Issue 1142: September 16, 2014
Ask the Experts–Question of the Week: Our 23-year-old patient has been accepted to a physician assistant program that … read more

CDC's Health Alert Network publishes an advisory to provide awareness of enterovirus D68 as a possible cause of acute unexplained respiratory illness, and to provide guidance to state health departments and healthcare providers

In August 2014, a children’s hospital in Kansas City, Missouri, and one in Chicago, Illinois, notified CDC of increases in pediatric patients examined and hospitalized with severe respiratory illness, including some admitted to pediatric intensive care units. Enterovirus D68 (EV-D68) was identified in 19 of 22 specimens from Kansas City and in 11 of 14 specimens from Chicago. Admissions for severe respiratory illness have continued at both facilities at rates higher than expected for this time of year. CDC has been notified by various states of similar clusters of respiratory illness, though confirmation of EV-D68 in these potential clusters is still under way. On September 12, the CDC Health Alert Network (HAN) issued a CDC Health Advisory titled Severe Respiratory Illness Associated with Enterovirus D68 – Multiple States, 2014. The "Summary" section is reprinted below. Other advisory sections that you may wish to consult are titled "Background," "Recommendations," and “For More Information.”

The Centers for Disease Control and Prevention (CDC) is working closely with hospitals and local and state health departments to investigate recent increases in hospitalizations of patients with severe respiratory illness. Enterovirus D68 (EV-D68) has been detected in specimens from children with severe illness in Missouri and Illinois. Investigations into suspected clusters in other jurisdictions are ongoing. The purpose of this HAN Advisory is to provide awareness of EV-D68 as a possible cause of acute unexplained respiratory illness, and to provide guidance to state health departments and health care providers. Please disseminate this information to infectious disease specialists, intensive care physicians, pediatricians, internists, infection preventionists, and primary care providers, as well as to emergency departments and microbiology laboratories.

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CDC reports on a measles outbreak in an unvaccinated family and a potentially associated international traveler in Florida

CDC published Measles Outbreak in an Unvaccinated Family and a Potentially Associated International Traveler—Orange County, Florida, December 2012–January 2013 in the September 12 issue of MMWR (pages 781–784). A summary made available to the press is reprinted below.

In January 2013 the Florida Department of Health in Orange County investigated a measles outbreak in four unvaccinated siblings with no travel history. A fifth possibly associated case was later reported in a Brazilian citizen with travel to Orange County, Fla. No source case was identified. A rapid and thorough public health response was conducted to prevent further transmission of measles. No additional cases were identified in Florida. Healthcare providers should learn to recognize measles infections and should consider measles diagnosis in persons with no or unknown vaccination history and compatible symptoms.

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Last call! Regular registration rate for National Immunization Conference extended until September 22

CDC, the Task Force for Global Health, and the CDC Foundation will host the National Immunization Conference, "U.S. Immunization in a Time of Change," September 29–30, in Atlanta, Georgia. The regular registration rate has been extended until September 22 (or until all available registration spots are filled, whichever comes first). Please note conference attendance will be limited to approximately 800 people. Registration is no longer available for federal government employees; the limit on federal travel set forth in the HHS conference approval has been reached. For more information about the National Immunization Conference, please contact the conference planning team at (404) 639-8225 or via email at

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IAC Spotlight! Sixteen more healthcare organizations join IAC's Influenza Vaccination Honor Roll for mandatory healthcare worker vaccination

IAC urges qualifying healthcare organizations to apply for its Influenza Vaccination Honor Roll. The honor roll recognizes hospitals, medical practices, professional organizations, health departments, and government entities that have taken a stand for patient safety by implementing mandatory influenza vaccination policies for healthcare personnel. More than 400 organizations are now enrolled.

Since August 26, when IAC Express last reported on the Influenza Vaccination Honor Roll, 16 healthcare organizations have been enrolled.

Newly added healthcare organizations, hospitals, and medical practices
  • Ambulatory Surgery Center, Arlington Heights, IL
  • Chesapeake Regional Medical Center, Chesapeake, VA
  • Cheyenne County Hospital & Clinic, Saint Francis, KS
  • Contra Costa Health Services, Martinez, CA
  • Eskenazi Health, Indianapolis, IN
  • Franklin Hospital, Benton, IL
  • Methodist Health System, Dallas, TX
  • Potomac Valley Hospital, Keyser, WV
  • Reno County Health Department, Hutchinson, KS
  • Southwestern Vermont Medical Center, Bennington, VT
  • University of California San Diego Health System, La Jolla, CA
  • University of California San Diego Health System, Moore's Cancer Center, La Jolla, CA
  • University of California San Diego Health System, Sulpizio Cardiovascular Center, La Jolla, CA
  • University of California San Diego Health System, San Diego, CA
  • Vascular Access Centers, Philadelphia, PA
  • West Sayville Pediatrics NPPC, West Sayville, NY
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NFID news conference on influenza and pneumococcal disease scheduled for September 18

On September 18, 2014, the National Foundation for Infectious Diseases (NFID) will host an Influenza/Pneumococcal News Conference at the National Press Club in Washington, DC, at 10:00 a.m. (ET).
In collaboration with the Centers for Disease Control and Prevention (CDC) and other leading medical and public health groups who rally together to show their strong support for influenza immunization, the event communicates critical messages including a call to action for everyone to get vaccinated. Other areas of focus include CDC’s “Take Three” approach to influenza prevention and the importance of pneumococcal vaccination for those for whom it is recommended.
NFID’s annual news conference creates excitement among the media and galvanizes the immunization community. You can join by accessing the webcast or listening via telephone (800-277-3988). Please note that as the news conference is a media-focused event, NFID is requesting that non-media attendees refrain from asking questions during the Q&A portion.

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CDC releases HPV vaccination data from 2011 NIS-Teen: nearly half of females age 13–17 years had not received their recommended first dose of HPV vaccine in 2011

CDC published Use of Selected Clinical Preventive Services to Improve the Health of Infants, Children, and Adolescents—United States, 1999–2011 as a September 12 MMWR Supplement. One of the sections is titled National Human Papillomavirus Vaccination Coverage Among Adolescents Aged 13–17 Years—National Immunization Survey-Teen, United States, 2011. The first two paragraphs of the "Discussion" section are reprinted below.

The results of this survey, which was conducted approximately 5 years after HPV4 was licensed in 2006 for use in females, demonstrate that approximately half of females aged 13–17 years sampled in 2011 had not yet received the recommended first HPV vaccine dose, and nearly two thirds had not received the ≥3 doses required for series completion. Among females who initiated the series, approximately 30% still needed to complete it. Among males, 2011 coverage estimates primarily reflect 2009 licensure and policy (i.e., HPV4's initial licensure for males and ACIP's guidance that HPV4 could be administered to males aged 9–26 years); these 2011 data provide a baseline for monitoring implementation of the October 2011 routine HPV4 vaccination recommendation for males.

At only 30.0%, coverage among females aged 13–15 years is substantially below the Healthy People 2020 target of 80% coverage for ≥3 HPV vaccine doses. In contrast, in 2011, coverage estimates among all adolescents aged 13–15 years for ≥1 dose Tdap and ≥1 dose MenACWY were 80.5% and 71.5%, respectively, demonstrating achievement of the Healthy People 2020 target for Tdap coverage and highlighting that 80% vaccination coverage is attainable among adolescents. These findings also indicate that opportunities are being missed to deliver HPV vaccine with other routinely recommended vaccines.
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From AAFP, AAP, ACOG, ACP, CDC, and IAC HPV Resources from IAC HPV Resources from CDC HPV Resources from the Vaccine Education Center
HPV resources from AAP
HPV resource from ACOG
HPV Resources from Voices for Vaccines
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Share your influenza prevention activities and ideas on CDC's influenza partner website

CDC has recently created a web section where partner organizations can share success stories and ideas about increasing influenza awareness and vaccination. The site will feature campaigns from around the nation, including photos from promotional activities. CDC has included links to many helpful resources and tools on this page, including print materials, posters, website widgets, coloring books, and toolkits for businesses and media.

To access CDC's Resources for Flu Prevention Partners web section, go to

For information about how to become a partner, send an email to:

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Help CDC by completing a survey about National Immunization Awareness Month

CDC thanks everyone who participated in outreach efforts during National Immunization Awareness Month (NIAM) in August. CDC would greatly appreciate learning what everyone did to promote adult immunization during NIAM, and whether people used CDC resources in their efforts. If your organization participated in adult immunization activities during NIAM, please complete this brief online survey from CDC.

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To help answer potential questions generated by September 11 Dr. Oz Show, access collected resources for healthcare professionals on the safety of thimerosal in vaccines

On September 11, the Dr. Oz Show discussed influenza vaccines and thimerosal. Robert F. Kennedy Jr. and the co-author of his recent book on thimerosal, Mark Hyman, MD, presented inaccurate information about the use of thimerosal as a preservative in vaccines. Below you will find links to resources about thimerosal and vaccines that healthcare providers may find useful when parents and patients come to them with questions generated by this show.

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IAC updates "Administering Vaccines to Adults: Dose, Route, Site, and Needle Size" and "Administering Vaccines: Dose, Route, Site, and Needle Size"

IAC recently revised the following two handouts for healthcare professionals.
  1. Administering Vaccines to Adults: Dose, Route, Site, and Needle Size
  2. Administering Vaccines: Dose, Route, Site, and Needle Size
The abbreviation for inactivated influenza vaccine (IIV) was changed on both handouts to "IIV," replacing TIV ("trivalent influenza vaccine"). A correction was also made to the adult handout regarding the age for the adult dosage of hepatitis B vaccine.

IAC's Handouts for Patients & Staff web section offers healthcare professionals and the public more than 250 FREE English-language handouts (many also available in translation), which we encourage website users to print out, copy, and distribute widely.

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"Declination of Influenza Vaccination" now available in Spanish

Updated for the 2014–15 influenza season, IAC's healthcare professional handout Declination of Influenza Vaccination is now available in Spanish.

For your reference: English-language version

Access all of IAC's influenza handouts for healthcare providers and their patients.

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IAC posts sixteen new translations of the 2014–15 influenza VISs

IAC recently posted Arabic, simplified Chinese, traditional Chinese, French, Karen, Russian, Somali, Thai, and Vietnamese translations of the 2014–15 inactivated influenza vaccine (IIV) Vaccine Information Statement (VIS), as well as Arabic, simplified Chinese, traditional Chinese, French, Russian, Somali, and Vietnamese translations of the 2014–15 live, intranasal influenza vaccine (LAIV) VIS on its website.

New translations of the 2014–15 inactivated influenza vaccine (IIV) VIS New translations of the 2014–15 live, intranasal influenza vaccine (LAIV) VIS IAC thanks St. Peter's Health Partners, St. Albany, NY for the Karen translation and Asian Pacific Health Care Venture, Los Angeles, CA, for the Thai translation.

IAC posted Spanish translations of the 2014–15 inactivated influenza vaccine (IIV) Vaccine Information Statement (VIS), as well as the 2014–15 live, intranasal influenza vaccine (LAIV) VIS on its website last week.

Please note: The 2014–15 influenza vaccine VISs will be available in additional languages in the weeks ahead. IAC Express will announce the availability of translations as soon as they are ready.

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CDC's 2012 Viral Hepatitis Surveillance Report is now available

CDC recently published Surveillance for Viral Hepatitis—United States, 2012. A selection of the "Summary" section is reprinted below.

Half of all hepatitis A infections now apparently are acquired outside the United States by adult travelers. The major public health demands regarding hepatitis A relate to newly discovered HAV-infected food handlers, as these place a large burden on local public health departments to notify, test, and vaccinate potentially infected restaurant patrons. There were 1,562 reported cases of acute HAV in 2012. After asymptomatic infections and under-reporting were taken into account, it was estimated that approximately 3,050 new infections occurred in 2012.

Acute hepatitis B has been declining in incidence since 1990 mainly due to effective vaccination strategies, but chronic HBV infection, estimated at 700,000–1.4 million of the US population, remains a major public health challenge. As the surveillance data in this report and other data indicate, about one-half of all chronic HBV infections are among persons born in Asia and Asian-Americans who were born to HBV-infected mothers in the United States. Identifying these chronically infected persons and linking them to care remains a challenge. There were 2,895 cases of acute hepatitis B reported in 2012. After adjusting for asymptomatic infections and under-reporting, the estimated number of new HBV infections was 18,760.

After receiving reports of approximately 800–1,000 cases of acute hepatitis C each year from 2006–2010, there was a significant increase of 45% in reported cases of acute HCV infection from 2010–2012, and a 75% increase from 2010–2012. Cases of acute HCV infection rose from 850 in 2010 to 1,229 in 2011 and to 1,778 in 2012. After adjusting for asymptomatic infections and under-reporting, 21,870 new infections of HCV occurred in 2012. This increase is thought to reflect a trend in new cases among adolescents and young adults, particularly in Eastern and Midwestern states. Based on epidemiologic studies, these cases of HCV infection are predominately among young persons who are white, live in non-urban areas, have a history of injection drug use, and previously used opioid agonists such as oxycodone.
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HealthMap Vaccine Finder lets the public find provider locations that administer adult vaccinations; now is a good time for providers to list their vaccination services on HealthMap

The HealthMap Vaccine Finder is a free online service that allows the public to use their zip codes to find adult vaccination services by location.

The start of influenza season is an excellent time for healthcare professionals who provide adult vaccines to list their location on this resource. If you provide influenza, hepatitis A, hepatitis B, HPV, MMR, Td, Tdap, meningococcal, pneumococcal, varicella, or zoster vaccine, consider adding your practice or clinic to HealthMap Vaccine Finder. You don't need to provide all adult vaccines to participate. If you are a provider who doesn't provide all adult vaccines, please refer your patients to HealthMap Vaccine Finder as a way to help them find a source for indicated vaccination.

If you are a provider who participated last year, you can log in to your account and update your information by following the directions on the Help tab.

If you are a new provider, you must first register for an account. Once you receive your password and log in, you can upload the required information to your account.

Access more information about HealthMap Vaccine Finder.

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CDC launches the second phase of the "Know Hepatitis B" campaign

CDC, in partnership with Hep B United, recently launched the second phase of the Know Hepatitis B campaign designed to promote hepatitis B testing among Asian Americans and Pacific Islanders (AAPIs). The Know Hepatitis B campaign began in 2013 with the goal of elevating awareness and understanding of hepatitis B and increasing testing and vaccination for the disease. Hepatitis B is a disease that disproportionately affects AAPIs, as the virus is common in many Asian and Pacific Island countries. While AAPIs make up less than 5% of the total U.S. population, they account for more than 50% of the 1.2 million Americans living with chronic hepatitis B.

The first phase of the campaign featured education materials in English, Chinese, Korean, and Vietnamese. For the second phase, culturally and linguistically appropriate hepatitis B education and outreach materials are available in English, Chinese, Korean, Vietnamese, Burmese, Khmer, Lao and Hmong. Campaign messages are delivered through a variety of multi-media channels including newspaper, radio, and TV PSAs that are aired on Chinese, Korean, and Vietnamese media outlets throughout the country. Additional campaign resources include posters, fact sheets, flyers, infographics, and risk assessments, which can help provide information and promote testing for hepatitis B.

Help spread the word by using and sharing the campaign’s free resources.

Visit the Know Hepatitis B campaign website.

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Influenza is serious; many resources are available to aid healthcare professionals in vaccinating

Vaccination remains the single most effective means of preventing influenza, and is recommended for everyone age six months and older. If you don't provide influenza vaccination in your clinic, please recommend vaccination to your patients and refer them to a clinic or pharmacy that provides vaccines or to the HealthMap Vaccine Finder to locate sites near their workplaces or homes that offer influenza vaccination services.

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

August issue of CDC's Immunization Works newsletter now available

CDC recently released the August issue of its monthly newsletter Immunization Works and posted it on the website of the National Center for Immunization and Respiratory Diseases (NCIRD). The newsletter offers the immunization community information about current topics. The information is in the public domain and can be reproduced and circulated widely.

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CDC publishes an assessment of varicella surveillance and outbreak control practices

CDC published Assessment of Varicella Surveillance and Outbreak Control Practices—United States, 2012 in the September 12 issue of MMWR (pages 785–788). The first paragraph of the "Discussion" section is reprinted below.

Because a large number of varicella cases occurred in the United States at the beginning of the varicella vaccination program (estimated at 4 million cases each year, which approximated the size of the U.S. birth cohort) and varicella was not included as a nationally notifiable condition, nationwide reporting of every varicella case was not feasible at that time. In the absence of robust national varicella surveillance, beginning in 1995, data from active surveillance sites were used to monitor impact of the 1-dose varicella vaccination program, and later, the 2-dose program that was recommended in 2006 and implemented in 2007. As varicella vaccination coverage increased nationwide, and the number of varicella cases decreased, CSTE [Council of State and Territorial Epidemiologists] recommended that states move to case-based varicella reporting by 2005. The findings in this report update an assessment conducted in 2004 and document a 63.0% increase in the number of jurisdictions that mandated varicella reporting, from 27 jurisdictions in 2004 to 44 in 2012. Since 2004, varicella surveillance has been greatly strengthened, with 38 (86.4%) of the jurisdictions that mandate varicella reporting now conducting statewide or sentinel site case-based reporting. In nearly all jurisdictions (95.4%) varicella cases are reported by schools. However, hospitals and health care providers also are important sources of reporting, particularly for cases in adults and infants. As varicella incidence continues to decline and vaccination coverage increases, monitoring disease severity, outcomes, and epidemiology among all age groups, including those not targeted for vaccination, remains important.

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CDC reports on measles outbreak in a Micronesian community in King County, Washington

CDC published Notes from the Field: Measles in a Micronesian Community—King County, Washington, 2014 in the September 12 issue of MMWR (page 800). The first paragraph and the first two sentences of the second paragraph are reprinted below.

Measles is a highly contagious viral disease that can lead to complications and death. The United States achieved measles elimination (interruption of continuous transmission lasting ≥12 months) in 2000. Despite elimination, 592 measles cases were reported in the United States during January 1–August 22, 2014, the highest number since 1994, primarily among unvaccinated travelers and their unvaccinated contacts. Measles remains endemic outside the Western Hemisphere, with outbreaks affecting communities in the Philippines, Vietnam, and China. An ongoing measles outbreak with approximately 350 measles cases and one death in the Federated States of Micronesia during January–July 2014 also has been reported.

On May 30, 2014, a child in King County, Washington, aged 4 years and unvaccinated against measles, developed a measles rash 4 days after returning home from 2 weeks in the Federated States of Micronesia. During the following 5 weeks, 14 additional measles cases (nine laboratory-confirmed B3 wild-type and five epidemiologically linked) were reported in King and Pierce counties.

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Hep B United to present a webinar on hepatitis B for healthcare professionals on September 30

Hep B United will present a one-hour webinar titled Hepatitis B Provider Knowledge and Screening Practices at 3:00 p.m. (ET) on September 30. Speakers will discuss barriers, model programs, and opportunities toward improving provider knowledge and reducing hepatitis B health disparities in the Asian American, Pacific Islander, and other at-risk communities. 

  • John Ward, MD, director, Viral Hepatitis Program, Division of Viral Hepatitis, STD and TB Prevention, CDC
  • Camilla Graham, MD, MPH, co-director, Viral Hepatitis Center, Division of Infectious Diseases, Beth Israel Deaconess Medical Center
  • Chrissy Cheung, MPH, hepatitis B prevention coordinator, Santa Clara County Public Health Department
Registration is required.

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Ask the Experts
Question of the Week

Our 23-year-old patient has been accepted to a physician assistant program that requires polio vaccine for all students. She has 2 documented doses of oral polio vaccine (OPV) as a child, then recently had a dose of inactivated polio vaccine (IPV). How many more doses of IPV does she need to complete the series and on what schedule? 
Answer: People who receive a mixed series of OPV and IPV should receive a total of 4 doses. The recent dose of IPV can be counted as the third dose in the primary series. The minimum interval between the third and last doses in the polio vaccination series is 6 months. So the final dose in the series should be given 6 months after the IPV dose.

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 new 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

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

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About IZ Express

IZ Express is supported in part by Grant No. 1NH23IP922654 from CDC’s National Center for Immunization and Respiratory Diseases. Its contents are solely the responsibility of and do not necessarily represent the official views of CDC.

IZ Express Disclaimer
ISSN 2771-8085

Editorial Information

  • Editor-in-Chief
    Kelly L. Moore, MD, MPH
  • Managing Editor
    John D. Grabenstein, RPh, PhD
  • Associate Editor
    Sharon G. Humiston, MD, MPH
  • Writer/Publication Coordinator
    Taryn Chapman, MS
    Courtnay Londo, MA
  • Style and Copy Editor
    Marian Deegan, JD
  • Web Edition Managers
    Arkady Shakhnovich
    Jermaine Royes
  • Contributing Writer
    Laurel H. Wood, MPA
  • Technical Reviewer
    Kayla Ohlde

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