News

Since 1986, the Healthcare Infection Control Practices Advisory Committee (HICPAC) and the Advisory Committee on Immunization Practices (ACIP) have recommended that all health care personnel (HCP) be vaccinated annually for influenza. Since 1989, overall influenza vaccination coverage among HCP has never exceeded 49% in any season, according to estimates from the National Health Interview Survey. In August 2009, ACIP recommended that HCP be 1 of 5 initial target groups to receive the influenza A (H1N1) 2009 monovalent vaccine when it first became available. By mid-January 2010, estimated vaccination coverage among HCP was 37.1% for 2009 pandemic influenza A (H1N1) and 61.9% for seasonal influenza. Overall, 64.3% received either of these influenza vaccines, higher coverage than any previous season, but only 34.7% of HCP reported receiving both vaccines. The existence of an employer requirement for vaccination at the facility where the respondent was employed was associated with an eightfold greater likelihood of 2009 H1N1 vaccination compared with respondents employed by facilities with neither requirement nor recommendations; likewise, the existence of a recommendation for vaccination was associated with a fourfold greater probability of 2009 H1N1 vaccination. Seasonal influenza vaccination coverage was substantially higher amongHCP working in hospitals (71.7%) than those working in long-termcare facilities (54.0%) or other settings (48.4%) (P = .003 and P = .001, respectively). 2009 H1N1 vaccination coverage also was higher among HCP working in hospitals (50.6%) than those working in outpatient clinics (39.2%), longterm care facilities (20.1%), or other settings (33.4%) (P = .003, P < .001, and P = .015, respectively). Seasonal influenza vaccination was reported to be required by employers for 11.1% of HCP and recommended by employers for 65.4%. An employer requirement was associated with an almost 2-fold higher coverage rate for seasonal influenza vaccination, compared with the rate among HCP whose employers neither required nor recommended seasonal vaccination (relative risk [RR], 1.7; P < .001); an employer requirement was associated with a rate almost 3-fold higher (RR, 2.6; P < .001). 2009 H1N1 vaccination was required by employers for 8.4% of HCP and recommended by employers for 61.8%. An employer requirement was associated with an almost 8-fold higher coverage rate for 2009 H1N1 influenza vaccination, compared with the rate among HCP whose employers neither required nor recommended seasonal (RR, 7.8; P < .001); an employer recommendation was associated with a rate almost 4-fold higher (RR, 3.9; P < .001). Centers for Disease Control and Prevention (CDC) announces the availability of a new heptavalent botulinum antitoxin (HBAT; Cangene Corporation) through a CDC-sponsored Food and Drug Administration (FDA) Investigational New Drug (IND) protocol. HBAT replaces a licensed bivalent botulinum antitoxin AB and an investigationalmonovalent botulinumantitoxin E (BAT-AB and BAT-E; Sanofi Pasteur) with expiration of these products on 12 March 2010. As of 13 March 2010, HBAT became the only botulinum antitoxin available in theUnited States for naturally occurring noninfant botulism. Botulinum antitoxin for treatment of naturally occurring noninfant botulism is available only from CDC. The transition to HBAT ensures uninterrupted availability of antitoxin. BabyBIG (botulism immune globulin) remains available for infant botulism through the California Infant Botulism Treatment and Prevention Program. BabyBIG is an orphan drug that consists of human-derived botulism antitoxin antibodies and is approved by FDA for the treatment of infant botulism types A and B. HBAT contains equine-derived antibody to the 7 known botulinum toxin types (A–G) with the following nominal potency values: 7500 U anti-A, 5500 U anti-B, 5000 U anti-C, 1000 U anti-D, 8500 U anti-E, 5000 U anti-F, and 1000 U anti-G. HBAT is composed of <2% intact immunoglobulin G (IgG) and ⩾90% Fab and F(ab′)2 immunoglobulin fragments; these fragments are created by the enzymatic cleavage and removal of Fc immunoglobulin components in a process sometimes referred to as despeciation. Fab and F(ab′)2 fragments are cleared from circulation more rapidly than intact IgG, and repeat HBAT dosing might be indicated for some wound or intestinal colonization patients if in situ botulinum toxin production continues after clearance of antitoxin. The HBAT FDA IND treatment protocol includes specific, detailed instructions for intravenous administration of antitoxin and return of required paperwork to CDC. Health care providers should report suspected botulism cases immediately to their state health department; all states maintain 24-hour telephone services for reporting of botulism and other public health emergencies. Additional emergency consultation is available from the CDC botulism duty officer via the CDC Emergency Operations Center, telephone, 770–488-7100. Additional information regarding CDC's botulism treatment program is available at http://www.bt.cdc.gov/agent/botulism. In early April 2010, a vancomycin-resistant Staphylococcus aureus (VRSA) was isolated from a patient in Philadelphia. The patient was a chronic kidney dialysis patient transferred from Delaware. The definition of VRSA is a minimum inhibitory concentration of 16 µg/mL vancomycin or higher. The first case in the world from which VRSA was isolated involved a patient in Japan in 1990. Subsequently isolates have been extremely rare and have occurred primarily in patients with prolonged exposure to vancomycin therapy. There have been as many as 12 strains of VRSA isolated from clinical specimens in the United States. The first was reported in 2002 and the last in 2007, when 2 cases were reported. These strains seem to evolve from methicillin-resistant S. aureus (MRSA) and do not seem to be more virulent than ordinary MRSA strains. The mechanism for high-level resistance to vancomycin in most if not all of the isolates has been transference of vancomycin resistant genes (VanA) from vancomycinresistant enterococci. The antimicrobial susceptibilities of VRSA to non-vancomycin-related drugs have been the same as typical for health care-associated MRSA. No spread from person to person has been documented for VRSA. (D.K.) Tick-borne encephalitis virus (TBEV) is the most common arbovirus transmitted by ticks in Europe. Approximately 10,000 cases of tick-borne encephalitis (TBE) are reported annually in Europe and Russia. Although TBE is endemic in parts of China, information regarding its incidence is limited. Before 2000, 2 cases of TBE in North American travelers to Europe were reported. State health officials or clinicians send specimens from patients with unexplained encephalitis to the Centers for Disease Control and Prevention (CDC) as part of routine surveillance and diagnostic testing. CDC recently reviewed all 2000–2009 laboratory records to identify cases of TBE among United States (US) travelers; 5 cases were identified. Of the 4 US patients who had traveled to Europe or Russia, all noted having tick bites and had biphasic illnesses. Two had encephalitis and 2 had meningitis; none had neurologic sequelae. The fifth patient, who traveled to China, had a monophasic illness with severe encephalitis and neurologic sequelae and no history of tick bite. TBEV is endemic from western Europe through Siberia and parts of Asia including certain areas in China. This is the first reported case of TBE in a US traveler returning from China. Approximately onethird of persons infected with TBEV develop clinical symptoms and about two-thirds of patients recall having a tick bite. Typically, patients infected with the European subtype have a biphasic illness. The first (viremic) phase consists of a nonspecific febrile illness, often followed by a remission of symptoms. Approximately one-third of these patients then develop the second, more severe (neuroinvasive) phase of illness, resulting in meningitis (approximately 50%), encephalitis (approximately 40%), or myelitis (approximately 10%). The case-fatality ratio for the European and Siberian subtypes is approximately 1%–3%. The Far Eastern TBEV subtype typically causes a more severe monophasic illness with a case-fatality ratio of approximately 20% and neurologic sequelae in up to 80% of survivors. No specific antiviral treatment for TBE exists. The main preventive measure is avoiding tick bites by applying insect repellents to clothing and exposed skin. No TBE vaccines are licensed or available in the United States, but 2 inactivated TBEV vaccines are licensed and available in Europe and Canada. TBEV testing can be performed at CDC's Special Pathogens Branch (telephone: 404-639-1115), and TBEV and other arboviral disease testing can be performed at CDC's Arboviral Diseases Branch (telephone: 970-221-6400).

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