Disease Control Bulletin: April 2003
- Vermont Asthma Action Plan
- Recommended Adult and Child Immunization Schedules
- Childhood Immunization Schedule, United States 2003
- Adult Immunization Schedule, United States 2003
- Selected Reportable Diseases March 15, 2003
- West Nile Virus Specimen Collection and Transport
- Update on West Nile Virus
Vermont Asthma Action Plan
It has been estimated that in 2001, 31 percent of Vermont adults with asthma had a written management plan, and 14.2 percent of Vermont adults with asthma reported one or more visits to the emergency room or sought urgent care for their asthma.1. Recently updated guidelines2 state that self-management education with written management plans has been shown, in adults, to reduce emergency department visits and hospitalizations and to result in improved lung function. Healthy Vermonters 2010,3 Vermont’s blueprint for improving health, contains four asthma-related objectives, which include reducing pediatric asthma hospitalizations, increasing asthma education, increasing the use of written management plans among persons with asthma, and reducing triggers that exacerbate asthma, namely environmental tobacco smoke.
Vermont Asthma Action Plan Developed
To meet the goals set forth by Healthy Vermonters 2010, the Vermont Department of Health in collaboration with other government, non-government, and community organizations, created the Vermont Asthma Action Plan. This document is a written management plan that includes a color-coded system linked to symptom severity; provides information on asthma medications, peak flow meters, and details identifying an asthma attack or episode in progress; and aids in identifying when it is appropriate/necessary to call the doctor. The triplicate nature of the form allows one copy to remain in the patient’s medical chart, one copy to be sent home with the patient/family, and a third copy to be kept on file with the child’s school nurse when appropriate .
Pilot programs tested form
Three pilot studies were designed to test the point of origin for the delivery of the Vermont Asthma Action Plan. All pilot-related information reported to the Vermont Department of Health was confidentially transmitted to protect the patient’s identity. In the first of these pilots, four physician offices of various sizes and locations across the state were used to test the implementation of the Vermont Asthma Action Plan from pediatric office settings. In the second pilot, seven school nurses from around the state initiated written management plans in a school setting. To obtain additional feedback, 26 other school nurses tested the use of the written management plans, but were not formal members of the pilot. Finally, the third pilot tested the delivery route of written management plans using insurance plans as the point of origin. This pilot used the HEDIS definition4 of ‘persistent asthma’ for insurance plans to identify patients and their doctors, resulting in the mailing of an appropriate number of Vermont Asthma Action Plans to these physician offices.
Nearly 70 percent of the physicians in pilot practices responded to a final survey, providing their impressions on their experience in the pilot. Suggestions and comments have been invaluable in providing direction for program activities such as the development of a school nurse manual for asthma.
Responses indicated there was no hesitation from parents to complete the form, and physicians indicated that the form complements asthma education and general health communication with families, as well as with other doctors and health care providers.
Feedback following the completion of the nurse pilot demonstrated general enthusiasm and support for the form, but reported some misunderstandings with parents and doctors concerning which portions of the forms they were each to complete and eventually return to the school. Additionally, there were requests made for the forms to include an area that indicates permission for the student to carry his/her inhaler on-person in the school, as well as for the school nurse to date and initial receipt of the form in their office. In the final pilot, insurers have sent out the Vermont Asthma Action Plans and will conduct chart audits in the summer of 2003 to examine the percentage of completed management plans in patient charts of those plans originally sent.
The most recent National Institutes of Health guidelines hypothesize that written management plans will reduce the occurrence of avoidable hospitalizations and ER visits. As we work toward achieving Healthy Vermonters 2010 goals, statewide efforts to increase the use of Vermont Asthma Action Plans will be monitored. Sources including the Vermont Behavioral Risk Factor Surveillance System and ER data will help us to see whether the presence of written management plans results in the desired benefit of improved quality of life for people in Vermont with asthma.
- 2001 VTBRFSS. The Vermont Behavioral Risk Factor Surveillance System is a random-digit dialed telephone survey of the non-institutionalized state population aged 18+ years.
- http://www.healthyvermonters.info/admin/pubs/hv2010/ hv2010.shtml
Tips for using the Vermont Asthma Plan: Advice from Physician Pilot Participants
- This form does not require use of peak flow readings to be useful in asthma management. Signs and symptoms can be used to designate the individual’s green, yellow, red zone conditions.
- The physician should sign the form and send the second page to the child’s school nurse. A list of addresses of Vermont schools is available from the Vermont Health Department. Call 1-800-439-8550 and ask to speak to the Asthma Program Coordinator.
- This form can be used by preschool and day care providers to manage asthma in preschool children. The form has not been tested on adults although the content is believed applicable to adults as well as children.
- To ensure that the asthma management form is used as intended:
- Encourage your colleagues to use the asthma form
- Identify the person in your office who will be responsible for:
- stocking the form
- getting the name and address of the child’s school
- getting the parent’s signature on the form
- seeing that the physician signs the form
- filling the first page of the form in the chart
- mailing the second page of the form to the school nurse
- seeing that the parent has the third page
Recommended Adult and Child Immunization Schedules
This issue of the Disease Control Bulletin contains the 2003 Childhood Immunization Schedule.1. Please replace your 2002 Childhood Immunization Schedule with this issue’s insert. Also included is the Recommended Adult Immunization Schedule,2 provided for the first time in a table format by the CDC’s Advisory Committee on Immunization Practices.
The 2003 Childhood Schedule is the same in content and format as the 2002 schedule. Changes to the schedule related to the licensing of a new vaccine were recently discussed by the ACIP. At its February 26-27, 2003, meeting, the ACIP voted on three issues regarding the use of the combination vaccine, Pediarix®. Manufactured by GlaxoSmithKline, Pediarix® was approved by the Food and Drug Administration in December 2002 to protect infants 6 weeks of age and older against diphtheria, tetanus, pertussis, hepatitis B, and polio. The results of the ACIP votes were:
- Pediarix® may be given to all infants at 2, 4, and 6 months of age, including infants of mothers who are HBsAg positive or whose status is unknown
- The recommended immunization schedule, when Pediarix® is used, also includes giving newborns the birth dose of monovalent hepatitis B vaccine before hospital discharge
- Pediarix® is recommended for inclusion in CDC’s Vaccines for Children (VFC) program. Since the vaccine’s approval, some health professionals have questioned whether it is still necessary to give the birth dose of monovalent hepatitis B vaccine before administering Pediarix®. According to the FDA’s prescribing information, Pediarix® is indicated only for infants of HBsAg-negative mothers. However, ACIP voted that Pediarix® may be used for ALL infants 6 weeks of age and older, including those born to HBsAg-positive mothers and to mothers whose HBsAg status in unknown. When the birth dose is included, up to four hepatitis B vaccine doses may be given. According to the ACIP, if the mother is HBsAg negative, the birth dose may be omitted, but this is NOT the preferred hepatitis B vaccination schedule of the ACIP.
The department has ordered Pediarix®, as well as separate vaccines for DTaP, Hepatitis B, and Polio.
- http://www.cdc.gov/nip/recs/child-schedule-twopages.pdf (pdf)
- http://www.cdc.gov/nip/recs/adult-schedule.pdf (pdf)
Recommended Childhood and Adolescent Immunization Schedule
United States, 2003
This schedule indicates the recommended ages for routine administration of currently licensed childhood vaccines, as of December 1, 2002, for children through age 18 years. Any dose not given at the recommended age should be given at any subsequent visit when indicated and feasible. Indicates age groups that warrant special effort to administer those vaccines not previously given. Additional vaccines may be licensed and recommended during the year. Licensed combination vaccines may be used whenever any components of the combination are indicated and the vaccine’s other components are not contraindicated. Providers should consult the manufacturers’ package inserts for detailed recommendations.
Recommended Childhood and Adolescent Immunization Schedule—
United States, 2003
Hepatitis B vaccine (HepB).
All infants should receive the first dose of hepatitis B vaccine soon after birth and before hospital discharge; the first dose may also be given by age 2 months if the infant’s mother is HBsAg-negative. Only monovalent HepB can be used for the birth dose.
Monovalent or combination vaccine containing HepB may be used to complete the series. Four doses of vaccine may be administered when a birth dose is given. The second dose should be given at least 4 weeks after the first dose, except for combination vaccines which cannot be administered before age 6 weeks. The third dose should be given at least 16 weeks after the first dose and at least 8 weeks after the second dose. The last dose in the vaccination series (third or fourth dose)should not be administered before age 6 months.
Infants born to HBsAg-positive mothers should receive HepB and 0.5mL Hepatitis B Immune Globulin (HBIG) within 12 hours of birth at separate sites. The second dose is recommended at age 1-2 months. The last dose in the vaccination series should not be administered before age 6 months. These infants should be tested for HBsAg and anti-HBs at 9-15 months of age.
Infants born to mothers whose HBsAg status is unknown should receive the first dose of the HepB series within 12 hours of birth. Maternal blood should be drawn as soon as possible to determine the mother' s HBsAg status; if the HBsAg test is positive, the infant should receive HBIG as soon as possible (no later than age 1 week). The second dose is recommended at age 1-2 months. The last dose in the vaccination series should not be administered before age 6 months.
Diphtheria and tetanus toxoids and acellular pertussis vaccine
(DTaP). The fourth dose of DTaP may be administered as early as age 12 months, provided 6 months have elapsed since the third dose and the child is unlikely to return at age 15-18 months. Tetanus and diphtheria toxoids (Td) is recommended at age 11-12 years if at least 5 years have elapsed since the last dose of tetanus and diphtheria toxoid-containing vaccine. Subsequent routine Td boosters are recommended every 10 years.
Haemophilus influenzae type b (Hib) conjugate vaccine.
Three Hib conjugate vaccines are licensed for infant use. If PRP-OMP (PedvaxHIB® or ComVax® [Merck]) is administered at ages 2 and 4 months, a dose at age 6 months is not required. DTaP/Hib combination products should not be used for primary immunization in infants at ages 2, 4 or 6 months, but can be used as boosters following any Hib vaccine.
Measles, mumps, and rubella vaccine (MMR).
The second dose of MMR is recommended routinely at age 4-6 years but may be administered during any visit, provided at least 4 weeks have elapsed since the first dose and that both doses are administered beginning at or after age 12 months. Those who have not previously received the second dose should complete the schedule by the 11-12 year old visit.
Varicella vaccine is recommended at any visit at or after age 12 months for susceptible children, i.e. those who lack a reliable history of chickenpox. Susceptible persons aged 13 years should receive two doses, given at least 4 weeks apart.
The heptavalent pneumococcal conjugate vaccine (PCV) is recommended for all children age 2-23 months. It is also recommended for certain children age 24-59 months. Pneumococcal polysaccharide vaccine (PPV) is recommended in addition to PCV for certain high-risk groups. See MMWR 2000;49(RR-9);1-38.
Hepatitis A vaccine.
Hepatitis A vaccine is recommended for children and adolescents in selected states and regions, and for certain high-risk groups; consult your local public health authority. Children and adolescents in these states, regions, and high risk groups who have not been immunized against hepatitis A can begin the hepatitis A vaccination series during any visit. The two doses in the series should be administered at least 6 months apart. See MMWR 1999;48(RR-12);1-37.
Influenza vaccine is recommended annually for children age 6 months with certain risk factors (including but not limited to asthma, cardiac disease, sickle cell disease, HIV, diabetes, and household members of persons in groups at high risk; see MMWR 2002;51(RR-3);1-31), and can be administered to all others wishing to obtain immunity. In addition, healthy children age 6-23 months are encouraged to receive influenza vaccine if feasible because children in this age group are at substantially increased risk for influenza-related hospitalizations. Children aged 12 years should receive vaccine in a dosage appropriate for their age (0.25 mL if age 6-35 months or 0.5 mL if aged 3 years). Children aged 8 years who are receiving influenza vaccine for the first time should receive two doses separated by at least 4 weeks.
For additional information about vaccines, including precautions and contraindications for immunization and vaccine shortages, please visit the National Immunization Program Website at www.cdc.gov/nip or call the National Immunization Information Hotline at 800-232-2522 (English) or 800-232-0233 (Spanish).
Recommended Adult Immunization Schedule
United States, 2002-2003
*Covered by the Vaccine Injury Compensation Program.For information on how to file a claim call 800-338-2382. Please also visit www.hrsa.gov/.osp/vicp To file a claim for vaccine injury write: U.S. Court of Federal Claims, 717 Madison Place, N.W.,Washington D.C. 20005. 202 219-9657.
This schedule indicates the recommended age groups for routine administration of currently licensed vaccines for persons 19 years of age and older. Licensed combination vaccines may be used whenever any components of the combination are indicated and the vaccine’s other components are not contraindicated. Providers should consult the manufacturers’ package inserts for detailed recommendations.
Report all clinically significant post-vaccination reactions to the Vaccine Adverse Event Reporting System (VAERS). Reporting forms and instructions on filing a VAERS report are available by calling 800-822-7967 or from the VAERS website at www.vaers.org.
For additional information about the vaccines listed above and contraindications for immunization, visit the National Immunization Program Website at www.cdc.gov/nip/ or call the National Immunization Hotline at 800-232-2522 (English) or 800-232-0233 (Spanish).
Approved by the Advisory Committee on Immunization Practices (ACIP), and accepted by the American College of Obstetricians and Gynecologists (ACOG) and the American Academy of Family Physicians (AAFP)
- If pregnancy is at 2nd or 3rd trimester during influenza season.
- Although chronic liver disease and alcoholism are not indicator conditions for influenza vaccination, give 1 dose annually if the patient is > 50 years, has other indications for influenza vaccine, or if the patient requests vaccination.
- Asthma is an indicator condition for influenza but not for pneumococcal vaccination.
- For all persons with chronic liver disease.
- Revaccinate once after 5 years or more have elapsed since initial vaccination.
- Persons with impaired humoral but not cellular immunity may be vaccinated. MMWR 1999; 48 (RR-06): 1-5.
- Hemodialysis patients: Use special formulation of vaccine (40 ug/mL) or two 1.0 mL 20 ug doses given at one site.Vaccinate early in the course of renal disease. Assess antibody titers to hep B surface antigen (anti-HBs) levels annually. Administer additional doses if anti-HBs levels decline to <10 milliinternational units (mlU)/ mL.
- Elective splenectomy: vaccinate at least 2 weeks before surgery.
- Vaccinate as close to diagnosis as possible when CD4 cell counts are highest.
- Withhold MMR or other measles containing vaccines from HIV-infected persons with evidence of severe immunosuppression. MMWR 1996; 45: 603-606, MMWR 1992; 41 (RR-17): 1-19.
Footnotes for Recommended Adult Immunization Schedule, United States, 2002-2003
- Tetanus and diphtheria (Td)—A primary series for adults is 3 doses: the first 2 doses given at least 4 weeks apart and the 3rd dose, 6-12 months after the second. Administer 1 dose if the person had received the primary series and the last vaccination was 10 years ago or longer. MMWR 1991; 40 (RR-10): 1-21.The ACP Task Force on Adult Immunization supports a second option: a single Td booster at age 50 years for persons who have completed the full pediatric series, including the teenage/young adult booster.
Guide for Adult Immunization. 3rd ed. ACP 1994: 20.
- Influenza vaccination—Medical indications: chronic disorders of the cardiovascular or pulmonary systems including asthma; chronic metabolic diseases including diabetes mellitus, renal dysfunction, hemoglobinopathies, immunosuppression (including immunosuppression caused by medications or by human immunodeficiency virus [HIV]), requiring regular medical follow-up or hospitalization during the preceding year; women who will be in the second or third trimester of pregnancy during the influenza season. Occupational indications: health-care workers. Other indications: residents of nursing homes and other long-term care facilities; persons likely to transmit influenza to persons at high-risk (in-home care givers to persons with medical indications, household contacts and out-of-home caregivers of children birth to 23 months of age, or children with asthma or other indicator conditions for influenza vaccination, household members and care givers of elderly and adults with high-risk conditions); and anyone who wishes to be vaccinated. MMWR 2002; 51 (RR-3): 1-31.
- Pneumococcal polysaccharide vaccination—Medical indications: chronic disorders of the pulmonary system (excluding asthma), cardiovascular diseases, diabetes mellitus, chronic liver diseases including liver disease as a result of alcohol abuse (e.g., cirrhosis), chronic renal failure or nephrotic syndrome, functional or anatomic asplenia (e.g., sickle cell disease or splenectomy), immunosuppressive conditions (e.g., congenital immunodeficiency, HIV infection, leukemia, lymphoma, multiple myeloma, Hodgkins disease, generalized malignancy, organ or bone marrow transplantation), chemotherapy with alkylating agents, anti-metabolites, or long-term systemic corticosteroids.
Geographic/other indications: Alaskan Natives and certain American Indian populations. Other indications: residents of nursing homes and other long-term care facilities. MMWR 1997; 47 (RR-8): 1-24.
- 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), immunosuppressive conditions (e.g., congenital immunodeficiency, HIV infection, leukemia, lymphoma, multiple myeloma, Hodgkins disease, generalized malignancy, organ or bone marrow transplantation), chemotherapy with alkylating agents, anti-metabolites, or long-term systemic corticosteroids. For persons 65 and older, one-time revaccination if they were vaccinated 5 or more years previously and were aged less than 65 years at the time of primary vaccination. MMWR 1997; 47 (RR-8): 1-24.
- Hepatitis B vaccination—Medical indications: hemodialysis patients, patients who receive clotting-factor concentrates. Occupational indications: health-care workers and public-safety workers who have exposure to blood in the workplace, persons in training in schools of medicine, dentistry, nursing, laboratory technology, and other allied health professions. Behavioral indications: injecting drug users, persons with more than one sex partner in the previous 6 months, persons with a recently acquired sexually-transmitted disease (STD), all clients in STD clinics, men who have sex with men. Other indications: household contacts and sex partners of persons with chronic HBV infection, clients and staff of institutions for the developmentally disabled, international travelers who will be in countries with high or intermediate prevalence of chronic HBV infection for more than 6 months, inmates of correctional facilities. MMWR 1991; 40 (RR-13): 1-25.
- Hepatitis A vaccination—For the combined HepA-HepB vaccine use 3 doses at 0, 1, 6 months). Medical indications: persons with clotting-factor disorders or chronic liver disease. Behavioral indications: men who have sex with men, users of injecting and noninjecting illegal drugs. Occupational indications: persons working with 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. MMWR 1999; 48 (RR-12): 1-37. (www.cdc.gov/travel/diseases/hav.htm)
Measles, Mumps, Rubella vaccination (MMR)—Measles component: Adults born before 1957 may be considered immune to measles. Adults born in or after 1957 should receive at least one dose of MMR unless they have a medical contraindication, documentation of at least one dose or other acceptable evidence of immunity. A second dose of MMR is recommended for adults who:
- are recently exposed to measles or in an outbreak setting
- were previously vaccinated with killed measles vaccine
- were vaccinated with an unknown vaccine between 1963 and 1967
- are students in post-secondary educational institutions
- work in health care facilities
- plan to travel internationally
Mumps component: 1 dose of MMR should be adequate for protection. Rubella component: Give 1 dose of MMR to women whose rubella vaccination history is unreliable and counsel women to avoid becoming pregnant for 4 weeks after vaccination. For women of child-bearing age, regardless of birth year, routinely determine rubella immunity and counsel women regarding congenital rubella syndrome. Do not vaccinate pregnant women or those planning to become pregnant in the next 4 weeks. If pregnant and susceptible, vaccinate as early in postpartum period as possible.
MMWR 1998; 47 (RR-8): 1-57.
- Varicella vaccination—Recommended for all persons who do not have reliable clinical history of varicella infection, or serological evidence of varicella zoster virus (VZV) infection; health-care workers and family contacts of immunocompromised persons, those who live or work in environments where transmission is likely (e.g., teachers of young children, day care employees, and residents and staff members in institutional settings), persons who live or work in environments where VZV transmission can occur (e.g., college students, inmates and staff members of correctional institutions, and military personnel), adolescents and adults living in households with children, women who are not pregnant but who may become pregnant in the future, international travelers who are not immune to infection. Note: Greater than 90% of U.S. born adults are immune to VZV. Do not vaccinate pregnant women or those planning to become pregnant in the next 4 weeks. If pregnant and susceptible, vaccinate as early in postpartum period as possible. MMWR 1996; 45 (RR-11): 1-36, MMWR 1999; 48 (RR-6): 1-5.
- Meningococcal vaccine (quadrivalent polysaccharide for serogroups A, C, Y, and W-135)—Consider vaccination for persons with medical indications: adults with terminal complement component deficiencies, with anatomic or functional asplenia. Other indications: travelers to countries in which disease is hyperendemic or epidemic (“meningitis belt” of sub-Saharan Africa, Mecca, Saudi Arabia for Hajj). Revaccination at 3-5 years may be indicated for persons at high risk for infection (e.g., persons residing in areas in which disease is epidemic). Counsel college freshmen, especially those who live in dormitories, regarding meningococcal disease and the vaccine so that they can make an educated decision about receiving the vaccination. MMWR 2000; 49 (RR-7): 1-20. Note:The AAFP recommends that colleges should take the lead on providing education on meningococcal infection and vaccination and offer it to those who are interested. Physicians need not initiate discussion of the meningococcal quadravalent polysaccharide vaccine as part of routine medical care.
Vermont Selected Reportable Diseases—March 15, 2003
West Nile Virus Specimen Collection and Transport
Acute and convalescent serum:
Collect 7–10 ml of blood in a red-top or tiger-top collection tube. Collect acute phase serum on day 10 of illness, as most cases have detectable serum IgM antibody by the eighth day of illness. Collect convalescent serum on day 21 of illness; most infected individuals demonstrate serum IgG antibody by three weeks post infection. Any patient whose acute phase serum tests negative for IgM antibody needs to have a convalescent phase specimen submitted for testing. Centrifuge specimens and submit 1–2 ml of serum at refrigerator temperature to the Vermont Department of Health Laboratory.
Collect 1–2 ml of cerebrospinal fluid (CSF) as early as possible in the first few days of illness. IgM antibody will almost always be detectable in CSF by the eighth day of illness and sometimes as early as the day of onset of symptoms; compared with serum, IgM antibody in CSF is relatively short-lived. IgG antibody in CSF often does not reach detectable levels. Submit specimens frozen to the Vermont Department of Health Laboratory.
All specimens must be accompanied by a completed form VDHL Micro 214 “Request for Serological Examination for Bacterial, Fungal, Parasitic & Viral Agents” and a CDC History Form # 50.34 (rev 11/90). Date of onset must be included.
Call the laboratory at 1-800-660-9997, extension 7560 or 863-7560 to obtain forms and serology mailers.
Update on West Nile Virus
West Nile virus (WNV) has become established in the United States, with 44 states and the District of Columbia reporting WNV activity in 2002. Nationally, there were 3,893 confirmed human cases last year. In Vermont, one human, five horses, 125 dead birds, and 11 mosquito pools tested positive for WNV in 2002. Positive surveillance indicators were documented in 11 of Vermont’s 14 counties. Surveillance for WNV will be conducted again throughout the 2003 transmission season.
Who should be tested for WNV
Hospitalized patients with encephalitis, meningitis of suspected viral origin, or Guillain-Barré syndrome should be tested. Testing is not recommended for persons with mild illness, such as fever or headache, because levels of West Nile virus activity in the community would have to be very high for such symptoms to likely be due to WNV infection. Knowledge of the etiology is not required for establishing a care plan for mild illness. These persons should be advised to seek medical attention if more severe symptoms develop.
Newly recognized modes of transmission to humans
While the vast majority of human infections with WNV are mosquito-borne, newly recognized mechanisms of transmission were described in 2002. A cluster of four WNV caseswas reported in recipients of organ transplants from a common donor. There is also evidence that WNV can be transmitted through blood transfusion. The Food and Drug Administration has issued a guidance document for deferral of blood donors with suspect or diagnosed WNV.1 The benefits of receiving needed transfusions or transplants outweigh the potential risk for WNV infection.
An investigation of WNV in an infant identified transmission from mother to infant through breast milk as the most likely source of infection.2. Because the health benefits of breast-feeding are well established and the risk for WNV transmission through breast-feeding is unknown, the Centers for Disease Control (CDC) does not suggest a change in breast-feeding recommendations. The first case of transpla-cental WNV transmission was also reported.3. The CDC recommends that pregnant women should take precautions to reduce their risk for WNV.
- FDA. October 2002. www.fda.gov/cber/gdlns/wnvguid.htm
- CDC. Possible West Nile virus transmission to an infant through breast-feeding – Michigan, 2002. MMWR 2002;51:877-878.
- CDC. Intrauterine West Nile virus infection – New York, 2002. MMWR 2002;51:1135-1136.
Report Disease: Vermont Toll-Free 1-800-640-4374 or 1-802-863-7240
Vermont Department of Health
Division of Health Surveillance P.O. Box 70 Burlington, VT 05402-0070
Agency of Human Services
Paul E. Jarris, MD, MPH
THIS BULLETIN IS PRODUCED BY THE DISEASE CONTROL BULLETIN EDITORIAL STAFF.
Curt Lohff, MD, MPH
Report Disease: Vermont Toll-Free 1-800-640-4374 or 1-802-863-7240