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Issue 1427: May 29, 2019











Maine eliminates non-medical exemptions to vaccination

On May 24, Governor Janet Mills signed a bill into law that will end non-medical exemptions for childhood vaccines in the state of Maine. LD 798 will eliminate religious and philosophical exemptions for receiving vaccines required by schools and day cares.

According to news reports, the new law will take effect 90 days after the Legislature adjourns and unvaccinated students will have until 2021 to receive required vaccines.

Access the bill as approved by the governor: An Act To Protect Maine Children and Students from Preventable Diseases by Repealing Certain Exemptions from the Laws Governing Immunization Requirements.

 Maine joins Mississippi, West Virginia, and California in eliminating all non-medical exemptions to childhood vaccination.

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Washington State passes law to eliminate philosophical exemptions to MMR vaccination
On May 20, Washington Governor Jay Inslee signed a bill that eliminated a personal/philosophical exemption choice for MMR vaccination from the state’s school and child care immunization requirements. Four paragraphs from a Washington State Department of Health news release are reprinted below.

Today Governor Jay Inslee signed EHB 1638, updating Washington state’s school and child care immunization requirements to remove the personal/philosophical exemption for the measles, mumps and rubella (MMR) vaccine....

The Department of Health will work with schools and child cares to make sure they are ready to take in students, track records and guide parents through the new law. The law takes effect July 28, 2019 and applies to public and private schools and child cares.

The department will also work to ensure parents and guardians are well-informed and prepared to get the right immunizations to comply with the law before they send their children to school or child care. Most parents choose to vaccinate their children and will not be affected by the changes....

The law also includes a new requirement for employees and volunteers at child care centers to provide records indicating they have received the MMR vaccine or proof of immunity. The requirement will help protect the young children they work with, who are most vulnerable to disease.

Read the complete press release: Governor Signs Law Strengthening MMR Immunization Requirements.

Access more information from the Washington State Department of Health: MMR Vaccine Exemption Law Change 2019.

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Total number of U.S. measles cases for 2019 climbs to 940 in 26 states, with 60 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 940 cases across 26 states as of May 24. 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, Maine, Maryland, Massachusetts, Michigan, Missouri, New Mexico, 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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IAC enrolls 9 new birthing institutions into its Hepatitis B Birth Dose Honor Roll; 21 previously honored institutions qualify for additional years' honors

The Immunization Action Coalition (IAC) is pleased to announce that 9 new institutions have been accepted into its Hepatitis B Birth Dose Honor Roll, for a total of 460 honorees. The birthing institutions are listed below with their reported hepatitis B birth dose coverage rates in parentheses.
  • 81st Keesler Medical Center, Biloxi, MS (98%)
  • Advent Health Tampa, Tampa, FL (92%)
  • Ascension Borgess Hospital, Kalamazoo, MI (90%)
  • Atchison Hospital, Atchison, KS (96%)
  • Exeter Hospital, Exeter, NH (92%)
  • Leesburg Regional Medical Center, Leesburg, FL (97%)
  • Montefiore New Rochelle, New Rochelle, NY (95%)
  • Nathan Littauer Hospital, Gloversville, NY (90%)
  • Sullivan County Community Hospital, Sullivan, IN (95%)

The following 5 institutions are being recognized for a second year:

  • Atchison Hospital, Atchison, KS (95%)
  • Beaumont Hospital–Trenton, Trenton, MI (90%)
  • Henry Ford Wyandotte Hospital, Wyandotte, MI (90%)
  • Kent Hospital, Warwick, RI (95%)
  • Samaritan Medical Center, Watertown, NY (91%)

In addition, the following 6 institutions are being recognized for a third year:

  • Atchison Hospital, Atchison, KS (90%)
  • Kent Hospital, Warwick, RI (96%)
  • Metro Health–University of Michigan Health, Wyoming, MI (90%)
  • MidMichigan Medical Center–Alpena, Alpena, MI (90%)
  • St. Mary Mercy Hospital, Livonia, MI (92%)
  • Spectrum Health Pennock, Hastings, MI (90%)

The following 6 institutions are being recognized for a fourth year:

  • Ascension St. Joseph Hospital, Tawas City, MI (90%)
  • Holland Hospital, Holland, MI (91%)
  • Kent Hospital, Warwick, RI (95%)
  • Memorial Healthcare, Owosso, MI (93%)
  • Munson Healthcare Manistee Hospital, Manistee, MI (90%)
  • ProMedica Monroe Regional Hospital, Monroe, MI (93%)

The following 7 institutions are being recognized for a fifth year:

  • Kent Hospital, Warwick, RI (95%)
  • McLaren Bay Region, Bay City, MI (94%)
  • Mercy Health Hackley Campus, Muskegon, MI (93%)
  • MidMichigan Health Gratiot, Alma, MI (95%)
  • MidMichigan Medical Center-Midland, Midland, MI (93%)
  • ProMedica Monroe Regional Hospital, Monroe, MI (91%)
  • Spectrum Health United Hospital, Greenville, MI (94%)

The following institution is being recognized for a sixth year:

  • Sturgis Hospital, Sturgis, MI (94%)

Last, but certainly not least, the following institution is being recognized for a seventh year:

  • Spectrum Health Ludington Hospital, Ludington, MI (92%)

Note: Three of these institutions qualified for multiple 12-month periods at one time.

The Honor Roll now includes 460 birthing institutions from 44 states, Puerto Rico, Guam, and an overseas U.S. military base. One hundred fourteen institutions have qualified for two years, 53 institutions have qualified three times, 27 institutions have qualified four times, 20 institutions have qualified five times, 4 institutions have qualified six times, 2 institutions have qualified seven times, and 1 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.

Related IAC Resources

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IAC Spotlight: Check out the unsolicited feedback IAC receives about its work every week

The What Others Say about IAC web section features a small selection of the unsolicited comments IAC receives from the immunization community. Of course, we'd like readers to check out this page because we're proud of this positive feedback, but you also might learn about some IAC resources or services of which you were previously unaware. Here's a sampling, listed under the headings in this section.

Website (

"I love your website and refer to it all of the time for vaccine-hesitant parents. Thanks again for all you do. It's an uphill battle to get these children immunized, but I'm on it!!!"

"I have found resources of the IAC invaluable—and I really mean invaluable—in assisting our staff to participate in the immunization process. You are my favorite website."

"In new-hire orientation, we always encourage subscribing to, as we find it to be full of information and easy to navigate."

Educational Materials

"I love being able to give our patients the VIS in their own language. They really appreciate it too. They usually express pleasant surprise when they see it."

"Tremendous help in organizing and providing appropriate assessment of patients, standing orders, and administration of vaccines in my local community pharmacy. I use them every day."

"I would really like to focus on preventing vaccination administration errors for upcoming provider training, so your materials are awesome to have! [To Err Is Human, Not to Err Is Better: Vaccination Errors and How to Prevent Them PowerPoint slide set] Thank you!"

"We appreciate the thoroughness and uniformity of the IAC standing order sets."

IAC Express

"I just wanted to let you know how much I appreciate your IAC Express. I am always learning so much from it. I find the information very helpful and very interesting. I look forward to reading it when I am able. I work in family practice and internal medicine clinics and your weekly news has helped me take better care of my patients. THANK YOU for all you do."

"I was so impressed with the abundance of timely, complete and succinct presentation and formatting of the weekly newsletter, that I felt compelled to thank you and acknowledge the excellence of your IAC Express. I publish a weekly Medical Staff blog for our physicians and plan to use a number of the concise topic renditions from the IAC Express on a regular basis. Thank you."

Ask the Experts

"Your Ask the Experts columns are SO helpful. I've been using them for more than 20 years!"

"Thanks for your work! Your Ask the Experts pages are my favorite clinical resource."

"I quoted excerpts from Ask the Experts twice last week to answer questions from clinicians. One was about revaccinating postpartum with MMR for a negative rubella titer. The other was about whether to repeat the dose if the syringe leaked. I was able to answer their questions quickly, completely, and with confidence. The clinicians were very appreciative. I had several similar experiences over the past few years. Thanks."

Other (from people who have called or emailed IAC)

"I really appreciate your help with everything; your customer service has been absolutely fantastic. Thanks."

"I cannot thank you enough for your patience in clarifying this issue which comes up for us all the time."

"Thank you SO much for your quick response and for directing me to the correct place. IAC does a really wonderful job and I read all of your correspondence thoroughly. You are so great for primary care physicians like me!"

“THANK YOU SO MUCH!! You were so helpful! You saved me so much time. I feel so confident now giving the parents the information. This is amazing that you got back to me so quickly. I am so appreciative."

Be sure to check out more of this feedback on the What Others Say about IAC web page. 

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Deadline for abstracts for the National Conference for Immunization Coalitions and Partnerships extended until June 30; presentations especially requested for the coalitions track

The 14th National Conference for Immunization Coalitions and Partnerships (NCICP) will take place in Honolulu from November 13–15. This is a great opportunity for coalition leaders to learn from expert speakers and network with members of immunization coalitions from around the nation.

There are four breakout tracks at the NCICP:

  • Coalition Track
  • Communication Track
  • Local/Pacific Track
  • Medical/Clinical Track

The deadline for abstract submission for breakout sessions and posters has been extended to June 30. The organizers especially need coalitions to propose breakout speakers, specifically for the Coalition Track.

Abstracts are welcome from representatives of all disciplines, including coalition staff and members, community-based providers, healthcare providers, social workers, researchers, government agencies, health communication specialists, and others. 

Access general conference information.

Submit an abstract.

Registration is open! Register by August 31 to receive the early bird rates.

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IAC updates "Need Help Responding to Vaccine-Hesitant Parents?"

IAC recently updated its resource for healthcare professionals titled Need Help Responding to Vaccine-Hesitant Parents? Science-based materials are available from these respected organizations. Changes were made to update URLs and available materials.

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IAC revises "Standing Orders for Administering Pneumococcal Vaccines (PCV13 and PPSV23) to Adults" and "Standing Orders for Administering Pneumococcal Polysaccharide Vaccine to Children and Teens"

IAC recently revised the following 2 standing orders templates related to pneumococcal vaccination:

  1. Standing Orders for Administering Pneumococcal Vaccines (PCV13 and PPSV23) to Adults: Changes were made to update URLs, add information to be documented in the patient's medical record, and to update the guidance on reporting to VAERS. These changes had been made previously to IAC's other standing orders for adults.
  2. Standing Orders for Administering Pneumococcal Polysaccharide Vaccine to Children and Teens: Changes were made to update URLs, add the "Needle Gauge" column to the chart in #4 (that had been previously inadvertently left off), and to update the guidance on reporting to VAERS. These changes had been made previously to IAC's other standing orders for children and teens.

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IAC revises "Standing Orders for Administering Human Papillomavirus Vaccine to Children and Teens"

IAC recently revised Standing Orders for Administering Human Papillomavirus Vaccine to Children and Teens to update URLs; change the guidance for choosing an appropriate needle gauge, length, and injection site from using gender/weight to instead be based on age; add information to be documented in the patient's medical record; and to update the guidance on reporting to VAERS. Note: these changes have been made previously to IAC's other standing orders for children and teens.

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Spanish-language version of "Vaccinations for Adults without a Spleen" was updated to match the English-language version
IAC recently posted an updated Spanish-language version of its handout for patients and healthcare professionals titled "Vaccinations for Adults without a Spleen."

Access this updated translation: Vacunas para adultos sin bazo.

This version now matches the English-language version, which was updated earlier this month.

Access the English-language version: Vaccinations for Adults without a Spleen.

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IAC posts updated Japanese-language translations of the hepatitis B and DTaP VISs

IAC recently posted updated Japanese-language translations of the hepatitis B and DTaP VISs. IAC thanks the Oregon Health Authority for the donation of these translations.

Access these updated translations below.

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WHO requests feedback from healthcare professionals for Draft Zero of its "Immunization Agenda 2030"

The World Health Organization (WHO) has requested feedback from healthcare professionals for Draft Zero of its "Immunization Agenda 2030." The agenda aims to set a new vision and strategy for vaccines and immunization for the next decade. It will be presented for endorsement at the 73rd World Health Assembly in May 2020.

This initial round of review will last one month. Please provide comments and feedback by June 14, 2019. You can provide your feedback in a variety of ways, which are described on page 3 of the document.

Access the document and instructions about providing feedback: Immunization Today and in the Next Decade: Developing Together the Vision and Strategy for Immunization, 2021–2030.

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Vaccine Confidence Project provides links to news articles about the consequences of vaccine hesitancy around the world 

The Vaccine Confidence Project, managed by the London School of Hygiene & Tropical Medicine, collects news articles related to vaccine hesitancy and confidence and offers links to them on its website. For example, articles from the last few days include such titles as State Vaccine Doctor Feeds Oregon Lawmakers Bunk, The Philippines Is Fighting One of the World’s Worst Measles Outbreaks, Infecting People Isn’t a Religious Right, and How the Battle against Measles Varies around the World. The site also offers links to related editorials and studies published in peer-reviewed journals.

Bookmark the Vaccine Confidence Project archive and keep checking back for additions.

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CDC and WHO report on progress toward polio eradication worldwide in this week's MMWR and Weekly Epidemiological Record, respectively

CDC published Progress toward Polio Eradication—Worldwide, January 2017–March 2019 in the May 24 issue of MMWR. On the same day, WHO's Weekly Epidemiological Record published a similar article titled Progress towards Polio Eradication, Worldwide, January 2017–March 2019. A media summary of the MMWR article is reprinted below.

 A new report describes the current status of the global polio eradication initiative during 2017–2019. In 1988, there were 350,000 cases of wild poliovirus (WPV) in 125 countries. In 2017, there were 22 WPV cases reported in Afghanistan and Pakistan, which was an historic low. In 2018, there were 33 cases from the same two countries, and the reported number in 2019 to date is higher than that in the same period in 2018. The greatest barrier to completing WPV eradication is the number of children who are missed by vaccination efforts. Health workers face steep challenges to vaccinating children in security-compromised areas, accessing mobile populations, and overcoming pockets of vaccine refusals due to misinformation and mistrust. Targeted efforts are underway to intensify program operations to reach and vaccinate every child; full implementation is critical to successfully eradicate polio.

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CDC updates the measles chapter of its Manual for the Surveillance of Vaccine-Preventable Diseases

CDC recently updated the measles chapter of its Manual for the Surveillance of Vaccine-Preventable Diseases. The revision includes guidance for infants, children, and adults who are residents or visitors of communities with sustained and ongoing measles outbreaks. This additional guidance can be found in the section titled “Role of community-wide vaccination efforts in outbreak control."

The Manual for the Surveillance of Vaccine-Preventable Diseases provides current guidelines for those directly involved in surveillance of vaccine-preventable diseases (VPD), especially personnel at the local health departments.

Access Chapter 7: Measles of CDC's Manual for the Surveillance of Vaccine-Preventable Diseases.

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WHO has updated its online library of vaccine safety resources contributed by organizations around the world

The Institute for Vaccine Safety at the Johns Hopkins Bloomberg School of Public Health has been working with the World Health Organization (WHO) to update and promote WHO's Vaccine Safety Communication eLibrary. This online resource is an open-source library of resources for vaccine safety communication, submitted by many reliable organizations from around the world. Users can filter their request by language, audience, vaccine, and resource type.

Check out the Vaccine Safety Communication eLibrary.

Anyone can access resources from this source. If you wish to contribute resources to the project, email for more information.

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Shot by Shot offers "Scotty's Story," a compelling video to promote meningococcal vaccination

Shot by Shot recently released a new video, "Scotty's Story," a story of an 18-year old recent high school graduate who fell ill one morning and died that day of a meningococcal B infection. The account is narrated by his mother, whose goal is to share her family’s experience to educate others.

Access Scotty's Story.

Shot by Shot Stories of Vaccine-Preventable Diseases is a project of the California Immunization Coalition. Visit to view the entire collection of video stories from people who have been touched by vaccine-preventable diseases.

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CDC offers guidance for people visiting pigs during fair season

CDC recently sent an email update titled "What to Consider When Visiting Pigs at a Fair." The text is reprinted below.

Swine influenza (flu) is a respiratory disease of pigs caused by type A influenza viruses that regularly cause outbreaks of influenza in pigs. While rare, human infections with influenza viruses that usually spread in pigs do occur and can be serious. 

Most human infections with swine flu viruses have happened in the agricultural fair settings, where pigs from different farms come into close contact with each other and with many people. Make sure to wash your hands often with soap and running water before and after exposure to pigs or their environments. If soap and water are not available, use an alcohol-based hand rub.

For more information, visit CDC's Variant Influenza Viruses in Humans web section. This section includes information for healthcare professionals; people who work with or raise pigs; and fair organizers, exhibitors, and visitors.

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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 "how to" guide on adult immunization provides easy-to-use, practical information covering essential adult immunization activities. It helps vaccine providers enhance their existing adult immunization services or introduce them into any clinical setting. Topics include:

  • 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 May 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 May issue includes the following articles:

Additional resources and articles are available in the full newsletter.

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

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Bioethicist publishes 10 steps to consider to protect communities from further vaccine-preventable disease outbreaks 

Arthur Caplan, PhD, bioethicist and director of the Department of Bioethics at New York University’s Langone Medical Center, has published a list of 10 steps to consider to protect communities from further vaccine-preventable disease outbreaks like the current measles outbreak. 

Read this May 9 thought-provoking column on Let’s Treat Measles Seriously: To stop outbreaks, we must halt the spread of anti-vaccination misinformation.

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Webinar titled "HPV Vaccination: Tools for Training Your Staff" scheduled for June 13
A webinar titled HPV Vaccination: Tools for Training Your Staff is scheduled for June 13 at 3:00 p.m. (ET). In this webinar, participants will learn to develop staff training within their office and effectively communicate with families about the importance of the HPV vaccine using the "Same Way, Same Day" app. The presenters include Sharon Humiston, MD, MPH, FAAP, IAC’s associate director for research, and Kristin Oliver, MD, MPH.

This webinar is offered through the National AHEC Organization HPV Immunization Project.

Registration information

Reminder: 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.

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.

IAC Express Disclaimer
ISSN: 1526-1786
Our mailing address is
Immunization Action Coalition
2550 University Avenue West, Suite 415 North
Saint Paul, MN 55114

Copyright (C) 2019 Immunization Action Coalition
All rights reserved.

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

This page was updated on .