INFECTIOUS DISEASES - PART 7 ppsx

or likely to become pregnant should try to avoid travel to areas where they could contract malaria. Women traveling to areas where drug-resistant P falciparum has not been reported may take chloroquine prophylaxis. Harmful effects on the fetus have not been demonstrated when chloroquine is given in the recommended doses for malaria prophylaxis. Pregnancy, therefore, is not a contraindication for malaria prophylaxis with chloroquine. For pregnant women who travel to areas where chloroquine-resistant P falciparum exists, mefloquine should be recommended for chemoprophylaxis during the second and third trimesters. For women in their first trimester, most evidence suggests that use of mefloquine is not associated with adverse fetal or pregnancy outcomes, such as spontaneous abortions, stillbirths, and birth defects when taken in prophylactic doses, but more data are necessary to make conclusive statements about its safety in early pregnancy. Consequently, mefloquine is the drug of choice for prophylactic use for women who are pregnant or likely to become pregnant when exposure to chloroquine-resistant P falciparum is unavoidable. Self-treatment of Malaria. Malaria can be treated effectively early in the course of disease, but delay of appropriate treatment can have serious or even fatal consequences. Travelers who do not take an antimalarial drug for prophylaxis or who are on a less-than-effective regimen or who may be in very remote areas can be given a self-treatment course of atovaquone- proguanil. Travelers should be advised that self-treatment is not considered a replacement for seeking prompt medical help. A self-treatment regimen should be discussed with a physician expert in travel medicine before departure. Travelers taking atovaquone-proguanil as their antimalarial drug regimen should not take atovaquone-proguanil as their self-treatment drug and should use an alternative treatment regimen; the CDC Malaria Hotline (770-488- 7788) provides advice on management of travelers who cannot use atovaquone-proguanil for self-treatment. Travelers should be advised that any fever or influenza-like illness that develops within 3 months of departure from an area with endemic infection requires immediate medical evaluation, including blood films to rule out malaria. Prevention of Relapses. To prevent relapses of P vivax or P ovale infection after departure from areas where these species are endemic, use of primaquine should be considered. Primaquine can cause hemolysis in patients with G6PD deficiency; thus, all patients should be screened for this condition before primaquine therapy is initiated. Personal Protective Measures. All travelers to areas where malaria is endemic should be advised to use personal protective measures, including the following: (1) using insecticide-impregnated mosquito nets while sleeping; (2) remaining in well-screened areas; (3) wearing protective clothing; and (4) using mosquito repellents containing DEET. To be effective, most of these repellents require frequent reapplications. See Prevention of Mosquitoborne Infections (p 197) for recommendations regarding prevention of mosquitoborne infections and use of insect repellents. Measles Clinical Manifestations: Measles is an acute disease characterized by fever, cough, coryza, conjunctivitis, an erythematous maculopapular rash, and a pathognomonic enanthema (Koplik spots). Complications including otitis media, bronchopneumonia, laryngotracheobronchitis (croup), and diarrhea occur commonly in young children. Acute encephalitis, which often results in permanent brain damage, occurs in approximately 1 of every 1000 cases. Death, predominantly resulting from respiratory and neurologic complications, occurs in 1 to 3 of every 1000 cases reported in the United States. Case fatality rates are increased in children younger than 5 years of age and immunocompromised children, including children with leukemia, human immunodeficiency virus (HIV) infection, and severe malnutrition. Sometimes the characteristic rash does not develop in immunocompromised patients. Subacute sclerosing panencephalitis (SSPE) is a rare degenerative central nervous system disease characterized by behavioral and intellectual deterioration and seizures. Widespread measles immunization has led to the virtual disappearance of SSPE in the United States. Etiology: Measles virus is an RNA virus with 1 serotype, classified as a member of the genus Morbillivirus in the Paramyxoviridae family. Epidemiology: The only natural hosts of measles virus are humans. Measles is transmitted by direct contact with infectious droplets or, less commonly, by airborne spread. In temperate areas, the peak incidence of infection usually occurs during late winter and spring. In the prevaccine era, most cases of measles in the United States occurred in preschool and young school-aged children, and few people remained susceptible by 20 years of age. The childhood and adolescent immunization program in the United States has resulted in a greater than 99% decrease in the reported incidence of measles since measles vaccine was first licensed in 1963. From 1989 to 1991, the incidence of measles in the United States increased because of low immunization rates in preschool-aged children, especially in urban areas. From 1997 to 2004, the incidence of measles in the United States has been low (37-116 cases reported per year), consistent with an absence of endemic transmission. Cases of measles continue to occur as a result of importation of the virus from other countries. Cases are considered international importations if the rash onset occurs within 18 days after entering the United States. Almost half of the imported cases occur in US residents returning from foreign travel. Vaccine failure occurs in as many as 5% of people who have received a single dose of vaccine at 12 months of age or older. Although waning immunity after immunization may be a factor in some cases, most cases of measles in previously immunized children seem to occur in people in whom response to the vaccine was inadequate (ie, primary vaccine failures). Patients are contagious from 1 to 2 days before onset of symptoms (3-5 days before the rash) to 4 days after appearance of the rash. Immunocompromised patients who may have prolonged excretion of the virus in respiratory tract secretions can be contagious for the duration of the illness. Patients with SSPE are not contagious. The incubation period generally is 8 to 12 days from exposure to onset of symptoms. In family studies, the average interval between appearance of rash in the index case and subsequent cases is 14 days, with a range of 7 to 18 days. In SSPE, the mean incubation period of 84 cases reported between 1976 and 1983 was 10.8 years. Diagnostic Tests: Measles virus infection can be diagnosed by a positive serologic test result for measles immunoglobulin (Ig) M antibody, a significant increase in measles IgG antibody concentration in paired acute and convalescent serum specimens by any standard serologic assay, or isolation of measles virus from clinical specimens, such as urine, blood, throat, or nasopharyngeal secretions. The state public health laboratory or the Centers for Disease Control and Prevention Measles Laboratory will process these viral specimens. The simplest method of establishing the diagnosis of measles is testing for IgM antibody on a single serum specimen obtained during the first encounter with a person suspected of having disease. The sensitivity of measles IgM assays varies and may be diminished during the first 72 hours after rash onset. If the result is negative for measles IgM and the patient has a generalized rash lasting more than 72 hours, the measles IgM test should be repeated. Measles IgM is detectable for at least 1 month after rash onset. People with febrile rash illness who are seronegative for measles IgM should be tested for rubella using the same specimens. Genotyping of viral isolates allows determination of patterns of importation and transmission, and genome sequencing can be used to differentiate between wild-type and vaccine virus infection. All cases of suspected measles should be reported immediately to the local or state health department without waiting for results of diagnostic tests. Treatment: No specific antiviral therapy is available. Measles virus is susceptible in vitro to ribavirin, which has been given by the intravenous and aerosol routes to treat severely affected and immunocompromised children with measles. However, no controlled trials have been conducted, and ribavirin is not approved by the US Food and Drug Administration for treatment of measles. Vitamin A. The World Health Organization and the United Nations International Children's Emergency Fund recommend administration of vitamin A to all children diagnosed with measles in communities where vitamin A deficiency is a recognized problem or the measles case fatality rate is 1% or greater. Vitamin A treatment of children with measles in developing countries has been associated with decreased morbidity and mortality rates. Although vitamin A deficiency is not recognized as a major problem in the United States, low serum concentrations of vitamin A have been found in children with severe measles. Hence, vitamin A supplementation should be considered in the following patients: Children 6 months to 2 years of age hospitalized with measles and its complications (eg, croup, pneumonia, and diarrhea). Limited data are available about the safety and need for vitamin A supplementation for infants younger than 6 months of age. Children older than 6 months of age with measles who are not already receiving vitamin A supplementation and who have any of the following risk factors: immunodeficiency, clinical evidence of vitamin A deficiency, impaired intestinal absorption, moderate to severe malnutrition, and recent immigration from areas where high mortality rates attributable to measles have been observed. Parenteral and oral formulations of vitamin A are available in the United States. The recommended dosage, administered as a capsule, is a single dose of 200,000 IU, orally, for children 1 year of age and older (100,000 IU for children 6 months-1 year of age). For children with ophthalmologic evidence of vitamin A deficiency, the dose should be repeated the next day and again 4 weeks later. Isolation of the Hospitalized Patient: In addition to standard precautions, airborne transmission precautions are indicated for 4 days after the onset of rash in otherwise healthy children and for the duration of illness in immunocompromised patients. Control Measures: Care of Exposed People. Use of Vaccine. Exposure to measles is not a contraindication to immunization. Available data suggest that live-virus measles vaccine, if given within 72 hours of measles exposure, will provide protection in some cases. If the exposure does not result in infection, the vaccine should induce protection against subsequent measles exposures. Immunization is the intervention of choice for control of measles outbreaks in schools and child care centers. Use of Immune Globulin. Immune Globulin (IG) can be given to prevent or modify measles in a susceptible person within 6 days of exposure. The usual recommended dose is 0.25 mL/kg given intramuscularly; immunocompromised children should receive 0.5 mL/kg (the maximum dose in either instance is 15 mL). Immune Globulin is indicated for susceptible household or other close contacts of patients with measles, particularly contacts younger than 1 year of age, pregnant women, and immunocompromised people for whom the risk of complications is highest. Immune Globulin is not indicated for household or other close contacts who have received 1 dose of vaccine at 12 months of age or older unless they are immunocompromised. Immune Globulin Intravenous (IGIV) preparations generally contain measles antibodies at approximately the same concentration per gram of protein as IG, although the concentration may vary by lot and manufacturer. For patients who regularly receive IGIV, the usual dose of 100 to 400 mg/kg should be adequate for measles prophylaxis after exposures occurring within 3 weeks of receiving IGIV. For children who receive IG for modification or prevention of measles after exposure, measles vaccine (if not contraindicated) should be given 5 months (if the dose was 0.25 mL/kg) or 6 months (if the dose was 0.5 mL/kg) after IG administration, provided that the child is at least 12 months of age. Intervals between administration of IGIV or other biologicals and measles-containing vaccines varies (see Table 3.32, p 445). Human Immunodeficiency Virus Infection. All children and adolescents with HIV infection and children of unknown HIV infection status born to HIV- infected women who are exposed to wild-type measles should receive IG prophylaxis (0.5 mL/kg, IM, maximum dose 15 mL), regardless of their measles immunization status (see Human Immunodeficiency Virus Infection, p 378). An exception is the patient receiving IGIV (400 mg/kg) at regular intervals whose last dose was received within 3 weeks of exposure. Because of the rapid metabolism of IGIV, some experts recommend administration of an additional dose of IGIV if exposure to measles occurs 2 or more weeks after the last regular dose of IGIV. Hospital Personnel. To decrease nosocomial infection, immunization programs should be established to ensure that all people who work or volunteer in health care facilities who may be in contact with patients with measles are immune to measles (see Health Care Personnel, p 94). Measles Vaccine. The only measles vaccine currently licensed in the United States is a live further-attenuated strain prepared in chicken embryo cell culture. Measles vaccines provided through the Expanded Programme on Immunization in developing countries meet the World Health Organization standards and usually are comparable to the vaccine available in the United States. Measles vaccine is available in monovalent (measles only) formulation and in combination formulations, such as measles-rubella (MR), measles- mumps-rubella (MMR), and measles-mumps-rubella-varicella (MMRV) vaccines. The MMR or MMRV vaccines are the recommended products of choice in most circumstances. Measles vaccine (as a combination or monovalent product) in a dose of 0.5 mL is given subcutaneously. Measles and measles-containing vaccines can be given simultaneously with other immunizations in a separate syringe at a separate site (see Simultaneous Administration of Multiple Vaccines, p 34). Serum measles antibodies develop in approximately 95% of children immunized at 12 months of age and 98% of children immunized at 15 months of age. Protection conferred by a single dose is durable in most people. However, a small proportion (5%) of immunized people may lose protection after several years. More than 99% of people who receive 2 doses separated by at least 4 weeks, with the first dose administered on or after their first birthday, develop serologic evidence of measles immunity. Immunization is not deleterious for people who already are immune. Improperly stored vaccine may fail to protect against measles. Since 1979, an improved stabilizer has been added to the vaccine that makes it more resistant to heat inactivation. For recommended storage of measles, MMR, and MMRV vaccines, see Recommended Storage of Commonly Used Vaccines (Table 1.4, p 13). Vaccine Recommendations (see Table 3.33, p 446, for summary). Age of Routine Immunization. The first dose of measles vaccine should be given at 12 to 15 months of age. Delays in administering the first dose contributed to large outbreaks in the United States from 1989 to 1991. Initial immunization at 12 months of age is recommended for preschool-aged children in high-risk areas, especially large urban areas. The second dose is recommended routinely at school entry (ie, 4-6 years of age) but can be given at any earlier age (eg, during an outbreak or before international travel), provided the interval between the first and second doses is at least 4 weeks. Children who were not reimmunized at school entry should receive the second dose by 11 to 12 years of age. If a child receives a dose of measles vaccine before 12 months of age, 2 additional doses are required beginning at 12 to 15 months of age and separated by at least 4 weeks. Use of MMRV Vaccine.* * Centers for Disease Control and Prevention. Notice to readers: licensure of a combined live attenuated measles, mumps, rubella, and varicella vaccine. MMWR Morb Mortal Wkly Rep. 2005;54:1212-1214 The MMRV vaccine is indicated for simultaneous immunization against measles, mumps, rubella, and varicella among children 12 months to 12 years of age; MMRV vaccine is not indicated for people outside this age group. The MMRV vaccine may be used whenever any of the components of the combination vaccine are indicated and the other components are not contraindicated. Using combination vaccines containing some antigens not indicated at the time of administration might be justified when (1) products that contain only the needed antigens are not readily available or would result in extra injections; and (2) potential benefits to the child outweigh the risk of adverse events associated with the extra antigen(s). At least 1 month should elapse between a dose of measles-containing vaccine, such as MMR vaccine, and a dose of MMRV vaccine. Should a second dose of varicella vaccine be indicated for children 12 months to 12 years of age (eg, during a varicella outbreak), at least 3 months should elapse between administration of any 2 doses of varicella-containing vaccine, including single-antigen varicella vaccine or MMRV vaccine. The MMRV vaccine may be administered simultaneously with other vaccines recommended from 12 months to 12 years of age, although data are absent or limited for the concomitant use of MMRV vaccine with diphtheria and tetanus toxoids and acellular pertussis (DTaP), inactivated poliovirus, pneumococcal conjugate, influenza, and hepatitis A vaccines. The MMRV vaccine should not be administered as a substitute for the component vaccines when immunizing children with HIV infection until revised recommendations can be considered for use of MMRV vaccine in this population. High School Students and Adults. Because of the occurrence of measles cases in older children and young adults, emphasis must be placed on identifying and appropriately immunizing potentially susceptible adolescents and young adults in high school, college, and health care settings. People should be considered susceptible unless they have documentation of at least 2 doses of measles vaccine administered at least 4 weeks apart, physician- diagnosed measles, or laboratory evidence of immunity to measles or were born before 1957. A parental report of immunization is not considered adequate documentation. Physicians should provide an immunization record for patients only if they have administered the vaccine or have seen a record documenting immunization. Colleges and Other Institutions for Education Beyond High School. Colleges and other institutions should require that all entering students have documentation of physician-diagnosed measles, serologic evidence of immunity, or receipt of 2 doses of measles-containing vaccines. Students without documentation of any measles immunization or immunity should receive MMR or another measles-containing vaccine on entry, followed by a second dose 4 weeks later, if not contraindicated. Immunization During an Outbreak. During an outbreak, monovalent measles vaccine may be given to infants as young as 6 months of age (see Outbreak Control, p 451). If monovalent vaccine is not available, MMR may be given. However, seroconversion rates after MMR immunization are significantly lower in children immunized before the first birthday than are seroconversion rates in children immunized after the first birthday. Therefore, children immunized before their first birthday should be immunized with MMR vaccine at 12 to 15 months of age (at least 4 weeks after the initial measles immunization) and again at school entry (4-6 years). International Travel. People traveling internationally should be immune to measles. For young children traveling internationally, the age for initial measles immunization may need to be lowered. Infants 6 to 11 months of age should receive a dose of monovalent measles vaccine before departure (MMR may be given), and then they should receive MMR vaccine at 12 to 15 months of age (at least 4 weeks after the initial measles immunization) and again at 4 to 6 years of age. Children 12 to 15 months of age should be given their first dose of MMR vaccine before departure and again by 4 to 6 years of age. Children who have received 1 dose and are traveling to areas where measles is endemic or epidemic should receive their second dose before departure, provided the interval between doses is 4 weeks or more. Health Care Facilities. Evidence of natural measles infection, of measles immunity, or of receipt of 2 doses of measles vaccine is recommended before beginning employment for all health care professionals born in 1957 or after (see Health Care Personnel, p 94). For recommendations during an outbreak, see Outbreak Control (p 451). Adverse Events. A temperature of 39.4C (103F) or higher develops in approximately 5% to 15% of susceptible vaccine recipients, usually between 6 and 12 days after receipt of MMR vaccine; fever generally lasts 1 to 2 days but may last as long as 5 days. Most people with fever are otherwise asymptomatic. Transient rashes have been reported in approximately 5% of vaccine recipients. Transient thrombocytopenia occurs in 1 in 25,000 to 1 in 2 million people after administration of measles-containing vaccines, specifically MMR (see Thrombocytopenia, p 450). Rates of most local and systemic adverse events for children immunized with MMRV vaccine were comparable to rates for children immunized with MMR and varicella vaccines administered concomitantly. However, MMRV recipients had a significantly greater rate of fever 102F (38.9C) than did MMR and varicella recipients (21.5% vs 15%, respectively), and measles-like rash was observed in 3% of MMRV recipients and 2% of MMR and varicella recipients. The reported frequency of central nervous system conditions after measles immunization, including encephalitis and encephalopathy, is less than 1 per million doses administered in the United States. Because the incidence of encephalitis or encephalopathy after measles immunization in the United States is lower than the observed incidence of encephalitis of unknown cause, some or most of the rare reported severe neurologic disorders may be related coincidentally, rather than causally, to measles immunization. Although cases of autism and inflammatory bowel disease have been reported subsequent to measles immunization, multiple studies, as well as an Institute of Medicine Vaccine Safety Review, refute a causal relationship between these diseases and MMR vaccine. After reimmunization, reactions are expected to be similar clinically but much less frequent, because most of these vaccine recipients are immune. Seizures. Children predisposed to febrile seizures can experience seizures after measles immunization. Children with histories of seizures or children whose first-degree relatives have histories of seizures may be at a slightly increased risk of a seizure but should be immunized, because the benefits greatly outweigh the risks. Subacute Sclerosing Panencephalitis. Measles vaccine, by protecting against measles, significantly decreases the possibility of developing SSPE. Precautions and Contraindications (see also Table 3.32, p 445). Febrile Illnesses. Children with minor illnesses, such as upper respiratory tract infections, may be immunized (see Vaccine Safety and Contraindications, p 39). Fever is not a contraindication to immunization. However, if other manifestations suggest a more serious illness, the child should not be immunized until recovered. Allergic Reactions. Hypersensitivity reactions occur rarely and usually are minor, consisting of wheal and flare reactions or urticaria at the injection site. Reactions have been attributed to trace amounts of neomycin or gelatin or some other component in the vaccine formulation. Anaphylaxis is rare. Measles vaccine is produced in chicken embryo cell culture and does not contain significant amounts of egg white (ovalbumin) cross-reacting proteins. Children with egg allergy are at low risk of anaphylactic reactions to measles- containing vaccines (including MMR). Skin testing of children for egg allergy is not predictive of reactions to MMR vaccine and is not required before administering MMR or other measles-containing vaccines. People with allergies to chickens or feathers are not at increased risk of reaction to the vaccine. People who have had a significant hypersensitivity reaction after the first dose of measles vaccine should: (1) be tested for measles immunity, and if immune, should not be given a second dose; or (2) receive evaluation and possible skin testing before receiving a second dose. People who have had an immediate anaphylactic reaction to previous measles immunization should not be reimmunized but require testing to determine whether they are immune. People who have experienced anaphylactic reactions to gelatin or topically or systemically administered neomycin should receive measles vaccine only in settings where such reactions could be managed and after consultation with an allergist or immunologist. Most often, however, neomycin allergy manifests as contact dermatitis, which is not a contraindication to receiving measles vaccine. Thrombocytopenia. Rarely, MMR vaccine can be associated with thrombocytopenia within 2 months of immunization, with a temporal clustering 2 to 3 weeks after immunization. On the basis of case reports, the risk of vaccine-associated thrombocytopenia may be higher for people who previously experienced thrombocytopenia, especially when it occurred in temporal association with earlier MMR immunization. The decision to immunize these children should be based on assessment of immunity after the first dose and the benefits of protection against measles, mumps, and rubella in comparison with the risks of recurrence of thrombocytopenia after immunization. There have been no reported cases of thrombocytopenia associated with receipt of MMR vaccine that have resulted in death in otherwise healthy individuals. Recent Administration of IG. Immune Globulin preparations interfere with the serologic response to measles vaccine for variable periods, depending on the dose of IG administered. Suggested intervals between IG or blood product administration and measles immunization are given in Table 3.32 (p 445). If vaccine is given at intervals shorter than those indicated, as may be warranted if the risk of exposure to measles is imminent, the child should be reimmunized at or after the appropriate interval for immunization (and at least 4 weeks after the earlier immunization) unless serologic testing indicates that measles-specific antibodies were produced. If IG is to be administered in preparation for international travel, administration of vaccine should precede receipt of IG by at least 2 weeks to preclude interference with replication of the vaccine virus. Tuberculosis. Tuberculin skin testing is not a prerequisite for measles immunization. Antituberculosis therapy should be initiated before administering MMR to people with untreated tuberculosis infection or disease. Tuberculin skin testing, if otherwise indicated, can be done on the day of immunization. Otherwise, testing should be postponed for 4 to 6 weeks, because measles immunization temporarily may suppress tuberculin skin test reactivity. Altered Immunity. Immunocompromised patients with disorders associated with increased severity of viral infections should not be given live measles virus vaccine (see Immunocompromised Children, p 71). The risk of exposure to measles for immunocompromised patients can be decreased by immunizing their close susceptible contacts. Management of immunodeficient and immunosuppressed patients exposed to measles can be facilitated by previous knowledge of their immune status. Susceptible patients with immunodeficiencies should receive IG after measles exposure (see Care of Exposed People, p 443). Corticosteroids. For patients who have received high doses of corticosteroids (2 mg/kg or 20 mg/day of prednisone or its equivalent) for 14 days or more and who are not otherwise immunocompromised, the recommended interval before immunization is at least 1 month (see Immunocompromised Children, p 71). In general, inhaled steroids do not cause immunosuppression and are not a contraindication to measles immunization. Human Immunodeficiency Virus Infection. Measles immunization (given as MMR vaccine) is recommended at the usual ages for people with asymptomatic HIV infection and for people with symptomatic infection who are not severely immunocompromised, because measles can be severe and often fatal in patients with HIV infection (see Human Immunodeficiency Virus Infection, p 378). Severely immunocompromised HIV-infected infants, children, adolescents, and young adults, as defined by low CD4+ T- lymphocyte counts or percentage of total lymphocytes, should not receive measles virus-containing vaccine, because vaccine-related pneumonia has been reported (see Human Immunodeficiency Virus Infection, p 378). All members of the household of an HIV-infected person should receive measles vaccine (preferably as MMR) unless they are HIV-infected and severely immunosuppressed, were born before 1957, have had physician-diagnosed measles, have laboratory evidence of measles immunity, have had age- appropriate immunizations, or have a contraindication to measles vaccine. Regardless of immunization status, symptomatic HIV-infected patients who are exposed to measles should receive IG prophylaxis, because immunization may not provide protection (see Care of Exposed People, p 443). Personal or Family History of Seizures. Children with a personal or family history of seizures should be immunized after advising parents or guardians [...]... recommended for children 2 years of age and older in high-risk groups, including people with functional or anatomic asplenia (see Children With Asplenia, p 83), children with terminal complement component or properdin deficiencies, and children who travel to or reside in areas where N menigitidis is hyperendemic or epidemic (CDC Travelers' Health Hotline, 877 -FYI-TRIP or online at www.cdc.gov/travel) Recommendations... Pediatrics, Committee on Infectious Diseases Prevention and control of meningococcal disease: recommendations for use of meningococcal vaccines in pediatric practice Pediatrics 2005;116:496505; and Centers for Disease Control and Prevention Prevention and control of meningococcal disease: recommendations of the Advisory Committee on Immunization Practices (ACIP) MMWR Recomm Rep 2005;54(RR -7 ) : 1-2 1 Meningococcal... more commonly, as the combined measles-mumps-rubella (MMR) vaccine Protective efficacy of the vaccine in clinical trials is estimated to be 95% with a single dose Serologic and epidemiologic evidence extending for more than 25 years indicates that vaccine-induced immunity is long lasting Vaccine Recommendations: Mumps vaccine should be given as MMR or measles-mumps-rubellavaricella (MMRV) routinely to... Contraindications [p 578 ]) Other reactions that occur after immunization with MMR or MMRV vaccine may be attributable to other components of the vaccines (see Measles, p 441, Rubella, p 574 , and Varicella-Zoster Infections, p 71 1) Reimmunization with mumps vaccine (monovalent or MMR) is not associated with an increased incidence of reactions Precautions and Contraindications See Measles, p 441, Rubella, p 574 , and... minor trauma Person-to-person and animal-to-human transmission does not occur The incubation period for pulmonary disease is unknown Diagnostic Tests: Isolation of Nocardia organisms from body fluid, abscess material, or tissue specimens provides a definitive diagnosis Stained smears of sputum, body fluids, or pus demonstrating beaded, branched, weakly grampositive, variably acid-fast rods suggest... should be reported to the CDC (www.vaers.hhs.gov) * Guillain-Barre syndrome among recipients of Menactra meningococcal conjugate vaccinemdashUnited States, June-July 2005 MMWR Morb Mortal Wkly Rep 2005;54:102 3-1 025 Reporting All confirmed, presumptive, and probable cases of invasive meningococcal disease must be reported to the regional health department (see Table 3.34, p 454) Timely reporting can facilitate... causes of chronic diarrhea in HIV-infected people Epidemiology: Most microsporidian infections are transmitted by oral ingestion of spores Microsporidium spores are found commonly in surface water, and human strains have been identified in municipal water supplies and ground water Several studies indicate that waterborne transmission occurs Person-to-person spread by the fecal-oral route also occurs Spores... Manifestations: Molluscum contagiosum is a benign, usually asymptomatic viral infection of the skin with no systemic manifestations It usually is characterized by 2 to 20 discrete, 5-mm-diameter, flesh-colored to translucent, dome-shaped papules, some with central umbilication Lesions commonly occur on the trunk, face, and extremities but rarely are generalized An eczematous reaction encircles lesions in... meningitis in neonates Other unusual manifestations include endocarditis, shunt-associated ventriculitis, and urinary tract infections Etiology: Moraxella catarrhalis is a gram-negative aerobic diplococcus Almost 100% of strains produce beta-lactamase that mediates resistance to penicillins Epidemiology: M catarrhalis is part of the normal flora of the upper respiratory tract of humans The mode of transmission... their siblings, and personnel born in 19 57 or after who cannot provide documentation that they received 2 doses of measles-containing vaccine on or after their first birthday or other evidence of measles immunity should be immunized People receiving their second dose, as well as unimmunized people receiving their first dose before or within 72 hours of exposure as part of the outbreak control program, . regimen should not take atovaquone-proguanil as their self-treatment drug and should use an alternative treatment regimen; the CDC Malaria Hotline (77 0-4 8 8- 77 88) provides advice on management. formulation and in combination formulations, such as measles-rubella (MR), measles- mumps-rubella (MMR), and measles-mumps-rubella-varicella (MMRV) vaccines. The MMR or MMRV vaccines are the. who are on a less-than-effective regimen or who may be in very remote areas can be given a self-treatment course of atovaquone- proguanil. Travelers should be advised that self-treatment is not