Issue 1157: December 9, 2014

Ask the Experts–Question of the Week: What is the acceptable volume for a single dose of immune globulin (IG) to inject into…read more

This is National Influenza Vaccination Week!

This is National Influenza Vaccination Week (NIVW): December 7–13. It highlights the importance of continuing influenza vaccination throughout the season. CDC features useful resources on its NIVW web section, including a new animated graphic and posters.

This year, CDC is placing more focus on vaccination promotion activities using digital media platforms, including:
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:
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CDC's Health Alert Network publishes an advisory on the potential for circulation of drifted influenza A (H3N2) viruses

On December 3, the CDC Health Alert Network (HAN) issued a CDC Health Advisory titled CDC Health Advisory Regarding the Potential for Circulation of Drifted Influenza A (H3N2) Viruses. The "Summary" section is reprinted below.

Influenza activity is currently low in the United States as a whole, but is increasing in some parts of the country. This season, influenza A (H3N2) viruses have been reported most frequently and have been detected in almost all states.

During past seasons when influenza A (H3N2) viruses have predominated, higher overall and age-specific hospitalization rates and more mortality have been observed, especially among older people, very young children, and persons with certain chronic medical conditions compared with seasons during which influenza A (H1N1) or influenza B viruses have predominated.

Influenza viral characterization data indicates that 48% of the influenza A (H3N2) viruses collected and analyzed in the United States from October 1 through November 22, 2014 were antigenically "like" the 2014–2015 influenza A (H3N2) vaccine component, but that 52% were antigenically different (drifted) from the H3N2 vaccine virus. In past seasons during which predominant circulating influenza viruses have been antigenically drifted, decreased vaccine effectiveness has been observed. However, vaccination has been found to provide some protection against drifted viruses. Though reduced, this cross-protection might reduce the likelihood of severe outcomes such as hospitalization and death. In addition, vaccination will offer protection against circulating influenza strains that have not undergone significant antigenic drift from the vaccine viruses (such as influenza A (H1N1) and B viruses).

Because of the detection of these drifted influenza A (H3N2) viruses, this CDC Health Advisory is being issued to re-emphasize the importance of the use of neuraminidase inhibitor antiviral medications when indicated for treatment and prevention of influenza, as an adjunct to vaccination.

The two prescription antiviral medications recommended for treatment or prevention of influenza are oseltamivir (Tamiflu) and zanamivir (Relenza). Evidence from past influenza seasons and the 2009 H1N1 pandemic has shown that treatment with neuraminidase inhibitors has clinical and public health benefit in reducing severe outcomes of influenza and, when indicated, should be initiated as soon as possible after illness onset. Clinical trials and observational data show that early antiviral treatment can:
  • shorten the duration of fever and illness symptoms;
  • reduce the risk of complications from influenza (e.g., otitis media in young children and pneumonia requiring antibiotics in adults); and
  • reduce the risk of death among hospitalized patients.
Access the complete HAN advisory to read more, including recommendations for healthcare providers.

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CDC provides information to the press about the potential for a severe influenza season

On December 4, CDC held a press conference and posted a related press release titled Early Data Suggests Potentially Severe Flu Season. The entire release is reprinted below.

Early data suggests that the current 2014–2015 flu season could be severe. The Centers for Disease Control and Prevention (CDC) urges immediate vaccination for anyone still unvaccinated this season and recommends prompt treatment with antiviral drugs for people at high risk of complications who develop flu.

So far this year, seasonal influenza A H3N2 viruses have been most common. There often are more severe flu illnesses, hospitalizations, and deaths during seasons when these viruses predominate. For example, H3N2 viruses were predominant during the 2012–2013, 2007–2008, and 2003–2004 seasons, the three seasons with the highest mortality levels in the past decade. All were characterized as “moderately severe.”

Increasing the risk of a severe flu season is the finding that roughly half of the H3N2 viruses analyzed are drift variants: viruses with antigenic or genetic changes that make them different from that season’s vaccine virus. This means the vaccine’s ability to protect against those viruses may be reduced, although vaccinated people may have a milder illness if they do become infected. During the 2007–2008 flu season, the predominant H3N2 virus was a drift variant yet the vaccine had an overall efficacy of 37 percent and 42 percent against H3N2 viruses.

“It’s too early to say for sure that this will be a severe flu season, but Americans should be prepared,” said CDC director Tom Frieden, M.D., M.P.H. “We can save lives with a three-pronged effort to fight the flu: vaccination, prompt treatment for people at high risk of complications, and preventive health measures, such as staying home when you’re sick, to reduce flu spread.”

Depending on the formulation, flu vaccines protect against three or four different flu viruses. Even during a season when the vaccine is only partially protective against one flu virus, it can protect against the others.

“While the vaccine’s ability to protect against drifted H3N2 viruses this season may be reduced, we are still strongly recommending vaccination,” said Joseph Bresee, M.D., Chief of the Influenza Epidemiology and Prevention Branch at CDC. “Vaccination has been found to provide some protection against drifted viruses in past seasons. Also, vaccination will offer protection against other flu viruses that may become more common later in the season.”

Influenza viruses are constantly changing. The drifted H3N2 viruses were first detected in late March 2014, after World Health Organization (WHO) recommendations for the 2014–2015 Northern Hemisphere vaccine had been made in mid-February. At that time, a very small number of these viruses had been found among the thousands of specimens that had been collected and tested.

A committee of experts must pick which viruses to include in the vaccine many months in advance in order for vaccine to be produced and delivered in time for the upcoming flu season. There is always the possibility that viruses will drift during that time.

Influenza activity is currently low in the United States as a whole, but is increasing in parts of the country. “We are just at the beginning of the season. It’s not too late to get your vaccine,” Dr. Frieden says.

Influenza antiviral drugs—Tamiflu (oseltamivir) and Relenza (zanamivir) can reduce severe complications such as hospitalization and potentially death for people who are at high risk of serious flu complications or are very sick. Treatment of high-risk patients should begin as soon after symptoms develop as possible, without waiting for lab tests to confirm flu infection.

Those at high risk from influenza include children younger than 5 years (especially those younger than 2 years); adults 65 years and older; pregnant women; and people with certain chronic health conditions such as asthma, diabetes, heart or lung disease, and kidney disease.

CDC recommends that people at high risk check with their doctor or other health care professional promptly if they get flu symptoms. Studies show that flu antiviral drugs work best for treatment when they are started in the first 48 hours after symptoms appear. Flu symptoms can include fever, cough, sore throat, runny or stuffy nose, body aches, headache, chills and fatigue.

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Seasonal Health campaign supplement of December 5 issue of USA Today features articles from Families Fighting Flu, IAC, CDC, VEC, and NFID

The Immunization Action Coalition (IAC) recently partnered with MediaplanetUSA in their just-released Seasonal Health campaign, which seeks to provide readers with tips and safety advice on protecting yourself from this season’s influenza viruses. The campaign was distributed through USA Today on December 5, 2014, and is published online at

Along with IAC, other contributors include Families Fighting Flu, CDC, National Foundation for Infectious Diseases (NFID), and the Vaccine Education Center at the Children's Hospital of Philadelphia (CHOP).

Access the entire supplement titled “The Fight Against The Flu." We encourage you to share it with your patients.

Selected Articles from the Seasonal Health Campaign  Back to top

ISMP publishes two-year summary on reported vaccine administration errors; separate article highlights serious mix-ups with influenza vaccine and other drugs

On December 4, the Institute for Safe Medication Practices (ISMP) published an article titled Confusion Abounds! 2-year Summary of the ISMP National Vaccine Errors Reporting Program (Part 1). Two summary paragraphs are reprinted below.

In September 2012, ISMP (in cooperation with the California Department of Public Health) established the ISMP National Vaccine Errors Reporting Program (ISMP VERP) to collect data about the types of errors occurring and their underlying causes. In our November 28, 2013 newsletter (, we provided a summary analysis of error reports submitted during its inaugural year. In this issue, we provide a 2-year summary of error reports submitted through October 2014.

Between September 2012 and October 2014, a total of 884 reports were submitted to the ISMP VERP. The error reports provide a steady stream of information to ISMP for analysis so that prevention strategies can be identified and shared. In the past 2 years, reports have increased from 373 in 2013 to 425 so far in 2014 (January–October). 

Access the complete article for much more detail on the types of errors and the settings in which they occur.

On the same day, ISMP published a companion article titled What Else Is Stored in a Refrigerator with Influenza Vaccine? This article describes the reported serious errors where influenza vaccine has been mixed up with other drugs stored nearby in a crowded refrigerator, and discusses ways to avoid such errors.

The Institute for Safe Medication Practices is the nation’s only 501(c)(3) nonprofit organization devoted entirely to medication error prevention and safe medication use. The Vaccine Error Reporting Program (VERP) was created to allow healthcare professionals and patients to report vaccine errors confidentially. By collecting and quantifying information about these errors, ISMP will be better able to advocate for changes in vaccine names, labeling, or other appropriate modifications that could reduce the likelihood of vaccine errors in the future. Reporting vaccination administration errors via this link will help improve health care for everyone.

Note: If an adverse event occurs following a vaccine administration error, a report should also be sent to Vaccine Adverse Event Reporting System (VAERS). Adverse events should be reported to VAERS regardless of whether a healthcare professional thinks its related to the vaccine or not, as long as it follows administering a dose of vaccine.

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CDC reports on the pertussis epidemic in California

CDC published Pertussis Epidemic—California, 2014 in the December 5 issue of MMWR (pages 1129–1132). A summary made available to the press is reprinted below.

Pertussis incidence is likely to continue to increase in the United States due to the natural cycle of disease and the waning of immunity conferred by currently available vaccines. Strategies to prevent the most severe cases of pertussis, which occur primarily in young infants, should be prioritized. California is experiencing a pertussis epidemic. During January 1–November 26, a total of 9,935 cases of pertussis with onset in 2014 were reported in California, for an incidence of 26.0 cases per 100,000 population. The highest burden of disease is being observed in infants aged <12 months, especially Hispanic infants, and in white, non-Hispanic teenagers aged 14–16 years. This is consistent with the upper age of the cohort of children who have only received acellular pertussis vaccine. Severe and fatal disease occurs almost exclusively in infants who are too young to be vaccinated against pertussis. Therefore, pregnant women are encouraged to receive tetanus, diphtheria, and acellular pertussis vaccine (Tdap) during the third trimester of each pregnancy to provide placental transfer of maternal antibodies to the infant. Prenatal care providers are encouraged to provide Tdap to pregnant women or refer patients to obtain vaccine from an alternative provider, such as a pharmacy or local public health department.

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IAC Spotlight! Thirteen 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 450 organizations are now enrolled.

Since November 18, when IAC Express last reported on the Influenza Vaccination Honor Roll, 13 healthcare organizations have been enrolled.

Newly added healthcare organizations, hospitals, and medical practices
  • Bakersfield Heart Hospital, Bakersfield, CA
  • CDT Javier Antón-Río Piedras, Rio Piedra, PR
  • CentraCare Health, Saint Cloud, MN
  • Enloe Medical Center, Chico, CA          
  • Finger Lakes Health, Geneva, NY
  • Georgetown Community Hospital, Georgetown, KY
  • Harbor Pediatrics, Gig Harbor, WA
  • Home of the Innocents, Louisville, KY
  • Lourdes Hospital, Paducah, KY
  • The Medical Center, Bowling Green, KY
  • Neosho Memorial Regional Medical Center, Chanute, KS
  • San Jorge Children's Hospital, San Juan, PR
  • Taylor Hospital, Crozer-Keystone Health System, Ridley Park, PA
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IAC updates "Checklist for Safe Vaccine Storage and Handling"

IAC recently made a small change to its handout for healthcare professionals, Checklist for Safe Vaccine Storage and Handling. This handout can help vaccine providers ensure they are doing everything possible to protect their valuable vaccine supply. The updated text to item 14 (d) is "has a resettable (automatic or manual) min/max display (applies only to thermometers that have a data logger)."

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WHO releases an updated guide to the prevention and control of cervical cancer

On December 3, the World Health Organization (WHO) released the second edition of its Comprehensive Cervical Cancer Control: A guide to essential practice. This version of the guide was revised and updated from the 2006 edition. The main elements in the new guidance are:
  • Vaccinate 9- to 13-year-old girls with two doses of human papillomavirus (HPV) vaccine to prevent infection with HPV. The 2-dose schedule has been shown to be as effective as the current 3-dose schedule, is easier to administer, and costs less—an important factor in developing countries.
  • Use HPV tests to screen women for cervical cancer prevention
  • Communicate more widely to reach women throughout their lives
Cervical cancer is one of the world's deadliest forms of cancer in women, responsible for more than 270, 000 deaths annually, 85% of which occur in developing countries. The updated guidance is intended to help countries better prevent and control cervical cancer. Back to top

CDC releases new toolkit to help employers increase influenza vaccination among long-term care healthcare personnel

The National Vaccine Program Office and the Centers for Disease Control and Prevention, with support from the Office of Disease Prevention and Health Promotion in the Department of Health and Human Services, have created an online toolkit to provide easily accessible tools and resources for managers in long-term care (LTC) facilities to improve influenza vaccination coverage among the healthcare personnel (HCP) working there.

As of 2010, it was reported there were about 2.2 million nursing aides, orderlies, attendants, and home health aides and an additional 644,850 registered nurses and licensed practical nurses working in nursing homes, assisted living facilities, and home health. All of these individuals are considered HCP and are recommended to receive annual influenza vaccination. Since the 2011–2012 influenza season, HCP in LTC settings have had the lowest reported influenza vaccination rates among all HCP. As reported in the September 19 MMWR, overall, 75.2 percent of HCP reported receiving an influenza vaccination for the 2013–2014 season; however, this number was only 63 percent for HCP working in LTC facilities.

A Toolkit for Long-Term Care Employers: Increasing Influenza Vaccination among Healthcare Personnel in Long-term Care Settings includes a number of useful resources and tools to help close the gap in vaccination of healthcare personnel in LTC facilities, including:
  • Guidance documents, campaign materials, and educational resources to share with managers and staff
  • Community best practices for achieving high influenza vaccination among staff
  • A chart of common barriers to influenza vaccination in these settings with recommended strategies for overcoming specific barriers
  • An easy-to-follow guide about the Affordable Care Act's role in increasing access to influenza vaccination in this population
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CDC publishes MMWR Early Release article about clinical inquiries regarding Ebola in the U.S.

On December 5, CDC published Clinical Inquiries Regarding Ebola Virus Disease Received by CDC—United States, July 9–November 15, 2014 as an MMWR Early Release. The text from a related CDC bulletin is presented below.

Evaluating and managing persons who might have Ebola virus disease (Ebola) is one component of the overall approach to domestic surveillance, the goal of which is to rapidly identify and isolate Ebola patients so they receive appropriate medical care and secondary transmission is prevented. During July 9–November 15, CDC responded to clinical inquiries from public health officials and health care providers in the United States regarding 650 persons thought to be at risk for Ebola. Health care providers should remain vigilant and consult their local and state health departments and CDC when assessing ill travelers from Ebola-affected countries.

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November issue of CDC's Immunization Works newsletter now available

CDC recently released the November 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. This information is in the public domain and can be reproduced and circulated widely.

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Vaccine Education Center posts Dr. Paul Offit's webinar on meningococcal B vaccines, HPV9, and other topics

The Vaccine Education Center (VEC) at Children's Hospital of Philadelphia recently made the recording of its November 19 Current Issues in Vaccines webinar available. Click on the purple button titled "View Winter 2014 Presentation" and register (at no cost) to listen to the webinar and view the accompanying slide set. The webinar is accredited for one continuing medical education (CME) credit through November 18, 2015.

Paul Offit, MD, director of VEC, covered the following topics during the webinar:
  • Meningococcal serogroup B vaccines: Will they receive a routine recommendation?
  • HPV vaccine: Update on the new 9-valent vaccine
  • The bird flu (H5N1) vaccine: Where do we stand?
  • Tdap vaccine and healthcare personnel
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Watch archived webinar about the impact of non-medical exemptions

On November 4, the Network for Public Health Law and The Immunization Partnership presented a webinar titled Immunization Laws: Impact of Non-Medical Exemptions. In recent years there has been an increase in the number of parents seeking exemptions from vaccines for personal beliefs, leading to concerns from those in public health about the potential spread of vaccine-preventable diseases. Learn about the history of this movement, the impact of non-medical exemptions, and the development of a collaborative effort to address this important issue via this webinar.

  • Allison N. Winnike, JD, research assistant professor, Health Law & Policy Institute at the University of Houston Law Center
  • Dorit Rubinstein Reiss, PhD, professor of law, University of California Hastings College of the Law
  • Anna Draegsback, JD, president and CEO, The Immunization Partnership
Access the slides and/or the recording of this webinar

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Question of the Week

What is the acceptable volume for a single dose of immune globulin (IG) to inject into the deltoid muscle of a normal-weight adult? What is the acceptable volume for a single dose of IG to inject into the vastus lateralis of a normal-weight adult? 

Answer: Here are the suggested volumes:

  • Average 0.5 mL
  • Range 0.5–2 mL
Vastus Lateralis:     
  • Average 1–4 mL          
  • Range 1–5 mL
Infants and toddlers would fall at the lower end of the range, whereas adolescents and adults would generally fall on the higher end of the range.

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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