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IAC Express 2009 |
| Issue number 810: July 13, 2009 |
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Please click here to subscribe to IAC Express
as well as other FREE IAC periodicals. |
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Contents
of this Issue
Select a title to jump to the article. |
-
Important: CDC's Q&A on HepB vaccine supply constraints presents advice on
judicious use of HepB when immunizing infants, children, and adults
- MMWR
article reports on imported human rabies in California in 2008
- ACIP
website posts provisional recommendations for prevention of human rabies
- HAN
issues Info Service Message on three reports of oseltamivir-resistant
novel influenza H1N1 viruses
- MMWR
Dispatch reports on intensive-care patients with severe influenza H1N1
infection in Michigan
- White
House's H1N1 Influenza Summit calls on nation to prepare for 2009-10
seasonal influenza and ongoing H1N1 influenza outbreak
- HHS
announces that states can receive $350 million for H1N1 and seasonal
influenza preparedness; list outlines funds available for each state
- CDC's
novel influenza H1N1 web section updated with plans for state/local
government vaccination programs, guidance for obstetric settings, and much
more
- ACIP
schedules special meeting on novel influenza H1N1 for July 29; be sure to
register ASAP
- IAC
updates two print pieces that answer the public's questions about shingles
and tetanus
- IAC's
Video of the Week features youth advocates making a difference by
supporting the Measles Initiative
- IAC's
padded screening questionnaires for contraindications now have English on
front, Spanish on the back--added value at no added cost
- MMWR
article reports on progress India made in eradicating polio during January
2007-May 2009
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| Abbreviations |
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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. |
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Issue 810: July 13, 2009 |
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1. |
Important: CDC's Q&A on HepB vaccine supply constraints presents advice on
judicious use of HepB when immunizing infants, children, and adults
On July 10, CDC posted an important document for
healthcare
professionals, "Hepatitis B (HepB) Vaccine Supply
Constraints: Questions and answers for infant, children, and
adult providers." The document discusses (1) the use of
monovalent HepB and the combination vaccines Pediarix and
Pentacel vaccines in infants and children and (2) the use of
adult HepB formulations, including combination and dialysis
formulations.
To access the document, go to:
http://www.cdc.gov/print.do?url=http://www.cdc.gov/vaccines/vac-gen/shortages/hepb-supply-07-10-09.htm
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2. |
MMWR article reports on imported human rabies in California in 2008
CDC published "Imported Human Rabies--California,
2008" in
the July 10 issue of MMWR. A portion of the article is
reprinted below.
Compared with rabies in developing countries, human rabies
is rare in the United States, but animal rabies is common.
In the United States, most human rabies cases are associated
with rabid bats, whereas in developing countries, dogs are
the most common reservoir and vector species. In March 2008,
a case of imported human rabies in a recently arrived,
undocumented Mexican immigrant was laboratory confirmed by
public health officials in California. The rabies virus
isolated from the patient was a previously uncharacterized
variant most closely related to viruses found in Mexican
free-tailed bats (Tadarida brasiliensis). The molecular and
phylogenetic characterizations of this rabies virus variant
have been described previously. This report summarizes the
epidemiologic investigation and the ensuing public health
response. A total of 20 persons, mostly household contacts,
received postexposure prophylaxis (PEP) because of potential
exposure to rabies virus from the patient. The findings
underscore the difficulties encountered in the diagnosis and
epidemiologic investigations of imported human rabies cases
and the importance of a coordinated public health response
across multiple international jurisdictions.
Case Report
On March 17, 2008, a male aged 16 years who had recently
entered the United States from Oaxaca, Mexico, was brought
by his family to an emergency department (ED) in Santa
Barbara County, California, with sore throat and a recent
history of not eating or drinking. The ED physician obtained
a history with assistance from a translator. The patient's
vital signs were remarkable for a mild temperature elevation
(100.6 degrees F [38.1 degrees C]) and tachycardia (140
beats per minute). He was awake and alert but agitated and
crying. His examination was notable for mild abdominal
tenderness. Laboratory studies included a complete blood
count, electrolytes, liver function tests, and urinalysis.
Results were normal except an elevated blood urea nitrogen
value of 20 mg/dL (normal range: 7-18 mg/dL). The patient
was given intravenous fluids and discharged with the
diagnosis of pharyngitis and abdominal pain.
Several hours later, the patient was brought by his family
to the same ED with nausea, vomiting, fever, and sore
throat. He was mildly febrile (99.1 degrees F [37.3 degrees
C]) with tachycardia (164 beats per minute) and was noted to
be agitated and uncooperative. He refused to take fluids and
was observed to spit frequently. Because of the patient's
agitated behavior and his refusal to take oral fluids, the
ED physician suggested that psychiatric consultation might
be needed. The patient was again given intravenous fluids
for dehydration. He was discharged to his aunt's home with
the diagnosis of viral pharyngitis, depression, and
anorexia.
The next day, on March 18, the patient experienced
vomiting and shaking and then collapsed at his aunt's
home. When paramedics arrived, the patient was not breathing
and was unresponsive. Resuscitation efforts
were not successful. . . .
The patient's mode of travel to the United States likely
hindered more immediate prevention efforts by local health
officials in his home jurisdiction. The undocumented status
of the patient might have led to the patient and his family
not readily disclosing complete information to healthcare
providers or officials, thereby delaying consideration of a
rabies diagnosis. Nevertheless, a disoriented, salivating,
and dehydrated patient who avoids water should prompt a
consideration of rabies in the differential diagnosis,
irrespective of a documented history of animal exposure.
Healthcare providers should consider rabies in patients with
acute progressive encephalitis. In particular, rabies should
be included in the differential diagnosis where a travel
history or immigration status has indicated time spent in a
canine rabies endemic country. . . .
To access a web-text (HTML) version of the complete article,
go to:
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5826a1.htm
To access a ready-to-print (PDF) version of this issue of
MMWR, go to:
http://www.cdc.gov/mmwr/PDF/wk/mm5826.pdf
To receive a FREE electronic subscription to MMWR (which
includes new ACIP recommendations), go to:
http://www.cdc.gov/mmwr/mmwrsubscribe.html
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3. |
ACIP website posts provisional recommendations for prevention of human rabies
On July 10, ACIP website posted "ACIP Provisional
Recommendations for the Prevention of Human Rabies." The
document is reprinted below in its entirety.
ACIP Provisional Recommendations for the Prevention Of Human
Rabies
Date of ACIP meeting and vote: June 24, 2009
Date of posting of provisional recommendations: July 10,
2009
On June 24, 2009, the ACIP approved new recommendations on
the use of rabies vaccine for post-exposure prophylaxis for
the prevention of human rabies.
A summary of the new provisional recommendations for the use
of rabies vaccine follows:
Post-exposure Prophylaxis for Unvaccinated Persons:
Vaccine Use. A regimen of 4 one-mL vaccine doses of rabies
vaccine (HDCV or PCEV) should be administered
intramuscularly to previously unvaccinated persons with no
immunosuppression. The first dose of the 4-dose course
should be administered as soon as possible after exposure.
This date is considered day 0 of the post-exposure
prophylaxis series. Additional doses should then be
administered on days 3, 7, and 14 after the first
vaccination. Considerations for the site of the
intramuscular vaccination remain unchanged.
Rabies Immune Globulin Use. The recommendations for use of
immune globulin remain unchanged.
Post-exposure Prophylaxis for Previously Vaccinated Persons:
The recommendations for the post-exposure management of
previously vaccinated individuals remain unchanged.
Post-Vaccination Serologic Testing:
No testing of healthy patients completing prophylaxis is
necessary to document seroconversion, unless the person is
immunosuppressed. When titers are obtained, specimens
collected from 1 to 2 weeks after prophylaxis should
completely neutralize challenge virus at a 1:5 serum
dilution by the rapid fluorescent focus inhibition test
(RFFIT).
Precautions--Immunosuppression:
Immunosuppression results from a wide variety of conditions.
Primary or secondary immunodeficiencies may significantly
reduce immune responses to vaccines. Given the large variety
of immunocompromising conditions, as well as subsequent
alterations in degrees of clinically significant
immunodeficiencies, the evaluation of a potentially
immunocompromised patient, as well as the decision about
proper immunization of the immunocompromised patient,
ultimately lies with the attending physician.
All rabies vaccines licensed in the U.S. are inactivated
cell culture vaccines and as such can be administered safely
to persons with altered immunocompetence. The effectiveness
of such vaccinations and quality of elicited immune
responses in immunocompromised patients could be suboptimal.
Extensive monitoring of the immune response after rabies
vaccination, specifically the determination of rabies virus-neutralizing antibodies, should be performed.
For persons with broadly defined immunosuppression, post-exposure prophylaxis should be administered using all 5
doses of vaccine, with the awareness that the immune
response may still be inadequate. When administered to an
immunosuppressed person, one or more serum samples should be
tested for rabies virus neutralizing antibody by the RFFIT
to ensure that an acceptable antibody response has developed
after completing the series. A patient who fails to
seroconvert with an acceptable antibody response after the
fifth and last dose should be managed in consultation with
their physician and appropriate public health officials.
The 2008 ACIP recommendations for the prevention of human
rabies are otherwise unchanged, and are available at
http://www.cdc.gov/mmwr/preview/mmwrhtml/rr57e507a1.htm
This document can be found at
http://www.cdc.gov/vaccines/recs/provisional/downloads/rabies-July2009-508.pdf
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4. |
HAN issues Info Service Message on three reports of oseltamivir-resistant
novel influenza H1N1 viruses
On July 9, CDC's Health Alert Network (HAN)
issued an Info
Service Message titled "Three Reports of Oseltamivir
Resistant Novel Influenza A (H1N1) Viruses." The summary
section of the message is reprinted below.
Summary
On July 7, 2009, the World Health Organization announced the
identification of a third person with oseltamivir resistant
novel H1N1 virus infection.
All three people fully recovered after uncomplicated
illnesses and did not have contact with each other. Two of
the three people are reported to have developed illness
while taking oseltamivir preventatively after an exposure to
a close contact with novel influenza A (H1N1). The third
person had no known exposure to oseltamivir.
Results from ongoing testing of novel influenza A (H1N1)
viruses indicate that oseltamivir resistance remains rare.
The interim recommendations for the use of antiviral
medications for chemoprophylaxis and treatment have not been
changed http://www.cdc.gov/h1n1flu/recommendations.htm
Judicious use of antiviral medications is recommended to
reduce the possibilities of the development and spread of
antiviral resistant influenza viruses.
Use of zanamivir or oseltamivir should be focused on
treatment of persons with suspected novel H1N1 influenza who
are (1) hospitalized or (2) at higher risk for complications
due to influenza, even if hospitalization is not required.
Personal hygiene practices such as hand washing and
practices to prevent the spread of an ill person's
respiratory secretions should continue during treatment
because an infected person may continue to shed virus in
respiratory secretions while on therapy.
Use of oseltamivir for chemoprophylaxis should be reserved
for certain specific situations, such as when a person at
high risk for influenza-related complications is exposed to
a person with influenza.
Monitoring for antiviral resistance is ongoing and
clinicians and state health departments should continue to
follow state and national guidance for submission and
testing of clinical specimens from persons with suspected
novel influenza A (H1N1) virus infection.
More information will be provided as it becomes
available. . . .
To access the complete Info Service Message, go to:
http://www.cdc.gov/h1n1flu/HAN/070909.htm
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5. |
MMWR Dispatch reports on intensive-care patients with severe influenza H1N1
infection in Michigan
On July 10, CDC published "Intensive-Care
Patients with
Severe Novel Influenza A (H1N1) Virus Infection--Michigan,
June 2009" as an electronic MMWR Dispatch. The first
paragraph is reprinted below.
In April 2009, CDC reported the first two cases in the
United States of human infection with a novel influenza A
(H1N1) virus. As of July 6, a total of 122 countries had
reported 94,512 cases of novel influenza A (H1N1) virus
infection, 429 of which were fatal; in the United States, a
total of 33,902 cases were reported, 170 of which were
fatal. Cases of novel influenza A (H1N1) virus infection
have included rapidly progressive lower respiratory tract
disease resulting in respiratory failure, development of
acute respiratory distress syndrome (ARDS), and prolonged
intensive care unit (ICU) admission. Since April 26,
communitywide transmission of novel influenza A (H1N1) virus
has occurred in Michigan, with 655 probable and confirmed
cases reported as of June 18 (Michigan Department of
Community Health [MDCH], unpublished data, 2009). This
report summarizes the clinical characteristics of a series
of 10 patients with novel influenza A (H1N1) virus infection
and ARDS at a tertiary-care ICU in Michigan. Of the 10
patients, nine were obese (body mass index [BMI] >=30),
including seven who were extremely obese (BMI >=40); five
had pulmonary emboli; and nine had multiorgan dysfunction
syndrome (MODS). Three patients died. Clinicians should be
aware of the potential for severe complications of novel
influenza A (H1N1) virus infection, particularly in
extremely obese patients. . . .
To access a web-text (HTML) version of the complete MMWR
Dispatch, which includes a table and references, go to:
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm58d0710a1.htm
To access a ready-to-print (PDF) version of the MMWR
Dispatch, go to:
http://www.cdc.gov/mmwr/PDF/wk/mm58d0710.pdf
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6. |
White House's H1N1 Influenza Summit calls on nation to prepare for 2009-10
seasonal influenza and ongoing H1N1 influenza outbreak
On July 9, the White House's H1N1 Influenza
Preparedness
Summit was held at the National Institutes of Health in
Bethesda, MD. The Department of Health and Human Services
(HHS) issued a related press release titled "Obama
Administration Calls on Nation to Begin Planning and
Preparing for Fall Flu Season & the New H1N1 Virus"
Portions of the press release are reprinted below.
The Obama Administration sent a strong message to the nation
today that it is time to start planning and preparing for
the fall flu season and the ongoing H1N1 flu outbreak and
that the federal government is prepared to commit resources,
training, and new tools to help state and local governments
and America's families get ready.
White House Homeland Security Advisor John Brennan,
Secretary of Health and Human Services Kathleen Sebelius,
Secretary of Homeland Security Janet Napolitano, [and]
Secretary of Education Arne Duncan joined with delegations
from 54 states, tribes, and territories today at the H1N1
Influenza Preparedness Summit at the National Institutes of
Health in Bethesda, MD, to kick-off the government's
nationwide fall flu preparedness efforts. . . .
Throughout the one-day summit, Administration officials laid
out specific ways that states and local governments could
start their planning and preparation efforts and announced
new programs and resources to help state and local
governments, the medical community, and everyday America
prepare for H1N1 and the fall flu season.
First, HHS will make available preparedness grants worth a
total of $350 million. These grants were funded by Congress
in the latest supplemental appropriations bill, and they
will give state and local public health offices and
healthcare systems valuable resources to step up their
preparedness efforts.
Second, the federal government will centralize
communications about H1N1 and seasonal flu on the federal
government's new website, www.flu.gov This one-stop,
comprehensive site brings together flu-related information
from across HHS and other federal agencies. The expanded
site builds on the pandemic planning information long
presented on www.pandemicflu.gov and incorporates
information about the novel H1N1 flu as well as the seasonal
flu. . . .
To access the entire press release, go to
http://www.hhs.gov/news/press/2009pres/07/20090709a.html
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7. |
HHS announces that states can receive $350 million for H1N1 and seasonal
influenza preparedness; list outlines funds available for each state
On July 10, the Department of Health and Human
Services
(HHS) issued a press release titled "States Eligible to
Receive $350 Million for H1N1, Seasonal Flu Preparedness
Efforts." A portion of the press release is reprinted below;
the complete press release includes a list that outlines the
funds available for each state. A link to the complete press
release is given at the end of this IAC Express article.
One day after hosting a summit on the 2009 novel H1N1 flu
with representatives from state, tribal, territorial, and
local governments from across the country, HHS Secretary
Kathleen Sebelius today announced the availability of $350
million in grants to help states and territories prepare for
the 2009 novel H1N1 flu virus and the fall flu season. The
grants were funded by the recent supplemental appropriations
bill that was passed by Congress and signed into law by
President Barack Obama on June 24, 2009. . . .
A total of $260 million in Public Health Emergency Response
Grants and $90 million in Hospital Preparedness grants will
be distributed nationwide.
Public Health Emergency Response grants help state public
health departments perform a variety of functions, including
preparing for potential vaccination campaigns, implementing
strategies to reduce people's exposure to the 2009 novel
H1N1 flu, and improving influenza surveillance and
investigations.
Hospital Preparedness grants enhance the ability of
hospitals and healthcare systems to prepare for and respond
to public health emergencies. Local outbreaks of the novel
H1N1 virus have produced a surge of patients at hospitals,
and these grants will help ensure hospitals are ready for
future outbreaks that may impact their community. . . .
To access the complete press release, go to:
http://www.hhs.gov/news/press/2009pres/07/20090710a.html
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8. |
CDC's novel influenza H1N1 web section updated with plans for state/local
government vaccination programs, guidance for obstetric settings, and much more
CDC recently posted new or updated information to
various
sub-sections of its H1N1 Flu web section. Following are the
titles and URLs of documents that have been posted since the
July 6 issue of IAC Express.
CDC Recommendations for State and Local Planning for a 2009
Novel H1N1 Influenza Vaccination Program
http://www.cdc.gov/h1n1flu/vaccination/statelocal/planning.htm
Considerations Regarding Novel H1N1 Flu Virus in Obstetric
Settings
http://www.cdc.gov/h1n1flu/guidance/obstetric.htm
Update: Interim Guidance for Novel H1N1 Flu (Swine Flu):
Taking Care of a Sick Person in Your Home
http://www.cdc.gov/h1n1flu/guidance_homecare.htm
Update: What to Do If You Get Flu-Like Symptoms
http://www.cdc.gov/h1n1flu/sick.htm
Update: Novel H1N1 Flu (Swine Flu) and Feeding your Baby:
What Parents Should Know
http://www.cdc.gov/h1n1flu/infantfeeding.htm
The home page of CDC's H1N1 Flu web section can be accessed
from http://www.cdc.gov/h1n1flu
IAC has gathered important information related to H1N1
influenza in a new web section to make it easier to keep up
to date with developments. To access this resource, go to:
http://www.immunize.org/h1n1
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9. |
ACIP
schedules special meeting on novel influenza H1N1 for July 29; be sure to
register ASAP
The Advisory Committee on Immunization Practices
(ACIP) has
planned a special 1-day meeting on novel influenza H1N1 for
July 29. It will be held at CDC's Clifton Road campus in
Atlanta. The meeting is open to the general public.
Advance online registration is required for all attendees
who are not employees of the Department of Health and Human
Services. The registration deadline for the July 29 meeting
for non-U.S. citizens is July 20. The deadline for U.S.
citizens is July 24.
To access the online registration form, go to:
http://www2a.cdc.gov/nip/ACIP/JulyRegistration.asp
A very preliminary meeting agenda is available at
http://www.cdc.gov/vaccines/recs/acip/downloads/agenda-jul09.pdf
A more detailed agenda will follow.
To access additional information about the meeting, go to:
http://www.cdc.gov/vaccines/recs/acip/meetings.htm#register
There you will find links to driving directions and hotel
accommodations.
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10. |
IAC updates two print pieces that answer the public's questions about
shingles and tetanus
IAC recently revised two of its Q&A
patient-education print
pieces: "Shingles (Zoster): Questions and Answers" and
"Tetanus: Questions and Answers." The shingles Q&A was
updated to incorporate changes made in vaccine
recommendations; the tetanus Q&A, to incorporate newer
statistics and additional information on combination
vaccines and Tdap vaccine.
The revised pieces are ready-to-print versions of some of
the CDC-reviewed material located on IAC's Vaccine
Information website (www.vaccineinformation.org). The
website is intended for the public, health professionals,
and the media.
To access the revised ready-to-print (PDF) print piece
"Shingles (Zoster): Questions and Answers," go to:
http://www.immunize.org/catg.d/p4221.pdf
To view an HTML version of these Q&As, go to the following:
(1) Herpes Zoster (Shingles) disease:
http://www.vaccineinformation.org/zoster/qandadis.asp
(2) Herpes Zoster (Shingles) vaccine:
http://www.vaccineinformation.org/zoster/qandavax.asp
To access the revised ready-to-print (PDF) print piece
"Tetanus: Questions and Answers," go to:
http://www.immunize.org/catg.d/p4220.pdf
To view an HTML version of these Q&As, go to the following:
(1) Tetanus disease:
http://www.vaccineinformation.org/tetanus/qandadis.asp
(2) Tetanus vaccine:
http://www.vaccineinformation.org/tetanus/qandavax.asp
To access Q&As about other diseases and vaccines in PDF
format, go to:
http://www.immunize.org/printmaterials/questions.asp
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11. |
IAC's Video of the Week features youth advocates making a difference by
supporting the Measles Initiative
IAC encourages IAC Express readers to watch a
3-minute video
featuring youth advocates encouraging others to "get active
and get involved" in the Measles Initiative. A link to
information about the work of the Measles Initiative is
given at the end of this IAC Express article.
The video will be available on the home page of IAC's
website through July 19. To access it, go to:
http://www.immunize.org and click on the image under the
words Video of the Week, which you'll find toward the top of
the page. It may take a few moments for the video to begin
playing; please be patient!
Remember to bookmark IAC's home page to view a new video
every Monday. While you're at our home page, we encourage
you to browse around--you're sure to find resources and
information that will enhance your practice's immunization
delivery.
All the videos featured as an IAC Video of the Week have
recently been archived in a new section of IAC's website. To
view any of the videos previously featured, go to:
http://www.immunize.org/votw/jun09.asp
To access information about the Measles Initiative, go to:
http://www.measlesinitiative.org
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12. |
IAC's padded screening questionnaires for contraindications now have English
on front, Spanish on the back--added value at no added cost
In response to demand, IAC now has a
Spanish-language
translation of the questions on its padded Screening
Questionnaire for Child and Teen Immunization and Screening
Questionnaire for Adult Immunization. Printed on the back of
the English page, the Spanish page has been added to this
product at no additional cost.
The questionnaires give you and your patients a quick, easy,
and thorough way to determine if they have contraindications
and precautions to vaccination. Patients fill out the
questionnaire with yes-or-no answers while waiting to be
seen, allowing you to review their responses quickly and be
confident you're not missing any contraindications or
precautions.
The questionnaires come in convenient tear-off pads of 100
sheets. The price per pad is economical (discounts for two
pads or more), so you'll be able to keep pads at the
receptionist's desk, the nurse's station, and in every exam
room. Each pad comes with four English-language reference
sheets (printed on heavy-weight paper) for health
professionals.
Prices start at $16 each for one pad and drop to $12 each
for two, $11 each for three, and $10 each for four. For
quotes on larger quantities or customizing, call (651) 647-9009 or email
admininfo@immunize.org
To learn more about the padded screening questionnaires, or
to order online or download an order form, visit
Screening Questionnaire for Child and Teen Immunization
http://www.immunize.org/shop/pad_sqchild.asp
Screening Questionnaire for Adult Immunization
http://www.immunize.org/shop/pad_sqadult.asp
IAC's offers other products for sale, including educational
videos and personal immunization record cards, at
http://www.immunize.org/shop
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13. |
MMWR article reports on progress India made in eradicating polio during
January 2007-May 2009
CDC published "Progress Toward Poliomyelitis
Eradication--India, January 2007-May 2009" in the July 10 issue of MMWR.
A portion of a summary made available to the press is
reprinted below.
Wild poliovirus (WPV) circulation in India has been
restricted to small areas in two northern states, Bihar and
Uttar Pradesh. These states have been the source of other
cases in India since 2002, and sometimes the source for
polio cases in other countries. With an accelerated effort
to stop transmission of WPV type 1 (WPV1) before WPV type 3
(WPV3) with preferential use of a monovalent vaccine
directed against WPV1 in campaigns, WPV1 is currently
circulating in the smallest historical area in each state.
Uttar Pradesh state, a densely populated area where the oral
poliovirus vaccine appears to be less effective than
elsewhere, had been free of WPV1 transmission for six
months. However, an outbreak in Uttar Pradesh started in May
2008 because of WPV imported from Bihar; this outbreak is
now waning. Bihar has had relatively few WPV1 cases in 2008-09 but because some areas are flood-prone, populations can
be difficult to access. While new approaches are being
explored to improve the effectiveness of vaccination,
current levels of WPV circulation make polio elimination in
India within reach.
To access a web-text (HTML) version of the complete article,
go to:
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5826a3.htm
To access a ready-to-print (PDF) version of this issue of
MMWR, go to:
http://www.cdc.gov/mmwr/PDF/wk/mm5826.pdf
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