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MD Consult: Books: Goldman: Cecil Medicine: INDIVIDUAL IMMUNOBIOLOGICS

Goldman: Cecil Medicine, 23rd ed.

Copyright © 2007 Saunders, An Imprint of Elsevier

INDIVIDUAL IMMUNOBIOLOGICS

   Hepatitis A

Two inactivated hepatitis A ( Chapter 151 ) vaccines are available in the United States. Seroconversion rates after a single dose of either vaccine in persons older than 1 year exceed 95%. Antibody levels shown to be protective in animals develop in almost all persons.

Indications

The vaccine is indicated primarily for persons traveling to countries, generally the developing world, with high or intermediate endemicity for hepatitis A, but it is also recommended for other groups at high risk for infection or for development of severe hepatitis. In addition, children living in communities with high rates of endemic hepatitis A (anti–hepatitis A prevalence of 30 to 40% by 5 years of age) should be vaccinated. Health care workers have not been shown to be at higher risk than the general population for hepatitis A and do not need routine immunization. Although food handlers are not at increased risk of hepatitis A compared with the general population, the consequences of infection or suspected infection in this group, which can lead to extensive public health investigations, may make vaccination cost-effective in some settings. Hepatitis A vaccine can be given to children 1 year of age or older to control outbreaks in communities with high rates of prior infection and be considered for communities with intermediate levels of prior infection (anti–hepatitis A seroprevalence of 10 to 25% by 5 years of age). In 2006, the Advisory Committee on Immunization Practices recommended universal vaccination of children. Doses vary by age and product. All schedules call for a second dose at least 6 months after the first dose, with a permissible range for one of the products 18 months after the initial dose. Vaccines are not indicated for children younger than 1 year because adequate data on safety and efficacy are lacking.

Side Effects

The most common side effect has been tenderness and soreness at the injection site. Although rare and more serious adverse events have been reported in temporal association with vaccination, a causal relationship has not been established.

   Hepatitis B

Hepatitis B ( Chapter 151 ) vaccine is the first vaccine that can prevent cancer (an estimated 800 persons per year in the United States die of hepatitis B–related liver cancer; many times more die in the developing world). It also can prevent acute and chronic complications of hepatitis B, including an estimated 4000 deaths annually from cirrhosis and 250 deaths annually from fulminant hepatic disease in the United States. The original hepatitis B vaccine in the United States consisted of purified, inactivated, alum-adsorbed, 22-nm HBsAg particles obtained from human plasma. Currently produced vaccines are derived from insertion of the gene for HBsAg into Saccharomyces cerevisiae. Hepatitis B vaccine, the first licensed vaccine made by use of recombinant techniques, produces adequate antibody responses in more than 90% of normal adults and more than 95% of normal infants, children, and adolescents when it is administered in a three-dose series. The dosage depends on the product, the age group, and the underlying clinical condition and can be determined by consulting the package insert. The duration of vaccine-conferred immunity is not known, although follow-up of vaccinees for more than 16 years indicates persistence of protection against clinically significant infections (i.e., detectable viremia and clinical disease). Booster doses are not currently recommended. Vaccine must be injected intramuscularly, preferably in the deltoid.

Indications

Hepatitis B vaccine is indicated for adults at high risk of infection (see Fig. 16-1B ). Because strategies targeting hepatitis B vaccine use only to high-risk populations have not had a significant impact on hepatitis B incidence, universal vaccination is now recommended for infants and for all adolescents who have not been previously vaccinated. Universal screening for HBsAg is recommended for all pregnant women; administration of three doses of vaccine and one dose of hepatitis B immune globulin is recommended for infants of acutely or chronically infected mothers.

Side Effects

The major side effect is soreness at the injection site. Alopecia, which is usually reversible, has been reported rarely. Hepatitis B vaccine has not been shown to induce multiple sclerosis in controlled studies and has not been shown to exacerbate illness in patients with multiple sclerosis who are vaccinated. There is no risk of acquiring HIV infection from either the recombinant or the plasma-derived vaccine.

   Human Papillomavirus

In 2006, a quadrivalent human papillomavirus (HPV) vaccine was licensed. The vaccine consists of the L1 capsid protein of types 16 and 18, which account for about 70% of cases of cervical cancer, and types 6 and 11, which are the most common causes of anogenital warts. An additional bivalent vaccine consisting of types 16 and 18 is in clinical trials.

Routine vaccination of 11- to 12-year-old girls is recommended in a three-dose schedule at 0, 2, and 6 months. Catch-up vaccination should be undertaken for females up through 26 years of age. Recipients of HPV vaccine should follow the same recommendations for Pap smear screening as unvaccinated females. Persons with prior abnormal Pap smears or genital warts may be vaccinated to prevent persistent infection with types of HPV that are in the vaccine and have not yet been acquired.

Side Effects

The most common reactions are local pain, swelling, and erythema, which may, in part, be explained by the aluminum adjuvant rather than the L1 capsid protein. There is a slightly higher incidence of fever within 15 days of vaccination in vaccine recipients compared with that in placebo recipients.

   Influenza

The two available influenza vaccines are the inactivated trivalent influenza vaccine (TIV) and the live attenuated influenza vaccine (LAIV). TIV, which contains split viruses of three major antigenic types, A (H3N2), A (H1N1), and B, is administered intramuscularly. LAIV, which consists of three cold-adapted, temperature-sensitive attenuated viruses, one for each of the expected circulating strains, is administered intranasally. LAIV is prepared by use of attenuated parent viruses that have been reassorted with circulating strains to contain six internal genes from the parent virus and genes for the surface hemagglutinin and neuraminidase of an A (H3N2), A (H1N1), or B strain.

Indications

Annual influenza ( Chapter 387 ) vaccination with TIV is indicated for adults at high risk of complications from the disease: persons with chronic cardiopulmonary disorders, residents of nursing homes or other long-term care facilities, persons 65 years of age or older, patients with other chronic diseases (e.g., diabetes mellitus, kidney dysfunction, hemoglobinopathies, and immunosuppression) who have required regular medical follow-up or hospitalization in the prior year, adults and children who have any condition (e.g., cognitive dysfunction, spinal cord injuries, seizure disorders, or other neuromuscular disorders) that can compromise respiratory function or the handling of respiratory secretions or that can increase the risk for aspiration, and children receiving long-term aspirin therapy. Women who will be pregnant during the influenza season (usually late December through mid-March) also should be vaccinated. Vaccination also has been recommended for all adults 50 to 64 years old to reduce influenza. Influenza vaccine can be considered for providers of essential community services and anyone who wants to avoid disease. To reduce transmission of influenza to high-risk patients, health care workers and household contacts of high-risk patients should also be vaccinated annually, including contacts of children younger than 5 years of age.

LAIV is licensed only for patients 5 to 49 years of age without underlying conditions that place them at high risk of complications from influenza. LAIV can be used for contacts of high-risk patients, if the contacts are of the appropriate age. LAIV, for theoretical concerns about live virus transmission, is not recommended for contacts of severely immunosuppressed patients such as patients with bone marrow transplants but can be given to contacts of persons with mild to moderate immunologic impairment.

The efficacy of TIV varies with the host’s condition and the degree to which antigens in the vaccine match viruses in circulation the following season. Provided the match is good, the vaccine’s efficacy is usually 70 to 90% in normal healthy young adults. Efficacy is substantially lower, often between 30 and 40%, in the institutionalized elderly; nevertheless, it seems to be 60 to 80% protective against pneumonia and death. LAIV has been found to be more than 85% effective in young children, even in a year when the circulating strain had antigenically drifted from the vaccine strain. Similar effects were seen in challenge studies in adults.

Ideally, vaccines should be administered between October and November of each year, although earlier in the autumn suffices if circumstances require. If vaccine is available in December and January, vaccination should continue because it still can offer protection for many individuals. A review of 29 consecutive influenza seasons documented that peak activity did not occur until January or later in 24 seasons and until February or later in 18 seasons.

Side Effects

Persons with anaphylactic allergy to eggs should not be immunized. The most common side effect of TIV is soreness at the injection site. Fever, malaise, and myalgia may begin 6 to 12 hours after vaccination and persist for 1 to 2 days, although such reactions are most common in children exposed to vaccine for the first time. Severe allergic reactions are rare. If current influenza vaccines cause Guillain-Barré syndrome, it is likely to be rare, on the order of 1 case per 1 million doses. The most common adverse events after LAIV in adults are runny nose, headache, and sore throat.

   Measles

Indications

Measles ( Chapter 390 ) immunization is recommended for all persons born in or after 1957 who lack evidence of prior physician-diagnosed measles or laboratory evidence of immunity or appropriate vaccination. Before 1989, appropriate vaccination consisted of a single dose of live vaccine administered on or after the first birthday. Since then, a routine two-dose schedule has been recommended: the first dose, which is 93 to 98% effective, at 12 to 15 months of age and the second dose at entry to primary school. All children from kindergarten through the 12th grade should have a second dose. Most adults are considered to have been appropriately vaccinated if they received one dose of vaccine administered on or after their first birthday. Some adults who are at increased risk of measles (health care workers with direct contact with patients, students in college, international travelers) should receive a second dose of vaccine, however, unless they have documentation of prior physician-diagnosed measles or serologic evidence of immunity. Persons embarking on foreign travel ideally should have received two doses or have other evidence of measles immunity. Persons born before 1957 are usually immune as a result of natural infection and do not require vaccination, although vaccination is not contraindicated if they are believed to be susceptible.

During outbreaks of measles in institutions, all persons at risk who have not received two doses or who lack other evidence of measles immunity should be vaccinated. Measles vaccine is usually administered along with mumps and rubella vaccines as MMR to ensure immunity against all three diseases. Individuals already immune to one or more of the components may receive MMR without harm.

Measles vaccine is contraindicated for pregnant women on theoretical grounds, for persons with moderate to severe acute febrile illnesses, and for persons with altered immunocompetence except persons with HIV infection who are not severely immunocompromised. Patients with anaphylactic reactions to eggs can be vaccinated without prior skin testing.

Side Effects

In approximately 5 to 15% of susceptible recipients of measles vaccine, temperatures of 39.4° C or higher develop 5 to 12 days after vaccination and last 1 to 2 days. Transient rashes develop in about 5%. Thrombocytopenic purpura has been reported rarely after MMR. The overall rate of reactions after the second dose of a measles-containing vaccine is substantially lower than after the first dose. Encephalopathy or encephalitis after measles vaccination has been reported at a rate lower than the background or expected rate.

   Meningococcal Vaccines

Two quadrivalent meningococcal polysaccharide vaccines against disease caused by serogroups A, C, Y, and W135 are available: meningococcal polysaccharide vaccine (MPSV4), which consists of 50 μg of polysaccharide of each of the four serogroups and is licensed for persons 2 years of age and older; and meningococcal conjugate vaccine (MCV4), which consists of 4 μg of each polysaccharide covalently linked to 48 μg of diphtheria toxoid and licensed for persons 11 to 55 years of age. The four serogroups in each vaccine account for approximately two thirds of meningococcal disease in the United States and about 75% of the disease in persons 11 years of age or older ( Chapter 437 ). Serogroup A and C polysaccharide vaccines have had 85 to 100% efficacy in epidemic settings, whereas polysaccharide vaccines for the other groups have documented good immunogenicity in adults. Meningococcal conjugate vaccine type C (MCV-C) has been associated with an estimated effectiveness of 88 to 98% in the year following vaccination in the United Kingdom, where it has been used widely. In addition, MCV-C has reduced colonization by 66% and decreased disease among unvaccinated persons by 67% in 1- to 17-year-olds and by 35% among those older than 25 years. In contrast to polysaccharide vaccines, conjugate vaccines induce immunologic memory, result in higher and more durable levels of high-avidity antibodies, and have been documented to induce herd immunity. The duration of immunity for both MPSV4 and MCV4 is unknown, although protection in older children and adults probably persists for at least 3 years for both vaccines. Protection after MPSV4 in preschool children may be shorter.

Indications

Routine vaccination with a single dose of MCV4 is recommended for all adolescents at 11 to 12 years of age, all persons at high school entry (approximately age 15 years) who have not been previously vaccinated, and college freshman who will live in dormitories. Vaccination is also recommended for persons with terminal complement component deficiencies, asplenia or splenic dysfunction, and travelers and persons who will live in areas with hyperendemic or epidemic disease (e.g., the “meningitis belt” of sub-Saharan Africa, stretching from Mauritania to Ethiopia). MPSV4 should be used for persons 2 to 10 years and older than 55 years with an indication for vaccine. MPSV4 is an acceptable alternative for college freshman living in dormitories, travelers, and patients with high-risk medical conditions. Meningococcal vaccination may be useful during localized epidemics of serogroups in the vaccine.

Revaccination should be considered 2 to 3 years after primary immunization with MPSV4 for children younger than 4 years at the initial vaccination. Revaccination 5 years after the initial dose also may be considered for older adolescents and adults at continued risk. At present, there are no recommendations for booster doses for persons vaccinated with MCV4.

Side Effects

The major side effects of MPSV4 are local reactions lasting 1 to 2 days. The incidence of local reactions and low-grade fever is slightly higher after MCV4 than with MPSV4. An excess risk of 1.25 cases of Guillain-Barré syndrome per million doses has been noted with the vaccination.

   Mumps

Indications

Mumps ( Chapter 392 ) vaccine is indicated for all persons, especially susceptible males, without evidence of immunity. For most adults, such evidence consists of a prior history of vaccination on or after the first birthday, physician-diagnosed mumps, or laboratory evidence of immunity. For adults at high risk, including health care workers, international travelers, and students at post–high school educational institutions, two doses of mumps vaccine constitute acceptable evidence of immunity. Most persons born before 1957 can be considered immune as a result of natural infection, although vaccination is not contraindicated if such persons are thought to be susceptible.

Side Effects

Adverse events after the Jeryl Lynn strain of mumps vaccine, the strain used in the United States, are uncommon—fever, parotitis, and allergic manifestations. Thrombocytopenic purpura has been reported rarely in persons administered MMR. Mumps vaccine is contraindicated for pregnant women on theoretical grounds, for persons with moderate to severe acute febrile illnesses, and for persons with altered immunocompetence. When combined with measles vaccine, it may be given to persons with asymptomatic HIV infection and considered for persons with symptomatic infection if they are not severely immunocompromised. Patients with anaphylactic reactions to eggs can be vaccinated without skin testing (see Measles earlier).

   Pertussis Vaccine

In 2005, two vaccines were licensed for boosting immunity to pertussis. Both vaccines are combined with the adult preparation of tetanus and diphtheria toxoids and have a reduced content of pertussis antigens compared with the childhood pertussis-containing vaccines (Tdap). Boostrix (GlaxoSmithKline), which is licensed for adolescents 10 to 18 years of age, contains three pertussis antigens—toxoid (PT), filamentous hemagglutinin (FHA), and pertactin (PRN). Adacel (Sanofi Pasteur, Inc.), which is licensed for 11- to 64-year-olds, contains five pertussis antigens, PT, FHA, PRN, and two fimbriae. Both vaccines, when administered to previously vaccinated adolescents and adults, induce serologic responses that are comparable to those induced during childhood vaccination with vaccines that have been proved to be effective. Adverse events, usually local reactions, are similar with the adult preparation of tetanus and diphtheria toxoids (Td) alone. Tdap is indicated for all adolescents at 11 to 12 years of age. Older adolescents should receive Tdap instead of Td if they have not received an adolescent Td booster. For patients who have received a Td booster, an interval of 5 years is encouraged before Tdap is received. However, Tdap can be given at any interval after Td when the risk of pertussis is judged to be high. All adults younger than 65 years of age should receive a single dose of TdaP to replace a Td booster.

   Pneumococcal Vaccine

Pneumococcal polysaccharide vaccine consists of purified polysaccharide capsular antigens from the 23 types of Streptococcus pneumoniae that are responsible for 85 to 90% of the bacteremic disease in the United States ( Chapter 311 ). Most adults, including the elderly and patients with alcoholic cirrhosis and diabetes mellitus, have a two-fold or greater rise in type-specific antibodies within 2 to 3 weeks of vaccination. Although the serologic response is generally acceptable, estimates of vaccine efficacy in preventing disease vary widely. Efficacy may be lower in some patients, such as patients with alcoholic cirrhosis or Hodgkin’s disease. There is good evidence that vaccination is approximately 60% effective against bacteremic pneumococcal disease, which accounts for an estimated 50,000 cases annually. Evidence regarding efficacy against pneumonia in high-risk populations is not clear, however.

Indications

Regardless, the preponderance of information supports the use of pneumococcal vaccine in high-risk populations, including all persons older than 65 years. Special efforts should target hospitalized patients. Approximately two thirds of patients who are admitted later with pneumococcal disease had been hospitalized for other reasons within the preceding 5 years.

Immunity may decrease 5 years or more after initial vaccination; a single booster dose should be considered at that time for adults at highest risk of disease, such as asplenic patients, and for adults who lose antibody rapidly, such as patients with nephrotic syndrome or renal failure. Persons older than 65 years who received a dose more than 5 years earlier when they were younger than 65 years should be revaccinated.

Side Effects

Local reactions are frequent. Less than 1% of vaccinees experience severe local reactions or systemic illness, such as fever and malaise. Severe events such as anaphylaxis are rare. Because of the rarity of severe reactions in revaccinated patients, persons with indications for vaccination but with unknown histories of prior vaccination should be vaccinated.

A pneumococcal conjugate vaccine in which the polysaccharides of seven types are covalently linked to a protein carrier was licensed and recommended for universal use in children in 2000. This vaccine, which covers substantially fewer types than the 23-valent polysaccharide vaccine, is not indicated for persons 9 years of age or older. Widespread vaccination of children in the United States has led to substantial reductions of invasive pneumococcal disease in adults, suggesting that children are the source for many adult infections.

   Poliomyelitis

The last documented cases of indigenously acquired poliomyelitis ( Chapters 402 and 440 ) caused by wild polioviruses in the United States were reported in 1979. In 2000, an all inactivated poliovirus vaccine (IPV) schedule was recommended in the United States; this vaccine replaced the live attenuated oral poliovirus vaccine (OPV), which, although it had eliminated wild poliovirus in the United States, caused about eight cases per year on average among OPV recipients or their contacts. IPV is the only vaccine available in the United States. OPV is still the vaccine used in most countries around the world, however. Between 1988, when the goal was announced to eradicate wild poliovirus from the world, and 2003, cases of poliomyelitis worldwide decreased by an estimated 99%. Polio was limited to six countries in South Asia and Africa, but a resurgence in Nigeria in 2004 led to transmission in several African countries that had been polio free. Four endemic countries remain, and efforts to eradicate polio globally continue.

Indications

Routine vaccination of persons 18 years of age or older is not warranted given the small risk of exposure to wild virus in the United States. The major indication for adult vaccination is travel to areas where wild poliovirus is endemic or epidemic. Previously unvaccinated adults should receive IPV. Adult travelers who have histories of partial vaccination should complete a primary series of three doses with IPV. Adults who formerly received three doses of OPV or IPV should receive a single booster of IPV. Health care personnel who come in contact with wild viruses should be immune to polio.

A primary series of IPV consists of three doses. A fourth dose is administered to children at school entry.

Side Effects

No serious side effects of IPV have been reported.

   Rabies

Indications

Rabies ( Chapter 441 ) vaccine is indicated for pre-exposure prophylaxis of high-risk persons, including animal handlers, selected laboratory and field workers, and persons traveling for more than 1 month to areas where rabies is a constant threat. The pre-exposure regimen consists of three 1-mL intramuscular injections on days 0, 7, and 21 or 28 for all rabies vaccines. Testing for serum antibody or a booster every 2 years is indicated for persons with continuing risk. Postexposure treatment depends on prior exposure to vaccine ( Chapter 441 ). Human rabies immune globulin is indicated for previously unvaccinated persons who are exposed.

   Rubella

Indications

Rubella ( Chapter 391 ) vaccine is indicated for susceptible adults born in 1957 or later and for susceptible women of any age who are considering becoming pregnant. Persons without a prior history of vaccination on or after the first birthday or laboratory evidence of immunity should be considered susceptible. A single dose of vaccine is 95% or more effective. Many persons receive two doses of rubella vaccine by the two-dose schedule of MMR.

Side Effects

Follow-up of susceptible pregnant women who received rubella vaccines within 3 months of the estimated date of conception has failed to reveal any evidence of defects compatible with congenital rubella syndrome in their offspring. Nevertheless, vaccine is contraindicated in pregnant women on theoretical grounds, and conception should be delayed for 1 month after rubella vaccination.

Adverse reactions occur only in susceptible persons. Arthralgia, usually of the small peripheral joints, develops in 40% of susceptible adults, and frank arthritis develops in 10 to 20%. Joint symptoms usually begin 1 to 3 weeks after vaccination and persist for 1 day to 3 weeks. Chronic recurrent or persistent joint symptoms have developed rarely after vaccination, but controlled studies have shown that the incidence of these events in vaccinees is similar to that in nonvaccinees. Other infrequent adverse events include transient peripheral neuritis and pain in the arms and legs. Thrombocytopenic purpura has been reported rarely when rubella vaccine is administered as MMR. Rubella vaccine is contraindicated for persons with moderate to severe acute febrile illnesses and for persons with reduced immunocompetence. When given with measles vaccine, it may be administered to persons with asymptomatic HIV infection and considered for persons with symptomatic infection without severe immunocompromise. Rubella vaccine is grown in human diploid cells and can be administered without problems to persons with allergy to eggs.

   Tetanus and Diphtheria

Tetanus ( Chapter 319 ) toxoid is one of the most effective immunizations, with more than 95% protection after a primary series. The adsorbed preparation is preferred to the fluid preparation because it induces protective levels of antitoxin that persist longer after fewer doses. A primary series consists of three doses. In persons aged 7 years or older, it should always be used in combination with diphtheria ( Chapter 315 ) toxoid (Td), which is more than 85% effective in preventing disease. Combinations also including pertussis antigens (Tdap) are preferred to Td for routine immunization of adolescents. Doses need not be repeated if the schedule is interrupted. Boosters of Td are recommended every 10 years. An easy way to remember is to schedule immunization at the middle of each decade (e.g., 25 years, 35 years).

Indications

After a wound, persons of unknown immunization status or persons who have received fewer than three doses of tetanus toxoid should receive a dose of Td regardless of the severity of the wound. Td also is indicated for persons who have previously received three or more doses if more than 10 years has elapsed since the last dose, in the case of clean and minor wounds, and if more than 5 years has elapsed for all other wounds. Persons who have never received a dose of TdaP should receive it in place of Td for wound management. Tetanus immune globulin should be administered simultaneously at a separate site to persons who have not received at least three doses of toxoid and who have wounds that are not clean and minor.

Side Effects

Most reactions to Td consist of local inflammation and low-grade fever. Guillain-Barré syndrome and brachial neuritis rarely have been associated with tetanus toxoid.

   Varicella: Chickenpox

A live attenuated varicella vaccine (Oka strain) was licensed in March 1995. A combination measles-mumps-rubella-varicella vaccine was licensed in September 2005. The vaccine protects 70 to 90% of recipients against any disease and more than 95% of recipients against severe disease. Vaccine effectiveness of at least 84% has been demonstrated up to 8 years after vaccination. Breakthrough infections in persons who have previously seroconverted have been reported. Such breakthroughs are typically mild and average fewer than 50 lesions compared with several hundred lesions in unvaccinated persons with varicella. Breakthrough illnesses do not seem to increase in incidence or severity with increasing time since vaccination, a finding compatible with long-term protection after initial vaccination. Persons 13 years or older require two doses at least 4 weeks apart to achieve seroconversion rates of approximately 99%, a rate comparable to that in younger children after one dose.

Indications

Varicella vaccine is indicated routinely for all children without a contraindication. A two-dose schedule is recommended, generally at 12 to 15 months of age and 4 to 6 years of age. For persons who previously received a single dose, catch-up vaccination with a second dose is recommended, provided at least 3 months have elapsed since the first dose. Persons who received a second dose at least 28 days after the first dose do not need a third dose. Persons with a prior history of varicella disease can be considered immune and do not need vaccination. Although a negative or unknown history of disease is predictive of susceptibility in children, many adults with such histories are immune. Serologic screening of adults in some situations may be cost-effective, provided that identified susceptible adults are vaccinated. The vaccine is contraindicated in the immunocompromised, persons with anaphylactic allergies to vaccine components, and pregnant women. Varicella vaccine is more temperature sensitive than other vaccines used in the United States. It must be stored frozen at -15° C or colder to retain potency, and it should be discarded if it is not used within 30 minutes of reconstitution.

Side Effects

The most common side effect is soreness at the injection site, which is reported in 25 to 35% of recipients 13 years or older. Varicella-like rashes at the injection site (median of two lesions) have been reported in 3% of recipients in this age group after the first dose and in 1% after the second dose. Nonlocalized rashes with a median of five lesions have been reported in 5.5% of recipients after the first dose and in 0.9% after the second dose. Although the vaccine can cause herpes zoster (shingles), the incidence is substantially lower than would be expected after natural varicella ( Chapter 398 ). More severe events occurring in temporal relation to the vaccine have been reported rarely, although a causal relationship has not been established. Transmission of vaccine virus to a contact is extremely rare and seems to take place only with vaccinees in whom a varicella-like rash has developed.

   Varicella: Zoster

Clinical trials of a varicella vaccine, approximately 14 times more potent than the varicella vaccine used routinely, among persons 60 years of age or older reported a 51% reduction in the incidence of zoster and a 67% decrease in postherpetic neuralgia. The efficacy against zoster declined with increasing age from 60 to 80 years or older, but there was evidence of continuing protection against postherpetic neuralgia. The vaccine requires special freezer storage.

Indications

Zoster vaccine is recommended as a single dose for persons 60 years of age or older. Persons with a prior history of zoster may be vaccinated. The vaccine is not recommended for immunocompromised persons.

Side Effects

The major side effect attributed to the vaccine is local reactions.

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