Antiviral agents vaccines and immunotherapies - part 8 ppsx

Vaccines and Immunotherapies 295 oral polio vaccine, and some adenovirus vaccines are examples of attenuated live viral vaccines. Killed viral vaccines (inactivated). Whole virus parti- cles or some component of the virus, either of which has been deactivated chemically or physically. These vaccines do not cause infection but stimulate an immune reaction. Usually, repeated doses are required as one dose does not confer lifelong immunity. Large quanti- ties of viral antigens per dose are necessary to produce an adequate response. Influenza, Salk polio, rabies, and Japanese encephalitis vaccines are of this type. Recombinant antigens. Tend to be newer versions of earlier vaccines and furnish better protection with less risk and fewer side effects. Specific components that elicit production of protective antibodies are cloned. These express the gene that encodes that protein or protein complex. The new hepatitis B vaccine is this type. The different types of vaccines that produce immune responses in a variety of cell types are shown in Table 4.2. Vaccine-induced immunity is a relative science. Selecting the correct dosage(s), timing of dosages, and determining the long- term efficacy are trials facing vaccine development. Normally, B cells, CD8 + T cells and CD4 + T cells mediate immune functions. B-cell functions may involve secretion of IgG antibodies or secretory IgA antibodies. CD4 + and CD8 + T cells provide support for B cells and CD8 + T cells assist in killing human leukocyte antigen (HLA)-matched infected cells. B cells, when mediated by T-helper cells, are thought to provide long-lasting immunity despite negative antibody test results (2). Table 4.2 Roles of Different Cell Types in Vaccine-Induced Immune System Development B-cells Live-attenuated virus vaccines, inactivated virus vaccines, protein antigens, capsular polysaccharides with or without carrier. CD8 + T cells Live-attenuated virus vaccines. CD4 + T cells Live-attenuated virus vaccines, inactivated virus vaccines, protein antigens, and capsular polysaccharides only with a protein carrier. 296 Antiviral Agents The development of vaccines may take decades to charac- terize, develop genetic-splicing methods to improve safety and efficacy, and complete appropriate testing. Still, even after vaccines are developed, many persons choose for a variety of reasons not to be vaccinated. Therefore antivirals, prophylaxis therapies, vaccines, and other immunomodulators all have a role to play in disease eradication and cure. SMALLPOX AND OTHER POXVIRUSES Smallpox In 1796, Edward Jenner first demonstrated that inoculation of cowpox virus into human skin could lead to protection from subsequent smallpox infection (3). He named the inoculation substance vaccine, based on the Latin word, vacca, meaning cow. The more effective vaccines used for smallpox vaccination are derived from the vaccinia virus that is similar to cowpox. Several strains of the live attenuated virus vaccine were employed in eradication of the disease. The smallpox vaccine has been the prototype of success of a viral vaccine. Prior to immunization, smallpox infection relentlessly killed hundreds of millions of persons and left many badly scarred and/or blind. The mortality rate ranged between 20–30%. The worldwide eradication of this disease in 1977 is considered the greatest success story in medical history. The recent acciden- tal introduction of monkeypox into the United States via the Gambian pouched rat illustrates the need for better vaccines and perhaps vaccines with a broader range of targets. Immu- nity provided by the current smallpox vaccination reduces the effects of monkeypox virus on humans by 85%. Vaccine production ended two decades ago and most Amer- icans under the age of 35 have not been vaccinated. Smallpox eradication occurred because every child was immunized before attending public school, thus reducing the exposure of infected children to nonimmunized children and their families (4). Approximately 60 million vaccine doses remain worldwide and more vaccine is bring produced (5). Immunologic status of the older population is questionable but there are some reports of Vaccines and Immunotherapies 297 lingering immunity (6–8). At least 119,000,000 people in the United States have never been immunized (9). There are some indications from recent revaccinations of older persons that some degree of immunity still exists, albeit variable among the population. The destruction of the two remaining smallpox virus reserves in Atlanta and near Moscow has been a source of ongo- ing debate. Opponents of destruction contend that the virus stocks would be helpful for future research, such as smallpox pathogenesis and the production of new antiviral agents (10,11). Fear of undisclosed reserves is also a concern. Proponents argue that the virus genome has already been cloned and sequenced and is unnecessary for research (12). Destruction of the virus reserves will likely be halted as concerns for bioterrorism increase. Of concern since the col- lapse of the Soviet Union is that existing stocks of virus, combined with the technology for maintaining and activating the stocks, may have passed into non-Russian hands (13). Should these undocumented virus stocks fall into the domain of ter- rorists, strategic outbreaks among the unvaccinated or under- immunized could begin an epidemic that would be difficult to contain. Smallpox is considered to be an ideal bioterroist ave- nue as it is easily transmitted, has a high mortality rate, requires specific action for public health response, and could cause social and community disarray (14). Models based on the assumption that 100 persons are initially infected and each infects three more predict that quarantine could stop or eradicate such an outbreak if 50% of those with overt symptoms were quarantined. At risk would be family members (50% risk to the unvaccinated), school children, health-care workers, etc. Vaccination alone would only stop the transmission within a year if the disease transmittal rate were reduced to < 0.85 persons infected per initially infected person. There- fore, a combination vaccination-quarantine program is necessary (25% daily quarantine and a vaccination reduction of smallpox transmission by > 33%). Given the scenario, approximately 4,200 cases would occur over the period of a year. Approximately 215,500 vaccine doses would need to be administered to stop the outbreak (15). Vaccination distribution using two distinct models predicts that mass vaccination (MV) 298 Antiviral Agents is superior over traced vaccination (TV). TV involves contact tracing with susceptible and exposed individuals being administered the vaccine, whereas MV occurs when everyone is vaccinated simultaneously according to a schedule. In these models, MV results in both fewer deaths and more rapid reso- lution of an epidemic (16). Vaccine production remains limited although numbers of available vaccine stock are increasing. Plans are to voluntarily vaccinate smallpox response teams, public health authorities and staff, and some law enforcement staff. The military were the first to be vaccinated (17). Smallpox transmission occurs via droplets or as an aero- sol from the respiratory tract or by fomite exposure to bed- ding or clothing. An incubation period of 7–17 days (average of 12 days) is followed by a fever for 2–4 days. A rash ensues that lasts for weeks as papules become vesicles, followed by pus- tules and scabs. A characteristic of smallpox that separates it from the initial chickenpox diagnosis is that all skin eruptions in a localized area are in the same stage at any given point in time. Chickenpox lesions are more superficial than the hard, deep-seated lesions of smallpox. Localized eruptions of HSV-2 may mimic smallpox (18). Disease transmission may occur as the fever (prodrome) phase ends and during the rash phase. As the lesions scab over, transmission decreases (19). The smallpox vaccination is a suspended live vaccine derived from vaccinia. To prevent bacterial contamination of the lyophilized vaccine, polymyxin B, dihydrostreptomycin, chlortetracycline, and neomycin are included in the preparation. Other preparations under study include a calf-derived vaccine and a vaccinia virus grown in monkey kidney and human fibroblast cells. Adverse Effects Live vaccine can cause many adverse effects. (20,21). In a mass smallpox vaccination plan, to immunize 75% of the population (aged 1–65), 4600 serious adverse events and 285 deaths will occur (22). Pustule formation. One of the negative impacts of the current smallpox vaccine program has been the realization Vaccines and Immunotherapies 299 that smallpox vaccine causes a noticeable pustule when immunization occurs. Many people currently being vaccinated have no prior experience with this type of vaccine. We have become accustomed to viral vaccines that are administered as a “shot”—i.e., influenza, hepatitis, MMR (measles, mumps and rubella), and VZV (chickenpox)—where an adverse effect consists of a little erythema and edema surrounding the injection sites. An open wound, improperly cared for, can become infected or can cause variolation on other body parts. The eyes are particularly sensitive to keratitis from fomite transmittal. Allergy to vaccine components or residual immunity. Presence of a rapidly-forming erythema without development of the vesicle or pustule may indicate past vaccination immunity and/or allergy to vaccine compounds. Death. Approximately one death per million vaccina- tions occurs. These usually occur among infants. Local reactions. Most brief symptomatic reactions include fever, muscle aches, headache, nausea, and/or fatigue. Eczema vaccinatum. Where active (or even healed) eczema/atopic dermatitis occurs, eczema vaccinatum can occur. Immunocompromised. Progressive vaccinia may occur in patients with depressed cell-mediated immunity with increased numbers of HIV-positive patients and widespread use of immunosuppressive drugs. Neurologic implications. Post vaccinal encephalomy- elitis (PVEM) may occur even if there is no contraindication for vaccination (23). There are few signs of viral dissemination on the vaccine skin site, but neurologic symptoms may begin in 2–30 days after rash onset. Ini- tial complaints are very similar to local reactions reported by others except that high fevers and other neurologic signs occur. Seizures are most frequent in children. Rates of PVEM differ and this is attributed to: 1) strain of vaccinia virus; 2) vaccine preparation; 3) viability of vaccinia virus used; 4) method of vaccine delivery; and 5) level of post vaccine surveillance (23). 300 Antiviral Agents Special Considerations Vaccination of pregnant women. There are reported cases of fetal vaccinia occuring after vaccination during pregnancy. Coadministration of vaccine immune globin (VIG) with smallpox vaccine. VIG may prevent or de- crease the severity of smallpox. Post-exposure vaccination may also be effective if it is administered with in 4 days of known exposure. Exposed persons with vaccine contraindications. Administration of smallpox vaccine and VIG simultaneously can reduce side effects for those with vaccine contraindications who are exposed to an infected person (24). New Vaccines for Poxviruses Currently under Investigation Cell culture and recombinant vaccines may produce solid immunity with fewer complications. Should monkeypox continue to be transmitted from animal reservoirs to humans, there may be some effort to develop a vaccine. Fortunately, some immunity to many of the poxviruses is provided by the smallpox vaccination. One of the positions against destroying the remaining smallpox cultures is that the smallpox virus, itself, may become the back- bone for a multiple-pox virus that would extend protection against orf, molluscum contagiosum, vaccinia, and other poxviruses. Others respond that the manipulated poxvirus strains are now the most important as they can confer immunity and do not cause disease. Obviously, the threat of poxviruses being used for terrorism is factored into the decision-making process. MEASLES, MUMPS, AND RUBELLA VACCINES Measles, mumps, and rubella are described in Chapter 3. Each of these viruses has its own vaccine to be described later. The vaccination for these three classic childhood diseases is typically given as a combination MMR vaccine (Table 4.3). Combination vaccines tend to require fewer total immuniza- tions to achieve a satisfactory efficacy rate, are usually less expensive, and provide a greater opportunity to inoculate masses of people in a short period of time (25). Vaccines and Immunotherapies 301 Table 4.3 Immunization Schedules Footnotes for Recommended Adult Immunization Schedule by Age Group and Medical Conditions, United States, 2003–2004 1. Tetanus and diphtheria (Td)—Adults including pregnant women with uncertain histo- ries of a complete primary vaccination series should receive a primary series of Td. A primary series for adults is 3 doses: the first 2 doses given at least 4 weeks apart and the 3rd dose, 6–12 months after the second. Adminis- ter 1 dose if the person had received the primary series and the last vaccination was 10 years ago or longer. Consult MMWR 1991; 40 (RR-10): 1–21 for administering Td as prophylaxis in wound management. The ACP Task Force on Adult Immunization supports a second option for Td use in adults: a single Td booster at age 50 years for persons who have completed the full pediatric series, including the teenage/young adult booster. Guide for Adult Immunization. 3rd ed. ACP 1994:20. 2. Influenza vaccination—Medical indications: chronic disorders of the cardiovascular or pulmonary systems including asthma; chronic metabolic diseases including diabetes mellitus, renal dysfunction, hemoglobin- opathies, or immunosuppression (including Immunosuppression caused by medications or by human immunodefidency virus [HIV]), requiring regular medical follow-up or hos- pitalization during the preceding year; women who will be in the second or third trimester of pregnancy during the influenza season. Occupational indications: health- care workers. Other indications: residents of nursing homes and other long-term care facilities; persons likely to transmit influenza to persons at high-risk (in-home care givers to persons with medical indications, household leukemia, lymphoma, multiple myeloma, Hodgkins disease, generalized malignancy, organ or bone marrow transplantation), chemotherapy with alkylating agents, antimetabolites, or long-term systemic corticosteroids. Geographic/other indications: Alas- kan Natives and certain American Indian populations. Other indications: residents of nursing homes and other long-term care facilities. MMWR 1997; 45(RR-8):1–24. 4. Revaccination with pneumococcal polysaccharide vaccine—One time revaccination after 5 years for persons with chronic renal failure or nephrotic syndrome, functional or anatomic asplenia (e.g., sickle cell disease or splenectomy), immunosuppressive conditions (e.g., congenital immunodeficiency, HIV infection, leukemia, lymphoma, multiple myeloma, Hodgkins disease, generalized malignancy, organ or bone marrow transplantation), chemotherapy with alkylating agents, antimetabolites, or long-term systemic corticosteroids. For persons 65 and older, one-time revaccination if they were vaccinated 5 or more years previously and were aged less than 65 years at the time of primary vaccination. MMWR 1997; 46(RR-8):1–24. 5. Hepatitis B vaccination—Medical indications: hemodialysis patients, patients who receive dotting-factor concentrates.Occupa- tional indications; health-care workers and public-safety workers who have exposure to blood in the workplace, persons in training in schools of medicine, dentistry, nursing, lab oratory technology, and other allied health pro contacts and out-of-home caregivers of children birth to 23 months of age, or children with asthma or other indicator conditions for influenza vaccination, household members and care givers of elderly and adults with high-risk conditions); and anyone who wishes to be vaccinated. For healthy persons aged 5–49 years without high risk conditions, either the inactivated vaccine or the intranasally administered influenza vaccine (Flumist) may be given. MMWR 2003; 52 (RR-B):1–36; MMWR 2003; 53 (RR-13):1–8. 3. Pneumococcal polysaccharide vaccination—Medical indications: chronic disorders of the pulmonary system (excluding asthma), cardiovascular diseases, diabetes mellitus, chronic liver diseases including liver disease as a result of alcohol abuse (e.g., cirrhosis), chronic renal failure or nephratic syndrome, functional or an atom- ic asplenia (e.g., sickle cell disease or splenectomy), fessions. Behavioral indications: injecting drug users, persons with more than one sex partner in the previous 6 months, persons with a recently acquired sexually-transmitted disease (STD), all clients in STD clinics, men who have sex with men. Other indications: household contacts and sex partners of persons with chronic HBV infection, clients and staff of institutions for the devel- opmentally disabled, international travelers who will be in countries with high or intermediate prevalence of chronic HBV infection for more than 6 months, inmates of correctional facilities. MMWR 1991; 40 (RR-13):1–19. (www .cdc.gov/travel/diseases/hby.htm) 6. Hepatitis A vaccination—For the combined HepA-HepB vaccine use 3 doses at 0, 1, 6 months). Medical indications: persons with immunosuppressive conditions (e.g., congenital immunodeficiency, HIV infection, dotting-factor disorders or chronic liver disease. Behavioral indications: men who have sex with (continued) 302 Antiviral Agents Table 4.3 (Continued) Footnotes for Recommended Adult Immunization Schedule by Age Group and Medical Conditions, United States, 2003–2004 men, users of injecting and noninjecting illegal drugs. Occupational indications: persons working with HAV-infected primates or with HAV in a research laboratory setting. Other indications: persons traveling to or working in countries that have high or intermediate endemicity of hepatitis A. MMWR 1999; 48 (RR-12):1–37, (www .cdc.gov/ travel/diseases/hav.htm) 7. Measles, Mumps, Rubella vaccination (MMR)—Measles component: Adults born before 1957 may be considered immune to measles. Adults born in or after 1957 should receive at least one dose of MMR unless they have a medical contraindication, documentation of at least one dose or other acceptable evidence of immunity. A second dose of MMR is recommended for adults who: • are recently exposed to measles or in an outbreak setting • were previously vaccinated with killed measles vaccine • were vaccinated with an unknown vaccine between 1963 and 1967 This includes, health-care workers and family contacts or immunocompromised persons, those who live or work in environments where transmission is likely (e.g., teachers of young children, day care employees, and residents and staff members in institutional settings), persons who live or work in environments where VZV transmission can occur (e.g., college students, inmates and staff members of correctional institutions, and military personnel), adolescents and adults living in households with children, women who are not pregnant but who may become pregnant in the future, international travelers who are not immune to infection. Note: Greater than 95% of U.S. born adults are immune to VZV. Do not vaccinate pregnant women or those planning to become pregnant in the next 4 weeks. If pregnant and susceptible, vaccinate as early in postpartum period as possible. MMWR 1996; 45 (RR-11):1–36; MMWR 1999; 48 (RR-6):1–5. 9. Meningococcal vaccine (quadrivalent polysaccharide for serogroups A, C, Y, • are students in post-secondary educational institutions • work in health care facilities • plan to travel internationally Mumps component: 1 dose of MMR should be adequate for protection. Rubella component: Give 1 dose of MMR to women whose rubella vaccination history is unreliable and counsel women to avoid becoming pregnant for 4 weeks after vaccination. For women of child-bearing age, regardless of birth year, routinely determine rubella immunity and counsel women regarding congenital rubella syndrome. Do not vaccinate pregnant women or those planning to become pregnant in the next 4 weeks. If pregnant and susceptible, vaccinate as early in postpartum period as possible. MMWR 1998; 47 (RR-8):1–57; MMWR 2001; 50:1117. 8. Varicella vaccination—Recommended for all persons who do not have reliable clinical history of varicella infection, or serological evidence of varicella zoster virus (VZV) infection who may be at high risk for exposure or transmission. and W-135)—Consider vaccination for persons with medical indications: adults with terminal complement component deficien- cies, with anatomic or functional asplenia. Other indications: travelers to countries in which disease is hyperendemic or epidemic (*meningitis belt* of sub-Saharan Africa, Mecca, Saudi Arabia for Hajj). Revaccina- tion at 3–5 years may be indicated for persons at high risk for infection (e.g., persons residing in areas in which disease is epidemic). Counsel college freshmen, especially those who live in dormitories, regarding meningococcal disease and the vaccine so that they can make an educated decision about receiving the vaccination. MMWR 2000; 49 (RR-7):1–20. Note: The AAFP recommends that colleges should take the lead on providing education on meningococcal infection and vaccination and offer it to those who are interested. Phy- sicians need not initiate discussion of the meningococcal quadravalent polysaccharide vaccine as part of routine medical care. (continued) Vaccines and Immunotherapies 303 Table 4.3 (Continued) Recommended Adult Immunization Schedule by Age Group and Medical Conditions United States, 2003–2004 Summary of Recommendations Published by The Advisory Committee on Immunization Practices Department of Health and Human Services Centers for Disease Control and Prevention (continued) 304 Antiviral Agents Table 4.3 (Continued) This schedule indicates the recommended ages for routine administration of currently licensed childhood vaccines, as of December 1, 2003, for children through age 18 years. Any dose not given at the recommended age should be given at any subsequent visit when indicated and feasible. Indicates age groups that warrant special effort to administer those vaccines not previously given. Additional vaccines may be licensed and recommended during the year. Licensed combination vaccines may be used whenever any components of the combination are indicated and the vaccine’s other components are not contraindicated. Providers should consult the manufacturers’ package inserts for detailed recommendations. Clinically significant adverse events that follow immunization should be reported to the Vaccine Adverse Event Reporting System (VAERS). Guidance about how to obtain and complete a VAERS form can be found on the internet: http://www .vaers.org/ or by calling 1-800-822-7967. 1. Hepatitis B (HepB) vaccine. All infants should receive the first dose of hepatitis B vaccine soon affer birth and before hospital discharge; the first dose may also be given by age 2 months if the infant’s mother is hepatitis B surface antigen (HBsAg) negative. Only monovalent HepB can be used for the birth dose. Monovalent or combination vaccine containing HepB may be used to complete the series. Four doses of vaccine may be administered when a birth dose is given. The second dose should be given at least 4 weeks after the first dose, except for combination vaccines which cannot be administered before age 6 weeks. The third dose should be given at least 16 weeks after the first dose and at least 8 weeks after the second dose. The last does in the vaccination series (third or fourth dose) should not be administered before age 24 weeks. Infants born to HBsAg-positive mothers should receive HepB and 0.5 mL of Hepatitis B Immune Globulin (HBIG) within 12 hours of birth at separate sites. The second dose is recommended at age 1 to 2 months. The last dose in the immunization series should not be administered before age 24 weeks. These infants should be tested for HBsAg and antibody to HBsAg (anti-HBs) at age 9 to 15 months. Infants born t o mothers whose HBsAg status is unknown should receive the first dose of the HepB series within 12 hours of birth. Maternal blood should be drawn as soon as possible to determine the mother’s HBsAg status; if the HBsAg test is positive, the infant should receive HBIG as soon as possible (no later than age 1 week). The second dose is recommended at age 1 to 2 months. The last dose in the immunization series should not be administered before age 24 weeks. (continued) Recommended Childhood and Adolescent Immunization Schedule – United States, January − June 2004 Range of Recommended Ages Catch-up Immunization Preadolescent Assessment Vaccine Age Birth 1 mo 2 mo 4 mo 6 mo 12 mo 15 mo 18 mo 24 mo 4−6 y 11−12 y 13−18 y Hepatitis B 1 Diphtheria, Tetanus, Pertussis 2 Haemophilus influenzae Type b 3 Inactivated Pollovirus Measles, Mumps, Rubella 4 Varicella 5 Pneumococcal 5 Hepatitis A 7 Influenza 8 Vaccines below this line are for selected populations DTaP DTaP DTaP DTaP DTaP Hib Hib Hib Hib 3 IPV IPV IPV IPV PCV PCV PCV PCV PPV MMR #2 MMR #1 HepB #1 HepB #2 HepB #3 Only if mother HBsAg (−) Varicella Influenza (yearly) Hepatitis A series PCV Varlcella MMR #2 HepB series Td Td [...]... or other measles containing vaccines intact cellular immunity may be vaccinated, from HIV-infected persons with evidence of severe MMWR 1999; 48 (RR-06):1–5 immunosuppression MMWR 19 98; 47 (RR -8 ) :21–22; G Hemodialysis patients: Use special formulation of MMWR 2002:51 (RR-02);22–24 vaccine (40 ug/mL) or two 1.0 ml 20 ug doses given Vaccines and Immunotherapies 311 Live virus vaccines for measles, mumps,... suspected cases of vaccine-preventable diseases to your state or local health department (continued) For additional information about vaccines, including precautions and contraindications for immunization and vaccine shortages, please visit the National Immunization Program Web site at www.cdc.gov/nip or call the National Immunization Information Hotline at 80 0-2 3 2-2 522 (English) or 80 0-2 3 2-0 233 (Spanish) Reporting... occur if a vaccine-associated rash develops, although the risk of transmission is about one-fourth that of natural varicella (20–25% vs 87 %) (88 ) The Oka vaccine should be given as a single dose to children 12 months to 12 years Vaccines and Immunotherapies 317 of age Individuals over the age of 13 should receive 2 doses, 4 8 weeks apart The duration of protection is unknown at this time, and the need for... an all-IPV or all-oral poliovirus (OPV) series, a fourth dose is not necessary if third dose was given at age ≥4 years If both OPV and IPV were given as part of a series, a total of 4 doses should be given, regardless of the child’s current age 1 DTaP: The fifth dose is not necessary if the fourth dose was given after the fourth birthday Table 4.3 (Continued) 3 08 Antiviral Agents Vaccines and Immunotherapies. .. information about the vaccines listed above and contraindications for immunization, visit the National Immunization Program Website at www.cdc.gov/nip/ or call the National Immunization Hotline at 80 023 2-2 522 (English) or 80 0-2 3 2-0 233 (Spanish) Approved by the Advisory Committee on Immunization Practices (ACIP), and accepted by the American College of Obstetridans and Gynecologists (ACOG) and the American... (separated by at least 4 weeks for TIV and at least 6 weeks for LAIV) For additional information about vaccines, including precautions and contraindications for immunization and vaccine shortages, please visit the National Immunization Program Web site at www.cdc.gov/nip/ or call the National Immunization Information Hotline at 80 0-2 3 2-2 522 (English) or 80 0-2 3 2-0 233 (Spanish) Approved by the Advisory... children and adolescents is selected states and regions and for certain high-risk groups; consult your local public health authority Children and adolescents in these states, regions, and high-risk groups who have not been immunized against hepatitis A can begin the hepatitis A immunization series during any visit The 2 doses in the series should be administered at least 6 months apart See MMWR 1999; 48( RR-12):1–37... sites Fever Fever occurred in 10.2–14.7% of clinical trial subjects and a generalized varicella-like rash developed in 3 .8 5.5% of subjects 3 18 Antiviral Agents Rash A generalized varicella-like rash developed in 3 .8 5.5% of cases A localized varicella-like rash at the injection site may also occur Special Considerations Exposure to high-risk patients The likelihood of transmission of the vaccine virus... chronic liver disease due to causes other than Vaccines and Immunotherapies 325 hepatitis B, prisoners, users of illicit injectable drugs, and police and fire department personnel who render first aid) and all children aged 0– 18 years Because of the current widespread use in children, a thimerosal-free vaccine was recently approved by the FDA Thimerosal is a mercury-containing preservative, which has prompted... reactions to vaccines through the federal Vaccine Adverse Event Reporting System For information on reporting reactions following immunization, please visit www vaers.org or call the 24-hour national toll-free information line (80 0 )82 2-7 967 10 Varlicella: Give 2-dose series to all susceptible adolescents age ≥13 years 9 IPV: Vaccine is not generally recommended for persons age ≥ 18 years 8 Td: For children . at 80 0-2 3 2-2 522 (English) or 80 0-2 3 2-0 233 (Spanish). (continued) Vaccines and Immunotherapies 309 Table 4.3 (Continued) See Footnotes for Recommended Adult Immunization Schedule, by Age Group and. Vaccines and Immunotherapies 295 oral polio vaccine, and some adenovirus vaccines are examples of attenuated live viral vaccines. Killed viral vaccines (inactivated). Whole virus parti- cles. transplantation), chemotherapy with alkylating agents, antimetabolites, or long-term systemic corticosteroids. For persons 65 and older, one-time revaccination if they were vaccinated 5

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