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Issue 1394: November 14, 2018








IAC Spotlight! Four states, CT, NJ, OH, and RI—plus NYC, require annual vaccination in child care facilities against influenza. Visit IAC’s "State Laws and Mandates" web section to find more information on state vaccination requirements 

Did you know that there currently are four states—Connecticut, New Jersey, Ohio, and Rhode Island—plus New York City that require annual vaccination against influenza for children enrolled in child care facilities? You can view this information available on IAC’s website both in table form or by viewing it on a U.S. map.

IAC's State Laws and Mandates web section on provides up-to-date access to vaccination requirements in child care facilities, schools, and colleges.
A complete list of web pages for various vaccines and whether or not a state mandates them is viewable from the links below. For many of the vaccines, you can also view a U.S. map showing which states mandate the vaccines. (The information for some of the items in the bulleted list (e.g., Hib, MMR, polio, DTaP [not Tdap]) was compiled and is maintained by the Centers for Disease Control and Prevention.)

In addition to the sections listed above, if you scroll half-way down the main web page, you'll find links to official policy statements about the importance of mandatory vaccination and the risks associated with personal belief exemptions issued by several professional medical organizations.

 Access the State Laws and Mandates web section.
If you have any additions or corrections for these pages, please email

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October's Technically Speaking column by IAC executive director Dr. Deborah Wexler is titled "Let's Get It Right! How to Avoid Shoulder Injury with Deltoid Intramuscular Injections"

Technically Speaking is a monthly column written by IAC executive director Dr. Deborah Wexler for Vaccine Update for Healthcare Providers, a monthly e-newsletter from the Children's Hospital of Philadelphia (CHOP). The column covers practical topics in immunization, such as vaccine administration, immunization scheduling, vaccine storage and handling, and vaccine recommendations.

October's column is titled Let's Get It Right! How to Avoid Shoulder Injury with Deltoid Intramuscular Injections and is reprinted below.

Let's Get It Right! How to Avoid Shoulder Injury with Deltoid Intramuscular Injections
Published October 2018

During influenza vaccination season, and at all times of the year, it is critically important that clinic staff who administer vaccines avoid injury to patients’ shoulders by being knowledgeable about how to properly administer intramuscular injections in the deltoid muscle.

At the October 2017 Advisory Committee on Immunization Practices meeting, a presentation titled Reports of Shoulder Dysfunction Following Inactivated Influenza Vaccine in the Vaccine Adverse Event Reporting System (VAERS), 2010–2016, included the following background information about shoulder injury related to vaccine administration (SIRVA):
  • Definition: SIRVA is caused by injury to the musculoskeletal structures of the shoulder (e.g., tendons, ligaments, bursae, etc.)
  • It manifests itself as shoulder pain and limited range of motion occurring after a patient receives a vaccine intended for intramuscular administration.
  • These symptoms are thought to occur as a result of unintended injection of vaccine antigen or trauma from the needle going into and around the underlying bursa of the shoulder, resulting in an inflammatory reaction.

SIRVA may result in patients having chronic shoulder pain and limited range of motion, and it may require ongoing medical intervention.

To avoid SIRVA, make sure clinic staff who administer vaccines recognize the anatomic landmarks for identifying the deltoid muscle and use proper intramuscular administration technique.

Helpful resources to assist with staff education

IAC resources

CDC resources

You can access the current and past issues of Technically Speaking in the following ways: from a box in the middle of the home page, from the "Guide to" at the bottom of every web page, or by going directly to the home page.

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New! CDC video for parents explains a vaccine's journey from development through post-licensure monitoring

CDC has recently posted a video for parents titled The Journey of Your Child's Vaccine. This 5-minute video describes the journey of a vaccine from development through post-licensure monitoring. Parents can learn about the three phases of clinical trials, vaccine licensing and manufacturing, how a vaccine is added to the U.S. recommended immunization schedule, and how the Food and Drug Administration and CDC monitor vaccine safety after the public begins using the vaccine. The content is based on CDC's infographic on this topic.

Visit CDC's Infant and Childhood Immunization Resources web page for parents, and scroll down to "Videos" to view "The Journey of Your Child's Vaccine."

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CDC publishes special issue on U.S. health disparities titled "Disparities in Prevention and Treatment of HIV, Viral Hepatitis, Sexually Transmitted Diseases, and Tuberculosis"

CDC's has announced the recent publication of Disparities in Prevention and Treatment of HIV, Viral Hepatitis, Sexually Transmitted Diseases, and Tuberculosis. Funded by CDC's National Center of HIV/AIDS, Viral Hepatitis, Sexually Transmitted Diseases, and Tuberculosis Prevention (NCHHSTP), this publication includes 20 articles—editorials, research and methods studies, and perspectives—presented in the special November issue of the American Journal of Public Health (AJFP). The following paragraph is excerpted from an announcement of this issue by Hazel D. Dean, ScD, DrPH (Hon), FACE, deputy director of NCHHSTP.

In this AJPH issue, emerging and best-available methods, metrics, and indicators for monitoring health disparities and preventing HIV, viral hepatitis, STDs, and TB are presented. The authors have examined health disparities related to age, sex, race/ethnicity, sexual orientation, gender identity, geographic location, and nativity and how these factors affect health outcomes in HIV, hepatitis B virus, syphilis, and TB infections, as well as youth risk behaviors. Together, these articles further our understanding of the disease trends and analysis methods for advancing public health science for monitoring health disparities and preventing disease.

Access the entire November issue and view the contents of the issue on the AJPH home page. (HTML)

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Reminder: Watch this unique series of six online training sessions to help you implement standing orders protocols for adult immunization in your healthcare setting

Looking for an evidence-based method to help increase your adult immunization rates? Are you wondering about using standing orders protocols (SOPs) but don’t know where to start? The content for this comprehensive six-part series available online 24/7 will help healthcare settings implement SOPs for adult immunizations.

Speakers include immunization experts Drs. Deborah Wexler, William Atkinson, and Litjen Tan. Attending this series does not earn Continuing Education (CE) credit. The series is developed and provided by IAC, IDCareLive, and Pfizer.

Registration is free, but is required in order to view any session. The link will bring up a short registration form to create a free IDCareLive account, if you don’t already have one. After signing up, you will be transferred directly to the intended page.

Related Link

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Voices for Vaccines releases new podcast episode titled "Vaccines Did Not Cause Rachel's Autism"

Voices for Vaccines (VFV) has posted a new entry in its Vax Talk podcast series: Vaccines Did Not Cause Rachel's Autism. Dr. Peter Hotez, pediatrician, vaccinologist, and a parent of Rachel, who has autism, has written a book titled Vaccines Did Not Cause Rachel's Autism. In this podcast, Dr. Hotez discusses his book and explains why he accepts the scientific consensus that vaccines cannot cause autism. He also discusses the anti-vaccine movement. 

If you or your organization would like information about how to become a sponsor of a VFV "Vax Talk" podcast, please contact VFV's executive director Karen Ernst, at  

Voices for Vaccines is a national organization of parents and others who are dedicated to raising the level of the voices of immunization supporters. VFV invites everyone who values vaccines to become a member. Please spread the word to your friends and colleagues to join VFV!

Related Links

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IAC updates four of its in-depth "Q&A: Diseases and Vaccines" handouts for the publicfor measles, mumps, rubella, and rabies

IAC recently updated four of its in-depth Q&A: Diseases and Vaccines handouts for the public:

Measles: Questions and Answers: Changes were made to update morbidity data for measles and to correct two URLs.

Mumps: Questions and Answers: Changes were made to correct two URLs.

Rubella: Questions and Answers: Changes were made to correct two URLs.

Rabies: Questions and Answers: Changes were made to update both epidemiologic and morbidity data for rabies.

Related Links

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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WHO releases “2018 Assessment Report of the Global Vaccine Action Plan”

The World Health Organization (WHO) Strategic Advisory Group of Experts (SAGE) on immunization recently released the 2018 Assessment Report of the Global Vaccine Action Plan. An announcement of its release by Martin Friede, PhD., a.i. Director of Immunization, Vaccines and Biologicals, WHO, is reprinted below.

This report comes at a crucial time, as the global immunization community looks towards shaping a new post-2020 strategy that aims to deliver the full benefits of vaccines to all.

The report highlights that without sustained attention, hard-fought gains can easily be lost. Where children are unvaccinated, outbreaks occur and diseases that were eliminated become endemic once again. Emerging issues such as mass urbanization and migration, population growth, conflict, natural disasters and environmental disruption are likely to exacerbate challenges to national immunization systems.

The final years of the Decade of Vaccines provide the global community with an opportunity to interrogate the impact of these emerging issues and design innovative programmes that addresses the challenges and accelerate progress towards the achievement of a world free of vaccine-preventable diseases.

Now more than ever, it is crucial that national immunization systems have the political commitment, sustainable investment and public support they need to succeed.

Currently, the report is available in English, but it will be posted online in Arabic, French, Russian, and Spanish when those versions become available.

Access the complete report in PDF format.

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CDC reports on progress on polio eradication in Pakistan in this week’s MMWR

CDC published Progress Toward Poliomyelitis Eradication—Pakistan, January 2017–September 2018 in the November 9 issue of MMWR (pages 1242–1245). The opening sentences of the first paragraph are reprinted below.

Among the three wild poliovirus (WPV) serotypes, only WPV type 1 (WPV1) has been reported in polio cases or detected from environmental surveillance globally since 2012. Pakistan remains one of only three countries worldwide (the others are Afghanistan and Nigeria) that has never had interrupted WPV1 transmission. This report documents Pakistan’s activities and progress toward polio eradication during January 2017–September 2018 and updates previous reports. ...

Related Link

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

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WHO reports on progress towards global malaria elimination in this week's Weekly Epidemiological Record

WHO published Progress towards malaria elimination: report of the second global forum of malaria-eliminating countries—June 2018 (pages 605–616) in the November 9 issue of its Weekly Epidemiological Record

Related Link

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New! NFID adult hepatitis B awareness toolkit includes free CME trainings, infographics, and social media posts

The National Foundation for Infectious Diseases (NFID) released a new Hepatitis B Toolkit. The toolkit contains free trainings that provide continuing medical education (CME) credit, infographics, sample newsletter and website content, and suggested sample media posts for healthcare professionals to increase awareness among colleagues.

The purpose of this toolkit is to increase awareness about the burden of hepatitis B among adults in the U.S. and to convey the importance of prevention through vaccination. Only about 25 percent of adults in the U.S. get the recommended vaccination against hepatitis B. This low immunization rate, as well as increased infection from injection drug use amidst the current opioid crisis, has led to an increase in new hepatitis B infections in the U.S.

The toolkit includes the following resources:

Access the NFID Hepatitis B Toolkit.

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Influenza is spreading and serious; please keep vaccinating your patients

Influenza season is now under way. Last season, there was a record-setting number of pediatric deaths in the United States (185), so be sure to protect all your patients for whom vaccination is recommended.

CDC has stated in its Weekly U.S. Influenza Surveillance Report, FluView, that as of the week ending November 3, local influenza-like illness (ILI) has been reported in Guam and six states (Connecticut, Kentucky, Massachusetts, New Hampshire, North Dakota, and Oregon), with sporadic ILI reported in 40 states and the District of Columbia, Puerto Rico, and the U.S. Virgin Islands. 

Two influenza-associated pediatric deaths have been reported for the 2018–19 season.

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. You can also refer them 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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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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Gerontological Society of America and mdBriefCase offer webinar on targeting older populations to improve influenza outcomes; free CME available

A free training for healthcare professionals titled Targeting Older Populations to imProve Influenza ouTcomes (TOPPiT), is now online. Sponsored by the Gerontological Society of America (GSA) and mdBriefCase, the training is available online 24/7. This online training allows participants to start and stop it as needed. The training offers 1.25 free CME credits and includes a communication-based counseling tool to help providers manage vaccine hesitancy with older patients. This counseling tool can assist providers with patients younger than age 65 as well.

Learn more about this program.

Register for the training program.

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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 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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