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BT 15.000 718.042 Td /F2 21.0 Tf  [(H1N1 vaccination and adults with underlying health conditions )] TJ ET
BT 15.000 693.094 Td /F2 21.0 Tf  [(in the US)] TJ ET
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BT 15.000 675.088 Td /F3 9.8 Tf  [(November 20, 2009)] TJ ET
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BT 26.250 663.247 Td /F1 9.8 Tf  [(Edward Goldstein)] TJ ET
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BT 103.197 663.247 Td /F1 9.8 Tf  [(, )] TJ ET
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BT 108.618 663.247 Td /F1 9.8 Tf  [(Marc Lipsitch)] TJ ET
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BT 26.250 651.342 Td /F1 9.8 Tf  [(Goldstein E, Lipsitch M. H1N1 vaccination and adults with underlying health conditions in the US. PLOS Currents Influenza. )] TJ ET
BT 26.250 639.438 Td /F1 9.8 Tf  [(2009 Nov 20 . Edition 1. doi: 10.1371/currents.RRN1132.)] TJ ET
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BT 26.250 610.335 Td /F4 12.0 Tf  [(Abstract)] TJ ET
BT 26.250 590.381 Td /F1 9.8 Tf  [(65% of fatalities from pH1N1 infections in a large US case series occur in adults with underlying health conditions other than )] TJ ET
BT 26.250 578.476 Td /F1 9.8 Tf  [(pregnancy, but it appears that only relatively few high-risk adults will get vaccinated during the fall wave of pH1N1 transmission. )] TJ ET
BT 26.250 566.571 Td /F1 9.8 Tf  [(There are several reasons for this problem; the most important is vaccine shortage. High risk adults \(other than pregnant )] TJ ET
BT 26.250 554.667 Td /F1 9.8 Tf  [(women\) were not part of the initial, narrow priority cohort which included pregnant women and children ages 0.5-4; this is )] TJ ET
BT 26.250 542.762 Td /F1 9.8 Tf  [(despite the fact that some of those high risk groups, such as adults with immunosuppressive conditions and possibly individuals )] TJ ET
BT 26.250 530.857 Td /F1 9.8 Tf  [(with neurological disorders, have a relative risk for fatality \(per capita\) higher than pregnant women, and over 28-fold higher )] TJ ET
BT 26.250 518.952 Td /F1 9.8 Tf  [(than healthy children under the age of 4. With more vaccine becoming available than needed in the initial priority cohort, a )] TJ ET
BT 26.250 507.048 Td /F1 9.8 Tf  [(broader group which includes high risk adults and individuals under 24 becomes eligible for vaccine in many locations. )] TJ ET
BT 26.250 495.143 Td /F1 9.8 Tf  [(Nonetheless, due to continuing high demand, high-risk adults face competition for vaccine from healthy individuals under 24; )] TJ ET
BT 26.250 483.238 Td /F1 9.8 Tf  [(additionally, some locations specifically prioritize school students over high-risk adults. Finally, there is an issue of awareness )] TJ ET
BT 26.250 471.333 Td /F1 9.8 Tf  [(and a shortage of specific channels that target high risk adults other than pregnant women and facilitate vaccine distribution )] TJ ET
BT 26.250 459.429 Td /F1 9.8 Tf  [(among them in the US.)] TJ ET
BT 26.250 440.024 Td /F1 9.8 Tf  [(A recent CDC estimate suggests that death toll from H1N1 is larger than previously thought )] TJ ET
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BT 422.373 440.024 Td /F1 9.8 Tf  [([1])] TJ ET
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BT 433.215 440.024 Td /F1 9.8 Tf  [( , approximately 4000 deaths )] TJ ET
BT 26.250 428.119 Td /F1 9.8 Tf  [(from April to October 2009. In a recent case series )] TJ ET
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0.271 0.267 0.267 rg
BT 258.719 428.119 Td /F1 9.8 Tf  [( , over 65% of fatalities among hospitalized H1N1 patients were adults )] TJ ET
BT 26.250 416.214 Td /F1 9.8 Tf  [(with underlying health conditions other than pregnancy. A previous study )] TJ ET
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BT 342.199 416.214 Td /F1 9.8 Tf  [([3])] TJ ET
0.271 0.267 0.267 rg
BT 353.041 416.214 Td /F1 9.8 Tf  [( , with a higher proportion of children among the )] TJ ET
BT 26.250 404.310 Td /F1 9.8 Tf  [(hospitalized patients than )] TJ ET
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BT 138.980 404.310 Td /F1 9.8 Tf  [([2])] TJ ET
0.271 0.267 0.267 rg
BT 149.822 404.310 Td /F1 9.8 Tf  [( , found that 72% of hospitalized adults had an underlying condition other than pregnancy. Among )] TJ ET
BT 26.250 392.405 Td /F1 9.8 Tf  [(individuals who died or were admitted to ICU in the same study, 67% had an underlying health condition. Other studies )] TJ ET
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BT 540.533 392.405 Td /F1 9.8 Tf  [([4])] TJ ET
BT 551.375 392.405 Td /F1 9.8 Tf  [([5])] TJ ET
0.271 0.267 0.267 rg
BT 26.250 380.500 Td /F1 9.8 Tf  [(have found a high percentage of individuals with underlying medical conditions among the H1N1 related fatalities. In children )] TJ ET
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BT 271.745 368.595 Td /F1 9.8 Tf  [([6])] TJ ET
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BT 282.587 368.595 Td /F1 9.8 Tf  [( \(particularly neurological disorders )] TJ ET
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BT 436.462 368.595 Td /F1 9.8 Tf  [([7])] TJ ET
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BT 447.304 368.595 Td /F1 9.8 Tf  [(\).)] TJ ET
BT 26.250 349.191 Td /F1 9.8 Tf  [(With limited information on H1N1 fatalities stratified by age and underlying conditions, we attempt to assess the relative risks of )] TJ ET
BT 26.250 337.286 Td /F1 9.8 Tf  [(some high risk group for which data is available. Our data sources are )] TJ ET
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BT 363.317 337.286 Td /F1 9.8 Tf  [([10])] TJ ET
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BT 379.580 337.286 Td /F1 9.8 Tf  [( . Also throughout this paper, a relative risk for )] TJ ET
BT 26.250 325.381 Td /F1 9.8 Tf  [(death for a high-risk group is the ratio of the death rate \(per capita\) in this high-risk group over the death rate in the whole )] TJ ET
BT 26.250 313.476 Td /F1 9.8 Tf  [(population.)] TJ ET
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BT 265.798 294.072 Td /F1 9.8 Tf  [( . The proportion of pregnant women among deaths in )] TJ ET
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BT 511.849 294.072 Td /F1 9.8 Tf  [( is 5.1%. Thus )] TJ ET
BT 26.250 282.167 Td /F1 9.8 Tf  [(an estimate of the relative risk for pH1N1 death for pregnant women in the US is 5.1.)] TJ ET
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BT 26.250 250.762 Td /F1 9.8 Tf  [(population[10]. Data in[2]suggest that morbidly obese adults constitute 31.5% of fatal cases. Thus, the relative risk for death for )] TJ ET
BT 26.250 238.857 Td /F1 9.8 Tf  [(morbidly obese adults may be estimated as 8.7.)] TJ ET
BT 26.250 219.453 Td /F1 9.8 Tf  [(Data on the prevalence of immunosuppressing conditions have been assembled by the MIDAS High Risk Segmentation Group )] TJ ET
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BT 26.250 207.548 Td /F1 9.8 Tf  [([9])] TJ ET
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BT 37.092 207.548 Td /F1 9.8 Tf  [( from the 2006 National Health Interview Survey, the CDC HIV/AIDS surveillance 2007 report, the US Renal Data System, )] TJ ET
BT 26.250 195.643 Td /F1 9.8 Tf  [(and the Organ Procurement and Transplantation Network, and kindly provided by Diane Wagener. Immunocompromised adults )] TJ ET
BT 26.250 183.738 Td /F1 9.8 Tf  [(represent 1.9% of the US population )] TJ ET
0.267 0.267 0.267 rg
BT 186.131 183.738 Td /F1 9.8 Tf  [([9])] TJ ET
0.271 0.267 0.267 rg
BT 196.973 183.738 Td /F1 9.8 Tf  [( . They represent 30.5% of all fatalities in )] TJ ET
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BT 375.807 183.738 Td /F1 9.8 Tf  [([2])] TJ ET
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BT 386.649 183.738 Td /F1 9.8 Tf  [( . Immunocompromised adults thus have an )] TJ ET
BT 26.250 171.834 Td /F1 9.8 Tf  [(estimated 16-fold higher risk of death than the general population.)] TJ ET
BT 26.250 152.429 Td /F1 9.8 Tf  [(We have no data on prevalence of individuals with neurological \(neurocognitive and neuromuscular\) disorders, but adults with )] TJ ET
BT 26.250 140.524 Td /F1 9.8 Tf  [(neuromuscular disorders represent 11.9% of all deaths in )] TJ ET
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BT 26.250 128.619 Td /F1 9.8 Tf  [(represent 13.4% of deaths or ICU admissions in )] TJ ET
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BT 26.250 109.215 Td /F1 9.8 Tf  [(Children aged 0.5-4 \(6-59 months\) without underlying conditions make up about 6% of the US population. We have no data on )] TJ ET
BT 26.250 97.310 Td /F1 9.8 Tf  [(their share among the H1N1-related fatalities. Children under 18 make up 13.9% of fatalities in )] TJ ET
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BT 446.777 97.310 Td /F1 9.8 Tf  [( , and 6.8% of fatalities in )] TJ ET
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BT 15.000 675.088 Td /F3 9.8 Tf  [(November 20, 2009)] TJ ET
0.267 0.267 0.267 rg
BT 26.250 663.247 Td /F1 9.8 Tf  [(Edward Goldstein)] TJ ET
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BT 103.197 663.247 Td /F1 9.8 Tf  [(, )] TJ ET
0.267 0.267 0.267 rg
BT 108.618 663.247 Td /F1 9.8 Tf  [(Marc Lipsitch)] TJ ET
0.271 0.267 0.267 rg
BT 26.250 651.342 Td /F1 9.8 Tf  [(Goldstein E, Lipsitch M. H1N1 vaccination and adults with underlying health conditions in the US. PLOS Currents Influenza. )] TJ ET
BT 26.250 639.438 Td /F1 9.8 Tf  [(2009 Nov 20 . Edition 1. doi: 10.1371/currents.RRN1132.)] TJ ET
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0.271 0.267 0.267 rg
BT 26.250 610.335 Td /F4 12.0 Tf  [(Abstract)] TJ ET
BT 26.250 590.381 Td /F1 9.8 Tf  [(65% of fatalities from pH1N1 infections in a large US case series occur in adults with underlying health conditions other than )] TJ ET
BT 26.250 578.476 Td /F1 9.8 Tf  [(pregnancy, but it appears that only relatively few high-risk adults will get vaccinated during the fall wave of pH1N1 transmission. )] TJ ET
BT 26.250 566.571 Td /F1 9.8 Tf  [(There are several reasons for this problem; the most important is vaccine shortage. High risk adults \(other than pregnant )] TJ ET
BT 26.250 554.667 Td /F1 9.8 Tf  [(women\) were not part of the initial, narrow priority cohort which included pregnant women and children ages 0.5-4; this is )] TJ ET
BT 26.250 542.762 Td /F1 9.8 Tf  [(despite the fact that some of those high risk groups, such as adults with immunosuppressive conditions and possibly individuals )] TJ ET
BT 26.250 530.857 Td /F1 9.8 Tf  [(with neurological disorders, have a relative risk for fatality \(per capita\) higher than pregnant women, and over 28-fold higher )] TJ ET
BT 26.250 518.952 Td /F1 9.8 Tf  [(than healthy children under the age of 4. With more vaccine becoming available than needed in the initial priority cohort, a )] TJ ET
BT 26.250 507.048 Td /F1 9.8 Tf  [(broader group which includes high risk adults and individuals under 24 becomes eligible for vaccine in many locations. )] TJ ET
BT 26.250 495.143 Td /F1 9.8 Tf  [(Nonetheless, due to continuing high demand, high-risk adults face competition for vaccine from healthy individuals under 24; )] TJ ET
BT 26.250 483.238 Td /F1 9.8 Tf  [(additionally, some locations specifically prioritize school students over high-risk adults. Finally, there is an issue of awareness )] TJ ET
BT 26.250 471.333 Td /F1 9.8 Tf  [(and a shortage of specific channels that target high risk adults other than pregnant women and facilitate vaccine distribution )] TJ ET
BT 26.250 459.429 Td /F1 9.8 Tf  [(among them in the US.)] TJ ET
BT 26.250 440.024 Td /F1 9.8 Tf  [(A recent CDC estimate suggests that death toll from H1N1 is larger than previously thought )] TJ ET
0.267 0.267 0.267 rg
BT 422.373 440.024 Td /F1 9.8 Tf  [([1])] TJ ET
0.271 0.267 0.267 rg
BT 433.215 440.024 Td /F1 9.8 Tf  [( , approximately 4000 deaths )] TJ ET
BT 26.250 428.119 Td /F1 9.8 Tf  [(from April to October 2009. In a recent case series )] TJ ET
0.267 0.267 0.267 rg
BT 246.805 428.119 Td /F4 9.8 Tf  [([2])] TJ ET
0.271 0.267 0.267 rg
BT 258.719 428.119 Td /F1 9.8 Tf  [( , over 65% of fatalities among hospitalized H1N1 patients were adults )] TJ ET
BT 26.250 416.214 Td /F1 9.8 Tf  [(with underlying health conditions other than pregnancy. A previous study )] TJ ET
0.267 0.267 0.267 rg
BT 342.199 416.214 Td /F1 9.8 Tf  [([3])] TJ ET
0.271 0.267 0.267 rg
BT 353.041 416.214 Td /F1 9.8 Tf  [( , with a higher proportion of children among the )] TJ ET
BT 26.250 404.310 Td /F1 9.8 Tf  [(hospitalized patients than )] TJ ET
0.267 0.267 0.267 rg
BT 138.980 404.310 Td /F1 9.8 Tf  [([2])] TJ ET
0.271 0.267 0.267 rg
BT 149.822 404.310 Td /F1 9.8 Tf  [( , found that 72% of hospitalized adults had an underlying condition other than pregnancy. Among )] TJ ET
BT 26.250 392.405 Td /F1 9.8 Tf  [(individuals who died or were admitted to ICU in the same study, 67% had an underlying health condition. Other studies )] TJ ET
0.267 0.267 0.267 rg
BT 540.533 392.405 Td /F1 9.8 Tf  [([4])] TJ ET
BT 551.375 392.405 Td /F1 9.8 Tf  [([5])] TJ ET
0.271 0.267 0.267 rg
BT 26.250 380.500 Td /F1 9.8 Tf  [(have found a high percentage of individuals with underlying medical conditions among the H1N1 related fatalities. In children )] TJ ET
BT 26.250 368.595 Td /F1 9.8 Tf  [(about 70-80% of fatalities involved underlying conditions )] TJ ET
0.267 0.267 0.267 rg
BT 271.745 368.595 Td /F1 9.8 Tf  [([6])] TJ ET
0.271 0.267 0.267 rg
BT 282.587 368.595 Td /F1 9.8 Tf  [( \(particularly neurological disorders )] TJ ET
0.267 0.267 0.267 rg
BT 436.462 368.595 Td /F1 9.8 Tf  [([7])] TJ ET
0.271 0.267 0.267 rg
BT 447.304 368.595 Td /F1 9.8 Tf  [(\).)] TJ ET
BT 26.250 349.191 Td /F1 9.8 Tf  [(With limited information on H1N1 fatalities stratified by age and underlying conditions, we attempt to assess the relative risks of )] TJ ET
BT 26.250 337.286 Td /F1 9.8 Tf  [(some high risk group for which data is available. Our data sources are )] TJ ET
0.267 0.267 0.267 rg
BT 330.791 337.286 Td /F1 9.8 Tf  [([2])] TJ ET
BT 341.633 337.286 Td /F1 9.8 Tf  [([8])] TJ ET
BT 352.475 337.286 Td /F1 9.8 Tf  [([9])] TJ ET
BT 363.317 337.286 Td /F1 9.8 Tf  [([10])] TJ ET
0.271 0.267 0.267 rg
BT 379.580 337.286 Td /F1 9.8 Tf  [( . Also throughout this paper, a relative risk for )] TJ ET
BT 26.250 325.381 Td /F1 9.8 Tf  [(death for a high-risk group is the ratio of the death rate \(per capita\) in this high-risk group over the death rate in the whole )] TJ ET
BT 26.250 313.476 Td /F1 9.8 Tf  [(population.)] TJ ET
BT 26.250 294.072 Td /F1 9.8 Tf  [(Pregnant women constitute 1% of the US population )] TJ ET
0.267 0.267 0.267 rg
BT 254.956 294.072 Td /F1 9.8 Tf  [([8])] TJ ET
0.271 0.267 0.267 rg
BT 265.798 294.072 Td /F1 9.8 Tf  [( . The proportion of pregnant women among deaths in )] TJ ET
0.267 0.267 0.267 rg
BT 501.007 294.072 Td /F1 9.8 Tf  [([2])] TJ ET
0.271 0.267 0.267 rg
BT 511.849 294.072 Td /F1 9.8 Tf  [( is 5.1%. Thus )] TJ ET
BT 26.250 282.167 Td /F1 9.8 Tf  [(an estimate of the relative risk for pH1N1 death for pregnant women in the US is 5.1.)] TJ ET
BT 26.250 262.686 Td /F1 9.8 Tf  [(Morbidly obese adults \(BMI )] TJ ET
q
9.000 0 0 12.000 147.082 260.286 cm /I6 Do
Q
BT 156.082 262.686 Td /F1 9.8 Tf  [( 40\) constitute 4.8% of the adult US population and correspondingly 3.63% of the of the whole US )] TJ ET
BT 26.250 250.762 Td /F1 9.8 Tf  [(population[10]. Data in[2]suggest that morbidly obese adults constitute 31.5% of fatal cases. Thus, the relative risk for death for )] TJ ET
BT 26.250 238.857 Td /F1 9.8 Tf  [(morbidly obese adults may be estimated as 8.7.)] TJ ET
BT 26.250 219.453 Td /F1 9.8 Tf  [(Data on the prevalence of immunosuppressing conditions have been assembled by the MIDAS High Risk Segmentation Group )] TJ ET
0.267 0.267 0.267 rg
BT 26.250 207.548 Td /F1 9.8 Tf  [([9])] TJ ET
0.271 0.267 0.267 rg
BT 37.092 207.548 Td /F1 9.8 Tf  [( from the 2006 National Health Interview Survey, the CDC HIV/AIDS surveillance 2007 report, the US Renal Data System, )] TJ ET
BT 26.250 195.643 Td /F1 9.8 Tf  [(and the Organ Procurement and Transplantation Network, and kindly provided by Diane Wagener. Immunocompromised adults )] TJ ET
BT 26.250 183.738 Td /F1 9.8 Tf  [(represent 1.9% of the US population )] TJ ET
0.267 0.267 0.267 rg
BT 186.131 183.738 Td /F1 9.8 Tf  [([9])] TJ ET
0.271 0.267 0.267 rg
BT 196.973 183.738 Td /F1 9.8 Tf  [( . They represent 30.5% of all fatalities in )] TJ ET
0.267 0.267 0.267 rg
BT 375.807 183.738 Td /F1 9.8 Tf  [([2])] TJ ET
0.271 0.267 0.267 rg
BT 386.649 183.738 Td /F1 9.8 Tf  [( . Immunocompromised adults thus have an )] TJ ET
BT 26.250 171.834 Td /F1 9.8 Tf  [(estimated 16-fold higher risk of death than the general population.)] TJ ET
BT 26.250 152.429 Td /F1 9.8 Tf  [(We have no data on prevalence of individuals with neurological \(neurocognitive and neuromuscular\) disorders, but adults with )] TJ ET
BT 26.250 140.524 Td /F1 9.8 Tf  [(neuromuscular disorders represent 11.9% of all deaths in )] TJ ET
0.267 0.267 0.267 rg
BT 276.065 140.524 Td /F1 9.8 Tf  [([2])] TJ ET
0.271 0.267 0.267 rg
BT 286.906 140.524 Td /F1 9.8 Tf  [( . People with neurocognitive or neuromuscular disorders each )] TJ ET
BT 26.250 128.619 Td /F1 9.8 Tf  [(represent 13.4% of deaths or ICU admissions in )] TJ ET
0.267 0.267 0.267 rg
BT 235.963 128.619 Td /F1 9.8 Tf  [([3])] TJ ET
0.271 0.267 0.267 rg
BT 246.805 128.619 Td /F1 9.8 Tf  [( .)] TJ ET
BT 26.250 109.215 Td /F1 9.8 Tf  [(Children aged 0.5-4 \(6-59 months\) without underlying conditions make up about 6% of the US population. We have no data on )] TJ ET
BT 26.250 97.310 Td /F1 9.8 Tf  [(their share among the H1N1-related fatalities. Children under 18 make up 13.9% of fatalities in )] TJ ET
0.267 0.267 0.267 rg
BT 435.935 97.310 Td /F1 9.8 Tf  [([1])] TJ ET
0.271 0.267 0.267 rg
BT 446.777 97.310 Td /F1 9.8 Tf  [( , and 6.8% of fatalities in )] TJ ET
0.267 0.267 0.267 rg
BT 558.424 97.310 Td /F1 9.8 Tf  [([2])] TJ ET
0.271 0.267 0.267 rg
BT 569.266 97.310 Td /F1 9.8 Tf  [( . )] TJ ET
BT 26.250 85.405 Td /F1 9.8 Tf  [(The number from )] TJ ET
0.267 0.267 0.267 rg
BT 103.733 85.405 Td /F1 9.8 Tf  [([1])] TJ ET
0.271 0.267 0.267 rg
BT 114.575 85.405 Td /F1 9.8 Tf  [( may be an overestimate as it makes certain assumptions on ascertainment of fatalities in children and )] TJ ET
BT 26.250 73.500 Td /F1 9.8 Tf  [(adults; nonetheless we assume it to estimate children�s share among the fatalities. )] TJ ET
0.267 0.267 0.267 rg
BT 383.909 73.500 Td /F1 9.8 Tf  [([6])] TJ ET
0.271 0.267 0.267 rg
BT 394.751 73.500 Td /F1 9.8 Tf  [( suggests that only 20-30% of fatalities in )] TJ ET
BT 26.250 61.596 Td /F1 9.8 Tf  [(children involve no major underlying conditions; the number in )] TJ ET
0.267 0.267 0.267 rg
BT 296.111 61.596 Td /F1 9.8 Tf  [([2])] TJ ET
0.271 0.267 0.267 rg
BT 306.952 61.596 Td /F1 9.8 Tf  [( is 2/8. We assume that 25% of fatalities in children involve no )] TJ ET
BT 26.250 49.691 Td /F1 9.8 Tf  [(major underlying conditions. Finally we need to know the share of those aged 0.5-4 among the fatalities in healthy children. )] TJ ET
BT 26.250 37.786 Td /F1 9.8 Tf  [(Even if we assume it is 100%, the relative risk for fatality of healthy children aged 0.5-4 \(compared to the whole US population\) )] TJ ET
Q
q
15.000 684.354 577.500 53.646 re W n
0.267 0.267 0.267 rg
BT 15.000 718.042 Td /F2 21.0 Tf  [(H1N1 vaccination and adults with underlying health conditions )] TJ ET
BT 15.000 693.094 Td /F2 21.0 Tf  [(in the US)] TJ ET
Q
0.271 0.267 0.267 rg
BT 15.000 675.088 Td /F3 9.8 Tf  [(November 20, 2009)] TJ ET
0.267 0.267 0.267 rg
BT 26.250 663.247 Td /F1 9.8 Tf  [(Edward Goldstein)] TJ ET
0.271 0.267 0.267 rg
BT 103.197 663.247 Td /F1 9.8 Tf  [(, )] TJ ET
0.267 0.267 0.267 rg
BT 108.618 663.247 Td /F1 9.8 Tf  [(Marc Lipsitch)] TJ ET
0.271 0.267 0.267 rg
BT 26.250 651.342 Td /F1 9.8 Tf  [(Goldstein E, Lipsitch M. H1N1 vaccination and adults with underlying health conditions in the US. PLOS Currents Influenza. )] TJ ET
BT 26.250 639.438 Td /F1 9.8 Tf  [(2009 Nov 20 . Edition 1. doi: 10.1371/currents.RRN1132.)] TJ ET
q
15.000 23.500 577.500 613.556 re W n
0.271 0.267 0.267 rg
BT 26.250 610.335 Td /F4 12.0 Tf  [(Abstract)] TJ ET
BT 26.250 590.381 Td /F1 9.8 Tf  [(65% of fatalities from pH1N1 infections in a large US case series occur in adults with underlying health conditions other than )] TJ ET
BT 26.250 578.476 Td /F1 9.8 Tf  [(pregnancy, but it appears that only relatively few high-risk adults will get vaccinated during the fall wave of pH1N1 transmission. )] TJ ET
BT 26.250 566.571 Td /F1 9.8 Tf  [(There are several reasons for this problem; the most important is vaccine shortage. High risk adults \(other than pregnant )] TJ ET
BT 26.250 554.667 Td /F1 9.8 Tf  [(women\) were not part of the initial, narrow priority cohort which included pregnant women and children ages 0.5-4; this is )] TJ ET
BT 26.250 542.762 Td /F1 9.8 Tf  [(despite the fact that some of those high risk groups, such as adults with immunosuppressive conditions and possibly individuals )] TJ ET
BT 26.250 530.857 Td /F1 9.8 Tf  [(with neurological disorders, have a relative risk for fatality \(per capita\) higher than pregnant women, and over 28-fold higher )] TJ ET
BT 26.250 518.952 Td /F1 9.8 Tf  [(than healthy children under the age of 4. With more vaccine becoming available than needed in the initial priority cohort, a )] TJ ET
BT 26.250 507.048 Td /F1 9.8 Tf  [(broader group which includes high risk adults and individuals under 24 becomes eligible for vaccine in many locations. )] TJ ET
BT 26.250 495.143 Td /F1 9.8 Tf  [(Nonetheless, due to continuing high demand, high-risk adults face competition for vaccine from healthy individuals under 24; )] TJ ET
BT 26.250 483.238 Td /F1 9.8 Tf  [(additionally, some locations specifically prioritize school students over high-risk adults. Finally, there is an issue of awareness )] TJ ET
BT 26.250 471.333 Td /F1 9.8 Tf  [(and a shortage of specific channels that target high risk adults other than pregnant women and facilitate vaccine distribution )] TJ ET
BT 26.250 459.429 Td /F1 9.8 Tf  [(among them in the US.)] TJ ET
BT 26.250 440.024 Td /F1 9.8 Tf  [(A recent CDC estimate suggests that death toll from H1N1 is larger than previously thought )] TJ ET
0.267 0.267 0.267 rg
BT 422.373 440.024 Td /F1 9.8 Tf  [([1])] TJ ET
0.271 0.267 0.267 rg
BT 433.215 440.024 Td /F1 9.8 Tf  [( , approximately 4000 deaths )] TJ ET
BT 26.250 428.119 Td /F1 9.8 Tf  [(from April to October 2009. In a recent case series )] TJ ET
0.267 0.267 0.267 rg
BT 246.805 428.119 Td /F4 9.8 Tf  [([2])] TJ ET
0.271 0.267 0.267 rg
BT 258.719 428.119 Td /F1 9.8 Tf  [( , over 65% of fatalities among hospitalized H1N1 patients were adults )] TJ ET
BT 26.250 416.214 Td /F1 9.8 Tf  [(with underlying health conditions other than pregnancy. A previous study )] TJ ET
0.267 0.267 0.267 rg
BT 342.199 416.214 Td /F1 9.8 Tf  [([3])] TJ ET
0.271 0.267 0.267 rg
BT 353.041 416.214 Td /F1 9.8 Tf  [( , with a higher proportion of children among the )] TJ ET
BT 26.250 404.310 Td /F1 9.8 Tf  [(hospitalized patients than )] TJ ET
0.267 0.267 0.267 rg
BT 138.980 404.310 Td /F1 9.8 Tf  [([2])] TJ ET
0.271 0.267 0.267 rg
BT 149.822 404.310 Td /F1 9.8 Tf  [( , found that 72% of hospitalized adults had an underlying condition other than pregnancy. Among )] TJ ET
BT 26.250 392.405 Td /F1 9.8 Tf  [(individuals who died or were admitted to ICU in the same study, 67% had an underlying health condition. Other studies )] TJ ET
0.267 0.267 0.267 rg
BT 540.533 392.405 Td /F1 9.8 Tf  [([4])] TJ ET
BT 551.375 392.405 Td /F1 9.8 Tf  [([5])] TJ ET
0.271 0.267 0.267 rg
BT 26.250 380.500 Td /F1 9.8 Tf  [(have found a high percentage of individuals with underlying medical conditions among the H1N1 related fatalities. In children )] TJ ET
BT 26.250 368.595 Td /F1 9.8 Tf  [(about 70-80% of fatalities involved underlying conditions )] TJ ET
0.267 0.267 0.267 rg
BT 271.745 368.595 Td /F1 9.8 Tf  [([6])] TJ ET
0.271 0.267 0.267 rg
BT 282.587 368.595 Td /F1 9.8 Tf  [( \(particularly neurological disorders )] TJ ET
0.267 0.267 0.267 rg
BT 436.462 368.595 Td /F1 9.8 Tf  [([7])] TJ ET
0.271 0.267 0.267 rg
BT 447.304 368.595 Td /F1 9.8 Tf  [(\).)] TJ ET
BT 26.250 349.191 Td /F1 9.8 Tf  [(With limited information on H1N1 fatalities stratified by age and underlying conditions, we attempt to assess the relative risks of )] TJ ET
BT 26.250 337.286 Td /F1 9.8 Tf  [(some high risk group for which data is available. Our data sources are )] TJ ET
0.267 0.267 0.267 rg
BT 330.791 337.286 Td /F1 9.8 Tf  [([2])] TJ ET
BT 341.633 337.286 Td /F1 9.8 Tf  [([8])] TJ ET
BT 352.475 337.286 Td /F1 9.8 Tf  [([9])] TJ ET
BT 363.317 337.286 Td /F1 9.8 Tf  [([10])] TJ ET
0.271 0.267 0.267 rg
BT 379.580 337.286 Td /F1 9.8 Tf  [( . Also throughout this paper, a relative risk for )] TJ ET
BT 26.250 325.381 Td /F1 9.8 Tf  [(death for a high-risk group is the ratio of the death rate \(per capita\) in this high-risk group over the death rate in the whole )] TJ ET
BT 26.250 313.476 Td /F1 9.8 Tf  [(population.)] TJ ET
BT 26.250 294.072 Td /F1 9.8 Tf  [(Pregnant women constitute 1% of the US population )] TJ ET
0.267 0.267 0.267 rg
BT 254.956 294.072 Td /F1 9.8 Tf  [([8])] TJ ET
0.271 0.267 0.267 rg
BT 265.798 294.072 Td /F1 9.8 Tf  [( . The proportion of pregnant women among deaths in )] TJ ET
0.267 0.267 0.267 rg
BT 501.007 294.072 Td /F1 9.8 Tf  [([2])] TJ ET
0.271 0.267 0.267 rg
BT 511.849 294.072 Td /F1 9.8 Tf  [( is 5.1%. Thus )] TJ ET
BT 26.250 282.167 Td /F1 9.8 Tf  [(an estimate of the relative risk for pH1N1 death for pregnant women in the US is 5.1.)] TJ ET
BT 26.250 262.686 Td /F1 9.8 Tf  [(Morbidly obese adults \(BMI )] TJ ET
q
9.000 0 0 12.000 147.082 260.286 cm /I8 Do
Q
BT 156.082 262.686 Td /F1 9.8 Tf  [( 40\) constitute 4.8% of the adult US population and correspondingly 3.63% of the of the whole US )] TJ ET
BT 26.250 250.762 Td /F1 9.8 Tf  [(population[10]. Data in[2]suggest that morbidly obese adults constitute 31.5% of fatal cases. Thus, the relative risk for death for )] TJ ET
BT 26.250 238.857 Td /F1 9.8 Tf  [(morbidly obese adults may be estimated as 8.7.)] TJ ET
BT 26.250 219.453 Td /F1 9.8 Tf  [(Data on the prevalence of immunosuppressing conditions have been assembled by the MIDAS High Risk Segmentation Group )] TJ ET
0.267 0.267 0.267 rg
BT 26.250 207.548 Td /F1 9.8 Tf  [([9])] TJ ET
0.271 0.267 0.267 rg
BT 37.092 207.548 Td /F1 9.8 Tf  [( from the 2006 National Health Interview Survey, the CDC HIV/AIDS surveillance 2007 report, the US Renal Data System, )] TJ ET
BT 26.250 195.643 Td /F1 9.8 Tf  [(and the Organ Procurement and Transplantation Network, and kindly provided by Diane Wagener. Immunocompromised adults )] TJ ET
BT 26.250 183.738 Td /F1 9.8 Tf  [(represent 1.9% of the US population )] TJ ET
0.267 0.267 0.267 rg
BT 186.131 183.738 Td /F1 9.8 Tf  [([9])] TJ ET
0.271 0.267 0.267 rg
BT 196.973 183.738 Td /F1 9.8 Tf  [( . They represent 30.5% of all fatalities in )] TJ ET
0.267 0.267 0.267 rg
BT 375.807 183.738 Td /F1 9.8 Tf  [([2])] TJ ET
0.271 0.267 0.267 rg
BT 386.649 183.738 Td /F1 9.8 Tf  [( . Immunocompromised adults thus have an )] TJ ET
BT 26.250 171.834 Td /F1 9.8 Tf  [(estimated 16-fold higher risk of death than the general population.)] TJ ET
BT 26.250 152.429 Td /F1 9.8 Tf  [(We have no data on prevalence of individuals with neurological \(neurocognitive and neuromuscular\) disorders, but adults with )] TJ ET
BT 26.250 140.524 Td /F1 9.8 Tf  [(neuromuscular disorders represent 11.9% of all deaths in )] TJ ET
0.267 0.267 0.267 rg
BT 276.065 140.524 Td /F1 9.8 Tf  [([2])] TJ ET
0.271 0.267 0.267 rg
BT 286.906 140.524 Td /F1 9.8 Tf  [( . People with neurocognitive or neuromuscular disorders each )] TJ ET
BT 26.250 128.619 Td /F1 9.8 Tf  [(represent 13.4% of deaths or ICU admissions in )] TJ ET
0.267 0.267 0.267 rg
BT 235.963 128.619 Td /F1 9.8 Tf  [([3])] TJ ET
0.271 0.267 0.267 rg
BT 246.805 128.619 Td /F1 9.8 Tf  [( .)] TJ ET
BT 26.250 109.215 Td /F1 9.8 Tf  [(Children aged 0.5-4 \(6-59 months\) without underlying conditions make up about 6% of the US population. We have no data on )] TJ ET
BT 26.250 97.310 Td /F1 9.8 Tf  [(their share among the H1N1-related fatalities. Children under 18 make up 13.9% of fatalities in )] TJ ET
0.267 0.267 0.267 rg
BT 435.935 97.310 Td /F1 9.8 Tf  [([1])] TJ ET
0.271 0.267 0.267 rg
BT 446.777 97.310 Td /F1 9.8 Tf  [( , and 6.8% of fatalities in )] TJ ET
0.267 0.267 0.267 rg
BT 558.424 97.310 Td /F1 9.8 Tf  [([2])] TJ ET
0.271 0.267 0.267 rg
BT 569.266 97.310 Td /F1 9.8 Tf  [( . )] TJ ET
BT 26.250 85.405 Td /F1 9.8 Tf  [(The number from )] TJ ET
0.267 0.267 0.267 rg
BT 103.733 85.405 Td /F1 9.8 Tf  [([1])] TJ ET
0.271 0.267 0.267 rg
BT 114.575 85.405 Td /F1 9.8 Tf  [( may be an overestimate as it makes certain assumptions on ascertainment of fatalities in children and )] TJ ET
BT 26.250 73.500 Td /F1 9.8 Tf  [(adults; nonetheless we assume it to estimate children�s share among the fatalities. )] TJ ET
0.267 0.267 0.267 rg
BT 383.909 73.500 Td /F1 9.8 Tf  [([6])] TJ ET
0.271 0.267 0.267 rg
BT 394.751 73.500 Td /F1 9.8 Tf  [( suggests that only 20-30% of fatalities in )] TJ ET
BT 26.250 61.596 Td /F1 9.8 Tf  [(children involve no major underlying conditions; the number in )] TJ ET
0.267 0.267 0.267 rg
BT 296.111 61.596 Td /F1 9.8 Tf  [([2])] TJ ET
0.271 0.267 0.267 rg
BT 306.952 61.596 Td /F1 9.8 Tf  [( is 2/8. We assume that 25% of fatalities in children involve no )] TJ ET
BT 26.250 49.691 Td /F1 9.8 Tf  [(major underlying conditions. Finally we need to know the share of those aged 0.5-4 among the fatalities in healthy children. )] TJ ET
BT 26.250 37.786 Td /F1 9.8 Tf  [(Even if we assume it is 100%, the relative risk for fatality of healthy children aged 0.5-4 \(compared to the whole US population\) )] TJ ET
Q
q
0.000 0.000 0.000 rg
BT 291.710 19.825 Td /F1 11.0 Tf  [(1)] TJ ET
BT 25.000 19.825 Td /F1 11.0 Tf  [(PLOS Currents Influenza)] TJ ET

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BT 26.250 257.303 Td /F4 12.0 Tf  [(References)] TJ ET
BT 26.250 229.848 Td /F1 9.8 Tf  [(1.)] TJ ET
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BT 38.132 198.539 Td /F1 9.8 Tf  [(Janice K. Louie; Meileen Acosta; Kathleen Winter; et al. Factors associated with death or hospitalization due to pandemic )] TJ ET
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BT 38.132 167.229 Td /F1 9.8 Tf  [(Jain S, Kamimoto L, Bramley AM, Schmitz AM, Benoit SR, Louie J, et al. Hospitalized Patients with 2009 H1N1 Influenza in )] TJ ET
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BT 26.250 135.920 Td /F1 9.8 Tf  [(4.)] TJ ET
BT 38.132 135.920 Td /F1 9.8 Tf  [(Ministerio de Salud, Chile. Influenza pandemica \(H1N1\) 2009. REPORTE 21 DE OCTUBRE DE )] TJ ET
BT 26.250 124.015 Td /F1 9.8 Tf  [(http://www.redsalud.gov.cl/minsalaudios/reporte22octubre.pdf)] TJ ET
BT 26.250 104.610 Td /F1 9.8 Tf  [(5.)] TJ ET
BT 38.132 104.610 Td /F1 9.8 Tf  [(Perez-Padilla R, de la Rosa-Zamboni D, Ponce de Leon S, Hernandez M, Quinones-Falconi F, Bautista E, et al. Pneumonia )] TJ ET
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BT 26.250 73.301 Td /F1 9.8 Tf  [(6.)] TJ ET
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BT 26.250 53.896 Td /F1 9.8 Tf  [(7.)] TJ ET
BT 38.132 53.896 Td /F1 9.8 Tf  [(Swine flu poses risks to kids with neurological conditions. Medline Plus, Sep. 3, 2009 )] TJ ET
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BT 426.712 423.548 Td /F1 9.8 Tf  [( . As public health messaging )] TJ ET
BT 26.250 411.643 Td /F1 9.8 Tf  [(expands beyond the initial �Subset of Target Groups,� we urge that special emphasis be placed on adults in documented high-)] TJ ET
BT 26.250 399.738 Td /F1 9.8 Tf  [(risk groups, in an effort to maximize the impact of remaining vaccine delivery on pH1N1 mortality.)] TJ ET
BT 26.250 380.334 Td /F4 9.8 Tf  [(Acknowledgment:)] TJ ET
BT 110.217 380.334 Td /F1 9.8 Tf  [( The MIDAS High Risk Segmentation Group \(D. Wagener, R. Zimmerman, D. Lauderdale\) kindly shared the )] TJ ET
BT 26.250 368.429 Td /F1 9.8 Tf  [(data from )] TJ ET
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BT 70.144 368.429 Td /F1 9.8 Tf  [([9])] TJ ET
0.271 0.267 0.267 rg
BT 80.987 368.429 Td /F1 9.8 Tf  [( .)] TJ ET
BT 26.250 349.024 Td /F4 9.8 Tf  [(Funding Information:)] TJ ET
BT 124.286 349.024 Td /F1 9.8 Tf  [( This work was funded by the US National Institutes of Health Models of Infectious Disease Agent Study )] TJ ET
BT 26.250 337.119 Td /F1 9.8 Tf  [(Cooperative Agreements 5U01GM076497 and 1U54GM088588 to ML for the Harvard Center for Communicable Disease )] TJ ET
BT 26.250 325.215 Td /F1 9.8 Tf  [(Dynamics \(ML,EG\).)] TJ ET
BT 26.250 305.810 Td /F4 9.8 Tf  [(Competing Interests:)] TJ ET
BT 123.760 305.810 Td /F1 9.8 Tf  [( ML has consulted for the Avian/Pandemic Flu Registry \(Outcome Sciences\), funded in part by Roche, )] TJ ET
BT 26.250 293.905 Td /F1 9.8 Tf  [(and for Novartis Vaccines and Diagnostics. EG declares no competing interests.)] TJ ET
BT 26.250 257.303 Td /F4 12.0 Tf  [(References)] TJ ET
BT 26.250 229.848 Td /F1 9.8 Tf  [(1.)] TJ ET
BT 38.132 229.848 Td /F1 9.8 Tf  [(CDC Estimates of 2009 H1N1 Influenza Cases, Hospitalizations and Deaths in the United States, April � October 17, 2009 )] TJ ET
BT 26.250 217.944 Td /F1 9.8 Tf  [(http://www.cdc.gov/h1n1flu/estimates_2009_h1n1.htm)] TJ ET
BT 26.250 198.539 Td /F1 9.8 Tf  [(2.)] TJ ET
BT 38.132 198.539 Td /F1 9.8 Tf  [(Janice K. Louie; Meileen Acosta; Kathleen Winter; et al. Factors associated with death or hospitalization due to pandemic )] TJ ET
BT 26.250 186.634 Td /F1 9.8 Tf  [(2009 influenza A\(H1N1\) infection in California. JAMA. 2009;302\(17\):1896-1902 http://doi:10.1001/jama.2009.1583)] TJ ET
BT 26.250 167.229 Td /F1 9.8 Tf  [(3.)] TJ ET
BT 38.132 167.229 Td /F1 9.8 Tf  [(Jain S, Kamimoto L, Bramley AM, Schmitz AM, Benoit SR, Louie J, et al. Hospitalized Patients with 2009 H1N1 Influenza in )] TJ ET
BT 26.250 155.325 Td /F1 9.8 Tf  [(the United States, April-June 2009. N Engl J Med 2009 Oct 8. http://content.nejm.org/cgi/content/full/NEJMoa0906695)] TJ ET
BT 26.250 135.920 Td /F1 9.8 Tf  [(4.)] TJ ET
BT 38.132 135.920 Td /F1 9.8 Tf  [(Ministerio de Salud, Chile. Influenza pandemica \(H1N1\) 2009. REPORTE 21 DE OCTUBRE DE )] TJ ET
BT 26.250 124.015 Td /F1 9.8 Tf  [(http://www.redsalud.gov.cl/minsalaudios/reporte22octubre.pdf)] TJ ET
BT 26.250 104.610 Td /F1 9.8 Tf  [(5.)] TJ ET
BT 38.132 104.610 Td /F1 9.8 Tf  [(Perez-Padilla R, de la Rosa-Zamboni D, Ponce de Leon S, Hernandez M, Quinones-Falconi F, Bautista E, et al. Pneumonia )] TJ ET
BT 26.250 92.706 Td /F1 9.8 Tf  [(and respiratory failure from swine-origin influenza A \(H1N1\) in Mexico. N Engl J Med2009 Aug 13;361\(7\):680-9.)] TJ ET
BT 26.250 73.301 Td /F1 9.8 Tf  [(6.)] TJ ET
BT 38.132 73.301 Td /F1 9.8 Tf  [(H1N1 leading to increased flu rates, more pediatric deaths http://www.rwjf.org/publichealth/digest.jsp?id=23828)] TJ ET
BT 26.250 53.896 Td /F1 9.8 Tf  [(7.)] TJ ET
BT 38.132 53.896 Td /F1 9.8 Tf  [(Swine flu poses risks to kids with neurological conditions. Medline Plus, Sep. 3, 2009 )] TJ ET
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BT 26.250 767.476 Td /F1 9.8 Tf  [(is estimated as at most 0.58 \(25% x 13.9%/6%\); the estimated risk for adults with immunosuppressive conditions is 28 times )] TJ ET
BT 26.250 755.571 Td /F1 9.8 Tf  [(that of healthy children aged 0.5-4. If we assume that at most half of all fatalities in healthy children occur in those aged 0.5-4, )] TJ ET
BT 26.250 743.667 Td /F1 9.8 Tf  [(the relative risk for adults with immunosuppressive conditions compared to healthy children aged 0.5-4 becomes 56.)] TJ ET
BT 26.250 724.262 Td /F1 9.8 Tf  [(We want to point out that unlike the case of fatalities, children have the highest rates for H1N1-related hospitalizations \()] TJ ET
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BT 26.250 712.357 Td /F1 9.8 Tf  [(http://www.cdc.gov/vaccines/recs/acip/downloads/mtg-slides-oct09/12-2-flu-vac.pdf)] TJ ET
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BT 384.416 712.357 Td /F1 9.8 Tf  [(\); moreover among children, the percentage )] TJ ET
BT 26.250 700.452 Td /F1 9.8 Tf  [(of those not having major underlying conditions is higher for hospitalizations than for fatalities )] TJ ET
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BT 429.978 700.452 Td /F1 9.8 Tf  [([2])] TJ ET
BT 440.820 700.452 Td /F1 9.8 Tf  [([3])] TJ ET
BT 451.662 700.452 Td /F1 9.8 Tf  [([6])] TJ ET
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BT 462.504 700.452 Td /F1 9.8 Tf  [( . The high percentage of )] TJ ET
BT 26.250 688.548 Td /F1 9.8 Tf  [(children among the hospitalizations, together with the perception that among all groups in the general population, children merit )] TJ ET
BT 26.250 676.643 Td /F1 9.8 Tf  [(the most protection \(http://www.flu.gov/individualfamily/vaccination/allocationguidance.pdf\) were some of the reasons behind the )] TJ ET
BT 26.250 664.738 Td /F1 9.8 Tf  [(high prioritization that healthy children received in the US.)] TJ ET
BT 26.250 645.333 Td /F4 9.8 Tf  [(Vaccine distribution to high-risk adults:)] TJ ET
BT 209.911 645.333 Td /F1 9.8 Tf  [( Despite high relative risks for certain groups of adults with underlying health )] TJ ET
BT 26.250 633.429 Td /F1 9.8 Tf  [(conditions, it appears that only a few of them will get immunized in time to be protected against the fall wave of H1N1 infections )] TJ ET
BT 26.250 621.524 Td /F1 9.8 Tf  [(in the US. With demand for vaccines exceeding supply, a number of jurisdictions, at least initially, have restricted vaccine )] TJ ET
BT 26.250 609.619 Td /F1 9.8 Tf  [(distribution to a priority cohort that does not include high risk adults )] TJ ET
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BT 317.258 609.619 Td /F1 9.8 Tf  [([11])] TJ ET
BT 333.521 609.619 Td /F1 9.8 Tf  [([12])] TJ ET
BT 349.784 609.619 Td /F1 9.8 Tf  [([13])] TJ ET
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BT 366.047 609.619 Td /F1 9.8 Tf  [( . The ACIP�s )] TJ ET
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BT 426.195 609.619 Td /F1 9.8 Tf  [(recommended)] TJ ET
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BT 488.507 609.619 Td /F1 9.8 Tf  [( �Subset of Target )] TJ ET
BT 26.250 597.714 Td /F1 9.8 Tf  [(Groups During Limited Vaccine Availability� includes pregnant women, caregivers for infants less than 6 months, health care )] TJ ET
BT 26.250 585.810 Td /F1 9.8 Tf  [(workers at direct infection risk, children 6 months to 4 years, and high-risk children 5-18, but not high-risk adults. While we )] TJ ET
BT 26.250 573.905 Td /F1 9.8 Tf  [(disagree with the choice to exclude high-risk adults from this �Subset of Target Groups,� we do not advocate changing it at this )] TJ ET
BT 26.250 562.000 Td /F1 9.8 Tf  [(time. However, many jurisdictions are beginning to expand vaccination beyond this Subset, and more will do so as vaccine )] TJ ET
BT 26.250 550.095 Td /F1 9.8 Tf  [(supplies grow. In some locations, this expansion involves prioritizing school-age children over high-risk adults )] TJ ET
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BT 499.837 550.095 Td /F1 9.8 Tf  [([14])] TJ ET
BT 516.100 550.095 Td /F1 9.8 Tf  [([15])] TJ ET
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BT 532.363 550.095 Td /F1 9.8 Tf  [( a choice )] TJ ET
BT 26.250 538.191 Td /F1 9.8 Tf  [(that does not maximize the use of the vaccine to prevent fatal outcomes. Evidently a more common strategy is to offer vaccine )] TJ ET
BT 26.250 526.286 Td /F1 9.8 Tf  [(to a broader group that includes high risk adults and all individuals under 24 )] TJ ET
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BT 355.205 526.286 Td /F1 9.8 Tf  [([16])] TJ ET
BT 371.468 526.286 Td /F1 9.8 Tf  [([17])] TJ ET
BT 387.731 526.286 Td /F1 9.8 Tf  [([18])] TJ ET
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BT 403.994 526.286 Td /F1 9.8 Tf  [( . Inevitably, this creates competition for )] TJ ET
BT 26.250 514.381 Td /F1 9.8 Tf  [(still-limited vaccine )] TJ ET
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BT 110.217 514.381 Td /F1 9.8 Tf  [([19])] TJ ET
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BT 126.480 514.381 Td /F1 9.8 Tf  [( .)] TJ ET
BT 26.250 494.976 Td /F1 9.8 Tf  [(One possible way to resolve the discrepancy above is creation of a channel which will specifically target high-risk adults, )] TJ ET
BT 26.250 483.072 Td /F1 9.8 Tf  [(increasing both their awareness and vaccination levels. For instance in the UK, GPs contact their priority patients and offer them )] TJ ET
BT 26.250 471.167 Td /F1 9.8 Tf  [(vaccine )] TJ ET
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BT 62.013 471.167 Td /F1 9.8 Tf  [([20])] TJ ET
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BT 78.276 471.167 Td /F1 9.8 Tf  [( ; also in the UK, people with underlying conditions are prioritized over children under 5 )] TJ ET
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BT 454.899 471.167 Td /F1 9.8 Tf  [([21])] TJ ET
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BT 471.162 471.167 Td /F1 9.8 Tf  [( . A similar strategy of )] TJ ET
BT 26.250 459.262 Td /F1 9.8 Tf  [(health care providers focusing on patients with underlying conditions is being pursued in Oregon )] TJ ET
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BT 443.531 459.262 Td /F1 9.8 Tf  [([22])] TJ ET
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BT 459.793 459.262 Td /F1 9.8 Tf  [( . An alternative suggestion )] TJ ET
BT 26.250 447.357 Td /F1 9.8 Tf  [(is to offer vaccines specifically for high risk individuals, perhaps opening clinics in large adult ambulatory care practices or in )] TJ ET
BT 26.250 435.453 Td /F1 9.8 Tf  [(other settings where high-risk adults are likely to be present. Such clinics might limit their offerings to individuals with high risk )] TJ ET
BT 26.250 423.548 Td /F1 9.8 Tf  [(conditions, similar to campaigns in schools that are limited to school-age children )] TJ ET
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BT 377.923 423.548 Td /F1 9.8 Tf  [([23])] TJ ET
BT 394.186 423.548 Td /F1 9.8 Tf  [([14])] TJ ET
BT 410.449 423.548 Td /F1 9.8 Tf  [([24])] TJ ET
0.271 0.267 0.267 rg
BT 426.712 423.548 Td /F1 9.8 Tf  [( . As public health messaging )] TJ ET
BT 26.250 411.643 Td /F1 9.8 Tf  [(expands beyond the initial �Subset of Target Groups,� we urge that special emphasis be placed on adults in documented high-)] TJ ET
BT 26.250 399.738 Td /F1 9.8 Tf  [(risk groups, in an effort to maximize the impact of remaining vaccine delivery on pH1N1 mortality.)] TJ ET
BT 26.250 380.334 Td /F4 9.8 Tf  [(Acknowledgment:)] TJ ET
BT 110.217 380.334 Td /F1 9.8 Tf  [( The MIDAS High Risk Segmentation Group \(D. Wagener, R. Zimmerman, D. Lauderdale\) kindly shared the )] TJ ET
BT 26.250 368.429 Td /F1 9.8 Tf  [(data from )] TJ ET
0.267 0.267 0.267 rg
BT 70.144 368.429 Td /F1 9.8 Tf  [([9])] TJ ET
0.271 0.267 0.267 rg
BT 80.987 368.429 Td /F1 9.8 Tf  [( .)] TJ ET
BT 26.250 349.024 Td /F4 9.8 Tf  [(Funding Information:)] TJ ET
BT 124.286 349.024 Td /F1 9.8 Tf  [( This work was funded by the US National Institutes of Health Models of Infectious Disease Agent Study )] TJ ET
BT 26.250 337.119 Td /F1 9.8 Tf  [(Cooperative Agreements 5U01GM076497 and 1U54GM088588 to ML for the Harvard Center for Communicable Disease )] TJ ET
BT 26.250 325.215 Td /F1 9.8 Tf  [(Dynamics \(ML,EG\).)] TJ ET
BT 26.250 305.810 Td /F4 9.8 Tf  [(Competing Interests:)] TJ ET
BT 123.760 305.810 Td /F1 9.8 Tf  [( ML has consulted for the Avian/Pandemic Flu Registry \(Outcome Sciences\), funded in part by Roche, )] TJ ET
BT 26.250 293.905 Td /F1 9.8 Tf  [(and for Novartis Vaccines and Diagnostics. EG declares no competing interests.)] TJ ET
BT 26.250 257.303 Td /F4 12.0 Tf  [(References)] TJ ET
BT 26.250 229.848 Td /F1 9.8 Tf  [(1.)] TJ ET
BT 38.132 229.848 Td /F1 9.8 Tf  [(CDC Estimates of 2009 H1N1 Influenza Cases, Hospitalizations and Deaths in the United States, April � October 17, 2009 )] TJ ET
BT 26.250 217.944 Td /F1 9.8 Tf  [(http://www.cdc.gov/h1n1flu/estimates_2009_h1n1.htm)] TJ ET
BT 26.250 198.539 Td /F1 9.8 Tf  [(2.)] TJ ET
BT 38.132 198.539 Td /F1 9.8 Tf  [(Janice K. Louie; Meileen Acosta; Kathleen Winter; et al. Factors associated with death or hospitalization due to pandemic )] TJ ET
BT 26.250 186.634 Td /F1 9.8 Tf  [(2009 influenza A\(H1N1\) infection in California. JAMA. 2009;302\(17\):1896-1902 http://doi:10.1001/jama.2009.1583)] TJ ET
BT 26.250 167.229 Td /F1 9.8 Tf  [(3.)] TJ ET
BT 38.132 167.229 Td /F1 9.8 Tf  [(Jain S, Kamimoto L, Bramley AM, Schmitz AM, Benoit SR, Louie J, et al. Hospitalized Patients with 2009 H1N1 Influenza in )] TJ ET
BT 26.250 155.325 Td /F1 9.8 Tf  [(the United States, April-June 2009. N Engl J Med 2009 Oct 8. http://content.nejm.org/cgi/content/full/NEJMoa0906695)] TJ ET
BT 26.250 135.920 Td /F1 9.8 Tf  [(4.)] TJ ET
BT 38.132 135.920 Td /F1 9.8 Tf  [(Ministerio de Salud, Chile. Influenza pandemica \(H1N1\) 2009. REPORTE 21 DE OCTUBRE DE )] TJ ET
BT 26.250 124.015 Td /F1 9.8 Tf  [(http://www.redsalud.gov.cl/minsalaudios/reporte22octubre.pdf)] TJ ET
BT 26.250 104.610 Td /F1 9.8 Tf  [(5.)] TJ ET
BT 38.132 104.610 Td /F1 9.8 Tf  [(Perez-Padilla R, de la Rosa-Zamboni D, Ponce de Leon S, Hernandez M, Quinones-Falconi F, Bautista E, et al. Pneumonia )] TJ ET
BT 26.250 92.706 Td /F1 9.8 Tf  [(and respiratory failure from swine-origin influenza A \(H1N1\) in Mexico. N Engl J Med2009 Aug 13;361\(7\):680-9.)] TJ ET
BT 26.250 73.301 Td /F1 9.8 Tf  [(6.)] TJ ET
BT 38.132 73.301 Td /F1 9.8 Tf  [(H1N1 leading to increased flu rates, more pediatric deaths http://www.rwjf.org/publichealth/digest.jsp?id=23828)] TJ ET
BT 26.250 53.896 Td /F1 9.8 Tf  [(7.)] TJ ET
BT 38.132 53.896 Td /F1 9.8 Tf  [(Swine flu poses risks to kids with neurological conditions. Medline Plus, Sep. 3, 2009 )] TJ ET
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BT 291.710 19.825 Td /F1 11.0 Tf  [(2)] TJ ET
BT 25.000 19.825 Td /F1 11.0 Tf  [(PLOS Currents Influenza)] TJ ET

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BT 26.250 564.619 Td /F1 9.8 Tf  [(15.)] TJ ET
BT 43.553 564.619 Td /F1 9.8 Tf  [(Central Ohio vaccination http://www2.nbc4i.com/cmh/news/local/article/central_ohios_h1n1_vaccine_clinics/25276/)] TJ ET
BT 26.250 545.214 Td /F1 9.8 Tf  [(16.)] TJ ET
BT 43.553 545.214 Td /F1 9.8 Tf  [(Wyoming vaccination http://www.thetimes-tribune.com/news/health_and_science/clinics_set_for_h1n1_shots)] TJ ET
BT 26.250 525.810 Td /F1 9.8 Tf  [(17.)] TJ ET
BT 43.553 525.810 Td /F1 9.8 Tf  [(Alabama vaccination http://www2.oanow.com/oan/news/local/article/h1n1_vaccination_clinic_set_for_tuesday/109199/)] TJ ET
BT 26.250 506.405 Td /F1 9.8 Tf  [(18.)] TJ ET
BT 43.553 506.405 Td /F1 9.8 Tf  [(Arizona vaccination http://www.yumasun.com/news/yuma-54207-county-clinic.html)] TJ ET
BT 26.250 487.000 Td /F1 9.8 Tf  [(19.)] TJ ET
BT 43.553 487.000 Td /F1 9.8 Tf  [(New York long lines http://gothamist.com/2009/11/14/long_lines_for_swine_flu_vaccine_at.php)] TJ ET
BT 26.250 467.595 Td /F1 9.8 Tf  [(20.)] TJ ET
BT 43.553 467.595 Td /F1 9.8 Tf  [(The Scottish Government. Influenza H1N1 � who will be vaccinated. )] TJ ET
BT 26.250 455.691 Td /F1 9.8 Tf  [(http://www.scotland.gov.uk/Topics/Health/health/AvianInfluenza/mexicanswiuneflu/mexicanswinefluQandA/vaccination/who)] TJ ET
BT 26.250 436.286 Td /F1 9.8 Tf  [(21.)] TJ ET
BT 43.553 436.286 Td /F1 9.8 Tf  [(HPA, November 19, 2009. Extension of the swine flu vaccination programme. )] TJ ET
BT 26.250 424.381 Td /F1 9.8 Tf  [(http://www.dh.gov.uk/en/Publichealth/Flu/Swineflu/InformationandGuidance/Vaccinationprogramme/DH_108850)] TJ ET
BT 26.250 404.976 Td /F1 9.8 Tf  [(22.)] TJ ET
BT 43.553 404.976 Td /F1 9.8 Tf  [(Oregon vaccination http://www.mailtribune.com/apps/pbcs.dll/article?AID=/20091114/NEWS/911140310)] TJ ET
BT 26.250 385.572 Td /F1 9.8 Tf  [(23.)] TJ ET
BT 43.553 385.572 Td /F1 9.8 Tf  [(South Carolina vaccination http://www.heraldonline.com/front/story/1744749.html)] TJ ET
BT 26.250 366.167 Td /F1 9.8 Tf  [(24.)] TJ ET
BT 43.553 366.167 Td /F1 9.8 Tf  [(NY schools vaccination http://www.wcax.com/Global/story.asp?S=11508539)] TJ ET
Q
q
0.000 0.000 0.000 rg
BT 291.710 19.825 Td /F1 11.0 Tf  [(3)] TJ ET
BT 25.000 19.825 Td /F1 11.0 Tf  [(PLOS Currents Influenza)] TJ ET

Q
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109405
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