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Issue Number 320            June 24, 2002


  1. ACIP approves post-9/11 recommendations on the use of smallpox vaccine
  2. CDC publishes notice on replenished Td supply
  3. New interim MMR Vaccine Information Statement is now available
  4. Revised! IAC's "Summary of Rules for Childhood Immunization"
  5. CDC reports on polio eradication in Pakistan and Afghanistan
  6. CDC announces National HIV Testing Day on June 27


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June 24, 2002

On June 20, 2002, one year after issuing general smallpox (vaccinia) vaccine recommendations, the Advisory Committee on Immunization Practices (ACIP) responded to the events of September 11, 2001, by voting to approve new "supplemental" recommendations on the use of smallpox (vaccinia) vaccine.

The Centers for Disease Control and Prevention (CDC) has posted a six-page document explaining the supplemental recommendations on its website. The sections of the document are: Introduction, Smallpox transmission and control, Critical considerations, Smallpox vaccines and VIG [vaccinia immune globulin] availability, Surveillance, and Recommendations.

The first paragraph of the Introduction reads as follows (Note: specific wording in this document is subject to minor change on CDC's website over the next few days):


In June 2001, the Advisory Committee on Immunization Practices (ACIP) made recommendations for use of smallpox (vaccinia) vaccine to protect persons working with Orthopoxviruses, to prepare for a  possible bioterrorism attack and respond to an attack involving smallpox. Because of the terrorist attacks in the fall of 2001, the Centers for Disease Control and Prevention (CDC) asked the ACIP to review  their previous recommendations for smallpox (vaccinia) vaccination. As a result of this review, these supplemental recommendations update those for vaccination of 1) the general population and 2) persons designated to respond or care for a suspected or confirmed case of smallpox. In addition, they clarify and expand the primary strategy for control and containment of smallpox in the event of an outbreak.


The complete Recommendations section reads as follows:



Under current circumstances, with no confirmed smallpox, and the risk of an attack assessed as low, vaccination of the general population is not recommended, as the potential benefits of vaccination do not outweigh the risks of vaccine complications.

Recommendations regarding pre-outbreak smallpox vaccination are being made on the basis of an assessment that considers the risks of disease and the benefits and risks of vaccination. The live smallpox (vaccinia) vaccine virus can be transmitted from person to person. In addition to sometimes causing adverse reactions in vaccinated persons, the vaccine virus can cause adverse reactions in the contacts of vaccinated persons. It is assumed that the risk of serious adverse events with currently  available vaccines would be similar to those previously observed and could be higher today due to the increased prevalence of persons with altered immune systems.


Smallpox Response Teams

Smallpox vaccination is recommended for persons pre-designated by the appropriate bioterrorism and public health authorities to conduct investigation and follow-up of initial smallpox cases that would  necessitate direct patient contact.

To enhance public health preparedness and response for smallpox control, specific teams at the federal, state and local level should be established to investigate and facilitate the diagnostic work-up of the initial suspect case(s) of smallpox and initiate control measures. These Smallpox Response Teams might include persons designated as medical team leader, public health advisor, medical epidemiologists, disease investigators, diagnostic laboratory scientist, nurse vaccinators, and security/law enforcement personnel. Such teams may also include medical personnel who would assist in the evaluation of suspected smallpox cases.

The ACIP recommends that each state and territory establish and maintain at least one Smallpox Response Team. Considerations for additional teams should take into account population and geographic considerations and should be developed in accordance with federal, state, and local bioterrorism plans.

Designated Smallpox Healthcare Personnel at Designated Hospitals

Smallpox vaccination is recommended for selected personnel in facilities pre-designated to serve as referral centers to provide care for the initial cases of smallpox. These facilities would be pre-designated  by the appropriate bioterrorism and public health authorities, and personnel within these facilities would  be designated by the hospital.

As outlined in the CDC Interim Smallpox Response Plan and Guidelines, state bioterrorism response plans should designate initial smallpox isolation and care facilities (e.g., type C facilities). In turn, these  facilities should pre-designate individuals who would care for the initial smallpox cases. To staff augmented medical response capabilities, additional personnel should be identified and trained to care for smallpox patients.

Implementation of Recommendations

The ACIP recognizes that the implementation of the supplemental recommendations presented in this document requires addressing a number of issues, and that this will take time. The issues include  provider and public education, health care provider training, availability of vaccine and VIG [vaccinia immune globulin], developing the appropriate investigational new drug protocols, screening, strategies to minimize vaccine wastage, vaccine adverse event surveillance, and other logistical and administrative issues.


To read the entire CDC document about the new supplemental smallpox recommendations, go to:

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June 24, 2002

On June 21, 2002, the Centers for Disease Control (CDC) published "Notice to Readers: Resumption of Routine Schedule for Tetanus and Diphtheria Toxoids" in the Morbidity and Mortality Weekly Report (MMWR).

The complete text of the Notice reads as follows:


The supply of adult tetanus and diphtheria toxoids (Td) in the United States has become sufficient to permit the resumption of the routine schedule for Td use as recommended by the Advisory Committee on Immunization Practices. Adolescents and adults for whom routine Td booster doses were deferred  should be recalled by their health-care providers to receive the delayed dose. School attendance provisions requiring students to have received a Td booster at age >11 years can be reinstituted.

The Td shortage began in the last quarter of 2000 and resulted from 1) decreased production in 2000 by both U.S. manufacturers (Wyeth Lederle [Pearl River, New York] and Aventis Pasteur [Swiftwater, Pennsylvania]), 2) the decision by Wyeth Lederle to cease Td production in 2001, and 3) the 11-month period required for vaccine production, which led to a lag before increased Td supplies were available from the remaining manufacturer distributing vaccine nationally (Aventis Pasteur). The amount of Td distributed nationally decreased 40% during 2001-2002, compared with preshortage distribution levels (Biological Surveillance System, unpublished data, 2002). To ensure vaccine availability for priority indications, CDC recommended in May 2001 that all routine Td boosters in adolescents and adults be deferred and that health-care providers record the names of patients whose booster doses were delayed for call-back once Td supplies are restored. Health-care providers should review the  vaccination status of their patients and administer Td and other indicated vaccines as appropriate.


To obtain the complete text of the article online, go to:

To obtain a camera-ready (PDF format) copy of this issue of MMWR, 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 email.

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June 24, 2002

The Centers for Disease Control and Prevention (CDC) has issued a new interim Vaccine Information Statement (VIS) for Measles-Mumps-Rubella (MMR) vaccine. Dated 6/13/02, this VIS replaces the previous one, dated 12/16/98.

The interim MMR VIS reflects the recent reduction in the recommended waiting period for women to  become pregnant after receiving MMR vaccine. Previously, women were advised not to become pregnant for 3 months after receiving MMR vaccine; now women are advised not to become pregnant within 4 weeks of receiving MMR vaccine. (For more information on this waiting-period recommendation change, see the December 14, 2001 issue of MMWR at

To obtain a copy of the interim MMR VIS in camera-ready (PDF) format, use either the following links:

To obtain copies of all other VISs, including some in up to 27 languages, visit IAC's website at:

IAC's website also has links to CDC instructions on how to use VISs and their legal requirements. For  "Vaccine Information Statements: What You Need to Know," go to:

For "Instructions for Use of Vaccine Information Statements," go to:

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June 24, 2002

The Immunization Action Coalition (IAC) has incorporated the most current guidelines for vaccinating children in the widely used two-sided chart, "Summary of Rules for Childhood Immunization."

Officially revised on June 2, 2002, the chart now includes language on the new recommendation to  encourage influenza vaccination for young children (aged 6-23 months) when feasible; a reminder to consult "The Red Book" regarding hepatitis B vaccination of preterm infants; and the meningococcal vaccination recommendation for young children with risk factors as well as the recommendation to discuss meningococcal disease, risk, and vaccine with college students. (This piece was last updated in March 2002 to reflect the shorter recommended waiting period to become pregnant following MMR vaccination.) The layout of the new "Summary of Rules for Childhood Immunization" has also been modified to accommodate the additional information.

To obtain a copy of the new "Summary of Rules for Childhood Immunization," go to:

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June 24, 2002

On June 21, 2002, the Centers for Disease Control and Prevention (CDC) published "Progress Toward Poliomyelitis Eradication--Pakistan and Afghanistan, January 2000-April 2002" in the Morbidity and  Mortality Weekly Report (MMWR). According to the article, "Both countries aim to stop transmission of poliovirus by the end of 2002; however, the unstable security situation in the region might threaten this success."

The Editorial Note reads in part as follows:


Pakistan and Afghanistan constitute a single epidemiologic block representing one of the three remaining major global reservoirs for poliovirus transmission (the other two being northern India and Nigeria). . . .

Although armed conflict in Afghanistan has posed many challenges to surveillance and vaccination activities, data from January-April 2002 indicate that progress toward eradication has resumed. The improved quality of SIAs [supplemental immunization activities] and the addition of targeted SNID [subnational immunization day] rounds in Afghanistan before September 2001 appear to have prevented a widespread resurgence of poliovirus in the country during the recent conflict. Despite continuing military and political instability, public health staff in Afghanistan and Pakistan succeeded in implementing NIDs in late September and November and continued essential surveillance activities. . . .

In Afghanistan, the new interim administration is committed to polio eradication, and in Pakistan, political commitment from the newly formed district governments to the federal government is high. Close collaboration between local governments and their global partners has been critical in sustaining eradication activities in both countries and will continue to be essential to achieve polio eradication.


To obtain the complete text of the article online, go to:

To obtain a camera-ready (PDF format) copy of this issue of MMWR, go to:

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June 24, 2002

The Centers for Disease Control and Prevention (CDC) announced in a Notice to Readers in the June  21, 2002, issue of Morbidity and Mortality Weekly Report (MMWR) that Thursday, June 27 is National HIV Testing Day.

The complete text reads as follows:


The National Association of People with AIDS will sponsor the eighth annual National HIV Testing Day on June 27. Testing Day is a nationwide campaign promoting human immunodeficiency virus (HIV)  education and voluntary HIV counseling, testing, and referral to encourage persons at risk for HIV infection to know their status and to reduce their risks for HIV transmission.

Public health departments and other partners are encouraged to support community HIV education and  testing efforts during June 23--29. Activities can include sponsoring mobile HIV counseling, testing, and  referral units; participating in health fairs at which HIV education, counseling, testing, and referral services are offered; and partnering with local media to promote HIV prevention and testing messages.

Additional information about HIV counseling, testing, and referral services is available at


To obtain the complete text of the article online, go to:

To obtain a camera-ready (PDF format) copy of this issue of MMWR, go to:

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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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