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Volume 14, Number 1—January 2008
Volume 14, Number 1—January 2008 PDF Version [PDF - 9.37 MB - 199 pages]
International Polar Year
The International Polar Year, 2007–2008, An Opportunity to Focus on Infectious Diseases in Arctic Regions
PDF Version [PDF - 97 KB - 3 pages]
A. J. Parkinson
Sexual Health and Sexually Transmitted Infections in the North American Arctic
PDF Version [PDF - 74 KB - 6 pages]
D. G. Law et al.View Abstract
Our objective was to describe the basic epidemiology of sexually transmitted infections for Arctic and sub-Arctic regions of North America. We summarized published and unpublished rates of chlamydial infection and gonorrhea reported from 2003 through 2006 for Alaska, Canada, and Greenland. In 2006, Alaska reported high rates of chlamydial infection (715 cases/100,000 population) compared with the United States as a whole; northern Canada reported high rates of chlamydial infection (1,693 cases/100,000) and gonorrhea (247 cases/100,000) compared with southern Canada; and Greenland consistently reported the highest rates of chlamydial infection (5,543 cases/100,000) and gonorrhea (1,738 cases/100,000) in the Arctic. Rates were high for both men and women, although the highest incidence of infection was predominantly reported for young women in their early twenties. We propose that community-based participatory research is an appropriate approach to improve sexual health in Arctic communities.
Integrated Approaches and Empirical Models for Investigation of Parasitic Diseases in Northern Wildlife
PDF Version [PDF - 196 KB - 8 pages]
E. P. Hoberg et al.View Abstract
The North is a frontier for exploration of emerging infectious diseases and the large-scale drivers influencing distribution, host associations, and evolution of pathogens among persons, domestic animals, and wildlife. Leading into the International Polar Year 2007–2008, we outline approaches, protocols, and empirical models derived from a decade of integrated research on northern host–parasite systems. Investigations of emerging infectious diseases associated with parasites in northern wildlife involved a network of multidisciplinary collaborators and incorporated geographic surveys, archival collections, historical foundations for diversity, and laboratory and field studies exploring the interface for hosts, parasites, and the environment. In this system, emergence of parasitic disease was linked to geographic expansion, host switching, resurgence due to climate change, and newly recognized parasite species. Such integrative approaches serve as cornerstones for detection, prediction, and potential mitigation of emerging infectious diseases in wildlife and persons in the North and elsewhere under a changing global climate.
International Circumpolar Surveillance, An Arctic Network for the Surveillance of Infectious Diseases
PDF Version [PDF - 261 KB - 7 pages]
A. J. Parkinson et al.View Abstract
Peoples of the Arctic and sub-Arctic regions live in social and physical environments that differ substantially from those of their more southern-dwelling counterparts. The cold northern climate keeps people indoors, amplifying the effects of household crowding, smoking, and inadequate ventilation on person-to-person spread of infectious disease. The emergence of antimicrobial drug resistance among bacterial pathogens, the reemergence of tuberculosis, the entrance of HIV into Arctic communities, and the specter of pandemic influenza or the sudden emergence and introduction of new viral pathogens such as severe acute respiratory syndrome are of increasing concern to residents, governments, and public health authorities. The International Circumpolar Surveillance system is a network of hospital, public health agencies, and reference laboratories throughout the Arctic linked together to collect, compare, and share uniform laboratory and epidemiologic data on infectious diseases and assist in the formulation of prevention and control strategies.
International Circumpolar Surveillance System for Invasive Pneumococcal Disease, 1999–2005
PDF Version [PDF - 145 KB - 9 pages]
M. G. Bruce et al.View Abstract
The International Circumpolar Surveillance System is a population-based surveillance network for invasive bacterial disease in the Arctic. The 7-valent pneumococcal conjugate vaccine (PCV7) was introduced for routine infant vaccination in Alaska (2001), northern Canada (2002–2006), and Norway (2006). Data for invasive pneumococcal disease (IPD) were analyzed to identify clinical findings, disease rates, serotype distribution, and antimicrobial drug susceptibility; 11,244 IPD cases were reported. Pneumonia and bacteremia were common clinical findings. Rates of IPD among indigenous persons in Alaska and northern Canada were 43 and 38 cases per 100,000 population, respectively. Rates in children <2 years of age ranged from 21 to 153 cases per 100,000 population. In Alaska and northern Canada, IPD rates in children <2 years of age caused by PCV7 serotypes decreased by >80% after routine vaccination. IPD rates are high among indigenous persons and children in Arctic countries. After vaccine introduction, IPD caused by non-PCV7 serotypes increased in Alaska.
Invasive Bacterial Diseases in Northern Canada
PDF Version [PDF - 161 KB - 7 pages]
N. Degani et al.View Abstract
International Circumpolar Surveillance (ICS) is a population-based invasive bacterial disease surveillance network. Participating Canadian regions include Yukon, Northwest Territories, Nunavut, and northern regions of Québec and Labrador (total population 132,956, 59% aboriginal). Clinical and demographic information were collected by using standardized surveillance forms. Bacterial isolates were forwarded to reference laboratories for confirmation and serotyping. After pneumococcal conjugate vaccine introduction, crude annual incidence rates of invasive Streptococcus pneumoniae decreased from 34.0/100,000 population (1999–2002) to 23.6/100,000 population (2003–2005); substantial reductions were shown among aboriginals. However, incidence rates of S. pneumoniae, Haemophilus influenzae, and group A streptococci were higher in aboriginal populations than in non-aboriginal populations. H. influenzae type b was rare; 52% of all H. influenzae cases were caused by type a. Data collected by ICS contribute to the understanding of the epidemiology of invasive bacterial diseases among northern populations, which assists in formulation of prevention and control strategies, including immunization recommendations.
Sindbis Virus Infection in Resident Birds, Migratory Birds, and Humans, Finland
PDF Version [PDF - 225 KB - 7 pages]
S. Kurkela et al.View Abstract
Sindbis virus (SINV), a mosquito-borne virus that causes rash and arthritis, has been causing outbreaks in humans every seventh year in northern Europe. To gain a better understanding of SINV epidemiology in Finland, we searched for SINV antibodies in 621 resident grouse, whose population declines have coincided with human SINV outbreaks, and in 836 migratory birds. We used hemagglutination-inhibition and neutralization tests for the bird samples and enzyme immunoassays and hemagglutination-inhibition for the human samples. SINV antibodies were first found in 3 birds (red-backed shrike, robin, song thrush) during their spring migration to northern Europe. Of the grouse, 27.4% were seropositive in 2003 (1 year after a human outbreak), but only 1.4% were seropositive in 2004. Among 2,529 persons, the age-standardized seroprevalence (1999–2003) was 5.2%; seroprevalence and incidence (1995–2003) were highest in North Karelia (eastern Finland). Grouse may contribute to the epidemiology of SINV in humans.
Epidemiology of Haemophilus influenzae Serotype a, North American Arctic, 2000–2005
PDF Version [PDF - 388 KB - 8 pages]
M. G. Bruce et al.View Abstract
Before the introduction of Haemophilus influenzae type b (Hib) conjugate vaccines, rates of invasive H. influenzae disease among indigenous people of the North American Arctic were among the highest in the world. Routine vaccination reduced rates to low levels; however, serotype replacement with non–type b strains may result in a reemergence of invasive disease in children. We reviewed population-based data on invasive H. influenzae in Alaska and northern Canada from 2000–2005; 138 cases were reported. Among 88 typeable isolates, 42 (48%) were H. influenzae type a (Hia); 35 (83%) occurred in indigenous peoples. Among Hia patients, median age was 1.1 years; 62% were male; 1 adult died. Common clinical manifestations included meningitis, pneumonia, and septic arthritis. Overall annual incidence was 0.9 cases per 100,000 population. Incidence among indigenous children <2 years of age in Alaska and northern Canada was 21 and 102, respectively. Serotype a is now the most common H. influenzae serotype in the North American Arctic; the highest rates are among indigenous children.
Implementation and Effectiveness of Antiretroviral Therapy in Greenland
PDF Version [PDF - 296 KB - 4 pages]
N. Lohse et al.View Abstract
Analyses from the Danish HIV Cohort Study showed that, despite comparable economic means and general education of healthcare personnel, antiretroviral treatment of HIV in Greenland began later and has been implemented at a slower pace with lower therapeutic effectiveness than in Denmark. However, implementation and quality of care improved considerably in recent years.
Dogs as Sources and Sentinels of Parasites in Humans and Wildlife, Northern Canada
PDF Version [PDF - 285 KB - 4 pages]
A. L. Salb et al.View Abstract
A minimum of 11 genera of parasites, including 7 known or suspected to cause zoonoses, were detected in dogs in 2 northern Canadian communities. Dogs in remote settlements receive minimal veterinary care and may serve as sources and sentinels for parasites in persons and wildlife, and as parasite bridges between wildlife and humans.
Human Ophthalmomyiasis Interna Caused by Hypoderma tarandi, Northern Canada
PDF Version [PDF - 211 KB - 3 pages]
P. R. Lagacé-Wiens et al.View Abstract
Human myiasis caused by bot flies of nonhuman animals is rare but may be increasing. The treatment of choice is laser photocoagulation or vitrectomy with larva removal and intraocular steroids. Ophthalmomyiasis caused by Hypoderma spp. should be recognized as a potentially reversible cause of vision loss.
Q Fever Update, Maritime Canada
PDF Version [PDF - 298 KB - 3 pages]
T. J. Marrie et al.View Abstract
Since the 1990s, reports of Q fever in Nova Scotia, Canada, have declined. Passive surveillance for Q fever in Nova Scotia and its neighboring provinces in eastern Canada indicates that the clinical manifestation of Q fever in the Maritime provinces is pneumonia and that incidence of the disease may fluctuate.
Dissemination of Multidrug-Resistant Bacteria into the Arctic
PDF Version [PDF - 151 KB - 3 pages]
M. Sjölund-Karlsson et al.View Abstract
We show that Escherichia coli isolates originating from Arctic birds carry antimicrobial drug resistance determinants. This finding implies that dissemination of drug-resistant bacteria is worldwide. Resistance genes can be found even in a region where no selection pressure for resistance development exists.
Spatial Distribution of Echinococcus multilocularis, Svalbard, Norway
PDF Version [PDF - 268 KB - 3 pages]
E. Fuglei et al.View Abstract
In Svalbard, Norway, the only intermediate host for Echinococcus multilocularis, the sibling vole, has restricted spatial distribution. A survey of feces from the main host, the arctic fox, showed that only the area occupied by the intermediate host is associated with increased risk for human infection.
Population-based Survey of Invasive Bacterial Diseases, Greenland, 1995–2004
PDF Version [PDF - 195 KB - 4 pages]
A. Meyer et al.View Abstract
Invasive bacterial disease occurs frequently among native populations in the Arctic. Although a variety of bacteria are involved in invasive bacterial disease in Greenland, Streptococcus pneumoniae, Escherichia coli, Staphylococcus aureus, and other staphylococci are responsible for most cases (69%); incidence varies according to region and ethnicity.
Molecular Epidemiology of Dengue Virus Strains from Finnish Travelers
PDF Version [PDF - 175 KB - 4 pages]
E. Huhtamo et al.View Abstract
We characterized 11 dengue virus (DENV) isolates obtained from Finnish travelers during 2000–2005 using monoclonal antibodies and phylogenetic analysis. The analysis of DENV isolated from travelers contributes to the global picture of strain distribution and circulation. The isolates included all serotypes, including a DENV-2 isolate from Ghana.
Wild Bird Influenza Survey, Canada, 2005
PDF Version [PDF - 225 KB - 4 pages]
E. J. Parmley et al.View Abstract
Of 4,268 wild ducks sampled in Canada in 2005, real-time reverse transcriptase–PCR detected influenza A matrix protein (M1) gene sequence in 37% and H5 gene sequence in 5%. Mallards accounted for 61% of samples, 73% of M1-positive ducks, and 90% of H5-positive ducks. Ducks hatched in 2005 accounted for 80% of the sample.
Volume 14, Number 1—January 2008 - Continued
Influenza Virus Samples, International Law, and Global Health Diplomacy
PDF Version [PDF - 184 KB - 7 pages]
D. P. FidlerView Abstract
Indonesia’s decision to withhold samples of avian influenza virus A (H5N1) from the World Health Organization for much of 2007 caused a crisis in global health. The World Health Assembly produced a resolution to try to address the crisis at its May 2007 meeting. I examine how the parties to this controversy used international law in framing and negotiating the dispute. Specifically, I analyze Indonesia’s use of the international legal principle of sovereignty and its appeal to rules on the protection of biological and genetic resources found in the Convention on Biological Diversity. In addition, I consider how the International Health Regulations 2005 applied to the controversy. The incident involving Indonesia’s actions with virus samples illustrates both the importance and the limitations of international law in global health diplomacy.
Pandemic Influenza and Pregnant Women
PDF Version [PDF - 64 KB - 6 pages]
S. A. Rasmussen et al.View Abstract
Planning for a future influenza pandemic should include considerations specific to pregnant women. First, pregnant women are at increased risk for influenza-associated illness and death. The effects on the fetus of maternal influenza infection, associated fever, and agents used for prophylaxis and treatment should be taken into account. Pregnant women might be reluctant to comply with public health recommendations during a pandemic because of concerns regarding effects of vaccines or medications on the fetus. Guidelines regarding nonpharmaceutical interventions (e.g., voluntary quarantine) also might present special challenges because of conflicting recommendations about routine prenatal care and delivery. Finally, healthcare facilities need to develop plans to minimize exposure of pregnant women to ill persons, while ensuring that women receive necessary care.
Human Metapneumovirus Infections in Children
PDF Version [PDF - 199 KB - 6 pages]
T. Heikkinen et al.View Abstract
Human metapneumovirus (hMPV) is an important cause of lower respiratory tract infections in hospitalized children, but the age-related incidence and effect of hMPV in unselected children in the community have not been evaluated. We studied a cohort of 1,338 children <13 years of age throughout 1 respiratory season in Finland during 2000–2001. We examined children and obtained a nasal swab for viral detection at any sign of respiratory infection. hMPV was detected in 47 (3.5%) of the 1,338 children. The age-related incidence of hMPV infection was highest (7.6%) in children <2 years of age, in whom hMPV accounted for 1.7% of all infections during the season. During the epidemic peak, hMPV caused 7.1% of all respiratory infections in the cohort. Acute otitis media developed in 61% of hMPV-infected children <3 years of age. Our findings demonstrate that the effect of hMPV in the community is greatest in children <2 years of age.
High Genetic Diversity of Measles Virus, World Health Organization European Region, 2005–2006
PDF Version [PDF - 429 KB - 8 pages]
J. R. Kremer et al.View Abstract
During 2005–2006, nine measles virus (MV) genotypes were identified throughout the World Health Organization European Region. All major epidemics were associated with genotypes D4, D6, and B3. Other genotypes (B2, D5, D8, D9, G2, and H1) were only found in limited numbers of cases after importation from other continents. The genetic diversity of endemic D6 strains was low; genotypes C2 and D7, circulating in Europe until recent years, were no longer identified. The transmission chains of several indigenous MV strains may thus have been interrupted by enhanced vaccination. However, multiple importations from Africa and Asia and virus introduction into highly mobile and unvaccinated communities caused a massive spread of D4 and B3 strains throughout much of the region. Thus, despite the reduction of endemic MV circulation, importation of MV from other continents caused prolonged circulation and large outbreaks after their introduction into unvaccinated and highly mobile communities.
Cryptosporidiosis and Filtration of Water from Loch Lomond, Scotland
PDF Version [PDF - 355 KB - 6 pages]
K. Pollock et al.View Abstract
Previous evidence has suggested an association between consumption of unfiltered water from Loch Lomond, Scotland, and cryptosporidiosis. Before November 1999, this water had been only microstrained and disinfected with chlorine; however, since that time, physical treatment of the water (coagulation, rapid gravity filtration) has been added. To determine risk factors, including drinking water, for cryptosporidiosis, we analyzed data on laboratory-confirmed cases of cryptosporidiosis collected from 1997 through 2003. We identified an association between the incidence of cryptosporidiosis and unfiltered drinking water supplied to the home. The association supports the view that adding a filtration system to minimally treated water can substantially reduce the number of confirmed cryptosporidiosis cases.
Cross-subtype Immunity against Avian Influenza in Persons Recently Vaccinated for Influenza
PDF Version [PDF - 306 KB - 8 pages]
C. Gioia et al.View Abstract
Avian influenza virus (H5N1) can be transmitted to humans, resulting in a severe or fatal disease. The aim of this study was to evaluate the immune cross-reactivity between human and avian influenza (H5N1) strains in healthy donors vaccinated for seasonal influenza A (H1N1)/(H3N2). A small frequency of CD4 T cells specific for subtype H5N1 was detected in several persons at baseline, and seasonal vaccine administration enhanced the frequency of such reactive CD4 T cells. We also observed that seasonal vaccination is able to raise neutralizing immunity against influenza (H5N1) in a large number of donors. No correlation between influenza-specific CD4 T cells and humoral responses was observed. N1 may possibly be a target for both cellular and humoral cross-type immunity, but additional experiments are needed to clarify this point. These findings highlight the possibility of boosting cross-type cellular and humoral immunity against highly pathogenic avian influenza A virus subtype H5N1 by seasonal influenza vaccination.
Telephone Survey to Assess Influenza-like Illness, United States, 2006
PDF Version [PDF - 187 KB - 7 pages]
J. L. Malone et al.View Abstract
Although current national response plans assume that most influenza-infected patients would stay home during a pandemic, surveillance systems might be overwhelmed and unable to monitor their health status. We explored the feasibility of using a nationwide telephone survey to monitor at-home patients. Of randomly selected adults surveyed during low influenza activity months (April–October 2006, surveillance weeks 17–41), 86% (7,268/8,449) agreed to answer questions about health status and influenza-like illness symptoms. Three percent (230/7,628) self-reported “flu.” A subset (0.9%, 68/230) self-reported fever. In comparison, the Centers for Disease Control and Prevention’s Sentinel Provider Network reported clinical influenza-like illness rates of 1.2%, 0.9%, and 1.2% for weeks 17, 20, and 41, respectively. The consistency between information obtained by telephone and surveillance data warrants further studies to determine whether telephone surveys can accurately monitor health status during seasonal influenza peaks and to augment current surveillance systems during a pandemic.
Experimental Infection of Swans and Geese with Highly Pathogenic Avian Influenza Virus (H5N1) of Asian Lineage
PDF Version [PDF - 273 KB - 7 pages]
J. D. Brown et al.View Abstract
The role of wild birds in the epidemiology of the Asian lineage highly pathogenic avian influenza (HPAI) virus subtype H5N1 epizootic and their contribution to the spread of the responsible viruses in Eurasia and Africa are unclear. To better understand the potential role of swans and geese in the epidemiology of this virus, we infected 4 species of swans and 2 species of geese with an HPAI virus of Asian lineage recovered from a whooper swan in Mongolia in 2005, A/whooper swan/Mongolia/244/2005 (H5N1). The highest mortality rates were observed in swans, and species-related differences in clinical illness and viral shedding were evident. These results suggest that the potential for HPAI (H5N1) viral shedding and the movement of infected birds may be species-dependent and can help explain observed deaths associated with HPAI (H5N1) infection in anseriforms in Eurasia.
Short- and Long-term Effects of Bacterial Gastrointestinal Infections
PDF Version [PDF - 206 KB - 6 pages]
A. Ternhag et al.View Abstract
During 1997–2004, microbiologically confirmed gastrointestinal infections were reported for 101,855 patients in Sweden. Among patients who had Salmonella infection (n = 34,664), we found an increased risk for aortic aneurysm (standardized incidence ratio [SIR] 6.4, 95% confidence interval [CI] 3.1–11.8) within 3 months after infection and an elevated risk for ulcerative colitis (SIR 3.2, 95% CI 2.2–4.6) within 1 year after infection. We also found this elevated risk for ulcerative colitis among Campylobacter infections (n = 57,425; SIR 2.8, 95% CI 2.0–3.8). Within 1 year, we found an increased risk for reactive arthritis among patients with Yersinia enteritis (n = 5,133; SIR 47.0, 95% CI 21.5–89.2), Salmonella infection (SIR 18.2, 95% CI 12.0–26.5), and Campylobacter infection (SIR 6.3, 95% CI 3.5–10.4). Acute gastroenteritis is sometimes associated with disease manifestations from several organ systems that may require hospitalization of patients.
Avian Influenza Virus (H5N1) Replication in Feathers of Domestic Waterfowl
PDF Version [PDF - 264 KB - 3 pages]
Y. Yamamoto et al.View Abstract
We examined feathers of domestic ducks and geese inoculated with 2 different avian influenza virus (H5N1) genotypes. Together with virus isolation from the skin, the detection of viral antigens and ultrastructural observation of the virions in the feather epidermis raise the possibility of feathers as sources of infection.
Prolonged Bartonella henselae Bacteremia Caused by Reinfection in Cats
PDF Version [PDF - 179 KB - 3 pages]
M. Arvand et al.View Abstract
We analyzed the genetic relatedness of blood culture isolates of Bartonella henselae from 2 cats of patients with cat-scratch disease at admission and after 12 months. Isolates from each cat at different times were clonally unrelated, which suggested reinfection by a second strain.
Human Case of Streptococcus suis Serotype 16 Infection
PDF Version [PDF - 278 KB - 3 pages]
H. D. Nghia et al.View Abstract
Streptococcus suis infection is an emerging zoonosis in Southeast Asia. We report a fatal case of S. suis serotype 16 infection in a Vietnamese man in 2001.
Magpies as Hosts for West Nile Virus, Southern France
PDF Version [PDF - 221 KB - 3 pages]
E. Jourdain et al.View Abstract
European magpies (Pica pica) from southern France were tested for antibodies to West Nile virus (WNV) and viral shedding in feces during spring–autumn 2005. Results suggest that this peridomestic species may be a suitable sentinel species and a relevant target for additional investigations on WNV ecology in Europe.
Emerging Angiostrongyliasis in Mainland China
PDF Version [PDF - 220 KB - 4 pages]
S. Lv et al.View Abstract
Our review of angiostrongyliasis in China found that the disease is emerging as a result of changes in food consumption habits and long-distance transportation of food. Enhanced understanding of angiostrongyliasis epidemiology, increased public awareness about the risks associated with eating raw food, and enhanced food safety measures are needed.
Hepatitis E in England and Wales
PDF Version [PDF - 167 KB - 3 pages]
H. C. Lewis et al.View Abstract
In 2005, 329 cases of hepatitis E virus infection were confirmed in England and Wales; 33 were confirmed indigenous infections, and a further 67 were estimated to be indigenous infections. Hepatitis E should be considered in the investigation of patients with hepatitis even if they have no history of travel.
Protochlamydia naegleriophila as Etiologic Agent of Pneumonia
PDF Version [PDF - 371 KB - 5 pages]
N. Casson et al.View Abstract
Using ameba coculture, we grew a Naegleria endosymbiont. Phenotypic, genetic, and phylogenetic analyses supported its affiliation as Protochlamydia naegleriophila sp. nov. We then developed a specific diagnostic PCR for Protochlamydia spp. When applied to bronchoalveolar lavages, results of this PCR were positive for 1 patient with pneumonia. Further studies are needed to assess the role of Protochlamydia spp. in pneumonia.
Adamantane-Resistant Influenza Infection During the 2004–05 Season
PDF Version [PDF - 203 KB - 4 pages]
M. Rahman et al.View Abstract
Adamantane-resistant influenza A is an emerging problem, but infections caused by resistant and susceptible viruses have not been compared. We identified adamantane resistance in 47% of 152 influenza A virus (H3N2) isolates collected during 2005. Resistant and susceptible viruses caused similar symptoms and illness duration. The prevalence of resistance was highest in children.
Chikungunya and Dengue Viruses in Travelers
PDF Version [PDF - 126 KB - 2 pages]
L. Nicoletti et al.
Acinetobacter spp. in Gunshot Injuries
PDF Version [PDF - 165 KB - 3 pages]
J. W. Elston et al.
Case Cluster of Necrotizing Fasciitis and Cellulitis Associated with Vein Sclerotherapy
PDF Version [PDF - 154 KB - 2 pages]
H. Chan et al.
Streptococcus suis in Humans, Thailand
PDF Version [PDF - 143 KB - 3 pages]
D. Takamatsu et al.
Streptococcus suis Meningitis, United States
PDF Version [PDF - 154 KB - 3 pages]
G. T. Lee et al.
Parvoviruses in Blood Donors and Transplant Patients, Italy
PDF Version [PDF - 133 KB - 3 pages]
D. Vallerini et al.
Antimicrobial Drug Use and Antibiotic-Resistant Bacteria
PDF Version [PDF - 127 KB - 2 pages]
About the Cover
The conclusions, findings, and opinions expressed by authors contributing to this journal do not necessarily reflect the official position of the U.S. Department of Health and Human Services, the Public Health Service, the Centers for Disease Control and Prevention, or the authors' affiliated institutions. Use of trade names is for identification only and does not imply endorsement by any of the groups named above.
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- Page created: July 09, 2012
- Page last updated: July 09, 2012
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