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Issue 1426: May 22, 2019









CDC issues "Dear Provider" letter with recommendations regarding adult immunization against measles in response to increase in measles cases  

On May 17, CDC issued the following letter to help clarify recommendations for adult MMR vaccination and for assessing immunity.

Dear Provider,

Due to the current increase in measles cases in the United States, the Centers for Disease Control and Prevention has developed the following summary for vaccination of adults against measles with measles, mumps, rubella (MMR) vaccine. Recommendations for vaccination and assessing immunity in adults have not changed since publication of the Advisory Committee on Immunization Practices (ACIP) recommendations for the Prevention of Measles, Rubella, Congenital Rubella Syndrome, and Mumps in June 2013

What adult providers need to know:

  • Providers do not need to actively screen adult patients for measles immunity. This is because of high population immunity and low risk of disease among adults in non-outbreak areas in the U.S.
  • Providers should make sure patients have measles protection before international travel. U.S. residents traveling internationally are at high risk for acquiring measles abroad. They can also transmit measles to susceptible persons, such as infants, when they return home.
  • If a patient is traveling internationally and measles immunity is unknown, providers should vaccinate, unless there are contraindications. Serologic testing for measles immunity is not recommended.
  • During outbreaks, providers should consult with local health departments for the most up-to-date recommendations for their community. This may include additional doses of MMR for your patients.  

Measles is an acute viral illness characterized by a prodrome of fever, cough, coryza, and conjunctivitis, followed by a maculopapular rash. The rash spreads from the head to trunk to the lower extremities. Measles is usually a mild or moderately severe illness, however, measles can result in complications such as pneumonia, encephalitis, and death.

Most adults in the U.S. are at low risk for measles. In general, providers do not need to actively screen low-risk adult patients for measles in non-outbreak areas in the U.S.

From 2001–2015, the annual reported incidence for adults ≥18 years of age was <0.5/1,000,000 population (Clemmons et al, JAMA 2017). Further, seroprevalence of measles immunoglobulin G (IgG) in the U.S. for persons 20–49 years of age ranges from 87.9% to 93.3%, suggesting high immunity among U.S. adults (Lebo et al., OFID 2017). From January 1 to May 10, 2019, 839 cases were reported to CDC. Of these, 218 (26%) measles cases were reported in adults ≥18 years of age. Among all adult cases, 65% were associated with outbreaks in underimmunized close-knit communities in two states (NY and WA). 

Certain adults are considered to be at high risk for either acquiring measles and/or transmitting disease to vulnerable persons.

High risk adults include:

  • Students at post-high school educational institutions
  • Healthcare personnel
  • International travelers to any country outside the United States

High-risk adults need written documentation of two doses of MMR vaccine (each dose separated by at least 28 days), or other presumptive evidence of immunity.  

Other presumptive evidence of measles immunity includes:

  • Birth before 1957
  • Laboratory evidence of immunity
  • Laboratory confirmation of disease

Healthcare facilities should consider vaccination of healthcare personnel born before 1957 with two doses of MMR who lack laboratory evidence of immunity or laboratory confirmation of disease.

During outbreaks, health departments may provide additional recommendations to protect their communities. The at-risk population is defined by local and state health departments, depending on the epidemiology of the outbreak. Thus, if the outbreak is affecting adults with community-wide transmission and ongoing risk of exposure to adults, a second dose should be considered for adults in these affected areas (including visitors) who have previously received one dose. During an outbreak of measles in a health-care facility, or in healthcare facilities serving a measles outbreak area, two doses of MMR vaccine are recommended for healthcare personnel regardless of birth year who lack other presumptive evidence of measles immunity. There are no recommendations to receive a third dose of MMR vaccine during measles outbreaks.

One dose of MMR vaccine, or other presumptive evidence of immunity (listed above), is sufficient for other U.S. adults. Some adults may have received a killed measles vaccine during the 1960s. The killed measles vaccine was available from 1963 to 1967 and administered to less than 5% of adults. The ACIP recommendation is to re-vaccinate anyone who received the killed vaccine or vaccine of unknown type. However, this only affects a very small proportion of adults who were vaccinated during those years. There is no recommendation for a catch-up program among adults for a second dose of MMR (e.g., persons born before or after 1989).

If a patient’s measles immunity is unknown, providers should vaccinate with MMR, unless there are contraindications. Contraindications to MMR vaccination include a history of severe allergic reaction to any component of the vaccine, pregnancy, and immunosuppression. MMR vaccine is safe, even if given to persons who were previously vaccinated or had prior disease. IgG serologic testing to assess measles immunity is NOT recommended during this period of increased measles activity. IgM testing should ONLY be used for patients suspected to have measles.  

We hope that you find this information helpful. Additional information can be found at Please direct any questions to

Access CDC's Dear Provider Letter in downloadable PDF format on

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Total number of U.S. measles cases for 2019 climbs to 880 with 41 new cases reported since last week

CDC has posted its latest update on 2019 measles cases in the U.S. on its Measles Cases and Outbreaks web page. The web page shows a preliminary estimate of 880 cases across 24 states as of May 17. This is the greatest number of cases reported in the U.S. since 1994 and since measles was declared eliminated in 2000.

The states that have reported cases to CDC are Arizona, California, Colorado, Connecticut, Florida, Georgia, Illinois, Indiana, Iowa, Kentucky, Maryland, Massachusetts, Michigan, Missouri, Nevada, New Hampshire, New Jersey, New York, Oklahoma, Oregon, Pennsylvania, Texas, Tennessee, and Washington.

Access additional information about U.S. measles cases in 2019 on CDC's Measles Cases and Outbreaks web page.

Click on the following links for information about specific outbreaks:

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CDC publishes "Notes from the Field: Measles Outbreaks from Imported Cases in Orthodox Jewish Communities—New York and New Jersey, 2018–2019" in this week’s MMWR

CDC published Notes from the Field: Measles Outbreaks from Imported Cases in Orthodox Jewish Communities—New York and New Jersey, 2018–2019 in the May 17 issue of MMWR (pages 444–445).

Access the article in HTML format.

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CDC publishes "Notes from the Field: Community Outbreak of Measles—Clark County, Washington, 2019–2019" in this week’s MMWR

CDC published Notes from the Field: Community Outbreak of Measles—Clark County, Washington, 2018–2019, in the May 17 issue of MMWR (pages 446–447).

Access the article in HTML format.

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IAC Spotlight! IAC’s newly updated “Talking about Vaccines: Autism” web page on provides an extensive range of resources to help you respond to concerns about vaccines and autism

IAC's Talking about Vaccines: Autism web page on was recently updated and contains an extensive range of resources to help healthcare professionals address concerns about vaccines and autism.

The resources listed in the left column of this web page link to materials on the websites of the following organizations:

  • Immunization Action Coalition
  • CDC
  • Vaccine Education Center at Children’s Hospital of Philadelphia
  • American Academy of Pediatrics 
  • Institute of Medicine
  • Vaxopedia
  • Autism Science Foundation

In the right column of the web page you will find more resources, include the following:

  • Videos for parents and videos for healthcare professionals
  • PowerPoint slide sets
  • Journal articles
  • Blog sites

To easily locate this web page from anywhere on, go to the light blue band of tabs across the top, choose the "Talking About Vaccines" tab (far right), and then select "Autism" from the drop-down menu.

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IAC posts revised translation of MMR VIS in Simplified Chinese 

IAC has recently posted a revised translation of the MMR VIS in Simplified Chinese. 

Access the updated translation below.

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Video on vaccines from Bill & Melinda Gates Foundation has generated over 4 million views since May 12

A video on vaccines titled The Side Effects of Vaccine—How High is the Risk? has generated over 4 million views on YouTube since May 12. The video, supported by the Bill & Melinda Gates Foundation, is from the Kurzgesagt—In a Nutshell series and comes with subtitles available in 15 languages. According to an analysis of online comments, the video has shown overwhelmingly positive remarks from viewers.

View the video: The Side Effects of Vaccine—How High is the Risk? (10:55)

Access the wide range of information and their sources used by those producing the video.

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National Public Health Information Coalition publishes article titled "These Moms Warn What Measles May Do to Your Baby"

In its recent weekly newsletter, the National Public Health Information Coalition (NPHIC) published the following article, which includes a story and video from two mothers whose children had measles and who both suffered severe complications. NPHIC has given IAC permission to reprint its article. Read the article below.

These Moms Warn What Measles May Do to Your Baby

Like all mothers who believe in facts and science, Jilly Moss and Audrey Clow are incredulous when they hear anti-vaxers say that measles is no big deal. Moss's 11-month-old baby ended up in the hospital in April because of the virus. Baby Alba had a fever that soared over 107 degrees, her eyes were swollen shut for days, and doctors had to give her medicine to prevent her from going blind. She couldn't eat or drink and had so much trouble breathing, doctors had to put her on oxygen. The doctors, unaccustomed to measles, misdiagnosed her repeatedly, sending her home, where she became sicker and sicker. At one point, her parents thought they might lose her. Clow's baby Sarah suffered brain damage from the measles, resulting in deafness, partial sight, muscular problems and learning difficulties. "She was in a coma for eight weeks—at death's door literally," says Clow. Sarah now "walks like a little rag doll," notes Clow, adding: "They're brain-damaged for life and that is something that is very hard to bear." Click here for more from Moss and here for a video from Clow.

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Immunization Techniques video on vaccine administration from the California Department of Public Health remains available online for free and as DVD

The 25-minute training video titled Immunization Techniques: Best Practices with Infants, Children, and Adults helps ensure that immunization providers administer vaccines correctly. Developed by the California Department of Public Health, Immunization Branch (CDPH), in collaboration with a team of national experts and updated in 2010, this video provides clear, detailed information on administering injectable, oral, and nasal vaccines to infants, children, and adults. CDPH has asked IAC to convey this message regarding the video:

People often ask whether CDPH has plans to update the video. No, at this time we do not have plans to update the video. Fortunately, vaccine preparation and administration techniques have remained constant, although some of the products and documentation technology have changed. We feel the video content is accurate and still relevant as is.

It is available online as a YouTube video or as a DVD for purchase from the Immunization Action Coalition at

California providers can contact their local health department immunization program to obtain a free copy of the DVD. 

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Still available! IAC’s sturdy laminated versions of the 2019 U.S. child/adolescent immunization schedule and the 2019 U.S. adult immunization schedule—order them for your exam rooms today! Bulk purchase prices available.

IAC's laminated versions of the 2019 U.S. child/adolescent immunization schedule and the 2019 U.S. adult immunization schedule are available now. These schedules are covered with a tough coating you can wipe down; they will stand up to a year's worth of use in every area of your healthcare setting where immunizations are given. The child/adolescent schedule is eight pages (i.e., four double-sided pages) and the adult schedule is six pages (i.e., three double-sided pages). Both schedules are folded to measure 8.5" x 11". 

Adult Laminated Immunization Schedules

Adult Laminated Immunization Schedules

Laminated schedules are printed in color for easy reading. They come complete with essential tables and notes, and they replicate the newly designed CDC schedule format.

1–4 copies: $7.50 each
5–19 copies: $5.50 each
20–99 copies: $4.50 each
100–499 copies: $4.00 each
500–999 copies: $3.50 each

For quotes on customizing or placing orders for 1,000 copies or more, call (651) 647-9009 or email

You can access specific information on both schedules, view images of both, order online, or download an order form at the Shop IAC: Laminated Schedules web page.

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IAC's 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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May's Parents PACK newsletter from Vaccine Education Center features video discussing limitations of blood tests in determining immunity

Parents PACK (Possessing, Accessing, and Communicating Knowledge about vaccines) from the Vaccine Education Center at Children's Hospital of Philadelphia offers an electronic newsletter for parents. The May issue features a video with Dr. Paul Offit titled Can a Blood Test Replace a Vaccine Dose? The May issue also includes a new Q&A sheet, developed in collaboration with the Divisions of Infectious Diseases and Organ Transplantation at Children's Hospital of Philadelphia, titled Vaccines and Solid Organ Transplants: What You Should Know. Healthcare providers should check out the issue and encourage parents to subscribe to the free Parents PACK newsletter.

To find more information about their resources and subscribe to their newsletter, visit the Parents PACK web page.

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Webinar on strategies for building school immunization rates, hosted by state of Washington organizations, scheduled for June 4

Within Reach, the Immunization Action Coalition of Washington, and Public Health Seattle and King County are co-sponsoring a June 4 webinar on strategies for improving school immunization rates. The webinar, titled Building School Immunity: Winning Strategies for Improving School Immunization Rates from Washington, California, and Colorado, will be held at 12:00 p.m. PT (3:00 p.m. ET). The webinar will include leaders from the following districts and organizations and topics:
  • Spokane Regional Health District: Reducing Barriers to Immunization
  • Oakland Unified School District and Alameda County Public Health Department: Collaborating with School Principals to Improve Immunization Compliance 
  • Colorado Children’s Immunization Coalition: Sharing District-Level Immunization Data through Fact Sheets and Interactive Online Dashboards

Register for the webinar.

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Weekly CDC webinar series on "The Pink Book" chapter topics runs June 5 through September 25; register now

CDC is again presenting a 15-part webinar series to provide a chapter-by-chapter overview of the 13th edition of Epidemiology and Prevention of Vaccine-Preventable Diseases (also known as "The Pink Book"). This is a live series of weekly 1-hour webinars that will start June 5 and run through September 25. The June 5 webinar is titled "Principles of Vaccination."

Recordings of sessions will be available online within 2 weeks after each webinar. All sessions begin at 12:00 p.m. (ET). Continuing education will be available for each event.

The webinar series will provide an overview of vaccines and the diseases they prevent, general recommendations for vaccines, vaccination principles, and immunization strategies for providers.

Registration and more information is available on CDC's Pink Book Webinar Series web page.

All the sections of "The Pink Book" (i.e., chapters, appendices, 2017 supplement) are available to download at no charge at

You can also order this resource from the Public Health Foundation for $40 plus shipping and handling.


Immunize Oregon to hold 2019 Northwest Immunization Conference conference on August 13–15 in Portland; early registration open

The Immunize Oregon Coalition will host the 2019 Northwest Immunization Conference (NWIC), which will be held on August 13–15 in Portland, Oregon. The presentations and workshops on Day 1 will focus on provider communication related to immunization and on clinical skill-building in management, vaccine administration, vaccine safety, and public health advocacy. On Days 2 and 3, experts from CDC will present the Epidemiology and Prevention of Vaccine-Preventable Diseases (the "Pink Book") course, with up-to-date information on immunizations and vaccine issues that affect health-care practices.

Find more information about the conference and registration on the conference website:

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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.

IZ Express Disclaimer
ISSN 2771-8085

Editorial Information

  • Editor-in-Chief
    Kelly L. Moore, MD, MPH
  • Managing Editor
    John D. Grabenstein, RPh, PhD
  • Associate Editor
    Sharon G. Humiston, MD, MPH
  • Writer/Publication Coordinator
    Taryn Chapman, MS
    Courtnay Londo, MA
  • Style and Copy Editor
    Marian Deegan, JD
  • Web Edition Managers
    Arkady Shakhnovich
    Jermaine Royes
  • Contributing Writer
    Laurel H. Wood, MPA
  • Technical Reviewer
    Kayla Ohlde

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