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Issue Number 249            May 25, 2001


  1. CDC seeks assistance from health professionals in implementing ACIP recommendations for influenza vaccine
  2. CDC announces deferral of routine booster doses of tetanus and diphtheria toxoids for adolescents and adults
  3. GAO issues report on flu vaccine and the need to ensure access for those at high risk for influenza
  4. Abstract deadline for the ICC Symposium on Minorities, the Medically Underserved, and Cancer is June 15
  5. CDC issues erratum to article on syringe exchange programs


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May 25, 2001

On May 18, 2001, Walter A. Orenstein, MD, Assistant Surgeon General and Director of the National Immunization Program of the Centers for Disease Control and Prevention (CDC), issued a letter seeking assistance from health care providers in implementing the recommendations of the Advisory Committee on Immunization Practices (ACIP) for the upcoming influenza season. His letter, along with its list of groups that should be targeted for influenza vaccination, is reprinted here in its entirety.

May 18, 2001

Dear Health Care Provider:

The Centers for Disease Control and Prevention (CDC) is asking your assistance in implementing the recommendations of the Advisory Committee on Immunization Practices (ACIP) for influenza vaccination. During the 2000-2001 influenza season, manufacturing problems resulted in a significant delay of influenza vaccine availability. This delay was due to a combination of factors including problems some manufacturers had in growing one of the virus strains used in vaccine and problems two manufacturers had with good manufacturing practices. Ultimately, one manufacturer withdrew from the market and did not distribute any vaccine. To make up for possible shortfalls of influenza vaccine, CDC contracted with one manufacturer to extend their production period and produce up to 9 million doses of additional influenza vaccine that was available in December 2000. As a result, flu vaccine supplies were approximately what was distributed in prior years; however, a substantial amount of vaccine reached providers much later than usual.

Because influenza vaccine is newly produced for each influenza season, numerous factors may affect the manufacturers' vaccine production and distribution. If some manufacturers are delayed in getting their vaccine to the providers, there will be uneven distribution of the vaccine with providers who ordered from some manufacturers receiving vaccine later than providers who ordered from other manufacturers. Further, providers who order late may receive vaccine late. Providers who order from third party distributors will be dependent upon which manufacturer is supplying that distributor. Manufacturers' current projections indicate that influenza vaccine supply should be similar to prior seasons. However, we will not know for certain until substantially later this year as manufacturers gain experience with production of this year's viral strains. Therefore, WE ASK YOU TO DEVELOP CONTINGENCY PLANS NOW SO IMMUNIZATION EFFORTS ARE BETTER TARGETED TO IMMUNIZE THOSE AT HIGHEST RISK FIRST, IN THE EVENT A DELAY OR SHORTAGE OCCURS.

In preparation for this year's influenza season, CDC STRONGLY ENCOURAGES THOSE OF YOU WITH HIGH-RISK PATIENTS TO ORDER VACCINE NOW, rather than waiting to order later in the spring, summer, or fall. Ordering now will help manufacturers and distributors gauge demand and improve the opportunity to immunize high-risk individuals as early in the season as possible.

CDC published the ACIP recommendations, "Prevention and Control of Influenza," in the April 20, 2001, Morbidity and Mortality Weekly Report (MMWR). (The MMWR can be found at Enclosed is a listing of individuals recommended to receive influenza vaccine.

An important change in the ACIP recommendations is to extend the optimal time for vaccinating high-risk individuals from mid-November to the end of November. In addition, ACIP recommends that efforts should continue to vaccinate individuals through December and later, even if influenza is occurring in the community. During 19 influenza seasons from 1982 to 2000, influenza peaked in January or later in 15 seasons and in February or later in 10. This indicates administration of vaccine in December or even January should have an impact in most influenza seasons.

The ACIP recommendations also suggest that persons planning substantial organized vaccination campaigns consider scheduling these events after mid-October, to minimize the need for cancellations because vaccine is unavailable. We would also ask that employee-based campaigns, which primarily immunize a healthy, younger population, consider postponing their campaigns even later, particularly if there is a significant delay or shortage of vaccine, so that high-risk individuals may be immunized first.

CDC will continue to work closely with the FDA, vaccine manufacturers, State and local health officials, and other partners to share information regarding the influenza vaccine supply as it becomes available. We appreciate your efforts to maximize influenza vaccine to prevent influenza complications.


Walter A. Orenstein, MD

Assistant Surgeon General
National Immunization Program




Persons at Increased Risk For Complications

  • persons aged > 65 years;
  • residents of nursing homes and other chronic-care facilities that house persons of any age who have chronic medical conditions;
  • adults and children who have chronic disorders of the pulmonary or cardiovascular systems, including asthma;
  • adults and children who have required medical follow-up or hospitalization during the preceding year because of chronic metabolic diseases (including diabetes mellitus), renal dysfunction, hemoglobinopathies, or immunosuppression (including immunosuppression caused by medications or by human immunodeficiency virus);
  • children and teenagers (aged 6 months to 18 years) who are receiving long-term aspirin therapy and therefore might be at risk for developing Reyes syndrome after influenza infection; and
  • women who will be in the second or third trimester of pregnancy during the influenza season.

Persons Aged 50-64 Years

Vaccination is recommended for persons aged 50-64 years because this group has an increased prevalence of persons with high-risk conditions. Persons aged 50-64 years without high-risk conditions also receive benefit from vaccination in the form of decreased rates of influenza illness, decreased work absenteeism, and decreased need for medical visits and medication, including antibiotics.

Persons Who Can Transmit Influenza to Those at High Risk

  • physicians, nurses, and other personnel in both hospital and outpatient-care settings, including emergency response workers
  • employees of nursing homes and chronic-care facilities who have contact with patients or residents
  • employees of assisted living and other residences for persons in groups at risk
  • persons who provide home care to persons in groups at high risk
  • household members (including children) of persons in groups at high risk


To read this letter and the list of groups to target for vaccination online in camera-ready (PDF format), go to:

To obtain the April 20, 2001, ACIP statement for influenza, go to:

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May 25, 2001

CDC published a Notice to Readers titled "Deferral of Routine Booster Doses of Tetanus and Diphtheria Toxoids for Adolescents and Adults" in the May 25, 2001, issue of Morbidity and Mortality Weekly Report (MMWR). The complete notice is reprinted below:


A shortage of tetanus and diphtheria toxoids (Td) and tetanus toxoid (TT) in the United States has resulted because one of two manufacturers discontinued production of tetanus toxoid-containing products. Aventis Pasteur (Swiftwater, Pennsylvania) is the only major manufacturer of tetanus and Td in the United States. In response to the shortage, Aventis Pasteur has increased production of Td to meet national needs; however, because 11 months are required for vaccine production, the shortage is expected to last for the remainder of 2001. To assure vaccine availability for priority indications, all routine Td boosters in adolescents and adults should be delayed until 2002. Td use should follow existing recommendations for all other indications, which include 1) persons traveling to a country where the risk for diphtheria is high; 2) persons requiring tetanus vaccination for prophylaxis in wound management; 3) persons who have received fewer than 3 doses of any vaccine containing Td; and 4) pregnant women who have not been vaccinated with Td during the preceding 10 years.

CDC recommends that health-care providers, including clinic personnel, record the names of patients whose booster dose is delayed during the shortage. When Td supplies are restored, these patients should be notified to return to their health-care provider for vaccination. According to Aventis Pasteur, sufficient vaccine will be available in early 2002 to supply the national demand.

Health-care providers using Td for wound management should follow recommendations from the Advisory Committee on Immunization Practices for wound management. All wound patients should receive Td if they have received fewer than 3 tetanus-containing vaccines or if vaccination history is uncertain. These patients also should receive tetanus immune globulin for wounds that are contaminated with dirt, feces, soil or saliva, puncture wounds, and avulsions and wounds resulting from missiles, crushing, burns or frostbite. For persons with more than 3 doses of TT-containing vaccine and severe or contaminated wounds, Td should be given only if more than 5 years have passed since the last dose of tetanus-containing vaccine. For clean and minor wounds, Td should be given only if the patient has not received a tetanus-containing vaccine during the preceding 10 years. Health-care providers should inquire from patients presenting for wound management about the timing of their last tetanus-containing vaccine to avoid unnecessary vaccination.

Pediatric formulations of diphtheria and tetanus toxoids (DT) and diphtheria and tetanus toxoids and acellular pertussis vaccine (DTaP) should not be used for persons aged 7 years or older. Although TT might be considered a substitute for Td in wound management when Td is not available, TT is not available for national distribution. Existing stocks of TT are extremely limited and are mainly reserved for production of tetanus immune globulin and other special circumstances.

Health-care providers and institutions requiring Td for priority indications should contact Aventis Pasteur, telephone (800) 822-2463 or (800) VACCINE. Institutions should place orders for their anticipated needs for priority indications only. Limiting quantities of vaccine in each order is necessary to assure the widest possible distribution of available vaccine. For emergency situations (e.g., natural disasters) requiring increased use of Td, Aventis Pasteur can provide vaccine within 24 hours.


To read the complete text of this notice online, go to:

To obtain a free email subscription to the MMWR, see the information following story five below.

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May 25, 2001

On May 15, 2001, the United States General Accounting Office (GAO) issued a report titled, "Flu Vaccine: Supply Problems Heighten Need to Ensure Access for High-Risk People." At the request of Congress, GAO looked at the production and distribution difficulties of influenza vaccine during the 2000-2001 flu season. The report explains how manufacturing problems caused temporary shortages and spikes in price, how current distribution of vaccine does not ensure priority to individuals at high risk for influenza, and what initiatives the U.S. Department of Health and Human Services has underway to prepare for future vaccine delays and shortages.

To obtain a copy of the report, go to: or call GAO's Document Distribution Center at (202) 512-6000 and request a copy of report number GAO-01-624 by mail.


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May 25, 2001

The Intercultural Cancer Council has issued a call for abstracts for its Biennial Symposium on Minorities, the Medically Underserved, and Cancer. The abstract deadline is June 15, and the symposium will take place February 6 to 10, 2002, at the Omni Shoreham Hotel in Washington, D.C.

Abstract and registration forms are available online at: or call (713) 798-5383.

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May 25, 2001

CDC published the following erratum in the May 25, 2001, issue of MMWR:


Vol. 50, No. 19
In the article, "Update: Syringe Exchange Programs--United States, 1998," on page 387, an error occurred in the fourth sentence of the last paragraph. It should read, "Assuring availability of sterile syringes for IDUs who continue to inject is only one component of a comprehensive approach to HIV prevention for IDUs."


To read the complete text of this erratum online, go to:

To obtain a free electronic subscription to the "Morbidity and Mortality Weekly Report" (MMWR), visit CDC's MMWR website at: Select "Free MMWR Subscription" from the menu at the left of the screen. Once you have submitted the required information, weekly issues of the MMWR and all new ACIP statements (published as MMWR's "Recommendations and Reports") will arrive automatically by e-mail.  

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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
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    Laurel H. Wood, MPA
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