Epidemiology and Prevention of Vaccine-Preventable Diseases

12th
EDITION
Revised May 2011
This book was produced by the Education, Information and Partnership Branch, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, who is solely responsible for its content. It was printed and distributed by the Public Health Foundation. For additional copies, contact the Public Health Foundation at 8772521200 or website http://bookstore.phf.org/. Slide sets to accompany this book are available on the CDC Vaccines and Immunization website at http://www.cdc.gov/vaccines/pubs/pinkbook/default.htm. E-mail address for comments, questions or suggestions about the contents of this book: nipinfo@cdc.gov.
EDITED BY:

CONTRIBUTIONS FROM:

William Atkinson, MD, MPH Charles (Skip) Wolfe Jennifer Hamborsky, MPH, CHES

Patricia Beckenhaupt, RN, MS, MPH Pamela Bryant, MS Andrew Kroger, MD, MPH JoEllen Wolicki, RN, BSN Pascale Wortley, MD, MPH Donna Weaver, RN, MN

Department of Health and Human Services

Centers for Disease Control and Prevention

On the cover
Four scientists who made major contributions to vaccine research and development (clockwise from top left): Emil von Behring (1854-1917) developed the first effective diphtheria antitoxin. For this work he received the first Nobel Prize for Medicine or Physiology in 1901; Gaston Ramon (1886-1963) French veterinarian who in the 1920s developed methods for inactivating diphtheria and tetanus toxoins, a critical discovery for the development of diphtheria and tetanus toxoids; Maurice Hilleman (1919-2005) researcher who developed numerous vaccines at Merck including hepatitis B., mumps, and MMR vaccines; John Enders (1897-1985) developed a method to grow poliovirus using tissue culture media which led to the development of the first successful polio vaccines. He and his coworkers received the Nobel Prize in Medicine in 1954 for this discovery. Dr. Enders was also the first to isolate measles virus in 1954, which led to the first measles vaccine. Images of these scientists appear in the animated gallery shown at the beginning of all NCIRD broadcasts and video productions.

Suggested Citation:
Centers for Disease Control and Prevention. Epidemiology and Prevention of Vaccine-Preventable Diseases. Atkinson W, Wolfe S, Hamborsky J, eds. 12th ed. Washington DC: Public Health Foundation, 2011.
Use of trade names and commercial sources is for identification only and does not imply endorsement by the Public Health Services or the U.S. Department of Health and Human Services. References to non-CDC sites on the Internet are provided as a service to readers and do not constitute or imply endorsement of these organizations or their programs by CDC or the U.S. Department of Health and Human Services. CDC is not responsible for the content of these sites. URL addresses were current as of the date of publication.
Life is a series of hellos and goodbyes Im afraid its time for goodbye again - Billy Joel, Say Goodbye to Hollywood, 1976

Milestones in the History of Vaccination

Hippocrates describes diphtheria, epidemic jaundice, and other conditions

400BCE

Variolation for smallpox first reported in China

1100s

Variolation introduced into Great Britain

1721

Edward Jenner inoculates James Phipps with cowpox, and calls the procedure vaccination (vacca is Latin for cow)

1796

ii

Table of Contents
1 Principles of Vaccination
Immunology and Vaccine-Preventable Diseases . . . . . . . . . . . . . 1 Classification of Vaccines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 Selected References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

2 General Recommendations on Immunization

Timing and Spacing of Vaccines . . . . . . . . . . . . . . . . . . . . . . . . . 9 Adverse Reactions Following Vaccination . . . . . . . . . . . . . . . . . 15 Contraindications and Precautions to Vaccination . . . . . . . . . . . 16 Invalid Contraindications to Vaccination . . . . . . . . . . . . . . . . . . 23 Screening for Contraindications and Precautions to Vaccination . 27 Selected References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30

3 Immunization Strategies for Healthcare Practices

and Providers
The Need for Strategies to Increase Immunization Levels . . . . . 31 The AFIX Approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 Other Essential Strategies . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38 Selected References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43

4 Vaccine Safety

The Importance of Vaccine Safety Programs . . . . . . . . . . . . . . 45 Sound Immunization Recommendations and Policy . . . . . . . . . . 46 Methods of Monitoring Vaccine Safety . . . . . . . . . . . . . . . . . . . 47 Vaccine Analytic Unit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52 Vaccine Injury Compensation . . . . . . . . . . . . . . . . . . . . . . . . . . 52 The Immunization Providers Role . . . . . . . . . . . . . . . . . . . . . . 54 Selected References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58

5 Vaccine Storage and Handling

Vaccine Storage Temperatures . . . . . . . . . . . . . . . . . . . . . . . . . 61 Storage and Handling Plans . . . . . . . . . . . . . . . . . . . . . . . . . . . 62 Personnel, Training and Education . . . . . . . . . . . . . . . . . . . . . . . 63 Vaccine Storage Equipment . . . . . . . . . . . . . . . . . . . . . . . . . . . 64 Temperature Monitoring . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66 Vaccine Placement and Labeling . . . . . . . . . . . . . . . . . . . . . . . . 68 Vaccine Storage Troubleshooting . . . . . . . . . . . . . . . . . . . . . . . 68 Vaccine Inventory Control . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70 Receiving and Unpacking Vaccine Shipments . . . . . . . . . . . . . . 71 Vaccine Transport to Off-site Clinics . . . . . . . . . . . . . . . . . . . . 72 Vaccine Preparation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73 Selected References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74

Milestones in the History of Vaccination

Louis Pasteur creates the first live attenuated bacterial vaccine (chicken cholera)

1870

Pasteur creates the first live attenuated viral vaccine (rabies)

1884

Pasteur first uses rabies vaccine in a human

1885

Institut Pasteur established

1887

Paul Ehrlich formulates receptor theory of immunity

1900

iii

Table of Contents
6 Diphtheria
Corynebacterium diphtheriae . . . . . . . . . . . . . . . . . . . . . . . . . . 75 Pathogenesis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75 Clinical Features . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75 Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77 Laboratory Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77 Medical Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78 Epidemiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79 Secular Trends in the United States . . . . . . . . . . . . . . . . . . . . . 80 Diphtheria Toxoid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81 Vaccination Schedule and Use . . . . . . . . . . . . . . . . . . . . . . . . . 82 Contraindications and Precautions to Vaccination . . . . . . . . . . . 83 Adverse Reactions Following Vaccination . . . . . . . . . . . . . . . . . 83 Vaccine Storage and Handling . . . . . . . . . . . . . . . . . . . . . . . . . 84 Suspect Case . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84 Investigation and Control . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84 Selected References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85 Haemophilus influenzae . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87 Pathogenesis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87 Clinical Features . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89 Laboratory Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89 Medical Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90 Epidemiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90 Secular Trends in the United States . . . . . . . . . . . . . . . . . . . . . 91 Haemophilus influenzae type b Vaccines . . . . . . . . . . . . . . . . . . 92 Vaccination Schedule and Use . . . . . . . . . . . . . . . . . . . . . . . . . 94 Combination Vaccines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96 Contraindications and Precautions to Vaccination . . . . . . . . . . . 97 Adverse Reactions Following Vaccination . . . . . . . . . . . . . . . . . 97 Vaccine Storage and Handling . . . . . . . . . . . . . . . . . . . . . . . . . 98 Surveillance and Reporting of Hib Disease . . . . . . . . . . . . . . . . 98 Selected References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98

7 Haemophilus influenzae

8 Hepatitis A

Hepatitis A Virus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101 Pathogenesis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101 Clinical Features . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102 Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102 Laboratory Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102 Medical Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103 Epidemiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103 Secular Trends in the United States . . . . . . . . . . . . . . . . . . . . 105 Case Definition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106

Milestones in the History of Vaccination

First Nobel Prize in Medicine to von Behring for diphtheria antitoxin

1901

Theobald Smith discovers a method for inactivating diphtheria toxin

1909

Calmette and Guerin create BCG, the first live attenuated bacterial vaccine for humans

1919

First whole-cell pertussis vaccine tested Gaston Ramon develops diphtheria toxoid

1923

Ramon and Christian Zoeller develop tetanus toxoid

1926

iv

Table of Contents
Hepatitis A Vaccine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106 Vaccination Schedule and Use . . . . . . . . . . . . . . . . . . . . . . . . 107 Contraindications and Precautions to Vaccination . . . . . . . . . . 112 Adverse Reactions Following Vaccination . . . . . . . . . . . . . . . . 112 Vaccine Storage and Handling . . . . . . . . . . . . . . . . . . . . . . . . 112 Postexposure Prophylaxis . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112 Selected References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113

9 Hepatitis B

Hepatitis B Virus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115 Clinical Features . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 116 Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117 Laboratory Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117 Medical Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119 Epidemiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119 Secular Trends in the United States . . . . . . . . . . . . . . . . . . . . 120 Hepatitis B Prevention Strategies . . . . . . . . . . . . . . . . . . . . . . 123 Hepatitis B Vaccine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123 Vaccination Schedule and Use . . . . . . . . . . . . . . . . . . . . . . . . 126 Serologic Testing of Vaccine Recipients . . . . . . . . . . . . . . . . . 131 Postexposure Management . . . . . . . . . . . . . . . . . . . . . . . . . . 134 Contraindications and Precautions to Vaccination . . . . . . . . . . 137 Adverse Reactions Following Vaccination . . . . . . . . . . . . . . . . 137 Vaccine Storage and Handling . . . . . . . . . . . . . . . . . . . . . . . . 138 Selected References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 138

10 Human Papillomavirus

Human Papillomavirus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 139 Pathogenesis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 139 Clinical Features . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 140 Laboratory Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 140 Medical Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141 Epidemiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141 Disease Burden in the United States . . . . . . . . . . . . . . . . . . . 142 Prevention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143 Human Papillomavirus Vaccine . . . . . . . . . . . . . . . . . . . . . . . . 143 Vaccination Schedule and Use . . . . . . . . . . . . . . . . . . . . . . . . 145 Contraindications and Precautions to Vaccination . . . . . . . . . . 147 Adverse Reactions Following Vaccination . . . . . . . . . . . . . . . . 148 Vaccine Storage and Handling . . . . . . . . . . . . . . . . . . . . . . . . 148 Selected References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 148

11 Influenza

Influenza Virus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151 Pathogenesis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 153

Milestones in the History of Vaccination

Yellow fever virus isolated

1927

Goodpasture describes a technique for viral culture in hens eggs

1931

Thomas Francis and Thomas Magill develop the first inactivated influenza vaccine

1936

John Enders and colleagues isolate Lansing Type II poliovirus in human cell line

1948

Enders and Peebles isolate measles virus Francis Field Trial of inactivated polio vaccine

1954

Table of Contents
Clinical Features . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 153 Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 154 Impact of Influenza . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 154 Laboratory Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155 Epidemiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 156 Secular Trends in the United States . . . . . . . . . . . . . . . . . . . . 157 Influenza Vaccine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 158 Vaccination Schedule and Use . . . . . . . . . . . . . . . . . . . . . . . . 160 Contraindications and Precautions to Vaccination . . . . . . . . . . 163 Adverse Reactions Following Vaccination . . . . . . . . . . . . . . . . 164 Vaccine Storage and Handling . . . . . . . . . . . . . . . . . . . . . . . . 167 Strategies for Improving Influenza Vaccine Coverage . . . . . . . 167 Antiviral Agents for Influenza . . . . . . . . . . . . . . . . . . . . . . . . . . 168 Nosocomial Influenza Control . . . . . . . . . . . . . . . . . . . . . . . . . 169 Influenza Surveillance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 169 Selected References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 170

12 Measles

Measles Virus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 173 Pathogenesis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 173 Clinical Features . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 174 Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 174 Laboratory Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 176 Epidemiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 177 Secular Trends in the United States . . . . . . . . . . . . . . . . . . . . 178 Measles Vaccine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 181 Vaccination Schedule and Use . . . . . . . . . . . . . . . . . . . . . . . . 182 Contraindications and Precautions to Vaccination . . . . . . . . . . 186 Adverse Reactions Following Vaccination . . . . . . . . . . . . . . . . 189 Vaccine Storage and Handling . . . . . . . . . . . . . . . . . . . . . . . . 191 Selected References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 191

13 Meningococcal Disease

Neisseria meningitidis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 193 Pathogenesis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 194 Clinical Features . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 194 Laboratory Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 195 Medical Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 195 Epidemiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 196 Secular Trends in the United States . . . . . . . . . . . . . . . . . . . . 196 Meningococcal Vaccines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 197 Vaccination Schedule And Use . . . . . . . . . . . . . . . . . . . . . . . . 199 Contraindications and Precautions to Vaccination . . . . . . . . . . 201 Adverse Reactions Following Vaccination . . . . . . . . . . . . . . . . 201 Vaccine Storage and Handling . . . . . . . . . . . . . . . . . . . . . . . . 202

Milestones in the History of Vaccination

Inactivated polio vaccine licensed

1955

Human diploid cell line developed

1961

Measles vaccine licensed Trivalent oral polio vaccine licensed

1963

Bifurcated needle for smallpox vaccine licensed

1965

World Health Assembly calls for global smallpox eradication

1966

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Table of Contents
Surveillance and Reporting of Meningococcal Disease . . . . . . 202 Antimicrobial Chemoprophylaxis . . . . . . . . . . . . . . . . . . . . . . . 203 Selected References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 203

14 Mumps

Mumps Virus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 205 Pathogenesis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 205 Clinical Features . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 205 Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 206 Laboratory Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 207 Epidemiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 207 Secular Trends in the United States . . . . . . . . . . . . . . . . . . . . 208 Mumps Vaccine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 209 Vaccination Schedule and Use . . . . . . . . . . . . . . . . . . . . . . . . 210 Contraindications and Precautions to Vaccination . . . . . . . . . 211 Adverse Reactions Following Vaccination . . . . . . . . . . . . . . . 213 Vaccine Storage and Handling . . . . . . . . . . . . . . . . . . . . . . . . 213 Selected References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 213

15 Pertussis

Bordetella pertussis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 215 Pathogenesis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 215 Clinical Features . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 215 Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 216 Laboratory Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 217 Medical Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 218 Epidemiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 219 Secular Trends in the United States . . . . . . . . . . . . . . . . . . . . 219 Pertussis Vaccines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 220 Vaccination Schedule and Use . . . . . . . . . . . . . . . . . . . . . . . . 222 Combination Vaccines Containing DTaP . . . . . . . . . . . . . . . . . 225 Other DTaP Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 226 Contraindications and Precautions to Vaccination . . . . . . . . . . 227 Adverse Reactions Following Vaccination . . . . . . . . . . . . . . . . 229 Vaccine Storage and Handling . . . . . . . . . . . . . . . . . . . . . . . . 230 Selected References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 230

16 Pneumococcal Disease

Streptococcus pneumoniae . . . . . . . . . . . . . . . . . . . . . . . . . . 233 Clinical Features . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 234 Laboratory Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 236 Medical Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 237 Epidemiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 237 Secular Trends in the United States . . . . . . . . . . . . . . . . . . . . 238

Milestones in the History of Vaccination

Maurice Hilleman develops Jeryl Lynn strain of mumps virus

1967

Stanley Plotkin develops RA27/3 strain of rubella vaccine virus

1969

MMR vaccine licensed

1971

Last indigenous case of smallpox (Somalia)

1977

Last wild poliovirus transmission in the U.S.

1979

vii

Table of Contents
Pneumococcal Vaccines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 238 Vaccination Schedule and Use . . . . . . . . . . . . . . . . . . . . . . . . 241 Contraindications and Precautions to Vaccination . . . . . . . . . . 244 Adverse Reactions Following Vaccination . . . . . . . . . . . . . . . . 244 Vaccine Storage and Handling . . . . . . . . . . . . . . . . . . . . . . . . 245 Goals and Coverage Levels . . . . . . . . . . . . . . . . . . . . . . . . . . 245 Selected References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 246

17 Poliomyelitis

Poliovirus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 249 Pathogenesis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 249 Clinical Features . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 250 Laboratory Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 251 Epidemiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 251 Secular Trends in the United States . . . . . . . . . . . . . . . . . . . . 252 Poliovirus Vaccines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 253 Vaccination Schedule and Use . . . . . . . . . . . . . . . . . . . . . . . . 255 Polio Vaccination of Adults . . . . . . . . . . . . . . . . . . . . . . . . . . . 257 Contraindications And Precautions To Vaccination . . . . . . . . . 258 Adverse Reactions Following Vaccination . . . . . . . . . . . . . . . . 258 Vaccine Storage and Handling . . . . . . . . . . . . . . . . . . . . . . . . 259 Outbreak Investigation and Control . . . . . . . . . . . . . . . . . . . . . 260 Polio Eradication . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 260 Postpolio Syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 261 Selected References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 261

18 Rotavirus

Rotavirus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 263 Pathogenesis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 263 Clinical Features . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 264 Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 264 Laboratory Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 264 Epidemiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 265 Secular Trends in the United States . . . . . . . . . . . . . . . . . . . . 266 Rotavirus Vaccines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 266 Vaccine Effectiveness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 268 Duration of Immunity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 268 Vaccination Schedule and Use . . . . . . . . . . . . . . . . . . . . . . . . 269 Contraindications and Precautions to Vaccination . . . . . . . . . . 270 Adverse Reactions Following Vaccination . . . . . . . . . . . . . . . . 272 Vaccine Storage and Handling . . . . . . . . . . . . . . . . . . . . . . . . 273 Rotavirus Surveillance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 273 Selected References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 274

Milestones in the History of Vaccination

First hepatitis B vaccine licensed

1981

Smallpox vaccine withdrawn from civilian market

1983

First recombinant vaccine licensed (hepatitis B) National Childhood Vaccine Injury Act

1986

Two-dose measles vaccine recommendation

1989

First polysaccharide conjugate vaccine licensed (Haemophilus influenzae type b)

1990

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19 Rubella
Rubella Virus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 275 Pathogenesis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 275 Clinical Features . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 275 Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 276 Congenital Rubella Syndrome . . . . . . . . . . . . . . . . . . . . . . . . . 276 Laboratory Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 277 Epidemiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 278 Secular Trends in the United States . . . . . . . . . . . . . . . . . . . . 279 Rubella Vaccine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 280 Vaccination Schedule and Use . . . . . . . . . . . . . . . . . . . . . . . . 281 Rubella Immunity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 283 Contraindications and Precautions to Vaccination . . . . . . . . . . 284 Adverse Reactions Following Vaccination . . . . . . . . . . . . . . . . 286 Rubella Vaccination of Women of Childbearing Age . . . . . . . . 286 Vaccine Storage and Handling . . . . . . . . . . . . . . . . . . . . . . . . 287 Strategies to Decrease Rubella and CRS . . . . . . . . . . . . . . . 288 Selected References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 288

20 Tetanus

Clostridium tetani . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 291 Pathogenesis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 292 Clinical Features . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 292 Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 293 Laboratory Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 293 Medical Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 293 Wound Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 294 Epidemiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 294 Secular Trends in the United States . . . . . . . . . . . . . . . . . . . . 295 Tetanus Toxoid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 296 Vaccination Schedule and Use . . . . . . . . . . . . . . . . . . . . . . . . 297 Contraindications and Precautions to Vaccination . . . . . . . . . . 298 Adverse Reactions Following Vaccination . . . . . . . . . . . . . . . . 299 Vaccine Storage and Handling . . . . . . . . . . . . . . . . . . . . . . . . 299 Selected References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 300

21 Varicella

Varicella Zoster Virus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 301 Pathogenesis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 301 Clinical Features . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 301 Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 303 Laboratory Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 304 Epidemiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 306

Milestones in the History of Vaccination

Polio elimination certified in the Americas Vaccines for Children program begins

1994

Varicella vaccine licensed Hepatitis A vaccine licensed First harmonized childhood immunization schedule published

1995

Acellular pertussis vaccine licensed for infants

1996

Sequential polio vaccination recommended

1997

First rotavirus vaccine licensed

1998

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Secular Trends in the United States . . . . . . . . . . . . . . . . . . . . 307 Vaccines Containing Varicella Virus . . . . . . . . . . . . . . . . . . . . 308 Vaccination Schedule and Use . . . . . . . . . . . . . . . . . . . . . . . . 311 Varicella Immunity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 315 Contraindications and Precautions to Vaccination . . . . . . . . . . 316 Zoster Vaccine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 318 Adverse Reactions Following Vaccination . . . . . . . . . . . . . . . . 319 Transmission of Varicella Vaccine Virus . . . . . . . . . . . . . . . . . 321 Vaccine Storage and Handling . . . . . . . . . . . . . . . . . . . . . . . . 321 Varicella Zoster Immune Globulin . . . . . . . . . . . . . . . . . . . . . . 322 Selected References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 323

APPENDICES A Schedules and Recommendations

Immunization Schedules on the Web . . . . . . . . . . . . . . . . . . . A-1 Childhood Immunization Schedule 2011 . . . . . . . . . . . . . . . . A-2 Adult Immunization Schedule 2011 . . . . . . . . . . . . . . . . . . . . A-5 Recommended Minimum Ages and Intervals . . . . . . . . . . . . . A-9 Summary of Recommendations for Childhood & Adolescent Immunizations . . . . . . . . . . . . . A-11 Summary of Recommendations for Adult Immunizations . . . A-15 AntibodyLive Vaccine Interval Table . . . . . . . . . . . . . . . . . . A-19 Healthcare Worker Vaccination Recommendations . . . . . . . A-20 Immunization of Immunocompromised Patients Tables . . . . . A-23

B Vaccines

U .S . Vaccines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . B-1 Selected Discontinued U .S . Vaccines . . . . . . . . . . . . . . . . . . B-5 Vaccine Excipient and Media Summary, by Excipient . . . . . . . B-7 Vaccine Excipient and Media Summary, by Vaccine . . . . . . . B-14 Latex in Vaccine Packaging . . . . . . . . . . . . . . . . . . . . . . . . . B-17 Thimerosal Table . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . B-19 Foreign Language Terms . . . . . . . . . . . . . . . . . . . . . . . . . . . B-21

C Vaccine Storage and Handling

Checklist for Safe Vaccine Handling and Storage . . . . . . . . . C-1 Vaccine Handling Tips . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . C-2 Recording Refrigerator Temperatures . . . . . . . . . . . . . . . . . . C-3 Safeguard Your Power Supply . . . . . . . . . . . . . . . . . . . . . . . . C-4 Vaccine Storage Temperature Recommendations . . . . . . . . . C-5 Vaccine Storage and Handling Resources . . . . . . . . . . . . . . . C-6 Vaccine Manufacturer Contact Information . . . . . . . . . . . . . . C-7

Milestones in the History of Vaccination

Exclusive use of inactivated polio vaccine recommended Rotavirus vaccine withdrawn

1999

Pneumococcal conjugate vaccine licensed for infants

2000

Live attenuated influenza vaccine licensed

2003

Inactivated influenza vaccine recommended for all children 623 months of age

2004

Indigenous transmission of rubella virus interrupted

2004

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D Vaccine Administration
"Vaccine Administration" Guidelines . . . . . . . . . . . . . . . . . . . D-1 Administering Vaccines . . . . . . . . . . . . . . . . . . . . . . . . . . . . D-17 Medical Management of Vaccine Reactions (Children & Teens) . . . . . . . . . . . . . . . . D-19 Medical Management of Vaccine Reactions (Adults) . . . . . . D-21

E Vaccine Information Statements

Its Federal Law . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Instructions for Use of VISs . . . . . . . . . . . . . . . . . . . . . . . . . How to Get Vaccine Information Statements . . . . . . . . . . . . . VIS Questions and Answers . . . . . . . . . . . . . . . . . . . . . . . . . CDCs Vaccine Information Statement Webpage . . . . . . . . . .

E-1 E-2 E-3 E-4 E-8

F Vaccine Safety

The Vaccine Adverse Event Reporting System (VAERS) . . . . Table of Reportable Events Following Vaccination . . . . . . . . . The Vaccine Injury Compensation Program (VICP) . . . . . . . . The VICP Vaccine Injury Table . . . . . . . . . . . . . . . . . . . . . . . .

F-1 F-2 F-4 F-6

G Data and Statistics

Reported Cases and Deaths from Vaccine-Preventable Diseases: 19502009 . . . . . . . . . . . . G-1 Impact of Vaccines in the 20th & 21st Centuries . . . . . . . . . . G-7 Vaccine Coverage Levels: 19622009 . . . . . . . . . . . . . . . . . G-8

H Immunization Resources

CDC Immunization Contacts & Resources . . . . . . . . . . . . . . IAC Online Directory of Immunization Resources . . . . . . . . . "Storage and Handling Toolkit" . . . . . . . . . . . . . . . . . . . . . . . . State and Local Immunization Grantee Contact Information . .

H-1 H-2 H-3 H-4

Milestones in the History of Vaccination

Acellular pertussis vaccines licensed for adolescents and adults

2005

MMR-varicella (MMRV) licensed

2005

Second generation rotavirus vaccine licensed

2006

First human papillomavirus vaccine licensed

2006

First herpes zoster vaccine licensed

2006

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Vaccines and Related Products Distributed in the United States - 2011 Tableonof Contents at http://www.cdc.gov/vaccines/vac-gen/shortages/default.htm Information vaccine shortages is available
Vaccine/Biologic
Anthrax, adsorbed
Diphtheria, Tetanus, acellular Pertussis Diphtheria, Tetanus, acellular Pertussis Diphtheria, Tetanus, acellular Pertussis Diphtheria, Tetanus, acellular Pertussis+HepB+IPV Diphtheria, Tetanus, acellular Pertussis+Hib+IPV Diphtheria, Tetanus, acellular Pertussis+IPV

Brand Name
BioThrax Infanrix Tripedia Daptacel Pediarix Pentacel Kinrix generic Decavac generic Boostrix Adacel generic generic HyperTET ActHIB PedvaxHIB Hiberix Comvax Havrix Vaqta Engerix-B Recombivax HB Recombivax HB HyperHEP B HyperHEP B Nabi-HB Twinrix Gardasil Cervarix multiple FluMist Ixiaro M-M-R II ProQuad Menactra Menveo Menomune Prevnar-13 Pneumovax 23 IPOL Imovax RabAvert Imogam Rabies-HT HyperRAB RotaTeq Rotarix Typhim Vi Vivotif Varivax VariZIG YF-Vax Zostavax

Manufacturer
Bioport GlaxoSmithKline sanofi pasteur sanofi pasteur GlaxoSmithKline sanofi pasteur GlaxoSmithKline sanofi pasteur sanofi pasteur Mass Biologic Labs GlaxoSmithKline sanofi pasteur sanofi pasteur sanofi pasteur Talecris sanofi pasteur Merck GlaxoSmithKline Merck GlaxoSmithKline Merck GlaxoSmithKline Merck Merck Talecris Talecris Nabi GlaxoSmithKline Merck GlaxoSmithKline multiple MedImmune Intercell Merck Merck sanofi pasteur Novartis sanofi pasteur Pfizer Merck sanofi pasteur sanofi pasteur Novartis sanofi pasteur Talecris Merck GlaxoSmithKline sanofi pasteur Berna Merck Cangene sanofi pasteur Merck

Type
inactivated inactivated inactivated inactivated inactivated inactivated inactivated inactivated inactivated inactivated inactivated inactivated inactivated inactivated human Immunoglobulin inactivated inactivated inactivated inactivated inactivated inactivated inactivated inactivated inactivated human Immunoglobulin human Immunoglobulin human Immunoglobulin inactivated inactivated inactivated inactivated live intranasal inactivated live attenuated live attenuated inactivated inactivated inactivated inactivated inactivated inactivated inactivated inactivated human Immunoglobulin human Immunoglobulin live oral live oral inactivated live attenuated live attenuated human Immunoglobulin live attenuated live attenuated

How Supplied
multi-dose vial single-dose vial or syringe single-dose vial single-dose vial single-dose vial or syringe single-dose vial single-dose vial or syringe single-dose vial single-dose syringe 15-dose vial single-dose vial or syringe single-dose vial 10-dose vial 15-dose vial single-dose syringe single-dose vial single-dose vial single-dose vial single-dose vial single-dose vial or syringe single-dose vial or syringe single-dose vial or syringe single-dose vial single-dose vial 1 mL syringe, 1 mL or 5 mL vial single-dose 0.5 mL neonatal syringe single-dose vial single-dose vial or syringe single-dose vial or syringe single-dose vial or syringe multiple single-use sprayer single-dose syringe single-dose vial single-dose vial single-dose vial single-dose vial single-dose vial single-dose vial single-dose or 5-dose vial single-dose syringe or 10-dose vial single-dose vial single-dose vial 2 mL and 10 mL vial 2 mL and 10 mL vial single-dose tube single-dose tube single-dose syringe and 20-dose vial 4-capsule pack single-dose vial 25-U vial single- and 5-dose vial single-dose vial

Diphtheria, Tetanus (DT, ped, <7 yrs)

Tetanus, Diphtheria, adsorbed (Td, >7 yrs) Tetanus, Diphtheria, adsorbed (Td, >7 yrs) Tetanus, Diphtheria, acellular Pertussis (Tdap, 10-64 yrs) Tetanus, Diphtheria, acellular Pertussis (Tdap, 11-64 yrs) Tetanus toxoid, adsorbed (TT, >7 yrs) Tetanus toxoid, adsorbed (TT, adult booster use only) Tetanus immune globulin (TIG) Haemophilus influenzae type b (PRP-T) Haemophilus influenzae type b (PRP-OMP) Haemophilus influenzae type b (PRP-T) (booster dose) Haemophilus influenzae type b (PRP-OMP)+HepB Hepatitis A, ped/adol & adult formulations Hepatitis A, ped/adol & adult formulations Hepatitis B, ped/adol & adult formulations Hepatitis B, ped/adol & adult formulations Hepatitis B dialysis formulation Hepatitis B immune globulin (HBIG) Hepatitis B immune globulin (HBIG) ped formulation Hepatitis B immune globulin (HBIG) Hepatitis A & B adult formulation Human papillomavirus, quadrivalent (HPV4) Human papillomavirus, bivalent (HPV2) Influenza, trivalent inactivated (TIV) Influenza, live attenuated (LAIV) Japanese encephalitis Measles, Mumps, Rubella (MMR) Measles, Mumps, Rubella, Varicella (MMRV) Meningococcal conjugate, quadrivalent Meningococcal conjugate, quadrivalent Meningococcal polysaccharide, quadrivalent Pneumococcal conjugate, 13-valent Pneumococcal polysaccharide, 23-valent Poliovirus inactivated (IPV) Rabies Rabies Rabies immune globulin (RIG) Rabies immune globulin (RIG) Rotavirus, pentavalent (RV5) Rotavirus, monovalent (RV1) Typhoid Vi polysaccharide Typhoid, live oral Ty21a Varicella Varicella Zoster immune globulin (VZIG) (IND) Yellow fever Zoster

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