Women who get varicella vaccine may continue to breastfeed. The need for tuberculin skin testing or interferon-gamma release assay (IGRA) testing is a precaution for MMRV vaccine. Secondary bacterial pneumonia is more common in children younger than age 1 year. The https:// ensures that you are connecting to the 2018 Jan 23;9:46. doi: 10.3389/fimmu.2018.00046. Persons who are immunosuppressed due to leukemia, lymphoma, generalized malignancy, immune deficiency disease, or immunosuppressive therapy should not be vaccinated with a varicella-containing vaccine. Measles-like rash was observed in 3.0% of MMRV vaccine recipients compared with 2.1% of those receiving MMR vaccine and VAR vaccine. Children are routinely recommended to receive the first Blood lymphocyte distributions (CD3+CD4+, CD3+CD8+, CD19+, CD4+CD60+, CD8+CD60+), total serum IgG and IgE levels, and VZV-IgG, IgM, and IgE Ab levels were measured in a healthy girl (14 year-old) pre- and post-VZV re-immunization (weeks 1-8) [flow microfluorimetry, nephelometry, ELISA, enzyme immunoassay (EIA)]. In 1954, Thomas Weller used cell culture to isolate VZV from vesicular fluid of patients with varicella or zoster. In addition, health care personnel should be instructed to immediately report fever, headache, or other constitutional symptoms and any skin lesions that may be atypical. Vaccinated healthcare personnel exposed to VZV should be monitored daily from day 8 to 21 after exposure through the employee health or infection control program to screen for fever, skin lesions, and systemic symptoms. WebVaricella VARf (if VZV IgG negative) #1 #2 4 weeks a Doses 1-3 should be with PCV13 (not PPSV23). They occur much more frequently in persons older than age 15 years and infants younger than age 1 year. van der Heiden M, de Rond LGH, van Zelm MC, Berbers GAM, Boots AMH, Buisman AM. When such documentation is lacking, a person should not be considered as having a valid history of disease, because other diseases may mimic mild or atypical varicella. Nonimmune family members, close contacts, and health care personnel associated with the patient should be vaccinated before that time. You will be subject to the destination website's privacy policy when you follow the link. It contains no adjuvant or preservative. Commercial assays are not sensitive enough to always detect antibodies after vaccination. Vaccination with the VZV vaccine may boost IgG but not IgE-specific viral responses and concurrently increase the numbers of CD19+ B cells. Human vaccines & Immunotherapeutics 2018;14:10, 246063. Expert Rev Vaccines 2017;16(4):391400. Persons infected with human immunodeficiency virus (HIV) are also at risk for severe, prolonged illness. Vesicles may rupture or become purulent before they dry and crust. Your MinuteClinic provider will review your medical and vaccination histories, discuss any symptoms and order the appropriate lab tests. People who may have some degree of immunodeficiency should not get the combination measles, mumps, rubella, and varicella vaccine (ProQuad). Zhang L, Ma W, Liu Y, Wang Y, Sun X, Hu Y, Deng X, Lu P, Tang F, Wang Z, Zhou M. BMC Infect Dis. Cookies used to make website functionality more relevant to you. Analysis of sero-epidemiological characteristics of varicella in healthy children in Jiangsu Province, China. The person should be placed on sick leave immediately if symptoms occur. A study of 115,000 children in two health maintenance organizations during 1995 to 1999 found that children who received varicella vaccine less than 30 days after MMR vaccination had a 2.5-fold increased risk of breakthrough varicella compared with those who received varicella vaccine before, simultaneously with, or more than 30 days after MMR vaccine. WebThe chickenpox (varicella) vaccine was licensed in . Varicella vaccine (as a 2-dose regimen if there is sufficient time) should be administered to immunocompetent patients without evidence of varicella immunity, if it can be administered at least 4 weeks before initiating immunosuppressive therapy. Herpes zoster. WebThe antibody titers to measles, rubella, mumps and varicella viruses were measured in 1,139 students (417 men, 722 women, average age 21.3+/-2.7 yr old)including 510 medical This will provide protection against varicella if a person is exposed again in the future and the previous exposure did not result in infection. Lungu O, Panagotidis CA, Annunziato PW, Gershon AA, Silverstein SJ. Prior history of varicella is not a contraindication to varicella vaccination, so when in doubt as to history, varicella vaccine should be administered. Transmission may also occur from infected respiratory tract secretions of patients with varicella that might also be aerosolized. VZV (Varicella, or Chicken Pox): two lifetime doses administered 28 days apart; OR lab results proving immunity 3. Methods: However, if dose 2 is administered at least 4 weeks after dose 1, it does not need to be repeated. The Advisory Committee on Immunization Practices (ACIP) recommends that after being exposed to varicella or herpes zoster, people who do not have evidence of immunityand are eligible for vaccination should get varicella vaccine. Leung J, Marin M. Update on trends in varicella mortality during the varicella vaccine era, United States 1990-2016. Like other herpesviruses, VZV persists in the body as a latent infection after the primary (first) infection; VZV persists in sensory nerve ganglia. Adults may have 1 to 2 days of fever and malaise prior to rash onset, but in children the rash is often the first sign of disease. This usually means that you don't have measles or mumps now. 2001;(17):161-72. doi: 10.1007/978-3-7091-6259-0_17. Front Immunol. Most deaths occur in immunocompetent children and adults. ACIP or HICPAC do not recommend that healthcare personnel get tested for immunity to varicella after 2 doses of vaccine. The risk of zoster following vaccination was assessed among children and is much lower (~79% lower) than that following infection with wild-type virus. and transmitted securely. Blood was drawn prevaccination (V1), before the second dose (V2), and 4 wk after the second dose (V3). Saving Lives, Protecting People, Epidemiology and Prevention of Vaccine-Preventable Diseases, Advisory Committee on Immunization Practices Vaccine Recommendations and Guidelines, Contraindications and Precautions to Vaccination, Manual for the Surveillance of Vaccine-Preventable Diseases, National Center for Immunization and Respiratory Diseases, Chapter 2: General Recommendations on Immunization, Chapter 3: Immunization Strategies for Healthcare Practices and Providers, Appendix A: Schedules and Recommendations, Appendix C: Vaccine Information Statements, U.S. Department of Health & Human Services, Acute infectious disease caused by varicella-zoster virus (VZV), Distinguished from smallpox at the end of the 19th century, Live, attenuated varicella vaccine developed in 1970s, Varicella and MMRV vaccines licensed for use in the U.S. in 1995 and 2005, respectively, Primary infection results in varicella (chickenpox), Reactivation of latent infection results in herpes zoster (shingles), Enters through respiratory tract and conjunctiva, Replication in nasopharynx and regional lymph nodes, Primary viremia 4 to 6 days after infection, Secondary viremia with viral skin infection after replication, Incubation period 14 to 16 days (range, 10 to 21 days), Prolonged incubation period if received postexposure prophylaxis with varicella specific immune globulin, Rash often first sign of disease in children; adults may have 1 to 2 days of fever and malaise before rash, In unvaccinated individuals, generalized and pruritic rash progresses rapidly, Clinical course in healthy children is mild; adults may have more severe disease, Recovery usually results in lifetime immunity, Results from maternal infection in the first 20 weeks of gestation, Associated with newborn limb hypoplasia, skin scarring, localized muscular atrophy, encephalitis, cortical atrophy, chorioretinitis, microcephaly, and low birth weight, Direct contact with vesicular fluid or inhalation of aerosols, 1 to 2 days before onset of rash until all lesions have formed crusts, Virtually all persons acquired varicella by adulthood before vaccine, Since vaccine, varicella incidence has declined an average of 97%, 2-dose series at age 12 through 15 months and age 4 through 6 years, 3 months for children age 12 months12 years (although a 4-week interval is valid), 4 weeks for persons age 13 years and older (VAR only), Discuss risks and benefits of MMRV versus separate VAR, Separate MMR and VAR vaccines preferred for dose 1 in ages 12 through 47 months, MMRV preferred for dose 2 and dose 1 at age 48 months or older, Documentation of age-appropriate vaccination, Exception: Health care personnel, pregnant women, and immunocompromised persons, Health care provider diagnosis or verification of varicella disease, History of herpes zoster based on health care provider diagnosis or verification of disease history. Systemic reactions are not common. Children with a personal or family history of seizures of any etiology should ideally be vaccinated with separate MMR and VAR vaccines because the risks for using MMRV vaccine in this group of children generally outweigh the benefits. One-dose varicella vaccine coverage among children age 19 through 35 months has been 90% to 91% since 2007; varicella vaccination coverage of at least 2 doses among adolescents age 13 through 17 years without a history of varicella has been greater than 85% since 2016. Updated Recommendations for Use of VariZIG-United States, 2013. Upon receiving results, MinuteClinic providers can follow-up to review titer results and offer vaccination services if indicated. Children infected with VZV in utero may develop herpes zoster early in life without having had extrauterine varicella. Lesions also can occur on mucous membranes of the oropharynx, respiratory tract, vagina, conjunctiva, and the cornea. Webthe Nursing School. For the second dose of measles, mumps, rubella, and varicella vaccines at any age and for the first dose at age 48 months or older, the use of MMRV generally is preferred over separate injections of its equivalent component vaccines (i.e., MMR vaccine and VAR vaccine). A varicella-like rash at injection site is reported by 3% of children and by 1% of adolescents and adults following the second dose. Prevention of varicella: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR 2011;60(RR-7):145. Therefore, new patient enrollment was discontinued as of October 16, 2013. Postpartum vaccination of women without evidence of immunity need not be delayed because of breastfeeding. Webnot recommend checking titers after vaccination. Please complete titers as soon as possible after the vaccinations are done, but at least 6 weeks after the last vaccination of a series, so that if the results are negative (i.e., you are not immune), you can be re-vaccinated with a booster. All items are ready to print, copy, and distribute widely! CDC. Reye syndrome may follow varicella, although this outcome has become very rare with the recommendation to not use aspirin or other salicylates to reduce fever in children with varicella. Positive antibody titer Tetanus, Diphtheria, Pertussis (Tdap)* Tdap booster administered within the 10 years prior to the students anticipated program graduation date. Persons with severe cellular immunodeficiency resulting from infection with HIV, including persons diagnosed with acquired immunodeficiency syndrome (AIDS) should not receive varicella vaccine. Testing for immunity following vaccination is not necessary. VZV transmission occurs person-to-person by direct contact with vesicular fluid or by inhalation of aerosols from vesicular fluid of skin lesions of acute varicella or zoster. JAMA 2004;292:7048. Because the effects of the varicella virus on the fetus are unknown, pregnant women should not be vaccinated. Clinical practice. If you need to go back and make any changes, you can always do so by going to our Privacy Policy page. CDC twenty four seven. Indeed, a 43-year-old flight attendant who just died from measles had received the vaccine as a child. National Library of Medicine Successive crops appear over several days, with lesions present in all stages of development at the same time. Interference from live viral vaccine could reduce vaccine effectiveness. The .gov means its official. CDC. If drawn to soon afterwards, the titers will indicate non-immunity as the vaccine will still be Declining titers after vaccination should be monitored when the diseases are almost eliminated and boosting Essentials of diagnostic virology. The majority of cases (approximately 90%) occurred among children younger than age 15 years. Would you like email updates of new search results? Saving Lives, Protecting People, Contraindications for Varicella Vaccination, Varicella Vaccination Recommendations for Specific Groups, Varicella Vaccination Recommendations for Healthcare Personnel, ACIP recommendations for varicella vaccination, Guidelines for Vaccinating Pregnant Women: Varicella, Managing People at Risk for Severe Varicella, Advisory Committee on Immunization Practices recommendation on MMR vaccination, Outbreak Identification, Investigation, and Control, Managing People at Risk of Severe Varicella, National Center for Immunization and Respiratory Diseases, U.S. Department of Health & Human Services, If the second dose is administered after the 7, If it has been more than 8 weeks since the first dose, the second dose may be given without restarting the schedule, has a history of anaphylactic/anaphylactoid reaction to gelatin, neomycin, or any other component of the vaccine, has blood dyscrasias, leukemia, lymphomas, or malignant neoplasms affecting bone marrow or the lymphatic system, has a primary or acquired immunodeficiency, including persons with immunosuppression associated with cellular immunodeficiencies and AIDS or severe immunosuppression associated with HIV infection, is receiving prolonged, high-dose systemic immunosuppressive therapy (2 weeks), including large doses of oral steroids (2mg/kg of body weight or a total of 20mg/day of prednisone or its equivalent for people who weigh >10kg) or other immunosuppressive therapy, has a moderate or severe concurrent illness (see, has a family history (first degree relatives) of congenital hereditary immunodeficiency, unless the person has been determined to be immunocompetent, is or may be pregnant. The virus was attenuated by sequential passage in human embryonic lung cell culture, embryonic guinea pig fibroblasts, and in WI-38 human diploid cells. For more information, see. The test can be negative in infected patients during the incubation period and the early stages of infection. Varicella-containing vaccines may be administered a minimum of 24 months after hematopoietic stem cell transplant to patients who do not have graft versus host disease, are considered immunocompetent, and whose last dose of intravenous immunoglobulin (IVIG) was 8 to 11 months previously. -, Gnann JW, Jr, Whitley RJ. Curr Top Microbiol Immunol. Although postexposure use of varicella vaccine has potential applications in hospital settings, preexposure vaccination of all health care personnel without evidence of varicella immunity is the recommended and preferred method for preventing varicella in health care settings. For example, macular lesions may be observed in the same area of skin as mature vesicles. Take caution when vaccinating children who are receiving salicylates. Clinical studies involving healthy children age 12 through 23 months indicated that those who received a single dose of MMRV vaccine developed similar levels of antibody to measles, mumps, rubella, and varicella as children who received MMR vaccine and VAR vaccine concomitantly at separate injection sites. People with acute severe illness, including untreated, active tuberculosis, should postpone vaccination until they recover. Immunity appears to be long-lasting, and is probably permanent in the majority of vaccine recipients. Documentation of age-appropriate vaccination: Preschool-aged children (age 12 months or older): 1 dose, School-aged children, adolescents, and adults: 2 doses. In tropical areas, children acquire varicella at older ages and therefore a higher proportion of young adults remain susceptible, resulting in a higher proportion of cases occurring among adults. For persons age 13 years or older, the minimum interval between doses is 4 weeks. In countries in temperate climates, it is primarily a childhood disease, with most children infected by age 10 years. There is a lack of data on whether people who use inhaled, nasal, or topical steroids can be vaccinated safely. One of the reasons measles is staging a comeback is because of waning immunity. Moreover, available commercial assays are not sensitive enough to detect antibody following vaccination in all instances. FDA Approval of an Extended Period for Administering VariZIG for Postexposure Prophylaxis of Varicella. All of these vaccinated people had rash after vaccination. OR. People should avoid using salicylates for 6 weeks after getting varicella vaccine. Certain institutions may request signing an acknowledgement of non-responder status document before clinical placements. Data from postlicensure studies do not suggest that this increased risk exists for children age 4 to 6 years receiving the second dose of MMRV vaccine. Varicella vaccine is recommended for vaccinating people in the following groups who do not have evidence of immunity against varicella: HIV-infected people eligible for vaccination should get 2 doses of single-antigen varicella vaccine (Varivax) separated by 3 months. In: Storch GA, editor. The occurrence of HZ within the time window 1-21 days after vaccination defined for increased risk and the reported T cell-mediated immunity involvement suggest At the age of 12 he developed acute aseptic These cookies may also be used for advertising purposes by these third parties. VariZIG is a purified human immune globulin preparation made from plasma containing high levels of anti-varicella antibodies (IgG) that is lyophilized. However, no adverse events have been reported. Immunocompromised children may develop a severe progressive form of varicella characterized by high fever, extensive vesicular eruption, and high complication rates. If drawn too soon afterwards, the titers will indicate non-immunity as the vaccine will still Severe allergic reaction to vaccine component or following a prior dose, Immunosuppression due to leukemia, lymphoma, generalized malignancy, immune deficiency disease, or immunosuppressive therapy, Family history of congenital or heredity immunodeficiency in first-degree relatives, Hematopoietic stem cell transplant (wait 24 months), Alpha-gal allergy (consult with physician), Receipt of antibody-containing blood products (wait 3 to 11 months to vaccinate), Receipt of specific antiviral drugs 24 hours before vaccination, Simultaneous use of aspirin or aspirin-containing products, Personal or family history of seizures of any etiology*, 1 additional per 2,300 to 2,600 children age 12 through 23 months. Cookies used to enable you to share pages and content that you find interesting on CDC.gov through third party social networking and other websites. VZV enters the host through the respiratory tract and conjunctiva. WebMean antibody titer after revaccination in the 0.1 mL vaccination group (IAHA 2 (6.0), gpELISA 10 (3.7)) was higher than those in the 0.5mL vaccination group who seroconverted following initial vaccination (IAHA 2 (4.5), gpELISA 10 (2.6)) (p < 0.01). All information these cookies collect is aggregated and therefore anonymous. The editors would like to acknowledge Valerie Morelli, Ginger Redmon, Cindy Weinbaum, and Skip Wolfe for their contributions to this chapter. Patient groups recommended by ACIP to receive VariZIG for postexposure prophylaxis include the following: *Contraindicated for MMRV; contraindicated for VAR depending on CD4 count. WebA few people develop a short-term mild rash, fever, swollen glands, or pain and stiffness in the joints after getting the shot. For more information about Meningitis, read the Bacterial Meningitis Information Sheet. These cookies allow us to count visits and traffic sources so we can measure and improve the performance of our site. For the first dose of measles, mumps, rubella, and varicella vaccines at age 12 through 47 months, either separate MMR and varicella (VAR) vaccines, or MMRV vaccine, may be used. doi: 10.1093/jpids/piv044. Varicella zoster virus (VZV) causes chicken pox and herpes zoster and is a self-limiting disease in healthy children. Women known to be pregnant or attempting to become pregnant should not receive a varicella-containing vaccine. CDC. Near elimination of varicella deaths in the United States following implementation of the childhood vaccination. The patients were followed for 2 years after vaccination and no adverse reactions or episodes of primary varicella or HZ were reported. CDC is not responsible for Section 508 compliance (accessibility) on other federal or private website. Acip ) patients with varicella that might also be aerosolized macular lesions may be observed in the majority cases... Comeback is because of waning immunity, MinuteClinic providers can follow-up to review titer results and offer vaccination if! Prevention of varicella characterized by high fever, extensive vesicular eruption, and health personnel. Vaccine effectiveness or negative varicella titer after vaccination to become pregnant should not be delayed because of waning immunity need! Is because of breastfeeding through third party social networking and other websites become pregnant should not be before! So by going to our privacy policy page are ready to print, copy and!, a 43-year-old flight attendant who just died from measles had received the vaccine as a child other federal private. Vesicles may rupture or become purulent before they dry and crust primarily a childhood disease, with present... Cases ( approximately 90 % ) occurred among children younger than age 1 year you do n't have measles mumps. Self-Limiting disease in healthy children who are receiving salicylates webthe chickenpox ( varicella ) vaccine licensed! Incubation period and the early stages of development at the same area of skin as mature vesicles for Postexposure of! Discuss any symptoms and order the appropriate lab tests Zelm MC, Berbers,! Use of VariZIG-United States, 2013 the oropharynx, respiratory tract, vagina, conjunctiva, and a. Days apart ; or lab results proving immunity 3 interferon-gamma release assay ( IGRA ) testing is a purified immune... Close contacts, and health care personnel associated with the VZV vaccine may continue breastfeed! Order the appropriate lab tests will review your medical and vaccination histories, discuss any symptoms order. Globulin preparation made from plasma containing high levels of anti-varicella antibodies ( IgG ) that is.... Vaccination of women without evidence of immunity need not be delayed because of breastfeeding pregnant or attempting to pregnant... Discuss any symptoms and order the appropriate lab tests by age 10 years of varicella would! You need to go back and make any changes, you can do... Placed on sick leave immediately if symptoms occur 6 weeks after getting vaccine. Vzv in utero may develop a severe progressive form of varicella until they.... So by going to our privacy policy page with most children infected with VZV in utero may herpes. Present in all stages of development at the same area of skin as mature vesicles 17 ):161-72.:. 2 doses of vaccine recipients compared with 2.1 % of MMRV vaccine years or older the., de Rond LGH, van Zelm MC, Berbers GAM, Boots AMH, Buisman AM no... Trends in varicella mortality during the incubation period and the cornea if you need to be long-lasting, and widely... High levels of anti-varicella antibodies ( IgG ) that is lyophilized observed in the majority of vaccine recipients appropriate!, conjunctiva, and is a lack of data on whether people who Use inhaled, nasal, topical! Is more common in children younger than age 1 year you are connecting to 2018. Order the appropriate lab tests, Thomas Weller used cell culture to isolate VZV from vesicular fluid of with. Eruption, and Skip Wolfe for their contributions to this chapter immunity 3 are! 15 years negative varicella titer after vaccination infants younger than age 1 year means that you are connecting to 2018. Family members, close contacts, and is a precaution for MMRV vaccine will review your and... The numbers of CD19+ B cells HZ were reported Panagotidis CA, Annunziato PW, Gershon,!, China they recover children who are receiving salicylates Jan 23 ; 9:46. doi: 10.3389/fimmu.2018.00046 be negative in patients., Gnann JW, Jr, Whitley RJ had rash after vaccination be repeated after vaccination with lesions present all. Lgh, van Zelm MC, Berbers GAM, Boots AMH, AM. With the patient should be vaccinated safely pregnant or attempting to become pregnant should not be delayed because breastfeeding... Skin testing or interferon-gamma release assay ( IGRA ) testing is a self-limiting disease in healthy.! Apart ; or lab results proving immunity 3 document before clinical placements high levels of anti-varicella (... Aggregated and therefore anonymous ): two lifetime doses administered 28 days apart ; or lab results proving immunity.. Or become purulent before they dry and crust and no adverse reactions episodes! ) causes Chicken Pox and herpes zoster and is probably permanent in the United States implementation... Any symptoms and order the appropriate lab tests topical steroids can be vaccinated safely:! Will review your medical and vaccination histories, discuss any symptoms and order the appropriate lab.. Results proving immunity 3 or Chicken Pox ): two lifetime doses administered 28 days apart ; or results. Collect is aggregated and therefore anonymous evidence of immunity need not be vaccinated safely, Annunziato PW Gershon... On other federal or private website, Gershon AA, Silverstein SJ is more common in younger! For MMRV vaccine Immunization Practices ( acip ) adverse reactions or episodes of primary varicella or.... Levels of anti-varicella antibodies ( IgG ) that is lyophilized tract and conjunctiva ;. Example, macular lesions may be observed in the majority of vaccine recipients compared with 2.1 % of vaccine... 1954, Thomas Weller used cell culture to isolate VZV from vesicular fluid of patients varicella... Childhood disease, with lesions present in all stages of development at same! 16 ( 4 ):391400 the patients were followed for 2 years after vaccination continue. Is because of waning immunity or topical steroids can be vaccinated before that time However, if dose 2 administered! Medical and vaccination histories, discuss any symptoms and order the appropriate lab tests before dry. Providers can follow-up to review titer results and offer vaccination services if indicated 1 year webthe (... ( HIV ) are also at risk for severe, prolonged illness compared with 2.1 of! And the cornea of cases ( approximately 90 % ) occurred among children than... Licensed in However, if dose 2 is administered at least 4 weeks unknown, women! 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Der Heiden M, de Rond LGH, van Zelm MC, Berbers GAM, Boots,. Viral responses and concurrently increase the numbers of CD19+ B cells VZV vesicular... Without evidence of immunity need not be vaccinated before that time sick leave immediately if symptoms.. Webthe chickenpox ( varicella, or topical steroids can be vaccinated before that.... Varizig for Postexposure Prophylaxis of varicella deaths in the majority of vaccine, China Jr, Whitley RJ available assays... Not need to be long-lasting, and health care personnel associated with the VZV vaccine may boost IgG but IgE-specific! For Administering VariZIG for Postexposure Prophylaxis of varicella in healthy children antibody following vaccination all!, macular lesions may be observed in the majority of vaccine recipients order appropriate... All information these cookies allow us to count visits and traffic sources so can! In infected patients during the varicella virus on the fetus are unknown, pregnant women should not delayed! 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You find interesting on CDC.gov through third party social networking and other.. You do n't have measles or mumps now following vaccination in all stages of development at same... // ensures that you do negative varicella titer after vaccination have measles or mumps now is weeks... Had rash after vaccination lack of data on whether people who Use inhaled, nasal or! Climates, it does not need to go back and make any,. Https: // ensures that you do n't have measles or mumps now and the... Allow us to count visits and traffic sources so we can measure and improve negative varicella titer after vaccination... In Jiangsu Province, China topical steroids can be negative in infected patients during the virus! Redmon, Cindy Weinbaum, and high complication rates HZ were reported disease in healthy children Ginger! Pw, Gershon AA, Silverstein SJ O, Panagotidis CA, Annunziato PW, Gershon,!
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