Children and ADHD

Is it ADHD?

Learn about the symptoms of ADHD and what to do if you’re concerned that your child might have this disorder.

Attention-Deficit / Hyperactivity Disorder (ADHD) is one of the most common neurobehavioral disorders of childhood. It is usually first diagnosed in childhood and often lasts into adulthood. Children with ADHD have trouble paying attention, controlling impulsive behaviors (may act without thinking about what the result will be), and in some cases, are overly active.

Signs and Symptoms

It is normal for children to have trouble focusing and behaving at one time or another. However, children with ADHD do not just grow out of these behaviors. The symptoms continue and can cause difficulty at school, at home, or with friends.

• have a hard time paying attention
• daydream a lot
• not seem to listen
• be easily distracted from schoolwork or play
• forget things
• be in constant motion or unable to stay seated
• squirm or fidget
• talk too much
• not be able to play quietly
• act and speak without thinking
• have trouble taking turns
• interrupt others

Diagnosis

Deciding if a child has ADHD is a several step process. There is no single test to diagnose ADHD, and many other problems, like anxiety, depression, and certain types of learning disabilities, can have similar symptoms. One step of the process involves having a medical exam, including hearing and vision tests, to rule out other problems with symptoms like ADHD. Another part of the process may include a checklist for rating ADHD symptoms and taking a history of the child from parents, teachers, and sometimes, the child.

Get Help!

If you or your doctor has concerns about ADHD, you can take your child to a specialist such as a child psychologist or developmental pediatrician, or you can contact your local early intervention agency (for children under 3) or public school (for children 3 and older).

To find out who to speak to in your area, you can contact the National Dissemination Center for Children with Disabilities by logging on to http://www.nichcy.org/ or calling 1-800-695-0285.

The Centers for Disease Control and Prevention (CDC) sponsors the National Resource Center, on AD/HD: A Program of CHADD – Children and Adults with Attention-Deficit/Hyperactivity Disorder. Their Web site has links to information for people with ADHD and their families. The National Resource Center on AD/HD operates a call center with trained staff to answer questions about ADHD. The number is 1-800-233-4050.
In order to make sure your child reaches his or her full potential, it is very important to get help for ADHD as early as possible.

cdc

Blood Donation

Donating Blood Questions and Answers

The blood safety system established by FDA is dependent upon: 1) accurate and complete educational material for donors so that they can assess their risk; 2) sensitive communication of the donor screening questions; 3) donor understanding and honesty; 4) quality controlled infectious marker testing procedures; and 5) appropriate handling and distribution of blood and blood products for patient use. Because of the improvements in donor screening procedures and the use of a variety of new tests in the last few years, the blood supply is safer from infectious diseases than it has been at any other time.

A person’s suitability to donate blood depends on two general considerations: that the donation will not be injurious to the donor, and that the donated blood will not be unnecessarily hazardous to the recipient. Regulations enforced by FDA require that as part of the suitability criteria, a donor be free from any disease transmissible by blood transfusion, in so far as can be determined by health history and medical examination.

Why are good donors being deferred because they have visited the U.K.?

Regulations enforced by FDA require that as part of the suitability criteria, a donor be free from any disease transmissible by blood transfusion, in so far as can be determined by health history and medical examination.

FDA periodically issues guidance providing recommendations to decrease the potential for transmission of infectious disease when new information or testing methodology becomes available. In August, 1999, FDA issued guidance for Industry entitled, “Revised Precautionary Measures to Reduce the Possible Risk of Transmission of Creutzfeldt-Jakob Disease (CJD) and New Variant Creutzfeldt-Jakob Disease (nvCJD) by Blood and Blood Products”. After reviewing the comments received, FDA further revised the guidance on November 23, 1999. A copy of the most recent revised guidance titled: Guidance for Industry Revised Preventive Measures to Reduce the Possible Risk of Transmission of CJD and Variant CJD by Blood and Blood Products is available.

The guidance states that, “FDA believes that donors who have resided in the United Kingdom (as identified by questions in section III.D) may be at risk for exposure to nvCJD. As a precaution, FDA recommends that donors who have spent six months or more cumulatively in the United Kingdom from 1980 through 1996 (i.e., from January 1, 1980 through December 31, 1996) be indefinitely deferred.”

FDA takes a conservative approach to ensure the safety of the Nation’s blood supply and therefore, issues guidance relating to both known infectious diseases as well as potentially emerging diseases. This conservative approach may result in the deferral of otherwise acceptable donors.

FDA recognizes that the scientific technology for determining individuals at risk for CJD and nvCJD, and detecting the infectious agents in tissues and in products, is continuing to advance, and that there may be a need for future updating of the relevant guidance.

How many people have died as a result of nvCJD?

Cases of variant CJD are very rare, and most have occurred in the United Kingdom. The latest information (October 2, 2000) issued by the Department of Health, United Kingdom indicates that there have been 73 confirmed cases of vCJD in the United Kingdom. These cases have all been diagnosed since 1995. France has reported two cases. The Republic of Ireland reported one case in 1999. No cases have been recognized in other European countries, or in the United States.

Where can I obtain more epidemiological information or statistics regarding nvCJD?

Further information about the disease can be obtained from the Centers for Disease Control and Prevention (CDC):

Centers for Disease Control and Prevention
1600 Clifton Road
Atlanta, Georgia 30333
Phone: 404-639-3091
Website: http://www.cdc.gov/

Is it true that individuals diagnosed with hemochromatosis can now donate?

FDA has always allowed individuals diagnosed with hemochromatosis to donate blood. However, FDA is now allowing variances to the requirements that blood establishments 1) label such blood with the donor’s disorder, and 2) have a physician examine the donor at the time of donation if less than eight weeks has passed since the previous donation. These variances are specific for individuals with hereditary hemochromatosis.

The existing regulations require that blood establishments using blood collected during therapeutic bleedings label these units with the disease that necessitated the therapeutic bleeding (21 CFR Part 640.3 (d)) and limit the frequency of whole blood collections (21 CFR Part 640.3 (f)). FDA has the authority to permit exemptions to the blood regulations under the provisions of 21 CFR 640.120, Alternative Procedures.

In August 2001, FDA issued Guidance for Industry: Variances for Blood Collection from Individuals with Hereditary Hemochromatosis providing recommendations to blood establishments that wish to apply for these variances. Refer to the guidance document for the conditions blood establishments must meet in order for us to approve the variance requests. Not all blood establishments have applied for these variances. Ultimately, it is the decision of each blood establishment to apply for any variance.

In summary, when a blood establishment desires to use blood from a therapeutic hemochromatosis bleeding for transfusion purposes, the blood establishment must either 1) label the collected blood with the donor’s disorder and have a physician examine the donor on the day of donation if less than eight weeks has passed since the previous donation, or 2) apply for the variances.

I was diagnosed with hepatitis at a young age. Am I still deferred?

Under Title 21 CFR 610.41, persons with a history of a positive (confirmed) test for hepatitis B virus surface antigen (HBsAg), regardless of age at the time of the positive test, may not serve as a donor of human blood, plasma, or serum.

Donor suitability in regard to a history of viral hepatitis at the age of 11 years or later should be assessed by asking the donor for recollections of experiencing physical signs or symptoms of clinical hepatitis (e.g., “yellow jaundice,” or other pertinent physical evidence of clinical hepatitis), or having received a diagnosis of viral hepatitis from a physician. Records of laboratory data (e.g., serology, ALT, AST, bilirubin, prothrombin time), if available, may assist the medical director in making the donor suitability determination in the face of an inconclusive history. However, certain isolated laboratory test results should not be considered equivalent to a history of viral hepatitis. In particular, a history of an elevated alanine aminotransferase (ALT) or a reactive test for antibodies to Hepatitis A Virus (anti-HAV) or Antibodies to Hepatitis B surface antigen (anti-HBs) need not be a cause to defer a donor.

If a clinical history or diagnosis of viral hepatitis occurring at age 11 years or later is established, the donor will should be permanently deferred, and blood and blood components collected from the donor should not be used in the manufacture of products intended for transfusion. If viral hepatitis infection before the age of 11 is suspected to have occurred, the donor should be temporarily deferred and blood and blood components collected from the donor should not be used in the manufacture of products intended for transfusion until the circumstances are investigated and a medical opinion rendered on the significance of the history, and the conclusion drawn that there is no history or diagnosis of viral hepatitis after age 11.

Please be aware, however, that a blood center may voluntarily elect to adopt more stringent donor deferral criteria in its Standard Operating Procedures (SOPs) than those required or recommended by the FDA. Under these circumstances, FDA does require that the blood center follow its own SOPs.

There are two relevant documents available that can further clarify FDA’s current donor deferral criteria:

Memorandum to blood establishments: “Exemptions to Permit Persons with a History of Viral Hepatitis Before the Age of Eleven Years to Serve as Donors of Whole Blood and Plasma: Alternative Procedures, 21 CFR 640.120″ – April 23, 1992.

Memorandum to blood establishments: “Donor Suitability Related to Laboratory Testing for Viral Hepatitis” – December 22, 1993.

I was recently deferred for an inconclusive Hepatitis B core test. Can you explain the reasoning behind the deferral?

Antibody to hepatitis B core antigen (anti-HBc) is an antibody that generally appears close to the onset of clinical hepatitis and may persist for years or life. In the mid-1980s, U.S. blood banks voluntarily began anti-HBc screening of blood and blood components for transfusion. This test was intended as a surrogate non-specific test for hepatitis C (formerly called non-A, non-B hepatitis). In addition, studies of transfusion-associated hepatitis B prior to anti-HBc testing indicated that hepatitis B still occurred, despite the use of a sensitive test for hepatitis B surface antigen (HBsAg).

On September 10, 1991, FDA issued a memorandum to all registered blood establishments providing recommendations and guidance on testing for anti-HBc, donor deferral, product labeling and quarantine. FDA recommends that blood and blood components found to be repeatedly reactive for anti-HBc should not be used for transfusion. Studies have demonstrated that transfusions of blood that is reactive for anti-HBc, but negative for Hepatitis B Surface Antigen, were associated with some cases of post-transfusion hepatitis. The numbers of transfusion recipients developing hepatitis in such circumstances are, indeed, extremely low, but FDA is committed to ensuring the safest blood supply possible. See the September 10, 1991, memorandum entitled “FDA Recommendations Concerning Testing for Antibody to Hepatitis B Core Antigen (Anti-HBc)”. In addition, FDA recommends that donors having a repeatedly reactive test for anti-HBc on more than one occasion be indefinitely deferred until a licensed confirmatory test is available for use. At present, there is no licensed confirmatory test available. Please note that the FDA does not prevent blood banks from developing procedures more stringent than FDA’s regulations and recommendations. When a blood bank incorporates a standard operating procedure, the FDA requires the blood center to specifically follow the procedures that the center has developed. Therefore, the blood bank where you donated may be following a standard operating procedure that is more rigid than current FDA recommendations.

If you have had only one reactive test for anti-HBc, then you may be eligible to donate blood again, provided that all other donor suitability criteria are met and the blood center’s procedures are followed. Again, the blood bank where you donated may be following a standard operating procedure that is more rigid than current FDA recommendations and, for that reason, you may be excluded from donating.

The reasons for testing blood donors for anti-HBc were reviewed in January 1995, when the National Institutes of Health held a Consensus Development Conference for Infectious Disease Testing for Blood Transfusions. The panel of experts, who are not government employees, based their report on presentations by investigators working in areas relevant to the consensus questions, questions and statements from the conference attendees, and closed deliberations by the panel. The panel’s recommendations included continuing testing for anti-HBc as part of the donor screening process, both to prevent hepatitis B and as a surrogate marker for HIV risk. The panel also emphasized the need to improve the specificity of screening tests for anti-HBc. FDA certainly will continue to cooperate in this effort, even potentially allowing a re-entry scheme in the future. In December 1998, a re-entry algorithm for anti-HBc was discussed at FDA’s Blood Products Advisory Committee (BPAC) meeting. However, after reviewing scientific data, this panel of outside experts, which provides scientific advice to FDA, did not recommend the re-entry algorithm at that time.

Individuals can be perfectly healthy, give a negative history, and yet be carriers of one or more hepatitis viruses. Unfortunately, the presence of hepatitis viruses cannot always be detected with absolute certainty by any presently available means, including history, physical exam, or laboratory tests. While some FDA requirements and recommendations may seem inconvenient or not reasonable in all situations, they actually represent measures taken to ensure that blood and blood products are as safe as possible. There is no doubt that some persons, without hepatitis or other infectious diseases, are deferred as a result of established criteria.

If you would like further information about the NIH Consensus Conference, a summary statement can be obtained from the NIH Consensus Program Information Service, P.O. Box 2577, Kensington, MD 20891, phone 1-800-644-6627.

More recently, on October 21, 2004, FDA discussed and obtained endorsement at our BPAC of a candidate re-entry algorithm, which is now being studied.

Recently, I was informed by my local blood bank that I would no longer be able to donate blood because of an indeterminate test result for HIV. My physician has tested my blood and determined that I am negative for any infectious diseases. In light of the fact that there is a reported blood shortage, how can I be deferred if it has been determined that I do not have HIV?

The Food and Drug Administration (FDA) is responsible for establishing policies which will maximally protect the recipients of blood products. Part of the protective strategy includes screening of all blood and plasma collections for markers of transmissible infectious diseases. Unfortunately, current technology does not permit perfect testing, i.e., 100% sensitivity with the absence of false positive tests.

The possibility does exist for indeterminate or inconclusive test results to occur when HIV-1 testing is performed. FDA recognizes that the deferral of donors who have had a repeatedly reactive screening test result may exclude individuals who probably have little risk of HIV-1 or other viral infection. FDA’s intent is to eliminate blood that has the potential to transmit HIV-1 viral infections from the nation’s blood supply. Although the need for donors is great, it is in the best interests of the recipients of such donations to err on the side of safety. Unfortunately, once an indeterminate or inconclusive result is obtained, the donor should be indefinitely deferred.

FDA established a mechanism for previously deferred donors to re-enter the donor program. Under certain circumstances a donor with an indeterminate Western Blot may be tested for possible re-entry after a six-month period if an unlicensed Western Blot was used for the original test. A licensed Western Blot must be used for re-entry. If a licensed Western Blot was used for the original test, a donor with indeterminate results may not currently be considered for re-entry.

Although it is highly unlikely that individuals with indeterminate or inconclusive test results are actually infected with HIV, FDA is erring on the side of safety to assure that the nation’s blood products are as safe as possible. Although this policy may disqualify some healthy individuals from donating blood, it has proven effective in protecting the nation’s blood supply.

FDA

Tips to Reduce Salmonella Risk

Tips to Reduce Your Risk of Salmonella from Eggs

Eggs are one of nature’s most nutritious and economical foods.

A bacterium, Salmonella Enteritidis, can be on both the outside and inside of eggs that appear to be normal, and if the eggs are eaten raw or undercooked, the bacterium can cause illness.

What can I do to reduce my risk of getting Salmonella Enteritidis from eggs?

Eggs, like meat, poultry, milk, and other foods, are safe when handled properly. Shell eggs are safest when stored in the refrigerator, individually and thoroughly cooked, and promptly consumed. The larger the number of Salmonella present in the egg, the more likely it is to cause illness. Keeping eggs adequately refrigerated prevents any Salmonella present in the eggs from growing to higher numbers, so eggs should be kept refrigerated until they are used.

Cooking reduces the number of bacteria present in an egg; however, an egg with a runny yolk still poses a greater risk than a completely cooked egg. Undercooked egg whites and yolks have been associated with outbreaks of Salmonella Enteritidis infections. Both should be consumed promptly and not be kept warm or at room temperature for more than 2 hours.

What are the specific actions I can take to reduce my risk of a Salmonella Enteritidis infection?

1. Keep eggs refrigerated at ≤ 45° F (≤7° C) at all times.
2. Discard cracked or dirty eggs.
3. Wash hands, cooking utensils, and food preparation surfaces with soap and water after contact with raw eggs.
4. Eggs should be cooked until both the white and the yolk are firm and eaten promptly after cooking.
5. Do not keep eggs warm or at room temperature for more than 2 hours.
6. Refrigerate unused or leftover egg-containing foods promptly.
7. Avoid eating raw eggs.
8. Avoid restaurant dishes made with raw or undercooked, unpasteurized eggs. Restaurants should use pasteurized eggs in any recipe (such as Hollandaise sauce or Caesar salad dressing) that calls for raw eggs.
9. Consumption of raw or undercooked eggs should be avoided, especially by young children, elderly persons, and persons with weakened immune systems or debilitating illness.

Who is most at risk for getting Salmonella Enteritidis?

The elderly, infants, and those with impaired immune systems may have a more severe illness. In these patients, the infection may spread from the intestines to the blood stream, and then to other body sites and can cause death unless the person is treated promptly with antibiotics.

How do I know if I have Salmonella Enteritidis?

A person infected with the Salmonella Enteritidis bacterium usually has fever, abdominal cramps, and diarrhea beginning 12 to 72 hours after consuming a contaminated food or beverage. The illness usually lasts 4 to 7 days, and most persons recover without antibiotic treatment. However, the diarrhea can be severe, and the person may be ill enough to require hospitalization.

CDC

Frozen Mamey Fruit Pulp Recall

URGENT Nationwide Frozen Mamey Fruit Pulp Recall
La Nuestra and Goya brand pulp may put consumers at risk for typhoid fever illnesses

Fast Facts:

• The U.S. Food and Drug Administration is warning consumers not to eat frozen mamey fruit pulp sold under the La Nuestra brand by Montalvan Sales Inc. Ontario, Calif., or the Goya brand by Goya Foods Inc. Secaucus, N.J..
• An investigation by the Centers for Disease Control and Prevention (CDC) and state partners showed an epidemiologic link between an ongoing outbreak of Salmonella Typhi infections and the products.
• The CDC reports that at least nine people in California and Nevada are ill with typhoid fever, caused by Salmonella Typhi.
• Ill individuals have reported consuming mamey fruit pulp, including mamey fruit smoothies at juice stands.
• Goya Foods Inc. and Montalvan’s (La Nuestra) have voluntarily recalled the products.
• Consumers who have the recalled La Nuestra brand or Goya brand frozen mamey pulp in their homes are urged to discard them immediately.
• Consumers also are urged to find out what brand of mamey products are being used in drinks prepared at juice stands and stores.
• This outbreak of Salmonella Typhi is not related to the current outbreak of Salmonella Enteritidis linked to eggs in their shells.

What is the Problem?
An investigation by the CDC and state partners showed an epidemiologic link between an ongoing outbreak of Salmonella Typhi and frozen mamey fruit pulp sold under the La Nuestra brand by Montalvan’s Sales Inc. Ontario, Calif, and under the Goya brand by Goya Foods Inc. Secaucus, New Jersey.

The CDC reports that at least nine people in California and Nevada are ill with typhoid fever, caused by Salmonella Typhi. Ill individuals have reported consuming products, including mamey fruit smoothies, made with La Nuestra or Goya brand frozen mamey fruit pulp.

Epidemiologic evidence has linked imported frozen mamey sold by Montalvan’s Sales Inc. (La Nuestra brand) and by Goya Foods Inc. to this ongoing outbreak. The two companies get their mamey fruit from a common supplier in Guatemala.

What are the Symptoms of Illness/Injury?
Infections with Salmonella Typhi cause typhoid fever. Typhoid fever is more common in developing countries. Eight of nine of the ill people report not having traveled outside the United States.

Typhoid fever is a serious illness that can result in death. People with typhoid fever usually have a sustained fever as high as 103° to 104° F (39° to 40° C). They may also feel weak, or have stomach pains, headache, or loss of appetite.

The only way to know for sure if an illness is typhoid fever is to have samples of stool or blood tested for the presence of Salmonella Typhi. Consumers who suspect that they have typhoid fever should see their health care professionals immediately.

What do Consumers Need to Do?
Consumers who have La Nuestra or Goya brand frozen mamey pulp in their homes are urged to discard them immediately. Consumers also are urged to find out what brand of mamey products are being used in drinks prepared at juice stands.

• For more information on typhoid fever.

What Do the Products Look Like?
Both the Goya and La Nuestra products are sold frozen. The Goya product is sold in 14-ounce packages in retail stores nationwide.  All production lot codes are being recalled. The UPC is 041331090803.

The La Nuestra brand mamey pulp comes in a 14-ounce plastic package.  All lot numbers are affected by this recall, however, packages produced prior to May 2009 are not identified with a lot number and are subject to this recall as well.  The UPC is 7-56869-10008-4.

Mamey fruit (sometime referred to as “zapote”) is large and round, has brown skin and a fleshy orange pulp. It is grown mainly in the tropical lowlands of Central America and is very popular among the Hispanic community, especially in juices and fruit shakes (called “batidos”).

What is Being Done about the Problem?
In addition to FDA’s collaborative effort with CDC and state partners to investigate the outbreak, the FDA is increasing its sampling of imported frozen mamey products at the borders to prevent contaminated product from entering the United States.

FDA

Children and Concussions

Concussion ABCs: Learn How to Respond

Learn concussion symptoms and how to respond. Know your concussion ABCs: A—Assess the situation. B—Be alert for signs and symptoms. C—Contact a health care professional.

What is a Concussion?

A concussion is a type of traumatic brain injury that changes the way the brain normally works. A concussion is caused by a bump, blow, or jolt to the head. Concussions can also occur from a fall or blow to the body that causes the head and brain to move rapidly back and forth. Even what seems to be a mild bump to the head can be serious.

How Can Concussions Happen in Schools?

Children and adolescents are among those at greatest risk for concussion. Concussions can result from a fall, or any time a student’s head comes into contact with a hard object, such as a floor, desk, or another student’s head or body. The potential for a concussion is greatest during activities where collisions can occur, such as during physical education (PE) class, playground time, or school-based sports activities.

Students may also get a concussion when doing activities outside of school, but then come to school when symptoms of the concussion are presenting. For example, adolescent drivers are at increased risk for concussion from motor vehicle crashes.

Concussions can have a more serious effect on a young, developing brain and need to be addressed correctly. Proper recognition and response to concussion symptoms in the school environment can prevent further injury and can help with recovery.

What Can I Do to Prevent and Prepare for Concussions?

Here are some steps you can take to prevent concussions in school and ensure the best outcome for your students:

Download or order CDC’s “Heads Up to Schools: Know Your Concussion ABCs” resources. Developed in collaboration with over 30 school, health, and medical organizations, the “Heads Up to Schools: Know Your Concussion ABCs,” materials include free resources for school nurses, administrators, counselors, teachers, parents, and students. See Heads Up to Schools, Know Your Concussion ABC’s.

Prepare a concussion action plan. To ensure that concussions are identified early and managed correctly, have an action plan in place before the start of the school year. This plan can be included in your school or district’s concussion policy.

Create safe school environments. Make sure your school has policies and procedures to ensure that the environment is a safe, healthy place for students. Talk to all school staff and administrators and encourage them to keep the physical space safe, keep stairs and hallways clear of clutter, secure rugs to the floor, and check the surfaces of all areas where students are physically active, such as playing fields and playgrounds. Playground surfaces should be made of shock-absorbing material, such as hardwood mulch or sand, and maintained to an appropriate depth. Proper supervision of students is also important.

Monitor the health of your student athletes. Make sure to ask whether an athlete has ever had a concussion and insist that your athletes are medically evaluated and are in good condition to participate in sports. Keep track of athletes who sustain concussions during the school year. This will help in monitoring injured athletes who participate in multiple sports throughout the school year.

CDC

Epstein- Barr Virus

DISEASE INFORMATION

Epstein-Barr virus, frequently referred to as EBV, is a member of the herpesvirus family and one of the most common human viruses. The virus occurs worldwide, and most people become infected with EBV sometime during their lives. In the United States, as many as 95% of adults between 35 and 40 years of age have been infected. Infants become susceptible to EBV as soon as maternal antibody protection (present at birth) disappears. Many children become infected with EBV, and these infections usually cause no symptoms or are indistinguishable from the other mild, brief illnesses of childhood. In the United States and in other developed countries, many persons are not infected with EBV in their childhood years. When infection with EBV occurs during adolescence or young adulthood, it causes infectious mononucleosis 35% to 50% of the time.

Symptoms of infectious mononucleosis are fever, sore throat, and swollen lymph glands. Sometimes, a swollen spleen or liver involvement may develop. Heart problems or involvement of the central nervous system occurs only rarely, and infectious mononucleosis is almost never fatal. There are no known associations between active EBV infection and problems during pregnancy, such as miscarriages or birth defects. Although the symptoms of infectious mononucleosis usually resolve in 1 or 2 months, EBV remains dormant or latent in a few cells in the throat and blood for the rest of the person’s life. Periodically, the virus can reactivate and is commonly found in the saliva of infected persons. This reactivation usually occurs without symptoms of illness.

EBV also establishes a lifelong dormant infection in some cells of the body’s immune system. A late event in a very few carriers of this virus is the emergence of Burkitt’s lymphoma and nasopharyngeal carcinoma, two rare cancers that are not normally found in the United States. EBV appears to play an important role in these malignancies, but is probably not the sole cause of disease.

Most individuals exposed to people with infectious mononucleosis have previously been infected with EBV and are not at risk for infectious mononucleosis. In addition, transmission of EBV requires intimate contact with the saliva (found in the mouth) of an infected person. Transmission of this virus through the air or blood does not normally occur. The incubation period, or the time from infection to appearance of symptoms, ranges from 4 to 6 weeks. Persons with infectious mononucleosis may be able to spread the infection to others for a period of weeks. However, no special precautions or isolation procedures are recommended, since the virus is also found frequently in the saliva of healthy people. In fact, many healthy people can carry and spread the virus intermittently for life. These people are usually the primary reservoir for person-to-person transmission. For this reason, transmission of the virus is almost impossible to prevent.

The clinical diagnosis of infectious mononucleosis is suggested on the basis of the symptoms of fever, sore throat, swollen lymph glands, and the age of the patient. Usually, laboratory tests are needed for confirmation. Serologic results for persons with infectious mononucleosis include an elevated white blood cell count, an increased percentage of certain atypical white blood cells, and a positive reaction to a “mono spot” test.

There is no specific treatment for infectious mononucleosis, other than treating the symptoms. No antiviral drugs or vaccines are available. Some physicians have prescribed a 5-day course of steroids to control the swelling of the throat and tonsils. The use of steroids has also been reported to decrease the overall length and severity of illness, but these reports have not been published.

It is important to note that symptoms related to infectious mononucleosis caused by EBV infection seldom last for more than 4 months. When such an illness lasts more than 6 months, it is frequently called chronic EBV infection. However, valid laboratory evidence for continued active EBV infection is seldom found in these patients. The illness should be investigated further to determine if it meets the criteria for chronic fatigue syndrome, or CFS. This process includes ruling out other causes of chronic illness or fatigue.

DIAGNOSIS OF EBV INFECTIONS

In most cases of infectious mononucleosis, the clinical diagnosis can be made from the characteristic triad of fever, pharyngitis, and lymphadenopathy lasting for 1 to 4 weeks. Serologic test results include a normal to moderately elevated white blood cell count, an increased total number of lymphocytes, greater than 10% atypical lymphocytes, and a positive reaction to a “mono spot” test. In patients with symptoms compatible with infectious mononucleosis, a positive Paul-Bunnell heterophile antibody test result is diagnostic, and no further testing is necessary. Moderate-to-high levels of heterophile antibodies are seen during the first month of illness and decrease rapidly after week 4. False-positive results may be found in a small number of patients, and false-negative results may be obtained in 10% to 15% of patients, primarily in children younger than 10 years of age. True outbreaks of infectious mononucleosis are extremely rare. A substantial number of pseudo-outbreaks have been linked to laboratory error, as reported in CDC’s Morbidity and Mortality Weekly Report, vol. 40, no. 32, on August 16, 1991.

When “mono spot” or heterophile test results are negative, additional laboratory testing may be needed to differentiate EBV infections from a mononucleosis-like illness induced by cytomegalovirus, adenovirus, or Toxoplasma gondii. Direct detection of EBV in blood or lymphoid tissues is a research tool and is not available for routine diagnosis. Instead, serologic testing is the method of choice for diagnosing primary infection.

EBV-Specific Laboratory Tests
Laboratory tests are not always foolproof. For various reasons, false-positive and false-negative results can occur for any test. However, the laboratory tests for EBV are for the most part accurate and specific. Because the antibody response in primary EBV infection appears to be quite rapid, in most cases testing paired acute- and convalescent-phase serum samples will not demonstrate a significant change in antibody level. Effective laboratory diagnosis can be made on a single acute-phase serum sample by testing for antibodies to several EBV-associated antigens simultaneously. In most cases, a distinction can be made as to whether a person is susceptible to EBV, has had a recent infection, has had infection in the past, or has a reactivated EBV infection.

Antibodies to several antigen complexes may be measured. These antigens are the viral capsid antigen, the early antigen, and the EBV nuclear antigen (EBNA). In addition, differentiation of immunoglobulin G and M subclasses to the viral capsid antigen can often be helpful for confirmation. When the “mono spot” test is negative, the optimal combination of EBV serologic testing consists of the antibody titration of four markers: IgM and IgG to the viral capsid antigen, IgM to the early antigen, and antibody to EBNA.

IgM to the viral capsid antigen appears early in infection and disappears within 4 to 6 weeks. IgG to the viral capsid antigen appears in the acute phase, peaks at 2 to 4 weeks after onset, declines slightly, and then persists for life. IgG to the early antigen appears in the acute phase and generally falls to undetectable levels after 3 to 6 months. In many people, detection of antibody to the early antigen is a sign of active infection, but 20% of healthy people may have this antibody for years.

Antibody to EBNA determined by the standard immunofluorescent test is not seen in the acute phase, but slowly appears 2 to 4 months after onset, and persists for life. This is not true for some EBNA enzyme immunoassays, which detect antibody within a few weeks of onset.

Finally, even when EBV antibody tests, such as the early antigen test, suggest that reactivated infection is present, this result does not necessarily indicate that a patient’s current medical condition is caused by EBV infection. A number of healthy people with no symptoms have antibodies to the EBV early antigen for years after their initial EBV infection.

Therefore, interpretation of laboratory results is somewhat complex and should be left to physicians who are familiar with EBV testing and who have access to the entire clinical picture of a person. To determine if EBV infection is associated with a current illness, consult with an experienced physician.

Additional Information about EBV Antibody Tests and Interpretation
Antibody tests for EBV can measure the presence and/or the concentration of at least six specific EBV antibodies. By evaluating the results of these different tests, the stage of EBV infection can be determined. However, these tests are expensive and not usually needed for the diagnosis of infectious mononucleosis.

It is not appropriate for CDC to interpret test results or to handle counseling for the public. We suggest that questions be directed to a local physician who is familiar with the patient’s history and laboratory test results. In addition, CDC cannot recommend specific physicians for referral. Our general recommendation is for patients to consult with an infectious disease specialist or their local or state public health department.

SUMMARY OF INTERPRETATION

The diagnosis of EBV infection is summarized as follows:

Susceptibility
If antibodies to the viral capsid antigen are not detected, the patient is susceptible to EBV infection.

Primary Infection
Primary EBV infection is indicated if IgM antibody to the viral capsid antigen is present and antibody to EBV nuclear antigen, or EBNA, is absent. A rising or high IgG antibody to the viral capsid antigen and negative antibody to EBNA after at least 4 weeks of illness is also strongly suggestive of primary infection. In addition, 80% of patients with active EBV infection produce antibody to early antigen.

Past Infection
If antibodies to both the viral capsid antigen and EBNA are present, then past infection (from 4 to 6 months to years earlier) is indicated. Since 95% of adults have been infected with EBV, most adults will show antibodies to EBV from infection years earlier. High or elevated antibody levels may be present for years and are not diagnostic of recent infection.

Reactivation
In the presence of antibodies to EBNA, an elevation of antibodies to early antigen suggests reactivation. However, when EBV antibody to the early antigen test is present, this result does not automatically indicate that a patient’s current medical condition is caused by EBV. A number of healthy people with no symptoms have antibodies to the EBV early antigen for years after their initial EBV infection. Many times reactivation occurs subclinically.

Chronic EBV Infection
Reliable laboratory evidence for continued active EBV infection is very seldom found in patients who have been ill for more than 4 months. When the illness lasts more than 6 months, it should be investigated to see if other causes of chronic illness or CFS are present.

CDC

Salmonella and Recalled Shell Eggs

Frequently Asked Questions and Answers: FDA’s Investigation into the Salmonella Enteritidis Outbreak Involving the Recall of Shell Eggs

Updated August 26, 2010

Why didn’t FDA require a vaccine for hens in the egg rule? NEW
There are several commercially available vaccines for Salmonella Enteritidis (SE)
infection in laying hens. These vaccines may help reduce the likelihood of SE infection, but do not eliminate it entirely. In the proposed egg rule issued in 2004, FDA considered the evidence on vaccination and determined that “vaccines show promise in reducing the prevalence” of SE in laying hens. However, FDA concluded that “more information on the effectiveness of vaccines needs to be generated before we would mandate vaccination as a (SE) prevention measure.” FDA cited the small number of flocks vaccinated in existing trials of the vaccine.

FDA received public comments following publication of the proposed rule. A few commentors called for FDA to include vaccination as a required part of the rule; some of these recommended that producers using vaccination should be allowed to follow a reduced testing regimen. Others stated that vaccination should be included only as a recommendation in control programs. In the final rule, FDA stated, “While vaccines have shown some promise in the lab, there is insufficient evidence from field trials about their efficacy to estimate any benefit from their use” and “there is no vaccine that has been shown to be efficacious in the field.” As a result, FDA did not require vaccination. FDA did encourage the use of the vaccine as a prevention measure where individual producers have had success with vaccination.

FDA is now working with USDA to review all recent and relevant data on these vaccines and determine whether additional recommendations or requirements are appropriate.

What is the size and scope of the recall?

The recent Wright County Egg in Iowa and Hillandale Farms of Iowa, Inc. voluntary recalls of shell eggs are considered nationwide recalls. Shell eggs from Wright County Egg were sold to distributors and wholesalers in 22 states and Mexico, who then distributed the shell eggs further throughout the country. According to Wright County Egg, 380 million of their shell eggs are being recalled under many different brand names.  Shell eggs under recall by Hillandale Farms of Iowa, Inc. were sold to grocery stores, distributors, and wholesalers in 14 states; these entities then distributed the shell eggs further throughout the country.

Please check FDA’s website for a listing of all the recalled shell eggs: http://www.fda.gov/Food/NewsEvents/WhatsNewinFood/ucm223536.htm.

Is this the largest egg recall in history?

It is one of the largest shell egg recalls in recent history. However, the FDA investigation is still ongoing; and it is too early to determine if all of the shell eggs that should be covered by voluntary recalls are covered and to estimate the magnitude of this recall.

With the second egg producer recalling, is this indicative of a more widespread problem in the egg producing industry?

The Hillandale Farms of Iowa, Inc. recall is related to FDA’s ongoing investigation of the SE illnesses. As the outbreak investigation unfolded, the traceback conducted by FDA, along with help from the State of Minnesota, and FDA investigational findings lead to Hillandale Farms of Iowa, Inc. FDA investigators are onsite at both Wright County Egg and Hillandale Farms of Iowa, Inc., examining potential commonalities among the two egg producers.

Does the FDA expect more companies to recall?

This is an ongoing investigation. Should FDA uncover information that leads to more contaminated shell eggs, then the Agency will work with the necessary parties to have them voluntarily recall product and take the necessary steps to protect the safety of the public’s health.

What are FDA investigators looking for on the farms?

FDA investigators are performing environmental assessments of farm conditions and practices including pest and rodent controls, biosecurity plans and controls; environmental monitoring; sanitary controls; and feed and laying hen sources. The investigators are also looking at commonalities between Wright County Egg and Hillandale Farms of Iowa, Inc.

How are eggs regulated by the Federal Government?

FDA has jurisdiction over the safety of foods in general, including shell eggs, under the Federal Food, Drug, and Cosmetic Act. FDA also has authority to take actions to help prevent the spread of communicable diseases under the Public Health Service Act. This authority includes regulating foods when foods may act as a vector of communicable disease, as eggs may for SE.

The USDA has responsibility for implementing the Egg Products Inspection Act (EPIA), which it carries out through programs administrated by the Food Safety and Inspection Service (FSIS) and the Agricultural Marketing Service (AMS). FSIS has primary responsibility for the inspection of processed egg products to prevent the distribution into commerce of adulterated or misbranded egg products, while AMS conducts a surveillance program to ensure proper disposition of restricted shell eggs. Additionally, AMS provides grading and certification services on a voluntary basis. All shell eggs are eligible for these services, which are provided by the AMS Poultry Programs. The shell egg grading and certification services ensure that requirements are met for quality, weight, condition, and/or other factors. Finally, the USDA’s Animal and Plant Health Inspection Service (APHIS) administers programs for animal health, including an SE control program for flocks that supply chicks to egg laying operations. FDA has primary responsibility for the parts of the continuum that involve the production and processing of shell eggs.

Are both farms subject to the Egg Safety Rule?

Yes, Wright County Egg in Iowa and Hillandale Farms of Iowa, Inc. are considered large egg producers with 50,000 or more laying hens. Therefore, they are subject to the rule that came into effect on July 9, 2010. The Egg Safety Rule requires preventive measures during the production of eggs in poultry houses and requires subsequent refrigeration during storage and transportation

Are both farms in compliance with the Egg Safety Rule?

As one part of the ongoing outbreak investigation, FDA investigators are on the farms examining their compliance with the Egg Safety Rule. But more importantly, the investigators are looking for the source of contamination in this outbreak. Our focus remains on the prevention of more illnesses due to the consumption of contaminated shell eggs.

Is this outbreak the first test of the Egg Safety Rule?

According to CDC, this outbreak started in May — at least two months before the Egg Safety Rule took effect for large egg producers. Large egg producers are those with 50,000 or more laying hens. This outbreak underscores the need for egg standards on the farm and for all covered by the rule to be in full compliance with them.

If the Egg Safety Rule were instituted earlier, would it have prevented the massive egg recall that is now ongoing?

We believe the Egg Safety Rule, once it is fully implemented by all shell egg producers, will reduce these types of SE outbreaks and prevent thousands of illnesses. The Egg Safety Rule is currently in effect for large producers, those that have 50,000 or more laying hens. It takes full effect in July 2012, when smaller producers, those with 3000 or more but less than 50,000 laying hens, must be in compliance. However, FDA strongly encourages all egg producers to implement the measures in the Egg Safety Rule as soon as possible.

What is the FDA doing to help farms implement the Egg Safety Rule?

FDA is working with United Egg Producers and other organizations to educate producers and those who store and/or transport eggs about the new requirements. FDA will continue its outreach sessions with producers and others around the country this fall. In the meantime, the FDA continues to issue guidance to all shell egg producers on how to implement these regulations. Soon, the FDA will begin inspecting all large shell egg producers to make sure they are in compliance with the Egg Safety Rule.

If a consumer has eggs in his or her refrigerator that are not in a package, how does he or she know if the eggs are safe?

If consumers are unsure about the source of their shell eggs, they are urged not to eat them and to throw them away immediately or return them to the store. They can check www.foodsafety.gov for a list of affected eggs and for safe handling practices. Pasteurized egg products and pasteurized in-shell eggs are not affected by this recall.

Are the recalled eggs incorporated into any processed products that consumers should be aware of, such as cookie dough or something else that is uncooked?

Many manufacturers use pasteurized egg products in ready-to-cook foods, such as raw cookie dough. FDA continues the traceback efforts to see if any smaller food operations may be using fresh eggs in ready-to-cook products. If we do find any, we will advise the public as necessary. But the FDA would like to remind all consumers against eating any raw cookie dough or any raw food products that may contain shell eggs that are supposed to be cooked or baked before eating because they could make you sick.

FDA

Recognnizing MRSA Infections

Recognize and Prevent MRSA Infections

As kids head back to classrooms and sports venues, parents are encouraged to learn how to recognize and prevent skin infections caused by methicillin-resistant Staphylococcus aureus (MRSA), a type of staph bacteria that is resistant to certain antibiotics.

Learn about MRSA

Visit www.cdc.gov/MRSA for posters, fact sheets, e-cards, graphics and more.

It is estimated that Americans of all ages visit the doctor more than 12 million times per year for skin infections that are typical of staph, more than half of which are MRSA. The good news is that a few simple steps can help parents protect their families.

MRSA is methicillin-resistant Staphylococcus aureus, a potentially dangerous type of staph bacteria that is resistant to certain antibiotics and may cause skin and other infections. As with regular staph infections, recognizing the signs and receiving treatment for MRSA skin infections in the early stages reduces the chances of the infection becoming severe. MRSA is spread by:

• Having direct contact with another person’s infection
• Sharing personal items, such as towels or razors, that have touched infected skin
• Touching surfaces or items, such as used bandages, contaminated with MRSA

Recognize the Signs and Symptoms of Infections

Most staph skin infections, including MRSA, appear as a bump or infected area on the skin that may be:

• Red
• Swollen
• Painful
• Warm to the touch
• Full of pus or other drainage
• Accompanied by a fever

Take Action if You Suspect an MRSA Skin Infection

Cover the area with a bandage and contact your healthcare professional. It’s especially important to contact your healthcare professional if signs and symptoms of an MRSA skin infection are accompanied by a fever.

Protect Yourself and Your Family from MRSA Skin Infections

• Know the signs of MRSA skin infections and get treated early
• Keep cuts and scrapes clean and covered
• Encourage good hygiene such as cleaning hands regularly
• Discourage sharing of personal items such as towels and razors

CDC

Tips for Safe Gardening

Be Healthy and Safe in the Garden

Stay safe and healthy while enjoying the benefits of gardening.

Whether you are a beginner or expert gardener, health and safety are important as you head out to your garden, vegetable plot, or grassy lawn. Gardening can be a great way to get physical activity, beautify the community, and go green. However, it also can expose you to potentially harmful elements, such as the sun, insects, lawn and garden equipment, and chemicals. Below are some health and safety tips for gardeners to follow while enjoying the beauty and bounty gardening can bring:

• Dress to protect. Prevent exposure to chemicals, insects, and the sun by wearing the proper clothing, safety equipment, and using an insect repellant and sunscreen.
• Put safety first. Limit distractions and follow the labels when using chemicals and equipment. Be aware of possible hazards to lower your risk for injury.
• Watch out for heat-related illness. Even being out for short periods of time in high temperatures can cause serious health problems. Monitor your activities and time in the sun to lower your risk for heat-related illness.
• Know your limits. Talk to your health care provider if you have concerns about your ability to work in the garden safely.
• Enjoy the benefits of physical activity. Gardening is an excellent way to get physical activity. Active people are less likely than inactive people to be obese or have high blood pressure, type 2 diabetes, osteoporosis, coronary artery disease, stroke, depression, colon cancer, and premature death.
• Get vaccinated. Vaccinations can prevent many diseases and save lives. Remember that tetanus lives in soil and all adults should get a tetanus vaccination every 10 years.
• Go green. Conserve water, reuse containers, recycle, and share your bounty.

CDC

Children and Rabies

Knowing How to Prevent Rabies isn’t Just for Adults. Kids Can Get the Facts Too.

Rabies is a dangerous virus that is found in the saliva of animals. It can infect and kill animals and humans. Every 10 minutes, someone dies from rabies. Even though anyone can get rabies, more than half of the people who get rabies are kids under the age of 15.

People usually get rabies when they are bitten by an animal that has the virus. When it’s likely that you or a child is at serious risk for rabies, get help right away. Symptoms of rabies might not show up for months, but it is important to receive proper care very soon. When symptoms of rabies appear, people often die within a few days.

Early symptoms of rabies in people can include:

• fever
• headache
• weakness

As it gets worse, symptoms may include:

• difficulty sleeping
• anxiety
• confusion
• tingling sensation (usually at the site of the bite)
• excitation (being too excited)
• hallucinations (seeing things that aren’t there)
• agitation
• salivating (drooling) more than usual
• difficulty swallowing
• fear of water

Below, you will learn about things you can do that will help make sure you never get rabies. Once you’ve read to the end, encourage a child to read through the information with you. Then visit the new Kids and Rabies Web site to learn more about rabies and to take a fun test of your rabies knowledge.

Help Your Pets Stay Rabies Free

Most people who have pets, such as dogs and cats, are very close to their animal companions. You might even have children and pets that are very close to each other. But there are times when pets are also in close contact with wild animals. If your pet is bitten by a wild animal that has rabies, your pet can get sick and die. It could also cause you or a child to get rabies from your sick pet.

When a human gets rabies, it’s often because a pet got rabies first. The good news is that there are things children and adults alike can do to help make sure your pets never get rabies. That way, they will stay healthy and won’t cause humans to get rabies.

Things you should do include:

• Take your pets to a veterinarian on a regular basis. They will keep your pets up-to-date on their rabies shots, which helps protect them from rabies.
• Talk to your veterinarian about spaying or neutering your pet. This helps cut down on the number of stray animals.
• Call animal control to remove all stray animals from your neighborhood. These animals may not have gotten their rabies shot and can give other animals and people rabies.
• Remind kids not to go near stray animals and remind them to tell an adult if they see a pet wandering around without any person watching them closely.
• Keep your pets indoors. When a dog goes outside, make sure an adult is there to watch it and keep it safe. Make sure children know not to take their pet outside without an adult around.
• Do not feed or put water for your pets outside. Keep your garbage covered. These items may cause wild animals to come near your yard or house.

Stay Away From Wild Animals

Most of the time, rabies is found in wild animals. The main animals that get rabies include raccoons, skunks, foxes and bats.

If you see a wild animal acting strangely, stay away from it. Help kids to understand that they should avoid wild animals at all times. Some things to look for are:

• General sickness
• Problems swallowing
• Lots of drool or saliva
• An animal that appears more tame than you would expect
• An animal that bites at everything
• An animal that’s having trouble moving or may even be paralyzed

Animals that act this way may need to be helped by people who know how to take care of wild animals. Call animal control and make sure the animal gets the help it needs.

Sometimes, people may come across a dead animal. Never pick up or touch dead animals and make sure children know to stay away from dead animals. Animals who have died can still give people rabies, especially if they have only been dead for a short time. If a dead animal is spotted, call animal control to properly take care of the animal’s body.

Get Help If An Animal Bites You

Animals can sometimes bite people even when you try to avoid them. If an animal bites you, seek help immediately. Let kids know that they should tell an adult immediately if they are bitten by an animal. Show them how to wash with soap and water so that they will know what to do if they are bitten. They should then be taken to a doctor who will know what to do next.

Most of the time, people know when an animal bites them. But that’s not always the case with bats, which are one of the main animals that can give you rabies. Bats have small teeth that might not always be felt when they bite and they don’t always leave bite marks that are easily seen.

Bats can be found indoors or out. Make sure children know to tell an adult when:

• a bat comes near or touches them
• a bat flies into their room or place where they sleep
• they find a dead bat
• they hear others talk about touching a living or dead bat

Visit CDC’s Kids and Rabies Web Site

CDC Kids and Rabies website is where children can learn more about how rabies affects animals and humans and get more tips on how to prevent rabies.

The website features an interactive quiz and e-cards, buttons, and badges that can be sent to family and friends so they can learn about rabies too.

NOTE: If you’ve read this website, you have all the information you need to ace the quiz. So, take the quiz by yourself or with your child and share the information so you can help protect others from getting rabies.

CDC

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