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15.1.3.1: Escherichia coli - Biology

15.1.3.1: Escherichia coli - Biology


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Gram Stain of Escherichia coli. Note Gram-negative (pink) bacilli.

Organism

  • E. coli is a member of the Enterobacteriaceae family which are all Gram-negative rods
  • Catalase positive
  • Oxidase negative
  • Facultative anaerobe
  • E. coli characteristically ferments lactose

Habitat

  • Normal inhabitant of the intestines of humans and other mammals

Source

  • Fecal contamination of food or water
  • Inadequate hygiene
  • Can be endogenous (from own flora) or exogenous (from outside the body)

Epidemiology

  • Certain strains can cause urinary tract infection (UTI) or gastrointestinal infection in people without specific risk factors
  • Extremely common cause of nosocomial infections
    • E. coli and other Enterobacteriaceae cause about 25-30% of the approximately 1.7 million nosocomial infections in the US each year
  • Outbreaks of enterohemorrhagic E. coli (EHEC) infection are associated with contaminated food

Clinical Disease and Virulence Factors

  • Urinary tract infection
    • E. coli is the most common cause of UTI
    • Much more common in women (about 14 times)
      • E. coli can be introduced into the urinary tract from the periurethral region during intercourse
    • Symptoms include:
      • A strong, persistent urge to urinate
      • A burning sensation when urinating
      • Passing frequent, small amounts of urine
      • Cloudy urine
      • Blood in the urine
      • Strong-smelling urine
      • Pelvic pain
    • Attach to the urinary tract with fimbriae and induce inflammation
  • Food poisoning (enterotoxigenic E. coli (ETEC)) (a.k.a. traveler's diarrhea)
    • due to consumption of food contaminated with enterotoxin-producing strains of E. coli
    • more common in areas with less developed sanitation
    • caused enterotoxins produced by the infecting bacteria
    • causes diarrhea without fever
    • Bismuth subsalicylate (Pepto-Bismol) binds to the enterotoxin and can be useful for treatment of symptoms or prophylaxis
    • Antibiotics may be warranted in more severe cases
  • Enterohemorrhagic E. coli (EHEC) (such as strain O157:H7)
    • Primarily associated with contaminated food. As an inhabitant of the GI tract of cows, it is commonly associated with beef. Ground beef is of particular concern because it is a mixture of various cuts, and if there is contamination it is distributed throughout the product rather than just on the surface as it would be in a steak or roast. Other foods have also been associated with outbreaks, such as leafy greens, sprouts, nuts, and nut butters.
    • Causes hemorrhagic (bloody) diarrhea, sometimes with cramping or vomiting
    • Can lead to potentially fatal hemolytic uremic syndrome (HUS)
      • blood vessels in kidneys are damaged
      • can cause kidney failure
    • The transfer of several proteins to the host cell through a pilus induces intestinal epithelial cells to produce pedestals to which the E. coli can tightly bind (Figure (PageIndex{1}))
    • Produces shiga toxin, which damages intestinal epithelium and causes hemorrhagic diarrhea. It may also play a significant role in the development of HUS.
      • Gene for the shiga toxin is phage-encoded

  • Common nosocomial infections
    • (although these are listed for E. coli, many other members of the Enterobacteriaceae such as Klebsiella and Citrobacter can cause similar infections)
    • neonatal meningitis
    • UTI
    • wound infections/abcesses
    • pneumonia
    • bacteremia/septicemia
  • Carbapenem-resistant Enterobacteriaceae (CRE)
    • CRE are resistant to nearly all antibiotics and are classified as an "urgent threat" by the CDC (fact sheet)
    • Produce beta-lactamases that can break down carbapenems and most other beta-lactam antibiotics
    • Genes for these beta-lactamases (such as NDM-1) are primarily found on mobile genetic elements (plasmids or phages) and can spread rapidly among the similarly pathogenic species of Enterobacteriaceae, especially since they are close together in the intestines and common in wastewater.
    • Prudent use of antibiotics, proper aseptic technique and hygiene, and monitoring for CRE infections are all critical to controlling the spread of CRE

Additional Information:

  • http://textbookofbacteriology.net/e.coli.html
  • https://www.cdc.gov/ecoli/pdfs/CDC-E...-Factsheet.pdf
  • https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3107499/

Escherichia coli

Escherichia coli (pronunciáu /eske'rikia 'koli/), tamién conocida pola abreviación del so nome, E. coli, ye un bacilu gramnegativo de la familia de les enterobacteries que s'atopa nel tracto gastrointestinal d'humanos y animales de sangre caliente. [3]

E. coli ye la bacteria anaerobia facultativa comensal más abondosa de la microbiota coles mesmes, ye unu de los organismos patóxenos más relevantes nel humanu, tantu na producción d'infeiciones gastrointestinales como d'otros sistemes (urinariu, sanguineu, nerviosu). Foi descrita per primer vegada en 1885 por Theodore von Escherich, bacteriólogo alemán, quien la denominó Bacterium coli commune. Darréu la taxonomía axudicó-y el nome de Escherichia coli, n'honor al so descubridor. [3] [4] [5]

Ésta y otres bacteries son necesaries pal funcionamientu correutu del proceso dixestivu, amás de producir les vitamines B y K. Ye un bacilu que reacciona negativamente a la tinción de Gram (gramnegativo), ye anaerobiu facultativu, móvil por flaxelos peritricos (qu'arrodien el so cuerpu), nun forma espores, ye capaz de lleldar la glucosa y la lactosa y la so prueba d'IMVIC ye ++--. [ensin referencies]

Ye una bacteria utilizada frecuentemente n'esperimentos de xenética y bioloxía molecular. [ensin referencies]

A pesar de que dambes compartan abreviatura, (E. coli), nun se debe confundir la bacteria Escherichia coli cola ameba Entamoeba coli (E. coli).


Summary of Notifiable Diseases, United States, 1994

This publication contains summary tables of the official statistics for the reported occurrence of nationally notifiable diseases in the United States for the year 1994. This information is collected and compiled from reports to the National Notifiable Diseases Surveillance System (NNDSS). Because the dates of onset and dates of diagnosis for notifiable diseases are often unknown, these surveillance data are presented by the week that they were reported to public health officials. These data are then finalized and published in the MMWR Summary of Notifiable Diseases, United States, for use by state and local health departments schools of medicine and public health communications media local, state, and federal agencies and other agencies or persons interested in following the trends of reportable conditions in the United States. Publication of the annual summary also ensures documentation of diseases that are considered national priorities for notification and of the annual number of cases of such diseases.

Part 1 contains information on morbidity for each of the conditions considered nationally notifiable during 1994. In all tables, leprosy is listed as Hansen disease and typhus fever (tick-borne) as Rocky Mountain spotted fever (RMSF). The tables show the number of cases of notifiable diseases reported to CDC for 1994, as well as the distribution of cases by month and geographic location, and by patient's age, race, and ethnicity. The data are final totals as of July 7, 1995, unless otherwise noted.

Part 2 contains graphs and maps depicting summary data for many of the notifiable conditions described in tabular form in Part

Part 3 includes tables showing the number of cases of notifiable diseases reported to CDC and to the National Office of Vital Statistics since 1945. It also includes a table on deaths associated with specified notifiable diseases reported to the National Center for Health Statistics, CDC, for the period 1983-1992. Background

As of January 1, 1994, 49 infectious diseases were designated as notifiable at the national level. A notifiable disease is one for which regular, frequent, and timely information on individual cases is considered necessary for the prevention and control of the disease. This section briefly summarizes the history of national notifiable disease reporting in the United States.

In 1878, Congress authorized the U.S. Marine Hospital Service (the precursor to the Public Health Service, PHS) to collect morbidity reports on cholera, smallpox, plague, and yellow fever from U.S. consuls overseas this information was to be used for instituting quarantine measures to prevent the introduction and spread of these diseases into the United States. In 1879, a specific Congressional appropriation was made for the collection and publication of reports of these notifiable diseases. The authority for weekly reporting and publication was expanded by Congress in 1893 to include data from states and municipal authorities. To increase the uniformity of the data, Congress enacted a law in 1902 directing the Surgeon General to provide forms for the collection and compilation of data and for the publication of reports at the national level. In 1912, state and territorial health authorities -- in conjunction with PHS -- recommended immediate telegraphic reporting of five infectious diseases and monthly reporting by letter of 10 additional diseases. The first annual summary of The Notifiable Diseases in 1912 included reports of 10 diseases from 19 states, the District of Columbia, and Hawaii. By 1928, all states, the District of Columbia, Hawaii, and Puerto Rico were participating in national reporting of nearly 30 specified conditions. At their annual meeting in 1950, the State and Territorial Health Officers authorized a conference of state and territorial epidemiologists whose purpose was to determine which diseases should be reported to PHS. CDC assumed responsibility for the collection and publication of data on nationally notifiable diseases in 1961.

The list of nationally notifiable diseases is revised periodically. For example, diseases may be added to the list as new pathogens emerge or deleted as their incidence declines. Public health officials at state health departments and CDC continue to collaborate in determining which diseases should be nationally notifiable the Council of State and Territorial Epidemiologists (CSTE), with CDC input, makes recommendations annually for additions and deletions to the list of nationally notifiable diseases. However, reporting of nationally notifiable diseases to CDC by the states is voluntary. Reporting is currently mandated (by state legislation or regulation) only at the state level. The list of diseases that are considered notifiable, therefore, varies slightly by state. All states generally report the internationally quarantinable diseases (i.e., cholera, plague, and yellow fever) in compliance with the World Health Organization's International Health Regulations. During 1994, 49 infectious diseases were considered notifiable at the national level and were reported to CDC 41 were reported on a weekly basis, and eight were reported monthly.

CSTE and CDC held a national surveillance conference November 30-December 2, 1994 to review the state of national infectious disease surveillance. Infectious diseases that have been approved for addition to national surveillance during 1995 are Chlamydia trachomatis (genital infections), coccidioidomycosis (for regional surveillance), cryptosporidiosis, hantavirus infection, (post-diarrheal) hemolytic uremic syndrome, pediatric infection with the human immunodeficiency virus, invasive group A streptococcal infections, streptococcal toxic-shock syndrome, and drug-resistant Streptococcus pneumoniae. These conditions currently are not reportable in all states, and the mechanism for reporting may not involve clinicians or consist of reports of individual cases (i.e., traditional notification methods). Reports of the number of cases of these conditions will not appear in the current year tables before 1996.

At the 1994 conference the following diseases were also proposed as deletions from the list of infectious diseases under national surveillance: amebiasis, aseptic meningitis, primary encephalitis (except for arboviral encephalitis), postinfectious encephalitis, granuloma inguinale, unspecified hepatitis, leptospirosis, lymphogranuloma venereum, rheumatic fever, and tularemia. These changes were confirmed by a vote of the full membership of CSTE in early 1995. The number of reported cases of these diseases will not appear in the current year tables after 1994.

The list of 49 infectious diseases that were designated as notifiable at the national level during 1994 appears below: AIDS Amebiasis Anthrax Aseptic meningitis * Botulism ** Brucellosis Chancroid ** Cholera Diphtheria Encephalitis, primary * Encephalitis, postinfectious * Escherichia coli O157:H7 ** Gonorrhea Granuloma inguinale * Haemophilus influenzae, invasive Hansen disease (leprosy) Hepatitis A Hepatitis B Hepatitis, non-A, non-B Hepatitis C, unspecified * Legionellosis Leptospirosis * Lyme disease Lymphogranuloma venereum * Malaria Measles Meningococcal disease Mumps Pertussis Plague Poliomyelitis Psittacosis Rabies, animal Rabies, human Rheumatic fever * Rocky Mountain spotted fever (RMSF) Rubella Rubella, congenital syndrome Salmonellosis ** Shigellosis ** Syphilis Syphilis, congenital Tetanus Toxic-shock syndrome Trichinosis Tuberculosis Tularemia * Typhoid fever Yellow fever **

Deleted from the nationally notifiable disease list in 1995 ** Not published in the weekly tables

Provisional data on the reported occurrence of notifiable diseases are published weekly in MMWR. After each reporting year, staff in state health departments finalize reports of cases for the year with local or county health departments, as well as reconcile the data with reports previously sent to CDC throughout the year these data are compiled in final form in this summary. Notifiable disease reports (published in the annual MMWR Summary of Notifiable Diseases only after the approval of each state epidemiologist) are the authoritative and archival counts of cases. MMWR Surveillance Summaries or other surveillance reports produced by CDC programs, which are useful for detailed epidemiologic analyses, may not agree exactly with numbers reported in the annual Summary of Notifiable Diseases due to differences in the timing of reports, the source of the data, and the use of different case definitions.

Data in this summary are derived primarily from reports transmitted to the Division of Surveillance and Epidemiology, Epidemiology Program Office, CDC, by the 50 state, two city, and five territorial health departments through the National Electronic Telecommunications System for Surveillance (NETSS). Final data for other diseases are from surveillance program records of the CDC programs listed below requests for further information regarding these data should be directed to the source specified. National Center for Health Statistics

Office of Vital and Health Statistics Systems (deaths from selected notifiable diseases) National Center for Infectious Diseases

Division of Bacterial and Mycotic Diseases (toxic-shock syndrome and laboratory data on botulism, Escherichia coli O157:H7, Salmonella, and Shigella)

Division of HIV/AIDS (human immunodeficiency virus/acquired immunodeficiency syndrome)

Division of Vector-Borne Infectious Diseases (laboratory data on arboviral encephalitis)

Division of Viral and Rickettsial Diseases (animal rabies) National Center for Prevention Services

Division of Sexually Transmitted Diseases and HIV Prevention (gonorrhea, syphilis, chancroid, granuloma inguinale, and lymphogranuloma venereum)

Division of Tuberculosis Elimination (tuberculosis) National Immunization Program

Epidemiology and Surveillance Division (poliomyelitis)

Disease totals for the United States, unless otherwise stated, do not include data for American Samoa, Guam, Puerto Rico, the Virgin Islands, and the Commonwealth of the Northern Mariana Islands (CNMI).

Data on notifiable diseases before 1960 (before CDC assumed responsibility for collection and publication of these data) are obtained from publications of the National Office of Vital Statistics.

Population estimates for states are based on the July 1, 1994, post-censal estimates made by the U.S. Department of Commerce, Bureau of the Census, Population Division, Population Estimates Branch, Press Release CB94-204.

Population estimates for territories are from the 1990 census, U.S. Department of Commerce, Bureau of the Census, Press Releases CB91-142, 242, 243, 263, and 276.

Rates in the 1994 Summary of Notifiable Diseases were based on data for the U.S. total resident population. However, population data from states in which diseases were not notifiable or disease data were not available were excluded from rate calculations.

The data reported in this summary are useful for analyzing disease trends and determining relative disease burdens. However, these data must be interpreted in light of reporting practices. Some diseases that cause severe clinical illness (e.g., plague or rabies), if diagnosed by a clinician, are most likely reported accurately. However, persons who have diseases that are clinically mild and infrequently associated with serious consequences (e.g., salmonellosis) may not even seek medical care from a health-care provider even if these diseases are diagnosed, they are less likely to be reported. The degree of completeness of reporting also is influenced by the diagnostic facilities available the control measures in effect the public awareness of a specific disease and the interests, resources, and priorities of state and local officials responsible for disease control and public health surveillance. Finally, factors such as changes in the case definitions for public health surveillance, the introduction of new diagnostic tests, or the discovery of new disease entities may cause changes in disease reporting that are independent of the true incidence of disease.

Public health surveillance data are published for selected racial and ethnic population groups because these variables may be risk markers for certain notifiable diseases. Risk markers can identify potential risk factors for investigation in future studies. Data on race and ethnicity also can be useful for identifying groups to target for prevention efforts. Year 2000 objectives for racial and ethnic groups (standardized to the 1940 U.S. population) have been established for several of the notifiable diseases.

HIGHLIGHTS FOR SELECTED INFECTIOUS DISEASES NOT NATIONALLY NOTIFIABLE DURING 1994 Chlamydia

Chlamydia trachomatis infections are common among adolescents and young adults. An estimated 10% of sexually active adolescent females are infected with chlamydia. In 1994, 47 states reported 448,984 chlamydia infections. From 1984 through 1994, reported cases increased from 3.2 cases per 100,000 to 188.4. This trend may reflect increasing recognition and interest among health-care providers and public health officials. Coccidioidomycosis

An outbreak of coccidioidomycosis occurred in Ventura County, California, following the 1994 Northridge earthquake. From January 24 through March 15, 1994, 203 infected persons were identified, compared with 52 cases that were reported through passive surveillance in the county in 1993. The National Center for Infectious Diseases (NCID/CDC) Emerging Infections Program (EIP), in collaboration with the State of California Department of Health Services, is conducting active surveillance for coccidioidomycosis in 10 California counties. Cryptosporidiosis

In 1994, waterborne outbreaks of cryptosporidiosis were investigated in Las Vegas, Nevada, Walla Walla, Washington, and Lake Nummy, New Jersey, focusing national attention on the potential for waterborne transmission of Cryptosporidium. In September 1994, a national workshop on waterborne cryptosporidiosis was held at CDC, which resulted in guidelines and recommendations for prevention of cryptosporidiosis in severely immunosuppressed persons, appropriate public health responses to the problem, and epidemiologic and laboratory-based surveillance and research. Hantavirus

Hantavirus Pulmonary Syndrome (HPS) is a recently recognized hantaviral illness caused by Sin Nombre virus and the newly identified Black Creek Canal and Bayou viruses. The identified rodent reservoirs for these viruses -- Peromyscus maniculatus and leucopus (deer and white-footed mice) for Sin Nombre virus and its variants and Sigmodon hispidus (cotton rat) for Black Creek Canal virus -- extend across the continental United States. As of July 20, 1995, national surveillance for HPS has identified 113 confirmed case-patients in 23 states (case fatality rate: 52%) 31 of these cases occurred in 1994. Invasive group A streptococcal infections

Prospective and retrospective active surveillance data for invasive group A streptococcal (GAS) infections were analyzed and several risk groups identified, including: persons who have human immunodeficiency virus (HIV) infections and acquired immunodeficiency syndrome (AIDS), injecting-drug users, persons who have cancer, diabetes mellitus, heart disease or chronic lung disease, alcohol abusers, and children who have varicella. Although different GAS strains have been identified from individual case patients, M-type 1 strains predominated. Drug-resistant Streptococcus pneumoniae

In the United States, the prevalence of drug-resistant Streptococcus pneumoniae (DRSP) has increased since 1987 from 3.6% to 14.5%, according to limited voluntary reporting by 12 sentinel hospitals. Limited 1994 surveillance data from these hospitals indicate the proportion of invasive disease (bacteremia and meningitis) caused by penicillin-resistant pneumococci ranges from 3% to 30% and shows widespread geographic variation. Information regarding community-specific DRSP prevalence is needed to assist clinicians in choosing optimal empiric therapy. To enhance efficient and timely reporting, CDC is currently piloting an electronic laboratory-based surveillance system. Vancomycin-resistant enterococci

In 1994, the percentage of nosocomial enterococci reported as resistant to vancomycin increased from 11.5% in 1993 to 13.6% among Intensive Care Unit (ICU) isolates and from 4.9% to 9.1% among noncritical care unit isolates. The increase was more dramatic among isolates from noncritical care units, suggesting that vancomycin-resistant enterococci are spreading from their focus in ICUs. Pneumonia of unknown etiology

From 1979 to 1994, the overall crude death rate for pneumonia and influenza increased 59%, from 20.0 to 31.8 deaths per 100,000. Through 1992 (the most recent year for which complete data are available), pneumonia of unspecified etiology (ICD-9 code 486) accounted for most of the overall increase -- the age-adjusted death rates in this diagnostic category increased 74%. Since the 1970s, several previously unrecognized infectious agents have been identified as causes of lower respiratory infections, including Legionella pneumophila, Chlamydia pneumoniae, and Sin Nombre virus. Recent prospective studies of community-acquired pneumonia indicate that an etiology cannot be identified in up to 50% of cases. Transfusion-associated infectious diseases

An Institute of Medicine committee recently released the report, "HIV and the Blood Supply: An Analysis of Crisis Decisionmaking," calling for the establishment of a surveillance system at CDC to detect, monitor, and warn of adverse effects in the recipients of blood and blood products. CDC is reviewing existing surveillance systems to highlight and address areas that need improvement. Diseases that are being examined to evaluate the level of risk associated with transfusion include HIV/AIDS, Chagas disease, babesiosis, Creutzfeld-Jacob disease, the hepatitis viruses, malaria, and transfusion-associated sepsis. INTERNATIONAL NOTES Dengue

Although dengue fever is not endemic in the United States, its incidence is increasing in most tropical areas throughout the world. In 1994, CDC processed serum samples from 91 residents of 27 states and the District of Columbia who had travelled to countries where dengue is endemic. Among these 91 persons, 37 (40.7%) cases of dengue were diagnosed serologically or virologically. Plague

During September and October 1994, outbreaks of bubonic and pneumonic plague were reported from sites east and north of Bombay, India, respectively. A lack of reliable epidemiologic information contributed to the ensuing international health emergency. Evidence revealed that plague did not occur in international travelers or spread beyond the original foci. Bibliography General Benenson AS. Control of communicable diseases in man. 15th ed. Washington, DC: American Public Health Association, 1990. CDC. Manual of procedures for the reporting of nationally notifiable diseases to CDC. Atlanta: US Department of Health and Human Services, Public Health Service, CDC, 1995. CDC. Case definitions for public health surveillance. MMWR 199039(No. RR-13). CDC. Mandatory reporting of infectious diseases by clinicians, and mandatory reporting of occupational diseases by clinicians. MMWR 199039(No. RR-9). CDC. National electronic telecommunications system for surveillance -- United States, 1990-1991. MMWR 199140:502. CDC. Update: graphic method for presentation of notifiable disease data -- United States, 1991. MMWR 199140:124-5. CDC. Use of race and ethnicity in public health surveillance. MMWR 199342(No. RR-10). CDC. Update: changes in notifiable disease surveillance data -- United States, 1992-1993. MMWR 42(42):824-6. CDC. Sexually transmitted disease surveillance, 1993. Atlanta: US Department of Health and Human Services, Public Health Service, 1994. Stroup DF, Wharton M, Kafadar K, Dean AG. An evaluation of a method for detecting aberrations in public health surveillance data. Am J Epidemiol 1993137(3):373-80. Teutsch SM, Churchill RE, eds. Principles and practice of public health surveillance. New York: Oxford University Press, 1994. Thacker SB, Choi K, Brachman PS. The surveillance of infectious diseases. JAMA 1983 249:1181-5.

AIDS CDC. AIDS among racial/ethnic minorities -- United States, 1993. MMWR 199443(35):644-7, 653-5. CDC. Heterosexually acquired AIDS -- United States, 1993. MMWR 199443(9):155-60. CDC. HIV/AIDS surveillance report. Atlanta: US Department of Health and Human Services, 19946(2):1-39. CDC. Recommendations of the U.S. Public Health Service Task Force on the use of zidovudine to reduce perinatal transmission of human immunodeficiency virus. MMWR 199443(No. RR-11):1-20. CDC. Update: acquired immunodeficiency syndrome -- United States, 1994. MMWR 199544(4):64-7. CDC. Update: trends in AIDS diagnosis and reporting under the expanded surveillance definition for adolescents and adults -- United States, 1993. MMWR 199443(45):826-31. CDC. Update: AIDS among women -- United States, 1994. MMWR 199544(5):81-4.

Amebiasis Katzenstein DA. Drug treatment of amebiasis. In: Peterson PK, Verhoef J, eds. Antimicrobial agents annual 2. New York: Elsevier Science Publishers, 1987:247-52. McAuley JB, Herwaldt BL, Stokes SL, et al. Diloxanide furoate for treating asymptomatic Entamoeba histolytica cyst passers: 14 years' experience in the United States. Clin Infect Dis 199215:464-8. Ravdin JI, ed. Amebiasis: human infection by Entamoeba histolytica. New York: John Wiley and Sons, Inc., 1988. Ravdin JI. Amebiasis. Clin Infect Dis 199520:1453-66.

Anthrax Brachman PS. Anthrax. In: Hoeprich PD, Jordan MC, Roland AR, eds. Infectious diseases. 5th ed. Philadelphia: JB Lippincott Co., 1994:1003-8. Meselson M, Guillemin J, Hugh-Jones M, et al. The Sverdlovsk anthrax outbreak of 1979. Science 1994 Nov266(5188):1202-8.

Arboviral Infections ( California serogroup viruses, Eastern equine encephalitis, St. Louis encephalitis, and Western equine encephalitis ) Monath TP, ed. The arboviruses: epidemiology and ecology. Boca Raton, FL: CRC Press, 1983. Tsai TF. Arboviral infections in the United States. Infect Dis Clin North Am 19915:73-102. Tsai TF. Arboviruses and related zoonotic viruses. In: Oski FJ, ed. Principles and practice of pediatrics. 2nd ed. Philadelphia: JB Lippincott Co., 1994:1266-88.

Aseptic Meningitis CDC. Aseptic meningitis -- New York State and United States, weeks 1-36, 1991. MMWR 1991 40(45):773-5. Moore M. Enteroviral disease in the United States, 1970-1979. J Infect Dis 1982146:103-8. Morens DM, Zweighaft RM, Bryan JA. Nonpolio enterovirus disease in the United States, 1971-1975. Int J Epidemiol 19798:49-54. Wilfert CM, Lehrman SN, Katz SL. Enteroviruses and meningitis. Pediatr Infect Dis J 19832:333-41.

Botulism St. Louis ME, Peck SHS, Bowering D, et al. Botulism from chopped garlic: delayed recognition of a major outbreak. Ann Intern Med 1988108:363-8. Webber JT, Hatheway CL, St. Louis ME. Botulism. In: Hoeprich PD, Jordan MC, Ronald AR. Infectious diseases: a treatise of infectious processes. 5th ed. Philadelphia: JB Lippincott Co., 1994:1185-94. Woodruff BA, Griffin PM, McCroskey LM, et al. Clinical and laboratory comparison of botulism from toxin types A, B, and E in the United States 1975-1988. J Infect Dis 1992166:1281-6.

Brucellosis CDC. Brucellosis outbreak at a pork processing plant -- North Carolina, 1992. MMWR 1994 43(7):113-6. Chomel BB, DeBess EE, Mangiamele DM, et al. Changing trends in the epidemiology of human brucellosis in California from 1973 to 1992: a shift toward foodborne transmission. J Infect Dis 1994 Nov170(5):1216-23. Kaufmann AF, Fox MD, Boyce JM, et al. Airborne spread of brucellosis. Ann NY Acad Sci 1980353:105-14. Kaufman AF, Wenger JD. Brucellosis. In: Last JM, Wallace RB, eds. Public health and preventive medicine. Norwalk, CT: Appleton and Lange, 1992:263-4. Staskiewicz J, Lewis CM, Colville J, Zervos M, Band J. Outbreak of Brucella melitensis among microbiology laboratory workers in a community hospital. J Clin Microbiol 199129:287-90.

Chancroid CDC. Chancroid in the United States, 1981-1990: evidence for underreporting of cases. MMWR 199241(No. SS-3):57-61. Schmid GP. Chancroid. In: Evans AS, Brachman PS, eds. Bacterial infections of humans: epidemiology and control. 2nd ed. New York: Plenum Medical Book Company, 1991173-8. Schmid GP. Chancroid and Granuloma inguinale. In: Kelley WB, ed. Textbook of internal medicine. 2nd ed. Philadelphia: JB Lippincott Co., 1991:1412-4.

Cholera Blake PA. Epidemiology of cholera in the Americas. Gastroenterol Clin North Am 199322:639-60. Swerdlow DL, Ries AA. Vibrio cholerae non-01 -- the eighth pandemic? Lancet 1993342:382-3. Wachsmuth IK, Blake PA, Olsvik O, eds. Vibrio cholerae and cholera: molecular to global perspectives. Washington, DC: American Society for Microbiology, 1994. World Health Organization. Guidelines for cholera control. Geneva: World Health Organization, 1993.

Congenital Syphilis CDC. Surveillance for geographic and secular trends in congenital syphilis -- United States, 1983-1991. MMWR 199342(No. SS-6):59-71. CDC. Evaluation of congenital syphilis surveillance system -- New Jersey, 1993. MMWR 1995 44:225-7. Zenker PN. Syphilis. In: Schdlower M, Shafer M-A, eds. Adolescent medicine: state of the art reviews. Philadelphia: Hanley and Belfus, Inc., 19901:511-29. Zenker PN, Berman SM. Congenital syphilis: trends and recommendations for evaluation and management. Pediatr Infect Dis J 199110(7):516-22.

Diphtheria CDC. Diphtheria acquired by U.S. citizens in the Russian Federation and Ukraine -- 1994. MMWR 199544:237,243-4. CDC. Diphtheria epidemic -- New Independent States of the Former Soviet Union, 1990-1994. MMWR 199544:177-81. Chen RT, Broome CV, Weinstein RA, Weaver R, Tsai TF. Diphtheria in the United States, 1971-81. Am J Public Health 198575:1393-7. Farizo KM, Strebel PM, Chen RT, Kimbler A, Cleary TJ, Cochi SL. Fatal respiratory disease due to Corynebacterium diphtheriae: case report and review of guidelines for management, investigation, and control. Clin Infect Dis 199316:59-68.

Escherichia coli O157:H7 Bell BP, Goldoft M, Griffin M,et al. A multistate outbreak of Escherichia coli O157:H7 -- associated bloody diarrhea and hemolytic uremic syndrome from hamburgers. The Washington experience. JAMA 1994272:1349-53. Besser RE, Lett SM, Webber JT,et al. An outbreak of diarrhea and hemolytic uremic syndrome from Escherichia coli O157:H7 in fresh-pressed apple cider. JAMA 1993269:2217-20. Griffin PM. Escherichia coli O157:H7 and other enterohemorrhagic Escherichia coli. In: Blaser MJ, Smith PD, Ravdin JI, Greenberg HB, Guerrant RL, eds. Infections of the gastrointestinal tract. New York: Raven Press, 1995:739-61. Griffin PM, Tauxe RV. The epidemiology of infections caused by Escherichia coli O157:H7, other enterohemorrhagic E. Coli, and the associated hemolytic uremic syndrome. Epidemiol Rev 199113:60-98.

Gonorrhea CDC. Special focus: surveillance for sexually transmitted diseases. MMWR 199342(No. SS-3):1-11, 29-39. CDC. Decreased susceptibility of Neisseria gonorrhoeae to fluoroquinolones -- Ohio and Hawaii, 1992-1994. MMWR 199443:325-7. CDC. Increasing incidence of gonorrhea -- Minnesota, 1994. MMWR 199544:282-6.

Granuloma inguinale Schmid GP. Chancroid and Granuloma inguinale. In: Kelley WB, ed. Textbook of internal medicine. 2nd ed. Philadelphia: JB Lippincott Co., 1989:1555-6.

Haemophilus influenzae, invasive CDC. Recommendations for use of Haemophilus b conjugate vaccines and a combined diphtheria, tetanus, pertussis, and Haemophilus b vaccine: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR 199342(No. RR-13). Adams WG, Deaver KA, Cochi SL, et al. Decline of childhood Haemophilus influenzae type b (Hib) disease in the Hib vaccine era. JAMA 1993269:221-6. CDC. Progress toward elimination of Haemophilus influenzae type b disease among infants and children -- United States, 1987-1993. MMWR 199443(8):144-8.

Hansen disease (Leprosy) Mastro TD, Redd SC, Breiman RF. Imported leprosy in the United States, 1978 through 1988 an epidemic without secondary transmission. Am J Public Health 1992 Aug82(8):1127-30. Noordeen SK. Epidemiology and control of leprosy -- a review of progress over the last 30 years. Trans R Soc Trop Med Hyg 1993 Sep-Oct87(5):515-7. Smith PG. Recent trends in the epidemiology of tuberculosis and leprosy. Trop Geogr Med 1991 Jul43(3):S22-9.

Hepatitis Alter MJ, Mares A, Hadler SC, Maynard JE. The effect of underreporting on the apparent incidence and epidemiology of acute viral hepatitis. Am J Epidemiol 1987125:133-9. CDC. Hepatitis surveillance report no. 55. Atlanta: US Department of Health and Human Services, Public Health Service, 1994.

Hepatitis A Shapiro CN, Coleman PJ, McQuillan GM, et al. Epidemiology of hepatitis A: seroepidemiology and risk groups in the U.S.A. Vaccine 199210(suppl 1):S59-62.

Hepatitis B Margolis HS, Alter MJ, Hadler SC. Hepatitis B: evolving epidemiology and implications for control. Semin Liver Dis 199111:84-92.

Hepatitis, C/Non-A, non-B Alter MJ, Hadler SC, Judson FN, et al. Risk factors for acute non-A, non-B hepatitis in the United States and association with hepatitis C virus infection. JAMA 1990264:2231-5. Alter MJ, Margolis HS, Krawczynski K, et al. The natural history of community-acquired hepatitis C in the United States. N Engl J Med 1992327:1899-905.

Legionellosis CDC. Legionnaires' disease associated with cooling towers -- Massachusetts, Michigan, and Rhode Island, 1993. MMWR 199443(27):491-9. Edelstein PH. Legionnaires' disease. Clin Infect Dis 199316:741-9. Hoge CW, Breiman RF. Advances in the epidemiology and control of Legionella infections. Epidemiol Rev 199113:329-40. Marston BJ, Lipman HB, Breiman RF. Surveillance for Legionnaires' disease: risk factors for morbidity and mortality. Arch Intern Med 1994154:2417-22. World Health Organization. Epidemiology, prevention and control of legionellosis: memorandum from a WHO meeting. Bull World Health Organ 199068:155-64.

Leptospirosis Anderson DC, Folland DS, Fox MD, Patton CM, Kaufmann AF. Leptospirosis: a common-source outbreak due to leptospires of the Grippotyphosa serogroup. Am J Epidemiol 1978107:538-44. Faine S. Guidelines for the control of leptospirosis. Geneva, Switzerland: World Health Organization, 1982. Takafuji ET, Kirkpatrick JW, Miller RN, et al. An efficacy trial of doxycycline chemoprophylaxis against leptospirosis. N Engl J Med 1984310:497-500.

Lyme disease CDC. Lyme disease surveillance -- United States, 1993. MMWR 199443(31):564-5,571-2. Kalish R. Lyme disease. Rheum Dis Clin North Am 199319:399-426. Steere AC. Lyme disease. N Engl J Med 1989321:586-96.

Lymphogranuloma venereum Perine PL, Osoba AO. Lymphogranuloma venereum. In: Holmes KK, Mardh PA, Sparling PF, et al. eds. Sexually transmitted disease. New York: McGraw-Hill, 1990:195-204.

Malaria CDC. Health information for international travel 1994. Atlanta: CDC, 1994: US Department of Health and Human Services, Public Health Service, CDC. DHHS publication no. (CDC) 94-8280. CDC. Local transmission of Plasmodium vivax malaria -- Houston, Texas, 1994, MMWR 1994 44(15):295. Lobel HO, Miani M, Eng T, Bernard KW, Hightower AW, Campbell CC. Long-term malaria prophylaxis with weekly mefloquine. Lancet 1993341:848-51. Zucker JR, Campbell CC. Malaria: principles of prevention and treatment. Infect Dis Clin North Am 19937:547-67.

Measles CDC. Measles prevention: recommendations of the Immunization Practices Advisory Committee. MMWR 198938(No. SS-9):1-18. CDC. Measles -- United States, first 26 weeks, 1993. MMWR 199342:813-6. CDC. Absence of reported measles -- United States, November 1993. MMWR 199342:925-6.

Meningococcal disease CDC. Meningococcal vaccines. MMWR 198534(18):255-9. CDC. Laboratory-based surveillance for meningococcal disease in selected areas -- United States, 1989-1991. MMWR 199342(No. SS-2):21-30. Jackson LA, Schuchat A, Reeves MW, Wenger JD. Serogroup C meningococcal outbreaks in the United States: an emerging threat. JAMA 1995273(5):383-9. Schwartz B, Moore PS, Broome CV. Global epidemiology of meningococcal disease. Clin Microbiol Rev 19892(suppl):S118-24.

Mumps Briss PA, Fehrs LJ, Parker RA, et al. Sustained transmission of mumps in a highly vaccinated population: assessment of primary vaccine failure and waning vaccine-induced immunity. J Infect Dis 1994169:77-82. CDC. Mumps prevention. MMWR 198938(22):388-92,397-400. CDC. Mumps -- United States, 1985-1988. MMWR 198938(7):101-5. CDC. Mumps Surveillance -- United States, 1988-1993. MMWR 199544(No. SS-3):1-14. Hersch BS, Fine PEM, Kent WK, et al. Mumps outbreak in a highly vaccinated population. J Pediatr 1991119:187-93.

Pertussis CDC. Pertussis surveillance -- United States, 1989-1991. MMWR 199241(No. SS-8):11-19. Cherry JD, Brunell PA, Golden GS, et al. Report of the Task Force on Pertussis and Pertussis Immunization, 1988. Pediatrics 198881(suppl):S939-84. Davis SF, Sutter RW, Strebel PM, et al. Concurrent outbreaks of pertussis and Mycoplasma pneumoniae infection: clinical and epidemiological characteristics of illnesses manifested by cough. Clin Infect Dis 199520(3):621-8.

Plague Craven RB, Barnes AM. Plague and tularemia. Infect Dis Clin North Am 19915:165-75. Poland JD. Plague. In: Hoeprich PD, ed. Infectious Diseases. 2nd ed. New York: Harper and Row, 1989:1511296-306.

Poliomyelitis CDC. Lack of evidence for wild poliovirus circulation -- United States, 1993. MMWR 199343:957-9. Prevots DR, Sutter RW, Strebel PM, Weibel RE, Cochi SL. Completeness of reporting for paralytic poliomyelitis, United States, 1980 through 1991. Archives of Pediatrics and Adolescent Medicine 1994148:479-85. Strebel PM, Sutter RW, Cochi SL, et al. Epidemiology of poliomyelitis in the United States: one decade after the last reported case of indigenous wild virus-associated disease. Clin Infect Dis 199214:568-79.

Psittacosis Anonymous. Compendium of chlamydiosis (psitticosis) control, 1994. National Association of State Public Health Veterinarians, Inc. JAVMA 1993203:1673-80. Barnes RC. Laboratory diagnosis of human chlamydial infections. Clin Microbiol Rev 1989 2:119-36. Kuritsky JN, Schmid GP, Potter ME, Anderson DC, Kaufmann AF. Psittacosis: a diagnostic challenge. J Occup Med 198426:731-3. Wong KH, Skelton SK, Daugharty H. Utility of complement fixation and microimmunofluorescence assays for detecting serologic responses in patients with clinically diagnosed psittacosis. J Clin Microbiol 199432:2417-21.

Rabies CDC. Rabies prevention -- United States, 1991: recommendations of the Immunization Practices Advisory Committee (ACIP). MMWR 199140(No. RR-3). Baer G. Natural history of rabies. 2nd ed. Boca Raton, FL: CRC press, 1991. CDC. Compendium of animal rabies control, 1995. MMWR 199544(No. RR-2). Krebs JW, Strine TW, Smith JS, Rupprecht CE, Childs JE. Rabies surveillance in the United States during 1993. JAVMA 1993205:1695-1709.

Rheumatic fever Dajani AS. Prevention of rheumatic fever: a statement for health professionals by the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease of the Council on Cardiovascular Disease in the Young, the American Heart Association. Pediatr Infect Dis J 19898:263-6. Kaplan EL, Johnson DR, Cleary PP. Group A streptococcal serotypes isolated from patients and sibling contacts during the resurgence of rheumatic fever in the United States in the mid-1980's. J Infect Dis 19891259:101-3. Veasy GL, Wiedmeier SE, Orsmond GS, et al. Resurgence of acute rheumatic fever in the intermountain area in the United States. N Engl J Med 1987316:421-8.

Rocky Mountain spotted fever (RMSF) Burgdorfer W, Anacker FL, eds. Rickettsiae and rickettsial diseases. New York: Academic Press, 1981. Dalton MJ, Clarke MJ, Holman RC, et al. National surveillance for Rocky Mountain spotted fever, 1981-1992, epidemiologic summary and evaluation of risk factors for fatal outcome. Am J Trop Med Hyg 199552(5):405-13. McDade JE, Fishbein DB. Rickettsiaceae: the rickettsiae. In: Laboratory diagnosis of infectious diseases: principles and practice. Vol II. Viral, rickettsial, and chlamydial diseases. New York: Springer-Verlag, 1988:864-89.

Rubella CDC. Rubella prevention: recommendations of the Immunization Practices Advisory Committee (ACIP). MMWR 199039(No. RR-15). CDC. Increase in rubella and congenital rubella syndrome -- United States, 1988-1990. MMWR 199140(6):93-9. CDC. Outbreaks of rubella among the Amish -- United States, 1991. MMWR 199140(16):264. CDC. Congenital rubella syndrome among the Amish -- Pennsylvania, 1991-1992. MMWR 1992 41(26):468-9,475-6. CDC. Rubella and congenital rubella syndrome -- United States, January 1, 1991-May 7, 1994. MMWR 199443(21):391,397-401. Lindegren ML, Fehrs LJ, Hadler SC, Hinman AR. Update: rubella and congenital rubella syndrome, 1980-1990. Epidemiol Rev 199113:341-8.

Salmonellosis Lee LA, Puhr ND, Maloney EK, Bean NH, Tauxe RV. Increase in antimicrobial-resistant Salmonella infections in the United States, 1989-1990. J Infect Dis 1994170:128-34. Mishu B, Griffin PM, Tauxe RV, Cameron DN, Hutcheson RH, Schaffner W. Salmonella enteritidis gastroenteritis transmitted by intact chicken eggs. Ann Intern Med 1991115:190-4. Mishu B, Koehler J, Lee LA, et al. Outbreaks of Salmonella enteritidis infections in the United States, 1985-1991. J Infect Dis 1994169:547-52. St. Louis ME, Morse DL, Potter ME, et al. The emergence of grade A eggs as a major source of Salmonella enteritidis infections: new implications for the control of salmonellosis. JAMA 1988259:2103-7. Tauxe RV. Salmonella: a postmodern pathogen. Journal of Food Protection 199154:563-8.

Shigellosis Lee LA, Shapiro CN, Hargrett-Bean N, Tauxe RV. Hyperendemic shigellosis in the United States: a review of surveillance data for 1967-1988. J Infect Dis 1991164:894-900. Parsonnet J, Greene KD, Gerber AR, et al. Shigella dysenteriae type 1 infections in U.S. travellers to Mexico. Lancet 1989:543-5. Ries AA, Wells JG, Olivola D, et al. Epidemic Shigella dysenteriae type 1 in Burundi: panresistance and implications for prevention. J Infect Dis 1994169:1035-41.

Syphilis Aral SO, Wasserheit JN, Green SB, Judson FN, Sparling FP. The NIAID/NIH working group on integrated behavioral research for prevention and control of STDs. Part III: Issues in evaluating behavioral interventions. Sex Transm Dis 199017:208-10. CDC. Primary and secondary syphilis -- United States, 1981-1990. MMWR 199140(19):314-5, 321-3. CDC. Regional and temporal trends in the surveillance of syphilis, United States, 1986-1990. MMWR 199140(No. SS-3):29-33. CDC. Special focus: surveillance for sexually transmitted diseases. MMWR 199342(No. SS-3):13-9. Nakashima AK, Rolfs RT, Flock ML, Kilmarx P, Greenspan GR. Epidemiology of syphilis in the United States, 1941-1993. Sex Transm Dis 1995 (in press).

Tetanus CDC. Surveillance of tetanus -- United States, 1989-1990. MMWR 199241(No. SS-8):1-9. Gergen PJ, McQuillan GM, Kiely M, et al. A population-based survey of immunity to tetanus in the United States. N Engl J Med 1995332:761-6. Sutter RW, Cochi SL, Brink EW, Sirotkin BI. Assessment of vital statistics and surveillance data for monitoring tetanus mortality, United States, 1979-1984. Am J Epidemiol 1990131:132-42.

Toxic-shock syndrome CDC. Reduced incidence of menstrual toxic shock syndrome -- United States, 1980-1990. MMWR 199039(25):421-3. Gaventa S, Reingold AL, Hightower AW, et al. Active surveillance for toxic shock syndrome in the United States, 1986. Rev Infect Dis 1989(suppl):S28-34. Schuchat A, Broome CV. Toxic shock syndrome and tampons. Epidemiol Rev 199113:99-112.

Trichinosis Bailey TM, Schantz PM. Trends in the incidence and transmission patterns of human trichinosis in the United States, 1982-1986. Rev Infect Dis 199012:5-11. Campbell WC, ed. Trichinella and trichinosis. New York: Plenum Press, 1983. CDC. Trichinosis surveillance -- United States, 1987-1990. MMWR 199140(No. SS-3):35-42. McAuley JB, Michelson MK, Hightower AW, Engeran S, Wintermeyer LA, Schantz PM. A trichinosis outbreak among Southeast Asian refugees. Am J Epidemiol 1992135:1404-10.

Tuberculosis American Thoracic Society/CDC. Treatment of tuberculosis and tuberculosis infection in adults and children. Am J Respir Crit Care Med 1994149:1359-74. CDC. Recommendations for counting reported tuberculosis cases. Atlanta: US Department of Health and Human Services, Public Health Service, 1977. CDC. Tuberculosis morbidity -- United States, 1994. MMWR 199544:(20)387-95.

Tularemia Evans ME, Gregory DW, Schaffner W, McGee ZA. Tularemia: a 30 year experience with 88 cases. Medicine 198564:251-69. Schmid GP, Kornblatt AN, Connors CA, et al. Clinically mild tularemia associated with tick-borne Francisella tularensis. J Infect Dis 1983148:63-7. Taylor JP, Istre GR, McChesny TC, Satalowich FT, Parker RE, McFarland LM. Epidemiologic characteristics of human tularemia in the southwest-central states, 1981-1987. Am J Epidemiol 1991133:1032-8.

Typhoid fever CDC. Typhoid immunization: recommendations of the Advisory Committee on Immunization Practices. MMWR 199443(No. RR-14). Ryan CA, Hargrett-Bean NT, Blake PA. Salmonella typhi infections in the United States, 1975-1984: increasing role of foreign travel. Rev Infect Dis 198911(1):1-8. Woodruff BA, Pavia AT, Blake PA. A new look at typhoid vaccination: information for the practicing physician. JAMA 1991265(6):756-9.

Varicella CDC. Varicella outbreak in a women's prison -- Kentucky. MMWR 198938(37):635-6,641-2. Gershon AA, LaRussa P, Hardy I, Steinberg S, Silverstein S. Varicella vaccine: the American experience. J Infect Dis 1992166(suppl 1):S63-8. Lieu TA, Cochi SL, Black SB, et al. Cost-effectiveness of a routine varicella vaccination program for U.S. children. JAMA 1994271:375-81. Varicella Vaccine. Medical Letter 199537(950):55-7.

Summaries of Notifiable Diseases in the United States

Table_1 NOTIFIABLE DISEASES -- Summary of reported cases, by

month, United States, 1994 Table_2A NOTIFIABLE DISEASES -- Reported cases, by geographic

division and area, United States, 1994 Table_2B NOTIFIABLE DISEASES -- Reported cases, by geographic

division and area, United States, 1994 (continued) Table_2C NOTIFIABLE DISEASES -- Reported cases, by geographic

division and area, United States, 1994 (continued) Table_2D NOTIFIABLE DISEASES -- Reported cases, by geographic

division and area, United States, 1994 (continued) Table_2E NOTIFIABLE DISEASES -- Reported cases, by geographic

division and area, United States, 1994 (continued) Table_2F NOTIFIABLE DISEASES -- Reported cases, by geographic

division and area, United States, 1994 (continued) Table_3 NOTIFIABLE DISEASES -- Summary of reported cases, by

age group, United States, 1994 Table_4 NOTIFIABLE DISEASES -- Summary of reported cases, by

age group, United States, 1994 Table_5 NOTIFIABLE DISEASES -- Summary of reported cases, by

race, United States, 1994 Table_6 NOTIFIABLE DISEASES -- Summary of reported cases, by

ethnicity, United States, 1994

Graphs and Maps for Selected Notifiable Diseases in the United States

Figure_1 ACQUIRED IMMUNODEFICIENCY SYNDROME (AIDS) -- reported

cases, by quarter, and definition category, United States, 1984-1994 Figure_2 ACQUIRED IMMUNODEFICIENCY SYNDROME (AIDS) -- reported

cases, per 100,000 population, United States and Puerto Rico, 1994 Figure_3 ACQUIRED IMMUNODEFICIENCY SYNDROME (AIDS) -- reported

pediatric cases, United States and Puerto Rico, 1994 Figure_4 ARBOVIRAL INFECTIONS (of the central nervous system) --

reported laboratory-confirmed cases caused by California serogroup viruses, by month of onset, United States, 1985-1994 Figure_5 ARBOVIRAL INFECTIONS (of the central nervous system) --

reported laboratory-confirmed cases caused by eastern equine encephalitis virus, by month of onset, United States, 1985-1994 Figure_6 ARBOVIRAL INFECTIONS (of the central nervous system) --

reported laboratory-confirmed cases caused by St. Louis encephalitis virus, by month of onset, United States, 1985-1994 Figure_7 ARBOVIRAL INFECTIONS (of the central nervous system) --

reported laboratory-confirmed cases caused by western equine encephalitis virus, by month of onset, United States, 1985-1994 Figure_8A BOTULISM (foodborne) -- by year, United States, 1975-1994 Figure_8B BOTULISM (foodborne) -- by year, United States, 1975-1994

(continued) Figure_9 BRUCELLOSIS -- by year, United States, 1965-1994 Figure_10 CHOLERA -- reported cases, United States and territories,

1994 Figure_11 DIPTHERIA -- by year, United States, 1965-1994 Figure_12 ESCHERICHIA COLI O157:H7 -- reported cases, United States

and territories, 1994 Figure_13 ESCHERICHIA COLI O157:H7 -- reported isolates, United

States, 1994 Figure_14 GONORRHEA -- by sex, United States, 1981-1994 Figure_15 GONORRHEA -- by race, United States, 1981-1994 Figure_16 GONORRHEA -- reported cases, per 100,000 population,

United States, 1994 Figure_17 HAEMOPHILUS INFLUENZAE, INVASIVE -- by age group, United

States, 1994 Figure_18 HANSEN DISEASE (leprosy) -- by year, United States,

1965-1994 Figure_19 HEPATITIS -- by year, United States, 1965-1994 Figure_20 HEPATITIS A -- reported cases, per 100,000 population,

United States and territories, 1994 Figure_21 HEPATITIS B -- reported cases, per 100,000 population,

United States and territories, 1994 Figure_22 LEGIONELLOSIS -- by year, United States, 1978-1994 Figure_23 LYME DISEASE -- reported cases, per 100,000 population,

United States and territories, 1994 Figure_24 MALARIA -- by year, United States, 1965-1994 Figure_25 MEASLES (rubeola) -- by year, United States, 1960-1994 Figure_26 MENINGOCOCCAL DISEASE -- by year, United States, 1965-1994 Figure_27 MUMPS -- by year, United States, 1968-1994 Figure_28 PERTUSSIS (whooping cough) -- by year, United States,

1965-1994 Figure_29 PERTUSSIS (whooping cough) -- by age group, United States,

1994 Figure_30 PLAGUE -- among humans, by year, United States, 1965-1994 Figure_31 POLIOMYELETIS (paralytic) -- by year, United States,

1965-1994 Figure_32 PSITTACOSIS -- by year, United States, 1965-1994 Figure_33 RABIES -- wild and domestic animals, by year, United States

and Puerto Rico, 1955-1994 Figure_34 ROCKY MOUNTAIN SPOTTED FEVER (RMSF) -- by year, United

States, 1965-1994 Figure_35 RUBELLA (German measles) -- by year, United States,

1966-1994 Figure_36 SALMONELLOSIS (excluding typhoid fever) -- by year,

United States, 1955-1994 Figure_37 SALMONELLA -- serotype of isolate by year, United States,

1968-1994 Figure_38 SHIGELLOSIS -- by year, United States, 1965-1994 Figure_39 SHIGELLA -- species of isolate by year, United States,

1968-1994 Figure_40 SYPHILIS (primary and secondary) -- reported cases, per

100,000 population, United States, 1994 Figure_41 SYPHILIS (primary and secondary) -- by sex, United States,

1981-1994 Figure_42 SYPHILIS (primary and secondary) -- by race, United States,

1981-1994 Figure_43 CONGENITAL SYPHILIS -- in infants Note: To print large tables and graphs users may have to change their printer settings to landscape and use a small font size.

Table_2A
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Table_2B
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Table_2C
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Table_2D
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Table_2E
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Table_2F
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Table_3
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Table_4
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Table_5
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Table_6
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Summary of Notifiable Diseases, United States, 1995

This publication contains summary tables of the official statistics for the reported occurrence of nationally notifiable diseases in the United States for 1995. These statistics are collected and compiled from reports to the National Notifiable Diseases Surveillance System (NNDSS), which is operated by CDC in collaboration with the Council of State and Territorial Epidemiologists (CSTE). Because the dates of onset and dates of diagnosis for notifiable diseases may not always be reported, these surveillance data are presented by the week that they were reported to CDC by public health officials in state and territorial health departments. These data are finalized and published in the MMWR Summary of Notifiable Diseases, United States for use by state and local health departments schools of medicine and public health communications media local, state, and federal agencies and other agencies or persons interested in following the trends of reportable diseases in the United States. The annual publication of the Summary also documents which diseases are considered national priorities for notification and the annual number of cases of such diseases.

Part 1 contains information regarding morbidity for each of the diseases considered nationally notifiable during 1995. The tables provide the number of cases of notifiable diseases reported to CDC for 1995, as well as the distribution of cases by month and geographic location and by patient's age, sex, race, and Hispanic ethnicity. The data are final totals as of July 26, 1996, unless otherwise noted. There were no reported cases of anthrax, diphtheria, and yellow fever in the United States during 1995 thus, these three nationally notifiable diseases do not appear in the tables in Part 1. In all tables, leprosy is listed as Hansen disease and tickborne typhus fever is listed as Rocky Mountain spotted fever (RMSF).

Part 2 contains graphs and maps. These graphs and maps depict summary data for many of the notifiable diseases that are described in tabular form in Part 1.

Part 3 includes tables that list the number of cases of notifiable diseases reported to CDC since 1966. It also includes a table enumerating deaths associated with specified notifiable diseases that were reported to the National Center for Health Statistics, CDC, during 1984-1993.

As of January 1, 1995, 49 infectious diseases were designated as notifiable at the national level. A notifiable disease is one for which regular, frequent, and timely information regarding individual cases is considered necessary for the prevention and control of the disease. This section briefly summarizes the history of the reporting of nationally notifiable diseases in the United States.

In 1878, Congress authorized the U.S. Marine Hospital Service (i.e., the forerunner of the Public Health Service ) to collect morbidity reports regarding cholera, smallpox, plague, and yellow fever from U.S. consuls overseas this information was to be used for instituting quarantine measures to prevent the introduction and spread of these diseases into the United States. In 1879, a specific Congressional appropriation was made for the collection and publication of reports of these notifiable diseases. The authority for weekly reporting and publication of these reports was expanded by Congress in 1893 to include data from states and municipal authorities. To increase the uniformity of the data, Congress enacted a law in 1902 directing the Surgeon General to provide forms for the collection and compilation of data and for the publication of reports at the national level. In 1912, state and territorial health authorities -- in conjunction with PHS -- recommended immediate telegraphic reporting of five infectious diseases and the monthly reporting, by letter, of 10 additional diseases. The first annual summary of The Notifiable Diseases in 1912 included reports of 10 diseases from 19 states, the District of Columbia, and Hawaii. By 1928, all states, the District of Columbia, Hawaii, and Puerto Rico were participating in national reporting of 29 specified diseases. At their annual meeting in 1950, the State and Territorial Health Officers authorized a conference of state and territorial epidemiologists whose purpose was to determine which diseases should be reported to PHS. In 1961, CDC assumed responsibility for the collection and publication of data concerning nationally notifiable diseases.

The list of nationally notifiable diseases is revised periodically. For example, a disease may be added to the list as a new pathogen emerges, or a disease may be deleted as its incidence declines. Public health officials at state health departments and CDC continue to collaborate in determining which diseases should be nationally notifiable CSTE, with input from CDC, makes recommendations annually for additions and deletions to the list of nationally notifiable diseases. However, reporting of nationally notifiable diseases to CDC by the states is voluntary. Reporting is currently mandated (i.e., by state legislation or regulation) only at the state level. The list of diseases that are considered notifiable, therefore, varies slightly by state. All states generally report the internationally quarantinable diseases (i.e., cholera, plague, and yellow fever) in compliance with the World Health Organization's International Health Regulations.

CSTE and CDC held a national surveillance conference November 30- December 2, 1994, to review the state of national surveillance for infectious diseases. Conditions that were approved for addition to national surveillance during 1995 are genital infections caused by Chlamydia trachomatis, coccidioidomycosis (for regional surveillance), cryptosporidiosis, hantavirus pulmonary syndrome (HPS), (post-diarrheal) hemolytic-uremic syndrome (HUS), pediatric infection with the human immunodeficiency virus (HIV), invasive group A streptococcal infections, streptococcal toxic-shock syndrome, and invasive infections caused by drug-resistant Streptococcus pneumoniae. These conditions currently are not reportable in all states, and the mechanism for reporting them may not involve clinicians or consist of reports of individual cases, which are the traditional reporting mechanisms. Reports of the number of cases of these conditions -- with the exception of genital infections caused by Chlamydia trachomatis (which has been reportable in many states for a number of years) -- will not appear in the current summary tables they will, however appear in the 1996 annual summary.

At the 1994 conference, the following diseases were also proposed as deletions from the list of infectious diseases under national surveillance: amebiasis, aseptic meningitis, primary encephalitis (except for arboviral encephalitis), postinfectious encephalitis, granuloma inguinale, unspecified hepatitis, leptospirosis, lymphogranuloma venereum, rheumatic fever, and tularemia. These changes were confirmed by a vote of the full membership of CSTE in early 1995. The number of reported cases of these diseases will not appear in the summary tables for 1995 or for future years.

The list of 52 infectious diseases that were designated as notifiable at the national level at the end of 1995 appears below: *

Acquired immunodeficiency syndrome (AIDS) Anthrax Botulism ** Brucellosis Chancroid Chlamydia trachomatis, genital infection Cholera Coccidioidomycosis ** Congenital rubella syndrome Congenital syphilis Cryptosporidiosis Diphtheria Encephalitis, California Encephalitis, eastern equine Encephalitis, St. Louis Encephalitis, western equine Escherichia coli O157:H7 Gonorrhea Haemophilus influenzae, invasive disease Hansen disease (leprosy) Hantavirus pulmonary syndrome Hemolytic-uremic syndrome, post-diarrheal ** Hepatitis A Hepatitis B Hepatitis, C/non-A, non-B HIV infection, pediatric (i.e., in persons ages less than 13 years) Legionellosis Lyme disease Malaria Measles Meningococcal disease Mumps Pertussis Plague Poliomyelitis, paralytic Psittacosis Rabies, animal Rabies, human Rocky Mountain spotted fever Rubella Salmonellosis ** Shigellosis ** Streptococcal disease, invasive, group A ** Streptococcus pneumoniae, drug-resistant ** Streptococcal toxic-shock syndrome ** Syphilis Tetanus Toxic-shock syndrome Trichinosis Tuberculosis Typhoid fever Yellow fever **

Although varicella is not a nationally notifiable disease, the Council of State and Territorial Epidemiologists recommends reporting of cases of this disease to CDC. ** Not currently published in the weekly tables.

Provisional data concerning the reported occurrence of notifiable diseases are published weekly in MMWR. After each reporting year, staff in state health departments finalize reports of cases for that year with local or county health departments and reconcile the data with reports previously sent to CDC throughout the year these data are compiled in final form in this summary. Notifiable disease reports are published in the annual MMWR Summary of Notifiable Diseases only after approval by the appropriate epidemiologist from each submitting state or territory and are the authoritative and archival counts of cases. Data published in MMWR Surveillance Summaries or other surveillance reports produced by CDC programs, which are useful for detailed epidemiologic analyses, may not agree exactly with data reported in the annual Summary of Notifiable Diseases because of differences in the timing of reports, the source of the data, and the use of different case definitions.

Data in this summary were derived primarily from reports transmitted to the Division of Surveillance and Epidemiology, Epidemiology Program Office, CDC, by the health departments of 50 states, two cities, and five territories through the National Electronic Telecommunications System for Surveillance (NETSS). Final data for other diseases are from the surveillance-program records of the following CDC programs (requests for further information regarding these data should be directed to the source specified):

National Center for Health Statistics

Office of Vital and Health Statistics Systems (deaths from selected

National Center for Infectious Diseases

Division of Bacterial and Mycotic Diseases (toxic-shock syndrome

and laboratory data regarding botulism, Escherichia coli O157:H7, Salmonella, Shigella, and penicillin-nonsusceptible S. pneumoniae ) Division of HIV/AIDS Division of Vector-Borne Infectious Diseases (laboratory data

regarding arboviral encephalitis) Division of Viral and Rickettsial Diseases (animal rabies)

National Center for HIV, STD, and TB Prevention (NCHSTP)

Division of Sexually Transmitted Diseases Prevention (chancroid,

chlamydia, gonorrhea, and syphilis) Division of Tuberculosis Elimination (tuberculosis)

National Immunization Program

Epidemiology and Surveillance Division (poliomyelitis)

Disease totals for the United States, unless otherwise stated, do not include data for American Samoa, Guam, Puerto Rico, the Virgin Islands, and the Commonwealth of the Northern Mariana Islands (CNMI). Disease totals from American Samoa were unavailable for 1995.

Population estimates for states are based on the July 1, 1995, post-censal estimates made by the U.S. Department of Commerce, Bureau of the Census, Population Division, Population Estimates Branch, Press Release CB94-204. Because these estimates are unavailable by age and sex for 1995, rates for reported disease occurrences by age group and among males and females use population totals from the July 1, 1993, post-censal estimates. Population estimates for territories are from the 1990 census, U.S. Department of Commerce, Bureau of the Census, Press Releases CB91-142, 242, 243, 263, and 276.

Rates in the 1995 Summary of Notifiable Diseases were based on data for the U.S. total-resident population. However, population data from states in which diseases were not notifiable or disease data were not available were excluded from rate calculations.

The data reported in this summary are useful for analyzing disease trends and determining relative disease burdens. However, these data must be interpreted in light of reporting practices. Some diseases that cause severe clinical illness (e.g., plague or rabies), if diagnosed by a clinician, are likely to be reported accurately. However, persons who have diseases that are clinically mild and infrequently associated with serious consequences (e.g., salmonellosis) may not even seek medical care from a health-care provider even if these less severe diseases are diagnosed, they are less likely to be reported. The degree of completeness of reporting also is influenced by the diagnostic facilities that are available the control measures that are in effect the public awareness of a specific disease and the interests, resources, and priorities of state and local officials responsible for disease control and public health surveillance. Finally, factors such as changes in the case definitions for public health surveillance, the introduction of new diagnostic tests, or the discovery of new disease entities may cause changes in disease reporting that are independent of the true incidence of disease.

Public health surveillance data are published for selected racial and ethnic population groups because these variables may be risk markers for certain notifiable diseases. Risk markers can identify potential risk factors for investigation in future studies. Data regarding race and ethnicity also can be useful for identifying groups to target for prevention efforts. However, caution must also be used when drawing conclusions from reported data relating to race and ethnicity. Among certain races and ethnicities, there are likely to be differential patterns of access to health care, interest in seeking health care, and detection of disease that would lead to data that are not representative of disease incidence in these populations. In addition, not all data concerning race and ethnicity are collected uniformly for all diseases. For example, the Division of HIV/AIDS Prevention and the Division of STD Prevention in NCHSTP collect information regarding race and ethnicity using a single variable instead of two separate variables. A person's racial and ethnic background is reported as either American Indian/Alaskan Native, Asian/Pacific Islander, Black non-Hispanic, White non-Hispanic, or Hispanic. Additionally, although the recommended standard for classifying a person's race or ethnicity is based on self-reporting, it is not clear that this procedure is always followed.

Highlights for Selected Infectious Diseases

In 1995, a case of encephalitis caused by Cache Valley virus was reported in North Carolina. Although this mosquito-borne bunyavirus was previously known to cause subclinical infections in humans, no clinical cases had been recognized previously.

In 1995, the CSTE recommended that coccidioidomycosis become a regionally reportable disease. Because the Emerging Infectious Program at the National Center for Infectious Diseases (NCID/CDC), in collaboration with the State of California Department of Health Services, has been conducting active surveillance for coccidioidomycosis in Kern County, California, for some time, its data are presented. The total number of coccidioidomycosis cases reported to the Kern County Health Department during 1995 was 770 this represents a drop in the number of cases when compared with the large number reported in the epidemic years during 1991- 1994 (e.g., during 1992, a peak of 3,342 cases occurred in Kern County alone).

Creutzfeldt-Jakob disease (CJD) is a subacute, degenerative disease of the brain that is classified as a transmissible, spongiform encephalopathy. More than 85% of CJD patients die within 1 year of onset. From 1979 through 1994, there were 3,642 CJD-related deaths in the United States (based on national data concerning multiple causes of death and a preliminary total of 280 deaths in 1994). The average annual age-adjusted death rate attributed to CJD is 0.95 deaths per million persons. As of September 15, 1996, evidence does not indicate that cases of the newly described variant of CJD (i.e., the type identified in the United Kingdom) have occurred in the United States. This evidence is based on the analysis of both national data and data from active, retrospective surveillance for CJD conducted since 1991 by special surveillance teams in five areas of the country (1993 population: 16.3 million persons).

National reporting of cryptosporidiosis began in 1995. During 1995, it was reportable in 24 of 50 states however, many other states have made or are in the process of making cryptosporidiosis a notifiable disease. Because the diagnosis of cryptosporidiosis is often not considered, and because most laboratories do not routinely test for Cryptosporidium infection, cryptosporidiosis will continue to be underdiagnosed and underreported.

Dengue and Dengue Hemorrhagic Fever

In 1995, most tropical countries in the Americas reported major outbreaks of dengue and dengue hemorrhagic fever (DHF). During this period, the Pan American Health Organization received reports of over 250,000 total cases of dengue and DHF from member countries. This was the largest number reported since 1981, when the worst epidemic in the Americas occurred in Cuba. As a result of this widespread activity, the number of laboratory-positive cases of imported dengue in the United States increased to 86 in 1995 from 37 in 1994. During 1995, the Texas State Health Department reported eight laboratory-positive cases resulting from local transmission by Aedes aegypti mosquitoes. Dengue transmission in the continental United States had not been reported since 1986.

Hantavirus Pulmonary Syndrome

Hantavirus pulmonary syndrome (HPS) is now recognized as a pan-American viral zoonosis caused by Sin Nombre virus and other New World hantaviruses. The identified rodent reservoirs for these viruses are as follows: Peromyscus maniculatus and P. leucopus (deer mouse and white-footed mouse, respectively) for Sin Nombre virus and its variants Sigmodon hispidus (cotton rat) for Black Creek Canal virus and Oryzomys palustris (rice rat) for Bayou virus. Cases of HPS have been found throughout the continental United States, in Canada, and in South America. As of August 22, 1996, national surveillance for HPS has identified 143 confirmed case-patients in 25 states (case-fatality rate: 50.2%) 23 of these cases occurred in 1995.

Infection caused by Shiga toxin-producing E. coli (i.e., STEC), especially serotype O157:H7, is the leading cause of hemolytic-uremic syndrome (HUS) in the United States. Although an estimated 1,200 HUS cases caused by infectious agents occur in the United States each year, the absence of longstanding surveillance data has limited the assessment of HUS as a public health problem. When surveyed in August 1994, only 15 states listed HUS as a notifiable disease. Recent efforts to improve surveillance include the creation of a unique International Classification of Diseases code for HUS the adoption of a uniform, post-diarrheal case definition for HUS by the CSTE and the recommendation by CSTE, in 1995, that HUS be made a notifiable disease in all states. Efforts are also underway to establish active surveillance for HUS in selected states.

HIV Infection in Children and Infants

In 1994, results of the AIDS Clinical Trials Group Protocol 076 indicated that administering zidovudine to a selected group of pregnant, HIV-infected women, and subsequently to their newly born infants, reduced the risk for perinatal HIV transmission to these infants by two thirds. The U.S. Public Health Service (USPHS) subsequently issued guidelines for the use of zidovudine to reduce perinatal transmission of HIV (MMWR 199443:1-20) and the routine counseling and voluntary HIV testing of all pregnant women (MMWR 199544:1-15). USPHS also issued revised guidelines on PCP prophylaxis for children (MMWR 199544 :1-11) that recommends each child born to an HIV-infected mother receive PCP prophylaxis until the child's HIV status is determined. States that conduct surveillance of pediatric HIV exposure/infection should be able to evaluate the implementation and impact of these guidelines most effectively and enhance early identification of HIV status in infants. In 1995, 28 states conducted surveillance of HIV infection in children. These states reported 332 HIV-infected children who had not progressed to acquired immunodeficiency syndrome (AIDS) and 229 children who had AIDS.

Penicillin-Nonsusceptible S. pneumoniae

The prevalence of cases of penicillin-nonsusceptible S. pneumoniae * (PNSP) among invasive pneumococcal infections in selected metropolitan areas for 1995 is presented. In these areas, population-based active surveillance for all invasive pneumococcal infections is ongoing in each of the regions, the denominator reflects greater than 100 cases of invasive pneumococcal disease. The prevalence of PNSP from hospital to hospital within each metropolitan area varied widely, suggesting that sentinel hospitals may not accurately reflect the prevalence of PNSP within a given city, let alone for the entire state. In addition, the prevalence of PNSP cases can increase rapidly (e.g., the prevalence of PNSP cases for Atlanta was 25% in 1994 and 33% in 1995).

Prevalence of PNSP among invasive Active surveillance area pneumococcal infections -------------------------------------------------------------------- - State of Connecticut ** 10%-19% Baltimore, MD Minneapolis/St. Paul, MN ** San Francisco, CA

Portland, OR ** 20%-29% San Antonio, TX

Atlanta, GA >= 30% Urban counties, TN ***

* S. pneumoniae isolates with penicillin minimum inhibitory concentration greater than or equal to 0.125 mg/mL. ** These figures are based on data from less than 1 year. *** Includes the metropolitan areas of Chattanooga, Knoxville, Memphis, and Nashville, Tennessee.

In 1995, an outbreak of Ebola hemorrhagic fever (EHF) caused by the Zaire subtype of Ebola virus occurred in Kikwit, Zaire. A total of 316 cases of EHF were confirmed, resulting in 244 deaths (case-fatality rate: 77%). Case-patients ranged in age from 3 days to 71 years (median age: 35 years), and slightly more than half of the case-patients (i.e., 53%) were female. The earliest identified case occurred in January, and the epidemic peaked in May 1995. In December 1995, a single case of EHF occurred in Cote d'Ivoire and was caused by the recently recognized Ivory Coast subtype of Ebola virus. The natural reservoir of Ebola virus remains unknown.

PART 1: Summaries of Notifiable Diseases in the United States

EXPLANATION OF SYMBOLS USED IN TABLES, GRAPHS, AND MAPS Data not available . NA Report of disease is not required

in that jurisdiction (not notifiable) . NN No reported cases .

Table_A NOTIFIABLE DISEASES -- Summary of reported cases, by month,

Table_B1 NOTIFIABLE DISEASES Reported cases, by geographic division

and area, United States, 1995

Table_B2 NOTIFIABLE DISEASES Reported cases, by geographic division

and area, United States, 1995 (continued)

Table_B3 NOTIFIABLE DISEASES Reported cases, by geographic division

and area, United States, 1995 (continued)

Table_B4 NOTIFIABLE DISEASES Reported cases, by geographic division

and area, United States, 1995 (continued)

Table_B5 NOTIFIABLE DISEASES Reported cases, by geographic division

and area, United States, 1995 (continued)

Table_B6 NOTIFIABLE DISEASES Reported cases, by geographic division

and area, United States, 1995 (continued)

Table_C NOTIFIABLE DISEASES -- Summary of reported cases, by age

Table_D NOTIFIABLE DISEASES -- Summary of reported cases, by sex,

Table_E NOTIFIABLE DISEASES -- Summary of reported cases, by race,

Table_F NOTIFIABLE DISEASES -- Summary of reported cases, by

ethnicity, United States, 1995

PART 2: Graphs and Maps for Selected Notifiable Diseases in the United States

EXPLANATION OF SYMBOLS USED IN TABLES, GRAPHS, AND MAPS Data not available. NA Report of disease is not required

in that jurisdiction (not notifiable) . NN No reported cases .

Figure_1 ACQUIRED IMMUNODEFICIENCY SYNDROME (AIDS) -- reported cases,

by quarter, United States, 1984-1995

Figure_2 ACQUIRED IMMUNODEFICIENCY SYNDROME (AIDS) -- reported cases,

per 100,000 population, United States and Puerto Rico, 1995

Figure_3 ACQUIRED IMMUNODEFICIENCY SYNDROME (AIDS) -- reported

pediatric cases, United States and Puerto Rico, 1995

Figure_4 ARBOVIRAL INFECTIONS (of the central nervous system) --

reported laboratory-confirmed cases caused by California serogroup viruses, by month of onset, United States, 1986 1995

Figure_5 ARBOVIRAL INFECTIONS (of the central nervous system) --

reported laboratory-confirmed cases caused by eastern equine encephalitis virus, by month of onset, United States, 1986 1995

Figure_6 ARBOVIRAL INFECTIONS (of the central nervous system) --

reported laboratory-confirmed cases caused by St. Louis encephalitis virus, by month of onset, United States, 1986 1995

Figure_7 ARBOVIRAL INFECTIONS (of the central nervous system) --

reported laboratory-confirmed cases caused by western equine encephalitis virus, by month of onset, United States, 1986 1995

Figure_8 BOTULISM (foodborne) -- by year, United States, 1975 1995

Figure_9 BOTULISM (infant) -- by year, United States, 1975 1995

Figure_10 BRUCELLOSIS -- by year, United States, 1965 1995

Figure_11 CHLAMYDIA -- reported cases among women, per 100,000

population, United States, 1995

Figure_12 CHOLERA -- reported cases, United States and territories,

Figure_13 DIPHTHERIA -- by year, United States, 1965 1995

Figure_14 ESCHERICHIA COLI O157:H7 -- reported cases, United States

Figure_15 ESCHERICHIA COLI O157:H7 -- reported isolates, United

Figure_16 GONORRHEA -- reported cases, per 100,000 population, United

Figure_17 GONORRHEA -- by sex, United States, 1981 1995

Figure_18 GONORRHEA -- by race and ethnicity, United States, 1981 1995

Figure_19 HAEMOPHILUS INFLUENZAE, INVASIVE -- by age group, United

Figure_20 HANSEN DISEASE (LEPROSY) -- by year, United States,

Figure_21 HEPATITIS -- by year, United States, 1965 1995

Figure_22 HEPATITIS A -- reported cases, per 100,000 population,

United States and territories, 1995

Figure_23 HEPATITIS B -- reported cases, per 100,000 population,

United States and territories, 1995

Figure_24 LEGIONELLOSIS -- by year, United States, 1980 1995

Figure_25 LYME DISEASE -- reported cases, per 100,000 population,

United States and territories, 1995

Figure_26 MALARIA -- by year, United States, 1965 1995

Figure_27 MEASLES (rubeola) -- by year, United States, 1960 1995

Figure_28 MENINGOCOCCAL DISEASE -- by year, United States, 1965 1995

Figure_29 MUMPS -- by year, United States, 1968 1995

Figure_30 PERTUSSIS (whooping cough) -- by year, United States,

Figure_31 PERTUSSIS (whooping cough) -- by age group, United States,

Figure_32 PLAGUE -- among humans, by year, United States, 1965 1995

Figure_33 POLIOMYELITIS (paralytic) -- by year, United States,

Figure_34 PSITTACOSIS -- by year, United States, 1965 1995

Figure_35 RABIES -- wild and domestic animals, by year, United States

and Puerto Rico, 1965 1995

Figure_36 ROCKY MOUNTAIN SPOTTED FEVER (RMSF) -- by year, United

Figure_37 RUBELLA (German measles) -- by year, United States,

Figure_38 SALMONELLOSIS (excluding typhoid fever) -- by year, United

Figure_39 SALMONELLA -- serotype of isolate by year, United States,

Figure_40 SHIGELLOSIS -- by year, United States, 1965 1995

Figure_41 SHIGELLA -- species of isolate by year, United States,

Figure_42 SYPHILIS (primary and secondary) -- reported cases, per

100,000 population, United States, 1995

Figure_43 SYPHILIS (primary and secondary) -- by sex, United States,

Figure_44 SYPHILIS (primary and secondary) -- by race, United States,

Figure_45 CONGENITAL SYPHILIS -- in infants Note: To print large tables and graphs users may have to change their printer settings to landscape and use a small font size.

Table_B1
Note: To print large tables and graphs users may have to change their printer settings to landscape and use a small font size.

Table_C
Note: To print large tables and graphs users may have to change their printer settings to landscape and use a small font size.

Table_D
Note: To print large tables and graphs users may have to change their printer settings to landscape and use a small font size.

Table_E
Note: To print large tables and graphs users may have to change their printer settings to landscape and use a small font size.

Table_F
Note: To print large tables and graphs users may have to change their printer settings to landscape and use a small font size.


All the authors declare that they have no conflicts of interest.

Figures S1 and S2. DNA fingerprinting of the 22 investigated extended-spectrum β-lactamase (ESBL) -producing Escherichia coli isolates in Ngaoundere Protestant Hospital (NH). Dendrogram, virtual gel image and similarity matrix demonstrate strain clustering. The horizontal bar on the bottom left indicates the percentage similarity within the strains. A cut-off of 95% similarity (vertical dashed red line) was chosen for determination of clonal relatedness. ICU, Intensive care unit.

Figures S3 and S4. DNA fingerprinting of the 22 investigated extended-spectrum β-lactamase (ESBL) -producing Klebsiella pneumoniae isolates in Ngaoundere Protestant Hospital (NH) and Ngaoundere Regional Hospital (RH). *hn59: inpatient identified with a strain of Escherichia coli, but the two carers (ng36 and ng37) of this patient carried K. pneumoniae isolates. The horizontal bar on the bottom left indicates the percentage similarity within the strains. A cut-off of 95% similarity (vertical dashed red line) was chosen for determination of clonal relatedness.

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Discussion

Multiple factors drive the development and spread of MDR bacteria. WHO showed that if we fail to act on this issue then an additional 10 million lives would be lost each year by 2050, at a cost to the world economy of 100 trillion USD. A concerted focus since the 1990s on tackling rising MDR Gram-positive bacteria within US and European healthcare systems appears to have been instrumental in stimulating the relatively large numbers of products targeting Gram-positive bacteria in recent years. The emergence of MDR Gram-negative bacteria presents a great threat to human life and is a challenge for modern medicine. The five most difficult-to-treat Gram-negative bacteria, K. pneumonia, A. baumannii, P. aeruginosa, E. cloacae, and E. coli, can be deadly in the clinic, causing urinary tract infections, life-threatening pneumonia and septicemia, with rare antibiotics that can currently combat them or that are being developed. We reported here that the synergistic bactericidal effect of Ag + with ebselen in combination was efficient against these MDR Gram-negative pathogens (Table 1). Further, results from animal experiments indicated that this new antibiotic combination should be considered as a candidate for clinical trials against MDR bacteria (Figs 6 and EV3, Table 1), and the system targeted by the combination is critical for bacterial survival, and thus, development of resistant mutants is not frequent as described by our previous study (Gustafsson et al, 2016 ).

The fact that Ag + and ebselen were efficiently against clinical isolates of MDR Gram-negative bacteria (Table 1), which indicated that they acted a mechanism that are different from existing antibiotics. The results we presented here proposed mechanisms for the synergistic antibacterial effect of Ag + with ebselen in combination. Silver and ebselen can directly inhibit E. coli TrxR, and fast deplete GSH, which resulted in the elevation of ROS production to determine cell death (synopsis). Thiol-dependent redox pathways regulate various central cellular functions. Thus, Ag + with ebselen in combination can react with SH-groups in GSH, and particularly Trx and TrxR and possibly many other proteins, indicating that the inhibitory effect of Ag + with ebselen in combination may involve several cellular targets. In addition, Ag + and ebselen might target other molecules: For example, diguanylate cyclase and M. tuberculosis antigen 85 have been reported to be targets of ebselen (Favrot et al, 2013 Lieberman et al, 2014 ). This may impair the development of antibiotic resistance in bacteria.

Though most of the Gram-negative bacteria have both Trx and GSH/Grx systems as mammalian cells, and silver can also inhibitory activity against mammalian TrxR (Fig EV4), yet the combination of Ag + and ebselen exhibited selective synergistic toxicity on bacteria (Figs 1 and 6). The reasons for the selective toxicity of Ag + with ebselen in combination toward prokaryotic cells might be explained by: First, mammalian cells possess various tissue-specific GPxs, which contain Sec in their active site and make them highly efficient to remove hydrogen peroxide with a reaction rate of 10 8 M −1 · s −1 (Papp et al, 2007 Lu & Holmgren, 2009 , 2014 ). In contrast, only a Cys-containing GPx with a low ROS removing capacity is predicted to be present in bacteria (Lu & Holmgren, 2014 ). Second, ebselen is a substrate of the Sec-containing TrxR of mammalian cells, which makes ebselen act as an antioxidant by facilitating the electron transfer to reduce peroxides and peroxynitrite (Zhao & Holmgren, 2002 ). Meanwhile, ebselen is an irreversible inhibitor of bacterial TrxR and only blocks the electron transfer via TrxR. The ebselen analog, ebsulfur, was toxic for the parasite Trypanosoma brucei and induced a high level of ROS to enhance the inhibition of trypanothione reductase (TryR) (Lu et al, 2013b ). The ROS elevation caused by Ag + and ebselen described here may cause damage in a similar manner. The increased ROS levels in bacteria may also increase ebselen binding resulting in the inhibition of other sulfhydryl-dependent enzymes.

Figure EV4. Inhibitory effects of silver on mammalian TrxR in vitro

  1. Inhibition of human TrxR by AgNO3. 5 nM silver can inhibit human TrxR (***P = 0.000054).
  2. Inhibition of rat TrxR by AgNO3. 5 nM silver can inhibit human TrxR (***P = 0.000019).

Previous work showed that silver can enhance antibacterial effects of classic antibiotics (Morones-Ramirez et al, 2013b ), and more works reported that the lethality of current antibiotics was accompanied by redox physiology alteration and ROS generation (Dwyer et al, 2014 Belenky et al, 2015 ). Our work directly showed that silver with ebselen in combination could target redox system, and has a significant synergistic antibacterial effect on clinic important Gram-negative bacteria.

Current antibacterial strategies are predominantly based on inhibition of cell wall synthesis, inhibition of DNA and RNA synthesis and replication, and inhibition of protein synthesis. Redox system is a universal anti-oxidative system, which is essential for living organism inhibition of redox system will result in oxidative stress, which showed a novel antibacterial principle that could be used to screen new antibiotics.

All in all, our results with silver and ebselen in synergistic combination implied that targeting bacterial thiol systems was a potent strategy against bacterial infections and a novel promising antibiotic mechanism.


Functional Display of an Amoebic Chitinase in Escherichia coli Expressing the Catalytic Domain of EhCHT1 on the Bacterial Cell Surface

Poor solubility is the main drawback of the direct industrial exploitation of chitin, the second most abundant biopolymer after cellulose. Chemical methods are conventional to solubilize chitin from natural sources. Enzymatic hydrolysis of soluble chitinous substrates is a promising approach to obtain value-added by-products, such as N-acetylglucosamine units or low molecular weight chito-oligomers. Protein display on the bacterial membrane remains attractive to produce active enzymes anchored to a biological surface. The Lpp-OmpA system, a gene fusion of the Lpp signal sequence with the OmpA transmembrane region, represents the traditional system for targeting enzymes to the E. coli surface. EhCHT1, the amoebic chitinase, exhibits an efficient endochitinolytic activity and significant biochemical features, such as stability over a wide range of pH values. Using an extended Lpp-OmpA system as a protein carrier, we engineered E. coli to express the catalytic domain of EhCHT1 on the surface and assess the endochitinase activity as a trait. Engineered bacteria showed a consistent hydrolytic rate over a typical substrate, suggesting that the displayed enzyme has operational stability. This study supports the potential of biomembrane-associated biocatalysts as a reliable technology for the hydrolysis of soluble chitinous substrates.

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About the Author

Virendra S. Bisaria is Professor in the Department of Biochemical Engineering and Biotechnology at the Indian Institute of Technology Delhi, New Delhi, India. He has published more than 100 original papers, 10 reviews and 15 book chapters.  He is Editor of the Journal of Bioscience and Bioengineering (Elsevier) and is on the editorial boards of Journal of Chemical Technology and Biotechnology (Wiley) and Process Biochemistry (Elsevier).  He was one of the International collaborators to recommend assay procedures for cellulase and xylanase activities on behalf of Commission on Biotechnology, International Union of Pure and Applied Chemistry. His awards include the Research Exchange Award from the Korean Society for Biotechnology and Bioengineering and fellowships from UNESCO and UNDP etc. He is Vice President of Asian Federation of Biotechnology from India.

Akihiko Kondo is Professor in the Department of Chemical Engineering and Director of Biorefinery Center at Kobe University, Kobe, Japan.  He is Team Leader, Biomass Engineering Program, RIKEN. He has published more than 330 original papers, 75 reviews and 55 book chapters. He is Editor of Journal of Biotechnology (Elsevier), Associate Editor of Biochemical Engineering Journal (Elsevier) and is on the editorial boards of Biotechnology for Biofuels (Springer), Bioresource Technology (Elsevier), Journal of Biological Engineering (Springer) and FEMS Yeast Research (Wiley).  He has won numerous awards which include the Advanced Technology Award by Fuji Sankei Business and Takeda International Contributions Award by Takeda Pharmaceuticals.


Introduction

For nearly a century, microbiologists from a range of industries and disciplines have been concerned with the detection and enumeration of micro-organisms.

An integral component of food safety and quality management systems is the verification that both HACCP and prerequisite programmes are being implemented correctly. Thus, within the food industry, microbiological samples are often taken from both food contact and environmental surfaces to assess the efficacy of the cleaning and disinfection procedures applied ( Rahkio and Korkeala 1997 Russell et al. 1997 Brown et al. 2000 Miettinen et al. 2001 ). Similarly, within healthcare institutions, concerns over the spread of methicillin-resistant Staphylococcus aureus (MRSA) and other nosocomial pathogens have prompted a renewed interest in cleaning ( Griffith et al. 2000 ) and environmental surface sampling can form part of the ‘Search and Destroy’ philosophy used in some countries to control infections ( Frank 2003 ).

The importance of cleaning and the removal of environmental reservoirs is, therefore, recognized and quantitative aerobic colony counts of <2·5 CFU cm −2 have been proposed as postclean microbiological surface standards for both the food and healthcare sectors ( Sveum et al. 1992 Mossel et al. 1999 Griffith et al. 2000 Dancer 2004 ). Consequently, surface sampling is becoming increasingly important and numerous investigations have been conducted to fill the need for a simple, reliable, bacteriological test to determine, quantitatively, the sanitary quality of environmental, food- and hand-contact surfaces ( Angelotti et al. 1958 Clark 1965 Scheusner 1982 ).

Contact plates, sampling sponges and adhesive tape have all been used to determine the level of microbial surface contamination ( Niskanen and Pohja 1977 Fung et al. 2000 Moore and Griffith 2002b ). However, the recommended procedure and the technique most commonly employed, remains one based upon the swab-rinse technique originally developed by Manheimer and Ybanez in 1917 ( Favero et al. 1968 ).

Traditional swabs are made from a wooden or plastic shaft with cotton, rayon, Dacron, or alginate fibres, spun to form a bud at one end. The swab is moistened (in an appropriate wetting agent) and rubbed over the surface to be tested. Bacteria are removed and then transferred directly to a solid nutrient medium or to an intermediate diluent, which can be quantitatively assayed. As with the type of swab used, there is wide variation in the choice of wetting solution/diluent. Some formulations, for example, aid the recovery of stressed bacteria whist others include agents capable of neutralizing the effects of any residual detergents and/or disinfectants that may be picked up by the swab during sampling. It is, however, imperative that the characteristics of the wetting solution do not alter, either qualitatively or quantitatively, the microbial population between sampling and enumeration.

The effectiveness of the swabbing technique depends, therefore, upon the efficacy of the three individual components of the swabbing protocol (i) the removal of bacterial contaminants from the surface, (ii) the release of these bacteria from the swab bud and (iii) their subsequent cultivation. However, swabbing efficiency is often poor previous studies have reported recovery rates ranging from 25% to just 0·1% of the original inoculum ( Niskanen and Pohja 1977 Roelofsen et al. 1999 Moore and Griffith 2002a Taku et al. 2002 Obee et al. 2004 ).

It has been stated that bacteria become increasingly difficult to remove once they have adhered to a surface, particularly if they have become associated with a biofilm ( Bredholt et al. 1999 ). Furthermore, the buds of cotton-tipped swabs are thought to retain some of the micro-organisms removed from the surface, again resulting in reduced recovery ( Favero et al. 1968 ). Surface hygiene swabbing is also subject to a number of inherent errors. It is, for example, very difficult to standardize the swabbing pattern and particularly, the angle and degree of pressure applied to the swab during use. This inability to control both the reproducibility and the repeatability of the swabbing technique can lead to extreme variability in the results obtained, limiting their use, especially in trend analysis.

These acknowledged shortcomings have led to continual attempts to improve the swabbing procedure and currently there is no one universally accepted swabbing protocol. Variations exist with regard to the type, number and dryness of the swab(s) used, the composition of the swab wetting solution and diluent, and, in addition, the state (i.e. wetness) and size of the surface area sampled. Different methods will influence results and this, in turn, can make it very difficult to relate microbial data obtained from one plant to that from another and is particularly relevant in relation to microbiological criteria. An important step is to develop and consistently use an optimized and validated protocol. However, first there must be a clear understanding of the variables that affect both the accuracy and precision of the swabbing technique. The potential errors in surface sampling need to be identified and the materials used for swabbing need to be evaluated and selected appropriately.


Acknowledgments

We would like to acknowledge the Canadian Institute for Health Information for their administration of the Hospital Morbidity Database. Parts of this study are based on data and information provided by the Canadian Institute for Health Information. However, the analyses, conclusions, opinions, and statements expressed herein are those of the author, and not necessarily those of the Canadian Institute for Health Information.

We would like to thank the experts (from federal and provincial governments and academic institutions) who provided their time to peer-review the approach taken to develop these estimates.


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