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SAMJ: South African Medical Journal
On-line version ISSN 2078-5135
Print version ISSN 0256-9574
SAMJ, S. Afr. med. j. vol.99 n.5 Pretoria May. 2009
Measles outbreak in South Africa, 2003 - 2005
Meredith L McMorrowI, *; Goitom GebremedhinII; Johann van den HeeverIV; Robert KezaalaV; Bernice N HarrisVI; Robin NandyVII; Peter StrebelV; Abdoulie JackIII; K Lisa CairnsVIII
IMD, MPH, Malaria Branch, Division of Parasitic Diseases, National Center for Zoonotic, Vector-Borne, and Enteric Diseases, Centers for Disease Control and Prevention and United States Public Health Service, Atlanta, USA
IIMD, MPH, World Health Organization, Abuja, Nigeria
IIIMD, PhD, World Health Organization, Abuja, Nigeria
IVBSocSc (Hons), MSocSc, Expanded Programme on Immunisation, Department of Health, Pretoria
VMB ChB, MPH, Department of Immunization, Vaccines, and Biologicals, World Health Organization, Geneva, Switzerland
VIMB ChB, MMed, National Institute for Communicable Diseases, National Health Laboratory Service, Johannesburg, and School of Health Systems and Public Health, University of Pretoria
VIIMBBS, MPH, Global Immunization Division, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, USA
VIIIMD, MPH, Global Immunization Division, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, USA
OBJECTIVES: Measles was virtually eliminated in South Africa following control activities in 1996/7. However, from July 2003 to November 2005, 1 676 laboratory-confirmed measles cases were reported in South Africa. We investigated the outbreak's cause and the role of HIV.
DESIGN: We traced laboratory-confirmed case-patients residing in the Johannesburg metropolitan (JBM) and O R Tambo districts. We interviewed laboratory- or epidemiologically confirmed case-patients or their caregivers to determine vaccination status and, in JBM, HIV status. We calculated vaccine effectiveness using the screening method.
SETTING: Household survey in JBM and O R Tambo districts.
OUTCOME MEASURES: Vaccine effectiveness, case-fatality rate, and hospitalisations.
RESULTS: In JBM, 109 case-patients were investigated. Of the 57 case-patients eligible for immunisation, 27 (47.4%) were vaccinated. Fourteen (12.8%) case-patients were HIV infected, 46 (42.2%) were HIV uninfected, and 49 (45.0%) had unknown HIV status. Among children aged 12 - 59 months, vaccine effectiveness was 85% (95% confidence interval (CI): 63, 94) for all children, 63% for HIV infected, 75% for HIV uninfected, and 96% for children with unknown HIV status. (Confidence intervals were not calculated for sub-groups owing to small sample size.) In O R Tambo district, 157 case-patients were investigated. Among the 138 case-patients eligible for immunisation, 41 (29.7%) were vaccinated. Vaccine effectiveness was 89% (95% CI 77, 95).
CONCLUSIONS: The outbreak's primary cause was failure to vaccinate enough of the population to prevent endemic measles transmission. Although vaccine effectiveness might have been lower in HIV-infected than in uninfected children, population vaccine effectiveness remained high.
Measles has recently been the focus of accelerated disease control activities in sub-Saharan Africa, resulting in a precipitous decline in reported cases and associated deaths.1 These activities were begun in the mid-1990s by seven African nations, including South Africa, and resulted in the virtual elimination of measles in southern Africa.2
South Africa has provided routine measles vaccination at 9 months of age since 1975. In 1995, the South African Department of Health (DoH) recommended that a second dose of measles vaccine be given at 18 months of age via routine health services, and set the goal of eliminating measles by 2002. To achieve this, South Africa used the strategy of the Pan American Health Organization.3 The first step was a nationwide measles vaccination campaign conducted in 1996 and 1997, targeting all children aged 9 months to 14 years, which achieved 85% administrative coverage. (Administrative coverage is the number of doses delivered divided by the target population. The target population is determined from census projections.) Subsequently, case-based surveillance with laboratory confirmation of suspected cases was established in South Africa. In 2000, a nationwide campaign targeting all children aged 9 months to 4 years reported 92% administrative coverage. From 1996 to 2004, routine measles first-dose coverage remained static at 76 - 83% while routine second-dose coverage was 63 - 78% from 2000 to 2004. Reported measles incidence reflected the reported success of the 1996 and 2000 campaigns; enhanced surveillance during 1999 - 2002 reported <60 measles cases annually and no associated deaths.1,2
However, measles virus was introduced in July 2003 to Mpumalanga and Gauteng provinces from Mozambique, which led to an epidemic lasting more than 2 years, with 1 676 reported laboratory-confirmed cases; 773 (46.1%) were from Gauteng and 506 (30.2%) from Eastern Cape; 27 measles-associated deaths were reported nationally. In Gauteng, 11 measles-associated deaths occurred in institutions for children; 8 were deaths of HIV-infected children.
In outbreak-affected provinces, teams investigated suspected measles cases and conducted response vaccination that targeted exposed children in preschools, schools and hospitals. In April 2004, Gauteng Province's DoH issued a directive to provide a supplemental dose of measles vaccine to all hospitalised and institutionalised children aged 6 months to 14 years. In addition, a national measles vaccination campaign targeting all children aged 9 months to 4 years was conducted in July 2004; reported administrative coverage was 102% in Gauteng but only 90% in Eastern Cape. Following this national campaign, measles virus transmission in Gauteng decreased, with the final case reported in May 2005. In contrast, measles transmission had not started in Eastern Cape until November 2004, months after the national campaign. To stop the spread of disease, a second province-wide vaccination campaign was conducted in Eastern Cape in May 2005, targeting children aged 6 months to 14 years and achieving 86% administrative coverage; nevertheless, measles virus transmission continued in the province until November 2005. This was the first large laboratory-confirmed measles outbreak following near-elimination in a setting with high HIV prevalence; in 2004, HIV seroprevalence in South Africa was estimated at 29.5% among antenatal clinic attendees.4 (HIV-infected children have a higher rate of primary measles vaccine failure than HIV-uninfected children.5) Questions have been raised as to whether the decreased efficacy of measles vaccine reported among HIV-infected children could affect the ability of high HIV-prevalence countries to achieve and sustain interruption of endemic measles virus transmission.5,6 We report on field investigations in two provinces to determine the cause of South Africa's measles outbreak and the role that HIV infection might have played in measles virus transmission.
We reviewed vaccination coverage data from 2000 to 2004 and case-based surveillance data for cases with date of rash onset falling between July 2003 and June 2005. Serum samples were collected for all suspected measles cases and sent to the National Institute for Communicable Diseases for analysis of measles IgM antibody using Enzygnost (Dade-Behring, Marburg, Germany) diagnostic kits.
For surveillance purposes, the South African definition of a laboratory-confirmed measles case-patient (LCMCP) is a person with fever, rash, and measles IgM-positive serum. In addition, we defined an epidemiologically confirmed measles case-patient (ECMCP) as a person with fever, rash, and at least 1 of 3 symptoms (cough, coryza or conjunctivitis), who had had contact with a LCMCP. A measles-associated death was defined as death of a LCMCP or an ECMCP within 30 days of rash onset; this death must not have obviously resulted from another cause, e.g. trauma.7 A case-patient was considered vaccinated if the respondent provided documentation or history of receipt of one or more doses of measles-containing vaccine at least 30 days prior to rash onset. HIV status of a case-patient or case-patient's mother was determined by respondent-provided history or documentation of HIV test results. In South Africa, HIV PCR is available for children <15 months of age, and HIV ELISA is used to test older children and adults. Treatment with vitamin A was assessed by showing a vitamin A capsule to the respondent and asking how many capsules the case-patient had received during the illness.
We selected two districts in which to conduct field investigations: the Johannesburg metropolitan district (JBM) in Gauteng province (the source of the largest absolute number of measles cases reported during the outbreak) and O R Tambo district in Eastern Cape province, which was the source of over half of all LCMCPs reported nationwide in 2005.
Gauteng province. From 25 May to 3 June 2005, we conducted an investigation of LCMCPs with rash onset between 1 July 2004 and 30 May 2005, residing in JBM and traced through available address information. We also investigated any household or school contacts meeting the ECMCP case definition identified during our investigation. We queried case-patients or their caregivers regarding the HIV status of the case-patient and the case-patient's mother, and obtained informed consent from all respondents.
Eastern Cape province. From 17 to 30 May 2005, a field investigation was conducted in O R Tambo district in all communities that reported LCMCPs with rash onset between 1 April and 30 May 2005. LCMCPs were interviewed and a house-to-house search was conducted in each case-patient's community to find ECMCPs with rash onset between 1 January and 30 May 2005.
Vaccine effectiveness
Vaccine effectiveness (VE) was calculated using the screening method with the formula VE=1-[PCV/(1-PCV)x(1-PPV)/PPV], where PCV refers to the percentage of cases vaccinated and PPV refers to the percentage of the population vaccinated.8 We confined our analysis to cases aged 12 - 59 months at the time of rash onset and our comparison population to this same age group, i.e. birth cohorts vaccinated in 2000 - 2004. Based on provincial routine measles first-dose vaccination coverage rates from 2000 to 2004, the PPV was estimated to be 80% in both Gauteng and Eastern Cape. Because some case-patients reported receiving vaccinations during campaigns only, we performed sensitivity analyses using an estimate of 90% as the PPV to account for the potential increase in the PPV following campaigns. We also calculated vaccine effectiveness among HIV-infected children, HIV-uninfected children, and children of unknown HIV status aged 12 - 59 months, assuming that there was no difference in age at vaccination or vaccination coverage between these groups.
Data analysis
Data were entered and analysed using EpiInfo v3.3.2 software (CDC, Atlanta, GA, USA). Calculation of vaccine effectiveness and confidence intervals was conducted using SAS 9.1 (SAS Institute, Cary, NC, USA). Confidence intervals were not calculated for sub-groups because of the small sample sizes.
Gauteng province
From 1 July 2004 to 30 May 2005, 454 LCMCPs were reported to the surveillance system from Gauteng province. Of these 454, 349 (76.9%) were reported from JBM (Fig. 1). Age distribution of the 349 LCMCPs from JBM is shown in Table I.
Address information to permit follow-up was available for 203 of the 349 LCMCPs. Among these 203, 2 refused consent, 107 were not found at the address given, and 94 were located and agreed to complete our questionnaire. While investigating the latter 94 cases, we identified an additional 15 ECMCPs for a total of 109 measles case-patients investigated (Table I). Fifty-seven (52.3%) case-patients reported having been hospitalised for measles, and 7 (6.4%) measles-associated deaths were reported to have occurred among the investigated case-patients. Among the 57 case-patients >9 months who were eligible for measles vaccination, 27 (47.4%) provided either documentation or a history of measles vaccination leaving 52.6% of vaccine-eligible case-patients unvaccinated (Fig. 2).
Of the 109 investigated case-patients, 57 (52.3%) were hospitalised with measles and 44 (77.2%) reported having been isolated upon hospital admission. All 109 investigated case-patients visited health care facilities, and 48 (44%) reported having received >1 dose of vitamin A during their measles illness.
Among the 109 case-patients investigated, caregivers reported that 14 (12.8%) were HIV infected, 46 (42.2%) were HIV uninfected, and 49 (45.0%) did not know their HIV status. HIV-infected case-patients ranged in age from 3 months to 32 years. Twenty-nine (26.6%) case-patients' mothers were reported to be HIV infected, 47 (43.1%) were reported to be HIV uninfected, and 33 (30.3%) respondents did not know the HIV status of the case-patient's mother. Among the 83 case-patients aged <59 months at rash onset and therefore probably exposed to HIV only via maternal infection, caregivers reported that 9 (10.8%) were HIV infected, 40 (48.2%) were HIV uninfected, and 34 (41%) were of unknown HIV status. All 14 (100%) HIV-infected case-patients were hospitalised with measles, and 2 (14.3%) died. Twenty-eight (60.9%) of the 46 known HIV-uninfected case-patients were hospitalised, and 2 (4.3%) died. HIV-infected case-patients were 1.6 times more likely to be hospitalised than known HIV-uninfected case-patients (p=0.003). The difference in risk of death between HIV-infected case-patients and HIV-uninfected case-patients was not statistically significant (risk ratio (RR)=3.3, 95% CI 0.5, 21.2).
Among the 19 investigated case-patients aged 12 - 59 months, 7 (36.8%) were vaccinated. Vaccine effectiveness among all children aged 12 - 59 months was estimated to be 85% (95% CI: 63, 94) assuming the PPV to be 80% (Table II). Among the 5 HIV-infected case-patients in this age group, 3 (60%) were vaccinated, and vaccine effectiveness was estimated to be 63%. Three (50%) of the 6 HIV-uninfected case-patients were vaccinated and vaccine effectiveness was estimated to be 75%. One (12.5%) of 8 case-patients of unknown HIV status was vaccinated, and vaccine effectiveness was estimated to be 96%. If we assume that the campaign increased the PPV to 90%, vaccine effectiveness increased to 94% (95% CI 84, 97) for all children aged 12 - 59 months, 83% for HIV-infected children, 90% for HIV-uninfected children, and 98% for children of unknown HIV status.
Eastern Cape province
From 1 January to 30 May 2005, 417 LCMCPs were reported to the surveillance system from Eastern Cape province, of whom 302 (72.4%) were reported in O R Tambo district (Fig. 1). Information on age was available for all case-patients (Table I).
Seventy LCMCPs with rash onset between 1 April and 30 May 2005 and 87 ECMCPs identified during the field investigation were interviewed. Seventy-nine (50.3%) of these patients were hospitalised for measles, and 8 (5.1%) measles-associated deaths were reported among the investigated case-patients. Of the 138 case-patients >9 months at the time of rash onset and eligible for routine measles vaccination, 41 (29.7%) provided either documentation or a history of measles vaccination, leaving 70.3% of vaccine-eligible case-patients unvaccinated (Fig. 2). Among the 30 case-patients aged 12 - 59 months, only 9 (30.0%) provided documentation or a history of measles vaccination. Vaccine effectiveness in children aged 12 - 59 months was estimated to be 89% (95% CI 77, 95) in O R Tambo district, assuming the PPV to be 80%, and 95% (95% CI 90, 98) assuming the PPV to be 90%.
Among the 131 investigated case-patients who visited health care facilities, 60 (45.8%) received >1 dose of vitamin A during their measles illness. Among the 79 case-patients who were hospitalised, 46 (58.2%) reported having been placed in isolation.
The primary cause of the measles outbreak in South Africa was the accumulation of susceptible children due to low routine immunisation coverage: 65% of vaccine-eligible case-patients interviewed in two districts born since the initial 1996 national campaign reported no measles vaccination in routine services or campaigns. This finding is consistent with reports of routine immunisation coverage of <83% since 2000. Although follow-up campaigns in 2000 and 2004 reported 92% administrative coverage nationally, these figures might have overestimated true coverage owing to inaccurate census estimates of the target populations. This tendency mirrors experience from the Americas, where relatively low routine and campaign coverage following years without measles transmission led to large outbreaks once the virus was reintroduced,9 which emphasises the importance of maintaining a very high population immunity even in the absence of a circulating virus.10
Our investigations supported national surveillance data in finding a substantial difference in the age distribution of measles case-patients between the two districts (Table I). The JBM outbreak primarily affected children <1 year old, while the O R Tambo outbreak affected children aged 5 - 14 years. Factors that could have lowered the age of measles acquisition in JBM district include high population density, poor maternal antibody transfer in HIV-exposed infants, and outbreaks in children's institutions.11 In O R Tambo district, historically low routine measles vaccination coverage and poor campaign performance might have left more school-age children susceptible to measles virus.
The World Health Organization (WHO) and United Nations Children's Fund (UNICEF) Integrated Management of Childhood Illness guidelines recommend 2 doses of vitamin A given 24 hours apart to reduce measles mortality.12 However, in this investigation, less than half of the children presenting to health facilities reported receiving any vitamin A. Isolation of suspected measles cases limits nosocomial measles transmission.13 Measles transmission probably occurred in institutions for children and health facilities in Gauteng province, as 58 measles cases were reported from these institutions, and isolation measures in the health facilities visited were inadequate. As with previous measles outbreaks, there is considerable need for more extensive therapeutic use of vitamin A and greater use of respiratory isolation.13,14
Maternal HIV infection might have contributed to measles virus transmission in JBM via reduced placental measles IgG transfer.11 The maximum expected HIV prevalence for the population of children aged <5 years in Gauteng province is 10%, given the 2004 antenatal clinic prevalence estimates of 33.1% in Gauteng (case-patient), and assuming 30% mother-to-child transmission.15 Prevention-of-mother-to-child-transmission (PMTCT) programmes might have reduced mother-to-child HIV transmission further in Gauteng,16 and higher mortality among HIV-infected children might also have reduced the proportion of HIV-infected children in the province. However, because we used facility-based surveillance to identify case-patients, HIV-infected measles case-patients might have been over-represented. Therefore, the rate of reported HIV infection of 10.8% among measles case-patients from JBM may reflect increased measles prevalence or morbidity in children with HIV, a bias in case finding, or a mix of these and other factors.
HIV infection among case-patients might have contributed to the morbidity and mortality associated with the Gauteng outbreak; 100% of the patients we investigated who were known to be HIV infected were hospitalised, compared with only 60.9% of known HIV-uninfected patients. This was the only statistically significant finding suggestive of an increase in measles morbidity attributable to HIV infection. Our higher case fatality rate (CFR) among HIV-infected patients was not statistically significant but is consistent with other findings of increased measles CFR in HIV-infected children.17 The decreased point estimate of vaccine effectiveness among HIV-infected children of 63% is consistent with reported estimates of lower measles vaccine effectiveness among HIV-infected children. Despite the possible decrease in vaccine effectiveness among HIV-infected children, overall vaccine effectiveness in Gauteng province remained relatively high at 85%, which suggests that decreased vaccine effectiveness in HIV-infected children should not pose a threat to regional or global measles mortality reduction goals and is consistent with modelling studies.18
For VE estimates, we chose to use a PPV of 80%. This PPV, based upon reported one-dose coverage, probably underestimates the true proportion of the population vaccinated. The primary purpose of calculating VE in our investigation was to ascertain the minimum VE. As demonstrated by our sensitivity analysis, a higher estimate of PPV would result in higher VE, therefore supporting our conclusion that vaccine failure did not play a substantial role in the outbreak.
Despite the activities of outbreak response teams, measles virus transmission continued until province-wide measles campaigns had been conducted. Vaccination of contacts alone has been shown to be ineffective in stopping transmission of measles in resource-limited settings.19 Prompt initiation of a wide age-range campaign in affected districts or provinces may be a more effective use of resources in halting measles transmission.20 Factors that might have resulted in shorter duration of the outbreak in Eastern Cape than in Gauteng include lower population density and earlier intervention with a wide age-range campaign.
There were several limitations to these field investigations. Firstly, small sample sizes made it difficult to detect differences among sub-groups and might have increased the effect of misclassification on VE estimates. Secondly, surveillance data from health facilities formed the basis of our investigations; but cases presenting to health facilities might not have been representative of all measles cases, particularly regarding age and HIV status. Thirdly, we were unable to locate more than half of the LCMCPs in Gauteng. Lastly, HIV status and vaccination status were determined by respondent report, and responses might have been affected by a social desirability bias. Additionally, unknown HIV status might have been a better marker of lack of access to care than HIV status, as only 1 child in this subgroup had been vaccinated prior to the outbreak. Mothers of infants of unknown HIV status were also more likely to be of unknown HIV status. Consequently, the increased VE among children with unknown HIV status is probably a mathematical artefact of the screening method, driven by a low PCV of 12.5%.
Our investigations showed the importance of maintaining high population immunity by means of routine immunisation services to prevent transmission following importation of the measles virus. Although HIV infection in measles case-patients might have contributed to outbreak-associated morbidity and mortality, high population vaccine effectiveness was maintained. Our investigation also revealed that vitamin A and respiratory isolation continue to be underutilised in measles outbreaks, and that case investigation with contact vaccination is not effective in stopping measles virus transmission.
We gratefully acknowledge the contributions of the Department of Health of the Republic of South Africa, the World Health Organization office in South Africa, the World Health Organization Regional Office for Africa Southern Bloc ICP, the National Institute for Communicable Diseases (NICD) and the Children's Homes Outreach Medical Program (CHOMP). We thank the following individuals: Mrs Estelle de Klerk, Dr Nthombenhle Ngcobo, Mrs Lindsay Botham, Ms Nthabeleng Motsomi, Dr Dan Kibuuka, Ms Thandi Chaane, Mrs Joy Mnyaluza, Mrs Antonia Barnard, Mr Alan Wild, Mrs Mvulakazi Thipanyane, Dr W Shasha, Mr Akpan Etukudo, Mr Eric Wiesen, Professor Barry Schoub, Mrs Jo McAnerney and Dr Michelle Meiring. We also thank Mr Thomas H Taylor Jr, in the Office of the Chief Science Officer at the US Centers for Disease Control and Prevention, for his assistance with statistical analysis.
1. Otten M, Kezaala R, Masresha B, et al. Public-health impact of accelerated measles control in the WHO African Region 2000-2003. Lancet 2005; 366: 832-839. [ Links ]
2. Biellik R, Madema S, Taole A, et al. First 5 years of measles elimination in southern Africa: 1996-2000. Lancet 2002; 359: 1564-1568. [ Links ]
3. de Quadros CA, Olive JM, Hersh BS, et al. Measles elimination in the Americas evolving strategies. JAMA 1996; 275: 224-229. [ Links ]
4. Department of Health. National HIV and syphilis antenatal sero-prevalence survey in South Africa 2004. Pretoria: Department of Health, 2005. http://www.doh.gov.za/docs/reports/2004/hiv-syphilis.pdf (accessed 14 April 2006). [ Links ]
5. Palumbo P, Hoyt L, Demasio K, Oleske J, Connor E. Population-based study of measles and measles immunization in human immunodeficiency virus-infected children. Pediatr Infect Dis J 1992; 11: 1008-1014. [ Links ]
6. Moss WJ, Clements CJ, Halsey NA. Immunization of children at risk of infection with human immunodeficiency virus. Bull World Health Organ 2003; 81: 61-70. http://www.who.int/bulletin/Moss0103.pdf (accessed 14 April 2006). [ Links ]
7. World Health Organization. Generic protocol for determining measles case fatality rates in a community, either during an epidemic or in a highly endemic area. WHO document WHO/EPI/GEN/93.3. Geneva: WHO, 1993. [ Links ]
8. Farrington CP. Estimation of vaccine effectiveness using the screening method. Int J Epidemiol 1993; 22: 742-746. [ Links ]
9. Centers for Disease Control and Prevention. Outbreak of Measles Venezuela and Colombia, 2001-2002. MMWR Morb Mortal Wkly Report 2002; 51: 757-760 http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5134a1.htm (accessed 14 April 2006). [ Links ]
10. Orenstein WA, Hinman AR, PJ Strebel. Measles: the need for 2 opportunities for prevention [commentary]. Clin Infect Dis 2006; 42: 320-321. [ Links ]
11. Scott S, Cumberland P, Schulman CE, et al. Neonatal measles in rural Kenya: The influence of HIV and placental malaria infections on placental transfer of antibodies and levels of antibody in maternal and cord serum samples. J Inf Dis 2005; 191: 1854-1860. [ Links ]
12. D'Souza RM, D'Souza RD. Vitamin A for the treatment of children with measles a systematic review. J Trop Pediatr 2002; 48: 323-327. [ Links ]
13. Biellik RJ, CJ Clements. Strategies for minimizing nosocomial measles transmission. Bull World Health Organ 1997; 75: 367-375. http://whqlibdoc.who.int/bulletin/1997/Vol75-No4/bulletin_1997_75(4)_367-375.pdf (accessed 14 April 2006). [ Links ]
14. Nandy R, Handzel T, Zaneidou M, et al. Case-fatality rate during a measles outbreak in eastern Niger in 2003. Clin Infect Dis 2006; 42: 322-328. [ Links ]
15. Nolan ML, Greenberg AD, Fowler MG. A review of clinical trials to prevent mother-to-child HIV-1 transmission in Africa and inform rational intervention strategies. AIDS 2002; 16: 1991-1999. [ Links ]
16. Coetzee D, Hilderbrand K, Boulle A, Draper B, Abdullah F, Goemaere E. Effectiveness of the first district-wide programme for the prevention of mother-to-child transmission of HIV in South Africa. Bull World Health Organ 2005; 83: 489-494. http://www.who.int/bulletin/volumes/83/7/489.pdf (accessed 14 April 2006). [ Links ]
17. Oshitani H, Suzuki H, Mpabalwani ME, Mitzuta K, Numazaki Y. Measles case fatality by sex, vaccination status and HIV-1 antibody in Zambian children. Lancet 1996; 348: 415. [ Links ]
18. Helfand RF, Moss WJ, Harpaz R, Scott S, Cutts F. Evaluating the impact of the HIV pandemic on measles control and elimination. Bull World Health Organ 2005; 83: 329-337. http://www.who.int/bulletin/volumes/83/5/329.pdf (accessed 14 April 2006). [ Links ]
19. Quiroga R, Barrezueta O, Venczel L, et al. Interruption of indigenous measles transmission in Bolivia since October 2000. J Infect Dis 2003; 187 (suppl 1): S121-126. [ Links ]
20. Pan American Health Organization. Update: Sao Paulo Measles Outbreak. PAHO EPI Newsletter 1998; 20: 5-6. http://www.paho.org/english/ad/fch/im/sne2001.pdf (accessed 14 April 2006). [ Links ]
Accepted 3 November 2008.
* Corresponding author: M McMorrow (firstname.lastname@example.com)


text:
Game Design by Steve Jackson Illustrated by John Kovalic
168 cards, a unique six-sided die, and a rulesheet.
Suggested Retail Price $24.95 Stock #1459 UPC 837654320600
Available Now – click here to order!
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Sail the seven seas. Plunder the treasure. Make your buddy walk the plank.
Munchkin Booty brings the greatest gold-grabbers in history – pirates! – to the world of Munchkin. Use your Silver Long Johns to beat the Lobster Mobster, drink your Demon Rum to fight off the Viking Kittens, and defend yourself with the Cutlass (or Cutlad, for the gents) against the Prince of Whales. But watch out for Sharks!
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Munchkin Booty is a stand-alone card game designed by Steve Jackson and illustrated by John Kovalic. It is completely compatible with the original Munchkin.
Munchkin Booty 2 – Jump the Shark
Return to the high seas for more Munchkin Booty action.
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More Sharks! More Ships!
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Multicolored sets of Munchkin character pawns!
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A brushed-metal pin in the shape of the Munchkin head!
Munchkin Bookmark Collection
Ten classic bookmarks and two NEW bookmarks!
- For even more expansions, variants, and accessories, go here!
- Download the official rules and card list.
- If you're playing a blended game, check out this list of Shark monsters from other sets!
- The Grim Pirate has made a turning Munchkin Booty level counter (PDF) that you can build from just cardstock and glue.
- To download the most up-to-date rules for all Munchkin games, go to our Rules page!
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subset: commoncrawl


text:
Encourage your local government officials to sign an official proclamation that designates September as National Recovery Month (Recovery Month). When local officials publicly sign such a statement, public attention is drawn to your Recovery Month events and activities, and the community as a whole recognizes that local governments are committed to improving citizens' access to treatment programs for alcohol and drug use disorders. Proclamations can be issued by governors, state legislatures, municipalities, counties, cities, or towns.
We would like to acknowledge your efforts and post your proclamation on our website.
Please mail the original signed or a copy of the signed proclamation to:
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Office of the Director, Consumer Affairs,
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Room 2-1062,
1 Choke Cherry Road,
Rockville, MD 20857
You can also email a copy of the signed proclamation in a high resolution jpeg file to email@example.com. We will scan and post it for you. Please note that you will not receive the proclamation back. Thank you for your support.
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Recovery Month promotes the societal benefits of prevention, treatment, and recovery for substance use and mental disorders, celebrates people in recovery, lauds the contributions of treatment and service providers, and promotes the message that recovery in all its forms is possible. Recovery Month spreads the positive message that behavioral health is essential to overall health, that prevention works, treatment is effective and people can and do recover.
National Recovery Month 2013


text:
"American Horror Story" mastermind Ryan Murphy will be teaming up with "Apollo 18" co-writer Brian Miller for a super hot super new Sci-Fi flick for Sony. The project is currently untitled, there's no director selected and details of the film have yet to be released. Sooooo... How's your day going so far? Did you watch "The Bad Girls Club" last night? Man what a crazy start, huh?
Get excited folks, Universal has picked up the rights to a new found footage flick titled "Thirteen" which focuses on the topic of possession. I for one applaud the good people at Universal for their not-rocking-the-boatness. If they made some crazy movie based off of a new idea no one had ever seen, well I might not be able to control myself in the theater. This way I know what I'm getting and I'll be able to relax. Thank you again, Universal.
Relativity Media and The Weinstein Company have apparently settled their differences of "The Crow" remake out of court and appear to be moving forward with the project. It's amazing to me that of all the movies that get tied up in legal problems the one film they pick to set aside their differences for is "The Crow". Thank you?
I have no idea what dubstep is but I know I hate it, a lot. I also have no idea who Jake Hoffman and Nikki Reed are either but apparently they're going to star in a new dubstep horror flick titled "Snap". I honestly don't even know what I just wrote there. Reed will play a social worker who finds herself drawn into the exciting world of dubstep. I don't know, it turns out she's a nut bag or something. I'm so lost right now.
Remember that movie "The Roommate" and how upset we all were when the girl put the kitten into the washing machine? Replace that girl with a guy from Arkansas and the kitten with a Chihuahua. Isn't that upsetting anymore is it? You're sick.
I don't know what it is but there's something about a coon skin cap that makes me both uncomfortable and proud to be an American. Both of those feelings would have been heightened this past weekend when an Oklahoma man walked into a grocery story wearing said hat and dropped trow showing the shoppers his bits. I hope that Lee Greenwood song was playing over the intercom.


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The Economic Train is giddy because of the trade deals that gone done this week. She is paying our President and country back BIGLY.
The Commerce Department announced U.S. housing starts in December jumped an amazing 16.9% in December with 1.608 million units. It once again blew away the forecast expectation of 1.375 million units. This was the largest gain since 2006.
From the article linked above:
Construction of new homes surged in December to the highest level in 13 years, capping a year in which falling mortgage rates and a strong labor market helped lift the prospects of the housing industry.
The Commerce Department reported Friday that builders started construction on 1.61 million homes at a seasonally adjusted annual rate in December, up 16.9% from the November pace of home building.
Housing construction has been rising since July, helped by falling mortgage rates and increased demand as the unemployment rate approached a half-century low. For the year, builders started work on a total of 1.29 million homes, the best showing since 2007.
The December building rate was the strongest number since December 2006 during the last housing boom.
I absolutely love this nugget that was reported. The South and the Midwest were willing to take a chance on our President. It is paying off in a BIG way!
From the article linked above:
Single-family homebuilding, which accounts for the largest share of the housing market, jumped 11.2% to a rate of 1.055 units in December, the highest level since June 2007. Single-family housing starts rose in the Midwest and the populous South. They, however, fell in the Northeast and West.
Once again all 3 indexes (DJIA, S&P 500 and Nasdaq Composite) set new records yesterday!
Larry Kudlow joined Varney to discuss all the Winning we are seeing under MAGAnomics.
National Association of Manufacturers (NAM) President and CEO Jay Timmons describes how President Donald Trump has "delivered Bigly" for manufacturers, noting that "promises are being kept" on tax reform, regulation, and trade.
Our President is putting in place a SLEDGEHAMMER to destroy China if they decide to try an embarrass him by reneging on the phase one deal.
From the article linked above:
Officials in India and the U.S. are preparing a limited bilateral trade agreement that could be unveiled during a visit by President Trump to New Delhi in the coming weeks, current and former government officials in both countries said.
The pact, described by a former U.S. government official as a "mini-deal," could ease some of the U.S.'s longstanding concerns with India's trade and economic practices, while in return restoring India's preferential trade status, allowing the nation to ship billions of dollars of duty-free…
I absolutely LOVE the fact our President is talking about what the Establishment Democrats are doing once again to Bernie Sanders. If they screw him, not only will it cause the Party to splinter, they will burn it down by voting for our President in November or just sitting the election out.
Our President sees the game and tweets about it:
Our President is right! Grab plenty of popcorn for the show.
Our President decided to give the former FLOTUS a birthday gift!
From the article linked above:
The Trump administration on Friday announced plans to roll back school lunch standards on vegetables and fruits originally promoted by Michelle Obama, unveiling the proposal on the former first lady's birthday.
The new standards will allow schools more flexibility "because they know their children best," the Agriculture Department said in a press release.
"Schools and school districts continue to tell us that there is still too much food waste and that more common-sense flexibility is needed to provide students nutritious and appetizing meals. We listened and now we're getting to work," Agriculture Secretary Sonny Perdue said in a statement.
We captured Jerry Nadler's brother in Iraq.
From the article linked above:
A morbidly obese ISIS fanatic dubbed "Jabba the Jihadi" has been captured by Iraqi forces — who loaded him onto a flatbed truck because he couldn't fit in a police car.
The 560-pound mufti Abu Abdul Bari, also known as Shifa al-Nima, was nabbed Thursday by an elite SWAT team of the Nineveh regiment in the city of Mosul, according to Stars and Stripes.
The jumbo jihadist was known for "provocative speeches against the security forces" and is considered one of the top leaders of "ISIS gangs," Iraqi security officials said in a statement.
Bari issued religious decrees — or fatwas — ordering the execution of scholars and clerics who refused to pledge allegiance to ISIS when the terror group occupied the city, the statement said.
Yesterday our President honored NCAA Football Champion LSU Tigers with a celebration at the White House.
I am a diehard Michigan Wolverine football fan. The way the LSU players and coaches respected our President will have me rooting for them in the future.
[Video and Transcript Below]
Here are some shorter video clips:
Our President teased the star QB, Joe Burrow, by telling him he thought he was going to give his Heisman Trophy to him.
Our President is having fun with getting impeached.
I have nothing but Love for coach O!
Our President absolutely gets it! He understands that the 2nd Amendment is under attack by the Democrats in the State of Virginia. This is how you win the State in November.
From the article linked above:
Trump's tweet comes as an uprising to the Democrats' anti-Second Amendment agenda has swelled across the state as the majority of cities, towns, and counties have declared themselves to be sanctuaries from the proposed unconstitutional restrictions on the Second Amendment.
"The grassroots resistance to Virginia Democrats' extreme anti-Second Amendment agenda has exploded as nearly 90% of the counties in the state have declared themselves to be sanctuary cities in response to the Democrats' anti-freedom agenda," The Daily Wire reported in November. "More than 100 cities, towns, and counties have passed resolutions in preparation for Democrats taking over the state who had indicated a desire to confiscate semi-automatic firearms from law-abiding citizens."
Who do you think they are voting for.
Our President continues to speak directly to the citizens of Iran. The Mullahs have some serious problems on their hands.
He also had words for Khamenei!
The Supreme Leader is scared! He normally doesn't lead the Friday prayers. This is the first time in 8 years.
Heshmat is absolutely right!
I hope our First Family enjoys their weekend in Mar-a-Lago.


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Daily Archives: September 10, 2009
An Indian Feast
Hey guys! Anyone ever watch Undergrads? That saying always reminds me of Cal.
Thanks for all the feedback on the tour :) I was actually kinda nervous about showing it. I still live very much like a student. And just know, no one ever gets into the private radio biz to make money ;)
Anyways, I realized the other day that I only own one massive-sized pot. So last night I picked up an $8 pot that's the perfect size for single batches of oats and boiling eggs. Obviously, I had to break it in today!
PB&J oats!! I've been seeing this pop up on a lot of blogs lately and had to join in on the party. As you may know, I've only just jumped on the PB&J wagon, after a lifetime without knowing it's one of the universe's greatest combinations.
I took a cue from Lori and put a little peanut butter and raspberry jam in the middle, then a little more on the top. Sosososososo good. I also don't have any bananas, so I upped the dry oatmeal to 3/4 cup. So filling! I really enjoyed the chewiness of the oats without the banana too…
I try not to delve into too much detail about my job. This is especially important because I work in the media, and keeping a good public reputation is important. But I had a pretty stellar moment at work today. I broke my first news story! It's big news locally, but certainly nothing large scale. The premier alluded to some future announcement while I was interviewing him today. Afterward, I was able to dig around and discover what the announcement was, and got the story on air a week before they were supposed to announce it! It's the kind of thing politicians hate, and other news media envy ;)
Anyways, all that investigative work left me starving for a pizza date, and my boyfriend was no where to be found. When he did finally show up, we went to Panago only to discover it's take-out only!! Not sure if all their locations are like that, as I didn't get that from the website. Anyways, we weren't really feeling the whole waiting for take-out thing, so we went to the restaurant next door – Yoo China Curry House. It's also a new restaurant, and a mix of Chinese and Indian cuisine. I'm kinda "meh" about both, but definitely appreciate a good Chinese or Indian dish when I get one!
The place was completely empty. Usually, not a good sign. Chris ordered a microbrew – Picaroon's Best Bitter.
I've only ever had this beer on draught but it was delicious from the bottle!
For his meal, he ordered the butter chicken.
Which came with potatoes, naan and some crispy bread.
I ordered a tava fry sumthin. I know, I suck. I tried repeating it in my head a bunch of times, but two outta three words ain't bad :P
It looks gross, but I assure you it was delicious!! It was roasted cauliflower, peppers, mushrooms and okra in a blend of Chinese and Indian spices. So flavourful. This was also my first okra experience. It was a good time. I know nothing about Indian food, but the brown stuff on the left is what I assume to be a common side dish. Some lentil thingy? The only thing I didn't eat most of was the rice. I never fill up on the cheap foods :P
Oh, and Chris loved his butter chicken. Place gets a thumbs up! :)
Afterwards, we ventured to Chapter's where I broke down and bought a book I've been wanting for ages.
I pick up this book every time I'm at a bookstore and just itch to make the easy, delicious looking recipes inside. I usually don't like following recipes, but there are some gems in here!
Plus, I love the design.
So cute :) I'm excited to finally try these recipes out!
Question of the day: What's your favourite cookbook?
Okee, it's my bedtime. I have a fun gym workout planned for the morning! Night night :)
P.S. My fibre tarts made it onto HealthyYum!! I'm alongside some other great dishes ;)


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And by the way, constant denigration of the other as Deplorables, know-nothings, red-necks, crackers, populists, the uneducated..... The Old Contemptibles..... will not have the desired effect. Unless, of course, one doesn't desire reconciliation.
The problem is really quite simple - the leaders are no longer leading in a direction that others wish to be led.Until those that see themselves as leaders stop patting themselves on the back for coming up with ever new and interesting ideas, promoting change, and thereby increasing the rate of change then the problems will continue. They are setting themselves apart from those who have quite enough change in their lives already from a variety of other causes. The Deplorables don't need self important gits with good idea fairies on their shoulders proposing the stabling of unicorns in their back yards.
I don't disagree with Tony but I challenge Edward.Consider the origins of Whigmaleeries and Tories. Or even the role of Freemasons in public discourse and their associations with Covenanters, Puritans and Quakers and all the other non-conformist disestablishmentarians.You can cite the Gordon Riots and Luddites amongst others but you also have to give credit to the Chartists.Of course reconciliation is possible, as is adjusting the flow of the mainstream.I just saw an article describing the secret of Trump as "Pace". I don't know if I accept that that is a conscious strategy by Trump but I do accept the validity of the concept. It is a restatement of the Ralph Doctrine of getting to the head of the parade and leading it. The best way to influence a herd is to become part of the herd, be accepted by the herd and then gently nudge the herd by the application of slow, continuous pressure. The article suggested that this is what Trump has been doing by taking "outlandish" positions and then slowly moderating them and bringing his new supporters with him back closer to centre. I do know that the surest way to come to a decidedly unpleasant end is to stand in the way of a charging herd or a bursting dam and demand your rights.With respect to the CCF, and the Progressives - they are still with us and their principles are part of the national dialogue. Pragmatism and time heal. Currently Wildrose and the PCs in Alberta are coming to the same conclusion. They can stand on ceremony or they can pragmaticallly accommodate the wishes of the electorate that care less for debates of angels on pins and more about jobs and bread on the table.
....Strange times indeed.
Blame Rich, Overeducated Elites as Society Frays143NOV 12, 2016 1:58 PM ESTByPeter TurchinThis article was first published in Bloomberg View on Nov. 20, 2013.Complex human societies, including our own, are fragile. They are held together by an invisible web of mutual trust and social cooperation. This web can fray easily, resulting in a wave of political instability, internal conflict and, sometimes, outright social collapse.Analysis of past societies shows that these destabilizing historical trends develop slowly, last many decades, and are slow to subside. The Roman Empire, Imperial China and medieval and early-modern England and France suffered such cycles, to cite a few examples. In the U.S., the last long period of instability began in the 1850s and lasted through the Gilded Age and the "violent 1910s."We now see the same forces in the contemporary U.S. Of about 30 detailed indicators I developed for tracing these historical cycles (reflecting popular well-being, inequality, social cooperation and its inverse, polarization and conflict), almost all have been moving in the wrong direction in the last three decades.The roots of the current American predicament go back to the 1970s, when wages of workers stopped keeping pace with their productivity. The two curves diverged: Productivity continued to rise, as wages stagnated. The "great divergence" between the fortunes of the top 1 percent and the other 99 percent is much discussed, yet its implications for long-term political disorder are underappreciated. Battles such as the recent government shutdown are only one manifestation of what is likely to be a decade-long period.WEALTH DISRUPTSHow does growing economic inequality lead to political instability? Partly this correlation reflects a direct, causal connection. High inequality is corrosive of social cooperation and willingness to compromise, and waning cooperation means more discord and political infighting. Perhaps more important, economic inequality is also a symptom of deeper social changes, which have gone largely unnoticed.Increasing inequality leads not only to the growth of top fortunes; it also results in greater numbers of wealth-holders. The "1 percent" becomes "2 percent." Or even more. There are many more millionaires, multimillionaires and billionaires today compared with 30 years ago, as a proportion of the population.Let's take households worth $10 million or more (in 1995 dollars). According to the research by economist Edward Wolff, from 1983 to 2010 the number of American households worth at least $10 million grew to 350,000 from 66,000.Rich Americans tend to be more politically active than the rest of the population. They support candidates who share their views and values; they sometimes run for office themselves. Yet the supply of political offices has stayed flat (there are still 100 senators and 435 representatives -- the same numbers as in 1970). In technical terms, such a situation is known as "elite overproduction."A related sign is the overproduction of law degrees. From the mid-1970s to 2011, according to the American Bar Association, the number of lawyers tripled to 1.2 million from 400,000. Meanwhile, the population grew by only 45 percent. Economic Modeling Specialists Intl. recently estimated that twice as many law graduates pass the bar exam as there are job openings for them. In other words, every year U.S. law schools churn out about 25,000 "surplus" lawyers, many of whom are in debt. A large number of them go to law school with an ambition to enter politics someday.Don't hate them for it -- they are at the mercy of the same large, impersonal social forces as the rest of us. The number of newly minted MBAs has expanded even faster than law degrees.LAWYER GLUTSo why is it important that we have a multitude of desperate law school graduates and many more politically ambitious rich than 30 years ago?Past waves of political instability, such as the civil wars of the late Roman Republic, the French Wars of Religion and the American Civil War, had many interlinking causes and circumstances unique to their age. But a common thread in the eras we studied was elite overproduction. The other two important elements were stagnating and declining living standards of the general population and increasing indebtedness of the state.Elite overproduction generally leads to more intra-elite competition that gradually undermines the spirit of cooperation, which is followed by ideological polarization and fragmentation of the political class. This happens because the more contenders there are, the more of them end up on the losing side. A large class of disgruntled elite-wannabes, often well-educated and highly capable, has been denied access to elite positions. Consider the antebellum U.S.From 1830 to 1860 the number of New Yorkers and Bostonians with fortunes of at least $100,000 (they would be multimillionaires today) increased fivefold. Many of these new rich (or their sons) had political ambitions. But the government, especially the presidency, Senate and Supreme Court, was dominated by the Southern elites. As many Northerners became frustrated and embittered, the Southerners also felt the pressure and became increasingly defensive.Slavery had been a divisive force since the inception of the Republic. For 70 years, the elites always managed to find a compromise. During the 1850s, however, intra-elite cooperation unraveled. On several occasions Congress was on the brink of a general shootout. (As one senator noted about his "armed and dangerous" colleagues, "The only persons who do not have a revolver and a knife are those who have two revolvers.")Although slavery was the overriding issue dividing the elites, they also differed over tariffs and cultural attitudes toward immigration. In the decade before the Civil War these centrifugal forces tore apart the two-party system. The Democratic Party split into its Northern and Southern factions, while the Whigs simply disintegrated.CIVIL WARSlavery was an absolute evil and was going to be abolished, sooner or later. But its abolition didn't need to result in hundreds of thousands of Civil War deaths. (About the same time, Russia banned serfdom without a civil war. The Russian Revolution came 50 years later -- when Russia was hit by its own elite overproduction.)This U.S. historical cycle didn't end with the cataclysm of the Civil War. Huge fortunes were made during the Gilded Age and economic inequality reached a peak, unrivaled even today. The number of lawyers tripled from 1870 to 1910. And the U.S. saw another wave of political violence, spiking in 1919–21.This was the worst period of political instability in U.S. history, barring the Civil War. Class warfare took the form of violent labor strikes. At one point 10,000 miners armed with rifles were battling against thousands of company troops and sheriff deputies. There was a wave of terrorism by labor radicals and anarchists. Race issues intertwined with class, leading to the Red Summer of 1919, with 26 major riots and more than 1,000 casualties. It was much, much worse than the 1960s and early 1970s, a period many of us remember well because we lived through it.The spike in violence then was relatively mild, perhaps because it fell in an era known as the Great Compression. Economic inequality had started to decline after 1930. The difference between the incomes of the rich and poor was compressed. Elite overproduction was reversed: The number of millionaires (in 1900 dollars, $1 million equals almost $30 million today) declined in absolute terms (while population continued to grow).The Great Compression unraveled in the late 1970s, when workers' wages stagnated. We are living in a new cycle of growing inequality, elite overproduction, ideological polarization and political fragmentation.Today we are seeing not just a bitter struggle between the Democrats and Republicans; the Republican Party itself is fragmenting. Now, as during the 1850s, many of the political elites disdain compromise and are instead inclined to fight to the bitter end. Thankfully our senators haven't armed themselves with revolvers and Bowie knives. (Interpolation: The Democrat party is suffering the same problem, consider how the "Bernie Bros" are going to interact with the various other wings of the party, for example).PREVENTING CATASTROPHEWe should expect many years of political turmoil, peaking in the 2020s. And because complex societies are much more fragile than we assume, there is a chance of a catastrophic failure of some kind, with a default on U.S. government bonds being among the less frightening possibilities.Of course, catastrophe isn't preordained. History shows a real indeterminacy about the routes societies follow out of instability waves. Some end with social revolutions, in which the rich and powerful are overthrown. This is what happened to the Southern elites -- decimated in the Civil War, beggared when their main assets, slaves, were freed, and excluded from national power in Washington. In other cases, recurrent civil wars result in a permanent fragmentation of the state and society.In some cases, however, societies come through relatively unscathed, by adopting a series of judicious reforms, initiated by elites who understand that we are all in this boat together. This is precisely what happened in the U.S. in the early 20th century. Several legislative initiatives, which created the framework for cooperative relations among labor, employers and the government, were introduced during the Progressive Era and cemented in the New Deal.By introducing the Great Compression, these policies benefited society as a whole. They enabled it to overcome the challenges of the Great Depression, World War II and the Cold War, and to achieve the postwar prosperity. Whether we can follow such a trajectory again is largely up to our political and economic leaders. It will depend on all of us, rich and poor alike, recognizing the real dangers and acting to address them.(Peter Turchin is the author, most recently, of "Ages of Discord: A Structural-Demographic Analysis of American History.")This column does not necessarily reflect the opinion of the editorial board or Bloomberg LP and its owners.To contact the author of this story:Peter Turchin at firstname.lastname@example.com contact the editor responsible for this story:Katy Roberts at firstname.lastname@example.com
This is an interesting article which goes a bit more in depth as to the sorts of conditions that change to create a "Revolt of the Elites". More ominously, it also suggests that these conditions are responsible for civilizational decline and fall as well. It is well that the people are reacting against this through measures like the BREXIT, voting for nationalist parties and other means to break the hold the "elites" have created, and hopefully the turmoil will be relatively mild as the drawdown occurs:https://www.bloomberg.com/view/articles/2016-11-12/blame-rich-overeducated-elites-as-society-frays
My problems with this world are with the supposed adults who prey on young kids and teach them to despair then harness their hormonally challenged, sleep deprived bodies and give them a "legitimate" outlet for their destructive impulses as they correct their world. Extreme athlete. Revolutionary. Soldier. Jihadi. Not much to choose amongst them. If you can bend them to your purpose.
Italy NEXT to reject establishment as protest vote set to WIN referendum, shock poll findsITALY is set to deal a hammer blow to its government as the latest polls revealed voters will punish Matteo Renzi's administration in the upcoming referendum.By REHEMA FIGUEIREDOPUBLISHED: 06:03, Fri, Nov 25, 2016 | UPDATED: 10:25, Fri, Nov 25, 2016The prime minister's failure to reach out to working class suggest large regions will snub Mr Renzi's plan for constitutional reform.A Demos poll has revealed Mr Renzi's reforms will be rejected by an 11 percentage point margin in the south of the country - where most of the poorest regions are located - compared with a seven-point margin across the country.As the nation prepares for a momentous referendum, which could spark an exit from the European Union, Mr Renzi said that he would have no interest in running the country if voters reject the proposed constitutional reform.Luca Comodo, director at polling company Ipsos, says most voters believe that rejecting Mr Renzi's plans is a vote for change, particularly in southern regions where the economic damage inflicted by the deep recession that followed the global financial crisis hit voters particularly hard.Mr Comodo said: "The south is where protest and rage are amplified."If the reform goes through - it will reduce the power of the senate (the equivalent of the House of Lords in the UK) and take back legal power from 20 regional governments.Those in favour of the change say it will make passing laws easier but those against it say it will centralise power too much.But many Italians are not voting based on the reforms but on their confidence in Mr Renzi's leadership.Mr Renzi's response has been to ramp up his campaign efforts in a desperate bid to win over voters in these regions - with visits to Sicily, Sardinia, Puglia and Campania (including the city of Naples).The embattled prime minister has also proposed tax breaks for companies that create jobs in the south to tackle youth unemployment and stimulate investment, in a last ditch attempt to swing the referendum his way.Italy is the eurozone's third-largest economy but most ordinary Italians, particularly those living in the south, still struggle to get by.Emanuele Fusco, a 25-year-old barman, said: "A Yes vote is just a way to fool people. We should send this government packing and let everyone know how much they've screwed us."Mr Renzi, 41, is coming under increasing pressure as the December 4 vote draws nearer with the anti-establishment Five Star Movement campaigning against him as well as a rebel faction within his own party.Martina Riccio, a 32-year-old market researcher, said: "I would change some things about the constitution but I wouldn't have it touched by those in power now."Many people are voting No because they are against Renzi, without even knowing what this entails."Italy's rules mean that if the vote goes against Mr Renzi, the country's president, Sergio Mattarella, could still ask him to lead a technical government which would have to amend the electoral system before an emergency election next year.Related articles EURO CRISIS: Renzi's referendum threatens single currency Italy's nervy PM says referendum wil will be DECISIVE for EU Eurosceptic party demands fresh election as Renzi faces referendum
A poll predicting a possible outcome to a referendum. If the poll is accurate .....then there will be some serious repercussions in the EU.And it hardly takes a master pollster to see a growing wave of people raising the middle finger to their so called elites.....
Next thing you'll be telling me you believe what you read in the papers.
And it hardly takes a master pollster to see a growing wave of people raising the middle finger to their so called elites.....
Spain Nixes Scottish Plan to Stay in the EUThe Spanish government has killed a Scottish plan to maintain Scotland's membership in Europe's common markets, saying that all of the UK must be either in or out. The Telegraph reports:Jorge Toledo, the Spanish Secretary of State for the European Union, flatly rejected the First Minister's proposals for a differentiated deal for Scotland whereby it would stay in the single market even if the rest of the UK comes out.His intervention is significant as all of the other 27 EU member states have to agree the terms of Brexit, effectively giving the Spanish a veto over any special treatment for Scotland.It came only 48 hours after Ms Sturgeon unveiled her highly complicated proposals at a press conference, during which she brushed away warnings that the Spanish would oppose the plans.[..]Ms Sturgeon's paper argued that Scotland could join the European Free Trade Association (EFTA) and the European Economic Area (EEA) as a means of gaining full access to the single market if the UK sponsored it.The Telegraph quotes a Scottish academic, Daniel Kenealy, who remarked that this seemed a back-door to the EU, which seems about right. It also would have been a front-door to independence. The Scottish would need to be assured of continued membership in the EU for Scottish independence to be attractive. Since Brexit, the Scottish National Party, which controls Scotland's devolved parliament in Edinburgh, seem to have been hoping that anger with London would lead to sympathy and a warm welcome from Brussels. (How little things change, the Scots thought: when Scotland was independent in the Middle Ages, France's perpetual war with England led to a natural and long-lasting "Auld Alliance" with Scotland.)But a desire to punish the Brits has been only one of many Continental reactions to Brexit—and arguably not even the dominant one. Another important one is a feeling that Continental Europe is lucky to be rid of the frightful headache that was the UK's membership—with Britain's different expectations and aims, for the EU, its different history, and enough economic weight to slow up the whole project of European integration. People who feel this way may be in no hurry to welcome a sub-tribe of the British (as they'll see it) back. And thirdly, Brexit has shown the Continentals just how serious the reemerging nationalism can be; people who focus on this aspect may be reluctant to fan its flames further by encouraging Scottish nationalists.For the Spanish in particular, as well as other nations with worries about break-away regions, the second and third combine to argue for putting any plans for Scottish EU membership into deep-freeze. Spain has been hinting at this for years, and it's something the SNP has signally failed to grapple with: Madrid is arguably a bigger foe to Scottish independence than London. Certainly, it has been a more effective one of late.Now, the SNP faces a big challenge—one that, whenever the situation becomes sufficiently clear to the Scottish voters, could prove existential. It's hard to miss the irony: the voters of Scotland strongly opposed Brexit, so much so that the difference in the vote north versus south of the ancient border was advanced at the time as a strong argument for a renewed push for independence. Now it looks like Brexit could do more to keep Scotland in the EU than anything in a generation.Scottish independence plus membership in a growing EU/common market looked like a smart, future-oriented play in the context of Scotland's left-wing political milieu. But being the smaller and poorer of two lonely, unwelcome nations on the fringes of Europe looks far less attractive.The Scots may jump yet; Brexit itself shows that rational calculation in such things only takes you so far. But the SNP's dreams of being an actual independence movement, rather than just a successful regional party, just took a big hit.
What slays me about BREXIT is the reaction to it on this side of the moat, especially down south. Why is anyone shocked that Britons would prefer to be ruled from Whitehall than Brussels? It seemed to be a pretty great idea in 1770 something, didn't it? If the EU would have stayed with the original plan, as a trading block only, it would still be flourishing, but it morphed into something rotten.
It is well that the people are reacting against this through measures like the BREXIT, voting for nationalist parties and other means to break the hold the "elites" have created, and hopefully the turmoil will be relatively mild as the drawdown occurs:QuotePREVENTING CATASTROPHEWe should expect many years of political turmoil, peaking in the 2020s. And because complex societies are much more fragile than we assume, there is a chance of a catastrophic failure of some kind, with a default on U.S. government bonds being among the less frightening possibilities.[...]In some cases, however, societies come through relatively unscathed, by adopting a series of judicious reforms, initiated by elites who understand that we are all in this boat together. This is precisely what happened in the U.S. in the early 20th century. Several legislative initiatives, which created the framework for cooperative relations among labor, employers and the government, were introduced during the Progressive Era and cemented in the New Deal.
PREVENTING CATASTROPHEWe should expect many years of political turmoil, peaking in the 2020s. And because complex societies are much more fragile than we assume, there is a chance of a catastrophic failure of some kind, with a default on U.S. government bonds being among the less frightening possibilities.[...]In some cases, however, societies come through relatively unscathed, by adopting a series of judicious reforms, initiated by elites who understand that we are all in this boat together. This is precisely what happened in the U.S. in the early 20th century. Several legislative initiatives, which created the framework for cooperative relations among labor, employers and the government, were introduced during the Progressive Era and cemented in the New Deal.
Brexit Is Like Repealing the Corn Laws All Over AgainPaul MarshallThursday, January 05, 2017 Of all my uplifting reading over the Christmas period, none was more so than John Morley's great "Life of Richard Cobden". One great Liberal's biography of another. It is uplifting not only because of the quality of the writing but also because of the many parallels between the Repeal of the Corn Laws in 1846 and Britain's decision to leave the European Union in 2016.Germany lacks the military ambitions of 1830s Prussia, but it is following the game plan of the Zollverein in most respects.Cobden rose from modest beginnings as the son of a Sussex farmer to become a highly successful Stockport manufacturer of calico and one of the co-founders, with John Bright, of the Anti-Corn-Law League.He was a great traveller, eager to learn from the lessons of rivals and neighbours. In 1838, he undertook a month's tour of Germany, paying particular attention to the workings of the Zollverein, the customs union established in 1833 under the leadership of Prussia.The parallels between the Zollverein and today's EU are striking, especially in so far as they relate to Prussia (then) and Germany (now). Here is what he wrote:"The effect of the League must be to throw the preponderating influence over thirty millions of people into the hands of the Cabinet of Berlin. By the terms of the Union, the money is to be collected and paid by Prussia; a very little financial skill will very easily make the smaller states the pensioners of the paymaster. Already…Prussia…is said to be two millions out of pocket …owing to her having guaranteed the smaller partners certain amounts of revenue. Besides the power that such a post of treasurer will confer upon Prussia, other causes must tend to weaken the influence of lesser states' governments…..A common standard of weights and measures, as well as money, is preparing, and these being assimilated….what shall prevent this entire family of one common language….from merging into one nation?"Ring any bells? Of course the eurozone does not speak one language and it has many more divergent cultures than the members of the Zollverein. So the process will take longer. But the process is the same: first the customs union, then a single currency, then merged sovereignty. What Cobden prescribed for Britain was global free trade and an end to protection.Germany today does not have any of the military ambitions of 1830s Prussia. But it is following the game plan of the Zollverein in most other respects. Poorer states are guaranteed income transfers (with Brussels taking a commission along the way). The ECB distorts monetary policy to keep alive the most indebted governments. And the "influence of lesser states' governments" has been weakened to the point of installing puppets in Italy and Greece. We already know that the eurozone will eventually face the choice between full fiscal union or enduring a series of state defaults.Cobden did not have any animus against the Zollverein. That was Germany's business. But he certainly didn't take it as a model. Instead, what he prescribed for Britain was global free trade and an end to protection.That was also Britain's choice in 2016. Would we continue to subscribe to a customs union which imposed tariffs of up to 30 per cent on agricultural products from Africa and prevented us from striking free-trade agreements with the developing (and developed) world? Or would we choose to break free and restore our status as the world's beacon of free trade?Thankfully we chose the latter.In 1846, the Repeal of the Corn Laws opened up a new era of unparalleled prosperity for this country based on the expansion of trade. Hopefully, Brexit will do the same as we gain access to the developing world for our service industries in return for opening up our agricultural markets.Yet the Liberal "Democrats" have set their face firmly, not only against the democratic will of the people but also against our re-opening to the world. Vince Cable, for one, must feel conflicted. In his contribution to the Orange Book (which I edited with David Laws in 2004), he described the Common Agricultural Policy as "an economic, environmental and moral disgrace".Not much has been done to reform it since then so presumably his views haven't changed.The only disgrace today is that the Liberal Democrats have so lost touch with their roots that they have subordinated all policy making to their infatuation with an undemocratic regional customs union. Cobden will be turning in his grave.


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Missouri bill could end red light cameras
Proposal would redirect revenue to education
A Missouri state senator has introduced a bill about the controversial red light cameras that critics say may end their use in the state.
Sen. Will Kraus said he hopes to stop cities from using the cameras as a revenue source and has proposed a measure requiring them to give the money to schools instead.
In 2009, Kansas City installed red light cameras at 18 dangerous intersections. Supporters said the Kraus bill would spell the end of those cameras.
"I don't think any of us really like the red light cameras," said Kansas City councilman John Sharp.
He said he thinks the cameras are making the city safer, leading to a 65-percent drop in crashes at the intersections that have them over the first year.
The cameras also raised $1.4 million for Kansas City in the first 10 months of 2009. Kraus said his measure will give that money to education.
"This legislation makes sure the cities are really after safety and not a backdoor revenue increase," he said.
Sharp said he opposes the bill.
"It's a very clever attempt to dissuade cities from having red light cameras because they could not even cover the cost," he said. "The purpose of this bill is to deter cities from having red light cameras."
He said money from the fines keeps the program running, paying for two full-time police officers to review the images and $4,500 per month to lease each camera.
More than 33,000 people were cited at red light cameras in Kansas City in the first 11 months of 2012, down 4,800 from the year before.
The Kansas City Police Department initially called into question the effectiveness of the red light cameras, but ultimate decided the cameras were decreasing the number of serious crashes.


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Whether it is a snow day, a scheduled absence for a conference or something more serious, it is important to have a plan for enabling continuity of instruction. This resource outlines steps that can be used to identify which course content needs to be replaced and how to create and deliver the material using different tools, including Canvas, Kaltura, and Zoom.
The resources listed on this page can help you get started using Sites at Penn State.
This hands-on online session focuses on the Sites at Penn State tool, a blogging and website platform powered by WordPress. Get started with the Sites at Penn State tool and learn to create a personal or course blog, department, event, or course website, or an ePortfolio. Discuss best practices for managing text, posts, pages, media, and themes while exercising best practices in site design.


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Squirrel monkey
|Squirrel monkeys[1]
|Common squirrel monkey
|Scientific classification
Miller, 1912 (1900)
Voigt, 1831
|Type species
|Saimiri sciureus
Squirrel monkeys are New World monkeys of the genus Saimiri. Saimiri is the only genus in the subfamily Saimirinae. The name of the genus is of Tupi origin (sai-mirim or gai-mbirin < sai 'monkey' and mirim 'small')[3][4] and was also used as an English name by early researchers.[5][6]
Squirrel monkeys live in the tropical forests of Central and South America in the canopy layer. Most species have parapatric or allopatric ranges in the Amazon, while S. oerstedii is found disjunctly in Costa Rica and Panama.
The common squirrel monkey is captured for the pet trade and for medical research[7] but it is not threatened. Two squirrel monkey species are threatened: the Central American squirrel monkey and the black squirrel monkey are listed as vulnerable by the IUCN.[8][9]
Evolutionary history[edit]
Until 1984, all South American squirrel monkeys were considered part of a single widespread species, and many zoologists considered the Central American squirrel monkey to be a member of that single species as well.[1][10] The two main groups currently recognized can be separated by the white above the eyes; it is shaped as a Gothic ("pointed") arch in the S. sciureus group, while it is shaped as a Roman ("rounded") arch in the S. boliviensis group.[11] Mammal Species of the World (2005) recognized the following 5 species:[1]
- Genus Saimiri
- S. sciureus group
- Central American squirrel monkey, Saimiri oerstedii
- Black-crowned Central American squirrel monkey, Saimiri oerstedii oerstedii
- Grey-crowned Central American squirrel monkey, Saimiri oerstedii citrinellus
- Common squirrel monkey, Saimiri sciureus
- Saimiri sciureus sciureus
- Saimiri sciureus albigena
- Humboldt's squirrel monkey, Saimiri sciureus cassiquiarensis
- Ecuadorian squirrel monkey, Saimiri sciureus macrodon
- Bare-eared squirrel monkey, Saimiri ustus
- Central American squirrel monkey, Saimiri oerstedii
- S. boliviensis group
- Black-capped squirrel monkey, Saimiri boliviensis
- Bolivian squirrel monkey, Saimiri boliviensis boliviensis
- Peruvian squirrel monkey, Saimiri boliviensis peruviensis
- Black squirrel monkey, Saimiri vanzolinii
- Black-capped squirrel monkey, Saimiri boliviensis
- Fossil species
- †Saimiri annectens, Honda Group, Kay and Meldrum 1997[2]
- †Saimiri fieldsi, Honda Group, Stirton 1951[2]
- S. sciureus group
Subsequent taxonomic research has recognized Saimiri sciureus cassiquiarensis as a separate species Saimiri cassiquiarensis, and also recognized an additional species, Collins' squirrel monkey Saimiri collinsi that had previously been considered to be within S. sciureus.[12] Some more recent taxonomies also recognize Saimiri sciureus macrodon as a separate species Saimiri macrodon, but others recognize S. macrodon to be a synonym of Saimiri cassiquiarensis.[13][14][15][16]
The crown lineage of the extant squirrel monkeys appears to have diverged around 1.5 million years ago.[17] S. boliviensis appears to be the first diverging species in the group. S. oerstedii and S. s. sciureus, are sister species. S. s. macrodon is the sister species to the S. oerstedii / S. s. sciureus clade.[clarification needed]
A squirrel monkey's fur is short and close, coloured black at the shoulders and yellowish orange on its back and extremities. The upper parts of their heads are hairy. This black-and-white face gives them the name "death's head monkey" in several Germanic languages (e.g., German Totenkopfaffen, Swedish dödskalleapor, Dutch doodshoofdaapjes) and Slovenian (smrtoglavka).
Squirrel monkeys grow from 25 to 35 centimetres (9.8 to 13.8 in) long, plus a 35 to 42 centimetres (14 to 17 in) tail. Male squirrel monkeys weigh 750 to 1,100 grams (26 to 39 oz). Females weigh 500 to 750 grams (18 to 26 oz). Both males and females are equipped with long and hairy tails, flat nails, and pointed claws.[18]
Female squirrel monkeys have pseudo-penises, which they use to display dominance over smaller monkeys, in much the same way that the male squirrel monkeys display their dominance.[citation needed]
Behaviour and ecology[edit]
Like most of their New World monkey relatives, squirrel monkeys are diurnal and arboreal. Unlike other New World monkeys, their tail is not used for climbing but as a kind of "balancing pole" and also as a tool. Their movements in the branches can be very rapid.
Squirrel monkeys live together in multi-male/multi-female groups with up to 500 members. These large groups, however, can occasionally break into smaller troupes. The groups have a number of vocal calls, including warning sounds to protect the group from large falcons, which are a natural threat. Their small body size also makes them susceptible to predators such as snakes and felids. For marking territory, squirrel monkeys rub their tail and their skin with their own urine.
Squirrel monkeys are omnivores, eating primarily fruits and insects. Occasionally, they also eat seeds, leaves, flowers, buds, nuts, and eggs.
Squirrel monkey mating is subject to seasonal influences. Females give birth to young during the rainy season, after a 150- to 170-day gestation. Only the mothers care for the young. Saimiri oerstedti are weaned by 4 months of age, while S. boliviensis are not fully weaned until 18 months old. Female squirrel monkeys reach sexual maturity at age 2–2.5 years, while males take until age 3.5–4 years. They live to about 15 years old in the wild, and over 20 years in captivity. Menopause in females probably occurs in the mid-teens.[19]
Colour vision[edit]
Colour vision in squirrel monkeys has been extensively studied as a stand-in for human ailments.[20] In humans, two genes for colour vision are found on the X chromosome. Typically, one gene (OPN1LW) produces a pigment that is most sensitive to the 564 nm wavelength, while the other gene (OPN1MW) produces a pigment most sensitive to 534 nm. In squirrel monkeys, there is only one gene on the X chromosome but it exists in three varieties: one is most sensitive to 538 nm, one to 551 nm, and one to 561 nm. Since males have only one X chromosome, they are dichromatic, although with different sensitivities. Females have two X chromosomes, so some of them can have copies of two different alleles. The three alleles seem to be equally common, leading to one-third of females being dichromatic, while two-thirds are trichromatic.[21] Recently, gene therapy has given the human OPN1LW gene to adult male squirrel monkeys, producing behaviour consistent with trichromatic colour vision.[20]
At the Phoenix Zoo
- ^ a b c Groves, C. P. (2005). Wilson, D. E.; Reeder, D. M. (eds.). Mammal Species of the World: A Taxonomic and Geographic Reference (3rd ed.). Baltimore: Johns Hopkins University Press. pp. 138–139. ISBN 0-801-88221-4. OCLC 62265494.
- ^ a b c d Saimiri – Paleobiology Database
- ^ Simpson, George Gaylord (1941). "Vernacular Names of South American Mammals". Journal of Mammalogy. 22 (1): 1–17. doi:10.2307/1374677. JSTOR 1374677.
- ^ Squirrel monkeys
- ^ Palmer, T. S. (1897). "Notes on the Nomenclature of Four Genera of Tropical American Mammals". Proceedings of the Biological Society of Washington. 11: 173–174.
- ^ Leclerc, Georges-Louis, Comte de Buffon (1797). "The Saimiri." In: Barr's Buffon. Buffon's Natural History. pp. 251–252. London: J. S. Barr.
- ^ Rhines, C. (2000). "Saimiri sciureus", Animal Diversity Web. Accessed November 26, 2007
- ^ Boubli, J.-P. & Rylands, A.B. (2008). "Saimiri vanzolinii". IUCN Red List of Threatened Species. 2008: e.T19839A9023022. doi:10.2305/IUCN.UK.2008.RLTS.T19839A9023022.en. Cite uses deprecated parameter
- ^ Wong, G.; Cuarón, A.D.; Rodriguez-Luna, E. & de Grammont, P.C. (2008). "Saimiri oerstedii". IUCN Red List of Threatened Species. 2008: e.T19836A9022609. doi:10.2305/IUCN.UK.2008.RLTS.T19836A9022609.en. Cite uses deprecated parameter
- ^ Kavanagh, Michael (1983). A Complete Guide to Monkeys, Apes and Other Primates. p. 84. ISBN 978-0-224-02168-5.
- ^ Rowe, N. (1996). The Pictorial Guide to the Living Primates. Pogonia Press, Charlestown, Rhode Island. ISBN 978-0-9648825-0-8.
- ^ Merces, Michelle P.; Lynch Alfaro, Jessica W.; et al. (January 2015). "Morphology and mitochondrial phylogenetics reveal that the Amazon River separates two eastern squirrel monkey species: Saimiri sciureus and S. collinsi". Molecular Phylogenetics and Evolution. 82 (B): 426–435. doi:10.1016/j.ympev.2014.09.020. PMID 25451802.
- ^ Lynch Alfaro, J.W.; et al. (2015). "Biogeography of squirrel monkeys (genus Saimiri): South-central Amazon origin and rapid pan-Amazonian diversification of a lowland primate". Molecular Phylogenetics and Evolution. 82: 436–454. doi:10.1016/j.ympev.2014.09.004. PMID 25305518.
- ^ "Saimiri". ITIS. Retrieved 2019-01-12.
- ^ "Saimiri". Mammal Diversity Database. Retrieved 2019-01-12.
- ^ Carretero-Pinzón, X.; Ruiz-García, M.; Defler, T. (2009). "The Taxonomy and Conservation Status of Saimiri sciureus albigena: A Squirrel Monkey Endemic to Colombia". Primate Conservation. 24: 59–64. doi:10.1896/052.024.0102. S2CID 85881653. Retrieved 2019-01-13.
- ^ Chiou, K. L.; Pozzi, L.; Lynch Alfaro, J. W.; Di Fiore, A. (2011). "Pleistocene diversification of living squirrel monkeys (Saimiri spp.) inferred from complete mitochondrial genome sequences". Molecular Phylogenetics and Evolution. 59 (3): 736–45. doi:10.1016/j.ympev.2011.03.025. PMID 21443955.
- ^ Lull, Richard Swann (1921). "Ch. 77". Organic Evolution. New York: The Macmillan Company.
- ^ Walker ML, Anderson DC, Herndon JG, Walker LC (2009). "Ovarian aging in squirrel monkeys (Saimiri sciureus)". Reproduction. 138 (4): 793–799. doi:10.1530/REP-08-0449. PMID 19656956.
- ^ a b Mancuso, Katherine; Hauswirth, William W.; Li, Qiuhong; Connor, Thomas B.; Kuchenbecker, James A.; Mauck, Matthew C.; Neitz, Jay; Neitz, Maureen (2009-09-16). "Gene therapy for red–green colour blindness in adult primates". Nature. 461 (7265): 784–787. Bibcode:2009Natur.461..784M. doi:10.1038/nature08401. ISSN 0028-0836. PMC 2782927. PMID 19759534.
- ^ Jacobs GH, Neitz J (April 1987). "Inheritance of color vision in a New World monkey (Saimiri sciureus)". Proc. Natl. Acad. Sci. U.S.A. 84 (8): 2545–9. Bibcode:1987PNAS...84.2545J. doi:10.1073/pnas.84.8.2545. PMC 304691. PMID 3470811.
External links[edit]
|Wikispecies has information related to Saimiriinae
|Wikispecies has information related to Saimiri
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