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Issue 1347: January 31, 2018









CDC publishes ACIP recommendations for use of herpes zoster vaccines in MMWR

CDC published Recommendations of the Advisory Committee on Immunization Practices for Use of Herpes Zoster Vaccines in the January 26 issue of MMWR (pages 103–8). The "Introduction" and "Clinical Guidance" sections are reprinted below.


On October 20, 2017, Zoster Vaccine Recombinant, Adjuvanted (Shingrix, GlaxoSmithKline, [GSK] Research Triangle Park, North Carolina), a 2-dose, subunit vaccine containing recombinant glycoprotein E in combination with a novel adjuvant (AS01B), was approved by the Food and Drug Administration for the prevention of herpes zoster in adults aged ≥50 years. The vaccine consists of 2 doses (0.5 mL each), administered intramuscularly, 2–6 months apart. On October 25, 2017, the Advisory Committee on Immunization Practices (ACIP) recommended the recombinant zoster vaccine (RZV) for use in immunocompetent adults aged ≥50 years.

Herpes zoster is a localized, usually painful, cutaneous eruption resulting from reactivation of latent varicella zoster virus (VZV). Herpes zoster is common: approximately one million cases occur each year in the United States. The incidence increases with age, from five cases per 1,000 population in adults aged 50–59 years to 11 cases per 1,000 population in persons aged ≥80 years. Postherpetic neuralgia, commonly defined as persistent pain for at least 90 days following the resolution of the herpes zoster rash, is the most common complication and occurs in 10%–13% of herpes zoster cases in persons aged >50 years. Among persons with herpes zoster, the risk for developing postherpetic neuralgia also increases with age.

Zoster Vaccine Live (ZVL) (Zostavax, Merck and Co., Inc., Whitehouse Station, New Jersey), a 1-dose live attenuated strain of VZV, is licensed for the prevention of herpes zoster in immunocompetent adults aged ≥50 years and is recommended by the ACIP for use in immunocompetent adults aged ≥60 years. Since licensure, vaccine coverage has increased each year, and by 2016, 33% of adults aged ≥60 years reported receipt of the vaccine (CDC, provisional unpublished data). ACIP considered use of RZV, as well as existing recommendations, to develop vaccination policy which would be safe and reduce disease burden. This report serves as a supplement to the 2008 Prevention of Herpes Zoster Recommendations of ACIP for the use of ZVL in adults aged ≥60 years and subsequent updates; it outlines recent ACIP recommendations as well as guidance for use of RZV and ZVL in adults.

Clinical Guidance

General use. RZV may be used in adults aged ≥50 years, irrespective of prior receipt of varicella vaccine or ZVL, and does not require screening for a history of chickenpox (varicella). ZVL remains a recommended vaccine for prevention of herpes zoster in immunocompetent adults aged ≥60 years. Care should be taken not to confuse ZVL, which is stored in the freezer and administered subcutaneously, with RZV, which is stored in the refrigerator and administered intramuscularly.

Dosing schedule. Following the first dose of RZV, the second dose should be given 2–6 months later. The vaccine series need not be restarted if more than 6 months have elapsed since the first dose; however, the efficacy of alternative dosing regimens has not been evaluated, data regarding the safety of alternative regimens are limited, and individuals might remain at risk for herpes zoster during a longer than recommended interval between doses 1 and 2. If the second dose of RZV is given less than 4 weeks after the first, the second dose should be repeated. Two doses of the vaccine are necessary regardless of prior history of herpes zoster or prior receipt of ZVL.

Timing of RZV for persons previously vaccinated with ZVL. Age and time since receipt of ZVL may be considered to determine when to vaccinate with RZV. Studies examined the safety and immunogenicity of RZV vaccination administered ≥5 years after ZVL; shorter intervals have not been studied. However, there are no data or theoretical concerns to indicate that RZV would be less safe or less effective when administered at an interval of <5 years. Clinical trials indicated lower efficacy of ZVL in adults aged ≥70 years; therefore, a shorter interval may be considered based on the recipient’s age when ZVL was administered. Based on expert opinion, RZV should not be given <2 months after receipt of ZVL.

Coadministration with other vaccines. CDC’s general best practice guidelines for immunization advise that recombinant and adjuvanted vaccines, such as RZV, can be administered concomitantly, at different anatomic sites, with other adult vaccines. Concomitant administration of RZV with Fluarix Quadrivalent (influenza vaccine) (QIV) has been studied, and there was no evidence for interference in the immune response to either vaccine or safety concerns. Evaluation of coadministration of RZV with 23-valent pneumococcal polysaccharide vaccine (PPSV23, Pneumovax23) and tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis vaccine, adsorbed (Tdap, Boostrix) is ongoing. The safety and efficacy of administration of two adjuvanted vaccines (e.g., RZV and adjuvanted influenza vaccine [Fluad]), either concomitantly or at other intervals, have not been evaluated.

Counseling for reactogenicity. Before vaccination, providers should counsel RZV recipients about expected systemic and local reactogenicity. Reactions to the first dose did not strongly predict reactions to the second dose; vaccine recipients should be encouraged to complete the series even if they experienced a grade 1–3 reaction to the first dose of RZV. The impact of prophylactic analgesics in conjunction with RZV has not been studied.

Access the complete recommendation: Recommendations of the Advisory Committee on Immunization Practices for Use of Herpes Zoster Vaccines.

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Widespread influenza has killed 37 children; CDC provides related media advisory

CDC has reported in its Weekly U.S. Influenza Surveillance Report, FluView, that as of the week ending January 20, influenza has caused nearly 12,000 hospitalizations and 37 pediatric deaths since October 1, 2017. Because it takes time for deaths outside of a hospital to be investigated, the reported number of pediatric deaths is likely to be an underestimate.

The geographic spread of influenza in Puerto Rico and 49 states was reported as widespread; Guam reported regional activity; the District of Columbia and one state reported local activity; and the U.S. Virgin Islands reported sporadic activity.

On January 26, CDC held an update for the media titled "CDC Update on Flu Activity." Part of the introductory statement from Dan Jernigan, MD, MPH, director, Influenza Division, National Center for Immunization and Respiratory Diseases, CDC, is reprinted below.

It has been a tough flu season so far this year. And while flu activity is beginning to go down in parts of the country, it remains high for most the U.S., with some areas still rising. Most people with influenza are being infected with the H3N2 influenza virus. And in seasons where H3N2 is the main cause of influenza, we see more cases, more visits to the doctor, more hospitalizations, and more deaths, especially among older people. This season now looking like the 2014–15 season where H3N2 predominated. ... We’ve experienced two notable characteristics of flu this season: The first is that flu activity became widespread within almost all states and jurisdictions at the same time. The second is that flu activity has now stayed at the same level for 3 weeks in a row, with 49 states reporting widespread activity, each week, for 3 weeks. We often see different parts of the country “light up” at different times, but for the past 3 weeks, the entire country has been experiencing lots of flu, all at the same time. 

Access the complete transcript or audio recording from this media advisory.

Influenza vaccination is recommended for everyone six months of age 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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Nominations are now open for the National Adult and Influenza Immunization Summit Excellence Awards

The National Adult and Influenza Immunization Summit (NAIIS) is soliciting candidates for the 2018 NAIIS Immunization Excellence Awards. The 2018 awards recognize individuals and organizations that have made extraordinary contributions towards improving vaccination rates within their communities during 2017. The awards focus on individuals and organizations that exemplify the meaning of the "immunization neighborhood" (collaboration, coordination, and communication among immunization stakeholders dedicated to meeting the immunization needs of the patient and protecting the community from vaccine-preventable diseases). Unless an award criteria is specifically focused on influenza, it is the intent of the Summit to recognize broader adult immunization activities.  
A national winner will be selected for each award category, and, where appropriate, an honorable mention recipient. The winners will be presented with their awards at the National Adult and Influenza Immunization Summit meeting to be held in May 17–18 in Atlanta. The national winner in each category will be invited to present their programs at the National Adult and Influenza Immunization Summit meeting.

Access information on the award categories and the nomination form.

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IAC Spotlight! IAC's recently updated Clinic Tools: Screening for Vaccine Contraindications and Precautions web page provides resources from IAC and CDC to help you assess whether your patients can be vaccinated 

Recently updated, IAC's Clinic Tools: Screening for Vaccine Contraindications and Precautions web page on is a collection of resources from IAC and CDC related to vaccine contraindications and precautions. This web page can be found by selecting the "Clinic Tools" tab (third from the left) in the light gray banner across the top of every web page and then selecting "Screening for Contraindications" in the drop-down menu.

In the left-hand column of the page you will find IAC's educational materials related to vaccine administration. From here, you can access IAC's screening checklists for vaccination as well as links to other related resources available on The right-hand column of the page includes resources from CDC.

Visit the Clinic Tools: Screening for Vaccine Contraindications and Precautions on

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CDC publishes report about people who erroneously received an excess dosage of yellow fever vaccine

CDC published Notes from the Field: Errors in Administration of an Excess Dosage of Yellow Fever Vaccine—United States, 2017 in the January 26 issue of MMWR (pages 109–10). Sections from the article are reprinted below.

Yellow fever vaccine (YF-VAX, Sanofi Pasteur, Swiftwater, Pennsylvania) is a live, attenuated virus vaccine recommended for persons aged ≥9 months who are traveling to or living in areas with risk for yellow fever virus transmission. For persons of all ages for whom vaccination is indicated, a single subcutaneous injection of 0.5 mL of reconstituted vaccine is used. ... Because no specific treatment for yellow fever exists, prevention through vaccination is critical to reduce yellow fever–associated morbidity and mortality. YF-VAX is the only yellow fever vaccine licensed in the United States, and approximately 500,000 doses are distributed annually to vaccinate military and civilian travelers. Yellow fever vaccine is supplied only to designated Yellow Fever Vaccination Centers authorized to issue certificates of yellow fever vaccination. YF-VAX is available in single-dose and 5-dose vials....

In March 2017, four persons at a single military clinic were vaccinated in error, each receiving an entire 5-dose vial of YF-VAX reconstituted with 0.6 mL of diluent before administration. No specific adverse events were reported; all persons were evaluated in an emergency department (ED) and released. The error was reported to the Vaccine Adverse Event Reporting System (VAERS), which prompted CDC to search the VAERS database for similar reports of incorrect dosage administration of YF-VAX. Eleven reports of similar errors in vaccine administration were identified, including a cluster of seven persons vaccinated at another military clinic in 2007 and four other reports...

Most reports did not involve an adverse event, but the error was costly in terms of follow-up medical evaluation and vaccine waste. Vaccine providers should follow the instructions provided with YF-VAX; preventive measures such as more distinctive packaging and in-service training in clinics that stock both the single and multidose vials might be helpful.

Please see the complete article for more details and for a photo showing the difference between yellow fever vaccine supplied as 5 single-dose vials and one 5-dose vial: Notes from the Field: Errors in Administration of an Excess Dosage of Yellow Fever Vaccine—United States, 2017.

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Voices for Vaccines celebrates 5 years of promoting vaccination!

Voices for Vaccines (VFV), a national organization of parents and others who are dedicated to raising the level of the voices of immunization supporters, has just turned 5! With the hard work and determination of its founders and members, Voices for Vaccines has accomplished much these last 5 years. Here is a very small selection of some of what the organization has done (in no particularly order):

VFV invites everyone who values vaccines to become a member. Please spread the word to your friends and colleagues to register for the conference call and to join VFV!
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IAC's new 142-page book, Vaccinating Adults: A Step-by-Step Guide, describes how to implement adult vaccination services in your healthcare setting and provides a review for staff who already vaccinate adults; IAC Guide available for free download or purchase

The Immunization Action Coalition (IAC) recently announced the publication of its 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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IAC updates "Administering Vaccines: Dose, Route, Site, and Needle Size”

IAC recently revised Administering Vaccines: Dose, Route, Site, and Needle Size to incorporate the recently licensed recombinant zoster vaccine (RZV), Shingrix, that is administered intramuscularly, as well as the recently licensed hepatitis B vaccine (Heplisav-B) that is licensed for use in adults.

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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 "How to Administer Intramuscular and Subcutaneous Vaccine Injections" and "How to Administer Intramuscular and Subcutaneous Vaccine Injections to Adults" 

IAC recently updated How to Administer Intramuscular and Subcutaneous Vaccine Injections and How to Administer Intramuscular and Subcutaneous Vaccine Injections to Adults. Changes were made to incorporate the recently licensed recombinant zoster vaccine (RZV), Shingrix, that is administered intramuscularly, in contrast to the live zoster vaccine (LZV), Zostavax, which is administered subcutaneously.

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A mother-daughter team of polio vaccinators killed in Pakistan

Two polio vaccinators, a 38-year-old woman and her 16-year-old daughter, were shot in the head and killed by gunmen on motorcycles in Pakistan on January 18. Local officials believe that unlike earlier incidents, this shooting was the work of anti-government militants who are not necessarily opposed to vaccination, but who attack targets associated with government authority.

Pakistan and Afghanistan are the only two countries with continuing transmission of polio, and the two countries now coordinate their national immunization days. Last year, Pakistan had only eight confirmed cases of polio paralysis and Afghanistan had 14.

Read more:

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Vaccine Education Center updates multiple resources, including its mumps Q&A sheet and adult vaccination booklet

The Vaccine Education Center (VEC) at Children's Hospital of Philadelphia has updated the following three print resources:
  • "Mumps: What you need to know" addresses mumps disease and vaccination. This Q&A sheet now also covers recent college outbreaks and the new ACIP third dose recommendation. This piece is part of VEC's Vaccine- and Vaccine Safety-Related Q&A Sheets series, and is available in English and Spanish
  • “Prescription for Information” pads (in English and Spanish) have been updated to include all recently revised Q&A sheets. Individual sheets can be sent home with patients/parents so they can view the materials online at their convenience.
  • The "Adults and Vaccines: A Lifetime of Health" booklet was updated to include information about the new shingles vaccine. Other minor changes were also made, including updated statistics, information about egg allergies, and mentions of recent measles and mumps outbreaks. This booklet is also available in English and Spanish.
You can download all VEC resources for free or order print copies from VEC (some free; most for a nominal charge).

In addition, Do I Need to Avoid Being Around Infants After a Shingles Vaccine? from the video series Talking about Vaccines with Dr. Paul Offit has been updated to address the new shingles vaccine, Shingrix.

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Vaccine Education Center publishes January issue of its newsletter for healthcare professionals

The Vaccine Education Center (VEC) at Children's Hospital of Philadelphia publishes a monthly immunization-focused newsletter titled Vaccine Update for Healthcare Professionals. The January issue includes the following articles:

Additional articles and resources, including handouts for patients, are available in the full newsletter.

Access the sign-up form to subscribe to Vaccine Update for Healthcare Professionals.

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Large review study investigates the effectiveness of patient reminders regarding vaccination

On January 18, the Cochrane Database of Systemic Reviews published a large review and meta-analysis by Vann Jacobson et al. titled Patient reminder and recall interventions to improve immunization rates. The "Background" and "Conclusions" sections of the abstract are reprinted below.

Immunization rates for children and adults are rising, but coverage levels have not reached optimal goals. As a result, vaccine-preventable diseases still occur. In an era of increasing complexity of immunization schedules, rising expectations about the performance of primary care, and large demands on primary care providers, it is important to understand and promote interventions that work in primary care settings to increase immunization coverage. One common theme across immunization programs in many nations involves the challenge of implementing a population-based approach and identifying all eligible recipients, for example the children who should receive the measles vaccine. However, this issue is gradually being addressed through the availability of immunization registries and electronic health records. A second common theme is identifying the best strategies to promote high vaccination rates. Three types of strategies have been studied: (1) patient-oriented interventions, such as patient reminder or recall, (2) provider interventions, and (3) system interventions, such as school laws. One of the most prominent intervention strategies, and perhaps best studied, involves patient reminder or recall systems. This is an update of a previously published review.

Authors' Conclusions
Patient reminder and recall systems, in primary care settings, are likely to be effective at improving the proportion of the target population who receive immunizations.

Access Patient reminder and recall interventions to improve immunization rates.

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Canadian study finds significant association between influenza and acute myocardial infarction

On January 25, the New England Journal of Medicine published an article online by Jeffrey Kwong et al. titled Acute Myocardial Infarction after Laboratory-Confirmed Influenza Infection. The "Background" and "Conclusions" sections of the abstract are reprinted below.

Acute myocardial infarction can be triggered by acute respiratory infections. Previous studies have suggested an association between influenza and acute myocardial infarction, but those studies used nonspecific measures of influenza infection or study designs that were susceptible to bias. We evaluated the association between laboratory-confirmed influenza infection and acute myocardial infarction.

We found a significant association between respiratory infections, especially influenza, and acute myocardial infarction. (Funded by the Canadian Institutes of Health Research and others.)

Access the abstract:  Acute Myocardial Infarction after Laboratory-Confirmed Influenza Infection.

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Study found that more than one third of people infected with HIV in U.S. had missed opportunities to initiate hepatitis B vaccination

On December 26, the Annals of Internal Medicine published an article online by John Weiser et al. titled Low Prevalence of Hepatitis B Vaccination Among Patients Receiving Medical Care for HIV Infection in the United States, 2009 to 2012. Three sections of the abstract are reprinted below.

Persons with HIV infection are at increased risk for hepatitis B virus infection. In 2016, the World Health Organization resolved to eliminate hepatitis B as a public health threat by 2030.

To estimate the prevalence of hepatitis B vaccination among U.S. patients receiving medical care for HIV infection (“HIV patients”).

More than one third of U.S. HIV patients had missed opportunities to initiate hepatitis B vaccination. Meeting goals for hepatitis B elimination will require increased vaccination of HIV patients in all practice settings, particularly at facilities not funded by RWHAP.

Access the abstract: Low Prevalence of Hepatitis B Vaccination Among Patients Receiving Medical Care for HIV Infection in the United States, 2009 to 2012.

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WHO report on immunization in older adults worldwide published in Vaccine

On January 12, Report on WHO meeting on immunization in older adults: Geneva, Switzerland, 22–23 March 2017, was published online in Vaccine. The abstract is reprinted below.

Many industrialized countries have implemented routine immunization policies for older adults, but similar strategies have not been widely implemented in low- and middle-income countries (LMICs). In March 2017, the World Health Organization (WHO) convened a meeting to identify policies and activities to promote access to vaccination of older adults, specifically in LMICs. Participants included academic and industry researchers, funders, civil society organizations, implementers of global health interventions, and stakeholders from developing countries with adult immunization needs. These experts reviewed vaccine performance in older adults, the anticipated impact of adult vaccination programs, and the challenges and opportunities of building or strengthening an adult and older adult immunization platforms. Key conclusions of the meeting were that there is a need for discussion of new opportunities for vaccination of all adults as well as for vaccination of older adults, as reflected in the recent shift by WHO to a life-course approach to immunization; that immunization in adults should be viewed in the context of a much broader model based on an individual’s abilities rather than chronological age; and that immunization beyond infancy is a global priority that can be successfully integrated with other interventions to promote healthy ageing. As WHO is looking ahead to a global Decade of Healthy Ageing starting in 2020, it will seek to define a roadmap for interdisciplinary collaborations to integrate immunization with improving access to preventive and other healthcare interventions for adults worldwide.

Access the complete report: Report on WHO meeting on immunization in older adults: Geneva, Switzerland, 22–23 March 2017.

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ACOG, ACNM, and CDC to present webinar on maternal immunization on March 1
The American College of Obstetricians and Gynecologists (ACOG), the American College of Nurse-Midwives (ACNM), and CDC will host a webinar titled "Maternal Immunization: Understanding Safety and Efficacy and Making a Strong Recommendation," on March 1 at 5:00 p.m. (ET). Upon completion of the webinar, participants will be able to:
  • Discuss the scientific evidence supporting maternal flu vaccination safety and monitoring
  • Educate pregnant patients about the importance of an annual flu vaccine
  • Name three components of a strong recommendation
  • Use CDC, ACOG, and ACNM messaging and resources to address patient questions and concerns regarding flu immunization

Registration information

This session is free and open to all. ACOG membership not required.

Following the live presentation, the webinar will be archived on the webinar section of ACOG’s Immunization for Women website for convenient viewing. The recording will not provide CME credit.

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National AHEC Organization to sponsor February 15 webinar titled "How HPV Causes Cancer and Why it Still Matters"

The National AHEC Organization is sponsoring a webinar titled "How HPV Causes Cancer and Why it Still Matters" on February 15 at 3:00 p.m. (ET). Peter C. Angeletti, associate professor, University of Nebraska–Lincoln, Nebraska Center for Virology, School of Biological Sciences, will explain the biology of HPV infection and the mechanism by which HPV causes cancer, and then show evidence of different manifestations of HPV-related dysplasia. He will also discuss the rationale for adopting an effective public HPV vaccination strategy and provide evidence for efficacy of the current vaccine.

Registration information

The National AHEC Organization supports and advances the Area Health Education Center (AHEC) Network to improve health by leading the nation in recruitment, training, and retention of a diverse health work force for underserved communities.

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About IAC Express
The Immunization Action Coalition welcomes redistribution of this issue of IAC Express or selected articles. When you do so, please add a note that the Immunization Action Coalition is the source of the material and provide a link to this issue.

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IAC Express is supported in part by Grant No. 6NH23IP922550 from the National Center for Immunization and Respiratory Diseases, CDC. Its contents are solely the responsibility of IAC and do not necessarily represent the official views of CDC. IAC Express is also supported by educational grants from the following companies: AstraZeneca, Inc.; Merck Sharp & Dohme Corp.; Pfizer, Inc.; and Sanofi Pasteur.

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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 DisclaimerISSN 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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