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Issue Number 598            May 15, 2006


  1. New: HAN issues official Health Advisory about a case of human rabies infection in Texas
  2. May is Hepatitis Awareness Month
  3. CDC reports chronic HBV infection among approximately 15% of newly tested Asian immigrants in New York City
  4. CDC reports on hepatitis B vaccination coverage of U.S. adults in 2004
  5. CDC reports on vaccine-preventable child deaths and on Global Immunization Vision and Strategy for 2006–15
  6. New: Professional-education sheet helps reduce confusion about similar-looking vials of Tdap, DTaP, and Td vaccines
  7. Government website posts a viewer's guide and Q&A section about the TV movie "Fatal Contact: Bird Flu in America"
  8. Reminder: Deadline for early-bird registration for Public Health and the Law conference is May 20
  9. CDC adds to and updates its Influenza web section with information about avian influenza
  10. New: CDC reports on 13-month delay between evaluation and diagnosis of autism in children


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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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May 15, 2006

On May 10, the Health Alert Network (HAN) issued an official CDC Health Advisory concerning a confirmed diagnosis of rabies in a Texas teenager. The Health Advisory is reprinted below in its entirety.


Distributed via Health Alert Network
May 10, 2006 12:40 EDT (12:40 PM EDT)


On May 9, 2006, the Centers for Disease Control and Prevention (CDC), working together with Harris County Public Health and Environmental Services (HCPHES) and the Texas Department of State Health Services (TDSHS), confirmed a diagnosis of rabies as the cause of illness in a Texas teenager, who has been hospitalized with encephalitis. This advisory provides information about this case, an update for states that may receive inquiries due to public concerns about rabies, and criteria for conducting risk assessments to determine the need for postexposure prophylaxis (PEP).

Four-to-six weeks prior to admission, the patient had awakened due to direct contact with a live bat in his bedroom. The bat was removed from the home and was not available for testing. Bats are a widely distributed reservoir of rabies throughout the United States. The child did not present for medical attention until after symptoms had developed, thus rabies PEP was not administered. Diagnosis was made on the basis of a positive direct fluorescent antibody test for rabies virus antigen on a nuchal skin biopsy. Further analysis of clinical specimens is ongoing in an effort to establish a likely animal source for the infection, based upon viral characterization.

HCPHES and TDSHS, in collaboration with CDC, are continuing to conduct investigations to identify contacts of the patient among family members, the local community, and healthcare workers and to identify other persons who may have had contact with the bat at the same time as the patient. Human rabies PEP is recommended only in situations in which potentially infectious material (e.g. saliva) from a rabid animal or human is introduced via a bite, or comes into direct contact with broken skin or mucous membranes. More detailed information regarding evaluation for and administration of PEP is available at

Additional information about rabies and its prevention is available from HCPHES at (713) 212-0200, TDSHS at (512) 458-7455 and CDC, telephone (800) CDC-INFO [232-4636] or at This website is updated as new information becomes available.


To access the Health Advisory, go to:

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May 15, 2006

CDC published "Hepatitis Awareness Month—May 2006" in the May 12 issue of MMWR. The article is reprinted below in its entirety, excluding the reference.


May 2006 marks the 11th anniversary of Hepatitis Awareness Month. In the United States, one of three persons has been infected with hepatitis A virus (HAV), hepatitis B virus (HBV), or hepatitis C virus (HCV).

HAV is spread by close contact with infected persons or through contaminated food. Since the introduction of hepatitis A vaccines in 1995, reports of hepatitis A have declined 84% (CDC, unpublished data, 2004).

HBV and HCV are spread by blood or sexual contact. In 2004, an estimated 60,000 new HBV infections and 26,000 new HCV infections occurred (CDC, unpublished data, 2004). In 1991, CDC adopted a national vaccination strategy to eliminate HBV transmission in the United States. Since then, acute hepatitis B has declined 75%, with the highest incidence remaining among adults.

Approximately 5%–25% of persons with chronic HBV and HCV infection will die prematurely from cirrhosis and liver cancer. Approximately 1 million persons in the United States have chronic HBV infection, and 3 million have chronic HCV infection (CDC unpublished data, 2004). Although effective therapies for viral hepatitis are available, the majority of persons with chronic HCV infection are unaware of their infection.

This issue of MMWR reports on the prevalence of chronic HBV infection among Asian/Pacific Islander populations in New York City and progress to eliminate HBV transmission through vaccination of adults. Additional information regarding hepatitis and Hepatitis Awareness Month is available at


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

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May 15, 2006

CDC published "Screening for Chronic Hepatitis B Among Asian/Pacific Islander Populations—New York City, 2005" in the May 12 issue of MMWR. A portion of the article is reprinted below.


Chronic hepatitis B virus (HBV) infection is the most common cause of cirrhosis and liver cancer worldwide. In Asian and western Pacific countries where HBV is endemic, estimated prevalence of chronic HBV infection ranges from 2.4%–16.0%, and liver cancer is a leading cause of mortality. Although population-based prevalence data for Asians/Pacific Islanders (A/PIs) living in the United States are lacking, they are believed to constitute a sizeable percentage of persons with chronic HBV infection in the United States, a country of low endemicity. To assess the prevalence of chronic HBV infection among A/PI populations living in New York City, the Asian American Hepatitis B Program (AAHBP) conducted a seroprevalence study among persons who participated in an ongoing hepatitis B screening, evaluation, and treatment program. The results indicated that approximately 15% of participants who had not been previously tested had chronic HBV infection; all were born outside the United States. Screening programs are needed in A/PI communities in the United States to identify persons with chronic HBV infection so that they can be referred for appropriate medical management to prevent cirrhosis and liver cancer and so that their susceptible household and sex contacts can receive hepatitis B vaccine. . . .

Editorial Note:
The findings in this report on a screening program conducted among a predominantly immigrant Asian population indicate that approximately 15% of newly tested persons living in New York City had chronic HBV infection. The prevalence among participants in the screening program was approximately 35 times that of the overall U.S. population. Half of those with chronic HBV infection had been living in the United States for more than 10 years. These persons likely acquired their infections in their countries of origin, where HBV infection is endemic and infections usually are acquired at birth or during early childhood. The majority of infected participants were successfully referred for medical evaluation and follow-up.

Although this study was limited to New York City, screening programs in Atlanta, Chicago, New York City, Philadelphia, and California have reported similar prevalences of chronic HBV infection (10%–15%) among A/PI immigrants to the United States. A smaller proportion of those born in South Korea, compared with those born in China, were documented with chronic HBV infection.

Perinatal and child-to-child transmission are the most common modes of HBV transmission in Asia and other countries where HBV is endemic. Of persons who acquire chronic HBV infection at early ages, an estimated 15%–40% will subsequently have chronic liver disease, including cirrhosis and liver cancer. Therefore, persons with chronic HBV infection need to be identified so that they can receive counseling and appropriate medical management to reduce their risk for chronic liver disease. Some will benefit from treatment or screening to detect liver cancer at an early stage. To prevent spread of HBV infection, household and sex contacts should be tested for HBV infection and offered hepatitis B vaccination, where indicated.

Although members of A/PI communities in the United States generally are aware that HBV infection is associated with increased risk for liver cancer, fewer than half recognize that HBV infection is endemic among persons born in Asia. Hepatitis B screening programs in U.S. A/PI communities can be an effective means of identifying persons with chronic HBV infection and motivating them to seek medical care. An evaluation of a hepatitis B screening program for A/PI in California determined that 67% of those with chronic HBV infection sought follow-up with their medical providers. Approximately 71% of participants in the California program reported that, before participating in the screening program, testing for HBV had not been recommended, although 89% had a regular family physician. . . .

In collaboration with state and local partners, CDC supports programs to prevent HBV infection in U.S. A/PI communities. Local health departments in New York City and San Francisco, two cities with large A/PI populations, conduct enhanced viral hepatitis surveillance for both acute and chronic hepatitis B. The Asian Liver Center of Stanford University has developed educational programs for A/PI youth and practitioners of traditional Chinese medicine. State and local health departments have successfully implemented vaccination strategies (e.g., achieving high vaccination coverage among children and adolescents and high rates of HBsAg screening among pregnant women) recommended by the Advisory Committee on Immunization Practices in 1991 to eliminate HBV transmission in the United States. Since 1991, acute hepatitis B incidence has declined sharply among U.S. A/PI populations, eliminating major health disparities in acute HBV infection. Additional information regarding acute and chronic HBV infection and prevention activities is available from CDC at

U.S. A/PI populations are at disproportionately high risk for hepatitis B-related chronic liver disease and liver cancer. Public health agencies and medical providers who serve U.S. A/PI populations and other communities with high proportions of persons born in countries where HBV infection is endemic should promote educational campaigns and screening programs. Such programs should identify persons with chronic HBV infection so that they can receive appropriate counseling and treatment to prevent cirrhosis and liver cancer and so that their contacts can be screened and given treatment, counseling, or vaccination as appropriate. Programs such as the comprehensive, community-based screening and evaluation program described in this report can effectively reach persons at risk for chronic HBV infection.


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

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

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May 15, 2006

CDC published "Hepatitis B Vaccination Coverage Among Adults—United States, 2004" in the May 12 issue of MMWR. Portions of the article are reprinted below.


Hepatitis B virus (HBV) infection is a major cause of cirrhosis and liver cancer in the United States. The Advisory Committee on Immunization Practices (ACIP) has recommended a comprehensive strategy to eliminate HBV transmission, including prevention of perinatal HBV transmission; universal vaccination of infants; catch-up vaccination of unvaccinated children and adolescents; and vaccination of unvaccinated adults at increased risk for infection. The incidence of acute hepatitis B has declined 75%, from 8.5 per 100,000 population in 1990 to 2.1 per 100,000 population in 2004, with the greatest declines (94%) among children and adolescents. Incidence remains highest among adults, who accounted for approximately 95% of the estimated 60,000 new infections in 2004. To measure hepatitis B vaccination coverage among adults, data were analyzed from the 2004 National Health Interview Survey (NHIS). This report summarizes the results of that analysis, which indicated that, during 2004, 34.6% of adults aged 18–49 years reported receiving hepatitis B vaccine, including 45.4% of adults at high risk for HBV infection. To accelerate elimination of HBV transmission in the United States, public health programs and clinical care providers should implement strategies to ensure that adults at high risk are offered hepatitis B vaccine.

NHIS is a multipurpose household health survey of the U.S. civilian, noninstitutionalized population, conducted by in-person interview. Hepatitis B vaccination coverage was estimated from self reports of sampled adults. The analysis was restricted to adults aged 18–49 years, age groups that account for approximately 80% of adult HBV infections.

In the 2004 NHIS, adults who responded "yes" to the question, "Have you ever received hepatitis B vaccine?" were assumed to have received [at least] 1 vaccine dose. For this analysis, adults were considered at high risk for HBV infection if they reported a risk factor in answering any of three questions related to human immunodeficiency virus (HIV) and sexually transmitted disease (STD) risk behaviors. . . .

During 2004, a total of 31,326 adults were interviewed, including 18,269 aged 18–49 years. The response rate was 72.5%. Of eligible adults aged 18–49 years, 17,249 (94%) who responded to the hepatitis B vaccination questions were included in this analysis, including 1,048 (5.7%) adults at high risk.

A weighted analysis of adults who were surveyed indicated that 34.6% (95% CI [confidence interval] = 33.5%–35.6%) reported receiving hepatitis B vaccine. Coverage was highest among persons aged 18–20 years and declined with increasing age. Coverage also was higher for persons in occupations for which vaccination is specifically recommended, including healthcare workers (80.5%; CI = 77.3%–83.4%) and police officers or firefighters (63.6%; CI = 56.6%–70.1%), and for adults at high risk (45.4%; CI = 41.7%–49.2%).

Report of hepatitis B vaccination also was associated with certain population characteristics, including female sex, non-Hispanic ethnicity, and higher educational achievement. Persons with a routine source of health care (e.g., primary doctor, health maintenance organization, or clinic) and persons with health insurance also were more likely to report vaccination than those with no routine source of health care. The same demographic and healthcare use characteristics were associated with higher likelihood of vaccination among persons at high risk as among other respondents. In a multivariate model, after controlling for age, sex, education, occupation, and HIV test history, high risk remained a statistically significant predictor (adjusted odds ratio = 1.3) of hepatitis B vaccination. . . .

Editorial Note:
The findings in this report suggest that hepatitis B vaccination coverage among adults at high risk, as measured by NHIS, has increased substantially from 30% in 2000 to 45% in 2004. Some of this increase in coverage represents the aging of persons vaccinated as adolescents, reflecting the effect of ACIP recommendations for routine vaccination of adolescents that were first made in 1995. In addition, higher vaccination coverage among persons of all ages at high risk suggests successes vaccinating targeted adults and likely contributed to a decline in hepatitis B incidence. From 2000 to 2004, hepatitis B incidence among adults decreased 27%, from 3.7 to 2.7 per 100,000 population (CDC, unpublished data, 2006). However, hepatitis B vaccination coverage of adults at high risk remained lower than vaccination coverage of children (92%) and adolescents (86%) in 2004, two other age groups included in the ACIP vaccination strategy to eliminate HBV transmission.

Several factors contribute to low hepatitis B vaccination coverage among adults at high risk. In contrast to vaccination of children, national programs that support vaccine purchase and infrastructure for vaccine administration are not available for adults. As a result, adults at increased risk often have missed opportunities to receive hepatitis B vaccination. In a study of 483 adults with acute hepatitis B infection, 61% reported a missed opportunity for vaccination during STD treatment, incarceration, or drug treatment during 2001–2004. In primary care settings, patients and providers might be reluctant to discuss risk behaviors, and providers might not prioritize vaccination in the context of other clinical care services.

Adult vaccination coverage can be increased through the use of provider reminders and other interventions to increase access to vaccination. Demonstration projects have determined that provision of comprehensive HIV, viral hepatitis, and STD services increases vaccination coverage. In October 2005, ACIP provisionally recommended strategies to improve vaccination for adults at risk for hepatitis B, emphasizing vaccination of all adults at venues where a high proportion of persons are likely to have risk factors for HBV infection (e.g., STD/HIV testing and treatment facilities, correctional facilities, and drug-abuse treatment facilities) and the adoption of practices that remove barriers to vaccination in primary care settings. . . .

Hepatitis B vaccine is safe and effective and the only licensed vaccine that prevents cancers. Despite these benefits, the majority of adults at risk for HBV remain unvaccinated. To increase coverage, public health programs and primary care providers should inform adults receiving preventive clinical services of the potential benefits of hepatitis B vaccination for their health, vaccinate all adults who seek protection from HBV, and adopt strategies appropriate for the practice setting to ensure that all adults at risk for HBV infection are offered hepatitis B vaccine.


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

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

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May 15, 2006

CDC published "Vaccine Preventable Deaths and the Global Immunization Vision and Strategy, 2006–2015" in the May 12 issue of MMWR. A portion of a summary made available to the press is reprinted below.


Immunization programs worldwide have made substantial progress since their inception, preventing an estimated 2 million child deaths annually. Nonetheless, as demonstrated by both global estimates of vaccine-preventable disease mortality and DTP3 coverage [receipt of three doses of diphtheria-tetanus-pertussis vaccine], currently available vaccines are not yet used to their fullest potential. Challenges include sustaining current immunization levels, extending immunizations to those currently unreached and those beyond infancy, and introducing new vaccines and technologies. The Global Immunization Vision and Strategy (GIVS), recently developed by WHO and the United Nations Children's Fund (UNICEF) in collaboration with partners, outlines their vision for immunizations from 2006–2015 and offers a conceptual framework within which these challenges may be addressed. Full implementation of GIVS will hopefully greatly reduce vaccine preventable deaths during the next 10 years.


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

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

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May 15, 2006

Early in 2006, the Immunization Branch of the California Department of Health Services, developed a full-color professional-education sheet "Check Your Vials: Is it Tdap, DTaP, or Td?" Intended to reduce confusion, the one-page sheet clearly pictures the vial and stopper of each of several brands of tetanus-and-diphtheria-toxoid-containing vaccines licensed for use in the United States.

To access this useful sheet, go to:

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May 15, 2006

Recently, the federal government's Pandemic Influenza website posted a viewer's guide and Q&A section about the made-for-TV movie "Fatal Contact: Bird Flu in America," which aired May 9 on ABC.

To access these resources, go to:

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May 15, 2006

The conference Public Health and the Law in the 21st Century will take place June 12–14 in Atlanta. Save $50 (pay $245 instead of $295) when you register by May 20, the early-bird deadline.

Speakers confirmed for the conference include U.S. Surgeon General Richard H. Carmona, MD, MPH; John O. Agwunobi, MD, MPH, assistant secretary for health, Department of Health and Human Services; and Michael R. Bloomberg, mayor of New York City.

Conference attendees involved in immunization and infectious diseases programs may benefit from the following conference sessions:

  • The Public Health Law Year in Review: Implications of Major Legal Developments, Trends, and Court Rulings
  • Vaccine Law 101
  • New Adolescent Vaccines: Legal and Legislative Issues
  • Incident at Airport X: Quarantine Enforcement: Law and Limits
  • Health Departments, Hospitals, and the Pandemic Flu: Overlapping Ethical and Legal Questions
  • Pandemic Flu: The Threat, Health System Implications, and Legal Preparedness
  • Closing the Gap between Science and Law
  • Training and Tools for a Legally Prepared Public Health Workforce

For comprehensive information and to register, go to: For registration information, email Katie Johnson at or phone her at (617) 262-4990.

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May 15, 2006

CDC recently added one page to and updated two pages of its Influenza web section:

(1) "Avian influenza update: Djibouti" describes a confirmed case of avian influenza in a toddler in Djibouti (posted 5/12/05)

To access this resource, go to: and click on the pertinent link.

(2) "Questions and answers about avian influenza (bird flu) & avian influenza virus" now has information about a confirmed case of human avian influenza in Djibouti and about food safety (updated 5/12/06 and 5/9/06)

(3) "Key facts: Information about avian influenza (bird flu) and avian influenza A (H5N1) virus" (updated 5/5/06)

To access these resources, go to: and click on the pertinent link.

To access a broad range of continually updated information on seasonal influenza, avian influenza, and pandemic influenza, go to:

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May 15, 2006

On May 10, CDC issued a press release reporting on study findings that show that children who were evaluated for developmental delays were not diagnosed with autism until 13 months after the initial assessment. Portions of the press release are reprinted below.


For immediate release
May 10, 2006


Children with autism spectrum disorders (ASDs) may experience a 13-month delay before they are diagnosed. A study in the April autism supplement of the Journal of Developmental and Behavioral Pediatrics released today, found that children diagnosed in metropolitan Atlanta were initially evaluated at an average of 4 years of age but were not diagnosed with an ASD until an average of 5 years 1 month. . . .

"Although this study draws upon data from the metro Atlanta area, it serves as an important indicator of the nationwide challenges of diagnosing autism, particularly more mild cases," said Dr. Jose Cordero, director of CDC's National Center on Birth Defects and Developmental Disabilities. "The real public health challenge is to educate doctors on the signs of autism and to encourage use of standardized diagnostic instruments that better identify symptoms relevant to ASD and help distinguish ASD from other developmental delays or disorders. . . ."


To access the complete press release, 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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