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Childhood Immunization
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Author: Julia Tortorice (RN, MBA, MSN, NEA-BC, CPHQ)
Diphtheria use to be a major cause of childhood illness and death. Through the 1920's about 150,000 people got diphtheria each year in the U.S. and about 10% of them died. "The word diphtheria struck fear into the hearts of parents in those days, but today there are only a few cases a year. This change is due largely to our parents and grandparents, who got their children immunized." 1
Diphtheria is a disease caused by bacteria called Corynebacterium diphtheriae. These bacteria live in the mouth, throat and nose of an infected person, and are easily spread to others through coughing or sneezing. Some people with diphtheria might not even seem ill, but they can still spread the disease.
Two to four days after a child is exposed to diphtheria, he might get a sore throat, a slight fever, and chills. If diphtheria is not properly diagnosed and treated, it can then produce a powerful toxin, which spreads throughout the body. Serious complications are heart failure or paralysis. Sometimes a thick membrane forms in a child's throat, making it hard to swallow or even breathe. The mortality is about 10%. A child with diphtheria is contagious for about 2 to 4 weeks.
Diphtheria vaccine protects children by creating immunity to the toxin that causes symptoms of illness, rather than immunity to the bacteria itself. Because it acts on the toxin, it is called a toxoid.
Diphtheria toxoid is almost always given to children together with tetanus toxoid and pertussis vaccine in a combined vaccination shot known as DTaP. Diphtheria toxoid was developed around 1921. In 1921 there were 206,939 cases reported; in 1931 there were 70,839 cases; in 1941 there were 17,987; in 1951 there were 3,983; and in 1961 there were 617 cases. Today there are only a few cases a year. 1
Tetanus (Lockjaw)
Tetanus enters the body through cuts in the skin. It can get in through even a tiny pinprick or scratch, but it prefers deep puncture wounds or cuts, like those made by nails or knives. Tetanus can be transmitted following severe burns, ear infections, tooth infections, or animal bites. Rusty nails are often blamed for causing tetanus, but it is the tetanus bacteria, and not rust, that causes the disease. You can get tetanus from a shiny nail as easily as from a rusty one. Tetanus is not contagious. People get it only from the environment and not from other people.
Tetanus bacteria can live anywhere, but they are usually found in soil, dust, and manure. Once they get into the body through a wound, it can take from 3 days to 3 weeks (usually about 8 days) for the first symptoms to appear. These are usually a headache, crankiness, and spasms of the jaw muscles.
Tetanus produces a toxin inside the body. As this toxin spreads, it causes muscle spasms in the neck, arms, legs, and stomach. It can cause painful muscle contractions strong enough to break a child's bones. Children with tetanus might have to spend several weeks in the hospital under intensive care. There are only about 50 cases of tetanus a year in the U.S. It has a 30% mortality rate.
As with the diphtheria vaccine, tetanus vaccine is really a toxoid, which protects against the toxin produced by tetanus bacteria. Tetanus toxoid is almost always given to children in DTaP vaccine, along with diphtheria and pertussis. Tetanus toxoid was first produced in 1924. In the 1940's about 400-500 tetanus cases were reported each year. By the mid-1970's this had dropped to 50-100 cases, and by the 1990's to between 40 and 50. 1
Pertussis causes a child to cough violently and rapidly, over and over, until the air is gone from his lungs. The child is then forced to inhale with the loud whooping sound that gives the disease its nickname, Whooping Cough. Then the coughing begins again. These severe coughing spells can go on for weeks. The child becomes cyanotic or vomits after a coughing spell. A child with Whooping Cough can have difficulty eating, drinking, or even breathing.
Pertussis is a very contagious disease, and one that is fairly common. It is caused by bacteria called Bordetella pertussis that live in the mouth, nose, and throat. Pertussis is spread by personal contact, coughing and sneezing.
It usually takes a week to 10 days from the time a child is exposed until symptoms appear. At first, pertussis looks like a common cold. The initial symptoms are sneezing, runny nose, fever and a mild cough. But after 1 or 2 weeks the severe coughing spells begin. This stage of the disease usually lasts 1 to 6 weeks, but can last longer. After the coughing stage has passed the child usually recovers gradually over 2 to 3 weeks. A child with pertussis can give the disease to another child from about a week after exposure till about 3 weeks after the severe coughing starts.
Pertussis is most severe in infants under 1 year old. More than half of these infants who get the disease must be hospitalized. Older children and adults can get pertussis too, but it is much less severe and might not even be recognized as pertussis. Many infants who get pertussis catch it from their older brothers and sisters or from their parents.
Pertussis can cause serious complications. About 10% of children with pertussis also get pneumonia, and about 2% will have convulsions. 0.4% of people who get pertussis develop encephalopathy. Pertussis causes about 10-15 deaths a year in the U.S.
The first pertussis vaccine was developed in the 1930's. In the early 1990's a new cellular pertussis vaccine became available. It works as well as the older vaccine but has fewer side effects. Pertussis vaccine is almost always given in DTaP vaccine, along with diphtheria and tetanus toxoids. The series of pertussis vaccinations give immunity until the age of 10. Pertussis vaccine is not licensed for older children, so we cannot give booster doses to keep protection from fading. However, pertussis vaccine for older children and adults might be available in the near future.
The number of pertussis cases reported to CDC has dropped by more than 98%. There were over 183,000 cases reported in 1940, about 120,000 cases in 1950, fewer than 15,000 cases in 1960, and fewer than 5,000 cases most years since 1970. 1
Vaccines for Diphtheria, Tetanus, and Pertussis
DTaP Vaccine protects against diphtheria, tetanus and pertussis. DTaP is actually three vaccines diphtheria, tetanus, and pertussis combined into one shot. DTaP contains only part of the pertussis bacteria. It is an updated version of DTP vaccine.
A child needs five DTaP shots for maximum protection. The first three shots should be given at 2, 4, and 6 months of age. The fourth (booster) shot is given between 15 and 18 months, and a fifth shot, another booster, is given when the child is about to enter school, at 4-6 years of age. 1 When given according to schedule, the DTaP vaccine protects most children from all three diseases. If a child does get one of the diseases in spite of the vaccine, it is usually milder than it would have been if unvaccinated.
Up to 33% of children who get DTaP have local reactions that include tenderness, pain, redness, and swelling. 1 These reactions are more likely after the fourth and fifth doses of DTaP, than after the earlier doses. The reactions may also be more pronounced as more doses are given. Reactions usually occur within two days after the shot. Some children also experience swelling of the entire leg or arm after the fourth or fifth. This happens within 3 days of the vaccination and usually lasts around 4 days, with no after-effects.
Fever is another common reaction. Up to 5% will get a fever of over 101°F, which occurs more often after the fourth or fifth dose. Up to 20% of children will be fussy or lose their appetite for a day or two after the shot and nearly 50% may be drowsy afterward. 1
Occasionally, a child will have a more serious side effect. About 0.03% will get a fever of 104°F or more. Up to 0.1% of children may cry continuously for 3 hours or more after getting the shot. 1
About once in 14,000 injections, a child may have convulsions or become limp or pale for a short while. 1 Convulsions that occur after a DTaP shot are usually caused by a fever that was triggered by the vaccine; not caused by the vaccine directly. These are called febrile seizures. Children recover quickly from febrile seizures and they do not cause permanent harm. A non-aspirin pain reliever (acetaminophen) will reduce the chances of a fever, which should also make febrile seizures less likely. These pain relievers can be given at the same time as the shot and then every 4-6 hours over the next 24 hours. 1
Serious reactions to DTaP have been very rare. DTaP shots were once suspected of causing Sudden Infant Death Syndrome (SIDS), but studies have not shown a connection. Most experts including the SIDS Alliance agree that vaccinations do not cause SIDS. No deaths are known to have ever been caused by DTaP vaccine.
A child who has had convulsions or other nervous system problems in the past is slightly more likely to have a serious reaction after DTaP. However the risk is still very small.
Reasons to delay a DTaP vaccination: 1
A child who has a moderate or severe illness on the day a DTaP (or any) vaccination is scheduled should probably delay the vaccination until recovery.
Reasons to not give a DTaP vaccination: 1
A child who had a severe (life-threatening) allergic reaction after a dose of DTaP vaccine should not get another dose.
A child who had encephalopathy (brain illness) within 7 days after a dose of DTaP should not get another dose of pertussis-containing vaccine.
A child who had a temperature of 105°F within 48 hours after a dose of DTaP should probably not get another dose of pertussis-containing vaccine.
A child who collapses or goes into a shock-like state within 48 hours after a dose of DTaP should probably not get another dose of pertussis-containing vaccine.
A child who cries continuously for 3 or more hours within 48 hours after a dose of DTaP should probably not get another dose of pertussis-containing vaccine.
A child who has convulsions within 3 days after a dose of DTaP should probably not get another dose of pertussis-containing vaccine.
Children who should not get a pertussis-containing vaccine can get DT (diphtheria/tetanus) vaccine instead of DTaP. If a child has any serious or unusual problem after getting DTaP or any other vaccine, call a doctor or get the child to a doctor right away.
DTP vaccine also protects from diphtheria, tetanus, and pertussis. It is actually three vaccines diphtheria, tetanus, and pertussis combined into one shot. This vaccine was sometimes thought to be unsafe, mainly because of the pertussis component. While DTP vaccine was associated with more reactions than many other vaccines, the small risk was still far outweighed by its benefits. "
The older DTP vaccine is rarely used in the U.S. However, it was DTP that was largely responsible for bringing diphtheria, tetanus and pertussis under control in the U.S. and around the world." 1
Side effects and precaution of DTP are the same as those of the DTaP vaccine. Over the years several cases of permanent brain damage were reported following DTP vaccination. But whether these were true vaccine reactions or merely coincidence is impossible to say, because they occurred so infrequently. DTP shots were once suspected of causing Sudden Infant Death Syndrome (SIDS), but studies have not shown a connection. Most experts including the SIDS Alliance agree that vaccinations do not cause SIDS. No deaths are known to have ever been caused by DTP vaccine.
DT contains diphtheria and tetanus toxoids but no pertussis vaccine. It is given to children under 7 years old who should not get pertussis vaccine. Usually these are children who have had certain reactions after a previous DTaP shot. Side effects from DT are not common. If they occur at all, they usually consist of localized soreness or a slight fever.
Td is a vaccine for children 7 years old and over, and for adults. It does not contain pertussis vaccine, and has tetanus toxoid and less diphtheria toxoid than DTaP. Immunity to diphtheria and tetanus starts to fade over time, and booster shot of Td every 10 years keeps you protected. The first dose of Td is recommended at 11-12 or 14-16 years of age, with another dose every 10 years after that. 1 Side effects from Td are not common. If it occurs, it usually consists of localized soreness or a slight fever.
Polio was one of the most dreaded childhood diseases of the 20th Century in the U.S. An epidemic in 1916 killed 6,000 people and left 27,000 more paralyzed. Since polio vaccine became available in 1955 the disease has disappeared from the U.S., and may soon be gone from the rest of the world as well. The number of cases of paralytic polio in the U.S. has fallen from more than 20,000 in 1952 to only a few cases a year today. 1 The few cases that have occurred in recent years have not been caused by the natural disease, but by one type of polio vaccine.
But even though there is no polio in the U.S. or in fact in the Western hemisphere it is still common in some parts of the world. A single infection brought into the country by someone traveling from one of these regions could lead to polio epidemics all over again if we were not protected. That is why we continue to vaccinate. Polio is caused by a virus that lives in the throat and intestinal tract. It is spread through contact with the bowel movements of an infected person (for instance, by changing diapers).
Some children who get polio don't feel ill at all. For others, polio simply feels like a cold, with symptoms appearing about 6-20 days after exposure. Sometimes these children will also feel some pain and stiffness in their neck, back, and legs, but this soon goes away.
However, some children who get polio become paralyzed. This is called paralytic polio. Paralytic polio can start like a common cold, but often with severe muscle pain. Paralysis usually comes within the first week. Most often it affects the child's legs, but sometimes it affects other muscles including those that control breathing. Some children recover from their paralysis, but many will be permanently disabled.
There is no treatment for polio, and some children die from it. Polio is most contagious from about 7-10 days before symptoms appear till about 7-10 days afterward.
There are two types of polio vaccine: Inactivated (killed) polio vaccine (IPV), which is a shot; and live oral polio vaccine (OPV), which is a liquid that is swallowed. CDC recommends only IPV, except in very limited circumstances. Children should get 4 doses of IPV at these ages:
A dose at 2 months of age
A dose at 6-18 months of age
A booster dose at 4-6 years of age
OPV is an excellent vaccine. "Without it we could not have eliminated polio from the western hemisphere, and would not be so close to eliminating it from the rest of the world." 1 Until recently, OPV was recommended for most children in the U.S. But OPV can also, in some situations, actually cause polio. This is rare about once in every 2.4 million doses.
When the vaccine was preventing thousands of cases of polio a year, having it occasionally cause a case was a small price to pay. But now that the risk of getting polio is extremely low, and because IPV is available, experts have decided that routinely using the oral vaccine in the U.S. is no longer worth the small risk. OPV is still used in parts of the world where the risk of polio disease is much higher. Four doses of polio vaccine will protect most children for life. However for certain people, for instance, those traveling to countries where polio is still common, a booster dose is recommended.
Inactivated polio vaccine is a very safe vaccine. It is not known to produce any side effects other than a local reaction. Like any vaccine, or medicine, IPV could theoretically trigger a serious reaction in someone who is allergic to one of its components. But severe allergic reactions to childhood vaccines are very rare (estimated at around one per million doses), and no child is ever known to have died from an allergic reaction to a vaccine.
Reasons to delay a polio vaccine: 1
A child who has a moderate or severe illness on the day an IPV (or any) vaccination is scheduled should probably delay the vaccination until he or she has recovered.
Reasons to not give a polio vaccine: 1
A child who is known to have a severe allergy to the antibiotics neomycin, streptomycin, or polymyxin B should not get IPV.
A child who has had a severe (life-threatening) allergic reaction after a dose of IPV should not get another dose.
Not everyone recognizes measles as the serious disease it really is, possibly because it used to be a routine part of everyone's childhood and also because we don't see it nearly as much as we used to. But measles can be deadly. Measles still kills about a million people a year around the world. Measles can also make a pregnant woman have a miscarriage or give birth prematurely.
For most children, measles means a rash and a cold, and missing a few days of school. But about 10% children who get measles also get an ear infection. And up to 5% of them get pneumonia. About 0.1% will get encephalitis. Out of every 1,000 children who get measles, 1 or 2 die from it. 1
Measles is caused by a virus. It spreads so easily that any child who is exposed to it and is not immune will probably get it. You can get measles from an infected person who coughs or sneezes around you or even talks to you. Before measles vaccine was available, nearly all children got measles by the time they were 15 years old. Around 500,000 cases a year were reported in the U.S. during the 10 years before measles vaccine, and there were probably another 3 million cases a year that were not reported. During each of these years more than 450 people died because of measles, 48,000 were hospitalized, 7,000 had seizures, and about 1,000 suffered permanent brain damage or deafness. 1
The first signs of measles are a fever, runny nose, and cough, which appear about 10-12 days after a child is exposed. The rash appears several days later. A child with measles is contagious from about 4 days before the rash appears to about 4 days after.
Measles vaccine became available in 1963. As children started getting the vaccine, measles quickly began to disappear. Today we see only about a hundred cases a year. But even though the number of measles cases each year is only a fraction of what it used to be, this doesn't mean that our children cannot get measles.
In 1989 and 1990 we saw a large jump in measles cases and deaths, partly because many parents weren't getting their preschool-aged children vaccinated. In response to this outbreak, doctors and health departments stepped up their efforts to vaccinate children, and measles cases have since dropped to all-time low levels.
The measles vaccine used today is a live, attenuated vaccine. In other words, the virus that is used to make the vaccine is not killed, but it is weakened so that doesn't cause measles. Measles vaccine can be given by itself, but it is usually given together with mumps and rubella vaccines in a shot called MMR.
Before vaccines, mumps was a common childhood disease. The most obvious sign of mumps is swelling of the cheeks and jaw, which is caused by inflammation in the salivary glands. Children with mumps usually also get a fever and headache. Generally, Mumps is a mild disease, but it does have its serious side:
About 10% of those who get mumps also get meningitis.
Occasionally mumps also causes encephalitis, which is inflammation of the brain itself. Usually the child recovers without permanent damage.
About 25% of teenage or adult men who get mumps develop a painful swelling of the testicles.
Mumps can, rarely, cause deafness (about 1 in 20,000 cases) or death (about 1 in 10,000 cases).
Children get mumps through contact with others who are already infected with the mumps virus. The virus is spread through the air by coughing, sneezing, or simply talking. Children start to show signs of mumps 2 to 3 weeks after they are exposed. They are contagious from about 12 to 24 days after exposure.
The mumps vaccine we use today was licensed in 1967, and is a live, attenuated (weakened) vaccine. The number of reported cases has dropped from over 150,000 in 1968 to only 666 in 1998. 1 Mumps vaccine is usually given together with measles and rubella vaccines in a shot called MMR.
When children get rubella, it is usually a mild disease, with a slight fever that lasts for about 24 hours, and a rash on the face and neck that lasts two or three days. Rubella is also called German measles or 3-day measles. It is caused by the rubella virus, and usually strikes in the winter and spring. It is spread through close contact such as coughing, sneezing, or talking. Most children recover quickly and completely.
Rubella also strikes adults, and outbreaks can occur among teenagers and adults who have not been immunized. Adults who get rubella may get swollen glands in the back of the neck and pain, swelling, or stiffness in their joints (arthritis).
But the greatest danger from rubella is not to children or adults, but to unborn babies. If a woman gets rubella in the early months of her pregnancy, there is an 80% chance that her baby will be born with birth defects. This is called Congenital Rubella Syndrome (CRS). Babies with CRS may be born deaf or blind. They may have damaged hearts or small brains. Many are mentally retarded. Miscarriages are also common among women who get rubella while they are pregnant.
It takes about 12-23 days from the time of exposure for people to start showing signs of the disease. Rubella is most contagious while the rash is visible, but it can be spread from about a week before the rash starts until about a week after. Rubella Fact: The last major rubella epidemic in the U.S. was in 1964-65. An estimated 12½ million people got the disease, including 20,000 babies born with congenital rubella syndrome. This epidemic cost the country an estimated $1.5 billion.
Rubella vaccine was first licensed in the U.S. in 1969, and the vaccine we use today was licensed in 1979. It is a live, attenuated (weakened) vaccine. There are now only several hundred cases reported each year, with the record low (128 cases) reported in 1995. Rubella vaccine can be given by itself, but it is usually given together with measles and mumps vaccines in a shot called MMR.
Vaccine for Measles, Mumps, and Rubella
Most children get Measles, Mumps and Rubella vaccines all together in one shot called MMR. All three of these vaccines work very well, and will protect most children for the rest of their life.
Children should get two doses of MMR vaccine. The first is given between 12 and 15 months of age. The second may be given at any time, as long as it is at least 28 days after the first. It is usually given at 4-6 years of age, before the child enters kindergarten or first grade.
Measles, mumps, and rubella vaccines can be given separately, too. But this is not usually done because it means giving a child three shots instead of one. Sometimes, usually during a measles outbreak, children might be given measles or MMR vaccine before their first birthday. This is for short-term protection only. These children should still be given two doses of MMR vaccine at the usual ages.
Measles, about 20% will get a mild rash or fever beginning a week or two after vaccination. These reactions last for a few days. 1
Mumps, very few children suffer any ill effects from mumps vaccine. Occasionally a child will get a mild fever one or two weeks after vaccination or swollen glands in the cheeks or under the jaw. More serious reactions are extremely rare.
Rubella, about 14% will get a rash or swelling in the lymph glands after getting rubella vaccine. This usually happens within a week or two after the shot and lasts 1 or 2 days. 1
Also, about 10% will have some pain or stiffness in the joints, which can last from a few days to a few weeks. There is a small chance (less than 1 in 100) that a child will have painful swelling of the joints (arthritis) after getting rubella vaccine. This usually lasts only a few days, but it can last longer, and can come and go. These joint problems occur more often in adults, especially women.
Febrile seizures have occasionally been reported among children who have gotten MMR vaccine. These usually happen 1 or 2 weeks after the shot and are caused by the fever that can accompany vaccination rather than the vaccine itself. Children recover from febrile seizures quickly, and they do not cause permanent harm.
There have been reports of children getting encephalitis after an MMR shot. This happens so rarely, less than once in a million shots, that experts are not sure whether the MMR vaccine causes this problem or whether it simply happens by chance. Remember, though, that if the same million children got measles, about 1,000 of them would get encephalitis, 6,000 to 7,000 would have convulsions, and several hundred would die. 1 The benefits of MMR vaccine greatly outweigh the slight risk.
MMR, like any vaccine or medicine, could trigger a severe allergic reaction in a child who was allergic to one of the vaccine's components. But severe allergic reactions to childhood vaccines are very rare (estimated at around one per million doses), and no child is ever known to have died from an allergic reaction to a vaccine.
Reasons to delay an MMR vaccine: 1
A child who has a moderate or severe illness on the day an MMR (or any) vaccination is scheduled should probably delay the vaccination until he or she has recovered.
A child who has recently gotten a transfusion or other blood product might have to wait up to several months before getting MMR.
Reasons to not give an MMR vaccine: 1
A child who is known to have a severe allergy to gelatin or the antibiotic neomycin should not get MMR.
A child who has had a severe (life-threatening) allergic reaction after a dose of MMR should not get another dose.
A child whose immune system is suppressed (because of a disease such as cancer or HIV infection or medication such as steroids) should be evaluated by a doctor before getting MMR vaccine.
Haemophilus influenzae type B
Haemophilus influenzae type b or Hib disease is a childhood disease that is not as well known, but is just as dangerous as other previously mentioned childhood diseases. Even though the word influenza is part of its name, Hib is not related to influenza (flu).
As recently as the mid-1980's, Hib disease struck 0.5% of children under 5 years old in the U.S. Every year about 12,000 children got meningitis as a result of Hib. In fact, Hib disease was the leading cause of bacterial meningitis in children under five. About 25% of these children suffered permanent brain damage, and about 5% died. In addition, about 8,000 children a year suffered from other serious complications, such as pneumonia. 1
Hib is a bacterial disease. It is spread through the air by coughing, sneezing, or even breathing. Hib bacteria enter a child' system through the nose or throat, and if they stay in the nose and throat the child will probably not become sick. But sometimes the bacteria spread into the lungs or bloodstream. This is called invasive Hib disease, and it can cause serious complications. In addition to meningitis, invasive Hib disease can lead to: pneumonia, epiglottitis, arthritis, and other problems.
Most invasive Hib disease occurs in children under 5 years old, and up to 60% in children younger than 1 year. The disease is not common in older children or adults. Most Hib disease today strikes infants who are not immunized. It probably takes about 2-4 days from the time a child is exposed to Hib bacteria until symptoms appear. An infected person can spread the disease to others for as long as the bacteria remain in the body. Antibiotics can stop the spread within 2-4 days.
Hib vaccine has had a dramatic impact on Haemophilus influenzae type B. As soon as the first vaccine came into use in 1985 the disease began to disappear. Several improved vaccines have been licensed since then, and the age for the first shot has been lowered from 24 months to 2 months. There were an estimated 20,000 cases of Hib disease a year in the mid-1980's, but now there are only a few hundred cases a year. 1 Hib vaccine is an inactivated (killed) vaccine. It is made from only a part of the Hib bacteria.
Several different companies make Hib vaccine. Children should get either 3 or 4 doses, depending on which company's vaccine your doctor or clinic is using. All children should get the vaccine at 2 and 4 months of age, and a booster dose between 12 and 15 months. Some children should get an additional dose at 6 months. Children who have passed their 5th birthday do not need Hib vaccination.
Hib vaccine can be combined (that is, given in the same shot) with DTaP vaccine, or with hepatitis B vaccine. Your doctor or nurse might offer the vaccines in these combination forms. They work just as well, and are just as safe, as if the vaccines were given separately.
Hib is a very safe vaccine. It cannot cause Hib disease or meningitis, and is not known to cause any other serious reactions. About 2% of children who get Hib vaccine get some redness, swelling or warmth where the shot was given, or a fever of over 101°F. These reactions usually begin within 24 hours after the shot and last up to 2 or 3 days. They do not cause any permanent harm.
Like any vaccine, or medicine, Hib vaccine could theoretically trigger a serious reaction in someone who is allergic to one of its components. But severe allergic reactions to childhood vaccines are very rare (estimated at around one per million doses), and no child is ever known to have died from an allergic reaction to a vaccine.
Reasons to delay giving Hib vaccine: 1
A child who has a moderate or severe illness on the day a Hib (or any) vaccination is scheduled should probably delay the vaccination until he or she has recovered.
Children under 4 weeks of age should not get Hib vaccine. This isn't because it is unsafe, but because the vaccine might not protect as well when the first dose is given too early.
Reasons to not give a Hib vaccine: 1
A child who has had a life-threatening allergic reaction after a dose of Hib vaccine should not get another dose.
The Streptococcus pneumoniae bacteria kills more people in the U.S. each year than all other vaccine-preventable diseases combined. It is commonly thought of as a disease of the elderly, but it also takes its toll among our children. Each year the pneumococcal bacteria cause invasive disease (mostly blood infection, or bacteremia) in about 16,500 children under 5 years old, including more than 700 cases of meningitis. It is the leading cause of bacterial meningitis in the country, hitting children under one year old the hardest. About 200 children die from invasive pneumococcal disease each year.
In addition, pneumococcal disease causes 25% - 40% of all middle ear infections in children. Middle ear infections are responsible for more visits to a pediatrician than any other complaint, and they are the number one reason for prescribing antibiotics to children. All children are susceptible to pneumococcal disease, but some groups have higher rates of the disease, including African Americans, American Indians, Alaska Natives, and children with certain medical conditions such as sickle cell disease or HIV infection, or who don't have a functioning spleen.
The pneumococcal bacteria are spread from person to person, mainly through the air. The disease can be spread by anyone who is infected, even if they don't have symptoms. Pneumococcal infections are more common during the winter and early spring.
Treating pneumococcal infections with penicillin and other antibiotics used to be effective, but the disease is becoming more and more resistant to antibiotic treatment, making immunization increasingly important.
Pneumococcal conjugate vaccine is the second part of our one-two punch against bacterial meningitis (Hib vaccine is the first). Until very recently, pneumococcal vaccine was recommended mostly for adults over 65 years old, and was not licensed at all for children under 2. This is because the only type of vaccine that was available (pneumococcal polysaccharidel vaccine) doesn't work very well for young children. Now a different type of vaccine (pneumococcal conjugate vaccine) has been licensed that works for children under 2, and it is finally possible to prevent pneumococcal disease in that vulnerable age group.
Pneumococcal conjugate vaccine is an inactivated (killed) vaccine. It gives immunity against the 7 strains of the pneumococcal bacterium that cause most of the serious infections in children. This vaccine should prevent most meningitis and bacteremia caused by pneumococcal bacteria. However, there are other causes of bacteremia and meningitis, and this vaccine will not prevent them. It will also not prevent all ear infections. Some ear infections are caused by pneumococcal disease, but many are caused by other germs too, and the vaccine will not prevent these.
Children should routinely get 4 doses of the vaccine, one dose each at 2, 4, 6, and 12-15 months of age. Children who begin the series later may not need as many doses. Children over 5 years old will generally not get the pneumococcal conjugate vaccine. Older children who need protection from pneumococcal disease (those with certain chronic diseases or damaged immune systems) can get the polysaccharide vaccine, or may get a series that includes both vaccines. Your doctor or clinic staff will tell you if our older children need protection from pneumococcal disease. Pneumococcal vaccine may be given at the same time as other childhood vaccines.
Since the pneumococcal conjugate vaccine is new, the only safety data come from clinical trials. The side effects that have been seen are mainly mild local reactions or a mild fever. The frequencies of these reactions vary from study to study, with the highest rates being about 40% of recipients. Moderately serious reactions, such as prolonged crying and febrile seizures were seen only rarely in these studies, and may not have been caused by the vaccine.
Like any vaccine, or medicine, pneumococcal vaccine could theoretically trigger a serious reaction in someone who is allergic to one of its components. But severe allergic reactions to childhood vaccines are very rare (estimated at around one per million doses), and no child is ever known to have died from an allergic reaction to a vaccine.
Reason to delay giving the pneumococcal vaccine: 1
A child who has a moderate or severe illness on the day a pneumococcal (or any) vaccination is scheduled should probably delay the vaccination until he or she has recovered.
Reasons to not give the pneumococcal vaccine: 1
A child who has had a life-threatening allergic reaction after a dose of pneumococcal vaccine should not get another dose.
Hepatitis B is a disease that affects the liver. It is one of several hepatitis diseases (for example, hepatitis A and hepatitis C). These are caused by different germs, but are similar in that they all affect the liver (hepatitis comes from the Greek words for liver and inflammation). Hepatitis B is caused by a virus. Some people who are infected with the hepatitis B virus never feel sick. Others have symptoms that might last for several weeks. Those symptoms can include: loss of appetite and tiredness, pains in muscles, joints or stomach, diarrhea, vomiting or jaundice. This is called acute hepatitis B.
Some people never recover from hepatitis B. They develop what is called chronic hepatitis B virus infection. They might not look or feel sick, but they will probably carry the hepatitis B virus in their blood for the rest of their lives, and they can infect other people. Many of these chronically infected people will suffer from serious health problems, such as cirrhosis or liver cancer. In fact, the hepatitis B virus causes most of the liver cancer in the world. In the U.S. alone, there are more than 1 million people chronically infected with the hepatitis B virus. In 1996, an estimated 200,000 people became infected with hepatitis B virus, and about 4,000 to 5,000 people a year die from hepatitis B. 1
Hepatitis B virus is spread through contact with the blood, or other body fluids, of an infected person. People can get hepatitis B by having unprotected sex, by sharing drug needles, or by sharing personal items like razors or toothbrushes with someone who is infected. Doctors, nurses, and other health care workers can get hepatitis B through exposure to blood from infected patients. Police, fire fighters, and paramedics who are exposed to blood are also at risk.
Why, then, do we immunize children against hepatitis B when they don't have sex, don't take drugs, and are not nurses or police officers? One important reason is that babies can get infected too. If a mother is chronically infected with hepatitis B, her baby could become infected during birth. If these babies are not immunized immediately, most of them will become chronically infected too. One out of 4 of these babies will eventually die from cirrhosis or liver cancer.
Also, children can be infected through exposure to blood, saliva, or other fluids from infected children or adults. While this is not common, vaccination is a reasonable precaution, particularly since the vaccine is a very safe one. Hepatitis B is a major cause of liver cancer, and hepatitis B vaccine can prevent the disease. Therefore, hepatitis B vaccine is the first vaccine that prevents cancer.
You can protect children from hepatitis B by getting them vaccinated with three doses of hepatitis B vaccine. Newborn babies whose mothers either are infected with the hepatitis B virus or have not been tested should get their first shot within 12 hours of birth, the second shot at 1-2 months of age, and the third shot at 6 months of age. Other babies can get their first shot between birth and 2 months of age, the second at 1-4 months of age, and the third at 6-18 months of age. 1
Babies born to infected mothers should also get Hepatitis B Immune Globulin (HBIG) within 12 hours of birth. These babies should also be checked when they are 9-15 months old to make sure the vaccine worked and that they do not have chronic hepatitis B virus infection.
The second shot should always be given at least one month after the first shot, and the third shot at least 2 months after the second and 4 months after the first. If you miss a dose or get behind schedule, there is no need to start over. Just get the next dose as soon as possible and continue on schedule. After the third shot, most children will be protected. They do not need booster shots.
Hepatitis B is a very safe vaccine. 9% of children will have some soreness where the shot is given, and up to about 6% will get a mild fever. Up to 20% might become tired or irritable. More serious reactions are extremely rare. Like any vaccine, or medicine, hepatitis B vaccine could theoretically trigger a serious reaction in someone who is allergic to one of its components. But severe allergic reactions to childhood vaccines are very rare (estimated at around one per million doses), and no child is ever known to have died from an allergic reaction to a vaccine.
Reasons to delay the hepatitis B vaccine:
A child who has a moderate or severe illness on the day a hepatitis B (or any) vaccination is scheduled should probably delay the vaccination until he or she has recovered.
Reasons to not give the hepatitis B vaccine:
A child who is known to have a severe allergy to baker's yeast (the kind used for making bread) should not get hepatitis B vaccine.
A child who had a life-threatening allergic reaction after a dose of hepatitis B vaccine should not get another dose.
Varicella or chickenpox is one of the most common childhood diseases. It is caused by the varicella-zoster virus. Most people in the U.S. get chickenpox while they are still children. Until the late 1990's there were about 4 million cases a year. But now that people are using varicella vaccine, that number has begun to drop. The most recognizable feature of chickenpox is an itchy rash all over the body. Children with chickenpox can also be drowsy and have a fever. The reason varicella is called chickenpox has nothing to do with chickens. Chickenpox got its nickname because the blisters look like chickpeas.
Chickenpox can be spread very easily from person to person. It is spread through the air, by coughing or sneezing, or even talking. It can also be spread by contact with fluid from the blisters. It usually takes 2-3 weeks from the time a child is exposed to chickenpox virus until he or she becomes ill. The disease is contagious from 1 or 2 days before the rash appears until all the blisters are dried up, which usually takes 4 to 5 days.
Chickenpox is usually a mild disease, uncomfortable but not dangerous. Still, serious problems do occur. The blisters can become infected, and some children get encephalitis. Of every 100,000 infants under one year old who get chickenpox, about 4 die. For older children, 1 to 14 years old, about 1 in 100,000 dies. 1
If a woman gets chickenpox just before or after giving birth, her baby can get very sick, and about 33% of these children die if they are not treated quickly. Even when chickenpox is not serious, it can create problems for the family because the parents may have to miss work to care for the sick child. About 1 child out of 500 who get chickenpox must be hospitalized. For adults who get chickenpox, 1 in 50 must be hospitalized. 1 After a person has chickenpox, the virus stays in the body. Years later, it can cause a painful disease called zoster, or shingles.
Varicella vaccine is a live-virus vaccine. It has been used in some parts of the world, such as Japan, for over 20 years. It was licensed in the U.S. in 1995. A single dose of varicella vaccine is recommended for children between 12 and 18 months of age. It is usually given at the same time as the MMR shot. Children who miss this shot can still get a single dose of the vaccine up to their 13th birthday. Adolescents or adults who haven't gotten the vaccine by their 13th birthday will need two doses, 4 to 8 weeks apart. A child who has already had chickenpox disease does not need to get the shot.
It appears that the vaccine prevents chickenpox in about 70% to 90% of people who get the shot, and prevents severe chickenpox in over 95%. The vaccine used in Japan is still protecting those people who were vaccinated 20 years ago. In the U.S., people who were vaccinated during testing, before the vaccine was licensed, are still immune to chickenpox. The vaccine is expected to give life-long immunity. Occasionally even children who respond to the vaccine get a very mild case of chickenpox (about 1-2 children out of a hundred).
There is some concern that a child who gets chickenpox vaccine can actually give chickenpox to other, unprotected, family members. This appears to happen extremely rarely, and only when the child who was vaccinated develops a rash. To be safe, anyone with a suppressed immune system should consider avoiding contact with a child who develops a rash after getting the chickenpox vaccination just as they should avoid anyone who has a case of chickenpox.
Varicella vaccine is very safe. 20% of children have a local reaction. Some children also get a mild rash (about 5 spots), about 1 to 3 weeks after the shot. Febrile seizures occur in less than 1 out of a thousand children; and other serious problems, such as encephalitis or loss of muscle coordination, have been reported very rarely. These problems happen so rarely that experts cannot tell whether or not they are caused by the vaccine, or just happen at the same time by chance.
Like any vaccine, or medicine, varicella vaccine could theoretically trigger a serious reaction in someone who is allergic to one of its components.
Reasons to delay giving the varicella vaccine: 1
A child who has recently gotten a transfusion or other blood product might have to wait several months before getting varicella vaccine.
A child who has a moderate or severe illness on the day a varicella (or any) vaccination is scheduled should probably delay the vaccination until he or she has recovered.
Reasons to not give a varicella vaccine: 1
A child who is known to have a severe allergy to gelatin or the antibiotic neomycin should not get varicella vaccine.
A child who had a life-threatening allergic reaction after a dose of varicella vaccine should not get another dose.
A child with a suppressed immune system (because of a disease such as cancer or HIV infection, or medication such as steroids) should be evaluated by a doctor before getting varicella vaccine.
Hepatitis A, like other types of hepatitis, is a disease that affects the liver. It is the most common type of hepatitis reported in the U.S., with an estimated 125,000 - 200,000 cases each year. About 3 cases out of 10 occur in children under 15 years old. 1
Hepatitis A is caused by a virus. Children under 6 years old who get infected often don't show any signs of illness. But for most older children, signs of hepatitis can come on quickly. They include: fever, loss of appetite and tiredness, stomach pain, vomiting, dark urine or jaundice. Hepatitis A cannot be distinguished from other types of hepatitis except by blood testing.
Hepatitis A does not cause long-term illness or liver damage like hepatitis B does. But every year about 100 people die from liver failure caused by severe hepatitis A.
Hepatitis A virus is found mainly in bowel movements, and is spread through personal contact or by eating contaminated food or drinking contaminated water. For almost half the cases in the U.S. the source of the infection is not known. An infected person can spread the virus to other people from about a week before symptoms appear through about a week after. People without symptoms can still spread the disease. Even though the diseases are quite different, the hepatitis A virus is closely related to the polio virus.
Hepatitis A vaccine is an inactivated (killed) vaccine. It can be given to children 2 years old or older. Two doses are needed, the second dose given 6-18 months after the first. Hepatitis A vaccine is recommended for children in certain states: Alaska, Arizona, California, Idaho, Nevada, New Mexico, Oklahoma, Oregon, South Dakota, Utah, and Washington. It may also be considered for children in Arkansas, Colorado, Missouri, Montana, Texas and Wyoming. The vaccine is also recommended for communities with high levels of hepatitis A, including Alaska native villages, American Indian reservations, some Hispanic communities and some religious communities. It is also recommended for others who are at high risk, including people traveling to countries where the disease is common.
Hepatitis A vaccine is very safe. Mild local reactions are reported in up to half of people who get it. Less than 10% report fatigue or a mild fever. No serious reactions have been reported. Like any vaccine, or medicine, hepatitis A vaccine could theoretically trigger a serious reaction in someone who is allergic to one of its components. But severe allergic reactions to childhood vaccines are very rare (estimated at around one per million doses), and no child is ever known to have died from an allergic reaction to a vaccine.
Reasons to delay giving the hepatitis A vaccine: 1
A child who has a moderate or severe illness on the day a hepatitis A (or any) vaccination is scheduled should probably delay the vaccination until he or she has recovered.
Reasons to not give the hepatitis A vaccine: 1
A child who is known to have a severe allergy to alum should not get hepatitis A vaccine.
A child who has had a life-threatening allergic reaction after the first dose of hepatitis A vaccine should not get the second dose.
Recommended Vaccination Schedule
The following is the vaccination schedule recommended by the Center for Disease Control (CDC). If you click on the yellow highlighted words in blue font, in this section, it will open the Internet to a CDC web page with more information on that subject.
At Birth
If the mother has hepatitis B disease (is HBsAg positive) the child should receive hepatitis B immune globulin (HBIG) within 12 hrs of birth, and hepatitis B vaccine* at a separate site (i.e. a different arm or leg). If the mother does not have hepatitis B (is HBsAg negative), they can wait until month 2. This is the one exception to this normal schedule.
If the child has received their first hepatitis B vaccine, they should receive the second one this month, at least 30 days after the first dose. If they have not received a hepatitis B vaccine, they can receive their first dose this month.
In the second month of life most children should start receiving the first series of recommended vaccines. The vaccines that a child should receive in their second month are:
Polio IPV* (the injected version) 1st of 4 doses. (OPV* (given by mouth) is only recommended for children in special cases). IPV protects children from Polio.
DTaP* vaccine 1st of 5 doses which protects children against: Diphtheria, Tetanus, and Pertussis
Hib* dose 1 of 4 protects children against Hib (Haemophilus Influenzae)
Hepatitis B* dose 1 of 3 (if the child hasn't received their first dose) which protects children against hepatitis B.
Pneumococcal Conjugate vaccine* dose 1 of 4 protects children from Pneumococcal disease.
DTaP dose 2 of 5
Hib dose 2 of 4
Hepatitis B dose 2 of 3 (if the child hasn't already received their second dose)
Pneumococcal conjugate dose 2 of 4
Hib (depending on the brand of Hib vaccine the child may need a 3rd dose at 6 months)
Hepatitis B dose 3 of 3 (final dose)
Hib dose 3 or 4 (depending on the brand of vaccine used) (final dose)
MMR 1st of 2 doses which protect children against
Varicella* one dose protects against Varicella (also called Chicken Pox)
Pneumococcal conjugate dose 4 (final dose)
Hepatitis A vaccine* should be given in certain areas of the country and to most people in high-risk groups. Hepatitis A vaccine is given in 2 doses with 6 months between doses.
Years 4 to 6
Polio dose 4 final dose
MMR dose 2 (final dose)
DTaP dose 5 (final dose)
Years 11 to 12
Td (repeat as a booster every 10 years) The Td vaccine* protects against both Tetanus and Diphtheria.
On the following quick reference chart, vaccines are listed under routinely recommended ages. Doses that span several ages indicate the range of recommended ages for immunization. Any dose not given at the recommended age should be given as a "catch-up" immunization at any subsequent visit when indicated and feasible. Those marked as "makeup missed dose" indicated vaccines to be given if previously recommended doses were missed or given earlier than recommended minimum age.
Quick Reference Chart 1
Age Vaccine
Hepatitis B*
Dose 1
Diphtheria, Tetanus, Pertussis*
H. influenzae
type B*
Make up missed dose
Inactivated Polio*
Pneumococcal Conjugate*
Measles, Mumps, Rubella*
Varicella*
Hepatitis A* (select areas)
1. Centers for Disease Control, (August 2, 2001).Parents Guide to Childhood Immunization, National Immunization Publication, Retrieved 10/25/03 from http://www.cdc.gov/nip/publications/Parents-Guide/default.htm.
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Royals sign pitcher Jake Diekman to a one-year deal with mutual option
The Kansas City Royals announced today that the club has signed left-handed pitcher Jake Diekman to a one-year contract, with a mutual option for the 2020 season. Consistent with club policy, terms of the agreement were not disclosed. In a corresponding move, the Royals have placed right-handed pitcher Jesse Hahn on the 60-day injured list (recovery from ulnar collateral ligament surgery).
KANSAS CITY, MO (February 13, 2019) - The Kansas City Royals announced today that the club has signed left-handed pitcher Jake Diekman to a one-year contract, with a mutual option for the 2020 season. Consistent with club policy, terms of the agreement were not disclosed. In a corresponding move, the Royals have placed right-handed pitcher Jesse Hahn on the 60-day injured list (recovery from ulnar collateral ligament surgery).
Diekman, 32, appeared in 71 games combined between Texas and Arizona last season, going 1-2 with two saves, 17 holds and a 4.73 ERA (28 ER in 53.1 IP). He ranked tied for seventh among left-handed relievers in appearances, while his 11.14 K/9 (66 K in 53.1 IP) was 13th among that group. He did his best work on the road, posting a 1.40 ERA (4 ER in 25.2 IP), which ranked ninth in the Majors (min. 25.0 IP). He made 15-straight scoreless appearances away from home (July 5-Sept. 11), while 39 of his last 41 road outings have been scoreless, dating back to Sept. 12, 2016.
Diekman, who will wear uniform No. 40 with Kansas City, is entering his eighth Major League season, having spent time with Philadelphia (2012-15), Texas (2015-18) and Arizona (2018). In 365 big league appearances, he's 14-15 with seven saves, a 3.75 ERA and 383 strikeouts in 312.0 innings. His career strikeout rate (11.05) ranks second in the Majors among active left-handed relievers that have worked at least 300.0 innings, trailing only Aroldis Chapman (15.00). In 2014, he became one of just seven left-handed relievers (14 occurrences) to record 100+ strikeouts in a season since 2010.
A native of Wymore, Neb., Diekman was originally selected by the Phillies in the 30th round of the 2007 First-Year Player Draft out of Cloud County Community College in Concordia, Kan.
Kansas City's Major League Reserve List is at 40 players.


Pros and Cons of the New Pass/Fail Step 1 of USMLE
On February 12th, it was announced that Step 1 of the United States Medical Licensing Exam (USMLE) will now be graded on a pass/fail basis, as opposed to a numerical score. According to the official announcement, the change will be phased in over the next 11-24 months.
The Biggest Residency Interview Trail Mistake
Ali Murtha
Marathons suck. The first few miles feel like a stampede, as the hordes of runners jostle for position. If you're lucky, the next few miles go well, but by the end of the race, your body breaks down and the pain becomes intolerable.
Residency Follow-up Communication: How One Applicant Got Themselves Blacklisted
Imagine sending one email and getting rejected from every single residency program. Ex-communicated with the click of a button.


Describe in fewer than 1,000 words your own contribution to the Banks mission and the potential role of World Bank in resolving some of the world economic and development challenges. You may focus on a region or set of countries as w
Application Essay for the 2020 Selection Process The international community is racing to achieve the Sustainable Development Goals in less than 12 years, with trillions of dollars needed to deliver on the promise. Overlapping crises, from climate change to pandemics, natural disasters to forced displacement, threaten to erase hard-earned development gains, and historic economic changes, in part from technological advancement and disruption, present risks for countries, but also opportunities if they have made the necessary investments in their people, communities, and economies to take advantage of them. The world needs partners that can help meet the challenges of today, while making the investments to prepare for the challenges of tomorrow. By offering financing, knowledge, experience, and a long-term commitment to its country clients, the World Bank is a trusted partner for all its members to help transform economies and advance the 2030 sustainable development agenda. With a mission to end extreme poverty and boost shared prosperity, the World Bank supports its client countries in three priority areas: promoting sustainable, inclusive economic growth; investing moreand more effectivelyin people; and building resilience to fragility, shocks, and threats to the global economy. The Bank applies this three-pronged approach across all sectors of development so that countries make the integrated investments that can best help people lift themselves out of poverty. (Extract from the 2018 WBG Annual Report) Describe in fewer than 1,000 words your own contribution to the Banks mission (if you were to work for the World Bank Group) and the potential role of World Bank in resolving some of the above challenges. You may focus on a region or set of countries as well as your area of expertise to describe your proposal.
Consider the causes and effects of the end of major warfare (among great powers) since WWII (you can disagree with the premise of this question)
The Young Housewife" by William Carlos Williams and "The Cars" by Kathleen Fraser


Lusts & Acclaim: Literary Memoir Novel about Gail Chord Schuler & Antichrist Zack Knight
Gail shares how her life story in her next book Lusts & Acclaim will resemble Pride & Prejudice.
Outline for the book. Introduction to the book. Character Sketches for the book. Sample First Chapter. The book's & Zack Knight's Hidden story. Sample sixth chapter. Sample from seventh chapter. Another sample from seventh chapter. Theme of Lusts & Acclaim revealed in the plot and characters.
Already well on her way into the first draft, Gail expects to finish at the end of 2017 or 2018 or later. Pray for her as she writes. She tries to improve with every book and hopes to add to the ranks of great literature with this work.
THE THEME OF THE BOOK, where the characters attempt to act out their love life elevated. Each character has their own theory of what constitutes a proper elevated love life: Both God and Satan use the strategy of elevation, but Satan uses it in temptation, and the effect is quite different. When the devil elevates you to a certain place, he causes you to fasten your idea of what holiness is far beyond what flesh and blood could ever bear or achieve. Your life becomes a spiritual acrobatic performance high atop a steeple. You cling to it, trying to maintain your balance and daring not to move. But when God elevates you by His grace into heavenly places, you find a vast plateau where you can move about with ease.
Jesus has told Gail to structure Lusts & Acclaim after Pride & Prejudice. Therefore, Gail has been studying both the book and movie versions of Pride & Prejudice to prepare for this novel. Pride & Prejudice is a novel of manners that emphasizes social customs, manners, conventions and mores of a definite social class. Such novels are always realistic, and sometimes they are satiric and comic, as in Jane Austen's work. Austen's work, written primarily in unlimited point of view, concentrated on character and personality, with an emphasis on the tensions between her heroines and their society. Also, Pride & Prejudice was written as a contemporary/mainstream romance in Jane Austen's time. Therefore, Lusts & Acclaim will be a romance novel of manners, set in contemporary period and locale, though the scenes with the Vatican, will make some scenes exotic. The story has a bit of the paranormal in it, because Gail is exposing Jesuit science, and there is skepticism over the existence of this science, but Gail will present it as fact. She will have to explain it, because many readers are unfamiliar with it, forcing Gail to use principles of fantasy writing for this book. However, she wants the voice of the novel to be literary, like Jane Austen.
Gail's first two memoirs she structured as non-fiction. But for her next books, she is returning to fiction writing format, as she feels it gives her the structure needed to write a compelling story about her life and those who have affected her. She handles this by admitting that the novel is mostly non-fiction, but that she has inserted some fiction elements into the story to allow deeper penetration into all the characters. In regard to defamation lawsuits, she ensures that all elements of the novel are truthful, even those sections where she speculates on certain events, with a focus (as a novelist) on emotional truth. She admits that most writers could not get away with this much exposure in their writings, but thanks her men, who are always battling for her and her writings in court.
Any person of destiny must have their life and marriage controlled by those in power. So begins the opening to Lusts & Acclaim, a coming-of-age memoir about how the Catholic Church rewrote history and transformed the world's morals in sex, love and marriage, to bring down the Catherine the Great and King David baby born in 1957. The leader of the Catholic Church, Antichrist Zack Knight, and Gail's soul mate Star Trek: The Next Generation star Brent Spiner, come to terms with their own hearts while the Catholic Church's Jesuit Order attempts to bring down the woman with the heart of God. This is a must-read memoir novel about Gail Chord Schuler and Antichrist Zack Knight for anybody who wants to understand what is driving the events that shape the end-times prophecies depicted in the Bible books of Daniel and Revelation. Other important characters are Pope John Paul II, Loree McBride, Satan, Jesus Christ, and Angelina Ballerina.
It appears God orchestrated the literature of the world, using Jane Austen to create Pride and Prejudice to give Gail Chord Schuler the model she uses for her book Lusts & Acclaim. Looks like this book will put Gail in the ranks of Nobel Laureates in Literature. Why does Gail self-publish? It's because she doesn't want any constraints over how she writes a book. Jesuits control the publishing industry.
Star Trek: The Next Generation's "Lal"
About Writer Gabrielle Chana
2 thoughts on "Lusts & Acclaim: Literary Memoir Novel about Gail Chord Schuler & Antichrist Zack Knight"
Videos Embedded on Gail Chord Schuler's Favorite Movies, Television Broadcasts & Books (www.gabriellechana.com/favorites.html) | Gabrielle Chana's Blog April 12, 2017, 9:19 pm
[…] my past books have been attempts to fix this, but I think I may really do it with my next book Lusts and Acclaim. The book or movie has to challenge my imagination and create a world of characters who explore the […]
Can Sit or Stand at Computer (Great Furniture!) | Furniture Idea April 19, 2017, 5:50 pm
[…] Gail Chord Schuler (pen name Gabrielle Chana) discusses her remake of Silver Skies (her first novel) and why she feels she needs to redo Silver Skies, and her brand new project Lusts & Acclaim (patterned after Jane Austen's Pride and Prejudice) but updated for the 21st century. As a writer, she discusses how she plans to create two novels that she hopes will live on into posterity. https://plus.google.com/107014997445256183039/posts/VNdv5vSzHbD & https://gabriellechana.wordpress.com/2017/02/09/lusts-acclaim-literary-memoir-about-gail-chord-schul… […]


Partial government shutdown likely to continue until after Christmas
The Senate adjourned for the day Saturday afternoon without coming to an agreement on a spending deal that w...
Posted: Dec 24, 2018 8:59 AM
Updated: Dec 24, 2018 8:59 AM
The Senate adjourned for the day Saturday afternoon without coming to an agreement on a spending deal that would end a partial government shutdown -- likely assuring the federal closures will continue until after Christmas.
The developments come hours after members of Congress and President Donald Trump were unable to reach an agreement Friday night, resulting in the third government shutdown of the year.
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There will be a pro forma Senate session on Monday, but the next actual session is scheduled for Thursday afternoon.
The move means members can travel home for Christmas and not worry about being called back to vote until a deal could be reached, but GOP leaders told senators that if there was no deal by Thursday, they would not have to return for that session, sources tell CNN.
Trump tweeted Saturday evening that he would remain in Washington for the Christmas holiday, writing on Twitter, "I will not be going to Florida because of the Shutdown - Staying in the White House! #MAGA."
White House press secretary Sarah Sanders said in a statement Saturday that first lady Melania Trump would return from their Mar-a-Lago resort, where she and the President had planned to spend the holiday.
"Due to the shutdown, President Trump will remain in Washington, D.C. and the First Lady will return from Florida so they can spend Christmas together," Sanders said.
In the unlikely event a deal is reached by Monday, the pro forma session could be used to pass it by unanimous consent or voice vote, something that would only require one senator to be in attendance.
"If an agreement is reached, we'll come back and pass it," Senate Majority Leader Mitch McConnell told reporters as he left the floor.
Vice President Mike Pence proposed spending $2.5 billion on border security, including the wall, in a stopgap spending bill during his meetings on Friday night and Saturday afternoon with Senate Minority Leader Chuck Schumer, three sources familiar with the matter told CNN.
Several of the sources said there were policy additions and restrictions included in the proposal to try to bridge the gap. Democrats said the number and the details tied to it aren't acceptable and have stayed at the $1.3 billion number.
Following the Saturday meeting, a Schumer spokesman said, "The Vice President came in for a discussion and made an offer. Unfortunately, we're still very far apart."
House Minority Leader Nancy Pelosi of California issued a letter to her Democratic colleagues on Saturday saying that "if nothing happens today, it is unlikely that there will be any progress to end the Trump Shutdown in the next several days."
"Until President Trump can publicly commit to a bipartisan resolution, there will be no agreement before January when the new House Democratic Majority will swiftly pass legislation to re-open government," Pelosi's letter later added. "Please be assured you will be made aware of any developments to re-open government in the days ahead."
McConnell announced on the Senate floor earlier Saturday that there would be no action on the floor until Trump and Senate Democrats come to an agreement.
McConnell said the Senate was, in the meantime, pushing "the pause button" while the two parties attempt to work out a deal.
He then began discussing the importance of border security and "securing the homeland."
Later in the day, Senate Minority Leader Chuck Schumer addressed Trump while speaking on the Senate floor, saying, "President Trump, if you want to open the government, you must abandon the wall -- plain and simple."
During his speech, Schumer said Trump must publicly say he will support any agreement in an effort to avoid what happened earlier in the week, when White House aides indicated Trump would sign a stopgap spending measure, but then later said he would not.
Schumer also responded to McConnell's earlier comments that an agreement would need to be made between both Trump and Senate Democrats.
Schumer said McConnell and House Speaker Paul Ryan must also support any deal publicly.
"Leader McConnell can't duck out of it," Schumer said.
Any bill to re-open the government will need 60 votes to pass the Senate because of procedural rules, meaning Republicans will need some Democratic votes.
Funding for roughly a quarter of the federal government expired at midnight, including appropriations for the departments of Homeland Security, Justice, Housing and Urban Development and other parts of the government. This is the first time in 40 years that the government will have been closed three times in a year.
The funding legislation that earlier this week seemed certain to pass both chambers was thrown into limbo on Thursday when Trump told House GOP members he would not sign a bill unless it included $5 billion to fund a border wall.
Despite the House of Representatives passing a bill on Thursday, which included this demand, it was clear on Friday that there was not enough support in the Senate for the bill, including the $5 billion for the wall, to clear.
Friday night, a path forward appeared ambiguous, as all sides seemed stagnant in their demands days before the Christmas holiday, when Congress was expected to be out of session.
Republican Sen. James Lankford of Oklahoma, who was briefed by Pence, Kushner and Mulvaney on Friday, told CNN's Suzanne Malveaux on Saturday morning that the hope is McConnell will have a deal to announce when the Senate reconvenes at noon.
The debate between the White House and Congress focuses not just on how much money to allocate to border security, but also on the language stipulating where and how that money can be spent, he said.
"What is fencing, what is land ports of entry, what's technology, what's staffing?" Lankford said. "I think there's a general agreement ... that we need to do border security. Now's figuring out how much for each amount."
"Right now we're trying to finalize all the final text and to be able to make sure everyone's looked at it, everyone's agreed, signed off on it. ..." he said. "Then we'll move to a vote 24 hours from there."
Lankford also said he is "confident" that if Pence says the President is on board with any deal, Trump will keep to his word.
"We've agreed in the Senate we're not bringing anything to the floor until we know all three bodies have agreed to it," Lankford said. "Then we can expedite it through the process on the floor."
If there's no an agreement, Lankford said he believes the American people will be looking at a much longer shutdown.
A Senate Democratic aide said Saturday that talks continue at the staff level and confirmed that any deal will need signoff from congressional leadership and Trump before it comes to a vote. Democrats continue to push for border security options that they believe work, rather than a wall. Senate Minority Leader Chuck Schumer has insisted to Pence and Republicans that the President must sign off on that before a vote.
Trump earlier on Friday predicted a shut down, but placed the blame on Democrats, saying "it's really the Democrat shutdown, because we've done our thing.
"The chances are probably very good" that there is a shutdown," Trump said Friday afternoon.
He later added: "Now it's up to the Democrats as to whether we have a shutdown tonight. I hope we don't, but we're totally prepared for a very long shutdown."
And in a White House-produced video posted on Twitter two hours before the government was partially closed, Trump said, "We're going to have a shutdown. There's nothing we can do about that because we need the Democrats to give us their votes." He added, "The shutdown hopefully will not last long."
Pelosi and Schumer threw the blame back at Trump and Republican lawmakers in a joint statement shortly after midnight, warning that if the "Trump shutdown" continued, House Democrats would pass a bill to re-open the government in January.
When he appeared to be leaving on Friday night, however, Senate Majority Leader Mitch McConnell said "constructive talks are underway."
When he was asked if he would be coming back to participate in the talks, the Kentucky Republican said, "as I've said repeatedly, we need Democratic votes and presidential signature."
A person familiar with Pence, Kushner and Mulvaney's five-hour trip to the Capitol said they made it clear that the initial request that included just $1.6 billion for the wall wasn't going to cut it.
"There is no quick end to this," said one source with direct knowledge of the talks.
If a deal is to be reached, votes could happen as early as Sunday.
Government shutdown stalemate continues
Partial government shutdown over border wall
No breakthrough to end partial government shutdown
Federal government partially shuts down
What to expect if there's a partial government shutdown
No signs of a deal to end partial government shutdown
How the partial government shutdown is playing out and what to expect as it continues
State of Play: 5 days away from a partial government shutdown
Washington is now five days away from a partial government shutdown


Corporate Structure of a Radio Station
Business Models & Organizational Structure
By James Rosado
Taxi Cab Company Structure
Ad Campaign Manager Requirements
What Is Theatrical Marketing?
How Do Radio Stations Make a Profit?
TV Advertising Agreement
Your favorite radio station must operate in a coherent fashion on the air and behind the scenes to provide information and entertainment. It is therefore imperative that it utilizes a strong corporate structure. Doing so makes it easy to divide responsibilities into departments, which come together to make the station function smoothly as a whole.
Station Manager
At the top of the pyramid is the station manager, who's responsible for day-to-day operations. She enforces the owner's standards while making sure the needs of all employees are being met. The station manager maintains the budget, hires and fires, trains personnel and reviews employee performance. She also ensures that operations comply with Federal Communications Commission regulations.
The operations manager holds down the No. 2 spot within a radio station and usually focuses on coordinating, scheduling and promoting on-air programming. He works closely with disc jockeys, anchors and hosts to make sure they represent the station's branding correctly. When new programming options must be found the operations manager is usually in charge of doing the detective work. He answers to the station manager.
Program directors create and plan the daily broadcast schedule. This means locating and providing the news, music, or entertainment that should be covered while monitoring on-air activity to ensure content is disseminated properly. There is usually a program director for each individual broadcast. Program directors generally work with the same staff every day and report to the operations manager.
Having a sales manager working with a team which constantly generates revenue by selling air time to advertisers is vital. Some of her charges research potential accounts, do some cold-calling and generally generate sales leads. Others actually sell air time to meet a quota while negotiating price and payment schedules. The sales manager must often designate employees to perform collections on past-due accounts. The sales manager usually reports to the station manager.
The office manager works with a team of administrative and finance employees to handle logistics, payroll, taxes, bills, audits and legal matters. Administrative employees also field phone calls and take messages for the station manager and operations director. They also book any outside business travel for station employees as well as lodging for guests. The office manager reports to the operations manager or station manager.
The chief engineer manages a team that handles all technical matters. In addition to supervising, he must regularly inspect equipment, maintain and repair it when necessary, purchase new equipment when merited and abide by FCC regulations. The engineering staff is often directly involved with broadcasts by editing tracks, managing sound effects and monitoring the station's signal for strength, quality and overall clarity. The chief engineer reports to the operations manager.
Transmitting the station's voice to the public falls to on-air personalities. Disc jockeys play music, take requests and provide information. Anchors deliver the news, weather and traffic updates. Hosts often conduct interviews and allow listeners to call in and become part of the show. All must align with station branding. On-air personalities report to their program director.
The Radio Station; Michael C. Keith
FCC: What We Do
FCC:Rules and Regulations for Title 47
Sound Concepts: Station and Organizational Structure
Based in Interlaken, N.Y., James Rosado has been writing articles on business, finance and marketing since 2009. His articles have appeared in regional publications across the Finger Lakes region of New York including the "Ithaca Times." He holds a Bachelor's of Arts in visual communication and an Associates of Arts in hospitality marketing.
Organizational Structure in Broadcasting
The Organizational Structure of a Television Station
Responsibilities of Advertising Operations
Role of Advertising in a Broadcast Media Organization
Sales Management Structure
What Is a Production Manager in the Fashion Industry?
Tips for a Brand Manager for a TV Station
How to Get on Community Access TV
What Is an Advertising Director?
1 Organizational Structure in Broadcasting
2 The Organizational Structure of a Television Station
3 Responsibilities of Advertising Operations
4 Role of Advertising in a Broadcast Media Organization


Explain the ramifications of this constitutional protection for defendants
Assignment: Complete the following below, must be in APA format. All work cited and perfer Turn It In used. Book for the class is Constitutional Law for Criminal Justice 14th Edition Jacqueline R. Kanovitz. Chapter 9 for this assignment.
1. As a police officer, it sometimes seems "unfair" to preserve and disclose evidence that is favorable to the defense when police are putting together evidence to convict the defendant (California v. Trombetta). Explain the ramifications of this constitutional protection for defendants. Do you agree with it? Why or why not?
2.Two tests are used to determine whether charges brought under different portions of the penal code represent the "same offense." Explain them and the standard each test uses to determine offense identity. Which test is most prevalent today?
3.The Sixth Amendment guarantees the right to a speedy trial. Explain the policies "the right to a speedy trial" promotes, and why you think they are, or are not, in place in our legal system.
4.Explain in detail the three precautions trial judges traditionally take to counteract the effects of prejudicial media coverage. What are their shortcomings of these precautions? What would you do differently if you were a judge in a high-profile case? Cite a high-profile case to support your writing.


When Ulster said 'Yes'!
NOEL COOGAN recalls the early years of the 1990s when Ulster teams dominated the All-Ireland Football Championship with debut wins for Donegal and Derry and a glorious double for Down.
Something happened in the All-Ireland Senior Football Championship in the first half of the 1990s which did not happen before and there is unlikely to be a repeat of it in the foreseeable future. In each of the years from 1991 to 1994, the Sam Maguire Cup was captured by Ulster teams with three different counties enjoying the sweet taste of success. In 1991, Down took the title for the fourth time and that was followed by first time triumphs by Donegal and Derry before Down reclaimed the big prize in '94. For many decades Cavan were the dominant force in the northern province and the only county from the region capable of putting in a serious challenge for All-Ireland honours. Between 1933 and '52, the Breffni county brought the game's most coveted trophy home on five occasions but they ceased being a strong force after the '60s. There was a sensational start to the sixties which was certainly a decade of significant change for Gaelic football with Down becoming the new glamour team of the game.
In 1960, the men in red and black created history when becoming the first side to take the Sam Maguire Cup across the border when inflicting an eight points final defeat on the championship's most successful county, Kerry.
To prove that victory was not a fluke, Down had six points to spare over the Kingdom in an All-Ireland semi-final clash in 1961 before emerging force, Offaly, were narrowly defeated before a record attendance of more than 90,000 as the title went back to the Mourne county.c
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Hellenistic Greece
The Hellenistic Age
After Alexander the Great died in 323 B.C., his generals (known as the Diadochoi) divided his conquered lands. These fragments of the Alexandrian empire became three powerful dynasties: the Seleucids of Syria and Persia, the Ptolemies of Egypt, and the Antigonids of Greece and Macedonia.
These dynasties were not politically united, but they all shared an essential "Greek-ness." Historians refer to these dynasties as the Hellenistic Age.
The Hellenistic states were ruled by absolute monarchies with a cosmopolitan view of the world. The kings developed commercial relationships throughout the Hellenistic world. They imported goods such as ivory, gold, cotton, and spices from India; furs and iron from the Far East; wine from Syria; papyrus, linen, and glass from Alexandria; olive oil from Athens; dates and prunes from Babylon; silver from Spain; copper from Cyprus; and tin from as far north as Brittany.
They displayed their wealth by building elaborate palaces and commissioning art and jewelry. They established museums, zoos, libraries, and universities. The Alexandria university was home to mathematicians Euclid and Archimedes, as well as inventors of the water clock and the model steam engine.
Hellenistic Culture
Subjects moved freely around the Hellenistic kingdoms. They all spoke and read koine, or "the common tongue," a kind of colloquial Greek. Language was a unifying cultural force, enabling people across the Hellenistic world to communicate with one another.
Many people did feel alienated because they were no longer involved with the workings of democratic city-states. Instead they lived in large empires governed by professional bureaucrats. Many people joined cults or "mystery religions," like those centered on the goddesses Isis and Fortune.
Hellenistic philosophers turned their focus inward. Diogenes the Cynic lived a simple life in protest against commercialism and cosmopolitanism. The philosopher Epicurus posited the centrality of the pursuit of the individual's pleasure and happiness. The Stoics argued that every individual man had within him a divine spark that could be cultivated by living a good and noble life.
The End of the Hellenistic Age
The Romans conquered the Hellenistic dynasties in stages, finally ending the Hellenistic Age in 31 B.C.E. when Octavian defeated Mark Antony and the Ptolemaic fleet at the Battle of Actium. Octavian adopted the name Augustus and became the first Roman emperor. The Hellenistic period may have been short, but its cultural and intellectual contributions have influenced readers, writers, artists, and scientists ever since.
Source: Hellenistic Greece


February 1, 2023 01:10 PM WAT
Processing facilities
Special palm oil
RBDO
Olein
Stearin
CPKO
RPKO
Future investments
/Products
/Stearin
Palm Stearin is the solid fraction obtained from the fractionation of Refined Bleached and Deodorized Palm Oil. It is mainly used by the food industry.
Presco's premium grade refined palm stearin is known as Palma.
Palma is used:
in dough for biscuits
in chocolate and confectionery products
in snacks, crisps, ...
Palma Specifications:
FFA (%) Max: 0.08-0.10
Moisture & Impurities (%) Max: 0.01 or 0.02
IV: ranging from 30 to 54 depending on the customer's specifications
PV (meq O²/kg): ranging from 0.8 to 3.5 depending on the customer's specifications
Melting Point (°C): ranging from 36 to 55 depending on the customer's specifications
Taste/Odour: Bland
Colour (5 ¼" Lovibond) R: ranging from 2.8 to 4.5 depending on the customer's specifications
Colour (5 ¼" Lovibond) Y: 30-35
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