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Review article: Biomedical intelligence

Vol. 144 No. 3940 (2014)

Live viral vaccines in transplanted patients

  • Arnaud G. L’Huillier
  • Klara Posfay Barbe
Cite this as:
Swiss Med Wkly. 2014;144:w14005


Live attenuated viral vaccines (LAVV) have been used safely and with great success for decades to protect healthy patients against sometimes life-threatening diseases. The current recommendations usually contraindicate their use in immunocompromised hosts, despite an often increased risk for a severe presentation of disease. In this article, we review currently available LAVV, such as varicella-zoster, measles/mumps/rubella, influenza, polio, rotavirus, and yellow fever in patients with solid organ or haematopoietic stem cell transplantation. The current paediatric and adult experience with pre- and post-transplantation vaccination is discussed. To date, because of insufficient data, evidence-based recommendations to safely vaccinate transplant recipients are not available. Hopefully in the near future, specific recommendations will be implemented for certain LAVV in these patients.


  1. Siegrist CA. Mechanisms underlying adverse reactions to vaccines. J Comp Pathol. 2007;137(Suppl 1):S46–50.
  2. Ljungman P, Engelhard D, de la Camara R, Einsele H, Locasciulli A, Martino R, et al. Vaccination of stem cell transplant recipients: recommendations of the Infectious Diseases Working Party of the EBMT. Bone Marrow Transplant. 2005;35:737–46.
  3. Jain A, Reyes J, Kashyap R, Dodson SF, Demetris AJ, Ruppert K, et al. Long-term survival after liver transplantation in 4,000 consecutive patients at a single center. Ann Surg. 2000;232:490–500.
  4. L’Huillier AG, Wildhaber BE, Belli DC, Diana A, Rodriguez M, Siegrist CA, et al. Successful serology-based intervention to increase protection against vaccine-preventable diseases in liver-transplanted children: a 19–yr review of the Swiss national reference center. Pediatr Transplant. 2012;16:50–7.
  5. Smith KG, Isbel NM, Catton MG, Leydon JA, Becker GJ, Walker RG. Suppression of the humoral immune response by mycophenolate mofetil. Nephrol Dial Transplant. 1998;13:160–4.
  6. Salles MJ, Sens YA, Boas LS, Machado CM. Influenza virus vaccination in kidney transplant recipients: serum antibody response to different immunosuppressive drugs. Clin Transplant. 2010;24:E17–23.
  7. Puissant-Lubrano B, Rostaing L, Kamar N, Abbal M, Fort M, Blancher A. Impact of rituximab therapy on response to tetanus toxoid vaccination in kidney-transplant patients. Exp Clin Transplant. 2010;8:19–28.
  8. Kapetanovic MC, Kristensen LE, Saxne T, Aktas T, Morner A, Geborek P. Impact of anti-rheumatic treatment on immunogenicity of pandemic H1N1 influenza vaccine in patients with arthritis. Arthritis Res Ther. 2014;16:R2.
  9. Banovic T, Yanilla M, Simmons R, Robertson I, Schroder WA, Raffelt NC, et al. Disseminated varicella infection caused by varicella vaccine strain in a child with low invariant natural killer T cells and diminished CD1d expression. J Infect Dis. 2011;204:1893–901.
  10. Jean-Philippe P, Freedman A, Chang MW, Steinberg SP, Gershon AA, LaRussa PS, et al. Severe varicella caused by varicella-vaccine strain in a child with significant T-cell dysfunction. Pediatrics. 2007;120:e1345–9.
  11. Lynfield R, Herrin JT, Rubin RH. Varicella in pediatric renal transplant recipients. Pediatrics. 1992;90:216–20.
  12. Feldhoff CM, Balfour HH, Jr., Simmons RL, Najarian JS, Mauer SM. Varicella in children with renal transplants. J Pediatr. 1981;98:25–31.
  13. Fehr T, Bossart W, Wahl C, Binswanger U. Disseminated varicella infection in adult renal allograft recipients: four cases and a review of the literature. Transplantation. 2002;73:608–11.
  14. Pergam SA, Limaye AP, Practice ASTIDCo. Varicella zoster virus (VZV) in solid organ transplant recipients. Am J Transplant. 2009;9(Suppl 4):S108–15.
  15. Takahashi M, Okuno Y, Otsuka T, Osame J, Takamizawa A. Development of a live attenuated varicella vaccine. Biken J. 1975;18:25–33.
  16. Gershon AA. Varicella zoster vaccines and their implications for development of HSV vaccines. Virology. 2013;435:29–36.
  17. de Boer PT, Pouwels KB, Cox JM, Hak E, Wilschut JC, Postma MJ. Cost-effectiveness of vaccination of the elderly against herpes zoster in The Netherlands. Vaccine. 2013;31:1276–83.
  18. Weaver BA. Update on the advisory committee on immunization practices’ recommendations for use of herpes zoster vaccine. J Am Osteopath Assoc. 2011;111:S31–3.
  19. Chaves Tdo S, Lopes MH, de Souza VA, Dos Santos Sde S, Pereira LM, Reis AD, et al. Seroprevalence of antibodies against varicella-zoster virus and response to the varicella vaccine in pediatric renal transplant patients. Pediatr Transplant. 2005;9:192–6.
  20. Tang H, Moriishi E, Okamoto S, Okuno Y, Iso H, Asada H, et al. A community-based survey of varicella-zoster virus-specific immune responses in the elderly. J Clin Virol. 2012;55:46–50.
  21. Prelog M, Schonlaub J, Jeller V, Almanzar G, Hofner K, Gruber S, et al. Reduced varicella-zoster-virus (VZV)-specific lymphocytes and IgG antibody avidity in solid organ transplant recipients. Vaccine. 2013;31:2420–6.
  22. Geel A, Zuidema W, van Gelder T, van Doornum G, Weimar W. Successful vaccination against varicella zoster virus prior to kidney transplantation. Transplant Proc. 2005;37:952–3.
  23. Prelog M, Zimmerhackl LB. Varicella vaccination in pediatric kidney and liver transplantation. Pediatr Transplant. 2010;14:41–7.
  24. Pittet LF, Posfay-Barbe KM. Immunization in transplantation: review of the recent literature. Curr Opin Organ Transplant. 2013.
  25. Danziger-Isakov L, Kumar D. Vaccination in solid organ transplantation. Am J Transplant. 2013;13(Suppl 4):311–7.
  26. Vaccinations CFpl. Recommendations for immunization of solid organ transplant (SOT) candidates and recipients. 2014.
  27. Kano H, Mizuta K, Sakakihara Y, Kato H, Miki Y, Shibuya N, et al. Efficacy and safety of immunization for pre- and post- liver transplant children. Transplantation. 2002;74:543–50.
  28. Furth SL, Hogg RJ, Tarver J, Moulton LH, Chan C, Fivush BA, et al. Varicella vaccination in children with chronic renal failure. A report of the Southwest Pediatric Nephrology Study Group. Pediatr Nephrol. 2003;18:33–8.
  29. Broyer M, Tete MJ, Guest G, Gagnadoux MF, Rouzioux C. Varicella and zoster in children after kidney transplantation: long-term results of vaccination. Pediatrics. 1997;99:35–9.
  30. Zamora I, Simon JM, Da Silva ME, Piqueras AI. Attenuated varicella virus vaccine in children with renal transplants. Pediatr Nephrol. 1994;8:190–2.
  31. Weinberg A, Horslen SP, Kaufman SS, Jesser R, Devoll-Zabrocki A, Fleckten BL, et al. Safety and immunogenicity of varicella-zoster virus vaccine in pediatric liver and intestine transplant recipients. Am J Transplant. 2006;6:565–8.
  32. Khan S, Erlichman J, Rand EB. Live virus immunization after orthotopic liver transplantation. Pediatr Transplant. 2006;10:78–82.
  33. Shinjoh M, Miyairi I, Hoshino K, Takahashi T, Nakayama T. Effective and safe immunizations with live-attenuated vaccines for children after living donor liver transplantation. Vaccine. 2008;26:6859–63.
  34. Posfay-Barbe KM, Pittet LF, Sottas C, Grillet S, Wildhaber BE, Rodriguez M, et al. Varicella-zoster immunization in pediatric liver transplant recipients: safe and immunogenic. Am J Transplant. 2012;12:2974–85.
  35. Kulcsar A TZ, Kolozsi T, Lukacs A. Vaccination of the liver transplant recipients in Hungary. How we do it… European Society of Pediatric Infectious Diseases (ESPID) Annual meeting 2013; 2013; Milano, Italy.
  36. Danerseau AM, Robinson JL. Efficacy and safety of measles, mumps, rubella and varicella live viral vaccines in transplant recipients receiving immunosuppressive drugs. World J Pediatr. 2008;4:254–8.
  37. Levitsky J, Te HS, Faust TW, Cohen SM. Varicella infection following varicella vaccination in a liver transplant recipient. Am J Transplant. 2002;2:880–2.
  38. Kraft JN, Shaw JC. Varicella infection caused by Oka strain vaccine in a heart transplant recipient. Arch Dermatol. 2006;142:943–5.
  39. Chou JF, Kernan NA, Prockop S, Heller G, Scaradavou A, Kobos R, et al. Safety and immunogenicity of the live attenuated varicella vaccine following T replete or T cell-depleted related and unrelated allogeneic hematopoietic cell transplantation (alloHCT). Biol Blood Marrow Transplant. 2011;17:1708–13.
  40. Kussmaul SC, Horn BN, Dvorak CC, Abramovitz L, Cowan MJ, Weintrub PS. Safety of the live, attenuated varicella vaccine in pediatric recipients of hematopoietic SCTs. Bone Marrow Transplant. 2010;45:1602–6.
  41. Ljungman P, Wang FZ, Nilsson C, Solheim V, Linde A. Vaccination of autologous stem cell transplant recipients with live varicella vaccine: a pilot study. Support Care Cancer. 2003;11:739–41.
  42. Guidelines for preventing opportunistic infections among hematopoietic stem cell transplant recipients. MMWR Recomm Rep. 2000;49:1–125, CE1–7.
  43. Turner A, Jeyaratnam D, Haworth F, Sinha MD, Hughes E, Cohen B, et al. Measles-associated encephalopathy in children with renal transplants. Am J Transplant. 2006;6:1459–65.
  44. Klapper PE, Cleator GM, Clarke MC, Postlethwaite RJ. Measles immunisation. Arch Dis Child. 1991;66:369.
  45. Kalman S, Bakkaloglu SA, Ozkaya O, Buyan N, Soylemezoglu O. Measles: a rare communicable disease in a child with renal transplantation. Pediatr Transplant. 2002;6:432–4.
  46. Ovsyannikova IG, Pankratz VS, Vierkant RA, Jacobson RM, Poland GA. Human leukocyte antigen haplotypes in the genetic control of immune response to measles-mumps-rubella vaccine. J Infect Dis. 2006;193:655–63.
  47. Dhiman N, Ovsyannikova IG, Vierkant RA, Ryan JE, Pankratz VS, Jacobson RM, et al. Associations between SNPs in toll-like receptors and related intracellular signaling molecules and immune responses to measles vaccine: preliminary results. Vaccine. 2008;26:1731–6.
  48. Flynn JT, Frisch K, Kershaw DB, Sedman AB, Bunchman TE. Response to early measles-mumps-rubella vaccination in infants with chronic renal failure and/or receiving peritoneal dialysis. Adv Perit Dial. 1999;15:269–72.
  49. Mori K, Kawamura K, Honda M, Sasaki N. Responses in children to measles vaccination associated with perirenal transplantation. Pediatr Int. 2009;51:617–20.
  50. Rand EB, McCarthy CA, Whitington PF. Measles vaccination after orthotopic liver transplantation. J Pediatr. 1993;123:87–9.
  51. Machado CM. Reimmunization after hematopoietic stem cell transplantation. Expert Rev Vaccines. 2005;4:219–28.
  52. Tomblyn M, Chiller T, Einsele H, Gress R, Sepkowitz K, Storek J, et al. Guidelines for preventing infectious complications among hematopoietic cell transplantation recipients: a global perspective. Biol Blood Marrow Transplant. 2009;15:1143–238.
  53. Machado CM, de Souza VA, Sumita LM, da Rocha IF, Dulley FL, Pannuti CS. Early measles vaccination in bone marrow transplant recipients. Bone Marrow Transplant. 2005;35:787–91.
  54. Lambert LC, Fauci AS. Influenza vaccines for the future. N Engl J Med. 2010;363:2036–44.
  55. Fiore AE, Uyeki TM, Broder K, Finelli L, Euler GL, Singleton JA, et al. Prevention and control of influenza with vaccines: recommendations of the Advisory Committee on Immunization Practices (ACIP), 2010. MMWR Recomm Rep. 2010;59:1–62.
  56. Harper SA, Fukuda K, Uyeki TM, Cox NJ, Bridges CB. Prevention and control of influenza: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2004;53:1–40.
  57. Ashkenazi S, Vertruyen A, Aristegui J, Esposito S, McKeith DD, Klemola T, et al. Superior relative efficacy of live attenuated influenza vaccine compared with inactivated influenza vaccine in young children with recurrent respiratory tract infections. Pediatr Infect Dis J. 2006;25:870–9.
  58. Fleming DM, Crovari P, Wahn U, Klemola T, Schlesinger Y, Langussis A, et al. Comparison of the efficacy and safety of live attenuated cold-adapted influenza vaccine, trivalent, with trivalent inactivated influenza virus vaccine in children and adolescents with asthma. Pediatr Infect Dis J. 2006;25:860–9.
  59. Belshe RB, Mendelman PM, Treanor J, King J, Gruber WC, Piedra P, et al. The efficacy of live attenuated, cold-adapted, trivalent, intranasal influenzavirus vaccine in children. N Engl J Med. 1998;338:1405–12.
  60. Bergen R, Black S, Shinefield H, Lewis E, Ray P, Hansen J, et al. Safety of cold-adapted live attenuated influenza vaccine in a large cohort of children and adolescents. Pediatr Infect Dis J. 2004;23:138–44.
  61. Mendelman PM, Cordova J, Cho I. Safety, efficacy and effectiveness of the influenza virus vaccine, trivalent, types A and B, live, cold-adapted (CAIV-T) in healthy children and healthy adults. Vaccine. 2001;19:2221–6.
  62. Ambrose CS, Wu X. The safety and effectiveness of self-administration of intranasal live attenuated influenza vaccine in adults. Vaccine. 2013;31:857–60.
  63. Nichol KL, Mendelman PM, Mallon KP, Jackson LA, Gorse GJ, Belshe RB, et al. Effectiveness of live, attenuated intranasal influenza virus vaccine in healthy, working adults: a randomized controlled trial. JAMA. 1999;282:137–44.
  64. Ohmit SE, Victor JC, Rotthoff JR, Teich ER, Truscon RK, Baum LL, et al. Prevention of antigenically drifted influenza by inactivated and live attenuated vaccines. N Engl J Med. 2006;355:2513–22.
  65. Treanor JJ, Kotloff K, Betts RF, Belshe R, Newman F, Iacuzio D, et al. Evaluation of trivalent, live, cold-adapted (CAIV-T) and inactivated (TIV) influenza vaccines in prevention of virus infection and illness following challenge of adults with wild-type influenza A (H1N1), A (H3N2), and B viruses. Vaccine. 1999;18:899–906.
  66. Ambrose CS, Luke C, Coelingh K. Current status of live attenuated influenza vaccine in the United States for seasonal and pandemic influenza. Influenza Other Respi Viruses. 2008;2:193–202.
  67. Gruber WC. The role of live influenza vaccines in children. Vaccine. 2002;20(Suppl 2):S66–73.
  68. Murphy BR, Coelingh K. Principles underlying the development and use of live attenuated cold-adapted influenza A and B virus vaccines. Viral Immunol. 2002;15:295–323.
  69. Gorse GJ, Otto EE, Powers DC, Chambers GW, Eickhoff CS, Newman FK. Induction of mucosal antibodies by live attenuated and inactivated influenza virus vaccines in the chronically ill elderly. J Infect Dis. 1996;173:285–90.
  70. Boyce TG, Gruber WC, Coleman-Dockery SD, Sannella EC, Reed GW, Wolff M, et al. Mucosal immune response to trivalent live attenuated intranasal influenza vaccine in children. Vaccine. 1999;18:82–8.
  71. Barria MI, Garrido JL, Stein C, Scher E, Ge Y, Engel SM, et al. Localized mucosal response to intranasal live attenuated influenza vaccine in adults. J Infect Dis. 2013;207:115–24.
  72. Horvath KM, Brighton LE, Herbst M, Noah TL, Jaspers I. Live attenuated influenza virus (LAIV) induces different mucosal T cell function in nonsmokers and smokers. Clin Immunol. 2012;142:232–6.
  73. Treanor J, Wright PF. Immune correlates of protection against influenza in the human challenge model. Dev Biol. (Basel) 2003;115:97–104.
  74. Forrest BD, Pride MW, Dunning AJ, Capeding MR, Chotpitayasunondh T, Tam JS, et al. Correlation of cellular immune responses with protection against culture-confirmed influenza virus in young children. Clin Vaccine Immunol. 2008;15:1042–53.
  75. Belshe RB, Edwards KM, Vesikari T, Black SV, Walker RE, Hultquist M, et al. Live attenuated versus inactivated influenza vaccine in infants and young children. N Engl J Med. 2007;356:685–96.
  76. Monto AS, Ohmit SE, Petrie JG, Johnson E, Truscon R, Teich E, et al. Comparative efficacy of inactivated and live attenuated influenza vaccines. N Engl J Med. 2009;361:1260–7.
  77. Tennis P, Toback SL, Andrews E, McQuay LJ, Ambrose CS. A postmarketing evaluation of the frequency of use and safety of live attenuated influenza vaccine use in nonrecommended children younger than 5 years. Vaccine. 2011;29:4947–52.
  78. Rhorer J, Ambrose CS, Dickinson S, Hamilton H, Oleka NA, Malinoski FJ, et al. Efficacy of live attenuated influenza vaccine in children: A meta-analysis of nine randomized clinical trials. Vaccine. 2009;27:1101–10.
  79. Belshe RB, Gruber WC, Mendelman PM, Cho I, Reisinger K, Block SL, et al. Efficacy of vaccination with live attenuated, cold-adapted, trivalent, intranasal influenza virus vaccine against a variant (A/Sydney) not contained in the vaccine. J Pediatr. 2000;136:168–75.
  80. Duchini A, Hendry RM, Redfield DC, Pockros PJ. Influenza infection in patients before and after liver transplantation. Liver Transpl. 2000;6:531–42.
  81. Vilchez RA, Fung J, Kusne S. The pathogenesis and management of influenza virus infection in organ transplant recipients. Transpl Infect Dis. 2002;4:177–82.
  82. Kumar D, Blumberg EA, Danziger-Isakov L, Kotton CN, Halasa NB, Ison MG, et al. Influenza vaccination in the organ transplant recipient: review and summary recommendations. Am J Transplant. 2011;11:2020–30.
  83. Kumar D, Morris MI, Kotton CN, Fischer SA, Michaels MG, Allen U, et al. Guidance on Novel Influenza A/H1N1 in Solid Organ Transplant Recipients†. Am J Transplant. 2010;10:18–25.
  84. Ballout A, Goffin E, Yombi JC, Vandercam B. Vaccinations for adult solid organ transplant recipient: current recommendations. Transplant Proc. 2005;37:2826–7.
  85. Hilgendorf I, Freund M, Jilg W, Einsele H, Gea-Banacloche J, Greinix H, et al. Vaccination of allogeneic haematopoietic stem cell transplant recipients: report from the international consensus conference on clinical practice in chronic GVHD. Vaccine. 2011;29:2825–33.
  86. Polio vaccines and polio immunization in the pre-eradication era: WHO position paper. Wkly Epidemiol Rec. 2010;85:213–28.
  87. Prevots DR, Burr RK, Sutter RW, Murphy TV. Poliomyelitis prevention in the United States. Updated recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2000;49:1–22; quiz CE1–7.
  88. Recommendations of the Advisory Committee on Immunization Practices: revised recommendations for routine poliomyelitis vaccination. MMWR Morb Mortal Wkly Rep. 1999;48:590.
  89. Prevention of poliomyelitis: recommendations for use of only inactivated poliovirus vaccine for routine immunization. Committee on Infectious Diseases. American Academy of Pediatrics. Pediatrics. 1999;104:1404–6.
  90. Polio vaccines and polio immunization in the pre-eradication era: WHO position paper – recommendations. Vaccine. 2010;28:6943–4.
  91. Prolonged poliovirus excretion in an immunodeficient person with vaccine-associated paralytic poliomyelitis. MMWR Morb Mortal Wkly Rep. 1997;46:641–3.
  92. Sutter RW, Prevots DR. Vaccine-associated paralytic poliomyelitis among immunodeficient persons. Infect Med. 1994;11:429–38.
  93. Kotton CN. Vaccination and immunization against travel-related diseases in immunocompromised hosts. Expert Rev Vaccines. 2008;7:663–72.
  94. Avery RK. Immunizations in adult immunocompromised patients: which to use and which to avoid. Cleve Clin J Med. 2001;68:337–48.
  95. Singhal S, Mehta J. Reimmunization after blood or marrow stem cell transplantation. Bone Marrow Transplant. 1999;23:637–46.
  96. Rotavirus vaccines. WHO position paper – January 2013. Wkly Epidemiol Rec. 2013;88:49–64.
  97. Parashar UD, Gibson CJ, Bresee JS, Glass RI. Rotavirus and severe childhood diarrhea. Emerg Infect Dis. 2006;12:304–6.
  98. Angel J, Franco MA, Greenberg HB. Rotavirus immune responses and correlates of protection. Curr Opin Virol. 2012;2:419–25.
  99. Soares-Weiser K, Maclehose H, Bergman H, Ben-Aharon I, Nagpal S, Goldberg E, et al. Vaccines for preventing rotavirus diarrhoea: vaccines in use. Cochrane Database Syst Rev 2012;11:CD008521.
  100. Mphahlele MJ, Mda S. Immunising the HIV-infected child: a view from sub-Saharan Africa. Vaccine. 2012;30(Suppl 3):C61–5.
  101. Cortese MM, Parashar UD. Prevention of rotavirus gastroenteritis among infants and children: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2009;58:1–25.
  102. Vaccines and vaccination against yellow fever. WHO position paper – June 2013. Wkly Epidemiol Rec 2013;88:269–83.
  103. Staples JE, Gershman M, Fischer M. Yellow fever vaccine: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2010;59:1–27.
  104. Wyplosz B, Burdet C, Francois H, Durrbach A, Duclos-Vallee JC, Mamzer-Bruneel MF, et al. Persistence of Yellow Fever Vaccine-Induced Antibodies After Solid Organ Transplantation. Am J Transplant. 2013.
  105. Azevedo LS, Lasmar EP, Contieri FL, Boin I, Percegona L, Saber LT, et al. Yellow fever vaccination in organ transplanted patients: is it safe? A multicenter study. Transpl Infect Dis. 2012;14:237–41.
  106. Gowda R, Cartwright K, Bremner JA, Green ST. Yellow fever vaccine: a successful vaccination of an immunocompromised patient. Eur J Haematol. 2004;72:299–301.
  107. Yax JA, Farnon EC, Cary Engleberg N. Successful immunization of an allogeneic bone marrow transplant recipient with live, attenuated yellow Fever vaccine. J Travel Med. 2009;16:365–7.
  108. Dropulic LK, Rubin RH, Bartlett JG. Smallpox vaccination and the patient with an organ transplant. Clin Infect Dis. 2003;36:786–8.
  109. Blanchard TJ, Alcami A, Andrea P, Smith GL. Modified vaccinia virus Ankara undergoes limited replication in human cells and lacks several immunomodulatory proteins: implications for use as a human vaccine. J Gen Virol. 1998;79(Pt 5):1159–67.
  110. Capeding RZ, Luna IA, Bomasang E, Lupisan S, Lang J, Forrat R, et al. Live-attenuated, tetravalent dengue vaccine in children, adolescents and adults in a dengue endemic country: randomized controlled phase I trial in the Philippines. Vaccine. 2011;29:3863–72.
  111. Thomas SJ, Eckels KH, Carletti I, De La Barrera R, Dessy F, Fernandez S, et al. A phase II, randomized, safety and immunogenicity study of a re-derived, live-attenuated dengue virus vaccine in healthy adults. Am J Trop Med Hyg. 2013;88:73–88.
  112. Morrison D, Legg TJ, Billings CW, Forrat R, Yoksan S, Lang J. A novel tetravalent dengue vaccine is well tolerated and immunogenic against all 4 serotypes in flavivirus-naive adults. J Infect Dis. 2010;201:370–7.
  113. Sun W, Cunningham D, Wasserman SS, Perry J, Putnak JR, Eckels KH, et al. Phase 2 clinical trial of three formulations of tetravalent live-attenuated dengue vaccine in flavivirus-naive adults. Hum Vaccin. 2009;5:33–40.
  114. Edelman R, Wasserman SS, Bodison SA, Putnak RJ, Eckels KH, Tang D, et al. Phase I trial of 16 formulations of a tetravalent live-attenuated dengue vaccine. Am J Trop Med Hyg. 2003;69:48–60.
  115. Watanaveeradej V, Simasathien S, Nisalak A, Endy TP, Jarman RG, Innis BL, et al. Safety and immunogenicity of a tetravalent live-attenuated dengue vaccine in flavivirus-naive infants. Am J Trop Med Hyg. 2011;85:341–51.
  116. Simasathien S, Thomas SJ, Watanaveeradej V, Nisalak A, Barberousse C, Innis BL, et al. Safety and immunogenicity of a tetravalent live-attenuated dengue vaccine in flavivirus naive children. Am J Trop Med Hyg. 2008;78:426–33.
  117. Poo J, Galan F, Forrat R, Zambrano B, Lang J, Dayan GH. Live-attenuated Tetravalent Dengue Vaccine in Dengue-naive Children, Adolescents, and Adults in Mexico City: Randomized Controlled Phase 1 Trial of Safety and Immunogenicity. Pediatr Infect Dis J. 2011.
  118. Kennedy RB, Ovsyannikova IG, Pankratz VS, Haralambieva IH, Vierkant RA, Poland GA. Genome-wide analysis of polymorphisms associated with cytokine responses in smallpox vaccine recipients. Hum Genet. 2012;131:1403–21.
  119. Haralambieva IH, Oberg AL, Ovsyannikova IG, Kennedy RB, Grill DE, Middha S, et al. Genome-wide characterization of transcriptional patterns in high and low antibody responders to rubella vaccination. PLoS One. 2013;8:e62149.