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IAC Express 2009 |
| Issue number 808: June 29, 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. |
- July 2009
issue of Needle Tips now available online
- CDC
recommends that providers reinstate the Hib booster dose for children ages
12-15 months
-
Important: During the novel influenza A (H1N1) outbreak, administer PPSV
to all people with existing indications
- Reminder:
Novel influenza A (H1N1) and the 2009-10 seasonal influenza
recommendations to be covered on CDC's July 16 net conference
- Florida
Department of Health looking for three boys who played with a rabid bat
- CDC
updates its novel influenza A H1N1 web section with revised guidance for
businesses
- IAC's
Video of the Week emphasizes the importance of hand-washing in stopping
the spread of disease
- June
issue of CDC's Immunization Works electronic newsletter recently released
-
Standardized injection site maps help everyone in the office use the same
anatomic sites for each vaccine
- IAC
updates a print piece that answers the public's questions about
meningococcal disease and vaccines
- HHS
announces $35 million contract for a new way to produce influenza vaccine
- Save the
date: July 7 is the new date for IZTA's Influenza Update conference call
- Order
laminated U.S. immunization schedules today!
- Perfect
for your waiting room: "The Saturday Shot" storybook presents a kid's-eye
view of getting immunized
- MMWR
article reports on the progress WHO's Western Pacific Region made in
eliminating measles during 1990-2008
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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 808: June 29, 2009 |
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1. |
July 2009 issue of Needle Tips now available online
The July 2009 issue of Needle Tips is now
available for
viewing and downloading. This free, popular, semi-annual,
24-page resource for health professionals is packed full of
easy-to-read and CDC-reviewed educational content, as well
as other resources for childhood, adolescent, and adult
immunization.
The July 2009 issue is the first issue of Needle Tips that
is not being distributed in print by U.S. mail. IAC assures
IAC Express and Needle Tips readers that the content of the
July 2009 issue--as well as all future issues--is fully up
to the standards you have come to expect from the hardcopies
of Needle Tips.
Here are the articles included in this issue:
-
Ask the Experts
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Vaccine Highlights: Recommendations, schedules, and more
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After the Shots . . . What to do if your child has
discomfort
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Do I Need Any Vaccinations Today?
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Handouts on Vaccination Schedules for Your Patients
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Recommended Immunization Schedules for Persons Ages 0
through 18 Years, U.S., 2009
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Recommended Adult Immunization Schedule, U.S., 2009
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How to Administer IM and SC Injections
-
Influenza Vaccination for Healthcare Workers: Our duty
to our patients
This online issue of Needle Tips allows readers to navigate
its content by using some of the more than 200 clickable
links located throughout.
To download the entire issue, go to:
http://www.immunize.org/nslt.d/n40/n40.pdf
If you don't have time to print the entire issue, select
from the clickable links, which you will find at
http://www.immunize.org/nt
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2. |
CDC recommends that providers reinstate the Hib booster dose for children
ages 12-15 months
CDC published "Updated Recommendations for Use of
Haemophilus Influenzae Type b (Hib) Vaccine: Reinstatement
of the Booster Dose at Ages 12-15 Months" in the June 26
issue of MMWR. It is reprinted below in its entirety,
excluding references.
On December 13, 2007, certain lots of Haemophilus influenzae
type b (Hib) vaccine marketed as PedvaxHIB (monovalent Hib
vaccine) and Comvax (Hib-HepB vaccine), and manufactured by
Merck & Co., Inc., were recalled voluntarily, and the
company temporarily suspended production of these vaccines.
To conserve the limited supply of Hib-containing vaccines,
CDC, in consultation with the Advisory Committee on
Immunization Practices (ACIP), the American Academy of
Family Physicians (AAFP), and the American Academy of
Pediatrics (AAP), on December 18, 2007, recommended that
vaccination providers temporarily defer the routine Hib
vaccine booster dose administered to most healthy children
at age 12-15 months.
Production of Merck Hib vaccine products is still suspended.
However, two other Hib-containing vaccines manufactured by
sanofi pasteur have been available for use in the United
States during this shortage: monovalent Hib vaccine (ActHIB)
and DTaP-IPV/Hib (Pentacel). Beginning in July 2009, the
manufacturer of these two vaccines will increase the number
of doses of these two products available for use in the
United States, which will result in the supply being
sufficient to reinstate the Hib vaccine booster dose.
Reinstatement of Hib Booster Dose
Effective immediately, CDC, in consultation with ACIP, AAFP,
and AAP, is recommending reinstatement of the booster dose
of Hib vaccine for children aged 12-15 months who have
completed the primary 3-dose series. Infants should continue
to receive the primary Hib vaccine series at ages 2, 4, and
6 months. Children aged 12-15 months should receive the
booster dose on time. Older children for whom the booster
dose was deferred should receive their Hib booster dose at
the next routinely scheduled visit or medical encounter.
Although supply is sufficient to reinstate the booster dose
and begin catch-up vaccination, supply is not yet ample
enough to support a mass notification process to contact all
children with deferred Hib booster doses.
Sufficient vaccine will be available to administer the
primary series at ages 2, 4, and 6 months and a booster dose
on time to children aged 12-15 months. As part of delivering
the booster dose to those children for whom it was deferred
at the next routinely scheduled appointment or medical
encounter, practices should discuss with parents the reasons
for the change in recommendation and might consider (1)
reviewing electronic or paper medical records or
immunization information system records to identify children
in need of a booster dose before physician encounters, (2)
evaluating children's vaccination status during their
scheduled visit, and (3) sharing immunization schedules with
parents to make them aware of this plan.
Use of Combination Vaccines
During the Hib shortage, children received protection from
certain vaccine-preventable diseases in their primary
vaccination series through various permutations of available
combination vaccines (e.g., DTaP-IPV/Hib [Pentacel] and
DTaP-IPV-HepB [Pediarix]) and monovalent vaccines (e.g.,
ActHib, HepB, and IPV). Therefore, a mismatch might exist
between patient vaccination needs and the available stock of
different vaccine formulations (e.g., combination products
versus single-antigen vaccines) in local provider offices.
This situation presents a challenge for providers to
administer vaccines to ensure appropriate coverage while
minimizing extra doses of unneeded vaccine. For example, if
a provider is using DTaP-IPV/Hib (Pentacel) vaccine to
protect infants against Hib disease, the provider should
ensure that adequate stock of monovalent HepB vaccine is
available to complete the HepB vaccine series [additional
information available at
http://www.cdc.gov/vaccines/vac-gen/shortages/downloads/eo-hib-hepb-cov.pdf].
Children who need the Hib booster and who already have received
4 doses of DTaP should receive monovalent Hib vaccine (ActHIB)
as their Hib booster dose. However, if DTaP-IPV/Hib is the only
Hib-containing vaccine available, this combination product
can be used to complete the series of Hib vaccination, even
if the child already has received all the necessary doses of
DTaP and IPV.
Information Regarding ActHIB or Pentacel
Vaccination providers with questions about their supplies of
monovalent Hib vaccine (ActHIB) or DTaP-IPV/Hib (Pentacel)
purchased with nonpublic funds should contact sanofi
pasteur's customer service department (telephone, [800] 822-2463). Sanofi pasteur will work directly with physicians to
increase allotments of Hib-containing vaccines on the basis
of previous purchasing patterns or practice birth cohort and
estimates of additional vaccine doses needed. For public
vaccine supplies, including Vaccines for Children Program
vaccine, providers should contact their state/local
immunization program to obtain vaccine.
This recommendation reflects CDC's assessment of the
existing national Hib vaccine supply and will be updated if
the supply changes. Updated information about the national
Hib vaccine supply is available at
http://www.cdc.gov/vaccines/vac-gen/shortages
Details about the routine Hib schedule are available at
http://www.cdc.gov/vaccines/recs/schedules/default.htm#child
Adverse events following receipt of any vaccine should be
reported to the Vaccine Adverse Event Reporting System
(VAERS) at http://vaers.hhs.gov
To access a web-text (HTML) version of the complete article,
go to:
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5824a5.htm
To access a ready-to-print (PDF) version of this issue of
MMWR, go to:
http://www.cdc.gov/mmwr/PDF/wk/mm5824.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. |
Important: During the novel influenza A (H1N1) outbreak, administer PPSV to
all people with existing indications
[The following is cross posted from CDC's
Immunization Works
electronic newsletter, June 2009.]
RECOMMENDATION FOR USE OF PPSV23 DURING NOVEL INFLUENZA A
(H1N1) OUTBREAK: CDC has issued interim guidance on the use
of pneumococcal polysaccharide vaccine during novel
influenza A (H1N1) outbreak
(http://www.cdc.gov/h1n1flu/guidance/ppsv_h1n1.htm). CDC
recommends a single dose of PPSV23 for all people 65 years
and older and for persons 2 [through] 64 years of age with
certain high-risk conditions. People in these groups are at
increased risk of pneumococcal disease as well as serious
complications from influenza. A single revaccination at
least five years after initial vaccination is recommended
for people 65 years and older who were first vaccinated
before age 65 years as well as for people at highest risk,
such as those who have no spleen, and those who have HIV
infection, AIDS, or malignancy.
All people who have existing indications for PPSV23 should
continue to be vaccinated according to current ACIP
recommendations during the outbreak of novel influenza A
(H1N1). Emphasis should be placed on vaccinating people aged
less than 65 years who have established high-risk conditions
because PPSV23 coverage among this group is low and because
people in this group appear to be overrepresented among
severe cases of novel influenza A (H1N1) infection, based on
currently available data. PPSV23 coverage estimates are
available online
(http://www.cdc.gov/flu/professionals/vaccination/pdf/NHIS89_07ppvvaxtrendtab.pdf).
Use of PPSV23 among people without current indications for
vaccination is not recommended at this time. This
recommendation may be revised as the epidemiology and
clinical presentation of novel influenza A (H1N1) virus
infection as well as the frequency and severity of secondary
pneumococcal infections are better understood.
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4. |
Reminder: Novel influenza A (H1N1) and the 2009-10 seasonal influenza
recommendations to be covered on CDC's July 16 net conference
[The following is cross posted from CDC's
Immunization Works
electronic newsletter, June 2009.]
UPCOMING NET CONFERENCE: Please mark your calendars for July
16th from 12 Noon-1:00 PM ET for a live net conference
program titled "Current Issues in Immunization." Dr. Joseph
Bresee, will present on "Novel Influenza A (H1N1) Update and
Seasonal Influenza Recommendations for the 2009-2010
Season." This program will combine a telephone audio
conference with simultaneous online visual content. It will
allow for a question and answer segment both by telephone
and via the Internet. Internet access and a separate phone
line are needed to participate. On-demand replays and
presentations will be available shortly after each event.
For more information, visit CDC's Current Issues in
Immunization web page
(http://www.cdc.gov/vaccines/ed/ciinc/#next).
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5. |
Florida Department of Health looking for three boys who played with a rabid
bat
On June 25, the Florida Department of Health
issued a press
release titled "Florida Health Department Still Looking for
3 Boys Who Played With Rabid Bat: Rabies Confirmed in
Rescued Bat." The press release is reprinted below in its
entirety.
Three of the 5 boys that were seen handling a rabid bat last
week on a Florida beach are still unidentified. Since rabies
is a fatal disease, the Lee County Health Department is
trying to locate the 3 remaining youth in order to
administer rabies vaccinations.
On Monday, June 15, at approximately 4:00 p.m., an
eyewitness saw at least 5 boys estimated to be between 10-12
years of age handling, playing, and kissing a bat at the Ft.
Myers Beach pier. An eyewitness retrieved the bat and since
bats are known to carry rabies, it was sent to the state
laboratory in Tampa, FL, for testing, which confirmed the
bat had rabies. The state laboratory identified the bat as a
Brazilian Free Tail bat.
"Rabies is a fatal disease. There is no known cure for
rabies, only vaccination. Therefore, it is critical that the
youth who were playing with the bat on Ft. Myers Beach pier
are vaccinated as soon as possible," said Dr. Judith A.
Hartner, MD, MPH, MPA, director of the Lee County Health
Department.
For those youth and parents that were visiting Ft. Myers
Beach pier in Florida on Monday, June 15, and have any
information on how to contact the youth seen handling a bat,
please contact the Lee County Health Department at (239)
332-9501. The phone number will be operational 24 hours per
day/7 days a week.
For more information concerning rabies and how it spreads,
please refer to the Florida Department of Health website:
http://www.doh.state.fl.us/environment/medicine/rabies/rabies-education.html
and the Centers for Disease Control website:
http://www.cdc.gov/RABIES/bats.html or
http://www.cdc.gov/ncidod/dvrd/kidsrabies
The press release has not yet been posted on the Florida
Department of Health website. When it is posted, you will
find it at
http://esetappsdoh.doh.state.fl.us/pressreleasesearch/search.aspx
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6. |
CDC updates its novel influenza A H1N1 web section with revised guidance for
businesses
CDC recently posted updated information to one of
the
documents in the "H1N1 Flu Clinical and Public Health
Guidance" sub-section of its H1N1 Flu web section. Titled
"General Business and Workplace Guidance for the Prevention
of Novel Influenza A (H1N1) Flu in Workers," the document is
available at http://www.cdc.gov/h1n1flu/guidance/workplace.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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7. |
IAC's Video of the Week emphasizes the importance of hand-washing in stopping
the spread of disease
IAC encourages IAC Express readers to watch "Put
Your Hands
Together," a 4-minute video created by CDC. It emphasizes
that frequent, thorough hand-washing may be the single most
important act a person can take to stop the spread of
infectious disease and stay healthy. An English-language
script is also available; you'll find a link to it at the
end of this IAC Express article.
The video will be available on the home page of IAC's
website through July 5. 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 are now
archived on IAC's website. To view any of the videos
previously featured, go to: http://www.immunize.org/votw/jun09.asp
To access the "Put Your Hands Together" script, go to:
http://www.cdc.gov/CDCTV/HandsTogether/Transcripts/HandsTogether.pdf
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8. |
June
issue of CDC's Immunization Works electronic newsletter recently released
CDC recently released the June issue of its
monthly
newsletter Immunization Works; it is posted on the website
of the National Center for Immunization and Respiratory
Diseases (NCIRD). The newsletter offers the immunization
community information about current topics. The information
is in the public domain and can be reproduced and circulated
widely.
Some of the information in the June issue has already
appeared in previous issues of IAC Express. Following is the
text of two articles we have not covered.
NEW ZOSTER (SHINGLES) MATERIALS: CDC has developed a new web
button for shingles vaccine resources
(http://www.cdc.gov/vaccines/vpd-vac/shingles/web-button.htm).
The button takes visitors directly to CDC's main shingles page,
which includes links to frequently asked questions about shingles
and shingles vaccine, fact sheets and printable materials, and
other useful resources. In addition, CDC updated its list of
Frequently Asked Questions for Shingles Vaccine
(http://www.cdc.gov/vaccines/vpd-vac/shingles/vac-faqs.htm).
The questions reflect the most up-to-date requests for information
about shingles vaccine from the general public and vaccination
providers. For all of CDC's shingles materials, visit the Shingles
(Herpes Zoster) Vaccination Web page
(http://www.cdc.gov/vaccines/vpd-vac/shingles).
IMPROVED WEBSITE FOR HEALTHCARE PROFESSIONALS: Visit CDC's
new web page, Vaccines and Immunizations for Healthcare
Professionals (http://www.cdc.gov/vaccines/hcp.htm) to see
its new look! Incorporating feedback directly from
healthcare professionals, CDC has organized topics under
clear headings and simplified the layout while still
providing the same reliable information on vaccines and
immunizations. Bookmark this page and quickly link to
information on immunization training, clinical resources,
administrative tools, patient education, and vaccine-preventable diseases. Be sure to email your feedback about
the website to NCIRDwebteam@cdc.gov
To access the complete June issue from CDC's Vaccines &
Immunizations website, go to:
http://www.cdc.gov/vaccines/news/newsltrs/imwrks/2009/200906.htm
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9. |
Standardized injection site maps help everyone in the office use the same
anatomic sites for each vaccine
Medical offices and clinics commonly administer
more than
one vaccine to a patient during a single visit. If a patient
or parent later calls to report a reaction, it can be
puzzling for healthcare personnel to determine which vaccine
caused the reaction.
Use of standardized injection site maps can help prevent
this dilemma. With site maps, healthcare personnel can
jointly decide which anatomic site everyone in the office
will use when administering a certain vaccine. For example,
everyone can agree to administer DTaP in the upper right
thigh, Hib in the lower right thigh or PCV7 in the upper
left thigh, HepB in the lower left thigh.
CDC has sample injection site maps for administering
vaccines to children. Included are illustrations that show
where healthcare workers can administer all indicated doses
to children ranging in age from infancy to pre-teen. To
access them, go to:
http://www.cdc.gov/vaccines/pubs/pinkbook/downloads/appendices/D/site-map.pdf
The California Department of Public Health has an injection
site map for administering vaccines to adults. Access it at
http://www.eziz.org/PDF/IMM-718adult.pdf
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10. |
IAC updates a print piece that answers the public's questions about
meningococcal disease and vaccines
IAC recently revised its print piece
"Meningococcal:
Questions and Answers" to incorporate changes made in the
age indication for meningococcal conjugate vaccine.
The piece is a ready-to-print version 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
"Meningococcal: Questions and Answers," go to:
http://www.immunize.org/catg.d/p4210.pdf
To view an HTML version of these Q&As, go to the following:
(1) Meningococcal disease:
http://www.vaccineinformation.org/menin/qandadis.asp
(2) Meningococcal vaccine:
http://www.vaccineinformation.org/menin/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. |
HHS announces $35 million contract for a new way to produce influenza vaccine
On June 23, the Department of Health and Human
Services
(HHS) issued a press release announcing that the department
will pursue a new way to make influenza vaccine. Portions of
the press release are reprinted below.
HHS Secretary Kathleen Sebelius announced today that the
department will pursue advanced development of new way to
make influenza vaccine. The work will be done by Protein
Sciences Corporation, Inc., of Meriden, Conn., under a new
$35 million contract. The contract could be extended up to
five years at a total cost of approximately $147 million.
"The technology has advanced in recent years to a point that
we believe it could help meet a surge in demand for U.S.-based vaccine for seasonal and pandemic flu," Secretary
Sebelius said. "We want to use the technology to help our
nation respond to emerging infectious diseases."
With this new technology, known as recombinant influenza
vaccine, a gene would be extracted from a flu virus and
placed into an insect virus called baculovirus, which does
not affect people and can multiply quickly to high levels in
insect cells. The cells are purified to become a basic part
of a human vaccine.
Using this method, vaccine candidates, clinical
investigational lots, and commercial-scale vaccine
production may be available faster than by using traditional
vaccine production methods. Because the basic cells can be
frozen and stored indefinitely, manufacturing large
quantities of a vaccine is also faster using this
recombinant technology. . . .
If this new technology is demonstrated to be safe and
effective and the FDA licenses the new technology for flu
vaccines, the contract requires the company to establish
domestic manufacturing capability to provide a finished
vaccine within 12 weeks of pandemic onset and to produce at
least 50 million doses of pandemic flu vaccine within six
months of pandemic onset. . . .
To read the complete press release, go to:
http://www.hhs.gov/news/press/2009pres/06/20090623c.html
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12. |
Save the date: July 7 is the new date for IZTA's Influenza Update conference
call
The Immunization Coalitions Technical Assistance
Network
(IZTA) has rescheduled its Influenza Update conference call.
Previously scheduled for June 16, it will now be held on
July 7. If you registered for the June 16 call, you do not
need to re-register.
The call features L.J. Tan, MS, PhD, presenting his engaging
and informative annual update. It will include the latest
research from the 2008-09 influenza season and predictions
and plans for the 2009-10 season.
The July 7 call will be held at 1PM, ET. To sign up, send an
email to izta@aed.org Include the subject line "Sign me up
for the Influenza Update call."
IZTA is a program of the Center for Health Communication,
Academy for Educational Development.
To access earlier programs, go to:
http://www.izta.org/confcall.cfm
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13. |
Order laminated U.S. immunization schedules today!
IAC has two laminated immunization schedules for
2009--one
for children/teens ages 0 through 18 years and one for
adults. Based on CDC's 2009 immunization schedules, the
laminated schedules offer two significant advantages over
paper schedules:
(1) They are covered with a tough, washable coating that
lets them stand up to a year's worth of use as at-your-fingertips guides to immunization and as teaching tools you
can use to give patients and parents authoritative
immunization information.
(2) Each schedule includes a guide to vaccine
contraindications and precautions, an additional feature
that will help you to make on-the-spot determinations about
vaccinating patients of any age.
IAC's laminated schedules come complete with essential
footnotes and are printed in color for easy reading. Each
schedule has six pages (i.e., three double-sided pages), and
when folded, measures 8.5" x 11".
For specific information about the child/teen schedule, to
view images of it, or to order online or download an order
form, visit
http://www.immunize.org/shop/schedule_child.asp
For specific information about the adult schedule, to view
images of it, or to order online or download an order form,
visit http://www.immunize.org/shop/schedule_adult.asp
Prices start at $10 each for 1-4 copies and drop to $6.50
each for 5-19 copies. Discount pricing is available for 20
or more copies. For quotes on customizing or placing orders
in excess of 999 schedules, call (651) 647-9009 or email
admininfo@immunize.org
To learn about other essential immunization resources
available for purchase from IAC, such as personal
immunization record cards, padded screening questionnaires,
and educational videos, go to: http://www.immunize.org/shop
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14. |
Perfect for your waiting room: "The Saturday Shot" storybook presents a
kid's-eye view of getting immunized
"The Saturday Shot" tells the story of a young
girl going to the doctor's office for a check-up and vaccine. Written by a
child for children, this book provides a child's perspective on getting
immunized.
Published in 2009, it is available from Tate Publishing. You can order it,
download it digitally, or download an audio book. To access the various
options, go to:
http://tatepublishing.com/bookstore/book.php?w=978-1-60696-129-2
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15. |
MMWR
article reports on the progress WHO's Western Pacific Region made in eliminating
measles during 1990-2008
CDC published "Progress Toward the 2012 Measles
Elimination
Goal--Western Pacific Region, 1990-2008" in the June 26
issue of MMWR. A portion of a summary made available to the
press is reprinted below.
The Western Pacific Region of WHO has made progress towards
its goal of measles elimination by 2012. Routine
immunization coverage has been increasing; more and better
vaccination campaigns have been conducted; surveillance is
being enhanced; and an extensive laboratory network is in
place. Twenty-four of the Region's 37 countries and
jurisdictions already have likely eliminated or nearly
eliminated measles. However, large numbers of measles cases
continue to occur in several countries, especially in China
and Japan, which together account for 82 percent of the
Region's population. Increased political, financial, and
human resource commitment, and efforts by countries and
partners, are required to implement the WHO-recommended
strategies and achieve the 2012 goal.
To access a web-text (HTML) version of the complete article,
go to:
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5824a4.htm
To access a ready-to-print (PDF) version of this issue of
MMWR, go to:
http://www.cdc.gov/mmwr/PDF/wk/mm5824.pdf
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