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Issue 1370: June 13, 2018









CDC Health Alert Network releases advisory about outbreak of hepatitis A virus infections among people who use drugs and people experiencing homelessness

On June 11, the CDC Health Alert Network released a "CDC Health Advisory" titled Outbreak of Hepatitis A Virus (HAV) Infections among Persons Who Use Drugs and Persons Experiencing Homelessness. The "Summary" and "Recommendations for Health Care Providers" sections are reprinted below.


The Centers for Disease Control and Prevention (CDC) and state health departments are investigating hepatitis A outbreaks in multiple states among persons reporting drug use and/or homelessness and their contacts. This Health Alert Network (HAN) Advisory alerts public health departments, healthcare facilities, and programs providing services to affected populations about these outbreaks of hepatitis A infections and provides guidance to assist in identifying and preventing new infections.

Recommendations for Health Care Providers
  1. Consider hepatitis A as a diagnosis in anyone with jaundice and clinically compatible symptoms.
  2. Encourage persons who have been exposed recently to HAV and who have not been vaccinated to be administered one dose of single-antigen hepatitis A vaccine or immune globulin (IG) as soon as possible, within 2 weeks after exposure. Guidelines vary by age and health status (please see Interim outbreak-specific guidance on hepatitis A vaccine administration for additional information).
  3. Consider saving serum samples for additional testing to assist public health officials in the investigation of transmission (i.e., confirmation of antibody test, HAV RNA test, genotyping, and sequencing). Contact the public health department for assistance with submitting specimens for molecular characterization.
  4. Ensure all persons diagnosed with hepatitis A are reported to the health department in a timely manner.
  5. Encourage hepatitis A vaccination for homeless individuals in areas where hepatitis A outbreaks are occurring.
  6. Encourage hepatitis A vaccination for persons who report drug use or other risk factors for hepatitis A.
  7. CDC recommends the following groups be vaccinated against hepatitis A:
  • All children at age 1 year
  • Persons who are at increased risk for infection:
    • persons traveling to or working in countries that have high or intermediate endemicity of hepatitis A;
    • men who have sex with men;
    • persons who use injection and non-injection drugs;
    • persons who have occupational risk for infection;
    • persons who have chronic liver disease;
    • persons who have clotting-factor disorders;
    • household members and other close personal contacts or adopted children newly arriving from countries with high or intermediate hepatitis A endemicity; and
    • persons with direct contact with persons who have hepatitis A
  • Persons who are at increased risk for complications from hepatitis A, including people with chronic liver diseases, such as hepatitis B or hepatitis C.
  • Any person wishing to obtain immunity.

Access the complete Health Advisory: Outbreak of Hepatitis A Virus (HAV) Infections among Persons Who Use Drugs and Persons Experiencing Homelessness.


CDC publishes updated ACIP recommendations for use of quadrivalent live attenuated influenza vaccine (LAIV4) for the 2018–19 flu season in MMWR​

CDC published Update: ACIP Recommendations for the Use of Quadrivalent Live Attenuated Influenza Vaccine (LAIV4)—United States, 2018–19 Influenza Season in the June 8 issue of MMWR. The recommendation section is reprinted below.

Recommendation of the ACIP
For the 2018–19 U.S. influenza season, providers may choose to administer any licensed, age-appropriate influenza vaccine (IIV, recombinant influenza vaccine [RIV], or LAIV4). LAIV4 is an option for those for whom it is otherwise appropriate. No preference is expressed for any influenza vaccine product. ACIP will continue to review data concerning the effectiveness of LAIV4 as they become available. Providers should be aware that the effectiveness of the updated LAIV4 containing A/Slovenia/2903/2015 against currently circulating influenza A(H1N1)pdm09-like viruses is not yet known.

Access Update: ACIP Recommendations for the Use of Quadrivalent Live Attenuated Influenza Vaccine (LAIV4)—United States, 2018–19 Influenza Season (PDF format; 3 pages).

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CDC publishes "Update: Influenza Activity in the United States During the 2017–18 Season and Composition of the 2018–19 Influenza Vaccine" in this week's MMWR

CDC has published Update: Influenza Activity in the United States During the 2017–18 Season and Composition of the 2018–19 Influenza Vaccine in the June 8 issue of MMWR (pages 634–42).

A summary provided by CDC is reprinted below.

The United States 2017–18 influenza season (October 1, 2017–May 19, 2018) was a high severity season with high levels of outpatient clinic and emergency department visits for influenza-like illness (ILI), high influenza-related hospitalization rates, and elevated and geographically widespread influenza activity across the country for an extended period. Nationally, ILI activity began increasing in November, reaching an extended period of high activity during January–February, and remaining elevated through March. Influenza A(H3N2) viruses predominated through February and were predominant overall for the season; influenza B viruses predominated from March onward. This report summarizes U.S. influenza activity* during October 1, 2017–May 19, 2018.

Access the full update from CDC. (PDF)

Study finds more hospitals are requiring flu vaccine for healthcare personnel

In June, JAMA Network Open published Changes in Influenza Vaccination Requirements for Health Care Personnel in US Hospitals (M.T.Greene, et al.) online. Portions of the abstract are reprinted below.

To compare the proportion of respondent hospitals requiring HCP to receive annual influenza vaccination between 2013 and 2017 and to assess the degree to which these proportions differed between Veterans Affairs (VA) and non-VA hospitals.

Design, Setting, and Participants 
This national survey study included responses from 1062 infection preventionists between 2013 and 2017 from nationally representative samples of all VA and non-VA hospitals in the United States. Data analysis was conducted from November 17, 2017, to March 26, 2018.
The overall response rate for the 2013 survey was 69.3% (non-VA, 70.6% [403 of 571]; VA, 63.5% [80 of 126]) and in 2017 was 59.1% (non-VA, 59.1% [530 of 897]; VA, 58.9% [73 of 124]). Among all responding hospitals, mandatory influenza vaccination requirements for HCP increased from 37.1% in 2013 to 61.4% in 2017 (difference, 24.3%; 95% CI, 18.4%-30.2%; P < .001). This change was driven by non-VA hospitals, as requirement policies increased from 44.3% (171 of 386) in 2013 to 69.4% (365 of 526) in 2017 (difference, 25.1%; 95% CI, 18.8%-31.4%; P < .001). Conversely, there was no significant change during this period in the proportion of VA hospitals that required influenza vaccinations for HCP (1.3% [1 of 77] to 4.1% [3 of 73]; difference, 2.8%; 95% CI, −2.4% to 8.0%; P = .29).

Conclusions and Relevance 
Despite a substantial increase in mandates among non-VA hospitals, we found that many non-VA hospitals and nearly all VA hospitals are still not currently mandating influenza vaccinations for HCP. In addition to implementing other well-described strategies to increase vaccination rates, health care organizations should consider mandating influenza vaccinations while appropriately weighing and managing the moral, ethical, and legal implications.
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IAC Spotlight: Explore the "Favorites" tab at the top of every page on

IAC's Favorites web page is accessible from the tab at the top of every page of the website to make it easy for users to find the most popular sections on the site. Featured as a dropdown tab, "Favorites" was inserted as the left-most tab on the dark gray banner that runs atop every page. When users hover over this tab with their mouse or click on it, the "Favorites" page content will appear.

The following web sections are offered as choices:

Visit the Favorites Tab often to find the most utilized content on


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

The June 8 edition of the WHO periodical Weekly Epidemiological Record reported on the April 2018 meeting of the Strategic Advisory Group of Experts on Immunization in an article titled Meeting of the Strategic Advisory Group of Experts on immunization, April 2018—conclusions and recommendations.

Related Links


WHO publishes newsletter with updates on using vaccines in the fight against Ebola, immunization in Africa, and Vaccination Week in the Americas

WHO publishes a monthly immunization-focused newsletter titled Global Immunization News. Several of the articles in the May issue are highlighted below.
  • World Health Assembly delegates agree on a new five-year strategic plan
  • Official launch of the business case for WHO immunization activities on the African continent
  • Delegates discuss progress and challenges towards global immunization goals
  • Using vaccines in the fight against Ebola virus disease
  • WHO Director-General calls for all countries to act to end suffering caused by cervical cancer
  • Largest cholera vaccine drive in history to target spike in outbreaks
  • European Immunization Week utilized to help sustain the positive impact of  vaccines
  • Vaccination Week in the Americas 2018 launches in Cuba
Additional resources, including past meetings and workshops, are available in the full newsletter.

Related Links


AAP has developed immunization-friendly social media content for pediatricians to share with patients

Does your practice Facebook page need a facelift? Add free immunization messaging for patients based on trusted AAP information. Sections of the Immunization Social Media Toolkit include:
  • 2018 Social Media Toolkit Pilot
  • Social Media Guidance
  • Memes and Videos to Share
  • Sharing Immunization Resources
  • Creating Immunization Videos to Share
These materials have been tested by a group of 15 practices in 13 states in rural and urban areas. 

Related Links

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

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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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


Pediatrics publishes “Safety Surveillance of Diphtheria and Tetanus Toxoids and Acellular Pertussis (DTaP) Vaccines”

Pediatrics published Safety Surveillance of Diphtheria and Tetanus Toxoids and Acellular Pertussis (DTaP) Vaccines, by P. Moro, et al., in its June 2018 issue. The abstract is reprinted below.

To assess the safety of currently licensed diphtheria-tetanus-acellular pertussis (DTaP) vaccines in the United States by using data from the Vaccine Adverse Event Reporting System (VAERS), a spontaneous reporting surveillance system.
We searched VAERS for US reports of DTaP vaccinations occurring from January 1, 1991, through December 31, 2016, and received by March 17, 2017. We reviewed available medical records for all death reports and a random sample of reports classified as nondeath serious. We used Empirical Bayesian data mining to identify adverse events that were disproportionally reported after DTaP vaccination.

VAERS received 50,157 reports after DTaP vaccination; 43,984 (87.7%) of them reported concomitant administration of other vaccines, and 5,627 (11.2%) were serious. Median age at vaccination was 19 months (interquartile range 35 months). The most frequently reported events were injection site erythema (12,695; 25.3%), pyrexia (9,913; 19.8%), injection site swelling (7,542; 15.0%), erythema (5,599; 11.2%), and injection site warmth (4,793; 9.6%). For 3 of the DTaP vaccines, we identified elevated values for vaccination errors using Empirical Bayesian data mining.
No new or unexpected adverse events were detected. The observed disproportionate reporting for some nonserious vaccination errors calls for better education of vaccine providers on the specific indications for each of the DTaP vaccines.

Read the entire article: Safety Surveillance of Diphtheria and Tetanus Toxoids and Acellular Pertussis (DTaP) Vaccines.

Related Links


Weekly CDC webinar series on "The Pink Book" chapter topics begins June 13 with "General Recommendations: Part 1"; register now for series running through September 26

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"). The June 13 webinar will cover "General Recommendations: Part 1" and include a live Q&A session. This is a live series of weekly 1-hour webinars that began on June 6 and will 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. 

Register for CDC’s #PreteenVaxScene webinar, “Back-to-School Showcase: Resources to Help You Become an HPV Champion,” on June 27

Join CDC on June 27 at 1:00 p.m. (ET) for the next #PreteenVaxScene webinar, “Back-to-School Showcase: Resources to Help You Become an HPV Champion.” This webinar will feature upcoming summer and back-to-school HPV vaccination campaigns and resources to help health care professionals take advantage of the back-to-school timeframe to boost their HPV vaccination rates.

Registration (required) is open now.

Related Link


Tune in to CDC's ACIP meeting June 20-21 (Wednesday and Thursday) via live webcast

Tune in to the Advisory Committee on Immunization Practices (ACIP) meeting in Atlanta on June 20 and 21 (Wednesday and Thursday) via live webcast.
These instructions also include information about how to listen to the meeting via phone only.

Related Links

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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.

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.

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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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