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Issue 1305
Issue 1305: May 10, 2017

Ask the Experts
Ask the Experts—Question of the Week: I had an 18-year-old in the clinic today for varicella vaccination. . . . read more


TOP STORIES


OFFICIAL RELEASES AND ANNOUNCEMENTS


WORLD NEWS


FEATURED RESOURCES


EDUCATION AND TRAINING

 


TOP STORIES


MMWR reports on vaccination coverage among U.S. adults in 2015

CDC published Surveillance of Vaccination Coverage Among Adult Populations—United States, 2015 in a May 5 issue of MMWR Surveillance Summaries. The abstract is reprinted below.

Problem/Condition
Overall, the prevalence of illness attributable to vaccine-preventable diseases is greater among adults than among children. Adults are recommended to receive vaccinations based on their age, underlying medical conditions, lifestyle, prior vaccinations, and other considerations. Updated vaccination recommendations from CDC are published annually in the U.S. Adult Immunization Schedule. Despite longstanding recommendations for use of many vaccines, vaccination coverage among U.S. adults is low.

Period Covered
August 2014–June 2015 (for influenza vaccination) and January–December 2015 (for pneumococcal, tetanus and diphtheria [Td] and tetanus and diphtheria with acellular pertussis [Tdap], hepatitis A, hepatitis B, herpes zoster, and human papillomavirus [HPV] vaccination).

Description of System
The National Health Interview Survey (NHIS) is a continuous, cross-sectional national household survey of the noninstitutionalized U.S. civilian population. In-person interviews are conducted throughout the year in a probability sample of households, and NHIS data are compiled and released annually. The survey objective is to monitor the health of the U.S. population and provide estimates of health indicators, health care use and access, and health-related behaviors.

Results
Compared with data from the 2014 NHIS, increases in vaccination coverage occurred for influenza vaccine among adults aged ≥19 years (a 1.6 percentage point increase compared with the 2013–14 season to 44.8%), pneumococcal vaccine among adults aged 19–64 years at increased risk for pneumococcal disease (a 2.8 percentage point increase to 23.0%), Tdap vaccine among adults aged ≥19 years and adults aged 19–64 years (a 3.1 percentage point and 3.3 percentage point increase to 23.1% and to 24.7%, respectively), herpes zoster vaccine among adults aged ≥60 years and adults aged ≥65 years (a 2.7 percentage point and 3.2 percentage point increase to 30.6% and to 34.2%, respectively), and hepatitis B vaccine among health care personnel (HCP) aged ≥19 years (a 4.1 percentage point increase to 64.7%). Herpes zoster vaccination coverage in 2015 met the Healthy People 2020 target of 30%. Aside from these modest improvements, vaccination coverage among adults in 2015 was similar to estimates from 2014. Racial/ethnic differences in coverage persisted for all seven vaccines, with higher coverage generally for whites compared with most other groups. Adults without health insurance reported receipt of influenza vaccine (all age groups), pneumococcal vaccine (adults aged 19–64 years at increased risk), Td vaccine (adults aged ≥19 years, 19–64 years, and 50–64 years), Tdap vaccine (adults aged ≥19 years and 19–64 years), hepatitis A vaccine (adults aged ≥19 years overall and among travelers), hepatitis B vaccine (adults aged ≥19 years, 19–49 years, and among travelers), herpes zoster vaccine (adults aged ≥60 years), and HPV vaccine (males and females aged 19–26 years) less often than those with health insurance. Adults who reported having a usual place for health care generally reported receipt of recommended vaccinations more often than those who did not have such a place, regardless of whether they had health insurance. Vaccination coverage was higher among adults reporting one or more physician contacts in the past year compared with those who had not visited a physician in the past year, regardless of whether they had health insurance. Even among adults who had health insurance and ≥10 physician contacts within the past year, depending on the vaccine, 18.2%–85.6% reported not having received vaccinations that were recommended either for all persons or for those with specific indications. Overall, vaccination coverage among U.S.-born adults was higher than that among foreign-born adults, with few exceptions (influenza vaccination [adults aged 19–49 years and 50–64 years], hepatitis A vaccination [adults aged ≥19 years], and hepatitis B vaccination [adults aged ≥19 years with diabetes or chronic liver conditions]).

Interpretation
Coverage for all vaccines for adults remained low but modest gains occurred in vaccination coverage for influenza (adults aged ≥19 years), pneumococcal (adults aged 19–64 years with increased risk), Tdap (adults aged ≥19 years and adults aged 19–64 years), herpes zoster (adults aged ≥60 years and ≥65 years), and hepatitis B (HCP aged ≥19 years); coverage for other vaccines and groups with vaccination indications did not improve. The 30% Healthy People 2020 target for herpes zoster vaccination was met. Racial/ethnic disparities persisted for routinely recommended adult vaccines. Missed opportunities to vaccinate remained. Although having health insurance coverage and a usual place for health care were associated with higher vaccination coverage, these factors alone were not associated with optimal adult vaccination coverage. HPV vaccination coverage for males and females has increased since CDC recommended vaccination to prevent cancers caused by HPV, but many adolescents and young adults remained unvaccinated.

Public Health Actions
Assessing factors associated with low coverage rates and disparities in vaccination is important for implementing strategies to improve vaccination coverage. Evidence-based practices that have been demonstrated to improve vaccination coverage should be used. These practices include assessment of patients’ vaccination indications by health care providers and routine recommendation and offer of needed vaccines to adults, implementation of reminder-recall systems, use of standing-order programs for vaccination, and assessment of practice-level vaccination rates with feedback to staff members. For vaccination coverage to be improved among those who reported lower coverage rates of recommended adult vaccines, efforts also are needed to identify adults who do not have a regular provider or insurance and who report fewer health care visits.


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Free app of The Vaccine Handbook newly available from the Immunization Action Coalition

A new app of The Vaccine Handbook is now available from the Immunization Action Coalition. The free app, which is available for Apple iPhones and iPads only, contains the complete 2017 (6th) edition of The Vaccine Handbook (“The Purple Book”), by Dr. Gary Marshall, professor of pediatrics and chief of the Division of Pediatric Infectious Diseases at the University of Louisville. The app is fully searchable, with functionality that includes bookmarking, highlighting, user annotation, and links to important vaccination resources.
 
"The Purple Book" is a comprehensive source of vaccine information, drawing together vaccine science, guidance, and practice into a user-friendly resource for the private office, public health clinic, academic medical center, classroom, and hospital. The first section provides background on vaccine immunology, development, infrastructure, policy, standards, implementation, special circumstances, and—perhaps most importantly—addressing concerns. The second section contains details about every vaccine currently licensed in the U.S., including the burden and epidemiology of the respective disease, history of the immunization program, vaccine constituents, efficacy, safety, and recommendations.

The free app may be found by searching the iTunes App Store for “The Vaccine Handbook App” or clicking on the following link:
https://itunes.apple.com/us/app/the-vaccine-handbook-app/id1043246009?ls=1&mt=8.

Print copies of the book ($34.95 each; bulk discounts are available from the publisher) can be ordered from the Immunization Action Coalition website at www.immunize.org/vaccine-handbook.

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Forty-eight cases of measles reported in Minnesota children 

The measles outbreak in Minnesota originally covered in the April 26 issue of IAC Express is ongoing.

  • 48 total cases have been confirmed; 45 in Hennepin County, 2 in Ramsey County, and 1 in Crow Wing County
  • 45 have been confirmed to be unvaccinated; 1 had received 1 dose of MMR and 2 had received 2 doses of MMR 
  • 46 cases have occurred in children ages 0 through 10 years; there have been 2 cases in adults 
  • 41 of the cases are Somali Minnesotan

The local Somali community has been targeted for years with misinformation about a connection between vaccination and autism, including visits from anti-vaccine activists, including Andrew Wakefield, the controversial physician whose license to practice medicine was revoked by Britain's General Medical Council as a result of ethical and financial misconduct. On May 5, The Washington Post published an insightful article about this background to the outbreak.



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The PolicyLab and the Vaccine Education Center release an Evidence to Action brief about addressing vaccine hesitancy 

The PolicyLab and the Vaccine Education Center (VEC) at Children's Hospital of Philadelphia recently released an Evidence to Action brief titled “Addressing Vaccine Hesitancy to Protect Children and Communities Against Preventable Diseases.” The brief included a review of vaccine hesitancy, identification of three areas of concern, and a series of recommendations to address the concerns.

The areas of concern include:

  • Diminished prioritization—delayed immunizations resulting from lack of experience with diseases being prevented and convenience factors and barriers related to access or philosophical beliefs or concerns
  • Lack of confidence in vaccine safety and efficacy—resistance to immunizations based on misinformation that is perpetrated in the media and online. Difficulty reversing misconceptions also contributes to this area of concern.
  • Inadequate state policies—nonmedical exemptions and pockets of noncompliance lead to regions or areas of increased susceptibility and decreased herd immunity

Recommendations focused on three areas of action related to healthcare provider recommendations, vaccine mandates, and education.

View or download the complete brief: Addressing Vaccine Hesitancy to Protect Children and Communities Against Preventable Diseases (PDF format; 20 pages).

More information, including a summary of the recommendations, a related webinar, and a social media toolkit, is available in the March issue of VEC's newsletter, Vaccine Update for Healthcare Professionals.

PolicyLab is an independent research center at Children’s Hospital of Philadelphia.

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The National Adult and Influenza Immunization Summit’s new coding and billing resource is now available online

The National Adult and Influenza Immunization Summit recently posted a coding and billing resource on its website. A summary from the web section is reprinted below.

A common problem that has been expressed by providers of adult vaccinations has been the intricacies and complexities associated with coding and billing for those services. Much discussion at meetings of the National Adult and Influenza Immunization Summit (“Summit”) has focused on opportunities to provide information to providers to reduce the errors and confusion associated with coding and billing for adult vaccines. The Summit’s Access and Provider Workgroup has developed this website in response to this identified need.

At this one web location, you will find the top questions identified with coding and/or billing for adult vaccinations, scenarios that detail how to go about coding and billing for adult vaccines, and collected resources from the Summit’s medical association, public health, and vaccine manufacturing partners.


Access Coding and Billing for Adult Vaccinations.

Related Link

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Please complete CDC’s post-NIIW survey and share your feedback on this year’s planning and promotional materials

CDC’s Childhood Immunization Communication Team thanks everyone for another successful National Infant Immunization Week (NIIW)! Your ongoing efforts and support of childhood immunization help us achieve overall high coverage for most vaccines routinely recommended for young children in the United States. 

While NIIW is still fresh in your mind, CDC has two requests.

First, please take a few minutes to complete CDC’s Post-NIIW Survey and share your feedback on this year’s planning and promotional materials available from the CDC. Your responses will help guide CDC as they begin planning activities for another successful NIIW in 2018. This survey is brief and should take less than 5 minutes to complete. Your responses will be kept private to the extent allowed by law, and we will only report answers that have been pooled together across all respondents. Your input is greatly appreciated.

Secondly, please let CDC know what you did in your community during NIIW by filling out the NIIW Activity Form. If you tried earlier and ran into technical difficulties, please try again as the problem has been fixed.

CDC would appreciate your input by May 15th.

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AAP invites all immunizers to join its Community of Immunizers Listserv

The American Academy of Pediatrics (AAP) would like to invite all immunizers to join its Community of Immunizers Listserv. The Community of Immunizers Listserv is currently comprised of more than 125 immunizers, including physicians, physician assistants, nurse practitioners, nurses, medical assistants, and other office staff. It allows users to communicate with fellow immunizers, ask questions, and share ideas, resources, and successes! Email immunize@aap.org and include IZCOMMUNITY and your role as an immunization advocate to request to be added to the Community of Immunizers Listserv.

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IAC Spotlight! IAC enrolls three new birthing institutions into its Hepatitis B Birth Dose Honor Roll; four previously honored institutions qualify for additional years' honors

The Immunization Action Coalition (IAC) is pleased to announce that three new institutions have been accepted into its Hepatitis B Birth Dose Honor Roll. The birthing institutions are listed below with their reported hepatitis B birth dose coverage rates in parentheses.

  • Covenant Health Levelland, Levelland, TX (97%)
  • MidMichigan Medical Center–Alpena, Alpena, MI (91%)
  • Valley Children's Hospital, Madera, CA (95%)

In addition, the following institution is being recognized for a second year:

  • MidMichigan Medical Center–Alpena, Alpena, MI (90%)

Finally, the following three institutions are being recognized for a third year:

  • Georgetown Community Hospital, Georgetown, KY (96%)
  • Harrison Memorial Hospital, Cynthiana, KY (97%)
  • ProMedica Monroe Regional Hospital, Monroe, MI (90%)

Note: MidMichigan Medical Center–Alpena qualified for two periods at one time.

The Honor Roll now includes 336 birthing institutions from 38 states, Puerto Rico, and Guam. Sixty-eight institutions have qualified for two years, 40 institutions have qualified three times, 8 institutions have qualified four times, and 3 institutions have qualified five times.

The Honor Roll is a key part of IAC’s major initiative urging the nation’s hospitals to Give birth to the end of Hep B. Hospitals and birthing centers are recognized for attaining high coverage rates for administering hepatitis B vaccine at birth and meeting specific additional criteria. The initiative urges qualifying healthcare organizations to apply for the Hepatitis B Birth Dose Honor Roll online.

To be included in the Hepatitis B Birth Dose Honor Roll, a birthing institution must have: (1) reported a coverage rate of 90 percent or greater, over a 12-month period, for administering hepatitis B vaccine before hospital discharge to all newborns, including those whose parents refuse vaccination, and (2) implemented specific written policies, procedures, and protocols to protect all newborns from hepatitis B virus infection prior to hospital discharge.

Honorees are also awarded an 8.5" x 11" color certificate suitable for framing and their acceptance is announced to IAC Express’s approximately 50,000 readers.

Please visit the Hepatitis B Birth Dose Honor Roll web page that lists these institutions and their exceptional efforts to protect infants from perinatal hepatitis B transmission.

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CDC publishes information about yellow fever vaccine shortage; previously published as an MMWR Early Report

CDC published Addressing a Yellow Fever Vaccine Shortage—United States, 2016–2017 in the May 5 issue of MMWR. This information was previously published as an MMWR Early Release and covered in IAC Express #1305.

Related Link

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OFFICIAL RELEASES AND ANNOUNCEMENTS


World Hand Hygiene Day celebrated May 5; CDC and WHO have many new resources on their websites

May 5 was World Hand Hygiene Day. CDC has this to say about hand hygiene:

Practicing hand hygiene is a simple yet effective way to prevent infections. Cleaning your hands can prevent the spread of germs, including those that are resistant to antibiotics and are becoming difficult, if not impossible, to treat. On average, healthcare providers clean their hands less than half of the times they should. On any given day, about one in 25 hospital patients has at least one healthcare-associated infection.

The related Clean Hands Count campaign aims to:

  • Improve healthcare provider adherence to CDC hand hygiene recommendations
  • Address the myths and misperceptions about hand hygiene
  • Empower patients to play a role in their care by asking or reminding healthcare providers to clean their hands

The Clean Hands Count Campaign on CDC's website offers online educational courses and a promotional video for healthcare providers, as well as other resources such as posters, fact sheets, and digital tools. The World Health Organization (WHO) also has much information related to cleaning hands appropriately on its SAVE LIVES: Clean Your Hands web section.

Clean Hands Count

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WORLD NEWS


Measles & Rubella Initiative announces the launch of its newly redesigned website

The Measles & Rubella Initiative partners are pleased to announce the launch of their newly redesigned website. New features include:

  • New and improved interactive map
  • Compatibility with mobile devices
  • Regularly updated links to recent peer reviewed publications
  • Up-to-date information on where the Initiative is operating around the world

Check out the redesigned website at http://measlesrubellainitiative.org.

The Measles & Rubella Initiative is led by the American Red Cross, the United Nations Foundation, the U.S. Centers for Disease Control and Prevention, UNICEF, and the World Health Organization. 

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CDC and WHO report on the progress toward measles elimination in Africa in this week's MMWR and Weekly Epidemiological Report, respectively
 
CDC published Progress Toward Measles Elimination—African Region, 2013–2016 in the May 5 issue of MMWR. On the same day, the World Health Organization (WHO) published Progress towards measles elimination—African Region, 2013–2016 in its Weekly Epidemiological Record. A summary of the MMWR article provided to the press is reprinted below.

Countries in the World Health Organization African Region show progress and setbacks toward a regional goal of measles elimination by 2020. The number of new cases annually in the region has decreased by 63% from 2013 to 2016. However, not enough children are receiving the recommended two doses of vaccine to provide full protection against measles. The majority of children in the region not being fully protected against measles reside in four countries: Nigeria, Ethiopia, the Democratic Republic of the Congo, and Angola; these countries also account for the majority of the region’s measles cases each year. Only half of all African Region countries have introduced a second vaccine dose against measles. For the region to eliminate measles by 2020, efforts are needed for countries to achieve ≥95% two-dose coverage.

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FEATURED RESOURCES


Dr. Paul Offit's column in The Daily Beast discusses the importance of influenza and Tdap vaccination during pregnancy

As reported in the February 1 issue of IAC Express, Dr. Paul A. Offit, MD, director of the Vaccine Education Center (VEC) at Children's Hospital of Philadelphia, is now contributing weekly columns to The Daily Beast. Columns will be about popular issues related to science, not limited to vaccines. This week's column about the importance of influenza and Tdap vaccination during pregnancy is titled This Could Save Your Baby’s Life.

You can follow Dr. Offit’s columns by visiting the relevant archive page on The Daily Beast.


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ECBT's "Shot of Prevention" blog provides a community forum for discussing immunization; May 4 post features "The Purple Book" app

"Shot of Prevention" is a community blog where individuals, parents, medical professionals, and others can discuss questions and current events regarding immunizations. Blog posts are written, and discussion is moderated, by Every Child By Two (ECBT).

The May 4 "Shot of Prevention" post includes information about the newly updated The Vaccine Handbook App, including input from the author, Dr. Gary Marshall, and a review by MaryBeth Koslap-Petraco, pediatric nurse practitioner and adjunct clinical assistant professor at Stony Brook University School of Nursing.

For more information on this free app for iPhones and iPads, see the second article in this issue of IAC Express.

Clinicians should feel free to refer vaccine-hesitant parents and patients to "Shot of Prevention" at www.shotofprevention.com. Feel free to visit and recommend the other ECBT websites as well: www.ecbt.org and www.vaccinateyourfamily.org.

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"Seattle Mama Doc" explores vaccine hesitancy in recent blog post

"Seattle Mama Doc," a blog by Dr. Wendy Sue Swanson, MD, MBE, FAAP, published on the Seattle Children’s Hospital's website, recently published a post titled Vaccination Hesitancy: 4 Myths Explained. The first three paragraphs are reprinted below.

Vaccination hesitancy or concern about getting your child their shots isn’t new. But it has recently been gaining attention in the media. In February, Robert Kennedy Jr. offered a $100,000 reward for anyone who could turn up a study showing that it is safe to administer vaccines to children and pregnant women. Let me start by saying that there are countlessstudies and data in support of vaccination safety. So the offer and claim should be given/received over and over and over again.

I mean, COME ON.

However, with politicians using their platform to blast these fallacies and doubts about vaccination, I worry there is a new sense of unease growing among parents. This unease is causing pediatricians to worry about what’s to come in the coming years for families and their safety.


Access the complete post: Vaccination Hesitancy: 4 Myths Explained

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Now available! IAC's sturdy laminated versions of the 2017 U.S. child/teen immunization schedule and the 2017 U.S. adult immunization schedule—order a supply for your healthcare setting today!

IAC's laminated versions of the 2017 U.S. child/teen immunization schedule and the 2017 U.S. adult immunization schedule are covered with a tough, washable coating; they will stand up to a year's worth of use in every area of your healthcare setting where immunizations are given. Both schedules are eight pages (i.e., four double-sided pages) and are folded to measure 8.5" x 11". 

Laminated Child and Teen Laminated Schedule

Adult Laminated Immunization Schedules

Laminated schedules are printed in color for easy reading, come complete with essential tables and footnotes, and include contraindications and precautions—a feature that will help you make an on-the-spot determination about the safety of vaccinating patients of any age.

PRICING
1–4 copies: $7.50 each
5–19 copies: $5.50 each
20–99 copies: $4.50 each
100–499 copies: $4.00 each
500–999 copies: $3.50 each

For quotes on customizing or placing orders for 1,000 copies or more, call (651) 647-9009 or email admininfo@immunize.org.

You can access specific information on both schedules, view images of both, order online, or download an order form at the Shop IAC: Laminated Schedules web page.

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EDUCATION AND TRAINING


Reminder: CDC's NetConference series about adult immunization runs every Wednesday, April 12–May 31

CDC is sponsoring a 6-part NetConference series on vaccinating adults that will address key issues related to protecting adults from vaccine-preventable diseases. A collaborative effort between CDC and Maryland’s adult immunization coalition and state immunization program, the "Vaccinating Adults" series will feature 6 presentations by experts in promoting, administering, and securing reimbursement for adult immunizations.
  • Wednesday, April 12—Burden of Vaccine-Preventable Diseases in Adults: Medical, Social, and Economic Costs
  • Wednesday, April 19—Provider Reimbursement for Adult Immunizations
  • Wednesday, April 26—Immunizing Adults: Immunization Schedule, Coverage, and Challenges
  • Wednesday, May 17—Immunizing Older Adults and the Chronically Ill
  • Wednesday, May 24—Immunizing Pregnant Women, Health Care Personnel, and in the Workplace
  • Wednesday, May 31—Clinic Logistics: Vaccine Administration, Storage, and Handling

Each session will start at 12:00 p.m. (ET).

Continuing education will be available for each event. The series will be archived later on CDC's website.

Advanced registration is required to participate.

Related Link

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ASK THE EXPERTS

Question of the Week

I had an 18-year-old in the clinic today for varicella vaccination. He reports having antiphospholipid syndrome being treated with rituximab (a drug that affects the function of B lymphocytes). The next dose of rituximab will be in 2 weeks. He has also had 12 immune globulin (IG) injections in the last year. Should he get the varicella vaccine at all with this condition, and if so, what time frame do we need to be concerned with in relation to the rituximab treatment and/or IG?

The Infectious Diseases Society of America guidelines indicate that persons receiving rituximab should be considered to have high-level immunosuppression. Both inactivated and live vaccines should be withheld at least 6 months following treatment with anti-B cell medications such as rituximab. As for the IG, the interval to live vaccination depends on the dose. Please refer to the table on pages 37–39 of the "General Best Practices Guidelines for Immunization" at www.cdc.gov/vaccines/hcp/acip-recs/general-recs/downloads/general-recs.pdf for guidance. This interval could be as long as 11 months, depending on the dose he receives.


About IAC's Question of the Week

Each week, IAC Express highlights a new, topical, or important-to-reiterate Q&A. This feature is a cooperative venture between IAC and CDC. William L. Atkinson, MD, MPH, IAC's associate director for immunization education, chooses a new Q&A to feature every week from a set of Q&As prepared by experts at CDC’s National Center for Immunization and Respiratory Diseases.

We hope you enjoy this feature and find it helpful when dealing with difficult real-life scenarios in your vaccination practice. Please encourage your healthcare professional colleagues to sign up to receive IAC Express at www.immunize.org/subscribe.

If you have a question for the CDC immunization experts, you can email them directly at nipinfo@cdc.gov. There is no charge for this service.

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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.

If you have trouble receiving or displaying IAC Express messages, visit our online help section.

IAC Express is supported in part by Grant No. 6NH23IP922550 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: AstraZeneca, Inc.; bioCSL Inc.; Merck Sharp & Dohme Corp.; Pfizer, Inc.; and Sanofi Pasteur.
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Editor: Deborah L. Wexler, MD
Managing Editor: Teresa Anderson, DDS, MPH
Consulting Editor: Marian Deegan, JD
Assistant Managing Editor: Liv Augusta Anderson, MPP
Issue Abbreviations
AAFP: American Academy of Family Physicians
AAP: American Academy of Pediatrics
ACIP: Advisory Committee on Immunization Practices
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
VIS: Vaccine Information Statement
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This website is supported in part by a cooperative agreement from the National Center for Immunization and Respiratory Diseases (Grant No. 6NH23IP22550) at the Centers for Disease Control and Prevention (CDC) in Atlanta, GA. The website content is the sole responsibility of IAC and does not necessarily represent the official views of CDC.