ࡱ> a "^bjbj >F\F\@U ;   lll8t8b^:JJ`v###aaaaaaa$dLgal##"###a`v3a7(7(7(#H8`lva7(#a7(7(2VTZvWΘ%W.ab08bWg%<g\ZZglZ##7(#####aa'$###8b####g######### > : 2016 CANINE VACCINATION Implementing the Protocol Richard B. Ford, DVM, MS Emeritus Professor of Medicine Diplomate ACVIM and ACVPM (Hon) North Carolina State University Each year, and despite the availability of published Vaccination Guidelines, veterinarians continue to be challenged with new, sometimes complex, even conflicting, information regarding the selection and use of companion animal vaccines. New products, new issues, and of course, new controversies seem to emerge regularly. Its all part of a dynamic, changing market that not only complicates the effort of publishing current and relevant Vaccination Guidelines, but challenges practitioners to maintain a level of vaccine awareness that goes beyond price and the marketing brochures. PART 1 of the 2016 Canine Vaccination manuscript summarizes current recommendations for the vaccination of dogs; this includes protocol-related information on the latest (canine) vaccines to be released in the US (eg, H3N2 canine influenza virus) since the last iteration of the AAHA Canine Vaccination Guidelines was published in 2011 (currently in revision). PART 2 of this manuscript attempts to address some of the more common controversial questions raised by practicing veterinarians as they review/revise current vaccination protocols in practice, for example: REDUCING the dose when vaccinating small breed dogs? Why not to do this? WHY VACCINATE at 8 weeks of age if Maternal Antibody interferes with vaccination? VACCINE TITERSwhen are they indicated? and what do the results really mean? LEGAL LIABILITY: Published Guidelines vs. Manufacturer recommendations? RABIES VACCINATION .required (in most States) by laware you really AWARE? and more It should be noted that this manuscript is written for and applicable to veterinarians practicing in the US and CANADA. While there are a small number of vaccines used in the US that are not currently available in Canada, the recommendations outlined in this paper are applicable to veterinarians practicing in both countries. For veterinarians practicing outside of the US and Canada, the World Small Animal Veterinary Association (WSAVA) has recently updated vaccination guidelines for the dog and cat (2016). There is considerable consistency among the recommendations outlined by respective Guidelines, highlighting the fact that vaccination guidelines are going global. Although veterinarians are encouraged to follow published Guidelines, unique variables (age, chronic illness, exposure risk, etc) exist that may require clinicians to modify a conventional vaccination protocol to meet specific needs of an individual patient/client. Therefore, vaccination recommendations outlined in this paper are NOT intended to define a universal vaccination protocol or the standard of care for vaccination. Instead, they are intended to guide practitioner decisions on how to best implement a rational vaccination protocol that provides maximum levels of protection among the patient population seen in an individual practice. NOTE: vaccination recommendations for the dog are based, whenever possible, on the results of current scientific studies. The reader is reminded, however, that for some of the recommendations offered, published studies are simply not available nor do they fall within the manufacturers label recommendations. PART I: Canine Vaccination Recommendations CORE VaccinesAdministrationBooster RecommendationsCombination product administered as: MLV or Recombinant Canine Distemper Virus + MLV Parvovirus + MLV Adenovirus-2 OPTION: May include MLV Canine Parainfluenza Virus.3 doses are recommended between 6 and 16 weeks of age. Example: 8 weeks; and 12 weeks; and 16 weeks of age. NOTE: the last dose in the initial series should be administered between 14 and 16 weeks of age.Administer a single dose (of a combination product) not later than 1 year following the last dose in the initial series. NOTE: a minimum interval of 2 weeks between any 2 doses of vaccine is recommended. Administer subsequent boosters every 3 years (or longer).Rabies (killed) 1-Year & 3-Year vaccines are available. A single dose of rabies vaccine should be administered not earlier than 12 weeks of age. (in most practices, rabies vaccine is usually administered at 12 or 16 weeks of age). (State/Local/Provincial law applies)Schedule a second dose to be administered not later than 1 year following administration of the 1st dose, regardless of the dogs age at the time the initial dose is given. Thenevery 3 years thereafter. (State/Local/Provincial law applies)NON-CORE VaccinesAdministrationBooster RecommendationsB. bronchiseptica + canine parainfluenza virus (intranasal only) OPTION: some IN products may also contain CAV-2 antigen.Single intranasal (IN) dose at 12 or 16 weeks of age. (optional-some authors recommended 2 doses at 12 and 16 weeks of age). IN vaccine may be administered as early as 3 to 4 weeks of age.Where risk of exposure is sustained, administer a single dose 1 year following the last dose administered then every year thereafter.B. bronchiseptica only (monovalent) Three (3) options are available: > Parenteral (killed-bacterin) or- > Intranasal (avirulent live) -or- > Intraoral (avirulent live).Parenteral (SQ): Two doses are required, 2 to 4 weeks apart. Intranasal (IN): The manufacturer recommends a single initial dose. Intraoral: The manufacturer recommends a single initial dose. Where risk of exposure is sustained, administer a single dose 1 year following the last dose administered, then every year thereafter.Leptospirosis (killed) 4-serovar NOTE: routine use of a 2-serovar Leptospirosis vaccine is not recommended.2 initial doses, 2 to 4 weeks, are required regardless of the dogs age. NOTE: it is not recommended to administer the 1st dose prior to 12 weeks of age. NOTE: Small Breed Dogs (< 20 pounds): consider delaying initial doses until the CORE vaccine series has been completed.Where risk of exposure is sustained, administer a single dose 1 year following completion of the initial 2-dose series, then every year thereafter.Lyme Disease (3 vaccine types are currently available: recombinant OspA, or killed whole cell bacterin, or chimeric/recombinant OspA/OspC 2 initial doses, 2 to 4 weeks, are required regardless of the dogs age. NOTE: Small Breed Dogs (<20 pounds): consider delaying initial doses until the CORE vaccine series has been completed.Where risk of exposure is sustained, administer a single dose 1 year following completion of the initial 2-dose series, then every year thereafter. OPTION: For dogs residing in endemic regions, administration of the first booster 6 months following completion of the initial 2-dose series is a reasonable alternative schedule. An additional booster is recommended at 1 year following completion of the initial series with annual vaccination recommended thereafter.Canine Influenza Virus-H3N8 (killed)2 initial doses, 2 to 4 weeks apart are required. Where risk of exposure is sustained, administer a single dose 1 year following completion of the initial 2-dose series, then every year thereafter.Canine Influenza Virus-H3N2 (killed)2 initial doses, 2 to 4 weeks apart are required. Where risk of exposure is sustained, administer a single dose 1 year following completion of the initial 2-dose series, then every year thereafter. NOTE: Canine coronavirus vaccination is not recommended. NOTE: Crotalus atrox (Western Diamondback rattlesnake) vaccine should only be used in dogs with a defined risk for exposure. Follow the manufacturers recommendations for dosing. Overdue for Vaccination Studies focused on dogs that are overdue for routine vaccination have not been published. The following recommendations represent expert opinion and are intended to provide a practical approach to immunizing dogs when conventional vaccination guidelines have not been followed: Overdue during the initial vaccine series: While most practices administer the initial core vaccine series to young dogs at intervals of 3 to 4 weeks, dogs exceeding a 6-week interval between any of the initial doses should receive 2 additional doses, 3 to 4 weeks apart. The same is true during the initial 2-dose series recommended for dogs receiving non-core vaccines. If the interval between doses exceeds 6 weeks, 2 additional doses, 3 to 4 weeks apart should be administered. Overdue for CORE vaccine booster: administer a single dose of a combination core vaccine regardless of the number of years that have lapsed. Overdue for RABIES booster: requirements for re-vaccination of dogs that are overdue for a rabies booster vary from State to State, and may vary within an individual State. Many States follow recommendations published in the 2011 Rabies Compendium that states: administer a single dose, after which the dog will be considered immediately immunized. Overdue for Leptospirosis, Lyme and/or parenteral Bordetella booster: dogs that are within 2 years of a previous dose may receive a single dose. Dogs exceeding a 2-year interval should re-start the initial 2-dose series. Overdue for intranasal or intraoral Bordetella booster: administer a single dose regardless of the number of years that have lapsed. Overdue for Canine Influenza Virus booster: dogs that are within 3 years of a previous dose may receive a single dose. Dogs exceeding a 3-year interval should re-start the initial 2-dose series. PART II: Questions on Vaccination Protocols The following questions are among most commonly asked questions Ive received that address vaccination protocols and recommendations. The responses are based on our understanding of immunologic principles as they apply to vaccines and vaccination as well as the collective opinion of internists, immunologists, and virologists If you have a question that is not represented here, I can be contacted at the email address below and Ill get a response to you.  1. Reducing the 1.0 mL vaccine dose for small breeds: This seems to be a relatively common practice todayBut it should NOT be. Generally, this is done for (at least) 2 reasons: a. Administering a 1.0 mL dose of vaccine to a 4 pound dog seems excessive when a the same dose is required for a 110 pound dogand b. Reducing the volume might reduce the risk of an adverse reaction (this is commonly done with leptospirosis and killed Lyme vaccines) when administering vaccine to small breed dogs. While all vaccine licensing studies are based on ~10 kg beagles, arbitrarily reducing the administered volume of vaccine because the patient weighs 2 kg may induce an immune response that is below that required to induce (or sustain) protectionfact is, youre experimenting. There are no published studies addressing the weight:vaccine dose. One might also argue that the 1.0 mL dose administered to a 110 pound Great Dane might be inadequatethats not been studied either. An immune response subsequent to administering a vaccine (biological product) is far more complex (antigen processing and presentation; expression of epitopes, B-cell activation, etc.) and quite unlike that associated with administering an antibiotic (pharmaceutical product). Additionally, if a dog/cat is truly hypersensitive to one or more components of a vaccine, simply reducing the volume is certainly no guarantee that the risk of a reaction will be reduced. Because inactivated (usually adjuvanted) vaccines tend to be associated with adverse reactions (although this is still argued), we (AAHA Guidelines Task Force) have recommended that veterinarians avoid administering multiple vaccine doses at a single appointment to small breed (< 10 kg estimated adult body weight) dogs. It is also recommended to give the full dose, but delay administration of non-core (optionaland usually killed) vaccines to small breed dogs until at least 2 weeks after administering core (priority) vaccines. Informal surveys with veterinarians who practice this approach to small breed dogs suggest that client compliance (additional vaccine appointments) is highespecially when it is explained that the reason for doing so is safety. REF: Moore GE, Guptill LF, Ward MP, et al. Adverse events diagnosed within three days of vaccine administration in dogs. J Am Vet Med Assoc. 227:11021108, 2005. REF: Ford RB: Acute Post-vaccinal Angioedema. Todays Veterinary Pract. 3:Jan-Feb, 2013 (accepted for publication). Available at:  HYPERLINK "http://www.tpvjournal.com" www.tpvjournal.com REF: 2011 AAHA Canine Vaccination Guidelines; available at:  HYPERLINK "http://www.aahanet.org" www.aahanet.org 2. If maternal antibody is so likely to interfere with a dose of vaccine administered at 6 to 8 weeks of agewhy even worry about this dose? Over the past few years, vaccination guidelines for the dog and the cat have emphasized extending the initial vaccine series to 14-16 weeks (dog) and 16 weeks (cat) to avoid vaccine interference with maternally derived antibody. Sowhy even bother with giving a dose at 6 to 8 weeks of age. Answer: in practice, there is really no practical means of measuring of interfering levels of maternal antibody. Conventional recommendations to administer the first dose between 6 and 8 weeks of age is intended to provide protection in the event there is no maternal antibody present. If, in fact, maternal antibody is not present at 6 weeks of age (eg, orphan pup), a single dose of a core vaccine will, quite likely, immunize. The goal is to be there with vaccine when maternal antibody is not there. Hence, the recommendation the initial vaccine series beginning at 6 to 8 weeks of age. 3. VACCINE TITERS: The demand for assessing antibody levels induced by vaccines has increased substantially over the past 2 years. Titers can be measured by either sending serum to a commercial laboratory or protective levels can be documented through use of test kits for point-of-care testing in practice (~25 minutes per test run). IMPORTANT: There are some limitations to be aware of. A positive result (does correlate with protection when assessing parvovirus (canine/feline) and canine distemper and adenovirus. But not all titers correlate with protection. For example, leptospirosis titers are measured in an attempt to diagnose infection, but the antibody levels do NOT correlate with protection. Same with Rabiesa titer can be measured, but rabies antibody titers represent prior/recent exposure to vaccination; they are NOT a legal index of protection. NO STATE in the US recognizes rabies antibody titers as protective. Indications for testing include: a. Assessing the antibody response following completion of the initial vaccine series (test 2 to 4 weeks following the last dose in the initial series). This is a valuable means of assessing whether maternal antibody interference OR identifying a so-called genetic non-responder (they still exist). b. Assessing antibody levels in a patient with a chronic illness (or history of immune-mediated disease) in which boosters might not be indicated. A positive test result indicates 2 things: (1) the patient is protected, and (2) the patient has memoryie, the presence of antibody indicates B-cell activation and memorywhich for parvovirus, distemper virus, and adenovirus likely correlates with life-long protection even though the antibody levels may decline in the future. c. Distinguishing protected from susceptible animals in the event of an infectious disease outbreak (eg, shelter-housed dogs). Knowledge of the antibody level enables selective isolation/fostering and avoids the need to arbitrarily euthanize large numbers of animals. 4. LEGAL LIABILITY: Guidelines vs. Manufacturer recommendations? True malpractice litigation linked to vaccination is rare in veterinary medicine. Yet, veterinarians continue to challenge the legality of administering (core) vaccines triennially when the majority of vaccine labels (package inserts) recommend annual vaccination. Weve looked at this issue carefully and from the legal perspective. Heres how it goesthe manufacturer cites recommendations for administering a vaccinenot requirements. FACT: with the exception of RABIES (which is required by State or Local statutes) veterinarians have considerable discretion in the selection and use of vaccine. There is nothing illegal about administering a vaccine every 3 years when the manufacture recommends annual boosters. Its your choice. 5. VACCINE STABILITY IN THE VIAL. Once a freeze-dried (lyophilized) is re-hydrated (reconstituted to a liquid state), how long will the vaccine remain stable and immunogenic? Vaccines sold as a freeze-dried (lyophilized) product (typically MLV vaccines) should be used promptly following reconstitution regardless of whether it is are stored in the refrigerator. Especially important is the fact that once reconstituted, MLV vaccines are susceptible to degradation and may become inactive within hours. In the case of canine distemper vaccines, for example, the reconstituted product can become inactive within 2 hours. THEREFOREwe have recommended the following: 1 HOURuse it.or lose it! regardless of how its stored. REF: 2011 AAHA Canine Vaccination Guidelines; available at:  HYPERLINK "http://www.aahanet.org" www.aahanet.org 6. Intranasal or Oral Bordetella vaccine given SQ! It happens. An intranasal or oral Bordetella bronchiseptica vaccine is inadvertently administered by the subcutaneous routeWhat action, if any, is appropriate? IMPORTANT: any vaccine specifically licensed for administration onto a mucosal surface (intranasal, conjunctival, or oral) is a live, attenuated bacteria or virus. (Killed vaccines administered onto a mucosal surface are not immunogenic). Because some of the Bordetella vaccines (intended for intranasal or oral administration) are sold in vials that resemble parenteral products, they are occasionally injected into the patient, usually via the SQ route. While anecdotal reports from veterinarians suggest that many dogs tolerate SQ injection of an IN or oral Bordetella vaccine with minimal consequences, some dogs will develop severe injection-site reactions, and a very small number are at risk of dyingfrom acute hepatic failure. In the event this does happenadministering an antibiotic (preferably doxycycline or amoxicillin-clavulanic acid) at conventional doses for at least 5 to 7 days starting as soon as possible subsequent to the injection. If an abscess develops at the injection site, it should be opened, drained and thoroughly lavaged. Although attenuated, the Bordetella bronchiseptica in the vaccine is live and is susceptible to antibiotics. Simply diluting the vaccine by injecting sterile saline into the injection site is not a reasonable treatment. AND.as a reminderwhen administering an intranasal or oral vaccine to a patient, it would be wise to assure that the patient is NOT also receiving concurrent antibiotic therapythereby avoiding the risk of killing the vaccine. 7. RABIES VACCINATION and the RABIES AWARENESS INITIATIVE. Rabies immunization is the ONLY companion animal vaccine that is required (at least in most States) by law. And, in many States, only a licensed veterinarian is authorized to administer the vaccine. While its not the veterinarians responsibility to ensure that animals are vaccinated, it is the veterinarians responsibility to understand State (and local) rabies law and the implications of rabies regulations when, for example, a dog/cat bites a human, or when a pet that is overdue for a rabies booster is exposed to rabies (wildlife or an unvaccinated dog). The application, interpretation, and enforcement of rabies vaccination laws is well known to vary significantly from State to State, and can even vary within States. We have learned that practitioner awareness of complex and sometimes conflicting rabies laws can lead to considerable confusion, misinterpretation of State/Local statutes, and inappropriate actionssome of which have led to unnecessary euthanasia of dog/cats. Knowledge and application of State/Local rabies law by veterinarians is further compounded in some States by outdated online resources, disparate distribution of rabies information, and the complexity of State/Local government websites citing immunization law. To address the most critical issues concerning Rabies Immunization and Law, the Rabies Awareness Initiative has been initiative for veterinarians practicing in the US (and Puerto Rico) The Rabies Awareness Initiative is a national educational program that is supported by Merial Ltd (Duluth, GA). Content is solely derived from the rabies control authorities in each state, generally the State Public Health Veterinarian. The National Association of State Public Health Veterinarians, Inc. has provided input on content structure and future implementation. The goal of the Rabies Awareness Initiative is to raise veterinarians awareness of (individual) State immunization requirements for rabies, enhance clinical services to companion animal clientele, and promote rabies vaccination compliance among pet owners. Online resources will soon be available (January 2016) that will significantly enhance access to a series of must know rabies vaccination issues facing veterinarians in clinical practice. Updated February 2016  World Small Animal Veterinary Associations Vaccine Guidelines-2016: soon to be available at  HYPERLINK "http://www.wsava.org" www.wsava.org.      HYPERLINK "mailto:rbford@ncsu.edu" rbford@ncsu.edu 123KLjkz~? Q  ! " + xpxpxh`X`P`p`phmcCJaJhdCJaJhxCJaJhACJaJh2!CJaJhgvCJaJhCJaJh@!hb[qCJaJh CJaJh=th[CJaJh=thsCJaJhsCJaJhb[qCJaJh=thb[qCJaJh@!hb[q5CJaJhAI5CJaJhd5CJaJhe[5CJaJh@!hhDF5CJaJ23Lk h i 9 : +v~Hgdgd2!$a$gd9$a$gd[+ 5 6 P e {     , - s {  ! , - 7 ; L d g h j p , 7 8 ; < D ̼ԴԼԼļĴļܠܴܘܴܐh CJaJhx[CJaJh*CJaJhkh,<65CJaJh JCJaJhgCJaJhkCJaJhCJaJhxCJaJhgvCJaJh,<6CJaJhxh,<65CJaJh2!CJaJhmcCJaJ5D N ^ j p u x +-?Ituv~DU{skshaCJaJhCJaJh`CJaJhCJaJhmcCJaJhx[6CJaJhzzCJaJh JCJaJhCJaJhxCJaJh*CJaJh CJaJhgCJaJhLhCJaJhI)hI)5CJaJhI)CJaJhvJCJaJhx[CJaJ'*456FGQ]hmyz} .ʷݟv埗埗էէէ՗ha6CJaJhJ/4CJaJhCJaJhh3CJaJhx[CJaJhnCJaJh*CJaJhkxCJaJ%jh@!h?0JCJU^JaJh@!h?CJaJh`CJaJh JCJaJhaCJaJhCJaJh@!hDCJaJ.FHIJKTgvwx!$%&}rrrrrjah>*CJaJhCJaJh@!hCJaJh#h6CJaJh@!h5CJaJhCJaJh`5CJaJhzg-5CJaJhh5CJaJhx[CJaJh6CJaJhd]h6CJaJhd]hCJaJhd]h5CJaJh5CJaJhCJaJ"HIJKwx $$Ifa$gdh$a$gd`gdn$I@@@@@@ $Ifgdhkd$$IflF '    t0r'6    44 lapyth$%&[+4 $Ifgd+*CJaJh5>*CJaJhCJaJht'hCJaJh+*CJaJh6CJaJh5N8hCJH*aJh@!hCJaJhF[hCJaJhnh>*CJaJh+*CJaJh0h>*CJaJhVzhCJaJht'hCJaJht'h5CJaJh"oh5>*CJaJh6CJaJh@!h>*CJaJhCJaJh@!hCJaJh5N8hCJaJh+$$IflF '   t0r'6    44 layth $Ifgdh lnw3DEXY]^beuvx%'FGHLO\_mpy~¶ߪߪߕԪԕԡ{{{{h@!h6CJaJh2h6CJH*aJhV$h5CJaJh6CJaJh2h6CJaJh2h5CJaJhLh5CJaJh+*CJaJh+h>*CJaJ0\]^GHZ [ i ekd$$IflF '   t0r'6    44 layth $Ifgdh  # * Y _ g j !6!7!8!*CJaJhCJaJh@!hCJaJh@!h6CJaJh6CJaJ3i 4!5!6!7!8!!I"J"# & F$IfgdQ $Ifgdh######z$neeeee $IfgdhkdN$$IflF '    t0r'6    44 laytJ$y${$$$$$$$$$$"%4%;%j%l%m%t%%%%%Z&[&\&s&t&u&'ººvk`Uhh:8CJaJhLh5>*CJaJh:85>*CJaJh$h:85>*CJaJhh:8CJaJhh:86CJaJh{h:8CJaJh:85CJaJhh:8CJaJh:8CJaJh@!h:8CJaJh:8h:8CJaJh5CJaJh:8h5CJaJh@!hCJaJhCJaJz${$$$$$k%nee\ee $Ifgd $Ifgdhkd$$IflF '    t0r'6    44 laytk%l%m%%[&\&t&u&''nf]]XPPXX$a$gd:8gd:8^gd:8$a$gdkdz$$IflF '    t0r'6    44 layt ''s)))))*****M+Y+e+~+++++++C,E,Q,[,_,h,~,,,,,,--V-Y---------˲˲ছ˓~uhpa;5CJaJhpa;h5CJaJhj5CJaJhCJaJhh:8CJaJhh:86CJaJhh:85>*CJaJh:85>*CJaJh:85CJaJhh:86CJaJh:8CJaJhh:8CJaJhh:85CJaJ-'((r)s)**d+e+D,E,,,------------.///$a$gdgd:8------..///K/x///////// 00070@0A0I0J0S0T0X0]0000ٮ~v~vjv~b~b~b~bZ~Zh*CJaJh2vCCJaJhR[h)5CJaJh)CJaJh5P1CJaJhpa;5CJaJh5P1CJaJh5P15CJaJjh5P1UmHnHuhLhCJaJh5P1hjCJaJh/+CJaJhjCJaJh)CJaJh5P1h/+CJaJhj5CJaJh5CJaJh/+5CJaJ#////////X0Y00011z3{344O5P5K8L889':(:):gd2/gdR[gdhgdpa;$a$gd00000&1.1h1i11111112'222P2Y2w22222222y3z3{3|33334444Y4Z4w4444444O5P5g6h6m66666e7f7ȴȴЬУЛhd<6CJaJhd<CJaJhR[>*CJaJhLhCJaJh-h-6CJaJhjCJaJh-CJaJhR[CJaJh)CJaJh2vCCJaJh5P1CJaJh*CJaJhQsCJaJ9f7C8I8J8K8L8O8888889989t9u999999999::$:%:':(:´¬qhYNhR[h2/CJaJhD1h2/0JCJ^JaJh2/5CJaJhubh2/0JCJ^JaJjh2/CJUaJh2/6CJaJh&h2/CJaJh&h2/5CJaJh2/CJaJh,h2/6CJ]aJh,h2/CJaJh,h2/5CJaJh2/CJaJh)CJaJhvJhd<56>*CJaJhd<CJaJ(:):*:+:,:s::::::;];;;'<:<Q<<<<===3>4>5>6>:>縰}umumbZNhQshQs5CJaJhfCJaJhLhhjCJaJh 6CJaJhLhCJaJhLh6CJaJhH86CJaJhH8CJaJhj6CJaJhpa;CJaJhjCJaJhCJaJhCJaJhI)5CJaJh#65CJaJhpa;5CJaJhpa;hpa;5CJaJhvJ5CJaJh2vCCJaJhR[CJaJ):*:::;;4>5>6>AABDC+E?FAFpIqILLRLSLLLLLMM$a$gd2/gd2/gdfgdh:>B>C>I>J>K>>>???????_@@~AAAAAAAABBCCCDCDDDD?F@FAFCFEFTFFHHκάΤƜƜ֔|tkhc\6CJaJhc\CJaJhQsh~c5CJaJhQshQs5CJaJhfCJaJh@dCJaJh8fCJaJh8fh&U5>*CJaJhNh&U>*CJaJhNCJaJh&UCJaJhH8CJaJhQs5CJaJhQshH85CJaJhQshf5CJaJ*H2HAHHHI)IZI\IoIpIqIIIIIJ JJJJJKKLL1L2L3LRLSL^LLLLLLLLLʾ޶޶޶޶ުޓphhCJaJhD1h2/0JCJ^JaJjh2/CJUaJh2/CJaJh2/5CJaJh2/h2/56CJaJh2/h2/5CJaJhQsCJaJhQsh2/5CJaJhQshQs5CJaJhfCJaJh2/CJaJh2/6CJaJhc\6CJaJhc\CJaJ&LLLLLLLLLMM%M0M>MBMIMMMMMMiN[O]OoOpOPPQQQQƺ匀xxph`p``p`X`Xh?CJaJhP}CJaJhc\CJaJhI)CJaJhCJaJhh6CJaJhh2/6CJaJh2/6CJaJhh2/56CJaJhv 56CJaJhv hQs5CJaJhQs56CJaJhv CJaJhv hv 5CJaJh2/CJaJhQsCJaJh2/h2/CJaJMpOqOPPRRSSS V VXXwYxYZZ\@]]]]]]]]gd?gd\`gdgdfQQ RRRRR_SSSSSSSSSSSSSS7T@T|TGUJUhU V V VVVWXvXXxY˿ӔӔӌ|||q|qqih\`CJaJhhCJaJhCJaJh8fCJaJhrCJaJhg<CJaJhI)hI)56CJaJhI)5CJaJhg.hf5CJaJhg.hg.5CJaJhCJaJhI)CJaJhQsCJaJh?hP}CJaJh?CJaJh?6CJaJ#xY|YYZZZZZ[[[[[([5[>[B[O[T[n[y[[[[[\\*]?]躩vnnfnvvnvfn^Uh?6CJaJh?CJaJh|.CJaJhg<CJaJhhCJaJh\`h5CJaJh\`h\`5CJaJh\`CJaJhCJaJ h\`h\`5B* CJaJph(h\`B*CJaJfHph"""q 1h\`h\`5B*CJaJfHph"""q .h\`h\`B*CJaJfHph"""q ?]@]A]B]g]]]]]]]]]]]]]]]]]]]]]]]] ^ ^ҳ}u}u}u}u}l_l_jh2vCh@dUaJh2vCh@daJjh#`Uh#`(h+*B*OJQJ^Jph#jh+*B*^JaJph<P1h:p / =!"#$% Dp$$If!vh#v~ #vz :V l  t0r'65 5 pyth$$If!vh#v~ #vz :V l t0r'65 5 yth$$If!vh#v~ #vz :V l t0r'65 5 yth$$If!vh#v~ #vz :V l  t0r'65 5 pyth$$If!vh#v~ #vz :V l t0r'65 5 yth$$If!vh#v~ #vz :V l t0r'65 5 yth$$If!vh#v~ #vz :V l t0r'65 5 yth$$If!vh#v~ #vz :V l t0r'65 5 / yt$$If!vh#v~ #vz :V l t0r'65 5 / yt$$If!vh#v~ #vz :V l t0r'65 5 / ytDyK www.wsava.orgyK Dhttp://www.wsava.org/yX;H,]ą'cs2 0@P`p2( 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p8XV~ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@_HmH nH sH tH L`L Normal$CJOJQJ^J_HaJmH sH tH ^^ 7 Heading 1$<@&"5CJ KH OJPJQJ\^JaJ DA D Default Paragraph FontRi@R 0 Table Normal4 l4a (k ( 0No List >@> 0 Footnote TextCJaJH/H 0Footnote Text Char OJQJ^JD&`D 0Footnote ReferenceH*^JP/!P p$info1.B*CJOJQJ^JaJfHphq :U`1: y0 Hyperlink>*B*^JphJV AJ y0FollowedHyperlink>*B* ^JphHRH V-0 Balloon TextCJOJQJ^JaJN/aN 0Balloon Text CharCJOJQJ^JaJjsj *vs Table Grid7:V0PP C List Paragraph ^m$ OJQJ^JV/V 7Heading 1 Char"5CJ KH OJPJQJ\^JaJ .X . 7Emphasis6]88 V'apple-style-spanBB V'apple-converted-spacePK![Content_Types].xmlN0EH-J@%ǎǢ|ș$زULTB l,3;rØJB+$G]7O٭VvnB`2ǃ,!"E3p#9GQd; H xuv 0F[,F᚜K sO'3w #vfSVbsؠyX p5veuw 1z@ l,i!b I jZ2|9L$Z15xl.(zm${d:\@'23œln$^-@^i?D&|#td!6lġB"&63yy@t!HjpU*yeXry3~{s:FXI O5Y[Y!}S˪.7bd|n]671. tn/w/+[t6}PsںsL. J;̊iN $AI)t2 Lmx:(}\-i*xQCJuWl'QyI@ھ m2DBAR4 w¢naQ`ԲɁ W=0#xBdT/.3-F>bYL%׭˓KK 6HhfPQ=h)GBms]_Ԡ'CZѨys v@c])h7Jهic?FS.NP$ e&\Ӏ+I "'%QÕ@c![paAV.9Hd<ӮHVX*%A{Yr Aբ pxSL9":3U5U NC(p%u@;[d`4)]t#9M4W=P5*f̰lk<_X-C wT%Ժ}B% Y,] A̠&oʰŨ; \lc`|,bUvPK! ѐ'theme/theme/_rels/themeManager.xml.relsM 0wooӺ&݈Э5 6?$Q ,.aic21h:qm@RN;d`o7gK(M&$R(.1r'JЊT8V"AȻHu}|$b{P8g/]QAsم(#L[PK-![Content_Types].xmlPK-!֧6 0_rels/.relsPK-!kytheme/theme/themeManager.xmlPK-!R%theme/theme/theme1.xmlPK-! ѐ' theme/theme/_rels/themeManager.xml.relsPK] "V:"V:="V + D &GlJ$'-0f7(::>HLQxY?] ^"^023459;>ACFIKMNOQRSUVWYH$4Hu\i #z$k%'/):M]"^1678:<=?@BDEGHJLPTXt11112$2DDD"VXXXbX&6=X8@(  P  R?"Text Box 2s"Ð?PK!8[Content_Types].xmlAN0EH%N@%邴K@`dOdlyLhoDX3'AL:*/@X*eRp208J妾)G,R}Q)=HiҺ0BL):T뢸WQDY;d]6O&8* VCLj"󃒝 yJ.;[wIC_ :{IOA !>Ø4 p;fɑ3׶Vc.ӵn(&poPK!8! _rels/.relsj0 }qN/k؊c[F232zQLZ%R6zPT]( LJ[ۑ̱j,Z˫fLV:*f"N.]m@= 7LuP[i?T;GI4Ew=}3b9`5YCƵkρؖ9#ۄo~e?zrPK!&b%Gdrs/e2oDoc.xmlSێ }@7vIvcYmMUi{v $vp6KU sfVV `*:áfWѯO77LQѣvժ(GBey 0litqGt"YoG']'<|n[/QB]g+wNSL u#{'Ғ;І AJ.R X4QcǬH 9ޞi:|qD6-הQ'1RD~zK {FS>扁MN9}'XM#Ha hh!QY j/7EX: $*P>tXdJ%rQi ^)C.|dyZ2`++zsbeiR?&xƔ9Y C=9"IC%=vuE=s,l 5rHܥ0 itaDly+vk4Yq.k?PK!H['rdrs/downrev.xmlLAO0 HHXc*MmH\&)Mڕ9b3{'&;.BTQzAj6U g!sЦRƺ"rhL7۪acU>nݷַ7Ds??|FNa$$ ٚٽZpţR B^PK-!8[Content_Types].xmlPK-!8! /_rels/.relsPK-!&b%G.drs/e2oDoc.xmlPK-!H['rdrs/downrev.xmlPK B S  ?'"V 4r=T **m-w-[0b0 111161@5B5F<H<==QQ;U?U@UUUUUUUUUU V#V *3&&&Y(j(((**91=1:":D;Q;@UUUUUUUUUU V#V3333333333jDDDDLELEGMJMM N N NNNPS5S>SBSOSUSUSnSySSTT?U@U@UBUBUUUUUUUUUUVV#VjDDDDLELEGMJMM N N NNNPS5S>SBSOSUSUSnSySSTT?U@U@UBUBUUUUUUUU#V{- BŸ]S`vj$Z,#F0U+$$zMT@,[(:2X3NGbː48^:N^ERO`M'q<PD~U?`US$h]c9cbpFR 5ltob^yҗh ^`o(hH. ^`hH. pLp^p`LhH. @ @ ^@ `hH. ^`hH. L^`LhH. ^`hH. ^`hH. PLP^P`LhH.^`^Jo()^`^J.pLp^p`L^J.@ @ ^@ `^J.^`^J.L^`L^J.^`^J.^`^J.PLP^P`L^J.h^`OJQJo(hHh^`OJQJ^Jo(hHohp^p`OJQJo(hHh@ ^@ `OJQJo(hHh^`OJQJ^Jo(hHoh^`OJQJo(hHh^`OJQJo(hHh^`OJQJ^Jo(hHohP^P`OJQJo(hH^`^Jo()^`^J.pLp^p`L^J.@ @ ^@ `^J.^`^J.L^`L^J.^`^J.^`^J.PLP^P`L^J.^`5o(.^`.pL^p`L.@ ^@ `.^`.L^`L.^`.^`.PL^P`L.h ^`hH.h ^`hH.h pL^p`LhH.h @ ^@ `hH.h ^`hH.h L^`LhH.h ^`hH.h ^`hH.h PL^P`LhH.h^`^J.h^`^J.hpLp^p`L^J.h@ @ ^@ `^J.h^`^J.hL^`L^J.h^`^J.h^`^J.hPLP^P`L^J.h^`OJQJo(hHh^`OJQJ^Jo(hHohp^p`OJQJo(hHh@ ^@ `OJQJo(hHh^`OJQJ^Jo(hHoh^`OJQJo(hHh^`OJQJo(hHh^`OJQJ^Jo(hHohP^P`OJQJo(hHh ^`hH.h ^`hH.h pL^p`LhH.h @ ^@ `hH.h ^`hH.h L^`LhH.h ^`hH.h ^`hH.h PL^P`LhH.h^`OJQJo(hHh^`^J.hpLp^p`L^J.h@ @ ^@ `^J.h^`^J.hL^`L^J.h^`^J.h^`^J.hPLP^P`L^J.h^`^J.h^`^J.hpLp^p`L^J.h@ @ ^@ `^J.h^`^J.hL^`L^J.h^`^J.h^`^J.hPLP^P`L^J.h^`OJQJo(hHh^`^J.hpLp^p`L^J.h@ @ ^@ `^J.h^`^J.hL^`L^J.h^`^J.h^`^J.hPLP^P`L^J.h ^`OJQJo(h ^`OJQJo(oh p^p`OJQJo(h @ ^@ `OJQJo(h ^`OJQJo(oh ^`OJQJo(h ^`OJQJo(h ^`OJQJo(oh P^P`OJQJo( ^`hH. ^`hH. pL^p`LhH. @ ^@ `hH. ^`hH. L^`LhH. ^`hH. ^`hH. PL^P`LhH.h^`^J.h^`^J.hpLp^p`L^J.h@ @ ^@ `^J.h^`^J.hL^`L^J.h^`^J.h^`^J.hPLP^P`L^J.h ^`hH.h ^`hH.h pL^p`LhH.h @ ^@ `hH.h ^`hH.h L^`LhH.h ^`hH.h ^`hH.h PL^P`LhH.^`^Jo()^`^J.pLp^p`L^J.@ @ ^@ `^J.^`^J.L^`L^J.^`^J.^`^J.PLP^P`L^J.h^`OJQJo(hHh^`^J.hpLp^p`L^J.h@ @ ^@ `^J.h^`^J.hL^`L^J.h^`^J.h^`^J.hPLP^P`L^J.h ^`OJQJo(h ^`OJQJo(oh p^p`OJQJo(h @ ^@ `OJQJo(h ^`OJQJo(oh ^`OJQJo(h ^`OJQJo(h ^`OJQJo(oh P^P`OJQJo(h ^`OJQJo(h ^`OJQJo(oh p^p`OJQJo(h @ ^@ `OJQJo(h ^`OJQJo(oh ^`OJQJo(h ^`OJQJo(h ^`OJQJo(oh P^P`OJQJo(?`U$Z8^:NS`,c9c5ltq<Pb^yG#bpERO3~U$h]U+$${- 2                                    lʬr                                                                                                                                               E alA P,&W H8:pQ?%IF   8 < ' U \09];qc> h?&Ugv)'\,Y|oj 2!"F4"L"p$$l-$/$$Q%j-% 7%5B%3T%|%B&-'V'.(I)Y)d+&U+,,-$-zg- .i .2.aH.2/305P1213h3J/4p,5Ja5#6,<6OA6a6o6{6K78878:85N899Pa9kE;pa;C <<=#>b> ?a@kA2vCxC++D;DeaD.ETE[EhDFpG;WH!N2ZyDc d9pomc{LAd<.SnhL]y8-o"oa7$\=tKs7~W(KTI)Y|=7 fVt+CJ^I]%[&QUw /+ W6":[@Z0 6?PQ V--G@!m?@/N=B]%$ BFK /QG:\me*C>V`j?@ABCDEFGHIJKLMNOPQRSTUVWXYZ\]^_`abdefghijklmnopqrstuvwxyz{|}~Root Entry F ZΘData [1TablecNhWordDocument >SummaryInformation(DocumentSummaryInformation8MsoDataStoreJΘWΘMDJYUOI44A==2JΘWΘItem  PropertiesUCompObj r   F Microsoft Word 97-2003 Document MSWordDocWord.Document.89q