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Book by Laurens Stephanie
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What would you do if you were kissed by the most handsome stranger you'd ever seen? And what if that man was a Cynster?
Every girl--even convent-educated ones--dreams of forbidden kisses. So when a man literally falls at Helena's feet as she's walking through the courtyard one moonlit Christmas Eve, the pretty, young comtesse d'Lisle knows he's up to no good. He's clearly a bit dangerous... and obviously caught in the middle of a clandestine rendezvous. Why else would he have risked his neck and jumped out of a window into the snow?
It's wrong, it's outlandish . . . and it's the most utterly romantic gesture she's ever seen. So when the good sisters rush up, demanding to know ifshe has seen a man on the grounds, Helena ignores the years of strict upbringing that insist she reveal his presence.
To lie would be a sin, but 'no one can be good all the time.
As a reward for her silence, the stranger takes her in his arms and enticingly, unforgettably kisses her--and then departs, leaving a lingering if unspoken promise of all that might be, should fate decree that they meet again. Although Helena doesn't know it, her wild Englishman is Sebastian Cynster, Duke of St. Ives, a nobleman who will prove to be her destiny.
Seven years later, Helena has been transformed from a pretty schoolgirl to an aristocratic beauty. Her sparkling wit has made her sought after by London's hostesses; her considerable dowry has made winning her hand the aim of many a gentleman . . . but she is deadeningly aware of how boring so many ofthese gentlemen are.
Her manipulative guardian has unexpectedly allowed her to find a husband of her own choosing, and she has no intention of marrying any man who tries to tame her. There must be someone perfect for her . . . someone who can live up to the promise ofthat long-ago kiss.
Then, at a ball, fate strikes. Once again, it is the Christmas season, and across the crowded room Helena stands transfixed . . . for there is the man whose kiss she has never forgotten, the man of her memory whom no other has ever been able to supplant. Her wild, mysterious Englishman, Sebastian Cynster, Duke of St. Ives.
One look, and he's determined to reclaim her . . . .Biografía del autor:
#1 New York Times bestselling author Stephanie Laurens began writing as an escape from the dry world of professional science, a hobby that quickly became a career. Her novels set in Regency England have captivated readers around the globe, making her one of the romance world's most beloved and popular authors.
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Carboflex 130
La raqueta jugada por Nour El Sherbini, 3 veces Campeones del Mundo Junior !
Team Squash mujer
En pista
Name : Nour El Sherbini
Nationality : Egyptian
Birth date : 1 November 1995
Best WSA ranking : 4
Racket and string you play with : Carboflex 130, Green 305 String Tecnifibre
At what age did you begin to play squash? 6
Did you have a weakness as a kid that you worked hard to improve? Yes, I always knew that my backhand was better than my forehand so I worked hard to make them both the same
How important was/is your family in your career? Extremely important and especially my brother who is the acting manager of Team Sherbini. My Mom and Dad gives me all the support I need
What other sports did you practice and why did you decide to concentrate fully on squash? I didn't practice any sport before, it was squash and only squash. My love to racket sports in general is infinite and I found myself in squash so I decided to go on. Also early achievements for me at a young age made me keep going…
What's your favorite tournament, and why? The British Open. Why? Good memories there. I also love the KL Open in Malaysia
Best win/memory? Reaching the Final of the British Open in 2012 and becoming the youngest World Champion in 2009
Worst loss/ashamed of? Losing in the second Round of the British Open 2013
Any advice for other players to progress in Squash? Don't ever listen to anyone who lets you down? Everyone must follow his dream and one day you will achieve it. The world is full of negative people. Just follow your thoughts and hold tight to people who love you because they are hard to find these days and they are the ones who will believe in you the most
Your power song in you iPod before entering the court? New Day by Alicia Keys, Hall of Fame by The Script
En la vida
What's your main objective in life? To achieve what no one can do and to impress the world with my achievements
What was the most the important piece of advice you received along the way? To give it a try in everything and don't say I am too young to do something
Nothing is better than? Watching TV Series in a chill place
Top 3 reasons to wake up every morning?
1) School
2) Training
3) Traveling
What's your favorite quotation? "If you are good at one thing, make it everything" Roger Federer

subset: commoncrawl


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Isa GT - Pela'o (Crookers Remix) [new video!]
This track has been lighting a fire under my feet for a pretty long time, but now that there is a video for the Crookers' remix of Isa GT's spicy stomper, Pela'o, we're super amped to add a load of kindling to the heat that's already been building up around this uniquely talented DJ, MC and producer. Jill of all trades, indeed.
The Medellin, Colombia native has recently chosen London as her base for the last few years...known in the UK capital as resident of the infamous nights Girlcore and Musicalia, which she has taken around the world.
Today marks the release of Isa GT's debut EP. Man Recordings proudly presents her Pa´Chikirri EP. which pairs Pela´o, a ride through an imaginary Colombian baile funk party, with hard hitting beats and tough raps that make any culo shake, with Pa´Las Mamasitas, a girl power song with a Cumbia influence. Lyrically, it´s on the lack of good guys in London.
Remixes come from Crookers, Joao Brasil and Daniel Haaksman. Buy the EP here, and watch the video for the Crookers' remix of Pela´O now.
BONUS! Isa GT is spinning at Sin Sin in New York City tomorrow night. Win.
mp3: Dutch Rhythm Combo (featuring Isa GT) - Alerta


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Coming back from a high dive
Did you miss Scott Spark's conversation with Olympic Diver, Matthew Mitcham on Sunday?
The 24-year-old diver has had a blockbuster season. Last year he represented Australia at the London Games but, just missed out on qualifying for the 10m finals.
Next came the bombshell. After the event he revealed that since the Beijing Olympics in 2008, where he was the first Australian male to win an Olympic gold medal in diving since 1924, he'd been addicted to methamphetamines.
How did he get clean, and what lessons does he have to share?
We've had lost of calls wanting to hear the story again so here it is. All you need to do is click on the player below to here the audio.


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Last weekend I went through my colony of SMR, I believe that they are Russians. I had reversed them once this Spring and installed checkmite. That was seven weeks ago and it was time to remove the strips and manipulate the frames.
This colony was a package that I installed last spring. It built very slow and never filled the second broodbox. I fed it heavily and also fed it pollen patties last fall to get it into shape for the winter.
It survived the winter, as all my hives did, and I started an early feeding program. I have one brood box with Perco frames and one with wax coated plastic foundation. They are poor builders, at first I blamed the Perco, but they draw wax just as badly on the other foundation as well. They cross connect frames and will draw away from the foundation and do a freestyle inbetween the frames.
So far this year they have yet to finish the second body.
They still can't draw a good looking frame of wax.
I saw them flying more when it was cold,42 degrees, than they are now.
AND they are VERY ANGRY and down right MEAN. At this point they make my Buckfast look tame.
They are very clean, the bottom board was spotless. AND ZERO MITES.
I had put the slatted rack on upside down and they had built under two frames an area about two and a half inches by about ten inches of drone brood. I unfortunatly removed all of it and took it back for a close inspection. After inspecting about seventy five of the unfortunate little critters I found absolutely no mites.
Would I go out and buy them again? No.
But I can see why they show promise. My plans for them is to not treat them anymore and see what their survivability is. I don't think that having the drones around will hurt, it may be a benifit.
I have installed a box of Permacomb above the two brood boxes. I figure if they can not draw wax, maybe they need a little help. Maybe that will change their habits, I'll keep you informed.


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European Commission Approves Late Post-MI Ticagrelor at 60 mg »
"LONDON, UK â" The European Commission (EC) has followed the recommendation last year from its Committee for Medicinal Products for Human Use (CHMP) for an additional indication for the oral platelet inhibitor ticagrelor (Brilique, AstraZe"...
Read the European Commission Approves Late Post-MI Ticagrelor at 60 mg article »
(ethambutol hcl) Tablets
MYAMBUTOL (ethambutol hydrochloride) is an oral chemotherapeutic agent which is specifically effective against actively growing microorganisms of the genus Mycobacterium, including M. tuberculosis. The structural formula is:
MYAMBUTOL (ethambutol hydrochloride) 100 and 400 mg tablets contain the following inactive ingredients: Gelatin, Hydroxypropyl Methylcellulose, Magnesium Stearate, Sodium Lauryl Sulfate, Sorbitol, Stearic Acid, Sucrose, Titanium Dioxide and other ingredients.
What are the possible side effects of ethambutol (Myambutol)?
If you experience any of the following serious side effects, stop taking ethambutol and seek emergency medical attention or contact your doctor immediately:
- an allergic reaction (difficulty breathing; closing of the throat; swelling of the lips, tongue, or face; or hives);
- vision changes (e.g., blurring, red-green color blindness);
- a rash;
- numbness or tingling in your fingers, toes, hands, or feet;
- confusion, disorientation, or hallucinations; or
- fever.
Other, less serious side effects may be more likely to occur. Continue to...
Read All Potential Side Effects and See Pictures of Myambutol »
What are the precautions when taking ethambutol (Myambutol)?
Before taking ethambutol, tell your doctor or pharmacist if you are allergic to it; or if you have any other allergies. This product may contain inactive ingredients, which can cause allergic reactions or other problems. Talk to your pharmacist for more details.
Before using this medication, tell your doctor or pharmacist your medical history, especially of: eye problems (such as optic neuritis, cataracts, diabetic retinopathy), liver disease, kidney disease, alcohol use.
Before having surgery, tell your doctor or dentist about all the products you use (including prescription drugs, nonprescription drugs, and herbal products).
Alcohol may increase the risk of liver disease. Avoid alcoholic beverages while using this medication.
During pregnancy, this...
Last reviewed on RxList: 2/23/2017
This monograph has been modified to include the generic and brand name in many instances.
Myambutol FDA Prescribing Information
Additional Myambutol Information
Myambutol - User Reviews
Myambutol User Reviews
Now you can gain knowledge and insight about a drug treatment with Patient Discussions.
Here is a collection of user reviews for the medication Myambutol sorted by most helpful.
Report Problems to the Food and Drug Administration
You are encouraged to report negative side effects of prescription drugs to the FDA. Visit the FDA MedWatch website or call 1-800-FDA-1088.
Women's Health
Find out what women really need.


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Greater Boston
Convention & visitors Bureau
Battleship Cove located in Fall River is a world-class maritime heritage museum that brings history to life and is the world's largest collection of historic naval ships. The Cove includes the Battleship MASSACHUSETTS, submarine LIONFISH, destroyer, JOSEPH P. KENNEDY, JR. and two PT boats. Don't miss the exciting "Pearl Harbor Experience", the only outdoor multimedia reenactment of the attack on Pearl Harbor anywhere. Open daily. Gift Shop, Wardroom Grille, free parking and special group rates.


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Currently not available
Model 616 & 647 - MX Lens - Blue
Out Of Stock!
We will notify you when this product becomes available.
The lense is made of an optical Lexan material which is durable, impact resistant, 100% UV protected and can fit the Summit, Impact, and All Sport Series Goggles. The lens comes with an anti-fog treatment and include Iridium lens coating for accurate Light Transmission. Light Transmission: 35%-40%. Good for desert riding.
The L/XL is larger by .08" x .79" vertically which will increase your field of view and improve your peripheral vision while wearing the goggles.
Need help? Check out our FAQ.


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In 1953, Carroll Reece, Tennessee Congressman and Chairman of the RNC (Republican National Committee) along with research director
Buy The Atlantean Conspiracy Now
Radio talk-show host Michael Savage ('Savage Nation') was talking about the censorship to come and the reinturnment camps on his national show Friday. I don't know of you're following any national news over here, but radio host Glen Beck of CNN also played a clip from a speech Obama made to the nefarious group Acorn that he will use their local town committees to contribute to setting the next presidential election. Central planning. He's a complete Leninist-Marxist. Not that there's an alternative, because it's all two sides of the same coin, a duality/dichotomy. Just continue to be aware to all who read, and denounce the lies.
If anyone wants much of this info in a documentary format to wake up the kind of people who won't read or even just for a great compilation of all the information for yourself then this video Wake Up Call (Remastered) is great.
Many students, especially those who are poor, intuitively know what the schools do for them. They school them to confuse process and substance. Once these become blurred, a new logic is assumed: the more treatment there is, the better are the results; or, escalation leads to success. The pupil is thereby "schooled" to confuse teaching with learning, grade advancement with education, a diploma with competence, and fluency with the ability to say something new. His imagination is "schooled" to accept service in place of value. - Ivan Illich
These words seems to echo ur thots. have fun cya
This is a Great article, i go to highschool and every school in fulton county is a brain washer school. Were being traught how to obey authority and put our heads down when our rights are challenged. Were learning retarded crap and getting in trouble way to harshly but all we do is take it up the ass. Schools are for evolution, not mind pollution... AG ...email@example.com
I loved this post, you are spot on, and it was very good read with the quotes.
I never forget my school days. It's like all your dreams are crushed when you start going to school, and when you finally are done with it, weather you quit or actually graduate you feel like it's a burden lifted off your shoulders, but the things you learned was basically to obey, and not say nothing.
I also want to bring up how sex education and drugs are pushed down your throats in school at an early age. Deep down it's like they KNOW you teach kids about sex in elementary school they are going to get interested and do it, yet no one wants to blame that on the teenage pregnancy that is so out of control now. Also drugs, we had the "say no to drugs" pushed down our throats all the way back to the 3rd grade from what I can remember. As we got older it wasn't a surprise that almost all my friends were experimenting when they got older.


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To the editor:
I would like to take this opportunity to thank those who were involved in funding and installing the sign and platforms for benches and trash cans at Flat Run Veterans Park. First, I would like to thank United Community Fund for donating $1,000 toward this endeavor. Also, thank you to the County Fiscal Court and the City Council for agreeing to pay half of the remaining balance, which was a very generous amount. Your kind attention was appreciated.
Thanks to Steve Snapp for designing a sign that is great looking and one in which we can be proud of.
On Monday, March 22, our son was involved in a single truck accident, in your county between Oddville and Claysville. The shoulder of the road gave away with him and his tri-axel dump truck rolled over.
One of my favorite jokes goes like this:
A woman whose husband just left her for another woman walks the beach and finds a bottle in the sand. After pulling out the cork, a genie appears and grants her three wishes, with one stipulation: Whatever she wishes for her husband receives double.
She wishes for a million dollars and — poof! — she gets it, and her husband gets two million. Next, she wishes for a diamond necklace. Poof! One is at her feet and two end up on the neck of her husband's new girlfriend.
One person has only one vote, and I cannot vote for all of the fine men running for District Court Judge. I am voting for Bill Kuster because of his experience, his efficiency in handling district court cases and his courtesy to all.
I have watched Bill in his legal career with great pleasure, as I taught him in high school. He is the best for the job (that court docket is sometimes half an inch thick). We need a judge who not only knows the law, but knows the people, and Bill is that candidate.
(Editor's note: This is an updated column from 2005, about a well-known and dearly loved local service dog that died this week. Charlie was a welcome guest at nursing homes and hospitals and marched in parades. This is a tribute to Charlie, who will be missed.)
Joan Chipkar has one of those kind hearts that I only dream of having.
She says there's no such thing as a stray — dog or person — as long as she has four walls and a roof. She adopts them all, believing that all God's creatures have a purpose.
My letter today is in regards to the election for city commissioner. I would like to publicly express my support for one candidate in particular, Roger D. Slade. I think it is important that the community of Cynthiana has an outsider's perspective concerning Roger Slade. I have resided in Cynthiana for just six years and Roger was one of the first few individuals that I met here. Roger was a very welcoming person, a true ambassador of a small town. His love and vision for Cynthiana was evident from the first day we met.
My father has frequently lamented the ole "If it walks like a duck and quacks like a duck…" as a cue for me to see the obvious.
So now, I find myself staring at endless e-mails claiming that I have recently inherited thousands of dollars or that I can acquire property overseas for a mere acknowledgement with my credit card numbers. Oh, and there was also the letter stating that I could receive a new roof for my house that came from California!
They are all ducks!
They waddle and quack and offer the unbelievable.
Everybody's fine and everybody lies.
That pretty much sums up the essence of life, doesn't it?
Last Saturday I watched the Robert DeNiro movie, "Everybody's Fine." DeNiro's character, recently widowed Frank, has four adult children scattered across the nation whom he has invited home for the weekend. He wants everyone to sit at the table together, just like they used to. He wants to know that he was a good dad, that his kids love him, especially now that his wife is gone.
It's easy to feel affected by Toyota's latest recalls that have affected 8.5 million vehicles.
If you don't drive a recalled Avalon, Camry, Corolla, Highlander, Matrix, Prius, RAV4, Sequoia, Tacoma, Tundra or VENZA, chances are you share the road with other drivers that do.
In Washington, D.C., last Wednesday, Toyota Motor Corporation president Akio Toyoda apologized to a U.S. Congressional Committee, saying "...I am deeply sorry for any accidents that Toyota drivers have experienced."
Between frigid temperatures and snowstorms, the winter of 2010 will be one we will not quickly forget. Snow and ice, compounded with the freezing temperatures day-after-day, have caused hazardous roads in most communities, including Bath, Bourbon, Clark, Harrison, Montgomery and Nicholas counties. However, the road departments performed remarkably, working around the clock to keep the roads as clear as possible.
I've wrecked a car twice in my life.
Two different vehicles, but both separate occasions were on the same downtown Cynthiana street that I travel through almost every single day.
I'm happy to report I was not text messaging while driving when either of the accidents occurred.
But was my attention on the road 100 percent?
I'll admit it.
My mother and I own the Rainbow Thrift Shop on the corner of Pike and Walnut Street. Anyone who has an emergency or fire, etc. we never turn them away for help with clothes, furniture or anything that is necessary. If it wasn't for Clarence Horn, John Hodge and the Salvation Army, along with local churches' participation, a lot of it couldn't be done because we do it out of our own finances and we are both on a fixed income.
When my sister was little, she wiped spaghetti sauce from her mouth with a piece of bread.
This is a significant event in our family's history because, as the Good Daughter, it is probably the one and only time Peggy ever got in trouble.
In a nanosecond, Peggy did the bread-wipe and Dad reached over and whacked her hand, which stunned us all. Not that Dad whacked one of us, but that it was Peggy — the Good Daughter!
Last Thursday, when the mail man delivered my mail, there was no Democrat. I immediately called the office to see if my subscription was still in effect. It was, so I then called the post office. I was told that every family received a free paper. I then asked why no one in my building received one. She repeated the same thing - our carriers were to be back at the post office by 5 p.m. (my mail man comes to my house between 2:30 and 3 p.m. and yet no paper). I was then told the my paper would be in my box on Friday.
Our community deserves to be represented by someone who is a strong and anchored part of Cynthiana; someone who cares for the future of our town. We deserve someone who wants our community to work together to create a place we are all proud to call home. There is such a person running for city commissioner who embodies all of these traits. This person is Roger Slade.
As a farmer in Harrison County, I take great pride in the way my livestock are cared for everyday. In fact, the proper care and welfare of livestock and poultry are essential to the production of food and fiber that we enjoy everyday. No segment of society has more concern for the well-being of poultry and livestock than the farmer, because the well-being of my livestock has a direct impact on whether or not I can make a living farming.
I urge everyone to read 'Jock - a coach's story.' It's not a book about basketball. It is a book about life - the good times, the rough times. It is about making mistakes, about doing the right thing. It's about patience. It's about impatience. It's about happy times and it's about sad times. It's a book about one of the best friends I've ever had. Stuart Warner put it together beautifully. Do read it. It will touch your life.
Gerald Whalen
Step away from the video games. Let go of the joy stick. Turn off the television.
Go play in the snow!
Finding snow pictures is getting more and more difficult as pastimes have changed direction.
I hate to sound like my grandfather spinning a yarn, but when I was growing up, a big, even a moderate, snowfall meant a day with rosy cheeks and cold hands.
My friends and I would go from yard to yard creating snowmen to adorn each of our lawns. We would also build igloos and have snowball wars.
Now, it's all about the video wars.
There's no doubt in my mind that it's going to be an exciting election year.
Cynthiana and Harrison County voters will actually have decisions to make this year when they step into the voting booth. Almost every magistrate seat has a set of contenders and the commission will have a spot on the May primary ballot since over eight candidates filed for the four commission positions.
Both for the county and city, many of the candidates are new to the local political world. While not endorsing anyone, I think that's exciting to see.
Copyright © 2017
The Cynthiana Democrat is your source for local news, sports, events, and information in Cynthiana, KY and the surrounding area.


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I am completely heartbroken about the news this past weekend of the missing elderly woman found dead in Lawrence County on Saturday, Nov. 28. She went missing Wednesday evening, Nov. 25. You can find the whole story about her at www.wsaz.com/newskentucky.
The week prior to Thanksgiving, my church participated in a week of hunger.
The plan was to eat only beans, rice and tortillas for five days to experience what a huge percent of people around the world eat all the time.
Then we were to take the money we would've spent on food and donate it to help feed orphans in Haiti. In addition, after a shortened worship service, we would be dismissed early to go grocery shopping to buy food items to benefit local food pantries.
Years ago, when I was still in Congress, I pulled up one day to address a public meeting in a remote and very rural part of Indiana. The sheriff, a friend of mine, met me outside the small volunteer firehouse where I was to speak. "The Ku Klux Klan is here in full regalia," he told me. "If you'd like, I'll keep them out of your meeting."
To the editor:
We would like to once again express our sincere appreciation to the Cynthiana Elks Lodge for hosting veterans with a fish fry luncheon. It was great! The food was delicious, but the camaraderie warm and inviting. We felt appreciated and welcome.
Before we know it, 2009 will come to a close. We'll ring in a new year and say goodbye to what has been.
Some people may describe 2009 as momentous. For others it was just another 12 months. However you look upon the last four seasons, I hope you looked at some of it through a camera's lens.
Our new publication will come with the close of the year. It will be our first Yearbook, and quite honestly, if we don't get some photographs from our readers, it will likely be our last yearbook.
Merciful God,
Every year at this time as I start to pen a psalm of Thanksgiving, I'm never quite sure where to begin, or even how to approach you.
I have so little to lay at your feet. No grand deeds, no souls saved because of something I've said or done. Truth is, I'm feeling empty-handed and ashamed, aware of my unworthiness, yet confident of your great mercy.
O, how I cherish your mercy!
With an election for state, county and city positions less than a year away, The Cynthiana Democrat welcomes letters of endorsement for candidates of the 2010 election.
The last date to publish a candidate endorsement is in the Oct. 21, 2010 issue. Those letters need to be received at the office no later than 5 p.m. Monday, Oct. 18, 2010. Letters should be no more than 300 words. All letters must be signed and include a daytime telephone number for verification purposes. Letters will not be published unless the author can be reached.
One childhood Christmas memory is receiving a shiny red plastic doctor's kit. I went from family member to family member looking inside their mouths while they played along with my fantasy career.
I'm beginning to think that we are humoring a group of lawmakers who have no more qualifications to make a diagnosis than I did.
In their fantasy careers, lawmakers believe they should go over the heads of experts to tell the public what's best for their health care.
I'm more than a little concerned.
Having been a substitute teacher for 13 years, it was time to retire. My last day of work was in December 2008. The need for substitute teachers in January and February increased my desire to retire.
As you know, the Kentucky legislators required all school personnel to contribute to a pension program. I did not want to participate in a pension program, but it was mandatory. However, when I retire, I would get my "contribution."
Leaves falling from trees onto city streets and rain do not make our streets very safe for a person who is speeding and is trying to stop. This makes for a very dangerous situation out here this time of year. Every driver needs to remember to adjust your driving habits to the road conditions because the roads are not going to adjust to your driving. Speed limits are posted for a reason and that is for people to drive safely in our community. They are not put out there for people to ignore.
A patient of the late Dr. Paul Brand had serious and painful circulation problems in his leg, but refused an amputation.
As his pain increased, so did his bitterness until finally he couldn't stand it any longer and told Dr. Brand, "Cut it off!"
However, he wanted his leg preserved in a pickling jar so he could put it on the mantle where he could taunt it — 'Ha! You can't hurt me anymore!"
I would like to begin by sharing my appreciation for the community, parents and students for their outstanding support in our efforts to be one of the best districts in the state. Also, I would like to commend our administrators and school staffs for their tremendous strides in moving our district forward in student performance. I would like to take this opportunity to share with our community the vision and mission statements for the Harrison County school district.
You recently published a letter from me in regards to dangerous driving on US 62 (Cynthiana Road). Thank you. I wanted to inform your readers of a possible concern I became aware of afterwards - using cruise control on one's vehicle on wet surfaces. Whenever cruise control is on, two other factors come into play.
1.) In order to maintain a constant speed, sometimes the vehicle will accelerate on its own... which could cause you to hydroplane, and thus lose control.
Our father, Noel Phillips Sr. was with the 735th Tank Battalion under the command of General George S. Patton during World War II. Dad entered the war in August of 1944 in France. He was in the 735th until the end of the European war that ended on his 20th birthday.
There is confusion between Memorial Day and Veterans Day sometimes.
Memorial Day, sometimes called Decoration Day, is a day to honor deceased friends and family, usually on the last Monday of May.
Veterans Day, Nov. 11, is a federal holiday to honor all veterans - both living and deceased. It is a time to honor the deceased and to recognize and thank those living that served and those that are serving the citizens of the United States throughout the world.
You probably know a veteran of past service, and more than likely, you have close kin that served.
To the elected officials of Cynthiana - I am writing with a tongue in cheek request for help. I own my residence, which is on the west end of Battle Grove Avenue. You may not have noticed but we haven't had the benefit of a nicely paved street for some years now here on Battle Grove. What with all the water and sewer leaks, not to mention the gas line leaks, a good part of our street has been made up of poorly applied cold patch and gravel for some time now.
People do crazy things on Halloween.
For the most part, my childhood Halloween's tend to blend together - a blur of witches' costumes, candy and orange and green swirls.
But there is one Halloween that continues to stand out from the rest.
It was the Halloween that proved all things normal are disregarded on the night of fright.
Copyright © 2017
The Cynthiana Democrat is your source for local news, sports, events, and information in Cynthiana, KY and the surrounding area.


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I bought up all of them 20 rnd and 32 rnd UZI mags 6 years ago. Had my first UZI but, what was this AR15 thing all about? Got some conversion parts from RRA and assemble a first AR15 as a 9mm. Got a job several years back where I can machine anything I want after hours. So, several dozen of them UZI mags got machined into real good AR15 9mm ones. Bead blasted and parked all of them up to last.
A 9mm AR15 is such a sure hitter under 100 yards. And, what you hit gets, plastered. Without a huge blast of noise.


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Late on Valentine's Day last year, a man rode the subway alone. He was 70 maybe, but in good nick for his age, and he wore a perfect tuxedo and bow-tie. His hands were lean and long, and he rested a small case upon his knees. In his hand he held a single red rose.
A tipsy young couple clattered aboard, and dropped upon a bench. They wrapped up their limbs and pashed and giggled together.
The man with the rose and the tux didn't move.
I wondered where in New York he'd spent Valentine's evening. I wondered about the tux, if he'd shared dinner at a fine, romantic restaurant, and where his date had ended up.
Most of all, I wondered about the single red rose - if it was a gift he'd give or had received.
The young couple spluttered with laughter and lust. The man stepped off the train.
New York is a city of romance, for sure. The streets are inviting, the architecture's grand, and the culture's as abundant and diversified as the dining is rich. I once plodded through the snow in the middle of Central Park and saw a man drop to his knee with a ring.
Are you kidding? Of course she said yes.
But sometimes, too, New York's a tough place for love. People are fickle, transient, aggressive and ambitious (myself included). Come Thursday, I'd be lying if I told you that I won't be riding the subway alone. It's a weird thing, in a city of 12 million people, to occasionally feel just a bit lonely.
For some time after Valentine's Day, I thought of the old man in the tux. I daydreamed of backstories and of who he might be. I wondered if he'd spent every Valentine's Day alone. Perhaps he was a widower. Perhaps his story was, in fact, too sad. Perhaps he'd had dinner alone at his wife's favourite restaurant. Perhaps she'd even left him for somebody else.
It was stupid, of course, to dream of a stranger so sad in a city so wild and exhilarating.
A few months later I spent a night at the city opera and waited as the orchestra packed up after the show. In the middle, by the flautists and oboe players, was a man of about 70, in good nick for his age. Each musician wore a black tuxedo. Each carried a case. And each of them had a single red rose.
On another auspicious occasion of sorts, the expat crowd gathered in a Manhattan bar this week to celebrate Waitangi Day. Instead of mussel fritters the masses ate pies. There was good Kiwi beer and rich Kiwi wine, rugby balls and Nature's Best on repeat. Any nationalistic surges didn't quite match the blind fervour of 'Straya Day, but we celebrated and appreciated our home.
Yes, history's blighted, grievances under-appreciated. But it is the contrast of Waitangi Day and the significance it carries that unites us all, wherever on Earth we might be.


text: During pregnancy, women need to take care of all health related issues for herself and unborn baby. Healthy diet, regular health check ups, exercise can help to keep her fit during pregnancy. One more important question that arises, Is sex safe during pregnancy? There are many reasons for positive answers of these questions.


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Father's Day
When our children were young they would often ask to play hide and seek. I would counter with an offer to play hide and don't find. Their response: "Dad, that's no fun!"
Every child (and every adult) longs to be valued and sought out.
This coming Sunday is celebrated as Father's Day - a day set aside to honor those men who give of themselves to raise up the next generation.
Over the past 50 years our nation has seen a steady decline in the honor bestowed upon fatherhood. Some men have never become fathers because they perceive children as a burden. Others have "fathered" many children yet have abdicated the responsibility for the lives they have created.
Our bookstores are sprinkled with texts promoting a return to true fatherhood, but what does that really look like?
I was blessed to be raised by a Godly man. He walked the walk before he talked the talk. Many of my skills, talents and priorities can be traced directly to my father.
I cannot remember a single experience of being dropped off at church. He parked the car and we attended as a family. That model of fatherhood resonates deeply within my soul.
Many men today have been scarred by a very different upbringing. To them the title "Father" conjures up memories of anger and abuse. Some have suggested that our understanding of God as Father is strongly influenced by our relationship with our earthly father. I believe this to be true.
While I wear the title of father with due honor, there is another title that is even more valuable to my heart – the title of "Daddy." Jesus understood the significance of this title. In the hour of his greatest need He cried out, "Abba, Father." The word "Abba" is the Aramaic word for "Father." And so its repetition would at first appear redundant.
But after deeper study one finds this form indicates intimacy and trust as opposed to the formalism of legalism. This depth of relationship with the Creator of the universe was not familiar to the Jews of his day. While most men today may not trace their roots back to the Jewish race, we bear a similar viewpoint.
We hide from our Heavenly Father fearing his punishment and hope He doesn't find us. But God doesn't seek to punish but to embrace us as his children. Jesus declares, "I am the way and the truth and the life. No one comes to the Father except through me. If you really know me, you will know my Father as well. From now on, you do know him and have seen him."
This is the amazing truth of Father's Day. "Our Father" so loved the world that he gave his one and only Son, that whoever believes in him shall not perish but have eternal life.
Happy Father's Day!
Tim Walker is the pastor at Faith Assembly of God.


text:
Day recognizes suicide survivors
POCATELLO, Idaho - Suicide survivors met in Pocatello on Saturday to help bring attention to a growing need for help.
The turnout was sobering, dozens of people most of who have lost a friend or relative.
"As you can imagine, with times the way they are, we are seeing more and more issues related to mental health and the issues of suicide," Portneuf Medical Center Behavioral Health Director Charlie Aasand said.
Aasand said those left behind are left with burning questions in their minds.
"They question why, what could I have done, what happened in our family, what happened in our relationship, that would have driven someone to seek such an end?" Aasand said.
Those putting on the event said in the United States issues of mental health and suicide are growing.
Idaho is one of a few states without a suicide hotline, but Aasand said that could soon change.
"We've spoken with legislators about that. We understand that there is some opportunity that they're working on so that we can put together maybe a joint venture with other states or organizations," Aasand said.


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May 23, 2017 @ 2:30 PM
12 Easy Ways to Look Thinner By Tonight
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1. Look Thinner By Tonight!In her new book, How to Never Look Fat Again, style expert and author Charla Krupp shares easy tips for looking long, lean and lovely-in an instant!
2. Wear Skinny Heels with Pointy Toes
Legs look slim and sexy in skirts paired with a shoe that has a tapered toe and at least a 2-inch stiletto. A slender toe and thin heel work to extend the narrow silhouette of calves. Square-toe styles with a thick, chunky heel give the appearance of a shorter, bulky leg.
Patent leather pumps, Guess, $90; 877-444-8377.
3. Show Some Skin Up Top
Expose a bit with a V-neckline. The open, upside-down triangle creates a high focal point up and away from your midsection and gives the illusion of a longer, slimmer upper body. The more skin displayed between chin and chest (within reason!), the more elegant your proportions will seem overall; wider V-necklines visually balance broad hips and thighs. So collect Vs in everything-camis, tanks, Ts, sweaters, cardigans, dresses and jackets.
Silk top, Erin Fetherston, $350; 323-655-2142.
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Polyamideelastane camisole, Spanx, $46; spanx.com.
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XEN-TAN's Dark Lotion Absolute Luxe, $56; xen-tan.com.
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Long necklaces add length to a short neck and bring attention away from hips and to the front and center of your body. Mid-chest bibs or big chandeliers say look at the face and not the middle. Sparkly cuffs, stacks of bangles, and cocktail rings draw the eye to wrists instead of upper arms.
Enamel and gold-plated necklace, Lisa Stewart, $320; lisastewartonline.com.
8. Match Your Shoe Color to Your LegCoordinate tones to elongate your bottom half. In winter, wear black opaque tights and black pumps; in summer, try neutral skin-hued versions with bare legs.
9. Wear Hair Up and Off Your FacePull tresses into a ponytail high on the back of your head and then lightly tease at the crown to bring out your bone structure and make your face look thinner.
10. Pick Simple, Unadorned Denim
Clean, streamlined jeans are the way to go. The most flattering styles are dark and feature unembellished pockets. Avoid extra details that catch the eye and give the illusion of bulk-think twice about tags, grommets, or decorative extras. The leanest silhouettes of all: boot cut and straight leg.
Straight-leg jean, 7 For All Mankind, $165; net-a-porter.com.
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A professional bra fitter can determine if you, like most women, are wearing a wrong-size band and too-small cups, which neither lift nor shape. Down below, too-snug panties create bulges, while visible panty lines (VPLS) disrupt the clean lines of top layers, contributing to bulk around the butt and hips. Get a smooth rear view with thongs or G-strings. For more backside coverage, consider seamless tangas or cheekies.
Nylon-spandex lace bra, Le Mystère, $82; at Bloomingdale's. Nylon-polyester lace bra, Soma Intimates, $44; soma.com.
12. Sport a Jacket Over JeansThe crisp straight lines and narrow lapels of a blazer counteract excess curves. An open jacket is extra-slimming worn over V-neck tanks and dark-wash jeans.
13. Choose the Right Fabrics• "Flat" materials don't add volume. Pick cotton, denim, silk, or wool gabardine.
• Some fabrics actually help slim and shape. Try jersey, cashmere, fine cotton, and anything with a touch of spandex.
• Wear bulky materials sparingly, such as wide-wale corduroy, crushed velvet, metallic, leather, suede, mohair, angora, brocade, taffeta, boucle, satin, fringe and flannel.
1 of 13
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In her new book, How to Never Look Fat Again, style expert and author Charla Krupp shares easy tips for looking long, lean and lovely-in an instant!
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Should NYS have a law that defines honey?
Should any state have a law that defines honey?
Why do people feel a need or desire to have a law that defines honey?
Cant we just look up the definition of honey in Websters dictionary?
Should NYS have a law that defines honey?
Should any state have a law that defines honey?
Why do people feel a need or desire to have a law that defines honey?
Cant we just look up the definition of honey in Websters dictionary?
Interesting. I know of a local guy that feeds Hi Fructose syrup all summer and bottles honey? Is it really honey?
OK, take Webster's definition, what ever it is. How do you take that definition to a testing lab and have them verify that the sample is or is not honey, in a manner that can be repeated, and hold up in a court of law? We all know that honey is that which is collected from flowers, but how do you prove or disprove that?
If you DO define honey in a manner that defines the lab tests, then if the sample fails a repeatable test, you CAN take it into a court of law and file for damages(you have been injured) against the individual that has sold a product as honey, that is not..
Crazy Roland
post # 13 and #15 says it all for me, I would go for the standard of identity, but it taking 5 years for something that most beeks want, and the consumer would want if they know what was going on is really to long. having only lived in N.Y. 10 years I can predict that N.Y. will never have a SOI or at least in my life time. Was a hot topic when floriday passed theirs, now not so much.
mike syracuse ny
Whatever you subsidize you get more of. Ronald Reagan
You'll have to call Paul Cappy, NYS Apiculturalist, for the particulars, but I was told that a random selection of a sizeable number, maybe 100, of jars of honey were collected from across NYS, tested and no contamination or adulteration found. I guess I should call him myself and see if there is any kind of report to be had.
Mark Berninghausen
Will legally defining honey prevent adulteration? Beekeepers and packers have been fighting adulterated honey in this country for well over 100 years. Will a new law magically prevent bad honey?
I understand the lawyers want new laws all the time. What is wroung with going after those offenders under mislabeling? Isn't the word PURE on the label adequate?
One comment at the annual meeting from a lady said she is all for the SOI so she can charge more money for her NYS Qualified honey. I thought about asking her why she dont just charge more for the honey now.
Good question Brian. I know people who already do. Nothing about the SOI will mean you can do that anymore in the future than now, imo.
I don't know why people don't just decide what they want for their honey and charge that price for it and see what happens. Every time I have raised my prices I sell more and I usually bottle evewry drop I produce This year I sold some buckets to another bkpr..
Nothing will prevent adulteration from happening. Packers have done it and been prosecuted and then do it again. Maybe not stiff enuf fines levied. (?)
Mark Berninghausen
I think you are correct about the stiffer fines. We can already chemical determine if something adulterated.
I absolutely agree that beekeepers need to challenge the market price if they do NOT feel like they are getting enough for their honey. We do it fairly frequent with good results. We have never had an issue selling our honey.
Members there are worried about commercial beekeepers packaging their melter honey as buckwheat honey also. I dont know every commercial operation or what they do but I think it would be fairly easy to identify melter honey compared to buckwheat honey.
In reality I dont believe we should put a new law in effect due to perception. Those who mentioned melter honey in or sold as buckwheat honey didnt identify any NYS commercial beekeeper who is guilty of doing such deceitful actions.
When I bought some Buckwheat from Wixsons Honey Inc which Jerry said came out of Washington State. It sure tasted like Buckwheat to me. When I sold that to one customer in particular, by the case, he had me pick up the rest of the case the next time I was around because he and his customers didn't like the taste. Said it wasn't Buckwheat. So, I'm thinking that "Buckwheat" is the new Buckwheat. Were it labeled Wax Melter Honey I wonder is people would still like it as well?
Other people run their wax melter honey through the bulk tank w/ the rest of the honey and into the barrel. I don't know if the price balances out or not. It's still honey, so would one really need to label it Clover/Wax Melter Honey?
Last edited by sqkcrk; 11-23-2012 at 07:55 AM. Reason: catch enuf flack from the pure and righteous
Mark Berninghausen
I would think the taste would come thru when they blend it as well. Maybe not. Maybe part of the issue is selling honey by color. That almost always forces packers and large beekeepers to blend their honey to the correct color. I know that is an industry wide practice. However selling melter honey as Buckwheat honey is still mislabeling. It's not adulterated, just mislabled and go under same existing labeling rules?
I have always sold mine to folks as just that, melter honey. Im sure some of the farmers I sold mine to mix it with corn (treat it as molasses).
Wont the consumer rectifier anyone who is producing low quality honey?
I would think so.
Mark Berninghausen
I would like to believe customers will figure it out pretty quick. Especially those who go out of their way to get your honey. I know I have quite a few that come out to the house to buy it anywhere from 1 gallon to 5 gallons at a shot.
So speaking of mislabeling how many times have beekeepers said their spring early summer honey is clover honey and the fall honey as wild flower honey?
Isn't it all wildflower honey?
The honey I get from Ga is mostly gallberry and black gum honey. Of course there is some titi coming in and a few others. Should I label it as gallberry, or black gum? Nobody ever heard of black gum honey less you are producing it in the south. Most folks heard of Gallberry.
What if we started calling the local honey dandelion and sumac honey?
Sometimes labeling can get pretty crazy.
If there is a difference in the color and taste I bet you could label it differently and charge more for it. I don't know who would check and how they would tell, beyond color and taste. Sure, if someone wanted to go to the expense of checking the pollen grains. But, realistically?
Mark Berninghausen
It would be expensive to send off each time I extract. Jerry has mentioned the cost of having a lab analyze it. It would also be scary to see what kind of other chemicals they maybe dragging in from things such as mosquito abaitment or other ag farming.
Maybe we would find chinese honey is cleaner than our own honey?
I would like to think we can produce cleaner honey than china can produce but who knows?
took me a while but I found the post I posted b/4.
I found where the usda was testing the method that they use for testing honey, I'll copy the interesting parts below and give the link.
http://ddr.nal.usda.gov/bitstream/10...ND44027553.pdf <---- note this url no longer works I'll see if I can find it again.
Incurred Honey Samples. The performance of the method
was evaluated with incurred honey obtained from treated
beehives. For most of the analytes, two incurred levels (n ) 5)
were assayed. Fumagillin and oxytetracycline residues were
detected in the incurred honey, but their levels were below the
validated range of the method. The highest CVs of the incurred
levels are reported in Table 5. The repeatability errors for the
tested analytes in the incurred honey were less than 14%.
Only three
of the 15 retail honeys tested were totally free from all 17
antibiotics. The majority of the honeys contained either one or
two of the antibiotics, and one sample had as many as four
different antibiotics. The positive findings are as follows: tylosin
(8), lincomycin (3), oxytetracycline (2), chloramphenicol (2),
streptomycin (2), sulfathiazole (1), tetracycline (1), and danofloxacin
now I didn't read all of the document and they didn't say where the honey came from but only 2 of the above are legal in the USA that I know of, and fumidil doesn't show up in any.
if anyone can read and understand the entire thing please let us know.
added they also said fumidil breaks down in light, my comment on that would be, if it actually made it into your jar of honey, wouldn't it then break down?? they also said at that time that they hadn't set a residual level yet for the legal chemicals, but that there is no legal level for the ilegal chems. if I read it correctly.
mike syracuse ny
Whatever you subsidize you get more of. Ronald Reagan
The break down product from exposure of Fumagilin-B to UV is still efficacious for Nosema so it must still be an antibiotic in some form. The big problem we have in North Carolina is not adulteration but honey brought in from other states and countries being sold as local honey. We bottle our honey and sell it the end retail seller (stores, health food coops, farmer's market vendors, etc.). All of our major competitors in this state sell non-NC honey as local honey. Very few of them have any bees although most claim to have bees. The prime example is a guy who claims to have 10,000 colonies in two other states but actually has no bees. Its hard to compete with that when you are actually producing the honey with your bees. At least its easier to sleep at night.
I don't think that a state standard will help much.
I think it wiser to produce really good honey, market it well, and let those who can't tell the difference buy what they will.
We don't have a standard now, and the honey i sell is going for well above commodity honey price.
If people can't tell the difference between what a guy produces and adulterated honey, how is his honey actually higher in value?
I know many will probably say SOI is for protecting the consumer, but truly, we are protecting the honey commodity market.
It all depends on how regulations are actually enforced. Usually by design or default its by the Keystone cops. North Carolina has given authority for initial investigative and enforcement actions to the state hobby beekeepers association. It is like letting everyone with a 10 gallon aquarium regulate (and potentially ruin the business of) commercial fisherman. Currently, if you pay the hobbyists $25.00 a year and swear "honest injun" you can buy unlimited "Certified North Carolina Honey" stickers from them as long as you buy them from "their vendor". No honey testing - no verification that you have any colonies. What a joke. One of the principals on the "Honey Standards Committee" is by his own admission one of the worst violators. That's where most attempts at regulation end up.


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Chapter 2 The Pre-Travel Consultation
General Recommendations for Vaccination & Immunoprophylaxis
Recommendations for the use of vaccines and other biologic products (such as immune globulin [IG] products) in the United States are developed by the Advisory Committee on Immunization Practices (ACIP) and are harmonized with ACIP liaison organizations including the American Academy of Pediatrics, the American Academy of Family Physicians, the American College of Physicians, the American College of Obstetricians and Gynecologists, and others. Recommendations voted on by the ACIP are reviewed by the CDC director and, if adopted, become official recommendations of the Department of Health and Human Services/CDC upon publication in CDC's Morbidity and Mortality Weekly Report (MMWR). ACIP recommendations are based on scientific evidence of benefits (disease immunity) and risks (vaccine adverse reactions) and, where few or no data are available, on expert opinion. Recommendations include information on general immunization issues and the use of specific vaccines. Box 2-01 provides more information about ACIP. This section is based primarily on the ACIP General Recommendations on Immunization.
Evaluation of people before travel should include a review and provision of routine vaccines recommended based on age and other individual characteristics. Additionally, some routine vaccines are recommended at earlier ages for international travelers. For example, MMR (measles-mumps-rubella) vaccine is recommended for infants aged 6–11 months who travel abroad to protect them from measles. Recommendations for specific vaccines related to travel will depend on itinerary, duration of travel, and host factors. Vaccinations against diphtheria, tetanus, pertussis, measles, mumps, rubella, varicella, poliomyelitis, hepatitis A, hepatitis B, Haemophilus influenzae type b (Hib), rotavirus, human papillomavirus (HPV), and pneumococcal and meningococcal invasive disease are routinely administered in the United States, usually in childhood or adolescence. Influenza vaccine is routinely recommended for all people aged ≥6 months, each year. A dose of herpes zoster (shingles) vaccine is recommended for adults aged ≥60 years. If a person does not have a history of adequate protection against these diseases, immunizations appropriate to age and previous immunization status should be obtained, whether or not international travel is planned. A visit to a clinician for travel-related immunizations should be seen as an opportunity to bring an incompletely vaccinated person up-to-date on his or her routine vaccinations.
Both the child and adolescent vaccination schedules, and an adult vaccination schedule, are published annually. Clinicians should obtain the most current schedules from the CDC Vaccines and Immunization website (www.cdc.gov/vaccines/schedules). The text and many tables of this publication present recommendations for the use, number of doses, dose intervals, adverse reactions, precautions, and contraindications for vaccines and toxoids that may be indicated for travelers. Recommendations for travelers are not always the same as routine recommendations. For instance, most adults born after 1956 are recommended to receive 1 dose of MMR vaccine; however, international travelers of this age are recommended to receive 2 doses. For specific vaccines and toxoids, additional details on background, adverse reactions, precautions, and contraindications, refer to the respective ACIP recommendations (www.cdc.gov/vaccines/acip/index.html).
Box 2-01. The Advisory Committee on Immunization Practices (ACIP)
In 1964, the Department of Health, Education, and Welfare chartered the Advisory Committee on Immunization Practices (ACIP) to provide guidance to CDC for making immunization policy. Guidance includes scheduling of vaccine doses, specific risk groups for whom vaccination is recommended, and vaccine contraindications and precautions.
ACIP is composed of 15 voting members selected by the Secretary of Health and Human Services. The ACIP chair, a consumer representative, and 13 members are balanced among various sectors, including academic immunology, medicine, and public health. In addition to the 15 voting members, the committee includes 8 ex officio members representing federal agencies and 35 nonvoting representatives of liaison organizations with broad responsibilities for vaccine development, administration of vaccines to various segments of the population, and operation of immunization programs. ACIP is subdivided into 4 permanent workgroups that address child/adolescent immunization schedules, adult immunization schedules, influenza vaccine, and general immunization issues. In addition to the 4 permanent workgroups, 10 additional workgroups focus on particular vaccines. Input into the development of immunization schedules is shared with professional organizations, including the American Academy of Pediatrics, American College of Physicians, American Academy of Family Physicians, American College of Obstetricians and Gynecologists, and American College of Nurse-Midwives.
ACIP workgroups are led by a member of ACIP who works in close collaboration with a CDC workgroup lead staff member. Members of the vaccine pharmaceutical industry may not serve as workgroup members. The workgroup develops consensus on various policy points, then the CDC workgroup lead writes specific content for presentation to the ACIP at large. When it is difficult to achieve consensus, options with plans are developed and presented to the ACIP at large for a vote.
ACIP holds 3 public meetings a year during which the various workgroups present content that has been developed and is ready for discussion or voting. Sometimes ACIP members are involved in academic vaccine research supported by the pharmaceutical industry. These members must state these conflicts and must recuse themselves from votes regarding vaccines manufactured by companies from which they receive support. The result of various discussions and votes is an ACIP document published in CDC's Morbidity and Mortality Weekly Report (www.cdc.gov/mmwr), representing the official policy of the Department of Health and Human Services.
Simultaneous Administration
With some exceptions (such as PCV13 and PPSV23, as well as PCV13 and MenACWY-D [Menactra]), all commonly used vaccines can safely and effectively be given simultaneously (on the same day) at separate sites without impairing antibody responses or increasing rates of adverse reactions. This knowledge is particularly helpful for international travelers, for whom exposure to several infectious diseases might be imminent. Simultaneous administration of all indicated vaccines is encouraged for people who are the recommended age to receive these vaccines and for whom no contraindications exist. If not administered on the same day, an inactivated vaccine may be given at any time before or after a different inactivated vaccine or a live-virus vaccine.
The immune response to an injected or intranasal live-virus vaccine (such as MMR, varicella, yellow fever, or live attenuated influenza vaccines) might be impaired if administered within 28 days of another live-virus vaccine (within 30 days for yellow fever vaccine). Whenever possible, injected live-virus vaccines administered on different days should be given ≥28 days apart (≥30 days for yellow fever vaccine). If 2 injected or intranasal live-virus vaccines are not administered on the same day but <28 days apart (<30 days for yellow fever vaccine), the second vaccine should be repeated in ≥28 days (≥30 days for yellow fever vaccine).
Measles and other live-virus vaccines may interfere with the response to tuberculin skin testing and the interferon-γ release assay. Tuberculin testing, if otherwise indicated, can be done either on the day that live-virus vaccines are administered or 4–6 weeks later. Tuberculin skin testing is not a prerequisite for administration of any vaccine. Oral typhoid vaccine, a live attenuated bacterial vaccine, has not been associated with suppressing the response to tuberculosis testing.
Missed Doses and Boosters
All vaccines require a primary dose or series to ensure immunity, and some require periodic repeat, or booster, doses to maintain immunity. Occasionally, the demand for a vaccine may exceed its supply, and providers may have difficulty obtaining vaccines. Information on vaccine shortages and recommendations can be found on the CDC Vaccines and Immunization website at www.cdc.gov/vaccines/vac-gen/shortages/default.htm.
In some cases, a scheduled dose of vaccine may not be given on time. If this occurs, the dose should be given at the next visit. However, travelers may forget to return to complete a series or for a booster at the specified time. Available data indicate that intervals between doses longer than those routinely recommended do not affect seroconversion rate or titer when the schedule is completed. Consequently, it is not necessary to restart the series or add doses of any vaccine because of an extended interval between doses. The only exception to this rule is oral typhoid vaccine in some circumstances. Some experts recommend repeating the series of oral typhoid vaccine if the 4-dose series is extended to more than 3 weeks.
Antibody-Containing Blood Products
Antibody-containing blood products from the United States, such as immune globulin (IG) products, do not interfere with the immune response to yellow fever vaccine and are not believed to interfere with the response to live typhoid, live attenuated influenza, rotavirus, or zoster vaccines. When MMR and varicella vaccines are given shortly before, simultaneously with, or after an antibody-containing blood product, response to the vaccine can be diminished. The duration of inhibition of MMR and varicella vaccines is related to the dose of IG in the product. MMR and varicella vaccines either should be administered ≥2 weeks before receipt of a blood product or should be delayed 3–11 months after receipt of the blood product, depending on the vaccine (Table 2-04).
IG administration may become necessary for another indication after MMR or varicella vaccines have been given. In such a situation, the IG may interfere with the immune response to the MMR or varicella vaccines. Vaccine virus replication and stimulation of immunity usually occur 2–3 weeks after vaccination. If the interval between administration of one of these vaccines and the subsequent administration of an IG preparation is ≥14 days, the vaccine need not be readministered. If the interval is <14 days, the vaccine should be readministered after the interval shown in Table 2-04, unless serologic testing indicates that antibodies have been produced. Such testing should be performed after the interval shown in Table 2-04, to avoid detecting antibodies from the IG preparation.
If administration of IG becomes necessary, MMR or varicella vaccines can be administered simultaneously with IG, with the recognition that vaccine-induced immunity can be compromised. The vaccine should be administered at a body site different from that chosen for the IG injection. Vaccination should be repeated after the interval noted in Table 2-04, unless serologic testing indicates antibodies have been produced.
When IG is given with the first dose of hepatitis A vaccine, the proportion of recipients who develop a protective level of antibody is not affected, but antibody concentrations are lower. Because the final concentrations of antibody are many times higher than those considered protective, this reduced immunogenicity is not expected to be clinically relevant.
IG preparations interact minimally with other inactivated vaccines and toxoids. Other inactivated vaccines may be given simultaneously, or at any time interval before or after an antibody-containing blood product is used. However, such vaccines should be administered at different sites from the IG.
Every opportunity should be taken to provide needed vaccinations. The decision to delay vaccination because of a current or recent acute illness depends on the severity of the symptoms and their cause. Although a moderate or severe acute illness is sufficient reason to postpone vaccination, minor illnesses (such as diarrhea, mild upper respiratory infection with or without low-grade fever, other low-grade febrile illness) are not contraindications to vaccination.
People with moderate or severe acute illness, with or without fever, should be vaccinated as soon as the condition improves. This precaution is to avoid superimposing adverse effects from the vaccine on underlying illness, or mistakenly attributing a manifestation of underlying illness to the vaccine. Antimicrobial therapy is not a contraindication to vaccination, with 3 exceptions:
- Antibacterial agents may interfere with the response to oral typhoid vaccine.
- Antiviral agents active against herpesviruses (such as acyclovir) may interfere with the response to varicella-containing vaccines.
- Antiviral agents active against influenza virus (such as zanamivir and oseltamivir) may interfere with the response to live attenuated influenza vaccine.
A physical examination or temperature measurement is not a prerequisite for vaccinating a person who appears to be in good health. Asking if a person is ill, postponing a vaccination for someone with moderate or severe acute illness, and vaccinating someone who does not have contraindications are appropriate procedures for clinic immunizations.
Table 2-04. Recommended intervals between administration of antibody-containing products and measles-containing vaccine or varicella-containing vaccine1
Blood Transfusion
Red blood cells (RBCs), washed
RBCs, adenine-saline added
Packed RBCs (hematocrit 65%)2
Whole blood (hematocrit 35%–50%)2
Plasma/platelet products
10 mL/kg (negligible IgG/kg) IV
10 mL/kg (10 mg IgG/kg) IV
10 mL/kg (60 mg IgG/kg) IV
10 mL/kg (80–100 mg IgG/kg) IV
10 mL/kg (160 mg IgG/kg) IV
3 months
6 months
6 months
7 months
|Botulism immune globulin, intravenous
|1.5 mL/kg (75 mg IgG/kg) IV
|6 months
|Cytomegalovirus prophylaxis (CMV IGIV)
|150 mg/kg IV (maximum)
|6 months
Hepatitis A (IG), duration of international travel
< 3-month stay
≥ 3-month stay
0.02 mL/kg (3.3 mg IgG/kg) IM
0.06 mL/kg (10 mg IgG/kg) IM
3 months
3 months
|Hepatitis B prophylaxis (HBIG)
|0.06 mL/kg (10 mg IgG/kg) IM
|3 months
Intravenous immune globulin (IVIG)
Replacement therapy
Immune thrombocytopenic purpura (ITP)
Postexposure measles prophylaxis (includes immunocompromised people)
Postexposure varicella prophylaxis3
Kawasaki disease
300-400 mg/kg IV
800 mg/kg IV or 1 g/kg IV
400 mg/kg IV
400 mg/kg IV
2 gm/kg IV
8 months
10 months5 (Updated Dec. 10, 2015)
8 months
8 months
11 months
Measles prophylaxis (IG)
Immunocompetent contact
0.5 mL/kg (80 mg IgG/kg) IM
6 months
|Monoclonal antibody to respiratory syncytial virus (RSV) F protein (Synagis [MedImmune])4
|15 mg/kg IM
|Rabies prophylaxis (HRIG)
|20 IU/kg (22 mg IgG/kg) IM
|4 months
|Tetanus (TIG)
|250 units (10 mg IgG/kg) IM
|3 months
|Varicella zoster immune globulin3
|125 units/10 kg (60–200 mg IgG/kg) IM (maximum 625 units)
|5 months
Abbreviations: IG, immune globulin; IM, intramuscular; IV, intravenous.
1Adapted from Table 5, CDC. General recommendations on immunization: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2011 Jan 28;60(RR-2):1–61. Updated with information from CDC. Prevention of measles, rubella, congenital rubella syndrome, and mumps, 2013: summary recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2013 Jun 14; 62(RR-04):1–34. This table is not intended for determining the correct indications and dosage for the use of IG preparations. Unvaccinated people may not be fully protected against measles during the entire recommended interval, and additional doses of IG or measles vaccine may be indicated after measles exposure. Concentrations of measles antibody in an IG preparation can vary by manufacturer's lot. For example, more than a 4-fold variation in the amount of measles antibody titers has been demonstrated in different IG preparations. Rates of antibody clearance after receipt of an IG preparation can also vary. Recommended intervals are extrapolated from an estimated half-life of 30 days for passively acquired antibody and an observed interference with the immune response to measles vaccine for 5 months after a dose of 80 mg IgG/kg. Does not include zoster vaccine. Zoster vaccine may be given with antibody-containing products.
2Assumes a serum IgG concentration of 16 mg/mL.
3If varicella zoster immune globulin is not available, IVIG can be used. The recommendation for use of IVIG is based on best judgment of experts and is supported by reports comparing varicella IgG titers measured in both IVIG and varicella zoster immune globulin preparations and patients given IVIG and varicella zoster immune globulin. Although licensed IVIG preparations contain antivaricella antibodies, the titer of any specific lot of IVIG is uncertain, because IVIG is not tested routinely for antivaricella antibodies. No clinical data demonstrating effectiveness of IVIG for postexposure prophylaxis of varicella are available. The recommended IVIG dose for postexposure prophylaxis of varicella is one dose of 400 mg/kg, intravenously (see http://aapredbook.aappublications.org/content/1/SEC131/SEC289.body).
4Contains only antibody to respiratory syncytial virus.
5Recommendation adapted from Neunert C, Lim W, Crowther M, Cohen A, Solberg L, Crowther MA, "The American Society of Hematology 2011 evidence-based practice guideline for immune thrombocytopenia", Blood. 2011:117(16), pg. 4190-4207 (Updated December 10, 2015)
Altered immunocompetence is a general term that is often used interchangeably with the terms immunosuppression, immunodeficiency, and a weakened immune system. It can be caused either by a disease (leukemia, HIV infection) or by drugs or other therapies (cancer chemotherapy, radiation therapy, prolonged high-dose corticosteroids). It can also include conditions such as asplenia and chronic renal disease.
Determination of altered immunocompetence is important because the incidence or severity of some vaccine-preventable diseases is higher in people with altered immunocompetence. Therefore, certain vaccines (such as inactivated influenza vaccine, pneumococcal vaccines) are recommended specifically for people with altered immunocompetence. Inactivated vaccines may be safely administered to a person with altered immunocompetence, although response to such vaccines may be suboptimal. These vaccines may need to be repeated after immune function has improved.
People with altered immunocompetence may be at increased risk for an adverse reaction after administration of live attenuated vaccines because of reduced ability to mount an effective immune response. Live vaccines should generally be deferred until immune function has improved. This is particularly important when planning to give yellow fever vaccine (see Chapter 3, Yellow Fever). For HIV-infected people with mild or moderate immunosuppression, MMR vaccine is recommended and varicella vaccine can be considered.
For an in-depth discussion, see Chapter 8, Immunocompromised Travelers.
As noted, for people anticipating imminent travel, most vaccine products can be given during the same visit. Unless the vaccines given are booster doses of those typically given during childhood, vaccines may require a month or more to induce a sufficient immune response, depending on the vaccine and the number of doses in the series. Some vaccines require more than 1 dose for best protection. Recommended spacing should be maintained between doses (Table 2-05). Doses given at less than minimum intervals can lessen the antibody response. It is important to note that if a traveler needs yellow fever vaccination to meet a country requirement under the International Health Regulations, the yellow fever vaccine is not considered valid until 10 days after administration. Intervals between doses longer than those routinely recommended do not affect the immune response when the schedule is completed. Consequently, it is not necessary to restart the series or add doses of any vaccine because of an extended interval between doses.
Administration of a vaccine earlier than the recommended minimum age or at an interval shorter than the recommended minimum is discouraged. Table 2-05 lists the minimum age and minimum interval between doses for vaccines routinely recommended in the United States.
Because some travelers visit their health care providers at the last minute, studies have been performed to determine whether accelerated scheduling is adequate. This concern is primarily the case for hepatitis B vaccine or the combined hepatitis A and B vaccine. An accelerated schedule for combined hepatitis A and B vaccine has been approved by the Food and Drug Administration (FDA). It is unclear what level of protection any given traveler will have if he or she does not complete a full series of multidose vaccination.
Table 2-05. Recommended and minimum ages and intervals between vaccine doses1,2
|Diphtheria and tetanus toxoids and acellular pertussis vaccine, pediatric (6 weeks through 6 years) (DTaP)-14
|2 months
|6 weeks
|4 weeks
|4 months
|10 weeks
|4 weeks
|6 months
|14 weeks
|6 months5
|15–18 months
|12 months
|6 months5
|4–6 years
|4 years
|Haemophilus influenzae type b (Hib)-14,6
|2 months
|6 weeks
|4 weeks
|4 months
|10 weeks
|4 weeks
|6 months
|14 weeks
|8 weeks
|12–15 months
|12 months
|Hepatitis A (HepA)-1
|12–23 months
|12 months
|6 months5
|≥18 months
|18 months
|Hepatitis B (HepB)-14
|4 weeks
|Hep B-2
|1–2 months
|4 weeks
|8 weeks
|Hep B-38
|6–18 months
|24 weeks
|Herpes zoster9
|≥60 years
|60 years
|Human papillomavirus (HPV)-110
|11–12 years
|9 years
|4 weeks
|2 months after dose 1
|9 years, 4 weeks
|12 weeks12
|6 months after dose 1
|9 years, 24 weeks
|Inactivated poliovirus (IPV)-14
|2 months
|6 weeks
|4 weeks
|4 months
|10 weeks
|4 weeks
|6–18 months
|14 weeks
|6 months
|4–6 years
|4 years
|Influenza, inactivated13
|≥6 months
|6 months15
|4 weeks
|Influenza, live attenuated13
|2–49 years
|2 years
|4 weeks
|Japanese encephalitis, Vero cell (Ixiaro)-115
|≥17 years
|≥17 years
|28 days
|28 days after dose 1
|≥17 years, 28 days
|Measles-mumps-rubella (MMR)-116
|12–15 months
|12 months
|4 weeks
|4–6 years
|13 months
|Meningococcal conjugate (MenACWY-1)17
|11–12 years
|2 months (Menveo) or 9 months (Menactra)
|8 weeks18
|16 years
|4 months (Menveo) or 11 months (Menactra)
|3–5 years if at increased risk of disease18
|Meningococcal polysaccharide (MPSV4)-117
|2 years
|5 years
|7 years
|Pneumococcal conjugate (PCV)-16
|2 months
|6 weeks
|4 weeks
|4 months
|10 weeks
|4 weeks
|6 months
|14 weeks
|8 weeks
|12–15 months
|12 months
|Pneumococcal polysaccharide (PPSV)-1
|2 years
|5 years
|7 years
|Rabies-1 (preexposure)
|See footnote 20
|See footnote 20
|7 days
|7 days after dose 1
|7 days after dose 1
|14 days
|21 days after dose 1
|21 days after dose 1
|Rotavirus (RV)-121
|2 months
|6 weeks
|4 weeks
|4 months
|10 weeks
|4 weeks
|6 months
|14 weeks
|Tetanus and reduced diphtheria toxoids (Td)
|11–12 years
|7 years
|5 years
|Tetanus toxoid, reduced diphtheria toxoid, and reduced acellular pertussis vaccine (Tdap)22
|≥11 years
|7 years
|Typhoid, inactivated (ViCPS)
|≥2 years
|≥2 years
|Typhoid, live attenuated (Ty21a)
|≥6 years
|≥6 years
|See footnote 23
|Varicella (Var)-116
|12–15 months
|12 months
|12 weeks24
|Varicella (Var)-2
|4–6 years
|15 months
|Yellow Fever
|>9 months25
|>9 months25
|10 years
1Adapted from Table 1, CDC. General recommendations on immunization: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2011 Jan 28;60(RR-2):1–61.
2Combination vaccines are available. Use of licensed combination vaccines is generally preferred over separate injections of their equivalent component vaccines (CDC. Combination vaccines for childhood immunization. MMWR Recomm Rep. 1999 May 14;48[RR-5]:1–14.). When administering combination vaccines, the minimum age for administration is the oldest age for any of the individual components (exception: the minimum age for the first dose of MenHibrix is 6 weeks); the minimum interval between doses is equal to the largest interval of any of the individual components.
3See www.cdc.gov/vaccines/schedules/ for recommended revaccination (booster) schedules.
4Combination vaccines containing the HepB component are available (HepB-Hib, DTaP-HepB-IPV, HepA-HepB). These vaccines should not be administered to infants aged <6 weeks because of the other components (Hib, DTaP, IPV). HepA-HepB is not licensed for children aged <18 years in the United States.
5 Calendar months.
6For Hib and PCV, children receiving the first dose of vaccine at ≥7 months of age require fewer doses to complete the series (see the current childhood and adolescent immunization schedule at www.cdc.gov/vaccines).
7If PRP-OMP (Pedvax-Hib, Merck Vaccine Division) was administered at 2 and 4 months of age, a dose at 6 months of age is not indicated. The final dose has a minimum age of 12 months.
8HepB-3 should be administered ≥8 weeks after Hep B-2 and ≥16 weeks after Hep B-1; it should not be administered before age 24 weeks.
9Herpes zoster (shingles) vaccine is recommended as a single dose for people aged ≥60 years.
10Bivalent HPV vaccine is approved for girls/women aged 10–26 years. It is recommended to prevent cervical and other anogenital cancers and precursors for girls/women aged 11–26 years. Quadrivalent HPV vaccine is approved for boys/men and girls/women aged 9–26 years. It is recommended to prevent cervical and other anogenital cancers, precursors, and genital warts for girls/women aged 11–26 years. It is recommended for boys/men aged 11–21 years and high-risk boys or men (men who have sex with men, HIV-positive men, or immunocompromised men) aged 22–26 years. It may be given to girls aged 9–10 years to prevent the same diseases, and to boys/men aged 9–10 years and 22–26 years to prevent genital warts.
11The third dose of HPV should be administered ≥12 weeks after the second and ≥24 weeks after the first. Dose 3 need not be repeated if administered ≥16 weeks after dose 1, as long as a minimum interval of 4 weeks is maintained between dose 1 and dose 2 and as long as a minimum interval of 12 weeks is maintained between dose 2 and dose 3.
12For people receiving an all-IPV or all-OPV series, if the third dose is given after the fourth birthday, a fourth dose is not needed. For IPV, the next-to-last and the last dose must be spaced by 6 months.
13Two doses of influenza vaccine are recommended for children aged <9 years who are receiving the vaccine for the first time, and for certain incompletely vaccinated children (see reference 2).
14The minimum age for inactivated influenza vaccine varies by vaccine manufacturer. See package insert for vaccine-specific minimum ages.
15Ixiaro is approved by the Food and Drug Administration for people aged ≥2 years.
16Combination MMR-varicella (MMRV) can be used for children aged 12 months through 12 years.
17Infants aged 2–18 months. Routine vaccination with HibMenCY – TT (MenHibrix) or Menveo (4-dose primary series) is recommended for infants aged 2–18 months who are at increased risk for meningococcal disease. The first dose of either vaccine may be administered as early as age 6 weeks. The fourth dose may be administered as late as age 18 months. Infants and children who received Hib-MenCY-TT and are traveling to areas with high endemic rates of meningococcal disease such as the African "meningitis belt" are not protected against serogroups A and W-135 and should receive a quadrivalent meningococcal vaccination before travel.
People aged 9 months through 55 years. People aged 9 months through 55 years at increased risk for meningococcal disease should receive Menveo or Menactra. Infants aged 9–23 months are recommended to receive a 2-dose primary series with a dosing interval of 12 weeks.
People aged ≥56 years. Menomune is the only licensed meningococcal vaccine for adults aged ≥56 years and is immunogenic in older adults. For adults who have received a conjugate meningococcal vaccine previously, limited data demonstrate a higher antibody response after a subsequent dose of a conjugate vaccine compared with a subsequent dose of Menomune. For meningococcal vaccine-naïve people aged ≥56 years who anticipate requiring a single dose of meningococcal vaccine (such as travelers and people at risk as a result of a community outbreak), Menomune is preferred. For people now aged ≥56 years who were vaccinated previously with a meningococcal conjugate vaccine and are recommended for revaccination or for whom multiple doses are anticipated (such as people with asplenia and microbiologists), a conjugate vaccine is preferred.
18Revaccination with meningococcal vaccine is recommended for people previously vaccinated who remain at high risk for meningococcal disease. MenACWY is preferred for revaccinating people aged 2–55 years (CDC. Prevention and control of meningococcal disease. Recommendations of the Advisory Committee on Immunization Practices [ACIP]. MMWR Recomm Rep. 2013 March 22;62[RR-2]:1–28.).
19A second dose of PPSV is recommended for people aged ≥65 years who received a first dose at an age <65 years and at a 5-year minimum interval. A second dose is also recommended for people aged <65 years at highest risk for serious pneumococcal infection and those who are likely to have a rapid decline in pneumococcal antibody concentration (CDC. Updated recommendations for prevention of invasive pneumococcal disease among adults using the 23-valent pneumococcal polysaccharide vaccine [PPSV23]. MMWR Recomm Rep. 2010;59[34]:1102–6.).
20There is no minimum age for preexposure immunization for rabies (CDC. Human rabies prevention—United States, 2008: recommendations of the Advisory Committee on Immunization Practices. MMWR Recomm Rep. 2008 May 23;57[RR-3]:1–28.).
21The first dose of RV must be administered by 14 weeks and 6 days of age. The vaccine series should not be started at ≥15 weeks of age. The final dose in the series should be administered by age 8 months, 0 days. If Rotarix rotavirus vaccine is administered at 2 and 4 months of age, a dose at 6 months of age is not indicated.
22Only 1 dose of Tdap is recommended. Subsequent doses should be given as Td. Children aged 7–10 years who are not fully vaccinated against pertussis and for whom no contraindication to pertussis vaccine exists should receive a single dose of Tdap. If additional doses of tetanus and diphtheria toxoid-containing vaccines are needed, then children aged 7–10 years should be vaccinated according to catch-up guidance, with Tdap preferred as the first dose. Tdap vaccine, when indicated, should be administered regardless of the interval since the last dose of Td vaccine. For management of a tetanus-prone wound, the minimum interval after a previous dose of any tetanus-containing vaccine is 5 years. A dose of Tdap is recommended for pregnant women, preferably at 27–36 weeks' gestation, regardless of history of previous Tdap vaccination.
23Oral typhoid vaccine is recommended to be administered 1 hour before a meal with a cold or lukewarm drink (temperature not to exceed body temperature—98.6°F [37°C]) on alternate days, for a total of 4 doses.
24The minimum interval from Var-1 to Var-2 for people beginning the series at ≥13 years of age is 4 weeks.
25Yellow fever vaccine may be administered to children aged <9 months in certain situations (CDC. Yellow fever vaccine: recommendations of the Advisory Committee on Immunization Practices [ACIP]. MMWR Recomm Rep. 2010 Jul 30;59[RR-7]:1–27.).
Vaccine components can cause allergic reactions in some recipients. These reactions can be local or systemic and can include anaphylaxis or anaphylactic-like responses. The vaccine components responsible can include the vaccine antigen, animal proteins, antibiotics, preservatives (such as thimerosal), or stabilizers (such as gelatin). The most common animal protein allergen is egg protein in vaccines prepared by using embryonated chicken eggs (influenza and yellow fever vaccines). Generally, people who can eat eggs or egg products safely may receive these vaccines, while those with histories of anaphylactic allergy (swelling of the mouth and throat, difficulty breathing, hypotension, shock) to eggs or egg proteins ordinarily should not. Screening people by asking whether they can eat eggs without adverse effects is a reasonable way to identify those who might be at risk from receiving yellow fever and influenza vaccines. Protocols have been developed for testing and vaccinating people with anaphylactic reactions to egg ingestion. The available recombinant influenza vaccine, Flublok, is manufactured without the use of eggs and does not carry a contraindication for egg allergy. Therefore, Flublok can be administered to people with egg allergy of any severity who are aged 18–49 years and do not have other contraindications. Recent studies have indicated that other components in vaccines in addition to egg proteins (such as gelatin) may cause allergic reactions, including anaphylaxis in rare instances.
Some vaccines contain a preservative or trace amounts of antibiotics to which people might be allergic. Providers administering the vaccines should carefully review the prescribing information before deciding if the rare person with such an allergy should receive the vaccine. No recommended vaccine contains penicillin or penicillin derivatives. Some vaccines (MMR vaccine, inactivated polio vaccine [IPV], hepatitis A vaccine, some hepatitis B vaccines, some influenza vaccines, rabies vaccine, varicella vaccine, and smallpox vaccine) contain trace amounts of neomycin or other antibiotics; the amount is less than would normally be used for the skin test to determine hypersensitivity. However, people who have experienced anaphylactic reactions to this antibiotic generally should not receive these vaccines. Most often, neomycin allergy is a contact dermatitis—a manifestation of a delayed-type (cell-mediated) immune response rather than anaphylaxis. A history of delayed-type reactions to neomycin is not a contraindication to receiving these vaccines.
Thimerosal, an organic mercurial compound in use since the 1930s, has been added to certain immunobiologic products as a preservative. Thimerosal is present at preservative concentrations in multidose vials of some brands of vaccine. Receiving thimerosal-containing vaccines has been postulated to lead to induction of allergy. However, there is limited scientific evidence for this assertion. Allergy to thimerosal usually consists of local delayed-type hypersensitivity reactions. Thimerosal elicits positive delayed-type hypersensitivity patch tests in 1%–18% of people tested, but these tests have limited or no clinical relevance. Most people do not experience reactions to thimerosal administered as a component of vaccines, even when patch or intradermal tests for thimerosal indicate hypersensitivity. A localized or delayed-type hypersensitivity reaction to thimerosal is not a contraindication to receipt of a vaccine that contains thimerosal.
Since mid-2001, vaccines routinely recommended for infants have been manufactured without thimerosal as a preservative. Additional information about thimerosal and the thimerosal content of vaccines is available on the FDA website (www.fda.gov/cber/vaccine/thimerosal.htm).
Modern vaccines are extremely safe and effective. Benefits and risks are associated with the use of all immunobiologics—no vaccine is completely effective or completely safe for all recipients. Adverse events after immunization have been reported with all vaccines, ranging from frequent, minor, local reactions to extremely rare, severe, systemic illness, such as that associated with yellow fever vaccine. Adverse events following specific vaccines and toxoids are discussed in detail in each ACIP statement. In the United States, clinicians are required by law to report selected adverse events occurring after vaccination with any vaccine in the recommended childhood series (see www.hrsa.gov/vaccinecompensation/authoringleg.pdf). In addition, CDC strongly recommends that all vaccine adverse events be reported to the Vaccine Adverse Event Reporting System (VAERS), even if a causal relation to vaccination is not certain. VAERS reporting forms and information are available electronically at www.vaers.hhs.gov, or they may be requested by telephone: 800-822-7967 (toll-free). Clinicians are encouraged to report electronically at https://vaers.hhs.gov/esub/step1.
Injectable vaccines are administered by intramuscular, intradermal, and subcutaneous routes. The method of administration of injectable vaccines depends in part on the presence of an adjuvant in some vaccines. The term adjuvant refers to a vaccine component distinct from the antigen, which enhances the immune response to the antigen. Vaccines containing an adjuvant (DTaP, DT, HPV, Td, Tdap, pneumococcal conjugate, Hib, hepatitis A, hepatitis B) should be injected into a muscle mass, because administration subcutaneously or intradermally can cause local irritation, induration, skin discoloration, inflammation, and granuloma formation.
Routes of administration are recommended by the manufacturer for each immunobiologic. Deviation from the recommended route of administration may reduce vaccine efficacy or increase local adverse reactions. Detailed recommendations on the route and site for all vaccines have been published in ACIP recommendations; a compiled list of these publications is available on the CDC website at www.cdc.gov/vaccines/hcp/acip-recs (also see Table B-01 in Appendix B).
- CDC. General recommendations on immunization: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2011 Jan 28;60(RR-2):1–64.
- CDC. Human rabies prevention—United States, 2008: recommendations of the Advisory Committee on Immunization Practices. MMWR Recomm Rep. 2008 May 23;57(RR-3):1–28.
- CDC. Prevention and control of meningococcal disease: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2013 Mar 22;62(RR-2):1–28.
- CDC. Prevention and control of seasonal influenza with vaccines: recommendations of the Advisory Committee on Immunization Practices—United States, 2013–2014. MMWR Recomm Rep. 2013 Sep 20;62(RR-07):1–43.
- CDC. Prevention of measles, rubella, congenital rubella syndrome, and mumps, 2013: summary recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2013 Jun 14;62(RR-04):1–34.
- CDC. Prevention of pneumococcal disease among infants and children—use of 13-valent pneumococcal conjugate vaccine and 23-valent pneumococcal polysaccharide vaccine: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2010 Dec 10;59(RR-11):1–18.
- CDC. Updated recommendations for prevention of invasive pneumococcal disease among adults using the 23-valent pneumococcal polysaccharide vaccine (PPSV23). MMWR Morb Mortal Wkly Rep. 2010 Sep 3;59(34):1102–6.
- CDC. Updated recommendations for use of tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) vaccine in adults aged 65 years and older—Advisory Committee on Immunization Practices (ACIP), 2012. MMWR Morb Mortal Wkly Rep. 2012 Jun 29;61(25):468–70.
- CDC. Yellow fever vaccine: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2010 Jul 30;59(RR-7):1–27.
- Varricchio F, Iskander J, Destefano F, Ball R, Pless R, Braun MM, et al. Understanding vaccine safety information from the Vaccine Adverse Event Reporting System. Pediatr Infect Dis J. 2004 Apr;23(4):287–94.
- Page created: July 10, 2015
- Page last updated: December 10, 2015
- Page last reviewed: December 10, 2015
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Yes, I'm calling about the FY14 Labor, Health and Human Services appropriations bill. I know Senator Murray is on that committee and as a biochemist at the University of Washington, I'd like her to make sure that the NIH recevies at least $32 billion for FY14. In an effort to provide predictable, sustained funding for the NIH and the researchers who receive NIH grants, I would also like Sen. Murray to support regular funding increases for the NIH with the goal of $35 billion by FY16. My colleagues and I are doing research on [insert your research here] that could affect the health and healthcare spending of thousands in Washington and it is important to maintain adequate resources at the NIH so we can continue our work.
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