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Issue 970
IAC Express: Weekly immunization news and information
Issue 970: December 27, 2011

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It's a new look for IAC Express!
Here it is—the first issue of IAC Express in our new format! We’re not changing the frequency or content of our IAC Express communications, but we've changed the look. In addition, you will now receive weekly issues on Tuesdays, rather than on Mondays.

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CDC publishes recommendations for use of HPV4 in males
In the December 23 issue of MMWR (pages 1705-1708), CDC published Recommendations on the Use of Quadrivalent Human Papillomavirus Vaccine in Males—Advisory Committee on Immunization Practices (ACIP), 2011. Part of the first paragraph and the sections titled "Recommendations" and "Recommendations for Special Populations" are reprinted below.

On October 25, 2011, the Advisory Committee on Immunization Practices (ACIP) recommended routine use of quadrivalent human papillomavirus (HPV) vaccine (HPV4; Gardasil, Merck & Co. Inc.) in males aged 11 or 12 years. ACIP also recommended vaccination with HPV4 for males aged 13 through 21 years who have not been vaccinated previously or who have not completed the 3-dose series; males aged 22 through 26 years may be vaccinated. These recommendations replace the October 2009 ACIP guidance that HPV4 may be given to males aged 9 through 26 years.

Recommendations
ACIP recommends routine vaccination of males aged 11 or 12 years with HPV4 administered as a 3-dose series (recommendation category: A, evidence type: efficacy for anal intraepithelial neoplasia [AIN] in men who have sex with men [MSM]). The vaccination series can be started beginning at age 9 years. Vaccination with HPV4 is recommended for males aged 13 through 21 years who have not been vaccinated previously or who have not completed the 3-dose series. Males aged 22 through 26 years may be vaccinated. Recommendations for administration and precautions are unchanged from previous recommendations.

Recommendations for Special Populations
HPV4 is not a live vaccine and can be administered to persons who are immunocompromised as a result of infection (including HIV), disease, or medications. The immune response and vaccine efficacy might be less than that in immunocompetent persons. For immunocompromised males, ACIP recommends routine vaccination with HPV4 as for all males, and vaccination through age 26 years for those who have not been vaccinated previously or who have not completed the 3-dose series.

MSM are at higher risk for infection with HPV types 6, 11, 16, and 18 and associated conditions, including genital warts and anal cancer. For MSM, ACIP recommends routine vaccination with HPV4 as for all males, and vaccination through age 26 years for those who have not been vaccinated previously or who have not completed the 3-dose series.


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CDC publishes recommendations for use of hepatitis B vaccine in adults with diabetes
In the December 23 issue of MMWR (pages 1709-1711), CDC published Use of Hepatitis B Vaccination for Adults with Diabetes Mellitus: Recommendations of the Advisory Committee on Immunization Practices (ACIP). Part of the first paragraph, the entire section titled "ACIP Recommendations," and part of the section titled "Remarks" are  reprinted below.

Hepatitis B virus (HBV) causes acute and chronic infection of the liver leading to substantial morbidity and mortality. In the United States, since 1996, a total of 29 outbreaks of HBV infection in one or multiple long-term–care (LTC) facilities, including nursing homes and assisted-living facilities, were reported to CDC; of these, 25 involved adults with diabetes receiving assisted blood glucose monitoring (CDC, unpublished data, 2011).

ACIP Recommendations
On the basis of available information about HBV risk, morbidity and mortality, available vaccines, age at diagnosis of diabetes, and cost-effectiveness, ACIP recommends the following:

  • Hepatitis B vaccination should be administered to unvaccinated adults with diabetes mellitus who are aged 19 through 59 years (recommendation category A; evidence type 2).
  • Hepatitis B vaccination may be administered at the discretion of the treating clinician to unvaccinated adults with diabetes mellitus who are aged ≥60 years (recommendation category B; evidence type 2).
Remarks
Administration of the hepatitis B vaccine series should be completed as soon as feasible after diabetes is diagnosed. Available data do not confirm an advantage to any specific hepatitis B vaccine, dosage, or approved schedule for adults with diabetes. No serologic testing or additional hepatitis B vaccination is recommended for adults who received a complete series of hepatitis B vaccinations at any time in the past.

The hepatitis B vaccination series can be given safely to persons of any age, but current hepatitis B vaccines are less efficacious and less cost-effective among older adults. Evidence for the extent of increased risk for acute HBV infection among persons with diabetes who are aged ≥60 years is less strong than for younger persons with diabetes. In 2008, the median age of diabetes diagnosis was 53 years; two thirds of adult diabetes diagnoses were made before age 60 years.

Decisions to vaccinate adults with diabetes who are aged ≥60 years of age should incorporate consideration of the patient's likelihood of acquiring HBV infection, including the risk posed by an increased need for assisted blood-glucose monitoring in LTC facilities, the likelihood of experiencing chronic sequelae if infected with HBV, and the declining immunologic responses to vaccines that are associated with frailty, a geriatric syndrome characterized by decreased physiologic reserve and increased vulnerability, leading to early mortality in older adults.

Hepatitis B vaccine may be administered during health-care visits scheduled for other purposes as long as minimum intervals between doses are observed; there is no maximum interval between doses that makes the hepatitis B vaccination series ineffective.


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CDC publishes an MMWR Early Release update on current influenza A(H3N2)v transmission in five U.S. states
On December 23, CDC published an MMWR Early Release titled Update: Influenza A (H3N2)v Transmission and Guidelines—Five States, 2011.The article includes information on recent cases in two states, influenza surveillance of U.S. swine, guidance for people exposed to swine in occupational settings, guidance for clinicians who suspect variant influenza in patients, and notes on changes in nomenclature. Portions of the article are reprinted below. Links to useful information for clinicians and the public are given at the end of this IAC Express article.

From August 17 to December 23, 2011,CDC received reports of 12 human infections with influenza A(H3N2)v viruses that have the matrix (M) gene from the influenza A(H1N1)pdm09 virus (formerly called swine-origin influenza A[H3N2] and pandemic influenza A[H1N1] 2009 viruses, respectively). The 12 cases occurred in five states (Indiana, Iowa, Maine, Pennsylvania, and West Virginia), and 11 were in children. Six of the 12 patients had no identified recent exposure to swine. Three of the 12 patients were hospitalized, and all have recovered fully.

A case in an adult male in Indiana with occupational exposure to swine was among the 12, and two children in West Virginia who regularly attended the same day care accounted for the latest cases. This report describes those cases and swine influenza virus (SIV) surveillance being conducted by the U.S. Department of Agriculture (USDA).


What is already known on this topic?
During August–December 2011, a total of 12 human infections with influenza A(H3N2)v viruses were identified in the United States (two from Indiana, three from Iowa, two from Maine, three from Pennsylvania, and two from West Virginia).

What is added by this report?
This report provides the new nomenclature for the virus and describes three cases, one in an adult with occupational exposure and two in children involving limited human-to-human transmission in a day care setting. It also provides an overview of the U.S. Department of Agriculture's swine influenza virus (SIV) surveillance program along with data on influenza A (H3N2) viruses in swine. Out of approximately 150 SIV isolates that have undergone sequencing of three genes (hemagglutinin, matrix, and neuraminidase gene segments), 30 have been identified as A(H3N2) viruses; eight of those 30 have the M gene from the influenza A(H1N1)pdm09 virus.

What are the implications for public health practice?
Nonhuman influenza virus infections rarely result in human-to-human transmission, but the implications of sustained ongoing transmission between humans is potentially severe; therefore, prompt and thorough identification and investigation of sporadic human infections with novel influenza viruses are needed to reduce the risk for sustained transmission.


CDC has posted a web page for healthcare professionals of updated information and guidance documents related to influenza A(H3N2)v viruses.

CDC has posted information for the public about influenza A(H3N2)v, including advice for people who are experiencing influenza-like illness, irrespective of their exposure to swine.

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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. 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: Baxter Healthcare Corp.; CSL Biotherapies; GlaxoSmithKline; MedImmune, Inc.; Merck Sharp & Dohme Corp.; Novartis Vaccines; Ortho Clinical Diagnostics, Inc.; Pfizer, Inc.; and sanofi pasteur.
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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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