Bryan L. Martin

International Consensus on Allergen Immunotherapy II: Mechanisms, standardization, and pharmacoeconomics

This article continues the comprehensive international consensus (ICON) statement on allergen immunotherapy (AIT). The initial article also recently appeared in the Journal. The conclusions below focus on key mechanisms of AIT-triggered tolerance, requirements in allergen standardization, AIT cost-effectiveness, and regulatory guidance. Potential barriers to and facilitators of the use of AIT are described in addition to future directions. International allergy specialists representing the European Academy of Allergy and Clinical Immunology; the American Academy of Allergy, Asthma & Immunology; the American College of Allergy, Asthma and Immunology; and the World Allergy Organization critically reviewed the existing literature and prepared this summary of recommendations for best AIT practice. The authors contributed equally and reached consensus on the statements presented herein.

Adverse reactions to vaccines

Abstract(The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the Department of the Army or the Department of Defense.)Immunization healthcare is becoming increasingly complex as the number and types of vaccines have continued to expand. Like all prescription drugs, vaccines may be associated with adverse events. The majority of these reactions are self-limited and not associated with prologned disability. The media, Internet and public advocacy groups have focused on potentially serious vaccine-associated adverse events with questions raised about causal linkages to increasing frequencies of diseases such as autism and asthma. Despite a lack of evidence of a causal relationship to a variety of vaccine safety concerns, including extensive reviews by the Institute of Medicine, questions regarding vaccine safety continue to threaten the success of immunization programs. Risk communication arid individual risk assessment is further challenged by the public health success of vaccine programs creating the perception that certain vaccines are no longer necessary or justified because of the rate reaction risk.There is a need for improved understanding of true vaccine contraindications and precautions as well as host factors and disease threat in order to develop a patient specific balanced treated, documented and reported through the VAERS system. The increasing complexity of vaccination health care has led the Center of Disease Control and Prevention (CDC) to identify Vaccine Safety Assessment and Evaluation as a potential new specialty.

Airway hyperresponsiveness by methacholine challenge testing following negative exercise challenge

Background. Exercise challenge testing (ECT) to diagnose exercise‐induced bronchospasm has been demonstrated to be an insensitive screening test to demonstrate the presence or absence of airway hyperreactivity. Previous studies have not compared this procedure to methacholine challenge testing (MCT) in a clinical setting. Objective. To determine the frequency of positive MCT in subjects with exertional dyspnea, normal baseline spirometry, and negative ECT. Methods. Observational study of 215 military patients at an Army Community Hospital referred for evaluation of exertional dyspnea with normal baseline spirometry. Subjects were further evaluated with ECT on a graded treadmill with pre‐ and postexercise spirometry. Those without evidence of bronchial hyperreactivity as defined by a 15% decrease in FEV1 postexercise were evaluated with methacholine challenge testing (MCT). Results. Two hundred ten military subjects were evaluated. Eighty‐two patients underwent ECT as the only method of bronchoprovocation testing with 25 positive tests (57 were negative but not referred for further testing). The remaining 128 patients with a negative ECT underwent MCT. Seventy‐six (59%) had a negative MCT and 52 (41%) had a positive MCT. Of the positive MCT studies, 74% were positive at a methacholine concentration of 2.5 mg/mL or less. Conclusions. Our study demonstrates that a significant number of patients being evaluated for exertional dyspnea will have a positive MCT after a negative ECT. Our findings lead us to question the utility of ECT as an initial diagnostic test for the exercise‐induced bronchospasm.

Absence of oropharyngeal vaccinia virus after vaccinia (smallpox) vaccination

BACKGROUND With the resumption of the vaccinia (smallpox) vaccination, questions regarding transmission risk prompted this study to determine whether vaccinia virus could be detected in the oropharynx of adults recently vaccinated with vaccinia (smallpox) vaccine. German, Russian, and American studies on the oropharyngeal presence of vaccinia virus revealed conflicting results in different age groups. OBJECTIVE To measure vaccinia viral particle or antigen presence in the oropharynx of adult health care workers after vaccination with vaccinia (smallpox) vaccine using viral culture and high-sensitivity assays (polymerase chain reaction [PCR] and electrochemiluminescence) and to determine whether there is an association between the presence of vaccinia virus and adverse reactions. METHODS A total of 155 adults (primary vaccinees and revaccinees) were enrolled for 1 baseline and 5 subsequent throat swabs. The swabs were evaluated using viral culture, PCR, and electrochemiluminescence. RESULTS Of the 155 participants, 144 had more than 2 throat swabs in the 2 weeks after vaccination. Of the 801 specimens evaluated, there were no positive results by culture, PCR, or electrochemiluminescence except in the control samples (n = 6), which were positive by all 3 methods. CONCLUSIONS Based on the absence of detectable vaccinia virus in this study population, one can be 95% certain that the true rate of vaccinia virus in the oropharynx of adults during the 2 weeks after vaccination with vaccinia (smallpox) vaccine is 0% to 3.3%. These data should be reassuring to the medical community and support the Advisory Committee on Immunization Practice guidelines that respiratory precautions are not necessary after vaccinia (smallpox) vaccination in healthy adults.

Implications of Venom Hypersensitivity for a Deploying Soldier

Venom immunotherapy (VIT) is a life-saving medical treatment for individuals allergic to Hymenoptera species. Delivery of VIT is a complex process that requires proper extract preparation, shipping, storage, refrigeration, and administration by qualified medical personnel in a facility that can manage a life-threatening allergic emergency (anaphylaxis). Successful VIT requires 3 to 5 years of uninterrupted maintenance injections, which may be difficult to maintain during deployments, particularly in combat operations. The complexity of VIT has resulted in service members being deemed nondeployable and has led to interruption or discontinuation of VIT for deployed service members in the past. We report the case of a 34-year-old Army National Guard soldier who successfully received maintenance VIT while deployed to Operation Iraqi Freedom. This case demonstrates that, with proper coordination and appropriate risk assessment, continuation of complex medical care, such as VIT, can be supported in a combat zone.