The FDA has licensed Penbraya (Pfizer), a pentavalent polysaccharide conjugate meningococcal vaccine, for prevention of invasive meningococcal disease caused by Neisseria meningitidis serogroups A, B, C, W, or Y (MenABCWY) in persons 10-25 years old. Penbraya is the only meningococcal vaccine that contains all five of these serogroups. Two quadrivalent polysaccharide conjugate meningococcal vaccines containing serogroups A, C, W, and Y (MenACWY; Menveo, MenQuadfi) and two meningococcal serogroup B vaccines (MenB; Bexsero, Trumenba) are available in the US (see Table 2).

The 2006 Medical Letter article on the then-new varicella-zoster vaccine concluded that Zostavax appears to be safe and effective in protecting patients ≥60 years old against herpes zoster and postherpetic neuralgia, especially in reducing the severity and duration of the disease.1 Some new information has recently become available.

CLINICAL STUDIES — A Veterans Administration randomized, double-blind trial enrolled more than 38,000 patients ≥60 years old and followed them for a mean of 3.4 years after administration of Zostavax or placebo. Since the efficacy of the vaccine had been demonstrated previously (51% in preventing zoster and 67% in preventing postherpetic neuralgia), the objective of this study was to examine its safety. Transient varicella-like rash occurred at the inoculation site in 0.11% of vaccine recipients and in 0.04% of patients who received a placebo injection. Erythema, swelling, pain and tenderness at the injection site were more frequent and more severe with the vaccine than with placebo. There were no other significant differences. Serious adverse events occurred in 1.4% of patients in each group.2

USE — Despite its efficacy and the frequency and morbidity of herpes zoster, this vaccine is hardly used. One study in 2007 found that only 2% of patients ≥60 years old had received it.3 A 2008 survey found that 7% of potential recipients had been vaccinated.4 A study of the reasons for such sparse usage concluded that the expense ($194 wholesale), the need for a freezer to store the vaccine (a vaccine that can be kept in a refrigerator is available in Europe), and reimbursement through Medicare Part D, which generally provides pharmacy benefits, rather than Part B, which physicians are more familiar with, were contributing factors.5

CONCLUSION — The efficacy of the herpes zoster vaccine (Zostavax) was well established before the FDA approved it in 2006. Several years’ use has now provided more data supporting the safety of the vaccine. It deserves wider use.

1. Herpes zoster vaccine (Zostavax). Med Lett Drugs Ther 2006; 48:73.
2. MS Simberkoff et al. Safety of herpes zoster vaccine in the shingles prevention study. Ann Intern Med 2010; 152:545.
3. PJ Lu et al. Herpes zoster vaccination among adults aged 60 years or older in the United States, 2007: uptake of the first new vaccine to target seniors. Vaccine 2009; 27:882.
4. JS Schiller and GL Euler. Vaccination coverage estimates from the National Health Interview Survey: United States, 2008. Atlanta: Centers for Disease Control and Prevention 2009. Accessed at www.cdc.gov/nchs/data/hestat/vaccine_coverage/vaccine_coverage.pdf on 12 May 2010.
5. LP Hurley et al. Barriers to the use of herpes zoster vaccine. Ann Intern Med 2010; 152:555.

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The FDA has approved a recombinant human papillomavirus (HPV) vaccine (Cervarix – GlaxoSmithKline) for use in girls and women 10-25 years old to prevent infection with HPV types 16 and 18, which have been associated with cervical cancer. A recombinant quadrivalent HPV vaccine (Gardasil – Merck) already on the market in the US prevents infection with HPV types 6, 11, 16 and 18.

The U.S. Advisory Committee on Immunization Practices has recommended administration of the quadrivalent conjugated polysaccharide meningococcal vaccine (Menactra – Sanofi Pasteur) to all persons 11 to 18 years old, particularly those entering high school and college freshmen living in dormitories.1,2 The peak incidence of meningococcal disease, after early childhood, occurs in the 15-19 year-old age group. The conjugate vaccine is more immunogenic than the meningococcal capsular polysaccharide vaccine (Menommune – Sanofi Pasteur).

ADVERSE EFFECTS — The most common adverse reactions with the conjugate vaccine have been headache, fatigue and malaise, in addition to pain, redness and induration at the injection site. Guillain-Barré syndrome has occurred rarely.3

CONCLUSION — Previously unvaccinated children starting high school or going away to college this fall should receive a single dose of meningococcal conjugate vaccine (Menactra).

1. Centers for Disease Control and Prevention (CDC). Advisory Committee on Immunization Practices. Revised recommendations of the Advisory Committee on Immunization Practices to vaccinate all persons aged 11-18 years with meningococcal conjugate vaccine. MMWR Morb Mortal Wkly Rep 2007; 56:794.
2. Menactra: a meningococcal conjugate vaccine. Med Lett Drugs Ther 2005; 47:29.
3. Centers for Disease Control and Prevention (CDC). Update: Guillain-Barre syndrome among recipients of Menactra meningococcal conjugate vaccine — United States, October 2005-February 2006. MMWR Morb Mortal Wkly Rep 2006; 55:364.

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The US Centers for Disease Control and Prevention (CDC) has reported that measles outbreaks have occurred in New York City, California and Arizona in 2008, and additional cases have been confirmed in Michigan, Wisconsin, Hawaii, New York State, Pennsylvania, Illinois and Virginia (CDC Health Advisory, May 1, 2008). To date, 63 of the 64 infected patients were unvaccinated, and 54 of the cases were associated with importation of the disease. Both measles infection and vaccination (2 doses at least 28 days apart, with the first dose no earlier than 12 months of age) generally provide lifelong immunity.Patients >12 months old with no evidence of immunity (not born before 1957, no convincing history of clinical measles, no documentation of vaccination, and no laboratory evidence of immunity) should be vaccinated with MMR or monovalent measles vaccine. In an outbreak, children 6-12 months old can also be vaccinated, but they will still need 2 subsequent doses after the age of 12 months to be fully immunized.¹ Contraindications to the attenuated live-virus vaccine include pregnancy, immunosuppressive therapy, leukemia or lymphoma, and congenital or acquired immunodeficiency. Transient fever and/or rash can occur after vaccination.

1. Committee on Infectious Diseases in LK Pickering et al eds, 2006 Red Book: Report of the Committee on Infectious Diseases 27th ed, Elk Grove, Ill: American Academy of Pediatrics 2006, page 446.

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Annual immunization against influenza A and B is the most effective method of preventing infection and has been shown to reduce associated complications.

A large mumps outbreak that began in Iowa in December 2005 has spread. About 40% of the cases have been in people 18-25 years old, many of whom are college students and had been vaccinated against the disease.

The FDA has licensed Adacel (Aventis Pasteur) and Boostrix (GlaxoSmithKline), two new combination vaccines that include tetanus toxoid, diphtheria toxoid and acellular pertussis antigens (Tdap), for use as a booster in adolescents and adults. In the past, older children and adults were not re-immunized against pertussis because of concerns about reactions to the whole-cell vaccine previously used in younger children. The CDC Advisory Committee on Immunization Practices (ACIP) and the American Academy of Pediatrics (AAP) have recommended that either of the new Tdap vaccines replace routine tetanus-diphtheria (Td) boosters in adolescents 11-18 years old, and Adacel should replace Td boosters in adults 19-64 years old.

Antiviral prophylaxis is indicated for influenza exposures that occur before (or less than 2 weeks after) vaccination with inactivated vaccine, or in years when circulating strains differ from those included in the vaccine. Antiviral drugs can also be used for treatment of patients who develop symptoms of influenza, regardless of vaccination status.
Please see Update: Influenza Resistance to Amantadine and Rimantadine

Annual immunization against influenza A and B is the most effective method of preventing infection and has been shown to reduce associated complications. A future issue of The Medical Letter will review drug prophylaxis and treatment of influenza.

The heptavalent pneumococcal conjugate vaccine (Prevnar - Wyeth) previously approved by the FDA for prevention of invasive pneumococcal disease in infants and children (Medical Letter 2000; 42:25) has now also been approved for prevention of otitis media. Infants and young children have higher antibody responses to the heptavalent conjugate vaccine (PCV7) than to the older 23-valent pneumococcal polysaccharide vaccine (PPV23) used in adults and older children (D Murray and C Jackson, Mil Med 2002; 167:671).

A new trivalent influenza vaccine is now available for the 1992-1993 influenza season (Morbid Mortal Weekly Rep, 41, RR-9:1, May 15, 1992). Vaccination is recommended especially for elderly and high-risk patients, their household contacts, and health-care personnel who may come in contact with such patients. Antigens in the current vaccine are derived from A/Texas/36/91 (H1N1), A/Beijing/353/89 (H3N2), and B/Panama/45/90. The A/Texas/36/91 (H1N1) strain is new this year.

Six vaccines are recommended for routine use in adults living in the USA (Guide for Adult Immunization, 2nd ed, Philadelphia:American College of Physicians, 1990). Immunization recommendations for travel outside the USA were published in The Medical Letter, volume 32, page 33, April 6, 1990.