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USA - 3 familial deaths, 2 hospitalized due to respiratory illness confirmed by Calvert County Health Dept Maryland - 4 test positive for Seasonal Influenza H3N2

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  • #61
    Re: USA - 3 familial deaths, 2 hospitalized due to respiratory illness confirmed by Calvert County Health Dept Maryland - 3 test positive for Seasonal Influenza A/H3

    Maryland tests confirm MRSA in fatal flu cases

    Lisa Schnirring Staff Writer

    Mar 9, 2012 (CIDRAP News) ? Maryland health officials today confirmed that at least 2 of 4 members of a Calvert County family who had severe influenza were co-infected with methicillin-resistant Staphylococcus aureus (MRSA).

    In a statement today, the Maryland Department of Health and Mental Hygiene (MDHMH) confirmed what some health officials had already suspected. It also said the state lab has confirmed that all four patients were infected with the H3N2 strain, which is circulating in Maryland and has been the nation's dominant strain this flu season. In an earlier statement, the department had confirmed seasonal H3N2 in two of the patients.

    The MDHMH, along with county health officials, has been investigating the cluster of severe respiratory infections that led to the deaths of an 81-year-old woman from Lusby and two adult children who cared for her after she got sick and until she died on Mar 1. Another of the woman's daughters is hospitalized with similar symptoms.

    So far no other related severe respiratory illnesses have been confirmed, and no similar clusters have been identified, the MDHMH said.

    In its confirmation of the two MRSA co-infections, the department said that S aureus infection is a known complication of influenza infection.

    Officials warned that flu season can last as late as May and said seasonal flu vaccination is the best way to prevent flu and related complications that can be severe. The DHMDH also urged Maryland residents to take basic flu precautions, such as hand washing and staying home when sick.

    CIDRAP
    "Addressing chronic disease is an issue of human rights that must be our call to arms"
    Richard Horton, Editor-in-Chief The Lancet

    ~~~~ Twitter:@GertvanderHoek ~~~ GertvanderHoek@gmail.com ~~~

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    • #62
      Re: USA - 3 familial deaths, 2 hospitalized due to respiratory illness confirmed by Calvert County Health Dept Maryland - 4 test positive for Seasonal Influenza H3N2

      FluTrackers Maryland Flu Cluster March 2012 Case List

      Index case - Woman, 81, disease onset February 23, death at home March 1 - seasonal influenza H3N2 confirmed

      Woman, 56, child of index case, disease onset February 28, died in hospital March 5 - seasonal influenza H3N2 confirmed + MRSA infection

      Man, 58, child of index case, disease onset February 28, died in hospital March 5 - seasonal influenza H3N2 confirmed + MRSA infection

      Woman, 51, child of index case hospitalized and recovering - seasonal influenza H3N2 confirmed - released from hospital March 9

      Woman - elderly, sister of index case hospitalized March 6 with fever - no diagnosis at this time - released from hospital


      Source: Maryland Department of Health & Mental Hygiene press release
      Source: CNN report
      Source: Washington Post
      Last edited by sharon sanders; March 15, 2012, 12:09 AM. Reason: updated release from hospital of sister of index case

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      • #63
        Re: USA - 3 familial deaths, 2 hospitalized due to respiratory illness confirmed by Calvert County Health Dept Maryland - 4 test positive for Seasonal Influenza H3N2

        Here's the hospitalization dates:

        Four members of the Calvert County family stricken by flu complications all had the same H3N2 strain of the influenza A virus, Maryland health officials said Friday....


        [snip]

        Lou Ruth Blake, 81, died at home March 1, and two of her children, Lowell, 58, and Vanessa, 56, who had cared for her, were hospitalized March 4 and died the next day.

        A third child, Elaine, 51, who lived with her mother and had been her main caregiver, was hospitalized March 5 and discharged late Thursday, a MedStar Washington Hopital Center spokeswoman said.

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        • #64
          Re: USA - 3 familial deaths, 2 hospitalized due to respiratory illness confirmed by Calvert County Health Dept Maryland - 4 test positive for Seasonal Influenza H3N2

          [Source: The USA State of Maryland, Calvert County Health Department, full page: (LINK). Edited.]

          Update on Calvert County Respiratory Illness Investigation

          DHMH PRESS RELEASE

          FROM: DHMH Office of Communications: Dori Henry, Karen Black

          DATE: March 9, 2012



          H3N2 Influenza Confirmed in Calvert County Cluster


          The Maryland Department of Health and Mental Hygiene (DHMH) and the Calvert County Health Department continue to investigate a cluster of cases of severe respiratory illnesses in four members of the same immediate family, of whom three have died. To date, no additional related severe respiratory illnesses have been confirmed and no other similar clusters have been identified.

          Testing by the DHMH Laboratories Administration has confirmed that all four cases had the H3N2 strain of influenza A, which is known to be one of the influenza strains currently circulating in Maryland and nationwide. At least two of these cases were complicated by bacterial co-infections with methicillin-resistant Staphylococcus aureus. Staphylococcus aureus co-infection is a known complication of influenza infection.

          The flu season typically can last as late as May. Vaccination is the best way to prevent influenza and its related complications that can lead to hospitalization and even death.

          This season's influenza vaccine offers protection against influenza A H3N2 as well as influenza H1N1 and influenza B.

          DHMH recommends all individuals over the age of six months get vaccinated. In addition, DHMH reminds Marylanders to take other precautionary measures, such as hand washing and staying home if sick. Individuals with influenza-like illness (fever and sore throat or cough) should consult their healthcare providers for evaluation.


          ---end of press release---


          No new cases reported as of March 12, 2012, 2:00 pm
          -
          ------

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          • #65
            Re: USA - 3 familial deaths, 2 hospitalized due to respiratory illness confirmed by Calvert County Health Dept Maryland - 4 test positive for Seasonal Influenza H3N2

            hat tip Crof

            At Calvert funeral, 3 family members felled by flu are mourned by hundreds

            By Annys Shin, Wednesday, March 14, 2:35 PM

            snip

            Two of the children ? Lowell Frederick Blake, 58, and Venessa Blake, 56, both of Lusby ? died March 4. The third ? Elaine Blake, 51, who lived with her mother ? was hospitalized but has since been released. A sister of Lou Ruth Blake?s was also hospitalized and released.

            more...

            At Dunkirk Baptist Church, three caskets held the bodies of Lou Ruth Blake, 81, and two of her adult children. They died within days of another this month from rare complications of flu.

            Comment


            • #66
              Re: USA - 3 familial deaths, 2 hospitalized due to respiratory illness confirmed by Calvert County Health Dept Maryland - 4 test positive for Seasonal Influenza H3N2

              Source: http://articles.baltimoresun.com/201...lth-conditions

              Funeral held for Calvert County family stricken with flu
              Relatives mourn mother, two adult children
              (Baltimore Sun)
              March 14, 2012|By Andrea K. Walker and Meredith Cohn, The Baltimore Sun

              Snip:

              The deaths are still being investigated, though state and local health officials believe they have a good idea about what happened.

              Officials from the state Department of Health and Mental Hygiene say that all four had the H3N2 influenza strain, a type circulating this season.

              Ruth Blake had been vaccinated, but it may not have been the higher dosage needed by seniors.

              Underlying health conditions probably prevented her from fighting it off, and she died at home from some undetermined complication, said Dr. David L. Rogers, the Calvert County health officer. Autopsy results were not yet complete.

              Her children also tested positive for methicillin-resistant Staphylococcus aureus, or MRSA, a staph bacteria that is resistant to some commonly used antibiotics and difficult to treat. They may have carried the bacteria on their skin or in their noses for years and it caused no harm, said Rogers, adding that 4 percent to 6 percent of the population carries MRSA. Or, he said, one may have spread it to the other with a cough.

              In their flu-weakened state, the bacteria made it to their lungs, giving them fatal bacterial pneumonia.

              Rogers said all the deaths weren't attributed at first to the flu, which hasn't been particularly bad this year.

              "We didn't know what we were dealing with initially," he said. "But it became clear quickly and we knew there was no public health threat."

              Including the Blakes, just five people have died in Maryland from laboratory-confirmed flu complications this year, compared with 34 at this time last year, though many illnesses and deaths don't get reported, said Frances B. Phillips, the state's deputy heath secretary for public health services...

              Comment


              • #67
                Re: USA - 3 familial deaths, 2 hospitalized due to respiratory illness confirmed by Calvert County Health Dept Maryland - 4 test positive for Seasonal Influenza H3N2

                Source: http://www.gazette.net/article/20120...mplate=gazette

                Calvert flu deaths mobilized health officials
                State collaboration steps up medical alerts to providers
                by C. Benjamin Ford, Staff Writer


                When 81-year-old Lou Ruth Blake of Lusby became ill and died, followed shortly by the deaths of two of her adult children and a critical illness to a third, state and county health officials raced to solve the potentially baffling medical mystery...

                ...Getting information early from the doctors and hospitals is important in dealing with an outbreak, as well as letting the medical providers know what is happening elsewhere, Phillips said.

                The state health department announced a collaboration this week with a web information service for health care providers, Medscape, to distribute health alerts about infectious disease outbreaks and other illnesses.

                "The ability to communicate quickly and efficiently with health care providers is critical to protecting and promoting the health of all Marylanders," Joshua M. Sharfstein, secretary of the Maryland Department of Health and Mental Hygiene, said in an emailed statement.

                About 50,000 health care providers in Maryland are enrolled in the voluntary program...

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                • #68
                  Re: USA - 3 familial deaths, 2 hospitalized due to respiratory illness confirmed by Calvert County Health Dept Maryland - 4 test positive for Seasonal Influenza H3N2




                  CDC: Calvert County Flu Typical Seasonal H3N2 Strain

                  # 6228

                  Earlier this month three members of a family (out of five who fell ill) died from a respiratory infection in Calvert County, Maryland (see Calvert County: Update On Fatal Cluster Of Respiratory Illness) sparking national headlines and a good deal of online speculation.



                  While early reports seemed to lay most of the blame for the severity of these cases on a bacterial pneumonia co-infection on top of flu, there has been an understandable degree of curiosity regarding the exact flu strain that was involved.



                  Tonight, the CDC has published a report that indicates a plain vanilla version of seasonal H3N2 was involved.



                  CDC Confirms Typical Human Influenza A H3N2 Virus in Maryland Cluster


                  March 16, 2012 -- CDC has confirmed that the influenza viruses isolated from the cluster of severe respiratory illness in one family in Maryland are seasonal influenza A H3N2 viruses. Genetic sequencing has confirmed that this is a typical human seasonal H3N2 virus that is more than 99% similar to other H3N2 influenza viruses submitted by the state of Maryland this season. While full antigenic testing is pending, based on genetic sequencing of some of the samples, these viruses are close to the H3N2 component of the 2011-2012 seasonal vaccine such that vaccination should offer protection against these viruses. Testing on the Methicillin-resistant staphylococcus aureus, (MRSA) isolates is ongoing, but preliminary results indicate that some of the MRSA isolates from Maryland are pulsed-field types USA300. Strains from the USA300 MRSA pulsed-field type can cause community MRSA infections including outbreaks of skin infections.



                  In early March 2012, Maryland reported a cluster of severe respiratory illness in four adults in the same immediate family. Three of the four family members died. The state of Maryland reported that all four people were confirmed to be positive for seasonal influenza A (H3N2) infection by the state Laboratories Administration. MRSA bacterial co-infections are reported to have occurred in at least two of the four patients. More information about the cases in Maryland is available at http://www.dhmh.maryland.gov/publicrelations/pr.

                  Bacterial infections can occur as co-infections with influenza or occur after influenza infection. Staphylococcus aureus (staph) is one such bacterial co-infection. Concurrent infection (co-infection) with staph – which is what seems to have occurred in the cluster in Maryland – is a potentially catastrophic complication of influenza that can progress rapidly to serious illness and death.



                  No formal surveillance is conducted for influenza with bacterial co-infections, however, these are well documented in the literature going back to the 1918 influenza pandemic. While not common, these co-infections have been reported in both children and adults.



                  The best way to prevent influenza and its complications is an annual influenza vaccine. The United States is experiencing a late influenza season. Activity has only recently begun to increase and may continue for some time. This week’s FluView is reporting 15 states with widespread influenza activity and 5 states with high influenza-like-illness activity. Nationally, the percent of respiratory specimens testing positive for flu is 23 percent. People who have not gotten vaccinated yet this season should get vaccinated now.





                  While perhaps a little anticlimactic for those who were expecting some sort of mutated flu strain, this does illustrate that even ordinary seasonal flu can induce serious, sometimes fatal, illness.

                  Comment


                  • #69
                    Re: USA - 3 familial deaths, 2 hospitalized due to respiratory illness confirmed by Calvert County Health Dept Maryland - 4 test positive for Seasonal Influenza H3N2

                    Source: http://www.somdnews.com/article/2012...uthernMaryland

                    Friday, Mar. 23, 2012
                    Officials examine response to flu deaths
                    by KATIE FITZPATRICK, Staff writer

                    The news that three members of a Lusby family died from a severe respiratory illness spread quickly throughout Calvert County two weeks ago, inciting alarm and confusion in some residents...

                    Comment


                    • #70
                      Re: USA - 3 familial deaths, 2 hospitalized due to respiratory illness confirmed by Calvert County Health Dept Maryland - 4 test positive for Seasonal Influenza H3N2



                      Severe Coinfection with Seasonal Influenza A (H3N2) Virus and Staphylococcus aureus ? Maryland, February?March 2012
                      Weekly
                      April 27, 2012 / 61(16);289-291


                      On March 5, 2012, the Maryland Department of Health and Mental Hygiene (DHMH) and the Calvert County Health Department were notified of three deaths following respiratory illness among members of a Maryland family. One family member (patient A) experienced upper-respiratory symptoms and died unexpectedly at home. Two others (patients B and C) sought medical care for fever, shortness of breath, and cough productive of bloody sputum and died during their hospitalizations. All three family members had confirmed infection with seasonal influenza A (H3N2) virus. Patients B and C had confirmed coinfection with methicillin-resistant Staphylococcus aureus (MRSA), which manifested in both patients as MRSA pneumonia and bacteremia. DHMH and the Calvert County Health Department, in collaboration with the District of Columbia Department of Health, local hospitals, and CDC, conducted an investigation to determine the cause of the illnesses and identify additional related cases. Three additional family members with influenza were identified, two of whom were confirmed to have influenza A (H3N2) and required hospitalization, but neither was coinfected with MRSA, and both recovered. Influenza vaccination remains the best method for preventing complications from influenza; when influenza infection is suspected, treatment with influenza antiviral agents is recommended in certain cases. In addition, when high clinical suspicion for serious S. aureus coinfection exists, empiric coverage with antibiotics, including those with activity against methicillin-resistant strains, should be instituted.

                      Case Reports

                      Patient A experienced upper-respiratory illness at the end of February and died 4 days later at home. Patient A had not gone to the hospital or seen a clinician but did receive a prescription for levofloxacin 1 day before death. Patients B and C, both family members of patient A, went to a hospital 3 days after patient A's death, with fever, cough productive of bloody sputum, and pleuritic chest pain. Chest radiographs of both patients were notable for extensive bilateral infiltrates with focal areas of consolidation. Patient B was treated with ceftriaxone and azithromycin, and patient C was treated with ceftriaxone, ciprofloxacin, levofloxacin, and vancomycin. Their conditions quickly worsened, and they required intubation; both died the day after admission.

                      All three patients were aged >50 years, including one aged >65 years; one patient had a history of smoking, and one was a current smoker. Two had known multiple comorbidities, including one requiring chronic low-dose corticosteroids. Two of the three had been vaccinated against seasonal influenza.

                      Laboratory and Epidemiologic Investigations

                      Rapid influenza diagnostic testing (RIDT) was performed on a nasopharyngeal specimen from patient B only and was negative, but testing by reverse transcription?polymerase chain reaction (RT-PCR) from upper- and lower-respiratory tract specimens was positive in all three patients for influenza A (H3N2) virus. Testing of original samples at DHMH and CDC indicated that the virus was a typical human seasonal influenza A (H3N2) virus (not an H3N2 variant virus), similar to other influenza A (H3N2) viruses circulating in Maryland and nationally this season. Blood and sputum cultures from patients B and C yielded MRSA. Further testing demonstrated that the MRSA isolates were indistinguishable by pulsed-field gel electrophoresis and were identified as part of the USA300 pulsed-field type. None of the patients had a known history of skin or soft-tissue infections. Extensive testing of upper- and lower-respiratory specimens did not reveal any other infectious agents.

                      The family members all lived in a small town with a population of <2,000 persons. Patients A, B, and C had extensive and frequent contact with each other and with other members of their extended family, some of whom had experienced upper-respiratory illnesses during the weeks preceding the deaths. DHMH, the Calvert County Health Department, and the District of Columbia Department of Health investigated all reports of severe illnesses among persons known to be associated with the family. In early March, three additional family members (patients D, E, and F) were identified with influenza virus infection. Patient D had a positive RIDT result from an upper-respiratory tract specimen. Patients E and F had negative RIDT results; however, RT-PCR testing was positive for influenza A (H3N2) virus. Although patients E and F were hospitalized, neither they nor other family contacts had pneumonia or MRSA infection. One of the three had been vaccinated against seasonal influenza. Other family members who reported upper-respiratory illness either were not tested or had negative RIDT results, with some confirmed negative by RT-PCR.

                      Public Health Actions

                      In accordance with CDC guidelines, antiviral chemoprophylaxis was recommended for contacts at greater risk for serious influenza complications. No special recommendations for antiviral chemoprophylaxis or MRSA decolonization were made. Through press releases and other media statements disseminated in Maryland and the District of Columbia, residents were urged to practice hand hygiene and respiratory hygiene with cough etiquette, get vaccinated for seasonal influenza if they had not yet done so, and seek medical care in accordance with CDC guidance if ill with symptoms of influenza or pneumonia.* In addition, guidance on testing, treatment, and chemoprophylaxis was disseminated to health-care providers locally and throughout Maryland. No additional cases of severe influenza and S. aureus coinfection have been reported.

                      Reported by
                      Linda O'Brien, Calvert Memorial Hospital; Nancy Donegan, MPH, Washington Hospital Center; Ann Flaniken, David Rogers, MD, Calvert County Health Dept; Robert Myers, PhD, Jafar Razeq, PhD, Ruth Thompson, Maryland Dept of Health and Mental Hygiene. Seema Jain, MD, Stephen Lindstrom, PhD, Influenza Div, National Center for Immunizations and Respiratory Diseases; Alexander Kallen, MD, Div of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Diseases; Maria A. Said, MD, Adena Greenbaum, MD, Tiana Garrett, PhD, EIS officers, CDC. Corresponding contributor: Maria A. Said, vih6@cdc.gov, 410-767-7395.

                      Editorial Note
                      Bacterial coinfection with S. aureus is a known complication of influenza that has been described since the 1918 influenza pandemic (1). These infections can be caused by methicillin-susceptible and methicillin-resistant strains. Although these reported cases occurred in three older persons, two of whom had comorbidities, coinfection with S. aureus can occur among otherwise healthy children and adults and has been associated with high mortality rates (2,3). This familial cluster of invasive MRSA with influenza highlights the potentially serious consequences of these coinfections.

                      Patients described in this report had severe, rapidly progressive, respiratory disease with bloody sputum. The rapid worsening of symptoms soon after illness onset and the subsequent severe outcomes are consistent with simultaneous coinfection with influenza and MRSA rather than a biphasic infection course (i.e., influenza infection followed by S. aureus infection); simultaneous coinfection has been reported previously (4). Health-care providers should consider the possibility of influenza and S. aureus coinfection, particularly among patients with severe or rapidly worsening disease or with imaging indicative of cavitary or necrotizing pneumonia; this recommendation applies especially when influenza is known to be circulating in the community? (5). Empiric treatment for both organisms should be considered for patients with these features (5).

                      Data from 2001?2004 indicated that approximately 25%?35% of children and adults are colonized with S. aureus, but only 1.5% are colonized with MRSA (6). MRSA can cause disease in the community among patients with and without health-care exposures, although community-associated MRSA accounts for only 18% of invasive MRSA infections (7). Community-associated MRSA most commonly produces skin and soft-tissue infections, which often are caused by USA300 (8). These strains present a treatment challenge because they are resistant to beta-lactam antibiotics, which are commonly used to treat outpatient infections. Among families in which someone is known to be infected with MRSA, the infected person should keep wounds clean and covered, and other household members who have direct contact with that person should employ frequent hand hygiene and not share personal items (e.g., towels or razors). Whereas decolonization of colonized persons is sometimes considered in specific circumstances (e.g., cases of recurrent MRSA-related skin infections), its role in preventing S. aureus pneumonia is unknown (5). Additional information regarding MRSA prevention and treatment is available? (5).

                      For optimal patient management, health-care providers should test persons hospitalized with respiratory illness for influenza, including those with suspected community-acquired pneumonia, especially when influenza is known to be circulating. Testing by PCR is preferred when available because it is more sensitive than rapid antigen tests that can yield false-negative results (9). Specimens that can be tested for influenza virus include nasopharyngeal or throat swabs, nasal or endotracheal aspirates, nasopharyngeal or bronchial washes, or sputum specimens. When influenza is suspected, droplet precautions should be practiced (10).

                      Advisory Committee for Immunization Practices guidelines recommend oseltamivir or zanamivir to treat 1) hospitalized patients with suspected or confirmed influenza, 2) outpatients who are at greater risk for influenza complications, and 3) persons with suspected or confirmed influenza who have evidence of severe illness (e.g., signs or symptoms of lower-respiratory tract infection or clinical deterioration), regardless of vaccination status (9). Empiric influenza antiviral treatment should be provided to such patients even if test results are not available immediately or if patients are not tested. Although benefits of antiviral treatment are likely to be greatest if treatment is initiated as soon as possible, treatment of hospitalized patients is recommended even >48 hours after illness onset. Approximately 99% of circulating seasonal strains of influenza A (H3N2), A (H1N1), and B viruses that were tested by CDC during October 1, 2011?April 7, 2012 were sensitive to oseltamivir and zanamivir. Postexposure chemoprophylaxis for influenza might be considered on the basis of the exposed person's risk for influenza complications, the type and duration of contact, recommendations from public health authorities, and clinical judgment (9). Postexposure chemoprophylaxis should be started ≤48 hours after the most recent exposure (9).

                      The cases in this report are a reminder that influenza and S. aureus coinfections, although uncommon, can lead to severe outcomes, including death. Although influenza vaccine is not 100% effective, influenza vaccination remains the best method for preventing influenza and its complications and should be encouraged for all persons aged ≥6 months. In addition to treatment with influenza antiviral agents, antibiotics should be considered when clinical suspicion for bacterial coinfection exists in an effort to reduce severe outcomes.

                      Acknowledgments
                      Jennifer Cotner, Calvert Memorial Hospital; Babs Buchheister, Christina Halt, Dan Williams, Calvert County Health Dept; Brian Bachaus, MS, Naomi Barker, MS, David Blythe, MD, Alvina Chu, MHS, Zachary Faigen, MSPH, Katherine Feldman, DVM, Damini Jain, MS, Jonathan Johnston, MD, Emily Luckman, MPH, Maya Monroe, MPH, Rene Najera, MPH, Dale Rohn, MPH, John Sweitzer, ScM, Lucy Wilson, MD, Maryland Dept of Health and Mental Hygiene. Infection Control Dept, Washington Hospital Center; John Davies-Cole, PhD, Gabrielle Ray, MPH, District of Columbia Dept of Health. Lyn Finelli, DrPH, Tim Uyeki, MD, Alexander Klimov, PhD, Lashondra Berman, MS, Bo Shu, MD, Influenza Div, National Center for Immunization and Respiratory Diseases; Valerie Albrecht, MPH, Linda McDougal, MS, Div of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Diseases, CDC.

                      References
                      1.Chickering HT, Park JH. Staphylococcus aureus pneumonia. JAMA 1919;72:617?26.
                      2.Hageman JC, Uyeki TM, Frances JS, et al. Severe community-acquired pneumonia due to Staphylococcus aureus, 2003?04 influenza season. Emerg Infect Dis 2006;12:894?9.
                      3.Kallen AJ, Brunkard J, Moore Z, et al. Staphylococcus aureus community-acquired pneumonia during the 2006 to 2007 influenza season. Ann Emerg Med 2009;53:358?65.
                      4.Jones TF, Creech CB, Erwin P, Baird SG, Woron AM, Schaffner W. Family outbreaks of invasive community-associated methicillin-resistant Staphylococcus aureus infection. Clin Infect Dis 2006;42:e76?8.
                      5.Liu C, Bayer A, Cosgrove S, et al. Clinical practice guidelines by the Infectious Diseases Society of America for the treatment of methicillin-resistant Staphylococcus aureus infections in adults and children. Clin Infect Dis 2011;52:e18?55.
                      6.Gorwitz R, Kruszon-Moran D, McAllister S, et al. Changes in the prevalence of nasal colonization with Staphylococcus aureus in the United States, 2001?2004. J Infect Dis 2008;197:1226?34.
                      7.Kallen A, Mu Y, Bulens S, et al. Health care-associated invasive MRSA infections, 2005?2008. JAMA 2010;304:641?8.
                      8.Limbago B, Fosheim GE, Schoonover V, et al.; Active Bacterial Core surveillance MRSA investigators. Characterization of methicillin-resistant Staphylococcus aureus isolates collected in 2005 and 2006 from patients with invasive disease: a population-based analysis. J Clin Microbiol 2009;47:1344?51.
                      9.CDC. Antiviral agents for the treatment and chemoprophylaxis of influenza: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR 2011;60(No. RR-1).
                      10.Siegel J, 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 settings. Am J Infect Control 2007;35(10 Suppl 2):S65?164.

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