Content

01 Abstract
02 Introduction
03 Vaccine & Vaccination
04 Immunization & Its benefits
05 Smallpox and the origin of vaccination
06 Vaccines Types
07 How vaccines work
08 Vaccines for Adults
09 Future of vaccines
10 Vaccines Importance
11 Safety of vaccines
12 Available vaccines
13 Some common vaccines
14 Routine vaccines for review before travelling
15 Effectiveness of vaccination
16 Global economy & vaccination
17 Vaccines quality: WHO Specifications
18 Excipients
19 Adjuvants and preservatives
20 Disease control benefits
21 Prevention
22 Societal and other benefits
23 Adverse Affects
24 Global coverage and cost of vaccines
25 Vaccines supply & cost
 26 Conclusion
Abstract
Vaccines are the health promise to the next generation. Immunization is the
powerful tool that provides immense health benefits to the individuals by the
eradication and protection from several diseases. The neonate health promise
begins with the maternal immunization. This immunization strategy is an
established strategy for the public health. For e.g., studies show immunization of
pregnant mother with influenza vaccine decreased the infant infection up to the 6
months of age by 63%. Vaccine efficacy should consider the health and non-health
benefits of the individuals of both vaccinated and unvaccinated population. This
vigilance helps to know the efficacy of the vaccine in the individuals, effectiveness
in the communities and further the impact in the society. The source from which
vaccine develops also have impact on the society. For e.g.: the administration
of vaccine developed from fetal cell line puts a negative impact to certain societies.
Vaccination has significant role in the creation of a healthy population and hence a
healthy and prosper nation. The intentional release of biological agents by
belligerents or terrorists is a possibility that has recently attracted increased
attention. Law enforcement agencies, military planners, public health officials, and
clinicians are gaining an increasing awareness of this potential threat. From a
military perspective, an important component of the protective pre-exposure
armamentarium against this threat is immunization. In addition, certain vaccines
are an accepted component of post exposure prophylaxis against potential
bioterrorist threat agents. These vaccines might, therefore, be used to respond to a
terrorist attack against civilians. We review the development of vaccines against
10 of the most credible biological threats.

Introduction
Immunization is a powerful tool that provides immense health benefits to the
humanity by extended life expectancy with the eradication and protection from
several diseases. Diseases like polio, small pox, diphtheria, measles, mumps,
rubella etc are some among them that have been thrown out from the globe
with the introduction of routine immunization programs. Vaccines are one of the
medical interventions in the 20th century for the upliftment of public health.
Reports reveal that lack of awareness about the routine vaccination and safety
measures among public leads to the re-emerge and out-break of defeated diseases.
The recent outbreak of measles, H1N1 influenza etc link to the lack of safety
concerns in the public. Currently there are routine vaccinations for pregnant
mother, infants, and children at different age groups and even for adults. The CDC
and American Academy of Pediatrics introduced a guideline for the wider
awareness and monitoring the parent’s concern in vaccination in association
with National Immunization survey. The ratio of immunization and medical
visits of teens and adults are very low compared to young children. The
complete benefits of all the medical interventions can be achieved by the sustained
social and political support. However, the efficacy and safety of the vaccines are
crucial during the regulatory decisions of the vaccine to be licensed.
The status of poor countries that unable to raise the fund for vaccine availability
makes them vulnerable to various diseases. Another reason that makes certain
population or communities to disagree to administer the vaccines is the source of
development of the vaccines. Certain vaccines are developed from cells derived
out of human fetal cells obtained from elective abortions that are used in
pharmaceutical industries and in medical research.

Vaccination in pregnant mother transfers the immunity to the fetus; hence both
mother and the child are protected. Rubella, Hepatitis B, whooping cough, zika etc
are some of the diseases that get transferred from mother to the fetus during
pregnancy. The health promise to the neonates begins at immunization of pregnant
mother. Hence vaccination during pregnancy has to be established wisely for the
buildup of a healthy generation. There are various routine immunizations programs
conducted by the governments to look after the public health. This review tries to
put light on some of the issues that sustains and hinders the vaccination and further
a healthy generation. Vaccination has greatly reduced the burden of infectious
diseases. Only clean water, also considered to be a basic human right, performs
better. Paradoxically, a vociferous anti-vaccine lobby thrives today in spite of the
undeniable success of vaccination programs against formerly fearsome diseases
that are now rare in developed countries.

Understandably, vaccine safety gets more public attention than vaccination

effectiveness, but independent experts and WHO have shown that vaccines are far
safer than therapeutic medicines. Modern research has spurred the development of
less reactogenic products, such as acellular pertussis vaccines and rabies vaccines
produced in cell culture. Today, vaccines have an excellent safety record and most
“vaccine scares” have been shown to be false alarms. Misguided safety concerns in
some countries have led to a fall in vaccination coverage, causing the re-emergence
of pertussis and measles.

Putative vaccine safety issues are commonly reported while reviews of vaccine
benefits are few. A Medline search over the past five years using the keywords
“vaccine risks” scored approximately five times as many hits (2655 versus 557) as
a Medline search using “vaccine benefits” as keywords. This reflects the fact that
negative aspects of vaccination get much more publicity than positive aspects.
How one addresses the antivaccine movement has been a problem since the time of
Jenner. The best way in the long term is to refute wrong allegations at the earliest
opportunity by providing scientifically valid data. This is easier said than done,
because the adversary in this game plays according to rules that are not generally
those of science. This issue will not be further addressed in this paper, which aims
to show how vaccines are valuable to both individuals and societies, to present
validated facts, and to help redress adverse perceptions. Without doubt, vaccines
are among the most efficient tools for promoting individual and public health and
deserve better press.

Vaccine
A vaccine is made from very small amounts of weak or dead germs that can cause
diseases — for example, viruses, bacteria, or toxins. It prepares your body to fight
the disease faster and more effectively so you won’t get sick.
Example: Children younger than age 13 need 2 doses of the chickenpox vaccine.

Vaccination
Vaccination is the act of getting a vaccine, usually as a shot.

Example: Schedule your tetanus vaccination today.

Immunization
Immunization is the process of becoming immune to (protected against) a disease.

Example: Because of continued and widespread immunization in the United

States, it’s rare for Americans to get polio.
Immunization can also mean the process of getting vaccinated. For example, your
“immunization schedule,” is the timing of your shots

Benefits of Immunization
Invention of vaccines is one of the great achievements in the medical field for the
public health during the 20th century [11]. Immunization programs benefit by
promising healthy immune system in a healthy body and hence an extended life
with the eradication of several diseases. Smallpox, polio, diphtheria, measles,
mumps, rubella, etc are some of the deadly diseases that have been thrown out
with the introduction of routine immunization programs. Some vaccines are
introduced specifically for travelling and occupational purposes also By increasing
the immunization coverage in young children, the elimination of diseases can be
sustained. During the 21st century, the routine immunization recommendation
expanded in the US. In 1980s the recommended list included vaccines against
6-7 diseases, but in the following decades the recommendations expanded to
about 20 diseases, which include rotavirus, HepB, HepA etc. The NIS report,
2013 says high vaccine coverage could sustain the low proportion of unvaccinated
children of age 19-35 months old, and the target named Healthy People 2020
monitors the children to get vaccinated and hence to create a healthy nation.
[21] The wide immunization programs increases the herd immunity of the
population. Infectious diseases such as small pox, whooping cough, diphtheria,
tetanus etc that were devastating throughout the history until 20th century are now
rarely seen or eradicated from the globe by the introduction of vaccines. Another
deadly disease called Homophiles influenza type b (Hib) that claimed about a lakh
of deaths in children of under 5 years age worldwide in the recent past has
been reduced drastically with the help of vaccines.
The CDC and American academy of pediatrics introduced a guide to expand the
awareness and also monitor parent’s concern with national immunization survey.
The ratio of vaccination and medical visits among teens and adults are very low
compared to young children. The complete benefits of all the medical
interventions can be achieved by the sustained social and political support to
immunization programs. Wide range of vaccines for various diseases are in
the developmental stage. Effective vaccines for malaria, tuberculosis, AIDS,
cardiovascular disease, autoimmune diseases, and various types of cancers may
be anticipated in nearby future.
Immunization during pregnancy – A health promise to next generation
The neonate health promise begins with the maternal immunization. This
immunization strategy is an established strategy for the public health [30].
Vaccinated pregnant mother protects the baby from diseases by immunizing them
during their first few months of life. The antibodies developed in the mother’s
body get transferred to the fetus during pregnancy [15]. Several diseases that may
pass on to the fetus through placenta and to the new born through breast feeding
from the mother include rubella, hepatitis, flue, whooping cough, zika, measles,
mumps, chickenpox etc. Effective vaccines are available except zika virus
infection. About 9% of pregnant mother infected with varicella virus are prone to
develop pneumonia and the placental transmission of virus cause congenital
varicella syndrome to the fetus that results neurological defects, skeletal
abnormalities etc

Vaccination against influenza during 2nd and 3rd trimester of pregnancy becomes
necessary to reduce the risk of fetal complication. Studies show immunization of
pregnant mother with influenza vaccine decreased the infant infection up to the 6
months of age by 63%. Also vaccinating the pregnant mother against whooping
cough, protect the babies from the severe complications of pneumonia and brain
inflammation that may develop following the infection [19]. Tetanus claims the
life of more than a lakh of neonates worldwide every year. Tetanus is caused by
toxin produced by an aerobic bacterium called Clostridium tetani. Infection occurs
environmental exposure of broken skin or wound to the spores of the bacteria that
is present universally in the soil Tetanus vaccination to the pregnant mother is one
of the successful proof of antibody transformation from mother to the fetus. Recent
evidences show maternal exposure to infection ‘in utero’ prime the infant immune
system, not necessary the infant’s exposure to the infection [15]. IgG transfer
through placenta during pregnancy is responsible for the passive immunity of
the new born. Vaccination during pregnancy boosts the mother’s immunity
against the vaccine specific antigen by increasing the antibody concentration,
further increase in the transplacental antibody concentration.
Immunization is a global health and development success story, saving millions of
lives every year. Vaccines reduce risks of getting a disease by working with your
body’s natural defenses to build protection. When you get a vaccine, your immune
system responds.

We now have vaccines to prevent more than 20 life-threatening diseases, helping

people of all ages live longer, healthier lives. Immunization currently prevents 2-3
million deaths every year from diseases like diphtheria, tetanus, pertussis,
influenza and measles.

Immunization is a key component of primary health care and an indisputable

human right. It’s also one of the best health investments money can buy. Vaccines
are also critical to the prevention and control of infectious-disease outbreaks. They
underpin global health security and will be a vital tool in the battle against
antimicrobial resistance.

Yet despite tremendous progress, far too many people around the world –
including nearly 20 million infants each year – have insufficient access to vaccines.
In some countries, progress has stalled or even reversed, and there is a real risk that
complacency will undermine past achievements.

Global vaccination coverage – the proportion of the world’s children who receive
recommended vaccines – has remained the same over the past few years.
Smallpox and the origin of vaccination
Vaccination has a long history. An early form of vaccination was referred to as
‘variolation’ or more broadly as ‘inoculation’. Practiced for a long time in Asia,
this was an ancient technique of deliberate smallpox infection in which dried
smallpox scabs were blown up the nose to infect the person with a form of the
disease which was often milder. By the 1700s variolation had spread to Africa,
India and the Ottoman Empire, followed by the UK and America, where the
method of infection more frequently used was a puncture to the skin.

Variolation did work, but there were large risks. Those variolated could contract
the more severe form of smallpox and die, and they could also transmit the disease
to others.
In 1796 English physician Edward Jenner demonstrated another method of
inoculation in which he relied on cowpox. Cowpox is a similar disease to smallpox
and it had previously been observed that an infection with cowpox can protect
against smallpox. Jenner conducted an experiment using matter from a cowpox
lesion to inoculate his gardener’s eight-year-old son James Phipps. Two months
later Jenner exposed the boy to smallpox lesion matter and when Phipps did not
develop smallpox he concluded that he was protected against the disease. Jenner
called the procedure ‘vaccination’ after ‘vacca’ the Latin word for cow because of
the origin of this first vaccination from the cowpox virus.
Following the findings of Jenner as the first scientific attempt to control disease by
vaccination, the smallpox vaccine went through many iterations, with the newer
vaccines produced by modern cell culture techniques (passing the virus through
cell culture makes the vaccine safer). By the middle of the 20th century confidence
grew that smallpox could be the first disease that humankind might be able to
eradicate. In 1967 the WHO launched a global eradication of smallpox program.
Mass vaccination of over 80% of a country’s population ensued but people who
were nomadic or lived in politically unstable regions posed particular problems. A
number of innovations came in the development of foot-powered injector called
the “ped-o-jet” and then the bifurcated needle, which was efficient and
costeffective to use.

In order to reach large sections of population, epidemiologist William

Foege developed Eradication Escalation (E2) to contain smallpox outbreaks during
October (the seasonal low point of smallpox transmission where prevention of just
few cases could stop a smallpox chain transmission). Other obstacles faced
included forcibly vaccinating an Indian religious leader to convince his followers
to be vaccinated, negotiation of ceasefires for vaccine transport in wartorn Nigeria,
vaccinating in concentric rings around an outbreak, and cash bounties to reward the
reporting of smallpox cases. Finally in 1977 the last case of naturally contracted
smallpox was reported in Somalia, in Ali Maow Maalin, and in 1980 the WHO
announced that smallpox had been eradicated. We cover the history of smallpox,
including the vaccination and eradication, in more detail in our entry on smallpox.

Vaccine innovation
The chart here shows a timeline of innovation in the development of vaccines.
Each bar begins in the year in which the pathogenic agent was first linked to the
disease and the bar ends in the year in which a vaccination against that pathogen
was licensed in the US.

For some diseases there has been a relatively short timespan between when the
infectious agent was linked to the disease and when a vaccine was developed. The
quickest was 10 years for measles. The agent was linked to the disease in 1953 and
the vaccine was licensed in the U.S. in 1963.

Malaria is proving harder as it has been over a century since the agent was linked
to the disease. Alphonse Laveran discovered in 1880 that the Plasmodium parasite
is the cause for malaria.8
Early vaccines developed in the last several decades were insufficiently effective
and until recently none of the scientific efforts led to a licensed vaccine. Recently
there has been new hope for a malaria vaccine as we document in the relevant
section in our entry on malaria.

Vaccine innovation has followed both scientific and political-economic

developments:

• Bacterial culture techniques which allowed the development of bacterial

vaccines for diphtheria, tetanus, and pertussis in the early 1900s.

• The first and second world wars prompted combined efforts by universities,
governments, and private companies.

• By the 1950s viral tissue culture techniques allowed the development of

vaccines against polio, measles, mumps, rubella, and varicella (chickenpox).

• New technologies in molecular biology and advanced chemistry techniques

have most recently led to vaccines against hepatitis B, influenza, and
pneumococcus, which causes pneumonia and meningococus, which causes
meningitis and septicaemia.

Vaccine Types
There are several different types of vaccines. Each type is designed to teach
your immune system how to fight off certain kinds of germs — and the serious
diseases they cause.
When scientists create vaccines, they consider:

• How your immune system responds to the germ

• Who needs to be vaccinated against the germ
• The best technology or approach to create the vaccine
Based on a number of these factors, scientists decide which type of vaccine they
will make. There are 4 main types of vaccines:

• Live-attenuated vaccines
• Inactivated vaccines
 • Subunit, recombinant, polysaccharide, and conjugate vaccines
• Toxoid vaccines

Live-attenuated vaccines
Live vaccines use a weakened (or attenuated) form of the germ that causes a
disease.

Because these vaccines are so similar to the natural infection that they help
prevent, they create a strong and long-lasting immune response. Just 1 or 2 doses
of most live vaccines can give you a lifetime of protection against a germ and the
disease it causes.

But live vaccines also have some limitations. For example:

• Because they contain a small amount of the weakened live virus, some
people should talk to their health care provider before receiving them, such
as people with weakened immune systems, long-term health problems, or
people who’ve had an organ transplant.
• They need to be kept cool, so they don’t travel well. That means they can’t
be used in countries with limited access to refrigerators.
Live vaccines are used to protect against:
• Measles, mumps, rubella (MMR combined vaccine)
• Rotavirus
• Smallpox
• Chickenpox
• Yellow fever

Inactivated vaccines
Inactivated vaccines use the killed version of the germ that causes a disease.
Inactivated vaccines usually don’t provide immunity (protection) that’s as strong
as live vaccines. So you may need several doses over time (booster shots) in order
to get ongoing immunity against diseases.

Inactivated vaccines are used to protect against:

 • Hepatitis A
• Flu (shot only)
• Polio (shot only)
• Rabies

Subunit, recombinant, polysaccharide, and conjugate vaccines

Subunit, recombinant, polysaccharide, and conjugate vaccines use specific pieces
of the germ — like its protein, sugar, or capsid (a casing around the germ).

Because these vaccines use only specific pieces of the germ, they give a very
strong immune response that’s targeted to key parts of the germ. They can also be
used on almost everyone who needs them, including people with weakened
immune systems and long-term health problems.

One limitation of these vaccines is that you may need booster shots to get ongoing
protection against diseases.

These vaccines are used to protect against:

• Hib (Haemophilus influenzae type b) disease

• Hepatitis B
• HPV (Human papillomavirus)
• Whooping cough (part of the DTaP combined vaccine)
• Pneumococcal disease
• Meningococcal disease
• Shingles

Toxoid vaccines
Toxoid vaccines use a toxin (harmful product) made by the germ that causes a
disease. They create immunity to the parts of the germ that cause a disease instead
of the germ itself. That means the immune response is targeted to the toxin instead
of the whole germ.

Like some other types of vaccines, you may need booster shots to get ongoing
protection against diseases.
Toxoid vaccines are used to protect against:

• Diphtheria
• Tetanus

Biosynthetic vaccines
contain manmade substances that are very similar to pieces of the virus or bacteria.
The Hepatitis B vaccine is an example.

Heterotypic
Main article: Heterologous vaccine

Also known as heterologous or "Jennerian" vaccines, these are vaccines that are
pathogens of other animals that either do not cause disease or cause mild disease in
the organism being treated. The classic example is Jenner's use of cowpox to
protect against smallpox. A current example is the use of BCG vaccine made from
Mycobacterium bovis to protect against human tuberculosis.
The future of vaccines
Experimental

Electroporation system for experimental "DNA vaccine" delivery

A number of innovative vaccines are also in development and in use:

• Dendritic cell vaccines combine dendritic cells with antigens in order to

present the antigens to the body's white blood cells, thus stimulating an
immune reaction. These vaccines have shown some positive preliminary
results for treating brain tumors and are also tested in malignant melanoma.
• Recombinant vector – by combining the physiology of one micro-organism
and the DNA of another, immunity can be created against diseases that have
complex infection processes. An example is the RVSV-ZEBOV
vaccine licensed to Merck that is being used in.
 • T-cell receptor peptide vaccines are under development for several diseases
using models of Valley Fever, stomatitis, and atopic dermatitis. These
peptides have been shown to modulate cytokine production and improve
cell-mediated immunity.
• Targeting of identified bacterial proteins that are involved in complement
inhibition would neutralize the key bacterial virulence mechanism.

Scientists are still working to create new types of vaccines. Here are 2 exciting
examples:

• DNA vaccines are easy and inexpensive to make — and they produce
strong, long-term immunity.
• Recombinant vector vaccines (platform-based vaccines) act like a natural
infection, so they're especially good at teaching the immune system how to
fight germs.

Vaccines for Adults

Every year, thousands of adults in the United States get sick and are hospitalized
from vaccine-preventable diseases. Getting vaccinated will help you stay healthy,
so you’ll miss less work and also have more time for your family and friends.

And did you know that when you get vaccinated, you also help protect your family
and your community? Because of community immunity, vaccines help keep
diseases from spreading to people who may not be able to get certain vaccines, like
newborn babies. Learn more about community immunity.

In this section, you’ll find the vaccine information and schedules for:

• Adults ages 19 through 26

• Adults ages 27 through 64
• Adults age 65 and older

Adults need vaccines for several reasons. For example:

• Some vaccines are recommended only for adults, who are more at risk for
certain diseases — like shingles.
• Protection from childhood vaccines wears off over time so you need
additional doses of certain vaccines to stay protected.
 • You may not have gotten some of the newer vaccines that are now available.
• Some viruses, like the virus that causes the flu, can change over time.
• You may be at increased risk for diseases based on travel plans, your job, or
health conditions.

How Vaccines Work

Vaccines "teach" your body how to defend itself when germs, such as viruses or
bacteria, invade it:

• Vaccines expose you to a very small, very safe amount of viruses or bacteria
that have been weakened or killed.
• Your immune system then learns to recognize and attack the infection if you
are exposed to it later in life.
• As a result, you will not become ill, or you may have a milder infection.
This is a natural way to deal with infectious diseases.

Why We Need Vaccines

For a few weeks after birth, babies have some protection from germs that cause
diseases. This protection is passed from their mother through the placenta before
birth. After a short period, this natural protection goes away.
Vaccines help protect against many diseases that used to be much more common.
Examples include tetanus, diphtheria, mumps, measles, pertussis (whooping
cough), meningitis, and polio. Many of these infections can cause serious or
lifethreatening illnesses and may lead to life-long health problems. Because of
vaccines, many of these illnesses are now rare.

Measles, mumps, and whooping cough may seem like quaint old illnesses confined
to 19th century novels. But more and more teens are being exposed to them,
especially in schools and on college campuses where large numbers of people are
together in close quarters.

Diseases like measles, which were on their way out in the United States, are
making a comeback as they are brought in from other countries by travelers. These
diseases wouldn't spread as quickly — or be as serious — if people were
immunized against them. But many teens aren't.
It's not your fault if you don't have all the immunizations (vaccinations) you need.
Shots that doctors recommend today may not have been required when you were
younger. So you may not have had them.

Some vaccinations (like the HPV vaccine) are given as a series of shots, not just
one single dose. Some people may have missed getting all the required shots. Not
getting a full course of a vaccine leaves a person unprotected and still at risk for
getting a disease. Other vaccinations require a booster shot every few years to
ensure that the level of immunity remains high.

Missing a shot may not seem like a bad thing — nobody wakes up in the morning
thinking they'd love to go out and get a jab in the arm. But there are good reasons
to get shots:

One little "ouch" moment protects you from some major health problems. For
example, older teens and adults who get diseases like mumps may be at risk for
side effects of the illness, such as infertility (the inability to have children).

Vaccinations are about protecting you in the future, not just as a kid. Many of
the diseases that we are vaccinated against when we're kids — like hepatitis B or
tetanus — actually affect more adults than kids. Plus, anyone can get "kid
diseases" like chickenpox, and they can be far more dangerous to teens and adults
than they are to little kids.
Shots could even save your life. Hepatitis B attacks the liver and can eventually
kill. The HPV vaccine can protect against several types of cancer. And scientists
are constantly working on new vaccines against deadly diseases like HIV.

Safety Of Vaccines
Some people worry that vaccines are not safe and may be harmful, especially for
children. They may ask their health care provider to wait or even choose not to
have the vaccine. But the benefits of vaccines far outweigh their risks.

The American Academy of Pediatrics, the Centers for Disease Control and
Prevention (CDC), and the Institute of Medicine all conclude that the benefits of
vaccines outweigh their risks.

Vaccines, such as the measles, mumps, rubella, chickenpox, and nasal spray flu
vaccines contain live, but weakened viruses:
 • Unless a person's immune system is weakened, it is unlikely that a vaccine
will give the person the infection. People with weakened immune systems
should not receive these live vaccines.
• These live vaccines may be dangerous to the fetus of a pregnant woman. To
avoid harm to the baby, pregnant women should not receive any of these
vaccines. The provider can tell you the right time to get these vaccines.

Thimerosal is a preservative that was found in most vaccines in the past. But now:

• There are infant and child flu vaccines that have no thimerosal.
• NO other vaccines commonly used for children or adults contain thimerosal.
• Research done over many years has NOT shown any link between
thimerosal and autism or other medical problems.

Allergic reactions are rare and are usually to some part (component) of the vaccine.

Like any medicine, vaccines may cause side effects, but receiving one is far safer
than getting the disease it prevents. The most common reactions include soreness,
redness, and swelling in the area of the shot or a low-grade fever. Usually
acetaminophen or ibuprofen will take care of these side effects.
It's rare to have any kind of bad reaction to a vaccine. If you've had reactions to
vaccines in the past, let your doctor know. Before getting a vaccine, discuss any
concerns that you have about it with your doctor.

Who Should Not Be Vaccinated?

People who have a weakened immune system (from AIDS or certain cancers, for
example) need to talk to their doctors before getting vaccinated. This is also true
for those who receive treatments like chemotherapy or who take medication that
can weaken the immune system. Girls who are pregnant can benefit from some
immunizations (like the Tdap or flu shot) but should talk to a doctor or health
clinic before getting vaccinated.

People with certain allergies may not be able to get some vaccines. For example,
people who have severe allergies to gelatin or the antibiotic neomycin should be
careful with the MMR and varicella vaccines. And if you're extremely allergic to
baker's yeast, which is used to make bread, you should not get a hepatitis B
vaccine. If you have allergies, talk to your doctor to see if any vaccine should be
avoided.
Vaccine Schedule
The recommended vaccination (immunization) schedule is updated every 12
months by the US Centers for Disease Control and Prevention (CDC). Talk to your
provider about specific immunizations for you or your child. Current
recommendations are available at the CDC website:
www.cdc.gov/vaccines/schedules. Travelers
The CDC website (www.cdc.gov/travel) has detailed information about
immunizations and other precautions for travelers to other countries. Many
immunizations should be received at least 1 month before travel.

Bring your immunization record with you when you travel to other countries.
Some countries require this record.

Common Vaccines
• Chickenpox vaccine
 •
•
•
•
•
DTaP immunization (vaccine)
Hepatitis A vaccine
Hepatitis B vaccine
Hib vaccine
HPV vaccine
• Influenza vaccine
• Meningococcal vaccine
• MMR vaccine
• Pneumococcal conjugate vaccine
• Pneumococcal polysaccharide vaccine
• Polio immunization (vaccine)
• Rotavirus vaccine
• Shingles vaccine
• Tdap vaccine
• Tetanus vaccine

Available vaccines
Under ‘Available vaccines’ is a list of certain diseases for which vaccines are
available. For each disease or pathogen, a link is provided to a webpage with
summary information on internationally available vaccines and WHO policy
recommendations, together with other key resources.

Under ‘Pipeline vaccines’ is a list of diseases for which vaccines are in

development. Pipeline vaccines are overseen by WHO’s Product Development
for Vaccines Advisory Committee (PDVAC). For each disease or pathogen, a link
is provided to a summary of vaccine research and development, prepared for
PDVAC.

• Cholera
 •
•
•
•
•
• Dengue
• Diphtheria
• Hepatitis A
• Hepatitis B
• Hepatitis E
Haemophilus influenzae type b (Hib)
Human papillomavirus (HPV)
Influenza
Japanese encephalitis
Malaria
• Measles
• Meningococcal meningitis
• Mumps
• Pertussis
• Pneumococcal disease
• Poliomyelitis
• Rabies
• Rotavirus
• Rubella
• Tetanus
• Tick-borne encephalitis
• Tuberculosis
• Typhoid
• Varicella
• Yellow Fever

Pipeline vaccines
• Campylobacter jejuni
 •
•
•
•
•
• Chagas Disease
• Chikungunya
• Dengue
• Enterotoxigenic Escherichia coli
• Enterovirus 71 (EV71)
• Group B Streptococcus (GBS)
• Herpes Simplex Virus
• HIV-1
• Human Hookworm Disease
• Leishmaniasis Disease
Malaria
Nipah Virus
Nontyphoidal Salmonella Disease
Norovirus
Paratyphoid fever
• Respiratory Syncytial Virus (RSV)
• Schistosomiasis Disease
• Shigella
• Staphylococcus aureus
• Streptococcus pneumoniae
• Streptococcus pyrogenes
• Tuberculosis
• Universal Influenza Vaccine

Routine vaccines for review before travelling

• Diphtheria
• Hepatitis B
• Haemophilus influenzae type b
•
•
•
•
•
• Human papillomavirus
• Seasonal influenza

• Measles
• Mumps
• Pertussis
• Rubella
• Pneumococcal disease

• Poliomyelitis (Polio)
• Rotavirus
• Tetanus
• Tuberculosis (TB)
• Varicella
Selective use for travelers
These vaccines are recommended to provide protection against diseases endemic to
the country of origin or of destination. They are intended to protect travellers and
to prevent disease spread within and between countries.
Some countries require proof of vaccination for travellers wishing to enter or exit
the country.

• Cholera
• Hepatitis A
• Hepatitis E

• Japanese encephalitis
• Meningococcal disease
• Polio (adult booster dose)
• Rabies

• Tick-borne encephalitis
• Typhoid fever
• Yellow fever

Effectiveness of vaccination
Vaccines are boon to the public health however, safety and effectiveness
after the vaccine administration is an important concern to be investigated. The
recent outbreak of vaccine preventable diseases such as measles, H1N1 influenza
etc. can be linked to lack of safety concerns among the public. The detailed
clarification of risk and benefits of vaccines during pregnancy increases the
confidence of pregnant mothers on vaccination. Vaccine efficacy should
consider the health and non-health benefits of the individuals of both
vaccinated and unvaccinated population. This vigilance helps to know the efficacy
of the vaccine in the individuals, effectiveness in the communities and further the
impact in the society. Efficacy is the performance of an intervention under
controlled circumstances; effectiveness is the performance of the same intervention
under real world or real condition. The effectiveness in a vaccinated population is
high by decreasing the disease rate, whereas the effectiveness in the unvaccinated
population will be low with a high rate of disease cases. The evaluation of a
vaccine efficacy by the traditional method i.e. against a placebo in an individual
randomized clinical trial (iRCT) gives insufficient data. In certain circumstances
cluster randomized clinical trial (cRCT) is more reliable than iRCT in evaluating
the vaccine. The impact of vaccination covers the health and non-health benefits of
the public. The non-health benefits include income, employment, education etc.
that emerge from the vaccine research, manufacturing and distribution and, another
indirect impact is the cost of the vaccine. Cost effectiveness broadens the
vaccinated population. The safety of pregnant mother is a key consideration after
the vaccine administration. Despite the vaccine recommendation and awareness on
the benefits of immunization during pregnancy, there is reluctance to accept the
vaccine. However the adverse effect after vaccination during pregnancy has been
studied and still in progress, in low and middle income countries (LMIC) the
vaccine safety study is hindered by lack of standards for post vaccine outcome
measurements and harmonized methods. This drawback affects the
pharmacovigilance program and other observational studies. Hence there is
recommendation for need of globally harmonized method to monitor the safety and
efficacy of vaccines and immunization by Food and Drug administration (FDA),
European Medicine Agency (EMA) and International Conference for
Harmonization (ICH).

The FDA issued the pregnancy and lactation labeling rule (PLLR) that summarizes
the information of risk of administration of different ingredients in vaccines
and drugs during pregnancy . The global alignment of immunization and safety
assessment in pregnancy (GAIA) project that funded by the Bill and Milinda
gates foundation in response to WHO call is for the active monitoring of the safety
of immunization in pregnancy program and with LMICs needs and requirements as
a specific focus. In GAIA 13 organizations were collaborated globally along with
200 volunteers to achieve the goal. Lack of base line guidelines for vaccination
during pregnancy may lead to challenges like unpredictable epidemiology,
receiving and retaining of pregnant mothers in the clinical trial etc. These
challenges can be overcome by tying up with Maternal,

Neonatal and Child Health (MNCH) and Antenatal care (ANC) providers. MNCH
and ANC are involved in the welfare of pregnant mothers by identifying and
monitoring them. This helps the clinical trial flexibility and conducting the
research in low resources. Different measures such as Vaccine Preventable Disease
Incidence (VPDI), Number Need to Vaccine (NNV) etc for the vaccine evaluation
need to be used more systematically to get a complete evaluation. Even though
VPDI and NNV have limitations that their metrics depends on local
epidemiological study, but advantage is that it focus not only on degree of
vaccination but also on disease prevention capacity of vaccine.

Global economy and vaccination

Healthy individuals build up a healthy society and can contribute to the
economic growth of the country. Vaccination has significant role in the creation
of a healthy population. Childhood vaccination programs offer individual child
protection from dangerous diseases, hence preventing fatality as well as
temporary and permanent squeal rate thus transformation of healthy childhood into
a healthy adulthood.

The poor countries that are in the claws of poverty, under nutrition and
epidemiology may struggle to raise the fund for the health industry and hence the
potential of youth diminishes due to health complications. Jeffrey Sachs, who is
an economist at Harvard University, noted that impoverishment is the culprit
of illness and mortality other than poverty. Immunization is at the forefront to
face these challenges. This may be achieved through proactive information
exchange, education, communication, sustained vigilance on public health.
Vaccine quality
Biological medicinal products differ from chemical drugs in that they cannot
normally be characterized molecularly; starting methods such as bacteria, viruses,
or genetically modified micro-organisms are of enormous complexity, as well as
having the capacity to vary from preparation to preparation. A certain amount of
these products, such as vaccines against transmissable disease, are also
administered to healthy individuals -- often children at the start of their lives, and
thus a strong emphasis must be placed on their quality to ensure, to the greatest
extent possible, that they are efficacious in preventing or treating life-threatening
disease, without themselves causing harm.

The increasing globalization in the production and distribution of these biological

medicines has opened new possibilities to better manage public health concerns,
but has also raised questions about the equivalence and interchangeability of
medicines procured across a variety of sources. International standardization of
starting materials, of production and quality control testing, and the setting of high
expectations for regulatory oversight on the way these products are manufactured
and used have thus been the cornerstone for their continued success. But it remains
a field in constant change. The continuous technical advances in the field offer a
promise of developing potent new weapons against our oldest public health threats,
as well as new ones - malaria, genetic deficiencies, pandemic influenza, and AIDS,
to name a few -- but also put a great pressure on manufacturers, regulatory
authorities, and the wider medical community to ensure that products continue to
meet the highest standards of quality attainable.

Production and Quality: WHO Specifications

Biological medicinal products, such as vaccines, blood and blood products,
diagnostics, gene therapy, biotechnology products, cytokines and growth factors,
and cell and tissue products rely heavily on international standardization to ensure
their quality and their equivalence across manufacturers. For over a half-century,
WHO has been active in the field of biological standardization, bringing together
scientists and policy makers on a global scale to find consensus approaches to the
manufacturing, testing and regulatory oversight of these medicinal products.
Through the WHO Technical Report Series (TRS) up-to-date methods are
described for the benefit of its Member States and manufacturers, and international
reference materials for the standardization of assays and testing are established
through collaborative studes for global distribution. Consultations and expert
working groups on technical issues important to the field are also documented,
giving interested parties the latest information available on complex issues such as
biocontainment of potential pandemic threats, clinical and non-clinical testing of
vaccines, risks of transmissible spongiform encephalopathies (TSE's), DNA
vaccines, and a variety of other topics.

Two workers make openings in chicken eggs in preparation for production of

measles vaccine.

Vaccine production has several stages. First, the antigen itself is generated. Viruses
are grown either on primary cells such as chicken eggs (e.g., for influenza) or on
continuous cell lines such as cultured human cells (e.g., for hepatitis A). Bacteria
are grown in bioreactors (e.g., Haemophilus influenzae type b). Likewise, a
recombinant protein derived from the viruses or bacteria can be generated in yeast,
bacteria, or cell cultures. After the antigen is generated, it is isolated from the cells
used to generate it. A virus may need to be inactivated, possibly with no further
purification required. Recombinant proteins need many operations involving
ultrafiltration and column chromatography. Finally, the vaccine is formulated by
adding adjuvant, stabilizers, and preservatives as needed. The adjuvant enhances
the immune response of the antigen, stabilizers increase the storage life, and
preservatives allow the use of multidose vials. Combination vaccines are harder to
develop and produce, because of potential incompatibilities and interactions among
the antigens and other ingredients involved.
Vaccine production techniques are evolving. Cultured mammalian cells are
expected to become increasingly important, compared to conventional options such
as chicken eggs, due to greater productivity and low incidence of problems with
contamination. Recombination technology that produces genetically detoxified
vaccine is expected to grow in popularity for the production of bacterial vaccines
that use toxoids. Combination vaccines are expected to reduce the quantities of
antigens they contain, and thereby decrease undesirable interactions, by using
pathogen-associated molecular patterns.

In 2010, India produced 60 percent of the world's vaccine worth about $900
million (€670 million).

Excipients
Beside the active vaccine itself, the following excipients and residual
manufacturing compounds are present or may be present in vaccine preparations:

• Aluminum salts or gels are added as adjuvants. Adjuvants are added to

promote an earlier, more potent response, and more persistent immune
response to the vaccine; they allow for a lower vaccine dosage.
• Antibiotics are added to some vaccines to prevent the growth of bacteria
during production and storage of the vaccine.
• Egg protein is present in influenza and yellow fever vaccines as they are
prepared using chicken eggs. Other proteins may be present.
• Formaldehyde is used to inactivate bacterial products for toxoid vaccines.
Formaldehyde is also used to inactivate unwanted viruses and kill bacteria
that might contaminate the vaccine during production.
• Monosodium glutamate (MSG) and 2-phenoxyethanol are used as stabilizers
in a few vaccines to help the vaccine remain unchanged when the vaccine is
exposed to heat, light, acidity, or humidity.
• Thiomersal is a mercury-containing antimicrobial that is added to vials of
vaccine that contain more than one dose to prevent contamination and
growth of potentially harmful bacteria. Due to the controversy surrounding
thiomersal it has been removed from most vaccines except multi-use
 influenza, where it was reduced to levels so that a single dose contained less
than 1 micro-gram of mercury, a level similar to eating 10 g of canned tuna.

Role of preservatives
Many vaccines need preservatives to prevent serious adverse effects such as
Staphylococcus infection, which in one 1928 incident killed 12 of 21 children
inoculated with a diphtheria vaccine that lacked a preservative. Several
preservatives are available, including thiomersal, phenoxyethanol,
and formaldehyde. Thiomersal is more effective against bacteria, has a better
shelflife, and improves vaccine stability, potency, and safety; but, in the U.S., the
European Union, and a few other affluent countries, it is no longer used as a
preservative in childhood vaccines, as a precautionary measure due to its mercury
content. Although controversial claims have been made that thiomersal contributes
to autism, no convincing scientific evidence supports these claims. Furthermore, a
10–11 year study of 657,461 children found that the MMR vaccine does not cause
autism and actually reduced the risk of autism by 7 percent.

Fill and finish

Main article: Fill and finish

The final stage in vaccine manufacture before distribution is fill and finish, which
is the process of filling vials with vaccines and packaging them for distribution.
Although this is a conceptually simple part of the vaccine manufacture process, it
is often a bottleneck in the process of distributing and adminstering vaccines.

Disease control benefits

Eradication
Unless an environmental reservoir exists, an eradicated pathogen cannot reemerge,
unless accidentally or malevolently reintroduced by humans, allowing vaccination
or other preventive measures to be discontinued.

While eradication may be an ideal goal for an immunization programme, to date

only smallpox has been eradicated, allowing discontinuation of routine smallpox
immunization globally. Potentially, other infectious diseases with no extrahuman
reservoir can be eradicated provided an effective vaccine and specific diagnostic
tests are available. Eradication requires high levels of population immunity in all
regions of the world over a prolonged period with adequate surveillance in place.
The next disease targeted for eradication is polio, which is still a global
challenge. Although high coverage with oral polio vaccine (OPV) has eliminated
type 2 poliovirus globally, transmission of types 1 and 3 continues in limited
areas in a few countries. OPV-caused paralytic disease, directly or by reversion
to virulence, and persistent vaccine-virus excretion in immunodeficient
individuals are problems yet to be solved. Global use of monovalent type 1 and
type 3 OPV and inactivated polio vaccine (IPV) may eventually be required.

Elimination
Diseases can be eliminated locally without global eradication of the causative
microorganism. In four of six WHO regions, substantial progress has been made in
measles elimination; transmission no longer occurs indigenously and importation
does not result in sustained spread of the virus. Key to this achievement is more
than 95% population immunity through a two-dose vaccination regimen.
Combined measles, mumps and rubella (MMR) vaccine could also eliminate and
eventually eradicate rubella and mumps. Increasing measles immunization levels
in Africa, where coverage averaged only 67% in 2004, is essential for eradication
of this disease. Already, elimination of measles from the Americas, and of measles,
mumps and rubella in Finland has been achieved, providing proof in principle of
the feasibility of their ultimate global eradication. It may also be possible to
eliminate Haemophilus influenzae type b (Hib) disease through well implemented
national programmes, as experience in the West has shown.

Local elimination does not remove the danger of reintroduction, such as in

Botswana, polio-free since 1991, with importation of type 1 poliovirus from
Nigeria in 2004,14 and in the United States of America (USA) with measles
reintroduced to Indiana in 2005 by a traveller from Romania.

For diseases with an environmental reservoir such as tetanus, or animal reservoirs

such as Japanese encephalitis and rabies, eradication may not be possible, but
global disease elimination is a feasible objective if vaccination of humans (and
animals for rabies) is maintained at high levels.
Control of mortality, morbidity and complications
For the individual
Efficacious vaccines protect individuals if administered before exposure.
Preexposure vaccination of infants with several antigens is the cornerstone of
successful immunization programmes against a cluster of childhood diseases.
Vaccine efficacy against invasive Hib disease of more than 90% was demonstrated
in European, Native American, Chilean and African children in large clinical
studies in the 1990s. In the United Kingdom, no infant given three doses developed
Hib disease in the short-term (boosters may be required for long-term protection),
and recent postmarketing studies have confirmed the high effectiveness of
vaccination of infants against Hib in Germany and pertussis in Sweden.

Many vaccines can also protect when administered after exposure – examples are
rabies, hepatitis B, hepatitis A, measles and varicella.

For society
Ehreth estimates that vaccines annually prevent almost 6 million deaths worldwide.
In the USA, there has been a 99% decrease in incidence for the nine diseases for
which vaccines have been recommended for decades, accompanied by a similar
decline in mortality and disease sequelae.

Complications such as congenital rubella syndrome, liver cirrhosis and cancer

caused by chronic hepatitis B infection or neurological lesions secondary to
measles or mumps can have a greater long-term impact than the acute disease. Up
to 40% of children who survive meningitis due to Hib may have life-long
neurological defects.

In field trials, mortality and morbidity reductions were seen for pneumococcal
disease in sub-Saharan Africa and rotavirus in Latin America.

Specific vaccines have also been used to protect those in greatest need of
protection against infectious diseases, such as pregnant women, cancer patients and
the immunocompromised.
Mitigation of disease severity
Disease may occur in previously vaccinated individuals. Such breakthroughs are
either primary – due to vaccine failure – or secondary. In such cases, the disease is
usually milder than in the non-vaccinated. In a German efficacy study of an
acellular pertussis vaccine, vaccinated individuals who developed whooping cough
had a significantly shorter duration of chronic cough than controls. Such findings
were confirmed in Senegal. Varicella breakthroughs exhibit little fever, fewer skin
lesions and fewer complications than unvaccinated cases. Milder disease in
vaccinees was also reported for rotavirus vaccine.
Prevention of infection
Many vaccines are primarily intended to prevent disease and do not necessarily
protect against infection. Some vaccines protect against infection as well. Hepatitis
A vaccine has been shown to be equally efficacious (over 90% protection) against
symptomatic disease and asymptomatic infections. Complete prevention of
persistent vaccine-type infection has been demonstrated for human papillomavirus
(HPV) vaccine. Such protection is referred to as “sterilizing immunity”. Sterilizing
immunity may wane in the long term, but protection against disease usually
persists because immune memory minimizes the consequences of infection.
Protection of the unvaccinated population
Herd protection
Efficacious vaccines not only protect the immunized, but can also reduce disease
among unimmunized individuals in the community through “indirect effects” or
“herd protection”. Hib vaccine coverage of less than 70% in the Gambia was
sufficient to eliminate Hib disease, with similar findings seen in Navajo
populations. Another example of herd protection is a measles outbreak among
preschool-age children in the USA in which the attack rate decreased faster than
coverage increased. Herd protection may also be conferred by vaccines against
diarrhoeal diseases, as has been demonstrated for oral cholera vaccines. “Herd
protection” of the unvaccinated occurs when a sufficient proportion of the group is
immune. The decline of disease incidence is greater than the proportion of
individuals immunized because vaccination reduces the spread of an infectious
agent by reducing the amount and/or duration of pathogen shedding by vaccinees,
retarding transmission. Herd protection as observed with OPV involves the
additional mechanism of “contact immunization” – vaccine viruses infect more
individuals than those administered vaccine.
The coverage rate necessary to stop transmission depends on the basic reproduction
number (R0), defined as the average number of transmissions expected from a
single primary case introduced into a totally susceptible population. Diseases with
high R0 (e.g. measles) require higher coverage to attain herd protection than a
disease with a lower R0 (e.g. rubella, polio and Hib).

Because of herd protection, some diseases can be eliminated without 100%

immunization coverage.
Source drying
Source drying is a related concept to herd protection. If a particular subgroup is
identified as the reservoir of infection, targeted vaccination will decrease disease in
the whole population.

In North Queensland, Australia, there was a high incidence of hepatitis A in the

indigenous population. Vaccination of indigenous toddlers, with catch-up up to the
sixth birthday, had a rapid and dramatic impact in eliminating the disease in the
indigenous population and in the much larger non-indigenous population (who
were not vaccinated) across the whole of Queensland. Similar approaches have
been very successfully applied in several other larger settings, including Israel and
the USA.

The success of source drying justifies vaccination of special occupational groups,

such as food handlers, to control typhoid and hepatitis A.

Pertussis vaccine boosters for close contacts (such as parents, grandparents,

nannies, siblings and baby unit nurses), who are the most common sources of
transmission to infants, protect those too young to be given primary vaccination
with a surrounding “pertussis-free cocoon”.

Prevention of related diseases and cancer

Protection against related diseases
Vaccines will also protect against diseases related to the targeted disease. For
example, in Finland, the USA and elsewhere, influenza vaccination has been found
protective for acute otitis media in children, with a vaccine efficacy of more than
30%. Measles vaccination protects against multiple complications such as
dysentery, bacterial pneumonia, keratomalacia and malnutrition. An enterotoxic
Escherichia coli vaccine demonstrated protection against diarrhoea due to
Salmonella enterica.

Cancer prevention
Infective agents cause several cancers. Chronic hepatitis B infection leads to liver
cancer. Vaccination against such pathogens should prevent the associated cancer as
already observed for hepatocellular carcinoma in Taiwan, China. These results
could be replicated in Africa.
Reduction of the incidence of cervical cancer is expected with the use of HPV
vaccines against serotypes 16 and 18, responsible for over 70% of the global
cervical cancer burden, as reduction in precancerous lesions has been demonstrated
in vaccinees.

Societal and other benefits

Health-care and other savings for society
Immunization programmes require funding for infrastructure (e.g. cold-chain
maintenance), purchase of vaccines and adequate staffing. However, the mortality
and morbidity prevented translates into long-term cost savings and potential
economic growth. Globally, the savings from vaccines were estimated by Ehreth in
2003 to be of the order of tens of billions of US dollars of direct savings. Malaria
(for which there are currently several promising vaccines in development) costs
sub-Saharan Africa US$ 100 billion worth of lost annual gross domestic product
(GDP).

Savings are enhanced if several antigens are delivered in a single vaccine.

Combination vaccines bring the added benefit of better compliance, coverage, and
injection safety. Introduction of a new antigen is facilitated with combination
vaccines, ensuring early high coverage by maintaining previous immunization
schedules, without compromising (and sometimes improving) immunogenicity and
reactogenicity.

When taking into account indirect costs, savings are higher for common diseases
with lower mortality and morbidity (such as varicella) than for more severe
diseases (such as polio). Indirect costs, such as lost productivity (as well as direct
medical costs) have been emphasized by eminent health economists in assessing
the full value of vaccination.
Immunization programmes, compared to other common public health interventions
such as wearing seat-belts and chlorination of drinking water, are a good
investment and more cost effective than, for example, advice on smoking
cessation.

Cost savings will be achieved with the new live-attenuated rotavirus and
conjugated pneumococcal vaccines, as well as wider use of hepatitis B and Hib
vaccines.
Preventing development of antibiotic resistance
By reducing the need for antibiotics, vaccines may reduce the prevalence and
hinder the development of resistant strains. Introduction of a conjugate
pneumococcal vaccine for infants in the USA in 2000 saw a 57% decline in
invasive disease caused by penicillin-resistant strains and a 59% decline in strains
resistant to multiple antibiotics by 2004 across a broad age spectrum: 81% among
children under 2 years of age and 49% among persons aged 65 years and older.

Vaccines against typhoid can prevent primary infection and the spread of
antibiotic-sensitive as well as multidrug-resistant strains. The development of new
vaccines against infectious pathogens where antibiotic resistance is a global threat
(e.g. Staphylococcus aureus) is viewed as a better long-term option to control the
problem of increasing resistance.

Extending life expectancy

Vaccines can increase life expectancy by protecting against diseases against which
one would not expect benefit. Elderly individuals given influenza vaccine in the
USA had approximately 20% less chance of suffering cardiovascular and
cerebrovascular disease and 50% lower risk of mortality from all causes compared
to their unvaccinated counterparts.

In Sweden, administration of polysaccharide pneumococcal vaccine and

inactivated influenza vaccine significantly reduced the risk of in-hospital mortality
for pneumonia and cardiac failure among elderly persons, with an additive effect
when both vaccines had been administered.
Safe travel and mobility
With global air travel rising, there is an increased risk of exposure to infectious
diseases abroad. Travellers transmit and disseminate disease, as has been observed
in the case of polio and in the dispersal of meningococcal strains by returning
pilgrims from Saudi Arabia. In the case of the Muslim Hajj (the largest annual
human gathering in the world), local authorities require meningococcal ACWY
vaccination and recommend various other vaccinations, such as influenza and
hepatitis B, for pilgrims.

The most common vaccine-preventable diseases among travellers are influenza and
hepatitis A. Other vaccines to consider for travel include rabies, hepatitis B,
typhoid, cholera, yellow fever, Japanese encephalitis and measles. Many vaccines
can be given by flexible accelerated schedules to ensure early protection. Thus the
traveller seeking health advice, even within a few weeks of departure, can travel
overseas without vaccine-preventable health risks to themselves and others.

Other public health benefits

In developing countries, vaccination programmes are cornerstones of primary
health-care services. The infrastructure and personnel required for an effective and
sustainable immunization programme give opportunities for better primary
healthcare services, particularly in the critical perinatal and early infancy period.

Empowerment of women
With improvements in infant and child mortality, women tend to opt for fewer
children as the need to have many children to ensure that some will reach
adulthood is reduced. This has significant health, educational, social and economic
benefits.

Protection against bioterrorism

The current concern about the potential use of smallpox virus in bioterror is due to
the cessation of vaccination (and of vaccine manufacture) following the
monumental achievement of smallpox eradication. The potential of vaccines to
protect populations from bioterrorism threats such as smallpox and anthrax has led
many governments to ensure an adequate supply of the necessary vaccines in
preparation against such an attack. Surveillance and response systems for
vaccinepreventable and other diseases play a critical role in identification,
characterization and response to biological weapons.

Promoting economic growth

Poor health has been shown to stunt economic growth while good health can
promote social development and economic growth. Health is fundamental to
economic growth for developing countries and vaccinations form the bedrock of
their public health program. The annual return on investment in vaccination has
been calculated to be in the range of 12% to 18%, but the economic benefits of
improved health continue to be largely underestimated.

Enhancing equity
The burden of infectious, including vaccine-preventable, diseases falls
disproportionately on the disadvantaged. Vaccines have clear benefits for the
disadvantaged. Pneumococcal immunization programmes in the USA have at least
temporarily removed racial and socioeconomic disparities in invasive
pneumococcal disease incidence, while in Bangladesh, measles vaccination has
enhanced equity between high- and low-socioeconomic groups. Promoting
peace
There were at least seven United Nations Children’s Fund (UNICEF)
vaccinemediated ceasefires during civil conflicts. These conflicts were in diverse
parts of the world, from Liberia to Afghanistan, where even warring factions see
the benefit of immunization programmes.

During protracted conflict it is possible to ensure that vaccination coverage remains

high. This is seen in Sri Lanka, where despite unrest for the last two decades
coverage in 2005 for both three doses of diphtheria–tetanus–pertussis vaccine and
one dose of measles vaccine was 99%.

The high cost-effectiveness and multiple benefits of relatively modest resource

investments in immunization contrast starkly with profligate global military
expenditures, currently over US$ 1 trillion annually.
Adverse effects
Vaccination given during childhood is generally safe. Adverse effects, if any, are
generally mild. The rate of side effects depends on the vaccine in question. Some
common side effects include fever, pain around the injection site, and muscle
aches. Additionally, some individuals may be allergic to ingredients in the vaccine.
MMR vaccine is rarely associated with febrile seizures.

Severe side effects are extremely rare. Varicella vaccine is rarely associated with
complications in immunodeficient individuals and rotavirus vaccines are
moderately associated with intussusception.

At least 19 countries have no-fault compensation programs to provide

compensation for those suffering severe adverse effects of vaccination. The United
States’ program is known as the National Childhood Vaccine Injury Act and the
United Kingdom employs the Vaccine Damage Payment. Adjuvants and
preservatives
Vaccines typically contain one or more adjuvants, used to boost the immune
response. Tetanus toxoid, for instance, is usually adsorbed onto alum. This presents
the antigen in such a way as to produce a greater action than the simple aqueous
tetanus toxoid. People who have an adverse reaction to adsorbed tetanus toxoid
may be given the simple vaccine when the time comes for a booster.

In the preparation for the 1990 Persian Gulf campaign, whole cell pertussis vaccine
was used as an adjuvant for anthrax vaccine. This produces a more rapid immune
response than giving only the anthrax vaccine, which is of some benefit if exposure
might be imminent.

Vaccines may also contain preservatives to prevent contamination

with bacteria or fungi. Until recent years, the preservative thiomersal (A.K.A.
Thimerosal in the US and Japan) was used in many vaccines that did not contain
live virus. As of 2005, the only childhood vaccine in the U.S. that contains
thiomersal in greater than trace amounts is the influenza vaccine, which is
currently recommended only for children with certain risk factors. Single-dose
influenza vaccines supplied in the UK do not list thiomersal in the ingredients.
Preservatives may be used at various stages of production of vaccines, and the
most sophisticated methods of measurement might detect traces of them in the
finished product, as they may in the environment and population as a whole.
Global vaccine coverage
This chart shows the global vaccination coverage of one-year-olds with some of
the most important vaccines recommended by the WHO. For many essential
vaccines coverage is now much higher than 80%. However, the rates of
vaccination are still not sufficient.

If you click the play button you see that the coverage for most vaccines has
increased substantially over time.

The vaccine against diphtheria, tetanus and pertussis, is often used as the key
metric for global vaccination coverage because it is a good indicator for access to
routine immunization services. In 2018, coverage of the third dose of DTP was
86%. This means that out of 135 million under-one-year-olds more than 19 million
did not receive full immunization. The coverage of the first dose of DTP was 90%
indicating that 13.5 million children were not vaccinated in 2018.

In 2018, only 35% of children globally received the rotavirus vaccine, which
protects children from diarrheal diseases — one of the leading causes of child
mortality. Similarly, pneumococcal vaccine that protects children
from pneumonia — the leading cause of child mortality — only reached 47% of
one-year-olds.

Prosperity and vaccination coverage

Why do not all children in the world receive vaccinations?

This chart shows that it is in poor countries where vaccination coverage is low. The
vaccine coverage against diphtheria, pertussis (whooping cough), and tetanus is a
good marker of the strength of a country’s immunization programs since several
administrations are required. All rich countries have vaccination coverage rates of
more than 90%. It is in low- and middle-income countries where coverage is low –
in some countries below 50%.

But the chart also shows that some poor countries – like Burundi, Rwanda, and
Bangladesh – achieve high coverage rates. Similarly, countries in which a large
share of the population is living in extreme poverty often – but not always – have
lower immunization rates, as this chart shows.
Vaccine supply
Supply constraints have caused problems for country access to vaccination.
Onethird of 194 countries have run out of a vaccine for a month or longer –
according to data submitted to WHO and UNICEF – and this includes both high-
and lowincome countries. In the US, the Centers for Disease Control and
Prevention
(CDC) stated that reasons for shortages were multi-factoral and included “…
companies leaving the vaccine market, manufacturing or production problems,
and insufficient stockpiles”. In 2018, it was reported that shortages where
supplies of vaccines were critically low included those that target yellow fever,
hepatitis B, cholera, meningitis C, diphtheria, whooping cough, tetanus, hepatitis
A, and tuberculosis.
Concerns about the supply of vaccines in an epidemic or pandemic have been
raised. For example, the supply of yellow fever vaccine was limited for the
outbreak in Angola in 2016 leading to the recommendation of a fractional dose to
extend existing supplies.

Laurie Garrett argues that because the drug had become so cheap (60 cents for each
vaccine 2008) few companies had an incentive to produce it and world stocks of
the vaccine were nearing zero, forcing the WHO to dilute donated vaccines from
countries like Brazil (which sent 18 million doses) by 5 to 1 with the hope they
would still be sufficiently effective. Romania experienced a situation of parallel
vaccine exports in 2016 where more vaccines were exported than was supplied to
meet the country’s needs. A shortage of the measles, mumps, and rubella (MMR)
vaccine was partly responsible for the measles outbreak in 2016-17.

In Venezuela, a country experiencing an economic crisis, there are

severe shortages of medicines, including vaccines, which has led to an estimated
one million unvaccinated children and the re-emergence of diseases such as
diphtheria and measles.

The cost of vaccines

There are five big pharmaceutical companies that account for 80% of vaccine
production: Sanofi Pasteur, GlaxoSmithKline, Merck, Pfizer, and Novartis.

Many vaccines are only provided by one or two suppliers. For newer vaccines
there are often particularly few suppliers due to the high investment needed to
develop a vaccine. As one would expect from competition, the WHO reports that
when vaccines are produced by a greater number of suppliers it leads to a decline
of the prices of those vaccines.

In the past vaccines were often viewed as less profitable products for
pharmaceutical companies, which led to a lack of investment and some companies
pulling out of production altogether.

But this has changed as the revenue of the global vaccines market has increased
and richer country governments and insurance companies have been willing to pay
more for new vaccines.

In addition, growing economies such as India and China are investing more in
vaccines as well as developing their domestic manufacturing capacity. Poorer
countries now have Gavi to help governments pool resources and make advance
purchase commitments.

Gavi is an international organisation created in 2000 to bring together public and

private sectors, with the goal of equal access to new and underused vaccines for
children in poorer countries. It subsidizes vaccines that otherwise would not be
affordable for low-income countries. In addition to subsidizing vaccines
themselves, Gavi offers vaccine introduction grants, which help to cover the costs
of introduction of new vaccines into routine immunization schedules. The map
here shows which countries are eligible for GAVI support.

Some vaccines still remain expensive. For example, the pertussis vaccine is
available in two versions: whole cell (wP) containing the whole pertussis
bacterium or acellular (aP) which contains a part of the pertussis bacterium. The
pertussis vaccine is often combined with diphtheria and tetanus to produce either a
DTwP or DTaP vaccine.

DTaP is slightly more expensive; it is sometimes called ‘the painless vaccine’

because it causes less of a local reaction and pain but should not be given to
children over the age of seven. However, DTwP has been shown to be more
efficacious at preventing the transmission and spread of disease to unvaccinated
people and to those with weak immunity.

New vaccines tend to be more expensive as they are under patent protection. For
example when the HepB vaccine was developed many lower income countries
could not afford to pay $30 per dose.
Conclusions
The benefits of vaccination extend beyond prevention of specific diseases in
individuals. They enable a rich, multifaceted harvest for societies and nations.
Vaccination makes good economic sense, and meets the need to care for the
weakest members of societies. Reducing global child mortality by facilitating
universal access to safe vaccines of proven efficacy is a moral obligation for the
international community as it is a human right for every individual to have the
opportunity to live a healthier and fuller life. We conclude that a comprehensive
vaccination programme is a cornerstone of good public health and will reduce
inequities and poverty.