Drotrecogin- (Xigris  ) primarily is used to treat severe sepsis. The drug is a recombinant form of human activated protein C that has antithrombocytic, antiinflammatory, and profibrinolytic properties.#
Tickborne relapsing fever (TBRF) is a bacterial illness caused by certain species of Borrelia and transmitted through brief and painless bites from Ornithodoros ticks (1,2). Illness usually is characterized by intermittent periods of fever, fatigue, and muscle aches. In April 2005, CDC received reports of two cases of severe TBRF associated with acute respiratory distress syndrome (ARDS) in residents of California and Nevada. After a report describing these cases was posted on CDC's Epidemic Information Exchange (Epi-X), health officials in Washington reported a third severe case associated with ARDS. This report summarizes these three cases and the results of the subsequent epidemiologic investigations. The findings indicate that ARDS might occur more frequently in patients with TBRF than previously recognized. Optimal management of TBRF requires both prompt diagnosis and careful observation during the initial phases of treatment.

# Case Reports
Nevada. On February 17, 2005, a previously healthy woman aged 46 years from Washoe County, Nevada, had onset of nonspecific leg pain, which progressed during the next 24 hours to generalized myalgia. She visited a local hospital emergency department (ED), where a viral syndrome was diagnosed. She was treated with intravenous (IV) fluids and pain medication and discharged home. Two days later, she returned to the ED with fever, chills, fatigue, anorexia, nausea, and an episode of syncope. On arrival, she was noted to be tachycardic (130 beats per minute ), tachypneic (24 breaths per minute), and hypotensive (systolic blood pressure: 89 mm Hg) with a temperature of 96.8F (36.0C). A physical examination was otherwise unremarkable. Pulse oximetry on room air indicated an oxygen saturation of 96%. Initial laboratory testing revealed a white blood cell count (WBC) of 11.4  10 3 /L, hemoglobin level of 13 g/dL, platelet count of 66  10 3 /L, and alanine aminotransferase (ALT) of 153 U/L. A chest radiograph revealed a right middle lobe infiltrate, consistent with community-acquired pneumonia.
She was treated with gatifloxacin and transferred to the intensive care unit (ICU). Approximately 10 hours after admission, she was intubated for worsening tachypnea (respiratory rate : 40 breaths per minute). Diffuse bilateral infiltrates were noted on chest radiograph, and an arterial blood gas sample yielded oxygenation of 53 mmHg on 100% inspired oxygen. The patient's antimicrobial treatment was broadened to include vancomycin and doxycycline. The next day, the treating physician was notified that spirochetes were observed during examination of a blood smear obtained when the patient was admitted; the smear had been manually reviewed because of thrombocytopenia. The patient remained intubated for 12 days for what was ultimately determined to be ARDS. During this time, she was administered three additional antimicrobials (ciprofloxacin, tobramycin, and ceftriaxone) and drotrecogin-.- She was discharged after 21 days and recovered completely. The causative organism was identified as Borrelia hermsii by polymerase chain reaction (PCR) performed on a whole blood sample and serologic testing of convalescent-phase serum, both performed at CDC. Although the patient did not recall receiving a tick bite, she did report staying at a resort near South Lake Tahoe (an area known to be highly endemic for TBRF) 5 days before becoming ill.
California. On April 12, 2005, a previously healthy woman aged 43 years from El Dorado County, California, had onset of lethargy and myalgia. She went to a local hospital ED on April 14 with fever, chills, headache, myalgia, and dehydration. She was febrile (100.5F ), tachycardic (138 bpm), mildly tachypneic (16 breaths per minute), and hypotensive (systolic blood pressure: 97 mm Hg). A physical examination was otherwise unremarkable. Pulse oximetry on room air indicated an oxygen saturation of 97%. A chest radiograph was not obtained, but initial blood tests indicated an elevated bilirubin level of 3.6 mg/ dL, aspartate aminotransferase (AST) of 93 U/L, and ALT of 88 U/L. She was treated with acetaminophen and discharged home with instructions to return for reevaluation of blood tests the next day.
The patient returned the next day with headache, sweating, fatigue, and nausea. A physical examination revealed rhonchi; a chest radiograph was obtained and read as normal. She was treated with IV fluids and IV ceftriaxone. Within 1 hour of receiving antibiotics, her pulse increased to 127 bpm, her systolic blood pressure decreased to 85 mm Hg, and pulse oximetry on room air indicated an oxygen saturation of 95%. TBRF was diagnosed by observation of spirochetes in smears of peripheral blood (Figure). The patient was treated with dopamine for hypotension and doxycycline for TBRF and transferred to another medical center. Shortly after arrival, a chest radiograph taken because of worsening respiratory distress demonstrated diffuse bilateral infiltrates. The patient was intubated for respiratory failure (RR: 44 breaths per minute; oxygen saturation of 82% on 100% inspired oxygen via nonrebreather mask) attributed to ARDS. Laboratory testing revealed a WBC of 3.4  10 3 /L, hemoglobin level of 11.4 g/dL, and platelet count of 19  10 3 /L. Platelets and fresh frozen plasma were administered.
The patient remained intubated for 10 days, during which she was administered four different antimicrobials (vancomycin, piperacillin/tazobactam, metronidazole, and doxycycline) and drotrecogin-a. She was discharged after 19 days of hospitalization and eventually recovered from her illness. A blood sample obtained early in illness and cultured at CDC yielded B. hermsii. An environmental investigation was conducted at her home, located 5 miles south of Lake Tahoe and approximately 10 miles from the resort visited by the Nevada patient. An engorged soft tick was found in her bedroom, and removal of house siding revealed multiple rodent nests from which approximately 30 Ornithodoros hermsi ticks were recovered.
Washington. A woman aged 40 years from King County, Washington, visited a hospital ED on September 21, 2004, with myalgia, arthralgia, nausea, vomiting, and headache. She was treated with IV fluids, promethazine, and hydrocodone. Hospital admission was recommended, but she refused. After experiencing a syncopal episode at home, she returned and was noted to be febrile (102 o F ), hypotensive (systolic blood pressure: 100 mm Hg), mildly tachycardic (107 bpm), and hypoxic (oxygen saturation: 92% on 4 L of oxygen). A physical examination was otherwise unremarkable. Her chest radiograph revealed bilateral lower lobe infiltrates. Initial laboratory studies indicated a WBC of 9.5 x 10 3 /L, hematocrit of 33%, platelet count of 49 x 10 3 /L, ALT of 192 U/L, and a D-dimer of 754. She was admitted for presumed community-acquired pneumonia with sepsis and treated empirically with IV cefuroxime and azithromycin. After receiving the cefuroxime, she was transiently hypotensive and became somnolent. She was intubated and transferred to the ICU with a diagnosis of ARDS and worsening mental status.
Because of thrombocytopenia, a peripheral blood smear was examined, revealing spirochetes diagnostic of TBRF. Her transient hypotension was attributed to a Jarisch-Herxheimer reaction (JHR).  She remained intubated for 3 days, was discharged home after 10 days, and eventually recovered from her illness. The most likely site of exposure was a forest cabin in Chelan County, Washington, where she had slept approximately 11 days before illness onset. On inspection, the cabin had evidence of rodent infestation; however, attempts to trap ticks and rodents were unsuccessful.

# Epidemiologic Investigations
To determine the frequency of ARDS among patients with TBRF acquired in the South Lake Tahoe area, case-report forms for all TBRF cases reported to Nevada and California state and local health departments during 1995-2004 were reviewed. Additionally, cases were ascertained by 1) a computerized search of discharge records from Lake Tahoe area hospitals where cases had been diagnosed; 2) interviews with physicians and laboratorians from area hospitals and private practices where cases had been diagnosed; and 3) postings on Epi-X and the Emerging Infections Network.
Including the California and Nevada cases described in this report, 65 cases of TBRF among persons who reported living in or visiting the Lake Tahoe area during the usual incubation period of 2-18 days before illness onset were ascertained. Thirty (46%) were in patients who required hospitalization. Detailed clinical information from medical records was available for 38 (58%) patients. Among these 38 patients, 16 (42%) experienced one or more of the following complications: eight (21%), JHR; six (16%), hypoxia; five (13%), elevated liver enzyme levels; three (8%), arrhythmia or myocarditis; two (5%), azotemia; and two (5%), ARDS.
TBRF cases in Washington state were similarly reviewed by using all case reports submitted to the state health department during 1996-2005. Including the single case described in this report, 46 TBRF cases were reported in Washington during 1996-2005, of which 37 (80%) were in patients who required hospitalization. Comments on case-report forms indicated that five (13%) patients required care in an ICU, three (6%) had JHR, and three (6%) had ARDS. All three ARDS cases occurred after 2001. been described previously (9), and this case occurred in a woman who was pregnant and therefore more susceptible to severe TBRF (10).
Results of this investigation indicate that ARDS might occur more frequently in patients with TBRF than previously recognized and can occur in persons without predisposing conditions. All cases of TBRF-associated ARDS identified in this review occurred after 2001, but further surveillance will be needed to determine whether the risk for ARDS in TBRF is increasing. Increases might be related to changes in medical practice, use of newer antimicrobials, or possibly the emergence of a more virulent strain. All three cases described in this report occurred in women, but no common medical history (e.g., menopausal status, hormone replacement therapy, or oral contraceptive use) was identified. All three patients had received antimicrobial treatment before onset of ARDS; however, whether they had ARDS as a result of JHR or underlying sepsis could not be determined.
The findings in this report are subject to at least two limitations. First, cases were evaluated in only two geographic areas; therefore, results might not be generalizable to the endemic western states. Second, TBRF is not a nationally notifiable disease, and each state has different reporting requirements; therefore, case information is subject to underreporting and ascertainment bias. These methodological differences might have affected the observed rates of hospitalization and classification of ARDS.
Health-care professionals should report suspected TBRF cases to local or state health departments, providing a thorough clinical and exposure history and, as appropriate, samples (i.e., serum or whole blood) for diagnostic testing. The observation of spirochetes in a Wright-or Giemsastained peripheral blood smear collected during a febrile episode is considered diagnostic of TBRF and is not typical of other spirochetal infections (1). Laboratory diagnosis also can be made by culture, serology, or PCR of serum and blood at certain reference laboratories.
TBRF can be prevented by minimizing rodent infestations in homes. Health officials in endemic areas should consider educational measures that increase awareness of potential exposures, demonstrate methods for rodent proofing dwellings, and promote early recognition of cases by health-care professionals (5). These measures are especially important in mountainous resort areas that serve numerous visitors.

# Emergence of Antimicrobial-Resistant Serotype 19A

# Streptococcus pneumoniae -Massachusetts, 2001-2006
Streptococcus pneumoniae (pneumococcus) is a leading cause of otitis, sinusitis, pneumonia, and meningitis worldwide. Treatment of the most serious type of pneumococcal infection, invasive pneumococcal disease (IPD),- is complicated by antimicrobial resistance. Widespread introduction in 2000 of heptavalent pneumococcal conjugate vaccine (PCV7) against serotypes 4, 6B, 9V, 14, 18C, 19F, and 23F resulted in a decline in antimicrobialnonsusceptible IPD in the United States (1,2), including in Massachusetts (3). However, development of antimicrobial resistance in serotypes not covered by PCV7 is a growing concern (1,4). In Massachusetts during 2001-2006, IPD surveillance identified an increased number of cases in children caused by pneumococcal serotypes (most notably 19A) not covered by PCV7 and an associated increase in antimicrobial resistance among these isolates. This report examines these trends and clinical characteristics of Massachusetts patients with antimicrobial-nonsusceptible, non-PCV7-type IPD. The findings indicated that, despite increases in incidence of antimicrobial-nonsusceptible IPD, overall rates of IPD remained stable during 2001-2006. In addition, persons with IPD caused by antimicrobialnonsusceptible S. pneumoniae had clinical outcomes comparable to persons with IPD caused by antimicrobialsusceptible serotypes. Although PCV7 is effective in preventing IPD, these results confirm that antimicrobial resistance among serotypes not covered by PCV7 remains a concern.
On October 1, 2001, the Massachusetts Department of Public Health and the Section of Pediatric Infectious Diseases at Boston University Medical Center initiated statewide laboratory-and population-based surveillance for IPD among children.  For this report, cases of IPD were defined by isolation of pneumococcus from a normally sterile body site (e.g., blood or cerebrospinal, pleural, or joint fluid) in a Massachusetts resident aged <18 years during October 1, 2001-September 30, 2006. Demographic and clinical data were obtained from telephone interviews with primarycare providers or adult caregivers. PCV7 vaccination rates were estimated using CDC's National Immunization Survey.  Serotyping was performed at Boston University Medical Center, using the Quellung reaction with pneumococcal antisera. Susceptibility to five antimicrobials often used in pediatric patients (i.e., amoxicillin, penicillin, ceftriaxone, azithromycin, and trimethoprim-sulfamethoxazole) was determined by E-test (epsilometer test, an agar diffusion method), and interpretations were based on Clinical and Laboratory Standards Institute 2007 guidelines (5). For each antimicrobial agent tested, isolates with either intermediate-level or high-level antimicrobial resistance were considered nonsusceptible to the antimicrobial agent unless otherwise indicated. Population denominators were obtained from 2000-2005 census figures. Mantel-Haenszel chi-square test for trend was used to identify changes in serotype distribution or antimicrobial resistance over time. Chi-square or Fisher's exact tests of proportions were used to compare risk factors and clinical characteristics of disease. Because IPD surveillance did not begin until after introduction of PCV7, no data on pre-PCV7 susceptibility were available for comparison.
PCV7  2). No significant changes were noted in the proportions of IPD caused by other PCV7 or PCV7related serotypes or by non-PCV7 serogroups (Figure 2). Because 19A was the most common serotype isolated during 2005-2006, the antimicrobial susceptibility of 19A isolates was examined further (Table ). The majority of 19A isolates were nonsusceptible to penicillin. During 2001-2006, significant increases were noted in the proportion of 19A isolates that were nonsusceptible to amoxicillin (minimum inhibitory concentration  >2 g/mL), ceftriaxone (MIC >0.5 g/mL), or three or more classes of antimicrobials (Table ). Fourteen (15%) of 94 isolates of 19A were highly resistant to ceftriaxone (MIC >2 g/ml), a first-line antimicrobial used for empiric bacterial meningitis treatment. No significant trends in the antimicrobial resistance of non-19A isolates were noted.
To describe the clinical features of and identify risk factors for infection with ceftriaxone-nonsusceptible serotype 19A, demographic and clinical characteristics of the 14 patients with highly ceftriaxone-resistant 19A IPD were compared with those of 73 patients with ceftriaxonesusceptible 19A IPD and 237 patients with ceftriaxonesusceptible non-19A IPD. The results indicated that patients with highly ceftriaxone-resistant 19A disease did not differ from the other groups with regard to established risk factors for antimicrobial-nonsusceptible pneumococcal disease, including age, sex, race/ethnicity, geographic region, degree of household crowding, or day care exposure. Underlying medical conditions that might predispose to IPD (e.g., sickle cell disease or congenital or acquired immune deficiencies) were not significantly more common among patients with highly ceftriaxone-resistant 19A IPD (three of 14 ) than among patients in the ceftriaxonesusceptible 19A group (nine of 73 ) or the non-19A group (33 of 237 ). In addition, no significant differences among the three groups were detected in the proportion of patients with meningitis, pneumonia, or bacteremia without focus, case-fatality ratios, rates of hospitalization (79% versus 68% and 59%, respectively), or longer hospital stay (64% with >4 days versus 40% and 51%, respectively).  (1,4,7,8). In Massachusetts and in other states, serotype 19A has emerged as the most common cause of IPD, and the proportion of 19A isolates that are nonsusceptible to commonly used antimicrobials is greater than the proportion for other serotypes (1,4). As a member of the same serogroup as the PCV7-type 19F, serotype 19A is considered a PCV7-related serotype. However, PCV7induced antibodies to 19F are not active against serotype 19A (9).  Concern exists that emergence of antimicrobialnonsusceptible non-PCV7-type IPD could erode the success of PCV7 against pneumococcal infections. The limited number of 19A cases restricted the ability of this study to identify risk factors or characteristic clinical features of antimicrobial-nonsusceptible 19A disease. However, the study found no evidence that infections caused by antimicrobial-nonsusceptible serotype 19A had different clinical syndromes or outcomes than infections caused by antimicrobial-susceptible 19A. Despite the lack of continuous surveillance data before PCV7 introduction, the overall stability of IPD incidence in Massachusetts during the study period indicates that the decline in IPD resulting from PCV7 introduction is being maintained (3,6). Furthermore, antimicrobial-nonsusceptible infections have not negated the positive impact of PCV7. Accordingly, vaccination with PCV7 remains a priority in Massachusetts.
Nonetheless, the emergence of antimicrobial-nonsusceptible non-PCV7-type IPD is of concern. Continued surveillance for IPD in Massachusetts will provide data on the clinical impact of antimicrobial-nonsusceptible 19A infection and will be useful in development and monitoring of new pneumococcal vaccines.
The findings in this report support the continued empiric use of combination therapy with vancomycin and cefotaxime or ceftriaxone (the antimicrobials of choice to treat nonsusceptible pneumococci) for children with bacterial meningitis caused by, or possibly caused by, S. pneumoniae, and for critically ill children with nonmeningeal IPD (10). Antimicrobial-resistance data obtained through surveillance will continue to guide empiric treatment regimens for IPD in Massachusetts and provide data that can be used to tailor treatment recommendations to state-specific resistance patterns. State-based surveillance also will help detect trends in the emergence of nonsusceptible non-PCV7 IPD.
The recent development of polymerase chain reaction (PCR)-based serotyping provides the opportunity for state public health laboratories and academic partners to identify IPD isolates by serotype. Serotyping based on the Quellung reaction requires expensive reagents and substantial training and experience to perform reliably. In contrast, PCR-based serotyping can be performed using commercially available reagents and equipment and technical expertise already available in most state public health laboratories.  If applied in other states, these techniques might increase understanding of IPD trends that have occurred nationally since introduction of PCV7.

# 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)
In 1995, highly effective inactivated hepatitis A vaccines were first licensed in the United States for preexposure prophylaxis against hepatitis A virus (HAV) among persons aged >2 years. In 2005, vaccine manufacturers received Food and Drug Administration approval for use of the vaccines in children aged 12-23 months (1).
The Advisory Committee on Immunization Practices (ACIP) issued recommendations for preexposure use of hepatitis A vaccine in 1996, 1999, and 2006 (1). Currently, ACIP recommends hepatitis A vaccination of all children at age 12-23 months, catch-up vaccination of older children in selected areas, and vaccination of persons at increased risk for hepatitis A (e.g., travelers to endemic areas, users of illicit drugs, or men who have sex with men) (1).
For decades, immune globulin (IG) has been recommended for prophylaxis after exposure to HAV (1). IG also has been recommended in addition to hepatitis A vaccine for preexposure prophylaxis for travelers to countries with high or intermediate hepatitis A endemicity who are scheduled to depart <4 weeks after receiving the initial vaccine dose. This report details updated recommendations, made by ACIP in June 2007, for prevention of hepatitis A after exposure to HAV and in departing international travelers (Box) and incorporates existing ACIP recommendations for prevention of hepatitis A (1).

# Rationale and Methods for Updated Recommendations
When administered within 2 weeks of last exposure, IG is 80%-90% effective in preventing clinical hepatitis A. Despite previously available limited data suggesting that hepatitis A vaccine might be efficacious when administered after exposure (2), in the absence of an appropriately

# BOX. Summary of updated recommendations for prevention of hepatitis A after exposure to hepatitis A virus (HAV) and in departing international travelers

# Postexposure prophylaxis
Persons who recently have been exposed to HAV and who previously have not received hepatitis A vaccine should be administered a single dose of single-antigen hepatitis A vaccine or immune globulin (IG) (0.02 mL/kg) as soon as possible.

# International travel
All susceptible persons traveling to or working in countries that have high or intermediate hepatitis A endemicity should be vaccinated or receive IG before departure. Hepatitis A vaccine at the age-appropriate dose is preferred to IG. The first dose of hepatitis A vaccine should be administered as soon as travel is considered.
- One dose of single-antigen hepatitis A vaccine administered at any time before departure can provide adequate protection for most healthy persons. - Older adults, immunocompromised persons, and persons with chronic liver disease or other chronic medical conditions planning to depart to an area in <2 weeks should receive the initial dose of vaccine and also simultaneously can be administered IG (0.02 mL/kg) at a separate anatomic injection site. - Travelers who elect not to receive vaccine, are aged <12 months, or are allergic to a vaccine component should receive a single dose of IG (0.02 mL/kg), which provides effective protection for up to 3 months.

# NOTE:
Previous recommendations remain unchanged regarding 1) settings in which postexposure prophylaxis is indicated, and 2) timing of administration of postexposure prophylaxis.
designed clinical trial comparing the postexposure efficacy of vaccine with that of IG, ACIP continued to recommend IG exclusively for postexposure use (1). Hepatitis A vaccine, if recommended for other reasons, could be given at the same time. ACIP was prompted to revisit these recommendations when findings became available from a randomized, double-blind noninferiority clinical trial comparing the efficacy of hepatitis A vaccine and IG after exposure to HAV (3). The results of this clinical trial were presented to ACIP at its February 2007 meeting. During April-May 2007, the ACIP Hepatitis Vaccines Workgroup considered these results in a series of teleconferences. During these teleconferences, the workgroup also considered the experiences of other countries (e.g., Canada and the United Kingdom) where hepatitis A vaccine has been recommended for postexposure use for >5 years and reviewed data on the immunogenicity of hepatitis A vaccine, the risk for HAV transmission in various settings, and factors known to affect the severity of hepatitis A. Additionally, the workgroup took into account potential advantages of vaccine, recognized disadvantages of IG, and relevance of these data to existing recommendations for use of hepatitis A vaccine and IG in international travelers departing <4 weeks after receiving the first dose of hepatitis A vaccine. The workgroup also considered the likelihood that no additional postexposure efficacy data would become available, because of the difficulties of conducting postexposure efficacy studies of IG and vaccine.
On the basis of this evidence and the expert opinions of workgroup members, other scientists, and feedback from ACIP partner organizations, the ACIP Hepatitis Vaccines Workgroup drafted a revision of the hepatitis A postexposure prophylaxis and travel recommendations. These updated recommendations were deliberated and approved by ACIP at the June 2007 meeting.

# I. Prevention of Hepatitis A After Exposure to HAV
Efficacy of hepatitis A vaccine versus IG. The clinical trial comparing hepatitis A vaccine with IG was conducted among 1,090 persons aged 2-40 years who were contacts of hepatitis A cases and susceptible to HAV infection. The trial compared the efficacy of hepatitis A vaccine and IG in preventing laboratory-confirmed symptomatic hepatitis A (i.e., the primary outcome) when administered <14 days after exposure to HAV (3). The primary outcome occurred among 25 (4.4%) of 568 recipients of hepatitis A vaccine and 17 (3.3%) of 522 IG recipients (relative risk: 1.35; 95% confidence interval  = 0.70-2.67); the prespecified statistical criterion for noninferiority was met. The low frequency of study endpoints among IG and vaccine recipients indicated that both interventions provided good protection. The risk for hepatitis A in the vaccine group was never more than 1.5 percentage points greater than that for the IG group for the primary outcome or any secondary study endpoint. Assuming IG is 90% efficacious, the point estimate for hepatitis A vaccine efficacy relative to IG in preventing clinical hepatitis A was 86% (CI = 73%-93%) (3). This clinical trial suggested that the performance of vaccine, when administered <14 days after exposure, approaches that of IG in healthy children and adults aged <40 years. However, these findings might not be generalizable to all populations and settings. In contrast, years of experience have demonstrated that IG performs well as postexposure prophylaxis in all populations and settings.
Advantages of hepatitis A vaccine. The ability to use hepatitis A vaccine for postexposure prophylaxis provides numerous public health advantages, including the induction of active immunity and longer protection, greater ease of administration, higher acceptability and availability, and a cost per dose that is similar to IG. Also, the greater availability and ease of administration of hepatitis A vaccine might increase the number of persons at risk for infection who receive postexposure prophylaxis.
Risk for HAV transmission in various settings. The risk for transmission of HAV is influenced by host and environmental factors and varies considerably in different settings. For example, without postexposure prophylaxis, secondary attack rates of 15%-30% have been reported in households, with higher rates of transmission occurring from infected young children than from infected adolescents and adults (4)(5)(6). In contrast, attack rates among patrons of food service establishments who have been exposed to HAV-infected food handlers generally are low (7). Indeed, most food handlers with hepatitis A do not transmit HAV to exposed consumers or restaurant patrons (7). Given the wide range of HAV transmission risks in various settings for which postexposure prophylaxis is recommended, magnitude of risk in each situation is an important factor in determining whether to use IG or vaccine.
Factors affecting clinical manifestations of hepatitis A. Older persons and persons with chronic liver disease are more likely to have severe manifestations of hepatitis A. Among older children and adults, infection typically is symptomatic, with jaundice occurring in >70% of patients (8). The case-fatality rate among cases reported through national surveillance reaches a high of 1.8% among persons aged >60 years, and fulminant hepatitis has been reported more frequently among older patients with hepatitis A (9). Although

# MMWR October 19, 2007
not at increased risk for HAV infection, persons with chronic liver disease also are at increased risk for fulminant hepatitis A (10). Because of the frequency of severe consequences, preventing hepatitis A among exposed older persons and persons with chronic liver disease is particularly vital. The performance of hepatitis A vaccine as postexposure prophylaxis in these groups was not assessed in the recent clinical trial and remains unknown. In contrast, IG has been recommended and used successfully for many years in these groups and in the general population. These recommendations replace previous ACIP recommendations for postexposure prophylaxis with IG (1), incorporating new recommendations for use of single-antigen hepatitis A vaccine and updated recommendations for use of IG postexposure. These recommendations also incorporate and consolidate existing recommendations regarding recommended settings for which postexposure prophylaxis is indicated, including close personal contact with a person with hepatitis A and selected circumstances in which hepatitis A is recognized in a food handler or in a child care center (1). Also, the updated recommendations leave unchanged the recommendation that postexposure prophylaxis (using vaccine or IG) should be administered as soon as possible. No information exists regarding the efficacy of IG or vaccine if administered >2 weeks after exposure (1). The updated recommendations for use of hepatitis A vaccine alone for postexposure prophylaxis do not apply to the combination hepatitis A/hepatitis B vaccine because no data exist regarding the performance of the combination vaccine for prophylaxis after exposure to HAV. The concentration of HAV antigen in the currently available combination vaccine formulation is half that included in the single-antigen vaccine available from the same manufacturer (1).
Recommendations for postexposure prophylaxis with IG or hepatitis A vaccine. Persons who recently have been exposed to HAV and who previously have not received hepatitis A vaccine should be administered a single dose of singleantigen vaccine or IG (0.02 mL/kg) as soon as possible. Information about the relative efficacy of vaccine compared with IG postexposure is limited, and no data are available for persons aged >40 years or those with underlying medical conditions. Therefore, decisions to use vaccine or IG should take into account patient characteristics associated with more severe manifestations of hepatitis A, including older age and chronic liver disease.
For healthy persons aged 12 months-40 years, singleantigen hepatitis A vaccine at the age-appropriate dose is preferred to IG because of vaccine advantages that include long-term protection and ease of administration. For persons aged >40 years, IG is preferred because of the absence of information regarding vaccine performance and the more severe manifestations of hepatitis A in this age group; vaccine can be used if IG cannot be obtained. The magnitude of the risk for HAV transmission from the exposure should be considered in decisions to use IG or vaccine. IG should be used for children aged <12 months, immunocompromised persons, persons who have had chronic liver disease diagnosed, and persons for whom vaccine is contraindicated.
Persons administered IG for whom hepatitis A vaccine also is recommended for other reasons should receive a dose of vaccine simultaneously with IG. For persons who receive vaccine, the second dose should be administered according to the licensed schedule to complete the series. The efficacy of IG or vaccine when administered >2 weeks after exposure has not been established.
Close personal contact. Hepatitis A vaccine or IG should be administered to all previously unvaccinated household and sexual contacts of persons with serologically confirmed hepatitis A. In addition, persons who have shared illicit drugs with a person who has serologically confirmed hepatitis A should receive hepatitis A vaccine, or IG and hepatitis A vaccine simultaneously. Consideration also should be given to providing IG or hepatitis A vaccine to persons with other types of ongoing, close personal contact (e.g., regular babysitting) with a person with hepatitis A.
Child care centers. Hepatitis A vaccine or IG should be administered to all previously unvaccinated staff members and attendees of child care centers or homes if 1) one or more cases of hepatitis A are recognized in children or employees or 2) cases are recognized in two or more households of center attendees. In centers that do not provide care to children who wear diapers, hepatitis A vaccine or IG need be administered only to classroom contacts of the index patient. When an outbreak occurs (i.e., hepatitis A cases in three or more families), hepatitis A vaccine or IG also should be considered for members of households that have children (center attendees) in diapers.
Common-source exposure. If a food handler receives a diagnosis of hepatitis A, vaccine or IG should be administered to other food handlers at the same establishment. Because common-source transmission to patrons is unlikely, hepatitis A vaccine or IG administration to patrons typically is not indicated but may be considered if 1) during the time when the food handler was likely to be infectious, the food handler both directly handled uncooked or cooked foods and had diarrhea or poor hygienic practices and 2) patrons can be identified and treated <2 weeks after the exposure. In settings in which repeated exposures to HAV might have occurred (e.g., institutional cafeterias), stronger consideration of hepatitis A vaccine or IG use could be warranted. In the event of a common-source outbreak, postexposure prophylaxis should not be provided to exposed persons after cases have begun to occur because the 2-week period after exposure during which IG or hepatitis A vaccine is known to be effective will have been exceeded.
Schools, hospitals, and work settings. Hepatitis A postexposure prophylaxis is not routinely indicated when a single case occurs in an elementary or secondary school or an office or other work setting, and the source of infection is outside the school or work setting. Similarly, when a person who has hepatitis A is admitted to a hospital, staff members should not routinely be administered hepatitis A postexposure prophylaxis; instead, careful hygienic practices should be emphasized. Hepatitis A vaccine or IG should be administered to persons who have close contact with index patients if an epidemiologic investigation indicates HAV transmission has occurred among students in a school or among patients or between patients and staff members in a hospital.

# II. Prevention of Hepatitis A Before International Travel
Hepatitis A vaccination is recommended to prevent hepatitis A among travelers to countries with high or intermediate hepatitis A endemicity. Previously, however, because few data were available regarding the immunogenicity of hepatitis A vaccine during the 4 weeks immediately following administration of the first dose, ACIP recommended that, for optimal protection, persons traveling to an area where the risk for transmission was high <4 weeks after the initial vaccine dose also could be administered IG (1). In June 2007, ACIP concluded that if hepatitis A vaccine alone can be recommended for prophylaxis after exposure to HAV, vaccine also should be recommended for healthy international travelers aged <40 years regardless of their scheduled dates for departure. Similar to updated recommendations for postexposure prophylaxis, ACIP recognized that, for certain international travelers (e.g., older adults or those with underlying medical conditions), the performance of vaccine alone is unknown and clinical manifestations of hepatitis A tend to be more severe. Hence, under the updated recommendations for international travelers, for optimal protection, IG can be considered in addition to vaccine for older adults, immunocompromised persons, and persons with chronic liver disease or other chronic medical conditions who are traveling to an area within 2 weeks.
The following recommendation updates recommendations for prevention of hepatitis A among travelers departing in <4 weeks to areas where prophylaxis is recommended and consolidates other recommendations for prevention of hepatitis A among international travelers (1). These recommendations replace previous ACIP recommendations for preexposure protection against hepatitis A for travelers (1).
Recommendations for preexposure protection against hepatitis A for travelers. All susceptible persons traveling to or working in countries that have high or intermediate hepatitis A endemicity are at increased risk for HAV infection and should be vaccinated or receive IG before departure.- Hepatitis A vaccination at the age-appropriate dose is preferred to IG. Data are not available regarding the risk for hepatitis A for persons traveling to certain areas of the Caribbean, although prophylaxis should be considered if travel to areas with questionable sanitation is anticipated. Travelers to Australia, Canada, western Europe, Japan, or New Zealand (i.e., countries in which endemicity is low) are at no greater risk for infection than persons living or traveling in the United States.
The first dose of hepatitis A vaccine should be administered as soon as travel is considered. Based on limited data indicating equivalent postexposure efficacy of IG and vaccine among healthy persons aged <40 years, 1 dose of single-antigen hepatitis A vaccine administered at any time before departure can provide adequate protection for most healthy persons. However, no data are available for other populations or other hepatitis A vaccine formulations (e.g., Twinrix  ). For optimal protection, older adults, immunocompromised persons, and persons with chronic liver disease or other chronic medical conditions planning to depart to an area in <2 weeks should receive the initial dose of vaccine and also simultaneously can be administered IG (0.02 mL/kg) at a separate anatomic injection site. Completion of the vaccine series according to the licensed schedule is necessary for long-term protection.
Travelers who elect not to receive vaccine, are aged 2 months should be administered IG at 0.06 mL/kg; administration must be repeated if the travel period is >5 months. The full statement containing licensed vaccination schedule and recommended dose of IG and vaccine has been published previously (1).  Conference attendees agreed that undergraduate public health education can help produce an educated citizenry that is better prepared to cope with public health challenges ranging from acquired immunodeficiency syndrome to aging, avian influenza, and health-care costs. Conference working groups recommended that two introductory courses, Public Health 101 and Epidemiology 101, be offered by all U.S. colleges and universities to fulfill undergraduate social science and science distribution requirements, respectively. The groups further recommended that high-quality minors in public health should be developed, with core courses, experiencebased learning, and focus areas such as global health. The full recommendations from the conference have been published online by CCAS at .
The modern era of undergraduate public health education began at Johns Hopkins University in the mid-1970s, when a public health major was approved through the School of Arts and Sciences in collaboration with what was then the School of Hygiene and Public Health. After slow growth in the 1980s, interest in undergraduate public health education grew rapidly in the 1990s. By the end of the 20th century, a substantial number of schools of public health were experimenting with undergraduate courses, minors, and majors. Programs in public health also were revising professionally focused curricula and developing broader approaches to undergraduate public health education (2,3).
Recent surveys indicate that the majority of the approximately 40 accredited public health schools (ASPH, unpublished data, 2006) and approximately 60 accredited public health programs (Association for Prevention Teaching and Research, unpublished data, 2006) offer undergraduate courses in public health. However, public health courses are offered rarely among the 1,900 colleges and universities that have no public health schools or programs yet might choose to include public health in their arts and sciences curricula.
The conference working groups recommended that Public Health 101 and Epidemiology 101 be designed to fit within the broadest possible array of arts and science In addition, 1,489 dead corvids and 435 other dead birds with WNV infection have been reported in 34 states and New York City during 2007. WNV infections have been reported in horses in 31 states, in three canines in Idaho and Oregon, in 26 squirrels in California and Oregon, and in three unidentified animal species in Idaho and Montana. WNV seroconversions have been reported in 637 sentinel chicken flocks in 11 states (Arizona, Arkansas, California, Delaware, Florida, Iowa, North Carolina, North Dakota, Oregon, Utah, and Virginia) and Puerto Rico. A total of 7,208 WNV-positive mosquito pools have been reported from 36 states, the District of Columbia, and New York City.
Additional information about national WNV activity is available from CDC at / westnile/index.htm and at .

# Notice to Readers

# Recommendations for Public Health Curriculum -Consensus Conference on Undergraduate Public Health Education, November 2006
The Institute of Medicine of the National Academies has recommended that all undergraduates have access to education in public health (1) Methods for integrating recommendations from the conference into the nation's long-term strategy for public health also were discussed. These included 1) websites to provide information on undergraduate public health and share curriculum materials, 2) faculty development measures to assist colleges and universities in developing new introductory public health courses, 3) encouragement of applicants by health professions education and graduate public health degree programs to enroll in introductory undergraduate public health courses, 4) continued discussion of approaches for developing minors in public health and global health in institutions with and without schools or programs in public health, and 5) participation by public-health practitioners in experiential or service-learning and other components of undergraduate education.

# Weekly

# Changes for October 2007-September 2008
Age-Based Schedule (Figure 1) - The yellow bar for varicella vaccine has been extended through all age groups, indicating that the vaccine is recommended for all adults without evidence of immunity to varicella. - Zoster vaccine has been added, with a yellow bar indicating that the vaccine is recommended for persons aged >60 years. Medical/Other Indications Schedule (Figure 2)
- The title has been changed to "Vaccines that might be indicated for adults based on medical and other indications," indicating that not all of the vaccines are recommended based on medical indications. - The word "contraindicated" has been added to the red bars and removed from the legend. - The "immunocompromising conditions" column heading has been shortened by removing the list of conditions. - The "human immunodeficiency virus (HIV) infection" column has been moved next to the "immunocompromising conditions" column. - The HIV column has been split into CD4+ T lymphocyte counts of 200 cells/L. - The indication "recipients of clotting factor concentrates" has been removed from the column heading "chronic liver disease" because only one vaccine has this recommendation. The indication remains in the hepatitis A vaccine footnote. - The varicella vaccine yellow bar has been extended to include persons infected with HIV who have CD4+ T lymphocyte counts of >200 cells/L (1).
- The influenza vaccine yellow bar for "health-care personnel" indicates that health-care personnel can receive either trivalent inactivated influenza vaccine (TIV) or live, attenuated influenza vaccine (LAIV). - The yellow bar for influenza vaccine has been extended to include persons in the "asplenia" risk group. - The bar for meningococcal vaccine has been revised to indicate that 1 or more doses might be indicated. - Zoster vaccine has been added to the schedule with a yellow bar to indicate that the vaccine is recommended for all indications except pregnancy, immunocompromising conditions, and HIV. A red bar, indicating a contraindication, has been inserted for pregnancy, immunocompromising conditions, and HIV infection with a CD4+ T lymphocyte count of <200 cells/L.

# Footnotes (Figures 1 and 2)
- Text for vaccine contraindications in pregnancy has been removed from the footnotes of human papillomavirus (HPV) (#2); measles, mumps, rubella (MMR) (#3); and varicella (#4) to be consistent with the intent of the footnotes to summarize the indications for vaccine use. Pregnancy contraindications are indicated with a red bar. - The HPV footnote (#2) has been revised to clarify evidence of prior infection, clarify that HPV vaccine is not specifically indicated based on medical conditions, and indicate that efficacy and immunogenicity might be lower in persons with certain medical conditions. - The varicella footnote (#4) has been revised to clarify that birth before 1980 for immunocompromised persons is not evidence of immunity and to add a requirement for evidence of immunity. - The pneumococcal polysaccharide vaccine (PPV) footnote (#6) has been revised by adding chronic alcoholism and cerebrospinal fluid leaks and deleting the immunocompromising conditions. - The hepatitis B footnote (#9) has been revised by removing persons who receive clotting factor concentrates as a risk group and by clarifying the special formulations dose. - The meningococcal vaccine footnote (#10) has been revised to clarify that persons who remain at increased risk for infection might be indicated for revaccination. - A footnote (#11) has been added to reflect ACIP recommendations for herpes zoster vaccination for persons aged >60 years. - A footnote (#13) has been added to provide a reference for vaccines in persons with immunocompromising conditions. Reference 1. CDC. Prevention of varicella: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR 2007; 56(No. RR-4).
The Recommended Adult Immunization Schedule has been approved by the Advisory Committee on Immunization Practices, the American Academy of Family Physicians, the American College of Obstetricians and Gynecologists, and the American College of Physicians. The standard MMWR footnote format has been modified for publication of this schedule. 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.

# 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.

# 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 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 healthcare 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 on completion or termination of pregnancy and before discharge from the health-care facility.

# 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 laboratoryconfirmed 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.

# 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 ); 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.

# HIV infection

# Q-4 MMWR QuickGuide October 19, 2007
Occupational indications: health-care personnel and employees of long-term-care and assisted-living facilities.
Other indications: residents of nursing homes and other long-termcare 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.

# 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 ); 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.

# 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.

# 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 ) 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.

# 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 one 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 / 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 day care facilities for persons with developmental disabilities.
Special formulation indications: for adult patients receiving hemodialysis and other immunocompromised adults, 1 dose of 40 g/mL (Recombivax HB  ) or 2 doses of 20 g/mL (Engerix-B  ), administered simultaneously.

# 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 ), 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).

# 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.

# 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.

# Immunocompromising conditions
Inactivated vaccines generally are acceptable (e.g., pneumococcal, meningococcal, and influenza ) and live vaccines generally are avoided in persons with immune deficiencies or immune suppressive conditions. Information on specific conditions is available at .
This schedule indicates the recommended age groups and medical indications for routine administration of currently licensed vaccines for persons aged >19 years, as of October 1, 2007. Licensed combination vaccines may be used whenever any components of the combination are indicated and when the vaccine's other components are not contraindicated. For detailed recommendations on all vaccines, including those used primarily for travelers or those issued during the year, consult the manufacturers' package inserts and the complete statements from the Advisory Committee on Immunization Practices (available at ).
Report all clinically significant postvaccination reactions to the Vaccine Adverse Event Reporting System (VAERS). Reporting forms and instructions on filing a VAERS report are available at  or by telephone, 800-822-7967.

# Information on how to file a Vaccine Injury Compensation