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Guideline Summary
Guideline Title
Use of combination measles, mumps, rubella, and varicella vaccine: recommendations of the Advisory Committee on Immunization Practices.
Bibliographic Source(s)
Marin M, Broder KR, Temte JL, Snider DE, Seward JF, Centers for Disease Control and Prevention (CDC). Use of combination measles, mumps, rubella, and varicella vaccine: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2010 May 7;59(RR-3):1-12. [50 references] PubMed External Web Site Policy
Guideline Status

This is the current release of the guideline.

Scope

Disease/Condition(s)
  • Measles
  • Mumps
  • Rubella
  • Varicella
Guideline Category
Prevention
Clinical Specialty
Family Practice
Infectious Diseases
Pediatrics
Preventive Medicine
Intended Users
Advanced Practice Nurses
Health Care Providers
Health Plans
Managed Care Organizations
Nurses
Pharmacists
Physician Assistants
Physicians
Public Health Departments
Guideline Objective(s)

To provide new recommendations regarding use of the combination measles, mumps, rubella, and varicella (MMRV) vaccine

Target Population

Children age 12 months through 12 years

Interventions and Practices Considered
  1. Measles, mumps, rubella, and varicella (MMRV) vaccine
  2. Measles, mumps, rubella (MMR) vaccine plus separate varicella vaccine
  3. Discussion of benefits and risks of both vaccine options with parents and caregivers
Major Outcomes Considered

Vaccine efficacy and safety

Methodology

Methods Used to Collect/Select the Evidence
Searches of Electronic Databases
Searches of Unpublished Data
Description of Methods Used to Collect/Select the Evidence

Not stated

Number of Source Documents

The workgroup reviewed findings from two unpublished (at the time of discussions, June 12, 2008-June 24, 2009) postlicensure studies on measles, mumps, rubella, and varicella (MMRV) vaccine and risk for febrile seizures.

Methods Used to Assess the Quality and Strength of the Evidence
Not stated
Rating Scheme for the Strength of the Evidence

Not applicable

Methods Used to Analyze the Evidence
Review
Description of the Methods Used to Analyze the Evidence

Each member of the Advisory Committee on Immunization Practices (ACIP) workgroup provided their individual interpretation of febrile seizure risk data and input on proposed policy options through two surveys that were subsequently discussed and compiled.

Methods Used to Formulate the Recommendations
Expert Consensus
Description of Methods Used to Formulate the Recommendations

The Advisory Committee on Immunization Practices (ACIP) MMRV Vaccine Safety Workgroup was formed in spring 2008 and included federal and nonfederal experts from diverse backgrounds, including vaccine safety; epidemiology and vaccines related to measles, mumps, rubella, and varicella (MMRV); statistics and pharmacoepidemiology; clinical pediatric neurology, infectious diseases, and primary care; and vaccinology and vaccine policy. The workgroup also sought input from partner organizations (e.g., the American Academy of Pediatrics and the American Academy of Family Physicians) and from local and state health departments. In addition, members of the Centers for Disease Control and Prevention (CDC) Public Health Ethics Committee and members of the Ethics Subcommittee of the Advisory Committee to the CDC Director (http://www.cdc.gov/od/science/integrity/phethics/jointMeetings/ External Web Site Policy) were consulted.

The workgroup reviewed findings from two unpublished (at the time of discussions, June 12, 2008-June 24, 2009) postlicensure studies on MMRV vaccine and risk for febrile seizures; prelicensure MMRV vaccine data; literature regarding measles, mumps, and rubella (MMR) vaccine and varicella vaccine immunogenicity, efficacy, effectiveness, and safety; measles, mumps, rubella, and varicella disease burden; the epidemiology of febrile seizures; the medical and psychosocial importance of febrile seizures; and program implementation considerations. The workgroup also reviewed data on provider and parental attitudes regarding multiple injections and the use of MMRV vaccine in the context of an increased risk for febrile seizures after the first dose of MMRV vaccine.

In June 2009, ACIP discussed the safety evidence for MMRV vaccine and febrile seizure risk and risk-benefit interpretation and approved policy recommendations for the use of MMRV vaccine compared with MMR vaccine and varicella vaccine. CDC provided guidance regarding implementation of these recommendations.

Rating Scheme for the Strength of the Recommendations

Not applicable

Cost Analysis

A formal cost analysis was not performed and published cost analyses were not reviewed.

Method of Guideline Validation
Comparison with Guidelines from Other Groups
Peer Review
Description of Method of Guideline Validation

The Advisory Committee on Immunization Practices (ACIP) MMRV Vaccine Safety Workgroup sought input from partner organizations (e.g., the American Academy of Pediatrics and the American Academy of Family Physicians) and from local and state health departments. In addition, members of the Centers for Disease Control and Prevention (CDC) Public Health Ethics Committee and members of the Ethics Subcommittee of the Advisory Committee to the CDC Director (http://www.cdc.gov/od/science/integrity/phethics/jointMeetings/ External Web Site Policy) were consulted.

In June 2009 after consideration of final data from the postlicensure studies and other evidence, ACIP adopted new recommendations regarding use of measles, mumps, rubella and varicella vaccine.

Recommendations

Major Recommendations

Recommendations for Use of Measles, Mumps, Rubella, and Varicella (MMRV) Vaccine

Advisory Committee on Immunization Practices (ACIP) recommendations for use of MMRV vaccine have been summarized (see Box below). The routinely recommended ages for measles, mumps, rubella, and varicella vaccination continue to be 12-15 months for the first dose and 4-6 years for the second dose.

Measles, mumps, rubella, and varicella (MMRV) vaccine may be administered simultaneously with other vaccines recommended for children aged 12-15 months and 4-6 years. If simultaneous administration is not possible, MMRV vaccine may be administered at any time before or after an inactivated vaccine but at least 28 days before or after another live, attenuated vaccine, except varicella vaccine, for which a minimum interval of 3 months is recommended. Guidance on administration of MMRV vaccine in special situations (e.g., administration of antibody-containing products or tuberculosis screening and skin test reactivity) has been published previously.

First Dose at Age 12-47 Months

The routinely recommended age for the first dose of measles, mumps, rubella, and varicella vaccines is age 12-15 months; children not vaccinated according to the routine schedule may receive the first dose of MMRV vaccine up to age 12 years. For the first dose of measles, mumps, rubella, and varicella vaccines at age 12-47 months, either measles, mumps, and rubella (MMR) vaccine and varicella vaccine or MMRV vaccine may be used. Providers who are considering administering MMRV vaccine should discuss the benefits and risks of both vaccination options with the parents or caregivers. Unless the parent or caregiver expresses a preference for MMRV vaccine, Centers for Disease Control and Prevention (CDC) recommends that MMR vaccine and varicella vaccine should be administered for the first dose in this age group.

The discussion with parents or caregivers should focus on helping them understand the risks and benefits using tools including the Vaccine Information Statements. Compared with use of MMR vaccine and varicella vaccine at the same visit, use of MMRV vaccine results in one fewer injection but is associated with a higher risk for fever and febrile seizures 5-12 days after the first dose among children aged 12-23 months (approximately one extra febrile seizure for every 2,300-2,600 MMRV vaccine doses). Use of MMR vaccine and varicella vaccine avoids this increased risk for fever and febrile seizures following MMRV vaccine.

The 47-month cutoff was selected on the basis of the epidemiology of febrile seizures. Approximately 97% of febrile seizures occur in children aged ≤47 months.

Second Dose at Any Age and First Dose at Age ≥48 Months

Although the routinely recommended age for the second dose of measles, mumps, rubella, and varicella vaccines is 4-6 years, the second dose may be administered before age 4 years, provided ≥3 months have elapsed since the first dose. MMRV vaccine is licensed for use among children through age 12 years. For the second dose of measles, mumps, rubella, and varicella vaccines at any age (15 months-12 years) and for the first dose at age ≥48 months, use of MMRV vaccine generally is preferred over separate injections of its equivalent component vaccines (i.e., MMR vaccine and varicella vaccine). Considerations should include provider assessment (i.e., the number of injections, vaccine availability, likelihood of improved coverage, likelihood of patient return, and storage and cost considerations), patient preference, and the potential for adverse events. This recommendation is consistent with ACIP's 2009 provisional general recommendations on combination vaccines.

Other MMRV Vaccine-Related Guidance

New Precaution for MMRV Vaccine Use

A personal or family (i.e., sibling or parent) history of seizures of any etiology is a precaution* for MMRV vaccination. Studies suggest that children who have a personal or family history of febrile seizures or family history of epilepsy are at increased risk for febrile seizures compared with children without such histories. Children with a personal or family history of seizures of any etiology generally should be vaccinated with MMR vaccine and varicella vaccine because the risks for using MMRV vaccine in this group of children generally outweigh the benefits.

*A precaution is a condition in a recipient that might increase the risk for a serious adverse reaction or that might compromise the ability of the vaccine to produce immunity (e.g., administering measles vaccine to a person with passive immunity to measles from a blood transfusion). A person might experience a more severe reaction to the vaccine than would have otherwise been expected; however, the risk for this happening is less than expected with a contraindication. In general, vaccinations should be deferred when a precaution is present. However, a vaccination might be indicated in the presence of a precaution because the benefit of protection from the vaccine outweighs the risk for an adverse reaction. (CDC. ACIP general recommendations on immunization. MMWR 2006;55[No. RR-15]).

Contraindications and Precautions for MMRV Vaccine Use

Contraindications for use of MMRV vaccine include:

  • History of anaphylactic reaction to neomycin
  • Allergic reaction to gelatin, other component of the vaccine, or after previous vaccination with MMRV vaccine, varicella vaccine or MMR vaccine
  • Altered immunity (i.e., blood dyscrasias, leukemia, lymphomas of any type, or other malignant neoplasms affecting the bone marrow or lymphatic system)
  • Primary or acquired immunodeficiency including human immunodeficiency virus (HIV) infections/acquired immune deficiency syndrome (AIDS), cellular immune deficiencies, hypogammaglobulinemia, and dysgammaglobulinemia
  • Family history of congenital or hereditary immunodeficiencies, unless the immune competence of the potential vaccine recipient has been demonstrated
  • Systemic immunosuppressive therapy, including oral steroids ≥2 mg/kg of body weight or ≥20 mg/day of prednisone or equivalent for persons who weigh >10 kg, when administered for ≥2 weeks)
  • Pregnancy

Precautions for use of MMRV vaccine include:

  • Recent (≤11 months) receipt of antibody-containing blood product (specific interval depends on dose administered)
  • History of thrombocytopenia or thrombocytopenic purpura
  • Moderate or severe acute illness with or without fever
  • A personal or family (i.e., sibling or parent) history of seizures of any etiology

Use of Antipyretics for Prevention of Febrile Seizures

Studies have not demonstrated that antipyretics (e.g., acetaminophen or ibuprofen) prevent febrile seizures. Vaccination with either MMR vaccine or MMRV vaccine can cause fever and, rarely, febrile seizures. Most fevers and febrile seizures after administration of a measles-containing vaccine occur 5-12 days after vaccination with the first dose. Parents and caregivers should be counseled about the possibility of fever after receipt of a measles-containing vaccine and educated on timing and measures to control it. Guidance on diagnosis and management of febrile seizures has been published previously.

Reporting of Adverse Events after Vaccination

Clinically significant adverse events that follow vaccination should be reported to the Vaccine Adverse Event Reporting System (VAERS) at http://vaers.hhs.gov/esub/index External Web Site Policy. Reports can be filed securely online, by mail, or by fax. A VAERS form can be downloaded from the VAERS website or requested by sending an e-mail message to info@vaers.org, by calling telephone 1-800-822-7967, or by sending a faxed request to 1-877-721-0366. Additional information on VAERS or vaccine safety is available at http://vaers.hhs.gov/about/index External Web Site Policy or by calling telephone 1-800-822-7967.

National Vaccine Injury Compensation Program

The National Vaccine Injury Compensation Program (VICP), established by the National Childhood Vaccine Injury Act of 1986 (as amended), provides a mechanism through which compensation can be paid on behalf of a person determined to have been injured or to have died as a result of receiving a vaccine covered by VICP. The Vaccine Injury Table lists the vaccines covered by VICP and the injuries and conditions (including death) for which compensation might be paid. If the injury or condition is not on the table, or does not occur within the specified time period on the table, persons must prove that the vaccine caused the injury or condition.

Persons of all ages who receive a VICP-covered vaccine might be eligible to file a claim. MMRV vaccine, MMR vaccine and varicella vaccine are covered under VICP. Additional information about VICP is available at http://www.hrsa.gov/vaccinecompensation External Web Site Policy or by calling telephone 1-800-338-2382.

BOX. Summary of Recommendations for Measles, Mumps, Rubella and Varicella (MMRV) Vaccine Use
  • The routinely recommended ages for measles, mumps, rubella and varicella vaccination continue to be age 12-15 months for the first dose and age 4-6 years for the second dose.
  • For the first dose of measles, mumps, rubella, and varicella vaccines at age 12-47 months, either measles, mumps, and rubella (MMR) vaccine and varicella vaccine or MMRV vaccine may be used. Providers who are considering administering MMRV vaccine should discuss the benefits and risks of both vaccination options with the parents or caregivers. Unless the parent or caregiver expresses a preference for MMRV vaccine, Centers for Disease Control and Prevention (CDC) recommends that MMR vaccine and varicella vaccine should be administered for the first dose in this age group.
  • For the second dose of measles, mumps, rubella, and varicella vaccines at any age (15 months-12 years) and for the first dose at age ≥48 months, use of MMRV vaccine generally is preferred over separate injections of its equivalent component vaccines (i.e., MMR vaccine and varicella vaccine). Considerations should include provider assessment, patient preference, and the potential for adverse events.
  • A personal or family (i.e., sibling or parent) history of seizures of any etiology is a precaution for MMRV vaccination. Children with a personal or family history of seizures of any etiology generally should be vaccinated with MMR vaccine and varicella vaccine.
Clinical Algorithm(s)

None provided

Evidence Supporting the Recommendations

Type of Evidence Supporting the Recommendations

The type of supporting evidence is not specifically stated for each recommendation.

Benefits/Harms of Implementing the Guideline Recommendations

Potential Benefits

Appropriate use of the combination measles, mumps, rubella, and varicella (MMRV) vaccine

Potential Harms

Risk for Febrile Seizure After First Dose of Measles, Mumps, Rubella, and Varicella (MMRV) Vaccine

In the MMRV vaccine prelicensure studies conducted among children aged 12-23 months, two systemic vaccine-related adverse reactions were reported at a significantly greater rate 0-42 days following vaccination in children who received a first dose of MMRV vaccine (n = 4,497) than in children who received first doses of measles, mumps, and rubella (MMR) vaccine and varicella vaccine (n = 2,038). Fever (reported as abnormal or elevated ≥102°F [≥39°C] oral equivalent) was observed in 21.5% of MMRV vaccine recipients compared with 14.9% of MMR vaccine and varicella vaccine recipients (risk difference [RD]: 6.6%; 95% confidence interval [CI] = 4.6-8.5). Measles-like rash was observed in 3.0% of MMRV vaccine recipients compared with 2.1% of those receiving MMR vaccine and varicella vaccine (RD: 1.0%; CI = 0.1-1.8). Both of these adverse events were reported to occur more frequently 5-12 days postvaccination and typically resolved spontaneously without sequelae.

Risk for Febrile Seizure After Second Dose of MMRV Vaccine

Rates for febrile seizures are lower among children aged 4-6 years (the recommended age for the second dose of MMRV vaccine, MMR vaccine, and varicella vaccine) than among children aged 12-15 months. In prelicensure studies conducted among children who received their second dose in their second year of life and 3 months after their first dose, the second dose of MMRV vaccine was less likely to cause fever than the first dose. Among children aged 4-6 years who received MMRV vaccine for their second dose, the rate of fever was similar to the rate following a second dose of MMR vaccine and varicella vaccine at the same visit.

Precautions for use of MMRV vaccine include:

  • Recent (≤11 months) receipt of antibody-containing blood product (specific interval depends on dose administered)
  • History of thrombocytopenia or thrombocytopenic purpura
  • Moderate or severe acute illness with or without fever
  • A personal or family (i.e., sibling or parent) history of seizures of any etiology

Contraindications

Contraindications

Contraindications for use of measles, mumps, rubella, and varicella (MMRV) vaccine include:

  • History of anaphylactic reaction to neomycin
  • Allergic reaction to gelatin, other component of the vaccine, or after previous vaccination with MMRV vaccine, varicella vaccine or measles, mumps, and rubella (MMR) vaccine
  • Altered immunity (i.e., blood dyscrasias, leukemia, lymphomas of any type, or other malignant neoplasms affecting the bone marrow or lymphatic system)
  • Primary or acquired immunodeficiency including human immunodeficiency virus (HIV) infections/acquired immunodeficiency syndrome (AIDS), cellular immune deficiencies, hypogammaglobulinemia, and dysgammaglobulinemia
  • Family history of congenital or hereditary immunodeficiencies, unless the immune competence of the potential vaccine recipient has been demonstrated
  • Systemic immunosuppressive therapy, including oral steroids ≥2 mg/kg of body weight or ≥20 mg/day of prednisone or equivalent for persons who weigh >10 kg, when administered for ≥2 weeks)
  • Pregnancy

Qualifying Statements

Qualifying Statements
  • Use of trade names and commercial sources is for identification only and does not imply endorsement by the U.S. Department of Health and Human Services.
  • References to non-Centers for Disease Control and Prevention (CDC) sites on the Internet are provided as a service to Morbidity and Mortality Weekly Report (MMWR) 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 pages found at these sites. URL addresses listed in MMWR were current as of the date of publication.

Implementation of the Guideline

Description of Implementation Strategy

An implementation strategy was not provided.

Implementation Tools
Chart Documentation/Checklists/Forms
Patient Resources
For information about availability, see the Availability of Companion Documents and Patient Resources fields below.

Institute of Medicine (IOM) National Healthcare Quality Report Categories

IOM Care Need
Staying Healthy
IOM Domain
Effectiveness
Patient-centeredness
Safety

Identifying Information and Availability

Bibliographic Source(s)
Marin M, Broder KR, Temte JL, Snider DE, Seward JF, Centers for Disease Control and Prevention (CDC). Use of combination measles, mumps, rubella, and varicella vaccine: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2010 May 7;59(RR-3):1-12. [50 references] PubMed External Web Site Policy
Adaptation

Not applicable: The guideline was not adapted from another source.

Date Released
2010 May 7
Guideline Developer(s)
Centers for Disease Control and Prevention - Federal Government Agency [U.S.]
Source(s) of Funding

United States Government

Guideline Committee

Advisory Committee on Immunization Practices (ACIP)

Composition of Group That Authored the Guideline

Advisory Committee on Immunization Practices (ACIP)

Membership as of June 24, 2009

Chair: Dale Morse, MD, New York State Department of Health, Albany, New York

Executive Secretary: Larry Pickering, MD, National Center for Immunization and Respiratory Diseases, CDC, Atlanta, Georgia

Members: Carol Baker, MD, Baylor College of Medicine, Houston, Texas; Robert Beck, JD, Consumer Representative, Palmyra, Virginia; Lance Chilton, MD, University of New Mexico, Albuquerque, New Mexico; Paul Cieslak, MD, Oregon Public Health Division, Portland, Oregon; Kristen Ehresmann, MPH, Minnesota Department of Health, St. Paul, Minnesota; Janet Englund, MD, University of Washington and Children's Hospital and Regional Medical Center, Seattle, Washington; Franklyn Judson, MD, University of Colorado Health Sciences Center, Denver, Colorado; Susan Lett, MD, Massachusetts Department of Public Health, Boston, Massachusetts; Michael Marcy, MD, UCLA Center for Vaccine Research, Torrance, California; Cody Meissner, MD, Tufts Medical Center, Boston, Massachusetts; Kathleen Neuzil, MD, University of Washington, Seattle, Washington; Mark Sawyer, MD, University of California--San Diego, California; Ciro Valent Sumaya, MD, Texas A&M Health Science Center, College Station, Texas; Jonathan Temte, MD, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin

Ex Officio Members: James E. Cheek, MD, Indian Health Service, Albuquerque, New Mexico; Wayne Hachey, DO, Department of Defense, Falls Church, Virginia; Geoffrey S. Evans, MD, Health Resources and Services Administration, Rockville, Maryland; Bruce Gellin, MD, National Vaccine Program Office, Washington, District of Columbia; Linda Murphy, Centers for Medicare and Medicaid Services, Baltimore, Maryland; George T. Curlin, MD, National Institutes of Health, Bethesda, Maryland; Norman Baylor, MD, Food and Drug Administration, Bethesda, Maryland; Linda Kinsinger, MD, Department of Veterans Affairs, Durham, North Carolina.

Liaison Representatives: American Academy of Family Physicians, Doug Campos-Outcalt, MD, Phoenix, Arizona; American Academy of Pediatrics, Joseph Bocchini, MD, Shreveport, Louisiana, David Kimberlin, MD, Birmingham, Alabama; American College Health Association, James C. Turner, MD, Charlottesville, Virginia; American College of Obstetricians and Gynecologists, Stanley Gall, MD, Louisville, Kentucky; American College of Physicians, Gregory Poland, MD, Rochester, Minnesota; American Geriatrics Society, Kenneth Schmader, MD, Durham, North Carolina; America's Health Insurance Plans, Tamara Lewis, MD, Salt Lake City, Utah; American Medical Association, Litjen Tan, PhD, Chicago, Illinois; American Osteopathic Association, Stanley Grogg, DO, Tulsa, Oklahoma; American Pharmacists Association, Stephan L. Foster, PharmD, Memphis, Tennessee; Association for Prevention Teaching and Research, W. Paul McKinney, MD, Louisville, Kentucky; Biotechnology Industry Organization, Clement Lewin, PhD, Cambridge, Massachusetts; Canadian National Advisory Committee on Immunization, Joanne Langley, MD, Halifax, Nova Scotia, Canada; Department of Health, United Kingdom, David M. Salisbury, MD, London, United Kingdom; Healthcare Infection Control Practices Advisory Committee, Alexis Elward, MD, St Louis, Missouri; Infectious Diseases Society of America, Samuel L. Katz, MD, Durham, North Carolina; National Association of County and City Health Officials, Jeff Duchin, MD, Seattle, Washington; National Association of Pediatric Nurse Practitioners, Patricia Stinchfield, MPH; National Foundation for Infectious Diseases, William Schaffner, MD, Nashville, Tennessee; National Immunization Council and Child Health Program, Mexico, Vesta Richardson, MD, Mexico City, Mexico; National Medical Association, Patricia Whitley-Williams, MD, New Brunswick, New Jersey; National Vaccine Advisory Committee, Guthrie Birkhead, MD, Albany, New York; Pharmaceutical Research and Manufacturers of America, Damian A. Braga, Swiftwater, Pennsylvania; Peter Paradiso, PhD, Collegeville, Pennsylvania; Society for Adolescent Medicine, Amy Middleman, MD, Houston, Texas; Society for Healthcare Epidemiology of America, Harry Keyserling, MD, Atlanta, Georgia

The ACIP MMRV Vaccine Safety Workgroup

Membership as of June 25, 2010

Chair: Jonathan L. Temte, MD, PhD, Madison, Wisconsin

Members: Elisabeth B. Andrews, PhD, Research Triangle Park, North Carolina; Judy Beeler, MD, Bethesda, Maryland; Karen R. Broder, MD, Atlanta, Georgia; Lawrence W. Brown, MD, Philadelphia, Pennsylvania; Bruce Fireman, PhD, Oakland, California; Kathleen F. Gensheimer, MD, Augusta, Maine; Anne A. Gershon, MD, New York, New York; Hector Izurieta, MD, Rockville, Maryland; Samuel L. Katz, MD, Durham, North Carolina; David W. Kimberlin, MD, Birmingham, Alabama; Nicola P. Klein, MD, PhD, Oakland, California; Thomas F. Koinis, MD, Oxford, North Carolina; Martin Kulldorff, PhD, Boston, Massachusetts; Preeta Kutty, MBBS, Atlanta, Georgia; Rosemary Johann-Liang, MD, Rockville, Maryland; Tracy Lieu, MD, Boston, Massachusetts; Mona Marin, MD, Atlanta, Georgia; H. Cody Meissner, MD, Boston, Massachusetts; Georges Peter, MD, Brookline, Massachusetts; Daniel Salmon, PhD, District of Columbia; Mark H. Sawyer, MD, San Diego, California; Jim Sejvar, MD, Atlanta, Georgia; Jane F. Seward, MBBS, Atlanta, Georgia; Dixie E. Snider, MD, Atlanta, Georgia; Lin Watson, Olympia, Washington; Eric S. Weintraub, MPH, Atlanta, Georgia; W. Katherine Yih, PhD, Boston, Massachusetts

Financial Disclosures/Conflicts of Interest

Not stated

Guideline Status

This is the current release of the guideline.

Guideline Availability

Electronic copies: Available from the Centers for Disease Control and Prevention (CDC) Web site External Web Site Policy.

Print copies: Available from the Centers for Disease Control and Prevention, MMWR, Atlanta, GA 30333. Additional copies can be purchased from the Superintendent of Documents, U.S. Government Printing Office, Washington, DC 20402-9325; (202) 783-3238.

Availability of Companion Documents

The following is available:

Patient Resources

The following are available:

Please note: This patient information is intended to provide health professionals with information to share with their patients to help them better understand their health and their diagnosed disorders. By providing access to this patient information, it is not the intention of NGC to provide specific medical advice for particular patients. Rather we urge patients and their representatives to review this material and then to consult with a licensed health professional for evaluation of treatment options suitable for them as well as for diagnosis and answers to their personal medical questions. This patient information has been derived and prepared from a guideline for health care professionals included on NGC by the authors or publishers of that original guideline. The patient information is not reviewed by NGC to establish whether or not it accurately reflects the original guideline's content.

NGC Status

This NGC summary was completed by ECRI Institute on December 22, 2010.

Copyright Statement

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