Volume 17, Number 4—April 2011
Volume 17, Number 4—April 2011 PDF Version [PDF - 6.30 MB - 195 pages]
Legionella longbeachae and Legionellosis
PDF Version [PDF - 136 KB - 5 pages]
H. Whiley and R. BenthamView Abstract
Reported cases of legionellosis attributable to Legionella longbeachae infection have increased worldwide. In Australia and New Zealand, L. longbeachae has been a known cause of legionellosis since the late 1980s. All cases for which a source was confirmed were associated with potting mixes and composts. Unlike the situation with other Legionella spp., L. longbeachae–contaminated water systems in the built environment that cause disease have not been reported. Spatially and temporally linked outbreaks of legionellosis associated with this organism also have not been reported. Sporadic cases of disease seem to be limited to persons who have had direct contact with potting soil or compost. Long-distance travel of the organism resulting in infection has not been reported. These factors indicate emergence of an agent of legionellosis that differs in etiology from other species and possibly in route of disease transmission.
Carriage of Streptococcus pneumoniae 3 Years after Start of Vaccination Program, the Netherlands
PDF Version [PDF - 261 KB - 8 pages]
J. Spijkerman et al.View Abstract
To evaluate the effectiveness of the 7-valent pneumococcal conjugate vaccine (PCV7) program, we conducted a cross-sectional observational study on nasopharyngeal carriage of Streptococcus pneumoniae 3 years after implementation of the program in the Netherlands. We compared pneumococcal serotypes in 329 prebooster 11-month-old children, 330 fully vaccinated 24-month-old children, and 324 parents with age-matched pre-PCV7 (unvaccinated) controls (ages 12 and 24 months, n = 319 and n = 321, respectively) and 296 of their parents. PCV7 serotype prevalences before and after PCV7 implementation, respectively, were 38% and 8% among 11-month-old children, 36% and 4% among 24-month-old children, and 8% and 1% among parents. Non-PCV7 serotype prevalences were 29% and 39% among 11-month-old children, 30% and 45% among 24-month-old children, and 8% and 15% among parents, respectively; serotypes 11A and 19A were most frequently isolated. PCV7 serotypes were largely replaced by non-PCV7 serotypes. Disappearance of PCV7 serotypes in parents suggests strong transmission reduction through vaccination.
Nosocomial Pandemic (H1N1) 2009, United Kingdom, 2009–2010
PDF Version [PDF - 177 KB - 7 pages]
J. E. Enstone et al.View Abstract
To determine clinical characteristics of patients hospitalized in the United Kingdom with pandemic (H1N1) 2009, we studied 1,520 patients in 75 National Health Service hospitals. We characterized patients who acquired influenza nosocomially during the pandemic (H1N1) 2009 outbreak. Of 30 patients, 12 (80%) of 15 adults and 14 (93%) of 15 children had serious underlying illnesses. Only 12 (57%) of 21 patients who received antiviral therapy did so within 48 hours after symptom onset, but 53% needed escalated care or mechanical ventilation; 8 (27%) of 30 died. Despite national guidelines and standardized infection control procedures, nosocomial transmission remains a problem when influenza is prevalent. Health care workers should be routinely offered influenza vaccine, and vaccination should be prioritized for all patients at high risk. Staff should remain alert to the possibility of influenza in patients with complex clinical problems and be ready to institute antiviral therapy while awaiting diagnosis during influenza outbreaks.
Genomic Analysis of Highly Virulent Georgia 2007/1 Isolate of African Swine Fever Virus
PDF Version [PDF - 181 KB - 7 pages]
D. A. Chapman et al.View Abstract
African swine fever is widespread in Africa but has occasionally been introduced into other continents. In June 2007, African swine fever was isolated in the Caucasus Region of the Republic of Georgia and subsequently in neighboring countries (Armenia, Azerbaijan, and 9 states of the Russian Federation). Previous data for sequencing of 3 genes indicated that the Georgia 2007/1 isolate is closely related to isolates of genotype II, which has been identified in Mozambique, Madagascar, and Zambia. We report the complete genomic coding sequence of the Georgia 2007/1 isolate and comparison with other isolates. A genome sequence of 189,344 bp encoding 166 open reading frames (ORFs) was obtained. Phylogeny based on concatenated sequences of 125 conserved ORFs showed that this isolate clustered most closely with the Mkuzi 1979 isolate. Some ORFs clustered differently, suggesting that recombination may have occurred. Results provide a baseline for monitoring genomic changes in this virus.
Diarrheagenic Pathogens in Polymicrobial Infections
PDF Version [PDF - 356 KB - 6 pages]
B. Lindsay et al.View Abstract
During systematic active surveillance of the causes of diarrhea in patients admitted to the Infectious Diseases and Beliaghata General Hospital in Kolkata, India, we looked for 26 known gastrointestinal pathogens in fecal samples from 2,748 patients. Samples from about one-third (29%) of the patients contained multiple pathogens. Polymicrobial infections frequently contained Vibrio cholerae O1 and rotavirus. When these agents were present, some co-infecting agents were found significantly less often (p = 10–5 to 10–33), some were detected significantly more often (p = 10–5 to 10–26), and others were detected equally as often as when V. cholerae O1 or rotavirus was absent. When data were stratified by patient age and season, many nonrandom associations remained statistically significant. The causes and effects of these nonrandom associations remain unknown.
Bordetella petrii Infection with Long-lasting Persistence in Human
PDF Version [PDF - 468 KB - 7 pages]
A. Le Coustumier et al.View Abstract
We report the repeated isolation of Bordetella petrii in the sputum of a 79-year-old female patient with diffuse bronchiectasis and persistence of the bacterium for >1 year. The patient was first hospitalized due to dyspnea, which developed into severe cough with purulent sputum that yielded B. petrii on culture. After this first episode, the patient was hospitalized an additional 4 times with bronchorrhea symptoms. The isolates collected were analyzed by using biochemical, genotypic, and proteomic tools. Expression of specific proteins was analyzed by using serum samples from the patient. The B. petrii isolates were compared with other B. petrii isolates collected from humans or the environment and with isolates of B. pertussis, B. parapertussis, B. bronchiseptica, and B. holmesii, obtained from human respiratory tract infections. Our observations indicate that B. petrii can persist in persons with chronic pulmonary obstructive disease as has been previously demonstrated for B. bronchiseptica.
Effects of Hand Hygiene Campaigns on Incidence of Laboratory-confirmed Influenza and Absenteeism in Schoolchildren, Cairo, Egypt
PDF Version [PDF - 190 KB - 7 pages]
M. Talaat et al.View Abstract
To evaluate the effectiveness of an intensive hand hygiene campaign on reducing absenteeism caused by influenza-like illness (ILI), diarrhea, conjunctivitis, and laboratory-confirmed influenza, we conducted a randomized control trial in 60 elementary schools in Cairo, Egypt. Children in the intervention schools were required to wash hands twice each day, and health messages were provided through entertainment activities. Data were collected on student absenteeism and reasons for illness. School nurses collected nasal swabs from students with ILI, which were tested by using a qualitative diagnostic test for influenza A and B. Compared with results for the control group, in the intervention group, overall absences caused by ILI, diarrhea, conjunctivitis, and laboratory-confirmed influenza were reduced by 40%, 30%, 67%, and 50%, respectively (p<0.0001 for each illness). An intensive hand hygiene campaign was effective in reducing absenteeism caused by these illnesses.
Orthopoxvirus DNA in Eurasian Lynx, Sweden
PDF Version [PDF - 284 KB - 7 pages]
M. Tryland et al.View Abstract
Cowpox virus, which has been used to protect humans against smallpox but may cause severe disease in immunocompromised persons, has reemerged in humans, domestic cats, and other animal species in Europe. Orthopoxvirus (OPV) DNA was detected in tissues (lung, kidney, spleen) in 24 (9%) of 263 free-ranging Eurasian lynx (Lynx lynx) from Sweden. Thymidine kinase gene amplicon sequences (339 bp) from 21 lynx were all identical to those from cowpox virus isolated from a person in Norway and phylogenetically closer to monkeypox virus than to vaccinia virus and isolates from 2 persons with cowpox virus in Sweden. Prevalence was higher among animals from regions with dense, rather than rural, human populations. Lynx are probably exposed to OPV through predation on small mammal reservoir species. We conclude that OPV is widely distributed in Sweden and may represent a threat to humans. Further studies are needed to verify whether this lynx OPV is cowpox virus.
Genome Sequence of SG33 Strain and Recombination between Wild-Type and Vaccine Myxoma Viruses
PDF Version [PDF - 364 KB - 6 pages]
C. Camus-Bouclainville et al.View Abstract
Myxomatosis in Europe is the result of the release of a South America strain of myxoma virus in 1952. Several attenuated strains with origins in South America or California have since been used as vaccines in the rabbit industry. We sequenced the genome of the SG33 myxoma virus vaccine strain and compared it with those of other myxoma virus strains. We show that SG33 genome carries a large deletion in its right end. Furthermore, our data strongly suggest that the virus isolate from which SG33 is derived results from an in vivo recombination between a wild-type South America (Lausanne) strain and a California MSD-derived strain. These findings raise questions about the use of insufficiently attenuated virus in vaccination.
Shedding of Pandemic (H1N1) 2009 Virus among Health Care Personnel, Seattle, Washington, USA
PDF Version [PDF - 154 KB - 6 pages]
M. K. Kay et al.View Abstract
The Centers for Disease Control and Prevention (CDC) recommends that health care personnel (HCP) infected with pandemic influenza (H1N1) 2009 virus not work until 24 hours after fever subsides without the use of antipyretics. During an influenza outbreak, we examined the association between viral shedding and fever among infected HCP. Participants recorded temperatures daily and provided nasal wash specimens for 2 weeks after symptom onset. Specimens were tested by using PCR and culture. When they met CDC criteria for returning to work, 12 of 16 HCP (75%) (95% confidence interval 48%–93%) had virus detected by PCR, and 9 (56%) (95% confidence interval 30%–80%) had virus detected by culture. Fever was not associated with shedding duration (p = 0.65). HCP might shed virus even when meeting CDC exclusion guidelines. Further research is needed to clarify the association between viral shedding, symptoms, and infectiousness.
Complete Sequence and Molecular Epidemiology of IncK Epidemic Plasmid Encoding bla
PDF Version [PDF - 462 KB - 8 pages]
J. L. Cottell et al.View Abstract
Antimicrobial drug resistance is a global challenge for the 21st century with the emergence of resistant bacterial strains worldwide. Transferable resistance to β-lactam antimicrobial drugs, mediated by production of extended-spectrum β-lactamases (ESBLs), is of particular concern. In 2004, an ESBL-carrying IncK plasmid (pCT) was isolated from cattle in the United Kingdom. The sequence was a 93,629-bp plasmid encoding a single antimicrobial drug resistance gene, blaCTX-M-14. From this information, PCRs identifying novel features of pCT were designed and applied to isolates from several countries, showing that the plasmid has disseminated worldwide in bacteria from humans and animals. Complete DNA sequences can be used as a platform to develop rapid epidemiologic tools to identify and trace the spread of plasmids in clinically relevant pathogens, thus facilitating a better understanding of their distribution and ability to transfer between bacteria of humans and animals.
Molecular Epidemiology of Coxiella burnetii from Ruminants in Q Fever Outbreak, the Netherlands
PDF Version [PDF - 592 KB - 8 pages]
H. I. Roest et al.View Abstract
Q fever is a zoonosis caused by the bacterium Coxiella burnetii. One of the largest reported outbreaks of Q fever in humans occurred in the Netherlands starting in 2007; epidemiologic investigations identified small ruminants as the source. To determine the genetic background of C. burnetii in domestic ruminants responsible for the human Q fever outbreak, we genotyped 126 C. burnetii–positive samples from ruminants by using a 10-loci multilocus variable-number tandem-repeat analyses panel and compared them with internationally known genotypes. One unique genotype predominated in dairy goat herds and 1 sheep herd in the human Q fever outbreak area in the south of the Netherlands. On the basis of 4 loci, this genotype is similar to a human genotype from the Netherlands. This finding strengthens the probability that this genotype of C. burnetii is responsible for the human Q fever epidemic in the Netherlands.
Medscape CME Activity
H275Y Mutant Pandemic (H1N1) 2009 Virus in Immunocompromised Patients PDF Version [PDF - 420 KB - 8 pages]C. Renaud et al.View Abstract
Most oseltamivir-resistant pandemic (H1N1) 2009 viruses have been isolated from immunocompromised patients. To describe the clinical features, treatment, outcomes, and virologic data associated with infection from pandemic (H1N1) 2009 virus with H275Y mutation in immunocompromised patients, we retrospectively identified 49 hematology–oncology patients infected with pandemic (H1N1) 2009 virus. Samples from 33 of those patients were tested for H275Y genotype by allele-specific real-time PCR. Of the 8 patients in whom H275Y mutations was identified, 1 had severe pneumonia; 3 had mild pneumonia with prolonged virus shedding; and 4 had upper respiratory tract infection, of whom 3 had prolonged virus shedding. All patients had received oseltamivir before the H275Y mutation was detected; 1 had received antiviral prophylaxis. Three patients excreted resistant virus for >60 days. Emergence of oseltamivir resistance is frequent in immunocompromised patients infected with pandemic (H1N1) 2009 virus and can be associated with a wide range of clinical disease and viral kinetics.
Medscape CME Activity
Mumps Complications and Effects of Mumps Vaccination, England and Wales, 2002–2006C. Yung et al.View Abstract
We analyzed data from hospital admissions and enhanced mumps surveillance to assess mumps complications during the largest mumps outbreak in England and Wales, 2004–2005, and their association with mumps vaccination. When compared with nonoutbreak periods, the outbreak was associated with a clear increase in hospitalized patients with orchitis, meningitis, and pancreatitis. Routine mumps surveillance and hospital data showed that 6.1% of estimated mumps patients were hospitalized, 4.4% had orchitis, 0.35% meningitis, and 0.33% pancreatitis. Enhanced surveillance data showed 2.9% of mumps patients were hospitalized, 6.1% had orchitis, 0.3% had meningitis, and 0.25% had pancreatitis. Risk was reduced for hospitalization (odds ratio [OR] 0.54, 95% confidence interval [CI] 0.43–0.68), mumps orchitis (OR 0.72, 95% CI 0.56–0.93) and mumps meningitis (OR 0.28, 95% CI 0.14–0.56) when patient had received 1 dose of measles, mumps, and rubella vaccine. The protective effect of vaccination on disease severity is critical in assessing the total effects of current and future mumps control strategies.
Remaining Questions about Clinical Variola Major
PDF Version [PDF - 208 KB - 5 pages]
J. M. LaneView Abstract
After the recent summary of World Health Organization–authorized research on smallpox, several clinical issues remain. This policy review addresses whether early hemorrhagic smallpox is disseminated intravascular coagulation and speculates about the cause of the high mortality rate among pregnant women and whether ocular smallpox is partly the result of trachoma or vitamin A deficiency. The joint destruction common in children with smallpox might be prevented by antiviral drugs, but intraarticular infusion of antiviral drugs is unprecedented. Development of highly effective antiviral drugs against smallpox raises the issue of whether postexposure vaccination can be performed without interference by an antiviral drug. Clinicians should consider whether patients with smallpox should be admitted to general hospitals. Although an adequate supply of second-generation smallpox vaccine exists in the United States, its use is unclear. Finally, political and ethical forces suggest that destruction of the remaining stocks of live smallpox virus is now appropriate.
Should Remaining Stockpiles of Smallpox Virus (Variola) Be Destroyed?
PDF Version [PDF - 215 KB - 2 pages]
R. S. WeinsteinView Abstract
In 2011, the World Health Organization will recommend the fate of existing smallpox stockpiles, but circumstances have changed since the complete destruction of these cultures was first proposed. Recent studies suggest that variola and its experimental surrogate, vaccinia, have a remarkable ability to modify the human immune response through complex mechanisms that scientists are only just beginning to unravel. Further study that might require intact virus is essential. Moreover, modern science now has the capability to recreate smallpox or a smallpox-like organism in the laboratory in addition to the risk of nature re-creating it as it did once before. These factors strongly suggest that relegating smallpox to the autoclave of extinction would be ill advised.
Parapoxvirus Infections of Red Deer, Italy
PDF Version [PDF - 310 KB - 4 pages]
A. Scagliarini et al.View Abstract
To characterize parapoxviruses causing severe disease in wild ruminants in Stelvio Park, Italy, we sequenced and compared the DNA of several isolates. Results demonstrated that the red deer isolates are closely related to the parapox of red deer in New Zealand virus.
Bacterial Meningitis and Haemophilus influenzae Type b Conjugate Vaccine, Malawi
PDF Version [PDF - 199 KB - 3 pages]
D. W. McCormick and E. M. MolyneuxView Abstract
A retrospective database review showed that Haemophilus influenzae type b conjugate vaccine decreased the annual number of cases of H. influenzae type b meningitis in children in Blantyre, Malawi. Among young bacterial meningitis patients, HIV prevalence was high (36.7% during 1997–2009), and pneumococcus was the most common etiologic agent (57% in 2009).
Rapid Genotyping of Swine Influenza Viruses
PDF Version [PDF - 310 KB - 4 pages]
P. W. Mak et al.View Abstract
The emergence of pandemic (H1N1) 2009 virus highlighted the need for enhanced surveillance of swine influenza viruses. We used real-time reverse–transcription PCR–based genotyping and found that this rapid and simple genotyping method may identify reassortants derived from viruses of Eurasian avian-like, triple reassortant-like, and pandemic (H1N1) 2009 virus lineages.
Molecular Discrimination of Sheep Bovine Spongiform Encephalopathy from Scrapie
PDF Version [PDF - 359 KB - 4 pages]
L. Pirisinu et al.View Abstract
Sheep CH1641-like transmissible spongiform encephalopathy isolates have shown molecular similarities to bovine spongiform encephalopathy (BSE) isolates. We report that the prion protein PrPSc from sheep BSE is extremely resistant to denaturation. This feature, combined with the N-terminal PrPSc cleavage, allowed differentiation of classical scrapie, including CH1641-like, from natural goat BSE and experimental sheep BSE.
Recent Clonal Origin of Cholera in Haiti
PDF Version [PDF - 196 KB - 3 pages]
A. Ali et al.View Abstract
Altered El Tor Vibrio cholerae O1, with classical cholera toxin B gene, was isolated from 16 patients with severe diarrhea at St. Mark’s Hospital, Arbonite, Haiti, <3 weeks after onset of the current cholera epidemic. Variable-number tandem-repeat typing of 187 isolates showed minimal diversity, consistent with a point source for the epidemic.
Drug-Resistant Pandemic (H1N1) 2009, South Korea
PDF Version [PDF - 158 KB - 3 pages]
S. Y. Shin et al.View Abstract
Eleven patients with drug-resistant pandemic (H1N1) 2009 were identified in South Korea during May 2009–January 2010. Virus isolates from all patients had the H275Y mutation in the neuraminidase gene. One isolate had the I117M mutation. Of the 11 patients, 6 were <59 months of age, and 5 had underlying immunosuppressive conditions.
Seasonality of Cat-Scratch Disease, France, 1999–2009
PDF Version [PDF - 174 KB - 3 pages]
D. Sanguinetti-Morelli et al.View Abstract
Cat-scratch disease is seasonal in the United States and Japan; but no data are available from Europe. To assess the seasonality of the disease in France, we analyzed lymph node biopsy specimens collected during 1999–2009. Most (87.5%) cases occurred during September–April and peaked in December.
Characteristics of Children Hospitalized for Pandemic (H1N1) 2009, Malaysia
PDF Version [PDF - 135 KB - 3 pages]
H. I. Ismail et al.View Abstract
To determine effects of pandemic (H1N1) 2009 on children in the tropics, we examined characteristics of children hospitalized for this disease in Malaysia. Of 1,362 children, 51 (3.7%) died, 46 of whom were in an intensive care unit. Although disease was usually mild, >1 concurrent conditions were associated with higher death rates.
Human Metapneumovirus Infection in Wild Mountain Gorillas, Rwanda
PDF Version [PDF - 180 KB - 3 pages]
G. Palacios et al.View Abstract
The genetic relatedness of mountain gorillas and humans has led to concerns about interspecies transmission of infectious agents. Human-to-gorilla transmission may explain human metapneumovirus in 2 wild mountain gorillas that died during a respiratory disease outbreak in Rwanda in 2009. Surveillance is needed to ensure survival of these critically endangered animals.
Highly Pathogenic Avian Influenza Virus Infection in Feral Raccoons, Japan
PDF Version [PDF - 287 KB - 4 pages]
T. Horimoto et al.View Abstract
Although raccoons (Procyon lotor) are susceptible to influenza viruses, highly pathogenic avian influenza virus (H5N1) infection in these animals has not been reported. We performed a serosurvey of apparently healthy feral raccoons in Japan and found specific antibodies to subtype H5N1 viruses. Feral raccoons may pose a risk to farms and public health.
Secondary and Tertiary Transmission of Vaccinia Virus from US Military Service Member
PDF Version [PDF - 316 KB - 4 pages]
G. E. Young et al.View Abstract
During February and March 2010, the New York State Department of Health investigated secondary and tertiary vaccinia contact transmission from a military vaccinee to 4 close contacts. Identification of these cases underscores the need for strict adherence to postvaccination infection control guidance to avoid transmission of the live virus.
High Rates of Staphylococcus aureus USA400 Infection, Northern Canada
PDF Version [PDF - 217 KB - 4 pages]
G. R. Golding et al.View Abstract
Surveillance of Staphylococcus aureus infections in 3 northern remote communities of Saskatchewan was undertaken. Rates of methicillin-resistant infections were extremely high (146–482/10,000 population), and most (98.2%) were caused by USA400 strains. Although USA400 prevalence has diminished in the United States, this strain is continuing to predominate throughout many northern communities in Canada.
Animal Movement and Establishment of Vaccinia Virus Cantagalo Strain in Amazon Biome, Brazil
PDF Version [PDF - 375 KB - 4 pages]
J. C. Quixabeira-Santos et al.View Abstract
To understand the emergence of vaccinia virus Cantagalo strain in the Amazon biome of Brazil, during 2008–2010 we conducted a molecular and epidemiologic survey of poxvirus outbreaks. Data indicate that animal movement was the major cause of virus dissemination within Rondônia State, leading to the establishment and spread of this pathogen.
Vaccinia Virus Infections in Martial Arts Gym, Maryland, USA, 2008
PDF Version [PDF - 287 KB - 4 pages]
C. M. Hughes et al.View Abstract
Vaccinia virus is an orthopoxvirus used in the live vaccine against smallpox. Vaccinia virus infections can be transmissible and can cause severe complications in those with weakened immune systems. We report on a cluster of 4 cases of vaccinia virus infection in Maryland, USA, likely acquired at a martial arts gym.
Hepatitis A Virus Vaccine Escape Variants and Potential New Serotype Emergence
PDF Version [PDF - 167 KB - 4 pages]
U. Pérez-Sautu et al.View Abstract
Six hepatitis A virus antigenic variants that likely escaped the protective effect of available vaccines were isolated, mostly from men who have sex with men. The need to complete the proper vaccination schedules is critical, particularly in the immunocompromised population, to prevent the emergence of vaccine-escaping variants.
Acute Cytomegalovirus Pneumonitis in Patient with Lymphomatoid Granulomatosis
PDF Version [PDF - 128 KB - 2 pages]
S. Wu et al.
Livestock-associated Staphylococcus aureus in Childcare Worker
PDF Version [PDF - 105 KB - 3 pages]
E. D. Moritz and T. C. Smith
Sequence Analysis of Feline Coronaviruses and the Circulating Virulent/Avirulent Theory
PDF Version [PDF - 415 KB - 3 pages]
H. Chang et al.
Effects of Vaccination against Pandemic (H1N1) 2009 among Japanese Children
PDF Version [PDF - 85 KB - 2 pages]
H. Nishiura and H. Oshitani
Pandemic (H1N1) 2009 Virus in 3 Wildlife Species, San Diego, California, USA
PDF Version [PDF - 162 KB - 3 pages]
M. D. Schrenzel et al.
Hemagglutinin 222 Variants in Pandemic (H1N1) 2009 Virus
PDF Version [PDF - 125 KB - 3 pages]
M. B. Valli et al.
Effect of School Closure from Pandemic (H1N1) 2009, Chicago, Illinois, USA
PDF Version [PDF - 46 KB - 3 pages]
V. G. Jarquin et al.
Imported Rabies, European Union and Switzerland, 2001–2010
N. Johnson et al.
Cytomegalovirus Viremia, Pneumonitis, and Tocilizumab Therapy
PDF Version [PDF - 127 KB - 3 pages]
D. van Duin et al.
Concurrent Influenza and Shigellosis Outbreaks, Papua New Guinea, 2009
PDF Version [PDF - 143 KB - 3 pages]
A. Rosewell et al.
About the Cover
- Page created: September 15, 2011
- Page last updated: September 15, 2011
- Page last reviewed: September 15, 2011
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