The National Center for Immunization and Respiratory Diseases
2008 Annual Report    (CDC logo image)

Table of Contents 
Mission 
Priorities 2008-2010
Healthy People in Every Stage of Life
CMV:  Increasing awareness, working toward prevention	5
Childhood immunization rates remain strong	5
National Infant Immunization Week	6
Protecting preteens	7
Partnering to fight hepatitis B among adults	8
Getting the word out on influenza vaccination	8
Building awareness	8
Educating and empowering public health partners	9
Tracking the impact of pneumococcal conjugate vaccine	10
Continuing to monitor vaccine safety	10
Neuropsychological function and thimerosal	10
Close monitoring to ensure varicella vaccine is safe and effective	11
Reassuring the public that a new rotavirus vaccine is safe	11
Healthy People in Healthy Places
Solving a pneumonia mystery	 12
Learning from an outbreak of human adenoviruses	13
Examining norovirus outbreaks	14
Keeping the United States free of measles and rubella	14
Immunization education and training:  Meeting the needs of tomorrow	15
Education and training for healthcare professionals	15
Epidemiology training takes new course	15
Making vaccines more accessible	16
Healthy People in a Healthy World
Polio	18
Changes in how outbreaks are tested and understood	18
Progress in eradication	18
Measles and rubella	20
Measles deaths continue to decrease globally	20
Rubella cases plummet in the Americas	20
Contributing to global surveillance	20
Linking routine immunization and malaria prevention in Malawi	21
Evaluating influenza burden among the poor	22
Getting new vaccines to children in developing countries	22
Better data management means better disease surveillance and service delivery	24
Improving detection of respiratory pathogens	24
Monitoring new vaccines to prevent rotavirus gastroenteritis	25
EPI Olympics 	26
Exploring a new role for CDC in international Bordetella Pertussis efforts	27
People Prepared for Emerging Health Threats
Avian Influenza	28
New research on prevention and treatment	28
Investigating flu outbreaks in poultry	28
Communities in Vietnam join the effort	29
Preparing CDC and the world for pandemic influenza	30
Training CDC staff	30
Creating domestic rapid response teams	30
Improving laboratory surge capacity	30
Training the global health community	31
Developing early-warning networks	31
Vaccine research and development	32
Global disease detection innovative project	33
Studying anthrax vaccine	34
Studying past pandemics gives hope for identifying new ones	34
Detecting and investigating swine influenza	35
Appendix
2008 Calendar of events	38
Who’s Who in NCIRD Leadership	40
NCIRD organization chart	42
International assignees field map	43
Immunization schedules with footnotes	44

Mission
Prevention of disease, disability, and death through immunization and by control of respiratory and related diseases
Priorities 2008-2010:

1. Implement new vaccines and new recommendations through: support of communication and outreach; strengthened monitoring of vaccine impact, and immunization coverage; and programmatic support to assure financing, distribution, storage, and handling. See Protecting Preteens, Partnering to Fight Hepatitis B Among Adults...

2. Reduce worldwide deaths from pneumonia, other severe respiratory and vaccine-preventable diseases by facilitating use of known interventions, devising sound approaches to monitor impact, and accelerating research to address key gaps. See Measles Deaths Continue to Decrease Globally, Getting New Vaccines to Children in Developing Countries...

3. Improve preparedness for global threats through strengthening epidemiologic, laboratory, and public health preparedness and response capacity against respiratory microbial threats.
See Preparing CDC and the World for Pandemic Influenza, Solving a Pneumonia Mystery...

Healthy People in Every Stage of Life
Picture of pregnant woman and little girl kissing the moms stomach.
CMV: Increasing Awareness, Working Toward Prevention

Congenital cytomegalovirus (CMV) is the leading cause of congenital infection in the United States. Passed from mother to fetus, this disease is estimated to infect up to 40,000 newborns every year and results in as many as 8,000 permanent disabilities, including hearing loss, vision loss, and mental retardation. Although no CMV vaccine is currently
available, NCIRD research is continuing to help lay the groundwork for how to use vaccines effectively in the future. In 2007, for example, NCIRD published: 

■The first national estimates of CMV
seroprevalence, demonstrating that more than 50% of women of childbearing age are susceptible to CMV infection; 

■The first national estimates of CMV
incidence, showing that each year, an estimated 27,000 women in the United States experience a primary CMV infection during pregnancy;

■ A survey showing that few women have heard of CMV, let alone know how to avoid infection during pregnancy; 

■ Comprehensive review articles of the prevalence of congenital CMV and the prevalence of neurological and sensory sequelae.
 
Not only does this research provide a baseline against which a future vaccine may be evaluated, it highlights the frequency and seriousness of the problem of CMV. Through these and other efforts, NCIRD and other centers within CDC are working to increase awareness and prevention of perinatal infections like CMV.

Childhood immunization rates remain strong
In 2006, the nation’s childhood immunization rates remained at or near record high levels for routinely recommended vaccines. According to the National Immunization Survey, 77% of U.S. children 19 to 35 months of age had received the complete recommended series of childhood vaccines, a slight increase from the previous year. 

National Infant Immunization Week 
During the week of April 21, 2007, NCIRD joined with partners in government and healthcare across America to launch the 13th annual National Infant Immunization Week (NIIW), a far-reaching effort to promote immunization against vaccine-preventable diseases for children under 2 years of age. Hundreds of communities in the United States participated in a variety of special NIIW activities designed to educate and inspire parents and healthcare providers. NCIRD supported state and local NIIW activities with web-based planning tools, Spanish- and English-language campaign materials, public relations tools, and technical assistance. Immunization messages were heard from coast to coast on television and radio as well as in newspapers and magazines. And for the fourth consecutive year, NIIW was held in conjunction with the Pan American Health Organization’s (PAHO) Vaccination Week in the Americas (VWA), which took place in 45 countries.

NCIRD officials, including Director Anne Schuchat, participated in nearly three dozen press conferences, media interviews, and other NIIW and VWA events. In Las Vegas, for example, Dr. Schuchat joined First Lady of Nevada Dawn Gibbons at La Oportunidad Expo, a community event featuring a free Helping Kids immunization clinic. The Nevada State Health Division Immunization Program and Nevada Immunization Coalitions worked with local officials to launch a number of other activities throughout the state, including free immunization clinics at health centers, fire stations, and community fairs, resulting in immunizations for nearly 5,000 at-risk children.   

Photo of ribbon cutting.

4 Posters from the Immunization campaign.

NCIRD Deputy Director Melinda Wharton was on hand at the Children’s Museum of Denver to present Colorado Lieutenant Governor Barbara O’Brien with an award for her state’s efforts to increase rates of childhood immunization. The Colorado Department of Health Immunization Program convened a statewide planning committee to organize additional NIIW activities, including immunization clinics, grand rounds, and a statewide provider education webcast.

Dr. Jeanne Santoli, deputy director of NCIRD’s Immunization Services Division, attended a kickoff event in Hidalgo County, Texas, to highlight how partnerships and collaborations have helped maintain and strengthen immunization rates throughout the U.S.-Mexico border region. One of the most important of these collaborations has been between CDC, the U.S.-Mexico Border Health Commission, state and local immunization programs, and PAHO.

During NIIW, CDC continued to promote a national Spanish-language public education campaign, Continuando con la promesa (“Keeping the Promise”), through television, radio, and print media. The campaign reached 23 of the top 30 Hispanic television markets and nine of the top 10 Hispanic radio markets in the United States. In the last two years, the campaign has garnered more than $350 million in donated media space, helping result in more than 554 million media impressions.

Protecting Preteens 
Between 2005 and 2007, CDC recommended three new vaccines for preteens (11-12 years of age) to protect against several serious, sometimes life-threatening diseases: meningococcal vaccine, which protects against meningococcal meningitis and other forms of meningococcal disease; Tdap vaccine, a booster against tetanus and diphtheria that also offers protection against pertussis (whooping cough); and HPV, which protects girls against types of human papillomavirus, which account for 70% of cervical cancer cases.

Promoting the new vaccines is a challenge. Research has indicated that some parents of preteens are wary about the safety and necessity of new vaccines—HPV, in particular—for their healthy preteens. Moreover, data from the 2006 National Immunization Survey revealed that immunization rates among 13-15 year-olds are far short of national Healthy People 2010 goals, especially with regard to the most recently recommended vaccines.

To raise awareness about the vaccines and the diseases they prevent, NCIRD launched a comprehensive campaign targeting parents—primarily mothers—and healthcare providers in August 2007, coinciding with National Immunization Awareness Month. The campaign included a variety of media in both English and Spanish, including radio broadcasts, media roundtables, direct mailings, and articles in professional and consumer publications. In addition, the campaign website contained an online gallery of campaign materials, including downloadable flyers and posters. Finally, we partnered with key organizations to increase the reach of the immunization message. One of the campaign’s most significant partners was the American Academy of Pediatrics (AAP), which participated in several media events during the campaign launch. Because many parents turn to pediatricians for guidance about their children’s health, AAP was an ideal fit to bring the message of these new recommendations to the public and to increase consumer confidence.

Media outreach for the preteen campaign was a success. By the end of August 2007, the campaign had been covered in more than 140 print and online articles, both in the United States and abroad, and had reached an estimated 26 million people through radio. And in its first month alone, the campaign website received more than 17,000 page views. These encouraging results will help continue to raise awareness about the importance of vaccinations for all age groups.

Partnering to Fight Hepatitis B Among Adults
One of the greatest remaining challenges to eliminating transmission of hepatitis B virus (HBV) in the United States is the need to increase vaccination rates among high-risk adults—primarily, those who inject drugs or  engage in risky sexual behavior. In response, the Advisory Committee on Immunization Practices (ACIP) has recommended universal hepatitis B vaccination in settings where these at-risk adults receive services, including STD clinics, HIV testing and treatment centers, drug treatment and prevention facilities, and correctional facilities.

To support the ACIP recommendation, multiple CDC programs collaborated with state and local health programs in 2007 to develop and begin implementing the Adult Hepatitis B Vaccination Initiative. This initiative provided grantees with more than $20.1 million to purchase hepatitis B vaccine. It will also enable state and local agencies to begin or expand delivery of viral hepatitis prevention services in healthcare settings and through public health programs that serve at-risk adults.

CHART: Reported Acute Hepatitis B by Age, United States, 1990-2006

Getting the Word Out on Influenza Vaccination
The 2007 flu season saw record amounts of influenza vaccine distributed as well as new and dynamic efforts to protect more Americans than ever before.

Building awareness

Building awareness of the importance of vaccination —particularly among groups at higher risk for complications from influenza—remained a top priority for CDC. Despite updated guidelines from the Advisory Committee on Immunization Practices (ACIP) that recommend influenza vaccination for nearly 75% of the U.S. population, many people remain unvaccinated.

In response, NCIRD used formative research to develop posters targeting parents of children with asthma and diabetes, adults who live with aging parents, and family members of newborns too young to be protected by vaccination. These materials are available free for download from CDC’s newly revised flu website (www.cdc.gov/flu ).

Ongoing media updates were also important to influenza communication activities. Throughout the flu season, press conferences and other media events took place across the country, featuring CDC experts and state and local health department staff. Efforts in 2007 included ethnic media roundtables, bilingual (English and Spanish) radio media tours, and bilingual radio and television public service announcements.

To help highlight the benefits of influenza vaccination throughout the entire influenza season, the Department of Health and Human Services, CDC, the National Influenza Vaccine Summit, and other partners held the second annual National Influenza Vaccination Week (NIVW) from November 26 to December 2, 2007. During NIVW, NCIRD emphasized the importance of influenza vaccination for all people at high risk, and those living with or caring for them. NIVW put a special focus on children. CDC, Families Fighting Flu, and other partners set aside November 27, 2007, as National Children’s Flu Vaccination Day, emphasizing the importance of vaccinating high-risk children and the people close to them.. 

Educating and empowering public health partners

CDC’s newly revised flu website provided a single online location where national, state, and local partners could share their flu season events, resources, and activities. It also offered them a
variety of valuable CDC resources, including:
■ A video podcast (or “vodcast”) that explains the complexities of vaccine production and distribution;
■ New “e-health” marketing tools, such as e-cards, web-based training events, outreach, and education in “virtual worlds”; and
■ Web-based tools specifically designed for public health partners.

There were also a variety of NCIRD professional education activities in 2007, including:
■ The Immunization Update satellite broadcast/webcast;
■ Netconferences and teleconferences to help extend the vaccination season;
■ Participation in grand rounds;
■ A two-day immunization training program for clinicians; and
■ Presentations to providers at a variety of medical and nursing conferences.

Posters from NIIW week English and Spanish versions.

Tracking the Impact of Pneumococcal Conjugate Vaccine 

Pneumococcus (Streptococcus pneumoniae) is the most common cause of bacterial meningitis, pneumonia, and ear infections in the United States, especially among young children and older adults. Pneumococcal conjugate vaccine protects young children against the seven strains that caused the most cases of pneumococcal disease. Data from the Active Bacterial Core surveillance (ABCs, part of the Emerging Infections Program Network—a system that monitors pneumonia, blood infections, and meningitis in more than 20 million people across the United States—indicate that the vaccine has had a tremendous impact on preventing severe infections caused by one or more of the seven strains.

According to ABCs, vaccination prevented approximately 30,000 cases of severe pneumonia, blood infections, and meningitis in 2006 alone. CDC epidemiologists also worked with scientists at Vanderbilt University to measure pneumococcal vaccine’s impact on pneumonia hospitalizations. They found that the vaccine is estimated to prevent approximately 41,000 pneumonia hospitalizations in the United States each year among children under five years of age. In addition, vaccinating young children is helping to prevent severe infections in older people, because the vaccine prevents the spread of the pneumococcus bacterium.

CHART: Rates of invasive pneumococal disease by serotype and year among children < 5 years old

Continuing to Monitor Vaccine Safety

Neuropsychological function and thimerosal
Thimerosal is a mercury-containing preservative that has been used in vaccines since the 1930s.  Since 2001, thimerosal has not been used in routinely recommended childhood vaccines, with the exception of some flu vaccines. Despite a lack of convincing scientific evidence that low doses of thimerosal in vaccines cause harm beyond minor reactions like redness and swelling at the injection site, there has been continued public concern about its effects. In response, CDC worked extensively with independent consultants to design a comprehensive study on vaccine safety—specifically to examine whether early exposure to mercury from thimerosal-containing vaccines and immune globulins was associated with neuropsychological function among children 7-10 years of age.

The study results appeared in the New England Journal of Medicine (September 27, 2007). The study found no consistent evidence of neurological problems in children exposed to mercury from thimerosal-containing vaccines or immune globulins. One finding related to thimerosal exposure and a possible risk of motor and phonic tics in boys may require further consideration. This study did not assess whether thimerosal exposure from vaccination is associated with autism; CDC is completing a separate study to address this hypothesis.

Picture of baby and dog.

Close monitoring to ensure varicella vaccine is safe and effective 

Since 1995, routine childhood immunization with the varicella vaccine has dramatically reduced sickness and death caused by the varicella zoster virus (VZV)—also known as chickenpox—in the United States. Because the varicella vaccine can occasionally cause a mild, chickenpox-like illness and, more rarely, a severe rash, pneumonia, or meningitis, the safety of the vaccine is being carefully monitored. 

To monitor vaccine safety, scientists must be able to differentiate between the weakened virus in the vaccine and the wild-type virus. CDC’s National VZV Laboratory receives clinical specimens from around the world that represent cases where varicella vaccine may have caused sickness or death. Using a panel of real-time polymerase chain reaction (PCR) methods, scientists can distinguish the vaccine strain from wild strains more dependably than by any previously reported method. 

Reassuring the public that a new rotavirus vaccine is safe 

Rotavirus is the leading cause of severe gastroenteritis (diarrhea and vomiting) in infants and young children worldwide. Every year in the United States, rotavirus is responsible for more than 400,000 doctor visits, more than 200,000 emergency room visits, 55,000-70,000 hospitalizations, and 20-60 deaths in children under 5 years of age. To control and prevent this severe childhood illness, a new oral rotavirus vaccine called RotaTeq™ was licensed and recommended in early 2006 for all U.S. infants. Evaluating and communicating the safety of a new vaccine is important—especially so in the case of RotaTeq™. In 1999, a different previously licensed rotavirus vaccine was withdrawn from the U.S. market after it was found to be associated with intussusception, a type of bowel obstruction. As a result, CDC has been working closely with the FDA to monitor the safety of the RotaTeq™ vaccine.

Data from the first year of post-licensure monitoring found no risk of intussuseption and more recent data are similarly reassuring. CDC and the FDA will continue to assess the safety of RotaTeq™ as its use increases.

CHART: Rates of Varicella-Related Ambulatory Visits, 1994-2002

Picture of Father and baby walking down a path holding hands.
Picture of three adults smiling and embracing

Healthy People in Healthy Places
Solving a Pneumonia Mystery
In Rhode Island, two classmates in one elementary school (designated the index school) and a child in a second school were diagnosed with encephalitis in late December 2006; one of these students from the index school later died. At the same time, these schools as well as two neighboring schools reported an unusually high number of children with pneumonia. In response, the Rhode Island Department of Health invited CDC Epidemic Intelligence Service Officers as well as epidemiology and laboratory staff to help identify the origin of the outbreak and recommend ways to stop it.

Field epidemiology and extensive specimens determined that the outbreak was caused by Mycoplasma pneumoniae, a small, highly infectious bacterium that is a common cause of mild pneumonia but occasionally causes severe pneumonia and encephalitis.   Among the four schools reporting pneumonia cases, 76 children were infected.
To stop ongoing transmission, students at the index school and their household contacts were offered preventive antibiotics. We disseminated materials for school hand hygiene and cough-etiquette campaigns. Alcohol-based hand sanitizing dispensers were installed in all schools in the state. These and other measures helped reduce on 
going transmission of mycoplasma as well as other pathogens during the peak respiratory illness season. 

Picture of little girl writing at a school desk.

Learning from an Outbreak of Human Adenoviruses
Among infants and young children, human adenoviruses are a frequent cause of mild gastroenteritis, conjunctivitis, and illnesses of the upper respiratory tract. Adenoviruses are generally rare among adults, but severe respiratory infections can afflict immunocompromised adults, those with underlying respiratory or cardiovascular disease, and, in particular, healthy military recruits, who are at greater risk due to the crowding and stress of basic training.

Picture of a Molecular.

In 2007, several outbreaks of severe respiratory disease associated with a rare adenovirus (HAd14) occurred in the United States. While the settings varied—the general population in Oregon, a psychiatric unit in Washington State, a military base in Texas—all were characterized by severe febrile respiratory illness. Overall, eight deaths were reported, some among previously healthy young adults. In addition, retrospective review found an infant who died of HAd14-associated pneumonia in New York City in 2006.  In response, NCIRD partnered with the U.S. Air Force and state public health departments in New York, Oregon, Texas, and Washington State to investigate the outbreaks and provide diagnostic and laboratory support. These investigations aimed to better characterize the virus that caused the outbreaks—learning how it was transmitted and the spectrum of illness caused by infection—and to help design control measures to prevent its spread.

Molecular biological investigations at a CDC laboratory found the same strain of HAd14 in all the outbreak sites, and suggested that a newly emerged strain of HAd14 accounted for the outbreak.

In collaboration with the Walter Reed Army Institute of Research, NCIRD is continuing to study whether antibodies to other HAds will cross-protect against HAd14. Results of these efforts will inform further development of adenovirus vaccines as well as future outbreak identification and control efforts. 

Examining Norovirus Outbreaks

In late 2006 and early 2007, several state health departments reported what they believed to be an increase in the number of outbreaks of acute gastroenteritis (AGE), especially those involving person-to-person transmission in long-term care facilities. In just three states— New York, North Carolina, and Wisconsin—there were more than 15,000 cases of gastroenteritis reported among patients and staff of these facilities. NCIRD undertook a comprehensive, multi-state investigation of the situation.

NCIRD examined outbreak data from a multitude of sources, including two dozen state health departments, while CDC laboratories tested hundreds of stool samples from across the country for the presence of norovirus—the most common cause of sporadic cases and outbreaks of AGE. The final analysis suggested that there had been a significant increase in the frequency of AGE outbreaks nationwide, particularly in nursing homes, and that this increase had been caused by two new strains of norovirus. Going forward, we will continue working to improve national outbreak surveillance, rapid laboratory assays, and a norovirus sequence database (CaliciNet) to help identify emerging norovirus strains and more accurately assess their threat to the public’s health. 

CHART: Vaccine-Preventable Disease Reports for Measles and Rubella, 2006

Keeping the United States Free of Measles and Rubella
  
Indigenous measles and rubella were declared eliminated in the United States in 2000 and 2004, respectively. These remarkable successes were achieved through sustained high vaccination rates among children, effective surveillance, and prompt outbreak response. Measles and rubella remain common in many parts of the world, however, travelers carrying these diseases pose an ongoing challenge to the United States. Substantial public health resources are required for investigating and controlling even small outbreaks.

There were 30 reported cases of measles nationwide in 2007, including an outbreak in which the first case-patient was a 12-year-old Japanese baseball player taking part in the Little League World Series in Pennsylvania. During the same time period, 11 cases of rubella were reported, including a three-case cluster among foreign-born college students in Michigan.  

Together with local and state health departments, CDC will continue working to prevent imported virus strains from gaining a foothold in the United States by ensuring high usage of the measles-mumps-rubella vaccine, conducting surveillance activities to quickly identify cases of measles and rubella, and  responding to individual cases or outbreaks of these diseases. 
Immunization Education and Training: Meeting the Needs of Tomorrow
Education and training for healthcare professionals 

■ NCIRD delivered 119 in-person presentations to 14,465 healthcare providers.  Other training
included nine net conferences, six satellite broadcasts, and two new web-based modules. 
■ More than 21,000 healthcare professionals were awarded continuing education credits for participating in training programs. Despite a six-month warehouse shutdown, the NCIRD Resource and Information Center distributed approximately 310,000 publications as well as 14,000 CD toolkits on vaccine storage and handling. 
■ NCIRD staff responded to approximately 5,700 immunization-related e-mail inquiries from healthcare professionals. 
■ A 2007-2008 Influenza Vaccine Production and Distribution vodcast was created to acquaint healthcare providers, public health partners, and others with the vaccine manufacturing process. 

Picture of a news broadcast.

Epidemiology training takes new course

For more than 25 years, CDC has presented live epidemiology training sessions related to vaccine-preventable diseases for healthcare professionals. Since 1995, this comprehensive, four-part course on immunization and vaccine-preventable diseases has been broadcast nationwide via satellite; with 5,000-10,000 healthcare providers participating in each broadcast, the program has become the backbone of CDC’s immunization training curriculum over the last decade. Its success has spawned additional training broadcasts on a host of issues, including disease surveillance, pandemic influenza preparedness, and vaccine safety.

In 2007, NCIRD presented the epidemiology course as a live satellite broadcast for the last time. Beginning in 2008, the program will be delivered exclusively in the form of archived webcasts and DVDs. These new formats will provide increased flexibility for participants, who will be able to access curricula at their convenience— and still earn continuing education credits.

Making Vaccines More Accessible

Throughout 2007, NCIRD worked to improve how vaccines are ordered and distributed throughout the United States. From producers to providers to patients themselves, these innovative new processes will create long-term benefits up and down the vaccine supply chain.

In September 2006, we began creating a consolidated national system to more efficiently inventory and distribute publicly purchased vaccines. Relying on a single, centralized distributor and a network of existing vaccine depots—facilities used to store and ship vaccines at the state or local level—this system will also improve CDC’s ability to gather information on inventory and distribution, down to the provider level. By November 2007, more than half (34) of CDC’s 64 immunization program grantees—including state and territorial health departments as well as selected metropolitan departments—were using the new system.  In addition, the system has been able to reduce the number of depots by 36%, further improving distribution efficiency.

The way healthcare providers order vaccines is also changing. NCIRD is developing a centralized vaccine ordering system called the Vaccine Tracking System, or VTrckS, that will greatly simplify and streamline the way providers place orders. While these orders are being processed, VTrckS will enable NCIRD to track which vaccines are being used across the country. Not only will the system help to more accurately forecast future vaccine needs and potential changes in program cost, it will be ready on a moment’s notice to assist in any future pandemic response.

CHART: CDC Immunization Grantees Using the New Vaccine Inventory/Distribution System (3/17/2008)
Picture of little girl getting a shot in left arm.
Healthy People in a Healthy World
Polio

Picture of baby getting vaccine drop.

Progress in eradication
 
NCIRD’s polio eradication efforts contributed to a significant decline in the number of cases worldwide in 2007. In particular, there were significant achievements in India and Nigeria, two of the four countries (including Afghanistan and Pakistan) that have never stopped indigenous transmission of polio: 

■ In the poor and densely populated Indian state of Uttar Pradesh, considered the most challenging area in the world for polio eradication, there was a sharp drop in wild poliovirus type 1 cases: from 520 in 2006 to only 21 in 2007. This small number of cases represents a major achievement in cutting the chain of transmission of the most dangerous type of poliovirus in a highly endemic area. 

■ Nigeria also experienced a significant decline in wild polio cases: from 1,122 in 2006 to only 286 as of December 31, 2007. During the year, Nigeria also saw stronger ownership and support for its eradication program among political, traditional, and religious leaders, as well as a marked improvement in community participation in immunization activities.

As of December 31, 2007, 1,303 confirmed polio cases had been reported globally for the year, compared with 1,874 cases during the same period in 2006. In addition, there was a 31% decline in polio-infected districts in endemic countries, and polio outbreaks were stopped in 10 countries. During the year, CDC purchased more than 260 million doses of oral polio vaccine for large-scale vaccination campaigns in India, Nigeria, and other priority countries. As part of these efforts, NCIRD staff provided a range of technical assistance: planning and monitoring national immunization days; designing and conducting programmatic research; developing enhanced data-management tools; and conferring with other polio experts.

Changes in how outbreaks are tested and understood

Oral polio vaccine (OPV) has long been the primary tool in global efforts to eradicate poliovirus. The vaccine has several advantages, including its simple oral delivery, low cost, and potential to achieve secondary immunization in people who come into close contact with those who have been vaccinated. In poorly immunized communities, however, this last property can, on occasion, lead to the creation of vaccine-derived polioviruses (VDPV) that continue to transmit in populations until they are stopped by increased immunization activities. VDPVs are very similar to the strains found in vaccine but have much greater potential to cause paralytic disease and outbreaks.

In late 2006, an observation in the NCIRD polio laboratory led to a series of discoveries that changed standard laboratory protocol/testing throughout the Global Polio Laboratory Network (GPLN)—a group of 145 sub-national, national, and regional laboratories responsible for detecting wild polioviruses—as well as the scientific community’s understanding of the outbreak risk associated with VDPVs. Scientists found that an excess of poliovirus type 2 vaccine-related isolates were geographically clustered in northern Nigeria. Genetic sequencing of the suspect isolates revealed, surprisingly, that they included VDPVs missed by established screening methods. During the next year, CDC initiated a three-part response.

■ First, the extent of the problem needed to be determined. NCIRD launched epidemiologic and laboratory investigations into other potential clusters of vaccine-related polioviruses and also began testing archived specimens throughout the GPLN; when completed, nearly 15,000 virus isolates from the last two years will have been re-screened or sequenced to ensure the highest level of virologic surveillance sensitivity.

■ Second, new molecular screening methods already in development at NCIRD were rapidly deployed to selected GPLN laboratories. These new methods allow for rapid screening of large numbers of isolates, which eliminates the need for more expensive sequencing and will enable many more laboratories to reliably screen for these VDPVs in the future.

■ The third activity involved the careful and comprehensive characterization of the VDPV isolates to better understand the nature of the genetic changes associated with their increased transmissibility. Along with epidemiologic data, this examination of the isolates makes clear that a smaller number of genetic changes than previously thought can result in outbreaks of polio. This information will help NCIRD more effectively assess the risks associated with OPV use.

Picture of women and babies waiting for shots.

Measles and Rubella 

Measles deaths continue to decrease globally 

Along with the World Health Organization, the American Red Cross, the United Nations Foundation, and UNICEF, CDC is helping to spearhead the Measles Initiative, a global partnership committed to reducing the number of deaths caused by measles, which occur primarily among young children in the developing world. Due in large part to the commitment and resources of national governments, together with technical assistance and funding from the Measles Initiative, annual worldwide deaths from measles plummeted 68% between 2000 and 2006—from an estimated 757,000 to an estimated 242,000. The largest percentage reduction in deaths was in the African region (91%); this means the region appears to have met the U.N. goal of a 90% reduction in measles deaths from 2000 to 2010 four years early. Sustaining this achievement is a priority.

Rubella cases plummet in the Americas  

From 1998 to 2006, rubella cases in the Americas fell by an astounding 98%—a significant accomplishment that bodes well for the Pan American Health Organization’s goal of eliminating the disease in the region by 2010. In 2007, rubella immunization campaigns were completed in Bolivia, Cuba, El Salvador, Guatemala, and Venezuela. NCIRD was on hand to monitor the campaign in Guatemala, and staff also provided technical assistance to health officials in Haiti as they planned that country’s measles-rubella vaccination campaign. In
 addition, NCIRD participated in an effort in Costa Rica to
develop guidelines for verifying rubella and congenital rubella syndrome (CRS) elimination in the Americas.

Contributing to global surveillance 

To improve global surveillance of measles, rubella, and congenital rubella syndrome, the World Health Organization (WHO) created LabNet, a network that has grown to approximately 700 laboratories serving 166 countries. NCIRD plays a key technical support role in this effort, providing LabNet and its members with laboratory training in disease diagnostics and virologic surveillance, methods development and implementation, and protocol and field manual development.

In 2007, NCIRD scientists participated in several international LabNet meetings and consultations, including in-country laboratory training workshops in Mexico and Oman. Staff also trained several visiting LabNet scientists and helped write the new WHO Measles/Rubella Laboratory Field Manual. In addition, NCIRD worked with LabNet and state laboratories to track the transmission pathways of measles viruses from a large outbreak in Japan to the United States and Europe. Information from NCIRD was also crucial in efforts to characterize a cluster of rubella cases in Michigan and to track the origin of a rubella case in Massachusetts to its source in Uganda.

CHART: Reducing Worldwide Deaths from Measles

Linking Routine Immunization and Malaria Prevention in Malawi

Malaria and vaccine-preventable diseases continue to cause widespread childhood illness and death in Malawi. In 2006, NCIRD teamed with the University of Malawi College of Medicine/Malaria Alert Center to launch a novel, dual-focus initiative to combat these diseases simultaneously. Implemented in two rural districts of the country, the pilot project gave children free, long-lasting insecticide-treated nets (ITNs) after they had completed their routine immunization series. The idea was that immunization sessions could be an effective venue for ITN distribution, and, conversely, the offer of free ITNs could be an incentive for families to increase timely immunization coverage for their children. ITNs were also given to pregnant women and to caretakers of children too young to complete their vaccinations.

Before this project was launched, less than 50% of children in these districts were completely vaccinated by their first birthday, and less than 30% of 1-year-olds slept under an ITN. By the end of the project, vaccination coverage in the two districts had increased to more than 60%, and more than half of all 1-year-olds were sleeping under an ITN. Over a 15-month period, more than 100,000 ITNs were distributed. Insecticide-treated nets were donated by the Finnish and Canadian Red Cross, the Exxon Mobil Corporation, and the International American Women’s Club of Geneva. The International Federation of the Red Cross coordinated the distribution. 

Not only did the project highlight the benefits of using immunization sessions as a platform for ITN distribution, it led the national Ministry of Health to fully subsidize ITNs for Malawi’s most vulnerable groups.  National implementation of this policy began in 2007. 

Picture of woman and five kids

Picture of baby holding a ceramic plate.

Evaluating Influenza Burden Among the Poor  

In developing countries, acute respiratory disease remains the most common cause of death among children under 5 years of age. Since 2004, CDC has been collaborating with the International Center for Diarrhea Disease Research in Dhaka, Bangladesh, to see how many of these deaths were caused by influenza. This ongoing study has provided the chance to examine the epidemiology of influenza among low-income urban populations and to better understand the particular virus strains circulating in the developing world.

So far, the study has found that influenza is a common cause of respiratory illness among young children in developing countries, a fact that can assist public health authorities in those countries in evaluating the benefits of flu vaccination. Researchers have also discovered that in the tropics, influenza occurs in seasonal peaks —a finding that will help improve the focus and efficiency of flu surveillance efforts as well as clinical care for children. In addition, a better understanding of the epidemiology of influenza may lead to improved prevention strategies, like a seasonal influenza vaccination program 
tailored to tropical settings.

During the study, NCIRD has been able to gather and characterize flu virus strains from Bangladesh to further its work as a World Health Organization Collaborating Center for Influenza. These samples will contribute to a better understanding of influenza virus evolution and global strain prevalence, and will also improve the strain selection process used in vaccine production.

Getting New Vaccines to Children in Developing Countries 

Pneumonia and meningitis are major killers of young children in the developing world. For a variety of economic and other reasons, vaccines to prevent these diseases are often underutilized or unavailable. In response, NCIRD is working with partners around the world to make life-saving vaccines available to those who need them most.

■ While a vaccine targeting Haemophilus influenzae type b (Hib) disease has been available for years, uptake in developing countries has been slow until recently. NCIRD epidemiologists and laboratory scientists are supporting efforts in a number of these countries to establish the burden of Hib and pneumococcal diseases, documenting the impact of 
vaccination, and evaluating vaccination strategies. 

■ Around the world, millions of young lives could be saved if developing countries quickly adopted a relatively new vaccine targeting pneumococcal infections in children. In 2006, NCIRD staff coauthored several documents on pneumococcal conjugate vaccine for the World Health Organization’s Strategic Advisory Group of Experts; these documents outlined policy for routine vaccine use in developing countries, alternative dosing schedules, and a target product profile for new vaccines. 

■ In the “meningitis belt” of sub-Saharan Africa— 
extending from Ethiopia in the east to Senegal in the west—bacterial meningitis is caused by Neisseria meningitidis serogroup A, a strain that rarely causes disease in industrialized countries, and for which there is not yet a vaccine to effectively protect young children. As part of its work with global partners to encourage the adoption of new vaccines, NCIRD has been collaborating with the Meningitis Vaccine Project (MVP) to create and test a Neisseria meningitidis serogroup A vaccine for Africa and other low-income regions.

Photo of mother holding baby.

CHART: GAVI-Eligible Countries Using or Approved to Use Hib Vaccine

Better Data Management Means Better Disease Surveillance and Service Delivery

One of the major stumbling blocks for global immunization programs is lack of rapid access to accurate and complete information. To address this problem, CDC is working with the World Health Organization to develop ways to more effectively manage data, which will strengthen both organizations’ global efforts to eradicate polio, reduce measles mortality, and increase routine immunization delivery. In 2007, NCIRD developed, piloted, and deployed a trio of systems for disease surveillance.

■ A case-based measles surveillance computer system was deployed for the entire African region. This system will help CDC and its partners monitor the impact of programs to reduce measles mortality and also detect and respond to epidemics as quickly as possible.

■ In September, a measles/rubella case-based surveillance data system for the European region was piloted in Albania and Kyrgyzstan.

■ In December, a system was deployed to enhance sentinel surveillance for pediatric bacterial meningitis. It will indicate the pathogens causing the meningitis and provide data to inform decisions on vaccine policy and impact.

Building upon this effort, CDC and its partners worked to develop and deploy systems around the world to support the improvement of routine immunization service delivery. In Sierra Leone, for example, CDC worked with its partners—the national Ministry of Health, WHO, the U.N. Foundation, and DataDyne—to deploy an integrated child-survival data system in every district of the country, and also a PDA-based system to provide data on integrated, supportive supervision on the provincial level. Together, these systems aim to provide program managers with timely information on routine immunization efforts as well as malaria and diarrheal disease control. NCIRD and its partners provided training and equipment for the PDA system to six other countries in 2007, with plans to expand deployment to 15 more in 2008.

Improving Detection of Respiratory Pathogens

Every year in the developing world, nearly 1 million children die from pneumonia and other infections of the lower respiratory tract. In addition, new respiratory infections, such as SARS, have demonstrated their ability to travel quickly across international borders, creating a larger global threat.

NCIRD epidemiologists and laboratory scientists have been working with CDC partners to build a new overseas network of sites that are able to detect, monitor, and prevent severe respiratory diseases using state-of-the-art diagnostic methods. In 2007, CDC investigators traveled to Bangladesh, China, Egypt, Guatemala, Kenya, and Thailand to train site investigators, analyze data, and develop system plans. They also worked with site investigators to evaluate where patients with severe respiratory infections seek care and how many of those infections are identified by the program. In addition, CDC held a Global Disease Detection laboratory workshop that trained participants from each site on new diagnostic methods, such as polymerase chain reaction testing and addressed challenges facing scientists in developing countries, such as obtaining critical laboratory reagents. Meanwhile, NCIRD continued developing new assays to detect respiratory pathogens and began building a bank of respiratory specimens that can be used to develop new diagnostic tests and discover new pathogens. 

Monitoring New Vaccines to Prevent Rotavirus Gastroenteritis

Worldwide, diarrheal diseases are the second leading cause of childhood death—nearly 1.8 million every year. Approximately one-third (530,000) of these deaths are attributable to rotavirus. In 2006, two new vaccines for preventing severe rotavirus gastroenteritis became available and have since been introduced into national immunization programs in the United States and several countries in Latin America (Brazil, El Salvador, Mexico, Nicaragua, Panama, and Venezuela). Surveillance will be crucial to assessing the field effectiveness and impact of these new vaccines. In partnership with the World Health Organization, the Global Alliance for Vaccines and Immunization, and Program for Appropriate Technology for Health, CDC has coordinated regional surveillance networks in Asia, Africa, Europe, and the Americas. In 2007, more than 80 sites in 40 countries implemented sentinel hospital surveillance, using a standard protocol developed by CDC and its partners. Field evaluations of these guidelines are underway in El Salvador, Nicaragua, and the United States, and it is anticipated that the first data on the real-world impact of rotavirus vaccines in preventing severe gastroenteritis in young infants will be available in late 2008.

Meanwhile, data from all the surveillance sites show that rotavirus accounts for approximately 40% of diarrhea-related hospitalizations — key information for countries considering the health and economic benefits of introducing rotavirus vaccines. In addition, a global network of six reference laboratories coordinated by NCIRD has trained local microbiologists on how to characterize rotavirus strains.
In 2007 alone, the CDC laboratory trained seven international investigators and analyzed viral strains from more than 1,000 rotavirus gastroenteritis cases in the United States and abroad.

Picture of people in a group.

EPI Olympics

In October 2007, NCIRD organized and conducted an Expanded Program for Immunizations (EPI) training course for 38 Chinese national and provincial health officials in Atlanta; in recognition of the 2008 Summer Olympics in Beijing, the training course was called the “EPI Olympics.” The first part of the course focused on strategies to achieve regional goals of measles elimination and hepatitis B control by 2012. Later, it addressed broader immunization systems issues—aiming to help China expand its routine vaccinations from six to 12 recommended antigens. Not only did the EPI Olympics give Chinese officials the chance to meet public health experts from CDC, Pan American Health Organization, and World Health Organization headquarters, they were able to meet some of their provincial colleagues, many for the first time.

Exploring A New Role for CDC in International Bordetella pertussis Efforts
During an international CDC-hosted meeting on Bordetella pertussis in July 2007, there was consensus that CDC should establish and maintain a pertussis reference laboratory for serodiagnosis and vaccine evaluation. A potential focal point for government, academic, and private sector researchers, the proposed laboratory would play a crucial role in the development, standardization, validation, and global dissemination of serologic assays for the diagnosis of pertussis. 

Picture of two scientists in hallway.
People Prepared for Emerging Health Threats
Avian Influenza
New Research on Prevention and Treatment

Over the last several years, the highly pathogenic avian influenza A (H5N1) virus has spread to birds in Asia, Africa, Europe, and the Near East—and some of those birds have passed the virus on to humans. Of the few avian flu viruses that have crossed the species barrier to infect humans, H5N1 has caused the largest number of detected cases of severe disease and death. From late 2003 through December 2007, the virus caused nearly 350 laboratory-confirmed human infections; more than 60 percent of those infected died. Most people were infected after coming into close contact with infected birds, but health experts worry that these viruses could develop the ability to spread easily among humans, creating the potential for a pandemic.

In response to this threat, NCIRD researchers recently collaborated on testing an experimental drug as an alternative approach to preventing and treating avian flu in humans. The study results were promising. The novel sialidase fusion protein protected 100% of test mice from fatal disease, effectively blocked infection in 70% of them, and prevented the virus from spreading to their brains. The study also showed that with early treatment, mice that were infected had a better chance for survival.

Investigating Flu Outbreaks in Poultry

In May 2007, NCIRD investigators went to Ghana to help investigate avian influenza outbreaks on poultry farms; these outbreaks marked the first known appearances of the H5N1 virus in the country. CDC staff joined national health officials on a mission to the neighboring Brong-Ahafo and Ashanti regions to conduct a needs assessment and assist with outbreak response.

The seven-person response team provided technical assistance and training for both local veterinary staff and human healthcare providers, and developed a set of recommendations based on their visit. One recommendation made after observing the response was the importance of having good communication and interactions between the human and veterinary health services so that both remain knowledgeable about the situation and are able to respond appropriately.

Communities in Vietnam join the effort

Vietnam has reported more human cases of avian influenza than almost any other country in the world. Thanks to a collaborative effort between CDC and the international relief and development organization CARE, residents of one region of Vietnam are making sustainable progress toward preventing and controlling outbreaks.

Every week, village health volunteers in Hai Phong, a province on the northeast coast of Vietnam, travel door-to-door talking to local farmers about bird flu. Using a questionnaire, they collect information from the farmers on local bird sickness and death. Since the project began in September 2006, the volunteers have been able to help identify several outbreaks of bird flu in the province. CARE has been responsible for project implementation, while CDC is providing the necessary technical expertise.

The results of the surveillance are helping CDC, CARE, and their local partners educate families in Hai Phong about the disease and how they can help prevent it. These efforts can reduce local outbreaks among poultry flocks and help prevent illness in humans—now and in the future. In addition, the project is helping link these efforts with the development of national and provincial early-warning systems. CDC and CARE are also planning to use this model to develop similar programs in other provinces in Vietnam, as well as in Laos, Cambodia, and other countries.

Picture of chicken.

Preparing CDC and the World for Pandemic Influenza

Training CDC staff

To increase its capacity to respond quickly and effectively to an influenza pandemic— both at home and globally—NCIRD provided Epidemic Intelligence Service (EIS) officers as well as CDC staff scientists and program officers with a comprehensive, three-day training course. This training covered a broad range of influenza-related topics, including surveillance, case investigation, case management, pandemic containment, infection control, and risk communications. As a result, CDC now has more than 500 staff members trained in the operational and scientific aspects of pandemic response.

Creating domestic rapid response teams

Working with the Council of State and Territorial Epidemiologists, NCIRD is helping every state in America create teams of public health responders to help combat potential outbreaks of avian influenza. Adapting its international rapid-response curricula for domestic use, NCIRD has created a three-day online training course, released May 15, 2007, that gives state and local responders the skills and knowledge they need to identify and control avian influenza—and potentially other emerging diseases. A novel aspect of the training is that it brings together human- and animal-health professionals in a multidisciplinary response to an avian influenza threat.

Improving laboratory surge capacity 

As one of four WHO Collaborating Centers for the Surveillance, Epidemiology and Control of Influenza, NCIRD will be at the nexus of the next global pandemic response. In 2007, NCIRD commissioned a series of computer simulations of its laboratory surveillance processes to examine how well it is prepared to handle a future pandemic. The computer simulations indicated that the demand for diagnostic testing during a pandemic could be more than 20 times that of a normal flu season. The analysis further found that testing the expected sample load would require more than a 200% increase in staff, assigned across multiple shifts, as well as more laboratory space and equipment. The analysis also identified process bottlenecks and determined the resources required to handle multiple response scenarios. These findings will help us continue to refine our pandemic preparedness plans.

Picture of scientist holding a flash light to an egg.

Training the global health community

NCIRD has collaborated with WHO and other international health partners to develop training curricula to guide the development and implementation of national pandemic plans. In addition, NCIRD is helping countries threatened by avian influenza to develop rapid response teams, enhance their flu surveillance systems, and implement advanced laboratory diagnostic techniques. 

Developing early-warning networks
 
To react quickly to a flu pandemic, the global health community must have in place effective and wide-reaching surveillance systems. CDC has been working to prepare its partners in Central Europe, Central and Southeast Asia, South America, and Africa through training on surveillance and other relevant topics. CDC  also provided on-site technical assistance at workshops for staff in Mongolia and Russia, and partnered with the World Health Organization to develop a generic influenza surveillance protocol for countries in Southeast Asia working to expand their flu and severe respiratory disease surveillance.

Picture of woman working in a lab.

Vaccine Research and Development 

Developing new vaccines is a critical aspect of preparing for new pandemic threats. In collaboration with the National Center for Environmental Health, NCIRD has been working to improve its method for testing the potency of pandemic and seasonal influenza vaccines, with the aim of greater speed, sensitivity,  precision, and accuracy in the quantification of influenza hemagglutinin, the component critical for immune response to a vaccine. Other NCIRD research is exploring how to create vaccines that offer broader cross-reactive immunity and protection, especially for the elderly, as well as how to develop techniques to speed vaccination and extend vaccine supply. For example, preliminary results from a study led by CDC and the Walter Reed Army Medical Center indicate that during a vaccine shortage, healthcare providers might be able to stretch limited vaccine supply by immunizing healthy adults with a half-dose of seasonal influenza vaccine.

Global Disease Detection Innovative Project

Disease surveillance systems depend on timely, accurate diagnoses in order to provide data for outbreak detection and response, as well as to correctly inform policy decisions. Now in its second year, NCIRD’s Global Disease Detection (GDD) Innovative Project is adapting existing polio and measles surveillance networks to build sustainable surveillance and laboratory capacity for emerging infectious diseases. The project focuses on surveillance for acute encephalitis and meningitis in Bangladesh, China, and India, with a combined population of more than 2.5 billion people. In addition, these systems will enable programs to distinguish between the many causes of these syndromes — for example, Japanese encephalitis, Neisseria meningitidis, Streptococcus pneumoniae and Haemophilus influenzae. This initiative will help ensure appropriate responses to outbreaks as well as necessary adjustments to vaccination strategies. In 2007, GDD project accomplishments included:

■ In-country assessments of surveillance/laboratory needs;
■ Development of technical protocols for surveillance of acute meningitis and encephalitis syndrome;
■ Training in surveillance, laboratory testing, bacteriology, and RT PCR; and
■ Initiation of surveillance activities in two sentinel sites in India, three sentinel sites in Bangladesh, and four provinces in China.

All the sentinel sites in these three countries are reporting acute encephalitis and meningitis cases. Specimens are being tested at the national laboratories with enhanced capacity developed through the GDD Innovative Project. 
Studying Anthrax Vaccine

Anthrax can cause serious illness or death in both humans and animals. Though it no longer captures headlines like it did in 2001—when 22 people were infected following distribution of mail contaminated with the anthrax-causing bacteria Bacillus anthracis— the disease is still considered a bioterrorist threat, and military personnel are routinely vaccinated against it.

There is currently only one anthrax vaccine licensed in the United States: Anthrax Vaccine Adsorbed (AVA), also known as Biothrax®. NCIRD is conducting ongoing research to ensure it is safe and easy to use. One of these studies—a large-scale, multi-center, Phase IV human clinical trial with more than 1,500 participants— is evaluating whether the vaccine can be administered more easily, using fewer vaccinations, and with fewer side effects. Though the study will not conclude until 2009, interim results have been submitted for U.S. Food and Drug Administration review.

Studying Past Pandemics Gives Hope for Identifying New Ones
Between 1918 and 1919, a flu pandemic (commonly referred to as the Spanish Flu) killed as many as 50 million people worldwide. Now NCIRD researchers and their colleagues have found molecular-level clues to how the virus that caused the pandemic was able to spread. In an article in the February 5, 2007, issue of Science entitled “A Two-Amino Acid Change in the Hemagglutinin of the 1918 Influenza Virus Abolishes Transmission,” the researchers reported that by altering two amino acids in one of the surface proteins of the virus, they could create a version of the virus that is unable to spread between test animals, yet still retains its ability to cause severe illness. This discovery provides insight into changes in the 1918 virus that led to person-to-person transmission. 

Detecting and Investigating Swine Influenza

On rare occasions, swine influenza virus can infect humans and cause serious illness, especially in young children or people with underlying health problems. In the past, CDC typically received one influenza virus isolate from humans each year that tested positive for swine influenza. However, more of these infections were detected in 2006 and 2007, likely as a result of increased diagnostic capabilities. In 2007, NCIRD helped identify and investigate five human cases of swine influenza in Illinois, Iowa, Michigan, and Ohio. These were detected as cases of novel influenza A virus infection, which became a nationally notifiable condition fairly recently.  Because person-to-person transmission of novel influenza A viruses could signal the beginning of an influenza pandemic, it was critical that CDC investigate the cases immediately. Working with state and local health departments as well as state animal health authorities, CDC staff helped assess the scope of swine-to-human infections, the sources of the infections, and any possible human-to-human transmission of the virus. These and future swine influenza investigations will help further national pandemic preparedness and response.

Appendix

Picture of girl scouts. As part of earning their Try-It career badge, members of Brownie Troop #3531 visit CDC’s TV studio, where they get to experience "the hot seat." 

Calendar of Events 2008
Who’s who in NCIRD center for Leadership pages
NCIRD Organization Chart
NCIRD international field staff 2007
Chart: Recommended immunization for Persons Aged 7-18 Years- United States 2008.
Chart: Recommended immunization for Persons Aged 0-6 Years- United States 2008.
Chart: Figure 1: Recommended Adult Immunization Schedule
Recommended Adult Immunization Schedule, by vaccine group - United States October 2007- September 2008.
Chart: Figure 2: Recommended Adult Immunization Schedule
Vaccines that might be indicated for adults on medical and other indications- United States October 2007- September 2008.
Chart: Catch-up Immunization schedule for Aged 4 months-18 Years Who Start Late or Who Are More Than 1 Month Behind.
Footnotes to immunization schedules

Childhood Schedule Footnotes
1. Hepatitis B vaccine (HepB). (Minimum age: birth)
	At birth:
• Administer monovalent HepB to all newborns prior to hospital discharge.
• If mother is hepatitis B surface antigen (HBsAg) positive, administer HepB and 0.5 mL of hepatitis B immune globulin (HBIG) within 12 hours of birth.
• If mother’s HBsAg status is unknown, administer HepB within 12 hours of birth. Determine the HBsAg status as soon as possible and if HBsAg
	positive, administer HBIG (no later than age 1 week).
• If mother is HBsAg negative, the birth dose can be delayed, in rare cases, with a provider’s order and a copy of the mother’s negative HBsAg laboratory report in the infant’s medical record.
	
After the birth dose:
• The HepB series should be completed with either monovalent HepB or a combination vaccine containing HepB. The second dose should be administered at age 1–2 months. The final dose should be administered no earlier than age 24 weeks. Infants born to HBsAg positive mothers should be tested for HBsAg and antibody to HBsAg after completion of at least 3 doses of a licensed HepB series, at age 9–18 months (generally at the next well-child visit).
	4-month dose:
• It is permissible to administer 4 doses of HepB when combination vaccines are administered after the birth dose. If monovalent HepB is used for doses after the birth dose, a dose at age 4 months is not needed.

2. Rotavirus vaccine (Rota). (Minimum age: 6 weeks)
• Administer the first dose at age 6–12 weeks. 
• Do not start the series later than age 12 weeks.
• Administer the final dose in the series by age 32 weeks. Do not administer any dose later than age 32 weeks.
• Data on safety and efficacy outside of these age ranges are insufficient.

3. Diphtheria and tetanus toxoids and acellular pertussis vaccine (DTaP). (Minimum age: 6 weeks)
• The fourth dose of DTaP may be administered as early as age 12 months, provided 6 months have elapsed since the third dose. 
• Administer the final dose in the series at age 4–6 years.

4. Haemophilus influenzae type b conjugate vaccine (Hib). (Minimum age: 6 weeks)
• If PRP-OMP (PedvaxHIB® or ComVax® [Merck]) is administered at ages 2 and 4 months, a dose at age 6 months is not required.
• TriHIBit® (DTaP/Hib) combination products should not be used for primary immunization but can be used as boosters following any Hib vaccine in children age 12 months or older.

5. Pneumococcal vaccine. (Minimum age: 6 weeks for pneumococcal conjugate vaccine [PCV]; 2 years for pneumococcal polysaccharide vaccine [PPV])
• Administer one dose of PCV to all healthy children aged 24–59 months having any incomplete schedule.
• Administer PPV to children aged 2 years and older with underlying medical conditions.

6. Influenza vaccine. (Minimum age: 6 months for trivalent inactivated influenza vaccine [TIV]; 2 years for live, attenuated influenza vaccine [LAIV])
• Administer annually to children aged 6–59 months and to all eligible close contacts of children aged 0–59 months. 
• Administer annually to children 5 years of age and older with certain risk factors, to other persons (including household members) in close contact with persons in groups at higher risk, and to any child whose parents request vaccination.
• For healthy persons (those who do not have underlying medical conditions that predispose them to influenza complications) ages 2–49 years, either LAIV or TIV may be used.
• Children receiving TIV should receive 0.25 mL if age 6–35 months or 0.5 mL if age 3 years or older.
• Administer 2 doses (separated by 4 weeks or longer) to children younger than 9 years who are receiving influenza vaccine for the first time or who were vaccinated for the first time last season but only received one dose.

7. Measles, mumps, and rubella vaccine (MMR). (Minimum age: 12 months)
• Administer the second dose of MMR at age 4–6 years. MMR may be administered before age 4–6 years, provided 4 weeks or more have elapsed since the first dose.

8. Varicella vaccine. (Minimum age: 12 months)
• Administer second dose at age 4–6 years; may be administered 3 months or more after first dose.
• Do not repeat second dose if administered 28 days or more after first dose.

9. Hepatitis A vaccine (HepA). (Minimum age: 12 months)
• Administer to all children aged 1 year (i.e., aged 12–23 months). Administer the 2 doses in the series at least 6 months apart.
• Children not fully vaccinated by age 2 years can be vaccinated at subsequent visits.
• HepA is recommended for certain other groups of children, including in areas where vaccination programs target older children. 

10. Meningococcal vaccine. (Minimum age: 2 years for meningococcal conjugate vaccine (MCV4) and for meningococcal polysaccharide vaccine (MPSV4))
• Administer MCV4 to children aged 2–10 years with terminal complement deficiencies or anatomic or functional asplenia and certain other high-risk groups. MPSV4 is also acceptable. 
• Administer MCV4 to persons who received MPSV4 3 or more years previously and remain at increased risk for meningococcal disease.
Adolescent Schedule Footnotes

1. Tetanus and diphtheria toxoids and acellular pertussis vaccine (Tdap). (Minimum age: 10 years for BOOSTRIX® and 11 years for ADACEL™)
• Administer at age 11–12 years for those who have completed the recommended childhood DTP/DTaP vaccination series and have not received a tetanus and diphtheria toxoids (Td) booster dose.
• 13–18-year-olds who missed the 11–12 year Tdap or received Td only are encouraged to receive one dose of Tdap 5 years after the last Td/DTaP dose.

2. Human papillomavirus vaccine (HPV). (Minimum age: 9 years)
• Administer the first dose of the HPV vaccine series to females at age 11–12 years.
• Administer the second dose 2 months after the first dose and the third dose 6 months after the first dose.
• Administer the HPV vaccine series to females at age 13–18 years if not previously vaccinated.

3. Meningococcal vaccine. 
• Administer MCV4 at age 11–12 years and at age 13–18 years if not previously vaccinated. MPSV4 is an acceptable alternative.
• Administer MCV4 to previously unvaccinated college freshmen living in dormitories.
• MCV4 is recommended for children aged 2–10 years with terminal complement deficiencies or anatomic or functional asplenia and certain other high-risk groups. 
• Persons who received MPSV4  3 or more years previously and remain at increased risk for meningococcal disease should be vaccinated with MCV4.

4. Pneumococcal polysaccharide vaccine (PPV). 
• Administer PPV to certain high-risk groups. 

5. Influenza vaccine. 
• Administer annually to all close contacts of children aged 0–59 months.
• Administer annually to persons with certain risk factors, health-care workers, and other persons (including household members) in close contact with persons in groups at higher risk.
• Administer 2 doses (separated by 4 weeks or longer) to children younger than 9 years who are receiving influenza vaccine for the first time or who were vaccinated for the first time last season but only received one dose.
• For healthy nonpregnant persons (those who do not have underlying medical conditions that predispose them to influenza complications) ages 2–49 years, either LAIV or TIV may be used.

6. Hepatitis A vaccine (HepA).
• Administer 2 doses in the series at least 6 months apart.
• HepA is recommended for certain other groups of children, including in areas where vaccination programs target older children. 

7. Hepatitis B vaccine (HepB).
• Administer the 3-dose series to those who were not previously vaccinated.
• A 2-dose series of Recombivax HB® is licensed for children aged 11–15 years.

8. Inactivated poliovirus vaccine (IPV).
• For children who received an all-IPV or all-oral poliovirus (OPV) series, a fourth dose is not necessary if the third dose was administered at age 4 years or older.
• If both OPV and IPV were administered as part of a series, a total of 4 doses should be administered, regardless of the child’s current age.

9. Measles, mumps, and rubella vaccine (MMR). 
• If not previously vaccinated, administer 2 doses of MMR during any visit, with 4 or more weeks between the doses.

10. Varicella vaccine.
• Administer 2 doses of varicella vaccine to persons younger than 13 years of age at least 3 months apart. Do not repeat the second dose if administered 28 or more days following the first dose.
• Administer 2 doses of varicella vaccine to persons aged 13 years or older at least 4 weeks apart.

Catch-up Schedule Footnotes

1. Hepatitis B vaccine (HepB).
• Administer the 3-dose series to those who were not previously vaccinated.
• A 2-dose series of Recombivax HB® is licensed for children aged 11–15 years.

2. Rotavirus vaccine (Rota).
• Do not start the series later than age 12 weeks.
• Administer the final dose in the series by age 32 weeks. 
• Do not administer a dose later than age 32 weeks.
• Data on safety and efficacy outside of these age ranges are insufficient.

3. Diphtheria and tetanus toxoids and acellular pertussis vaccine (DTaP).
• The fifth dose is not necessary if the fourth dose was administered at age 4 years or older.
• DTaP is not indicated for persons aged 7 years or older.

4. Haemophilus influenzae type b conjugate vaccine (Hib).
• Vaccine is not generally recommended for children aged 5 years or older.
• If current age is younger than 12 months and the first 2 doses were PRP-OMP (PedvaxHIB® or ComVax® [Merck]), the third (and final) dose should be administered at age 12–15 months and at least 8 weeks after the second dose.
• If first dose was administered at age 7–11 months, administer 2 doses separated by 4 weeks plus a booster at age 12–15 months.

5. Pneumococcal conjugate vaccine (PCV).
•Administer one dose of PCV to all healthy children aged 24–59 months having any incomplete schedule.
•For children with underlying medical conditions, administer 2 doses of PCV at least 8 weeks apart if previously received less than 3 doses, or 1 dose of PCV if previously received 3 doses.

6. Inactivated poliovirus vaccine (IPV).
• For children who received an all-IPV or all-oral poliovirus (OPV) series, a fourth dose is not necessary if third dose was administered at age 4 years or older.
• If both OPV and IPV were administered as part of a series, a total of 4 doses should be administered, regardless of the child’s current age.
• IPV is not routinely recommended for persons aged 18 years and older.

7. Measles, mumps, and rubella vaccine (MMR).
• The second dose of MMR is recommended routinely at age 4–6 years but may be administered earlier if desired.
• If not previously vaccinated, administer 2 doses of MMR during any visit with4 or more weeks between the doses.

8. Varicella vaccine.
• The second dose of varicella vaccine is recommended routinely at age 4–6 years but may be administered earlier if desired.
• Do not repeat the second dose in persons younger than 13 years of age if administered 28 or more days after the first dose.

9. Hepatitis A vaccine (HepA).
• HepA is recommended for certain groups of children, including in areas where vaccination programs target older children. See MMWR 2006;55(No. RR-7):1–23.

10. Tetanus and diphtheria toxoids vaccine (Td) and tetanus and diphtheria toxoids and acellular pertussis vaccine (Tdap). 
• Tdap should be substituted for a single dose of Td in the primary catch-up series or as a booster if age appropriate; use Td for other doses.
• A 5-year interval from the last Td dose is encouraged when Tdap is used as a booster dose. A booster (fourth) dose is needed if any of the previous doses were administered at younger than 12 months of age. Refer to ACIP recommendations for further information. See MMWR 2006;55(No. RR-3).

11. Human papillomavirus vaccine (HPV).
• Administer the HPV vaccine series to females at age 13–18 years if not previously vaccinated.
Adult
1.	Tetanus, diphtheria, and acellular pertussis (Td/Tdap) vaccination 
Tdap should replace a single dose of Td for adults aged <65 years who have not previously received a dose of Tdap. Only one of two Tdap products (Adacel®[sanofi pasteur]) is licensed for use in adults. Adults with uncertain histories of a complete primary vaccination series with tetanus and diphtheria toxoid–containing vaccines should begin or complete a primary vaccination series. A primary series for adults is 3 doses of tetanus and diphtheria toxoid–containing vaccines; administer the first 2 doses at least 4 weeks apart and the third dose 6–12 months after the second. However, Tdap can substitute for any one of the doses of Td in the 3-dose primary series. The booster dose of tetanus and diphtheria toxoid–containing vaccine should be administered to adults who have completed a primary series and if the last vaccination was received >10 years previously. Tdap or Td vaccine may be used, as indicated. If the person is pregnant and received the last Td vaccination >10 years previously, administer Td during the second or third trimester; if the person received the last Td vaccination in <10 years, administer Tdap during the immediate postpartum period. A one-time administration of 1 dose of Tdap with an interval as short as 2 years from a previous Td vaccination is recommended for postpartum women, close contacts of infants aged <12 months, and all health-care workers with direct patient contact. In certain situations, Td can be deferred during pregnancy and Tdap substituted in the immediate postpartum period, or Tdap can be administered instead of Td to a pregnant woman after an informed discussion with the woman. Consult the ACIP statement for recommendations for administering Td as prophylaxis in wound management.

2.	Human papillomavirus (HPV) vaccination 
HPV vaccination is recommended for all females aged <26 years who have not completed the vaccine series. History of genital warts, 	abnormal Papanicolaou test, or positive HPV DNA test is not evidence of prior infection with all vaccine HPV types; HPV vaccination is still recommended for these persons. Ideally, vaccine should be administered before potential exposure to HPV through sexual activity; however, females who are sexually active should still be vaccinated. Sexually active females who have not been infected with any of the HPV vaccine types receive the full benefit of the vaccination. Vaccination is less beneficial for females who have already been infected with one or more of the HPV vaccine types.  A complete series consists of 3 doses. The second dose should be administered 2 months after the first dose; the third dose should be administered 6 months after the first dose. Although HPV vaccination is not specifically recommended for females with the medical indications described in Figure 2, "Vaccines that might be indicated for adults based on medical and other indications," it is not a live-virus vaccine and can be administered. However, immune response and vaccine efficacy might be less than in persons who do not have the medical indications described or who are immunocompetent.

3.	Measles, mumps, rubella (MMR) vaccination 
Measles component: Adults born before 1957 can be considered immune to measles. Adults born during or after 1957 should receive >1 dose of MMR unless they have a medical contraindication, documentation of >1 dose, history of measles based on health-care provider diagnosis, or laboratory evidence of immunity. A second dose of MMR is recommended for adults who 1) have been recently exposed to measles or are in an outbreak setting; 2) have been previously vaccinated with killed measles vaccine; 3) have been vaccinated with an unknown type of measles vaccine during 1963–1967; 4) are students in postsecondary educational institutions; 5) work in a health-care facility; or 6) plan to travel internationally. Mumps component: Adults born before 1957 can generally be considered immune to mumps. Adults born during or after 1957 should receive 1 dose of MMR unless they have a medical contraindication, history of mumps based on health-care provider diagnosis, or laboratory evidence of immunity. A second dose of MMR is recommended for adults who 1) are in an age group that is affected during a mumps outbreak; 2) are students in postsecondary educational institutions; 3) work in a health-care facility; or 4) plan to travel internationally. For unvaccinated health-care workers born before 1957 who do not have other evidence of mumps immunity, consider administering 1 dose on a routine basis and strongly consider administering a second dose during an outbreak. Rubella component: Administer 1 dose of MMR vaccine to women whose rubella vaccination history is unreliable or who lack laboratory evidence of immunity. For women of childbearing age, regardless of birth year, routinely determine rubella immunity and counsel women regarding congenital rubella syndrome. Women who do not have evidence of immunity should receive MMR vaccine upon completion or termination of pregnancy and before discharge from the health-care facility.
4. Varicella vaccination  
All adults without evidence of immunity to varicella should receive 2 doses of single-antigen varicella vaccine unless they have a medical contraindication. Special consideration should be given to those who 1) have close contact with persons at high risk for severe disease (e.g., health-care personnel and family contacts of immunocompromised persons) or 2) are at high risk for exposure or transmission (e.g., teachers; child care employees; residents and staff members of institutional settings, including correctional institutions; college students; military personnel; adolescents and adults living in households with children; nonpregnant women of childbearing age; and international travelers). Evidence of immunity to varicella in adults includes any of the following: 1) documentation of 2 doses of varicella vaccine at least 4 weeks apart; 2) U.S.-born before 1980 (although for health-care personnel and pregnant women birth before 1980 should not be considered evidence of immunity); 3) history of varicella based on diagnosis or verification of varicella by a health-care provider (for a patient reporting a history of or presenting with an atypical case, a mild case, or both, health-care providers should seek either an epidemiologic link with a typical varicella case or to a laboratory-confirmed case or evidence of laboratory confirmation, if it was performed at the time of acute disease); 4) history of herpes zoster based on health-care provider diagnosis; or 5) laboratory evidence of immunity or laboratory confirmation of disease. Assess pregnant women for evidence of varicella immunity. Women who do not have evidence of immunity should receive the first dose of varicella vaccine upon completion or termination of pregnancy and before discharge from the health-care facility. The second dose should be administered 4–8 weeks after the first dose.
5. Influenza vaccination 
Medical indications: Chronic disorders of the cardiovascular or pulmonary systems, including asthma; chronic metabolic diseases, including diabetes mellitus, renal or hepatic dysfunction, hemoglobinopathies, or immunosuppression (including immunosuppression caused by medications or human immunodeficiency virus [HIV]); any condition that compromises respiratory function or the handling of respiratory secretions or that can increase the risk of aspiration (e.g., cognitive dysfunction, spinal cord injury, or seizure disorder or other neuromuscular disorder); and pregnancy during the influenza season. No data exist on the risk for severe or complicated influenza disease among persons with asplenia; however, influenza is a risk factor for secondary bacterial infections that can cause severe disease among persons with asplenia. Occupational indications: Health-care personnel and employees of long-term care and assisted-living facilities. Other indications: Residents of nursing homes and other long-term care and assisted-living facilities; persons likely to transmit influenza to persons at high risk (e.g., in-home household contacts and caregivers of children aged 0–59 months, or persons of all ages with high-risk conditions); and anyone who would like to be vaccinated. Healthy, nonpregnant adults aged <49 years without high-risk medical conditions who are not contacts of severely immunocompromised persons in special care units can receive either intranasally administered live, attenuated influenza vaccine (FluMist®) or inactivated vaccine. Other persons should receive the inactivated vaccine.
6. Pneumococcal polysaccharide vaccination 
Medical indications: Chronic pulmonary disease (excluding asthma); chronic cardiovascular diseases; diabetes mellitus; chronic liver diseases, including liver disease as a result of alcohol abuse (e.g., cirrhosis); chronic alcoholism, chronic renal failure or nephrotic syndrome; functional or anatomic asplenia (e.g., sickle cell disease or splenectomy [if elective splenectomy is planned, vaccinate at least 2 weeks before surgery]); immunosuppressive conditions; and cochlear implants and cerebrospinal fluid leaks. Vaccinate as close to HIV diagnosis as possible. Other indications: Alaska Natives and certain American Indian populations and residents of nursing homes or other long-term care facilities.
7. Revaccination with pneumococcal polysaccharide vaccine 
One-time revaccination after 5 years for persons with chronic renal failure or nephrotic syndrome; functional or anatomic asplenia (e.g., sickle cell disease or splenectomy); or immunosuppressive conditions. For persons aged >65 years, one-time revaccination if they were vaccinated >5 years previously and were aged <65 years at the time of primary vaccination.
8. Hepatitis A vaccination
Medical indications: Persons with chronic liver disease and persons who receive clotting factor concentrates. Behavioral indications: Men who have sex with men and persons who use illegal drugs. Occupational indications: Persons working with hepatitis A virus (HAV)–infected primates or with HAV in a research laboratory setting.  Other indications: Persons traveling to or working in countries that have high or intermediate endemicity of hepatitis A (a list of countries is available at http://wwwn.cdc.gov/travel/contentdiseases.aspx  ) and any person seeking protection from HAV infection.  Single-antigen vaccine formulations should be administered in a 2-dose schedule at either 0 and 6–12 months (Havrix®), or 0 and 6–18 months (Vaqta®). If the combined hepatitis A and hepatitis B vaccine (Twinrix®) is used, administer 3 doses at 0, 1, and 6 months.
9. Hepatitis B vaccination 
Medical indications: Persons with end-stage renal disease, including patients receiving hemodialysis; persons seeking evaluation or treatment for a sexually transmitted disease (STD); persons with HIV infection; and persons with chronic liver disease. Occupational indications: Health-care personnel and public-safety workers who are exposed to blood or other potentially infectious body fluids. Behavioral indications: Sexually active persons who are not in a long-term, mutually monogamous relationship (e.g., persons with more than 1 sex partner during the previous 6 months); current or recent injection-drug users; and men who have sex with men. Other indications: Household contacts and sex partners of persons with chronic hepatitis B virus (HBV) infection; clients and staff members of institutions for persons with developmental disabilities; international travelers to countries with high or intermediate prevalence of chronic HBV infection (a list of countries is available at http://wwwn.cdc.gov/travel/contentdiseases.aspx ); and any adult seeking protection from HBV infection. Settings where hepatitis B vaccination is recommended for all adults: STD treatment facilities; HIV testing and treatment facilities; facilities providing drug-abuse treatment and prevention services; health-care settings targeting services to injection-drug users or men who have sex with men; correctional facilities; end-stage renal disease programs and facilities for chronic hemodialysis patients; and institutions and nonresidential daycare facilities for persons with developmental disabilities. Special formulation indications: 
For adult patients receiving hemodialysis and other immunocompromised adults, 1 dose of 40 µg/mL (Recombivax HB®), or 2 doses of 20 µg/mL (Engerix-B®) administered simultaneously.

10. Meningococcal vaccination 
Medical indications: Adults with anatomic or functional asplenia, or terminal complement component deficiencies. Other indications: First-year college students living in dormitories; microbiologists who are routinely exposed to isolates of Neisseria meningitidis; military recruits; and persons who travel to or live in countries in which meningococcal disease is hyperendemic or epidemic (e.g., the “meningitis belt” of sub-Saharan Africa during the dry season [December–June]), particularly if their contact with local populations will be prolonged. Vaccination is required by the government of Saudi Arabia for all travelers to Mecca during the annual Hajj. Meningococcal conjugate vaccine is preferred for adults with any of the preceding indications who are aged <55 years, although meningococcal polysaccharide vaccine (MPSV4) is an acceptable alternative. Revaccination after 3–5 years might be indicated for adults previously vaccinated with MPSV4 who remain at increased risk for infection (e.g., persons residing in areas in which disease is epidemic).

11. Herpes zoster vaccination 
A single dose of zoster vaccine is recommended for adults aged >60 years regardless of whether they report a prior episode of herpes zoster. Persons with chronic medical conditions may be vaccinated unless a contraindication or precaution exists for their condition. 

12. Selected conditions for which Haemophilus influenzae type b (Hib) vaccine may be used Hib conjugate vaccines are licensed for children aged 6 weeks–71 months. No efficacy data are available on which to base a recommendation concerning use of Hib vaccine for older children and adults with the chronic conditions associated with an increased risk for Hib disease. However, studies suggest good immunogenicity in patients who have sickle cell disease, leukemia, or HIV infection or who have had splenectomies; administering vaccine to these patients is not contraindicated.

13. Immunocompromising conditions 
Inactivated vaccines are generally acceptable (e.g., pneumococcal, meningococcal, and influenza [trivalent inactivated influenza vaccine]), and live vaccines generally are avoided in persons with immune deficiencies or immune suppressive conditions. Information on specific conditions is available at http://www.cdc.gov/vaccines/pubs/acip-list.htm
2007 NCIRD Publications
Peer-reviewed Scientific Journals
1.	Adu F, Iber J, Bukbuk D, et al. Isolation of recombinant type 2 vaccine-derived poliovirus (VDPV) from a Nigerian child. Virus Res. 2007;127:17-25.

2.	Albrecht MT, Li H, Williamson ED, et al. Human monoclonal antibodies against anthrax lethal factor and protective antigen act independently to protect against Bacillus anthracis infection and enhance endogenous immunity to anthrax. Infect Immun. 2007;11:5425-33.

3.	Allred NJ, Wooten KG, Kong Y. The association of health insurance and continuous primary care in the medical home on vaccination coverage for 19-35 month old children. Pediatrics. 2007;119(Suppl 1):S4-11.

4.	Anderton JM, Gowrisankar R, Romero-Steiner S, et al. E-cadherin is a receptor for the common protein pneumococcal surface adhesin A (PsaA) of Streptococcus pneumoniae. Microb Pathog. 2007;42:225-36.

5.	Andrus JK, Toscano C, Lewis M, et al. A model for enhancing evidenced-based capacity to make informed policy decisions on the introduction of new vaccines in the Americas: PAHO’s ProVac Initiative. Public Health Rep. 2007;122:811-16.

6.	Arevshatian L, Clements CJ, Lwanga SK, et al. An evaluation of infant immunization in Africa: is a transformation in progress? Bull WHO. 2007;85:449-57. 

7.	Badilla X, Morice A, Avila-Aguero ML, et al. Fetal risk associated with rubella vaccination during pregnancy. Pediatr Infect Dis J. 2007;26:830-5. 

8.	Baggett HC, Duchin JS, Shelton W, et al. Two nosocomial pertussis outbreaks and their associated costs–King County, WA, 2004. Infect Control Hosp Epidemiol. 2007;28:537-43.

9.	Bányai K, Bogdán Á, Kisfali P, et al. Emergence of serotype G12 rotaviruses, Hungary. Emerg Infect Dis. 2007;13:916-9. 

10.Bardenheier B, Kong Y, Shefer A, Zhou F, Shih S. Managed Care Organizations’ Performance in Delivery of Childhood Immunizations. Am J Managed Care. 2007;13:193-200.

11. Bardenheier B, Strikas R, Kempe A, Stokley S, Ellis J. Influenza vaccine supply, 2005-2006: did we come up short? BMC Health Services Res. 2007;7:66.

12. Bartlett DL, Washington ML, Thurston N, Bryant A, Perfili CA. Cost savings associated with using immunization information systems for Vaccines for Children administrative tasks. J Public Health Manag Pract. 2007;13:559-66. 

13. Baskin CR, Bielefeldt-Ohmann H, Garcia-Sastre A, et al. Functional genomic and serological analysis of the protective immune response resulting from vaccination of macaques with an NS1-truncated influenza virus. J Virol. 2007;81:11817-27.

14. Baughman AL. Mixture model framework facilitates understanding of zero-inflated and hurdle models for count data. 	J Biopharm Stat. 2007;17:943-6.

15. Beall B. Vaccination with the pneumococcal 7-valent conjugate: a successful experiment but the species is adapting. Expert Rev Vaccines. 2007;6:297-300.

16. Belser JA, Lu X, Maines TR, et al. Pathogenesis of avian influenza (H7) virus infection in mice and ferrets: enhanced virulence of Eurasian H7N7 viruses isolated from humans. J Virol. 2007;81:11139-47.

17. Belser JA, Lu X, Szretter KJ, et al. DAS181, a novel sialidase fusion protein, protects mice from lethal avian influenza H5N1 virus infection. J Infect Dis. 2007;196:1493-9.

18. Bihl F, Mosam A, Chisholm JV III, et al. KSHV-specific immune reconstitution and antiviral effect of combined HAART/chemotherapy in HIV clade C infected individuals with Kaposi’s Sarcoma. AIDS. 2007;21:1245-52.

19. Bihl F, Narayan M, Chisholm JV III, et al. Lytic and latent antigens of the human γ -herpesviruses KSHV and EBV induce T cell responses with similar functional properties and memory phenotypes. J Virol. 2007;81:4904-8.

20. Bilukha O, Messonnier N, Fischer M. Use of meningococcal
vaccines in the United States. Pediatr Infect Dis J. 2007;26:371-6.

21. Binongo JNG, Taylor A, Hill AN, et al. Use of classification and regression trees in diuresis renography. Acad Radiol. 2007;14:306-11.

22. Boddicker JD, Rota PA, Kreman T, et al. Real-time RT-PCR 	Assay for the detection of mumps virus RNA in clinical  specimens. J Clin Micro. 2007;45:2902-8.

23. Bolu O, Anand A, Swartzendruber A, et al. Utility of antenatal HIV surveillance data to evaluate prevention of mother-to-child HIV transmission programs in resource-limited settings. Am J Obstet Gynecol. 2007;197(Suppl 3):S17-25.

24. Bouwknegt M, Engel B, Herremans T, et al. Bayesian estimation of hepatitis E virus seroprevalence for populations with different exposure levels to swine in The Netherlands. Epidemiol Infect. 2007;20:1-10.

25. Boyer AE, Quinn CP, Woolfitt AR, et al. Detection and quantification of anthrax lethal factor in serum by mass spectrometry. Anal Chem. 2007;70:1741-79.

26. Breiman RF, Nasidi A, Katz MA, Njenga MK, Vertefeuille 
J. Preparedness for highly pathogenic avian influenza pandemic in Africa. Emerg Infect Dis. 2007;13:1453-8.

27 Brooks WA, Erdman D, Terebuh P, et al. Human metapneumovirus infection among children, Bangladesh. Emerg Infect Dis. 2007;13:1611-13.
28. Brown JM, Cowley KD, Manninen KI, McNeil MM. Phenotypic and molecular epidemiologic evaluation of a Nocardia farcinica mastitis epizootic.Vet Microbiol. 2007;125:66-72.

29. Brueggemann A, Pai R, Crook D, Beall B. Vaccine escape recombinants emerge after pneumococcal vaccination in the United States. PLoS Pathol. 2007;3:e168.

30. Burnsed L, Hicks L, Smithee L, et al. A large travel-associated outbreak of legionellosis among hotel guests: utility of the urine antigen assay in confirming Pontiac fever. Clin Infect Dis. 2007;442:222-8.

31. Carvalho M, Tondella M, McCaustland K, et al. Evaluation and improvement of real-time PCR assays targeting lytA, ply, and psaA genes for detection of pneumococcal DNA. J Clin Microbiol. 2007;45:2460-6.

32. Chaves SS, Gargiullo P, Zhang JX, et al. Loss of vaccine-induced immunity to Varicella over time. N Engl J Med. 2007;356:1121-9. 

33. Chaves SS, Santibanez TA, Gargiullo P, Guris D. Chickenpox exposure and herpes zoster disease incidence in older adults in the U.S. Public Health Rep. 2007;122:155-9.

34. Chen H, Bright RA, Subbarao K, et al. Polygenic virulence factors involved in pathogenesis of 1997 Hong Kong H5N1 influenza viruses in mice. Virus Res. 2007;128:159-63.

35. Chen MH, Zhu Z, Zhang Y, et al. An indirect immunocolorimetric assay to detect rubella virus infected cells. J Virol Meth. 2007;146:414-8.

36. Ching P. Evaluating accountability in the Vaccines for Children Program. Public Health Rep. 2007;122:718-24.

37. Clayton HB, Schieve LA, Peterson HB, Jamieson DJ, Reynolds MA, Wright VC. Comparison of heterotopic and intrauterine-only pregnancy outcomes after the application of assisted reproductive technologies in the United States from 1999 to 2002. Fertility and Sterility. 2007;87:303-9.

38. Coffin SE, Zaoutis TE, Rosenquist AB, et al. Incidence, complications, and risk factors for prolonged stay in children hospitalized with community-acquired influenza. Pediatrics. 2007;119:740-8.

39. Colugnati FAB, Staras SAS, Dollard SC, Cannon MJ. Incidence of cytomegalovirus infection among the general population and pregnant women in the United States. BMC Infect Dis. 2007;7:71. 

40. Conenello GM, Zamarin D, Perrone LA, Tumpey T, Palese P. A single mutation in the PB1-F2 of H5N1 (HK/97) and 1918 influenza A viruses contributes to increased virulence. PloS Pathog. 2007;3:e141.
41. Cortese MM, Baughman AL, Brown K, et al. A “new age” in pertussis prevention: new opportunities through adult vaccination. Am J Prev Med. 2007;32:177-85.

42. Crump JA, Mendoza CE, Priest JW, et al. Comparing serologic response against enteric pathogens with reported diarrhea to assess the impact of improved household drinking water quality. Am J Trop Med Hyg. 2007;77:136-41. 

43. CT, Boohene PA, Mowrer A, et al. Measles-mumps-rubella and varicella vaccine responses in extremely premature infants. Pediatrics. 2007;119:e574-9.

44. Dabbagh A, Eggers R, Cochi S, Dietz V, Strebel P, Cherian T. A new global framework for immunization monitoring and surveillance. Bulletin Wrld Health Org. 2007;85:901-80.

45. Daley MF, Crane LA, Chandramouli V, et al. Misperceptions about influenza vaccination among parents of healthy young children. Clin Pediatr. 2007;46:408-17.

46. Dankbar DM, Dawson ED, Mehlmann M, et al. Diagnostic microarray for influenza B viruses. Anal Chem. 2007;79:2084-90.

47. Dare R, Fry AM, Chittaganpitch M, Olsen SJ, Erdman DD. Characteristics of human coronavirus infections in rural Thailand. J Infect Dis. 2007;196:1321.

48. Davis MM, Kretsinger K, Cowan AE, Stokley S, Clark SJ. New combined tetanus-diphtheria-acellular pertussis vaccines for adults: primary care physician attitudes and preferences. Human Vaccines. 2007;3:130-4.

49. Davis MM, Marin M, Cowan AE, Guris D, Clark SJ. Physician attitudes regarding breakthrough varicella disease and a potential second dose of varicella vaccine. Pediatrics. 2007;119:258-64. 

50. Dawson ED, Moore CL, Dankbar DM, et al. Identification of A/H5N1 influenza viruses using a single gene diagnostic microarray. Anal Chem. 2007;79:378-84.

51. Dayan GH, Thorley M, Yamamura Y, et al. Serologic response to inactivated polio vaccine: a randomized clinical trial comparing 2 vaccination schedules in Puerto Rico. J Infect Dis. 2007;195:12-20. 

52. de Wit MAS, Widdowson MA, Koopmans MPG, Vennema H. Large outbreak of Norwalk-like virus in staff of an administrative department in The Netherlands. J Infect. 2007:55:188-93.

53. Deyde VM, Xu X, Bright RA, et al. Surveillance of resistance to adamantanes among influenza A(H3N2) and A(H1N1) viruses isolated worldwide. J Infect Dis. 2007;196:249-57.

54. Dias C, Agnes G, Frazzon A, et al. Diversity of mutation in the atpC gene coding for the c subunit of F0F1 ATPase in clinical isolates of optochin-resistant Streptococcus pneumoniae from Brazil. J Microbiol. 2007;45:3065-7.

55. Dias C, Teixeira L, Carvalho MDG, Beall B. Sequential multiplex PCR for determining capsular serotypes of pneumococci recovered from Brazilian children. J Microbiol. 2007;56:1185-8.

56. Dollard SD, Grosse SD, Ross DS. New estimates of the prevalence of neurological and sensory sequelae and mortality associated with congenital cytomegalovirus infection. Rev Med Virol. 2007;
17:355-63.

57. Duan Z-J, Li D-D, Zhang Q, et al. Novel human rotavirus of genotype G5P[6] identified in a stool specimen from a Chinese girl with diarrhea. J Clin Microbiol. 2007;45:1614-7.

58. El-Sayed N, Al-Jorf S, Hennessey KA, et al. Survey of poliovirus antibodies during the final stage of polio eradication in Egypt. Vaccine. 2007;25:5062-70.

59. Enger K, Stokley S. Meningococcal conjugate vaccine uptake, measured by Michigan’s immunization registry. J Adolesc Health. 2007;40:398-404.

60. Fang Z-Y, Xie HP, Lu HX, et al. Investigation of human calicivirus (HuCV) diarrhea among infants and young children in China, 1999-2005. Chinese J Virol. 2007;23:9-15. 

61. Fischer TK, Viboud C, Parashar U, et al. Hospitalizations and deaths from diarrhea and rotavirus among children <5 years of age in the United States, 1993-2003. J Infect Dis. 2007;195:1117-25.

62. Flannery B, Whitney C. Uncovering pneumococcal disease burden in Bangladesh. Am J Trop Med Hygiene. 2007;77:793-4.

63. Fontanesi JF, Messonnier ML, Hill L, Shefer A. A new model of adoption of clinical practice guidelines. J Public Health Manage Pract. 2007;13:605-11.

64. Fowler GF, Kennedy A, Leidel L, et al. Vaccine safety perceptions and experience with adverse events following immunization in Kazakhstan and Uzbekistan: A summary of key informant interviews and focus groups. Vaccine. 2007;25:3536-43.

65. Fry AM, Lu X, Chittaganpitch M, et al. Human bocavirus: a novel parvovirus epidemiologically associated with pneumonia requiring hospitalization in Thailand. J Infect Dis. 2007;195:1038-45.

66. Garg S, Hoelscher M, Belser JA, et al. Needle-free skin patch delivery of a vaccine for a potentially pandemic influenza virus provides protection against lethal challenge in mice. Clin Vac Immunol. 2007;14:926-8.

67. Gary H, Smith B, Jenks J, et al. Failure to detect infection by vaccine-derived poliovirus following natural exposure among inactivated polio vaccine recipients. Epidemiol Infect. 2007;22:1-4.

68. Gazmararian JA, Coleman MS, Prill M, et al. Influenza vaccination of hospital workers: practices, policy and attitudes of hospital facilities. Am J Infect Control. 2007;35:441-7.

69. George T, Shefer AM, Rickert D, David F, Stevenson JM, Fishbein DB. A status report from 1996-2004: are more effective immunization interventions being used in the women, infants, and children (WIC) program? Maternal Child Health J. 2007;11:327-33.

70. Gottlieb SL, Kretsinger K, Tarkhashvili N, et al. Long-term outcomes of 217 botulism cases in the Republic of Georgia. Clin Infect Dis. 2007;45:174-80.

71. Grijalva C, Nuorti J, Arbogast P, Martin S, Edwards K, Griffin M. Decline in pneumonia admissions after routine childhood immunization with pneumococcal conjugate vaccine in the USA; a time-series analysis. Lancet. 2007;369:1179-86.

72. . Grijalva CG, Poehling KA, Edwards KM, et al. Accuracy and interpretation of rapid influenza tests in children. Pediatrics. 2007;119:6-11.
73. Grijalva CG, Weinberg GA, Bennett NM, et al. Estimating the undetected burden of influenza hospitalizations in children. Epidemiol Infect. 2007;135:951-8.

74. Groom H, Kolasa M, Wooten K, Ching P, Shefer A. Differences in childhood immunization coverage rates among public and private providers. J Public Health Manag Pract. 2007;13:584-9.

75. Guarner J, Bhatnagar J, Shieh W-J, et al. Histopathologic, immunohistochemical, and polymerase chain reaction essays in the study of cases with fatal sporadic myocarditis. Human Pathol. 2007;38:1412-9.

76. Guarner J, Packard MM, Nolte KB, et al. Usefulness of immunohistochemical diagnosis of Streptococcus pneumoniae in formalin-fixed, paraffin-embedded specimens compared with culture and gram stain techniques. Am J Clin Pathol. 2007;127:612-8.

77. Guo Z, Chen L-M, Zeng H, et al. NS1 protein of influenza A virus inhibits the function of intracytoplasmic pathogen sensor,RIG-I. Am J Resp Cell Mol Biol. 2007;36:263-9. 

78. Gurley E, Montgomery J, Jahangir Hossain M, et al. Person-to-person transmission of Nipah virus in a Bangladeshi Community. Emerg Infect Dis. 2007;13:1031-7.

79. Haber M, Barskey A, Baughman W, et al. Herd immunity and pneumococcal conjugate vaccine: a quantitative model. Vaccine. 2007;25:5390-8.

80. Haber MJ, Shay DK, Davis XM, et al. Effectiveness of interventions to reduce contact rates during a simulated influenza pandemic. Emerg Infect Dis. 2007;13:581-9.

81. Haynes LM, Miao C, Harcourt JL, et al. Recombinant protein-based assays for detection of antibodies to severe acute respiratory syndrome coronavirus spike and nucleocapsid proteins. Clin Vaccine Immunol. 2007;14:331-3. 

82. Heath P, Schuchat A. Perinatal group B streptococcal disease. Best Pract Res Clin Obstet Gynaecol. 2007;21:411-24.

83. Helfand RF, Cabezas C, Abernathy E, et al. Dried Blood Spots versus Sera for Detection of Rubella Virus-Specific Immunoglobulin M (IgM) and IgG in Samples Collected during a Rubella Outbreak in Peru. Clin Vaccine Immunol. 2007;14:1522-5.

84. Herrera GA, Iwane MK, Cortese M, et al. Influenza vaccine effectiveness among 50-64-year-old persons during a season of poor antigenic match between vaccine and circulating influenza virus strains: Colorado, United States, 2003-2004. Vaccine. 2007;259:154-60. 

85. Hicks L, Harrison L, Flannery B, et al. Incidence of pneumococcal disease due to non-pneumococcal conjugate vaccine (PCV7) serotypes in the United States during the era of widespread PCV7 vaccination, 1998-2004. J Infect Dis. 2007;196:1346-54.

86. Hicks L, Rose CE Jr, Fields B, et al. Increased rainfall is associated with increased risk for legionellosis. Epidemiol Infect. 2007;135:811-7.

87. Hinman AR, Urquhart GA, Strikas RA. Immunization information systems: National Vaccine Advisory Committee progress report, 2007. J Public Health Manag Pract. 2007;13:553-8.

88. Hoelscher MA, Jayashankar L, Garg S, et al. New pre-pandemic influenza vaccines: an egg- and adjuvant-independent human adenoviral vector strategy induces long-lasting protective immune responses in mice. Clin Pharmacol Ther. 2007;82:665-71.

89. Holman RC, Yorita KL, Singleton RJ, Cheek JE, Paisano EL, Butler JC, et al. Pneumonia hospitalizations among American Indian and Alaska Native adults 65 years of age and older. J Health Disparities Res Pract. 2007;2:35-48.

90. Honeycutt AA, Coleman MS, Anderson WL, Wirth KE. Cost-effectiveness of standing orders for influenza and pneumococcal vaccinations in North Carolina hospitals. Vaccine. 2007;25:
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91. Honma S, Chizhikov V, Santos N, et al. Development and validation of DNA microarray for genotyping group A rotavirus VP4 (P[4], P[6], P[8], P[9], and P[14]) and VP7 (G1 to G6, G8 to G10, and G12) genes. J Clin Microbiol. 2007;45:2641-8.

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244.Wolfson LJ, Strebel PM, Gacic-Dobo M, Hoekstra EJ, McFarland JW, Hersh BS. Measles Initiative. Has the 2005 measles mortality reduction goal been achieved? A natural history modelling study. Lancet. 2007;369:191-200. 

245. Woodard S, Archer L, Zell E, Ronveaux O, Birmingham M. Design and simulation study of the immunization data quality audit (DQA). Ann Epidemiol. 2007;17:628-33.

246. Wooten K, Luman E, Barker L. Socioeconomic factors and persistent racial disparities in childhood vaccination. Am J Health Behavior. 2007;31:434-45.

247. Wortley PM, Levy PS, Quick L, et al. Predictors of smallpox vaccination among healthcare workers and other first responders. Am J Prev Med. 2007;32:538-41.

248. Yee EL, Palacio H, Atmar RL, et al. Widespread outbreak of norovirus gastroenteritis among evacuees of Hurricane Katrina residing in a large “megashelter” in Houston, Texas: lessons learned for prevention. Clin Infect Dis. 2007;44:1032-9. 

249. Yu H, Feng Z, Zhang X, et al. Human influenza A (H5N1) cases, urban areas of People’s Republic of China, 2005-2006. Emerg Infect Dis. 2007;13:1061-4.

250. Zeng H, Goldsmith C, Thawatsupha P, et al. Highly pathogenic avian influenza H5N1 viruses elicit an attenuated type I interferon response in polarized human bronchial epithelial cells. J Virol. 2007;81:12439-49.

251. Zhang X, Shao Z, Yang E, et al. The molecular epidemiology of disease caused by serogroup C Neisseria meningitidis in China, during 2003 to 2006. J Med Microbiol. 2007;56:1224-9.

252. Zhang Y, Zhu Z, Rota PA, et al. Molecular epidemiology of measles viruses in China, 1995-2003. Virology Journal. 2007; 5:4-14.

253. Zhao Z. Early stopping clinical trials of binomial response with an exact group sequential method. Statistics in Medicine. 2007;26:1724-9. 

254. Zhou F, Kyaw M, Shefer A, Winston C, Nuorti J. Health care utilization for pneumonia in young children after routine pneumococcal conjugate vaccine use in the United States. Arch Pediatr Adol Med. 2007;161:1162-8.

255. Zhou F, Shefer A, Weinbaum C, McCauley M, Kong Y. Impact of hepatitis A vaccination on health care utilization in the United States, 1996–2004. Vaccine. 2007;25: 3581-7.

256. Zhu Z, Xu W, Abernathy ES, et al. Comparison of four methods using throat swabs to confirm rubella virus infection. J Clin Microbiol. 2007;45:2847-52.

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Zimmerman LA, Bartlett DL, Enger KS, Gosney K, Williams WG. Influenza vaccination coverage: findings from immunization information systems. BMC Pediat. 2007;7:28. 

MMWR (weekly)

1. CDC. Acute respiratory disease associated with adenovirus type 14 in the U.S.: reports from four states. MMWR 2007;56(45):1181-4.

2. CDC. Elimination of measles — South Korea, 2001-2006. MMWR 2007;56(13):304-7. 

3. CDC. Emergence of antimicrobial-resistant serotype 19A Streptococus pneumoniae. MMWR 2007;56(41):1077-80.

4. CDC. Hepatitis A vaccination coverage among children aged 24–35 months — United States, 2004–2005. MMWR 2007;56(27):678-81. 

5. CDC. Influenza vaccination coverage among children aged 6–23 months — United States, 2005–06 influenza season. MMWR 2007;56(37):959-63.

6. CDC. Influenza vaccination coverage among children aged 6–59 months — six immunization information system sentinel sites, United States, 2006–07 influenza season. MMWR 2007;56(37):963-5.

7. CDC. Influenza vaccination coverage among children with asthma — United States, 2004–05 influenza season (September 2004–February 2005). MMWR 2007;56(9):193-6.

8. CDC. Laboratory surveillance for wild and vaccine-derived polioviruses, January 2006–June 2007. MMWR 2007;56(38):965-9.

9. CDC. National vaccination coverage among adolescents aged 13–17 years — United States, 2006. MMWR 2007;56(34):885-8.

10. CDC. National, state, and local area vaccination coverage among children aged 19–35 months — United States, 2006. MMWR 2007;56(34):880-5.

11. CDC. Norovirus activity United States — 2006–2007. MMWR 2007;56(33):842-6.

12. CDC. Notice to Readers: National influenza vaccination week — November 26–December 2, 2007. MMWR 2007;56(46):1216-7.

13. CDC. Notice to Readers: Update of recommended nomenclature for the genetic characteristics of wild-type rubella viruses 2007. MMWR 2007;56(23):582.

14. CDC. Outbreaks of respiratory illness mistakenly attributed to pertussis — New Hampshire, Massachusetts, and Tennessee, 2004–2006. MMWR 2007;56(33):837-42.

15. CDC. Perinatal group B streptococcal disease after universal screening recommendations — United States, 2003-2005. MMWR 2007;56(28):701-5.

16. CDC. Postmarketing monitoring of intussusception after RotaTeq™ vaccination — United States, February1, 2006–February 15, 2007. MMWR 2007;56(10):218-22. 

17. CDC. Progress in global measles control and mortality reduction, 2000–2006. MMWR 2007;56(47):1237-41.

18. CDC. Progress in measles control — Kenya, 2002–2007. MMWR 2007;56(37):969-72. 

19. CDC. Progress in measles control — Nepal, 2000–2006. MMWR 2007;56(39):1028-31.

20. CDC. Progress toward interruption of wild poliovirus transmission — worldwide, January 2006–May 2007. MMWR 2007;56(27):682-5.

21. CDC. Progress toward poliomyelitis eradication — India, January 2006–September 2007. MMWR 2007;56(45):1187-91.

22. CDC. Progress toward poliomyelitis eradication — Nigeria, 2005–2006. MMWR 2007;56(12):278-81. 

23. CDC. Progress toward poliomyelitis eradication — Pakistan and Afganistan, January 2006–February 2007. MMWR 2007;56(14):340-3.

24. CDC. Respiratory syncytial virus activity — United States, July 2006–October 2007. MMWR 2007;56(48):1263-5.

25. CDC. Severe methicillin-resistant staphylococcus aureus community-acquired pneumonia associated with influenza — Louisiana and Georgia, December 2006–January 2007. MMWR 2007;56(14):325-9.

26. CDC. State-specific influenza vaccination coverage among adults aged ≥18 years — United States, 2003–04 and 2005–06 influenza seasons. MMWR 2007;56(37):953-9.

27. CDC. Update on vaccine-derived polioviruses — Worldwide, January 2006–June 2007. MMWR 2007;56(38):996-1001

28. CDC. Update: influenza activity — United States and worldwide, May 20–September 15, 2007. MMWR 2007;56(38):1001-4.

29. CDC. Update: influenza activity — United States and worldwide, 2006–07 season, and composition of the 2007–08 influenza vaccine. MMWR 2007;56(31):789-94.

30. CDC. Update: influenza activity — United States, October 1, 2006–February 3, 2007. MMWR 2007;56(06):118-21.

31. CDC. Update: influenza activity — United States, September 30–December 1, 2007. MMWR 2007;56(49):1287-91.

32. CDC. Vaccination coverage among children in Kindergarten — United States, 2006–07 school year. MMWR 2007;56(32):819-21. 

33. CDC. Vulvar vaccinia infection after sexual contact with a military smallpox vaccinee: case report and use of the pathogen discovery program — Alaska, 2007. MMWR 2007;56(17):417-9.

34.	CDC. Interim recommendations for the use of haemophilus influenzae type b (Hib) conjugate vaccines related to the recall of certain lots of Hib-containing vaccines (PedvaxHIB® and Comvax®). MMWR 2007;56(50):1318-20.

35.CDC. Measles among adults associated with adoption of children in China – California, Missouri, and Washington, July – August 2006. MMWR 2007;56(07):144-6.

36.CDC. Notice to Readers: Availability of additional trivalent inactivated influenza vaccine for adults (Afluria®). MMWR 2007;56(46):1219.

37.CDC. Notice to Readers: Expansion of use of live attenuated influenza vaccine (FluMist®) to children aged 2-4 years and other FluMist changes for the 2007-08 influenza season. MMWR 2007;56(46):1217-9.

38.CDC. Notice to Readers: FDA approval of an alternate dosing schedule for a combined hepatitis A and B vaccine (Twinrix®). MMWR 2007;56(40):1057.

39.CDC. Notice to Readers: National infant immunization week – April 21-28, 2007. MMWR 2007;56(15):371.

40.CDC. Notice to Readers: Recommendation from the Advisory Committee on Immunization Practices (ACIP) for use of quadrivalent meningococcal conjugate vaccine (MCV4) in children aged 2-10 years at increased risk for invasive meningococcal disease. MMWR 2007;56(48):1265-6.

41.CDC. Notice to Readers: Revised recommendations of the Advisory Committee on Immunization Practices to vaccinate all persons aged 11-18 years with meningococcal conjugate vaccine. MMWR 2007;56(31):794-5.

42.CDC. Notice to Readers: Supply of vaccines containing varicella-zoster virus. MMWR 2007;56(07):146-7.

43.CDC. Notice to Readers: Update on supply of vaccines containing varicella-zoster virus. MMWR 2007;56(18):453.

44.CDC. Recommended adult immunization schedule – United States, October 2007 – September 2008. MMWR 2007;56(41):Q1-Q4.

45.CDC. Surveillance for travel-associated legionnaires disease – United States, 2005-2006. MMWR 2007;56(48):1261-3.

46.CDC. Update: Prevention of hepatitis A after exposure to hepatitis A virus and in international travelers. Updated recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR 2007;56(41):1080-4.

MMWR (Recommendations and Reports)

1. CDC. Prevention and control of influenza: recommendations of the advisory committee on immunization practices (ACIP). MMWR 2007;56(RR-6):1-54.

2. CDC. Prevention of varicella. Recommendations of the Advisory Committee on Immunization Practices. MMWR 2007;56(RR-4):
1-40. 

This document can be found on the CDC website at:      
http://www.cdc.gov/vaccines/about/annual-rpts/ar2008/bk-ar2008-s1-4.rtf