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A. Vaccination Schedule

  1. At Birth
    1. HepB (Hepatitis B Virus Vaccine) #1 - may be given up to 2 months of age
    2. HepB double dose and hepatitis B immune globulin (infants born to HBsAg+ mothers) [3]
    3. See recommendations below
  2. Two Months
    1. HepB #2 - should be given at least 1 month after first dose (range 1-4 months)
    2. DTaP #1
    3. HIB (Haemophilus influenzae type B conjugate vaccine) #1
    4. HIB-DTaP conjugate vaccines are now available [48]
    5. Inactivated Polio Vaccine (IPV) #1 (see below)
    6. Pneumococcal conjugate (heptavalent) vaccine (PCV) #1
  3. Four Months
    1. DTaP #2
    2. HIB #2 (or conbination HIB-DTaP vaccine)
    3. IPV #2
    4. PCV #2
  4. Six Months
    1. HepB #3 (must be >2 months after second dose; range 6-18 months)
    2. DTaP #3
    3. HIB #3 (depends on product; may be given at 12 or 15 months)
    4. IPV #3 (range 6-18 months)
    5. PCV #3
    6. Children 6-23 months old candidates for influenza vaccine [14]
  5. Twelve to 15 Months
    1. HepB #3 (if not given at 6 months)
    2. HIB #4 (dose #4 is optional and may not be clinically relevant [62])
    3. IPV #3 (if not given at 6 months)
    4. MMR (Measles / Mumps / Rubella) #1 or MMR+Varicella (Proquad®)
    5. PCV #4
    6. Varicella Zoster (VZV) Vaccine (anytime age 12-18 months if no clinical chicken pox) [44]
    7. VZV now available as part of MMR-Var (Proquad®)
  6. Fifteen to 18 Months
    1. DTaP #4
    2. HepB #3 (if not previously given)
    3. IPV #3 (if not given at 12-15 months)
  7. Four to 6 Years
    1. DTaP #5
    2. IPV #4
    3. MMR #2 (waiting until age 12 is no longer recommended) [3]
    4. Hepatitis A Vaccine (HAV) in selected (endemic) areas (age >2)
  8. Nine Years (up to 26 years): HPV vaccine (see below)
  9. Eleven to 12 Years
    1. HepB (booster if needed)
    2. Tetanus and Diphtheria Toxoids - booster (pertussis boosters may be needed) [68]
    3. MMR #3 (booster; if not given age 4-6 years)
    4. Varicella Vaccine #2 [94]
  10. Fourteen to 16 Years
    1. Tetanus and Diphtheria Toxoids (if not given at 11-12 years)
    2. Check anti-HBV titers; consider booster
  11. Booster Vaccinations
    1. Tetanus / Diphtheria / Pertussis booster (TDaP) every 10 years
    2. Rubella - pre-pregnancy check titers; boost if not protective
    3. Hepatitis - boost for high risk activity or immunosuppression if titers low
  12. Notes on Pertussis Vaccine
    1. Acellular pertussis vaccine has replaced cellular vaccine
    2. Acellular pertussis vaccine appears effective in ~70% and very well tolerated
    3. Acellular pertussis vaccine is effective in 92% of adolescents and adults [68]
    4. Combination DTaP is available and all Td boosters should be replaced with TDaP [19]

B. Adult Immunizations [9,10]

  1. Individuals Unvaccinated During Childhood
    1. Inactivated Polio Vaccine (IPV) should be given at 0, 1, 6 months
    2. Tetanus / Diphtheria (Td) Vaccine 0, 1, 6-12 months
    3. Measles / Mumps / Reubella (MMR) 0,1 months
    4. Varicella Zoster 2 doses (0, 4-8 weeks) if no evidence of VZV immunity [9]
    5. Hepatitis A (at risk): 0, 6-18 months
    6. Hepatitis B (all): 0, 1-2, 4-6 months
    7. Meningococal (at risk): 1 or more doses
    8. Herpes zoster vaccine: age >60 years (prevents zoster and post-herpetic neuralgia)
    9. HPV (papillomavirus): woman age <26 who have not completed 3 doses
  2. Boosters [10]
    1. Td boosters should be replaced with TDaP boosters (Adacel®, Boostrix®) q10 years [19]
    2. These TDaP boosters contain well tolerated acellular pertussis immunogens
    3. Persons MMR age (>12 or) 18-24 should have at least one vaccination [11]
    4. Persons in high risk groups should have at least one booster MMR
    5. High risk includes students living in dormatories, foreign travel, healthcare workers
  3. Influenza Vaccine (see below) [14,15]
    1. Vaccine is tailored to major strains and administered annually October-November (optimal)
    2. Inactivated intramuscular vaccine targeted to those at highest risk for complications
    3. Attenuated intransal vaccine (FluMist®) for anyone who wants it without contraindications
    4. High risk: pregnant women, persons >64 years old, children 6-23 months, patients 2-64 years old with chronic medical conditions, previous severe influenza infection
    5. Immunocompromised patients should only receive the inactivated vaccines
    6. In >64 year patients there was a ~50% reduction in hospitalizations for pneumonia and influenza [13]
    7. The vaccine is safe and effective in younger persons (18-65 years), and in areas with high attack rates of influenza, may be cost effective in this group [16]
  4. Pneumococcal Vaccine (see below) [67]
    1. Given once in most patients; >65 years age
    2. Functional or anatomic splenectomy (should be given q6 years)
    3. Immunosuppression - including lymphoma, multiple myeloma (probably q6 years), HIV
    4. Alcoholism, Smoking
    5. Major systems compromise
    6. Cerebral fluid leakage
    7. ~70% effective in preventing hospitalizations for pneumococcal infections
    8. May be repeated q5-10 years in immunocompromised hosts
  5. HBV
    1. Currently recommended for all at risk individuals
    2. Normal dosing is 3 vaccinations at 0,1 and 6 months
    3. Give to all Homosexual males and Household contacts of HBV carriers
    4. HIV Positive Patients
    5. Health care workers
    6. Hemophiliacs
    7. Recommend double dose at 0, 1, 2 and 6 months for hemodialysis and alcoholics
  6. HIB (H. influenza B; given once) - day care workers; consider in smokers
  7. Varicella Zoster Virus (VZV) Vaccine
    1. Recommended in all persons >60 years old
    2. In persons >60 years old, live-attenuated varicella zoster virus (VZV) vaccine reduced zoster ~50% and post-herpetic neuralgia ~67% [6]
    3. Vaccine associated with reduction of hospitalizations by 88%, ambulatory visits by 59% [90]
    4. Second vaccine dose 4-8 weeks after initial vaccination recommended [94]
  8. Lyme Disease vaccine has been withdrawn [12,52]
  9. Vaccinations for Travel

C. Special Circumstances

  1. HIV Positive Patients
    1. Check Hepatitis Status: Immunize if not already infected or immune
    2. Tetanus Boosters every 5 years
    3. Pneumococcal Vaccine
    4. HIB - may be helpful but no clear data
    5. Influenza Vaccine yearly
    6. Varicella vaccine is contraindicated
  2. Asplenia
    1. Includes functional (sickle cell and thalassemia) and surgical splenectomy
    2. Pneumococcal, meningococcal, influenza, and HIB vaccines should be given
    3. Prefer to give vaccines at least 2 weeks before elective splenectomy
    4. 23-valent pneumococcal and 4-valent meningococcal vaccines are effective in Hodgkin's Disease including those with splenectomy
  3. Complement Deficiency
    1. Meningococcal vaccine (4-valent)
    2. Pneumococcal vaccine is probably also helpful
  4. Glucocorticoid Immunosuppression
    1. Long term and high dose glucocorticoid therapy is indication for vaccinations
    2. Live virus vaccines (VZV and MMR) are generally contraindicated
    3. Influenza, pneumococcal, tetanus booster and possibly HIB vaccines should be given
    4. IPV can be given in appropriate patients
  5. Solid Organ Transplant Patients [74]
    1. Immunizations / boosters should not be done during first 6 months after transplant
    2. When possible, appropriate booster immunizations should be done prior to transplant
    3. Live virus vaccines should be completed at >4 weeks pre-transplant
    4. Live virus vaccines are not generally recommended in solid organ transplant recipients
    5. Booster recommendations are provided in "Transplantation Immunology" outline
  6. Malignancy
    1. Similar to glucocorticoid immunosuppressed patients
    2. Varicella (live virus VZV) vaccine protocol in selected patients
  7. Pregnancy [10]
    1. Live virus vaccines MMR and varicella are contraindicated
    2. Pneumococcal vaccine 1-2 doses recommended if at any risk
    3. HAV 2 doses recommended if at any risk
    4. HBV 3 doses recommended if at any risk
    5. Meningococcal in at risk (1 dose)
  8. Vaccinations for Travel

D. Bone Marrow Transplantation (BMT) [20]

  1. Most centers reimmunize patients 1-2 years after Allogeneic BMT
  2. Presence of graft versus host disease (GVHD) decreases vaccination efficacy
  3. Pneumococcal vaccine should be given at 7 and 24 months post-BMT
  4. H. influenza B (HIB) Vaccine should be given 6 months apart for 3 doses, begin 7 months
  5. Diphtheria and Tetanus (DT or DTaP) should be given after 12 months
  6. Enhanced inactivated poliovirus vaccine (eIPV)
    1. 3 doses, 1 months intervals, beginning at 12 months
    2. With chronic GVHD, vaccinated at 12, 24, and 36 months
    3. Oral polio vaccine is no longer available
  7. Hepatitis B Vaccine is recommended and can be given as for eIPV
  8. Titers can be checked 3 months after vaccinations
  9. MMR (live virus) vaccine should be delayed until 2 years post-BMT

E. Poliovirus

  1. Enhanced inactivated poliovirus vaccine (eIPV) available
  2. OPV is no longer available

F. Measles, Mumps, Rubella (MMR)

  1. Called MMR; live attenuated virus combination
  2. Rubella titers should be checked in all pregnant females
  3. Should not be used for immunocompromised persons (this is a live virus)
  4. Boosters are required for all persons; now recommended age 4-6 [2]
  5. Overall seroconcersion rates are 98% for rubella and ~83% for mumps
  6. Single Dose MMR gives ~80% seroconversion for measles; 2 doses >98% [11]
  7. MMR may be given to children with mild illness without efficacy reduction
  8. Newer MMR do not contain egg proteins and are safe in persons with egg allergies
  9. Slight (2.7X) increase in risk of febrile seizures in children within 2 weeks of MMR, but no longterm sequellae or increase in epilepsy [83]
  10. No link between MMR vaccination and autism [78,79]

G. Hepatitis B Vaccine (HBV) [3,39]

  1. Recommended (and cost effective) for all infants and children [21,22]
  2. Expansion to general population is under study
  3. Vaccines are based on surface antigens, so recipients convert to HBsAb+ (HBsAg-, HBcAb-)
  4. Two recombinant vaccines (using surface antigen) are available: Energix-B®, Recombivax®
  5. Three doses are required, and cost is high
  6. Pediatric doses are about half of adult doses; immunosuppressed patients received 2X dose
  7. Vaccination against HBV reduces incidence of hepatocellular Ca [10]
  8. All infants born to HBsAg+ mothers receive hepatitis B immune globulin + vaccine [3]
  9. Booster vaccinations unnecessary in immunocompetent persons [50]
  10. However, in immunocompromised persons, test anti-HBS titer
  11. Booster vaccinations should be given when titer is below 10 mIU/mL [50]
  12. Combination hepatitis B and A vaccine now available (3 doses at 0, 1, 6 months) [66]
  13. Vaccination (including hepatitis B vaccine) does not increase risk of multiple sclerosis (MS) or of MS relapse [59,60]
  14. HBV vaccine induces protective antibody levels for at least 15 years in most people [87]

H. Hepatitis A Vaccine (HAV Vaccine) [9,23,39]

  1. High risk Populations should be vaccinated:
    1. Frequent raw shellfish intake
    2. Travelling to endemic areas
    3. Children living in 17 states with highest incidence of HAV
  2. Efficacy of Inactivated Virus Vaccine
    1. 96% of recipients have high antibody titers in 30 days
    2. About 80% effective in prevention of secondary HAV infection (household contacts) [42]
    3. HAV vaccination in children lead to reduction in disease rates ~75% [89]
  3. Overall 90-100% effective in preventing disease
  4. Two Formulations: Havrix® or Vaqta®, both given as 0.5mL or 1.0mL aliquots
  5. Adult dose is 1.0mL initially, then booster in 6-12 months
  6. Pediatric Use
    1. Doses are about half of adult doses (0.5mL)
    2. Vaccinating children in an endemic area prevents disease and outbreaks and is safe [71]
  7. Immune globulin
    1. Effective for pre-exposure prophylaxis ~90% of cases
    2. Effective for post-exposure prophylaxis ~85% of cases
    3. HAV vaccine about as effective as immune globulin for post-exposure prophylaxis [18]
  8. Combination Hepatitis A+B vaccine now avaialble (Twinrix®, see above) [66]

I. Influenza Virus Vaccine [14,70]

  1. Clear benefits with essentially no risks in healthy and chronically ill elderly persons [38]
  2. Types [14]
    1. Parenteral (injected) inactivated - FluShield®, Fluvirin®, Fluzone®, Fluarix®
    2. Fluzone® Preservative free also available
    3. Intranasal live vaccine - approved 2003 for age >5 years; FluMist® [15]
    4. Both inactivated and live attenuated vaccines are effective against influenza virus strains that have shown significant drift from vaccine strain [4]
    5. Safe and more effective than trivalent killed vaccine in children without history of wheezing/asthma 12-59 months old [95]
  3. Egg Allergies and Inactivated Parenteral Vaccine:
    1. Caution in patients with egg allergies
    2. If vaccine egg protein content is <1.2µg/mL, patients with egg allergies may safely receive vaccine [69] ci. Inactivated influenza vaccine is safe and beneficial; asthmatics should receive it [69]
  4. Recommendations for Influenza Vaccination 2007-8 [44]
    1. All persons at least 6 months old without contradindication
    2. Should definitely be given to persons at high risk of influenza complications
    3. Children ages 6-59 months old, all persons >50 years old, all chronic medical conditions
    4. All women who will be pregnant during influenza season
    5. Residents of nursing homes and long-term care facilities
    6. Health-care workers involved in direct patient care [49]
    7. Out-of-home caregivers and household contacts of children <5 years of age
  5. Given yearly, usually in October through January [14]
    1. Vaccine consists of three distinct serotype hemagluttinen (H) and neuraminidase (N) antigens and is therefore "trivalent"
    2. Year 2007 Vaccine: A/Solomon Islands/3/2006 (H1N1), A/Wisconsin67/2005 (H3N2) and B/Malaysia/2506/2004
  6. Vaccine Utility
    1. Vaccinating healthy working adults <65 years reduces lost workdays, influenza- like illness, physician visits [57]
    2. Vaccination associated with 27-45% reduction hospitalizations in elderly [65,85]
    3. Vaccinating healthy working adults is cost-effective when viral strains and vaccine strains are the same [57,70]
    4. Influenza vaccination in elderly persons reduces their risk of hospitalizations for cardiac disease + stroke ~20%, respiratory infection ~30%, and any-cause death ~50% [81]
    5. Vaccinating children in day care also reduced febrile respiratory illness in contacts 80% [56]
    6. Vaccinating elementary school students associated with reduced influenza symptoms in students and their households [7]
  7. Live Intranasal Vaccine (FluMist®) [15,22]
    1. Three strains (2 influenza A, 1 B) attenuated by reassortment with mutant virus
    2. Efficacy ~90% in chilren 15-71 months old
    3. Reduced febrile respiratory illness, workdays lost, physician visits in adults 18-64
    4. Efficacy likely 10-15% better than inactivated virus
    5. Increase in runny nose, nasal congestion, headache versus placebo
    6. FDA approved for healthy people 5-49 years old, 0.25mL per nostril annually
  8. Neurological Adverse Events [41]
    1. No increased risk for neurologic or other diseases with vaccines after 85
    2. The influenza A New Jersey/swine flew vaccine from 1976-77 caused a clear increase in Guillain-Barre Syndrome
  9. As effective in HIV+ as in HIV- persons regardless of CD4+ T cell counts [46]

J. Pneumococcus [67]

  1. Older 23-valent nonconjugated and newer conjugated hepta (7-) valent vaccines available
  2. Vaccine issues, risk factors, reviewed as early as age 50 in all patients
    1. At least 30% of persons age 50-60 should receive pneumococcal vaccine
    2. There is little risk in taking vaccine, and increased use is strongly recommended
    3. Vaccine is cost effective for preventing bacteremia as well [27]
  3. Nonconjugated 23 Valent Polysaccharide Vaccine
    1. Requires intact T-lymphocyte independent immunity (direct B-cell activation)
    2. Poor or no responses in infants and young (age <2) children
    3. Given once for normal hosts (at high risk and >age 60-65)
    4. Given q3-6 years for immunocompromised hosts and persons with chronic diseases
    5. Children age <4 undergoing heart transplants respond poorly to single dose vaccine [37]
    6. 23-vaccine most beneficial in reducing pneumococcal bacteremia in age >65 years [82]
    7. No effect on incidence of pneumococcal pneumonia in age >65 years [82]
    8. Nonjugated vaccine has broader coverage but lower responses than conjugated vaccine
  4. Heptavalent Conjugate Vaccine [51]
    1. Pneumococcal capsular polysaccharides linked to diphtheria toxoid derivative CRM197
    2. Uses T-lymphocyte dependent immune responses with high vaccination rates
    3. Recommended for ALL infants <2 years old
    4. Also recommended for children 2-5 years old at increased risk for pneumococcus
    5. Strongly consider in any patient with poor immune function
    6. Covers ~80% of invasive childhood pneumococcal infections in USA
    7. This vaccine reduces acute otitis media caused by serotypes in the vaccine >50% [61]
    8. Reduced rates of invasive pneumococcal disease in children by 30% (50% in <2 year olds) [24]
    9. Efficacy ~80% in very high risk populations of young children [25]
    10. In general, the 23-valent nonconjugated vaccine is not as immunogenic as conjugated
    11. Dosage: 3 total for 7-11 months, 2 total for 12-23 months, 1-2 for >23 months
    12. Conjugated vaccine covers nearly all pencillin-resistant pneumococcal strains
    13. Dosage: 3 total for 7-11 months, 2 total for 12-23 months, 1-2 for >23 months [12]
    14. Very safe in postmarketing studies similar to other vaccines [26]
    15. Use in children strongly associated with reduction in invasive pneumococcal disease in adults >50 years old [91]

K. Haemophilus influenza Type B (HIB) [3]

  1. All newborns
  2. For all immunosuppressed young patients
  3. Questionable whether immunosuppressed adults derive benefit
  4. Nearly 75% reduction in invasive H. influenza B infection in Alaska after vaccine use [53]
  5. HIB-DTaP conjugate vaccines are now available and very effective [48]
  6. HIB disease in Kenya reduced by ~8X observed only 3 years after institution of vaccine [92]

L. Meningococcus [28,54,76]

  1. Most common strain in USA and Europe is now Group B (was group C previously)
  2. Preferred Multiserotype Vaccine (Menomune®)
    1. Covers serotypes A, C, Y, and W-135
    2. Mainly used in military personell and in outbreaks
    3. College freshman living in dorms have high rates and may be immunized
    4. Age 15 or higher is now generally recommended (single dose)
  3. Indications for Vaccination
    1. Mainly used in military personell and in outbreaks in USA
    2. College freshman living in dorms have high rates now recommended
    3. Travel to endemic areas, particularly in Third World (Sub-Saharan Africa, Saudia Arabia)
    4. High risk, especially splenectomized and complement deficient patients
  4. Vaccine is 75-85% effective in preventing spread of Group C infections for age >9 [58]
    1. In age 2-9, vaccine effectiveness was ~40%
    2. In age <2 years, vaccine was not effective
    3. Standard vaccination schedule may lead to waining immunity after 1 year [84]
  5. Vaccine is used in controlling spread, and is generally not given routinely

M. Tetanus Vaccine

  1. 48-64 cases of tetanus per year in USA, mainly in young adults
  2. Vaccine is a purified toxoid usually given with Diphtheria ±Pertussis
    1. Efficacy is generally excellent, but wanes with time
    2. Boosters are now recommended every ten years (q5 years for HIV patients)
  3. Combined Tetanus/Diphtheria/Pertussis (5 component) Vaccine (Tdap) [88]
    1. Increasing reports of pertussis in adults have driven this combination vaccine
    2. 94% of volunteers vaccinees with Tdap have protective antibody concentrations
    3. Similar incidence of local and systemic reactions with Td versus Tdap vaccines
  4. Only ~25% of >70year old patients are adequately vaccinated

N. Varicella Zoster (VZV) Vaccine [2,30,44]

  1. Live vaccines are FDA approved for prevention of primary infection and reactivation
  2. Primary Vaccination (Varivax®)
    1. Live vaccine recommended for immunocompetent persons >12 months of age without any history of varicella infection
    2. In intensely exposed children, reduced risk of chicken pox >80% [31]
    3. Effiacy 87-97% for preventing moderate and severe infection [64]
    4. Vaccine efficacy wanes after ~1 year, but breakthrough cases remain mild [8]
    5. Strongly recommend that vaccination rates be increased
    6. Reduced mortality by >50% in USA since implementation [17]
    7. Likely that vaccine reduces incidence of shingles, but this is not proved
    8. Presence of asthma or other hyperreactive airways diseases may reduce efficacy [31]
    9. Adult dosage is two doses of 0.5mL sc vaccine, second dose is 1-2 months after first
    10. Very few serious adverse events reported, most with unclear relationship to vaccine [55]
  3. Secondary Vaccination (Zostavax®) [5,6]
    1. Live attenuated vaccine with ~14 times as much VZV as Varivax®
    2. Approved for prevention of herpes zoster (shingles) in persons at least 60 years old
    3. In persons >60 years old, reduced shingles by 50% and post-herpetic neuralgia ~67% [6]
    4. Single dose recommended in all persons >60 years regardless of previous disease [96]
    5. Adverse effects very mild, mainly injection site reactions
    6. Dose: single sc injection 0.65mL
  4. Heat-inactivated vaccine in development particularly for immunocompromised persons [77]

O. Herpes Simplex Type 2 (HSV2) Vaccine [32]

  1. Neutralizing antibodies to HSV type 2 glycoproteins B and D are protective
  2. New vaccines based on gB2 and gD2 protines with new adjuvant MF59 under study
  3. This subunit vaccine induces both antibody and cellular immunity to HSV-2
  4. Stage II clinical trials underway

P. Typhoid Fever Vaccine [9]

  1. ~500 cases annually in USA due to Salmonella typhi; millions in developing countries
  2. New capsular polysaccharide vaccine bound to nontoxigenic pseudomonas exotoxin A
  3. This vaccine has enhanced immunogenecity
  4. Requires two injections 6 weeks apart
  5. Vaccine efficacy 91% in 2-5 year old children
  6. Vaccine is recommended for pregnant and immunocompromised persons
  7. Vaccine is given to persons traveling to endemic areas

Q. Rotavirus Vaccine [43]

  1. Rotavirus is major cause of severe diarrhea, mainly in children
  2. About 100 deaths per year in USA, and >800,000 deaths / year worldwide
  3. Four major serotypes cause disease in humans and can cause disease in rhesus monkeys
  4. Quadravalent vaccine (RotaShield®) withdrawn from market [29,33]
    1. Live virus attenuated in rhesus monkeys
    2. Demonstrated efficacy in USA and Venezuala [34]
    3. Vaccine withdrawn from market due to increased risk of intussusception [33]
  5. Human Rotavirus Vaccine [40,43,98]
    1. Attenuated live human rotavirus vaccine RIX4414 G1P(8), Rotarix®
    2. Derived from an attenuated G1 (P8) human isolate called 89-12
    3. Two oral doses of vaccine given
    4. Vaccine reduced incidence of rotavirus ~90%, hospitalizations 85%
    5. Severe diarrhea reduced 90-100%
    6. Mild fever in 20% of vaccinated subjects after first dose only
    7. No increased risk of intussusception compared with placebo
  6. Pentavalent Human-Bovine WC3 Reassortment Vaccine [45]
    1. 3 oral doses
    2. Hospitalizations reduced 95% after 3rd dose
    3. Reduced severe diarrhea 98%
    4. No increased risk of intussusception compared with placebo

R. Staphylococcus Vaccine [73]

  1. Major cause of nosocomial pneumonia and skin infections
  2. Major problem in patients on dialysis
  3. Capsular polysaccharide (types 5 and 8) vaccine in development
  4. This vaccine showed 57% reduction in Staphylococcal bacteremia over 40 weeks

S. Anthrax Vaccine [36,47]

  1. Indicated for vaccination of military (and more recently civilians) in US
  2. Provides protection against anthrax
  3. Current vaccine is a sterile filtrate of cultures from an avirulent strain
  4. Given as 0.5mL subcuteneous injections at 0, 2, 4 weeks, and at 6, 12, 18 months
  5. Appears to be effective in preventing anthrax, which is usually transmitted by animals
  6. Reduces incidence of cutaneous and inhalational anthrax
  7. No effect on pregnancy, birth rates or adverse birth outcomes [75]

T. Human Papillomavirus Virus (HPV) [72,80,93,97]

  1. Recombinant Quadrivalent Vaccine (Gardasil®)
  2. Approved and recommended for females 9-26 years old to prevent HPV associated disease
  3. Includes types 6, 11, 16 and 18
  4. Prevents genital wars, precancerous cervical, vaginal, vulvar lesions, cervical cancer
  5. 98% reduction in serious pre-cancerous (CIN2/3, CIS) cervical lesions after 3 doses [72]
  6. Essentially 100% effective in preventing any anogenital lesions after 3 doses in women [80]
  7. Composoite of 4 trials in ~10,000 patients showed 99% efficacy in women negative for HPV 16 or 18 at the beginning of the trial [97]
  8. Administered as 3 separate 0.5mL intramuscular injections at 0, 2, 6 months
  9. Need for booster is not yet known
  10. Bivalent vaccine also effective for prevention, but no therapeutic benefit in infection [86]

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