Issue Number 77
May 18, 1999
CONTENTS OF THIS ISSUE
- MMWR publishes recommendations on
combination vaccines for childhood immunization
- MMWR publishes article about
varicella-related deaths in Florida in 1998
- MMWR publishes update on influenza
activity, 1998-99 season
- How to get a free electronic
subscription to the MMWR
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(1)
May 14, 1999
MMWR PUBLISHES RECOMMENDATIONS ON COMBINATION VACCINES FOR CHILDHOOD IMMUNIZATION
On May 14, 1999, the Centers for Disease Control and Prevention (CDC) released
"Combination Vaccines for Childhood Immunization," the joint recommendations of
the Advisory Committee on Immunization Practices (ACIP), the American Academy of
Pediatrics (AAP), and the American Academy of Family Physicians (AAFP).
Published in MMWR, Recommendations and Reports, Volume 48, No. RR-5, as well as in the May
1999 issue of the AAP's journal, "Pediatrics," these recommendations provide
information concerning the optimal use of existing and anticipated parenteral combination
vaccines, along with relevant background, rationale, and discussion of questions raised by
the use of these products.
The summary statement of the recommendations is as follows:
"An increasing number of new and improved vaccines to prevent childhood diseases are
being introduced. Combination vaccines represent one solution to the problem of increased
numbers of injections during single clinic visits. This statement provides general
guidance on the use of combination vaccines and related issues and questions.
"To minimize the number of injections children receive, parenteral combination
vaccines should be used, if licensed and indicated for the patient's age, instead of their
equivalent component vaccines. Hepatitis A, hepatitis B, and Haemophilus influenzae type b
vaccines, in either monovalent or combination formulations from the same or different
manufacturers, are interchangeable for sequential doses in the vaccination series.
However, using acellular pertussis vaccine product(s) from the same manufacturer is
preferable for at least the first three doses, until studies demonstrate the
interchangeability of these vaccines. Immunization providers should stock sufficient types
of combination and monovalent vaccines needed to vaccinate children against all diseases
for which vaccines are recommended, but they need not stock all available types or
brand-name products. When patients have already received the recommended vaccinations for
some of the components in a combination vaccine, administering the extra antigen(s) in the
combination is often permissible if doing so will reduce the number of injections
required.
"To overcome recording errors and ambiguities in the names of vaccine combinations,
improved systems are needed to enhance the convenience and accuracy of transferring
vaccine-identifying information into medical records and immunization registries. Further
scientific and programmatic research is needed on specific questions related to the use of
combination vaccines."
NOTE: Continuing education credits (CMEs, CEUs, CNEs) sponsored by CDC are available for
reading the 1999 ACIP recommendations on combination vaccines for childhood immunization
and completing the test which is printed at the end of the document.
The entire statement, as published in the May 14, 1999, issue of the MMWR, can be read
and/or downloaded by clicking here: http://www.cdc.gov/epo/mmwr/preview/mmwrhtml/rr4805a1.htm
For the camera-ready copy (PDF format) of the document, click here:
ftp://ftp.cdc.gov/pub/Publications/mmwr/rr/rr4805.pdf
Click here for a copy of the continuing education test:
http://www2.cdc.gov/mmwr/cme/conted.html
For information on how to get a free electronic subscription to the MMWR, see article four
below.
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(2)
May 14, 1999
MMWR PUBLISHES ARTICLE ABOUT VARICELLA-RELATED DEATHS IN FLORIDA IN 1998
An article entitled "Varicella-Related Deaths Florida, 1998" was published in
the May 14, 1999, issue of the MMWR. During 1998, the Florida Department of Health
reported six fatal cases of varicella to CDC. Two deaths occurred in children and four in
adults; five of the six case-patients who died were eligible for varicella vaccination,
but none had been vaccinated.
The entire article, which includes information on ACIP's recommendation to vaccinate all
susceptible persons aged greater than or equal to 12 months is printed below:
VARICELLA-RELATED DEATHS -- FLORIDA, 1998
During 1998, the Florida Department of Health (FDH) reported to CDC six fatal cases of
varicella (chickenpox). FDH investigated all death certificates for 1998 with any mention
of varicella as a contributory or underlying cause (1). Eight deaths were identified; two
were reclassified as disseminated herpes zoster and six were related to varicella, for an
annual varicella death rate of 0.4 deaths per million population. Two deaths occurred in
children and four in adults; none had received varicella vaccine. The infection source was
identified for three cases; two adults acquired varicella from children in the home, and
one child acquired varicella from a classmate. One infection source was known to be
unvaccinated; the other two were presumed to be unvaccinated. This report summarizes these
varicella deaths and recommends prevention strategies.
Case 1. On February 19, a healthy, unvaccinated 6-year-old boy developed
a varicella rash, abdominal pain, malaise, and loss of appetite following exposure to a
classmate with varicella. The child had asthma and intermittently had been on inhaled
steroid therapy but had not received steroids within the previous month. On February 22,
he was hospitalized with hemorrhagic skin lesions, tachycardia, tachypnea, and a platelet
count of 89,000 (normal range: 150,000-350,000). Several hours after admission he
developed pulmonary edema and respiratory insufficiency and required mechanical
ventilation. He died on February 23. Tissue samples of multiple organs had a positive
polymerase chain reaction for varicella zoster virus (VZV).
Case 2. On March 27, a healthy, unvaccinated 58-year-old woman developed
a varicella rash. She was born in Cuba and had moved to the United States in 1995. She did
not have a history of or known exposure to varicella. On April 3, she was hospitalized
with a 5-day history of increasing shortness of breath and productive cough and was
diagnosed with varicella pneumonitis. She was treated with intravenous acyclovir and
ceftriaxone, but developed adult respiratory distress syndrome (ARDS), disseminated
intravascular coagulopathy, renal failure, and coma. She died on April 20.
Case 3. On April 27, a healthy, unvaccinated 29-year-old man developed a
varicella rash. In early April, his children had contracted varicella. On April 29, he
sought care at a local emergency department for chest pain and respiratory distress. Chest
radiographs showed bilateral pulmonary interstitial infiltrates. On April 30, he began
coughing up blood, was intubated because of increasing respiratory insufficiency, and was
treated with intravenous acyclovir and antibiotics. He developed sepsis, ARDS, and
multiorgan failure, and died May 12.
Case 4. On May 5, a 21-year-old unvaccinated female employee at a family
child care center developed a varicella rash after exposure to a child with varicella. The
employee had a history of asthma and was treated with 5 mg prednisolone per day. She was
hospitalized on May 7 with varicella pneumonitis and received intravenous acyclovir on May
8, but she died the same day.
Case 5. On July 11, an 8-year-old unvaccinated boy developed a
maculopapular rash diagnosed clinically as varicella and confirmed by direct flourescent
antibody test on July 23. He had acute lymphocytic leukemia (ALL) and had been on
immunosuppressive therapy since receiving a bone marrow transplant on May 15. He had not
had varicella and had no known varicella exposure. He was treated with varicella zoster
immunoglobulin on July 16 and acyclovir on July 23. He died on July 25 after recurrence of
leukemia with a graft-versus-host reaction complicated by disseminated varicella,
cellulitis, ileus, and hypertension.
Case 6. On October 3, an unvaccinated 45-year-old man with diabetes
mellitus, asthma, and cirrhosis of the liver developed a varicella rash. He was born in
Cuba and had resided in the United States for 35 years. He had no history of varicella and
no known exposure. He was not receiving steroids or immunosuppressive drugs. He was
admitted to the hospital with varicella on October 5 and on October 6, treatment was
initiated with oral acyclovir. He died on October 8; pathologic evidence from the
postmortem examination revealed VZV in all major organs.
Reported by: B Shelton, E Uribarri, M McCullom, S Heller, V Logsdon, B Keith, S Noll, P
Molina, Florida county health depts; P Yambor, H Janowski, MPH, Bur of Immunizations,
Florida Dept of Health; S Wiersma, MD, RS Hopkins, MD, State Epidemiologist, Bur of
Epidemiology, Florida Dept of Health. SA Hall, MS, Association of Schools of Public
Health, Atlanta, Georgia. Varicella Activity, Child Vaccine Preventable Diseases Br,
Epidemiology and Surveillance Div, National Immunization Program; State Br, Div of Applied
Public Health Training, Epidemiology Program Office; and an EIS Officer, CDC.
Editorial Note: Deaths continue to occur from varicella, a disease that
is now vaccine-preventable. In Florida in 1998, the death rate was similar to the crude
national varicella death rate of 0.4 per million population for 1990-1994, the 5 years
preceding vaccine licensure (2). During this period, approximately 100 varicella-related
deaths occurred yearly in the United States. Similar to Florida in 1998, in the rest of
the United States 55% of varicella-associated deaths occurred among persons aged greater
than or equal to 20 years (CDC, unpublished
data, 1998).
Varicella vaccine has been available since 1995 and is recommended for all susceptible
persons aged greater than or equal to 12 months (3,4). During July 1997-June 1998, the
coverage level among children aged 19-35 months in Florida was 31%, slightly lower than
the national coverage rate of 34% (CDC, unpublished data, 1999). In February 1999, the
Advisory Committee on Immunization Practices (ACIP) recommended that all states require
varicella vaccine for child care and school entry; implementation of this requirement
should increase vaccine coverage dramatically. ACIP also strengthened recommendations for
the vaccination of susceptible adults at high risk for exposure, including men living in
households with children (5). ACIP continues to recommend that vaccination be considered
for all susceptible adolescents and adults.
Five of the six case-patients who died because of varicella were eligible for vaccination.
The sixth, a child with active ALL (case 5), was ineligible for vaccination. Under a
special protocol, children with ALL who meet inclusion criteria may be vaccinated (3).
Although one case-patient was receiving systemic steroids when she contracted varicella,
the dose was not large enough to be a contraindication; varicella vaccine can be
administered to adults receiving less than 20 mg prednisone per day or its equivalent, and
to children receiving less than 2 mg per kg body weight per day or a total of less than 20
mg per day (3).
Two case-patients (2 and 6) were aged greater than 30 years and were born and raised in
Cuba. The epidemiology of varicella in tropical regions differs from that in temperate
regions. VZV is heat labile and may not survive and transmit well in warm climates. In the
tropics, age distribution of cases and VZV seroprevalence data have indicated a higher
proportion of cases occurring among adults (6,7). Clinicians should be aware of the
greater susceptibility of adults to varicella when evaluating persons from tropical
countries.
Widespread implementation of ACIP recommendations will protect healthy children and
adults, thus protecting persons with contraindications to vaccination from exposure to
VZV. This includes infants aged less than 12 months, pregnant women, persons with cancers
or other immunocompromising conditions, and persons on high-dose systemic steroids (3).
Efforts to increase varicella vaccination of susceptible children, adolescents, and adults
should include educating health-care providers that severe morbidity and death from
varicella are preventable.
Varicella-related deaths became nationally notifiable on January 1, 1999. A standard form
for reporting varicella-related deaths is available through state public health
departments. Detailed investigations of these deaths, including history of varicella,
presence of immunocompromising conditions, and initiation and progression of rash, will
assist state health departments in differentiating between varicella-related and
disseminated herpes zoster-related deaths. Varicella death surveillance data will be used
by state health departments and CDC to improve prevention efforts.
References
- Council of State and Territorial Epidemiologists.
Inclusion of varicella-related deaths in the National Public Health Surveillance System.
Atlanta, Georgia: Council of State and Territorial Epidemiologists, 1998 (position
statement no. ID-10).
- Seward J, Meyer P, Singleton J, et al. Varicella
incidence and
mortality, USA, 1990-1994. In: Abstracts of the 36th annual meeting of the Infectious
Diseases Society of America. Denver, Colorado: Infectious Diseases Society of America,
November 1998.
- CDC. Prevention of varicella: recommendations of
the Advisory
Committee on Immunization Practices (ACIP). MMWR 1996;45(no. RR-11).
- Committee on Infectious Diseases, American Academy
of Pediatrics. Recommendations for the use of live attenuated varicella vaccine.
Pediatrics 1995;95:791-6.
- CDC. Prevention of varicella: updated
recommendations of the
Advisory Committee on Immunization Practices (ACIP). MMWR 1999:48 (in press).
- Longfield JN, Winn RE, Gibson RL, Juchau SV,
Hoffman PV. Varicella outbreaks in Army recruits from Puerto Rico. Arch Intern Med
1990;150:970-4.
- Garnett GP, Cox MJ, Bundy DA, Didier JM, St.
Catherine J. The age of infection with varicella-zoster virus in St Lucia, West Indies.
Epidemiol Infect 1993;110:361-72.
To access the complete document in text or
camera-ready (PFD)
format, click here:
http://www.cdc.gov/epo/mmwr/preview/mmwrhtml/mm4818a3.htm
For information on how to get a free electronic subscription to the MMWR, see article four
below.
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(3)
May 14, 1999
MMWR PUBLISHES UPDATE ON INFLUENZA ACTIVITY, 1998-99 SEASON
An article entitled "Update: Influenza Activity--United States and Worldwide, 1998-99
Season, and Composition of the 1999-2000 Influenza Vaccine" was published in the May
14, 1999, issue of the MMWR. In collaboration with the World Health Organization and state
and local health departments, CDC conducts surveillance to monitor influenza activity and
to detect antigenic changes in the circulating strains of influenza viruses. This report
summarizes surveillance for influenza during the 1998-99 season and describes the
composition of the 1999-2000 influenza vaccine.
During the 1998-99 influenza season, both influenza A (H3N2) and influenza B viruses
circulated worldwide, and influenza A (H3N2) predominated in the United States. Overall,
the 1998-99 influenza vaccine strains were well matched with the circulating virus
strains.
The Food and Drug Administration's Vaccines and Related Biologic Products Advisory
Committee recommended that the 1999-2000 trivalent vaccine for the United States contain
A/Sydney/5/97- like(H3N2), A/Beijing/262/95-like(H1N1), and B/Beijing/184/93- like
viruses. Strains to be included in the influenza vaccine are selected during the previous
January through March to meet scheduling deadlines for production, quality control,
packaging, distribution, and vaccine administration.
To read the entire article in text or camera-ready (PDF) format, please click here:
http://www.cdc.gov/epo/mmwr/preview/mmwrhtml/mm4818a2.htm
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4)
May 18, 1999
HOW TO GET A FREE ELECTRONIC SUBSCRIPTION TO THE MMWR
To get a free electronic subscription to the MMWR (delivered weekly), go to the MMWR
website and sign up. When you sign up, you will also automatically begin to receive all
new ACIP statements which are published as MMWR's "Recommendations and Reports."
To get to the MMWR website, click here: http://www.cdc.gov/epo/mmwr/mmwr.html |
