Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are addressed by vetting through a multi-level review process, and through requirements for references to be provided to support the content. Appropriately referenced content is required of all authors and must conform to UpToDate standards of evidence.
The following represent additions to UpToDate from the past six months that were considered by the editors and authors to be of particular interest. The most recent What's New entries are at the top of each subsection.
Bezlotoxumab for secondary prevention of C. difficile infection (February 2017)
Bezlotoxumab is a monoclonal antibody against Clostridium difficile toxin B (which is essential for the virulence of the organism) that received US Food and Drug Administration approval in 2016 for secondary prevention of C. difficile infection in patients at high risk for recurrence. In two randomized trials including more than 2500 patients with C. difficile infection, the addition of bezlotoxumab to standard oral antibiotic therapy lowered the rate of recurrence (16 to 17 versus 26 to 28 percent with antibiotics alone) . However, further evaluation to identify those who would be most likely to benefit is needed to define the optimal role of bezlotoxumab relative to other approaches to C. difficile infection treatment, including fecal microbiota transplant. (See "Clostridium difficile in adults: Treatment", section on 'Alternative therapies'.)
Cranberry products and urinary tract infection in women (October 2016)
Numerous clinical studies on the effects of cranberry products on recurrent urinary tract infection (UTI) in women have failed to clearly demonstrate a preventive benefit. In a year-long randomized trial among female nursing home residents, cranberry capsules similarly did not reduce adjusted rates of bacteriuria plus pyuria or symptomatic UTI compared with placebo . While we do not suggest cranberry products to reduce the risk of recurrent UTI, there is likely little harmful effect. (See "Recurrent urinary tract infection in women", section on 'Cranberry products'.)
IDSA/ATS guidelines for the management of hospital-acquired pneumonia and ventilator-associated pneumonia (August 2016)
The Infectious Diseases Society of America and the American Thoracic Society have released updated guidelines for the management of hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP) . Empiric therapy for HAP (algorithm 1) and VAP (algorithm 2) should include agents with activity against Staphylococcus aureus, Pseudomonas aeruginosa, and other gram-negative bacilli. Choice of a specific regimen for empiric therapy should be based upon knowledge of the prevailing pathogens (and susceptibility patterns) within the healthcare setting as well as risk factors for multidrug resistance in the individual patient. The guidelines emphasize that a seven-day course of antimicrobial therapy is appropriate for most patients rather than a longer duration. (See "Treatment of hospital-acquired and ventilator-associated pneumonia in adults", section on 'Treatment'.)
WHO recommendations on HIV self-testing (December 2016)
The World Health Organization (WHO) recently updated its HIV testing guidelines to advocate expanded use of self-testing with rapid home diagnostic tests as an effort to improve HIV testing uptake [4,5]. This recommendation is supported by trials that found higher rates of HIV testing with self-testing compared with facility-based testing among couples and individuals at high risk for infection (eg, men who have sex with men and partners of HIV-infected individuals). Self-testers with a reactive test should undergo confirmatory testing by a trained provider. (See "Screening and diagnostic testing for HIV infection", section on 'Resource-limited settings'.)
Combination antiretroviral treatment in pregnancy (November 2016)
Combination antiretroviral treatment (ART) has become the worldwide standard of care for HIV-infected pregnant women, both for their own health and for prevention of HIV transmission to their infants. In a large randomized trial of HIV-infected pregnant women in Africa and India, antepartum ART (with one of two different protease inhibitor-based regimens) resulted in lower transmission rates compared with zidovudine plus single-dose nevirapine (0.5 versus 1.8 percent) . Rates of preterm birth at <37 weeks were higher with the ART regimens than with zidovudine, but more significant prematurity (<34 weeks) and neonatal deaths were not increased. Clinicians should discuss with patients the potential risk for adverse pregnancy outcome with certain ART regimens. (See "Safety and dosing of antiretroviral medications in pregnancy", section on 'Preterm birth'.)
Meningococcal conjugate vaccination for HIV-infected patients (November 2016)
Growing evidence has suggested that HIV-infected individuals have a disproportionate incidence of invasive meningococcal disease, with an estimated risk 5 to 13 times that of the general population. Because of this, the Centers for Disease Control and Prevention in the United States now recommends meningococcal conjugate vaccination (with MenACWY-CRM [Menveo] or MenACWY-D [Menactra]) for all HIV-infected individuals older than two months . This includes a primary vaccine series for those who have not previously received it and interval booster doses every several years; the precise schedule depends on the age of the patient (table 1). Individuals may also have separate indications for serogroup B meningococcal vaccination. Evidence of vaccine efficacy in HIV-infected patients is limited to immunologic outcomes. (See "Immunizations in HIV-infected patients", section on 'Meningococcal vaccine' and "Meningococcal vaccines".)
Updated US guidelines on HIV infection and pregnancy (November 2016)
The Department of Health and Human Services in the United States recently published updated guidelines on the evaluation and management of HIV-infected pregnant women to reduce the risk of perinatal transmission . Preferred antiretroviral agents for initiation in pregnant women are now tenofovir-disoproxil-fumarate plus emtricitabine or lamivudine, abacavir-lamivudine, ritonavir-boosted atazanavir, ritonavir-boosted darunavir, and raltegravir. Other agents are not recommended for routine initiation in pregnant women because of limited data during pregnancy, but women who become pregnant while taking other commonly used agents can continue their regimen if they have achieved viral suppression. (See "Antiretroviral and intrapartum management of pregnant HIV-infected women and their infants in resource-rich settings", section on 'Antiretroviral selection and management'.)
Early antiretroviral therapy and cancer risk in HIV-infected patients (October 2016)
Antiretroviral therapy (ART) should be initiated in all HIV-infected individuals to reduce AIDS and non-AIDS related events, regardless of the baseline CD4 count. Further analysis of a randomized trial in which over 4500 HIV-infected participants received ART immediately or delayed ART until the CD4 count was <350 cells/microL demonstrated a reduction in infection-related cancers (ie, those associated with human herpesvirus 8, Epstein-Barr virus, and human papillomavirus) with immediate ART (6 versus 23 cases with delayed ART) . There was also a trend towards fewer noninfection-related malignancies with immediate ART. (See "When to initiate antiretroviral therapy in HIV-infected patients", section on 'HIV-related comorbidities'.)
Condom use in HIV serodiscordant couples (August 2016)
HIV serodiscordant couples may question whether continued condom use is necessary for HIV prevention if the HIV-infected partner is on antiretroviral therapy (ART). One observational study followed over 900 serodiscordant couples (both heterosexual couples and men who have sex with men [MSM]) in whom the HIV-infected partner was virally suppressed on ART and who chose not to use condoms . After more than 1200 couple-years of follow-up, there were no intra-couple transmission events. Ten MSM and one heterosexual partner acquired HIV infection during the study period, but viral sequence analysis suggested that these infections were not transmitted from the long-term HIV-infected partner. We continue to encourage condom use in HIV serodiscordant couples, as condoms offer protection from other sexually transmitted infections and provide back-up for potential periods of loss of virologic suppression. We advise couples who choose not to use condoms that the risk of HIV transmission in the setting of stable virologic suppression of the infected partner, while apparently negligible, cannot be ruled out completely. (See "HIV infection: Risk factors and prevention strategies", section on 'Serodiscordant couples'.)
HIV treatment to prevent sexual transmission (August 2016)
Growing evidence has bolstered the concept that successful antiretroviral therapy (ART) of HIV-infected individuals substantially reduces the risk of sexual HIV transmission. Final analysis of a multinational randomized trial (HPTN 052) of over 1700 HIV serodiscordant heterosexual couples demonstrated that early ART for the HIV-infected partner, compared with delaying ART until certain clinical parameters were met, reduced HIV transmission risk by 93 percent . All participants received condoms and risk reduction counseling. There were no linked transmissions (determined by detecting the same virus in both partners through viral sequencing) from HIV-infected individuals who had achieved stable viral suppression on ART; all eight linked transmissions from HIV-infected individuals using ART occurred within three months of ART initiation or in the setting of ART failure. This preventive benefit of ART is one of the reasons that early ART is recommended for all HIV-infected individuals, regardless of CD4 cell count. (See "HIV infection: Risk factors and prevention strategies", section on 'Treatment as prevention' and "When to initiate antiretroviral therapy in HIV-infected patients", section on 'Benefits of antiretroviral therapy'.)
Ibrutinib and Pneumocystis pneumonia (December 2016)
The Bruton tyrosine kinase inhibitor ibrutinib has not clearly been associated with an increased risk of opportunistic infections, but cases have been reported. In a series of 96 patients receiving ibrutinib as the sole agent for chronic lymphocytic leukemia (CLL), five were reported to have Pneumocystis pneumonia . All of the infections were grade ≤2 and resolved with oral trimethoprim-sulfamethoxazole. A limitation is that the diagnoses were made by polymerase chain reaction (PCR) of bronchoalveolar lavage fluid, which could represent a false positive in the setting of colonization with Pneumocystis. Nevertheless, clinicians should have a high index of suspicion for Pneumocystis pneumonia in patients receiving ibrutinib, and the diagnosis should be sought in those with compatible signs and symptoms. (See "Risk of infections in patients with chronic lymphocytic leukemia", section on 'Ibrutinib' and "Prevention of infections in patients with chronic lymphocytic leukemia", section on 'Ibrutinib and idelalisib'.)
HPV vaccine dosing for individuals younger than 15 years (November 2016)
For individuals younger than 15 years receiving human papillomavirus (HPV) vaccination, two vaccine doses administered at least six months apart are now recommended by the Centers for Disease Control and Prevention in the United States . This new vaccine schedule is similar to schedules used in other countries and is supported by data demonstrating that two vaccine doses in young females have similar immunogenicity to three doses. However, the efficacy of fewer than three doses for prevention of cervical neoplastic disease has not been directly established. Three doses are still recommended for individuals older than 15 years because they have lower immunologic responses to HPV vaccination. (See "Recommendations for the use of human papillomavirus vaccines", section on 'Immunization schedule'.)
Ultraviolet environmental disinfection and in-hospital transmission of resistant organisms (January 2017)
Ultraviolet (UV) radiation may be a useful adjunctive tool for surface disinfection to reduce in-hospital transmission of multidrug-resistant organisms. One cluster-randomized crossover study evaluated the addition of UV light to standard disinfection alone (quaternary ammonium for methicillin-resistant Staphylococcus aureus, vancomycin-resistant enterococci or multidrug-resistant Acinetobacter, and bleach for Clostridium difficile) for rooms from which a patient on contact precautions for these pathogens was discharged . Among over 20,000 patients subsequently admitted to these rooms, UV light reduced the overall incidence of colonization or infection with these pathogens by 30 percent, but it did not substantially reduce the individual incidence of C. difficile infection. (See "Infection prevention: General principles", section on 'Healthcare environment: Cleaning and disinfection'.)
Role of person-to-person transmission in extensively drug-resistant tuberculosis (XDR-TB) (January 2017)
It has been postulated that extensively drug-resistant tuberculosis (XDR-TB) is acquired mainly as the result of inadequate treatment. However, in a study of 400 South African patients with XDR-TB, 69 percent had not received prior treatment for multidrug-resistant TB, and genotypic analysis demonstrated that over 80 percent of isolates belonged to one of several defined phylogenetic clusters, suggesting person-to-person transmission in the majority of cases . These findings imply that focus on interrupting transmission (both community-based and health care facility-based) is paramount to limiting spread of complex drug-resistant TB strains. (See "Epidemiology of extensively drug-resistant tuberculosis", section on 'South Africa'.)
Guidelines on diagnosis of tuberculosis (January 2017)
Guidelines from the American Thoracic Society, Infectious Diseases Society of America, and the Centers for Disease Control and Prevention on the diagnosis of tuberculosis in adults and children were published in December 2016 . They state that an interferon-gamma release assay (IGRA) is generally preferred for diagnosis of latent tuberculosis infection (LTBI) in individuals five years or older who have low-to-intermediate risk of progression to active disease (table 2), although the tuberculin skin test (TST) is an acceptable alternative if IGRA is not available or too costly. For those who have high risk of progression to active disease, either IGRA or TST is acceptable, but many guideline panel members noted using the alternative test if the initial one was negative and considering a positive result from either test to indicate LTBI. The evaluation of suspected tuberculosis disease should include three sputum specimens for acid-fast bacilli (AFB) smear and culture and one or more specimens for nucleic acid amplification (NAA) testing. (See "Diagnosis of latent tuberculosis infection (tuberculosis screening) in HIV-uninfected adults" and "Diagnosis of pulmonary tuberculosis in HIV-uninfected patients" and "Latent tuberculosis infection in children" and "Tuberculosis disease in children".)
M. chimaera infections associated with cardiac surgery (October 2016)
Clusters of disseminated infection with Mycobacterium chimaera in the United States, Europe, and elsewhere have been linked to exposure to contaminated Stockert 3T heater-cooler devices during cardiac surgery . In the United States, the Food and Drug Administration recommends retiring 3T heater-cooler devices and accessories that have tested positive for M. chimaera or that have been linked to known infections and refraining from using any 3T heater-cooler device manufactured before September 2014 except in emergency situations. Providers of patients who have undergone cardiac surgery should be aware of the possibility of M. chimaera infection, even months to years following the procedure. (See "Overview of nontuberculous mycobacterial infections in HIV-negative patients", section on 'Disseminated disease'.)
New guideline recommendations on treatment of drug-susceptible tuberculosis in HIV-infected patients (September 2016)
For patients with tuberculosis (TB) and newly diagnosed HIV infection, a number of trials have established the benefits of initiating antiretroviral therapy (ART) soon after initiating TB therapy. New guidelines on the treatment of drug-susceptible tuberculosis (TB), developed jointly by the American Thoracic Society, Centers for Disease Control and Prevention, and Infectious Diseases Society of America, also recommend initiating ART during TB treatment (within the first two weeks if the CD4 cell count <50 cells/microL and within 8 to 12 weeks if the CD4 cell count >50 cells/microL), rather than waiting until after TB therapy is completed . However, HIV-infected patients with TB involvement of the central nervous system (CNS) are an exception; for these patients, the guidelines recommend against initiating ART in the first eight weeks of antituberculous therapy (even for patients with CD4 cell counts <50 cells/microL), since development of immune reconstitution inflammatory syndrome in patients with CNS TB may cause severe or fatal neurological complications. (See "Treatment of pulmonary tuberculosis in HIV-infected adults", section on 'Timing of ART in the treatment-naive patient' and "Central nervous system tuberculosis".)
Guidelines on diagnosis and treatment of leishmaniasis (January 2017)
Guidelines on the management of leishmaniasis in North America were published by the Infectious Diseases Society of America (IDSA) and the American Society of Tropical Medicine and Hygiene (ASTMH) in December 2016 . They emphasize use of multiple diagnostic tools to maximize diagnostic likelihood and submission of relevant specimens to a reference laboratory for parasite species identification. For suspected cutaneous leishmaniasis (CL), a full-thickness skin biopsy from a clean, active-appearing ulcer is recommended; for patients with mucocutaneous leishmaniasis (ML), biopsy specimens should be obtained by an otolaryngologist. For suspected visceral leishmaniasis (VL), bone marrow aspirate is the preferred sample; in addition, serum should be tested for antileishmanial antibodies. The treatment approach to CL depends on several factors, including the extent of disease, the infecting parasite species, and the presence of immunocompromising conditions. For VL, liposomal amphotericin B is the preferred treatment; miltefosine, pentavalent antimonials, and other forms of amphotericin are alternatives. (See "Cutaneous leishmaniasis: Clinical manifestations and diagnosis" and "Cutaneous leishmaniasis: Treatment" and "Visceral leishmaniasis: Clinical manifestations and diagnosis" and "Visceral leishmaniasis: Treatment".)
SEXUALLY TRANSMITTED DISEASES
Incidence of sexually transmitted infections in the United States (November 2016)
The total number of cases of chlamydia (over 1.5 million), gonorrhea (nearly 400,000), and syphilis (nearly 24,000) reported to the Centers for Disease Control and Prevention in the United States in 2015 was the highest ever recorded in a given year . Chlamydia and gonorrhea continued to occur most commonly among 15 to 24 year olds, and men who have sex with men accounted for the majority of gonorrhea and primary/secondary syphilis cases. These surveillance data highlight the importance of sexually transmitted infection prevention efforts, screening, and treatment among at-risk individuals. (See "Epidemiology of Chlamydia trachomatis infections", section on 'Incidence' and "Epidemiology and pathogenesis of Neisseria gonorrhoeae infection", section on 'Incidence' and "Syphilis: Epidemiology, pathophysiology, and clinical manifestations in HIV-uninfected patients", section on 'Epidemiology' and "Screening for sexually transmitted infections".)
Screening donated blood for babesiosis in the United States (December 2016)
Naturally occurring Babesia microti infection within the United States is regionally distributed, with high-risk areas located in the Northeast and upper Midwest. In an analysis of almost 90,000 blood donations from four states in these regions, 335 (0.38 percent) were found to be positive for B. microti using a DNA-based or antibody-based test . Screening of donated units was found to be effective in preventing transmission. Testing blood donations for B. microti is not mandatory in the US, but many units collected in high-risk regions are being screened. (See "Blood donor screening: Laboratory testing", section on 'Babesia microti'.)
VIRAL INFECTIONS, NON-HIV
Avian influenza H7N9 in China (February 2017)
A novel avian influenza A H7N9 virus emerged in China in 2013 and caused a wave of cases in humans with a mortality rate of approximately 40 percent. Additional waves have occurred during influenza seasons since then. The fifth wave in late 2016 and early 2017 has been particularly large, involving more than 300 cases . Over 90 percent of cases reported exposure to poultry, mostly at live poultry markets. Three clusters of cases have been detected, but there has been no evidence of sustained human-to-human transmission . Three of 83 viruses had mutations in the neuraminidase gene that confer reduced susceptibility to neuraminidase inhibitors. (See "Avian influenza A H7N9: Epidemiology, clinical manifestations, and diagnosis", section on 'Case counts' and "Avian influenza A H7N9: Treatment and prevention", section on 'Neuraminidase inhibitor resistance'.)
Outbreak of Seoul virus in rat handlers in the United States (January 2017)
In December 2016, a rat breeder in Wisconsin developed an acute febrile illness and was found to be infected with Seoul virus, a type of hantavirus that can cause hemorrhagic fever with renal syndrome . An outbreak investigation revealed additional infections in rat breeders and rats at the facilities in Wisconsin and Illinois that supplied the index patient's rats. States that have received potentially infected rats include Alabama, Arkansas, Colorado, Illinois, Indiana, Louisiana, Michigan, Minnesota, South Carolina, Tennessee, Utah, and Wisconsin. Recommendations for testing potentially exposed individuals and other information can be found on the United States Centers for Disease Control and Prevention’s website. (See "Epidemiology and diagnosis of hantavirus infections", section on 'Outbreaks'.)
Risk of birth defects with Zika virus infection during pregnancy (January 2017)
The risk of birth defects resulting from in utero exposure to Zika virus was 6 and 42 percent in two recent reports [25,26]. The wide range likely reflects differences in study design, populations studied, maternal Zika case definition, and the range of clinical abnormalities included. The most common fetal/newborn findings in these reports were abnormal brain imaging, microcephaly, small size for gestational age, and abnormal neurologic examination. The greatest risk of serious sequelae in offspring appeared to be with first or second trimester infection, but serious sequelae also occurred with third trimester infection. (See "Zika virus infection: Evaluation and management of pregnant women", section on 'Risk of vertical transmission and anomalies' and "Congenital Zika virus infection: Clinical features, evaluation, and management of the neonate", section on 'Clinical findings'.)
Tenofovir alafenamide for the treatment of chronic hepatitis B virus infection (December 2016)
Tenofovir disoproxil fumarate is a first-line therapy for chronic hepatitis B virus (HBV) infection. A newer formulation of tenofovir, tenofovir alafenamide, was approved by the US Food and Drug Administration in November 2016 for the treatment of chronic HBV in patients with compensated liver disease . In two large randomized noninferiority trials among patients with chronic HBV infection (both treatment-naive and experienced, and including patients positive or negative for HBV e antigen), tenofovir alafenamide resulted in similar rates of HBV suppression and fewer adverse effects on renal function and bone density at 48 weeks compared with tenofovir disoproxil fumarate [28,29]. Given these findings, tenofovir alafenamide is our preferred formulation for patients with chronic HBV who initiate therapy with tenofovir. We also favor switching those initially started on tenofovir disoproxil fumarate to tenofovir alafenamide. Given limited available safety data, we do not currently use tenofovir alafenamide in pregnant women. (See "Hepatitis B virus: Overview of management", section on 'Nucleos(t)ide analogues'.)
No role for routine serologic screening for genital herpes infection (December 2016)
Genital herpes, which can be caused by herpes simplex virus type 1 or 2 (HSV-1 or HSV-2), is one of the most common sexually transmitted infections, and sexual transmission can occur even in the absence of symptoms. Despite this, routine serologic screening for herpes simplex is not recommended in asymptomatic adolescents and adults due to significant limitations of available tests, as highlighted in a recent US Preventive Services Task Force statement . Limitations include the low specificity and high false positive rate of serologic tests for HSV-2 and the inability of serologic tests for HSV-1 to differentiate oral from genital infection. Furthermore, there are no specific treatment interventions for asymptomatic patients, so the anxiety and disruption of personal relationships associated with a positive test outweigh any potential benefits. (See "Epidemiology, clinical manifestations, and diagnosis of genital herpes simplex virus infection", section on 'Screening'.)
Prevention of graft reinfection in HCV-infected patients undergoing liver transplantation (December 2016)
In the absence of viral suppression or clearance of chronic hepatitis C virus (HCV) in patients who undergo liver transplantation, the new liver is almost always reinfected. In an open-label study, 16 HCV genotype 1-infected patients undergoing their first liver transplantation from an uninfected donor received a single dose of ledipasvir-sofosbuvir the day they arrived at the hospital for transplantation and once daily for four weeks postoperatively . The sustained virologic response rate 12 weeks after completion of treatment was 88 percent, suggesting that an abbreviated perioperative course of direct-acting antiviral (DAA) treatment can prevent reinfection of the graft. Additional studies are warranted to confirm the efficacy and safety of this approach in other HCV-infected populations and with other DAA regimens. (See "Recurrence of hepatitis C virus infection following liver transplantation", section on 'Perioperative therapy'.)
Pattern of anomalies in congenital Zika syndrome (November 2016)
The clinical spectrum of congenital Zika syndrome (CZS) is evolving as more cases are described. A comprehensive review of the available published data identified five unique features of CZS that are rarely seen with other congenital infections: (1) severe microcephaly with partially collapsed skull, (2) thin cerebral cortices with subcortical calcifications, (3) macular scarring and focal pigmentary retinal mottling, (4) congenital contractures (arthrogryposis), and (5) marked early hypertonia . Recognition of this distinctive phenotype can help clinicians identify infants with CZS and ensure appropriate etiologic evaluation and comprehensive clinical investigation. (See "Congenital Zika virus infection: Clinical features, evaluation, and management of the neonate", section on 'Clinical findings'.)
HBV reactivation during HCV antiviral therapy (October 2016)
Reactivation of hepatitis B virus (HBV) infection, including cases with fatal fulminant hepatitis, has been reported in several patients receiving direct-acting antiviral therapy for hepatitis C virus (HCV) infection . Patients should be tested for HBV coinfection prior to initiation of HCV therapy, with HBV treatment initiated for those who meet criteria (table 3). HBV surface antigen (HBsAg) positive patients who do not initially meet HBV treatment criteria should be monitored with HBV DNA testing during HCV treatment. In patients with a positive HBV core antibody (HBcAb) but negative HBsAg, we check liver enzymes during HCV treatment and perform reflex HBsAg and HBV DNA testing for unexplained elevations. (See "Patient evaluation and selection for antiviral therapy for chronic hepatitis C virus infection", section on 'HBV coinfection' and "Overview of the management of chronic hepatitis C virus infection", section on 'Other monitoring'.)
Investigational inactivated vaccine to prevent zoster and postherpetic neuralgia (September 2016)
The live attenuated zoster vaccine reduces the risk of herpes zoster with a reported vaccine efficacy of 60 to 70 percent in adults 50 years and older but appears to have decreased efficacy in adults 70 years and older. In an initial trial of the experimental recombinant inactivated zoster vaccine (HZ/su), administered in two doses, overall vaccine efficacy was 97 percent in adults 50 years and older. In a subsequent randomized, placebo-controlled trial of 13,900 patients aged 70 and older, vaccine efficacy for preventing herpes zoster and postherpetic neuralgia was each approximately 90 percent after a mean 3.7-year follow-up . No serious adverse events were reported in either trial; however, reactions such as pain at the injection site and myalgias were more common among those who received the vaccine. If approved, this inactivated vaccine may be particularly useful for such older individuals and immunocompromised individuals who cannot receive live vaccines, but it requires two doses for initial protection. (See "Vaccination for the prevention of shingles (herpes zoster)", section on 'Investigational vaccines'.)
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- World Health Organization. Guidelines on HIV self-testing and partner notification. http://www.who.int/hiv/pub/vct/hiv-self-testing-guidelines/en/ (Accessed on December 07, 2016).
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