Unusual complications (e.g., severe bacterial superinfections, Reye syndrome,

encephalopathies) are markedly reduced with an immunization program.

103 Before the

vaccine was available, approximately 4 million cases of chickenpox were reported

annually, with 4,000 to 9,000 hospitalizations and 100 deaths.

103 Historically, 55% of

varicella-related deaths occurred in adults, many of whom were infected by exposure

to unvaccinated preschool-aged children with typical cases of varicella.

106

Despite high vaccine coverage rates and 85% vaccine efficacy with the previous

single dose vaccination, outbreaks of breakthrough varicella continued to occur in the

United States.

107 As a result, current guidelines recommend a two-dose series for all

children, adolescents, and adults without evidence of immunity.

1

,

27

,

107 The first

varicella vaccine dose should be administered at 12 to 15 months of age, followed

by the second dose at 4 to 6 years of age. For persons 7 to 12 years of age who have

not received varicella vaccine, two doses of varicella vaccine should be

administered at least 3 months apart. For persons older than 13 years of age,

administer two doses of varicella vaccine at least 4 weeks apart.

107

Postexposure varicella vaccination should be considered for J.T. Chickenpox

infection can be prevented or symptoms reduced if varicella vaccine is administered

within 3 days of exposure and may provide some protection within 5 days.

105

,

107

If

J.T. also needs MMR vaccination, the quadrivalent combination vaccine ProQuad

containing measles, mumps, rubella, and varicella antigens may be considered. A

second dose of varicella vaccine in 3 months should be recommended to ensure longterm protection.

The most common adverse effect associated with varicella vaccine administration

is rash. Transmission of the virus from the vaccine has been documented in only 3 of

15 million doses administered, all of which occurred in the presence of a vesicular

rash after vaccination.

103 Caution should be used when patients exhibit a rash

postvaccination to avoid contact with immunocompromised individuals until rash

resolution.

107

Although varicella vaccine might not entirely prevent the occurrence of chickenpox

in an immunocompromised patient, it can modify the disease. In the National

Institutes of Health’s Collaborative Varicella Vaccine Study, a seroconversion rate

of only 85% was observed after a single dose in adults, compared with 95% in

healthy children and 90% in children with leukemia.

108 Varicella vaccine is generally

not recommended in children who have cellular immunodeficiencies, but it can be

used in those with impaired humoral immunity.

107 The vaccine should be avoided in

children with symptomatic HIV, but it may be considered in asymptomatic or mildly

symptomatic patients.

103

,

107

CASE 64-16, QUESTION 2: If the varicella vaccine is now universally recommended, what is the role of the

herpes zoster vaccine?

After a primary infection with varicella, 15% to 30% of the population

experiences a latent infection in the sensory nerve ganglia that reactivates, causing

herpes zoster (HZ).

107

,

109 HZ typically occurs decades after initial varicella infection.

This reactivation can result in post-herpetic neuralgia or dissemination which results

in skin eruptions (“shingles”) and potential CNS, pulmonary, or hepatic

complications.

107

,

109 Although some have theorized that universal varicella

vaccination should eventually reduce the incidence of HZ because it prevents

primary infection, others debate that the attenuated virus may have greater potential

for becoming latent and reactiving.

107

,

109 Still others argue that with the elimination of

wild-type virus in the community, the exposure of individuals with latent wild-type

varicella to help boost immunity and prevent HZ is reduced. In this situation, the risk

of HZ may be increased.

107

,

109 Routine varicella immunization began in 1995 and only

long-term studies of vaccinated individuals will answer the questions about the

impact of the varicella vaccination upon the incidence of HZ. However, currently the

majority of adults are not immunized against varicella (unless required as a health

care worker) and have previously acquired wild-type varicella infections. Therefore,

most adults in the United States are at risk for exhibiting HZ as they age.

The zoster vaccine (Zostavax) is a live attenuated varicella zoster vaccine that

uses the same strain and antigens as the varicella vaccines (Varivax and ProQuad);

however, it is 14 times more potent and contains additional antigenic components. It

was initially recommended for all individuals older than 60 years of age as a single

subcutaneous injection to prevent HZ.

28–30,109,110

In 2011, FDA approval was given to

use HZ vaccine in individuals 50 years of age or older; however, ACIP

recommendations remain for patients 60 years and older.

110

It may be given to

patients with a previous history of HZ, but it is not indicated to treat acute zoster or

prevent further complications during an acute episode.

109

It is not recommended for

routine immunization for anyone who has previously received the varicella vaccine.

The zoster vaccine was shown in the Shingles Prevention Study to reduce the

incidence of HZ by more than 50% and resulted in reductions in the severity and

duration of pain, in addition to preventing the development of post-herpetic

neuralgia.

111

ADMINISTRATION TECHNIQUES

Vaccines or other biological agents are typically administered as either an

intramuscular (IM) or subcutaneous injection.

Because appropriate administration by the correct route and technique is critical to

the effectiveness of the specified vaccine, it is essential to consult the prescribing

and administration information for each specific vaccination administered to a patient

(see also Table 64-1). The technique of vaccine administration by either route should

include sterilizing the skin surface, drawing up the vaccine from the vial into a

syringe using sterile technique, protecting the patient and health care provider

regarding biological hazards, performing proper disposal of biohazardous/sharps

materials (needles and blood-borne products), observing for adverse effects after

administration, and reassuring the patient postvaccine administration. Table 64-3

includes general guidelines for safe and effective parenteral administration.

CASE 64-17

QUESTION 1: B.D., a nurse from a family medicine clinic, frantically calls you because she mistakenly

administered a Pneumovax vaccination subcutaneously. How to you respond to B.D.’s call?

The majority of vaccines, including Pneumovax, specify IM administration. This

technique involves penetration of the appropriate muscle at a 90-degree angle. For

graphical illustration of intramuscular vaccine administration, see

http://www.immunize.org/catg.d/p2020.pdf. Site of IM injections include the

anterolateral thigh muscle in infants and toddlers, and the deltoid (upper arm) muscle

for children and adults.

1

,

112 The typical needle used to administer an IM injection is 1

inch long and 22 to 25 gauge. A shorter needle (e.g., 5/8 inch) may be used for

newborns, whereas a 1 to 1/2-inch needle may be needed for adults weighing greater

than 90 kg for women and 118 kg for men.

112

,

113 Multiple IM injections given in the

same extremity during the same time period should be placed at least 1 inch apart.

1

Although most vaccine products specify the route of administration, Pneumovax may

be administered either IM or into subcutaneous tissue.

114 Therefore, B.D. should be

reassured that she has administered the Pneumovax correctly because it is acceptable

to administer this vaccination by either route.

p. 1363

p. 1364

Table 64-3

Subcutaneous and Intramuscular Vaccine Administration Techniques

Patient Age Site Injection Area

Typical Needle

Length (inch)

Needle

Gauge

Birth to 12 months Subcutaneous Fatty tissue over the

anterolateral thigh muscle

5/8 23–25

12 months and older Subcutaneous Fatty tissue over anterolateral

thigh or fatty tissue over triceps

5/8 23–25

Newborn (0–28

days)

Intramuscular Anterolateral thigh muscle 5/8 22–25

Infant (1–12 months) Intramuscular Anterolateral thigh muscle 1 22–25

Toddler (1–3 years) Intramuscular Anterolateral thigh muscle OR

Deltoid muscle of arm if muscle

mass is adequate

1–1¼

5/8–1

22–25

Children (3–18

years)

Intramuscular Deltoid muscle OR

Anterolateral thigh muscle

5/8–1

1–1¼

22–25

Adults ≥19 years Intramuscular Deltoid muscle OR

Anterolateral thigh muscle

1–1½ 22–25

Sources: National Center for Immunization and Respiratory Diseases. General recommendations on

immunizations-recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR

Recomm Rep. 2011;60:1–61; Immunization Action Coalition. How to Administer Intramuscular (IM) Vaccine

Injections. http://www.immunize.org/catg.d/p2020.pdf. Accessed May 27 2015; Immunization Action Coalition.

Administering Vaccines: Dose, route, site, and needle size. http://www.immunize.org/catg.d/p3085.pdf.

Accessed May 27 2015.

Subcutaneous vaccinations involve injection of vaccine into fatty subcutaneous

tissue between the layer of skin and the layer of muscle.

1

,

112 Subcutaneous

vaccinations are administered with a 5/8-inch needle, 23 to 25 gauge, inserted at a

45-degree angle to the skin, while pinching up on the subcutaneous tissue to prevent

injection into the muscle. For graphical illustration of subcutaneous vaccination

administration, see http://www.immunize.org/catg.d/p2020.pdf. Sites of

subcutaneous injections include the fatty tissue over the anterolateral thigh muscle in

children newborn to 1 year old, and fatty tissue over the triceps in children 1 year old

to adults. Multiple subcutaneous injections given in the same extremity during the

same time period should be placed at least 1 inch apart.

Other routes of administration for vaccinations include the oral, intranasal, and

intradermal routes. Rotavirus and oral typhoid are the only orally administered

vaccines in the United States.

1

Inactivated influenza is the only intranasal vaccine,

administered via a nasal sprayer with a dose divider. Intradermal influenza is the

only intradermally administered vaccine, and it is administered in the area of the

deltoid at a 90-degree angle into the skin.

113

LEGAL REQUIREMENTS

CASE 64-18

QUESTION 1: What are the requirements necessary to become a pharmacist immunizer? How are

pharmacists advocates for improving population immunization rates?

Pharmacists have varying authority to administer vaccinations within the United

States based on each state’s Pharmacy Practice Act. The rationale for pharmacists to

deliver immunizations to the public includes pharmacist accessibility in every

community and overall low vaccination rates throughout the population.

115 The

Department of Health & Human Services and Centers for Disease Control and

Prevention recognized pharmacist’s unique position to promote vaccines and also

influence vaccination in diverse populations through a letter from the Assistant

Surgeon General.

116 This letter also acknowledged pharmacist’s contribution to

increase immunization awareness in the past, but it also requested continued

assistance in this endeavor through the following:

Increasing vaccine awareness in the adult and adolescent population

Ensuring patient’s vaccine requirements are assessed when they visit pharmacies

Offering vaccinations to patients with certain medical conditions (high risk)

Entering adult immunizations into vaccine registries where possible

Partnering and collaborating with local and state health departments, immunization

coalitions, medical providers, and other vaccination outreach programs

The American Pharmacist’s Association has developed a national competencybased certificate training program for pharmacists, and most schools of pharmacy

across the country contain or provide an opportunity to learn immunization

administration within their curriculum.

117 These programs include both didactic and

hands-on training and prepare the learners to be public health educators regarding

immunizations, to promote vaccinations within their community, and to administer

vaccines at their practice sites.

Although each state’s requirements regarding necessary training, protocols, and

notification systems may differ, there are some standardized requirements a

pharmacist immunizer must follow. Current cardiopulmonary resuscitation

certification is a common requirement for pharmacist immunizers. Immunization

administration curricula typically contain information regarding basic immunology,

specifics regarding vaccine information, practice implementation, legal and

regulatory issues, and administration techniques.

117 Each state stipulates the statutes

on patient age that

p. 1364

p. 1365

may receive a pharmacist-administered vaccination; what types of vaccinations

pharmacists are able to administer; and the mechanism by which pharmacists are

authorized to administer vaccines by physicians, such as through a prescription,

collaborative drug therapy management agreement, protocol, or standing order.

118

Some states require continuing-education credit maintenance specific to

immunizations or vaccinations for pharmacists who immunize; some states are very

specific in their requirements, and others are more general. It is important to check

with the state licensing board regarding specific statutes and regulations relating to

pharmacist immunization practices. In addition, a growing number of states have

passed legislation allowing pharmacy interns with the necessary training to

administer immunizations. Currently, 44 states and territories have adopted

legislation allowing pharmacy interns to administer vaccines, given the student has

completed an immunization certificate program and operates only under supervision

of an immunizing pharmacist.

118

Patient consent forms for immunization and vaccine information sheets are

important aspects for patient safety that pharmacists are required to use as part of an

approved immunization program. Consent forms should include screening

questionnaires specific for each vaccine, should be signed prior to vaccine

administration, and should be reviewed by the pharmacist with the patient present.

Vaccine information sheets are patient information developed by the CDC providing

specific individual vaccine information benefits and risks, and they are required to

be distributed to the patient with each vaccine by the National Childhood Vaccine

Injury Act of 1986. Resources for pharmacists are available through the CDC,

Immunization Action Coalition, and American Pharmacists Association.

119–121

KEY REFERENCES AND WEBSITES

A full list of references for this chapter can be found at

http://thepoint.lww.com/AT11e. Below are the key references and websites for this

chapter, with the corresponding reference number in this chapter found in parentheses

after the reference.

Key References

Bonten MJM et al. Polysaccharide conjugate vaccine against pneumococcal pneumonia in adults. N Engl J Med.

2015;372:1114–1125. (80)

Centers for Disease Control. Prevention and control of influenza with vaccines: recommendations of the Advisory

Committee on Immunization Practices (ACIP), 2010 [published corrections appear in MMWR Recomm Rep.

2010;59:1147; MMWR Recomm Rep. 2010;59:993]. MMWR Recomm Rep. 2010;59(RR-8):1. (92)

Centers for Disease Control. Updated recommendations for prevention of invasive pneumococcal disease among

adults using the 23-valent pneumococcal polysaccharide vaccine (PPSV23). MMWR Morb Mortal Wkly Rep.

2010;59:1102. (74)

Centers for Disease Control and Prevention. Prevention and control of meningococcal disease: recommendations

of the Advisory Committee of Immunization Practices (ACIP). MMWR Morb Mortal Wkly Rep. 2013;62(RR2):1-22. (62)

Centers for Disease Control and Prevention. Updated recommendations for use of tetanus toxoid, reduced

diphtheria toxoid, and acellular pertussis vaccine (Tdap) in pregnant women: Advisory Committee on

Immunization Practices (ACIP). MMWR Morb Mortal Wkly Rep. 2013; 62:131–135. (46)

Cortese MM et al. Prevention of rotavirus gastroenteritis among infants and children: recommendations of the

Advisory Committee on Immunization Practices (ACIP) [published correction appears in MMWR Recomm

Rep. 2010;59:1074]. MMWR Recomm Rep. 2009;58(RR-2):1. (96)

Harpaz R et al. Prevention of herpes zoster: recommendations of the Advisory Committee on Immunization

Practices (ACIP). MMWR Recomm Rep. 2008;57(RR-5):1. (110)

Marin M et al. Prevention of varicella: recommendations of the Advisory Committee on Immunization Practices

(ACIP). MMWR Recomm Rep. 2007;56(RR-4):1. (108)

Marin M et al. Use of combination measles, mumps, rubella and varicella vaccine: recommendations of the

Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2010;59(RR-3):1. (102)

Mast EE et al. A comprehensive immunization strategy to eliminate the transmission of hepatitis B virus infection in

the United States: recommendations of the Advisory Committee on Immunization Practices (ACIP) part I:

immunization of infants, children, and adolescents [published corrections appear in MMWR Morb Mortal Wkly

Rep. 2006;55:158; MMWR Morb Mortal Wkly Rep. 2007;56:1267]. MMWR Recomm Rep. 2005;54(RR-16):1.

(33)

Mast EE et al. A comprehensive immunization strategy to eliminate the transmission of hepatitis B virus infection in

the United States: recommendations of the Advisory Committee on Immunization Practices (ACIP) part II:

immunization of adults [published correction appears in MMWR Morb Mortal Wkly Rep. 2007;56:1114].

MMWR Recomm Rep. 2006;55(RR-16):1. (34)

National Center for Immunization and Respiratory Diseases. General recommendations on immunizations—

recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep.

2011;60:1. (1)

Nuorti JP et al. Prevention of pneumococcal disease among infants and children—use of 13-valent pneumococcal

conjugate vaccine and 23-valent pneumococcal polysaccharide vaccine. Recommendations of the Advisory

Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2010;59(RR-11):1. (75)

Petrosky et al. Use of 9-valent human papillomavirus (HPV) vaccine: updated HPV vaccination recommendations

of the Advisory Committee on Immunization Practices. MMWR Morb Motal Wkly Rep. 2015;64:300–304. (66)

Key Websites

American Pharmacists Association. Immunization Center. http://www.pharmacist.com/immunization-center.

Accessed June 1, 2015.

APhA authority to immunize website.

http://www.pharmacist.com/sites/default/files/files/Pharmacist_IZ_Authority_1_31_15.pdf. Accessed

June 1, 2015.

Centers for Disease Control. Vaccine information statements.

http://www.cdc.gov/vaccines/hcp/vis/index.html. Published April 27, 2015. Accessed June 1, 2015.

Centers for Disease Control and Prevention. Immunization schedules: adult immunization schedules, United States,

2017. http://www.cdc.gov/vaccines/schedules/hcp/adult.html. Accessed June 5, 2017.

Centers for Disease Control and Prevention. Immunization schedules: birth-18 years & “catch-up” immunizations

schedules, United States, 2017. http://www.cdc.gov/vaccines/schedules/hcp/child-adolescent.html.

Accessed June 5, 2017.

Immunization Action Coalition. Administering Vaccines: dose, route, site, and needle size.

http://www.immunize.org/catg.d/p3085.pdf. Accessed May 27, 2015.

Immunization Action Coalition. Handouts: clinic resources. http://www.immunize.org/handouts/screeningvaccines.asp. Reviewed March 27, 2015. Accessed June 1, 2015.

Immunization Action Coalition. How to Administer Intramuscular (IM) Vaccine Injections.

http://www.immunize.org/catg.d/p2020.pdf. Accessed May 27, 2015.

COMPLETE REFERENCES CHAPTER 64 VACCINATIONS

National Center for Immunization and Respiratory Diseases. General recommendations on immunizationsrecommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep.

2011;60:1–61.

Elam-Evans LD et al. National, state, and selected local area vaccination coverage among children aged 19–35

months – United States, 2013. MMWR. 2014;63:741–748.

Williams WW et al. Surveillance of Vaccination Coverage Among Adult Populations: United States, 2014. MMWR

Surveill Summ 2016;65(No. SS-1):1–36

Luman ET et al. Timliness of childhood vaccinations in the United States: days undervaccinated and number of

vaccines delayed. JAMA. 2005;293:1204–1211.

Constable C et al. Rising rates of vaccine exemptions: problems with current policy and more promising remedies.

Vaccine. 2014;32:1793–1797.

Siddiqui M et al. Epidemiology of vaccine hesitancy in the United States. Hum Vaccin Immunother. 2013;9:2643–

2648.

Omer SB et al. Vaccine refusal, mandatory immunization, and the risks of vaccine-preventable diseases. N EnglJ

Med. 2009;360:1981–1988.

Keeton VF, Chen AK. Immunization updates and challenges. Curr Opin Pediatr. 2010;22:234–240.

Zepp F. Principles of vaccine design—lessons from nature. Vaccine. 2010;28S:C14–C24.

Moser M, Leo O. Key concepts in immunology. Vaccine. 2010;28S:C2–C13.

Lee S, Nguyen MT. Recent advances of vaccine adjuvants for infectious diseases. Immune Netw. 2015;15:51–

57.

Jennings GT, Bachmann MF. Designing recombinant vaccines with viral properties: a rational approach to more

effective vaccines. Curr Mol Med. 2007;7:143–145.

Coffman RL et al. Vaccine adjuvants: putting innate immunity to work. Immunity. 2010;33:492–503.

Centers for Disease Control and Prevention. Principles of vaccinations. In: Hamborsky J et al, eds. Epidemiology

and Prevention of Vaccine-Preventable Diseases. 13th ed. Washington D.C.: Public Health Foundation;

2015:1–8.

Braun MM et al. Syncope after immunization. Arch Pediatr Adolesc Med. 1997;151:255.

Centers for Disease Control and Prevention. Syncope after vaccination—United States, January 2005–July 2007.

MMWR Morb Mortal Wkly Rep. 2008;57:457.

Babl FE et al. Vaccination-related adverse events. Pediatr Emerg Care. 2006;22:514.

Bohlke K et al. Risk of anaphylaxis after vaccination of children and adolescents. Pediatrics. 2003;112:815.

Kemp A et al. Measles immunization in children with clinical reactions to egg protein. Am J Dis Child.

1990;144:33.

Fasano MB et al. Egg hypersensitivity and adverse reactions to measles, mumps, and rubella vaccine. J Pediatr.

1992;120:878.

James JM et al. Safe administration of the measles vaccine to children allergic to eggs. N Engl J Med.

1995;332:1262.

Advisory Committee on Immunization Practices (ACIP). Update: vaccine side effects, adverse reactions,

contraindications, and precautions. Recommendations of the Advisory Committee on Immunization Practices

(ACIP) [published correction appears in MMWR Morb Mortal Wkly Rep. 1997;46:227]. MMWR Recomm

Rep. 1996;45(RR-12):1.

Centers for Disease Control and Prevention. From the Centers for Disease Control and Prevention. Progress

toward elimination of Haemophilus influenzae type b disease among infants and children—United States, 1987–

1995. JAMA. 1996;276:1542.

Smith M. National childhood vaccine injury compensation act. Pediatrics. 1988;82:264.

Saari TN; American Academy of Pediatrics Committee on Infectious Disease. Immunization of preterm and low

birth weight infants. Pediatrics. 2003;112:193.

Strikas RA; Advisory Committee on Immunization Practices (ACIP), ACIP Child/Adolescent Immunization Work

Group. Advisory Committee on Immunization Practices recommended immunization schedules for persons aged

0 through 18 years—United States, 2015. MMWR Morb Mortality Wkly Rep. 2015;64:93–94.

Centers for Disease Control and Prevention. Immunization schedules: birth-18 years & “catch-up” immunizations

schedules, United States, 2017. http://www.cdc.gov/vaccines/schedules/hcp/child-adolescent.html.

Accessed June 5, 2017.

Kim DK et al; Advisory Committee on Immunization Practices (ACIP). Advisory Committee on Immunization

Practices recommended immunization schedule for adults aged 19 years or older: United States, 2017. MMWR

Morb Mortal Wkly Rep. 2017;66(5):136–138.

Kim DK et al; Advisory Committee on Immunization Practices (ACIP), ACIP Adult Immunization Work Group.

Advisory Committee on Immunization Practices Recommended Immunization Schedule for Adults aged 19

years or older – Unites States, 2015. MMWR Morb Mortality Wkly Rep. 2015;64:91–92.

Centers for Disease Control and Prevention. Immunization schedules: adult immunization schedules, United

States, 2017. http://www.cdc.gov/vaccines/schedules/hcp/adult.html. Accessed June 5, 2017.

Foster SL et al. Vaccination of patients with altered immunocompetence. J Am Pharm Assoc. 2013;53:438–440.

Margolis HS et al. Hepatitis B: evolving epidemiology and implications for control. Semin Liver Dis. 1991;11:84.

Schillie S et al. Update: shortened interval for postvaccination serologic testing of infants born to hepatitis binfected mothers. MMWR Morb Mortal Wkly Rep. 2015;64(39):1118–1120.

Mast EE et al. A comprehensive immunization strategy to eliminate the transmission of hepatitis B virus infection

in the United States: recommendations of the Advisory Committee on Immunization Practices (ACIP) part II:

immunization of adults [published correction appears in MMWR Morb Mortal Wkly Rep. 2007;56:1114].

MMWR Recomm Rep. 2006;55(RR-16):1.

Advisory Committee on Immunization Practices (ACIP), the American Academy of Pediatrics (AAP), and the

American Academy of Family Practice (AAFP). Combination vaccines for childhood immunization:

recommendations of the Advisory Committee on Immunization Practices (ACIP), the American Academy of

Pediatrics (AAP), and the American Academy of Family Practice (AAFP). Pediatrics. 1999;103:1064.

Centers for Disease Control and Prevention. Use of hepatitis B vaccination for adults with diabetes mellitus:

recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Morb Mortal Wkly

Rep. 2011;60:1709–1711.

Advisory Committee on Immunization Practices (ACIP). Prevention of hepatitis A through active or passive

immunization: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR

Recomm Rep. 2006;55(RR-7):1.

National Immunization Program, Department of Health and Human Services. Hepatitis A. In: Epidemiology and

Revention of Accine Preventable Diseases. 9th ed. Atlanta, GA: Centers for Disease Control and Prevention;

2006:101.

Dagan R et al. Incidence of hepatitis A in Israel following universal immunization of toddlers. JAMA.

2005;294:202–210.

Katz SL. Controversies in immunization. Pediatr Infect Dis J. 1987;6:607.

Advisory Committee on Immunizations Practices (ACIP). Pertussis vaccination: use of acellular pertussis

vaccines among infants and young children. Recommendations of the Advisory Committee on Immunizations

Practices (ACIP) [published correction appears in MMWR Morb Mortal Wkly Rep. 1997;46:706]. MMWR

Recomm Rep. 1997;46(RR-7):1.

Broder KR et al. Preventing tetanus, diphtheria, and pertussis among adolescents: use of tetanus toxoid, reduced

diphtheria toxoid and acellular pertussis vaccines: recommendations of the Advisory Committee on

Immunization Practices (ACIP). MMWR Recomm Rep. 2006;55(RR-3):1.

Kretsinger K et al. Preventing tetanus, diphtheria, and pertussis among adults: use of tetanus toxoid, reduced

diphtheria toxoid and acellular pertussis vaccines: recommendations of the Advisory Committee on

Immunization Practices (ACIP). MMWR Recomm Rep. 2006;55(RR-17):1.

Centers for Disease Control and Prevention. Updated recommendations for use of tetanus toxoid, reduced

diphtheria toxoid, and acellular pertussis vaccine (Tdap) vaccine from the Advisory Committee on Immunization

Practices (ACIP), 2010. MMWR Morb Mortal Wkly Rep. 2011; 60:13–15.

Nennig ME et al. Prevalence and incidence of adult pertussis in an urban population. JAMA. 1996;275:1772.

Centers for Disease Control and Prevention. Updated recommendations for use of tetanus toxoid, reduced

diphtheria toxoid, and acellular pertussis vaccine (Tdap) in pregnant women: Advisory Committee on

Immunization Practices (ACIP). MMWR Morb Mortal Wkly Rep. 2013; 62:131–135.

Advisory Committee on Immunization Practices (ACIP). Diphtheria, tetanus, and pertussis: recommendations for

vaccine use and other preventive measures: recommendations of the Advisory Committee on Immunization

Practices (ACIP). MMWR Recomm Rep. 1991;40(RR-10):1.

Fraser DW. Haemophilus influenzae in the community and the home. In: Sell SH, Wright PF, eds. Haemophilus

Influenzae: Epidemiology, Immunology, and Prevention of Disease. New York, NY: Elsevier Science; 1982:11.

Schlech W III et al. Bacterial meningitis in the United States, 1978 through 1981. The National Bacterial

Meningitis Surveillance Study. JAMA. 1985;253:1749.

Dajani AS et al. Systemic Haemophilus influenzae disease: an overview. J Pediatr. 1979;98:355.

Taylor HG et al. Intellectual, neuropsychological, and achievement outcomes in children six to eight years after

recovery from Haemophilus influenzae meningitis. Pediatrics. 1984;74:198.

Peltola H et al. Prevention of Haemophilus influenzae type b bacteremic infections with the capsular

polysaccharide vaccine. N EnglJ Med. 1984;310:1561.

[No authors listed]. Polysaccharide vaccine for prevention of Haemophilus influenzae type b disease. JAMA.

1985;253:2630.

[No authors listed]. Progress toward elimination of Haemophilus influenzae type b disease among infants and

children—United States, 1987–1995. JAMA. 1996;276:1542.

Lepow ML et al. Safety and immunogenicity of Haemophilus influenzae type b diphtheria toxoid conjugate

vaccine (PRP-D) in infants. J Infect Dis. 1987;156:591.

Briere EC et al. Prevention and control of Haemophilus influenzae Type B disease: recommendations of the

Advisory Committee on Immunization Practices (ACIP). MMWR Morb Mortal Wkly Rep. 2014;63(RR-01):1–

14.

National Immunization Program, Department of Health and Human Services. Poliomyelitis. In: Epidemiology and

Prevention of Vaccine Preventable Diseases. 9th ed. Atlanta, GA: Centers for Disease Control and Prevention;

2006:249.

Sutter RW, Prevots DR. Vaccine-associated paralytic poliomyelitis among immunodeficient persons. Infect Med.

1994;11:426.

Prevots DR et al. Poliomyelitis prevention in the United States. Updated recommendations of the Advisory

Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2000;49(RR-5):1.

Centers for Disease Control and Prevention. Updated recommendations of the Advisory Committee on

Immunization Practices (ACIP) regarding routine poliovirus vaccination. MMWR Morb Mortal Wkly Rep.

2009;58:829

Centers for Disease Control and Prevention. Prevention and control of meningococcal disease: recommendations

of the Advisory Committee of Immunization Practices (ACIP). MMWR Morb Mortal Wkly Rep. 2017;

66(19):509–513.

Centers for Disease Control and Prevention. Update: Guillain-Barre syndrome among recipients of Menactra

meningococcal conjugate vaccine—United States, June 2005–September 2006. MMWR Morb Mortal Wkly

Rep. 2006;55:1120.

Workowski KA, Berman S. Sexually transmitted diseases treatment guidelines, 2010 [published correction

appears in MMWR Recomm Rep. 2011;60:18]. MMWR Recomm Rep. 2010;59(RR-12):1.

Dunne EF et al. CDC Grand Rounds: reducing the burden of HPV-associated cancer and disease. MMWR Morb

Mortal Wkly Rep. 2014;63;69–72.

Meites E, Kempe A, Markowitz LE. Use of a 2-Dose Schedule for Human Papillomavirus Vaccination: Updated

Recommendations of the Advisory Committee on Immunization Practices. MMWR Morb Mortal Wkly Rep.

2016;65:1405–1408.

Guiliano AR et al. Efficacy of quadrivalent HPV vaccine against HPV infection and disease in males [published

correction appears in N EnglJ Med. 2011;364:1481]. N EnglJ Med. 2011;364:401.

Saslow D et al. American Cancer Society Guideline for human papillomavirus (HPV) vaccine use to prevent

cervical cancer and its precursors. CA Cancer J Clin. 2007; 57:7.

Garland SM et al. Quadrivalent vaccine against human papillomavirus to prevent anogenital diseases. N Engl J

Med. 2007;356:1928.

Kahn JA. HPV vaccination for the prevention of cervical intraepithelial neoplasia. N EnglJ Med. 2009;361:271.

FUTURE II Study Group. Quadrivalent vaccine against human papillomavirus to prevent high-grade cervical

lesions. N EnglJ Med. 2007;356:1915.

Centers for Disease Control and Prevention (CDC). FDA licensure of bivalent human papillomavirus vaccine

(HPV2, Cervarix) for use in females and updated HPV vaccination recommendations from the Advisory

Committee on Immunization Practices (ACIP) [published correction appears in MMWR Morb Mortal Wkly

Rep. 2010;59:1184]. MMWR Morb Mortal Wkly Rep. 2010; 59:626.

Gardasil 9 [package insert]. Whitehouse Station, NJ: Merck & Co; 2015.

Centers for Disease Control and Prevention. Updated recommendations for prevention of invasive pneumococcal

disease among adults using the 23-valent pneumococcal polysaccharide vaccine (PPSV23). MMWR Morb

Mortal Wkly Rep. 2010;59:1102–1106.

NuortiJP et al. Prevention of pneumococcal disease among infants and children—use of 13-valent pneumococcal

conjugate vaccine and 23-valent pneumococcal polysaccharide vaccine. Recommendations of the Advisory

Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2010;59(RR-11):1–22.

Centers for Disease Control and Prevention. Use of 12-valent pneumococcal conjugate vaccine and 23-valent

pneumococcal polysaccharide vaccine for adults with immunocompromising conditions: recommendations of the

Advisory Committee on Immunization Practices (ACIP). MMWR Morb Mortal Wkly Rep. 2012;61:816–819.

Esposito S et al. Safety and immunogenicity of a 13-valent pneumococcal conjugate vaccine compared to those of

a 7-valent pneumococcal conjugate vaccine given as a three-dose series with routine vaccines in healthy infants

and toddlers. Clin Vaccine Immunol. 2010;17:1017.

Centers for Disease Control and Prevention. Use of 13-valent pneumococcal conjugate vaccine and 23-valent

pneumococcal polysaccharide vaccine among children aged 6–18 years with immunocompromising conditions:

recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Morb Mortal Wkly

Rep. 2013;62:521–524.

Tomczyk S et al. Use of 13-valent pneumococcal conjugate vaccine and 23-valent pneumococcal polysaccharide

vaccine among adults aged >65 years: recommendations of the Advisory Committee on Immunization Practices

(ACIP). MMWR Morb Mortal Wkly Rep. 2014;63:822–826.

Bonten MJM et al. Polysaccharide conjugate vaccine against pneumococcal pneumonia in adults. N EnglJ Med.

2015;372:1114–1125.

Centers for Disease Control and Prevention. Prevention and control of seasonal influenza with vaccines:

recommendations of the Advisory Committee on Immunization Practices—United States, 2013–2014. MMWR

Recomm Rep. 2013;62(R-07):1–46.

Grohskopf LA et al. Prevention and control of seasonal influenza with vaccines: recommendations of the

Advisory Committee on Immunization Practices (ACIP)-United States, 2016-2017 influenza season. MMWR.

2016;65:1–54.

Centers for Disease Control and Prevention. Licensure of a high-dose inactivated influenza vaccine for persons

aged >65 years (Fluzone High-Dose) and guideance for use—United States, 2010. MMWR Morb Mortal Wkly

Rep. 2010;59:485–486.

Couch RB et al. Safety and immunogenicity of a high dosage trivalent influenza vaccine among elderly subjects.

Vaccine. 2007;25:7656–7663.

Falsey AR et al. Randomized, double-blind controlled phase 3 trial comparing the immunogenicity of high-dose

and standard-dose influenza vaccine in adults 65 years of age and older. J Infect Dis. 2009;200:172–180.

Keitel WA et al. Safety of high doses of influenza vaccine and effect on antibody responses in elderly persons.

Arch Intern Med. 2006:1121–1127.

DiazGranados CA et al. Efficacy of high-dose versus standard-dose influenza vaccine in older adults. N Engl J

Med. 2014;371:635–645.

Belshe RB et al. The efficacy of live attenuated, cold-adapted, trivalent, intranasal influenza virus vaccine in

children. N EnglJ Med. 1998;338:1405.

Edwards KM et al. A randomized controlled trial of cold-adapted and inactivated vaccines for the prevention of

influenza A disease. J Infect Dis. 1994;169:68.

Nichol KL et al. Effectiveness of live, attenuated intranasal influenza virus vaccine in healthy, working adults.

JAMA. 1999;282:137.

Belshe RB et al. Efficacy of accination with live attenuated, cold-adapted, trivalent, intranasal influenza virus

100.

101.

102.

103.

104.

105.

106.

107.

108.

109.

110.

111.

112.

113.

114.

115.