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Issue 1448: September 25, 2019









CDC shares tips on how to make a strong flu vaccine recommendation

CDC recently promoted a new web page titled Make a Strong Flu Vaccine Recommendation. Some of the text is reprinted below.

Making a Strong Flu Vaccine Recommendation (SHARE)

It is necessary for some patients to receive a strong recommendation from their provider. CDC suggests using the SHARE method to make a strong vaccine recommendation and provide important information to help patients make informed decisions about vaccinations:

SHARE the reasons why the influenza vaccine is right for the patient given his or her age, health status, lifestyle, occupation, or other risk factors.

HIGHLIGHT positive experiences with influenza vaccines (personal or in your practice), as appropriate, to reinforce the benefits and strengthen confidence in influenza vaccination.

ADDRESS patient questions and any concerns about the influenza vaccine, including side effects, safety, and vaccine effectiveness in plain and understandable language.

REMIND patients that influenza vaccines protect them and their loved ones from serious influenza illness and influenza-related complications.

EXPLAIN the potential costs of getting influenza, including serious health effects, time lost (such as missing work or family obligations), and financial costs.

Visit CDC's Make a Strong Flu Vaccine Recommendation web page for much more information to help you make a strong recommendation for influenza vaccination, including a video, descriptions of all recommended flu vaccines, and a link to the HCP Fight Flu Toolkit.

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CDC study finds the number of infants hospitalized with influenza is at least double previous estimates

CDC has posted an online summary of its September 3 article in The Lancet Child & Adolescent Health titled Underdetection of Laboratory-Confirmed Influenza-Associated Hospital Admissions among Infants: A Multicentre, Prospective Study. The researchers found that in four countries, Albania, Jordan, Nicaragua, and the Philippines, the number of children younger than 1 year of age hospitalized with flu was at least double current estimates. Sections of the CDC summary are reprinted below.

A CDC multi-country study reported in The Lancet Child & Adolescent Health has found that the number of children younger than 1 year who are hospitalized with flu is at least double current estimates. These findings underscore the danger flu poses to young children, and the importance of vaccination policies that protect babies, including vaccination of pregnant women, babies 6 months and older, and the close contacts of babies younger than 6 months who are too young to be vaccinated themselves....

Flu among babies is not as widely studied as it is among children in general, with most studies examining babies as part of larger age groups, such as 0–2 years old or children younger than 5. However, babies are different from older children in ways that make them particularly vulnerable to complications from flu, making it especially important to study them separately. Babies hospitalized with flu are likely experiencing their first flu infection—and fighting it with an immature immune system and underdeveloped airways and lungs. To further complicate things, flu symptoms often present differently in babies than they do in older children and adults, making flu infection more difficult for clinicians to spot....

If the true number of babies younger than 1 year hospitalized with flu is at least double previous estimates, this substantially increases estimates of the global burden of flu among this group and has profound implications for the preventive value of maternal and childhood vaccination programs—especially in middle and low-income countries that may face additional challenges in terms of flu vaccine funding and public health infrastructure....

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In case you missed it, IAC Express special edition of Ask the Experts influenza Q&As was issued on September 13; all Ask the Experts influenza Q&As on the IAC website also updated

On September 13, a special edition of IAC Express with new and revised Q&As about influenza vaccination was emailed to subscribers. If you missed it, just click on the image below to access this issue.

New and updated Ask the Experts questions and answers are emailed to IAC Express subscribers five times per year. You can access the most recent Ask the Experts issues from the right column of the Ask the Experts index page.

In addition, IAC and CDC have reviewed all the Q&As in the online Ask the Experts influenza section and updated them as needed to reflect the ACIP recommendations and the available licensed vaccines for the 2019–20 flu season.

IAC’s Ask the Experts web section is a compilation of common as well as challenging questions and answers (Q&As) about vaccines and their administration. Here you will find more than 1,000 Q&As on all vaccines routinely recommended in the United States, as well as information on such topics as administering vaccines, documenting vaccination, scheduling vaccines, vaccine recommendations, precautions and contraindications, storage and handling, and vaccine safety. 

Answers are provided by experts from CDC's National Center for Immunization and Respiratory Diseases, including Andrew T. Kroger, MD, MPH; Mark S. Freedman, DVM, MPH, DACVPM; Tina S. Objio, MSN, MHA, RN; Candice L. Robinson, MD, MPH; Raymond A. Strikas, MD, MPH, FACP, FIDSA; and JoEllen Wolicki, BSN, RN.  

Explore all IAC's "Ask the Experts" Q&As by clicking on the graphic below and bookmarking this valuable resource.

If you have a question about vaccination that is not covered in the "Ask the Experts" web section, feel free to email it to us at

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HHS Secretary Azar releases statement on executive order to modernize influenza vaccine manufacturing

On September 19, President Trump signed an executive order about influenza vaccine research and production. U.S. Health and Human Services (HHS) Secretary Alex Azar released the following related statement the same day:

HHS Secretary Azar Statement on Flu Vaccine Executive Order

“President Trump’s executive order to modernize influenza vaccine manufacturing reflects his commitment both to America’s national security and to America’s health. Faster methods of producing influenza vaccines will help keep Americans safer both from seasonal influenza, which kills tens of thousands of Americans each year, and from the potential of pandemic influenza, which is the single greatest biodefense threat our country faces. Under this executive order, HHS will lead on coordinating and advancing work to modernize influenza vaccine production, as part of the important work we do to protect Americans from all infectious threats, whether naturally occurring, accidental, or manmade.”

Read the Executive Order on Modernizing Influenza Vaccines in the United States to Promote National Security and Public Health.

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Supplies of pediatric and adult hepatitis B vaccine from Merck will continue to be limited into 2020; CDC offers guidance 

CDC has recently updated information about shortages of Merck's pediatric and adult hepatitis B vaccine on its Current Vaccine Shortages & Delays web section. The relevant text from the “Hepatitis B note” is reprinted below. In addition, CDC has made a 3-page guidance document available titled 2019 Pediatric Hepatitis B Vaccine Update and Guidance Table.

Pediatric hepatitis B vaccine: Merck anticipates having a limited supply of pediatric monovalent hepatitis B vaccine through mid 2020. GSK has confirmed its ability to continue to address supply gaps for pediatric hepatitis b vaccine during this period, using a combination of monovalent pediatric hepatitis B vaccine and its DTaP-HepB-IPV pediatric combination vaccine (Pediarix). The expected monovalent supply continues to provide sufficient vaccine to cover the hepatitis B birth dose for all children as well as additional pediatric hepatitis B vaccine for second and third doses. However, some adjustments will be needed from providers because of the decrease in monovalent vaccine (see attached guidance in the table above). To ensure an equitable distribution of monovalent hepatitis B vaccine and direct vaccine doses according to CDC’s clinical guidance, CDC continues to implement controlled vaccine ordering in the public sector using both Merck’s and GSK’s monovalent pediatric hepatitis B vaccines. In addition, GSK is providing monovalent doses to the private sector market directly and through their channels consistent with CDC’s clinical guidance. GSK’s DTaP-HepB-IPV pediatric combination vaccine (Pediarix) continues to be available in both the public and private sectors. 

Adult hepatitis B vaccine: With the exception of a limited release of vaccine available in the fall of 2019, Merck does not expect to be distributing adult hepatitis B vaccine or dialysis formulation during the remainder of 2019 or during 2020. Dynavax and GSK have sufficient supplies of adult hepatitis B vaccines to address the anticipated gap in Merck’s supply of adult hepatitis B vaccine during this period; however, preference for a specific presentation (i.e., vial versus syringe) may not be met uniformly during this time. 

It is important to note that the recommendations for hepatitis B vaccination of infants have not changed.

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IAC Spotlight! Check out all of IAC's print materials about administering vaccines

IAC's Handouts: Administering Vaccines web page features two dozen IAC pieces related to vaccine administration, including screening for contraindications and precautions, selecting and preparing the vaccine, and properly administering the vaccine. All have been reviewed by CDC for technical accuracy. A few examples follow:

Check out the Handouts: Administering Vaccines web page to access all these practical clinical resources.

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

The Immunization Action Coalition (IAC) is pleased to announce that six new institutions have been accepted into its Hepatitis B Birth Dose Honor Roll, for a total of 482 honorees. The birthing institutions are listed below with their reported hepatitis B birth dose coverage rates in parentheses.

  • Charlotte Hungerford Hospital, Torrington, CT (93%)
  • Flagler Hospital, St. Augustine, FL (90%)
  • Indiana University Ball Memorial Hospital, Muncie, IN (96%)
  • ProMedica Bixby Hospital, Adrian, MI (90%)
  • Salina Regional Health Center, Salina, KS (92%)
  • Sentara Northern Virginia Medical Center, Woodbridge, VA (96%)

The following institution is being recognized for a third year:

  • Andalusia Health, Andalusia, AL (97%)

In addition, the following institution is being recognized for a fourth year:

  • St. Rose Hospital, Hayward, CA (99%)

Finally, the following institution is being recognized for a fifth year:

  • Oneida Healthcare, Oneida, NY (93%)

The Honor Roll now includes 482 birthing institutions from 44 states, Puerto Rico, Guam, and an overseas U.S. military base. One hundred eleven institutions have qualified for two years, 56 institutions have qualified three times, 28 institutions have qualified four times, 20 institutions have qualified five times, seven institutions have qualified six times, four institutions have qualified seven 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 51,000 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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Reminder: Association of Immunization Managers requests nominations of its members for outstanding leadership awards through October 7

Each year, the Association of Immunization Managers (AIM) presents awards to its selected members in recognition of their outstanding initiatives, service, dedication, and leadership. The awards will be presented at the 2019 AIM Leadership in Action Conference in New Orleans in December. The Natalie J. Smith, MD Award, Bull’s-Eye Awards, and Rising Star Awards have an open nomination process.

For more detailed information about each award and the nomination process, visit the awards page on the AIM website. Nominations are due by October 7. Contact Mary Waterman at with any questions.

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CDC publishes 2019 National Viral Hepatitis Progress Report online

CDC has published an online 2019 National Viral Hepatitis Progress Report to share trends in viral hepatitis vaccination efforts, and disease incidence and mortality.  This annual report measures the nation’s progress in preventing and controlling viral hepatitis and updates the 2018 National Viral Hepatitis Progress Report.
Two summary points from the progress report’s web section regarding hepatitis A and B vaccination are reprinted below. 

  • No progress was made over the past year in increasing hepatitis A vaccination coverage. The large increases in the hepatitis A incidence rate for 2016 and 2017 related to widespread person-to-person outbreaks highlights the importance of vaccination as well as public health surveillance to identify and respond to outbreaks of hepatitis A.
  • Progress is not being made in reducing the incidence of acute hepatitis B among adults, and incidence increased slightly from 2016 to 2017. Furthermore, while there was a slight increase in newborn hepatitis B vaccination coverage from 2016 to 2017, it was not enough to reach the annual target, and more than a quarter of newborns did not receive hepatitis B vaccination within 3 days of birth in 2017, leaving these young children unnecessarily vulnerable to hepatitis B virus infection.

CDC has included a related 1-page fact sheet. Click on the image below to access the fact sheet.

Access the report online: 2019 National Viral Hepatitis Progress Report.

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CDC publishes report on global epidemiology of diphtheria in Emerging Infectious Diseases

CDC published Global Epidemiology of Diphtheria, 2000–2017 by Kristie Clarke, et al. in the October 2019 issue of Emerging Infectious Diseases. The abstract is reprinted below.

In 2017, a total of 8,819 cases of diphtheria were reported worldwide, the most since 2004. However, recent diphtheria epidemiology has not been well described. We analyzed incidence data and data from the literature to describe diphtheria epidemiology. World Health Organization surveillance data were 81% complete; completeness varied by region, indicating underreporting. As national diphtheria–tetanus–pertussis (DTP) 3 coverage increased, the proportion of case-patients <15 years of age decreased, indicating increased protection of young children. In countries with higher case counts, 66% of case-patients were unvaccinated and 63% were <15 years of age. In countries with sporadic cases, 32% of case-patients were unvaccinated and 66% were ≥15 years of age, consistent with waning vaccine immunity. Global DTP3 coverage is suboptimal. Attaining high DTP3 coverage and implementing recommended booster doses are necessary to decrease diphtheria incidence. Collection and use of data on subnational and booster dose coverage, enhanced laboratory capacity, and case-based surveillance would improve data quality.

Access the complete article: Global Epidemiology of Diphtheria, 2000–2017.

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WHO reports that Kenya joins Ghana and Malawi in roll-out of landmark malaria vaccine in pilot program

On September 13, the World Health Organization (WHO) posted a press release titled Malaria Vaccine Launched in Kenya: Kenya Joins Ghana and Malawi to Roll Out Landmark Vaccine in Pilot Introduction. The first four paragraphs are reprinted below.

The World Health Organization (WHO) congratulates the Government of Kenya for launching the world’s first malaria vaccine today in Homa Bay County, western Kenya.

The malaria vaccine pilot programme is now fully under way in Africa, as Kenya joins Ghana and Malawi to introduce the landmark vaccine as a tool against a disease that continues to affect millions of children in Africa.

The vaccine, known as RTS,S, will be available to children from 6 months of age in selected areas of the country in a phased pilot introduction. It is the first and only vaccine to significantly reduce malaria in children, including life-threatening malaria.

Malaria claims the life of one child every two minutes. The disease is a leading killer of children younger than 5 years in Kenya.

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IAC’s new FLU VACCINE buttons and stickers are flying out the door! But don't worry. We’ve got you covered. Keep stocking up for flu season!

Everyone wants to display flu shot support—don’t be left out! Jump-start your preparations for the 2019–20 influenza season by ordering IAC's new “FLU VACCINE” buttons and stickers from SHOP IAC. These popular new resources are modeled after “I Voted” stickers, which are given to voters in many states as they leave the polls on Election Day. The flu vaccine buttons and stickers are bright red to help broadcast your important vaccination message. And the cost is low!


Demonstrate your clinic-wide support for protecting everyone from influenza by purchasing buttons for all staff to wear. Measuring 1.25" across, the button is understated in size but carries a bold message! Brightly colored red, round button with white text and a metal pin that clasps on the back.

Pin on your lab coat, uniform, other clothing, tote bag, or backpack to show support for influenza vaccination. Wear it when flu vaccine is available in your clinic to remind patients and the public to protect themselves from influenza.
Buttons are delivered in bags of 10 buttons per bag. Click here for pricing and ordering information.

These brightly colored red, round stickers measure 1.5" across. Printed on Avery labels, they adhere well to clothing and have an easy-peel-off back.
Wearing these brightly colored stickers, your patients will be letting their communities know that influenza vaccination is important.

Suitable for clinic staff, too! Urge all staff to wear them at work during flu vaccination season. This sends a powerful reminder to patients to get vaccinated.
Stickers are delivered to you cut individually (not on rolls)—available in bundles of 100. 

Click here for pricing and ordering information for “FLU VACCINE” buttons and stickers.

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American College of Obstetricians and Gynecologists develops infographics and text to promote prenatal influenza and Tdap vaccination

The American College of Obstetricians and Gynecologists (ACOG) has developed infographics and corresponding text on prenatal influenza and Tdap immunization for use on practice websites, patient portals, and social media pages through a cooperative agreement with CDC. Healthcare providers are encouraged to download these graphics and post them on the trusted web platforms associated with their practice to help ensure patients have access to accurate information on maternal immunization outside of the office setting. 

Click on either image below to access these graphics on the ACOG Maternal Immunization Tools for Educating Pregnant Women web page.

For additional information, clinical guidance, and patient and provider resources on maternal immunization, please visit ACOG’s Immunization for Women website.

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CDC updates the diphtheria and hepatitis A chapters of its Manual for the Surveillance of Vaccine-Preventable Diseases

CDC recently updated the diphtheria and hepatitis A chapters of its Manual for the Surveillance of Vaccine-Preventable Diseases

  • Chapter 1: Diphtheria has been updated to reflect authorship conservation and elimination of duplication for the Lab Testing section, which now refers the reader to the Laboratory Support Chapter 22
  • Chapter 3: Hepatitis A has been updated to reflect 1) the CSTE 2018 revised case definition for hepatitis A and 2) elimination of duplication and authorship conservation for the Lab Testing section, which now refers the reader to the Laboratory Support Chapter 22 and for the Vaccination section, which now refers the reader to the "Pink Book"

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.

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IAC's comprehensive Vaccinating Adults: A Step-by-Step Guide is available for free download either by chapter or in its entirety (142 pages)

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 Guide is available to download/print either by chapter or in its entirety free of charge at The downloaded version is suitable for double-sided printing. The National Vaccine Program Office and CDC both supported the development of the Guide and provided early technical review.

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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Reminder: CDC’s Current Issues in Immunization webinar titled “Influenza Update—2019–2020” is scheduled for October 2

CDC will present a Current Issues in Immunization NetConference on October 2 at 12:00 p.m. (ET). The topic will be "Influenza Update—2019–2020," and the speaker will be Lisa Grohskopf, MD, MPH, medical officer, Influenza Division, NCIRD, CDC.

Immunization NetConferences are live, 1-hour presentations combining an online visual presentation with simultaneous audio via telephone conference call, plus a live question and answer session. On-demand replays and presentations will be available shortly after each event.

Registration is required and limited. Should you miss the live event, you can watch the archived version when it is posted later on CDC’s website.

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NFID offers webinar on vaccine safety monitoring on October 8
The National Foundation for Infectious Diseases (NFID) will present a webinar titled Vaccine Safety Monitoring on October 8 at 12:00 p.m. (ET). William Schaffner, MD, medical director, NFID, will moderate the webinar with a presentation by Daniel A. Salmon, PhD, professor, International Health and Health, Behavior & Society, and director, Institute for Vaccine Safety, Johns Hopkins Bloomberg School of Public Health. 

At the conclusion of this activity, participants will be able to:
  • Explain the rationale for, and purpose of, post-licensure vaccine safety monitoring
  • Describe the public health surveillance systems used for post-licensure vaccine safety monitoring
  • Summarize the process of signal detection, signal assessment, and signal verification in post-licensure vaccine safety monitoring


Reminder: National Conference for Immunization Coalitions and Partnerships will take place November 13–15 in Honolulu

The 14th National Conference for Immunization Coalitions and Partnerships (NCICP) will take place in beautiful Honolulu from November 13–15. Conference attendees will learn from expert speakers and network with members of immunization coalitions from around the nation.

Keynote speakers will include Nancy Messonnier, MD, director, National Center for Immunization and Respiratory Diseases, CDC, and Erica DeWald, directory of advocacy, Vaccinate Your Family. The conference will also include 40 breakout sessions, as well as research and coalition posters.

Click on the graphic below for more information about the conference, including registration.

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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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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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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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