Issue 1339: December 6, 2017

Ask the Experts
Ask the Experts—Question of the Week: My 11-year-old patient inadvertently received a dose of Td instead of Tdap. . . . read more










It's National Influenza Vaccination Week; make sure all your patients are protected against flu!

It's National Influenza Vaccination Week! This event highlights the importance of continuing influenza vaccination throughout the season. Resources to encourage vaccination—in English and Spanish—including fact sheets, flyers, and posters, are available on CDC's website. Web buttons, badges, animated GIFs, and web banners are available from CDC as well.

Visit CDC's National Influenza Vaccination Week web section to explore the many resources for healthcare professionals, patients, parents, and the media.

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New! IAC's updated 142-page book, Vaccinating Adults: A Step-by-Step Guide now available for purchase or free download

The Immunization Action Coalition (IAC) has announced the publication of a new book, Vaccinating Adults: A Step-by-Step Guide (Guide).

This completely updated guide on adult immunization (originally published in 2004) provides easy-to-use, practical information covering important “how-to” activities to help providers enhance their existing adult immunization services or introduce them into any clinical setting, including:

  • setting up for vaccination services,
  • storing and handling vaccines,
  • deciding which people should receive which vaccines,
  • administering vaccines,
  • documenting vaccinations (including legal issues), and
  • understanding financial considerations and billing information. 

In addition, the Guide is filled with hundreds of web addresses and references to help providers stay up to date on the latest immunization information, both now and in the future.

Two options are available to obtain a copy of the updated Guide:

  • Purchase a copy
    A limited number of printed editions of this 142-page book are available for purchase at The Guide’s lie-flat binding and 10 tabbed sections make it easy to locate the information being sought. Purchased copies are delivered in a box that includes Immunization Techniques: Best Practices with Infants, Children, and Adults, a 25-minute training DVD developed by the California Department of Public Health. Also included are several selected IAC print materials, such as the "Skills Checklist for Vaccine Administration," an assessment tool to assist in evaluating the skill level of staff who administer vaccines.
  • Download for free and print it yourself
    The entire Guide is available to download/print free of charge at The downloaded version is suitable for double-sided printing. Options are available online to download the entire book or selected chapters.

The development of the Guide was supported by the National Vaccine Program Office (NVPO) and the Centers for Disease Control and Prevention (CDC). Expert staff from both agencies also provided early technical review of the content.

The Guide is a uniquely valuable resource to assist providers in increasing adult immunization rates. Be sure to get a copy today!

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AAFP announces it joined more than 50 additional organizations in signing a joint letter calling for fully funding the Section 317 federal immunization program

The American Academy of Family Physicians (AAFP) released a news story that they joined more than 50 organizations in signing a joint letter drafted by The 317 Coalition. The letter calls on leaders of House and Senate subcommittees to fully fund the national immunization program authorized under Section 317 of the Public Health Service Act. The first three paragraphs are reprinted below.

Thank you for your leadership on our nation’s immunization network in your work on the Labor, HHS, and Education Appropriations Subcommittees. As you move into conference for the fiscal year 2018 Labor-HHS-Education appropriations bill, we urge you to fund the national immunization program authorized under Section 317 of the Public Health Service Act at the Centers for Disease Control and Prevention (CDC) at $606,972,000, the level included in the Senate bill.

Vaccines are one of the greatest success stories in public health and are among the most cost-effective ways to prevent disease. Indeed, we know that for each dollar invested in the U.S. childhood immunization program, there are over ten dollars of societal savings and three dollars in direct medical savings. Moreover, childhood immunizations over the past twenty-three years have prevented 381 million illnesses, 855,000 early deaths, and $1.65 trillion in total society costs.

However, purchasing vaccines is not enough to protect a population. A robust immunization infrastructure is required to support programs such as Vaccines for Children, which relies upon the critical infrastructure and operations funded through Section 317 to effectively serve its target population: the 54% of American children, nearly 45 million, who get their vaccines for free every year through this program. The Section 317 program also serves as the backbone of our nation’s public health infrastructure, supporting the science that informs our national immunization policy; providing a safety net to uninsured, poor adults for vaccine purchases; monitoring the safety of vaccines; educating providers and performing community outreach; and conducting surveillance, laboratory testing, and epidemiology to respond to disease outbreaks.

Access the November 9 letter drafted by The 317 Coalition.

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Daily Beast publishes plea for increased HPV vaccination by man dying of HPV-related cancer

On December 1, the Daily Beast published an article by Michael Becker titled A Dying Plea: Young Men Should Be Required to Get the HPV Vaccine. It Would Have Saved Me From Cancer. Selections from this personal account are reprinted below.

In December 2015, at the age of 47, I was diagnosed with Stage IV oral squamous cell carcinoma.

More simply, I have advanced cancer of the head and neck. While initial treatment with grueling chemo-radiation appeared successful, the cancer returned one year later in both of my lungs. My prognosis shifted from potentially curable to terminal disease. The news was shocking and devastating—not just for me, but for my wife, two teenage daughters, and the rest of our family and friends....

My cancer started with a human papillomavirus (HPV) infection, a virus that is preventable with vaccines available for adolescent girls since 2006 and boys starting in 2011....

According to the Centers for Disease Control and Prevention (CDC), more than 30,000 new cancers attributable to HPV are diagnosed each year....

Researchers believe that it can take between 10 and 30 years from the time of an initial HPV infection until a tumor forms. That’s why preventing HPV in the first place is so important and the HPV vaccine is so essential.

However, only 49.5 percent of girls and 37.5 percent of boys in the United States were up to date with this potentially lifesaving vaccination series, according to a 2017 CDC report....

As a cancer patient with a terminal prognosis, I find it infuriating that the HPV vaccine is tragically underutilized more than a decade since its introduction. Two simple shots administered in early adolescence can reduce a child’s risk of receiving a cancer diagnosis much later in life....

Access the full article: A Dying Plea: Young Men Should Be Required to Get the HPV Vaccine. It Would Have Saved Me From Cancer.
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Utah hepatitis A outbreak hits 95 cases with over 60% needing hospitalization; Los Angeles County approves portable toilets and washbasins to stop spread of HAV among homeless population

The Utah Department of Health has released information about an ongoing hepatitis A outbreak in the state that includes 95 cases. The first paragraph is reprinted below.

Since January 1, 2017, Utah public health has identified 95 confirmed cases of hepatitis A virus (HAV) infection; many among persons who are homeless and/or using illicit drugs. Several cases have been linked by investigation and/or viral sequencing to a national outbreak of hepatitis A involving cases in California and Arizona. Hospitalization rates of less than 40% have been described in previous hepatitis A outbreaks; however, other jurisdictions associated with this outbreak are reporting case hospitalization rates approaching 70%. The high rate of hospitalization may be a result of cases having underlying illnesses (e.g., alcoholism), or a higher rate of hepatitis comorbidities (e.g., hepatitis B or C). In response to the outbreak, public health officials have been working to identify cases and contacts, provide education, and ensure opportunities for vaccination of close contacts to cases and vulnerable populations.

In California, on November 28, the Los Angeles County Board of Supervisors took action to stop the spread of HAV there by providing portable bathrooms to homeless encampments of 30 people or more in unincorporated parts of the county.

Besides Utah and California, the hepatitis A outbreak includes cases in Michigan, Kentucky, Arizona, and Colorado.

A webinar titled Hepatitis A 2017 Outbreak Response—Lessons from Big Cities, hosted and recorded by the National Association of County and City Health Officials (NACCHO) on November 3, is now available online. In the webinar, county health officials from California and Michigan describe the outbreak, lessons learned, and ways other health departments can prepare against hepatitis A outbreaks.

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IAC Spotlight! IAC enrolls five new birthing institutions into its Hepatitis B Birth Dose Honor Roll; ten previously honored institutions qualify for additional years' honors

The Immunization Action Coalition (IAC) is pleased to announce that five new institutions have been accepted into its Hepatitis B Birth Dose Honor Roll. The birthing institutions are listed below with their reported hepatitis B birth dose coverage rates in parentheses.

  • Franciscan Health Hammond, Hammond, IN (100%)
  • Franciscan Health Dyer, Dyer, IN (99%)
  • Sterling Regional Medical Center, Sterling, CO (94%)
  • Wilson N. Jones Regional Medical Center, Sherman, TX (96%)
  • Witham Health Services, Lebanon, IN (95%)

In addition, the following six institutions are being recognized for a second year:

  • Bradford Regional Medical Center, Bradford, PA (96%)
  • Halifax Regional Medical Center, Roanoke Rapids, NC (98%)
  • Missouri Delta Medical Center, Sikeston, MO (98%)
  • St. Anthony Shawnee Hospital, Shawnee, OK (98%)
  • Terre Haute Regional Hospital, Terre Haute, IN (99%)
  • Wilson N. Jones Regional Medical Center, Sherman, TX (98%)

The following institution is being recognized for a third year:

  • Terre Haute Regional Hospital, Terre Haute, IN (99%)

The following two institutions are being recognized for a fourth year:

  • Highlands Regional Medical Center, Prestonsburg, KY (97%)
  • Platte Valley Medical Center, Brighton, CO (90%)

Finally, the following institution is being recognized for a fifth year:

  • Laughlin Memorial Hospital, Greeneville, TN (100%)

Note: Two of these institutions qualified for multiple 12-month periods at one time.

The Honor Roll now includes 370 birthing institutions from 39 states, Puerto Rico, and Guam. Eighty-one institutions have qualified for two years, 41 institutions have qualified three times, 12 institutions have qualified four times, and 5 institutions have qualified five times.

The Honor Roll is a key part of IAC’s major initiative urging the nation’s hospitals to Give birth to the end of Hep B. Hospitals and birthing centers are recognized for attaining high coverage rates for administering hepatitis B vaccine at birth and meeting specific additional criteria. The initiative urges qualifying healthcare organizations to apply for the Hepatitis B Birth Dose Honor Roll online.

To be included in the Hepatitis B Birth Dose Honor Roll, a birthing institution must have: (1) reported a coverage rate of 90 percent or greater, over a 12-month period, for administering hepatitis B vaccine before hospital discharge to all newborns, including those whose parents refuse vaccination, and (2) implemented specific written policies, procedures, and protocols to protect all newborns from hepatitis B virus infection prior to hospital discharge.

Honorees are also awarded an 8.5" x 11" color certificate suitable for framing and their acceptance is announced to IAC Express’s approximately 50,000 readers.

Please visit the Hepatitis B Birth Dose Honor Roll web page that lists these institutions and their exceptional efforts to protect infants from perinatal hepatitis B transmission.

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IAC updates "Hepatitis A and Hepatitis B Vaccines: Be Sure Your Patients Get the Correct Dose"

IAC recently updated Hepatitis A and Hepatitis B Vaccines: Be Sure Your Patients Get the Correct Dose. Changes were made to incorporate the CDC recommendation to vaccinate newborns within 24 hours of birth (previously stated "prior to discharge from the facility").

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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 "Hepatitis B and Healthcare Personnel: CDC answers frequently asked questions about how to protect healthcare personnel"

IAC recently revised its resource titled Hepatitis B and Healthcare Personnel. This piece includes many Q&As from IAC's "Ask the Experts" feature. Changes were made to incorporate more precise text from the 2013 CDC recommendations regarding the procedure for determining the response to HBIG and HepB vaccine in an unvaccinated or incompletely vaccinated healthcare worker who has a needlestick from an HBsAg-positive patient.

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IAC revises two handouts for parents: "Hepatitis B Shots Are Recommended for All New Babies" and "All Kids Need Hepatitis B Shots!"

IAC has revised the following two handouts for parents:

  1. Hepatitis B Shots Are Recommended for All New Babies
  2. All Kids Need Hepatitis B Shots!

Changes were made to incorporate the CDC recommendation to vaccinate newborns within 24 hours of birth (previously stated "before leaving the hospital").

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IAC updates its resource for healthcare professionals, "Hepatitis B Facts: Testing and Vaccination" 

IAC recently updated its resource for healthcare professionals titled Hepatitis B Facts: Testing and Vaccination. Changes were made to incorporate the CDC recommendation to vaccinate newborns within 24 hours of birth (previously stated "prior to hospital discharge") and to include the recommendation for physician discretion in vaccinating adults with diabetes who are age 60 years and older.

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IAC revises its sample standing orders for administering Haemophilus influenzae type b vaccine for both children/teens and adults

IAC recently revised the following sample standing orders:

Access IAC's Standing Orders for Administering Vaccines web page with templates for all routinely recommended vaccines.

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ACP and CDC jointly publish clinical guidelines for hepatitis B screening and treatment 

On November 21, the American College of Physicians (ACP) and CDC published Hepatitis B Vaccination, Screening, and Linkage to Care: Best Practice Advice From the American College of Physicians and the Centers for Disease Control and Prevention in the Annals of Internal Medicine. Sections of the abstract are reprinted below.

Vaccination, screening, and linkage to care can reduce the burden of chronic hepatitis B virus (HBV) infection. However, recommendations vary among organizations, and their implementation has been suboptimal. The American College of Physicians' High Value Care Task Force and the Centers for Disease Control and Prevention developed this article to present best practice statements for hepatitis B vaccination, screening, and linkage to care.

Best Practice Advice 1
Clinicians should vaccinate against hepatitis B virus (HBV) in all unvaccinated adults (including pregnant women) at risk for infection due to sexual, percutaneous, or mucosal exposure; health care and public safety workers at risk for blood exposure; adults with chronic liver disease, end-stage renal disease (including hemodialysis patients), or HIV infection; travelers to HBV-endemic regions; and adults seeking protection from HBV infection.

Best Practice Advice 2
Clinicians should screen (hepatitis B surface antigen, antibody to hepatitis B core antigen, and antibody to hepatitis B surface antigen) for HBV in high-risk persons, including persons born in countries with 2% or higher HBV prevalence, men who have sex with men, persons who inject drugs, HIV-positive persons, household and sexual contacts of HBV-infected persons, persons requiring immunosuppressive therapy, persons with end-stage renal disease (including hemodialysis patients), blood and tissue donors, persons infected with hepatitis C virus, persons with elevated alanine aminotransferase levels (≥19 IU/L for women and ≥30 IU/L for men), incarcerated persons, pregnant women, and infants born to HBV-infected mothers.

Best Practice Advice 3
Clinicians should provide or refer all patients identified with HBV (HBsAg-positive) for posttest counseling and hepatitis B–directed care.

Access the complete guidelines: Hepatitis B Vaccination, Screening, and Linkage to Care: Best Practice Advice From the American College of Physicians and the Centers for Disease Control and Prevention.

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WHO reports on the October meeting of the Strategic Advisory Group of Experts on Immunization in Weekly Epidemiological Record

The December 1 edition of the WHO periodical Weekly Epidemiological Record reported on the October 2017 meeting of the Strategic Advisory Group of Experts on Immunization in an article titled Meeting of the Strategic Advisory Group of Experts on immunization, October 2017—conclusions and recommendations.

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CDC reports on fractional-dose IPV campaign in Pakistan

CDC published Fractional-Dose Inactivated Poliovirus Vaccine Campaign—Sindh Province, Pakistan, 2016 in the December 1 issue of MMWR (pages 1295–9). A summary made available to the press is reprinted below.

In response to isolation of type 2 vaccine derived poliovirus (VDPV2) from sewage samples taken from Hyderabad, Pakistan, fIPV was used in a polio vaccination campaign targeting children ages 4–23 months. The vaccine coverage rate during the campaign was relatively high; however, operational challenges related to the use of an intradermally injected vaccine were encountered during the campaign. Countries that decide to use fIPV should undertake meticulous planning and preparation to address operational challenges and to ensure judicious use of fIPV due to the limited global stock of IPV.

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2017 edition of The Vaccine Handbook: A Practical Guide for Clinicians, a.k.a. "The Purple Book," available for purchase

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. 

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! 

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.

Click here to visit the The Vaccine Handbook App page in the iTunes store.

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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CDC reports on the absence of asymptomatic mumps virus shedding among vaccinated college students during an outbreak

CDC published Notes from the Field: Absence of Asymptomatic Mumps Virus Shedding Among Vaccinated College Students During a Mumps Outbreak—Washington, February–June 2017 in the December 1 issue of MMWR (pages 1307–8). Selections from the article are reprinted below.

On February 8, 2017, a suspected case of mumps in a member of a fraternity or sorority at the University of Washington, Seattle campus (UW) was reported to Public Health–Seattle & King County (PHSKC). Additional confirmed and probable mumps cases were subsequently identified among UW students and staff members according to the national case definition. By July 19, 2017, a total of 42 (16 confirmed and 26 probable) mumps cases were reported among UW students and associated community members, with symptom onset February 6–June 4....

All mumps patients had received ≥2 documented doses of measles-mumps-rubella (MMR) vaccine, as is currently recommended; 2-dose MMR coverage among all UW students exceeded 99%....

Previous studies have suggested that mumps might be propagated by vaccinated persons with nonspecific symptoms or asymptomatic infection. Before licensure of mumps vaccine in 1967, 15%–27% of mumps infections were asymptomatic. How vaccination modifies clinical signs and symptoms of mumps is unknown. The prevalence of asymptomatic infection has not been assessed in the postvaccination era.

To assess the presence, prevalence, symptoms, and associated risk factors of asymptomatic mumps virus shedding in vaccinated persons, PHSKC, Washington State Department of Health, and CDC recruited a convenience sample of students at each MMR vaccination clinic....

This evaluation found no laboratory evidence of asymptomatic mumps virus shedding....

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Next ACIP meeting scheduled for February 21–22

ACIP will hold its next meeting on February 21–22 in Atlanta. To attend the meeting, ACIP attendees (participants and visitors) must register online. The registration deadline for non-U.S. citizens is January 24; for U.S. citizens, it's February 5. Registration is not required to watch the meeting via webcast or listen to the proceedings via phone. See the second link below for the toll-free phone number and passcode.

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Question of the Week

My 11-year-old patient inadvertently received a dose of Td instead of Tdap. He received a 5-dose series of DTaP in childhood. Do I need to wait a specific interval before giving him Tdap?  

No. Tdap should be administered as soon as possible.

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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