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Issue 1327: September 20, 2017

Ask the Experts
Ask the Experts—Question of the Week: A 22-year-old female is going to pharmacy school and the school wants . . . read more









CDC releases guidance for prevention of tetanus in areas affected by a hurricane

On September 12, the Clinician Outreach and Communication Activity (COCA) service at CDC sent email guidance titled Tetanus in Areas Affected by a Hurricane: Risk, Prevention, and Management Guidelines for Clinicians. One paragraph from the guidance is reprinted below.

Exposure to flood waters does not increase the risk of tetanus. However, some people impacted by floods and other disasters may have wounds such as puncture to the skin, cuts, bruises, lacerations, scrapes, or other skin injuries that become contaminated with flood waters, human or animal wastes, soil, dirt, or saliva. Besides treatment of these wounds, the vaccination status of such persons should be assessed and an age-appropriate tetanus vaccine given if needed. In some of these situations, the clinician may decide that a tetanus vaccine is needed as early as 5 years since the last dose. Being up to date for tetanus vaccine can greatly simplify the treatment for any wound that might occur.

Access the complete guidance document for more information: Tetanus in Areas Affected by a Hurricane: Risk, Prevention, and Management Guidelines for Clinicians.

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CDC releases information about influenza and influenza vaccination during pregnancy and provides guidance on how to address concerns that patients may have about vaccination

On September 13, CDC posted information on its website about a potential safety signal with influenza vaccination of pregnant women. Two paragraphs from the information are reprinted below.

A Potential Safety Signal Associated with Flu Vaccination of Pregnant Women
A CDC-funded study found that women vaccinated early in pregnancy with a flu vaccine containing the pandemic H1N1 (H1N1pdm09) component and who also had been vaccinated the prior season with a H1N1pdm09-containing flu vaccine had an increased risk of spontaneous abortion (miscarriage) in the 28 days after vaccination. While most miscarriages occurred in the first trimester, several occurred during the second trimester. The median gestational age at the time of miscarriage was 7 weeks. This study does not quantify the risk of miscarriage and does not prove that flu vaccine was the cause of the miscarriage. Earlier studies have not found a link between flu vaccination and miscarriage. There is an ongoing investigation to study this issue further among women who were pregnant and eligible to receive flu vaccine during the 2012–13 through 2014–15 flu seasons. Results are anticipated in late 2018 or 2019.

CDC Recommendation
CDC and its Advisory Committee on Immunization Practices (ACIP) are aware of these data, which were first presented to ACIP at a public meeting in June 2015. At this time, CDC and ACIP have not changed the recommendation for influenza vaccination of pregnant women. It is recommended that pregnant women get a flu vaccine during any trimester of their pregnancy because flu poses a danger to pregnant women and a flu vaccine can prevent influenza in pregnant women.

Access the CDC web page: Flu Vaccination & Possible Safety Signal.

Access the abstract from the article published in Vaccine on September 25: Association of spontaneous abortion with receipt of inactivated influenza vaccine containing H1N1pdm09 in 2010–11 and 2011–12.

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CDC publishes updated dosing instructions for hepatitis A prophylaxis with immune globulin

CDC published Updated Dosing Instructions for Immune Globulin (Human) GamaSTAN S/D for Hepatitis A Virus Prophylaxis in the September 15 issue of MMWR (pages 959–60). The first paragraph is reprinted below.

GamaSTAN S/D (Grifols Therapeutics, Inc., Research Triangle Park, North Carolina) is a sterile, preservative-free solution of immune globulin (IG) for intramuscular administration and is used for prophylaxis against disease caused by infection with hepatitis A, measles, varicella, and rubella viruses. GamaSTAN S/D is the only IG product approved by the Food and Drug Administration for hepatitis A virus (HAV) prophylaxis. In July 2017, GamaSTAN S/D prescribing information was updated with changes to the dosing instructions for hepatitis A preexposure and postexposure prophylaxis indications. These changes were made because of concerns about decreased HAV immunoglobulin G antibody (anti-HAV IgG) potency, likely resulting from decreasing prevalence of previous HAV infection among plasma donors, leading to declining anti-HAV antibody levels in donor plasma. No changes in dosing instructions were made for measles, varicella, or rubella preexposure or postexposure prophylaxis.

The following topics are covered in this document:

  • Preexposure Prophylaxis in Persons Who Plan to Travel in Areas with High or Intermediate Hepatitis A Endemicity
  • Postexposure Prophylaxis of Household and Institutional Hepatitis A Case Contacts
  • Preexposure Prophylaxis for International Travel
  • Postexposure Prophylaxis

Access the updated dosing instructions: Updated Dosing Instructions for Immune Globulin (Human) GamaSTAN S/D for Hepatitis A Virus Prophylaxis.

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New Technically Speaking column: "Standing Orders Protocols Can Improve Your Vaccination Rates"

Technically Speaking, a monthly column written by IAC executive director Dr. Deborah Wexler, covers practical topics in immunization delivery such as needle length, vaccine administration, cold chain, and immunization schedules. The most recent column is reprinted below. 

Standing Orders Protocols Can Improve Your Vaccination Rates
Published August 2017

Standing orders for vaccine administration are written protocols approved by a physician or other authorized practitioner that allow qualified healthcare professionals (who are eligible to do so under state law, such as RNs or pharmacists) to assess the need for and administer vaccine to patients. The qualified healthcare professionals also must be eligible by state law to administer certain medications, such as epinephrine, under standing orders (should a medical emergency occur and a clinician not be available).

Having standing orders in place streamlines your practice workflow by eliminating the need to obtain an individual clinician’s order to vaccinate each patient. The use of standing orders is recommended by CDC’s Advisory Committee on Immunization Practices and by the Community Preventive Services Task Force.

Standing orders protocols will:

  • Facilitate efficient assessment for and administration of vaccines in your practice
  • Improve vaccination rates in your patients 
  • Protect more of your patients from vaccine-preventable diseases 
  • Empower nurses and/or other eligible staff to provide a valuable and potentially life-saving preventive service to patients 
  • Decrease opportunities for disease transmission, such as influenza, in your healthcare setting

The Immunization Action Coalition (IAC) has many free downloadable materials available on its website, including standing orders templates for vaccination and for how to medically manage vaccine reactions. These resources can help you implement standing orders in your office.

Resources from IAC

There are many IAC resources available on the website:

You can access the current and past issues of Technically Speaking from a box in the middle of the home page, from the "Guide to" at the bottom of every web page, or by going directly to

The column is featured in The Children's Hospital of Philadelphia Vaccine Education Center’s (VEC's) monthly e-newsletter for healthcare professionals. Check out the August 2017 issue of VEC's Vaccine Update for Healthcare Providers. The VEC e-newsletter keeps providers up to date on vaccine-related issues and includes reviews of recently published journal articles, media recaps, announcements about new resources, and a regularly updated calendar of events. To subscribe to this newsletter, go to the sign-up form.

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NAIIS's Influenza Vaccine Availability Tracking System is now available for the 2017–2018 season

To assist clinics and others that need influenza vaccine for the 2017–2018 influenza season, the National Adult and Influenza Immunization Summit (NAIIS) is pleased to announce that the Influenza Vaccine Availability Tracking System (IVATS) is up and operational. Several features to highlight include:

Please check back periodically for updates.

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CDC and NFID to host a Thunderclap for flu prevention on September 28

CDC and the National Foundation for Infectious Diseases (NFID) will host a Thunderclap that will go live on September 28 at 10:30 a.m. (ET) in conjunction with the seasonal flu kick-off. At the Thunderclap page, choose one of the red buttons to select which channel (Facebook, Twitter, and/or Tumblr) you want to use to support the campaign and authorize Thunderclap to use your account. Then watch #FightFlu on September 28 as Thunderclap supporters proclaim #FightFlu together!

For more information, visit the campaign web page.

Thunderclap is a social media tool that allows supporters to sign up in advance to share a unified message at a specific time via their individual social media accounts. The collective action creates a wave of support—or “thunderclap”—across social media.

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Voices for Vaccines releases new podcast—an interview with Dr. Tara Smith about how individuals can promote vaccination in their communities

Voices for Vaccines (VFV) has posted the ninth entry in its Vax Talk podcast series: What Can I Do? Many people like the idea of highly immunized communities, but they aren’t sure what they can do to solve the problems of vaccine refusal and hesitancy. In this podcast, VFV talks to Tara Smith, PhD, about her ideas, which she outlined in a July article published in Open Forum Infectious Diseases titled Vaccine Rejection and Hesitancy: A Review and Call to Action. Dr. Smith is a faculty member at Kent State University College of Public Health.

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 values vaccines to become a member. Please spread the word to your friends and colleagues to join VFV!
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IAC posts six new translations of "Vaccinations for Infants and Children, Age 0–10 Years"

IAC recently posted the following new translations of its very popular 1-page handout for parents titled Vaccinations for Infants and Children, Age 0–10 Years:

The Spanish-language translation has been available previously. In the future, IAC will be making translations available of several of its most popular pieces in these seven languages, in addition to English.

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IAC makes correction to the recently updated "Standing Orders for Administering Meningococcal ACWY Vaccine to Adults"

IAC recently announced that it had updated its "Standing Orders for Administering Meningococcal ACWY Vaccine to Adults" to incorporate a new section on how to administer MenACWY as well as new procedures for submitting reports to the Vaccine Adverse Event Reporting System. Since then, a correction was made on page 2, section 6, which now reads “1 previous dose given before age 16 years, and . . . ” (previously read “before age 17 years”). 

Access the corrected version: Standing Orders for Administering Meningococcal ACWY Vaccine to Adults.

Related Link

  • IAC's Standing Orders web section contains standing orders templates for administering all routinely recommended vaccines and for the medical management of vaccine reactions

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Report on June meeting of the International Task Force for Disease Eradication available; focus was on HBV and HCV

The World Health Organization (WHO) published Meeting of the International Task Force for Disease Eradication, June 2017 in the September 15 issue of its Weekly Epidemiological Record. The 26th meeting of the International Task Force for Disease Eradication (ITFDE) was convened in Atlanta on June 20 to discuss WHO goals for the elimination of hepatitis B infection (HBV) and hepatitis C infection (HCV) as public health threats. The first paragraph of the "Background" section is reprinted below.

Five types of viral hepatitis are known to cause infection in humans (hepatitis A, B, C, D and E). Only 2 types, HBV and HCV, typically cause chronic liver disease, which remains largely asymptomatic until late in the course of illness. Many persons infected with HBV or HCV are unaware they are infected and have clinically silent infections sometimes for decades until developing cirrhosis, hepatocellular carcinoma (HCC), and extra-hepatic manifestations of the disease. WHO estimates that in 2015, viral hepatitis was responsible for 1.34 million deaths per year. Worldwide, mortality attributed to viral hepatitis has increased by 22% since 2000 despite declines in deaths caused by other infectious diseases, including HIV, tuberculosis, and malaria. Certain countries and subnational areas experience disproportionately high rates of viral hepatitis, highlighting the need for strategic information to appropriately target interventions.

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New edition of The Vaccine Handbook: A Practical Guide for Clinicians, a.k.a. "The Purple Book," by Dr. Gary Marshall available for purchase from IAC; free app for iPhones and iPads available from IAC

The 6th edition of The Vaccine Handbook: A Practical Guide for Clinicians ("The Purple Book") is considered a vital source of practical, up-to-date information for vaccine providers and educators. Now printed in color and updated with the latest vaccine information through early 2017, "The Purple Book" draws together the latest vaccine science and guidance into a concise, user-friendly, practical resource for the private office, public health clinic, academic medical center, and hospital.

The sixth edition of this valuable guide (592 pages) is available on IAC's website at The price of the handbook is $34.95 per copy, plus shipping charges. Order copies for your staff or for distribution at an upcoming conference.

Discount pricing is available for more than 10 copies. For quotes on larger quantities, email

Order your copy today! Click on the image below to visit the "Shop IAC: The Vaccine Handbook" web page.

Order your copy of The Vaccine Handbook today!

The Vaccine Handbook App for Apple iPhones and iPads is available free from IAC. Sorry, the app is not available for android devices. Book purchase is not necessary but registration to obtain the app is required.

The app is fully searchable, allows for bookmarking, highlighting and annotation, and contains hyperlinks to valuable content from nonprofit and governmental sources.

Click on the image below to visit the The Vaccine Handbook App page in the iTunes store.

Download new app!

About the Author
Gary S. Marshall, MD, is professor of pediatrics at the University of Louisville School of Medicine in Kentucky, where he serves as chief of the Division of Pediatric Infectious Diseases and director of the Pediatric Clinical Trials Unit. In addition to being a busy clinician, he is nationally known for his work in the areas of vaccine research, advocacy, and education.

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Still available! IAC's sturdy laminated versions of the 2017 U.S. child/teen immunization schedule and the 2017 U.S. adult immunization schedule—order a supply for your healthcare setting today!

IAC's laminated versions of the 2017 U.S. child/teen immunization schedule and the 2017 U.S. adult immunization schedule are covered with a tough, washable coating; they will stand up to a year's worth of use in every area of your healthcare setting where immunizations are given. Both schedules are eight pages (i.e., four double-sided pages) and are folded to measure 8.5" x 11". 

Laminated Child and Teen Laminated Schedule

Adult Laminated Immunization Schedules

Laminated schedules are printed in color for easy reading, come complete with essential tables and footnotes, and include contraindications and precautions—a feature that will help you make an on-the-spot determination about the safety of vaccinating patients of any age.

1–4 copies: $7.50 each
5–19 copies: $5.50 each
20–99 copies: $4.50 each
100–499 copies: $4.00 each
500–999 copies: $3.50 each

For quotes on customizing or placing orders for 1,000 copies or more, call (651) 647-9009 or email

You can access specific information on both schedules, view images of both, order online, or download an order form at the Shop IAC: Laminated Schedules web page.

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Study shows that HPV vaccine does not have a negative impact on fertility

On September 7, the journal Paediatric and Perinatal Epidemiology published an article titled The Effect of Vaccination Against Human Papillomavirus on Fecundability (K.A. McInerney et al.). Sections of the abstract are reprinted below.

The human papillomavirus (HPV) vaccine was developed to prevent infection with strains of HPV that cause cervical cancer. While HPV infection has been associated with reduced semen quality and lower pregnancy rates in some studies, no studies have examined the relationship between HPV vaccination and fecundability. We hypothesize that HPV prevention via vaccination will protect fecundity.

HPV vaccination was more prevalent among females (33.9%) than males (5.2%). There was little overall association between female vaccination (FR 0.98, 95% CI 0.90, 1.08) or male vaccination (FR 1.07, 95% CI 0.79, 1.46) and fecundability. Among females with a history of sexually transmitted infections or pelvic inflammatory disease (i.e. a group at high risk of exposure to HPV infection), those vaccinated against HPV had higher fecundability than those not vaccinated (FR 1.35, 95% CI 0.99, 1.86).

Although HPV vaccination had little effect on fecundability overall, HPV vaccination was positively associated with fecundability among women with a history of sexually transmitted infections.

Access the abstract: The Effect of Vaccination Against Human Papillomavirus on Fecundability.

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AAFP to sponsor webinar about the 2017–18 influenza recommendations on September 26
The American Academy of Family Physicians (AAFP) is sponsoring a webinar on September 26 at 12:00 p.m. (ET) titled "Increasing Influenza Vaccinations for Adults 65 years and Older: Evidence-Based Strategies in Primary Care."

The webinar will focus on how family physicians and their healthcare teams can implement updates in the 2017–18 influenza recommendations. The webinar will introduce evidence-based resources to increase the recommended influenza rates for all persons, with a specific focus on influenza in adult 65 years and older, especially the at-risk older adult population. Information and resources on coding and billing for influenza vaccines and how family physicians can be properly reimbursed for providing those services will also be discussed.

Registration information

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Reminder: Weekly CDC webinar series on "The Pink Book" chapter topics runs through October 11; register now 

CDC is presenting a 15-part webinar series to provide a chapter-by-chapter overview of the 13th edition of Epidemiology and Prevention of Vaccine-Preventable Diseases (also known as "The Pink Book"). This is a live series of weekly 1-hour webinars that started June 14 and will run through October 11. Recordings of sessions will be available online within 2 weeks after each webinar. All sessions begin at 12:00 p.m. (ET). Continuing education will be available for each event.

The webinar series will provide an overview of vaccines and the diseases they prevent, general recommendations for vaccines, vaccination principles, and immunization strategies for providers. 

Registration and more information is available on CDC's Pink Book Webinar Series web page.

All the sections of "The Pink Book" (i.e., chapters, appendices, 2017 supplement) are available to download at no charge at

You can also order this resource from the Public Health Foundation for $40 plus shipping and handling. This print version does not include the 2017 supplement.

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Question of the Week

A 22-year-old female is going to pharmacy school and the school wants her to have a second dose of MMR vaccine. She had the first dose as a child and developed measles within 24 hours of receiving the vaccine. Recent serologic testing showed she is immune to mumps and measles but not immune to rubella. Can I give her a second dose of the MMR with her having measles after the first dose? 

Yes, as a healthcare professional, this person should get a second dose of MMR to ensure she is immune to rubella. There is no harm in providing MMR to a person who is already immune to one or more of the components. If she developed measles only one day after getting her first MMR, she must have been exposed to the disease prior to vaccination.

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 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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