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Combined Hepatitis A & B Vaccine
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A combined hepatitis A and B vaccine is approved for use in individuals 18 years of age and older The components are identical to individual vaccines It is highly immunogenic and should be used in individuals who have an indication for both hepatitis A and B vaccination, as noted above The product is safe, and adverse effects are similar to those of the individual components It is administered in three doses at 0, 1 and 6 months
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Smallpox vaccination, discontinued in the United States in the early 1970s, has been reinstituted because of concerns about bioterrorism The vaccine is a live vaccinia virus derived through serial passage of cowpox and does not contain the actual smallpox virus Vaccine is administered with a bifurcated needle, making 15 puncture wounds in a small area of the skin (5 mm) just deep enough to cause bleeding Because the inoculation site is contagious, it should be covered with gauze or a semipermeable dressing such as OpSite If vaccination is successful, the site goes through a characteristic evolution: In 3 4 days the site becomes red, itchy, and indurated; a vesicle umbilicates and evolves into a well-formed pustule by day 6 11; the pustule scabs over between week 2 and week 3; and by the end of the third week the scab falls off, leaving a scar At the end of the first week, fever for several days, tenderness at the vaccination site, and localized axillary adenopathy occur in 10 20% of first-time vaccinees, but these reactions are less common in those who have been previously vaccinated within the last 10 years Successful vaccination is indicated by the presence of a pustular lesion at day 7 in a
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Two vaccines are currently available, a polysaccharide vaccine (MPSV4) and the newer protein conjugated vaccine (MCV4) Both are highly immunogenic to serogroups A,C,Y and W135 and well tolerated Whereas the polysaccharide vaccine
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requires revaccination of at-risk groups every 3 5 years due to waning immunity, the protein conjugated vaccine likely will provide longer protection, although data on need for revaccination with MCV4 is not currently available MCV4 is licensed for use in individuals 11 55 years of age, and MPSV4 is licensed for ages 2 years and above Vaccination with MCV4 is routinely recommended for adolescents aged 11 12 For those who miss that vaccination, catch up is recommended at high school entry (approximately age 15) MCV4 is also recommended for certain highrisk groups, including college freshman living in dormitories (the risk to nonfreshman and freshman not living in dormitories is the same as the general population and vaccination of these groups is elective), microbiologists who are routinely exposed to N meningiditis, military recruits, persons who travel to or reside in areas in which N meningitides is hyperendemic or epidemic (see below), those with terminal complement deficiencies, and persons with anatomic or functional asplenia HIV-infected patients may be at increased risk for meningococcal disease, and vaccination should be considered elective in that group MCV4 is the preferred preparation, but if availability is an issue, MPSV4 can be substituted MCV4 is administered as a single 05-mL dose intramuscularly and MPSV4 as a single 05-mL dose subcutaneously Both can be administered with other vaccines, but at different sites and both produce an antibody response in 7 10 days Both are inactivated vaccines and can be administered to immunocompromised patients MPSV4 is safe in pregnancy, but there are no safety or efficacy data for MCV4 in pregnancy Minor reactions (fever, redness, swelling, erythema, pain) occur slightly more commonly with MCV4 Major reactions are rare The protein conjugate used in MCV4 is diphtheria toxoid, so individuals with a history of adverse reaction to that component should not receive MCV4 A potential association between Guillain-Barr syndrome and vaccination with MCV4 has been reported, but current recommendations favor continued use of MCV4, since the benefits of preventing the serious consequences of meningococcal infection outweigh the theoretical risk of Guillain-Barr syndrome
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