The Ethics of Public Health Laws, and the Special Case of the New "Model Law".

The "model law" in Israel forbids underweight models (BMI below 18.5) to work. The stated goal of the law is to prevent eating disorders among the general audience of the models. Most public health laws that aim to encourage healthy lifestyles target issues related to unhealthy products, for instance taxes and limitations on advertisements. A law that aims to prevent the imitation of an unhealthy lifestyle is unique. A similar law against showing movies with smoking actors has previously passed in India. Notwithstanding the good intentions, these new laws and other similar legislation raise significant ethical issues, such as limitations on personal freedom and the potential for discrimination.

Disseminated, persistent, and fatal infection due to the vaccine strain of varicella-zoster virus in an adult following stem cell transplantation.

Live attenuated varicella vaccine is recommended for healthy individuals who are susceptible to varicella. Although the vaccine is safe, effective, and used worldwide, serious adverse events have been reported, mainly in immunocompromised patients who subsequently recovered. Here, we describe the fatality of an immunocompromised patient who received the varicella vaccine. His medical history provides a cautionary lens through which to view the decision of when vaccination is appropriate. A middle-aged man with non-Hodgkin lymphoma received chemotherapy and a stem cell transplant. He was vaccinated 4 years post-transplantation, despite diagnosis of a new low-grade lymphoma confined to the lymph nodes. Within 3 months of vaccination, he developed recurrent rashes with fever, malaise, weakness, hepatitis, weight loss, and renal failure. The syndrome was eventually determined to be associated with persistent disseminated zoster caused by the vaccine virus. This case illustrates a circumstance when a live viral vaccine should not be used.

Deep sequencing of viral genomes provides insight into the evolution and pathogenesis of varicella zoster virus and its vaccine in humans.

Immunization with the vOka vaccine prevents varicella (chickenpox) in children and susceptible adults. The vOka vaccine strain comprises a mixture of genotypes and, despite attenuation, causes rashes in small numbers of recipients. Like wild-type virus, the vaccine establishes latency in neuronal tissue and can later reactivate to cause Herpes zoster (shingles). Using hybridization-based methodologies, we have purified and sequenced vOka directly from skin lesions. We show that alleles present in the vaccine can be recovered from the lesions and demonstrate the presence of a severe bottleneck between inoculation and lesion formation. Genotypes in any one lesion appear to be descended from one to three vaccine-genotypes with a low frequency of novel mutations. No single vOka haplotype and no novel mutations are consistently present in rashes, indicating that neither new mutations nor recombination with wild type are critical to the evolution of vOka rashes. Instead, alleles arising from attenuation (i.e., not derived from free-living virus) are present at lower frequencies in rash genotypes. We identify 11 loci at which the ancestral allele is selected for in vOka rash formation and show genotypes in rashes that have reactivated from latency cannot be distinguished from rashes occurring immediately after inoculation. We conclude that the vOka vaccine, although heterogeneous, has not evolved to form rashes through positive selection in the mode of a quasispecies, but rather alleles that were essentially neutral during the vaccine production have been selected against in the human subjects, allowing us to identify key loci for rash formation.

Effectiveness of 2 doses of varicella vaccine in children.

BACKGROUND: Because of ongoing outbreaks of varicella, a second dose of varicella vaccine was added to the routine immunization schedule for children in June 2006 by the Centers for Disease Control and Prevention. METHODS: We assessed the effectiveness of 2 doses of varicella vaccine in a case-control study by identifying children ≥4 years of age with varicella confirmed by polymerase chain reaction assay and up to 2 controls matched by age and pediatric practice. Effectiveness was calculated using exact conditional logistic regression. RESULTS: From July 2006 to January 2010, of the 71 case subjects and 140 matched controls enrolled, no cases (0%) vs 22 controls (15.7%) had received 2 doses of varicella vaccine, 66 cases (93.0%) vs 117 controls (83.6%) had received 1 dose, and 5 cases (7.0%) vs 1 control (0.7%) did not receive varicella vaccine (P < .001). The effectiveness of 2 doses of the vaccine was 98.3% (95% confidence level [CI]: 83.5%-100%; P < .001). The matched odds ratio for 2 doses vs 1 dose of the vaccine was 0.053 (95% CI: 0.002-0.320; P < .001). CONCLUSION: The effectiveness of 2 doses of varicella vaccine in the first 2.5 years after recommendation of a routine second dose of the vaccine for children is excellent. Odds of developing varicella were 95% lower for children who received 2 doses compared with 1 dose of varicella vaccine.

Integrating practice issues in managed care into the curriculum: a Delphi survey.

PURPOSE: This project evolved from a partnership between an advanced practice nurse (APN) graduate program and a care management insurer. The purpose of this Delphi survey was to identify (a) role components germane to the practice of APNs in managed care and (b) topics reflecting these components in the curriculum. DATA SOURCES: Data were gathered from two expert panels, clinician preceptors and faculty members. Each panel had 11 members: 11.3% and 100%, respectively, of the target populations of clinicians and faculty in the partnering agencies. CONCLUSIONS: There was considerable congruence between the panels on the survey. IMPLICATIONS FOR PRACTICE: Case vignettes could be used as a vehicle for discussion of the broader issues of population approaches to specific problems. Faculty could partner with clinicians to develop cases for discussion of evidence-based practice. Faculty and clinicians could create preceptorships focused on business management, postgraduate fellowships within managed care systems, and regular opportunities to dialogue about curriculum and essential attributes of APN graduates.

Safety and Immunogenicity of the Recombinant BCG Vaccine AERAS-422 in Healthy BCG-naïve Adults: A Randomized, Active-controlled, First-in-human Phase 1 Trial.

BACKGROUND: We report a first-in-human trial evaluating safety and immunogenicity of a recombinant BCG, AERAS-422, over-expressing TB antigens Ag85A, Ag85B, and Rv3407 and expressing mutant perfringolysin. METHODS: This was a randomized, double-blind, dose-escalation trial in HIV-negative, healthy adult, BCG-naïve volunteers, negative for prior exposure to Mtb, at one US clinical site. Volunteers were randomized 2:1 at each dose level to receive a single intradermal dose of AERAS-422 (>10(5)-<10(6)CFU=low dose, ≥10(6)-<10(7)CFU=high dose) or non-recombinant Tice BCG (1-8×10(5)CFU). Randomization used an independently prepared randomly generated sequence of treatment assignments. The primary and secondary outcomes were safety and immunogenicity, respectively, assessed in all participants through 182days post-vaccination. ClinicalTrials.gov registration number: NCT01340820. FINDINGS: Between Nov 2010 and Aug 2011, 24 volunteers were enrolled (AERAS-422 high dose, n=8; AERAS-422 low dose, n=8; Tice BCG, n=8); all were included in the safety and immunogenicity analyses. All 24 subjects had at least one adverse event, primarily expected local reactions. High dose AERAS-422 vaccination induced Ag85A- and Ag85B-specific lymphoproliferative responses and marked anti-mycobacterial activity in a whole blood bactericidal activity culture assay (WBA), but was associated with varicella zoster virus (VZV) reactivation in two vaccinees. These volunteers displayed high BCG-specific IFN-γ responses pre- and post-vaccination possibly predisposing them to autocrine/paracrine negative regulation of immune control of latent VZV. A systems biology transcriptomal approach identified positive correlations between post-vaccination T cell expression modules and WBA, and negative correlations between post-vaccination monocyte expression modules and WBA. The expression of one key macrophage marker (F4/80) was constitutively elevated in the two volunteers with zoster. INTERPRETATION: The unexpected development of VZV in two of eight healthy adult vaccine recipients resulted in discontinuation of AERAS-422 vaccine development. Immunological and transcriptomal data identified correlations with the development of TB immunity and VZV that require further investigation. FUNDING: Aeras, FDA, Bill and Melinda Gates Foundation.

Persistence of immunity to live attenuated varicella vaccine in healthy adults.

The varicella vaccine was approved in 1995 for use in healthy varicella-susceptible children and adults. Long-term immunity in 461 healthy adults who were enrolled in varicella vaccine trials in 1979-1999 were studied. Forty vaccinees (9%), including 19 (21%) of 89 vaccinees with household exposure (HHE) to chickenpox, developed breakthrough chickenpox 8 weeks to 11.8 years (mean, 3.3 years) after vaccination. The median number of skin lesions among the 36 untreated vaccinees was 20 (range, 1-240 lesions), and the number of lesions was essentially the same with time since vaccination. Breakthrough chickenpox was mild, even among vaccinees who did not have seroconversion or those recipients who lost detectable antibody. Lower varicella-zoster virus (VZV) antibody titers measured within 3 months of vaccination as well as at the time of HHE were associated with an increased risk of breakthrough disease. This study demonstrated that the varicella vaccine was effective in providing adults with long-term protection from serious VZV disease.

Effectiveness over time of varicella vaccine.

CONTEXT: Reports of outbreaks of varicella in highly immunized groups have increased concern about the effectiveness of varicella vaccine. OBJECTIVE: To assess whether the effectiveness of varicella vaccine is affected either by time since vaccination or by age at the time of vaccination. DESIGN: Case-control study conducted from March 1997 through June 2003. SETTING: Twenty different group practices in southern Connecticut. PARTICIPANTS: Case subjects, identified by active surveillance of all practices, consisted of 339 eligible children 13 months or older who were clinically diagnosed as having chickenpox and who also had a polymerase chain reaction (PCR) test result that was positive for varicella-zoster virus DNA. For each case subject, 2 controls were selected, matched by both age and pediatric practice. MAIN OUTCOME MEASURES: The effectiveness of the vaccine, especially the effects of time since vaccination and age at the time of vaccination, adjusted for possible confounders. RESULTS: Although the adjusted overall effectiveness of the vaccine was 87% (95% confidence interval, 81%-91%; P<.001), there was a substantial difference in the vaccine's effectiveness in the first year after vaccination (97%) and in years 2 to 8 after vaccination (84%, P =.003). The vaccine's effectiveness in year 1 was substantially lower if the vaccine was administered at younger than 15 months (73%) than if it was administered at 15 months or older (99%, P =.01), although the difference in effectiveness overall for children immunized at younger than 15 months was not statistically significantly different than for those immunized at 15 months or older (81% vs 88%, P =.17). Most cases of chickenpox in vaccinees were mild. CONCLUSIONS: Although varicella vaccine is effective, its effectiveness decreases significantly after 1 year, although most cases of breakthrough disease are mild. If administered at younger than 15 months, the vaccine's effectiveness was lower in the first year after vaccination, but the difference in effectiveness was not statistically significant for subsequent years.

Evaluations of clinical learning in a managed care environment.

TOPIC: Clinical learning in a managed-care environment. PURPOSE: To obtain evaluative data about clinical learning experiences for graduate nursing students based on the domains of competence for successful practice in managed-care organizations. METHODS: A survey of 42 nurses (20 graduate students, 22 nurse practitioner preceptors) self-reported on two questionnaires. FINDINGS: Both the students and preceptors reported that there were learning opportunities for research utilization, the development of clinical competence, the identification of group dynamics, the development of leadership skills. In addition, the respondents reported learning opportunities to examine the financial impact on healthcare delivery and clinician decision making. The area of ethics and its impact on clinical decision making is an apparent void, as reported by the respondents. CONCLUSIONS: A managed care environment does provide an effective learning environment for nurse practitioner students.

Detection of antibodies to varicella-zoster virus in recipients of the varicella vaccine by using a luciferase immunoprecipitation system assay.

A high-throughput test to detect varicella-zoster virus (VZV) antibodies in varicella vaccine recipients is not currently available. One of the most sensitive tests for detecting VZV antibodies after vaccination is the fluorescent antibody to membrane antigen (FAMA) test. Unfortunately, this test is labor-intensive, somewhat subjective to read, and not commercially available. Therefore, we developed a highly quantitative and high-throughput luciferase immunoprecipitation system (LIPS) assay to detect antibody to VZV glycoprotein E (gE). Tests of children who received the varicella vaccine showed that the gE LIPS assay had 90% sensitivity and 70% specificity, a viral capsid antigen enzyme-linked immunosorbent assay (ELISA) had 67% and 87% specificity, and a glycoprotein ELISA (not commercially available in the United States) had 94% sensitivity and 74% specificity compared with the FAMA test. The rates of antibody detection by the gE LIPS and glycoprotein ELISA were not statistically different. Therefore, the gE LIPS assay may be useful for detecting VZV antibodies in varicella vaccine recipients. (This study has been registered at ClinicalTrials.gov under registration no. NCT00921999.).

Vaccine-related varicella-zoster rash in a hospitalized immunocompetent patient.

An immunocompetent health care worker with no known history of varicella-zoster virus (VZV) disease was exposed to a patient with herpes zoster and was immunized 2 days later. Twenty-seven days after receiving the varicella vaccine, while hospitalized, she developed a disseminated rash. This exposure and subsequent development of symptoms posed infection control challenges. A polymerase chain reaction analysis of her vesicular fluid was positive for vaccine-type VZV, and a blood specimen collected before vaccination demonstrated a positive VZV titer by the fluorescent antibody to membrane antigen test. To the best of our knowledge, there have been no previous reports of an immunocompetent seropositive person developing vaccine-type VZV after receiving the vaccine.

VZV meningitis following varicella vaccine.

Live attenuated varicella zoster virus is administered to prevent varicella in children and herpes zoster in the elderly. We report a case of disseminated herpes zoster in a previously healthy elderly woman hours after Oka strain vaccination. PCR and restriction enzyme analysis revealed that symptoms were caused by wild type virus.

A phase I-II study of live attenuated varicella-zoster virus vaccine to boost immunity in human immunodeficiency virus-infected children with previous varicella.

Herpes zoster, may be severe and recurrent in HIV-infected children. We determined the safety and immunogenicity of live attenuated varicella-zoster virus (VZV) vaccine in 46 HIV-infected children who had experienced varicella. There were no serious adverse events. Two years after vaccination 82% of subjects remained VZV-antibody positive and 60% had VZV-specific cell-mediated immunity. No child developed herpes zoster.

Risk of herpes zoster in adults immunized with varicella vaccine.

A program of routine varicella vaccination of children 12-18 months of age, begun in the United States in 1995, has been very successful in reducing the incidence of varicella. Varicella-zoster virus (VZV), in both wild-type and live attenuated forms, is notable for its ability to produce latent infection of sensory neurons from which it can later reactivate to cause herpes zoster (HZ). Therefore, the effects of vaccination on this secondary VZV-related disease are important to consider; in practice, however, such studies are complicated by the typically long delay between acquisition of the virus and its reactivation. Studies of immunocompromised children have shown that vaccination is relatively protective against HZ in this highly vulnerable group. We now present long-term follow-up data on a group of individuals who received varicella vaccine as healthy young adults 10-26 years ago and who have been followed prospectively by means of active surveillance. Among some 2000 person-years of follow-up, 2 cases of HZ have occurred, for a rate of 1.00 case/1000 person-years. Overall, the incidence of HZ in this cohort, therefore, is similar to published data for the US population in the prevaccine era.

The safety profile of varicella vaccine: a 10-year review.

Varivax (varicella virus vaccine live [Oka/Merck]; Merck), a live attenuated varicella vaccine, is indicated for vaccination against varicella in appropriate individuals > or =12 months of age. The 10-year safety profile for Varivax is described using data submitted to Merck from routine global postmarketing surveillance, combined with information from a Varicella Zoster Virus Identification Program, which uses polymerase chain reaction (PCR) analysis to identify the presence and strain of VZV in selected specimens. There were 16,683 reports worldwide voluntarily submitted to Merck, for an overall reporting rate of 3.4 reports/10,000 doses of vaccine distributed. PCR analysis of vesicular rashes that occurred within the first 2 weeks after vaccination was more likely to identify wild-type varicella-zoster virus (VZV), whereas the presence of Oka VZV was generally associated with vesicular rashes that occurred 15-42 days after vaccination. Reports of breakthrough varicella that occurred >42 days after vaccination were associated with wild-type VZV. Among 697 herpes zoster reports, PCR analysis identified Oka VZV in 57 reports and wild-type VZV in 38 reports. There were no primary neurologic adverse events associated with Oka VZV. Secondary transmission of Oka VZV from vaccine recipients with postvaccination vesicular rashes was identified in 3 susceptible household contacts. Disseminated Oka VZV was identified in 6 immunocompromised patients and 1 patient with Down syndrome. This review has shown that the vaccine is generally safe and well tolerated.

Primary vaccine failure after 1 dose of varicella vaccine in healthy children.

Universal immunization of young children with 1 dose of varicella vaccine was recommended in the United States in 1995, and it has significantly decreased the incidence of chickenpox. Outbreaks of varicella, however, are reported among vaccinated children. Although vaccine effectiveness has usually been 85%, rates as low as 44% have been observed. Whether this is from primary or secondary vaccine failure-or both-is unclear. We tested serum samples from 148 healthy children immunized against varicella in New York, Tennessee, and California to determine their seroconversion rates, before and after 1 dose of Merck/Oka varicella vaccine. The median age at vaccination was 12.5 months; postvaccination serum samples were obtained on average 4 months later. Serum was tested for antibodies against varicella-zoster virus (VZV) by use of the previously validated sensitive and specific fluorescent antibody to membrane antigen (FAMA) assay. Of 148 healthy child vaccinees, 113 (76%) seroconverted, and 24% had no detectable VZV FAMA antibodies. Our data contrast with reported seroconversion rates of 86%-96% by other VZV antibody tests and suggest that many cases of varicella in immunized children are due to primary vaccine failure. A second dose of varicella vaccine is expected to increase seroconversion rates and vaccine effectiveness.

Severe varicella caused by varicella-vaccine strain in a child with significant T-cell dysfunction.

In March 1995, the US Food and Drug Administration approved a live attenuated varicella vaccine for use in healthy children 12 months to 12 years old. We report here an 18-month-old girl with cell-mediated immunodeficiency who developed a severe vaccine-associated rash and clinical evidence of vaccine-associated pneumonia 1 month after inadvertent receipt of varicella vaccine.

Natural selection for rash-forming genotypes of the varicella-zoster vaccine virus detected within immunized human hosts.

The Oka vaccine strain is a live attenuated virus that is routinely administered to children in the United States and Europe to prevent chickenpox. It is effective and safe but occasionally produces a rash. The vaccine virus has accumulated mutations during its attenuation, but the rashes are not explained by their reversion, unlike complications reported for other viral vaccines. Indeed, most of the novel mutations distinguishing the Oka vaccine from the more virulent parental virus have not actually become fixed. Because the parental alleles are still present, the vaccine is polymorphic at >30 loci and therefore contains a mixture of related viruses. The inoculation of >40 million patients has consequently created a highly replicated evolutionary experiment that we have used to assess the competitive ability of these different viral genotypes in a human host. Using virus recovered from rash vesicles, we show that two vaccine mutations, causing amino acid substitutions in the major transactivating protein IE62, are outcompeted by the ancestral alleles. Standard interpretations of varicella disease severity concentrate on the undeniably important effects of host genotype and immune status, yet our results allow us to demonstrate that the viral genotype is associated with virulence and to identify the key sites. We propose that these loci have pleiotropic effects on the immunogenic properties of the virus, rash formation, and its epidemiological spread, which mould the evolution of its virulence. These findings are of practical importance for reducing the incidence of vaccine-associated rash and promoting public acceptance of the vaccine.

Vaccine Oka varicella-zoster virus genotypes are monomorphic in single vesicles and polymorphic in respiratory tract secretions.

We previously found that, after immunization with vaccine Oka varicella-zoster virus, virus obtained from a single vesicle were monomorphic, and virus obtained from different individuals were heterogeneous. Here we show that virus obtained from the lungs of a patient were a mixture of vaccine Oka variants. We hypothesize that complications after immunization are unlikely to be caused by expansion of a single, biologically more virulent clone of virus that either pre-exists in the vaccine or develops after random mutation of different clones. We hypothesize that some clones are more trophic than others for skin.