of 69
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Vaccines in childrenWhat they are
How they workN. IagruAssociate Professor of Pediatrics
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A short history(What Do Cows to Do with Vaccines?)
The word vaccine comes from Latin vaccinuswhich meanspertaining to cows
Edward Jenner (more than 200yrs ago), a
country physician, noticed that milkmaids rarelysuffer from smallpox. Jenner took a few drops offluid from a skin sore of a woman who hadcowpox ( a related but far less serious disease),
and injected the fluid into the arm of a healthyyoung boy who never had cowpox or smallpox.
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Six weeks later, Jenner injected the boy with fluidfrom a smallpox sore, but the boy remained free of
smallpox
Dr. Eduard Jenner
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The modern vaccine
A preparation of proteins,polysaccharides, or nucleic acids ofpathogens that are delivered to the
immune system as single entities, aspart of complex particles, or by live-attenuated agents or vectors, to
induce specific responses thatinactivate, destroy, or suppress thepathogen
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Public Health
Vaccines are crucial to maitaining publichealth:
Vaccines are safe, cost-effective, and
efficient way to prevent sickness anddeath from infectious diseases
Vaccines has lead to some of the greatestpublic health triumphs ever, including the
eradication of naturally occurring smalpoxfrom the globe and the near eradication ofpolio
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Variola virus
Which causes smallpox, was once thescourge of the world
This virus passes from person to person
trough the air : fever, severe aches andpains, scarring sores that cover the body,blindness, and, often,death
In the 18th
century, variola killed every 7th
child born in Rusia and every 10th inSweden and France
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Naturally acquired immunity
Before vaccines, the only way to becomeimmune to a disease was to actually get it, and,with luck, survive it (naturally acquiredimmunity)
This means to suffer the symptoms of thedisease and also the risk of complications, whichcan be quite serious or even deadly
On the other side, the patient may bycontagious and pass the disease to familymembers, to friends and to colleagues
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Vaccination against variola
WHO:1950/50million killed people
1967/10-15 million killedpeople
1977: the last case of naturally
occurring smallpox was in
Somalia
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Diphteria
1900, USA: diphteria killed more than cancer did
Corynebacterium diphteriae : upper airwayinfection with a grayish, thick membrane that
grows in the throat and obstructs breathing,fever, hoarseness, and coughing
Deaths not only by blocked airways but from theparalyzing toxin secreted by the bacterium,which can cause heart or other organs to fail
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Infectious poliovirus
USA, till 1954: polio crippled 13,000 to20,000 people every year
1954, before the first polio vaccine:18,000 cases of paralizing polio in USA
Just 3 year later: 2,500/yr
2006, WHO: 2,000 cases worldwide
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Statistica in Romania
1957-1961 1987-1991 Scadere (%)
cazuri decese cazuri decese cazuri decese
Poliomielita 1531 889 74 2 99,3 99,9
Difterie 3982 319 9 1 99,7 99,6
Tetanos 4224 1843 144 65 96,5 99,7
Pertussis 448.882 663 10.413 22 97,6 96,6
Rujeola 513.547 860 23.976 25 95,3 97,1
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Active ImmunisationArtificially acquired immunity
Vaccinations or immunizations (hardcore of primary profilaxy) are,generally speaking, interchangeableterms ( active immunisation!)
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Active immunization 2
Vaccination is administration of anyvaccine (inactivated or killed wholeorganisms or a part from an
organism), toxoid (inactivated toxin),or of a specific recombinant productin order to produce an immune
response similarly to those fromnaturally infection.
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To become immune
Once the immune system is trainedto resist a disease, the person aresaid to be immune to it
Is provided by vaccines and are aneasier and less risky way to becomeimmune
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Herd immunity
Vaccines protect not only yourselfbut also others around you
Similarly, when other people arevaccinated, they are less likely togive the disease to you
So, vaccines protect not onlyindividuals, but entire communities
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Community immunity
If a critical number of people withina community are vaccinated againsta particular ilness, the entire group
becomes less likely to get thedisease.
This protection is called community
immunity, or herd immunity
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Community immunity: if enough people in a community arevaccinated against a particular ilness, the entire group becomes lesslikely to get the disease, even those who are not vaccinated
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x
x x
Efectul indirect / Herd protection:Populatia vaccinata partial
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Passive immunity
Immunity transferred from oneperson to another:
- antibodies passed from mothers beforebirth or through breastfeeding protect thebabies against some diseases
- purified blood serum which contains theantibodies produced after someonesuffered from an ilness in the past
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Passive immunization II
Involves also the administration ofpreformed antibody in the form ofintramuscular immunoglobulin, intravenousimmunoglobulin, or concentrated monoclonalantibodies (Palivizumab for RSV)
Indications: after high-risk exposure toindividuals not immunized against the disease inquestion; high-risk of severe complications(children born to women who are chroniccarriers of hepatitis B surface antigen); PID
( replacement IVIG)
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Passive Immunization Products
Rabies immune globulin
Tetanus immune globulin
Diphteria antitoxin(horse serum derived)
Hepatitis B immune globulin
Cytomegalovirus immune globulin I.V.
Varicella-zoster immune globulin
I.V.I.G.(PID)
Botulism immune globulin I.V.
Immune globulin for prevention of Hepatitis A inunimmunized individual after exposure
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Types of vaccines
Live, Attenuated Vaccines
Inactivated Vaccines
Subunit Vaccines Toxoid Vaccines
Conjugate Vaccines
DNA Vaccines
Recombinant Vector Vaccines
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Live, Attenuated Vaccines
Contain a version of the living microbe that havebeen weakened (attenuated) in the lab so itcant cause disease
Because a live, attenuated vaccine is the closestthing to a natural infection, these vaccines aregood teachers of the immune system: theyelicit strong cellular and antibody responses, and
often confer lifelong immunity with only one ortwo doses
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I. Live, attenuated vaccines
This image shows the live microbes antigens,
membrane, and genetic material
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Downsides
The organisms used in live, attenuated vaccinescan change or mutate ( is the nature of livingthings to change!), and could revert to a virulentforme and cause disease
Persons with damaged or weakened immunesystems (PID, HIV, chemotherapy)
Need to be refrigerated to stay potent(the
shipping overseas and stored by health careworkers in developing countries that lackwidespread refrigeration)
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Live, attenuated
Are relatively easy to create for certainviruses (contain a small number of genes):
-measles, rubella,polio (Sabinvaccine),mumps chickenpox,yellow fever
Are more difficult to create for bacteria(have thousands of genes, much harder to
control): vaccine against Vibrio cholerae
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II. Inactivated Vaccines(killed vaccines)
By killing the disease-causing microbe withchemicals,heat, or radiation
Are more stable and safer than live vaccines(the
dead microbes cant mutate!) Dont require refrigeration ( can be easily stored
and transported in a freeze-dried form)
Stimulate a weaker immune system responsethan live vaccines (need booster shots, thatcould be a drawbackin developing areas !)
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Exemples for inactivated vaccines
V. bacteriene inactivate : DTPa sauDTPw, HI tip b, meningococic(A,C,Y,W135), cholera, plague
Vaccinuri viraleinactivate: Flu,VPI(Salk vaccine), hepatita B, hepatita A,
rabies,Japanese encephalitis.
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Inactivated vaccines
Inactivated vaccines contain microbes that have beeninactivated with chemicals, heat, or radiation. Themicrobes antigens, membrane, and genetic material arestill present.
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III. Subunit vaccines
Instead of entire microbe, subunit vaccinesinclude only the antigens that best stimulate theimmune system
In some cases, Subunit Vaccines use epitopes(the very specific parts of the antigen) thatantibodies or T cells recognize and bind to
Because SUV contain only the essential antigens
(1-20 or more antigens) and not other moleculesthat make up the microbe, the risks of adversereactions to the vaccine are lower
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Subunit vaccines
The imagine depicts antigens that have been separated
from the rest of the microbe for use in a subunit vaccine
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Subunit Vaccines
SUV are vaccines produced by recombinanttechnology
They are called Recombinant Subunit Vaccines :
- vaccine against hepatitis B virus
Scientists inserted hepatitis B genes that code forimportant antigens into common bakers yeast
The yeast then produced the antigens, they arecollected and purified for use in the vaccine
Other vaccines: pertussis, pneumonia caused byS.pneumoniae
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IV. Toxoid vaccines
They are used when a bacterial toxin isthe main cause of illness
Toxins are inactivate by treating themwith formalin (a solution of formaldehydeand sterilized water)
Detoxified toxins are called toxoids and
they are safe for use in vaccines
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Toxoid Vaccines
Harmless toxoid molecules (artists representation) are used in
toxoid vaccines to immunize and protect people against harmfultoxins secreted by some microbes
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Toxoid Vaccines
The immune system producesantibodies that lock onto and blockthe toxin
Exemples of toxoid vaccines:
- Vaccine against diphteria
- Vaccine against tetanus
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V. Conjugate Vaccines
Are used against bacteria which possessed anouter coating of sugar called polysaccharides
Polysaccharide coating disguise a bacteriumsantigens so that the immature immune systems
of infants and younger children cant recognizeor respond to them Scientists link antigens or toxoid from a microbe
that an infants immune system can recognize,
to the polysaccharides. The linkage helps the immature immune systemreact to polysaccharide coating and defendagainst the disease-causing bacterium
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Conjugate vaccines
Conjugate vaccines link antigens or toxoids to the polysaccharid or sugar moleculethat certainbacteria use as a protective coating,thereby allowing the immune system to recognize and attackthes disguised bacteria. A conjugate vaccine contains the molecules shown in the foreground.The bacterium, part of which is shown in the upper left background, is not part of the vaccine.In fact, this kind of vaccine is a subunit vaccine
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Exemples of Conjugate Vaccines
Vaccine against HI b
Vaccine against Streptococcuspneumoniae: Prevenar 7 valent
Prevenar 13 valent
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VI. DNA Vaccines
Experimental stages ! (but several typesalready tested in humans)
DNA vaccines take immunization to a new
technological level Dispense with both the whole organism
and its parts and get right down at the
essentials: the microbes genetic material DNA vaccines use the genes that code for
those all-important antigens
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DNA Vaccines II
When the genes for a mirobesantigens are introduced into thebody, some cells will take up that
DNA
The DNA then instructs those cells tomake the antigen molecules
The cells secrete the antigens anddisplay them on their surfaces
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DNA Vaccines
In other words, the bodys own cellsbecome vaccine-making factories,creating the antigens necessary to
stimulate the immune system
DNA vaccines are relatively easy and
inexpensive to design and produce
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DNA Vaccines
DNA vaccines use a microbes genetic material, in particular, the genesthat code for important antigens. The DNA in these vaccines is a circular
form known as a plasmid
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DNA Vaccines III
SO-called naked DNA vaccines consist ofDNA that is administered directly into thebody
These vaccines can be administered with aneedle and syringe or with a needle-lessdevice that uses high-pressure gas toshoot microscopic gold particles coatedwith DNA directly into cells
Tested in humans: influenza, herpes, HIV
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VII. Recombinant Vector Vaccines
These experimental vaccines are similar toDNA vaccines, but they use an attenuatedvirus or bacterium to introduce microbial
DNA to cells of the body
Vectors refers to the virus or bacteriumused as a carrier
In nature, viruses latch on the cells andinject their genetic material into them
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Recombinant Vector Vaccines II
In the lab, scientists have takenadvantage of this process.
They figured out how to take the
roomy genomes of certain harmlessor attenuated viruses and insertportions of the genetic material fromother microbes into them
The carrier viruses then ferry thatmicrobial DNA to cells
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Recombinant Vector Vaccines III
They closely mimic a natural infection andtherefore do a good job of stimulating theimmune system
Attenuated bacteria as vectors : the
inserted genetic material causes thebacteria to display the antigens of othermicrobes on its surfaace.
In effect, the harmless bacterium mimics aharmful microbe provoking an immuneresponse
Researches: vaccines for HIV, rabies, andmeasles
R bi V V i
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Recombinant Vector VaccinesRecombinantvector vaccines use the harmless shell of one microbe. The
genetic material contains the code for marking vaccine antigen inside some of
the bodys cells, using those cells as factories
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Reportable events after vaccinations
Anaphylaxis or anaphylactic shock,brachial neuritis and theirsequela(DTP, DTPHiB)
Idem, Encephalopathy(orencephalitis):MMR; chronic arthritis(rubella in any combination);Thrombocytopenic purpura (measlesin any combination); Paralytic polio(OPV); Intussusception (Rotavirus).
Romanian National Program for
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gImmunization
(Calendarul de vaccinare 2009)
Varsta recomandata Vaccin ComentariiPrimele 24 ore
2-7 zile
Hep. B
BCG
In maternitate
2 luni DTP, VPI, Hep. B Simultan
4 luni DTP, VPI Simultan
6 luni DTP, VPI, Hep. B Simultan
12 luni DTP, VPI,
RRO(MMR)
Simultan
4 ani DTaP*
7 ani (cls.I) RRO (MMR) Campanii scolare
9 ani (cls. a III-a) VPI Campanii scolare
14 ani (cls. a IV-a) dT Campanii scolare
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U.S. Vaccine-Preventable InfectiousDiseases
Anthrax, Bacterial meningitis, Chickenpox,Diphteria,Haemophilus influenzae typeb,Hepatitis A, Hepatitis B, Cervical
cancer(HPV),Influenza, Japaneseencephalitis,Measles, Mumps, Pertussis,Pneumococcal pneumonia, Polio, Rotavirusdiarrhea, Rabies, Rubella, Smallpox,
Shingles, Tetanus, Tuberculosis,Typhoid,Yellow fever
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Programul national de imunizare (PNI)
Absente notabile fata de PNI-urile din tariledezvoltate din UE si din SUA :
Vaccinarea anti-HI tip b
Vaccinarea antipneumococica
Vaccinarea anti-Rotavirus
Vaccinarea anti-varicela
Vaccinarea anti-meningococica
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U.S.Routine Immunization Schedule
American Academy of Pediatrics
American Academy of Family Phisicians
Advisory Committee on Immunization
Practices of the Centers for DiseasesControl and Prevention (CDC)
jointly prepare and updated immunizationschedule every January, which is published inthe Pediatrics, Morbidity and MortalityWeekly Reportand in Family Physician
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Contraindications
For children with intact immunesystem there are few absolutecontraindications to receiving the
first dose of any vaccine ! Inactivated or subcomponent
vaccines pose no additional risk topatients with immune deficiency
disorders, but some patients may notbe protected from the target disease
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Contraindications
Immediate Hypersensitivity Reactions( Anaphylaxis or angioedema after a previous dose ofvaccine is usually a contraindication for the subsequentdoses of the same vaccine)-Vaccines produced in the chick embryo tissue culturesdo not contain detectable amounts of egg proteins-Some of hypersensitivity reactions are caused bycomponents added to vaccines( the gel stabilizer inmeasles vaccine)
- The mild allergic reactions are not a contraindication toreceive the subsequent doses, but may require specialinvestigations and a consult with an allergist or vaccinesafety specialist
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Encephalopathy or Encephalitis
Both of them, within a few days after DTP vaccineadministration is a contraindication to receipt ofthe subsequent doses
A febrile seizure after any vaccine is not acontraindication to receipt a subsequent doses of
vaccine were other vaccines that might inducefever
Children who have had encephalitis orencephalopathy of unknown cause unrelated toimmunization can safely receive all recommended
vaccines if neurologic condition is stable Children with progressive neurologic disorders
should defer the DTaP vaccine until the conditionis stable
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Immune Deficiency Disorders
Live vaccines can cause serious adverseevents in patients with immune deficiencydisorders (i.e risk of vaccine-associatedparalysis after OPV is increased at least
1,000-fold in persons withagammaglobulinemia) Patients with HIV infection can receive live
MMR or varicella vaccine if their CD4 countis greater than 15%
Other patients with primary or acquireddeficiency of T cells generally should notreceive live viral vaccines
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Immune deficiency Disorders II
Some patients can safely receive live vaccines:- Patients successfully treated for cancer can be
usually be immunized with both live andinactivated vaccines after completion ofchemotherapy, but specific waiting times are
recommended- Mild immune deficiency disorders, such a
subclass IgG deficiency disorders, are notassociated with adverse events followingvaccination
- Patients with disorders of white blood cellfunctions (CGD), can receive all inactivated
varicella and live viral vaccines
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Other contraindications
Severe ilnesses ( infectious diseases,TBC evolutiva, chronic nephropaty,chronic liver diseases, severe
cardiovascular diseases) Cachexy
Pregnancy,live vaccines are
prohibited in the first 3 monthsbecause they may be teratogenic.
N t i di ti d
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Noncontraindications andMisconception
Children with mild upper respiratory infections orgastroenteritis can receive routine immunizationsas there is no evidence of any increased risk fromvaccinationof children with these infections
Low-grade fever-less than 39C-is not acontraindication to immunization ! ( Although, ismore prudent to wait for a few days to beimmunized if uncertainty exists regarding the
cause of the concurent ilness)----------------------------------------------------------Neal A.Halsey. Immunization. Oskis Pediatrics Principle &Practice, 2006:118-134
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Some specific immunizing agents
Meningococcal Vaccine :1.A plain polysaccharide vaccine against Neisseriameningitidestypes A,C, Y, and W135 in children 2 ormore years of age, recommended for children atincreased risk of disease including those with asplenia or
complement deficiency. It is not administered routinelyto children because the risk of disease is relatively low2.A polysaccharide-protein conjugate vaccinecontaining types A, C, Y, and W135 (2005) for allchildren 11-12 years of age, for previously
unvaccinated 15-16 yr old, college freshman living indorms, and others at high risk of disease
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Vaccine strategies
Some vaccines come incombinations:
DTP, MMR
Combination vaccines reduce visit tothe doctor, saving time and moneyand sparing children extra
needlestick
V i C M th d S f t
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Vaccine Concerns, Myths, and SafetyIssues on the Web
Rumors and misinformation about vaccinesafety abound
Now that vaccines have virtuallyeliminated many once-feared diseases,
the possibility of vaccine side effects oradverse reactions loom larger in somepeoples minds than the diseases thatvaccines prevent
Most parents today have never seen a caseof diphteria or measles, and some wonderwhy their children must receive so manyshots
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Safety Issues
Many parents are concerned thatmultiple vaccines may weaken or
overwhelm an infants immunesystem or that certain vaccines maycause autism, multiple sclerosis, or
diabet
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Combination vaccines
May they overwhelm or weaken childs immunesystem ?
The immune system contains billion of circulatingB and T cells capable of responding to millions of
different antigens at once Because the body constantly replenishes these
cells, a healthy immune system cannot be usedup or weakened by a vaccine
According to one published estimation, infants
could easily handle 10,000 vaccines at once !
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Further reading
http://www.cdc.gov/vaccines/schedules/
http://www.cdc.gov/vaccines/vpd-vac/vpd-vac-basics.htm
http://www.cdc.gov/vaccines//vpd-vac/vaccines-list.htm
http://www.cdc.gov/vaccines/schedules/http://www.cdc.gov/vaccines/vpd-vac/vpd-vac-basics.htmhttp://www.cdc.gov/vaccines/vpd-vac/vpd-vac-basics.htmhttp://www.cdc.gov/vaccines//vpd-vac/vaccines-list.htmhttp://www.cdc.gov/vaccines//vpd-vac/vaccines-list.htmhttp://www.cdc.gov/vaccines//vpd-vac/vaccines-list.htmhttp://www.cdc.gov/vaccines//vpd-vac/vaccines-list.htmhttp://www.cdc.gov/vaccines//vpd-vac/vaccines-list.htmhttp://www.cdc.gov/vaccines//vpd-vac/vaccines-list.htmhttp://www.cdc.gov/vaccines//vpd-vac/vaccines-list.htmhttp://www.cdc.gov/vaccines/vpd-vac/vpd-vac-basics.htmhttp://www.cdc.gov/vaccines/vpd-vac/vpd-vac-basics.htmhttp://www.cdc.gov/vaccines/vpd-vac/vpd-vac-basics.htmhttp://www.cdc.gov/vaccines/vpd-vac/vpd-vac-basics.htmhttp://www.cdc.gov/vaccines/vpd-vac/vpd-vac-basics.htmhttp://www.cdc.gov/vaccines/vpd-vac/vpd-vac-basics.htmhttp://www.cdc.gov/vaccines/vpd-vac/vpd-vac-basics.htmhttp://www.cdc.gov/vaccines/schedules/7/28/2019 64 Vaccines Children[1]
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List of Vaccine-Preventable
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List of Vaccine-PreventableDiseases [1]
Anthrax Cervical Cancer (Human
Papillomavirus) Diphtheria Hepatitis A Hepatitis B Haemophilus influenzae
type b (Hib) Human Papillomavirus
(HPV) Influenza (Flu) Japanese encephalitis
(JE)
Lyme diseaseLyme disease vaccine nolonger available in theUnited States.
Measles
Meningococcal Monkeypox
There is NO monkeypoxvaccine. The smallpoxvaccine is used for this
disease. Mumps Pertussis
List of Vaccine-Preventable
http://www.cdc.gov/vaccines/vpd-vac/anthrax/default.htmhttp://www.cdc.gov/vaccines/vpd-vac/hpv/default.htmhttp://www.cdc.gov/vaccines/vpd-vac/diphtheria/default.htmhttp://www.cdc.gov/vaccines/vpd-vac/hepa/default.htmhttp://www.cdc.gov/vaccines/vpd-vac/hepb/default.htmhttp://www.cdc.gov/vaccines/vpd-vac/hib/default.htmhttp://www.cdc.gov/vaccines/vpd-vac/hib/default.htmhttp://www.cdc.gov/vaccines/vpd-vac/hib/default.htmhttp://www.cdc.gov/vaccines/vpd-vac/hpv/default.htmhttp://www.cdc.gov/vaccines/vpd-vac/flu/default.htmhttp://www.cdc.gov/vaccines/vpd-vac/j-enceph/default.htmhttp://www.cdc.gov/vaccines/vpd-vac/lyme/default.htmhttp://www.cdc.gov/vaccines/vpd-vac/measles/default.htmhttp://www.cdc.gov/vaccines/vpd-vac/mening/default.htmhttp://www.cdc.gov/vaccines/vpd-vac/monkeypox/default.htmhttp://www.cdc.gov/vaccines/vpd-vac/mumps/default.htmhttp://www.cdc.gov/vaccines/vpd-vac/pertussis/default.htmhttp://www.cdc.gov/vaccines/vpd-vac/pertussis/default.htmhttp://www.cdc.gov/vaccines/vpd-vac/mumps/default.htmhttp://www.cdc.gov/vaccines/vpd-vac/monkeypox/default.htmhttp://www.cdc.gov/vaccines/vpd-vac/mening/default.htmhttp://www.cdc.gov/vaccines/vpd-vac/measles/default.htmhttp://www.cdc.gov/vaccines/vpd-vac/lyme/default.htmhttp://www.cdc.gov/vaccines/vpd-vac/j-enceph/default.htmhttp://www.cdc.gov/vaccines/vpd-vac/flu/default.htmhttp://www.cdc.gov/vaccines/vpd-vac/hpv/default.htmhttp://www.cdc.gov/vaccines/vpd-vac/hib/default.htmhttp://www.cdc.gov/vaccines/vpd-vac/hib/default.htmhttp://www.cdc.gov/vaccines/vpd-vac/hib/default.htmhttp://www.cdc.gov/vaccines/vpd-vac/hepb/default.htmhttp://www.cdc.gov/vaccines/vpd-vac/hepa/default.htmhttp://www.cdc.gov/vaccines/vpd-vac/diphtheria/default.htmhttp://www.cdc.gov/vaccines/vpd-vac/hpv/default.htmhttp://www.cdc.gov/vaccines/vpd-vac/anthrax/default.htm7/28/2019 64 Vaccines Children[1]
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List of Vaccine-PreventableDiseases [2]
Pneumococcal
Polio
Rabies
Rotavirus Rubella
Shingles (Herpes
Zoster) Smallpox
Tetanus
Typhoid
Tuberculosis (TB)
Varicella (Chickenpox)Yellow Fever
http://www.cdc.gov/vaccines/vpd-vac/pneumo/default.htmhttp://www.cdc.gov/vaccines/vpd-vac/polio/default.htmhttp://www.cdc.gov/vaccines/vpd-vac/rabies/default.htmhttp://www.cdc.gov/vaccines/vpd-vac/rotavirus/default.htmhttp://www.cdc.gov/vaccines/vpd-vac/rubella/default.htmhttp://www.cdc.gov/vaccines/vpd-vac/shingles/default.htmhttp://www.cdc.gov/vaccines/vpd-vac/smallpox/default.htmhttp://www.cdc.gov/vaccines/vpd-vac/tetanus/default.htmhttp://www.cdc.gov/vaccines/vpd-vac/typhoid/default.htmhttp://www.cdc.gov/vaccines/vpd-vac/tb/default.htmhttp://www.cdc.gov/vaccines/vpd-vac/varicella/default.htmhttp://www.cdc.gov/vaccines/vpd-vac/yf/default.htmhttp://www.cdc.gov/vaccines/vpd-vac/yf/default.htmhttp://www.cdc.gov/vaccines/vpd-vac/varicella/default.htmhttp://www.cdc.gov/vaccines/vpd-vac/tb/default.htmhttp://www.cdc.gov/vaccines/vpd-vac/typhoid/default.htmhttp://www.cdc.gov/vaccines/vpd-vac/tetanus/default.htmhttp://www.cdc.gov/vaccines/vpd-vac/smallpox/default.htmhttp://www.cdc.gov/vaccines/vpd-vac/shingles/default.htmhttp://www.cdc.gov/vaccines/vpd-vac/rubella/default.htmhttp://www.cdc.gov/vaccines/vpd-vac/rotavirus/default.htmhttp://www.cdc.gov/vaccines/vpd-vac/rabies/default.htmhttp://www.cdc.gov/vaccines/vpd-vac/polio/default.htmhttp://www.cdc.gov/vaccines/vpd-vac/pneumo/default.htm