CDC - Severe Acute Respiratory Syndrome: Clinical = Outcome and Prognostic Correlates

From: Subject: CDC - Severe Acute Respiratory Syndrome: Clinical Outcome and Prognostic Correlates Date: Tue, 2 Sep 2003 11:12:45 +0300 MIME-Version: 1.0 Content-Type: multipart/related; boundary="----=_NextPart_000_005C_01C37143.22A9B280"; type="text/html" X-MimeOLE: Produced By Microsoft MimeOLE V6.00.2800.1165 This is a multi-part message in MIME format. ------=_NextPart_000_005C_01C37143.22A9B280 Content-Type: text/html; charset="Windows-1252" Content-Transfer-Encoding: quoted-printable Content-Location: http://www.cdc.gov/ncidod/EID/vol9no9/03-0362.htm CDC - Severe Acute Respiratory Syndrome: Clinical = Outcome and Prognostic Correlates

<= IMG=20 height=3D1 alt=3D"Skip Standard Navigation Links"=20 src=3D"http://www.cdc.gov/navimages/spacer.gif" width=3D"100%"=20 border=3D0>

Current Issue
3D"

Vol.=20 9, No. 9
September = 2003

PDF=20 Version | Download Adobe = Acrobat | Comments=20 | Email= =20 this article


=95	Methods
=95	Results
=95	Discussion=
=95	Conclusion=
=95	Acknowledgments
=95	References
=95	Figure = 1
=95	Figure = 2
=95	Figure = 3
=95	Table = 1
=95	Table = 2
=95	Table = 3
=95	Table = 4
=95	Table=20 5

Research

Severe Acute = Respiratory=20 Syndrome: Clinical Outcome and Prognostic Correlates

Ping Tim Tsui,*Man Leung Kwok,* Hon Yuen,* and Sik To = Lai*¹=
*Princess=20 Margaret Hospital, Hong Kong, China

Suggested=20 citation for this article: Tsui PT, Kwok = ML, Yuen H,=20 Lai ST. Severe acute respiratory syndrome: clinical outcome and=20 prognostic correlates. Emerg Infect Dis [serial online] 2003 = Sept=20 [date cited]. Available from: URL:=20 = http://www.cdc.gov/ncidod/EID/vol9no9/03-0362.htm

Severe = acute=20 respiratory syndrome (SARS) poses a major threat to the health = of people=20 worldwide. We performed a retrospective case series analysis to = assess=20 clinical outcome and identify pretreatment prognostic correlates = of=20 SARS, managed under a standardized treatment protocol. We = studied 127=20 male and 196 female patients with a mean age of 41=B114 (range = 18=9683). All=20 patients, except two, received ribavirin and steroid combination = therapy. In 115 (36%) patients, the course of disease was = limited.=20 Pneumonitis progressed rapidly in the remaining patients. = Sixty-seven=20 (21%) patients required intensive care, and 42 (13%) required = ventilator=20 support. Advanced age, high admission neutrophil count, and high = initial=20 lactate dehydrogenase level were independent correlates of an = adverse=20 clinical outcome. SARS-associated coronavirus caused severe = illnesses in=20 most patients, despite early treatment with ribavirin and = steroid. This=20 study has identified three independent pretreatment prognostic=20 correlates.

The outbreak of severe acute respiratory syndrome (SARS) = in Hong=20 Kong was caused by a novel virus belonging to the family=20 Coronaviridae (1,2). = The=20 virus is transmitted through respiratory droplets, direct contact = with=20 fomites, and aerosolized respiratory secretions (3,4). = The=20 first outbreak was linked to an index patient treated in the = Prince of=20 Wales Hospital (4). The = second wave of spread in the community was started by an infected = patient=20 with renal disease and amplified by the sewage system of Amoy = Gardens, a=20 densely populated condominium in Hong Kong (5). The = floor drain traps in many apartments of Amoy Gardens were not = filled with=20 water and thus lost the sealing function. Therefore, the bathrooms = of many=20 apartments were openly connected with the soil stack. Virus-loaded = droplets of an affected apartment could have been spread through = the floor=20 drain system. Hundreds of patients were then treated in public = hospitals.=20 The virus was highly contagious and caused substantial illness and = death=20 among the general population as well as among healthcare = workers.

The Hong Kong Hospital Authority, which provides more than 90% = of=20 inpatient care in Hong Kong, has been responsible for the = management of=20 all SARS patients (6). The = Princess Margaret Hospital is a designated treatment center for = SARS=20 patients. Convalescent-phase SARS patients are treated in Wong Tai = Sin=20 Hospital. More than 500 SARS patients have been treated in these = two=20 hospitals since March 2003. The Hospital Authority has established = a=20 structured approach in the diagnosis, investigation, and treatment = of=20 SARS. The clinical diagnostic criteria of the Hospital = Authority=92s SARS=20 registry (defined in Table=20 1) were similar to the case definition of probable SARS by the = World=20 Health Organization (3).

Persons infected with the SARS-associated coronavirus may = exhibit a=20 wide spectrum of signs and symptoms and a varied clinical course. = We have=20 found asymptomatic cases and patients with spontaneous recovery = without=20 antiviral or steroid therapy (7); = SARS is=20 at the other end of the disease spectrum. The Hospital = Authority=92s=20 hypothetical disease model has three phases: viral replication, = immune=20 hyperactivity, and pulmonary destruction (8). = Autopsy=20 findings have supported the theory of cytokine deregulation in = SARS (9). = Using=20 steroids in the treatment of SARS was based on this hypothesis and = on=20 initial clinical experience in the management of SARS in Hong Kong = (4).

The recommended treatment regime at the time of the Amoy = Gardens=20 outbreak consisted of antibiotics, ribavirin, and steroid = combination=20 therapy. Patients without known epidemiologic contact with SARS = patients=20 were treated with antibiotics that would prevent both community- = acquired=20 pneumonia and hospital infections. If patients did not respond to=20 antibiotics in 48 h, they would be given a combination of = ribavirin and=20 steroid. For patients with an epidemiologic history of contact = with a SARS=20 patient, this combination would be started together with the above = antibiotic. Ribavirin would be given at a dose of 8 mg/kg = intravenously=20 every 8 h. For patients who appeared for treatment with extensive=20 pneumonitis, a loading dose of 33 mg/kg of ribavirin, followed by = 20 mg/kg=20 every 8 h, was given intravenously. Hydrocortisone, 2 mg/kg every = 6 h or 4=20 mg/kg every 8 h, would be administered, together with ribavirin. = Oral=20 equivalent doses of ribavirin and prednisolone could be prescribed = at any=20 stage of the disease. The total duration of therapy could range = from 14 to=20 21 days. Besides administering steroids, we have tried in selected = cases=20 immunomodulation through the use of intravenous pentaglobin. = Pulsed doses=20 of methylprednisolone were restricted to those with disease = progression=20 and marked lung involvement. Lee et al. have made a comprehensive = report=20 of 138 cases of suspected SARS during a hospital outbreak in Hong = Kong (4). Our = study investigated the SARS patients after the Amoy Gardens = outbreak to=20 identify associated pretreatment prognostic factors for risk=20 stratification and assess the clinical outcome of SARS under a=20 standardized treatment protocol.

Methods

We performed a retrospective case series study. All reported = SARS=20 patients who stayed in the medical wards or intensive care unit of = Princess Margaret Hospital and Wong Tai Sin Hospital on April 16, = 2003,=20 were screened. Patients were excluded if subsequent follow-up = serologic=20 tests showed no rise in antibody titer against SARS-associated=20 coronavirus. All eligible SARS patients, except three, were = recruited into=20 the study. One healthcare worker refused to be studied, and two = patients=20 who were suspected of contracting the infection during their = hospital stay=20 were also excluded. This cohort was followed up until May 20, = 2003. Data=20 were collected through the Hong Kong Hospital Authority=92s = computerized=20 clinical management system, case record review, and a = questionnaire survey=20 assisted by the nursing staff of each SARS ward. Age, sex, = occupation,=20 residential address, smoking habit, time between onset of fever = and start=20 of antiviral therapy, coexisting conditions, and laboratory data = were the=20 variables under study. Outcome variables were the following: = dependency on=20 high amounts of oxygen (requiring at least 3 L/min of oxygen = through a=20 nasal cannula) and admission to an intensive care unit or = death.

Statistical=20 Analysis

Categorical variables were analyzed with the chi-square test = and the=20 means of continuous variables were compared with the Student t = test.=20 Association among continuous variables was assessed with Pearson=20 correlation coefficient. Multivariate logistic regression by = backward=20 stepwise analysis was performed to identify independent variables = that=20 correlated with the clinical outcome as of May 20, 2003. Cox=92s = regression=20 model was used to study survival data. Plus-minus values are mean = =B1=20 standard deviation; a p value of <0.05 was considered = significant, and=20 all probabilities were two-tailed. SYSTAT software (version 10.0, = SPSS,=20 Chicago, IL) was used for statistical analysis.

Results

The study population consisted of 127 male and 196 female = patients,=20 ranging in age from 18 to 83 (41=B114). Forty-seven (15%) patients = were=20 healthcare workers. One hundred thirty-three (41%) were Amoy = Gardens=20 residents. Two hundred seventy-three (85%) patients were in good = health.=20 The coexisting conditions are listed in Table=20 2. Psychiatric illness, hepatitis B carrier status, and = thalassemia=20 trait status were not classified as coexisting conditions. Fifteen = (14%)=20 males and 7 (4%) females were current smokers. The overall = prevalence of=20 smoking among SARS patients was 7.6% (9.1% if healthcare workers = are=20 excluded). None of the affected healthcare workers smoked. The = symptoms=20 exhibited fulfilled the diagnostic criteria of the Hospital = Authority=92s=20 SARS registry.

All patients had lung involvement, documented either by chest = x-ray or=20 high-resolution computed tomographic scan of the thorax. = Lymphopenia,=20 found in 221 (68%) patients, was a prominent feature in those who = sought=20 treatment. Other initial laboratory findings included = thrombocytopenia=20 (41%), elevated creatine kinase level (14%), and elevated lactate=20 dehydrogenase level (42%). Initial bacterial cultures were = negative. Virus=20 screening was negative for adenovirus, respiratory syncytial = virus,=20 influenza A and B, and parainfluenza virus. Two hundred and seven = (64%)=20 patients had reverse transcriptase=96polymerase chain reaction = (RT-PCR)=20 assays performed for SARS-associated coronavirus, and 128 (62%) of = the=20 results were positive. Two hundred and forty-two (75%) patients = had=20 completed serologic testing. The diagnosis of recent = SARS-associated=20 coronavirus infection was confirmed by either RT-PCR assays or = serologic=20 test in 286 (89%) patients. The sensitivity of RT-PCR assays was = 58% (95%=20 confidence interval [CI], 50% to 66%).

Our patients sought treatment 3.9=B12.7 days after onset of = fever. The=20 interval between onset of fever and admission was positively = correlated=20 with admission neutrophil count (Pearson r=3D0.1, p=3D0.07), = admission=20 platelet count (Pearson r=3D0.1, p=3D0.06), and initial lactate = dehydrogenase=20 level (Pearson r=3D0.36, p<0.001). An antibiotic was started = immediately=20 after admission in all cases. Either levofloxacin, 500 mg once a = day, or=20 amoxicillin/clavulinate acid, 375 mg three times a day plus=20 clarithromycin, 500 mg twice a day, was used to protect against=20 community-acquired pneumonia. All patients were also treated with = oral or=20 intravenous ribavirin, according to protocol. Most (94%) were = given either=20 intravenous hydrocortisone or oral prednisolone, according to = protocol.=20 Five patients received intravenous methylprednisolone as a form of = steroid=20 therapy. The dose was administered at 3 mg/kg once a day and would = be=20 tapered down to 1 mg/kg if the patient showed a clinical response. = Pulsed=20 doses of methylprednisolone (500 mg per dose) were given as = initial=20 treatment in 12 patients, who then received maintenance steroid = therapy.=20 Two patients were treated with ribavirin only. Ribavirin plus = steroid=20 therapy was administered 1.2=B11.7 days after admission. The = interval=20 between admission and initiation of antiviral therapy was = negatively=20 correlated with the interval between onset of fever and admission = (Pearson=20 r =3D =960.17, p=3D0.003).

Clinical = Outcome

In 115 (36%) patients, the disease was limited with resolution = of fever=20 and pneumonitis. Two hundred and eight (64%) patients had either = clinical=20 or radiologic evidence of progression of pneumonitis, and they = received=20 2.9=B12 gm pulsed dose methylprednisolone therapy. Maintenance = steroid was=20 resumed after pulsed dose therapy. Patients who were given pulsed = doses of=20 steroids were treated with potent broad-spectrum intravenous = antibiotics=20 (piperacillin and tazobactam) to protect against hospital-acquired = infection. Hyperglycemia, hypokalemia, flare up of hepatitis B = infection,=20 hospital-acquired infection, and steroid psychosis were the acute = side=20 effects encountered. Hepatitis B carriers were treated with = lamivudine,=20 100 mg once a day; no liver failure occurred in members of = this=20 cohort. Disease progression was apparently arrested by pulsed dose = steroid=20 therapy in 98 (30%) patients. In the remaining 110 (34%) patients, = the=20 illness ran a severe and protracted course, and the patient needed = high=20 doses of oxygen. Sixty-seven (21%) had been admitted to intensive = care=20 unit, and 42 (13%) required ventilator support. Twenty-six = patients died=20 (12 males and 14 females). The crude mortality rate of our cohort = after=20 47=B18 days of follow-up was 7.9% (95% CI, 5% to 10.8%) and was an = underestimation because of sampling bias. Those who died before = April 16,=20 2003, were excluded from our sample, while long-term survivors = were=20 retained for study. Among them, 10 had concurrent medical illness. = No=20 healthcare worker in this cohort died. Diabetes was found in three = patients who died, and hypertension in four who died. Eleven of = those who=20 died lived in Amoy Gardens. A young pregnant woman died after = delivery,=20 despite aggressive treatment.

	Figure = 1

	Click to view enlarged = image Figure 1. = Relationship between=20 age and fatal severe acute respiratory syndrome illness, = Hong Kong,=20 2003.

	Figure=20 2

	Click to view enlarged = image Figure 2. = Relationship between=20 neutrophil count and fatal severe acute respiratory syndrome = illness, Hong Kong, 2003.

	Figure=20 3

	Click to view enlarged = image Figure 3. = Relationship between=20 lactate dehydrogenase level (LDH) and fatal severe acute = respiratory=20 syndrome illness, Hong Kong, 2003

Age, sex, healthcare worker status, Amoy Gardens resident = status,=20 presence of coexisting conditions, interval between onset of fever = and=20 therapy (ribavirin plus steroid), neutrophil and platelet count on = admission, and initial creatine kinase and lactate dehydrogenase = levels=20 were the correlates of clinical outcome under study. Variables = with a p=20 value of <0.1 by univariate analysis were entered into the = multivariate=20 regression model. By multivariate logistic regression, advanced = age, high=20 neutrophil count on admission, and high initial lactate = dehydrogenase=20 level were independent correlates of high oxygen dependency as = well as=20 intensive care unit admission or death (Table=20 3). By Cox=92s backward stepwise regression, young age, low = neutrophil=20 count on admission, and healthcare worker status (p=3D0.05) were = favorable=20 independent correlates of survival time (Table=20 3). A dose-response relationship also existed between the = independent=20 correlates and clinical outcome (Figure= s=20 1=963). We used the term =93correlates=94 instead of = =93predictors=94 of outcome=20 because of the method we used, a case series.

The second serology titer obtained after the end of second week = was=20 negatively correlated with age (Pearson r=3D=960.13, p=3D0.05) and = admission=20 lymphocyte count (Pearson r=3D=960.17, p=3D0.01). Conversely, the = neutrophil=20 count on admission was positively correlated with the second = serology=20 titer (Pearson r=3D0.2, p=3D0.003). The pulsed dose of steroid was = not shown=20 to affect the second serology titer (Pearson r=3D0.1, p=3D0.18). = Patients who=20 depended on high oxygen therapy had a higher second antibody titer = against=20 SARS-associated coronavirus (p =3D 0.05).

Discussion

The virus attacked persons of both sexes and all ages. Many = were=20 previously in good health and the wage earners in their families. = Not=20 infrequently, several members of a family were admitted to the = hospital.=20 The need for isolation discouraged close social contact. = Unfortunately,=20 some of the patients were also stigmatized. The psychosocial = effect of=20 SARS is by no means a lesser problem.

RT-PCR assay for SARS-associated coronavirus is a new test, and = its=20 sensitivity and specificity have yet to be established. In our = cohort, the=20 sensitivity was 58%, and results depended on sampling = technique and=20 stage of disease (10).=20 Contamination of specimen could lead to a false-positive result. A = false-negative result could arise from performing the test in the = very=20 early or late stage of the disease. Diarrhea was common among Amoy = Gardens=20 SARS patients. The virus could be found in stool by RT-PCR assays. = A=20 negative test does not rule out the diagnosis, however. The = serologic test=20 remains as the standard criterion of definitive diagnosis. Pulsed = doses of=20 steroid did not seem to affect the humoral response of SARS = patients. In=20 retrospect, the intensity of antibody response was related to = clinical=20 outcome and associated pretreatment prognostic factors. The viral = load=20 could be a determinant of these prognostic association = factors.

Our hematologic and biochemical data, as well as associated = prognostic=20 factors, agreed with the work of Lee et al. (4). = Both=20 advanced age and high neutrophil count on admission were = associated with=20 poor outcome. We found that initial lactate dehydrogenase level = was also=20 an associated prognostic factor. The early phase of SARS is = characterized=20 by lymphopenia and thrombocytopenia. As the disease progresses, = both=20 neutrophil and platelet counts rise, accompanied by an elevation = in=20 lactate dehydrogenase level. The neutrophilic response is = important in the=20 pathogenesis of hypersensitivity pneumonitis, and thus the initial = neutrophil count could also indicate disease progression. Lactate=20 dehydrogenase level reflects tissue necrosis related to immune=20 hyperactivity in SARS and thus relates to poor outcome. Patients = with high=20 neutrophil counts and lactate dehydrogenase levels on admission = could have=20 been late in seeking treatment or have experienced heavy exposure = to the=20 virus.

Effect on = Healthcare=20 Workers

The spread of the disease to healthcare workers is a major = problem in=20 any country dealing with SARS. Intubation, nasopharyngeal = aspiration,=20 chest physiotherapy, handling of excreta, and even feeding become=20 high-risk procedures. All healthcare workers working in Hospital = Authority=20 hospitals are required to follow the recommended personal = protection=20 equipment standards (11). = The=20 level of precaution depends on the risk in the work area and the = type of=20 procedure performed. All healthcare workers working in a SARS area = wore=20 N-95 masks, face shields, caps, gowns, and surgical gloves. The = intensive=20 care unit was high-risk area in this cohort (Table=20 4). However, healthcare workers working in a non-SARS area = were not=20 exempted. They contracted the disease from SARS patients who = sought=20 treatment early or exhibited atypical signs and symptoms. By = univariate=20 analysis, healthcare worker status was negatively correlated with = death.=20 Healthcare workers were younger. They sought treatment earlier and = had a=20 lower neutrophil count and lower initial lactate dehydrogenase = level on=20 admission (Table=20 5). Nevertheless, healthcare worker status was still an = independent=20 survival correlate after controlling these confounding variables. = The=20 current safety precaution could not prevent all frontline = healthcare=20 workers from contracting SARS, but minimizing individual exposure = to the=20 virus might reduce the viral load, subsequent immune = hyperactivity, and=20 the risk for a fatal outcome.

Benefit of=20 Treatment

Most of the patients in this cohort were treated according to = protocol.=20 The clinical outcome did not represent the natural history of = SARS. The=20 only variable that was related to the benefit of treatment was the = time=20 from onset to treatment. Donnelly et al. found that the time = between the=20 onset of symptoms and admission to hospital did not affect the = death rate=20 (12).=20 In this study, patients who sought treatment early and received = antiviral=20 and steroid combination therapy were not shown to do better by=20 multivariate analysis.

The Hospital Authority adopted an aggressive treatment protocol = during=20 the peak of the SARS epidemic in Hong Kong. Broad-spectrum = antibiotics and=20 a combination of ribavirin and steroid were the mainstays of = treatment.=20 The dose of ribavirin used was small to prevent major side = effects. The=20 administration of steroids in SARS treatment is controversial, = however.=20 Theoretically, the early use of steroids promotes viral = replication,=20 enhances infectivity, and possibly causes a rebound of infection. = Peiris=20 et al. found that the viral load peaked at day 10 in SARS patients = treated=20 with both ribavirin and steroids (13).=20 However, immunosuppression or, more precisely, immunomodulation, = is=20 believed to be an effective therapy at the second stage of SARS. = The=20 current consensus among the Hospital Authority=92s expert panel is = to begin=20 administering a steroid or pentaglobin at the second stage of SARS = when a=20 hypersensitivity immune reaction occurs (8).

Patients who sought treatment early tended to receive antiviral = therapy=20 at a later time. This is understandable since the symptoms of SARS = are=20 nonspecific, and clinicians also rely on laboratory data for = diagnosis.=20 The sensitivity of current RT-PCR assays is not satisfactory. A = more=20 sensitive and rapid diagnostic test must be developed, = particularly if we=20 have an effective treatment regime in the future.

Conclusion

One third of the SARS patients in our study had a limited = disease=20 course. In the remaining two thirds, pneumonitis progressed = rapidly after=20 the early use of ribavirin and steroid combination therapy. = Apparently,=20 approximately one third responded to pulsed doses of steroids, = while the=20 other third depended on treatment with high amounts of oxygen. = Intensive=20 care was required for 21% of patients. Advanced age, high = neutrophil count=20 on admission, and elevated initial lactate dehydrogenase level = were=20 independent correlates of an adverse clinical outcome. Strong = evidence to=20 support early and routine use of ribavirin and steroid combination = therapy=20 in all SARS patients does not exist.

We need to investigate new antiviral agents and test the = efficacy of=20 steroids in randomized controlled trials. SARS is an entirely new = emerging=20 disease and its clinical course varies widely. By stratifying our = patients=20 according to risk, we could individualize our treatment protocol. = In=20 addition, we need a more sensitive and rapid diagnostic test for=20 SARS-associated coronavirus infection, both for treatment and for = forming=20 cohorts of patients infected with this deadly disease.

Acknowledgments

We thank = all medical=20 staff of the Department of Medicine and Geriatrics, Princess = Margaret=20 Hospital, Tom Buckley, W.W. Yan, Winnie Chan, Y.C. Chan, H.P. = So, and=20 Eva Y.W. Ng for their dedication in combating the SARS outbreak = in Hong=20 Kong.

References

Peiris JS, Lai ST, Poon LL, Guan Y, Yam LY, = Lim W, et=20 al. Coronavirus as a possible cause of severe acute=20 respiratory syndrome. Lancet 2003;361:1319=9625.=20
Centers for Disease Control and Prevention. SARS coronavirus = sequencing. [Accessed May 26, 2003] Available from: URL: http://www.cdc.gov/ncidod/sars/sequence.htm=20
World Health Organization. Interim guidelines for national = SARS=20 preparedness. [Accessed May 26, 2003] Available from: URL: http://www.cdc.gov/ncidod/EID/vol9no9/disc22.htm=20
Lee N, Hui D, Wu A, Chan P, Cameron P, Joynt GM, et al. A major outbreak of severe acute respiratory = syndrome in=20 Hong Kong. N Engl J Med 2003;348:1986=9694.=20
Department of Health, HKSAR. Outbreak of severe acute = respiratory=20 syndrome (SARS) at Amoy Gardens, Kowloon Bay, Hong Kong. = [Accessed June=20 2, 2003] Available from: URL: http://www.cdc.gov/ncidod/EID/vol9no9/disc23.htm=20
Hong Kong Hospital Authority. [Accessed May 28 2003] = Available from:=20 URL: http://www.cdc.gov/ncidod/EID/vol9no9/disc24.htm=20
Tsui PT, Mok NS, Kwan CP, Lee KK, Law CB, Lai ST. Wide = spectrum of=20 clinical course in subjects infected with SARS associated = coronavirus:=20 case report. In press=20
Hong Kong Hospital Authority. HA information on management = of SARS.=20 [Accessed May 28, 2003] Available from: URL: http://www.cdc.gov/ncidod/EID/vol9no9/disc25.htm=20
Nicholls JM, Poon LLM, Lee KC, Ng WF, Lai ST, Leung CY, et = al. Lung pathology of fatal severe acute respiratory = syndrome. Lancet 2003;361:1773=968.=20
World Health Organization. Severe acute respiratory syndrome = (SARS):=20 laboratory diagnostic tests. [Accessed June 2, 2003] Available = from:=20 URL: http://www.cdc.gov/ncidod/EID/vol9no9/disc26.htm=20
Hong Kong Hospital Authority. HA = information on=20 management of SARS: infection control. [Accessed June 3, 2003] = Available=20 from: URL: http://www.cdc.gov/ncidod/EID/vol9no9/disc27.htm=20
Donnelly CA, Ghani AC, Leung GM, Hedley AJ, Fraser C, Riley = S, et=20 al. Epidemiological determinants of spread of causal agent of = severe=20 acute respiratory syndrome in Hong Kong. Lancet = 2003;361:1761=966.=20
Peiris JS, Chu CM, Cheng VC, Chan KS, Hung IFN, Poon LLM, et = al. Clinical progression and viral load in a = community=20 outbreak of coronavirus-associated SARS pneumonia: a prospective = study. Lancet 2003;361:1767=9672.

Table=20 1. Case definition of SARS, Hong Kong Hospital Authority = SARS=20 Registry, April 22, 2003^a,b

Inclusion criteria	Exclusion criterion

Radiographic evidence of infiltrates = consistent with=20 pneumonia	A case should be excluded if an = alternative=20 diagnosis can fully explain the illness
Temperature >38=B0C or history of such = temperature=20 at any time in the past 2 days
At least two of the = following:
History of chills in the past 2 = days Cough (new=20 or increased cough) or breathing difficulty General = malaise or=20 myalgia Known history of = exposure

^aSARS, = severe acute=20 respiratory syndrome.

Table=20 2. Coexisting conditions in patients with severe acute=20 respiratory syndrome

Coexisting condition	No. of = patients

Hypertension	16
Diabetes mellitus	8
Chronic lung disease	6
Pregnancy	5
Neurologic disease	5
Renal disease	4
Cardiovascular disease	3
Immunologic disease	3
Malignancy	1

Table=20 3. Independent prognostic correlates and clinical=20 outcome

Correlates	High oxygen = dependency	ICU care or = death	Survival = time

	OR (95% CI) p = value	OR (95% CI) p = value	Hazard ratio (95% CI) p=20 value
Age (per 10-y increase)	1.48 (1.21 to=20 1.8) p<0.001	1.57 (1.26 to=20 1.95) p<0.001	1.75 (1.38 to=20 2.2) p<0.001
Admission neutrophil (per = 1x10⁹/L=20 increase)	1.31 (1.14 to=20 1.5) p<0.001	1.28 (1.13 to=20 1.46) p<0.001	1.17 (1.09 to=20 1.26) p<0.001
Initial LDH level (per 100 IU/L=20 increase)	1.49 (1.23 to=20 1.82) p<0.001	1.35 (1.11 to=20 1.64) p=3D0.003	p value not=20 significant

^aICU, = intensive=20 care unit; LDH, lactate dehydrogenase; OR, odds ratio; CI,=20 confidence interval.

Table=20 4. Number of infected healthcare workers treated in = Princess=20 Margaret Hospital, Hong Kong, = 2003^a

	ICU	SARS area	Non-SARS = area	Total no. = (%)

Doctor	2	1	1	4 (9)
Nurse	9	15	3	27 = (57)
Other	6	3	7	16 = (34)

^aICU, = intensive=20 care unit; SARS, severe acute respiratory=20 syndrome.

Table=20 5. Relationship between healthcare worker status and = other=20 prognostic variables

Variable	Non-HCW	HCW	p = value

Age	42=B114	37=B111	0.007
Onset-to-treatment (d)	5.3=B13.0	3.8=B12.2	0.001
Neutrophil = (x10⁹/L)	4.5=B12.8	3.9=B11.5	0.04
Lactate dehydrogenase = (IU/L)	276=B1161	188=B163	<0.001

^aHCW, = healthcare=20 worker.

¹P.T. Tsui and M.L. Kwok were = coprincipal=20 investigators and responsible for data collection. Dr. Tsui wrote = the=20 manuscript. H. Yuen and S.T. Lai led and fine tuned the research = from=20 hypothesis generation to writing the=20 paper.

Comments to the = Authors

Please use=20 the form below to submit correspondence to the authors = or=20 contact them at the following address:

Ping Tim=20 Tsui, Department of Medicine and Geriatrics, 2-10 = Princess=20 Margaret Hospital Road, Hong Kong, Special = Administrative=20 Region, China; fax: 852 2990 3329; email: tsuipt@netvigator.com

<= /TBODY>

Comments to the EID=20 Editors

Please contact the EID Editors at eideditor@cdc.gov

Email this = article

		EID = Home \| Top = of=20 Page \| Ahead-of-Print \| = Past=20 Issues \| Suggested=20 Citation \| EID Search \| = Contact Us = \| Accessibility = \| Privacy Policy Notice = \| CDC Home \| CDC Search \| = Health Topics=20 A-Z

		This page = posted August 5, 2003 This=20 page last reviewed August 25, 2003=20

		Emerging = Infectious=20 Diseases Journal National Center for = Infectious=20 Diseases Centers for = Disease Control=20 and Prevention

------=_NextPart_000_005C_01C37143.22A9B280 Content-Type: application/octet-stream Content-Transfer-Encoding: base64 Content-Location: http://www.cdc.gov/navimages/spacer.gif R0lGODlhBAAEAIEAAP///////wAAAAAAACH5BAEAAAAALAAAAAAEAAQAQAIEhI8JBQA7 ------=_NextPart_000_005C_01C37143.22A9B280 Content-Type: application/octet-stream Content-Transfer-Encoding: base64 Content-Location: http://www.cdc.gov/navimages/nav11.gif R0lGODlhjAA8ALMAAP///wAAmf///zMzrR4epY+P0gsLnl1dvp6e2G5uxUhItrS04fDw+YSEztDQ 7Ht7yiH5BAEAAAAALAAAAACMADwAAAT/MMhJq7046827/2AojmRpnqgxrGzrvnAsz3RNG2hOCHzv /8CgcEgsGouEHGqnaCFeT9cCFpXGpjREU5Yo2AaIhCCpNO3IkkKFkKgYGhd1ZXC4JAYbRT1DkHMa CmdlZmMUfhIKChWJFnQWBThuhxcGCBqVkRsPioKDJJ1pFQloEg2ZE6ZucBZ3Gw2kFgiwGJsSoJ4h oG8VkwG9vqyzBr8UCm0ZD3gctbaFuCKgbLyPjXuGFw+zFJUaeh3MzdrPG6CO1wEKBQsLDusIyQGp EgcHBQX0+PQLCU0YrxkD/BBogGCdwXv81jgb96GcIgoFGRBx4IDCEQHtwAUYcIwSAgPD/xwQYWCJ wi2GHEAxsrXgB8UCEXtUnHCxB0lF3DLIaiDR5gIE6kT2UCgO5QVQB5Qd6MnDQYJhE/pIXGDxR1IF CwgK9cGgQYGim7by8EKhi1CiRj2AGhVAjI8FSXZRGMCAKs0fbQYGMKDggdimp4o1EMvAmoQEdSoJ QJs25cIHBg64JLMyqrqqPtr8mzDgr4BfAf8aDkBvggG7URc25rPwK1Me1uRNuEMKyKhVJv8WdlPw R8kJpU0yXs0ajbofCzL1mrQD7+YKkpGfeveDAangGk4SH97S6jnTuEsBefAgQ3cfsRX8RU16NAbt 21Oj0a1s4+ik2woASW4eSEl6bmUGnP9776kWn0nOGACEA5ng9908A+wHkH4uqQDHeT2QcUBHjhW1 XSfR+fAbMNuEB4xtGHCjmwKWEPDXTBuCAN+BnSCA4gSTOCgBRwHcaAE8GPLAX4gykcZhBxF6SFwn QQrQkQHlPegLDj7OFWWTqwTYwwIxgpCOgQeGI4Fn1lS2V3hQ9YiXBTkFYOOaATyw4JEcJDAKmGF2 QiYqp5jpYJUSwCPBmwLGsyAIw3CCJ43OeNbRJLKRqGahnEU56I1yIteQLGKGyZhnlk5yiDmT9sAh JhQ0uYeWTXmQTiYzxsckEHKQap8hmVQp6ASePURkq3UeGeuHzhC6JQ46xpOJXBL4OID/pRIY8BpG ZHQGhIeJWjDsks40sKAiopZVG5xuBvarACM6ygen2i4qqzPHeTeqYZPc2EoFqnLW5IjFQFKgkqt1 co9/BEArm5kKoPhsI/tFMsArus3yAJ0IAtyYwAEEyUABD4WCYwXG8tDGRxbotkdA4v1wSCX1/esp Y2rQ5VJ9PNoCrR627TpBk7X6cVp1J7ObnbvEkiEHq58pk80ES+9hCRANQBuAiw1vNIm1PjiQiL+N kLJtwPDuPC0CB6SZxgELMDAAIwtmkgAC06KLA8qN6PZEIwVsXPHLe0t6j90LNJEAOz3A1KxL7HjW 1MnETN3kAg8kdcADcAM2G9HcGv2x/1RHOADI4Rftw1nj0R6gOBBd7agF5mDHFeoEYSCgeDtP/WYQ O7evQ1EYpNC9QT31OBB3O/+8kRfrFxdCwB7SeLw2l/oEMk/Hs7WMDsW+a9CANXxxhE8ikaRDxtfJ J2HOSgUDp4zZbmprYh8XBBQYm3d3QADZffM9dSErsYVOx37QUbIGdQpUzYFrACFZBxIQqf1ZLC2C cBBu5MGs37SpeiCbxf3mBx0TJdB6ndJfBDXnMdIoo2ZtsZ5eKKAzWygwRdvrgPGKoz8xLc1vH0tD JNhHwGK4Z4PZqV8evjK0BxpFEH6o1R7SZLZ7YXB02nph/KT4HvyRA3kQLIQcmue//v+tjzlooiIQ MzC5BTbQZTVEIiIekkTYPRF204HFGCnBMQ6AAYQ0TKMW50FCEpmDhwlhmgqpaBKhwZBiRayhA0mU iuatTYeBatkK5zGaOTaCkIswpFqweMQ9kmgl/lohD1/4sDVg8jCIjIoVQxAQTqJEjYyMxNHIcMPp mUaKlswP9exwRg6w6ACCQIAwObaHWnYyCXJI5o72IAf2wQ92Xjvl/Tx0RxEcQAudOoAiHkAVF+Hx GWeA0tTaIJdUrOQ55UKFJE/5qgzMEFFvk6QztBknL8QTbFvjyB0mt4IoYIFFLWjAHVZAnhZgZQsv sMcMBodQG6SDbC9ImIa22ZcCtJA3Ic2piUY3ytGO8mCicQJDAi46DhV84aQoTalKYxAJAphPBQQY AAcVSdOabmSlOM2pTnfK0xlEAAA7 ------=_NextPart_000_005C_01C37143.22A9B280 Content-Type: application/octet-stream Content-Transfer-Encoding: base64 Content-Location: http://www.cdc.gov/navimages/nav21.gif R0lGODlhjAAIALMAAP///////8zM6wAAmTAwrO/v+eLi85eX1h0dpQ0Nnn9/zElJtmdnwre34qam 21pavSH5BAEAAAAALAAAAACMAAgAAAT/MMhJq7046827/2AojmRpio0gBA1WEPAjHYnMDjgRPPjg BAMCAmGwHBABwaCI6BUbCV1yKVn0ZIjfghFwIAOJXjdauywQQoOhhxQQBogWjZDQKibr3KRRUAi4 FwIJDAcrAQs0BVMHBxIMiIYDB1AtO3djDDyKBISKOzRFa54BohIIWwh3DV+DjSwIAgoJEg4Lng8M bg4FAwquC3dHXbCPh5cBvIwUfA0MPxgCB7KkCUeNSgyAj4USAwuDEwg2XtIDm53I1QR3pRLtCITr rxKtElBWlbJFO5x3vL4SCDRahYlBEWATkrmSoKiAQ2hRCCwIoCCXAh1KKDBAQ+DHgGhSZyo40FFK CAwDBxZEQ7IGBklzplo8UMXK5TyEFmYmDCKRBZlGIymcgbGL58QQAvYlRbbCgCEJKlQUSVpAwCg8 K6oqimp1qdaqUZl6WrrUKdSwZs1aWMqQ64Snas9KBavihN27ePPmjQAAOw== ------=_NextPart_000_005C_01C37143.22A9B280 Content-Type: application/octet-stream Content-Transfer-Encoding: base64 Content-Location: http://www.cdc.gov/navimages/nav12.gif R0lGODlhDAA/ALMAAP///////wAAmTQ0rpSU1MPD597e8nJyx3h4yczM60VFtZmZ1ufn9QC34qam 21pavSH5BAEAAAAALAAAAAAMAD8AAAQ+UMhJq7046827/2AojmRJKQugVkOivhTyzhMx08Jx08NO F75XL6iyEQGGo3LJbDqf0Kh0Sq1ar9isdsvlRgAAOw== ------=_NextPart_000_005C_01C37143.22A9B280 Content-Type: application/octet-stream Content-Transfer-Encoding: base64 Content-Location: http://www.cdc.gov/navimages/nav13.gif R0lGODlhCwETALMAAP///wAAmf///4WFz0JCtaWl2/Pz/+Li9xAQnMrK6yEhpWhowNbW7zExrbq6 51JSvSH5BAEAAAAALAAAAAALARMAAAT/MMhJq7046827/2AoisVonmiqrmzrvlIJz3Rt37gt53zv /8DWLkgsGo+8oURBQGwQBAVySq0WlQOB9hEwaAWDyeOrFBgkXqt6zQ4NG+DAwnkQEBzxgBlKqBgO EgdnbYSFhkNZUhMHDBJmAQQCCxgHgAEMlpADkwEICwoLA1ADDROhioapqixDaRSMEgkCAVl9F4IE BAaNAWNaYQhaXl+zXV+2q8nKIK3FiwkSeLR2lMTQXY1ZTnEJgFm9AlICDsvl5hnNFbABstPI6rwJ 13GRfdzQ31lfg+f954gCSi3iJQDaGE4WKklgQDBMPT1h5E1zl0ugv4vKhkQq0SRAnTuSWTppQaDA IppBCgNIK1AsDsOJkcI0QIWx5qEKeLRMGpZHzpdrEx51GQRHp6MwCr8FYGnUplNCSgIwoXkBiskn UTxMfcqVTdSuYMOm+Cq2rNkOZM+qXTsh7bkIADs= ------=_NextPart_000_005C_01C37143.22A9B280 Content-Type: application/octet-stream Content-Transfer-Encoding: base64 Content-Location: http://www.cdc.gov/navimages/nav14.gif R0lGODdhOgATALMAAAAAmXNzxs7O7zExraSk2xAQnFJSve/v/72950JCtSEhpYWFz////2Njvd7e 962t3iH5BAAAAAAALAAAAAA6ABMAQATYEBBAq704683ppAlzBNVyIMwCDOchrIzDNAuDKqE7d9rH /8Cg5DJICDeFhuJ48SkagBCU8SgoBgCEo/BgUFKAAjUaZRjBTB9zffQ1GINkgV0JGelqgKJrCDH+ XlyAXyp2dWYAaG0WBQlYFY2PelhLGDhzdBZ5mZwZm52gHqGjmpACgHd0hnglcBcJC3cFBgsBmA0F AUa0BmUGASRraiZjYlALDhY1Xw96YHMhvYpCm2KxDLoJRgQOCsuJhYggiNNBboAIFG9/zQZ/p1ho NSJlZypppPmf+WwRADs= ------=_NextPart_000_005C_01C37143.22A9B280 Content-Type: application/octet-stream Content-Transfer-Encoding: base64 Content-Location: http://www.cdc.gov/navimages/nav15.gif R0lGODdhdgATALMAAAAAmnNzxs7O7zExrZyc3u/v/xAQnFJSvb2954WFz0JCtSEhpf///97e92Nj vaen2yH5BAAAAAAALAAAAAB2ABMAQAT/EDxAq7046827/6A3UYigKAJCCY3AKEDQIEwCJAygMLxK C4VGpkbBuQ4AB6NF7AEWwQYB0JgVDBbcgpihLUKYEXhM1jUG5bRanF4EMgOHOnNAghUJGGaQ6OfT YggqAII6RANfDA8GMzcvhglIhThDNgAFUw0TOwcGAgIkKjiICwYOBgePFA85T4oXNDwMBYBztre4 toGDhR+Uhnq9GA44CAlovpYhBQi0GwQMyGS7oY6yKgMuDKKtO8HclcCO4r+FwgYFDAJ2FFuyDAs7 PDDNWGse8V8UiAb2A8jx7IEJSIGTAn0YFEhTmGsMm4YQI0Z8KLGixTIUL2rcuIEaoUEev37psCcM 1jtlHXg4fIUBhyyUYDwKI6ZvATE54wwEYBCAHgI80ixwSfLnSYAFCXCeABjgKACdxy7s2KkHw5Yp tUi8U5HqiwCs1X55IwFKpFAbBoiUMCRJyMcbV57uwHmhQY4lT/x82QHTYYVek14spbIocEFVhjEQ GUuJcStzIJ/KgFdhZ08cbyyk6uu32lsA0Hi8cQnEEDx0KhNf4KJkFhp5POwUWmCXp4J0LIvQDQCT mB+6nTneUSX8XvHjxSMAADs= ------=_NextPart_000_005C_01C37143.22A9B280 Content-Type: application/octet-stream Content-Transfer-Encoding: base64 Content-Location: http://www.cdc.gov/ncidod/EID/images/peer-reviewed.gif R0lGODlhuwESAJEAAP///zwwhcDAwAAAACH5BAEAAAIALAAAAAC7ARIAAAKHhI+py+0Po5y02ouz 3rz7D4biSJbmiabqyrbuC8fyTNf2jef6zvf+DwwKh8Si8YhMKpfMpvMJjUqn1Kr1is1qt9yu9wsO i8fksvmMTqvX7Lb7DY/L5/S6/Y7P64+Bvv8PGCg4SFhoeIiYqLjI2Oj4CBkpOUlZaXmJmam5ydnp +QkaKjpKSlkAADs= ------=_NextPart_000_005C_01C37143.22A9B280 Content-Type: application/octet-stream Content-Transfer-Encoding: base64 Content-Location: http://www.cdc.gov/ncidod/EID/images/spacer.gif R0lGODlhAQABAJH/AP///wAAAMDAwAAAACH5BAEAAAIALAAAAAABAAEAAAICVAEAOw== ------=_NextPart_000_005C_01C37143.22A9B280 Content-Type: application/octet-stream Content-Transfer-Encoding: base64 Content-Location: http://www.cdc.gov/ncidod/EID/images/eid_header.gif R0lGODlhuwEaAMQAAKPM3gFur2KmzQCLqP///wCXnCGbxdDm7HzM1QAyiQqtrgBFl4641QCkmQJZ pQAaeOjx9EyTwrnc5SK0ui5yrd3s8S+GvAF9qvn6+Ty2xe709vb4+PP29//8/Pv7+1jEyyH5BAAA AAAALAAAAAC7ARoAQAX/ICGOZGmeaKqubOu+cCzPdG3feK7vfK8yjyDglChGFg8JIfJwUIqOkaNI OS2oo2tCQAAkrtyRIBE5jCLfxLC7cLgXFtFxEZAu6KQDfH2quB0RIxcOAYUOGwQHf0oEDIQBZiUR jxwmAo8XKRCFAQYkGJwDIwMBFxcYJAOmogQQpheeIxmrIrMDAxosGLcDEyMSvL4iBbcFIggDxIwk HQXOGSgSzh8KDQXLDdkKJwgF2ZEjANkNCD7m5+ZAQiYUQQsiRUhVAA8JDwwiUwlVJloRFXe2nEnD h4CHgGvQXFnj5U6kOxYC4CEgoc2CQCQCOICDwo8bjAQ0OoizhFBEB4wc/2lcduZRrhIXOIXpwymW CA6hRHgwFYDVCAOvELkyZZPALFMeTCC4oOrDiV23hA0rNoJYshPSnAlzVkDqiAPOGijIkKFathMT xinp9k1FhXEN0MmdS7eu3bt48+rdy7ev3xTqgghOcEZwkxH2ijyYiaSI4gdrHEt+sKCgl3gB1ZCw 4Bhfly93OozgnCBKxi9/7oA8oQfiCIkbZwK4U1kEgzac/oiexElkUQ2DejtA4Kd3bk8eOGUiYYDQ q0JFD9QkMaHQqWOveBYloYEXL1MFwInw/quYVVYbuKofwBKAepYEJoS1VqAcAbZwC2wj8BZuNtF/ BXgDEI4JFgaBhAnQBP8G9hyAoBSgKfaOCFfQloZmBExxhwjtTMaPQhjOdgcEc2hw20QCWGRGQxZO aIJHgLz2EQZu4CNSSo8YsoB9lwiHEkXKuTXdCDgVwgoApQTgFAkIJFkOB68UdZRPEqyiSkElQHWB V0vdEolVxogAgXkDLElAM97QN0BcIoDlTSJcoSLCB2l6A8EI+I1zzQhmZQONgIDWoM5j9cATBD8K 1pPUBvY8wI8+k0WGBQFP2ONZhhFGSJIInF3hWUMYEjDGHaaJMMYbpLaBCAqKbASSRgss18ofPzbS Rq3M5ehbrsYN99WQImiQE56lZMeTZcUaGxNDyd5ywX4mcOCdd8+WwEv/mMCYR0wBoqGpnjNmcGUm AQqERQCd81ljX57Z6Hemf+PcGei8L3RQgQYbYLABBxDIK6YGGkCQlAgbQACwv61AwAEG+gY8gsEc bLCqChxIIEEl0fZbAQn9QgBgsBVUgDAJEgCwcQsiK/xwxyWIfPKZCueLAQcOG6RBxPryi7EJGlgs 7835euDBzPiKyTJrErxcQscv3XQ0CRVIIN4JELPQ8cj8Sb00vgxvEPDHwR6MQgcHSIBwBzHnDHAJ PUsANr1w/1DPPhHUPVOHWrQ52Uz6OCCAAHWfrEUVFVSKIYgL/K3hA5uCyNCtbZxxRx0iAHRrBAxY YNECWLf5BkjBabSG/wSL2PZIBH//beojqQvAR49GMoBABABgkPorA/xt37D8WXdBBggcZcpLFURJ wpTY8QKABAZ49QkvCnwwgXdhTnUVRck4g4AEdIrgbfQfhC+efO16RX4DE5RMzjFpfoBA+OVoANcH 3DcwcNz4m0DgA2WUfPIBcztAOwLhgMUwIB4Q2kfZlpeFIpDkgAshQKc4twLHiWA2hLjEAvAxB8rd ZiOXcgGMQPcRCzggExAoXSMeAQANVOAAcoIdAMq2jN4orWXAIkCRetKmJP2JWKZQAnCIcjxadIEp XloBVHpxPF58iSr8yV4BsOStCRyAhsdzRgXcU4AfZiBN0MJTmhBAQ//ReAAu9smfGvVXj8W48ACr YkIREkEZhXRhbozQBwU48EJwVOgNZDjNhpaAmoBgxIKfucPGJEKBE1EuRRsZAgZpVaqW/eFVbvAE ANwAgEHUSiUBYMAC5cWbAJjthT3khJCgQ4IdskICSRrXfZykQ+PJ4hVgA8B3BnC/50WFSU60XvXa tJ4vaYVfB3iZfLoognbJkk7t+hN+WvjCXkIgLePA0hrjtj/PbGBgjTJNh+6RCMVgRI8iwEDTtBCH AxbhUhXCUAqvwA9CRjCRC2BERd5AuSVYZCaa20jn+PM5GY1ERobAkRvgU5JCmKEDHBhYcnrjGVRW LoeuBGInbhkTM+H/LhVGBEAaM+CsNPpyAH/6wHeWASYRSCCN6GImAbgiDA+s6ot6SpO67gOOPm0M P0rogMRa8QEASWAcYdxm3CaZmiq0JnFtugM/NvAGflDADRS46kJFIBKQaPUQI+iABtsQwtWJzqWE wNUSCrGpETBAJH5rGqtkMppCrAZJQbxgsRgqAFgY4K9AmclX+soJPlSAFz9sBS+2QxGgEEWbFyTp KgxQEA2QlBcfkNMJNKCAzk6ALMQ5QWc7672YFuADL9uAZyfA2s5CQAKjZQkCRhsybIrFpABQAGt3 O5Zj9CkDU1OqcIdL3OIa97jI3UtgDEMYUxmmno2xVBbmViBJOaYN/wLY2QgKp4U2wIc0CfhUGvop QShYYiOTK6sJKuIarlqED/v8JG5yA9bm9IqxS4HrDI3TG0/sUFZ4iol1TJqIHFZneOFQxSogq1gk 6ucDkCXPVxRwrSVp4FtcYYmbwGWCD9BHPydjlzWgVQHbNkCWyfXLoAzzgBF0yB4T6sDeGligdRCg QplBYAMzk5mXdSq8FwTNBkeDGhKgAVUWEQirCsrVP8iKdFtdoSHe4IDd5OgNRQmdSHbUqmQZghW8 O1exfNfR7WqniKYQBBJ54rwRbGBa0xJPS5spRVWEyVtcUQVLoLnTX+iUK2tgl7ni4x9vvC3FfAkM Q29MmUohAghtcP9gAutJAnbqDQwUAo2/rkCZgdyTqbXx50T8GcnRBES9lWMyAUJ3UIqoEJQ3FNUj Dl2B3iSWGWcewUR5eAwfjuADsRSTLWthxA8w5QLLmFiWEOvS7/BhzsggRhoB5K1bk2DE47h2tsPK vmyM7KjZMJOyEd0XRZtAxu8sID7aQYExlGbSVpjUjYvAhVElgCX7kgRBLogbzU2og/yOTctWMEJB mEQjXGjVJx8R61KeQMABIDDUcriBYXUg17IoViWGCAs0s8LYqpC4CZbolfNUBYrRRqkJPMAVa7Ov PuhKI1yCi59vj6PN5FYxdQ3k0rlVgAlVQAID3OkiDWmh05leAAX/JJCiCnEINEmRwNCnzgBGIFJE DkASHgAuKosogQNDB4DYGcDggovAk4pzQFJuZDrh7Mis9FVCrVWZgrlvlEjDgmWZmZSkIUCJiBz1 iSqUpwKSMwmJT7xefLI3AJOi6cOKJ4A14pIVaEmjXQpAmKD3ZJT55VxACHrMgebWCMpc5o5FwJjR JbRj2ij9ZUbnVD0sRJKr04ZfdxCAI02lInxSuSOXNGggTJgJtks5N2+XtY+UAEvrrPLuNxkWXpVU gibF5EnDNgouA7xmBmuJS4gXJsnWk8awqIdN9zEXBtrFEpyOGEAi5jx//IPiz+MlMNqUY3O/8IQo SKCNa4BO/fAF/3VDG00zQUpzEJhmTyECGmbwQZMwERg0ZCQwCLECfB9hUCShERFgQgtXCA03ayXQ Ab0RXNuFUcNSPDFxa9YXAEPAcVKyfVDjbE8RDE10CyczZ5+gJkvScucmLiKQFu5SfTolGvgRa9SB VPaXaIKhTUiAdEcXCBKgGGEggCVgafrgIqDSVhDkIlcHGowQUBvRTxvhBp/wBqhGUBnYZK1GOrmB IythAqWkWXiSIybYO6yEd0YyCkmiNDzBCn/HFNTxClhxbPW3RD+EDKrwQzpIAumhFcPwDErxZ3+G NR6WDWuRJkhIAn2yhMpFXY0yIY3yIW2kBBBgTvmAGYqxBoOTaf9fIAZCZgH+dk8MyBBgaAdj+DCp cgERABscsWSuooFi8AgLF2VGpisaYRMfgIwaYSZ29xu8c3HFMgAGoGBIMQpRggAIABSqEAtI0gvV 6CyLtkT6QS0lB0VV0hXl4gyNF4nmx2HrqABXVDbRZBT6MQF9sh8iJhYEsH7oY2L154lzsVyDQUeH YhuCQTCCYRpPSCiREQSmERilogeg+G4kME6egSB8cACOUUnl5XrepQLslQCbgl7kdQG0sQZNF2rM cSupsR0CoBGcsABmonA+oYYnVAIZ4DucgGI7mSw88UN4lR0DMFBDsWZMkQFvo2Cv5GDbwgjpIUXs WDbJ0I4jsEwkBbABMUUfiahTmPcuXtkAiyaQZFmWZnmWaJmWarmWbNmWaRkCADs= ------=_NextPart_000_005C_01C37143.22A9B280 Content-Type: application/octet-stream Content-Transfer-Encoding: base64 Content-Location: http://www.cdc.gov/ncidod/EID/images/second_navbar2.gif R0lGODlhuwEQAIAAAP///zwwhSH5BAAAAAAALAAAAAC7ARAAAAJ/jI+py+0Po5y02ouz3rz7D4bi SJbmiabqyrYdAMfyTNf2jef6zvf+DwwKh8Si8YhMKpfMpvMJjUqn1Kr1is1qt9yu9wsOi8fksvmM TqvX7Lb7DY/L5/S6/Y7P6/f8vv8PGCg4SFhoeIiYqLjI2Oj4CBkpOUlZaXmJmam5yflYAAA7 ------=_NextPart_000_005C_01C37143.22A9B280 Content-Type: application/octet-stream Content-Transfer-Encoding: base64 Content-Location: http://www.cdc.gov/ncidod/eid/images/short_line.gif R0lGODlheAACAIAAAAAAmQAAACH5BAQUAP8ALAAAAAB4AAIAAAINhI+py+0Po5y02otzKwA7 ------=_NextPart_000_005C_01C37143.22A9B280 Content-Type: application/octet-stream Content-Transfer-Encoding: base64 Content-Location: http://www.cdc.gov/ncidod/EID/images/email.gif R0lGODlhDgAJAJEAALi4uN7e3gAAAP//zCH5BAAAAAAALAAAAAAOAAkAAAIglI8pw+0XlmsirjhH 1RLTwBiNZYChBDCBmXJDm6XKbBQAOw== ------=_NextPart_000_005C_01C37143.22A9B280 Content-Type: application/octet-stream Content-Transfer-Encoding: base64 Content-Location: http://www.cdc.gov/ncidod/EID/vol9no9/images/03-0362_1t.jpg /9j/4AAQSkZJRgABAgAAZABkAAD/7AARRHVja3kAAQAEAAAAHgAA/+4ADkFkb2JlAGTAAAAAAf/b AIQAEAsLCwwLEAwMEBcPDQ8XGxQQEBQbHxcXFxcXHx4XGhoaGhceHiMlJyUjHi8vMzMvL0BAQEBA QEBAQEBAQEBAQAERDw8RExEVEhIVFBEUERQaFBYWFBomGhocGhomMCMeHh4eIzArLicnJy4rNTUw MDU1QEA/QEBAQEBAQEBAQEBA/8AAEQgAPQCWAwEiAAIRAQMRAf/EAJQAAAIDAQEAAAAAAAAAAAAA AAAEAgMFAQYBAQEBAQEAAAAAAAAAAAAAAAABAgMEEAABAgMEBggEBAQHAQAAAAABAgMAEQQhMRIT QVGh0VMFYXEiMlKSFBWRQuIGgSNzNLFicrLwweGDJDUWNhEAAgIABQEHBQAAAAAAAAAAAAERAiEx QRIDoWFxgSIyQmLRchMENP/aAAwDAQACEQMRAD8A9nUVVa26pDNNmJAmlc5BVk9UUr5q4F5aWSha QCsL1qAVKQPTF1Q5zJLqk07aFNy7Kla5abYyqg1LlY6pYDKiEFSe+Z4EzF8oAe9zf8KNu+D3N/wo 274z8D/FHk+qOtU9TUPZKXgkBJUThkbwOmI3Clgf9zf8KNu+D3N/wo274ySmpb5g7Sl6YbQDMgG0 yPRri7A/xR5PqgnKkGh7m/4Ubd8Hub/hRt3xn4H+KPJ9UGB/ijyfVFBoe5v+FG3fB7m/4Ubd8Z+B /ijyfVBgf4o8n1QBoe5v+FG3fB7m/wCFG3fGfgf4o8n1QYH+KPJ9UAb1K8p9kOKABJIkLrDKLoU5 aCKNAUZmapmUvmMNwAQQQQAQQQQAQQQQAlUnmecoU6WwzhGFSrTitnMWRlVAqF1jpdk2qSMSU29r AmdpEatS1zFbpNO6ltoiycicUr7oyqhD6qx3OXhXJGLLuxYEztIgDmWriK2boZ5alSaxU1FX5Rvl 4hqjF50VtURy3lhSlpSrtCcjOdwnHfswSq6m0n8tN5J+bpjN15GzpXjbo7zgnA5UgnndTJRT2E3S 1J1xZlq4itm6K6pOLndSMRT2E93qTE8k8RfxG6FPSjDAoUATmKs6t0Rfp65ihNYpxJSEhWEXyURL 5emOqZOE/mLuOkboc5l/0Cv0m/4oiXbURqwhGnzHGG3FOHEpIJkBeR1RZlq4itm6KKRomlaOYsTQ mwEauqLsk8RfxG6NkO5auIrZugy1cRWzdHMk8RfxG6DJPEc+I3QBtctEqRAJnaq0/wBRhqFOXSRR JxKsSVTUrrN8Xeop+KjzCALYIr9QxxUeYRz1FPxUeYQBbBFXqKfio8wg9RT8VHmEAWwRWH2SCQ4k gXnELIIAXqaetddJZfykESAFpnrujGr0Oh6oLq5uJSmZRNIxBtNt842qqjdfXiQ+tpMpFKSb9Ytj E5gwoPVIeWXVpSntd0TDabZCAMLmNO02wFpBxYxaSTr1xo/Zv7up/TT/AHQlzT9sP60/5w79m/u6 n9NP90b/AGPS+5Ho4/57fd9BupQF87qQZ2ITcSNCdUTyG/5vMrfEKptLnO6kKEwEJ0kaE6oUrads upR2gnDOQUZTmemOfEpSR52Z3NK6raqnGWF5bbdmlRMxOZmY9RXkn7emb8lqfxRHi6xAQ+6lNwOm 3QI9pX//ADv+y1/FETmUbV2no5K1XHxtKHauIjSMoNKyTitQn5lauuLchH83mVvimkp2lUrRKTMo BNp1dcFUKalp1vrQopRoBMyTYNMaPPngM09E0/UJbWpYThUogKNpBAtnPXC1TTIZ5uKdBVlhrFKc rTPwy1RH7arxV17iQxk4GiZ4yuc1Ji3mSEr56EqExkjWPFqjm5/JBq1XXBqGaDqQnkL6RcELvt0n XCqXKb0yXGa9xxJUtOdgJAtTinO2zR/rDimlHkbrbSSpWFYSkTJNpipVQ+lE0UzSiJ9jLULSR0XX x0IccRSLbbCq0zIsWUyVMjELparpRzEzktlqtW42B30JClG1Rtn0CUTdeqXGcJQ3ORBQG1lBukLU zEdFVVBpDYYaJAkvsLCbz3RLVAhUoU6m8xXMVpbJwiaZSIwnrthpir5fTtJbdqA8s2hSk9ohRssA hddRWG5hiy45a+ifyw3TvsloGqaSHtIQ2ojovRAEBXUCnjUJUksIaOMgXEqRIEfjBFgVTmoK0oOS lohf5agJlSZWYbboIAuq6T1QSMxTYTPumU57oTqeSsuoU44t113CAQFYAspGEWAdEasQdllLxTlh M8N8paIA86eUNVDmQ9SvYE4lKVmCU09yRw6YlR0KOXqUulpahC3JJIxhVk+lBlE0e36PV4JjXLRq +XZEh7dnq/dYvxw92z8Za4tp90+Jpb9rjdt1jIu9lp6sqqajObfcElDME5C7upEKDlcnFf8AEfNw Cs0Wi06UxtUGD0qcGIpme/Yq/wDxKGYldNvQyeY/8/RvuFTtI+CqeJWaNCbNGmUodUw6+yqjcp3x ThOAdtImECaZdiegRW97dmu4/Vd85ku5O2Nily/Toyp5cuzivlC3y6m3vhTuj2zl4GZT8gpFtJUr OZJsyy5PCAZDRFFb9uUaUJwIefxE4hjJNgmNGk2R6CCKp0MqZUZ6Hn+V8qRTVRUzTPU4UMKnFOBV neuKdcPVHIqSpez3XHS5hw4gqVg6hGlBGcJ7epbbp80z8itllthpLLQkhAkBOe0xZBBFMhBBBABB BBABBBBAH//Z ------=_NextPart_000_005C_01C37143.22A9B280 Content-Type: application/octet-stream Content-Transfer-Encoding: base64 Content-Location: http://www.cdc.gov/ncidod/EID/vol9no9/images/03-0362_2t.jpg /9j/4AAQSkZJRgABAgAAZABkAAD/7AARRHVja3kAAQAEAAAAHgAA/+4ADkFkb2JlAGTAAAAAAf/b AIQAEAsLCwwLEAwMEBcPDQ8XGxQQEBQbHxcXFxcXHx4XGhoaGhceHiMlJyUjHi8vMzMvL0BAQEBA QEBAQEBAQEBAQAERDw8RExEVEhIVFBEUERQaFBYWFBomGhocGhomMCMeHh4eIzArLicnJy4rNTUw MDU1QEA/QEBAQEBAQEBAQEBA/8AAEQgAQACWAwEiAAIRAQMRAf/EAI0AAAMBAQEBAAAAAAAAAAAA AAAEBQMBBgIBAQEBAQEAAAAAAAAAAAAAAAACAQMEEAABAwIEAgYHBwEJAAAAAAABEQIDAAQhMRIF IhNBUWEyolNxkdFCkhQVgbHBcuIjBjOhUmKykzR0JTYRAAMAAQMDBAMAAAAAAAAAAAABAhEhMQNx IjJBYdFCcgQ0/9oADAMBAAIRAxEAPwD2U026NkeIYWOYDwknvD151jNuVyJnRta2MMwx4icAfxra eXdGyPEETHsBVhOChBh3s6mXXPdeSlRHxKiaj3WquVANfUbrrb6q+Xblf6g2JnMcinS1QB2pSeif zR8A9tObW14uH63auAJgnTU08S2EZM3q9N0bWRgY9rdRUImWCH01v9RuutvqqbeB53+bQ7SeW3FF 91laaJ/NHwD21svKTA99Ruutvqo+o3XW31Ujon80fAPbXy5z2lDOF/Iv3GtBQ+o3XW31UfUbrrb6 qnx8yRofHOHNORDB0YddfWifzR8A9tAPfUbrrb6qPqN11t9VI6J/NHwD20aJ/NHwD20BasLiWcP5 hB0kIgTOm6m7OHhsut2oqMUToqlQBRRRQBRRRQBRRRQCNxPubZHiG3a6NvdJPeHTkcKmXXOfeSlR FxKB3j3W51Tnm3NsjxBC17G90uKagmPvVMuua+8lK8viywce61VoDPlz+d4RTm1teLiTW/XwBMAO mpG6XF1Z2vNikBeXBo1NCBemtf4peXd1Pcm5eH6GN0o0NRSVyqbXY2Wopy7+q0Pq8Dzv82h2k8tu KL7rK05c/neEVneBx3+bS7SeW3FAfdZ11rol83wikeKJZzlz+d4RTXytv9HfIY2mTlPJegUuxxpb RL5vhFPY/RHrieS/H7DU8my6hEfb2Sm1aWyaQrkGkH3jTPLn87wil9vbIbVpEmkK7BAfeNM6JfN8 Iq1sjDnLn87wijlz+d4RXdEvm+EUaJfN8IrQUtna8Nl1u1lRiidFUqnbQHBsup2rEdAHR2VRoAoo ooAooooAooooBG4uNxbK9sEAkY1EJUKExTGpO4yTia4kakZbxAEaiulueVV7mbcGPIt4WyNGIJOY QL051G3QyufdEgMGaHiJ4WKOhKLcETchPyFkndINY4TgFxqj/DP611+Vn3mkd0/24/OPxp7+Gf1r r8rPvNX+wkpePY9MfzV+Xwb3ged/m0O0nltxIX3WdorXRP5o+D9VZXged/m0ODTy24kL7rO0V2aQ wN1SztYDgFZn4q5R4o87J247vcWdxyI2iVzQC5xAaMcQmJr0EDzJ/HhI4I59u5xHaQTXjtzkbLev e14kBDeIDTkOqvX2v/m2f8Y/5TWcqwp6na+OZ44pb0tSbt7ZTatLZA0K7DSvvHpWmdE/mj4P1Utt 7ZTatLXgBXYaV94/4qZ0zea34P1VS2RwOcu7c5rI5Gl7yjVagyXr7Kzu/nrSaCGRzFnKKAqAEA9P bXbC/tpdxhgZcslk1Hga09DXLipFbb+pvbFChVyHP3mVNNqkjcaajVoZo7Wc61fqjALRpOJA7a7G d3LA58LgVQsEoB9K4182wcLSfW5eOPEDSnEO01i2GwbEyOa/keWqWyyLq4se8eyrA1KNyQGJjwc9 Lng4ekIhrv8A2PCOU8uIGo80AA49lZSQ2hfGG3c6pymuYVAKtz6q68bdIrZLxz3tBJJJJYFVcsMq GH076ooDIXoSASZRki5J105DBI+JrpXSRyEcTNap9qVNZ8iXR28e4yjINAJBcSf7x66cftReEN1M nCg1YcJ/GgN2Ru1yxcx5CMIJOIUuyP2UVjHZHRNa8+TFrP3V401Oci/2UUBpeT3kRb8tCJQhLlXo 6BUvcbLcJnTSRxsbE8ai57kIGlq4DJEq/XzINUbmoHKCNJyOGRoDx11tdxdRiKKSHUXYfujHTnTW w2c21yTOmfC/mhoAbK3BCc1p8Wt9zDJ8lBzCuOohqEnFFRa66xuXEarKAhoy1FDl2449dbTdaMtc lKHC8XqKz2G5XF/Jf2rInMe0NaDIDkADi30UtLZ3E0yTm21RhzdJkCgqFwdXpbNrmQBro2xEEgMb kgKL9tcdYWT5OY6FhepdqIxU4k1k9uMehB464/j13NOXRPt2h2TeYBkMcquwcxm1jb/2zMITGola i6c+utZbS6ZK75eyt3NavKc444qq49NNWtjHyw+4gjbcY6i3HMaVUk5ild2/Ut8lOVL2nYi2m3bv HC1kTYZGBTqD1xJXor4urDfRG4yOhjjeNGkFe9gndJr08cbImCONoaxuTRlRLFHK3RINTVBTtHoo tCDxu07PPY7jbzufbuDdSNZK3U5WluH2mrO6WG43k9vLDE1vIUkPeMVLSMvRVNu3WLXiRsDGuGRA Tp1ffTNY0m8vcu+SreWT7GymFs9l5p1SkEtjJ4dOXF11oNrtQNI1pmmspTlFaQKfTrfDGTh7vG7D 0Y1wbXagINYGXfNOUUAmNstQQ4a1GR1lQlafJs8yX/Uf7aYooDBtqxrXtDpFeiuL3F3DkhXCit6K A//Z ------=_NextPart_000_005C_01C37143.22A9B280 Content-Type: application/octet-stream Content-Transfer-Encoding: base64 Content-Location: http://www.cdc.gov/ncidod/EID/vol9no9/images/03-0362_3t.jpg /9j/4AAQSkZJRgABAgAAZABkAAD/7AARRHVja3kAAQAEAAAAHgAA/+4ADkFkb2JlAGTAAAAAAf/b AIQAEAsLCwwLEAwMEBcPDQ8XGxQQEBQbHxcXFxcXHx4XGhoaGhceHiMlJyUjHi8vMzMvL0BAQEBA QEBAQEBAQEBAQAERDw8RExEVEhIVFBEUERQaFBYWFBomGhocGhomMCMeHh4eIzArLicnJy4rNTUw MDU1QEA/QEBAQEBAQEBAQEBA/8AAEQgAPQCWAwEiAAIRAQMRAf/EAJIAAAIDAQEAAAAAAAAAAAAA AAAEAgMFBgEBAQEBAQEAAAAAAAAAAAAAAAACAQMEEAACAAUBAwgIAggHAAAAAAABAgAREgMEITET BUFRYZHRIlMUMkJSYpLSFQaBonGxcoKywiM18KHBM3ODJREBAAIBAgUCBwAAAAAAAAAAAAERAhID ITFBYaFxMoHB0SJiEzP/2gAMAwEAAhEDEQA/AO4yky2KnGcJKdQMtZkc4OyEr2TxDHCWrrJW1RrU akAiXQNsM5thLtxC2RuZA9ycqhMa7RGZnWEtCyHvm9aAcqSRTIsuhPLKAu87l+IeodkHncvxD1Ds hCeF7kStW8K9ftWu6Q7AEKZGUieSMmaiw4M/IOguz+Hsj3zuX4h6h2Rn8bxcbGyMQItKMxLzMxoy 8/6Y9nhe5GY5XFh/zuX4h6h2Qedy/EPUOyEJ4XuQTwvcig/53L8Q9Q7IPO5fiHqHZCE8L3IJ4XuQ D/ncvxD1Dsg87l+IeodkITwvcgnhe5Aa2Hk5FzICXHJUg6SHZGlGHwry/nF3VNVLbOaNyAIIIIAg gggCCCCARz/p+8t+aP8AU13aicyOXZyRmZRwUaw2LNgRcKqJlgalqAB2RrZt5LT2w1jfkzkZA0y/ CMzMv7w2jasG0xrqVhSAwZdSQNZwFO+bwrnUPmizGulsqyCjr39pAlsPTFLXL6KXZUCqCSam2D92 E+GcbGXxOxjLZKqzmVwnTRSdkozL2z6KjGZ4xHLm0PuEyysIyJkToNvpJEd83hXOofNEvuKfmsKn UzMp7PSSIzyfZT4j8sTt+1kjfN4VzqHzR4cin0kcfppH80ezyfZT4j8sMYGFZyTefJSdxWCilmkF pB5Jc8bllpi2FhkhvRR2ltlSf5o93zeFc6h80KYYuLkZa2wCBcI7zGcgzAch5Ibnk+ynxH5Y2JuL Bvm8K51D5oN83hXOofNBPJ9lPiPywTyfZT4j8saGuGXC2WoKMvdbVgJfrMbUYnDmuDKBuhFWk6hj /qBGxvrPtr1iAnBEN9a9tesQb6z7a9YgJwRDfWfbXrEG+s+2vWICcEQ3togkOsht1EEBTlPmKyDG UMDOssNBs94RmZ7ZjtZF9Vt3AHBK6gipZFR09MamVZv3Au5um1Lb0zIjLzbN9WspfvbyQeTDQlal lUYDHzOIWlS7Z3jOaWUkKspylKcIfb394xf2j/C0OXdLF0dD/rMJ/b394xf2j/C0XnjEYTXXF6dj +e76fV0P3DM5WFIyMzr+8kRou+L+URL7hE8rCB5z0eskU5ErNouoLtoFWsjU/jHHa5PPJfiWc+Bb Uza69wkKoCgabZmNL7Yyny8S9fdaGN2VMwdirzRy/E3yH3e+AEp0yJPNzsY6P7P/ALdd/wCY/wAK xW9jWPHnbrox/TGfWcqKYiucnMpen+q3ID6z88NUXfF/KIVxEVsnMmSJXW2Ej1n5oa3dsbWPxHth jyhxFF3xfyiCm5s33+SxgZfFMzzTWrJCWlejUszGRlOc46DjXDsTH4a920pDTUTLE6MwB2xmWWmu 68tvLGImeGqLhBwVUm7f3aAGd2kdzT0/whhGwxZtF8ytD3lvi202BI2HUerLZzwtZUpZtMi71qF7 jksp02Ec0PC/3QBj2lIOg3fdpBAHPLuziko3bONu5ebJCCRuBSSDKqbUyGgUwOcehSmYaLYpZkt1 klZzq00ie/uM1t7lqzMS3gCMTt5CV00gGbfcGvHtajYQZtPUz00gxWyYzKL31Ci03ogpSJCU9sjD NnK4bYsqL19LramsqASCTLQCF0ybzOu8xbFAksgD3VJ73JzAckPm5w07UU/9Z+WApGVw8uchWTcL bNZA0nUkgRLpgiYbDN4lUG5Fs1ig0zLLLSmCAayLCZFvduSFmDp0QqeD4bWxau13EUkoCxFIbWQp lpD8EBz7cMCsLIw0ZWakyuuQqak1d7Qyg+lY2JeN3GwAGQndOlxqpcrSqiy/9E8028r3tTVyqlOk z/wIP/AmPS/PLlnONm6438VRqqdN11r5rrfDlzTPiOOV3f8Atf1mcifpbDFGRwdLVw+WwluoCCpN 1lOzX1oe4d5Kq75Wr1Z1c2uyesPxkdvCXPXeE27hld4ejMomgN5tvRrF9nEfFVreBi025kkLfIFW nTthjiX0zfJ5yreU92mrZP3Ylwj6dun+nzomK5z2/jDL8vKvu09dPgvb4JiXL9w3sWhSag+8Yl2J mSe9Flz7f4XSzLYqcA0zdtvJ60akEIvp4S5puBWxKjhqMZiVxrjDpmUD6dcbNzh1jJsi3kh3VpFr ZuMRMa8/PDkEJ7+VTq4Xq7WVxOG4WGzNj2grNoWJLGXNNpw1BBBIggggCCCCAIIIID//2Q== ------=_NextPart_000_005C_01C37143.22A9B280 Content-Type: application/octet-stream Content-Transfer-Encoding: quoted-printable Content-Location: http://www.cdc.gov/ncidod/eid/eidscript.js function getFooter(){ //document.write('

'); //document.write('

URL: '+ window.location.href +'
Updated: = '+document.lastModified+'
'); //document.write(window.location.href); document.write(''); document.write(''); document.write(''); document.write(''); document.write(''); document.write(''); document.write('

URL: '+ = window.location.href +'

'); } ------=_NextPart_000_005C_01C37143.22A9B280--