Emerging Infectious Diseases Volume 21 Issue 9

2015·9.2 MB·English

by  CDC

Peer-Reviewed Journal Tracking and Analyzing Disease Trends pages 1497–1696
EDITOR-IN-CHIEF
D. Peter Drotman
Associate Editors EDITORIAL BOARD
Paul Arguin, Atlanta, Georgia, USA Dennis Alexander, Addlestone, Surrey, UK
Charles Ben Beard, Ft. Collins, Colorado, USA Timothy Barrett, Atlanta, Georgia, USA
Ermias Belay, Atlanta, Georgia, USA Barry J. Beaty, Ft. Collins, Colorado, USA
David Bell, Atlanta, Georgia, USA Martin J. Blaser, New York, New York, USA
Sharon Bloom, Atlanta, GA, USA Christopher Braden, Atlanta, Georgia, USA
Mary Brandt, Atlanta, Georgia, USA Arturo Casadevall, New York, New York, USA
Corrie Brown, Athens, Georgia, USA Kenneth C. Castro, Atlanta, Georgia, USA
Charles H. Calisher, Ft. Collins, Colorado, USA Louisa Chapman, Atlanta, Georgia, USA
Michel Drancourt, Marseille, France Thomas Cleary, Houston, Texas, USA
Paul V. Effler, Perth, Australia Vincent Deubel, Shanghai, China
David Freedman, Birmingham, Alabama, USA Ed Eitzen, Washington, DC, USA
Peter Gerner-Smidt, Atlanta, Georgia, USA Daniel Feikin, Baltimore, Maryland, USA
Stephen Hadler, Atlanta, Georgia, USA Anthony Fiore, Atlanta, Georgia, USA
Isaac Chun-Hai Fung, Statesboro, Georgia, USA
Nina Marano, Nairobi, Kenya
Kathleen Gensheimer, College Park, MD, USA
Martin I. Meltzer, Atlanta, Georgia, USA
Duane J. Gubler, Singapore
David Morens, Bethesda, Maryland, USA
Richard L. Guerrant, Charlottesville, Virginia, USA
J. Glenn Morris, Gainesville, Florida, USA
Scott Halstead, Arlington, Virginia, USA
Patrice Nordmann, Fribourg, Switzerland
Katrina Hedberg, Portland, Oregon, USA
Didier Raoult, Marseille, France
David L. Heymann, London, UK
Pierre Rollin, Atlanta, Georgia, USA
Charles King, Cleveland, Ohio, USA
Ronald M. Rosenberg, Fort Collins, Colorado, USA
Keith Klugman, Seattle, Washington, USA
Frank Sorvillo, Los Angeles, California, USA
Takeshi Kurata, Tokyo, Japan
David Walker, Galveston, Texas, USA
S.K. Lam, Kuala Lumpur, Malaysia
Senior Associate Editor, Emeritus Stuart Levy, Boston, Massachusetts, USA
Brian W.J. Mahy, Bury St. Edmunds, Suffolk, UK John S. MacKenzie, Perth, Australia
Marian McDonald, Atlanta, Georgia, USA
Managing Editor
John E. McGowan, Jr., Atlanta, Georgia, USA
Byron Breedlove, Atlanta, Georgia, USA
Jennifer H. McQuiston, Atlanta, Georgia, USA
Tom Marrie, Halifax, Nova Scotia, Canada
Copy Editors Claudia Chesley, Laurie Dieterich, Karen Foster,
Thomas Gryczan, Jean Michaels Jones, Shannon O’Connor, Nkuchia M. M’ikanatha, Harrisburg, Pennsylvania, USA
Rhonda Ray, Carol Snarey, P. Lynne Stockton Philip P. Mortimer, London, UK
Fred A. Murphy, Galveston, Texas, USA
Production William Hale, Aaron Moore, Barbara Segal, Barbara E. Murray, Houston, Texas, USA
Reginald Tucker P. Keith Murray, Geelong, Australia
Stephen M. Ostroff, Silver Spring, MD, USA
Editorial Assistant Jared Friedberg
Ann Powers, Fort Collins, Colorado, USA
Communications/Social Media Sarah Logan Gregory Gabriel Rabinovich, Buenos Aires, Argentina
Mario Raviglione, Geneva, Switzerland
Founding Editor David Relman, Palo Alto, California, USA
Joseph E. McDade, Rome, Georgia, USA Connie Schmaljohn, Frederick, Maryland, USA
Tom Schwan, Hamilton, Montana, USA
Emerging Infectious Diseases is published monthly by the Centers for Disease Control and Ira Schwartz, Valhalla, New York, USA
Prevention, 1600 Clifton Road, Mailstop D61, Atlanta, GA 30329-4027, USA. Telephone
Tom Shinnick, Atlanta, Georgia, USA
404-639-1960, fax [phone], email [email protected].
Bonnie Smoak, Bethesda, Maryland, USA
Rosemary Soave, New York, New York, USA
The conclusions, findings, and opinions expressed by authors contributing
P. Frederick Sparling, Chapel Hill, North Carolina, USA
to this journal do not necessarily reflect the official position of the U.S. Depart-
ment of Health and Human Services, the Public Health Service, the Centers for Robert Swanepoel, Pretoria, South Africa
Disease Control and Prevention, or the authors’ affiliated institutions. Use of Phillip Tarr, St. Louis, Missouri, USA
trade names is for identification only and does not imply endorsement by any of Timothy Tucker, Cape Town, South Africa
the groups named above. Elaine Tuomanen, Memphis, Tennessee, USA
All material published in Emerging Infectious Diseases is in the public John Ward, Atlanta, Georgia, USA
domain and may be used and reprinted without special permission; proper
J. Todd Weber, Atlanta, Georgia, USA
citation, however, is required.
Use of trade names is for identification only and does not imply Mary E. Wilson, Cambridge, Massachusetts, USA ∞
endorsement by the Public Health Service or by the U.S. Department of Health Emerging Infectious Diseases is printed on acid-free paper that meets the
and Human Services. requirements of ANSI/NISO 239.48-1992 (Permanence of Paper)
Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 21, No. 9, September 2015
September 2015
On the Cover Twenty Years of Active
Bacterial Core Surveillance ........1520
Edward Middleton
G. Langley et al.
Manigault (1863–1923)
This program has directly affected public health
The Rocket, 1909.
policies and practices.
Oil on canvas, 20 × 24 in /
50.8 × 60.69 cm. Columbus The Foodborne Diseases Active
Museum of Art, Ohio, USA; Surveillance Network—2 Decades of
Museum Purchase, Achievements, 1996–2015 ........1529
Howald Fund II, 1981.009. O.L. Henao et al.
FoodNet has provided a foundation for food
About the Cover p. 1690
safety policy and illness prevention since 1996.
Emerging Infections Evaluating Epidemiology and
Program Improving Surveillance of
Infections Associated with
Emerging Infections Program— Health Care, United States ........1537
20 Years of Achievements and S.S. Magill et al.
Future Prospects .......................1497 This national resource provides much-needed
R. Lynfield and W. Schaffner data on pathogens, infections, and antimicrobial
drug use.
Cultivation of an Adaptive
Domestic Network for The US Influenza Hospitalization
Surveillance and Evaluation of Surveillance Network ................1543
Emerging Infections ..................1499 S.S. Chaves et al.
R.W. Pinner et al. This network has helped determine risk, define
Accomplishments of this program have p. 1500 severity, and guide recommendations for
provided numerous dividends and might treatment and vaccination programs.
benefit areas outside infectious diseases.
Use of Pneumococcal Disease
Emerging Infections Epidemiology to Set Policy
Program—State Health and Prevent Disease during
Department Perspective ............1510 20 Years of the Emerging
J.L. Hadler et al. Infections Program ...................1551
This network has enriched research and p. 1530 M.R. Moore and C.G. Whitney
workforce training and produced a synergy This program has been a flexible platform for
between state and federal levels. following trends of this disease and evaluating
vaccine effectiveness.
Training in Infectious Disease
Epidemiology through the Emerging Monitoring Effect of Human
Infections Program Sites ...........1516 Papillomavirus Vaccines in US
D.J. Vugia et al. Population, Emerging Infections
EIP sites contribute substantially to Program, 2008–2012 ................1557
training current and future public S. Hariri et al.
health professionals. Methods for surveillance of cervical precancers
and associated types were developed to
monitor effect of HPV vaccination.
Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 21, No. 9, September 2015
Emerging Infections
Program
September 2015
Improving Accuracy of Influenza-
Associated Hospitalization
Encephalitis Surveillance Rate Estimates ..........................1595
through the Emerging A.J. Millman et al.
Infections Program, Adjusting for diagnostic test sensitivity
1997–2010 ..................1562 enables more accurate and timely
K.C. Bloch and C.A. Glaser comparisons over time.
A 3-state syndromic surveillance system
documented reduction and emergence of Socioeconomic Disparities and
neurologic infectious diseases. Influenza Hospitalizations,
Tennessee, USA .........................1602
Tracking Pertussis and Evaluating C. Sloan et al.
Control Measures through High rates of poverty, low education, and
Enhanced Pertussis Surveillance, female single-parent households are
Emerging Infections Program, associated with these hospitalizations.
p. 1575
United States .............................1568
T.S. Skoff et al. Improved Phenotype-Based
This program can improve pertussis Definition for Identifying
prevention and control and be a model for Carbapenemase Producers
surveillance programs. among Carbapenem-Resistant
Enterobacteriaceae ...................1611
TickNET—A Collaborative Public N. Chea et al.
Health Approach to Tickborne A new, less restrictive definition increases
Disease Surveillance detection of Klebsiella pneumoniae
and Research.............................1574 carbapenemase producers.
P. Mead et al.
Activities include burden-of-illness Socioeconomic Status and
studies, high-quality prevention trials, and Foodborne Pathogens in
pathogen discovery. Connecticut, USA,
p. 1633 2000–2011 ................................1617
Emerging Infections Program B.M. Whitney et al.
as Surveillance for Antimicrobial Diseases were associated with high
Drug Resistance ........................1578 socioeconomic status and age of patient
S.K. Fridkin et al. and serotype of organism.
This program is a national resource for data on
the epidemiology of antimicrobial drug–resistant Incidence of Clinician-Diagnosed
infections and characteristics of isolates. Lyme Disease, United States,
2005–2010 ................................1625
Effect of Culture-Independent C.A. Nelson et al.
Diagnostic Tests on Future Extrapolation from a large medical claims
Emerging Infections database to the US population suggests that
Program Surveillance ................1582 329,000 cases occur annually.
G. Langley et al.
Use of such tests in clinical settings presents Enhancing Lyme Disease
opportunities and challenges. Surveillance by Using
Administrative Claims Data,
Emerging Infections Tennessee, USA ........................1632
Program Efforts to Address J.L. Clayton et al.
Health Equity .............................1589 We identified 20% more cases, but the method
J.L. Hadler at al. was resource intensive.
The EIP has expanded efforts by using
area-based socioeconomic analyses.
Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 21, No. 9, September 2015
1667 Follow-up of Contacts of
Middle East Respiratory
September 2015 Syndrome Coronavirus–
Infected Returning Travelers,
Emerging Infections the Netherlands, 2014
Program M. Mollers et al.
1515 Etymologia 1670 Reemergence and
Surveillance Autochthonous Transmission
of Dengue Virus,
1635 Photo Quiz
Eastern China, 2014
W. Wang et al.
Synopsis
Letters
1674 Bidifobacterium breve Sepsis
Mycobacterium abscessus
in Child with High-Risk Acute
Complex Infections
Lymphoblastic Leukemia
in Humans ...................1638
M.-R. Lee et al. 1675 Filovirus RNA in Fruit Bats,
New treatments, rapid and inexpensive China
p. 1662
identification methods, and measures
to contain nosocomial transmission and 1677 Increase in Lymphadenitis
outbreaks are urgently needed. Cases after Shift in BCG
Vaccine Strain
Dispatches
1679 Fatal Accelerated Cirrhosis
after Imported HEV
1647 Putative Lineage of Novel
Genotype 4 Infection
African Usutu Virus,
Central Europe
1681 Measles Reemergence in
D. Cadar et al.
Ceará, Northeast Brazil,
15 Years after Elimination
1651 Randomness of Dengue
Outbreaks on the Equator
1683 Chikungunya Virus in
Y. Chen et al.
Macaques, Malaysia
1654 Acute Respiratory Infections p. 1680 1685 Functional Immune
in Travelers Returning from
Reconstitution by
MERS-CoV–Affected Areas
Interleuken-2 Adjunctive
M. German et al. Therapy for HIV
Mycobacterial Co-infection
1657 Third Wave of Influenza
A(H7N9) Virus from Poultry, 1687 Corynebacterium bovis
Guangdong Province, China, Eye Infections, Washington,
2014–2015 USA, 2013
S. Xie et al.
About the Cover
1661 Disseminated Enteroviral
Infection Associated with 1690 Ceaseless Experimentation
Obinutuzumab Sparks Fireworks, Art,
C. Dendle et al. and Science
1664 Laboratory Testing for Middle
International Conference
East Respiratory Syndrome
on Emerging Infectious
Coronavirus, California, USA,
Diseases 2015 Poster and
2013–2014
Oral Presentation Abstracts
M. Shahkarami et al.
http://go.usa.gov/3AwnF
Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 21, No. 9, September 2015
Presenting the ongoing challenges
that emerging microbial threats
pose to global health
Emerging Infections Program—
20 Years of Achievements
and Future Prospects
Ruth Lynfield, William Schaffner
“Disease-causing microbes have threatened human describes the considerable training and teaching activi-
health for centuries. The Institute of Medicine’s ties undertaken by EIP investigators. Although training
Committee on Emerging Microbial Threats to Health be- was among the consortium’s explicit goals when EIP was
lieves that this threat will continue and may even intensify initiated, its funding has been evanescent, thus requiring
in coming years” (1). Thus begins the Institute of Medi- commitment and imaginative flexibility to create train-
cine’s 1992 Report on Emerging Infections. The Institute ing opportunities in the context of active investigations.
of Medicine indicated that “emergence may be due to the However, EIP investigators have derived great pleasure in
introduction of a new agent, to the recognition of an exist- training the next generation of public health epidemiolo-
ing disease that has gone undetected, or to a change in the gists, and this has yielded dividends for mentees, mentors,
environment that provides an epidemiologic bridge.” The and public health.
recommendations encompassed both the ability to detect These initial articles are followed by a series of re-
(surveillance) and respond to emerging infections. These views that summarize and assess core EIP areas and some
recommendations laid the groundwork for establishment of related noteworthy projects. The network has successfully
the Emerging Infections Program (EIP). established population-based surveillance for many patho-
This issue of Emerging Infectious Diseases marks the gens of public health importance and has been able to pro-
20th anniversary of the EIP. Sponsored and organized by vide insights into risk factors for disease, and characteriza-
the Centers for Disease Control and Prevention (CDC), tion of pathogens. EIP data have been used to inform public
the EIP is a multifaceted collaboration of CDC with 10 health recommendations for the prevention and control of
state health departments and their academic partners, with multiple infectious diseases and to evaluate public health
the goal of conducting a portfolio of work that can be
characterized as enhanced public health surveillance and
Guest Editors
applied research to detect, prevent, and control emerg-
ing infectious diseases. Collaboration derives from the Dr. Lynfield is State Epidemiologist
Latin word “collaboratus,” meaning to labor together. and Medical Director, Minnesota
The collaboration has been profound and successful, with Department of Health, St. Paul.
marked commitment, creativity, and passion contributed Minnesota. Her research interests
by all participants. are emerging infectious diseases,
This special issue incorporates a Festschrift for the antimicrobial resistance, and
EIP, celebrating the accomplishments of this distinctive infection prevention.
enterprise over the past 2 decades. The first article of the
series uses a tree metaphor to describe the history of the
EIP over the past 20 years and discusses future directions
for the network. The following article provides a state- Dr. Schaffner is Professor of
based perspective, which includes the enhancement of Preventive Medicine, Department of
public health infrastructure and the development of new Health Policy and Professor of
academic and public health partnerships. Another article Medicine, Division of Infectious
Diseases, Vanderbilt University School
Author affiliations: Minnesota Department of Health, St. Paul, of Medicine, Nashville, Tennessee.
Minnesota, USA (R. Lynfield); Vanderbilt University School of His research interests are
Medicine, Nashville, Tennessee, USA (W. Schaffner) communicable disease control and
vaccine-preventable diseases.
DOI: http://dx.doi.org/10.3201/eid2109.150564
Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 21, No. 9, September 2015 1497
interventions. Not resting on their laurels, the authors of become true partners and value the mutual trust, sense of
these articles also look to future challenges, including those harmony, and friendships that have flourished over the
directly related to the infections, as well as others imposed years. These qualities, along with a shared commitment
by health inequities and changes in technology. A series to science-based public health practice, have led to the
of original research contributions by EIP investigators and success of the EIP and bode well as the network looks
their collaborators follows the reviews. forward to tackling the next generation of emerging issues
The scientific work of the EIP is directed through a of public health importance.
genuinely collaborative steering committee comprised of
lead investigators from all sites in the field, as well as Reference
CDC. It is co-chaired by a CDC investigator and a site 1 Lederberg J, Shope RE, Oaks SC Jr, editors. Emerging infections:
microbial threats to health in the United States. Washington (DC):
senior investigator. Priority-setting discussions are open
The National Academies Press; 1992 [cited 2015 Jun 18].
and genial, informed equally by national views and lo-
http://www.nap.edu/catalog/2008/emerging-infections-
cal perspectives. Formal votes are rare; consensus build- microbial-threats-to-health-in-the-united-states
ing is the norm. The participants have longevity; many
have been with the program since its inception and have Address for correspondence: Ruth Lynfield, Minnesota Department of
nurtured it through 2 decades of administrative, fiscal, Health, 625 Robert St N, PO Box 64975, St. Paul, MN 55164, USA;
and scientific labyrinths. As such, the participants have email: [email protected]
March 2015:
Tuberculosis
Including:
• Evaluation of the Benefits and Risks of Introducing
Ebola Community Care Centers, Sierra Leone
• N anomicroarray and Multiplex Next-Generation
Sequencing for Simultaneous Identification and
Characterization of Influenza Viruses
• M ultidrug-Resistant Tuberculosis in Europe,
2010–2011
• R isk Factors for Death from Invasive Pneumococcal
Disease, Europe, 2010
• M ycoplasma pneumoniae and Chlamydia spp.
Infection in Community-Acquired Pneumonia,
Germany, 2011–2012
• E pidemiology of Human Mycobacterium bovis
Disease, California, USA, 2003–2011
• Regional Spread of Ebola Virus, West Africa, 2014
• Spillover of Mycobacterium bovis from Wildlife to
Livestock, South Africa
• Prisons as Reservoir for Community Transmission of
Tuberculosis, Brazil
• Polycystic Echinococcosis in Pacas,
Amazon Region, Peru
• Red Deer as Maintenance Host for Bovine
Tuberculosis, Alpine Region
http://wwwnc.cdc.gov/eid/articles/issue/21/3/table-of-contents
1498 Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 21, No. 9, September 2015
Cultivation of an Adaptive Domestic
Network for Surveillance and
Evaluation of Emerging Infections
Robert W. Pinner, Ruth Lynfield, James L. Hadler, William Schaffner,
Monica M. Farley, Mark E. Frank, Anne Schuchat
“The best time to plant a tree was 20 years ago; model for the EIP. Active surveillance and related research
the second best time is now.” —Chinese Proverb conducted through collaborations between CDC and health
departments generated information on the burden of and
Through the metaphor of an adaptive, organic entity—a risk factors for toxic shock syndrome, listeriosis, Hae-
tree with roots, a trunk, large limbs and smaller branch- mophilus influenzae type b (Hib) and group B Streptococ-
es, fruits, and seeds (Figure 1)—this article describes the cus (GBS) infections, and meningococcal disease (3–6).
Emerging Infections Program (EIP), reflects on this net- An earlier population-based active surveillance effort on
work’s accomplishments over the past 20 years, and con- bacterial meningitis conducted in Bernalillo County, New
siders opportunities and challenges for the future. Other Mexico, provided a similar model (7). The approach—pop-
articles in this 2015 20th anniversary issue of Emerging ulation-based, active, laboratory-based surveillance, some-
Infectious Diseases focusing on the EIP expand on many of times coupled with collection of disease-causing isolates
the ideas introduced here, providing additional discussion, and always including key epidemiologic information—was
details, and references. incorporated into today’s EIP activities.
Whereas earlier activities focused on a single disease
Roots or a small number of diseases and activities and operated
The concepts of emerging infectious diseases are now fa- through contracts between CDC and health departments,
miliar to the scientific community and the public. However, from the beginning the EIP dealt with multiple public health
it took a 1992 Institute of Medicine report to emphasize the issues concurrently; engaged experts in state public health
dynamic and modern factors that cause infectious diseases agencies, academic institutions, and a variety of CDC pro-
to emerge and re-emerge and to put to rest the idea of infec- grams; and operated as a consortium in which stakeholders
tious diseases as a solved problem, a worry for earlier times have mutual responsibilities for setting priorities, planning
(1). The Centers for Disease Control and Prevention (CDC) and executing activities, and synthesizing and communi-
Plan to Address Emerging Infections, released in April cating results (8,9).
1994, provided recommendations for action by CDC and
other public health agencies (2). The CDC Plan highlighted
Trunk
the foundational role of surveillance and included in the Understanding the urgency, challenge, and complexity of
recommendations creation of a network comprising state its mission and the need for a flexible model to support it,
public health agencies, academic institutions, and CDC for the EIP built a network of collaborator sites, each contrib-
special surveillance and applied public health research. The uting to shared governance, and established a strategic ap-
EIP sprang from these recommendations. proach to guide projects. These elements serve as the trunk,
Even before that time, active, population-based surveil- or supportive infrastructure, for EIP efforts.
lance projects dating to the 1970s had provided a general The number of sites increased—from 4 in 1994 to the
current number of 10 by 2002—as EIP activities demon-
Author affiliations: Centers for Disease Control and Prevention,
strated success, the need for broader geographic and de-
Atlanta, Georgia, USA (R.W. Pinner, M.E. Frank, A. Schuchat);
mographic representation was recognized, and funds be-
Minnesota Department of Health, St. Paul, Minnesota, USA
came available (Figure 2). EIP sites involve state health
(R. Lynfield); Yale University School of Public Health, New Haven,
department personnel and key collaborators in academic
Connecticut, USA; (J.L. Hadler); Vanderbilt University School of
institutions; each site engages others to conduct activities,
Medicine, Nashville, Tennessee, USA (W. Shaffner); Emory
including clinical laboratories and infection control pro-
University School of Medicine, Atlanta (M.M. Farley)
fessionals throughout each EIP area. The 10 EIP sites, to-
DOI: http:;//dx.doi.org/10.3201/eid2109.150619 gether with several CDC programs and a coordinating unit
Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 21, No. 9, September 2015 1499
Figure 1. Structure and
development of the Emerging
Infections Program, United
States. ABCs, Active Bacterial
Core Surveillance; CDC,
Centers for Disease Control and
Prevention; IOM, Institute of
Medicine; EI, emerging infections;
HPV, human papillomavirus.
at CDC, form the EIP network. EIP support comes from EIP activities. By the time of the Steering Group meeting in
core funding intended to maintain and support the network November 1996, the group had adopted guiding principles
and invest in key activities. In addition, other sources sup- and approved a framework for evaluating ideas for new proj-
port specific EIP activities. For example, funding from the ects, which has guided assessment of potential new areas of
US Department of Agriculture (USDA), the Food and Drug work and strategic directions (Table).
Administration (FDA), and the Food Safety Initiative of Responsibilities and authorities are distributed across
CDC have supported foodborne diseases work; the immu- the network’s membership. State public health agencies
nization program of CDC supports vaccine effectiveness have legal authority for conducting surveillance; in this
evaluation and related surveillance of vaccine-preventable context, academic partners function as agents of the state
disease. Extramural funding for EIP cooperative agree- health departments. CDC has responsibility for expending
ments has ranged from $2.3 million for 4 sites in 1995 to and managing federal funds invested in the EIP. Resources
an average annual total of $33.8 million for the current 10 come from several funding streams, and each source requires
sites during 2010–2014. accountability for ensuring that funds are spent well on ap-
As early as the first EIP meeting in November 1994, propriate activities. This distribution of responsibilities and
principals at CDC and EIP sites (including representatives authorities, coupled with the need for ensuring that the EIP
from state health departments and academic partners) formed can respond nimbly to emerging issues, has meant that gov-
an EIP Steering Group to provide guidance and strategy for ernance works flexibly, not rigidly—through negotiations
1500 Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 21, No. 9, September 2015