Number of Immigrants, Estimated HBsAg prevalence, and number of imported chronic hepatitis B cases by country of birth, 1974–2008.

<p>*From United States Department of Homeland Security, for persons obtaining legal permanent residency in United States (<a href="http://www.dhs.gov/files/statistics/publications/yearbook.shtm" target="_blank">www.dhs.gov/files/statistics/publications/yearbook.shtm</a>).</p><p>**World Health Organization regions. Estimated HBsAg prevalence by region is the weighted average of estimated prevalence for each country in the region.</p>‡<p>Top 10 countries by estimated number of imported chronic hepatitis B cases.</p

Incidence of Chronic Hepatitis B, U.S.-Acquired vs. Estimated Imported, United States, 1980–2008.

<p>Incidence of Chronic Hepatitis B, U.S.-Acquired vs. Estimated Imported, United States, 1980–2008.</p

U.S. Immigration by WHO Region of Origin, 1974–2008.

<p>U.S. Immigration by WHO Region of Origin, 1974–2008.</p

Neurologic Manifestations Associated with an Outbreak of Typhoid Fever, Malawi - Mozambique, 2009: An Epidemiologic Investigation

<div><p>Background</p><p>The bacterium <i>Salmonella enterica</i> serovar Typhi causes typhoid fever, which is typically associated with fever and abdominal pain. An outbreak of typhoid fever in Malawi-Mozambique in 2009 was notable for a high proportion of neurologic illness.</p><p>Objective</p><p>Describe neurologic features complicating typhoid fever during an outbreak in Malawi-Mozambique</p><p>Methods</p><p>Persons meeting a clinical case definition were identified through surveillance, with laboratory confirmation of typhoid by antibody testing or blood/stool culture. We gathered demographic and clinical information, examined patients, and evaluated a subset of patients 11 months after onset. A sample of persons with and without neurologic signs was tested for vitamin B6 and B12 levels and urinary thiocyanate.</p><p>Results</p><p>Between March – November 2009, 303 cases of typhoid fever were identified. Forty (13%) persons had objective neurologic findings, including 14 confirmed by culture/serology; 27 (68%) were hospitalized, and 5 (13%) died. Seventeen (43%) had a constellation of upper motor neuron findings, including hyperreflexia, spasticity, or sustained ankle clonus. Other neurologic features included ataxia (22, 55%), parkinsonism (8, 20%), and tremors (4, 10%). Brain MRI of 3 (ages 5, 7, and 18 years) demonstrated cerebral atrophy but no other abnormalities. Of 13 patients re-evaluated 11 months later, 11 recovered completely, and 2 had persistent hyperreflexia and ataxia. Vitamin B6 levels were markedly low in typhoid fever patients both with and without neurologic signs.</p><p>Conclusions</p><p>Neurologic signs may complicate typhoid fever, and the diagnosis should be considered in persons with acute febrile neurologic illness in endemic areas.</p></div

Demographics, clinical features, and outcomes of 17 persons with typhoid-associated neurologic illness, Malawi-Mozambique, 2009.

<p>Demographics, clinical features, and outcomes of 17 persons with typhoid-associated neurologic illness, Malawi-Mozambique, 2009.</p

Magnetic resonance imaging (MRI) of a patient with neurologic illness associated with typhoid fever, Malawi.

<p>Coronal T1 FLAIR (A) and axial T2 FLAIR (B) MRI Images demonstrating generalized cerebral atrophy, 7 year-old male with neurologic illness associated with acute typhoid fever, Malawi.</p

Levels of serum vitamin B12, vitamin B6 (PLP and 4PA), and urine thiocyanate In typhoid fever patients with and without neurologic signs.

<p>Levels of serum vitamin B12, vitamin B6 (PLP and 4PA), and urine thiocyanate In typhoid fever patients with and without neurologic signs.</p

Case definition for typhoid fever used in outbreak investigation, Malawi/Mozambique.

<p>Case definition for typhoid fever used in outbreak investigation, Malawi/Mozambique.</p