64 vaccines children[1]

7/28/2019 64 Vaccines Children[1]

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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/


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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.htm


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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

64 vaccines children[1]

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