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Issue Number 473            August 2, 2004


  1. CDC reports on 2003 vaccination coverage levels among U.S. children ages 19-35 months
  2. August is National Immunization Awareness Month--download promotional materials from the NPI website
  3. CDC notifies readers of medical errors involving inadvertent administration of tetanus toxoid-containing vaccines
  4. Reminder: August 19 is the date for CDC's satellite broadcast "Immunization Update 2004"
  5. GLMA develops new hepatitis prevention materials for MSM
  6. July 28 issue of IAC's "HEP EXPRESS" electronic newsletter now available online
  7. Don't miss out: Register today for the National Conference on Immunization Coalitions
  8. September 10 is the registration deadline for CHOP's vaccine education symposium
  9. Update: "CDC Public Health Law News" electronic newsletter switches to weekly format


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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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August 2, 2004

CDC published "National, State, and Urban Area Vaccination Coverage Among Children Aged 19-35 Months--United States, 2003" in the July 30 issue of MMWR. A link to tables describing data collected during the 2003 National Immunization Survey will be given at the end of this "IAC EXPRESS" article.

Portions of the MMWR article are reprinted below.


Each annual birth cohort in the United States comprises approximately 4 million infants. Maintaining the gains in vaccination coverage achieved during the 1990s among these children poses a continuing challenge for public health practitioners. The National Immunization Survey (NIS) provides estimates of vaccination coverage among children aged 19-35 months for each of the 50 states and 28 selected urban areas. This report summarizes NIS results for 2003, which indicated substantial increases nationwide in coverage with =>1 dose of varicella vaccine (VAR) and =>3 doses of pneumococcal conjugate vaccine (PCV) and the highest coverage ever for all vaccines; however, wide variability in coverage continues among states and urban areas. Continued vigilance is needed to maintain high levels of coverage, and sustained efforts will be required to reduce geographic disparities in coverage. . . .

National vaccination coverage with =>1 dose of VAR increased from 80.6% (95% confidence interval [CI] = +/-0.9%) in 2002 to 84.8% (95% CI = +/-0.8%) in 2003. Coverage for =>3 doses of PCV increased from 40.9% (95% CI = +/-1.1%) in 2002 to 68.1% (95% CI = +/-1.0%) in 2003. Coverage for =>4 doses of PCV, reported for the first time in 2003, was 36.7% (95% CI = +/-1.1%). For all other vaccines and series, coverage increased in 2003 compared with 2002.

In 2003, substantial differences remained in estimated vaccination coverage among states. Estimated coverage with the 4:3:1:3:3 series ranged from 94.0% in Connecticut to 67.5% in Colorado. The range in coverage among the 28 urban areas was less than that among the states. Among the 28 urban areas, the highest estimated coverage for the 4:3:1:3:3 series was 88.8% in Boston, Massachusetts, and the lowest was 69.2% in Houston, Texas.

Editorial Note:

The findings in this report indicate that among U.S. children aged 19-35 months, estimated coverage with recommended vaccines was greater in 2003 than in 2002 and represented all-time highs. In addition, coverage for the two most recently recommended vaccines, VAR and PCV, increased substantially. The increases in coverage reflect ongoing progress toward achieving the 2010 national health objectives for childhood vaccinations (objectives 14-22 to 14-24). Notably, vaccine coverage for the fourth dose of diphtheria and tetanus toxoids and acellular pertussis (DTaP) vaccine continues to lag behind other vaccines in the 4:3:1:3:3 series, reducing the coverage percentage for the overall series.

Continued vigilance is needed to maintain high levels of coverage. Moreover, increasing coverage in areas where coverage is low remains a priority to reduce the risk for infection and ongoing transmission if disease is introduced. . . .


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:

To access NIS 2003 data tables from the CDC website, go to:

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

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August 2, 2004

This year, National Immunization Awareness Month is focused on the theme "Are you up-to-date? Vaccinate!" The National Partnership for Immunization (NPI) has developed a promotional kit with suggested activities, recommendations, and immunization information designed to involve parents, public health professionals, employers, and health care providers in efforts to raise immunization rates throughout the United States.

The materials include a poster, brochures, bookmarks, and stickers. To access them, go to:

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August 2, 2004

CDC published "Inadvertent Intradermal Administration of Tetanus Toxoid-containing Vaccines Instead of Tuberculosis Skin Tests" in the July 30 issue of MMWR. The article is reprinted below in its entirety, excluding references.


CDC and the Food and Drug Administration (FDA) have been notified about the potential for inadvertent administration of tetanus toxoid-containing vaccines (TTCVs) instead of tuberculin
purified protein derivative (PPD) (Tubersol, Aventis Pasteur, Swiftwater, Pennsylvania; Aplisol, Parkedale Pharmaceuticals, Rochester, Michigan) used for tuberculosis skin tests (TSTs). The Vaccine Adverse Event Reporting System (VAERS), a passive surveillance system jointly operated by CDC and FDA, detected clusters of medication errors in at least two states. These findings, along with another previously reported investigation involving the same error, suggest the need for health care providers to take additional steps to minimize the risk for inadvertent intradermal injections of TTCVs.

In April 2004, five reports of medication error involving tetanus toxoid (TT) from a health care provider were identified. Patients were vaccinated on three different dates; all experienced local reactions without complications. Another cluster reported to VAERS in June 2003 involved an undisclosed number of patients; a health care provider confused tetanus and diphtheria toxoids (Td) vaccine for adult use (adsorbed) with PPD and administered Td intradermally. Patients with adverse reactions to these administrations had skin reactions interpreted as positive TSTs, which resulted in treatment with isoniazid (INH). Review of the lot numbers on products thought to be PPD revealed they were Td. Affected patients were identified and retested with PPD; all TSTs were negative. INH was discontinued, and no adverse reactions were observed.

As of March 2004, approximately 100 patients had been identified in reports of TTCV administration instead of PPD. A total of 21 states have reported both clusters and single cases. Vaccines substituted mistakenly for PPD include Td (n = 13 reports), TT (n = 12), and diphtheria and tetanus toxoids, (DT) adsorbed (n = five). For reports of Td, TT, and DT, products involved included those manufactured by Aventis Pasteur and Wyeth (Collegeville, Pennsylvania) and vaccines from other unspecified manufacturers. CDC and FDA have initiated a full review of adverse events caused by inadvertent administration of vaccines and PPD products reported to VAERS and the FDA MedWatch Program. A preliminary review indicates that multiple vaccines other than TTCVs have been involved.

Similarities in packaging of PPD and TTCVs might have contributed to the medication errors. Both products require refrigeration and often are stored side by side. Lack of availability of Td in single-dose syringes, resulting in provider purchase of multiple-dose vials, was cited as a contributing factor to medication error in one cluster. Conversely, at least eight reports have been documented of inadvertent substitution for vaccine products, resulting in intramuscular administration of PPD (FDA, unpublished data, 2004).

Health care providers should consider ways to prevent vaccine misadministration. As more vaccines and combination products become available, the potential for medication errors might increase. Possible measures to prevent misadministration should include pharmacy dispensing of vaccines when feasible, physical separation of products, careful visual inspection and reading of labels, preparation of PPD for patient use only at time of testing, and improved record keeping of lot numbers of vaccines and other injectable products. Prevention of such errors through barcode scanning technology is the goal of a recent FDA rule requiring individual drug packages to have identifying barcodes. For health care facilities that possess such technology, package scanning could help prevent errors made during pharmacy dispensing of products or during vaccine or PPD administration. In addition, the Product Identification Guide for Routine Vaccines is a helpful resource for distinguishing commonly used vaccine products; the guide can be ordered from the California Department of Health Services, telephone (619) 594-5933. [IAC EXPRESS Editor's Note: the guide can also be ordered online at] Adverse events associated with inadvertent vaccine administration can be reported to VAERS at or by telephone, (800) 822-7967. Adverse events after PPD administration can be reported to the FDA MedWatch program at or by telephone, (800) 332-1088.


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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August 2, 2004

The live satellite broadcast and webcast "Immunization Update 2004" will provide up-to-date information on the rapidly changing field of immunization. Following is the anticipated course content: new recommendations for influenza vaccine, including routine vaccination of children ages 6-23 months and expanded use of live attenuated intranasal vaccine; pneumococcal conjugate vaccine shortage; varicella vaccine; and vaccine safety issues.

Sponsored by CDC, the live broadcast is scheduled for August 19 from 9AM to 11:30AM ET. It will be rebroadcast later in the day from noon to 2:30PM ET. Both broadcasts will feature a live Q&A session in which participants nationwide can interact with the course instructors via toll-free telephone lines.

The course instructors are William L. Atkinson, MD, MPH; Donna Weaver, MN, RN; Sharon Roy, MD, MPH; and Andrew Kroger, MD, MPH. All are with the CDC's National Immunization Program.

The program's intended audience includes physicians, nurses, nurse practitioners, physician assistants, Department of Defense paraprofessionals, pharmacists, and their colleagues who either administer vaccines or set policy for their offices, clinics, or communicable disease or infection control programs. Private and public health care providers, including pediatricians, family physicians, residents, and medical and nursing students are encouraged to participate.

You DO NOT need to register to participate in the webcast. ONLINE REGISTRATION IS REQUIRED TO RECEIVE CONTINUING EDUCATION CREDITS. To register, go to:

Pharmacists can earn continuing education credit through their own online learning system. To register, pharmacists should go to:

For additional information, go to, email or call (800) 418-7246.

The program will have a live webcast at

For technical support and to prepare for the webcast ahead of time, go to:

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August 2, 2004

[The following is cross posted from the Immunization Action Coalition's "HEP EXPRESS" electronic newsletter, 7/28/04.]

The Gay & Lesbian Medical Association (GLMA) has developed a new brochure and matching poster to prevent vaccine-preventable hepatitis (VPH) in men who have sex with men (MSM). These glossy, full-colored materials are stylish and eye-catching.

The lead-in message states "Vaccine-preventable hepatitis (VPH) is... joint pain, nausea, fever, loss of appetite, liver cancer, death, extreme tiredness, headache, yellow skin, dark urine, yellow eyes, bloated stomach... vaccine preventable." The brochure clearly explains the risk factors for hepatitis A and hepatitis B, and the vaccination options.

The MSM educational materials are available from GLMA free of charge by sending an email to or calling GLMA at (415) 255-4547. Brochures are packaged in sets of ten; posters individually. Please provide a complete mailing address and phone number.

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August 2, 2004

The July 28 issue of "HEP EXPRESS," an electronic newsletter published by IAC, is now available online. "HEP EXPRESS" is intended for health and social service professionals involved in the prevention and treatment of viral hepatitis. The July 28 issue includes articles on the following:

  • Two online physician resources: a guide to chronic hepatitis B treatment and a CME course on current issues in hepatitis B
  • New hepatitis prevention materials for men who have sex with men (see article #5 above)
  • The 2004 "Answer to Cancer" fund-raising race in support of the Asian Liver Center, Hepatitis B Foundation, American Liver Foundation, and MD Anderson Cancer Center
  • The Summer 2004 issue of the Hepatitis B Foundation's newsletter, "B Informed"
  • New online resources posted on the Viral Hepatitis Prevention Board's website

To access the July 28 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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August 2, 2004

The National Conference on Immunization Coalitions will be held September 20-22 in Norfolk, VA. Leaders of immunization coalitions well meet to discuss resources for funding, models of coalition activities to increase community awareness and immunization rates, information on how to advocate for legislative change, and more.

This year's conference theme is "Chart Your Coalition's Course for Norfolk." It sums up the conference's primary goal, which is to provide training in creating, leading, and sustaining effective local and state coalitions that address childhood, adolescent, and adult immunization. This year's program will also focus on coalitions as agents of social change, elements of successful coalitions, and social and ethnic diversity in coalitions.

Physicians, nurses, community-based health care providers, health educators, social workers, managed care organizations, grass roots community-based organizations, and individuals are encouraged to participate, even if immunization is not the focus of their health coalition work.

For comprehensive information on the conference, including the conference brochure, go to:

To register online, go to:

For additional information, email or call (888) 873-2674, press "2," and reference the Immunization Conference.

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August 2, 2004

The Vaccine Education Center at the Children's Hospital of Philadelphia (CHOP) will host its fourth annual Vaccine Education Symposium on September 18 in Philadelphia. The registration deadline is September 10.

The one-day course will focus on the health of the U.S. vaccine infrastructure in light of recent vaccine shortages, new vaccines, practical considerations for administering influenza vaccine in an office-based setting, and the value and limitations of meningococcal vaccination of all adolescents.

The faculty includes Paul A. Offit, MD, Vaccine Education Center at CHOP; Walter A. Orenstein, MD, Emory Vaccine Center, Atlanta; Emilio Emini, PhD, International AIDS Vaccine Initiative, New York; Bruce Gellin, MD, National Vaccine Program Office, Washington, DC; and Michael Torrence, MD, Children's Medical Associates, Ridley Park, PA.

To access a camera-ready (PDF) copy of the symposium brochure, go to:

Registration is required. To register online, go to:

For additional information or to have the symposium brochure mailed to you, contact Glorene Ford by email at or by phone at (215) 590-5263.

To visit the Vaccine Education Center website, go to:

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August 2, 2004

Begun as a daily in July 2003, the "CDC Public Health Law News" electronic newsletter is now being distributed on a weekly basis. Published by the CDC Public Health Law Program, the newsletter is intended for persons who wish to keep up with developments in public health law, regulation, legislation, and related topics.

The newsletter contains abstracts of current news stories on public health law and related subjects; announcements from publications related to public health law, conferences, Congressional hearings, and other events; a news quotation of the day; and other timely material.

For a free subscription, go to:

To access the most recent issue or search back issues, visit the CDC Public Health Law Program web site at

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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