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PURPOSE: To present progress toward Healthy People 2010 vaccination objectives for adolescents aged 13-15 years, and to determine how much catch-up and routine vaccination was administered at the recommended ages of 11-12 years. METHODS: Data from the 1997-2003 National Health Interview Survey were evaluated. In the first analysis, vaccination coverage levels for adolescents aged 13-15 years were determined for each survey year. Main outcome measures include the percent of adolescents who had received the three-dose hepatitis B vaccine (Hep B) series, the two-dose measles/mumps/rubella vaccine (MMR) series, the tetanus and diphtheria toxoids (Td) booster, and one dose of varicella vaccine. In the second analysis, data from all survey years were combined and vaccination dates were analyzed to determine the percentage of adolescents who were missing any vaccines at ages 11-12 and received them at that age. Data for varicella vaccine were sufficient only for the first analysis. RESULTS: Among the approximately 15%-20% of respondents who reported vaccination history from records in the home and who were reporting on a 13-15-year-old, coverage with three doses of Hep B increased significantly during 1997-2001, from 15.2% to 55.0%. Coverage with MMR and Td fluctuated, with no significant increase; highs were 76.7% for MMR in 2003 and 36.2% for Td in 2002. Examination of vaccination dates for all surveyed adolescents showed that among 11-12-year-olds who needed catch-up vaccine, 0.6%-31.3% were brought up to date for Hep B and 22.1%-31.8% were brought up to date for MMR. For Td, 2.6%-15.4% of 11-12-year-olds who had not previously received Td received the vaccine. CONCLUSION: Vaccination coverage among adolescents aged 13-15 years was below the Healthy People 2010 goals of 90%, but generally increased over the survey years. However, the suboptimal delivery of needed vaccines during ages 11 and 12 is concerning in light of recent vaccine recommendations targeted at this age. Continuing to focus on strategies to make adolescent preventive care, including vaccination, a new norm is essential. [ABSTRACT FROM AUTHOR]

Background: The Special Supplemental Nutrition Program for Women, Infants and Children (WIC) enrolls almost 50% of the US birth cohort and these children have significantly lower immunization coverage rates than their counterparts not eligible for WIC. In 1994, the Centers for Disease Control and Prevention (CDC) and USDA began a national initiative to increase immunization coverage in low-income children by incorporating immunization-promoting activities into WIC visits (WIC/Immunization linkages). Since 1998, CDC has monitored the WIC/Immunization linkages assessment and referral (with and without the more aggressive strategy of monthly voucher pick-up, client outreach and tracking and parental incentives) and three other immunization supporting activities (computerized systems to assess immunization status, collocation of WIC and immunization services, coordination of WIC and immunization services). Methods: Through an annual survey of state Immunization and WIC programs, a trend analysis was conducted for years 1998 through 2004 to determine changes in the use and frequency of WIC/Immunization linkage activities. Results: During the 7-year study period, the use of assessment and referral increased from 71% to 94%, monthly voucher pick-up from 24% to 35%, and coordination of WIC and immunization services from 61% to 78% (p<0.0001 for all comparisons) in WIC sites nationwide. The frequency of assessment and referral (at each visit [four or more times/ year] versus certification visits [two times/year]) was reported to decrease during the study period (p<0.0001). Outreach and tracking and collocation of services did not change significantly while the use of parental incentives decreased (p<0.0001). The availability of computers and their use immunization assessment increased during the period. From 2002-2004, the number of states reporting that they base assessment and referral on a single vaccine (diphtheria-tetanus-acellular pertussis) instead of counting multiple vaccines increased from 5 to 10. Conclusions: Immunization promoting activities, especially those known to be most effective in improving coverage such as monthly voucher pickup, are increasing in WIC. Focusing on effective interventions including supporting activities such as computerized assessment will be essential in meeting Healthy People 2010 infant and childhood immunization coverage goals. In addition, the use of WIC resources can be minimized by encouraging evaluation of diphtheria-tetanus-acellular pertussis coverage as a marker for up to date status, instead of counting all vaccine doses. [ABSTRACT FROM AUTHOR]

To identify adolescent hepatitis B coverage levels, a survey was conducted of seventh grade parents in San Diego County, California, using a random digit-dial telephone survey. A written survey was fielded also that was distributed at selected schools. Results were validated using data from a mandated report from all schools. Both survey methods overestimated the proportion completing the hepatitis B series by about 10%. Parents accurately reported immunization shot dates from the child's parent-held immunization shot record on the telephone and written surveys. The written survey, in addition to having a somewhat lower cost, may be useful when focusing on a localized area, whereas the telephone survey permits a more representative sample of a larger county-wide population. [ABSTRACT FROM AUTHOR]

Meeting the health needs of adolescents who live in high-risk settings such as homeless shelters, migrant camps, juvenile detention centers, prisons, and other types of residential facilities presents many challenges. Although there is no doubt that adolescents in many high-risk settings are at increased risk for hepatitis B and human papillomavirus, acute medical and psychological problems may consume all of the provider's time and resources. Potential health threats such as vaccine-preventable diseases must necessarily be given lower priority. Lack of vaccination expertise, supplies, and access to records further complicate delivery of vaccines. Since the 1990s, a number of approaches have been used to deliver hepatitis B vaccine to adolescents in many high-risk settings. Close collaboration among state and federal programs, local health departments, and community-based organizations has been necessary to introduce and sustain the delivery of vaccines to these young people. Medicaid, Statute 317 of the Public Health Service Act, the Vaccines for Children program, and State Children's Health Insurance Program have been used to finance vaccinations for adolescents 18 years or younger, and the expanded Medicaid option in the Foster Care Independence Act of 1999 has been used for adolescents older than 18 years of age. A number of states allow adolescents under age 18 to consent to their own hepatitis B vaccination under laws passed to allow treatment of sexually transmitted infections without parental consent. In this article, we present the experiences of several model programs that developed successful hepatitis B vaccination programs in venues that serve adolescents at risk, the important role of state laws and state agencies in funding immunization and other preventive health services for adolescents in high-risk situations, and discuss barriers and means to resolve them. [ABSTRACT FROM AUTHOR]

Adolescents in the United States now have the opportunity to receive new vaccines that prevent invasive meningococcal infections, pertussis (whooping cough), and cervical cancer. Except for their potential to cause serious illness, these infections could not be more different. Their incidence ranges from extremely low to quite high. Early clinical manifestations of infection range from none to life-threatening illness. Two of the vaccines are similar to those already in use, whereas 1 is completely new. In conjunction with the 4 vaccines previously recommended for adolescents (the tetanus and diphtheria booster, hepatitis B, measles-mumps-rubella, and varicella), the 3 new vaccines (meningococcal, human papillomavirus, and the tetanus-diphtheria-pertussis booster [which replaced the tetanus-diphtheria booster]) bring the number recommended for adolescents to 6. In this article, we describe key characteristics of the 3 new vaccines and infections they were designed to prevent. We also briefly discuss other vaccines recommended for all adolescents who have not already received them and new vaccines that are still under development. [ABSTRACT FROM AUTHOR]

Objectives: We investigated school factors associated with successful implementation of a seventh grade vaccination requirement.Methods: The proportion of students vaccinated with hepatitis B vaccine and measles containing vaccine was determined from records of schools in San Diego County, California. A school survey identified compliance strategies. Analysis identified factors associated with coverage.Results: In October 1999, 67.2% of 38,875 students had received the required vaccine doses. Of 315 schools, coverage was less than 40% in 60 schools and exceeded 80% in 111 schools. Factors associated with high coverage included private schools, early and frequent notice to parents, and, for public schools, higher overall socioeconomic status of students.Conclusions: In preparation for a middle school vaccination requirement, early and frequent notification of parents improves coverage. Schools with a high percentage of low socioeconomic status students may require extra resources to support implementation. [ABSTRACT FROM AUTHOR]

Background: After the military coup in Myanmar in February 2021, the health system began to disintegrate when staff who called for the restoration of the democratic government resigned and fled to states controlled by ethnic minorities. The military retaliated by blocking the shipment of humanitarian aid, including vaccines, and attacked the ethnic states. After two years without vaccines for their children, parents urged a nurse-led civil society organization in an ethnic state to find a way to resume vaccination. The nurses developed a vaccination program, which we evaluated., Methods: A retrospective cohort study and participatory evaluation were conducted. We interviewed the healthcare workers about vaccine acquisition, transportation, and administration and assessed compliance with WHO-recommended practices. We analyzed the participating children's characteristics. We calculated the proportion of children vaccinated before and after the program. We calculated the probability children would become up-to-date after the program using inverse survival., Results: Since United Nations agencies could not assist, private donations were raised to purchase, smuggle into Myanmar, and administer five vaccines. Cold chain standards were maintained. Compliance with other WHO-recommended vaccination practices was 74%. Of the 184 participating children, 145 (79%, median age five months [IQR 6.5]) were previously unvaccinated, and 71 (41%) were internally displaced. During five monthly sessions, the probability that age-eligible zero-dose children would receive the recommended number of doses of MMR was 92% (95% confidence interval [CI] 83-100%), Penta 87% (95% CI 80%-94%); BCG 76% (95% CI 69%-83%); and OPV 68% (95% CI 59%-78%). Migration of internally displaced children and stockouts of vaccines were the primary factors responsible for decreased coverage., Conclusions: This is the first study to describe the situation, barriers, and outcomes of a childhood vaccination program in one of the many conflict-affected states since the coup in Myanmar. Even though the proportion of previously unvaccinated children was large, the program was successful. While the target population was necessarily small, the program's success led to a donor-funded expansion to 2,000 children. Without renewed efforts, the proportion of unvaccinated children in other parts of Myanmar will approach 100%., (© 2024. The Author(s).)

Mexican-style soft cheese known as queso fresco (QF), which is often unpasteurized, has been implicated in outbreaks of foodborne illness in the United States. The U.S. Food and Drug Administration (FDA) exercises discretion in enforcement of noncommercial importation of cheese. To test control measures aimed at decreasing unlawful QF importation, in 2009 the FDA temporarily enforced a requirement for formal commercial entry for all cheeses over 5 lb (2.3 kg) at the San Diego-Tijuana border. Enforcement was combined with educational outreach. Border crossers importing cheese and those not importing cheese were surveyed at the beginning and end of the temporary enforcement period. Data collected included participant demographic information, knowledge of QF-associated health risks, and attitudes and practices regarding QF consumption and importation. We surveyed 306 importers and 381 nonimporters. Compared with nonimporters, importers had a lower level of knowledge regarding QF-associated health risks (P < 0.0001). Border crossers carrying cheese were more likely to have less education, be U.S. or dual residents, consume QF more frequently, and cross the border less often. Importation and consumption of unpasteurized QF remained prevalent among border crossers during the temporary enforcement period, and the level of knowledge regarding QF-associated risks remained low among these crossers. More vigorous, sustained messaging targeted at high-risk groups is needed to change behaviors. Definition and consistent enforcement of limits will likely be needed to reduce QF importation and the risk of QF-associated diseases along the U.S.-Mexico border; however, public health benefits will need to be balanced against the cost of enforcement.

Objectives: To describe student and faculty attitudes towards and adherence to nonpharmaceutical control measures during the first-known university outbreak of 2009 pandemic influenza A (H1N1)., Methods: Preferred information sources, control measure adherence and likelihood of adherence during future out-breaks, and perceived illness risk, were explored through focus groups and patient interviews., Results: We conducted 7 focus groups (N=48) and 9 patient inter- views. Measures (eg, hand hygiene, self-isolation while ill) were initially heeded. Limited information regarding A(H1N1) pdm09, insufficient understanding of university decisions, and perceived university alert overuse led to reports that future outbreaks would be regarded less seriously., Conclusions: Reported concern and commitment to recommendations decreased rapidly. Initial university messaging and response was critical in shaping participants' later perceptions.

Objectives: Infrared thermal detection systems (ITDSs) have been used with limited success outside the United States to screen for fever during recent outbreaks of novel infectious diseases. Although ITDSs are fairly accurate in detecting fever in adults, there is little information about their utility in children., Methods: In a pediatric emergency department, we compared temperatures of children (<18 years old) measured using 3 ITDSs (OptoTherm Thermoscreen, FLIR ThermoVision 360, and Thermofocus 0800H3) to standard, age-appropriate temperature measurements (confirmed fever defined as ≥38.0°C [oral or rectal], ≥37.0°C [axillary]). Measured temperatures were compared with parental reports of fever using descriptive, multivariate, and receiver operating characteristic analyses., Results: Of 855 patients, 400 (46.8%) had parent-reported fever, and 306 (35.8%) had confirmed fever. At optimal fever thresholds, OptoTherm and FLIR had sensitivity (83.0% and 83.7%, respectively) approximately equal to parental report (83.9%) and greater than Thermofocus (76.8%), and specificity (86.3% and 85.7%) greater than parental report (70.8%) and Thermofocus (79.4%). Correlation coefficients between traditional thermometry and ITDSs were 0.78 (OptoTherm), 0.75 (FLIR), and 0.66 (Thermofocus)., Conclusions: Compared with traditional thermometry, FLIR and OptoTherm were reasonably accurate in detecting fever in children and better predictors of fever than parental report. These findings suggest that ITDSs could be a useful noninvasive screening tool for fever in the pediatric age group.

The global spread of the influenza A(H1N1)pdm09 virus (pH1N1) associated with travelers from North America during the onset of the 2009 pandemic demonstrates the central role of international air travel in virus migration. To characterize risk factors for pH1N1 transmission during air travel, we investigated travelers and airline employees from four North American flights carrying ill travelers with confirmed pH1N1 infection. Of 392 passengers and crew identified, information was available for 290 (74%) passengers were interviewed. Overall attack rates for acute respiratory infection and influenza-like illness 1-7 days after travel were 5.2% and 2.4% respectively. Of 43 individuals that provided sera, 4 (9.3%) tested positive for pH1N1 antibodies, including 3 with serologic evidence of asymptomatic infection. Investigation of novel influenza aboard aircraft may be instructive. However, beyond the initial outbreak phase, it may compete with community-based mitigation activities, and interpretation of findings will be difficult in the context of established community transmission., (Published by Elsevier Ltd.)

Background: Following detection of pandemic influenza A H1N1 (pH1N1) in Dallas/Fort Worth, Texas, a school district (intervention community, [IC]) closed all public schools for 8 days to reduce transmission. Nearby school districts (control community [CC]) mostly remained open., Methods: We collected household data to measure self-reported acute respiratory illness (ARI), before, during, and after school closures. We also collected influenza-related visits to emergency departments (ED(flu))., Results: In both communities, self-reported ARIs and ED(flu) visits increased from before to during the school closure, but the increase in ARI rates was 45% lower in the IC (0.6% before to 1.2% during) than in the CC (0.4% before to 1.5% during) (RRR(During)(/Before) = 0.55, P < .001; adjusted OR(During/Before) = 0.49, P < .03). For households with school-aged children only (no children 0-5 years), IC had even lower increases in adjusted ARI than in the CC (adjusted OR(During/Before) = 0.28, P < .001). The relative increase of total ED(flu) visits in the IC was 27% lower (2.8% before to 4.4% during) compared with the CC (2.9% before to 6.2% during). Among children aged 6-18 years, the percentage of ED(flu) in IC remained constant (5.1% before vs 5.2% during), whereas in the CC it more than doubled (5.2% before vs 10.9% during). After schools reopened, ARI rates and ED(flu) visits decreased in both communities., Conclusions: Our study documents a reduction in ARI and ED(flu) visits in the intervention community. Our findings can be used to assess the potential benefit of school closures during pandemics.

In October 2007, wildfires burned nearly 300,000 acres in San Diego County, California. Emergency risk communication messages were broadcast to reduce community exposure to air pollution caused by the fires. The objective of this investigation was to determine residents' exposure to, understanding of, and compliance with these messages. From March to June 2008, the authors surveyed San Diego County residents using a 40-question instrument and random digit dialing. The 1,802 respondents sampled were predominantly 35-64 years old (65.9%), White (65.5%), and educated past high school (79.0%). Most (82.5%) lived more than 1 mile away from the fires, although many were exposed to smoky air for 5-7 days (60.7%) inside and outside their homes. Most persons surveyed reported hearing fire-related health messages (87.9%) and nearly all (97.9%) understood the messages they heard. Respondents complied with most to all of the nontechnical health messages, including staying inside the home (58.7%), avoiding outdoor exercise (88.4%), keeping windows and doors closed (75.8%), and wetting ash before cleanup (75.6%). In contrast, few (<5%) recalled hearing technical messages to place air conditioners on recirculate, use High-Efficiency Particulate Air filters, or use N-95 respirators during ash cleanup, and less than 10% of all respondents followed these specific recommendations. The authors found that nontechnical message recall, understanding, and compliance were high during the wildfires, and reported recall and compliance with technical messages were much lower. Future disaster health communication should further explore barriers to recall and compliance with technical recommendations.

Nonpharmaceutical interventions (NPIs), such as home isolation, social distancing, and infection control measures, are recommended by public health agencies as strategies to mitigate transmission during influenza pandemics. However, NPI implementation has rarely been studied in large populations. During an outbreak of 2009 Pandemic Influenza A (H1N1) virus infection at a large public university in April 2009, an online survey was conducted among students, faculty, and staff to assess knowledge of and adherence to university-recommended NPI. Although 3924 (65%) of 6049 student respondents and 1057 (74%) of 1401 faculty respondents reported increased use of self-protective NPI, such as hand washing, only 27 (6.4%) of 423 students and 5 (8.6%) of 58 faculty with acute respiratory infection (ARI) reported staying home while ill. Nearly one-half (46%) of student respondents, including 44.7% of those with ARI, attended social events. Results indicate a need for efforts to increase compliance with home isolation and social distancing measures.

Despite limited evidence regarding their utility, infrared thermal detection systems (ITDS) are increasingly being used for mass fever detection. We compared temperature measurements for 3 ITDS (FLIR ThermoVision A20M [FLIR Systems Inc., Boston, MA, USA], OptoTherm Thermoscreen [OptoTherm Thermal Imaging Systems and Infrared Cameras Inc., Sewickley, PA, USA], and Wahl Fever Alert Imager HSI2000S [Wahl Instruments Inc., Asheville, NC, USA]) with oral temperatures (≥ 100 °F = confirmed fever) and self-reported fever. Of 2,873 patients enrolled, 476 (16.6%) reported a fever, and 64 (2.2%) had a confirmed fever. Self-reported fever had a sensitivity of 75.0%, specificity 84.7%, and positive predictive value 10.1%. At optimal cutoff values for detecting fever, temperature measurements by OptoTherm and FLIR had greater sensitivity (91.0% and 90.0%, respectively) and specificity (86.0% and 80.0%, respectively) than did self-reports. Correlations between ITDS and oral temperatures were similar for OptoTherm (ρ = 0.43) and FLIR (ρ = 0.42) but significantly lower for Wahl (ρ = 0.14; p < 0.001). When compared with oral temperatures, 2 systems (OptoTherm and FLIR) were reasonably accurate for detecting fever and predicted fever better than self-reports.

Background: In the United States, the risk of rabies transmission to humans in most situations of possible exposure is unknown. Controlled studies on rabies are clearly not possible. Thus, the limited data on risk has led to the frequent administration of rabies post-exposure prophylaxis (PEP), often in inappropriate circumstances., Methods: We used the Delphi method to obtain an expert group consensus estimate of the risk of rabies transmission to humans in seven scenarios of potential rabies exposure. We also surveyed and discussed the merits of recommending rabies PEP for each scenario., Results: The median risk of rabies transmission without rabies PEP for a bite exposure by a skunk, bat, cat, and dog was estimated to be 0.05, 0.001, 0.001, and 0.00001, respectively. Rabies PEP was unanimously recommended in these scenarios. However, rabies PEP was overwhelmingly not recommended for non-bite exposures (e.g. dog licking hand but unavailable for subsequent testing), estimated to have less than 1 in 1,000,000 (0.000001) risk of transmission., Conclusions: Our results suggest that there are many common situations in which the risk of rabies transmission is so low that rabies PEP should not be recommended. These risk estimates also provide a key parameter for cost-effective models of human rabies prevention and can be used to educate health professionals about situation-specific administration of rabies PEP.

Background: On 8 October 2008, members of a tour group experienced diarrhea and vomiting throughout an airplane flight from Boston, Massachusetts, to Los Angeles, California, resulting in an emergency diversion 3 h after takeoff. An investigation was conducted to determine the cause of the outbreak, assess whether transmission occurred on the airplane, and describe risk factors for transmission., Methods: Passengers and crew were contacted to obtain information about demographics, symptoms, locations on the airplane, and possible risk factors for transmission. Case patients were defined as passengers with vomiting or diarrhea (> or =3 loose stools in 24 h) and were asked to submit stool samples for norovirus testing by real-time reverse-transcription polymerase chain reaction., Results: Thirty-six (88%) of 41 tour group members were interviewed, and 15 (41%) met the case definition (peak date of illness onset, 8 October 2008). Of 106 passengers who were not tour group members, 85 (80%) were interviewed, and 7 (8%) met the case definition after the flight (peak date of illness onset, 10 October 2008). Multivariate logistic regression analysis showed that sitting in an aisle seat (adjusted relative risk, 11.0; 95% confidence interval, 1.4-84.9) and sitting near any tour group member (adjusted relative risk, 7.5; 95% confidence interval, 1.7-33.6) were associated with the development of illness. Norovirus genotype II was detected by reverse-transcription polymerase chain reaction in stool samples from case patients in both groups., Conclusions: Despite the short duration, transmission of norovirus likely occurred during the flight.

Background: As part of efforts to prevent the introduction of communicable diseases into the United States, the Centers for Disease Control and Prevention (CDC) conducts surveillance for selected diseases in international travelers. One of these diseases, tuberculosis (TB), received substantial attention in May 2007 when the CDC issued travel restrictions and a federal isolation order for a person with drug-resistant TB who traveled internationally against public health recommendations., Methods: Reports of TB in international travelers in the CDC's Quarantine Activity Reporting System (QARS) from 1 June 2006 through 31 May 2007 (year 1) were compared with reports from 1 June 2007 through 31 May 2008 (year 2). These reports were classified using the CDC and American Thoracic Society guidelines and analyzed for epidemiologic characteristics and trends., Results: Among QARS reports, 4.6% were classified as active TB disease and 1.7% as no TB disease. Active TB disease reports increased from 2.5% of QARS reports in year 1 to 6.4% in year 2 (p < .001). The proportion of active TB disease reports leading to a federal travel restriction increased from 6.8% in year 1 to 15.4% in year 2 (p = .08)., Conclusions: The significant increase in reports of international travelers with TB disease likely represents more attention to and a higher index of suspicion for TB. The increased use of federal travel restrictions was associated with the development of new procedures to limit travel for public health reasons. Continued efforts are needed to decrease the number of persons with TB who travel while potentially contagious.

The Institute of Medicine (IOM) report Quarantine Stations at Ports of Entry: Protecting the Public's Health focused almost exclusively on U.S. airports and seaports, which served 106 million entries in 2005. IOM concluded that the primary function of these quarantine stations (QSs) should shift from providing inspection to providing strategic national public health leadership. The large expanse of our national borders, large number of crossings, sparse federal resources, and decreased regulation regarding conveyances crossing these borders make land borders more permeable to a variety of threats. To address the health challenges related to land borders, the QSs serving such borders must assume unique roles and partnerships to achieve the strategic leadership and public health research roles envisioned by the IOM. In this article, we examine how the IOM recommendations apply to the QSs that serve the land borders through which more than 319 million travelers, immigrants, and refugees entered the U.S. in 2005.

Annual influenza vaccination of schoolchildren will protect individual vaccines and, with high coverage, may protect entire communities. Because schoolchildren are more difficult to reach than preschoolers, school-based immunization programs may be needed to reach a high percentage of children. We offered free live, attenuated influenza vaccine to all healthy schoolchildren (K-12) in three Minnesota counties. Counties vaccinated from 33% to 58% of students. Overall, 41% of enrolled children were vaccinated. Elementary students were vaccinated at higher rates than older students. Administrative costs averaged $9.78 per dose delivered. School-based immunization programs offer the potential to achieve higher vaccination coverage of schoolchildren at modest cost.

We determined if a patient-self assessment/provider reminder tool (A/R) would increase administration of the eight vaccines that may be indicated for adults. In three family practice clinics, the A/R was completed by intervention patients and given to their provider. Control patients received an exercise reminder. On the day of the intervention, influenza, pneumococcal polysaccharide, and tetanus-diphtheria (Td) vaccines vaccine were administered significantly (P<0.01) more commonly to intervention patients in one clinic, Td in the second, and none in the third. There were no additional significant differences during one year of follow-up. A number of barriers to comprehensive vaccination were encountered.

New vaccines are being targeted to help protect the adolescent population from disease. The Society for Adolescent Medicine strongly urges compliance with adolescent vaccination recommendations provided by the Advisory Committee on Immunization Practices. These vaccines will significantly impact the health and well-being of the adolescent population. To enhance vaccination compliance and access to prevention health care and promotion, the Society supports linking vaccination to the three distinct comprehensive preventive health care visits already recommended by multiple organizations during early, middle, and late adolescence. In addition, multiple provider strategies should be used to increase vaccination rates among adolescents.

Background: Influenza vaccination levels in older patients have changed little since the mid-1990s. Despite frequent health care visits by a majority of older persons, many missed opportunities continue to occur., Methods: Patients were eligible for the study if they were age 50 and older, had not received influenza vaccine during the current season and were making a scheduled visit to one of the 13 study sites in California, New York, or New Mexico for purposes other than vaccination. Through direct observation, we determined if office staff inquired about vaccination status, discussed vaccination, or both. We defined missed opportunities as failure to administer influenza vaccine to patients for whom it was indicated., Results: Missed opportunities increased steadily from October to January (P < 0.0001), and were more common when there was no inquiry or discussion (P < 0.00001), among patients aged 50-64 (P < 0.0001) and in California and New Mexico (P = 0.001). A classification tree analysis revealed that lack of inquiry and week of visit contributed most to missed opportunities., Discussion: Early in the vaccination season, missed opportunities were uncommon and specific inquiries into or discussion of vaccination did not appear necessary. In December and January, patients tended to be vaccinated only when vaccination was addressed during the visit. Efforts to remind patients about vaccination later in the vaccination season may be essential to achieving higher coverage in the U.S.

Context: Eight or more vaccines may be indicated for adults in the United States. Determining if any vaccines are needed requires integrating information on the patient's demographic and behavioral risk factors and health status, the health status of the patient's close contacts, and the patient's immunization history. This process can be time consuming for providers and their staff. We used patient self-assessment as a method of determining which vaccines are indicated for a patient and whether indicated vaccines had been received., Design, Setting, and Participants: Cross-sectional convenience sample of 300 adults in three family practice settings. Participants completed a self-assessment tool to determine if influenza, pneumococcal, measles, mumps, and rubella (MMR), tetanus, hepatitis A and hepatitis B vaccines were indicated and previously received. A chart audit was then performed to obtain similar information., Main Outcome Measures: Agreement (kappa statistic [< 0.00: poor agreement; 0.00-0.20: slight; 0.21-0.40: fair; 0.41-0.60: moderate; 0.61-0.80: substantial; 0.81-1.00: almost perfect]) between the self-assessment tool and the audit for (1) indicated vaccines and (2) previous receipt of indicated vaccines indicated according to both the assessment form and the audit., Results: Agreement between the self-assessment tool and chart review was substantial or better only for pneumococcal and MMR vaccines (kappa=0.65 and 0.85, respectively). For influenza vaccine, agreement improved (from kappa = 0.56 to kappa = 0.74) when indications attributable to health conditions of family members were excluded. Agreement regarding receipt of vaccines was highest for influenza vaccine (kappa = 0.70). Only 57% of patients correctly recalled tetanus vaccination that were documented in the medical record (kappa = -0.04). Kappa statistics were unreliable for hepatitis A and B vaccines because so few vaccinations had been received., Conclusions: Discrepancies in agreement regarding indications for vaccines appeared to result from absence of information in the medical record regarding high risk behaviors and family contacts. Lack of agreement regarding vaccines that had been previously been received appeared due to both poor recall and lack of documentation. Combining medical record audit with self-assessment may be the most complete assessment of vaccination status of adults, but requires reconciling disagreements. Electronic medical records and registries that contain information about risk factors and previously administered vaccines may be necessary to overcome some these problems.

Purpose: Middle school entry laws increase coverage with recommended vaccines, but their effect on vaccines that are not required is unknown. We compared vaccination coverage for hepatitis B, tetanus and diphtheria (Td), and measles, mumps and rubella (MMR) in areas of states with discordant middle school, hepatitis B school entry laws, and evaluated the relationship between demographic characteristics and adolescent immunization rates., Methods: Retrospective design with purposive school sampling, using location of residence to determine study group. In each school, immunization records from a random sample of up to 75 students in ninth grade (affected by a new hepatitis B law) and 12th grade (not affected by the law) from 11 schools in two areas discordant for the law were analyzed. All areas had long standing two-dose MMR and Td requirements., Results: Ninth graders in schools with the law had hepatitis B rates higher (72.8%) than those without the law (18.6%) (U = 2.0, p < .01). There were no significant differences between grades or schools for MMR and Td. However, even in the presence of the law, rates were significantly lower in schools with lower socioeconomic indicators., Conclusions: Middle school immunization laws are effective at raising adolescent hepatitis B, but in this study there wasn't enough power to discern the effect on rates for other vaccines or the influence of demographic variables on rates. Results suggested that laws did not appear to completely overcome disparities. For school mandates to be more effective, additional efforts, presumably on enforcement, especially in areas with lower socioeconomic indicators, are needed.

Potential business losses incurred vaccinating adults against influenza have not been defined because of a lack of estimates for medical practice costs incurred delivering vaccines. We collected data on vaccination labor time and other associated expenses. We modeled estimates of per-vaccination medical practice business costs associated with delivering adult influenza vaccine in different sized practices. Per-shot costs ranged from USD 13.87 to USD 46.27 (2001 dollars). When compared with average Medicare payments of USD 11.71, per-shot losses ranged from US$ 2.16 to USD 34.56. More research is needed to determine less expensive delivery settings and/or whether third-party payers need to make higher payments for adult vaccinations.

Background: The content and context of the process of vaccinating older adults against influenza in outpatient settings has not been adequately described. Failure to appreciate the causal antecedents or precursors to the act of provider recommendation may explain why so many efficacious interventions identified by the U.S. Task Force on Community Preventive Services fail to be routinely implemented and why influenza immunization rates have remained static over the past decade., Methods: This study used critical path analysis from data collected during standardized workflow observations of patients more than 50 years of age from a convenience sample of 16 ambulatory care settings in San Diego, California; Rochester, New York; and Albuquerque, New Mexico. Observations were made from October 23, 2001 to January 31, 2002., Results: In this study, 62% (151/243) of patients observed during scheduled extended visits received influenza vaccinations. When operational, temporal, and clinical factors are examined altogether through critical path analysis, a model of seven critical organizational support, temporal, and clinical activities emerges that is able to predict 93% of the immunizations. Variation from the model predicts 73% of the missed opportunities., Conclusions: Vaccination of adults should not be seen as simply an incremental activity added to the general health encounter. Assuring a high rate of vaccination requires adequate time and operational support. Provider-patient discussion is more productively viewed as the culmination of the immunization process, not the beginning. Finally, this study indicates the potential need to identify and compare processes of care associated with other specific preventive services.

Between 1981 and 1992, the Centers for Disease Control collected and summarized 9,223 cases of Rocky Mountain spotted fever (RMSF) reported from 46 states. Four states (North Carolina, Oklahoma, Tennessee, and South Carolina) accounted for 48% of the reports. The annual incidence per million U.S. population decreased from a high in 1981 of 5.2 to a low in 1992 of 2.0, primarily due to decreased incidence in the southeast. Case report forms were filed on 7,650 patients, of whom 4,217 had laboratory-confirmed RMSF. The age group with the highest incidence was those 5-9 years of age. Most cases (90.0%) occurred between April 1 and September 30 and included a history of tick attachment (59.6%). Reported symptoms included fever (94.0%), headache (86.2%), myalgia (82.5%), and rash (80.2%). The case-fatality ratio was 4.0%. Risk factors associated with death included older age, delay in treatment or no treatment, and treatment with chloramphenicol (compared with tetracycline); however, insufficient data existed to fully assess the confounding effect of severity of illness on antibiotic choice.

A prospective, seroepidemiologic study of spotted fever group rickettsiae (SFGR) and Ehrlichia infections was done among 1194 US military personnel exposed in a heavily tick-infested area of Arkansas in 1990. Seroconversion (4-fold) and seroprevalence rates were determined by indirect immunofluorescent antibody assays. Seroconversions to SFGR occurred in 30 persons (2.5%), whereas seroconversion to Ehrlichia species occurred in 15 (1.3%). The majority of seroconverters did not report symptoms (22/30 [73%] of SFGR seroconverters; 10/15 [67%] of Ehrlichia species seroconverters). History of tick attachment was associated with seroconversion to SFGR (relative risk [RR] = 4.3, P < .001) and Ehrlichia species (RR = 3.6, P < .05). Use of permethrin-impregnated uniforms significantly decreased risk of infection (P < .01); use of bed nets increased risk by 4-fold. Tickborne infections represent a significant threat to military personnel training in areas in which these infections are endemic.

From 1 July 1987 to 31 December 1988, 30% of 247 rabid dogs in Hermosillo, Mexico had a positive history of rabies vaccination. Serosurveys suggested that inactivated suckling mouse brain vaccine (INACT-SMBV) and inactivated tissue culture vaccine (INACT-TC) used before and during the epizootic were poor immunogens. Prospective studies showed that only about one-third of dogs vaccinated with INACT-SMBV were seropositive 5 weeks after vaccination. Lack of vaccine potency was the most likely cause of poor immunogenicity. Rabies vaccines should be evaluated periodically by measuring antibody responses in animals. In some circumstances, minimum seroconversion rates and antibody titres in vaccinated animals may be better measures of immunogenicity than relative potency.

Ninety-five acute- and convalescent-phase serum specimens from 48 patients suspected of having rickettsial or Legionella infections were assayed for antibodies to Coxiella burnetii, the causative agent of Q fever. To evaluate the specificity of the indirect enzyme-linked immunosorbent assay (ELISA) for human Q fever, we compared the ELISA results with those of the indirect immunofluorescence antibody (IFA) test. The ELISA data were analyzed by two different criteria for a positive test. The first criterion for positive results by ELISA was based upon diagnostic titers established in a study of 150 subjects who had no demonstrable cellular or humoral immune responses to C. burnetii phase I or phase II whole cells or phase I lipopolysaccharide. The second criterion was based upon diagnostic antibody titers in a study of 51 subjects who had been diagnosed as having clinical Q fever and had fourfold or greater rises in humoral immune responses to C. burnetii phase I and phase II whole-cell antigens. A comparison of the ELISA and IFA test results of the 95 serum specimens indicated excellent agreement between the tests (Kappa = 92.9%; P < 0.05). None of the 38 patients whose etiologies were confirmed serologically as Legionnaires' disease or rickettsial diseases other than Q fever were classified as positive for C. burnetii by the ELISA. Only one patient identified by the IFA test as having Q fever was not scored positive by the ELISA. These results suggest that the ELISA is useful for epidemiologic screening and as a diagnostic test for human Q fever.

Objective: To describe the epidemiology, clinical features, laboratory manifestations, response to therapy, and factors related to morbidity and mortality in a large group of patients with ehrlichiosis., Design: Case-series., Setting: Laboratory-based surveillance in the United States., Patients: 237 patients whose serum had a fourfold increase or decrease in antibodies to Ehrlichia canis or E. chaffeensis., Measurements: Epidemiologic, clinical, laboratory data, hospitalization, duration of illness, complications, and treatment response., Results: From 1985 through 1990, 237 case-patients were identified in 21 states; rates exceeded 1 per 100,000 per year in only 5 counties. Incidence rates increased with age and were higher among men. Most case-patients had nonspecific illness and were not suspected of having a rickettsial infection. Many patients (60.8%) were hospitalized. Leukocyte and platelet counts typically decreased and liver function tests typically increased through day 7. Three (6.1%) of 49 outpatients treated only with tetracycline were hospitalized compared with 35 (92%) of 38 outpatients treated only with antibiotics other than tetracycline or chloramphenicol (P < 0.001). Among hospitalized patients, recovery was faster for those initially treated with tetracycline (median, 16 days) or chloramphenicol (median, 12 days) than for those initially treated with other antibiotics (median, 27 days; P = 0.03 for both comparisons). In a logistic regression analysis, severe illness or death was more probable among case-patients 60 years or older (odds ratio [OR], 4.60; 95% CI, 1.87 to 11.2) and among those who did not receive tetracycline or chloramphenicol until 8 or more days after symptom onset (OR, 4.38; CI, 1.36 to 14.0)., Conclusions: The findings of this study are primarily representative of more seriously ill patients with human ehrlichiosis. Although rates are low, ehrlichiosis is found in many areas of the United States. Patients with a history of tick exposure, acute febrile illness, decreasing leukocyte counts, and decreasing platelet counts may have ehrlichiosis. Prompt treatment with tetracycline or chloramphenicol markedly decreases the morbidity.

To determine the incidence of and risk factors for adverse reactions following the boosters, we conducted a nationwide prospective study of persons receiving pre-exposure booster vaccination with human diploid cell rabies vaccine (HDCV). Persons who had previously received three pre-exposure doses of HDCV and whose rabies neutralizing antibody titres were < or = 1:5 were enrolled in the study if they stated that they intended to receive a booster. Of the 98 persons enrolled in the study, 40 (41%) were in risk groups for whom boosters are not recommended. Three (3%) of 98 developed generalized urticaria or wheezing within 1 day of receiving boosters and three others (3%) developed urticaria 6 to 14 days after the booster. No differences were found between individuals with reactions (either type) and those with no adverse reaction according to age, gender, occupation, history of previous allergies, or time since or route of primary vaccination. Reactions were somewhat more common among persons who received primary vaccinations by the intramuscular route (i.m.) and booster vaccinations by the intradermal route (i.d.) (3/15, 20%) or primary vaccinations i.d. and booster vaccinations i.m. (2/10, 20%), and somewhat less common among persons who received both these vaccinations i.d. (1/52, 2%) or i.m. (0/7). The number of persons who develop allergic reactions may be minimized by administering vaccinations only when vaccination is strictly indicated. The influence of the route of primary and booster vaccinations on the development of reactions deserves further study.

From 1 July 1987 to 31 December 1988, a total of 317 animals (91% of which were dogs) were confirmed to have rabies in Hermosillo, Mexico. The median age of rabid dogs was 1 year, 69% were male, and 98% were owned. The epizootic started in the southern areas of the city, rapidly involved the entire city, and persisted mainly in lower socioeconomic status areas. The area of the city and mean household size were significant predictor variables for the population density of rabid dogs around household clusters (Poisson linear regression, P < 0.001 and P = 0.03, resp). Approximately 2.5% of city residents were bitten by dogs in 1987, with the rate of reported dog bite injuries being positively correlated with mean household size and the proportion of households that owned dogs. Visits to the city health centre for evaluation of possible exposures to rabies increased by 135% after the start of the epizootic; approximately 273 per 100,000 city residents were administered a full or partial course of rabies post-exposure prophylaxis in 1987. Children were at greatest risk for exposures to rabies, accounting for 60% of all reported animal bite injuries evaluated at the health centre. Also they were more likely than older persons to have received bite injuries to the head, face, and neck (odds ratio = 21.6, 95% confidence interval = 5.4, 186.5).

In November 1989, the epizootic of rabies affecting raccoons in the mid-Atlantic states reached New Jersey. An economic evaluation was conducted in 2 counties first affected by the epizootic to estimate the costs of the epizootic and to assess the costs and benefits of orally administering a newly developed recombinant rabies vaccine to prevent further spread of the disease. Data on expenditures associated with prevention of rabies in human beings and domestic animals and laboratory testing of suspect animals were collected and analyzed for 1988 (before the epizootic) and 1990 (first full year of the epizootic). Benefit-cost ratios were calculated and used to evaluate the economic advisability of the vaccine at various vaccination program alternatives. Two indices of capital investment analysis, payback period and net present value, were used to evaluate the economic benefits of the rabies vaccine. Expenditures were estimated to be $1,952,014 in 1990 (primarily for pet animal vaccinations), compared with $768,488 in 1988. Benefit-cost ratios ranged from 2.21 for the most expensive vaccination program alternative to 6.80 for the least expensive alternative. The payback period varied from 0.69 to 2.11 years, and the net present value ranged from $2,105,453 to $4,877,452. The high costs of this epizootic necessitated the reallocation of scarce public health resources to various rabies prevention activities, particularly the vaccination of dogs. This study also demonstrated the usefulness of benefit-cost analysis in developing public health strategies. Although the mass application of this recombinant vaccine was found to be economically beneficial, other qualitative considerations must be used to supplement these findings.

We compared three vaccination strategies in three rural communities in Mexico to determine the factors associated with the success of vaccination programs in areas where canine rabies is poorly controlled. In town A, intensive publicity and community participation were used; owners were instructed to bring their dogs to temporary centralized clinics for vaccination. In town B, only brief precampaign publicity was used, followed by vaccination at a centralized site. Minimal publicity was also used in town C, but the vaccination campaign was conducted house to house. A total of 5,426 residents and 1,597 dogs were counted in the three towns (mean human:dog ratio 3.4:1). In Town A, 70.1% (472 of 673) of the dogs were vaccinated; the campaign required 40 person-minutes per dog. Significantly greater proportions were vaccinated in town B (262 of 318 [82.4%]; P less than 0.001) and town C (483 of 561 [86.1%]; P less than 0.00001); each of these latter campaigns required 10 person-minutes per dog. The following factors were positively associated (by multivariate analyses) with vaccination of individual dogs: non-intensive publicity, house-to-house vaccination, dogs owned by a single member of the household, and dogs acquired greater than 15 days after birth. Intensive publicity did not increase the overall success of the vaccination program; the efficiency of centralized versus and house-to-house vaccination was comparable.

We evaluated four baits for the delivery of oral rabies vaccines to dogs. In a controlled study in a town in rural Mexico, 177 randomly selected dogs were assigned to receive one of four experimental baits (two of which were developed by the Denver Wildlife Research Center [DWRC]): one of two cylindrical polyurethane sponges with a corn meal coating (one fried in corn oil [DWRC-corn], the other in fish oil [DWRC-fish]), a fish-flavored polymer bait, or a wax bait. Each dog was also offered a commercial dog biscuit. We recorded whether or not the bait was completely consumed, and used the following measures to estimate the amount of oropharyngeal contact with each bait: total chewing time, presence of pieces of bait on the ground following administration, the total area of ground surrounding the location of ingestion that was covered with green dye contained in each bait, and condition of ampules that contained the dye. The dog biscuits were completely consumed significantly more often than the baits (155 of 176 [88%] for the biscuits versus 89 of 176 [50.5%] for the four baits; P less than 10(-6)), but were chewed for a significantly shorter time than the baits (mean time 34 sec for the biscuit versus 60-82 sec for the four baits: P less than 0.001). The ideal bait would probably combine the attractiveness of the commercial biscuit and the ability of the sponge baits to promote contact with the mucous membranes.

An outbreak of Q fever occurred among patients and staff of a psychiatric institution in southern France. Some of the patients and staff left the institution daily to work on a farm where goats were raised for raw milk and cheese production. The goats had all been vaccinated annually with a commercial vaccine containing phase II Coxiella burnetii antigen. A serologic survey revealed that 40 (66%) of the 61 patients and staff had elevated titers to C. burnetii. Seropositive persons were more likely to report an acute illness (P = 0.001), fever (P = 0.04), weakness (P = 0.04), arthralgia (P = 0.04), and headaches (P = 0.06) in the preceding year than were seronegative persons. Seropositivity rates were significantly higher among persons who worked on the farm and consumed unpasteurized milk products (69% [22 of 32]; P = 0.007), those who only had worked on the farm (75% [9 of 12]; P = 0.009), and those who only had consumed unpasteurized milk products (75% [9 of 12]; P = 0.009), compared with those who had not worked with the goats or consumed unpasteurized milk products (0 of 5). Despite vaccination against Q fever, no antibodies to C. burnetii were detectable in 17 (59%) of 29 goats. All 12 seropositive goats had antibodies to both phase I and phase II antigens, indicating that they were naturally infected, and two of three goats examined were shedding C. burnetii in their milk. Vaccination of this herd did not prevent the outbreak and might have increased shedding of C. burnetii in the dairy products.

During the spring of 1989, 86 members of a military unit from the state of Maryland, USA, participated in two-week-long training manoeuvres in the states of Arkansas (location FC) and Virginia (location FAPH). Acute febrile illnesses due to infections with two tick-borne pathogens, Rickettsia rickettsii and Ehrlichia sp., were confirmed serologically in 2 initial cases who were admitted to the hospital. A seroepidemiological investigation among unit members found an additional 17 of 109 individuals (16%) with elevated post-exposure indirect immunofluorescent antibody (IFA) titres to R. rickettsii (16 cases) and/or E. canis (2 cases). The seropositivity rate of personnel who trained at FC was 38% (15 of 40), compared to only 13% (4 of 31) and 8% (3 of 38) of personnel who trained at FAPH or who did not train in the field, respectively (P < 0.001). Seropositivity was associated with symptoms suggestive of a tick-borne illness. Only 4 (22%) and 6 (33%) of the 18 personnel seropositive for R. rickettsii reported an erythematous or petechial type of rash or a febrile illness, respectively, within 4 weeks of exposure; 5 of 18 (28%) personnel infected with R. rickettsii reported no symptoms and only 8 of 18 (44%) received medical treatment. Mild infections with R. rickettsii, or a closely related spotted fever group agent, may have accounted for the high infection rate experienced by this group.