Issue 1145: September 30, 2014

Ask the Experts–Question of the Week: Can we give Tdap and RhoGam (anti-Rho[D] immune globulin) at the same prenatal … read more


CDC publishes report on Tdap vaccination of pregnant women enrolled in Medicaid

CDC published Vaccination with Tetanus, Diphtheria, and Acellular Pertussis Vaccine of Pregnant Women Enrolled in Medicaid—Michigan, 2011–2013 in the September 26 issue of MMWR (pages 839–842). A summary made available to the press is reprinted below.

Vaccinating pregnant women with tetanus, diphtheria and acellular pertussis (Tdap) vaccines is an important strategy for providing passive immunity to infants, who are at highest risk of mortality and morbidity from pertussis. In 2011, the Advisory Committee on Immunization Practices (ACIP) first recommended the routine administration of Tdap during pregnancy. Using Michigan Medicaid administrative claims data and statewide immunization information system data, this is the first study to examine Tdap vaccination among a publicly insured cohort of pregnant women. Results indicated that only 14.3% of women received Tdap during pregnancy, with rates highest among whites and lowest among Arab women. Ensuring that all infants receive the protection against pertussis afforded by maternal vaccination will require enhanced efforts, including increased education of health care providers, parents, and families.

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Wall Street Journal features editorial by Dr. Paul Offit about the epidemic of misguided vaccine distrust

On September 24, the Wall Street Journal published an editorial by Paul Offit, MD, director, Vaccine Education Center at the Children's Hospital of Philadelphia, titled The Anti-Vaccination Epidemic. In this column, Dr. Offit describes how well-educated, affluent, but misguided parents who refuse to vaccinate their children are contributing to an increase of vaccine-preventable diseases. The concluding paragraph is reprinted below.

Because we're unwilling to learn from history, we are starting to relive it. And children are the victims of our ignorance. An ignorance that, ironically, is cloaked in education, wealth and privilege.

The full article is currently available on the Wall Street Journal’s website (log in is required).

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National Adult and Influenza Immunization Summit offers up-to-date information about adult immunization

The National Adult and Influenza Immunization Summit (NAIIS) is led by IAC, CDC, and the National Vaccine Program Office, and includes more than 140 organizations and 800 participants. NAIIS maintains a website at to provide information about its annual summit meeting and NAIIS workgroups, as well as links to many resources related to adult vaccination. Explore the new website by clicking on any of the featured sections.

NAIIS sponsors a weekly phone conference and provides a written summary of the discussions in The Summit Buzz section of its website. Bookmark this link and visit it often to access current information about adult vaccines like influenza and pneumococcal, as well as adult immunization issues such as reimbursement.

If you are an adult vaccine advocate and would like to become part of NAIIS, please email Dr. Litjen Tan, chief strategy officer at IAC and co-chair of NAIIS, for more information.

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IAC Spotlight! Refer parents and patients to, IAC's website for the public

IAC's website for the public,, is one of the most user-friendly sources of scientifically accurate and easily navigable immunization information on the Web today. Titled “Vaccine Information You Need,” the website offers parents, other adults, legislators, the media, and all interested visitors a one-stop shop for learning about vaccines and their importance.

Information on the website is organized into sections based on the four age groups listed below. This arrangement allows visitors to easily find vaccine schedules and other information pertinent to people of a specific age: Highlights of
  • Vaccines You Need: Detailed information about the immunization schedules, arranged by age group—infants and childrenpreteensteens, and adults
  • Personal Testimonies: Stories of suffering and loss from vaccine-preventable diseases, organized by age group and disease
  • Video Library: Searchable collection of videos and public service announcements about vaccine-preventable diseases and the importance of vaccination
  • Vaccine-Preventable Diseases: Information and resources for all vaccine-preventable diseases, including those associated with international travel
  • Vaccine Basics: Basic and helpful information on vaccines and vaccination, ranging from “Paying for Vaccines” to “How Vaccines Work”
  • Resources: Frequently updated listing of helpful resources, including brochures, blogs, videos, and more, for people in all age groups who seek information about vaccines
If you have a website, blog, or Facebook page, please link to

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CDC publishes updated preparedness and response framework for influenza pandemics

CDC published Updated Preparedness and Response Framework for Influenza Pandemics in the September 26 issue of MMWR Recommendations and Reports. Two sentences from each of the first two paragraphs are reprinted below.

On the basis of experience from recent influenza responses, CDC has updated its framework to describe influenza pandemic progression using six intervals (two prepandemic and four pandemic intervals) and eight domains. This updated framework can be used for influenza pandemic planning and serves as recommendations for risk assessment, decision-making, and action in the United States.

Compared with the previous U.S. government stages, this updated framework provides greater detail and clarity regarding the potential timing of key decisions and actions aimed at slowing the spread and mitigating the impact of an emerging pandemic. Use of this updated framework is anticipated to improve pandemic preparedness and response in the United States.

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CDC's Health Alert Network publishes an advisory to provide awareness of an acute neurologic syndrome with focal limb weakness in children; CDC is seeking information about other similar neurologic illnesses in all states

On September 26, the CDC Health Alert Network (HAN) issued a CDC Health Advisory titled: Acute Neurologic Illness with Focal Limb Weakness of Unknown Etiology in Children. The "Summary" and "Background" sections are reprinted below. Other advisory sections that you may wish to consult are titled "Recommendations" and “For More Information.”

The Centers for Disease Control and Prevention (CDC) is working closely with the Colorado Department of Public Health and Environment (CDPHE) and Children’s Hospital Colorado to investigate a cluster of nine pediatric patients hospitalized with acute neurologic illness of undetermined etiology. The illness is characterized by focal limb weakness and abnormalities of the spinal cord gray matter on MRI. These illnesses have occurred since August 1, 2014 coincident with an increase of respiratory illnesses among children in Colorado. The purpose of this HAN Advisory is to provide awareness of this neurologic syndrome under investigation with the aim of determining if children with similar clinical and radiographic findings are being cared for in other geographic areas. Guidance about reporting cases to state and local health departments and CDC is provided. Please disseminate this information to infectious disease specialists, intensive care physicians, pediatricians, neurologists, radiologists/neuroradiologists, infection preventionists, and primary care providers, as well as to emergency departments and microbiology laboratories.

The CDPHE, Children’s Hospital Colorado, and CDC are investigating nine cases of acute neurologic illness among pediatric patients. The cases were identified during August 9–September 17, 2014, among children aged 1–18 years (median age 10 years). Most of the children were from the Denver metropolitan area. All were hospitalized. Common features included acute focal limb weakness and specific findings on magnetic resonance imaging (MRI) of the spinal cord consisting of non-enhancing lesions largely restricted to the gray matter. In most cases, these lesions spanned more than one level of the spinal cord. Some also had acute cranial nerve dysfunction with correlating non-enhancing brainstem lesions on MRI. None of the children experienced altered mental status or seizures. None had any cortical, subcortical, basal ganglia, or thalamic lesions on MRI. Most children reported a febrile respiratory illness in the two weeks preceding development of neurologic symptoms. In most cases, cerebrospinal fluid (CSF) analyses demonstrated mild-moderate pleocytosis (increased cell count in the CSF) consistent with an inflammatory or infectious process. CSF testing to date has been negative for West Nile virus and enteroviruses, including poliovirus. Nasopharyngeal specimens were positive for rhinovirus/enterovirus in six out of eight patients that were tested. Of the six positive specimens, four were typed as EV-D68, and the other two are pending typing results. Testing of other specimens is still in process. Eight out of nine children have been confirmed to be up to date on polio vaccinations. Epidemiologic and laboratory investigations of these cases are ongoing.

The United States is currently experiencing a nationwide outbreak of EV-D68 associated with severe respiratory disease. The possible linkage of this cluster of neurologic disease to this large EV-D68 outbreak is part of the current investigation. CDC is seeking information about other similar neurologic illnesses in all states, especially cases clustered in time and place. CDC has particular interest in characterizing the epidemiology and etiology of such cases.

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IAC updates its screening checklists for contraindications and precautions to vaccination for children/teens and adults

IAC recently revised the following two patient screening questionnaires.
  1. Screening Checklist for Contraindications to Vaccines for Children and Teens with a clarification on the age range in Question #5 on page 1, an edit to Question #2 regarding recombinant influenza vaccine and egg allergy on page 2, and changes to the contraindications and precautions to live, attenuated influenza vaccine (LAIV) in Question #4 on page 2.
  2. Screening Checklist for Contraindications to Vaccines for Adults with an edit to Question #2 regarding recombinant influenza vaccine and egg allergy on page 2, and changes to the contraindications and precautions to LAIV in Question #4 on page 2.
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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IAC updates "Medical Management of Vaccine Reactions in Children and Teens" and "Medical Management of Vaccine Reactions in Adult Patients"

IAC recently revised the following two standing orders protocols regarding guidance on vaccine reactions.

  1. Medical Management of Vaccine Reactions in Children and Teens
  2. Medical Management of Vaccine Reactions in Adult Patients
Information was revised about epinephrine, diphenhydramine, and hydoxyzine in both documents, and references were updated. A third page that includes dosing charts for diphenhydramine, and hydoxyzine was added to Medical Management of Vaccine Reactions in Children and Teens.

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"Keep your kids safe—get them vaccinated every fall or winter!" now available in Arabic, Chinese, and Spanish

Updated in early September, IAC's parent handout "Keep your kids safe—get them vaccinated every fall or winter!" is now available in Arabic, Chinese, and Spanish.

For your reference: English-language version

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AAP releases updated recommendations on the use of influenza vaccines in 2014-2015 

On September 22, the American Academy of Pediatrics (AAP) released a policy statement online titled Recommendations for Prevention and Control of Influenza in Children, 2014–2015. The first two sentences of the abstract are reprinted below.

The purpose of this statement is to update recommendations for routine use of seasonal influenza vaccine and antiviral medications for the prevention and treatment of influenza in children. The American Academy of Pediatrics recommends annual seasonal influenza immunization for all people 6 months and older, including all children and adolescents.

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CDC announces September 28 as World Rabies Day

CDC published Announcements: World Rabies Day—September 28, 2014 in the September 26 issue of MMWR (page 843). The complete announcement is reprinted below.

September 28, 2014, is the 8th annual World Rabies Day. Rabies is a fatal acute encephalitis caused by lyssaviruses. The number of human rabies deaths worldwide is estimated to exceed 55,000 each year. In the United States, wild animal reservoirs serve as the most important source of infection. However, over 90% of human deaths globally are caused by bites by rabid dogs.

Rabies control and prevention efforts focus on elimination of canine rabies through mass vaccination campaigns and treatment of exposed persons with prompt wound care and administration of human rabies immune globulin and vaccine. Although rabies is preventable, a lack of accurate data on the burden of disease, inadequate rabies diagnostic laboratory capacity, and poor access to rabies vaccine for postexposure prophylaxis has delayed progress towards regional goals for human rabies elimination.

Blueprints developed by international rabies experts can be used for the development of country-specific rabies elimination plans. These blueprints focus on describing the epidemiology of rabies, improving surveillance, raising awareness among clinicians and the public, achieving high canine vaccination coverage, and ensuring reliable diagnostic, cold chain, and vaccine procurement capacity.

Despite many challenges, considerable progress has been made in the Western Hemisphere; human rabies mortality has been reduced by more than 90% over the past century. Communicable disease programs proven to be successful in settings similar to those where canine rabies is endemic can be emulated for rabies control and prevention efforts in the future. Also, lessons learned during rabies control efforts can prove valuable for responding to emerging zoonotic diseases.

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ACOG releases updated committee opinion on influenza vaccination in pregnancy

In September, the American College of Obstetricians and Gynecologists (ACOG) released an updated committee opinion online titled Influenza Vaccination During Pregnancy. The abstract is reprinted below.

The Centers for Disease Control and Prevention’s Advisory Committee on Immunization Practices and the American College of Obstetricians and Gynecologists recommend that all adults receive an annual influenza vaccine. Influenza vaccination is an essential element of preconception, prenatal, and postpartum care because pregnant women are at an increased risk of serious illness due to seasonal and pandemic influenza. Since 2010, influenza vaccination rates among pregnant women have increased but still need significant improvement. It is particularly important that women who are or will be pregnant during influenza season receive an inactivated influenza vaccine as soon as it is available. It is critically important that all obstetrician–gynecologists and all providers of obstetric care advocate for influenza vaccination, provide the influenza vaccine to their pregnant patients, and receive the influenza vaccine themselves every season. It is imperative that obstetrician–gynecologists, other health care providers, health care organizations, and public health officials continue efforts to improve the rate of influenza vaccination among pregnant women.
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CDC develops new resources to help healthcare professionals and the public understand the new pneumococcal vaccination recommendations for adults

On September 19, CDC published Use of 13-Valent Pneumococcal Conjugate Vaccine and 23-Valent Pneumococcal Polysaccharide Vaccine Among Adults Aged ≥65 Years: Recommendations of the Advisory Committee on Immunization Practices (ACIP) in MMWR. CDC has developed new resources to help both healthcare professionals and members of the public understand these somewhat complicated new recommendations, and suggests the following activities to help raise awareness.

To help increase awareness of the new recommendations among healthcare professionals To help increase awareness among adults age 65 years and older Back to top

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

September issue of CDC's Immunization Works newsletter now available

CDC recently released the September 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 MMWR Supplement about estimating the future number of Ebola cases

CDC published Estimating the Future Number of Cases in the Ebola Epidemic—Liberia and Sierra Leone, 2014–2015 in a September 26 MMWR Supplement. The first portion of the "Abstract" section is reprinted below.

The first cases of the current West African epidemic of Ebola virus disease (hereafter referred to as Ebola) were reported on March 22, 2014, with a report of 49 cases in Guinea. By August 31, 2014, a total of 3,685 probable, confirmed, and suspected cases in West Africa had been reported. To aid in planning for additional disease-control efforts, CDC constructed a modeling tool called EbolaResponse to provide estimates of the potential number of future cases. If trends continue without scale-up of effective interventions, by September 30, 2014, Sierra Leone and Liberia will have a total of approximately 8,000 Ebola cases. A potential underreporting correction factor of 2.5 also was calculated. Using this correction factor, the model estimates that approximately 21,000 total cases will have occurred in Liberia and Sierra Leone by September 30, 2014. Reported cases in Liberia are doubling every 15–20 days, and those in Sierra Leone are doubling every 30–40 days.

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New England Journal of Medicine publishes a collection of articles and resources on the Ebola outbreak

The New England Journal of Medicine recently posted a collection of articles and other resources on the Ebola outbreak, including clinical reports, management guidelines, and commentary on an Ebola Outbreak web page. You do not need to be a subscriber to the journal to access the articles from this page.

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Ask the Experts
Question of the Week

Can we give Tdap and RhoGam (anti-Rho[D] immune globulin) at the same prenatal visit? 
Answer: Tdap is an inactivated vaccine and may be given at the same prenatal visit with RhoGam. For more information on this topic, including the timing for the use of other vaccines with regards to RhoGam, see ACIP's General Recommendations on Immunization at, page 9.

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.

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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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