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Issue Number 613            August 7, 2006


  1. New: HAN issues official Health Advisory about a multi-state investigation of potential rabies exposure at a summer camp
  2. ACIP publishes provisional recommendations for prevention of tetanus, diphtheria, and pertussis among pregnant women
  3. ACIP updates provisional recommendations for prevention of varicella
  4. August is National Immunization Awareness Month
  5. MMWR publishes report on a pertussis outbreak in an Amish community
  6. FDA approves influenza vaccines to be manufactured for upcoming influenza season
  7. New BRFSS estimates for influenza and pneumococcal vaccination coverage among adults available from CDC
  8. National Influenza Vaccine Summit releases July newsletter
  9. Updated: IAC revises injection technique piece for providers
  10. IAC adds HPV and herpes zoster pages to its websites
  11. CDC releases guidelines for vaccinating kidney dialysis patients and patients with chronic kidney disease
  12. New: 2006-07 inactivated influenza VIS available in audio and video formats


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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 7, 2006

On August 3, the Health Alert Network (HAN) issued an official CDC Health Advisory concerning a multi-state investigation of potential rabies exposure at a summer camp. The Health Advisory is reprinted below in its entirety.


Distributed via Health Alert Network
August 3, 2006, 13:47 EDT (01:47 PM EDT)


Since August 2, 2006, the Centers for Disease Control and Prevention (CDC) has been collaborating with Group Workcamps Foundation, and state and local health departments in 13 states, to investigate reports of the presence of bats at a summer camp and assess the potential for exposures to rabies. The camp lodging facility which is located in New Richmond, Ohio, hosted approximately 440 teenagers and adults from 13 states (Florida, Illinois, Indiana, Kansas, Kentucky, Michigan, Missouri, Ohio, Pennsylvania, Tennessee, Virginia, West Virginia, and Wisconsin) from June 11-July 28. This advisory provides information about the investigation, an update for states that may receive inquiries due to public concerns about bats and rabies, and criteria for conducting risk assessments to determine the need for postexposure prophylaxis (PEP).

One or a few bats were observed to be present in the structure where the campers slept on at least four different occasions. At the time of the first observation on 2 July, two bats were present in the foyer of the building. One bat escaped and one was killed and discarded by an adult. The following week (9 July) another bat was seen in the sleeping area and it was similarly killed and discarded. A few weeks later, on July 23, another bat was seen in the sleeping area; it was also killed and discarded. On the night of the fourth incident (25 or 26 July), a single bat was observed flying above the sleeping area and then roosting on the ceiling 30-40 feet above the campers. Adult chaperones monitored the situation to ensure the bat was not mobile, before going to sleep. The Group Workcamps Foundation is working collaboratively with local and state health departments and CDC to notify the parents of each camper who attended the camp during the summer so that any potential exposures to rabies will be identified and managed appropriately. To date, no apparent direct contact with bats has been reported by any camper and the actions being taken by the Group Workcamps Foundation and the public health authorities are precautionary.

Similar potential rabies exposures occurred at a summer camp at Camp Potomac Woods in Lucketts, Virginia. A follow-up evaluation found that the presence of bats was common around the camp area, with additional bats found in several sleeping shelters. Prompt action by the part of the Loudon County Health Department and Virginia Department of Health identified 14 candidates for PEP out of 950 total campers.

Human rabies PEP is recommended when 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 your state health department and CDC, telephone 1-800-CDC-INFO (1-800-232-4636) or at


To access the Health Advisory online, go to:

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August 7, 2006

On August 1, ACIP posted "Prevention of Tetanus, Diphtheria and Pertussis among Pregnant Women: Provisional ACIP Recommendations for the Use of Tdap Vaccine." ACIP voted on these recommendations on June 30.

The provisional recommendations are reprinted below in their entirety.


Provisional Recommendations for use of Td and Tdap in Pregnant Women (adolescents 11-18 years and adults 19-64 years of age) who previously have not received Tdap

  • Routine post-partum Tdap: Pregnant women who previously have not received a dose of Tdap (including women who are breastfeeding) should receive Tdap after delivery, before discharge from the hospital or birthing center, if 2 years or more have elapsed since the last Td; shorter intervals can be used (see Special Situations). If Tdap cannot be administered before discharge, it should be given as soon as feasible. The dose of Tdap replaces the next decennial dose of Td.
  • Simultaneous administration: Tdap can be administered with other vaccines that are indicated. Each vaccine should be administered using a separate syringe at a different anatomic site.

Special Situations

  • Post-partum Tdap when less than 2 years have elapsed since the last Td: Healthcare providers should obtain a history of adverse reaction following previous doses of vaccines containing tetanus and diphtheria toxoids. Available information is limited on the risk of local and systemic reactions after Tdap at interval shorter than 2 years. Providers can choose to administer Tdap to these post-partum women for protection against pertussis.
  • Protection against tetanus, diphtheria, and neonatal tetanus: ACIP recommends Td for booster vaccination during pregnancy if 10 years or more have elapsed since a previous Td booster. To provide protection against pertussis in addition to tetanus and diphtheria, healthcare providers can defer the Td vaccination until delivery if sufficient tetanus protection is likely. Sufficient tetanus protection is likely if:

    1. The pregnant woman is younger than 30 years of age and has received a complete childhood series of immunization (4 or 5 doses of pediatric DTP, DTaP, DT)** and at least one Td booster during adolescence or as an adult.
    2. The pregnant woman is older than 30 years of age and has received a complete childhood series of immunization (4 or 5 doses of pediatric DTP, DTaP, DT)**, and at least two Td booster doses.
    3. The pregnant woman has a protective level of serum tetanus antitoxin (0.1 IU/mL or more by ELISA).

      ** A primary series consisting of 3 doses of Td (or TT) administered during adolescence or as an adult substitutes for the childhood series of immunization.
  • Considerations for use of Td and Tdap in pregnant women: ACIP recommends Td when tetanus and diphtheria protection is required during pregnancy. In some situations (see below), healthcare providers can choose to administer Tdap instead of Td to add protection against pertussis. When Td or Tdap is administered during pregnancy, the second or third trimester is preferred. Pregnancy is not a contraindication for use of Tdap. Data on safety, immunogenicity, and the outcomes of pregnancy are not available for pregnant women who receive Tdap. When Tdap is administered during pregnancy, transplacental maternal antibodies might protect the infant against pertussis in early life. They also could interfere with the infant's immune response to infant doses of DTaP, and leave the infant less well protected against pertussis.
    1. Providers who choose to administer Tdap to pregnant women should discuss the lack of data with the pregnant women and are encouraged to report Tdap administrations regardless of the trimester, to the appropriate manufacturers' pregnancy registry: for BOOSTRIX(R) to GlaxoSmithKline Biologicals at 1-888-825-5249, or for ADACEL (R) to sanofi pasteur at 1-800-822-2463 (1-800-VACCINE).
  • Situations with increased risk for pertussis: Healthcare providers can choose to administer Tdap instead of Td to protect against pertussis in pregnant adolescents for routine or "catch-up" vaccination because the incidence of pertussis is high among adolescents, in pregnant healthcare personnel, and child care providers to prevent transmission to infants younger than 12 months of age and to other vulnerable persons, and in pregnant women employed in an institution or living in a community with increased pertussis activity.
  • Tetanus prophylaxis for wound protection: ACIP recommends Td booster for wound management in pregnant women in some situations if 5 or more years have elapsed since the previous Td. Healthcare providers can choose to substitute Tdap for Td in this situation.
  • Incomplete or unknown vaccination history: Pregnant women who have not received three doses of a vaccine containing tetanus and diphtheria toxoids should complete a series of 3 vaccinations. Two doses of Td should be administered during pregnancy to ensure protection against maternal and neonatal tetanus. The preferred schedule in pregnant women is two doses of Td separated by 4 weeks, and a dose of Tdap 6 months after the second dose (post-partum). Healthcare providers can choose to substitute a single dose of Tdap for a dose of Td during pregnancy.
  • Alternatives to Tdap for protection against pertussis: Healthcare providers should encourage vaccination of household and child care provider contacts of infants younger than 12 months to protect against pertussis. Families can be advised of the symptoms of pertussis and that early antimicrobial prophylaxis can be effective preventing transmission of pertussis to infants.

Contraindications to Td and Tdap

  • History of serious allergic reaction (i.e., anaphylaxis) to any component of the vaccine.
  • For Tdap (but not Td), history of encephalopathy (e.g., coma or prolonged seizures) not attributable to an identifiable cause within 7 days of administration of a vaccine with pertussis components.

Precautions and Reasons to Defer Td or Tdap

  • Guillain-Barré syndrome with onset 6 weeks or less after the previous dose of tetanus toxoid-containing vaccine.
  • Moderate or severe acute illness
  • History of an Arthus reaction to tetanus toxoid and/or diphtheria toxoid-containing vaccine less than 10 years previously
  • For adults, unstable neurologic conditions (e.g., cerebrovascular events, acute encephalopathic conditions)
  • For adolescents, any progressive neurologic disorder including progressive encephalopathy or uncontrolled epilepsy (until the condition has stabilized)

To access these provisional recommendations online, go to:

All provisional ACIP recommendations can be found at

All published ACIP recommendations can be accessed at

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August 7, 2006

On August 3, ACIP updated its provisional recommendations for prevention of varicella. The provisional recommendations were first posted in November 2005.

The updated provisional recommendations are reprinted below in their entirety.


In June 2005 and June 2006, the ACIP made policy changes for use of live, attenuated varicella-containing vaccines for prevention of varicella. Changes include routine two dose varicella vaccination of children and second dose catch-up varicella vaccination for children, adolescents, and adults who previously had received only one dose. The ACIP also expanded recommendations for varicella-containing vaccines to promote wider use of the vaccine for adolescents, adults, and HIV-infected children and approved new criteria for evidence of immunity to varicella.

Provisional recommendations for prevention of varicella:

  • All children <13 years of age should be administered routinely two doses of varicella-containing vaccine, with the first dose administered at 12-15 months of age and the second dose at 4-6 years of age (i.e., before a child enters kindergarten or first grade). The second dose can be administered at an earlier age provided the interval between the first and second dose is at least 3 months. However, if the second dose is administered at least 28 days following the first dose, the second dose does not need to be repeated.
  • A second dose catch-up varicella vaccination is recommended for children, adolescents, and adults who previously had received one dose, to improve individual protection against varicella and for more rapid impact on school outbreaks. Catch-up vaccination can be implemented during routine healthcare provider visits and through school and college entry requirements. Catch-up second dose can be administered at any interval longer than 3 months after the first dose.

The two-dose varicella vaccination schedule is similar to the measles, mumps, and rubella (MMR) vaccination schedule. Measles, mumps, rubella, and varicella (MMRV) vaccine is licensed and indicated for simultaneous vaccination against measles, mumps, rubella, and varicella among children 12 months through 12 years of age. For routine immunization, use of licensed combination vaccines, such as MMRV vaccine, is preferred over separate injection of equivalent component vaccines.

  • Middle, high school, and college requirements. ACIP reiterates its previous recommendation that official health agencies should take necessary steps, including developing and enforcing school immunization requirements, to ensure that students at all grade levels (including college) and children in child care facilities are protected against vaccine-preventable diseases, including varicella. For varicella, this recommendation adds middle school, high school, and college requirements to the child care and elementary school entry requirements already covered by the 1999 recommendation ( School and child care immunization requirements should be implemented when provision of varicella vaccine has been well incorporated into practice and supply is adequate.
  • Varicella vaccination of HIV-infected children. HIV-infected children >=12 months of age in CDC clinical class N, A, or B with CD4+ T-lymphocyte counts >=15% and without evidence of varicella immunity should receive two doses of single antigen varicella vaccine at a minimum interval of 3 months. Varicella vaccine was recommended previously for asymptomatic or mildly symptomatic HIV-infected children (CDC clinical class N and A) with age-specific CD4+ T-lymphocyte counts >=25% ( Because data are not available on safety, immunogenicity or efficacy of MMRV vaccine in HIV-infected children, MMRV vaccine should not be administered as a substitute for the component vaccines when vaccinating HIV infected children.
  • Prenatal assessment and postpartum vaccination. Women should be assessed prenatally for evidence of varicella immunity. Upon completion or termination of their pregnancies, women who do not have evidence of varicella immunity should receive the first dose of varicella vaccine before discharge from the healthcare facility. The second dose should be administered 4 to 8 weeks later (at the postpartum or other healthcare visit). To ensure administration of varicella vaccine, standing orders are recommended for healthcare settings where completion or termination of pregnancy occurs.
  • Vaccination of people >=13 years of age. Varicella vaccine was recommended previously for people >=13 years of age without evidence of immunity who 1) have close contact with people at high risk for severe disease (healthcare providers and family contacts of immunocompromised people) or 2) are at high risk for exposure or transmission ( The ACIP now recommends that all other people >=13 years of age without evidence of immunity be vaccinated with two doses of varicella vaccine at an interval of 4-8 weeks. The vaccine may be offered during routine healthcare visits.
  • Second dose varicella vaccine for outbreak control. During a varicella outbreak, people who have received one dose of varicella vaccine should receive a second dose, provided the appropriate vaccination interval has elapsed since the first dose (3 months for people 12 months to 12 years of age and at least 4 weeks for people >=13 years of age).

Contraindications and precautions to use of varicella vaccine are available at:

Revised criteria for evidence of immunity to varicella includes any of the following:

  1. Documentation of age-appropriate vaccination:
    1. Preschool-aged children >=12 months of age: one dose
    2. School-aged children, adolescents, and adults: two doses(1)
  2. Laboratory evidence of immunity(2) or laboratory confirmation of disease
  3. Born in the U.S. before 1980(3)
  4. A healthcare provider diagnosis of varicella or healthcare provider verification of history of varicella disease(4)
  5. History of herpes zoster based on healthcare provider diagnosis.


  1. For children who have received their first dose before age 13 years and the interval between the two doses was at least 28 days, the second dose is considered valid.
  2. Commercial assays can be used to assess disease-induced immunity, but they lack adequate sensitivity to detect reliably vaccine-induced immunity (may yield false negative results).
  3. For healthcare providers and pregnant women, birth before 1980 should not be considered evidence of immunity.
  4. Verification of history or diagnosis of typical disease can be done by any healthcare provider (e.g., school or occupational clinic nurse, nurse practitioner, physician assistant, physician). For people reporting a history of or presenting with atypical and/or mild cases, assessment by a physician or their designee is recommended and one of the following should be sought: a) an epidemiologic link to a typical varicella case or b) evidence of laboratory confirmation, if laboratory testing was performed at the time of acute disease. When such documentation is lacking, people should not be considered as having a valid history of disease, because other diseases may mimic mild atypical varicella.


To access the provisional varicella prevention recommendations online, go to:

All provisional ACIP recommendations can be found at

All published ACIP recommendations can be accessed at

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August 7, 2006

August is recognized as National Immunization Awareness Month (NIAM). The goal of NIAM is to increase awareness about immunization across the life span. August is the perfect time to encourage family, friends, coworkers, and patients to catch up on their vaccinations as students get ready for school and healthcare workers prepare for the upcoming influenza season.

Communities are encouraged to plan local health screenings or fairs, media events, and other related immunization outreach efforts during August to promote the benefits of immunization.

For more information and links to NIAM resources, go to CDC's web page at

The following are some useful resources for educating parents and patients on the value of vaccines.

"Parents' Guide to Immunization" (CDC)

"Plain Talk About Childhood Immunizations"
(Public Health-Seattle & King County, Washington)

"Vaccines and Your Baby" (Vaccine Education Center)

"Vaccines: Separating Fact from Fear" (Vaccine Education Center)

Video clips related to vaccine-preventable diseases (IAC)

Photos related to vaccine-preventable diseases (IAC)

"Immunizations for Babies. . . A Guide for Parents" (IAC)

"When Do Children and Teens Need Vaccinations?" (IAC)

"Vaccinations for Adults. . . You're NEVER too old to get immunized!" (IAC)

"Do I Need Any Vaccinations Today?" (IAC)

"Questions parents ask about baby shots" (IAC)

For more immunization educational tools for parents and patients, visit the following web pages:

Vaccine Education Center:
National Network for Immunization Information:
American Academy of Pediatrics:

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August 7, 2006

CDC published "Pertussis Outbreak in an Amish Community—Kent County, Delaware, September 2004–February 2005" in the August 4 issue of MMWR. Excerpts from the introduction and editorial note, excluding references, are reprinted below.


Vaccine-preventable disease outbreaks continue to occur among undervaccinated populations in the United States, including contained religious communities. The Amish practice separation from the world through group solidarity and caring for their own. Amish religious doctrine does not prohibit vaccination; however, coverage levels for routine childhood vaccination remain low in many Amish communities. This report describes an outbreak of pertussis in an Amish community in Kent County, Delaware, during September 2004–February 2005, that resulted in 345 cases and affected primarily preschool-aged children. The outbreak underscores the need to promote vaccination in Amish communities through culturally appropriate strategies, such as education and outreach to community leaders. . .

Outbreaks of vaccine-preventable diseases (VPDs), such as rubella and Haemophilus influenzae type b, have been reported in Amish communities. Control of VPDs in these communities presents unique challenges, in part because of their isolation. Amish persons typically have lower vaccination coverage and often delay or avoid seeking medical care. Since 1980, public health nurses in Delaware have conducted immunization clinics at two fixed outreach sites in Amish homes, but coverage rates have remained low. After the outbreak described in this report, DPH staff distributed educational pamphlets discussing immunization and VPDs, including information about Amish immunization outreach clinics. The reasons cited by persons in Amish households for failure to vaccinate children (e.g., fears of vaccine-related adverse events and general lack of awareness regarding vaccination) were not religious or doctrinal. This suggests that enhanced outreach and education regarding vaccination safety and protective benefits might help increase coverage rates.


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:

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

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August 7, 2006

On August 2, the Food and Drug Administration (FDA) announced that it had approved this year's seasonal influenza vaccines that include the new strains of virus judged likely to cause influenza in the Northern Hemisphere in 2006–07.

This season's approved formulation for the U.S. vaccine is identical to that recommended by both the World Health Organization and FDA's Advisory Committee. The formulation includes one strain that was used in last year's vaccine and two new strains.

There are four vaccine manufacturers approved to market influenza vaccines in the United States: Chiron Vaccines, Ltd; GlaxoSmithKline Biologicals; MedImmune Vaccines, Inc.; and Sanofi Pasteur. The manufacturers have projected making a total of about 100 million doses of influenza vaccine for this season, but these projections could change as manufacturing continues.

To read the complete FDA press release, go to:

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August 7, 2006

New estimates are available for influenza and pneumococcal vaccination coverage among adults age 65 years and older from CDC's Behavioral Risk Factor Surveillance System (BRFSS).

To obtain the 2005 BRFSS estimates online, go to: Estimates can be obtained for all states or by individual state. Choose "Immunization" as the category.

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August 7, 2006

The National Influenza Vaccine Summit has posted its July 2006 newsletter online at

The National Influenza Vaccine Summit website is sponsored by CDC and the American Medical Association. Besides the two issues of its newsletter, the site includes presentations from meetings and information about influenza vaccine manufacturing, supply, and distribution.

To visit the National Influenza Vaccine Summit website, go to:

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August 7, 2006

IAC recently revised its two-page piece on injection technique. Changes include the addition of newly licensed vaccines, minor revisions in language, and one change in recommended needle size.

To access a ready-to-print (PDF) version of How to Administer Intramuscular (IM) Injections and How to Administer Subcutaneous (SC) Injections go to:

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August 7, 2006

Due to the licensure of human papillomavirus (HPV) and herpes zoster (shingles) vaccines, IAC has added related informational pages to its websites.

For HPV information for health professionals, go to:

For HPV information for the public, go to:

For herpes zoster information for health professionals, go to:

For herpes zoster information for the public, go to:

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August 7, 2006

CDC released a document titled "Guidelines for Vaccinating Kidney Dialysis Patients and Patients with Chronic Kidney Disease" in June 2006. The guidelines are summarized from recommendations of the ACIP, and are available in PDF format at

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August 7, 2006

The 2006-07 VIS for injectable trivalent inactivated influenza vaccine (dated 6/30/06) is now available on IAC's website in audio, multimedia, and web-page video formats. These formats are intended for use with low-literacy, English-speaking patients. The web-page video is specifically tailored to be able to work for people who have slow Internet connections.

IAC is grateful to Healthy Roads Media for providing these alternative versions. Healthy Roads Media offers health information in a variety of formats and languages. For information, go to:

To access the audio version of the VIS, go to: In the Inactivated Influenza Vaccine section, click on the link titled "English 6/30/06 (audio VIS*)."

To access the multimedia or web-page video versions of the VIS, go to: In the Inactivated Influenza Vaccine section, click on the link titled "English 6/30/06 (multimedia "movie" VIS*)." This will bring you to a menu on the Healthy Roads Media website where you can chose either the multimedia or web-page video format.

To access a ready-to-print (PDF) hard-copy version of the VIS, go to:

For information about the use of VISs, and for VISs in a total of 33 languages, visit IAC's VIS web section at

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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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