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Foodborne Pathogens: Microbiology and Molecular Biology Pina M. Fratamico, Arun K. Bhunia, and James L. Smith, editors Caister Academic Press, Norwich, England, 2005 ISBN: 1-9044550-00-X Pages: 453; Price: US $299.00 [...]

On June 7, 2013, a man was diagnosed in a Texas hospital with rabies. He had been detained in a U.S. detention facility during his infectious period. To identify persons exposed to rabies who might require rabies postexposure prophylaxis (PEP), CDC and the Texas Department of State Health Services (DSHS) conducted investigations at four detention facilities, one medical clinic, and two hospitals. In all, 25 of 742 persons assessed for rabies exposure were advised to receive PEP. Early diagnosis of rabies is essential for implementation of appropriate hospital infection control measures and for rapid assessment of potential contacts for PEP recommendations. [ABSTRACT FROM AUTHOR]

To improve the response to foodborne disease outbreaks, health departments should have adequate surveillance of such diseases. One key factor in accomplishing this is performance by health departments of timely hypothesis-generating interviews in cases of foodborne illness. In 2009, the New york City (NYC) Department of Health and Mental Hygiene (DOHMH) received funding from the Foodborne Diseases Centers for Outbreak Response Enhancement (FoodCORE) to hire students to perform all salmonellosis case-patient interviews. This study evaluated the effectiveness of implementing a student-interview model to conduct surveillance. Before enhancing surveillance, DOHMH interviewed only those salmonellosis case-patients associated with clusters or high-risk settings. Cases of salmonellosis diagnosed a year prior to enhancing surveillance (pre-enhanced surveillance) were compared with cases diagnosed the first and second years of enhanced surveillance. Overall, a higher proportion of case-patients were interviewed during year 1 (83%) and 2 (79%) of enhanced surveillance than during pre-enhanced surveillance (7%). When year 1 and 2 of enhanced and pre-enhanced surveillance were compared, case-patient interviews were more timely (median: 3, 2, and 21 days, respectively) and more case-patients answered all food-exposure questions (24%, 37%, and 2%, respectively). This approach to Salmonella surveillance appears to be successful and could be implemented in other health departments to cost-effectively expand epidemiologic capacity with a modest investment. [ABSTRACT FROM AUTHOR]

Investigates the effectiveness of vaccines administered in infants in the Dominican Republic in preventing Haemophilus influenzae type b (Hib) colonization. Correlation with serum anti-capsular immunoglobulin G concentration; Lower prevalence of Hib colonization among vaccinated infants.

Cryptosporidiosis is a parasitic diarrheal infection that is transmitted by the fecal-oral route. We assessed trends in incidence and demographic characteristics for the 3,984 cases diagnosed during 1995-2018 in New York City, New York, USA, and reported to the New York City Department of Health and Mental Hygiene. Reported cryptosporidiosis incidence decreased with HIV/AIDS treatment rollout in the mid-1990s, but the introduction of syndromic multiplex diagnostic panels in 2015 led to a major increase in incidence and to a shift in the demographic profile of reported patients. Incidence was highest among men 20-59 years of age, who consistently represented most (54%) reported patients. In addition, 30% of interviewed patients reported recent international travel. The burden of cryptosporidiosis in New York City is probably highest among men who have sex with men. Prevention messaging is warranted for men who have sex with men and their healthcare providers, as well as for international travelers. [ABSTRACT FROM AUTHOR]

Tecovirimat is the first-line antiviral treatment recommended for severe mpox or for persons with mpox who are at risk for severe disease; tecovirimat is available in the United States under an expanded access investigational new drug (IND) protocol. During the 2022-2023 mpox outbreak, local U.S. health jurisdictions facilitated access to tecovirimat. In June 2022, Los Angeles County (LAC) rapidly developed strategies for tecovirimat distribution using existing medical countermeasure distribution networks established by the Public Health Emergency Preparedness Program and the Hospital Preparedness Program, creating a hub and spoke distribution network consisting of 44 hub facilities serving 456 satellite sites across LAC. IND patient intake forms were analyzed to describe mpox patients treated with tecovirimat. Tecovirimat treatment data were matched with case surveillance data to calculate time from specimen collection to patients receiving tecovirimat. Among 2,281 patients with mpox in LAC, 735 (32%) received tecovirimat during June 2022-January 2023. Among treated patients, approximately two thirds (508; 69%) received treatment through community clinics and pharmacies. The median interval from specimen collection to treatment was 2 days (IQR = 0-5 days). Local data collection and analysis helped to minimize gaps in treatment access and facilitated network performance monitoring. During public health emergencies, medical countermeasures can be rapidly deployed across a large jurisdiction using existing distribution networks, including clinics and pharmacies., Competing Interests: All authors have completed and submitted the International Committee of Medical Journal Editors form for disclosure of potential conflicts of interest. No potential conflicts of interest were disclosed.

Flea-borne typhus (FBT), also referred to as murine typhus, is an acute febrile disease in humans caused by the bacteria Rickettsia typhi. Currently, cases of FBT are reported for public health surveillance purposes (i.e., to detect incidence and outbreaks) in a few U.S. states. In California, healthcare providers and testing laboratories are mandated to report to their respective local public health jurisdictions whenever R. typhi or antibodies reactive to R. typhi are detected in a patient, who then report cases to state health department. In this study, we characterize the epidemiology of flea-borne typhus cases in California from 2011 to 2019. A total of 881 cases were reported during this period, with most cases reported among residents of Los Angeles and Orange Counties (97%). Demographics, animal exposures, and clinical courses for case patients were summarized. Additionally, spatiotemporal cluster analyses pointed to five areas in southern California with persistent FBT transmission.

Prompt and accurate detection of SARS-CoV-2, the virus that causes COVID-19, has been important during public health responses for containing the spread of COVID-19, including in hospital settings (1-3). In vitro diagnostic nucleic acid amplification tests (NAAT), such as real-time reverse transcription-polymerase chain reaction (RT-PCR) can be expensive, have relatively long turnaround times, and require experienced laboratory personnel.* Antigen detection tests can be rapidly and more easily performed and are less expensive. The performance † of antigen detection tests, compared with that of NAATs, is an area of interest for the rapid diagnosis of SARS-CoV-2 infection. The Quidel Sofia 2 SARS Antigen Fluorescent Immunoassay (FIA) (Quidel Corporation) received Food and Drug Administration Emergency Use Authorization for use in symptomatic patients within 5 days of symptom onset (4). The reported test positive percentage agreement § between this test and an RT-PCR test result is 96.7% (95% confidence interval [CI] = 83.3%-99.4%), and the negative percentage agreement is 100.0% (95% CI = 97.9%-100.0%) in symptomatic patients. ¶ However, performance in asymptomatic persons in a university setting has shown lower sensitivity (5); assessment of performance in a clinical setting is ongoing. Data collected during June 30-August 31, 2020, were analyzed to compare antigen test performance with that of RT-PCR in a hospital setting. Among 1,732 paired samples from asymptomatic patients, the antigen test sensitivity was 60.5%, and specificity was 99.5% when compared with RT-PCR. Among 307 symptomatic persons, sensitivity and specificity were 72.1% and 98.7%, respectively. Health care providers must remain aware of the lower sensitivity of this test among asymptomatic and symptomatic persons and consider confirmatory NAAT testing in high-prevalence settings because a false-negative result might lead to failures in infection control and prevention practices and cause delays in diagnosis, isolation, and treatment., Competing Interests: All authors have completed and submitted the International Committee of Medical Journal Editors form for disclosure of potential conflicts of interest. No potential conflicts of interest were disclosed.

Worksites with on-site operations have experienced coronavirus disease (COVID-19) outbreaks. We analyzed data for 698 nonresidential, nonhealthcare worksite COVID-19 outbreaks investigated in Los Angeles County, California, USA, during March 19, 2020‒September 30, 2020, by using North American Industry Classification System sectors and subsectors. Nearly 60% of these outbreaks occurred in 3 sectors: manufacturing (n = 184, 26.4%), retail trade (n = 137, 19.6%), and transportation and warehousing (n = 73, 10.5%). The largest number of outbreaks and largest number and highest incidence rate of outbreak-associated cases occurred in manufacturing. Furthermore, 7 of the 10 industry subsectors with the highest incidence rates were within manufacturing. Approximately 70% of outbreak-associated case-patients reported Hispanic ethnicity. Facilities employing more on-site staff had larger and longer outbreaks. Identification of highly affected industry sectors and subsectors is necessary for targeted public health planning, outreach, and response, including ensuring vaccine access, to reduce burden of COVID-19 in vulnerable workers.

Context: Infectious disease threats, high incidence/prevalence of health care-associated infections, and multidrug-resistant organisms challenge hospitals to improve infection prevention/control strategies and infectious disease preparedness/response efforts., Program: The Los Angeles County (LAC) Department of Public Health (DPH), Hospital Outreach Unit (HOU) addressed this need with the liaison public health nurse (LPHN) project, which is designed to strengthen capacity and bridge the care continuum with hospitals to prevent/control infectious disease., Implementation: The project utilizes 5 LPHNs who interface with LAC hospitals to improve reporting of infectious disease/hospital outbreaks, strengthen the surveillance infrastructure, and enhance communication/collaboration. The LPHNs communicate regularly and meet one-on-one with hospital infection preventionists with focused discussion, consultation, and assessment of infectious disease, participate in joint infection control meetings/conferences/calls, outreach on joint public health projects, and educate/train hospital staff., Evaluation: Within the first 7 years of implementation (2003) of the unit, reporting of hospital outbreaks increased 27%; hospitals reporting infectious disease via a county reporting system increased 95% during the same period. Currently, 64% of hospitals are reporting via the electronic laboratory reporting system (automated transmission to public health of reportable laboratory findings). In addition, the number of hospital infection control committee meetings LPHNs were invited to increased 96% during the first 7 years. The LPHNs/HOU participate(d) in 9 joint infection prevention/control projects with hospitals., Discussion: The threat of emerging infectious disease, health care-associated infections, and multidrug-resistant organisms is an ongoing challenge. Preventing infectious disease requires innovative approaches to effect and empower hospitals to respond. The LAC DPH LPHN project has proved to be an invaluable resource and key component to enable effective communication/collaboration to improve infection prevention and control strategies/preparedness efforts and protect the public's health from infectious disease.

Cryptosporidiosis is a parasitic diarrheal infection that is transmitted by the fecal-oral route. We assessed trends in incidence and demographic characteristics for the 3,984 cases diagnosed during 1995-2018 in New York City, New York, USA, and reported to the New York City Department of Health and Mental Hygiene. Reported cryptosporidiosis incidence decreased with HIV/AIDS treatment rollout in the mid-1990s, but the introduction of syndromic multiplex diagnostic panels in 2015 led to a major increase in incidence and to a shift in the demographic profile of reported patients. Incidence was highest among men 20-59 years of age, who consistently represented most (54%) reported patients. In addition, 30% of interviewed patients reported recent international travel. The burden of cryptosporidiosis in New York City is probably highest among men who have sex with men. Prevention messaging is warranted for men who have sex with men and their healthcare providers, as well as for international travelers.

During 2014-2016, the largest outbreak of Ebola virus disease (EVD) in history occurred in West Africa. The New York City Department of Health and Mental Hygiene (DOHMH) worked with health care providers to prepare for persons under investigation (PUIs) for EVD in New York City. From July 1, 2014, through December 29, 2015, we classified as a PUI a person with EVD-compatible signs or symptoms and an epidemiologic risk factor within 21 days before illness onset. Of 112 persons who met PUI criteria, 74 (66%) sought medical care and 49 (44%) were hospitalized. The remaining 38 (34%) were isolated at home with daily contact by DOHMH staff members. Thirty-two (29%) PUIs received a diagnosis of malaria. Of 10 PUIs tested, 1 received a diagnosis of EVD. Home isolation minimized unnecessary hospitalization. This case study highlights the importance of developing competency among clinical and public health staff managing persons suspected to be infected with a high-consequence pathogen.

Objectives: Death certificates are an important source of information for understanding life expectancy and mortality trends; however, misclassification and incompleteness are common. Although deaths caused by Legionnaires' disease might be identified through routine surveillance, it is unclear whether Legionnaires' disease is accurately recorded on death certificates. We evaluated the sensitivity and positive predictive value of death certificates for identifying deaths from confirmed or suspected Legionnaires' disease among adults in New York City., Methods: We deterministically matched death certificate data from January 1, 2008, through December 31, 2013, on New York City residents aged ≥18 years to surveillance data on confirmed and suspected cases of Legionnaires' disease from January 1, 2008, through October 31, 2013. We estimated sensitivity and positive predictive value by using surveillance data as the reference standard., Results: Of 294 755 deaths, 27 (<0.01%) had an underlying cause of death of Legionnaires' disease and 33 (0.01%) had any mention of Legionnaires' disease on the death certificate. Of 1211 confirmed or suspected cases of Legionnaires' disease, 267 (22.0%) matched to a record in the death certificate data set. The sensitivity of death certificates that listed Legionnaires' disease as the underlying cause of death was 17.3% and of death certificates with any mention of Legionnaires' disease was 20.9%. The positive predictive value of death certificates that listed Legionnaires' disease as the underlying cause of death was 70.4% and of death certificates with any mention of Legionnaires' disease was 69.7%., Conclusions: Death certificates had limited ability to identify confirmed or suspected deaths with Legionnaires' disease. Provider trainings on the diagnosis of Legionnaires' disease, particularly hospital settings, and proper completion of death certificates might improve the sensitivity of death certificates for people who die of Legionnaires' disease.

We investigated an outbreak of eight Legionnaires' disease cases among persons living in an urban residential community of 60,000 people. Possible environmental sources included two active cooling towers (air-conditioning units for large buildings) <1 km from patient residences, a market misting system, a community-wide water system used for heating and cooling, and potable water. To support a timely public health response, we used real-time polymerase chain reaction (PCR) to identify Legionella DNA in environmental samples within hours of specimen collection. We detected L. pneumophila serogroup 1 DNA only at a power plant cooling tower, supporting the decision to order remediation before culture results were available. An isolate from a power plant cooling tower sample was indistinguishable from a patient isolate by pulsed-field gel electrophoresis, suggesting the cooling tower was the outbreak source. PCR results were available <1 day after sample collection, and culture results were available as early as 5 days after plating. PCR is a valuable tool for identifying Legionella DNA in environmental samples in outbreak settings.

During 2013, the New York City Department of Health and Mental Hygiene (DOHMH) received reports of 6 hepatitis A cases among food handlers. We describe our decision-making process for public notification, type of postexposure prophylaxis (PEP) offered, and lessons learned. For 3 cases, public notification was issued and DOHMH offered only hepatitis A vaccine as PEP. Subsequent outbreaks resulted from 1 case for which no public notification was issued or PEP offered, and 1 for which public notification was issued and PEP was offered too late. DOHMH continues to use environmental assessments to guide public notification decisions and offer only hepatitis A vaccine as PEP after public notification but recognizes the need to evaluate each situation individually. The PEP strategy employed by DOHMH should be considered because hepatitis A vaccine is immunogenic in all age groups, can be obtained by local jurisdictions more quickly, and is logistically easier to administer in mass clinics than immunoglobulin.

In late October 2014, Ebola virus disease (Ebola) was diagnosed in a humanitarian aid worker who recently returned from West Africa to New York City (NYC). The NYC Department of Health and Mental Hygiene (DOHMH) actively monitored three close contacts of the patient and 114 health care personnel. No secondary cases of Ebola were detected. In collaboration with local and state partners, DOHMH had developed protocols to respond to such an event beginning in July 2014. These protocols included safely transporting a person at the first report of symptoms to a local hospital prepared to treat a patient with Ebola, laboratory testing for Ebola, and monitoring of contacts. In response to this single case of Ebola, initial health care worker active monitoring protocols needed modification to improve clarity about what types of exposure should be monitored. The response costs were high in both human resources and money: DOHMH alone spent $4.3 million. However, preparedness activities that include planning and practice in effectively monitoring the health of workers involved in Ebola patient care can help prevent transmission of Ebola.

In July 2014, as the Ebola virus disease (Ebola) epidemic expanded in Guinea, Liberia, and Sierra Leone, an air traveler brought Ebola to Nigeria and two American health care workers in West Africa were diagnosed with Ebola and later medically evacuated to a U.S. hospital. New York City (NYC) is a frequent port of entry for travelers from West Africa, a home to communities of West African immigrants who travel back to their home countries, and a home to health care workers who travel to West Africa to treat Ebola patients. Ongoing transmission of Ebolavirus in West Africa could result in an infected person arriving in NYC. The announcement on September 30 of an Ebola case diagnosed in Texas in a person who had recently arrived from an Ebola-affected country further reinforced the need in NYC for local preparedness for Ebola.

While investigating an outbreak of gastrointestinal disease associated with a restaurant, the New York City Department of Health and Mental Hygiene (DOHMH) noted that patrons had reported illnesses on the business review website Yelp (http://www.yelp.com) that had not been reported to DOHMH. To explore the potential of using Yelp to identify unreported outbreaks, DOHMH worked with Columbia University and Yelp on a pilot project to prospectively identify restaurant reviews on Yelp that referred to foodborne illness. During July 1, 2012-March 31, 2013, approximately 294,000 Yelp restaurant reviews were analyzed by a software program developed for the project. The program identified 893 reviews that required further evaluation by a foodborne disease epidemiologist. Of the 893 reviews, 499 (56%) described an event consistent with foodborne illness (e.g., patrons reported diarrhea or vomiting after their meal), and 468 of those described an illness within 4 weeks of the review or did not provide a period. Only 3% of the illnesses referred to in the 468 reviews had also been reported directly to DOHMH via telephone and online systems during the same period. Closer examination determined that 129 of the 468 reviews required further investigation, resulting in telephone interviews with 27 reviewers. From those 27 interviews, three previously unreported restaurant-related outbreaks linked to 16 illnesses met DOHMH outbreak investigation criteria; environmental investigation of the three restaurants identified multiple food-handling violations. The results suggest that online restaurant reviews might help to identify unreported outbreaks of foodborne illness and restaurants with deficiencies in food handling. However, investigating reports of illness in this manner might require considerable time and resources.

In May 2001, The New York City Department of Health and Mental Hygiene was informed of a cluster of 4 patients treated at an outpatient gastroenterology center who developed acute hepatitis C virus infection. An investigation identified a total of 12 clinic-associated hepatitis C virus transmissions and the outbreak and was traced to unsafe handling of multidose anesthetic vials and possible re-use of contaminated needles. This report typifies the types of outbreaks that continue to occur despite safe injection guidelines., (Copyright © 2013 Association for Professionals in Infection Control and Epidemiology, Inc. All rights reserved.)

Shigellosis is the third most common enteric bacterial infection in the United States. Although infection is typically self-limiting, empiric treatment is often prescribed. Because of increasing antimicrobial resistance to Shigella, empiric treatment options are decreasing. Identifying resistance patterns can inform empiric treatment recommendations. The goals of our study were to examine risk factors associated with antimicrobial resistance of Shigella and examine issues related to empiric treatment and antimicrobial resistance of Shigella. During June 2006-February 2009, we attempted to interview all New York City patients reported to have shigellosis. Their Shigella isolates were tested for antimicrobial susceptibility to examine the level of resistance and identify risk factors for resistance. Analysis was conducted on two groups distinguished by a large outbreak that was documented during the data collection period. Of the 477 nonoutbreak patients, 333 (70%) patients reported taking an antibiotic for shigellosis and 36 (11%) were treated with an antibiotic to which their Shigella infection was resistant. Among this group, high levels of antimicrobial resistance were detected to amoxicillin-clavulanate (66%), ampicillin (68%), and trimethoprim-sulfamethoxazole (66%). Non-travel-associated ciprofloxacin-resistant Shigella (five patients) and ciprofloxacin-resistant Shigella sonnei (four patients) were reported for the first time to our knowledge. Antimicrobial resistance is significantly higher in New York City residents compared with national data. Some patients were treated with therapies that were not effective and to which the patient's Shigella infection was resistant. Shigella infections should not be treated with antibiotics unless the patient presents with severe or underlying illness and is at risk for systemic illness. When treatment is indicated, local monitoring of Shigella for antimicrobial resistance will provide local clinicians with the best guidance for effective empiric treatments.

In Pennsylvania on February 16, 2006, a New York City resident collapsed with rigors and was hospitalized. On February 21, the Centers for Disease Control and Prevention and the New York City Department of Health and Mental Hygiene were notified that Bacillus anthracis had been identified in the patient's blood. Although the patient's history of working with dried animal hides to make African drums indicated the likelihood of a natural exposure to aerosolized anthrax spores, bioterrorism had to be ruled out first. Ultimately, this case proved to be the first case of naturally occurring inhalational anthrax in 30 years. This article describes the epidemiologic and environmental investigation to identify other cases and persons at risk and to determine the source of exposure and scope of contamination. Because stricter regulation of the importation of animal hides from areas where anthrax is enzootic is difficult, public healthcare officials should consider the possibility of future naturally occurring anthrax cases caused by contaminated hides. Federal protocols are needed to assist in the local response, which should be tempered by our growing understanding of the epidemiology of naturally acquired anthrax. These protocols should include recommended methods for reliable and efficient environmental sample collection and laboratory testing, and environmental risk assessments and remediation.

Background: Use of syndromic surveillance as a tool to detect outbreaks and potential biologic or chemical terrorist attacks is increasing. Evaluating health departments' use of syndromic surveillance is necessary to determine the value of this methodology., Methods: Syndromic surveillance signals detected by the New York City Department of Health and Mental Hygiene (DOHMH) during November 2001-August 2004 were reviewed for diarrhea and vomiting syndromes, the methods used to investigate such signals, and results of these investigations to determine if any unreported outbreaks were detected. Gastrointestinal (GI) outbreaks reported to DOHMH also were reviewed to understand why they were not detected by DOHMH's Emergency Department (ED) syndromic surveillance system., Results: During the study period, ED surveillance generated 98 citywide and 138 spatial GI signals. Multiple outbreaks suspected to be caused by norovirus and rotavirus were identified, as well as a citywide increase in diarrheal illness. Of 98 citywide signals detected, 73 (75%) occurred during seasonal outbreaks. During the same period, 49 GI outbreaks were reported to DOHMH; none was detected simultaneously by ED surveillance., Conclusion: Only substantial, citywide syndromic signals were identified as outbreaks and routinely reported. GI outbreaks did not generate syndromic signals. Syndromic surveillance signals occur frequently, are difficult to investigate satisfactorily, and should be viewed as a supplement to, rather than a replacement for, well-maintained traditional surveillance systems that rely on strong ties between clinicians and public health authorities.

Objectives: Pneumococcal conjugate vaccine (PCV) was first licensed for routine administration to young children in February 2000. The objective of this study was to assess physician perspectives about the use of PCV, to ascertain which children were being given the vaccine soon after licensure, and to determine how the addition of PCV to the schedule of recommended childhood vaccines may affect the timing of other vaccinations., Methods: A 30-item survey containing questions about the use of PCV was sent to all pediatricians and family physicians who provide primary care to young children in Monroe County (Rochester, NY) and Davidson County (Nashville, TN) in October 2000. As many as 3 subsequent mailings were sent to nonresponders. Descriptive and chi(2) statistical analyses and logistic regression were used to evaluate the responses., Results: Response rates were 82% in Rochester and 78% in Nashville. Eighty-two percent of responding physicians, including 92% of pediatricians and 55% of family physicians, indicated that they were giving PCV to their patients at the time of the survey. Sixty percent noted that an initial lack of insurance reimbursement for the cost of the vaccine caused them to delay introducing PCV. Fifty-one percent delayed initially offering the vaccine to any of their patients because the Vaccines for Children (VFC) program did not begin to offer PCV until several months later. The vast majority routinely vaccinated healthy children who are younger than 2 years as well as older children who had defined chronic medical conditions that put them at high risk of invasive pneumococcal disease. Fewer than 15% were recalling patients for PCV, with most recall efforts focused on patients who had chronic medical conditions. When discussing PCV with parents, 78% of physicians primarily emphasized the vaccine's potential to decrease the risk of sepsis and/or meningitis, whereas smaller percentages primarily emphasized the vaccine's potential to decrease the risk of pneumonia or ear infections. Approximately 20% of physicians who gave PCV delayed other vaccinations (primarily varicella vaccine, hepatitis B vaccine, or polio vaccine) because of concern about administering 4 or more vaccines simultaneously. Similarly, 40% of physicians indicated that they considered PCV to be more important than varicella vaccine or hepatitis B vaccine, whereas 26% percent considered PCV to be more important than polio vaccine., Conclusions: PCV has been widely accepted by physicians in both Rochester and Nashville. However, many physicians delayed introducing the vaccine for reasons that were ultimately related to financial considerations. For privately insured patients, delays were related to when coverage for PCV was added to benefit packages. For patients who receive publicly purchased vaccine via the VFC program, delays were related to availability of the vaccine through the VFC program. In addition, after the introduction of PCV, some physicians began delaying the administration of other vaccines because of the need to give multiple vaccinations simultaneously. Although lack of insurance or VFC coverage and concerns about multiple simultaneous injections may somewhat delay the initial use of newly recommended vaccines, physicians rapidly begin to provide new vaccines that they believe to be beneficial once those vaccines are incorporated into existing payment mechanisms.