The document discusses vaccination programs and policies in Malaysia and Saudi Arabia. The Malaysian National Immunization Program provides vaccines for major childhood diseases free of charge at government clinics. Vaccine safety is monitored by the National Centre of Adverse Drug Reactions. Saudi Arabia's Ministry of Health operates vaccination programs through over 2,000 primary health centers, achieving over 90% childhood immunization coverage. Vaccination requirements include proof of meningitis vaccination for Hajj pilgrims. Both countries' programs aim to expand access and monitor vaccine safety.

1. 1
Global Vaccination (attach this please with the previous
sections)
WHO estimates that three million cases of disease could be
avoided annually with an appropriate prevention by vaccination.
Immunization System in Malasyia (more info please add to US)
Religious Views of Vaccination (Malaysia)(please attach this
with the previous sections)
Grabenstein (2013) noted that polio immunization is obligatory
when disease risk is high and the vaccine shown to have
benefits far outweighing its risks.
National Immunization Program (NIP)
The Malaysian National Immunization Program (NIP) was
introduced in the early 1950s and it has been given free to the
children for their protection against major childhood diseases.
The immunization program offers protection against major
childhood diseases that can be prevented with vaccines
including diphtheria, tetanus, pertussis, Haemophilus influenzae
type b, hepatitis B, measles, mumps, rubella, tuberculosis, polio
and some diseases caused by the human papillomavirus. This
program is available at all government clinics across the
country.
Parents are responsible for ensuring that their children are
protected from dangerous infectious diseases that can be
prevented with a vaccine. Below is the national immunization
schedule to ensure your child receives the vaccination at the
right time (Malaysian MOH, 2017).
Vaccine Safety Surveillance
National Centre of Adverse Drug Reactions (ADR) Monitoring,

2. National Pharmaceutical Control Bureau (NPCB) is responsible
to monitor the safety of medicines and vaccines that are
registered in Malaysia. NPCB is responsible for collecting all
reporting adverse events related pharmaceutical products
including vaccines. All reported adverse events will be
documented and serious cases following vaccination will be
investigated promptly to identify the cause of the adverse
events. NPCB will make further investigation in terms of
product quality and regulatory action will be taken based on the
results of the investigation. Types of regulatory action that can
be taken are the suspension of the product registration, product
recall or cancellation of the product registration.
ADR reporting system has been introduced in Malaysia to
enable health providers to participate in monitoring the safety
of medicines and vaccines by reporting the adverse events.
Ministry of Health Malaysia (MOH) has organized trainings to
the health professionals on the importance of reporting of
Adverse events following immunization (AEFIs) as described in
the Guidelines for the Pharmacovigilance of Vaccines. Ongoing
training will be conducted more actively to increase awareness
among health care providers to report AEFI and importance of
disseminating the information to parents/guardians.
Currently, the AEFI reporting system has been extended to the
public whereby the parents/guardians of children who
experience any adverse events can report to us by themselves
(Malaysian MOH, 2017).
Immunization System in the US (more info please add to US)
In the United States of America (US), vaccines almost
eliminated congenital rubella, tetanus, and diphtheria, and
significantly reduced the incidence of pertussis, rubella,
measles, and mumps. In the US, vaccination is considered
primarily the responsibility of individual health care providers
and health care systems serving patients.WIC (Kindly make it 5
lines)The Special Supplemental Nutrition Program for Women,
Infants, and Children (WIC) is a categorical federal grant

3. program administered by the U.S. Department of Agriculture
through state health departments. The program provides
supplemental foods, health-care referrals, and nutrition
education to low-income pregnant, breastfeeding, or postpartum
women, as well as to infants and children aged <5 years.
Between 8.5 and 8.9 million people participated in this program
in 2013. In collaboration, WIC and state vaccination programs
assess regularly the vaccination coverage levels of WIC
participants and develop new strategies and aggressive outreach
procedures in sites with coverage levels <90%. Vaccination
programs and private providers are encouraged to refer eligible
children to obtain WIC nutritional services.Vaccination of
Children and Adolescents (Kindly make it 4-5 lines)
Physicians and other pediatric vaccination providers should
adhere to the standards for child and adolescent vaccination
practices. These standards are published by the National
Vaccine Advisory Committee and define appropriate
vaccination practices for both public and private sectors. The
standards provide guidance on practices that eliminate barriers
to vaccination, including eliminating unnecessary prerequisites
for receiving vaccinations, eliminating missed opportunities to
vaccinate, improving procedures to assess vaccination needs,
enhancing knowledge about vaccinations among parents and
providers, and improving management and reporting of adverse
events. In addition, the standards address the importance of
recall and reminder systems and using assessments to monitor
clinic or office vaccination coverage levels. Health-care
providers should simultaneously administer as many vaccine
doses as possible as indicated on the Recommended
Immunization Schedules for Persons Aged 0 Through 18
Years.Adolescent-Specific Issues I need only the current status
and the challenges
Vaccinations are recommended throughout life, including
during adolescence. The age range for adolescence is defined as
11-21 years by many professional associations, including the
American Academy of Pediatrics and the American Medical

4. Association. Definitions of these age cutoffs differ depending
on the source of the definition and the source’s purpose for
creating a definition. Vaccination of adolescents is critical for
preventing diseases for which adolescents are at particularly
high or increasing risk, such as meningococcal disease and
human papillomavirus infection. Three vaccines recommended
for adolescents have been licensed since 2005: MenACWY and
Tdap were licensed in 2005, and HPV was licensed in 2006. A
second dose of varicella vaccine is recommended for persons
who received 1 dose of varicella vaccine after age 12 months. In
addition, annual seasonal influenza vaccination is recommended
for persons aged >6 months who have no contraindications. To
ensure vaccine coverage, clinicians and other health-care
providers who treat adolescents must review vaccination history
on every occasion that an adolescent has an office visit.
National goals for vaccination coverage for adolescents aged
13-15 years were included in Healthy People 2020. Targets of
80% coverage were specified for one dose of Tdap, one dose of
meningococcal conjugate vaccine, and 3 doses of HPV vaccine.
Results of the published 2014 National Immunization Survey—
Teen indicate that coverage rates for 13-17 years olds is 87.6%
for one dose of Tdap and 79.3% for one dose of meningococcal
vaccine. Coverage rates for 13-17 years olds for HPV vaccine
are considerably lower—39.7% for females and 21.6% for
males.
Ensuring adolescents receive routine and catch-up vaccination
and achieving high levels of vaccination coverage present
challenges. In general, adolescents do not visit health care
providers frequently. Health care providers should promote
annual preventive visits (11), including one specifically for
adolescents aged 11 and 12 years. The annual visits should be
used as opportunities to provide routinely recommended vaccine
doses, additional catch-up doses needed for lapsed vaccine
series, vaccines recommended for high-risk groups, additional
doses that might have been recently recommended, and other
recommended health-care services. Additional strategies include

5. adolescent immunizations at community-based venues such as
pharmacies and schools.
All vaccine doses should be administered according to ACIP
vaccine-specific statements and with the most recent schedules
for both routine and catch-up vaccination. Before leaving any
visit for medical care, adolescents should be encouraged to
schedule return visits for any additional vaccine doses needed.
During visits that occur outside of influenza season, providers
should discuss and recommend seasonal influenza vaccination
and make explicit plans for vaccination, including timing and
anticipated setting (e.g., health care provider’s office, school,
or pharmacy). Catch-up vaccination with multidose adolescent
vaccines generally can occur according to the routine dosing
schedule for these vaccines, although in some circumstances the
clinician or health care provider might use minimum intervals
for vaccine doses. These circumstances include an outbreak that
increases risk for disease or the likelihood that doses will be
missed in the future (e.g., because of transportation challenges).
Because of lack of efficacy data for HPV vaccine administration
using minimum intervals, providers are encouraged, when
possible, to use routine dosing intervals for females aged 11-26
years and males aged 11-21 years who have not yet received 3
HPV vaccine doses as recommended (3,4).
One of the challenges of adolescent vaccination is ensuring that
current, complete vaccination histories are available. Insurers,
covered services, or reimbursement levels can change, and these
changes might affect reimbursement for vaccine doses and
vaccination services directly while also causing disruptions in
an adolescent’s access to vaccination providers or venues. In
circumstances in which a vaccination record is unavailable,
vaccination providers should attempt to obtain this information
from various sources (e.g., parent, previous providers, or school
records). More detail about how to obtain these records is
available from CDC. With the exception of influenza and
pneumococcal polysaccharide vaccines, if documentation of a
vaccine dose is not available, the adolescent should be

6. considered unvaccinated for that dose. Regardless of the venue
in which an adolescent receives a dose of vaccine, that vaccine
dose should be documented in the patient’s chart or in an office
log, and the information should be entered into an IIS. The
adolescent also should be provided with a record that documents
the vaccination history.Adult Vaccination (Kindly make it 4-5
lines)
In 2013, the National Vaccine Advisory Committee published
updated standards for adult vaccination (12). These standards
are targeted to distinct groups involved in adult vaccination,
including immunizing providers, non-immunizing providers,
professional health-care organizations, and public health
departments. All health-care providers, whether they provide
immunizations or not, should incorporate immunization needs
assessment into every clinical encounter, strongly recommend
needed vaccine(s) and either administer vaccine(s) or refer
patients to a provider who can immunize, stay up-to-date on,
and educate patients about vaccine recommendations, implement
systems to incorporate vaccine assessment into routine clinical
care, and understand how to access immunization information
systems (i.e., immunization registries) (12).
Vaccination rates in adults are considered suboptimal. New
Healthy People 2020 goals include specific subsets of adults,
including institutionalized adults aged ≥18 years (for
pneumococcal vaccines) and noninstitutionalized adults at high
risk aged >18 years (for pneumococcal vaccines).
The most substantial barrier to vaccination coverage is lack of
knowledge about these vaccines among adult patients and adult
providers. Other barriers are cost (incomplete Medicare
coverage for recommended vaccines) and the lack of financing
mechanisms for newly licensed and recommended vaccines.
Effective for private health insurance plans drafted or updated
after September 2010, coverage for all immunizations that are
included on the immunization schedule(s) must be covered
without deductibles or co-pays, when delivered by an in-
network provider. For this reason, cost may present less of a

7. barrier to adult vaccination as time passes.
A common challenge for health-care providers is vaccinating
adults with unknown vaccination records. In general (except for
influenza and pneumococcal polysaccharide vaccines), adults
should receive a vaccine dose if the dose is recommended and
no record of previous administration exists. If an adult has a
record of military service and does not have records available,
providers can assume that the person has received all vaccines
recommended by the military at the time of service entry.
Serologic testing might be helpful in clarifying immune status if
questions remain, because at different times and depending on
military assignments, there might be inter-service and
individual differences.Evidence-based Interventions to Increase
Vaccination Coverage (Kindly make it 4-5 lines)
The independent, nonfederal Task Force on Community
Preventive Services, whose membership is appointed by CDC,
provides public health decision-makers with recommendations
on population-based interventions to promote health and prevent
disease, injury, disability, and premature death. The
recommendations are based on systematic reviews of the
scientific literature about effectiveness and cost-effectiveness
of these interventions. In addition, the task force identifies
critical information about the other effects of these
interventions, the applicability to specific populations and
settings, and the potential barriers to implementation.
Additional information, including updates of published reviews,
is available from The Community Guide.
Beginning in 1996, the task force systematically reviewed
published evidence on the effectiveness and cost-effectiveness
of population-based interventions to increase coverage of
vaccines recommended for routine use among children,
adolescents, and adults. A total of 197 articles were identified
that evaluated a relevant intervention, met inclusion criteria,
and were published during 1980-1997. Reviews of 17 specific
interventions were published in 1999 (13,14,16,17). Using the
results of their review, the task force made recommendations

8. about the use of these interventions (15). Several interventions
were identified and recommended on the basis of published
evidence. Follow-up reviews were published in 2000, and a
review of interventions to improve the coverage of adults at
high risk was conducted in 2005. The interventions and the
recommendations are summarized in this section of this report
(Table 11-1). Interventions designated for adults younger than
65 years at high risk for influenza, invasive pneumococcal
disease, and hepatitis B, include provider reminder systems or a
menu of items (combinations of strategies ) (Table 11-2). In
1997, the task force categorized vaccination requirements for
child care, school, and college as a recommended strategy.
The Current Status
Since 1995, all states receiving federal funds for vaccination
programs have been required to conduct annual assessments of
vaccination rates both in public health clinics and in private
provider offices. Primarily to aid local and state health
departments in their efforts to conduct assessments and assist
providers, CDC has developed numerous software applications
to measure vaccination rates in provider practices.Other General
Programmatic Issues
With availability of safe and effective vaccines for 18 vaccine-
preventable diseases, the capacity for realizing the potential
benefits of these products in the United States depends on
reaching children, adolescents, and adults through dedicated,
knowledgeable vaccination providers and efficient, strong
vaccination programs at local, state, and federal levels.For
Healthcare ProfessionalsEach year, the Advisory Committee on
Immunization Practices (ACIP) approves immunization
schedules recommended for persons living in the United States.
The adult immunization schedule provides a summary of ACIP
recommendations on the use of licensed vaccines routinely
recommended for adults aged 19 years or older. The adult
immunization schedule is also approved by the American
College of Physicians (ACP), the American Academy of Family
Physicians (AAFP), the American College of Obstetricians and

9. Gynecologists (ACOG), and the American College of Nurse-
Midwives (ACNM).
Immunization System in Saudi Arabia
Ministry of Health
There are more than 2,000 primary health care centers
throughout the Kingdom. A ministry official said all children’s
vaccines are available in these centers except the one against
hepatitis A, which is experiencing a global shortage. Last year,
90 percent of children in the Kingdom were immunized,
resulting in a sharp drop in the incidence of rubella (German
measles). However, the MOH implements its immunization
program in line with the Atlanta-based Center for Disease
Control and Prevention (CDC) and the World Health
Organization (WHO).
The Current Status of MOH
According to Rukban et al. (2005), immunization in Riyadh is
mainly conducted by males, Pediatricians and doctors with no
postgraduate qualification. Self-confidence is relatively higher
among Pediatricians, holders of PhD and MS, physicians
working in private hospitals and those with more than four
years of experience. National and International protocols were
less frequently used. The majority of immunization providers
did not have enough experience in dealing with situations not
related to childhood immunization.
However, Saudi Arabia demands proof of recent meningococcal
vaccination (with a polysaccharide or conjugate tetravalent
vaccine) as a visa requirement for pilgrims and guest workers
(WHO, 2015). Some polio-free countries may also require
travellers resident in countries or areas reporting wild
polioviruses to be immunized against polio in order to obtain a
n entry visa, as in the case of Saudi Arabia. Travellers should
be provided with a written record of all vaccines administered
(patien t-retained record), preferably using the International
Certificate of Vaccination or Prophyl axis (which is required in
the case of yellow fever vaccination). The certificate can be a
ccessed on the WHO website (WHO, 2015).

10. Vaccine Safety Surveillance
In Saudi Arabia, the Ministry of Health (MOH) operates the
Expanded Programme on Immunization (EPI) through the
National Immunization program (NIP) department. NIP is
responsible for setting up policy guidelines and standards for
selection, supply and utilization of vaccines in the country. NIP
has done a tremendous job and some of the notable
achievements of the program include achieving immunization
coverage of over 95 % for all primary immunization,
establishing a cold chain system, engaging state a nd district
authorities in monitoring vaccine use, training and developing
healthcare providers as well as establishing linkages and
networking with international stakeholders.
Likewise, the National Regulatory Authorities - NRAs (Saudi
Food and Drugs Aut hority – SFDA) monitor the safety of all
medical products including vaccines. The SFDA uses
spontaneous pharmacovigilance system to collect any suspected
adverse drug reactions experienced by patients. The SFDA is
also responsible for authorization of marke ting all medicines
including vaccines. All vaccine manufacturers are required by
law to register their products before supplying and distributing
them in the country. The overall goal is t he protection of the
health and wellbeing of the entire population particularly
infants, children and pregnant women and the general
population who depend on vaccines to protect them from serious
vaccine preventable diseases (VPD).
School Health ProgramSchool Health Program is delivered by
the Ministry of National Guard Health Affairs. The school
health team is organizing scheduled pre-school clinic, which is
targeting the students who are entering the 1st new school
grades (NGHA, 2014). School Immunization contains:
· Complete obligatory vaccinations for those entering KG &
Elementary school (4-6 years): MMR, DPT, Varicella & polio.
· Tetanus vaccine for females in 1st grade high schools.
· Meningitis Vaccine for 1st, 4th Elementary school, 1st
intermediate & 1st grade secondary.

11. · Other vaccinations such as measles
Health Services in the Pilgrimage (Hajj) Season
During the month of Ramadan or during Umrah and Hajj
pilgrimages, millions of Muslims from highly diverse
geographical regions visit these holy places mostly via Jeddah
City. These individuals remain in contact with each other for an
extended period of time reaching up to 1 month during some
occasions (Hashem, 2016). This could introduce not only new or
highly pathogenic strains but also resistant viruses into Saudi
Arabia, particularly during peak influenza seasons. Thus,
healthcare services in the hajj season provide preventive and
curative care for all pilgrims, irrespective of their nationality.
Preventive care includes health education programmes,
vaccination and chemoprophylaxis for all pilgrims via
quarantine services at airports and land ports (Almalki,
FitzGerald, & Clark, 2011).
The Saudi Thoracic Society has recently published its
guidelines for influenza immunization with particular emphasis
on Hajj and Umrah. Implementation of these guidelines will
undoubtedly require the involvement of the Saudi Ministry of
Hajj, its counterpart agencies in other countries and public
health agencies worldwide. An accumulating body of evidence
suggests that influenza infections are very common during Hajj
and pilgrims can import influenza back to their home countries.
Importantly, the incidence of influenza infection among
vaccinated individuals is not uncommon most probably due to
strain mismatch. Furthermore, pilgrims from countries where
influenza circulates year-round or influenza seasons are usually
ahead of the season in Saudi, which extends from September to
March, could complicate the situation even more. Therefore,
inclusion of both influenza vaccines from the Northern and
Southern Hemispheres could be considered for all pilgrims
when the two vaccines are different.
Another critical point to consider is that current
epidemiological and virological data on circulating influenza
viruses in Saudi Arabia are seriously deficient, and there is no

12. existing influenza surveillance program in the Kingdom. Only
limited number of studies have reported and/or characterized
circulating influenza viruses during few Hajj seasons.
Therefore, it is important to monitor circulating influenza
viruses by launching and implementing an active human
influenza surveillance program in Saudi Arabia with particular
emphasis on Hajj and Umrah seasons. Such program can provide
significant virological, molecular, and epidemiological
information on circulating influenza strains, and its associated
morbidity and mortality to decision-makers globally to make
informed decisions and to undertake effective control measures
in order to decrease the disease burden (Hashem, 2016).
Recommendations. Continual vigilance to improve public health
effectiveness and efficiency should become best practice—ie,
the state-of-the-art policies, planning, communications,
surveillance, and operations in stressful and emergency
conditions should be continually reviewed. Furthermore, after-
action reviews should be done to improve future performance on
the basis of real-time experience. Noteworthy is that the
recommendations generated during this meeting were based on
the current status of the pandemic and therefore might need
revision, dependent on the changes in virus characteristics and
epidemiology of infections with the 2009 pandemic influenza A
H1N1 virus (Memish et al., 2009).
Limitation
· To achieve an effective disease prevention program, we should
have qualified doctors, cooperative patients and well-developed
health system. Doctors’ mistakes and poor knowledge of
immunizations could be very harmful. Therefore, it is important
to evaluate the competence of immunization providers.
· To improve immunization services, physicians should be given
the appropriate training. This training would have a positive
impact on their performance. Frequent distribution of national
and international protocols on immunization, as well as proper
regular auditing practice would hopefully improve and sustain
an effective service.

13. · Several studies documented considerable delays in the
administration of primary vaccinations due to difficulties with
the appointment, non-febrile upper respiratory tract illness, and
most of the parents were not concerned at all regarding the
vaccination delay (Hasanain, & Jan, 2002).
Religious Views of Vaccination
faith type alone is not linked to vaccination issues and interacts
with other national factors: Saudi Arabia – a country with 100%
Muslim respondents – has a very low religious objection rate
(2%) (Grabenstein, 2013).
Recommendations at the end of the paper for all the systems
According to CDC 2017), the following are recommendations
regarding interventions to improve coverage of vaccines
recommended for routine use among children, adolescents, and
adults
1- Increase community demand for vaccination
· Client reminder or recall systems
· Requirements for entry to schools, child- care facilities, and
colleges
· Community education alone
· Community-based interventions implemented in combination
· Clinic-based education
· Patient or family incentives
· Patient or family monetary sanctions
· Client-held medical records
2- Enhance access to vaccination services
· Reducing out-of-pocket costs
· Enhancing access through the U.S. Department of
Agriculture’s Women, Infants, and Children (WIC) program
· Home visits, outreach, and case management targeted to
particularly hard-to-reach populations to increase vaccination
rates
· Enhancing access at schools
· Expanding access in health-care settings
· Enhancing access at organized child care centers

14. 3- Focus on providers
· Provider reminder or recall systems
· Provider assessment and feedback
· Standing orders
· Provider education alone
· Health-care systems-based interventions integrated in
combination
· Immunization information systems
Reference:
Almalki, M., FitzGerald, G., & Clark, M. (2011). Health care
system in Saudi Arabia: an overview/Aperçu du système de
santé en Arabie saoudite. Eastern Mediterranean health journal,
17(10), 784.
Memish, Z. A., McNabb, S. J. N., Mahoney, F., Alrabiah, F.,
Marano, N., Ahmed, Q. A., ... & El Bushra, H. (2009).
Establishment of public health security in Saudi Arabia for the
2009 Hajj in response to pandemic influenza A H1N1. The
Lancet, 374(9703), 1786-1791.
Al-Rukban, M. O., Al-Migbal, T. H., Al-Mutlaq, A. A., Al-
Marshady, M. A., Al-Salhi, A. H., Al-Rsheed, A. A., … Al-
Thagafi, S. A. (2005). CHARACTERISTICS OF
IMMUNIZATION PROVIDERS IN RIYADH AND THEIR
SELF-PERCEPTION OF COMPETENCY. Journal of Family &
Community Medicine, 12(1), 35–41.
Vaccine-preventable diseases and vaccines WHO (2015)
http://www.who.int/ith/ITH-Chapter6.pdf
Hasanain, F. H., & Jan, M. M. (2002). Delays in primary
vaccination of infants living in Western Saudi Arabia. Saudi
medical journal, 23(9), 1087-1089.
NGHA (2014)
http://ngha.med.sa/English/MedicalCities/Jeddah/FCM/Pages/S
HP.aspx
Grabenstein, J. D. (2013). What the world's religions teach,
applied to vaccines and immune globulins. Vaccine, 31(16),
2011-2023.

15. CDC (2017) https://www.cdc.gov/vaccines/hcp/acip-
recs/general-recs/programs.html
Hashem, A. M. (2016). Influenza immunization and surveillance
in Saudi Arabia. Annals of Thoracic Medicine, 11(2), 161.
http://doi.org/10.4103/1817-1737.180022
Malaysian Ministry of Health (MOH). Surveillance of Adverse
Events Following Immunization
http://www.myhealth.gov.my/en/surveillance-of-adverse-
events-following-immunization/
1
Introduction
Vaccination has greatly reduced the burden of infectious
diseases. Only clean water, also considered to be a basic human
right, performs better. Paradoxically, a vociferous anti-vaccine
lobby thrives today in spite of the undeniable success of
vaccination programs against formerly fearsome diseases that
are now rare in developed countries. Understandably, vaccine
safety gets more public attention than vaccination effectiveness,
but independent experts and WHO have shown that vaccines are
far safer than therapeutic medicines. Modern research has
spurred the development of less reactogenic products, such as
acellular pertussis vaccines and rabies vaccines produced in cell
culture.
Today, vaccines have an excellent safety record and most
“vaccine scares” have been shown to be false alarms. Misguided

16. safety concerns in some developing countries have led to a fall
in vaccination coverage, causing the re-emergence of pertussis
and measles. However, on the global scale, health organizations
continue to distribute vaccines to poorer countries. Thanks to
increased access to the measles vaccine internationally, the
annual death toll from the disease has fallen from almost
600,000 in 2000 to just 122,000 in 2012, a reduction of 79%.
Moreover, 86% of the world’s children received the required 3
doses of diphtheria-tetanus-pertussis containing vaccines
(DTP3) in 2015, a coverage level that has been sustained above
85% since 2010. As a result, the number of children who did not
receive routine life-saving vaccinations has dropped to an
estimated 19.4 million, down from 33.8 million in 2000.
However, this progress falls short of global immunization
targets. In 2012, all 194 WHO Member States endorsed the
Global Vaccine Action Plan (GVAP) and committed to ensuring
no one misses out on vital immunizations, with a target of
achieving 90% DTP3 vaccination coverage in all countries by
2015 (UNICEF, 2015).
Immunization System in the US
Since 1995, five new vaccines were added to the children’s
immunization schedule in the U.S., which the CDC estimated
saved thousands of lives. The pneumococcal conjugate vaccine,
added in 2001, likely saved 13,000 U.S. lives from 2001 to
2008. And the rotavirus vaccination, added in 2006, is now
estimated to prevent 40,000 – 60,000 hospitalizations yearly.
The Advisory Committee on Immunization Practices makes
scientific recommendations which are generally followed by the
federal government, state governments, and private health
insurance companies. The public sector still vaccinates many
children, including disenfranchised and hard-to-reach patients,
and is now also assuming newer functions including assessment
of local vaccination rates, policy development, and assurance of
immunization delivery.
States in the U.S. mandate immunization, or obtaining
exemption, before children enroll in public school. Exemptions

17. are typically for people who have compromised immune
systems, allergies to the components used in vaccinations, or
strongly held objections. A widespread and growing number of
parents claim religious and philosophical beliefs to get
vaccination exemptions: researchers have cited these
exemptions as contributing to loss of herd immunity within
these communities, and hence an increasing number of disease
outbreaks.
The American Academy of Pediatrics (AAP) advises physicians
to respect the refusal of parents to vaccinate their child after
adequate discussion, unless the child is put at significant risk of
harm (e.g., during an epidemic, or after a deep and
contaminated puncture wound). Under such circumstances, the
AAP states that parental refusal of immunization constitutes a
form of medical neglect and should be reported to state child
protective services agencies.
Vaccination Policy
Developing sound policy now will help to reduce the severity of
or altogether stop future outbreaks in the US. There are a
myriad of ethical issues regarding such topics as vaccination
development, administration, communication, and safety
monitoring. We focus on a few key ethical issues concerning
childhood immunization in the United States—what we refer to
as a “vaccine ethics” approach—and describe how such an
approach affects policy development and clinical immunization
practice (Hendrix, Sturm, Zimet, & Meslin, 2016).
Limitation
· Concern About Side Effects. Some parents question the safety
of vaccines, think their children are more likely to acquire
infectious diseases if vaccinated, and even consider vaccines to
cause attention-deficit/hyperactivity disorder and/or autism.
Some parents believe that vaccines will weaken their child’s
immune system or cause chronic illnesses, such as asthma or
multiple sclerosis. Others parents assert that infants and young
children should not be vaccinated because their bodies are still
immature and fragile (Ventola, 2016).

18. · Lack of Access Due to Cost and Other Reasons. lack of access
to health care due to socioeconomic and other factors (Ventola,
2016).
· Lack of Information. Language barriers and insufficient
knowledge about immunizations contribute to reduced
immunization adherence (Ventola, 2016).
· Moral or Religious Grounds. Objection to vaccination on the
basis of moral or religious grounds is particularly relevant to
the Human Papillomavirus (HPV) vaccine. Apparently, there are
some misconceptions regarding the HPV vaccine, such as
believing that it’s not safe or that it’s only necessary for
sexually active teens (Ventola, 2016).
· Parental Refusal of Vaccines. In an effort to reduce childhood
morbidity and mortality, the Centers for Disease Control and
Prevention (CDC) Advisory Committee on Immunization
Practices (ACIP) issues annual recommendations and guidelines
for childhood and adolescent immunizations. However, some
parents decline or delay vaccinating their children or follow
alternative immunization schedules because of medical,
religious, philosophical, or socioeconomic reasons. Health care
provider-based interventions have been suggested to overcome
such vaccine noncompliance, including patient counseling;
improving access to vaccinations; maximizing patient office
visits; offering combination vaccines; and using electronic
medical records (EMRs) and practice alerts. Community- and
government-based interventions to improve parent and patient
adherence include public education and reminder/recall
strategies, financial incentives, and providing alternative venues
for vaccination (Ventola, 2016).
The National Immunization Survey
The National Immunization Survey (NIS)provides one such
mechanism by systematically collecting data about the
structure, process, and outcomes of the U.S. childhood
immunization program. This supplement to the American
Journal of Preventive Medicine showcases the NIS and
highlights several articles that address important topics

19. regarding quality of the immunization program. Thus, the NIS is
an important yardstick with which we can measure key aspects
of the quality of our national immunization program.
Vaccines for Children
The Vaccines for Children (VFC) program is a federally funded
program that provides vaccines at no cost to children who might
not otherwise be vaccinated because of inability to pay. CDC
buys vaccines at a discount and distributes them to grantees—
i.e., state health departments and certain local and territorial
public health agencies—which in turn distribute them at no
charge to those private physicians' offices and public health
clinics registered as VFC providers. VFC program has markedly
reduced the cost of vaccinations for patients and
providers).Vaccine Adverse Event Reporting System
The Vaccine Adverse Event Reporting System (VAERS) is a
national vaccine safety surveillance program run by CDC and
the Food and Drug Administration (FDA). VAERS serves as an
early warning system to detect possible safety issues with U.S.
vaccines by collecting information about adverse events
(possible side effects or health problems) that occur after
vaccination. VAERS is detecting unusual or unexpected patterns
of adverse event reporting that might indicate a possible safety
problem with a vaccine (VAERS, 2017).
Immunization Systems in Malaysia
In Malaysia, mass vaccination is practiced in public schools.
The vaccines may be administered by a school nurse or a team
of other medical staff from outside the school. All the children
in a given school year are vaccinated as a cohort. For example,
children may receive the oral polio vaccine in Year One of
primary school (about six or seven years of age), the BCG in
Year Six, and the MMR in Form Three of secondary school.
Therefore, most people have received their core vaccines by the
time they finish secondary school.
Children who did not receive complete primary immunization at
the age of 12 months were more likely to be girls, from urban
areas, belonging to mothers who do not trust that vaccines can

20. prevent spread of diseases, and received care at private
facilities (Ahmad, Jahis, Kuay, Jamaluddin, & Aris, 2017).
Immunization coverage for each of the recommended vaccine
was high. However, more attention should be given to
immunization timeliness to ensure that the benefits of the
available vaccines are fully utilized. Immunization timeliness of
children of low educated parents, born in large family should be
closely monitored (Awadh, A. I., Hassali, M. A., Al-lela, O. Q.,
& Bux, S. H. (2015).
The School Health Program
The school health program in Malaysia has remained well
established since its inception in 1967, with a strong track
record. It was initiated as a pilot program and after experience
had been gained, it was extended nationwide. Strong school
health teams have been created through adequate capacity-
building (training and periodic re-training, supportive
supervision, etc.), and work is being guided by written standard
operating procedures, used nationwide and with infrequent
operational changes, thus ensuring universal awareness of
procedures. Adequate resources are being provided, including
person power, transportation and free vaccines. Incorporating
school-based immunization as part of a comprehensive school
health program seems to facilitate the acceptance of vaccination
as multiple and non-threatening interactions take place between
the members of the school health team and the pupils before
immunizations are being given. General parent consent obtained
upon establishing the individual school health records supports
administration of all subsequent vaccinations. AEFI
management appears well established.
Optional Vaccines in Malaysia
Most paediatricians will recommend additional or optional
vaccinations in addition to the ones mandated by the Ministry of
Health. You can choose to administer them to your children,
based on your doctor’s advice.
· > 6 weeks : Rotavirus
· > 2 months : Pneumococcal

21. · > 6 months : Influenza
· > 10 months : Hepatitis A
· > 12 months :Chicken pox
Seasonal Influenza
Conducted study was undertaken in a cross-sectional survey at
three hospitals in Kuala Lumpur and Selangor, Malaysia, to
ascertain the rate of influenza vaccination uptake, the
knowledge and attitude of HCWs regarding the influenza
vaccine as well as the employers’ policy on encouraging their
workers’ influenza vaccination uptake. This study has
demonstrated more workers were vaccinated, with a significant
proportion of the healthcare workers believed they were
vaccinated to protect themselves, while most of those that were
not vaccinated claimed they are worried about the safety of the
vaccine. Most employers did not have a flu vaccination policy
in place. Hence, the need for government to enforce such policy
and make annual flu vaccination free and compulsory for all
healthcare workers.
Workplace Vaccination Against Influenza
Samad et al. (2006) sonducted a study to evaluate the health and
economic benefits of a workplace vaccination program against
influenza funded by the employer. Workplace vaccination of
healthy adults against influenza had a clear impact on ILI rates,
absenteeism and reduced productivity in this Malaysian
company. The health benefits translated into financial benefits
for the employer, with cost savings significantly outweighing
the costs of the vaccination programm.
Limitations
· School-based vaccine program. The two key informants
working in a low income countries said poor timetable planning
and documentation were concerns as these could result in
missed dosages, decreasing vaccine coverage and overall
program success
· Low Level of Awareness. Pathmanathan and Lakshmanan
(2014) stated that the rate of Hepatitis B infection is becoming
a growing concern where approximately 1.1 million people are

22. chronically infected with this virus. However, Overall, the level
of awareness and knowledge of hepatitis B is low. Each of the
three demographic characteristics such as age group, ethnic
group and educational qualification are a predictive factor. This
low level of awareness and knowledge should be improved
through health education and frequent vaccination programs on
Hepatitis B among the public; especially in Puchong, Malaysia
(Pathmanathan, & Lakshmanan, 2014).
· Vaccination Refusal. The increase in Muslim parents’ refusal
and hesitancy to accept childhood vaccination was identified as
one of the contributing factors in the increase of vaccine-
preventable diseases cases in countries such as Afghanistan,
Malaysia and Pakistan. The spread of inaccurate and
irresponsible information by the anti-vaccination movement
may inflict more harm than good on Muslim communities. To
curb this issue, health authorities in Pakistan and Malaysia have
resorted to imposing strict punishments on parents who refuse
to allow their children to be vaccinated. Information addressing
religious concerns such as the halal issue must be made priority
and communicated well to the general public, encouraging not
only the acceptance of vaccinations but motivating communities
to play an active role in promoting vaccination. Local
government of the affected region need to work towards
creating awareness among Muslim parents that vaccinations are
a preventative public health strategy that has been practiced and
acknowledged by many doctors of all faiths (Ahmed et el.,
2017).
· Parents’ Knowledge. The educational intervention used in this
study focused on improving parents’ knowledge about
childhood immunization in Malaysia and has brought about a
significant positive change in their knowledge about childhood
immunization, compared with the baseline results.
· Other Factors. Multivariable logistic regression analyses
model revealed that factors significantly associated with
complete immunization coverage were ethnicity, occupation of
the mother, head of household's education level, and head of

23. household's occupation. While sex, citizenship, household
income, mother's age, and marital status were not significantly
associated with complete immunization coverage (Lim et el.,
2017).
Global Immunization
Global Immunization Vision and Strategy
In response to challenges in global immunization, WHO and
UNICEF developed the Global Immunization Vision and
Strategy (GIVS). Launched in 2006, GIVS is the first ever ten-
year Framework aimed at controlling morbidity and mortality
from vaccine-preventable diseases and helping countries to
immunize more people, from infants to seniors, with a greater
range of vaccines (WHO, 2011).
According to WHO (2011), GIVS has four main aims:
· to immunize more people against more diseases;
· to introduce a range of newly available vaccines and
technologies;
· to integrate other critical health interventions with
immunization; and
· to manage vaccination programs within the context of global
interdependence. CDC's Strategic Framework for Global
Immunization
CDC’s Strategic Framework for Global Immunization 2016-
2020, is built around five interconnected goals: an overarching
goal to improve global health impacts; three goals to increase
the amount of people reached by strengthening country-owned
immunization programs; and CDC’s foundational goal of
providing evidence for effective policy and program
implementation (CDC, 2016).
Global Policy Recommendation
In developing and formulating policy recommendations, WHO
considers factors in addition to the benefit - risk assessment
performed by regulators, e.g. important contextual elements
such as the feasibility of implementation, epidemiological
factors that influence performance of the vaccine, the value of
the vaccine in the context of other control measures, and the

24. likely cost - effectiveness of the intervention in different
settings (WHO, 2017).
References
CDC (2016)
https://www.cdc.gov/globalhealth/immunization/framework.htm
l
WHO (2017)
http://www.who.int/immunization/policy/WHO_vaccine_develo
pment_policy.pdf?ua=1
WHO (2011). http://www.who.int/immunization/givs/en/
UNICEF (2015)
https://www.unicef.org/immunization/files/unicef-who-
immunization-coverage-2015.pdf
VAERS (2017). https://vaers.hhs.gov/
Ventola, C. L. (2016). Immunization in the United States:
Recommendations, Barriers, and Measures to Improve
Compliance: Part 1: Childhood Vaccinations. Pharmacy and
Therapeutics, 41(7), 426–436.
Ahmad, N. A., Jahis, R., Kuay, L. K., Jamaluddin, R., & Aris,
T. (2017). Primary Immunization among Children in Malaysia:
Reasons for Incomplete Vaccination. Journal of Vaccines &
Vaccination, 8(3), 1-8.
Awadh, A. I., Hassali, M. A., Al-lela, O. Q., & Bux, S. H.
(2015). Factors Affecting Parents’ Knowledge And Practice
About Childhood Immunization: Experience From Malaysia.
Value in Health, 18(3), A104-A105.
Pathmanathan, H., & Lakshmanan, P. (2014). Assessment of
awareness and knowledge of hepatitis B among the residents of
Puchong, Malaysia. Tropical Journal of Pharmaceutical
Research, 13(10), 1719-1724.
Ahmed, A., Lee, K. S., Bukhsh, A., Al-Worafi, Y. M., Sarker,
M. M. R., Ming, L. C., & Khan, T. M. (2017). Outbreak of
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Journal of infection and public health.

25. Lim, K. K., Chan, Y. Y., Ani, A. N., Rohani, J., Norfadhilah, Z.
S., & Santhi, M. R. (2017). Complete immunization coverage
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Samad, A. H., Usul, M. H., Zakaria, D., Ismail, R., Tasset-
Tisseau, A., Baron-Papillon, F., & Follet, A. (2006). Workplace
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Hendrix, K. S., Sturm, L. A., Zimet, G. D., & Meslin, E. M.
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Vaccination Systems
As indicated in your readings, health and development work
together. Compare and contrast vaccination systems in two
developing countries and one more economically developed
country (MEDC).
1. Address how the developing countries can improve their
systems, including:
· current systems,
· weak components in the current system, and
· elements that can be improved, as seen in MEDC successes.
Your paper should meet the following structural requirements:
· Be six to eight pages in length, not including the cover or
reference pages
· Be formatted according to APA format.
· Provide support for your statements with in-text citations from
a minimum of seven scholarly articles.

26. · Utilize headings to organize the content in your work.
You can use the following references
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