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Issue Number 475            August 16, 2004


  1. CDC Health Update contains information and recommendations on the current avian influenza A situation
  2. CDC reports on studies assessing the effectiveness of the 2003-04 influenza vaccine in Colorado
  3. JAMA publishes study showing varicella vaccine effective in preventing disease
  4. CDC reports on US measles epidemiology during 2001-03
  5. CDC seeks public's comments on its vaccine safety program
  6. Michigan has distributed 300,000 adult immunization record cards--IAC urges you to distribute them, too!
  7. Updated: IAC revises educational pieces on vaccine storage and handling--just in time for influenza vaccination season
  8. Coming this week: August 19 is the date for CDC's satellite broadcast "Immunization Update 2004"
  9. Act now: August 20 is the deadline for early-bird registration for the Immunization Registry Conference


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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 16, 2004

On August 12, CDC issued an official CDC Health Update on avian influenza A (H5N1). It is reprinted below in its entirety.


This is an official CDC Health Update
Distributed via Health Alert Network
August 12, 2004, 18:21 EDT (06:21PM EDT)


This update reviews the current situation and the surveillance and diagnostic recommendations for avian influenza A (H5N1). The recommendations for avian influenza A (H5N1) remain at the enhanced level established in February 2004. As detailed in the recommendations below, vigilance in the clinical setting for avian influenza (H5N1) requires that health care providers consistently obtain international travel and other exposure risk information for persons who have specified respiratory symptoms.

Current Situation

On August 12, 2004, the Vietnamese Ministry of Health officially reported to the World Health Organization (WHO; see three human deaths from confirmed avian influenza H5 infection. Additional tests are needed to determine whether the virus belongs to the same H5N1 strain that caused 22 cases (15 deaths) in Vietnam and 12 cases (8 deaths) in Thailand earlier this year.

Cambodia, China, Indonesia, Japan, Laos, South Korea, Thailand, and Vietnam were previously affected by widespread H5N1 outbreaks in poultry during early 2004. At that time, more than 100 million birds either died from the disease or were culled (killed) in efforts to contain the outbreaks. Human cases (34 in all) were reported only in Thailand and Vietnam. The last case officially confirmed and reported to WHO by Vietnam occurred in February 2004.

Beginning in late June 2004, however, new lethal outbreaks of highly pathogenic avian influenza A (H5N1) among poultry were reported to the World Organization for Animal Health (OIE) by China, Indonesia, Thailand, and Vietnam. The deaths reported by Vietnam on August 12 are the first reported human cases associated with this second wave of H5N1 infection among poultry. CDC is in communication with WHO and will continue to monitor the situation.

Enhanced U.S. Surveillance, Diagnostic Evaluation, and Infection Control Precautions for Avian Influenza A (H5N1)

CDC recommends maintaining the enhanced surveillance efforts by state and local health departments, hospitals, and clinicians to identify patients at increased risk for avian influenza A (H5N1) that were issued by CDC on February 3, 2004 (see Guidelines for enhanced surveillance are:

Testing for avian influenza A (H5N1) is indicated for hospitalized patients with:

  1. Radiographically confirmed pneumonia, acute respiratory distress syndrome (ARDS), or other severe respiratory illness for which an alternate diagnosis has not been established, AND
  2. History of travel within 10 days of symptom onset to a country with documented H5N1 avian influenza in poultry and/or humans (for a regularly updated listing of H5N1-affected countries, see the OIE website at and the WHO website at

Testing for avian influenza A (H5N1) should be considered on a case-by-case basis in consultation with state and local health departments for hospitalized or ambulatory patients with:

  1. Documented temperature of >38蚓 (>100.4蚌), AND
  2. One or more of the following: cough, sore throat, shortness of breath, AND
  3. History of contact with poultry (e.g., visited a poultry farm, a household raising poultry, or a bird market) or a known or suspected human case of influenza A (H5N1) in an H5N1-affected country within 10 days of symptom onset.

Infection control precautions for H5N1 remain unchanged from the CDC interim recommendations published on February 3, 2004 These recommendations are further described in the CDC guidance document "Interim Recommendations for Infection Control in Health Care Facilities Caring for Patients with Known or Suspected Avian Influenza"

Laboratory Testing Procedures

Highly pathogenic avian influenza A (H5N1) is classified as a select agent and must be worked with under Biosafety Level (BSL) 3+ laboratory conditions. This includes controlled access double door entry with change room and shower, use of respirators, decontamination of all wastes, and showering out of all personnel. Laboratories working on these viruses must be certified by the U.S. Department of Agriculture. CDC does not recommend that virus isolation studies on respiratory specimens from patients who meet the above criteria be conducted unless stringent BSL 3+ conditions can be met. Therefore, respiratory virus cultures should not be performed in most clinical laboratories and such cultures should not be ordered for patients suspected of having H5N1 infection.

Clinical specimens from suspect A (H5N1) cases may be tested by PCR [polymerase chain reaction] assays using standard BSL 2 work practices in a Class II biological safety cabinet. In addition, commercial antigen detection testing can be conducted under BSL 2 levels to test for influenza.

Specimens from persons meeting the above clinical and epidemiologic criteria should be sent to CDC if

  • The specimen tests positive for influenza A by PCR or by antigen detection testing, OR
  • PCR assays for influenza are not available at the state public health laboratory.

Because the sensitivity of commercially available rapid diagnostic tests for influenza may not always be optimal, CDC also will accept specimens from persons meeting the above clinical criteria even if they test negative by influenza rapid diagnostic testing if PCR assays are not available at the state laboratory.

Requests for testing should come through the state and local health departments, which should contact (404) 639-3747 or (404) 639-3591 and ask for the epidemiologist on call before sending specimens for influenza A (H5N1) testing.

Additional Avian Influenza A (H5N1) Information


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August 16, 2004

CDC published "Assessment of the Effectiveness of the 2003-04 Influenza Vaccine Among Children and Adults--Colorado, 2003" in the August 13 issue of MMWR. Portions of the article and its Editorial Note are reprinted below.


[The article's opening paragraph]
The 2003-04 influenza season was characterized by the early onset of influenza activity, reports of severe illness, particularly in children, and predominant circulation of an influenza A (H3N2) virus strain that was antigenically different from the influenza A (H3N2) vaccine strain. In 2003, a retrospective cohort study among children and a case-control study among adults in Colorado were conducted to provide preliminary data on the effectiveness of the 2003-04 influenza vaccine. This report summarizes the results of those studies, which indicated vaccine effectiveness (VE) among both adults and children, differing from results of a previous study that did not indicate effectiveness among adults. . . .

[From the article's Editorial Note]
The findings from the two studies indicated that the influenza vaccine had some effectiveness (25%-49% against nonlaboratory-confirmed influenza and 38%-52% against laboratory-confirmed influenza) in preventing illness during the 2003-04 influenza season, supporting recommendations to continue influenza vaccination efforts despite a suboptimal match between the predominant influenza A (H3N2) circulating and vaccine strains. The effectiveness of the inactivated influenza vaccine against laboratory-confirmed illness among healthy adults aged <65 years is expected to be 70%-90% in years when the vaccine and circulating strains are well matched. The estimated 52% VE against laboratory-confirmed influenza among adults with no high-risk conditions in this study was lower, but still provided substantial health benefit. The study among children aged 6-23 months provides further data that 2 doses of vaccine (i.e., a dose of the current vaccine plus a primer dose) are needed to optimize protection compared with a single dose.

Results from these studies differ from those of a study of health care workers that did not find the 2003-04 influenza vaccine to be effective against ILI [influenza-like illness]. However, the health care worker study might have had an insufficient number of subjects to detect low effectiveness against ILI compared with the pediatric ILI study, which included approximately three times as many subjects in a population expected to have a higher influenza illness attack rate than adults. In addition, the more specific outcome of medically attended, laboratory-confirmed influenza used in the case-control study of persons aged 50-64 years was more likely to find effectiveness, compared with the less influenza-specific ILI outcome used in the health care worker study. . . .

Influenza vaccine remains the primary means for the prevention of influenza and its complications and can provide benefit even in years when the influenza vaccine and circulating strains are not matched optimally. Efforts to increase vaccination rates in groups at high risk and their contacts are needed to reduce the burden of influenza. In addition, vaccination with 2 doses of influenza vaccine for children not vaccinated previously against influenza is needed to maximize protection. For optimal assessment of influenza VE, prospective studies should be conducted annually.


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

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August 16, 2004

On August 11, the Journal of the American Medical Association (JAMA) published "Contagiousness of Varicella in Vaccinated Cases: A Household Contact Study." The article concluded in part that "Under conditions of intense exposure, varicella vaccine was highly effective in preventing moderate and severe disease and about 80% effective in preventing all disease." The article abstract is reprinted below.


Context: Limited data are available on the contagiousness of vaccinated varicella cases.

Objectives: To describe secondary attack rates within households according to disease history and vaccination status of the primary case and household contacts and to estimate varicella vaccine effectiveness.

Design, Setting, and Patients: Population-based, active varicella surveillance project in a community of approximately 320,000 in Los Angeles County, California, during 1997 and 2001. Varicella cases were reported by childcare centers, private and public schools, and health care clinicians and were investigated to collect demographic, clinical, medical, and vaccination data. Information on household contacts' age, varicella history, and vaccination status was collected.

Main Outcome Measures: Varicella secondary attack rate among household contacts; vaccine effectiveness using secondary attack rates in unvaccinated and vaccinated children and adolescents.

Results: A total of 6,316 varicella cases were reported. Among children and adolescents aged 1 to 14 years, secondary attack rates varied according to age and by disease and vaccination status of the primary case and exposed household contacts. Among contacts aged 1 to 14 years exposed to unvaccinated cases, the secondary attack rate was 71.5% if they were unvaccinated and 15.1% if they were vaccinated (risk ratio [RR], 0.21; 95% confidence interval [CI], 0.15-0.30). Overall, vaccinated cases were half as contagious as unvaccinated cases. However, vaccinated cases with 50 lesions or more were similarly contagious as unvaccinated cases, whereas those with fewer than 50 lesions were only one-third as contagious (secondary attack rate, 23.4%; RR, 0.32 [95% CI, 0.19-0.53]). Vaccine effectiveness for prevention of all disease was 78.9% (95% CI, 69.7%-85.3%); moderate disease, 92% (50-500 lesions) and 100% (clinician visit); and severe disease, 100%.

Conclusions: Under conditions of intense exposure, varicella vaccine was highly effective in preventing moderate and severe disease and about 80% effective in preventing all disease. Breakthrough varicella cases in household settings were half as contagious as unvaccinated persons with varicella, although contagiousness varied with numbers of lesions.


To access the abstract, go to:

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August 16, 2004

CDC published "Epidemiology of Measles--United States, 2001-2003" in the August 13 issue of MMWR. The article's opening paragraph is reprinted below.


Measles is a highly infectious, acute viral illness that can cause severe pneumonia, diarrhea, encephalitis, and death. To characterize the epidemiology of measles in the United States during 2001-2003, CDC analyzed data reported by state and local health departments. This report summarizes the results of that analysis, which indicated that no endemic measles virus is circulating in the United States; however, imported measles cases continue to occur and can result in limited indigenous transmission. Maintaining immunity through high vaccination coverage levels is essential to limit the spread of measles from imported cases and prevent measles from becoming endemic.


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 16, 2004

CDC published "Notice to Readers: Public Comment Sought on CDC's Vaccine Safety" in the August 13 issue of MMWR. It is reprinted below in its entirety.


In consultation with outside stakeholders, the CDC has undertaken a review of vaccine safety activities at CDC. As part of this effort, the CDC is seeking public comments regarding the current state of the agency's vaccine safety program and to identify ways in which excellence in vaccine safety monitoring, research, and communication can be maximized and sustained in the future. Comments should focus on the objectives listed below:

  1. Review the structure, function, credibility, effectiveness, efficiency, and support of CDC's vaccine safety program and assess how it can be maximized and sustained.
    • Assess the program's ability to detect emerging or rare adverse events.
    • Assess the capacity of the program to provide comprehensive monitoring of the growing number of vaccines.
  2. Review the intramural and extramural collaborative activities of the vaccine safety program and determine their effectiveness and efficiency.
    • Assess additional steps CDC can institute to enhance coordination with other federal agencies and partners, including consumer and advocacy groups.
  3. Determine the optimal organizational location for vaccine safety activities within the CDC to ensure scientific objectivity, transparency, and oversight while at the same time ensuring that program priorities are appropriately established and are relevant to the immunization program and other stakeholder needs.

CDC will post presentations of facts about CDC's vaccine safety activities on the CDC website so that the public can make informed comments about the objectives listed above. The link to the objectives is at The links to the presentations are also provided on the website.

We invite the public to review the available information and follow the instructions for providing comments and input. The public comment period will end on October 12, 2004.

If you have any questions or need more information, please email the following address:


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 16, 2004

The Michigan Department of Community Health must believe in making it easy for Michigan adults to keep track of their vaccination status. In the past few years, the department has distributed more than 300,000 IAC adult immunization record cards.

"We love the IAC adult immunization record cards," said Rosemary Franklin, the immunization division's information and education coordinator. Why? One big reason is that it gives adult patients a PERMANENT record of their immunizations. At times, this can be invaluable. For example, if a person sustains a wound and is brought to a hospital emergency room that has no access to vaccination records, the person can refer to their immunization record card to find out their tetanus-diphtheria vaccination status.

Another reason is that the canary-yellow card, which is small enough to fit in a wallet, is easy to spot. "The card is bright, easy to find, and virtually indestructible," Franklin said. "One of my co-workers added a card to a load of laundry, and it came out legible and intact!"

How to use the card
In addition to being a foolproof way to help patients keep track of their vaccination status, the record card is an inexpensive educational tool. The card lists seven vaccines that all adults or certain adults should receive. Health care professionals (HCPs) can use it during patient encounters to discuss a patient's vaccination status with them. At the end of the visit, the HCP gives the card to the patient and encourages them to refer to it to find out when they're due for their next Td booster, a pneumococcal vaccine dose, or other vaccination.

Almost 2 million cards shipped
The Adult Immunization Record Card was developed by IAC in collaboration with CDC and several state health departments. Since introducing it in May 2002, IAC has shipped more than 1.8 million cards to health care providers across the United States.

To view a color image of the bright yellow, rip-proof, smudge-proof, waterproof card, go to:

Cost and ordering information
The cost for one 250-count box is $30; two boxes (500 cards), $55; three boxes (750 cards), $75; four boxes (1,000 cards), $90. Additional pricing for larger quantities can be found on the online order form (see link below). NOTE: THE FIRST ORDER OF A 250-CARD BOX COMES WITH A 30-DAY MONEY-BACK GUARANTEE.

To order IAC's Adult Immunization Record Cards online (including online with a purchase order), go to:

To print an order form to send with payment information by fax or mail, go to:

If you have questions about IAC's Adult Immunization Record Card, call us at (651) 647-9009, or email us at (Use the same email address to receive sample cards.)

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August 16, 2004

IAC recently made minor but significant changes to five professional-education pieces on vaccine storage and handling. The five updated pieces include checklists, temperature logs, and other aids that simplify and take the guesswork out of storage and handling. Information and links to the five pieces follow:

  1. "Maintaining the Cold Chain During Transport," gives instructions for maintaining inactivated and live-virus vaccines at the proper temperature during transport.
    To obtain a ready-to-copy (PDF) version of the updated sheet, go to:
  2. "Checklist for Safe Vaccine Handling and Storage," lists the 20 most important things to do to safeguard your vaccine supply.
    To obtain a ready-to-copy (PDF) version of the updated sheet, go to:
    To obtain a web-text (HTML) version, go to:
  3. "Don't be Guilty of These Errors in Vaccine Storage and Handling," lists the 11 most frequently reported errors. Use it to review your practice or clinic's storage and handling procedures.
    To obtain a ready-to-copy (PDF) version of the updated sheet, go to:
    To obtain a web-text (HTML) version, go to:
  4. "Temperature Log for Vaccines" (Fahrenheit or Celsius) has been expanded from two pages to four. Each log has space for tracking refrigerator and freezer temperatures for a month and also includes space for maintaining a vaccine storage troubleshooting record.
    To obtain a ready-to-copy (PDF) version of the Fahrenheit log, go to:
    To obtain a ready-to-copy (PDF) version of the Celsius log, go to:
  5. "Emergency Response Worksheet" outlines the procedures to follow in case of a power failure or other event that results in vaccine storage outside the recommended temperature range.
    To obtain a ready-to-copy (PDF) version of the updated sheet, go to:

In addition, IAC updated a one-page checklist, "Suggested Supplies Checklist for Adult Immunization Clinic," that serves as a reminder of the medical supplies and other items needed to set up an adult vaccination clinic.

To obtain a ready-to-copy (PDF) version of the updated sheet, go to:

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August 16, 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 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 16, 2004

August 20 is the early-bird registration deadline for the 5th Immunization Registry Conference. The conference will be held October 18-20 at the Crowne Plaza Ravinia in Atlanta. In addition, three preconference workshops, sponsored by the American Immunization Registry Association (AIRA), are planned for October 17 (for details, see final paragraph in this article).

Expected to bring together more than 450 local, state, federal, and private sector immunization registry partners, the conference is intended to promote knowledge and information about the development and use of immunization registries. The conference will give participants programmatic, technical, and scientific information that will improve the use of immunization registries. It will also provide a forum to build support for registries, enhance collaboration, promote multiple and innovative uses of registry data, explore alternative funding strategies, and demonstrate registry successes.

For comprehensive information about the conference, including the agenda, continuing education credit, registration details, and more, go to:

To register online, go to:

For questions and additional information, contact the conference planning team by email at or by phone at (404) 639-8225.

For details on AIRA's October 17 preconference workshops, go to: Additional information is available by emailing

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.

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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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