Issue 1146: October 7, 2014

Ask the Experts–Question of the Week: I have a 24-year-old patient who received influenza vaccine in Colombia, South…read more


CDC's Health Alert Network publishes an advisory to help healthcare professionals evaluate patients for possible Ebola disease

On October 3, the CDC Health Alert Network (HAN) issued a CDC Health Advisory titled Evaluating Patients for Possible Ebola Virus Disease: Recommendations for Healthcare Personnel and Health Officials. The "Summary" section is reprinted below. Other advisory sections that you may wish to consult are titled "Background" and "Recommendations."

The first case of Ebola Virus Disease (Ebola) diagnosed in the United States was reported to CDC by Dallas County Health and Human Services on September 28, 2014, and laboratory-confirmed by CDC and the Texas Laboratory Response Network (LRN) laboratory on September 30. The patient departed Monrovia, Liberia, on September 19, and arrived in Dallas, Texas, on September 20. The patient was asymptomatic during travel and upon his arrival in the United States; he fell ill on September 24 and sought medical care at Texas Health Presbyterian Hospital of Dallas on September 26. He was treated and released. On September 28, he returned to the same hospital, and was admitted for treatment.

The purpose of this HAN Advisory is to remind healthcare personnel and health officials to:

(1) increase their vigilance in inquiring about a history of travel to West Africa in the 21 days before illness onset for any patient presenting with fever or other symptoms consistent with Ebola;

(2) isolate patients who report a travel history to an Ebola-affected country (currently Liberia, Sierra Leone, and Guinea) and who are exhibiting Ebola symptoms in a private room with a private bathroom and implement standard, contact, and droplet precautions (gowns, facemask, eye protection, and gloves); and

(3) immediately notify the local/state health department.

Please disseminate this information to infectious disease specialists, intensive care physicians, primary care physicians, and infection control specialists, as well as to emergency departments, urgent care centers, and microbiology laboratories.

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CDC publishes three MMWR articles about the Ebola virus outbreak in Africa

CDC published three articles about the Ebola virus outbreak in Africa in the October 3 issue of MMWR.
  1. Ebola Virus Disease Outbreak—West Africa, September 2014 (pages 865–866); this report was previously published as an MMWR Early Release on September 30
  2. Ebola Virus Disease Outbreak—Nigeria, July–September 2014 (pages 867–872)
  3. Importation and Containment of Ebola Virus Disease—Senegal, August–September 2014 (pages 873–874)
The first two paragraphs of Ebola Virus Disease Outbreak—West Africa, September 2014 are reprinted below.

CDC is assisting ministries of health and working with other organizations to control and end the ongoing outbreak of Ebola virus disease (Ebola) in West Africa. The updated data in this report were compiled from ministry of health situation reports and World Health Organization (WHO) sources. Total case counts include all suspected, probable, and confirmed cases as defined by each country. These data reflect reported cases, which make up an unknown proportion of all actual cases. The data also reflect reporting delays that might vary from country to country.

According to the latest WHO update, a total of 6,574 Ebola cases had been reported as of September 23 from five West Africa countries (Guinea, Liberia, Nigeria, Senegal, and Sierra Leone). The highest reported case counts were from Liberia (3,458 cases), Sierra Leone (2,021), and Guinea (1,074).

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CDC publishes MMWR Early Release article about acute neurologic illness of unknown etiology in Colorado children

CDC published Acute Neurologic Illness of Unknown Etiology in Children—Colorado, August–September 2014 in an October 3 MMWR Early Release (pages 1–2). The first sentence and last two paragraphs are reprinted below.

On September 12, 2014, CDC was notified by the Colorado Department of Public Health and Environment of a cluster of nine children evaluated at Children's Hospital Colorado with acute neurologic illness characterized by extremity weakness, cranial nerve dysfunction (e.g., diplopia, facial droop, dysphagia, or dysarthria), or both.

This cluster of acute neurologic illnesses occurred against a backdrop of detection of EV-D68 causing severe respiratory disease in many parts of the United States, including Colorado. There are two case reports in the literature of EV-D68 causing neurologic illness (acute flaccid paralysis and encephalomyelitis) as evidenced by detection of EV-D68 in the CSF. However, given the current suspected widespread circulation of EV-D68 respiratory infections in Colorado, and the antecedent respiratory illness in most of these children, the detection of EV-D68 in nonsterile upper respiratory tract specimens in those with neurologic illness might be coincidental. Epidemiologic and laboratory investigations of these cases are ongoing.

On September 19, the Colorado Department of Public Health and Environment issued a Health Alert informing Colorado clinicians of this cluster and requesting reports of similar cases. One additional case with similar neurologic findings was reported as a result of this advisory and is currently under investigation. On September 26, CDC issued a national Health Advisory (available at, which provides guidance for identifying and reporting cases. Clinicians should report to their local and state health departments patients aged ≤21 years with 1) acute onset of focal limb weakness occurring on or after August 1, 2014, and 2) magnetic resonance imaging showing a spinal cord lesion largely restricted to gray matter. To prevent infections in general, persons should stay home if they are ill, wash their hands often with soap and water, avoid close contact (such as touching and shaking hands) with those who are ill, and clean and disinfect frequently touched surfaces.

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CDC publishes MMWR Early Release article on cases of acute flaccid paralysis with anterior myelitis in California

CDC published Acute Flaccid Paralysis with Anterior Myelitis—California, June 2012–June 2014 in an October 3 MMWR Early Release (pages 1–4). A section of the first paragraph is reprinted below.

In August 2012, the California Department of Public Health (CDPH) was contacted by a San Francisco Bay area clinician who requested poliovirus testing for an unvaccinated man aged 29 years with acute flaccid paralysis (AFP) associated with anterior myelitis (i.e., evidence of inflammation of the spinal cord involving the grey matter including anterior horn cell bodies) and no history of international travel during the month before symptom onset. Within 2 weeks, CDPH had received reports of two additional cases of AFP with anterior myelitis of unknown etiology…To identify other cases of AFP with anterior myelitis and elucidate possible common etiologies, CDPH posted alerts in official communications for California local health departments during December 2012, July 2013, and February 2014. Reports of cases of neurologic illness received by CDPH were investigated throughout this period, and clinicians were encouraged to submit clinical samples for testing. A total of 23 cases of AFP with anterior myelitis of unknown etiology were identified. Epidemiologic and laboratory investigation did not identify poliovirus infection as a possible cause for the observed cases. No common etiology was identified to explain the reported cases, although EV-D68 was identified in upper respiratory tract specimens of two patients. EV infection, including poliovirus infection, should be considered in the differential diagnosis in cases of AFP with anterior myelitis and testing performed per CDC guidelines.

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CDC reports on influenza activity from May 18 through September 20

CDC published Update: Influenza Activity—United States and Worldwide, May 18–September 20, 2014 in the October 3 issue of MMWR (pages 861–864). The first two paragraphs of the "Discussion" section are reprinted below.

During May 18–September 20, 2014, pH1N1, influenza A (H3N2), and influenza B viruses cocirculated worldwide. It is not possible to predict which influenza virus will predominate or how severe influenza-related disease activity will be during 2014–15 influenza season.

Annual influenza vaccination is the best method for preventing influenza and its potentially severe complications. In the United States, an influenza vaccine is recommended for all persons aged ≥6 months without contraindications and can reduce the likelihood of becoming ill with influenza and transmitting the virus to others. Annual influenza vaccination is recommended for optimal protection regardless of whether the vaccine composition has changed since the previous season because immunity wanes over time. For the 2014–15 influenza season, manufacturers have projected a vaccine supply for the U.S. market ranging between 151 million and 159 million doses of vaccine. Although it is difficult to predict the type and subtype of influenza viruses that might circulate during the 2014–15 season, many of the recently examined influenza A (H3N2) viruses show reduced reactivity with sera produced against the A/Texas/50/2012 (H3N2) vaccine virus (the H3N2 component of the 2014–15 influenza vaccine). Vaccination, which includes three or four different influenza viruses depending on the vaccine formulation, is the first line of defense against influenza. Even during seasons when the match between the vaccine viruses and circulating viruses is less than optimal and protection against illness might be reduced, vaccination can offer substantial benefit and might reduce the likelihood of severe outcomes such as hospitalization and death.

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IAC Spotlight! Nine 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 September 16, when IAC Express last reported on the Influenza Vaccination Honor Roll, nine healthcare organizations have been enrolled.

Newly added healthcare organizations, hospitals, health departments, and government entities
  • Alameda County Public Health Department, Oakland, CA
  • Baptist South Medical Center, Montgomery, AL
  • City of Berkeley Public Health, Berkeley, CA
  • Delta Regional Medical Center, Greenville, MS
  • Duke University Health System, Durham, NC
  • Iroquois Memorial Hospital, Watseka, IL
  • Novant Health, Winston-Salem, NC
  • Salinas Valley Memorial Healthcare System, Salinas, CA
  • Southeast Mississippi Rural Health Initiative, Inc., Hattiesburg, MS
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Voices for Vaccines hosts call featuring three moms who were formerly vaccine hesitant on October 14

Parents become vaccine hesitant for many reasons, and they often keep those reasons private, making it difficult for concerned friends, family members, and healthcare professionals to know how to begin a conversation about immunization with them. 

On October 14 at 1:30 p.m. (ET), Voices for Vaccines will host a conference call featuring three moms who were formerly anti-vaccine.

To register for this call, you must email

Click here for more information about this conference call: A Discussion with Former Anti-Vax Moms

Voices for Vaccines is a national organization of parents and others who are dedicated to raising the level of the voices of immunization supporters. VFV invites everyone who appreciates vaccines to become a member of their organization. Please spread the word to your friends and colleagues to register for the conference call and to join VFV!
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IAC updates "Personal belief exemptions for vaccination put people at risk"

IAC recently revised Personal belief exemptions for vaccination put people at risk. Examine the evidence for yourself. This four-page handout helps parents and healthcare professionals understand the impact of vaccine refusal by listing information about recent outbreaks of measles, pertussis, and varicella that have been traced to pockets of unvaccinated children in states that allow personal belief exemptions. IAC updated this resource with two new articles about measles outbreaks.

Related Links 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 "First Do No Harm: Mandatory Influenza Vaccination Policies for Healthcare Personnel Help Protect Patients"

IAC recently updated First Do No Harm: Mandatory Influenza Vaccination Policies for Healthcare Personnel Help Protect Patients. This resource provides the position statements of leading medical organizations to help healthcare institutions and medical settings develop and implement mandatory influenza vaccination policies. The revised version includes an updated statement from the Infectious Diseases Society of America, as well as updated resources and links.

Related Link
  • Influenza Vaccination Honor Roll section on, which includes access to position statements from professional societies and leading healthcare organizations in support of mandatory influenza vaccination and the honor roll application form
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CDC releases supplemental information for healthcare providers to accompany the 2014–15 influenza VISs 

On October 3, CDC posted Provider Information: Influenza VISs on its website as a PDF document. These provider guidelines supplement the 2014–15 influenza VISs and summarize relevant ACIP recommendations; include more detailed information about indications, schedules, and precautions; and contain other information giving providers a quick reference to help address common patient questions.

All available provider Information documents are posted on CDC's What's New with VISs web page.

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World Pneumonia Day is scheduled for November 12

Established in 2009, World Pneumonia Day is marked every year on November 12. The day was established to:
  • Raise awareness about pneumonia, the world’s leading killer of children under the age of five
  • Promote interventions to protect against, prevent, and treat pneumonia
  • Generate action to combat pneumonia
Pneumonia is one of the most solvable problems in global health, yet a child dies from pneumonia every 20 seconds. Visit the World Pneumonia Day website to see how you can help in the effort to end child pneumonia worldwide.

The Global Coalition Against Child Pneumonia provides leadership for World Pneumonia Day and is comprised of more than 140 non-governmental organizations (NGOs), academic institutions, government agencies, and foundations.

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AAP to release new Red Book Online on October 9

On October 9, the American Academy of Pediatrics (AAP) will be releasing its provider resource, Red Book Online, along with other AAP Point-of-Care Solutions sites (Pediatric Care Online, Pediatric Patient Education, and AAP Pediatric Coding Newsletter). The revised Red Book Online will use a newly designed and updated platform that allows for improved site navigation and searching, as well as accessibility from different devices.

To get a sneak preview of the revised Red Book Online, visit AAP's website to view a short video.

Full information will be available on the Red Book Online website after October 9. Red Book Online requires a subscription for access to all of its features.

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Just Released: On Immunity: An Inoculation by essayist Eula Biss

Essayist Eula Biss, who won the National Book Critics Circle Award in 2010 for Notes from No Man’s Land: American Essays, has released a new book of essays about vaccination. She writes about the metaphors and myths surrounding immunizations as she navigates new motherhood. 

On Immunity: An Inoculation is available at local bookstores.

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Influenza is serious; many resources are available to help 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

CDC reports on typhoid fever surveillance and vaccination in the South-East Asia and Western Pacific Regions in MMWR

CDC published Typhoid Fever Surveillance and Vaccine Use—South-East Asia and Western Pacific Regions, 2009–2013 in the October 3 issue of MMWR (pages 855–860). A section of the first paragraph is reprinted below.

Typhoid fever is a serious, systemic infection resulting in nearly 22 million cases and 216,500 deaths annually, primarily in Asia. Safe water, adequate sanitation, appropriate personal and food hygiene, and vaccination are the most effective strategies for prevention and control. In 2008, the World Health Organization (WHO) recommended use of available typhoid vaccines to control endemic disease and outbreaks and strengthening of typhoid surveillance to improve disease estimates and identify high-risk populations (e.g., persons without access to potable water and adequate sanitation). This report summarizes the status of typhoid surveillance and vaccination programs in the WHO South-East Asia (SEAR) and Western Pacific regions (WPR) during 2009–2013, after the revised WHO recommendations…Despite the high incidence, typhoid surveillance is weak in these two regions, and vaccination efforts have been limited. Further progress toward typhoid fever prevention and control in SEAR and WPR will require country commitment and international support for enhanced surveillance, targeted use of existing vaccines and availability of newer vaccines integrated within routine immunization programs, and integration of vaccination with safe water, sanitation, and hygiene measures.

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Slides and audio recording now online for the August 2014 special ACIP meeting 

ACIP recently posted the audio recording from the special ACIP meeting held on August 13 about recommendations for the use of pneumococcal vaccines in adults. Presentation slides from this meeting are also available.

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Ask the Experts
Question of the Week

I have a 24-year-old patient who received influenza vaccine in Colombia, South America, on June 19, 2014. Does he need to get another influenza vaccine during the current U.S. influenza season? 
Answer: Yes. The person should be revaccinated with the 2014–15 U.S. vaccine, even though the strains in the U.S. vaccine are the same as the 2014 Southern hemisphere vaccine. Vaccination again with the current vaccine will help assure protection through the influenza season into next spring. 

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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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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