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erences Kösters K, Riffelmann M, Wirsing von König CH. Evaluation of a real-time PCR assay for detection of Bordetella pertussis and

B. parapertussis in clinical samples. J Med Microbiol 2001;50:436–40. CDC. Hypertrophic pyloric stenosis in infants following pertussis pro

phylaxis with erythromycin-Knoxville, Tennessee, 1999. MMWR 1999;48:1117–20. - CDC. Preventing tetanus, diphtheria, and pertussis among adults: use

of tetanus toxoid, reduced diphtheria toxoid and acellular pertussis a vaccine: Recommendations of the Advisory Committee on Immuniza* tion Practices (ACIP) and recommendation of ACIP, supported by the

Healthcare Infection Control Practices Advisory Committee (HICPAC), for use of Tdap among health-care personnel. MMWR * 2006;55(No. RR-17).

Vitek CR, Pascual FB, Baughman AL, Murphy TV. Increase in deaths
from pertussis among young infants in the United States in the 1990s.
Pediatr Infect Dis J 2003;22:628–34.
Bamberger E, Starets-Haham O, Greenberg D, et al. Adult pertussis is

hazardous for the newborn. Infect Control Hosp Epidemiol **_2006;27:623–5.

Bryant KA, Humbaugh K, Brothers K, et al. Measures to control an outbreak of pertussis in a neonatal intermediate care nursery after exposure to a healthcare worker. Infect Control Hosp Epidemiol 2006;27:541-5. CDC. Outbreaks of pertussis associated with hospitals-Kentucky, Pennsylvania, and Oregon, 2003. MMWR 2005;54:67–71. CDC. Summary of notifiable diseases, United States, 2004. MMWR 2006;53(53). CDC. Outbreaks of respiratory illness mistakenly attributed to pertussis—New Hampshire, Massachusetts, and Tennessee, 2004–2006. MMWR 2007;56:837-42. Calugar A, Ortega-Sanchez I, Tiwari T, Oakes L, Jahre J, Murphy TV. Nosocomial pertussis: costs of an outbreak and benefits of vaccinating health care workers. Clin Infect Dis 2006;42:981-8.

antibody testing by Brucella microagglutination test (BMAT) performed at CDC on the patient's serum was negative. The case did not meet the CDC/Council of State and Territorial Epidemiologists' (CSTE) definition for a probable or confirmed brucellosis case (3) (Box), and the initial EIA result was determined to be a false positive. This report summarizes the case history, laboratory findings, and public health investigations. CDC recommends that Brucella serology testing only be performed using tests cleared or approved by the Food and Drug Administration (FDA) or validated under the Clinical Laboratory Improvement Amendments (CLIA) and shown to reliably detect the presence of Brucella infection. Results from these tests should be considered supportive evidence for recent infection only and interpreted in the context of a clinically compatible illness and exposure history. EIA is not considered a confirmatory Brucella antibody test; positive screening test results should be confirmed by Brucella-specific agglutination (i.e., BMAT or standard tube agglutination test) methods.

On February 1, 2005, the Nassau County Health Department received a report, based on a positive Brucella antibody test result, of a possible case of brucellosis in a

BOX. CDC/Council of State and Territorial Epidemiologists case definition for human brucellosis for public health surveillance

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Public Health Consequences of a » False-Positive Laboratory Test

Result for Brucella Florida, Georgia, and Michigan, 2005 luman brucellosis, a nationally notifiable disease, is common in the United States. Most human cases have urred in returned travelers or immigrants from regions ere brucellosis is endemic, or were acquired domestiу from eating illegally imported, unpasteurized fresh* eses (1,2). In January 2005, a woman aged 35 years c) lived in Nassau County, Florida, received a diagnosis brucellosis, based on results of a Brucella immunoglobuM (IgM) enzyme immunoassay (EIA) performed in a amercial laboratory using analyte specific reagents Rs); this diagnosis prompted an investigation of dairy ducts in two other states. Subsequent confirmatory

Clinical description

An illness characterized by acute or insidious onset of fever, night sweats, undue fatigue, anorexia, weight loss, headache, and arthralgia. Laboratory criteria for diagnosis • Isolation of Brucella spp. from a clinical specimen, or • Fourfold or greater rise in Brucella agglutination titer

between acute- and convalescent-phase serum specimens obtained 2 weeks apart and studied at the same

laboratory, or • Demonstration by immunofluorescence of Brucella

spp. in a clinical specimen. Case classification

Probable: clinically compatible case that is epidemiologically linked to a confirmed case or that has supportive serology (i.e., Brucella agglutination titer >160 in one or more serum specimens obtained after onset of symptoms).

Confirmed: a clinically compatible illness that is laboratory confirmed.

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female resident aged 35 years. The woman reported having intermittent fever, chills, sweats, body aches, weakness, headaches, and malaise since October 13, 2004. She was examined first at a local emergency department in November 2004, diagnosed with acute bronchitis, and discharged without a prescription for antimicrobials. She subsequently was examined by an infectious disease specialist on January 3, 2005, at which time brucellosis was considered based on continued nonspecific symptoms, polyarthritis, and an atypical lymphocytosis seen on a peripheral blood smear. Blood was obtained for culture and Brucella antibody testing on January 3 and January 24. Blood cultures were negative after 10 days. The EIA results from a commercial laboratory were interpreted as positive IgM and negative IgG, consistent with early brucellosis. On the basis of these results, on February 1 the patient was prescribed a twice daily, 6-week course of antimicrobial therapy of doxycycline (100 mg) and rifampin (300 mg). She stopped taking both antimicrobials after a short period because of side effects. After confirmatory testing by BMAT of the January 24 serum sample, performed February 14 at CDC, was negative, no further treatment for brucellosis was recommended. No other infectious etiologies were identified as a cause of the patient's symptoms, and she was lost to followup.

After the February 1 report, but before receiving the negative BMAT results, Nassau County and Florida epidemiologists began an investigation to identify possible exposures to Brucella species. The patient reported no recent contact with animals or animal fluids. She had eaten goat cheese from several sources while traveling in Michigan during May-July 2004 and while staying at a Georgia youth hostel in July 2004, 3–5 months before her illness onset. No unpasteurized dairy products were discovered at the identified sources that supplied locations where the woman ate. At the youth hostel, all dairy products used for cooking were pasteurized and purchased from local markets; however, guests often contributed food they had brought with them, and exact origins of shared foods were difficult to determine. Reported by: A Pragle, MS, C Blackmore, DVM, Florida Dept of Health. TA Clark, MD, Div of Bacterial Diseases, National Center for Immunization and Respiratory Diseases; MD Ari, PhD, PP Wilkins, PhD, Div of Foodborne, Bacterial, and Mycotic Diseases, National Center for Zoonotic, Vector-Borne, and Enteric Diseases; D Gross, DVM, PhD, EJ Stern, MD, EIS officers

, CDC. Editorial Note: Brucellosis is a classic bacterial zoonosis. Common Brucella species that are pathogenic in humans and their usual animal reservoirs include B. melitensis in

sheep and goats, B. abortus in cattle, and B. suis in su.:. B. melitensis, considered the most pathogenic species humans, has not been reported in animals in the Units. States since 1999. Symptoms of human brucellosis va and include periodic or undulant fever, muscle aches, bà pain, and fatigue. Diagnosis can be difficult because bo cellosis has a prolonged and variable incubation period days to 5 months), often presents as a nonspecific febris syndrome, and occurs in acute, chronic, and asymptomatic forms.

Definitive diagnosis of brucellosis requires isolation anú identification of the Brucella species. More commonly, cases are diagnosed serologically by detection of agglutinating antibodies. The reference method is the standard tube agglutination test (SAT), of which ВMAT is a modified format (4). Brucella-specific agglutination tests invo.se direct agglutination of bacterial antigens by specific antibodies. Agglutination tests detect antibodies of IgM, IgG, and IgA classes. IgM antibodies are predominant in acute infection but decline within weeks, whereas relapses are accompanied by transient elevations of IgG and IgA anzbodies but not IgM (5).

Evidence of Brucella antibody by nonagglutination-based tests does not meet the current CDC/CSTE case definition for brucellosis (Box). In the context of a clinically compatible illness, brucellosis is confirmed by a fourfold or greater rise in Brucella agglutination titer between acute- and convalescent-phase serum specimens obtained at least weeks apart, isolation of Brucellae in culture, or demonstrar tion of organism presence by specific immunohistochem: cal staining (3). A clinically compatible case that is epidemiologically linked to a confirmed case or that has supportive serology (i.e., Brucella agglutination titer of 216 in one or more serum specimens obtained after onset of symptoms) is considered a probable case.

The Brucella EIA reagents used in this investigation were: obtained from Panbio, Inc. (Columbia, Maryland); the are sold as ASRs in the United States but elsewhere as com plete test kits. ASRs are used as active components of | assays developed by individual clinical laboratories loi Laboratories that use ASRs are responsible for evaluating and validating their assay and for establishing and main taining assay interpretation and performance criteria i including sensitivity and specificity (6). Specificity of the Panbio IgM and IgG EIA, based on a study in a brucellosis endemic area, was reported as 100% (7); IgM detective sensitivities using different EIA formats has been reporred as 67%-100%, with limited specificity data (8). Such teos might have different performance characteristics when used

- areas with low disease prevalence, such as the United tes. The CDC laboratory has observed that specimens t were positive using EIA tests from commercial laboraies often were negative when tested by BMAT. Results EIA tests must be confirmed by a reference method such BMAT, which is quantitative and provides evidence of ng antibody titers when paired sera are tested. Cross-reactions and false-positive test results can occur Brucella antibody tests. The primary immunodeterminant | virulence factor for Brucella species is the cell wall sure lipopolysaccharide, which is antigenically similar to

lipopolysaccharide of other gram-negative rods. Falseitive Brucella antibody test results can be caused by crossctivity of antibodies to Escherichia coli O157, Francisella irensis, Moraxella phenylpyruvica, Yersinia enterocolitica, I certain Salmonella species (9). Most cross-reacting ibodies are IgM (10), making interpretation of any IgM uy difficult because of false positivity. Therefore, results ained using EIA should be confirmed by a reference thod. This investigation highlights the need to confirm screenserologic test results by using established reference test

methods and to identify the presence of known risk cors before committing a patient to prolonged antimibial therapy for brucellosis or initiating public health estigations. Testing of persons with compatible signs and iptoms for brucellosis should be supported by a thorzh history that reveals likely exposure through travel to area where brucellosis is endemic, consumption of an pasteurized dairy product, hunting potentially infected dlife species, or laboratory exposure. Testing of persons he absence of a suggestive exposure increases the likeliod of false-positive results and lowers the overall positive dictive value of the assay used. Rapid Brucella antibody iys can be useful as screening tools when results are erpreted in the context of performance characteristics of

particular test; however, CDC recommends that all itive results obtained by rapid serologic assays be conned with Brucella-specific agglutination testing. For stions about risk factors or to request confirmatory testfor brucellosis in patients with strong evidence of expo, health-care providers should contact their local or state Ith department.

References 1. Chomel BB, DeBess EE, Mangiamele DM, et al. Changing trends in

the epidemiology of human brucellosis in California from 1973 to 1992: a shift toward foodborne transmission. J Infect Dis

1994;170:1216-23. 2. Thapar MK, Young EJ. Urban outbreak of goat cheese brucellosis.

Pediatr Infect Dis 1986;40:677-82. 3. CDC. Case definitions for infectious conditions under public health

surveillance. MMWR 1997;46(No. RR-10):8–9. 4. Brown SL, Klein GC, McKinney FT, Jones WL. Safranin O-stained

antigen microagglutination test for detection of Brucella antibodies.

J Clin Microbiol 1981;13:398-400. 5. Reddin JL, Anderson RK, Jenness R, Spink WW. Significance of 7S

and macroglobulin Brucella agglutinins in human brucellosis. N Engl J

Med 1965;272:1263–8. 6. Food and Drug Administration. Guidance for industry and FDA staff.

Commercially distributed analyte specific reagents (ASRs): frequently asked questions. Rockville, MD: US Department of Health and Human Services; 2007. Available at http://www.fda.gov/cdrh/oivd/

guidance/1590.pdf. 7. Araj G, Kattar M, Fattouh L, Bajakian KO, Kobeissi SA. Evaluation of

the PANBIO Brucella immunoglobulin G (IgG) and IgM enzymelinked immunosorbent assays for diagnosis of human brucellosis. Clin

Diag Lab Immun 2005;12:1334–5. 8. Memish ZA, Almuneef M, Mah MW, Qassem LA, Osoba AO. Com

parison of Brucella standard agglutination test with the ELISA IgG and IgM in patients with Brucella bacteremia. Diag Microbiol Infect

Dis 2002;44:129–32. 9. Corbel MJ. Brucellosis: an overview. Emerg Infect Dis 1997;3:

213-21. 10. Corbel MJ. Recent advances in the study of Brucella antigens and their

serological cross-reactions. Vet Bull 1985;55:927-42.

Notice to Readers

Cancer Survivorship — June 2008 National Cancer Survivors Day was June 1. Throughout the month of June, CDC is focusing attention on the needs of cancer survivors. Currently, approximately 11 million persons in the United States are living with a previously diagnosed cancer, a threefold increase from the estimated 3 million persons who were living with cancer in 1971 (1,2).

Today, approximately 65% of persons diagnosed with cancer are expected to live at least 5 years after diagnosis (2), but disparities in health care can affect survival. Lowincome persons who have inadequate or no health insurance coverage are more likely to be diagnosed with cancer at later stages, when the potential for survival is reduced (3).

The National Action Plan for Cancer Survivorship (4), developed by CDC, the Lance Armstrong Foundation, and multiple partners, identified public health needs of cancer survivors and proposed strategies to meet those needs. Additional information, including descriptions of CDC's cancer survivorship research initiatives and partnerships and

Acknowledgments he findings in this report are based, in part, on contributions by eib, Nassau County Health Dept; K Ward, Florida Dept of Health; L Brumble, MD, Mayo Clinic, Jacksonville, Florida.

Notice to Readers

links to national publications highlighting health-care needs of cancer survivors is available at http://www.cdc.gov/ features/cancersurvivors. References 1. CDC. Cancer survivorship—United States, 1971–2001. MMWR

2004;53:526–9. 2. Ries LAG, Melbert D, Krapcho M, et al., eds. SEER cancer statistics

review, 1975–2004. Bethesda, MD: National Cancer Institute; 2007.

Available at http://seer.cancer.gov/csr/1975_2004. 3. Schwartz KL, Crossley-May H, Vigneau FD, Brown K, Banerjee M.

Race, socioeconomic status and stage at diagnosis for five common

malignancies. Cancer Causes Control 2003;14:761–6. 4. CDC, Lance Armstrong Foundation. A national action plan for cancer

survivorship: advancing public health strategies. Atlanta, GA: US Department of Health and Human Services, CDC; 2004.

Assessment Tool for Evaluating

Emergency and Disaster Shelters Shelters provide refuge for communities and at-risk porlations during and after emergencies and disasters. Efte. tive emergency response requires that environmental healt practitioners rapidly assess the health and safety of the shelse environment for these populations.

To help meet this challenge, CDC and partners have developed an environmental health shelter assessment for (available in English and Spanish) that covers general alca of environmental health, such as food safety, sanitation and service and companion animal care. It also provide space for listing immediate needs. The form provides gu. ance and information that environmental health practi.cners and shelter managers can use with existing plans, procedures, resources, and management systems.

The environmental health shelter assessment tool, induing the assessment form, instructions for its use, and train ing materials, is available at http://www.emergency.cdc.gos shelterassessment.

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Percentage of Adults Aged >25 Years with Limitation of Activity Caused by One or More Chronic Conditions,* by Education Level and Sex —

National Health Interview Survey, United States, 2006

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* Limitation in usual activity is determined from responses to a series of questions
about limitations in a person's ability to engage in work, school, play, or other
activities for health reasons; the specific conditions causing the limitations;
and the duration of these conditions. Conditions lasting >3 months are classified
as chronic; selected conditions (e.g., arthritis, diabetes, cancer, and heart
conditions) are considered chronic regardless of duration.
Estimates are age adjusted using the projected 2000 U.S. population as the
standard population and using four age groups: 25–44 years, 45–64 years,
65–74 years, and >75 years. Estimates are based on household interviews of
a sample of the civilian, noninstitutionalized U.S. population. Persons who did
not know whether they had a limitation and those with a limitation who did not
know whether the condition causing the limitation was chronic were excluded
from the denominators.

s General Educational Development.
In 2006, persons who had less than a high school diploma were more than twice as likely as persons who had
a bachelor's degree or higher to be limited in their usual activities because of one or more chronic conditions.
At lower education levels (less than a high school diploma or a high school or GED diploma), women were
more likely than men to be limited in usual activities. At higher education levels, no significant difference in
limitation was observed between men and women.
SOURCES: 2006 National Health Interview Survey. Available at http://www.cdc.gov/nchs/nhis.htm.

Adams PF, Lucas JW, Barnes PM. Summary health statistics for the U.S. population: National Health Interview Survey, 2006. Vital Health Stat 2008;10(236). Available at http://www.cdc.gov/nchs/data/series/sr_10/ sr10_236.pdf.

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