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Crimean-Congo hemorrhagic fever (CCHF) is a zoonotic disease transmitted by ticks and characterized by fever and hemorrhage [1,2]. It was first described in Soviet soldiers in the Crimea in 1944 and was named Crimean fever. In 1956, the virus was isolated from a child in the Congo with similar sympt

CloseCountry abbreviations used in "Brand Names: International" field of Lexicomp monographsCountry abbreviations used in "Brand Names: International" field of Lexicomp monographsCode Country name Code Country name Code Country name AE United Arab Emirates GT Guatemala NZ New Zealand AG Antigua and Barbuda GY Guyana OM Oman AR Argentina HK Hong Kong PA Panama AT Austria HN Honduras PE Peru AU Australia HR Croatia PH Philippines AW Aruba HT Haiti PK Pakistan BB Barbados HU Hungary PL Poland BD Bangladesh ID Indonesia PR Puerto Rico BE Belgium IE Ireland PT Portugal BF Burkina Faso IL Israel PY Paraguay BG Bulgaria IN India QA Qatar BH Bahrain IQ Iraq RO Romania BJ Benin IR Iran, Islamic Republic of RU Russian Federation BM Bermuda IS Iceland SA Saudi Arabia BN Brunei Darussalam IT Italy SC Seychelles BO Bolivia, Plurinational State of JM Jamaica SD Sudan BR Brazil JO Jordan SE Sweden BS Bahamas JP Japan SG Singapore BZ Belize KE Kenya SI Slovenia CH Switzerland KR Korea, Republic of SK Slovakia CI Côte d'Ivoire KW Kuwait SL Sierra Leone CL Chile KY Cayman Islands SN Senegal CN China LB Lebanon SO Somalia CO Colombia LC Saint Lucia SR Suriname CR Costa Rica LI Liechtenstein SV El Salvador CU Cuba LK Sri Lanka SY Syrian Arab Republic CY Cyprus LR Liberia TC Turks and Caicos Islands CZ Czech Republic LT Lithuania TH Thailand DE Germany LU Luxembourg TN Tunisia DK Denmark LV Latvia TR Turkey DO Dominican Republic LY Libyan Arab Jamahiriya TT Trinidad and Tobago EC Ecuador MA Morocco TW Taiwan, Province of China EE Estonia MC Monaco TZ Tanzania, United Republic of EG Egypt ML Mali UA Ukraine ES Spain MR Mauritania UG Uganda ET Ethiopia MT Malta UY Uruguay FI Finland MU Mauritius VC Saint Vincent and the Grenadines FR France MW Malawi VE Venezuela, Bolivarian Republic of GB United Kingdom MX Mexico VN Viet Nam GD Grenada MY Malaysia WS Samoa GH Ghana NE Niger YE Yemen GL Greenland NG Nigeria ZA South Africa GM Gambia NI Nicaragua ZM Zambia GN Guinea NL Netherlands ZW Zimbabwe GR Greece NO Norway  Reproduced with permission from: Lexicomp Online. Copyright © 1978-2023 Lexicomp, Inc. All Rights Reserved. Source: International Organization for Standardization (ISO) alpha-2 country codes (https://www.iso.org/home.html).Graphic 116421 Version 10.0

CloseEpidemic curve of laboratory-confirmed Middle East respiratory syndrome coronavirus human infections reported to the World Health Organization as of June 30, 2019Epidemic curve of laboratory-confirmed Middle East respiratory syndrome coronavirus human infections reported to the World Health Organization as of June 30, 2019Other countries: Algeria, Austria, Bahrain, China, Egypt, France, Germany, Greece, Iran, Italy, Jordan, Kuwait, Lebanon, Malaysia, Netherlands, Oman, Philippines, Qatar, Thailand, Tunisia, Turkey, United Arab Emirates, United Kingdom, United States of America, Yemen.Please note that the underlying data is subject to change as the investigations around cases are ongoing. Onset date estimated if not available.Reproduced with permission from: World Health Organization. Emergencies preparedness, response: Middle East respiratory syndrome coronavirus (MERS-CoV) maps and epicurves, 16 July 2019. https://www.who.int/emergencies/mers-cov/epi-16-july-2019.png?ua=1 (Accessed on December 2, 2019).Graphic 95981 Version 11.0

ClosePatient education: Foodborne illness (food poisoning) (Beyond the Basics)Patient education: Foodborne illness (food poisoning) (Beyond the Basics)Authors:Regina LaRocque, MD, MPHJason B Harris, MD, MPH Section Editor:Stephen B Calderwood, MD Deputy Editor:Elinor L Baron, MD, DTMHLiterature review current through: Nov 2022. | This topic last updated: Jul 13, 2021.Please read the Disclaimer at the end of this page.FOODBORNE ILLNESS OVERVIEW — Microbial foodborne illness, sometimes called 'food poisoning,' occurs commonly throughout the world, including in the United States. Fortunately, most people recover from an episode of foodborne illness without any need to consult with a health care provider and without any long-term complications.This topic review discusses the causes, signs and symptoms, and treatment of foodborne illness, along with ways to avoid it.CAUSES OF FOODBORNE ILLNESS — There are many ways that food can lead to illness. This article will focus on illness caused by eating food that is contaminated by a microorganism: a bacterium, virus, or parasite.Microorganisms that cause foodborne illness — Many different microorganisms can cause foodborne illness. Updated information on outbreaks may be found on websites maintained by the United States Centers for Disease Control and Prevention and the US Food and Drug Administration.Some of the most common include the following:Salmonella — Salmonella is the leading bacterial cause of foodborne illness in the United States with an estimated one million cases of salmonellosis each year. There are many types of Salmonella, including those that cause typhoid fever and those that cause gastroenteritis. In the United States, the type that causes gastroenteritis is much more common.Salmonella is very common in the intestines of animals and reptiles and may exist in the environment. When food is contaminated from the environment or from contact with animals, it can make humans sick when they subsequently consume that food. Contamination of food can occur on a farm, during food processing, or as a result of cross-contamination (transfer from raw meat to salad) in the home, at a restaurant, or at some other point in the supply chain. Thus, most cases of Salmonella foodborne illness are due to either cross-contamination or undercooking of raw meat or poultry products or contamination of fresh produce. However, there have also been large outbreaks of Salmonella from other foods, such as peanut butter.Norovirus — Norovirus infection is the most common foodborne illness and is often acquired when infected food handlers contaminate the food they are preparing (eg, in restaurants). Norovirus is very infectious and easily passed from person to person or by touching contaminated surfaces. Symptoms usually start 24 to 48 hours after exposure with nausea, vomiting, diarrhea, and abdominal pain. Most cases resolve without medical treatment.Escherichia coli — Certain Escherichia coli (E. coli) bacteria can cause foodborne illness, particularly an illness known as "traveler's diarrhea." Infection with E. coli can occur when food or water becomes contaminated with infected feces. Some types of E. coli infection can be very serious, resulting in kidney failure or worse.Hepatitis A virus — Hepatitis A virus is transmitted in foods contaminated by an infected human, such as a food handler, or from raw shellfish. Hepatitis A causes jaundice (yellowing of the skin or whites of the eyes) and occasionally liver failure. Symptoms do not usually appear until 15 to 50 days after infection, which can make it difficult to determine the source of infection. In nonimmune individuals, post-exposure vaccination or administration of passive immune globulin can help prevent infection. In the United States, a vaccine for hepatitis A is recommended for all children. Detailed information about hepatitis A is available separately. (See"Patient education: Hepatitis A (Beyond the Basics)".)Listeria monocytogenes — Listeria is a bacterium that has traditionally been found in unpasteurized or contaminated milk, soft cheese, and other dairy products or in contaminated processed/deli meats, hot dogs, and smoked seafood. More recently, Listeria monocytogenes has been found in a variety of other ready-to-eat foods such as hummus, sunflower seeds, and frozen vegetables. Listeria infection may cause gastrointestinal symptoms. A much more serious infection, known as listeriosis, may occur one to three weeks later if the bacteria invade the bloodstream. Listeriosis can occur without any of the gastrointestinal symptoms. Listeriosis is usually seen in pregnant women or older adults and the immunocompromised. (See"Treatment and prevention of Listeria monocytogenes infection".)FOODBORNE ILLNESS RISK FACTORS — There are several factors that can increase your risk of developing foodborne illness. Ask a health care provider if you are in a group that needs to take extra precautions to avoid foodborne illness.●A weakened immune system – The immune system plays a major role in protecting against a foodborne illness; when your immune system is weakened, you become more vulnerable. A health care provider should be able to provide guidance on whether you fall into this group. A few examples of people with a weakened immune system include the very young, older adults, people with chronic disease, pregnant women, and people who take certain types of medication that reduce the ability to fight off foodborne infections. Pregnant women, in particular, should avoid eating foods that may contain Listeria, including soft cheeses and delicatessen meats.●Improper food storage or handling, leaving prepared food at room temperature for more than two hours, or improperly cooking or reheating food increase the risk of foodborne illness. Use a food thermometer to check internal temperatures of meat, poultry, and seafood before eating them to make sure they are properly cooked. Food should not be left out for more than two hours at room temperature. The "best before" or "use by" dates printed on food are markers of quality, not safety, and should not be used to determine if a food is "safe" to eat. Just because a food looks and smells okay does not mean that it is safe to eat. (See 'Food safety recommendations' below.)●Cross-contamination of food can occur when one contaminated food touches another or when a food comes in contact with a contaminated food preparation surface, such as a counter or cutting board. Keep foods like meat, poultry, and raw fish separate from foods that will not be cooked, such as salads. (See 'Food safety recommendations' below.)●Anyone who handles food should wash their hands before handling food and after using the bathroom, changing diapers, or handling pets. It is easy to pass microbes from the hands into food. Food handlers who fail to wash their hands after using the bathroom can contaminate food with fecal microorganisms. (See 'Preventing the spread of infection' below.)FOODBORNE ILLNESS SYMPTOMS — The symptoms of foodborne illness depend upon which microbe gets into your system. Symptoms can appear hours after you eat the contaminated food, or may not appear until days or weeks later. The most common symptoms include:●Nausea●Vomiting●Abdominal pain●Diarrhea, which may be watery or bloody●FeverLess commonly, neurologic symptoms develop, such as blurry vision, dizziness, or tingling in the arms. In some instances, the most life-threatening problems occur several days after the start of intestinal symptoms, and these can include kidney failure, meningitis, arthritis, and paralysis, depending on which foodborne microbe you have been exposed to.FOODBORNE ILLNESS DIAGNOSIS — Foodborne illness is usually diagnosed based on a person's symptoms and history of what they have eaten in the prior week. However, it is not always possible or necessary to determine the particular food or microorganism that caused the illness, especially if the illness is mild and begins to improve within a few days.When to seek help — If your symptoms are persistent or severe, if you have an underlying medical condition, or if there are worrisome signs or symptoms (temperature greater than 100.4°F/38°C, severe abdominal pain, inability to eat or drink, bloody stool, or vomit), you should see a health care provider for evaluation and treatment.Young children and older adults with these symptoms should also be evaluated quickly. Children and older people can lose fluid rapidly from vomiting or having diarrhea, which can quickly lead to dehydration. (See"Patient education: Nausea and vomiting in infants and children (Beyond the Basics)" and"Patient education: Acute diarrhea in children (Beyond the Basics)".)The health care provider will ask questions about the type, duration, and severity of symptoms. The person's blood pressure, pulse, weight, and temperature will be measured, and a physical examination will be performed. In some cases, blood or urine tests will be done to determine if the person is dehydrated or has signs of a body-wide infection.If needed, a sample of stool or blood can be sent to a laboratory to determine which microorganism is responsible for the symptoms. The need for this type of testing depends upon the person's symptoms and history.If a microbe is found, the local health department may be contacted to help determine if the illness is linked to an outbreak in the community. If that happens, the health department may contact you too to ask about what foods you ate before you became sick and where you ate them.FOODBORNE ILLNESS TREATMENT — In most cases of foodborne illness, treatment is primarily supportive. Supportive treatment includes drinking adequate fluids, eating small, low-fat meals, and resting as needed. Oral rehydration solutions (sample brand name: Pedialyte) are particularly useful for providing adequate hydration.Antibiotics are not usually needed or recommended but may be used for some types of foodborne illness. In most cases, symptoms resolve quickly and no special treatment is necessary. In people with persistent diarrhea and/or vomiting, intravenous fluids may be needed to prevent dehydration. Antidiarrheal medications, such as loperamide (brand name: Imodium), can be useful for the symptomatic treatment of watery diarrhea.The treatment of nausea, vomiting, and diarrhea is discussed in detail in separate topic reviews. (See"Patient education: Acute diarrhea in adults (Beyond the Basics)" and"Patient education: Acute diarrhea in children (Beyond the Basics)" and"Patient education: Nausea and vomiting in infants and children (Beyond the Basics)".)FOODBORNE ILLNESS PREVENTION — Although it is not always possible to avoid exposure to a microbe that can cause foodborne illness, certain precautions can decrease the chances that it will occur.Washing your hands thoroughly with soap and clean, running water is the best way to prevent foodborne illness. Handwashing is especially important after using the bathroom, after changing a diaper, before preparing food, and after touching animals.Food safety recommendations — The following general precautionary measures are recommended by the United States federal government (www.foodsafety.gov):●Do not drink raw (unpasteurized) milk or foods that contain unpasteurized milk.●Wash raw fruits and vegetables thoroughly before eating using clean, cold running water.●Keep the refrigerator temperature at 40°F (4.4°C) or lower; the freezer at 0°F (-17.8°C) or lower.●Use precooked, perishable, or ready-to-eat food as soon as possible.●Avoid cross-contamination; keep raw meat, fish, and poultry separate from other foods.●Wash hands, knives, and cutting boards after handling uncooked food, including produce and raw meat, fish, or poultry.●Thoroughly cook raw food from animal sources to a safe internal temperature and check the temperature by using a food thermometer: ground beef 160°F (71°C); chicken 165°F (77°C); turkey 165°F (82°C); pork 145°F (71°C).●Seafood and shellfish should be cooked thoroughly to minimize the risk of foodborne illness. Eating raw fish (eg, sushi) poses a risk for a variety of parasitic worms (in addition to the risks associated with organisms carried by food handlers). Freezing kills some, although not all, harmful microorganisms. Raw fish that is labeled "sushi-grade" or "sashimi-grade" has been frozen.●Cook eggs thoroughly, until the yolk is firm.●Refrigerate foods promptly. Never leave cooked foods at room temperature for more than two hours (one hour if the room temperature is above 90°F/32°C).The United States Centers for Disease Control and Prevention (CDC) has a similar set of guidelines, which they categorize into four themes: "clean, separate, cook, and chill" (www.cdc.gov/foodsafety/keep-food-safe.html).The following additional recommendations apply to pregnant women and those who have a weakened immune system:●Do not eat hot dogs, pâtés, luncheon meats, bologna, or other delicatessen meats unless they are reheated until steaming hot; avoid the use of microwave ovens since uneven cooking may occur.●Avoid spilling fluids from raw meat and hot dog packages on other foods, utensils, and food preparation surfaces. In addition, wash hands after handling hot dogs, luncheon meats, delicatessen meats, and raw meat, chicken, turkey, or seafood or their juices.●Do not eat pre-prepared salads, such as ham salad, chicken salad, egg salad, tuna salad, or seafood salad.●Do not eat soft cheeses such as feta, Brie and Camembert, blue-veined cheeses, or Mexican-style cheeses such as queso blanco, queso fresco, or Panela, unless they have a label that clearly states that the cheese is made from pasteurized milk.●Do not eat refrigerated pâtés or meat spreads. Canned or shelf-stable products may be eaten.●Do not eat refrigerated smoked seafood unless it has been cooked. Refrigerated smoked seafood, such as salmon, trout, whitefish, cod, tuna, or mackerel, is most often labeled as "nova-style," "lox," "kippered," "smoked," or "jerky." The fish is found in the refrigerator section or sold at deli counters of grocery stores and delicatessens. Canned or shelf-stable smoked seafood may be eaten.●Bacteria like Listeria can grow in the refrigerator so, even if you consume foods that are considered safe, be sure to eat them from freshly opened packs and not from leftovers in the refrigerator.Preventing the spread of infection — People with diarrhea and/or vomiting should be cautious to avoid spreading infection to family, friends, and coworkers. This includes avoiding or limiting contact with others, until the person gets better, and washing hands frequently. A person is considered infectious (contagious) for at least as long as vomiting or diarrhea continues and sometimes even longer, depending upon the microbe.WHERE TO GET MORE INFORMATION — Your health care provider is the best source of information for questions and concerns related to your medical problem.This article will be updated as needed on our website (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for health care professionals, are also available. Some of the most relevant are listed below.Patient level information — UpToDate offers two types of patient education materials.The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Patient education: Food poisoning (The Basics) Patient education: Diarrhea in adolescents and adults (The Basics) Patient education: Diarrhea in children (The Basics) Patient education: Nausea and vomiting in adults (The Basics) Patient education: Avoiding infections in pregnancy (The Basics) Patient education: Giardia (The Basics) Patient education: Reactive arthritis (The Basics) Patient education: Cryptosporidiosis (The Basics) Patient education: Salmonella infection (The Basics) Patient education: Travelers' diarrhea (The Basics) Patient education: Enteric (typhoid and paratyphoid) fever (The Basics) Patient education: Listeria (The Basics) Patient education: Campylobacter infection (The Basics) Patient education: When to worry about a fever in adults (The Basics)Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon. Patient education: Hepatitis A (Beyond the Basics) Patient education: Nausea and vomiting in infants and children (Beyond the Basics) Patient education: Acute diarrhea in children (Beyond the Basics) Patient education: Acute diarrhea in adults (Beyond the Basics)Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading. Approach to the adult with acute diarrhea in resource-rich settings Botulism Clinical manifestations and diagnosis of Yersinia infections Clinical manifestations, diagnosis, and treatment of Campylobacter infection Clinical manifestations and diagnosis of Listeria monocytogenes infection Shigella infection: Clinical manifestations and diagnosis Shiga toxin-producing Escherichia coli: Clinical manifestations, diagnosis, and treatment Cryptosporidiosis: Epidemiology, clinical manifestations, and diagnosis Pathogenic Escherichia coli associated with diarrhea Shigella infection: Treatment and prevention in adults Overview of shellfish, pufferfish, and other marine toxin poisoning Treatment and prevention of Yersinia enterocolitica and Yersinia pseudotuberculosis infection Treatment and prevention of Listeria monocytogenes infection Nontyphoidal Salmonella: Gastrointestinal infection and carriage Causes of acute infectious diarrhea and other foodborne illnesses in resource-rich settingsThe following organizations also provide reliable health information.●Centers for Disease Control and Prevention (CDC)(www.cdc.gov)●Food and Drug Administration(www.fda.gov)●National Institute of Allergy and Infectious Diseases(www.niaid.nih.gov) [1-6]ACKNOWLEDGMENT — The editorial staff at UpToDate would like to acknowledge David WK Acheson, MD, FRCP, who contributed to an earlier version of this topic review.Crim SM, Griffin PM, Tauxe R, et al. Preliminary incidence and trends of infection with pathogens transmitted commonly through food - Foodborne Diseases Active Surveillance Network, 10 U.S. sites, 2006-2014. MMWR Morb Mortal Wkly Rep 2015; 64:495.American Medical Association, Centers for Disease Control and Prevention, Center for Food Safety and Applied Nutrition, Food and Drug Administration, Food Safety and Inspection Service, US Department of Agriculture. Diagnosis and management of foodborne illnesses: a primer for physicians. MMWR Recomm Rep 2001; 50:1.Guerrant RL, Van Gilder T, Steiner TS, et al. Practice guidelines for the management of infectious diarrhea. Clin Infect Dis 2001; 32:331.Mead PS, slu*tsker L, Dietz V, et al. Food-related illness and death in the United States. Emerg Infect Dis 1999; 5:607.Federal Food Safety Information http://foodsafety.gov/ (Accessed on February 09, 2012).Bad Bug Book: Foodborne Pathogenic Microorganisms and Natural Toxins Handbook http://www.fda.gov/food/foodsafety/foodborneillness/foodborneillnessfoodbornepathogensnaturaltoxins/badbugbook/default.htm (Accessed on February 09, 2012).This generalized information is a limited summary of diagnosis, treatment, and/or medication information. It is not meant to be comprehensive and should be used as a tool to help the user understand and/or assess potential diagnostic and treatment options. It does NOT include all information about conditions, treatments, medications, side effects, or risks that may apply to a specific patient. It is not intended to be medical advice or a substitute for the medical advice, diagnosis, or treatment of a health care provider based on the health care provider's examination and assessment of a patient's specific and unique circ*mstances. Patients must speak with a health care provider for complete information about their health, medical questions, and treatment options, including any risks or benefits regarding use of medications. This information does not endorse any treatments or medications as safe, effective, or approved for treating a specific patient. UpToDate, Inc. and its affiliates disclaim any warranty or liability relating to this information or the use thereof.The use of this information is governed by the Terms of Use, available at https://www.wolterskluwer.com/en/know/clinical-effectiveness-terms ©2023 UpToDate, Inc. and its affiliates and/or licensors. All rights reserved.Topic 7959 Version 29.0References1 : Preliminary incidence and trends of infection with pathogens transmitted commonly through food - Foodborne Diseases Active Surveillance Network, 10 U.S. sites, 2006-2014.2 : Diagnosis and management of foodborne illnesses: a primer for physicians.3 : Practice guidelines for the management of infectious diarrhea.4 : Food-related illness and death in the United States.

Leishmaniasis consists of a complex of vector-borne diseases caused by a heterogeneous group of protozoa belonging to the genus Leishmania; it is transmitted by sand fly vectors. Clinical manifestations range from cutaneous ulcers to systemic multiorgan disease. The epidemiology and control of cutan

CloseAvian influenza virus vaccine (H5N1) (United States: Availability limited to CDC distribution from Strategic National Stockpile in consultation with local health department): Pediatric drug informationAvian influenza virus vaccine (H5N1) (United States: Availability limited to CDC distribution from Strategic National Stockpile in consultation with local health department): Pediatric drug information(For additional information see "Avian influenza virus vaccine (H5N1) (United States: Availability limited to CDC distribution from Strategic National Stockpile in consultation with local health department): Drug information" and see "Avian influenza virus vaccine (H5N1) (United States: Availability limited to CDC distribution from Strategic National Stockpile in consultation with local health department): Patient drug information")For abbreviations, symbols, and age group definitions used in Lexicomp (show table)Brand Names: USAudenzBrand Names: CanadaArepanrix;FocliviaTherapeutic CategoryVaccine;Vaccine, Inactivated (Viral)Dosing: PediatricInfluenza A subtype H5N1, immunizationInfluenza A subtype H5N1, immunization:Note: Available vaccines are manufactured differently; dose volumes are different (eg, 0.25 mL vs 0.5 mL per dose); use caution when verifying product selection and dose volume.GlaxoSmithKline product (AS03-adjuvanted):Infants ≥6 months, Children, and Adolescents ≤17 years: IM: 0.25 mL, followed by a second 0.25 mL dose 21 days later.Adolescents ≥18 years: IM: 0.5 mL, followed by a second 0.5 mL dose 21 days later.Seqirus product (MF59-adjuvanted: Audenz, Foclivia [Canadian product]):Infants ≥6 months, Children, and Adolescents: IM: 0.5 mL, followed by a second 0.5 mL dose 21 days later.Dosing: Kidney Impairment: PediatricThere are no dosage adjustments provided in the manufacturer's labeling.Dosing: Hepatic Impairment: PediatricThere are no dosage adjustments provided in the manufacturer's labeling.Dosing: Adult(For additional information see "Avian influenza virus vaccine (H5N1) (United States: Availability limited to CDC distribution from Strategic National Stockpile in consultation with local health department): Drug information")Influenza A preventionInfluenza A (H5N1) prevention: Note: There are no data to support the interchangeability of vaccines.Seqirus (MF59-adjuvanted: Audenz, Foclivia [Canadian product]) and GlaxoSmithKline (AS03-adjuvanted) products: IM: 0.5 mL followed by a second 0.5 mL dose administered 21 days later.Sanofi Pasteur product: Adults 18 to 64 years of age: IM: 1 mL followed by second 1 mL dose administered ~28 days later (acceptable range: 21 to 35 days).Dosing: Kidney Impairment: AdultThere are no dosage adjustments provided in the manufacturer's labeling.Dosing: Hepatic Impairment: AdultThere are no dosage adjustments provided in the manufacturer's labeling.Dosage Forms: USExcipient information presented when available (limited, particularly for generics); consult specific product labeling.Injection, emulsion [monovalent]:GlaxoSmithKline product: Adjuvanted Hemagglutinin [A/Indonesia/05/2005 (H5N1)] 3.75 mcg/0.5 mL (5 mL) [contains egg protein, polysorbate 80, and thimerosal]Seqirus product: Adjuvanted Hemagglutinin [A/turkey/Turkey/1/2005 NIBRG-23 (H5N1)] 7.5 mcg/0.5 mL (0.5 mL, 5 mL) [contains polysorbate 80; 0.5 mL prefilled syringe contains mercury; 5 mL vial contains thimerosal]Injection, suspension [monovalent]:Sanofi Pasteur product: Hemagglutinin [A/Vietnam/1203/2004 (H5N1)] 90 mcg/mL (5 mL) [contains chicken and egg protein, porcine gelatin, and thimerosal]Generic Equivalent Available: USNoDosage Forms: CanadaExcipient information presented when available (limited, particularly for generics); consult specific product labeling.Injection, emulsion [monovalent]:GlaxoSmithKline product: Adjuvanted Hemagglutinin [A/Indonesia/5/2005 (H5N1)] 3.75 mcg/0.5 mL (5 mL) [contains egg protein, polysorbate 80, and thimerosal]Seqirus product: Adjuvanted Hemagglutinin [A/Vietnam/1194/2004 (H5N1)] 7.5 mcg/0.5 mL (0.5 mL, 5 mL) [contains polysorbate 80; 5 mL vial contains thimerosal]Product AvailabilityProducts will not be commercially available; distribution will be limited as part of the US Strategic National Stockpile.Prescribing and Access RestrictionsCommercial distribution is not planned. The vaccine will be included as part of the US Strategic National Stockpile. It will be distributed by public health officials if needed.Administration: PediatricParenteral: IM: For IM administration only. Inspect for particulate matter and discoloration prior to administration. Administer into the deltoid muscle in children and adolescents; the anterolateral thigh is preferred for infants ≥6 months. Do not inject into areas where there may be a major nerve trunk, including the gluteal region. Use proper injection technique in the deltoid muscle (eg, injecting in the central, thickest part of the muscle) to reduce the risk of shoulder injury related to vaccine administration (Cross 2016; Foster 2013). Do not mix with other vaccines or injections; separate needles and syringes should be used for each injection (ACIP [Kroger 2021]). To prevent syncope-related injuries, adolescents should be vaccinated while seated or lying down (ACIP [Kroger 2021]). US law requires that the date of administration; the vaccine manufacturer; lot number of vaccine; and the administering person's name, title, and address be entered into the patient's permanent medical record.GlaxoSmithKline product (AS03-adjuvanted): If vaccine is stored under refrigeration after mixing, bring to room temperature prior to administration (minimum 15 minutes). Mix thoroughly by inversion prior to administration.Seqirus product (MF59-adjuvanted: Audenz, Foclivia [Canadian product]): Gently shake syringe prior to administration; appearance should be milky-white.For patients at risk of hemorrhage following IM injection, the vaccine should be administered IM if, in the opinion of the physician familiar with the patient's bleeding risk, the vaccine can be administered by this route with reasonable safety. If the patient receives antihemophilia or other similar therapy, IM vaccination can be scheduled shortly after such therapy is administered. A fine needle (23-gauge or smaller) can be used for the vaccination and firm pressure applied to the site (without rubbing) for at least 2 minutes. The patient should be instructed concerning the risk of hematoma from the injection. Patients on anticoagulant therapy should be considered to have the same bleeding risks and treated as those with clotting factor disorders (ACIP [Kroger 2021]).Administration: AdultIM: For IM administration only. Gently shake prior to use. Inspect for particulate matter and discoloration prior to administration. Administer into the deltoid muscle; do not inject into the gluteal region or areas where there may be a major nerve trunk. Use proper injection technique in the deltoid muscle (eg, injecting in the central, thickest part of the muscle) to reduce the risk of shoulder injury related to vaccine administration (Cross 2016; Foster 2013). Do not mix with other vaccines or injections; separate needles and syringes should be used for each injection (ACIP [Kroger 2021]). To prevent syncope-related injuries, patients should be vaccinated while seated or lying down (ACIP [Kroger 2021]). US law requires that the date of administration, the vaccine manufacturer, lot number of vaccine, and the administering person's name, title, and address be entered into the patient's permanent medical record.GlaxoSmithKline product (AS03-adjuvanted): If vaccine is stored under refrigeration after mixing, bring to room temperature prior to administration (minimum 15 minutes). Mix thoroughly by inversion prior to administration.Seqirus product (MF59-adjuvanted: Audenz, Foclivia [Canadian product]): Gently shake prior to administration; appearance should be milky white.For patients at risk of hemorrhage following IM injection, the vaccine should be administered IM if, in the opinion of the physician familiar with the patient's bleeding risk, the vaccine can be administered by this route with reasonable safety. If the patient receives antihemophilia or other similar therapy, IM vaccination can be scheduled shortly after such therapy is administered. A fine needle (23 gauge or smaller) can be used for the vaccination and firm pressure applied to the site (without rubbing) for at least 2 minutes. The patient should be instructed concerning the risk of hematoma from the injection. Patients on anticoagulant therapy should be considered to have the same bleeding risks and treated as those with clotting factor disorders (ACIP [Kroger 2021]).Storage/StabilityAudenz, Foclivia [Canadian product], and Sanofi Pasteur products: Store in a refrigerator at 2°C to 8°C (36°F to 46°F). Do not freeze. Discard if frozen. Protect from light.GlaxoSmithKline product (adjuvanted): Prior to mixing, the H5N1 antigen and AS03 adjuvant vials should be stored in a refrigerator between 2°C and 8°C (36°F and 46°F). Do not freeze. Discard if frozen. Protect from light. After mixing, the vaccine may be stored under refrigeration between 2°C and 8°C (36°F and 46°F) or at room temperature up to 30°C (86°F) for up to 24 hours. Do not freeze. Discard if frozen. Protect from light.UseActive immunization against disease caused by the influenza A virus H5N1 subtype contained in the vaccine in patients at increased risk of exposure to the virus (FDA approved in ages ≥6 months and adults). Note: General recommendations for who should be vaccinated are not available (CDC 2019); products are part of US National Stockpile (ie, not commercially available); immunization should be under the direction of public health officials.Medication Safety IssuesSound-alike/look-alike issues: Influenza A virus vaccine (H5N1) may be confused with the nonavian or avian strains of influenza virus vaccineAdverse ReactionsThe following adverse drug reactions and incidences are derived from product labeling unless otherwise specified. Actual percentages may vary by product and age group.>10%:Dermatologic: Diaphoresis (6% to 11%)Gastrointestinal: Abdominal pain (children and adolescents: ≤17%), anorexia (children and adolescents: 14% to 29%), change in appetite (infants and children: 18%), diarrhea (≤17%), nausea (≤17%), vomiting (children and adolescents: ≤17%)Local: Erythema at injection site (≤34%), induration at injection site (≤15%), pain at injection site (36% to 83%), swelling at injection site (adults: ≤15%; infants, children, and adolescents: 28% to 29%), tenderness at injection site (adults: 70%; infants and children: 56%)Nervous system: Drowsiness (infants and children: 25% to 38%), fatigue (20% to 34%), headache (3% to 35%), irritability (infants and children: ≤51%), malaise (16% to 25%), shivering (adults: 17%; children and adolescents: 4% to 10%)Neuromuscular & skeletal: Arthralgia (10% to 25%), myalgia (9% to 45%)Miscellaneous: Fever (3% to 22%), fussiness in an infant or toddler (≤51%)1% to 10%:Gastrointestinal: Gastroenteritis (children and adolescents: 1%)Local: Itching at injection site (adults: 2%), warm sensation at injection site (adults: 1%)Nervous system: Chills (older adults: 4%), dizziness (adults: 1%)<1%:Dermatologic: Skin rash (adults)Local: Bruising at injection site (adults)ContraindicationsSeqirus products (Audenz, Foclivia [Canadian product]) (MF59-adjuvanted): Severe allergic reactions (eg, anaphylaxis) to any component of the vaccine or after a previous dose of an influenza vaccine. Note: The Foclivia product labeling states that administration to persons with a history of anaphylaxis to a vaccine component may be appropriate during a pandemic situation if acute medical facilities/treatment are available.GlaxoSmithKline product (AS03-adjuvanted): Severe allergic reactions (eg, anaphylaxis) to any component of the vaccine, including egg protein, or after a previous dose of an influenza vaccine.Sanofi Pasteur product: There are no contraindications listed in the manufacturer's labeling.Warnings/PrecautionsConcerns related to adverse effects:• Anaphylactoid/hypersensitivity reactions: Immediate treatment (including epinephrine 1 mg/mL) for anaphylactoid and/or hypersensitivity reactions should be available during vaccine use (ACIP [Kroger 2021]).• Shoulder injury related to vaccine administration: Vaccine administration that is too high on the upper arm may cause shoulder injury (eg, shoulder bursitis or tendinopathy) resulting in shoulder pain and reduced range of motion following injection. Use proper injection technique for vaccines administered in the deltoid muscle (eg, injecting in the central, thickest part of the muscle) to reduce the risk of shoulder injury related to vaccine administration (Cross 2016; Foster 2013).• Syncope: Syncope has been reported with use of injectable vaccines and may be accompanied by transient visual disturbances, weakness, or tonic-clonic movements. Procedures should be in place to avoid injuries from falling and to restore cerebral perfusion if syncope occurs (ACIP [Kroger 2021]).Disease-related concerns:• Acute illness: The decision to administer or delay vaccination because of current or recent febrile illness depends on the severity of symptoms and the etiology of the disease. Defer administration in patients with moderate or severe acute illness (with or without fever); vaccination should not be delayed for patients with mild acute illness (with or without fever) (ACIP [Kroger 2021]).• Bleeding disorders: Use with caution in patients with bleeding disorders (including thrombocytopenia); bleeding/hematoma may occur from IM administration; if the patient receives antihemophilia or other similar therapy, IM injection can be scheduled shortly after such therapy is administered (ACIP [Kroger 2021]).• Guillain-Barré syndrome: Use with caution in patients with a history of Guillain-Barré syndrome (GBS); patients with history of GBS have a greater likelihood of developing GBS than those without. Although data specific to the influenza A virus vaccine (H5N1) are unavailable, the following guidance is based on seasonal influenza vaccines: As a precaution, the Advisory Committee on Immunization Practices (ACIP) recommends that patients with a history of GBS and who are at low risk for severe influenza complications and patients known to have experienced GBS within 6 weeks following previous vaccination should generally not be vaccinated (consider influenza antiviral chemoprophylaxis in these patients). The benefits of vaccination may outweigh the potential risks in persons with a history of GBS who are also at high risk for complications of influenza (CDC/ACIP [Grohskopf 2019]). Studies of patients who received the trivalent inactivated influenza vaccine or the monovalent H1N1 influenza vaccine have shown the risk of GBS is lower with vaccination than with influenza infection (Baxter 2013; Greene 2013; Kwong 2013).Concurrent drug therapy issues:• Anticoagulant therapy: Use with caution in patients receiving anticoagulant therapy; bleeding/hematoma may occur from IM administration (ACIP [Kroger 2021]).• Vaccines: In order to maximize vaccination rates, the ACIP recommends simultaneous administration (ie, >1 vaccine on the same day at different anatomic sites) of all age-appropriate vaccines (live or inactivated) for which a person is eligible at a single clinic visit, unless contraindications exist. The ACIP prefers each dose of a specific vaccine in a series come from the same manufacturer when possible; however vaccination should not be deferred because a specific brand name is unavailable (ACIP [Kroger 2021]).Special populations:• Altered immunocompetence: Consider deferring immunization during periods of severe immunosuppression (eg, patients receiving chemo/radiation therapy or other immunosuppressive therapy [including high-dose corticosteroids]); may have a reduced response to vaccination. In general, household and close contacts of persons with altered immunocompetence may receive all age appropriate vaccines. Inactivated vaccines should be administered ≥2 weeks prior to planned immunosuppression when feasible; inactivated vaccines administered during chemotherapy should be readministered after immune competence is regained (ACIP [Kroger 2021]; IDSA [Rubin 2014]).• Older adult: Sanofi Pasteur product has not been evaluated in patients ≥65 years of age• Pediatric: Apnea has occurred following intramuscular vaccine administration in premature infants; consider clinical status implications. In general, preterm infants should be vaccinated at the same chronological age as full-term infants (ACIP [Kroger 2021]).Dosage form specific issues:• Chicken egg protein: Some products may be manufactured with chicken egg protein.• Kanamycin: Some products may be manufactured with kanamycin.• Neomycin: Some products may be manufactured with neomycin.• Thimerosal: Some products may contain thimerosal; hypersensitivity reactions may occur.Other warnings/precautions:• Antipyretics: Antipyretics have not been shown to prevent febrile seizures; antipyretics may be used to treat fever or discomfort following vaccination (ACIP [Kroger 2021]). One study reported that routine prophylactic administration of acetaminophen prior to vaccination to prevent fever decreased the immune response of some vaccines; the clinical significance of this reduction in immune response has not been established (Prymula 2009).• Effective immunity: Vaccination may not result in effective immunity in all patients. Response depends upon multiple factors (eg, type of vaccine, age of patient) and may be improved by administering the vaccine at the recommended dose, route, and interval. Vaccines may not be effective if administered during periods of altered immune competence (ACIP [Kroger 2021]).Metabolism/Transport EffectsNone known.Drug InteractionsNote: Interacting drugs may not be individually listed below if they are part of a group interaction (eg, individual drugs within “CYP3A4 Inducers [Strong]” are NOT listed).For a complete list of drug interactions by individual drug name and detailed management recommendations, use the Lexicomp drug interactions program by clicking on the “Launch drug interactions program” link above.Note: Interacting drugs may not be individually listed below if they are part of a group interaction (eg, individual drugs within “CYP3A4 Inducers [Strong]” are NOT listed). For a complete list of drug interactions by individual drug name and detailed management recommendations, use the Lexicomp drug interactions programAcetaminophen: May diminish the therapeutic effect of Vaccines. Management: Consider avoiding routine prophylactic use of acetaminophen before or during vaccine administration when possible. Acetaminophen is still recommended to treat fevers and/or pain that occurs after vaccination. Risk D: Consider therapy modificationCorticosteroids (Systemic): May diminish the therapeutic effect of Influenza Virus Vaccines. Management: Administer influenza vaccines at least 2 weeks prior to initiation of systemic corticosteroids at immunosuppressive doses. Influenza vaccines administered less than 14 days prior to or during such therapy should be repeated 3 months after therapy. Risk D: Consider therapy modificationElivaldogene Autotemcel: May enhance the adverse/toxic effect of Vaccines. Specifically, there may be a greater risk for contracting an infection from any live vaccine. Elivaldogene Autotemcel may diminish the therapeutic effect of Vaccines. Management: Administration of vaccines is not recommended in the 6 weeks before myeloablative conditioning, and until hematologic recovery after elivaldogene autotemcel treatment. Risk X: Avoid combinationFingolimod: May diminish the therapeutic effect of Vaccines (Inactivated/Non-Replicating). Management: Vaccine efficacy may be reduced. Complete all age-appropriate vaccinations at least 2 weeks prior to starting fingolimod. If vaccinated during fingolimod therapy, revaccinate 2 to 3 months after fingolimod discontinuation. Risk D: Consider therapy modificationImmunosuppressants (Cytotoxic Chemotherapy): May diminish the therapeutic effect of Influenza Virus Vaccines. Management: Administer influenza vaccines at least 2 weeks prior to initiating chemotherapy if possible. If vaccination occurs less than 2 weeks prior to or during chemotherapy, revaccinate at least 3 months after therapy discontinued if immune competence restored. Risk D: Consider therapy modificationImmunosuppressants (Miscellaneous Oncologic Agents): May diminish the therapeutic effect of Influenza Virus Vaccines. Management: Administer influenza vaccines at least 2 weeks prior to initiating immunosuppressants if possible. If vaccination occurs less than 2 weeks prior to or during therapy, revaccinate at least 3 months after therapy discontinued if immune competence restored. Risk D: Consider therapy modificationImmunosuppressants (Therapeutic Immunosuppressant Agents): May diminish the therapeutic effect of Influenza Virus Vaccines. Management: Administer influenza vaccines at least 2 weeks prior to initiating immunosuppressants if possible. If vaccination occurs less than 2 weeks prior to or during therapy, revaccinate 2 to 3 months after therapy discontinued if immune competence restored. Risk D: Consider therapy modificationMethotrexate: May diminish the therapeutic effect of Influenza Virus Vaccines. Management: Administer influenza vaccines at least 2 weeks prior to initiating methotrexate if possible. If vaccination occurs less than 2 weeks prior to or during methotrexate therapy, revaccinate 3 months after therapy discontinued if immune competence restored. Risk D: Consider therapy modificationPropacetamol: May diminish the therapeutic effect of Vaccines. Management: Consider avoiding routine prophylactic use of propacetamol before or during vaccine administration when possible. Propacetamol is still recommended to treat fevers and/or pain that occurs after vaccination. Risk D: Consider therapy modificationRiTUXimab: May diminish the therapeutic effect of Influenza Virus Vaccines. Management: Administer influenza vaccines 2 weeks prior to starting rituximab. Vaccination of patients treated with rituximab in the past 6 months is not recommended. If vaccinated less than 2 weeks prior to rituximab, revaccinate 6 months after rituximab treatment. Risk D: Consider therapy modificationRiTUXimab: May diminish the therapeutic effect of Vaccines (Inactivated/Non-Replicating). Management: Give inactivated vaccines at least 2 weeks prior to initiation of rituximab when possible. Patients vaccinated less than 14 days before initiating or during therapy should be revaccinated at least 6 months after therapy is complete. Risk D: Consider therapy modificationSiponimod: May diminish the therapeutic effect of Vaccines (Inactivated/Non-Replicating). Management: Avoid administration of vaccines (inactivated) during treatment with siponimod and for 1 month after discontinuation due to potential decreased vaccine efficacy. Risk D: Consider therapy modificationTeplizumab: May diminish the therapeutic effect of Influenza Virus Vaccines. Management: Influenza virus vaccines are not recommended in the 2 weeks prior to teplizumab treatment, during treatment, or for 6 weeks after treatment. Reduced efficacy of the vaccine may occur if administer to patients taking teplizumab. Risk D: Consider therapy modificationTeplizumab: May diminish the therapeutic effect of Vaccines (Inactivated/Non-Replicating). Management: Vaccination with inactivated or non-replicating vaccines is not recommended in the 2 weeks prior to teplizumab therapy, during treatment, or for 6 weeks following completion of therapy. Risk D: Consider therapy modificationPregnancy ConsiderationsAdverse events were not observed in animal reproduction studies using the H5N1 vaccine GlaxoSmithKline adjuvanted product; animal reproduction studies have not been conducted with the Sanofi Pasteur product. Inactivated viral vaccines have not been shown to cause increased risks to the fetus (ACIP [Kroger 2021]).Monitoring ParametersObserve for syncope for 15 minutes following administration (ACIP [Ezeanolue 2020]). If seizure-like activity associated with syncope occurs, maintain patient in supine or Trendelenburg position to reestablish adequate cerebral perfusion.Mechanism of ActionPromotes active immunity to influenza A H5N1 (avian).Pharmaco*kinetics (Adult data unless noted)Onset of action: Most persons have antibody protection within 3 weeks (Audenz, GlaxoSmithKline vaccine, and Foclivia [Canadian product]) or 4 weeks (Sanofi Pasteur vaccine) after complete vaccination.Additional InformationH5N1 influenza virus strain:GlaxoSmithKline product: A/Indonesia/05/2005Seqirus products:Audenz: A/turkey/Turkey/1/2005 NIBRG-23Foclivia [Canadian product]: A/Vietnam/1194/2004Sanofi Pasteur product: A/Vietnam/1203/2004Abdel-Ghafar AN, Chotpitayasunondh T, Gao Z, et al; Writing Committee of the Second World Health Organization Consultation on Clinical Aspects of Human Infection with Avian Influenza A (H5N1) Virus. Update on avian influenza A (H5N1) virus infection in humans. N Engl J Med. 2008;358(3):261-273. [PubMed 18199865]Audenz (influenza A virus vaccine [H5N1]) [prescribing information]. Holly Springs, NC: Seqirus Inc; September 2021.Baxter R, Bakshi N, Fireman B, et al. Lack of association of Guillain-Barre syndrome with vaccinations. Clin Infect Dis. 2013;57(2):197-204. [PubMed 23580737]Centers for Disease Control and Prevention (CDC). Information on avian influenza. https://www.cdc.gov/flu/avianflu/index.htm. Updated March 21, 2019. Accessed February 21, 2020.Cross GB, Moghaddas J, Buttery J, Ayoub S, Korman TM. Don't aim too high: avoiding shoulder injury related to vaccine administration. Aust Fam Physician. 2016;45(5):303-306. [PubMed 27166466]Foclivia (pandemic influenza vaccine) [product monograph]. Kirkland, Quebec, Canada: Seqirus Canada Inc; January 2021.Foster SL, Davis MV. Vaccine administration: preventing serious shoulder injuries. J Am Pharm Assoc (2003). 2013;53(1):102-103. doi:10.1331/JAPhA.2013.13503 [PubMed 23636163]Greene SK, Rett MD, Vellozzi C, et al. Guillain-Barré Syndrome, Influenza Vaccination, and Antecedent Respiratory and Gastrointestinal Infections: A Case-Centered Analysis in the Vaccine Safety Datalink, 2009-2011. PLoS One. 2013;8(6):e67185. [PubMed 23840621]Grohskopf LA, Alyanak E, Broder KR, Walter EB, Fry AM, Jernigan DB. Prevention and control of seasonal influenza with vaccines: recommendations of the Advisory Committee on Immunization Practices - United States, 2019-20 influenza season. MMWR Recomm Rep. 2019;68(3):1-21. doi: 10.15585/mmwr.rr6803a1. [PubMed 31441906]Influenza A (H5N1) virus monovalent vaccine, adjuvanted [prescribing information]. Research Triangle Park, NC: GlaxoSmithKline; September 2016.Influenza virus vaccine, H5N1 [prescribing information]. Swiftwater, PA: Sanofi Pasteur; April 2007.Kroger A, Bahta L, Hunter P. General best practice guidelines for immunization: best practices guidance of the Advisory Committee on Immunization Practices (ACIP). https://www.cdc.gov/vaccines/hcp/acip-recs/general-recs/downloads/general-recs.pdf. Accessed April 30, 2021.Kwong JC, Vasa PP, Campetelli MA, et al. Risk of Guillain-Barré syndrome after seasonal influenza vaccination and influenza health-care encounters: a self-controlled study. Lancet Infect Dis. 2013;13(9):769-776. [PubMed 23810252]Langley JM, Risi G, Caldwell M, et al. Dose-sparing H5N1 A/Indonesia/05/2005 pre-pandemic influenza vaccine in adults and elderly adults: a phase III, placebo-controlled, randomized study. J Infect Dis. 2011;203(12):1729-1738. [PubMed 21606531]OSHA Guidance Update on Protecting Employees From Avian Flu (Avian Influenza) Viruses, Washington, DC: US Department of Labor, Occupational Safety and Health Administration; 2006. Available at http://www.osha.gov/OshDoc/data_AvianFlu/avian_flu_guidance_english.pdf Prymula R, Siegrist CA, Chlibek R, et al, “Effect of Prophylactic Paracetamol Administration at Time of Vaccination on Febrile Reactions and Antibody Responses in Children: Two Open-Label, Randomised Controlled Trials,” Lancet, 2009, 374(9698):1339-50. [PubMed 19837254]Rubin LG, Levin MJ, Ljungman P, et al. 2013 IDSA clinical practice guideline for vaccination of the immunocompromised host. Clin Infect Dis. 2014;58(3):e44-e100. [PubMed 24311479]Treanor JJ, Campbell JD, Zangwill KM, et al, “Safety and Immunogenicity of an Inactivated Subvirion Influenza A (H5N1) Vaccine,” N Engl J Med, 2006, 354(13):1343-51. [PubMed 16571878]Zangwill KM, Treanor JJ, Campbell JD, et al, "Evaluation of the Safety and Immunogenicity of a Booster (Third) Dose of Inactivated Subvirion H5N1 Influenza Vaccine in Humans," J Infect Dis, 2008, 197(4):580-3. [PubMed 18237269]Topic 127186 Version 37.0

CloseRabies immune globulin (human): Pediatric drug informationRabies immune globulin (human): Pediatric drug information(For additional information see "Rabies immune globulin (human): Drug information" and see "Rabies immune globulin (human): Patient drug information")For abbreviations, symbols, and age group definitions used in Lexicomp (show table)Brand Names: USHyperRAB;HyperRAB S/D;Imogam Rabies-HT;KedrabBrand Names: CanadaHyperRAB;HyperRAB S/D [DSC];Imogam Rabies Pasteurized [DSC];KamrabTherapeutic CategoryImmune GlobulinDosing: NeonatalNote: Potency varies among currently available products; use caution to ensure correct dose is administered.Postexposure prophylaxisPostexposure prophylaxis (ACIP Recommendation): Local wound infiltration: 20 units/kg single dose administered as soon as possible after exposure. If anatomically feasible, the full rabies immune globulin (RIG) dose should be infiltrated around and into the wound(s); any remaining volume should be administered IM at a site distant from the vaccine administration site. If rabies vaccine was initiated without rabies immune globulin, rabies immune globulin may be administered through the seventh day after the first vaccine dose. Administration of RIG is not recommended after the seventh day postvaccine since an antibody response to the vaccine is expected during this time period (CDC/ACIP [Rupprecht 2010]).Dosing: PediatricNote: Not recommended for use in persons with a history of vaccination (preexposure or postexposure) and documentation of antibody response. Potency varies among currently available products; use caution to ensure correct dose is administered.Postexposure prophylaxisPostexposure prophylaxis: Infants, Children, and Adolescents: Local wound infiltration/IM: 20 units/kg single dose administered as soon as possible after exposure and as part of a rabies vaccine regimen; do not exceed recommended dose since passive antibody can interfere with response to rabies vaccine. If anatomically feasible, the full rabies immune globulin (RIG) dose should be infiltrated around and into the wound(s); any remaining volume should be administered IM at a site distant from the vaccine administration site. If rabies vaccine was initiated without rabies immune globulin, rabies immune globulin may be administered through the seventh day after the first vaccine dose. Administration of RIG is not recommended after the seventh day postvaccine since an antibody response to the vaccine is expected during this time period.Dosing: Kidney Impairment: PediatricThere are no dosage adjustments provided in manufacturer's labeling.Dosing: Hepatic Impairment: PediatricThere are no dosage adjustments provided in manufacturer's labeling.Dosing: Adult(For additional information see "Rabies immune globulin (human): Drug information")Note: Potency varies among currently available products; use caution to ensure correct dose is administered.Rabies, postexposure prophylaxisRabies, postexposure prophylaxis: Local wound infiltration/IM: 20 units/kg in a single dose, rabies immune globulin (human) (HRIG) should always be administered as part of rabies vaccine regimen. If anatomically feasible, the full rabies immune globulin dose should be infiltrated around and into the wound(s); remaining volume should be administered IM at a site distant from the vaccine administration site. HRIG should be administered as soon as possible after exposure, preferably at time of first rabies vaccine dose. If rabies vaccine was initiated without HRIG, HRIG may be administered through the seventh day after the administration of the first dose of the vaccine (day 0). Administration of HRIG is not recommended after the seventh day post vaccine since an antibody response to the vaccine is expected during this time period.Note: Not recommended for use in persons with a history of complete rabies vaccination (preexposure or postexposure prophylaxis) and documentation of antibody response.Dosing: Kidney Impairment: AdultThere are no dosage adjustments provided in the manufacturer’s labeling.Dosing: Hepatic Impairment: AdultThere are no dosage adjustments provided in the manufacturer’s labeling.Dosage Forms: USExcipient information presented when available (limited, particularly for generics); consult specific product labeling.[DSC] = Discontinued productSolution, Injection: Imogam Rabies-HT: 300 units/2 mL (2 mL); 1500 units/10 mL (10 mL [DSC])Solution, Injection [preservative free]: HyperRAB: 300 units/mL (1 mL); 900 units/3 mL (3 mL); 1500 units/5 mL (5 mL)HyperRAB S/D: 300 units/2 mL (2 mL); 1500 units/10 mL (10 mL)Kedrab: 300 units/2 mL (2 mL); 1500 units/10 mL (10 mL) [latex free, pyrogen free]Generic Equivalent Available: USYesDosage Forms: CanadaExcipient information presented when available (limited, particularly for generics); consult specific product labeling.[DSC] = Discontinued productInjectable, Intramuscular: HyperRAB S/D: 150 units/mL ([DSC])Generic: 150 units/mL ([DSC])Solution, Injection: HyperRAB: 300 units/mL (1 mL, 5 mL)Kamrab: 300 units/2 mL (2 mL)Administration: PediatricParenteral: Postexposure wound infiltration: Thoroughly cleanse wound(s) with soap and water; irrigate wounds with viricidal agent (eg, povidone-iodine) if available. If anatomically feasible, the full rabies immune globulin (RIG) dose should be infiltrated around and into the wound(s); remaining volume should be administered IM in the deltoid muscle of the upper arm or lateral thigh muscle at a site distant from rabies vaccine administration. Per the manufacturer, the gluteal area should be avoided to reduce the risk of sciatic nerve damage or unpredictable absorbance (unless exposure area is the gluteal area). Do not administer IV. If IM administration is contraindicated (eg, patients with uncorrectable bleeding disorders), Kedrab may be administered SubQ; however, no clinical efficacy data are available to support administration SubQ. Do not administer rabies vaccine in the same syringe or at the same administration site as RIG. For extensive wounds, do not exceed the calculated dose. For extensive wounds, do not exceed the calculated dose. If the location of the wound is unknown or if infiltration is difficult at the bite site (eg, lips, fingers, knee), administer the full dose at a site distant from the site of the rabies vaccination​. If additional volume is needed to infiltrate the wound(s), may dilute with an equal volume of D5W (HyperRAB) or NS (Kedrab, Imogam) (Red Book [AAP 2018]); HyperRAB should not be diluted with NS. If a large intramuscular volume is required (>2 mL for children or >5 mL for adults), administer the total volume in divided doses at different sites.Administration: AdultIM: Postexposure wound infiltration: For wound infiltration and IM use only; do not administer IV. Clean wounds immediately with soap and water; irrigate wounds with viricidal agent (eg, povidone-iodine) if available. If anatomically feasible, the full rabies immune globulin (human) (HRIG) dose should be infiltrated around and into the wound(s); remaining volume should be administered IM in the deltoid muscle of the upper arm or lateral thigh muscle. Per the manufacturer, the gluteal area should be avoided to reduce the risk of sciatic nerve damage or unpredictable absorbance, unless gluteal region is exposure site. Do not administer rabies vaccine in the same syringe or at the same administration site as HRIG. For extensive wounds, do not exceed the calculated dose. If the location of the wound is unknown or if infiltration is difficult at the bite site (eg, lips, fingers, knee), administer the full dose at a site distant from the site of the rabies vaccination. If additional volume is needed to infiltrate the wound(s), may dilute with an equal volume of D5W (HyperRAB) or NS (Kedrab, Imogam) (CDC 2014); HyperRAB should not be diluted with NS.Storage/StabilityStore between 2°C to 8°C (36°F to 46°F); do not freeze. Discard unused portion immediately and any product exposed to freezing. HyperRAB may be stored at room temperature (≤25°C [≤77°F]) for up to 6 months; do not return to refrigeration. Kedrab may be stored at room temperature (≤25°C [≤77°F]) for up to 1 month; do not return to refrigeration. Extended storage information at room temperature for other products may be available; contact product manufacturer to obtain current recommendations.UsePart of postexposure prophylaxis of persons with suspected rabies exposure. Provides passive immunity until active immunity with rabies vaccine is established (FDA approved in all patients). Not for use in persons with a history of vaccination (preexposure or postexposure) and documentation of antibody response. Each exposure to possible rabies infection should be individually evaluated. Factors to consider include: Species of biting animal, circ*mstances of biting incident (provoked vs unprovoked bite), type of exposure to rabies infection (bite vs nonbite), vaccination status of biting animal, and presence of rabies in the region. See product information for additional details. Medication Safety IssuesInternational issues:Bayrab [Philippines, Turkey] may be confused with Bayhep-B which is a brand name for hepatitis Bimmune globulin [Philippines, Turkey]; Bayrho-D which is brand name for RhoD immune globulin [Israel, Turkey] Adverse ReactionsThe following adverse drug reactions and incidences are derived from product labeling unless otherwise specified.>10%:Central nervous system: Headache (8% to 15%)Local: Pain at injection site (31% to 33%)1% to 10%:Central nervous system: Fatigue (2% to 6%), dizziness (1% to 6%)Dermatologic: Sunburn (≤3%)Gastrointestinal: Diarrhea (8%), flatulence (8%), nausea (4%), abdominal pain (1% to 4%)Genitourinary: Leukocyturia (3% to 5%), hematuria (2% to 4%)Hematologic & oncologic: Bruise (1% to 3%)Local: Injection site nodule (8%)Neuromuscular & skeletal: Myalgia (7% to 9%), arthralgia (≤6%)Respiratory: Upper respiratory tract infection (9% to 10%), nasal congestion (8%), oropharyngeal pain (8%)Frequency not defined:Central nervous system: MalaiseDermatologic: Skin rashGenitourinary: Nephrotic syndromeHypersensitivity: Anaphylaxis, angioedemaLocal: Local soreness/soreness at injection site, tenderness at injection siteNeuromuscular & skeletal: Stiffness (at injection site)Miscellaneous: Fever (mild)<1%, postmarketing, and/or case reports: Hypersensitivity reaction, hypoesthesia, limb painContraindicationsImogam Rabies-HT: Should not be administered in repeated doses once vaccine treatment has been initiated (may interfere with active immunity of vaccine).HyperRAB, Kedrab: There are no contraindications listed in the manufacturer's labeling.Documentation of allergenic cross-reactivity for immune globulins is limited. However, because of similarities in chemical structure and/or pharmacologic actions, the possibility of cross-sensitivity cannot be ruled out with certainty.Warnings/PrecautionsConcerns related to adverse effects:• Anaphylaxis/hypersensitivity reactions: Hypersensitivity and anaphylactic reactions can occur; discontinue immediately and institute supportive emergency measures if hypersensitivity or anaphylaxis occurs. Use with caution in patients with isolated immunoglobulin A deficiency or a history of systemic hypersensitivity to human immunoglobulins. Medications for the treatment of acute allergic reactions should be available for immediate use.• Hemolysis: May occur; risk is increased in patients with non-O blood group types, underlying associated inflammatory conditions, and those receiving high cumulative doses of immune globulins over several days. Monitor patients for signs and symptoms of hemolysis (eg, fever, chills, dark urine).• Thrombosis: Use with caution in patients at increased risk of thrombosis (eg, acquired or hereditary hypercoagulable states, prolonged immobilization, indwelling vascular catheters, advanced age, estrogen use, history of thrombosis, cardiovascular risk factors, hyperviscosity syndromes). Monitor these patients for at least 24 hours after administration; consider measuring a baseline blood viscosity in patients at risk for hyperviscosity.Disease-related concerns:• Bleeding disorders: Use with caution in patients with a history of bleeding disorders (including thrombocytopenia) and/or patients on anticoagulant therapy; bleeding/hematoma may occur from IM administration.Dosage form specific issues:• Human plasma: Product of human plasma; may potentially contain infectious agents (eg, viruses, the variant Creutzfeldt-Jakob disease agent and, theoretically, the Creutzfeldt-Jakob disease agent), which could transmit disease. Screening of donors, as well as testing and/or inactivation or removal of certain viruses, reduces the risk. Infections thought to be transmitted by this product should be reported to the manufacturer.Other warnings/precautions:• Administration: Not for intravenous administration.• Administration: Administration is a medical urgency (not emergency); however, do not delay decision to treat.• Appropriate use: A single dose is recommended; repeating the dose may interfere with maximum active immunity expected from the vaccine. Repeated doses of Imogam Rabies-HT after vaccine treatment has been initiated are contraindicated.• Immunizations: Antibodies may interfere with the immune response to live vaccines. Live vaccines should be given ≥3 months after rabies immune globulin (defer live vaccines ≥4 months after HyperRAB); measles vaccine should be given ≥4 months after Kedrab.Metabolism/Transport EffectsNone known.Drug InteractionsNote: Interacting drugs may not be individually listed below if they are part of a group interaction (eg, individual drugs within “CYP3A4 Inducers [Strong]” are NOT listed).For a complete list of drug interactions by individual drug name and detailed management recommendations, use the Lexicomp drug interactions program by clicking on the “Launch drug interactions program” link above.Note: Interacting drugs may not be individually listed below if they are part of a group interaction (eg, individual drugs within “CYP3A4 Inducers [Strong]” are NOT listed). For a complete list of drug interactions by individual drug name and detailed management recommendations, use the Lexicomp drug interactions programEfgartigimod Alfa: May diminish the therapeutic effect of Fc Receptor-Binding Agents. Risk C: Monitor therapyRabies Vaccine: Rabies Immune Globulin (Human) may diminish the therapeutic effect of Rabies Vaccine.Management: Do not administer additional or repeated doses of rabies immune globulin once rabies vaccine has been administered. The rabies immune globulin should also not be administered in the same site as the vaccine. Risk D: Consider therapy modificationVaccines (Live): Rabies Immune Globulin (Human) may diminish the therapeutic effect of Vaccines (Live).Management: Avoid administering the measles vaccine within 4 months after administration of rabies immune globulin. Avoid administering other live vaccines within 3 months after administration of rabies immune globulin. Risk D: Consider therapy modificationPregnancy ConsiderationsAnimal reproduction studies have not been conducted. Pregnancy is not a contraindication to postexposure prophylaxis. Pre-exposure prophylaxis may be indicated during pregnancy if the risk for exposure to rabies is significant (CDC 2011).Monitoring ParametersSerum rabies antibody titer (if rabies immune globulin is inadvertently administered after the eighth day from the first rabies vaccine dose).Mechanism of ActionRabies immune globulin is a solution of globulins dried from the plasma or serum of selected adult human donors who have been immunized with rabies vaccine and have developed high titers of rabies antibody.Pricing: USSolution (HyperRAB Injection)300 units/mL (per mL): $816.60900UNIT/3ML (per mL): $816.601500 unit/5 mL (per mL): $816.59Solution (Imogam Rabies-HT Injection)300 units/2 mL (per mL): $543.08Disclaimer: A representative AWP (Average Wholesale Price) price or price range is provided as reference price only. A range is provided when more than one manufacturer's AWP price is available and uses the low and high price reported by the manufacturers to determine the range. The pricing data should be used for benchmarking purposes only, and as such should not be used alone to set or adjudicate any prices for reimbursem*nt or purchasing functions or considered to be an exact price for a single product and/or manufacturer.Medi-Span expressly disclaims all warranties of any kind or nature, whether express or implied, and assumes no liability with respect to accuracy of price or price range data published in its solutions.In no event shall Medi-Span be liable for special, indirect, incidental, or consequential damages arising from use of price or price range data.Pricing data is updated monthly.Brand Names: InternationalBayrab (PK);Berirab (GR, IL);Berirab P (PH);Berirab-P (LK, MX);Berirap (GR);Equirab (TZ);Favirab (ID, VN);Hyperrab (SG, TW);Hyperrab S D (IL);Imogam (AU);Imogam Rabia (AR, PY);Imogam Rabies (BF, BG, BJ, CI, EE, ET, GH, GM, GN, ID, KE, LR, MA, ML, MR, MU, MW, NE, NG, SC, SD, SL, SN, TN, TZ, UG, ZA, ZM, ZW);Imogan Rabia (ES);Imogan Rabies (LT, LV);Kamrab (KR);PARS (IN);Rabigam (ZA);Rabix-IG (BD);Rabuman Berna (TH);Rebinolin (RU);SII Rabivax (ET, ZW);Vinrab (PH);Yi Sheng Bao Er (CN)For country code abbreviations (show table)American Academy of Pediatrics (AAP). In: Kimberlin DW, Brady MT, Jackson MA, Long SA, eds. Red Book: 2018 Report of the Committee on Infectious Diseases. 31st ed. Itasca, IL: American Academy of Pediatrics; 2018.Centers for Disease Control and Prevention, “CDC Health Information for International Travel 2014.” New York: Oxford University Press; 2014.Centers for Disease Control and Prevention. Precautions or contraindications for rabies vaccination. 2011. Available at https://www.cdc.gov/rabies/specific_groups/doctors/vaccination_precautions.html.Centers for Disease Control, “Recommendations of the Advisory Committee on Immunization Practices (ACIP): General Recommendations on Immunization,” MMWR Recomm Rep, 2002, 51(RR-2):1-36.Centers for Disease Control and Prevention, “Use of a Reduced (4-Dose) Vaccine Schedule for Postexposure Prophylaxis to Prevent Human Rabies,” MMWR Recomm Rep, 2010, 59(RR-2):1-9. Available at http://www.cdc.gov/mmwr/PDF/rr/rr5902.pdf [PubMed 20300058]HyperRAB (rabies immune globulin [human] injection) [prescribing information]. Research Triangle Park, NC: Grifols Therapeutics LLC; January 2021.Imogam (rabies immune globulin [human] injection) [prescribing information]. Swiftwater, PA: Sanofi Pasteur; October 2014.Imogam Rabies - HT (rabies immune globulin [human] USP, injection) [prescribing information]. Swiftwater, PA: Sanofi Pasteur Inc; December 2020.Kedrab (rabies immune globulin [human] injection) [prescribing information]. Fort Lee, NJ: Kedrion Biopharma; received May 2021.Lang J and Plotkin SA, “Rabies Risk and Immunoprophylaxis in Children,” Adv Pediatr Infect Dis, 1997, 13:219-55. [PubMed 9544314]Manning SE, Rupprecht CE, Fishbein D, et al. Human rabies prevention--United States, 2008: recommendations of the Advisory Committee on Immunization Practices. MMWR Recomm Rep. 2008;57(RR-3):1-28. [PubMed 18496505]Strady A, Lang J, Lienard M, et al, “Antibody Persistence Following Pre-exposure Regimens of Cell-Culture Rabies Vaccines: 10-Year Follow-up and Proposal for a New Booster Policy,” J Infect Dis, 1998, 177(5):1290-5. [PubMed 9593014]Willoughby RE Jr and Hammarin AL, "Prophylaxis Against Rabies in Children Exposed to Bats," Pediatr Infect Dis Jp, 2005, 24(12):1109-10. [PubMed 16371876]Topic 12955 Version 175.0

ClosePatient education: Acute diarrhea in adults (Beyond the Basics)Patient education: Acute diarrhea in adults (Beyond the Basics)Authors:Regina LaRocque, MD, MPHJason B Harris, MD, MPH Section Editor:Stephen B Calderwood, MD Deputy Editor:Elinor L Baron, MD, DTMHLiterature review current through: Nov 2022. | This topic last updated: May 24, 2022.Please read the Disclaimer at the end of this page.DIARRHEA OVERVIEW — Diarrhea is commonly defined as three or more loose or watery stools per day. Nearly everyone will have an episode of diarrhea at some point during their life, with the average adult experiencing it four times per year. Although most cases of diarrhea resolve within a few days without treatment, it's important to know when to seek help.This topic review discusses the causes and treatments of sudden onset (acute) diarrhea in adults in developed countries. A discussion of acute diarrhea in resource-limited countries and returning travelers is not included here. Diarrhea that lasts for more than 14 days (called chronic diarrhea) and acute diarrhea in children are discussed in separate topic reviews. (See"Patient education: Chronic diarrhea in adults (Beyond the Basics)" and"Patient education: Acute diarrhea in children (Beyond the Basics)".) A topic review that discusses antibiotic-associated diarrhea is also available. (See"Patient education: Antibiotic-associated diarrhea caused by Clostridioides difficile (Beyond the Basics)".)DIARRHEA CAUSES — Diarrhea can be caused by infections or a variety of other factors. The cause of diarrhea is not identified in most people, especially those who improve without treatment.Diarrhea caused by infections usually results from eating or drinking contaminated food or water. Signs and symptoms of infection usually begin 12 hours to four days after exposure and resolve within three to seven days. (See"Patient education: Foodborne illness (food poisoning) (Beyond the Basics)".)Diarrhea not related to an infection can occur as a side effect of antibiotics or other drugs, food allergies, gastrointestinal diseases such as inflammatory bowel disease, and other diseases. In addition, there are many less common causes of diarrhea. A summary of the various common causes of diarrhea is available in the table (table 1).DIARRHEA SYMPTOMS — A person with diarrhea may be mildly to severely ill. A person who has mild illness may have a few loose bowel movements but otherwise feels well. By contrast, a person with severe diarrhea may have 20 or more bowel movements per day, happening up to every 20 or 30 minutes. In this situation, a significant amount of water and salts can be lost, seriously increasing the risk of dehydration. Diarrhea may be accompanied by fever (temperature greater than 100.4°F or 38°C), abdominal pain, or cramping.DIARRHEA HOME CAREDrink adequate fluids — If you have mild to moderate diarrhea, you can usually be treated at home by drinking extra fluids. The fluids should contain water, salt, and sugar. Oral rehydration solution (ORS), a specific mixture of glucose and sodium, is the best first-line treatment and is available in over-the-counter commercial preparations. Sports drinks (eg, Gatorade) are not optimal for fluid replacement, although they may be sufficient for a person with diarrhea who is not dehydrated and is otherwise healthy. Diluted fruit juices and flavored soft drinks along with salted crackers and broths or soups may also be acceptable.One way to judge hydration is by looking at the color of your urine and monitoring how frequently you urinate. If you urinate infrequently or have urine that is dark yellow, you should drink more fluids. Normally, urine should be light yellow to nearly colorless. If you are well hydrated, you normally pass urine every three to five hours.If you become dehydrated and are unable to take fluids by mouth, a rehydration solution can be given into a vein (intravenous fluids) in a health care provider's office or in the emergency department.Diet — There is no particular food or group of foods that is best while you have diarrhea. However, adequate nutrition is important during an episode of acute diarrhea. If you do not have an appetite, you can drink only liquids for a short period of time. Boiled starches and cereals (eg, potatoes, noodles, rice, wheat, and oats) with salt are recommended if you have watery diarrhea; crackers, bananas, soup, and boiled vegetables may also be eaten.Antidiarrheal medications — Medications to reduce diarrhea are available, and are safe if there is no fever (temperature greater than 100.4°F or 38°C) and the stools are not bloody. These medications do not cure the cause of the diarrhea, but help to reduce the frequency of bowel movements.●Loperamide (Imodium®) is available without a prescription; the dose is two tablets (4 mg) initially, then 1 tablet (2 mg) after each unformed stool. No more than 16 mg is recommended per day. If you take loperamide, be careful to never exceed the dose on the label unless specifically instructed by your doctor. Taking more than the recommended dose has led to serious heart problems in some people.●Diphenoxylate-atropine (Lomotil®) is a prescription medication used to treat diarrhea; its benefit is similar to loperamide, although it can be associated with more bothersome side effects.●Bismuth subsalicylate (Pepto-Bismol®, Kaopectate®) has also been used for treatment of acute diarrhea, although it is not as effective as loperamide. Bismuth subsalicylate may be recommended in certain situations, such as if you have fever and bloody diarrhea. However, women who are pregnant should not take bismuth subsalicylate. The dose of bismuth subsalicylate is 30 mL or two tablets every 30 minutes for up to eight doses.Antibiotics — Antibiotics are not needed in most cases of acute diarrhea, and they can cause further complications if used inappropriately. Antibiotics may be recommended in certain situations, such as if you have the following signs or symptoms:●More than eight loose stools per day ●Fever●Bloody stool●Dehydration●Symptoms that continue for more than one week●A weakened immune system●You require hospitalizationHowever, the decision to use antibiotics must be made carefully after discussing the potential risks and benefits with a health care provider who is familiar with the situation.Preventing spread — Adults with diarrhea should be cautious to avoid spreading infection to family, friends, and co-workers. You are considered infectious for as long as diarrhea continues. Microorganisms causing diarrhea are spread from hand to mouth; hand washing, care with diapering, and staying out of work or school are a few ways to prevent infecting family and other contacts.Hand washing — Hand washing is an effective way to prevent the spread of infection. Hands should ideally be wet with water and plain or antibacterial soap and rubbed together for 15 to 30 seconds. Pay special attention to the fingernails, between the fingers, and the wrists. Rinse your hands thoroughly and dry with a single use towel.If a sink is not available, alcohol-based hand rubs are a good alternative for disinfecting hands. Spread the hand rub over the entire surface of your hands, fingers, and wrists until dry. Hand rubs may be used several times. Hand rubs are available as a liquid or wipe in small, portable sizes that are easy to carry in a pocket or handbag. When a sink is available and your hands are visibly dirty, it is best to wash them with soap and water.Clean your hands after changing a diaper, before and after preparing food and eating, after going to the bathroom, after handling garbage or dirty laundry, after touching animals or pets, and after blowing your nose or sneezing.DIARRHEA PREVENTIONFood safety — The following precautions have been recommended for all consumers by the Food Safety and Inspection Services (www.fsis.usda.gov) and the Centers for Disease Control and Prevention.●Do not drink raw (unpasteurized) milk or foods that contain unpasteurized milk.●Wash raw fruits and vegetables thoroughly before eating.●Keep the refrigerator temperature at 40°F (4.4°C) or lower; the freezer at 0°F (-17.8°C) or lower.●Eat precooked, perishable, or ready-to-eat food as soon as possible.●Keep raw meat, fish, and poultry separate from other food.●Wash hands, knives, and cutting boards after handling uncooked food, including produce and raw meat, fish, or poultry.●Thoroughly cook raw food from animal sources to a safe internal temperature: ground beef 160°F (71°C); chicken 170°F (77°C); turkey 180°F (82°C); pork 145°F (63°C) with a three minute rest time.●Seafood should be cooked thoroughly to minimize the risk of food poisoning. Eating raw fish (eg, sushi) poses a risk for a variety of parasitic worms (in addition to the risks associated with organisms carried by food handlers). Freezing kills some, although not all, harmful microorganisms. Raw fish that is labeled "sushi-grade" or "sashimi-grade" has been frozen.●Cook chicken eggs thoroughly, until the yolk is firm.●Refrigerate foods promptly. Never leave cooked foods at room temperature for more than two hours (one hour if the room temperature is above 90°F/32°C).Food safety for pregnant women or those with a weakened immune system — The following additional recommendations apply to pregnant women and those who have a weakened immune system:●Do not eat hot dogs, pâtés, luncheon meats, bologna, or other delicatessen meats unless they are reheated until steaming hot; avoid the use of microwave ovens since uneven cooking may occur.●Avoid spilling fluids from raw meat and hot dog packages on other foods, utensils, and food preparation surfaces. In addition, wash your hands after handling hot dogs, luncheon meats, delicatessen meats, and raw meat, chicken, turkey, or seafood or their juices.●Do not eat pre-prepared salads, such as ham salad, chicken salad, egg salad, tuna salad, or seafood salad.●Do not eat soft cheeses such as feta, Brie, and Camembert, blue-veined cheeses, or Mexican-style cheeses such as queso blanco, queso fresco, or Panela, unless they have a label that clearly states that the cheese is made from pasteurized milk.●Do not eat refrigerated pates or meat spreads. Canned or shelf-stable products may be eaten.●Do not eat refrigerated smoked seafood unless it has been cooked. Refrigerated smoked seafood, such as salmon, trout, whitefish, cod, tuna or mackerel, is most often labeled as "nova-style," "lox," "kippered," "smoked," or "jerky." The fish is found in the refrigerator section or sold at deli counters of grocery stores and delicatessens. Canned or shelf-stable smoked seafood may be eaten.Travelers' diarrhea prevention — Recommendations to prevent travelers' diarrhea are available separately. (See"Patient education: General travel advice (Beyond the Basics)".)WHEN TO SEEK HELP FOR DIARRHEA — If your diarrhea is not severe, you do not always need to be seen by a doctor, especially if the diarrhea begins to improve within 48 hours. Self-care measures for this situation are discussed above (see 'Diarrhea home care' above).However, if you have one or more of the following signs or symptoms, you should be evaluated by a health care provider:●Profuse watery diarrhea with signs of dehydration. Early features of dehydration include sluggishness, becoming tired easily, dry mouth and tongue, thirst, muscle cramps, dark-colored urine, urinating infrequently, and dizziness or lightheadedness after standing or sitting up. More severe features include abdominal pain, chest pain, confusion, or difficulty remaining alert.●Many small stools containing blood and mucus●Bloody or black diarrhea●Temperature ≥38.5°C (101.3°F)●Passage of ≥6 unformed stools per 24 hours or illness that lasts more than 48 hours●Severe abdominal pain/painful passage of stoolIn addition, if you have persistent diarrhea following antibiotics, are older than 65 years, have other medical illness or a weakened immune system, you should also consult your health care provider.SUMMARY●Acute diarrhea is defined as three or more loose or watery stools per day.●Diarrhea can be caused by infections or other factors. Sometimes, the cause of diarrhea is not known. Diarrhea caused by an infection usually begins 12 hours to four days after exposure and resolves within three to seven days.●A person may have mild to severe diarrhea. Some people with diarrhea also have fever (temperature greater than 100.4°F or 38°C), abdominal pain, or cramping.●People with mild diarrhea do not usually need to go to the doctor, especially if the diarrhea begins to improve within 48 hours. If you develop any of the following, you should call your doctor or nurse immediately:•Profuse watery diarrhea with sluggishness, becoming tired easily, dry mouth and tongue, thirst, muscle cramps, dark-colored urine, urinating infrequently, and dizziness or lightheadedness after standing or sitting up. More severe features include abdominal pain, chest pain, confusion, or difficulty remaining alert.•Passage of many small stools containing blood and mucus•Bloody or black diarrhea•Temperature ≥38.5°C (101.3°F)•Passing 6 or more watery stools per 24 hours or illness that lasts more than 48 hours•Severe abdominal pain●In addition, if you have persistent diarrhea after finishing antibiotics, are older than 69, or have other medical illness or a weakened immune system, you should also consult your doctor or nurse.●The most important treatment for diarrhea is to drink fluids that contain water, salt, and sugar, such as oral rehydration solution (ORS). Sports drinks (eg, Gatorade) may be acceptable if you are not dehydrated and are otherwise healthy. Diluted fruit juices and flavored soft drinks along with saltine crackers and broths or soups may also be acceptable.●If you have dark yellow colored urine or do not pass urine frequently, you should drink more fluids. The urine should normally be light yellow to clear colored.●Medications to reduce diarrhea are available without a prescription, and are safe if there is no fever (temperature greater than 100.4°F or 38°C) and the stools are not bloody. These medications do not cure the cause of the diarrhea, but help to reduce the frequency of bowel movements. Common medications include loperamide (Imodium®), diphenoxylate-atropine (Lomotil®), and bismuth subsalicylate (Pepto-Bismol® or Kaopectate®).●If you do not have an appetite, you can drink only liquids for a short period of time. Boiled starches and cereals (eg, potatoes, noodles, rice, wheat, and oat) with salt are recommended if you have watery diarrhea; crackers, bananas, soup, and boiled vegetables may also be eaten.●Antibiotics are not needed for most people with diarrhea.●If you have diarrhea, be careful to avoid spreading the infection to family, friends, and co-workers. You are contagious for as long as diarrhea continues. Infections are usually spread from hand to mouth; hand washing, care with diapering, and staying out of work or school are a few ways to prevent infecting family and other contacts.WHERE TO GET MORE INFORMATION — Your health care provider is the best source of information for questions and concerns related to your medical problem.This article will be updated as needed on our web site (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for health care professionals, are also available. Some of the most relevant are listed below.Patient level information — UpToDate offers two types of patient education materials.The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Patient education: Diarrhea in adolescents and adults (The Basics) Patient education: Diarrhea in children (The Basics) Patient education: Food poisoning (The Basics) Patient education: Lactose intolerance (The Basics) Patient education: C. difficile infection (The Basics) Patient education: Managing loss of appetite and weight loss with cancer (The Basics) Patient education: Dehydration in children (The Basics) Patient education: Ischemic bowel disease (The Basics) Patient education: Cryptosporidiosis (The Basics) Patient education: Salmonella infection (The Basics) Patient education: Travelers' diarrhea (The Basics) Patient education: E. coli diarrhea (The Basics) Patient education: Listeria (The Basics) Patient education: Campylobacter infection (The Basics)Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon. Patient education: Chronic diarrhea in adults (Beyond the Basics) Patient education: Acute diarrhea in children (Beyond the Basics) Patient education: Antibiotic-associated diarrhea caused by Clostridioides difficile (Beyond the Basics) Patient education: Foodborne illness (food poisoning) (Beyond the Basics) Patient education: General travel advice (Beyond the Basics)Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading. Approach to the adult with acute diarrhea in resource-rich settings Clinical manifestations, diagnosis, and treatment of Campylobacter infection Clostridioides difficile infection in adults: Clinical manifestations and diagnosis Shigella infection: Clinical manifestations and diagnosis Shiga toxin-producing Escherichia coli: Clinical manifestations, diagnosis, and treatment Clinical manifestations and diagnosis of rotavirus infection Cryptosporidiosis: Epidemiology, clinical manifestations, and diagnosis Pathogenic Escherichia coli associated with diarrhea Causes of acute infectious diarrhea and other foodborne illnesses in resource-rich settings Norovirus Cholera: Clinical features, diagnosis, treatment, and prevention Acute viral gastroenteritis in adultsThe following organizations also provide reliable health information.●National Library of Medicine(www.nlm.nih.gov/medlineplus/healthtopics.html)●National Institute of Digestive and Diabetes and Kidney Diseases(www.niddk.nih.gov/health-information/digestive-diseases/diarrhea)●Center for Disease Control and Prevention(www.cdc.gov)●American College of Gastroenterology(www.acg.gi.org/patients/gihealth/diarrheal.asp)[1-3]Shane AL, Mody RK, Crump JA, et al. 2017 Infectious Diseases Society of America Clinical Practice Guidelines for the Diagnosis and Management of Infectious Diarrhea. Clin Infect Dis 2017; 65:e45.Riddle MS, DuPont HL, Connor BA. ACG Clinical Guideline: Diagnosis, Treatment, and Prevention of Acute Diarrheal Infections in Adults. Am J Gastroenterol 2016; 111:602.DuPont HL. Acute infectious diarrhea in immunocompetent adults. N Engl J Med 2014; 370:1532.This generalized information is a limited summary of diagnosis, treatment, and/or medication information. It is not meant to be comprehensive and should be used as a tool to help the user understand and/or assess potential diagnostic and treatment options. It does NOT include all information about conditions, treatments, medications, side effects, or risks that may apply to a specific patient. It is not intended to be medical advice or a substitute for the medical advice, diagnosis, or treatment of a health care provider based on the health care provider's examination and assessment of a patient's specific and unique circ*mstances. Patients must speak with a health care provider for complete information about their health, medical questions, and treatment options, including any risks or benefits regarding use of medications. This information does not endorse any treatments or medications as safe, effective, or approved for treating a specific patient. UpToDate, Inc. and its affiliates disclaim any warranty or liability relating to this information or the use thereof.The use of this information is governed by the Terms of Use, available at https://www.wolterskluwer.com/en/know/clinical-effectiveness-terms ©2023 UpToDate, Inc. and its affiliates and/or licensors. All rights reserved.Topic 4021 Version 32.0References1 : 2017 Infectious Diseases Society of America Clinical Practice Guidelines for the Diagnosis and Management of Infectious Diarrhea.2 : ACG Clinical Guideline: Diagnosis, Treatment, and Prevention of Acute Diarrheal Infections in Adults.3 : Acute infectious diarrhea in immunocompetent adults.

CloseRabies immune globulin (human): Drug informationRabies immune globulin (human): Drug information(For additional information see "Rabies immune globulin (human): Patient drug information" and see "Rabies immune globulin (human): Pediatric drug information")For abbreviations, symbols, and age group definitions used in Lexicomp (show table)Brand Names: USHyperRAB;HyperRAB S/D;Imogam Rabies-HT;KedrabBrand Names: CanadaHyperRAB;HyperRAB S/D [DSC];Imogam Rabies Pasteurized [DSC];KamrabPharmacologic CategoryBlood Product Derivative;Immune GlobulinDosing: AdultNote: Potency varies among currently available products; use caution to ensure correct dose is administered.Rabies, postexposure prophylaxisRabies, postexposure prophylaxis: Local wound infiltration/IM: 20 units/kg in a single dose, rabies immune globulin (human) (HRIG) should always be administered as part of rabies vaccine regimen. If anatomically feasible, the full rabies immune globulin dose should be infiltrated around and into the wound(s); remaining volume should be administered IM at a site distant from the vaccine administration site. HRIG should be administered as soon as possible after exposure, preferably at time of first rabies vaccine dose. If rabies vaccine was initiated without HRIG, HRIG may be administered through the seventh day after the administration of the first dose of the vaccine (day 0). Administration of HRIG is not recommended after the seventh day post vaccine since an antibody response to the vaccine is expected during this time period.Note: Not recommended for use in persons with a history of complete rabies vaccination (preexposure or postexposure prophylaxis) and documentation of antibody response.Dosing: Kidney Impairment: AdultThere are no dosage adjustments provided in the manufacturer’s labeling.Dosing: Hepatic Impairment: AdultThere are no dosage adjustments provided in the manufacturer’s labeling.Dosing: Pediatric(For additional information see "Rabies immune globulin (human): Pediatric drug information")Note: Not recommended for use in persons with a history of vaccination (preexposure or postexposure) and documentation of antibody response. Potency varies among currently available products; use caution to ensure correct dose is administered.Postexposure prophylaxisPostexposure prophylaxis: Infants, Children, and Adolescents: Local wound infiltration/IM: 20 units/kg single dose administered as soon as possible after exposure and as part of a rabies vaccine regimen; do not exceed recommended dose since passive antibody can interfere with response to rabies vaccine. If anatomically feasible, the full rabies immune globulin (RIG) dose should be infiltrated around and into the wound(s); any remaining volume should be administered IM at a site distant from the vaccine administration site. If rabies vaccine was initiated without rabies immune globulin, rabies immune globulin may be administered through the seventh day after the first vaccine dose. Administration of RIG is not recommended after the seventh day postvaccine since an antibody response to the vaccine is expected during this time period.Dosing: Kidney Impairment: PediatricThere are no dosage adjustments provided in manufacturer's labeling.Dosing: Hepatic Impairment: PediatricThere are no dosage adjustments provided in manufacturer's labeling.Dosing: Older AdultRefer to adult dosing.Dosage Forms: USExcipient information presented when available (limited, particularly for generics); consult specific product labeling.[DSC] = Discontinued productSolution, Injection: Imogam Rabies-HT: 300 units/2 mL (2 mL); 1500 units/10 mL (10 mL [DSC])Solution, Injection [preservative free]: HyperRAB: 300 units/mL (1 mL); 900 units/3 mL (3 mL); 1500 units/5 mL (5 mL)HyperRAB S/D: 300 units/2 mL (2 mL); 1500 units/10 mL (10 mL)Kedrab: 300 units/2 mL (2 mL); 1500 units/10 mL (10 mL) [latex free, pyrogen free]Generic Equivalent Available: USYesDosage Forms: CanadaExcipient information presented when available (limited, particularly for generics); consult specific product labeling.[DSC] = Discontinued productInjectable, Intramuscular: HyperRAB S/D: 150 units/mL ([DSC])Generic: 150 units/mL ([DSC])Solution, Injection: HyperRAB: 300 units/mL (1 mL, 5 mL)Kamrab: 300 units/2 mL (2 mL)Administration: AdultIM: Postexposure wound infiltration: For wound infiltration and IM use only; do not administer IV. Clean wounds immediately with soap and water; irrigate wounds with viricidal agent (eg, povidone-iodine) if available. If anatomically feasible, the full rabies immune globulin (human) (HRIG) dose should be infiltrated around and into the wound(s); remaining volume should be administered IM in the deltoid muscle of the upper arm or lateral thigh muscle. Per the manufacturer, the gluteal area should be avoided to reduce the risk of sciatic nerve damage or unpredictable absorbance, unless gluteal region is exposure site. Do not administer rabies vaccine in the same syringe or at the same administration site as HRIG. For extensive wounds, do not exceed the calculated dose. If the location of the wound is unknown or if infiltration is difficult at the bite site (eg, lips, fingers, knee), administer the full dose at a site distant from the site of the rabies vaccination. If additional volume is needed to infiltrate the wound(s), may dilute with an equal volume of D5W (HyperRAB) or NS (Kedrab, Imogam) (CDC 2014); HyperRAB should not be diluted with NS.Administration: PediatricParenteral: Postexposure wound infiltration: Thoroughly cleanse wound(s) with soap and water; irrigate wounds with viricidal agent (eg, povidone-iodine) if available. If anatomically feasible, the full rabies immune globulin (RIG) dose should be infiltrated around and into the wound(s); remaining volume should be administered IM in the deltoid muscle of the upper arm or lateral thigh muscle at a site distant from rabies vaccine administration. Per the manufacturer, the gluteal area should be avoided to reduce the risk of sciatic nerve damage or unpredictable absorbance (unless exposure area is the gluteal area). Do not administer IV. If IM administration is contraindicated (eg, patients with uncorrectable bleeding disorders), Kedrab may be administered SubQ; however, no clinical efficacy data are available to support administration SubQ. Do not administer rabies vaccine in the same syringe or at the same administration site as RIG. For extensive wounds, do not exceed the calculated dose. For extensive wounds, do not exceed the calculated dose. If the location of the wound is unknown or if infiltration is difficult at the bite site (eg, lips, fingers, knee), administer the full dose at a site distant from the site of the rabies vaccination​. If additional volume is needed to infiltrate the wound(s), may dilute with an equal volume of D5W (HyperRAB) or NS (Kedrab, Imogam) (Red Book [AAP 2018]); HyperRAB should not be diluted with NS. If a large intramuscular volume is required (>2 mL for children or >5 mL for adults), administer the total volume in divided doses at different sites.Use: Labeled IndicationsRabies, postexposure prophylaxis: Component of postexposure prophylaxis for patients with suspected rabies exposure. Provides passive immunity until active immunity with rabies vaccine is established. Not for use in patients with a history of complete vaccination (preexposure or postexposure prophylaxis) and documentation of antibody response, as these patients require only the vaccination. Each exposure to possible rabies infection should be individually evaluated.Factors to consider include: species of biting animal, circ*mstances of biting incident (provoked vs unprovoked bite), type of exposure to rabies infection (bite vs nonbite), vaccination status of biting animal, presence of rabies in the region. See product information for additional details.Medication Safety IssuesInternational issues:Bayrab [Philippines, Turkey] may be confused with Bayhep-B which is a brand name for hepatitis Bimmune globulin [Philippines, Turkey]; Bayrho-D which is brand name for RhoD immune globulin [Israel, Turkey] Adverse ReactionsThe following adverse drug reactions and incidences are derived from product labeling unless otherwise specified.>10%:Central nervous system: Headache (8% to 15%)Local: Pain at injection site (31% to 33%)1% to 10%:Central nervous system: Fatigue (2% to 6%), dizziness (1% to 6%)Dermatologic: Sunburn (≤3%)Gastrointestinal: Diarrhea (8%), flatulence (8%), nausea (4%), abdominal pain (1% to 4%)Genitourinary: Leukocyturia (3% to 5%), hematuria (2% to 4%)Hematologic & oncologic: Bruise (1% to 3%)Local: Injection site nodule (8%)Neuromuscular & skeletal: Myalgia (7% to 9%), arthralgia (≤6%)Respiratory: Upper respiratory tract infection (9% to 10%), nasal congestion (8%), oropharyngeal pain (8%)Frequency not defined:Central nervous system: MalaiseDermatologic: Skin rashGenitourinary: Nephrotic syndromeHypersensitivity: Anaphylaxis, angioedemaLocal: Local soreness/soreness at injection site, tenderness at injection siteNeuromuscular & skeletal: Stiffness (at injection site)Miscellaneous: Fever (mild)<1%, postmarketing, and/or case reports: Hypersensitivity reaction, hypoesthesia, limb painContraindicationsImogam Rabies-HT: Should not be administered in repeated doses once vaccine treatment has been initiated (may interfere with active immunity of vaccine).HyperRAB, Kedrab: There are no contraindications listed in the manufacturer's labeling.Documentation of allergenic cross-reactivity for immune globulins is limited. However, because of similarities in chemical structure and/or pharmacologic actions, the possibility of cross-sensitivity cannot be ruled out with certainty.Warnings/PrecautionsConcerns related to adverse effects:• Anaphylaxis/hypersensitivity reactions: Hypersensitivity and anaphylactic reactions can occur; discontinue immediately and institute supportive emergency measures if hypersensitivity or anaphylaxis occurs. Use with caution in patients with isolated immunoglobulin A deficiency or a history of systemic hypersensitivity to human immunoglobulins. Medications for the treatment of acute allergic reactions should be available for immediate use.• Hemolysis: May occur; risk is increased in patients with non-O blood group types, underlying associated inflammatory conditions, and those receiving high cumulative doses of immune globulins over several days. Monitor patients for signs and symptoms of hemolysis (eg, fever, chills, dark urine).• Thrombosis: Use with caution in patients at increased risk of thrombosis (eg, acquired or hereditary hypercoagulable states, prolonged immobilization, indwelling vascular catheters, advanced age, estrogen use, history of thrombosis, cardiovascular risk factors, hyperviscosity syndromes). Monitor these patients for at least 24 hours after administration; consider measuring a baseline blood viscosity in patients at risk for hyperviscosity.Disease-related concerns:• Bleeding disorders: Use with caution in patients with a history of bleeding disorders (including thrombocytopenia) and/or patients on anticoagulant therapy; bleeding/hematoma may occur from IM administration.Dosage form specific issues:• Human plasma: Product of human plasma; may potentially contain infectious agents (eg, viruses, the variant Creutzfeldt-Jakob disease agent and, theoretically, the Creutzfeldt-Jakob disease agent), which could transmit disease. Screening of donors, as well as testing and/or inactivation or removal of certain viruses, reduces the risk. Infections thought to be transmitted by this product should be reported to the manufacturer.Other warnings/precautions:• Administration: Not for intravenous administration.• Administration: Administration is a medical urgency (not emergency); however, do not delay decision to treat.• Appropriate use: A single dose is recommended; repeating the dose may interfere with maximum active immunity expected from the vaccine. Repeated doses of Imogam Rabies-HT after vaccine treatment has been initiated are contraindicated.• Immunizations: Antibodies may interfere with the immune response to live vaccines. Live vaccines should be given ≥3 months after rabies immune globulin (defer live vaccines ≥4 months after HyperRAB); measles vaccine should be given ≥4 months after Kedrab.Metabolism/Transport EffectsNone known.Drug InteractionsNote: Interacting drugs may not be individually listed below if they are part of a group interaction (eg, individual drugs within “CYP3A4 Inducers [Strong]” are NOT listed).For a complete list of drug interactions by individual drug name and detailed management recommendations, use the Lexicomp drug interactions program by clicking on the “Launch drug interactions program” link above.Efgartigimod Alfa: May diminish the therapeutic effect of Fc Receptor-Binding Agents. Risk C: Monitor therapyRabies Vaccine: Rabies Immune Globulin (Human) may diminish the therapeutic effect of Rabies Vaccine.Management: Do not administer additional or repeated doses of rabies immune globulin once rabies vaccine has been administered. The rabies immune globulin should also not be administered in the same site as the vaccine. Risk D: Consider therapy modificationVaccines (Live): Rabies Immune Globulin (Human) may diminish the therapeutic effect of Vaccines (Live).Management: Avoid administering the measles vaccine within 4 months after administration of rabies immune globulin. Avoid administering other live vaccines within 3 months after administration of rabies immune globulin. Risk D: Consider therapy modificationPregnancy ConsiderationsAnimal reproduction studies have not been conducted. Pregnancy is not a contraindication to postexposure prophylaxis. Pre-exposure prophylaxis may be indicated during pregnancy if the risk for exposure to rabies is significant (CDC 2011).Breastfeeding ConsiderationsImmunoglobulins are excreted in breast milk. According to the manufacturer, the decision to continue or discontinue breastfeeding during therapy should take into account the risk of infant exposure, the benefits of breastfeeding to the infant, and benefits of treatment to the mother.Mechanism of ActionRabies immune globulin is a solution of globulins dried from the plasma or serum of selected adult human donors who have been immunized with rabies vaccine and have developed high titers of rabies antibody.Pricing: USSolution (HyperRAB Injection)300 units/mL (per mL): $816.60900UNIT/3ML (per mL): $816.601500 unit/5 mL (per mL): $816.59Solution (Imogam Rabies-HT Injection)300 units/2 mL (per mL): $543.08Disclaimer: A representative AWP (Average Wholesale Price) price or price range is provided as reference price only. A range is provided when more than one manufacturer's AWP price is available and uses the low and high price reported by the manufacturers to determine the range. The pricing data should be used for benchmarking purposes only, and as such should not be used alone to set or adjudicate any prices for reimbursem*nt or purchasing functions or considered to be an exact price for a single product and/or manufacturer.Medi-Span expressly disclaims all warranties of any kind or nature, whether express or implied, and assumes no liability with respect to accuracy of price or price range data published in its solutions.In no event shall Medi-Span be liable for special, indirect, incidental, or consequential damages arising from use of price or price range data.Pricing data is updated monthly.Brand Names: InternationalBayrab (PK);Berirab (GR, IL);Berirab P (PH);Berirab-P (LK, MX);Berirap (GR);Equirab (TZ);Favirab (ID, VN);Hyperrab (SG, TW);Hyperrab S D (IL);Imogam (AU);Imogam Rabia (AR, PY);Imogam Rabies (BF, BG, BJ, CI, EE, ET, GH, GM, GN, ID, KE, LR, MA, ML, MR, MU, MW, NE, NG, SC, SD, SL, SN, TN, TZ, UG, ZA, ZM, ZW);Imogan Rabia (ES);Imogan Rabies (LT, LV);Kamrab (KR);PARS (IN);Rabigam (ZA);Rabix-IG (BD);Rabuman Berna (TH);Rebinolin (RU);SII Rabivax (ET, ZW);Vinrab (PH);Yi Sheng Bao Er (CN)For country code abbreviations (show table)American Academy of Pediatrics (AAP). In: Kimberlin DW, Brady MT, Jackson MA, Long SA, eds. Red Book: 2018 Report of the Committee on Infectious Diseases. 31st ed. Itasca, IL: American Academy of Pediatrics; 2018.Centers for Disease Control and Prevention, “CDC Health Information for International Travel 2014.” New York: Oxford University Press; 2014.Centers for Disease Control and Prevention. Precautions or contraindications for rabies vaccination. 2011. Available at https://www.cdc.gov/rabies/specific_groups/doctors/vaccination_precautions.html.Centers for Disease Control, “Recommendations of the Advisory Committee on Immunization Practices (ACIP): General Recommendations on Immunization,” MMWR Recomm Rep, 2002, 51(RR-2):1-36.Centers for Disease Control and Prevention, “Use of a Reduced (4-Dose) Vaccine Schedule for Postexposure Prophylaxis to Prevent Human Rabies,” MMWR Recomm Rep, 2010, 59(RR-2):1-9. Available at http://www.cdc.gov/mmwr/PDF/rr/rr5902.pdf [PubMed 20300058]HyperRAB (rabies immune globulin [human] injection) [prescribing information]. Research Triangle Park, NC: Grifols Therapeutics LLC; January 2021.Imogam (rabies immune globulin [human] injection) [prescribing information]. Swiftwater, PA: Sanofi Pasteur; October 2014.Imogam Rabies - HT (rabies immune globulin [human] USP, injection) [prescribing information]. Swiftwater, PA: Sanofi Pasteur Inc; December 2020.Kedrab (rabies immune globulin [human] injection) [prescribing information]. Fort Lee, NJ: Kedrion Biopharma; received May 2021.Lang J and Plotkin SA, “Rabies Risk and Immunoprophylaxis in Children,” Adv Pediatr Infect Dis, 1997, 13:219-55. [PubMed 9544314]Manning SE, Rupprecht CE, Fishbein D, et al. Human rabies prevention--United States, 2008: recommendations of the Advisory Committee on Immunization Practices. MMWR Recomm Rep. 2008;57(RR-3):1-28. [PubMed 18496505]Strady A, Lang J, Lienard M, et al, “Antibody Persistence Following Pre-exposure Regimens of Cell-Culture Rabies Vaccines: 10-Year Follow-up and Proposal for a New Booster Policy,” J Infect Dis, 1998, 177(5):1290-5. [PubMed 9593014]Willoughby RE Jr and Hammarin AL, "Prophylaxis Against Rabies in Children Exposed to Bats," Pediatr Infect Dis Jp, 2005, 24(12):1109-10. [PubMed 16371876]Topic 9848 Version 199.0

CloseRandomized trials of surgery of the primary tumor in patients with de novo stage IV breast cancerRandomized trials of surgery of the primary tumor in patients with de novo stage IV breast cancer   Trial ECOG E2108[1] Austria[2,3] India[4] Turkey MF07-01[5] Accrual period 2011 to 2015 2011 to 2015 2005 to 2013 2007 to 2012 Number of patients 256 90 350 274 Inclusion De novo stage IV breast cancer on systemic therapy for 4 to 8 months without progression Stage IV breast cancer De novo stage IV breast cancer with resectable hormone receptor-positive disease, or others with a partial or complete response to anthracycline-based chemotherapy De novo stage IV breast cancer Prerandomization systemic therapy Optimal systemic therapy × 4 to 8 months None 6 to 8 cycles of anthracycline-based chemotherapy None Stratification Hormone receptor statusHER2 statusNumber of metastatic sitesEndocrine therapyChemotherapyHormone receptor statusHER2 statusGradeLocation of metastasesUse of 1st-line chemotherapyHormone receptor statusSite of metastasisNumber of metastatic lesionsNone Locoregional therapy in surgery group 87% surgery (BCS + RT or mastectomy ± RT)AxD rate not reported80% clear margins71% mastectomy29% BCS + RT93% AxD76% clear margins72% mastectomy23% BCS + RT100% AxDMargin status not reported74% mastectomy26% BCS + RT93% AxD100% clear marginsMedian follow-up (months) 53 37.5 23 40 OS (surgery versus no surgery) Median OS 54 months in both arms3-year OS 68 versus 68%HR 1.09, 90% CI 0.80-1.49; p = 0.63Median OS 35 versus 55 monthsHR 0.69, 95% CI 0.36-1.33; p = 0.27Median OS 19 versus 20.5 months2-year OS 42 versus 43%HR 1.04, 95% CI 0.81-1.34; p = 0.795-year OS 42 versus 24%HR 0.66, 95% CI 0.49-0.88; p = 0.005LRP (surgery versus no surgery) LRP 10 versus 26%, p = 0.003 LRP 9 versus 18%, p = 0.22 LRP-free survival: Median not attained versus 18.2 months; HR 0.16, 95% CI 0.10-0.26; p <0.0001 LRP 1 versus 11%, p = 0.001 Quality of life Worse in surgery group at 18 months; no difference at 6 or 30 months No difference Not reported Not reportedECOG: Eastern Cooperative Oncology Group; HER2: human epidermal growth factor receptor 2; BCS: breast-conserving surgery; RT: radiation therapy; AxD: axillary dissection; OS: overall survival; HR: hazard ratio; CI: confidence interval; LRP: locoregional progression.References: Khan SA, Zhao F, Solin LJ, et al. A randomized phase III trial of systemic therapy plus early local therapy versus systemic therapy alone in women with de novo stage IV breast cancer: A trial of the ECOG-ACRIN Research Group (E2108). J Clin Oncol 2020; 38S: ASCO #LBA2.Fitzal F, Bjelic-Radisic V, Knauer M, et al. Impact of breast surgery in primary metastasized breast cancer: Outcomes of the prospective randomized phase III ABCSG-28 POSYTIVE trial. Ann Surg 2019; 269:1163.Bjelic-Radisic V, Fitzal F, Knauer M, et al. Primary surgery versus no surgery in synchronous metastatic breast cancer: Patient-reported quality-of-life outcomes of the prospective randomized multicenter ABCSG-28 Posytive Trial. BMC Cancer 2020; 20:392.Badwe R, Hawaldar R, Nair N, et al. Locoregional treatment versus no treatment of the primary tumour in metastatic breast cancer: An open-label randomised controlled trial. Lancet Oncol 2015; 16:1380.Soran A, Ozmen V, Ozbas S, et al. Randomized trial comparing resection of primary tumor with no surgery in stage IV breast cancer at presentation: Protocol MF07-01. Ann Surg Oncol 2018; 25:3141.Graphic 130510 Version 1.0

Pitted keratolysis (also known as keratolysis sulcata, keratolysis plantare sulcatum, and ringed keratolysis) is a superficial bacterial skin infection confined to the stratum corneum. Clinically, pitted keratolysis is characterized by malodor and multifocal, discrete, superficial crateriform pits a

Mesothelioma is an insidious neoplasm arising from the mesothelial surfaces of the pleural and peritoneal cavities, the tunica vagin*lis, or the pericardium. Eighty percent of cases are pleural in origin. The predominant cause of malignant mesothelioma is inhalational exposure to asbestos, with appr

ClosePrevalence of symptoms and signs related to bronchiectasis in childrenPrevalence of symptoms and signs related to bronchiectasis in children   Frequency among children with bronchiectasis[1] Comments Odds ratio for predicting bronchiectasis*[2] (95% CI) Symptom Chronic wet or productive cough Very common Present in up to 50% of children with bronchiectasis in resource-rich settings and up to 100% in resource-limited settings or certain indigenous populations 527 (45.4-6102) Recurrent protracted bacterial bronchitis Unknown (but probably somewhat common) Diagnosis is made based on clinical criteria; management requires follow-up through resolution  18.4 (1.0-349.7) Recurrent or previous pneumonia Very common Particularly common in low-resource populations (up to 100% of cohort) 22.8 (1.2-424.3) Wheeze or reversible airway obstruction Common (10 to 66%) Likely differs from classic asthma; manage based on clinical response to therapy     Hemoptysis Uncommon Suggests advanced disease   Chest pain Uncommon Symptom is typically intermittent rather than chronic   Dyspnea/exertional dyspnea Highly variable among different populations Common in low-resource settings or when diagnosis is delayed in more severe disease 4.3 (0.2-109.7) Sinusitis/otitis problems Highly variable among different populations Often associated with underlying immunodeficiency¶[3]   Faltering growth Uncommon Common in low-resource settings or when diagnosis is delayed   Feeding difficulties Uncommon Suggests possibility of recurrent small-volume aspiration  22.8 (1.2-424.3) Signs Digital clubbing Highly variable among different populations Uncommon in resource-rich settings, but found in up to 70% of children in low-resource settings or when diagnosis is delayed 7.5 (0.3-161.5) Chest deformity Common (15 to 30%) Includes hyperinflation, Harrison sulci, pectus carinatum 4.3 (0.2-109.7) Differential airway sounds (on chest auscultation) Unknown More likely with focal disease or during an exacerbation 7.5 (0.3-161.5) Crackles Uncommon More common prior to antibiotic treatment, during an exacerbation, when disease is severe, or in patients with certain underlying diseases such as bronchiolitis obliterans 10.8 (0.5-218.9) Basic tests Chest radiograph abnormal Uncommon Low sensitivity to detect bronchiectasis 41.6 (2.3-750) FEV1 percent predicted (median) 52 to 95% Median FEV1 is lower in resource-limited settings or when diagnosis is delayed 4.3 (0.2-109.7) FVC percent predicted (median) 58 to 96% Median FVC is lower in resource-limited settings or when diagnosis is delayed Not statedBold text indicates strongest predictors of bronchiectasis compared with self-limited cough*.FEV1: forced expiratory volume in 1 second; FVC: forced vital capacity.* For each symptom/sign, the odds ratio of having bronchiectasis is compared with children whose cough resolved without any specific treatment, based on a study involving 326 Australian children with chronic cough newly referred to a respiratory pediatrician[2].¶ In a study from Turkey, otitis/sinusitis was present in 64% of children with bronchiectasis. The high prevalence of otitis/sinusitis in this study is from a population in Turkey with very high rates of consanguinity (present in 59.4% of children with bronchiectasis)[3] and associated risk of rare primary immunodeficiency disorders.References:Chang AB, Bush A, Grimwood K. Bronchiectasis in children: Diagnosis and Treatment. Lancet 2018; 392:866.Chang AB, Robertson CF, van Asperen PP, et al. Children with chronic cough: when is watchful waiting appropriate? Development of likelihood ratios for assessing children with chronic cough. Chest 2015; 147:745.Satirer O, Mete YA, Emiralioglu N, et al. A review of the etiology and clinical presentation of non-cystic fibrosis bronchiectasis: A tertiary care experience. Respir Med 2018; 137:35.Graphic 131075 Version 1.0

CloseIron and zinc content of selected foodsIron and zinc content of selected foods All serving sizes are 3 oz (85 g) cooked portions unless otherwise noted. Foods are grouped by their iron content; ranges depend on the type of animal (in the case of organ meats) or the cut of the meat. Check your local food composition tables for additional options.   Iron (mg) Zinc (mg) Excellent sources of iron Bear 9.12 8.73 Beaver 8.50 1.93 Blood sausage 5.44 1.10 Caribou 4.08 to 5.24 3.65 to 4.47 Cuttlefish 9.21 2.94 Emu 3.88 to 6.18 2.71 to 4.33 Heart 3.67 to 7.68 1.90 to 6.21 Horse 4.28 3.25 Kidneys 2.58 to 10.54 2.41 to 3.61 Liver 4.34 to 15.23 3.38 to 10.12 Liver sausage (packaged; Braunschweiger, liverwurst, paté) 4.67 to 9.52 0.78 to 2.89 Lungs 3.07 to 13.95 1.02 to 2.08 Moose 3.59 3.13 Muskrat 6.04 1.93 Mussels, blue 5.71 2.27 Mutton 4.05 5.04 Octopus 8.11 2.86 Opossum 3.94 1.94 Oysters 5.70 to 7.83 28.25 to 77.31 Quail 3.77 2.63 Raccoon 6.04 1.93 Squirrel 5.79 1.51 Spleen 6.26 to 33.46 1.62 to 3.35 Whelk 8.55 2.77 Good sources of iron Antelope 3.57 1.43 Beef 1.54 to 3.20 3.98 to 9.33 Bison/buffalo 2.45 to 4.13 3.13 to 7.34 Brains 0.91 to 1.95 0.93 to 1.70 Clams 2.28 to 2.39 0.71 to 2.32 Deer/venison 2.85 to 4.26 3.09 to 7.34 Duck 2.29 to 3.82 2.21 Elk 2.28 to 7.70 2.69 to 6.62 Gizzards 2.71 to 3.13 3.33 to 3.76 Goat 3.17 4.48 Lamb 1.52 to 1.93 3.51 to 7.36 Ostrich 2.37 to 4.08 3.68 to 4.17 Pancreas 1.80 to 2.29 2.28 to 4.42 Rabbit 1.93 to 4.12 1.93 to 2.02 Sardines 1.95 to 2.48 1.11 to 1.19 Tongue 1.78 to 4.24 2.54 to 3.85 Fair sources of iron Boar, wild 0.95 2.56 Chicken breast 0.88 0.85 Chicken leg/thigh 1.13 2.38 Cod 0.14 to 0.42 0.33 to 0.49 Intestines (chitterlings) 1.25 1.57 Pork 0.54 to 1.57 1.79 to 4.11 Salmon 0.29 to 0.88 0.37 to 0.85 Shrimp 0.27 to 1.81 1.39 to 1.67 Stomach/tripe 0.56 to 1.05 1.45 to 2.48 Tilapia 0.59 0.35 Trout 0.31 to 1.63 0.43 to 0.72 Tuna 0.55 to 1.36 0.38 to 0.89 Turkey breast 0.60 1.46 Turkey leg, thigh 1.22 2.98Adapted from: US Department of Agriculture (USDA), Agricultural Research Service, Nutrient Data Laboratory. USDA National Nutrient Database for Standard Reference, Legacy. Version Current: April 2018. Available at: http://www.ars.usda.gov/nutrientdata (Accessed on February 21, 2019).Graphic 100190 Version 6.0

CloseClassification of Leishmania species that cause human cutaneous disease*Classification of Leishmania species that cause human cutaneous disease* Subgenus Complex Species Main geographic locations Main clinical manifestations Other Old World Leishmania L.L. major L.L. major India, Pakistan, Central and Southwest Asia, Turkey, areas in Africa, Middle East Cutaneous leishmaniasis   L.L. tropica L.L. tropica Central and Southwest Asia, Middle East, Turkey, Greece, India, Pakistan, Yemen, Northern Africa, Ethiopia, Kenya Cutaneous leishmaniasis Leishmaniasis recidivans (LR), occasionally viscerotropic leishmaniasis L.L. aethiopica L.L. aethiopica Ethiopia, Kenya, Uganda Cutaneous leishmaniasis Diffuse cutaneous leishmaniasis (DCL), mucosal leishmaniasis L.L. infantum (syn chagasi) L.L. infantum (syn chagasi) Mediterranean, Northern Africa, Middle East, Central and Southwest Asia, Balkans, China, sporadic in sub-Saharan Africa Visceral leishmaniasis Localized cutaneous leishmaniasis (LCL), mucosal leishmaniasis L.L. donovani L.L. donovani India, China, Pakistan, Southwest Asia, Horn of Africa (Ethiopia, Somalia, Sudan, Kenya, Uganda) Visceral leishmaniasis Post kala-azar dermal leishmaniasis (PKDL), occasional localized cutaneous leishmaniasis New World Leishmania L.L. mexicana L.L. mexicana Central and South America, Mexico, sporadic Texas and Oklahoma, United States Cutaneous leishmaniasis DCL L.L. venezuelensis Venezuela Cutaneous leishmaniasis   L.L. amazonensis Panama, South America (especially Amazon Basin) Cutaneous leishmaniasis DCL, occasionally visceral or mucosal leishmaniasis L.L. donovani L.L. infantum (syn chagasi) Central and South America Visceral leishmaniasis Occasional cutaneous leishmaniasis Viannia L.V. braziliensis L.V. braziliensis Central and South America Cutaneous and mucosal leishmaniasis Mucosal leishmaniasis (especially Bolivia, Brazil, Peru), disseminated cutaneous leishmaniasis L.V. peruviana Peru and Argentina (western Andes slope) Cutaneous leishmaniasis   L.V. guyanensis L.V. guyanensis South America (especially Northern Amazon Basin, Guyana, French Guiana) Cutaneous leishmaniasis Mucosal leishmaniasis L.V. panamensis Panama, Costa Rica, Colombia, Ecuador, Peru, Venezuela Cutaneous leishmaniasis Occasional mucosal leishmaniasis* Not all Leishmania organisms are included here; for example, the Leishmania subgenus Mundinia is not included; it causes cutaneous leishmaniasis and has been reported from Thailand, the Caribbean, Guyana, and Ghana.Graphic 86988 Version 10.0

Listeria monocytogenes is an important bacterial pathogen in neonates, immunosuppressed patients, older adults, pregnant women, and, occasionally, previously healthy individuals. The clinical manifestations and diagnosis of listerial infection will be reviewed here. The treatment, prognosis, and pre

ClosePatient education: Hepatitis A (Beyond the Basics)Patient education: Hepatitis A (Beyond the Basics)Authors:Michelle Lai, MD, MPHSanjiv Chopra, MD, MACP Section Editor:Martin S Hirsch, MD Deputy Editor:Elinor L Baron, MD, DTMHLiterature review current through: Nov 2022. | This topic last updated: Jul 27, 2021.Please read the Disclaimer at the end of this page.HEPATITIS A OVERVIEW — Hepatitis is a common form of liver injury that simply means "inflammation of the liver" (the suffix "itis" means inflammation and "hepa" means liver). Hepatitis A is a specific type of hepatitis that is caused by a virus.Hepatitis A virus infection occurs worldwide. The number of people who become infected with hepatitis A in the United States has declined substantially since vaccination became available; the vaccine is routinely recommended for all infants and any adult who is at high risk of becoming infected. However, the infection rate is much higher in resource-limited countries, including among travelers.This topic review discusses how hepatitis A is spread, the signs and symptoms of hepatitis A infection, how it is diagnosed and treated, and how it can be prevented. Other types of hepatitis are discussed separately. (See"Patient education: Hepatitis B (Beyond the Basics)" and"Patient education: Hepatitis C (Beyond the Basics)".)HOW DID I GET INFECTED WITH HEPATITIS A? — The hepatitis A virus is carried in the stool (bowel movements) of infected people. The most common way for the virus to be spread is when a person who has the infection does not wash their hands after using the bathroom and then touches food, a surface, or another person's mouth. A person with hepatitis A may be contagious before their symptoms begin, as well as for a period of time after they improve.Hepatitis A virus is more common in areas that lack adequate sanitation or have poor hygiene practices. The majority of people who acquire the illness have had direct personal contact with an infected person.Community outbreaks have occurred as a result of drinking contaminated well water or eating contaminated food (often raw shellfish that is harvested from contaminated water).HEPATITIS A SYMPTOMS — Hepatitis A virus usually causes a sudden and short-lived illness. The severity of symptoms depends upon the person's age; in children, there may be few or no symptoms. In adults, infection usually causes a mild flu-like illness. Less commonly in adults, hepatitis A virus infection causes liver failure, which can lead to death.When there are symptoms, they most often develop between two and seven weeks after acquiring the infection. Initial symptoms usually include:●Fatigue●Feeling run down●Nausea●Vomiting●Lack of appetite●Fever (temperature greater than 100.4ºF or 38ºC)●Pain under the ribs on the right side of the abdomen (where the liver is located) (figure 1)As the illness progresses, other signs and symptoms develop, including dark-colored urine, light-colored stools, yellowing of the skin or whites of the eyes (jaundice), and itchy skin.HEPATITIS A DIAGNOSIS — A person is diagnosed with hepatitis A virus based upon their signs or symptoms, a physical examination, and blood testing.HEPATITIS A TREATMENT — There is no cure for hepatitis A virus; most people recover with supportive treatments at home, including rest. The amount of time it takes to feel better can vary from person to person; in general, a person with hepatitis A should not return to work or school until the fever and jaundice have resolved and the appetite has returned.During the recovery period, it is important to avoid drinking alcohol and taking certain prescription and over-the-counter medications (including acetaminophen [sample brand name: Tylenol]) that can injure the liver.Less commonly, people infected with hepatitis A virus require treatment in a hospital so doctors can monitor their liver function, manage any complications, and provide adequate nutrition.HEPATITIS A COMPLICATIONS — Most people feel better within three months of becoming infected with hepatitis A virus, and almost everyone completely recovers within six months. About 15 percent of people infected with hepatitis A virus will have prolonged or relapsing symptoms for six to nine months.The most serious complication of hepatitis A virus infection is death. This occurs rarely but is more likely in older adults and those with chronic liver infections such as hepatitis C. Children die as a result of hepatitis A virus in less than 0.1 percent of cases. (See"Patient education: Hepatitis C (Beyond the Basics)".)Unlike with other forms of hepatitis, people with hepatitis A do not develop chronic liver disease as a result of their infection. Once a person is infected with hepatitis A virus, it is not possible to become infected again.HEPATITIS A PREVENTION — There are several strategies to prevent the spread of hepatitis A virus, discussed below. Hand washing is one of the most effective strategies for reducing transmission since the virus can live on a person's fingers for up to four hours.Hand hygiene — Hand washing is an essential and effective way to prevent the spread of infection. Hands should ideally be wet with water and plain or antimicrobial soap and rubbed together for 15 to 30 seconds. Special attention should be paid to the fingernails, between the fingers, and the wrists. Hands should be rinsed thoroughly and dried with a single-use towel.It is not clear if alcohol-based hand rubs are effective against hepatitis A virus. For this reason, food handlers, daycare providers, travelers, and anyone else who is at risk of transmitting or becoming infected with hepatitis A is advised to wash their hands with soap and water when possible. Alcohol-based hand rubs are a reasonable alternative if a sink is not available.Hands should be cleaned after changing a diaper or touching any soiled item. They should also be washed before and after preparing food and eating, after going to the bathroom, and after handling garbage or dirty laundry.Safe food preparation — Taking precautions when preparing foods can reduce the risk of becoming ill. The following precautions have been recommended by the Food Safety and Inspection Services and the United States Centers for Disease Control and Prevention.●Do not drink raw (unpasteurized) milk or foods that contain unpasteurized milk.●Wash raw fruits and vegetables thoroughly before eating.●Keep the refrigerator temperature at 40ºF (4.4ºC) or lower; the freezer at 0ºF (-17.8ºC) or lower.●Use precooked, perishable, or ready-to-eat food as soon as possible.●Keep raw meat, fish, and poultry separate from other food.●Wash hands, knives, and cutting boards after handling uncooked food, including produce and raw meat, fish, or poultry.●Thoroughly cook raw food from animal sources to a safe internal temperature: ground beef 160ºF (71ºC); chicken 170ºF (77ºC); turkey 180ºF (82ºC); pork 160ºF (71ºC).●Cook chicken eggs thoroughly, until the yolk is firm.●Refrigerate foods promptly. Never leave cooked foods at room temperature for more than two hours (one hour if the room temperature is above 90ºF/32ºC).People who are preparing to travel to areas where hepatitis A is common should take precautions when eating and drinking to avoid becoming ill. If you are planning international travel, you can visit a travel medicine clinic to better understand your risk as well as what precautions you can take. Travel advice is discussed in more detail separately. (See"Patient education: General travel advice (Beyond the Basics)", section on 'Food and water precautions'.)Hepatitis A vaccination — Available vaccines to prevent infection with hepatitis A virus include VAQTA and HAVRIX. Both are equally effective and protect nearly 100 percent of people who receive the recommended two doses for a lifetime. The initial dose of either vaccine usually provides adequate short-term protection, and the subsequent dose provides long-term protection. Thus, if a person does not have time to receive both doses before traveling, it is worth getting the first dose and then completing the second 6 to 12 months later.The most common side effect of the hepatitis A virus vaccine is brief redness or discomfort at the injection site.●VAQTA is given in two doses, with the second dose given 6 to 18 months after the first.●HAVRIX is given in two doses, with the second dose given 6 to 12 months after the first.If the second dose is not given within the recommended time frame, it can be given without restarting the series. A vaccination series started with one brand of vaccine may be completed with the same or the other brand of hepatitis A vaccine.In the United States, hepatitis A vaccine is recommended for all children between 12 and 23 months of age. It is also recommended for children ages 2 to 18 who did not previously receive the vaccine. (See"Patient education: Vaccines for infants and children age 0 to 6 years (Beyond the Basics)".)The hepatitis A virus vaccine is also recommended for all at-risk individuals, including:●Travelers to countries where hepatitis A virus is common; the vaccine can be given at any time before traveling.•Babies 6 to 11 months who are travelling internationally should receive the vaccine; the travel-related dose should not be counted toward the routine two-dose series.●People who use injection or noninjection illegal drugs.●Men who have sex with men.●People with chronic liver disease.●Anyone who is in close personal contact with a person who was adopted from a country in which hepatitis A is common during the first 60 days following arrival in the United States (eg, family members or caregivers).●People who are in direct contact with others who have hepatitis A.●People who are homeless.●People who work in settings that provide services for adults who may be at increased risk, for example, in substance abuse treatment or support centers, group homes, or non-residential care facilities for people with developmental disabilities.The hepatitis A vaccine can be given to women during pregnancy, as it has not shown to be associated with an increased risk of problems. Women who are at risk for hepatitis A and are pregnant should talk with their health care provider about whether they should get the vaccine.Immune globulin — People who are at risk for hepatitis A but who are allergic to components of the hepatitis A vaccine, or who prefer not to receive the vaccine, should consider taking a dose of immune globulin. Immune globulin is an injection that provides temporary protection against hepatitis A and reduces the risk of infection by more than 90 percent. However, the hepatitis A vaccine is preferred to immune globulin in most cases because it provides long-lasting protection and because immune globulin is not always available.Immune globulin is given in a single injection shortly before travel. A single dose provides protection for about two months. People who plan to travel for more than two months in areas where hepatitis A is endemic should have an additional dose(s) of immune globulin.Older adults and people with a weakened immune system, chronic liver disease, or other underlying medical problem who plan to travel within two weeks should get a dose of hepatitis A vaccine in addition to a dose of immune globulin. The second dose of the hepatitis A vaccine should be given 6 to 12 months later. Immune globulin is not required for healthy travelers who are immunized with the hepatitis A vaccine.TREATMENT AFTER EXPOSURE TO HEPATITIS A — If a person has a known exposure to hepatitis A and has not previously received the hepatitis A vaccine, "postexposure protection" with either the vaccine or immune globulin should be given as soon as possible, within two weeks of exposure.In general, for healthy people over the age of one year, the vaccination is preferred over immune globulin since it is more effective, easier to administer, and more readily available than immune globulin. However, in some situations, immune globulin is appropriate (either instead of or in addition to the vaccine). Your health care provider can talk to you about which approach is best for you.Certain people are candidates for postexposure protection after a potential exposure to hepatitis A. They include:●Close personal contacts of a person with hepatitis A confirmed by blood testing, including:•Household contacts (eg, family members)•Sexual partners•People who have shared illicit drugs (injection and noninjection)●Child care center contacts, if one or more children in the center have confirmed hepatitis A or there are two or more cases of hepatitis A in households of people who attend the center:•For centers providing care to children in diapers – Any staff members or other children in the center should receive postexposure protection if they haven't already been vaccinated. In the setting of an outbreak (cases in ≥3 families), postexposure protection is also appropriate for household members of diaper-wearing children.•For centers providing care to children who no longer wear diapers – All classroom contacts of the child with hepatitis A should receive postexposure protection if they haven't already been vaccinated. It is not required for children and staff in other classrooms.●Food handlers:•In locations (eg, restaurants) with a food handler diagnosed with hepatitis A, postexposure protection is warranted for other food handlers. Administration of postexposure protection to patrons and customers is typically not indicated.•Postexposure protection is reasonable in settings in which repeated exposures to hepatitis A might have occurred, for example, school or office cafeterias.WHERE TO GET MORE INFORMATION — Your health care provider is the best source of information for questions and concerns related to your medical problem.This article will be updated as needed on our web site (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for health care professionals, are also available. Some of the most relevant are listed below.Patient level information — UpToDate offers two types of patient education materials.The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Patient education: Hepatitis A (The Basics) Patient education: Treatment for hepatitis C (The Basics)Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon. Patient education: Hepatitis B (Beyond the Basics) Patient education: Hepatitis C (Beyond the Basics) Patient education: General travel advice (Beyond the Basics) Patient education: Vaccines for infants and children age 0 to 6 years (Beyond the Basics)Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading. Hepatitis A virus infection: Treatment and prevention Hepatitis A virus infection in adults: Epidemiology, clinical manifestations, and diagnosis Hepatitis A virus infection in adults: Epidemiology, clinical manifestations, and diagnosis, section on 'Information for patients'The following organizations also provide reliable health information.●United States Centers for Disease Control and Prevention (CDC) (available in Spanish)      (www.cdc.gov)      Toll-free: (800) 311-3435●National Library of Medicine      (www.nlm.nih.gov/medlineplus/hepatitisa.html)●National Institute of Diabetes and Digestive and Kidney Diseases (available in Spanish)(www.niddk.nih.gov/health-information/liver-disease/viral-hepatitis/hepatitis-a)●American Liver Foundation      (www.liverfoundation.org)ACKNOWLEDGMENT — The editorial staff at UpToDate would like to acknowledge Dr. Catherine Cheney, who contributed to earlier versions of this topic review.This generalized information is a limited summary of diagnosis, treatment, and/or medication information. It is not meant to be comprehensive and should be used as a tool to help the user understand and/or assess potential diagnostic and treatment options. It does NOT include all information about conditions, treatments, medications, side effects, or risks that may apply to a specific patient. It is not intended to be medical advice or a substitute for the medical advice, diagnosis, or treatment of a health care provider based on the health care provider's examination and assessment of a patient's specific and unique circ*mstances. Patients must speak with a health care provider for complete information about their health, medical questions, and treatment options, including any risks or benefits regarding use of medications. This information does not endorse any treatments or medications as safe, effective, or approved for treating a specific patient. UpToDate, Inc. and its affiliates disclaim any warranty or liability relating to this information or the use thereof.The use of this information is governed by the Terms of Use, available at https://www.wolterskluwer.com/en/know/clinical-effectiveness-terms ©2023 UpToDate, Inc. and its affiliates and/or licensors. All rights reserved.Topic 4572 Version 24.0

CloseHypersensitivity pneumonitides associated with birds and poultry handlingHypersensitivity pneumonitides associated with birds and poultry handlingEnvironmental sourceMajor causative antigenBird fancier's lung (parakeets, budgerigars, pigeons)Droppings, feathers, serum proteinsPoultry worker's lung (feather plucker's disease) Serum proteins (chicken products)Turkey handling diseaseSerum proteins (turkey products)Canary fancier's lung Serum proteinsDuck feverFeathers, serum proteins14.0000000000000Table<a href="/Graphics/Pages/TableEditor.aspx?SPID=67823&Mode=Edit"></a>Poultry_related_antigens_in.htmGraphic 72774 Version 1.0

Advanced technologies have resulted in development of imaging techniques for diagnosis and interventional treatment of various medical conditions and injuries that once required open surgical procedures in an operating room (OR). Patients with significant comorbidities may require complex or prolong

CloseHepatitis B immune globulin: Pediatric drug informationHepatitis B immune globulin: Pediatric drug information(For additional information see "Hepatitis B immune globulin: Drug information" and see "Hepatitis B immune globulin: Patient drug information")For abbreviations, symbols, and age group definitions used in Lexicomp (show table)Brand Names: USHepaGam B;HyperHEP B;Nabi-HBBrand Names: CanadaHepaGam B;HyperHEP B;HyperHep B S/D;HyperHEP B S/DTherapeutic CategoryImmune GlobulinDosing: NeonatalPerinatal exposure, prophylaxisPerinatal exposure, prophylaxis (CDC, 2005): Note: HBIG may be administered at the same time (but at a different site) or up to 1 month preceding hepatitis B vaccination without impairing the active immune response:Neonates born to HBsAg-positive mothers: IM: 0.5 mL as soon after birth as possible (within 12 hours; efficacy decreases significantly if treatment is delayed >48 hours); hepatitis B vaccine series to begin at the same time; if this series is delayed for as long as 3 months, the HBIG dose may be repeated (Saari, 2003)Neonates born to mothers with unknown HBsAg status at birth: IM:Birth weight <2 kg: 0.5 mL within 12 hours of birth (along with hepatitis B vaccine) if unable to determine maternal HBsAg status within that timeBirth weight ≥2 kg: 0.5 mL within 7 days of birth while awaiting maternal HBsAg results; if mother is determined to be HBsAg positive, administer dose as soon as possible.Dosing: PediatricNote: For exposure prophylaxis, HBIG may be administered at the same time (but at a different site) or up to 1 month preceding hepatitis B vaccination without impairing the active immune response.Perinatal exposure, prophylaxisPerinatal exposure, prophylaxis (CDC 2005): Infants born to HBsAg-positive mothers: IM: 0.5 mL as a repeat of birth dose if the hepatitis B vaccination series is delayed for as long as 3 months (hepatitis B vaccine should also be administered at the same time/different site)Postexposure, prophylaxisPostexposure, prophylaxis: Infants <12 months: IM: 0.5 mL as soon as possible after exposure (eg, mother or primary caregiver with acute HBV infection); initiate hepatitis B vaccine seriesChildren ≥12 months and Adolescents: IM: 0.06 mL/kg as soon as possible after exposure (ie, within 24 hours of needlestick, ocular, or mucosal exposure or within 14 days of sexual exposure); repeat at 28 to 30 days after exposureDosing: Kidney Impairment: PediatricThere are no dosage adjustments provided in the manufacturer's labeling.Dosing: Hepatic Impairment: PediatricThere are no dosing adjustments provided in the manufacturer's labeling.Dosing: Adult(For additional information see "Hepatitis B immune globulin: Drug information")Postexposure prophylaxisPostexposure prophylaxis: IM: 0.06 mL/kg as soon as possible after exposure (ie, within 24 hours of needlestick, ocular, or mucosal exposure or within 14 days of sexual exposure); repeat at 28 to 30 days after exposure in non-responders to hepatitis B vaccine or in patients who refuse vaccinationPostexposure management of health care personnel (HCP) (CDC/ACIP [Schillie 2018]):If the HCP has prior documentation of ≥3 doses of a hepatitis B vaccine and a post-vaccination anti-HBs ≥10 milliunits/mL, then HBIG is not needed, regardless of the patients HBsAg status.If the HCP is unvaccinated or incompletely vaccinated, and if the source patient is HBsAg positive or their status is unknown, one dose HBIG should be administered. If the source patient is HBsAg negative, then HBIG is not needed.If the HCP is vaccinated with 3 doses of hepatitis B vaccine but post-vaccination anti-HBs status is unknown, test HCP for anti-HBs. If anti-HBs ≥10 milliunits/mL then HBIG is not needed. If anti-HBs <10 milliunits/mL, and if the source patient is HBsAg positive or their status is unknown, 1 dose of HBIG should be administered. If anti-HBs <10 milliunits/mL, and if the source patient is HBsAg negative, then HBIG is not needed.If the HCP is vaccinated with 6 doses of hepatitis B vaccine but documented as a non-responder to the vaccine, and if the source patient is HBsAg negative, then HBIG is not needed. If the source patient is HBsAg positive or unknown, administer 2 doses of HBIG separated by 1 month.Postexposure management in nonoccupational settings (CDC [Schillie 2018]): IM:If the exposed person is in the process of completing the hepatitis B vaccination series and the exposure was to an HBsAg-positive source, administer one dose of HBIG and complete the vaccination series. If exposure was to an HBsAg-unknown source, HBIG treatment is not required but the hepatitis B vaccine series should be completed.If the exposed person is unvaccinated and the exposure was to an HBsAg-positive source, administer one dose of HBIG and hepatitis B vaccine as soon as possible (preferably within 24 hours after exposure [<7 days for percutaneous exposure or <14 days for sexual exposure]); complete the vaccination series. If exposure was to an HBsAg-unknown source, HBIG treatment is not required but the hepatitis B vaccine series should be completed.If the exposed person has prior documentation of ≥3 doses of a hepatitis B vaccine then HBIG treatment is not required.Prevention of hepatitis B virus recurrence after liver transplantationPrevention of hepatitis B virus recurrence after liver transplantation (HepaGam B): IV: 20,000 units/dose according to the following schedule:Anhepatic phase (Initial dose): One dose (20,000 units) given with the liver transplantWeek 1 postop: One dose (20,000 units) daily for 7 days (days 1 to 7)Weeks 2 to 12 postop: One dose (20,000 units) every 2 weeks starting day 14Month 4 onward: One dose (20,000 units) monthly starting on month 4Dose adjustment: Adjust dose to reach anti-HBs levels of 500 units/L within the first week after transplantation. In patients with surgical bleeding, abdominal fluid drainage >500 mL or those undergoing plasmapheresis, administer 10,000 units/dose every 6 hours until target anti-HBs levels are reached.Dosing: Kidney Impairment: AdultThere are no dosage adjustments provided in the manufacturer’s labeling.Dosing: Hepatic Impairment: AdultThere are no dosage adjustments provided in the manufacturer’s labeling.Dosage Forms: USExcipient information presented when available (limited, particularly for generics); consult specific product labeling.Solution, Injection [preservative free]: HepaGam B: 312 units/mL (1 mL, 5 mL) [contains polysorbate 80]Solution, Intramuscular: HyperHEP B:(0.5 mL, 1 mL, 5 mL)Nabi-HB:(1 mL, 5 mL) [thimerosal free; contains polysorbate 80]Solution, Intramuscular [preservative free]: Nabi-HB:(1 mL, 5 mL) [contains polysorbate 80]Generic Equivalent Available: USNoDosage Forms: CanadaExcipient information presented when available (limited, particularly for generics); consult specific product labeling.Solution, Injection: HepaGam B: 312 units/mL (1 mL, 5 mL) [contains polysorbate 80]Solution, Intramuscular: HyperHep B S/D: 217 units/mL (0.5 mL, 1 mL, 5 mL)Solution Prefilled Syringe, Intramuscular: HyperHEP B: 110 units/0.5 mL (0.5 mL)HyperHEP B S/D: 110 units/0.5 mL (0.5 mL)Administration: PediatricIM: Inject only in the anterolateral aspects of the upper thigh or the deltoid muscle; multiple injections may be necessary when the dosage is a large volume (postexposure prophylaxis). Do not administer hepatitis vaccine and HBIG in same syringe (vaccine will be neutralized); hepatitis vaccine may be administered at the same time at a separate siteAdministration: AdultHBIG may be administered at the same time (but at a different site) or up to 1 month preceding hepatitis B vaccination without impairing the active immune response.IM: Post-exposure prophylaxis: IM injection only in anterolateral aspect of upper thigh and deltoid muscle of upper arm; to prevent injury from injection, care should be taken when giving to patients with thrombocytopenia or bleeding disorders.IV:HepaGam B: Liver transplant: Administer at 2 mL/minute. Decrease infusion to ≤1 mL/minute for patient discomfort or infusion-related adverse events. Actual volume of infusion is dependent upon potency labeled on each individual vial.Nabi-HB: Although not FDA-approved for this purpose, Nabi-HB has been administered intravenously in hepatitis B-positive liver transplant recipients (Dickson 2006).Storage/StabilityRefrigerate at 2°C to 8°C (36°F to 46°F); do not freeze. Do not shake vial; avoid foaming. Extended storage information at room temperature may be available; contact product manufacturer to obtain current recommendations.HepaGamB; Nabi-HB: Use within 6 hours of entering vial.UseParenteral:IM: HepaGam B, HyperHEP B S/D, Nabi-HB: Provide prophylactic postexposure passive immunity to hepatitis B following perinatal exposure of infants born to HBsAg-positive mothers (FDA approved in neonates and infants); provide prophylactic postexposure passive immunity to hepatitis B following acute exposure to blood containing hepatitis B surface antigen (HBsAg), sexual exposure to HBsAg-positive persons, or household exposure to persons with acute HBV infection (FDA approved in infants, children, and adults)IV: HepaGam B: Prevention of hepatitis B virus recurrence after liver transplantation in HBsAg-positive transplant patients (FDA approved in adults)Note: Hepatitis B immune globulin is not indicated for treatment of active hepatitis B infection and is ineffective in the treatment of chronic active hepatitis B infection.Medication Safety IssuesSound-alike/look-alike issues:HBIG may be confused with BabyBIGInternational issues:Bayhep-B [Philippines, Turkey] may be confused with Bayrab which is a brand name for rabies immune globulin [Philippines, Turkey]; Bayrho-D which is brand name for RhoD immune globulin [Israel, Turkey] Adverse ReactionsThe following adverse drug reactions and incidences are derived from product labeling unless otherwise specified. Reported with postexposure prophylaxis. Adverse events reported in liver transplant patients included tremor and hypotension, were associated with a single infusion during the first week of treatment, and did not recur with additional infusions.>10%:Central nervous system: Headache (14%)Dermatologic: Erythema (12%)1% to 10%:Cardiovascular: Hypotension (2%)Central nervous system: Malaise (6%)Dermatologic: Ecchymoses (2%)Gastrointestinal: Nausea (2% to 4%), vomiting (2%)Hematologic & oncologic: Change in WBC count (2%)Hepatic: Increased serum alkaline phosphatase (4%), increased liver enzymes (2%)Local: Pain at injection site (4%)Neuromuscular & skeletal: Myalgia (10%), joint stiffness (2%)Renal: Increased serum creatinine (2%)<1%, postmarketing, and/or case reports: Abdominal pain, anaphylactic reaction (rare), angioedema, back pain, chills, diaphoresis, dizziness, dyspnea, fever, flu-like symptoms, hypersensitivity, increased serum lipase, increased serum transaminases, sinus tachycardia, tenderness at injection site, urticariaContraindicationsHepaGam B: Anaphylactic or severe systemic reaction to human globulin preparations; IgA deficiency; postexposure prophylaxis in patients with severe thrombocytopenia or other coagulation disorders which would contraindicate IM injections (administer only if benefit outweighs the risk).HyperHEP B:US labeling: There are no contraindications listed in the US manufacturer's labeling.Canadian labeling:HyperHEP B: Hypersensitivity to hepatitis B immune globulin or any component of the formulation; severe thrombocytopenia or other coagulation disorders that would contraindicate IM injections; IgA deficient patients with antibodies against IgA and a history of sensitivity.HyperHEP B S/D: Hypersensitivity to hepatitis B immune globulin or any component of the formulation; severe thrombocytopenia or other coagulation disorders that would contraindicate IM injections (administer only if benefit outweighs the risk).Nabi-HB: Anaphylactic or severe systemic reaction to human globulin preparations.Warnings/PrecautionsConcerns related to adverse effects:• Anaphylaxis/hypersensitivity reactions: Hypersensitivity and anaphylactic reactions can occur; immediate treatment (including epinephrine 1 mg/mL) should be available. Use with caution in patients with isolated immunoglobulin A deficiency or a history of systemic hypersensitivity to human immunoglobulins.• Infusion reactions: When administered IV, do not exceed recommended infusion rates; may increase risk of adverse events. Patients should be monitored for adverse events during and after the infusion.• Thrombotic events: Thrombotic events have been reported with administration of intravenous immune globulin; use with caution in patients of advanced age, with a history of atherosclerosis or cardiovascular and/or thrombotic risk factors, patients with impaired cardiac output, coagulation disorders, prolonged immobilization, or patients with known/suspected hyperviscosity. Consider a baseline assessment of blood viscosity in patients at risk for hyperviscosity.Disease-related concerns:• Bleeding disorders: Use with caution in patients with thrombocytopenia or coagulation disorders; IM injections may be contraindicated.Dosage form specific issues:• Human plasma: Product of human plasma; may potentially contain infectious agents which could transmit disease. Screening of donors, as well as testing and/or inactivation or removal of certain viruses, reduces the risk. Infections thought to be transmitted by this product should be reported to the manufacturer.• Maltose: Some products may contain maltose, which may result in falsely-elevated blood glucose readings.• Polysorbate 80: Some dosage forms may contain polysorbate 80 (also known as Tweens). Hypersensitivity reactions, usually a delayed reaction, have been reported following exposure to pharmaceutical products containing polysorbate 80 in certain individuals (Isaksson 2002; Lucente 2000; Shelley 1995). Thrombocytopenia, ascites, pulmonary deterioration, and renal and hepatic failure have been reported in premature neonates after receiving parenteral products containing polysorbate 80 (Alade 1986; CDC 1984). See manufacturer’s labeling.Metabolism/Transport EffectsNone known.Drug InteractionsNote: Interacting drugs may not be individually listed below if they are part of a group interaction (eg, individual drugs within “CYP3A4 Inducers [Strong]” are NOT listed).For a complete list of drug interactions by individual drug name and detailed management recommendations, use the Lexicomp drug interactions program by clicking on the “Launch drug interactions program” link above.Note: Interacting drugs may not be individually listed below if they are part of a group interaction (eg, individual drugs within “CYP3A4 Inducers [Strong]” are NOT listed). For a complete list of drug interactions by individual drug name and detailed management recommendations, use the Lexicomp drug interactions programEfgartigimod Alfa: May diminish the therapeutic effect of Fc Receptor-Binding Agents. Risk C: Monitor therapyVaccines (Live): Immune Globulins may diminish the therapeutic effect of Vaccines (Live).Management: Live organism vaccination should be withheld for as long as 6 to 11 months following immune globulin administration. Recommendations vary by product and immune globulin dose, see full monograph for details. Risk D: Consider therapy modificationPregnancy ConsiderationsUse of HBIG is not contraindicated in pregnant females and may be used for postexposure prophylaxis when indicated (CDC 2001). In addition, use of HBIG has been evaluated to reduce maternal to fetal transmission of hepatis B virus during pregnancy (ACOG 2007)Monitoring ParametersLiver transplant patients: anti-HB levels; infusion-related adverse eventsMechanism of ActionHepatitis B immune globulin (HBIG) is a nonpyrogenic sterile solution containing immunoglobulin G (IgG) specific to hepatitis B surface antigen (HBsAg). HBIG differs from immune globulin in the amount of anti-HBs. Immune globulin is prepared from plasma that is not preselected for anti-HBs content. HBIG is prepared from plasma preselected for high titer anti-HBs. In the US, HBIG has an anti-HBs high titer >1:100,000 by IRA.Pharmaco*kinetics (Adult data unless noted)Duration: Postexposure prophylaxis: 3 to 6 monthsAbsorption: IM: SlowHalf-life: 17 to 25 daysDistribution: Vd: 7 to 15 LTime to peak, serum: IM: 2 to 10 daysPricing: USSolution (HepaGam B Injection)312 units/mL (per mL): $244.02Solution (HyperHEP B Intramuscular)220 units/mL (per mL): $192.06Solution (Nabi-HB Intramuscular)312 units/mL (per mL): $194.42Solution Prefilled Syringe (HyperHEP B Intramuscular)110 units/0.5 mL (per 0.5 mL): $106.14220 units/mL (per mL): $200.15Disclaimer: A representative AWP (Average Wholesale Price) price or price range is provided as reference price only. A range is provided when more than one manufacturer's AWP price is available and uses the low and high price reported by the manufacturers to determine the range. The pricing data should be used for benchmarking purposes only, and as such should not be used alone to set or adjudicate any prices for reimbursem*nt or purchasing functions or considered to be an exact price for a single product and/or manufacturer.Medi-Span expressly disclaims all warranties of any kind or nature, whether express or implied, and assumes no liability with respect to accuracy of price or price range data published in its solutions.In no event shall Medi-Span be liable for special, indirect, incidental, or consequential damages arising from use of price or price range data.Pricing data is updated monthly.Brand Names: InternationalBayhep (PK);Euvax-B (KR);Fovepta (VN);Hebagam IM (ZA);Hep-B Gammagee (AE);Hepabig (IN, KR, MY, PH);Hepacaf (BE);Hepagam B (IL);Hepatect (AT, CH, CO, DE, EE, ES, HN, IE, NO, PL, PT, RO, TR, TW);Hepatect CP (VN);Hepatitis B Immunoglobulin-VF (AU);HepBQuin (IN, NL);Hepuman Berna (PE);HyperHEP B (HK, IL, NZ);Igantibe (ID);IMMUNOHBs (TH);IVheBex (FR, GR);Neohepatect (BE);NEOHepatect (CZ);Niuliva (SG);VENBIG (DK, TH);Zutectra (BE, GB, IE)For country code abbreviations (show table)Agarwal S, Karmaus W, Davis S, Gangur V. Immune markers in breast milk and fetal and maternal body fluids: a systematic review of perinatal concentrations. J Hum Lact. 2011;27(2):171-186. [PubMed 21678611]Alade SL, Brown RE, Paquet A Jr. Polysorbate 80 and E-Ferol toxicity. Pediatrics. 1986;77(4):593-597. [PubMed 3960626]American College of Obstetricians and Gynecologists, ACOG Practice Bulletin No. 86: “Viral Hepatitis in Pregnancy,” Obstet Gynecol, 2007, 110(4):941-56. [PubMed 17906043]Centers for Disease Control (CDC). Unusual syndrome with fatalities among premature infants: association with a new intravenous vitamin E product. MMWR Morb Mortal Wkly Rep. 1984;33(14):198-199. http://www.cdc.gov/mmwr/preview/mmwrhtml/00000319.htm. [PubMed 6423951]Centers for Disease Control and Prevention (CDC), “A Comprehensive Immunization Strategy to Eliminate 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,” MMWR Recomm Rep, 2005, 54(RR-16):1-31.Centers for Disease Control and Prevention (CDC), U.S. Public Health Service, "Updated U.S. Public Health Service Guidelines for the Management of Occupational Exposures to HBV, HCV, and HIV and Recommendations for Postexposure Prophylaxis," MMWR Recomm Rep, 2001, 50(RR-11):1-52. [PubMed 11442229]Cohen V, Jellinek SP, Teperikidis L, et al, “Room-Temperature Storage of Medications Labeled for Refrigeration,” Am J Health-Syst Pharm, 2007, 64(16):1711-15. [PubMed 17687059]Dickson RC, Terrault NA, Ish*tani M, et al, “Protective Antibody Levels and Dose Requirements for IV 5% Nabi Hepatitis B Immune Globulin Combined With Lamivudine in Liver Transplantation for Hepatitis B-Induced End Stage Liver Disease,” Liver Transpl, 2006, 12(1):124-33. doi: 10.1002/lt.20582. [PubMed 16382463]HepaGam B (hepatitis B immune globulin intravenous [human]) [prescribing information]. Roswell, GA: Saol Therapeutics Inc; March 2021.HyperHEP B (hepatitis B immune globulin intravenous [human]) [prescribing information]. Research Triangle Park, NC: Grifols Therapeutics LLC; December 2020.HyperHEP B (hepatitis B immune globulin intravenous [human]) [product monograph]. Mississauga, Ontario, Canada: Grifols Canada Ltd; September 2021.HyperHEP B S/D (hepatitis B immune globulin [human]) [product monograph]. Mississauga, Ontario, Canada: Grifols Canada Ltd; February 2012.Isaksson M, Jansson L. Contact allergy to Tween 80 in an inhalation suspension. Contact Dermatitis. 2002;47(5):312-313. [PubMed 12534540]Lucente P, Iorizzo M, Pazzaglia M. Contact sensitivity to Tween 80 in a child. Contact Dermatitis. 2000;43(3):172. [PubMed 10985636]Nabi-HB (hepatitis B immune globulin intravenous [human]) [prescribing information]. Boca Raton, FL: ADMA Biologics; October 2019.Saari TN and American Academy of Pediatrics Committee on Infectious Diseases, "Immunization of Preterm and Low Birth Weight Infants. American Academy of Pediatrics Committee on Infectious Diseases," Pediatrics, 2003, 112(1 Pt 1):193-8. [PubMed 12837889]Schillie S, Vellozzi C, Reingold A, et al. Prevention of hepatitis B virus infection in the United States: recommendations of the Advisory Committee on Immunization Practices. MMWR Recomm Rep. 2018;67(No. RR-1):1-31. doi: 10.15585/mmwr.rr6701a1.Shelley WB, Talanin N, Shelley ED. Polysorbate 80 hypersensitivity. Lancet. 1995;345(8980):1312-1313. [PubMed 7746084]Tung BY and Kowdley KV, “Hepatitis B and Liver Transplantation,” Clin Infect Dis, 2005, 41(10):1461-6. [PubMed 16231258]Topic 13229 Version 219.0