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Issue Number 431            December 15, 2003


  1. CDC launches new influenza web section
  2. CDC's update on influenza activity for the 2003-04 season includes new recommendations for influenza prevention
  3. Standards for Adult Immunization Practices and Child and Adolescent Immunization Practices both available in journal-article format
  4. CDC requests information about acute encephalopathy associated with influenza virus infection in U.S. children
  5. Measles immunization campaigns in Iran and Turkey to reach 53 million children and young people
  6. IOM meeting on vaccines and autism set for February 9, 2004


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December 15, 2003

On December 10, the Centers for Disease Control and Prevention (CDC) consolidated information about influenza onto a new web section, "Influenza (Flu) Protect Yourself & Your Loved Ones" (

The well-designed main page has links to abundant information for the public and health care professionals. The subsection for the public is divided between information about the disease and information about protecting oneself and others from it. The subsection for professionals directs them to contacts for vaccine supply, information on prevention and control, and various government documents such as Vaccine Information Statements, Influenza Vaccine Bulletins, and pertinent recommendations from the Advisory Committee on Immunization Practices.

Several web pages keep the public and health professionals up to date on the status of the current influenza season. The "Flu Activity Update" includes a map depicting the spread of influenza across the country and a weekly report summarizing influenza activity. "What's New" has links to documents recently posted or updated on the flu website; these include Q&As about the disease, key facts about it, CDC recommendations for preventing it, and much more. "News and Highlights" includes links to pertinent MMWR articles, press releases, teleconferences, press conferences, and more.

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December 15, 2003

The Centers for Disease Control and Prevention (CDC) published "Update: Influenza Activity--United States, 2003-04 Season" in the December 12 issue of "Morbidity and Mortality Weekly Report" (MMWR). Portions of the article, including new recommendations for influenza prevention, are reprinted below.


Influenza began circulating in the United States unusually early this season, and influenza activity nationwide is expected to increase. Cases of severe disease, including deaths, have been reported in children. This report summarizes influenza activity in the United States during the weeks ending October 4- December 6, 2003. During the week ending December 6, influenza activity was reported to CDC as widespread in 24 states. The early season and the unusually high and persistent demand for vaccine have resulted in a decreasing supply of trivalent inactivated vaccine. Emphasis should be placed on vaccinating persons at high risk for complications from influenza, including healthy children aged 6-23 months. Healthy persons aged 5-49 years who wish to receive vaccine should consider being vaccinated with the intranasally administered live, attenuated influenza vaccine (LAIV), a substantial supply of which remains available. . . .

Reports of Severe Illness and Deaths

Pediatric cases. CDC has received reports of severe complications of influenza occurring in young infants, school-age children, and adolescents. Complications have included encephalopathy, seizures, dehydration with severe hypotension, respiratory failure requiring mechanical ventilation, and secondary bacterial pneumonia, including necrotizing pneumonia with community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA). Three deaths (an infant aged 20 months with underlying reactive airways disease, a previously healthy infant aged 22 months, and a previously healthy child aged 16 years) have been associated with secondary pneumonia caused by CA-MRSA. Other influenza-related deaths not related to CA-MRSA in children have occurred. Fatal cases reported to CDC are being investigated by local and state health authorities. Laboratory testing has confirmed influenza A virus infection in these fatal cases; antigenic characterization is pending. The vaccination status of the majority of the deceased children has not been determined.

Pregnant women. In Texas, 88 pregnant women had laboratory-confirmed influenza A infections. Symptoms included fever, cough, and profound sinus tachycardia (i.e., 150-170 beats per minute) that resolved subsequently. One patient required intensive care for bilateral pneumonia and myocarditis. Of the 88 patients, two (2.3%) had been vaccinated 2 and 10 days before admission, respectively. No influenza-associated maternal deaths occurred; one case of fetal loss occurred but was not attributed to maternal influenza infection. The majority of the 88 cases were associated with influenza A infection; however, influenza B viruses also were detected. . . .

Editorial Note:

Influenza seasons can vary substantially in terms of timing and pattern of onset, peaking, decline, and overall severity. In the United States, the 2003-04 influenza season began unusually early, with community activity first reported in early October, followed by continued spread of influenza activity during the weeks ending October 4-December 6. National activity levels have not yet peaked, and neither the duration of activity nor the season's eventual magnitude is known. As of December 6, influenza A (H3N2) viruses predominated in the United States, but different influenza viruses might predominate later in the season. Influenza seasons dominated by A (H3N2) viruses (e.g., those in 1996-97, 1997-98, and 1998-99) typically are associated with high levels of severe illness and deaths. No evidence exists to indicate that the A/Fujian-like viruses in circulation are more virulent than other influenza A (H3N2) viruses. However, reports of severe pediatric illnesses and deaths underscore the severe consequences that influenza infections can cause in children.

Cases of sudden death associated with influenza in previously healthy children also were reported in the United States during the 2002-03 season (CDC unpublished data, 2003). Although the pathophysiology of sudden deaths associated with influenza in children is unknown, atypical symptoms (e.g., abdominal pain, absence of fever, and mild respiratory symptoms) have been reported.

Encephalopathy is another severe and potentially under-recognized complication of influenza in children. One case so far this season has resulted in the death of a patient (CDC, unpublished data, 2003). Patients might report high fevers, seizures, headaches, abnormal mental status, and/or confusion and do not always exhibit classic influenza symptoms. Cases have been reported among young children and school-aged children, including adolescents. Suspected cases should be reported to CDC at telephone, (404) 639-0277 or (404) 639-2893; fax, (404) 639-3866; or e-mail, or

Although secondary bacterial pneumonia is a common complication of influenza infection, S. aureus typically occurs in a minority of such cases. Clinical and laboratory features of S. aureus pneumonia are similar to other types of community-acquired pneumonia. Clinicians should be aware that CA-RSA can be a cause of community-acquired pneumonia. Treatment for pneumonia after influenza infection should be guided by bacterial culture results when possible. Aspirin and other salicylate-containing medications should not be administered to children with fever and respiratory illness.

Pregnant women are at higher risk than nonpregnant women for having complications secondary to influenza. Pregnant women who will be in their second or third trimester during influenza season should be vaccinated against influenza.

CDC Recommendations To Prevent Influenza


  • Emphasis should be placed on targeting trivalent inactivated vaccine to persons at high risk for complications from influenza: healthy children aged 6–23 months, adults aged 65 years and older, pregnant women in their second or third trimester during influenza season, and persons aged 2 years and older with underlying chronic conditions.
  • Persons at high risk should be encouraged to search locally for vaccine if their usual health-care provider no longer has vaccine available.
  • All children at high risk, including those aged 6–23 months, who report for vaccination should be vaccinated with a first or second dose, depending on vaccination status. Doses should not be held in reserve to ensure that two doses will be available.
  • Next priority should be given to vaccinating those persons at greatest risk for transmission of disease to persons at high risk, including household contacts and health-care workers.
  • Healthy persons aged 5–49 years should be encouraged to be vaccinated with intranasally administered live, attenuated influenza vaccine.
  • Decisions about vaccinating healthy persons, including adults aged 50–64 years, with inactivated influenza vaccine should be made on a case-by-case basis, depending on local disease activity, vaccine coverage, feasibility, and supply.
  • Health departments should work with their health-care providers to reallocate influenza vaccine to health-care providers in need when possible.


  • Good respiratory hygiene should be encouraged, including cleaning of hands, and staying at home when symptomatic with fever and respiratory illness.


  • Antiviral medications with specific activity against influenza A viruses should be considered either for treatment or chemoprophylaxis for influenza A, especially in persons at high risk for complications from influenza.


To access a web-text (HTML) version of the complete article, go to:

To access a ready-to-copy (PDF) version of this issue of MMWR, go to:

Receive a FREE electronic subscription to MMWR (which includes new ACIP statements) by going to

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December 15, 2003

Published in the August 2003 issue of the "American Journal of Preventive Medicine," the article "Standards for Adult Immunization Practices" is available in PDF format on the Centers for Disease Control and Prevention (CDC) website at

Published in the October 2003 issue of "Pediatrics," the article "Standards for Child and Adolescent Immunization Practices" is available in PDF format on the "Pediatrics" website. Click here to view the article.

To access both standards from the CDC website, as well as explanatory information about them, go to:

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December 15, 2003

The Centers for Disease Control and Prevention (CDC) published "Notice to Readers: Request for Information About Acute Encephalopathy Associated with Influenza Virus Infection in U.S. Children" in the December 12 issue of "Morbidity and Mortality Weekly Report" (MMWR). The notice is reprinted below in its entirety, excluding references.


Since the mid-1990s, several hundred cases of acute encephalopathy have been reported in Japanese children with influenza virus infection. These cases have been characterized by fever and rapid onset of encephalopathy, resulting in a high frequency of neurologic sequelae and mortality. The majority of the children have had laboratory-confirmed evidence of influenza.

Reports of influenza-associated encephalopathy have been uncommon in the United States. To determine if a similar pattern is occurring in the United States, CDC is requesting information on any case meeting certain criteria. The criteria include a person aged less than 18 years with altered mental status or personality change lasting more than 24 hours and occurring within 5 days of onset of an acute febrile respiratory illness, laboratory or rapid diagnostic test evidence of acute influenza virus infection associated with the respiratory illness, and diagnosis of the condition in the United States. Cases meeting these criteria should be reported to CDC [telephone, (404) 639-0277 or (404) 639-2893; fax, (404) 639-3866; or e-mail, or].


To access a web-text (HTML) version of the complete article, go to:

To access a ready-to-copy (PDF) version of this issue of MMWR, go to:

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December 15, 2003

On December 9, UNICEF issued a press release announcing that Iran and Turkey have launched the largest, most ambitious measles campaigns in the world. The campaigns are expected to reach a combined total of 53 million children and young people within the next year. In addition, Iran will also introduce the rubella vaccine as a part of its immunization schedule for the first time.

To access the press release from the UNICEF website, go to:

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December 15, 2003

On February 9, 2004, the Immunization Safety Review Committee of the Institute of Medicine (IOM) will hold an information-gathering meeting on the topic Vaccines and Autism. The registration deadline is February 2, 2004. The committee is seeking input on the topic; the deadline for submitting input is January 16, 2004.

For information about the meeting and to register online, go to:

For additional information or to submit input, contact Amy Grossman at (202) 334-1361 or (202) 334-1342.

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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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