WHO Vaccine Manual PDF
WHO Vaccine Manual PDF
WHO Vaccine Manual PDF
FALSE CONTRAINDICATIONS
TO VACCINATION
Training manual
VACCINE SAFETY AND
FALSE CONTRAINDICATIONS
TO VACCINATION
Training manual
Abstract
Health professionals are the single most important influence on whether individuals decide to have
themselves or their children vaccinated; therefore, information and education for health professionals are
essential. The aim of this training manual is to present “state-of-the-art”, authoritative, scientifically valid
advice to counter common misperceptions of vaccination.
Keywords
IMMUNIZATION
VACCINE SAFETY
VACCINE SIDE EFFECTS
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Table of contents
Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vi
Abbreviations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii
1. Scope and purpose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
2. Safety of vaccines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1
2.1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
2.1.1. Pre-licensure testing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
2.1.2. Post-licensure testing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
2.1.3. Manufacture of vaccines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
2.1.4. Addition of a vaccine to a recommended immunization schedule . . . . . . . . . . . . 4
2.1.5. Continuous monitoring of the safety of vaccines . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
2.1.6. Role of clinicians in vaccine safety . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
2.1.7. Predictable pattern of behaviour when a new vaccine is introduced . . . . . . . . . . 5
2.2. Vaccine safety institutions and mechanisms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
2.2.1. National regulatory authorities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
2.2.2. Immunization safety surveillance system . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
2.3. Adverse events after vaccination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
2.3.1. Vaccine reactions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
2.3.2. Reactions associated with defective vaccine quality . . . . . . . . . . . . . . . . . . . . . . 12
2.3.3. Reactions due to vaccination errors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
2.3.4. Reactions due to anxiety about vaccination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
2.3.5. Coincidental events . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
2.4. Case definitions and treatment of adverse events after vaccination . . . . . . . . . . . 14
2.5. Reporting of adverse events after vaccination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
2.5.1. Events to be reported . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
2.5.2. Timing of reporting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
2.5.3. Mode of reporting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
2.5.4. Reporting adverse events during immunization campaigns . . . . . . . . . . . . . . . 20
2.5.5. Barriers to reporting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
2.5.6. Vaccine Adverse Events Information Management System (VAEIMS) . . . . . . . 21
3. Valid and false contraindications to vaccination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
3.1. When to vaccinate safely . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
3.1.1. Contraindications to commonly used vaccines and precautions to be taken . 22
3.1.2. Precautions for administration of rotavirus vaccine . . . . . . . . . . . . . . . . . . . . . . 25
3.2. Misperceptions about vaccination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
4. Facts and myths about vaccination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
4.1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
4.2. Reasons given for refusing vaccination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
4.2.1. Barriers to vaccination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
4.2.2. Objections to vaccines based on religious beliefs . . . . . . . . . . . . . . . . . . . . . . . . . 30
iii
4.3. Responding to concerns . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
4.3.1. Vaccine manufacture and testing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
4.3.2. The immune system and the host response . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
4.3.3. Are vaccines really necessary? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
4.3.4. Relations between vaccination and neurological disease . . . . . . . . . . . . . . . . . . 38
4.3.5. Relation with other diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
5.1. Conservation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
5.1.1. The cold chain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
5.1.2. Vaccine storage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
5.1.3. Vaccine vial monitors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
5.2. Vaccine administration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
5.2.1. Which, when, where and how . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
5.2.2. Simultaneous administration of several vaccines . . . . . . . . . . . . . . . . . . . . . . . . 50
5.3. Vaccination records . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
5.3.1. Records of health care providers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
5.3.2. Patient records . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
5.3.3. Vaccination information systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
5.4. Advice on vaccination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
5.4.1. Before vaccination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
5.4.2. At the doctor’s office . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
5.4.3. After vaccination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
6. Vaccination in special situations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
6.1. Altered immunocompetence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
6.1.1. Immunodeficiency . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
6.1.2. Vaccination of contacts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
6.2. Conditions that might cause immunodeficiency . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
6.2.1. HIV infection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
6.2.2. Congenital immunodeficiency in children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
6.2.3. Recipients of haematopoietic cell transplants . . . . . . . . . . . . . . . . . . . . . . . . . . . 56
6.2.4. Recipients of solid organ transplants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
6.2.5. Anatomical or functional asplenia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
6.2.6. Bleeding disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
6.2.7. Chronic illnesses in children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
6.3. Drugs that might cause immunodeficiency . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60
6.3.1. Corticosteroids . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60
6.3.2. Other immunosuppressive drugs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60
6.3.3. Antibody-containing products . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
6.3.4. Concurrent administration of antimicrobial agents and vaccines . . . . . . . . . . 62
6.4. Vaccination of preterm infants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
6.5. Vaccination during breastfeeding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64
6.6. Vaccination during pregnancy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64
6.7. Vaccination of patients with tuberculosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66
6.7.1. Tuberculosis skin test reactivity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66
6.7.2. Screening of people vaccinated with bacille Calmette-Guérin (BCG) . . . . . . . . 67
iv
6.7.3. Efficacy of BCG . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68
6.7.4. Revaccination with BCG . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68
6.7.5. Screening for severe combined immunodeficiency disease in countries with
universal BCG vaccination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68
6.8. Vaccination of people with lapsed or unknown immunity . . . . . . . . . . . . . . . . . . . . 69
6.8.1. Interchangeability of brands . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
6.8.2. Catch-up vaccination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
6.10 Vaccination for travellers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
7. Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72
8. Clinical cases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72
8.1. Case 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72
8.2. Case 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79
Annex. Frequency of adverse reactions to commonly used vaccines . . . . . . . . . . . . . . . . 99
v
Acknowledgements
The authors of the training manual are listed below. They received guidance from WHO Regional
Office for Europe.
Professor Federico Martinón-Torres, the Head of Translational Paediatrics and Infectious Diseases
Service of Hospital Clínico of the University of Santiago, the Associate Professor of Paediatrics of
the University of Santiago, and the Coordinator of Genetics, Vaccines, Infections and Paediatrics
Research Group of the Health Care Research Institute of Santiago, Spain.
Dr Irene Rivero Calle, the Consultant in Paediatrics of Translational Paediatrics and Infectious
Diseases Service of the Hospital Clínico of the University of Santiago, Spain.
vii
1. Scope and purpose
Vaccination has been demonstrated repeatedly to be one of the most effective interventions for
preventing disease worldwide. Ironically, the fact that vaccines are administered to healthy people
to prevent diseases that have become rare, largely thanks to vaccination, contributes to concern
about vaccine safety. Because the devastating effects of the diseases are no longer prominent,
public attention is focused on side-effects of vaccination. This influences how people weigh up
the risks and benefits of vaccination, leading in some instances to reduced vaccination rates
and outbreaks of disease; however, the minimal risks associated with vaccination are totally
overshadowed by the health risks associated with non-vaccination.
Health professionals are the single most important influence on whether individuals decide to
have themselves or their children vaccinated; therefore, information and education for health
professionals are essential. The aim of this training manual is to present “state-of-the-art”,
authoritative, scientifically valid advice to counter common misperceptions of vaccination.
2. Safety of vaccines
2.1. Introduction
The vaccines used in national immunization programmes are safe and effective; however, like
other pharmaceutical products, vaccines are not completely risk-free, and adverse events occur
occasionally after vaccination. Although most such events are minor (e.g. redness at the injection
site, fever), more serious reactions (e.g. seizures, anaphylaxis) can occur at a very low frequency
(Annex 1).
The general public has low tolerance for any adverse events after vaccination, because vaccines
are given to healthy people to prevent disease. Therefore, vaccines are expected to have a
higher standard of safety than the medications used to treat people who are sick (e.g. antibiotics
and insulin)1,2. The lower public tolerance for risk after vaccination means that a greater effort
must be made to detect and investigate any adverse event than is generally expected for other
pharmaceutical products.
National regulatory authorities are responsible for ensuring the quality, safety and effectiveness
of vaccines and other pharmaceutical products3. Before vaccines are introduced into an
immunization programme, they are evaluated for their safety and efficacy in clinical trials. Once
they are introduced, their manufacturing process undergoes thorough, continuous review, and the
national regulatory authorities continue to monitor and investigate adverse events to ensure that
the vaccines are safe for the entire population.
National regulatory authorities set the rules for three phases of clinical trials in order to ensure
the safety of the volunteers. Researchers test vaccines in adults first.
• Phase 1: 20–100 healthy volunteers are tested to determine whether a vaccine is safe, appears
to work and has any serious adverse effects.
• Phase 2: Several hundred volunteers are tested to determine the commonest short-term side-
effects, whether the size of the dose is related to any side-effects and how the volunteers’
immune systems respond to the vaccine.
• Phase 3: Hundreds or thousands of volunteers are tested to determine whether the people who
receive the vaccine are similar to those who don’t, whether the vaccine is safe and effective
and the commonest side-effects.
Once a vaccine has been determined to be safe and effective, the regulatory authority grants a license
to allow its sale and distribution. It is at this point that post-licensure monitoring of the vaccine begins.
A national regulatory authority licenses a vaccine only if it is safe and effective and if the benefits
outweigh the risks1-3. Vaccines are then made in batches, called “lots”. Manufacturers must test
all lots to make sure that they are safe, pure and potent. Lots can be released only after the
national regulatory authority has reviewed their safety and quality by inspecting manufacturing
facilities regularly. Every lot of vaccine must be tested and double-checked for safety, potency
and purity to assure the uniformity of every dose of vaccine given. Each lot is precisely identified
to allow follow-up.
PRODUCTION
VIRUS
VESSEL
GENERATE ANTIGEN,
PURIFY STRENGTHEN VIALS
RELEASE & ISOLATE
BACTERIA
DISTRIBUTE
Viruses: For many viral vaccines, the process begins with small amounts of a specific virus that
can be grown in cell cultures. Various cell types may be used, such as cells from chicken embryos
and cell lines that reproduce repeatedly.
Bacteria: Bacteria can be grown in bioreactors. Some antigens can be manufactured within
bacteria or yeast.
The second step is to release the antigen from the cells and isolate it from the material in which
it is grown. As proteins and other parts of the growth medium may still be present, they must be
removed in the next step. The goal in this stage is to release as much virus or bacteria as possible.
The third step is purification of the antigen. For vaccines that are made from recombinant proteins,
this may involve chromatography and ultrafiltration.
The fourth step may be addition of an adjuvant, which is a material that nonspecifically enhances
immune responses. Vaccines may also include stabilizers to prolong shelf-life or preservatives to
allow safe use of multi-dose vials.
In the final step, all the components of the final vaccine are combined and mixed uniformly in
a single vessel. Then, the vaccine is placed into vials or syringe packages, sealed with sterile
Safety of vaccines 3
stoppers or plungers and labelled for distribution. Some vaccines are freeze-dried and then
rehydrated at the time of administration.
Additives are used in vaccines for several reasons, such as to stabilize vaccines in adverse conditions
(e.g. extreme temperatures of heat and freeze-drying), to improve the immune response to the
vaccine, to prevent the vaccine components from adhering to the sides of the vial and to prevent
fungal or bacterial contamination4, 5. Examples of additives include lactose and sucrose (sugars),
glycine and monosodium glutamate (amino acids or salts of amino acids), human or bovine serum
albumin (proteins) and gelatin. These additives ensure that vaccines remain safe and effective.
Some vaccines contain stabilizers to maintain the vaccine’s safety and effectiveness under various
conditions and temperatures. Gelatin and lactose–sorbitol are examples of stabilizers.
Adjuvants are chemicals added to enhance the body’s immune response to a vaccine. Various
forms of aluminium salts are commonly used. A recent review of all the available studies
of aluminium-containing diphtheria, tetanus and pertussis (DTP) vaccines (either alone or in
combination) provided no evidence that aluminium salts in vaccines cause any serious or long-
term adverse events6-9.
A diluent is a liquid used to dilute a vaccine to the proper concentration. In vaccines, it is usually
sterile saline or water.
Preservatives are included in some vaccines to prevent fungal or bacterial contamination, mostly
in vaccines that are manufactured in multi-dose vials.
Remnants after manufacture: Often, chemicals are used during vaccine manufacture and then
removed from the final product. For example, formaldehyde might be used to kill a vaccine virus,
or antibiotics might be used to prevent bacterial contamination while viruses are growing in the
laboratory. When these chemicals are removed, trace amounts might remain. While some of
these chemicals might be harmful in large doses, the trace amounts left are too small to have any
toxic effect4,5.
A “vaccine adverse event information management system” (VAEIMS) is used to collect and
analyse reports of adverse events after vaccination11. For example, in the USA, anyone can submit
such a report, including parents, patients and health care professionals. A vaccine safety datalink
is a network of health care organizations, through which information is made available to the
population.
The vaccinee should be informed or motivated to receive the vaccine and educated by receiving
clear facts. The person delivering the vaccine should then screen the vaccinee for potential
contraindications, including pre-existing health conditions, allergies, previous adverse events,
antecedents of fainting (syncope) and pregnancy. The vaccinee should be asked to sit or lie down
and should be observed for at least 30 min. The person giving the vaccine should be ready in
advance for common events such as fainting and rare anaphylactic reactions.
The success of vaccination makes it its own worst enemy. Owing to effective vaccination
programmes, most people in industrialized countries have never experienced the devastating
vaccine-preventable diseases, and many people believe that these diseases no longer pose a
threat, as they are no longer visible. Now, some people consider that vaccines are more dangerous
than the diseases they prevent. In some countries, such misperceptions have led to decreased
coverage and a resurgence of contagious diseases12, as viruses do not respect borders.
Vaccination is a changing science, and, like all aspects of public health, it has social, political and
economic implications. The behaviour towards introduction of a new vaccine is cyclical, with a
similar pattern observed in the past, the present and probably again in the future (Fig. 2).
Safety of vaccines 5
Fig. 2. Pattern of perception of vaccination
Source: Adapted from Chen RT, Rastogi SC, Mullen JR, Hayes SW, Cochi SL, Donlon JA, et al. The Vaccine Adverse Event Reporting
System (VAERS). Vaccine. 1994 May;12(6):542-50
As vaccination coverage increases, the prevalence, and thus the fear, of the disease decreases. The
rate of adverse events remains constant until very high coverage has been achieved, when more
adverse effects are seen globally, with a rapid effect on the mass media, which leads to doubts,
fears and finally denial of vaccination. Coverage rapidly decreases, and the disease reappears.
Resurgence of the disease usually recalls fear of the disease, and vaccination is resumed. Ideally,
the disease is eradicated, and the vaccine is no longer necessary.
Fig. 3 illustrates this pattern. When vaccine coverage is 80%, about 2000 cases may be found;
when coverage falls to 20%, the number of cases increases dramatically, to 45 00013. Subsequently,
vaccination is resumed, and the disease is again controlled.
Fig. 3. Reappearance of pertussis in the United Kingdom due to reduced vaccination coverage
Notifications Vaccine
coverage (%)
200,000 100
Notifications Vaccine coverage (%)
180,000
Immunisation 80
160,000
140,000 60
120,000
40
100,000
20
80,000
60,000 0
40,000
20,000
0
1940 1950 1960 1970 1980 1990 2000
Year
Source: Immunisation against infectious disease 1996, Eds. Salisbury DM and Begg NT. En: Edward Jenner, Bicentenary Edition
Fig. 4. Components of a global vaccine safety monitoring, investigation and response system
Other partners
Product monitoring
Vaccine Licensing authorities in Procurement
manufacturers country of manufacture agencies
GACVS, Global Advisory Committee on Vaccine Safety; CIOMS, Council for International Organizations of Medical Sciences; AEFI,
adverse effects after vaccination; PIDM, Programme for International Drug Monitoring
The national regulatory authority and the national immunization programme together are
responsible for seting up and maintaining a national surveillance system for adverse events
after vaccination, often with a review committee and other support groups, such as academic
institutions and technical agencies1-3, 10, 11. In countries that produce their own vaccines, vaccine
manufacturers and national control laboratories may be part of the surveillance system.
Safety of vaccines 7
Fig. 5. Functions of a national regulatory authority, depending on the source of vaccines15
FUNCTION 1
Marketing authorization
and licensing activities
FUNCTION 2
AEFI surveillance
FUNCTION 3
NRA lot release
• passive surveillance, or reporting all spontaneous adverse events after vaccination. Its main
strength is early detection of previously undetected serious adverse events (signals), but it
has many limitations, including underreporting.
• active surveillance, used primarily to characterize the rates of adverse events and risk factors.
Countries may conduct active surveillance for only selected adverse events at selected
institutions (sentinel sites) or in the community (e.g. cohort event monitoring).
• ad hoc studies, in which epidemiological studies are conducted to extend specific aspects of
vaccination safety surveillance, such as testing hypotheses of causality.
Safety of vaccines 9
Adverse events after vaccination are grouped into five categories17, depending on whether they are
due to:
• the vaccine product: an adverse event caused or precipitated by a vaccine due to one or more of
its inherent properties. Example: extensive limb swelling after administration of DTP vaccine
• quality: an adverse event caused or precipitated by a vaccine with one or more defects, including
the administration device provided by the manufacturer. Example: paralytic poliomyelitis due
to failure by a manufacturer to completely inactivate a lot of poliovirus vaccine
• vaccination error: an adverse event due to inappropriate handling, prescription or administration
of a vaccine. Example: transmission of infection from a contaminated multidose vial
• anxiety: an adverse events arising from anxiety about the procedure. Example: vasovagal
syncope in an adolescent during or after vaccination
• a coincidental event: an adverse event caused by an event other than the vaccine, vaccination
error or anxiety. Example: a fever occurring at the time of vaccination (temporal association)
that is in fact due to a viral infection
Vaccine reactions are due to either the vaccine product or the quality of the vaccine quality.
Vaccination induces immunity by causing the recipient’s immune system to react to the antigens
contained in the vaccine. Local and systemic reactions such as pain or fever may be part of the
immune response. Other vaccine components (e.g. adjuvants, stabilizers and preservatives) can
also trigger reactions17. In a successful vaccine, even minor reactions are kept to a minimum while
the best possible immune response is elicited.
Vaccine reactions likely to be observed with some of the most commonly used vaccines, their
frequency and their treatment are listed in Table 218. Reactions typically occur within 1–2 days of
vaccination (except for rash reactions after measles vaccination, which can arise 6–12 days after
vaccination) and persist for 1–2 days19.
Severe vaccine reactions include seizures, thrombocytopenia, hypotonic hyporesponsive episodes and
prolonged crying (Table 3), all of which should be reported. Most severe vaccine reactions do not result
in long-term problems. Anaphylaxis, while potentially fatal, is treatable without long-term effects.
Table 3. Frequency and delay to onset of severe reactions to commonly used vaccines
Safety of vaccines 11
2.3.2. Reactions associated with defective vaccine quality
These adverse events are caused or precipitated by a vaccine that has one or more defects, including the
administration device provided by the manufacturer. An example would be failure by the manufacturer
to completely inactivate a lot of poliovirus vaccine. If the reaction is related to a particular lot or batch,
the distribution of the lot or batch should be ascertained and instructions provided on its use. The
national regulatory authority and the marketing authorization holder should be notified about the
adverse event, and these bodies should communicate the information to the manufacturer18.
Table 4. Vaccination errors resulting from errors in vaccine preparation, handling, storage or administration
Vaccination errors can result in a cluster of events, i.e. two or more cases of the same adverse
event related in time, place or the vaccine administered. Clusters are usually associated with a
particular provider or health facility or a vial of vaccine that has been inappropriately prepared or
contaminated. Errors may affect many vials; for example, freezing vaccine during transport may
increase the number of local reactions.
• Fainting is relatively common, mainly among older children and adults. This vasovagal reaction may
lead to loss of postural tone and consciousness. Patients recover spontaneously, and the main risks
are related to falling and not to the underlying mechanism or syncope. Fainting can be prevented by
adequate explanation, vaccination of a patient when he or she is seated or lying down (to avoid injury
caused by falling) and placing patients in a recumbent position after the injection, particularly if they
are prone to fainting (such as adolescents and people with a previous history of fainting).
• Hyperventilation due to anxiety about vaccination can cause light-headedness, dizziness and tingling
around the mouth and in the hands.
• Vomiting: Vomiting is a common anxiety symptom in young children. Breath-holding spells may
occur, which can result in brief unconsciousness, during which breathing resumes.
• Convulsions: An anxiety reaction to injection can, on rare cases, include convulsions. Convulsions
usually occur in the context of a vasovagal reaction and syncope, soon after or with the loss of
postural tone and consciousness that characterizes syncope. Such seizures are due to anoxia, are
usually self-limited and benign and do not require antiepileptic drug therapy.
Mass vaccination events can generate a mass psychogenic reaction25, which is the collective
occurrence of symptoms (e.g. headache, dizziness, loss of consciousness) suggestive of organic
illness in a group with shared beliefs about the cause of the symptoms. Adolescents are particularly
prone, resulting in fainting, sometimes accompanied by tonic–clonic seizure-like movements (not
seizures). Clear explanation of vaccination and calm, confident delivery will decrease the level of
anxiety and reduce the likelihood of an occurrence.
Coincidental events are inevitable when children in these age groups are vaccinated, especially
during mass campaigns. The commonest mistake is to establish a causal link between vaccination
and the coincidental event because of the temporal relation. Individual case ascertaiment is not
always easy for a frontline physician, and epidemiological surveillance is essential. The expected
numbers of coincidental events after vaccination can be obtained by comparing the normal
incidences of disease and death in these age groups with the coverage and timing of vaccination.
Safety of vaccines 13
2.4. Case definitions and treatment of adverse events after
vaccination
Health workers should know how to recognize and treat adverse events after vaccination,
immediately if they are serious. Common adverse events and their treatment are listed below17,18,24,25.
• Fever
Fever can be classified (on the basis of rectal temperature) as mild (38–38.9 °C), high (39-40.4 °C) and
extreme (≥40.5°C). Fever on its own need not be reported. Treatment is symptomatic with paracetamol.
• Local infection
A fluctuant or draining fluid-filled lesion at the site of injection is of bacterial origin if there is
evidence of infection (e.g. purulent, inflammatory signs, fever, culture) and a sterile abscess if not.
Treatment involves incision and drainage; antibiotics should be given if the infection is bacterial.
Local reactions of lesser intensity occur commonly and and need not be reported. They resolve
spontaneously within a few days to a week, and symptomatic treatment with analgesics or
antibiotics is inappropriate.
• Seizures
These comprise generalized convulsions that are not accompanied by focal neurological signs or
symptoms. Febrile seizures occur if the rectal temperature is >38°C (rectal) and afebrile seizures
if the temperature is normal. Seizures are self-limiting; supportive care with paracetamol and
cooling may be given if the patient is febrile. Anticonvulsants are rarely required.
• Encephalopathy
Acute onset of major illness characterized by any two of the following:
• seizures,
• evere alteration in the level of consciousness lasting for ≥ 1 day,
• distinct change in behaviour lasting ≥ 1 day.
If it is related to vaccination, it should occur 7–12 days after administration. No specific treatment
is available; supportive care should be given.
• Thrombocytopenia
Serum platelet count < 50 000/mL, leading to bruising and/or bleeding. The condition is usually
mild and self-limiting; occasionally, steroids or platelet transfusion is required.
Less severe allergic reactions need not be reported. Self-limiting; antihistamines may be helpful.
• Anaphylaxis
Anaphylaxis is very rare (estimated as once every million doses of vaccine given) but is a severe,
potentially life-threatening allergic reaction. When anaphylaxis occurs, it must be diagnosed
properly and the patient treated and managed urgently by trained staff and transferred to hospital.
Health workers who lack training are highly likely to misdiagnose fainting (vasovagal syncope)
and dizziness after vaccination as the onset on anaphylaxis; most episodes of malaise or fainting
that occur immediately after vaccination are not due to the onset of anaphylaxis.
Programme managers must take these aspects into consideration before deciding at which level of
the health system treatment for anaphylaxis will be provided during a campaign. Once a decision is
made, the appropriate staff should receive training and equipment for the management of anaphylaxis.
Vaccinators should be able to distinguish anaphylaxis from fainting, anxiety and breath-holding
spells, which are common benign reactions (Table 5). A person who is fainting suddenly becomes
pale, loses consciousness and collapses (unless supported). Fainting is sometimes accompanied by
brief clonic seizure activity (i.e. rhythmic jerking of the limbs), which requires no specific treatment
or investigation. Fainting is relatively common after vaccination of adults and adolescents but
very rare in young children. It is managed by simply placing the patient in a recumbent position.
Consciousness is recovered within 1–2 min, but the patient may take more time to recover fully.
An anxiety spell can lead to a pale, fearful appearance and symptoms of hyperventilation (light-headed,
dizziness, tingling in the hands and around the mouth). Breath-holding occurs in young children, leading
to facial flushing and cyanosis, and may end in unconsciousness, during which breathing resumes.
Safety of vaccines 15
Recognition of anaphylaxis
Anaphylaxis is a severe reaction of rapid onset (usually 5–30 min after the injection), characterized
by circulatory collapse. The early signs of anaphylaxis are generalized erythema and urticaria and
upper and/or lower respiratory tract obstruction. In more severe cases, limpness, pallor, loss of
consciousness and hypotension are also seen.
Vaccinators should be able to recognize the signs and symptoms of anaphylaxis. In general, the
more severe the reaction, the more rapid the onset. As most life-threatening reactions begin
within 10 min of vaccination, recipients should be kept under observation for at least 30 min after
the injection18,24,25. The clinical progression of anaphylaxis from mild, early-warning signs to late,
life-threatening symtoms is as follows:
Unconsciousness is rarely the sole manifestation of anaphylaxis and occurs only as a late event
in severe cases. A strong central pulse (e.g. in the carotid) is maintained during a faint but not in
anaphylaxis. Although anaphylaxis usually involves multiple body systems, symptoms may be
seen in only one body system (e.g. skin), leading to delayed diagnosis. Occasional reports have
been made of symptoms recurring 8–12 h after the onset of the original attack and of prolonged
attacks lasting up to 48 h18,25.
Treatment of anaphylaxis
Once anaphylaxis has been diagnosed, the patient should be considered as having a potentially fatal
condition, regardless of the severity of the symptoms. Treatment should be started immediately
and plans made to transfer the patient swiftly to hospital (if he or she is not already in hospital).
Adrenaline stimulates the heart, reverses spasm in the lung passages and reduces oedema and
urticaria, thus countering anaphylaxis. This very potent agent can, however, cause an irregular
heartbeat, heart failure, severe hypertension and tissue necrosis if used at an inappropriate dose.
Administration of adrenaline for fainting is not only contraindicated but is very dangerous.
Vaccinators trained in the treatment of anaphylaxis should have rapid access to an emergency
kit with adrenaline and be familiar with its dosage and administration24,25. The expiry date of the
adrenaline should be written on the outside of the emergency kit, and the whole kit should be
checked three or four times a year. Adrenaline that has a brown tinge must be discarded18.
To improve detection of adverse events, the primary reporter should have good knowledge of
the types of events and the purpose of surveillance. Regular orientation, training and awareness
programmes can be used to update knowledge and maintain willingness among primary
reporters24,25.
Parents of infants and children to be vaccinated, health workers in vaccination facilities and the
staff of hospital accident and emergency departments are most likely to recognize or detect
adverse events after vaccination when they first occur. Health workers are responsible for
detecting adverse events after vaccination and reporting them when appropriate; they are also
responsible for treating or referring patients17,24,25. All vaccination staff and medical workers must
be capable of diagnosing adverse events. This requires effective training and education to ensure
accurate diagnosis based on clear case definitions, which can be included on the reporting form
and in national guidelines for adverse events after vaccination.
Reporting of minor adverse events, such as high fever and minor local reactions, is optional.
These are expected vaccine reactions; if all were reported, the reports would overwhelm the
system with information of limited value17. It is nevertheless helpful to record crude numbers of
events and compare them with background rates, which might indicate a product quality defects,
vaccination errors or even increased susceptibility for vaccine reactions in a particular population.
Table 6 lists suggested reportable events24,25. Each country should decide which events should
appropriately be included in its reporting system; however, they are encouraged to include a
broad range of events for the purposes of global harmonization of data.
Safety of vaccines 17
Table 6. Adverse events after vaccination that it is suggested be reported
BCG, bacille Calmette-Guérin; MMR, measles, mumps and rubella; DTP, diphtheria, tetanus toxoids and pertussis
The interval between vaccination and the onset of an event may not always be precise or well
established. Consequently, an interval is included in case definitions only for selected adverse
reactions. Case definitions should be simple. Those of the Brighton Collaboration provide different
levels of diagnostic certainty and are widely used27. Countries that find it difficult to adapt them
to their situations can, however, adopt other, valid case definitions for reporting purposes. Local
reactions that occur at increased frequency, even if they are not severe, should also be reported,
as they may indicate vaccination errors or inadequate quality of specific lots.
Table 7. Example of a standard form for reporting adverse events after vaccination
Patient identification
Case
For optimal monitoring of vaccine safety and meaningful analysis of adverse events after
vaccination, systematic, standard collection of critical data is essential. A limited number of
variables are required to manage adverse events properly, including the unique identifier of
the report, the primary source of information, patient characteristics, details of the event, the
vaccine(s) of interest and the possibility for collecting additional information if needed.
Safety of vaccines 19
2.5.4. Reporting adverse events during immunization campaigns
In a campaign, a large number of doses are given during a short period, so that there will be
more vaccine reactions and coincidental events26. The rate of events remains unchanged, but the
increased number is readily apparent to both staff and the public, particularly when injectable
vaccines are used and especially at a time of intensive social mobilization26. Programme errors
may also increase during campaigns.
Careful planning will limit negative publicity about an adverse event after vaccination. During
a mass or a special vaccination programme, it is of utmost importance to ensure that adverse
events are reported, for two reasons26:
• Unless an event that occurs during a mass vaccination campaign is properly investigated and
analysed, it may raise concern in the public and may affect the vaccination programme.
• In special immunization programmes, a new vaccine may be introduced for which there is no prior
experience of or little information on adverse reactions. Signs can be detected by strengthening
surveillance during such programmes and may be used to improve the quality of the vaccine.
Even if a national programme does not yet have a functioning adverse events surveillance system,
some form of monitoring is essential in mass campaigns. Otherwise, the public is likely to hear of
an adverse event before the programme manager does, and the situation may become difficult to
control. Surveillance should be simple, flexible and rapid.
One person should be assigned overall responsibility for surveillance of adverse events, who
should be the focal point and the spokesperson. The person may be the manager of the Expanded
Programme on Immunization, the person in charge of surveillance at national level or a staff
member at the national regulatory authority. This is particularly important if surveillance is
conducted by a structure other than the Expanded Programme, if there is a national regulatory
authority or if there is a common monitoring scheme for drugs and vaccines26. Decisions should
be made on what to report, how to report and who is to receive reports. The list of events to
be reported should not be complicated. Countries with limited reporting capacity should decide
which events should be reported during a campaign26.
• deciding that the event was not due to vaccination (however, all events after vaccination as per
the definition should be reported);
• lack of knowledge about the reporting system and process;
• apathy, procrastination, lack of interest or time; inability to find the reporting form;
• fear that the report will have personal consequences; and
• guilt for having caused harm and being held responsible for the event and diffidence about
reporting an event for which the reporter is not confident about the diagnosis.
VAEIMS allows transfer of data from a national database to the global database (Vigibase), as it is
E2B-compatible, for sharing information on adverse events after vaccination25. Both a web-based
and an offline version of VAEIMS are available free of charge. The web-based version includes real-
time data uploading, data sharing and analysis. Later, reporting of adverse events after vaccination
from the periphery to national level will be facilitated by the collection of data on mobile telephones.
A contraindication to vaccination is a rare characteristic of a recipient that increases their risk for a
serious adverse reaction. Ignoring contraindications can lead to vaccine reactions. One of the most
serious reactions after vaccination is anaphylaxis, which is the only absolute contraindication to
subsequent doses of the same vaccine25. Most contraindications, such as severe acute illness (e.g.
acute respiratory tract infection) or treatment with steroids, are temporary, and the vaccination can
be administered later. These are known as “temporary” or “relative” contraindications. In addition,
people who are severely immunocompromised generally should not receive live vaccines25.
Children who experience encephalopathy within 7 days of a dose of diphtheria and tetanus toxoids,
There is no evidence that the fetuses of pregnant women vaccinated with inactivated virus, bacterial
vaccines or toxoids are at risk28,29. Live attenuated vaccines administered to a pregnant woman pose
a theoretical risk to the fetus, but the benefits of vaccinating pregnant women usually outweigh the
potential risks when the likelihood of exposure to the disease-causing agent is high, when infection
would pose a risk to the mother or the fetus and when the vaccine is unlikely to cause harm29.
The safety and effectiveness of vaccines in immunocompromised persons are determined by the
type of immunodeficiency and degree of immunosuppression. Each person is different and should
be considered unique with regard to vaccination. Under-immunized people are at risk for serious
illness and death, and every effort should be made to ensure adequate protection through vaccination.
Nevertheless, inappropriate use of live attenuated vaccine can cause serious adverse events in some
immunocompromised people due to uncontrolled replication of the vaccine virus or bacterium29.
Precautions should be taken when a recipient has a condition that might increase his or her risk for
a serious adverse reaction or that might compromise the ability of the vaccine to produce immunity;
examples are administration of measles vaccine to a person who is passively immune to measles due
to exposure during a blood transfusion, or administration of influenza vaccine to a person with a history
of Guillain-Barré syndrome within 6 weeks of a previous influenza vaccination. Such people might
experience more severe reactions to the vaccine than would otherwise have been expected; however,
the risk is lower than that expected with a contraindication. In general, vaccination should be deferred
if precaution is indicated. Vaccination might be indicated, however, if the benefit of protection outweighs
the risk for an adverse reaction. For example, a dose of DTaP should be considered for a person in a
community with a pertussis outbreak, even if he or she had Guillain-Barré syndrome after a dose. The
presence of a moderate or severe acute illness with or without a fever calls for caution in administering
any vaccine, and a personal or family history of seizures calls for caution in giving MMR vaccine29.
DT, diphtheria and tetanus toxoids; DTwP, diphtheria and tetanus toxoids and whole-cell pertussis; GBS, Guillian-Barré syndrome;
HBsAg, hepatitis B surface antigen; Hib, Haemophilus influenzae type b; HIV, human immunodeficiency virus; HPV, human
papillomavirus; OPV, oral poliovirus vaccine; MMR, measles, mumps and rubella; PCV, pneumococcal conjugate vaccine; SCID,
severe combined immunodeficiency; Td, tetanus and diphtheria toxoids; Tdwp, tetanus toxoid, reduced diphtheria toxoid and whole-
cell pertussis.
Events or conditions listed as indications for precautions should be reviewed carefully, and the benefits and risks of administering
a specific vaccine to a person under these circum¬stances should be considered. If the risk of adverse events from the vaccine is
considered to outweigh the benefits, the vaccine should not be administered. If the benefit of vaccination is considered to outweigh
the risk, the vaccine should be administered. Whether and when to administer DTaP to children with a proven or suspected
underlying neurological disorder should be decided case by case.
a HIV-infected children may receive varicella and measles vaccine if their CD4+ T-lymphocyte count is > 15%30
b MMR and varicella vaccines may be administered on the same day. If not, vaccination with these products should be separated
by at least 28 days. Measles vaccine might temporarily suppress tuberculin reactivity. Measles-containing vaccine can be
administered on the same day as tuberculin skin testing. If testing cannot be performed until after MMR vaccination, it should
be postponed for ≥ 4 weeks after vaccination. If skin testing is urgently required, it should be done on the understanding that
reactivity might be reduced by the vaccine.
c A substantially immunosuppressive steroid dose is considered to be 20 mg or 2 mg/kg body weight per day of prednisone or
equivalent for ≥ 2 weeks.
d Hepatitis B vaccination should be deferred for infants weighing < 2000 g if the mother is documented as HBsAg-negative at
the time of the infant’s birth. Vaccination can commence at a chronological age of 1 month or at hospital discharge. For infants
born to HBsAg-positive women, hepatitis B immune globulin and hepatitis B vaccine should be administered within 12 h of
birth, regardless of their weight.
e Vaccination should be deferred for an appropriate interval if replacement immune globulin products are being administered.
Altered immunocompetence
Children and adults who are immunocompromised due to congenital immunodeficiency or
haematopoietic or solid organ transplantation sometimes experience severe or prolonged
rotaviral gastroenteritis31,32. No data are available, however, on the safety or efficacy of rotavirus
vaccine in infants who are immunocompromised or potentially immunocompromised.
In the case of infants who are exposed to or infected with HIV, two considerations support
vaccination31,32:
• A diagnosis of infection might not be established in infants born to HIV-infected mothers before
the age at which they receive the first dose of rotavirus vaccine (for example, only 1.5–3% of
HIV-exposed infants in the USA are found to be HIV-infected).
• Vaccine strains of rotavirus are considerably attenuated.
Acute gastroenteritis
Under usual circumstances, rotavirus vaccine should not be administered to infants with acute
moderate or severe gastroenteritis until the condition improves; however, infants with mild acute
gastroenteritis can be vaccinated, particularly if the delay in vaccination would be substantial,
making the infant ineligible for vaccination (e.g. aged > 15 weeks and 0 days before the vaccine
series is started)31,32.
History of intussusception
Practitioners should consider the potential risks and benefits of administering rotavirus vaccine
to infants with a history of intussusception, who are at higher risk for a repeat episode than
infants who have never had intussusception31,32.
DT, diphtheria and tetanus toxoids; DTP, diphtheria toxoid, tetanus toxoid and pertussis; DTwP, diphtheria and tetanus toxoids and
whole-cell pertussis; HBsAg, hepatitis B surface antigen; Hib, Haemophilus influenzae type b; HPV, human papillomavirus; OPV, oral
poliovirus; MMR, measles, mumps and rubella; PCV, pneumococcal conjugate vaccine; Td, tetanus and diphtheria toxoids; Tdwp,
tetanus toxoid, reduced diphtheria toxoid and whole-cell pertussis
a Antibacterial agents have no effect on the response to live, attenuated vaccines, except for live oral typhoid vaccine, and
have no effect on inactivated, recombinant subunit or polysaccharide vaccines or toxoids. Typhoid vaccine should not be
administered to people receiving antimicrobial agents until 24 h after the last dose. If feasible, to avoid a possible reduction
in vaccine effectiveness, antibacterial drugs should not be started or resumed until 1 week after the last dose of oral typhoid
vaccine.
b Hepatitis B vaccination should be deferred for infants weighing < 2000 g if the mother is documented as HBsAg-negative at
the time of the infant’s birth. Vaccination can done at a chronological age of 1 month or at hospital discharge. For infants born
to HBsAg-positive women, hepatitis B immune globulin and hepatitis B vaccine should be administered within 12 h of birth,
regardless of weight.
c MMR and varicella vaccines can be administered on the same day. If not, the two vaccinations should be separated by at least
28 days.
d HIV-infected children should receive immune globulin after exposure to measles. They may receive varicella and measles
vaccines if their CD4+ T-lymphocyte count is > 15%.
e Measles vaccination might suppress tuberculin reactivity temporarily. Measles-containing vaccine can be administered on
the same day as tuberculin skin testing. If testing cannot be performed on the same day, it should be postponed for at least 4
weeks after vaccination. If a skin test is urgent, it should be understood that reactivity might be reduced by the vaccine.
f If a vaccinee experiences a presumed vaccine-related rash 7–25 days after vaccination, he or she should avoid direct contact
with immunocompromised people for the duration of the rash.
Routine physical examinations and procedures such as measur¬ing temperature are not necessary
for vaccinating people who appear to be healthy. The provider should ask the parent or guardian
of a child whether he or she is ill. If the child has a moderate or severe illness, vaccination should
be postponed.
Modern vaccines provide high levels of protection against an increasing number of diseases and
the symptoms, disability and death that may occur. At the same time, serious reactions to vaccines
are rare. The fact that vaccines are administered to healthy people to prevent diseases that have
become rare, largely thanks to vaccination, contributes to concern about vaccine safety35. Because
the devastating effects of these diseases are no longer so evident, public attention is focused on
the side-effects of vaccination, which influences how people weigh up the risks and benefits of
vaccination.
In some instances, concerns about the safety of certain vaccines have led to downturns in
vaccination rates and outbreaks of disease13. Most of the arguments against vaccination appeal
to parents’ understandable, deep concern for the health of their children, particularly very young
infants. Unfounded allegations of adverse effects of vaccines typically relate to feared diseases
• Uninformed, ignorant, passive objectors: Such people have no objective reasons or good
objective information about vaccines. They are not aware that a decision not to vaccinate is an
active decision with consequences. They can be addressed with education and information.
• Conspiracy freaks: Such people have hilarious reasons or have built up their own theories
of how vaccines are made and the side-effects that can occur, with no supporting rationale.
They spread their messages through blogs, web pages and books with no scientific basis and
offer alternative explanations for the outstanding benefits of vaccines. This group is difficult
to address, and investing time on them is usually not efficient, as they do not listen to reason.
• Pseudo-intellectuals and alternative life-style parents: This group is generally made up of
parents with a medium or high level of education. They have read or heard information with no
scientific basis but have built their own theories about vaccination. They rely on herd protection
from vaccinated children around their own children. This group requires education and
information to make them change their minds. They usually use homeopathy and “alternative”
or “natural” medicine and have a pure, ecological life-style.
Anti-vaccination movements aren’t new. Newspaper articles on false concerns about the safety
of vaccines can be very harmful, as they tend to appear on the first page! Many publishers are not
concerned about whether the information has been countered or confirmed, and the consequences
of such statements can reduce vaccine dose distribution rapidly.
Good examples of vaccination information sheets for parents are available on the WHO web site:
At the same time, general practitioners and paediatricians should be trained. Many web sites offer
this kind of training, information and fact sheets, including those of WHO, the Centers for Disease
Control and Prevention in the USA, the European Centre for Disease Prevention and Control and
local and national authorities.
Some people with religious objections to abortion have questioned the use of these vaccines. A
statement from the Vatican47 includes the comment that “as regards the disease against which
there is no alternative … if the latter [population as a whole] are exposed to considerable dangers
to their health, vaccines with moral problems pertaining to them may also be used on a temporary
basis … this is particularly true in the case of vaccination against German measles [rubella]”.
Depending on their purpose and composition, vaccines can contain live viruses, killed viruses,
purified viral proteins, inactivated bacterial toxins or bacterial polysaccharides. Vaccines are
complex pharmaceutical products that must be able to withstand transport, storage and adverse
environmental factors. To ensure that they are stable over time, vaccines may contain additives,
such as gelatin or albumin4,5,36. Furthermore, some vaccines contain trace residual quantities
of substances used during the manufacturing process, such as formaldehyde, antibiotics, egg
proteins and yeast proteins4,5,36.
A question that arises about vaccines that contain foreign material is the presence of egg proteins.
Some vaccines are grown in eggs and should be given with caution to people with known egg
allergy. The risk for an allergic reaction to these vaccines depends on the amount of egg protein
(ovalbumin) in the vaccine and the severity of the allergy50,51. Most influenza vaccines currently
in use have only trace amounts of ovalbumin (< 1 µg) per dose and can be given safely to most
people who are allergic to eggs51. Nevertheless, individuals with a severe allergy should seek
specialist advice. Yellow fever and one of the rabies vaccines contain larger amounts of ovalbumin
and generally should not be given to people with a severe allergy to eggs52.
The measles and mumps viruses used in vaccines are grown in chick embryo cell lines, not in
eggs50. It is now recognized that measles- and mumps-containing vaccines (MMR and MMRV)
contain negligible amounts of egg protein and can be given to children with an egg allergy, even
those who respond with anaphylaxis to egg50. If parents ask for reassurance about vaccination of
a child with an egg or other allergy, the child can be referred to a specialist immunization clinic,
paediatrician or infectious diseases specialist with an interest in immunization. Specialist advice
can also be obtained from state or territorial health authorities.
Healthy people can mount a response to any infection they encounter. Vaccines do not weaken
their immune system but strengthen it by stimulating the defence mechanisms that provide
protection against diseases53,54. The body’s immune system begins developing before birth. During
and soon after birth, when the immune system is still maturing, newborns are protected against
many, but not all, serious infections by antibodies from their mothers (maternal antibodies). This
protection usually lasts about 4 months55. National immunization programmes are planned to
balance the capacity of the infant’s immune system to respond to a vaccine against their risk for
infection. Vaccines contain many fewer antigens than those that children encounter every day in
their environment while eating, drinking and playing, and they do not overwhelm or “use up” the
immune system53,54.
If the administration of multiple vaccines overwhelmed the immune system, much weaker
immune responses might be expected than when they are given at different times. During the
Vaccines stimulate the natural immune response, so that exposure to the same pathogen in the
future triggers the immune system to “remember” it and mount an effective response to stop the
disease from developing or to reduce the severity of disease53-55.
Some people consider that vaccination is unnatural and that contracting a disease provides optimal
protection, as well as benefits to overall health56. Tied to this is the belief that vaccination interferes
with the body’s natural processes53. Choosing to remain unvaccinated and have the disease rather
than prevent it can, however, have serious consequences. Diseases such as tetanus and meningitis
can kill and maim, whereas the vaccines against these diseases are generally well tolerated, with
minor side-effects. Vaccines provide the same stimulus to the immune system as an infection and
can offer more effective protection against certain pathogens. Most importantly, protection through
vaccination avoids the complications associated with the disease. For example, infection with wild
measles virus causes encephalitis (inflammation of the brain) in one in 1000 infected individuals,
and measles infection kills two of every 1000 infected individuals. In contrast, the combination
MMR vaccine causes a severe allergic reaction only once in every 1 000 000 vaccinated individuals,
while preventing measles infection25,26. The benefits of vaccine-acquired immunity heavily outweigh
the serious risks associated with natural infection. The Haemophilus influenzae type b (Hib) and
tetanus vaccines actually provide more effective immunity than natural infection53-55. The benefits of
vaccination far outweigh those of infection with a vaccine-preventable disease.
There is no scientific evidence that any homoeopathic preparation can prevent the diseases
targeted by conventional vaccines, whereas the effectiveness of conventional vaccines is well
established by large-scale studies57. Homoeopathic preparations have been subjected to scientific
scrutiny in very few studies57. As none included a preparation for use against a disease on the
current national immunization schedule, the efficacy of these preparations against those diseases
has not been established57.
Several homoeopathic substances are marketed as “vaccines”. Most are manufactured by serial
dilutions of a disease-causing organism, tissue or plant extract, to the point where only an
infinitesimal amount of the original material is present. This process of “succussion” is said to
transfer the protective activity of the original material to the diluting water; however, there is no
physically plausible mechanism by which ingestion of such preparations could prevent infection
and/or the related diseases. These preparations are unfortunately widely diffused and accepted
even by some health care professionals on the basis of their “placebo” effect.
There is no evidence that vaccines cause or worsen allergic diseases such as asthma or
eczema58-62. Many studies have been conducted to determine whether wheezing occurs more
commonly in children after they have received a vaccine, and it is clear that this is not the case58-
62
. It is especially important that children with asthma are given all the recommended vaccines,
as a disease like pertussis or influenza can worsen asthma. Influenza vaccination is particularly
recommended for children with asthma because of this risk62.
Vaccines or their components can cause allergic reactions in some people; however, the risk is
low18. For example, the risk for anaphylaxis after a single vaccine dose has been estimated as less
than one in a million63. The risk depends, however, on the vaccine type. Components of vaccines
that can trigger an allergic reaction include gelatin, yeast and egg protein50-52. (Vaccination of
people who are allergic to eggs is discussed above.) It is important to determine the presence
of an allergy and the exact nature of the allergic response, if present. Children and adults with
most food or environmental allergies, such as dust mite or hayfever, can be safely vaccinated18.
Vaccination is contraindicated for people who have experienced anaphylaxis after a previous dose
of a particular vaccine or any vaccine component18,36.
If a health care provider is unsure about vaccinating a person with a history of an allergic reaction
after a vaccine or vaccine component, he or she should contact a specialist immunization clinic, a
paediatrician or an infectious diseases specialist with an interest in immunization.
Some people argue that infections are a normal, healthy part of growing up; however, the infectious
diseases targeted by vaccines can be serious and even fatal64-67. These diseases were common in
many countries before vaccination, but the number of cases of these diseases has been reduced
with the introduction of vaccines and very high vaccination rates in the community64-67. Current
generations of parents are unlikely to have seen a child paralysed by poliomyelitis, who requires an
“iron-lung” to breathe, a child with obstructed breathing due to diphtheria or someone with brain
damage due to measles. Other diseases like varicella (chickenpox) are generally considered mild
childhood diseases; however, varicella can be severe or fatal, particularly in immunocompromised
children and adults68. Influenza is sometimes dismissed as not being serious: many people refer
to the common cold as “the flu”; however, influenza is not the same as the common cold and can
be a serious infection, particularly in elderly people, causing dozens of deaths every year69-73.
Some people argue that improved health and hygiene were the reasons for the dramatic decrease
in infectious diseases during the past century, not vaccines12. To support this argument, they use
graphs showing decreasing death rates from disease before the introduction of vaccines and
no visible impact of vaccination. All these graphs show overall death rates rather than disease
incidence, thus hiding the true effect of vaccines.
While overall improvements in living standards, health care and treatment have reduced the
numbers of deaths from all diseases, the additional impact of vaccines is illustrated by the near
disappearance of deaths from diphtheria, tetanus, pertussis, poliomyelitis and measles64-67. Such
dramatic decreases after the introduction of vaccines, often over a short period, could not be due
to improved living conditions or medical treatment alone.
Examples that demonstrate that vaccines have had a marked impact on the incidence of infectious
diseases are listed below.
• Smallpox, which used to kill 5 million people worldwide every year, was eradicated in 1978
and is now all but forgotten12.
• The WHO Region of the Americas eliminated measles in 2002, only 12 years after a large
measles outbreak in 1990, which resulted in more than 250.000 cases and over 10,000
deaths12,76.
• In the WHO European Region, all Member States agreed upon the target of measles and rubella
elimination by 2015. There is still a large burden of measles in the Region, but the number of
cases reported has decreased by more than 96%, from 215,767 in 1997 to 7,499 cases in 201012,76.
• The WHO European Region was declared free from polio (no endemic polio transmission) in 2002
and reported no cases for 7 years. While the Region has experienced outbreaks of imported
wild poliovirus in 2010, it has been interrupted, and the goal of global polio eradication lies
within reach. Four countries globally remain endemic for poliovirus (Afghanistan, India, Nigeria
and Pakistan). So far, the global fight against polio has saved 5 million people from paralysis12
One of the best ways to demonstrate the impact of a vaccination programme on the incidence of a
vaccine-preventable disease is to study a community in which the vaccination rate is low but living
standards are high. For example:
• Two major epidemics of poliomyelitis occurred in the Netherlands, in 1984 and 1991, in a
religious community that refused vaccination. The disease did not spread to the rest of the
population, which was well covered with polio vaccine77.
• The acceptance of pertussis vaccine decreased in the United Kingdom in the mid-1970s.
Between 1977 and 1979, there was an epidemic of 102 500 cases of pertussis, during which
27 children died as a direct consequence of pertussis and 17 had permanent neurological
damage13. Acceptance of pertussis vaccine has now improved to about 93%, and the incidence
of pertussis has fallen. Similar large epidemics occurred in Japan and Sweden at about the
same time, due to low acceptance of pertussis vaccine78.
Some countries with high vaccine coverage and known to have no local measles, having eliminated
the disease, are now experiencing measles outbreaks due to imported cases from countries in
which measles vaccine coverage rates are low12. Higher standards of living and sanitation alone
do not ensure protection from infectious diseases. With short travel times over large distances,
infectious diseases can be carried from countries with a high disease prevalence. Cases have
occurred in unvaccinated people all over the world as a result of travel to and from areas where
vaccine-preventable diseases are still common.
Some people believe that vaccine-preventable diseases have been almost entirely eliminated
and that the risk for exposure to infectious disease is minimal. Therefore, they conclude that
a vaccination programme is unnecessary. Although many people around the world have been
immunized, resulting in a marked reduction in the targeted diseases, it is important that
the vaccination rates be kept as high as possible, mainly to protect the wider community and
vulnerable people with medical problems who cannot be vaccinated12.
Although many vaccine-preventable diseases are rarely seen in some countries today, they are
still common in many other countries. Travellers returning from such countries have been known
to bring home diseases such as measles, increasing the potential for an outbreak in communities
in which the vaccination rates are low. Reductions in vaccination rates can lead to recurrence of
diseases, as seen with regard to polio in many developed countries, diphtheria in eastern Europe
and more recently in Spain, and measles in Germany80-82.
The majority of vaccines are inactivated or prepared from only part of the pathogen. The components
of the vaccine are therefore not living and therefore cannot cause disease18. Exceptions are live
attenuated viral vaccines, which contain weakened (“attenuated”) forms of the virus against which
the vaccine is meant to protect people. The weakened virus replicates in the host to create an
immune response but cannot cause disease, except on very rare occasions18. Other types of live
vaccine contain a naturally occurring organism that does not itself cause the disease in humans but
which is closely related to the pathogen that causes the disease and can therefore induce protection
against it. Some of the available live vaccines are MMR and MMRV, varicella (chickenpox) and BCG.
It has been argued that, as cases of vaccine-preventable disease occur in people who have been
vaccinated, vaccines are not effective. This is not completely true, although there is a relation
between vaccination rates, vaccine effectiveness and apparent vaccine failures. Thus, where
vaccination rates are high and a disease breaks out, the numbers of cases in vaccinated people
may appear high in relation to the number of cases among people who were not vaccinated, for
two reasons. First, no vaccine is 100% effective. In order to ensure that vaccines are safer than
the disease they are designed to prevent, the vaccine bacteria or virus is killed or attenuated.
Furthermore, individual genetic make-up means that not all vaccinated people develop immunity.
Most routine childhood vaccines are effective in 85–95% of recipients; therefore, 5–15 of every
100 people who receive a vaccine do not develop protective immunity. Secondly, in a country such
as Spain, people who have been vaccinated against the common childhood vaccine-preventable
diseases vastly outnumber those who have not.
How these two factors bring about a situation in which the majority of cases in an outbreak occur
among people who have been vaccinated is illustrated in the following hypothetical scenario. In a
school with 1000 pupils, none has had measles. All but five of the pupils have received two doses
of measles vaccine and are fully vaccinated. The entire student body is exposed to measles, and
every susceptible student becomes infected, including the five unvaccinated pupils. Of the 995
who were vaccinated, several can be expected not to have responded to the vaccine. If the efficacy
rate of two doses of measles vaccine is as high as 99%, in this school, 10 pupils will not have
responded to the vaccine and will become infected. Therefore, 10 of 15 (67%) of the cases will
occur in pupils who were fully vaccinated.
This does not, however, prove that the vaccine did not work. As most of the children in the school
had been vaccinated, those who were vaccinated and did not respond outnumbered those who
had not been vaccinated. In other words, 100% of the children who had not been vaccinated and
only about 1% of those who were vaccinated got measles. Measles vaccine protected most of the
pupils. If none of the pupils in the school had been vaccinated, there would probably have been
1000 cases of measles.
• Lack of association between MMR vaccine and autism and inflammatory bowel disease
The MMR vaccine does not cause autism or inflammatory bowel disease91-125. These associations
were proposed by researchers in the United Kingdom in 1998, who suggested that measles virus
in the gut caused a new syndrome of inflammatory bowel disease that resulted in decreased
absorption of essential vitamins and nutrients through the intestinal tract126. They suggested that
this, in turn, caused developmental disorders such as autism or worsened symptoms in children
with already diagnosed autism, so-called “regressive autism”126.
Although this report generated much media attention, the few studies on which it was based127-130
had a number of significant weaknesses that have been highlighted by a plethora of letters to the
editor91-100 and have since been retracted. Ten of the 13 authors of the original study (published
in The Lancet) published a statement in 2004 retracting the paper’s findings, stating that the
data were insufficient to establish a causal link between MMR vaccine and autism. The Lancet
subsequently retracted the original paper131, and an investigation into the original data showed it
to be fraudulent.
Numerous well-conducted studies and expert panel reviews since 1998 have now provided
conclusive evidence that there is no link between MMR vaccine and autism or inflammatory bowel
disease132-139 (4, 5), WHO concluded that current scientific data do not show a causal link between
the measles virus and autism or inflammatory bowel disease137. Extensive reviews published by
the Institute of Medicine, an independent expert body in the United States, also concluded that
It has been suggested that it would be better to give each component of the MMR vaccine separately
rather than giving it as a combination vaccine; however, there is no scientific support for this
suggestion140. In fact, giving each component separately might be harmful, because vaccination
against each disease would be delayed, leaving the child (and, in turn, the population) susceptible
to the disease12. National and international expert bodies all recommend that MMR vaccine should
continue to be used132-139.
Mercury is used in industrial processes, dental fillings and thermometers. It is harmful to the body
only after it reaches a certain level, and its toxicity depends on the amount consumed, the form of
mercury, body weight and the length of exposure. Although methyl mercury has clear neurotoxic
effects in humans after absorption, well-designed toxicity studies of the accumulation of ethyl
mercury suggest that a relation between ethyl mercury in vaccines and neurological toxicity is
biologically implausible6,7. Many well-conducted studies and reviews by expert panels have shown
that there is no evidence of developmental or neurological abnormalities, such as autism, due to
administration of vaccines containing thiomersal141-148.
Thiomersal has not been used in vaccines since 2000, as they are now produced in single-use sealed
vials that do not require addition of a preservative. This reduces the total exposure of young children
to any form of mercury in a world where other environmental sources (particularly food such as fish)
may be more difficult to eliminate. Some vaccines, such as pneumococcal vaccines, MMR vaccine
and other live attenuated viral vaccines, never contained thiomersal141-148. Thiomersal may be used
as a preservative to prevent the growth of bacteria in vaccines produced in multi-dose vials after the
vial has been opened for the first time, for example, as an emergency measure during a pandemic.
The pertussis vaccine does not cause brain damage149-152. The pertussis component of DTP vaccine
was originally manufactured from inactivated whole pertussis organisms, designated DTPw.
DTPw (or whole-cell) vaccines were commonly associated with local reactions such as redness,
In the USA in 1976, the seasonal influenza vaccine formulation was associated with an increased
risk for Guillain-Barré syndrome. Several long-term studies to determine whether influenza
vaccines since 1976 were associated with this syndrome found only a very small increase after
influenza vaccination, with approximately one case among every one million people vaccinated
against influenza additional to the number that would have occurred without vaccination153-155.
Isolated case reports have suggested a possible association between Guillain-Barré syndrome
and several other vaccines, including oral poliovirus, MMR, tetanus toxoid-containing and hepatitis
B vaccines156. Robust epidemiological studies have not, however, demonstrated a link157. In the USA,
a possible association with quadrivalent meningococcal conjugate vaccine used in adolescents
was reported to the adverse events reporting system, but a subsequent investigation found no
increased risk158.
Febrile convulsions (sometimes referred to as seizures) are a relatively common response to fever
of any cause in young children159. In most cases, the seizures are mild and resolve spontaneously.
Overall, by the age of 5 years, about three in every 100 children will have experienced a febrile
convulsion, irrespective of whether they received a vaccine159. As fever is a well-documented
adverse event after the administration of many common childhood vaccines, it is not unexpected
that febrile convulsions may occur after vaccination, although it is still very rare.
The risk is higher after administration of certain vaccines, such as influenza, MMR and MMRV
vaccines18. For example, MMR and MMRV vaccines are associated with a higher risk for a febrile
convulsion 7–12 days after the first dose of vaccine than at other times18,160. It is estimated that
one child of every 3000 who receive MMR vaccine will experience a febrile convulsion during this
period18,160. When MMRV vaccine is given as the first MMR-containing vaccine, the risk for fever
and febrile convulsions during this period is approximately two times higher than when MMR and
varicella vaccines are given separately160. Therefore, MMRV vaccines are not recommended as the
The development and increasing use of new vaccines and global vaccination protocols have
stimulated burning debates about the safety of adjuvants and whether they enhance the
immunogenicity of vaccines4,5,8. An adjuvant is a substance that enhances the antigen-specific
immune response, induces the release of inflammatory cytokines and interacts with toll-like
receptors and the NALP3 inflammasome161. The immunological consequence is stimulation of the
innate and adaptive immune responses. Activation of the immune system by adjuvants, a desirable
effect, could, however, trigger manifestations of autoimmunity or autoimmune disease161.
Shoenfeld and Agmon-Levin used the term “autoimmune inflammatory syndrome induced by
adjuvants” to describe a complex of variable signs and symptoms that may occur after previous
exposure to adjuvants and external environmental triggers and may elicit specific, overt immune-
mediated disorders162. This entity subsumes five medical conditions: post-vaccination phenomena,
Gulf War syndrome, macrophagic myofasciitis syndrome, siliconosis and “sick building” syndrome,
but the relevance and extent of the syndrome in children is limited mainly to post-vaccination
autoimmune or inflammatory disorders162.
The main substances associated with autoimmune inflammatory syndrome are squalene (Gulf War
syndrome), aluminium hydroxide (post-vaccination phenomena, macrophagic myofasciitis) and
silicone (siliconosis)161,162. Aluminium hydroxide is the adjuvant used most often in vaccines, but the
mechanisms by which it works are complex and little known. Alum adjuvants are good humoral
immune potentiators in vaccine formulations, and this property has recently been attributed to
NLRP3 inflammasome activation163. The inflammasome is an intracellular multiprotein complex
that mediates caspase-1 cleavage of the inactive precursor of the pro-inflammatory cytokine
interleukin-1β, leading to the release of mature cytokine161-163. Inflammasome-mediated cleavage
of pro-interleukin-1β in vitro depends on signals that activate both toll-like receptor and nucleotide
oligomerization domain-like receptors, such as NLRP3163. Activation of these innate immune
system receptors is now recognized as a step in effective adaptive immunity in a combination of
stimuli for naive T cells. Aluminium salts induce humoral immunity via Th2 responses but have
less effect on cell-mediated immunity and are therefore not useful in vaccines against intracellular
pathogens163.
Narcolepsy is a chronic disorder presenting as excessive daytime sleepiness, and its variant with
cataplexy, referred to as type 1 narcolepsy, is closely associated with HLA-DQB1*0602, which
plays a central role in the immune system by presenting peptides derived from extracellular
proteins165, 166. Investigations of patients with narcolepsy–cataplexy show that the neuropeptide
orexin, which regulates arousal, wakefulness and appetite, is deficient in the cerebrospinal fluid of
the majority of these patients167,168. More than 1300 cases of narcolepsy had been reported to the
European Medicines Agency by January 2015 associated with an AS03-adjuvant influenza vaccine
that was distributed to more than 30.5 million people in countries of the European Union and the
European Economic Area during the outbreak of A(H1N1)pdm09 influenza169. In 2012, studies in
Finland and Sweden showed an association between narcolepsy and vaccination with a European
A(H1N1)pdm09 vaccine with AS03 adjuvant, an oil-in-water emulsion170.
With regard to squalene-based adjuvants, no increased risk has been associated with the A(H1N1)
pdm09 vaccine in which the adjuvant is MF59, with an estimated 6.5 million doses distributed in
Europe and 25 million doses used in Europe and Latin America170. A lower risk for narcolepsy was
found with an AS03 adjuvant pandemic vaccine, Arepanrix, in Canada than with a similar vaccine,
Pandemrix, used in Europe169. These observations indicate that vaccine-associated narcolepsy is
not due solely to the characteristics of the adjuvant165-170.
• Haemangioma
The vast majority of infantile haemangiomas do not require medical or surgical intervention, unless
they interfere with vision or breathing178. Medical care of clinically significant haemangiomas is
limited to a few medications178, including glucocorticosteroids179-181 (topical, intralesional and oral),
interferon α and, rarely, vincristine and topical imiquimod. Beta-blockers, specifically propranolol,
were found serendipitously to induce involution of infantile haemangiomas182-184.
If treatment with glucocorticosteroids is initiated, especially at a high dose (2 mg/kg body weight per
day for more than 14 days), the immune system is weakened, resulting in increased susceptibility to
infection. Therefore, it is important to reduce exposure to infections during treatment. No live virus
vaccines should be given to people on steroid medication until treatment has been discontinued for at
least 1 month18, 179-181. There are no other contraindications to vaccination. Non-live vaccines may be
administered179-181. The beta blocker propanolol does not appear to affect the immune system182-184.
Sudden infant death syndrome is the sudden, otherwise unexplained death of an infant. The
incidence of the syndrome peaks at 2 months of age, at which most infants receive their first
vaccinations. The apparent association between the timing of vaccination and sudden infant death
syndrome has been examined to determine whether there is a causal link. Almost all the well-
controlled studies in the past 20 years showed that the number of deaths associated in time with
DTP vaccination was within the range expected to occur by chance, irrespective of vaccination185-192.
To date, all the published evidence suggests that vaccination does not increase the risk for sudden
infant death syndrome, and some studies suggest that vaccination may lower the risk187, 190-192.
The well-established risk factors for sudden infant death syndrome include gender (more likely in
boys), age (2–3 months), race (in the USA, Black, American Indian and Alaskan Native infants are
at higher risk), having siblings or cousins, prematurity, low birth weight, prone face-down sleeping
position and parental smoking185-192. Major reductions in deaths from this syndrome followed
successful campaigns to reduce the risk factors.
• Diabetes
Despite research throughout the world, there is no evidence that vaccines cause diabetes193-202.
The incidence of type 1 diabetes began to increase in developed countries at a similar time to the
introduction of widespread childhood vaccination. It was postulated in two studies that vaccination
before 2 months of age protected against type 1 diabetes, whereas vaccination after that age
increased the risk203, 204. The claim implicated hepatitis B and Hib vaccines and later included BCG
and more recently MMR and pertussis-containing vaccines203,204.
Subsequent to those reports, large, well-conducted studies found no link between any of the
recommended childhood vaccines and type 1 diabetes, nor could they verify the findings of the
earlier studies193-202. Changes in the timing of vaccination have not been shown to alter the risk for
diabetes193.
It is recommended that people with diabetes be vaccinated according to the national immunization
programme schedule193. Furthermore, annual influenza vaccination is currently recommended for
people with diabetes205.
• Cancer
Two vaccines, hepatitis B and human papillomavirus (HPV) vaccine directly prevent cancer, as
opposed to modifying the risk for cancer by attention to factors such as diet, exposure to tobacco
smoke and lifestyle behaviour206,207. The hepatitis B vaccine prevents liver cancer (associated
Some people believe that vaccines can cause cancer, because some batches of injectable polio
vaccine produced between 1957 and 1963 were contaminated with a simian virus (SV40) that may
be linked to the development of some cancers208-209. SV40 is found in some species of monkey
and may be involved in causing cancer208. Between 1955 and 1963, some of the poliovirus vaccine
administered in the USA was unknowingly contaminated with SV40 from the monkey kidney
cell lines used to produce the vaccine208-210. Because SV40 was not identified until 1960, no one
was aware that poliovirus vaccines made in the 1950s could have been contaminated208-210. All
poliovirus vaccines manufactured since the early 1960s have been screened for SV40.
None of the current poliomyelitis vaccines contains SV40. SV40 is found in certain types of human
cancer, such as mesothelioma (rare tumours located in the lungs), brain and bone tumours and
some types of non-Hodgkin lymphoma208-209. The role of SV40 in human cancers is not, however, fully
understood and is the topic of continued research. Most information, including many large studies in
Europe and the USA208, strongly suggests that people given vaccine containing SV40 between 1955 and
1963 were at no higher risk for cancer than people who did not receive poliovirus vaccine at that time.
Some people have argued that an oral poliovirus vaccine used in the 1950s was contaminated
with simian immunodeficiency virus (SIV), a primate virus that gave rise to HIV-1 that infects
humans and causes AIDS211. A number of factors counter this argument:
Even if a rumour of unofficial use of cells from chimpanzees in the Belgian Congo were true,
recent molecular epidemiological research shows that the form of SIV in these animals did not
match the HIV-1 strains that affect humans212. The argument that the Koprowski polivrus vaccine
contained HIV is therefore thoroughly discredited212.
There is no evidence that hepatitis B vaccine, or any other vaccine, causes multiple sclerosis, a
chronic illness resulting from inflammation of myelin, the protective covering nerves in the brain
and spinal cord213-217. The cause of multiple sclerosis is unknown, but genetic and environmental
factors appear to be important214.
Numerous other studies around the world and expert panels of WHO and the Institute of Medicine
and the Centers for Disease Control and Prevention in the USA agree that there is no evidence to
support the theory that vaccination with hepatitis B vaccine, or any other vaccine, is associated
with an increased risk for multiple sclerosis213-217. There is also evidence that vaccination does not
worsen the symptoms or cause relapses of multiple sclerosis217.
HPV vaccines were developed primarily to prevent cervical cancer; however, they also provide
protection against other cancers in both men and women, including anal cancer, penile cancer and
head-and neck-cancers219,220. HPV vaccines have been evaluated for safety and efficacy in the same
way as all other vaccines. The European Medicines Agency, the Food and Drug Administration in
the USA and WHO have concluded that HPV vaccines are safe and effective219-229.
In clinical trials222-226, the main side-effect of HPV vaccines was a local reaction at the injection site
(pain, redness and swelling) in about 80% of those who received the vaccine. Other reported side-
effects were fever, headache and fatigue but these were no more common in recipients of vaccine
and of placebo222-226. Very few serious adverse events were reported after vaccination (in < 0.1%),
and they were no more frequent than in those receiving the placebo vaccine222-226. Participants in
the clinical trials were evaluated for up to 4 years after vaccination to determine whether they had
experienced higher rates of new medical conditions, including autoimmune diseases227. No trends
or patterns of new medical conditions or safety concerns were identified during the follow-up
period221-229. As with all vaccines, adverse events after vaccination are still being monitored now
that the vaccine is in use. Post-licensure surveillance data from various regulatory agencies in
different countries confirm these reassuring findings223, 224, 226.
There is no biologically plausible way in which HPV vaccine could cause infertility in either women
or men219-230. HPV infection, unlike some other sexually transmitted infections such as chlamydia,
is not a cause of infertility. Studies with high doses of HPV vaccine in female and male rats showed
no effect on fertility229,230. Some Internet sites report a disturbing claim that one ingredient of the
vaccine, polysorbate 80, caused infertility in rats. This claim is based on one study of newborn
rats (weighing 10–17 g) that were injected in the abdomen with doses of polysorbate 80 that were
20–200 times the amount in Gardasil® HPV vaccine231. Several health institutions have reviewed
the evidence and concluded that there is no evidence that polysorbate 80 at the level of 50 µg per
0.5-mL dose in Gardasil® poses a hazard to human reproduction or fertility232. Polysorbate 80 is
found in numerous medications, including other vaccines, and is used as an additive in foods and
cosmetics233.
OPV, oral poliovirus vaccine; DTwP, diphtheria and tetanus toxoids and whole-cell pertussis; DTaP, diphtheria and tetanus toxoids
and acellular pertussis; DT, diphtheria and tetanus toxoids; Td, tetanus and diphtheria toxoids; TT, tetanus toxoid; IPV, inactivated
poliovirus vaccine; Hib, Haemophilus influenzae type b; PCV-7, pneumococcal conjugate vaccine; BCG, bacille Calmette-Guérin
OPV, oral poliovirus vaccine; DTwP, diphtheria and tetanus toxoids and whole-cell pertussis; DTaP,
diphtheria and tetanus toxoids and acellular pertussis; DT, diphtheria and tetanus toxoids; Td, tetanus
and diphtheria toxoids; TT, tetanus toxoid; IPV, inactivated poliovirus vaccine; Hib, Haemophilus
influenzae type b; PCV-7, pneumococcal conjugate vaccine; BCG, bacille Calmette-Guérin
mid-thigh
OPV booster 16–24 months 2 drops Oral Oral
DPT booster 5–6 years 0.5 mL Intramuscular Upper arm
Tetanus toxoid 10 and 16 years 0.5 mL Intramuscular Upper arm
BCG, bacille Calmette-Guérin; OPV, oral poliovirus vaccine; DPT, diphtheria, pertussis and tetanus
For many years, there has been a recommendation that when two live vaccines are required in the
same individual, then the vaccines should either be given on the same day, or separated by an interval
of at least four weeks237. This was based on early studies with measles and smallpox vaccines240,
and supported by the theory that interferon production stimulated by the replication of first vaccine
prevented replication of the second agent, thus leading to a poor response to the second vaccine.
Based upon the available evidence and on the different immune mechanisms used by the various
vaccines, in February 2014 the JCVI agreed that the guidance to either administer the vaccines on
the same day or at four week interval period should not be generalised to all live vaccines241. They
concluded therefore, that intervals between vaccines should be based only upon specific evidence
for any interference of those vaccines (Table 13).
Table 13. Recommendations for giving more than one live attenuated vaccine
Increasing the interval between doses of a multidose vaccine does not diminish its effectiveness237.
Decreasing the interval between doses of a multidose vaccine may interfere with antibody
response and protection237. It is not necessary to restart the series or add doses because of an
extended interval between doses237.
Vaccination providers often change during a vaccination series, and these changes and the
vaccination records are often unavailable or not entered into an information system. Missing
or inaccurate information on the vaccines received can preclude accurate determination of
the vaccines required at the time of a visit, resulting in administration of extra doses245. A fully
operational information system prevents duplicate vaccination, missed appointments, vaccine
waste and staff time required to produce or locate vaccination records or certificates245. Most
health information systems also allow vaccine management, maintenance of lifetime vaccination
histories and interoperability with other systems245.
• read all the material about vaccination that they receive from their child’s health care
professional and write down any questions they may have;
• find their child’s vaccination record and bring it to the appointment to ensure that their doctor
knows exactly what vaccines their child has already received;
• pack a favourite toy, book or blanket that their child uses regularly for comfort;
• be honest with older children and explain that vaccination may pinch or sting but won’t hurt
for long;
• engage other family members, especially older siblings, in the support of the child; and
• avoid telling scary stories or making threats about injections.
Remember to schedule your next visit. Familiarization with a child’s vaccinations is the best
protection against disease. Support is important once a child has received all of the injections,
and infants should be held, cuddled, breastfed or offered a bottle. A soothing voice, praise and
hugs reassure a child that everything is under control.
• Review any information from your doctor about the injections, especially vaccine information
statements and other information on what side-effects to expected.
• Use a cool, wet cloth to reduce redness, soreness and swelling at the place the injection was
given.
• Reduce any fever with a cool sponge bath. If your doctor approves, give a non-aspirin pain
reliever.
• Give your child lots of liquid. It’s normal for some children to eat less during the 24 h after
vaccination.
• Pay extra attention to your child for a few days. If you see something that concerns you, call
your doctor.
Clinicians and other health care providers must assess the safety and effectiveness of vaccines.
Laboratory studies can be useful for assessing the effects of a disease or drug on the immune
system. The general principles are:
6.1.1. Immunodeficiency
Before vaccination of a patient who is immunodeficient, consideration must be taken of whether
the vaccine is inactivated or live. All inactivated vaccines can be administered safely to people with
altered immunocompetence, and the usual doses and schedules are recommended; however,
the effectiveness of the vaccine might be suboptimal237,248. People with any of most forms of
altered immunocompetence should not receive live vaccines, and those with severe cell-mediated
immunodeficiency should not receive live attenuated viral or bacterial vaccines237,248.
Vaccines
Type of immunodeficiency contraindicated Vaccines indicated Comments
Major antibody deficiency All live vaccines Influenza Vaccination with Men C
(agammaglobulinaemia, or Men ACWY (preferred)
Other inactivated
hypogammaglobulinaemia) recommended
vaccines on
immunization calendar
Minor antibody deficiency OPV All vaccines on Vaccination with Men C
(IgA deficiency of immunization calendar, or Men ACWY (preferred)
polysaccharide antibody including live vaccines recommended
deficiency)
Influenza Pneumococcal
vaccination in combined
schedule (PCV13 + PS23)
recommended
Complement deficiency No All vaccines on Vaccination with Men C or
(classical or alternative contraindications immunization calendar Men ACWY (preferred)
pathway)
Pneumococcal, Hib New Men B vaccine
and meningococcal are recommended
mandatory
Phagocytic system Live bacterial All vaccines on Pneumococcal
deficiencies (chronic vaccines (BCG, oral immunization calendar, vaccination in combined
granulomatous disease), typhoid vaccines) except all live vaccines schedule (PCV13 + PS23)
adhesion molecule defect, in chronic in adhesion molecule recommended
Chédiak–Higashi syndrome, granulomatous defect and Chédiak–
congenital neutropenia disease Higashi syndrome
All live vaccines in
adhesion molecule
defect and
Chédiak–Higashi
syndrome
Innate immune defects (IL- All live vaccines All vaccines on Pneumococcal
12, interferon-γ (BCG, oral typhoid, immunization calendar, vaccination in combined
MMR, varicella) except live vaccines schedule (PCV13 + PS23)
recommended
Influenza
Mixed or combined T-cell All live vaccines Some guidance does not Patients with incomplete
deficiency (complete (BCG, oral typhoid, recommend inactivated DiGeorge syndrome may
DiGeorge syndrome, ataxia MMR, varicella) vaccines if the patient receive MMR and varicella
telangiectasia, Wiskott- is receiving intravenous vaccines if their CD3
Aldrich syndrome, hyper- immunoglobulin count is > 500/m3, their
IgE syndrome) CD8 count ≥ 200/m3 and a
Influenza
normal mitogen response
Men, meningococcus; Ig, immunoglobulin; OPV, oral poliovirus vaccine; PCV, pneumococcal conjugate vaccine; PS23, 23-valent
pneumococcal polysaccharide vaccine; IL, interleukin; MMR, measles, mumps and rubella
Pneumococcal, meningococcal and Hib vaccines should be administered at least 14 days before
elective splenectomy, if possible237,253. If they are not administered before surgery, they should be
administered 2 weeks after the procedure, as soon as the patient’s condition is stable237.
When hepatitis B or another intramuscularly administered vaccine is indicated for a patient with a
bleeding disorder, it should be administered only if a physician familiar with the patient’s risk for
bleeding determines that the administration would be reasonably safe237. If the patient receives
Patients receiving anticoagulation therapy presumably have the same bleeding risk as patients
with clotting factor disorders, and the same guidelines for intramuscular administration should
be followed237,254.
Men ACYW
indicated
Pneumonia Recommended (all Recommended Recommended Recommended Recommended Recommended Recommended Recommended if Recommended in
13-V ages) immune-suppressed haemoglobinopathy
Pneumonia Recommended (> 2 Recommended Recommended Recommended Recommended Recommended Recommended Recommended if Recommended in
23-V years) (> 2 years) (> 2 years) (> 2 years) (> 2 years) in diabetes (> 2 years) immune-suppressed haemoglobinopathy
Live
BCG Routine use Routine use Routine use Routine use Routine use Routine use Routine use Routine use Routine use
MMR Routine use Routine use Routine use Routine use Routine use Routine use Routine use Routine use if not Routine use
immune-suppressed
OPV Routine use Routine use Routine use Routine use Routine use Routine use Routine use Routine use if not Routine use
immune-suppressed
Rotavirus Routine use Routine use Routine use Routine use Routine use Routine use Routine use Routine use if not Routine use
immune-suppressed
Varicella Routine use Routine use Routine use Routine use Routine use Routine use Routine use Routine use if not Routine use
immune-suppressed
DTaP, diphtheria and tetanus toxoids and acellular pertussis; Hib, Haemophilus influenzae type b; TIV, trivalent inactivated vaccine; V, valent; BCG, bacille Calmette-Guérin; MMR, measles, mumps and
59
6.3. Drugs that might cause immunodeficiency
6.3.1. Corticosteroids
Corticosteroid therapy is not usually a contraindication to administering live-virus vaccine when
it is given237,259:
No severe reactions have been reported to live, attenuated viral vaccines in people receiving
corticosteroid therapy by aerosol, and this therapy should not delay vaccination237,259.
Although the immunosuppressive effects of steroid treatment vary, most clinicians consider that
a dose equivalent to ≥ 2 mg/kg body weight per day or ≥ 20 mg/day of prednisone or equivalent
to people who weigh > 10 kg administered for ≥ 14 days at ≥ 2 mg/kg body weight per day (or ≥
28 days at ≥ 1 mg/kg body weight per day) is sufficiently immunosuppressive to raise concern
about the safety of vaccination with live-virus vaccines237,259. Corticosteroids given at greater than
physiological doses can reduce the immune response to vaccines. Vaccination providers should
defer live-virus vaccination for at least 1 month after discontinuation of high-dose, systemically
absorbed corticosteroid therapy administered for > 14 days237,259.
Timing of administration
Product of MMR vaccine (months)
Non-specific immunoglobulins 3
Polyvalent Ig at 0.02–0.06 mL/kg body weight 5
Polyvalent Ig at 0.25 mL/kg body weight 6
Polyvalent Ig at 0.50 mL/kg body weight 8
Polyvalent Ig immunodeficiency therapy at 300–400 mg/kg body weight 8–10
Polyvalent Ig immunodeficiency therapy at 400–1000 mg/kg body weight 8
Prophylaxis after exposure to varicella at 400 mg/kg body weight 11
Therapy for Kawasaki disease at 2 g/kg body weight 3
Anti-hepatitis B immunoglobulin 4
Anti-rabies immunoglobulin 3
Anti-tetanus immunoglobulin 5
Anti-varicella zoster immunoglobulin
Blood and blood products
Blood 6
Red cells 6
Plasma or platelets 7
Antiviral drugs used for treatment or prophylaxis of influenza virus infections have no effect
on the response to inactivated influenza vaccine; however, live, attenuated influenza vaccine
should not be administered until 48 h after cessation of therapy137,271. If feasible, to avoid possible
reduction in vaccine effectiveness, antiviral medication should not be administered for 14 days
after live attenuated influenza vaccine271. Antiviral drugs that are active against herpesviruses
(e.g. acyclovir and valacyclovir) might reduce the efficacy of live, attenuated varicella and zoster
vaccines, and these drugs should be discontinued at least 24 h before administration of vaccines
containing varicella zoster virus, including zoster vaccine, if possible137,272,273. Use or resumption of
antiviral therapy should be delayed for 14 days after vaccination137,272,273. There is no evidence that
commonly used antiviral drugs affect the efficacy or safety of rotavirus or MMR vaccine137.
If a child aged at least 6 weeks has been in hospital since birth, deferral of rotavirus vaccination
is recommended until the time of discharge285. The rotavirus vaccine series should not be initiated
for infants aged ≥ 15 weeks285.
Preterm infants weighing < 2000 g at birth may have decreased seroconversion rates after
administration of hepatitis B vaccine at birth. By a chronological age of 1 month, however, all
Inactivated, recombinant, subunit, polysaccharide and conjugate vaccines, as well as toxoids, pose
no risk for mothers who are breastfeeding or for their infants. Breastfeeding is a contraindication
for smallpox vaccination of the mother because of the theoretical risk for contact transmission
from mother to infant. Yellow fever vaccine should be not be given to breastfeeding women290;
however, if a nursing mother cannot avoid or postpone travel to areas endemic for yellow fever in
which risk for acquisition is high, she should be vaccinated.
Limited data indicate that breastfeeding enhances the response to certain vaccine antigens292. There
is no evidence that passive transfer of antibodies to human milk affects the efficacy of live-virus
vaccines. Breastfed infants should be vaccinated according to the recommended schedule292-294.
Pregnant women who received the last dose of tetanus toxoid-containing vaccine > 10 years
previously should generally receive tetanus and diphtheria toxoids while they are pregnant297. A
dose during pregnancy ensures adequate immunity to tetanus in the mother and prevents disease
in both the mother and infant. The dose of Td can be withheld if the provider is confident that the
pregnant woman is immune to tetanus298. Pregnant women who have not been vaccinated or are
only partly vaccinated against tetanus should complete the primary series297. Women for whom
Td is indicated but who did not complete the recommended three-dose series during pregnancy
should receive follow-up after delivery to ensure that the series is completed.
Women in the second and third trimesters of pregnancy are at increased risk for hospitalization for
influenza299,300. As vaccination against influenza before the season begins is critical and predicting
IPV can be administered to pregnant women who are at risk for exposure to wild-type
poliovirus infection. Hepatitis A, pneumococcal polysaccharide, meningococcal conjugate and
meningococcal polysaccharide vaccines should be considered for women at increased risk for
those infections301-303. Pregnant women who must travel to areas where the risk for yellow fever
is high should receive yellow fever vaccine because the limited theoretical risk from vaccination
is outweighed substantially by the risk for infection304. Hepatitis B vaccine is not contraindicated in
pregnancy and should be given to any pregnant woman for whom it is indicated305.
Pregnancy is a contraindication for smallpox vaccine and measles-, mumps-, rubella- and
varicella-containing vaccines137. Smallpox vaccine is the only vaccine known to harm the fetus when
administered to a pregnant woman137. In addition, smallpox vaccine should not be administered to
a household contact of a pregnant woman306.
Studies of children born to mothers vaccinated with rubella vaccine during pregnancy indicate
the presence of rubella antibodies in unvaccinated infants, which may represent passive transfer
of maternal antibody or a fetal antibody response to vaccine virus infection307-309. No cases of
congenital rubella, varicella syndrome or abnormalities attributable to fetal infection have been
observed in infants born to susceptible women who received rubella or varicella vaccines during
pregnancy307-309. Because of the importance of protecting women of childbearing age against
rubella and varicella, reasonable practices in any vaccination programme include asking women
whether they are pregnant or might become pregnant in the coming 4 weeks; not vaccinating
women who state that they are or plan to become pregnant; explaining the theoretical risk of the
fetus if MMR, varicella or MMRV vaccine is administered to the pregnant mother and counselling
women who are vaccinated not to become pregnant for 4 weeks after MMR, varicella or MMRV
vaccination137. Vaccination with MMRV is an unlikely option for a pregnant woman because the
vaccine is licensed only for children < 12 years of age. Routine pregnancy testing of women
of childbearing age before administration of a live-virus vaccine is not recommended137. If a
pregnant woman is inadvertently vaccinated or becomes pregnant within 4 weeks of MMR or
varicella vaccination, she should be counselled about the theoretical basis of concern for the
fetus; however, MMR or varicella vaccination during pregnancy should not be considered a reason
to terminate pregnancy310-311.
People who receive MMR vaccine do not transmit the vaccine viruses to contacts310, and
transmission of varicella vaccine virus to contacts is rare137. MMR and varicella vaccines should
be administered when indicated to children and other household contacts of pregnant women.
Infants living in households with pregnant women should be vaccinated with rotavirus vaccine
according to the same schedule as infants in households without pregnant women137,310.
Vaccination of pregnant women with Tdap in the second and third trimester is well tolerated
and elicits immune responses similar to those in vaccinated nonpregnant women313. Preliminary
evaluation indicated no increased risk for adverse events among women who received Tdap
vaccine during gestation or in their infants313. Secondary assessments showed that maternal
vaccination with Tdap resulted in significantly higher concentrations of antibodies to all vaccine
antigens in their infants from birth until initiation of vaccination at 2 months of age and did not
substantially alter the infants’ response to DTaP313. As the kinetics of maternal antibodies might
differ by region according to the country’s epidemiology, vaccine strategy, vaccine brand used and
population targeted, larger studies should be conducted, with longer follow-up, to understand
the immunological responses of pregnant women, the required frequency of booster Tdap
administration and the consequences on neonatal immunity.
No information is available about the extent of TST suppression that might be associated with
other live, attenuated virus vaccines (e.g. varicella or yellow fever). In the absence of information,
A more specific test for diagnosis of TB or latent TB infection was licensed in 2005. The interferon-γ
release assay requires only one visit and is less sensitive to the effects of previous BCG vaccination.
The same timing guidelines that apply to the interval between a live vaccine and TST apply to this
assay (28 days if they are not done on the same day), because the interferon-γ release assay (like
TST) might be suppressed by immunological mechanisms321.
The potential that TST can boost results should be considered in patients who might have latent
TB and have a negative initial TST, and the two-step tuberculin test is recommended in certain
situations321. As this test consists of two TSTs (or a TST followed by interferon-γ release assay)
separated by an interval of 1–3 weeks, there is a longer time during which live vaccine replication
could suppress reactivity321. If a live vaccine is administered, the first dose of a two-step TST should
be delayed for 4 weeks, and, if additional doses of live vaccines are indicated thereafter, they should
be delayed until the second TST (or the interferon-γ release assay after an initial TST)321.
TST is not contraindicated for people who have been vaccinated with BCG, and the results are
used to diagnose M. tuberculosis infection324. A diagnosis of infection and treatment of latent TB
infection should be considered for any BCG-vaccinated person who has a TST reaction of > 15 mm
of induration, especially if the person137,322-324:
• is a contact of another person who has infectious TB, particularly if the infectious person has
transmitted M. tuberculosis to others;
• was born or has resided in a country in which the prevalence of TB is high; or
• is exposed continually to populations in which the prevalence of TB is high, such as health care
workers, employees and volunteers at homeless shelters and workers at drug-treatment centres.
Athough revaccination does not confer additional protection against TB, BCG provides protection
against the severe form of TB and TB in childhood326. Meta-analyses of studies on the protective
effect of a single dose of BCG showed an effect of 73–86%324. A study in Brazil of adolescents aged
15–20 years who received BCG vaccination at birth found a prolonged protective effect of the first
dose, of 9–58%327.
The worldwide coverage of BCG vaccination is 88%334, and it is usually administered at birth335
Until safer, more efficient anti-TB vaccines become available, delaying BCG vaccination beyond 1
month of age is likely to be favourable for this highly vulnerable population and in neonates who
are susceptible due to e.g. HIV infection. Moreover, delaying BCG vaccination enhances the clinical
impact of neonatal SCID screening, obviating administration of a contraindicated vaccine before
the diagnosis is established. Two major drawbacks to delaying BCG vaccination can, however,
be foreseen: the “missed opportunity” of vaccinating infants after birth might lead to decreased
coverage, and there is a very low potential of increased risk for BCG-preventable diseases during
the “unprotected” interval. WHO data demonstrate BCG coverage of 89.2% in countries that
encourage vaccination at birth, similar to the 89% coverage with the third dose of DPT in the same
countries, which is typically given at 6 months of age336. This suggests little or no decrease in
coverage due to delaying BCG vaccination. In addition, BCG-preventable mycobacterial diseases
within the first 6 months of age are extremely uncommon. Studies on paediatric tuberculous
meningitis, a BCG-preventable disease, show that the mean age at which this life-threatening
disease occurs is 23–49 months, although a few cases have been described during the first
6 months of life, and the median is 12–24 months337-341. Modification of BCG vaccination policy
requires extensive discussion, balancing the needs of the immunocompetent general population
and highly vulnerable immunodeficient patients.
Catch-up schedule tables are useful for planning the number of doses and the best way to
organize visits and coadministration for unimmunized children or children who have interrupted
the primary series137,237,241. Table 19 gives examples.
If interruption between
Typhoid 14 3-4 doses (1 day)
doses is < 21 days resume
Ty21a Capsules 5 years (min) (see footnote) without repeating previous Not recommended > 5 yrs: 3-4 doses Every 3-7 years
(see footnote)
dose; If > 21 days restart
primary series
≥ 2 years 1 NA
Hepatitis A 17 1 year (min) At least 1 dose Not recommended At least 1 dose Not recommended
Seasonal influenza (inactivated tri- and < 9 yrs: 2 doses (4 weeks) Resume without repeating < 9 yrs: 2 doses
6 months (min) 2 doses Revaccinate annually 1 dose only
qudri-valent) 21 ≥ 9 yrs: 1 dose previous dose ≥ 9 yrs: 1 dose
P.2 /9
BCG, bacille Calmette-Guérin; NA, not applicable; DTP, diphtheria and tetanus toxoids and pertussis; OPV, oral poliovirus vaccine;
IPV, inactivated poliovirus vaccine; HPV, human papillomavirus
Table 20 shows a suggested catch-up schedule. Other vaccines may be given after discussion
with parents.
MMR, measles, mumps and rubella; DTwP, diphtheria and tetanus toxoids and whole-cell pertussis;
DTaP, diphtheria and tetanus toxoids and acellular pertussis; Tdap, tetanus toxoid and acellular
pertussis; OPV, oral poliovirus vaccine; IPV, inactivated poliovirus vaccine; Hib, Haemophilus
influenzae type b; Td, tetanus and diphtheria toxoids; IPV B1,
Examples of the most frequent vaccine-preventable diseases and the dose schedules are shown
In Table 21.
7. Conclusion
Non-vaccination is an
ACTIVE decision
Minimal risks of vaccination are
completely overshadowed by the
health risks of non-vaccination
8. Clinical cases
8.1. Case 1
A 2-month-old infant born prematurely at 32 weeks of gestational age with cerebral palsy as
a sequel of ventricular leukomalacia visits a clinic for routine vaccination. The mother reports
that the infant has had diarrhoea for the past 2 days and has been taking antibiotic therapy for
pharyngoamigdalitis for 10 days. The physical examination shows increased bowel sounds but no
other acute major finding. Please choose among the following answers for this patient:
Q1. Can this patient be vaccinated with DTwp, Hib and hepatitis B vaccines at this
visit?
1. No, the patient has several absolute contraindications for vaccination (prematurity, cerebral
palsy).
2. No, vaccination should be re-scheduled once the acute episode of diarrhoea has resolved.
3. Yes, I would not lose the opportunity to vaccinate the patient.
4. No, because the antibiotic therapy might interfere the immune response.
Answer to Q1:
There is no evidence that acute illness reduces the efficacy of vaccines or increases the
incidence of adverse events after vaccination. As a precaution, however, in cases of moderate
or severe acute illness, all vaccines should be delayed until the illness has resolved. Mild
Vaccination should not be withheld for a person taking antibiotics. Antibiotics do not affect
the immune response to most vaccines. The only commonly used antimicrobial drug that will
inactivate a live-virus vaccine is a sulfonamide, which will inactivate the oral typhoid vaccine, which
should therefore be administered at least 72 h after a dose of sulfonamide. Antiviral drugs may
affect vaccine replication in some circumstances, and live attenuated influenza vaccine should not
be administered until 48 h after cessation of therapy with drugs against influenza (amantadine,
rimantadine, zanamivir, oseltamivir). Antiviral drugs against herpesviruses (acyclovir, famciclovir)
should be discontinued 24 h before administration of a varicella-containing vaccine, if possible.
Answer to Q2:
Prematurity is not a contraindication for vaccination. On the contrary, premature patients
are at increased risk for infectious diseases and for more severe disease than healthy children.
Timely vaccination of premature infants is therefore essential.
Answer to Q3:
There are very few contraindications to rotavirus vaccines. These are:
Clinical cases 73
• a history of a severe allergic reaction (e.g. anaphylaxis) after a previous dose of either rotavirus
vaccine or any component of the vaccine being given;
• severe combined immunodeficiency; the risk–benefit ratio for children with known or suspected
altered immunocompetence should be assessed individually. Children and adults with
congenital immunodeficiency, haematopoietic transplantation or solid organ transplantation
sometimes experience severe or prolonged rotavirus gastroenteritis.
• a history of intussusception, which places children at greater risk than children who have
never had it.
Moderate or severe acute illness with or without a fever indicates precaution in administering
all vaccines, including rotavirus vaccine. Vaccination should not, however, be delayed due to mild
respiratory tract or other acute illness with or without fever. In the case described above, the patient
had diarrhoea, probably related to antibiotics, and rotavirus vaccine could be administered safely,
although some authors350 consider diarrhoea in acute gastroenteritis a reason for postponing
rotavirus vaccination. Usually, rotavirus vaccine should not be administered to infants with acute
moderate or severe gastroenteritis until the condition improves.
Infants with mild acute gastroenteritis can be vaccinated, particularly if the delay in vaccination
might be substantial and might make the infant ineligible to receive vaccine (e.g. age > 15 weeks
before the vaccine series is started). Even a documented episode of naturally occurring rotavirus
acute gastroenteritis after an episode of acute gastroenteritis does not contraindicate rotavirus
vaccination.
In some low- and middle-income countries, the window for rotavirus vaccination is wider (up to 3
years of age), as the additional lives saved by removing age restrictions on rotavirus vaccination
by far outnumber the excess vaccine-associated deaths due to intussusception. In other cases, a
restricted schedule (initiate by 15 weeks and complete by 32 weeks) should be followed strictly.
Q4. This patient has cerebral palsy as a sequel of prematurity. Which of the
following statements is true?
1. Cerebral palsy is an absolute contraindication for vaccination.
2. The vaccine is not contraindicated, but the schedule of vaccination is different.
3. The patient can be vaccinated normally.
4. The patient can be vaccinated normally except with any vaccine containing pertussis antigen.
Answer to Q4:
Chronic diseases may increase a person’s risk for infection or for more severe disease
if infection occurs, so that prevention by vaccination is essential. The patient is also at
increased risk for nosocomial infection with vaccine-preventable diseases because of the
increased likelihood of prolonged hospitalization and frequent outpatient visits. Therefore, it is
particularly important that people with chronic diseases who are immunocompetent be
immunized in a timely manner with both live and inactivated vaccines according to the
routine immunization schedule. Vaccines may be less immunogenic in this population. Ideally,
vaccination should be completed early in the disease course when the response is likely to be
The vaccine requirements and recommendations may change for people with immunosuppression
or receiving immunosuppressive therapy, and the vaccination scheduled should be carefully
reviewed, particularly for live vaccines.
As our patient has a stable, chronic neurological disease, he or she should be vaccinated normally.
Q5. The mother is breastfeeding the preterm baby. Which of the following
statements is true?
1. Vaccination might interfere with the immune response of the infant but with no clinical
consequences.
2. Vaccination should be postponed until breastfeeding is finished.
3. Vaccination interferes only with rotavirus vaccine.
4. Breastfed infants should be vaccinated according to the recommended schedule.
Answer to Q5:
Breastfeeding does not decrease the responses to routine childhood vaccines and is not a
contraindication for any vaccine except smallpox. Yellow fever vaccine should be avoided;
however, if a nursing mother cannot avoid or postpone travel to areas endemic for yellow fever
in which risk for acquisition is high, they should be vaccinated. Breastfeeding does not extend or
improve the passive immunity to vaccine-preventable disease provided by maternal antibodies,
except possibly for Hib. Breastfed infants should be vaccinated according to the recommended
schedule. Although rubella vaccine virus might be shed in human milk, infection of infants is rare.
Breastfeeding and prematurity (< 37 weeks’ gestation) do not impair the immune response to
rotavirus vaccine, as proven in recent studies in Africa and Asia351-353.
8.2. Case 2
An 18-month-old boy is taken to a clinic because of a tonic–clonic seizure that lasted 2 min and
ceased spontaneously. He has fever of 38.5 °C. He had received DTwp-Hib-hepatitis B vaccine
the day before. After careful history-taking and a physical examination, no other findings are
detected. Please answer the following questions regarding this patient:
Answers to Q1:
Febrile seizures can occur with any condition that causes fever. During a febrile seizure,
a child often has spasms or jerking movements and may lose consciousness. Febrile seizures
usually last 1–2 min, and they do not cause any permanent neurological damage. They are most
Clinical cases 75
common with fevers of ≥ 38.9 °C but can also occur at lower body temperatures or when a fever is
going down. One in three children who have one febrile seizure will have at least one more during
childhood; some are linked to the family health history.
The causes include common childhood illnesses like colds, influenza, an ear infection or roseola.
Vaccines sometimes cause fevers but rarely febrile seizures. Infants and young children are
at highest risk for febrile seizures: ≤ 5% of young children will have at least one febrile seizure,
usually associated with illness. Most febrile seizures occur in children aged 6 months to 5 years,
although the commonest age range is 14–18 months.
Q2. How would you interpret the event with regards to the vaccine?
1. The seizure was caused by the vaccine.
2. The seizure was temporarily related to vaccination.
3. The seizure was totally unrelated to vaccination.
4. The vaccination caused epilepsy in the child.
Answer to Q2:
Vaccines, like any medication, can have side-effects; however, most are minor (for example, a
sore arm or low-grade fever) and resolve within a few days. Usually, there is only a temporary
link between vaccination and the event, which does not indicate a causal relation. Caution
should be exercised before a judgement is made or communicating it to the parent, as it may
affect future vaccination.
Studies have indicated that there is no increased risk for febrile seizures after administration
of acellular pertussis vaccine, DTaP, Hib, hepatitis B or varicella vaccine159,160,354,. DTwP has
been reported to be associated with a small increase in risk for febrile seizures the day after
administration355. This small or absent risk is, however, negligible in comparison with the benefits
that the vaccine may provide. Furthermore, the risk does not appear to be associated with any
long-term adverse consequences356.
Q3. How would you manage the patient with regard to future vaccination?
1. The patient shouldnot receive this or any other vaccine in the future.
2. The patient should not receive this vaccine but could receive other vaccines.
3. The patient can receive this vaccine only under surveillance in a special unit for vaccine allergy.
4. The patient can be vaccinated normally with this or any other vaccine.
Answer to Q3:
The parents should be informed that vaccines are prepared in accordance with the highest standards
Febrile seizures can be frightening, but nearly all children who have a febrile seizure recover
quickly and are healthy afterwards. Even in the rare cases that an episode of febrile seizure can
be related to administration of DTwp-Hib-hepatitis B, future doses of this and other vaccines can
be administered safely.
Q4. If it is suspected that this case and any other unusual reaction or clinical
event is related to vaccination, what should be the procedure?
1. Don’t tell anyone, as this is bad publicity for vaccines.
2. Vaccines have no adverse effects.
3. The event should be reported to the local authorities, even if it is only suspected.
4. The event should be reported to the local authorities according to the procedure only if the
relation is proven.
Answer to Q4:
Anyone who administers vaccines is encouraged to report any significant health problem or
unexpected event, even if they are uncertain that the vaccine caused the event. Adverse events
listed on the manufacturer’s package insert and any other clinically significant or unexpected
event after vaccination should be reported. A report of an adverse event does not necessarily
mean that the vaccine caused the event. The report should include
Q5. If in the same week that the child was vaccinated, two other children who
received the same type of vaccine in the same facilities present with the
same symptoms, how would you interpret the episode?
1. I would clearly associate the vaccine with seizures and never vaccinate other children with
DTwp-Hib-hepatitis B vaccine.
2. I would report the event for further investigations of the vaccine lot, transport and storage.
3. I would inform the parents that an increased rate of seizures due to DTwp-Hib-hepatitis B
vaccine has been confirmed.
4. I would assume that the event was coincidental and take no further measures.
Clinical cases 77
Answer to Q5:
It may be difficult to identify the causes of adverse events after vaccination. Once the adverse
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be continued; however, if further cases of the same adverse event occur with the same vaccine,
errors in its manufacture, transport and storage must be ruled out. Meanwhile, health care
professionals should remain alert for new cases but provide the same information to parents. No
alarm should be given until an official report of causality is available, as it is essential to build trust
in immunization programmes.
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103
Key
Very common > 1/10 > 10%
Common > 1/100 and < 1/10 > 1% and < 10% F
Uncommon > 1/1,000 and < 1/100 > 0.1% and < 1 %
Rare > 1/10,000 and < 1/1,000 > 0.01% and < 0.1%
Very rare < 1/10,000 < 0.01%
N
104 *
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