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Issue 1390: October 17, 2018











CDC publishes report on vaccination rates among children age 19–35 months of age in 2017

CDC published Vaccination Coverage Among Children Aged 19–35 Months—United States, 2017 in the October 12 issue of MMWR (pages 1123–1128). The first paragraph is reprinted below.

The Advisory Committee on Immunization Practices (ACIP) recommends routine vaccination by age 24 months against 14 potentially serious illnesses. CDC used data from the 2017 National Immunization Survey-Child (NIS-Child) to assess vaccination coverage at national, state, territorial, and selected local levels among children aged 19–35 months in the United States. Coverage remained high and stable overall, exceeding 90% for ≥3 doses of poliovirus vaccine, ≥1 dose of measles, mumps, and rubella vaccine (MMR), ≥3 doses of hepatitis B vaccine (HepB), and ≥1 dose of varicella vaccine. Although the proportion of children who received no vaccine doses by age 24 months was low, this proportion increased gradually from 0.9% for children born in 2011 to 1.3% for children born in 2015. Coverage was lower for most vaccines among uninsured children and those insured by Medicaid, compared with those having private health insurance, and for children living outside of metropolitan statistical areas (MSAs), compared with those living in MSA principal cities. These disparities could be reduced with greater awareness and use of the Vaccines for Children (VFC) program, eliminating missed opportunities to vaccinate children during visits to health care providers, and minimizing interruptions in health insurance coverage.

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CDC reports on vaccination coverage of kindergarten students during 2017–18 in MMWR

CDC published Vaccination Coverage for Selected Vaccines and Exemption Rates Among Children in Kindergarten—United States, 2017–18 School Year in the October 12 issue of MMWR (pages 1115–1122). The first paragraph is reprinted below.

State and local school vaccination requirements exist to ensure that students are protected from vaccine-preventable diseases. This report summarizes vaccination coverage and exemption estimates collected by state and local immunization programs for children in kindergarten (kindergartners) in 49 states and the District of Columbia (DC) and kindergartners provisionally enrolled (attending school without complete vaccination or exemption while completing a catch-up vaccination schedule) or in a grace period (a set interval during which a student may be enrolled and attend school without proof of complete vaccination or exemption) for 28 states. Median vaccination coverage was 95.1% for the state-required number of doses of diphtheria and tetanus toxoids, and acellular pertussis vaccine (DTaP); 94.3% for 2 doses of measles, mumps, and rubella vaccine (MMR); and 93.8% for 2 doses of varicella vaccine. The median percentage of kindergartners with an exemption from at least one vaccine was 2.2%, and the median percentage provisionally enrolled or attending school during a grace period was 1.8%. Vaccination coverage among kindergartners remained high; however, schools can improve coverage by following up with students who are provisionally enrolled, in a grace period, or lacking complete documentation of required vaccinations.

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CDC releases updated VIS for hepatitis B vaccine

On October 12, CDC released a revised Vaccine information Statement (VIS) for hepatitis B vaccine. 

The Hepatitis B VIS has received a minor update, noting that a 2-dose series is available. Stocks of the existing (7/20/16) edition may be used up before switching to this updated edition.

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New 65+ Flu Defense website features tools and resources for healthcare professionals serving adults age 65 and older

Annual influenza vaccination is the best way to prevent influenza, but vaccination coverage among older adults in the U.S. has stagnated, and in some years has declined significantly over the previous season’s rate. In the 2016–2017 season, only 65.3% of adults age 65 and older were vaccinated against the flu.

However, seniors are at greater risk of severe complications from influenza, due both to their increased likelihood of having chronic conditions and to the decline of their immune systems with aging.
As a healthcare provider (HCP), your strong, confident recommendation for flu vaccine is a very powerful and persuasive tool in determining if your patients are vaccinated. To assist you in this effort, the new 65+ Flu Defense website at has been launched. This project, a collaboration between IAC and Seqirus, aims to reach HCPs with information, tools, and resources they need to better communicate the impact of flu and its complications in older adults, and to proactively discuss flu vaccination with their patients age 65 and older.
65+ Flu Defense is divided into several easy-to-use topic areas, including:  

Two new patient handouts are also available on the website:

Be sure to check out the information and printable materials for your patients available on the 65+ Flu Defense website at to help your efforts in protecting this vulnerable population.

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FDA approves expanded age indication for Afluria

On October 4, the U.S. Food and Drug Administration (FDA) approved expanding the age indication for Afluria and Afluria Quadrivalent (Seqirus) to include children age 6 months through 59 months. Previously, Afluria was licensed for people age 5 years and older.

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CDC study shows that during the last six influenza seasons, getting a flu shot reduced a pregnant woman’s risk of being hospitalized from flu by an average of 40%

On October 11, CDC issued a press release titled Flu vaccine reduces risk of flu hospitalization among pregnant women. The complete release is reprinted below.

Over the course of six flu seasons, getting a flu shot reduced a pregnant woman’s risk of being hospitalized from flu by an average of 40 percent.

The findings come from a multi-country, CDC-coauthored study published today in
Clinical Infectious Diseases. This is the first study to show vaccination protected pregnant women against flu-associated hospitalization. Previous studies have shown that a flu shot can reduce a pregnant woman’s risk of flu illness.

CDC recommends pregnant women get a flu shot because they are at high risk of developing serious flu illness, including illness resulting in hospitalization.

“Expecting mothers face a number of threats to their health and the health of their baby during pregnancy, and getting the flu is one of them,” explains Allison Naleway, PhD, a study coauthor from the Kaiser Permanente Center for Health Research. “This study’s findings underscore the fact that there is a simple, yet impactful way to reduce the possibility of complications from flu during pregnancy: get a flu shot.”

Flu study analyzed data from over 2 million pregnant women

For this study, CDC partnered with a number of other public health agencies and health care systems in Australia, Canada, Israel, and the United States through the Pregnancy Influenza Vaccine Effectiveness Network (PREVENT), which consists of health care systems with integrated laboratory, medical, and vaccination records. Sites retrospectively examined medical records of more than two million women who were pregnant from 2010 through 2016 to identify those who were hospitalized with laboratory-confirmed flu.

Key findings include:

  • More than 80 percent of pregnancies overlapped with flu season, underscoring the likelihood that pregnant women will be exposed to flu at some point during their pregnancy.
  • Flu vaccine was equally protective for pregnant women with underlying medical problems such as asthma and diabetes, which also increase the risk of serious medical complications including a worsening of those chronic conditions.
  • Flu vaccine was equally protective for women during all three trimesters.

Flu during pregnancy

Flu illness can range from mild to severe, but it presents a heightened risk for pregnant women who undergo changes to their immune system, heart, and lungs. These changes make them more prone to severe illness from flu throughout their pregnancy and for two weeks after pregnancy.

These findings underscore the importance of ongoing efforts by CDC and other public health agencies and partners to promote influenza vaccination during pregnancy. During recent seasons in the United States, only about half of pregnant women report getting a flu shot (pregnant women should not get the nasal spray vaccine.)

“Our study found that flu vaccination worked equally well for women in any trimester and even reduced the risk of being sick with influenza during delivery,” adds Mark Thompson, Ph.D., a study coauthor and epidemiologist with CDC’s Influenza Division.

Benefits of flu vaccine for pregnant women and their babies

Other studies have shown that in addition to helping to protect the pregnant woman, a flu vaccine given during pregnancy helps protect the baby from flu infection for several months after birth, before he or she is old enough to be vaccinated themselves. Flu shots have been given to millions of pregnant women over many years with a good safety record. CDC and ACIP recommend that pregnant women get vaccinated during any trimester of their pregnancy. Learn more about flu vaccination in pregnant women at

The study will be available online after publication:

Access the press release online: Flu vaccine reduces risk of flu hospitalization among pregnant women.

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CDC reports on rubella infection in an unvaccinated pregnant woman in Kansas

CDC published Notes from the Field: Rubella Infection in an Unvaccinated Pregnant Woman—Johnson County, Kansas, December 2017 in the October 12 issue of MMWR (pages 1132–1133). Selections from this report are published below.

On December 14, 2017, a school nurse notified the Johnson County (Kansas) Department of Health and Environment (JCDHE) that a student’s mother (patient) had received a diagnosis of rubella. The school nurse learned of the patient’s diagnosis when the patient picked up her daughter at school the day of the diagnosis. Follow-up by JCDHE revealed that the U.S.-born patient, aged 27 years, was 19 weeks pregnant and had not been vaccinated against rubella because of personal choice. She had tested negative for rubella by immunoglobulin G (IgG) serology during her first trimester of pregnancy....

JCDHE determined the patient had no travel history. When the patient was 15 weeks pregnant (17 days before her rash onset), her unvaccinated U.S.-born brother, aged 22 years, stayed in her home after returning from India, a country with endemic rubella transmission. The brother had a rash on his lower extremities that was diagnosed as poison ivy. Specimens from the patient and brother were collected and submitted to CDC; results were rubella IgG-positive with low avidity, indicating recent infection.

Among approximately 120 contacts of the patient, three were not vaccinated, including the patient’s daughter, aged 11 years, one hospital staff member, and the patient’s female coworker at a call center. All three were advised to avoid contact with pregnant women for 23 days; the patient’s daughter and the hospital staff member were excluded from school and work, respectively, for 21 days....

Rubella infection in pregnancy can result in miscarriage, stillbirth, or congenital rubella syndrome (CRS), which is characterized by low birthweight and birth defects including deafness, cataracts, heart defects, and intellectual disabilities. The severity and nature of defects depend upon the gestational age of the fetus at the time of infection....

An obstetrician specializing in high-risk pregnancies followed the patient for the remainder of her pregnancy. All follow-up testing was negative, and the patient delivered a full-term, apparently normal, infant in May. ... Based on test results and the absence of congenital defects, indications are that this infant meets the criteria for congenital rubella infection and not CRS. The infant will continue to be followed by an infectious disease specialist.

This case highlights several important points. Per the Advisory Committee on Immunization Practices recommendations, health care institutions should ensure that all persons working in health care facilities have documentation of adequate vaccination against measles, mumps, and rubella or evidence of immunity; the hospital staff member who was excluded received the MMR vaccine before returning to work. Health care providers should routinely assess women of childbearing age for evidence of rubella immunity (IgG antibodies) and recommend vaccination when appropriate. Pregnant women testing negative for rubella immunity should be vaccinated immediately after delivery; this case represents a missed opportunity for rubella vaccination after the birth of the patient’s first child. When a pregnant woman develops a rash illness, providers should ask about international travel for both the patient and her contacts. Finally, more emphasis and education are required for health care providers on the importance of timely reporting of suspected vaccine-preventable diseases.

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CDC experts update information on Ask the Experts sections about Meningococcal ACWY and Meningococcal B vaccines 

IAC's Ask the Experts: Meningococcal ACWY and Ask the Experts: Meningococcal B web pages have been completely reviewed and updated by experts at CDC.

Ask the Experts: Meningococcal ACWY: Revisions were limited to removal of references to an obsolete vaccine (meningococcal polysaccharide vaccine). There are no new recommendations.

Ask the Experts: Meningococcal B: Revisions were minor and include updating website links and removal of reference to an obsolete vaccine. There are no new recommendations.

IAC’s Ask the Experts web section is a compilation of common as well as challenging questions and answers (Q&As) about vaccines and their administration. William Atkinson, MD, MPH, IAC's associate director for immunization education, manages this web section, with answers provided by Andrew T. Kroger, MD, MPH; Candice L. Robinson, MD, MPH; Raymond A. Strikas, MD, MPH, FACP, FIDSA; Tina S. Objio, MSN, MHA, RN; and JoEllen Wolicki, BSN, RN, all from the National Center for Immunization and Respiratory Diseases, CDC.

IAC Express publishes five special editions each year of Ask the Experts Q&As answered by CDC experts. You can access the four most recent IAC Express Ask the Experts sets of Q&As from the main web page of Ask the Experts, in the right-hand column.

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IAC Spotlight! Get a copy of "Immunization Techniques: Best Practices with Infants, Children, and Adults" DVD for staff training

Revised in 2010 by the California Department of Public Health, Immunization Techniques: Best Practices with Infants, Children, and Adults, a 25-minute training DVD, focuses on the skills and techniques needed for vaccine administration. Every organization that administers vaccine should have a copy of this comprehensive educational program. The content covers children, teens, and adults. It can be used for training and orientation, as well as a refresher for more experienced staff.

Note: Go to the subhead titled "Watch Video Clip" to view a 2-minute segment of the DVD.

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IAC updates "Current Dates of Vaccine Information Statements" and "You Must Give Your Patients Vaccine Information Statements (VISs)—It’s Federal Law!"

IAC recently updated Current Dates of Vaccine Information Statements as well as You Must Give Your Patients Vaccine Information Statements (VISs)—It’s Federal Law! to incorporate the 10/12/2018 date of the recently updated Hepatitis B VIS.

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IAC posts nine updated translations of its "Screening Checklist for Contraindications to Vaccines for Adults" and seven translations of its "Screening Checklist for Contraindications to Vaccines for Children and Teens"

IAC recently posted updated translations of its "Screening Checklist for Contraindications to Vaccines for Adults" and "Screening Checklist for Contraindications to Vaccines for Children and Teens."

Revisions to the English version of the "Screening Checklist for Contraindications to Vaccines for Adults" were made recently to add LAIV as an option for influenza vaccines available to people with egg allergy and other minor edits in references.

The following nine updated translations now include those changes:

English-language version: Screening Checklist for Contraindications to Vaccines for Adults

Revisions to the English version of the "Screening Checklist for Contraindications to Vaccines for Children and Teens" were made to remove the “Note” that stated ACIP did not recommend use of live attenuated influenza vaccine (LAIV) for the current vaccination season, to delete several precautions for receipt of DTaP, consistent with ACIP's 2018 recommendations and the DTaP Vaccine Information Statement, dated 8/24/2018  (i.e., seizure within 3 days, pale or limp episode or collapse within 48 hours, continuous crying for 3 or more hours within 48 hours, and/or fever of 105F within 48 hours of a previous dose), and to clarify the degree of immunosuppression for HIV-infected children who may be candidates for varicella vaccine.

The following seven translations now include these updates:

English-language version: Screening Checklist for Contraindications to Vaccines for Children and Teens

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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 revises the Spanish-language translations of its screening checklists for contraindications to inactivated injectable influenza and live attenuated intranasal influenza vaccines

IAC recently revised the Spanish-language translations of "Screening Checklist for Contraindications to Inactivated Injectable Influenza Vaccination" and "Screening Checklist for Contraindications to Live Attenuated Intranasal Influenza Vaccination" to match the recently updated English-language versions.

Screening Checklist for Contraindications to Inactivated Injectable Influenza Vaccination: Changes were made to include LAIV as one of the vaccine options for people with egg allergy and to note that latex is no longer present in prefilled syringe caps of some influenza vaccines.

Screening Checklist for Contraindications to Live Attenuated Intranasal Influenza Vaccination: Changes were made to remove the “Note” that stated the ACIP did not recommend use of LAIV for the current vaccination season.

IAC posts updated Spanish-language translation of "Questions Frequently Asked about Hepatitis B"

IAC recently made a small correction to its popular 4-page handout for patients titled Questions Frequently Asked about Hepatitis B to clarify the common modes of transmission of hepatitis A. The Spanish-language translation now matches the updated English version.

Access Preguntas frecuentes acerca de la hepatitis B.

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IAC posts eight new translations of the Meningococcal ACWY VIS

IAC recently posted eight new translations of the Meningococcal ACWY VIS, which was updated on 8/24/18.

The Spanish translation was posted earlier. 

The Spanish-language rich text format (otherwise known as RTF) file for the updated Meningococcal ACWY VIS is available by going to This format can be used with electronic medical records system such as GE Centricity or Epic. English VISs in RTF can be downloaded from CDC's website (click on any VIS to access all available formats).

IAC provided these translations as part of a cooperative agreement with CDC, with the exception of the Turkish-language version. That translation was donated by Betül Polatdemir, MD, Lokman Hekim Hospital Group, Ankara and Sibel Bostancıoğlu, MD, Ankara Occupational and Environmental Diseases Hospital, Ankara, Turkey.

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WHO publishes guidance for evaluating progress towards elimination of measles and rubella in this week's Weekly Epidemiological Record

The World Health Organization (WHO) published Guidance for evaluating progress towards elimination of measles and rubella in the October 12 issue of its Weekly Epidemiological Record. The first paragraph is reprinted below.

The target of the WHO Global Vaccine Action Plan 2011–2020 is the elimination of measles and rubella in at least 5 WHO regions by 2020. Elimination of measles and rubella is defined as the absence of endemic transmission in a defined geographical region or country for ≥12 months, documented by a well-performing surveillance system. As long as measles or rubella remains endemic in at least one country, however, all countries remain at risk for outbreaks due to imported cases. The 6 Regional Verification Commissions (RVCs), the Measles and Rubella Working Group of the Strategic Advisory Group of Experts on Immunization and other experts have revised guidance on monitoring progress and verifying elimination to ensure alignment among regions. The guidance presented here is based on experience gained in some regions and Member States and replaces older WHO global guidance.

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American Immunization Registry Association releases resource about how to use small area analysis to find pockets of vaccination need, as well as suggestions about responding to the need 

The American Immunization Registry Association has published a new resource called Identifying Immunization Pockets of Need. Part of the Executive Summary is reprinted below.

Over the past several years, vaccine-preventable disease outbreaks have emerged from small populations with low vaccination coverage. These populations of unimmunized or underimmunized individuals are referred to as “pockets of need.” It can be challenging to identify low vaccination coverage in small populations. Fortunately, improvements in the quantity and quality of data in immunization information systems (IIS) have led to an increased ability to perform small area analysis that can identify pockets of need. By identifying pockets of need, immunization programs can strategically use limited resources to prevent or control vaccine-preventable disease outbreaks. Likewise, identification of pockets of need can help target resources to address health disparities and improve health equity.

This guide is intended for IIS and immunization program staff; epidemiologists at the state and local level; and public health staff who work with specific geographic areas or populations, vaccine hesitancy issues, school and childcare immunization laws, and surveillance or response to outbreaks of vaccine-preventable diseases.

Download Identifying Immunization Pockets of Need as a PDF document (59 pages).

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IAC's 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

In late 2017, the Immunization Action Coalition (IAC) 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!

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JAMA publishes study on optimal timing of Tdap vaccination during pregnancy

On October 9, JAMA published Association Between Third-Trimester Tdap Immunization and Neonatal Pertussis Antibody Concentration online. The Key Points provided by JAMA are reprinted below.

Question: Does maternal immunization with Tdap vaccine during the third trimester of pregnancy yield high concentrations of pertussis antibodies at birth? Is there an optimal gestational age for immunization?

Findings: In this prospective cohort study of 626 pregnancies, neonates whose mothers received Tdap immunization in the third trimester compared with those whose mothers received no Tdap vaccine during pregnancy had a geometric mean concentration of pertussis toxin antibodies in cord blood of 47.3 IU/mL vs 12.9 IU/mL, a difference that was statistically significant. Concentrations of cord blood antibodies were highest when immunization occurred at 27 to 30 weeks and declined thereafter.

Meaning: Maternal immunization with Tdap vaccine during the third trimester was associated with higher pertussis toxin antibody concentrations in neonates than no maternal immunization; immunization early in the third trimester was associated with the highest concentrations.

Access the abstract: Association Between Third-Trimester Tdap Immunization and Neonatal Pertussis Antibody Concentration

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BuzzFeed provides good overview of the importance of influenza vaccination—share with patients and parents!

On October 2, BuzzFeed, a popular social media news company, published an article titled Here's Why You Absolutely Need To Get A Flu Shot This Year, According To Experts. This piece answers commonly asked questions such as the following in a very readable—and accurate—manner.

  • Which type of flu vaccine should I get?
  • Is it possible to get vaccinated “too early”?
  • I heard the flu shot didn't work well last year. What happened?
  • Last year I got the vaccine and I still got the flu—what gives?
  • The flu isn’t that serious, and if I get it and recover, I’ll get some immune protection, right?
  • I’ve never gotten a flu shot and I’m still alive. Why should I get one now?

Providers may wish to share this article with patients and parents, and/or read it themselves to obtain some pithy answers to questions that are sure to arise.

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NFID to offer October 30 webinar about pneumococcal vaccination of adults
The National Foundation for Infectious Diseases (NFID) will present a webinar titled Pneumococcal Vaccines: Strategies to Increase Adult Immunization Rates on October 30 at 12:00 p.m. (ET). NFID medical director William Schaffner, MD, will moderate the webinar with a presentation by Thomas M. File, Jr., MD, MS, chair, Infectious Disease Division of Summa Health and professor, Internal Medicine; chair, Infectious Disease Section of Northeast Ohio Medical University.

Tune in to ACIP's October 24–25 meeting via live webcast

Tune in to the Advisory Committee on Immunization Practices (ACIP) meeting in Atlanta on October 24 and 25 (Wednesday and Thursday) via live webcast or by phone.

Live Webcast and Call-in Instructions

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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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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.

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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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