MMWR: Flu recommendations and polio eradication update

Several interesting items related to vaccination appear in today's issue of MMWR. Among them:

-- A revision to the ACIP document "Prevention and Control of Influenza," an expansive review of all aspects of seasonal flu vaccination guidance and related data. Notable in this updated version is additional encouragement aimed at promoting influenza vaccination of health care workers as well as information on the composition of the 2007-08 vaccine.

-- A report on worldwide progress toward polio eradication, as of May 2007. The number of polio-endemic countries remains at four (Pakistan, Afghanistan, Nigeria, and India) with the vast majority of the 1,997 cases reported in 2006 occurring in Nigeria (1,123) and India (676). Global vaccination coverage stands at 78%, a number that is well over 90% in the Americas but far lower in Nigeria (39%) and India (58%). Those interested in polio eradication should visit our previous posts about polio, which include several items discussing the merits and challenges associated with pursuing eradication.

JAMA and Slate on vaccine-related replacement disease

A common question asked about vaccines that target specific variants of a pathogen (such as HPV, pneumococcus, or meningococcus) is how great the likelihood is that 'replacement disease' may occur. Simply stated, this phenomenon describes the emergence of new serotypes or subtypes not included in a vaccine becoming more prevalent as those that are included in the vaccine are eliminated.

A paper in JAMA this spring suggested replacement disease may be occurring among recipients of Prevnar, Wyeth's pneumococcal conjugate vaccine. (Four doses of the vaccine are recommended for all U.S. infants.) The paper was the basis for a commentary by Arthur Allen ("Fear of Replacement: What if a vaccine kills off one strain of a disease—but makes room for another?") that appeared in Slate late last month.

Ben Kleifgen, working at the Penn Center for Bioethics this summer, summarizes both items:

"In the JAMA paper, CDC’s Arctic Investigations Program observed an increase in pneumococcal infections in Native Alaskans receiving Prevnar. Of particular concern to researchers is the fact that the infections are largely from serotype 19A, a highly virulent but previously quite rare strain. Allen wonders if the threat of replacement disease may discourage further vaccine development, although the situation may not be that bleak. There is evidence that the new strain may be on the rise worldwide, unrelated to the use of Prevnar. In addition, Wyeth and GSK are both working on new pneumococcal vaccines that will cover 19A."

Info on Kawasaki disease added to RotaTeq label

A colleague from CDC alerted us to this announcement regarding a change to the label of RotaTeq, Merck's rotavirus vaccine recommended to all infants at 2, 4, and 6 months. Here's the first paragraph of the CDC statement:

"The Food and Drug Administration (FDA) approved today a revised label for RotaTeq, a rotavirus vaccine manufactured by Merck and Co., Inc., to include information on reports of Kawasaki disease occurring before and after the vaccine’s licensure in February 2006. FDA has not made any changes to its indications for use of RotaTeq nor has it issued new or revised warnings or precautions. Likewise, the Centers for Disease Control and Prevention (CDC) has not made any changes in its recommendations regarding the use of RotaTeq. Healthcare providers and parents should remain confident in using RotaTeq in infants."

Here's the FDA release and a related story from Reuters (the only media outlet to have reported on this item as of now.)

General info on Kawasaki disease can be found here and here. It's a rare and poorly understood inflammatory condition that affects 4,000 American children annually.

The "label" referred to in the announcements above is actually this document, an 11-page, single-spaced, data-laden product insert unlikely to top the reading lists of most parents (or pediatricians, for that matter).

The FDA statement notes, "The cases reported to date are not more frequent than what could be expected to occur by coincidence," a statement that could also describe its announcement in February regarding intussusception reports among recipients of RotaTeq.

Similar to that earlier occasion, this announcement was seemingly made so that providers and parents may be vigilant in looking for symptoms of Kawasaki disease, in case a connection to the vaccine does exist. However, calling attention to severe conditions for which no evidence suggests a vaccine link may create undue confusion and worry among parents still told to vaccinate their children with RotaTeq. Admittedly, it is a difficult balance that must be weighed by policy-makers, but one that merits further study.

Gardasil: CDC response on safety/efficacy; survey on parental support for mandates

The weekly news update from the Immunization Action Coalition alerted us to this CDC Q&A released last week titled "CDC Questions and Answers Concerning the Safety and Efficacy of Gardasil." The three-page document outlines the current status regarding safety monitoring, known safety concerns, the potential need for boosters, and the ongoing necessity of Pap screening.

It seems likely that the fact sheet was this breathless press release from JudicialWatch.org asserting (based on VAERS reports) that "three deaths were related to the vaccine." The CDC fact sheet clearly explains how and why this statement is a misinterpretation of VAERS data, reaching conclusions that are no possible from that information alone. Not surprisingly, a search of Google News suggests that the press release garnered virtually no attention from the print media. While safety concerns linked to Gardasil could still surface, there's no evidence at present to suggest such a connection.

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One other item related to Gardasil: The headline from a survey released by a group at the University of Michigan C.S. Mott Children's Hospital reads: "Majority of U.S. Parents Not in Favor of State HPV Vaccine Mandates." The report is available here, and here is coverage from CBS News and the Washington Times.

However, the headline -- while likely shrewdly written to generate the media coverage sampled above -- is very misleading. The report's own data (Table 1 in the report) lists 26% of parents disagreeing with an HPV mandate, 44% of parents agreeing, and a very significant 30% as 'neutral.'

Therefore, the same data could also carry the headline, "76% of parents not opposed to HPV mandate," which would actually more accurately capture the large percentage of respondents with no opinion for or against a mandate.

New and improved CDC website for vaccines

Last week the CDC launched a new web home for all of its vaccine-related content -- www.cdc.gov/vaccines. Timed with the creation of the National Center for Immunization and Respiratory Diseases, which replaces the National Immunization Program,
the website has many more resources, is better organized, and is a dramatic visual improvement over the former NIP site.

We're still exploring the new site, but there is clearly a great deal of new information in addition to the expected info regarding the ACIP, recommended vaccination schedules, safety, cost/access, and much more. Also prevalent are links to websites of non-CDC (but like-minded) advocates of vaccination.

There's no doubt that the new CDC vaccines site is the premier source for understanding the federal governments' responsibilities, activities, and recommendations on vaccination.

New data on HPV prevalence; conflicting thoughts on relevance to vaccine debate

Last week's JAMA paper by Dunne, et al., -- "Prevalence of HPV Infection Among Females in the United States" -- garnered a significant bit of media attention. An accompanying editorial, "Estimating the Population Prevalence of HPV," by Weller and Stanberry, makes a point of examining the implications of this data to HPV vaccination policy, specifically cost-effectiveness calculations. (Free abstracts; subscription required for full text).

Here's some of the coverage of the paper by the popular press: Associated Press, Dallas Morning News, Washington Times, and Washington Post.

The data has provided ammunition for both sides of the vaccine mandate debate. Proponents of vaccination (and mandates, specifically) are pointing to the surprisingly high prevalence of HPV, of all types, in women: 24.8%

Those on the other side note the study's findings that the specific HPV types included in Gardasil are present in only 3.4% of females. To critics of mandates, this suggests that it is unnecessary to vaccinate all young girls when only a small percentage of females have the specific strains included in the vaccine. However, these numbers do not change the overall facts regarding cervical cancer incidence and mortality.

If anything, the ways in which the Dunne, et al., paper's findings have been used and will continue to be used in the Gardasil debate offer a valuable lesson of the potential dangers of using statistics in isolation to advance a policy argument.

2007 Pediatric & adolescent immunization schedules released

Yesterday, the American Academy of Pediatrics released the 2007 recommended immunization schedules for children, adolescents and catch-up immunization. (As always, the schedules are a joint production of the ACIP, AAP, and American Academy of Family Physicians, but it appears that the AAP website is first to release it publicly.) The new schedule includes, among other changes, the new recommendations for rotavirus and HPV vaccination, as announced in 2006.

The traditional one-page schedule covering all vaccine doses from birth to 18 years had grown increasingly complex and crowded in recent years, a multi-colored sea of bars, shaded boxes, dotted lines, abbreviations, and minuscule print. The chief solution to this problem is the expansion of the single-page schedule to three pages, one for birth-6 years, another for ages 7-18, and a third for catch-up immunization spacing. Many of the more confusing design elements from years past have been eliminated and the fine-print footnotes are now bullet points.

While this update is marked improvement over previous versions with respect to comprehensibility, most parents will still be far better served consulting their physician to understand clearly which vaccines are recommended for their children and when.

Update, 1/5/06 -- The latest issue of CDC's MMWR also announces the newly revised schedules.

Updates on measles epidemics in U.S. and worldwide

A few items of note regarding measles outbreaks during the past few years:

• We've written several times about the 2005 measles outbreak in Indiana that sickened 34 (such as here and here). This AP story from late last month confirms what was widely speculated to be the cause of the outbreak: a 17-year old unvaccinated girl who traveled to a Romanian orphanage as part of a church mission trip, according to CDC.

• Farther from home, PLoS Medicine published yesterday a paper with the provocative (but accurate) title: "Unacceptably high mortality related to measles epidemics in Niger, Nigeria, and Chad," looking at mortality rates in three epidemics in 2004 and 2005. Accompanying the paper is an editorial titled "Measles still has a devastating impact on unvaccinated populations." To those close to global vaccination programs, the title will likely seem laughably obvious, but the paper is a noble effort to draw attention to the continued suffering caused by a completely preventable disease.
  

CDC releases updated "General Recommendations on Immunization"

Every few years, the Advisory Committee on Immunization Practices releases an updated version of its "General Recommendations on Immunization." The new document released Friday is an update to the previous version released in 2002.

As the title suggests, it is a series of recommendations that are not specific to a particular vaccine, addressing issues such as vaccine handling, administration, spacing, contraindications, and vaccination of specific populations (such as pregnant women or those with altered immune systems). Coupled with 200+ references to the medical literature, it's an excellent resource for those looking for a synopsis of a particular topic and directions for further study.

HPV: favorable data for male vaccination; VFC action; CDC shift in research focus

A paper published in the November issue of the journal Pediatrics includes new data from Merck on some of their ongoing trials of Gardasil in different populations. It's a highly technical paper with an equally complex title: "Comparison of the Immunogenicity and Reactogenicity of a Prophylactic Quadrivalent Human Papillomavirus (Types 6, 11, 16, and 18) L1 Virus-Like Particle Vaccine in Male and Female Adolescents and Young Adult Women." (free abstract; subscription required for full-text).

To summarize, the paper reports the results of trials examining whether the vaccine's response in 10-15 year olds mirrors what's been shown in older females (16-23 year-olds). The short answer is that it does generate a comparable ('noninferior,' in scientific jargon) immune response in younger populations. Good news. The most interesting finding from the perspective of potential ethical issues is the comparison of data between 10-15 year old boys versus girls. Boys had a nearly identical response to the vaccine as their female counterparts did as well as a virtually identical safety profile between genders. As the paper's authors (all of whom are employees or consultants of Merck, critics might note, despite that being an obvious result of a Merck trial) note:

"Our findings in boys lend support for implementation of gender-neutral immunization using this vaccine for the purpose of preventing the widespread morbidity and mortality from anogenital cancer, as well as dysplastic cervical and external genital lesions, in the general population."

Speaking of Gardasil, news earlier this week that the vaccine has officially been added to the federal government's Vaccines for Children program, ensuring its availability to uninsured children age 18 or under. Here's a brief story from UPI.

One final related item: a story from Wednesday's Washington Post, "CDC Shifts Vaccine-Data Focus," reports on the decision to refocus intensive data-collection activities on immunization in 22 major cities on teenagers rather than young children. The move is a result of multiple new vaccines recommended for adolescents, including vaccines against HPV, meningococcus, and tetanus/diphtheria/pertussis (Tdap).

From MMWR: childhood & 65+ vaccination rates, 2006-07 adult schedule, and Menactra safety update

A great deal of news on vaccines and vaccination efforts has appeared in recent issues of the CDC's Morbidity and Mortality Weekly Report. Here are some items of note:

• "Childhood Influenza Vaccination Coverage -- United States, 2004-05 Influenza Season" and "Influenza and Pneumococcal Vaccination Coverage Among Persons >65 Years -- United States, 2004-05." With flu cases starting (very slowly) to appear, these two pieces offer some data on the effectiveness of efforts to vaccinate two populations at higher risk of influenza-related complications. For children, the headline is that young children (19-35 months) had a substantially higher vaccination rate in the 04-05 season than for the previous year -- likely attributable to stronger ACIP recommendations. However, the overall percentage of fully vaccinated children in this age group was still very low (17.8%). For 65+ adults, the reverse phenomenon is true: both flu and pneumococcal vaccination rates are over 60%, but flu vaccination rates in 2005 were 4% lower than a year earlier. (The MMWR story notes that all of these numbers are well below the goal of 90% included in Healthy People 2010.)

• Better news can be found in this report, "Vaccination Coverage Among Children Entering School, 2005-2006 School Year." Compiling the latest data available, a editorial note accompanying the report explains, "More than half of reporting states indicate that they have already reached the Healthy People 2010 goal of >95% coverage for each of the vaccines recommended by the Advisory Committee on Immunization Practices (ACIP); the remaining states are making progress toward this goal."

• The 2006-2007 Recommended Adult Immunization Schedule, approved by the ACIP at their June meeting, has been published. Particularly because of efforts made at simplifying the schedule's design, the document is a great source for a general overview of recommended vaccinations in the 18+ population.

• One final item provides an update on reports of cases of Guillain-Barre Syndrome (GBS) among recipients of Menactra, Sanofi Pasteur's meningococcal vaccine. (We've written previously about this story in April.) A total of 17 cases have been reported with a suspected link to Menactra vaccination. As the report explains, analysis of these cases suggests a slightly increased risk of GBS among Menactra recipients, but the risk of meningococcus itself is among the reasons why no change in the current recommendation is being made at this time.
  

CDC Weekly Flu Update

We've added a link at the right to the CDC's Weekly Influenza Update. For those interested in tracking the flu season, the page includes week-by-week updates on the number of seasonal flu cases identified, the specific flu strains isolated, geographical variation, mortality, and more.

ACIP: June minutes and October agenda

The folks at the Immunization Action Coalition pointed out that the full minutes from the June 2006 meeting of the CDC Advisory Committee on Immunization Practices are now available here. The 96-page PDF is the next best thing to attending the meeting yourself, as it provides comprehensive coverage of everything that took place. In June, of course, the major news was the recommendation vote for Merck's HPV vaccine, Gardasil. For those interested in the data that informed the ACIP's recommendation, the report is invaluable.

Also on the ACIP website is a draft agenda for the group's next meeting, scheduled for October 25-26. The most notable item is a scheduled vote on a recommendation for Merck's shingles vaccine, Zostavax, for use in adults.

CDC report on 2005 infant vaccination coverage

The National Immunization Survey is an annual effort by the CDC to evaluate coverage rates in infant populations (19-35 months) across the country. The telephone survey has several limitations and many critics, but it remains the best available, most comprehensive source of data on the success of vaccination programs nationwide.

In this week's MMWR, the 2005 data and discussion has been published. The report doesn't lend itself well to summary here, but suffice it to say that it is an excellent starting point for those looking for data of the scope of U.S. vaccination efforts in infants.

'06 flu vaccine supply might set records

During our Labor Day publishing hiatus, good news came from CDC that the total supply of flu vaccine for the upcoming flu season may reach an all-time high. The headline is that more than 100 million doses are expected to be available by late fall, a number that could reach as high as 115 million if a new vaccine from ID Biomedical (part of GSK) is licensed in the near future, as is anticipated. Either estimate would easily surpass the previous all-time high of 83 million doses administered in a single season.

Here's the detailed CDC press release as well as the related news story from CIDRAP. Between the impressive supply forecasts and the expected arrival of a fifth vaccine, signs suggest that at least some lessons were learned from the Chiron-induced flu vaccine shortage of 2004. The next challenge will be working to ensure that those 100+ million doses are administered, particularly to those groups identified as high-risk populations.

June ACIP presentations available online

We neglected to mention that the slides from speakers at June's ACIP meeting were posted online in the last few weeks. For those looking for details, data, references, and scientific sophistication well beyond anything available in the media (for understandable reasons), these are great resources, particularly regarding Merck's HPV vaccine, the main item on the June agenda.

The files available include several presentations on Gardasil (safety and efficacy data from Merck, cost-effectiveness analyses, recommendation details, etc.), as well as the many other topics the committee considered, including a new recommendation for varicella vaccination, updates on influenza, mumps, rotavirus, avian flu, and much more.

Follow-up on ACIP Gardasil recommendation

Following up on last Thursday's post on the ACIP recommendation of Gardasil, here's a sampling of reaction in newspapers around the country:

• Both the Detroit Free Press and Press of Atlantic City ran 'local reaction' stories about the ACIP recommendation, surveying views from parents and physicians in their communities. Though some reservations are expressed -- both those unique to HPV as well as those common across all vaccines (i.e., safety) -- the vast majority of opinions in the story are positive.

• Two editorials specifically address the ACIP recommendation -- "A cancer vaccine triumph" (Chicago Tribune) and "Cancer prevention: Protect our girls" (Seattle Post-Intelligencer). Both pieces praise the recommendation (as the headlines would suggest), while postponing discussion of possible state mandates. The Tribune editorial ends this way:

  "But please, let's remember, this is a cancer vaccine. It's not a surrogate for the abstinence debate. Everyone is best served if this public discussion is about the safety, efficacy and cost-effectiveness of the new vaccine--and that's all."

Finally, the CDC website on HPV has been updated to reflect the Gardasil licensure and ACIP recommendation.

CDC: 2005-06 flu season mild; vaccine an ideal match

Last week's MMWR included a report on the flu season that concluded last month. It noted that this year was milder than the past several flu seasons and that the three flu strains selected for the '05-'06 vaccine matched the predominant strains isolated throughout the season. As the selection of viral strains to be included in the next year's vaccine is by no means an error-proof process, WHO should be lauded for their work.

The University of Minnesota's CIDRAP has a story of its own on the CDC report.

CDC update on Midwest mumps outbreak

Yesterday, the MMWR website posted a dispatch with an update on the mumps outbreak in the Midwest followed by a discussion of possible causes.

Through 2 May, 2,597 cases have been reported, 57% of which coming from Iowa. Fortunately, no more than 25 hospitalizations can be attributed to mumps among these cases, with no deaths.

Among the possible causes for the outbreak discussed in an accompanying editorial note are: 1) the close quarters of college dormitories, 2) the absence of 2-dose MMR vaccination requirements for college attendance in 8 of the 11 states affected, 3) delayed recognition of mumps by younger physicians with limited exposure (so to speak) to it or physicians not initially suspecting mumps among vaccinated patients, both leading to more time for transmission to occur, and 4) the long-known fact that the vaccine is less than 100% effective at preventing disease.

CDC fact sheet/Q&A on HPV vaccines

Likely of interest to many visitors to this site is a fact sheet recently posted by CDC on HPV vaccines. There's not much in the way of new information, but the site concisely covers most of the basic questions that might be missed by many amidst the more specific controversy surrounding the vaccine's arrival and implementation.

CDC update on global polio eradication efforts

The latest MMWR reports on progress made over the past 15 months in the quest to eradicate polio worldwide. Among the details included:

• The number of polio-endemic countries now stands at 4 (Afghanistan, India, Nigeria, and Pakistan), down from 6 as recently as February 2006 (Egypt and Niger have been dropped from the list.)
• India and Pakistan are moving closer to eradication, with a 50% decrease in cases over the past year.
• Nigeria remains the primary nation of concern (as we've written about previously). 41% of cases worldwide (799 of 1,948) occurred in Nigeria, and 94% of global cases were caused by viruses originating in northern Nigeria.
• Worldwide infant vaccination levels are estimated at 80%, but are much lower (as expected) in polio-endemic countries. The number is only 39% in Nigeria overall, and lower still in provinces with higher rates of polio transmission.

Today's report comes a month after an extended feature in the New York Times on polio eradication efforts, which we previously discussed here.

Provisional rotavirus recommendations expected within a month

This afternoon, the National Immunization Program hosted a live netconference titled "Current Issues in Immunization". Among the topics covered in the one-hour session were revisions to the General Recommendations on Immunization, the document updated every few years that provides general guidance of immunization practices in the U.S. The revisions, addressing particulars of simultaneous administration of multiple vaccines and the impact of altered immunocompetence on vaccination recommendations, were discussed in detail at the February ACIP meeting.

Also presented was an update on the recently licensed and recommended rotavirus vaccine, Merck's RotaTeq. CDC's Dr. Umesh Parashar gave an overview of rotavirus epidemiology worldwide and in the U.S., contrasted RotaTeq with RotaShield (Wyeth's failed vaccine of 1998-99), and offered an update on the current status of the ACIP recommendation approved in February that all infants receive the vaccine at 2, 4, and 6 months.

According to Dr. Parashar, the ACIP recommendation is currently undergoing final clearance from the CDC and HHS. These required approvals are expected within the next month, at which point provisional recommendations will be posted online here. Recommendations do not become official until printed in the Morbidity and Mortality Weekly Report (MMWR), a step expected to occur sometime in fall 2006.

Still, federal government vaccination recommendations remain only recommendations unless individual states act to require the vaccine as a condition of school or day care attendance. These mandates are widely expected for RotaTeq, but require actions by state departments of health or (in some cases) legislatures. Mandates for rotavirus vaccination are not expected to be nearly as contentious as those for HPV vaccines in the months and years ahead.

Evaluating the adequacy of pediatric vaccine stockpiles

While the Chiron-induced flu vaccine shortage in 2004 received far more public attention, there have been a number of shortages of universally-recommended pediatric vaccines since 2001. Among the vaccines in limited supply at some point in the past five years are measles/mumps/rubella, varicella, and diphtheria/tetanus/pertussis, among others. There's little doubt that the likelihood of temporary shortages is increased by the presence of only a single manufacturer of many recommended pediatric vaccines. Ensuring an adequate supply of those vaccines recommended to be administered to all children is very much an ethical issue.

The reasons for the current shape of the U.S. vaccine marketplace are many and well documented elsewhere. While some may hope for a wholesale redesign of the vaccine production marketplace, a more immediate response implemented by the CDC has been the creation of a 6-month stockpile of many recommended pediatric vaccines. The stockpile is intended to provide a buffer against short-term disruptions.

The current issue of Vaccine has an interesting paper that examines the adequacy of current stockpile levels to respond to shortages. The paper is titled "Stockpile levels for pediatric vaccines: How much is enough?" (free abstract, subscription required for full text). Using mathematical modeling, the authors' data validate the belief that current levels are adequate for a 6-month shortage of the vaccines included in the stockpile. Not surprisingly, the current stockpiles are very likely too small for a shortage of 8 months or longer, depending on how severe the shortage is. It should be noted that most recent pediatric vaccine shortages have lasted over one year.

CDC update on possible link between meningitis vaccine and Guillain-Barre Syndrome

Today's issue of the Morbidity and Mortality Weekly Report (MMWR -- the widely-read CDC infectious disease publication) includes an update on a series of cases of Guillain-Barre Syndrome among college-age students shortly after receiving meningococcal vaccine. Below are excerpts from the CDC summary of the report. The bottom line: It's unclear whether the vaccine is responsible for the GBS cases, further study is needed, and no changes for the time being regarding the recommendation status of the vaccine.

"In October 2005, a possible association between Guillain-Barré Syndrome (GBS) and receipt of meningococcal conjugate vaccine (MCV4)...was reported. GBS is a serious neurologic disorder involving inflammatory demyelination of the peripheral nerves. At the time of the first report, five confirmed cases of GBS after receipt of MCV4 had been reported to the Vaccine Adverse Events Reporting System (VAERS). During the 4 months since, three additional confirmed cases of GBS have been reported...

Because available evidence neither proves nor disproves a causal relation between MCV4 and GBS, further monitoring and studies are ongoing within VAERS and the Vaccine Safety Datalink (VSD). CDC continues to recommend use of MCV4 for persons for whom vaccination is indicated; the additional reported cases have not resulted in any change to that recommendation."

"Autism controversy eats at credibility of CDC"

Thursday's Atlanta Journal-Constitution (registration required) has a very good story detailing some of the recent developments in the continuing vaccines and autism controversy. As to the validity of such a link, there's no news and still no evidence to support it, according to the American Academy of Pediatrics and the CDC, among many others. But renewed interest and support from members have Congress have redirected attention to the topic, which by itself has an impact on vaccination, as the story explains...

"As the debate and controversy increasingly finds its way into pediatricians' offices, average parents of healthy children are questioning whether vaccines are safe, sometimes even refusing inoculations.

The CDC and other public health officials insist such questions lack a basis in fact or science. Their greatest concern is that the broadening debate holds the potential to put a new generation of children at certain risk of deadly diseases if confidence in the safety of vaccines is lost and they don't receive recommended shots.

'I think it's huge,' said Dr. Julia McMillan, a member of the American Academy of Pediatrics committee that makes vaccine recommendations. 'There's no pediatrician in practice that doesn't confront this on a weekly basis: families who are questioning the need for – and in some cases refusing — vaccines for their children.'"

Yesterday's USA Today featured a full page ad paid for by several autism advocacy groups which cites Robert F. Kennedy's comments on the CDC last month (which we wrote about here) and links to the website www.putchildrenfirst.org. That site, which includes links to numerous CDC documents, memoranda, and e-mails, describes its mission as follows...

"In our efforts to share the truth with other parents, we have been frustrated by the amount of misinformation in the press stating that the connection between mercury and autism has been disproven. This website was constructed to share the truth about what 'proof' actually means.

The National Immunization program (sic) is at risk. The CDC through the choices made, has eroded public trust. Autism is a national emergency and a national shame. We need independent journalists and members of Congress to take action now and put our children first."

In the AJC, the CDC responds... "CDC spokesman Glen Nowak said many of the documents on the site have been in the public domain for years, and are presented out of context and in ways that may 'look quite ominous' – when they're not." Regarding the USA Today advertisement, the CDC released this response, expressing 'disappointment' at how their (and others') efforts were characterized.

Finally, the Vaccine Education Center at the Children's Hospital of Philadelphia recently updated its page on "Thimerosal and Autism."