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Health-care personnel place themselves and their patients at risk if they are not protected against measles. In accordance with current recommendations, health-care personnel should have documented evidence of measles immunitySS readily available at their work location (3). If this documentation is not available when measles is introduced, major costs and disruptions to health-care operations can result from the need to exclude potentially infected staff members and rapidly ensure immunity for others (6).

Many of the measles cases in children in 2008 have occurred among children whose parents claimed exemption from vaccination because of religious or personal beliefs and in infants too young to be vaccinated. Forty-eight states currently allow religious exemptions to school vaccination requirements, and 21 states allow exemptions based on personal beliefs. *** During 2002 and 2003, nonmedical exemption rates were higher in states that easily granted exemptions than states with medium or difficult exemption processes (7); in such states, the process of claiming a nonmedical exemption might require less effort than fulfilling vaccination requirements (8).

Although national vaccination levels are high, it cinated children tend to be clustered geographically or socially, increasing their risk for outbreaks (6,9). An upward trend in the mean proportion of school children who were not vaccinated because of personal belief exemptions was observed from 1991 to 2004 (7). Increases in the proportion of persons declining vaccination for themselves or their children might lead to large-scale outbreaks in the United States, such as those that have occurred in other countries (e.g., United Kingdom and Netherlands) (10).

Ongoing measles virus transmission has been eliminated in the United States, but the risk for imported disease and outbreaks remains. High vaccination coverage in the United States has limited the spread of imported measles in 2008. Nevertheless, the measles outbreaks in 2008 illustrate the risk created by importation of disease into clusters of persons with low vaccination rates, both for the unvaccinated and those who come into contact with them.

References 1. Orenstein WA, Papania MJ, Wharton ME. Measles elimination in s

United States. J Infect Dis 2004;189(Suppl 1):S1–3. 2. De Quadros CA, Andrus JK, Danovaro-Holliday MC, Castüür.

Solórzano C. Feasibility of global measles eradication after intern? tion of transmission in the Americas. Expert Rey Vacc.ro

2008;7:355-62 . 3. CDC. Measles, mumps, and rubella—vaccine use and strategies

elimination of measles, rubella, and congenital rubella syndrome 22 control of mumps: recommendations of the Advisory Committee on

Immunization Practices (ACIP). MMWR 1998;47(No. RR-8. 4. Farizo KM, Stehr-Green PA, Simpson DM, Markowitz LE. Pediazi

emergency room visits: a risk factor for acquiring measles. Pediatra

1991:87:74-9. 5. Siegel JD, Rhinehart E, Jackson M, Chiarello L, Health Care Inter

tion Control Practices Advisory Committee. 2007 guideline for isca tion precautions: preventing transmission of infectious agents in hea

care settings. Am J Infect Control 2007;35(Suppl 2):S65–164. 6. Parker AA, Staggs W, Dayan GH, et al. Implications of a 2005 measia

outbreak in Indiana for sustained elimination of measles in the l'nce

States. N Engl J Med 2006;355:447-55. 7. Omer SB, Pan WK, Halsey NA, et al. Nonmedical exemptions I

school immunization requirements: secular trends and associatior. O

state policies with pertussis incidence. JAMA 2006;296:1757-63. 8. Rota JS, Salmon DA, Rodewald LE, Chen RT, Hibbs BF, Gangaus

EJ. Processes for obtaining nonmedical exemptions to state immut:

zation laws. Am J Public Health 2001;91:645–8. 9. Smith PJ, Chu SY, Barker LE. Children who have received no vaccines

who are they and where do they live? Pediatrics 2004;114:187-95. 10. CDC. Measles outbreak—Netherlands, April 1999-January 2009

MMWR 2000;49:299-303.

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Notice to Readers

Arthritis Awareness Month - May 2008

May is Arthritis Awareness Month, an observance intended to focus attention on the substantial and growing problem of arthritis in the United States. Arthritis, the most common cause of disability in the United States, affects one in five adults and nearly 300,000 children (1–3). By the year 2030, approximately 67 million U.S. adults will be affected by arthritis (4), compared with an estimated 46 million during 2003–2005 (3).

The emphasis of this year's observance is on encouraging persons with arthritis to stay physically active. The U.S. Sur geon General has stated that regular physical activity is necessary for everyone to maintain normal muscle strength, joint structure, and joint function (5). Moderate physical activity is recommended for all children and adults with arthritis and walking might be one of the most accessible ways to become physically active. Walking is low impact, can be done almost anywhere and anytime, and requires only a good par of shoes. For persons with arthritis, walking might be counterintuitive when joints hurt; however, it is a safe, effective, and

"Documented receipt of 2 doses of live measles virus vaccine, laboratory evidence

of immunity, documentation of physician-diagnosed measles, or birth before 1957. Institute for Vaccine Safety. Vaccine exemptions. Baltimore, MD: Johns Hopkins Bloomberg School Public Health; 2007. Available at http://www.vaccine

safety.edu/cc-exem.htm. ++ CDC. Statistics and surveillance: immunization coverage in the U.S. Atlanta,

GA: US Department of Health and Human Services, CDC; 2008. Available at http://www.cdc.gov/vaccines/stats-surv/imz-coverage.htm.

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nderused intervention that helps reduce joint pain, rengthen joints, and improve joint function. The CDC Arthritis Program helps fund state arthritis 'ograms designed to increase the quality of life among ersons affected by arthritis by implementing recommenitions in the National Arthritis Action Plan: A Public Health rategy (6). The program also promotes progress toward hieving the arthritis-related objectives in Healthy People 210 (7). Information about physical activity and self-manjement education programs for adults with arthritis is railable from CDC at http://www.cdc.gov/arthritis/ tervention/index.htm. Additional information about rthritis Awareness Month activities is available from the rthritis Foundation online (http://www.arthritis.org) or telephone (800-568-4045). eferences CDC. Prevalence of disabilities and associated health conditions among adults—United States, 1999. MMWR 2001;50:120–5. CDC. Prevalence of doctor-diagnosed arthritis and arthritis-attributable activity limitation—United States, 2003–2005. MMWR 2006;55: 1089-92. Sacks JJ, Helmick CG, Luo YH, Ilowite NT, Bowyer S. Prevalence of and annual ambulatory health care visits for pediatric arthritis and other rheumatologic conditions in the United States in 2001–2004. Arthritis Rheum 2007;57:1439–45. Hootman JM, Helmick CG. Projections of US prevalence of arthritis and associated activity limitations. Arthritis Rheum 2006;54:226–9. CDC. Physical activity and health: a report of the Surgeon General. Atlanta, GA: US Department of Health and Human Services, CDC; 1999. Available at http://www.cdc.gov/nccdphp/sgr/sgr.htm. Arthritis Foundation, Association of State and Territorial Health Offi- kcials, CDC. National arthritis action plan: a public health strategy.

Atlanta, GA: Arthritis Foundation; 1999. Available at http://www.cdc. gov/nccdphp/pdf/naap.pdf. : US Department of Health and Human Services. Healthy people 2010 midcourse review. Washington, DC: US Department of Health and Human Services; 2006. Available at http://www.healthypeople.gov/data/ midcourse.

Annual Conference on Assessment

Initiative August 18-20, 2008 The Annual Conference on Assessment Initiative, sponsored by CDC, will be held August 18–20, 2008, in Atlanta, Georgia. This meeting will focus on sharing information on innovative systems and methods that improve the way data are used for public health programs, services, and policies at the local and state levels. Sessions will address data dissemination, health assessment research, applied data analysis, presentation techniques, and community healthassessment processes and outcomes.

Participants will include staff members from local and state health departments, federal agencies, and community organizations interested in the collection, analysis, and dissemination of data for community health assessments. Conference attendees can register online at http://www.ppleventreg.com/ events/hhs/index.php?id=19; the deadline for online registration is August 4, and no registration fee is charged. The deadline for making reservations with the Sheraton Atlanta Hotel is July 14 (at the conference website or by telephone, 800-833-8624 or 404-659-6500).

Abstracts for the poster session are due by July 18 and should be e-mailed to Nelson Adekoya at nba7@cdc.gov. Abstracts should be a maximum of 250 words and clearly state the purpose of the poster. Topics of interest include approaches to assessment, impact and outcome of community health assessment, systems and approaches used for data dissemination, community partnerships, and statistical methods used in assessment. A maximum of 40 abstracts will be accepted, and applicants will be notified of acceptance by August 1. Additional information regarding the Assessment Initiative is available at http://www.cdc. gov/ncphilod/ai.

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TABLE I. Provisional cases of infrequently reported notifiable diseases (<1,000 cases reported during the preceding year) United States week ending May 3, 2008 (18th Week)*

5-year Current Qum weekly

Total cases reported for previous years Disease

week 2008 average 2007 2006 2005 2004 2003 States reporting cases during current week (No Anthrax

1 Botulism: foodborne

1

29 20 19 16 20 infant

20

1

87 97 85 87 76 other (wound & unspecified)

1

26
48
31 30 33

AZ (1)
Brucellosis

1
18
3 129 121 120 114 104

CA (1)
Chancroid

17

1
24 33

17

30 54 Cholera

0
7
9
8
6

2 Cyclosporiasis

26 14

91 137 543 160 75 Diphtheria

1 Domestic arboviral diseases$.1: California serogroup

44

67 80 112 108 eastern equine

4
8
21

14 Powassan

1
1
1

1 St. Louis

7
10 13

12 41
western equine
Ehrlichiosis/Anaplasmosiss.**:
Ehrlichia chaffeensis

18

4 765 578 506 338 321 Ehrlichia ewingii Anaplasma phagocytophilum

5

4 727 646 786 537 362 undetermined

2 134 231 112 59

44
Haemophilus influenzae, **
invasive disease (age <5 yrs):
serotype b

11
22

9

19 32 nonserotype b

3 54

3 177 175 135 135 117 OK (1), WA (2) unknown serotype

76
4 186
179 217 177 227

GA (1)
Hansen disease

27
2 96 66

87 105 95 Hantavirus pulmonary syndrome

3

1
32

40 26 24 26 Hemolytic uremic syndrome, postdiarrheals

27
3 278 288 221 200 178

OR (1)
Hepatitis C viral, acute

1 225 15 854 766 652 720 1,102 WA (1) HIV infection, pediatric (age <13 yrs)s

3

380 436 504 Influenza-associated pediatric mortality 11

1
69

2
76
43
45

N NYC (1)
Listeriosis

5 151 10

789 884

896

753 696 NY (2), PA (1), NC (1), WA (1) Measles***

32

1
42
55
66
37

56
Meningococcal disease, invasivetit:
A, C, Y, & W-135

109

6 308 318 297 serogroup B

58

2 152 193 156 other serogroup

15

1

31 32 27 unknown serogroup 4 255 15 574 651 765

PA (3), OH (1) Mumps

200 122 775 6,584 314

258
231

MI (1), WA (1), CA (1)
Novel influenza A virus infections

1
N
N
N

N
Plague

0
7 17

8
3

1 Poliomyelitis, paralytic

1 Poliovirus infection, nonparalytics

N
N
N

N
Psittacosis

10 21 16

12 12 Q fever: 195 total:

15

174 169 136 70 71 acute

11 chronic

4 Rabies, human

3
2
7

2 Rubella

3

10
11
11
10

7 Rubella, congenital syndrome

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 a

influenza-associated pediatric mortality, and in 2003 for SARS-COV. Reporting exceptions are available at http://www.cdc.gov/epo/dphsi/phs/infdis.htm. 1 Includes both neuroinvasive and nonneuroinvasive. Updated weekly from reports to the Division of Vector-Borne Infectious Diseases, National Center for Zoonotic, Vects.

Borne, 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 categnes

Ehrlichiosis, human monocytic (analogous to Ē. chaffeensis); Ehrlichiosis, human granulocytic (analogous to Anaplasma phagocytophilum), and Ehrlichiosis, unspecified I

other agent (which included cases unable to be clearly placed in other categories, as well as possible cases of E. ewingii). # 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 reports

influences the number of cases reported. Updates of pediatric HIV data have been temporarily suspended until upgrading of the national HIV/AIDS surveillance management system is completed. Data for HIV/AIDS, when available, are displayed in Table IV, which appears quarterly. Updated weekly from reports to the Influenza Division, National Center for Immunization and Respiratory Diseases. Sixty-nine cases occurring during the 2007–08 iritera

season have been reported. *** No measles cases were reported for the current week. 17 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 77

differentiated with respect to acute and chronic Q fever cases. 911 No rubella cases were reported for the current week.

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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ABLE I. (Continued) Provisional cases of infrequently reported notifiable diseases (<1,000 cases reported during the preceding year) — nited States, week ending May 3, 2008 (18th Week)*

5-year Current Cum weekly

Total cases reported for previous years sease

week 2008 averaget 2007 2006 2005 2004 2003 States reporting cases during current week (No.) nallpoxi reptococcal toxic-shock syndrome

48

118 125 129 132 161 philis, congenital (age <1 yr)

40
328 349 329 353

413 tanus

2

24 41 27 34 20 xic-shock syndrome (staphylococcal)

19 2 87 101 90 95 133 CA (1) chinellosis

2

6 15 16 5 6 laremia

5 1
95 154 134

129 phoid fever

111

6 418 353 324 322 356 MA (1), FL (1), CA (1) ncomycin-intermediate Staphylococcus aureus

0 28
6 2

N ncomycin-resistant Staphylococcus aureuss

2
1
3

N priosis (noncholera Vibrio species infections) 2 44

381
N N N N

FL (2) llow fever 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.

122

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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

Patsy A. Hall
Deborah A. Adams Rosaline Dhara
Willie J. Anderson Carol Worsham
Lenee Blanton

Pearl C. Sharp

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TABLE II. Provisional cases of selected notifiable diseases, United States, weeks ending May 3, 2008, and May 5, 2007
(18th Week)*
Chlamydia
Coccidioidomycosis

Cryptosporidiosis
Previous

Previous

Previous
Current 52 weeks Cum Qum Current 52 weeks Cum Cum Current 52 weeks Cum
Reporting area
week Med Max 2008 2007

week
Med Max 2008 2007 week Med

Max 2008 United States 12,011 21,043 24,727 339,318 369,159

134 131 308 2,307 2,581

41 85 974 1,072 New England

657
684 1,517 11,827 11,174

1
1
1
2 5

16
Connecticut
334 214 1.093 3,086 2,697

5 Maine 51 50 67 896 876

1

5 Massachusetts 269 313 661 6,197 5,471

2

11

30 New Hampshire

3
39
73 617 665

1

11 Rhode Islands 62 98 1,025 1,169

0
3

3 Vermont

10
32
6 296

N
N

1

13 Mid. Atlantic 2,298 2,781 4,886 49,835 48,398

9 12 120 145 * New Jersey 143 404 520 6,311 7,521

N

8

3 New York (Upstate) 524 557 2,044 9,051 8,398

6
4
20

43 New York City

1,085
975 3,203 20,151 17,881

10
Pennsylvania
546 796 1,754 14,322 14,598

N

103 E.N. Central 1,202 3,375 4,395 54,548 63,127

14

8 20 134 245 Illinois 12 1,004 1,711 13,187 17,639

N

13

21 Indiana 386 651 6.480 7,484

N

2 41

34 Michigan 906 741 1.184 15.828 13,452

10

2
4
11

59 Ohio

117
872 1,824 12,231 17,693

4

3 5

60
Wisconsin
167 377 611 6.822 6,859

0
N

3 7 59
W.N. Central
325 1,218 1,693 20,431 21,757

77

3

9 16 125 198 lowa

123
166
251 2,950 3,022

0
N

3
61

43 Kansas 89 158 529 3,078 2,741

0

1
2
16

19 Minnesota 2 258 333 4,164 4,706

77

7
4
34

53 Missouri 464 551 7,270 8,016

14

44 Nebraskas

55
89 183 1,489 1.801

N
N

24 North Dakota

31
65
506 624

N
N

6

1 South Dakota

56 52
81 974 847

N
N

16

16 2 S. Atlantic 3,514 3,697 7,484 62,474 67,796

1
2

20
65

2. Delaware 70 65 144 1,300 1,229

4

6 District of Columbia 156 114 200 2,047 1,958

0
3

5 Florida 1,023 1,280 1,556 22,998 16,882

35 Georgia

260 1,502

507
14,141

4 15
Marylands
379 466 675 7,546 5,948

3

3 North Carolina 271 206 4,656 7,645 10,438

18

9 South Carolinas 780 445 3,345 9,444 7,364

15

11 Virginia 823 485 1,061 9,923 8,750

1
6

11 West Virginia

11 62
96 1,064 1,086

5

5 E.S. Central

551
1,496 2,393 25,804 29,619

4 65 33 Alabama 21 480 605 7,136 8,808

N

14
Kentucky
199 302 3,326 2,617

N
N

5 Mississippi 290 1,048 5,731 8,128

N

3 Tennessees 530 503 717 9,611 10,066

N

18

10 W.S. Central 823 2,621 3,768 46,559 40,547

1

28 57 5 Arkansas

225
217 455 4,917 3,157

N
N

8

7 Louisiana 285 304 851 4,125 6,717

1
1

4

3 Oklahoma 313 243 418 4,339 4,448

N
N

11

14 Texas 1,778 3,382 33,178 26,225

N
N

3 16
Mountain
1,360 1,841 12,432 25,653
75 88 170 1,562 1,727

567 86 Arizona 138 421 681 1,039 8,272

74
84 168 1,532 1,678

4

12 Colorado 19 293 488 1,759 6,240

N
N

26

17 Idahos 130 56 233 1,302 1,428

N
N

2 72

20 Montanas 48 363 953 969

N

7

10 Nevada 399 183 340 3,323 3,278

17
17

6
New Mexicos
158 562 2,016 3,282

10

11 Utah 126 124 216 2,029 1,751

3 21

484 Wyoming

18
34

11

433 Pacific 1,829 3,330 4,055 55,408 61,088 59 34 217 727 837

20 Alaska

106
91 137 1,418 1,704

0
N
N

2
California
1,530 2,811 3,464 48,477 47,874

217 727 837

0 Hawaii

110
143 1,716 1.986

0
N
N

4

1 Oregons

193 191
403 3,684 3,250

16

17 Washington 117 613 113 6,274

0 American Samoa

0
32
62
41

N

N
C.N.M.I.
Guam

6
34

46 276
Puerto Rico
210 112 612 2,327 2,732

N
U.S. Virgin Islands

4
27 192

71
C.N.MI: Commonwealth of Northern Mariana Islands.
U: Unavailable. - No reported cases. N: Not notifiable. Cum: Cumulative year-to-date counts. Med: Median. Max: Maximum.
Incidence data for reporting years 2007 and 2008 are provisional. Data for HIV/AIDS, AIDS, and TB, when available, are displayed in Table IV, which appears quarterly.
Chlamydia refers to genital infections caused by Chlamydia trachomatis.
Contains data reported through the National Electronic Disease Surveillance System (NEDSS). Due to technical difficulty no data from the NEDSS system was included in week

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