Issue 1463: November 27, 2019









CDC publishes updated ACIP recommendations for the use of PCV13 and PPSV23 pneumococcal vaccines for adults age 65 and older in this week’s MMWR

CDC published Use of 13-Valent Pneumococcal Conjugate Vaccine and 23-Valent Pneumococcal Polysaccharide Vaccine among Adults Aged ≥65 Years: Updated Recommendations of the Advisory Committee on Immunization Practices in the November 22 issue of MMWR (pages 1069–1075). Two important sections are reprinted below.

New Pneumococcal Vaccine Recommendations for Adults Aged ≥65 Years Old (page 1073)

PCV13. PCV13 vaccination is no longer routinely recommended for all adults aged ≥65 years. Instead, shared clinical decision-making for PCV13 use is recommended for persons aged ≥65 years who do not have an immunocompromising condition, CSF leak, or cochlear implant and who have not previously received PCV13.

CDC guidance for shared clinical decision-making. When patients and vaccine providers engage in shared clinical decision-making for PCV13 use to determine whether PCV13 is right for the specific individual aged ≥65 years, considerations may include the individual patient’s risk for exposure to PCV13 serotypes and the risk for pneumococcal disease for that person as a result of underlying medical conditions. 

If a decision to administer PCV13 is made, it should be administered before PPSV23 (5). The recommended intervals between pneumococcal vaccines remain unchanged for adults without an immunocompromising condition, CSF leak, or cochlear implant (≥1 year between pneumococcal vaccines, regardless of the order in which they were received). PCV13 and PPSV23 should not be coadministered.

ACIP continues to recommend PCV13 in series with PPSV23 for adults aged ≥19 years (including those aged ≥65 years) with immunocompromising conditions, CSF leaks, or cochlear implants.

PPSV23 for adults aged ≥65 years. ACIP continues to recommend that all adults aged ≥65 years receive 1 dose of PPSV23. A single dose of PPSV23 is recommended for routine use among all adults aged ≥65 years. PPSV23 contains 12 serotypes in common with PCV13 and an additional 11 serotypes for which there are no indirect effects from PCV13 use in children. The additional 11 serotypes account for 32%–37% of IPD among adults aged ≥65 years. Adults aged ≥65 years who received ≥1 dose of PPSV23 before age 65 years should receive 1 additional dose of PPSV23 at age ≥65 years, at least 5 years after the previous PPSV23 dose.

Considerations for shared clinical decision-making regarding use of 13-valent pneumococcal conjugate vaccine (PCV13) in adults aged ≥65 years (page 1074)

  • PCV13 is a safe and effective vaccine for older adults. The risk for PCV13-type disease among adults aged ≥65 years is much lower than it was before the pediatric program was implemented, as a result of indirect PCV13 effects (by preventing carriage and, thereby, transmission of PCV13-type strains). The remaining risk is a function of each individual patient’s risk for exposure to PCV13 serotypes and the influence of underlying medical conditions on the patient’s risk for developing pneumococcal disease if exposure occurs.
  • The following adults aged ≥65 years are potentially at increased risk for exposure to PCV13 serotypes and might attain higher than average benefit from PCV13 vaccination, and providers/practices caring for many patients in these groups may consider regularly offering PCV13 to their patients aged ≥65 years who have not previously received PCV13:
    • Persons residing in nursing homes or other long-term care facilities
    • Persons residing in settings with low pediatric PCV13 uptake
    • Persons traveling to settings with no pediatric PCV13 program
  • Incidence of PCV13-type invasive pneumococcal disease and pneumonia increases with increasing age and is higher among persons with chronic heart, lung, or liver disease, diabetes, or alcoholism, and those who smoke cigarettes or who have more than one chronic medical condition. Although indirect effects from pediatric PCV13 use were documented for these groups of adults and were comparable to those observed among healthy adults, the residual PCV13- type disease burden remains higher in these groups. Providers/practices caring for patients with these medical conditions may consider offering PCV13 to such patients who are aged ≥65 years and who have not previously received PCV13.

Access the complete MMWR article:

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CDC issues press release titled “CDC Updates EVALI Guidance for Health Care Providers as Flu Activity Increases Nationally—EVALI and Flu Symptoms Often Similar”

On November 19, CDC issued a press release titled CDC Updates EVALI [e-cigarette or vaping lung injury] Guidance for Health Care Providers as Flu Activity Increases Nationally—EVALI and Flu Symptoms Often Similar. The press release is reprinted below.

CDC today released updated guidance for health care providers to help diagnose and treat patients with e-cigarette or vaping lung injury (EVALI). This updated guidance, published in Morbidity and Mortality Weekly Reports (MMWR), comes as the 2019–2020 influenza season approaches, when many patients may show up in outpatient clinics or hospitals with symptoms of respiratory illness.

This new guidance is an update to the clinical guidance CDC previously released in October 2019. “Clinicians serve a critical role in both identifying and treating patients with EVALI,” said CDC Principal Deputy Director, Anne Schuchat, MD (RADM, USPHS, RET).

Key Recommendations from Updated Guidance
  • Health care providers should ask patients with symptoms of respiratory or gastrointestinal illness, or other symptoms such as fever, chills or weight loss, about their use of e-cigarette, or vaping, products. They should evaluate patients with suspected EVALI according to previously published CDC recommendations.
  • Not all patients with a history of e-cigarette or vaping, product use who present for evaluation of respiratory, gastrointestinal, or other symptoms require hospitalization. EVALI patients can be managed on an outpatient basis if they have normal levels of oxygen in their blood, no respiratory distress, no other health conditions that might compromise lung capacity, reliable access to health care should their symptoms worsen, and strong social support systems.
  • Influenza testing should be strongly considered, especially during flu season. Health care providers should consider prescribing antiviral medications if clinically indicated.
  • Corticosteroids can be considered for outpatients on a case-by-case basis, however, they should be used with caution in outpatients, because this treatment modality has not been well studied among outpatients, and corticosteroids could worsen respiratory infections.
  • Treatment strategies such as behavioral counseling are recommended to help EVALI patients discontinue using e-cigarette, or vaping, products.
  • Health care providers should emphasize the importance of annual flu vaccines for all patients 6 months of age or older, including patients at risk of EVALI.

Characteristics of Non-Hospitalized EVALI Patients

This clinical guidance was released along with a second report in MMWR that provides new information about both hospitalized and non-hospitalized EVALI patients. The report found that as of November 5, 2019, among the 1,977 EVALI patients with available data on hospitalization status, 94% were hospitalized. Demographic characteristics were similar between hospitalized and non-hospitalized patients with most being male and under 35 years of age.

Both reports continue to reinforce key public health recommendations to prevent EVALI, which are based on epidemiologic, laboratory, and clinical data being analyzed by CDC.

Access the entire CDC press release.

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Reminder! CDC's National Influenza Vaccination Week, observed December 1–7, will highlight the importance of continuing flu vaccination through the holiday season and beyond

National Influenza Vaccination Week (NIVW), observed December 1–7, was established by CDC in 2005 as an awareness week to highlight the importance of continuing influenza vaccination activities throughout the holiday season and beyond. It's a great time to vaccinate people who have not yet been protected against flu and to call or send a reminder message to those who have not been vaccinated to be sure they get protected. Vaccination efforts should continue through the holiday season and beyond because peak influenza activity generally does not occur until February (with some variability year to year). Providers are encouraged to continue vaccinating patients throughout the influenza season, including into the spring months.

This year, CDC is focusing on groups at high risk of flu-related complications, hospitalizations, and death, such as children younger than 5 years, adults over 65, people with chronic conditions such as asthma, heart disease, and diabetes, and pregnant women. Click on the graphic below to access the NIVW campaign resources from CDC, including web tools, videos, communication hints, matte articles to submit to newspapers, animated images, graphics, and more. 

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IAC Spotlight! IAC’s “Talking about Vaccines: Responding to Parents” web page features many resources to help providers respond to parents’ questions about vaccines 

IAC's Talking about Vaccines: Responding to Parents web page on contains many resources from IAC, CDC, the American Academy of Pediatrics, and others to help healthcare professionals respond to the questions parents ask about vaccines. 

The resources listed in the left column of this web page link to materials from several organizations, including:

  • IAC
  • CDC
  • Vaccine Education Center, Children's Hospital of Philadelphia
  • Vaccinate Your Family 
  • American Academy of Pediatrics

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

  • Videos for parents and healthcare professionals
  • PowerPoint slide sets
  • Journal articles
  • A link to IAC's website for the public,

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 "Responding to Parents" from the drop-down menu.

Visit the IAC's Talking about Vaccines: Responding to Parents web page to see how its wide range of resources can help you respond to parents' questions.

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IAC's elegantly designed "Vaccines Save Lives" black enamel pins make great gifts for the holidays!

IAC's new, elegantly designed “Vaccines Save Lives” pin on hard black enamel with gold lettering and edges makes a meaningful gift for people who care about immunization. 

The pin is a stick-through-post variety with the back end covered by a round rubber cap that holds the pin securely. A gold metal spring-lock clasp is also provided. The pin makes a refined statement, measuring 1.125" x 0.75". 

Wear these pins on clothing, uniforms, lab coats, tote bags, and backpacks to show that you value vaccines!

Click here for "Vaccines Save Lives" pins pricing and ordering information.

Visit Shop IAC for additional items, including "FLU VACCINE" buttons and stickers, patient record cards, and a vaccine administration training video.

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Flu season is here, so make sure you have IAC's new "FLU VACCINE" buttons for staff and patient stickers on hand!

IAC's new “FLU VACCINE” buttons and stickers are ready to ship! Their bright red color helps broadcast your important message about the need for flu vaccination. And the cost is nominal.


The button measures 1.25" across and carries a bold message! Pin on lab coats, uniforms, other clothing, tote bags, or backpacks to show support for flu vaccine.
Buttons are delivered in bags of 10 buttons per bag.

Click here for pricing and ordering information for "FLU VACCINE" buttons.

Measuring 1.5" across and printed on Avery labels, theses stickers adhere well to clothing and have an easy-peel-off back.
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” stickers.

Visit Shop IAC for additional items, including "Vaccines Save Lives" enamel pins, patient record cards, and a vaccine administration training video.

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Voices for Vaccines releases new podcast episode titled "Protect Me Later: Alternative Vaccine Schedules"

Voices for Vaccines (VFV) has posted a new episode in its Vax Talk podcast series: Protect Me Later: Alternative Vaccine Schedules. In this podcast, Karen Ernst, executive director, VFV, and Nathan Boonstra, MD, pediatrician, Blank Children's Hospital, discuss with Dr. Paul Offit the science behind vaccination schedules and the dangers in delaying vaccination.

If you or your organization would like information about how to become a sponsor of a VFV "Vax Talk" podcast, please contact VFV's executive director Karen Ernst, at  

Voices for Vaccines is a national organization of parents and others who are dedicated to raising the level of the voices of immunization supporters. VFV invites everyone who values vaccines to become a member. Please spread the word to your friends and colleagues to join VFV!

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IAC and AIM update “Communicating the Benefits of Influenza Vaccine,” a 1-page fact sheet for healthcare professionals

IAC and the Association of Immunization Managers (AIM) and IAC recently revised their 1-page fact sheet for healthcare professionals titled Communicating the Benefits of Influenza Vaccine by updating the statistics and references and redesigning it.

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WHO reports on October 2019 meeting of the Strategic Advisory Group of Experts on Immunization in this week's Weekly Epidemiological Record

The November 22 edition of the WHO periodical Weekly Epidemiological Record reported on the October 2019 meeting of the Strategic Advisory Group of Experts on Immunization in an article titled Meeting of the Strategic Advisory Group of Experts on Immunization, October 2019—Conclusions and Recommendations

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Vaccinate Your Family’s Shot of Prevention series features "The Vaccine Mom," Taryn Chapman, in a video blog interview titled “Flu Myth Busting”

As part of its Shot of Prevention blog series, Vaccinate Your Family recently posted a video interview titled Flu Myth Busting with Taryn Chapman, the creator of The Vaccine Mom blog. In this video, Taryn interviews her friend Jeff, who is hesitant about getting flu vaccine because he thinks that it might not be effective and that it might make him sick. Engaging him in a lively conversation, Taryn, a trained medical molecular biologist, responds to his concerns and explains why it's important for him and his children to get vaccinated against the flu. 

Watch the video on the Shot of Prevention blog: The Vaccine Mom Busts Flu Myths

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NFID releases new online toolkit to raise awareness of the burden of flu in adults with chronic health conditions

The National Foundation for Infectious Diseases (NFID) has developed a new online Flu & Chronic Health Conditions Toolkit to increase awareness of the dangers of influenza in U.S. adults with chronic health conditions and the importance of annual vaccination. Estimates indicate that 31% of U.S. adults age 50–64 and 47% of those age 65 and older have at least one chronic health condition that puts them at high risk for flu-related complications, including hospitalization, catastrophic disability, and even death. 

These tools are all available at and include:

Access NFID's Flu and Chronic Health Conditions online toolkit.

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Influenza season has begun; check out these resources and make sure all your patients are getting vaccinated!

Nationally, flu activity is increasing, as shown in CDC’s Weekly U.S. Influenza Surveillance Report, FluView. For the week ending November 16, the geographic spread of influenza was reported as widespread in 6 states, with regional activity in 9 states. Puerto Rico and 23 states reported local activity; the District of Columbia, the U.S. Virgin Islands, and 11 states reported sporadic activity; 1 state reported no activity; and Guam did not report.

Four influenza-associated pediatric deaths have been reported for the 2019–20 season. One new influenza-related pediatric death was reported during the week ending November 16. 

Visit the CDC’s Weekly U.S. Influenza Surveillance Report, FluView, for details.

Influenza vaccination is recommended for everyone six months of age and older, so please continue to vaccinate all your patients in this age range. 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. The HealthMap Vaccine Finder can help patients locate influenza vaccination services near them.

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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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Vaccine Education Center at Children's Hospital of Philadelphia publishes November issue of its newsletter Vaccine Update 

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

Additional resources, including information booklets for patients, are available in the full newsletter.

Access the sign-up form to subscribe to Vaccine Update.

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CDC and Medscape offer new online CE program on ACIP recommendations for prevention of influenza

CDC and Medscape are providing online continuing education (CE) for selected MMWR publications. Recently, they posted an online training program titled Prevention and Control of Seasonal Influenza with Vaccines: Recommendations of the Advisory Committee on Immunization Practices—United States, 2019–20 Influenza Season. You must be registered on Medscape to access this link. If you are not a registered user, you can register for free by visiting and clicking on the Register link in the upper right corner of the page.

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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.IZ Express DisclaimerISSN 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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