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Volume 18, Number 5—May 2012
Volume 18, Number 5—May 2012 PDF Version [PDF - 6.76 MB - 191 pages]
Medscape CME Activity
Risk Factors for Intestinal Invasive Amebiasis in Japan, 2003–2009 PDF Version [PDF - 562 KB - 8 pages]N. Nagata et al.View SummaryView Abstract
Amebic colitis is increasing among younger men who have syphilis or HIV.
We determined yearly change in prevalence and risk factors for amebic colitis caused by intestinal invasive amebiasis among persons who underwent endoscopy and assessed differences between HIV-positive and HIV-negative persons in Japan. A total of 10,930 patients were selected for analysis, of whom 54 had amebic colitis. Prevalence was in 2009 (0.88%, 12/1360) compared with 2003 (0.16%, 3/1904). Male sex (odds ratio [OR] 8.39, 95% CI 1.99–35.40), age <50 years (OR 4.73, 95% CI 2.43–9.20), history of syphilis (OR 2.90, 95% CI 1.40–5.99), and HIV infection (OR 15.85, 95% CI 7.93–31.70) were independent risk factors. No differences in risk factors were identified between HIV-positive and HIV-negative patients. Contact with commercial sex workers was a new risk factor among HIV-negative patients. Homosexual intercourse, rather than immunosuppressed status, appears to be a risk factor among HIV-positive patients.
Medscape CME Activity
Invasive Haemophilus influenzae Serotype e and f Disease, England and Wales PDF Version [PDF - 300 KB - 8 pages]S. N. Ladhani et al.View SummaryView Abstract
Incidence of serotype e was 3-fold lower than serotype f, but it caused more severe clinical disease.
Haemophilus influenzae infection causes serious invasive disease, but incidence of the most virulent serotype, Hib, has dropped since introduction of routine Hib vaccination. In England and Wales, the incidence of 2 other serotypes, Hie and Hif, is increasing; during 2001–2010, there was an 11.0% year-on-year increase in Hif and a 7.4% increase in Hie. In 2009–2010, Hif incidence was 0.090/100,000 persons and Hie incidence 0.030/100,000, with higher rates among infants and older adults. Hie had a more severe clinical course; although outcome at 6 months was comparable for the 2 serotypes, case-fatality rate within 7 days of diagnosis was higher for Hie, even after adjustment for age and comorbidities. Multilocus sequence typing revealed a single major circulating clone for both Hif (sequence type 124; 89/99 isolates, 90%) and Hie (sequence type 18; 21/33, 64%), but no association between type and clinical disease or outcome was found.
Epidemic of Invasive Pneumococcal Disease, Western Canada, 2005–2009
PDF Version [PDF - 285 KB - 8 pages]
G. J. Tyrrell et al.View SummaryView Abstract
A single clone of Streptococcus pneumoniae serotype 5 caused this epidemic.
In Canada before 2005, large outbreaks of pneumococcal disease, including invasive pneumococcal disease caused by serotype 5, were rare. Since then, an epidemic of serotype 5 invasive pneumococcal disease was reported: 52 cases during 2005, 393 during 2006, 457 during 2007, 104 during 2008, and 42 during in 2009. Of these 1,048 cases, 1,043 (99.5%) occurred in the western provinces of Canada. Median patient age was 41 years, and most (659 [59.3%]) patients were male. Most frequently representing serotype 5 cases (compared with a subset of persons with non–serotype 5 cases) were persons who were of First Nations heritage or homeless. Restriction fragment-length polymorphism typing indicated that the epidemic was caused by a single clone, which multilocus sequence typing identified as sequence type 289. Large pneumococcal epidemics might go unrecognized without surveillance programs to document fluctuations in serotype prevalence.
Antimicrobial Drug Resistance in Escherichia coli from Humans and Food Animals, United States, 1950–2002
PDF Version [PDF - 484 KB - 9 pages]
D. A. Tadesse et al.View SummaryView Abstract
Determining drug resistance trends will optimize treatment and public health responses.
We conducted a retrospective study of Escherichia coli isolates recovered from human and food animal samples during 1950–2002 to assess historical changes in antimicrobial drug resistance. A total of 1,729 E. coli isolates (983 from humans, 323 from cattle, 138 from chickens, and 285 from pigs) were tested for susceptibility to 15 antimicrobial drugs. A significant upward trend in resistance was observed for ampicillin (p<0.001), sulfonamide (p<0.001), and tetracycline (p<0.001). Animal strains showed increased resistance to 11/15 antimicrobial agents, including ampicillin (p<0.001), sulfonamide (p<0.01), and gentamicin (p<0.001). Multidrug resistance (≥3 antimicrobial drug classes) in E. coli increased from 7.2% during the 1950s to 63.6% during the 2000s. The most frequent co-resistant phenotype observed was to tetracycline and streptomycin (29.7%), followed by tetracycline and sulfonamide (29.0%). These data describe the evolution of resistance after introduction of new antimicrobial agents into clinical medicine and help explain the range of resistance in modern E. coli isolates.
Novel Strain of Andes Virus Associated with Fatal Human Infection, Central Bolivia
PDF Version [PDF - 367 KB - 8 pages]
C. D. Cruz et al.View SummaryView Abstract
Interventions are needed to reduce human exposure to hantaviruses.
To better describe the genetic diversity of hantaviruses associated with human illness in South America, we screened blood samples from febrile patients in Chapare Province in central Bolivia during 2008–2009 for recent hantavirus infection. Hantavirus RNA was detected in 3 patients, including 1 who died. Partial RNA sequences of small and medium segments from the 3 patients were most closely related to Andes virus lineages but distinct (<90% nt identity) from reported strains. A survey for IgG against hantaviruses among residents of Chapare Province indicated that 12.2% of the population had past exposure to >1 hantaviruses; the highest prevalence was among agricultural workers. Because of the high level of human exposure to hantavirus strains and the severity of resulting disease, additional studies are warranted to determine the reservoirs, ecologic range, and public health effect of this novel strain of hantavirus.
Transmission Dynamics, Border Entry Screening, and School Holidays during the 2009 Influenza A (H1N1) Pandemic, China
PDF Version [PDF - 726 KB - 9 pages]
E. Chen et al.View SummaryView Abstract
Screening delayed spread by <4 days; autumn school holidays reduced the effective reproduction number by ≈40%.
Pandemic influenza A (H1N1) 2009 virus spread rapidly around the world in 2009. We used multiple data sources from surveillance systems and specific investigations to characterize the transmission patterns of this virus in China during May–November 2009 and analyze the effectiveness of border entry screening and holiday-related school closures on transmission. In China, age distribution and transmission dynamic characteristics were similar to those in Northern Hemisphere temperate countries. The epidemic was focused in children, with an effective reproduction number of ≈1.2–1.3. The 8 days of national holidays in October reduced the effective reproduction number by 37% (95% credible interval 28%–45%) and increased underreporting by ≈20%–30%. Border entry screening detected at most 37% of international travel–related cases, with most (89%) persons identified as having fever at time of entry. These findings suggest that border entry screening was unlikely to have delayed spread in China by >4 days.
Temporal Trends in Bordetella pertussis Populations, Denmark, 1949–2010
PDF Version [PDF - 532 KB - 8 pages]
R. Petersen et al.View SummaryView Abstract
Reduced genetic diversity possibly resulted from introduction of pertussis vaccines
We used multilocus variable-number tandem repeat analysis and multiple antigen sequence typing to characterize isolates of Bordetella pertussis strains circulating in Denmark during periods with and without pertussis vaccination coverage. Our results show substantial shifts in the B. pertussis population over time and a reduction in genetic diversity. These changes might have resulted from the introduction of pertussis vaccines in Denmark and other parts of Europe. The predominant strains currently circulating in Denmark resemble those in other European countries.
A Spatial Analysis of Individual- and Neighborhood-Level Determinants of Malaria Incidence in Adults, Ontario, Canada
PDF Version [PDF - 332 KB - 8 pages]
R. Eckhardt et al.View SummaryView Abstract
Imported malaria cases in adults are strongly patterned by neighborhood economic and immigration levels.
Malaria, once endemic in Canada, is now restricted to imported cases. Imported malaria in Canada has not been examined recently in the context of increased international mobility, which may influence incidence of imported and autochthonous cases. Surveillance of imported cases can highlight high-risk populations and help target prevention and control measures. To identify geographic and individual determinants of malaria incidence in Ontario, Canada, we conducted a descriptive spatial analysis. We then compared characteristics of case-patients and controls. Case-patients were significantly more likely to be male and live in low-income neighborhoods that had a higher proportion of residents who had emigrated from malaria-endemic regions. This method’s usefulness in clarifying the local patterns of imported malaria in Ontario shows its potential to help identify areas and populations at highest risk for imported and emerging infectious disease.
Bartonella spp. Bacteremia and Rheumatic Symptoms in Patients from Lyme Disease–endemic Region
PDF Version [PDF - 245 KB - 9 pages]
R. G. Maggi et al.View SummaryView Abstract
Prevalence of Bartonella spp. was high, especially among patients with a history of Lyme disease.
Bartonella spp. infection has been reported in association with an expanding spectrum of symptoms and lesions. Among 296 patients examined by a rheumatologist, prevalence of antibodies against Bartonella henselae, B. koehlerae, or B. vinsonii subsp. berkhoffii (185 [62%]) and Bartonella spp. bacteremia (122 [41.1%]) was high. Conditions diagnosed before referral included Lyme disease (46.6%), arthralgia/arthritis (20.6%), chronic fatigue (19.6%), and fibromyalgia (6.1%). B. henselae bacteremia was significantly associated with prior referral to a neurologist, most often for blurred vision, subcortical neurologic deficits, or numbness in the extremities, whereas B. koehlerae bacteremia was associated with examination by an infectious disease physician. This cross-sectional study cannot establish a causal link between Bartonella spp. infection and the high frequency of neurologic symptoms, myalgia, joint pain, or progressive arthropathy in this population; however, the contribution of Bartonella spp. infection, if any, to these symptoms should be systematically investigated.
Characterization of Virulent West Nile Virus Kunjin Strain, Australia, 2011
PDF Version [PDF - 419 KB - 9 pages]
M. J. Frost et al.View SummaryView Abstract
An encephalitis outbreak among horses was caused by a pathogenic variant of Kunjin virus.
To determine the cause of an unprecedented outbreak of encephalitis among horses in New South Wales, Australia, in 2011, we performed genomic sequencing of viruses isolated from affected horses and mosquitoes. Results showed that most of the cases were caused by a variant West Nile virus (WNV) strain, WNVNSW2011, that is most closely related to WNV Kunjin (WNVKUN), the indigenous WNV strain in Australia. Studies in mouse models for WNV pathogenesis showed that WNVNSW2011 is substantially more neuroinvasive than the prototype WNVKUN strain. In WNVNSW2011, this apparent increase in virulence over that of the prototype strain correlated with at least 2 known markers of WNV virulence that are not found in WNVKUN. Additional studies are needed to determine the relationship of the WNVNSW2011 strain to currently and previously circulating WNVKUN strains and to confirm the cause of the increased virulence of this emerging WNV strain.
No Association between 2008–09 Influenza Vaccine and Influenza A(H1N1)pdm09 Virus Infection, Manitoba, Canada, 2009
PDF Version [PDF - 246 KB - 10 pages]
S. M. Mahmud et al.View SummaryView Abstract
Receipt of seasonal inactivated trivalent vaccine neither increased nor decreased the risk for pandemic influenza virus infection.
We conducted a population-based study in Manitoba, Canada, to investigate whether use of inactivated trivalent influenza vaccine (TIV) during the 2008–09 influenza season was associated with subsequent infection with influenza A(H1N1)pdm09 virus during the first wave of the 2009 pandemic. Data were obtained from a provincewide population-based immunization registry and laboratory-based influenza surveillance system. The test-negative case–control study included 831 case-patients with confirmed influenza A(H1N1)pdm09 virus infection and 2,479 controls, participants with test results negative for influenza A and B viruses. For the association of TIV receipt with influenza A(H1N1)pdm09 virus infection, the fully adjusted odds ratio was 1.0 (95% CI 0.7–1.4). Among case-patients, receipt of 2008–09 TIV was associated with a statistically nonsignificant 49% reduction in risk for hospitalization. In agreement with study findings outside Canada, our study in Manitoba indicates that the 2008–09 TIV neither increased nor decreased the risk for infection with influenza A(H1N1)pdm09 virus.
Use of Spatial Information to Predict Multidrug Resistance in Tuberculosis Patients, Peru
PDF Version [PDF - 239 KB - 3 pages]
H. Lin et al.View SummaryView Abstract
Knowing whether a patient has multidrug-resistant tuberculosis is crucial for prescribing the best treatment. The challenge is choosing the most effective drug with the fewest side effects while saving the “big guns” for the most resistant infections. The best way to find out whether a patient has this type of infection is to conduct drug-susceptibility testing. Unfortunately, this testing requires laboratory capabilities that are in short supply, so often only patients at high risk are tested. But who is at high risk? A recent study found an association between patients’ locations (health center at which they were seen) and likelihood of multidrug-resistant infection. Added to other known risk factors (young age, previous TB treatment, or contact with someone with similar infection), this information can further pinpoint who should be tested, which will ultimately lead to faster diagnoses, better treatments and less spread of multidrug-resistant TB.
To determine whether spatiotemporal information could help predict multidrug resistance at the time of tuberculosis diagnosis, we investigated tuberculosis patients who underwent drug susceptibility testing in Lima, Peru, during 2005–2007. We found that crude representation of spatial location at the level of the health center improved prediction of multidrug resistance.
Influenza Virus A (H10N7) in Chickens and Poultry Abattoir Workers, Australia
PDF Version [PDF - 188 KB - 3 pages]
G. G. Arzey et al.View Abstract
In March 2010, an outbreak of low pathogenicity avian influenza A (H10N7) occurred on a chicken farm in Australia. After processing clinically normal birds from the farm, 7 abattoir workers reported conjunctivitis and minor upper respiratory tract symptoms. Influenza virus A subtype H10 infection was detected in 2 workers.
Influenza A and B Virus Attachment to Respiratory Tract in Marine Mammals
PDF Version [PDF - 567 KB - 4 pages]
A. J. Ramis et al.View Abstract
Patterns of virus attachment to the respiratory tract of 4 marine mammal species were determined for avian and human influenza viruses. Attachment of avian influenza A viruses (H4N5) and (H7N7) and human influenza B viruses to trachea and bronchi of harbor seals is consistent with reported influenza outbreaks in this species.
Coxsackievirus A21, Enterovirus 68, and Acute Respiratory Tract Infection, China
PDF Version [PDF - 234 KB - 4 pages]
Z. Xiang et al.View Abstract
During August 2006–April 2010, in Beijing, China, 2 rare human enterovirus serotypes, coxsackievirus A21 and enterovirus 68, were detected most frequently in human enterovirus–positive adults with acute respiratory tract infections. Thus, during some years, these 2 viruses cause a substantial proportion of enterovirus-associated adult acute respiratory tract infections.
Unsuspected Rickettsioses among Patients with Acute Febrile Illness, Sri Lanka, 2007
PDF Version [PDF - 305 KB - 5 pages]
M. E. Reller et al.View Abstract
We studied rickettsioses in southern Sri Lanka. Of 883 febrile patients with paired serum samples, 156 (17.7%) had acute rickettsioses; rickettsioses were unsuspected at presentation. Additionally, 342 (38.7%) had exposure to spotted fever and/or typhus group rickettsioses and 121 (13.7%) scrub typhus. Increased awareness of rickettsioses and better tests are needed.
Origin of Human T-Lymphotropic Virus Type 1 in Rural Côte d’Ivoire
PDF Version [PDF - 246 KB - 4 pages]
S. Calvignac-Spencer et al.View Abstract
Simian T-lymphotropic virus type 1 (STLV-1) strains occasionally infect humans. However, the frequency of such infections is unknown. We show that direct transmission of STLV-1 from nonhuman primates to humans may be responsible for a substantial proportion of human T-lymphotropic virus type 1 infections in rural Côte d’Ivoire, where primate hunting is common.
Human Infections with Novel Reassortant Influenza A(H3N2)v Viruses, United States, 2011
PDF Version [PDF - 303 KB - 4 pages]
S. Lindstrom et al.View Abstract
During July–December 2011, a variant virus, influenza A(H3N2)v, caused 12 human cases of influenza. The virus contained genes originating from swine, avian, and human viruses, including the M gene from influenza A(H1N1)pdm09 virus. Influenza A(H3N2)v viruses were antigenically distinct from seasonal influenza viruses and similar to proposed vaccine virus A/Minnesota/11/2010.
Pigs as Natural Hosts of Dientamoeba fragilis Genotypes Found in Humans
PDF Version [PDF - 213 KB - 4 pages]
S. M. Cacciò et al.View SummaryView Abstract
The world is home to more than 1 billion pigs, which produce large quantities of feces. We know that some organisms in pig feces can cause human disease, and now we might have another to add to the list. Little is known about where the common intestinal parasite Dientamoeba fragilis comes from and how it is spread. However, recent molecular analysis confirmed that the organism found in pigs is indeed the same as the one found in humans. Therefore, pigs (or their feces) might be a source of this parasitic infection in humans.
Dientamoeba fragilis is a common intestinal parasite in humans. Transmission routes and natural host range are unknown. To determine whether pigs are hosts, we analyzed 152 fecal samples by microscopy and molecular methods. We confirmed that pigs are a natural host and harbor genotypes found in humans, suggesting zoonotic potential.
Plasmodium vivax Malaria–associated Acute Kidney Injury, India, 2010–2011
PDF Version [PDF - 336 KB - 4 pages]
V. B. Kute et al.View Abstract
Plasmodium vivax is causing increasingly more cases of severe malaria worldwide. Among 25 cases in India during 2010–2011, associated conditions were renal failure, thrombocytopenia, jaundice, severe anemia, acute respiratory distress syndrome, shock, cerebral malaria, hypoglycemia, and death. Further studies are needed to determine why P. vivax malaria is becoming more severe.
Novel Human Adenovirus Strain, Bangladesh
PDF Version [PDF - 271 KB - 3 pages]
Y. Matsushima et al.View Abstract
We report a novel human adenovirus D (HAdV-65) isolated from feces of 4 children in Bangladesh who had acute gastroenteritis. Corresponding genes of HAdV-65 were related to a hexon gene of HAdV-10, penton base genes of HAdV-37 and HAdV-58, and a fiber gene of HAdV-9. This novel virus may be a serious threat to public health.
Rhabdomyolysis Associated with Antimicrobial Drug–Resistant Mycoplasma pneumoniae
PDF Version [PDF - 247 KB - 3 pages]
T. Oishi et al.View Abstract
We describe a case of rhabdomyolysis in a patient infected with antimicrobial drug–resistant Mycoplasma pneumoniae The patient’s acute-phase serum levels of interleukin-18 and tumor necrosis factor–α were high, which suggests a pathogenic role for M. pneumoniae. In an era of increasing antimicrobial drug resistance, a system for rapidly identifying resistant M. pneumoniae would be beneficial.
Human Adenovirus Type 7 Outbreak in Police Training Center, Malaysia, 2011
PDF Version [PDF - 162 KB - 3 pages]
M. Yusof et al.View Abstract
In March 2011, an outbreak of acute respiratory disease was reported at the Kuala Lumpur (Malaysia) Police Training Centre. Approximately 100 trainees were hospitalized and 5 were admitted to the intensive care unit. Three of these 5 trainees died. Human adenovirus type 7 was identified as the etiologic agent.
Lymphocytic Choriomeningitis Virus–associated Meningitis, Southern Spain
PDF Version [PDF - 321 KB - 4 pages]
M. Pérez-Ruiz et al.View Abstract
Lymphocytic choriomeningitis virus (LCMV) was detected in 2 patients with acute meningitis in southern Spain within a 3-year period. Although the prevalence of LCMV infection was low (2 [1.3%] of 159 meningitis patients), it represents 2.9% of all pathogens detected. LCMV is a noteworthy agent of neurologic illness in immunocompetent persons.
Diversity of Parvovirus 4–like Viruses in Humans, Chimpanzees, and Monkeys in Hunter–Prey Relationships
PDF Version [PDF - 298 KB - 4 pages]
C. Adlhoch et al.View Abstract
During 2010–2011, we investigated interspecies transmission of partetraviruses between predators (humans and chimpanzees) and their prey (colobus monkeys) in Côte d’Ivoire. Despite widespread infection in all species investigated, no interspecies transmission could be detected by PCR and genome analysis. All sequences identified formed species- or subspecies (chimpanzee)-specific clusters, which supports a co-evolution hypothesis.
Emergency Department Visits for Influenza A(H1N1)pdm09, Davidson County, Tennessee, USA
PDF Version [PDF - 156 KB - 3 pages]
W. H. Self et al.View Abstract
To determine the number of emergency department visits attributable to influenza A(H1N1)pdm09 in Davidson County, Tennessee, USA, we used active, population-based surveillance and laboratory-confirmed influenza data. We estimated ≈10 visits per 1,000 residents during the pandemic period. This estimate should help emergency departments prepare for future pandemics.
Screening for Influenza A(H1N1)pdm09, Auckland International Airport, New Zealand
PDF Version [PDF - 184 KB - 3 pages]
M. J. Hale et al.View Abstract
Entry screening for influenza A(H1N1)pdm09 at Auckland International Airport, New Zealand, detected 4 cases, which were later confirmed, among 456,518 passengers arriving April 27–June 22, 2009. On the basis of national influenza surveillance data, which suggest that ≈69 infected travelers passed through the airport, sensitivity for screening was only 5.8%.
Hepatitis E Virus Infection among Solid Organ Transplant Recipients, the Netherlands
PDF Version [PDF - 238 KB - 4 pages]
S. D. Pas et al.View Abstract
We screened 1,200 living heart, lung, liver, and kidney transplant recipients for hepatitis E virus infection by reverse transcription PCR. In 12 (1%) patients, hepatitis E virus infection was identified; in 11 patients, chronic infection developed. This immunocompromised population is at risk for hepatitis E virus infection.
Sapovirus Outbreaks in Long-Term Care Facilities, Oregon and Minnesota, USA, 2002–2009
PDF Version [PDF - 188 KB - 4 pages]
L. E. Lee et al.View SummaryView Abstract
Sapovirus gives new meaning to the phrase “cradle to grave.” Historically, sapovirus has been associated with gastrointestinal illness in children living in group settings such as hospitals, shelters, or refugee camps. But now, sapovirus outbreaks are occurring among elderly residents of long-term care and similar facilities. These elderly residents are especially vulnerable to rapidly transmitted gastrointestinal viruses and serious complications. This virus has been making the rounds in long-term care facilities since 2002, and outbreaks started increasing in 2007. Sapovirus testing should be added to routine diagnostic workups for gastrointestinal infections, regardless of patient age group. Results can be used to develop prevention, control, and treatment guidelines, especially for vulnerable elderly populations.
We tested fecal samples from 93 norovirus-negative gastroenteritis outbreaks; 21 outbreaks were caused by sapovirus. Of these, 71% were caused by sapovirus genogroup IV and 66% occurred in long-term care facilities. Future investigation of gastroenteritis outbreaks should include multi-organism testing.
Possible Nosocomial Transmission of Pneumocystis jirovecii
PDF Version [PDF - 107 KB - 2 pages]
C. Damiani et al.
Fatal Human Co-infection with Leptospira spp. and Dengue Virus, Puerto Rico, 2010
PDF Version [PDF - 198 KB - 3 pages]
T. M. Sharp et al.
Serologic Evidence of West Nile Virus Infection among Humans, Morocco
PDF Version [PDF - 130 KB - 2 pages]
H. El Rhaffouli et al.
Enterovirus 104 Infection in Adult, Japan, 2011
PDF Version [PDF - 125 KB - 2 pages]
A. Kaida et al.
Clonal Spread of Geomyces destructans among Bats, Midwestern and Southern United States
PDF Version [PDF - 165 KB - 3 pages]
P. Ren et al.
Electronic School Absenteeism Monitoring and Influenza Surveillance, Hong Kong
PDF Version [PDF - 156 KB - 3 pages]
C. Cheng et al.
Epidemic Genotype of Coxiella burnetii among Goats, Sheep, and Humans in the Netherlands
PDF Version [PDF - 119 KB - 3 pages]
J. Tilburg et al.
High Anti–Phenolic Glycolipid-I IgM Titers and Hidden Leprosy Cases, Amazon Region
PDF Version [PDF - 111 KB - 2 pages]
C. Salgado et al.
Novel Prion Protein in BSE-affected Cattle, Switzerland
PDF Version [PDF - 213 KB - 3 pages]
About the Cover
Peer Reviewed Report Available Online OnlyReport on the International Symposium on Hepatitis E, Seoul, South Korea, 2010T. F. Wierzba and U. Panzner
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: April 26, 2012
- Page last updated: April 26, 2012
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