Issue 1415: March 13, 2019
EDUCATION AND TRAINING
U.S. Senate Committee on Health, Education, Labor, and Pensions (HELP) holds hearing: “Vaccines Save Lives: What Is Driving Preventable Disease Outbreaks?”
On March 5, witnesses representing a broad range of expertise testified at a Senate hearing on the re-emergence of vaccine-preventable diseases. The hearing, Vaccines Save Lives: What Is Driving Preventable Disease Outbreaks?, was called to discuss the current multi-state outbreak of measles. Witnesses addressed the link between recent outbreaks of diseases such as measles, and some parents' decision not to vaccinate their children. The hearing witnesses, and links to the transcripts of their testimonies, are listed below.
- John Wiesman, DrPH, MPH, secretary of health, Washington State Department of Health, Olympia, WA
- Saad B. Omer, MBBS, MPH, PhD, William H. Foege professor of global health, professor of epidemiology & pediatrics, Emory University
- Jonathan A. McCullers, MD, professor and chair, Department of Pediatrics, University of Tennessee Health Science Center, pediatrician-in-chief, Le Bonheur Children's Hospital
- John G. Boyle, president and CEO, Immune Deficiency Foundation
- Ethan Lindenberger, student, Norwalk High School, Norwalk, OH
Access the committee membership roster and video of the full committee hearing: Vaccines Save Lives: What Is Driving Preventable Disease Outbreaks?
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U.S. Representative Adam Schiff (California) receives official responses from Facebook and Google regarding his letter about anti-vaccine misinformation
On February 14, Representative Adam Schiff (California) wrote to Google CEO Sundar Pichai and Facebook CEO Mark Zuckerberg, urging them to address anti-vaccine misinformation on their platforms. On March 1, Schiff followed up with a letter to Amazon CEO Jeff Bezos, asking that Bezos’ company also address the public health issue of anti-vaccine misinformation. Schiff received official responses from Google and Facebook on March 7. Excerpts from the press releases are reprinted below.
February 14—Press release from U.S. Representative Schiff regarding letters to Google and Facebook
“As a Member of Congress who is deeply concerned about declining vaccination rates, I am requesting additional information on the steps that you currently take to provide medically accurate information on vaccinations to your users, and to encourage you to consider additional steps you can take to address this growing problem,” Schiff wrote in the letter. “I was pleased to see YouTube’s recent announcement that it will no longer recommend videos that violate its community guidelines, such as conspiracy theories or medically inaccurate videos, and encourage further action to be taken related to vaccine misinformation.”
March 1—Press release from U.S. Representative Schiff regarding letter to Amazon
“As the largest online marketplace in the world, Amazon is in a unique position to shape consumption,” Schiff wrote in the letter. “The algorithms which power social media platforms and Amazon's recommendations are not designed to distinguish quality information from misinformation or misleading information and, as a result, harmful anti-vaccine messages have been able to thrive and spread. The consequences are particularly troubling for public health issues.”
March 7—Press release from U.S. Representative Schiff regarding responses from Google and Facebook
“We have put a lot of effort into curbing misinformation in our products—from better Search ranking algorithms, to improving our ability to surface authoritative content, to tougher policies against monetization of harmful or dangerous content. Under YouTube’s Advertiser-Friendly Content Guidelines, we are and have been demonetizing anti-vaccination content under our longstanding harmful or dangerous advertising policy,” wrote Karan Bhatia, Vice President of Global Public Policy and Government Affairs at Google.
“Our approach…is to reduce the spread of inaccurate information about vaccines by reducing its distribution in News Feed, removing groups and pages that promote misinformation from recommendation surfaces, and providing authoritative information to people who might encounter it,” wrote Kevin Martin, Vice President of U.S. Public Policy at Facebook.
To thank Representative Schiff for being a vaccine advocate, you can mail or fax a message to one of his three offices or use the contact us box at the bottom of https://schiff.house.gov/contact.
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AAP president urges tech companies to combat vaccine misinformation online
an article in AAP News, the president of the American Academy of Pediatrics (AAP) has reached out to tech companies to urge them to combat vaccine misinformation online. The following is an excerpt from the article:
As measles outbreaks grow, the AAP is taking aim at vaccine misinformation online.
AAP President Kyle E. Yasuda, M.D., FAAP, sent letters today to the CEOs of Google (which owns YouTube), Facebook (which owns WhatsApp and Instagram) and Pinterest requesting that they partner with the Academy to make sure parents using their platforms are seeing credible, science-based information....
Every day, pediatricians talk with families about vaccines' crucial role in protecting children from deadly diseases and about their safety. However, many parents also are reading inaccurate and misleading information online, which can have serious real-world consequences.
The Academy is not requesting that technology companies censor their users. Instead, Dr. Yasuda called on the CEOs to elevate scientific content from verified sources to equip parents with credible information....
Reprinted with permission of AAP News, March 2019.
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Facebook taking steps to stop vaccine misinformation
Facebook joined two popular social media platforms, Pinterest and YouTube, as well as the e-commerce site Amazon, to make changes to counter vaccine misinformation. On March 7, Monika Bickert, vice president of global policy management at Facebook, posted a statement titled Combatting Vaccine Misinformation. A portion of the statement is reprinted below.
We are working to tackle vaccine misinformation on Facebook by reducing its distribution and providing people with authoritative information on the topic. We are starting by taking a series of steps:
- We will reduce the ranking of groups and Pages that spread misinformation about vaccinations in News Feed and Search. These groups and Pages will not be included in recommendations or in predictions when you type into Search.
- When we find ads that include misinformation about vaccinations, we will reject them. We also removed related targeting options, like “vaccine controversies.” For ad accounts that continue to violate our policies, we may take further action, such as disabling the ad account.
- We won’t show or recommend content that contains misinformation about vaccinations on Instagram Explore or hashtag pages.
- We are exploring ways to share educational information about vaccines when people come across misinformation on this topic.
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Dr. Paul Offit responds to measles outbreaks with opinion piece titled "Facebook, Twitter are blocking dangerous antivaccine posts. It’s about time.”
Dr. Paul Offit, director of the Vaccine Education Center at the Children's Hospital of Philadelphia, wrote an opinion piece in Philadelphia's The Inquirer in response to social media platforms making changes to counter vaccine misinformation. The commentary, published March 4, is titled Facebook, Twitter Are Blocking Dangerous Antivaccine Posts. It’s About Time. An excerpt is reprinted below.
....Mainstream media, in the face of overwhelming scientific evidence supporting the safety of vaccines, realizes that there aren’t two sides to this story. Also, nothing educates like outbreaks.
Although marginalized, activists haven’t given up, turning their attention from mainstream media to social media, where their misinformation continues to cause harm. It is here that the anti-vaccine groups have thrived. Anti-vaccine blogs, websites, books, live streamings, podcasts, chat rooms, and Facebook pages dominate the landscape.
Recently, and surprisingly, social media outlets have started to push back. Pinterest now bars searches for vaccine content. YouTube no longer allows anti-vaccine groups to monetize their videos with ads. Facebook fact-checks health articles to determine which will appear less prominently in news feeds. And Amazon has started removing anti-vaccine documentaries from its video streaming service....
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A nationwide cohort study published in Annals of Internal Medicine finds MMR vaccine is not linked to autism; adds to body of evidence confirming MMR vaccine safety
On March 5, the Annals of Internal Medicine published an article online by Anders Hviid et al. titled Measles, Mumps, Rubella Vaccination and Autism: A Nationwide Cohort Study. Four sections of the abstract are reprinted below.
The hypothesized link between the measles, mumps, rubella (MMR) vaccine and autism continues to cause concern and challenge vaccine uptake.
To evaluate whether the MMR vaccine increases the risk for autism in children, subgroups of children, or time periods after vaccination.
657,461 children born in Denmark from 1999 through 31 December 2010, with follow-up from 1 year of age and through 31 August 2013.
During 5,025,754 person-years of follow-up, 6,517 children were diagnosed with autism (incidence rate, 129.7 per 100,000 person-years). Comparing MMR-vaccinated with MMR-unvaccinated children yielded a fully adjusted autism hazard ratio of 0.93 (95% CI, 0.85 to 1.02). Similarly, no increased risk for autism after MMR vaccination was consistently observed in subgroups of children defined according to sibling history of autism, autism risk factors (based on a disease risk score) or other childhood vaccinations, or during specified time periods after vaccination.
The study strongly supports that MMR vaccination does not increase the risk for autism, does not trigger autism in susceptible children, and is not associated with clustering of autism cases after vaccination. It adds to previous studies through significant additional statistical power and by addressing hypotheses of susceptible subgroups and clustering of cases.
Access the abstract: Measles, Mumps, Rubella Vaccination and Autism: A Nationwide Cohort Study.
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IAC Spotlight! Find a comprehensive range of valuable measles information and ready-to-print materials for patients and staff on IAC's website
On IAC’s immunize.org website, you will find a range of educational and other materials related to measles and MMR vaccine. These materials provide healthcare professionals and patients with resources to protect children and adults.
Measles Handouts web page
IAC's Measles Handouts web page gives users free access to measles and MMR-related handouts for patients and fact sheets for healthcare professionals. All items are ready to print and distribute widely. Technical accuracy has been confirmed by immunization experts at the Centers for Disease Control and Prevention. Below are just a few of the educational materials available on IAC's Measles Handouts web page:
Vaccines: Measles web page
On IAC's Vaccines: Measles web page, you will find links to the latest ACIP recommendations, government resources, IAC’s "Ask the Experts" Q&As, photos and videos, package inserts, and standing orders. You'll also find a prominent box that links to CDC's “Information for Healthcare Professionals” web page.
Vaccine Information Statements: MMR web page
The Vaccine Information Statements (VIS) MMR web page includes up-to-date translations of the MMR VIS in 20 different languages, including:
Unprotected People Stories: Measles web page
IAC's Unprotected People Stories: Measles web page includes 13 real-life accounts of people who have suffered or died from measles. The stories offer personal testimonies, remembrances, case reports, and newspaper articles, as well as opinion pieces about the value of immunization.
Check out the broad range of educational and other materials related to measles and MMR vaccine on immunize.org today!
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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National Academies of Sciences, Engineering, and Medicine's presidents highlight facts on vaccine safety in light of measles outbreaks
The presidents of the National Academy of Sciences (NAS), the National Academy of Engineering (NAE), and the National Academy of Medicine (NAM) have joined together to highlight facts about vaccine safety and promote their new website titled Vaccines Are Safe. A recent announcement, signed by Marcia McNutt, president, NAS; C. D. Mote, Jr., president, NAE; and Victor J. Dzau, president, NAM; is reprinted below.
The current measles outbreaks in the United States and elsewhere are being fueled by misinformation about the safety of vaccines. To help counter such misinformation, we created a website that provides clear, concise, and evidence-based answers to questions about vaccine safety and other commonly asked questions about health and science as identified through our partnership with Google.
The evidence base includes a number of our studies examining vaccine access, safety, scheduling, and possible side effects. Our work has validated that the science is clear—vaccines are extremely safe.
Given our shared congressional mandate to advise the nation, we are compelled to draw attention to these facts in order to inform better decision-making at a time when it is urgently needed to protect the health of communities in our country and around the world. Furthermore, we call on our professional colleagues everywhere to share these facts as widely as possible. Please consider sharing our social media posts on your own accounts through the links below.
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February's Technically Speaking column by IAC executive director Dr. Deborah Wexler is titled "Questions about Proper Vaccine Storage and Handling? CDC's Redesigned Toolkit Has Answers!"
- What’s the appropriate temperature range for storage of refrigerated vaccines?
- What types of devices are recommended for monitoring temperatures in vaccine storage units?
- What should be done if it is discovered vaccines have been stored at inappropriate temperatures?
- Is it acceptable to remove vaccines from their original packaging to save space during storage?
Practical answers to these and many other vaccine storage and handling questions are found in CDC’s newly redesigned 2019 Vaccine Storage and Handling Toolkit. This indispensable 48-page resource includes guidance on managing and storing vaccine inventory, using and maintaining storage unit and temperature monitoring equipment, preparing for emergency situations, and training staff.
Toolkit reflects the best practices for vaccine storage and handling compiled from ACIP recommendations, product information from vaccine manufacturers, and scientific studies.
Toolkit helps healthcare clinic staff find the information they need quickly and easily. Revisions in this new edition 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
Each year, storage and handling errors result in revaccination of many patients and significant financial loss due to wasted vaccines. Failure to store and handle vaccines properly can reduce vaccine potency, resulting in inadequate immune responses in patients and poor protection against disease. Patients can lose confidence in vaccines and providers if they require revaccination because the vaccines they received may have been compromised.
Be sure to implement the best practices and recommendations outlined in the CDC Toolkit to help protect your patients, safeguard your vaccine supply, and avoid the unnecessary costs of revaccinating patients and replacing expensive vaccines.
Valuable vaccine storage and handling resources
CDC publishes “Notes from the Field: Tetanus in an Unvaccinated Child—Oregon, 2017” in this week's MMWR
CDC published Notes from the Field: Tetanus in an Unvaccinated Child—Oregon, 2017 in the March 8 issue of MMWR (pages 231–232). The entire article is reprinted below (without acknowledgments or footnotes).
Tetanus is an acute neuromuscular disease caused by the bacterium Clostridium tetani. Bacterial spores found in soil can enter the body through skin disruption, with subsequent onset of clinical illness ranging from 3 to 21 days (usually within 8 days). In 2017, a boy aged 6 years who had received no immunizations sustained a forehead laceration while playing outdoors on a farm; the wound was cleaned and sutured at home. Six days later, he had episodes of crying, jaw clenching, and involuntary upper extremity muscle spasms, followed by arching of the neck and back (opisthotonus) and generalized spasticity. Later that day, at the onset of breathing difficulty, the parents contacted emergency medical services, who air-transported him directly to a tertiary pediatric medical center. The boy subsequently received a diagnosis of tetanus and required approximately 8 weeks of inpatient care, followed by rehabilitation care, before he was able to resume normal activities.
Upon hospital arrival, the child had jaw muscle spasms (trismus). He was alert and requested water but was unable to open his mouth; respiratory distress caused by diaphragmatic and laryngeal spasm necessitated sedation, endotracheal intubation, and mechanical ventilation. Tetanus immune globulin (3,000 units) and diphtheria and tetanus toxoids and acellular pertussis vaccine (DTaP) were administered for presumed tetanus. He was admitted to the pediatric intensive care unit and cared for in a darkened room with ear plugs and minimal stimulation (stimulation increased the intensity of his spasms). Intravenous metronidazole was initiated, and the scalp laceration was irrigated and debrided.
His opisthotonus worsened, and he developed autonomic instability (hypertension, tachycardia, and body temperatures of 97.0°F–104.9°F [36.1°C–40.5°C]). He was treated with multiple continuous intravenous medication infusions to control his pain and blood pressure, and with neuromuscular blockade to manage his muscle spasms. A tracheostomy was placed on hospital day 5 for prolonged ventilator support. Starting on hospital day 35, the patient tolerated a 5-day wean from neuromuscular blockade. On day 44, his ventilator support was discontinued, and he tolerated sips of clear liquids. On day 47, he was transferred to the intermediate care unit. Three days later, he walked 20 feet with assistance. On day 54, his tracheostomy was removed, and 3 days later, he was transferred to a rehabilitation center for 17 days.
The boy required 57 days of inpatient acute care, including 47 days in the intensive care unit. The inpatient charges totaled $811,929 (excluding air transportation, inpatient rehabilitation, and ambulatory follow-up costs). One month after inpatient rehabilitation, he returned to all normal activities, including running and bicycling. Despite extensive review of the risks and benefits of tetanus vaccination by physicians, the family declined the second dose of DTaP and any other recommended immunizations.
This is the first pediatric tetanus case in >30 years in Oregon (unpublished data, Oregon Health Authority, 2018). The diagnosis of tetanus is made based on clinical findings because the bacterium C. tetani is difficult to grow from wounds. A wound culture from the child’s laceration did not grow C. tetani. However, a negative wound culture does not rule out disease. The health care costs to treat this child’s preventable disease were approximately 72 times the mean (2012) cost of $11,143 for a U.S. pediatric hospitalization. A recent report describing adult tetanus cases included hospital charges ranging from $22,229 to $1,024,672.
Widespread use of tetanus toxoid–containing vaccines (tetanus toxoid inactivated vaccine or a combination vaccine that contains tetanus toxoid) and tetanus immune globulin for wound management has led to a 95% decline in the number of tetanus cases and a 99% decrease in the number of tetanus-related deaths since the 1940s. From 2009 to 2015, 197 tetanus cases and 16 tetanus-associated deaths were reported in the United States. Unvaccinated or inadequately vaccinated persons are at risk for tetanus, irrespective of age, and recovery from tetanus disease does not confer immunity.
Routine administration of a 5-dose DTaP series is recommended for all eligible children at 2, 4, and 6 months of age, then a dose at 15–18 months of age, and a fifth dose at 4–6 years of age. Booster doses of diphtheria and tetanus toxoids are recommended every 10 years throughout life. Uninsured or underinsured eligible children may receive vaccines at no cost through the Vaccine For Children program (https://www.cdc.gov/vaccines/programs/vfc/index.html). Resources to assist health care providers in discussing vaccination with their patients, including how to address questions, are available online (https://www.cdc.gov/vaccines/partners/childhood/professionals.html).
Access Notes from the Field: Tetanus in an Unvaccinated Child—Oregon, 2017 in HTML format.
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Influenza remains widespread; CDC reports 8 additional pediatric deaths from influenza in the U.S.
Influenza continues to be widespread and CDC estimates that flu has caused as many as 26.3 million flu illnesses, 347,000 hospitalizations and 31,200 deaths so far this season. CDC has reported 8 additional influenza-associated pediatric deaths this season, for a total of 64. Last season, there was a record-setting number of pediatric deaths in the U.S. (185). 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 March 2, the geographic spread of influenza in Puerto Rico and 48 states was reported as widespread; the District of Columbia and two states reported local activity; 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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IAC updates “Standing Orders for Administering Hepatitis A Vaccine to Adults”
IAC recently revised Standing Orders for Administering Hepatitis A Vaccine to Adults. Changes were made to clarify the recommendation for pre-exposure protection against hepatitis A in adults age 41 years or older who are immunocompromised or have chronic liver disease or another chronic medical condition.
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IAC updates “Supplies You May Need at an Immunization Clinic”
IAC updated its handout for immunization providers titled Supplies You May Need at an Immunization Clinic. Changes were made to add Shingrix (RZV) to the list of vaccines, to add 1¼-inch needles (for use in the various sizes of needles to bring to clinics), and to include other smaller non-technical edits.
This one-page checklist provides an easy-to-use way to ensure that nothing essential is forgotten. Categories of supplies include vaccines, documentation, emergency supplies, miscellaneous vaccination supplies, Vaccine Information Statements, and office supplies.
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UNICEF warns that global surge of measles cases is a growing threat to children
On March 1, UNICEF issued a news release
about the global surge of measles cases and the threat this disease poses to children. The lead-in to the news release states that, "Ten countries accounted for approximately three-quarters of the total increase in measles in 2018, including significant outbreaks in Brazil, Madagascar, the Philippines, Ukraine, and Yemen." A section of the news release is reprinted below.
UNICEF warned today that global cases of measles are surging to alarmingly high levels, led by ten countries accounting for more than 74 percent of the total increase, and several others that had previously been declared measles free.
Globally, 98 countries reported more cases of measles in 2018 compared to 2017, eroding progress against this highly preventable, but potentially deadly disease....
"This is a wake up call. We have a safe, effective and inexpensive vaccine against a highly contagious disease—a vaccine that has saved almost a million lives every year over the last two decades,” said Henrietta Fore, UNICEF’s Executive Director. “These cases haven’t happened overnight. Just as the serious outbreaks we are seeing today took hold in 2018, lack of action today will have disastrous consequences for children tomorrow.”
Read the complete press release: Alarming global surge of measles cases a growing threat to children—UNICEF
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CDC and WHO publish "Update on Vaccine-Derived Poliovirus Outbreaks—Democratic Republic of the Congo and Horn of Africa, 2017–2018" in this week's MMWR and Weekly Epidemiological Record, respectively
CDC published Update on Vaccine-Derived Poliovirus Outbreaks—Democratic Republic of the Congo and Horn of Africa, 2017–2018 in the March 8 issue of MMWR (pages 225–230). On the same day, WHO's Weekly Epidemiological Record published a similar article titled Update on Vaccine-Derived Poliovirus Outbreaks—Democratic Republic of the Congo and Horn of Africa, 2017–2018. A summary of the MMWR article is reprinted below.
What is already known about this topic?
Prolonged person-to-person transmission of polio vaccine viruses in underimmunized populations can lead to emergence of outbreaks of paralysis from circulating vaccine-derived poliovirus (cVDPV).
What is added by this report?
During 2017–2018, four cVDPV type 2 outbreaks, with 42 cases to date, occurred in six provinces of the Democratic Republic of the Congo and required multiple response supplementary immunization activities (SIAs). In Somalia, concurrent cVDPV type 2 and cVDPV type 3 outbreaks occurred, first identified by sewage testing months before occurrence of 12 paralytic cases to date.
What are the implications for public health practice?
To promptly interrupt cVDPV transmission, country programs must effectively plan and implement timely response SIAs to optimize their quality and reach.
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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 www.immunize.org/guide. 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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EDUCATION AND TRAINING
Colorado Children's Immunization Coalition to offer March 20 webinar on hepatitis B in immigrant populations
- Describe the epidemiology of hepatitis B in immigrant populations
- Discuss hepatitis B screening and vaccination approaches for refugees, overseas and at U.S. arrival
- Review strategies to improve hepatitis B screening and vaccination in immigrant populations