Participants who responded "yes" to either question were classified as having a disability. To assess self-rated health status, participants were asked, "Would you say that in general your health is excellent, very good, good, fair, or poor?" The following racial/ethnic categories were included in this analysis: white, black, Hispanic, Asian, Native Hawaiian or Other Pacific Islander, and AI/AN.  Data from 2004, 2005,  and 2006  were aggregated to provide sufficient power to analyze low-count racial/ethnic populations. Prevalence estimates were weighted and age adjusted to the 2000 U.S. standard population. Weighted population estimates were determined by taking the final weights for each year during 2004-2006 and dividing by three. Data were weighted to compensate for unequal probabilities of selection, to adjust for nonresponse and telephone noncoverage, to ensure that results were consistent with population data, and to make population estimates. #
Self-rated health status has been found to be an independent predictor of morbidity and mortality (1), and racial/ethnic disparities in self-rated health status persist among the U.S. adult population (2). Black and Hispanic adults are more likely to report their general health status as fair or poor compared with white adults (2). In addition, the prevalence of disability has been shown to be higher among blacks and American Indians/Alaska Natives (AI/ANs) (3). To estimate differences in self-rated health status by race/ethnicity and disability, CDC analyzed data from the 2004-2006 Behavioral Risk Factor Surveillance System (BRFSS) surveys. This report summarizes the results of that analysis, which indicated that the prevalence of disability among U.S. adults ranged from 11.6% among Asians to 29.9% among AI/ANs. Within each racial/ethnic population, adults with a disability were more likely to report fair or poor health than adults without a disability, with differences ranging from 16.8 percentage points among Asians to 37.9 percentage points among AI/ANs. Efforts to reduce racial/ ethnic health disparities should explicitly include strategies to improve the health and well being of persons with disabilities within each racial/ethnic population.
BRFSS is a state-based, random-digit-dialed telephone survey of the noninstitutionalized, U.S. civilian population aged >18 years. , approximately 1 million persons from all 50 states, the District of Columbia, Puerto Rico, and the U.S. Virgin Islands participated in the BRFSS survey.- Consistent with the definition of disability from Healthy People 2010 (4), respondents were asked, "Are you limited in any way in any activities because of physical, mental, or emotional problems?" and "Do you now have any health problem that requires you to use special equipment, such as a cane, a wheelchair, a special bed, or a special telephone?" Prevalence estimates and standard errors were obtained using statistical software to account for the complex sampling design. Chi-square tests were used to compare self-rated health status between racial/ethnic populations and by disability status. Council of American Survey Research Organizations (CASRO) median response rates  for the 2004-2006 BRFSS surveys were 52.7% (2004), 51.1% (2005), and 51.4% (2006). The median cooperation rates for each year were 74.3% (2004), 75.1% (2005), and 74.5% (2006).
During 2004-2006, an estimated 19.9% of the total U.S. population aged >18 years (i.e., an average of 43 million persons) had a disability. The prevalence of disability was highest among AI/ANs (29.9%) and lowest among Asians (11.6%) (Table 1). Nearly 84% of the total U.S. adult population reported having good or better health, but substantial variation was observed in self-rated health status across racial/ethnic populations. Nearly 60% of white, Asian, and Native Hawaiian or Other Pacific Islander respondents (59.3%, 55.8%, and 55.4%, respectively) rated their health as very good or excellent, whereas 44.4% of black respondents reported their health to be very good or excellent. White and Asian adults had similar rates of self-rated fair or poor health (12.9% and 10.4%, respectively), whereas fair or poor health was reported more frequently among other minority populations: 21.1% among blacks, 14.8% among Native Hawaiian or Other Pacific Islanders, and 24.5% among AI/ANs. Hispanic adults rated their health status approximately equally across the three health status categories: very good or excellent (33.6%), good (35.4%), and fair or poor (31.1%).
Overall, adults with a disability were less likely to report excellent or very good health (27.2% versus 60.2%; p<0.01) and more likely to report fair or poor health (40.3% versus 9.9%; p<0.01), compared with adults without disability (Table 2). White adults without a disability had the highest proportion of respondents who rated their health as very good or excellent (66.9%), whereas 49.9% of black respondents without a disability reported very good or excellent health. Reports of fair or poor health among adults with a disability were most common among Hispanics and AI/ANs (55.2% and 50.5%, respectively) and least common among Asians (24.9%).

# MMWR
October 3,2008 tions should also address the needs of adults with disabilities. Such efforts must ensure that persons with disabilities have accessible, available, and appropriate health-care and wellness promotion services (5).

# HIV Prevalence Estimates -United States, 2006
Accurate and timely data on the number of persons in the United States living with human immunodeficiency virus (HIV) infection (HIV prevalence) are needed to guide planning for disease prevention, program evaluation, and resource allocation. However, overall HIV prevalence cannot be measured directly because a proportion of persons infected with HIV have neither been diagnosed nor reported to local surveillance programs. In addition, national HIV prevalence data are incomplete because local reporting systems for confidential, name-based HIV reporting have been fully implemented only since April 2008. With the advent of highly active antiretroviral therapies that delay the progression of HIV to acquired immunodeficiency syndrome (AIDS), and of AIDS to death (1), and changes in the AIDS case definition to include an immunologic diagnosis (2), earlier back-calculation methods from the 1990s for estimating HIV prevalence based on the number of reported AIDS cases are no longer reliable. With 80% of states reporting name-based HIV diagnoses as of January 2006, an extended back-calculation method now can be used to estimate HIV prevalence more accurately. Based on this method, CDC now estimates that 1.1 million adults and adolescents (prevalence rate: 447.8 per 100,000 population) were living with diagnosed or undiagnosed HIV infection in the United States at the end of 2006. The majority of those living with HIV were nonwhite (65.4%), and nearly half (48.1%) were men who have sex with men (MSM). The HIV prevalence rates for blacks (1,715.1 per 100,000) and Hispanics (585.3 per 100,000) were, respectively, 7.6 and 2.6 times the rate for whites (224.3 per 100,000).
An extended back-calculation method has been described in detail and was used recently to calculate the incidence of HIV infection in the United States (3). The method was used in this analysis to estimate HIV prevalence based on the number of HIV diagnoses by calendar year and disease severity (i.e., whether the person received an AIDS diagnosis in the same calendar year as the HIV diagnosis). HIV prevalence at the end of 2006 for the 50 states and District of Columbia was estimated using information from the national HIV/AIDS Reporting System for persons aged >13 years who were diagnosed with HIV during 2006 and reported to CDC by the end of June 2007. Forty states provided data on both HIV and AIDS diagnoses, whereas 10 states (California, Delaware, Hawaii, Illinois, Maryland, Massachusetts, Montana, Oregon, Rhode Island, and Vermont) and the District of Columbia provided data only for AIDS diagnoses. For the areas without name-based HIV data, statistical procedures and AIDS data were used to estimate HIV cases, based on the ratio of HIV to AIDS in states with integrated surveillance systems (4). The number of undiagnosed HIV infections was calculated by subtracting diagnosed AIDS prevalence and diagnosed HIV prevalence from the estimated overall HIV prevalence. Using an established method, data also were adjusted for reporting delays and redistribution of risk factors among persons initially reported without sufficient information to be classified into an HIV transmission category (5). HIV prevalence rates per 100,000 population were calculated for various demographic characteristics; population denominators for rate calculations were based on official postcensus estimates for 2006 (6).
Among the estimated number of persons living with HIV at the end of 2006, 46.1% (1,715.1 per 100,000 population) were black, 34.6% (224.3 per 100,000) were white, 17.5% (585.3 per 100,000) were Hispanic, 1.4% (129.6 per 100,000) were Asian/Pacific Islander, and 0.4% (231.4 per 100,000) were American Indian/Alaska Native (Table ). Males accounted for 74.8% of prevalent HIV cases (685.7 per 100,000). The greatest percentage of cases was attributed to male-to-male sexual contact, accounting for 48.1% overall (and 64.3% among men). High-risk heterosexual contact, defined as heterosexual contact with a person known to have, or to be at high risk for, October 3, 2008 HIV infection (e.g., an injection drug user) accounted for 27.6% of prevalent cases overall (12.6% of cases among men and 72.4% of cases among women). Injection drug use (IDU) accounted for 18.5% of total cases (15.9% of cases among men and 26.3% of cases among women). The remainder of cases were attributed to men who reported both male-to-male sexual contact and IDU (5.0%) or whose transmission category was classified as other (0.8%; including hemophilia, blood transfusion, perinatal exposure, and risk factors not reported or not identified). Overall, an estimated 232,700 (21.0%) persons living with HIV infection had not been diagnosed as of the end of 2006.
The HIV prevalence rate for black men (2,388.2 per 100,000 population; 95% confidence interval  = 2,197.9-2,578.4) was six times the rate for white men (394.6 per 100,000; CI = 363.3-425.9) (Figure ), and the rate for Hispanic men (883.4 per 100,000; CI = 784.9-982.4) was more than twice the rate for white men. The HIV prevalence rate for black women (1,122.4 per 100,000; CI = 1,002.2-1,242.5) was nearly 18 times the rate for white women (62.7 per 100,000; CI = 54.7-70.7), and the rate for Hispanic women (263.0 per 100,000; CI = 231.6-294.4) was more than four times the rate for white women. The HIV prevalence rate for black women was greater than the rate for all other groups, except for black men.
Reported by: ML Campsmith, DDS, P Rhodes, PhD, HI Hall, PhD, T Green, PhD, Div of HIV/AIDS Prevention, National Center for HIV/ AIDS, Viral Hepatitis, STD, and TB Prevention, CDC. Editorial Note: Reduced mortality resulting from the use of highly active antiretroviral therapies is a major factor contributing to the number of persons in the United States living with HIV disease (1). Additionally, more than 56,000 new HIV infections are estimated to occur annually (3).
The estimate of HIV prevalence in this report is similar to an estimate for 2003 (1,039,000-1,185,000) that used the same extended back-calculation method (4). However, because of improvements in national HIV surveillance data since 2003, the two estimates cannot be compared directly. The 2006 estimate is based on a data set that 1) includes HIV diagnoses from 10 states that were not reporting in 2003 and 2) has been refined by an improved ability to identify and remove duplicate HIV case data that reflect reports by more than one state. Using the refined data set, CDC now estimates the HIV prevalence for 2003 to have been 994,000, suggesting that HIV  3.7% ever have had anal sex with another male, and the proportion of men who had a male sexual partner in the past 12 months was 2.9% (7).
The findings in this report are subject to at least three limitations. First, reported HIV data used in the extended back-calculation method represent only a portion of persons in the United States who were diagnosed with HIV infection; several high-morbidity areas, including California, Illinois, Maryland, and the District of Columbia, did not contribute HIV data. Availability of reported HIV data from these areas will increase accuracy of future prevalence estimates. Second, not all persons who are infected with HIV have been diagnosed and reported to the public health surveillance system, and data must be estimated for undiagnosed persons. Finally, the data have been adjusted statistically to account for delays in reporting new cases and deaths, and cases reported without risk factor information have been redistributed among other transmission categories (5). These adjustments were based on risk redistribution assumptions from the mid-1990s that might no longer be valid, which could result in over-or underadjustment of the data.
Previous studies have indicated that persons generally reduce their sexual risk behaviors (e.g., decrease the number of sex partners and reduce unprotected intercourse through increased condom use) after being diagnosed with HIV (8). Thus, increasing the percentage of HIV-infected persons who are diagnosed and linked with effective care and prevention services has the potential to reduce new HIV infections over time. To help achieve that, CDC has focused resources on increasing testing for HIV, particularly among populations that are disproportionately affected by HIV infection. Recent CDC activities have included publication of revised recommendations for HIV testing in health-care settings (9) and creation of a new program, the Heightened National Response to the HIV/AIDS Crisis in the African American Community (10). In 2007, as part of the President's Domestic HIV Initiative, CDC allocated funds to expand routine HIV testing, primarily among blacks. In addition to testing, expanding the number and reach of effective HIV prevention services for at-risk populations, including blacks, Hispanics, and MSM of all races, can contribute to reducing the disproportionate numbers of infections in these groups. Culturally appropriate opportunities for HIV testing, diagnosis, and access to early treatment and prevention services to reduce further HIV transmission are key to reducing new infections and ultimately decreasing HIV prevalence in the United States.

# FIGURE. Estimated human immunodeficiency virus (HIV

# Rabies in a Dog Imported from Iraq -New Jersey, June 2008
Rabies vaccination and stray dog control have led to successful control of canine rabies in the United States. The number of rabid dogs reported decreased from approximately 5,000 in 1950 to 79 in 2006, when the canine rabies virus variant associated with dog-to-dog rabies transmission was declared eliminated in the United States (1). On June 18, 2008, a mixed-breed dog, recently shipped from Iraq into the United States, was confirmed to have rabies by the Public Health and Environmental Laboratories of the New Jersey Department of Health and Senior Services. A total of 24 additional animals in the shipment, all potentially exposed to the rabid dog, were distributed to 16 states. This report summarizes the epidemiologic investigation by the New Jersey Department of Health and Senior Services, Bergen County Department of Health, and CDC, and the ensuing public health response. These findings underscore the need for vigilance regarding rabies (and other zoonotic diseases) during animal importation to prevent the possible reintroduction and sustained transmission of canine rabies in U.S. dog populations.

# Case Report
On June 5, 2008, a shipment of 24 dogs and two cats arrived in the United States from Iraq as part of an international animal rescue operation. The goal of the operation was to reunite servicemen returning to the United States with animals they had adopted in Iraq. Upon arrival at Newark Liberty International Airport, the animals received physical examinations from volunteer licensed veterinarians. One cat became ill with neurologic signs during transport and was euthanized on arrival. The cat was tested for rabies and was negative. The remaining 24 dogs and one cat were housed for several days at the airport before distribution to their final U.S. destinations.
On June 8, one of the 24 dogs, a mixed-breed aged 11 months (dog A), became ill and was taken to a veterinarian the next day. The dog was hospitalized with fever, diarrhea, wobbly gait, agitation, and crying. The dog's condition deteriorated, progressing to lateral recumbency with periods of agitation. On June 11, the dog was euthanized. Specimens were shipped to the Public Health and Environmental Laboratories for rabies testing, but delivery of the specimens was delayed. On June 18, the specimens were tested, and rabies was diagnosed. Specimens also were submitted to CDC, where rabies was confirmed on June 26 and typed as a rabies virus variant associated with dogs in the Middle East.

# Public Health Investigation
The potentially infectious period for a dog, cat, or ferret with rabies can begin as many as 10 days before the onset of clinical signs and continue throughout the clinical course until death (2). To identify potential rabies exposure to humans or other animals while dog A was in Iraq, during transport, or at the airport shelter, an investigation was initiated by the New Jersey Department of Health and Senior Services and the Bergen County Department of Health, with participation from CDC. The dog was reportedly in the possession of a U.S. soldier in Baghdad for approximately 7 months before shipment to the United States. The dog had been kept in an indoor-outdoor run on a military base and had not been vaccinated for rabies; the owner reported no signs of illness in the dog or potential exposure to other rabid animals during the 7 months. The owner also reported no potential exposures to other persons or animals during the 2 days of potential infectivity before the dog was transferred to the animal rescue operation for shipment on May 31.
Upon arrival in the United States, none of the 24 dogs were accompanied by the valid rabies vaccination certificates required for admission by CDC animal importation regulations.- For dogs aged >3 months, a rabies vaccination must be administered at least 30 days before the date of arrival at a U.S. port. Five of the 24 dogs (not including dog A) reportedly had received a previous rabies vaccination; however, none of the information required for a valid rabies vaccination certificate was available, including vaccine manufacturer, lot numbers, or a certifying veterinarian signature. Twenty-one of the animals in the shipment, including dog A, had received a primary rabies vaccination in Iraq during May 28-31, immediately before being shipped to New Jersey. Because none of the dogs met rabies vaccination requirements for importation, in accordance with the importation regulation, a confinement agreement was issued by CDC, stating where the animals would be held for at least 30 days after vaccination. During shipment and upon arrival in New Jersey, all the animals were housed in separate crates; however, interviews with persons present during the animals' arrival and stay in Newark identified potential periods during which dogs, including dog A, were allowed to intermingle.
On June 10, 1 day before dog A was euthanized and 8 days before rabies was diagnosed, the remaining 23 dogs and one cat were shipped to destinations in 16 states.  Because none of the surviving animals had a verifiable history of vaccination at least 30 days before their potential exposure to dog A, CDC recommended immediate vaccination and a 6-month quarantine for all of them (2). State health departments in the 16 states were advised of the recommendations.
During the public health investigation, 28 persons were evaluated for potential rabies exposure; 13 were identified with potential exposure because of direct contact with possibly infectious saliva (3) and were recommended to initiate rabies postexposure prophylaxis (PEP). All 23 dogs and one cat were located by state and local health authorities within 2 weeks of the rabies diagnosis. No clinical signs consistent with rabies were reported in the animals during 20 days of follow-up. All 24 animals continue to be monitored during the 6-month quarantine period. Editorial Note: Rabies virus infection results in a fatal encephalomyelitis in humans and other mammals. Globally, the most common sources of human rabies are geographically distinct rabies virus variants maintained predominantly through dogto-dog transmission (i.e., canine rabies), but sometimes with spillover  into other species. In the United States, occasional spillover into dogs of rabies virus variants associated with wildlife has occurred. However, since 2004, no rabies case attributable to an indigenously acquired canine rabies virus variant has been reported (1).
Canine rabies virus variants most commonly are imported via unvaccinated dogs from areas where rabies is enzootic, such as Asia, Africa, the Middle East, and parts of Latin America, where canine variants are responsible for most of the 55,000 human rabies deaths estimated worldwide each year (4). In May 2004, an unvaccinated puppy was flown from Puerto Rico to Massachusetts as part of an animal rescue program. The day after arrival, the puppy exhibited neurologic signs, was euthanized, and was subsequently confirmed to have rabies. Six persons were recommended to receive PEP because of potential exposure. In June 2004, an unvaccinated puppy adopted by a U.S. resident in Thailand was confirmed to have rabies by the California Department of Public Health. Of 40 persons interviewed for potential rabies exposure, 12 received PEP. In March 2007, a puppy adopted by a U.S. veterinarian while volunteering in India was confirmed to have rabies by the Alaska Department of Health and Social Services. The puppy was flown in cargo to Seattle, Washington, then adopted by another veterinarian in Juneau, Alaska, where it was flown 7 days after arrival. Of 20 persons interviewed for potential rabies exposure, eight received PEP (5,6). In all three cases, the rabies virus variant was typed as a variant circulating in dogs and terrestrial wildlife in the animal's country of origin (i.e., mongoose and canine rabies virus variants enzootic in Puerto Rico, Thailand, and India, respectively).
This report reiterates the need for education of the public regarding rabies incidence in other countries and preventing rabies exposure. While traveling in areas that are endemic for rabies, travelers should not pet stray animals. In addition, travelers should not adopt stray animals without acquiring a veterinarian's health assessment and ensuring proper animal vaccination for importation. Travelers also should consider their potential for rabies exposure from animals, understand proper wound management, and promptly report animal bites to health-care providers (7). Health information for travelers is available at . cdc.gov/travel/contentyellowbook.aspx.
CDC administers federal importation regulations for dogs. These regulations allow admittance of unvaccinated dogs aged 3 months that have not been vaccinated for rabies also must be confined until vaccinated and for 3 months after vaccination. Upon arrival in the United States, importers should declare animals to federal authorities and comply with those requirements for confinement of unvaccinated puppies.
CDC's regulations were created in the early 1950s to guide persons importing dogs or cats as their personal pets. However, recent trends in dog importations have shown an increase in the numbers of animals being imported for commercial pet trade (8). CDC is working to update current regulations and better address the importation of dogs. In July 2007, the U.S. Department of Health and Human Services posted an advance notice of proposed rulemaking to begin the process of revising CDC's animal importation regulations, including those that apply to dogs and other companion animals.  U.S. animal importation regulations, rabies vaccination requirements for dogs, wildlife rabies surveillance and vaccination programs, and prophylaxis for human exposures all contribute to public health protection from rabies. Continued vigilance and partnership between federal and state agencies, as well as health professionals and pet importers, are vital to decrease the risk for reemergence of canine rabies virus in the United States.  Available at . The individual antigens (diphtheria, tetanus, and pertussis toxoids, filamentous hemagglutinin, pertactin, and poliovirus types 1, 2, and 3) contained in combined DTaP-IPV are identical to the antigens contained in GlaxoSmithKline's DTaP (Infanrix) and DTaP-Hepatitis B-IPV (Pediarix) and have been described previously (3). DTaP-IPV contains no preservatives. DTaP-IPV is administered as an intramuscular injection, preferably into the deltoid region. Two clinical trials conducted in U.S. children aged 4-6 years showed that combined DTaP-IPV and separately administered DTaP and IPV vaccines had comparable safety and reactogenicity profiles, with or without a co-administered second dose of measles, mumps, and rubella (MMR) vaccine (3,4). The immunogenicity of all antigens was similar between the treatment groups, with or without a co-administered second dose of MMR vaccine. In comparative studies, the frequency of solicited local and systemic adverse events and of serious adverse events after administration of DTaP-IPV/Hib was similar to that observed following separately administered DTaP, IPV, and Hib component vaccines (2,3). The immunologic responses after the third dose or the fourth dose of DTaP-IPV-Hib generally were comparable to those following separately administered component vaccines, and have been published (2,3). Immune responses following the first and second doses were not measured.

# Licensure of a Diphtheria and Tetanus Toxoids and Acellular Pertussis

# Indications and Guidance for Use

# Indications and Guidance for Use
DTaP-IPV/Hib is licensed for use in children aged 6 weeks through 4 years. DTaP-IPV/Hib is indicated for use in infants and children at ages 2, 4, 6, and 15-18 months (1). DTaP-IPV/ Hib is not licensed for use in children aged >5 years, and is not indicated for the booster dose at age 4-6 years (2). However, DTaP-IPV/Hib that is inadvertently administered to children aged >5 years should be counted as a valid dose.
For prevention of diphtheria, tetanus, and pertussis, all children are recommended to receive 4 doses of DTaP, at ages 2, 4, 6, and 15-18 months, and a booster dose at age 4-6 years. who received DTaP (Infanrix) and/or DTaP-Hepatitis B-IPV (Pediarix) as the first 3 doses and DTaP (Infanrix) as the fourth dose (1,2). This vaccine should not be administered to children aged 7 years; however, if DTaP-IPV (Kinrix) is inadvertently administered for an earlier dose of the DTaP and/or IPV series, the dose should be counted as valid and does not need to be repeated provided minimum interval requirements have been met (5). Data are limited on the safety and immunogenicity of interchanging DTaP vaccines from different manufacturers (6). ACIP recommends that, whenever feasible, the same manufacturer's DTaP vaccines should be used for each dose in the series; however, vaccination should not be deferred because the type of DTaP previously administered is unavailable or unknown (6).  Although an 8-week interval between doses is preferred, if an accelerated schedule is needed, a minimum interval of 4 weeks should occur between the first and second doses, and the third dose should not be administered before age 14 weeks (4). The fourth dose of DTaP-IPV/Hib may be administered as early as 12 months of age if the clinician feels an opportunity to vaccinate may be missed later and if 6 months has elapsed since the third dose of DTaP-IPV/Hib (1). Data are limited on the safety and immunogenicity of interchanging DTaP vaccines from different manufacturers (2). ACIP recommends that, whenever feasible, the same manufacturer's DTaP product should be used for the pertussis series; however, that vaccination should not be deferred if the specific DTaP vaccine brand previously administered is unavailable or unknown (2).

# Licensure of a Diphtheria and Tetanus Toxoids and
For prevention of poliomyelitis, all children are recommended to receive 4 doses of IPV, at ages 2, 4, 6-18 months, and 4-6 years. DTaP-IPV/Hib may be used for 1 or more doses of the IPV series, including in children who have received 1 or more doses of another licensed IPV vaccine and who also are scheduled to receive DTaP and Hib vaccination. When an accelerated or catch-up schedule is needed, IPV doses may be administered at 4-week intervals and the fourth dose counted as valid if administered as early as age 18 weeks when the proper spacing of prior doses is maintained (1). Therefore, DTaP-IPV/Hib (Pentacel) doses administered at 2, 4, 6, and 12-18 months would provide 4 valid doses of IPV under these circumstances.
The recommended vaccination schedule for Hib-TT vaccines (e.g., Pentacel) consists of a 3-dose primary series at ages 2, 4, and 6 months, and a booster dose at age 12-15 months (1). Intervals between doses of the primary series as short as 1 month are acceptable but not optimal. Minimum intervals for the booster dose vary by age at first vaccination and have been published (5). DTaP-IPV/Hib may be administered at 12 months and counted as a valid Hib-TT dose if the minimum intervals are followed; however, the safety and efficacy of DTaP-IPV/Hib in this circumstance have not been evaluated. DTaP-IPV/Hib may be administered at separate injection sites with other vaccines administered at age 12-18 months, such as hepatitis A, hepatitis B, pneumococcal conjugate, measles, mumps, and rubella (MMR), and varicella vaccines (2).

# Special Considerations
Certain American Indian/Alaska Native (AI/AN) children are at increased risk for Hib disease, particularly in the first 6 months of life (6). Furthermore, the immunologic response to different Hib conjugate vaccine preparations can vary. Compared with other Hib conjugate vaccines (e.g., Hib-TT), administration of polyribosylribitol phosphate-meningococcal outer membrane protein (PRP-OMP)-containing Hib vaccine preparations leads to a more rapid seroconversion to protective antibody concentrations within the first 6 months of life. Although for subsequent doses, PRP-OMP and other Hib conjugate vaccines appear to have equal efficacy, failure to use PRP-OMP vaccines for the first dose has been associated with excess cases of Hib disease in AI/AN infants living in communities where Hib transmission is ongoing and exposure to colonized persons is likely (6,7). In addition, stocking of both PRP-OMP and other Hib conjugate vaccine preparations in the same clinic might lead to inadvertent administration of another vaccine for the first Hib dose. For this reason, clinics that serve predominantly AI/AN children might elect to stock and use only PRP-OMP-containing Hib vaccines (6).
Different lot numbers for the different components of DTaP-IPV/Hib are included on the DTaP-IPV vial and on the Hib powder vial. Providers should record lot numbers separately for the DTaP-IPV and Hib components.

# Notice to Readers

# Get Smart About Antibiotics Week -October 6-10, 2008
October 6-10 is Get Smart About Antibiotics Week. The theme of this observance is "The power to prevent resistance is in your hands."
Inappropriate use of antibiotics to treat upper respiratory infections (URIs) can result in unnecessary risk for adverse events and contribute to the likelihood of antibiotic resistance. Adverse events related to antibiotics (usually aller-  gies or drug intolerance) resulted in an estimated 142,500 emergency department visits annually in the United States during 2004-2006 (1). In addition, inappropriate and excessive antimicrobial use can increase a community's risk for antibiotic-resistant bacterial infections that might lead to severe or prolonged illness, hospitalization, and sometimes death. Educating clinicians and the public regarding appropriate use of antibiotics might help reduce adverse drug events, including antibiotic resistance.
As part of Get Smart About Antibiotics Week, health-care providers are urged to take the following actions to help reduce antibiotic resistance and other adverse drug events:
- Know when antibiotics are indicated, and avoid prescribing antibiotics for URIs such as pharyngitis, bronchitis, sinusitis, and the common cold, which are primarily caused by viruses. - Instead of prescribing antibiotics for URIs, identify and validate patient concerns and recommend symptomatic therapy.

# Additional information about Get Smart About Antibiotics
Week is available at . The course includes a review of the fundamentals of descriptive epidemiology and biostatistics, measures of association, normal and binomial distributions, confounding, statistical tests, stratification, logistic regression models, and computer programs used in epidemiology.
The prerequisite is an introductory course in epidemiology, such as Epidemiology in Action or the International Course in Applied Epidemiology. Tuition will be charged. The application deadline is December 15, 2008, or until all slots have been filled.  Children were considered fully vaccinated if they had 1) received no doses of influenza vaccine before September 1 and received 2 doses from September 1 through the date of interview or January 31 (whichever was earlier), or 2) received 1 or more doses of influenza vaccine before September 1 and received 1 or more doses during September-December.  - Depression was measured using the Patient Health Questionnaire (PHQ-9), a nine-item screening instrument that asks questions about the frequency of symptoms of depression during the preceding 2 weeks. Response categories "not at all," "several days," "more than half the days," and "nearly every day" were given a score ranging from 0 to 3. Depression was defined as a total score of 10 or higher on the PHQ-9. This cut point has been well validated and is commonly used in clinical studies that measure depression with the PHQ-9.  Poverty status was defined using the poverty income ratio (PIR), an index calculated by dividing the family income by a poverty threshold that is based on the size of the family. A PIR of less than 1 was used as the cut point for below the poverty level.  95% confidence interval.

# Poverty status
Percentage