Issue 1414: March 6, 2019
TOP STORIES
VACCINE INFORMATION STATEMENTS
WORLD NEWS
FEATURED RESOURCES
JOURNAL ARTICLES AND NEWSLETTERS
EDUCATION AND TRAINING
TOP STORIES
CDC requests healthcare providers' help in containing measles outbreaks; 159 measles cases from 10 states reported
On February 27, CDC's National Center for Immunization and Respiratory Diseases sent the following email to partners, with a request to share widely.
From January 1 to February 21, 2019, 159* people from 10 states (CA, CO, CT, GA, IL, KY, NY, OR, TX, and WA) have been reported as having measles. Six outbreaks (defined as 3 or more linked cases) have been reported, in Rockland County, New York; Monroe County, New York; New York City; Washington; Texas; and Illinois. Of these outbreaks, 2 outbreaks are ongoing from 2018.
CDC is asking for your help to ensure that all patients are up to date on MMR vaccine. When it comes to vaccinations, parents trust the expertise of their doctor more than anyone else. Explain to patients that MMR vaccine is the best protection against measles infection.
Here’s what you can do:
1. Send an e-mail blast to your members.
CDC drafted the following message that you can share with healthcare professionals in your network:
From January 1 to February 21, 2019, 159* people from 10 states (CA, CO, CT, GA, IL, NJ, NY, OR, TX, and WA) have been reported as having measles. Six outbreaks (defined as 3 or more linked cases) have been reported, in Rockland County, New York; Monroe County, New York; New York City; Washington; Texas; and Illinois. Of these outbreaks, 2 outbreaks are ongoing from 2018. CDC urges healthcare professionals to ensure that all patients are up to date on MMR vaccine, including before international travel.
What Should Clinicians Do?
- Discuss the importance of MMR vaccine with parents. Listen and respond to parents’ questions. When parents have questions, it does not necessarily mean they won’t accept vaccines. Sometimes, they simply want your answers to their questions.
- Ensure all patients are up to date on measles, mumps, rubella (MMR) vaccine.
- Children need 2 doses of MMR: one dose at 12–15 months and another dose at 4–6 years.
- Before any international travel, infants 6–11 months need 1 dose of MMR vaccine, children 12 months and older need 2 doses separated by at least 28 days, and teenagers and adults who do not have evidence of immunity against measles need 2 doses separated by at least 28 days.
- Consider measles in patients presenting with febrile rash illness and clinically compatible measles symptoms (cough, coryza, and conjunctivitis), and ask patients about recent travel internationally or to domestic venues frequented by international travelers, as well as a history of measles exposures in their communities.
- Promptly isolate patients with suspected measles to avoid disease transmission and immediately report the suspect measles case to the health department.
- Obtain specimens for testing from patients with suspected measles, including viral specimens for genotyping, which can help determine the source of the virus. Contact the local health department with questions about submitting specimens for testing.
For more information, including guidelines for patient evaluation, diagnosis and management, visit www.cdc.gov/measles/hcp/index.html.
2. Post measles buttons, banners, and links to CDC communication resources for healthcare professionals.
By posting measles buttons and banners on your website or blog, you will remind clinicians to consider measles diagnoses. They link to CDC’s measles webpage for healthcare professionals. Get these web tools here: www.cdc.gov/measles/resources/web-buttons.html.
You can also post a link to CDC’s Provider Resources for Vaccine Conversations with Parents, which aim to strengthen communication between healthcare professionals and parents. Specific resources to highlight include:
3. Share information about measles with parents and the public in your office.
4. Learn more about measles and encourage your members to do the same.
Below is information about measles that you can promote to other healthcare professionals:
*Preliminary data reported to CDC’s National Center for Immunization and Respiratory Diseases.
Thank you for your assistance!
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CDC's Travelers' Health Update publishes information for clinicians and the public about measles prevention during international travel
The February issue of CDC's Travelers' Health Update includes an article titled Measles Outbreaks Continue. The article is reprinted below in its entirety.
Measles is a concern for several popular travel destinations. Countries with current measles travel notices include: England, Italy, France, Greece, Romania, Moldova, Serbia, Ukraine, Israel, Kazakhstan, Columbia, Brazil, Congo, Madagascar, Indonesia, the Philippines, and Japan.
What can you do? Everyone 6 months and older needs the measles vaccine before international travel. Make sure your patients are up to date on the MMR vaccine and on other routine shots, including the yearly flu shot. Use our Vaccine Quick Guide, a two-page guide with commonly recommended travel vaccines and medications.
Have a patient that is traveling? If your patient says they are going to Brazil, what should you recommend? Our destination tool has clinical recommendations and advice for every country.
Have a sick patient? Consider measles if they have a fever, rash, and cough, coryza and conjunctivitis—the three “C”s. Ask your patient if they are vaccinated against measles and whether they have recently traveled internationally or if there’s measles in the community use our Yellow Book- Infectious Diseases Related to Travel: Measles.
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CDC publishes report on measles outbreak in era of stricter immunization requirements in California
CDC published Notes from the Field: Measles Outbreak in an Era of Stricter Immunization Requirements—California, March 2018 in the March 1 issue of MMWR. The concluding paragraph is reprinted below.
MMR vaccine is recommended for all persons born in the United States since 1957 who do not have a contraindication for the vaccine. In this outbreak, the six unvaccinated patients with measles all had parents who had chosen not to vaccinate them during childhood. Since California Senate Bill 277 (SB277) went into effect in 2016, children entering school in California may no longer receive exemptions from immunization requirements based on parental personal beliefs. However, medical exemptions for reasons determined by individual physicians, including family medical history, rather than a uniform standard (i.e., a medical contraindication to vaccination), remain permitted. Interviews with local health authorities suggest that some students without contraindications to vaccination have received medical exemptions. Patients F and G received identical broad medical exemptions to all vaccines from a physician located several hundred miles away from the patients’ residence. Patients E and G represent the first documented cases of measles in California infected by a child with a medical exemption since SB277 became law; had SCCPHD received accurate information about patient F’s immunization status, these two illnesses might have been prevented, and the expenditure of resources to investigate their contacts might have been avoided. Prompt public health action and continued maintenance of a high level of population immunity to measles likely averted a larger outbreak.
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Influenza remains widespread; CDC reports 15 additional pediatric deaths from influenza in the U.S.
Influenza activity remains elevated in the United States. Influenza A(H1N1)pdm09, influenza A(H3N2), and influenza B viruses continue to co-circulate. CDC has reported 15 additional pediatric deaths from influenza this season, for a total of 56. Last season, there was a record-setting number of pediatric deaths in the U.S. (185), so be sure to protect all your patients for whom vaccination is recommended.
CDC estimates that there have been 252,000–302,000 hospitalizations and 16,400–26,700 deaths related to influenza from October 1, 2018, through February 23, 2019.
CDC stated in its Weekly U.S. Influenza Surveillance Report, FluView, that during the week ending February 23, the geographic spread of influenza in Puerto Rico and 49 states was reported as widespread; the District of Columbia and one state reported local activity; the U.S. Virgin Islands reported sporadic activity; and Guam did not report.
Influenza vaccination is recommended for everyone six months of age and older. If you don't provide influenza vaccination in your clinic, please recommend vaccination to your patients and refer them to a clinic or pharmacy that provides vaccines or to the HealthMap Vaccine Finder to locate sites near their workplaces or homes that offer influenza vaccination services.
Following is a list of resources related to influenza disease and vaccination for healthcare professionals and the public:
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IAC provides a summary article about votes taken at February 26–27 ACIP meeting
The Advisory Committee on Immunization Practices (ACIP) met in Atlanta on February 26–27. During the meeting, several topics were discussed for informational purposes only. Specifically, the committee reviewed seasonal influenza surveillance and interim vaccine effectiveness data; the potential of expanding the age recommendation for human papillomavirus (HPV) vaccine; and possible future VFC program approval for the use of Vaxelis (Sanofi-Merck), a new pediatric hexavalent (DTaP/IPV/HepB/Hib) vaccine. The group also examined data on the impact of pneumococcal conjugate vaccine (PCV13) among adults ≥65 years; evidence related to the need for a potential booster dose of meningococcal B (MenB) vaccine; zoster vaccine uptake, supply, and safety; and data on the use of hepatitis A vaccine in persons with HIV infection.
In addition to reviewing these informational topics, ACIP voted on recommendations for the use of Japanese encephalitis and anthrax vaccines.
Japanese Encephalitis (JE) Vaccine – The committee reviewed newly available safety, immunogenicity, and traveler risk data to develop updated JE vaccine recommendations for U.S. travelers. The new recommendations incorporate minor changes to the current JE vaccine recommendations, including providing additional information on factors that increase JE risk to assist providers with decision-making, revising the terminology for longer-term travel, removing consideration of vaccination for travelers to an area with an ongoing JE outbreak, and applying small wording changes to address questions (e.g., changing “expatriates” to “persons moving to a JE-endemic country to take up residence.) Ixiaro (Valneva Austria GMBH) is the only JE vaccine licensed and available in the U.S.
The recommendations were approved through three separate votes (shown below), all of which passed unanimously.
Vote 1: Japanese Encephalitis Vaccine Recommendations
- JE vaccine is recommended for persons moving to a JE-endemic country to take up residence, longer-term (e.g., >1 month) travelers to JE-endemic areas, and frequent travelers to JE-endemic areas.
- JE vaccine also should be considered for shorter-term (e.g., <1 month) travelers with an increased risk of JE based on planned travel duration, season, locations, activities, and accommodations. Vaccination also should be considered for travelers to endemic areas who are uncertain of specific duration of travel, destinations, or activities.
- JE vaccine is not recommended for travelers with very low-risk itineraries, such as shorter-term travel limited to urban areas or travel that occurs outside of a well-defined JE virus transmission season.
Vote 2: New JE Vaccine Recommendation for Primary Series Schedule in Adults Age 18–65 Years
- In adults aged 18–65 years, the primary vaccination schedule is two doses administered on days 0 and 7–28.
Vote 3: New Recommendation for JE Vaccine Booster Dose
- For adults and children, a booster dose (i.e., third dose) should be given at >1 year after completion of the primary JE vaccine series if ongoing exposure or re-exposure to JE virus is expected.
Anthrax Vaccine – The U.S. government stockpiles medical countermeasures, including anthrax vaccine (AVA, anthrax vaccine adsorbed). CDC provides guidance on vaccine use and other aspects of preparedness should there be a wide-area release of Bacillus anthracis spores. During the meeting, ACIP received information on use of the “next generation” anthrax vaccine, AV7909 (anthrax vaccine adsorbed with CPG7909 adjuvant), for post-exposure prophylaxis (PEP). The group also unanimously approved a change to the pre-exposure prophylaxis (PrEP) recommendation for persons who are not at current high risk of exposure to anthrax.
Vote: Anthrax Vaccine
- A booster dose of AVA may be given every 3 years to persons not currently at high risk of exposure to B. anthracis who have been previously primed with AVA and wish to maintain protection.
All recommendations approved by ACIP are provisional until they are approved by the CDC director and published in MMWR. Presentation slides from the February meeting should be posted on the ACIP website in the next 4–6 weeks.
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IAC Spotlight! IAC creates separate web page for its print materials related to vaccine contraindications and precautions
Last month, IAC reorganized its Handouts web section to make it easier to locate its free, CDC-reviewed, ready-to-print educational materials. The following new categories were added to its list of topics: Adolescent Vaccination, Contraindications and Precautions, Healthcare Personnel, Pregnancy and Vaccines, Strategies and Policies for Healthcare Settings, and Vaccine Hesitancy.
This week's Spotlight article will highlight the resources found in the Contraindications and Precautions section. Check out some of the free IAC print materials included in this section. You'll also find that a number of these pieces intended for parents and patients are also available in other languages. To access all IAC print materials related to contraindications and precautions, visit www.immunize.org/handouts/contraindications.asp.
All of IAC’s handouts are ready to print, copy, and distribute widely. Technical accuracy has been confirmed by immunization experts at the Centers for Disease Control and Prevention.
As always, you can find over 250 IAC-created educational materials in the Handouts section of immunize.org, indexed by topic, vaccine, and language.
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Ask the Experts Q&A web page titled Vaccine Administration recently updated
IAC and CDC recently reviewed and revised its Ask the Experts: Administering Vaccines web page. Revisions include updated references and website links and addition of content regarding administration of recombinant zoster vaccine (Shingrix, GSK).
IAC’s Ask the Experts web section is a compilation of common as well as challenging questions and answers (Q&As) about vaccines and their administration. William Atkinson, MD, MPH, IAC's associate director for immunization education, manages this web section, with answers provided by Andrew T. Kroger, MD, MPH; Mark S. Freedman, DVM, MPH, DACVPM; Tina S. Objio, MSN, MHA, RN; Candice L. Robinson, MD, MPH; Raymond A. Strikas, MD, MPH, FACP, FIDSA; and JoEllen Wolicki, BSN, RN, all from the National Center for Immunization and Respiratory Diseases, CDC.
Some of the most frequently visited sections of Ask the Experts Q&As include the following:
IAC Express publishes five special editions each year of Ask the Experts Q&As answered by CDC experts. You can access the four most recent IAC Express Ask the Experts sets of Q&As from the main web page of Ask the Experts, in the right-hand column.
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Pinterest, YouTube, and Amazon make changes to counter vaccine misinformation
Two popular social media platforms, as well as the e-commerce site Amazon, recently made changes to counter vaccine misinformation.
1) Pinterest, a popular site with new parents, has taken the step of blocking search results if certain vaccine-related terms are used.
New York Times: Pinterest Restricts Vaccine Search Results to Curb Spread of Misinformation (2/23/19)
2) YouTube has adopted a policy of "demonetizing" sites that promote anti-vaccine misinformation by not allowing them to run ads.
BuzzFeed News: YouTube Just Demonetized Anti-Vax Channels (2/22/19)
3) Amazon has removed anti-vaccination movies and other videos from search results and its catalog of videos included with its Prime service.
BuzzFeed News: Amazon Removed Anti-Vax Documentaries From Prime Video
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VACCINE INFORMATION STATEMENTS
New or updated Bengali, Haitian Creole, Italian, Polish, Urdu, and Yiddish translations of the DTaP and MenACWY VISs now available
IAC recently posted Bengali, Haitian Creole, Italian, Polish, Urdu, and Yiddish translations of the DTaP and MenACWY VISs. IAC thanks the New York City Department of Health and Mental Hygiene for their donation of all of these VIS translations.
DTaP VIS
Access all DTaP VIS translations, as well as the English-language version.
MenACWY VIS
Access all MenACWY VIS translations, as well as the English-language version.
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IAC posts Simplified Chinese, Traditional Chinese, and Korean translations of the rotavirus VIS
IAC recently posted updated Simplified Chinese, Traditional Chinese, and Korean translations of the rotavirus VIS. The changes in the VIS were minimal—just the version date and a link at the bottom of page 1, section 2. These translations were made possible through a cooperative agreement between IAC and CDC.
Access all rotavirus VIS translations, as well as the English-language version.
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IAC posts Indonesian-language version of the hepatitis B VIS
IAC recently posted an updated Indonesian-language version of the hepatitis B VIS. IAC thanks the Wentworth-Douglass Hospital, of Dover, New Hampshire for their donation of this translation.
Access all hepatitis B VIS translations, as well as the English-language version.
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WORLD NEWS
CDC and WHO report on progress toward hepatitis B control, including perinatal transmission, in the Western Pacific Region
CDC published Progress toward Hepatitis B Control and Elimination of Mother-to-Child Transmission of Hepatitis B Virus—Western Pacific Region, 2005–2017 in the March 1 issue of MMWR. On the same day, WHO's Weekly Epidemiological Record published a similar article titled Progress towards Control of Hepatitis B and Elimination of Mother-to-Child Transmission of Hepatitis B Virus—Western Pacific Region, 2005–2017. A media summary of the MMWR article is reprinted below.
Hepatitis B (HepB), a vaccine preventable disease, is a major cause of liver cancer. After all countries/areas in the Western Pacific Region (WPR) introduced the HepB vaccine into childhood immunization schedules, childhood infections dropped from a high of more than 8 percent in 1990 to less than 1 percent by 2017. These remarkable immunization achievements prevented more than 37 million chronic infections and 7 million HepB-related deaths. Further HepB control includes improving HepB birth-dose coverage through increased health facility births, antenatal training, and outside-the-cold-chain use. In addition to maintaining high vaccine coverage, additional interventions like routine antenatal testing, administration of hepatitis B immunoglobulin to exposed newborns, and antiviral treatment of mothers would be needed to achieve elimination of mother-to-child transmission of HepB by 2030.
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CDC updates its job aids that help providers properly catch up children who are behind schedule with PCV13, Hib, DTaP, and Tdap
In 2018, CDC developed several new job aids to help providers figure out exactly what is needed for children who are behind schedule with PCV13, Hib, DTaP, and/or Tdap vaccines. CDC has now updated these resources to match the 2019 immunization recommendations.
Although this information is available in the annual U.S. Catch-Up Immunization Schedule for Persons Aged 4 Months Through 18 Years Who Start Late or Who Are More Than 1 Month Behind, the format of these resources makes it easier to determine what is needed (number of doses and timing) in a particular situation. For example, the first page of the revised 2-page Tdap piece is shown below to illustrate the easy-to-follow format.
Explore these revised resources by clicking on the following links:
All these job aids can be accessed from CDC's Vaccine Catch-Up Guidance web section.
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Reminder: "65+ Flu Defense" website features information and resources for healthcare professionals serving adults age 65 and older
In 2018, IAC and Seqirus launched its 65+ Flu Defense website at www.influenza-defense.org to help with vaccinating adults 65 years of age and older.
The website equips healthcare professionals with information, tools, and resources needed to proactively discuss flu vaccination with patients age 65 and older and to better communicate the impact of flu and its complications in older adults.
Annual influenza vaccination is the best way to prevent influenza, but vaccination coverage among older adults in the U.S. has stagnated, and in some years has declined significantly over the previous season’s rate.
Seniors are at greater risk of severe complications from influenza, due both to their increased likelihood of having chronic conditions and to the decline of their immune systems as they age.
As a healthcare professional, your strong, confident recommendation for flu vaccine is a very powerful and persuasive tool in determining if your patients are vaccinated.
"65+ Flu Defense" is divided into several easy-to-use topic areas, including:
Two new patient handouts are also available on the website:
 
Be sure to check out the information and printable materials for your patients available on the 65+ Flu Defense website at www.influenza-defense.org and boost your efforts aimed at protecting this vulnerable population.
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IAC's 142-page book, Vaccinating Adults: A Step-by-Step Guide, describes how to implement adult vaccination services in your healthcare setting and provides a review for staff who already vaccinate adults; IAC Guide available for free download
In late 2017, the Immunization Action Coalition (IAC) announced the publication of its new book, Vaccinating Adults: A Step-by-Step Guide (Guide).
This completely updated guide on adult immunization (originally published in 2004) provides easy-to-use, practical information covering important “how-to” activities to help providers enhance their existing adult immunization services or introduce them into any clinical setting, including:
- setting up for vaccination services,
- storing and handling vaccines,
- deciding which people should receive which vaccines,
- administering vaccines,
- documenting vaccinations (including legal issues), and
- understanding financial considerations and billing information.
- In addition, the Guide is filled with hundreds of web addresses and references to help providers stay up to date on the latest immunization information, both now and in the future.
The entire Guide is available to download/print free of charge at www.immunize.org/guide. The downloaded version is suitable for double-sided printing. Options are available online to download the entire book or selected chapters. The development of the Guide was supported by the National Vaccine Program Office (NVPO) and the Centers for Disease Control and Prevention (CDC). Expert staff from both agencies also provided early technical review of the content.
The Guide is a uniquely valuable resource to assist providers in increasing adult immunization rates. Be sure to get a copy today!
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JOURNAL ARTICLES AND NEWSLETTERS
February issue of CDC's Immunization Works newsletter now available
CDC recently released the February issue of its monthly newsletter Immunization Works. The newsletter offers the immunization community information about current topics. The information is in the public domain and can be reproduced and circulated widely.
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Vaccine Education Center at Children's Hospital of Philadelphia publishes February issue of its newsletter Vaccine Update for Healthcare Professionals
The Vaccine Education Center (VEC) at Children's Hospital of Philadelphia publishes a monthly immunization-focused newsletter titled Vaccine Update for Healthcare Professionals. The February issue includes the following articles:
The newsletter also includes discussion of whether the current measles outbreaks will result in changes to exemption laws, an interview Dr. Offit did with a vaccine activist, and links to VEC's measles and influenza resources.
Access all this information and more in the full newsletter.
Access the sign-up form to subscribe to Vaccine Update for Healthcare Professionals.
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Clinical Infectious Diseases publishes article titled "Principal Controversies in Vaccine Safety in the United States"
On February 12, Clinical Infectious Diseases published Principal Controversies in Vaccine Safety in the United States online. This is a summary article authored by Frank DeStefano, MD, MPH; Heather Monk Bodenstab, PharmD; and Paul Offit, MD. The abstract is reprinted below.
Concerns about vaccine safety can lead to decreased acceptance of vaccines and resurgence of vaccine-preventable diseases. We summarize the key evidence on some of the main current vaccine safety controversies in the United States, including: 1) MMR vaccine and autism; 2) thimerosal, a mercury-based vaccine preservative, and the risk of neurodevelopmental disorders; 3) vaccine-induced Guillain-Barré Syndrome (GBS); 4) vaccine-induced autoimmune diseases; 5) safety of HPV vaccine; 6) aluminum adjuvant-induced autoimmune diseases and other disorders; and 7) too many vaccines given early in life predisposing children to health and developmental problems. A possible small increased risk of GBS following influenza vaccination has been identified, but the magnitude of the increase is less than the risk of GBS following influenza infection. Otherwise, the biological and epidemiologic evidence does not support any of the reviewed vaccine safety concerns.
Access the complete article in pre-publication format by clicking on the PDF link from this page: Principal Controversies in Vaccine Safety in the United States.
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EDUCATION AND TRAINING
CDC to offer March 13 webinar about the changes in the 2019 child/teen and adult immunization schedules
CDC will offer a 1-hour Current Issues in Immunization NetConference webinar about the 2019 immunization schedules on March 13 at noon (ET).
Topics and Speakers
- 2019 Child/Adolescent Immunization Schedule: Candice Robinson, MD, MPH, Communications and Education Branch, Immunization Services Division, National Center for Immunization and Respiratory Diseases (NCIRD), CDC
- 2019 Adult Immunization Schedule: David Kim, MD, MPH, Deputy Associate Director for Adult Immunization, Immunization Services Division, CDC
Andrew Kroger, MD, MPH, Medical Officer, NCIRD, CDC will moderate the session.
Attendance for each live webinar is limited to 1,500 registrants. CDC advises registrants to log in early before a webinar begins to secure a virtual “seat.” Should you miss the live event, you can watch the archived version when it is posted later on CDC’s website.
Registration information
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National Infant Immunization Week scheduled for April 27–May 4; CDC to offer related planning webinar on March 12
This year marks the 25th anniversary of National Infant Immunization Week (NIIW). From April 27–May 4, 2019, NIIW will highlight the importance of protecting infants from vaccine-preventable diseases and will celebrate the achievements of immunization programs in promoting healthy communities throughout the United States.
Join CDC for an NIIW planning webinar on March 12 at 1:00 p.m. (ET). During the webinar, participants will learn about NIIW planning tools, digital communication resources, engaging partners, and how to get involved with CDC activities planned for the week. Immunize Nevada will also share lessons learned from their experience building community partnerships to support infant immunization during NIIW and throughout the year.
Registration information
Click on the graphic below for more information about National Infant Immunization Week.
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Vaccine Education Center plans Current Issues in Vaccines webinar on April 3
The Vaccine Education Center (VEC) at Children's Hospital of Philadelphia, together with the Pennsylvania chapter of the American Academy of Pediatrics, will present a one-hour webinar, beginning at 12:00 p.m. (ET) on April 3. Part of its Current Issues in Vaccines series, the webinar will feature Paul Offit, MD, director of VEC. Dr. Offit's topics for this webinar will be:
- Influenza vaccines: Surveillance update
- Zoster vaccines: Shingrix availability
- HPV vaccines: Most recent uptake data
Free continuing education credits (CME, CEU, and CPE) will be available for both the live and archived events.
Registration (required) is open now.
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NACCHO and Hep B United to offer 3-part webinar series on local strategies to eliminate hepatitis B; first session scheduled for March 20
Recent data indicate that there has been an increase in the rate of new hepatitis B infections in the U.S., which many largely attribute to increasing injection drug use. To address this, Hep B United and the National Association of County and City Health Officials (NACCHO) will present a 3-part webinar series on local strategies to eliminate hepatitis B virus (HBV) infections.
Join one or more of these sessions to learn about the current state of HBV in the U.S. and local health department efforts and model programs to increase HBV testing, vaccination, and access to care. The webinars will cover:
Click on any of the links above for more information about a session. Registration is only open for the March 20 webinar at this time.
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