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Great farming spot if you have a mining/skinner who can pick up cobalt nodes around the spot as well as skin the trapdoor crawlers. You could swap mining for herbalism I believe as there are talandra's roses spread around the area as well. The point of this area is to get iceweb spider silk and borean leather, everything else is just icing on the cake. I averaged one iceweb spider silk per minute farmed, which is just nasty!
I use the silk for the four spellthreads on my tailor because sometimes there literally are 0 on the auction house. Check out this video for location and more details.
Great farming spot if you have a mining/skinner who can pick up cobalt nodes around the spot as well as skin the trapdoor crawlers. You could swap mining for herbalism I believe as there are talandra's roses spread around the area as well. The point of this area is to get iceweb spider silk and borean leather, everything else is just icing on the cake. I averaged one iceweb spider silk per minute farmed, which is just nasty!
7 comments: on "700g an hour - Iceweb Spider Silk and Borean Leather"
Anonymous said... June 29, 2010 at 8:12 AM
I dropped skinning for a second jewelcrafter. Skinning cannot make money as fast as a 2nd jewelcrafting daily to get a dragon's eye into a nightmare tear.
Plus my favorite way to move leather is cross faction.
Sorry to disagree with you markco ;)
Markco said... June 29, 2010 at 8:32 AM
How are you disagreeing? I too love to move materials cross faction such as borean leather (that has become a necessity as of late) but there are times when there is just no leather and no spidersilk on the ah (remember I am on a very small server).
Also, remember that the audience here is not all players trying to squeeze out the best strategy to make gold, some are just trying to find a place to farm and get enough gold quickly before a raid.
Hopefully both farmers and non farmers will benefit from the spots I've covered on this blog.
Anonymous said... June 29, 2010 at 11:52 AM
Oh how I miss when people raided naxx, iceweb spider silk was so common back then.
Anonymous said... June 30, 2010 at 4:47 AM
I have a pet that needs leveling so this looks like a good spot to kill 2 birds with one stone. Don't forget arctic fur can drop too.
Anonymous said... June 30, 2010 at 10:45 PM
Looks like a good spot, very server dependent of course, a couple months ago on my (very high pop) realm, iceweb silk was going for almost 10g each and I was farming it in the cave north of K3 like there was no tomorrow. At first I was the only one there, but gradually other people caught on that it was a ridiculously easy way to make some quick cash, and now the competition for farming spots is too high and the price has dropped to almost 3g. Not worth the effort anymore, better off fighting the bots over eternal fire at the anvil at this point. That's not uncommon for a high pop realm though, there are rapid shifts in the market sometimes. Glyphs for example which had been flooded and nearly unprofitable a couple months ago is a great market on my server again, as are low level greens which can be easily farmed from instances on pretty much any level 80 character. One of my favourite farming methods is emptying my bags and pulling an entire instance on my 80 frost tank, then deathchill + howling blast and loot loot loot xD
Raddik said... July 6, 2010 at 4:48 PM
Just tried 5 minutes ago with my skinner Rogue and noticed that the spider silk is a DROP and not a skinning material... so... now I'm flying there with my lvl76 priest ^^ leveling and making gold together is awesome.
Richard said... August 28, 2010 at 11:09 AM
just working my way through back posts as I begin to learn my way around the AH.
I tried this the other night and ended up with 20 iceweb silks and 120 borean leather (a hunter there was looting but not skinning). At most this is worth 150g on my server and there are more profitable things I can do with my time, but I'm a great believer in trying things out and keeping what works.
What I do have is a nice supply of the 'silks' for my professions that is non-auction house dependant and that is a plus.
Onto the next post :)
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East of England leads in export growth
17:45 18 March 2013
The East of England is the fastest growing region in the country when it comes to non-EU exports, according to research.
The latest trade figures from HM Revenue and Customs have shown that the East's exports outside the EU now stand at 16.4pc year on year – while exports to the recovering US market have grown 28pc year on year.
The total value of exports from the region during the final three months of 2012 (October-December) was £6.7bn.
Meanwhile, the annual total for exports from the region was £26.7bn.
Liz Basing, regional director for UK Trade & Investment (UKTI), said: "East of England companies are doing brilliantly in markets outside Europe. That is where the best long- term growth prospects are but that does not mean Europe isn't important.
"The EU still accounts for more than half the exports and the US is once more the single most important overseas market for businesses in the East of England. My team at UKTI East is looking forward to helping even more regional companies do more business across the full range of markets from Brazil, Boston or Benelux.
Exports to the USA and Hong Kong are the region's fastest growing markets amongst the top 10 export destinations with increases of 28pc and 57pc respectively year on year.
There was also strong growth in exports to some of the BRICS countries Brazil, India and South Africa, with increases of 19%, 13% and 21pc year on year respectively.

subset: commoncrawl


text:
A British woman's entry in a London cake decorating competition is a cake bust of Prince William and fiancee Kate Middleton.
Wibowo, who runs her own company, Sugarart, said her traditional English fruit cake is carved into 3D busts of the royal couple with an armature inside and is covered with apricot jam.
The cake is to go on display with other entries Wednesday.
"I used this cake competition as a great opportunity to do something different, other than the usual traditional decorated round tiered cake people normally expect for a wedding cake. It was really a challenge for me to do this cake. It's hard work, but I really enjoyed making it," Wibowo said.
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MSI Wind, fixing the touchpad after resume
By David Clack on Feb 10, 2009
Hi All,
So I went back to B104 on the MSI Wind, just could not really get suspend / resume working on B107.
Suspend / resume works fine, the touchpad does not work after resume.
If I do this:
modinfo | grep mouse8042
grab the index
modunload -i <index>
modload /kernel/driver/mouse8042
Touchpad comes back on again
So I later found out you really don't have to do the modload, something, is doing it.
Randy F. gave me this:
MODID=`modinfo | grep mouse8042 | awk '{print $1}'`
modunload -i $MODID
I've just put it in a script in /usr/bin, I'll have to find a way to activate it after resume.


text:
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Wednesday, September 14, 2011
First, a big
for the start of week 4 of my life
When I made the decision to change my lifestyle, I choose walking and riding my bicycle as my primary forms of cardio. For one reason or another, I have not been on my bike in almost 3 weeks. I got my bike in working order and decided to take a ride yesterday. Now, when I stared this plan of change, I would ride just over 5 miles. I slowly worked up to just over 6 miles, but I was really working. I'd get off my bike and my legs would feel like Jell-o. When I started yesterday, I decided I would check my time at my turn around point. If it was 15 minutes or less, I would keep going. Sure enough, 15 minutes, so I kept going. As I would approach a new traffic light, I would think to myself, "I'm doing okay, so let's go to the next light." When I reached Makaha Valley Road, it came as a shock. I decided to turn around there, with the thought that if the trip back became too much, I would just stop and wait for the bus. As I pedaled back towards Nanakuli, I realized that school had gotten out, and that the bus would be packed, and all I can say is I DO NOT enjoy riding a bus packed with High Schoolers. I pushed it until I had no choice because the next bus stop is the one I get off at anyway. When I got home, I was breathing hard, but not on the verge of gasping. I got off my bike, and my legs did not feel like they would crumple out from under me at any moment. I was feeling good, and proud of my accomplishment. When I mapped my trip, I was completely shocked to see how far I had actually gone. My round trip was 11.66 miles. I have NEVER ridden that far. The furthest I had gone was just over 6 miles. I am amazed and proud and feel like a champ!
I have an appointment at 11:45 to donate blood. As a Nursing Assistant in the major hospital and trauma center for Honolulu and as someone with one of the rarer blood types, I know how important blood donation is. It is not unusual for the Blood Bank to call me and request I come in to donate. I have not made a donation for a while, because the last 2 times I tried, my blood clotted off before they were able to collect the full pint. I felt like I failed, because they can use the blood for research, but it won't be able to be used for transfusions. I have found that when I am eating healthy, drinking plenty of water and exercising, blood donation is a snap. Not only do I not clot off before they get enough, but the blood flows quickly and I fill a pint bag in 10 minutes instead of 30. I want to earn a spot on the 100 pint wall of honor, so I am determined to donate as often as I can.
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Pullmoddai (Trincomalee District) – Relief
The IDP site in Sahanagama in Pulmodai, Trincomalee accommodates 2,300 IDPs in blocks C and D and Sarvodaya has provided non-food relief items including baby kits, bed sheets, shorts, baby mosquito nets, mats and soft toys to IDP families.
Presently communal cooking is taking place in Sahanagama IDP site and Sarvodaya is providing supplementary food items to cook the food and WFP is providing rice, dhal and cooking oil. So far 27,600 food parcels have been provided to Sahanagama.
For the latest statistics of Sarvodaya work in Pullmodai, please click here.
Updated 01st June, 2009, Sarvodaya Emergency Relief Operation Center


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You will need the following items for this spell:
- 4 Red candles.
- Lighter
Use this simple wiccan spell to create wealth for you in your everday life.
Casting Instructions for 'Simple Money Spell'
Similar Spells
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SpellsOfMagic has a huge online store, supplying you with any and all your occult and new age needs.
Light the candles one by one while imagining the dream of cash that you desire.
After five minutes of imagination, pronounce, "Lovy Lady of the Moon, bring to me your wealth right soon. Fill my hands with silver and gold. All you give, my purse can hold."
Repeat this three times and then blow out the candles.
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Women's Swimming Duo Sweep Weekly Honors
Jan. 15, 2013
AMHERST, Mass. - This week the Atlantic 10 Conference recognized both Michaela Butler and Jocelyn Yuen for their outstanding performances this past weekend at the Rhode Island Invitational. Michaela Butler was named women's A-10 Performer of the Week, while Yuen was named women's A-10 Rookie of the Week.
Butler, a redshirt junior out of Dennisport, Mass., receives this honor after sweeping both the one- and three-meter boards this past weekend. She was able to capture the one-meter dive with a score of 268.20, and the three-meter with a score of 294.55. This is her second Performer of the Week nod of the season.
Yuen, a freshman from Princeton, N.J., receives her third Rookie of the Week honor of the season following her three individual wins at the URI Invite. She was able to sweep the butterfly events, pulling times of 57.98 in the 100 and 2:08.07 in the 200. She also took first in the 200-yard IM with a time of 2:09.79.
The Minutewomen will be back in action this weekend as they take on Bryant University in their final home meet of the 2012-13 season. The meet is set to kick off from Joseph Rogers Pool at 1 p.m., with senior day festivities taking place prior to the meet.
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Working for CASA
Find a job in care with CASA
The CASA group employs over 450 people across England.
If you are considering a career with us, this is where you can find out more.
Margaret Elliott, Director CASA
If people are valued, they respond to that and give back…
We can offer you a great career with CASA. Working with us is different because all members of the CASA Family are social enterprises – they are employee owned and controlled, so frontline workers are directly involved in how their service is managed and delivered. Every employee is entitled to free shares in the company after 6 months, so you become one of the owners of the company.
We believe that by supporting and training all our staff, we can provide a better service as well as offering people the chance to progress through the organisation.
Here are some of the things people say about working with us:
It's more like a family oriented company
It's a nicer way to work
I just love what we're about
There's so many different variations of different training we can do
The support network is second to none
We all have a vested interest in ensuring that the company we work for is a success
I love it working here… there's a great camaraderie between the support workers


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Temporarily Unavailable Grown in the remote jungles of Sulawesi where it takes at least four days to transport items to the nearest city, this organic coffee is a coveted delight. The coffee trees in Sulawesi typically produce small yields, and while under strict organic practices, each tree is cultivated without the use of man-made pesticides; this is why the supply is limited.
Organic Sulawesi 'Port Icewik' Fair-Trade coffee is a direct descendant of Arabica coffee varietals found in Yemen. Brought to Sulawesi by a Dutchman named Icewik, the trees prospered in the humid, tropical climate. The coffee trees were abandoned, but despite being unattended for almost 400 years the trees survived.
When we have the beans in stock, we medium-light roast each small batch to produce a delightful aroma and unique flavor profile. We hope to have it back very soon!
Organic Sulawesi 'Port Icewik' Fair-Trade Coffee (5lb Bag)
Organic Sulawesi 'Port Icewik' Fair-Trade Coffee (5lb Bag)
Arthur Arens
Colorado Springs, CO
5 Stars
I would recommend this item to a friend.
Outstanding Flavor!
February 5, 2011
This coffee provides a flavor like no other. Smooth, low on acid and a true uniqueness in flavor. I look forward to a cup every morning. A true gem.
Pros:Flavor Smoothness Aroma
Rose Anne
Mansura, LA
5 Stars
I would recommend this item to a friend.
Best coffee ever!
January 10, 2011
I've tried at least 10 different kinds of organic whole bean coffees from this website and this particular bean makes THE BEST coffee I've ever tasted in my life -- rich, mellow, full-bodied. It's even better than Starbucks!!


text:
Martin L. Young Jr.
Industry Consultant and Trainer
Martin L. Young Jr. has been an industry consultant and trainer for 20 years, and a member of various stakeholder groups on environmental issues. He is a past president of the North Carolina Association of Launderers & Cleaners (NCALC). He grew up in his parents' plant in Concord, N.C., Young Cleaners, which he operates to this day. Contact him by phone at 704-786-3011, or via e-mail at firstname.lastname@example.com.


text:
This spherical four-bar linkage was designed by Kaustubh Sonawale to guide the wings of the Icon A5 from deployed to stowed positions and back.
Archive | August, 2012
Spherical Four-bar Linkage Design: Mech Gen 4
This version of Mechanism Generator uses five orientations of a moving body to design a spherical four-bar linkage. As with other versions of Mech Gen the system searches in tolerance zones around the task positions to find a number of useful designs. This is more good work by the team of Alex Arredondo and Kaustubh Sonawale.
Bobbin Linkage for a Rotating Weaver
This linkage is designed to guide the bobbin thread of a rotating weaver to knit the reinforcement web for hosing. Though only one linkage is shown, there is one linkage for each bobbin. This design was developed by Mark Plecnik with help from Kaustubh Sonawale.
Workshop Presentations: 21st Century Kinematics
The NSF Workshop on 21st Century Kinematics at the 2012 ASME IDETC Conference in Chicago, IL on August 11-12, 2012 consisted of a series of presentations and a book of supporting material prepared by the workshop contributors.
The book is now available at amazon.com: 21st Century Kinematics–The 2012 NSF Workshop.
And here are the seven primary presentations given at the workshop.
- Computer-Aided Invention of Mechanisms and Robots. J. Michael McCarthy, Professor, University of California, Irvine.
- Mechanism Synthesis for Modeling Human Movement. Vincenzo Parenti-Castelli, Professor, University of Bologna.
- Algebraic Geometry and Kinematic Synthesis. Manfred Husty, Professor, University of Innsbruck.
- Kinematic Synthesis of Compliant Mechanisms. Larry Howell, Professor, Brigham Young University.
- Kinematics and Numerical Algebraic Geometry. Charles Wampler, Technical Fellow, General Motors Research and Development.
- Kinematic Analysis of Cable Robotic Systems. Vijay Kumar, Professor, University of Pennsylvania.
- Protein Kinematics. Kazem Kazerounian, Professor, University of Connecticut.
Colleagues joined in with two additional presentations:
- Development of Fast Pick and Place Robots. Jorge Angeles, Professor, McGill University.
- Kinestatic Analysis of Mechanisms with Compliant Elements. Carl Crane, Professor, University of Florida.
Many thanks to the contributors and the attendees for an outstanding workshop.
Icon A5 spherical four-bar wing linkage
This shows the wing movement of the Icon A5 as guided by a spherical four-bar linkage. This is a new design by Kaustubh Sonawale which ensures the wing clears the horizontal stabilizers in the rear as it moves from the deployed to folded positions and back again.
Six-bar gripper with fine adjustment
This is a robotic gripper designed by Andrea Carli and Kaustubh Sonawale. It uses a six-bar linkage for the primary movement and a slider adjustment to provide a gripping fine movement.
21st Century Kinematics: Workshop Schedule
Here is the schedule for the IDETC/NSF Workshop on 21st Century Kinematics:
Workshop on 21st Century Kinematics: The Book
The presenters for the 2012 IDETC/NSF Workshop on 21st Century Kinematics, August 11-12, 2012, Chicago, Il, have gathered background information into this book published by Springer. It is a guided compilation of work by the presenters found in their recent papers and books. We are grateful to ASME, IJRR, Robotica and Springer for the permission to reprint these excerpts.


text:
"Immunizations." has been saved, and will be accessible from the My NGC page.
Go to My NGC
Alert me when this guideline summary is updated.
This is the current release of the guideline.
This guideline updates a previous version: Institute for Clinical Systems Improvement (ICSI). Immunizations. Bloomington (MN): Institute for Clinical Systems Improvement (ICSI); 2011 Mar. 70 p. [72 references]
Persons of all ages in the United States
A consistent and defined process is used for literature search and review for the development and revision of Institute for Clinical Systems Improvement (ICSI) guidelines. The literature search was divided into two stages to identify systematic reviews (stage I) and randomized controlled trials, meta-analyses and other literature (stage II). Literature search terms used for this revision are below and include literature from October 1, 2010, through December 31, 2011.
Search terms included: diphtheria, tetanus; pertussis; hepatitis A and B; rotavirus; meningococcal, pneumococcal, inactivated polio virus, herpes zoster, human papillomavirus; influenza; measles, mumps, rubella; varicella; haemophilus influenzae B. The Cochrane and PubMed databases were searched. The search was limited to systematic reviews and randomized control trials.
Not stated
Following a review of several evidence rating and recommendation writing systems, Institute for Clinical System Improvement (ICSI) has made a decision to transition to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system.
Crosswalk between ICSI Evidence Grading System and GRADE
Evidence Definitions
High Quality Evidence = Further research is very unlikely to change confidence in the estimate of effect.
Moderate Quality Evidence = Further research is likely to have an important impact on confidence in the estimate of effect and may change the estimate.
Low Quality Evidence = Further research is very likely to have an important impact on confidence in the estimate of effect and is likely to change the estimate or any estimate of effect is very uncertain.
In addition to evidence that is graded and used to formulate recommendations, additional pieces of literature will be used to inform the reader of other topics of interest. This literature is not given an evidence grade and is instead identified as a Reference throughout the document.
Guideline Development Process
A work group consisting of 6 to 12 members that includes physicians, nurses, pharmacists, and other healthcare professionals relevant to the topic, along with an Institute for Clinical Systems Improvement (ICSI) staff facilitator, develops each document. Ordinarily, one of the physicians will be the leader. Most work group members are recruited from ICSI member organizations, but if there is expertise not represented by ICSI members, 1 or 2 members may be recruited from medical groups or hospitals outside of ICSI.
The work group will meet for 7 to 8 three-hour meetings to develop the guideline. A literature search and review is performed and the work group members, under the coordination of the ICSI staff facilitator, develop the algorithm and write the annotations and literature citations.
Once the final draft copy of the guideline is developed, the guideline goes to the ICSI members for critical review.
Not applicable
Cost-Effectiveness of Varicella Vaccine
It is cost effective to do immune status testing for all persons 13 years of age and older, who believe they are nonimmune, before vaccinating against varicella. More than 75% of them will be immune. The prevaccination testing will also substantially reduce the average number of needle sticks that patients in this age range need. For most that number will be only one.
Critical Review Process
Every newly developed guideline or a guideline with significant change is sent to Institute for Clinical Systems Improvement (ICSI) members for Critical Review. The purpose of critical review is to provide an opportunity for the clinicians in the member groups to review the science behind the recommendations and focus on the content of the guideline. Critical review also provides an opportunity for clinicians in each group to come to consensus on feedback they wish to give the work group and to consider changes necessary across systems in their organization to implement the guideline.
All member organizations are expected to respond to critical review guidelines. Critical review of guidelines is a criterion for continued membership within ICSI.
After the critical review period, the guideline work group reconvenes to review the comments and make changes, as appropriate. The work group prepares a written response to all comments.
Each guideline, order set, and protocol is approved by the appropriate steering committee. There is a steering committee for Respiratory, Cardiovascular, Women's Health, and Preventive Services. The Committee for Evidence-based Practice approves guidelines, order sets, and protocols not associated with a particular category. The steering committees review and approve each guideline based on the following:
Once the guideline, order set, or protocol has been approved, it is posted on the ICSI Web site and released to members for use.
Revision Process of Existing Guidelines
ICSI scientific documents are revised every 12 to 36 months as indicated by changes in clinical practice and literature. ICSI checks with every work group 6 months before the schedule revision to determine if there have been changes in the literature significant enough to cause the document to be revised earlier than scheduled.
ICSI staff working with the work group to identify any pertinent clinical trials, meta-analysis, systematic reviews, or regulatory statements and other professional guidelines conduct a literature search. The work group will meet for 1-2 three-hour meetings to review the literature, respond to member organization comments, and revise the document as appropriate.
A second review by members is indicated if there are changes or additions to the document that would be unfamiliar or unacceptable to member organizations. If a review by members is not needed, the document goes to the appropriate steering committee for approval according to the criteria outlined above.
Note from the National Guideline Clearinghouse (NGC) and the Institute for Clinical Systems Improvement (ICSI): In January 2013 the ICSI Immunization Work Group created new recommendations for the pneumococcal vaccination. The updated recommendations are included in Annotation #20 below. In May 2014 the ICSI Immunization Work Group modified the recommendations for haemophilus influenza b Conjugate (HIB) vaccine and the meningococcal vaccine. The modified recommendations are included in Annotations #10 and #19 below, respectively. The Work Group has also included supplemental information about the pending human papillomavirus 9 (HPV9) vaccine in Annotation #19 below
For a description of what has changed since the previous version of this guidance, refer to Summary of Changes Report -- March 2012 . In addition, ICSI has made a decision to transition to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system. This document is in transition to the GRADE methodology. Transition steps incorporating GRADE methodology for this document include the following:
The recommendations for immunizations are presented in the form an algorithm and immunization schedules with a total of 23 components accompanied by detailed annotations. Immunization schedules and an algorithm for Immunization Administration are provided in the original guideline document at the ICSI Web site. Clinical highlights and selected annotations (numbered to correspond with the algorithm) are provided below.
See the "Qualifying Statements" field for specific information related to vaccine shortages; persons vaccinated outside the United States, including internationally adopted children; and combination vaccines.
Class of evidence (Low Quality, Moderate Quality, High Quality, Meta-analysis, Systematic Review, Decision Analysis, Cost-Effectiveness Analysis, Guideline, and Reference) definitions are provided at the end of the "Major Recommendations" field.
Clinical Highlights
Immunization Schedules
See the original guideline document for the following immunization schedules:
Immunization Administration Algorithm Annotations
Ask patient if they have received vaccinations elsewhere and/or review immunizations information in state or local immunization information systems (i.e., immunization registries).
Providers should only accept written, dated records as evidence of vaccination. With the exception of influenza vaccine and pneumococcal polysaccharide vaccine (PPSV), self-reported doses of vaccine without written documentation should not be accepted. Although vaccinations should not be postponed if records cannot be found, an attempt to locate missing records should be made by contacting previous health care providers, reviewing state or local immunization information systems (IIS), and searching for a personally held record. If records cannot be located, these persons should be considered susceptible and should be started on the age-appropriate vaccination schedule. Serologic testing for immunity is an alternative to vaccination for certain antigens (e.g., measles, rubella, hepatitis A, and tetanus).
Document historical vaccines in patient's medical record. At a minimum, include vaccine and date administered.
Compare patient's immunization history to current recommended immunization schedules to identify needed immunizations (see schedules in the original guideline document).
Vaccine recommendations are determined after extensive studies in large clinical trials. They include studies on how vaccine recipients respond to multiple vaccines given simultaneously. The overall aim is to provide early protection for infants and children against vaccine-preventable diseases that could endanger their health and life. No scientific evidence exists to support that delaying vaccinations or separating them into individual antigens is beneficial for children. Rather, this practice prolongs susceptibility to disease, which could result in a greater likelihood of the child becoming sick with a serious or life-threatening disease. There could also be added expense (e.g., multiple office visits), additional time off from work for parents, and increased likelihood that the child will fail to get all necessary vaccinations.
For more information refer to the Childhood Immunization Schedule: Why Is It Like That? (AAP) http://www.vaccinateyourbaby.org/pdfs/Vaccine_schedule.pdf
Patients should receive all routinely recommended immunizations.
Patients with medical risk factors, lifestyle risk factors, or certain occupations may need additional vaccines.
If the minimum interval between doses in a series has not been met, defer vaccine and schedule appointment when dose can be administered (see Catch-Up Immunization Schedule for Persons Aged 4 Months Through 18 Years Who Start Late or Are More Than 1 Month Behind [CDC] or Catch-Up Schedule and Minimum Intervals for Adults [Minnesota Department of Health (MDH)]) in the original guideline document). It is not necessary to restart the series if there has been a delay between doses of vaccine in a series.
Responding to Vaccine-Hesitant Parents
Most parents believe in the benefits of immunization for their children. However, health care providers may encounter parents who question the need for, or safety of, childhood vaccines. Such parents may choose to delay or forgo immunizing their children with some or all of the recommended vaccines. To assist parents in making fully informed immunization decisions, providers should try to understand differing views of vaccine risks and benefits, and be prepared to respond effectively to concerns and questions. There are many tools available to assist with this discussion such as:
Educate Patient, Parent/Guardian about Vaccine
Providers should discuss with the patient the benefits of vaccines, the diseases that the vaccines prevent, and any known risks from vaccines. These issues should be discussed in the patient's native language, whenever possible. Printed materials, accurately translated into the patient's language, should be provided. For most commonly used vaccines, the U.S. federal government has developed Vaccine Information Statements (VISs) to give to potential vaccine recipients. For vaccines covered by the National Childhood Vaccine Injury Act, including those vaccines used in children, these forms are required. These statements are available in English and other languages. Where a form is available for vaccines not covered by the National Childhood Vaccine Injury Act, it should be used. Ample time should be allotted with patients, parents/guardians to review written materials and address questions and concerns. Patients, parents/guardians should be encouraged to take responsibility for ensuring that the patient is fully vaccinated. Providers should encourage patients, parents/guardians to inform the health care professional of adverse events after the vaccine is administered and explain how to obtain medical care, if necessary. Information and assistance can be obtained by calling the CDC-INFO Contact Center (1-800-232-4636) or on the Internet at http://www.cdc.gov/vaccines .
Assess Patient for Contraindications or Precautions
Providers should follow only medically accepted contraindications. Failure to differentiate between valid and invalid contraindications often results in the needless deferral of indicated vaccinations. Some of the most common invalid contraindications are mild illnesses, conditions related to pregnancy and breast-feeding, allergies that are not anaphylactic in nature, and certain aspects of the patient's family history. Providers should ask about any condition or circumstance that might indicate that a vaccination should be withheld or delayed. Providers should also inquire about previous adverse events temporally associated with any vaccination [Guideline].
Health care professionals should refer to the Guide to Contraindications to Vaccinations published by the CDC at http://www.cdc.gov/vaccines/recs/vac-admin/contraindications-vacc.htm .
Simultaneously Administer All Doses of Vaccine for Which the Patient Is Eligible
Administering vaccines simultaneously (at the same visit), in accordance with recommendations from the Advisory Committee on Immunization Practices, the American Academy of Pediatrics and the American Academy of Family Physicians is safe, effective and indicated. Although the immunization schedule provides age flexibility for administering certain vaccine doses, simultaneous administration decreases the number of visits needed and the potential for missed doses, and it enables earlier protection. When indicated vaccines are not simultaneously administered, arrangements should be made for the patient's earliest return to receive the needed vaccination(s). See Annotation #2, "Are Immunizations Needed Today?" above for additional information regarding the recommended immunization schedule.
If a vaccine is contraindicated or deferred, the provider should document the reason and flag the record for future visits.
Patients, Parents/Guardians Who Refuse Immunizations
Document the discussion and keep the form in the patient's medical record. Revisit the immunization discussion at each subsequent appointment, and carefully document the discussion, including the benefits to each immunization and the risk of not being age-appropriately immunized. For unimmunized or partially immunized children, some providers may want to flag the chart to be reminded to revisit the immunization discussion, as well as to alert the provider about missed immunizations when considering the evaluation of future illness, especially young children with fever of unknown origin.
State Immunization Laws
As a core component of public health practice in the United States, vaccination programs are supported by state legal requirements. Each state has school vaccination laws that require children of appropriate age to be vaccinated for several communicable diseases. In addition to medical exemptions offered in each state, 48 states allow for religious exemptions, and 21 states allow personal belief exemptions for day care and school. For additional information on state requirements and exemptions, see Immunization Action Coalition at http://www.immunize.org/laws or CDC at http://www.cdc.gov/vaccines/vac-gen/laws/default.htm .
Immunizations should be administered by properly trained individuals. Health care professionals or others who administer vaccinations should be knowledgeable and receive continuing education in vaccine storage and handling; the recommended vaccine schedule, contraindications, and administration techniques; treatment and reporting of adverse events; vaccine benefit and risk communication; and vaccination record maintenance and accessibility. The CDC sponsors distance-based training opportunities for health care professionals. Information about training is available at http://www.cdc.gov/vaccines/ed/default.htm .
Accurate record keeping helps ensure that needed vaccinations are administered and unnecessary vaccinations are not administered. The medical record at the primary care provider's office, clinic or worksite should include all vaccinations received (such as those received at a specialist's office or in another health care setting). When a health care professional who does not routinely care for a patient vaccinates that patient, the patient's primary care provider should be informed.
Document Vaccine(s) Given
Providers of routine childhood immunizations are required by federal law (42 U.S. Code 300aa-25) to record the vaccine, the date of administration, the vaccine manufacturer, lot number, the date the VIS was given to the patient, the publication date of the VIS, the signature and title of the person administering the vaccine, and the address where the vaccine was administered. It is recommended that providers of other vaccines also record this information. All information should be recorded in single summary form in the patient's record in order to allow easy retrieval of information. For additional information, see http://www.cdc.gov/vaccines/pubs/vis/downloads/vis-instructions.pdf .
Personal Immunization Record
Health care professionals should ensure that each patient has a hand-held vaccination record that documents each vaccine received, including the date and the name of the health care professional who administered the vaccine. Health care professionals should encourage patients and/or parents/guardians to bring the patient's handheld record to each health care visit so that it can be updated.
Report Vaccine(s) Given to Immunization Information Systems (i.e., Immunization Registries)
All vaccinations administered should be reported to state or local immunization registries, where available, to ensure that each patient's vaccination history remains accurate and complete. Registries are useful for verifying the vaccination status of new patients, determining which vaccines are needed at a visit, printing official records, and providing reminders and recalls to parents/guardians and patients. For additional information, see Every Child by Two, at http://www.ecbt.org/registries .
Report Vaccine Adverse Events
Providers should document fully any adverse event in the medical record at the time of the event, or as soon as possible. Health care professionals should promptly report all clinically significant adverse events after vaccination to the Vaccine Adverse Event Reporting System (VAERS) even if the health care professional is not certain that the vaccine caused the event. Health care professionals should be aware that patients and parents/guardians may report to Vaccine Adverse Event Reporting System; if they choose to do so, they are encouraged to seek the help of their health care professional. Report forms and assistance are available by calling 1-800-822-7967 or on the Internet at http://vaers.hhs.gov/index .
Discuss with the patient, parent/guardian when next vaccines are due (including vaccines that may have been deferred), and schedule appointment if possible. For additional information, refer to Annotation #3, "Can Needed Immunizations be Given Today? (Educate, Reassure and Screen for Contraindications)." Educate the patient and/or parent/guardian about vaccines.
Assessment of Vaccination Coverage Rates
Assessments are most effective in improving vaccination coverage when they combine chart reviews to determine coverage with the provision of results to health care professionals and staff. Provider assessment can be performed by the staff in the practice or by other organizations, including state and local health departments. Effective interventions that include assessment and provision of results may also incorporate incentives or compare performance to a goal or standard. This process is commonly referred to as AFIX (assessment, feedback, incentives and exchange of information). Coverage should be assessed annually so that reasons for low coverage in the practice, or in a subgroup of the patients served, can be identified and interventions implemented to address them.
Reminder/recall systems improve vaccination coverage. Patient reminder/recall interventions inform individuals that they are due (reminder) or overdue (recall) for specific vaccinations. Patient reminders/recalls can be mailed or communicated by telephone; an autodialer system can be used to expedite telephone reminders. Patients who might be at high risk for not complying with medical recommendations – for example, those who have missed previous appointments – should receive more intensive follow-up. Similarly, provider reminder/recall systems alert health care professionals when vaccines are due or overdue. Notices should be placed in patient charts or communicated to health care professionals by computer or other means. Immunization registries can facilitate automatic generation of reminder/recall notices.
Information about assessing vaccination coverage rates and reminder/recall systems is available through the CDC at http://www.cdc.gov/vaccines/programs/afix/default.html and through the American Academy of Pediatrics at http://www2.aap.org/immunization/pediatricians/pdf/ReminderRecall.pdf . Software to assist in conducting coverage rate assessments and feedback is available at http://www.cdc.gov/vaccines/programs/cocasa/default.html . Model reminder/recall templates are also available at http://www.ahcpr.gov/ppip/postcard.pdf .
Immunization Schedule Annotations
Children up to Age 7
It is recommended that children receive a series of five doses of vaccine against diphtheria, tetanus and pertussis administered at ages 2, 4, 6 and 15-18 months and the fifth dose at age 4-6 years. The fourth dose of DTaP may be administered as early as age 12 months, provided six months have elapsed since the third dose and the child is unlikely to return at 15-18 months.
DTaP can be given in single syringe combination with Hib (Haemophilus influenzae B) and IPV (inactivated polio virus) [Guideline], [High Quality Evidence], [Low Quality Evidence], or in combination in a single syringe with hepatitis B vaccine and IPV [High Quality Evidence]. Whether given alone or in combination, whenever feasible use the same brand of DTaP throughout the five-dose series to minimize injection site swelling.
Children with neurologic disorders may have the DTaP vaccine deferred on an individual basis for such reasons as progressive neurologic disorder, children with poorly controlled seizures, and neurologic conditions predisposing to seizures or neurologic deterioration (e.g., tuberous sclerosis). DTaP use should be reconsidered at each visit and initiated if the clinical condition is stable or controlled. If DTaP has not been initiated by one year of age, DT series should be started. A personal or family history of stable convulsive disorder is not a contraindication to DTaP vaccination. Counseling of the family should be undertaken prior to administration.
Preterm infants in stable medical condition should be immunized with DTaP at two months of chronological age [Moderate Quality Evidence].
Children Ages 7 through 10
A single dose of tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap) should be given to children aged 7 through 10 years who are not fully vaccinated against pertussis (five doses of DTaP or four doses of DTaP if the fourth dose was given on or after the fourth birthday), provided they have no contraindication to pertussis vaccine [Guideline].
Children aged 7 through 10 years who were never vaccinated against tetanus, diphtheria or pertussis, or who have unknown vaccination status, should receive a series of three vaccinations containing tetanus and diphtheria toxoids with Tdap as the first of these three doses [Guideline].
Adolescents and Adults
A single dose of Tdap should be given routinely to adolescents (target age 11-12) who completed the recommended childhood diphtheria and tetanus toxoids, pertussis/diphtheria and tetanus toxoids, and acellular pertussis (DTP/DTaP) vaccination series. Tdap can be given regardless of the time elapsed since the last vaccine containing tetanus toxoid or diphtheria toxoid [Guideline].
Pertussis appears to be endemic in middle and high schools [Low Quality Evidence]. Although mortality is very low in patients ages 11 to 65 years, pertussis causes substantial morbidity in this age as well as transmission to incompletely immunized infants [Guideline]. Thus, the availability of a safe Tdap for adolescents and adults means it should be routinely given to these age groups. In most situations, Tdap will substitute for tetanus and diphtheria (Td). Immunization should be provided to those who may expose infants less than six months of age, because these infants are the most vulnerable to the disease. This cocoon strategy will maximize the effectiveness of the vaccine in reducing disease [Guideline].
Given the epidemiology of the disease, the most important groups to immunize with Tdap are listed below:
Primary Immunization of Adults 18 and Older
All adults should have completed a primary Td series. A complete series includes two doses given four weeks apart and a third dose given 6-12 months after the second dose. Tdap should be used as the first dose (Tdap is not tested or licensed as a repeated immunization) [Guideline].
Repeat Immunization of Adults 18 and Older
For all adults, a booster dose of Td is recommended every 10 years. Those who have not had a one-time dose of Tdap, or if status is unknown, the next booster dose should be Tdap. Adults 65 years and older who haven't received Tdap SHOULD be vaccinated [Guideline].
For patients presenting with severe or complicated trauma wounds, an additional dose is recommended if Td has not been administered within the preceding 5 years. If available, Tdap should be given. If the initial tetanus series is incomplete, the tetanus diphtheria status is unknown or patient is human immunodeficiency virus (HIV)-positive, tetanus immune globulin should be given in addition to starting the series [Reference].
Pregnancy and Postpartum Period
Pregnant women who were not vaccinated previously with Tdap should receive Tdap during pregnancy, preferably during the third or late second trimester (after 20 weeks gestation). If not administered during pregnancy, Tdap should be administered immediately postpartum.
In addition, parents of infants, siblings of newborns, day care providers and others caring for the newborn should all be offered Tdap.
Tdap vaccination of parents and household contacts of premature infants has been advocated [Reference]. Premature and low-birth-weight infants are at increased risk for severe and complicated pertussis.
See the original guideline document for information about the available Haemophilus influenza b conjugate (Hib) vaccines, including trade name, carrier, and usual schedule.
This information is current as of February 2014. See prescribing information for complete details of the products' licensure http://www.immunize.org/packageinserts . For the most up-to-date information about specific recommendation, see Child, Adolescent, and Catch-Up Schedules.
Initiation of hepatitis A vaccine is recommended for all children between 12 and 23 months.
Hepatitis A requires two doses administered at least 6 months apart. It is not necessary to restart the series if the interval between doses is longer than recommended. Those 24 months and older who have started the series should complete it. Otherwise, those 24 months and older who have not started the series, should be considered for vaccination if they are at increased risk. It is also recommended for those who live in areas where vaccination programs target older children, or who are at increased risk for infection, or for whom immunity against hepatitis A is desired. States and regions that have risk-based hepatitis A vaccination programs for children 2 to 18 years of age should continue these programs [Reference].
Increased Risk
Hepatitis A vaccine is recommended for persons 12 months and older who are at increased risk for the disease, including:
The ICSI work group recommends universal vaccination for those less than 40 years of age and for those over age 40 at high risk.
High Risk
Those at high risk for exposure include the following:
Hepatitis B vaccination is recommended for all adults in the following settings:
Schedule and Dosing Considerations
The recommended amount of hepatitis B vaccine varies by age and manufacturer and schedule. The package insert information should be consulted for details.
All infants and children not previously immunized should receive three doses of hepatitis B vaccine. Four doses may be given if the first dose is given at birth. The first and second doses should be given a minimum of 4 weeks apart. The second and third doses are to be given a minimum of 8 weeks apart. The first and third doses are to be given at least 16 weeks apart. The last (third or fourth) dose of Hepatitis B vaccine should not be given before 6 months of age.
Authorities recommend that whenever possible, the routine series of hepatitis B vaccination should begin at the infant's birth [Reference].
There is an accelerated or alternate schedule of 0, 1, 2 and 12 months for hepatitis B vaccine (Engerix B®). This vaccine is available for use in special circumstances where faster and prolonged sero-protective levels are desired, such as neonates born of hepatitis B-infected mothers, recent exposure to the virus, or travelers to high-risk areas leaving in less than three months.
See the original guideline document for special considerations with regard to infants born to hepatitis B-positive mothers, adolescents, and recipients of hemodialysis and other immunosuppressed adults, as well as the role of postimmunization testing and the management of postimmunization serology test results.
Twinrix® contains both hepatitis A vaccine and hepatitis B vaccine, and is licensed for adults 18 years and older. Twinrix® requires three doses. The second dose should be given 1 month after the first, and the third dose 6 months after the first dose and 5 months after the second dose.
A dose of Twinrix® contains less hepatitis A viral antigen than a dose of single antigen adult hepatitis A vaccine. To complete the hepatitis A vaccine series, an adult patient must receive three doses of Twinrix® or two adult doses of single-antigen hepatitis A vaccine. It is not recommended to administer two doses of Twinrix® and one dose of single-antigen hepatitis B vaccine to complete the hepatitis A and B series [Reference].
In 2007, the Food and Drug Administration approved the hyperaccelerated 0, 7-, 21- to 30-day and 12-month booster schedule for Twinrix® for people needing protection in a short period of time (i.e., travelers). Seroprotection against hepatitis A and hepatitis B from the accelerated Twinrix® schedule was comparable to monovalent hepatitis A vaccine and hepatitis B vaccine schedules [Guideline].
Zoster vaccine is recommended for all persons aged 60 years or older who have no contraindications, including persons who report a previous episode of zoster or who have chronic medical conditions. The vaccine should be offered at the patient's first clinical encounter with his or her health care provider. It is administered as a single 0.65 mL dose subcutaneously in the deltoid region of the arm. A booster dose is not licensed for the vaccine.
The Zostavax® Efficacy & Safety Trial ("ZEST") was recently completed in persons ages 50 to 59. In March 2011, the Food and Drug Administration extended the indications for zoster vaccine to adults ages 50 to 59. However, the work group concurs with the recent Advisory Committee on Immunization Practices (ACIP) recommendation and does not propose revision of existing recommendations regarding zoster vaccine [Guideline]. The rationale for this conclusion is that there is insufficient evidence regarding duration of vaccine protection to vaccinate well before the peak of zoster incidence.
Zoster vaccination is not indicated to treat acute zoster, to prevent persons with acute zoster from developing postherpetic neuralgia, or to treat ongoing postherpetic neuralgia. Before administration of zoster vaccine, patients do not need to be asked about their history of varicella (chicken pox) or to have serologic testing conducted to determine varicella immunity [Reference].
There is a recently published study that looks at the antibody response that occurred with the concomitant administration of zoster vaccine (VZV) and pneumococcal vaccine (PPV 23) in adults >60 years old [High Quality Evidence]. The concomitant administration did not affect the immunogenic response to PPV 23 in those tested and both vaccine groups achieved acceptable levels of antibody titers. However, the zoster vaccine antibody response was lower in those individuals who received concomitant vaccines as compared to those who received the vaccine alone. The study recommends that these vaccines not be administered together as lower immune responses correlate with lower efficacy. It is the opinion of the work group that efforts should be made to administer these vaccines separately unless there is doubt about an individual's ability to return in a timely manner for further vaccines. In that case, given the data that indicates that acceptable immunity is reached, it would be reasonable to administer both vaccines at a single visit.
Due to lack of data, zoster vaccination is not recommended for persons of any age who have received varicella vaccine. However, health care providers do not need to inquire about varicella vaccination or disease history before administering zoster vaccine because virtually all persons currently or soon to be in the recommended age group have not received varicella vaccine [Reference]. Adult immigrants coming from tropical climates should have a varicella titer drawn, and if it suggests previous varicella infection, patients ages 60 and older should be offered ZOSTAVAX®, and those without a positive titer should receive two doses of the varicella vaccine [Reference].
See the "Contraindications" field for information about who should not receive the zoster vaccine.
The doses may be given on a 0, 2- and 6-month schedule. Minimum intervals between doses are as follows: 4 weeks between the first and second dose, 12 weeks between the second and third dose, and 24 weeks between the first and third dose. The prelicensure trials were very relaxed about schedule, and all intervals worked well. Thus, it is never necessary to restart the series. It is acceptable to administer doses beyond 27 years of age if the series is started prior to 27 years.
Two human papillomavirus vaccines are licensed: a quadrivalent vaccine, HPV4 (Gardasil), for the prevention of cervical, vaginal, vulvar, anal, and orofacial cancers and genital warts; and a bivalent vaccine, HPV2 (Cervarix), for the prevention of cervical, vaginal, vulvar, and orofacial cancers in females. They are licensed for ages 9 through 26, and the Advisory Committee on Immunization Practices recommends routine use of the vaccine for all 11- to 12-year-old females, and catch-up use of the vaccine for females ages 12 through 26 [Reference]. The strains included in HPV4 (Gardasil) are 6, 11, 16 and 18. Strains 6 and 11 (present only in HPV4) account for 90% of venereal warts. Strains 16 and 18 are present in both HPV4 and HPV2 and account for 70% of oncogenic infections [Guideline].
If pregnancy occurs before the series is completed, further vaccination should occur after the pregnancy is over.
Currently an HPV9 (9-valent HPV) vaccine is being investigated by the FDA and anticipated review of recommendations by ACIP in early 2015. The strains included in the new HPV9 are 6, 7, 16, 18 (in current vaccine) plus 31, 33, 45, 52, 58. Strains 16 and 18 account for 50% of High-grade cervical lesions (CIN2) and 25% are attributable to the additional five types in HPV9. Strains 16 and 18 account for 62% of associated cancers and 11% are attributable to the additional five types in HPV 9. This vaccine is currently being studied in female populations, and may expand to the male population.
The ACIP has recently recommended the routine vaccination of boys ages 11 or 12 with three doses of quadrivalent vaccine, HPV4 (Gardasil), to protect them against HPV. The vaccine received a permissive recommendation in 2009, but it was not part of the routine ACIP recommended vaccines. On further review, it was felt that this new recommendation was justified due to increasing rates of anal cancer and head and neck cancers, as well as the direct benefit of preventing genital warts in males. It is also postulated that the vaccine will reduce male-to-female transmission of HPV due to disappointing rates of female HPV vaccinations.
Current guidelines are as follows: routine vaccination of males ages 11 to 12 years with 3 doses of HPV4. The vaccination series can be started beginning at age 9. Males ages 13 to 21 years who had not already received the HPV4 vaccine should also be vaccinated. Males ages 22 through 26 years of age may be vaccinated.
Oral poliovirus vaccine (OPV) is no longer available in the United States but is used in increasingly successful eradication efforts worldwide [Guideline].
Most adults living in the United States are immune as a result of vaccination received as children. Furthermore, adults in the United States, in general, have little risk of exposure to wild-type poliovirus. Vaccination is recommended for non-immune adults who are at a greater risk of exposure to wild-type polioviruses, including the following:
Fully immunized adults with high risk of exposure to wild-type virus may receive one dose of inactivated polio vaccine.
Incompletely immunized adults may receive the remaining doses of inactive poliovirus vaccine regardless of the length of time since the past doses or the forms of the vaccine.
Unimmunized adults should undergo primary immunization with the inactivated poliovirus vaccine. This is recommended over a minimum of 7 months. The second dose should be given 4 to 8 weeks after the first, followed by a third dose given 6 to 12 months after the second dose.
See the original guideline document for considerations for the unimmunized adults.
Influenza vaccination of all people ages 6 months and older is recommended annually, through the entire influenza season [High Quality Evidence] including women who are pregnant or will be pregnant during the influenza season. Limited safety data exist for the first trimester; however, the ACIP suggests that vaccination may occur in any trimester and should be completed with inactivated injectable influenza vaccine (TIV).
Children age 6 months through 8 years receiving influenza vaccine for the first time should receive two doses administered at least one month apart. For the 2011-12 influenza season, a second dose of influenza vaccine was recommended for children age 6 months through 8 years who did not receive influenza vaccine during the 2010-11 season regardless of the number of doses of influenza vaccine received in prior years. For the 2012-13 season, follow dosing guidelines in the 2012 ACIP influenza vaccine recommendations.
Contraindications include severe allergic reaction to any component of the vaccine, including egg protein, or after previous dose of any influenza vaccine.
Although data are limited, the established benefits of influenza vaccination for the majority of persons who have a history of Guillain-Barré syndrome (GBS) and who are at high risk for severe complications from influenza justify yearly vaccination. It is prudent to avoid vaccinating persons who are not at high risk for severe influenza complications but who are known to have developed Guillain-Barré syndrome within 6 weeks after receiving a previous influenza vaccination.
[Guideline], [Reference]
Recommendations Regarding Persons with Egg Allergy
Persons who have experienced only hives following exposure to egg should receive influenza vaccine with the following additional measures:
Other measures, such as dividing and administering the vaccine by a two-step approach and skin testing with vaccine, are not necessary.
Live attenuated influenza vaccine is a good alternative for healthy health care workers up to 50 years of age. Only those caring for patients in protective environments, such as bone marrow transplant wards, should not receive live attenuated influenza vaccine. For persons directly caring for a person who is severely immunocompromised and in protective isolation, inactivated vaccine is preferred over live attenuated vaccine.
Live attenuated influenza vaccine can be administered simultaneously with other inactivated vaccines or live vaccines. Live attenuated influenza vaccine may be given to persons with minor illnesses (e.g., diarrhea or mild upper respiratory tract infection with or without fever). However, if nasal congestion is present, that might limit delivery of the vaccine to the nasal lining. Consider delaying the vaccination until nasal congestion subsides. Health care workers should wear disposable gloves when administering live attenuated influenza vaccine.
Side effects of live attenuated influenza vaccine can include runny nose, headache, vomiting, muscle aches, sore throat, cough and fever (though fever is not a common side effect in adults receiving live attenuated influenza vaccine).
The effect on safety and efficacy of live attenuated influenza vaccine co-administration with influenza antiviral medications has not been studied. However, because influenza antivirals reduce replication of influenza viruses, live attenuated influenza vaccine should not be administered within 48 hours after cessation of influenza antiviral therapy, and influenza antiviral medications should not be administered for 2 weeks after receipt of live attenuated influenza vaccine.
Forms of TIV
The immunogenicity of the intradermal vaccine is similar to the intramuscular vaccine. The high-dose vaccine does produce better antibodies in the elderly and somewhat more side effects. It is not known yet whether this vaccine is more effective in this age group.
See the original guideline document for additional information.
The first dose of measles, mumps and rubella (MMR) immunization is recommended between 12 to 15 months of age (minimum age 12 months).
Recommended timing for the second immunization is at 4-6 years, but it is acceptable to give as soon as 4 weeks after the first.
A personal or family history of convulsive disorders is not a contraindication to measles vaccination. There is good epidemiologic evidence that autism is not caused by measles-containing vaccine [Reference], [Low Quality Evidence].
Adults lacking documentation of vaccination or evidence of disease who were born during or after 1957 should receive one dose of MMR. A second dose of MMR is recommended for adults who:
Vaccination should not occur during pregnancy. Pregnant women who test negative for rubella immunity may need to receive another MMR vaccine postpartum. Based on community consensus, if the patient has documentation of two previous vaccinations, then a third vaccination should not be given. If two previous vaccinations have not been given, a dose of MMR should be given soon after delivery.
Combined measles, mumps, rubella and varicella vaccine (MMRV) may be provided for children 12 months through 12 years of age in lieu of separate injection of equivalent component vaccines.
For children younger than 13 years of age, the minimum interval between the first dose of varicella and a dose of MMRV (MMR and varicella in combination) is 12 weeks [Guideline].
However, if the second dose of varicella vaccine was administered 28 days or more after the first dose, the second dose is considered valid and does not need to be repeated [Reference].
As a general rule, the ACIP of the CDC has stated a preference for combination vaccines over separate injections of the same antigens. However, providers who are considering administering MMRV vaccine should discuss the benefits and risks of both vaccination options with the parents or caregivers. Unless the parent or caregiver expresses a preference for MMRV vaccine, the CDC recommends that MMR vaccine and varicella vaccine should be administered for the first dose. Given this information, the Immunizations work group consensus is that in most instances, separate administration of MMR and varicella vaccine is preferred at age 12 to 47 months, while at ages 4 to 6 years, the MMRV combination vaccine is preferred. [Guideline]
Vaccination Recommendation
MCV4-D/MCV4-CRM (Meningococcal conjugate A, C, W and Y) is recommended for all children aged 11 through 18 years:
There are four meningococcal vaccines currently Federal Drug Administration (FDA) approved for use in the United States. Three are quadrivalent vaccines effective against serogroups A, C, W135, and Y; polysaccharide vaccine Menomune®, and two conjugated vaccines – Menactra® and Menveo®. The fourth vaccine HibMenCY (MenHibrix) protects against serogroups C and Y and Haemophilus influenza type b and is recommended for children aged 2 through 18 months who are at increased risk for meningococcal disease (e.g., persistent complement component deficiencies, anatomic or functional asplenia, including sickle cell disease).
Vaccination for Persons at Increased Risk
Persons at increased risk for meningococcal disease are recommended for routine meningococcal vaccination. Vaccine product, number of doses and booster dose recommendations are based on age and risk factor and are shown in a table in the original guideline document.
HIV-positive adolescents aged 11 through 18 years should receive a two-dose primary series of MCV4, at least eight weeks apart. Patients of other ages with human immunodeficiency virus are likely to be at increased risk for meningococcal disease and may elect vaccination.
Colleges may elect to target their vaccination campaigns to all matriculating freshmen to facilitate vaccination of those at higher risk or those previously unvaccinated.
The vaccines are safe and immunogenic and can be provided to nonfreshmen college students who want to reduce their risk for meningococcal disease and have not been previously vaccinated.
While the risk is relatively lower for adults aged 20 through 55 years who are not at increased risk for meningococcal disease, persons who wish to decrease their risk for meningococcal disease may elect to be vaccinated with the meningococcal conjugate vaccine.
The unconjugated meningococcal polysaccharide vaccine (MPSV4) is thought to give protection for at least two to three years but no more than five years. The meningococcal conjugated vaccine (MCV4) is thought to give protection for at least five years.
Persons with increased risk who were first vaccinated at less than four years of age with the unconjugated meningococcal polysaccharide vaccine should be considered for revaccination after two to three years with the conjugated vaccine.
The information on the 2012 Centers for Disease Control and Prevention immunization schedules are not current. The 2013 schedules, which are expected for release in February 2013, will include the information shown below.
Routine vaccination of children:
Vaccination of Persons with High-Risk Conditions
Persons with the high-risk conditions shown below are recommended to receive either PCV13 or PPSV23 or both vaccines.
Categories of High-Risk Conditions
Vaccination of Children Age 2 through 18 Years with High-Risk Conditions
Vaccination of Adults (Age 19 Years and Older) with High-Risk Conditions
Although PCV13 is licensed by the Food and Drug Administration (FDA) for persons age 50 years and older, the Advisory Committee on Immunization Practices (ACIP) recommends PCV13 for adults age 19 years and older with immunocompromising conditions. Greater immune response was demonstrated when PCV13 was administered before PPSV23.
*Additional doses of PPSV23 should be administered ≥5 years after previous PPSV23 dose.
See the original guideline document for a flowchart for pneumococcal vaccine recommendations for adults age 19 years and older.
*Recent ACIP recommendations for both rotavirus vaccines include changes for the maximum age for the first dose (14 weeks 6 days) and the maximum age for the final dose of the series (8 months 0 days) [Guideline].
See the original guideline document for information on special considerations for rotavirus vaccine.
Catch-up Regimens*
*Vaccination occurs when evidence of immunity does not exist.
A catch-up second dose of varicella vaccine is recommended for all children, adolescents and adults who received only one dose previously. The second dose of varicella vaccine improves individual protection and reduces the risk of school outbreaks. Providers should use every encounter to assess the need for a catch-up second dose of varicella vaccine, especially in those persons who received varicella vaccine between the ages of 12 months through 12 years at a time when only one dose had been recommended.
See the original guideline document for assessment of evidence of immunity and special indications for varicella vaccination.
Vaccine Considerations for Special Case Patients
Experience with vaccine use in immunocompromised persons and persons with chronic, underlying disease is limited. Each situation should be evaluated on an individual basis. Some general guidelines are presented in the original guideline document, which may help in making immunization decisions.
See the original guideline document for information regarding vaccine considerations for the following special cases:
A detailed and annotated clinical algorithm for immunization administration is provided in the original guideline document .
The type of supporting evidence is classified for selected recommendations (see the "Major Recommendations" field).
Appropriate and timely administration of vaccines
See also Appendix A, "Guide to Contraindications and Precautions to Commonly Used Vaccines," in the original guideline document for more information.
See original guideline document and Appendix A, "Guide to Contraindications and Precautions to Commonly Used Vaccines," for more information. See also http://www.cdc.gov/vaccines/recs/vac-admin/contraindications.htm .
Once a guideline is approved for general implementation, a medical group can choose to concentrate on the implementation of that guideline. When four or more groups choose the same guideline to implement and they wish to collaborate with others, they may form an action group.
In the action group, each medical group sets specific goals they plan to achieve in improving patient care based on the particular guideline(s). Each medical group shares its experiences and supporting measurement results within the action group. This sharing facilitates a collaborative learning environment. Action group learnings are also documented and shared with interested medical groups within the collaborative.
Currently, action groups may focus on one guideline or a set of guidelines such as hypertension, lipid treatment, and tobacco cessation.
Detailed measurement strategies are presented in the original guideline document to help close the gap between clinical practice and the guideline recommendations. Summaries of the measures are provided in the National Quality Measures Clearinghouse (NQMC).
Implementation Recommendation
Prior to implementation, it is important to consider current organizational infrastructure that address the following:
The following system changes were identified by the guideline work group as key strategies for health care systems to incorporate in support of the implementation of this guideline.
Not applicable: The guideline was not adapted from another source.
Organizations participating in the Institute for Clinical Systems Improvement (ICSI): Affiliated Community Medical Centers; Allina Medical Clinic; Aspen Medical Group; Baldwin Area Medical Center; Brown Clinic; Center for Diagnostic Imaging/Medical Scanning Consultants; CentraCare; Chippewa County – Montevideo Hospital & Clinic; Cuyuna Regional Medical Center; Essentia Health; Fairview Health Services; Family HealthServices Minnesota; Family Practice Medical Center; Gillette Children's Specialty Healthcare; Grand Itasca Clinic and Hospital; Hamm Clinic; HealthEast Care System; HealthPartners Central Minnesota Clinics; HealthPartners Medical Group & Regions Hospital; Hennepin County Medical Center; Howard Young Medical Center; Hudson Physicians; Hutchinson Area Health Care; Hutchinson Medical Center; Integrity Health Network; Lake Region Healthcare Corporation; Lakeview Clinic; Mankato Clinic; MAPS Medical Pain Clinics; Marshfield Clinic; Mayo Clinic; Mercy Hospital and Health Care Center; Midwest Spine Institute; Minnesota Association of Community Health Centers; Minnesota Gastroenterology; Multicare Associates; New Richmond Clinic; North Central Heart Institute; North Clinic; North Memorial Health Care; Northwest Family Physicians; Obstetrics and Gynecology Specialists; Olmsted Medical Center; Park Nicollet Health Services; Planned Parenthood Minnesota, North Dakota, South Dakota; Quello Clinic; Rice Memorial Hospital; Ridgeview Medical Center; River Falls Medical Clinic; Riverwood Healthcare Center; South Lake Pediatrics; Southside Community Health Services; Stillwater Medical Group; University of Minnesota Physicians; Winona Health
ICSI, 8009 34th Avenue South, Suite 1200, Bloomington, MN 55425; telephone, (952) 814-7060; fax, (952) 858-9675; e-mail: email@example.com; Web site: www.icsi.org .
The Institute for Clinical Systems Improvement's (ICSI's) work is funded by the annual dues of the member medical groups and five sponsoring health plans in Minnesota and Wisconsin.
Immunizations Work Group
Work Group Members: James Nordin, MD (Work Group Leader) (HealthPartners Medical Group) (Pediatrics); Ken Kephart, MD (Fairview Health Services) (Family Medicine/Geriatrics); Rosanne Anderson, RN (Family Practice Medical Center) (Family Practice); Sarah Rall, PharmD (Marshfield Clinic) (Pharmacy); Adele Starr, RNC, ANP (NorthPoint Health & Wellness) (Advanced Practitioner); Renner Anderson, MD (Park Nicollet Health Services) (Pediatrics); Barbara Ottis, RN (Park Nicollet Health Services) (Infection Control and Prevention Services); Mike Garvis (South Lake Pediatrics) (Pediatrics); Kari Retzer, RN (Institute for Clinical Systems Improvement) (Facilitator); Cassie Myers (Institute for Clinical Systems Improvement) (Coordinator)
Renner Anderson, MD, Work Group Member
Consultant, Pediatrics, Park Nicollet Health Services
National, Regional, Local Committee Affiliations: None
Guideline Related Activities: None
Research Grants: Receives grant money paid to his institution for federally funded vaccine research related to vaccine safety
Financial/Non-Financial Conflicts of Interest: None
Rosanne Anderson, RN, Work Group Member
Medical Support Supervisor, Family Practice Medical Center
National, Regional, Local Committee Affiliations: None
Guideline Related Activities: None
Research Grants: None
Financial/Non-Financial Conflicts of Interest: None
Mike Garvis, MD, Work Group Member
Director of Immunizations, Pediatrics, South Lake Pediatrics
National, Regional, Local Committee Affiliations: Serves as a non-paid board member for Allina Physician Governance Council and Abbott Northwestern Hospital Medical Executive Committee
Guideline Related Activities: None
Research Grants: None
Financial/Non-Financial Conflicts of Interest: None
Ken Kephart, MD, Work Group Member
Medical Director for Fairview Geriatric Services and Hospice, Fairview Health Services
National, Regional, Local Committee Affiliations: None
Guideline Related Activities: None
Research Grants: None
Financial/Non-Financial Conflicts of Interest: None
James Nordin, MD Work Group Leader
Pediatrician, HealthPartners Medical Group
National, Regional, Local Committee Affiliations: None
Guideline Related Activities: None
Research Grants: None
Financial/Non-Financial Conflicts of Interest: None
Barbara Ottis, RN, Work Group Member
Infection Control and Prevention Services, Immunization Specialist for Park Nicollet Health Services
National, Regional, Local Committee Affiliations: None
Guideline Related Activities: None
Research Grants: None
Financial/Non-Financial Conflicts of Interest: Previously served on a speakers bureau for GlaxoSmithKline. This relationship ended in 2011, prior to the start of this revision.
Sarah Rall, PharmD, Work Group Member
Director of Pharmacy Purchasing and Supply, Pharmacist, Marshfield Clinic
National, Regional, Local Committee Affiliations: None
Guideline Related Activities: None
Research Grants: None
Financial/Non-Financial Conflicts of Interest: None
Adele Starr, RNC, ANP, Work Group Member
Adult Nurse Practitioner, Minnesota Association of Community Health Centers
National, Regional, Local Committee Affiliations: None
Guideline Related Activities: None
Research Grants: None
Financial/Non-Financial Conflicts of Interest: None
Electronic copies of the guideline: Available from the Institute for Clinical Systems Improvement (ICSI) Web site .
Print copies: Available from ICSI, 8009 34th Avenue South, Suite 1200, Bloomington, MN 55425; telephone, (952) 814-7060; fax, (952) 858-9675; Web site: www.icsi.org ; e-mail: firstname.lastname@example.com.
The following is available:
None available
This summary was completed by ECRI on August 30, 1999. The information was verified by the guideline developer on October 11, 1999. This summary was updated by ECRI on May 15, 2000 and on October 22, 2001. This summary was updated by ECRI on December 4, 2002. The updated information was verified by the guideline developer on December 24, 2002. This summary was updated by ECRI on April 12, 2004, September 20, 2004, August 9, 2005, July 5, 2006, November, 30, 2006, and March 6, 2007. This summary was updated by ECRI Institute on July 9, 2007 following the FDA advisory on RotaTeq (Rotavirus, Live, Oral, Pentavalent) vaccine. This NGC summary was updated by ECRI Institute on December 18, 2007 and again on January 8, 2009. This summary was updated by ECRI Institute on April 1, 2010 following the U.S. Food and Drug Administration advisory on Rotarix Vaccine. This summary was updated by ECRI Institute on September 16, 2010. This summary was updated by ECRI Institute on November 12, 2010 following the U.S. Food and Drug Administration (FDA) advisory on Afluria (influenza virus vaccine). This NGC summary was updated by ECRI Institute on June 30, 2011. This NGC summary was updated by ECRI Institute on June 28, 2012.
This NGC summary (abstracted ICSI Guideline) is based on the original guideline, which is subject to the guideline developer's copyright restrictions.
The abstracted ICSI Guidelines contained in this Web site may be downloaded by any individual or organization. If the abstracted ICSI Guidelines are downloaded by an individual, the individual may not distribute copies to third parties.
If the abstracted ICSI Guidelines are downloaded by an organization, copies may be distributed to the organization's employees but may not be distributed outside of the organization without the prior written consent of the Institute for Clinical Systems Improvement, Inc.
All other copyright rights in the abstracted ICSI Guidelines are reserved by the Institute for Clinical Systems Improvement, Inc. The Institute for Clinical Systems Improvement, Inc. assumes no liability for any adaptations or revisions or modifications made to the abstracts of the ICSI Guidelines.
The National Guideline Clearinghouse™ (NGC) does not develop, produce, approve, or endorse the guidelines represented on this site.
All guidelines summarized by NGC and hosted on our site are produced under the auspices of medical specialty societies, relevant professional associations, public or private organizations, other government agencies, health care organizations or plans, and similar entities.
Guidelines represented on the NGC Web site are submitted by guideline developers, and are screened solely to determine that they meet the NGC Inclusion Criteria which may be found at http://www.guideline.gov/about/inclusion-criteria.aspx.
NGC, AHRQ, and its contractor ECRI Institute make no warranties concerning the content or clinical efficacy or effectiveness of the clinical practice guidelines and related materials represented on this site. Moreover, the views and opinions of developers or authors of guidelines represented on this site do not necessarily state or reflect those of NGC, AHRQ, or its contractor ECRI Institute, and inclusion or hosting of guidelines in NGC may not be used for advertising or commercial endorsement purposes.
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Good week all in allPosted by Aug01, 2008 Comments /span>
Well we had a very educational week. We learned a lot and now we will definately have to hit the drawing board, but that is exactly what we hoped for. Our guest of honor Vijay will be exiting tomorrow so we had a party tonight. In fact i am still buzzing from the rounds of Pilsen and Imperial from earlier. We will post some video and audio content as soon as we get a little editing help done.
But i will end with this. Since i have been hanging out with adaptive surfers and the like, It has realy helped progress my thinking as well as my apreciation for many other things. I will always hold these experiences deer to my heart
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Encounter a ptarmigan, designated as a Natural Monument
On terrace plateau with rich nature facing 3,000-meter high mountains
At 2450 meters above sea level, Murododaira is a lava plateau consisting of lava that flowed from the former Tateyama crater. This plateau which faces 3,000-meter mountains such as the Three Tateyama Mountains, Mt. Tsurugidake and the Dainichi Mountain Range, serves as the base of the Tateyama Kurobe Alpine Route.
"Murodo" means a building in which practitioners of austerities stay and pray. The place is so named because a murodo was built in the area where mountains were worshiped during the Edo Period (1603-1868). The building is now called "Shitsudo-goya", and was designated as an Important Cultural Property of Japan.
The hiking trail around the place has many spots worth seeing such as the beautiful Mikurigaike pond with a mirror-smooth surface and Jikogudani, with its smell of sulfur. There is also Murodo garden, a memorial tower dedicated to victims of mountaineering accidents; Tamadono cave, Kokuzo cave, stone Buddhist images and stone pagodas, indicating that this is a sacred place that has been worshiped by many practitioners.
The area is also a rich habitat of rare wild animals including the ptarmigan, which is a Natural Monument. In summer you can see Japan's endemic species such as the Gentiana thunbergii var. minor and Veratrum stamineum as well as other beautiful alpine plants including avens (Geum pentapetala). This is a sacred place where you can feel the history of faith in Japan in beautiful landscape and affluent nature.
Address: Murodo, Iwakuraji, Tateyama-machi, Toyama
Phone: 076-432-2819 (Tateyama Kurobe Alpine Route Official Website)
Directions: (From the Toyama side) 2 hours through Tateyama Kurobe Alpine Route from JR Toyama Station (3 hours and 30 minutes from Shin-Osaka and Nagoya Station; 1 hour and 30 minutes by air from Tokyo via Toyama Airport) to Murodo, the terminal of Tateyama Kogen Bus. (From the Nagano side) one hour and 30 minutes from JR Shinano Omachi Station (4 hours and 30 minutes from Tokyo Station) through Tateyama Kurobe Alpine Route to Murodo, the terminal of Tateyama Tunnel trolleybus followed by a short walk.


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Kanye West may have dumped Nike, but girlfriend Kim Kardashian hasn't ditched her Nike clothes in favor of Adidas ones. In fact, she wore leggings with the Nike logo on them to a meeting with Adidas.
Rapper, Kanye West, signed with Nike to sell his Air Yeezy sneakers. At a concert stop in Brooklyn, Kayne told his fans that he signed a deal a week and a half ago. No one knew what Kanye was talking about until November 25, 2013. According to Chuba, Kanye elaborated with Angie Martinez, radio host from New York's Hot 97 about his new deal. He said that he's dropped the Nike contract and signed with Adidas.
Nike is a name brand that many athletes endorse, but it wasn't lucrative enough for Kanye even though he admitted to loving Nike. However that doesn't mean much when another company agrees to give you more money. Kanye will receive $10 million endorsement from Adidas.
When Hot 97's, Angie Martinez asked Kanye why he was dumping Nike, he replied that Nike wasn't going to pay him any royalties. Apparently they reserve their royalty payments for professional athletes, not rappers. Kanye became further disgusted with Nike when they didn't know when his shoes, Air Yezzy 'Red Octobers' would be released.
Kanye said, "The old me without a daughter might have taken the Nike deal cause I just love Nikes so much . . . But the new me with a daughter, takes the Adidas deal, cause I have royalties-and I have to provide for my family."
No one can accuse Kanye of not being ambitious or having a low self esteem.. He plans on being the 'Tupack of the Product,' but he doesn't stop there. He also told Angie Martinez "I'm going to be the first Hip Hop designer and because of that I'mma be bigger than Walmart."
Adidas gave this statement. "For 2014, we welcome to the adidas family one of the most influential cultural icons of this generation, Kanye West. Well known for breaking boundaries across music, film and design and partnering with our history in street wear culture and leading innovations in sport, we look forward to creating a new chapter. Details to follow."
Some fans of Kanye agree that he made a wise decision in dumping Nike, while others say Nike is better off without the controversial rap star. What do you think.


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Mathematical Experiment Tool on the NetBeans Platform
By Geertjan-Oracle on Jan 10, 2013
The year is freshly born and already there's yet another NetBeans Platform application... named TeaCat. TeaCat is a dynamic mathematical application that aims to enable high school students to experiment with and to exercise a variety of mathematical topics. Even engineers may benefit from TeaCat for rather complex calculations, since TeaCat includes working with derivatives, integrals, systems of equations and matrices.


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Dear Young Leader,
Consider joining DLA for the adventure of a lifetime.
DLA is designed to allow students to be a part of a fervent community, receive dynamic teaching, and partner in prayer for a move of God in this generation.
You will be involved in everything Desperation ministries does including, Desperation conferences, tours, high school and junior high youth group leadership, retreats, and a lot more! DLA is not just for those looking to go into full-time ministry, instead it will equip you with the tools you need to lead in the gifting and area of ministry or business that God is leading you to.
Students in DLA receive hands on ministry training, personal discipleship and leadership opportunities.
We are now accepting applications and would love for you to be a part.
For His Reward,
David and Renata Perkins
- Founder


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Dell and Microsoft back Moblin
Intel gets by with a little help from its friends
MOBLIN 2.0, the Linux-based operating system (OS) designed for Atom netbooks, is due to come pre-installed on some Dell netbooks from tomorrow.
Dell turned to Ubuntu creator Canonical to create the Ubuntu Moblin Remix Developer Edition for its Inspiron Mini 10v netbook, and will aim the package at developers.
"Moblin keeps on getting more exciting as a project with new applications and improved user experiences. It's great to be delivering this release with Dell to developers wanting to participate in Moblin," said Mark Shuttleworth, founder and chief executive of Canonical.
"Intel and the Moblin community are bringing tremendous resource and investment into the Linux ecosystem and this product acts as a bridge to Moblin for developers."
Yesterday, Intel demonstrated the next version of the OS, Moblin 2.1, running on a smartphone – highlighting the company's increased focus on the mobile space and its push towards creating a consistent experience across a wide range of devices.
Further highlighting the mobile OS's coming of age it was also revealed, from early next year, Moblin will get support from both Microsoft's Silverlight and Adobe's Air platforms as part of the Intel Atom Developer Program, which will see Intel create an app store framework for developers.
With this support developers can target Silverlight or Air as a preferred client runtime and know they will get solid support on Atom-based devices.
During her keynote at the show, Intel corporate vice president and general manager of Software and Services Group Renee James was joined by Ian Ellison-Taylor, Microsoft's general manager for Client Platforms and Tools to announce the collaboration.
This partnership is expected to help developers write applications once and have them run across Windows and Moblin devices, expanding the reach of Silverlight from the desktop and into mobile consumer electronic devices.
"We see this as a clear extension of our current efforts with Novell where we are building an open source implementation of Silverlight called Moonlight that is targeted at the broad range of Linux–based PCs," said Ellison-Taylor. µ
INQ Latest
Google Updates: YouTube live after you check you're not dead
It's time for our regular two-step through the Google news
Uber picks up Portugese pen-testers with profiteering plans
Bug bounty offer: accepted


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Healthcare Navigation is the leading firm providing professional healthcare insurance consulting and advocacy services. We evaluate coverage, plan for future needs and make sure our clients get the protection they deserve.
We do not and never have sold insurance.
Our professionals understand healthcare coverage and our complex healthcare system. We provide impartial, objective advice and work solely to protect our clients. We offer three levels of subscription services to maintain an ongoing, proactive relationship with those who have authorized us to represent them. We also provide non-subscription consulting services on a project basis to individuals, families and to businesses of all sizes.
Non-Subscription Services - Healthcare Consulting
- Professional Consultation. Discuss your concerns and develop a plan to address them.
- Medicare Essentials Consultation. A Medicare primer on the program's complexities, rules, penalties and a plan for your future (offered on an individual or group basis).
- Coverage Transition. Anticipatory planning and/or evaluating options regarding individual or group healthcare coverage. We also manage the enrollment process.
- Medicare Coverage Transition. Anticipatory planning and/or evaluating options regarding Medicare and related products. We also manage the enrollment process.
Subscription Services - Ongoing Healthcare Advocacy
- Basic. Occasional Support. A service for those who need occasional advice and assistance from HN professionals so they can effectively manage and get the most out of their coverage.
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Please call us at 203-655-2614 for more information.


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When you're looking at PC fans, there's two general categories they'll be grouped into: performance fans and silent fans. Performance fans will give you incredibly high airflow ratings, great for overclocking, water cooling, and other areas where a large airflow is needed. Performance fans usually come at a cost though - they can be pretty loud. Silent fans are fairly self explanatory - they're optimized to be as quiet as they can and move as much air as they can - although always a much reduced airflow compared to a performance model. Now that new bearing designs have allowed a lot of manufacturers to really conquer the silent fan market, they've spent their attention on making performance fans quieter, while still keeping those high airflow ratings they're known for.
The Wing 14 is the the latest performance fan from GELID. This is a 140mm fan that comes straight from the "Gamer" class of fans in GELID's product lineup. However, GELID is working on cross advertising some of these gamer designed fans into the silent field as well - the Wing 14 included. The front of the box highlights in quite large letters that this is a "low speed optimized silent fan". My regular readers will know how fan crazy I am, so I'm already excited to put the Wing 14 up against the competition to see where it stands!
Read our reviews of the best tablets on DreamWare Computers and compare tablets characteristics here.