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1 Updates from October 2017 ACIP Meeting Thursday, November 9, :00 PM ET In Case of Technical Difficulties If you hear an echo: Make sure you are only logged in once on your computer Select one form of audio only (either computer speakers or telephone connection) If the audio is choppy: Press pause in the top left corner of your screen Wait 10 seconds and then click play Dial at any time for live assistance 1

2 Agenda Agenda Welcome and Introductions William Schaffner, MD, NFID Medical Director Professor of Preventive Medicine and Infectious Diseases Vanderbilt University School of Medicine Updates from October 2017 ACIP Meeting William Schaffner, MD, NFID Medical Director Amanda C. Cohn, MD, MPH Executive Secretary, Advisory Committee on Immunization Practices (ACIP) CDR, US Public Health Service Centers for Disease Control and Prevention Questions and Answers This webinar is supported by an unrestricted educational grant from Merck & Co., Inc. NFID policies restrict funders from controlling program content. General Information Please note that today s webinar is being recorded All phone lines will be placed on mute throughout the program To hear audio: Computer: Follow directions Phone: ; Access Code After the presentations, there will be a Question and Answer period Use the Chat box on the lower left side of your screen to type your question At the end of the webinar, participants will be directed to an online evaluation Following the webinar, registered participants will receive an with a link to the presentation slides 2

3 CME/CNE Credit & Webinar Evaluation The National Foundation for Infectious Diseases (NFID) is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education (CME) for physicians. NFID designates this enduring material for a maximum of 1.0 AMA PRA Category 1 Credit TM. This continuing nursing education activity was approved by the Ohio Nurses Association, an accredited approver by the American Nurses Credentialing Center s Commission on Accreditation (OBN ). This education activity has been approved for a maximum of 1.o contact hour. To receive credit or contact hours, you must complete the online evaluation and pass the post-test with a score of 80% or higher Online evaluation and post-test will be available following the webinar at: Certificate will be available for print or download following successful completion of online evaluation and post-test until November 9, CPE Credit & Webinar Evaluation The National Association of Chain Drug Stores (NACDS) is accredited by the Accreditation Council for Pharmacy Education to provide continuing pharmacy education (CPE) for pharmacists. NACDS designates this enduring material for a maximum of 1.0 contact hour of CPE credit. To receive contact hour, you must complete the online evaluation and pass the post-test with a score of 80% or higher Online evaluation and post-test will be available following the webinar at: webinars/acip-recommendations

4 Disclosures Marla Dalton (NFID staff, content reviewer) owns stock, stock options, patent, or other intellectual property from Merck & Co., Inc. William Schaffner (NFID medical director, presenter) served as an advisor or consultant for Dynavax, Merck & Co., Inc., Pfizer Inc., Seqirus, and SutroVax All other activity planners/reviewers and staff for this activity have no relevant financial relationships to disclose Learning Objectives At the conclusion of this activity, participants will be able to: Describe current ACIP recommendations for adult and childhood/adolescent immunization Explain the impact of recent changes to vaccine recommendations on vaccination programs Discuss information on new and/or future vaccines for potential use in practice 4

5 About NFID Non-profit 501(c)(3) organization dedicated to educating the public and healthcare professionals about causes, prevention, and treatment of infectious diseases across the lifespan Reaches consumers, healthcare professionals, and media through: Coalition-building activities Public outreach initiatives Professional educational programs (ACCME accredited with commendation) Scientific meetings, research, and training Longstanding partnerships to facilitate rapid program initiation and increase programming impact Flexible and nimble organization Updates from October 2017 ACIP Meeting Wednesday, October 5, :00 PM ET William Schaffner, MD NFID Medical Director Professor of Preventive Medicine and Infectious Diseases Vanderbilt University School of Medicine Nashville, TN 5

6 Herpes Zoster Vaccines (Shingles) Herpes Zoster and Postherpetic Neuralgia (PHN) About 1 million cases of shingles in the US annually Incidence increases with age, immunocompromise By age 80, 35-50% 50+ with HZ, 10-18% develop PHN, increases with age Zostavax licensed in US in 2006; 31% persons 60+ have received it 6

7 HZ Incidence per 1000 persons 11/9/2017 Herpes Zoster incidence per 1000 persons, by age group, MarketScan, Year 0-19 y y y 60 y Adapted from Harpaz et al IDweek Herpes Zoster (HZ): Clinical Manifestations Courtesy of NIAID Courtesy of CDC Courtesy of CDC/Robert Sumpter 7

8 HZ Vaccine Uptake (%), Adults 60 11/9/2017 Herpes Zoster and PHN: Clinical HZ 90% of HZ episodes associated with pain Antivirals reduce duration of rash and pain PHN Pain at least 90 days following resolution of rash Treatment has minimal or no efficacy Can alter life profoundly Vaccination Coverage of Zoster Vaccine Live (ZVL), Among Adults 60 years, United States, * 2007: National immunization Survey (Lu et al, Vaccine 27:882-7); : NHIS (Am J Prev Med 40:e1-6 & MMWR February 5, 2016 / 65(1);1 36) 8

9 Zostavax (Merck) Shingrix (GSK) Live, attenuated Subunit, adjuvanted 1 dose 2 doses Effectiveness Prevention of herpes zoster Zostavax Shringrix % 97% % 97% % 91% % 91% Prevention of PHN % % % 89% 9

10 Adverse Events Zostavax Injection site reactions, ~48%, mild Grade 3 reactions 0 4% Systemic events 0 8% Several cases of PCR-positive rash, mild Shingrix Grade 3 reactions Injection site 9% Systemic 8% Duration of Protection of ZVL Against Herpes Zoster by Year (RCT) (KPNC) (KPSC) (Medicare, 70-79y) Year post vaccination Note: The Shingles Prevention Study, Short-term Persistence Study, and Long-term Persistence Study followed the same study population in a randomized control trial over time. Baxter (2015), Tseng (2016), and Izurieta (2017) are observational studies. Studies were done in different time periods and among different study populations that had different age structures. 10

11 Vaccine Efficacy Against HZ for ZVL and HZ/su, by Year Following Vaccination VE % ZVL HZ/su (SPS+STPS+LTPS) (ZOE 70) Note: The Shingles Prevention Study, Short-term Persistence Study, and Long-term Persistence Study followed the same study population in a randomized control trial over time. Vaccine Efficacy and Effectiveness Against HZ for HZ/su and ZVL, by Age Group, During the First 4 Years Following Vaccination VE % yrs Median follow up may be less than 3 yrs: Schmader 2012= 1.3 yrs, ^ ZOE 50= 50-69yr: Lal 2015, 70+yrs: Cunningham 2016 * RCTs= yrs: Schmader 2012, and 70+ yrs: Oxman 2005, yrs 70 + yrs HZ/su (ZOE 50/70)^ ZVL (RCTs*) ZVL (Baxter 2015) ZVL (Izurieta 2017)

12 Vaccine Efficacy and Effectiveness Against PHN for HZ/su and ZVL, in Adults 70 Years and Older During the First 4 Years Following Vaccination VE % HZ/su (ZOE 50/70)^ 70 + yrs ZVL (RCTs*) ZVL (Baxter 2015) ZVL (Izurieta 2017) Median follow up may be less than 3 yrs: Schmader 2012= 1.3 yrs, ^ ZOE 50= 50-69yr: Lal 2015, 70+yrs: Cunningham 2016 * RCTs= yrs: Schmader 2012, and 70+ yrs: Oxman 2005, Q1. Should ACIP recommend Shingrix (HZ/su) for vaccination of immunocompetent adults 50 years and older? YES 12

13 Q2. Should ACIP recommend Shingrix (HZ/su) for persons who previously had received Zostavax (ZVL)? Small study (5 year interval) did not alter immunogenicity or safety of Shingrix Substantial proportion of prior recipients now have diminished protection YES Q3. Should ACIP recommend a preference for Shingrix over Zostovax? Pro: Prevent more disease and disability Is refrigerator stable (no freezer needed) Assure insurance/medical system coverage Con: Supply concern Potential unexpected safety signal with widespread use 2 doses More reactogenic YES 13

14 HBV INCIDENCE /9/2017 Hepatitis B Reported Number of Acute Hepatitis B Cases United States, ,000 Hepatitis B Incidence in the United States 300,000 New Hepatitis B Infections 250, , , ,000 Vaccine for high-risk groups*, , s 1990s 2000s 2010s *Healthcare providers, MSM, IDU, hemodialysis patients, household, & sexual partners of persons with chronic HBV, persons in certain institutional settings, e.g., inmates of long-term correctional facilities. Source: National Notifiable Diseases Surveillance System (NNDSS) 14

15 Percentage 11/9/2017 Rates of Reported Acute Hepatitis B by Age Group United States, Source: National Notifiable Diseases Surveillance System (NNDSS) Hepatitis B Vaccine Coverage ( 3 doses) Among Adults Age 19 years 1, National Health Interview Survey (NHIS) United States, Overall Travelers Chronic liver conditions Healthcare personnel Diabetes (19-59yrs) Diabetes (60+yrs) yrs and 60+ yrs for adults with diabetes Vaccination Coverage among Adult Populations - United States, MMWR Surveill Summ May 5;66(11):

16 Limitations of Existing Hepatitis B Vaccines Require 3 doses administered over 6 months* Reduced seroprotection in some populations: Diabetes ( 90% for aged 40 yrs; <40% for aged 70 yrs) 1 Renal disease (77% hemodialysis patients) 2 Immunosuppressed Obese Elderly Smokers *Minimum interval between dose 1 and 3 = 16 weeks 1Murphy TM, et al.; MMWR 2011 Dec 23;60( ) 2Cordova E, et al; Ann Ig 2017;29(27-37) HEPLISAV B (Dynavax) Not yet FDA-licensed new Hepatitis B vaccine Adjuvanted 2 doses 16

17 HEPLISAV B Yeast-derived recombinant hepatitis B surface antigen Adjuvant Toll-like receptor 9 (TLR 9) agonist Mimics natural innate immune response to bacterial and viral DNA Enhances B and T cell responses to co-administered vaccine antigens HEPLISAV B Several double-blinded, randomized, multicenter trials Seroprotection rate (% with anti-hbs ml U/ml) compared with Engerix B 17

18 Illustrative Study Design (HBV-16) (40 70 Years, United States and Canada) Primary Endpoint Week 12 H H Placebo HEPLISAV-B N=2,452 Week Week 4:1 0 4 Week 12 Week 24 Week 32 Week 52 E E E Engerix-B Primary Endpoint Week 32 HBV-10: HEPLISAV-B Met Primary Endpoint Δ= 13.7%, 95% CI [10.4, 17.5] (p< ) 95.0% 81.2% Per-protocol population Seroprotection Rate (%) Week 12 Week 28 HEPLISAV-B (N=1,511) Engerix-B (N=521) 18

19 HBV-10: HEPLISAV-B Induced Significantly Higher Peak SPR 100 HEPLISAV-B (N=1,503) Seroprotection Rate (%) Δ=17.0% 95% CI [13.8, 20.6] 98.2% 81.2% 20 Engerix-B (N=521) Per-protocol population Injections HEPLISAV-B Engerix-B 0 Baseline Weeks Post-Injection Reactions (PIR) Balanced Between HEPLISAV-B and Engerix-B HEPLISAV-B N=3,777 Engerix-B N=1,087 a HBV-10 and HBV-16 % % Any solicited PIR Local PIR Pain Redness Swelling Systemic PIR Fatigue Headache Malaise Fever 38 C a. One subject in HBV-10 erroneously included in Engerix-B was correctly included in HEPLISAV-B group in the PSP. 19

20 Type and Frequency of SAEs Between HEPLISAV-B and Engerix-B PSP (HBV-10, HBV-16 and HBV-23) Preferred Term HEPLISAV-B Engerix-B N=9,365 N=3,867 % % At least 1 SAE Pneumonia Osteoarthritis Acute myocardial infarction Non-cardiac chest pain Chronic obstructive pulmonary disease Cellulitis Prostate cancer Cardiovascular Conclusion No biologically plausible explanation for imbalance Lack of consistency across trials CV events occurred at expected rates in patients with CV risk No temporal association 20

21 Safety Summary Similar to Engerix-B Similar rates of post-injection reactions, AEs / MAEs SAEs similar with imbalances in individual terms Acute MI for HEPLISAV-B Prostate cancer for Engerix-B No evidence for an increase in the rate of any single immune-mediated event Autoantibody conversions balanced Planned Post-Marketing Surveillance Studies at Kaiser Permanente Southern and Northern California Electronic Medical Record analysis Acute myocardial infarction (Southern region) 25,000 HEPLISAV-B : 25,000 other hepatitis B vaccine Non randomized cluster design Immune-mediated events (Southern and Northern regions) 30,000 HEPLISAV-B : 30,000 other hepatitis B vaccine 21

22 HEPLISAV-B Conclusions Induces high rates of seroprotection in all adults Including populations with reduced response to current vaccines Provides earlier seroprotection Similar safety profile Should increase adherence with 2-dose schedule over 1 month INFLUENZA VACCINES The manufacturer of LAIV (FluMist ) intends to provide immunogenicity data on their revised LAIV formulation at the February 2018 ACIP meeting 22

23 Updates from October 2017 ACIP Meeting Wednesday, October 5, :00 PM ET Amanda C. Cohn, MD, MPH Executive Secretary, Advisory Committee on Immunization Practices CDR, US Public Health Service Centers for Disease Control and Prevention Atlanta, GA Mumps Vaccine Mumps outbreaks have been increasing in recent years, in part due to waning immunity of the 2 dose mumps-containing vaccine series Data support use of a third dose of a mumpscontaining vaccine for persons at risk for mumps during an outbreak 23

24 Number of Mumps Cases Number of Mumps Cases Number of Mumps Cases Incidence Rate per Million 11/9/2017 Number of Reported Mumps Cases, United States st Dose ACIP Recommendation nd Dose MMR ACIP Recommendation Year Vaccine Implementation Resurgence First National Outbreak Source: National Notifiable Diseases Surveillance System (passive surveillance); 2017 data as of October 7, Mumps Cases and Outbreak (OB) Related Data Case Count Incidence rate OB Cases Oct % of OB Cases Jurisdicti ons w/ob cases Mumps Cases and Incidence by Year, January 2011-October Cases Year IR Source: National Notifiable Disease Surveillance System (passive surveillance); 2017 data as of October 7,

25 Number of Outbreaks 11/9/2017 Mumps Outbreaks by Size and Setting, United States, January 2016-June Outbreak Size University Community-wide Household *Schools: K-12, dance, hair, and any other school that is not a university setting. Organized groups: workplace, theater groups, parties, fitness centers, other. Vaccine Effectiveness of MMR3 Study population University students School children aged years School children aged 9 14 years No. of subjects (# studies) No. of MMR3 vaccinated subjects No. of MMR3 vaccinated casepatients AR in MMR2 (cases/1000 person-yr) AR in MMR3 (cases/1000 person-yr) 20,496 (1) 5, VE of MMR3 (95% CI), 7 days 60% (38 74%)* VE of MMR3 (95% CI), days 78% (61 88%)* 2,178 (1) 1, % (-32 99%) 3,239 (1) 1, *P value <.001 Calculated as (1-HR)*100; adjusted for 28 days post-vaccination and time since MMR2 Includes case-patients with <2 MMR doses Calculated by reviewers; not reported in article 61% ( %) 50 25

26 Policy Question: Should a 3 rd Dose of MMR Vaccine Be Administered to Persons at Increased Risk for Mumps Because of an Outbreak? Factor Problem Benefits and harms Values Acceptability Implementation Summary WG Interpretation Persons at increased risk for mumps because of an outbreak are a public health priority for the mumps vaccination program; waning immunity in the setting of increased force of infection typical of outbreaks contributes to this risk Benefits outweigh the risks; evidence type is 4 for effectiveness and 2 for safety WG considered that persons in outbreak settings value prevention of: mumps, mumps complications, and loss of productivity MMR3 vaccination was considered acceptable to students, parents, universities/ schools, and health departments Providers and the target population have experience with MMR vaccination. Public health should be involved in identifying target groups at increased risk for mumps WG agreement that a 3 rd dose of MMR vaccine would improve protection for persons at increased risk for mumps because of an outbreak October 2017 ACIP Mumps Recommendation Persons previously vaccinated with two doses of a mumps-containing vaccine* who are identified by public health as at increased risk for mumps because of an outbreak should receive a third dose of a mumps-containing vaccine to improve protection against mumps disease and related complications *As stated in Prevention of Measles, Rubella, Congenital Rubella Syndrome, and Mumps, 2013: Summary Recommendations of the Advisory Committee on Immunization Practices (ACIP); wording includes MMR and MMRV 26

27 Shoulder Dysfunction Following Vaccination: SIRVA Anatomy of the Upper Arm 27

28 Background: Shoulder Injury Following Vaccination Background 1 Shoulder injury related to vaccine administration (SIRVA) manifests as shoulder pain and limited range of motion occurring after the administration of a vaccine intended for intramuscular administration in the upper arm These symptoms are thought to occur as a result of unintended injection of vaccine antigen or trauma from the needle into and around the underlying bursa of the shoulder resulting in an inflammatory reaction [By definition] SIRVA is caused by an injury to the musculoskeletal structures of the shoulder (e.g., tendons, ligaments, bursae, etc.) SIRVA is not a neurological injury and abnormalities on neurological examination or nerve conduction studies (NCS) and/or electromyographic (EMG) studies would not support SIRVA as a diagnosis (even if the condition causing the neurological abnormality is not known) 1 Reference: Vaccine Injury Table ( Summary Reports to Vaccine Adverse Event Reporting System (VAERS) of shoulder dysfunction following IIV ranged from during the six influenza seasons from to During that period around 130 million doses of IIV were distributed each influenza season in the United States There was a higher percentage of reports of shoulder dysfunction following IIV among females when compared to non-shoulder dysfunction reports Most (70%) reports were in the age group years; few were in individuals 0-18 years (<1%) When possible contributing factors were described, vaccination given too high on the arm was most commonly reported The most common place of vaccination documented in reports was in pharmacies/drug stores and doctor s offices/hospitals 28

29 Making the Schedules Easier to Read! 29

30 2017 HPV Footnote Proposed 2018 HPV Footnote Human papillomavirus (HPV) vaccine. (Minimum age: 9 years) Routine and catch-up vaccination: Administer a 2-dose series of HPV vaccine on a schedule of 0, 6-12 months to all adolescents aged 11 or 12 years. The vaccination series can start at age 9 years. Administer HPV vaccine to all adolescents through age 18 years who were not previously adequately vaccinated. The number of recommended doses is based on age at administration of the first dose. For persons initiating vaccination before age 15, the recommended immunization schedule is 2 doses of HPV vaccine at 0, 6-12 months. For persons initiating vaccination at age 15 years or older, the recommended immunization schedule is 3 doses of HPV vaccine at 0, 1 2, 6 months. A vaccine dose administered at a shorter interval should be readministered at the recommended interval. o In a 2-dose schedule of HPV vaccine, the minimum interval is 5 months between the first and second dose. If the second dose is administered at a shorter interval, a third dose should be administered a minimum of 12 weeks after the second dose and a minimum of 5 months after the first dose. o In a 3-dose schedule of HPV vaccine, the minimum intervals are 4 weeks between the first and second dose, 12 weeks between the second and third dose, and 5 months between the first and third dose. If a vaccine dose is administered at a shorter interval, it should be readministered after another minimum interval has been met since the most recent dose. Persons who have completed an age-appropriate HPV vaccine series (i.e, either 2 or 3 doses of 2vHPV, 4vHPV, or 9vHPV at the recommended intervals) are considered adequately vaccinated. Special populations: For children with history of sexual abuse or assault, administer HPV vaccine beginning at age 9 years. Immunocompromised persons* aged 9 26 years, including those with human immunodeficiency virus (HIV) infection, should receive a 3-dose series at 0, 1 2, and 6 months. Note: HPV vaccination is not recommended during pregnancy, although there is no evidence that the vaccine poses harm. If a woman is found to be pregnant after initiating the vaccination series, no intervention is needed; the remaining vaccine doses should be delayed until after the pregnancy. Pregnancy testing is not needed before HPV vaccination. Human papillomavirus (HPV) vaccine (minimum age: 9 years) Routine and catch-up vaccination: Routine vaccination at years (can start at age 9) and through age 18 if not previously adequately vaccinated. Number of doses dependent on age at initial vaccination: o Age 9 14 years at initiation: 2-dose series at 0 and 6 12 months. Minimum interval: 5 months (repeat a dose given too soon at least 12 weeks after the invalid dose and at least 5 months after the 1st dose). o Age 15 years or older at initiation: 3-dose series at 0, 1 2 months, and 6 months. Minimum intervals: 4 weeks between 1st and 2nd dose; 12 weeks between 2nd and 3rd dose; 5 months between 1st and 3rd dose (repeat dose/s given too soon). Persons who have completed a valid series with any HPV vaccine do not need any additional doses. Special situations: History of sexual abuse or assault: Begin series at age 9 years. Immunocompromised* (including human immunodeficiency virus [HIV]) aged 9 26 years: 3-dose series at 0, 1 2 months, and 6 months. Pregnancy: Vaccination not recommended, but there is no evidence the vaccine is harmful and no intervention needed for women who inadvertently received a dose of HPV vaccine while pregnant. Delay remaining doses until after pregnancy. Pregnancy testing not needed before vaccination. *See MMWR, December 16, 2016;65(49): , at *See MMWR December 16, 2016;65(49): , available at 30

31 Summary of Pneumococcal Epidemiology Significant reductions in overall and PCV13 serotype IPD among children and adults since PCV13 introduction Reductions driven by types 19A and 7F Rates plateaued in No further reductions in PCV13 serotype IPD among adults 65 years since 2014 adult PCV13 recommendations Despite reductions, IPD rates including PCV13 serotypes, remained high in adults with HIV compared to those without HIV No large increases in any non-pcv13 serotype among children or adults, including those living with HIV Similar trends observed for pneumococcal meningitis Key Questions To Be Answered Before 2018 Review Is PCV13 use among adults >65 years old preventing disease? To what extent are the observed benefits driven by adult PCV13 use (direct effects) vs. pediatric PCV13 use (indirect effects)? What benefits would we expect from continued PCV13 use among adults? 62 31

32 Cases per 100,000 11/9/2017 Estimated PCV13 Adult Cumulative Uptake, Adults >65 Years Old, IMS Claims Data and Manufacturer Sales, August 2014 May 2017 Slide courtesy of Pfizer IPD Rates Among Adults 65 Years by PCV13 Plus 6C Serotypes, PCV13 introduction for children PCV7 (except 19F) 19F PCV13 introduction for adults

33 Laboratory Results 3,008 people enrolled 1398 specimens (699 participants) 2,984 3,008 people included 24 excluded poor specimen quality 45 (1.5%) Spn culture positive on NP or OP Spn carriage prevalence: 1.8% 2,939 Spn culture negative 10 lyta positive on NP 7 vaccine type and 38 non-vaccine type VT-carriage prevalence: 0.2% 2 non vaccine type and 8 negative for serotypes tested Carriage by Vaccination Status Vaccinated N= 1353 Non-Vaccinated N=1464 Pneumococcal carriage, n(%)* 24 (1.8%) 23 (1.6%) VT-Pneumococcal carriage, n(%) ⱡ 3 (0.2%) 2 (0.1%) * 8 excluded due to unknown vaccination status ⱡ 2 excluded due to unknown vaccination status 66 33

34 Impact on IPD observed to date Changes in PCV13-type IPD burden among adults >65 years old PCV13-type IPD rates declined through 2014 due to indirect PCV13 effects No additional declines in annual rates observed in PCV13-types account for 22% of IPD in 2016 compared to 43% pre-pcv13 Changes in IPD among adults <65 years old with and without indications for PCV13 use PCV13-type IPD burden continues to decline among adults with and without current indications for PCV13 use Similar reductions among those with chronic medical conditions, current indications for PPSV23-only use Questions & Answers

35 CME/CNE Credit & Webinar Evaluation The National Foundation for Infectious Diseases (NFID) is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education (CME) for physicians. NFID designates this enduring material for a maximum of 1.0 AMA PRA Category 1 Credit TM. This continuing nursing education activity was approved by the Ohio Nurses Association, an accredited approver by the American Nurses Credentialing Center s Commission on Accreditation (OBN ). This education activity has been approved for a maximum of 1.o contact hour. To receive credit or contact hours, you must complete the online evaluation and pass the post-test with a score of 80% or higher Online evaluation and post-test will be available following the webinar at: Certificate will be available for print or download following successful completion of online evaluation and post-test until November 9, CPE Credit & Webinar Evaluation Visit: Select course Advisory Committee on Immunization Practices (ACIP) Recommendations, 2017 Live under Claiming Credit Select Add to Cart Login or sign-up for a LearnSomething account Select View Enrollment and course title under Activities Enter Attendance Code, complete Post-Test and Evaluation, and enter NABP number and birthdate to claim credit Contact education@nacds.org with any questions ATTENDANCE CODE: XGC9MG 35

36 Join Us For Upcoming NFID Webinars Be Antibiotics Aware: Smart Use, Best Care November 14, 2017 at 12:00 PM ET Shingles Vaccines: What You Need to Know December 6, 2017 at 12:00 PM ET Registration: Subscribe to NFID updates: 36