Vaccination guidelines for female infertility patients

Encounters for infertility care are opportunities to assess and update immunization status. Women of reproductive age are often unaware of their need for immunization, their own immunization status, and the potentially serious consequences of preventable disease on pregnancy outcome. The purpose of this ASRM Practice Committee document is to summarize current recommendations regarding vaccinations for women of reproductive age.

Methodological issues in design and analysis of a matched case-control study of a vaccine's effectiveness

OBJECTIVE

Case-control studies of the effectiveness of a vaccine are useful to answer important questions, such as the effectiveness of a vaccine over time, that usually are not addressed by prelicensure clinical trials of the vaccine's efficacy. This report describes methodological issues related to design and analysis that were used to determine the effects of time since vaccination and age at the time of vaccination.

STUDY DESIGN AND SETTING

A matched case-control study of the effectiveness of varicella vaccine was conducted.

RESULTS

Sampling procedures and conditional logistic regression models including interaction terms are described.

CONCLUSION

Use of these methods will allow investigators to assess the effects of a wide range of variables, such as time since vaccination and age at the time of vaccination, on the effectiveness of a vaccine.

Varicella vaccination in children with atopic eczema

Chickenpox in children may be complicated by local or systemic bacterial infections. Group A streptococci and S. aureus are the predominant pathogens. Children with atopic dermatitis are particularly prone to bacterial superinfection. After the introduction of universal varicella vaccination in the USA ten years ago, the number of serious bacterial soft tissue infections in children dropped significantly. Since 2004, the VZV immunization has also been included in the routine German series.Many children with atopic dermatitis have not been immunized because of concerns on the part of parents or physicians. Recent studies demonstrated the safety and efficacy of VZV vaccination in children with atopic dermatitis who appear to benefit particularly from this vaccination.

Varicella zoster virus serostatus before and after kidney transplantation, and vaccination of adult kidney transplant candidates

In recent years we observed 3 lethal primary varicella infections in adult kidney transplant recipients. Therefore, we wondered how many of our adult renal transplant patients were not protected against varicella zoster virus (VZV), and therefore were at risk for such a primary infection. We also studied the prevalence of VZV seronegativity in the adult patients on our waitlist for kidney transplantation. Finally, we vaccinated these seronegative patients with an attenuated live vaccine. Sera were obtained from 854 transplanted patients, and from 286 candidates on the waitlist for kidney transplantation. We observed that 2.1% of our renal transplant recipients and 3.2% of the patients on the waitlist were seronegative for VZV. We vaccinated 11 seronegative patients on the waitlist twice without side effects. In 7 of 11 patients this resulted in a positive serologic response. In conclusion, the prevalence of VZV seronegativity was low both in renal transplant recipients (2%) and in patients on the waitlist (3%). Vaccination of transplant candidates resulted in a moderate efficiency of 64%.

Survey of the status of self-paid varicella vaccination among children one to six years of age in Taiwan

BACKGROUND AND PURPOSE

Prior to 2004, the mass immunization program in Taiwan did not include varicella vaccine; however, parents could have their children vaccinated by the self-payment option.

METHODS

In April 2002, we distributed 1271 questionnaires to the caregivers of children aged 1 to 6 years in Taoyuan county, Taiwan, to survey the status of vaccination rate against varicella, parental attitudes toward self-paid varicella vaccine, and the demographic characteristics of the family.

RESULTS

Based on the answers provided in the questionnaires (99% response rate), we learned that until April 2002, the vaccination rate against varicella was 26%. Most children received this vaccine by the age of 1 to 2 years (64%) mainly at local clinics (66%). Majority of the caregivers (94%) would have immunized their children against varicella if the vaccines were freely provided or partially paid for. Caregivers living in the city, those children whose parents had a relatively high education level, those from families with fewer children, those whose children were inoculated with other self-paid vaccines, and those parents with a higher family income were significantly (p<0.0001) willing to have their children inoculated.

CONCLUSIONS

In Taiwan, most caregivers were willing to have their children immunized against varicella if the vaccines were freely provided, or even if they were partially paid for. In case of other effective vaccines of high cost and not included in mass immunization, partially paying for the vaccine may be an option, since the parents' willingness was substantially greater when the cost is lowered.

Post-herpetic neuralgia in older adults: evidence-based approaches to clinical management

Many individuals across the globe have been exposed to the varicella-zoster virus (VZV) that causes chickenpox. After chickenpox has resolved, the virus remains latent in the dorsal root ganglia where it can re-emerge later in life as herpes zoster, otherwise known as shingles. Herpes zoster is a transient disease characterised by a dermatomal rash that is usually associated with significant pain. Post-herpetic neuralgia (PHN) is the term used for the condition that exists if the pain persists after the rash has resolved. Advanced age and compromised cell-mediated immunity are significant risk factors for reactivation of herpes zoster and the subsequent development of PHN. Though the pathophysiology of PHN is unclear, studies suggest peripheral and central demyelination as well as neuronal destruction are involved. Both the vaccine against VZV (Varivax) and the newly released vaccine against herpes zoster (Zostavax) may lead to substantial reductions in morbidity from herpes zoster and PHN. In addition, current evidence suggests that multiple medications are effective in reducing the pain associated with PHN. These include tricyclic antidepressants, antiepileptics, opioids, NMDA receptor antagonists as well as topical lidocaine (lignocaine) and capsaicin. Reasonable evidence supports the use of intrathecal corticosteroids, but the potential for neurological sequelae should prompt caution with their application. Epidural corticosteroids have not been shown to provide effective analgesia for PHN. Sympathetic blockade may assist in treating the pain of herpes zoster or PHN. For intractable PHN pain, practitioners have performed delicate surgeries and attempted novel therapies. Although such therapies may help reduce pain, they have been associated with disappointing results, with up to 50% of patients failing to receive acceptable pain relief. Hence, it is likely that the most effective future treatment for this disease will focus on prevention of VZV infection and immunisation against herpes zoster infection with a novel vaccine.

Outbreak of varicella-zoster virus infection among Thai healthcare workers

OBJECTIVE

To evaluate the correlation between self-report of a prior history of chickenpox and results of varicella-zoster virus (VZV) immunoglobulin (Ig) G serologic test results in an outbreak of VZV infection among Thai healthcare workers (HCWs) and to conduct a cost-benefit analysis of establishing routine VZV immunization as part of an occupational health program on the basis of the outbreak data.

METHODS

All exposed patients received prophylaxis and the HCWs in our 3 intensive care units (ICUs) were prospectively evaluated. HCWs were assessed for disease history and serologic evidence of VZV IgG. A cost-benefit analysis was performed.

RESULTS

After 140 HCWs and 18 ICU patients were exposed to VZV, 10 HCWs (7%) with active VZV infection were relieved from work until skin lesions were crusted. Acyclovir (ACV) was prescribed to all 10 HCWs with active disease, and all 18 exposed patients received prophylaxis with ACV. Of 140 HCWs, 100 consented to longitudinal follow-up. Twenty-three (100%) of the HCWs who reported a history of chickenpox also had serologic test results that were positive for VZV IgG, compared with 30 (39%) of 77 HCWs who reported no prior history of chickenpox, yet had test results that were positive for VZV IgG. Reported history of chickenpox had a sensitivity of 43%, a specificity of 100%, a positive predictive value of 100%, and a negative predictive value of 61% with respect to VZV infection immunity. The total cost estimate for this outbreak investigation was $23,087.

CONCLUSIONS

An HCW's reported history of chickenpox was a reliable predictor of immunity; a report of no prior history of chickenpox was unreliable. Our cost-benefit analysis suggests that the costs of an occupational health program that included VZV surveillance and immunization for the next 323 HCWs would be approximately equal to the excess costs of $17,227 for the ACV therapy, HCW furloughs, and staff overtime associated with this outbreak.

Quality improvement for medicaid members of a commercial health plan: impact on racial/ethnic differences

OBJECTIVE

To describe one commercial Medicaid Managed Care (MMC) health plan's quality improvement (QI) program that achieved high varicella immunization rates among members of an ethnically diverse population in California.

DESIGN

Retrospective study using administrative data.

PATIENTS

Blue Cross of California Medicaid enrolled children who turned two years old during each calendar year of the study.

INTERVENTION

A specialized immunization strategy was implemented with data collected at three time points, pre-intervention (baseline--1998/1999), two-year followup (2001) and three-year followup (2002).

MAIN OUTCOME MEASURE

Varicella vaccination coverage after the QI initiative.

RESULTS

A statistically significant increase in varicella immunization rates for the study population was observed between baseline (49.5%) and three-year follow up (89.4%). Baseline differences in immunization rates by physician type and patient ethnicity were reduced.

CONCLUSION

Trends in varicella vaccination coverage among members of this commercial MMC plan are in line with trends in overall vaccination coverage in California, indicating that commercial MMC health plans have the capacity to offer accessible and high quality care to ethnically diverse patients to mediate racial/ethnic differences. More work is needed to explore the impact of quality improvement programs of MMC plans in other areas.

Seroprevalence of measles, mumps, rubella and varicella among staff of a hospital in Riyadh, Saudi Arabia

This study aimed at screening immune status of Health Care Workers (HCWs) against measles, mumps, rubella, and varicella, and assessing the reliability of the history of previous illness due to these infections or vaccination against them as an indicator of the immune status, as checked by laboratory tests. Demographic data, history of previous illnesses and previous vaccinations were collected using a self-administered questionnaire. Also, serologic screening was done for these infections. Antibodies tested using ELISA. Among tested hospital staff, 71.8%, 60.3%, 47.9% and 68.4% reported history of infection or vaccination against measles, mumps, rubella and varicella respectively, while laboratory results proved that 4.5%, 10.8%, 12.9% and 11.3% were susceptible respectively. Susceptibility was most frequent among housekeeping staff against measles and varicella, while administrative staff were the most susceptibles to mumps, and nurses were the most susceptibles to rubella. Sensitivity of past history of illness as an indicator of the immune status, was found to be (85%, 83%, 66%, 86%); Specificity was (81%, 81%, 89%, 87%); Positive Predictive value (PV) was (99%, 98%, 98%, 98%) and Negative PV was (16%, 29%, 22%, 39%) for measles, mumps, rubella and varicella respectively. Screening for measles, mumps, rubella and varicella among hospital staff is mandatory to detect those who are susceptible for infections and should be vaccinated, and so preventing transmission of these infections to their colleagues or patients.

The preteen visit: an opportunity for prevention

All early adolescents should visit a physician at age 11 or 12 years to receive a set of recommended vaccines. Two vaccines are recommended for boys in this age group-quadrivalent meningococcal conjugate vaccine (MCV4) and tetanus toxoid, reduced diphtheria, and acellular pertussis vaccine (Tdap). Three vaccines are recommended for girls--MCV4, Tdap, and human papilloma virus (HPV) vaccine. In addition, 2 doses of varicella vaccine are now recommended before age 5 years; both boys and girls at age 11 or 12 who have received only 1 dose should be given a second.

Post-herpetic neuralgia: a review of advances in treatment and prevention

Post-herpetic neuralgia (PHN) is primarily a disease of the elderly and often refractory to treatment. Randomized and controlled trials have yielded several significant advances in the treatment and prevention of this disease. Treatment advances include the lidocaine patch, opioid analgesics, nortriptyline, amitriptyline, and gabapentin. However, no treatment regimen fully eliminates the pain. Improvements in prevention include prompt recognition and treatment of high-risk herpes zoster (HZ) patients with antiviral and analgesic therapies. Even with these advances, PHN remains a debilitating and painful disease. Vaccines offer the greatest promise of relief. The childhood vaccine against varicella zoster virus offers long-lasting immunity, largely preventing HZ and PHN. But most adults have already had varicella and are at risk for HZ and PHN as they age. Therefore, a more potent vaccine against varicella has been developed for use in adults. This vaccine offers a new and significant advance in the prevention of HZ and its most noteworthy complication, PHN.

Varicella vaccine effectiveness during an outbreak in a partially vaccinated population in Spain

BACKGROUND

An outbreak of varicella occurred between December 2004 and April 2005 in the primary school and day-care center of a town of 5430 inhabitants in Spain. Although the varicella vaccine is not included in the infant vaccination program, some children had been vaccinated before the outbreak.

STUDY AIM

The aim of this study was to estimate varicella vaccine effectiveness during an outbreak that took place in a partially vaccinated population of children.

METHODS

A cohort study was carried out. Cases were identified through notification by doctors and active search. Information was gathered on the current disease, history of varicella and previous vaccinations together with age, course, school year and other sociodemographic factors. The relative risk (RR) of varicella and the contribution of the previously mentioned factors to the probability of contracting the disease was estimated for vaccinated and unvaccinated children.

RESULTS

Participation reached 96.5% (387 of 401 children) in the school and 91.2% (31 of 34 children) in the day-care center. Of 269 children with no history of varicella and with a documented vaccination record, 96 (35.7%) had been previously vaccinated. During the outbreak, 148 cases of varicella were observed. The overall attack rate was 54.4%, 22.9% in vaccinated and 72.8% in unvaccinated children. RR of varicella in vaccinated children was 0.31 (95% confidence interval [CI] = 0.21-0.46). The overall adjusted vaccine effectiveness against varicella was 69.5% (95% CI = 50.5-81.5%) and 96.9% (95% CI = 77.5-99.6%) against mild and severe forms. Only time since vaccination was associated with vaccine failure.

CONCLUSIONS

In the varicella outbreak studied, we conclude that vaccine was effective in the prevention of the disease, particularly in its moderate and severe forms, but because the proportion of vaccinated children was low, an outbreak still occurred.

Varicella vaccination update Neuere Erkenntnisse zur Varizellenimpfung

Varicella is the most common infection which is preventable by vaccination. Even though varicella usually runs a mild course, some patients require hospitalization and a small number die. The German Immunization Commission (STIKO) in 2004 recommended varicella vaccination for all children. The discussion remains controversial. We review the most frequently asked questions about varicella vaccination, with emphasis on its effectiveness with the possibilities for use after incubation or exposure to limit the spread, as well as its effects on the prevalence of herpes zoster. The average age of varicella patients has not increased in the USA after 10 years of childhood vaccination. In addition, there has not been an expected increase of herpes zoster in non-immunized individuals. Vaccinated children have a lower incidence of herpes zoster than those who have had varicella. Finally, a recent study using a live zoster vaccine with increased antigenicity in older adults halved the incidence of herpes zoster and reduced that of post-herpetic neuralgia to one-third.

Varicella vaccines and measles, mumps, rubella, and varicella vaccine

OBJECTIVES

To present an up-to-date review of studies investigating the efficacy, adverse events and vaccination regimens of the varicella vaccine and the new presentation combined with the vaccine for measles, mumps and rubella.

SOURCES OF DATA

Bibliographic review of the MEDLINE and LILACS databases covering the period 1999 to 2006.

SUMMARY OF THE FINDINGS

The varicella vaccine protects 70 to 90% of immunized children against any form of varicella zoster infection, but the efficacy against severe forms is higher (95 to 98%). This is a well-tolerated vaccine that causes few reactions. Since the vaccine was licensed, there have been three confirmed cases of transmission of the vaccine virus by domestic contacts to previously healthy people, who went on to develop mild disease. Despite evidence that the protection offered by this vaccine can wane over a number of years, it is not yet possible to state that a second dose is warranted, bearing in mind exposure to wild virus. After universal vaccination the chances of natural stimulation should drop and it is very probable that booster doses will become necessary. A measles, mumps, rubella, and varicella vaccine has recently been licensed that combines vaccines for measles, mumps, rubella and varicella in a single product with high rates of seroconversion.

CONCLUSIONS

The Brazilian Society of Pediatrics recommends the varicella vaccine for children from 1 year on. We hope that the measles, mumps, rubella, and varicella vaccine will soon be available in Brazil, since combined vaccines facilitate wider vaccination coverage.

Actualización en el tratamiento del herpes zóster

The systemic treatment of herpes zoster shortens the healing process, and prevents or alleviates pain and other acute or chronic complications, especially when it is administered in the first 72 hours after symptoms appear. This treatment is especially indicated in patients over the age of 50 and in those who, regardless of age, have head and neck involvement, especially in herpes zoster ophthalmicus. The drugs approved in Europe for the systemic treatment of herpes zoster are aciclovir, valaciclovir, famciclovir and brivudine. Brivudine shows greater effectiveness against the varicella-zoster virus than aciclovir and its derivatives, and can be given just once a day for seven days, compared to multiple doses of the latter. As opposed to the others, brivudine is a non-nephrotoxic drug that should not be administered to immunodepressed patients or to those being treated with 5-fluorouracil. The treatment of herpes zoster to reduce pain should be combined with analgesics and neuroactive agents (amitriptyline, gabapentin, etc). While corticosteroids are of dubious efficacy in the treatment of post-herpes neuralgia, the intensity and duration of the pain can be reduced with some topical treatments (capsaicin, lidocaine patches, etc). Finally, this review discusses treatment guidelines for special locations (cranial nerves) and different subpopulations (children, pregnant women, immunodepressed patients, etc).