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Volume 16, Number 1—January 2010
Volume 16, Number 1—January 2010 PDF Version [PDF - 4.25 MB - 187 pages]
Medscape CME Activity
Public Health Threat of New, Reemerging, and Neglected Zoonoses in the Industrialized World PDF Version [PDF - 180 KB - 8 pages]S. J. Cutler et al.View Abstract
Microbiologic infections acquired from animals, known as zoonoses, pose a risk to public health. An estimated 60% of emerging human pathogens are zoonotic. Of these pathogens, >71% have wildlife origins. These pathogens can switch hosts by acquiring new genetic combinations that have altered pathogenic potential or by changes in behavior or socioeconomic, environmental, or ecologic characteristics of the hosts. We discuss causal factors that influence the dynamics associated with emergence or reemergence of zoonoses, particularly in the industrialized world, and highlight selected examples to provide a comprehensive view of their range and diversity.
Laboratory Surge Response to Pandemic (H1N1) 2009 Outbreak, New York City Metropolitan Area, USA
PDF Version [PDF - 111 KB - 6 pages]
J. M. Crawford et al.View Abstract
The North Shore–Long Island Jewish Health System Laboratories serve 15 hospitals and affiliated regional physician practices in the New York City metropolitan area, with virus testing performed at a central reference laboratory. The influenza A pandemic (H1N1) 2009 outbreak began in this area on April 24, 2009, and within weeks respiratory virus testing increased 7.5 times. In response, laboratory and client service workforces were increased, physical plant build-out was completed, testing paradigms were converted from routine screening tests and viral culture to a high-capacity molecular assay for respiratory viruses, laboratory information system interfaces were built, and same-day epidemiologic reports were produced. Daily review by leadership of data from emergency rooms, hospital facilities, and the Health System Laboratories enabled real-time management of unfolding events. The ability of System laboratories to rapidly increase to high-volume comprehensive diagnostics, including influenza A subtyping, provided key epidemiologic information for local and state public health departments.
Projecting Global Occurrence of Cryptococcus gattii
PDF Version [PDF - 142 KB - 7 pages]
D. J. Springer and V. ChaturvediView Abstract
Cryptococcus gattii and C. neoformans cause pulmonary and systemic cryptococcosis. Recently, C. gattii was recognized as a distinct pathogen of humans and animals. We analyzed information from 400 publications (1948–2008) to examine whether the fungus occurs globally. Known distribution of C. gattii is possibly limited because specialized reagents for differentiation from C. neoformans are not readily available and not always used, and environmental surveys are patchy. However, autochthonous reports of C. gattii cryptococcosis have now been recognized from tropical and temperate regions. An ongoing outbreak in western Canada strengthens the case that the range of the pathogen has expanded. A few studies have highlighted differences in cryptococcosis between C. gattii and C. neoformans. More than 50 tree species have yielded C. gattii especially from decayed hollows suggesting a possible ecologic niche. This pathogen merits more attention so its environmental occurrence and role in cryptococcosis can be accurately determined.
Epidemiology of Travel-associated Pandemic (H1N1) 2009 Infection in 116 Patients, Singapore
PDF Version [PDF - 308 KB - 6 pages]
P. Mukherjee et al.View Abstract
In June 2009, during Singapore’s pandemic influenza plan containment phase, pandemic (H1N1) 2009 was introduced into the country through imported cases. To understand how travel patterns affected the initial outbreak, we examined epidemiologic and travel data for the first 116 case-patients admitted to Tan Tock Seng Hospital, Singapore, with travel-associated infection. Sixty-one percent and 54% of patients, respectively, met US Centers for Disease Control and Prevention and World Health Organization temperature criteria for influenza-like illness. One fourth of the case-patients traveled after illness onset, and 15% became ill while traveling. Regions of exposure for imported infections changed rapidly; case-patients initially arrived from North America, followed by Australasia and Southeast Asia. Case-patients on longer flights were more likely to become ill before arrival; those with shorter flights tended to become ill after arrival. Thermal scanners detected fevers in 12% of the arriving case-patients, resulting in a shorter time to isolation.
Severe Pneumonia Associated with Pandemic (H1N1) 2009 Outbreak, San Luis Potosí, Mexico
PDF Version [PDF - 280 KB - 8 pages]
A. Gómez-Gómez et al.View Abstract
We describe the clinical characteristics and outcomes of adults hospitalized with pneumonia during the pandemic (H1N1) 2009 outbreak. Patients admitted to a general hospital in San Luis Potosí, Mexico, from April 10 through May 11, 2009, suspected to have influenza virus–associated pneumonia were evaluated. We identified 50 patients with suspected influenza pneumonia; the presence of influenza virus was confirmed in 18: 11 with pandemic (H1N1) 2009 virus, 5 with unsubtypeable influenza A virus, 1 with seasonal influenza A virus (H3N2), and 1 in whom assay results for seasonal and pandemic (H1N1) 2009 viruses were positive. Eighteen patients were treated in the intensive care unit, and 10 died. During the pandemic (H1N1) 2009 outbreak, severe pneumonia developed in young adults who had no identifiable risk factors; early diagnosis and treatment of influenza virus infections may have a determinant role in outcome.
Worldwide Dissemination of the bla Carbapenemase Gene of Acinetobacter baumannii
PDF Version [PDF - 276 KB - 6 pages]
P. D. Mugnier et al.View Abstract
To assess dissemination of OXA-23–producing strains of Acinetobacter baumannii, we obtained 20 carbapenem-resistant, OXA-23–producing isolates from different regions. Their clonal relationship was assessed by pulsed-field gel electrophoresis and multilocus sequence typing. We identified 8 sequence types, including 4 novel types. All except 2 strains belonged to 2 main European clonal lineages. The blaOXA-23 gene was either located on the chromosome or on plasmids and associated with 4 genetic structures.
Recombinant Canine Coronaviruses in Dogs, Europe
PDF Version [PDF - 266 KB - 7 pages]
N. Decaro et al.View Abstract
Coronaviruses of potential recombinant origin with porcine transmissible gastroenteritis virus (TGEV), referred to as a new subtype (IIb) of canine coronavirus (CCoV), were recently identified in dogs in Europe. To assess the distribution of the TGEV-like CCoV subtype, during 2001–2008 we tested fecal samples from dogs with gastroenteritis. Of 1,172 samples, 493 (42.06%) were positive for CCoV. CCoV-II was found in 218 samples, and CCoV-I and CCoV-II genotypes were found in 182. Approximately 20% of the samples with CCoV-II had the TGEV-like subtype; detection rates varied according to geographic origin. The highest and lowest rates of prevalence for CCoV-II infection were found in samples from Hungary and Greece (96.87% and 3.45%, respectively). Sequence and phylogenetic analyses showed that the CCoV-IIb strains were related to prototype TGEV-like strains in the 5′ and the 3′ ends of the spike protein gene.
Ceftiofur Resistance in Salmonella enterica Serovar Heidelberg from Chicken Meat and Humans, Canada
PDF Version [PDF - 278 KB - 7 pages]
L. Dutil et al.View Abstract
The Canadian Integrated Program for Antimicrobial Resistance Surveillance describes a strong correlation (r = 0.9, p<0.0001) between ceftiofur-resistant Salmonella enterica serovar Heidelberg isolated from retail chicken and incidence of ceftiofur-resistant Salmonella serovar Heidelberg infections in humans across Canada. In Québec, changes of ceftiofur resistance in chicken Salmonella Heidelberg and Escherichia coli isolates appear related to changing levels of ceftiofur use in hatcheries during the study period, from highest to lowest levels before and after a voluntary withdrawal, to increasing levels after reintroduction of use (62% to 7% to 20%, and 34% to 6% to 19%, respectively). These events provide evidence that ceftiofur use in chickens results in extended-spectrum cephalosporin resistance in bacteria from chicken and humans. To ensure the continued effectiveness of extended-spectrum cephalosporins for treating serious infections in humans, multidisciplinary efforts are needed to scrutinize and, where appropriate, limit use of ceftiofur in chicken production in Canada.
Healthcare-associated Viral Gastroenteritis among Children in a Large Pediatric Hospital, United Kingdom
PDF Version [PDF - 339 KB - 8 pages]
N. A. Cunliffe et al.View Abstract
Viruses are the major pathogens of community-acquired (CA) acute gastroenteritis (AGE) in children, but their role in healthcare-associated (HA) AGE is poorly understood. Children with AGE hospitalized at Alder Hey Children’s Hospital, Liverpool, UK, were enrolled over a 2-year period. AGE was classified as HA if diarrhea developed >48 hours after admission. Rotavirus, norovirus, adenovirus 40/41, astrovirus, and sapovirus were detected by PCR. A total of 225 children with HA-AGE and 351 with CA-AGE were enrolled in the study. HA viral gastroenteritis constituted one fifth of the diarrheal diseases among hospitalized children and commonly occurred in critical care areas. We detected >1 virus in 120 (53%) of HA-AGE cases; rotavirus (31%), norovirus (16%), and adenovirus 40/41 (15%) were the predominant viruses identified. Molecular evidence indicated rotaviruses and noroviruses were frequently introduced into the hospital from the community. Rotavirus vaccines could substantially reduce the incidence of HA-AGE in children.
Meningitis and a Febrile Vomiting illness Caused by Echovirus Type 4, Northern Territory, Australia
PDF Version [PDF - 318 KB - 6 pages]
P. G. Markey et al.View Abstract
In July 2007, a cluster of meningitis cases caused by an echovirus 4 strain was detected in 1 indigenous community in the Top End of the Northern Territory of Australia. Illness was characterized by fever, vomiting, and headache. Over the next 4 months, additional cases of meningitis and the fever and vomiting syndrome emerged in other indigenous communities and subsequently in the major urban center of Darwin. We describe the epidemiology of 95 laboratory-confirmed meningitis cases and conclude that the epidemic fever and vomiting syndrome was caused by the same enterovirus. Nucleotide sequencing of the whole genome verified this enterovirus (AUS250G) as a strain of echovirus type 4. Viral protein 1 nucleotide sequencing demonstrated 96% homology with an echovirus 4 strain responsible for a large outbreak of meningitis in the Yanbian Prefecture of China in 1996.
Methicillin-Resistant and -Susceptible Staphylococcus aureus Infections in Dogs
PDF Version [PDF - 250 KB - 7 pages]
M. C. Faires et al.View Abstract
Methicillin-resistant Staphylococcus aureus (MRSA) has become a pathogen of animals. To compare types of infections, clinical outcomes, and risk factors associated with MRSA in dogs with those associated with methicillin-susceptible Staphylococcus aureus (MSSA) infections, we conducted a case–control study at 3 veterinary referral hospitals in the United States and Canada during 2001–2007. Risk factors analyzed were signalment, medical and surgical history, and infection site. Among 40 dogs with MRSA and 80 with MSSA infections, highest prevalence of both infections was found in skin and ears. Although most (92.3%) dogs with MRSA infections were discharged from the hospital, we found that significant risk factors for MRSA infection were receipt of antimicrobial drugs (odds ratio [OR] 3.84, p = 0.02), β-lactams (OR 3.58, p = 0.04), or fluoroquinolones (OR 5.34, p = 0.01), and intravenous catheterization (OR 3.72, p = 0.02). Prudent use of antimicrobial drugs in veterinary hospitals is advised.
Actinobaculum schaalii, a Common Uropathogen in Elderly Patients, Denmark
PDF Version [PDF - 212 KB - 5 pages]
S. Bank et al.View Abstract
Actinobaculum schaalii can cause urinary tract infections and septicemia but is difficult to identify by cultivation. To obtain a fast diagnosis and identify A. schaalii, we developed a TaqMan real-time quantitative PCR. Routine urine samples were obtained from 177 hospitalized patients and 75 outpatients in Viborg County, Denmark, in 2008–2009. The PCR detected A. schaalii in 22% of samples from patients >60 years of age. This assay showed that A. schaalii is more common than implied by routine cultivation. In 90% of PCR-positive urine samples, other common uropathogens were identified. This finding suggests that A. schaalii is a common, undetected, bacterial pathogen. Our results suggest that A. schaalii may be a more common pathogen than previously thought, especially in patients with unexplained chronic urinary tract infections, who are often treated with trimethoprim or ciprofloxacin, to which A. schaalii is resistant.
Norovirus Gastroenteritis Outbreak with a Secretor-independent Susceptibility Pattern, Sweden
PDF Version [PDF - 242 KB - 7 pages]
J. Nordgren et al.View Abstract
Norovirus (NoV) is recognized as the commonest cause of acute gastroenteritis among adults. Susceptibility to disease has been associated with histo-blood group antigens and secretor status; nonsecretors are almost completely resistant to disease. We report a foodborne outbreak of GI.3 NoV gastroenteritis that affected 33/83 (40%) persons. Symptomatic disease was as likely to develop in nonsecretors as in secretors (odds ratio [OR] 1.41, 95% confidence interval [CI] 0.46–4.36 vs. OR 0.71, 95% CI 0.23–2.18, p = 0.57). Moreover, no statistical difference in susceptibility was found between persons of different Lewis or ABO phenotypes. The capsid gene of the outbreak strain shares high amino acid homology with the Kashiwa645 GI.3 strain, previously shown to recognize nonsecretor saliva, as well as synthetic Lewis a. This norovirus outbreak affected persons regardless of secretor status or Lewis or ABO phenotypes.
Food Reservoir for Escherichia coli Causing Urinary Tract Infections
PDF Version [PDF - 479 KB - 8 pages]
C. Vincent et al.View Abstract
Closely related strains of Escherichia coli have been shown to cause extraintestinal infections in unrelated persons. This study tests whether a food reservoir may exist for these E. coli. Isolates from 3 sources over the same time period (2005–2007) and geographic area were compared. The sources comprised prospectively collected E. coli isolates from women with urinary tract infection (UTI) (n = 353); retail meat (n = 417); and restaurant/ready-to-eat foods (n = 74). E. coli were evaluated for antimicrobial drug susceptibility and O:H serotype and compared by using 4 different genotyping methods. We identified 17 clonal groups that contained E. coli isolates (n = 72) from >1 source. E. coli from retail chicken (O25:H4-ST131 and O114:H4-ST117) and honeydew melon (O2:H7-ST95) were indistinguishable from or closely related to E. coli from human UTIs. This study provides strong support for the role of food reservoirs or foodborne transmission in the dissemination of E. coli causing common community-acquired UTIs.
Serologic Cross-Reactivity with Pandemic (H1N1) 2009 Virus in Pigs, Europe
PDF Version [PDF - 210 KB - 4 pages]
C. S. Kyriakis et al.View Abstract
We tested serum samples from pigs infected or vaccinated with European swine influenza viruses (SIVs) in hemagglutination-inhibition assays against pandemic (H1N1) 2009 virus and related North American SIVs. We found more serologic cross-reaction than expected. Data suggest pigs in Europe may have partial immunity to pandemic (H1N1) 2009 virus.
Hospitalizations for Pandemic (H1N1) 2009 among Maori and Pacific Islanders, New Zealand
PDF Version [PDF - 212 KB - 3 pages]
A. Verrall et al.View Abstract
Community transmission of influenza A pandemic (H1N1) 2009 was followed by high rates of hospital admissions in the Wellington region of New Zealand, particularly among Maori and Pacific Islanders. These findings may help health authorities anticipate the effects of pandemic (H1N1) 2009 in other communities.
Pandemic (H1N1) 2009 Surveillance and Prevalence of Seasonal Influenza, Singapore
PDF Version [PDF - 236 KB - 3 pages]
Y. Leo et al.View Abstract
On April 25, 2009, Singapore implemented strict containment measures for pandemic (H1N1) 2009 with enhanced surveillance and hospital isolation. In the first month, seasonal influenza, predominantly virus subtype H3N2, was diagnosed for 32% of patients with acute febrile respiratory illness. Our findings underscore the high prevalence of seasonal influenza in Singapore.
Reemergence of Syphilis in Martinique, 2001–2008
PDF Version [PDF - 314 KB - 4 pages]
A. Cabié et al.View Abstract
Syphilis reemerged in Martinique in 2004 and initially affected 3 HIV-infected patients. By March 2008, syphilis was diagnosed for 37 men and 18 women. As of October 31, 2009, this outbreak had not yet been brought under control. It initially affected mainly men who had sex with men before it spread to heterosexual persons, minority group members, and crack cocaine users.
Seagulls and Beaches as Reservoirs for Multidrug-Resistant Escherichia coli
PDF Version [PDF - 253 KB - 3 pages]
R. R. Simões et al.View Abstract
A variety of extended-spectrum β-lactamase–producing Escherichia coli isolates, with a high rate of cefotaximase-15 resistance, were identified in seagull feces from Porto, Portugal, beaches. Beaches may therefore present a risk to public health because of the potential pathogen-spreading capacity of migratory birds.
Cluster of Serogroup W135 Meningococci, Southeastern Florida, 2008–2009
PDF Version [PDF - 323 KB - 3 pages]
T. J. Doyle et al.View Abstract
Recently, 14 persons in southeastern Florida were identified with Neisseria meningitidis serogroup W135 invasive infections. All isolates tested had matching or near-matching pulsed-field gel electrophoresis patterns and belonged to the multilocus sequence type 11 clonal complex. The epidemiologic investigation suggested recent endemic transmission of this clonal complex in southeastern Florida.
Human Group A Streptococci Virulence Genes in Bovine Group C Streptococci
PDF Version [PDF - 324 KB - 4 pages]
M. G. Rato et al.View Abstract
Phage-encoded virulence genes of group A streptococci were detected in 10 (55.6%) of 18 isolates of group C streptococci that had caused bovine mastitis. Bovine isolates carried other genetic determinants, such as composite transposon Tn1207.3/Φ10394.4 (100%) and antimicrobial drug resistance genes erm(B)/erm(A) (22.2%), linB (16.6%), and tet(M)/tet(O) (66.7%), located on mobile elements.
Perceptions and Reactions with Regard to Pneumonic Plague
PDF Version [PDF - 154 KB - 3 pages]
G. J. Rubin et al.View Abstract
We assessed perceptions and likely reactions of 1,005 UK adults to a hypothetical terrorist attack involving pneumonic plague. Likely compliance with official recommendations ranged from good (98% would take antimicrobial drugs) to poor (76% would visit a treatment center). Perceptions about plague were associated with these intentions.
Rapid Displacement of Dengue Virus Type 1 by Type 4, Pacific Region, 2007–2009
PDF Version [PDF - 239 KB - 3 pages]
D. Li et al.View Abstract
Since 2000–2001, dengue virus type 1 has circulated in the Pacific region. However, in 2007, type 4 reemerged and has almost completely displaced the strains of type 1. If only 1 serotype circulates at any time and is replaced approximately every 5 years, DENV-3 may reappear in 2012.
Hepatitis E Epidemic, Uganda
PDF Version [PDF - 266 KB - 3 pages]
E. H. Teshale et al.View Abstract
In October 2007, an epidemic of hepatitis E was suspected in Kitgum District of northern Uganda where no previous epidemics had been documented. This outbreak has progressed to become one of the largest hepatitis E outbreaks in the world. By June 2009, the epidemic had caused illness in >10,196 persons and 160 deaths.
Novel Human Parechovirus, Sri Lanka
PDF Version [PDF - 242 KB - 3 pages]
N. T. Pham et al.View Abstract
Of 362 fecal samples collected from children with acute gastroenteritis in Sri Lanka during 2005–2006, 30 (8.3%) were positive for human parechovirus (HPeV) by reverse transcription–PCR. A novel HPeV, designated as HPeV10, was identified in 2 samples by sequence analysis of the viral protein 1 gene of the detected HPeVs.
Broiler Chickens as Source of Human Fluoroquinolone-Resistant Escherichia coli, Iceland
PDF Version [PDF - 197 KB - 3 pages]
T. R. Thorsteinsdottir et al.View Abstract
To investigate feed as a source for fluoroquinolone-resistant Escherichia coli in broiler chickens, we compared antimicrobial drug–resistant E. coli from broiler feed and broilers with ciprofloxacin-resistant human clinical isolates by using pulsed-field gel electrophoresis. Feed was implicated as a source for ciprofloxacin-resistant broiler-derived E. coli and broilers as a source for ciprofloxacin-resistant human-derived E. coli.
Human Listeriosis Caused by Listeria ivanovii
PDF Version [PDF - 190 KB - 3 pages]
C. Guillet et al.View Abstract
Two species of Listeria are pathogenic; L. monocytogenes infects humans and animals, and L. ivanovii has been considered to infect ruminants only. We report L. ivanovii–associated gastroenteritis and bacteremia in a man. This isolate was indistinguishable from prototypic ruminant strains. L. ivanovii is thus an enteric opportunistic human pathogen.
Acute Encephalopathy Associated with Influenza A Infection in Adults
PDF Version [PDF - 199 KB - 4 pages]
N. Lee et al.View Abstract
We report acute encephalopathy associated with influenza A infection in 3 adults. We detected high cerebrospinal fluid (CSF) and plasma concentrations of CXCL8/IL-8 and CCL2/MCP-1 (CSF/plasma ratios >3), and interleukin-6, CXCL10/IP-10, but no evidence of viral neuroinvasion. Patients recovered without sequelae. Hyperactivated cytokine response may play a role in pathogenesis.
Enterotoxigenic Escherichia coli Multilocus Sequence Types in Guatemala and Mexico
PDF Version [PDF - 254 KB - 4 pages]
M. Nicklasson et al.View Abstract
The genetic backgrounds of 24 enterotoxigenic Escherichia coli (ETEC) strains from Mexico and Guatemala expressing heat-stable toxin (ST) and coli surface antigen 6 (CS6) were analyzed. US travelers to these countries and resident children in Guatemala were infected by ETEC strains of sequence type 398, expressing STp and carrying genetically identical CS6 sequences.
Laboratory Surge Capacity and Pandemic Influenza
PDF Version [PDF - 216 KB - 2 pages]
M. I. Meltzer et al.
Some Haphazard Aphorisms for Epidemiology and Life
PDF Version [PDF - 142 KB - 4 pages]
J. M. Cowden
Fatal Case of Pneumonia Associated with Pandemic (H1N1) 2009 in HIV-Positive Patient
PDF Version [PDF - 158 KB - 2 pages]
N. C. Klein et al.
Age-based Human Influenza A Virus (H5N1) Infection Patterns, Egypt
PDF Version [PDF - 143 KB - 2 pages]
Human Herpesvirus 8 in Healthy Blood Donors, Argentina
PDF Version [PDF - 152 KB - 2 pages]
C. L. Pérez et al.
Real-Time PCR for Diagnosis of Oculoglandular Tularemia
PDF Version [PDF - 170 KB - 2 pages]
M. Maurin et al.
Increase in Serotype 6C Pneumococcal Carriage, United Kingdom
PDF Version [PDF - 151 KB - 2 pages]
A. S. Tocheva et al.
Oseltamivir- and Amantadine-Resistant Influenza Virus A (H1N1)
PDF Version [PDF - 152 KB - 2 pages]
P. K. Cheng et al.
Pandemic (H1N1) 2009 Reinfection, Chile
PDF Version [PDF - 161 KB - 2 pages]
C. M. Perez et al.
Skin Lesion Caused by ST398 and ST1 MRSA, Spain
PDF Version [PDF - 176 KB - 3 pages]
C. Aspiroz et al.
Identification of a Rotavirus G12 Strain, Indonesia
PDF Version [PDF - 179 KB - 3 pages]
W. N. Wulan et al.
Imported Chikungunya Virus Infection
PDF Version [PDF - 142 KB - 2 pages]
M. Soumahoro et al.
Distinct Molecular Signature of Bovine Spongiform Encephalopathy Prion in Pigs
PDF Version [PDF - 151 KB - 1 page]
T. Seuberlich and A. Zurbriggen
Parvovirus 4 in Blood Donors, France
PDF Version [PDF - 232 KB - 2 pages]
M. Touinssi et al.
Otomastoiditis Caused by Mycobacterium abscessus, the Netherlands
PDF Version [PDF - 156 KB - 3 pages]
J. van Ingen et al.
Diseases Tracked by Using Google Trends, Spain
PDF Version [PDF - 145 KB - 1 page]
A. Valdivia and S. Monge-Corella
Detection of Newly Described Astrovirus MLB1 in Stool Samples from Children
PDF Version [PDF - 163 KB - 2 pages]
K. Bányai et al.
Optimal Therapy for Multidrug-Resistant Acinetobacter baumannii
PDF Version [PDF - 193 KB - 2 pages]
B. A. Cunha
Books and Media
Case Studies in Infectious Disease
PDF Version [PDF - 110 KB - 1 page]
P. S. Brachman
Infectious Disease: Pathogenesis, Prevention and Case Studies
PDF Version [PDF - 168 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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