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3m.1 What other vaccines are available and when are they given?


This article is from the Childhood Vaccinations FAQ, by Lynn Gazis-Sax lynng@alsirat.com with numerous contributions by others.

3m.1 What other vaccines are available and when are they given?

Other vaccines available include vaccines for cholera, Japanese
encephalitis, typhoid, yellow fever, rabies, plague, Lyme disease, and
anthrax. _Travel Medicine Advisor_ also mentions a vaccine for typhus,
but, according to the 1996-1997 edition of the CDC Yellow Book (CDC
Health Information for International Travel), "production of this
vaccine has been discontinued in the US and there are no plans for
commercial production of a new vaccine." Since other countries may
offer typhus vaccination (though, to the best of my knowledge, it is
not required for travel to any country), I am drawing information for
this vaccine from a German web site. Immune globulins are also
available for a variety of diseases.

For more information on these other vaccines, check the _American
Hospital Formulary Service Drug Information_ (a better source than the
PDR in this case) and _Health Information for Travelers_, which is put
out by the CDC every year (vaccination and booster schedules for all
of these vaccines can be found there, as can information on where
these diseases are common and what vaccination requirements various
countries have for entrance). The latter can be purchased from the
Superintendent of Documents, U.S. Government Printing Office,
Washington, D.C. 20402, and most local health departments have a copy
which can be consulted, sometimes by telephone. It can also be found
in some public libraries. The CDC also has a Worldwide Web site which
can be accessed for travel information: http://www.cdc.gov/. The
International Association for Medical Assistance to Travellers
(IAMAT), which has affiliated institutions in over 115 countries, puts
out a _World Immunization Chart_. The address of the U.S. affiliate is
IAMAT, 736 Center Street, Lewiston, N.Y. 14092. The World Health
Organization produces a publication on international travel; it is
called _INTERNATIONAL TRAVEL AND HEALTH: Vaccination Requirements and
Health Advice_, and copies may be ordered from WHO Distribution and
Sales, CH-1211, Geneva 27, telephone (41 22) 791 2476; fax (41 22) 788
0401. The price is 15 Swiss Francs; in developing countries: 10.50
Swiss Francs. Further information about rabies can be found in books
on mountaineering and spelunking (the one I consulted is _Medicine for
Mountaineering_, by James A. Wilkerson, M.D.). Hepatitis B, hepatitis
A, and meningococcus vaccines are given for travel, so people
interested in travel vaccinations may want to check the sections of
this FAQ dealing with those vaccines.

Anthrax vaccine, in the US, is mainly used by the military as a
protection against biological warfare; small quantities are also made
available to people with an occupational exposure, such as
veterinarians and lab workers. Since vaccines given by the military to
soldiers are outside the scope of a FAQ primarily concerned with
vaccines which might be given to children, I will not be discussing
the anthrax vaccine further.

Cholera is an intestinal infection spread by contaminated food and
water. Cholera vaccination is about 25-50% effective in reducing
clinical illness for 3-6 months after vaccination (with the greatest
protection during the first two months). (_Health Information for
Travellers_ gives the effectiveness as 50%, and AHFS Drug Information
gives it as 25-50%.) Boosters are every six months for travelers who
will be staying for a long time in cholera-endemic areas. Serious
reactions are rare. Since the effectiveness is so low, neither the CDC
nor the WHO actually recommends the vaccine, but some countries
require it. According to AHFS Drug Information, "_Cholera vaccine
does not prevent transmission of infection_, and should not be used to
manage contacts of imported cholera cases or to control the spread of

Vaccine components capable of causing adverse reactions: bacterial
components (Travel Medicine Advisor). The vaccine should not be given
to children under 6 months.

Japanese encephalitis B vaccine, licensed in 1993, is given to
travelers "who expect to go beyond the usual tourist routes or to
spend extended time in rural areas in disease endemic regions"
(Harrison's) Its efficacy is estimated at 80-90%. Anaphylactic and
severe delayed allergic reactions are common, so people who receive
this vaccine should be observed for ten days.

Lyme disease vaccine, licensed on December 21, 1998, is licensed (as
of September, 1999) only for people 15 years or older, though that age
limit may soon be eliminated. It is recommended for adults and older
teens who spend lots of time outdoors in Lyme-endemic areas. You
should still protect yourself against ticks if using the vaccine, both
because the vaccine isn't 100 per cent effective and because ticks
also carry other diseases. In a randomized, double-blind, multicenter
trial involving 10,936 people living in the northeastern and upper
north central United States, the vaccine efficacy at preventing Lyme
disease was 50% (MMWR, January 22, 1999 / 48(02);35-36,43). The
duration of immunity is unknown. Side effects included local
reactions, transient myalgia or arthralgia, influenza-like illness,
fever, and chills.

It is unlikely that your child will ever need a plague
vaccination. The disease is found among rural rodents in some areas,
including the Western third of the US, but urban outbreaks are now
rare. Vaccination is only recommended for people at increased risk due
to research or field activities in epizootic areas. An alternative for
people at increased risk is tetracycline prophylaxis. _AHFS Drug
Information_ gives the vaccine's effectiveness as 90% for 6-12
months. Other measures for avoiding plague in epizootic areas are
getting rid of wild rodent food and shelter, defleaing dogs and cats
weekly, avoiding sick or dead rodents, and routine bacteriologic
precautions in labs.

Vaccine components capable of causing adverse reactions: phenol, beef
protein, soya, casein (Travel Medicine Advisor).

Rabies, an almost universally fatal disease transmitted by saliva and
brain tissue of infected animals, is rare in the US but more common in
some countries where pet vaccination is not common. Dogs are the main
reservoir in developing countries, but all animal bites should be
evaluated. The most common animal vectors in the US are carnivorous
small animals (such as skunks, racoons, foxes, coyotes, and bobcats)
and bats. There has been a recent increase in racoon rabies in the
mid-Atlantic and northeastern states of the US (MMWR 29 Apr 1994), and
programs to institute oral rabies vaccination of racoons, foxes and
coyotes have been initiated in some state (similar programs have been
used to control fox rabies in Canada and Europe). More than 50% of
rabies cases in the US come from exposure to rabid dogs outside the
US. The disease is most commonly spread by animal bites, but can also
be caught through non-bute exposure, including contact between
infected saliva or brain tissue and pre-existing cuts, scratches, open
wounds, or mucuous membranes. There are also cases of aerosolized
transmission in medical laboratories and caves inhabited by rabid
bats, and transmission through cornea transplants from people who had
died of undiagnosed (before the transplant) cases of rabies. The
chance of infection is more likely in case of bite or non-bite
exposure to the head, neck, face, shoulders, or hands, than with
similar exposure to the trunk or legs.

In case of exposure to rabies, the wound should be immediately and
thoroughly cleaned with soap and water. "Although not included in the
ACIP recommendations, some clinicians also rinse the wound thoroughly
with water or 0.9% sodium chloride solution and then cleanse with a
topical antiseptic (e.g. povidone-iodine)." (AHFS Drug Information
1992) It is also important to promptly vaccinate anyone exposed to
rabies (and give rabies immune globulin if the person has not been
previously vaccinated), as the disease is, for all practical purposes,
always fatal once rabies symptoms begin to show up. (A few people have
recently survived after symptoms appeared, but they all had serious
brain damage.) Pre-exposure vaccination is given to people who live in
or visit rabies endemic areas and to people whose professions or
activities put them at extra risk, such as lab workers, veterinarians,
and spelunkers. The highest travel risk is where dog rabies is still

There is some drug interference between chloroquine (an anti-malarial
drug) and rabies vaccine, but intramuscular injection can take care of
the problem. Need for boosters depends on risk category, and ranges
from regular tests of antibody levels every six months, with
vaccination when they drop, for rabies lab workers, to no pre-exposure
vaccination for most people. Post-exposure, unvaccinated people get
rabies immune globulin and rabies vaccine, while previously vaccinated
people get rabies vaccine alone, in a smaller amount. Adverse effects
include local reactions (30-74% of vaccinees) and mild systemic
reactions (e.g. headache, nausea, 5-40% of vaccinees). About 6% of
vaccinees have a reaction characterized by urticaria, pruritis, and
malaise. Rarely, anaphylactic shock may occur. Because rabies is so
deadly, pregnancy is *not* a contraindication to postexposure

Vaccine components capable of causing adverse reactions: neomycin,
phenol red, thimerosal (Travel Medicine Advisor).

The following posting from sci.med, by Achim Lohse, provides further
information about rabies vaccine (the side effect under discussion is
anaphylactic shock):

In Canada (at least as of two years ago) there is only one rabies
vaccine availble, and the manufacturer supplies it only in
one-millitre vials, with strict instructions to use the entire vial
for one injection only. At $60 + per vial, the series of three costs
over $180. I was fortunate to have a physician who had worked among
fur trappers up north, and had some familiarity with the vaccine. He
informed me that if injected _intra_dermally, a dose of only 0.1
millilitre is enough. I confirmed this with the local public health
nurse, who showed me that it had been standard public health procedure
in British Columbia for five years to use the 10% dose intradermally
(10 trappers would arrange to share the contents of a standard vial).

Later investigation via Medline showed that this particular vaccine
human diploid cell (HDCV) is not only the most expensive to produce,
but may also have a significantly higher rate of side-effects when
compared to the much less expensive purified chick embryo vaccine.

I had a taste of physician non-acceptance when my physician was away
after administering the first in the series of three shots. He
assumed any of the other five doctors in the rural practice could and
would complete the series. NOT! I was turned down flat by the two
experienced doctors on duty, and had to get my shot from the public
health nurse.

Rabies antibodies (assuming the initial titres are adequate) are
considered to be reliably adequate for only three years, after which a
booster is required (and with the HDVC adverse reactions have most
often been experienced with the booster). The alternative is to get a
Rabies titre test, but I understand (anyone have figures?) that this
is quite expensive, and in Canada's health system, may simply not be
available on demand in some provinces (unless you can persuade a
sympathetic public health official of the need).

>However, since it's unusual for people to get rabies and the vaccine
>does work fine after exposure, it will probably not be part of the
>usual childhood vaccines.
>Mike K

As someone noted in a previous post, the urgency of treatment depends
on the proximity of the infection site to the brain. A report from a
researcher from pre-war Yugoslavia (Zagreb) indicated that there wolf
attacks resulting in bites to the face and neck have resulted in
death, due to inability to get the antibody titres high enough in
time. One possible strategy to improve this situation (suggested to me
by Richard Passwater's book "Selenium as Food and Medicine") is to
take a large dose of selenium concurrent with or within a few hours of
vaccination. He reports that this
has greatly increased antibody titres with other vaccines.

Finally, aside from the risk of not being able to get to treatment in
time after clear exposure, there is the very real danger of unnoticed
infection, expecially in children, by having a cut finger or lip,
etc. come in contact with saliva from the tongue or coat of an
infected animal. There is even one reported instance of a spelunker
dying after supposedly no other exposure than inhaling saliva droplets
from rabid bats. Since unvaccinated victims can't be treated
successfully once symptoms appear, pre-vaccination is the only
available protection for this last type of exposure.


lohseach@max.cc.uregina.ca achim.lohse@f45.n140.z1.fidonet.org

From: Achim Lohse Subject: rabies vaccine - update

Hi Lynn. I did a little more reasearch on rabies vaccine in the past
two days, and learned that the Canadian manufacturer - Connaught Labs,
also markets the vaccine in the U.S.. In fact, it markets two
versions in the U.S., both are human deploid cell vaccines (HDCV), but
one, called "Merieux" is marketed in a 0.1 ml format for intradermal
injection. In Canada, ironically, this form is not available, and
only the 1 ml intramuscular form is marketed (suggested retail about
CDN$75 per vial).

I wasn't able to get any us prices, but was given a U.S. information

1-800-VACCINE , which of course, doesn't work from my (Canadian)
calling area.

I wasn't able to learn whether HDCV is the still the _only_ type of
rabies vaccine available in the U.S. (it is the only typpe in Canada).

Finally, I learned that there are two methods of testing rabies
antibody titre (to find out if you need a booster). The preferred one
is the neutralization assay type, in which diluted serum is mixed with
infected cell culture and checked for reaction. The titre is reported
as the highest dilution ratio that provokes a reaction, with 1:32
being the minimal acceptable titre. If titre is at 1:32, then
retesting or boosting is adviseable in a year to maintain adequate
protection. I couldn't get any details about the other method, called
complement fixation, except that the local expert considered it less
reliable. BTW - for Alberta and Saskatchewan (and possibly other
Canadian provinces) all rabies titre testing is done by the _Ontario_
Provincial Laboratory, so it's a slow and costly undertaking.





Smallpox vaccine is no longer given, because smallpox has been
eliminated by vaccination. The virus is currently kept in labs in the
US and Russia, just in case it is needed at some point (there has been
talk of destroying the last samples, but the virus recently got a
reprieve). Since the elimination of smallpox is one of the major
triumphs of vaccination, which is mentioned in many medical texts
which I consulted as an argument in favor of vaccination, I'll also
mention at this point that smallpox mortality was 25-30%, that it
infected 90% of the population at risk, and that there were 10-15
million cases worldwide as recently as 1967. The last natural case was
reported in 1977, and the last cases were reported in 1978, as a
result of an escape of the virus from a lab (the lab director
committed suicide while under quarantine). (Kiple) The only people who
still need to be vaccinated for smallpox are the people who work in
the labs where the virus is kept.

Vaccine components capable of causing adverse reactions: polymyxin B,
streptomycin, chlortetracycline, neomycin, phenol, brilliant green
dye, glycerin (Travel Medicine Advisor).

Typhoid is spread by contaminated food and water. The vaccine protects
70-90% of recipients. There are two forms of the vaccine: oral (live),
and parenteral (killed). The oral vaccine shouldn't be given to
immune-compromised people. Otherwise, there are few adverse reactions,
mostly local discomfort and sometimes fever and malaise. Boosters are
every three years for parenteral and five years for oral vaccine.

Vaccine components capable of causing adverse reactions: phenol,
bacterial components (Travel Medicine Advisor).

The following posting from sci.med gives further information on
typhoid vaccine:

From: "Mark A. Shelly" Subject: Re: Oral form of typhoid vaccine

>A typhoid vaccination is recommended for a trip to Costa Rica. My
>family doctor said that the last time she gave someone a prescription
>for the vaccine they came back with an oral vaccine. Since then she
>hasn't been able to find any information comparing the oral to the
>injectable form:
> - efficacy
> - scheduling (the injectable form requires 2 doses, the first a month
> before the trip)
> - side effects (she says that the injectable form tends to make you feel
> sick, the oral form may be an improvement).

Oral typhoid vaccine is a live but weakened (attenuated) strain
(Ty21a) of the Salmonella germ that causes typhoid fever.

The oral vaccine is probably equal to the injected vaccine in
efficacy, at about 80%.

It is given orally on an empty stomach every other day for 4 doses
(total elapsed time 6 days). It must be kept refrigerated but not
frozen, a significant limitation to use in other countries. You can't
be taking antibiotics at the same time.

It is very well tolerated. (The injected form has 80+% side
effects). If you have weakened immunity, or if you are too young to
take pills, you shouldn't use this vaccine.

I almost never recommend the injected form of typhoid vaccine. Typhoid
vaccine is recommended for travel to areas with poor water supplies
when the trip is over 3 weeks and when your eating will be "high

Hope this helps

Mark Shelly mshelly@medicine.rochester.edu

Typhus vaccine (not available in the US) is described by Andreas
Kaunzner's travel medicine Web site
(http://members.aol.com/reisemed/impfung/typhus.htm). According to
this site, there are two different typhus vaccines on the market in
Germany. One is a live oral vaccine, which is given in three doses,
and gives protection for about three years, if one stays in a region
where typhus is endemic; otherwise its immunity lasts for about a
year. The most common side effect, seen in fewer than 1% of those
receiving the vaccine, is stomach trouble. General symptoms such as
fever and chills can appear, and very seldom a rash. The other is a
killed vaccine, which may be given to adults and children two years or
older, and which provides immunity for at least three years. Its side
effects are described as "typical side effects of vaccinations" (local
reactions, fever, and allergic reactions) appearing only seldom. Kabel
1 Online has a chart of German travel vaccine recommendations
(http://www.kabel1.de/reise/1998/06/26/11/) which says that typhus
vaccine is given for trips of more than three months. The CDC, on the
other hand, recommends hygiene and, in areas where tick typhus is
endemic, tick removal and tick repellant; typhus vaccine production
has been discontinued in the US.

Yellow fever is a viral infection which is spread by mosquitos. Yellow
fever vaccine is a live vaccine which can be given only at certain
vaccination centers. Many countries require this vaccination for
entry. A booster is needed every ten years. Contraindications include
egg allergy and immune deficiency. Reactions are mostly mild.

Vaccine components capable of causing adverse reactions: chick embryo
components (Travel Medicine Advisor).

Travelers may also want to take anti-malarial drugs, bring insect
repellant containing N,N diethylmethylbenzamide, and avoid unboiled
water, raw vegetables, fruit they haven't peeled themselves,
undercooked fish and shellfish, and food kept at room
temperature. Other sources of travel health information are
_Fielding's Travelers' Medical Companion_ and the US State Department
Citizen's Emergency Center, which provides information on a variety of
foreign travel risks 24 hours a day at 202-647-5225. CDC Travelers'
Health Section, 404-332-4559, and Immunization Alert, 203-487-0611,
have up-to-date information on vaccinations for international travel.


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