Continuing Education examination available at
http://www.cdc.gov/mmwr/cme/conted_info.html#weekly.
U.S. Department of Health and Human Services
Centers for Disease Control and Prevention
Morbidity and Mortality Weekly Report
Weekly / Vol. 65 / No. 10 March 18, 2016
INSIDE
257 Use of Vaccinia Virus Smallpox Vaccine in Laboratory
and Health Care Personnel at Risk for Occupational
Exposure to Orthopoxviruses — Recommendations
of the Advisory Committee on Immunization
Practices (ACIP), 2015
263 Building and Strengthening Infection Control
Strategies to Prevent Tuberculosis — Nigeria, 2015
267 Revision to CDC’s Zika Travel Notices: Minimal
Likelihood for Mosquito-Borne Zika Virus
Transmission at Elevations Above 2,000 Meters
269 Announcements
270 QuickStats
On September 18, 2014, the Missouri Department of
Health and Senior Services (MDHSS) was notified of a sus-
pected rabies case in a Missouri resident. The patient, a man
aged 52 years, lived in a rural, deeply wooded area, and bat
sightings in and around his home were anecdotally reported.
Exposure to bats poses a risk for rabies. After two emergency
department visits for severe neck pain, paresthesia in the
left arm, upper body tremors, and anxiety, he was hospital-
ized on September 13 for encephalitis of unknown etiology.
On September 24, he received a diagnosis of rabies and on
September 26, he died. Genetic sequencing tests confirmed
infection with a rabies virus variant associated with tricolored
bats. Health care providers need to maintain a high index of
clinical suspicion for rabies in patients who have unexplained,
rapidly progressive encephalitis, and adhere to recommended
infection control practices when examining and treating
patients with suspected infectious diseases.
Case Report
On the morning of September 12, 2014, a Missouri
resident, a man aged 52 years, visited hospital A’s emergency
department for evaluation of acute onset of severe neck pain
that radiated down his left arm to his hand. After a cervical
spine radiograph, a diagnosis of cervical muscle strain and
radiculopathy was made, for which the patient received injec-
tions of orphenadrine (a muscle relaxant) and ketolorac (a
nonsteroidal anti-inflammatory drug). He was instructed to
take ibuprofen and cyclobenzaprine (a muscle relaxant) for
pain relief and to return if symptoms worsened. The next
day, he awoke with numbness and tingling in his left arm,
severe bilateral upper body tremors, and sweating, as well as
continued neck pain. He returned to hospital A’s emergency
department, where he received a diagnosis of a herniated disc
and was discharged with instructions to take oral prednisone
and oxycodone HCl/acetaminophen. That same evening,
while the patient was at home, his symptoms progressed, and
he became anxious and fearful; family members transported
him back to the emergency department, during which time he
began experiencing visual hallucinations. He was admitted to
hospital A with a diagnosis of suspected serotonin syndrome
secondary to the cyclobenzaprine.
On September 13, the patient was treated with oral ibupro-
fen and cyproheptadine and with parenteral lorazepam, diaz-
epam, diphenhydramine, and haloperidol. On September 14,
losartan and hydrochlorothizide were prescribed to be taken
orally for hypertension, but the patient was unable to swallow
these medications. His condition progressively worsened, with
the development of considerable rigidity and action tremors
in his upper extremities. That same day, he was transferred
to hospital B, a tertiary care referral hospital, for neurologic
Human Rabies — Missouri, 2014
P. Drew Pratt, MS
1
; Kathleen Henschel, MPH
1
; George Turabelidze, MD, PhD
1
; Autumn Grim, MPH
1
; James A. Ellison, PhD
2
; Lillian Orciari, MS
2
;
Pamela Yager
2
; Richard Franka, DVM, PhD
2
; Xianfu Wu, DVM, PhD
2
; Xiaoyue Ma, MPH
2
; Ashutosh Wadhwa, PhD
2
; Todd G. Smith, PhD
2
;
Brett Petersen, MD
2
; Miriam Shiferaw, MD
2
Please note: An erratum has been published for this issue. To view the erratum, please click here.
Morbidity and Mortality Weekly Report
254 MMWR / March 18, 2016 / Vol. 65 / No. 10 US Department of Health and Human Services/Centers for Disease Control and Prevention
The MMWR series of publications is published by the Center for Surveillance, Epidemiology, and Laboratory Services, Centers for Disease Control and Prevention (CDC),
U.S. Department of Health and Human Services, Atlanta, GA 30329-4027.
Suggested citation: [Author names; first three, then et al., if more than six.] [Report title]. MMWR Morb Mortal Wkly Rep 2016;65:[inclusive page numbers].
Centers for Disease Control and Prevention
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William L. Roper, MD, MPH
William Schaffner, MD
evaluation. Upon admission, he was febrile (104.9°F [40.5°C]),
tachycardic, tachypneic, and hypertensive with bilateral upper
extremity tremors and whole body myoclonic jerks. On
September 15, he required intubation and mechanical ventila-
tion for airway protection. Before intubation, the patient orally
communicated an aversion to water.
During the next 11 days the patient underwent an extensive
laboratory evaluation to determine the cause of his encepha-
lopathy, including a urine drug screen, tricyclic antidepressant
levels, an arbovirus panel, and testing for antibodies to Rocky
Mountain spotted fever, ehrlichiosis, syphilis, and herpes sim-
plex virus; all test results were negative. The peripheral white
blood cell count and liver enzymes were both slightly elevated.
On September 19, a traumatic lumbar puncture yielded
hemorrhagic cerebrospinal fluid (CSF) with elevated glucose,
protein, and white blood cells. Electroencephalogram studies
indicated generalized slowing of brain activity, minimal reac-
tivity to noxious stimulation, and absent posterior dominant
rhythm, consistent with encephalopathy. The patient required
dopamine and norepinephrine for cardiovascular support,
continuous mechanical ventilation for acute hypoxemic respira-
tory failure, and hemodialysis for acute kidney injury. Initial
treatment included broad-spectrum antibiotics for presumed
sepsis and acyclovir for suspected herpes encephalitis.
Family members initially reported that the patient lived in a
trailer on 97 densely wooded acres, but his exposure to wildlife
was not known at that time. Because of the acute and rapidly
progressive clinical course of his illness and the elimination
of the most common etiologies of encephalitis from the dif-
ferential diagnoses, the possibility of rabies was considered,
public health officials notified, and confirmatory laboratory
testing initiated on September 18. Serum, CSF, nuchal skin
biopsy, and saliva specimens collected on September 19 were
submitted to CDC on September 22 for rabies testing.
On September 24, rabies was confirmed by the presence of
rabies virus antigen in the skin biopsy, and the detection of
rabies virus in saliva and skin by reverse transcription poly-
merase chain reaction. Genomic sequencing found the variant
to be associated with the tricolored bat (Perimyotis subflavus
[formerly Pipistrellus subflavus]). Neither antirabies antibodies
(immunoglobulin G or immunoglobulin M) nor rabies virus
neutralizing antibodies were detected by indirect fluorescent
antibody or rapid fluorescent focus inhibition tests in the serum
and CSF specimens collected on September 19. However, both
antirabies antibodies and rabies virus neutralizing antibodies
were subsequently detected in a serum specimen collected on
September 25. Because of the advanced stage of illness and
worsening prognosis, the Milwaukee protocol (1) was not
initiated. On September 26, the family elected to withdraw
life support, and the patient died shortly thereafter.
Public Health Investigation
On September 18, an infectious disease specialist at
hospital B notified MDHSS of the suspected human rabies
case. After confirmation of the diagnosis, MDHSS, local public
Morbidity and Mortality Weekly Report
MMWR / March 18, 2016 / Vol. 65 / No. 10 255
US Department of Health and Human Services/Centers for Disease Control and Prevention
health agency officials, and infection prevention specialists at
hospitals A and B interviewed family members, friends, and
hospital personnel in an effort to determine the patient’s expo-
sure and travel history and to identify any high-risk exposures
that would require rabies postexposure prophylaxis (PEP) (2).
Two questionnaires developed by CDC were used to evaluate
health care workers and family and community members for
possible exposure to the patient.
The variant identified from genetic sequencing of rabies virus
from the patient was from Perimyotis subflavus (tricolored bat),
one of the smallest bats in eastern North America. The rabies
variant associated with this bat species occasionally infects
other bats (e.g., Tadarida braziliensis [big brown bat]) as well
as cats, foxes, and other species. Any of these animal sources
could have accounted for the patient’s exposure.
Although the exact exposure date is unknown, the patient
had reported seeing a bat in his home in late August or early
September 2014. He also worked in a warehouse in which
coworkers reported that bats are occasionally seen, but no bat
sightings in the several weeks before the patient’s illness onset
were reported. Public health investigators who visited the
patient’s trailer home noted several places where a small animal,
such as a bat, could have entered. A family member reported
having observed bats roosting on a utility pole near the trailer
in the past. This information, combined with documentation
of previous bat-variant rabies cases with undocumented or
unidentified exposures (3), makes a bat the most likely source of
rabies infection in this patient. Symptom onset was estimated
to be September 6, based on a family member’s recollection
that the patient complained of fatigue and neck pain during
that weekend. Rabies infection from a bat exposure during
late August or early September would suggest a shorter incu-
bation period than the typical 3–8 weeks (2). Thus an earlier,
undetected bat exposure might be more likely.
Nine family members and friends were identified as having
potential high-risk exposures to the saliva from the patient
through mucous membranes or small, open hand wounds; all
received rabies PEP. Among the 73 health care workers who
provided care to the patient at hospitals A and B, seven met
Advisory Committee on Immunization Practices criteria for
rabies PEP (2). Health care–associated exposures primarily
occurred through prolonged contact with the patient’s face,
saliva, or tears with ungloved hands and nonintact skin.
Discussion
This case illustrates the importance of educating the public
about potential rabies reservoirs and exposure sources in the
United States and of promptly seeking medical attention after
any potential rabies exposure. Rabies is preventable after an
exposure through timely PEP, which includes wound wash-
ing and administration of rabies immune globulin and rabies
vaccine (2). Bat exposures are high-risk exposures for rabies
virus infection, particularly because the wounds inflicted by
bats are often minor and easily overlooked. No evidence-based
treatment approach for clinical rabies exists. An experimental
approach, the Milwaukee protocol, which was first used in
2004 in a Wisconsin patient who survived rabies infection (4),
has been implemented with varying outcomes (1).
This case is the second case of human rabies in Missouri in
6 years; during this time, specimens from six humans were
referred from the Missouri State Public Health Laboratory
to CDC for antemortem rabies testing. In 2008, a male aged
55 years died of rabies in Missouri after being bitten on the
ear by a bat (5); before this, the last Missouri rabies case was
reported in 1959. During 2008–2011, a total of 11 human
rabies cases were reported in the United States and Puerto
Rico, including five cases with infections acquired overseas (6).
Among the six domestically acquired cases, five were associated
with bat variant rabies viruses; in three cases, a confirmed bat
bite was reported. In Missouri, bats and skunks are principal
reservoirs of rabies (7). Given that wild animals might not
display obvious signs of rabies illness, it is important that,
whenever possible, all bats and wild terrestrial carnivores impli-
cated in a potential rabies exposure be euthanized and tested
for rabies. This testing can ensure that PEP is appropriately
administered to prevent rabies in persons with exposures to
confirmed rabid animals, and might avoid misadministration
of PEP to nonexposed persons.
Summary
What is already known about this topic?
Human rabies in the United States is rare (one to three cases are
reported annually). However, because the virus is endemic in
the U.S. wildlife population, susceptible domestic animals and
humans exposed to rabid animals are at risk for developing
rabies infection.
What is added by this report?
Early diagnosis of human rabies infection might be hampered
by delayed recognition, given the rarity of the disease, nonspe-
cific initial symptoms, and difficulty in obtaining animal
exposure history once the patient is in the later stages of illness.
What are the implications for public health practice?
To prevent rabies 1) continue to educate the public and health
care providers about the risk for exposure to rabies virus from
bats and other mammalian species and the importance of
prompt medical evaluation and initiation of postexposure
prophylaxis and 2) promote consistent adherence to standard
precautions among health care providers in the treatment of all
potentially infectious patients.
Please note: An erratum has been published for this issue. To view the erratum, please click here.
Morbidity and Mortality Weekly Report
256 MMWR / March 18, 2016 / Vol. 65 / No. 10 US Department of Health and Human Services/Centers for Disease Control and Prevention
A review of human rabies cases in the United States dur-
ing 1960–2010 found that a median of 39 contacts per case
(range=1–180) received PEP (8). Sixteen persons with possible
exposure to the 2014 Missouri patient were identified (seven
health care workers and nine community members). According
to the indications for rabies PEP (2), human-to-human trans-
mission of rabies virus can occur through exposure to virus in
saliva through mucous membranes or fresh, open cuts in the
skin. Consistent adherence to standard precautions should
minimize the need for rabies PEP in health care settings (9).
Public education campaigns aimed at raising rabies aware-
ness should address misconceptions about risk associated with
bat encounters (e.g., lack of knowledge that bats can transmit
rabies through small, undetected bites) that can lead to a delay
in the timely response to potential rabies virus exposures. These
campaigns should also emphasize the importance of complet-
ing the full rabies PEP series once initiated, unless the exposure
source is determined not to be rabid through laboratory testing
or successful (i.e., remains healthy) completion of a 10-day
observation period for a dog, cat, or ferret (2). In addition to
the importance of public education, health care workers should
consider rabies in the differential diagnosis of any patient with
acute, unexplained encephalitis, and use appropriate infection
control practices when examining and treating patients with a
suspected infectious disease.
Acknowledgments
Howard Pue, Douglas Baker, Randy Schillers, Ralph Home,
Missouri Department of Health and Senior Services; Paula Elkin,
Stephanie Stevens, Bruce Jenkins, Miller County Health Department,
Tuscumbia, Missouri; Jaime Young, Cole County Health
Department, Jefferson City, Missouri; Cathy Schlotzhauer, Stephen
Whitt, University of Missouri Hospital, Columbia, Missouri; Valerie
Lyon, Capital Region Medical Center, Jefferson City, Missouri; Jesse
Blanton, Cathleen Hanlon, Ryan Wallace, Michael Niezgoda, Andres
Velasco-Villa, CDC.
1
Division of Community and Public Health Missouri Department of Health and
Senior Services, Jefferson City,
2
Division of High-Consequence Pathogens and
Pathology/National Center for Emerging and Zoonotic Infectious Diseases, CDC.
Corresponding author: Miriam Shiferaw, [email protected], 404-639-0802.
References
1. Medical College of Wisconsin. Milwaukee protocol, version 4.0.
Milwaukee, WI: Medical College of Wisconsin; 2012. http://www.mcw.
edu/FileLibrary/Groups/PedsInfectiousDiseases/Rabies/Milwaukee_
protocol_v4_20913.pdf
2. Manning SE, Rupprecht CE, Fishbein D, et al. Human rabies
prevention—United States, 2008: recommendations of the Advisory
Committee on Immunization Practices. MMWR Recomm Rep
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exposure and rabies virus variant [Table]. Atlanta, GA: CDC; 2015. http://
www.cdc.gov/rabies/location/usa/surveillance/human_rabies.html
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of rabies with induction of coma. N Engl J Med 2005;352:2508–14.
http://dx.doi.org/10.1056/NEJMoa050382
5. CDC. Human rabies—Missouri, 2008. MMWR Morb Mortal Wkly Rep
2009;58:1207–9.
6. CDC. Human rabies. Atlanta, GA: US Department of Health and Human
Services, CDC; 2015. http://www.cdc.gov/rabies/location/usa/
surveillance/human_rabies.html
7. Blanton JD, Robertson K, Palmer D, Rupprecht CE. Rabies surveillance
in the United States during 2008. J Am Vet Med Assoc 2009;235:676–89.
http://dx.doi.org/10.2460/javma.235.6.676
8. Petersen BW, Rupprecht CE. Human rabies epidemiology and diagnosis
[Chapter 10]. In: Tkachev S, ed. Non-flavivirus encephalitis. Rijeka,
Crotia: InTech Open Science, 2011. http://dx.doi.org/10.5772/21708
9. Siegel JD, Rhinehart E, Jackson M, Chiarello L; Health Care Infection
Control Practices Advisory Committee. 2007 guideline for isolation
precautions: preventing transmission of infectious agents in health care
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org/10.1016/j.ajic.2007.10.007
Morbidity and Mortality Weekly Report
MMWR / March 18, 2016 / Vol. 65 / No. 10 257
US Department of Health and Human Services/Centers for Disease Control and Prevention
Use of Vaccinia Virus Smallpox Vaccine in Laboratory and Health Care
Personnel at Risk for Occupational Exposure to Orthopoxviruses —
Recommendations of the Advisory Committee on Immunization Practices
(ACIP), 2015
Brett W. Petersen, MD
1
; Tiara J. Harms, MS, MPH
2
; Mary G. Reynolds, PhD
1
; Lee H. Harrison, MD
3,4
On June 25, 2015, the Advisory Committee on Immunization
Practices (ACIP) recommended routine vaccination with live
smallpox (vaccinia) vaccine (ACAM2000) for laboratory
personnel who directly handle 1) cultures or 2) animals con-
taminated or infected with replication-competent vaccinia
virus, recombinant vaccinia viruses derived from replication-
competent vaccinia strains (i.e., those that are capable of
causing clinical infection and producing infectious virus in
humans), or other orthopoxviruses that infect humans (e.g.,
monkeypox, cowpox, and variola) (recommendation category:
A, evidence type 2 [Box]). Health care personnel (e.g., physi-
cians and nurses) who currently treat or anticipate treating
patients with vaccinia virus infections and whose contact
with replication-competent vaccinia viruses is limited to con-
taminated materials (e.g., dressings) and persons administer-
ing ACAM2000 smallpox vaccine who adhere to appropriate
infection prevention measures can be offered vaccination with
ACAM2000 (recommendation category: B, evidence type 2
[Box]). These revised recommendations update the previous
ACIP recommendations for nonemergency use of vaccinia virus
smallpox vaccine for laboratory and health care personnel at
risk for occupational exposure to orthopoxviruses (1). Since
2001, when the previous ACIP recommendations were devel-
oped, ACAM2000 has replaced Dryvax as the only smallpox
vaccine licensed by the U.S. Food and Drug Administration
(FDA) and available for use in the United States (2). These
recommendations contain information on ACAM2000 and
its use in laboratory and health care personnel at risk for occu-
pational exposure to orthopoxviruses.
Background
Smallpox vaccines containing vaccinia virus were used to
successfully eradicate smallpox as a disease of humans (3).
Eradication was made possible by the ability of vaccinia virus to
induce cross-protective immunity against other viruses within
the orthopoxvirus genus capable of producing human infec-
tion (e.g., variola, monkeypox, and cowpox) (3). ACAM2000
(Smallpox [Vaccinia] Vaccine, Live) is currently the only
smallpox vaccine licensed by FDA and available for use in the
United States. The license for Dryvax vaccine, the smallpox
vaccine previously recommended by ACIP, was withdrawn in
Recommendations for routine use of vaccines in children,
adolescents, and adults are developed by the Advisory Committee
on Immunization Practices (ACIP). ACIP is chartered as a
federal advisory committee to provide expert external advice and
guidance to the Director of the Centers for Disease Control and
Prevention (CDC) on use of vaccines and related agents for the
control of vaccine-preventable diseases in the civilian population
of the United States. Recommendations for routine use of vaccines
in children and adolescents are harmonized to the greatest
extent possible with recommendations made by the American
Academy of Pediatrics (AAP), the American Academy of Family
Physicians (AAFP), and the American College of Obstetricians
and Gynecologists (ACOG). Recommendations for routine use
of vaccines in adults are harmonized with recommendations
of AAFP, ACOG, the American College of Physicians (ACP),
and the American College of Nurse-Midwives (ACNM). ACIP
recommendations adopted by the CDC Director become agency
guidelines on the date published in the Morbidity and Mortality
Weekly Report (MMWR). Additional information regarding
ACIP is available at http://www.cdc.gov/vaccines/acip.
BOX. The U.S. Advisory Committee on Immunization Practices system
for grading evidence and recommendations*
Recommendation categories
Category A: Recommendation that applies to all persons
in an age- or risk-based group.
Category B: Recommendation for individual clinical
decision-making.
Type or quality of evidence
1. Randomized controlled trials (RCTs), or
overwhelming evidence from observational studies.
2. RCTs with important limitations, or exceptionally
strong evidence from observational studies.
3. RCTs with notable limitations, or observational studies.
4. RCTs with several major limitations, observational
studies with important limitations, or clinical
experience and observations.
* Adopted from the GRADE (Grading of Recommendations Assessment,
Development, and Evaluation) system.
Morbidity and Mortality Weekly Report
258 MMWR / March 18, 2016 / Vol. 65 / No. 10 US Department of Health and Human Services/Centers for Disease Control and Prevention
2008, and all remaining supplies of this vaccine were subse-
quently destroyed (2).
ACAM2000 is a vaccinia virus vaccine derived from a
plaque-purified clone of the same New York City Board of
Health strain that was used to manufacture Dryvax vaccine.
ACAM2000 is grown in African green monkey kidney (Vero)
cells and tested to be free of known adventitious agents (4).
Safety data from ACAM2000 clinical trials indicate a similar
safety profile to Dryvax, including a risk for serious adverse
events (e.g., progressive vaccinia, postvaccinial encephalitis, and
eczema vaccinatum) (5,6). Myopericarditis has also been asso-
ciated with ACAM2000 and is estimated to occur at a rate of
5.7 per 1,000 primary vaccinees based on clinical trial data (6).
ACAM2000 is provided as a lyophilized preparation of
purified live virus containing the following nonactive excipi-
ents: 6 mM–8 mM HEPES (pH 6.5–7.5), 2% human serum
albumin United States Pharmacopeia (USP), 0.5%–0.7%
sodium chloride USP, 5% mannitol USP, and trace amounts
of neomycin and polymyxin B (6). Diluent for ACAM2000
contains 50% (v/v) glycerin USP and 0.25% (v/v) phenol USP
in water for injection USP. Diluent is supplied as 0.6 mL of
liquid in 3 mL clear glass vials (6).
ACAM2000 is administered in a single dose by the percu-
taneous route (scarification) using 15 jabs of a stainless steel
bifurcated needle that has been dipped into the reconstituted
vaccine (6). Following successful administration of vaccine,
ACAM2000 produces vaccination site lesions containing
infectious vaccinia virus capable of transmission through
autoinoculation and inadvertent inoculation of close contacts
of vaccinees. The development of vaccination site lesions may
be modified or greatly reduced in revaccinees (3,6).
Poxviruses are increasingly being used in biomedical research
for a wide range of purposes. Vaccinia virus is the most fre-
quently studied poxvirus and serves as the prototype of the
orthopoxvirus genus. It has not only been used in the area
of basic virology but also as both an immunology tool and
potential vaccine vector because of its ability to serve as a vec-
tor for the expression of foreign genes (antigens) (7,8). Many
strains of vaccinia virus exist with different levels of virulence
in humans and animals. Distinguishing between replication-
competent and replication-deficient poxvirus strains is useful
in establishing the risk they pose to persons who might be
occupationally exposed to such viruses. Replication-deficient
poxvirus strains can be defined as those that do not produce
infectious virus in humans (and therefore do not cause clinical
infection), and as such, pose a substantially lower risk com-
pared with replication-competent poxvirus strains, which
are capable of causing clinical infection in humans as well as
producing infectious virus that can be transmitted to others.
Modified vaccinia Ankara (MVA), NYVAC, TROVAC, and
ALVAC are examples of replication-deficient poxvirus strains
(9,10). The categories replication-competent and replication-
deficient replace the previous poxvirus strain categories of
highly attenuated and nonhighly attenuated to add clarity and
specificity to the vaccination recommendations (1). Persons
at risk for occupational exposure to orthopoxviruses might
include laboratory personnel who have contact or work with
live orthopoxviruses or clinical samples from suspected cases of
orthopoxvirus infection, animal care personnel who have direct
contact with orthopoxvirus-inoculated or -infected animals or
their secretions, and health care personnel (e.g., physicians and
nurses) involved in caring for orthopoxvirus-infected persons
or administering biological agents containing orthopoxviruses.
Methods
These recommendations were developed using the Grading
of Recommendations Assessment, Development and
Evaluation (GRADE) methodology (Box) (11–13). GRADE
steps include defining specific questions, identifying impor-
tant health outcomes, summarizing evidence for important
outcomes, assessing quality of evidence, and formulating
recommendations. Principal considerations for formulating
recommendations include balance of benefits and harms; qual-
ity of evidence; values and preferences; and health economic
analyses. The central policy question for this policy note was
whether routine vaccination with ACAM2000 should be rec-
ommended for laboratory and health care personnel at risk for
occupational exposure to orthopoxviruses (13).
Rationale and Evidence
ACIP considered the risk for infection, the risk for an adverse
event following vaccination, and the benefit from vaccination
in developing these recommendations. Vaccinia virus smallpox
vaccine has been recommended by ACIP for the protection
of laboratory personnel against orthopoxviruses since 1980.
However, 14 orthopoxvirus infections were reported in labo-
ratory personnel in the United States during 2004–2014; 13
of these infections occurred in laboratory personnel who
were not vaccinated according to ACIP recommendations
(8) (CDC unpublished data 1/1/2015). Although these data
indicate the presence of risk, it is difficult to quantify the
absolute number of persons at risk for occupational exposure
to orthopoxviruses because the size of the population at risk
is not known and vaccinia virus and cowpox virus exposures
and infections among this population are not notifiable events.
During the same 2004–2014 period, no reports of preventable
vaccine-associated serious adverse events (e.g., eczema vac-
cinatum, progressive vaccinia, or contact transmission) were
documented among laboratory and health care personnel at
risk for occupational exposure who had been vaccinated with
Morbidity and Mortality Weekly Report
MMWR / March 18, 2016 / Vol. 65 / No. 10 259
US Department of Health and Human Services/Centers for Disease Control and Prevention
smallpox vaccine. Furthermore, data from U.S. military per-
sonnel and civilian first responders vaccinated during smallpox
vaccination campaigns that were initiated in 2002 indicate
that the incidence of serious adverse events overall was lower
than previously reported in 1968 (14–16). Although serious
adverse events have occurred, this decrease in incidence is likely
attributable to more stringent prevaccination screening proce-
dures to identify persons who should not receive the vaccine,
to increased use of protective bandages to cover the vaccina-
tion site, and to enhanced education of vaccinees compared
with the routine vaccination practices in place in the 1960s.
Vaccination with ACAM2000 is expected to provide benefit to
persons at risk for occupational exposure to orthopoxviruses,
given the ability of vaccinia virus smallpox vaccines to induce
cross-protective immunity against other viruses within the
orthopoxvirus genus.
Recommendations
Laboratory and health care personnel at risk for occupational
exposure to orthopoxviruses should follow recommended
biosafety guidelines and adhere to published infection pre-
vention and control procedures (17–19). Laboratories using
both replication-competent and replication-deficient vaccinia
virus strains where working areas for these viruses cannot be
clearly segregated should follow increased biosafety precautions
because laboratory infections caused by contamination have
been previously documented (8,17). Persons with immuno-
compromising conditions or other contraindications to vacci-
nation are at increased risk for severe disease if an occupational
exposure occurs.
Routine vaccination with ACAM2000 is recommended for
laboratory personnel who directly handle 1) cultures or 2) ani-
mals contaminated or infected with replication-competent
vaccinia virus, recombinant vaccinia viruses derived from
replication-competent vaccinia strains (i.e., those that are
capable of causing clinical infection and producing infectious
virus in humans), or other orthopoxviruses that infect humans
(e.g., monkeypox, cowpox, and variola) (recommendation
category: A, evidence type 2 [Box]). However, vaccination
with ACAM2000 is not recommended for persons who work
only with replication-deficient poxvirus strains (e.g., MVA,
NYVAC, TROVAC, and ALVAC) (recommendation category:
A, evidence type 2 [Box]).
Laboratory personnel working with replication-competent
vaccinia viruses and recombinant viruses developed from
replication-competent vaccinia viruses should be revaccinated
with ACAM2000 at least every 10 years (recommendation
category: A, evidence type 2 [Box]). To ensure an increased
level of protection against more virulent orthopoxviruses (e.g.,
variola, monkeypox), revaccination with ACAM2000 every 3
years is recommended for personnel handling these viruses (rec-
ommendation category: A, evidence type 2 [Box]) (Table 1).
Public health and health care volunteers who were vaccinated
as responders in the U.S. Civilian Smallpox Preparedness
and Response Program should refer to the October 2008
CDC Interim Guidance for Revaccination of Eligible Persons
who Participated in the US Civilian Smallpox Preparedness and
Response Program (http://emergency.cdc.gov/agent/smallpox/
revaxmemo.asp).
Health care personnel (e.g., physicians and nurses) or ani-
mal care personnel whose contact with replication-competent
vaccinia viruses is limited to contaminated materials (e.g.,
dressings or cages), but who adhere to appropriate infection
prevention measures, are at lower risk for inadvertent infection
than laboratory personnel. Similarly, persons administering
ACAM2000 smallpox vaccine to laboratory and health care
personnel at risk for occupational exposure to orthopoxviruses
can decrease the risk for inadvertent infection through recom-
mended infection prevention measures. However, because of
a theoretical risk for infection, vaccination with ACAM2000
can be offered to health care or animal care personnel, pro-
vided individual persons have no specified contraindications
to vaccination (recommendation category: B, evidence type 2
[Box]). Persons with an orthopoxvirus exposure should be
evaluated by a health care provider and clinical management
decisions, including postexposure smallpox vaccination should
be made on a case-by-case basis in consultation with public
health authorities.
Precautions and Contraindications
Nonemergency use of ACAM2000 should be avoided
in persons with increased risk for adverse events following
TABLE 1. Recommendations for revaccination of laboratory and health care personnel at risk for occupational exposure to orthopoxviruses
Orthopoxvirus Revaccination schedule
Replication-competent vaccinia viruses and recombinant viruses developed from replication-competent vaccinia viruses At least every 10 years
More virulent orthopoxviruses (e.g., variola, monkeypox) Every 3 years
Replication-deficient vaccinia viruses and recombinant viruses developed from replication-deficient vaccinia viruses* Not recommended
* Laboratories that use both replication-competent and replication-deficient vaccinia virus strains but where working areas for these viruses cannot be clearly
segregated should follow increased biosafety precautions because laboratory infections due to contamination have previously been documented. Sources: MacNeil A,
Reynolds MG, Damon IK. Risks associated with vaccinia virus in the laboratory. Virology 2009;385:1–4; Chosewood LC, Wilson DE. CDC; National Institutes of Health.
Biosafety in microbiological and biomedical laboratories. 5th ed. Washington, DC: US Department of Health and Human Services, Public Health Service, CDC, National
Institutes of Health; 2009.
Morbidity and Mortality Weekly Report
260 MMWR / March 18, 2016 / Vol. 65 / No. 10 US Department of Health and Human Services/Centers for Disease Control and Prevention
administration of smallpox vaccine. Contraindications for
nonemergency use of ACAM2000 include persons with a
history or presence of atopic dermatitis, persons with other
active exfoliative skin conditions (e.g., eczema, burns, impetigo,
varicella zoster virus infection, herpes simplex virus infection,
severe acne, severe diaper dermatitis with extensive areas of
denuded skin, psoriasis, or Darier disease [keratosis follicu-
laris]); persons with conditions associated with immunosup-
pression (e.g., human immunodeficiency virus [HIV] infection
or acquired immune deficiency syndrome [AIDS], leukemia,
lymphoma, generalized malignancy, solid organ transplan-
tation, or therapy with alkylating agents, antimetabolites,
radiation, tumor necrosis factor [TNF] inhibitors, or high-
dose corticosteroids [≥2 mg/kg body weight or ≥20 mg/day
of prednisone or its equivalent for ≥2 weeks], hematopoietic
stem cell transplant recipients <24 months post-transplant
or ≥24 months, but who have graft-versus-host disease or
disease relapse, or autoimmune disease [e.g. systemic lupus
erythematosus] with immunodeficiency as a clinical com-
ponent); persons aged <1 year; women who are pregnant or
breastfeeding; persons with a serious allergy to any component
of ACAM2000; persons with known underlying heart disease
with or without symptoms (e.g., coronary artery disease or
cardiomyopathy); and primary vaccinees with three or more
known major cardiac risk factors (i.e., hypertension, diabetes,
hypercholesterolemia, heart disease at age 50 years in a first-
degree relative, and smoking) (recommendation category: A,
evidence type 2). Data from clinical trials and epidemiologic
studies suggest that primary vaccinees might be at increased
risk for myopericarditis (20,21). Although the specific risk fac-
tors for myopericarditis following smallpox vaccination have
not been identified, the consequences of myopericarditis are
more likely to be severe in persons with known heart disease or
cardiac risk factors than in persons without these conditions.
Given the risk for vaccinia virus transmission from recently
vaccinated persons through inadvertent inoculation, non-
emergency use of ACAM2000 is also contraindicated in
persons with household contacts with a history or presence
of atopic dermatitis, other active exfoliative skin conditions
(e.g., eczema, burns, impetigo, varicella zoster, herpes, severe
acne, severe diaper dermatitis with extensive areas of denuded
skin, psoriasis, or Darier disease [keratosis follicularis]); condi-
tions associated with immunosuppression (e.g., HIV/AIDS,
leukemia, lymphoma, generalized malignancy, solid organ
transplantation, or therapy with alkylating agents, antimetabo-
lites, radiation, TNF inhibitors, or high-dose corticosteroids
[i.e., ≥2 mg/kg body weight or 20 mg/day of prednisone or
its equivalent for ≥2 weeks], hematopoietic stem cell trans-
plant recipients <24 months post-transplant or ≥24 months,
but who have graft-versus-host disease or disease relapse,
or autoimmune disease [e.g. systemic lupus erythematosus]
with immunodeficiency as a clinical component); household
contacts aged <1 year; and household contacts who are preg-
nant (recommendation category: A, evidence type 2 [Box]).
Household contacts include persons with prolonged intimate
contact with the potential vaccinee (e.g. sexual contacts) and
others who might have direct contact with the vaccination
site or with potentially contaminated materials (e.g., dress-
ings or clothing) (Table 2). ACIP also does not recommend
nonemergency vaccination with ACAM2000 for children and
adolescents aged <18 years.
TABLE 2. Contraindications to using ACAM2000 smallpox vaccine in laboratory and health care personnel at risk for occupational exposure to
orthopoxviruses
Contraindication Primary vaccinees Revaccinees Household contacts*
History or presence of atopic dermatitis
√ √ √
Other active exfoliative skin conditions
†
√ √ √
Conditions associated with immunosuppression
§
√ √ √
Pregnancy
√ √ √
Aged <1 yr
¶
√ √ √
Breastfeeding
√ √
Serious vaccine component allergy
√ √
Known underlying heart disease (e.g., coronary artery disease or cardiomyopathy)
√ √
Three or more known major cardiac risk factors**
√
* Household contacts include persons with prolonged intimate contact with the potential vaccinee (e.g., sexual contacts) and others who might have direct contact
with the vaccination site or with potentially contaminated materials (e.g., dressings or clothing).
†
Conditions include eczema, burns, impetigo, varicella zoster, herpes, severe acne, severe diaper dermatitis with extensive areas of denuded skin, psoriasis, or Darier
disease (keratosis follicularis).
§
Conditions include human immunodeficiency virus/acquired immune deficiency syndrome infection, leukemia, lymphoma, generalized malignancy, solid organ
transplantation, therapy with alkylating agents, antimetabolites, radiation, tumor necrosis factor inhibitors, high-dose corticosteroids, being a recipient with
hematopoietic stem cell transplant <24 months post-transplant or ≥24 months but with graft-versus-host disease or disease relapse, or having autoimmune disease
with immunodeficiency as a clinical component.
¶
Vaccination of infants aged <1 year is contraindicated. Additionally, the Advisory Committee on Immunization Practices does not recommend vaccinating children
and adolescents aged <18 years.
** Major cardiac risk factors include hypertension, diabetes, hypercholesterolemia, heart disease at age 50 years in a first-degree relative, and smoking.
Morbidity and Mortality Weekly Report
MMWR / March 18, 2016 / Vol. 65 / No. 10 261
US Department of Health and Human Services/Centers for Disease Control and Prevention
Persons with inflammatory eye disease might be at increased
risk for inadvertent inoculation as a result of touching or
rubbing the eye. Therefore, deferring vaccination is prudent
for persons with inflammatory eye diseases requiring steroid
treatment until the condition resolves and the course of
therapy is complete (recommendation category: B, evidence
type 4 [Box]).
Adverse events occurring after administration of any vaccine
should be reported to the Vaccine Adverse Event Reporting
System (VAERS). Reports can be submitted to VAERS online,
by fax, or by mail. Additional information about VAERS is
available by telephone (1-800-822-7967) or online (https://
vaers.hhs.gov).
ACAM2000 Availability
CDC is the only source of ACAM2000 for civilians. CDC
will provide ACAM2000 to protect laboratory and other health
care and animal care personnel whose occupations place them
at risk for exposure to vaccinia and other orthopoxviruses,
including recombinant vaccinia viruses. Vaccine should be
administered under the supervision of a physician selected
by the requesting institution. Vaccine will be shipped to the
responsible physician. Requests for vaccine, including the
reason for the request, should be referred to the following:
CDC Drug Service, Division of Scientific Resources, National
Center for Emerging and Zoonotic Infectious Diseases, Office
of Infectious Diseases,Mailstop D-09, Atlanta, GA 30329;
telephone: 404-639-3670; fax: 404-639-3717; e-mail: drug-
Future Directions
ACIP will review these recommendations as new information
or developments related to orthopoxvirus disease, smallpox
vaccines (including licensure of additional smallpox vaccines),
smallpox vaccine adverse events, and the experience gained in
the implementation of these recommendations becomes avail-
able. Revised recommendations will be developed as needed.
Acknowledgments
Members of the Advisory Committee on Immunization Practices
(ACIP); members of the ACIP Smallpox Vaccine Workgroup (ACIP
member roster for July 2014–June 2015 is available online [http://
www.cdc.gov/vaccines/acip/committee/members.html]); Faruque
Ahmed, Nancy M. Bennett, Maria Cano, Mark D. Challberg, Paul
Chaplin, Emily A. Cloessner, Limone C. Collins, Inger K. Damon,
Michael D. Decker, Renata J. Engler, Doran L. Fink, Jesse R. Geibe,
Richard L. Gorman, Richard N. Greenberg, Laura Hughes-Baker,
Stuart N. Isaacs, M. Shannon Keckler, Grace Kubin, Alison C.
Mawle, Michael M. McNeil, Sharon Medcalf, Michael Merchlinsky,
Howard L. Minkoff, Jay R. Montgomery, Richard W. Moyer, Lynda
Osadebe, Larry K. Pickering, Greg A. Poland, James M. Schmitt,
Eric M. Sergienko, Jean C. Smith, Neil M. Vora, Sixun Yang.
1
National Center for Emerging and Zoonotic Infectious Diseases, CDC;
2
Emory University Rollins School of Public Health, Atlanta, Georgia;
3
Advisory
Committee on Immunization Practices;
4
Infectious Diseases Epidemiology
Research Unit, University of Pittsburgh, Pennsylvania.
References
1. Rotz LD, Dotson DA, Damon IK, Becher JA; Advisory Committee on
Immunization Practices. Vaccinia (smallpox) vaccine: recommendations
of the Advisory Committee on Immunization Practices (ACIP), 2001.
MMWR Recomm Rep 2001;50(No. RR-10).
2. CDC. Newly licensed smallpox vaccine to replace old smallpox vaccine.
MMWR Morb Mortal Wkly Rep 2008;57:207–8.
Summary
What is currently recommended?
In 2001, the Advisory Committee on Immunization Practices
approved revised recommendations that laboratory and health
care personnel occupationally exposed to vaccinia virus,
recombinant vaccinia viruses, and other orthopoxviruses that
can infect humans be vaccinated with Dryvax smallpox vaccine.
Why are the recommendations being modified now?
In 2007, ACAM2000 was licensed by the U.S. Food and Drug
Administration and replaced Dryvax as the only smallpox vaccine
available for use in the United States. The evidence supporting
routine vaccination with ACAM2000 for laboratory personnel at
risk for occupational exposure to orthopoxviruses was evaluated
using the Grading of Recommendations, Assessment,
Development, and Evaluation framework and determined to be
type 2 (moderate level of evidence); the recommendation was
designated as a Category A recommendation.
What are the new recommendations?
Routine vaccination with ACAM2000 is recommended for
laboratory personnel who directly handle 1) cultures or
2) animals contaminated or infected with replication-
competent vaccinia virus, recombinant vaccinia viruses derived
from replication-competent vaccinia strains (i.e., those that are
capable of causing clinical infection and producing infectious
virus in humans), or other orthopoxviruses that infect humans
(e.g., monkeypox, cowpox, and variola) (recommendation
category: A, evidence type 2). Health care personnel (e.g.,
physicians and nurses) who currently treat or anticipate treating
patients with vaccinia virus infections and whose contact with
replication-competent vaccinia viruses is limited to
contaminated materials (e.g., dressings) and persons
administering ACAM2000 smallpox vaccine who adhere to
appropriate infection prevention measures can be offered
vaccination with ACAM2000 (recommendation category: B,
evidence type 2).
Morbidity and Mortality Weekly Report
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3. Fenner F, Henderson D, Arita I, Jezek Z, Ladnyi I. Smallpox and its
eradication. Geneva, Switzerland: World Health Organization; 1988.
4. Greenberg RN, Kennedy JS. ACAM2000: a newly licensed cell culture-
based live vaccinia smallpox vaccine. Expert Opin Investig Drugs
2008;17:555–64. http://dx.doi.org/10.1517/13543784.17.4.555
5. Frey SE, Newman FK, Kennedy JS, et al. Comparison of the safety and
immunogenicity of ACAM1000, ACAM2000 and Dryvax in healthy
vaccinia-naive adults. Vaccine 2009;27:1637–44. http://dx.doi.
org/10.1016/j.vaccine.2008.11.079
6. Sanofi-Pasteur. ACAM2000, (smallpox (vaccinia) vaccine, live) [package
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downloads/BiologicsBloodVaccines/Vaccines/ApprovedProducts/
UCM142572.pdf
7. Verardi PH, Titong A, Hagen CJ. A vaccinia virus renaissance: new vaccine
and immunotherapeutic uses after smallpox eradication. Hum Vaccin
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8. MacNeil A, Reynolds MG, Damon IK. Risks associated with vaccinia
virus in the laboratory. Virology 2009;385:1–4. http://dx.doi.
org/10.1016/j.virol.2008.11.045
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vectors: NYVAC, ALVAC and TROVAC. Dev Biol Stand 1995;84:159–63.
10. Moss B. Replicating and host-restricted non-replicating vaccinia virus
vectors for vaccine development. Dev Biol Stand 1994;82:55–63.
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Evidence Based Recommendations Work Group (EBRWG). Methods
for developing evidence-based recommendations by the Advisory
Committee on Immunization Practices (ACIP) of the US Centers for
Disease Control and Prevention (CDC). Vaccine 2011;29:9171–6.
http://dx.doi.org/10.1016/j.vaccine.2011.08.005
12. Ahmed F. US Advisory Committee on Immunization Practices handbook
for developing evidence-based recommendations [Version 1.2]. Atlanta,
GA: CDC; 2013. http://www.cdc.gov/vaccines/acip/recs/GRADE/
about-grade.html
13. CDC. GRADE evidence tables—recommendations in MMWR. Atlanta,
GA: US Department of Health and Human Services, CDC; 2015. http://
www.cdc.gov/vaccines/acip/recs/GRADE/table-refs.html
14. Poland GA, Grabenstein JD, Neff JM. The US smallpox vaccination program:
a review of a large modern era smallpox vaccination implementation program.
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vaccination, 1968. N Engl J Med 1969;281:1201–8. http://dx.doi.
org/10.1056/NEJM196911272812201
16. Lane JM, Ruben FL, Neff JM, Millar JD. Complications of smallpox
vaccination, 1968: results of ten statewide surveys. J Infect Dis
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17. Chosewood LC, Wilson DE; CDC; National Institutes of Health.
Biosafety in microbiological and biomedical laboratories. 5th ed.
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Public Health Service, CDC, National Institutes of Health; 2009.
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1997;25:287–8. http://dx.doi.org/10.1016/S0196-6553(97)90017-1
19. Sehulster L, Chinn RY. Guidelines for environmental infection control
in health-care facilities. Recommendations of CDC and the Healthcare
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Recomm Rep 2003;52(No. RR-10).
20. US Food and Drug Administration. ACAM2000 smallpox vaccine:
Vaccines and Related Biological Products Advisory Committee
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Administration; 2007. http://www.fda.gov/ohrms/dockets/ac/07/
briefing/2007-4292b2-02.pdf
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org/10.1093/aje/kwh269
Morbidity and Mortality Weekly Report
MMWR / March 18, 2016 / Vol. 65 / No. 10 263
US Department of Health and Human Services/Centers for Disease Control and Prevention
Tuberculosis (TB) is the leading cause of infectious disease
mortality worldwide, accounting for more than 1.5 million
deaths in 2014, and is the leading cause of death among
persons living with human immunodeficiency virus (HIV)
infection (1). Nigeria has the fourth highest annual number
of TB cases among countries, with an estimated incidence
of 322 per 100,000 population (1), and the second highest
prevalence of HIV infection, with 3.4 million infected persons
(2). In 2014, 100,000 incident TB cases and 78,000 TB deaths
occurred among persons living with HIV infection in Nigeria
(1). Nosocomial transmission is a significant source of TB
infection in resource-limited settings (3), and persons with
HIV infection and health care workers are at increased risk
for TB infection because of their routine exposure to patients
with TB in health care facilities (3–5). A lack of TB infection
control in health care settings has resulted in outbreaks of TB
and drug-resistant TB among patients and health care workers,
leading to excess morbidity and mortality. In March 2015, in
collaboration with the Nigeria Ministry of Health (MoH),
CDC implemented a pilot initiative, aimed at increasing health
care worker knowledge about TB infection control, assessing
infection control measures in health facilities, and developing
plans to address identified gaps. The approach resulted in
substantial improvements in TB infection control practices at
seven selected facilities, and scale-up of these measures across
other facilities might lead to a reduction in TB transmission
in Nigeria and globally.
To address the risk for TB transmission to uninfected
persons, the World Health Organization (WHO) recom-
mends implementation and scale-up of TB infection control
measures, including managerial (leadership and commitment
for establishing and implementing infection control policies
at the health facility), administrative (prompt identification
and separation of persons with presumptive TB, with timely
diagnosis and treatment of TB patients), and environmental
(optimization of building design and patient flow to reduce
the concentration of TB droplet nuclei in the air and control
directional flow of potentially infectious aerosols) measures
and personal protective equipment (PPE) use, implemented
in conjunction with other infection control measures, to
reduce the risk for TB transmission in health care facilities
(6). Preventing nosocomial TB transmission, aimed at reduc-
ing the impact of TB on persons living with HIV, is also a
priority for the U.S. President’s Emergency Plan for AIDS
Relief (PEPFAR) (7). However, infection control measures
to prevent TB transmission in health care facilities have not
been adequately implemented, especially in settings with high
incidence of TB and limited resources (8,9).
A four-phase TB infection control initiative, Building and
Strengthening Infection Control Strategies (TB BASICS), was
developed by CDC to assess and improve health care facility
infection control practices in countries with high numbers of
TB cases, using a continuous quality improvement approach.
The initiative includes 1) TB infection control training of
health care workers, 2) baseline health facility assessments and
development of intervention plans, 3) implementation, and
4) monitoring and evaluation through engagement of local
health officials and health care workers to encourage commit-
ment to the initiative. The pilot project was conducted in seven
health care facilities in Ebonyi, Enugu, and Imo states that are
supported by a PEPFAR implementing partner in southeastern
Nigeria. These facilities provide services to 1.48 million persons
and, during the past year, treated 1,600 TB patients.
A 3-day training workshop based on the WHO policy on
TB infection control in health care facilities, congregate set-
tings, and households (6) and delivered by MoH and CDC
was conducted for 50 health care workers, including physi-
cians, nurses, residents from the Nigeria Field Epidemiology
and Laboratory Training Program (NFELTP), TB and HIV
program coordinators, and TB/HIV program officers from the
MoH. A precourse assessment identified environmental and
administrative measures for infection control as the main gaps
in participant knowledge. Training materials, videos, and job
aids* were provided to all participants to facilitate their train-
ing of other staff members in their respective health facilities.
Teams
†
conducted baseline assessments of TB infection control
practices at each of the seven facilities using a standardized facil-
ity assessment tool that included staff interviews, observation of
* http://www.cdc.gov/globalaids/Resources/pmtct-care/tuberculosis-infection-
control.html.
†
The seven teams included state, regional, and federal MoH officials, NFELTP
residents, PEPFAR implementing partners, WHO staff members, and CDC
staff members and were led by health care providers from the pilot health facilities.
Building and Strengthening Infection Control Strategies to Prevent
Tuberculosis — Nigeria, 2015
E. Kainne Dokubo, MD
1
; Bethrand Odume, MBBS
2
; Virginia Lipke
1
; Custodio Muianga, PhD
3
; Eugene Onu, MBBS
4
; Ayodotun Olutola, MBBS
4
;
Lucy Ukachukwu
4
; Patricia Igweike
4
; Nneka Chukwura, PhD
5
; Emperor Ubochioma, MBBS
5
; Everistus Aniaku, MBBS
6
; Chinyere Ezeudu, MBBS
6
;
Joseph Agboeze, MBBS
6
; Gabriel Iroh, MBBS
6
; Elvina Orji, MBBS
6
; Okezue Godwin, MBBS
6
; Hasiya Bello Raji
7
; S.A. Aboje, MBBS
8
;
Chijioke Osakwe, MBBS
9
; Henry Debem, MSc
2
; Mustapha Bello, MBBS
2
; Dennis Onotu, MBBS
2
; Susan Maloney, MD
1
Morbidity and Mortality Weekly Report
264 MMWR / March 18, 2016 / Vol. 65 / No. 10 US Department of Health and Human Services/Centers for Disease Control and Prevention
routine practices, and review of available policies and procedures
on infection control. After completion of the baseline assessments
and identification of programmatic areas for strengthening, each
team developed a facility-specific intervention plan with a timeline
for implementation. Implementation of TB infection control
measures at each facility was reassessed at 2, 4, and 6 months after
the baseline assessment. Monitoring of 14 managerial measures,
13 administrative measures, seven environmental measures, and
three PPE measures was conducted by NFELTP residents, and
the final evaluations were performed by the teams that conducted
the baseline assessments. Data were displayed in a color-coded
dashboard (http://stacks.cdc.gov/view/cdc/38109) that indicated
elements that were not implemented (and for which there was
no implementation plan) in red, elements that were planned but
not yet implemented in yellow, elements that were not applicable
or assessed in blue, and elements that were fully implemented in
green. Site-specific feedback and a copy of the dashboard were
provided to the facilities immediately after the baseline assessment
was completed and at each of the bimonthly evaluations so that
staff members could visually track their own progress.
Baseline Assessment of TB Infection Control
Measures
At baseline, managerial measures were lacking in almost all
facilities. Only one site had national infection control policy
and guidelines or facility-specific plans available. There were
no infection control committees or designated practitioners, no
routine risk assessments or daily monitoring of infection control
activities, no ongoing or planned operational research to improve
infection control practices, and no occupational health programs.
All facilities had systems in place for reporting all new TB diagno-
ses, and all patients with diagnosed TB disease were referred for
treatment. In accordance with the national TB treatment policy,
directly observed therapy was provided for TB patients; however,
staff members did not know how to properly educate patients
and their visitors or provide them with information on infection
prevention. Administrative measures also were generally not in
place. Only three facilities had posters describing proper cough
etiquette, and most did not have tissue or hygiene supplies for
coughing patients, staff members designated to identify cough-
ing patients and separate them from other patients to reduce
possible exposure to TB, or systems in place for patients with
presumptive TB to be prioritized for clinical evaluation. None
of the facilities provided routine TB evaluation, HIV testing or
secure documentation of health information for their staffs, and
most did not have WHO-recommended isoniazid preventive
therapy available for staff members with HIV infection.
§
Collection of sputum in a designated location away from other
patients and timely processing of sputum samples were in place in
five of the seven facilities. Although all of the facilities had outdoor
patient waiting areas with good ventilation, other environmental
measures were poorly implemented. None of the facilities rou-
tinely checked airflow in examination rooms and waiting areas
to ensure adequate air exchange; signage reinforcing the opening
of doors and windows for cross-ventilation was not displayed,
and the facilities did not have extractor fans to facilitate removal
of infectious aerosols or use ultraviolet germicidal irradiation of
TB droplet nuclei. PPE was not consistently used in any of the
facilities. Coughing patients were not provided masks to cover the
nose and mouth. Staff members had not undergone respirator fit
testing and did not routinely wear respirators when interacting
with patients with presumptive or diagnosed TB disease.
Implementation of TB Infection Control
Improvements
Interventions to improve infection control practices were
carried out at each site to promote and enable facility-driven
program changes. No-cost interventions were immediately
put in place, and providers who had attended the training
used workshop materials to train other staff members at their
facilities. Posters and pamphlets with information on cough
etiquette, hygiene, and handwashing were provided to each
facility for display in patient waiting areas. Purchase of supplies
and minor renovations, including the construction of designated
sputum collection booths in remote areas of the facilities, were
undertaken. Facilities developed plans to monitor average patient
wait times and ensure that presumptive TB patients received
expedited care to reduce the amount of time they spent around
other patients and health care workers. Occupational health
programs were established at each facility, including routine TB
evaluations for health care workers, which led to the diagnosis
of TB in three staff members at two of the pilot facilities.
As measured by the dashboard, progress from predominantly
red indicators at baseline (indicating nonimplementation
of recommended measures), to almost all green indicators
(indicating full implementation) at the 6-month evaluation
reflected improvements made by the seven pilot facilities. At
baseline, only two of the 14 managerial measures were imple-
mented at all seven facilities. At the 6-month evaluation, 13
of the 14 managerial indicators had been implemented at all
of the facilities. Of the 13 administrative measures, the num-
ber implemented increased from zero at baseline to 10 at the
6-month evaluation. Of the seven environmental measures, the
number implemented increased from one to four, and of the
three PPE measures, the number implemented increased from
zero to three. As of February 2016, NFELTP residents, health
care providers, and health officials from the initial training
§
http://www.who.int/hiv/strategy2016-2021/Draft_global_health_sector_
strategy_hiv_01Dec2015.pdf?ua=1&ua=1.
Morbidity and Mortality Weekly Report
MMWR / March 18, 2016 / Vol. 65 / No. 10 265
US Department of Health and Human Services/Centers for Disease Control and Prevention
workshop had trained approximately 200 health care workers,
using materials and videos developed by CDC. The experiences
of participants in the project helped to inform revisions being
made to the TB infection control section of the Nigeria MoH
guidelines for TB/HIV collaborative activities.
Discussion
TB prevention is a key element in the strategy to end the global
TB epidemic (10) and an important component of prevention is
TB infection control. In Nigeria, as in many countries with high
numbers of cases and limited resources, implementation of TB
infection control measures has been inadequate (8). An initia-
tive aimed at increasing health care worker knowledge about TB
infection control and implementing measures to reduce nosoco-
mial transmission in Nigeria resulted in substantial improvement
in managerial, administrative, environmental, and personal
protective measures and in demonstrable country and facility
commitment to the initiative during a 6-month implementation
period. Managerial and administrative measures mainly involved
implementation of existing policies and change in practices and
were rapidly put into place. Environmental improvements and
PPE use were instituted at minimal cost.
Commitment from MoH and the conscientiousness of
participating health care workers were critical to the success
of this project. The limited knowledge of health care providers
and minimal implementation of infection control measures at
baseline was challenging. However, country capacity was built
by engaging local stakeholders in all aspects of the project,
including training, facility assessment, intervention planning
and implementation, monitoring, and evaluation. In addition,
many of the implemented practices required minimal interven-
tion. Continuing education and training of health care workers,
as well as monitoring of infection control practices, will help
to ensure that the progress attained is sustained.
The findings in this report are subject to at least two limi-
tations. First, the pilot project was conducted in PEPFAR-
supported facilities in southeastern Nigeria and might not
be representative of other facilities or sites in other parts of
the country. Second, although the initial achievements have
been encouraging, the long-term impact and sustainability of
the TB infection control practices implemented have not yet
been assessed.
The incidental diagnoses of TB among health care workers
as a result of this project highlight the value of routine health
care worker screening and underscore the importance of TB
infection control in health care settings. The outcome of the
pilot project and recommendations have been shared with
the government of Nigeria and in-country TB stakeholders,
and will guide ongoing capacity-building efforts, scale-up of
infection control practices in other health facilities in Nigeria,
and long-term monitoring plans.
Preventing TB infection is key to reducing the number of
TB cases worldwide, but there are still critical infection control
gaps in health facilities, posing a continued risk to persons liv-
ing with HIV infection, health care workers, and uninfected
persons. Widespread implementation of infection control
measures, especially in settings with high numbers of cases,
should help prevent further TB transmission and ultimately
bring the global TB epidemic to an end.
Acknowledgments
Staff members and management of Federal Teaching Hospital
Abakaliki, General Hospital Ezamgbo, St. Patrick’s Hospital Abakaliki,
District Hospital Enugu Ezike, General Hospital Nsukka, General
Hospital Abo-Mbaise, General Hospital Awo-Omamma, Nigeria;
Nigeria Federal Ministry of Health; National TB and Leprosy Control
Program; National Agency for Control of AIDS; National AIDS and
STD Control Program; Ebonyi State Ministry of Health; Enugu
State Ministry of Health; Imo State Ministry of Health; Nigeria Field
Epidemiology and Laboratory Training Program; Centre for Clinical
Care and Clinical Research, Nigeria; CDC Nigeria leadership and staff
members; TB BASICS Team, CDC.
1
Division of Global HIV and TB, Center for Global Health, CDC;
2
CDC
Nigeria;
3
Agency for Toxic Substances and Disease Registry;
4
Centre for Clinical
Care and Clinical Research, Nigeria;
5
National TB and Leprosy Control
Program, Nigeria;
6
Nigeria Field Epidemiology and Laboratory Training
Program;
7
National Agency for Control of AIDS, Nigeria;
8
National AIDS
and STD Control Program, Nigeria;
9
WHO, Nigeria.
Corresponding author: E. Kainne Dokubo, [email protected]v, 404-797-7459.
Summary
What is already known about this topic?
Tuberculosis (TB) is the leading cause of infectious disease
mortality globally. Nosocomial transmission is a significant source
of TB infection and of particular risk for health care workers and
persons living with human immunodeficiency virus infection. TB
infection control measures to reduce the transmission of TB in
health care facilities have not been well implemented in settings
with high numbers of cases and limited resources.
What is added by this report?
An intervention in Nigeria that focused on training health care
workers, identifying TB infection control gaps, and using
continuous quality improvement measures to monitor strate-
gies in health care facilities was effective in improving TB
infection control.
What are the implications for public health practice?
Increasing health care worker knowledge and implementation
of TB infection control measures in health facilities are key to
preventing the nosocomial spread of TB and reducing the
incidence of TB globally. Ongoing support will be required to
ensure that gains are maintained and that the infection control
program is sustainable.
Morbidity and Mortality Weekly Report
266 MMWR / March 18, 2016 / Vol. 65 / No. 10 US Department of Health and Human Services/Centers for Disease Control and Prevention
References
1. World Health Organization. Global tuberculosis report 2015. Geneva,
Switzerland: World Health Organization; 2015. http://www.who.int/tb/
publications/global_report/en
2. Joint United Nations Programme on HIV/AIDS (UNAIDS). Nigeria global
AIDS response country progress report; 2015. http://www.unaids.org/sites/
default/files/country/documents/NGA_narrative_report_2015.pdf
3. Joshi R, Reingold AL, Menzies D, Pai M. Tuberculosis among health-care
workers in low- and middle-income countries: a systematic review. PLoS
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4. Galgalo T, Dalal S, Cain KP, et al. Tuberculosis risk among staff of a large
public hospital in Kenya. Int J Tuberc Lung Dis 2008;12:949–54.
5. Baussano I, Nunn P, Williams B, Pivetta E, Bugiani M, Scano F.
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94. http://dx.doi.org/10.3201/eid1703.100947
6. World Health Organization. WHO policy on TB infection control in
health-care facilities, congregate settings, and households; 2009. Geneva,
Switzerland: World Health Organization; 2009. http://apps.who.int/
iris/bitstream/10665/44148/1/9789241598323_eng.pdf
7. US Department of State. The President’s Emergency Plan for AIDS
Relief (PEPFAR) blueprint: creating an AIDS-free generation.
Washington DC: US Department of State; 2012. http://www.state.
gov/r/pa/prs/ps/2012/11/201195.htm
8. Reid MJ, Saito S, Nash D, Scardigli A, Casalini C, Howard AA.
Implementation of tuberculosis infection control measures at HIV care and
treatment sites in sub-Saharan Africa. Int J Tuberc Lung Dis 2012;16:1605–12.
http://dx.doi.org/10.5588/ijtld.12.0033
9. Farley JE, Tudor C, Mphahlele M, et al. A national infection control
evaluation of drug-resistant tuberculosis hospitals in South Africa. Int J
Tuberc Lung Dis 2012;16:82–9. http://dx.doi.org/10.5588/ijtld.10.0791
10. World Health Organization. The End TB Strategy. Geneva, Switzerland: World
Health Organization; 2016. http://www.who.int/tb/strategy/end-tb/en/
Morbidity and Mortality Weekly Report
MMWR / March 18, 2016 / Vol. 65 / No. 10 267
US Department of Health and Human Services/Centers for Disease Control and Prevention
On March 11, 2016, this report was posted as an MMWR
Early Release on the MMWR website (http://www.cdc.gov/mmwr).
Since May 2015, when Zika virus, a flavivirus transmitted
primarily by Aedes aegypti mosquitoes, was reported in Brazil,
the virus has rapidly spread across the Region of the Americas
and the Caribbean. The association between maternal Zika
virus infection and adverse fetal and reproductive outcomes,
including microcephaly, prompted CDC to issue a Level 2
alert travel notice* for the 37 countries and U.S. territories
(at the national and territorial level) that have reported recent
Zika virus transmission as of March 11, 2016. In addition to
mosquito bite precautions for all travelers, CDC advises that
pregnant women postpone travel to affected countries and
U.S. territories. Within a nation’s borders, ecologic character-
istics, which determine the distribution of mosquito vectors,
can vary considerably. CDC conducted a spatial analysis,
focusing on the probability of occurrence of Ae. aegypti, to
support the demarcation for subnational travel alerts. Based
on results of this analysis, travel that is limited to elevations
higher than 2,000 m (6,562 ft) above sea level is considered
to have minimal (approximately 1%) likelihood for mosquito-
borne Zika virus transmission, even within countries reporting
active transmission. Women who are pregnant should avoid
travel to elevations <2,000 m in countries with active Zika
virus transmission.
Zika virus is a flavivirus primarily transmitted by Aedes spe-
cies mosquitoes (1). In May 2015, the Pan American Health
Organization (PAHO) issued an alert regarding the first con-
firmed Zika virus infections in Brazil (2). Currently, outbreaks
of Zika virus disease are occurring in many countries and U.S.
territories, and as of March 11, 2016, CDC had issued 37
Level 2 travel notices for areas with ongoing Zika virus trans-
mission.
†
Currently, when laboratory-confirmed local Zika
virus transmission is first reported, travel notices are issued for
the entire country or U.S. territory. Establishing more precisely
defined areas of Zika virus risk in a country or U.S. territory
is complicated by incomplete surveillance data on the disease
and the presence of the mosquito vector.
In an effort to develop more precise guidance for travelers,
CDC evaluated whether subnational travel notices could be
based on an ecologic indicator of the probable absence of the
predominant Zika virus mosquito vector, Ae. aegypti. Within
a nation’s borders, ecologic factors, such as temperature,
precipitation, vegetation, and human population density, that
define suitable habitats for Aedes species vary. Where habitat
is unsuitable, the mosquito vector is likely to be absent, and
risk for mosquito-borne Zika virus transmission is likely to
be negligible.
The first step in developing subnational travel notices
required identification of a single, easily quantifiable ecologic
variable that could be used as a substitute for the likely absence
of Ae. aegypti. Of the many ecologic factors affecting habitat
suitability and Ae. aegypti survival as a vector for Zika virus,
temperature has been the most frequently investigated and
rigorously quantified (3); however, temperature varies widely
and is difficult to predict locally and over the long term.
Historically, elevation has served as a reasonable proxy for
temperature. Because it is static and relatively easy to measure
(4), elevation was selected for further investigation. Previous
reports from various global regions suggest that Ae. aegypti is
present, but rare, between elevations of 1,700–2,100 m (5,6).
Therefore, this analysis was restricted to countries and U.S.
territories that have 1) ongoing Zika virus transmission and
2) areas with high elevations (starting at >1,500 m). Sixteen
countries, including Bolivia, Brazil, Colombia, Costa Rica,
Dominican Republic, Ecuador, El Salvador, Guatemala,
Guyana, Haiti, Honduras, Jamaica, Mexico, Nicaragua,
Panama, and Venezuela have areas which fit these criteria.
§
No U.S. territories had elevations at that level.
Spatial analyses were conducted using multiple data sets:
global data on predicted probabilities of the presence of
Ae. aegypti based on 20,000 observed occurrences during
1960–2014 (7); remotely sensed data on human population
density (8); global geographic data on human dengue cases
Revision to CDC’s Zika Travel Notices: Minimal Likelihood for Mosquito-Borne
Zika Virus Transmission at Elevations Above 2,000 Meters
Martin Cetron, MD
1
* CDC provides updated travel information on areas with ongoing Zika virus
transmission. http://wwwnc.cdc.gov/travel/notices.
†
American Samoa, Aruba, Barbados, Bolivia, Bonaire, Brazil, Cape Verde,
Colombia, Costa Rica, Curacao, Dominican Republic, Ecuador, El Salvador,
French Guiana, Guadeloupe, Guatemala, Guyana, Haiti, Honduras, Jamaica,
Marshall Islands, Martinique, Mexico, New Caledonia, Nicaragua, Panama,
Paraguay, Puerto Rico, Saint Martin, Saint Vincent and Grenadines, Samoa,
Sint Maarten, Suriname, Tonga, Trinidad and Tobago, U.S. Virgin Islands,
and Venezuela.
§
CDC provides updated travel notice maps for areas with ongoing Zika virus
transmission, including Bolivia, Brazil, Colombia, Costa Rica, Dominican
Republic, Ecuador, El Salvador, Guatemala, Guyana, Haiti, Honduras, Jamaica,
Mexico, Nicaragua, Panama, and Venezuela. http://wwwnc.cdc.gov/travel/page/
zika-travel-information.
Morbidity and Mortality Weekly Report
268 MMWR / March 18, 2016 / Vol. 65 / No. 10 US Department of Health and Human Services/Centers for Disease Control and Prevention
during 1960–2012 (9); and a digital elevation model (10);
zonal statistics were used to relate the data sets. Within each of
the 16 countries, the area of land suitable for Ae. aegypti, and
the human population counts within each area were quantified.
The quantification was done in 100-m elevation segments for
elevations between 0 m and 2,500 m. Across all 16 countries,
at elevations >2,000 m, Ae. aegypti was predicted to be largely
absent. Because of sparse current geographic data on Zika virus
cases, cases of dengue, another vector-borne viral disease spread
primarily by Ae. aegypti, were examined as a proxy for Zika
cases. Only 1.1% (28/2,682) of dengue cases in the global data
set (9) were reported to have occurred at elevations >2,000 m
in the 16 countries.
A CDC Zika virus travel notice is currently applied to an
entire country or U.S. territory when transmission is confirmed
by a local public health authority. However, Ae. aegypti might
not be uniformly present because of differences in ecologic
suitability. Recent advances in scientific modeling have allowed
for more precision in geospatial analyses. CDC applied these
approaches to previously published and rigorously evaluated
data to determine if more precise guidance to travelers and
persons living in affected regions could be established. The
results from the spatial analyses of 16 countries with ongo-
ing Zika virus transmission and elevation points >1,500 m
indicate that Ae. aegypti is unlikely to be found at elevations
>2,000 m because of unsuitable ecologic factors, including but
not limited to, low temperatures. Consequently, at elevations
above 2,000 m, the risk for mosquito-borne exposure to Zika
virus is considered to be minimal. These findings support
revising the Zika travel notice to reflect enhanced geographic
precision regarding the likelihood of Zika virus presence at
certain elevations.
With this revision, CDC recommends that women who are
pregnant should postpone travel to areas that are at elevations
<2,000 m above sea level in countries and U.S. territories with
ongoing Zika virus transmission. Because Zika virus is primar-
ily spread by mosquitoes, CDC recommends that travelers
protect themselves from mosquito bites.
¶
Travel that is entirely
limited to elevations >2,000 m is considered to pose minimal
likelihood for mosquito-borne Zika virus transmission.** As
additional geographic data specific to Zika virus cases in rela-
tion to elevation become available, these recommendations
will be reviewed and revised as needed.
1
Division of Global Migration and Quarantine, National Center for Emerging
and Zoonotic Infectious Diseases, CDC.
Corresponding author: Martin Cetron, [email protected]v, 770-488-7100.
References
1. Chouin-Carneiro T, Vega-Rua A, Vazeille M, et al. Differential
susceptibilities of Aedes aegypti and Aedes albopictus from the Americas
to Zika virus. PLoS Negl Trop Dis 2016;10:e0004543. http://dx.doi.
org/10.1371/journal.pntd.0004543
2. Pan American Health Organization. Epidemiological alert: Zika virus infection.
2015 May 7. Washington, DC: Pan American Health Organization, World
Health Organization; 2015. http://www.paho.org/hq/index.
php?option=com_docman&task=doc_view&Itemid=270&gid=30075
3. Brady OJ, Golding N, Pigott DM, et al. Global temperature constraints
on Aedes aegypti and Ae. albopictus persistence and competence for dengue
virus transmission. Parasit Vectors 2014;7:338. http://dx.doi.
org/10.1186/1756-3305-7-338
4. Garnham PC. Malaria epidemics at exceptionally high altitudes. BMJ
1945;2:45–7. http://dx.doi.org/10.1136/bmj.2.4410.45
5. Lozano-Fuentes S, Hayden MH, Welsh-Rodriguez C, et al. The dengue
virus mosquito vector Aedes aegypti at high elevation in Mexico. Am J
Trop Med Hyg 2012;87:902–9. http://dx.doi.org/10.4269/
ajtmh.2012.12-0244
6. Dhimal M, Gautam I, Joshi HD, O’Hara RB, Ahrens B, Kuch U. Risk
factors for the presence of chikungunya and dengue vectors (Aedes aegypti
and Aedes albopictus), their altitudinal distribution and climatic
determinants of their abundance in central Nepal. PLoS Negl Trop Dis
2015;9:e0003545. http://dx.doi.org/10.1371/journal.pntd.0003545
7. Kraemer MU, Sinka ME, Duda KA, et al. The global distribution of
the arbovirus vectors Aedes aegypti and Ae. albopictus. eLife 2015;4:e08347.
http://dx.doi.org/10.7554/eLife.08347
8. LandScan. 2014. High resolution global population data set copyrighted
by UT-Battelle, LLC, operator of Oak Ridge National Laboratory under
contract no. DE-AC05–00OR22725 [dataset]. 2014. http://web.ornl.
gov/sci/landscan/
9. Messina JP, Brady OJ, Pigott DM, Brownstein JS, Hoen AG, Hay SI.
A global compendium of human dengue virus occurrence. Sci Data
2014;1:140004. http://dx.doi.org/10.1038/sdata.2014.4
10. Danielson JJ, Gesch DB. Global multi-resolution terrain elevation data
2010 (GMTED2010): US Geological Survey Open-File Report.
Washington, DC: US Department of the Interior, US Geological Survey;
2011. http://pubs.usgs.gov/of/2011/1073/pdf/of2011-1073.pdf
¶
http://wwwnc.cdc.gov/travel/page/avoid-bug-bites.
** The low oxygen levels found at high elevations can cause problems for travelers
who are going to elevations above 2,400 m (8,000 ft). The best way to prevent
altitude illness is to ascend slowly and take time to get used to the lower oxygen
levels. Pregnant women should avoid strenuous activities at high elevations,
and some doctors recommend that pregnant women not spend the night at
altitudes above 3,650 m (12,000 ft). Pregnant women should also consider
whether they will have access to medical care at a high-elevation destination.
Morbidity and Mortality Weekly Report
MMWR / March 18, 2016 / Vol. 65 / No. 10 269
US Department of Health and Human Services/Centers for Disease Control and Prevention
Announcements
Diabetes Alert Day — March 22, 2016
March 22 is Diabetes Alert Day, dedicated to raising aware-
ness about type 2 diabetes, its risk factors, and its prevention.
Type 2 diabetes, which accounts for 90%–95% of all cases of
diagnosed diabetes in U.S. adults, might be prevented through
lifestyle changes, such as losing weight and increasing physical
activity (1,2). In the United States, 86 million adults have pre-
diabetes, putting them at increased risk for developing type 2
diabetes, heart disease, and stroke. Only 10% of adults with
prediabetes know they have it (1,3).
In partnership with the Ad Council, the American Diabetes
Association, and the American Medical Association, CDC’s
Division of Diabetes Translation developed and launched the
first national prediabetes awareness campaign to encourage
people to take steps to prevent type 2 diabetes. The website
DoIHavePrediabetes.org (https://doihaveprediabetes.org)
features a short test for people to find out their prediabetes
risk and includes lifestyle tips and links to CDC-recognized
prevention programs across the country that are part of the
National Diabetes Prevention Program (http://www.cdc.
gov/diabetes/prevention/index.html). The U.S. Diabetes
Surveillance System includes an updated Diabetes State Atlas
(http://www.cdc.gov/diabetes/data) that allows users to view
data and trends on any mobile device. In addition to containing
the latest state-level data, the atlas now presents estimates of
the percentage of adults without diagnosed diabetes who report
having had a test for diabetes or high blood glucose in the past
3 years. Additional information about diabetes prevention and
control is available from CDC (http://www.cdc.gov/diabetes).
References
1. CDC. National diabetes statistics report: estimates of diabetes and its
burden in the United States, 2014. Atlanta, GA: US Department of Health
and Human Services, CDC; 2014.
2. Knowler WC, Barrett-Connor E, Fowler SE, et al.; Diabetes Prevention
Program Research Group. Reduction in the incidence of type 2 diabetes
with lifestyle intervention or metformin. N Engl J Med 2002;346:393–
403. http://dx.doi.org/10.1056/NEJMoa012512
3. Li YF, Geiss LS, Burrows NR, Rolka DB, Albright A. Awareness of
prediabetes—United States, 2005–2010. MMWR Morb Mortal Wkly
Rep 2013;62:209–12.
World Water Day — March 22, 2016
World Water Day 2016, sponsored by the United Nations,
is focused on water and jobs. Approximately half of workers
around the world (1.5 billion persons) have jobs in water-
related industries (1). Many industries rely on water to perform
jobs, such as fishing, agriculture, manufacturing, and food ser-
vice. Societies and economies depend on the men and women
who work to keep the world’s drinking water safe.
Climate change affects the economies and infrastructure that
provide access to safe drinking water around the world. The
World Health Organization estimates that during 2030–2050,
an additional 250,000 persons will die each year as a result of
climate change (2). Diarrheal diseases from contaminated water
and lack of adequate sanitation and hygiene will be a major
cause of these additional deaths (3). Now is the time to address
these challenges and commit to the responsible management
of water resources to ensure sustainable development in the
present and for generations to come.
Information is available about World Water Day, includ-
ing ideas on how to get involved (http://www.unwater.org/
worldwaterday). Information on CDC’s efforts to ensure global
access to improved water, sanitation, and hygiene is also avail-
able (http://www.cdc.gov/healthywater/global).
References
1. United Nations. World Water Day. New York, NY: United Nations; 2016.
http://www.unwater.org/worldwaterday
2. World Health Organization. Economic, social and environmental context
of health [Chapter 2]. In: Health in 2015: from MDGs (millennium
development goals) to SDGs (sustainable development goals). Geneva,
Switzerland: World Health Organization; 2015. http://www.who.int/gho/
publications/mdgs-sdgs/MDGs-SDGs2015_chapter2.pdf
3. World Health Organization. Infectious diseases [Chapter 5]. In: Health
in 2015: from MDGs (millennium development goals) to SDGs
(sustainable development goals). Geneva, Switzerland: World Health
Organization; 2015. http://www.who.int/gho/publications/mdgs-sdgs/
MDGs-SDGs2015_chapter5.pdf?ua=1
Morbidity and Mortality Weekly Report
270 MMWR / March 18, 2016 / Vol. 65 / No. 10 US Department of Health and Human Services/Centers for Disease Control and Prevention
* With 95% confidence intervals indicated with error bars.
†
Age-adjusted using the direct method to the year 2000 projected Census population using three age groups:
20–39 years, 40–59 years, and ≥60 years.
§
Defined by an affirmative response to the question, “Have you ever had your blood cholesterol checked?” and
a response indicating <5 years ago to the question, “About how long has it been since you last had your blood
cholesterol level checked?”
During 2011–2014, 71.2% of adults aged ≥20 years had their blood cholesterol checked in the past 5 years. A smaller percentage
of Hispanic adults (62.1%) had their cholesterol checked in the past 5 years compared with non-Hispanic white (73.5%), non-
Hispanic black (72.3%), and non-Hispanic Asian (72.9%) adults. This pattern was observed for both men and women. A larger
percentage of non-Hispanic white, non-Hispanic black, and Hispanic women had their cholesterol checked compared with their
male counterparts, but there was no difference between non-Hispanic Asian men and women.
Source: Carroll MD, Kit BK, Lacher DA, Yoon SS. Total and high-density lipoprotein cholesterol in adults: National Health and Nutrition Examination
Survey, 2011–2012. NCHS Data Brief no. 132; 2013. http://www.cdc.gov/nchs/data/databriefs/db132.htm.
CDC. National Health and Nutrition Examination Survey Data. Hyattsville, MD: US Department of Health and Human Services, CDC, National
Center for Health Statistics; 2011–2014. http://www.cdc.gov/nchs/nhanes.htm.
Reported by: Margaret D. Carroll, MSPH, [email protected], 301-458-4136; Cheryl D. Fryar, MSPH; Brian K. Kit, MD; Steven M. Frenk, PhD.
0
10
20
30
40
50
60
70
80
90
100
Overall Men Women
Percentage
Sex
White, non-Hispanic
Black, non-Hispanic
Asian, non-Hispanic
Hispanic
QuickStats
FROM THE NATIONAL CENTER FOR HEALTH STATISTICS
Age-Adjusted Percentage*
,†
of Adults Aged ≥20 Years Who Had Their
Cholesterol Checked in the Past 5 Years,
§
by Sex and Race/Ethnicity —
National Health and Nutrition Examination Survey, United States, 2011–2014
ISSN: 0149-2195 (Print)
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