“…This failure to provide adequate protection is observed despite the development of high titers of circulating antibodies and may be mostly due to an inadequate stimulation of local immunity (53). In addition, parenteral administration of large numbers of killed organisms frequently results in adverse reactions such as local discomfort, redness, swelling, fever, headache, myalgia, and general malaise (1,21,73,145). More severe systemic manifestations such as anaphylactic shock, acute renal disease, appendicitis, and erythema nodosum, although rare, have also been observed (13,75,80,101).…”