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Morbidity and Mortality Weekly Report

Weekly / Vol. 59 / No. 26 July 9, 2010

Centers for Disease Control and Preventionwww.cdc.gov/mmwr

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Understanding the trends in the prevalence o cigarettesmoking among youths enables policy makers to target preven-tion resources more eectively. Every 2 years, CDC analyzesdata rom the national Youth Risk Behavior Survey (YRBS) toevaluate trends in cigarette use among high school students inthe United States. Tis report updates a previous report (1) anddescribes results o CDCs 2010 analysis o YRBS data rom19912009 or three measures: ever smoked cigarettes, cur-rent cigarette use, and current requent cigarette use. For eversmoked cigarettes, the prevalence did not change rom 1991(70.1%) to 1999 (70.4%), declined to 58.4% in 2003, andthen declined more gradually, to 46.3% in 2009. For currentcigarette use, the prevalence increased rom 27.5% in 1991 to36.4% in 1997, declined to 21.9% in 2003, and then declinedmore gradually, to 19.5% in 2009. For current requent cigaretteuse, the prevalence increased rom 12.7% in 1991 to 16.8%in 1999, declined to 9.7% in 2003, and then declined moregradually, to 7.3% in 2009. For all three measures, rates beganto decline in the late 1990s, but the rate o decline slowed dur-

ing 20032009. o increase the rate o decline in cigarette useamong high school students, reductions in advertising, promo-tions, and commercial availability o tobacco products shouldbe combined with ull implementation o communitywide,comprehensive tobacco control programs (25).

Te biennial national YRBS, a component o CDCs YouthRisk Behavior Surveillance System, used independent, three-stage cluster samples or the 19912009 surveys to obtaincross-sectional data representative o public and private schoolstudents in grades 912 in all 50 states and the District oColumbia.* For each survey, students completed anonymous,sel-administered questionnaires that included identically

worded questions about cigarette use. During 19912009, thenumber o participating schools ranged rom 110 to 159, andthe number o participating students ranged rom 10,904 to16,410. School response rates ranged rom 70% to 81%, stu-

dent response rates ranged rom 83% to 90%, and the overalresponse rates ranged rom 60% to 71%.

For this analysis, ever smoked cigarettes was dened as evertrying cigarette smoking, even one or two pus; current cigaretteuse was dened as smoking cigarettes on at least 1 day duringthe 30 days beore the survey; and current requent cigarette usewas dened as smoking cigarettes on 20 or more days duringthe 30 days beore the survey. Race/ethnicity data were analyzedonly or non-Hispanic black, non-Hispanic white, and Hispanicstudents (who might be o any race); the numbers o studentrom other racial/ethnic groups were too small or meaninguanalysis. Data were weighted to provide national estimates, andthe statistical sotware used or all data analyses accounted orthe complex sample design. emporal changes were analyzedusing logistic regression analyses, which controlled or sexrace/ethnicity, and grade and simultaneously assessed linearquadratic, and cubic time eects (p


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TeMMWRseries o publications is published by the Oce o Surveillance, Epidemiology, and Laboratory Services, Centers or DiseaseControl and Prevention (CDC), U.S. Department o Health and Human Services, Atlanta, GA 30333.

Suggested citation: Centers or Disease Control and Prevention. [Article title]. MMWR 2010;59:[inclusive page numbers].

Centers or Disease Control and Prevention

Tomas R. Frieden, MD, MPH, Director

Harold W. Jae, MD, MA,Associate Director or Science

James W. Stephens, PhD, Oce o the Associate Director or Science

Stephen B. Tacker, MD, MSc, Deputy Director or Surveillance, Epidemiology, and Laboratory Services

MMWR Editorial and Production Sta

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Robert A. Gunn, MD, MPH,Associate Editor, MMWRSeries

eresa F. Rutledge,Managing Editor, MMWRSeries

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Inormation Technology Specialists

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Dixie E. Snider, MD, MPH, Atlanta, GAJohn W. Ward, MD, Atlanta, GA

MMWR Editorial Board

William L. Roper, MD, MPH, Chapel Hill, NC, Chairman

MMWR Morbidity and Mortality Weekly Report

798 MMWR / July 9, 2010 / Vol. 59 / No. 26

cigarette use increased rom 1991 to 1999, declinedrom 1999 to 2003, and then remained stable. Amongblack emale students, only linear and quadratic eectswere observed, indicating that the prevalence o cur-rent cigarette use increased rom 1991 to 1999 andthen declined, with no slowing or leveling o.

Reported by

Oce on Smoking and Health, Div o Adolescent andSchool Health, National Center or Chronic DiseasePrevention and Health Promotion, CDC.

Editorial Note

Te ndings in this report show that or threemeasures o cigarette use (ever smoked cigarettes, cur-rent cigarette use, and current requent cigarette use)rates among high school students began to decline inthe late 1990s, but the rate o decline slowed during

20032009. Tese trends are consistent with trendsor 30-day and daily cigarette use reported rom theMonitoring the Future survey (an ongoing nationastudy o the behaviors, attitudes, and values o 8th-10th- , and 12th-grade students), which also showeddeclines starting in the late 1990s but gradual declinesmost recently (6). As a result o the slow declines inyouth smoking described in this report, the Healthy

1991 (70.1%) to 1999 (70.4%), declined to 58.4%in 2003, and then declined more gradually to 46.3%in 2009. Te percentage o students who reportedcurrent cigarette use increased rom 27.5% in 1991to 36.4% in 1997, declined to 21.9% in 2003, anddeclined more gradually to 19.5% in 2009. Te per-

centage o students who reported current requentcigarette use increased rom 12.7% in 1991 to 16.8%in 1999, declined to 9.7% in 2003, and then declinedmore gradually to 7.3% in 2009.

For current cigarette use, trend analyses wereconducted by sex, race/ethnicity, and grade in school(Figures 2 and 3). Signicant linear, quadratic, andcubic eects similar to the overall analysis wereobserved or current cigarette use among emale stu-dents overall, white emale students, black studentsoverall, black male students, 9th-grade students, and10th-grade students (able 2). Among male studentsoverall, white students overall, white male students,Hispanic male students, and 11th-grade students,current cigarette use increased rom 1991 to 1997,declined rom 1997 to 2003, and then remainedstable. Among Hispanic students overall and Hispanicemale students, current cigarette use increased rom1991 to 1995, declined rom 1995 to 2003, and thenremained stable. Among 12th-grade students, current


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MMWR / July 9, 2010 / Vol. 59 / No. 26 799

ree environments, programs that promote changes insocial norms, and comprehensive communitywide andschool-based tobacco-use prevention policies)(25).

Te ndings in this report are subject to at leasttwo limitations. First, these data apply only to youthswho attend school and, thereore, are not representa-tive o all persons in this age group. Nationwide, in2007, o persons aged 1617 years, approximately 4%were not enrolled in a high school program and hadnot completed high school (9). Second, the extento underreporting or overreporting o cigarette usecannot be determined, although the survey questionsdemonstrate good test-retest reliability (10).

People 2010national health objective to reduce theprevalence o current cigarette use among high schoolstudents to 16% has not been met.

Te ndings in this report also show that since2003 the rate o decline in current cigarette use slowedor leveled o or all racial/ethnic and sex subgroupsexcept black emale students, or which no slowingor leveling o occurred in the rate o decline ater1999. Cigarette smoking rates refect complex andinterrelated individual, social, and environmentalactors (4,7). More detailed research is needed toexplain why current cigarette use during 20032009declined more slowly among some racial/ethnic andsex subgroups o high school students but remainedstable among others.

Te impact o tobacco advertising and promo-tion activities on youth smoking initiation has beendocumented previously (8). Te increase in currentcigarette use among high school students during theearly to mid-1990s observed in this and other surveysmight have resulted rom expanded tobacco companypromotional eorts, including discounted prices oncigarette brands most oten smoked by adolescents,depictions o tobacco use in movies, distribution onontobacco products with company symbols (e.g.,hats and -shirts), and sponsorship o music concertsand other youth-ocused events (7). Reductions inadvertising, promotions, and commercial availabil-ity o tobacco products should be combined withexpanded counter-advertising mass media campaignsand implemented with other well-documented andeective strategies (e.g., higher prices or tobaccoproducts through increases in excise taxes, tobacco-

TABLE 1. Percentage o high school students who had ever smoked cigarettes,* were current cigarette users, and were current requentcigarette users Youth Risk Behavior Survey, United States, 19912009

Category

1991 1993 1995 1997 1999 2001 2003 2005 2007 2009

%(95% CI**)

%(95% CI)

%(95% CI)

%(95% CI)

%(95% CI)

%(95% CI)

%(95% CI)

%(95% CI)

%(95% CI)

%(95% CI)

Ever smoked cigarettes 70.1(67.872.3)

69.5(68.170.8)

71.3(69.573.0)

70.2(68.272.1)

70.4(67.373.3)

63.9(61.666.0)

58.4(55.161.6)

54.3(51.257.3)

50.3(47.253.5)

46.3(43.7-48.9)

Current cigarette use 27.5(24.830.3)

30.5(28.632.4)

34.8(32.537.2)

36.4(34.138.7)

34.8(32.337.4)

28.5(26.430.6)

21.9(19.824.2)

23.0(20.725.5)

20.0(17.622.6)

19.5(17.9-21.2)

Current requent cigarette use 12.7(10.615.3)

13.8(12.115.5)

16.1(13.619.1)

16.7(14.818.7)

16.8(14.319.6)

13.8(12.315.5)

9.7(8.311.3)

9.4(7.911.0)

8.1(6.79.8)

7.3(6.4-8.3)

* Ever tried cigarette smoking, even one or t wo pus. Smoked cigarettes on at least 1 day during the 30 days beore the survey. Smoked cigarettes on 20 or more days during the 30 days beore the survey. Linear, quadratic, and cubic trend analyses were conducted using a logistic regression model controlling or sex, race/ethnicity, and grade.

** Condence interval. Signicant linear, quadratic, and cubic eects were detected (p


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800 MMWR / July 9, 2010 / Vol. 59 / No. 26

Te Family Smoking Prevention and obaccoControl Act (obacco Control Act), enacted in 2009provides new opportunities or broad scale reductionsin tobacco use. Tis statute gives the Food and DrugAdministration (FDA) additional authority to regu-late the tobacco industry. Te Act imposes specicmarketing, labeling, and advertising requirementsand establishes restrictions on youth access and pro-motional practices that are particularly attractive toyouth. Te provisions o the Act oer opportunities

or FDA to work as a partner in tobacco preventionand control (e.g., through collaborations with CDCand other ederal and state agencies) (5). As suggestedby the Institute o Medicine, the regulation o tobaccoproducts is an important component o a comprehen-sive national tobacco prevention and control strategythat will complement and strengthen the impact otraditional, evidence-based interventions (4).

What is already known on this topic?

National data show that the prevalence o cigarette

use among youths began to decline in the late 1990s.

What is added by this report?

The ndings in this report show that or three mea-

sures o cigarette use (ever smoked cigarettes, currentcigarette use, and current requent cigarette use),

rates among high school students began to decline in

the late 1990s, but the rate o decline slowed during

20032009.

What are the implications or public health practice?

To reduce the adverse health consequences associ-

ated with tobacco use, the most eective evidence-

based strategies to reduce initiation o tobacco use

among youths should be implemented nationwide,

including higher prices or tobacco products,

tobacco-ree environment policies, and counter-

advertising mass media campaigns.

Family Smoking Prevention and obacco Control Act, Pub. LNo.111-31, 123 Stat 1776 (2009). Additional inormation availableat http://www.gpo.gov/dsys/pkg/PLAW-111publ31/content-detaihtml.

* Smoked cigarettes on at least 1 day during the 30 days beore the survey.

FIGURE 3. Percentage o high school students who were current cigaretteusers,* by grade Youth Risk Behavior Survey, United States, 19912009

12th grade

11th grade

10th grade

9th grade

Year

Pe

rcen

tage

0

10

20

30

40

50

1991 1993 1995 1997 1999 2001 2003 2005 2007 2009

* Smoked cigarettes on at least 1 day during the 30 days beore the survey.

FIGURE 2. Percentage o high school students who were current cigaretteusers,* by sex and race/ethnicity Youth Risk Behavior Survey, United States,19912009

Female

Male

White, non-Hispanic

Black, non-HispanicHispanic

Year

Percen

tage

0

10

20

30

40

50

1991 1993 1995 1997 1999 2001 2003 2005 2007 2009
http://www.gpo.gov/fdsys/pkg/PLAW-111publ31/content-detail.htmlhttp://www.gpo.gov/fdsys/pkg/PLAW-111publ31/content-detail.htmlhttp://www.gpo.gov/fdsys/pkg/PLAW-111publ31/content-detail.htmlhttp://www.gpo.gov/fdsys/pkg/PLAW-111publ31/content-detail.html


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MMWR / July 9, 2010 / Vol. 59 / No. 26 801

Reerences

1. CDC. Cigarette use among high school studentsUnitedStates, 19912007. MMWR 2008;57:6868.

2. Zaza S, Briss PA, Harris KW, eds. obacco. In: Te guideto community preventive services: what works to promotehealth? New York, NY: Oxord University Press; 2005.

Available at http://www.thecommunityguide.org/tobacco/deault.htm. Accessed July 1, 2010.

3. CDC. Best practices or comprehensive tobacco controlprograms2007. Atlanta, GA: US Department o Healthand Human Services, CDC; 2007. Available athttp://www.cdc.gov/tobacco/tobacco_control_programs/stateandcommunity/

best_practices. Accessed July 1, 2010.4. Institute o Medicine. Ending the tobacco problem: a blue-

print or the nation. Washington DC: National AcademiesPress; 2007.

5. CDC. CDC grand rounds: current opportunities in tobaccocontrol. MMWR 2010;59:48792.

6. Johnston LD, OMalley PM, Bachman JG, Schulenberg JE.rends in prevalence o use o cigarettes in grades 8, 10, and12. able 1. Ann Arbor, MI: University o Michigan; 2009.

Available at http://monitoringtheuture.org/data/09data.html#2009data-cigs . Accessed July 1, 2010.

TABLE 2. Percentage o high school students who were current cigarette users,* by sex, race/ethnicity, and grade Youth Risk Behavior Survey, United States, 19912009

1991 1993 1995 1997 1999 2001 2003 2005 2007 2009

Characteristic%

(95% CI)%

(95% CI)%

(95% CI)%

(95% CI)%

(95% CI)%

(95% CI)%

(95% CI)%

(95% CI)%

(95% CI)%

(95% CI)

Sex

Female 27.3

(23.931.0)

31.2

(29.133.4)

34.3

(31.037.7)

34.7

(31.837.6)

34.9

(32.337.7)

27.7

(25.630.0)

21.9

(19.224.9)

23.0

(20.425.8)

18.7

(16.521.1)

19.1

(17.221.0)Male 27.6(24.630.9)

29.8(27.432.3)

35.4(32.937.9)

37.7(35.040.6)

34.7(31.837.7)

29.2(26.732.0)

21.8(19.824.1)

22.9(20.725.3)

21.3(18.324.6)

19.8(17.821.9)

Race/Ethnicity**

White, non-Hispanic 30.9(27.634.5)

33.7(31.436.0)

38.3(35.641.1)

39.7(37.342.2)

38.6(35.541.9)

31.9(29.634.4)

24.9(22.427.5)

25.9(22.929.2)

23.2

(20.426.2)22.5

(20.025.2)

Female 31.7(27.136.7)

35.3(32.638.0)

39.8(36.343.5)

39.9(36.643.2)

39.1(35.442.9)

31.2(28.733.7)

26.6(23.030.5)

27.0(23.431.0)

22.5(19.625.7)

22.8(20.325.5)

Male 30.2(26.534.3)

32.2(29.435.0)

37.0(33.740.5)

39.6(35.843.5)

38.2(34.641.8)

32.7(29.735.9)

23.3(20.726.0)

24.9(22.227.7)

23.8(20.227.8)

22.3(18.926.0)

Black, non-Hispanic 12.6(10.215.5)

15.4(12.918.2)

19.1(16.122.6)

22.7(19.026.8)

19.7(15.824.3)

14.7(12.017.9)

15.1(12.418.2)

12.9(11.114.8)

11.6(9.514.1)

9.5(8.211.1)

Female 11.3(9.213.9)

14.4(11.917.4)

12.2(9.315.7)

17.4(13.821.7)

17.7(14.421.7)

13.3(10.117.2)

10.8(8.214.2)

11.9(10.213.8)

8.4(6.610.6)

8.4(6.510.9)

Male 14.1(10.119.4)

16.3(12.421.1)

27.8(22.533.9)

28.2(23.034.1)

21.8(15.429.9)

16.3(13.219.8)

19.3(15.823.5)

14.0(11.516.9)

14.9(11.718.8)

10.7(8.413.5)

Hispanic 25.3(22.528.2)

28.7(25.831.8)

34.0(28.739.6)

34.0(31.336.9)

32.7(29.036.6)

26.6(22.431.2)

18.4(16.120.9)

22.0(18.725.8)

16.7

(13.520.4)18.0

(16.020.2)

Female 22.9(19.227.1)

27.3(23.531.5)

32.9(27.439.0)

32.3(28.636.2)

31.5(26.836.5)

26.0(22.330.0)

17.7(15.619.9)

19.2(16.422.5)

14.6(11.318.8)

16.7(14.419.2)

Male 27.8(24.331.8)

30.2(26.733.8)

34.9(26.644.3)

35.5(31.939.2)

34.0(29.738.7)

27.2(20.635.0)

19.1(15.823.0)

24.8(20.030.4)

18.7

(15.0-23.2)19.4

(16.722.5)

School grade

9th 23.2(19.527.4)

27.8(25.430.3)

31.2(29.532.9)

33.4(28.438.9)

27.6(24.031.6)

23.9(21.127.0)

17.4(15.020.1)

19.7(17.522.1)

14.3

(11.917.1)13.5

(12.015.3)

10th 25.2(22.528.1)

28.0(24.731.6)

33.1(29.337.1)

35.3(31.239.7)

34.7(32.237.2)

26.9(23.830.3)

21.8(19.024.9)

21.4(18.424.8)

19.6(16.722.8)

18.3(15.921.0)

11th 31.6(27.835.7)

31.1(27.934.4)

35.9(32.039.9)

36.6(32.940.4)

36.0(33.139.1)

29.8(26.133.7)

23.6(20.527.0)

24.3(21.227.7)

21.6

(18.425.2)22.3

(19.625.2)

12th 30.1(25.734.8)

34.5(30.738.5)

38.2(34.641.9)

39.6(34.744.6)

42.8(37.248.5)

35.2(31.139.5)

26.2(23.429.3)

27.6(24.031.5)

26.5(22.530.8)

25.2(22.528.1)

* Smoked cigarettes on at least 1 day during the 30 days beore the survey. Linear, quadratic, and cubic trend analyses were conducted using a logistic regression model controlling or sex, race/ethnicity, and grade. Condence intervals. Signicant linear, quadratic, and cubic eects were detected (p


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802 MMWR / July 9, 2010 / Vol. 59 / No. 26

Nigeria has maintained a high incidence o wild

poliovirus (WPV) cases attributed to persistently highproportions o under- and unimmunized children,and, or many years, the country has served as a reser-voir or substantial international spread (1). In 2008,Nigeria reported 798 polio cases, the highest numbero any country in the world (2). Tis report providesan update on poliovirus epidemiology in Nigeriaduring the past 18 months, January 2009June 2010,and describes activities planned to interrupt transmis-sion. Reported WPV cases in Nigeria decreased to388 during 2009 (24% o global cases), and WPVincidence in Nigeria reached an all-time low during

JanuaryJune 2010, with only three reported cases.Cases o circulating type 2 vaccine-derived poliovi-rus (cVDPV2), which rst occurred in Nigeria in2005 (3), also declined, rom 148 during the 12months o 2009, to eight during the 6-month period,JanuaryJune 2010. One indicator o the eectivenesso immunization activities is the proportion o chil-dren with nonpolio acute faccid paralysis (AFP) whonever have received oral poliovirus vaccine (OPV). Inseven high-incidence northern states o Nigeria, thisproportion declined rom 17.6% in 2008 to 10.7%in 2009. During 20092010, increased engagement

o traditional, religious, and political leaders hasimproved community acceptance o vaccinationand implementation o high-quality supplementaryimmunization activities (SIAs). Enhanced surveillanceor polioviruses, urther strengthened implementationo SIAs, and immediate immunization responses tonewly identied WPV and cVDPV2 cases will bepivotal in interrupting WPV and cVDPV2 transmis-sion in Nigeria.

Immunization Activities

Routine immunization against polio in Nigeriaconsists o trivalent OPV (tOPV, types 1, 2, and 3) atbirth and at ages 6, 10, and 14 weeks. Immunizationcoverage is measured using both administrative data(estimated doses administered per targeted childpopulation, determined by ocial census numbers)and coverage surveys. In 2009, using administrativedata, national routine immunization coverage o chil-dren by age 12 months with three tOPV doses was

63% (range by state: 35%90%) (4). Using coverage

surveys, the estimated national coverage with threetOPV doses at 1223 months was 39%, but lowerin the northeast (28.6%) and northwest (24.3%)areas o Nigeria, including the seven high-incidencenorthern states (5).*

In addition to routine immunization, Nigeriaconducts SIAs or polio eradication using monova-lent OPV type 1 (mOPV1), monovalent OPV type3 (mOPV3), bivalent OPV types 1 and 3 (bOPV), ortOPV. Monovalent vaccines are more eective thantOPV in providing protection against the correspond-ing WPV serotype; bOPV is nearly equivalent to

mOPV and superior to tOPV in producing serocon-version to WPV1 and WPV3 (6). Tree national SIAswere conducted in 2009, using mOPV3, mOPV1and tOPV. Five subnational SIAs were conducted in2009, each using mOPV1, mOPV3, tOPV, or bothmOPV1 and mOPV3. During JanuaryJune 2010two national SIAs were conducted, one with bOPVand one with tOPV; bOPV, mOPV1, and mOPV3were used in three subnational SIAs (Figure 1).

Vaccination histories o children with nonpolioAFP are used to estimate OPV coverage amongthe population o children aged 659 months. Te

proportion o children with nonpolio AFP reportedto have never received an OPV dose (zero-dose chil-dren) rom the seven high-incidence northern statesdeclined rom 17.6% in 2008 to 10.7% in 2009(range: 0%17.0%), with the highest proportionsoccurring in Zamara and Kano states (able). In con-trast, the proportion o reported zero-dose childrenwas 2.2% in 13 other northern states and 1.8% in 17southern states in 2009. Te proportion o childrenwith nonpolio AFP reported to have received 4 OPVdoses was 37.4% in the seven high-incidence northernstates and 60.8% or the entire country.

Progress Toward Poliomyelitis Eradication Nigeria,January 2009June 2010

* For this report, high-incidence northern states are dened as statewith 0.8 conrmed WPV cases per 100,000 population during2008. Tey are Bauchi, Jigawa, Kaduna, Kano, Katsina, Yobe, andZamara.

Mass campaigns conducted during a short period (days to weeks)during which a dose o OPV is administered to all children aged


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MMWR / July 9, 2010 / Vol. 59 / No. 26 803

AFP SurveillanceAFP surveillance is monitored using World Health

Organization (WHO) targets or case detection andadequate stool specimen collection. Te national

annualized nonpolio AFP detection rate amongchildren aged


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804 MMWR / July 9, 2010 / Vol. 59 / No. 26

JanuaryMarch 2010. he proportion o LGAsmeeting both surveillance indicators (nonpolio AFPdetection rate meeting the target and adequate stoolspecimen collection rate) rose rom 78% in 2008 to86% in 2009.

WPV and cVDPV IncidenceReported WPV type 1 (WPV1) cases declined rom

67 during JanuaryJune 2009 to seven during JulyDecember 2009, and to one case during JanuaryJune2010 (provisional data, as o July 5, 2010) (Figure 2).

O the 75 WPV1 cases reported during the entire18-month period, January 2009June 2010, seven(9%) occurred in the seven high-incidence northernstates, 33 (44%) in other northern states, and 35(47%) in southern states. Te number o LGAs withWPV1 cases declined rom 49 during JanuaryJune2009 to one during JanuaryJune 2010 (Figure 2).Reported WPV type 3 (WPV3) cases declined rom290 during JanuaryJune 2009 to 24 during JulyDecember 2009, and to two during JanuaryJune2010. Only three cases o WPV have been reportedduring the irst 6 months o 2010. Among 316

WPV3 cases reported rom January 2009June 2010,240 (76%) occurred in the high-incidence northernstates, 75 (24%) in other northern states, and one(


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MMWR / July 9, 2010 / Vol. 59 / No. 26 805

FIGURE 2. Local government areas (LGAs) with laboratory-conrmed cases o wild poliovirus type 1 (WPV1) and type 3 (WPV3) NigeriaJanuaryJune 2009 and JanuaryJune 2010*

* During 2008, Bauchi, Jigawa, Kaduna, Kano, Katsina, Yobe, and Zamara had 0.8 conrmed WPV cases per 100,000 population and were dened as high-incidencenorthern states. During JanuaryJune 2010, conrmed WPV1 in Nigeria occurred only in Sokoto, and WPV3 occurred only in Delta and Zamara.

JanuaryJune 2009

WPV1 (n = 67)

Afected LGAs = 49

Zamara Katsina Jigawa Yobe

KanoKaduna Bauchi

Sokoto

Delta

WPV1 (n = 1)

Afected LGAs = 1

WPV3 (n = 290)

Afected LGAs = 147WPV3 (n = 2)

Afected LGAs = 2

JanuaryJune 2010

Zamara

KatsinaJigawa

Yobe

Kano

Kaduna Bauchi

Sokoto

Delta

Zamara

JigawaYobe

Kano

Kaduna Bauchi

Sokoto

Delta

Zamara JigawaYobe

Kano

Kaduna Bauchi

Sokoto

Delta

Katsina

Katsina


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806 MMWR / July 9, 2010 / Vol. 59 / No. 26

eases and Global Immunization Div, National Centeror Immunization and Respiratory Diseases, CDC.

Editorial Note

Since 2003, Nigeria has served as the majorreservoir or WPV1 and WPV3 circulation in WestArica and Central Arica (7). Over the past 8 years,WPV o Nigerian origin has been imported into 26countries in Arica, the Middle East, and Asia, andhas led to reestablished transmission (>12 months)in Chad and Sudan.

Factors related to high WPV incidence in Nigeriaduring the last decade have included loss o publiccondence in OPV during 20032004 (8), long-standing insuciencies in health inrastructure result-ing in low routine vaccination coverage, and poorlyimplemented SIAs that have ailed to reach >80% ochildren in high-risk states. With substantial reduc-

tions in WPV1, WPV3, and cVDPV2 cases duringJanuaryJune 2010 compared with the same periodin 2009, Nigeria has shown substantial progress, sug-gesting improvements in vaccine coverage with high-quality SIAs. Te increased engagement o traditional,religious, and political leadership at the ederal, state,and local levels has been instrumental in improving

vaccine acceptance and SIA implementation. I thisprogress can be sustained throughout the upcomingseason (JulySeptember), during which WPV trans-mission is traditionally high, WPV transmission inNigeria could be disrupted in the near uture. Progresselsewhere, including successul implementation osynchronized SIAs in West Arica and Central Aricato stem regional WPV circulation, would remove apotential threat o reimportation into Nigeria andultimately lead to a polio-ree Arica. Howevermultiple challenges must be overcome to sustain thegains in Nigeria.

Within the seven high-incidence northern states, ahigh proportion o children remain at risk as a resulto low routine immunization coverage and high birthrates. Tis report indicates that, during 20082009a substantial drop occurred in the proportion o chil-

dren with nonpolio AFP who had received no doses ovaccine (i.e., rom 17.6% in 2008 to 10.7% in 2009in the seven high-incidence states. However, even withthis decrease, in 2009, a majority o such children(50.7%) remained undervaccinated with 13 doseso OPV. Until the proportion o children vaccinatedwith 4 doses is >80% and the proportion o zerodose children is


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MMWR / July 9, 2010 / Vol. 59 / No. 26 807

exceeding targets at national and virtually all statelevels. Surveillance gaps might be occurring amongspecic subpopulations such as migrants in northernNigeria, including Fulani nomads, who have limitedaccess to immunization activities and health-careproviders. Further eorts to enhance and supplementAFP surveillance to detect WPV and cVDPV shouldinclude seeking reports rom nontraditional healers,testing waste water or polioviruses, and identiyingand improving surveillance in LGAs not meetingperormance criteria.

Reerences

1. CDC. Wild poliovirus type 1 and type 3 importations15countries, Arica, 20082009. MMWR 2009;58:35762.

2. CDC. Progress toward poliomyelitis eradicationNigeria,20082009. MMWR 2009;58:11504.

3. CDC. Update on vaccine-derived poliovirusesworldwide,January 2008June 2009. MMWR 2009;58:10026.

4. World Health Organization. Immunization surveillance,assessment, and monitoring. country immunization proleNigeria. Geneva, Switzerland: World Health Organization;2010. Available at http://apps.who.int/immunization_monitoring/en/globalsummary/countryproileselect.cm.

Accessed June 11, 2010.5. ICF Macro. Nigeria, 2008 demographic health survey, key

ndings. Calverton, MD: ICF Macro; 2008. Available athttp://www.measuredhs.com/pubs/pd/sr173/sr173.pd. AccessedFebruary 26, 2010.

6. World Health Organization. Advisory Committee onPoliomyelitis Eradication: recommendations on the use obivalent oral poliovirus vaccine types 1 and 3. Wkly EpidemiolRec 2009;84:28990.

7. CDC. Progress toward interruption o wild poliovirustransmissionworldwide, 2009. MMWR 2010;59:54550.

8. Jegede AS. What led to the Nigerian boycott o the poliovaccination campaign? PLoS Med 2007;4(3):e73.

9. Jenkins HE, Aylward RB, Gasasira A, et al. Eectiveness oimmunization against paralytic poliomyelitis in Nigeria. NEngl J Med 2008;359:166674.
http://www.measuredhs.com/pubs/pdf/sr173/sr173.pdfhttp://www.measuredhs.com/pubs/pdf/sr173/sr173.pdfhttp://www.measuredhs.com/pubs/pdf/sr173/sr173.pdfhttp://www.measuredhs.com/pubs/pdf/sr173/sr173.pdf


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808 MMWR / July 9, 2010 / Vol. 59 / No. 26

Despite recent declines in both incidence andmortality, colorectal cancer (CRC) remains the secondmost common cause o cancer deaths ater lung can-cer in the United States (1) and the leading cause ocancer deaths among nonsmokers. In 2006 (the mostrecent data available), 139,127 people were diagnosedwith colorectal cancer, and 53,196 people died (1).Screening or colorectal cancer is eective in reducingincidence and mortality by removal o premalignantpolyps and through early detection and treatment o

CDC Vital Signs is a new series o MMWRreports that will announce the latestresults or key public health indicators.

Vital Signs: Colorectal Cancer Screening Among AdultsAged 5075 Years United States, 2008

On July 6, this report was posted as an MMWREarly Release on theMMWRwebsite (http://www.cdc.gov/mmwr).

ABSTRACT

Background: Colorectal cancer (CRC) remains the second leading cause o cancer deaths inthe United States and the leading cause o cancer deaths among nonsmokers. Statistical mod-eling indicates that, i current trends in health behaviors, screening, and treatment continue,U.S. residents can expect to see a 36% decrease in the CRC mortality rate by 2020, comparedwith 2000.

Methods: Every 2 years, CDC uses Behavioral Risk Factor Surveillance System data to estimateup-to-date CRC screening prevalence in the United States. Adults aged 50 years were con-sidered to be up-to-date with CRC screening i they reported having a ecal occult blood test(FOB) within the past year or lower endoscopy (i.e., sigmoidoscopy or colonoscopy) within

the preceding 10 years. Prevalence was calculated or adults aged 5075 years based on currentU.S. Preventive Services ask Force recommendations.

Results: For 2008, the overall age-adjusted CRC screening prevalence or the United States was62.9% among adult respondents aged 5075 years, increased rom 51.9% in 2002. Amongthe lowest screening prevalences were those reported by persons aged 5059 years (53.9%),Hispanics (49.8%), persons with lower income (47.6%), those with less than a high schooleducation (46.1%), and those without health insurance (35.6%).

Conclusions: CRC screening rates continue to increase in the United States. Underscreeningpersists or certain racial/ethnic groups, lower socioeconomic groups, and the uninsured.

Implications or Public Health Practice: Health reorm is anticipated to reduce nancialbarriers to CRC screening, but many actors infuence CRC screening. Te public health and

medical communities should use methods, including client and provider reminders, to ensuretest completion and receipt o ollow-up care. Public health surveillance should be expanded andcommunication eorts enhanced to help the public understand the benets o CRC screening.

cancer (2). CRC screening prevalence has improvedover the past decade (3); however, in 2006, approxi-mately 30% o eligible U.S. residents had never beenscreened or CRC (3). Tis Vital Signs report updatesscreening prevalence in the United States using datarom the 2008 Behavioral Risk Factor SurveillanceSystem (BRFSS) survey or persons aged 5075 yearsbased on recommendations or up-to-date CRCscreening rom the U.S. Preventive Services ask Force(USPSF) (4).

MethodsBRFSS is a state-based, random-digit dialed

telephone survey o the civilian, noninstitutional-ized adult population that collects inormation on
http://www.cdc.gov/mmwrhttp://www.cdc.gov/mmwr


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MMWR / July 9, 2010 / Vol. 59 / No. 26 809

use declined rom 20.9% o CRC screening in 2002

to 14.1% in 2008.

Conclusions and CommentTe results in this Vital Signs report indicate that

the prevalence o up-to-date CRC screening in theUnited States is continuing to increase. An increase(rom 38% in 2000 to 53% in 2008) also has beenreported using National Health Interview Surveydata (6). However, in 2008, certain populations inthe United States remained underscreened, includingthose with lower socioeconomic status, Hispanics,and those without health insurance. Multiple actors

might explain these dierences, including patienteducation and income, as well as provider and clinicalsystems actors. As in previous surveys, the 2008 sur-vey indicated notable geographic dierences in CRCscreening prevalence. Te reasons or these geographicdierences remain unknown, but screening capac-ity, lack o physician availability, and patient actorsincluding income, education, and lack o awarenesshave been proposed as reasons (6).

CRC screening rates continue to increase in theUnited States. Additional improvements in screen-ing prevalence might have substantive impact on

CRC mortality. Statistical modeling indicates that,i current trends in health behaviors, screening, andtreatment continue, U.S. residents can expect to seea 36% decrease in the CRC mortality rate by 2020,compared with 2000 (7).

Insucient evidence exists to recommend onebest test or CRC screening. Several proven, eec-tive tests exist and are recommended by USPSF,including annual FOB, sigmoidoscopy every 5 years,

Key Points or the Public

Over53,000U.S.residentsdieeachyearrom colorectal cancer.

1,900deathscouldbepreventedeachyearor every 10% increase in colonoscopyscreening.

Only36%ofmenandwomenwithouthealth insurance are up-to-date withcolorectal cancer screening.

Additionalinformationisavailableathttp://www.cdc.gov/vitalsigns.

health risk behaviors, preventive health practices, andhealth-care access in the United States (5). Every 2years (in even numbered years), respondents aged 50years are asked whether they have ever used a specialkit at home to determine whether the stool containsblood (ecal occult blood test [FOB]), whether

they have ever had a tube inserted into the rectumto view the colon or signs o cancer or other healthproblems (sigmoidoscopy or colonoscopy), and whenthese tests were last perormed. CDC calculated theprevalence o adults who reported having had anFOB within the past year or lower endoscopy (i.e.,sigmoidoscopy or colonoscopy) within the preceding10 years, as was done in previous reports (3). Based onthe U.S. Preventive Services ask Force recommendedscreening age, this analysis was restricted to personsaged 5075 years (4). Data were aggregated across all50 states and the District o Columbia. Respondentswho reused to answer, had a missing answer, or whoanswered dont know/not sure were excluded romanalysis o the question.

Te median Council o American Survey andResearch Organizations (CASRO) response rate was53.3%, and the median CASRO cooperation ratewas 75.0% (5). Data were weighted to the age, sex,and racial/ethnic distribution o each states adultpopulation using intercensal estimates and were age-standardized to the 2008 BRFSS population.

ResultsTe 2008 BRFSS survey was administered to414,509 respondents, o whom 201,157 were aged5075 years. Te overall, age-adjusted combined up-to-date CRC screening (FOB and lower endoscopy)prevalence or the United States was 62.9% amongadult respondents aged 5075 years (able). Amongthe lowest screening prevalences were those reportedby persons aged 5059 years (53.9%), Hispanics(49.8%), persons with lower income (47.6%), thosewith less than a high school education (46.1%), andthose without health insurance (35.6%). Similar pat-

terns were noted or FOB in the preceding year andor lower endoscopy in the preceding 10 years. Tepercentage o persons up-to-date with CRC screen-ing ranged rom 53.2% in Oklahoma to 74.1% inMassachusetts (Figure 1). States with the highestscreening prevalence were concentrated in the north-eastern United States. CRC screening increased rom51.9% in 2002 to 62.9% in 2008 (Figure 2). Duringthat period, use o endoscopy increased, while FOB
http://www.cdc.gov/vitalsignshttp://www.cdc.gov/vitalsigns


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810 MMWR / July 9, 2010 / Vol. 59 / No. 26

and colonoscopy every 10 years (4). In addition tomaximizing prevalence o CRC screening to reducemorbidity and mortality, ensuring proper ollow-upo abnormal results is important to maximize thebenets o screening (4).

Te ndings in this report are subject to at leastthree limitations. First, because BRFSS is a telephone

survey o residential households, only adults in house-holds with landline telephones are represented; there-ore, the results might not be representative o the U.S.population. Evidence suggests that adults living inwireless-only households tend to be younger and havelower incomes, and are more likely to be members ominority populations, which might result in eitherunderestimates or overestimates. Second, responsesare sel-reported and not conrmed by review o

medical records. Finally, the survey response rate walow, which increases the risk or response bias.

Policy changes in the Patient Protection andAordable Care Act are expected to remove nancialbarriers to CRC screening by expanding insurancecoverage and eliminating cost sharing in Medicareand private plans, but additional barriers remain

(8). Evidence-based, systems-change interventionsincluding client and provider reminders to ensuretest completion and receipt o ollow-up care, havebeen shown by the Guide to Community PreventiveServices*to increase CRC screening; however, theseapproaches have not been widely adopted in clinica

TABLE. Percentage o respondents aged 5075 years who reported receiving a ecal occult blood test (FOBT) within 1year, or a lower endoscopy* within 10 years, by selected characteristices Behavioral Risk Factor Surveillance System(BRFSS), United States, 2008

Characteristic

FOBT within 1 yrLower endoscopy

within 10 yrsFOBT within 1 yr or lowerendoscopy within 10 yrs

% (95% CI) % (95% CI) % (95% CI)

Overall 14.1 (13.814.4) 58.5 (58.159.0) 62.9 (62.563.3)

Age group (yrs)5059 11.0 (10.611.4) 49.7 (49.050.3) 53.9 (53.354.5)

6069 17.0 (16.517.6) 66.7 (66.067.3) 71.1 (70.571.7)

7075 18.2 (17.419.1) 71.4 (70.472.3) 75.8 (74.876.7)

SexMen 14.6 (14.215.1) 59.0 (58.459.7) 63.2 (62.663.9)

Women 13.6 (13.213.9) 58.1 (57.658.6) 62.6 (62.063.1)

RaceWhite 13.8 (13.514.1) 59.8 (59.460.2) 63.9 (63.564.4)Black 17.2 (16.018.6) 56.6 (55.058.2) 62.0 (60.563.6)

Asian/Pacic Islander 13.5 (11.016.6) 51.1 (47.255.0) 55.5 (51.659.4)

American Indian/Alaska Native 15.1 (12.318.3) 50.7 (46.754.6) 54.4 (50.458.4)Other 11.8 (9.714.1) 43.7 (40.646.9) 49.3 (46.152.6)

EthnicityHispanic 12.0 (10.513.7) 45.8 (43.648.0) 49.8 (47.652.0)

Non-Hispanic 14.3 (14.014.6) 59.8 (59.460.2) 64.2 (63.864.6)

Education level< High school 11.3 (10.412.3) 41.8 (40.143.5) 46.1 (44.447.8)

High school graduate/GED 13.3 (12.813.8) 53.3 (52.554.0) 58.1 (57.358.8)

Some college/tech school 15.0 (14.415.6) 59.2 (58.460.0) 63.7 (63.064.5)

College graduate 14.9 (14.315.4) 66.9 (66.367.6) 70.6 (70.071.3)

Annual household income ($)


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MMWR / July 9, 2010 / Vol. 59 / No. 26 811

practice. Physician recommendation remains animportant but underutilized acilitator o CRCscreening. Improving cancer screening benchmarksin clinical practice should be a high priority ornew patient-care improvement models such as thepatient-centered medical home (9). Case manage-

ment approaches such as patient navigation models tomaximize patient participation and ensure adequateollow-up also appear promising (10). Utah has usedmultiple approaches to improve its CRC screeningprevalence. Reported use o CRC endoscopy increasedrom 32.1% in 1999 to 51.9% in 2005 through theuse o small media (e.g., videos, letters, brochures, andfyers) and large media campaigns and by providingCRC screening tests (mainly FOB) or those whocould not aord it.

CDCs CRC screening program, unded in 2009,places emphasis on population-based approaches toincrease CRC screening. Te program is based onthe recommendations o the Guide to CommunityPreventive Services, which has identied evidence-based interventions to increase cancer screening incommunities by targeting providers and the generalpopulation. Full implementation o these recommen-dations, including a ocus on reaching disadvantagedpopulations, can achieve the goal o more completepopulation coverage.

Surveillance o cancer screening and diagnosticactivities currently is limited to population surveys

and is only collected every other year by BRFSS.Additional surveillance eorts might guide popula-tion-based outreach, identiy and target unscreenedpopulations, and ensure adequate ollow-up (10).CDC and state and local health departments shoulddevelop and monitor centralized population-basedregistries o persons eligible or screening, provideappropriate outreach, and ensure adequate ollow-up. Tese registries could be developed to track andpromote screening awareness and subsequent utiliza-tion through communication media (e.g., telephone,mail, or electronic reminders) or use o peer outreach.

Registries o underserved populations, includingMedicaid enrollees and those without a regular pro-vider, could be used to promote screening amongpersons in vulnerable populations at greater risk.

FIGURE 2. Percentage o respondents aged 5075 yearswho reported receiving a ecal occult blood test (FOBT)within 1 year or a lower endoscopy* within 10 years Behavioral Risk Factor Surveillance System (BRFSS), UnitedStates, 2002, 2004, 2006, and 2008

0

10

20

30

40

50

60

70

2002 2004 2006 2008

Combined tests

Lower endoscopy

FOBT

Year

Percentage

* Sigmoidoscopy or colonoscopy. Percentages standardized to the age distribution in the 2008 BRFSS

survey.

FIGURE 1. Percentage o respondents aged 5075 years who reported receivinga ecal occult blood test (FOBT) within 1 year or a lower endoscopy* within 10years, by state Behavioral Risk Factor Surveillance System (BRFSS), UnitedStates, 2008

68.374.1

64.168.2

61.264.0

57.061.1

53.256.9

* Sigmoidoscopy or colonoscopy. Percentages standardized to the age distribution in the 2008 BRFSS survey.

Additional inormation available at http://health.utah.gov/ucan/partners/pub/pds/utahcancerplan080206.pd.

Available at http://www.cdc.gov/cancer/crccp.
http://health.utah.gov/ucan/partners/pub/pdfs/utahcancerplan080206.pdfhttp://health.utah.gov/ucan/partners/pub/pdfs/utahcancerplan080206.pdfhttp://www.cdc.gov/cancer/crccphttp://www.cdc.gov/cancer/crccphttp://health.utah.gov/ucan/partners/pub/pdfs/utahcancerplan080206.pdfhttp://health.utah.gov/ucan/partners/pub/pdfs/utahcancerplan080206.pdf


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812 MMWR / July 9, 2010 / Vol. 59 / No. 26

Reported by

LC Richardson, MD, SH Rim, MPH, M Plescia, MD;Div o Cancer Prevention and Control, National CenterChronic Disease Prevention and Health Promotion,CDC.

Reerences1. US Cancer Statistics Working Group. United States cancer

statistics: 19992006 incidence and mortality web-basedreport. Atlanta, GA: US Department o Health and HumanServices, CDC, and National Cancer Institute; 2010.

Available at http://www.cdc.gov/uscs . Accessed June 23,2010.

2. Winawer SJ, Zauber AG, Ho MN, et al. Prevention o colorectalcancer by colonoscopic polypectomy. Te National PolypStudy Workgroup. N Engl J Med 1993;329:197781.

3. CDC. Use o colorectal cancer testsUnited States, 2002,2004, and 2006. MMWR 2008;57:2538.

4. US Preventive Services ask Force. Screening or colorectalcancer. Rockville, MD: Agency or Healthcare Research andQuality; 2008. Available at http://www.ahrq.gov/clinic/

uspst/uspscolo.htm. Accessed June 20, 2010.5. CDC. Behavioral Risk Factor Surveillance System. Atlanta,

GA: US Department o Health and Human Services, CDC;2010. Available at http://www.cdc.gov/brss . Accessed June20, 2010.

6. American Cancer Society. Cancer prevention and earlydetection acts and gures 2010. Atlanta, GA: American CancerSociety; 2010. Available at http://www.cancer.org/research/canceractsgures/cancerpreventionearlydetectionactsguresindex. Accessed July 6, 2010.

7. Edwards BK, Ward E, Kohler BA, et al. Annual report tothe nation on the status o cancer, 19752006, eaturingcolorectal cancer trends and impact o interventions (riskactors, screening, and treatment) to reduce uture ratesCancer 2010;116:54473.

8. Te Patient Protection and Aordable Care Act. Pub. LNo. 111-148. Available at http://rwebgate.access.gpo.govcgi-bin/getdoc.cgi?dbname=111_cong_bills&docid=:h3590enr.txt.pd. Accessed June 20, 2010.

9. Wender RC, Altshuler M. Can the medical home reduce cancemorbidity and mortality? Prim Care 2009;36:84558.

10. New York City Department o Health and Mental HygieneA practical guide to increasing screening colonoscopy: provenmethods or health care acilities to prevent colorectal cancedeaths. New York, NY: New York City Department o Healthand Mental Hygiene; 2006. Available at http://www.nyc.govhtml/doh/downloads/pd/cancer/cancer-colonoscopy-guide.pd. Accessed June 20, 2010.
http://www.cdc.gov/uscshttp://www.ahrq.gov/clinic/uspstf/uspscolo.htmhttp://www.ahrq.gov/clinic/uspstf/uspscolo.htmhttp://www.cdc.gov/brfsshttp://www.cancer.org/research/cancerfactsfigures/cancerpreventionearlydetectionfactsfigures/indexhttp://www.cancer.org/research/cancerfactsfigures/cancerpreventionearlydetectionfactsfigures/indexhttp://www.cancer.org/research/cancerfactsfigures/cancerpreventionearlydetectionfactsfigures/indexhttp://frwebgate.access.gpo.gov/cgi-bin/getdoc.cgi?dbname=111_cong_bills&docid=f:h3590enr.txt.pdfhttp://frwebgate.access.gpo.gov/cgi-bin/getdoc.cgi?dbname=111_cong_bills&docid=f:h3590enr.txt.pdfhttp://frwebgate.access.gpo.gov/cgi-bin/getdoc.cgi?dbname=111_cong_bills&docid=f:h3590enr.txt.pdfhttp://www.nyc.gov/html/doh/downloads/pdf/cancer/cancer-colonoscopy-guide.pdfhttp://www.nyc.gov/html/doh/downloads/pdf/cancer/cancer-colonoscopy-guide.pdfhttp://www.nyc.gov/html/doh/downloads/pdf/cancer/cancer-colonoscopy-guide.pdfhttp://www.nyc.gov/html/doh/downloads/pdf/cancer/cancer-colonoscopy-guide.pdfhttp://www.nyc.gov/html/doh/downloads/pdf/cancer/cancer-colonoscopy-guide.pdfhttp://www.nyc.gov/html/doh/downloads/pdf/cancer/cancer-colonoscopy-guide.pdfhttp://frwebgate.access.gpo.gov/cgi-bin/getdoc.cgi?dbname=111_cong_bills&docid=f:h3590enr.txt.pdfhttp://frwebgate.access.gpo.gov/cgi-bin/getdoc.cgi?dbname=111_cong_bills&docid=f:h3590enr.txt.pdfhttp://frwebgate.access.gpo.gov/cgi-bin/getdoc.cgi?dbname=111_cong_bills&docid=f:h3590enr.txt.pdfhttp://www.cancer.org/research/cancerfactsfigures/cancerpreventionearlydetectionfactsfigures/indexhttp://www.cancer.org/research/cancerfactsfigures/cancerpreventionearlydetectionfactsfigures/indexhttp://www.cancer.org/research/cancerfactsfigures/cancerpreventionearlydetectionfactsfigures/indexhttp://www.cdc.gov/brfsshttp://www.ahrq.gov/clinic/uspstf/uspscolo.htmhttp://www.ahrq.gov/clinic/uspstf/uspscolo.htmhttp://www.cdc.gov/uscs


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MMWR / July 9, 2010 / Vol. 59 / No. 26 813

Breast cancer remains the most commonly diag-nosed cancer and the second leading cause o cancerdeaths among women in the United States. In 2006(the most recent data available), approximately191,410 women were diagnosed with invasive breastcancer, and 40,820 women died (1). Te incidenceand mortality have been declining since 1996 at arate o approximately 2% per year (2), possibly as aresult o widespread screening with mammographyand the development o more eective therapies (3).Mammography use declined slightly in 2004, but roseagain in 2006 (4,5). Tis Vital Signs report updatesmammography screening prevalence in the UnitedStates, using data rom the 2008 Behavioral RiskFactor Surveillance System (BRFSS).

Vital Signs: Breast Cancer Screening Among WomenAged 5074 Years United States, 2008

On July 6, this report was posted as an MMWREarly Release on theMMWRwebsite (http://www.cdc.gov/mmwr).

ABSTRACT

Background: Breast cancer remains the second leading cause o cancer deaths or women in theUnited States. Screening with treatment has lowered breast cancer mortality.

Methods: Every 2 years, CDC uses Behavioral Risk Factor Surveillance System data to estimatemammography prevalence in the United States. Up-to-date mammography prevalence is calcu-lated or women aged 5074 years who report they had the test in the preceding 2 years.

Results: For 2008, overall, age-adjusted, up-to-date mammography prevalence or U.S. womenaged 5074 years was 81.1%, compared with 81.5% in 2006. Among the lowest prevalencesreported were those by women aged 5059 years (79.9%), persons who did not nish highschool (72.6%), American Indian/Alaska Natives (70.4%), those with annual household income


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814 MMWR / July 9, 2010 / Vol. 59 / No. 26

prevalences reported were those by women aged5059 years (79.9%), persons who did not nishhigh school (72.6%), American Indian/Alaska Native(70.4%), those with annual household income40years who had a mammogram within the past 2 years.*

Te target was met in 2003 and exceeded by 11 per-centage points in 2008. Nonetheless, approximately7 million eligible women in the United States are nobeing screened regularly, and they remain at greaterrisk o death rom breast cancer. One recent reportestimated that as many as 560 breast cancer deathscould be prevented each year with each 5% increasein mammography (8). One successul program thareaches out to minority, low income, uninsuredwomen is the National Breast and Cervical CanceEarly Detection Program. Te program has providedhigh quality screening, diagnostic and treatment ser

vices or the past 20 years.Mammography utilization is inluenced by

multiple actors, including patient and providercharacteristics, health-care norms, and access to andavailability o health-care services. Similar to previou

a missing answer, or answered dont know/not surewere excluded.

Te median Council o American Survey andResearch Organizations (CASRO) response rate was 53.3%, and the median CASRO cooperationrate was 75.0% (6). Data were weighted to the age,

sex, and racial and ethnic distribution o each statesadult population using intercensal estimates and were age-standardized to the 2008 BRFSS emalepopulation.

ResultsIn 2008, the BRFSS survey was administered to

414,509 respondents, o whom 120,095 were womenaged 5074 years. Te age-adjusted prevalence oup-to-date mammography or women overall in theUnited States was 81.1% (able). Among the lowest

TABLE. Percentage o women aged 5074 years whoreported receiving up-to-date* mammography, by selectedcharacteristics Behavioral Risk Factor SurveillanceSystem (BRFSS), United States, 2008

Characteristic No. % (95% CI)

Total 117,450 81.1 (80.781.6)

Age group (yrs)5059 52,421 79.9 (79.280.5)6069 46,711 82.4 (81.883.0)

7074 18,318 82.7 (81.783.7)

RaceWhite 101,245 81.4 (81.081.8)Black 9,805 82.1 (80.583.7)

Asian/Pacic Islander 1,665 80.4 (75.984.3)

American Indian/Alaska Native

1,736 70.4 (65.674.7)

Other 2,257 77.0 (73.480.3)

EthnicityHispanic 4,886 81.4 (79.183.4)

Non-Hispanic 112,115 81.1 (80.781.5)

Education level


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MMWR / July 9, 2010 / Vol. 59 / No. 26 815

analyses, the analysis in this report ound pocketso mammography underscreening among severallarge U.S. populations. For example, the screening

rate varied considerably by geography and was low-est in west-central states, the states with the lowestpopulation densities as well as the states with theewest mammography acilities.A study rom exashighlighted the association between mammographysupply and mammography use at the county level.Counties with no mammography units had the lowestmammography utilization (9).

he passage o the Patient Protection andAordability Act should remove the nancial barrierto mammography screening by expanding coverageand eliminating cost sharing in Medicare and pri-

vate plans; however, barriers remain. For example,in 2008 the dierence in mammography prevalencebetween women with and without health insurancewas 27.5%. Even among women with health insur-ance, 16.2% had not received mammography in thepreceding 2 years. Similar dierences in receipt omammography by insurance status were noted in a2009 study (9). Tese ndings suggest new roles orpublic health to improve screening through increasededucation o women and providers, and throughadditional targeted outreach to underscreened groupsincluding lower SES, uninsured and select minority

groups. Several evidence-based interventions arerecommended by the Guide to Community PreventiveServices to increase mammography screening in

communities.** Tese include sending client remind-ers to women, using small media (e.g., videos, letters,fyers, and brochures), and reducing structural barriers(e.g., providing more convenient hours and increasing

Key Points or the Public

Oneinvewomenaged5074isnotup-to-date with mammograms.

Over40,000U.S.womendieeachyearrom breast cancer.

560deathscanbepreventedeachyearor each 5% increase in mammography.

Additionalinformationisavailableathttp://www.cdc.gov/vitalsigns.

Additional inormation available at http://www.rontierus.org/ 2000update.htm and http://www.shepscenter.unc.edu/rural/maps/Frontier_counties07.pd.

Additional inormation available at http://www.gao.gov/new.items/d06724.pd.

FIGURE 2. Percentage o women aged 5074 years whoreported receiving up-to-date* mammography Behavioral Risk Factor Surveillance System (BRFSS),United States, 1997, 1998, 1999, 2000, 2002, 2004, 2006,and 2008

40

50

60

70

80

90

100

199 7 1 998 199 9 2 000 200 2 2 004 2006 20 08

Year

Percentage

* Within the preceding 2 years. Percentages standardized to the age distribution in the 2008 BRFSS

survey.

FIGURE 1. Percentage o women aged 5074 years who reported receivingup-to-date* mammography, by state Behavioral Risk Factor SurveillanceSystem (BRFSS), United States, 2008

83.989.8

81.783.8

79.981.6

76.879.8

72.176.7

* Within the preceding 2 years. Percentages standardized to the age distribution in the 2008 BRFSS survey.

** Additional inormation available at http://www.thecommunityguide.org/index.htm.
http://www.cdc.gov/vitalsignshttp://www.cdc.gov/vitalsignshttp://www.frontierus.org/2000update.htmhttp://www.frontierus.org/2000update.htmhttp://www.shepscenter.unc.edu/rural/maps/Frontier_counties07.pdfhttp://www.shepscenter.unc.edu/rural/maps/Frontier_counties07.pdfhttp://www.gao.gov/new.items/d06724.pdfhttp://www.gao.gov/new.items/d06724.pdfhttp://www.thecommunityguide.org/index.htmhttp://www.thecommunityguide.org/index.htmhttp://www.thecommunityguide.org/index.htmhttp://www.thecommunityguide.org/index.htmhttp://www.gao.gov/new.items/d06724.pdfhttp://www.gao.gov/new.items/d06724.pdfhttp://www.shepscenter.unc.edu/rural/maps/Frontier_counties07.pdfhttp://www.shepscenter.unc.edu/rural/maps/Frontier_counties07.pdfhttp://www.frontierus.org/2000update.htmhttp://www.frontierus.org/2000update.htmhttp://www.cdc.gov/vitalsigns


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816 MMWR / July 9, 2010 / Vol. 59 / No. 26

attention to language, health literacy, and culturalactors). Surveillance with targeted outreach, casemanagement, and quality assurance through systemschange are productive uture roles or public healthagencies to improve the delivery o clinical preventiveservices in the era o health reorm.

Te ndings in this report are subject to at leastthree limitations. First, because BRFSS is a telephonesurvey o residential households, only women inhouseholds with landline telephones participated;thereore, the results might not be representative oall women. Second, responses are sel-reported andnot conrmed by review o medical records. Finally,the survey response rate was low, which increases therisk or response bias.

Many actors infuence a womans intent andability to access screening services, including socio-economic status, awareness o the benets o screen-ing, and mammography acceptability and availability(10). However, the most common reason women giveor not having a mammogram is that no one recom-mended the test; thereore, health-care providers havethe most important role in increasing the prevalenceo up-to-date mammography among women in theUnited States (10).

Reported by

LC Richardson, MD, SH Rim, MPH, M Plescia, MD,Div o Cancer Prevention and Control, National Centeror Chronic Disease Prevention and Health Promotion,CDC.

Reerences

1. US Cancer Statistics Working Group. United States cancestatistics: 19992006 incidence and mortality web-basedreport. Atlanta, GA: US Department o Health and HumanServices, CDC, and National Cancer Institute; 2010. Availablat: http://www.cdc.gov/uscs. Accessed June 23, 2010.

2. Edwards BK, Ward E, Kohler BA, et al. Annual report to

the nation on the status o cancer, 19752006, eaturingcolorectal cancer trends and impact o interventions (riskactors, screening, and treatment) to reduce uture ratesCancer 2010;116:54473.

3. Berry DA, Cronin KA, Plevritis SK, et al. Cancer Interventionand Surveillance Modeling Network (CISNE) collaboratorsEect o screening and adjuvant therapy on mortality rombreast cancer. N Engl J Med 2005 Oct 27;353:178492.

4. CDC. Health, United States, 2009: with special eature onmedical technology. Hyattsville, MD: US Department oHealth and Human Services, CDC, National Center oHealth Statistics; 2010. Available at http://www.cdc.govnchs/data/hus/hus09.pd. Accessed June 20, 2010.

5. Miller JW, King JB, Ryerson AB, Eheman CR, White MCMammography use rom 2000 to 2006: state-level trends withcorresponding breast cancer incidence rates. Am J Roentgeno2009;192:35260.

6. CDC. Behavioral Risk Factor Surveillance System. AtlantaGA: US Department o Health and Human Services, CDC2010. Available at http://www.cdc.gov/brss . Accessed June20, 2010.

7. US Preventive Services ask Force. Screening or breast cancerrecommendation statement. Rockville, MD: Agency oHealthcare Research and Quality; 2009. Available at http:/

www.ahrq.gov/clinic/uspst09/breastcancer/brcanrs.htmAccessed June 20, 2010.

8. Farley A, Dalal MA, Mostashari F, Frieden R. Deathspreventable in the U.S. by improvements in use o clinicapreventive services. Am J Prev Med 2010;38:6009.

9. Elting LS, Cooksley CD, Bekele BN, et al. Mammographycapacity impact on screening rates and breast cancer stage a

diagnosis. Am J Prev Med 2009;37:1028.10. Schueler KM, Chu PW, Smith-Bindman R. Factors

associated with mammography utilization: a systematicquantitative review o the literature. J Womens Health2008;17:147798.
http://www.cdc.gov/uscshttp://www.cdc.gov/nchs/data/hus/hus09.pdfhttp://www.cdc.gov/nchs/data/hus/hus09.pdfhttp://www.cdc.gov/brfsshttp://www.ahrq.gov/clinic/uspstf09/breastcancer/brcanrs.htmhttp://www.ahrq.gov/clinic/uspstf09/breastcancer/brcanrs.htmhttp://www.ahrq.gov/clinic/uspstf09/breastcancer/brcanrs.htmhttp://www.ahrq.gov/clinic/uspstf09/breastcancer/brcanrs.htmhttp://www.cdc.gov/brfsshttp://www.cdc.gov/nchs/data/hus/hus09.pdfhttp://www.cdc.gov/nchs/data/hus/hus09.pdfhttp://www.cdc.gov/uscs


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MMWR / July 9, 2010 / Vol. 59 / No. 26 817

birthing hospitals and local health departments tosupport postpartum vaccination o mothers and close

contacts o newborns.Reported by

K Winter, MPH, K Harriman, PhD, R Schechter, MD,E Yamada, MD, J Talarico, DO, G Chavez, MD, Cali-ornia Dept o Public Health.

Reerences

1. CDC. Manual or the surveillance o vaccine-preventablediseases. Atlanta, GA: US Department o Health and HumanServices, CDC; 2008.

2. Farizo KM, Cochi SL, Zell ER, Brink EW, Wassilak SG,Patriarca PA. Epidemiologic eatures o pertussis in the UnitedStates, 19801989. Clin Inect Dis 1992;14:70819.

3. CDC. Prevention o pertussis, tetanus, and diphtheria amongpregnant and postpartum women and their inants. MMWR2008;57(No. RR-4).

Salmonella Newport Inections Associatedwith Consumption o UnpasteurizedMilk Utah, AprilJune 2010

On April 29, 2010, the Utah Department oHealth (UDOH) was notiied o three cases oSalmonella enterica serotype Newport inection. Tethree patients recently had consumed unpasteurizedmilk purchased rom a store in northern Utah (storeA). In Utah, unpasteurized milk can be sold legally atlicensed dairies or by licensed dairies at dairy-ownedretail stores meeting specic requirements (1). Acentral Utah dairy licensed to sell unpasteurized milk(dairy A) owns and sells unpasteurized milk at store Aand a second northern Utah store (store B). By May 3,2010, three additional patients with S. Newport inec-tions had been reported; all recently had consumedunpasteurized milk purchased rom store A. UDOHnotied the Utah Department o Agriculture andFood (UDAF) o the suspected association between

illness and unpasteurized milk consumption, andUDAF suspended sales o unpasteurized milk at thetwo stores on May 3, 2010.

During April 29June 3, 2010, a total o 10S. Newport cases were reported to UDOH; all 10patients had consumed unpasteurized milk romstore A (seven patients) or store B (three patients).he patients ranged in age rom 2 to 56 years(median: 21 years); six were emale. One patient was

Pertussis Caliornia, JanuaryJune 2010

Te number o pertussis cases reported to the

Caliornia Department o Public Health (CDPH)has increased substantially during 2010. Te increasein cases was rst noted in late March among patientsadmitted to a childrens hospital. During January 1June 30, 2010, a total o 1,337 cases were reported, a418% increase rom the 258 cases reported during thesame period in 2009. All cases either met the Councilo State and erritorial Epidemiologists denitionsor conrmed or probable pertussis or had an acutecough illness and Bordetella pertussisspecic nucleicacid detected by polymerase chain reaction romnasopharyngeal specimens (1).

During JanuaryJune in Caliornia, the incidenceo pertussis was 3.4 cases per 100,000 population.County rates ranged rom zero to 76.9 cases per100,000 (median: 2.0 cases). By age group, incidencewas highest (38.5 cases per 100,000) among inantsaged


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818 MMWR / July 9, 2010 / Vol. 59 / No. 26

MMWR on Facebook and Twitter

MMWR reports now can be accessed on socialnetworking websites Facebook and witter. Readerscan download and comment on MMWR weeklyreports, recommendations and reports, surveillance

summaries, and podcasts rom theMMWRwebsite.Readers can ollowMMWRon Facebook by visitinghttp://www.acebook.com/cdcmmwr, and on witterby visiting http://www.twitter.com/cdcmmwr.

hospitalized. Isolates rom all 10 patients were identi-ed as indistinguishable by two-enzyme pulsed-eldgel electrophoresis (PFGE), with pattern combinationUJJPX01.098/UJJPA26.009, and were sensitive toroutinely used antibiotics. Cultures o rozen, unpas-teurized milk samples stored at dairy A rom batches

o milk sold during the outbreak period yielded S.Newport isolates indistinguishable by PFGE romthe outbreak strain. An inspection o dairy A onMay 7, 2010, did not reveal any obvious sources ocontamination.

On May 12, 2010, on the basis o coliorm testresults within legal limits, the dairy was permitted toresume sales o unpasteurized milk. Ongoing test-ing includes monthly screening or Salmonella spp.in retail samples o unpasteurized milk. As o June21, 2010, no additional cases had been reportedto UDOH. Consumption o unpasteurized dairy

Announcement

products poses a risk or oodborne illness (2), andconsumers o unpasteurized milk should be awareo this risk.

Reported by

JM Hall, MPH, RT Rols, MD, RK Herlihy, MD, MPS

Dimond, MPH, Bur o Epidemiology, Utah Dept oHealth; J Holbrook, MPH, Utah County Health DeptLH Smith, JM Wagner, Unifed State LaboratoriesPublic Health, Utah Dept o Health; RW Clark, MPHUtah Dept o Agriculture and Food. WA Lanier, DVMEIS Ocer, CDC.

Reerences

1. Utah Dairy Act. Utah Code sec 4-3-14. Available at http://leutah.gov/~code/ILE04/htm/04_03_001400.htm . Accessed

July 1, 2010.2. Oliver SP, Boor KJ, Murphy SC, Murinda SE. Food saety

hazards associated with consumption o raw milk. FoodbornPath Dis 2009;6:793806.
http://www.facebook.com/cdcmmwrhttp://www.twitter.com/cdcmmwrhttp://le.utah.gov/~code/TITLE04/htm/04_03_001400.htmhttp://le.utah.gov/~code/TITLE04/htm/04_03_001400.htmhttp://le.utah.gov/~code/TITLE04/htm/04_03_001400.htmhttp://le.utah.gov/~code/TITLE04/htm/04_03_001400.htmhttp://www.twitter.com/cdcmmwrhttp://www.facebook.com/cdcmmwr


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MMWR / July 9, 2010 / Vol. 59 / No. 26 819

QuickStats

FROM HE NAIONAL CENER FOR HEALH SAISICS

Never-Married Females and Males Aged 1519 Years Who HaveEver Had Sexual Intercourse* National Survey o Family Growth,

United States, 19882008

* Based on responses by emales to the question, At any time in your lie have you ever had sexual intercourse

with a man, that is, made love, had sex, or gone all the way? and by males to the question, Have you ever hadsexual intercourse with a emale (sometimes this is called making love, having sex, or going all the way)? 95% condence interval.

From 1988 to 20062008, the percentage o never-married teenage emales (ages 1519 years) who ever had sexual intercourse

declined rom 51% to 42%, and the percentage or never-married teenage males declined rom 60% to 43%. In 1988, teenage

males were more likely than teenage emales to have ever have had sexual intercourse, but by 20062008, the percentages

were equivalent.

Source: Abma JC, Martinez GM, Copen CE. Teenagers in the United States: sexual activity, contraceptive use, and childbearing, National Survey

o Family Growth, 20062008. Vital Health Stat 2010; 23(30). Available at http://www.cdc.gov/nchs/data/series/sr_23/sr23_030.pd.

Perce

ntage

1988

1995

2002

20062008

0

10

20

30

40

50

60

70

Female Male

80

Sex
http://www.cdc.gov/nchs/data/series/sr_23/sr23_030.pdfhttp://www.cdc.gov/nchs/data/series/sr_23/sr23_030.pdf


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820 MMWR / July 9, 2010 / Vol. 59 / No. 26

TABLE I. Provisional cases o inrequently reported notiable diseases (


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MMWR / July 9, 2010 / Vol. 59 / No. 26 821

Notifable Disease Data Team and 122 Cities Mortality Data Team

Patsy A. Hall-BakerDeborah A. Adams Rosaline Dhara

Willie J. Anderson Pearl C. Sharp Jose Aponte Michael S. WodajoLenee Blanton

* Ratio o current 4-week total to mean o 15 4-week totals (rom previous, comparable, and subsequent 4-week periods or thepast 5 years). The point where the hatched area begins is based on the mean and two standard deviations o these 4-weektotals.

FIGURE I. Selected notiable disease reports, United States, comparison o provisional 4-weektotals July 3, 2010, with historical data

4210.50.250.125

Beyond historical limits

DISEASE

Ratio (Log scale)*

DECREASE INCREASECASES CURRENT

4 WEEKS

776

61

123

33

186

1

26

303

521

Hepatitis A, acute

Hepatitis B, acute

Hepatitis C, acute

Legionellosis

Measles

Mumps

Pertussis

Giardiasis

Meningococcal disease

8

TABLE I. (Continued) Provisional cases o inrequently reported notiable diseases (


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822 MMWR / July 9, 2010 / Vol. 59 / No. 26

TABLE II. Provisional cases o selected notiable diseases, United States, weeks ending July 3, 2010, and July 4, 2009 (26th week)*

Reporting area

Chlamydia trachomatis inection Cryptosporidiosis

Currentweek

Previous 52 weeks Cum2010

Cum2009

Currentweek


Cum2009Med Max Med Max

United States 10,018 22,061 26,080 523,942 625,532 84 116 284 2,558 2,678

New England 640 743 1,396 18,838 19,888 2 6 40 130 173Connecticut 210 736 4,023 5,874 0 36 36 38

Maine

39 49 75 1,229 1,257 1 1 4 28 18Massachusetts 445 395 638 10,087 9,413 1 15 51New Hampshire 57 38 122 1,121 1,051 1 6 28 27Rhode Island 81 70 130 1,773 1,694 0 8 7 4Vermont 18 23 63 605 599 1 1 9 31 35

Mid. Atlantic 2,438 3,182 4,619 82,008 77,902 16 15 38 291 302New Jersey 380 440 624 10,831 12,395 0 5 21New York (Upstate) 505 657 2,530 16,454 14,415 1 3 16 63 64New York City 993 1,186 2,144 31,788 29,326 1 5 27 39Pennsylvania 560 865 1,089 22,935 21,766 15 9 19 201 178

E.N. Central 910 3,409 4,413 73,093 101,723 17 28 73 610 650Illinois 712 1,322 9,334 30,974 3 8 71 65Indiana 296 602 6,194 11,876 4 11 76 128Michigan 596 888 1,417 24,475 23,730 6 6 11 137 115Ohio 136 966 1,077 23,026 24,447 7 7 16 179 178Wisconsin 178 402 494 10,064 10,696 4 8 39 147 164

W.N. Central 225 1,313 1,711 31,707 35,064 12 20 59 402 375Iowa 15 181 299 4,929 4,925 1 4 13 90 88Kansas 193 571 4,554 4,816 1 2 6 47 41Minnesota 271 337 6,508 7,311 5 31 97 77Missouri 169 493 638 12,399 13,037 5 3 12 77 71Nebraska 95 237 2,322 2,623 5 2 9 53 41North Dakota 41 34 93 995 840 0 18 11 6South Dakota 46 82 1,512 2 10 27 51

S. Atlantic 2,507 3,791 5,681 87,283 129,320 17 18 50 433 439Delaware 115 87 156 2,169 2,417 0 2 2 1District o Columbia 108 178 2,291 3,623 0 1 2 4Florida 557 1,405 1,669 36,005 37,317 12 8 24 179 139Georgia 5 368 1,323 4,902 20,841 3 6 31 152 179Maryland 564 452 1,031 11,169 11,089 1 3 13 22North Carolina 523 908 22,147 1 11 11 38South Carolina 679 522 729 13,750 14,171 1 1 7 24 23Virginia 526 592 924 15,209 15,773 1 2 7 44 28West Virginia 61 67 137 1,788 1,942 0 2 6 5

E.S. Central 1,296 1,761 2,321 42,030 46,568 4 10 86 80Alabama 473 652 11,515 13,892 1 5 34 27Kentucky 467 328 642 8,012 5,677 1 4 26 20Mississippi 367 424 784 9,142 12,043 0 3 6 6Tennessee 462 564 734 13,361 14,956 1 5 20 27

W.S. Central 530 2,907 4,578 71,605 82,455 4 8 40 144 148Arkansas 304 232 402 4,127 7,276 1 5 17 15Louisiana 311 1,055 2,922 15,145 1 6 17 16Oklahoma 226 261 1,564 7,469 6,598 3 2 9 32 35Texas 2,065 3,213 57,087 53,436 1 5 30 78 82

Mountain 512 1,522 2,118 34,277 36,376 7 9 25 207 213Arizona 471 713 9,605 12,859 0 3 14 20Colorado 318 400 709 9,463 6,839 3 2 10 57 57Idaho 66 192 1,522 1,780 2 2 7 40 26Montana 22 58 77 1,498 1,549 1 4 26 17Nevada 133 177 478 4,928 4,974 1 0 2 7 7New Mexico 163 453 3,304 4,229 2 8 31 61Utah 39 117 175 3,062 3,168 1 1 4 24 11Wyoming 36 70 895 978 0 2 8 14

Pacic 960 3,467 5,350 83,101 96,236 9 12 27 255 298Alaska 105 146 2,828 2,652 0 1 2 2Caliornia 712 2,713 4,406 66,684 73,868 3 8 20 151 163Hawaii 113 159 2,646 3,116 0 0 1Oregon 162 468 1,367 5,487 4 2 10 64 94

Washington 248 391 638 9,576 11,113 2 1 8 38 38American Samoa 0 0 N 0 0 N NC.N.M.I. Guam 4 27 88 221 0 0 Puerto Rico 99 329 2,469 4,021 N 0 0 N N

U.S. Virgin Islands 8 15 132 288 0 0

C.N.M.I.: Commonwealth o Northern Mariana Islands.U: Unavailable. : No reported cases. N: Not reportable. NN: Not Nationally Notiable. Cum: Cumulative year-to-date counts. Med: Median. Max: Maximum.* Incidence data or reporting years 2009 and 2010 are provisional. Data or HIV/AIDS, AIDS, and TB, when available, are displayed in Table IV, which appears quarterly. Contains data reported through the National Electronic Disease Surveillance System (NEDSS).


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MMWR / July 9, 2010 / Vol. 59 / No. 26 823

TABLE II. (Continued) Provisional cases o selected notiable diseases, United States, weeks ending July 3, 2010, and July 4, 2009 (26th week)*

Dengue Virus Inection

Reporting area

Dengue Fever Dengue Hemorrhagic Fever

Currentweek


Cum2009

Currentweek


Cum2009Med Max Med Max

United States 0 8 69 NN 0 1 1 NN

New England 0 1 1 NN 0 0 NNConnecticut 0 0 NN 0 0 NNMaine 0 1 1 NN 0 0 NNMassachusetts 0 0 NN 0 0 NNNew Hampshire 0 0 NN 0 0 NNRhode Island 0 0 NN 0 0 NNVermont 0 0 NN 0 0 NN

Mid. Atlantic 0 4 24 NN 0 0 NNNew Jersey 0 0 NN 0 0 NNNew York (Upstate) 0 0 NN 0 0 NNNew York City 0 4 20 NN 0 0 NNPennsylvania 0 2 4 NN 0 0 NN

E.N. Central 0 2 5 NN 0 0 NNIllinois 0 0 NN 0 0 NNIndiana 0 0 NN 0 0 NNMichigan 0 0 NN 0 0 NNOhio 0 2 5 NN 0 0 NNWisconsin 0 0 NN 0 0 NN

W.N. Central 0 0 NN 0 0 NNIowa 0 0 NN 0 0 NN

Kansas 0 0 NN 0 0 NNMinnesota 0 0 NN 0 0 NNMissouri 0 0 NN 0 0 NNNebraska 0 0 NN 0 0 NNNorth Dakota 0 0 NN 0 0 NNSouth Dakota 0 0 NN 0 0 NN

S. Atlantic 0 5 30 NN 0 1 1 NNDelaware 0 0 NN 0 0 NNDistrict o Columbia 0 0 NN 0 0 NNFlorida 0 5 25 NN 0 1 1 NNGeorgia 0 2 3 NN 0 0 NNMaryland 0 0 NN 0 0 NNNorth Carolina 0 0 NN 0 0 NNSouth Carolina 0 1 2 NN 0 0 NNVirginia 0 0 NN 0 0 NNWest Virginia 0 0 NN 0 0 NN

E.S. Central 0 0 NN 0 0 NNAlabama 0 0 NN 0 0 NNKentucky 0 0 NN 0 0 NN

Mississippi 0 0 NN 0 0 NNTennessee 0 0 NN 0 0 NN

W.S. Central 0 0 NN 0 0 NNArkansas 0 0 NN 0 0 NNLouisiana 0 0 NN 0 0 NNOklahoma 0 0 NN 0 0 NNTexas 0 0 NN 0 0 NN

Mountain 0 1 2 NN 0 0 NNArizona 0 0 NN 0 0 NNColorado 0 0 NN 0 0 NNIdaho 0 0 NN 0 0 NNMontana 0 0 NN 0 0 NNNevada 0 1 1 NN 0 0 NNNew Mexico 0 1 1 NN 0 0 NNUtah 0 0 NN 0 0 NNWyoming 0 0 NN 0 0 NN

Pacic 0 2 7 NN 0 0 NNAlaska 0 0 NN 0 0 NNCaliornia 0 1 4 NN 0 0 NN

Hawaii 0 0 NN 0 0 NNOregon 0 0 NN 0 0 NNWashington 0 2 3 NN 0 0 NN

American Samoa 0 0 NN 0 0 NNC.N.M.I. NN NNGuam 0 0 NN 0 0 NNPuerto Rico 0 82 942 NN 0 3 22 NN

U.S. Virgin Islands 0 0 NN 0 0 NN

C.N.M.I.: Commonwealth o Northern Mariana Islands.U: Unavailable. : No reported cases. N: Not reportable. NN: Not Nationally Notiable. Cum: Cumulative year-to-date counts. Med: Median. Max: Maximum.* Incidence data or reporting years 2009 and 2010 are provisional. Dengue Fever includes cases that meet criteria or Dengue Fever with hemorrhage. DHF includes cases that meet criteria or dengue shock syndrome (DSS), a more severe orm o DHF. Contains data reported through the National Electronic Disease Surveillance System (NEDSS).


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824 MMWR / July 9, 2010 / Vol. 59 / No. 26


Ehrlichiosis/Anaplasmosis

Reporting area

Ehrlichia chaeensis Anaplasma phagocytophilum Undetermined

Currentweek

Previous 52 weeksCum2010

Cum2009

Currentweek


Cum2009

Currentweek


Cum2009Med Max Med Max Med Max

United States 7 9 176 158 316 11 13 309 134 350 1 1 35 19 74

New England 0 6 4 18 2 22 16 107 0 1 2 2Connecticut 0 0 0 13 1 0 0 Maine 0 1 3 2 0 2 7 10 0 0 Massachusetts 0 3 5 0 11 64 0 0 New Hampshire 0 1 1 3 0 3 6 12 0 1 2 1Rhode Island 0 4 8 0 20 3 20 0 0 1Vermont 0 1 0 0 0 0

Mid. Atlantic 1 15 13 62 10 3 27 52 98 0 4 1 20

New Jersey 0 8 40 0 6 1 39 0 0 New York (Upstate) 1 15 8 12 10 2 20 51 55 0 2 1 1New York City 0 2 4 4 0 1 3 0 0 1Pennsylvania 0 5 1 6 0 1 1 0 3 18

E.N. Central 0 7 5 50 1 3 22 46 139 0 6 5 35

Illinois 0 4 2 25 0 1 3 0 0 3Indiana 0 0 0 0 0 3 4 20Michigan 0 1 1 0 0 0 0 Ohio 0 2 3 0 0 1 0 1 Wisconsin 0 3 3 21 1 3 22 46 135 0 3 1 12

W.N. Central 2 2 23 47 62 0 261 2 1 0 30 7 5

Iowa 0 0 0 0 0 0 Kansas 0 1 2 4 0 1 0 0 Minnesota 0 6 0 261 0 30 2Missouri 2 1 22 44 58 0 2 2 1 0 4 7 3Nebraska 0 1 1 0 1 0 0 North Dakota 0 0 0 0 0 0 South Dakota 0 0 0 0 0 0

S. Atlantic 4 3 14 56 64 0 4 16 4 0 2

Delaware 0 3 9 8 0 1 2 1 0 0 District o Columbia 0 0 0 0 0 0 Florida 1 0 2 6 6 0 1 1 0 0 Georgia 0 2 6 12 0 1 1 1 0 0 Maryland 1 0 3 8 23 0 2 7 2 0 0 North Carolina 0 3 7 0 1 1 0 0 South Carolina 0 2 2 6 0 0 0 0 Virginia 2 1 13 18 9 0 2 4 0 2 West Virginia 0 1 0 0 0 1

E.S. Central 1 1 11 25 45 0 1 2 1 0 5 4 12

Alabama 0 3 4 1 0 1 1 0 0 Kentucky 0 2 2 4 0 0 0 0

Mississippi 0 2 5 0 0 0 0 Tennessee 1 1 10 19 35 0 1 1 1 0 5 4 12

W.S. Central 0 141 8 13 0 23 1 0 1

Arkansas 0 34 2 0 6 0 0 Louisiana 0 0 0 0 0 0 Oklahoma 0 105 7 11 0 16 1 0 0 Texas 0 2 1 0 1 0 1

Mountain 0 0 0 0 0 1

Arizona 0 0 0 0 0 1 Colorado 0 0 0 0 0 0 Idaho 0 0 0 0 0 0 Montana 0 0 0 0 0 0 Nevada 0 0 0 0 0 0 New Mexico 0 0 0 0 0 0 Utah 0 0 0 0 0 0 Wyoming 0 0 0 0 0 0

Pacic 0 1 2 0 1 0 1

Alaska 0 0 0 0 0 0 Caliornia 0 1 2 0 1 0 1

Hawaii 0 0 0 0 0 0 Oregon 0 0 0 0 0 0 Washington 0 0 0 0 0 0

American Samoa 0 0 0 0 0 0

C.N.M.I. Guam 0 0 0 0 0 0 Puerto Rico 0 0 0 0 0 0

U.S. Virgin Islands 0 0 0 0 0 0

C.N.M.I.: Commonwealth o Northern Mariana Islands.U: Unavailable. : No reported cases. N: Not reportable. NN: Not Nationally Notiable. Cum: Cumulative year-to-date counts. Med: Median. Max: Maximum.* Incidence data or reporting years 2009 and 2010 are provisional. Cumulative total E. ewingiicases reported or year 2010 = 2. Contains data reported through the National Electronic Disease Surveillance System (NEDSS).


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MMWR / July 9, 2010 / Vol. 59 / No. 26 825


Reporting area

Giardiasis GonorrheaHaemophilus infuenzae, invasive

All ages, all serotypes

Currentweek


Cum2009

Currentweek


Cum2009

Currentweek


Cum2009Med Max Med Max Med Max

United States 200 345 662 7,593 7,993 2,351 5,171 6,656 118,083 150,824 27 52 171 1,449 1,608

New England 3 24 65 362 648 48 92 197 2,422 2,416 3 2 21 41 103Connecticut 5 15 112 129 45 170 1,044 1,123 3 0 15 20 28Maine 1 4 13 93 88 1 3 11 98 71 0 2 6 12Massachusetts 8 36 274 45 40 72 1,044 967 0 8 51New Hampshire 1 3 11 62 70 2 2 7 75 53 0 2 7 6Rhode Island 1 7 19 30 6 13 134 179 0 2 4 2Vermont 1 4 14 76 57 1 17 27 23 0 1 4 4

Mid. Atlantic 34 61 112 1,324 1,511 493 641 941 16,272 14,935 8 11 34 309 292

New Jersey 7 15 113 211 90 93 134 2,305 2,314 2 7 41 67New York (Upstate) 26 24 84 506 550 93 104 422 2,604 2,526 4 3 20 87 69New York City 16 26 372 405 179 215 394 5,849 5,349 2 6 61 33Pennsylvania 8 15 37 333 345 131 209 277 5,514 4,746 4 4 9 120 123

E.N. Central 27 52 92 1,194 1,258 283 1,033 1,536 20,116 32,273 3 8 19 244 263

Illinois 12 22 227 276 232 441 2,305 10,329 2 9 59 100Indiana 6 14 115 115 77 183 1,662 3,865 1 6 43 49Michigan 6 13 25 296 296 200 248 502 6,867 7,705 0 4 19 12Ohio 18 16 28 405 377 39 319 372 7,107 7,720 3 2 6 63 58Wisconsin 3 8 23 151 194 44 91 192 2,175 2,654 2 5 60 44

W.N. Central 18 27 165 668 674 71 267 367 6,354 7,492 3 24 90 82

Iowa 8 5 13 130 137 3 31 55 779 847 0 1 1 Kansas 3 4 14 101 62 40 83 917 1,277 0 2 8 11Minnesota 0 135 136 137 41 64 927 1,171 0 17 24 18Missouri 2 9 27 170 215 60 122 172 3,148 3,295 1 6 40 35Nebraska 5 3 9 91 79 22 54 511 659 0 3 9 13North Dakota 0 8 11 7 8 2 11 72 57 0 4 8 5South Dakota 1 10 29 37 3 16 186 0 0

S. Atlantic 60 73 143 1,830 1,703 665 1,108 1,656 24,299 37,867 6 13 27 359 450

Delaware 0 3 12 15 27 19 37 486 434 0 1 5 3District o Columbia 1 4 16 37 42 86 863 1,394 0 1 1 1Florida 33 39 87 946 891 169 381 482 9,616 10,689 2 3 9 104 146Georgia 16 13 52 421 356 132 494 1,765 7,083 1 3 9 91 88Maryland 1 6 12 141 132 150 128 237 3,210 2,967 1 1 6 29 53North Carolina N 0 0 N N 143 331 7,380 1 6 20 56South Carolina 4 2 7 56 43 206 159 217 4,087 4,253 2 2 7 54 37Virginia 6 8 36 222 209 109 164 271 4,048 3,390 2 4 44 48West Virginia 1 5 16 20 4 8 19 224 277 0 5 11 18

E.S. Central 7 22 116 178 372 481 689 11,421 13,260 3 12 95 107

Alabama 4 13 69 85 138 187 3,376 3,795 0 3 15 28Kentucky N 0 0 N N 132 88 156 2,021 1,655 0 2 14 15Mississippi N 0 0 N N 112 125 219 2,544 3,729 0 2 9 7

Tennessee

3 18 47 93 128 145 206 3,480 4,081 2 10 57 57W.S. Central 9 9 18 163 199 160 819 1,230 18,743 23,932 4 2 20 77 75

Arkansas 4 2 9 50 59 86 74 139 1,196 2,202 1 0 3 12 15Louisiana 1 3 10 63 85 106 343 910 4,920 0 3 15 13Oklahoma 4 3 10 50 55 74 80 381 2,092 2,150 3 1 15 44 44Texas N 0 0 N N 565 965 14,545 14,660 0 2 6 3

Mountain 15 33 64 692 647 40 168 266 3,957 4,442 2 5 14 176 142

Arizona 3 7 65 91 62 109 1,121 1,436 1 2 10 69 49Colorado 13 12 26 334 182 18 50 127 1,270 1,376 1 6 47 40Idaho 1 4 10 96 64 2 8 38 47 1 0 2 9 2Montana 3 11 54 47 1 2 6 58 40 0 1 2 1Nevada 1 1 11 27 46 20 27 94 881 859 0 2 5 11New Mexico 1 8 32 57 20 41 405 502 1 5 24 18Utah 4 13 66 131 1 7 15 168 150 0 4 15 19Wyoming 1 5 18 29 1 7 16 32 0 2 5 2

Pacic 34 54 133 1,244 1,175 219 561 663 14,499 14,207 1 2 9 58 94

Alaska 2 7 40 39 23 36 634 426 0 2 11 9Caliornia 18 34 61 793 824 181 460 556 12,268 11,707 0 2 6 34Hawaii 0 3 3 11 11 24 300 326 0 2 20

Oregon 8 9 17 228 159 11 43 106 563 1 1 5 38 28Washington 8 9 75 180 142 38 43 84 1,191 1,185 0 4 3 3

American Samoa 0 0 0 0 0 0

C.N.M.I. Guam 0 2 1 1 0 3 8 12 0 0 Puerto Rico 1 10 11 81 4 24 117 116 0 1 1 2

U.S. Virgin Islands 0 0 1 4 25 82 0 0

C.N.M.I.: Commonwealth o Northern Mariana Islands.U: Unavailable. : No reported cases. N: Not reportable. NN: Not Nationally Notiable. Cum: Cumulative year-to-date counts. Med: Median. Max: Maximum.* Incidence data or reporting years 2009 and 2010 are provisional. Data or H. infuenzae (age


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