Monitoring anthrax vaccine safety in US military service members on active duty: surveillance of 1998 hospitalizations in temporal association with anthrax immunization

[Systemic treatment of bladder cancer]

With around 30,000 new cases annually bladder cancer (BC) is one of the most frequent cancers in Germany and the incidence is associated with advanced age and nicotine use. Urothelial carcinoma is the most frequent histological variant of BC in Central Europe. Nonmuscle-invasive BC can be resected endourologically and treated with intravesical instillation therapy. In the case of progression to nonmetastatic muscle-invasive disease radical cystectomy with accompanying neoadjuvant or adjuvant chemotherapy can be curative. Systemic treatment is the standard of care in metastatic disease. Although immunotherapy has made great progress in recent years, palliative chemotherapy remains the gold standard in first-line treatment. The armamentarium is continuously evolving: systemic immunotherapy is currently being investigated in nonmuscle-invasive BC as well as in perioperative and maintenance treatment after first-line chemotherapy and several studies are testing new targeted agents in palliative systemic therapy. This article gives an overview of current innovations and the expected paradigm shift in systemic treatment of BC.

Radiation Exposure Predicts Reported Vaccine Adverse Effects in Veterans with Gulf War Illness

Most people have no problems when administered vaccines; however, as with all drugs, reported adverse effects (rAEs) do occur. There is a need to better understand the potential predictors of reported vaccine AEs (rVaxAEs), including modifiable (environmental) predictors. Gulf War Veterans (GWV) who have Gulf War illness (GWI) report increased experiences of drug and chemical rAEs, extending to rVaxAEs. GWV provide an opportunity to examine the relationship between their reported exposures and rAEs. Forty one GWV with GWI and 40 healthy controls reported exposure and rAEs to exposure, including for 14 vaccines. Individual and summed vaccine exposures, rVaxAEs, and reported Vaccine AE Propensity (summed rVaxAEs/summed vaccines exposures) were compared in cases vs. controls. Exposure-outcome assessments focused on GWV, using a multivariable regression with robust standard error. More designated vaccines were reported in cases than in controls: 9.0 (2.3) vs. 3.8 (2.3), p < 0.0001. The fraction of vaccines received that led to rAEs was ten-fold higher in cases: 0.24 (0.21), vs. 0.023 (0.081), p < 0.0001. Multivariable assessment confirmed that radiation and pesticides remained significant statistical predictors of reported Vaccine AE Propensity. Exposure tied to excess rVaxAEs in GWV may contribute to, or underlie, the reported link between rVaxAEs in GWV and later ill health.

Recent developments in the understanding and use of anthrax vaccine adsorbed: achieving more with less

Anthrax Vaccine Adsorbed (AVA, BioThrax™) is the only Food and Drug Administration (FDA) approved vaccine for the prevention of anthrax in humans. Recent improvements in pre-exposure prophylaxis (PrEP) use of AVA include intramuscular (IM) administration and simplification of the priming series to three doses over 6 months. Administration IM markedly reduced the frequency, severity and duration of injection site reactions. Refinement of animal models for inhalation anthrax, identification of immune correlates of protection and cross-species modeling have created opportunities for reductions in the PrEP booster schedule and were pivotal in FDA approval of a post-exposure prophylaxis (PEP) indication. Clinical and nonclinical studies of accelerated PEP schedules and divided doses may provide prospects for shortening the PEP antimicrobial treatment period. These data may assist in determining feasibility of expanded coverage in a large-scale emergency when vaccine demand may exceed availability. Enhancements to the AVA formulation may broaden the vaccine's PEP application.

Bioterrorism for the respiratory physician

Terrorist attacks by definition are designed to cause fear and panic. There is no question that a terrorist attack using biological agents would present a grave threat to stability of the society in which they were released. Early recognition of such a bioterrorist attack is crucial to containing the damage they could cause. As many of the most likely bioterrorism agents present with pulmonary disease, respiratory physicians may be crucial in the initial recognition and diagnosis phase, and certainly would be drawn into treatment of affected individuals. This review focuses on the biological agents thought most likely to be used by terrorists that have predominantly respiratory presentations. The primary focus of this review is on anthrax, plague, tularaemia, ricin, and Staphylococcal enterotoxin B. The pathogenesis, clinical manifestations and treatment of these agents will be discussed as well as historical examples of their use. Other potential bioterrorism agents with respiratory manifestations will also be discussed briefly.

Birth defects among infants born to women who received anthrax vaccine in pregnancy

In response to bioterrorism threats, anthrax vaccine has been used by the US military and considered for civilian use. Concerns exist about the potential for adverse reproductive health effects among vaccine recipients. This retrospective cohort evaluated birth defects, in relation to maternal anthrax vaccination, among all infants born to US military service women between 1998 and 2004. Department of Defense databases defined maternal vaccination and infant diagnoses; multivariable regression models described potential associations between anthrax vaccination and birth defects in liveborn infants. Among 115,169 infants born to military women during this period, 37,140 were born to women ever vaccinated against anthrax, and 3,465 were born to women vaccinated in the first trimester of pregnancy. Birth defects were slightly more common in first trimester-exposed infants (odds ratio = 1.18, 95% confidence interval: 0.997, 1.41) when compared with infants of women vaccinated outside of the first trimester, but this association was statistically significant only when alternative referent groups were used. Although the small observed association may be unlikely to represent a causal relation between vaccination in early pregnancy and birth defects, this information should be considered when making decisions about administering anthrax vaccine to pregnant women.

Evaluation of preterm births and birth defects in liveborn infants of US military women who received smallpox vaccine

BACKGROUND

Women serving in the US military have some unique occupational exposures, including exposure to vaccinations that are rarely required in civilian professions. When vaccinations are inadvertently given during pregnancy, such exposures raise special concerns. These analyses address health outcomes, particularly preterm births and birth defects, among infants who appear to have been exposed to maternal smallpox vaccination in pregnancy.

METHODS

This retrospective cohort study included 31,420 infants born to active-duty military women during 2003-2004. We used Department of Defense databases to define maternal vaccination and infant health outcomes. Multivariable regression models were developed to describe associations between maternal smallpox vaccination and preterm births and birth defects in liveborn infants.

RESULTS

There were 7,735 infants identified as born to women ever vaccinated against smallpox, and 672 infants born to women vaccinated in the first trimester of pregnancy. In multivariable modeling, maternal smallpox vaccination in pregnancy was not associated with preterm or extreme preterm delivery. Maternal smallpox vaccination in the first trimester of pregnancy was not significantly associated with overall birth defects (OR 1.40; 95% CI: 0.94, 2.07), or any of seven specific defects individually modeled.

CONCLUSIONS

Results may be reassuring that smallpox vaccine, when inadvertently administered to pregnant women, is not associated with preterm delivery or birth defects in liveborn infants.

US military service members vaccinated against smallpox in 2003 and 2004 experience a slightly higher risk of hospitalization postvaccination

This study explores adverse events severe enough to warrant hospitalization that may have been associated with receiving the smallpox vaccine in conjunction with military service. Cox proportional hazards modeling was used to identify the risk of hospitalization among US active-duty military personnel during a 1-year period following receipt of the smallpox vaccine. The reference group consisted of active-duty military personnel who also received the smallpox vaccine after the conclusion of their health care observation period, allowing for comparison to a temporally and demographically similar population. The risk of hospitalization was slightly elevated among the postvaccine group for any-cause hospitalization and for hospitalization in several broad diagnostic categories. Hospitalizations for asthma, autoimmune diseases, and myopericarditis, were more likely in the postvaccine group. The increased risk of hospitalization for varied outcomes does not necessarily imply a cause-effect relationship, but it does offer areas for more focused study, using longitudinal data to explore the long-term impact of smallpox vaccination on the health of young adults.

Anthrax vaccination in a military population before the war in Iraq: side effects and informed choice

BACKGROUND

To assess any health consequences of the anthrax vaccination programme in UK Armed Forces deployed to Iraq.

METHODS

Data were collected from two samples simultaneously. The first was 5302 randomly selected UK service personnel. The second was 607 service personnel involved in a longitudinal study, where pre-vaccination health had previously been collected. Both samples were offered the anthrax vaccination before they deployed to Iraq in 2003 and subsequently following their service in Iraq. Participants completed a detailed questionnaire, including a range of health outcomes, receipt of the anthrax vaccination and quality of choice.

RESULTS

Seventy-two percent of the combined sample had the anthrax vaccination. Being a member of the Army, a commissioned officer or a reservist was associated with higher uptake. No differences in self-reported health were observed between those who did and did not receive the vaccination. For participants who accepted the vaccination, we found an association between making an uninformed choice and adverse health. After adjustment for baseline health in the longitudinal cohort these associations remained significant.

CONCLUSIONS

Anthrax vaccination used by the UK Armed Forces in preparation for the Iraq War has not resulted in adverse health outcomes. However, of those who did accept the vaccination, reported side effects were related to whether acceptance of vaccination was perceived to be informed. Improving the quality of choice may improve self-reported ill health.

Millennium Cohort: enrollment begins a 21-year contribution to understanding the impact of military service

OBJECTIVE

In response to health concerns of military members about deployment and other service-related exposures, the Department of Defense (DoD) initiated the largest prospective study ever undertaken in the U.S. military.

STUDY DESIGN AND SETTING

The Millennium Cohort uses a phased enrollment strategy to eventually include more than 100,000 U.S. service members who will be followed up through the year 2022, even after leaving military service. Subjects will be linked to DoD and Veterans Affairs databases and surveyed every 3 years to obtain objective and self-reported data on exposures and health outcomes.

RESULTS

The first enrollment phase was completed in July 2003 and resulted in 77,047 consenting participants, well representative of both active-duty and Reserve/Guard forces. This report documents the baseline characteristics of these Cohort members, describes traditional, postal, and Web-based enrollment methods; and describes the unique challenges of enrolling, retaining, and following such a large Cohort.

CONCLUSION

The Millennium Cohort was successfully launched and is becoming especially relevant, given current deployment and exposure concerns. The Cohort is representative of the U.S. military and promises to provide new insight into the long-term effects of military occupations on health for years to come.

Molecular basis for improved anthrax vaccines

The current vaccine for anthrax has been licensed since 1970 and was developed based on the outcome of human trials conducted in the 1950s. This vaccine, known as anthrax vaccine adsorbed (AVA), consists of a culture filtrate from an attenuated strain of Bacillus anthracis adsorbed to aluminum salts as an adjuvant. This vaccine is considered safe and effective, but is difficult to produce and is associated with complaints about reactogenicity among users of the vaccine. Much of the work in the past decade on generating a second generation vaccine is based on the observation that antibodies to protective antigen (PA) are crucial in the protection against exposure to virulent anthrax spores. Antibodies to PA are thought to prevent binding to its cellular receptor and subsequent binding of lethal factor (LF) and edema factor (EF), which are required events for the action of the two toxins: lethal toxin (LeTx) and edema toxin (EdTx). The bacterial capsule as well as the two toxins are virulence factors of B. anthracis. The levels of antibodies to PA must exceed a certain minimal threshold in order to induce and maintain protective immunity. Immunity can be generated by vaccination with purified PA, as well as spores and DNA plasmids that express PA. Although antibodies to PA address the toxemia component of anthrax disease, antibodies to additional virulence factors, including the capsule or somatic antigens in the spore, may be critical in development of complete, sterilizing immunity to anthrax exposure. The next generation anthrax vaccines will be derived from the thorough understanding of the interaction of virulence factors with human and animal hosts and the role the immune response plays in providing protective immunity.

Anthrax vaccines

Anthrax, an uncommon disease in humans, is caused by a large bacterium, Bacillus anthracis. The risk of inhalation infection is the main indication for anthrax vaccination. Pre-exposure vaccination is provided by an acellular vaccine (anthrax vaccine adsorbed or AVA), which contains anthrax toxin elements and results in protective immunity after 3 to 6 doses. Anthrax vaccine precipitated (AVP) is administered at primovaccination in 3 doses with a booster dose after 6 months. To evoke and maintain protective immunity, it is necessary to administer a booster dose once at 12 months. In Russia, live spore vaccine (STI) has been used in a two-dose schedule. Current anthrax vaccines show considerable local and general reactogenicity (erythema, induration, soreness, fever). Serious adverse reactions occur in about 1% of vaccinations. New second-generation vaccines in current research programs include recombinant live vaccines and recombinant sub-unit vaccines.

The Postwar Hospitalization Experience of Gulf War Veterans Participating in U.S. Health Registries

In response to concerns that Gulf War veterans were experiencing increased morbidity resulting from wartime exposures in the Gulf War, the Department of Veterans Affairs and the Department of Defense (DoD) initiated clinical registries to provide systematic health evaluations for self-referred Gulf War veterans. The authors used Cox's proportional hazard modeling with data from all DoD hospitals to estimate the probability of hospitalization resulting from any cause, resulting from diagnosis in a major diagnostic category, and resulting from a specific diagnosis of interest. After adjusting for other risk factors, registry participants were 1.43 times more likely to have a postwar hospitalization than registry nonparticipants (95% confidence interval, 1.40-1.46). These findings support the hypothesis that registry participants were more likely to experience postwar morbidity than veterans who chose not to enroll in the health registries.

Anthrax vaccine: a review

Anthrax can be a deadly disease if treatment does not begin early in the course of infection. An effective vaccine has been available in the United States since 1970, although it was not used widely until 1998. A comprehensive, peer-reviewed evaluation by the National Academy of Sciences affirmed the findings of multiple previous independent panels that found that the US-licensed anthrax vaccine is safe and effective.

Comprehensive systematic surveillance for adverse effects of anthrax vaccine adsorbed, US Armed Forces, 1998-2000

Routine vaccinations of US military personnel with Anthrax Vaccine Adsorbed began in 1998. To systematically identify clinical diagnoses reported more frequently after vaccination than before, all military personnel were retrospectively assigned to pre- or post-vaccination cohorts. Cohort assignments were based on vaccination statuses each day of the 3-year surveillance period. For each cohort, rates of hospitalizations and ambulatory visits for 843 specific diagnoses were calculated using data in a public health surveillance system. Compared to the pre-vaccination cohort, the post-vaccination cohort had statistically higher rates of hospitalizations for 17 diagnoses, of ambulatory visits for 34 diagnoses, and in both clinical settings for one diagnosis (malaria). After accounting for systematic differences in coding/reporting and residual confounding, the number and nature of clinical diagnoses more frequent after anthrax vaccination than before were consistent with expectations due to random variation. This surveillance suggests that Anthrax Vaccine Adsorbed has few, if any, clinically significant adverse effects.

Analysis of adverse events after anthrax immunization in US Army medical personnel

A broad range of health effects in a cohort of 601 health care personnel, immunized with anthrax vaccine adsorbed (AVA) as a military occupational health requirement, were assessed to evaluate adverse events both qualitatively and quantitatively. Active surveillance showed that localized reactions were common and occurred more often in women than men. Five patients were reported to the Vaccine Adverse Event Reporting System, but only one event could be definitively attributed to immunization, a large localized reaction. Two separate cohort studies, one using nested data from a standardized health risk appraisal instrument and the other comparing rates of outpatient visits and hospitalizations, did not reveal significant differences between AVA-immunized and unimmunized individuals. Our findings suggest that AVA is relatively reactogenic but do not indicate serious adverse health effects due to immunization.