Routine infant immunization with PCV7 since 2000 has decreased rates of IPD in young children markedly, but IPD from non-PCV7 serotypes, - Cases per 100,000 population. A case of IPD was defined as isolation of Streptococcus pneumoniae from a normally sterile body site (primarily blood or cerebrospinal fluid) in a resident of an ABCs surveillance area. Sites include Connecticut, Minnesota, and New Mexico, and selected counties in California,#
Invasive pneumococcal disease (IPD), caused by Streptococcus pneumoniae (pneumococcus), remains a leading cause of serious illness in children and adults worldwide (1). After routine infant immunization with a 7-valent pneumococcal conjugate vaccine (PCV7) began in 2000, IPD among children aged <5 years in the United States decreased by 76%; however, IPD from non-PCV7 serotypes, particularly 19A, has increased (2). In February 2010, the Advisory Committee on Immunization Practices (ACIP) issued recommendations for use of a newly licensed 13-valent pneumococcal conjugate vaccine (PCV13) (3). PCV13 contains the seven serotypes in PCV7 (4, 6B, 9V, 14, 18C, 19F, and 23F) and six additional serotypes (1, 3, 5, 6A, 7F, and 19A). To characterize the potentially vaccinepreventable IPD burden among children aged <5 years in the United States, CDC and investigators analyzed 2007 data from Active Bacterial Core surveillance (ABCs). This report summarizes the results of that analysis, which found that among 427 IPD cases with known serotype in children aged <5 years, 274 (64%) were caused by serotypes contained in PCV13. In 2007, an estimated 4,600 cases of IPD occurred in children in this age group in the United States, including approximately 2,900 cases caused by serotypes covered in PCV13 (versus 70 cases caused by PCV7 serotypes). PCV13 use has the potential to further reduce IPD in the United States. Post-licensure monitoring will help characterize the effectiveness of PCV13 in different populations and track the potential changes in disease burden caused by non-PCV13 serotypes.
ABCs- of the Emerging Infections Program (EIP) Network is a collaboration between CDC and 10 selected sites. ABCs conducts population-and laboratory-based active surveillance. During 2006 and 2007, IPD surveillance was conducted in Connecticut, Minnesota, and New Mexico, and selected counties in California, Colorado, Georgia, Maryland, New York, Oregon, and Tennessee. In 2007, the total catchment population of children aged <5 years for these 10 sites was 2.1 million. A case of IPD was defined as isolation of S. pneumoniae from a normally sterile body site (primarily blood or cerebrospinal fluid) in a resident of an ABCs area. Pneumococcal isolates were serotyped at CDC and reference laboratories. Serotype information was analyzed by vaccine serotype group (Table 1). Age-, race-and vaccine serotype-specific rates of IPD were calculated using observed IPD cases in the 2007 ABCs data as the numerator and U.S. Census Bureau projections of the 2007 population of ABCs sites as the denominator. To estimate the incidence and total number of IPD cases in the United States in 2007, rates were standardized to the entire U.S. population, adjusting for small differences between age and race distributions of ABCs areas and the U.S. population.
Investigators reviewed medical records to identify children aged 24-59 months with underlying medical conditions who are recommended by ACIP to receive the 23-valent pneumococcal polysaccharide vaccine (PPSV23) (1). Characteristics of these high-risk children and healthy children were compared by chi-square test; data from 2006 and 2007 were summed because of the small number of IPD cases with underlying medical conditions among persons in this age group.
In 2007, a total of 493 children aged <5 years (<60 months) with IPD were identified in the ABCs population (Table 2), and information on the serotype of the pneumococcal isolate was available for 427 (87%) of those children. Among the 427, the group aged <12 months accounted for 36% of all cases, and the 12-23 months group accounted for 29%. Overall rates were highest in children aged <12 months and 12-23 months (40.5 and 31.2 cases per 100,000 population, respectively); among children aged 24-59 months, rates of all IPD decreased with each additional year of age. Information on race was available for 378 (89%) cases for which serotype information was available. Among children aged <5 years, rates of overall IPD in black children (35.8 cases per 100,000) and children of other races (30.7 cases per 100,000) were approximately twofold and 1.7fold higher, respectively, than rates for white children (18.4 per 100,000). Among the 427 IPD cases with known serotype in children aged <5 years, 274 (64%) were caused by serotypes contained in PCV13. Of these 274 cases, 260 (95%) were caused by three of the six additional serotypes (3, 7F, and 19A) that are not included in PCV7; overall, 180 (42%) of the 427 were caused by serotype 19A. Within each 1-year age group, the proportions of all IPD cases caused by serotypes covered by PCV13 were relatively similar, ranging from 59% to 71%. The proportions of all IPD cases caused by the 13 serotypes were comparable in black children (61%), children of other races (62%), and white children (67%).
Information on hospitalization and clinical outcome was available for 99% of serotyped IPD cases. Among 272 children with IPD caused by serotypes covered by PCV13 for whom hospitalization status, clinical presentation, and outcome were known, 168 (62%) were hospitalized, and four (2%) died; 101 (37%) had bacteremia without confirmed source, 24 (9%) had meningitis, and 115 (42%) had pneumonia with bacteremia.
Based on the 2007 rate of IPD in children aged <5 years (22 cases per 100,000), an estimated 4,600 cases of IPD occurred in this age group in the United States. Included among those cases were an estimated 70 cases caused by serotypes covered in PCV7 and 2,900 cases caused by serotypes covered in PCV13.
During 2006-2007, a total of 301 IPD cases with a known serotype occurred among children aged 24-59 months; 31 cases (10%) occurred in a child at high risk recommended for vaccination with PPSV23 (1). Of these 31 cases, the 11 serotypes included in PPSV23 but not in PCV13 (Table 1) accounted for four cases (13%), serotypes covered in PCV13 accounted for 13 cases (42%), and the remaining 14 cases (45%) were caused by serotypes not covered in either vaccine. PCV13 serotypes accounted for a smaller proportion of cases among children with underlying medical conditions than among healthy children aged 24-59 months (42%  versus 65% ; p = 0.01).
PCV7 PCV13 PPSV23 4 X X X 6B X X X 9V X X X 14 X X X 18C X X X 19F X X X 23F X X X 1 X X 3 X X 5 X X 6A X 7F X X 19A X X 2 X 8 X 9N X 10A X 11A X 12F X 15B X 17F X 20 X 22F X 33F X *
The 13-valent pneumococcal conjugate vaccine (PCV13) includes the seven serotypes in the 7-valent vaccine (PCV7) and six additional serotypes. The 23-valent pneumococcal polysaccharide vaccine (PPSV23) includes 12 of the serotypes included in PCV13 (it does not include serotype 6A) and 11 additional serotypes.
predominantly serotype 19A, has increased and partially offset these reductions (2,4). Overall, rates of IPD have remained stable at 22-25 cases per 100,000 since 2002 (2,4). Based on the findings in this report, the use of PCV13 in the routine immunization schedule has the potential to further reduce IPD caused by the six additional serotypes (1, 3, 5, 6A, 7F, or 19A) among children aged <5 years. PPSV23 has been available for use in adults aged 65 years and persons aged 2 years with certain underlying medical conditions since 1983 (1). In this analysis, approximately 42% of IPD cases among children aged 24-59 months with underlying medical conditions were caused by serotypes covered in PCV13; an additional 13% of cases were caused by serotypes not covered in PCV13 but included in PPSV23. The role for PPSV23 in high-risk children might become clearer when more data are available on disease burden and serotype distribution after routine use of PCV13.
Based on available safety, immunogenicity and disease burden data, ACIP also recommends that a single supplemental PCV13 dose be given to healthy children aged 14-59 months and to children with underlying medical conditions up to age 71 months who already have completed a schedule of PCV7 (3). In one study, a single dose of PCV13 in children aged 12 months who had received 3 previous doses of PCV7 induced an antibody response comparable to the 3-dose infant PCV13 series, and the safety profile of this supplemental dose was comparable to that after a fourth dose of PCV13 (5). Although rates of IPD are relatively low in these older children, ACIP also considered the emergence of multidrug-resistant serotype 19A strains causing meningitis and other severe invasive infections (6,7) and the substantial burden of noninvasive pneumococcal disease as additional factors in making the recommendation. Cost-effectiveness evaluations suggest that supplemental PCV13 vaccination appears comparable in cost effectiveness to other accepted interventions (CDC, unpublished data, 2009). After PCV7 was introduced, rates of IPD caused by the seven serotypes covered in the vaccine also decreased substantially among unvaccinated children and adults. This indirect (or herd) effect resulted from reduced nasopharyngeal carriage of pneumococcus in vaccinated children and reduced transmission from children to unvaccinated children and adults (8). Immunization of children with PCV13 also is anticipated to have herd effects among adults. For example, as of 2007, serotype 19A had emerged as the most common cause of IPD in all age groups after PCV7 introduction (CDC, unpublished data, 2009). Colonization and disease caused by serotype 19A have a similar epidemiological pattern to those caused by PCV7 serotypes, and some degree of herd effects in the population might be expected. In contrast, some of the other new serotypes in PCV13 might have different epidemiologic characteristics (9). In particular, serotypes 1 and 5 are rarely found in the nasopharynx, so the potential herd effects of PCV13 vaccination on disease caused by these serotypes is uncertain. In the United States, however, serotypes 1 and 5 are relatively uncommon causes of IPD.
Although rates of pneumonia hospitalizations decreased after PCV7 introduction among children aged <2 years (10), the potential effects of PCV13 on noninvasive disease, such as nonbacteremic pneumonia and otitis media, are difficult to evaluate because of lack of standard case definitions, sensitive and specific diagnostic methods, and routine surveillance for these conditions. Information on these noninvasive pneumococcal diseases is not available in the ABCs dataset. Because PCV13 was licensed on the basis of immunogenicity studies rather than clinical efficacy trials, post-licensure monitoring is important to characterize On February 24, 2010, a 13-valent pneumococcal conjugate vaccine (PCV13 ) was licensed by the Food and Drug Administration (FDA) for prevention of invasive pneumococcal disease (IPD) caused by the 13 pneumococcal serotypes covered by the vaccine and for prevention of otitis media caused by serotypes in the 7-valent pneumococcal conjugate vaccine formulation (PCV7 ). PCV13 is approved for use among children aged 6 weeks-71 months and succeeds PCV7, which was licensed by FDA in 2000. The Pneumococcal Vaccines Work Group of the Advisory Committee on Immunization Practices (ACIP) reviewed available data on the immunogenicity, safety, and costeffectiveness of PCV13, and on estimates of the vaccine-preventable pneumococcal disease burden. The working group then presented policy options for consideration of the full ACIP. This report summarizes recommendations approved by ACIP on February 24, 2010, for 1) routine vaccination of all children aged 2-59 months with PCV13, 2) vaccination with PCV13 of children aged 60-71 months with underlying medical conditions that increase their risk for pneumococcal disease or complications, and 3) PCV13 vaccination of children who previously received 1 or more doses of PCV7 (1). CDC guidance for vaccination providers regarding transition from PCV7 to the PCV13 immunization program also is included.

# Prevnar 13 Licensure
Vaccine formulation. PCV13 contains polysaccharides of the capsular antigens of Streptococcus pneumoniae serotypes 1, 3, 4, 5, 6A, 6B, 7F, 9V, 14, 18C, 19A, 19F, and 23F, individually conjugated to a nontoxic diphtheria CRM 197 (CRM, crossreactive material) carrier protein. A 0.5-mL PCV13 dose contains approximately 2 g of polysaccharide from each of 12 serotypes and approximately 4 g of polysaccharide from serotype 6B; the total concentration of CRM 197 is approximately 34 g. The vaccine contains 0.125 mg of aluminum as aluminum phosphate adjuvant and no thimerosal preservative. PCV13 is administered intramuscularly and is available in single-dose, prefilled syringes that do not contain latex (2).
Immunogenicity profile. The immunogenicity of PCV13 was evaluated in a randomized, doubleblind, active-controlled trial in which 663 U.S. infants received at least 1 dose of PCV13 or PCV7 (3). To compare PCV13 antibody responses with those for PCV7, criteria for noninferior immunogenicity after 3 and 4 doses of PCV13 (pneumococcal immunoglobulin G  antibody concentrations measured by enzyme immunoassay) were defined for the seven serotypes common to PCV7 and PCV13 (4, 6B, 9V, 14, 18C, 19F, and 23F) and for the six additional serotypes in PCV13 (serotypes 1, 3, 5, 6A, 7F, and 19A). Functional antibody responses were measured by opsonophagocytosis assay (OPA) in a subset of the study population. Evaluation of these immunologic parameters indicated that PCV13 induced levels of antibodies that were comparable to those induced by PCV7 and shown to be protective against IPD (3).
Among infants receiving the 3-dose primary series, responses to three PCV13 serotypes (the shared serotypes 6B and 9V, and new serotype 3) did not meet the prespecified, primary endpoint criterion (percentage of subjects achieving an IgG seroresponse of 0.35 g/ mL 1 month after the third dose); however, detectable OPA antibodies to each of these three serotypes indicated the presence of functional antibodies (3). The percentages of subjects with an OPA titer 1:8 were similar for the seven common serotypes among PCV13 recipients (range: 90%-100%) and PCV7 recipients (range: 93%-100%); the proportion of PCV13 recipients with an OPA titer 1:8 was >90% for all of the 13 serotypes (3).
After the fourth dose, the IgG geometric mean concentrations (GMCs) were comparable for 12 of the 13 serotypes; the noninferiority criterion was not met for serotype 3. However, measurable OPA titers were present for all serotypes after the fourth dose; the percentage of PCV13 recipients with an OPA titer 1:8 ranged from 97% to 100% for the 13 serotypes and was 98% for serotype 3 (3).

# Licensure of a 13-Valent Pneumococcal Conjugate Vaccine (PCV13) and Recommendations for Use Among Children -Advisory Committee on Immunization Practices (ACIP), 2010
A schedule of 3 doses of PCV7 followed by 1 dose of PCV13 resulted in somewhat lower IgG GMCs for the six additional serotypes compared with a 4-dose PCV13 series. However, the OPA responses after the fourth dose were comparable for the two groups, and the clinical relevance of these lower antibody responses is not known. The single dose of PCV13 among children aged 12 months who had received 3 doses of PCV7 elicited IgG immune responses to the six additional serotypes that were comparable to those after a 3-dose infant PCV13 series (3).
Safety profile. The safety of PCV13 was assessed in 13 clinical trials in which 4,729 healthy infants and toddlers were administered at least 1 dose of PCV13 and 2,760 children received at least 1 dose of PCV7, concomitantly with other routine pediatric vaccines. The most commonly reported (more than 20% of subjects) solicited adverse reactions that occurred within 7 days after each dose of PCV13 were injection-site reactions, fever, decreased appetite, irritability, and increased or decreased sleep (2). The incidence and severity of solicited local reactions at the injection site (pain/tenderness, erythema, and induration/ swelling) and solicited systemic reactions (irritability, drowsiness/increased sleep, decreased appetite, fever, and restless sleep/decreased sleep) were similar in the PCV13 and PCV7 groups. These data suggest that the safety profiles of PCV13 and PCV7 are comparable (2); CDC will conduct postlicensure monitoring for adverse events, and the manufacturer will conduct a Phase IV study.
Supportive data for safety outcomes were provided by a catch-up study among 354 children aged 7-71 months who received at least 1 dose of PCV13. In addition, an open label study was conducted among 284 healthy U.S. children aged 15-59 months who had previously received 3 or 4 doses of PCV7 (2). Among these children, the frequency and severity of solicited local reactions and systemic adverse reactions after 1 dose of PCV13 were comparable to those among children receiving their fourth dose of PCV13 (2).

# Indications and Guidance for Use
ACIP recommends PCV13 for all children aged 2-59 months. ACIP also recommends PCV13 for children aged 60-71 months with underlying medical conditions that increase their risk for pneumococcal disease or complications (Table 1).
No previous PCV7/PCV13 vaccination. The ACIP recommendation for routine vaccination with PCV13 and the immunization schedules for infants and toddlers through age 59 months who have not received any previous PCV7 or PCV13 doses are the same as those previously published for PCV7 (4,5). PCV13 is recommended as a 4-dose series at ages 2, 4, 6, and 12-15 months. Infants receiving their first dose at age 6 months should receive 3 doses of PCV13 at intervals of approximately 8 weeks (the minimum interval is 4 weeks). The fourth dose is recommended at age 12-15 months, and at least 8 weeks after the third dose (Table 2).
Children aged 7-59 months who have not been vaccinated with PCV7 or PCV13 previously should receive 1 to 3 doses of PCV13, depending on their age at the time when vaccination begins and whether underlying medical conditions are present (Table 2). Children aged 24-71 months with chronic medical conditions that increase their risk for pneumococcal disease should receive 2 doses of PCV13. Interruption of the vaccination schedule does not require reinstitution of the entire series or the addition of extra doses.
Incomplete PCV7/ PCV13 vaccination. Infants and children who have received 1 or more doses of PCV7 should complete the immunization series with PCV13 (Table 3). Children aged 12-23 months who have received 3 doses of PCV7 before age 12 months are recommended to receive 1 dose of PCV13, given at least 8 weeks after the last dose of PCV7. No additional PCV13 doses are recommended for children aged 12-23 months who received 2 or 3 doses of PCV7 before age 12 months and at least 1 dose of PCV13 at age 12 months.
Similar to the previous ACIP recommendation for use of PCV7 (6), 1 dose of PCV13 is recommended for all healthy children aged 24-59 months with any incomplete PCV schedule (PCV7 or PCV13). For children aged 24-71 months with underlying medical conditions who have received any incomplete schedule of <3 doses of PCV (PCV7 or PCV13) before age 24 months, 2 doses of PCV13 are recommended. For children with underlying medical conditions who have received 3 doses of PCV (PCV7 or PCV13) a single dose of PCV13 is recommended through age 71 months. The minimum interval between doses is 8 weeks.    1), a single supplemental PCV13 dose is recommended through age 71 months Complete PCV7 vaccination. A single supplemental dose of PCV13 is recommended for all children aged 14-59 months who have received 4 doses of PCV7 or another age-appropriate, complete PCV7 schedule (Table 3). For children who have underlying medical conditions, a single supplemental PCV13 dose is recommended through age 71 months. This includes children who have previously received the 23-valent pneumococcal polysaccharide vaccine (PPSV23). PCV13 should be given at least 8 weeks after the last dose of PCV7 or PPSV23.
In addition, a single dose of PCV13 may be administered to children aged 6-18 years who are at increased risk for IPD because of sickle cell disease, human immunodeficiency virus (HIV) infection or other immunocompromising condition, cochlear implant, or cerebrospinal fluid leaks, regardless of whether they have previously received PCV7 or PPSV23. Routine use of PCV13 is not recommended for healthy children aged 5 years.

# Precautions and Contraindications
Before administering PCV13, vaccination providers should consult the package insert for precautions, warnings, and contraindications. Vaccination with PCV13 is contraindicated among persons known to have severe allergic reaction (e.g., anaphylaxis) to any component of PCV13 or PCV7 or to any diphtheria toxoid-containing vaccine (2).

# Transition from PCV7 to PCV13
When PCV13 is available in the vaccination provider's office, unvaccinated children and children incompletely vaccinated with PCV7 should complete the immunization series with PCV13. If the only pneumococcal conjugate vaccine available in a provider's office is PCV7, that vaccine should be provided to children and infants who are due for vaccination; these children should complete their series with PCV13 at subsequent visits. Children for whom the supplemental PCV13 dose is recommended should receive it at their next medical visit, at least 8 weeks after the last dose of PCV7. ) other insurance: some other source of health insurance, such as a self-directed plan or student health insurance.  A key element of the health-care legislation in Massachusetts was creation of the Commonwealth Health Insurance Connector, the agency responsible for connecting residents to either Commonwealth Care, a subsidized program for certain adults who have not been offered employer-sponsored insurance, or Commonwealth Choice, an unsubsidized offering of six private health plans available through the Health Connector to individuals, families, and certain employers.
data for adults aged 18-34 years also were analyzed separately to more closely examine this traditionally underinsured age group. The statistical significance (p<0.05) of differences between health indicators in the pre-law and post-law periods was estimated using the Wald chi-square test. Variability of point estimates of weighted proportions was indicated by 95% confidence intervals.
The percentage of respondents who reported having health insurance rose 5.5%, from 91.3% in the pre-law period to 96.3% in the post-law period (Table 1). Among major subpopulations, the largest increases were observed among Hispanics (14.2%), persons with less than a high school diploma (12.0%), and persons with annual household incomes <$25,000 (11.9%). Nonetheless, in the post-law period, these same three subpopulations continued to have the lowest percentages of health insurance coverage: 89.0% for Hispanics, 88.6% for persons with less than a high school diploma, and 89.0% for persons with annual household incomes <$25,000.
By 2008, approximately 8% of publicly insured Massachusetts residents were obtaining their health insurance through the new public Commonwealth Care program. The percentage of insured residents with public health insurance (including those aged 18-64 years who were eligible for Medicare) increased 29.7%, from 14.8% in the pre-law period to 19.2% in the post-law period (Table 1). The percentage of insured residents with private insurance decreased 3.2%, from 80.8% to 78.2%, and the percentage of insured residents with other types of insurance (e.g., a self-directed plan or student health insurance) decreased 40.9%, from 4.4% to 2.6% (Table 1).
The overall percentage of respondents who reported having a personal health-care provider increased significantly, from 86.1% in the pre-law period to 87.7% in the post-law period (Table 2). The largest reported increases occurred among Hispanic respondents who answered the survey in Spanish (30.3% increase) and among Hispanics overall (17.0% increase).
The percentage of respondents who reported having a routine checkup within the past year also increased significantly, from 71.9% in the pre-law period to 74.1% in the post-law period (Table 3). The largest reported increases occurred among Hispanic respondents who answered the survey in Spanish (19.9% increase) and among Hispanics overall (14.1% increase). The percentage of men reporting a routine checkup increased 5.1%, from 66.4% to 69.8%, but the percentage of women reporting a routine checkup did not change significantly. The percentage of respondents with chronic conditions who reported having a personal health-care provider or having had an annual checkup also did not change significantly after enactment of the health-care coverage law.

# Editorial Note
The results of this analysis indicate that the estimated percentage of Massachusetts residents covered by health insurance increased significantly after passage of health-care coverage legislation. A wider comparison, between 2005 BRFSS state survey results and 2008 results, indicated that health insurance coverage increased from 89% to 97% among all state residents (including children and adults aged 65 years); the increase included an estimated 300,000 newly insured persons aged 18-64 years (3). After implementation of the health-care coverage law, the proportion of respondents who said they lacked health insurance was approximately cut in half, and 8% of publicly insured respondents were obtaining health insurance through the state's new Commonwealth Care program. The effects observed likely are attributable to the new law; although, because of limitations inherent in such studies, a causal link cannot be proven. Increases in health insurance coverage can result from multiple factors, such as a higher employment rate, reduction in health insurance premiums, or expansion of existing public health insurance programs. During 1996-1999, Massachusetts observed an increase in the percentage of persons with health insurance (3) after the state expanded Medicaid eligibility; as a result, an additional 124,000 Massachusetts residents obtained insurance coverage (4).
In this analysis, the observed increases in the percentage of insured among traditionally underserved subpopulations (e.g., Hispanics, persons with less than a high school diploma, and persons with annual household incomes 1 year when asked, "For how long have your activities been limited because of your major impairment, health problem, or disability?"    Responded "yes" to the question, "Have you ever been told by a doctor that you have diabetes?"    Responded "yes" to both of these questions: "Have you ever been told by a doctor, nurse, or other health professional that you had asthma?" and "Do you still have asthma?"    Defined as coverage through an employer, someone else's employer, or a plan purchased by the person covered.  Defined as coverage through Medicare, Medicaid, MassHealth, CommonHealth MassHealth, health maintenance organizations offered through Neighborhood Health Plan, Fallon Community Health Plan, BMC HealthNet or Network Health, Commonwealth Care, the military, CHAMPUS, TriCare, Veterans Administration (VA), CHAMP-VA, Indian Health Service, or the Alaska Native Health Service.     Defined as some other source of health insurance such as a self-directed plan or student health insurance.
attributable to the health-care coverage law, because implementation of heavily subsidized health insurance programs likely would affect these subpopulations first. Data from similar surveys in Massachusetts support this same hypothesis (5-7). For example, reports from the Massachusetts Division of Health Care Finance and Policy, which were focused on insurance status specifically, found that from fall 2006 to fall 2008, the number of uninsured working-age adults was reduced by nearly 70%. Most of the gains in insurance coverage were concentrated among lower-income adults (7). In contrast, according to U.S. Census data, from 2007 to 2008, the overall proportion of U.S. adults with health insurance declined (8).
The largest increases in insurance coverage were among Hispanic respondents overall and Hispanic respondents who answered the survey in Spanish. Traditionally, a larger proportion of Hispanics in   p values were calculated using the Wald chi-square test of the difference between each period.   General Educational Development certificate.   Responded "fair" or "poor" to the question, "Would you say that in general your health is excellent, very good, good, fair, or poor?" * Responded "yes" to the question, "A disability can be physical, mental, emotional, or communication-related. Would you describe yourself as having a disability of any kind?" plus indicated >1 year when asked, "For how long have your activities been limited because of your major impairment, health problem, or disability?"    Responded "yes" to the question, "Have you ever been told by a doctor that you have diabetes?"    Responded "yes" to both of these questions: "Have you ever been told by a doctor, nurse, or other health professional that you had asthma?" and "Do you still have asthma?"
Massachusetts have lacked access to health care, compared with other racial/ethnic populations (9,10). The results showed an 18.4% increase for persons responding in Spanish and a 14.2% increase for Hispanics overall. However, despite these increases, Hispanics continued to have the lowest health insurance coverage and the lowest percentage of persons with a personal health-care provider than any other subpopulation. The percentage of younger adults, whites, blacks, and persons with chronic diseases who reported having a personal health-care provider did not change significantly. One reason might be that more time is needed for the effects of improved healthcare access to be realized in these groups. Another reason might be that health-care providers are not equally accessible for certain groups or in certain areas   p values were calculated using the Wald chi-square test of the difference between each period.   General Educational Development certificate.   Responded "fair" or "poor" to the question, "Would you say that in general your health is excellent, very good, good, fair, or poor?" * Responded "yes" to the question, "A disability can be physical, mental, emotional, or communication-related. Would you describe yourself as having a disability of any kind?" plus indicated >1 year when asked, "For how long have your activities been limited because of your major impairment, health problem, or disability?"    Responded "yes" to the question, "Have you ever been told by a doctor that you have diabetes?"    Responded "yes" to both of these questions: "Have you ever been told by a doctor, nurse, or other health professional that you had asthma?" and "Do you still have asthma?" of the state. Although the cost of a doctor visit might also be a factor, 2008 BRFSS data have shown that only 6% of all respondents reported that they were unable to visit a doctor during the past year because of cost, compared with 8% in 2006 (9).
In addition to an increase in the percentage of persons with health insurance, the findings in this analysis indicate changes in the proportion of plans that were private, public, or other (e.g., a self-directed plan or student health insurance) in Massachusetts. Those proportions changed from 80.8% private, 14.8% public, and 4.4% other before the law was enacted to 78.2%, 19.2%, and 2.6%, respectively. These changes were similar to U.S. Census data, which found that the proportion of adults with private health insurance declined from 2007 to 2008, while the proportion of publicly insured adults increased (8).
In addition to the limitations on establishing causality, the findings in this report are subject to at least three other limitations. First, BRFSS only samples households with landline telephones. Minorities, persons with lower socioeconomic status, and younger adults typically have lower landline telephone coverage and might be underrepresented in this report. However, poststratification weighting might correct some bias resulting from lack of landline telephones. Second, depending on when the survey was administered, some responses might pertain to health-care activities (e.g., having a personal-care provider in the past year) that actually occurred during the 12-month transition period. Finally, BRFSS data are based on self-report and might be subject to error (e.g., underreporting of chronic conditions).
The findings in this report and others (10) can help local health departments in areas with large underserved populations assess local public health needs, enhance cultural competency, engage hospitals in community primary-care efforts, and address the availability of health-care providers. MDPH is targeting outreach more precisely to increase health insurance enrollment and health-care access among state residents. Afghanistan, Pakistan, India, and Nigeria are the four remaining countries where indigenous wild poliovirus (WPV) transmission has never been interrupted (1). This report updates previous reports (1,2) and describes polio eradication activities in Afghanistan and Pakistan during January-December 2009 and proposed activities in 2010 to address challenges. During 2009, both countries continued to conduct coordinated supplemental immunization activities (SIAs) and used multiple strategies to reach previously unreached children. These strategies included 1) use of short interval additional dose (SIAD) SIAs to administer a dose of oral poliovirus vaccine (OPV) within 1-2 weeks after a prior dose during negotiated periods of security; 2) systematic engagement of local leaders; 3) negotiations with conflict parties; and 4) increased engagement of nongovernmental organizations delivering basic health services. However, security problems continued to limit access by vaccination teams to large numbers of children. In Afghanistan, poliovirus transmission during 2009 predominantly occurred in 12 highrisk districts in the conflict-affected South Region; 38 WPV cases were confirmed in 2009, compared with 31 in 2008. In Pakistan, 89 WPV cases were confirmed in 2009, compared with 118 in 2008, but transmission persisted both in security-compromised areas and in accessible areas, where managerial and operational problems continued to affect immunization coverage. Continued efforts to enhance safe access of vaccination teams in insecure areas will be required for further progress toward interruption of WPV transmission in Afghanistan and Pakistan. In addition, substantial improvements in subnational accountability and oversight are needed to improve immunization activities in Pakistan.

# Immunization Activities
Reported routine vaccination coverage of infants with 3 OPV doses (OPV3) in 2009 was 85% nationally in Afghanistan and 81% in Pakistan During 2009, large-scale house-to-house SIAs  targeting children aged 370,000 children aged 20% during SIAs conducted in January and March to 5% during the July and September SIAs. In Pakistan, the percentage of children aged <5 years who were living in SIA-inaccessible areas of NWFP increased from 10% in January to 20% in May and July, and then decreased to <5% in October and November. However, in FATA itself, the estimated percentage of children aged <5 years living in inaccessible areas increased from 15% in January to 30% by November.

# Progress Toward Poliomyelitis Eradication

# AFP Surveillance
In 2009, AFP surveillance performance indicators remained high in both countries, including in areas with ongoing WPV transmission.   The annual national nonpolio AFP rate (per 100,000 population aged <15 years) was 8.5 in Afghanistan (range among the eight regions: 6.7-12.0) and 6.1 in Pakistan (range among the six provinces/territories: 2.9-9.2). The percentage of nonpolio AFP cases for which adequate specimens were collected was 93% in Afghanistan (range: 81%-97%) and 90% in Pakistan (range: 83%-96%) (Table 2).

# Editorial Note
During 2009, the total number of WPV cases reported in Afghanistan and Pakistan did not substantially change compared with 2008, and both WPV1 and WPV3 serotypes continued to circulate in the In Afghanistan, WPV transmission during the past 5 years has remained largely restricted to 12 insecure districts in the South Region. Since 2008, multiple strategies have been implemented to immunize these children. As a result, the proportion of children in the South Region who are not vaccinated in a given SIA was reduced to 5% of the overall target population toward the end of 2009. Meanwhile, Afghanistan has been able to keep most of the country free of endemic WPV transmission despite extensive population movements due to economic, social/cultural, and security reasons.
In Pakistan, circulation of both WPV serotypes persists in both transmission zones, with WPV repeatedly occurring, primarily in nine districts during the past 5 years. In the northern zone, WPV transmission continues because of limited access to children during SIAs in insecure areas of NWFP and FATA. Largescale population movements from NWFP and FATA have caused renewed WPV transmission in polio-free areas. Access to districts in NWFP improved during the last quarter of 2009, but access into FATA deteriorated. In the southern zone, WPV circulation continued mainly due to weak routine vaccination programs and managerial and operational gaps during SIAs, compounded by large-scale population movements from insecure areas in southern Afghanistan. Substantial improvements in subnational accountability and oversight are needed to improve the quality of immunization activities in Pakistan.
During 2010, planning, resources, and immunization activities need to focus on the small number of persistently affected districts in Afghanistan and Pakistan. In insecure areas, negotiations with community leaders need to be enhanced, and efforts are needed to achieve agreement of all parties to conflict regarding Days of Tranquility during SIAs to ensure access to the target population of children aged <5 years and the safety of vaccination teams. Negotiations with conflict parties have been and will be supported by the International Federation of Red Cross and Red Crescent Societies. Coordination of both SIAs and AFP surveillance between both countries also needs to be strengthened further to interrupt transmission from cross-border movements. In addition, specific mechanisms need to be established to hold provincial, district, and local administrative leaders accountable for program performance. MenACWY-CRM consists of two components: 1) 10 g of lyophilized meningococcal serogroup A capsular polysaccharide conjugated to CRM 197 (MenA) and 2) 5 g each of capsular polysaccharide of serogroup C, Y, and W135 conjugated to CRM 197 in 0.5 mL of phosphate buffered saline, which is used to reconstitute the lyophilized MenA component before injection (1). The reconstituted vaccine should be used immediately, but may be held at or below 77F (25C) for up to 8 hours. MenACWY-CRM is administered as an intramuscular injection, preferably into the deltoid region (1).
The capsular polysaccharide serogroups included in MenACWY-CRM are the same as those contained in Sanofi Pasteur's MCV4 (Menactra). In study participants aged 11-18 years, noninferiority of MenACWY-CRM to MCV4 was demonstrated for all four serogroups using the primary endpoint, hSBA seroresponse (serum bactericidal assay using human complement). The proportions of subjects with hSBA seroresponse were statistically higher for serogroups A, W, and Y in the MenACWY-CRM group, compared with the MCV4 group. The clinical relevance of higher postvaccination immune responses is not known (1). Safety and reactogenicity profiles were comparable to those observed with MCV4 (1).

# Guidance for Use of MenACWY-CRM
MenACWY-CRM is licensed by the FDA as a single dose in persons aged 11-55 years (1). ACIP recommends quadrivalent meningococcal conjugate vaccine for all persons aged 11-18 years and for persons aged 2-55 years who are at increased risk for meningococcal disease. Persons at increased risk for meningococcal disease include 1) college freshmen living in dormitories, 2) microbiologists who are exposed routinely to isolates of Neisseria meningitidis, 3) military recruits, 4) persons who travel to or reside in countries where meningococcal disease is hyperendemic or epidemic Severe allergic reaction (e.g., anaphylaxis) after a previous dose of Menveo, any component of this vaccine, or any other CRM 197 , diphtheria toxoid, or meningococcal-containing vaccine is a contraindication to administration of Menveo. Details regarding the recommended meningococcal vaccination schedule are available at / recs/schedules/default.htm#child. Adverse events after receipt of any vaccine should be reported to the Vaccine Adverse Event Reporting System at http:// vaers.hhs.gov.

# Licensure of a Meningococcal Conjugate Vaccine (Menveo) and
Guidance for Use -Advisory Committee on Immunization Practices (ACIP), 2010  IV, which appears quarterly.   Updated weekly from reports to the Influenza Division, National Center for Immunization and Respiratory Diseases. Since April 26, 2009, a total of 278 influenza-associated pediatric deaths associated with 2009 influenza A (H1N1) virus infection have been reported. Since August 30, 2009, a total of 265 influenza-associated pediatric deaths occurring during the 2009-10 influenza season have been reported. A total of 133 influenza-associated pediatric deaths occurring during the 2008-09 influenza season have been reported.   No measles cases were reported for the current week. * Data for meningococcal disease (all serogroups) are available in Table II.
   CDC discontinued reporting of individual confirmed and probable cases of 2009 pandemic influenza A (H1N1) virus infections on July 24, 2009. CDC will report the total number of 2009 pandemic influenza A (H1N1) hospitalizations and deaths weekly on the CDC H1N1 influenza website (). In addition, three cases of novel influenza A virus infections, unrelated to the 2009 pandemic influenza A (H1N1) virus, were reported to CDC during 2009.    In 2009, Q fever acute and chronic reporting categories were recognized as a result of revisions to the Q fever case definition. Prior to that time, case counts were not differentiated with respect to acute and chronic Q fever cases.                       A death is reported by the place of its occurrence and by the week that the death certificate was filed. Fetal deaths are not included.  Pneumonia and influenza.  Because of changes in reporting methods in this Pennsylvania city, these numbers are partial counts for the current week. Complete counts will be available in 4 to 6 weeks.  Total includes unknown ages.
American Samoa - 0 0 - - N 0 0 N N C.N.M.I. - - - - - - - - - - Guam - 0 0 - - - 0 0 - - Puerto
- 0 0 - NN New England - 0 1 1 NN - 0 0 - NN Connecticut - 0 0 - NN - 0 0 - NN Maine  - 0 1 1 NN - 0 0 - NN Massachusetts - 0 0 - NN - 0 0 - NN New Hampshire - 0 0 - NN - 0 0 - NN Rhode Island  - 0 0 - NN - 0 0 - NN Vermont  - 0 0 - NN - 0 0 - NN Mid. Atlantic - 0 1 2 NN - 0 0 - NN New Jersey - 0 0 - NN - 0 0 - NN New York (Upstate) - 0 0 - NN - 0 0 - NN New York City - 0 0 - NN - 0 0 - NN Pennsylvania - 0 1 2 NN - 0 0 - NN E.N. Central - 0 1 1 NN - 0 0 - NN Illinois - 0 0 - NN - 0 0 - NN Indiana - 0 0 - NN - 0 0 - NN Michigan - 0 0 - NN - 0 0 - NN Ohio - 0 1 1 NN - 0 0 - NN Wisconsin - 0 0 - NN - 0 0 - NN W.N. Central - 0 0 - NN - 0 0 - NN Iowa - 0 0 - NN - 0 0 - NN Kansas - 0 0 - NN - 0 0 - NN Minnesota - 0 0 - NN - 0 0 - NN Missouri - 0 0 - NN - 0 0 - NN Nebraska  - 0 0 - NN - 0 0 - NN North Dakota - 0 0 - NN - 0 0 - NN South Dakota - 0 0 - NN - 0 0 - NN S. Atlantic - 0 1 1 NN - 0 0 - NN Delaware - 0 0 - NN - 0 0 - NN District of Columbia - 0 0 - NN - 0 0 - NN Florida - 0 0 - NN - 0 0 - NN Georgia - 0 1 1 NN - 0 0 - NN Maryland  - 0 0 - NN - 0 0 - NN North Carolina - 0 0 - NN - 0 0 - NN South Carolina  - 0 0 - NN - 0 0 - NN Virginia  - 0 0 - NN - 0 0 - NN West Virginia - 0 0 - NN - 0 0 - NN E.S. Central - 0 0 - NN - 0 0 - NN Alabama  - 0 0 - NN - 0 0 - NN Kentucky - 0 0 - NN - 0 0 - NN Mississippi - 0 0 - NN - 0 0 - NN Tennessee  - 0 0 - NN - 0 0 - NN W.S. Central - 0 0 - NN - 0 0 - NN Arkansas  - 0 0 - NN - 0 0 - NN Louisiana - 0 0 - NN - 0 0 - NN Oklahoma - 0 0 - NN - 0 0 - NN Texas  - 0 0 - NN - 0 0 - NN Mountain - 0 0 - NN - 0 0 - NN Arizona - 0 0 - NN - 0 0 - NN Colorado - 0 0 - NN - 0 0 - NN Idaho  - 0 0 - NN - 0 0 - NN Montana  - 0 0 - NN - 0 0 - NN Nevada  - 0 0 - NN - 0 0 - NN New Mexico  - 0 0 - NN - 0 0 - NN Utah - 0 0 - NN - 0 0 - NN Wyoming  - 0 0 - NN - 0 0 - NN Pacific - 0 2 2 NN - 0 0 - NN Alaska - 0 0 - NN - 0 0 - NN California - 0 0 - NN - 0 0 - NN Hawaii - 0 0 - NN - 0 0 - NN Oregon - 0 0 - NN - 0 0 - NN Washington - 0 2 2 NN - 0 0 - NN American Samoa - 0 0 - NN - 0 0 - NN C.N.M.I. - - - - NN - - - - NN Guam - 0 0 - NN - 0 0 - NN Puerto Rico - 0 0 - NN - 0 0 - NN U.S.
- 0 4 1 1 - 2 21 4 3 - 0 2 - - Connecticut - 0 0 - - - 0 11 - - - 0 1 - - Maine  - 0 1 1 - - 0 3 2 - - 0 0 - - Massachusetts - 0 0 - - - 0 0 - - - 0 0 - - New Hampshire - 0 1 - - - 0 3 - 1 - 0 1 - - Rhode Island  - 0 4 - 1 - 0 20 2 2 - 0 1 - - Vermont  - 0 1 - - - 0 0 - - - 0 0 - - Mid. Atlantic 1 2 17 2 1 - 3 22 1 - - 0 2 - - New Jersey - 0 1 - - - 0 0 - - - 0 0 - - New York (Upstate) 1 1 17 1 - - 3 21 1 - - 0 1 - - New York City - 0 3 - 1 - 0 1 - - - 0 2 - - Pennsylvania - 0 1 1 - - 0 0 - - - 0 0 - - E.N. Central - 1 8 - - - 3 22 1 2 - 1 9 - - Illinois - 0 4 - - - 0 1 - - - 0 1 - - Indiana - 0 0 - - - 0 0 - - - 0 8 - - Michigan - 0 0 - - - 0 0 - - - 0 0 - - Ohio - 0 2 - - - 0 1 - - - 0 1 - - Wisconsin - 0 5 - - - 3 22 1 2 - 0 3 - - W.N. Central - 2 23 1 1 - 0 41 - - - 0 5 1 - Iowa - 0 0 - - - 0 0 - - - 0 0 - - Kansas - 0 2 - - - 0 0 - - - 0 0 - - Minnesota - 0 3 - 1 - 0 41 - - - 0 5 - - Missouri - 1 22 1 - - 0 1 - - - 0 3 1 - Nebraska  - 0 1 - - - 0 1 - - - 0 0 - - North Dakota - 0 0 - - - 0 0 - - - 0 0 - - South Dakota - 0 0 - - - 0 0 - - - 0 0 - - S. Atlantic 3 3 19 12 15 - 0 2 2 3 - 0 2 - - Delaware - 0 2 1 1 - 0 1 - - - 0 0 - - District of Columbia - 0 0 - - - 0 0 - - - 0 0 - - Florida - 0 1 1 2 - 0 1 - - - 0 0 - - Georgia - 0 2 3 3 - 0 1 1 1 - 0 0 - - Maryland  - 1 4 4 4 - 0 1 - 1 - 0 1 - - North Carolina 3 0 4 3 5 - 0 1 1 1 - 0 0 - - South Carolina  - 0 1 - - - 0 0 - - - 0 0 - - Virginia  - 1 13 - - - 0 1 - - - 0 2 - - West Virginia - 0 1 - - - 0 0 - - - 0 0 - - E.S. Central - 1 11 - 2 - 0 1 - 1 - 0 5 - 1 Alabama  - 0 3 - - - 0 1 - - - 0 0 - - Kentucky - 0 2 - - - 0 0 - - - 0 1 - - Mississippi - 0 0 - - - 0 0 - - - 0 0 - - Tennessee  - 1 10 - 2 - 0 1 - 1 - 0 5 - 1 W.S. Central - 0 9 1 - - 0 1 - - - 0 0 - - Arkansas  - 0 5 - - - 0 0 - - - 0 0 - - Louisiana - 0 0 - - - 0 0 - - - 0 0 - - Oklahoma - 0 8 - - - 0 1 - - - 0 0 - - Texas  - 0 1 1 - - 0 1 - - - 0 0 - - Mountain - 0 0 - - - 0 0 - - - 0 1 - - Arizona - 0 0 - - - 0 0 - - - 0 1 - - Colorado - 0 0 - - - 0 0 - - - 0 0 - - Idaho  - 0 0 - - - 0 0 - - - 0 0 - - Montana  - 0 0 - - - 0 0 - - - 0 0 - - Nevada  - 0 0 - - - 0 0 - - - 0 0 - - New Mexico  - 0 0 - - - 0 0 - - - 0 0 - - Utah - 0 0 - - - 0 0 - - - 0 0 - - Wyoming  - 0 0 - - - 0 0 - - - 0 0 - - Pacific - 0 1 - - - 0 0 - - - 0 0 - - Alaska - 0 0 - - - 0 0 - - - 0 0 - - California - 0 1 - - - 0 0 - - - 0 0 - - Hawaii - 0 0 - - - 0 0 - - - 0 0 - - Oregon - 0 0 - - - 0 0 - - - 0 0 - - Washington - 0 0 - - - 0 0 - - - 0 0 - - American Samoa - 0 0 - - - 0 0 - - - 0 0 - - C.N.M.I. - - - - - - - - - - - - - - - Guam - 0 0 - - - 0 0 - - - 0 0 - - Puerto Rico - 0 0 - - - 0 0 - - - 0 0 - - U.
American Samoa - 0 0 - - - 0 0 - - - 0 0 - - C.N.M.I. - - - - - - - - - - - - - - - Guam - 0 0 - - - 0 0 - - - 0 0 - - Puerto Rico - 1
- 0 1 1 1 - 0 2 1 1 - 0 2 - - Massachusetts - 1 4 - 10 - 0 2 - 3 - 0 1 - 2 New Hampshire - 0 1 - 1 - 0 1 - 1 - 0 0 - - Rhode Island  - 0 1 - 1 - 0 0 - - - 0 0 - - Vermont  - 0 1 - - - 0 0 - - - 0 0 - 1 Mid.
- 0 3 - 4 1 0 2 6 5 - 0 1 1 1 North Dakota - 0 1 - - - 0 0 - - - 0 1 - - South Dakota - 0 1 - - - 0 1 - 1 - 0 1 1 - S.
- Colorado - 1 5 5 6 - 0 2 1 6 - 0 3 - 8 Idaho  - 0 1 2 - - 0 2 1 1 - 0 2 3 - Montana  - 0 1 - 2 - 0 0 - - - 0 0 - - Nevada  - 0 2 1 - - 0 3 4 5 - 0 1 - - New Mexico  - 0 1 1 1 - 0 1 - 4 - 0 1 - 4 Utah - 0 2 - 3 - 0 1 - 3 - 0 2 2 - Wyoming  - 0 1 - - - 0 2 - - - 0 0 - - Pacific 6
American Samoa - 0 0 - - - 0 0 - - - 0 0 - - C.N.M.I. - - - - - - - - - - - - - - - Guam - 0 0 - - - 0 0 - - - 0 0 - - Puerto Rico - 0 2 2 7 - 0 5 1 1 - 0 0 - - U.
5 - 0 1 1 3 Kansas - 0 1 1 2 - 0 2 - 4 - 0 1 3 1 Minnesota 1 0 11 3 - - 0 196 - 4 - 0 8 3 1 Missouri - 1 5 2 - - 0 1 - - - 0 1 2 3 Nebraska  - 0 2 2 - - 0 3 1 - - 0 2 3 - North Dakota - 0 1 - - - 0 0 - - - 0 1 - - South Dakota - 0 1 - - - 0 0 - 1 - 0 1 - - S.
- 0 1 - - - 0 0 - - - 0 1 1 - Louisiana - 0 2 - 1 - 0 0 - - - 0 1 - 1 Oklahoma - 0 2 - - - 0 0 - - - 0 1 1 - Texas  - 2
- - - 0 2 1 - Colorado - 0 4 2 2 - 0 1 1 - - 0 3 - 1 Idaho  - 0 2 - 1 - 0 3 1 1 - 0 1 - - Montana  - 0 1 1 3 - 0 1 - - - 0 3 - - Nevada  - 0 1 2 3 - 0 1 - - - 0 1 1 - New Mexico  - 0 2 1 - - 0 1 - - - 0 0 - - Utah - 0 4 1 5 - 0 1 1 1 - 0 1 3 2 Wyoming  - 0 2 - - - 0 1 - - - 0 0 - - Pacific 6
- 0 0 - 1 N 0 0 N N - 0 1 - - Oregon - 0 2 - 3 - 1 4 8 3 - 0 2 - 2 Washington 1 0 4 1 2 - 0 3 - - 1 0 4 4 3 American Samoa N 0 0 N N N 0 0 N N - 0 0 - - C.N.M.I. - - - - - - - - - - - - - - - Guam - 0 0 - - - 0 0 - - - 0 0 - - Puerto Rico - 0 1 - - N 0 0 N N - 0 1 1 1 U.S. Virgin Islands - 0 0 - - N 0 0 N N - 0 0 - - C.
American Samoa - 0 0 - - - 0 0 - - N 0 0 N N C.N.M.I. - - - - - - - - - - - - - - - Guam - 0 0 - - - 0 0 - - - 0 0 - - Puerto Rico - 0 0 - - - 0 1 - - 3 1 3 12 9 U.S. Virgin Islands - 0 0 - - - 0 0 - - N 0 0 N N C.