Preventable diseases & vaccines

Vaccine Recommendations Roto virus

-ACIP does not express a preference for RotaTeq or Rotarix but does recommend that the same product be used to complete the series whenever possible. -RotaTeq is administered orally in a 3-dose series, with doses administered at ages 2, 4, and 6 months. -Rotarix is administered orally in a 2-dose series, with doses administered at ages 2 and 4 months. If RotaTeq is administered for any of the doses in the series, a total of 3 doses must be given to provide adequate protection for the patient. The minimum age for the first dose of rotavirus vaccine is 6 weeks, and the maximum age for the first dose is 14 weeks, 6 days. Vaccination should not be initiated for infants age 15 weeks, 0 days or older because there are insufficient data on the safety of a first dose in older infants. The minimum interval between doses of rotavirus vaccine is 4 weeks. The maximum age for the last dose of rotavirus vaccine is 8 months, 0 days.

Target Groups for Vaccination (Influenza)

-ACIP recommends that all persons aged 6 months and older be vaccinated against influenza each year. It should be offered throughout the entire influenza season. -ACIP recommends focusing vaccination efforts on individuals at higher risk for influenza-related complications. While vaccination of high-risk individuals should still be a target, vaccinating younger, healthier people has the potential not only to protect the individual, but also to promote herd immunity through reduced community transmission. -ACIP recommends that all women who will be pregnant during the influenza season be vaccinated against influenza, regardless of trimester. (In pregnant women, influenza vaccination appears to provide benefits to infants after birth. Infants born to women vaccinated against influenza during pregnancy experience fewer influenza-related hospitalizations.)

Vaccine recommendations (Influenza)

-All people aged 6 months and older should receive 1 dose of the influenza vaccine each year during the influenza season. -The single exception to this recommendation is for all children aged 6 months to 8 years receiving influenza vaccination for the first time. These children should receive 2 doses, administered at least 4 weeks apart in the same season. If a child younger than 9 years old has received a total of 2 or more doses of seasonal influenza vaccine since before July 1, 2016, then only 1 dose is required during the current season. The two previous doses need not have been given during the same season or consecutive seasons. If the child has not received a total of 2 or more doses of seasonal influenza vaccine since before July 1, 2016, or the health care provider cannot verify how many doses the child has received, then 2 doses should be administered in the current influenza season. Once a child has completed the priming series of 2 doses, the child will need only 1 dose of vaccine in each subsequent year.

Non-egg-based influenza vaccines

-In November 2012, the FDA approved Flucelvax, the first U.S.-licensed influenza vaccine manufactured with virus propagated in canine kidney cells rather than in eggs to avoid the risk of anaphylaxis in patients with egg allergy (ccIIV3; Novartis).6 It was approved for the prevention of influenza in patients 18 years of age and older. -In May 2016, FDA licensed Flucelvax Quadrivalent (ccIIV4) for persons 4 years of age and older to replace the previously-licensed trivalent formulation of Flucelvax. As of 2017, this vaccine is available only as a quadrivalent formulation. -In January 2013, the FDA approved another non-egg-based influenza vaccine (RIV3; Flublok—Protein Sciences), made withrecombinant hemagglutinin, for the prevention of seasonal influenza in adults 18 to 49 years of age. In October 2016, Flublok quadrivalent vaccine (RIV4) was approved for the 2017-18 season. -These two new vaccines require less time to manufacture mainly because the process is not dependent on egg growth and supply, nor is it limited by the selection of strains that are adapted for growth in eggs. The shorter manufacturing time could be useful in the event of a pandemic or vaccine supply shortage

RotaTeq Administration

-RotaTeq is an oral suspension supplied in ready-to-use, 2 mL, single-dose tubes. -After removal of the twist-off cap, the dosing tube should be placed in the infant's mouth, pointed toward the inner cheek, and the tube squeezed gently until empty. The entire contents of the tube should be administered to the infant; however, the tip of the tube may hold a residual drop. There are no food or drink restrictions after the vaccine dose. If the infant regurgitates, vomits, or spits out a small amount of the vaccine, readministration is not recommended, and the infant should receive future vaccinations as scheduled. RotaTeq should be administered as a 3-dose series to infants at 2, 4, and 6 months of age.

Diphtheria

-caused by Corynebacterium diphtheriae, an aerobic, gram-positive bacterium -can enter the body through the respiratory tract -produces a toxin that can be absorbed into the bloodstream and distributed -throughout the body, causing the clinical features and complications of the disease. Infection with C. diphtheriae can occur at any mucous membrane in the body. The most common sites of infection include the tonsils, pharynx, larynx, and nasal mucosa. Other mucous tissues that can be affected include the skin, ocular tissue, or genital area. The infection can cause tissue destruction and usually results in the formation of a pseudomembrane, which is a characteristic sign of diphtheria infection. Most commonly, diphtheria infection affects the pharynx and tonsils. Early symptoms are similar to pharyngitis: malaise, sore throat, low-grade fever, and anorexia. However, within 2 to 3 days, a bluish-white membrane develops on the tonsils and pharynx. The color of the membrane can change as the disease progresses. This membrane may extend into the airway and ultimately cause respiratory obstruction. Attempts to remove the membrane will result in significant bleeding because the membrane is firmly attached to surrounding tissue Laryngeal diphtheria often follows the same course as pharyngeal diphtheria; however, only the larynx is involved. When patients experience laryngeal diphtheria, they may complain of symptoms such as a fever, hoarseness, and a barking cough. Adherence of the membrane to the larynx can lead to airway obstruction, coma, and death. Diphtheria infection can lead to serious complications such as myocarditis (inflammation of the heart) and neuritis (inflammation of the motor nerves). Serious complications are due to absorption of the bacteria's toxin. Recovery depends on the amount of toxin absorbed and the extent of the complications caused by the toxin. The overall death rate from diphtheria infection is 10% and mortality is higher among children and adults older than 40 years. It is not sufficient to give patients periodic booster doses of tetanus toxoid alone. Instead, booster doses of diphtheria are needed to boost immunity after a patient has completed a primary immunizing series with diphtheria-containing vaccines.

Influenza Vaccination of Persons with Egg Allergy

1. Persons with a history of egg allergy who have experienced only hives after exposure to egg should receive influenza vaccine. 2. Persons who have other reactions other than hives after egg exposure, may receive any licensed and recommended influenza vaccine. 3. A previous severe allergic reaction to influenza vaccine is a contraindication to future receipt of the vaccine.

Inactivated influenza vaccine Intramuscular dosing

6-35 months, 1 or 2 doses (4 weeks apart) 3-8 years, 1 or 2 doses (4 weeks apart) 9 years and above 0.05 ml

Target Groups for Vaccination for HPV

9vHPV is indicated for administration to girls and women 9 to 45 years of age for the prevention of cervical vulvar, vagina, and anal cancers, precancerous or dysplastic lesions, and genital warts. It is also indicated for boys and men through 45 years of age for the prevention of anal cancer, precancerous or dysplastic lesions, and genital warts. Ideally, HPV vaccine should be given prior to the onset of sexual activity to provide protection before potential exposure to HPV occurs through sexual contact. Vaccination before exposure to any type of HPV will allow the individual to receive full benefit from the vaccine. However, patients who are already sexually active should be vaccinated because they still may receive benefit from vaccination. The HPV vaccines are not indicated for the treatment of HPV infection. These vaccines are for prophylaxis only and cannot prevent disease due to an existing HPV infection and will not prevent HPV due to other types of HPV. However, in patients with HPV infection, the vaccination can provide protection against infection with additional types of HPV.

Pneumococcal vaccine(23-Valent Pneumococcal Polysaccharide Vaccine)

A 23-valent polysaccharide vaccine (PPSV23; Pneumovax 23—Merck). This vaccine contains polysaccharides from 23 strains of S. pneumoniae that cause 60% to 76% of invasive pneumococcal disease. More than 80% of healthy adults who receive PPSV23 will develop antibodies against the serotypes contained in the vaccine within 2 to 3 weeks after vaccination. Vaccine efficacy declines with advancing age and may be less effective in patients with underlying illness. However, the vaccine can still provide protection for these high-risk patients and should be administered. Because this is a pure polysaccharide vaccine, it is not adequately effective in children younger than 2 years of age. PPSV23 has been shown to reduce the risk of invasive disease (e.g., bacteremia, meningitis) caused by the serotypes included in the vaccine by 60% to 70%.3,56 Study results have not consistently shown that PPSV23 reduces the incidence of pneumococcal pneumonia. However, studies do suggest that even if PPSV23 does not prevent pneumococcal pneumonia, vaccination with PPSV23 can improve outcomes in patients with pneumococcal pneumonia. In these studies, patients with pneumococcal pneumonia who had been vaccinated experienced fewer complications, decreased length of hospital stay, decreased need for admission to the intensive care unit, and a lower rate of death

Target groups for vaccination Hepatitis B

ACIP has adopted a comprehensive strategy to eliminate hepatitis B in infants, children, adolescents, and adults.66,67 Infants should receive their first dose of hepatitis B vaccine shortly after birth but before hospital discharge.65 A birth dose is vital to protect against maternal transmission. Infants born to mothers positive for HBsAg need both hepatitis B vaccine and hepatitis B immune globulin (HBIG) promptly at birth, ideally within 12 hours of birth. The comprehensive strategy also calls for immunization of all susceptible children and adolescents not previously vaccinated. Adults who should receive hepatitis B vaccination include those at risk for infection by sexual exposure (e.g., people with multiple sex partners), those at risk for percutaneous exposure to blood (e.g., health care workers), patients with diabetes, patients with chronic liver or renal disease, patients infected with HIV, international travelers, and all unvaccinated adults who want to be protected against the illness regardless of risk factors. In 2011, ACIP recommended that all previously unvaccinated adults aged 19 to 59 years with diabetes type 1 or type 2 should be vaccinated against hepatitis B as soon as possible after a diagnosis of diabetes is made.68 Patients with diabetes aged 60 years and older may be vaccinated at the discretion of the treating clinician on the basis of increased need for assisted blood glucose monitoring in long-term care facilities, likelihood of acquiring hepatitis B infection, need to manage its complications or chronic sequelae, and likelihood of immune response to vaccination.46 Because this is a relatively new recommendation, many patients with diabetes have not yet been vaccinated against hepatitis B. Pharmacists should be proactive in offering hepatitis B vaccination to patients with diabetes.

Tdap

ACIP recommended vaccination with Tdap for adolescents and adults to improve immunity against pertussis. Because pertussis remains poorly controlled in the United States and vaccination rates in adolescents and adults are low, ACIP expanded its recommendations to include the following All patients aged 11 to 64 years should receive a one-time dose of Tdap. - Preferably, all adolescents would receive a dose of Tdap at 11 or 12 years of age. - Any person 11 to 64 years of age without documentation of a Tdap dose should receive a one-time dose. All adults aged 65 years and older who have or who anticipate having close contact with an infant younger than 12 months of age and who previously have not received Tdap should receive a single dose of Tdap. For other adults aged 65 years and older who have not previously received Tdap, a single dose of Tdap vaccine may be given in place of 1 dose of Td vaccine. Children aged 7 to 10 years who are not fully vaccinated against pertussis and for whom no contraindication to pertussis vaccine exists should receive a single dose of Tdap. ACIP is considering a revaccination recommendation for certain high-risk groups, such as health care providers.

Target Groups for Vaccination Meningococcal disease

ACIP recommends MenACWY routine vaccination for the following patients61: • Adolescents aged 11 to 12 years, with a booster dose at 16 years. • All previously unvaccinated adolescents aged 13 to 15 years, with one booster dose at age 16 to 18 years. • Children aged 2 months to 10 years with high-risk conditions. • Adults who are at high risk for meningococcal disease. People at high risk who should receive MenACWY include: • College freshmen living in dormitories. • Military recruits. • Patients with anatomic or functional asplenia. • Patients with HIV infection • Patients with immunodeficiencies (e.g., complement component deficiency). • People who travel to countries where N. meningitidis is endemic (e.g., "meningitis belt" of sub-Saharan Africa). • People who travel to countries where vaccination is required (e.g., travelers to Saudi Arabia for annual Hajj). • Microbiologists who routinely handle N. meningitidis isolates. • People at risk because of an outbreak of MenACWY. MenB routine vaccination is recommended for: • Young adults 16 to 23 years of age (preferred age is 16 to 18 years), based on individual clinical decision making High-risk patients 10 years of age and older who should receive MenB include: • Patients with anatomic or functional asplenia. • Microbiologists who routinely handle N. meningitidis isolates. • People at risk because of an outbreak of MenB.

Vaccine Recommendations for herpes Zoster vaccine (needs updating)

ACIP recommends a single dose of HZV for adults 60 years of age and older, regardless of whether they have had a prior episode of herpes zoster or report a history of chickenpox. Those with chronic medical conditions may be vaccinated unless a contraindication or precaution exists because of their condition. In 2011, FDA expanded the age indication for zoster vaccine to include adults 50 to 59 years of age for preventing herpes zoster. This decision was based on a large study showing that the vaccine reduced the risk of herpes zoster by approximately 70% in this population. Because the risk of getting shingles and developing PHN is much lower for adults 50 to 59 years of age than for those aged 60 years and older and because the vaccine is only indicated for one dose, ACIP recommends zoster vaccine only for adults at least 60 years of age. Nonetheless, CDC recommends that individuals 50 to 59 years of age may be vaccinated. Health care providers may consider whether the patient would have poor tolerance to herpes zoster PHN symptoms when making a recommendation. For example, the provider may recommend HZV for a patient with preexisting chronic neuropathic pain, severe depression, other comorbidities, intolerance to treatment medications due to hypersensitivity or interactions with other medications, or occupational considerations.41 In a randomized clinical study, a reduced immune response to HZV vaccine was observed in individuals who received concurrent administration of 23-valent pneumococcal polysaccharide vaccine (PPSV23) and HZV compared with individuals who received these vaccines 4 weeks apart. Based on these data, the package insert for HZV vaccine advises that health care providers "consider administration of the two vaccines separated by at least 4 weeks."42 However, the clinical relevance of the observed reduction in antibody titers is unknown because there is no correlate of protection for antibody titers against varicella zoster virus as a measure of protection against herpes zoster. It is likely that cell-mediated immunity plays a larger role, but T-cell function was not assessed in this study. The results were additionally confounded by unexplained differences across comparison groups in the baseline varicella zoster virus antibody titers. Antibody levels to PPSV23 serotypes 3, 14,19A, and 22F also were assessed during this study and were unaffected by simultaneous administration; the significance of this observation is unknown. Finally, study results indicated that the safety profile of HZV is unaffected by simultaneous administration of PPSV23. Consequently, to avoid introducing barriers to patients and providers who are interested in administration of these two vaccines, ACIP has not changed its recommendation for simultaneous vaccination. ACIP continues to recommend that HZV and PPSV23 be administered at the same visit if the patient is eligible for both vaccines. Practitioners should use their professional judgment on

Vaccine Recommendations Meningococcal disease MenACWY Vaccines

ACIP recommends routine vaccination with MenACWY for all adolescents 11 to 12 years of age, followed by a booster dose given at 16 years of age.61 This recommendation is based on evidence suggesting that people immunized at age 11 or 12 years may have decreased protective immunity after 5 years, when their risk for meningococcal disease is greatest. All adolescents aged 13 to 18 years who have not yet received MenACWY should receive catch-up vaccination. Adolescents who receive the first dose of MenACWY between 13 and 15 years of age should receive a booster dose at 16 to 18 years of age with a minimum interval of at least 8 weeks between doses. Adolescents who first receive MenACWY between 16 and 18 years of age only need a single dose. MenACWY vaccine is not recommended for routine use in healthy adults who do not have high-risk conditions. Adults who are at high risk should receive MenACWY as follows: • Patients with HIV, persistent complement component deficiency, or anatomical or functional asplenia: two doses at least 8 weeks apart followed by revaccination every 5 years.61 • Microbiologists: one dose followed by revaccination every 5 years if the risk remains. • Military personnel: one dose followed by revaccination every 5 years if the risk remains. • At risk because of a disease outbreak: one dose. • First-year college students living in dormitories: one dose, if not previously vaccinated. • Adults living in or traveling to high-risk countries: one dose, with revaccination every 5 years if the risk remains. Children younger than 19 months at increased risk of exposure or with high-risk medical conditions (e.g., asplenia) should receive either an infant age-appropriate series of Hib-MenCY or MenACWY (see the child and adolescent schedule for detailed recommendations based on high-risk condition) MenHibrix should not be administered to a child who travels to sub-Saharan Africa or the Hajj or to international travelers who require meningococcal vaccine because it does not contain serogroups A or W-135. Children at continued risk for meningococcal disease who were previously vaccinated with MenACWY should receive an additional dose after 3 years if the first dose was administered at 2 to 6 years of age. All meningococcal vaccines are recommended for control of disease during community meningitis outbreaks. Pharmacists should refer to their local health department for advice about immunization during meningococcal outbreaks.

Immunocompromised patient (influenza)

ACIP recommends that people with immunosuppression should receive influenza vaccine annually. However, only IIV should be administered to a person immunosuppressed for any reason (either from the underlying illness or treatment of an illness).

Target Groups for Vaccination Hepatitis A

According to ACIP, hepatitis A vaccine should be routinely recommended for all children 12 to 23 months of age, any person at increased risk for infection, or any person wanting to reduce the risk of hepatitis A infection. People traveling internationally—with the exception of travel to Canada, Western Europe, Japan, New Zealand, or Australia—should be vaccinated against hepatitis A. Vaccination should be routinely recommended for household members and other close personal contacts of internationally adopted children arriving from areas of the world where hepatitis A is endemic. Additionally, men who have sex with men, injection drug users, laboratory workers potentially exposed to this virus, people with chronic liver disease or clotting factor disorders, or any other person at increased risk for hepatitis A infection should be vaccinated. Hepatitis A vaccine is not routinely recommended for health care workers, day careworkers, sanitation workers, or food handlers, although the vaccine may be recommended for food handlers in some areas. Hepatitis A vaccine also plays a role in postexposure prophylaxis for individuals who have been exposed to hepatitis A. Pharmacists should refer to up-to-date recommendations in such circumstances

Potential Adverse Reactions (Tetanus, diphtheria) pertussis only

Acellular pertussis vaccines (i.e., DTaP and Tdap) may produce local reactions including redness and swelling at the injection site. Local reactions have been reported more frequently in children after the fourth and/or fifth doses of DTaP.3 Low-grade fever also has been reported after vaccination with DTaP and Tdap. Severe adverse events (e.g., fever greater than 40.5°C [105°F], febrile seizures, persistent crying lasting 3 hours or longer, hypotonic/hyporesponsive episodes) have been reported after DTaP vaccination but occur less frequently than after vaccination with the whole-cell vaccines. None of these conditions have been associated with permanent brain injury. No increased risk of encephalopathy has been observed with DTaP administration. The CDC continues to monitor long-term surveillance data on the safety of DTaP relative to the more severe and rare adverse events that were seen after vaccination with DTwP.

Target groups for vaccination Varicella

All children older than 12 months of age should be vaccinated against varicella. Susceptible adolescents and adults should be vaccinated if they do not have evidence of immunity. According to ACIP recommendations, patients who can demonstrate evidence of immunity to varicella do not need to be vaccinated. Evidence of immunity can include any of the following: 1 Documentation of age-appropriate vaccination. 2 Laboratory evidence of immunity or laboratory confirmation of disease. 3 Birth in the United States before 1980. (However, for health care providers, women of childbearing age, and immunocompromised patients, birth before 1980 should not be considered evidence of immunity because certainty regarding immunity is desirable in these populations.) 4 Diagnosis or verification of history of varicella disease or herpes zoster by a health care provider. (Verification of history of disease or diagnosis should be provided by a health care provider rather than relying on parental or self-reporting.)

Target Groups for Vaccination Haemophilus Influenza type B

All infants without a valid contraindication should receive Hib vaccine.

Target Groups for Vaccination Rotavirus

All infants without a valid contraindication should receive the rotavirus vaccine. Infants who have had rotavirus gastroenteritis before completing the primary series should still complete the entire series. Premature infants born before 37 weeks of gestation may receive the vaccine if they are at least 6 weeks of age, are being or have been discharged from the hospital and are clinically stable, and the benefits of receiving the vaccine outweigh the risks.

Target groups for vaccination (tetanus, Diphtheria, pertussis)

All infants, adolescents, and adults should be immunized against tetanus, diphtheria, and pertussis unless there is a valid contraindication or precaution to receiving the vaccine

Storage and Administration of Influenza Vaccines

All influenza vaccines should be stored in the refrigerator at 2°C to 8°C (36°F to 46°F). These vaccines should not be frozen

Storage and Administration of Meningococcal Vaccines

All meningococcal vaccines should be stored in the refrigerator at 2°C to 8°C (36°F to 46°F) and protected from light at all times. All meningococcal vaccines should be shaken before use and administered intramuscularly. Menveo must be preparedfor administration by reconstituting the MenA lyophilized conjugate vaccine component with the MenCYW-135 liquid conjugate vaccine component with the MenCYW-135 liquid conjugate vaccine component according to manufacturer's instructions.

Storage and Administration of Tetanus, Diphtheria, pertussis

All vaccines containing tetanus, diphtheria, and pertussis should be stored in the refrigerator at 2°C to 8°C (36°F to 46°F); these vaccines should not be frozen.30 When administering the vaccine, pharmacists should shake the vial or prefilled syringe before use and administer the 0.5 mL dose intramuscularly (for all vaccines containing tetanus, diphtheria, and pertussis). These vaccines should never be administered subcutaneously.

Use of Tdap in childbearing age

All women of childbearing age should be vaccinated with Tdap during every pregnancy. Tdap given to pregnant women will stimulate the production of pertussis antibodies that will be transferred through the placenta and help protect the infant; it also will protect the mother from developing pertussis. Administer any time during pregnancy but preferred during the third trimester (between 27 and 36 weeks gestation) to transfer the highest concentration of antibodies through the placenta. Data presented to ACIP suggest that vaccinating women earlier in the 27- to 36-week window maximizes passive antibody transfer to the infant. Women who have just given birth should receive a single dose of Tdap immediately postpartum if they have not received a dose previously. For women who have multiple closely spaced pregnancies, there is a theoretical risk for severe local reactions (e.g., Arthus reactions, whole limb swelling); however, available data have not found an increased incidence of these reactions. ACIP currently recommends only one lifetime dose of Tdap, except for pregnant women, who should receive a dose during each pregnancy

Antigenic shift

An antigenic shift involves major changes of one or both of the surface antigens, creating a new strain of the virus. Antigenic shifts are probably due to genetic recombination (an exchange of a gene segment called genetic reassortment) between influenza A viruses, usually those that affect humans, pigs, and birds. When the new strain of the influenza virus differs significantly from past strains, a global pandemic may occur. During a pandemic, serious disease spreads quickly because the population has little or no antibody protection from the new strain. Mortality associated with a pandemic is usually higher than during interpandemic periods.

Vaccines for Poliomyelitis

An inactivated poliovirus vaccine (IPV) was first licensed in 1955. A trivalent, oral attenuated poliovirus vaccine (OPV) was licensed in 1963. OPV was the vaccine of choice in the United States following its approval; this live vaccine was very effective, conferred long-lasting immunity, and was easy to administer. Unfortunately, because the live attenuated viruses in the vaccine were shed in the stool, it was possible for the shed virus to spread to susceptible contacts of the vaccinated person, thereby causing vaccine-associated paralytic poliomyelitis. The overall risk of vaccine-associated paralytic poliomyelitis was 1 case per 2 million to 3 million OPV doses distributed, affecting 8 to 10 people per year in the United States.3 Concerns about the risks associated with OPV prompted the development of an enhanced potency inactivated poliovirus vaccine (IPOL—Sanofi Pasteur), which was licensed in 1987. Owing to the availability of this safe, effective IPV, distribution of OPV in the United States ceased in 2001, and IPV became the vaccine of choice. IPV is highly effective in producing immunity, with 99% of patients developing protective antibody levels after 3 doses.3 In addition to protecting people from the disease, IPV has the advantage of being an inactivated vaccine and therefore cannot cause paralytic poliomyelitis.

Antigenic drift

Antigenic drift occurs continuously and results in minor changes in the antigenic structure of the virus, but the H and N numbers do not change. When the new version of the virus is different enough from the previous version, the virus can cause an epidemic because protection that remains from previous exposures to similar influenza viruses is incomplete.

Contraindications and Precautions Poliomyelitis

Any child or adult who needs IPV should receive the vaccine unless a valid contraindication or precaution is present. IPV contains trace amounts of streptomycin, polymyxin B, and neomycin, which can cause hypersensitivity in patients who are sensitive to these antibiotics Precautions include moderate or severe acute illness with or without fever and use during pregnancy.

Contraindications and Precautions Poliomyelitis

Any child or adult who needs IPV should receive the vaccine unless a valid contraindication or precaution is present. IPV contains trace amounts of streptomycin, polymyxin B, and neomycin, which can cause hypersensitivity in patients who are sensitive to these antibiotics. Precautions include moderate or severe acute illness with or without fever and use during pregnancy.

Contraindications and Precautions Meningococcal disease

Any patient meeting the above criteria and having no valid contraindications or precautions should receive meningococcal vaccine. Meningococcal vaccines are contraindicated in individuals who have had a severe allergic reaction (e.g., anaphylaxis) to a previous vaccine dose or to a vaccine component. Moderate or severe acute illness with or without fever is a precaution.

Td vaccine

Any person who does not have a valid contraindication to receiving tetanus and diphtheria toxoids-containing vaccines should receive booster doses of Td every 10 years once a primary series has been completed and the person has a record of receiving 1 dose of Tdap

Influenza vaccines contra indications and precautions

As with all other vaccines, a previous severe allergic reaction to a vaccine or a vaccine component is a contraindication to receiving the vaccine (regardless of the component suspected of being responsible for the reaction) With the exception of RIV and ccIIV, influenza vaccines are produced in fertilized chicken eggs, creating the potential for an allergic reaction in patients who are allergic to eggs. Patients with a history of egg allergy, experiencing hives only after exposure should receive influenza vaccine and may receive any licensed and recommended influenza vaccine (any form of IIV or RIV) that is otherwise appropriate. Persons who report having allergic reactions to egg involving symptoms other than hives, such as angioedema, respiratory distress, lightheadedness, or recurrent emesis; or who required epinephrine or another emergency medical intervention, may similarly receive any licensed and recommended influenza vaccine. The selected vaccine should be administered in an inpatient or outpatient medical setting (including but not necessarily limited to hospitals, clinics, health departments, and physician offices). Vaccine administration should be supervised by a health care provider who is able to recognize and manage severe allergic conditions. Prior history of Guillain-Barré syndrome is not an absolute contraindication to vaccination with influenza vaccine, but it is a precaution if it occurred within 42 days of vaccination. Any patient with a history of Guillain-Barré syndrome associated with influenza vaccination should be referred to a physician for assessment to evaluate the risks versus the benefits of receiving influenza vaccine. If the patient has a valid contraindication or precaution to receiving influenza vaccine, vaccination should be deferred, or the patient should be referred to his or her primary care provider

Clinical Features and Potential Complications Haemophilus influenza type B

Before the availability of vaccines, Hib affected 1 of every 200 children in the United States, accounting for more than 20,000 cases each year. It was the leading cause of bacterial meningitis in children younger than 5 years of age. Invasive Hib disease also caused epiglottitis, pneumonia, osteomyelitis, arthritis, cellulitis, and bacteremia. Complications of invasive Hib infection were significant, including deafness and other neurologic sequelae (e.g., mental retardation, seizures, developmental delay) in up to 30% of survivors. Hib had been the leading cause of acquired mental retardation before widespread vaccination. Mortality rates associated with Hib disease were also high before vaccine use, with up to 5% of patients dying despite appropriate antibiotic treatment. Hib vaccines have significantly lowered disease incidence from 20,000 cases in 1985 to 17 cases reported in 2010.

Vaccine Recommendations Meningococcal disease MenB Vaccines

Both MenB vaccines are FDA approved for use in patients aged 10 years to 25 years; however, because there is no theoretical difference in safety for those older than 25 years, ACIP recommends MenB for routine use in all individuals aged 10 years and older who are at increased risk, including patients with anatomic or functional asplenia or complement component deficiency as well as those traveling to or living in a high-risk country. The appropriate dosing schedule for MenB depends on the vaccine and indication. Bexsero is administered as a two-dose series given at 0 and at least 1 month later, while Trumenba is given either as 2 doses at 0 and 6 months or as 3 doses at 0, 1 to 2, and 6 months, depending on the reason for vaccination. If a second dose of Trumenba is inadvertently given at an interval of less than 6 months, a third dose should be administered at least 4 weeks later, making it a 3-dose series. MenB vaccine series may be administered to adolescents and young adults aged 16 through 23 years (preferred age is 16 to 18 years) to provide short-term protection against most strains of serogroup B meningococcal disease. The child and adolescent schedule includes a blue bar for use of MenB vaccine in adolescents aged 16 to 18. The blue bar indicates "clinical discretion," which means that the vaccine may be recommended subject to individual clinical decision making. Bexsero 2-dose or the 2-dose series of Trumenba is appropriate for vaccination of these individuals. For patients aged 10 years and older who receive MenB because of a high-risk condition, the 2-dose Bexsero or the 3-dose series of Trumenba should be used. High-risk conditions include: • Functional or anatomical asplenia. • Persistent complement component deficiencies. • Microbiologists. • Patients at risk because of an outbreak. Of note, patients with HIV are not considered high risk for MenB, nor is it recommended for individuals traveling to other countries. MenB vaccines are not interchangeable—the same MenB vaccine product must be used for all doses. If both MenB and MenACWY are indicated, they may be administered concomitantly but at different anatomic sites, if feasible.

Storage and Administration of Pneumococcal Vaccines

Both the PCV13 and PPSV23 vaccines should be stored in the refrigerator at 2°C to 8°C (36°F to 46°F); these vaccines should not be frozen. Pneumococcal polysaccharide should be protected from light. When administering the vaccine, the vial or manufacturer-filled syringe should be shaken before use. The 0.5 mL dose of PCV13 should be administered intramuscularly. The dose of PPSV23 is also 0.5 mL, and this vaccine may be administered either intramuscularly or subcutaneously.

DTaP vaccine

Children 6 weeks to 6 years of age should receive diphtheria and tetanus toxoids combined with pertussis vaccine (DTaP). If a specific contraindication to pertussis vaccine is present, then pediatric DT should be used to provide protection against tetanus. The primary immunizing series in children should include doses of DTaP given at 2 months, 4 months, 6 months, 15 to 18 months, and 4 to 6 years of age.20 All adolescents and adults should have written documentation of a primary series of tetanus and diphtheria toxoids- containing vaccines. If these records do not exist, a primary series of 3 doses is needed to provide protection. This series should consist of 1 dose of Tdap and 2 doses of Td; Tdap is preferred as the first dose. The first 2 doses must be separated by at least 4 weeks, and the third dose should be given at least 6 months after the first dose.

Vaccine recommendations for varicella

Children should receive a total of 2 doses of varicella vaccine to provide immunity. The recommended schedule for varicella vaccine in children is as follows: • First dose at 12 to 15 months of age. • Second dose at 4 to 6 years of age. The first dose of varicella vaccine should not be given before the child's first birthday because circulating maternal antibodies can interfere with the live vaccine. Any dose of varicella vaccine administered before the first birthday should not be counted as valid. All susceptible adolescents and adults should receive 2 doses of the varicella vaccine if they cannot demonstrate immunity to varicella. For children younger than 13 years of age, the second dose should be given at least 3 months after the first dose. If the second dose is given sooner than 3 months (e.g., to provide protection during an outbreak), the dose can be considered a valid dose as long as the second dose was given at least 28 days after the first dose. For patients older than 13 years of age, the 2 doses should be separated by at least 4 weeks. Susceptible women of childbearing age should be vaccinated before pregnancy because of a theoretical risk that varicella is a teratogen at vulnerable stages of fetal development. Although it is unknown if varicella vaccine is teratogenic, more than a decade of monitoring inadvertent administration during or just before pregnancy suggests this is unlikely. After immunization, women should wait at least 4 weeks before becoming pregnant. For unvaccinated women who become pregnant, varicella vaccine should not be administered during pregnancy. Rather, the first dose of varicella vaccine shouldbe administered immediately after childbirth (before the woman is discharged from the hospital). The second dose can be administered 4 to 8 weeks following delivery during a postpartum health care visit. For children receiving varicella vaccine, there are two options: varicella vaccine as a single-antigen vaccine or varicella in combination with the measles, mumps, rubella vaccine (MMRV). Postlicensure studies indicated that among children 12 to 23 months of age, one additional febrile seizure occurred 5 to 12 days after vaccination for every 2,300 to 2,600 children who received the first dose of MMRV vaccine, compared with children who had received the first dose of MMR vaccine and varicella vaccine administered as separate injections at the same visit. ACIP has released recommendations on the use of MMRV. -For the first dose of measles, mumps, rubella, and varicella vaccines at age 12 to 47 months, either MMR vaccine and varicella vaccine or MMRV vaccine may be used. Providers who are considering administering MMRV vaccine should discuss the benefits and risks of both vaccination options with the parents or caregivers. Unless the parent or caregiver expresses a preference for MMRV vaccine, CDC recommends that MMR vaccine and varicella vaccine should be administered separately for the first dose in this age group. For the second dose of measles, mumps, rubella, and varicella vaccines at any age (15 months to 12 years) and for the first dose at age 48 months or older, use of MMRV vaccine generally is preferred over separate injections of its equivalent component vaccines (i.e., MMR vaccine and varicella vaccine). This recommendation is consistent with the ACIP's general recommendations regarding the use of combination vaccines, which state that use of a combination vaccine generally is preferred over its equivalent component vaccines.

Contraindications and Precautions Rotavirus

Children with a serious allergic reaction to a prior dose should not receive the rotavirus vaccine. These vaccines are contraindicated in children with gastrointestinal problems or a history of intussusception. Because these are live vaccines, they should not be administered to immunocompromised children or to children with a history of severe combined immunodeficiency because of the potential risk for vaccine- acquired rotavirus infection. Rotavirus vaccines are contraindicated in patients who have had a severe allergic reaction (e.g., anaphylaxis) to a previous vaccine dose or to a vaccine component. The oral applicator for Rotarix contains latex; patients with a history of anaphylactic reaction to latex should not receive this brand. Precautions include moderate or severe acute illness with or without fever, preexisting gastrointestinal disease, previous history of intussusception, altered immunocompetence other than severe combined immunodeficiency, spina bifida, or bladder exstrophy.

Vaccines of the Rotavirus

Currently, there are two FDA-licensed rotavirus vaccines, RV1 (Rotarix—GlaxoSmithKline) and RV5 (RotaTeq—Merck). Both are live, oral vaccines indicated for the prevention of rotavirus gastroenteritis in infants and children. Although RotaTeq and Rotarix are currently marketed in the United States, they were not the first vaccines against rotavirus. In 1998, an FDA-licensed rhesus-based tetravalent vaccine (RotaShield—Wyeth) was recommended for routine vaccination of infants. However, in 1999, this vaccine was voluntarily removed from the market because of an apparent association with the development of intussusception. Intussusception is an uncommon type of bowel obstruction that occurs when the bowel folds in on itself. Intussusception occurs most frequently in young children, and often there is no known cause. When the obstruction is identified and treated early, most individuals will fully recover. Following administration of RotaShield, the risk for intussusception was most elevated within 3 to 14 days after receipt of the first dose of the vaccine; there was also an increased risk within 3 to 14 days after the second dose. Therefore, RotaShield was removed.

Special Contraindication Concerning DTaP

DTaP vaccine is contraindicated in children who have had a serious allergic reaction to it or who developed encephalopathy within 7 days of a previous dose. ACIP and the American Academy of Pediatrics (AAP) cite several precautions for use of pertussis vaccine. The precautions regarding adverse events after a previous dose of DTaP include: -Fever of 40.5°C (105°F) or greater within 48 hours following the vaccine dose -Collapse or shock-like state (i.e., hypotonic/ hyporesponsive episode) within 48 hours following the vaccine dose -Persistent, inconsolable crying for 3 hours or more within 48 hours following the vaccine dose -Convulsions or seizure with or without fever occurring within 3 days of the vaccine dose These adverse events were more common after receipt of DTwP but can occur after DTaP. Under usual circumstances, a child should not be given additional doses of DTaP if one of these precautionary adverse events occurred following a prior dose. However, if the risk of pertussis is high (e.g., during a community outbreak of pertussis), the benefit of pertussis immunity may outweigh the risk of an adverse event, and the child's primary care provider may decide to administer the vaccine. An adult who has a history of a reaction to DTP as a child (except a severe allergic reaction) may receive Tdap vaccine. Experts at ACIP and AAP consider it inappropriate to deny the benefits of pertussis immunization to children with underlying neurologic conditions (e.g., seizure disorders, epilepsy, cerebral palsy). However, vaccination should be deferred until after an evolving neurologic condition resolves or stabilizes.

List vaccines for Tetanus, diphtheria, pertussis

Diphtheria and tetanus toxoids and acellular pertussis adsorbed (DTaP): - Daptacel (Sanofi Pasteur) - Infanrix (GlaxoSmithKline) Diphtheria and tetanus toxoids adsorbed (DT) Tetanus and diphtheria toxoids adsorbed, adult (Td): - Decavac (Sanofi Pasteur) - No trade name (Massachusetts Biological Laboratories) Tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis adsorbed (Tdap) - Adacel (Sanofi Pasteur) - Boostrix (GlaxoSmithKline) Tetanus toxoid (TT) adsorbed: - No trade name (Sanofi Pasteur)

Polio Eradication

Disease rates fell rapidly with widespread use of polio vaccines, leading to elimination of polio in the United States and other countries. The Western hemisphere was certified as polio free in 1994. Even though there are no reported cases of polio in the United States, continued immunization is needed to guard against imported infections. The World Health Organization (WHO) had hoped to eradicate poliovirus from the entire planet by 2005, but disease still exists in a few countries in Africa, Asia, and the Middle East. More information on global poliovirus eradication efforts can be found online at www.polioeradication.org.

Fluzone

Fluzone is the only IIV approved for children younger than 36 months of age. Fluzone Intradermal is approved for adults 18 to 64 years of age and only the manufacturer's microneedle injector should be used to administer this vaccine.

Herpes zoster (shingles)

Following an acute varicella infection (i.e., chickenpox), the varicella zoster virus can lie dormant in the neural dorsal root ganglia. When the virus is reactivated, it causes herpes zoster (i.e., shingles). Since herpes zoster is a reactivation of the varicella zoster virus, it can only occur in patients who previously had chickenpox or, more rarely, in a patient who has received the live varicella vaccine. Approximately one of every three people will develop herpes zoster during his or her lifetime. Risk factors associated with the development of herpes zoster include advanced age, immunosuppression, intrauterine exposure, or contracting varicella when younger than 18 months of age.

Vaccine Recommendations for pneumococcal disease Adults

General rules about use of these vaccines in adults include the following • All adults should receive only one dose of PCV13 and one to three doses of PPSV23, depending upon age and medical conditions. • When both PCV13 and PPSV23 are indicated, PCV13 optimally should be administered first. • PPSV23 should be administered at least 1 year after PCV13, except among adults with immunocompromising conditions, anatomical or functional asplenia, cerebrospinal fluid leak, or cochlear implant, for whom the interval should be at least 8 weeks. • The interval between two PPSV23 doses should be at least 5 years. • The interval between PCV13 and PPSV23 in immunocompetent individuals should be at least 1 year if given after 65 years of age. • The two vaccines should not be administered simultaneously. Immunocompetent adults 65 years of age and older should receive both vaccines, as follows and as shown in Table 3.6:46,60 • Patients who have never received either vaccine should receive one dose of PCV13 and one dose of PPSV23 at least 1 year apart. If PPSV23 happens to be administered first (at age ≥65 years), PCV13 should be administered at least 1 year later. • Patients who received PPSV23 before they turned 65 should have both vaccines administered after 65 years. The patient should first receive PCV13 at least 1 year after the most recent dose of PPSV23, then a dose of PPSV23 at least 1 year after PCV13 and at least 5 years after the last dose of PPSV23. • Patients who received PCV13 (but not PPSV23) before they turned 65 should receive one dose of PPSV23 at least 1 year after the PCV13. • Patients who received both PPSV23 and PCV13 before they turned 65 should receive one dose of PPPSV23 least 1 year after PCV13 and at least 5 years after the last dose of PPSV23

Haemophilus influenzae type b

H. influenzae type b (Hib) is an aerobic gram-negative coccobacillus spread by respiratory transmission from asymptomatic carriers. The polysaccharide capsule on the bacteria allows it to evade the immune system and cause disease. While this disease is rarely seen in patients older than the age of 5 years, invasive Hib disease can cause significant morbidity and mortality in children younger than 5 years of age.

Storage and Administration of Human Papillomavirus Vaccine

HPV vaccine should be stored in the refrigerator at 2°C to 8°C (36°F to 46°F). It must be protected from light and should not be frozen. When administering the vaccine, providers should shake the vial or prefilled syringe before use. The 0.5 mL dose should be administered intramuscularly, preferably in the deltoid muscle

Hepatitis A

Hepatitis A is an acute infection caused by a picornavirus. Hepatitis A is spread by the fecal-oral route and by consuming contaminated food and water. The hepatitis A virus enters the body through the mouth and can be found in the stool of infected people. The virus replicates in the liver of infected people. Approximately 20,000 to 30,000 cases of hepatitis A were reported in the United States each year before hepatitis A vaccine became available. With the use of safe and effective vaccines, the incidence of hepatitis A in this country has declined significantly. Between 2010 and 2014, there was a 25.8% decrease in the number of reported cases of hepatitis A. A total of 1,239 cases were reported in 2014; suggesting a total of 2,500 cases after adjusting for underreporting. However, hepatitis A infection remains endemic in other areas of the world. People at risk for hepatitis A infection include international travelers, men who have sex with men, and users of illegal drugs.

Vaccine for hepatitis B

Hepatitis B vaccines are inactivated vaccines that contain purified hepatitis B surface antigen (HBsAg), a protein found on the outer viral coat. Two vaccines are currently licensed for use in the United States (Recombivax HB—Merck and Engerix-B—GlaxoSmithKline). Both of these vaccines reduce the risk of disease by 80% to 100% after 3 doses.3 Combination vaccines that contain Hepatitis B include Twinrix (GlaxoSmithKline Biologicals), Comvax

Storage and Administration of Hepatitis B Vaccine

Hepatitis B vaccines should be stored in the refrigerator at 2°C to 8°C (36°F to 46°F); these vaccines should not be frozen. To administer hepatitis B vaccines, shake the vial or prefilled syringe before use. Administer the appropriate dose (Table 3.8) intramuscularly shortly after preparation. Hepatitis B doses must be repeated if administered subcutaneously.

Contraindications and Precautions Haemophilus influenza type B

Hib vaccines are contraindicated for patients who have had a severe allergic reaction (e.g., anaphylaxis) to a previous vaccine dose or to a vaccine component. Precautions include moderate or severe acute illness with or without fever.

Potential Adverse Reactions Haemophilus Influenza type B

Hib vaccines are well tolerated, and adverse events after vaccination are not common. Adverse events that may be reported after receipt of Hib vaccine include transient injection-site reactions such as swelling, redness, or pain. Systemic reactions (e.g., fever) after vaccination are unusual, and serious reactions are rare.

Storage and Administration of Haemophilus influenzae type b Vaccines

Hib vaccines should be stored in the refrigerator at 2°C to 8°C (36°F to 46°F); these vaccines should not be frozen.30 When administering Hib vaccines, providers should shake the vial or prefilled syringe before use and administer the 0.5 mL dose intramuscularly.

Human Papillomavirus (HPV)

Human papillomavirus (HPV) infection is the most common sexually transmitted infection in the United States. An estimated 79 million individuals in the United States are infected, and an estimated 14 million new HPV infections occur annually, with half of these in persons 15 to 24 years of age. Important risk factors for acquiring HPV infection include sexual activity at an early age and with multiple partners; however, infection can occur following a single sexual encounter. At least 50% of sexually active people will get HPV at some point in their lifetime. HPV is a double-stranded DNA virus that preferentially infects epithelial cells. It has been identified as the etiologic agent for cervical and other cancers, genital warts, and other diseases. Of the nearly 100 HPV types that have been identified, approximately 40 can infect the genital mucosa, and 16 are considered high-risk carcinogens. The high-risk HPV types include 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 68, 69, 73, and 82. High-risk HPV types are detected in 99% of cervical cancers. Together, HPV types 16, 18, 31, 33, 45, 52, and 58 account for approximately 85% to 90% of all cervical cancers.43 In 2010, almost 12,000 new cases of cervical cancer were diagnosed in the United States, and nearly 4,000 women died from cervical cancer in 2010.44 In addition to cervical cancer, high-risk HPV has been associated with vulvar, vaginal, anal, penile, oral, and pharyngeal cancers.3 Low-risk HPV types (e.g., 6, 11) cause the majority of cases of genital warts. Genital warts, or condylomata acuminata, are growths of the cervicovaginal, vulvar, and external genitalia. While these growths rarely progress to cancer, they are responsible for numerous physician visits each year and considerable concern among patients with the disorder.

Storage and Administration of Poliomyelitis Vaccine

IPV should be stored in the refrigerator at 2°C to 8°C (36°F to 46°F); the vaccine should not be frozen.30 When administering IPV, providers should shake the vial or prefilled syringe before use and administer the 0.5 mL dose of IPV either intramuscularly or subcutaneously.

Timing of Tdap Following Td

If a person is a candidate for pertussis vaccination and has recently received a Td booster dose, ACIP recommends that Tdap vaccination should not be delayed. Tdap vaccine should be administered regardless of the interval since the last tetanus or diphtheria toxoid-containing vaccine. ACIP reviewed the available evidence and concluded that while longer intervals between Td and Tdap vaccination could decrease the potential occurrence of local reactions, the benefits of protection against pertussis outweigh the potential risk for adverse events.

Pneumococcal vaccine (13-Valent Pneumococcal Conjugate Vaccine)

In 2010, the FDA approved PCV13 (Prevnar 13—Pfizer), a 13-valent pneumococcal conjugated vaccine. PCV13 targets 13 serotypes of S. pneumoniae (i.e., 1, 3, 4, 5, 6A, 6B, 7F, 9V, 14, 18C, 19A, 19F, and 23F). It is approved in adults for the prevention of pneumonia and invasive disease caused by the S. pneumoniae serotypes in the vaccine. It is also approved in children aged 6 weeks to 5 years for the prevention of invasive disease caused by the 13 serotypes in the vaccine and otitis media caused by 7 of the 13 serotypes in the vaccine, in addition to children aged 6 to 17 years for invasive disease caused by the 13 serotypes in the vaccine. PCV13 is a conjugate vaccine, meaning that polysaccharides are linked to a protein (a diphtheria protein in this case) during the manufacturing process. As discussed in Module 2, the process of conjugation is necessary because children younger than 2 years of age do not consistently mount an effective immune response to pure polysaccharide vaccines.

Vaccines for HPV

In 2016, the FDA approved a 9-valent HPV vaccine (9vHPV, Gardasil 9) (Recombinant) that provides protection against the four HPV types included in HPV4 as well as five additional high-risk types of HPV (31, 33, 45, 52, and 58). These five additional types are responsible for 11% of all HPV-associated cancers. 9vHPV has similar immunogenicity to HPV4 for the four shared types of HPV and is approximately 95% effective for the five additional types.

Influenza Virus

Influenza A viruses are categorized into subtypes on the basis of the two major surface antigens: hemagglutinin (H) and neuraminidase (N). The hemagglutinin surface antigens (numbered 1 through 9) help the influenza virus attach to cells in the body, while the neuraminidase surface antigens (numbered 1 through 9) help the virus leave the cell and antigenic spread to other cells. Types A and B cause human disease Yearly changes Responds to avoid human antibodies Shifts — major change in Type A antigen Drifts — minor change in A or B antigens Many type A lineages (human and animal) 2 human type As in circulation A (H1N1) and A (H3N2) Responsible for pandemics Two type B lineages Yamagata and Victoria Both circulated in past few years A and B cause human disease

Influenza Disease

Influenza I. I-caused by virus of the orthomyxovirus family -spread primarily by aerosolized respiratory droplets from a cough or sneeze -spread by direct contact of droplets from nasal secretions or saliva -incubation period 1 to 4 days Onset 2 days (1-4) after exposure Contagious 1 day before symptomatic and 5-7 days after onset Symptoms High fever, cough (can be severe), fatigue, weakness, headache, myalgias Different presentation than common cold Complications -Pneumonia, exacerbation of pulmonary and cardiac conditions Hospitalizations and deaths -Since 2010, estimated hospitalizations ranged from 140,000 to 810,000 annually -Since 2019, estimated deaths from 12,000 to 61,000 annually

Special consideration for administration of LAIV

Influenza antiviral medications reduce the replication of influenza virus and could potentially interfere with LAIV, because it must replicate to stimulate an immune response. If a patient is being treated for influenza with antiviral medications, LAIV should not be administered until 48 hours after cessation of the antiviral therapy.6 If the patient must be treated with antiviral medications within 2 weeks after receiving LAIV, the vaccine dose should be repeated 48 hours or more after the final dose of antiviral medication.

When is the influenza vaccine offered?

Influenza disease generally occurs in the United States from December to March each year. Influenza vaccination programs should be started as soon as vaccine is available (if possible, by October) and should be continued until vaccine is no longer available or has expired. (After a person is vaccinated, it typically takes approximately 2 weeks before the vaccine provides protection.)

Laiv

LAIV is administered intranasally using a sprayer device; it should never be administered orally, or by injection. The sprayer device contains a total dose of 0.2 mL. Half of the volume (0.1 mL) is administered into one nostril, then the dose-divider clip is removed and the remaining half (0.1 mL) is administered into the other nostril.

Knowledge Check: Influenza Vaccines Summary

Live or inactivated: Both options are available. (However, the live vaccine is not recommended for the 2016-17 and 2017-18 influenza seasons.) Target groups for vaccination: All persons 6 months of age and older. If there is a vaccine shortage, vaccination efforts should focus on high-risk people. Doses: 1 dose each year, except in children aged 6 months to 8 years, who should receive 2 doses 4 weeks apart the first season they receive the vaccine. Timing of administration: As soon as possible after the vaccine becomes available each season.

Knowledge Check: Varicella Vaccines Summary

Live or inactivated: Live Target groups for vaccination: All children aged 12 months and older as well as susceptible adolescents and adults Doses: 2 doses Timing of administration: For routine use, 12 to 15 months and 4 to 6 years. For adolescents and adults who are susceptible, 2 doses at least 4 weeks apart.

Potential Adverse Reactions Pneumococcal Conjugate Vaccine

Local injection-site reactions are the most commonly reported adverse reactions after administration of PCV. Fever also has been reported. Less-frequent adverse events that can occur include irritability, drowsiness, restless sleep, and decreased appetite.

Meningococcal disease

Meningococcal disease includes the spectrum of illness caused by Neisseria meningitidis, including meningitis, bacteremia, and bacteremic pneumonia. N. meningitidis is an aerobic, gram-negative bacterium with a polysaccharide capsule that surrounds the outer membrane of the bacteria and helps it evade certain cells of the immune system (e.g., phagocytes). N. meningitidis is classified into serogroups on the basis of the structure of the polysaccharide capsule. Although 13 polysaccharide capsules have been identified, five specific serogroups cause almost all invasive disease: A, B, C, Y, and W-135.3 Serogroups B, C, and Y are common causes of meningococcal disease in the United States, each being responsible for approximately one-third of cases.

Clinical Features and Potential Complications Meningococcal disease

N. meningitidis is transmitted by the respiratory route. Once the bacteria colonize in the nasopharynx, they begin to replicate. The bacteria are capable of invading the body through the bloodstream, causing invasive disease. The number of reported cases of invasive meningococcal disease has been declining in the last few years. Fewer than 1,000 cases of invasive meningococcal disease have been reported each year since 2009. The reason for this decline is not known with certainty but may be at least partially due to increased use of meningococcal conjugate vaccine. The most common form of invasive disease caused by N. meningitidis is meningitis. It typically presents with nonspecific symptoms similar to other types of meningitis. Symptom onset is usually sudden and can include high fever, headache, myalgia, stiffness of the neck, and sensitivity to light. In addition to meningitis, N. meningitidis can cause sepsis, pneumonia, arthritis, otitis media, and epiglottitis. Despite appropriate antibiotic therapy, approximately 9% to 12% of patients die from invasive meningococcal disease. If the bacteria invade the bloodstream, the death rate can reach up to 40%. Those who survive meningococcal infection can have significant complications such as hearing loss, neurological damage, and limb loss. Risk factors for meningococcal disease include certain immunodeficiencies. In addition, antecedent viral infection, crowded housing, chronic underlying illness, and active and passive smoking are associated with increased risk for disease.61 First-year college students living in dormitories have been found to have higher risk for meningococcal disease than other students. The first quadrivalent polysaccharide for the prevention of meningococcal disease was licensed in 1981. The first conjugate vaccine was approved and recommended for use in 2005. The incidence of meningococcal disease has declined annually since a peak of disease in the late 1990s. Although the disease incidence is currently at a historically low rate, 10% to 15% of those who contract the disease continue to die from it, and an additional 11% to 19% have long-term sequelae.

Clinical Features and Potential Complications Varicella

Natural varicella is characterized by a generalized rash, consisting of several hundred to more than a thousand pruritic vesicles. The highest concentration of vesicles is usually on the trunk. Lesions also can appear on the face, scalp, extremities, and mucous membranes of the body. The vesicles contain a clear fluid and often rupture or drain before they dry and develop a crust. Complications of varicella most commonly involve secondary bacterial infections of the lesions with group A streptococci or staphylococci. These secondary infections can be serious, leading to clinic visits, hospitalizations, and even death. Other complications may include cerebellar ataxia, encephalitis, and pneumonia. Complications from varicella are more frequent in adults, children younger than 1 year of age, immunocompromised patients, and newborns of mothers infected with varicella

Herpes zoster Clinical Features and Potential Complications

Once the virus is reactivated, it travels along the sensory nerves to the skin's surface and results in a painful condition known as herpes zoster or shingles. Acute pain is the most common symptom of shingles and usually precedes the appearance of the rash. The rash from herpes zoster usually appears as discrete patches of erythema that progress to grouped vesicles over a period of 7 to 10 days. The rash usually appears on one side of the body and is typically distributed along one of the dermatomes (Figure 3.11). (A dermatome is a localized area of the skin that is innervated by one spinal nerve.) Patients with active zoster lesions can transmit varicella zoster virus to susceptible people from the time the rash develops until the lesions crust over. If the virus is transmitted to a susceptible person through contact with the lesions, it can cause primary varicella infection (i.e chickenpox) in this person rather than causing herpes zoster. In addition to the rash, patients with herpes zoster may experience itching, paresthesia, fever, headache, chills, upset stomach, and malaise. Very rarely, herpes zoster can result in pneumonia, hearing problems, blindness, encephalitis, or death. Postherpetic neuralgia (PHN), a chronic neuropathic pain condition, is the most common sequela of herpes zoster. PHN is defined as pain that lasts 90 days or more after the onset of the rash,. PHN may persist for months or years and has an impact on quality of life that has been found to be comparable to that of congestive heart failure, myocardial infarction, type 2 diabetes, and major depression. PHN develops in 10% to 50% of patients with herpes zoster and increases with age and in immunocompromised individuals. Herpes zoster is also associated with the development of other neurologic conditions, including ophthalmologic complications, Bell's palsy, transient ischemic attacks, and stroke.

Potential Adverse Reactions of HPV

Pain, swelling, and erythema at the injection site were the most common adverse events reported with 9vHPV. Rates of injection-site swelling and erythema increased following each successive dose in the series and in patients who had previously been vaccinated with HPV4.45 Syncope (i.e., fainting) after vaccination with HPV also has been reported. This may be attributable to vaccinating adolescents; syncope following vaccination appears to be more common in this age group. Immunizing pharmacists should be prepared to protect the patient from injury from falling during fainting. According to ACIP, clinicians should observe vaccinated patients for at least 15 minutes after vaccination to monitor for syncope adverse events.

Complications of pertussis

Pertussis can affect children, adolescents, and adults. Complications from pertussis occur most often among young children. The most common complication is pneumonia. Other complications that can occur include seizures and encephalopathy, which can be caused by extended periods of low oxygen supply during the coughing attacks. Pertussis infection can result in hospitalization or death. Adolescents and adults infected with pertussis usually experience a milder form of the disease and are less likely to develop complications.

Pertussis

Pertussis, also called whooping cough, is caused by Bordetella pertussis, a gram-negative bacterium. Extremely contagious. B. pertussis is most commonly transmitted by respiratory droplets that are released in the air when an infected person coughs or sneezes. The bacteria infect the respiratory tract and produce toxins that interfere with the function of the respiratory tract, ultimately causing the characteristic symptoms of pertussis. Begins with a catarrhal stage that lasts approximately 1 to 2 weeks. Symptoms of this stage are similar to those of the common cold: mild cough, runny nose, sneezing, and fever. Second, follows a paroxysmal cough stage, which can last from 1 to 6 weeks. During this stage, the patient will experience paroxysms, which are coughing attacks characterized by numerous, rapid coughs. During the coughing attacks, a high-pitched "whooping" sound often can be heard. The whooping sound results when the patient tries to take a deep breath against a closed glottis. The paroxysmal coughing can cause vomiting and exhaustion. The last stage is convalescence. Complete recovery is gradual and can take months.

Pneumococcal Disease

Pneumococcal disease is caused by Streptococcus pneumoniae, a gram-positive coccobacillus bacteria. Some pneumococci are encapsulated, with surfaces composed of complex polysaccharides. These capsules allow the bacteria to evade some immune cells (e.g., phagocytes) and interfere with activation of an immune response. A person's immune system must be able to recognize the polysaccharide capsule and create antibodies directed against the polysaccharide capsule to provide protection against this infection.

Clinical Features and Potential Complications Poliomyelitis

Polio viruses enter the body through the mouth and replicate in the pharynx and gastrointestinal tract. Approximately 95% of poliovirus infections are asymptomatic. Approximately 4% to 8% of polio infections consist of a minor, nonspecific illness that is indistinguishable from other viral illnesses. In approximately 1% of infections, viruses enter the central nervous system from the bloodstream and destroy the anterior horn cells of the spinal cord. This causes flaccid paralysis of muscles but leaves sensory function intact.1 Many individuals with paralytic poliomyelitis recover completely, and in most, muscle function returns to some degree. Weakness or paralysis that is still present 12 months after onset is usually permanent. Asymptomatic patients can transmit the virus to other people. Poliomyelitis is communicable beginning 7 to 10 days before onset of symptoms. Viruses can be shed in the stool for 3 to 6 weeks in infected patients who are both symptomatic and asymptomatic.

poliomyelitis (polio)

Poliomyelitis is caused by an enterovirus. Three poliovirus serotypes can cause disease, although type 2 virus was eradicated worldwide in 1999. Antibodies against one serotype do not produce significant protection against other serotypes

Additional Dosing Information for Hepatitis B Vaccine

Recombivax HB and Engerix-B are essentially interchangeable, but the dosage in microgram content per dose varies between the two brands). Because intermittent changes in recommended dosing or package concentrations can occur, pharmacists should not memorize this dosing table. Pharmacists should always refer to updated references and be familiar with the vaccine they stock and the appropriate doses for that product. Pharmacists should verify the volume to be administered to deliver the appropriate dose in micrograms on the basis of the specific product being used

Rotavirus

Rotavirus is a double-stranded RNA virus that, before the availability of a vaccine, infected nearly every child by 5 years of age. It is the most common cause of severe gastroenteritis in infants and children. Rotavirus is most commonly contracted by children between the ages of 6 and 24 months. In the prevaccine era in the United States, rotavirus gastroenteritis peaked in the cooler months and typically progressed from the Southwest during November and December to the Northeast by April and May.

Storage and Administration of Rotavirus Vaccines

Rotavirus vaccines should be stored in the refrigerator at 2°C to 8°C (36°F to 46°F) and protected from light at all times.

Shingrix Recommendations

Routine Vaccination of People 50 Years Old and Older CDC recommends Shingrix (recombinant zoster vaccine) for the prevention of herpes zoster (shingles) and related complications. CDC recommends two doses of Shingrix separated by 2 to 6 months for immunocompetent adults age 50 years and older: CDC Expert Commentary with Medscape Medscape video; Dr. Kathleen Dooling Everything You Need to Know About Shingrix [3:58 mins] Dr. Kathleen Dooling discusses storage, administration, and patient counseling for the new shingles vaccine Released: 4/30/18 Whether or not they report a prior episode of herpes zoster Whether or not they report a prior dose of Zostavax, a shingles vaccine that is no longer available for use in the United States Who have chronic medical conditions (e.g., chronic renal failure, diabetes mellitus, rheumatoid arthritis, chronic pulmonary disease), unless a contraindication or precaution exists. Shingrix may be used for adults who are are taking low-dose immunosuppressive therapy are anticipating immunosuppression have recovered from an immunocompromising illness Who are getting other adult vaccines in the same doctor's visit, including those routinely recommended for adults age 50 years and older, such as influenza and pneumococcal vaccines. The safety and efficacy of concomitant administration of two adjuvanted vaccines, such as Shingrix and Fluad, have not been evaluated. It is not necessary to screen, either verbally or by laboratory serology, for evidence of prior varicella infection.

Clinical Features and Potential Complications Pneumococcal disease

S. pneumoniae is a human pathogen that colonizes the nasopharynx of up to 5% to 90% of healthy persons. More than 90 serotypes of S. pneumoniae have been known to cause serious disease. In the years before widespread use of pneumococcal conjugate vaccine, the 10 most common serotypes accounted for approximately 62% of invasive pneumococcal disease. Although carriers of S. pneumoniae may be asymptomatic, they can transmit the bacteria to others. S. pneumoniae can be transmitted by airborne respiratory droplets or by direct contact with infected respiratory secretions and is a significant cause of illness in adults and children. Infections associated with S. pneumoniae include pneumonia, bacteremia, meningitis, sinusitis, and otitis media. More than 35,000 cases and more than 4,200 deaths from invasive pneumococcal disease (bacteremia and meningitis) are estimated to have occurred in the United States in 2011. Pneumococcal pneumonia is the most common infection resulting from S. pneumoniae, accounting for approximately one-third of community-acquired pneumonias and half of all hospital-acquired pneumonias. Approximately 400,000 adults are hospitalized with pneumococcal pneumonia each year in the Unites States. Pneumococcal pneumonia can occur as the primary infection or as a secondary complication from influenza infection. Pneumococcal pneumonia has a short incubation period of only 1 to 3 days and typically has an abrupt onset, with symptoms of fever, shaking, chills, productive cough, pleuritic chest pain, malaise, weakness, difficulty breathing, and rapid, shallow breathing. Bacteremic pneumococcal pneumonia is a serious infection of the bloodstream caused by S. pneumoniae. Bacteremia occurs in approximately one-third of patients who have pneumococcal pneumonia. While the symptoms of pneumococcal bacteremia are usually nonspecific (e.g., fever, chills, difficulty breathing), this is a serious infection that can lead to septicemia and cause death in 20% of patients (up to 60% of elderly patients). S. pneumoniae can cause pneumococcal meningitis, which is inflammation of the membranes surrounding the brain and spinal cord that affects an estimated 3,000 to 6,000 patients per year in the United States and is fatal in more than 20% of cases (up to 60% among elderly patients). One-fourth of all people with pneumococcal meningitis also have pneumonia. Signs and symptoms of pneumococcal meningitis are similar to other bacterial causes of meningitis and may include headache, lethargy, irritability, seizures, vomiting, cranial nerve involvement, and coma. Neurologic sequelae are common in patients who survive a case of pneumococcal meningitis. Before the availability of a pneumococcal conjugate vaccine for infants and toddlers, invasive pneumococcal disease caused significant morbidity and mortality in this age group. Each year in the United States, an estimated 17,000 cases of invasive pneumococcal disease occurred in children, and an estimated 200 children died from these infections. S. pneumoniae also caused up to 5 million cases of acute otitis media each year. While the burden of otitis media is not significant in terms of mortality data, it is a significant cause of lost time from work for parents and caregivers. It also contributes to the health care dollars spent on visits to physicians and medication therapies. The introduction of 7-valent pneumococcal conjugate vaccine (PCV7; Prevnar—Wyeth) in 2000 for use in children younger than 7 years of age resulted in reduced transmission of pneumococcal infection caused by the serotypes contained in the vaccine. Even though this vaccine was only given to young children, it decreased the overall rate of invasive pneumococcal disease in people of all ages. (This decrease in invasive pneumococcal disease for adults is thought to result from herd immunity.)

Contraindications and Precautions Tentanus, Diphtheria, pertussis

Tetanus and diphtheria toxoids and acellular pertussis- containing vaccines should be administered when appropriate to a patient unless there is a valid contraindication or precaution to receiving the vaccines. Contraindications include severe allergic reactions (e.g., anaphylaxis) to a previous vaccine dose or to a vaccine component. Precautions include a history of Guillain-Barré syndrome within 6 weeks following a previous dose of tetanus-containing vaccine, as well as a history of Arthus-type hypersensitivity reactions after a previous dose of tetanus-containing vaccine. As for all vaccines, moderate or severe acute illness with or without fever is also a precaution

Tetanus

Tetanus is caused by a toxin produced by Clostridium tetani, a gram-positive, spore-forming bacterium. Tetanus spores are widespread in the environment and thrive in anaerobic conditions. C. tetani can enter the body through any major or minor wound. Exposure to C. tetani can occur when there is acute trauma resulting in tissue injury, puncture wounds, lacerations, abrasions, chronic wounds, or injection drug use. Many people think that tetanus is associated only with outdoor injuries (e.g., stepping on a rusty nail). However, approximately 45% of the reported acute injuries resulting in tetanus infection occurred indoors or at home. Once C. tetani enters the body through a wound, the spores begin to germinate and the bacteria replicate. During this process, the bacteria produce a toxin called tetanospasmin, which causes the clinical features and complications of the disease. The toxin is released into the bloodstream and acts in the central nervous system. The toxin blocks the release of neurotransmitters that ultimately prevents muscle relaxation and results in severe muscle spasms. The incubation period can vary from 3 to 21 days. In general, the shorter the incubation period, the higher the chance of death. Four forms of clinical illness are recognized: local tetanus, cephalic tetanus, neonatal tetanus, and generalized tetanus. Local and cephalic tetanus are rare forms of the disease. Neonatal tetanus is also extremely rare in the United States Neonatal tetanus occurs primarily in infants of mothers who were not immune to tetanus, resulting in no protective passive immunity of the infant neonatal tetanus typically occurs when the umbilicus is cut with an unsterile instrument, resulting in an infection of the umbilicus. . More than 80% of tetanus cases are generalized tetanus. Generalized tetanus often presents with descending symptoms, usually starting with trismus (i.e., lockjaw), followed by stiffness in the neck, difficulty swallowing, muscle rigidity, and severe muscle spasms. The symptoms associated with generalized tetanus can persist for 3 to 4 weeks and complete recovery may take many months. Tetanus can be complicated by respiratory insufficiency, bone fractures, and infections (e.g., pneumonia). Tetanus can be fatal, resulting in death in approximately 10% of reported cases. Rates of tetanus in the United States began to decline from 1900 to the 1940s, when approximately 500 to 600 cases were reported each year. Tetanus vaccine was introduced in the late 1940s and the rate of this disease has declined since that time. During 2001 through 2008, the last years for which data have been compiled, a total of 233 tetanus cases in the United States was reported, an average of 29 cases per year. Almost all reported cases of tetanus are in people who either have never been vaccinated or those who completed a primary series but have not had a booster in the preceding 10 years.

Contraindications and Precautions for HPV

The HPV vaccine should be administered to a patient when appropriate unless there is a valid contraindication or precaution to receiving the vaccine. -Contraindications include a severe allergic reaction to a previous vaccine dose or to a vaccine component. -Precautions include moderate or severe illness with or without fever. -Pregnant women should not be vaccinated because it is not knwn whether the vaccine can cause fetal harm. If pregnancy is identified after the vaccine series has begun, the remaining doses should be delayed until pregnancy is completed.

Potential Adverse Reactions Live Attenuated Influenza Vaccine

The adverse reactions reported after administration of LAIV are usually mild and self-limiting. Runny nose or nasal congestion is the most common adverse effect. Other possible adverse effects include headache, fever, vomiting, myalgias, and abdominal pain, but these appear to be more common after the first dose than subsequent doses.

Vaccine Recommendations Hepatitis B

The first dose of hepatitis B vaccine should be administered to all infants at birth before hospital discharge. The second dose should be administered at 1 to 2 months of age followed by the third and final dose at 6 months of age. For infants who do not receive a birth dose, the series should be started as soon as possible. If the infant falls behind the recommended schedule, the second dose should be administered at least 4 weeks after the first dose. The third dose should be administered at least 2 months after the second dose and at least 4 months after the first dose. The third dose should not be administered before 24 weeks of age. All adolescents without documentation of hepatitis B vaccine should receive a primary series of hepatitis B vaccine.66 This can be accomplished in one of two ways. -The first option is a 3-dose series with either Engerix-B or Recombivax HB. The routine schedule for the 3-dose series is 0, 1, and 6 months. -Another option is to use the adult dose of Recombivax HB (10 μg/1 mL) and administer this vaccine in a 2-dose series to adolescents aged 11 to 15 years. This 2-dose series has been approved for use only in this age group and only for Recombivax HB. The recommended schedule for the 2-dose series is to administer the initial dose to patients at age 11 to 12 years, followed by a second dose 4 to 6 months after the first dose. This 2-dose series has been shown to produce the same immunologic response in this age group as the standard dose (5 μg/0.5 mL) given in the 3-dose series.66 All adults with an indication for the vaccine should receive a complete 3-dose series of hepatitis B vaccine with either Recombivax HB or Engerix-B. The routine schedule for vaccination is also required, Twinrix may be used.) Dosing of hepatitis B vaccine in patients on dialysis depends on the vaccine used; specific dosing information is shown in Table 3.8

Storage and Administration of Herpes Zoster Vaccine

The herpes zoster vaccine is supplied in vials of lyophilized vaccine and a separate package of diluent and must be reconstituted prior to injection. All varicella-containing vaccines are live vaccines that should be protected from light and stored in the freezer at temperatures of -50°C to -15°C (-58°F to 5°F).30 The vaccine may be kept at refrigerator temperatures of 2°C to 8°C (36°F to 46°F) for up to 72 hours prior to reconstitution.42 If this vaccine is not used within 72 hours after removal from the freezer or is not used within 30 minutes of reconstitution, it should be discarded. The diluent should be stored separately from the vaccine and may be stored in the refrigerator or at room temperature. The vaccine should be reconstituted with the diluent immediately upon removal from the freezer and administered within 30 minutes of reconstitution. If the reconstituted vaccine is not administered within 30 minutes, the vaccine should be discarded. Reconstituted or unreconstituted refrigerated vaccine should never be refrozen. The dose of the HZV is a single 0.65 mL subcutaneous injection, preferably in the posterior upper arm.

Clinical Features and Potential Complications Hepatitis A

The incubation period for hepatitis A is 15 to 50 days. Hepatitis A is characterized by fever, nausea, vomiting, liver inflammation, jaundice, and dark urine. The disease is usually more severe among adults than children. Symptoms of hepatitis A usually last 1 to 2 months but can persist up to 6 months. Complications can include liver failure and, rarely, death. Hepatitis A does not cause chronic infection or chronic liver disease.

Vaccines Haemophilus Influenza type B

The initial Hib vaccines were purified polysaccharide vaccines, first licensed in 1985. Because polysaccharide vaccines are not as effective in children younger than 2 years of age— and this disease most commonly affects young children— conjugated vaccines were developed to increase effectiveness in young children. The single-antigen Hib vaccines currently available in the U.S. market include: • ActHIB (Sanofi Pasteur). • PedvaxHIB (Merck). • Hiberix (GlaxoSmithKline). Currently available combination Hib vaccines include: • Comvax (Merck)—protects against Hib and hepatitis B. • Pentacel (Sanofi Pasteur)—protects against Hib, diphtheria, tetanus, pertussis, and polio. • MenHibrix (GlaxoSmithKline)—protects against Hib and meningococcal serogroups C and Y

Clinical Features and Potential Complications of HPV

The initial infection with HPV typically causes no signs or symptoms; consequently many people unknowingly spread the virus to others. In some individuals, the infection resolves spontaneously without adverse health consequences; in others the infection persists. Older age, infection with multiple HPV types, and infection with a high-risk HPV type are risk factors for persistent infection. Persistent infection is a key risk factor for the development of moderate- or high-grade cervical dysplasia and cancer. Although there is no cure for persistent HPV infection, there are treatments for the pathologic conditions caused by the infection, most notably cervical cancer and genital warts. Because cervical and other HPV-related cancers occur after many years of persistent infection, cases and deaths from these cancers will continue to occur owing to the large number of people currently infected with HPV.

Potential Adverse Reactions Meningococcal disease

The most common adverse events after administration of MenACWY vaccine are injection-site reactions. Adverse effects are generally mild and may include pain and redness at the injection site. Systemic reactions (e.g., headache, malaise, fever) also have been reported. The most common adverse events following MenB vaccination include injection-site pain, fatigue, headache, myalgia, and chills. Serious adverse events including pyrexia, vomiting, vertigo, chills, headache, anaphylaxis, and neutropenia have also been reported.

Potential Adverse Reactions Rotavirus

The most common adverse events associated with rotavirus vaccines include fever, vomiting, diarrhea, loss of appetite, and irritability. There is a theoretical risk that the live virus from the vaccine could be spread to susceptible contacts after vaccination. Infants who have close contact with pregnant women, immunocompromised individuals, and those on immunosuppressive therapy may be vaccinated with consideration of the risks and benefits. Large prelicensure clinical trials of both RotaTeq and Rotarix did not find an increased risk for intussusception among vaccine recipients. A large postlicensure study of more than 1.2 million rotavirus vaccine recipients found a very small increased risk of intussusception (1 to 1.5 additional cases of intussusception per 100,000 vaccinated infants) in the 7 to 21 days following the first dose. No increased risk of intussusception was found after the second or third doses. The CDC and FDA continue to believe that the benefits of rotavirus vaccination outweigh the risks associated with vaccination and that routine vaccination of infants should continue. A study conducted by the CDC Vaccine Safety Datalink from May 2006 to February 2010 found no increased risk of intussusception following vaccination with RotaTeq. However, the study indicated an increased risk of intussusception following the first and second dose of Rotarix. More than 200,000 doses of Rotarix have been given to children monitored in the Vaccine Safety Datalink. On the basis of these findings, 1 case of intussusception would be expected for approximately each 20,000 children who are fully vaccinated.

Potential Adverse Reactions Herpes zoster virus

The most common adverse events reported with HZV include redness, pain or tenderness, swelling, and pruritus at the injection site. Patients also have reported headache after receiving the vaccine. Following receipt of HZV, transmission of the virus from a vaccinated person to a susceptible person has not been documented.37 According to the current recommendations, vaccinated people do not need to take any precautions around young children, pregnant women, and immunocompromised patients following receipt of the vaccine unless a varicella-like rash develops after vaccination. Rates of this type of rash occurring after administration of HZV are rare, but if a rash develops, susceptible people should avoid contact with the infected lesions.

Potential Adverse Reactions Tetanus diphtheria (pertussis separate for study purposes onl

The most common adverse reactions associated with tetanus and diphtheria toxoids-containing vaccines are local injection-site reactions. These injection-site reactions are usually mild and self-limiting. However, Arthus reactions have been reported after administration of these vaccines. Arthus reactions are the development of exaggerated symptoms such as severe pain, swelling, edema, and possibly necrosis near the injection site. An Arthus reaction after vaccination with tetanus and diphtheria toxoids is not an allergic reaction and is not common. However, these reactions may occur if a patient is immunized with tetanus or diphtheria toxoids too frequently. Patients with a history of Arthus reactions after vaccination should not receive doses of Td or Tdap any more frequently than every 10 years.

Potential Adverse Reactions Poliomyelitis

The most commonly reported adverse events after IPV administration are local injection-site reactions. No serious adverse reactions have been reported after vaccination.

Potential Adverse Reactions Inactivated Influenza Vaccine

The most commonly reported adverse reactions with IIV include local reactions at the injection site. Rarely, patients may report fever, malaise, or myalgias after receiving IIV. These effects are more common if the patient has had no prior exposure to influenza vaccine (e.g., young children).

Vaccine recommendations for HPV?

The number of doses administered is determined on the basis of the age the first dose is administered. ACIP recommends routine vaccination of boys and girls aged 11 to 12 years with a 2-dose series of 9vHPV vaccine (0 and 6 to 12 months), with the second dose administered 6 to 12 months after the first dose. If patients do not initiate vaccination before 15 years of age, they should receive a 3-dose series, with the second dose administered 1 to 2 months after the first dose and the third dose administered 6 months after the first dose. Catch-up vaccination is recommended for patients until they reach 26 years of age. Vaccination can be given as early as 9 years of age at the discretion of the health care provider (e.g., for a child who has a history of sexual abuse or assault). If the series has been interrupted, it does not need to be restarted. For example, a 16-year-old patient who received the first dose at age 14 years would require only one more dose. For immunocompromised male patients, ACIP recommends routine vaccination with a 3-dose series regardless of the age of the patient. In addition, men who have sex with men are at higher risk for infection and should receive a 3-dose series. The HPV vaccine may be given concurrently with other age-appropriate vaccines. If given simultaneously, each vaccine should be administered using a separate syringe at a different anatomic site. A series that was initiated with HPV2 or HPV4 may be completed with 9vHPV. ACIP has not provided a recommendation on routine vaccination with 9vHPV for patients who previously completed a series with HPV2 or HPV4.

Contraindications and Precautions Pneumococcal vaccines

The pneumococcal vaccine should be administered unless there is a valid contraindication or precaution to receiving the vaccine. PCV13 and PPSV23 are contraindicated for patients who have had a severe allergic reaction (e.g., anaphylaxis) to a previous vaccine dose or to a vaccine component (including a diphtheria toxoid-containing vaccine for the PCV13 vaccine). Precautions include moderate or severe acute illness with or without fever.

Clinical Features and Potential Complications Rotavirus

The primary means of transmission is by the fecal-oral route through person-to-person contact or contact with fomites (contaminated objects). After an incubation period of 24 to 72 hours, the infected person may develop symptoms that can range from self-limiting watery diarrhea to severe diarrhea with fever and vomiting. Symptoms typically last for 3 to 7 days. Rotavirus infection in infants and children can result in more serious disease such as severe diarrhea, dehydration, electrolyte imbalances, and in some cases, death. An initial infection with rotavirus after 3 months of age is most likely to cause severe gastroenteritis and dehydration. Infection with rotavirus can occur several times throughout a person's lifetime, and it appears that initial infection may protect a child from developing subsequent severe gastroenteritis. After a single natural infection, 38% of children are protected against subsequent infection with rotavirus, 77% are protected against subsequent rotavirus-associated diarrhea of any severity, and 87% are protected against subsequent moderate to severe rotavirus-associated diarrhea. Therefore, vaccination, which mimics the immunoprotective response from a natural infection in an individual, should help prevent rotavirus infection and its associated complications. Each year during the 1990s and early 2000s, rotavirus resulted in approximately 410,000 physician visits; 205,000 to 272,000 emergency department visits; and 55,000 to 70,000 hospitalizations among U.S. infants and children, with total annual direct and indirect costs of approximately $1 billion.69 Vaccination against rotavirus has been shown to decrease the morbidity, health care expenditures, and mortality associated with this disease.

Vaccine Recommendations Poliomyelitis

The recommended IPV schedule is to vaccinate all children at ages 2 months, 4 months, 6 to 18 months, and 4 to 6 years. For an adult requiring vaccination, the recommendations vary depending on the individual's vaccination history77: • Written documentation of having completed the primary series: Administer 1 booster dose of IPV. • Written documentation of having received 1 but not all doses of the series: Administer the remaining doses of the series. • No documentation of polio vaccination: Administer the primary series of 3 doses of IPV. The recommended schedule is 0, 1 to 2 months, and 6 to 12 months. However, if time is a factor and the patient must travel before completing the series, refer to the ACIP guidelines for additional information on how to appropriately schedule the vaccine series to maximize protection for the patient.

Vaccine recommendations Poliomyelitis

The recommended IPV schedule is to vaccinate all children at ages 2 months, 4 months, 6 to 18 months, and 4 to 6 years. For an adult requiring vaccination, the recommendations vary depending on the individual's vaccination history77: • Written documentation of having completed the primary series: Administer 1 booster dose of IPV. • Written documentation of having received 1 but not all doses of the series: Administer the remaining doses of the series. • No documentation of polio vaccination: Administer the primary series of 3 doses of IPV. The recommended schedule is 0, 1 to 2 months, and 6 to 12 months. However, if time is a factor and the patient must travel before completing the series, refer to the ACIP guidelines for additional information on how to appropriately schedule the vaccine series to maximize protection for the patient.

Vaccine Recommendations Haemophilus influenza type B

The recommended schedule for vaccine use and the number of doses needed depend on the vaccine product selected. ActHIB, MenHibrix, Hiberix, and Pentacel require a 3-dose primary series (at ages 2, 4, and 6 months) followed by a booster dose (at ages 12 to 15 months), and PedvaxHIB requires a 2-dose primary series (at ages 2 and 4 months) followed by a booster dose (at ages 12 to 15 months).34 Combination vaccines may be used in situations where children require protection against more than one disease. Children who are behind schedule may not require a full series of 3 or 4 doses of Hib vaccine, and the health care provider should consult the current childhood immunization schedule to determine the appropriate dosing schedule for the series when a child falls behind. Hib vaccine is not routinely given to children aged 5 years or older. However, patients with certain conditions (i.e., anatomic or functional asplenia, sickle-cell disease, and hematopoietic stem cell transplant (HSCT) immunodeficiency, immunosuppression, leukemia, or HIV infection) may be at increased risk for invasive Hib disease. One dose of single- antigen Hib vaccine should be administered to older children, adolescents, and adults with anatomic or functional asplenia. HSCT patients should receive 2 doses of Hib vaccine in at least 4-week intervals 6 to 12 months after transplant, regardless of Hib vaccine history. If Hib conjugate vaccine is indicated, these patients should receive a single 0.5 mL dose.

Target Groups for Vaccination For pneumococcal disease

The recommended uses of PCV13 and PPSV23 are complicated and have undergone several changes in recent years. Careful reading of the ACIP schedules and footnotes will help pharmacists determine the recommended schedules for use of these vaccines in various patient populations. Both vaccines have recommendations for routine use and for use in patients with high-risk conditions.

Contraindications and Precautions Of herpes zoster vaccine

The vaccine for herpes zoster is contraindicated in individuals with a history of anaphylaxis to a previous dose of the vaccine or to gelatin, neomycin, or any other component of the vaccine. However, a neomycin allergy that manifests as contact dermatitis should not be considered a contraindication. The vaccine is also contraindicated in patients with the following conditions: • Immunosuppression due to leukemia, lymphoma, generalized malignancy, immune deficiency disease, or immunosuppressive therapy • Active untreated tuberculosis • Pregnancy HZV may be administered to certain persons 60 years of age or older with altered immunocompetence, such as persons receiving low dosages of immunosuppressive medications, those with isolated B-cell deficiencies (i.e., impaired humoral immunity), or those with HIV infection who have CD4+ T-lymphocyte counts of greater than 200 cells/mm3.18 Moderate or severe acute illness with or without fever is a precaution for receipt of HZV. If there is no valid contraindication or precaution to receipt of HZV, the vaccine should be administered.

Meningococcal vaccines

There are several vaccines in the U.S. market that protect against N. meningitidis serogroups A, B, C, Y, and W-135. The quadrivalent vaccines are referred to as MenACWY and were previously referred to as MCV4. They include MenACWY135-D (Menactra—Sanofi Pasteur) and MenACWY-135-CRM (Menveo—Novartis). (Menomune, referred to as MPSV4, is a non-conjugate quadrivalent vaccine that was discontinued and will not be available after September 2017.) In addition, a bivalent meningococcal vaccine, HibMenCY-TT (MenHibrix—GlaxoSmithKline), protects against C and Y in combination with providing protection against Hib for high-risk children. Two vaccines have been approved by the FDA to provide protection against N. meningitidis serogroup B (MenB): MenB-FHbp (Trumenba—Pfizer), approved in 2014, and MenB-4C (Bexsero—Novartis), approved in 2015.62 Menactra and Menveo are protein-conjugated meningococcal vaccines. Menactra is licensed for patients 9 months to 55 years of age; Menveo is licensed for patients 2 months to 55 years of age. MenHibrix is a conjugate polysaccharide vaccine that is combined with Hib and approved only for high-risk children 6 weeks to 18 months of age. Nearly 98% of patients will develop high levels of antibodies after vaccination.1 Protection will not usually be achieved for at least 7 to 10 days after vaccination

Potential Adverse Reactions Hepatitis B

Transient adverse events that can be expected after administration of hepatitis B vaccine include injection-site pain, fatigue, headache, or low-grade fever. Serious reactions are rare.

2020-21 Influenza Vaccine Composition

Trivalent and Quadrivalent Egg-b-ased Vaccines (IIV4, IIV4- HD, LAIV4, aIIV3/4) -A/Guangdong-Maonan/SWL1536/2019 (H1N1)pdm09-like virus - change from 2019-2020 -A/Hong Kong/2671/2019 (H3N2)-like virus - change from 2019-2020 -B/Washington/02/2019 (Victoria lineage) - change from 2019-2020 -B/Phuket/3073/2013 (Yamagata lineage) - additional B strain for quadrivalent vaccines Quadrivalent Cell or Recombinant-based Vaccines (ccIIV4, RIV4) -A/Hawaii/70/2019 (H1N1)pdm09-like virus instead of A/Guangdong-Maonan SWL1536/2019 -A/Hong Kong/45/2019 (h3N2)-like virus

Vaccines for hepatitis A

Two inactivated vaccines are currently licensed in the United States (Havrix—GlaxoSmithKline and Vaqta—Merck). Each of these vaccines is available in two different formulations: a pediatric formulation for patients aged 12 months to 18 years and an adult formulation for patients older than 18 years of age. Pharmacists should choose the appropriate formulation according to the age of the patient receiving the vaccine. The volume of the dose differs depending on the formulation used. The recommended vaccine schedule is the same for both brands. Vaccine brands are interchangeable. Twinrix (GlaxoSmithKline) may be used for individuals who require both hepatitis A and hepatitis B vaccine. The first dose of the hepatitis A vaccine provides protective levels of antibodies in more than 95% of patients, and nearly 100% of patients will be fully protected after completing the 2-dose series.3

Pneumococcal vaccine

Two vaccines are currently available for the prevention of disease caused by S. pneumoniae. One vaccine is a conjugate vaccine (PCV13), and the other is a pure polysaccharide vaccine (PPSV23).

Contraindications and Precautions Hepatitis A

Unless a contraindication or precaution is present, the vaccine can be administered to all eligible infants, children, adolescents, and adults. Hepatitis B vaccines are contraindicated in individuals who have had a severe allergic reaction (e.g., anaphylaxis) to a previous vaccine dose or to a vaccine component. Moderate or severe acute illness with or without fever is a precaution.

Vaccine Recommendations The pneumococcal disease (Children and Adolescence)

Unless there is a contraindication, PCV13 is recommended for use in all children aged 2 months to 59 months as a four-dose series, and PPSV23 is recommended for children with certain high-risk conditions. All children aged 2 months to 59 months should be routinely vaccinated with PCV13. The recommended routine vaccination schedule for the four-dose series is administration at 2, 4, 6, and 12 to 15 months of age. Children 7 months of age and older who have not previously received PCV13 do not require a full series of 4 doses. -The number of doses a child needs to complete the series depends on the child's current age and previous PCV13 doses. -Unvaccinated children aged 7 to 11 months should receive 2 doses of vaccine at least 4 weeks apart, followed by a booster dose at age 12 to 15 months. -Unvaccinated children aged 12 to 23 months should receive 2 doses of PCV13 at least 8 weeks apart. -Previously unvaccinated healthy children 24 to 59 months of age should receive a single dose of PCV13. -Unvaccinated children 24 to 71 months of age with certain chronic medical conditions should receive 2 doses of PCV13 separated by at least 8 weeks. These conditions include chronic heart and lung disease, diabetes, cerebrospinal fluid leak, cochlear implant, sickle cell disease and other hemoglobinopathies, functional or anatomic asplenia, HIV infection, or immunocompromising conditions resulting from disease or treatment of a disease. -High-risk children 6 to 18 years of age who have received a 3-dose series of PCV7 should receive a supplemental single dose of PCV13 up to the age of 18 years regardless of whether they have previously received PCV7 or PPSV23. -PPSV23 is recommended only for children who have high-risk conditions. For these children, PPSV23 should be administered at least 8 weeks after the last dose of PCV13 to children aged 2 years or older. A second PPSV23 dose should be administered after 5 years to children with anatomic or functional asplenia (including sickle cell disease) or an ongoing immunocompromising condition.

Potential Adverse Reactions Pneumococcal Polysaccharide Vaccine

Up to half of the patients who receive PPSV23 will develop a mild, local reaction that may include mild pain, swelling, and redness at the injection site.3 Fever and myalgias after PPSV23 administration occur in fewer than 1% of recipients.

Target Groups for Vaccination Poliomyelitis

Vaccinate all children against poliovirus. Routine vaccination of adults is not recommended unless the adult is traveling overseas to a poliovirus-endemic area.

target groups for vaccination Poliomyelitis

Vaccinate all children against poliovirus.77 Routine vaccination of adults is not recommended unless the adult is traveling overseas to a poliovirus-endemic area

Important Patient Counseling Information for HPV

Vaccination against HPV does not replace the need for routine cervical cancer screening. Women who have been vaccinated should maintain the same recommended schedule of screening with annual examinations including Papanicolaou (Pap) tests. In addition, sexually active patients should be educated to use barrier protection to prevent sexually transmitted infections.

''2020-21 Influenza Vaccines

Vaccine (manufacturer)* Inactivated Influenza Vaccine Fluzone (Sanofi Pasteur) IIV4 Fluarix (GSK) IIV4 FluLaval (GSK) IIV4 Afluria (Seqirus) IIV4 Fluzone High-Dose (Sanofi Pasteur) IIV4 Flucelvax (Seqirus)-cell cultured (not eggs) ccIIV4 Approved Age Indications 6 months and older 6 months and older 6 months and older 6 months and older 65 years and older 4 years and older Flublok (Sanofi Pasteur) RIV4 18 years and older Fluad (Seqirus) IIV3/4** Live Attenuated Influenza Vaccine*** FluMist (MedImmune) LAIV4 65 years and older 2 years to 49 years 5, *Pharmacists should always verify product availability and age indications for each vaccine. **Fluad is an adjuvanted vaccine ***For the 2020-2021 season, immunization providers may choose to administer any licensed, age-appropriate influenza vaccine (LAIV, IIV and RIV). LAIV4 is an option for influenza vaccination for persons for whom it is appropriate

Knowledge Check: Human Papillomavirus Vaccines Summary

Vaccine abbreviation: 9vHPV Live or inactivated: Inactivated Target groups for vaccination: Children, adolescents, and adults 9 to 45 years of age, ideally at 11 to 12 years Doses: 2 or 3 doses, depending on age of first dose Timing of administration: 2 doses given 6 to 12 months apart; 3 doses given at 0, 1 to 2 months, and 6 months

Knowledge Check: Zoster Vaccines Summary

Vaccine abbreviation: HZV Live or inactivated: Live Target groups for vaccination: All adults 60 years of age and older Doses: 1 dose Timing of administration: At age 60 years

Knowledge Check: Hepatitis B Vaccines Summary

Vaccine abbreviation: HepB Live or inactivated: Inactivated Target groups for vaccination: All children and high-risk adults Doses: 3 doses Timing of administration: At birth, 1 to 2, and 6 to 18 months of age. For older patients, at 0, 1, and 6 months.

Knowledge Check: Haemophilus influenza type b Vaccines Summary

Vaccine abbreviation: Hib Live or inactivated: Inactivated Target groups for vaccination: All infants Doses: 3 or 4 doses depending on vaccine Timing of administration: At 2, 4, 6, and 12 to 15 months of age, or at 2, 4, and 12 to 15 months of age

Knowledge Check: Poliomyelitis Vaccines Summary

Vaccine abbreviation: IPV Live or inactivated: Inactivated Target groups for vaccination: Infants 6 weeks to 8 months. Doses: 4 doses Timing of administration: At 2, 4, 6 to 18 months, and 4 to 6 years of age

Knowledge Check: Tetanus, Diphtheria, and Pertussis Vaccines Summary

Vaccine abbreviations: DTaP, DP, Td, Tdap, TT Live or inactivated: Inactivated Target groups for vaccination: Children 6 weeks to 6 years of age should receive DTaP and those 11 to 12 years of age should receive Tdap. All adults should receive a one-time dose of Tdap and then Td every 10 years. Tdap is also used for cocooning. Doses: 5 doses for children; 1 dose for all adults, and 1 dose per pregnancy for women. Timing of administration: DTaP given at 2 months, 4 months, 6 months, 15 to 18 months, and 4 to 6 years of age. Variable for adults. Tdap given at 27 to 36 weeks of each pregnancy

Knowledge Check: Meningococcal Vaccines Summary

Vaccine abbreviations: MenACWY and MenB Live or inactivated: Inactivated Target groups for vaccination: MenACWY for all adolescents and high-risk individuals 2 months of age and older. MenB based on clinical discretion for all adolescents; for high-risk individuals, age 10 years and older. Doses: MenACWY as 2 doses, Men B as 2 or 3 doses depending on the vaccine and indication Timing of administration: MenACWY at age 11 to 12 years and a booster at 16 years. For high-risk conditions, 1 dose, or 1 dose followed by revaccination every 5 years if the risk remains. MenB at age 16 to 18 years based on clinical discretion, given at 0 and at least 1 month later, or 0 and 6 months depending on vaccine. For high-risk conditions, given at 0 and at least 1 month later, or at 0, 1 to 2, and 6 months, depending on vaccine.

Knowledge Check: Pneumococcal Vaccines Summary

Vaccine abbreviations: PCV13 and PPSV23 Live or inactivated: Inactivated Target groups for vaccination: For children, routine use of PCV13 for all children and PPSV23 for children with high-risk conditions. For adults, both PCV13 and PPSV23 are recommended for high-risk adults 19 to 65 years of age and those who are 65 years and older. Doses: For children, PCV13 as a 4-dose series for all children and PPSV23 as 1- or 2-dose series for high-risk children. For adults, 1 dose of PCV13 and 1, 2, or 3 doses of PPSV23 depending on indication. Timing of administration: PCV13 for children at ages 2, 4, 6, and 12 to 15 months. PPSV23 doses should be given at least 5 years apart. At least 1 year between PCV13 and PPSV23 for adults 65 years of age and older only, otherwise 8 weeks apart.

Knowledge Check: Rotavirus Vaccines Summary

Vaccine abbreviations: RV1 and RV5 Live or inactivated: Live Target groups for vaccination: Infants 6 weeks to 8 months of age Doses: 2 or 3 doses depending on vaccine Timing of administration: At 2, 4, and 6 months of age or at 2 and 4 months of age

Varicella vaccine

Varicella vaccine (Varivax—Merck) is a live attenuated virus vaccine. Because this is a live vaccine, it must replicate to stimulate an immune response. Immune response similar to that produced by natural infection The varicella vaccine has been shown to reduce the risk of varicella infection by up to 90% and reduces the risk of moderate to severe disease by up to 95%.3 Since varicella vaccine was first introduced in the United States in 1995, it has significantly reduced morbidity and mortality related to varicella. Breakthrough infections have been reported in people who have been immunized with 1 dose of vaccine. These people are more likely to have only mild disease with few lesions. Data from a 10-year surveillance period revealed that increases in the severity and incidence of breakthrough infection were associated with the length of time since vaccination, suggesting that the protection provided by a single dose of varicella vaccine wanes over time. Therefore, a second dose of varicella vaccine was added to the immunization schedule in 2006. Of note, investigational vaccines for the prevention of zoster include V212 (Merck), which is an inactivated formulation of Zostavax that was in Phase III trials in 2017, and HZ/su (Shingrix), which was submitted to the FDA for approval in late 2016.

Storage and Administration of Varicella Vaccine

Varicella vaccine is a live vaccine that is sensitive to temperature. Proper storage conditions are essential to ensure vaccine potency. Varicella-containing vaccines should be protected from light and kept frozen at a temperature of -15°C (5°F) to -50°C (-58°F) or colder before use. Varicella- containing vaccine must be stored in refrigerator/freezer units that have a separate sealed freezer compartment or preferably in a separate freezer unit. If unreconstituted vaccine powder is inadvertently stored in the refrigerator, it can remain viable for up to 72 hours at this temperature, but it must be discarded if unused within 72 hours. The vaccine, which requires reconstitution before injection, should be reconstituted with the diluent provided with the vaccine. The diluent can be stored in the refrigerator or at room temperature before use. Once reconstituted, varicella vaccine should be administered immediately to avoid loss of potency. Vaccine that is not administered within 30 minutes of reconstitution must be discarded. The dose of varicella vaccine is 0.5 mL. This vaccine should be administered subcutaneously

Contraindications and Precautions of Varicella Vaccine

Varicella vaccine is contraindicated in patients with a history of hypersensitivity to a prior dose or to any component of the vaccine. The varicella vaccine contains very small amounts of neomycin and gelatin. Patients with a history of anaphylaxis to either of these components should be referred to an allergy specialist for vaccine decisions. Women who are pregnant should not receive varicella-containing vaccine during pregnancy. Because varicella vaccine is a live vaccine, it has some additional contraindications and precautions to consider. -Patients with immunosuppression should be referred to their primary care provider for vaccine decisions. -If a patient has recently received a blood product, live vaccines can be inactivated by antibodies that may be present in the blood products, such as immune globulin, whole blood, or plasma. *For patients in need of varicella vaccine who have received a blood product in the previous year, the pharmacist should refer to updated references (e.g., Epidemiology and Prevention of Vaccine-Preventable Diseases, also known as "The Pink Book," and the ACIP general recommendations on immunization) to determine the appropriate interval before the vaccine can be administered. A personal or family (i.e., sibling or parent) history of seizure is a precaution for use of MMRV vaccine.

Potential Adverse Reactions of Varicella

Varicella vaccine must replicate to evoke an immune response, and thus adverse reactions that are similar to symptoms of the natural disease can occur. For example, patients may develop a varicella-like rash after vaccination. These rashes are usually minor, with few lesions, and usually are maculopapular rather than vesicular. In addition, this live vaccine can result in a latent infection that can later present as herpes zoster. Herpes zoster has occurred among patients who have received varicella vaccine, although at a lower rate than after natural infection. As with other vaccines, local injection site reactions can be expected after vaccination. Systemic symptoms (e.g., fever) after varicella vaccination are not commonly reported. Transmission of the attenuated virus in varicella vaccine is rare, although it has been reported. From the reported cases, it appears that this occurs only in patients who develop a rash after vaccination. If a rash develops, patients should avoid contact with people who do not have evidence of immunity (e.g., infants) or those at high risk for complications from varicella (e.g., immunocompromised individuals) until the rash resolves.

Varicella

Varicella zoster virus is a herpes virus that causes two kinds of disease. -Primary infection causes varicella (i.e., chickenpox). -After an acute infection with varicella, the virus lies dormant in nerve root ganglia. If the virus is reactivated, usually many years later, a painful condition called herpes zoster (i.e., shingles) occurs. This very contagious virus is communicable from 1 to 2 days before onset through 4 to 5 days after onset of the characteristic rash. Infection with varicella zoster virus can be spread to a susceptible person by respiratory transmission through airborne droplets or by direct contact with varicella or herpes zoster lesions