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Thursday, September 23, 2010

4.2 Immunizations

Physician's Notebooks 4 - http://physiciansnotebook.blogspot.com - See Homepage

2. Immunization Update 13 Dec. 2017)
To scan what is in this chapter and search & find topics, use the descending column)
History
Anti immunization mentality & vaccine risks
Administration of Vaccines - Sites of injection
Specific Vaccine Info:
Alphabetic single word: cholera, hepatitis immunizations, Diphtheria/Tetanus/Pertussis (Whooping Cough) & Hemophilus (DTP & DTP-HbCV), Measles/Mumps/Rubella (German Measles) MMR, influenza immunization, poliomyelitis, typhoid, meningococcal meningitis, Pneumovax, yellow fever, Insect-borne encephalitis, Lyme disease, chickenpox/shingles-zoster
Less Frequently Used Vaccines:
 common cold, tularemia, botulinus, BCG vaccine snakebite, black widow, smallpox
Bioterrorism: Anthrax, Plague, Smallpox, Botulinum Poisoning
Deciding on Immunization for Children or Adults
End Note: human papilloma virus vaccine contra cevix cancer
Allergies to Vaccines
Live Vaccine Contras

History: Immunization originated in an observation that survivors of a serious infectious disease rarely caught it again. The infection gave immunity to the disease. One was smallpox: a physician, Jenner, noted farm girls who milked cows and caught a related, milder infection – cowpox – did not get smallpox. In 1796 he started rubbing a scraping from cowpox blister into the arm-skin of volunteers who’d never had smallpox. When next the epidemic hit, none of the volunteers caught smallpox. Thus the first immunization! Later, cowpox was replaced by vaccinia, a virus that also provides safe cross-protection from smallpox. Immunization came to be called vaccination and the material used to induce it, a vaccine.
   The discovery that germs cause infection, made vaccines scientific. Investigators identified the germ, grew its microbe in culture, killed it by heat or chemical treatment, and injected a dose of the killed germ into a person who had never had the disease. Then, after weeks the injected person became immune. This is active immunization with killed-germ vaccine (e.g., the inactivated polio vaccine).
   In the 1800s, doctors did not know how vaccines worked but it seemed that the vaccine provoked a response whose material got in the blood. Studying blood serum (cell-free fluid part of clotted blood) from immunized patients, doctors found a protective factor they called antibody. Each infectious disease germ provoked an antibody that neutralized that disease germ and no other. Since antibody could not at first be purified, doctors started using blood serum from patient who had recently recovered from a serious infection to cure those who had newly caught the infection. (In 2015 this technique was used again, this time in victims of the Ebola virus) Using antibody produced in one individual to cure same infection in another is passive immunization. Today most immunization is the active type, but passive immunization is done, eg, against hepatitis-A. Passive immunization is not long-lasting but useful during a short period of high risk such as travel to infectious area.
While we are on passive immunization, we meet “globulin”, a blood serum fraction that contains the antibody. Passive immunization works because of the blood's globulin fraction. As more became known about the immune response, the globulin fraction was isolated from the blood serum of patients who had had a specific infection for use against new infections of the same germ. Pooled globulin from many immune patients is immune globulin. Its “gamma” fraction contains antibody to hepatitis A; hence, gamma globulin injection to prevent hepatitis A in travelers.
   Diphtheria and tetanus immunization give insight into vaccine protection. Both are infections that cause disease from powerful nerve toxins that are easily purified, and heating eliminates toxicity and the resulting detoxified substance is toxoid. When tetanus toxoid is injected, no illness is produced. Three weeks later, serum from such a person will neutralize tetanus toxin. What has happened is that the toxoid evokes antibody neutralizing the toxin. (The antibody is an antitoxin, which also can be harvested from lab animal and used for passive immunization)
   It teaches that immunization can work without preventing infection by neutralizing the toxin of an infectious germ. For example, if immunized with tetanus toxoid, you can still get infected with the tetanus germ but you won’t develop lockjaw that normally goes with the infection and is its killer symptom. Your own tetanus antitoxin stimulated by tetanus toxoid injection will protect you from the toxin but not from getting infected
   More recent development is cultured live vaccine. (Jenner’s cowpox was live vaccine naturally produced) The germ is cultivated to lose ability to cause disease. Vaccination with it causes only brief mild illness or none at all. Live vaccine has an advantage of more powerful and longer lasting immunity and also may be administered by mouth. Most live vaccines have had good safety records, but the worry has been that a germ in the live vaccine may revert to killer state. This has happened with oral polio vaccine so that it stopped being advised in the USA.
   Another development is acellular vaccine. Older vaccine, killed or live, contained the full cell body of the germ and has caused allergic reaction directed toward cellular part of germ. Acellular vaccine has only the chemical part. So we have polysaccharide vaccine, which has a complex sugar that is specific to the infective germ, and DNA vaccine which is mostly the DNA of the germ. These have lower side effect, but may be less effective. Another advantage of acellular vaccine is against infection by a germ like HIV where there is tremendous fear the germ body in the killed vaccine may retain or revert to infectiousness.
   A vaccine may vary over time among batches of the same vaccine. Expiration date is usually 1 year. A vaccine should be kept and stored according to instruction. Usually that means refrigerate but not freeze. Before you get immunized, remind whoever is giving it to check expiration date and have it be shown (printed on vial).
   Loss of effectiveness is important. Immunization with Pneumovax against pneumococcal pneumonia is highly effective for first year but loses effectiveness in 5 years and should be repeated by booster dose.

Vaccine risk you tolerate is a balance that will vary with a vaccine's safety record, with the individual risk from getting the vaccine versus dying from the infection, and with the state of your immune system. Oral Polio Vaccine was advised for children but, rarely, it may kill an adult who has weak immunity. The pertussis vaccine against whooping cough is advisable where pertussis is common or medical treatment not accessible or poor, but it is controversial where whooping cough is rare or antibiotic treatment easy. Rabies vaccine has neurological side effect unacceptable for other vaccines but it is lifesaving if given promptly after potentially fatal bite of rabid animal.
   Relating to danger of vaccine is its ‘track record’. Examples of vaccines supposedly safe after lab and field test but causing unexpected problem were the first live measles vaccine of the 1960s and the swine flu vaccine of 1976. So avoid recently released vaccine until its safety has been established by use unless the infection it protects against has immediate high risk for you.
   Do not be careless about where you get immunized. It is best in certified clinic, HMO, hospital or government center, from doctor or nurse you can be sure is observing Standard Operating Procedure and getting no financial benefit from vaccinations. You want assurance the vaccine you get is still potent (vaccine within expiration date, received properly transported and refrigerated) and given for proper reason, in correct dose, under sterile precaution in way that will not lower effectiveness. (Proper site of injection)
   
Administration of Vaccines - Sites of Injection: A number of vaccines are now given by mouth - all are live vaccines like the no-longer-advised oral polio. The injected vaccines are killed bacterial or killed viral cells or acellular chemical parts of the cells or, with tetanus and diphtheria, the toxoids.
   Depending on the vaccine, the site may be intra-muscular (IM, in deltoid muscle in upper arm or gluteus muscle deep in buttock), subcutaneous (SC, in outer fat layer) or intra-dermal (ID, in skin either scraped in or using a fine needle). Vaccines given to adults SC are injected by short, thin needle. The IM injection  is given, 90-degrees to skin surface through a needle whose length is determined by the recipient's gender and weight. 
   More than one vaccine may be given at the same time at separate sites.
   Warning: Injections into the arm, especially IM, occasionally disable a major cutaneous nerve, resulting in months to years of neuralgic arm pain. (It happened to me with a vitamin injection) Best to get all injections in the upper, outer quadrant of your buttock.
   The basic sterile precautions (the injector washes hands or uses sterile gloves, the equipment is sterile one-time use and disposable, and the skin rubbed with alcohol swab) should be carried out just before and during the injection and a band-aid placed over the injection site after.
   The most frequent immediate side effect of an injection is fainting, within 5 minutes. So be seated and remain in the injection area for 10 minutes afterward. The very rare severe allergic reaction (collapse, airway obstruction and facial swelling) makes a requirement to have CPR qualified persons, an AED and an injection of epinephrine immediately available and usable at once on the spot; also a tracheotomy kit available and immediately usable. Therefore, immunizations are best given in hospital or well equipped clinic.
SPECIFIC VACCINE INFO
Cholera is an infection which kills by diarrhea that depletes the body of fluid and electrolyte and results in cardiovascular shock. Antibiotic alone is not effective. Best treatment is oral electrolyte fluid replacement or in severe case intravenous replacement. At risk is anywhere with unclean water supply. If wartime chaos developed, cholera could rapidly become epidemic anywhere. (It did in 2010, November, after the earthquake in Haiti)
  The oral vaccine Dukoral is live strain of inactivated vibrio cholera. It is given to adults and children over the age 6 to drink as two doses of a bubbly soda-like solution a week apart and a booster after two years. The older killed injected vaccine is no longer recommended. And do not forget clean water and food precautions.
Hepatitis Immunizations
Hepatitis is inflammation of liver with dull pain beneath right lower rib, fever and jaundice that starts with darkening urine, and lightening color of stool, then, yellowing of whites of eye followed in a day by skin yellowing that deepens over next weeks before getting better. Blood test shows high bilirubin and high transaminase (ALT/AST). Hepatitis comes from virus or toxin.
   Virus hepatitis due to A-type or B-type virus is hepatitis A or B and each has good vaccine. 
   Suspect a viral hepatitis if you develop yellowing not due to cancer, alcohol, gallstone or obvious chemical poisoning. Get Hep A and Hep B antigen/antibody blood test to differentiate. (Other types of viral hepatitis are Hep C, Hep D, and Hep E; none are prevented by immunization; the diagnosis must be made by antigen/antibody blood tests)
   Passive immunization should come to mind when friend has infectious hepatitis. The virus is transmitted because one does not wash hands or food, or because one eats food from an animal infected with virus or licks asshole as sex play on partner who is shedding virus in stool by putting feces with virus in mouth . You can also get Hep A or B from injection or from body fluid of someone that carries hepatitis virus (blood transfusion, or from sex in which skin barrier is breached especially with rectal sex). Usual situation: you are told your friend has hepatitis. Then you must find out if it is A, if it is B or if other because A or B type each has separate passive and active vaccines. In Hep A or B, each passive vaccine is a pooled immune globulin (IG for Hep A or separate IG for Hep B). The IG (immune globulin) has the fraction from persons who are highly immune to hepatitis A or B. Immune globulin for Hep A or Hep B gives immediate temporary prevention of getting one for its specific hepatitis. The immunity lasts a month. Since Hep A is the risk on overseas trips (from contaminated food mostly) some trippers opt to get immune globulin against Hep A if not previously immunized at onset of trip. For list of places with high risk for hepatitis go to http://wwwn.cdc.gov/travel/content-diseases.aspxIG against Hep B may be given after contact with Hep B. Hep B is mostly person-to-person infection and can exist in a carrier who does not look or feel ill but is infectious. The carrier state can be determined by blood test. 
   Immune globulin is a blood product. Can it transmit HIV, hepatitis virus, or other STD?  No. (But the needle used to give it might be contaminated by HIV due to unclean injection technique)
   Active immunization is done using, usually, the combined Hep A and Hep B vaccine (Twinrix) as 3 doses at 0, 1 and 6 months; or 4 doses on days 0, 7, and 21-30, followed by a booster at 12 months. Single injection is given in upper outer arm. One series is good for life but effectiveness is not complete until 1 week after last injection. Immunity is complete and lifetime from 1 week after last injection. No age limit. The vaccine has no important side effect. For best effect of active vaccine, administer 2 weeks prior to or 3 months after the immune globulin. (Sometime they are given together for practical reason) Safe in pregnancy.
   One should get blood test to check immunity to either virus before getting immunization. Antibody to Hep A or Hep B virus is evidence of immunity and predicts no benefit from one or the other virus protected by the vaccine. In a case of immunity to A or B but not the other, a single A or single B vaccine is available.
   Advisories are more and more favoring children being immunized against Hep A and Hep B early as possible. (Because the immunization will lower the risk of liver cancer)

(DTP) Diphtheria/Tetanus/Pertussis & Hemophilus
Diphtheria once was a winter epidemic infection of throat, nostril and skin but no longer because of immunization. It is caused by bacteria that produce toxin that kills by paralyzing the heart. You catch diphtheria by someone sneezing or coughing on you; in 2 days it is bad sore throat with swollen bull neck appearance; toxin is produced and gets into blood and in worst case your heart stops. Vaccine is a toxoid that stimulates immune system to produce antitoxin. It protects from toxin but still one can get diphtheria infection, which then is like a bad cold.

Pertussis (whooping cough) infection of infant and toddler is caught from coughing bacteria into air, and susceptible infant breathing it in. It causes severe bronchopneumonia and was once epidemic but is now sporadic, thanks to immunization and antibiotic. But due to worry about risk of immunization and anti immunization propaganda, whooping cough is coming back. The older vaccine is composed of killed bacteria. One serious side effect has been the rare occurrence of encephalitis leaving infants dead or retarded. It seems to be allergic reaction to something in the bacterial body. The newer acellular pertussis vaccine has shown lower incidence of encephalitis.

Tetanus is a toxin-producing illness from bacteria in a deep wound, and its toxin kills by muscle spasm “lockjaw”. Its vaccine is toxoid that stimulates antitoxin production. Immediate treatment of wound is first wash with soap and water and rinse out but do not waste time delaying getting to emergency; then, in ER while cleaning surgically, a standard dose of antitoxin should be infiltrated around the wound and another dose injected; and tetanus toxoid is also given to induce active immunization. Two antitoxins exist: older type from horse, which has high incidence of allergic reaction, and more recent type from human, which is safer. In the U.S., the human antitoxin known as tetanus immune globulin, human should be used. But in foreign country horse serum may still be the sole available antitoxin. Tetanus immunization is normally started in child using either combined DTP or DTP-HbCV vaccine and is renewed in adult by tetanus diphtheria (Td) booster every 10 years and whenever potentially tetanus-infected wound occurs.

Hemophilus influenzae causes pneumonia and meningitis mostly in infant. It can be deadly or result in brain damage.  Vaccine is a killed bacterial aggregate.

In 1993, a vaccine for Hemophilus influenzae, type b, Conjugate Vaccine (HbCV) was approved and combined with DTP to make the 4-vaccine immunization labeled DTP-HbCV. In adults, the pertussis and HbCV are removed and vaccine against tetanus and diphtheria (Td) is given. (Recently Tdap includes acellular pertussis)
Measles/Mumps/Rubella (MMR Vaccine)
 MMR immunization fell in mid 1990's, because of parent concern about safety, with resulting increases in mumps and measles. Note that in 2010, the Lancet disavowed as bogus the article used by parents as evidence against getting MMR immunization because, the parents claimed, it caused autism.
Measles, beyond being bothersome may infrequently cause encephalitis-death or retardation. It is also believed to be a factor in developing multiple sclerosis.
Mumps gives lump on side of face with fever. It may cause encephalitis, or, in adult, inflammation of testes, ovary, and pancreas; the first two causing sterility and the last, diabetes.
Rubella causes malformed baby or abortion in early months of pregnancy. Also encephalitis. Every woman should be immunized against it before childbearing age.
   Rubella vaccine live virus has not been implicated in fetus malformation but it is best not to get pregnant in the several months after MMR. A routine 2-dose schedule is recommended, the first dose at age 12-15 months (93-98% effective) and second at entry to primary school.
   The MMR injection gives 5% to 15% children fever >39.4C (103F), 5-12 days later, lasting 1-2 days and with transient rash in 5%. In child, side effects are attributed to the measles part of vaccine. In adult, the mumps part of vaccine causes arthralgia in one or more small joints in 40%, going to frank arthritis in 10-20% starting 1-3 weeks after the shot and persisting 1 day to 3 weeks. Mumps vaccine in adult has caused fever and rarely parotitis (mini-mumps of face).

Influenza Immunization
People cough or sneeze flu virus into air or touch others; then one who lacks immunity to the current flu virus breathes it in or puts hand to mouth and gets flu. It gives cold symptoms, muscle ache, cough and fever. It can hospitalize or kill the over-65, and those with chronic lung or heart disease or with weak immune system. Flu virus comes in types and its immune-stimulating property changes yearly so every year a new vaccine must be produced based on latest varieties of virus noted the year before. Flu season in U.S. begins in November, peaks in early February, and by April has dropped to a low. Every year in October, the new vaccine is released.
   Injected Flu vaccine is made of inactivated virus types grown in egg. First-time immunization is usually injected into upper outer arm, two shots given 1 month apart. In those who have had flu vaccine, a single booster shot is OK. Immunity is 70-90% in healthy young adult and less in the elderly, but even if one gets flu after immunization it will be milder. Side effect is sore arm. The Guillain-Barré syndrome (polio-like paralysis) has occurred in 1 case per million flu immunizations. In 2005 I got my flu shot in right arm and a day or so later I noted mild painful right side of neck lymph node that lasted a week. (In 2007 I got a shot in same arm and noted nothing at all)
   The flu shot is approved for child from age > 6 months.
   In 2003, intranasal, trivalent, cold-adapted, attenuated live influenza vaccine (LAIV) was newly approved for use in healthy person ages 5 to 49. Before age 9, two doses given 6-10 weeks apart; age 9 or after, 1 dose.
   No pregnant woman should get live vaccine but inactivated vaccine is OK after first 3 months pregnancy.
   For most, a bout of flu is at worst a bloody bore that keeps you out of work a few days. But if you are aged or have chronic illness or poorly functioning vital organ or more than 3 months pregnant, flu could kill or cause abortion, so it’s wise to get the shot in season. Even if you are healthy and young but happen to live with someone in whom flu might complicate or end life, getting an immunization is wise. I am getting my next flu shot tomorrow.
Poliomyelitis Immunization
One gets polio by putting something in mouth contaminated with polio virus usually from feces. Once polio virus gets in your mouth it makes intestinal or throat infection, and the virus gets absorbed into blood and goes to brain and spinal cord and causes rapidly ascending paralysis that may end in death from failure of breathing. Before immunization, polio epidemics swept the country. The last documented case of natural polio in the U.S. was in 1979.
   Polio has rarely popped up in U.S. since then but all from exposure to oral polio vaccine (OPV), which contains attenuated live polio virus in sweetened fluid that is swallowed. Therefore, in year 2000 – after 40 years favoring the OPV – the old IPV inactivated polio vaccine schedule was recommended and has replaced OPV immunization in the U.S. http://www.cdc.gov.
   Booster polio immunization is now being advised if adult received polio immunization series as child and now makes foreign trip. (Recently the West Nile Virus has arrived in the U.S. by mosquito bites. It may give a polio like illness but no vaccine is good against it; just anti mosquito bite precautions)
Typhoid Fever
is a bacterial food & drink infection that gives high fever with diarrhea which may become bloody with rose-spot skin rash; mostly in undeveloped country from unclean food preparation and feces contaminated water supply. Today, 2 new safe, low side-effect vaccines are available: For adult and child from 6 y/o, a live attenuated bacteria vaccine (Vivotif-Berna-Ty21a) as swallowed capsule every other day for total 4 caps and then as booster not less than 5 years after and at interval if risk exists. Live vaccine must not be taken if pregnant, or not by anyone who has a damaged or defective immune system, or who must take antibiotic. I took it and no problems.
   The second vaccine,Vi polysaccharide has no bacteria cell body, just a chemical derived from typhoid bacteria that stimulates immunity with minimum side effect. The vaccine is injected either under the skin or into a muscle at least 7 days before traveling to the typhoid-affected area (the CDC recommends 14 days). The vaccine is not effective in children under the age of two years old. Effectiveness for both vaccines in adults is 50 to 77%. (An older killed vaccine that caused high fevers & occasional convulsion should no longer be used)
   Indication for typhoid immunization today is foreign travel to area of risk.
Meningococcal Meningitis
Meningitis is an infection of surface of brain and surface of spinal cord spread there usually from upper respiratory (sore throat, running nose, earache). Victim is mostly institutionalized child but also adult tourist to undeveloped area. Symptom: terrible headache with stiff neck and high fever. The meningococcal type is prevented by immunization. For adults 55 years and younger, the advice is meningococcal conjugate vaccine, quadrivalent (MCV4) and booster every 5 years; for age 56 and older, meningococcal polysaccharide vaccine (MPSV4) is preferred. The MPSV4 does not contain bacterial body. The vaccines are given SC shot in arm.
The vaccines are advised against local outbreak in orphanage or for tourist traveling to Tibet, Nepal and Sikkim; also sub-Saharan Africa “meningitis belt” from Mauritania to Ethiopia.
   The meningococcal vaccines are not stocked in Doctor office; and even in large clinic it may take several days to get. If you have an infant, a good idea is preliminary inquiry of local HMO (Major clinic) whether they have the vaccine, and, if not, where it can be obtained at short notice. Need for it has suddenly arisen with report of outbreak in local community and then long line forms and infant may not get immunization on time.
   Another bacteria that causes meningitis is Hemophilus influenzae for which separate immunization was mentioned above under DPT and hemophilus combined immunization for infants and children.
   Viral or chemical meningitis is not protected by immunization.
Pneumococcal Pneumonia Vaccine (Pneumovax)
 Pneumococcus gets name from being bacteria identified with pneumonia. It is the most frequent cause of death in oldster. The pneumococcus comes in 23 capsular polysaccharides and from that comes the acellular vaccine, pneumovax, which is advised for age 65 or over, and even earlier if high risk or if one has no spleen. Single SC injection in arm given once every 5 years is 60% effective. A must for my healthy longevity program! Old Bones? Want to make them? Get pneumovax!
   In year 2000, a polysaccharide acellular vaccine made from 7 types of pneumococcus common in childhood infections was approved for children at risk <9 years old. Don’t use in adults.
   I got my most recent pneumovax 30 March 2011, also with separate injection Tet/diphth in same part of lower right arm. It caused a few days arm soreness and right underarm lymph node tenderness and appetite change.
Yellow Fever Immunization
YF is a hemorrhagic fever virus. It is of concern to traveler in Africa, Latin America and planning trip to India. (May require immunization for entry & exit if you came from YF endemic area)  Transmitted by bite of a type of mosquito; its symptoms are fever: jaundice and bleeding into urine. No antiviral treatment exists, and death rate high. Live virus vaccine combines attenuated virus from Africa and Latin America, can be given from age 9 months with single SC injection in arm, and induces protective antibody for at least 10 yrs in more than 90%. Adequate documentation of receiving this vaccine on shot record with appropriate government stamp indicating everything done SOP is important because the countries you are visiting may require the vaccine be given only in government clinic. Failure to follow rule may cause you to be stuck in quarantine in some awful airport. Important pearl point is that official WHO stamp that makes this immunization valid cannot be applied until 10 days after you get injected.
   Head and muscle ache and fever may occur and go for up to 10 days after the vaccine. Also, being a live virus, the YF vaccine should not be given in pregnancy or with weak immunity. And separate it from cholera shot by at least 3 weeks.
   Flash, Newly Reported Complication! In last few years a serious, rare syndrome, “febrile multiple organ system failure”, has been reported, rarely, shortly after receiving this vaccine with high death rate among age 60 or older adults. All older persons are now advised to consider carefully before consenting to YF vaccination.

Insect-borne Encephalitis: Infection inside brain is encephalitis. Its symptom: fever, headache and loss of mental function. Many die and some who recover are left with damage that will show later as epileptic convulsion or Parkinson disease or early dementia or bad personality change. Most virus encephalitis is transmitted by a type of mosquito or tick bite. Japanese encephalitis and tick-borne encephalitis each have a vaccine.
   Japanese Encephalitis is due to virus in rural Japan, Korea and Russian maritime Far East transmitted by mosquito bite. Vaccine is inactivated virus. Initial immunization from age 3 yrs is three 1-ml SC shots in arm given on day 0, 7, and 30 (shortened for short stays). Before age 3 requires half adult dose. Booster is single dose after 2 yrs from initial series or from last booster, when entering area of risk. Effectiveness is about 80% starting after completion of series or booster. Side effect: fever, headache and hives occur in 10% within first week.
Comment: Not necessary for usual visitor to Japan. Today, only consider for one who will spend time in rural farm areas.
Tick-borne Encephalitis of Eastern Europe & Russian Far East
I had experience with this rarely used vaccine. A tick is tiny insect that lives in heavy grass and bush area and attaches to exposed leg and foot. The virus is transmitted and causes encephalitis. Indication for immunization is mostly for visitors in Russian Far East forest areas. Spring-summer seasonal risk. Protective vaccine might be obtained thru CDC Emergency Drug Release Program by calling in USA, area code 1-613 941-2108. To be emphasized is that protection should mostly rely on protective clothing (Long pants or stockings) and good insect repellent (DEET, or N,N-diethyl-metatoluamide)
Lyme Disease (LD)
Caused by bacteria and transmitted to human by bite of tick. Occurs around suburban Connecticut. (In the U.S. Northeast, Maine to Maryland), upper Midwest and northern California; also in Japan, U.K. and most of Europe. After the tick bites, the bacteria go into blood. Many persons never know they got infected because immune system kills the bacteria but evidence of infection can be found by antibody blood test. More and more tick-bite patients report in with with flat red spot at site of bite and over next days it spreads like circular ripple to 12 inches (30 cm) diameter. In months or years, the disease may cause joint pain, irregular heartbeat, nerve palsy, and spinal and brain inflammation.
   Treatment of LD is antibiotic: tetracyclines, amoxicillin and others. Many untreated cases turn up months or years later recognized by late complication.
Two vaccines are developed and tested. Both are acellular and make antibody against outer surface protein of the bacteria and are unique in how they work. The tick that bites an LD-immunized person draws off blood with antibody to LD bacteria and and it kills the bacteria while still in the body of the tick, preventing infection of the immunized human.  The LYMErix vaccine was licensed by US FDA 1998. LYMErix is 49% effective against symptomatic infection after two SC shots at 0 and 1 month and 76% effective after a 3rd shot at 12 months in persons 15 to 70 years old. Even higher success rates are reported for asymptomatic infection (83% and 100% respectively). The vaccine OspA is produced by Pasteur, Merrieux, Loynaught and available in Europe but not USA. It has same success rate as LYMErix. Need for booster shot is unknown. Side effects have been local in arm (c.20%) and minor, transient flu-like illness (c.1%)
   Those at risk should have blood test for the LD antibody before requesting the vaccine, to determine immune status. If the test shows you are immune, no need for vaccine. This is a preventive immunization and of no use if you already contacted infection or have symptom of it. It is for healthy person in area at risk who never got bitten by LD-infected tick.
Rabies
Most people know rabies from bite of mad dog or cat and one dies horribly. You can also get it from bites of wild animal, most commonly raccoon, skunk and fox, or eating insufficiently cooked infected flesh. And in South America, rabid bat can give it if you simply breathe deeply in cave.
  In U.S. between 1980 and 1997, only 34 rabies cases known; since 1960, never more than 5 a year. In Hawaii, Australia, England, and Scandinavia no case reported. But undeveloped countries show high incidence. Despite low incidence in developed countries 20,000 to 30,000 rabies vaccinations are dispensed a year with high incidence of serious side effect.
   Start with practical situation: A dog bites you. If you know the dog, its master can quickly furnish evidence of rabies immunization. If you don’t know but can catch it, the police can arrange for examination and observation. But rabies is almost always fatal once transmitted and speed is crucial in prevention by antitoxin so, unless immediate proof to contrary, presume that the dog or animal bite is rabid. The closer the site of bite to the head the more rush to get rabies antitoxin treatment.
   Quickly wash bite site well with warm water and soap. After rinsing off soap, cleanse with benzyl ammonium chloride (Zephiran, if available). While doing this, get to local emergency center. And if someone is with you, delegate to identify animal involved. If the pet is un-immunized against rabies, a 10-day observation without sign of illness rules out rabies. If you cannot quickly rule out rabies, get rabies immune globulin (RIG). Unless previously immunized, RIG should be administered 20 I.U. per kg of body weight, and one half total dose infiltrated at site of bite and remainder injected IM in upper arm. RIG may neutralize rabies virus or at least provide passive immunization for 10 to 20 days. At the time that the RIG is given, get starting dose of rabies active immunization. Vaccines now use inactivated virus. The human diploid cell vaccine (HDCV) has fewest side effects. It is given as three 1 ml IM shots on day 0 (day of bite), 7, and 21 or 28. Also there is the rabies vaccine adsorbed (RVA, cultured from rhesus monkey fetal kidneys) or a chick embryo vaccine with same side effects as RVA is given in same regimen at same dose as HDCV. If previously immunized against rabies, it may suffice to receive only two doses of HDCV on day 0 and 3. Because of need for speed go to large hospital and if in doubt, call police.
   Occasional need is a person at high risk of rabies bite, such as veterinarian and other professional who deals closely with animals. Active immunization should be with HDCV because lower side effect. Three injections 1 ml each intramuscular (IM) in arm on initial day, day 7, and 21 or 28 will produce antibody response but still cannot be completely relied on unless test for serum antibody shows adequate response. Get booster every 2 years if risk continues. Advantage of pre-exposure immunization is it makes high antibody level and one can avoid RIG injection, which carries highest risk.
Side effect of all rabies vaccines is neurological: RIG has highest incidence, then RVA, and HDCV, lowest. Bites from local pets that are either immunized or can be observed and are not obviously ill can be waited on. Specific high risk wild animal bites (skunk, fox, raccoon) where animal not available should be immunized at once.
Chicken Pox/Shingles-Zoster (Varicella/Herpes Zoster) Vaccines
Chickenpox aka Varicella is a childhood rash febrile illness. Its complication is the deadly Reye syndrome in liver and brain brought on by taking aspirin. Before getting the vaccine against varicella, one should be sure one does not already have immunity by the following: a definite history of CP, a previous attack of herpes zoster (shingles) or antibody blood tests. If there already is immunity, the varicella vaccine will be useless. It is preventive based on no previous varicella immunization or infection. The vaccine,Varivax in the U.S. or Varitrix internationally, is attenuated live virus given SC injection as single 0.5 ml between ages 1 to 12 for lifetime immunity. From age 13 up, two doses 4 to 8 weeks apart are required and 99% show good antibody response after immunization. Cases of CP after the shot have been mild. Side effects: 25 to 35% soreness at injection site, occasionally mild rash. Live vaccine should not be given to pregnant person.
   Shingles (Herpes zoster) is late recurrence of varicella (Chickenpox) in older person who had the pox as kid and his or her immunity weakened due to aging or other reason. The vaccine to prevent, reduce incidence or lessen the effect of shingles, Zostavax, which is hi-dose Varivax, is available as single injection and recommended for age 60 or older regardless of past history suggesting immune status to CP. Data show it is moderately effective.
   The varicella vaccine is more sensitive to room temperature than others. It consists of powder in vial and sterile solution in ampoule that must be mixed immediately before injecting. Stored at minus 15C (5F) in freezer) when not being handled, and once mixed, the injection should be given within 30 minutes of defreezing.
   Passive immunization with varicella-zoster immune globulin (VZIG) will prevent or shorten chickenpox or shingles and should be used where high risk of complications. The single IM injection must be given quickly. (Ideally before rash) Anti-varicella antibiotic, acyclovir, is available.
Less Frequently Used Vaccines
Common Cold/Adenovirus causes cold-like illness, red eye, atypical pneumonia; also cystitis with bloody urine and vomiting and diarrhea. Live virus vaccine administered as capsule by mouth has worked well with low side effect in cutting the rate of atypical pneumonia and sore throat in military recruits during high-risk period.
BCG vaccine is bacillus Calmette-Guérin, a live tuberculosis-like bacteria vaccine used much by the French to prevent tuberculosis. Given only to tuberculin-negative skin test person by scraping vaccine into skin, and the vaccination leaves a scar. Sign of successful vaccination is conversion of previously tuberculin-negative person to positive. In the U.S. the argument against BCG is that it does not have a high degree of effectiveness and tuberculosis is now treated by anti-TB drug, and once BCG is used it ends the usefulness of the tuberculin skin test by causing conversion to TB positive. Still, in the U.S., the BCG has found a use among TB negative members of families that have a member who acquires TB and it is also used in a tuberculin test negative child who is at high risk for TB.

Snakebite or Black-widow Spider Antitoxin can be lifesaving after bite of poisonous species and is available in kits dispensed by major medical center in area of risk.


Bioterrorism
Bioterrorism has left its mark with weaponized anthrax bacterial spores. Anthrax is transmitted by bacteria found in soil and infected animal. Human gets it from contact with an anthrax-infected animal or by breathing in anthrax spores as in the letter mailing cases. Anthrax as weapon is made from spores that are infectious as a fine powder that can be dispersed by cluster bombing, by release in places like subways or, as Americans discovered in 2001, by envelopes in mail. The spores contaminate the air, are breathed into lung where, once established, the anthrax kills within a few days by enlarging lymph nodes, blocking airway, and producing a toxin that puts its victim into shock. 
   The 1st episode was the accidental release of the spores in Russia. Victims were exposed in an area within 4 km downwind of the facility. Of 77 cases 66 were fatal and the interval between first exposure and last case was 43 days although most cases were in the first 2 weeks. Death typically was within 1 to 4 days following onset of symptoms. Penicillin probably limited the total number of cases.
   A 2nd case was in the early 1990s in Tokyo when a religious cult released anthrax spores from a building with no effect. Subsequently they used sarin gas in a subway with great effect.
   A 3rd case was in October 2001 in USA when a former employee of the U.S. Army Research Institute for Infectious Diseases sent anthrax spores in the U.S. mail causing 22 anthrax infections - 11 inhalations of whom 5 died; 11 were on skin and all survived. Those who opened contaminated letters as well as postal workers who handled the mail caught the anthrax.
   The best protection in such attacks are particular antibiotics, best of all of the ciprofloxacin type.
   At present Anthrax vaccine absorbed (AVA) is licensed and available in USA. For best immunization, 0.5 ml should be injected SC at week 0, 2 and 4, and then at 6, 12 and 18 months followed by yearly boosters.
   Another potential bioterrorism germ is Yersinia pestis which causes plague (from the Black Plague). It has not yet been used and its weapon form is a mist bomb. Its use is unlikely and best defenses are various antibiotics. No vaccine is available. 
   Another one is Francisella tularensis, which causes Tularemia, rabbit fever from handling or eating infected, poorly cooked rabbit, by breathing its dried feces, or by being bitten by a tick that transmits it. It mostly infects hunter and rural farm worker. As weapon it is like Plague. Protection is an attenuated live vaccine by dermal puncture. May be obtained from Commander, US Army Medical Research Institute of Infectious Disease: Frederick MD 21701

Botulinus toxin has the possibility of being put in water or food by crazy person or terrorist. It is dealt with in the Notebooks 2 chapter on food poisoning. Trivalent (3-type) antitoxin against toxin A, B and E produced by immunizing a horse and extracting antitoxin from its blood serum may be lifesaving if administered quickly. Needs rapid diagnosis.


Finally, smallpox or Variola virus has been touted as a bioterrorism virus. It was declared eradicated from the Earth in 1980 and its vaccination program ended but the virus as of year 2000 was known to exist at CDC in Atlanta Ga USA, and in a Russian State Research Center. The former Soviet Union produced biological weapons that could include the virus, and with the ensuing chaos after its breakup, it is feared that anti-American terrorists may have gotten a supply of weapons-grade variola virus. So smallpox vaccination is being revived. Smallpox vaccine (live virus) is scraped into skin of arm using special 2-prong scraping needle. If alcohol is used for cleaning, the skin site should be allowed to dry before vaccination to avoid inactivating the vaccine. Needle should be held perpendicular to skin; 3 punctures for primary (first) vaccination (or for revaccination, 15 punctures) are made rapidly and with enough vigor so a trace of blood appears at site in 15 sec. With primary take the site should become red and itchy by 3 to 4 days; then a pox-like pimple (small blister with central nipple-like elevation) forms, becomes pussy by 7 to 11 days and it scabs by 3rd week. Fever is common side effect but most feared is eczema vaccinatum, generalized eczema that can kill in those with history of eczema, atopic dermatitis or immune disease. Risk of death has been estimated as 1 per million primary vaccinations. Blindness can occur when the skin lesion involves cornea of eye. Protection is 100% after successful primary take. The protection declines in 10 years and needs redoing in 10 years. In 2003, the US started again to advise vaccination for smallpox. To find out more access the website, www.cdc.gov/smallpox.

Deciding on Immunizations for Children or Adults
  End Note: A vaccine against uterine-cervix cancer-causing Human Papilloma virus (HPV) is offered in the U.S. Either quadrivalent (HPV4) or bivalent (HPV2) is recommended for girls at age 11 - 12 and catch up vaccination for girls age 13 - 26 who missed the early one. The complete series is 3 doses; the 2nd dose, 1 to 2 mos after the 1st; and the 3rd dose, 6 mos after the 1st. For best results against the cancer, the vaccine should be administered before a girl becomes sexually active and it is not useful once one has developed a case of sexual herpes.

Allergies to vaccines  are mostly egg or rubber allergies . Tell your doctor or nurse who gives the vaccine about any allergies beforehand.
Live Vaccine Contras:
Pregnant women should not receive live vaccines. Persons with weakened immunity like those with AIDS, leukemia, taking steroids should not receive live vaccines.
    END OF CHAPTER - CHECK ON INTERNET FOR NEW VACCINES.  HIV/AIDS immunization is dealt with in the Notebooks 8  HIV/AIDS chapter.
   To read on next, now, click 4.3 Medications - Everything to Know





























































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