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Volume 15, Number 12—December 2009
Volume 15, Number 12—December 2009 PDF Version [PDF - 7.25 MB - 215 pages]
Towards Control of Streptococcus iniae
PDF Version [PDF - 381 KB - 6 pages]
J. C. Baiano and A. C. BarnesView Abstract
Streptococcus iniae is an emerging zoonotic pathogen; such infections generally occur through injuries associated with preparing whole fresh fish for cooking. Those infected to date have been of Asian descent, are usually elderly (average age 68 years), and have had >1 underlying conditions that may predispose them to infection. Studies of the foundations of growth characteristics of S. iniae and its interactions with piscine host cells have recently been complemented by molecular studies. Advances in molecular biology have allowed research groups to identify numerous virulence factors and to explore their roles in the progression of S. iniae infection. Many of these virulence factors are homologous to those found in the major human pathogen S. pyogenes. An increased understanding of the properties of these factors and their effect on the success of infection is leading to novel approaches to control S. iniae infection; in particular, vaccination programs at fish farms have reduced the reservoir of infection for additional clinical cases.
Genomic Signatures of Influenza A Pandemic (H1N1) 2009 Virus
PDF Version [PDF - 231 KB - 7 pages]
G. Chen and S. ShihView Abstract
Adaptive mutations that have contributed to the emergence of influenza A pandemic (H1N1) 2009 virus, which can replicate and transmit among humans, remain unknown. We conducted a large-scale scanning of influenza protein sequences and identified amino acid–conserving positions that are specific to host species, called signatures. Of 47 signatures that separate avian viruses from human viruses by their nonglycoproteins, 8 were human-like in the pandemic (H1N1) 2009 virus. Close examination of their amino acid residues in the recent ancestral swine viruses of pandemic (H1N1) 2009 virus showed that 7 had already transitioned to human-like residues and only PA 356 retained an avian-like K; in pandemic (H1N1) 2009 virus, this residue changed into a human-like R. Signatures that separate swine viruses from human viruses were also present. Continuous monitoring of these signatures in nonhuman species will help with influenza surveillance and with evaluation of the likelihood of further adaptation to humans.
Cost-effectiveness Analysis of Hospital Infection Control Response to an Epidemic Respiratory Virus Threat
PDF Version [PDF - 286 KB - 8 pages]
Y. Y. Dan et al.View Abstract
The outbreak of influenza A pandemic (H1N1) 2009 prompted many countries in Asia, previously strongly affected by severe acute respiratory syndrome (SARS), to respond with stringent measures, particularly in preventing outbreaks in hospitals. We studied actual direct costs and cost-effectiveness of different response measures from a hospital perspective in tertiary hospitals in Singapore by simulating outbreaks of SARS, pandemic (H1N1) 2009, and 1918 Spanish influenza. Protection measures targeting only infected patients yielded lowest incremental cost/death averted of $23,000 (US$) for pandemic (H1N1) 2009. Enforced protection in high-risk areas (Yellow Alert) and full protection throughout the hospital (Orange Alert) averted deaths but came at an incremental cost of up to $2.5 million/death averted. SARS and Spanish influenza favored more stringent measures. High case-fatality rates, virulence, and high proportion of atypical manifestations impacted cost-effectiveness the most. A calibrated approach in accordance with viral characteristics and community risks may help refine responses to future epidemics.
Possible Interruption of Malaria Transmission, Highland Kenya, 2007–2008
PDF Version [PDF - 380 KB - 8 pages]
C. C. John et al.View Abstract
Highland areas where malaria transmission is unstable are targets for malaria elimination because transmission decreases to low levels during the dry season. In highland areas of Kipsamoite and Kapsisiywa, Kenya (population ≈7,400 persons), annual household indoor residual spraying with a synthetic pyrethroid was performed starting in 2005, and artemether/lumefantrine was implemented as first-line malaria treatment in October 2006. During April 2007–March 2008, no microscopy-confirmed cases of malaria occurred at the sites. In 4 assessments of asymptomatic persons during May 2007–April 2008, a total of <0.3% of persons were positive for asexual Plasmodium falciparum by microscopy or PCR at any time, and none were positive by PCR at the last 2 sample collections. Our findings show that in such areas, interruption and eventual elimination of malaria transmission may be achievable with widespread annual indoor residual spraying of households and artemisinin combination therapy.
Medscape CME Activity
Community-associated Methicillin-Resistant Staphylococcus aureus in Outpatients, United States, 1999–2006 PDF Version [PDF - 213 KB - 6 pages]E. Klein et al.View Abstract
Community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) has become a major problem in US hospitals already dealing with high levels of hospital-associated MRSA (HA-MRSA). Using antimicrobial drug susceptibility data for 1999–2006 from The Surveillance Network, we characterized the relationship between outpatient and inpatient levels of CA-MRSA nationally. In outpatients, the frequency of CA-MRSA isolates has increased >7× during 1999–2006, which suggests that outpatients have become a major reservoir for CA-MRSA. However, contrary to results in other reports, although CA-MRSA increases are associated with decreases in the frequency of HA-MRSA in hospitals, the decreases are only modest. This finding suggests that instead of replacing HA-MRSA in the hospital, CA-MRSA is adding to the overall presence of MRSA already found within the hospital population.
Risk for Infection with Highly Pathogenic Avian Influenza Virus (H5N1) in Backyard Chickens, Bangladesh
PDF Version [PDF - 223 KB - 6 pages]
P. K. Biswas et al.View Abstract
To evaluate risk factors for infection with highly pathogenic avian influenza A virus (H5N1) in backyard chickens in Bangladesh, we conducted a matched case–control study. We enrolled 25 case farms (cases March–November 2007) and 75 control farms (June–November 2007). We used a questionnaire to collect farm data, which were analyzed by matched-pair analysis and multivariate conditional logistic regression. Factors independently associated were offering slaughter remnants of purchased chickens to backyard chickens (odds ratio [OR] 13.29, 95% confidence interval [CI] 1.34–131.98, p = 0.027), having a nearby water body (OR 5.27, 95% CI 1.24–22.34, p = 0.024), and having contact with pigeons (OR 4.47, 95% CI 1.14–17.50, p = 0.032). Separating chickens and ducks at night was protective (OR 0.06, 95% CI 0.01–0.45, p = 0.006). Reducing these risks and taking protective measures might reduce the risk for influenza (H5N1) infection in backyard chickens.
Landscape Epidemiology of Tularemia Outbreaks in Sweden
PDF Version [PDF - 807 KB - 11 pages]
K. Svensson et al.View Abstract
Summer outbreaks of tularemia that occurred from 1995 through 2005 in 2 locations in Sweden affected 441 persons. We performed an epidemiologic investigation of these outbreaks using a novel strategy, involving high-resolution genotyping of Francisella tularensis isolates obtained from 136 patients (using 18 genetic markers developed from 6 F. tularensis genome sequences) and interviews with the patients. Strong spatial associations were found between F. tularensis subpopulations and the places of disease transmission; infection by some subpopulations occurred within areas as small as 2 km2, indicating unidentified environmental point sources of tularemia. In both locations, disease clusters were associated with recreational areas beside water, and genetic subpopulations were present throughout the tularemia season and persisted over years. High-resolution genotyping in combination with patients’ statements about geographic places of disease transmission provided valuable indications of likely sources of infection and the causal genotypes during these tularemia outbreaks.
Delineating Anaplasma phagocytophilum Ecotypes in Coexisting, Discrete Enzootic Cycles
PDF Version [PDF - 232 KB - 7 pages]
K. J. Bown et al.View Abstract
The emerging tick-borne pathogen Anaplasma phagocytophilum is under increasing scrutiny for the existence of subpopulations that are adapted to different natural cycles. Here, we characterized the diversity of A. phagocytophilum genotypes circulating in a natural system that includes multiple hosts and at least 2 tick species, Ixodes ricinus and the small mammal specialist I. trianguliceps. We encountered numerous genotypes, but only 1 in rodents, with the remainder limited to deer and host-seeking I. ricinus ticks. The absence of the rodent-associated genotype from host-seeking I. ricinus ticks was notable because we demonstrated that rodents fed a large proportion of the I. ricinus larval population and that these larvae were abundant when infections caused by the rodent-associated genotype were prevalent. These observations are consistent with the conclusion that genotypically distinct subpopulations of A. phagocytophilum are restricted to coexisting but separate enzootic cycles and suggest that this restriction may result from specific vector compatibility.
Novel Calicivirus Identified in Rabbits, Michigan, USA
PDF Version [PDF - 439 KB - 8 pages]
I. L. Bergin et al.View Abstract
We report a disease outbreak in a Michigan rabbitry of a rabbit calicivirus distinct from the foreign animal disease agent, rabbit hemorrhagic disease virus (RHDV). The novel virus has been designated Michigan rabbit calicivirus (MRCV). Caliciviruses of the Lagovirus genus other than RHDV have not been described in US rabbit populations. The case-fatality rate was 32.5% (65/200). Clinical signs included hemorrhage and sudden death, with hepatic necrosis. Analysis of viral RNA sequence from >95% of the viral genome showed an average similarity of 79% with RHDV. Similarity of the predicted MRCV capsid amino acid sequence ranged from 89.8% to 91.3%, much lower than the 98% amino acid similarity between RHDV strains. Experimentally infected rabbits lacked clinical disease, but MRCV was detected in tissues by PCR. We propose that MRCV primarily causes subclinical infection but may induce overt RHD-like disease under certain field conditions.
Tick-borne Agents in Rodents, China, 2004–2006
PDF Version [PDF - 206 KB - 5 pages]
L. Zhan et al.View Abstract
A total of 705 rodents from 6 provinces and autonomous regions of mainland People’s Republic of China were tested by PCRs for tick-borne agents (Anaplasma phagocytophilum, Borrelia burgdorferi sensu lato, spotted fever group rickettsiae, and Francisella tularensis). Infection rates were 5.5%, 6.7%, 9.1% and 5.0%, respectively. Eighteen (2.6%) rodents of 10 species were positive for 2 or 3 agents. Sequence analysis of PCR products confirmed the presence and genotypes of detected agents. These findings demonstrate that these tick-borne agents cocirculate and that a variety of rodent species may be involved in their enzootic maintenance.
Pandemic Influenza as 21st Century Urban Public Health Crisis
PDF Version [PDF - 274 KB - 7 pages]
D. M. Bell et al.View Abstract
The percentage of the world’s population living in urban areas will increase from 50% in 2008 to 70% (4.9 billion) in 2025. Crowded urban areas in developing and industrialized countries are uniquely vulnerable to public health crises and face daunting challenges in surveillance, response, and public communication. The revised International Health Regulations require all countries to have core surveillance and response capacity by 2012. Innovative approaches are needed because traditional local-level strategies may not be easily scalable upward to meet the needs of huge, densely populated cities, especially in developing countries. The responses of Mexico City and New York City to the initial appearance of influenza A pandemic (H1N1) 2009 virus during spring 2009 illustrate some of the new challenges and creative response strategies that will increasingly be needed in cities worldwide.
Oseltamivir-Resistant Influenza A Pandemic (H1N1) 2009 Virus, Hong Kong, China
PDF Version [PDF - 259 KB - 3 pages]
H. Chen et al.View Abstract
Resistance to oseltamivir was observed in influenza A pandemic (H1N1) 2009 virus isolated from an untreated person in Hong Kong, China. Investigations showed a resistant virus with the neuraminidase (NA) 274Y genotype in quasi-species from a nasopharyngeal aspirate. Monitoring for the naturally occurring NA 274Y mutation in this virus is necessary.
Outbreak of Antiviral Drug–Resistant Influenza A in Long-Term Care Facility, Illinois, USA, 2008
PDF Version [PDF - 282 KB - 4 pages]
N. J. Dharan et al.View Abstract
An outbreak of oseltamivir-resistant influenza A (H1N1) occurred in a long-term care facility. Eight (47%) of 17 and 1 (6%) of 16 residents in 2 wards had oseltamivir-resistant influenza A virus (H1N1) infections. Initial outbreak response included treatment and prophylaxis with oseltamivir. The outbreak abated, likely because of infection control measures.
Sympatry of 2 Hantavirus Strains, Paraguay, 2003–2007
PDF Version [PDF - 331 KB - 4 pages]
Y. Chu et al.View Abstract
To explore geographic and host-taxonomic patterns of hantaviruses in Paraguay, we established sampling sites in the Mbaracayú Biosphere Reserve. We detected Jaborá virus and Itapúa37/Juquitiba–related virus in locations ≈20 m apart in different years, which suggested sympatry of 2 distinct hantaviruses.
Cross-sectional Survey of Hantavirus Infection, Brazil
PDF Version [PDF - 226 KB - 3 pages]
J. E. Limongi et al.View Abstract
A cross-sectional serosurvey was conducted to assess the proportion of persons exposed to hantaviruses in a virus-endemic area of the state of Minas Gerais, Brazil. Findings of this study suggested the presence of >1 hantaviruses circulating in this region causing hantavirus pulmonary syndrome, mild disease, or asymptomatic infection.
Bartonella rochalimae in Raccoons, Coyotes, and Red Foxes
PDF Version [PDF - 299 KB - 4 pages]
J. B. Henn et al.View Abstract
To determine additional reservoirs for Bartonella rochalimae, we examined samples from several wildlife species. We isolated B. rochalimae from 1 red fox near Paris, France, and from 11 raccoons and 2 coyotes from California, USA. Co-infection with B. vinsonii subsp. berkhoffii was documented in 1 of the coyotes.
CTX-M β-Lactamase Production and Virulence of Escherichia coli K1
PDF Version [PDF - 182 KB - 3 pages]
D. Dubois et al.View Abstract
We report a patient with neonatal meningitis caused by a CTX-M-1–producing Escherichia coli K1 strain. The influence of CTX-M production on virulence was investigated in cell culture and a newborn mouse model of meningitis. CTX-M production had no influence on virulence but was a major factor in clinical outcome.
Ehrlichia chaffeensis Infection of Sika Deer, Japan
PDF Version [PDF - 181 KB - 3 pages]
M. Kawahara et al.View Abstract
To determine whether Ehrlichia chaffeensis exists in Japan, we used PCR to examine blood from sika deer in Nara, Japan. Of 117 deer, 36 (31%) were infected with E. chaffeensis. The E. chaffeensis 16S rRNA base and GroEL amino acid sequences from Japan were most closely related to those of E. chaffeensis Arkansas.
Diagnostic Assay for Rickettsia japonica
PDF Version [PDF - 217 KB - 4 pages]
N. Hanaoka et al.View Abstract
We developed a specific and rapid detection system for Rickettsia japonica and R. heilongjiangensis, the causative agents of spotted fever, using a TaqMan minor groove binder probe for a particular open reading frame (ORF) identified by the R. japonica genome project. The target ORF was present only in R. japonica–related strains.
Novel Lineage of Methicillin-Resistant Staphylococcus aureus, Hong Kong
PDF Version [PDF - 159 KB - 3 pages]
L. Guardabassi et al.View Abstract
To determine whether spa type of methicillin-resistant Staphylococcus aureus in pigs belonged to sequence type (ST) 398, we analyzed nasal swabs from pig carcasses at Hong Kong markets in 2008. ST9 belonging to spa type t899 was found for 16/100 samples, which indicates that a distinct lineage has emerged in pigs.
Respiratory Infection in Institutions during Early Stages of Pandemic (H1N1) 2009, Canada
PDF Version [PDF - 139 KB - 3 pages]
A. Marchand-Austin et al.View Abstract
Outbreaks of respiratory infection in institutions in Ontario, Canada were studied from April 20 to June 12, 2009, during the early stages of the emergence of influenza A pandemic (H1N1) 2009. Despite widespread presence of influenza in the general population, only 2 of 83 outbreaks evaluated by molecular methods were associated with pandemic (H1N1) 2009.
Estimates of the Prevalence of Pandemic (H1N1) 2009, United States, April–July 2009
PDF Version [PDF - 267 KB - 4 pages]
C. Reed et al.View Abstract
Through July 2009, a total of 43,677 laboratory-confirmed cases of influenza A pandemic (H1N1) 2009 were reported in the United States, which is likely a substantial underestimate of the true number. Correcting for under-ascertainment using a multiplier model, we estimate that 1.8 million–5.7 million cases occurred, including 9,000–21,000 hospitalizations.
Mopeia Virus–related Arenavirus in Natal Multimammate Mice, Morogoro, Tanzania
PDF Version [PDF - 522 KB - 3 pages]
S. Günther et al.View Abstract
A serosurvey involving 2,520 small mammals from Tanzania identified a hot spot of arenavirus circulation in Morogoro. Molecular screening detected a new arenavirus in Natal multimammate mice (Mastomys natalensis), Morogoro virus, related to Mopeia virus. Only a small percentage of mice carry Morogoro virus, although a large proportion shows specific antibodies.
Molecular Model of Prion Transmission to Humans
PDF Version [PDF - 522 KB - 4 pages]
M. Jones et al.View Abstract
To assess interspecies barriers to transmission of transmissible spongiform encephalopathies, we investigated the ability of disease-associated prion proteins (PrPd) to initiate conversion of the human normal cellular form of prion protein of the 3 major PRNP polymorphic variants in vitro. Protein misfolding cyclic amplification showed that conformation of PrPd partly determines host susceptibility.
Dobrava-Belgrade Virus Spillover Infections, Germany
PDF Version [PDF - 307 KB - 4 pages]
M. Schlegel et al.View Abstract
We present the molecular identification of Apodemus agrarius (striped field mouse) as reservoir host of the Dobrava-Belgrade virus (DOBV) lineage DOBV-Aa in 3 federal states of Germany. Phylogenetic analyses provided evidence for multiple spillover of DOBV-Aa to A. flavicollis, a crucial prerequisite for host switch and genetic reassortment.
Wild Felids as Hosts for Human Plague, Western United States
PDF Version [PDF - 339 KB - 4 pages]
S. N. Bevins et al.View Abstract
Plague seroprevalence was estimated in populations of pumas and bobcats in the western United States. High levels of exposure in plague-endemic regions indicate the need to consider the ecology and pathobiology of plague in nondomestic felid hosts to better understand the role of these species in disease persistence and transmission.
Transplacental Transmission of Bluetongue Virus 8 in Cattle, UK
PDF Version [PDF - 279 KB - 4 pages]
K. E. Darpel et al.View Abstract
To determine whether transplacental transmission could explain overwintering of bluetongue virus in the United Kingdom, we studied calves born to dams naturally infected during pregnancy in 2007–08. Approximately 33% were infected transplacentally; some had compromised health. In all infected calves, viral load decreased after birth; no evidence of persistent infection was found.
Echinococcus vogeli Infection in a Hunter, French Guiana
PDF Version [PDF - 215 KB - 3 pages]
J. Knapp et al.View Abstract
Echinococcus vogeli infection in a hunter from the rain forest of French Guiana was confirmed by imaging and mitochondrial DNA sequence analysis. Serologic examination showed typical patterns for both alveolar and cystic echinococcosis. Polycystic echinococcis caused by E. vogeli may be an emerging parasitic disease in Central and South America.
Recombination in Vaccine and Circulating Strains of Porcine Reproductive and Respiratory Syndrome Viruses
PDF Version [PDF - 268 KB - 4 pages]
B. Li et al.View Abstract
Em2007, a porcine reproductive and respiratory syndrome virus (PRRSV) variant with a unique 68 aa deletion in Nsp2, was recently isolated in China. Phylogenetic and molecular evolutionary analyses indicated that Em2007 is a natural recombinant between a vaccine strain of PRRSV and circulating virus. We also tested its pathogenicity in piglets.
Molecular Epidemiology of Glanders, Pakistan
PDF Version [PDF - 233 KB - 4 pages]
H. Hornstra et al.View Abstract
We collected epidemiologic and molecular data from Burkholderia mallei isolates from equines in Punjab, Pakistan from 1999 through 2007. We show that recent outbreaks are genetically distinct from available whole genome sequences and that these genotypes are persistent and ubiquitous in Punjab, probably due to human-mediated movement of equines.
Aleutian Mink Disease Virus and Humans
PDF Version [PDF - 294 KB - 3 pages]
J. R. Jepsen et al.View Abstract
Reports of a possible relationship between Aleutian mink disease parvovirus (AMDV) and human infection are rare. However, 2 mink farmers with vascular disease and microangiopathy similar to that in mink with Aleutian disease were found to have AMDV-specific antibodies and AMDV DNA. These findings raise the suspicion that AMDV may play a role in human disease.
Changing Patterns of Human Campylobacteriosis, England and Wales, 1990–2007
PDF Version [PDF - 241 KB - 3 pages]
I. Gillespie et al.View Abstract
To explore hypotheses for age-related changes in the incidence of Campylobacter infections in England and Wales during 1990–2007, we analyzed electronic laboratory data. Disease incidence was reduced among children, and the greatest increase in risk was for those >60 years of age. Risk factors for campylobacteriosis in the elderly population should be identified.
New Adenovirus in Bats, Germany
PDF Version [PDF - 372 KB - 4 pages]
M. Sonntag et al.View Abstract
We tested 55 deceased vespertilionid bats of 12 species from southern Germany for virus infections. A new adenovirus was isolated from tissue samples of 2 Pipistrellus pipistrellus bats, which represents the only chiropteran virus isolate found in Europe besides lyssavirus (rabies virus). Evidence was found for adenovirus transmission between bats.
Human Trichinosis after Consumption of Soft-Shelled Turtles, Taiwan
PDF Version [PDF - 149 KB - 3 pages]
Y. Lo et al.View Abstract
In 2008, an outbreak of human trichinosis associated with ingestion of raw soft-shelled turtles was identified and investigated in Taiwan. The data suggested that patients were likely infected with Trichinella papuae.
Identification of Francisella tularensis Cluster in Central and Western Europe
PDF Version [PDF - 236 KB - 3 pages]
P. Pilo et al.View Abstract
We conducted a molecular analysis of Francisella tularensis strains isolated in Switzerland and identified a specific subpopulation belonging to a cluster of F. tularensis subsp. holarctica that is widely dispersed in central and western continental Europe. This subpopulation was present before the tularemia epidemics on the Iberian Peninsula.
Spatiotemporal Dynamics of Hemorrhagic Fever with Renal Syndrome, Beijing, People’s Republic of China
PDF Version [PDF - 388 KB - 3 pages]
We used geographic information systems to characterize the dynamic change in spatial distribution of hemorrhagic fever with renal syndrome (HFRS) in Beijing, People’s Republic of China. The seasonal variation in its incidence was observed by creating an epidemic curve. HFRS was associated with developed land, orchards, and rice paddies.
A Groundhog, a Novel Bartonella Sequence, and My Father’s Death
PDF Version [PDF - 184 KB - 7 pages]
E. B. Breitschwerdt et al.
Extracorporeal Membrane Oxygenation for Pandemic (H1N1) 2009
PDF Version [PDF - 92 KB - 2 pages]
M. S. Firstenberg et al.
Respiratory Disease in Adults during Pandemic (H1N1) 2009 Outbreak, Argentina
PDF Version [PDF - 85 KB - 2 pages]
C. Zala and R. Gonzalez
Susceptibility of Poultry to Pandemic (H1N1) 2009 Virus
PDF Version [PDF - 102 KB - 3 pages]
D. E. Swayne et al.
Oropouche Fever Outbreak, Manaus, Brazil, 2007–2008
PDF Version [PDF - 91 KB - 2 pages]
M. P. Mourão et al.
Identical Strains of Borrelia hermsii in Mammal and Bird
PDF Version [PDF - 109 KB - 3 pages]
R. J. Fischer et al.
Mycobacterium bovis and M. tuberculosis in Goats, Nigeria
PDF Version [PDF - 92 KB - 2 pages]
S. I. Cadmus et al.
Streptococcus suis Meningitis, Hawaii
PDF Version [PDF - 119 KB - 3 pages]
N. Fittipaldi et al.
Chorioamnionitis and Neonatal Sepsis from Community-associated MRSA
PDF Version [PDF - 85 KB - 3 pages]
J. D. Pimentel et al.
Methicillin-Resistant Staphylococcus aureus in Marine Mammals
PDF Version [PDF - 80 KB - 2 pages]
M. C. Faires et al.
Parachlamydia and Rhabdochlamydia in Premature Neonates
PDF Version [PDF - 107 KB - 4 pages]
F. Lamoth et al.
Porcine Kobuvirus in Piglets, Thailand
PDF Version [PDF - 109 KB - 2 pages]
P. Khamrin et al.
Rickettsia slovaca in Dermacentor marginatus ticks, Germany
PDF Version [PDF - 169 KB - 2 pages]
S. Pluta et al.
Books and Media
Filoviruses: A Compendium of 40 Years of Epidemiological, Clinical, and Laboratory Studies
PDF Version [PDF - 98 KB - 1 page]
P. E. Rollin
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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