CATTARAUGUS COUNTY BOARD of HEALTH Publichea1th Prevent

Home , BOH (drug), Mephedrone, Methylone

CATTARAUGUS COUNTY BOARD OF HEALTH PublicHea1th Prevent. Promote. Protect. 1 Leo Moss Drive, Olean, NY 14760, Tel. (716) 373-8050, Fax (716) 701-3737 Established 1923 Andrew Klaczynski, MD, President Joseph Bohan, MD, Vice-President Giles Hamlin, MD Joseph Eade Sondra Fox, RN Richard Haberer James Lapey Georgina Paul, FNP MINUTES James Snyder August 1,2012

The 80ih meeting of the Cattaraugus County Board of Health was held at St. Bonaventure Clubhouse Restaurant, Route 417, Allegany, N ew York on August 1, 2012.

The following members were present:

Andrew Klaczynski, MD Richard Haberer Joseph Bohan, MD James Lapey Joseph Eade Georgina Paul, FNP Sondra Fox, RN James Snyder

Also present were: Kevin D. Watkins, MD, MPH, Public Health Director Thomas Brady, County Attomey Paula Stockman, County Legislator Linda Edstrom, County Legislator Susan Labuhn, County Legislator Gilbert Witte, MD, Medical Director Karen Manners, Secretary to Public Health Director Henry Storch, MD, Clinic Physician Eric Wohlers, Environmental Health Director Raymond Jordan, Sr. Sanitarian Susan Andrews, Director of Patient Services Rick Miller, Olean Times Herald

The meeting was called to order by Dr. Klaczynski. The roll was called and a quorum declared. Mr. Eade made a motion to approve the minutes of the June 6, 2012 Board of Health meeting. It was seconded by Dr. Bohan and unanimously approved.

Director's Report: Dr. Watkins welcomed Dr. Storch to the meeting. Dr. Storch recently retired from the Olean Medical Group and has offered his expertise to the Health Department. He completed his residency at Charity Hospital in Louisiana and his cardiology fellowship at the University of Florida in Gainesville and served as the Chief Medical Officer in the Army in Oklahoma City, Oklahoma. He also had private practices in Jacksonville, Florida; Sanford, Maine; and Olean from 1986 until he retired this year. He is the recipient of multiple awards and it is a Cattaraugus County Board of Health Meeting August 1,2012 Page Two pleasure to have him at the Health Department.

Dr. Watkins stated that the Health Department is applying for a Community Transformation Grant which will implement changes within our community to reduce childhood obesity. Obesity among children and adolescents has tripled over the past three decades and currently a third of children in New York are obese/overweight. This grant is sponsored by the Centers for Disease Control and Prevention (CDC). New York State Department of Health will be the lead applicant and Cattaraugus County Health Department along with Chautauqua and Broome County Health Departments have been asked by the State to participate in this joint application process.

The changes that will be implemented will be to increase physical activity in early child care and school settings, increase early child care center nutritional programs, restrict the sale of sugar sweetened beverages in schools and municipal buildings, restrict the use of tobacco products at school events that are not on school grounds, and to reduce the exposure to second hand smoke in multi-unit housing settings. The schools that have been identified to participate in this grant are Salamanca, Gowanda and the Olean school districts. The two-year grant is for $500,000 and we will involve the participation of our municipalities, the school superintendents and the community as well. This is a positive initiative to implement changes that we need to see within our community.

Dr. Watkins stated that we continue to monitor the outbreak of Whooping Cough (Pertussis). As of 7119112 there have been 18,000 cases reported in the United States this year which is more than twice as many as last year. According to the CDC if it continues at this rate, the outbreak will be worse than in 1959 where there were more than 40,000 cases ofWhooping Cough. In New York State, the number of cases has increased to approximately 1,217 so far and the incidence of Pertussis in New York State outside of New York City is about 11 per every 100,000 individuals, but the national incidence is about 5 per every 100,000 individuals. There have been no deaths in New York State secondary to Pertussis so far this year. We continue to be vigilant and warn our residents ofthe need to get a Tdap booster. The hospital has been working with us to assure that all mothers that have recently delivered are offered the vaccine. We have had two confirmed cases and two probable cases within Cattaraugus County this year. All ofthose cases have been treated and families have received the appropriate prophylaxis. We are working with the State to see if these vaccines can be made available at no cost to the public but at this particular time there has been no movement by the State on that effort.

Today in the Journal of American Medical Association there was an interesting article (enclosed). stating that the nwnber ofindividuals that are part ofthis epidemic ofWhooping Cough is secondary to the type ofvaccine that is currently being used. The acellular pertussis vaccine, which is currently being used may not have the same effective immune response as when the whole cellular pertussis vaccine was being used. The vaccine was switched in the 1990's and that is when the epidemic seems to have began to flourish around 2000 or so when there was an increase in Whooping Cough. Their study shows that ifwe switch back to the whole cellular Pertussis vaccine we will probably not see the high nwnber of individuals redeveloping or coming down with Whooping Cough.

The treatment for Pertussis has not changed at all, we continue to treat those individuals with the macrolide agents such as Azithromycin, Clarithromycin or Erythromycin and if they are allergic to any ofthose, then they are given Bactrium as an alternative. Children are still vaccinated at 2,4, Cattaraugus County Board of Health Meeting August 1,2012 Page Three and 6 months of age, at 15-18 months of age and between 4 - 6 years of age as well.

Dr. Watkins reported that we continue to watch the public health and health planning council minutes and agendas to monitor the approval ofhome health agencies that have applied to expand or become certified home health agencies. Their last meeting was on July 26,2012 and there were several applications for the Certified Home Health Agency licensure expansion on their agenda for upstate and downstate New York. There was one application for review from our area; however the panel denied their request to expand into our area, which leaves four other applicants whose decision is still pending by this particular board. We will continue to update the Board on future outcomes.

Dr. Watkins also reported that on July 25, 2012 the County Legislature overwhelming supported a resolution to encourage the State legislators to pass a State law to ban the manufacture, distribution, sale and possession ofdangerous, unregulated synthetic drugs like bath salts. These designer drugs are specifically synthesized with a similar modified structure ofa Schedule 1 controlled substance in order to avoid existing drug laws and can be continually chemically modified to avoid legal repercussions while maintaining their intended effects and usages. That schedule one controlled substance is amphetamine. The resolution urges the State Legislators to prohibit the use of cathinones; the parent compound for the designer drug bath salts. Amphetamines and cathinones are very similar in structure, adding methyl groups or non-metals (i.e. fluorine) to the cathinones allow manufacturers to get around the current order, which list the components ofthe drugs.

Bath salts are frequently made up ofone ofseveral types ofdesigner drugs. Mephedrone, methylone and Methylenedioxyprovalerone are the three most popular types ofbath salts. Dr. Watkins handed out a copy ofthe chemical structures. Bath salts stimulate the body's central nervous and has similar effects to cocaine and amphetamines.

Dr. Watkins stated that some of the side affects of the synthetic drugs include increased heart rate and blood pressure, hallucinations, paranoia, suicidal thoughts, violent behavior, nausea and vomiting. In Cattaraugus County the sale or production of this product is prohibited, but there should be a nationwide law that would ban the sale and use of synthetic drugs.

Dr. Watkins stated that there was discussion at the last meeting regarding the Clean Indoor Air Act waivers for establishments that will be requesting renewals at the end of the year. At that time, Dr. Bohan requested information on how long each establishment has had a waiver to determine ifthese establishments have recouped their investments that they made (building a separate area to accommodate smokers in their establishments) in order to be in compliance with the regulations that granted them the waiver. Dr. Watkins handed out a copy of that information.

Mr. Eade made a motion to move into Executive Session to seek advice from Mr. Brady, County Attorney. It was seconded by Dr. Bohan and unanimously approved.

After moving out ofExecutive Session, it was noted that no actions were taken; advice was obtained from Mr. Brady, County Attorney. Mr. Snyder explained that the Board has discussed the Clean Indoor Air Act waivers several times in the past and he feels that currently there is 99.9% compliance with the Clean Indoor Air Act from establishments. He believes ifthese establishments are not granted waivers they will go out ofbusiness. Dr. Bohan asked ifwe can get information from Cattaraugus County Board of Health Meeting August 1,2012 Page Four other counties on whether they have had any legal issues when disapproving waivers, whether they have been successful in discontinuing waivers and if other Off Track Betting (OTB) offices allow smoking before any decisions are made. Mr. Brady agreed to do the legal research to answer that question. Mr. Haberer stated that the OTB office in Olean generates approximately $1,000,000 a year with 40% - 50% generated in the smoking area. lfthe facility lost $400,000 or $500,000 a year, chances are that it would have to close. Mr. Wohlers said that he will contact the program manager at the State Health Department to see if they have the latest statistics on how many counties have issued waivers and how many were issued. Dr. Bohan made a motion to have the Health Department gather more information for the Board before making a decision on the waivers. It was seconded by Mrs. Fox and unanimously approved.

Nursing Division Report: Mrs. Andrews reported that Barb Parish, Supervising Community Health Nurse, resigned in July to work for the Veteran's Administration.

The Nurse Practitioner that was going to begin at the end ofAugust has decided to stay in her current job, so we are still looking for a Nurse Practitioner. Until we find a replacement, a Nurse Practitioner is being contracted from Universal Primary Care (UPC) one day a week and Marian Graczyk, our part time Nurse Practitioner, is still maintaining her time with the department. Dr. Storch is helping by doing physicals. We will continue to advertise in order to fill the position.

Mrs. Andrews also reported that we are still receiving reports oflab confirmed flu. We received a partial shipment of flu vaccine for the upcoming season. Along with Allegany and Chautauqua counties we now have an organized immunization coalition, which the State has urged us to do. As Dr. Watkins mentioned, Pertussis cases continue; we had two cases this month and we will investigate another case today.

We have had 18 post-exposure rabies treatments to date for this year, which is down from the previous year. Ten ofthe post-exposure treatments were related to bat exposures. Mrs. Andrews mentioned that there was a concern over capturing bats for testing because of the white-nose syndrome that is killing bats. She wanted to assure everyone that the bats that the Health Department recommend killing are because of potential human exposure and need to be tested for rabies.

Training will be held because of the changes to the Family Planning Benefit Program, which is a federal program that helps residents' access contraception; now, under the affordable care act, there is no co-pay for contraception.

There was one new lead case in July. There was a separate case in Machias that has been ongoing for about three years where we were trying to get the child's lead level down. Environmental Health assisted in the lead abatement at the residence and the lead level finally went down; a younger sibling ofthis child was tested and that test came back within normal limits making this a success story.

Mrs. Andrews stated that there are approximately 400 patients in Home Care. As Dr. Watkins mentioned, there were 87 certificate ofneed applications submitted to the State and 14 ofthose were recommended for approval. Cattaraugus County Board of Health Meeting August 1, 2012 Page Five

Two nurses are attending two days of Outcome and Assessment Information Set (OASIS) training in Syracuse. We wanted to send our nurses to this training for quite a few years and this year it was approved. These are the assessments that are done that affect our reimbursement and also our outcomes, so it was very important for them to attend this training.

Environmental Health Division: Mr. Wohlers reported that Environmental Health has been very busy with temporary food inspections at various summer events. They have made a presence at all of these events and luckily have not had any food borne outbreaks to investigate, which is a good tribute to our staff.

Also, this is the active season for animal bite and rabies investigations. We have had a number of investigations involving bats.

Mr. Wohlers said that the Sanitary Code revisions have been completed and we will be submitted to the State Health Department for their review. When they concur that everything is consistent with State regulations, we will bring it to the Board for approval.

Mr. Wohlers mentioned that Mr. Jordan heard that the State may be taking action to move the issue of under aged tattooing being illegal under the State Penal Law to being covered under the State Public Health Law. Health departments may be getting full responsibility for enforcing under aged tattooing and body piercing. As we find out more about that, we will let the Board know. In the past, we have always had parents calling and complaining that their under aged child was pierced or tattooed without their permission.

Mr. Wohlers also reported that there are a couple projects in Cattaraugus County that are being funded through the State Drinking Water Revolving Fund. The Town ofRandolph should be getting an official letter stating that they qualify for hardship eligibility. Their water system project is estimated at $7,500,000 and whatever portion ofthe project they don't receive as a grant they will be eligible for zero percent interest on the loan portion, which will save their residents a lot ofmoney on the overall project.

Also, in the Hamlet of West Valley a $3,500,000 water project is planned. The town board has realized that they need to form a municipal water district and take over the private water company that is now there and do this project.

Mr. Wohlers stated that because it has been hot and dry, we don't anticipate doing any spraying for mosquitoes although the Seneca Nation may have hired the contractor to do some mosquito spraying over the Salamanca area. The Central New York area does a lot ofmosquito trapping to have them tested for eastern equine encephalitis because two people died in that area from that last year or the year before, they always spray this time of year.

Mr. Wohlers also stated that the State Health Department is sponsoring a free water operator training in Olean on 8/16/12 that approximately 60 water operators from our county and neighboring counties will attend. One is also being set up in September. Cattaraugus County Board of Health Meeting August 1,2012 Page Six

The State Health Department released their new revised design handbook for septic systems. We will be discussing that in upcoming weeks to see if there are any significant changes in how we design private septic systems.

Dr. Bohan commented that it is a shame that because there is no active mosquito surveillance, there is no way oflmowing ifthere are mosquitoes in the area that are carriers ofencephalitis and ifa case shows up then it would be necessary to do the more controversial adulticide spraying. Mr. Wohlers agreed that ifwe don't have active surveillance, we won't have the warnings of mosquito specimens testing positive and will learn about it after the fact when there are cases reported. Dr. Watkins stated that although we cannot determine what will happen in the future, surveillance in the past has not shown any eastern equine encephalitis specimens in this area for several years.

Mrs. Stockman thanked Mr. Wohlers and staff for distributing the flyers and information on bats at the town clerk's meeting last month. Mr. Wohlers stated that the information was sent to a lot of different places in order to get the message out to capture the bat for testing because the rabies post exposure treatments are so expensive.

Dr. Watkins updated the following enforcement case for Board action: Docket 09-036, Roger & Kathleen Hanley - On 1114/09 the Board ordered Respondents to pump the septic tank as needed so as to prevent an illegal discharge ofsewage as a short term solution. At the end of 6 months the Cattaraugus County Health Department reviewed the case to determine the effectiveness of the short term solution. It was determined that the short term solution was not acceptable because Respondents are pumping their grey water into the road ditch. Respondents have filed a claim against New York State Department ofTransportation (NYSDOT) on 12/9/11, but it is in the discovery phase and may take years to resolve. Mr. Brady suggests that Respondents appear either before Mr. Porter or the Board of Health to determine if the violation still exists and what action should be taken. After discussion, Dr. Bohan made a motion to have Mr. Porter hold the hearing and the Board will review his recommendation; it was seconded by Mr. Eade and unanimously approved.

There being no further business to discuss, Mr. Eade made a motion to adjourn. It was seconded by Dr. Bohan and carried to adjourn. b~m~,~.o. Kevin D. Watkins, M.D., M.P.H. Secretary

KDWIkm LETTERS

John's wort, echinacea, saw palmetto, and glucosamine fol am the co-inventor and co-patent holder of the bovine lowing negative studies. Despite studies showing that echi human reassortant rotavirus vaccine Rotateq. My hospital nacea does not treat cold symptoms, it is one of the best sell sold the patent more than 3 years ago, but I retained inter ing supplements in the United States with estimated sales est in the vaccine through the Wistar Institute. I sold that exceeding $300 million per year.; interest 2 years ago and do not currently receive royalties Dr Leach claims that I supported my position "through from the sales of Rotateq. In addition, I have been the au the selective reporting of a few clinical studies." However, thor of a number ofbooks related to vaccine safety; all prof all studies are not equal. The studies I selected regarding its from the sales of these books are donated to charity. gingko, chondroitin sulfate, glucosamine, garlic, St John's I apologize to the readers and editors ofJAMA for failing wort, milk thistle, and echinacea were the best controlled, to report this disclosure. most rigorous, and most internally consistent. Indeed, most Paul A. Offit, MD of these excellent studies were supported by NCCAM . Author Affiliations: Division of Infectious Diseases, Children's Hospital of Phila Briggs and Killen and Leach argue that refraining from delphia, Philadelphia, Pennsylvania ([email protected]). studying alternative medicine would deny the public much 1. Offit PA. Studying complementary and alternative therapies. lAMA. 2012; needed clinical data to make informed health care deci 307(17):1803-1804. sions. In a better world, of course, this discussion would not be happening. In a better world, dietary supplements and alternative therapies would be subject to testing before claims were allowed, as is reqUired by the US Food and Drug Ad RESEARCH LETTER ministration (FDA) for licensure of drugs, biologicals, and Number and Order of Whole Cell Pertussis medical devices. Now patients are stuck with a system in Vaccines in Infancy and Disease Protection which some alternative medicines might be tested after claims have been made and after nutraceutical companies have spent To the Editor: Due to their lower rate of adverse events, acel millions of dollars "educating" the public. At best, NCCAM lular pertussis vaccines (diphtheria-tetanus-acellular per functions as a post-hoc FDA, except without the FDA's regu tussis; DTaP) replaced whole cell vaccines (diphtheria latory authority and without the communication skills or tetanus-whole cell pertussis; DTwP) in many developed dollars to confront a well-heeled nutraceutical industry. Sadly, countries during the 1990s. DTaP became available in until the 1994 Dietary Supplement and Health Education Queensland, Australia, in 1996 and replaced DTwP for pub Act-which essentially freed the nutraceutical industry from licly funded primary course immunizations delivered at ages FDA oversight-is repealed, consumers will continue to re 2 months, 4 months, and 6 months in March 1999. This ceive bad information that could lead to bad medical deci meant children born in 1998 could receive a primary course sions, NCCAM or no NCCAM. consisting of only DTwP, only DTaP, or a mixed schedule. 1 Paul Offit, MD Similar to North America, Australia is experiencing a sus tained pertussis epidemic,2 with the highest incidence rates Author Affiliations: Division of Infectious Diseases. Children's Hospital of Phila delphia, Philadelphia, Pennsylvania ([email protected]). in Queensland during 2011 in children aged 6 to 11 years. Conflict of Interest Disclosures: The author has completed and submitted the ICMJE The recent changes in pertussis epidemiology may be re Form for Disclosure of Potential Conflicts of Interest and reported having held the patent and received royalties from the sale of Rotateq vaccine within the last 3 lated to the shift from DTwP to DTaP. To test this hypoth years, although his interest in the vaccine was sold 2 years ago. esis, we compared pertussis reporting rates by primary course 1. Levine JD, Gordon NC, Fields HL. The mechanism of placebo analgesia. Lancet. vaccination in the 1998 birth cohort. 1978;2(8091 ):654-657. Methods. Reporting pertussis cases to the health depart 2, White P, Bishop FL, Prescott P, et al. Practice, practitioner, or placebo? A mul tifactorial, mixed-methods randomized controlled trial of acupuncture [published ment is mandatOlY in Queensland. For children born in 1998, online December 12, 2011]. Pain. 2012;153(2):455-462. we calculated pertussis reporting rates in both the preepi 3. TilburtJC, Emanuel EJ, Miller FG. Does the evidence make a difference in con sumer behavior? Sales of supplements before and after publication of negative demic (1998-2008) and outbreak periods (2009-2011) , by research results. 1 Gen Intern Med. 2008;23(9):1495-1498. number and order ofDTwP doses given before their first birth 4. Ostrow N. Echinacea shows little benefit as remedy for treating colds, study day. We linked data from the Queensland vaccination reg finds . Bloomberg News. December 20, 2010. ister (QVR) with case reports of pertussis. The QVR is not a population-based register so we could not construct a group Incomplete Financial Disclosure in a Viewpoint of wholly unvaccinated children for comparison. Children on Complementary and Alternative Therapies were censored follOWing initial reporting. We calculated av To the Editor: I would like to report an incomplete finan erage annual incidence rates, incidence rate differences, in cial disclosure related to a Viewpoint published inJAMA.1 cidence rate ratios, and 95% confidence intervals using Stata While the topic of the Viewpoint was complementary and version 12 (StataCorp). The Queensland Children's Health alternative therapies, vaccine safety was mentioned. I did Services ethics committee approved the study. not understand then that conflicts of interest related to vac Results. Of 58 233 children born in 1998 identified in the cines needed to be reported. I would like to disclose that I QVR, 40494 (69.5%) received at least 3 doses of any per

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tllssis-conLaining vaccine during the first year from a Queens in the first year of life, although it did not reach statistical land vaccine service provider and were included in the analy significance (Table). Children who received a mixed course sis. Overall. 267 first pertussis cases were reported from this with DTwP as the initial dose had incidence rates that were cohort between 1999 and 2011; 2 second reports were between rates for the pure course DTwP and DTaP cohorts excluded. (Table). Children who received a 3-close DTaP primary course had Comment. Infant priming with DTwP was associated with higher rates of pertussis than those who received a 3-dose a lower risk ofsubsequent pertussis than DTaP only primed DTwP primary course in the preepidemic and outbreak pe children in this cohort. This difference persisted for more riods (TABLE and FIGURE). Among those who received mixed than a decade. being evident in preepidemic and outbreak courses, rates in the current epidemic were highest for chil periods. A primary course using even a moderately effec dren receiving DTaP as their first dose. This pattern re tive DTwP vaccine may be more protective than DTap' 3 In mained when looking at subgroups with 1 or 2 DTwP doses the preacellular era, Australia used a locally produced DTwP

Table. Pertussis Reports Between 1999 and 2011 for Children Born in 1998 (N = 40 694)a Incidence (95% CI) No. of I Reports Average Annual Rateb Rate Difference b Rate Ratio Rate Ratio C Preepidemic (1999-2008) Pure course d DTaP primary course (n = 9827) 13 13.2 (7.0 to 22.6) 8.0 (0 to 15.8) 2.53 (1 .06 to 6.07) DTwP primary course (n =22956) 12 5.2 (2.7 to 9.1) 1 [Reference] 1 [Reference] Outbreak (2009-2011) Pure course DTaP primary course (n = 9827) 110 373.1 (306.7 to 449.7) 259.9 (185.7 to 334.0) 3.29 (2.44 to 4.46) DTwP primary course (n = 22956) 78 113.3 (89.5 to 141 .3) 1 [Reference) 1 [Reference) Mixed course Rrst dose of DTaP (n =978) 12 409.0 (211.3 to 714.4) 295.7 (63.0 to 528.5) 3.61 (1.79 to 6.67) First dose of DTwP (n =6933) 42 201.9 (145.5 to 273.0) 88.7 (22.6 to 154.7) 1.78 (1.20 to 2.63) Mixed course by No. of DTwP doses 1 dose of DTwP only First dose of DTaP (n = 549) 6 364.3 (133.7 to 792.9) 251 .0 (-41 .5 to 543.6) 3.22 (1.15 to 7.32) 1.37 (0.45 to 3.53) Rrst dose of DTwP (n = 2501) 20 266.6 (162.8 to 411.7) 153.3 (33.8 to 272.8) 2.35 (1.36 to 3.89) 1 [Reference) 2:2 doses of DTwP Rrst dose of DTaP (n =429)9 6 466.2 (171.1 to 1014.7) 352.9 (-20.9 to 726.8) 4.12 (1.47 to 9.37) 2.82 (0.93 to 7.17) Rrst dose of DTwP (n = 4432)f 22 165.5 (103.7 to 250.5) 52.2 (-21 .4 to 125.8) 1.46 (0.87 to 2.37) 1 [Reference] Abbreviations: DTaP. diphtheria-tetanus-acellular pertussis; DTwP. diphtheria-tetanus-whole cell pertussis. aA primary vaccination course Is defined as 3 or more doses of a pertussis-containing vaccine for infants younger than 12 months of age. Analysis excludes records for infants with no vaccination history recorded before 12 months of age (n =6806). those wilh vaccination history provided by outside source (not a Queensland vaccine service provider; n = 4129), those with irregularity of the vaccine dose by number Or description (n = 191). and those with less than 3 vaccination doses recorded (n=6412). bRate per 100000 per year. cComparing dose order in mixed course cohorts. dDefined as 3 or more doses of a single vaccine only. "Only 2 children had 3 doses of DTwP before the age of 12 months. fOnly 40 children had 3 doses ofDTwP before the age of 12 months.

Figure. Pertussis Reporting Rates Between 1999 and 2011 by Primary Course of Pertussis Vaccination for Children Born in 1998

900 Mixed primary course. first dose DTaP / 0:* 800700 I >1'~ I 't: ~ 600 I 8.Qj I Pure OTeP primary course I £ f!; 500 '1)0 400 ~ 8 I I / Mixed primary course, first dose DTwP ~ ~ 300 I , I / ~ a. 200 I / ~::.:,.;;"""""", Pure DTwP primary course ~ 100 ...... o >~

1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 Year

DTaP indicates diphtheria-tetanus-acellular pertussis; DTwP, diphtheria-tetanus-whole cell pertussis.

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vaccine with very good to excellent effectiveness.i Our find vestigator on clinical studies sponsored by GlaxoSmithKline and sanofi-pasteur (both manufacturers of pertussis-containing vaccines), and serving on GlaxoSmithKline ings suggest the most important factor, in this cohort, may and sanofi-pasteur advisory boards for pneumococcal and Influenza vaccines, re be the initial vaccine received. spectively. Drs Sheridan and Ware did not report any disclosures. Funding/Support: Dr Sheridan is supported by an Australian postgraduate award Itis unlikely our findings during the current outbreak are from the Australian government and a clinical scholarship from Queensland Chil the result of detection bias because this would require health dren's Medical Research Institute. Dr Lambert is supported by an early career fel care-seeking behavior, or the likelihood oflaboratory test lowship from the National Health and Medical Research Council and is a Queens land Children'S Medical Research Institute senior research fellow. ing or reporting, to be associated with the primary course Role of the Sponsor: None of the funding sources had a role in the design and received by children over a decade previously. conduct of the study; in the collection, analysis, and interpretation of the data: or in the preparation, review, or approval of the manuscript. Possible explanations for our findings could include an Additional Contributions: We recognize Christine E. Selvey, MBBS, MSc (senior tigenic shifts in circulating Bordetella pertllssis strainsl or the director of Communicable Diseases Branch, Queensland Health), for supporting the research; Craig A. Davis, MAppSc, BA, MAppEpid, and Angela Wakefield, BHSc different immune responses from acellular and whole-cell (both with Communicable Diseases Branch, Queensland Health), for data extrac priming.s The lesser protection provided by DTap, both as tion; and Vicki Bryant. BNurs. and Madeline A. Hall, BNurs (both with the Immu nisation Program, Queensland Health). for assisting in vaccination record inter the initial vaccine or full plimary course, may be due to linked pretation. The persons listed in this section provided assistance while employed epitope suppression, when the initial exposure locks in the by Queensland Health and did not received additional financial compensation for immune response to certain epitopes and inhibits response their contributions. to other linked epitopes on subsequent exposures.6 1. Witt MA, Katz PH. Witt OJ. Unexpected limited durability of immunity follow ing acellular pertussis vaccination in preadolescents in a North American outbreak. The challenge for future pertussis vaccine development Clin Infect Dis. 2012;54(12):1730-1735. is to address the benefit-risk trade-off highlighted by our 2. Octavia S. Sintchenko V. Gilbert GL. et al. Newly emerging clones of Borde· study, and to develop vaccines that induce long-lasting pro tella pertussis carrying pm2 and ptxP3 alleles implicated in Australian pertussis epi· demic in 2008-2010. J Infect Dis. 2012;205(8):1220·1224. tection from the first dose, \vithout the adverse events as 3. Zhang L. Prietsch SOM, Axelsson I. Halperin SA. Acellular vaccines for pre sociated with DTwP use. venting whooping cough in children. Cochrane Database Sys/ Rev. 2011 ;(1): CD001478. Sarah L Sheridan, BMed, MAppEpid 4. Torvaldsen S. Simpson JM. Mcintyre PB. Effectiveness of pertussis vaccination Robert S. Ware, PhD in New South Wales. Australia. 1996-1998. Eur J Epidemlol. 2003;18(1):63· 69. Keilh Grimwood, MB, ChB, MD 5. Mascart F. Hainaut M. Peltier A. Verscheure V. Levy J. Locht C. Modulation of Slephen B. lamberl, MBBS, PhD the infant immune responses by the first pertussis vaccine administrations. Vaccine . Author Affiliations: Queensland Children's Medical Research Institute, University 2007;25(2):391·398. of Queensland. Brisbane, Australia ([email protected]). 6. Cherry JD. Heininger U. Richards OM. et al. Antibody response patterns to Bor· Author Contributions: Dr Sheridan had full access to all of the data in the study de/ella pertussis antigens in vaccinated (primed) and unvaccinated (unprimed) young and takes responsibility for the integrity of the data and the accuracy of the data children with pertussis. c/in Vaccine Immunol. 2010;17(5):741-747. analysis. Study concept and design: Sheridan, Ware, Grimwood, Lambert. Analysis and interpretation of data: Sheridan, Ware, Lambert. Drafting of the manuscript: Sheridan, Lambert. Critical revision of the manuscript for important intellectual content· Sheridan, CORRECTION Ware, Grimwood, Lambert. Stati>lical analysis: Sheridan. Clarification of Conflict of Interest Disclosure: In a Viewpoint entiUed "Studying Administrative, technical, or material support: Sheridan, Ware. Complementary and Alternative Therapies" published in the May 2.2012, issue Study supervision: Grimwood, Lambert. ofJAMA (2012;307[17]:1803·1804). the conflict of interest disclosure for Dr Of Conflict of Interest Disclosures: The authors have completed and submitted the fit should have read as follows: "Dr Offit reports having held the patent and re ICMJE Form for Disclosure of Potential Conflicts of Interest. Drs Grimwood and ceived royalties from the sale of Rotateq vaccine within the last 3 years. although Lambert reported receiving honoraria for serving on the GlaxoSmithKline advi his interest in the vaccine was sold 2 years ago." A letter regarding the correction sory boards for pneumonia and pneumonia conjugate vaccine, serving as an in appears in this issue. The article has been corrected online.

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Amphetamine Cathinone

Methamphetamine Methcathinone to

Mephedrone Methylenedioxyprovalerone

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Methylone CI

Bupriopion (IAA - WAIVER

Dated Waiver Number of Date of First Granted Waivers Granted Expiration

Ischua Fire Department 5/11/2004 8 12/31/2012 P.O.Box 24 Ischua, NY 14743

Off Track Betting 6/14/2004 8 12/31/2012 700 Ellicott Street Batavia, NY 14020

Rough Kutts 5/11/2004 8 12/31/2012 15 Park Street South Dayton, NY 14138

Little Valley V.F.W. #8734 5/2/2007 5 12/31/2012 5460 Route 353 Little Valley, NY 14755