Immunization Action Coalition and the Hepatitis B Coalition

IAC EXPRESS

Previous issues index

Home page

Issue Number 508            January 31, 2005

CONTENTS OF THIS ISSUE

  1. CDC reports on an outbreak of invasive pneumococcal disease in Alaska during 2003-04
  2. CDC reports on outbreaks of pertussis associated with hospitals in the United States during 2003
  3. Note: On February 1, IAC will publish an Unprotected People report about a fatal case of pertussis in West Virginia
  4. Update: CDC continues to supplement its Influenza web section
  5. New: January issue of CDC's Immunization Works electronic newsletter now available on the NIP website
  6. Association of Immunization Managers seeks nominations for the 2nd annual "Natalie J. Smith, MD, Award"
  7. Save the date: National Viral Hepatitis Prevention Conference set for December 5-9 in Washington, DC
  8. CDC launches web page devoted to perinatal hepatitis B information and resources
  9. IAC updates immunization and viral hepatitis materials
  10. New: January 21 issue of IAC's Hep Express electronic newsletter available online

----------------------------------------------------------

Back to Top

---------------------------------------------------------------

ABBREVIATIONS: AAFP, American Academy of Family Physicians; AAP, American Academy of Pediatrics; ACIP, Advisory Committee on Immunization Practices; CDC, Centers for Disease Control and Prevention; FDA, Food and Drug Administration; IAC, Immunization Action Coalition; MMWR, Morbidity and Mortality Weekly Report; NIP, National Immunization Program; VIS, Vaccine Information Statement; VPD, vaccine-preventable disease; WHO, World Health Organization.
---------------------------------------------------------------

(1 of 10)
January 31, 2005
CDC REPORTS ON AN OUTBREAK OF INVASIVE PNEUMOCOCCAL DISEASE IN ALASKA DURING 2003-04

CDC published "Outbreak of Invasive Pneumococcal Disease--Alaska, 2003-2004" in the January 28 issue of MMWR. Portions of the article are reprinted below.

**********************

[From the article text]
In Alaska, statewide laboratory-based surveillance revealed an increase in invasive pneumococcal disease (IPD) in a rural region during 2003-2004. This report summarizes the outbreak, regional trends in serotype-specific pneumococcal carriage, and an assessment of use of standing orders for vaccination. The results of this analysis underscore the preventability of IPD and the importance of vaccination. . . .

[From the Editorial Note]
During 2003-2004, region A [a remote area of Alaska; 80% of its residents are Alaska Natives] experienced an outbreak of IPD in which seven (50%) of 14 patients had indications for vaccination and had disease caused by a vaccine-preventable serotype. Pneumococcal carriage is a dynamic process, and carriage of specific serotypes in a population fluctuates over time. On a statewide level, during 1986-1990, [serotype] 12F was the most common pneumococcal serotype isolated in Alaska Natives aged >=2 years, accounting for 20.1% of IPD. However, during 1991-2000, the frequency of IPD caused by serotype 12F in this same population subset decreased to 2.2%. In the 2003-2004 region A outbreak, an increase in carriage of serotype 12F was temporally associated with an increase in serotype 12F IPD.

The Advisory Committee on Immunization Practices (ACIP) recommends a one-time vaccination with PPV-23 [pneumococcal polysaccharide vaccine, 23-valent] for all persons aged >=65 years on the basis of its effectiveness against pneumococcal bacteremia. One revaccination after >=5 years is recommended for persons aged >=65 years if the first vaccine was administered before age 65 years. Revaccination >=5 years after the first dose is also recommended for persons aged >=2 years who are at high risk for invasive pneumococcal infection and who are likely to have rapid declines in pneumococcal antibody levels.

Surveillance for IPD in Alaska has documented that Alaska Natives have one of the highest rates of IPD in the world. In addition, age-related increases in rates of IPD occur at a younger age among Alaska Native adults compared with non-Alaska Native adults. Because of these findings, the Alaska Division of Health and Human Services recommends that all Alaska residents receive PPV-23 beginning at age 55 years and be revaccinated every 6 years. In the region A outbreak, adequate vaccination might have averted 50% of IPD cases.

A national health objective for 2010 is to achieve pneumococcal vaccination in 90% of adults aged >=65 years. The national self-reported prevalence of pneumococcal vaccination among persons aged >=65 years was 61.8% (95% confidence interval [CI] = 61.0-62.6) in 2002. The corresponding rate for residents of Alaska was 59.8% (CI = 50.3-69.1).

On the basis of evidence that standing orders programs improve vaccination rates, ACIP strongly recommends standing orders for pneumococcal and influenza vaccinations in inpatient and outpatient settings, long-term-care facilities, managed-care organizations, assisted-living facilities, and home healthcare agencies. Standing orders programs allow clinical staff to administer vaccinations according to an institution- or physician-approved protocol without the need for a physician's examination or direct order. Survey results suggest that successful standing orders programs depend on convenient access to reliable immunization records and adequate clinical staff support. When resources are available, computer-based standing orders effectively increase vaccination rates. In the case of missing immunization records, providers should follow the 1997 ACIP recommendations to vaccinate patients who are uncertain about their vaccination histories or have incomplete records.

The 2003-2004 region A outbreak emphasizes the need to take every opportunity for vaccination in both inpatient and outpatient settings. Many patients with risk factors indicating vaccination might not have a regular primary-care provider but instead might seek medical attention in an emergency department or urgent-care clinic. Screening and subsequent immunization of persons with indications for vaccination in both primary-care and urgent-care settings could substantially reduce complications and death associated with pneumococcal disease. Region A initiated provider education and a standing orders program in response to the outbreak; surveillance for IPD continues. Other healthcare providers, both in Alaska and nationally, should identify and address barriers to vaccination. Implementation of ACIP recommendations for standing orders programs is strongly recommended to take advantage of opportunities for vaccination and reduce pneumococcal morbidity and mortality.

***********************

To access a web-text (HTML) version of the complete article, go to: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5403a5.htm

To access a ready-to-copy (PDF) version of this issue of MMWR, go to: http://www.cdc.gov/mmwr/PDF/wk/mm5403.pdf

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

Back to Top

(2 of 10)
January 31, 2005
CDC REPORTS ON OUTBREAKS OF PERTUSSIS ASSOCIATED WITH HOSPITALS IN THE UNITED STATES IN 2003

CDC published "Outbreaks of Pertussis Associated with Hospitals--Kentucky, Pennsylvania, and Oregon, 2003" in the January 28 issue of MMWR. Portions of the article are reprinted below.

***********************

[From the article text]
Pertussis outbreaks have been reported in various settings, including sports facilities, summer camps, schools, and health-care facilities. Mild and atypical manifestations of pertussis among infected persons and the lack of quick and accurate diagnostic tests can make pertussis outbreaks difficult to recognize and therefore difficult to control. Outbreaks among healthcare workers (HCWs) are of special concern because of the risk for transmission to vulnerable patients. This report describes three pertussis outbreaks among HCWs and patients that occurred in hospitals in Kentucky, Pennsylvania, and Oregon in 2003. These outbreaks illustrate the importance of complying with measures to reduce nosocomial infection when evaluating or caring for patients with acute respiratory distress or cough illness of unknown etiology. . . .

Case Investigations

Kentucky. In early August 2003, an infant aged 2 months, who was born at 26 weeks' gestation and hospitalized in the intermediate care nursery (ICN) since birth, exhibited cough and apnea. Two days later, the infant was transferred to a neonatal intensive care unit (NICU) and ventilated mechanically. Seven days later, pertussis was suspected; 3 days later, nasopharyngeal (NP) secretions tested positive for B. pertussis DNA by PCR [polymerase chain reaction]. The infant was treated with azithromycin (10 mg/kg/day on day 1 and 5 mg/kg/day on days 2-5), and droplet precautions were initiated in the NICU. . . .

Pennsylvania. In early September 2003, an infant aged 3 weeks was admitted to the pediatric unit at hospital A for 1 day before being transferred to a referral hospital. The infant had cough, posttussive vomiting, and fever for 5 days. Pertussis infection was considered unlikely in the differential diagnosis, the patient was not tested for pertussis, and droplet precautions were not observed by staff. NP secretions were obtained for culture from the infant at the referral hospital, and B. pertussis was isolated 16 days later. Pediatrician B, who cared for the infant at hospital A, had onset of a cough illness 9 days after exposure. Even though he remained symptomatic, the pediatrician continued to treat patients without wearing a mask and was in contact with other HCWs, family members, and friends. Twenty-two days after his initial exposure, NP secretions obtained from pediatrician B were positive for B. pertussis DNA by PCR. . . .

Oregon. In late September 2003, physician C treated an infant aged 12 months with PCR-confirmed pertussis in the pediatric ICU. Physician C, who wore a mask while providing care to the infant, had been exposed to a colleague who had prolonged cough illness since mid-September. The colleague was subsequently found to have elevated IgG anti-pertussis-toxin antibody levels (i.e., >20 [micrograms]/mL, as measured by the MSLI [Massachusetts State Laboratory Institute] assay) consistent with recent pertussis infection. . . .

[From the Editorial Note]
Despite high childhood coverage for pertussis vaccination, reported pertussis incidence in the United States has increased from a low of 1,248 cases (0.54 per 100,000 population) in 1981 to an annual average of 9,431 cases during 1996-2003 (average annual rate: 3.3 per 100,000 population). During 1996-2004, the majority of pertussis patients were either aged <6 months (35.1%) (i.e., too young to have received the 3-dose primary series) or aged >=7 years (60.7%) (i.e., too old to receive a pertussis vaccination). Adolescents and adults, including HCWs, might become susceptible to pertussis because of waning immunity. No pertussis vaccine is approved in the United States for persons aged >=7 years; however, in 2004, two pharmaceutical companies submitted biologics license applications to the Food and Drug Administration (FDA) for two tetanus toxoid and reduced diphtheria toxoid and acellular pertussis vaccine adsorbed (Tdap) products, one for persons aged 10-18 years and the other for persons aged 11-64 years.

This report highlights two primary difficulties in the diagnosis of pertussis. First, diagnosis might be delayed or missed because symptoms are atypical. In adolescents and adults, symptoms during the catarrhal stage are most often nonspecific, but the disease is already highly communicable. In infants, diagnosis might be delayed when the presentation is respiratory distress with apnea without the typical cough. Second, sensitive and specific diagnostic tests for pertussis are not readily available in many settings; culture, the standard test, has diminishing sensitivity with progression of the classic symptoms of the infection. PCR for pertussis is not standardized, and false-positive and false-negative results can occur. In addition, no serologic test for pertussis has yet been validated and made available nationally, although CDC and FDA are developing such a test.

Because droplet transmission of pertussis can occur at the first contact with an ill patient, HCWs and hospital infection-control services should take measures to prevent hospital transmission. Many nosocomial outbreaks might be prevented by HCWs' observing droplet precautions (i.e., wearing procedural or surgical masks and hand washing). Delay in recognizing pertussis can result in spread of disease to HCWs, patients, and other contacts. HCWs should suspect pertussis in unvaccinated or partially vaccinated infants with respiratory distress (e.g., apnea or cough) and obtain NP secretions for culture. Isolation precautions are recommended for confirmed and suspected cases of pertussis.

Erythromycin is recommended for treatment and prophylaxis of pertussis. However, because erythromycin frequently causes gastrointestinal disturbance, many patients do not complete the recommended 2-week course. Azithromycin was used during all the outbreaks described in this report because it causes fewer and milder side effects than erythromycin and its longer half-life means that fewer daily doses are required, thereby increasing the potential for patient compliance. A recent study that compared azithromycin administered as 10 mg/kg (maximum: 500 mg) on day 1 followed by 5 mg/kg (maximum: 250 mg) on days 2-5 with a 7-day treatment of erythromycin demonstrated equivalence between the two treatments.

Nosocomial pertussis outbreaks can result in substantial public health and economic costs. Public health professionals and hospital decision-makers should consider potential savings and benefits from implementing effective infection-control strategies and from selective pertussis vaccination of HCWs when adult vaccines become available in the United States.

[Excerpted from the box titled "Epidemiology, diagnosis, treatment, and prevention of transmission among healthcare workers (HCWs) and close contacts"]

Prevention

  • Vaccination of children is available in a 5-dose series administered at ages 2, 4, 6, and 15-18 months and age 4-6 years.
     
  • HCWs or patients with pertussis-like cough illness (i.e., highly suspected for pertussis) should be tested and treated.
     
  • HCWs with pertussis should be excluded from work for 5 days from the start of antibiotic use; if no antibiotic is taken, HCWs should be excluded from work for 21 days from onset of symptoms.
     
  • HCWs should keep coughing patients >3 feet from other persons and implement droplet precautions, including wearing of procedural or surgical masks.
     
  • Isolation precautions are recommended for confirmed and suspected pertussis cases.

***********************

To access a web-text (HTML) version of the complete article, go to: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5403a3.htm

To access a ready-to-copy (PDF) version of this issue of MMWR, go to: http://www.cdc.gov/mmwr/PDF/wk/mm5403.pdf
---------------------------------------------------------------

Back to Top

(3 of 10)
January 31, 2005
NOTE: ON FEBRUARY 1, IAC WILL PUBLISH AN UNPROTECTED PEOPLE REPORT ABOUT A FATAL CASE OF PERTUSSIS IN WEST VIRGINIA

On February 1, IAC will publish an IAC Express Unprotected People report about a fatal case of pertussis in West Virginia in 2004. The report is based on information reported to CDC by hospitals and local and state public health departments in West Virginia.
---------------------------------------------------------------

Back to Top

(4 of 10)
January 31, 2005
UPDATE: CDC CONTINUES TO SUPPLEMENT ITS INFLUENZA WEB SECTION

CDC recently posted the following new and updated information to its Influenza web section.

REVISED INTERIM GUIDANCE
(1) On January 27, the Health Alert Network issued an official Health Update titled Revised Interim Guidance for Late-Season Influenza Vaccination. The revised interim guidance is now available on CDC's Influenza web section. To access a ready-to-print (PDF) version of it, go to:
http://www.cdc.gov/flu/protect/pdf/fluvaccine-lateseasonguidance.pdf

To access a web-text (HTML) version, go to:
http://www.cdc.gov/flu/protect/lateseasonguidance.htm

CDC updated the following to reflect the revised interim guidance:

(2) Questions and Answers: Flu Vaccination in the 2004-05 Season
To access a web-text (HTML) version, go to:
http://www.cdc.gov/flu/about/qa/0405vaccination.htm

(3) Fact Sheet: Key Facts About Flu Vaccine
To access a ready-to-print (PDF) version of it, go to:
http://www.cdc.gov/flu/protect/pdf/vaccinekeyfacts.pdf

To access a web-text (HTML) version, go to:
http://www.cdc.gov/flu/protect/keyfacts.htm

(4) Fact Sheet: Who Should Get Flu Vaccine This Season?
To access a ready-to-print (PDF) version of it, go to:
http://www.cdc.gov/flu/protect/pdf/0405shortage.pdf

To access a web-text (HTML) version, go to:
http://www.cdc.gov/flu/protect/0405shortage.htm

(5) Business and the Workplace: 2004-05 Influenza Season
To access a ready-to-print (PDF) version of it, go to:
http://www.cdc.gov/flu/protect/pdf/workplace-flu0405.pdf

To access a web-text (HTML) version, go to:
http://www.cdc.gov/flu/protect/workplace.htm

(6) Colleges and Universities: 2004-05 Influenza Season
To access a ready-to-print (PDF) version of it, go to:
http://www.cdc.gov/flu/school/pdf/college.pdf

To access a web-text (HTML) version, go to:
http://www.cdc.gov/flu/school/college.htm

AVIAN INFLUENZA OUTBREAKS IN ASIA
(7) On January 24, CDC added a revised case count to its web page Recent Avian Influenza Outbreaks in Asia. To access it, go to:
http://www.cdc.gov/flu/avian/outbreaks/asia.htm

For ongoing information about new and updated materials on CDC's Influenza web section, go to:
http://www.cdc.gov/flu/whatsnew.htm
---------------------------------------------------------------

Back to Top

(5 of 10)
January 31, 2005
NEW: JANUARY ISSUE OF CDC'S IMMUNIZATION WORKS ELECTRONIC NEWSLETTER NOW AVAILABLE ON THE NIP WEBSITE

The January issue of Immunization Works, a monthly email newsletter published by CDC, is available on NIP's website. The newsletter offers members of the immunization community non-proprietary information about current topics. CDC encourages its wide dissemination.

To access the January issue from the NIP website, go to:
http://www.cdc.gov/nip/news/newsltrs/imwrks/2005/200501.htm
---------------------------------------------------------------

Back to Top

(6 of 10)
January 31, 2005
ASSOCIATION OF IMMUNIZATION MANAGERS SEEKS NOMINATIONS FOR THE 2ND ANNUAL "NATALIE J. SMITH, MD, AWARD"

The Association of Immunization Managers (AIM) is seeking nominations for the 2005 "Natalie J. Smith, MD, Award." The award, which will be presented at the National Immunization Conference in March, was established to honor the memory of Dr. Smith's outstanding management and leadership skills in the area of state and national vaccine-preventable disease programs. Eligible candidates are current or recently retired immunization program managers who are designated as the persons primarily responsible for directing the 64 city, state, or territorial immunization programs directly funded by the National Immunization Program. THE DEADLINE FOR NOMINATIONS IS FEBRUARY 28.

Dr. Smith, who died in 2003 at age 41, was deputy director, National Immunization Program, CDC. Prior to accepting the NIP position, she served for eight years as chief, Immunization Branch, California Department of Health Services. Dr. Smith served as a member of the Advisory Committee on Immunization Practices and as chair of the Association of Immunization Managers. She wrote numerous significant publications on immunization and was a frequent presenter and consultant on immunization-related issues.

To access more information about the award, including the nomination criteria and a 2005 nomination form, go to:
http://www.immunize.org/news.d/smithaward05.pdf

For additional information, contact Claire Hannan, AIM Executive Director, by email at channan@astho.org, by phone at (202) 715-1676, or by fax at (202) 371-9797.
---------------------------------------------------------------

Back to Top

(7 of 10)
January 31, 2005
SAVE THE DATE: NATIONAL VIRAL HEPATITIS PREVENTION CONFERENCE SET FOR DECEMBER 5-9 IN WASHINGTON, DC

[The following is cross posted from IAC's Hep Express electronic newsletter, 1/21/05.]

The 2005 National Viral Hepatitis Prevention Conference (previously known as the National Hepatitis Coordinators' Conference) will be held on December 5-9, in Washington, D.C.

The focus of the conference will be on the prevention of viral hepatitis through every stage of life. Attendees will receive the latest scientific updates related to hepatitis A, B, and C. Workshops will address providing services to injection drug users and men who have sex with men; overcoming health disparities; designing, implementing, and evaluating successful outreach, education, and counseling activities; identifying and overcoming barriers to integrating hepatitis prevention activities into existing programs; and obtaining funding and other resources.

The conference is intended for public health professionals, counselors, administrators, health policy makers, educators, and others interested in the control of viral hepatitis, including those working in perinatal or immunization programs, STD and HIV clinics, correctional health care, and substance abuse programs.

For more information, visit http://www.cdc.gov/ncidod/diseases/hepatitis/conference.htm Registration information, abstract submission guidelines, and a draft conference agenda will be forthcoming on this site.
---------------------------------------------------------------

Back to Top

(8 of 10)
January 31, 2005
CDC LAUNCHES WEB PAGE DEVOTED TO PERINATAL HEPATITIS B INFORMATION AND RESOURCES

[The following is cross posted from IAC's Hep Express electronic newsletter, 1/21/05.]

CDC's National Immunization Program (NIP) has recently added a web page of perinatal hepatitis B information to its website. The new section features pertinent brochures, flyers, slide sets, and websites for parents, healthcare professionals, and state hepatitis B coordinators.

The new web page also includes a link to 2003 National Immunization Survey (NIS) data, which includes the 2003 birth dose data.

Visit this valuable new resource at
http://www.cdc.gov/nip/diseases/hepB/pubs_other.htm
---------------------------------------------------------------

Back to Top

(9 of 10)
January 31, 2005
IAC UPDATES IMMUNIZATION AND VIRAL HEPATITIS MATERIALS

IAC recently reviewed several of its print pieces related to immunization and viral hepatitis for accuracy and updated some of them. Following is a list of pieces reviewed and/or updated in January 2005.

IMMUNIZATION MATERIALS
The following pieces were REVIEWED AND UPDATED:
(1) "What would happen if we stopped vaccinations" was revised to reflect 2003 data.
To access a ready-to-print (PDF) version of it, go to:
http://www.immunize.org/catg.d/4037stop.pdf

To access a web-text (HTML) version, go to:
http://www.immunize.org/catg.d/4037stop.htm

(2) "Vaccines and autism" was revised to add a new study.
To access a ready-to-print (PDF) version of it, go to:
http://www.immunize.org/catg.d/p2065.pdf

To access a web-text (HTML) version, go to:
http://www.immunize.org/catg.d/p2065.htm


VIRAL HEPATITIS MATERIALS
The following pieces were REVIEWED AND UPDATED:
(3) "States Report Hundreds of Medical Errors in Perinatal Hepatitis B Prevention"
To access a ready-to-print (PDF) version of it, go to:
http://www.immunize.org/catg.d/p2062.pdf

To access web-text (HTML) version, go to:
http://www.immunize.org/catg.d/p2062.htm

(4) "Unprotected Babies: Two more infants chronically infected with hepatitis B virus . . . the medical errors continue"
To access a ready-to-print (PDF) version of it, go to:
http://www.immunize.org/catg.d/p2127.pdf

To access web-text (HTML) version, go to:
http://www.immunize.org/catg.d/p2127.htm

(5) "Management of Chronic Hepatitis B in Adults" by Brian J. McMahon, MD
To access a ready-to-print (PDF) version of it, go to:
http://www.immunize.org/catg.d/p2161.pdf

To access web-text (HTML) version, go to:
http://www.immunize.org/catg.d/p2161.htm

(6) "Every day, teens are infected with hepatitis B"
To access a ready-to-print (PDF) version of it, go to:
http://www.immunize.org/catg.d/p4100tee.pdf

To access web-text (HTML) version, go to:
http://www.immunize.org/catg.d/p4100tee.htm

The following pieces were REVIEWED AND LEFT UNCHANGED:
(7) "Hepatitis B and the Health Care Worker"
To access a ready-to-print (PDF) version of it, go to:
http://www.immunize.org/catg.d/2109hcw.pdf

To access a web-text (HTML) version, go to:
http://www.immunize.org/catg.d/2109hcw.htm

(8) "Hospitals & Doctors Sued for Failing to Protect Newborns from Hepatitis B Virus Transmission"
To access a ready-to-print (PDF) version of it, go to:
http://www.immunize.org/catg.d/p2061.pdf

To access a web-text (HTML) version, go to:
http://www.immunize.org/catg.d/p2061.htm

(9) "If you have chronic hepatitis B virus (HBV) infection..."
To access a ready-to-print (PDF) version of it, go to:
http://www.immunize.org/catg.d/p4120eng.pdf

To access a web-text (HTML) version, go to:
http://www.immunize.org/catg.d/p4120.htm
---------------------------------------------------------------

Back to Top

(10 of 10)
January 31. 2005
NEW: JANUARY 21 ISSUE OF IAC'S HEP EXPRESS ELECTRONIC NEWSLETTER AVAILABLE ONLINE

The January 21 issue of Hep Express, an electronic newsletter published by IAC, is now available online. Hep Express is intended for health and social service professionals involved in the prevention and treatment of viral hepatitis. The January 21 issue includes articles on the following:

Upcoming conferences: (1) the National Viral Hepatitis Prevention Conference (see article #7 above) and (2) a conference on hepatitis C sponsored by the American Association for the Study of Liver Diseases.

Hepatitis-related information from CDC and the Department of Health and Human Services (DHHS): (1) CDC fact sheets about hepatitis A and hepatitis E for tsunami survivors, (2) NIP's web page of perinatal hepatitis B information (see article #8 above), and (3) DHHS funds available for prevention of substance abuse, HIV, and hepatitis in minority populations.

Recently reviewed and revised IAC materials related to viral hepatitis (see article #9) above.

Presentations made at the Viral Hepatitis Prevention Board's November 2004 meeting.

To access the January 21 issue, go to:
http://www.hepprograms.org/hepexpress/issue25.asp


To sign up for a free subscription to Hep Express, go to:
http://www.hepprograms.org/hepexpress/signup.asp
 
 
To access previous issues of Hep Express, go to:
http://www.hepprograms.org/hepexpress/index.asp

 

Immunization Action Coalition1573 Selby AvenueSt. Paul MN 55104
E-mail: admin@immunize.org Web: http://www.immunize.org/
Tel: (651) 647-9009Fax: (651) 647-9131

This page was updated on February 2, 2005