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Immunization Action Coalition
IAC Express 2009
Issue number 810: July 13, 2009
Please click here to subscribe to IAC Express as well as other FREE IAC periodicals.
Contents of this Issue
Select a title to jump to the article.
  1. Important: CDC's Q&A on HepB vaccine supply constraints presents advice on judicious use of HepB when immunizing infants, children, and adults
  2. MMWR article reports on imported human rabies in California in 2008
  3. ACIP website posts provisional recommendations for prevention of human rabies
  4. HAN issues Info Service Message on three reports of oseltamivir-resistant novel influenza H1N1 viruses
  5. MMWR Dispatch reports on intensive-care patients with severe influenza H1N1 infection in Michigan
  6. White House's H1N1 Influenza Summit calls on nation to prepare for 2009-10 seasonal influenza and ongoing H1N1 influenza outbreak
  7. HHS announces that states can receive $350 million for H1N1 and seasonal influenza preparedness; list outlines funds available for each state
  8. CDC's novel influenza H1N1 web section updated with plans for state/local government vaccination programs, guidance for obstetric settings, and much more
  9. ACIP schedules special meeting on novel influenza H1N1 for July 29; be sure to register ASAP
  10. IAC updates two print pieces that answer the public's questions about shingles and tetanus
  11. IAC's Video of the Week features youth advocates making a difference by supporting the Measles Initiative
  12. IAC's padded screening questionnaires for contraindications now have English on front, Spanish on the back--added value at no added cost
  13. MMWR article reports on progress India made in eradicating polio during January 2007-May 2009
 
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 810: July 13, 2009
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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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.