The following are pre-publication drafts of articles from the
Morbidity and Mortality Weekly Report dated August 18, 1995. Late-breaking articles, and final editorial revisions are not included;
therefore, these articles should be considered preliminary, and not
to be released to the public. --CDC
--------------------------------------------------------------
Human Granulocytic Ehrlichiosis -- New York, 1995
     Since 1986, two human tickborne diseases caused by Ehrlichia
spp. have been recognized in the United States: human monocytic
ehrlichiosis (HME), caused by E. chaffeensis, and human
granulocytic ehrlichiosis (HGE), caused by an agent closely related
to E. equi (1,2). In June 1995, the Westchester County (New York)
Department of Health (WCDOH) received reports from physicians who
were treating patients for suspected HGE. In response, the WCDOH
sent information to all primary-care physicians in Westchester
County describing the clinical and laboratory features of
ehrlichiosis (fever, myalgia, headache, leukopenia, and
thrombocytopenia) and requested that they voluntarily report
suspected cases of ehrlichiosis. This report summarizes an
investigation by the New York State Department of Health (NYSDOH)
and the WCDOH of suspected ehrlichiosis cases and the clinical
characteristics of confirmed and probable cases.
     Hospitals and large group practices in Westchester County were
asked to report current and past suspected cases, and the NYSDOH
laboratory initiated free diagnostic testing for ehrlichiosis for
New York state residents. Potential cases of ehrlichiosis were
identified through reports submitted by health-care providers to
their county health departments and from a review of NYSDOH
laboratory records of serum specimens that were submitted for
diagnostic testing for ehrlichiosis since 1994. Serum specimens
from potential cases were tested for antibodies to E. equi and/or
E. chaffeensis, and/or the presence of DNA of the HGE agent by
polymerase chain reaction (PCR) assay. A confirmed case of HGE was
defined as either a fourfold change in antibody titer to E. equi or
identification of DNA sequences of the HGE agent by PCR assay. A
probable case of HGE was defined as a single antibody titer greater
than or equal to 64 by immunofluorescent assay to E. equi or the
identification of organisms (morulae) in granulocytes on a
peripheral blood smear from a patient with an acute illness
characterized by fever, headache, myalgia, and/or malaise.
     As of August 15, 1995, medical records and/or clinical
information had been reviewed for 68 patients with suspected
ehrlichiosis: 50 had onset in 1995; 17, in 1994; and one, in 1992.
Serum specimens from 30 patients had been tested for antibodies to
E. equi and/or E. chaffeensis; 20 patients had acute serum
specimens tested by PCR analysis.
     Illnesses in 29 patients met the case definition of either
confirmed (23 patients) or probable (six patients) HGE, 20 from
1995 and nine from 1994; other potential cases remain under
investigation. Eighteen (62%) case-patients had onset of symptoms
in June or July 1995. Twenty-five patients lived in Westchester
County, two lived north of Westchester in adjacent Putnam County,
and two lived on Long Island in Nassau and Suffolk counties. The
mean age of patients with confirmed or probable HGE was 49 years
(range: 21-90 years), and 15 (52%) were male. Fourteen (48%) of the
29 case-patients reported a tick bite less than or equal to 21 days
before onset of illness. Fever greater than 101.0 F ( greater than
38.3 C) was noted in 27 patients. Reported symptoms included
headache (22 patients), arthralgia (13), malaise (11), and myalgia
(11). The lowest reported platelet count for 21 patients averaged
106,000 mm3 (range: 28,000-275,000 mm3; normal: 150,000-350,000
mm3), and the lowest reported white blood cell count for 26
patients averaged 4200 mm3 (range: 700-7700 mm3; normal: 4300-10,800 mm3). Thirteen patients had mild serum elevations of liver
enzymes aspartase aminotransferase, alanine aminotransferase, and
lactate dehydrogenase. Thirteen patients were hospitalized, and
none died. Twenty-two patients received doxycycline during their
acute illness.
     Of the 23 confirmed cases, 11 had a fourfold rise in antibody
titer to E. equi using a polyvalent antihuman conjugate, and 15 had
HGE 16S ribosomal DNA detected from acute serum specimens (a
positive PCR test). One confirmed case also had characteristic
morulae observed in granulocytes on a peripheral blood smear. The
six probable cases had single titers greater than or equal to 64 to
E. equi. Five case-patients had serologic evidence of E.
chaffeensis infection (titer greater than or equal to 64) but all
had at least a 10-fold greater titer to E. equi.
Reported by: G Wormser, MD, D McKenna, M Aguero-Rosenfeld, MD, H
Horowitz, MD, J Munoz, MD, J Nowakowski, MD, G Gerina, MD,
Westchester County Medical Center, Valhalla; P Welch, MD, Mt.
Kisco; H Moorjani, MD, T Rush, MD, Tarrytown; G Jacquette, MD, A
Stankey, R Falco, PhD, M Rapoport, MD, Westchester County Dept of
Health, Hawthorne; D Ackman, MD, J Talarico, DO, D White, PhD, L
Friedlander, R Gallo, G Brady, M Mauer, DO, S Wong, PhD, R Duncan,
L Kingsley, R Taylor, G Birkhead, MD, D Morse, MD, State
Epidemiologist, New York State Dept of Health. JS Dumler, MD, Univ
of Maryland Medical Center, Baltimore, Maryland. Viral and
Rickettsial Zoonoses Br, Div of Viral and Rickettsial Diseases,
National Center for Infectious Diseases, CDC.
Editorial Note: HGE was first described in 1994 among patients in
Minnesota and Wisconsin. In addition to these cases, reports have
suggested that acquisition of HGE may have occurred in California,
Florida, Maryland, Massachusetts, and New York (4,5). Approximately
400 cases of HME have been confirmed in 30 states, primarily in the
southeastern and south central regions (3). E. chaffeensis has most
commonly been identified in the Lone Star tick (Amblyomma
americanum), while HGE has been identified in the deer (Ixodes
scapularis) and dog (Dermacentor variabilis) ticks (2).
     Physicians evaluating patients with an acute febrile illness
should consider ehrlichiosis in the differential diagnosis,
particularly if the patient is leukopenic or thrombocytopenic, and
should solicit a history of known or possible exposure to ticks.
Empiric therapy with doxycycline antibiotics should be considered
if the diagnosis of ehrlichiosis is suspected because delayed
treatment while awaiting laboratory confirmation may increase the
risk for adverse outcomes. The diagnosis can be confirmed through
antibody assays and/or PCR. The agent that causes HGE has not been
identified in cell culture, but tests for antibody to E. equi have
been used to confirm the diagnosis. The sensitivity, specificity,
and cross-reactivity of serologic assays for the two species are
not well established. Because the geographic distribution of HME
and HGE overlap, physicians should consider obtaining serologic
tests for both E. equi and E. chaffeensis. PCR is a useful research
tool but is not widely available for diagnostic purposes.
     The patients described in this report live in areas where I.
scapularis is common. I. scapularis collected in Westchester and
Suffolk counties have been found positive for the HGE agent by PCR
assay (CDC, unpublished data, 1995). The geographic extent of HGE
in New York is not known. Persons spending time outdoors in
tick-infested areas should take precautions against tickborne
diseases, including wearing light-colored clothing, using insect
repellent, and checking thoroughly for ticks after being outdoors.
The NYSDOH has asked physicians in New York to report suspected
cases to their local health departments. In addition, the NYSDOH is
working with local health departments to provide information to the
public and medical community and is offering serologic testing for
HME and HGE through the NYSDOH laboratory. CDC provides serologic
and PCR testing for HME and HGE of specimens sent through state
health departments.
References
1. Dawson JE, Anderson BE, Fishbein DB, et al. Isolation and
characterization of and Ehrlichia sp. from a patient diagnosed with
human ehrlichiosis. J Clin Microbiol 1991;29:2741-5.
2. Bakken JS, Dumler JS, Chen SM, Eckman MR, Van Etta LL, Walker
DH. Human granulocytic ehrlichiosis in the upper midwest United
States. JAMA 1994;272:212-8.
3. Fishbein DB, Dawson JE, Robinson LE. Human ehrlichiosis in the
United States, 1985-1990. Ann Intern Med 1994;120:736-43.
4. Dumler JS, Bakken JS. Ehrlichial diseases of humans: emerging
tick-borne infections. Clin Infect Dis 1995;20:1102-10.
5. Telford SR, Lepore TJ, Snow P, Warner CK, Dawson JE. Human
granulocytic ehrlichiosis in Massachusetts. Ann Intern Med
1995;123:277-9.


Injuries Associated with Self-Unloading Forage Wagons -- New York,
1991-1994
     In New York, an estimated 3600 injuries occur each year to
farmers operating farm machines (1). In October 1993, the
Occupational Health Nurses in Agricultural Communities (OHNAC)*
program in the New York State Department of Health received a
report of a man who sustained severe injuries when he became
entangled in the power take-off (PTO) driveline to a self-unloading
forage wagon**. Subsequent investigation by OHNAC identified four
additional similar incidents in New York that occurred during
September 1991-October 1994, including one fatality and one injury
to a 9-year-old girl working on a family farm. This report
summarizes the results of the investigation of these forage-wagon-related injuries and presents recommendations to reduce the risk
for such injuries.
     On October 1, 1993, a 66-year-old farmer was using a
self-unloading forage wagon to unload chopped corn into a blower
for transfer into a silo. To unload the corn, he used a tractor to
pull the loaded forage wagon next to the blower (which was attached
to a second tractor). To reach the speed-control lever, he stepped
over the rotating PTO driveline that connected his tractor to the
wagon and supplied its power. As he stepped, his pants became
entangled around the unprotected rotating driveline. A nearby
worker witnessed the incident and turned off the driveline. The
farmer's injuries included amputation of the genitalia and deep
tissue damage to the buttocks, requiring extensive grafting. He was
hospitalized for 2 weeks and unable to work for 1 month.
     On investigation by OHNAC, with assistance from the
Cooperative Extension Service, four other incidents were identified
since 1991 involving forage wagons with unprotected drivelines. In
September 1991, a 33-year-old farmer sustained multiple fractures
of the right leg with amputation of the right foot when his shirt
blew into a rotating driveline of a forage wagon while he was
working between two drivelines on a windy day. In October 1992, a
41-year-old farm operator sustained avulsion of the entire scrotal
area when his pants became entangled while he was stepping over the
unprotected PTO driveline. In November 1992, a 9-year-old girl
sustained bilateral above-the-knee amputations when her jacket
became entangled while she was reaching over the unprotected
rotating driveline to operate the speed control of the forage wagon
she was unloading. Finally, in an unwitnessed incident in October
1994, a 19-year-old male farmer sustained fatal internal injuries
after apparently stepping too close to the driveline of a forage
wagon while unloading chopped corn.
Reported by: S Roerig, J Melius, MD, J Pollock, MSP, M London, MS,
G Casey, New York State Dept of Health. Div of Surveillance, Hazard
Evaluations, and Field Studies, National Institute for Occupational
Safety and Health, CDC.
Editorial Note: In the United States, farm machinery is a leading
source of traumatic injuries to farmers, accounting for an
estimated 34,000 lost-time work injuries to farmers nationally in
1993 (2). Mechanical devices are associated with approximately 30%
of the work-related injuries on farms (2). Forage wagons are used
most often on farms that raise large animals and grow their own
feed grain. The fatal and severe nonfatal injuries described in
this report were caused by a combination of factors. To unload feed
grain, the forage wagon and silo blower must be in close proximity,
which requires that the two tractors that power these machines also
be in close proximity (Figure 1). The speed-control lever for the
wagon is often located on the discharge side near the silo blower
(i.e., between the two pieces of equipment). Many older tractors
are small enough that, when the forage wagon and blower are thus
positioned for proper operation, sufficient space remains between
the adjacent rear tires of the two tractors to allow the operator
to dismount from either tractor seat and walk between the two
tractors directly to the forage wagon speed control without
crossing over a revolving PTO driveline. However, as both silos and
self-unloading forage wagons have increased in capacity, both the
size and horsepower of the associated tractors have increased
concomitantly. When these larger tractors are used, their rear
wheels abut, blocking access between the tractors and requiring the
operator to cross over a revolving driveline to operate the forage
wagon.
     Since the 1930s, PTO drivelines have been manufactured with
shields. However, shields are often damaged or removed during
operation or maintenance of the farm equipment. Of the estimated
29,000 self-unloading wagons in use on New York farms, 3000-5000
are believed to lack shields to protect workers adequately from a
revolving PTO driveline (J. Pollock, Cornell University, personal
communication, 1995). Entanglement in PTO drivelines, including
entanglement in those equipped with intact U-shaped shields that
leave one side (generally the underside) unguarded, previously has
been recognized as a hazard in the agricultural industry (3-6).
     Drivelines should be equipped with proper functioning guards
in any work situation,*** especially when the worker must work
between two operating PTO drivelines. Furthermore, workers must be
trained in safe work practices, which include shutting off PTO
drivelines whenever possible before dismounting tractors,
maintaining warning decals, not wearing loose or bulky clothing
around and avoiding close proximity to rotating PTO drivelines, and
keeping bystanders--especially children--away from PTO-driven
equipment (7). To assist in preventing injuries to children,
farmers should recognize that farm equipment is designed for
operation by adults; be aware of the physical, emotional, and
mental characteristics and abilities of children; and select
age-appropriate tasks for children (8). Because of the need for
immediate response to serious injuries, workers should not work
alone when using hazardous equipment; however, if persons do work
alone, they should be monitored frequently to ensure immediate
response in the event of injuries (7).
     The National Institute for Farm Safety is reviewing approaches
to reduce the risk for forage-wagon-related injuries. In addition
to proper shielding of the drivelines, placement of the
speed-control devices to enable operation of such devices from the
tractor driver's seat or from another location on the wagon would
eliminate the need for the operator to step over the driveline.
Leading manufacturers of forage wagons have designed conveyor
extensions that allow for an increase in the space between the two
tractors; the extension can be supplied with new equipment or used
to retrofit some older equipment. An informal survey of forage
wagon equipment indicated that conveyor extensions are available
for all seven wagons selected in a nonrandom sample; costs for the
retrofits ranged from $35 to $600 each. Although these extensions
are marketed to promote productivity, not safety, manufacturers and
dealers should be made aware that these extensions can contribute
to safer operation of the equipment, and farmers should be
encouraged to use them to enhance safety as well as increase
productivity.
     In New York, OHNAC, in collaboration with farm groups, have
alerted farmers about the hazards associated with PTO drivelines--especially on forage wagons--through educational presentations and
articles in regional agricultural publications.
References
1. Pollock J. Perspectives of New York farm safety: workplace
injuries and worker opinions [Thesis]. Ithaca, New York: Cornell
University, 1990. 68 p.
2. NIOSH. Traumatic injury surveillance of farmers: annual
statistical abstract, 1993. Morgantown, West Virginia: US
Department of Health and Human Services, Public Health Service,
CDC, NIOSH, 1995 (in press).
3. Cogbill TH, Steenlage ES, Landercasper J, Strutt PJ. Death and
disability from agricultural injuries in Wisconsin: a 12-year
experience with 739 patients. J Trauma 1991;31:1632-7.
4. Heeg M, ten Duis HJ, Klasen HJ. Power take-off injuries. British
Journal of Accident Surgery 1986;17:28-30.
5. Roerig S. Scalping accidents with shielded PTO units: four case
reports. American Association of Occupational Health Nursing
Journal 1993;41:437-9.
6. CDC. Scalping incidents involving hay balers--New York. MMWR
1992;41:489-91.
7. Demmin D, Hallman E. Cornell Cooperative Extension rural health
and safety fact sheet: power take-off (PTO) safety. Ithaca, New
York: Cornell University, 1995; publication no. 123FSF56.
8. Bean TL, Wojtowicz J. Farm safety for children: what job is
right for my child? Columbus, Ohio: Ohio State University, 1992;
publication no. AEX-991.1.
* OHNAC is a national surveillance program conducted by CDC's
National Institute for Occupational Safety and Health that has
placed public health nurses in rural communities and hospitals in
10 states (California, Georgia, Iowa, Kentucky, Maine, Minnesota,
New York, North Carolina, North Dakota, and Ohio) to conduct
surveillance for agriculture-related illnesses and injuries that
occur among farmers and their family members. These surveillance
data are used to assist in reducing the risk for occupational
illness and injury in agricultural populations.
** A forage wagon is used to transport and unload feed into a
storage (e.g., silo) or feed area.
*** 29 CFR section 1928.57. Occupational Safety and Health
Administration (OSHA) Standard for Safety for Agricultural
Equipment. Family-run farms with no other employees are exempt from
compliance with federal OSHA standards, and those with less than or
equal to 10 employees are generally not subject to OSHA inspection.


Update: HIV-2 Infection Among Blood and Plasma Donors -- United
States, June 1992-June 1995
Human immunodeficiency virus type 1 (HIV-1) and type 2 (HIV-2) both
cause acquired immunodeficiency syndrome (AIDS). Following the
licensure of combination HIV-1/HIV-2 screening enzyme immunoassays
(EIA), the Food and Drug Administration (FDA) recommended that
beginning in June 1992 all donated whole blood, blood components,
and source plasma be screened for antibody to HIV-2 because not all
persons infected with HIV-2 can be detected by HIV-1 testing (1,2).
This report describes the first two cases of HIV-2 infection
detected among potential blood donors since the implementation of
recommended HIV-2 screening and summarizes national data about
persons known to be infected with HIV-2 during December 1987-June
1995.*
Donor 1
     In June 1994, a blood donation was discarded after it tested
positive by combination HIV-1/HIV-2 EIA and indeterminate by HIV-1
Western blot assay (WB). The donor was notified about the test
results and consented to an interview and repeat testing. Testing
at CDC indicated the specimen was positive by HIV-1 EIA, HIV-1 WB,
HIV-2 EIA, and HIV-2 WB for research use only (RUO). Results of RUO
synthetic peptide tests indicated cross-reactivity to HIV-1 and
were interpreted as HIV-2 infection.
     The donor was born and resided in the United States. She
previously had not donated blood or plasma. She reported no
symptoms related to HIV infection and denied injecting-drug use,
receipt of transfusions, and travel outside the United States.
Since 1982, she had had four male sex partners; all were born in
the United States. The HIV status of her partners is unknown, and
she was unaware of any HIV-infection risks among them. She has no
children. She received HIV counseling--including instructions to
refrain from donating blood, blood components, and tissues or
organs--and referral to a health-care provider.
Donor 2
     In November 1994, a plasma donation was destroyed after the
serum tested positive by combination HIV-1/HIV-2 EIA and RUO HIV-2
WB. Attempts by the plasma center to notify the donor were
unsuccessful. However, the donor independently sought HIV testing
2 weeks later at a counseling and testing site (CTS). The CTS
laboratory results were HIV-1 EIA positive with an atypical HIV-1
WB indeterminate band pattern suggestive of HIV-2 infection.
Subsequent testing at CDC indicated the specimen was HIV-1 EIA
positive, HIV-1 WB indeterminate, HIV-2 EIA positive, and HIV-2 WB
positive. RUO synthetic peptide EIA and dot blots were also
positive for HIV-2. These results were interpreted as confirmed
HIV-2 infection.
     During the follow-up interview, the male donor reported no
symptoms of HIV infection. He had not previously donated blood or
plasma. He was born in France and had lived in several countries in
western Africa during 1979-1985 before moving to the United States.
While in western Africa, he was vaccinated on two occasions with
needles that were wiped with cotton and reused between patients. He
also received several tattoos in Africa. Of his estimated 35
lifetime sex partners, most were African. The donor denied having
had sex with men, injecting-drug use, and receipt of transfusions.
He received HIV counseling--including instructions to refrain from
donating blood, blood components, and tissues or organs--and
referral to a health-care provider.
U.S. Reports of HIV-2 Infection
     As of June 30, 1995, a total of 62 persons in the United
States were reported with HIV-2 infection (Figure 1). Of 58 persons
for whom sex data were available, 38 (66%) were male. At least 11
of the 62 persons had an AIDS-defining condition at the time of
report, and five are known to have died. Of these 62 persons, 42
(68%) were born in western Africa and two in Europe; for nine, the
region of origin was unknown although four had malaria antibody
profiles consistent with previous residence in western Africa. Of
the nine persons with HIV-2 infection born in the United States,
six were adults of whom four had either traveled to or had a sex
partner from western Africa, and three were infants born to mothers
of unknown national origin.
Reported by: MD Herr, HIV/AIDS Epidemiology; AL Hathcock, PhD,
State Epidemiologist, Delaware Div of Public Health. DW Hamaker, JM
Schulte, DO, D Hoehns, BE Mitchell, MPH, Bur of HIV and STD
Prevention; DM Simpson, MD, State Epidemiologist, Texas Dept of
Health. Local and state health depts. Office of Blood Research and
Review; Div of Transfusion Transmitted Diseases, Center for
Biologics Evaluation and Research, Food and Drug Administration.
Div of HIV/AIDS, National Center for Infectious Diseases; Div of
HIV/AIDS Prevention, National Center for Prevention Svcs, CDC.
Editorial Note: In the United States, HIV-2 infection among blood
donors is extremely rare. Since the implementation of combination
HIV-1/HIV-2 EIA screening of blood and plasma donations, an
estimated 74 million donations have been tested for HIV. Including
the two cases described in this report, three cases of HIV-2
infection have been detected among blood and plasma donors in the
United States; the first case was detected by HIV-1 screening in
1986 (3). These findings are consistent with previous surveys of
approximately 20 million U.S. blood donations during 1987-1989 in
which no blood-donor specimens with HIV-2 antibody were detected
(4,5).
     The national blood supply is protected from HIV primarily
through two methods: 1) interviewing donors about risk behaviors
for HIV infection and 2) laboratory screening donations for HIV
(6,7). All donations detected with HIV are excluded from any
clinical use,** and donors are deferred from further donations***.
For both donors described in this report, although no HIV risk
factors were identified during the interview preceding blood
donation, laboratory screening of their blood and plasma donations
detected HIV infection. Subsequent testing revealed HIV-2
cross-reactivity resulting in a positive HIV-1 EIA (which would
have led to exclusion even in the absence of HIV-2 testing) and a
positive or indeterminate HIV-1 WB.
     HIV-1 is distributed worldwide and is prevalent in the United
States; however, HIV-2 is endemic in western Africa with limited
distribution to other regions of the world. Of the 62 persons
reported with HIV-2 infection in the United States, at least 48
(77%) were born in, had traveled to, and/or had a sex partner from
western Africa.
     In addition to detection of HIV-2 cases through blood and
plasma donor screening, epidemiologic data about HIV-2 cases are
collected through the CDC-supported national HIV/AIDS surveillance
system and serosurveys (8,9). Because not all persons who are
infected with HIV-2 donate blood or are otherwise tested for HIV-2,
the number of persons reported with HIV-2 infection probably is
underestimated. Nonetheless, the data from these sources indicate
that HIV-2 is uncommon in the United States.
     Blood centers detecting a repeatedly reactive specimen by
combination HIV-1/HIV-2 EIA should follow the recommended CDC/FDA
testing algorithm (1). Specimens suspected of being HIV-2 positive
may be referred to state health department laboratories or to CDC
for confirmatory HIV-2 testing. Cases of HIV-2 infection should be
reported to state and local health departments as allowed by law
and/or regulation. Periodic updates about the number of persons
known to be infected with HIV-2 in the United States are available
from the CDC National AIDS Clearinghouse.
References
1. CDC. Testing for antibodies to human immunodeficiency virus type
2 in the United States. MMWR 1992;41(no. RR-12).
2. George JR, Rayfield MA, Phillips S, et al. Efficacies of US Food
and Drug Administration-licensed HIV-1-screening enzyme
immunoassays for detecting antibodies to HIV-2. AIDS 1990;4:321-6.
3. O'Brien TR, Polon C, Schable CA, et al. HIV-2 infection in an
American. AIDS 1991;5:85-8.
4. CDC. Surveillance for HIV-2 infection in blood donors--United
States, 1987-1989. MMWR 1990;39:829-31.
5. CDC. AIDS due to HIV-2 infection--New Jersey. MMWR 1988;37:33-5.
6. Food and Drug Administration. Revised recommendations for the
prevention of human immunodeficiency virus (HIV) transmission by
blood and blood products [Memorandum to all registered blood
establishments]. Bethesda, Maryland: US Department of Health and
Human Services, Public Health Service, Food and Drug
Administration, Center for Biologics Evaluation and Research, 1992.
7. Food and Drug Administration. Recommendations for donor
screening with a licensed test for HIV-1 antigen [Memorandum to all
registered blood and plasma establishments]. Rockville, Maryland:
US Department of Health and Human Services, Public Health Service,
Food and Drug Administration, Center for Biologics Evaluation and
Research, 1995.
8. CDC. HIV/AIDS surveillance report. Atlanta, Georgia: US
Department of Health and Human Services, Public Health Service,
1995:36-7. (Vol 6, no. 2).
9. O'Brien TR, George JR, Holmberg SD. Human immunodeficiency virus
type 2 infection in the United States. JAMA 1992;267:2775-9.
* Single copies of this report will be available until August 18,
1996, from the CDC National AIDS Clearinghouse, P.O. Box 6003,
Rockville, MD 20849-6003; telephone (800) 458-5231 or (301)
217-0023.
** 21 CFR section 610.45(c).
*** 21 CFR section 606.160(e).


Monthly Immunization Table
     To track progress toward achieving the goals of the Childhood
Immunization Initiative (CII), CDC publishes monthly a tabular
summary of the number of cases of all diseases preventable by
routine childhood vaccination reported during the previous month
and year-to-date (provisional data). In addition, the table
compares provisional data with final data for the previous year and
highlights the number of reported cases among children aged less
than 5 years, who are the primary focus of CII. Data in the table
are reported through the National Electronic Telecommunications
System for Surveillance.