Vaccines are designed to elicit an immune response against the particular microbe or bits of the microbe from which the vaccine is made. This idea dates back several centuries, when British surgeon, Edward Jenner developed the first vaccine against a lethal infectious disease, small pox. Between the 18th century and now, more than 65 products have been approved which, together with public health and other developments, have contributed to the tapering and, in some cases, eradication of infectious diseases that used to kill millions. The problem is that the design is based on the physical attributes of the microbe. So, one person might be infected with virus x, which mutates rapidly to become 10 or more different strains. So, between approval and reaching the public, effectiveness may drop or wane over time. The sheer logistics of designing a trial means that follow-up periods are not long enough to account for every possible safety issue. Nevertheless, they remain our go-to defense for lethal infections, such as Ebola, and ones that reduce productivity. In other cases, timely inoculations may protect against the risk of developing specific cancers later in life. They have also contributed to the fact that most people are not at home sick with polio or some of the other ancient plagues. However, anti-infective vaccines are typically given to healthy children and people on the basis that it will not make them sick or that it will reduce the risk of premature death. Because vaccines need to be preserved, properly stored and kept free of other contamination before it reaches many distribution sites, other ingredients are added to the mix. And some people, especially those with weakened immune systems, may have severe/life-threatening allergies to additives or a contaminated batch. So, one in a million complications/deaths is one in a million too many. To this end, I have compiled a summary culled from various sources, to foster a positive dialogue towards improvements.

1. The Vaccine Debate
Pros and Cons

2. Selected Vaccine
Milestones
0
10
20
30
40
50
60
70
1795 1880 1920 1952 1955 1987 2002 2003 2010
CumulativeTotalofLicensed/
ClinicalProducts
Years
Smallpox
Koch’s
postulates
Anti-
toxins Tissue
Culture
Bio-
technology
Novel delivery
Strategies
Adjuvants/
Gene delivery
> 65 Licensed
Products
Nabel GJ. NEJM. 2013;368(6):551-560.

3. General Vaccine Formulations
Active Ingredients
• Whole or ‘bits’ of
bacteria/viruses
• A few μg per vaccine
Added Ingredients
• Aluminum
• Thimerosal
• Gelatin
• Human serum/recombinant
albumin
• Sorbitol/Other emulsifiers
• Taste improvers
Products for Manufacture
• Antibiotics
• Egg proteins (ovalbumin)
• Yeast proteins
• Latex (in packaging)
• Formaldehyde
• Acidity regulators
• Human cell-lines, animal cell-
lines and GMOs
• Recombinant DNA technology
• Bovine products
• Other growing media
Abbreviations: GMO, Genetically modified organism
University of Oxford. Vaccine Knowledge Project. 2017; http://vk.ovg.ox.ac.uk/vaccine-ingredients

4. Types of Routinely
Administered Vaccines
• Attenuated (weakened) live viruses
– eg, chickenpox, rotavirus, measles, mumps and rubella
• Inactivated (killed) viruses
– eg, polio and Hepatitis A
• Subunits
– eg, influenza (“flu”) virus
• Toxoids
– eg, tetanus and diptheria (HPV)
• Recombinant
– eg, human papilloma virus
• Polysaccharide-protein conjugates
– eg, Haemophilus influenzae type b
US Food and Drug Administration. Vaccines for Children - A Guide for Parents and Caregivers. 2017; https://www.fda.gov/biologicsbloodvaccines/resourcesforyou/consumers/ucm345587.htm#vaccines
h
This Photo by Unknown Author is licensed under CC BY

5. Pros and Cons of Different Types of Vaccines
Attenuated (live)a Weakened forms of the virus are the closest thing to a natural infection
and often elicit lasting immune responses
Not everyone can receive this vaccine and there is always the remote
possibility of reversion of the weakened strain
Inactivea In addition to being more stable and safer than live vaccines, products can
be easily be transported in freeze-dried form
Elicit a weaker immune response and may require several booster shots to
maintain immunity
Subunitsa Contains only essential antigens, thereby lowering risk of adverse
reactions to vaccine
Tricky and time-consuming process to develop the “right” combination of
subunits
Toxoidsa Inactivating toxins secreted by bacteria with chemicals/heat and teaching
the immune system to respond to these toxoids may prevent infection
with specific pathogens
Recombinant
Vector and DNA
A DNA vaccine against a microbe would evoke a strong antibody response
to free-floating antigen secreted by cells, and the vaccine also would
stimulate a strong cellular response against the microbial antigens
displayed on cell surfaces. Recombinant vector vaccines consist of DNA
and an attenuated virus or vector to introduce the material into cells.
Products closely mimic a natural infection and therefore do a good job of
stimulating the immune system.a.
There is the slight risk of disrupting normal cellular processes. Moreover,
DNA vaccines may be restricted to pathogens with a distinctive protein
immunogen.b
Polysaccharide-
proteinc
Polysaccharide constituents of certain bacteria may help them hide from
the immune system. Because polysaccharides are poorly immunogenic,
linking a toxoid or microbe antigen to form a conjugate, can vastly
improve the immune response to bacteria with distinctive polysaccharide
coats; can usually be safely used among vulnerable groups
a. National Institutes of Health. National Institute of Allergy and Infectious Diseases. Vaccine Types. 2012; https://www.niaid.nih.gov/research/vaccine-types
b. UK Health Centre. Advantages & Disadvantages of DNA Vaccines. 2016; http://www.healthcentre.org.uk/vaccine/advantages-disadvantages-dna-vaccines.html.;
c. UK Health Centre. Are conjugate vaccines safe? 2016; http://www.healthcentre.org.uk/vaccine/are-conjugate-vaccines-safe.html
.

6. Vaccine Stability & Herd Immunity
• Liquid vaccines must be kept at
2–8 oCa
• Herd Immunityb
a. Kanojia G, Have Rt, Soema PC, et al. Human Vaccines & Immunotherapeutics. 2017;13(10):2364-2378.
b. University of Oxford. Vaccine Knowledge Project. 2017; http://vk.ovg.ox.ac.uk/herd-immunity
.
~ Half of all vaccines lost due
to cold chain disruption
Stability could be optimized
with additives/use of freeze-
or spray-dried vaccines
If most people in a
community are
immunized against a
contagion, it may
confer protection to
vulnerable members
of the community.
Herd immunity does NOT protect against all
vaccine-preventable diseases eg, no matter how
many people around you are immunized, you can
still get tetanus from the environmental
pathogen.

7. Duration of Protection
• Duration of Immunity • Criteria (Vaccinated vs.
unvaccinated)
– Immunogenicity = Measure of
antibodies to a specific vaccine
– Effectiveness = How well the
vaccine works in the general
population
– Efficacy = Measured within
controlled clinical trials (ie, less
people)
a. The Immunisation Advisory Centre (New Zealand). 2017; http://www.immune.org.nz/vaccines/efficiency-effectiveness
No vaccine is 100% effective. Some people are not protected, in some cases due to immune suppression (maintaining
immunity in people around them may help these individuals), and, depending on various factors, the efficacy of any given
vaccine may wane over time.a
Duration of
immunity varies
with different
diseases and
different
vaccines.
Data for many new
approved vaccines
continue to be
updated.
•Sub unit vaccines
frequently require
primary courses
and boosters
•Polysaccharide
vaccines do not
generate long-lived
memory cells
•If the interval
between doses is
too short the
duration of
immunity can be
affected
•Immunity may be
limited in some
very young and
very old people
•Live vaccines
generally induce
longer lived
immunity than sub
unit vaccines

8. Safety Issues
This Photo by Unknown Author is licensed
under CC BY-SA
More
Common:
1: 100 Doses
Less
Common:
1: 100 to 1 in
100,000
Doses
Rare:
1: 100 to 1
in a million
Doses
Inconclusive:
Not enough data
Kwok R. Nature. 2011;473(7348):436-438.

9. Adverse Events
Following
Immunization
Responses may be due
the product, quality
defect/error.
Individuals may exhibit
physical symptoms of
anxiety eg, nausea or
fainting in anticipation
of a shot.
Adults and children
may exhibit congenital
or developmental
disorders that develop
throughout life and it is
inevitable that some of
these events will occur
after immunization.
The Immunisation Advisory Centre (New Zealand). Adverse events following immunisation. 2017; http://www.immune.org.nz/vaccines/vaccine-safety/adverse-events-following-
immunisation-aefi

10. Thimerosal (used to
prevent contamination
of multi-dose vials) in
Vaccines
Unlike methylmercury, thimerosal is broken
down to ethylmercury and thiosalicylate and
readily eliminated by the body; Nevertheless,
in July 1999, the Public Health Service
agencies, the American Academy of Pediatrics,
and vaccine manufacturers agreed that
thimerosal should be reduced or eliminated in
vaccines as a precautionary measure.
US Centers for Disease Control and Prevention. 2015;
https://www.cdc.gov/vaccinesafety/concerns/thimerosal/index.html

11. Vaccines and
Autism Spectrum
Disorder (ASD)
• ~1 in 68 children identified with ASD
ie, a condition that affects how the
brain functionsa
– Boys are about 4.5x likely to be
diagnosed with ASD than girlsa
– Numerous studies have shown
no link between thimerosal-
containing vaccines or other
ingredients and ASDb
• In an effort to move forward
initiatives, the CDC’s Autism and
Developmental Disabilities
Monitoring (ADDM) Network tracks
and characterizes children with the
conditiona
a. US Centers for Disease Control and Prevention. Autism and Developmental Disabilities Monitoring
(ADDM) Network. 2017; https://www.cdc.gov/ncbddd/autism/addm.html; b. US Centers for Disease Control
and Prevention. 2017; https://www.cdc.gov/vaccinesafety/concerns/autism.html

12. National Programs for Adverse Effects &
Injuries
• Reporting System • Compensation

13. Why Education is Needed to
Make Informed Choices
Some of the reasons for vaccine hesitancy or refusal

14. Concerns
McKee C, Bohannon K. JPPT. 2016;21(2):104-109.
Religion
Personal or
philosophical
Safety
Need more
information from
healthcare providers

15. Politics of Vaccines
• Smallpox eradication by vaccination envisioned as
early as 1802, but only realized in 1966
– However, mass vaccine campaigns have also inspired
non-compliance and backlash
– Public health ethics suggest that, once trust in the
state is lost, these programs will be reframed as
“assaults on human rights.”
• One-size-fits all immunization programs do not
always translate to locally defined health needs of
each country
– Sovereign versus privatized vaccine production against
country-specific pathogens is also an issue
Greenough P, Blume S, Holmberg C. Introduction. In: The Politics of Vaccination. Manchester University Press; 2017:1-16.
BUT
Infant Mortality
Serves as
Bellweather
Of Societal
Affluence

16. Federal Immunization Courses
• You Call The Shots • Training Modules

17. Routine & Non-Routine
Vaccines
Routine vaccinations are recommended in the United States to maintain the health of children and
adults, while travel vaccinations are suggested for infectious illnesses that are rare in this country, but
more prevalent in foreign countries.

18. Measles, Mumps, and Rubella
Vaccine

19. Measles, Mumps, and Rubella Vaccine
Why get the
vaccine?a
• Three common
childhood diseases
associated with
serious complications
and/or death
– Caused by measles,
paramyxo- (mumps), and
toga viruses (rubella),
respectively
• >99%incidence of
these illnesses since
vaccine introduction
Indicationsb
• Children (0 to 6 years
old)/Adults
– Unless contra-indicated
– Unless documentary evidence
provided of prior
immunization
• Second dose may be
recommended for
high-risks persons eg,
healthcare workers
Who should not get
the vaccinea
• People with allergies
to vaccine ingredients
• People with a
weakened immune
system
• People taking high
doses of steroids by
mouth
• Have a fever
• Are pregnant or plan
to get pregnant within
the next 3 months
a. US Food and Drug Administration. Measles, Mumps and Rubella Virus Vaccine, Live. 2017; https://www.fda.gov/biologicsbloodvaccines/vaccines/approvedproducts/ucm094050.htm
b. Surkis WD. Merck Manual (Professional Version). Measles, Mumps and Rubella Vaccine. 2014; http://www.merckmanuals.com/professional/infectious-diseases/immunization/measles,-mumps,-and-
rubella-vaccine.

20. Hepatitis Vaccines (A, B, and E)

21. Hepatitis A
Why get the vaccine?
• Serious liver disease
• Intense symptoms may
affect ability to work
• Although symptoms are
temporary, liver failure
and death have occurred
in rare cases
– Usually in persons over 50 or with
other chronic liver diseases
Indications
•Two-shot vaccine routinely
given to children
•Adults
– Traveling to countries where
hepatitis A is common,
– Men who have sex with men
– Who use illegal drugs,
– Who have chronic liver diseases
such as hepatitis B or hepatitis C,
– Who are being treated with
clotting-factor concentrates,
– Work with hepatitis A-infected
animals or in a hepatitis A research
laboratory, or
– Expect to have close personal
contact with an international
adoptee from a country where
hepatitis A is common
Which groups do not need routine
shots?
• Food service workers
• Sewage workers
• Healthcare workers
• Children <12 months of
age
• Child care center staff
US Centers for Disease Control and Prevention. Hepatitis A Vaccine Information Sheet. 2017; https://www.cdc.gov/vaccines/hcp/vis/vis-statements/hep-a.html.
Disease
> 95% since
vaccine
introduced
in USA

22. Hepatitis B
Why get the vaccine?a
• Liver disease can be acute
or chronic
– Even chronically infected,
asymptomatic persons can spread
infection to others
• Chronic infections may
lead to:
– Cirrhosis
– Liver cancer
– Death
• About 1 out of 4 infected
infants may die of the
disease
Indicationsb
• People who want but have
not previously been given a
shot
•Sexually active people with
eg, > 1 partner in prior 6
months
•Need for STD
evaluation/treatment
•Current/recent use of illicit
injection drugs
•Sex between men
•Employees with potential
exposure
•End-stage renal disease
•Diabetics based on disease
and exposure risk
Beliefs and Concernsa
• No confirmed evidence of
a link between multiple
sclerosis and the vaccine
• Consult screening and
referral algorithm for
pregnant women and
package insert for other
concerns
a. US Centers for Disease Control and Prevention. Hepatitis B Vaccine Information Sheet. 2017; https://www.cdc.gov/vaccines/hcp/vis/vis-statements/hep-b.html.
b. Surkis WD, Santoro J. Merck Manual (Professional Version). Hepatitis B Vaccine. 2014; http://www.merckmanuals.com/professional/infectious-diseases/immunization/hepatitis-b-vaccine

23. Hepatitis E
Why get the vaccine?
• Fecal-oral transmission
• Causes typical symptoms
of viral hepatitis,
including anorexia,
malaise, and jaundice
• Fulminant disease is rare,
but can cause death
• Suspect disease in
travelers to endemic
regions
Indications
• Vaccine available in China,
but not the USA
• Supportive care
Rutherford AE. Merck Manual (Professional Version). Hepatitis E. 2016; http://www.merckmanuals.com/professional/hepatic-and-biliary-disorders/hepatitis/hepatitis-e.
No outbreaks in
USA, but outbreaks
have been reported in
China, India, Mexico,
Pakistan, Peru, Russia,
and central and
northern Africa.

24. Diptheria, Tetanus, and Pertussis
Vaccine

25. Diptheria, Tetanus, and Pertussis
Why get the vaccine?a
• Diptheria (D)
• can lead to breathing problems,
heart failure, paralysis, and death
• Tetanus (T; ‘lock jaw’)
• Muscle stiffness
• (Acellular [a]) Pertussis
• Severe coughing spells
• May lead to hospitalization due
to complications
Indicationsb
• DTaP is a routine
childhood vaccine
• Unless contra-indicated
• Tdap is routinely given as
a single lifetime dose to
children at age 11 or 12 yr
and to people ≥ 13 yr who
have never received Tdap
• Added boosters may be
needed for specific groups
Contraindicationsb
• Severe allergic reaction to
a previous
dose/ingredient
• For the pertussis part:
Encephalopathy that
occurs after a previous
dose that occurred within
7 days of a shot and that
is not attributable to
another cause
• See package insert for
other precautions
a. US Centers for Disease Control and Prevention. Tdap (Tetanus, Diphtheria, Pertussis) VIS. 2017; https://www.cdc.gov/vaccines/hcp/vis/vis-statements/tdap.html.
b. Surkis WD. Merck Manual (Professional Version). Diphtheria-Tetanus-Pertussis Vaccine. 2014; http://www.merckmanuals.com/professional/infectious-diseases/immunization/diphtheria-tetanus-pertussis-vaccine.
.
.

26. Vaccine-Preventable Respiratory
Disease
• Influenza (Seasonal viruses/
H. influenzae b) and Pneumococcal Disease

27. Influenza
Why get the vaccine?a
• Anyone can get this
respiratory contagion
– More dangerous for some people
eg, infants and persons ≥65 years
old
– Thousands of people are
hospitalized or die of the flu each
year in the USA
Indicationsb
• Annual vaccinations
for all people ≥ 6 mo
• Age-appropriate
vaccines can be given
to all people ≥ 6 mo,
including pregnant
women
• Trivalent/LAIV should
be given to
prespecified groups
Some Contraindications &
Precautionsb
• People with allergies
• Immunocompromised
people
• Certain chronic disorders
• Children/adolescents with
long-term use of
aspirin/salicylates
• Pregnancy
• Guillain-Barré syndrome
within 6 wks after a
previous dose of an
influenza vaccine
Abbreviations: LAIV, Live attenuated influenza vaccine
Surkis WD, Santoro J. Merck Manual (Professional Version). Influenza Vaccine. 2014; http://www.merckmanuals.com/professional/infectious-diseases/immunization/influenza-vaccine

28. Haemophilus influenzae type b (Hib)
Why get the vaccine?
• Children under 5 years
old/adults with certain
medical conditions can
get this serious disease
• Before the vaccine, Hib
disease was the leading
cause of bacterial
meningitis among
children < 5 years old
• Meningitis, a disease of
the brain lining and spinal
cord, can lead to brain
damage and deafness
Indications
• Age-appropriate
dosing based on
recommended
schedule
• HIV-infected persons
(5 to 18 years old) and
specific groups over
the age of 5 may also
receive shots
Some Contraindications &
Precautions
• Infants <6 weeks of age
should not receive the
vaccine
• Severe/life-threatening
allergies to
components/prior dose
• Delay shots for people
with moderate to severe
illness at time of visit
• See CDC reference for
more information on risks
US Centers for Disease Control and Prevention. Haemophilus Influenzae Type b (Hib) Vaccination Information Statement. 2015;
https://www.cdc.gov/vaccines/hcp/vis/vis-statements/hib.html.

29. Pneumococcal Disease
Why get the vaccine?
• Chronic disorders,
cerebrospinal fluid leaks,
cochlear implants,
immunocompromising
illnesses and other
conditions may
predispose persons to
pneumococcal diseasea
• Disease88% in children
<5 years since vaccineb
Indications
• Conjugate vaccine is
routinely given to children
at 2, 4, 6, and 12–15
months of age. It is also
recommended for
children and adults 2 to
64 years of age with
certain health conditions,
and for all adults 65 years
of age and older
Some Contraindications &
Precautions
• People with life-
threatening allergies to
vaccine ingredients/a
prior vaccine, PCV7/any
vaccine with the diptheria
toxoid should not get the
conjugate vaccine
• Risks of a reaction with
any of the different
pneumococcal vaccines
are further described on
the CDC site
US Centers for Disease Control and Prevention. Pneumococcal Conjugate Vaccine Statement. 2015; https://www.cdc.gov/vaccines/hcp/vis/vis-statements/pcv13.html.
.
.

30. Vaccines against Central Nervous
System Disorders
• Rabies, Meningitis, Poliomyelitis,
Japanese encephalitis

31. Rabies
Why get the vaccine?
• Non-human reservoirs in
the USA include some
insectivorous bats,
skunks, foxes, coyotes,
and raccoonsa
• Globally, this viral
encephalitis kills >55,000
people annually, mainly in
endemic regionsb
• Without treatment, this
disease is almost
universally fatal
Indicationsb
• Pre-exposure prophylaxis
for people at risk, including
veterinarians, animal
handlers, spelunkers,
workers who handle the
virus, and travelers to
endemic areas
• Post-exposure prophylaxis
(PEP) with rabies vaccine
and rabies immune globulin
(RIG) is given depending on
the biting animal and
circumstances
Other Notesb
• People do not transmit
disease to others unless
they are sick with rabies
a. US Centers for Disease Control and Prevention. Rabies Home Page. What care will I receive? 2017; https://www.cdc.gov/rabies/medical_care/index.html.
b. Greenlee JE. Merck Manual (Professional Version). Rabies. 2017; http://www.merckmanuals.com/professional/neurologic-disorders/brain-infections/rabies

32. Meningococcal Disease
Why get the vaccine?
• Vaccine protects against
Neisseria meningitidis
infections which can lead
to meningitis,
dangerously low blood
pressure (shock), and
deatha
• Vaccines help protect
against all three
serogroups (B, C, and Y) of
meningococcal disease
usually seen in the USAb
Indicationsa
• Routine childhood
vaccination given to
adolescents, preferably at
age 11 or 12 yr, with a
booster dose at age 16 yr
• At-risk adults
Some Contraindications &
Precautionsb
• Life-threatening or severe
allergic reaction
• Pregnant or breastfeeding
• Feeling ill prior to
vaccination
Surkis WD, Santoro J. Merck Manual (Professional Version). Meningococcal Vaccine. 2014; http://www.merckmanuals.com/professional/infectious-diseases/immunization/meningococcal-vaccine.
.

33. Polio
Some Contraindications &
Precautionsb
• Hypersensitivity/anaphylaxis
• Pregnancy
• Immunodeficiency
• See CDC reference for further
information
Why get the vaccine?
• Person-to-person spread
prior to introduction of this
virus used to kill thousands
in the USA before vaccine
was introduced in 1955
• Some people may become
paralyzed or die
Indicationsa
• Children in the US receive inactivated poliovirus
vaccine (IPV) to protect against polio, or
poliomyelitis
• Travelers to endemic regions
• Members of communities or specific population
groups with disease caused by wild polioviruses;
• Laboratory workers who handle specimens that
might contain polioviruses;
• Health-care workers who have close contact with
patients who might be excreting wild polioviruses;
• Unvaccinated adults whose children will be
receiving oral poliovirus vaccine
US Centers for Disease Control and Prevention. Polio Vaccination: Information for Healthcare Professionals. 2017; https://www.cdc.gov/vaccines/vpd/polio/hcp/index.html
.
.

34. Japanese Encephalitis
Why get the vaccine?
• Mosquito-borne virus
found mainly in rural
parts of Asia
• Symptoms range from
mild fever to encephalitis
• About 1 in 4 people with
encephalitis dies
Indications
• Travelers (≥2 mo.-old) to
endemic regions in Asia,
especially if they will be
there for more than a mo.
• Travelers to areas with
known outbreaks
• Travelers unsure of travel
plans
• Laboratory workers
exposed to the virus
Some Contraindications
& Precautions
• Severe allergy to any
vaccine component/dose
• Pregnancy
• Travel for fewer than 30
days
•
US Centers for Disease Control and Prevention. Japanese Encephalitis Vaccination: Information Statement. 2014; https://www.cdc.gov/vaccines/hcp/vis/vis-statements/je-ixiaro.html

35. Vaccine-Preventable
Diarrheal Disease
• Rotavirus, Typhoid, Yellow Fever,
and Cholera

36. Rotavirus
Why get the vaccine?
• Almost all American children will
be infected with this causative
agent of gastroenteritis before
their 5th birthday
• Before the vaccine was available,
thousands of babies became ill/
were hospitalized and 20 to 60
babies died every yearb
• Hospitalizations and emergency
room visits have dropped
dramatically since introduction of
the vaccine
Indicationsb
• Three-shot series is
typically started before 15
weeks of age and the last
dose is given by 8 months
Some Contraindications &
Precautionsb
• Babies with severe, life-
threatening allergies to any
part of the vaccine
• Babies with severe, combined
immunodeficiency
• Vaccine does not protect
against other diarrhea-
causing bacteria
• Babies with a type of bowel
blockage known as
intussusception
a. MedlinePlus. Rotavirus infections. 2017; https://medlineplus.gov/rotavirusinfections.html
b. US Centers for Disease Control and Prevention. Rotavirus Vaccination Information Statement. 2015; https://www.cdc.gov/vaccines/hcp/vis/vis-statements/rotavirus.html
.
.

37. Typhoid Fever
Why get the vaccine?
• Untreated typhoid can kill up
to 30% of people who get it
• Caused by Salmonella Typhi,
this food- and waterborne
disease kills ~ 200,000
people worldwide
Indications
• Travelers to parts of the
world where typhoid is
common
• People in close contact with a
typhoid carrier
• Laboratory workers who work
with Salmonella Typhi
bacteria.
Some Contraindications &
Precautions
• Inactivated typhoid shots
should not be given to
children <2 years old
• Severe allergies to vaccine
components or prior dose
• Delay shots for someone ill at
time of visit
• Live vaccine should not be
given to children <6 years old
• See package insert for more
information
US Centers for Disease Control and Prevention. Typhoid Fever Vaccination: Information for Healthcare Providers. 2010;
https://www.cdc.gov/vaccines/vpd/typhoid/hcp/index.html
.
.

38. Yellow Fever
Why get the vaccine?
• Mosquito-borne disease
found in some parts of Africa
and South America can cause
fever and flu-like symptoms,
jaundice (yellow skin or eyes),
bleeding from multiple body
sites, liver, kidney, respiratory,
and other organ failure
• About 20% - 50% of serious
cases result in death
• Vaccine can prevent the
disease
Indications
• Persons 9 months through
59 years visiting countries
where vaccination is an
entry requirement or those
visiting endemic regions
• Lab workers with exposure
to the virus
Some Contraindications &
Precautions
• People with a weakened
immune system or deficiency
• Severe/life-threatening
allergies to vaccine
components or prior dose
• Infants < 6 mo. old
• See package insert for more
information
.
US Centers for Disease Control and Prevention. Yellow Fever Vaccination: Information Statement. 2011; https://www.cdc.gov/vaccines/hcp/vis/vis-statements/yf.pdf

39. Cholera
Why get the vaccine?
• Travelers to endemic regions
may encounter this
waterborne disease
• Untreated cholera may cause
severe diarrhea, vomiting,
and even death
• Although effective against
severe or life-threatening
forms of cholera, it does not
protect against other
waterborne and foodborne
diseases
Indicationsb
• Cholera is rare in the USA
• Travelers to endemic
regions may receive the
vaccine
Some Contraindications &
Precautionsb
• People with severe, life-
threatening allergies
• Pregnancy or breastfeeding
• People who have recently
taken antibiotics
• People who are taking anti-
malaria drugs
• See reference for information
on risk of a vaccine reaction
US Centers for Disease Control and Prevention. Cholera Vaccination Information Statement. 2017; https://www.cdc.gov/vaccines/hcp/vis/vis-statements/cholera.pdf
.
.

40. Chickenpox &
Shingles
Vaccines

41. Chickenpox (Varicella zoster)
Why get the vaccine?
• Systemic, usually childhood
disease characterized by skin
lesions and sometimes severe
neurologic/other
complicationsa
• Secondary complications
include bacterial infections of
lesions and cerebellar ataxiab
• Varicella-zoster virus (human
herpesvirus type 3) causes
this highly contagious
diseaseb
• Two doses of the vaccine are
about 90% effective at
preventing chickenpoxb
Indicationsb
• Healthy individuals with no
evidence of immunity should
receive shots per
recommended schedule
• Healthcare professionals
• People who care for or are
around immunocompromised
people
• Teachers
• See CDC reference for
complete list
Some Contraindications &
Precautionsb
• People with a history of
allergies to vaccine
ingredients
• People wit conditions
affecting the bone
marrow/lymphatic system
• People on
prolonged/systemic
immunosuppressive therapy
• See package insert for
additional information
a. Kaye KM. Merck Manual (Professional Version). Varicella Vaccine. 2016; http://www.merckmanuals.com/professional/infectious-diseases/immunization/measles,-mumps,-and-rubella-vaccine
b. US Centers for Disease Control and Prevention. Chickenpox/Varicella Vaccination. 2017; https://www.cdc.gov/vaccines/vpd/varicella/index.html
.

42. Shingles (Herpes zoster)
Why get the vaccine?
• Reactivation of the latent
phase of varicella zoster virus
causes posterior ganglionitis
ie, shinglesa
• Years after this painful rash
disappears, some people may
have persistent pain known as
postherpetic neuralgia (PHN)b
• Vaccination reduces the risk
of shingles and PHN by more
than 50%b
Indicationsb
• The shingles vaccine is
recommended for
adults ≥ 60 yr whether they
have had herpes zoster or
not. It is not routinely
recommended for people
aged 50 to 59 yr but can be
used in this age group
Some Contraindications &
Precautionsb
• Severe allergic reaction to
vaccine ingredients
• Known severe primary or
acquired immunodeficiency
• Consult package insert for
further information
a. Surkis WD, Santoro J. Merck Manual (Professional Version). Herpes Zoster Vaccine. 2014;
http://www.merckmanuals.com/professional/infectious-diseases/immunization/measles,-mumps,-and-rubella-vaccine.
b. US Centers for Disease Control and Prevention. Shingles Vaccine Information Sheet. 2017; https://www.cdc.gov/vaccines/vpd/shingles/index.html
.

43. Human Papilloma Virus
(HPV) vaccine
This Photo by Unknown Author is licensed under CC BY-SA

44. Human Papilloma Virus (HPV)
Why get the vaccine?
• This common virus may
cause cancer
• Screening exists for HPV--
induced cervical cancers,
but not for other tumors
eg, cancers of the
mouth/throat,
anus/rectum, penis,
vagina, or vulva
Indications
• For girls and boys at ages 11 or 12
years to protect against cancers
caused by HPV infections
• Vaccination for females aged 13
through 26 years and males aged 13
through 21 years not adequately
vaccinated previously
• Also recommended through age 26
years for gay, bisexual, and other men
who have sex with men, transgender
people, and for immunocompromised
persons (including those with HIV
infection) not adequately vaccinated
previously
Some Contraindications
& Precautions
• Anaphylactic allergy to
latex
• Immune hypersensitivity
to yeast
• Pregnancy
• Moderate/severe illness
prior to a shot
• See package insert for
more information
US Centers for Disease Control and Prevention. Chickenpox/Varicella Vaccination. 2017; https://www.cdc.gov/vaccines/vpd/hpv/index.html.

45. Recommended
Immunization Schedules
Infants, Children, Preteens, and Adults

46. 2017 Recommended Immunizations
Birth through 6 Years old
US Centers for Disease Control and Prevention. For Immunization Schedules for Infants and Children. 2017; https://www.cdc.gov/vaccines/parents/downloads/parent-ver-sch-
0-6yrs.pdf
.

47. 2017 Recommended Immunizations
How to Generate a Catch-up Schedule
US Centers for Disease Control and Prevention. For Everyone: Easy-to-read schedules. Generate a Catch-up or Accelerated Schedule. 2017;
https://www.vacscheduler.org/index.html
.

48. 2017 Recommended Immunizations
Preteens and Teens ( 7 to 18 Years old)
US Centers for Disease Control and Prevention. For Everyone: Easy-to-read schedules. Preteens and Teens. 2017; https://www.cdc.gov/vaccines/schedules/downloads/teen/parent-
version-schedule-7-18yrs.pdf
.

49. 2017 Recommended Immunizations
Adults ( ≥ 19 Years old)
US Centers for Disease Control and Prevention. Recommended Immunizations for Adults (19 Years and Older) by Age and Medical Condition. 2017;
https://www.cdc.gov/vaccines/schedules/downloads/adult/adult-schedule-easy-read.pdf

50. How to Improve Responses to Outbreaks
Gardy JL, Loman NJ. Nat. Rev. Gen. 2017 (e-pub)
Use of portable genomic sequencers and digital epidemiology platforms form the foundation for
both real-time pathogen and disease surveillance systems and outbreak response efforts,
•In One Health Model,
“portable, in-country
genomic diagnostics are
targeted to key settings
for routine human,
animal and
environmental
surveillance or rapidly
deployed to a setting
with a nascent outbreak”
(Ebola and Zika represent
examples of this
approach)

51. Further Enhancements to Public Health Value
Before Approval
• Some trials require novel designs (eg, Ebola)
that could be deemed valid for approval
• Additional endpoints could include:
– All-cause hospitalizations
– Pneumonias
– Gastroenteritis (or others as appropriate to
the vaccine target)
• Outcomes should include:
– Vaccine-preventable-disease incidence
– Number needed to vaccinate
After Approval
• Estimate population-level impact, including
indirect, total, and overall effects
– Phase IV cluster, randomized trials
• Use dynamic (rather than static) models
– Avoids underestimation of impact
• Separate systems to monitor safety:
– Vaccine Adverse Event Reporting System
(VAERS)
– Vaccine Safety Datalink (VSD)
– Clinical Immunization Safety Assessment
(CISA) Project
Wilder-Smith A, Longini I, Zuber PL, et al. BMC Medicine. 2017;15(1):138.
Degree to which broad public health benefits is provided is stronger than for other preventive and curative
interventions.

52. Past and the Future
Measles, mumps, rubella, and polio – 20th
- century diseases that used to infect ~39
million US infants – are uncommon today;
More than 70 vaccines are available
against 39 microbes.
Despite successes, ~3 children continue to die
per minute from vaccine-preventable diseases
worldwide; no effective vaccines are available for
the top infectious killers eg, HIV, tuberculosis,
and malaria; However scientific, medical, and
biotechnological advances hold promise for
improving the use of existing vaccines and
expanding the pipeline of tomorrow’s vaccines.
Nabel GJ. NEJM. 2013;368(6):551-560.