Issue Number 468            July 6, 2004


  1. CDC confirms first reported cases of rabies transmission through solid organ transplantation
  2. CDC reports on 2003-04 influenza activity in the U.S. and worldwide and on composition of the 2004-05 influenza vaccine
  3. CME teleconferences on childhood influenza prevention are scheduled for July 13-15
  4. Attention: July 19 is the application deadline for the position of director, Division of Viral Hepatitis
  5. Reminder: July 31 is the early-bird registration deadline for the National Conference on Immunization Coalitions
  6. Coming soon: HFI's National Viral Hepatitis Summit scheduled for August 26-27 in Baltimore, MD
  7. September 7 is registration deadline for Immunize Georgia's Little Guys conference
  8. CDC notifies readers about free software for influenza pandemic preparedness planning
  9. CDC reports on progress toward measles mortality reduction in South East Asia, 1999-2002


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ABBREVIATIONS: AAFP, American Academy of Family Physicians; AAP, American Academy of Pediatrics; ACIP, Advisory Committee on Immunization Practices; CDC, Centers for Disease Control and Prevention; FDA, Food and Drug Administration; IAC, Immunization Action Coalition; MMWR, Morbidity and Mortality Weekly Report; NIP, National Immunization Program; VIS, Vaccine Information Statement; VPD, vaccine-preventable disease; WHO, World Health Organization.

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July 6, 2004

CDC published "Investigation of Rabies Infections in Organ Donor and Transplant Recipients--Alabama, Arkansas, Oklahoma, and Texas, 2004" in the July 2 issue of "MMWR Dispatch." CDC publishes the web-based "MMWR Dispatch" only for the immediate release of important public health information. The article will be published in a print issue of MMWR in the future.

The July 2 "MMWR Dispatch" is reprinted below in its entirety, excluding references and two figures.


On June 30, 2004, CDC confirmed diagnoses of rabies in three recipients of transplanted organs and in their common donor, who was found subsequently to have serologic evidence of rabies infection. The transplant recipients had encephalitis of unknown etiology after transplantation and subsequently died. Specimens were sent to CDC for diagnostic evaluation. This report provides a brief summary of the ongoing investigation and information on exposure risks and postexposure measures.

Organ donor
The organ donor was an Arkansas man who visited two hospitals in Texas with severe mental status changes and a low-grade fever. Neurologic imaging indicated findings consistent with a subarachnoid hemorrhage, which expanded rapidly in the 48 hours after admission, leading to cerebral herniation and death. Donor eligibility screening and testing did not reveal any contraindications to transplantation, and the patient's family agreed to organ donation. Lungs, kidneys, and liver were recovered. No other organs or tissues were recovered from the donor, and the donor did not receive any blood products before death. The liver and kidneys were transplanted into three recipients on May 4 at a transplant center in Texas. The lungs were transplanted in an Alabama hospital into a patient who died of intraoperative complications.

Liver recipient
The liver recipient was a man with end-stage liver disease. The patient did well immediately after transplantation and was discharged home on postoperative day 5. Twenty-one days after transplant, the patient was readmitted with tremors, lethargy, and anorexia; he was afebrile. The patient's neurologic status deteriorated rapidly during the next 24 hours; he required intubation and critical care support. A lumbar puncture indicated a mild lymphocytic pleocytosis (25 white blood cells/cubic mm) and a mildly elevated protein. Magnetic resonance imaging (MRI) of the brain indicated increased signal in the cerebrospinal fluid. His neurologic status continued to deteriorate. Six days after admission, a repeat MRI indicated diffuse encephalitis. The patient subsequently died.

Female kidney recipient
The first kidney recipient was a woman with end-stage renal disease caused by hypertension and diabetes. She had no postoperative complications and was discharged home on postoperative day 7. Twenty-five days after transplant, she was readmitted with right-side flank pain and underwent an appendectomy. Two days after this procedure, she had diffuse twitching and was noted to be increasingly lethargic. Neurologic imaging with computed tomography and MRI indicated no abnormality. During the next 24-48 hours, the patient had worsening mental status, seizures, hypotension, and respiratory failure requiring intubation. Her mental status continued to deteriorate, and cerebral imaging 2 weeks after admission indicated severe cerebral edema. The patient subsequently died.

Male kidney recipient
The second renal recipient was a man with end-stage renal disease caused by focal, segmental glomerulosclerosis. His posttransplant course was complicated briefly by occlusions of an arterial graft leading to infarction of the lower pole of the transplanted kidney. The patient was discharged home 12 days after transplantation. Twenty-seven days after transplantation, he visited a hospital emergency department and was then transferred to the transplant center with myoclonic jerks and altered mental status; he was afebrile. An MRI of the brain performed on admission revealed no abnormalities. His mental status deteriorated rapidly during the next 24 hours. A lumbar puncture revealed mild lymphocytic pleocytosis (16 white blood cells/cubic mm) and a mildly elevated protein. His mental status continued to deteriorate, leading to respiratory failure requiring intubation. A repeat MRI performed 10 days after admission indicated diffuse edema. The patient subsequently died.

Laboratory investigation
In all three patients, histopathologic examination of central nervous system (CNS) tissues at CDC revealed an encephalitis with viral inclusions suggestive of Negri bodies; the diagnosis of rabies in all three recipients was confirmed by immunohistochemical testing and by the detection of rabies virus antigen in fixed brain tissue by direct fluorescent antibody tests. Electron microscopy of CNS tissue of one of the renal transplant recipients also identified characteristic rhabdovirus inclusions and viral particles.

Suckling mice inoculated intracranially and intraperitoneally with brain tissue from one kidney recipient died 7-9 days after injection. Thin-section electron microscopy of CNS tissue of the mice had visible rhabdovirus particles, and immunohistochemical testing detected rabies viral antigens. Antigenic typing performed upon brain tissue from one recipient was compatible with a rabies virus variant associated with bats. Rabies virus antibodies were demonstrated in blood from two of the three recipients and the donor. Detecting rabies antibodies in the donor suggests that he was the likely source of rabies transmission to the organ recipients. Testing of additional donor specimens is ongoing.

Editorial Note:
Rabies is an acute fatal encephalitis caused by neurotropic viruses in the genus Lyssavirus, family Rhabdoviridae. The majority of rabies cases are caused by bites by rabid mammals. Nonbite exposures, including scratches, contamination of an open wound, or direct mucous membrane contact with infectious material (e.g., saliva or neuronal tissue from rabid animals), rarely cause rabies. After an incubation period of several weeks to months, the virus passes via the peripheral nervous system and replicates in the central nervous system. Rabies virus can then be disseminated to salivary glands and other organs via neural innervation. Rabies can be prevented by administration of rabies postexposure prophylaxis, which is highly effective in preventing rabies when administered before onset of clinical signs.

Although transmission of rabies has occurred previously among eight recipients of transplanted corneas in five countries, this report describes the first documented cases of rabies virus transmission among solid organ transplant recipients. Infection with rabies virus likely occurred via neuronal tissue contained in the transplanted organs, as rabies virus is not spread hematologically. In collaboration with CDC, state and local health departments in Alabama, Arkansas, Oklahoma, and Texas have initiated investigations to identify a potential source of exposure for the donor and to identify contacts of patients among health care providers or domestic contacts who might need rabies PEP.

The risk for health-care-associated transmission of rabies is extremely low; transmission of rabies virus from infected patients to health care providers has not been documented. The use of Standard Precautions for contact with blood and body fluids (e.g., gloves, gown, mask, goggles, or face shield as indicated for the type of patient contact) prevents exposure to the rabies virus. No laboratory-confirmed cases of human-to-human transmission of rabies among household contacts have been reported. No cases of rabies have been reported in association with transmission by fomites or environmental surfaces.

Routes of possible exposure include percutaneous and mucocutaneous entry of the rabies virus through a wound, nonintact skin, or mucous membrane contact. Intact skin contact with infectious materials is not considered an exposure to the rabies virus. Persons with exposure as defined above to saliva, nerve tissue, or cerebral spinal fluid from any of the four infected patients should receive rabies PEP. Types of exposures in domestic settings for which administration of PEP would be appropriate include bites, sexual activity, exchanging kisses on the mouth or other direct mucous membrane contact with saliva, and sharing eating or drinking utensils or cigarettes. In health care settings, additional opportunities that can lead to contamination of mucous membranes or nonintact skin with oral secretions include procedures such as intubation or suctioning of respiratory secretions or injuries with sharp instruments (e.g., needlesticks or scalpel cuts). Percutaneous injuries (e.g., needlesticks) are considered exposures because of potential contact with nervous tissue. Contact with patient fluids (e.g., blood, urine, or feces) does not pose a risk for rabies exposure.

All potential organ donors in the United States are screened and tested to identify if the donor might present an infectious risk. Organ procurement organizations are responsible for evaluating organ donor suitability, consistent with minimum procurement standards. Donor eligibility is determined through a series of questions posed to family and contacts, physical examination, and blood testing for evidence of organ dysfunction and selected bloodborne viral pathogens and syphilis. Laboratory testing for rabies is not performed. In the case reported here, the donor's death was attributed to noninfectious causes. The role of organ donor deferral is to optimize successful transplantation in the recipient, including minimizing risk of infectious disease transmission to the lowest level reasonably achievable without unduly decreasing the availability of this life-saving resource. The benefits from transplanted organs outweigh the risk for transmission of infectious diseases from screened donors. CDC is working with federal and organ procurement agencies to review donor screening practices.

Additional information about rabies and its prevention is available from CDC, telephone (404) 639-1050, or at Additional information about organ transplantation is available at


To access a web-text (HTML) version of the "MMWR Dispatch," go to:

To access a ready-to-copy (PDF) version of it, go to:

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(2 of 9)
July 6, 2004

CDC published "Update: Influenza Activity--United States and Worldwide, 2003-04 Season, and Composition of the 2004-05 Influenza Vaccine" in the July 2 issue of MMWR. Portions of the article and of a summary made available to the press are reprinted below.



In the United States, the 2003-04 influenza season began and peaked earlier than usual, and was more severe than the previous three seasons. . . . In several Asian countries, widespread outbreaks of avian influenza A (H5N1) among poultry were reported. In Vietnam and Thailand, these poultry outbreaks were associated with 34 confirmed human infections with avian influenza A (H5N1) viruses, resulting in severe illnesses and 23 deaths. No evidence of efficient person-to-person spread of H5N1 has been found to date. CDC continues to recommend enhanced surveillance for suspected H5N1 cases among travelers with severe unexplained respiratory illness returning from H5N1-affected countries.


Composition of the Influenza Vaccine for the 2004-05 Season

On the basis of antigenic analyses of recently isolated influenza viruses, epidemiologic data, and postvaccination serologic studies in humans, the Food and Drug Administration's Vaccines and Related Biological Products Advisory Committee (VRBPAC) recommended that the 2004-05 trivalent influenza vaccine for the United States contain A/New Caledonia/20/99-like (H1N1), A/Fujian/411/2002-like (H3N2), and B/Shanghai/361/2002-like viruses.

Because of the growth properties of the A/Wyoming/3/2003 and B/Jiangsu/10/2003 viruses, U.S. vaccine manufacturers are using these antigenically equivalent strains in the vaccine as the H3N2 and B components, respectively. The A/New Caledonia/20/99 virus will be retained as the H1N1 component of the vaccine. . . .

Editorial Note

Beginning with the 2004-05 influenza season, the Advisory Committee on Immunization Practices (ACIP) recommends that all children aged 6-23 months and close contacts of children aged 0-23 months receive annual influenza vaccination. ACIP continues to recommend that all persons aged >6 months with certain chronic underlying medical conditions, their household contacts, and health care workers receive annual influenza vaccination. . . .

Influenza vaccine manufacturers project that approximately 90-100 million total doses of influenza vaccine will be available for distribution during the 2004-05 season in the United States. These influenza vaccine projections are preliminary and could change as the season progresses. CDC has contracted to purchase up to 8 million doses of influenza vaccine for use in the public sector, including up to 3 million doses of preservative-free vaccine for children. CDC also has received $40 million through the Vaccines for Children program to purchase approximately 4-4.5 million doses of influenza vaccine for a national stockpile, which could be made available to state and local health departments and manufacturers for distribution. . . .


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July 6, 2004

Intended for health professionals who provide services for children, the hour-long CME [continuing medical education] teleconference New Developments in Childhood Influenza Prevention, will cover the following topics:

  • Disease burden and prevention (10 minutes)
  • Vaccination and strain drift (10 minutes)
  • Efficacy and safety of trivalent inactivated influenza vaccine and live attenuated intranasal vaccine (15 minutes)
  • Questions and answers (25 minutes)

The presenter is Robert B. Belshe, MD, professor of medicine, pediatrics, and molecular microbiology, St. Louis University School of Medicine. The sponsor is the Chatham Institute, Chatham, NJ.

Participants have a choice of three sessions:

  • July 13, 7PM ET
  • July 14, 12PM ET
  • July 15, 7PM ET

To access a registration form and register online, go to:

To register by phone, call (800) 305-2303 between 9AM and 5PM ET, Monday through Friday.

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(4 of 9)
July 6, 2004

CDC announced it has extended the application deadline to July 19 for the position of director, Division of Viral Hepatitis. The following partial description of the position's responsibilities is taken from the vacancy announcement:


DUTIES: The National Center for Infectious Diseases (NCID) is seeking exceptional candidates for the position of Director, Division of Viral Hepatitis (DVH), CDC. The mission of this Division is to prevent, control, and eliminate hepatitis virus infections. The Division is divided into 4 major organizational units, Office of the Director, Epidemiology, Prevention, and Laboratory Branches. The Director manages a division budget exceeding $25 million and approximately 130 professional and support staff. The Director is responsible for providing the scientific, programmatic, and management leadership required for a program to prevent infection with hepatitis viruses and the liver disease associated with these infections. The programs conducted by the Division are national and international in scope and involve laboratory, epidemiologic, and clinical research; surveillance; and development, implementation, and evaluation of prevention programs. . . .


To access the entire vacancy announcement, go to:

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July 6, 2004

The National Conference on Immunization Coalitions will be held September 20-22 in Norfolk, VA. The early-bird registration deadline is July 31.

Intended to provide training in creating, leading, and sustaining effective local and state coalitions that address childhood, adolescent, and adult immunization, the conference will bring together more than 400 attendees from immunization coalitions across the nation. This year's program will focus on coalitions as agents of social change, elements of a successful coalition, and social and ethnic diversity in coalitions.

For information, go to:

To register online, go to:

Contact Annemarie Beardsworth with questions about content by email at or by phone at (401) 222-5658. Contact Tracey Ryan with questions about logistics by email at or by phone at (813) 974-6682.

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July 6, 2004

[The following is cross posted from the Immunization Action Coalition's "HEP EXPRESS" electronic newsletter, 6/25/04.]

The Third Annual National Viral Hepatitis Summit will be held August 26-27, 2004, in Baltimore, MD. The conference is sponsored by Hepatitis Foundation International (HFI) and is intended for physicians, nurses, psychologists, counselors, outreach workers, patient advocates, and others working with people who are affected by or infected with viral hepatitis.

For information about the agenda and/or registration, go to or call (800) 891-0707.

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July 6, 2004

Immunize Georgia's Little Guys Conference is scheduled for September 28 at the Georgia International Convention Center, College Park, GA. The registration deadline is September 7.

The theme is "Seeking the Gold Standard--Strategies for Improving Immunization Practices." Speakers include William Atkinson, MD, MPH, from NIP, and Michael Chaney and others from Georgia Immunization Program.

To access registration information and the conference agenda online, go to:

For additional information, contact Angie Matthiessen, conference coordinator, by phone at (404) 785-7216 or email at

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(8 of 9)
July 6, 2004

CDC published "Notice to Readers: Availability of Influenza Pandemic Preparedness Software for Hospital Planning" in the July 2 issue of MMWR. The notice is reprinted below in its entirety, excluding references.


Influenza pandemics have occurred three times during the 20th century: in 1918, 1957, and 1968. Another influenza pandemic is likely, if not inevitable. To help public health officials and hospital administrators prepare for the next influenza pandemic, CDC has developed FluSurge 1.0, a specialized spreadsheet-based software that estimates the potential surge in demand for hospital-based health care during a pandemic. For each week of a pandemic, FluSurge calculates the potential demand for hospital beds, intensive care unit beds, and mechanical ventilators. Demand for resources is compared with actual capacity. FluSurge is a companion to the previously released FluAid 2.0, which provides estimates of the total deaths, hospitalizations, and outpatient visits that might occur during an influenza pandemic.

Both FluSurge 1.0 and FluAid 2.0, including accompanying manuals, are now available from the National Vaccine Program Office's website at The software programs and manuals are available free of charge.


To access a web-text (HTML) version of the notice, go to:

To access a ready-to-copy (PDF) version of this issue of MMWR, go to:

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(9 of 9)
July 6, 2004

CDC published "Progress Toward Sustainable Measles Mortality Reduction, South East Asia Region, 1999-2002" in the July 2 issue of MMWR. A portion of a summary made available to the press is reprinted below.


Measles remains the leading cause of vaccine-preventable deaths among children worldwide. This report summarizes progress in measles control in SEAR [the South East Asia Region] during 1999-2002 and outlines plans for future activities. During this time, reported measles cases increased, primarily due to increases in India, Indonesia, and Thailand, and several nationwide outbreaks. This increase in reported measles incidence was primarily due to inadequate measles vaccination coverage as well as improvements in surveillance. From 1999-2002, four countries in SEAR introduced case-based measles surveillance, and a regional measles laboratory network was established. Six countries conducted national or sub-national measles vaccination campaigns. In June 2003, the South East Asian Regional (SEAR) Technical Advisory Group on Immunization endorsed a Regional Strategic Plan for Measles Mortality Reduction (2003-2005) with the ultimate goal of achieving sustainable measles mortality reduction. Countries should prepare national action plans for measles control that are linked to their national Expanded Program on Immunization Plans.


To access a web-text (HTML) version of the complete article, go to:

To access a ready-to-copy (PDF) version of this issue of MMWR, go to:

About IZ Express

IZ Express is supported in part by Grant No. 1NH23IP922654 from CDC’s National Center for Immunization and Respiratory Diseases. Its contents are solely the responsibility of and do not necessarily represent the official views of CDC.

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Editorial Information

  • Editor-in-Chief
    Kelly L. Moore, MD, MPH
  • Managing Editor
    John D. Grabenstein, RPh, PhD
  • Associate Editor
    Sharon G. Humiston, MD, MPH
  • Writer/Publication Coordinator
    Taryn Chapman, MS
    Courtnay Londo, MA
  • Style and Copy Editor
    Marian Deegan, JD
  • Web Edition Managers
    Arkady Shakhnovich
    Jermaine Royes
  • Contributing Writer
    Laurel H. Wood, MPA
  • Technical Reviewer
    Kayla Ohlde

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