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GURE. Number of cases of Salmonella enterica serotype Newport infection,* by week of onset - Illinois, March 2, 2006-April 25, 2007 heex 8

Mexican-style aged cheese

discovered in grocery store A 7 Find

Press release issued

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12 26 12 26 9 23 7 21 14 18 2 16 3 13 27 10 24 8 22 5 19 3 17 31 14 28 11 25 11 25 8 22
Feb Mar Apr May Jun Jul

Aug Sep Oct Nov Dec Jan Feb Mar Apr



Week beginning

= 85.

d 27 controls were enrolled. The study included ques

ns 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 it might have biased responses. A matched-pair analysis s performed; no statistical association was found between ness and cotija or grocery store A (Tables 1 and 2).

TABLE 1. Number and percentage of case-patients and controls
who ate various cheeses during a salmonellosis outbreak, by
type of cheese — Illinois, 2006-2007

Case-patients Controls Matched
Type of
(n = 12)

(n = 27)* odds
cheese No. (%) No. (%) ratiot (95% CIS)
Cotija 3/12 (25) 6/27 (22) 1.4 (0.2-11.6)
Cuajada 1/12 (8) 1/26 (4) 3.0 (0.04-235.5)
Fresco 9/12 (75) 18/27 (67) 1.3 (0.2–9.6)
Requéson 1/12 (8) 1/26 (4) 1.7 (0.02–56.7)
Other 6/12 (50) 11/26 (42) 1.1 (0.16-6.9)
* Controls were excluded from analysis if the relevant interview question
was not answered or the respondent answered "unknown.”
Adjusted odds ratio (maximum likelihood estimate), Fisher's exact test.
Confidence interval.

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 ocery store A. The cheese label did not specify the manuturer or distributor; inspectors were unable to determine lether the cheese had been obtained from a licensed

source. Illinois law requires grocery stores to purchase dairy products from a licensed manufacturer or distributor (2). An embargo was immediately placed on the cheese, preventing sale to the public. Cheese samples were sent to the IDPH laboratory for testing. Cotija from grocery store A had >29,400 mU/L of alkaline phosphatase activity,

TABLE 2. Number and percentage of case-patients and controls who shopped at selected grocery stores during a salmonellosis outbreak, by grocery store Illinois, 2006-2007

Case-patients Controls Matched Grocery (n = 12)*

(n = 27)*

odds store

No. (%) No. (%) ratiot (95% CIS) A

1/12 (8) 0/27 (0) B 1/11 (9) 14/27 (52)

0.1 (0-0.82) С

0/11 (0) 0/27 (0)

0/12 (0) 2/27 (7) E 2/12 (17) 6/27 (22)

0.3 (0-26.2) F 0/11 (0)

3/27 (11) G

0/11 (0) 1/27 (4) H

0/11 (0) 0/27
0/11 (0) 0/27 (0)

3/12 (25) 2/27 (7) 4.2 (0.3–236.0) Other 6/12 (50) 8/27

(30) 2.0 (0.4-14.0) * Case-patients and controls were excluded from analysis if the relevant

interview question was not answered or the respondent answered "unknown." t Adjusted odds ratio (maximum likelihood estimate), Fisher's exact test. $ Confidence interval.


indicating inadequate pasteurization (3). On March 19, S. Newport was isolated from the cheese and had a PFGE pattern indistinguishable from the outbreak strain.

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.

Information on Illinois regulations regarding sale of da products was provided to Hispanic grocery stores. Inc. 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 Bou. Illinois Dept of Public Health; C Dobbins, MS, C Gross, K Marek. MPH, F Carlson, MPH, G Maurice, Kane County Dept of Her IC Trevino, DVM, EIS Officer, CDC. Editorial Note: Consumption of unpasteurized dairy pir ucts in the United States has been associated with foodbor illnesses attributed to multiple pathogens, including monella species, Campylobacter jejuni, Listeria monocytogene and Escherichia coli O157:H7 (4-7). During 1998–2011 45 outbreaks of foodborne illness were reported to CDC which either unpasteurized milk or cheese made fra unpasteurized milk was implicated. Approximately 1,[4. persons became ill; 104 were hospitalized, and two di (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 indistinguis able PFGE pattern. Although no significant association found between consumption of the Mexican-style agt cheese and illness, no cases of S. Newport matching ttoutbreak pattern have been identified since April 25, 2010 and cases of S. Newport have returned to preoutbre levels in Kane County.

Newport-MDRAmpC has become a public health car cern because of the increase in reported incidence in t. United States during the last 10 years (1). Antibiotics : cally used to treat Salmonella infections, especially in ch. dren, are ineffective against this strain (9). Outbreaks Newport-MDRAmpC infection have been associated wir an Italian-style soft cheese and ground beef from dairy carde 1.9

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 allos certain cheeses to be manufactured using unpasteuritei milk if they are aged for at least 60 days.* Although U.S. dairy manufacturers and distributors are inspected.


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.

* Food and Drug Administration, Center for Food Safety and Applied Nutica Grade “A” pasteurized milk ordinance: 2003 revision. Available at http: -ear/pmo03toc.html.

9. Gupta A, Fontana ), Crow C, et al. Emergence of multidrug-resistant

Salmonella enterica serotype Newport infections resistant to expandedspectrum cephalosporins in the United States. J Infect Dis 2003;

188:1707-16. 10. Bachmann HP, Spahr U. The fate of potentially pathogenic bacteria in

Swiss hard and semihard cheeses made from raw milk. J Dairy Sci 1995;78:476–83.

uirements 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 return

from abroad, small Hispanic grocery stores also have en implicated (5–7). o prevent future outbreaks and reduce sales of illegally

nufactured cheese, local and state food regulatory ausrities should enforce compliance with unpasteurized

Ik sale and distribution regulations; dairy farms' bulk

Ik weight sheets should be monitored. Food regulatory ... horities should be aware that illegally manufactured miese might be sold at grocery stores, be alert for missing I - incomplete labeling, and ensure that dairy products are

m an inspected manufacturer or distributor. Finally, food ulatory and public health officials should recognize that id Mexican-style cheese can be a source of infection.

Acknowledgments Chis

report is based, in part, on contributions by C Conover, MD, m.kelly-Shannon, P Ward, R Lucht, MBA, D Hennings, Div of Infec- Is 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.

Availability of Cefixime 400 mg Tablets United States, April 2008

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 References 1. CDC. Update to CDC's sexually transmitted diseases treatment guide

lines, 2006: fluoroquinolones no longer recommended for treatment of

gonococcal infections. MMWR 2007;56:332–6. 2. CDC. Discontinuation of cefixime tablets—United States. MMWR


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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 com

piled statutes 635. Effective October 1, 2003. Available at http:// fr a 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.

* Information available at

Notice to Readers

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Additional information about World Malaria Day is avai able at Information about malaria and CDC's malaria-conta activities is available at Intis mation about PMI is available at References 1. Bryce J, Boschi-Pinto C, Shibuya K, Black RE, WHO Child He.

Epidemiology Reference Group. WHO estimates of the causes of der

in children. Lancet 2005;365:1147–52. 2. CDC. Malaria surveillance-United States, 2006. MMWR. In pre


World Malaria Day April 25, 2008 April 25, 2008, marks the first World Malaria Day. In previous years, Africa Malaria Day was commemorated on April 25, the date in 2000 when 44 African leaders met in Abuja, Nigeria, and signed the Abuja Declaration, committing their countries to cutting malaria deaths in half by 2010.

Malaria is a preventable and treatable parasitic disease, transmitted by the female Anopheles mosquito. Malaria continues to cause approximately 1 million deaths worldwide each year, with nearly 90% of these deaths occurring among young children in Africa (1).

The theme for World Malaria Day is A Disease Without Borders, reflecting the geographic expansion of the observance and serving as a reminder that malaria also affects other parts of the globe, including Asia, Central and South America, and Oceania. Although malaria has been eliminated from the United States, approximately 1,400 travelers from the United States return with malaria each

year; on average, seven of these travelers will die from their infection (2).

An integrated package of effective interventions (i.e., a combination of insecticide-treated bed nets, antimalarial drugs to treat malaria illness, preventive treatment for pregnant women, and indoor residual spraying) can substantially decrease the burden of malaria in endemic areas. In recent years, the Roll Back Malaria Partnership, including the World Bank, the United Nations Children's Fund (UNICEF), the President's Malaria Initiative (PMI), and the Global Fund to Fight AIDS, TB, and Malaria, have joined together to fight malaria by scaling up the use of these interventions.

CDC contributes to malaria control through PMI, a U.S. government interagency initiative begun in 2005 to halve malaria deaths in 15 countries in sub-Saharan Africa (Angola, Benin, Ethiopia, Ghana, Kenya, Liberia, Madagascar, Malawi, Mali, Mozambique, Rwanda, Senegal, Tanzania, Uganda, and Zambia). PMI is led by the U.S. Agency for International Development (USAID) and is implemented jointly by CDC and USAID, in close collaboration with host ministries of health and other local and international partners in the public and private spheres. CDC also conducts programmatically relevant malaria research to serve as the basis for future malaria prevention and control strategies.

Errata: Vol. 56, No. SS-10 In the MMWR Surveillance Summary, “Preconception as Interconception Health Status of Women who Recent Gave Birth to a Live-Born Infant — Pregnancy Risk Asses ment Monitoring System (PRAMS), United States, Reporting Areas, 2004,” the following errors occurred:

On page 18, in Table 1 the definition of preconceptie tobacco use should read, “Reported cigarette smoking dur ing the 3 months before pregnancy"; the definition of prs conception alcohol use should read, “Reported drinking alcohol during the 3 months before pregnancy”; and to definition of interconception tobacco use should read “Reported cigarette smoking at time of survey (2-4 months postpartum).”

On page 30, in Table 22, under the column for Race Ethnicity, Black, the plus or minus confidence interva: should read: Arkansas (7.4), Florida (3.9), Georgia (4.0 Illinois (6.4), Louisiana (4.4), Maryland (6.3), Michiga (8.3), Minnesota (11.8), Mississippi (4.9), Nebraska (5.2 New Jersey (5.6), New York City (6.4), North Carolin (6.0), Oklahoma (18.0), Oregon (4.9), Rhode Island (5.1 South Carolina (5.2), Washington (4.8), and Total (1.6

Errata: Vol. 57, No. SS-3 In the MMWR Surveillance Summary, “Surveillance so Violent Deaths — National Violent Death Reporting S tem, 16 States, 2005,” two errors occurred. On


IS in Table 2, the sixth age group should read, “20–24." () page 28, in Table 16, the footnote symbol should apper on the second line of the first column, after “Crime is progress."

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Non-Hispanic Asians aged 18 years.
+ Based on response to the following question: "Would you say your health in

general is excellent, very good, good, fair, or poor?” Health status data were
obtained by asking respondents to assess their own health and that of other

family members living in the same household.
$ Estimates are age adjusted using the projected 2000 U.S. population as the

standard population and using four age groups: 18–24 years, 25–44 years,
45–64 years, and >65 years. Estimates are based on household interviews
of a sample of the civilian, noninstitutionalized U.S. population and are derived
from the National Health Interview Survey sample adult component. Data
were combined from 3 years of surveys to increase reliability of estimates in

smaller subpopulations.
1 95% confidence interval.
** Includes Chinese, Filipino, Asian Indian, Japanese, Vietnamese, and Korean

subpopulations; also includes Other Asian and Native Hawaiian or Other
Pacific Islander subpopulations, which are not shown separately because

of small sample sizes.

# Among persons who reported a single Asian subpopulation. During 2004–2006, approximately 9% of Asian adults reported being in fair or poor health, compared with higher rates among blacks (20%), American Indian/Alaska Natives (18%), Hispanics (17%), and whites (11%). Among Asian subpopulations, the percentage reporting fair or poor health ranged from 5% among Japanese adults to 19% among Vietnamese adults.

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SOURCE: Barnes PM, Adams PF, Powell-Griner E. Health characteristics of the Asian adult population: United
States, 2004-2006. Adv Data 2008;394. Available at

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