HPV vaccination US Medical PG Practice Questions and MCQs
Practice US Medical PG questions for HPV vaccination. These multiple choice questions (MCQs) cover important concepts and help you prepare for your exams.
HPV vaccination US Medical PG Question 1: A vaccination campaign designed to increase the uptake of HPV vaccine was instituted in chosen counties of a certain state in order to educate parents not only about the disease itself, but also about why children should be vaccinated against this viral sexually transmitted disease. At the end of the campaign, children living in counties in which it was conducted were 3 times more likely to receive the HPV vaccine compared with children living in counties where no campaign was instituted. As well, after evaluating only the counties that were part of the vaccination campaign, the researchers found that families with higher incomes were 2 times more likely to vaccinate their children against HPV compared with families with lower incomes. What conclusion can be drawn from these results?
- A. Family income appears to be an effect modifier. (Correct Answer)
- B. The vaccination campaign appears to have been ineffective.
- C. The vaccination campaign is the study outcome.
- D. The vaccine uptake is the study exposure.
- E. Family income appears to be a confounder.
HPV vaccination Explanation: ***Family income appears to be an effect modifier.***
- An **effect modifier** occurs when the relationship between an exposure (vaccination campaign) and an outcome (vaccine uptake) differs across categories of a third variable (family income).
- Here, the campaign's effect on vaccine uptake is *different* depending on family income (higher-income families were still more likely to vaccinate even within campaign counties), indicating **effect modification**.
*The vaccination campaign appears to have been ineffective.*
- The campaign actually led to a **3-fold increase** in HPV vaccine uptake in campaign counties compared to non-campaign counties, demonstrating its effectiveness in increasing overall uptake.
- While income still played a role, the campaign itself achieved its primary goal of increasing vaccination rates where implemented.
*The vaccination campaign is the study outcome.*
- The **vaccination campaign** is the **exposure** or intervention being studied, as its impact on vaccination rates is being assessed.
- The **outcome** is the **HPV vaccine uptake** (i.e., whether children received the vaccine or not).
*The vaccine uptake is the study exposure.*
- **Vaccine uptake** is the **outcome** or the dependent variable that is being measured, to see if it changes in response to the campaign.
- The **exposure** is the **vaccination campaign** itself, or living in a county with a campaign.
*Family income appears to be a confounder.*
- A **confounder** is a variable that is associated with both the exposure and the outcome, and *distorts* the observed association between them.
- While family income is associated with vaccine uptake, its main role here is to show *how* the campaign's effect varied by income, not necessarily to create a spurious association between the campaign and uptake where none existed. If it were a confounder, it would need to be associated with both the campaign (which it isn't, as campaigns were in specific counties regardless of income distribution) and the outcome, and not be on the causal pathway.
HPV vaccination US Medical PG Question 2: An 18-year-old woman presents for a routine check-up. She is a college student with no complaints. She has a 2 pack-year history of smoking and consumes alcohol occasionally. Her sexual debut was at 15 years of age and has had 2 sexual partners. She takes oral contraceptives and uses barrier contraception. Her family history is significant for cervical cancer in her aunt. Which of the following statements regarding cervical cancer screening in this patient is correct?
- A. The patient requires annual Pap testing due to her family history of cervical cancer.
- B. HPV testing is more preferable than Pap testing in sexually active women under 21 years of age.
- C. It is reasonable to start Pap-test screening at the current visit and repeat it every 3 years.
- D. The patient should undergo screening every 3 years after she turns 21 years of age. (Correct Answer)
- E. The patient does not require Pap testing as long as she uses barrier contraception.
HPV vaccination Explanation: **The patient should undergo screening every 3 years after she turns 21 years of age.**
- Current guidelines recommend initiating cervical cancer screening at **age 21**, regardless of sexual activity.
- The recommended interval for cytology-only screening is **every 3 years** for women aged 21-29.
*The patient requires annual Pap testing due to her family history of cervical cancer.*
- **Family history of cervical cancer** is generally not considered a reason for earlier or more frequent screening in individuals under 21 years of age, unless specific genetic syndromes are suspected, which is not mentioned here.
- The primary risk factor for cervical cancer is **HPV infection**, not direct family history.
*HPV testing is more preferable than Pap testing in sexually active women under 21 years of age.*
- **HPV testing** as a primary screening method is **not recommended for women younger than 25** due to the high prevalence of transient HPV infections that resolve spontaneously in this age group.
- Over-screening and subsequent interventions could lead to unnecessary anxiety and procedures for conditions that would likely resolve on their own.
*It is reasonable to start Pap-test screening at the current visit and repeat it every 3 years.*
- Starting screening at the current age of **18 years is not recommended** according to current guidelines, as screening typically begins at age 21.
- Early screening in this age group often leads to the detection of **transient HPV infections** that would otherwise resolve without intervention, causing undue stress and follow-up.
*The patient does not require Pap testing as long as she uses barrier contraception.*
- While **barrier contraception** (condoms) reduces the risk of HPV transmission, it does not eliminate it entirely and therefore **does not negate the need for cervical cancer screening.**
- Regular screening is still recommended to detect any persistent HPV infections and associated cervical changes early.
HPV vaccination US Medical PG Question 3: A 12-year-old girl presents to her primary care physician for a well-child visit. She has a history of asthma and uses her inhaler 1-2 times per week when she exercises. She does not smoke and is not currently sexually active; however, she does have a boyfriend. She lives with her mother in an apartment and is doing well in school. Her temperature is 97.6°F (36.4°C), blood pressure is 124/75 mmHg, pulse is 80/min, respirations are 12/min, and oxygen saturation is 98% on room air. Physical exam is notable for a healthy young girl with no findings. Which of the following is most appropriate for this patient at this time?
- A. Pelvic examination
- B. Serum lipids and cholesterol
- C. HPV vaccine (Correct Answer)
- D. Hypertension screening
- E. Human papilloma virus PCR
HPV vaccination Explanation: ***HPV vaccine***
- The **HPV vaccine** is recommended for all adolescents, typically starting at **age 11 or 12**, to prevent HPV-related cancers and genital warts.
- While she may not be currently sexually active, the vaccine is most effective when administered **before exposure** to the virus.
*Pelvic examination*
- A **pelvic examination** is not routinely recommended for a 12-year-old girl during a well-child visit unless there are specific symptoms or concerns.
- The patient has no complaints indicating the need for such an invasive procedure.
*Serum lipids and cholesterol*
- **Lipid screening** is typically recommended for adolescents with risk factors like a family history of early cardiovascular disease or dyslipidemia, or for all adolescents sometime between ages 9 and 11 and again between 17 and 21.
- This patient does not present with any specific risk factors that would warrant immediate screening at this age, and it is not the most appropriate *initial* intervention.
*Hypertension screening*
- **Blood pressure** is already routinely measured at well-child visits, as indicated by the patient's vitals (124/75 mmHg). This is part of the standard physical exam, not a separate intervention to be chosen.
- While her blood pressure is at the higher end for her age, further evaluation would come after initial screening, which has already occurred.
*Human papilloma virus PCR*
- **HPV PCR testing** is used for screening for cervical cancer in adults (typically women age 25 and older) or for diagnostic evaluation of HPV-related lesions.
- This test is not indicated for routine screening in a 12-year-old girl, as it does not prevent HPV and is not a part of adolescent preventive care.
HPV vaccination US Medical PG Question 4: A 16-year-old girl comes to her primary care physician for an annual check-up. She has no specific complaints. Her medical history is significant for asthma. She uses an albuterol inhaler as needed. She has no notable surgical history. Her mom had breast cancer and her grandfather died of colon cancer. She received all her childhood scheduled vaccinations up to age 8. She reports that she is doing well in school but hates math. She is sexually active with her boyfriend. They use condoms consistently, and they both tested negative recently for gonorrhea, chlamydia, syphilis and human immunodeficiency virus. She asks about birth control. In addition to educating the patient on her options for contraception, which of the following is the best next step in management?
- A. Cytology and human papilloma virus (HPV) testing now and then every 3 years
- B. No HPV-related screening as the patient is low risk
- C. No HPV-related screening and administer HPV vaccine (Correct Answer)
- D. Cytology and HPV testing now and then every 5 years
- E. Cytology now and then every 3 years
HPV vaccination Explanation: ***No HPV-related screening and administer HPV vaccine***
- Current guidelines from organizations like the **American College of Obstetricians and Gynecologists (ACOG)** recommend **HPV vaccination** for individuals aged 9 to 26 years, regardless of sexual activity.
- **Cervical cancer screening (Pap smears and HPV testing)** is not recommended for individuals under 21 years old, as HPV infections in this age group are highly likely to clear spontaneously.
*Cytology and human papilloma virus (HPV) testing now and then every 3 years*
- **Cervical cancer screening** with cytology and HPV testing is not recommended for individuals under **21 years old**, even if sexually active.
- Initiating screening now at age 16 would be **over-screening** and could lead to unnecessary procedures and anxiety given the high rate of spontaneous HPV clearance in adolescents.
*No HPV-related screening as the patient is low risk*
- While the patient is not yet indicated for cervical cancer screening, stating "no HPV-related screening as the patient is low risk" is incomplete. The patient is sexually active, putting her at risk for future HPV infection.
- The most appropriate action is to **offer the HPV vaccine** to prevent future infections, regardless of current screening guidelines.
*Cytology and HPV testing now and then every 5 years*
- This screening frequency (every 5 years) for co-testing is typically recommended for women **over 30 years old** with negative results, not for a 16-year-old.
- As with other screening options, initiating any cervical cancer screening at this age is **not recommended** by current guidelines.
*Cytology now and then every 3 years*
- This option refers to **cytology-only screening**, which is recommended every 3 years for individuals aged 21-29.
- Again, initiating any form of cervical cancer screening at **age 16 is not appropriate** according to current guidelines.
HPV vaccination US Medical PG Question 5: A 2-year-old boy presents to the pediatrician for evaluation of an elevated temperature, sore throat, runny nose, and lacrimation for the past week, and a rash which he developed yesterday. The rash began on the patient’s face and spread down to the trunk, hands, and feet. The patient’s mother gave him ibuprofen to control the fever. The child has not received mumps, measles, and rubella vaccinations because he was ill when the vaccine was scheduled and was later lost to follow-up. The vital signs include blood pressure 90/50 mm Hg, heart rate 110/min, respiratory rate 22/min, and temperature 37.8°C (100.0℉). On physical examination, the child was drowsy. His face, trunk, and extremities were covered with a maculopapular erythematous rash. Two irregularly-shaped red dots were also noted on the mucosa of the lower lip. The remainder of the physical examination was within normal limits. What is the probable causative agent for this child’s condition?
- A. Group A Streptococcus
- B. Rubulavirus
- C. Influenzavirus
- D. Morbillivirus (Correct Answer)
- E. Herpesvirus
HPV vaccination Explanation: ***Morbillivirus***
- The constellation of symptoms—**elevated temperature**, **sore throat**, **runny nose**, **lacrimation**, a **maculopapular erythematous rash** that began on the face and spread downward, and especially the **irregularly-shaped red dots on the mucosa of the lower lip** (likely **Koplik spots**)—are classic for **measles**, caused by Morbillivirus.
- The patient's **unvaccinated status** against MMR further supports measles as the most probable diagnosis, as it is a highly contagious disease prevented by vaccination.
*Group A Streptococcus*
- This bacterium causes **scarlet fever**, characterized by a **sandpaper-like rash** and **strawberry tongue**, not a maculopapular rash spreading from face to extremities with Koplik spots.
- While it can cause pharyngitis and fever, the specific rash progression and oral lesions rule out Group A Streptococcus.
*Rubulavirus*
- Rubulavirus causes **mumps**, which primarily presents with **parotitis** (swelling of parotid glands), fever, and headache.
- It does not typically cause a generalized maculopapular rash or Koplik spots, making it an unlikely cause for the described symptoms.
*Influenzavirus*
- Influenzavirus causes **influenza**, characterized by sudden onset of high fever, cough, myalgia, and headache.
- While it can cause fever and respiratory symptoms, it does not typically present with a widespread maculopapular rash or Koplik spots.
*Herpesvirus*
- Herpesviruses cause a variety of conditions, including **chickenpox** (Varicella-zoster virus), which presents with **vesicular lesions** that crust over, and **roseola infantum** (HHV-6/7), which primarily causes a high fever followed by a non-pruritic rash appearing *after* the fever subsides.
- Neither of these typically presents with Koplik spots or the specific maculopapular rash progression described.
HPV vaccination US Medical PG Question 6: Two viruses, X and Y, infect the same cell and begin to reproduce within the cell. As a result of the co-infection, some viruses are produced where the genome of Y is surrounded by the nucleocapsid of X and vice versa with the genome of X and nucleocapsid of Y. When the virus containing genome X surrounded by the nucleocapsid of Y infects another cell, what is the most likely outcome?
- A. Virions containing genome Y and nucleocapsid Y will be produced
- B. No virions will be produced
- C. Virions containing genome X and nucleocapsid Y will be produced
- D. Virions containing genome Y and nucleocapsid X will be produced
- E. Virions containing genome X and nucleocapsid X will be produced (Correct Answer)
HPV vaccination Explanation: ***Virions containing genome X and nucleocapsid X will be produced***
- The virus containing **genome X** surrounded by **nucleocapsid Y** is a pseudotype. During the infection of a new cell, the **genome X** will direct the synthesis of new viral components, including **nucleocapsid X**.
- Since the genetic material (genome X) dictates the production of viral proteins, the new virions will be genetically identical to virus X, thus containing its own genome and nucleocapsid.
*Virions containing genome Y and nucleocapsid Y will be produced*
- This is incorrect because the infecting particle carried **genome X**, not genome Y.
- The genetic information encoded in the genome determines the type of progeny viruses produced.
*No virions will be produced*
- This is unlikely as the pseudotyped virus is capable of infection and delivery of a functional genome into the host cell.
- The cell is presumed to be permissive for virus replication.
*Virions containing genome X and nucleocapsid Y will be produced*
- This would only happen if the **nucleocapsid Y** was somehow replicated independently of its original genome, which is not how viral replication works.
- The progeny nucleocapsids are always encoded by the genome that is replicating within the cell.
*Virions containing genome Y and nucleocapsid X will be produced*
- This is incorrect. The infecting virus introduced **genome X** into the cell, not genome Y.
- The genetic material delivered determines the type of viral particles that will be synthesized.
HPV vaccination US Medical PG Question 7: A 32-year-old pregnant woman at 32 weeks gestation presents with a 2-day history of low-grade fever, headache, and myalgias. She works at a daycare where several children recently had 'slapped cheek' rash. Laboratory studies show hemoglobin 8.5 g/dL (baseline 12 g/dL), reticulocyte count 0.1%, and positive parvovirus B19 IgM. Fetal ultrasound shows hydrops fetalis with ascites, pleural effusions, and severe anemia on cordocentesis. Evaluate the pathophysiologic mechanism and management approach that best addresses both maternal and fetal complications.
- A. Vertical transmission causing fetal aplastic crisis; intrauterine transfusion with close monitoring (Correct Answer)
- B. Fetal cardiac failure from myocarditis; deliver immediately for neonatal intensive care
- C. Placental insufficiency from maternal viremia; administer antivirals and corticosteroids
- D. Maternal immune thrombocytopenia causing fetal bleeding; administer IVIG to mother
- E. Maternal-fetal ABO incompatibility exacerbated by viral infection; plasmapheresis
HPV vaccination Explanation: ***Vertical transmission causing fetal aplastic crisis; intrauterine transfusion with close monitoring***
- **Parvovirus B19** targets **erythroid progenitor cells** by binding to the **P antigen**, causing a temporary halt in RBC production known as **aplastic crisis**.
- In the fetus, this leads to **high-output heart failure** and **hydrops fetalis** (ascites, effusions); **intrauterine transfusion** is the definitive treatment to manage severe fetal anemia.
*Fetal cardiac failure from myocarditis; deliver immediately for neonatal intensive care*
- While Parvovirus can cause some direct **myocarditis**, the primary driver of hydrops is **anemia-induced failure**, not primary cardiac muscle death.
- Immediate delivery at 32 weeks carries risks of **prematurity**; treating the anemia **in utero** via transfusion usually allows the pregnancy to continue to a safer gestational age.
*Placental insufficiency from maternal viremia; administer antivirals and corticosteroids*
- The primary pathology is a direct viral attack on **fetal bone marrow**, not a failure of blood flow through the **placenta**.
- There are no specific **antiviral medications** proven effective against Parvovirus B19; management is strictly **supportive care** through transfusion.
*Maternal immune thrombocytopenia causing fetal bleeding; administer IVIG to mother*
- The presentation clearly shows **anemia** and **reticulocytopenia** (low RBC precursors), not a decrease in **platelets** (thrombocytopenia).
- While **IVIG** is used for chronic B19 infections in immunocompromised patients, it does not treat the acute **fetal hydrops** already visible on ultrasound.
*Maternal-fetal ABO incompatibility exacerbated by viral infection; plasmapheresis*
- Hydrops fetalis in this context is **nonimmune**, caused by viral destruction of RBCs, rather than **immune-mediated hemolysis** from ABO/Rh mismatch.
- **Plasmapheresis** is not indicated for Parvovirus B19 infection; it does nothing to restore the destroyed **erythroid progenitors** in the fetus.
HPV vaccination US Medical PG Question 8: A public health official must design a vaccination strategy for a refugee camp with 10,000 children under 5 years old. Resources allow for only one vaccine initially. Current diseases in the camp include measles (15 cases/week), diphtheria (5 cases/week), pertussis (20 cases/week), and rotavirus diarrhea (100 cases/week). Three children have died from measles, two from pertussis, and ten from dehydration due to diarrhea. Evaluate which vaccine should be prioritized and justify the decision.
- A. MMR vaccine because measles has the highest case fatality rate and transmission potential (Correct Answer)
- B. DTaP vaccine because pertussis has the highest incidence
- C. Oral rehydration therapy instead of vaccination to address immediate mortality
- D. Rotavirus vaccine because diarrhea has caused the most deaths
- E. Pneumococcal vaccine because it prevents the leading cause of childhood mortality globally
HPV vaccination Explanation: ***MMR vaccine because measles has the highest case fatality rate and transmission potential***
- In this scenario, **Measles** has the highest **Case Fatality Rate (CFR)** at 20% (3 deaths/15 cases), compared to pertussis (10%) and rotavirus (10%).
- Measles is prioritized in refugee settings due to its extreme **transmissibility (R0 of 12-18)** and its ability to cause **secondary immunosuppression**, which leads to further mortality from other infections.
*DTaP vaccine because pertussis has the highest incidence*
- While **pertussis** has a higher weekly incidence (20 cases/week), its **mortality rate** in this cohort is lower than that of measles.
- Public health prioritization in crisis settings focuses on **epidemic potential** and virulence; measles poses a greater risk for explosive, high-mortality outbreaks.
*Oral rehydration therapy instead of vaccination to address immediate mortality*
- **Oral Rehydration Therapy (ORT)** is a treatment modality for symptoms, not a **preventative vaccination strategy** as requested by the prompt.
- While ORT is critical for managing active diarrhea cases, it does not stop the transmission of **rotavirus** or provide the long-term community protection that a vaccine does.
*Rotavirus vaccine because diarrhea has caused the most deaths*
- Although **rotavirus** caused the highest absolute number of deaths (10), its **case fatality rate** (10/100 = 10%) is significantly lower than that of measles.
- Vaccination for measles is prioritized because it is a more effective single-dose intervention for preventing **explosive outbreaks** in overcrowded refugee conditions.
*Pneumococcal vaccine because it prevents the leading cause of childhood mortality globally*
- While the **Pneumococcal vaccine** addresses significant global mortality, it is not targeted toward the **active infectious outbreaks** (measles, pertussis, rotavirus) currently occurring in the camp.
- Resource allocation in an emergency must address the **current epidemiological profile** and immediate threats rather than general global health statistics.
HPV vaccination US Medical PG Question 9: A hospital infection control committee reviews a cluster of 5 cases of invasive pneumococcal disease over 6 months, all caused by serotype 19A, in vaccinated children aged 3-5 years who received all recommended doses of PCV13. All isolates show resistance to penicillin and macrolides. The committee must evaluate the outbreak and recommend interventions. Which factor most likely explains this outbreak despite appropriate vaccination?
- A. Serotype replacement with non-vaccine serotypes after PCV7 was replaced by PCV13
- B. Evolution of antibiotic resistance in serotype 19A reducing vaccine effectiveness
- C. Inadequate immune response in children with undiagnosed primary immunodeficiency
- D. Vaccine storage failure leading to loss of immunogenicity
- E. Serotype 19A strain with capsular switching evading vaccine-induced immunity (Correct Answer)
HPV vaccination Explanation: ***Serotype 19A strain with capsular switching evading vaccine-induced immunity***
- **Capsular switching** occurs when *Streptococcus pneumoniae* undergoes **horizontal gene transfer**, allowing a strain to express a capsule (like 19A) that may have slight antigenic variations or different genetic backgrounds from the vaccine strain.
- This evolutionary mechanism allows the bacteria to evade **vaccine-induced immunity** provided by **PCV13**, even though 19A is a covered serotype, leading to breakthrough invasive disease.
*Serotype replacement with non-vaccine serotypes after PCV7 was replaced by PCV13*
- **Serotype replacement** refers to an increase in disease caused by serotypes **not included** in the vaccine, whereas 19A is specifically included in PCV13.
- This phenomenon explained the rise of 19A after PCV7 usage, but it does not explain why 19A specifically is causing an outbreak in **PCV13-vaccinated** children.
*Evolution of antibiotic resistance in serotype 19A reducing vaccine effectiveness*
- **Antibiotic resistance** (to penicillin and macrolides) is a common feature of serotype 19A but does not directly impact **vaccine effectiveness**.
- The vaccine targets the **polysaccharide capsule**, and the immune response is independent of the bacterial mechanisms used to resist antibiotics.
*Inadequate immune response in children with undiagnosed primary immunodeficiency*
- While **immunodeficiency** can lead to vaccine failure, it is highly unlikely that a cluster of five unrelated children would all have the same undiagnosed condition.
- An outbreak or **cluster** suggests a factor related to the pathogen's evolution or the vaccine's delivery rather than host-specific immune defects.
*Vaccine storage failure leading to loss of immunogenicity*
- **Cold chain failure** or storage issues could lead to loss of potency, but this usually results in a broader lack of protection against many serotypes, not just 19A.
- Capsular switching is a more scientifically documented reason for **specific serotype breakthrough** in controlled clinical populations receiving the same vaccine profile.
HPV vaccination US Medical PG Question 10: A 65-year-old man with diabetes mellitus and chronic kidney disease presents with sudden onset right-sided facial weakness, inability to close his right eye, and loss of taste on the anterior two-thirds of his tongue. He has vesicular lesions in his right external auditory canal. He received varicella vaccine 20 years ago and had shingles on his trunk 5 years ago. Analyze the relationship between his current presentation and his varicella vaccination history.
- A. His previous shingles and current presentation both resulted from reactivation of wild-type VZV acquired before vaccination (Correct Answer)
- B. The varicella vaccine virus has reactivated to cause this condition
- C. This is a bacterial infection unrelated to varicella-zoster virus
- D. The current infection represents primary varicella despite previous vaccination
- E. Simultaneous reactivation of vaccine and wild-type VZV strains
HPV vaccination Explanation: ***His previous shingles and current presentation both resulted from reactivation of wild-type VZV acquired before vaccination***
- The patient presents with **Ramsay Hunt syndrome** (herpes zoster oticus), characterized by facial nerve palsy, ear canal vesicles, and taste loss, caused by **VZV reactivation** in the **geniculate ganglion**.
- Given his age, he likely contracted **wild-type VZV** (chickenpox) in childhood before the vaccine was available in 1995; subsequent adult vaccination does not eliminate already latent wild-type virus.
*The varicella vaccine virus has reactivated to cause this condition*
- While the **Oka strain** (live-attenuated vaccine) can establish latency, it is significantly less virulent and less likely to reactivate compared to the **wild-type strain**.
- Reactivation of vaccine-strain VZV is extremely rare in immunocompetent or even partially immunocompromised adults who had prior natural chickenpox.
*This is a bacterial infection unrelated to varicella-zoster virus*
- The combination of **vesicular lesions** and cranial nerve involvement is pathognomonic for a viral etiology, specifically a **herpetic infection**.
- Bacterial conditions like **otitis externa** or **malignant otitis externa** would present with different findings such as severe ear canal edema or bone destruction rather than specific taste loss and zoster-like vesicles.
*The current infection represents primary varicella despite previous vaccination*
- Primary varicella (chickenpox) presents as a **diffuse pruritic rash** in varying stages of development, not a localized dermatomal or cranial nerve distribution.
- The patient's history of prior shingles confirms he already had a latent **VZV infection**, making a "primary" infection (first exposure) impossible.
*Simultaneous reactivation of vaccine and wild-type VZV strains*
- There is no clinical evidence or common pathophysiological mechanism to support the **simultaneous reactivation** of two different VZV strains.
- The **wild-type virus** is the dominant latent pathogen that typically reactivates during periods of **immunocompromise** (like CKD and diabetes), suppressing any potential activity from the weaker vaccine strain.
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