of illegal sale of unpasteurized milk to grocery store A; a subsequent investigation was inconclusive. In Illinois, a dairy producer may sell unpasteurized milk from its farm to an individual for personal consumption but not for commercial resale (2). Investigators visited dairy farm A on March 27, collected samples of unpasteurized milk, and reviewed bulk-milk weight sheets. The data indicated large variations in pounds of milk sold for pasteurization, suggesting possible illegal sales of unpasteurized milk. Unpasteurized milk collected from the bulk tank tested positive for S. Newport, with a PFGE pattern indistinguishable from the outbreak strain. On April 5, IDPH prohibited unpasteurized milk sale by farm A to the public until a negative. Salmonella culture was obtained from the bulk milk tank. No additional cases of S. Newport matching the outbreak pattern were identified after April 25.

Public Health Action

After the investigation, review of dairy farms' daily bulkmilk weight sheets was heightened by IDPH inspectors statewide to monitor fluctuations in milk sales that could indicate improper distribution of unpasteurized milk. Local Illinois health departments were encouraged to visit Hispanic grocery stores and restaurants to ensure cheese products sold were from licensed dairy manufacturers.

Information on Illinois regulations regarding sale of da products was provided to Hispanic grocery stores. Int mation was provided to the Spanish-language media to ak their audience about the risks associated with consum tion of illegally manufactured Mexican-style cheese. Reported by: C Austin, DVM, L Saathoff-Huber, MPH, M Bord Illinois Dept of Public Health; C Dobbins, MS, C Gross, K Mar MPH, F Carlson, MPH, G Maurice, Kane County Dept of He IC Trevino, DVM, EIS Officer, CDC.

Editorial Note: Consumption of unpasteurized dairy proc ucts in the United States has been associated with foodbor illnesses attributed to multiple pathogens, including S monella species, Campylobacter jejuni, Listeria monocytoge and Escherichia coli O157:H7 (4-7). During 1998-2013 45 outbreaks of foodborne illness were reported to CDC which either unpasteurized milk or cheese made fre unpasteurized milk was implicated. Approximately 1, persons became ill; 104 were hospitalized, and two d.. (CDC, unpublished data, 2007). Hispanics have a high incidence of salmonellosis and are more likely to consum high-risk foods, including unpasteurized milk and chees than other ethnic populations (8).

Dairy products made with dairy farm A milk were like responsible for this outbreak. All 85 patients, an age Mexican-style cheese (cotija), and raw milk from a loc dairy had an isolate of S. Newport with an indistinguish able PFGE pattern. Although no significant association w found between consumption of the Mexican-style ages cheese and illness, no cases of S. Newport matching th outbreak pattern have been identified since April 25, 2007 and cases of S. Newport have returned to preoutbrea levels in Kane County.

Newport-MDRAmpC has become a public health con cern because of the increase in reported incidence in th United States during the last 10 years (1). Antibiotics ty cally used to treat Salmonella infections, especially in ch dren, are ineffective against this strain (9). Outbreaks Newport-MDRAmpC infection have been associated wi an Italian-style soft cheese and ground beef from dairy cattle ( This is the first report of Salmonella isolated from an age rather than fresh, Mexican-style cheese. Performed correct the aging process inhibits pathogenic bacteria such as sa monellae (10). The Food and Drug Administration allow certain cheeses to be manufactured using unpasteurize milk if they are aged for at least 60 days.* Although a U.S. dairy manufacturers and distributors are inspected

* Food and Drug Administration, Center for Food Safety and Applied Nutrit© Grade "A" pasteurized milk ordinance: 2003 revision. Available at hup www.cfsan.fda.gov/-ear/pmo03toc.html.

Fuirements for cheese-manufacturing licensure vary ong states. In Illinois, manufacturers must be licensed the state (2). Although outbreaks caused by illegally nufactured Mexican-style cheese have been commonly ociated with sales by street vendors, door-to-door salesn, and flea markets and with gifts from relatives returnfrom abroad, small Hispanic grocery stores also have en implicated (5–7).

To prevent future outbreaks and reduce sales of illegally nufactured cheese, local and state food regulatory auorities should enforce compliance with unpasteurized Ik sale and distribution regulations; dairy farms' bulkIk weight sheets should be monitored. Food regulatory horities should be aware that illegally manufactured ese might be sold at grocery stores, be alert for missing incomplete labeling, and ensure that dairy products are m an inspected manufacturer or distributor. Finally, food ulatory and public health officials should recognize that d Mexican-style cheese can be a source of infection.

Acknowledgments

This report is based, in part, on contributions by C Conover, MD, Kelly-Shannon, P Ward, R Lucht, MBA, D Hennings, Div of Infecis Diseases, Illinois Dept of Public Health; P Dombroski, J Price, , Div of Laboratories, Illinois Dept of Public Health; and G Ewald, PH, S Greene, MPH, M Lynch, MD, and M Biggerstaff, MPH, tional Center for Zoonotic, Vector-Borne, and Enteric Diseases, C.

ferences

CDC. National Antimicrobial Resistance Monitoring System for enteric bacteria (NARMS): Human isolates final report, 2004. Atlanta, GA: US Department of Health and Human Services, CDC; 2007. Grade A pasteurized milk and milk products act. 410 Illinois compiled statutes 635. Effective October 1, 2003. Available at http:// www.ilga.gov/legislation/ilcs/ilcs2.asp?chapterid=35.

Salter RS, Fitchen J. Evaluation of a chemiluminescense method for measuring alkaline phosphatase activity in whole milk of multiple species and bovine dairy drinks: interlaboratory study. J AOAC Int 2006;89:1061-70.

D'Aoust JY. Manufacture of dairy products from unpasteurized milk: a safety assessment. J Food Prot 1989;52:906-14.

Villar RG, Macek MD, Simons S, et al. Investigation of multidrugresistant Salmonella serotype typhimurium DT104 infections linked to raw-milk cheese in Washington State. JAMA 1999;281:1811–6. Cody SH, Abbott SL, Marfin AA, et al. Two outbreaks of multidrugresistant Salmonella serotype Typhimurium DT104 infections linked to raw-milk cheese in Northern California. JAMA 1999;281:1805–10. MacDonald PD, Whitwam RE, Boggs JD, et al. Outbreak of listeriosis among Mexican immigrants as a result of consumption of illicitly produced Mexican-style cheese. Clin Infect Dis 2005;40:677-82. Banerjee A, Frierman M; EIP FoodNet Working Group, et al. Characterization of high risk food consumption practices among the Hispanic population. FoodNet 2000-2001. Chicago, IL: Infectious Diseases Society of America; 2002.

The only current CDC-recommended options for treating Neisseria gonorrhoeae infections are from a single class of antibiotics, the cephalosporins. Within this class, ceftriaxone, available only as an injection, is the recommended treatment for all types of gonorrhea infections (i.e., urogenital, rectal, and pharyngeal). The only oral agent recommended currently by CDC for treatment of uncomplicated urogenital or rectal gonorrhea is a single dose of cefixime 400 mg (1). Availability of cefixime had been limited since July 2002, when Wyeth Pharmaceuticals (Collegeville, Pennsylvania) discontinued manufacturing cefixime tablets in the United States (2). Beginning in April 2008, cefixime (Suprax®) 400 mg tablets are again available in the United States.

Oral cefixime is now being provided by Lupin Pharmaceuticals, Inc. (Baltimore, Maryland), which received Food and Drug Administration approval in February 2004 to manufacture and market cefixime. Lupin has been manufacturing and marketing cefixime oral suspension (100 mg/5 mL) since February 2004 and cefixime oral suspension (200 mg/5 mL) since April 2007. Public health pricing* will be available for the 400 mg cefixime tablets.

Information on obtaining cefixime is available from Lupin by telephone (866-587-4617). Guidance on treatment of N. gonorrhoeae infections and updates on the availability of recommended antimicrobials are available from CDC at http://www.cdc.gov/std/treatment.

References

1. CDC. Update to CDC's sexually transmitted diseases treatment guidelines, 2006: fluoroquinolones no longer recommended for treatment of gonococcal infections. MMWR 2007;56:332–6.

2. CDC. Discontinuation of cefixime tablets-United States. MMWR 2002;51:1052.

* Information available at http://www.hrsa.gov/opa/introduction.htm.