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Immunization Action Coalition
IAC Express 2008
Issue number 729: May 5, 2008
 
Contents of this Issue
Select a title to jump to the article.
  1. CDC study finds 28 percent of toddlers not vaccinated in compliance with ACIP recommendations; CDC develops related talking points
  2. CDC reports on syncope after vaccination from January 2005 to July 2007
  3. Immunization Safety Office website posts VAERS reports related to HPV vaccine
  4. CDC reports on human rabies fatality in Minnesota in 2007
  5. New: Multi-vaccine VIS now available in Hmong, Russian,Somali, and Vietnamese
  6. For coalitions: IZTA's June 3 teleconference to feature National Influenza Vaccine Summit's update on vaccine supply
  7. April issue of CDC's Immunization Works electronic newsletter now online
  8. Important: Be sure to give influenza vaccine throughout the influenza season--through the spring months
  9. CDC reports on ACIP decision not to recommend routine MCV4 vaccination of all children ages 2-10 years
  10. Reminder: National Conference on Immunization & Health Coalitions will be held in San Francisco May 21-23
 
Abbreviations
AAFP, American Academy of Family Physicians; AAP, American Academy of Pediatrics; ACIP, Advisory Committee on Immunization Practices; AMA, American Medical Association; CDC, Centers for Disease Control and Prevention; FDA, Food and Drug Administration; IAC, Immunization Action Coalition; MMWR, Morbidity and Mortality Weekly Report; NCIRD, National Center for Immunization and Respiratory Diseases; NIVS, National Influenza Vaccine Summit; VIS, Vaccine Information Statement; VPD, vaccine-preventable disease; WHO, World Health Organization.
  
Issue 729: May 5, 2008
1.  CDC study finds 28 percent of toddlers not vaccinated in compliance with ACIP recommendations; CDC develops related talking points

The June issue of the American Journal of Preventive Medicine (AJPM) includes an article by CDC researchers titled "Compliance with Vaccination Recommendations for U.S. Children." Using data from the 2005 National Immunization Survey, the study, which measures vaccination coverage using all the ACIP recommendations for valid doses, found that 28 percent of children ages 19-35 months were not vaccinated in compliance with ACIP recommendations. The article abstract is reprinted below.

CDC has developed talking points to assist states in answering questions they may get about why this ACIP-compliant measure differs from the federally reported estimates of vaccine coverage. Portions of the talking points are reprinted below.

IAC Express editor's note: The article "Compliance with Vaccination Recommendations for U.S. Children" is not available online as the AJPM website has not yet posted the June 2008 issue. Also, the CDC website has not posted the talking points it developed related to the article.


ARTICLE ABSTRACT
Background: Official recommendations for the routine vaccination of U.S. children, made by the Advisory Committee on Immunization Practices (ACIP), specify the vaccines for administration, the number of doses that should be given, the age ranges for administration, the minimum ages at which doses are considered valid, the minimum intervals between doses within a series, and several additional vaccine-specific adjustments and exceptions. Federally reported estimates of vaccination coverage measure only compliance with the required number of doses; other recommendations are not routinely evaluated.

Methods: Analysis of vaccination histories for 17,563 U.S. children aged 19-35 months from the 2005 National Immunization Survey.

Main outcome measures: Compliance with, and incremental impact of, each vaccination recommendation.

Results: Estimated coverage was 72% for the standard vaccination series accounting for all recommendations, 9 percentage points lower than coverage based solely on counting doses. Overall, 19% of children were missing one or more doses, while 8% had received an invalid dose, and 9% were affected by other recommendations. The proportion of noncompliance due to missed doses versus other recommendations varied by state and by antigen.

Conclusions: Approximately 28% of children were not in compliance with the official vaccination recommendations. Missed doses accounted for approximately two-thirds of noncompliance, with the remainder due to mis-timed doses and other requirements. Measuring compliance with all ACIP recommendations provides a valuable tool to assess and improve the quality of healthcare delivery and ensure that children and communities are optimally protected from vaccine-preventable diseases.


TALKING POINTS
Portions of the study details not covered in the abstract above:
  • The CDC annually reports coverage with the required number of doses in a vaccine series. However, it has not previously reported coverage based on all ACIP requirements. The National Immunization Survey can be used to analyze both.
     
  • Most commonly, children were missing the fourth dose of DTaP (14%); the single dose of MMR (9%); or the third dose of poliovirus vaccine (8%).
     
  • The findings suggest that the number of children who needed additional doses to bring them into compliance with ACIP recommendations at the time of the interview was nearly 50% greater than dose-counting alone would imply.

Study interpretation:

  • The impact of measuring compliance with all aspects of the ACIP recommendations in lowering estimated coverage is the largest when looking at the coverage measure for all needed doses, and that's because being early for a vaccine or not following one of the vaccine-specific requirements for just a single dose of vaccines makes an individual child fall into the noncompliant category.
     
  • When we look at coverage for MMR vaccine nationally in both ways, we see that the difference is <1%.
     
  • This rigorous measure of coverage can be used by health departments to target educational efforts to improve healthcare delivery.
     
  • There is no reason to conclude from this more rigorous measure of coverage that coverage is not at or near all-time highs, as previously reported. This measure of coverage simply reveals additional information about how compliance with ACIP recommendations could be improved by improvements in healthcare delivery.
     
  • These data cannot be used to conclude that parents are electing to postpone vaccination of their children--it does not examine late doses. However, previous studies have looked at late doses of vaccine.
     
  • Mis-timed vaccinations can lead to the reduced immunity of individuals and increased levels of population susceptibility and could lead to increases in disease.
     
  • While priority should be given to ensuring that children receive all of the recommended vaccine doses, compliance with the remaining recommendations should not be overlooked.
     
  • Vaccination providers should balance the competing goals of administering valid vaccinations and reducing missed opportunities.
     
  • Administering a vaccination a few days early is preferred to missing the opportunity to vaccinate a child who is unlikely to return at the appropriate time.
     
  • However, in general, providers and parents should adhere to the specifics of published guidelines whenever possible.

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2 CDC reports on syncope after vaccination from January 2005 to July 2007

CDC published "Syncope After Vaccination--United States, January 2005-July 2007" in the May 2 issue of MMWR. Portions of the article are reprinted below.


Syncope (vasovagal reaction), or fainting, can be triggered by various stimuli, including medical procedures. Syncope has been documented to occur after vaccination, most commonly among adolescents, and can result in hospitalization for a medical evaluation or because of injury. During 2005 and 2006, the Advisory Committee on Immunization Practices (ACIP) recommended use of three newly licensed vaccines for adolescents: the quadrivalent human papillomavirus recombinant vaccine (HPV) (Gardasil, Merck & Co., Inc., Whitehouse Station, New Jersey) in a 3-dose series, the quadrivalent meningococcal conjugate vaccine (MCV4) (Menactra, sanofi pasteur, Inc., Swiftwater, Pennsylvania) in a single dose, and the tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis vaccine (Tdap) (Adacel, Sanofi Pasteur; Boostrix, GlaxoSmithKline Biologicals, Research Triangle Park, North Carolina) in a single dose. To describe trends in occurrence of postvaccination syncope, CDC and the Food and Drug Administration (FDA) analyzed data from the Vaccine Adverse Event Reporting System (VAERS) for January 1, 2005-July 31, 2007, and compared the results with VAERS reports received during January 1, 2002-December 31, 2004. The findings indicated that, since 2005, reports to VAERS regarding postvaccination syncope have increased, primarily among females aged 11-18 years, and rarely, subsequent serious injuries have occurred. To prevent syncope-related injuries, vaccine providers should follow the ACIP recommendation to strongly consider observing patients for 15 minutes after vaccination. . . .

A total of 463 reports of postvaccination syncope during January 1, 2005-July 31, 2007, were identified among persons aged >=5 years, compared with 203 reports during 2002-2004. The rate of reports for postvaccination syncope among persons aged >=5 years were as follows: 0.30 reports per million doses distributed in 2002, 0.35 per million doses distributed in 2003, 0.28 per million doses distributed in 2004, 0.31 per million doses distributed in 2005, and 0.54 per million doses distributed in 2006. Compared with reports received during 2002-2004, those received during 2005-2007 were more likely to involve females (61.1% versus 77.5%) or persons aged 11-18 years (47.3% versus 62.0%). In 292 (63.1%) of the 463 reports during 2005-2007, syncope was associated with at least one of the following recently approved and recommended adolescent vaccines: MCV4, Tdap, and HPV.

Thirty-three (7.1%) of the 463 postvaccination syncope reports during 2005-2007 were coded as serious; the percentage was not substantially different from the corresponding 20 (9.9%) serious reports during the earlier comparison period. . . .


To access a web-text (HTML) version of the complete article, go to: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5717a2.htm

To access a ready-to-print (PDF) version of this issue of MMWR, go to: http://www.cdc.gov/mmwr/PDF/wk/mm5717.pdf

To receive a FREE electronic subscription to MMWR (which includes new ACIP statements), go to:
http://www.cdc.gov/mmwr/mmwrsubscribe.html

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3 Vaccine Safety Office website posts VAERS reports related to HPV vaccine

On April 29, CDC's Immunization Safety Office (ISO) posted reports on human papillomavirus (HPV) vaccination that were submitted to the Vaccine Adverse Events Reporting System (VAERS) from June 8, 2006, to January 31, 2008.

On June 8, 2006, FDA licensed Gardasil, the first vaccine developed to prevent cervical cancer caused by certain kinds of human papillomavirus (HPV). Since then, more than 12 million doses of Gardasil vaccine have been distributed. The total number of people vaccinated with HPV vaccine in the U.S. is unknown. In that period, VAERS received 5,070 reports related to HPV vaccination; less than 7 percent reported serious side effects.

To access the reports, go to:
http://www.cdc.gov/vaccinesafety/vaers/gardasil.htm

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4 CDC reports on human rabies fatality in Minnesota in 2007

CDC published "Human Rabies--Minnesota, 2007" in the May 2 issue of MMWR. Portions of the article are reprinted below.


On October 20, 2007, a Minnesota resident died from rabies, approximately 1 month after initial symptoms of limb paresthesia, which progressed to flaccid weakness and ataxia. This was the only human rabies case reported in the United States in 2007. A presumptive diagnosis of idiopathic transverse myelitis was considered initially, because of abnormalities detected via spinal cord imaging studies and a lack of laboratory confirmation of a specific infectious etiology. The presumptive diagnosis subsequently was changed to include rabies, based on the patient's rapidly deteriorating neurologic status and elicitation of a history involving bat exposure during the month before illness onset. This report summarizes the medical and epidemiologic investigation by the Minnesota Department of Health and CDC and the ensuing public health response. The findings underscore the need for early inclusion of rabies in the differential diagnosis of rapidly progressive encephalitis, improved public awareness of the risks associated with animal bites, and appropriate rabies prophylaxis after exposure. . . .

This report describes the only reported case of human rabies in the United States in 2007 and the first case in Minnesota since 2000. Investigators determined that the likely source of rabies in this case was a bat. In Minnesota, bats and skunks are the only known reservoirs of rabies. In 2006, 42 rabid animals were reported in the state, including 17 bats and 20 skunks.

During 2000-2007, a total of 25 cases of human rabies were reported in the United States. Eighteen (28%) cases were associated with suspected exposure to rabid bats or infection with bat rabies virus variants. Most of these human cases occurred in late summer or early autumn, coincident with a seasonal increase in the prevalence of rabid bats detected in the United States. Despite repeated documentation of human rabies attributable to bat exposures and identification of 1,212-1,692 rabid bats in the United States during 2000-2006, the significance of bat exposures often is ignored.

The animal contact, incubation period, clinical presentation, and laboratory findings for the patient described in this report were typical of human rabies cases reported in the United States. However, a diagnosis of rabies was not considered until the clinical course appeared atypical of the presumptive diagnosis of idiopathic transverse myelitis and brain imaging abnormalities resembled those observed in rabies. One unusual facet of this case was the inability to detect viral antigens or nucleic acids in patient samples, although rabies virus antibodies were identified in the serum and cerebrospinal fluid (CSF). The only other human rabies case in the United States in which viral antigens or nucleic acids could not be detected, since such laboratory methods became more widely available in the early 1990s, was a 2004 Wisconsin patient, who survived rabies after a bat bite. However, the Wisconsin patient was an adolescent girl treated successfully with a drug-induced coma and antiviral drugs, and the significance of any similarities between that case and the Minnesota case is unclear.

This report underscores the need for increased public awareness of the risks of direct contact with bats and other wild animals. After exposure, human rabies is preventable with timely and appropriate postexposure prophylaxis (PEP), consisting of proper wound care and prompt administration of rabies biologicals. Rabies PEP is recommended for all persons with direct transdermal or mucous membrane exposure to a bat, unless the animal is found not to have rabies. However, bite lesions from certain animals, including bats, can be difficult to detect. Consequently, proper tailoring of health communications to medical practitioners and the public remains a challenge to ensure that appropriate PEP is administered when indicated but not unnecessarily.

Rabies should be considered in the differential diagnosis of human cases involving acute, rapidly progressive encephalitis, especially when the clinical course and neuroimaging findings are compatible, regardless of history of animal exposure. If a patient is unresponsive, interview of family members and close contacts might reveal potential exposures. Prompt diagnosis of rabies can enable rapid case investigation, implementation of appropriate infection-control measures, and consideration of experimental therapy.


To access a web-text (HTML) version of the complete article, go to: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5717a3.htm

To access a ready-to-print (PDF) version of this issue of MMWR, go to: http://www.cdc.gov/mmwr/PDF/wk/mm5717.pdf

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5 New: Multi-vaccine VIS now available in Hmong, Russian, Somali, and Vietnamese

Dated 1/30/08, the multi-vaccine VIS is now available in Hmong, Russian, Somali, and Vietnamese. IAC gratefully acknowledges the Minnesota Department of Health for the translations.

To access the Hmong version of the multi-vaccine VIS, go to:
http://www.immunize.org/vis/hm_multi.pdf

To access the Russian version of the multi-vaccine VIS, go to:
http://www.immunize.org/vis/ru_multi.pdf

To access the Somali version of the multi-vaccine VIS, go to:
http://www.immunize.org/vis/so_multi.pdf

To access the Vietnamese version of the multi-vaccine VIS, go
to: http://www.immunize.org/vis/vn_multi.pdf

To access English version of the multi-vaccine VIS, go to:
http://www.immunize.org/vis/vis_multi1.pdf

NOTE: The multi-vaccine VIS comes in additional languages, including Spanish. To access them, go to: http://www.immunize.org/vis/vis_multi1.asp Click on the link to the pertinent language.

For information about the use of VISs, and for VISs in more than 30 languages, visit IAC's VIS web section at http://www.immunize.org/vis

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6 For coalitions: IZTA's June 3 teleconference to feature National Influenza Vaccine Summit's update on vaccine supply

The Immunization Coalitions Technical Assistance Network (IZTA) conference call on June 3 will feature an update on the current supply of influenza vaccine and other information shared during the National Influenza Vaccine Summit (aka, Flu Summit). IZTA is a program of the Center for Health Communication, Academy for Educational Development.

The presenter is L.J. Tan, PhD, director, Infectious Disease, Immunology, and Molecular Medicine, American Medical Association.

The June 3 call will be offered twice: first at 1PM ET, and again at 3PM, ET. To register, send an email to izta@aed.org Include either of these messages in the subject line: "sign me up for the Flu Summit update at 1PM" or "sign me up for the Flu Summit update at 3PM."

For additional information, or to access earlier programs, go to: http://www.izta.org/confcall.cfm

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7 April issue of CDC's Immunization Works electronic newsletter now online

The April issue of Immunization Works, a monthly email newsletter published by CDC, is available on the website of the National Center for Immunization and Respiratory Diseases (NCIRD). The newsletter offers members of the immunization community non-proprietary information about current topics. CDC encourages its wide dissemination.

Some of the information in the April issue has already appeared in previous issues of IAC Express. Following is the text of six articles we have not covered.


OTHER NEWS & SUMMARIES
42ND NIC DRAWS NEARLY 1,500 ATTENDEES: Nearly 1,500 attendees participated in the 42nd National Immunization Conference (NIC), which was held March 17-20, 2008, in Atlanta, GA. Dr. Anne Schuchat, director of CDC's National Center for Immunization and Respiratory Diseases (NCIRD), and Dr. Renee Jenkins, president of the American Academy of Pediatrics (AAP; http://www.aap.org), spoke at the opening session. The Phil Horne award was presented to Jane Seward, a deputy director with CDC's viral diseases division. The Hilleman Lecture was delivered by Dr. Mathu Santosham, of the Johns Hopkins' Bloomberg School of Public Health, and a primary investigator in an effort to promote the integration of Hib vaccine into immunization programs around the world. Closing remarks were delivered by Joe Lastinger, a founding board member of Families Fighting Flu (http://www.familiesfightingflu.org) and father to Emily, who died at 3-1/2-years-old from influenza. Handouts and audio/video recordings from the conference are available online at the NIC website (http://www.cdc.gov/vaccines/events/nic/#agenda). Remember to mark your calendars for the 43rd NIC, to be held March 30-April 2, 2009, in Dallas, TX.


MEETINGS, CONFERENCES & RESOURCES
DATA INTERACTIVE QUERY TOOL: CDC has launched a new tool for research concerning Immunization Information Systems (IIS) called the IIS Data Interactive Query Tool (http://www2a.cdc.gov/nip/registry/IISAR/IISAR_QUERY.asp). The searchable database contains detailed calendar-year 2004-2006 data--previously unavailable to the public--from the Immunization Information Systems Annual Report (IISAR). IISAR is an annual assessment of IIS activity among the 64 immunization program grantees that receive funding under section 317b of the Public Health Service Act. For more information, please contact Bobby Rasulnia at bba9@cdc.gov


IIS SEARCHABLE PUBLICATIONS DATABASE: CDC has launched a new tool for searching Immunization Information Systems (IIS) publications called the IIS Publications Searchable Database (http://www2a.cdc.gov/nip/IIS/IISPubs/IISPubsMain.asp). The database contains references for IIS-related articles published in peer-reviewed journals, IIS guidance documents, and CDC Morbidity and Mortality Weekly Reports (MMWRs) from 2000 to the present. This database will be updated as new articles and guidance documents are published. For more information, please contact Bobby Rasulnia at bba9@cdc.gov


BEST PRACTICES FOR HEALTHCARE WORKER INFLUENZA VACCINATION: NFID
has recently released a new "Best Practices" report called Immunizing Healthcare Personnel Against Influenza (http://www.nfid.org/HCWtoolkit/report.html). The basis for the report, which was developed with input from The National Influenza Vaccine Summit (http://www.preventinfluenza.org/nivs.asp), was to locate successful programs for immunizing healthcare workers against influenza, and present them as models that could be replicated by other organizations.


IMMUNIZATION LEGISLATION TRACKING WEBSITE: The Association of State and Territorial Health Officials (ASTHO) has created an Immunization Legislation Tracking website (http://www.astho.org/templates/display_pub.php?pub_id=2919&admin=1) that follows state and federal legislation and provides links to external immunization legislation resources. For more information, please contact Olivia Chang, analyst, Immunization Policy, at ochang@astho.org


SPANISH LANGUAGE MATERIALS: A Spanish-language version of the Recommended Immunizations for Babies is now available (http://www.cdc.gov/vaccines/spec-grps/infants/downloads/rec-iz-babies-sp.pdf). In addition, a Spanish-language version of CDC's Multi-Vaccine Vaccine Information Statement (http://www.immunize.org/vis/sp_multi.pdf) is now available.


NATIONAL INFLUENZA VACCINE SUMMIT: The 2008 National Influenza Vaccine Summit (NIVS; http://www.preventinfluenza.org/2008_summit_info.pdf) will be held on May 12-13 in Atlanta, GA. NIVS, co-sponsored by the American Medical Association (http://www.ama-assn.org) and CDC, meets annually to provide a forum for discussing influenza vaccine issues with diverse stakeholders.

To access the complete April issue from CDC's Vaccines & Immunizations website, go to:
http://www.cdc.gov/vaccines/news/newsltrs/imwrks/2008/200804.htm

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8 Important: Be sure to give influenza vaccine throughout the influenza season--through the spring months

Influenza is currently circulating, and vaccination should continue through the spring months. Visit the following websites often to find the information you need to keep vaccinating. Both are continually updated with the latest resources.

The National Influenza Vaccine Summit website at http://www.preventinfluenza.org

CDC's Seasonal Flu web section at http://www.cdc.gov/flu

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9 CDC reports on ACIP decision not to recommend routine MCV4 vaccination of all children ages 2-10 years

CDC published "Report from the Advisory Committee on Immunization Practices (ACIP): Decision Not to Recommend Routine Vaccination of All Children Aged 2-10 Years with Quadrivalent Meningococcal Conjugate Vaccine (MCV4)" in the May 2 issue of MMWR. Portions of the article are reprinted below.


At its February 2008 meeting, the Advisory Committee on Immunization Practices (ACIP) decided not to recommend routine vaccination of children aged 2-10 years against meningococcal disease unless the child is at increased risk for the disease. This report summarizes the deliberations of ACIP and the rationale for its decision and restates existing recommendations for meningococcal vaccination among children aged 2-10 years at increased risk for meningococcal disease. . . .

Based on reviews of safety and immunogenicity data, the epidemiology of meningococcal disease, a cost-effectiveness analysis, and programmatic considerations, ACIP decided not to recommend routine vaccination against meningococcal disease for all children aged 2-10 years at its February 2008 meeting. ACIP continues to recommend vaccination for children aged 2-10 years at increased risk for meningococcal disease. These children include travelers to or residents of countries in which meningococcal disease is hyperendemic or epidemic, children who have terminal complement deficiencies, and children who have anatomic or functional asplenia. Healthcare providers also may elect to vaccinate children aged 2-10 years who are infected with human immunodeficiency virus (HIV). MCV4 is preferred to MPSV4 for children aged 2-10 years in these groups at increased risk and for control of meningococcal disease outbreaks. In addition, if healthcare providers or parents elect to provide meningococcal vaccination to other children in this age group, MCV4 is preferred to MPSV4. Recommendations for use of MCV4 in persons aged 11-55 years, including a recommendation for routine vaccination with MCV4 of persons aged 11-18 years, have been published previously and remain unchanged.

For children aged 2-10 years who have received MPSV4 and remain at increased risk for meningococcal disease, ACIP recommends vaccination with MCV4 at 3 years after receipt of MPSV4. Children who last received MPSV4 more than 3 years before and remain at increased risk for meningococcal disease should be vaccinated with MCV4 as soon as possible. For children at lifelong increased risk for meningococcal disease, subsequent doses of MCV4 likely will be needed. ACIP will monitor available data on duration of protection to determine whether recommendations for revaccination with MCV4 are indicated. Persons with a history of Guillain-Barre syndrome (GBS) might be at increased risk for GBS after MCV4 vaccination; therefore, a history of GBS is a precaution to administration of MCV4.

Effective meningococcal conjugate vaccines for infants might be available in the near future. Phase III clinical trials for meningococcal conjugate vaccine in infants are ongoing, and published data suggest these vaccines are safe and immunogenic. Vaccines that provide protection against meningococcal disease early in life have the potential to greatly reduce the burden of meningococcal disease, especially if they provide protection against serogroup B meningococcal disease.


To access a web-text (HTML) version of the complete article, go to: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5717a4.htm

To access a ready-to-print (PDF) version of this issue of MMWR, go to: http://www.cdc.gov/mmwr/PDF/wk/mm5717.pdf

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10.  Reminder: National Conference on Immunization & Health Coalitions will be held in San Francisco May 21-23

The eighth National Conference on Immunization & Health Coalitions will be held in San Francisco on May 21-23. The deadline for standard registration is May 15.

To access comprehensive conference information, including an updated conference agenda, go to:
http://www.sfimmunize.org/page2.html

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Immunization Action Coalition  •  Saint Paul, MN
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This website is supported in part by a cooperative agreement from the National Center for Immunization and Respiratory Diseases (Grant No. 5U38IP000290) at the Centers for Disease Control and Prevention (CDC) in Atlanta, GA. The website content is the sole responsibility of IAC and does not necessarily represent the official views of CDC.