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EDMONTON - This past week has felt like a prize fight to Ryan Smyth.
Smyth's proposed trade to Edmonton from Los Angeles had been rumoured for days, but hit several snags before the two sides eventually came to an agreement Sunday that saw the Oilers send the Kings forward Colin Fraser and a seventh-round draft choice in the 2012 NHL entry draft.
"It was tough and it was exhausting," Smyth said on a conference call. "It was almost like going through a boxing match, 12 rounds, and in the end finding out that you're appreciated in regards to being an Oiler again.
"It was a pretty emotional ride but in the end I really believe this is where God wanted us to be. So we're really excited."
Smyth and his family had been thinking about the possibility of moving for six weeks.
"My wife and I discussed for a little while that we wanted to come back to Canada for personal reasons. That's where home is for us," Smyth said. "The kids are starting out in school. We just felt it would be best for us to come back."
Smyth asked Kings general manager Dean Lombardi for the trade but didn't anticipate the circus that would surround it.
"My wife and I discussed it just after the end of the season and we really felt it would be best if we could orchestrate it, talk with Dean about it," he said.
"I didn't want everything to explode to the level that it did. I thoroughly enjoyed every moment down there. It was just a different lifestyle for my wife and I and my family to live in. I hope nothing but the best for the organization of the Kings and the fans."
Smyth had 23 goals and 24 assists in 82 games last season with Los Angeles. He started his NHL career with the Oilers in 1994-'95 when Edmonton drafted him sixth overall in the 1994 draft. He spent over a decade with the team before being dealt to the New York Islanders in a surprise deadline deal in February 2007.
The six-foot-two, 192-pounder is 12th on Edmonton's all-time scoring list with 549 points (265 goals, 284 assists.)
Fraser is due to make $825,000 next season after finishing last season with three goals, two assists and 60 penalty minutes in 67 games with the Oilers last season.
"I still have a lot to offer," Smyth said. "I felt great last year. I felt like I was a little kid again. I stayed healthy, which was the number one thing. I just want to bring my leadership and wherever Tom (Renney) and the coaching staff want me to play I'll play."
Smyth joins an Oilers team that is going in a different direction to the one he left in 2007.
"When we left it was the year (after) we went to the cup. We lost Prongs (Chris Pronger) and then it just started to filter on after that," he said. "I see a huge upside. Obviously with the new draftees, Taylor Hall. Really exciting. (Jordan) Eberle. I just see a huge tremendous upside."
Smyth, who has played on the Canadian Olympic team twice and has represented Canada at the World Championships seven times, will bring his own brand of leadership to the young Oilers.
"What I've experienced along the way in my journey is a tremendous amount," Smyth said.
"I've been fortunate and blessed to play on the Olympics a couple times around, the world championships, a run to the Stanley Cup. I've been around the Lemieuxs, the Gretzkys, the Yzermans. I've hung around those type of players and seen what they bring on a consistent basis.
"It's all about how you come to the rink and how you execute as a hockey player. Just how you compete. Sometimes it's not what you say, it's how you act. Just going out and playing and being yourself."
Oilers general manager Steve Tambellini said part of the reason the team acquired Smyth was to help Edmonton's younger players in their development.
"You need people that are respectful of these young players," Tambellini said. "You need people that are encouraging as far as their development. You need people that want to share in their success. There's extreme passion there in Ryan Smyth."
While the 35-year-old is approaching the end of his career, thoughts of retirement are "way farfetched."
"I've got many years left in me," Smyth said. "I know that I'm older but I still got lots left in me. I feel like I've played some of my best hockey within the last few years. I felt excellent just this past season.
"Being around some young guys is going to push me and make me better. And hopefully I can bring some experience, some leadership and just enjoy."
Smyth is heading into the last year of his contract where he will cost the Oilers US$4.5 million.
"I got this last year and hopefully the organization can see that I would like to extend my deal and go from there," Smyth said. "But I'm just thrilled to be an Oiler."
Smyth admitted he thought about joining the Oilers' fierce provincial rivals, the Calgary Flames, but the pull of the Oilers was too strong.
"There was a couple of teams in the mix," he said. "(The Flames) were one of them for sure. The fact that they were willing and excited I thank them for that. But obviously it would have been really tough emotionally with the Edmonton blood that's in me."


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The ramblings & obsessions of a fisherman's wife! ~ a potpourri of history, genealogy and books. Also some general ramblings if they take my fancy!
Sunday, 10 November 2013
Remembrance Day Photo Collage - Day Seven
It is the War Memorial at Elstead in Surrey, about 2 miles from Puttenham where the majority of my Great Grandmother's family hailed from.
My Great Great Grandmother was called Caroline Ellis. Born in Puttenham in 1844 the daughter of George and Prudence Budd.
My Grandfather's cousin always maintained the Elstead got it's name from the multiple Ellis families in the area, Ellis-Stead. How much of that is true I don't know, except there were multiple Ellis families and unravelling them is a genealogist nightmare. The same names keep appearing; so I have three George and Sarah Ellis' giving birth to children, with the same names around the same time. Nightmare to research!
The Ellis' on this memorial are in fact cousins of Caroline Ellis. I do have photographs of those named, but have elected to share them a little later on a project I have planned for 2014. However, this memorial is in fact incomplete. There was at least one more Ellis that gave his life and he is not named on the memorial.
I became aware of Amos Ellis a few weeks ago when I received an email from someone. I had up until this point not been aware of Amos, because he was not a direct ancestor. I felt so sad that someone can contribute so much and yet simply slip through the cracks.
So today, as I post late on Sunday and we roll across into Armistice Day it seems fitting to mention Amos and be aware that there are instances like this across the Country. Do we not owe it to these men and their descendants to put the matter right?
Posted by Julie Goucher at 11:02 pm
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subset: commoncrawl


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Clifton and Glendale Communities
The first large mill in the district was constructed about 50 years after the Revolutionary War. The man at the center of the development was Dr. James Bivings, who came to the area from Lincolnton, North Carolina, about 1832. The mill contained 1,200 spindles and 24 looms, and its power was produced by an overshot waterwheel of "26 foot diameter and 12 foot breast." The community took the name Bivingsville.
Records indicate that the mill was sold for $19,500 in bankruptcy proceedings in 1856. A group that included Dexter Edgar Converse bought the mill. Converse was chosen as manager of the mill. After the Civil War, Converse became the principal owner of the property. In 1880, apparently at the urging of Converse's wife, Helen, the name of the village was changed from Bivingsville to Glendale.
In the 1880s, D.E. Converse & Company bought property on the
Pacolet River and expanded beyond the mill at Glendale. In 1881, the first mill of Clifton
Manufacturing Company was opened. In
1889, Clifton Mill No. 2 began operation about three-fourths of a mile below
No. 1.
The shoals on Lawson Fork Creek above the Glendale Mill.
Photographs by Kacie C.
Postcards from The
Postcard History, Spartanburg, South Carolina
by Jeffrey R. Willis
Information from
Glendale, A Pictorial History
by Michael Hembree and Paul Crocker


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The Bonobo and the Atheist: In Search of Humanism among the Primates
Frans de Waal
W. W. Norton, 2013 ($27.95)
Chimpanzees are said to be about as clever as toddlers, but who is the more superstitious ape? In one study that set out to investigate this question, young chimps observed a researcher using a stick to retrieve candy from a clear plastic box, employing both effective and ineffective motions. The chimps quickly discerned the candy-releasing moves and proceeded to repeat only those. Four-year-old children who watched the same demonstration, however, imitated the entire routine, including the unnecessary moves. The children seemed to put their trust in the experimenter and thus invest some magical significance or "blind faith" in actions of no practical value—perhaps a symptom of the human predisposition for superstition, de Waal posits.
The ease with which our brain suspends reality—call it irrationality, imagination or faith—has been crucial to the development of religion in human culture, according to de Waal, a respected primatologist and avowed atheist. He has a scientist's curiosity about religion. Unlike prominent neo-atheists of our time, he has no interest in disproving God's existence or proving that religion poisons everything. Instead, in this richly observed and intelligent book, de Waal ponders our natural receptiveness to religion, how religion evolved and what if anything might take its place.
De Waal's dispute with religion is its self-assigned monopoly on morality. The greatest enforcer of good behavior isn't the wrath of an omniscient deity or any dogmatic ethical framework, the Emory University primatologist says, but our emotions. De Waal offers vivid examples of emotionally guided moral behavior in animals: elephants recruiting friends to help pull a heavy box, chimps refusing undeserved rewards and bonobos comforting losers after a fight. Empathy and reciprocity, the basis of prosocial behavior, appear to have deeper evolutionary roots than religion.
If morality comes from emotions and religion from superstitions, what explains their entanglement? De Waal suggests that as communities grew larger and more impersonal, religion gained influence as a supervisor of moral behavior. But he believes secular humanism could serve a similar role and do so by appealing to human potential rather than defaming human nature.
Along the same lines, de Waal rejects Darwinian fundamentalism, which supposes that all our actions, whether ostensibly naughty or nice, are dictated by selfish genes. We can extrapolate only so much about human nature from genes and social insects that lack the neural circuitry necessary for empathy.
De Waal's view of human nature is optimistic but not naive. The good news is that if we didn't already lean in an ethical direction, moral rules "would be like seeds dropped onto a glass plate." The bad news is that both our innate empathy and the religions we create have strong in-group biases. In an ever more globalized society, humanity's greatest moral innovation—to make prosocial sentiments universal and impartial—will demand more than clashing faiths or biology.


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I was so pleased to see so many lovely Designer me-made Copies entered this year! 22 sewists posted on their blogs, 35 on their Instagram accounts, and of those 18 posted on both to increase their chances! I thank you all for planning and sewing and joining in, and thank you to those who followed along and voted! A special thank you to our PRIZE SPONSORS! Didn't we have fun! 🎉🕺💃🎊
Everyone had the chance for two entries if they followed my blog and my Instagram. The IG "likes' were easy to see, but the blog votes were hidden from everyone. I only just looked myself tonight! If someone won on both my blog and my Instagram, I gave them the win where they had more votes and then was able to add on another winner – one prize per sewist!
Our PRIZE SPONSORS generously donated ten prizes, which were chosen blindly and randomly, from:
Well you have had plenty of time to look over the Designer Originals and Designer me-made Copies so let's just get right to it!
So who did you think was most successful in making a COPY of their DESIGNER ORIGINAL?
With the most votes on my Instagram, the answer is:
@suestoney wins one $25 Gift Certificate from the Vintage Pattern Lending Library
@lisascarolina wins one ePattern from Sense & Sensibility Patterns
@thimble.pleasures wins one Pattern from the Itch to Stitch Shop
@sewing_in_spain wins one $25 Gift Certificate from the Vintage Pattern Lending Library
@sewordinary wins a Sewing Grab Bag from "Nice dress! Thanks, I made it!!"
With the most votes on my blog, the answer is:
Emma and her Machine wins one pattern from Paprika Patterns
Seam Racer wins a box set of 10 Art Cards from Joannas Art and Cards
Mema wins one $25 Gift Certificate from the Vintage Pattern Lending Library
Paisley Pirouette wins one PDF pattern from Skinny Bitch Curvy Chick Patterns
Corecouture wins one PDF pattern from Named Patterns
Congratulations to all of you, you are the DESIGNIN' DECEMBER 2017 WINNERS! Please send me an email ( imadeit362436 [at] gmail [dot] com ) within 7 days and we will discuss how to claim your prize.
HOLD ON! You didn't make the entry deadline? Let me know when you have chosen your DESIGNER ORIGINAL and your DESIGNER me-made COPY is completed (anytime during 2018!), link back to me here, hashtag it #DESIGNINDECEMBER on Twitter, Facebook and/or Instagram and I will share it on my blog during the DESIGNIN' DECEMBER 2018 CHALLENGE!
If any new Challengers would like all the details of DESIGNIN' DECEMBER you will always be able to find the most up to date news by clicking on the DESIGNIN' DECEMBER ICON in my menu, or join the DESIGNER FASHION and DESIGNIN' DECEMBER Pinterest boards, or join the DESIGNIN' DECEMBER Facebook Group!
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Persons using assistive technology might not be able to fully access information in this file. For assistance, please send e-mail to: email@example.com. Type 508 Accommodation and the title of the report in the subject line of e-mail.
A Comprehensive Immunization Strategy to Eliminate Transmission of Hepatitis B Virus Infection in the United States
Recommendations of the Advisory Committee on Immunization Practices (ACIP) Part II: Immunization of Adults
Please note: An erratum has been published for this article. To view the erratum, please click here.
Prepared by
The material in this report originated in the National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (proposed), Kevin A. Fenton, MD, PhD, Director; the Division of Viral Hepatitis, John W. Ward, MD, Director; the Division of STD Prevention, John M. Douglas, Jr., MD, Director; and the Division of HIV/AIDS Prevention, Robert S. Janssen, MD, Director; the National Center for Immunization and Respiratory Diseases, Anne Schuchat, MD, Director; and the Immunization Services Division, Lance E. Rodewald, MD, Director.
Corresponding preparer: Eric E. Mast, MD, Division of Viral Hepatitis, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (proposed), 1600 Clifton Road, NE, MS G-37, Atlanta, GA 30333. Telephone: 404-718-8500; Fax: 404-718-8595; E-mail: firstname.lastname@example.com.
Hepatitis B vaccination is the most effective measure to prevent hepatitis B virus (HBV) infection and its consequences, including cirrhosis of the liver, liver cancer, liver failure, and death. In adults, ongoing HBV transmission occurs primarily among unvaccinated persons with behavioral risks for HBV transmission (e.g., heterosexuals with multiple sex partners, injection-drug users [IDUs], and men who have sex with men [MSM]) and among household contacts and sex partners of persons with chronic HBV infection.
This report, the second of a two-part statement from the Advisory Committee on Immunization Practices (ACIP), provides updated recommendations to increase hepatitis B vaccination of adults at risk for HBV infection. The first part of the ACIP statement, which provided recommendations for immunization of infants, children, and adolescents, was published previously (CDC. A comprehensive immunization strategy to eliminate transmission of hepatitis B virus infection in the United States: recommendations of the Advisory Committee on Immunization Practices [ACIP]. Part 1: immunization of infants, children, and adolescents. MMWR 2005;54[No. RR-16]:1--33).
In settings in which a high proportion of adults have risks for HBV infection (e.g., sexually transmitted disease/human immunodeficiency virus testing and treatment facilities, drug-abuse treatment and prevention settings, health-care settings targeting services to IDUs, health-care settings targeting services to MSM, and correctional facilities), ACIP recommends universal hepatitis B vaccination for all unvaccinated adults. In other primary care and specialty medical settings in which adults at risk for HBV infection receive care, health-care providers should inform all patients about the health benefits of vaccination, including risks for HBV infection and persons for whom vaccination is recommended, and vaccinate adults who report risks for HBV infection and any adults requesting protection from HBV infection. To promote vaccination in all settings, health-care providers should implement standing orders to identify adults recommended for hepatitis B vaccination and administer vaccination as part of routine clinical services, not require acknowledgment of an HBV infection risk factor for adults to receive vaccine, and use available reimbursement mechanisms to remove financial barriers to hepatitis B vaccination.
Hepatitis B is a disease caused by the hepatitis B virus (HBV), which is transmitted through percutaneous (i.e., puncture through the skin) or mucosal (i.e., direct contact with mucous membranes) exposure to infectious blood or body fluids. HBV can cause chronic infection, resulting in cirrhosis of the liver, liver cancer, liver failure, and death. Persons with chronic infection also serve as the main reservoir for continued HBV transmission. Although chronic infection is more likely to develop in persons infected as infants or young children, rates of new infection and acute disease are highest among adults.
Hepatitis B vaccination is the most effective measure to prevent HBV infection and its consequences. Since recommendations for hepatitis B vaccination were first issued in 1982, a comprehensive strategy to eliminate HBV transmission in the United States has evolved (1--5). This strategy includes 1) universal vaccination of infants beginning at birth, 2) prevention of perinatal HBV infection through routine screening of all pregnant women for hepatitis B surface antigen (HBsAg) and postexposure immunoprophylaxis of infants born to HBsAg-positive women or to women with unknown HBsAg status, 3) vaccination of all children and adolescents who were not vaccinated previously, and 4) vaccination of previously unvaccinated adults at risk for HBV infection (Box 1).
To date, immunization strategies for infants, children, and adolescents have been implemented with considerable success. Recent estimates indicate that approximately 95% of pregnant women are tested for HBsAg and that case management has been effective in ensuring high levels of initiation and completion of postexposure immunoprophylaxis among infants born to HBsAg-positive women (6). Hepatitis B vaccine has been integrated successfully into the childhood vaccination schedule, and infant vaccination coverage levels now are equivalent to those of other vaccines in the childhood schedule (7). Vaccination coverage among adolescents also has increased substantially; preliminary data from 2003 indicated that approximately 50%--60% of adolescents aged 13--15 years have records indicating vaccination (with 3 doses) against hepatitis B (8). During 1990--2005, incidence of acute hepatitis B in the United States declined 78%. The greatest decline (96%) occurred among children and adolescents, coincident with an increase in hepatitis B vaccination coverage. This success can be attributed in part to the established infrastructure for vaccine delivery to children and to federal support for perinatal hepatitis B prevention programs.
Among adults, ongoing HBV transmission occurs primarily among unvaccinated adults with risk behaviors for HBV transmission (e.g., heterosexuals with multiple sex partners, injection-drug users [IDUs], and men who have sex with men [MSM]) and among household contacts and sex partners of persons with chronic HBV infection. During 2000--2004, self-reported hepatitis B vaccination coverage among adults at risk for HBV infection increased from 30% to 45% (9); this increase in vaccination coverage likely contributed to the 35% decline in acute hepatitis B incidence that occurred during this period (from 3.7 to 2.4 per 100,000 population). However, incidence of acute hepatitis B remains highest among adults, who accounted for approximately 95% of an estimated 51,000 new HBV infections in 2005. Although acceptance of vaccination is high among adults offered vaccination (10), the low adult vaccination coverage reflects the lack of hepatitis B vaccination services in settings in which a high proportion of adults have risk factors for HBV infection (e.g., sexually transmitted disease [STD]/human immunodeficiency virus [HIV] testing and treatment facilities, drug-abuse treatment and prevention settings, health-care settings targeting services to IDUs, health-care settings targeting services to MSM, and correctional facilities) and missed opportunities to vaccinate adults at risk for HBV infection in primary care and specialty medical settings. Although hepatitis B incidence among adults is expected to continue to decline during the next decade as successive cohorts of persons vaccinated in infancy, childhood, and adolescence reach adulthood, new implementation strategies are needed to protect unvaccinated adults at risk for HBV infection.
This report provides updated guidance from the Advisory Committee on Immunization Practices (ACIP) to increase hepatitis B vaccination coverage among adults. It includes recommendations regarding which adults should receive hepatitis B vaccine and outlines implementation strategies to ensure that those adults are vaccinated. The first part of this statement, which provided recommendations for immunization of infants, children, and adolescents, was published previously (11).
In response to continuing low rates of hepatitis B vaccination among adults at risk for HBV infection, ACIP's Hepatitis Vaccines Work Group met multiple times during October 2004--September 2005 to review previous guidelines and make recommendations for improving vaccination coverage in adults. The work group examined the progress made since 1991 in implementing the U.S. strategy to eliminate HBV transmission (e.g., vaccination coverage data and hepatitis B disease rates), surveillance data on missed opportunities for hepatitis B vaccination among adults with acute hepatitis B, and results of cost-effectiveness analyses. In addition, demonstration projects conducted in settings in which a high proportion of clients were at risk for HBV infection identified the components of successful adult hepatitis B vaccination programs and ongoing challenges to implementing adult hepatitis B vaccination.
In January 2005, the proposed recommendations were posted online for public comment. In May 2005, CDC convened a meeting of external consultants, including researchers, physicians, state and local public health professionals, immunization program directors, and directors of viral hepatitis, STD, and HIV/AIDS prevention programs, to obtain input into the draft recommendations and consider the feasibility of the recommended strategies. In October 2005, the revised recommendations were approved by ACIP.
Major Updates to the Recommendations
This report updates ACIP recommendations published previously for hepatitis B vaccination of adults (3). The primary changes from previous recommendations are as follows:
Clinical Features and Natural History of HBV Infection
HBV is a 42-nm DNA virus classified in the Hepadnaviridae family. The liver is the primary site of HBV replication. After a susceptible person is exposed, the virus enters the liver via the bloodstream; no evidence exists indicating that the virus replicates at mucosal surfaces. HBV infection can produce either asymptomatic or symptomatic infection. The average incubation period is 90 days (range: 60--150 days) from exposure to onset of jaundice and 60 days (range: 40--90 days) from exposure to onset of abnormal serum alanine aminotransferase (ALT) levels (12,13).
The onset of acute disease typically is insidious. Infants, children aged <5 years, and immunosuppressed adults with newly acquired HBV infection typically are asymptomatic, whereas 30%--50% of children aged >5 years and adults have initial clinical signs or symptoms (14). When present, clinical symptoms and signs can include anorexia, malaise, nausea, vomiting, abdominal pain, and jaundice. Extrahepatic manifestations of disease (e.g., skin rashes, arthralgias, and arthritis) also can occur (15). The fatality rate among persons with reported cases of acute hepatitis B is 0.5%--1.0%, with the highest rates in adults aged >60 years; however, because a substantial number of infections are asymptomatic and therefore are not reported, the overall fatality rate among all persons with HBV infection likely is lower (16).
Approximately 95% of primary infections in adults with normal immune status are self-limited, with elimination of virus from blood and subsequent lasting immunity to reinfection. Chronic infection occurs in <5% of infected persons aged >5 years, approximately 30% of infected children aged <5 years, and approximately 90% of infected infants, with continuing viral replication in the liver and persistent viremia (14,17--19). Primary infections become chronic more frequently in immunosuppressed persons (e.g., hemodialysis patients and persons with HIV infection) (19,20) and persons with diabetes (21). Overall, approximately 25% of persons who become chronically infected during childhood and 15% of those who become chronically infected after childhood die prematurely from cirrhosis or liver cancer; the majority remain asymptomatic until onset of cirrhosis or end-stage liver disease (22).
No specific treatment exists for acute hepatitis B; supportive care is the mainstay of therapy. Persons who have chronic HBV infection require medical evaluation and regular monitoring (23--25). Therapeutic agents approved by the Food and Drug Administration (FDA) for treatment of chronic hepatitis B can achieve sustained suppression of HBV replication and remission of liver disease in certain persons (24). Periodic screening with ultrasonography and alfa-fetoprotein has been demonstrated to enhance early detection of hepatocellular carcinoma (HCC) (25). Certain chronically infected persons with HCC have experienced long-term survival after resection of small hepatocellular carcinomas, and persons who were screened had HCC detected at an earlier stage and had a substantial survival advantage compared with historical controls (25); however, data from controlled studies are lacking. Guidance for the diagnosis and management of hepatitis B is available (26).
Interpretation of Serologic Markers of HBV Infection
Antigens and antibodies associated with HBV infection include HBsAg and antibody to HBsAg (anti-HBs), hepatitis B core antigen (HBcAg) and antibody to HBcAg (anti-HBc), and hepatitis B e antigen (HBeAg) and antibody to HBeAg (anti-HBe). At least one serologic marker is present during each of the different phases of HBV infection (13,27). The serologic markers typically used to differentiate between acute, resolving, and chronic infection are HBsAg, anti-HBc, and anti-HBs (Table 1). HBeAg and anti-HBe screening typically is used for the management of patients with chronic infection. Serologic assays are available commercially for all markers except HBcAg because no free HBcAg circulates in blood.
The presence of a confirmed HBsAg-positive result in serum indicates active HBV infection. All HBsAg-positive persons should be considered infectious. In newly infected persons, HBsAg is the only serologic marker detected during the first 3--5 weeks after infection. The average time from exposure to detection of HBsAg is 30 days (range: 6--60 days) (12,13). Highly sensitive single-sample nucleic acid tests can detect HBV DNA in the serum of an infected person 10--20 days before detection of HBsAg (28). Transient HBsAg positivity has been reported for up to 18 days after hepatitis B vaccination and is clinically insignificant (29,30).
Anti-HBc appears at the onset of symptoms or liver-test abnormalities in acute HBV infection and persists for life. Acute or recently acquired infection can be distinguished by the presence of the immunoglobulin M (IgM) class of anti-HBc, which is detected at the onset of acute hepatitis B and persists for up to 6 months if the disease resolves. In patients who have chronic HBV infection, IgM anti-HBc can persist during viral replication at low levels that typically are not detectable by assays used in the United States. However, persons with exacerbations of chronic infection can test positive for IgM anti-HBc (31). Using IgM anti-HBc testing for diagnosis of acute hepatitis B should be limited to persons for whom clinical evidence of acute hepatitis or an epidemiologic link to a case has been identified because the positive predictive value of this test is low in asymptomatic persons.
In persons who recover from HBV infection, HBsAg is eliminated from the blood, and anti-HBs develops, typically within 3--4 months. The presence of anti-HBs typically indicates immunity from HBV infection. Infection or immunization with one serotype of HBV confers immunity to all serotypes. In addition, anti-HBs can be detected for several months after hepatitis B immune globulin (HBIG) administration. Persons who recover from natural infection typically will be positive for both anti-HBs and anti-HBc, whereas persons who respond to hepatitis B vaccine have only anti-HBs. In persons who become chronically infected, HBsAg and anti-HBc persist, typically for life. HBsAg will become undetectable in approximately 0.5%--2% of persons with chronic infection yearly; anti-HBs will occur in the majority of these persons (32--35).
In certain persons, the only HBV serologic marker detected in serum is anti-HBc. Isolated anti-HBc can be detected after HBV infection in persons who have recovered but whose anti-HBs levels have waned. Certain chronically infected persons with anti-HBc alone have circulating HBsAg not detectable by commercial serology. HBV DNA has been detected in the blood of <10% of persons with isolated anti-HBc (36,37). These persons are unlikely to be infectious except under circumstances in which they are a source for direct percutaneous exposure of susceptible recipients to substantial quantities of virus (e.g., through blood transfusion or organ transplantation) (38). An isolated anti-HBc result also can be a false-positive. Typically, the frequency of isolated anti-HBc relates directly to the prevalence of HBV infection in the population. In populations with a high prevalence of HBV infection, isolated anti-HBc likely indicates previous infection, with loss of anti-HBs. For persons in populations with a low prevalence of HBV infection, isolated anti-HBc is found in approximately 10%--20% of persons with serologic markers of HBV infection (37) and often represents a false-positive reaction; the majority of these persons have a primary anti-HBs response after a 3-dose series of hepatitis B vaccine (39,40).
HBeAg can be detected in the serum of persons with acute or chronic HBV infection. The presence of HBeAg correlates with high levels of viral replication (i.e., HBV DNA levels typically of 107--109 IU/mL, indicating high infectivity) (41,42). Loss of HBeAg correlates with low levels (i.e., HBV DNA levels of <105 IU/mL) of replicating virus, although certain HBeAg-negative persons have HBV DNA levels up to 108--109 IU/mL (43). A mutation in the precore region of the HBV genome has been identified in HBeAg-negative persons with high HBV DNA levels (44,45).
Epidemiology of HBV Infection
HBV is transmitted by percutaneous or mucosal exposure to infectious blood or body fluids. Although HBsAg has been detected in multiple body fluids, only serum, semen, and saliva have been demonstrated to be infectious (46,47). HBV is concentrated most highly in serum, with lower concentrations in semen and saliva. All HBsAg-positive persons are infectious, but those who are also HBeAg positive are more infectious because their blood contains high titers of HBV (typically HBV DNA levels of 107--109 IU/mL) (41,42). HBV is comparatively stable in the environment and remains viable for >7 days on environmental surfaces at room temperature (48). HBV DNA at concentrations of 102--103 IU/mL can be present on environmental surfaces in the absence of any visible blood and still cause transmission (48,49).
For adults, the two primary sources of HBV infection are sexual contact and percutaneous exposure to blood. Person-to-person transmission of HBV also can occur in settings involving nonsexual interpersonal contact over an extended period (e.g., among household contacts of a person with chronic HBV infection and developmentally disabled persons living in a long-term--care facility).
HBV is transmitted efficiently by sexual contact among heterosexuals and among MSM. Risk factors associated with sexual transmission among heterosexuals include having unprotected sex with an infected partner, having unprotected sex with more than one partner, and history of another STD. Risk factors associated with sexual transmission among MSM include having multiple sex partners, history of another STD, and anal intercourse.
Percutaneous transmission of HBV can occur from receipt of blood transfusion or organ or tissue transplant from an infectious donor; injection-drug use, including sharing of injection-preparation equipment; and frequent exposure to blood or needles among health-care workers. In the United States, donor selection procedures and routine testing of donors have made transmission of HBV via transfusion of whole blood and blood components a rare occurrence (50,51). Persons with hemophilia who received plasma-derived clotting factor concentrates were previously at high risk for HBV infection, but such transmission has been eliminated through viral inactivation procedures and use of recombinant clotting factor concentrates. Among persons with bleeding disorders treated at U.S. hemophilia treatment centers during 1998--2002, no infections with viral hepatitis, including HBV, were attributable to blood products received during that time (52). Outbreaks of HBV infection from exposure to contaminated equipment used for therapeutic injections and other health-care--related procedures, tattooing, and acupuncture also have been reported, although such exposures among patients with acute hepatitis B are reported rarely (53--57). In the majority of cases, transmission resulted from noncompliance with aseptic techniques for administering injections and recommended infection-control practices designed to prevent cross-contamination of medical equipment and devices. No infections have been demonstrated in susceptible persons who had oral mucous membrane exposure to HBsAg-positive saliva, but transmission has occurred through a human bite and has been demonstrated in animals by subcutaneous inoculation of saliva (46,58--60).
Persons living with chronically infected persons are at risk for HBV infection through percutaneous or mucosal exposures to blood or infectious body fluids (e.g., sharing a toothbrush or razor, contact with exudates from dermatologic lesions, or contact with HBsAg-contaminated surfaces). Persons with chronic HBV infection also can transmit HBV in other settings (e.g., schools, child care centers, or facilities for developmentally disabled persons), especially if they behave aggressively or have medical problems (e.g., exudative dermatitis or open skin lesions) that increase the risk for exposure to blood or serous secretions.
Adults at Risk for HBV Infection
In the United States in 2005, the highest incidence of acute hepatitis B was among adults aged 25--45 years (Figure 1). Approximately 79% of newly acquired cases of hepatitis B are associated with high-risk sexual activity or injection-drug use; other known exposures (i.e., occupational, household, travel, and health-care--related) together account for 5% of new cases, and 16% deny a specific risk factor for infection (61; CDC, unpublished data, 2001--2005).
Adults at risk for infection by sexual exposure. The most common source of HBV infection among adults in the United States is sexual contact. Heterosexual transmission accounts for approximately 39% of new HBV infections among adults, and transmission among MSM accounts for approximately 24% (CDC, unpublishe data, 2001--2005). Serologic evidence of HBV infection (i.e., anti-HBc positive) has ranged from 10% to 40% among adults seeking treatment in STD clinics (62--64) and from 10% to 25% among MSM aged <30 years (65; CDC, unpublished data, 1999--2000). Follow-up studies identified HBV infection in 20%--42% of susceptible heterosexual partners of persons with acute hepatitis B (66--68). Among susceptible heterosexual spouses of persons with chronic HBV infection, the seroprevalence of HBV infection ranged from 25% to 59% (69--71).
Injection-drug users. IDUs account for approximately 16% of new HBV infections in the United States (CDC, unpublished data, 2001--2005). Incidence of HBV infection among unvaccinated IDUs is high, ranging from 10 to 31 per 100 person-years (72--74). Risk for HBV transmission increases with the number of years of drug use and is associated with frequency of injection and with sharing of drug-preparation equipment (e.g., cottons, cookers, and rinse water), independent of syringe sharing (73,75).
In a study of the seroprevalence of HBV infection among IDUs admitted to drug treatment in six U.S. cities, 64% (range: 50%--81%) had serologic evidence of HBV infection, and seroprevalence increased with age (76). Studies of street-recruited IDUs (77,78) and female IDUs (79) have identified similar prevalence of HBV infection, whereas a lower prevalence (25%) was found in a study of young IDUs (aged 18--30 years) (74). Chronic HBV infection has been identified in 3.1% of IDUs in a detention setting (77) and 7.1% of IDUs with HIV coinfection (80).
Household contacts of persons with chronic HBV infection. Seroprevalence of HBV infection among susceptible household contacts of persons with chronic infection has varied, ranging from 14% to 60% (69,71,81--85). The risk for infection is highest among sex partners of, and children living with, a person with chronic HBV infection in a household or extended family setting (83--85).
Developmentally disabled persons in long-term--care facilities. Developmentally disabled persons in residential and nonresidential facilities historically have had high rates of HBV infection (86,87), but the prevalence of infection has declined substantially since the implementation of routine hepatitis B vaccination in these settings (88,89). Nonetheless, because HBsAg-positive persons reside in such facilities, clients and staff continue to be at risk for infection.
Persons at risk for occupational exposure to HBV. Before hepatitis B vaccination was widely implemented, HBV infection was recognized as a common occupational hazard among persons who were exposed to blood while caring for patients or working in laboratories (90,91). Since then, routine hepatitis B vaccination of health-care workers and use of standard precautions to prevent exposure to bloodborne pathogens have made HBV infection a rare event in these populations (92--94). Since the mid-1990s, the incidence of HBV infection among health-care workers has been lower than that among the general population (94). Public safety workers with exposures to blood also might be at risk for HBV infection (95--97); however, the prevalence of HBV infection in occupational groups such as police officers, firefighters, and corrections officers generally does not differ from that in the general population when adjusted for race and age (97), and infection is associated most often with nonoccupational risk factors (97,98). No increased risk for occupationally acquired HBV infection has been documented in workers exposed infrequently to blood or body fluids (e.g., ward clerks, dietary workers, maintenance workers, housekeeping personnel, teachers, and persons employed in day care settings) (91).
Hemodialysis patients. Since the initiation of strict infection-control practices and hepatitis B vaccination, the rate of HBV infection among patients undergoing hemodialysis has declined approximately 95% (99,100). Nonetheless, repeated outbreaks of HBV infection among unvaccinated patients underscore the continued risk for infection in this population (101).
Persons with chronic liver disease. Persons with chronic liver disease are not at increased risk for HBV infection unless they have percutaneous or mucosal exposure to infectious blood or body fluids. Furthermore, studies of the outcomes of acute hepatitis B among patients with chronic liver disease provide little evidence that acute hepatitis B increases their risk for an acute liver failure. However, concurrent chronic HBV infection might increase the risk for progressive chronic liver disease in HCV-infected patients (102).
Travelers to HBV-endemic regions. Short-term travelers to regions in which HBV infection is of high or intermediate endemicity (Box 2) typically are at risk for infection only through exposure to blood in medical, health-care, or disaster-relief activities; receipt of medical care that involves parenteral exposures; or sexual activity or drug use (103). Infection rates of 2%--5% per year among persons working in such regions for >6 months have been reported (104,105).
HIV-positive persons. Published data on the overall prevalence of HBV and HIV coinfection in the United States are limited. Studies of certain subgroups have identified prevalence of previous or current HBV infection of 45% in HIV-infected MSM aged 22--29 years (CDC, unpublished data, 1998--2000), 24% in adolescent HIV-infected males (106), and 43% in HIV-infected women, including 76% among HIV-infected female IDUs (79). Chronic HBV infection has been identified in 6%--14% of HIV-positive persons from Western Europe and the United States, including 9%--17% of MSM, 7%--10% of IDUs, and 4%--6% of heterosexuals (107).
The course of HBV infection can be modified in the presence of HIV, with a lower incidence of jaundice and a higher incidence of chronic HBV infection (20,108,109). Limited data also indicate that HIV-infected patients with chronic HBV infection have an increased risk for liver-related mortality and morbidity (110).
Incidence of Acute Hepatitis B
During 1990--2005, the overall incidence of reported acute hepatitis B declined 78%, from 8.5 to 1.9 per 100,000 population (Figure 2), and the estimated number of new HBV infections, after adjusting for underreporting and asymptomatic infections, declined from approximately 232,000 to approximately 51,000 infections (CDC, unpublished data, 1990--2005). Among children and adolescents aged <19 years, incidence declined 96%, from 2.4 to 0.1 per 100,000 population. Among adults aged >19 years, incidence declined 76%, from 9.9 to 2.4 per 100,000 population, and racial/ethnic disparities in incidence were nearly eliminated for Asians/Pacific Islanders, American Indians/Alaska Natives, and Hispanics (Figure 3). Incidence also declined substantially among blacks aged >19 years during this period, from 19.7 to 4.2 per 100,000 population; however, in 2005, incidence among blacks remained nearly three times higher than that among other racial/ethnic populations. After leveling during 1999--2002, acute hepatitis B incidence among adults decreased 35% during 2002--2005, from 3.7 to 2.4 per 100,000 population (CDC, unpublished data, 2006). In 2005, the highest incidence of acute hepatitis B occurred among persons aged 25--44 years.
Prevalence of HBV Infection
During 1988--1994, the overall age-adjusted prevalence of HBV infection (including previous or chronic infection) in the U.S. population was 4.9%, and the prevalence of chronic infection was 0.4% (111). Persons who have immigrated to the United States from countries in which HBV is endemic (Box 2, Figure 4) are affected disproportionately by chronic HBV infection; in particular, the majority of chronic HBV infections in the United States are among Asians/Pacific Islanders (112--114). The prevalence of chronic HBV infection among persons immigrating to the United States from Central and Southeast Asia, the Middle East, and Africa varies (range: 5%--15%) and reflects the patterns of HBV infection in the countries and regions of origin. During 1994--2003, approximately 40,000 immigrants with chronic HBV infection were admitted annually to the United States for permanent residence (115; CDC, unpublished data, 2005).
Prophylaxis Against HBV Infection
Hepatitis B Vaccine
Hepatitis B vaccine is available as a single-antigen formulation and also in fixed combination with other vaccines. Two single-antigen vaccines are available in the United States: Recombivax HB® (Merck & Co., Inc., Whitehouse Station, New Jersey) and Engerix-B® (GlaxoSmithKline Biologicals, Rixensart, Belgium). Of the three licensed combination vaccines, one (Twinrix® [GlaxoSmithKline Biologicals, Rixensart, Belgium]) is used for vaccination of adults and two (Comvax® [Merck & Co., Inc., Whitehouse Station, New Jersey] and Pediarix® [GlaxoSmithKline Biologicals, Rixensart, Belgium]) are used for vaccination of infants and young children. Twinrix contains recombinant HBsAg and inactivated hepatitis A virus. Comvax contains recombinant HBsAg and Haemophilus influenzae type b (Hib) polyribosylribitol phosphate conjugated to Neisseria meningitidis outer membrane protein complex. Pediarix contains recombinant HBsAg, diphtheria and tetanus toxoids and acellular pertussis adsorbed (DTaP), and inactivated poliovirus (IPV).
HBsAg is the antigen used for hepatitis B vaccination (116,117). Vaccine antigen can be purified from the plasma of persons with chronic HBV infection or produced by recombinant DNA technology. For vaccines available in the United States, recombinant DNA technology is used to express HBsAg in yeast, which then is purified from the cells by biochemical and biophysical separation techniques (118,119). Hepatitis B vaccines licensed in the United States are formulated to contain 10--40 µg of HBsAg protein/mL. Hepatitis B vaccines produced for distribution in the United States do not contain thimerosal as a preservative or contain only a trace amount (<1.0 µg mercury/mL) from the manufacturing process (120,121).
Hepatitis B Immune Globulin
HBIG provides passively acquired anti-HBs and temporary protection (i.e., 3--6 months) when administered in standard doses. HBIG typically is used as an adjunct to hepatitis B vaccine for postexposure immunoprophylaxis to prevent HBV infection. For nonresponders to hepatitis B vaccination, HBIG administered alone is the primary means of protection after an HBV exposure.
HBIG is prepared from the plasma of donors with high concentrations of anti-HBs. The plasma is screened to eliminate donors who are positive for HBsAg, antibodies to HIV and hepatitis C virus (HCV), and HCV RNA. In addition, proper manufacturing techniques for HBIG inactivate viruses (e.g., HBV, HCV, and HIV) from the final product (122,123). No evidence exists to indicate that HBV, HCV, or HIV ever has been transmitted by HBIG commercially available in the United States. HBIG that is commercially available in the United States does not contain thimerosal.
Adult Vaccination Schedules and Results of Vaccination
Preexposure Vaccination
Vaccination of Adults
Primary vaccination consists of >3 intramuscular doses of hepatitis B vaccine (Table 2). The 3-dose vaccine series administered intramuscularly at 0, 1, and 6 months produces a protective antibody response in approximately 30%--55% of healthy adults aged <40 years after the first dose, 75% after the second dose, and >90% after the third dose (124,125). After age 40 years, the proportion of persons who have a protective antibody response after a 3-dose vaccination regimen declines below 90%, and by age 60 years, protective levels of antibody develop in only 75% of vaccinated persons (126). In addition to age, other host factors (e.g., smoking, obesity, genetic factors, and immune suppression) contribute to decreased vaccine response (127--130). Alternative vaccination schedules (e.g., 0, 1, and 4 months or 0, 2, and 4 months) have been demonstrated to elicit dose-specific and final rates of seroprotection similar to those obtained on a 0-, 1-, 6-month schedule (131).
The combined hepatitis A--hepatitis B vaccine (Twinrix) is indicated for vaccination of persons aged >18 years with risk factors for both hepatitis A and hepatitis B. The dosage of the hepatitis A component in the combined vaccine is lower than that in the single-antigen hepatitis A vaccine, allowing it to be administered in a 3-dose schedule instead of the 2-dose schedule used for the single-antigen vaccine.
Nonstandard Vaccine Schedules
No apparent effect on immunogenicity has been documented when minimum spacing of doses (i.e., 4 weeks between doses 1 and 2, 8 weeks between doses 2 and 3, and 16 weeks between doses 1 and 3) is not achieved precisely. Increasing the interval between the first 2 doses has little effect on immunogenicity or final antibody concentration (132--134). The third dose confers the maximum level of seroprotection but acts primarily as a booster and appears to provide optimal long-term protection (135). Longer intervals between the last 2 doses result in higher final antibody levels but might increase the risk for acquisition of HBV infection among persons who have a delayed response to vaccination. No differences in immunogenicity are observed when vaccines from different manufacturers are used to complete the vaccine series.
Response to Revaccination
Although serologic testing for immunity is not necessary after routine vaccination of adults, postvaccination testing is recommended for persons whose subsequent clinical management depends on knowledge of their immune status, including certain health-care and public safety workers; chronic hemodialysis patients, HIV-infected persons, and other immunocompromised persons; and sex or needle-sharing partners of HBsAg-positive persons (Appendix A). Of persons who did not respond to a primary 3-dose vaccine series with anti-HBs concentrations of >10 mIU/mL, 25%--50% responded to an additional vaccine dose, and 44%--100% responded to a 3-dose revaccination series (136--141). Better response to revaccination occurs in persons who have measurable but low (<10 mIU/mL) levels of antibody after the initial series (136,137). Increased vaccine doses (e.g., double the standard dose) were demonstrated to enhance revaccination response rates in one study (140) but not in another (138). Intradermal vaccination has been reported to be immunogenic in persons who did not respond to intramuscular vaccination (142,143); however, intradermal vaccination is not a route of administration indicated in the manufacturers' package labeling. Persons who do not have protective levels of anti-HBs 1--2 months after revaccination either are primary nonresponders or are infected with HBV. Genetic factors might contribute to nonresponse to hepatitis B vaccination (130,137).
Groups Requiring Different Vaccination Doses or Schedules
Compared with immunocompetent adults, hemodialysis patients are less likely to have protective levels of antibody after vaccination with standard vaccine dosages; protective levels of antibody developed in 67%--86% (median: 64%) of adult hemodialysis patients who received 3--4 doses of either vaccine in various dosages and schedules (100). Higher seroprotection rates have been identified in patients with chronic renal failure, particularly those with mild or moderate renal failure, who were vaccinated before becoming dialysis dependent. After vaccination with a 4-dose series, the seroprotection rate among adult predialysis patients with serum creatinine levels of <4.0 mg/dL was 86%, compared with 37% among patients with serum creatinine levels of >4.0 mg/dL, 88% of whom were dialysis patients (144).
Humoral response to hepatitis B vaccination also is reduced in other immunocompromised persons (e.g., HIV-infected persons, hematopoietic stem-cell transplant recipients, and patients undergoing chemotherapy) (145--147). Modified dosing regimens, including doubling the standard antigen dose or administering additional doses, might increase response rates (148--150). However, limited data regarding response to these alternative vaccination schedules are available.
Immune Memory
Anti-HBs is the only easily measurable correlate of vaccine-induced protection. Immunocompetent persons who achieve anti-HBs concentrations of >10 mIU/mL after preexposure vaccination have nearly complete protection against both acute disease and chronic infection, even if anti-HBs concentrations decline subsequently to <10 mIU/mL (151--154). Although immunogenicity is lower among immunocompromised persons, those who achieve and maintain a protective antibody response before exposure to HBV have a high level of protection from infection (155,156).
After primary immunization with hepatitis B vaccine, anti-HBs levels decline rapidly within the first year and more slowly thereafter. Among young adults who respond to a primary vaccine series with antibody concentrations of >10 mIU/mL, 17%--50% have low or undetectable concentrations of anti-HBs (reflecting anti-HBs loss) 10--15 years after vaccination (155--157). In the absence of exposure to HBV, the persistence of detectable anti-HBs after vaccination depends on the concentration of postvaccination antibodies (158).
Even when anti-HBs concentrations decline to <10 mIU/mL, nearly all vaccinated persons remain protected against HBV infection. The mechanism for continued vaccine-induced protection is thought to be the preservation of immune memory through selective expansion and differentiation of clones of antigen-specific B and T lymphocytes (159). Persistence of vaccine-induced immune memory among persons who responded to a primary adult vaccine series 4--23 years previously but then had anti-HBs concentrations of <10 mIU/mL has been demonstrated by an anamnestic increase in anti-HBs concentrations in 74%--100% of these persons 2--4 weeks after administration of an additional vaccine dose and by antigen-specific B and T cell proliferation (160). Although direct measurement of immune memory is not yet possible, these data indicate that a high proportion of vaccinees retain immune memory and would have an anti-HBs response upon exposure to HBV.
Population-based studies of highly vaccinated populations have demonstrated elimination of new HBV infections for up to 2 decades after hepatitis B immunization programs were initiated (161--163). Breakthrough infections (detected by the presence of anti-HBc or HBV DNA) have been documented in a limited percentage of vaccinated persons (159,164), but these infections typically are transient and asymptomatic; breakthrough infections resulting in chronic HBV infection have been documented only rarely among infants born to HBsAg-positive mothers (165) and have not been observed among immunocompetent adults.
Limited data are available on the duration of immune memory after hepatitis B vaccination in immunocompromised persons (e.g., HIV-infected patients, dialysis patients, patients undergoing chemotherapy, or hematopoietic stem-cell transplant patients). No clinically significant HBV infections have been documented among immunocompromised persons who maintain protective levels of anti-HBs. In studies of long-term protection among HIV-infected persons, breakthrough infections occurring after a decline in anti-HBs concentrations to <10 mIU/mL have been transient and asymptomatic (155). However, among hemodialysis patients who responded to the vaccine, clinically significant HBV infection has been documented in persons who have not maintained anti-HBs concentrations of >10 mIU/mL (166).
Postexposure Prophylaxis
Both passive-active postexposure prophylaxis (PEP) using HBIG and hepatitis B vaccine and active PEP using hepatitis B vaccine alone are highly effective in preventing infection after exposure to HBV (167--170). HBIG alone has also been demonstrated to be effective in preventing HBV transmission (68,171--173), but with the availability of hepatitis B vaccine, HBIG typically is used as an adjunct to vaccination. Guidelines for PEP for adults with occupational (174) and nonoccupational exposures (Appendix B) to HBV have been developed.
The major determinant of the effectiveness of PEP is early administration of the initial dose of vaccine. The effectiveness of PEP diminishes the longer after exposure it is initiated (27,175,176). Studies are limited on the maximum interval after exposure during which PEP is effective, but the interval is likely <7 days for needlestick (171,172,177) exposures and <14 days for sexual exposures (68,154,168,170,173).
Substantial evidence suggests that adults who respond to hepatitis B vaccination are protected from chronic HBV infection for at least 20 years even if vaccinees lack detectable anti-HBs at the time of an exposure (151--153). For this reason, immunocompetent persons who have had postvaccination testing and are known to have responded to hepatitis B vaccination with anti-HBs concentrations of >10 mIU/mL do not require additional passive or active immunization after an HBV exposure and do not need further periodic testing to assess anti-HBs concentrations.
Vaccine Safety
Hepatitis B vaccines have been demonstrated to be safe when administered to infants, children, adolescents, and adults (178). Since 1982, an estimated 70 million adolescents and adults and 50 million infants and children in the United States have received >1 dose of hepatitis B vaccine (CDC, unpublished data, 2004).
Vaccine Reactogenicity
The most frequently reported side effects in persons receiving hepatitis B vaccine are pain at the injection site (3%--29%) and temperature of >99.9°F (>37.7°C) (1%--6%) (124,125). However, in placebo-controlled studies, these side effects were reported no more frequently among persons receiving hepatitis B vaccine than among persons receiving placebo (179).
Adverse Events
CDC and FDA continually assess the safety of hepatitis B vaccine and other vaccines through ongoing monitoring of data from the Vaccine Safety Datalink (VSD) project, the Vaccine Adverse Events Reporting System (VAERS), and other surveillance systems. A causal association has been established between receipt of hepatitis B vaccine and anaphylaxis (178). On the basis of VSD data, the estimated incidence of anaphylaxis among children and adolescents who received hepatitis B vaccine is one case per 1.1 million vaccine doses distributed (95% confidence interval = 0.1--3.9) (180).
Early postlicensure surveillance of adverse events suggested a possible association between Guillain-Barré syndrome (GBS) and receipt of the first dose of plasma-derived hepatitis B vaccine among U.S. adults (181). However, in a subsequent analysis of GBS cases reported to CDC, FDA, and vaccine manufacturers, among an estimated 2.5 million adults who received >1 dose of recombinant hepatitis B vaccine during 1986--1990, the rate of GBS that occurred after hepatitis B vaccination did not exceed the background rate among unvaccinated persons (CDC, unpublished data, 1992). An Institute of Medicine review concluded that evidence was insufficient to reject or accept a causal association between GBS and hepatitis B vaccination (178,182,183).
One retrospective case-control study (184,185) reported an association between hepatitis B vaccine and multiple sclerosis (MS) among adults. However, multiple studies (186--189) have demonstrated no such association. Reviews by scientific panels have favored rejection of a causal association between hepatitis B vaccination and MS (190,191).
In rare instances, chronic illnesses have been reported after hepatitis B vaccination, including chronic fatigue syndrome (192), neurologic disorders (e.g., leukoencephalitis, optic neuritis, and transverse myelitis) (193--195), rheumatoid arthritis (196,197), type 1 diabetes (198), and autoimmune disease (199). However, no evidence of a causal association between these conditions or other chronic illnesses and hepatitis B vaccine has been demonstrated (183,190,200--203).
Reported episodes of alopecia (hair loss) after rechallenge with hepatitis B vaccine suggest that vaccination might, in rare cases, trigger episodes of alopecia (204). However, a population-based study determined no statistically significant association between alopecia and hepatitis B vaccine (205).
Contraindications and Precautions
Hepatitis B vaccination is contraindicated for persons with a history of hypersensitivity to yeast or any vaccine component (206--209). Despite a theoretic risk for allergic reaction to vaccination in persons with allergy to Saccharomyces cerevisiae (baker's yeast), no evidence exists to document adverse reactions after vaccination of persons with a history of yeast allergy.
Persons with a history of serious adverse events (e.g., anaphylaxis) after receipt of hepatitis B vaccine should not receive additional doses. As with other vaccines, vaccination of persons with moderate or severe acute illness, with or without fever, should be deferred until illness resolves (210). Vaccination is not contraindicated in persons with a history of MS, GBS, autoimmune disease (e.g., systemic lupus erythematosis or rheumatoid arthritis), or other chronic diseases.
Pregnancy is not a contraindication to vaccination. Limited data suggest that developing fetuses are not at risk for adverse events when hepatitis B vaccine is administered to pregnant women (211). Available vaccines contain noninfectious HBsAg and should cause no risk of infection to the fetus.
Implementation Barriers and Rationale for New Recommendations
Soon after hepatitis B vaccine was licensed in 1982, ACIP recommended vaccination for adults at increased risk for HBV infection (212). However, the recommendations were not widely implemented, and coverage among adults at risk for HBV infection remained low. By the early 1990s, the difficulty in vaccinating adults at risk for HBV infection and the substantial burden of HBV-related disease resulting from infections acquired during childhood indicated that additional hepatitis B vaccination strategies were needed (213,214). In 1991, recommendations for vaccination of unvaccinated adults at high risk for HBV infection became part of the national strategy adopted by ACIP and professional medical organizations to eliminate HBV transmission in the United States (3). However, hepatitis B vaccine still is not offered routinely in medical settings serving adults, and a substantial number of adults at risk for HBV infection remain unvaccinated.
Multiple factors contribute to low hepatitis B vaccination coverage among adults at risk. In contrast to vaccination of children, no national program exists to support vaccine purchase and infrastructure for vaccine delivery to uninsured and underinsured adults. Reimbursement mechanisms for vaccination of adults with health insurance also are not widely used. In addition, certain patients and health-care providers are reluctant to discuss risk behaviors (215), and providers might not make hepatitis B vaccination a priority compared with other clinical care services.
One strategy demonstrated to be effective at increasing vaccination coverage among adults at risk for HBV infection is to offer vaccination to all adults as part of routine prevention services in settings in which a high proportion of adults have HBV risk factors (10,216--223). In STD and HIV treatment facilities, health-care settings serving IDUs, and health-care settings targeting services to MSM, nearly all patients have behavioral risk factors for HBV infection. Furthermore, a high proportion of persons receiving health care in HIV testing facilities or correctional facilities report sexual and drug-use risk behaviors (224,225). Therefore, providing hepatitis B vaccination in these settings offers an efficient and effective way to reach adults at highest risk. During 2001--2004, in a study of 760 adults with reported acute hepatitis B who participated in CDC's Sentinel Counties Study of Viral Hepatitis, 39% reported a history of STD treatment, 40% reported a history of incarceration, and 22% reported a history of drug treatment; overall, 61% would have had at least one opportunity to be vaccinated either during STD or drug treatment or at a correctional facility (226).
Demonstration projects that supported the purchase of hepatitis B vaccine and its administration in settings in which a high proportion of adults have HBV risk factors have established the feasibility of providing the vaccine as part of comprehensive STD, HIV, and hepatitis prevention services (10). When clients were offered hepatitis B vaccination in such settings, first-dose acceptance rates of 70%--85% were achieved (10,216,223,227). These demonstration projects have identified the components of successful adult hepatitis B vaccination programs (Box 3). In addition, "one-stop" delivery of integrated prevention services was preferred by the majority of patients and typically resulted in enhanced delivery of all prevention services (227). Return visits for second and third doses of hepatitis B vaccine also provide opportunities for patients to receive other STD/HIV-related services (e.g., test results, additional counseling, and referral). Multiple studies have established the cost-effectiveness of providing hepatitis B vaccination at STD/HIV counseling and testing sites, correctional institutions, drug-abuse treatment centers, and other settings serving adults at risk for HBV infection (228--231).
Universal vaccination of adults in settings in which a high proportion of persons have HBV risk factors will reach a substantial proportion of all adults at risk for HBV infection. However, not all adults with risk factors for HBV infection visit these settings. For example, an estimated 80%--95% of STDs are diagnosed in settings other than STD clinics (232,233). Therefore, primary care and clinical preventive service providers (e.g., physicians' offices, community health centers, family planning clinics, liver disease clinics, and travel clinics) also should provide hepatitis B vaccine whenever indicated or requested as part of regular preventive care. Limited data are available regarding best practices in primary care and specialty medical settings to achieve high vaccination coverage among adults at risk for HBV infection. In one project in which hepatitis B vaccine was made available free of charge to primary care clients in community clinics, low vaccination coverage rates were observed, compared with rates at other venues (10). This finding suggests that provision of free vaccine alone might not ensure increased use of hepatitis B vaccine and that other implementation strategies (e.g., education and training of clinicians and standing orders) are needed to prompt providers to offer vaccination to adults.
In primary care settings, targeting vaccination to persons at risk is an efficient approach to preventing HBV infection. During 2001--2005, among persons with acute hepatitis B who participated in CDC's Sentinel Counties Study of Viral Hepatitis, 84% reported risk behaviors or characteristics, either during the incubation period (i.e., 6 weeks--6 months) or during their lifetimes, that placed them in a group for which hepatitis B vaccination was recommended (CDC, unpublished data, 2001--2005). Providers in primary care settings can ascertain patients' risks for HBV infection and identify candidates for hepatitis B vaccination during routine patient visits. Assessment of patients' sex- and drug-related risk factors is recommended by the U.S. Preventive Services Task Force and the American Medical Association (AMA) (234,235) and has the ancillary benefit of identifying candidates for other prevention interventions (e.g., screening for HIV infection and other STDs and drug-abuse treatment).
However, risk-targeted approaches can miss persons in need of prevention services. Patients might be reluctant to report sex- and drug-related behaviors, particularly when these behaviors are not perceived as relevant to the clinical encounter. In addition, despite recommendations of the U.S. Preventive Services Task Force and AMA, providers might be reluctant to inquire about behavioral risk factors. For example, surveys of physicians and patients conducted during 1995--1999 indicated that fewer than half of patients were asked about sexual behaviors (236--238). Health-care providers should educate all patients about the health benefits of hepatitis B vaccination, including risk factors for HBV infection and the importance of vaccination for persons who engage in certain risk behaviors. This information might stimulate patients to request vaccination from their primary care providers, without requiring them to acknowledge a specific risk factor.
Another possible strategy is to offer vaccination to all adults in age groups with the highest incidence of infection as part of routine medical care (Figure 1). An age-based approach might simplify vaccination-related decision-making by practitioners and remove the stigma associated with disclosure of risk behaviors. Other adult vaccines, including those for influenza and pneumococcal disease, are delivered on age-based schedules. However, the effectiveness of age-based strategies in increasing hepatitis B vaccination coverage among adults at risk is unknown. In addition, age-based strategies for adult vaccination would be substantially more costly than risk-targeted approaches (CDC, unpublished data, 2005).
Lack of funding for vaccine and its administration is a major barrier to provision of hepatitis B vaccine to adults. Hepatitis B vaccine often is a reimbursable charge in health-care settings that bill insurance or Medicaid for services, and surveys of public and private insurers indicate high rates of coverage for hepatitis B vaccination (239,240). In one study, an estimated 74% of adults aged 18--49 years with risk factors for HBV infection had health insurance coverage (241). However, public clinics might not have systems in place to bill for vaccination services, and reimbursement of private providers might be inadequate to cover the purchase and administration of vaccine. Other adults either lack private insurance or are not eligible for reimbursement by Medicaid. Although the Vaccines for Children program provides federally funded vaccine and administration costs for vaccination of uninsured and underinsured children and youth aged <19 years, no similar program supports adult vaccination.
Certain adult hepatitis B vaccination programs have been successful at identifying federal, state, or local funds to provide free or low-cost hepatitis B vaccination to uninsured or underinsured adults. For example, the Immunization Grant Program, created under Section 317 of the Public Health Service Act, provides funding to state, local, and territorial public health agencies for vaccine purchase and vaccination-program operation (242). Section 317 funds can be used to purchase childhood and adult vaccines, including adult hepatitis B vaccine. However, lack of adequate funding constrains efforts to increase vaccination coverage among adults. To maximize available resources for hepatitis B vaccination, public and private health-care providers should become familiar with insurance billing and reimbursement mechanisms that can be used for hepatitis B vaccine. AMA billing and reimbursement guidelines are available at http://www.ama-assn.org/ama1/pub/upload/mm/36/ama_hep_coding_trifo.pdf.
Although HBV infections are expected to decline as a result of universal childhood immunization and increased vaccination of adults at risk, an estimated 1.25 million persons in the United States are living with chronic HBV infection and require essential prevention services and medical management. In particular, Asians/Pacific Islanders in the United States have a high prevalence of chronic HBV infection, representing a major health disparity. Persons with chronic HBV infection often are unaware of their infection status or do not receive needed care. Few programs have been implemented to identify HBsAg-positive persons, provide or refer these persons for appropriate medical management, and provide vaccination to their contacts (243). During delivery of hepatitis B vaccination and provision of other preventive services, health-care providers have opportunities to identify persons with chronic HBV infection, refer them for counseling and management, and ensure that their susceptible contacts receive vaccination. Guidelines to identify and manage HBsAg-positive persons have been developed (Appendix C).
Implementation of the recommendations and strategies outlined in this report and the companion ACIP recommendations for infants, children, and adolescents (11) should lead ultimately to the elimination of HBV transmission in the United States. New information will have implications for this effort, and adjustments and changes are expected to occur.
Recommendations and Implementation Strategies for Hepatitis B Vaccination of Adults
Implementation Strategies
The following persons contributed to the development of this report: Guthrie S. Birkhead, MD, AIDS Institute, New York State Department of Health, Albany, New York; Anna S. F. Lok, MD, Division of Gastroenterology, University of Michigan, Ann Arbor, Michigan; Molli C. Conti, Hepatitis B Foundation, Doylestown, Pennsylvania; Josiah D. Rich, MD, Brown University, Providence, Rhode Island; Robert A. Gunn, MD, San Diego County Health and Human Services Agency, San Diego, California; Harold S. Margolis, MD, Joanna Buffington, MD, Alison Greenspan, MPH, Stephanie M. Neitzel, Kevin P. O'Connor, MA, Annemarie Wasley, PhD, Brigette F. Ulin, MPH, Ian T. Williams, PhD, Division of Viral Hepatitis, Matthew T. McKenna, MD, Division of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (proposed); William L. Atkinson, MD, Edward W. Brink, MD, Immunization Services Division, Susan A. Maloney, MD, Division of Global Migration and Quarantine, National Center for Immunization and Respiratory Diseases (proposed), CDC.
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Date last reviewed: 11/21/2006


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Here Comes The Waterfall: 15 MLB Teams To Lift Streaming Blackout For Fox Broadcasts
from the half-way dept
And away we go. Techdirt (myself specifically) has been talking for some time about the impending expansion of major sports streaming options as the cord-cutting trend has continued. It only makes sense: leagues and marketers will go where the audience is. The most recent trend started slowly with the FCC voting to end its blackout rule. That decision was important for streaming, because one of the dumbest ideas that migrated over from broadcast and cable television was the idea that local blackouts of broadcasts and streams were in any way a good idea. Even as the NFL, NBA, NHL and MLB all have incrementally increased streaming options, those efforts have continued to be hampered by local blackout restrictions.
Well, Major League Baseball just took a giant step over the blackout line and is now effectively straddling it, announcing that local streaming will be available in fifteen markets in the 2016 season.
There is no specific timetable for a potential announcement of a deal between FOX and MLB. The two sides hope to complete the agreement around the end of this season, which would give the league and RSNs a full offseason to market the availability of the new local streams before Opening Day 2016. MLB Commissioner Rob Manfred, working with the league's president of business and media, Bob Bowman, has made in-market baseball streaming a key league priority, including personally participating in several negotiating sessions.
Per the above, this specific deal is going to be done with MLB teams that have broadcasting deals with Fox. But don't think for a single moment that that's where it ends. Even if MLB can't get similar deals in place for the other half of teams in the league, which would fully free up the fantastic MLB.TV product for local streaming, any modicum of success that Fox has with this program will be immediately adopted by the other broadcasters. They really don't have a choice. Cord-cutting isn't going away and it's been professional and college sports that have long kept subscribers tethered. The trickle of streaming options in sports has been turning into more of a deluge, and the cable industry should be expecting some tough times ahead in the next, oh, say three to five years. Because if Manfred has this on his priority list for MLB, please believe that the commissioners in the other leagues have it on theirs as well.
And when sports streaming really gets going, it's the end of cable as we currently know it.
Filed Under: baseball, blackouts, local, mlb, online, sports, streaming


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Today's Birthdays: January 08
January 08
Stephen William Hawking
1942–, British theoretical physicist.
Born in Oxford, England and graduated University College, Oxford, 1962, Ph.D. Trinity Hall, Cambridge, 1966. In 1962 Hawking was diagnosed as having an incurable muscular disease, amyotrophic lateral sclerosis (ALS). Although the disease eventually confined him to a wheelchair and forced him to use a computer-generated voice synthesizer to communicate, he continued to teach and to lecture and began his research in cosmology. In 1971 Hawking provided mathematical support for the big-bang theory of the origin of the universe; he showed that if the general theory of relativity was correct the universe must have a singularity, or starting point, in space-time.
This cosmological thread led him to the study of black holes and his suggestion that following the big bang primordial, or mini, black holes—objects of immense mass occupying only the space of an elementary particle—were formed. He also showed that the surface area of a black hole can increase but never decrease, that there is a limit on the radiation emitted when black holes collide, and that a single black hole cannot cleave into two black holes. In 1974 Hawking calculated that black holes thermally create and emit subatomic particles until they exhaust their energy and explode. This so-called Hawking radiation linked gravity, quantum mechanics, and thermodynamics mathematically for the first time. Hawking proposed in 1981 that although the universe has no boundary, it is finite in space-time; he collaborated with James Hartle to formulate this mathematically in 1983.
Hawking wrote an explanation of his work that became a popular bestseller, A Brief History of Time: From the Big Bang to Black Holes (1988). He has also published Superspace and Supergravity (1981), The Very Early Universe (1983), Black Holes and Baby Universes and Other Essays (1993), and The Nature of Space and Time (1995).
See M. White, Stephen Hawking: A Life in Science (1992); D. Wilkenson, God, the Big Bang, and Stephen Hawking (1993); M. McDaniel, Stephen Hawking: Revolutionary Physicist (1994).
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- John Carrollchurchman (1735)
- Edmond Charles Genêtdiplomat (1763)
- Nicholas Biddlefinancier (1786)
- Wilkie Collinsauthor (1824)
- Emily Greene Balcheconomist and sociologist (1867)
- William Piperairplane manufacturer (1881)
- Carl Rogerspsychologist (1902)
- Jose Ferreractor (1912)
- Elvis Presleysinger, actor (1935)
- David Bowiemusician, actor (197)


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Ambergris Caye Snorkeling
Most of the area inside the reef is less than 20 feet deep and you can see as much with a mask and snorkel from the surface as you can diving. In just 6-10 feet of water you'll find an amazing diversity of marine life. Also the reef provides protection which makes for extremely clear, calm water so it's ideal for snorkeling.
The most-popular areas for snorkeling from Ambergris Caye are Hol Chan Marine Reserve, Shark Ray Alley and Mexico Rocks. Visits to Hol Chan and Shark Ray Alley to the south of San Pedro are usually combined into one trip, while Mexico Rocks to the north of town is usually a separate trip.
Our snorkeling trips usually last three to three and half hours. Typically, our snorkel boats go out once in the morning at 9:00 am and once in the afternoon, at 2:00 pm. We pick you up at your hotel or other requested location. The best snorkeling trip you will ever experience will be the combination of Hol Chan & Shark Ray Alley. You can't leave the island without experiencing these two snorkel adventures.
About Hol Chan Marine Reserve
Hol Chan is located 4 miles southeast of San Pedro. It's like diving in your own aquarium. The ocean floor has a maximum depth of 30 feet, so both divers and snorkelers have the opportunity to swim in waters teeming with colorful tropical fish of all sizes and types along with beautiful coral formations. Divers can also enjoy the deeper waters outside the channel.
Shark Ray Alley
Shark Ray Alley is a must and it's only a few minutes by boat from San Pedro. Hundreds of sting rays of all sizes congregate here accompanied by families of nurse sharks. With a depth of only 8 feet, the Sand Bar offers great photo opportunities.
Other Snorkeling
Mexico Rocks & Tres Locos is the second favorite spot of Lil' Alphonse and his crew. It's located on the North of Ambergris Caye island. You'll snorkel the shallow waters of Mexico Rocks and Tres Locos. See a wide range of coral formations including flower, elk-horn and giant brain coral. This area is protected from ocean swells and currents, so it makes for easier snorkeling. Depth is only about 6 to 12 feet, so you can see everything up close. Water visibility is about 50 feet or more. Typically, we'll go out in the morning at 9:00 am and or in the afternoon, at 2:00 pm. Again, we'll pick you up at your hotel or other requested location.
Night Snorkel and experience Hol Chan as it's a totally new world at night. Huge stingrays sleep in the sand. Immense rainbow parrot fish are wedged in the most improbably-tiny coral caverns Octopus, sea snails, lobsters and moray eels can be seen foraging. Smaller creatures like glowing marginella, harlequin shrimp and hot pink file clams with their pure white tentacles can be found in their secret places. Lil' Alphonse provide underwater lights to assist you in seeing the unbelievable sites.
Charters on our boats for private tour of any snorkel location. We have a great deal of fun and experience with private groups. We can provide a photographer or video photographer as well if requested.
On Da Boat, Lil' Alphonse has snorkel equipment to fit anyone as well as Marine Park Tickets and flotation devices to assist those not as experienced. Upon early request his guides can provide RX mask as well. Lil' Alphonse and his crew have been swimming, fishing and snorkeling the island waters since they were small children and have grown up with the importance of the taking care of the reef. Lil' Alphonse Tours carry marine radio's at all times for complete safety and valid tour guide's license.


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Monday, April 30, 2012
Fellow Drawn and Quarterlarian and master cartoonist Guy Delisle is in Minneapolis touring on his new book Jerusalem: Chronicles from the Holy City. He's at Magers and Quinn on Tuesday. Recommended.
Posted by Anders Brekhus Nilsen at 9:22 PM No comments:
Thursday, April 26, 2012
Friday, April 20, 2012
Of apples and apple trees
My father drew this in... 1966? It recently came to light in the collection of an old football buddy of his from college. He doesn't know it exists as I write this and probably won't see it until he opens his email tomorrow. I think it's amazing, although he might want me to mention that he spent considerably more time and care on some later efforts, which might also be worth a blog post at some point. But anyway... today is his birthday. Happy birthday, dad.
Posted by Anders Brekhus Nilsen at 8:41 PM 1 comment:
Posted by Anders Brekhus Nilsen at 9:50 AM No comments:
Sunday, April 15, 2012
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Hallberg leads Senior British Open
Gary Hallberg of the United States made eight birdies in a 7-under 63 Friday during the windy second round of the Senior British Open, taking a three-stroke lead on Bernhard Langer and Tom Lehman.
Langer had a 73 after his opening 64, logging a triple-bogey 7 on the 13th hole.
''I think Gary's 63 is the round of the year. Shooting 7 under today is like 10 or 11 under on a decent day. That's how good it was and I take my hat off to him,'' Langer said.
Like Langer, Lehman played when the wind was at its strongest, with gusts up to 25 mph. He managed one birdie at the 17th and dropped shots on the 11th and 14th to finish with a 71.
''When I saw Gary's score going on the board I thought, `Wow! Did he play the par-3 course across the road?' He's a bit of a character, so nothing surprises me what he might shoot,'' Lehman said.
Hallberg dropped his only shot at the second hole, then mastered the conditions with eight birdies. He got three on the run from the fifth to go out in 33. He had another run at 10, 11, 13, 14 and the 17th for a 30.
''It was one of the greatest days I've had in many years; it was just a pleasure,'' Hallberg said. ''I played aggressively and had some great putts go in, but I started to choke a bit near the end and left putts at 15, 16 and 18 short.''
Fred Couples shot a 68, one of only two under-par rounds. He had birdies at the fifth and seventh, dropped a stroke at the 15th and birdied 16 and 17 before dropping another stroke at the last hole.
He's six strokes back, along with fellow American Michael Allen (74) and Ireland's Mark McNulty, whose 75 was 10 shots worse than his opening effort. Tom Watson followed his 69 with a 75 on Friday, 10 strokes behind the leader.
Greg Norman (77) missed the cut.


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MIAMI GARDENS, Fla. – Michael Andretti walked through the Formula One paddock quite literally going door-to-door. He wants into the most exclusive club in motorsports and figured pleading his case to the current team bosses was his best shot.
Andretti carried with him a white Miami Dolphins folder — he said he borrowed it from the promoters of the inaugural Miami Grand Prix last weekend — and inside was a piece of paper asking the 10 current F1 team leaders to support the addition of Andretti Global to the grid.
By the time he made it to the end of the paddock, Andretti's chances seemed grim. He left his conversation with Red Bull principal Christian Horner — held in the outdoor, open area of Red Bull hospitality — with only two signatures. Horner did not sign.
Andretti didn't even bother going next door to Mercedes, where boss Toto Wolff has not wavered in his opposition to adding teams because he believes that would dilute profits for those on the grid.
Andretti was discouraged but not defeated. By the time Sunday's race began, he felt a lot better about his chances of returning the Andretti name to F1.
Andretti told The Associated Press he had an encouraging meeting with F1 CEO Stefano Domenicali. He said the same thing to new FIA president Mohammed Ben Sulayem when they spoke before the race.
"We finally have some direction," Andretti told AP. "It's the first time we've been given any direction on how to make this happen."
Just when it seemed that Andretti had no shot at cracking the country club — there's a $200 million buy-in fee — he was given hope. It had to have been encouraging that Sulayem, who was elected head of F1's governing body in December, not only recognized Andretti but stopped to lean into his ear for an exchange in which Sulayem did most of the talking.
The Andretti effort to field an American team was the talk of F1's first-ever race in Miami. The North American market has at last embraced the series — Sunday's race on ABC was the most-watched live F1 race in U.S. history — and Andretti wants to expand the famed racing name.
Mario Andretti, Michael's father, is the 1978 F1 champion and one of the greatest drivers in motorsports history. But there has not been an American driver in F1 since Alexander Rossi in 2015. The only current American team is Haas F1, which is owned by California businessman Gene Haas, partially headquartered in North Carolina but does not employ any American drivers.
Michael Andretti, who spent the 1993 season commuting back and forth from the U.S. to Europe to drive for McLaren in F1, wants to put IndyCar driver Colton Herta of California in his seat.
Andretti maintains he's committed to a true effort, and argues an American team with an American driver can only add to F1's financial worth. He figures Andretti involvement will help all existing teams court North American sponsorship.
Wolff has yet to see any benefit to expanding the grid to anyone and estimates F1's current successful teams have "put more than a billion into the Formula 1 projects over the years."
"We have 10 entries today, we divide the prize fund among those 10 entries," Wolff said. "If a team comes in, how can you demonstrate that you're bringing in more money than it's actually costing? The 11th team means a 10% dilution for everybody else. So, if one is able to demonstrate that, then we should all be sitting on the table and cheer for such an entry. But that hasn't been demonstrated yet."
Zak Brown, the head of McLaren Racing, joined Alpine CEO Laurent Rossi as the only F1 team leaders to sign Andretti's form in Miami. Brown, a Californian, has a long relationship with the Andrettis and announced Tuesday he will let Mario Andretti drive a McLaren F1 car at the U.S. Grand Prix in October.
He believes Andretti Global would be a benefit.
"A very credible racing team with a credible brand, with the right resources, I think is additive to the sport," Brown said. "That appears to be what Michael has put together. So, on that basis, we are supportive."
Rossi said he he believes adding an American team "goes along with the expansion in the U.S." There are two F1 races in the United States this year for the first time since 1984, and a 2023 trip to Las Vegas will make three American races on the schedule.
"An American team will directly generate interest in the U.S., and therefore, revenue," Rossi said. "We need to demonstrate that it's enough to compensate for the dilution that Toto was mentioning. Gut feeling? I think he would."
More AP auto racing: https://apnews.com/hub/auto-racing and https://twitter.com/AP_Sports


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Search Results
Code Fire II
Code Fire II is an Basic Warlock Armor found in Destiny. There is also other variations of this Armor, the only differences being cosmetic. There are no Armor Upgrades for this set.
- These Armor pieces are random drops from enemies in Story Mode, Strike, Exploration and can be awarded in Crucible or Strike.
- The Armor Value of each piece varies by the level of the piece obtained.
- Note: You cannot obtain Armor from a different Class than your own via drops or vendors.
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With the imageRUNNER 2230, you can achieve more without exhausting your budget.
Operating at 22-pages-per-minute, this device is the ideal solution for smaller corporate workgroups and departments. The imageRUNNER 2230 supports basic digital copying and the ability to add Mail Box features, network printing, scanning, and fax capabilities. Plus, you can add stapling, sorting, and hole-punching all within the original footprint of the device, even the most space-conscious environment can create professional-looking output.
The imageRUNNER 2230 is an extremely compact, cost-effective system your business can count on.
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