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1.  Effects of Vaccine Program against Pandemic Influenza A(H1N1) Virus, United States, 2009–2010 
Emerging Infectious Diseases  2013;19(3):439-448.
Vaccination likely prevented 700,000–1,500,000 clinical cases, 4,000–10,000 hospitalizations, and 200–500 deaths.
In April 2009, the United States began a response to the emergence of a pandemic influenza virus strain: A(H1N1)pdm09. Vaccination began in October 2009. By using US surveillance data (April 12, 2009–April 10, 2010) and vaccine coverage estimates (October 3, 2009–April 18, 2010), we estimated that the A(H1N1)pdm09 virus vaccination program prevented 700,000–1,500,000 clinical cases, 4,000–10,000 hospitalizations, and 200–500 deaths. We found that the national health effects were greatly influenced by the timing of vaccine administration and the effectiveness of the vaccine. We estimated that recommendations for priority vaccination of targeted priority groups were not inferior to other vaccination prioritization strategies. These results emphasize the need for relevant surveillance data to facilitate a rapid evaluation of vaccine recommendations and effects.
doi:10.3201/eid1903.120394
PMCID: PMC3647645  PMID: 23622679
Influenza; viruses; vaccine; vaccination; A(H1N1)pdm09; H1N1; pandemic; model
2.  Efficiency of Points of Dispensing for Influenza A(H1N1)pdm09 Vaccination, Los Angeles County, California, USA, 2009 
Emerging Infectious Diseases  2014;20(4):590-595.
During October 23–December 8, 2009, the Los Angeles County Department of Public Health used points of dispensing (PODs) to improve access to and increase the number of vaccinations against influenza A(H1N1)pdm09. We assessed the efficiency of these units and access to vaccines among ethnic groups. An average of 251 persons per hour (SE 65) were vaccinated at the PODs; a 10% increase in use of live-attenuated monovalent vaccines reduced that rate by 23 persons per hour (SE 7). Vaccination rates were highest for Asians (257/10,000 persons), followed by Hispanics (114/10,000), whites (75/100,000), and African Americans (37/10,000). Average distance traveled to a POD was highest for whites (6.6 miles; SD 6.5) and lowest for Hispanics (4.7 miles; SD ±5.3). Placing PODs in areas of high population density could be an effective strategy to reach large numbers of persons for mass vaccination, but additional PODs may be needed to improve coverage for specific populations.
doi:10.3201/eid2004.130725
PMCID: PMC3966367  PMID: 24656212
H1N1; mass vaccination; points of dispensing; throughput; access; influenza; pandemic; influenza A(H1N1)pdm09; pH1N1; vaccination; vaccine; immunization; California; United States
3.  Cost-Effectiveness of Alternative Strategies for Annual Influenza Vaccination among Children Aged 6 Months to 14 Years in Four Provinces in China 
PLoS ONE  2014;9(1):e87590.
Background
To support policy making, we developed an initial model to assess the cost-effectiveness of potential strategies to increase influenza vaccination rates among children in China.
Methods
We studied on children aged 6 months to 14 years in four provinces (Shandong, Henan, Hunan, and Sichuan), with a health care system perspective. We used data from 2005/6 to 2010/11, excluding 2009/10. Costs are reported in 2010 U.S. dollars.
Results
In comparison with no vaccination, the mean (range) of Medically Attended Cases averted by the current self-payment policy for the two age groups (6 to 59 months and 60 months to 14 years) was 1,465 (23∼11,132) and 792 (36∼4,247), and the cost effectiveness ratios were $ 0 (-11-51) and $ 37 (6-125) per case adverted, respectively. In comparison with the current policy, the incremental cost effectiveness ratio (ICER) of alternative strategies, OPTION One-reminder and OPTION Two-comprehensive package, decreased as vaccination rate increased. The ICER for children aged 6 to 59 months was lower than that for children aged 60 months to 14 years.
Conclusions
The model is a useful tool in identifying elements for evaluating vaccination strategies. However, more data are needed to produce more accurate cost-effectiveness estimates of potential vaccination policies.
doi:10.1371/journal.pone.0087590
PMCID: PMC3909220  PMID: 24498145
4.  Modeling the Effect of Water, Sanitation, and Hygiene and Oral Cholera Vaccine Implementation in Haiti 
In 2010, toxigenic Vibrio cholerae was newly introduced to Haiti. Because resources are limited, decision-makers need to understand the effect of different preventive interventions. We built a static model to estimate the potential number of cholera cases averted through improvements in coverage in water, sanitation and hygiene (WASH) (i.e., latrines, point-of-use chlorination, and piped water), oral cholera vaccine (OCV), or a combination of both. We allowed indirect effects and non-linear relationships between effect and population coverage. Because there are limited incidence data for endemic cholera in Haiti, we estimated the incidence of cholera over 20 years in Haiti by using data from Malawi. Over the next two decades, scalable WASH interventions could avert 57,949–78,567 cholera cases, OCV could avert 38,569–77,636 cases, and interventions that combined WASH and OCV could avert 71,586–88,974 cases. Rate of implementation is the most influential variable, and combined approaches maximized the effect.
doi:10.4269/ajtmh.13-0201
PMCID: PMC3795092  PMID: 24106189
5.  Estimating Effect of Antiviral Drug Use during Pandemic (H1N1) 2009 Outbreak, United States 
Emerging Infectious Diseases  2011;17(9):1591-1598.
From April 2009 through March 2010, during the pandemic (H1N1) 2009 outbreak, ≈8.2 million prescriptions for influenza neuraminidase-inhibiting antiviral drugs were filled in the United States. We estimated the number of hospitalizations likely averted due to use of these antiviral medications. After adjusting for prescriptions that were used for prophylaxis and personal stockpiles, as well as for patients who did not complete their drug regimen, we estimated the filled prescriptions prevented ≈8,400–12,600 hospitalizations (on the basis of median values). Approximately 60% of these prevented hospitalizations were among adults 18–64 years of age, with the remainder almost equally divided between children 0–17 years of age and adults >65 years of age. Public health officials should consider these estimates an indication of success of treating patients during the 2009 pandemic and a warning of the need for renewed planning to cope with the next pandemic.
doi:10.3201/eid1709.110295
PMCID: PMC3358088  PMID: 21888783
antiviral drugs; hospitalizations; impact; influenza; pandemic; pandemic (H1N1) 2009; research; respiratory infections; United States; viruses
6.  Economics of Malaria Prevention in US Travelers to West Africa 
Costs and benefits of malaria prevention are provided during domestic pretravel health consultations. Healthcare payers always, and travelers often, save money when travelers adhere to malaria recommendations and prophylactic regimens in West Africa, especially for longer durations of travel.
Background. Pretravel health consultations help international travelers manage travel-related illness risks through education, vaccination, and medication. This study evaluated costs and benefits of that portion of the health consultation associated with malaria prevention provided to US travelers bound for West Africa.
Methods. The estimated change in disease risk and associated costs and benefits resulting from traveler adherence to malaria chemoprophylaxis were calculated from 2 perspectives: the healthcare payer's and the traveler's. We used data from the Global TravEpiNet network of US travel clinics that collect de-identified pretravel data for international travelers. Disease risk and chemoprophylaxis effectiveness were estimated from published medical reports. Direct medical costs were obtained from the Nationwide Inpatient Sample and published literature.
Results. We analyzed 1029 records from January 2009 to January 2011. Assuming full adherence to chemoprophylaxis regimens, consultations saved healthcare payers a per-traveler average of $14 (9-day trip) to $372 (30-day trip). For travelers, consultations resulted in a range of net cost of $20 (9-day trip) to a net savings of $32 (30-day trip). Differences were mostly driven by risk of malaria in the destination country.
Conclusions. Our model suggests that healthcare payers save money for short- and longer-term trips, and that travelers save money for longer trips when travelers adhere to malaria recommendations and prophylactic regimens in West Africa. This is a potential incentive to healthcare payers to offer consistent pretravel preventive care to travelers. This financial benefit complements the medical benefit of reducing the risk of malaria.
doi:10.1093/cid/cit570
PMCID: PMC3864498  PMID: 24014735
costs; benefits; malaria prevention; pretravel health consultation
7.  Influenza Illness and Hospitalizations Averted by Influenza Vaccination in the United States, 2005–2011 
PLoS ONE  2013;8(6):e66312.
Context
The goal of influenza vaccination programs is to reduce influenza-associated disease outcomes. Therefore, estimating the reduced burden of influenza as a result of vaccination over time and by age group would allow for a clear understanding of the value of influenza vaccines in the US, and of areas where improvements could lead to greatest benefits.
Objective
To estimate the direct effect of influenza vaccination in the US in terms of averted number of cases, medically-attended cases, and hospitalizations over six recent influenza seasons.
Design
Using existing surveillance data, we present a method for assessing the impact of influenza vaccination where impact is defined as either the number of averted outcomes or as the prevented disease fraction (the number of cases estimated to have been averted relative to the number of cases that would have occurred in the absence of vaccination).
Results
We estimated that during our 6-year study period, the number of influenza illnesses averted by vaccination ranged from a low of approximately 1.1 million (95% confidence interval (CI) 0.6–1.7 million) during the 2006–2007 season to a high of 5 million (CI 2.9–8.6 million) during the 2010–2011 season while the number of averted hospitalizations ranged from a low of 7,700 (CI 3,700–14,100) in 2009–2010 to a high of 40,400 (CI 20,800–73,000) in 2010–2011. Prevented fractions varied across age groups and over time. The highest prevented fraction in the study period was observed in 2010–2011, reflecting the post-pandemic expansion of vaccination coverage.
Conclusions
Influenza vaccination programs in the US produce a substantial health benefit in terms of averted cases, clinic visits and hospitalizations. Our results underscore the potential for additional disease prevention through increased vaccination coverage, particularly among nonelderly adults, and increased vaccine effectiveness, particularly among the elderly.
doi:10.1371/journal.pone.0066312
PMCID: PMC3686813  PMID: 23840439
8.  Effect of Winter School Breaks on Influenza-like Illness, Argentina, 2005–2008 
Emerging Infectious Diseases  2013;19(6):938-944.
School closures are used to reduce seasonal and pandemic influenza transmission, yet evidence of their effectiveness is sparse. In Argentina, annual winter school breaks occur during the influenza season, providing an opportunity to study this intervention. We used 2005–2008 national weekly surveillance data of visits to a health care provider for influenza-like illness (ILI) from all provinces. Using Serfling-specified Poisson regressions and population-based census denominators, we developed incidence rate ratios (IRRs) for the 3 weeks before, 2 weeks during, and 3 weeks after the break. For persons 5–64 years of age, IRRs were <1 for at least 1 week after the break. Observed rates returned to expected by the third week after the break; overall decrease among persons of all ages was 14%. The largest decrease was among children 5–14 years of age during the week after the break (37% lower IRR). Among adults, effects were weaker and delayed. Two-week winter school breaks significantly decreased visits to a health care provider for ILI among school-aged children and nonelderly adults.
doi:10.3201/eid1906.120916
PMCID: PMC3713818  PMID: 23735682
Influenza; school closure; community mitigation; social isolation; Argentina; winter; viruses; respiratory infections
9.  Laboratory Surge Capacity and Pandemic Influenza 
Emerging Infectious Diseases  2010;16(1):8-13.
doi:10.3201/eid1601.091741
PMCID: PMC2874389  PMID: 20031064
Laboratory; testing; capacity; pandemic influenza; influenza; virus; public health; commentary
10.  The Mystery of Increased Hospitalizations of Elderly Patients 
Emerging Infectious Diseases  2008;14(5):727-33.
doi:10.3201/eid1405.080217
PMCID: PMC2600238  PMID: 18439380
Hospitalizations; elderly; pneumonia; community-acquired staphyloccal pneumonia; commentary
11.  Pandemic Influenza, Reopening Schools, and Returning to Work 
Emerging Infectious Diseases  2008;14(3):365-72.
Pandemic Influenza, Reopening Schools, and Returning to Work
In this issue of Emerging Infectious Diseases, Victoria Davey and Robert Glass present a paper (1) in which they consider the question of when to “switch off” community-based interventions designed to reduce the spread of pandemic influenza. These authors attempt to answers questions such as when it would be optimal to reopen schools that have been closed as part of a nonpharmaceutical, communitywide influenza mitigation strategy.
doi:10.3201/eid1403.080026
PMCID: PMC2570811  PMID: 18325276
Influenza pandemic; mathematical models; reopening schools; returning to work; commentary
13.  Interdisciplinary Public Health Reasoning and Epidemic Modelling: The Case of Black Death 
Emerging Infectious Diseases  2006;12(2):361-362.
doi:10.3201/eid1202.051330
PMCID: PMC3373092
epidemic modeling; mathematical modeling; black death; plague; book review
14.  Syndromic Surveillance in Bioterrorist Attacks 
Emerging Infectious Diseases  2005;11(9):1396-400.
doi:10.3201/eid1109.050981
PMCID: PMC3310639  PMID: 16673516
syndromic surveillance; bioterrorist; anthrax; commentary
15.  Multiple Contact Dates and SARS Incubation Periods 
Emerging Infectious Diseases  2004;10(2):207-209.
Many severe acute respiratory syndrome (SARS) patients have multiple possible incubation periods due to multiple contact dates. Multiple contact dates cannot be used in standard statistical analytic techniques, however. I present a simple spreadsheet-based method that uses multiple contact dates to calculate the possible incubation periods of SARS.
doi:10.3201/eid1002.030426
PMCID: PMC3322923  PMID: 15030684
severe acute respiratory syndrome; incubation period; multiple contact dates; estimation; spreadsheet
16.  Influenza Pandemic Preparedness 
Emerging Infectious Diseases  2003;8(12):225-30.
doi:10.3201/eid0912.030289
PMCID: PMC3034335  PMID: 14725306
influenza; pandemic; preparedness; bioterrorism; resource allocation; priorities
17.  Risks and Benefits of Preexposure and Postexposure Smallpox Vaccination1 
Emerging Infectious Diseases  2003;9(11):1363-1370.
This article presents a model and decision criteria for evaluating a person’s risk of pre- or postexposure smallpox vaccination in light of serious vaccine-related adverse events (death, postvaccine encephalitis and progressive vaccinia). Even at a 1-in-10 risk of 1,000 initial smallpox cases, a person in a population of 280 million has a greater risk for serious vaccine-related adverse events than a risk for smallpox. For a healthcare worker to accept preexposure vaccination, the risk for contact with an infectious smallpox case-patient must be >1 in 100, and the probability of 1,000 initial cases must be >1 in 1,000. A member of an investigation team would accept preexposure vaccination if his or her anticipated risk of contact is 1 in 2.5 and the risk of attack is assumed to be >1 in 16,000. The only circumstances in which postexposure vaccination would not be accepted are the following: if vaccine efficacy were <1%, the risk of transmission were <1%, and (simultaneously) the risk for serious vaccine-related adverse events were >1 in 5,000.
doi:10.3201/eid0911.030369
PMCID: PMC3035543  PMID: 14718077
18.  Community-Based Values for 2009 Pandemic Influenza A H1N1 Illnesses and Vaccination-Related Adverse Events 
PLoS ONE  2011;6(12):e27777.
Objective
To evaluate community-based values for avoiding pandemic influenza (A) H1N1 (pH1N1) illness and vaccination-related adverse events in adults and children.
Methods
Adult community members were randomly selected from a nationally representative research panel to complete an internet survey (response rate = 65%; n = 718). Respondents answered a series of time trade-off questions to value four hypothetical health state scenarios for varying ages (1, 8, 35, or 70 years): uncomplicated pH1N1 illness, pH1N1 illness-related hospitalization, severe allergic reaction to the pH1N1 vaccine, and Guillain-Barré syndrome. We calculated descriptive statistics for time trade-off amounts and derived quality adjusted life year losses for these events. Multivariate regression analyses evaluated the effect of scenario age, as well as respondent socio-demographic and health characteristics on time trade-off amounts.
Results
Respondents were willing to trade more time to avoid the more severe outcomes, hospitalization and Guillain-Barré syndrome. In our adjusted and unadjusted analyses, age of the patient in the scenario was significantly associated with time trade-off amounts (p-value<0.05), with respondents willing to trade more time to prevent outcomes in children versus adults. Persons who had received the pH1N1 vaccination were willing to trade significantly more time to avoid hospitalization, severe allergic reaction, and Guillain-Barré syndrome, controlling for other variables in adjusted analyses.(p-value<0.05)
Conclusions
Community members placed the highest value on preventing outcomes in children, compared with adults, and the time trade-off values reported were consistent with the severity of the outcomes presented. Considering these public values along with other decision-making factors may help policy makers improve the allocation of pandemic vaccine resources.
doi:10.1371/journal.pone.0027777
PMCID: PMC3242758  PMID: 22205927
19.  Cost-Effectiveness of 2009 Pandemic Influenza A(H1N1) Vaccination in the United States 
PLoS ONE  2011;6(7):e22308.
Background
Pandemic influenza A(H1N1) (pH1N1) was first identified in North America in April 2009. Vaccination against pH1N1 commenced in the U.S. in October 2009 and continued through January 2010. The objective of this study was to evaluate the cost-effectiveness of pH1N1 vaccination.
Methodology
A computer simulation model was developed to predict costs and health outcomes for a pH1N1 vaccination program using inactivated vaccine compared to no vaccination. Probabilities, costs and quality-of-life weights were derived from emerging primary data on pH1N1 infections in the US, published and unpublished data for seasonal and pH1N1 illnesses, supplemented by expert opinion. The modeled target population included hypothetical cohorts of persons aged 6 months and older stratified by age and risk. The analysis used a one-year time horizon for most endpoints but also includes longer-term costs and consequences of long-term sequelae deaths. A societal perspective was used. Indirect effects (i.e., herd effects) were not included in the primary analysis. The main endpoint was the incremental cost-effectiveness ratio in dollars per quality-adjusted life year (QALY) gained. Sensitivity analyses were conducted.
Results
For vaccination initiated prior to the outbreak, pH1N1 vaccination was cost-saving for persons 6 months to 64 years under many assumptions. For those without high risk conditions, incremental cost-effectiveness ratios ranged from $8,000–$52,000/QALY depending on age and risk status. Results were sensitive to the number of vaccine doses needed, costs of vaccination, illness rates, and timing of vaccine delivery.
Conclusions
Vaccination for pH1N1 for children and working-age adults is cost-effective compared to other preventive health interventions under a wide range of scenarios. The economic evidence was consistent with target recommendations that were in place for pH1N1 vaccination. We also found that the delays in vaccine availability had a substantial impact on the cost-effectiveness of vaccination.
doi:10.1371/journal.pone.0022308
PMCID: PMC3146485  PMID: 21829456
20.  Health Economics of Dengue: A Systematic Literature Review and Expert Panel's Assessment 
Dengue vaccines are currently in development and policymakers need appropriate economic studies to determine their potential financial and public health impact. We searched five databases (PubMed, EMBASE, LILAC, EconLit, and WHOLIS) to identify health economics studies of dengue. Forty-three manuscripts were identified that provided primary data: 32 report economic burden of dengue and nine are comparative economic analyses assessing various interventions. The remaining two were a willingness-to-pay study and a policymaker survey. An expert panel reviewed the existing dengue economic literature and recommended future research to fill information gaps. Although dengue is an important vector-borne disease, the economic literature is relatively sparse and results have often been conflicting because of use of inconsistent assumptions. Health economic research specific to dengue is urgently needed to ensure informed decision making on the various options for controlling and preventing this disease.
doi:10.4269/ajtmh.2011.10-0521
PMCID: PMC3042827  PMID: 21363989
21.  Modeling the Cost-Effectiveness of the Integrated Disease Surveillance and Response (IDSR) System: Meningitis in Burkina Faso 
PLoS ONE  2010;5(9):e13044.
Background
Effective surveillance for infectious diseases is an essential component of public health. There are few studies estimating the cost-effectiveness of starting or improving disease surveillance. We present a cost-effectiveness analysis the Integrated Disease Surveillance and Response (IDSR) strategy in Africa.
Methodology/Principal Findings
To assess the impact of the IDSR in Africa, we used pre- and post- IDSR meningococcal meningitis surveillance data from Burkina Faso (1996–2002 and 2003–2007). IDSR implementation was correlated with a median reduction of 2 weeks to peak of outbreaks (25th percentile 1 week; 75th percentile 4 weeks). IDSR was also correlated with a reduction of 43 meningitis cases per 100,000 (25th–40: 75th-129). Assuming the correlations between reductions in time to peak of outbreaks and cases are related, the cost-effectiveness of IDSR was $23 per case averted (25th-$30; 75th - cost saving), and $98 per meningitis-related death averted (25th-$140: 75th – cost saving).
Conclusions/Significance
We cannot absolutely claim that the measured differences were due to IDSR. We believe, however, that it is reasonable to claim that IDSR can improve the cost-effectiveness of public health surveillance.
doi:10.1371/journal.pone.0013044
PMCID: PMC2946913  PMID: 20927386
22.  Household Effects of School Closure during Pandemic (H1N1) 2009, Pennsylvania, USA 
Emerging Infectious Diseases  2010;16(8):1315-1317.
To determine the effects of school closure, we surveyed 214 households after a 1-week elementary school closure because of pandemic (H1N1) 2009. Students spent 77% of the closure days at home, 69% of students visited at least 1 other location, and 79% of households reported that adults missed no days of work to watch children.
doi:10.3201/eid1608.091827
PMCID: PMC3298323  PMID: 20678335
Influenza A virus; influenza; H1N1 subtype; pandemic (H1N1) 2009; compliance; economics; school closure; Pennsylvania; viruses; dispatch
23.  Estimating the risk of rabies transmission to humans in the U.S.: a delphi analysis 
BMC Public Health  2010;10:278.
Background
In the United States, the risk of rabies transmission to humans in most situations of possible exposure is unknown. Controlled studies on rabies are clearly not possible. Thus, the limited data on risk has led to the frequent administration of rabies post-exposure prophylaxis (PEP), often in inappropriate circumstances.
Methods
We used the Delphi method to obtain an expert group consensus estimate of the risk of rabies transmission to humans in seven scenarios of potential rabies exposure. We also surveyed and discussed the merits of recommending rabies PEP for each scenario.
Results
The median risk of rabies transmission without rabies PEP for a bite exposure by a skunk, bat, cat, and dog was estimated to be 0.05, 0.001, 0.001, and 0.00001, respectively. Rabies PEP was unanimously recommended in these scenarios. However, rabies PEP was overwhelmingly not recommended for non-bite exposures (e.g. dog licking hand but unavailable for subsequent testing), estimated to have less than 1 in 1,000,000 (0.000001) risk of transmission.
Conclusions
Our results suggest that there are many common situations in which the risk of rabies transmission is so low that rabies PEP should not be recommended. These risk estimates also provide a key parameter for cost-effective models of human rabies prevention and can be used to educate health professionals about situation-specific administration of rabies PEP.
doi:10.1186/1471-2458-10-278
PMCID: PMC2887820  PMID: 20500896
24.  Estimates of the Prevalence of Pandemic (H1N1) 2009, United States, April–July 2009 
Emerging Infectious Diseases  2009;15(12):2004-2007.
Through July 2009, a total of 43,677 laboratory-confirmed cases of influenza A pandemic (H1N1) 2009 were reported in the United States, which is likely a substantial underestimate of the true number. Correcting for under-ascertainment using a multiplier model, we estimate that 1.8 million–5.7 million cases occurred, including 9,000–21,000 hospitalizations.
doi:10.3201/eid1512.091413
PMCID: PMC3375879  PMID: 19961687
Influenza; pandemic; pandemic (H1N1) 2009; viruses; dispatch; expedited
25.  Tactics and Economics of Wildlife Oral Rabies Vaccination, Canada and the United States 
Emerging Infectious Diseases  2009;15(8):1176-1184.
Economic assessments and modeling studies suggest that these programs yield cost savings and public health benefits.
Progressive elimination of rabies in wildlife has been a general strategy in Canada and the United States; common campaign tactics are trap–vaccinate–release (TVR), point infection control (PIC), and oral rabies vaccination (ORV). TVR and PIC are labor intensive and the most expensive tactics per unit area (≈$616/km2 [in 2008 Can$, converted from the reported $450/km2 in 1991 Can$] and ≈$612/km2 [$500/km2 in 1999 Can$], respectively), but these tactics have proven crucial to elimination of raccoon rabies in Canada and to maintenance of ORV zones for preventing the spread of raccoon rabies in the United States. Economic assessments have shown that during rabies epizootics, costs of human postexposure prophylaxis, pet vaccination, public health, and animal control spike. Modeling studies, involving diverse assumptions, have shown that ORV programs can be cost-efficient and yield benefit:cost ratios >1.0.
doi:10.3201/eid1508.081061
PMCID: PMC2815952  PMID: 19757549
Coyote; economics; fox; North America; oral rabies vaccination; rabies; raccoon; viruses; zoonoses; synopsis

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