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Issue 1408: January 30, 2019









State of Washington health officials and governor declare public health emergency due to measles outbreak in Vancouver, WA, and Portland, OR, area; 35 cases confirmed

On January 18, Clark County, Washington, officials declared a public health emergency in response to a measles outbreak in the area. On January 25, Washington Governor Jay Inslee proclaimed a related state of emergency for all counties in the state. Clark County continues to update information about this outbreak on its website. Clark County is the home of Vancouver, Washington, and is located on the state's southern border near Portland, Oregon.

Currently, officials have identified 35 confirmed cases and 11 suspect cases. Here is a breakdown of the confirmed cases from the county's website:


  • 1 to 10 years: 25 cases
  • 11 to 18 years: 9 cases
  • 19 to 29 years: 1 case

Immunization status

  • Unverified: 4 cases
  • Unimmunized: 31 cases

Over forty public exposure sites have been identified. Clark County Public Health is urging anyone who has been exposed and believes they have symptoms of measles to call their health care provider prior to visiting the medical office to make a plan that avoids exposing others in the waiting room. 

Access up-to-date information about this outbreak from Clark County, Washington Public Health.

Access the proclamation from Governor Jay Inslee.

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CDC releases updated version of its Vaccine Storage and Handling Toolkit

CDC’s Vaccine Storage and Handling Toolkit has just been updated for 2019. This indispensable 48-page guide reflects the best practices for vaccine storage and handling compiled from ACIP recommendations, product information from vaccine manufacturers, and scientific studies. The redesigned toolkit helps healthcare providers find the information they need quickly and easily. Revisions include:

  • A reorganized layout with color-coded sections to help better navigate the toolkit
  • Updated job aids and resource documents
  • Updated visuals for the vaccine storage and handling recommendations and best practices

 Access CDC's Vaccine Storage and Handling Toolkit web section.

Access CDC's updated Vaccine Storage and Handling Toolkit (PDF format; 48 pages).

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FDA approves use of the 0.5 mL dose of Sanofi's Fluzone Quadrivalent influenza vaccine to include children age 6 through 35 months 

The U.S. Food and Drug Administration has approved the use of the 0.5 mL dose of Fluzone Quadrivalent influenza vaccine to include children age 6 through 35 months. This means Sanofi will have the 0.5 mL dose in addition to the 0.25 mL dosage available for the upcoming 2019–20 season for this expanded age range.

Access the Sanofi press release: FDA Approves Use of 0.5 mL Dose of Fluzone® Quadrivalent (Influenza Vaccine) in Children as Young as 6 Months of Age.

Access the updated package insert.

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IAC Spotlight! IAC’s ACIP web section on provides links to ACIP recommendations from 1991 to the present as well as other valuable information

The ACIP web section on provides links to almost all of the past ACIP recommendations from 1991 to the present, as well as other valuable information. You can access the ACIP recommendations in two ways: sorted alphabetically by diseases and vaccines or chronologically.

View the ACIP recommendations in the Vaccine Index, where they are sorted alphabetically by diseases and vaccines.

View the ACIP recommendations chronologically if you are interested in seeing recommendations by date, divided into two web pages:

On the ACIP Additional Information web page in the ACIP web section, you will find the following list that will direct you to related CDC resources pages:

  • About ACIP, with descriptions of the committee and contact information
  • ACIP Recommendations, with a current listing of official ACIP recommendations on the CDC website
  • ACIP Meetings 
  • ACIP: U.S. Vaccine Abbreviations
  • ACIP & Vaccines For Children (VFC)—Vaccine Resolutions
  • MMWR Continuing Education: ACIP Recommendations
  • Vaccine Price List

Visit the ACIP web section on where you will access the information and resources you need related to ACIP recommendations.

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IAC enrolls 3 new birthing institutions into its Hepatitis B Birth Dose Honor Roll; 22 previously honored institutions qualify for additional years' honors

The Immunization Action Coalition (IAC) is pleased to announce that 3 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.

  • Bayfront Health, Port Charlotte, FL (96%)
  • Brandon Regional Hospital, Brandon, FL (90%)
  • Central Vermont Medical Center, Berlin, VT (94%)

The following 11 institutions are being recognized for a second year:

  • Abington Hospital–Jefferson Health, Abington, PA (91%)
  • Alaska Native Medical Center, Anchorage, AK (94%)
  • Bronson Battle Creek Hospital, Battle Creek, MI (90%)
  • Frances Mahon Deaconess Hospital, Glasgow, MT (91%)
  • McLaren Greater Lansing, Lansing, MI (91%)
  • Memorial Medical Center, Las Cruces, NM (99%)
  • Norton Women's and Children's Hospital, Louisville, KY (100%)
  • St. David's Round Rock Medical Center, Round Rock, TX (91%)
  • Southern Maine Health Care, Biddeford, ME (92%)
  • Westmoreland Hospital, Greensburg, PA (91%)
  • Woodlawn Hospital, Rochester, IN (96%)

In addition, the following 5 institutions are being recognized for a third year:

  • Bradford Regional Medical Center, Bradford, PA (99%)
  • McLaren Central Michigan, Mount Pleasant, MI (91%)
  • NYC Health + Hospitals/Metropolitan, New York, NY (94%)
  • RC Hospital & Clinics, Olivia, MN (100%)
  • St. Mary's General Hospital, Passaic, NJ (97%)

The following 4 institutions are being recognized for a fourth year:

  • Georgetown Community Hospital, Georgetown, KY (98%)
  • Holy Family Hospital, Methuen, MA (94%)
  • Mercy Health Hackley Campus, Muskegon, MI (93%)
  • MetroHealth Medical Center, Cleveland, OH (94%)

The following institution is being recognized for a fifth year:

  • Sagua Managu, Tamuning, GU (100%)

Last, but certainly not least, the following institution is being recognized for an eighth year:

  • Guam Memorial Hospital Authority, Oka Tamuning, GU (100%)

The Honor Roll now includes 427 birthing institutions from 41 states, Puerto Rico, Guam, and an overseas U.S. military base. One hundred eight institutions have qualified for two years, 46 institutions have qualified three times, 25 institutions have qualified four times, 11 institutions have qualified five times, three institutions have qualified six times, and one institution has qualified eight 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.

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Reminder: Nominations for CDC's Childhood Immunization Champion Awards due by February 8

Last week, CDC and the Association of Immunization Managers (AIM) announced that nominations were open for the 2019 CDC Childhood Immunization Champion Award. The CDC Childhood Immunization Champion Award is an annual award that recognizes individuals who make a significant contribution toward improving public health through their work in childhood immunization. Each year, the CDC Childhood Immunization Champion honors up to one person from each of the 50 U.S. states, 8 U.S. Territories and Freely Associated States, and the District of Columbia.  

Nominations should be submitted to the immunization program manager in the state or territory where the nominee resides by February 8. Program managers will review all nominations received and select one for submission to CDC by March 1. CDC will review nominations for each state and announce awardees during National Infant Immunization Week, April 27–May 4. 
CDC and AIM would appreciate your help in promoting this award to your constituents or members. Champions can come from a variety of settings. Please ask your constituents to consider all kinds of nominees, including parent advocates, community members, and healthcare professionals who go above and beyond their expected responsibilities to ensure that children in their communities get their vaccines on time. Self-nominations are welcome.

Access the nomination packet (10-page PDF; includes contact information for the immunization program managers).
For more information about the CDC Childhood Immunization Champion Award, please visit You can access information about the 2012–2018 winners from the bottom on this page.

If you have any questions please email

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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. 


WHO publishes list of "Ten Threats to Global Health in 2019": vaccine hesitancy makes the list

The World Health Organization (WHO) recently published an online report titled Ten Threats to Global Health in 2019. One of the threats identified is "Vaccine Hesitancy." A section of that text is reprinted below.

Vaccine hesitancy—the reluctance or refusal to vaccinate despite the availability of vaccines—threatens to reverse progress made in tackling vaccine-preventable diseases. Vaccination is one of the most cost-effective ways of avoiding disease—it currently prevents 2–3 million deaths a year, and a further 1.5 million could be avoided if global coverage of vaccinations improved. 

Measles, for example, has seen a 30% increase in cases globally. The reasons for this rise are complex, and not all of these cases are due to vaccine hesitancy. However, some countries that were close to eliminating the disease have seen a resurgence. 

The reasons why people choose not to vaccinate are complex; a vaccines advisory group to WHO identified complacency, inconvenience in accessing vaccines, and lack of confidence are key reasons underlying hesitancy. Health workers, especially those in communities, remain the most trusted advisor and influencer of vaccination decisions, and they must be supported to provide trusted, credible information on vaccines.... 

The report also includes "Global Influenza Pandemic" as a threat.

Read the complete article: Ten Threats to Global Health in 2019.

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WHO publishes report from the December meeting of the Global Advisory Committee on Vaccine Safety in this week's Weekly Epidemiological Record

WHO published a report from the most recent meeting of the Global Advisory Committee on Vaccine Safety in the January 25 issue of its Weekly Epidemiological Record. The report is titled Global Advisory Committee on Vaccine Safety, 5–6 December 2018.

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Influenza remains widespread; CDC reports 3 additional pediatric deaths from influenza in the U.S. 

Influenza season is now under way, and CDC has reported 3 additional pediatric deaths from influenza in the U.S. this season, for a total of 22. Last season, there was a record-setting number of pediatric deaths in the U.S. (185), so be sure to protect all your patients for whom vaccination is recommended.

CDC stated in its Weekly U.S. Influenza Surveillance Report, FluView, that during the week ending January 19, the geographic spread of influenza in 36 states was reported as widespread; Puerto Rico and 11 states reported regional activity; three states reported local activity; the District of Columbia and the U.S. Virgin Islands reported sporadic activity; and Guam did not report.

Influenza vaccination is recommended for everyone six months of age and older. If you don't provide influenza vaccination in your clinic, please recommend vaccination to your patients and refer them to a clinic or pharmacy that provides vaccines or to the HealthMap Vaccine Finder to locate sites near their workplaces or homes that offer influenza vaccination services.

Following is a list of resources related to influenza disease and vaccination for healthcare professionals and the public:

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AAP posts information to guide providers in prebooking pediatric influenza vaccine for the 2019–20 flu season  

The American Academy of Pediatrics (AAP) has published guidance for providers looking to prebook pediatric influenza vaccine for the 2019–20 flu season. 

Access AAP's Prebooking web page.

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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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Vaccine Education Center at Children's Hospital of Philadelphia publishes January issue of its newsletter Vaccine Update for Healthcare Professionals

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

In addition, new references and summaries have been posted for the following topics:

Additional resources and information are available in the full newsletter.

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

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New York Times publishes opinion piece titled "How to Inoculate Against Anti-Vaxxers"

On January 19, the New York Times editorial board published an opinion piece titled How to Inoculate Against Anti-Vaxxers. A selection of the text is reprinted below.

According to the Centers for Disease Control and Prevention, the percentage of children who are unvaccinated has quadrupled since 2001, even though the overall utilization of most vaccines remains high. More than 100,000 American infants and toddlers have received no vaccines whatsoever, and millions more have received only some crucial shots.

It’s no mystery how we got here. On the internet, anti-vaccine propaganda has outpaced pro-vaccine public health information. The anti-vaxxers, as they are colloquially known, have hundreds of websites promoting their message, a roster of tech- and media-savvy influencers and an aggressive political arm that includes at least a dozen political action committees. Defense against this onslaught has been meager. The C.D.C., the nation’s leading public health agency, has a website with accurate information, but no loud public voice. The United States Surgeon General’s office has been mum. So has the White House—and not just under the current administration. That leaves just a handful of academics who get bombarded with vitriol, including outright threats, every time they try to counter pseudoscience with fact....

The next major disease outbreak “will not be due to a lack of preventive technologies,” Heidi Larson, a professor at the London School of Hygiene and Tropical Medicine, writes in the journal Nature, but to an “emotional contagion, digitally enabled.”

Thwarting this danger will require a campaign as bold and aggressive as the one being waged by the anti-vaccination contingent....

The piece concludes with ideas about how to get started countering anti-vaccine misinformation, under the headings of:

  • Get tough
  • Be savvy
  • Be clear
  • Know the enemy
  • Know the audience
  • Enlist the right support

Read the complete opinion piece: How to Inoculate Against Anti-Vaxxers.

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Vaccine publishes study about parents' lack of awareness of meningococcal B vaccines and impact on vaccine use

On January 21, the journal Vaccine published a study titled Parental Awareness of Meningococcal B Vaccines and Willingness to Vaccinate Their Teens (Basta NE, et al.). The abstract is reprinted below.

In the U.S., Meningococcal B (MenB) vaccines were first licensed in 2014. In 2015, the Advisory Committee on Immunization Practices recommended that parents of teens talk to their provider about receiving MenB vaccine, rather than issuing a routine recommendation. We assessed parental awareness of MenB vaccines and willingness to vaccinate their teens with MenB vaccines compared to MenACWY vaccines, which have been routinely recommended for many years.

We surveyed parents of teens attending high school in 2017–18 during the Minnesota State Fair. Parents reported via iPad their knowledge of and concern about meningococcal disease and their awareness of and willingness to vaccinate with MenB and MenACWY vaccines. We assessed the relationship between meningococcal disease knowledge and concern, MenB and MenACWY vaccine awareness, and willingness to vaccinate with MenB and MenACWY using adjusted logistic regression.

Among 445 parents, the majority had not heard of the newly introduced MenB vaccines Bexsero (80.0%; 95% CI: 76.0–83.6) or Trumenba (82.0%; 95% CI: 78.1–85.5) or the MenACWY vaccines Menactra or Menveo (68.8%; 95% CI: 64.2–73.0). The majority were at least somewhat willing to vaccinate their teen with MenB vaccine (89.6%; 95% CI: 86.5, 92.3) and MenACWY vaccine (91.2%; 95% CI: 88.2, 93.7). Awareness of MenB vaccines (OR: 3.8; 95% CI: 1.2-12.2) and concern about meningococcal disease (OR: 3.1; 95% CI: 1.5–6.3) were significantly associated with willingness to vaccinate with MenB vaccine.

Awareness of MenB vaccine is lacking among parents of teens but is an important predictor of willingness to vaccinate with the newly licensed MenB vaccines.

The journal noted the following highlights from this survey:

  • Awareness of MenB vaccines is lacking among parents of teenagers in the U.S.
  • Awareness of MenB vaccines was strongly associated with vaccine willingness
  • Concern about meningitis was also strongly associated with vaccine willingness
  • Parents want more information from their physicians about meningococcal vaccines

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Pediatrics publishes study of HPV vaccine effectiveness and herd protection in young women 

The January issue of Pediatrics includes an article titled Human Papillomavirus Vaccine Effectiveness and Herd Protection in Young Women (Spinner C, et al.). The abstract is reprinted below.

Clinical trials of the 4-valent human papillomavirus (HPV) vaccine demonstrate high efficacy, but surveillance studies are essential to examine the long-term impact of vaccine introduction on HPV prevalence in community settings. The aims of this study were to determine during the 11 years after vaccine introduction the prevalence of (1) vaccine-type HPV in adolescent and young adult women who were vaccinated (to assess vaccine effectiveness) and (2) vaccine-type HPV in women who were unvaccinated (to assess herd protection).

Young women 13 to 26 years of age were recruited from hospital-based and community health clinics for 4 surveillance studies from 2006 to 2017. We determined the proportion of vaccinated and unvaccinated women who were positive for vaccine-type HPV across the studies, and the odds of positivity for vaccine-type HPV using logistic regression; all analyses were propensity score–adjusted to control for between-wave differences in participant characteristics.

Vaccination rates increased from 0% to 84.3% (97% of study participants received the 4-valent vaccine). Among women who were vaccinated, 4-valent vaccine–type HPV detection decreased from 35% to 6.7% (80.9% decline; odds ratio 0.13, 95% confidence interval 0.08 to 0.22). Among women who were unvaccinated, 4-valent vaccine–type HPV detection decreased from 32.4% to 19.4% (40% decline; odds ratio 0.50, 95% confidence interval 0.26 to 0.97). Estimated vaccine effectiveness was 90.6% in wave 3 and 80.1% in wave 4.

In this study in which trends in HPV in a U.S. community >10 years after 4-valent HPV vaccine introduction and after 9-valent vaccine introduction were examined, we found evidence of vaccine effectiveness and herd protection. Further research is needed to examine trends in 9-valent vaccine–type HPV after higher rates of vaccination are achieved.

Access the complete article: Human Papillomavirus Vaccine Effectiveness and Herd Protection in Young Women.

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MMWR publishes graph of the percentage of adults who had an influenza vaccination in the past 12 months, by gender and asthma status

  • Adults age 18–64 years with current asthma were more likely to have had an influenza vaccination in the past 12 months (47.9%) than those without asthma (36.4%)
  • Regardless of asthma status, women were more likely than men to have had an influenza vaccination in the past 12 months
  • Women aged 18–64 years with current asthma (51.3%) were more likely to have had an influenza vaccination than men with current asthma in this age group (41.6%)
  • Among adults aged 18–64 years without asthma, women also were more likely to have had an influenza vaccination (40.0%) than were men (32.8%)

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CDC to offer February 7 webinar on cholera vaccines and travelers

CDC will offer a Clinical Outreach and Communication Activity (COCA) webinar on February 7 from 2:00–3:00 p.m. (ET) titled Clinical Update: Cholera Vaccine for Travelers. From CDC's description:

During this COCA Call, CDC travel medicine subject matter expert and infectious diseases physician Dr. Kristina Angelo and food and water expert Dr. Erin Connors will
  • Highlight critical information about cholera biology and prevention;
  • Discuss strategies primary care providers and medical subspecialists can use to decrease the likelihood of cholera illness in their patients; and
  • Review CDC resources on the epidemiology of cholera vaccine to use in clinical decision making about offering vaccine to patients.
Access more information about this webinar, including how to register: Clinical Update: Cholera Vaccine for Travelers.

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CDC to offer webinar titled "Perspectives on Oropharyngeal Cancer" on February 13; discussion includes importance of HPV vaccination to prevent this cancer

CDC will offer a webinar on February 13 from 2:00–3:00 p.m. (ET) titled Perspectives on Oropharyngeal Cancer: Scientific Overview, Clinical Expertise, and Personal Experience. Part of the description follows.

Every year, over 33,000 men and women are diagnosed with a cancer caused by HPV. While cervical cancer is the most well-known cancer that is caused by HPV, there are five other types of cancers that can develop from HPV. Oropharyngeal cancer has recently surpassed cervical cancer as the most common cancer caused by HPV, accounting for nearly 13,000 cases every year in the United States.

Compared to HPV and cervical cancer, awareness of the link between HPV and oropharyngeal cancer is still low, which presents an important opportunity for more education. During this webinar, two experts will explain the burden of oropharyngeal cancer, current trends in the epidemiology of oropharyngeal cancer, a clinical picture of the disease, and the importance of vaccination to prevent HPV infections. They will also address common questions related to HPV and oropharyngeal cancer.

Access more information about the webinar: Perspectives on Oropharyngeal Cancer: Scientific Overview, Clinical Expertise, and Personal Experience.

Registration information

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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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Copyright (C) 2019 Immunization Action Coalition
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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.

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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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