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Issue Number 456            April 19, 2004


  1. New: CDC's latest video on vaccine storage and handling is available through NIP and IAC
  2. CDC recommends temporary suspension of adoptions from a Chinese orphanage in response to measles outbreak
  3. CDC reports on a 2003 measles outbreak in a Pennsylvania boarding school
  4. CDC briefly reports on continuing measles outbreak among adoptees from China
  5. CDC's new primer on diagnosing and managing foodborne illnesses includes information on hepatitis A virus
  6. Free: Bulk copies of the latest issue of "Vaccinate Adults!" (February 2004) are available--place your order now
  7. New: April issue of IAC's "HEP EXPRESS" electronic newsletter now available online
  8. New: Second edition of "Vaccinating Your Child: Questions & Answers for the Concerned Parent" has updated information
  9. CDC publishes hard copy of April 9 electronic article on the current measles outbreak among adoptees from China
  10. CDC reports on progress toward eliminating measles from the Americas during 2002-03
  11. CDC notifies readers about Vaccination Week of the Americas
  12. New translation: "Summary of Rules for Childhood and Adolescent Immunization" now in Turkish


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ABBREVIATIONS: AAFP, American Academy of Family Physicians; AAP, American Academy of Pediatrics; ACIP, Advisory Committee on Immunization Practices; CDC, Centers for Disease Control and Prevention; FDA, Food and Drug Administration; IAC, Immunization Action Coalition; MMWR, Morbidity and Mortality Weekly Report; NIP, National Immunization Program; VIS, Vaccine Information Statement; VPD, vaccine-preventable disease; WHO, World Health Organization.

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April 19, 2004

Produced by CDC in 2004, the 23-minute video "How to Protect Your Vaccine Supply" presents practical, up-to-date information on all aspects of vaccine storage and handling. The video covers temperature monitoring equipment, required documentation and record-keeping, storage and handling procedures, and action steps to take when a problem occurs.

ORDERING FROM NIP. You can order one copy from NIP free of charge. To order online, go to the online order form at The video is product number 00-6526. A BETA master tape is also available if you want to reproduce the video in bulk.

To order by phone, call the CDC Immunization Information Hotline at (800) 232-2522.

To play the video online, using Windows Media Player, go to:

ORDERING FROM IAC. You can order single or multiple copies from IAC for $15 per copy (discount pricing is available for orders of 20 or more). To order online, go to:

For additional information, contact IAC by email at or by phone at (651) 647-9009.

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April 19, 2004

On April 16, CDC issued both a Health Alert Network (HAN) message and an "MMWR Dispatch" relating to its recommendation to temporarily suspend adoptions from a Chinese orphanage in response to the current measles outbreak among adoptees. The HAN message is reprinted immediately below in its entirety. The "MMWR Dispatch" follows the HAN message.


[HAN message]
This is an official CDC HAN Info Service Message
April 16, 2004 9:14 PM ET


The Centers for Disease Control and Prevention (CDC) today recommended a temporary suspension of adoption proceedings for children from the Zhuzhou Child Welfare Institute in the Hunan Province of China, which is experiencing an outbreak of measles.

On April 6, 2004, public health officials in Seattle and King County, Washington, reported a laboratory-confirmed case of measles in a recently adopted child from China. An investigation identified measles-like rash illness in 9 of 12 children adopted by 11 families who traveled to China in March. Six of the 9 have laboratory-confirmed measles (

CDC is working with public health partners in China to implement control measures and prevent further spread of measles. The temporary suspension of adoption proceedings at the affected orphanage is recommended while control measures are implemented.

"Adopting children is such a wonderful experience for so many people," said CDC Director Dr. Julie Gerberding. "To make this experience as safe and healthy as possible for everyone, we ask prospective parents traveling internationally to adopt children to ensure that their and their family members' immunizations are current."

Recommendations for vaccination are

  • Children should receive two doses of measles vaccine at 12-15 months of age and at 4-6 years of age. (The second dose may be received at any age, as long as it is at least 28 days after the first dose.)
  • Adults born after 1956, who are at least 18 years of age, should receive at least one dose of vaccine unless they have had measles or been previously vaccinated.

The incubation period for measles ranges from 7-21 days. Adoptees and their families who returned from China more than 21 days ago and have not had contact with recent cases should not be at risk for measles.

Measles is a highly infectious viral illness that resides in mucus in the nose and throat of infected people. Droplets containing the virus are spread through the air by sneezing and coughing. The virus can remain active and contagious on infected surfaces for up to two hours.

CDC recommended a similar suspension in 2001 when an outbreak among children adopted internationally resulted in 14 U.S. measles cases, 10 among adopted children and four among caregivers and siblings.

For more information, the public should contact the CDC Public Inquiry hotline at (800) 311-3435 or (404) 639-3534.


["MMWR Dispatch" article]
CDC published "Update: Multistate Investigation of Measles Among Adoptees from China--April 16, 2004" in an April 16 issue of its electronic newsletter "MMWR Dispatch." The update is reprinted below in its entirety, excluding references.


CDC recently published information about six confirmed and three suspected cases of measles among children who were adopted in China. Preliminary investigation into the source of measles exposure among the recent U.S. adoptees has traced the presumed source of the outbreak to an orphanage in China where an outbreak of measles has been reported. While control measures are being implemented, CDC recommends that adoption proceedings of children from the affected orphanage be suspended temporarily.

The children departed for the United States with their families on March 26. Four of these children probably were infectious while traveling from China to the United States.

The Chinese Ministry of Health and the Central China Adoption Agency are aware of the problem and are investigating further. CDC is collaborating with these agencies and other partners in China to initiate measures to control and prevent further spread of measles among adopted children. The public health response to this outbreak is similar to the activities conducted after an outbreak of measles among adoptees from China in 2001.

Prospective parents who are traveling internationally to adopt children and their household contacts should ensure that they have a history of natural disease or have been vaccinated according to guidelines of the Advisory Committee on Immunization Practices. Prospective parents of international adoptees from China should stay informed as more information becomes available about the measles outbreak. Additional information about this outbreak and information for prospective parents adopting children internationally is available from CDC at


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

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

To receive a FREE electronic subscription to MMWR (which includes new ACIP statements), go to:

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April 19, 2004

CDC published "Measles Outbreak in a Boarding School--Pennsylvania, 2003" in the April 16 issue of MMWR. The article is reprinted below in its entirety, excluding one figure, one table, and references.


Measles has not been endemic in the United States since 1997, although limited outbreaks continue to be caused by imported cases. In 2003, CDC assisted in investigating the largest school outbreak of measles in the United States since 1998. The outbreak consisted of 11 laboratory-confirmed cases: nine cases in a boarding school in eastern Pennsylvania and two epidemiologically linked cases in New York City (NYC). This report summarizes the results of the outbreak investigation, which indicated that measles continues to be imported into the United States and that high coverage with 2 doses of measles-containing vaccine (MCV) among students was effective in limiting the size of the outbreak. Health care providers should maintain a high index of suspicion for measles, especially in those who have traveled abroad recently, and recommendations for 2 doses of MCV in all school-aged children should be followed.

In April 2003, the Pennsylvania Department of Health reported to CDC two cases of measles in unvaccinated twins aged 13 years in a boarding school with 663 students. Active surveillance for measles was conducted in the school, hospitals, and doctors' offices through May 2003. Patients were interviewed, acute- and convalescent-phase sera were collected for measles IgM enzyme-linked immunosorbent assay testing, and throat swabs and urine samples were collected for viral genotyping. Efforts to control the outbreak included vaccinating or excluding from campus and isolating all students and staff members with no evidence of immunity to measles. School and personal vaccination records were reviewed to identify susceptible students and staff members, respectively.

For evaluation of vaccine effectiveness, only students enrolled in the school at the beginning of the outbreak were included. All staff members and those students who received measles vaccination during the outbreak were excluded. Vaccine effectiveness (VE) was calculated as VE(%)=[(ARU-ARV)/ARU] x 100, where ARU is the attack rate in unvaccinated persons and ARV is the attack rate in students who had received 2 doses of MCV previously.

A total of 11 laboratory-confirmed cases of measles were identified. The source patient was a student aged 17 years who had received 2 doses of MCV. On March 15, 2003, the student had returned to the United States from Beirut, Lebanon, where measles was known to be circulating. He had cough and fever the following day and rash on March 21, when he visited an emergency department and was diagnosed with a viral exanthem. Upon returning to school, the patient stayed at the school health center before returning to his dormitory.

Five persons with laboratory-confirmed measles were linked epidemiologically to the source patient. These five included the unvaccinated twins who lived in the same dormitory, the dormitory houseparent, and two other students in different dormitories. One of these latter students infected two additional students in his dormitory and an unvaccinated child aged 13 months in NYC, who was linked epidemiologically to an unvaccinated immigrant aged 33 years, who was diagnosed with measles and who lived in the same apartment building. The ninth school patient was linked epidemiologically to, and might have been infected by, any one of five infected persons from different dormitories.

All nine measles cases in the school were confirmed serologically. Measles genotype D4 was identified in two school patients and the child in NYC. The last date of rash onset in a boarding school patient was April 15. No deaths or major complications were reported; two students with measles, who were unvaccinated because of religious exemptions, required hospitalization for dehydration.

The median age of the nine patients in the school was 17 years (range: 13-26 years). Of the nine, two had not received any doses of MCV, one had received 1 dose, and six had received 2 doses. Patients with 1 or 2 doses of MCV had milder illness than unvaccinated patients, including a shorter duration of rash (median: 5 days versus 10 days; p<0.05) and fewer days of school or work missed (median: 5 days versus 8 days; p<0.05).

Of the 663 students in the boarding school, eight (1.2%) students had never received any doses of MCV, 26 (3.9%) students had received 1 dose, and 629 (94.9%) students had received 2 doses before the outbreak. Thus, vaccine coverage for 2 doses was 94.9% and for >=1 dose was 98.8%. Vaccination with measles, mumps, and rubella vaccine was begun on April 3. Of the eight unvaccinated students, four had claimed religious or philosophical exemptions. Of these four students, two contracted measles, one was excluded from the school, and one was vaccinated during the outbreak. All of the remaining four unvaccinated students who did not claim any exemptions were vaccinated during the outbreak as well as other susceptible students and staff members.

Excluding five previously unvaccinated students who were vaccinated during the outbreak and two students who had 2 doses of MCV previously but were inadvertently revaccinated during the outbreak, the measles attack rate was 66.7% (two of three) among unvaccinated students and 1.0% (six of 627) among students who had received 2 doses of MCV. All vaccinees with 1 dose of MCV received a second dose during the outbreak; no measles cases were diagnosed among these students. VE was 98.6% among students who had received 2 doses of MCV.

Editorial Note:
Measles is rare in the United States, with only 42 confirmed cases in 2003, according to provisional data. The limited outbreak described in this report highlights both the success of the U.S. vaccination program and the continuing risk for imported measles despite a high immunity among the U.S. population. The last reported U.S. school outbreak occurred in 2000 and involved nine persons, including six high school students. Five of those six student patients had received only 1 dose of MCV, which was in compliance with state requirements at that time.

Before 1989, when the Advisory Committee on Immunization Practices recommended a routine 2-dose MCV schedule for school-aged children, larger measles outbreaks with >100 cases occurred in schools. All states but one now require 2 doses of MCV for children attending school. However, exemptions for religious or philosophical reasons are permitted in the majority of states, resulting in exemption for 0.6% of the nation's children. These children have a higher likelihood of acquiring and spreading measles than those who have been vaccinated.

In the outbreak described in this report, consistent with previous evaluations, 2 doses of MCV were highly effective in preventing the spread of measles, although a substantial number of exposed students, combined with a 1% failure rate among recipients with 2 doses, resulted in two generations of transmission in the school. Recipients of 2 doses of MCV had milder symptoms and shorter duration of illness than unvaccinated patients. Two unvaccinated students were hospitalized for dehydration, but none of the vaccinated students required hospitalization.

If an outbreak occurs, all persons whose illness is consistent with the definition for suspected measles should be tested for both measles IgM and measles virus by culture or reverse transcriptase polymerase chain reaction. A convalescent serum should be obtained if the acute IgM is negative. This investigation highlighted the importance of viral specimens to document importation from overseas, confirm spread of the same genotype to NYC, and provide continued evidence for the absence of endemic transmission in the United States.

This outbreak of measles was caused by importation; the source patient was infected in Lebanon. Although the patient had classic signs for the disease (e.g., fever, rash, cough, and coryza), measles was not diagnosed initially, and the outbreak was not recognized until two unvaccinated students were hospitalized. A history of recent travel outside the United States should raise suspicion for a diagnosis of measles in a patient with appropriate clinical signs, regardless of vaccination status.


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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April 19, 2004

CDC published "Brief Report: Update: Measles Among Adoptees from China--April 14, 2004" the April16 issue of MMWR. It updates a CDC report issued April 9. The article is reprinted below in its entirety, excluding a reference.


As of April 14, 2004, investigators had identified six confirmed and three suspected cases of measles among the 12 adoptees from China who departed for the United States on March 26. Three other children remain under observation by public health authorities. The latest confirmed cases of measles were in an adoptee aged 13 months who traveled to New York state and in an adoptee aged 12 months who traveled to Washington state.

Among the nine children with either confirmed or suspected measles, three had been considered infectious while traveling. A fourth child has been identified as potentially infectious during travel on the following commercial airline flights:

  • March 26, China Southern flight 327 from Guangzhou, China, to Los Angeles
  • March 27, Delta Airlines flight 484 from Los Angeles to Cincinnati
  • March 27, Delta Airlines flight 518 from Cincinnati to Washington, DC.

Persons on these flights who have fever and rash on or before April 17 should be evaluated for measles by a health care provider. Although the typical incubation period for measles from exposure to rash onset is approximately 10 days (range: 7-18 days), on rare occasions the incubation period can be as long as 19-21 days.

Other children adopted recently from China, not identified by this investigation, might have been exposed to measles and become potentially infectious. Health care providers should remain vigilant for measles among persons with febrile rash illness. Persons with suspected measles should be reported immediately to local public health officials.


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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April 19, 2004

CDC published "Diagnosis and Management of Foodborne Illnesses: A Primer for Physicians and Other Health Care Professionals" in the April 16 issue of "MMWR Recommendations and Reports." The primer has a section on acute hepatitis A, which includes a patient scenario and several sets of questions that lead the reader through diagnosis, treatment, transmission, prevention, and notification.

The preface to the primer is reprinted below, as are the hepatitis A patient scenario and essential questions from the question sets.


Foodborne illness is a serious public health problem. CDC estimates that each year 76 million people get sick, more than 300,000 are hospitalized, and 5,000 die as a result of foodborne illnesses. Primarily the very young, the elderly, and the immunocompromised are affected. Recent changes in human demographics and food preferences, changes in food production and distribution systems, microbial adaptation, and lack of support for public health resources and infrastructure have led to the emergence of novel as well as traditional foodborne diseases. With increasing travel and trade opportunities, it is not surprising that now there is a greater risk of contracting and spreading a foodborne illness locally, regionally, and even globally.

Physicians and other health care professionals have a critical role in the prevention and control of food-related disease outbreaks. This primer is intended to provide practical and concise information on the diagnosis, treatment, and reporting of foodborne illnesses. It was developed collaboratively by the American Medical Association, the American Nurses Association-American Nurse Foundation, CDC, the Food and Drug Administration's Center for Food Safety and Nutrition, and the United States Department of Agriculture's Food Safety and Inspection Service.

Clinicians are encouraged to review the primer and participate in the attached continuing medical education (CME) program. . . .

Acute Hepatitis A: A Patient Scenario
While working in an emergency room, you are asked to see a 31-year-old Asian-American woman who has had fever, nausea, and fatigue for the past 24 hours. She also reports dark urine and has had 3 light colored stools since yesterday. She has previously been healthy and has no previous history of jaundice. Her physical examination shows a low-grade fever of 100.6 degrees F/38.1 degrees C, faint scleral icterus, and hepatomegaly. Her blood pressure and neurologic exam are normal and there is no rash. Initial laboratory studies show an alanine aminotransferase (ALT) result of 877 IU/L, aspartate amino transferase (AST) enzyme levels of 650 IU/L, an alkaline phosphatase of 58 IU/L and a total bilirubin of 3.4 mg/dL. White blood cell count is 4.6, with a normal differential; electrolytes are normal; the blood urea nitrogen level is 18 mg/dL; and serum creatinine level is 0.6 mg/dL. Pregnancy test is negative.

She has no children, and her boyfriend is not ill. She has been in a monogamous relationship with her boyfriend for 2 years. She was born in the United States; her parents immigrated to the United States from Taiwan in the 1950s. She works as a food preparer for a catering business. She returned 4 weeks ago from a 1-week vacation in Mexico (Mexico City and nearby areas), where she stayed with her boyfriend in several hotels. She drank only bottled water but ate both cooked and uncooked food at numerous restaurants while in Mexico, and she visited a family friend and her 3 young children in a Mexico City suburb.

She did not receive hepatitis A vaccine or immune globulin before going on vacation. She is not sure if she has received hepatitis B vaccine. She has not gone camping or hiking and had no recent tick exposures. She has never used illicit drugs, drinks alcohol rarely, and has never received a transfusion. She is taking oral contraceptives but no other prescription medication, and took 500 milligrams of Tylenol once after onset of her current symptoms. She has a pet cat but no other animal exposures. She had chickenpox and mononucleosis during childhood.

[Essential questions]

  • What should be included in the differential diagnosis of acute hepatitis?
  • What additional information would assist with the diagnosis?
  • How does this information assist with the diagnosis?
  • What diagnostic tests are needed?
  • What is the diagnosis?
  • What treatment is indicated?
  • How is hepatitis A virus transmitted, and who is at risk for this disease?
  • How might this illness have been prevented?
  • What else needs to be done? . . . .


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

To access a ready-to-copy (PDF) version, go to:

The PDF version includes a free CDC-sponsored education activity that can be completed online or submitted by U.S. mail for CME, CEU, CNE, or CHES credit. Simply read the primer, answer the questions at the end, and follow instructions for submitting your answers.

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April 19, 2004

The Immunization Action Coalition (IAC) is giving away bulk copies (up to 50 per request) of the February 2004 issue of "VACCINATE ADULTS!"

If you have an immunization conference or an educational program coming up for adult medical specialists, this 12-page publication is an excellent item to distribute. The February issue includes three hepatitis resources and two practical pieces on storing and administering vaccines.

Because supplies are limited, it's best to make your request right away. The free copies go quickly. Sorry, we can mail orders only to addresses within the United States.

To request copies, fill out the online form on IAC's website:

You will be asked to supply the following information:

  • The number of copies you want (maximum 50)
  • A description of how you plan to use the copies
  • Your name and complete contact information, including mailing address, telephone number, and email address

For further information, please contact Robin VanOss by email at

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April 19, 2004

The April 15 issue of "HEP EXPRESS," an electronic newsletter published by IAC, is available online. Published since March 2003, "HEP EXPRESS" is intended for health and social service professionals involved in the prevention and treatment of viral hepatitis. The April 15 issue includes articles on the following:

  • Recommendations for hepatitis C screening
  • Hepatitis B PowerPoint presentations in English, Vietnamese, Korean, and Chinese
  • The Hepatitis B Foundation's new electronic newsletter
  • A comprehensive resource for starting hepatitis C support groups
  • Three upcoming conferences for health professionals and the public
  • Four new viral hepatitis prevention programs
  • Five recent journal articles related to viral hepatitis

To access the April 15 issue, go to:

To sign up for a free subscription to "HEP EXPRESS," go to:

To access previous issues of "HEP EXPRESS," go to:

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April 19, 2004

A resource for parents, the second edition of "Vaccinating Your Child: Questions & Answers for the Concerned Parent" addresses the medical, ethical, and legal issues parents need to know about to make informed decisions about individual vaccinations. It is written by Sharon G. Humiston, MD, MPH, and Cynthia Good.

Issued recently, the second edition updates the first edition, which was published in 2000. It includes the most current information on influenza, as well as sections on vaccine controversies and bioterrorism. It also reviews vaccines children may need as they grow older and the vaccines a family may need when traveling outside the United States.

Available in paperback, the book costs $14.95. Order it from your local bookstore or directly from the publisher, Peachtree Publishers, by email at or by phone at (800) 241-0113.

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April 19, 2004

CDC published "Multistate Investigation of Measles Among Adoptees from China--April 9, 2004" in the April 16 issue of MMWR. Originally published in the web-based "MMWR Dispatch," the article has not been available in hard-copy format until now.

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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April 19, 2004

CDC published "Progress Toward Measles Elimination--Region of the Americas, 2002-03" in the April 16 issue of MMWR. Portions of a summary made available to the press are reprinted below.


. . . . Enormous progress has been made toward eliminating endemic measles transmission in the Region of the Americas. The number of measles cases has declined from approximately 250,000 in 1990 to only 105 confirmed cases in six countries in 2003, the lowest ever number of reported cases in the region. There were 42 cases in the United States last year; 33 were importations from other countries, while the remaining nine cases were of unknown origin. Two of the measles cases in the United States resulted in deaths: a 13-year old male and a 75-year old man. These measles-associated deaths underscore the risks from importation of measles.


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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April 19, 2004

CDC published "Notice to Readers: Vaccination Week of the Americas, April 24-30, 2004" in the April 16 issue of MMWR. The article is reprinted below in its entirety.


During April 24-30, all 42 countries in the Region of the Americas will participate in Vaccination Week of the Americas (VWA). The objective is to vaccinate susceptible populations by improving access among underserved populations, keeping vaccination programs on the political agendas of countries in the Western Hemisphere, and promoting cooperation among countries in the region. By ensuring the vaccination of susceptible persons, health authorities will maintain measles-elimination programs in the region and support implementation of rubella and congenital rubella syndrome-elimination plans.

During VWA, surveillance gaps will be identified through active searches for unreported cases of measles, rubella, and acute flaccid paralysis. The target group to be vaccinated during this week is children aged <5 years who have incomplete vaccination series and adults, including women of childbearing age (WCBA), with no previous contact with the vaccination program. The total population to be vaccinated is estimated at 40 million persons. Countries with vaccination activities scheduled for 2004 will conduct these activities during VWA. Other countries of the region will intensify vaccination efforts among children aged <5 years and WCBA. Additional information is available from the Pan American Health Organization at


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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April 19, 2004

Updated in March 2004, the "Summary of Rules for Childhood and Adolescent Immunization" is now available in Turkish translation. IAC gratefully acknowledges Mustafa Kozanoglu, MD, and Murat Serbest, MD, for the translation.

To access a ready-to-copy (PDF) version of the Turkish translation, go to:

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 Disclaimer
ISSN 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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