Rafael Harpaz

The number of immunosuppressed adults in the United States is unknown but thought to be increasing because of both greater life expectancy among immunosuppressed adults due to improvements in medical management, as well as new indications for immunosuppressive treatments.^1- 4 Immunosuppression increases the risks and severity of primary or reactivation infections; its prevalence has implications for food and water safety, tuberculosis control, vaccine programs, infection control strategies, outbreak preparedness, travel medicine, and other facets of public health.¹ We present data on the prevalence of self-reported immunosuppressed adults in the United States.

The causes for zoster remain largely unknown. Psychological stress is one commonly considered risk factor. We used self-controlled case series methods to look for increases in zoster following death or catastrophic health event occurring in a previously healthy spouse. We found no increase, although this stressor led to increased mental health visits.

Measles surveillance is complex: the patient must seek health care, the diagnosis must be recognized by the physician, and the case must be reported

As part of a strategy to eliminate measles,7 indicators were adopted in the United States in 1996 to ensure the quality of measles surveillance. This report summarizes the US experience with these indicators during 1996–1998. The indicators are compiled from data reported to the Centers for Disease Control and Prevention (CDC) during routine surveillance supplemented with information collected directly from states. Measles case investigations are generally thorough, and sufficient information is collected to control and monitor disease. A high proportion of measles cases are imported from other countries, suggesting that investigations are complete. For some states, the lag from disease onset to reporting is long, and the number of health department investigations of measleslike illnesses is low. Most of these investigations include laboratory testing of clinical specimens. Collection of measles virus specimens from cases for genetic analysis needs improvement. The CDC and health departments need to continue efforts directed at health care professionals to ensure the recognition, proper diagnostic workup, and reporting of measles.

Evidence that endemic measles has been eliminated in the United States rests on the performance of the surveillance system. Information from national

To determine whether measles case finding is sensitive, we developed a standard by which to evaluate measles surveillance. We compiled data on the incidence of measleslike illnesses (MLIs) from multiple, diverse sources and used the distribution of these values to determine the minimum level of measles case-finding activity that could be expected in a given region. Among surveillance programs in the United States, other countries in the Americas, and other World Health Organization regions, the median annual rates for rash investigations that were ruled out for measles were 4.3, 4.1, and 1.8/100,000 population, respectively. The annual rates of measles IgM testing in the United States in public laboratories and commercial laboratories were 1.6 and 9.2/ 100,000 population, respectively. In total, we collected data on annual MLI incidence from >80 sources. Values ranged from 0.1 to 22.6 cases of MLI per 100,000 population, and 90% of values were ⩾1.0/100,000 population. On the basis of these findings, we propose that programs attempting measles ehmination consider evaluating surveillance by comparing the annual rate of suspected measles investigations against a minimum standard of 1/100,000 population.

An immunization assessment and a serologic survey were conducted to evaluate the effectiveness of a hepatitis B immunization program in eliminating h