Issue 1367: May 30, 2018







CDC publishes data on vaccine administration errors involving recombinant zoster vaccine

CDC published Notes from the Field: Vaccine Administration Errors Involving Recombinant Zoster Vaccine—United States, 2017–2018 in the May 25 issue of MMWR (pages 585–6). The complete article (excluding table) is reprinted below.

Two vaccines for the prevention of herpes zoster (shingles) are licensed for use in the United States and recommended by the Advisory Committee on Immunization Practices (ACIP). Zoster vaccine live (ZVL; Zostavax, Merck), licensed in 2006, is a live attenuated virus vaccine administered as a single subcutaneous (SQ) dose. Although the Food and Drug Administration (FDA) approved ZVL for adults aged ≥50 years, ACIP recommends ZVL for immunocompetent adults aged ≥60 years. Recombinant zoster vaccine (RZV; Shingrix, GlaxoSmithKline), licensed October 2017, is also approved by the FDA for adults aged ≥50 years and is recommended by ACIP for immunocompetent adults aged ≥50 years. RZV is administered as a 2-dose intramuscular (IM) series, with the second dose given anytime from 2 to 6 months after the first. RZV is preferentially recommended by ACIP over ZVL. Furthermore, ACIP recommends that persons previously vaccinated with ZVL receive the full 2-dose RZV series.

RZV and ZVL differ with regard to vaccine type, dose, and schedule; ACIP recommendation; route of administration; and storage requirements. Prior experience indicates that administration errors are reported most frequently shortly after vaccine licensure and publication of recommendations, likely because of lack of vaccine provider familiarity with the new vaccine.

During the first 4 months of RZV monitoring (October 20, 2017–February 20, 2018), the Vaccine Adverse Event Reporting System (VAERS) received 155 reports involving RZV, 13 (8%) of which documented an administration error, including some reports documenting more than one error. Among these reports, nine involved RZV given by the SQ route rather than the IM route; injection site reactions (e.g., pain, erythema, and pruritus) were described in eight of these nine reports. One of the nine reports describing errors in the route of administration also described vaccination of a person aged 48 years (inappropriate age), and two described patients receiving the vaccine information statement for ZVL instead of RZV and not being instructed to return for the second RZV dose. The remaining four reports included 1) administration of RZV instead of the intended varicella (Varivax) vaccine to a person of unreported age, 2) administration of RZV after incorrect frozen storage, 3) administration of RZV to a person aged 39 years, and 4) administration of only the adjuvant component without reconstitution with the vaccine antigen. Vaccine administration errors occurred in a pharmacy (nine reports), a health care provider’s office (two), and unknown sites (two). CDC also received 13 public inquiries concerning RZV administration errors or questions asked to avoid errors. Topics included SQ administration (five), reconstitution (five), incorrect interval or schedule (two), and administration of previously frozen vaccine (one).

Although data from passive reporting to VAERS and inquiries submitted to CDC limit the ability to draw conclusions regarding the cause of the administration errors, early monitoring indicates that vaccine providers might confuse administration procedures and storage requirements of the older ZVL and the newer RZV. Failure to reconstitute the vaccine and administration of only one component of RZV also appears to be occurring, similar to errors observed for other vaccines that require mixing. Whereas RZV administered through the appropriate IM route is associated with high rates of local and systemic reactions, erroneous SQ injection can increase the likelihood of these episodes. In addition, some errors could potentially affect vaccine effectiveness. To prevent RZV administration errors, vaccine providers should be aware of prescribing information, storage requirements, preparation guidelines, and ACIP recommendations for herpes zoster vaccines.

Access the complete article online to view the helpful comparison table: Notes from the Field: Vaccine Administration Errors Involving Recombinant Zoster Vaccine—United States, 2017–2018

Related Link
  • MMWR main page provides access to MMWR Weekly, MMWR Recommendations and Reports, MMWR Surveillance Summaries, and MMWR Supplements

Back to top


2018 edition of The Vaccine Handbook: A Practical Guide for Clinicians, a.k.a. "The Purple Book," by Dr. Gary Marshall available for purchase; free app for iPhones and iPads available 

The new (7th) edition of The Vaccine Handbook: A Practical Guide for Clinicians by Gary Marshall has just been released. Also known as "The Purple Book," this resource is a vital source of practical, up-to-date information for vaccine providers and educators. A section of the publisher's description is reprinted below.

Easy to navigate yet replete with up-to-date information, the "Purple Book" contains practical advice and background on vaccine program infrastructure, standards and regulations, business aspects of vaccine practice, general recommendations, schedules, special circumstances, and how to address the concerns of parents and patients. Specific information about vaccine-preventable diseases, the rationale for vaccine use, and available products is included. The book is targeted to pediatricians, family practitioners, internists, obstetricians, residents, medical students nurse practitioners, and physician assistants. 

Access information about ordering the print version of the 7th edition of The Vaccine Handbook: A Practical Guide for Clinicians ($39.95).


The Vaccine Handbook App for Apple iPhones and iPads is available courtesy of the Pediatric Infectious Diseases Society. 

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.

AAP gives preferential recommendation to use injectable influenza vaccine during the 2018–19 flu season 

On May 21, AAP News reported that the American Academy of Pediatrics (AAP) has recommended that pediatricians give children inactivated influenza vaccine (IIV) during the 2018–19 flu season preferentially, rather than quadrivalent live attenuated influenza vaccine (LAIV4, FluMist).

CDC's Advisory Committee on Immunization Practices (ACIP) voted at its February meeting to reintroduce LAIV4 for the upcoming flu season after reviewing data after the manufacturer introduced a new H1N1 strain to the vaccine. This means that AAP and ACIP influenza vaccine recommendations are not harmonized for the 2018–19 influenza season.

More detail will be available in the July edition of AAP News and in the AAP influenza policy released in early September.

CDC develops job aids to help providers properly catch up children who are behind schedule with PCV13, Hib, DTaP, and Tdap

CDC recently developed several new job aids to help providers figure out exactly what is needed for children who are behind schedule with PCV13, Hib, DTaP, and/or Tdap vaccines. Although this information is available in the annual U.S. Catch-Up Immunization Schedule for Persons Aged 4 Months Through 18 Years Who Start Late or Who Are More Than 1 Month Behind, the format of these resources makes it easier to determine what is needed (number of doses and timing) in a particular situation. For example, the first page of the 2-page Tdap piece is shown below to illustrate the easy-to-follow format.

Explore these new resources by clicking on the following links:

All these job aids can be accessed from CDC's Vaccine Catch-Up Guidance web section.

Related Link

Back to top

IAC Spotlight! Visit IAC's "CDC Schedules" web page which provides direct links to CDC's recommended immunization schedules for children and adults

Recently updated, IAC's CDC Schedules web page on is a fast way to access the official "Recommended Immunization Schedule for Children and Adolescents Aged 18 Years or Younger" and "Recommended Immunization Schedule for Adults Aged 19 Years or Older," as well as the related MMWR articles, the CDC Vaccine Schedules App, and information about IAC's laminated schedules.

Visit CDC Schedules on

Related Links

Back to top

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

The Immunization Action Coalition (IAC) is pleased to announce that six 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.

  • Florida Hospital Waterman, Tavares, FL (92%)
  • Hennepin Healthcare, Minneapolis, MN (94%)
  • Memorial Hermann Pearland Hospital, Pearland, TX (95%)
  • Texas Health Harris Methodist Hospital Stephenville, Stephenville, TX (95%)
  • The Hospitals of Providence Transmountain Campus, El Paso, TX (90%)
  • United Regional, Wichita Falls, TX (95%)

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

  • CHI St. Joseph Health, Bryan, TX (91%)
  • Memorial Hermann Pearland Hospital, Pearland, TX (96%)
  • Memorial Hospital and Manor, Bainbridge, GA (93%)
  • St. David's Round Rock Medical Center, Round Rock, TX (92%)
  • Yoakum County Hospital, Denver City, TX (93%)

Finally, the following two institutions are being recognized for a third year:

  • St. David's Round Rock Medical Center, Round Rock, TX (92%)
  • Yoakum County Hospital, Denver City, TX (92%)

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

The Honor Roll now includes 393 birthing institutions from 40 states, Puerto Rico, Guam, and an overseas U.S. military base. Eighty-eight institutions have qualified for two years, 48 institutions have qualified three times, 15 institutions have qualified four times, six institutions have qualified five times, one institution has qualified six times, and one institution has qualified seven 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.

Related Links

Back to top

Still available! IAC's sturdy laminated versions of the 2018 U.S. child/teen immunization schedule and the 2018 U.S. adult immunization schedule—order a supply for your healthcare setting today!

IAC's laminated versions of the 2018 U.S. child/teen immunization schedule and the 2018 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".

Adult Laminated Immunization Schedules

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.

Back to top


IAC revises two of its most popular staff education materials, "Summary of Recommendations for Child/Teen Immunization" and "Summary of Recommendations for Adult Immunization"

IAC recently updated its popular resources for healthcare professionals, Summary of Recommendations for Child/Teen Immunization and Summary of Recommendations for Adult Immunization.

Summary of Recommendations for Child/Teen Immunization was changed to incorporate an additional contraindication related to family history of immunodeficiency for both varicella and MMR vaccines, the newest recommendation for HepA vaccination of infants 6 through 11 months who are traveling to a hepatitis A endemic country, an additional influenza vaccine for children 6 through 35 months, and to change a reference to the "Best Practices Guidance of the Advisory Committee on Immunization Practices (ACIP)."

Summary of Recommendations for Adult Immunization was revised to incorporate the ACIP recommendations for Shingrix and Heplisav-B vaccines, and to change a reference to the "Best Practices Guidance of the Advisory Committee on Immunization Practices (ACIP)."

The child/teen piece covers age birth through age 18 years, while the adult piece covers age 19 years and older. Both include columns for vaccine name/route, routine schedule and guidelines, schedule for catch-up and related issues, and contraindications and precautions.

Related Link

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.

Back to top

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

IAC recently revised its resource for healthcare professionals titled Hepatitis A and Hepatitis B Vaccines: Be Sure Your Patients Get the Correct Dose. Changes were made to incorporate the recently licensed 2-dose Heplisav-B vaccine.

Related Links

Back to top

IAC updates "Standing Orders for Administering Hepatitis B Vaccine to Adults"

IAC recently updated its Standing Orders for Administering Hepatitis B Vaccine to Adults to incorporate the adult Heplisav-B vaccine.
Related Links

Back to top

IAC updates "Which Vaccines Do I Need Today?," a checklist for adult patients to help with assessing their immunization needs

IAC updated Which Vaccines Do I Need Today?, a self-administered screening checklist for adults, to incorporate additional screening statements for adults who are candidates for the Shingrix (zoster) vaccine.

Access IAC's Screening Checklists web page for more screening questionnaires for use by healthcare professionals and their patients.

Back to top

IAC revises "Pre-exposure Management for Healthcare Personnel with a Documented Hepatitis B Vaccine Series Who Have Not Had Post-vaccination Serologic Testing"

IAC recently revised Pre-exposure Management for Healthcare Personnel with a Documented Hepatitis B Vaccine Series Who Have Not Had Post-vaccination Serologic Testing to update key references and to incorporate the ACIP recommendation to complete a second series of HepB vaccine in healthcare personnel who continue to test negative for anti-HBs after receiving a single "booster" dose of HepB.

Related Links

Back to top


WHO publishes helpful 52-page guide: "How to respond to vocal vaccine deniers in public"

The World Health Organization (WHO) recently published the second edition of its Best practice guidance: How to respond to vocal vaccine deniers in public. The beginning of the "Introduction" section is reprinted below.

This guidance document provides basic, broad principles for a spokesperson of any health authority on how to behave when confronted by and how to respond to vocal vaccine deniers. Vocal vaccine deniers do not accept recommended vaccines and are not open to a change of mind no matter what the scientific evidence says. The suggestions on how to respond to vocal vaccine deniers are based on psychological research on persuasion, on research in public health, communication studies, and on WHO risk communication guidelines. The guidance is primarily intended for spokespersons of health authorities who want to prepare themselves for a public event with a vocal vaccine denier.

Scientific evidence indicates that no one is born a good speaker. Training is needed to achieve this. Not everyone who is asked to speak on behalf of a health authority is a trained spokesperson. Addressing vocal vaccine deniers in the media can be fraught with danger and angst. While the recommended rules of thumb outlined in this document cannot substitute for professional education in rhetoric and interview skills, they provide a practical, easy-to-use approach to improve your ability to respond to issues raised by vocal vaccine deniers. 

Access the complete guide: Best practice guidance: How to respond to vocal vaccine deniers in public (PDF format; 52 pages)

Back to top

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

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.

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!

Related Links

Back to top


CDC reports on vaccination coverage of children in the U.S. Affiliated Pacific Islands

CDC published Vaccination Coverage Among Children Aged 2 Years—U.S. Affiliated Pacific Islands, April–October, 2016 in the May 25 issue of MMWR (pages 579–84). A summary made available to the press is reprinted below.

CDC conducted the first region-wide assessment of vaccination coverage in the United States Affiliated Pacific Islands (USAPI). Vaccination coverage was low and varied widely among children age 2 years in the five USAPI assessed. Coverage for the recommended six-vaccine series did not meet the 85% coverage target in any jurisdiction. The results serve as a baseline for coordinated USAPI and CDC efforts to improve vaccination coverage. By using medical records, CDC is able to overcome the challenges of geographic remoteness and difficulty tracking highly mobile populations to conduct rapid vaccination coverage assessment to support timely programmatic decision-making. Effectively monitoring vaccination coverage, coupled with implementation of data-driven interventions, is essential to maintain protection from VPD outbreaks.

Related Link

  • MMWR main page provides access to MMWR Weekly, MMWR Recommendations and Reports, MMWR Surveillance Summaries, and MMWR Supplements

Back to top


ACOG to sponsor June 14 webinar about the latest recommendations regarding Zika virus and pregnant women

The American College of Obstetricians and Gynecologists (ACOG) will present a webinar, Zika Refresher: The Latest Recommendations on Counseling, Testing, and Management of Zika Virus in Pregnant Women, on June 14, at 12:00 p.m.–1:00 p.m. (ET). This free, 1 CME credit webinar is open to all and will explain how Zika virus is contracted, prevention methods, who should be assessed for Zika virus exposure, current testing recommendations, and what follow-up is recommended for the infants of women with possible Zika virus exposure during pregnancy.

After June 14, the webinar will be archived on ACOG's Zika web page for convenient viewing, but will not provide CME credit.

Registration information

Back to top

Weekly CDC webinar series on "The Pink Book" chapter topics runs June 6 through September 26; register now

CDC is again 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 will start June 6 and run through September 26. 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.

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.

If you have trouble receiving or displaying IAC Express messages, visit our online help section.

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.

IAC Express Disclaimer
ISSN: 1526-1786
Our mailing address is
Immunization Action Coalition
2550 University Avenue West, Suite 415 North
Saint Paul, MN 55114

Copyright (C) 2018 Immunization Action Coalition
All rights reserved.

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

This page was updated on .