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nonimmune individual and by the presence of a pustule or area of induration in a previously vaccinated person Failure to see these reactions is an indication for revaccination In general, adverse effects are more common in children under 5 years of age and in first-time vaccinees Other than the local reactions, the most common adverse effect (estimated at 1:2000) is autoinoculation to another site, most commonly the face, eyelid, mouth, and genitalia These lesions usually are selflimited and heal without specific therapy Generalized vaccinia occurs in 1:5000 vaccinees and is characterized by widespread lesions appearing 6 9 days after vaccination, the result of hematogenous spread The lesions usually heal without therapy in immunocompetent individuals but can be life-threatening in the immunosuppressed Eczema vaccinatum occurs in patients with active or healed eczema and can progress to involve all areas of the skin involved with the skin disorder Although uncommon (1:25,000), this is a potentially fatal complication Progressive vaccinia or vaccinia necrosum is seen in immunocompromised individuals The vaccination site fails to heal and the virus spreads to surrounding areas with progressive necrosis and gangrene, a serious complication with a high mortality Postvaccination encephalitis occurs 1 2 weeks after vaccination, is usually seen in those under 1 year of age, occurs in 1:300,000 vaccinations, and is associated with death in 25% and severe disability in another 25% Following mass vaccination of military personnel, two additional adverse events have been described local and generalized folliculitis and myopericarditis Folliculitis occurred 8 10 days following vaccination, was concentrated in hair-bearing areas (face, extremities, back), resolved spontaneously in 3 5 days, and was not associated with scarring Myopericarditis was seen in first-time vaccine recipients, occurred 7 19 days after vaccination, and was self-limited In brief follow-up, permanent sequelae have not been described Vaccinia immune globulin is available from the Centers of Disease Control and Prevention (CDC) but is in limited supply It is recommended for severe adverse reactions such as eczema vaccinatum, progressive vaccinia, severe generalized vaccinia, and inadvertent inoculation of the eye or eyelid without vaccinia keratitis It is not recommended for postvaccination encephalitis Cidofovir, a nucleotide analog used to treat CMV infections, has activity against variola virus and has been effective in animal models for the therapy of vaccinia infections It should be considered for those with serious adverse effects Routine vaccination in the absence of a case of smallpox is not recommended for those under 18 years of age It is also not recommended for those with a history of or active eczema or household associates of such individuals Those with other skin diseases (atopic dermatitis, impetigo) may also be at risk for complications and should not be vaccinated until skin lesions have healed Pregnancy, altered immune states as described above, and allergy to vaccine components (neomycin, streptomycin, polymyxin, chlortetracycline) are contraindications to smallpox vaccination Household contacts of individuals with altered immunity should also not be vaccinated.

munities and states where the risk of hepatitis A is high among children); employees of day care centers, caretakers for developmentally impaired institutionalized individuals, and laboratory workers who handle live hepatitis A virus or work closely with nonhuman primates; men who have sex with men; illicit drug users; persons who receive clotting factor concentrates; and those with chronic liver disease The role of hepatitis A vaccine in controlling outbreaks in day care centers, hospitals, and institutions for the disabled has not been investigated, and immune globulin is used in those settings A single intramuscular injection of vaccine in adults elicits antibodies in 55 60% of individuals at 2 weeks and 95% by 1 month, although rates of seroconversion may be lower in immunocompromised individuals The different formulations come in different strengths, and dosage depends on the age of the vaccine and the preparation used (see package insert) In general, two doses are required, the second 6 18 months after the first The duration of immunity may be lifelong, and at present repeat vaccination is not recommended Adverse effects are minimal and consist mainly of pain at the injection site If vaccine is not available, temporary passive immunity may be induced by the intramuscular injection of immune globulin, 002 mL/kg every 2 3 months or 01 mL/kg every 6 months Protection with immune globulin is recommended for persons traveling to areas where sanitation is poor and the risk of exposure to hepatitis A high because of contaminated food and water supplies and contact with infected persons Preparation of immunoglobulin from plasma involves steps that inactivate HIV, thus making it incapable of transmitting HIV infection

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A combined hepatitis A and B vaccine is approved for use in individuals 18 years of age and older The components are identical to individual vaccines It is highly immunogenic and should be used in individuals who have an indication for both hepatitis A and B vaccination, as noted above The product is safe, and adverse effects are similar to those of the individual components It is administered in three doses at 0, 1 and 6 months

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Smallpox vaccination, discontinued in the United States in the early 1970s, has been reinstituted because of concerns about bioterrorism The vaccine is a live vaccinia virus derived through serial passage of cowpox and does not contain the actual smallpox virus Vaccine is administered with a bifurcated needle, making 15 puncture wounds in a small area of the skin (5 mm) just deep enough to cause bleeding Because the inoculation site is contagious, it should be covered with gauze or a semipermeable dressing such as OpSite If vaccination is successful, the site goes through a characteristic evolution: In 3 4 days the site becomes red, itchy, and indurated; a vesicle umbilicates and evolves into a well-formed pustule by day 6 11; the pustule scabs over between week 2 and week 3; and by the end of the third week the scab falls off, leaving a scar At the end of the first week, fever for several days, tenderness at the vaccination site, and localized axillary adenopathy occur in 10 20% of first-time vaccinees, but these reactions are less common in those who have been previously vaccinated within the last 10 years Successful vaccination is indicated by the presence of a pustular lesion at day 7 in a

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Two vaccines are currently available, a polysaccharide vaccine (MPSV4) and the newer protein conjugated vaccine (MCV4) Both are highly immunogenic to serogroups A,C,Y and W135 and well tolerated Whereas the polysaccharide vaccine

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