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Issue 1048
IAC Express: Weekly immunization news and information
IAC Express 1048: April 2, 2013

TOP STORIES

VACCINE INFORMATION STATEMENTS

FEATURED RESOURCES

EDUCATION AND TRAINING

CONFERENCES AND MEETINGS


TOP STORIES

CDC study indicates vaccines recommended for young children during the first two years of life do not increase the risk of autism
On March 29, the Journal of Pediatrics published an online article titled Increasing Exposure to Antibody-Stimulating Proteins and Polysaccharides in Vaccines Is Not Associated with Risk of Autism. According to information from CDC, "the study looked at the amount of antigens from vaccines received on one day of vaccination and the amount of antigens from vaccines received in total during the first two years of life and found no connection to the development of autism spectrum disorder (ASD) in children."

Related Links
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CDC publishes report on measles outbreaks after importation
CDC published Two Measles Outbreaks After Importation—Utah, March–June 2011 in the March 29 issue of MMWR (pages 222-225). The first paragraph and other selected paragraphs are reprinted below.

Before licensure of a measles vaccine in 1963, more than 500,000 measles cases on average were reported in the United States each year during 1951–1962. By 1993, through measles vaccination and control efforts, only 312 cases were reported nationwide. In 2000, the last year in which an outbreak had occurred in Utah, measles was declared "not endemic in the United States," but measles importations continue to occur, leading to outbreaks, especially among unvaccinated persons. Many U.S. health-care personnel have never seen a measles patient, which might hamper diagnosis and delay reporting. During March–June 2011, local health departments collaborated with the state health department in Utah to investigate two measles outbreaks comprising 13 confirmed cases. The first outbreak, with seven confirmed cases, was associated with an unvaccinated U.S. resident who traveled internationally; the second, with six confirmed cases, had an undetermined source. The genotype D4 sequences obtained from these two outbreaks differed by a single nucleotide, suggesting two separate importations. Health-care providers should remind their patients of the importance of being current with measles, mumps, and rubella (MMR) vaccination; this is especially important before international travel. Measles should be considered in the differential diagnosis of febrile rash illness, especially in unvaccinated persons with recent international travel. Reporting a confirmed or suspected case immediately to public health authorities is critical to limit the spread of measles. . . .

For both outbreaks, approximately 13,000 contacts of patients were notified by visit, phone, letter, or e-mail. Health officials reviewed vaccination records of approximately 8,700 exposed persons, conducted 253 measles IgG antibody tests, and administered 484 MMR vaccine and 28 measles immunoglobulin doses as postexposure prophylaxis. Voluntary home quarantine of 192 exposed persons without presumptive evidence of immunity was requested.

Because measles remains endemic in many regions of the world, the United States continues to be at risk for measles importations and outbreaks. In 2011, a total of 220 measles cases were reported in the United States, the highest number of reported measles cases since 1996; 89% were associated with importations. The outbreaks in Utah and elsewhere during 2011 highlight the critical need for appropriate vaccination of U.S. residents, particularly those who travel internationally. The Salt Lake County outbreak began when an unvaccinated traveler from the United States developed measles on returning to the United States and infected four other unvaccinated persons . . . .

For patients with risk factors for measles (e.g., unvaccinated status, recent travel history, or known epidemiologic link to a confirmed measles case), health-care providers and public health officials should consider measles in the differential diagnosis of febrile rash illness and should consider other potential exposures, including parvovirus, when ordering laboratory tests. Because measles now occurs so rarely in the United States, interpretation of measles tests can be challenging, especially during outbreaks, and confirming and correctly classifying measles in vaccinated persons can be particularly difficult. False-positive measles IgM results might be obtained in response to infections caused by parvovirus and other viruses, including enteroviruses, Epstein-Barr virus, and varicella zoster virus. The capture IgM assay methodology available at CDC's Measles Virus Laboratory generally is less prone to nonspecific reactions; however, the low prevalence of measles in the United States results in a low positive predictive value regardless of the IgM assay used. Serum and respiratory specimens both should be collected from suspected patients at first contact, because serological testing coupled with molecular testing provides the best opportunity for laboratory confirmation.

Measles cases and outbreaks can have considerable impact on communities in the United States and often require substantial resources for public health response. Recognition of suspected measles cases by health-care providers and immediate reporting to public health officials can help limit illness and associated costs. For the two Utah outbreaks combined, those costs were estimated from multiple sources to exceed $330,000 for public health personnel time at state and local levels, vaccine administration, laboratory testing, and outbreak control efforts. Unvaccinated persons put themselves and their communities at risk for measles. Maintaining high vaccination coverage and rapid public health response is critical to ensuring continued measles elimination in the United States.


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CDC publishes report on three cases of congenital rubella syndrome in the U.S.
In the March 29 issue of MMWR (pages 226-229), CDC published Three Cases of Congenital Rubella Syndrome in the Postelimination Era—Maryland, Alabama, and Illinois, 2012. The first paragraph and selected text from the editorial note are reprinted below.

Infection with rubella virus during pregnancy, especially during the first trimester, can result in congenital rubella syndrome (CRS). Serious manifestations of CRS include deafness, cataracts, cardiac defects, mental retardation, and death. In the last major rubella epidemic in the United States, during 1964–1965, an estimated 12.5 million rubella virus infections resulted in 11,250 therapeutic or spontaneous abortions, 2,100 neonatal deaths, and 20,000 infants born with CRS. In 2004, after implementation of a universal vaccination program, elimination of endemic rubella virus transmission was documented in the United States; evidence also suggests that endemic rubella has been eliminated in the entire World Health Organization (WHO) Region of the Americas. However, rubella virus continues to circulate elsewhere in the world, especially in regions where rubella vaccination programs have not been established (e.g., the African Region), placing the United States at risk for imported cases of rubella and CRS. During 2004–2012, 79 cases of rubella and six cases of CRS were reported in the United States; all of the cases were import-associated or from unknown sources. Of the three cases of CRS that occurred in 2012, conditions included cardiac defects, cataracts, hearing impairment, and pericardial effusion in one infant; patent ductus arteriosus, cardiomegaly, thrombocytopenia, and pneumonitis in a second infant; and cataracts, thrombocytopenia, and cardiac defects in a third infant. All three mothers had been in Africa early in their pregnancies. While rubella remains endemic elsewhere in the world, imported CRS will continue to be a public health concern in the United States. . . .

Since 2004, when rubella and CRS elimination were documented in the United States, six cases of CRS have been reported, including the three cases described here. In five cases, infection of the mother in a foreign country was thought highly probable, given travel history (i.e., Nigeria, Tanzania, Sudan, Ivory Coast, and either India, China, or Singapore). In one case, the mother did not report international travel. Although few cases of CRS have been reported in the United States, rubella continues to circulate in many other parts of the world, and the risk remains for severe effects from CRS, including death. In this report, one of the three infants with CRS died. . . .

Health-care providers should consider CRS if the mother of an infant with compatible congenital birth defects traveled during her pregnancy to an area where rubella circulates or was exposed to someone who traveled to such an area. As a nationally notifiable condition, all suspected cases of CRS should be reported immediately to the local health department, which, in turn, reports them to CDC via the state health department. Both serum and throat swab specimens should be collected as soon as CRS is suspected. Either serum positive for rubella IgM antibody or a throat swab positive for rubella RNA is confirmatory for CRS in a patient with compatible signs.

At this time, during maintenance of CRS elimination in the United States, confirmation at CDC of all laboratory results that support diagnoses of CRS cases is recommended. Molecular characterization of the virus is critical because the viral genotype can substantiate the suspected source of the virus or suggest one if the source is unknown, because some of the circulating genotypes are associated with specific geographic areas. Heightened awareness, gathering of pertinent information, and collection of appropriate specimens are required of the health-care provider and public health department to diagnose and investigate a case of CRS; however, these surveillance efforts are crucial to maintaining elimination in the United States.

As long as rubella remains endemic in any area of the world, imported CRS will continue to be a public health concern in the United States. Residents or foreign visitors entering the United States from rubella-endemic areas can introduce the virus. In addition, infants born with CRS can shed infectious virus for several months; therefore, care must be taken to avoid contact with others who are susceptible to rubella (e.g., unvaccinated infants in day-care settings). Although levels of vaccination with rubella-containing vaccine are high in the United States, a small proportion of persons are not vaccinated for medical or personal reasons. Those who are not vaccinated against rubella virus can become infected if exposed. If a pregnant woman is infected with rubella virus, the fetus also can become infected. Fetal infection with rubella virus, especially early during pregnancy, often leads to CRS. The risk for CRS in the unborn child of a mother with rubella infection might be as high as 90% for infections occurring through week 10 of pregnancy. Clusters of unvaccinated persons are at high risk for an outbreak, as in the Netherlands and Canada in 2009. Health-care providers and public health workers should remain vigilant for imported cases of CRS.


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CDC publishes report on outbreak of severe respiratory disease in an assisted living facility
In the March 29 issue of MMWR (page 230), CDC published Notes from the Field: Outbreak of Severe Respiratory Illness in an Assisted-Living Facility—Colorado, 2012. The first three paragraphs and the last paragraph are reprinted below.

On May 28, 2012, the Colorado Department of Public Health and Environment (CDPHE) was notified of six cases of severe respiratory illness among 12 residents of an assisted-living facility (ALF) specializing in the care of elderly persons with dementia or memory loss. During May 22–27, 2012, five residents were hospitalized, and two developed invasive disease with Streptococcus pneumoniae (pneumococcal) bacteremia. S. pneumoniae is spread by airborne droplets and causes an estimated 175,000 hospitalizations and 50,000 cases of pneumococcal bacteremia each year. The case-fatality rate of pneumococcal bacteremia can be as high as 60% among the elderly.

CDPHE and CDC conducted an investigation to determine the extent of the outbreak and to assess the infection control capabilities at the facility. A probable case of pneumococcal disease was defined in a resident or staff member who received a diagnosis of pneumonia by a health-care provider during May 15–June 3, 2012. Confirmed cases met criteria for probable infection and also had
S. pneumoniae isolated from a normally sterile site. CDPHE performed serotyping of culture isolates from confirmed cases.

Two confirmed and five probable cases of pneumococcal disease were identified; six patients (two with confirmed and four with probable pneumococcal disease) were residents, and one patient with probable pneumococcal disease was a staff member. Three of the six resident patients died. Median age of the seven patients was 80 years (range: 39–97 years) and all had received the 23-valent pneumococcal polysaccharide vaccine, consistent with guidelines from the Advisory Committee on Immunization Practices. The staff member had received pneumococcal polysaccharide vaccine because of a history of asthma. . . .

To prevent future outbreaks of communicable illness in the Colorado ALF, CDC, and CDPHE provided recommendations to increase support and awareness of existing sick-leave policies among staff members (e.g., not reporting to work when ill), and to develop and implement written infection control policies that include staff education, adequate availability and appropriate use of personal protective equipment, and recognition and reporting of disease outbreaks to public health authorities.


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ACOG publishes committee opinion regarding integrating immunizations into practice
 In April, the American College of Obstetricians and Gynecologists (ACOG) published Integrating Immunizations Into Practice. The document was developed by ACOG's Immunization Expert Work Group, Committee on Obstetric Practice, and Committee on Gynecologic Practice. The abstract is reprinted below.

Given demonstrated vaccine efficacy, safety, and the large potential for prevention of many infectious diseases among adults, newborns, and pregnant women, obstetrician–gynecologists should embrace immunizations as an integral part of their women’s health care practice. To provide direct examples, evidence-based recommendations for three commonly administered immunizations by practicing obstetrician–gynecologists are discussed: 1) human papillomavirus vaccine, 2) influenza vaccine, and 3) tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis vaccine.

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IAC Spotlight! Where you'll find books and periodicals for reference and reading
The Books and Periodicals section on immunize.org provides up-to-date listings of key vaccine-related reference books and nonfiction reading material for healthcare professionals and their patients. For each item listed, you’ll find publication details, a brief summary, and ordering information.

The Reference Books web section includes books such as The Vaccine Handbook: A Practical Guide for Clinicians (4th edition) by Gary Marshall, MD; Vaccines (6th edition) by Stanley A. Plotkin, MD, Walter A. Orenstein, MD, and Paul A. Offit, MD; and Epidemiology and Prevention of Vaccine-Preventable Diseases (12th edition) by William Atkinson, MD, MPH, Charles (Skip) Wolfe, and Jennifer Hamborsky, MPH, CHES.

The Publications for Parents web section includes the new book for teens titled The History of Vaccines by Karie Youngdahl, Babi Hammond, and Michelle Sipics and Baby 411: Clear Answers and Smart Advice for Your Baby's First Year (5th edition) by Ari Brown, MD, and Denise Fields.

The Nonfiction Books web section includes books such as The Panic Virus: A True Story of Medicine, Science, and Fear by journalist Seth Mnookin and Deadly Choices: How the Anti-Vaccine Movement Threatens Us All by Paul A. Offit, MD.

The Periodicals web section includes journals on immunization topics and vaccine research.

If you have additional books or periodicals to recommend for inclusion on immunize.org, please send your suggestion(s) to maryq@immunize.org

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VACCINE INFORMATION STATEMENTS

VISs for MMR, varicella, hepatitis A, and hepatitis B vaccines now available in Hindi
IAC recently posted Hindi translations of the VISs for measles-mumps-rubella (MMR) vaccine, varicella vaccine, hepatitis A vaccine, and hepatitis B vaccine. IAC thanks the California Department of Public Health for the translations.
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FEATURED RESOURCES

AAP and ACOG publish 7th edition of Guidelines to Perinatal Care
Guidelines to Perinatal Care is a joint project of the American College of Obstetricians and Gynecologists (ACOG) and the American Academy of Pediatrics (AAP). The 7th edition provides updated information on maternal transport, definitions of levels of neonatal care, immunizations (including the hepatitis B birth dose), nutrition, and much more, with an added focus on patient safety and quality improvement. This unique resource addresses the full spectrum of perinatal medicine from both the obstetric and pediatric standpoint.

Related Links
The book is also available from various online booksellers.

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Influenza is serious; vaccination is recommended for nearly everyone, so please keep vaccinating your patients
Vaccination remains the single most effective means of preventing influenza. Vaccination is recommended for everyone age 6 months and older, so please continue to vaccinate your patients. If you don't provide influenza vaccination in your clinic, please recommend vaccination to your patients and refer them to the HealthMap Vaccine Finder to locate sites near their workplaces or homes that offer influenza vaccination services.

If you are seeking influenza vaccine for your clinic, check the Influenza Vaccine Availability Tracking System (IVATS), which is a resource for healthcare settings looking to purchase influenza vaccine. The IVATS chart contains information from approved, enrolled, and participating wholesale vaccine distributors or manufacturers of U.S. licensed influenza vaccine. Information is updated on an ongoing basis.

Following is a list of resources related to influenza disease and vaccination for healthcare professionals and the public.

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EDUCATION AND TRAINING

Hepatitis B Foundation to offer webinar on liver cancer and hepatitis C on April 3
The Hepatitis B Foundation (HBF) will present a free webinar titled Liver Cancer and Hepatitis C: What You Need to Know on Wednesday, April 3, 3:00 pm ET.
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CONFERENCES AND MEETINGS

Iowa Immunization Conference scheduled for June 12-13 in Des Moines
The Immunization Program of the Iowa Department of Public Health recently posted information about the 2013 Iowa Immunization Conference. It will be held in Des Moines on June 12-13. Speakers include Paul Offit, MD, Children’s Hospital of Philadelphia; Bill Foege, MD, MPH, Global Health Program, Bill & Melinda Gates Foundation; Anne Schuchat, MD, National Center for Immunization and Respiratory Diseases, CDC; Thomas Evans, MD, Iowa Healthcare Collaborative; Gregory Poland, MD, Mayo Clinic and Foundation; Cynthia Poland, MA, BA, Taylor University; and Steven Rinderknecht, DO, Iowa Health Physicians.

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About IAC Express
The Immunization Action Coalition welcomes redistribution of this issue of IAC Express or selected articles. When you do so, please add a note that the Immunization Action Coalition is the source of the material and provide a link to this issue.
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IAC Express is supported in part by Grant No. U38IP000589 from the National Center for Immunization and Respiratory Diseases, CDC. Its contents are solely the responsibility of IAC and do not necessarily represent the official views of CDC. IAC Express is also supported by educational grants from the following companies: CSL Biotherapies; GlaxoSmithKline; MedImmune, Inc.; Merck Sharp & Dohme Corp.; Novartis Vaccines; Ortho Clinical Diagnostics, Inc.; Pfizer, Inc.; and sanofi pasteur.
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Video: Parents May Hesitate On Teen Vaccines
Parents May Hesitate On Teen Vaccines: Wendy Sue Swanson, MD, MBE (aka Seattle Mama Doc) talks about a survey on teen vaccination, which was published in the March issue of Pediatrics. The survey revealed that parents may not get shots for their teens due to concerns about safety or not understanding the shot was recommended. In the survey conducted between 2008-2010, researchers sought to understand trends and rationale for lagging shots.
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Issue Abbreviations
AAFP, American Academy of Family Physicians; AAP, American Academy of Pediatrics; ACIP, Advisory Committee on Immunization Practices; AMA, American Medical Association; CDC, Centers for Disease Control and Prevention; FDA, Food and Drug Administration; IAC, Immunization Action Coalition; MMWR, Morbidity and Mortality Weekly Report; NCIRD, National Center for Immunization and Respiratory Diseases; NIVS, National Influenza Vaccine Summit; VIS, Vaccine Information Statement; VPD, vaccine-preventable disease; WHO, World Health Organization.
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Editor: Deborah L. Wexler, MD
Managing Editor: Dale Thompson, MA
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This page was reviewed on April 2, 2013
 
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