8.11: Immunizations

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People all over the world have become more aware of vaccinations and how they help increase health, since the COVID 19 pandemic that started in 2020. The world heaved a collective sigh when emergency approvals were given to pharmaceutical companies to produce and market these. Governments fought over vaccine supplies, and culture wars erupted. While some of the wars were over vaccine hoarding by economically privileged countries like the US, some were about individual choice, religious freedom, justified wariness of minoritized groups about testing, reliability and government responsibility, and political identity groups.

While the CDC recommends vaccines for newborns and in infancy, it is important for children to receive additional doses of vaccines to keep them protected. These boosters, given between ages 4 and 6, are doses of the vaccines they received earlier in life to help them maintain the best protection against vaccine-preventable diseases.

Two syringes, medication vial and a form on a desk with someone's hands in foreground — Figure $\PageIndex{1}$: Governments in most industrialized countries support childhood vaccination programs to keep populations healthy.[1]

Many states in the United States require children to be fully vaccinated (unless they have a medical reason to be exempt) before they can enroll in licensed child care or public school. If vaccinations were missed, a health care provider can help the child’s caregivers to create a catch up schedule to ensure the child correctly “catches up” with the recommended childhood vaccination schedule.[2]

One way we can protect a child’s health (and those around them) is through immunization. The vaccines (given through injection) may hurt a little…but the diseases they can prevent can hurt a lot more! Immunization shots, or vaccinations, are essential. They protect against things like measles, mumps, rubella, hepatitis B, polio, diphtheria, tetanus and pertussis (whooping cough). Immunizations are important for adults as well as for children. Here’s why:

The immune system helps the human body fight germs by producing substances to combat them. Once it does, the immune system “remembers” the germ and can fight it again. Vaccines contain germs that have been killed or weakened. When given to a healthy person, the vaccine triggers the immune system to respond and thus build immunity.

Before vaccines, people became immune only by actually getting a disease and surviving it. Immunizations are an easier and less risky way to become immune.

Vaccines are the best defense we have against serious, preventable, and sometimes deadly contagious diseases. Vaccines are some of the safest medical products available, but like any other medical product, there may be risks. Accurate information about the value of vaccines as well as their possible side effects helps people to make informed decisions about vaccination.

Layperson and nurse (in a nun habit) with baby on examining table — Figure $\PageIndex{2}$: There are a list of childhood vaccines that are available in most countries of the world to keep populations healthy.[3]

Potential Side Effects

Vaccines, like all medical products, may cause side effects in some people. For the most part these are minor (for example, a sore arm or low-grade fever) and go away within a few days.[4] Serious side effects after vaccination, such as severe allergic reaction, are very rare.[5]

Remember, vaccines are continually monitored for safety, and like any medication, vaccines can cause side effects. However, a decision not to immunize a child involves a much greater risk. It could put the child and others who come into contact with him or her at risk of contracting a potentially deadly disease. Measles, polio, chickenpox, meningococcal virus and many of the other routinely vaccinated against diseases caused a lot of illness, disability and harm that is now mostly eradicated from the world, though in developing nations like India there is still much work to be done. Especially the COVID pandemic caused much backslide in the number of children who received no vaccinations at all. For example in India between 2005 and 2015, there was a 33% reduction in the gaps in vaccine coverage, and by 2016 the number of 0-dose children dropped to 10.1%. However, since the start of the pandemic, BCG vaccine coverage dropped from 92 to 85% and DTP-1 from 94 to 87%.

The controversies about vaccines

Vaccines work really well. No medicine is perfect, of course, but most childhood vaccines produce immunity about 90–100% of the time. When people do get breakthrough infections (get the disease despite being vaccinated) the symptoms are much less harsh, and the harm is much less. For example, people died of COVID-19 in the hundreds before the vaccine became available. I did get COVID in November 2022 after being vaccinated and boosted, but the symptoms were relatively mild. I had a fever for about two days and felt a bit lousy for a week. My friend who contracted the disease in May 2020, before the vaccines were available, had to be hospitalized for about 3 weeks and took months to recuperate. An older friend who contracted the disease in Jan 2021 had to be hospitalized, put on a ventilator and finally passed away.

What about the argument made by some people that vaccines don’t work that well . . . that diseases would be going away on their own because of better hygiene or sanitation, even if there were no vaccines? That simply isn’t true. Certainly better hygiene and sanitation can help prevent the spread of disease, but the germs that cause disease will still be around, and as long as they are they will continue to make people sick. Further, the viruses will also continue to mutate within human hosts making the disease harder to treat.

All vaccines must be licensed (approved) by the Food and Drug Administration (FDA) before being used in the United States, and a vaccine must go through extensive testing to show that it works and that it is safe before the FDA will approve it. Among these tests are clinical trials, which compare groups of people who get a vaccine with groups of people who get a control. A vaccine is approved only if FDA makes the determination that it is safe and effective for its intended use.

If you look at the history of any vaccine-preventable disease, you will virtually always see that the number of cases of disease starts to drop when a vaccine is licensed. Vaccines are the most effective tool we have to prevent infectious diseases. I was born in 1969 in India and grew up there till I was 20 years old. I did get chickenpox and therefore got shingles when I was under a lot of stress a few years ago. I am glad that my kids have gotten the varicella vaccine and will therefore not have to worry about getting shingles when they are older. I also remember the horror of people getting small pox, and being vaccinated against it myself. I remember the celebration and jubilation in the streets of my city when small pox vaccines caused the disease to be eradicated. You are welcome -- from my generation to yours!

Opposition to Vaccines in the US

In 2010, a pertussis (whooping cough) outbreak in California sickened 9,143 people and resulted in 10 infant deaths: the worst outbreak in 63 years (Centers for Disease Control 2011b). Researchers, suspecting that the primary cause of the outbreak was the waning strength of pertussis vaccines in older children, recommended a booster vaccination for 11–12-year-olds and also for pregnant women (Zacharyczuk 2011). Pertussis is most serious for babies; one in five needs to be hospitalized, and since they are too young for the vaccine themselves, it is crucial that people around them be immunized (Centers for Disease Control 2011b). Several states, including California, have been requiring the pertussis booster for older children in recent years with the hope of staving off another outbreak.

But what about people who do not want their children to have this vaccine, or any other? That question is at the heart of a debate that has been simmering for years. Vaccines are biological preparations that improve immunity against a certain disease. Vaccines have contributed to the eradication and weakening of numerous infectious diseases, including smallpox, polio, mumps, chicken pox, and meningitis.

Nurse helping two children with leg braces walk - photo is black and white — Figure $\PageIndex{3}$: These two young children contracted polio – but these scenes are highly uncommon in most countries since the wide availability and dispensation of the polio vaccine.[6]

However, many people express concern about potential negative side effects from vaccines. These concerns range from fears about overloading the child’s immune system to controversial reports about devastating side effects of the vaccines.[7]

Although children continue to get several vaccines up to their second birthday, these vaccines do not overload the immune system. Every day, an infant’s healthy immune system successfully fights off thousands of antigens – the parts of germs that cause their immune system to respond. Even if your child receives several vaccines in one day, vaccines contain only a tiny amount of antigens compared to the antigens your baby encounters every day in the normal world.

This is the case even if your child receives combination vaccines. Combination vaccines take two or more vaccines that could be given individually and put them into one shot. Children get the same protection as they do from individual vaccines given separately—but with fewer shots.[8]

One misapprehension is that the vaccine itself might cause the disease it is supposed to be immunizing against.[9] Vaccines help develop immunity by imitating an infection, but this “imitation” infection does not cause illness. Instead it causes the immune system to develop the same response as it does to a real infection so the body can recognize and fight the vaccine-preventable disease in the future. Sometimes, after getting a vaccine, the imitation infection can cause minor symptoms, such as fever and pain at the site of the injection. Such minor symptoms are normal and should be expected as the body builds immunity.[10]

Another commonly circulated concern is that vaccinations, specifically the MMR vaccine (MMR stands for measles, mumps, and rubella), are linked to autism. The autism connection has been particularly controversial and caused a great deal of public harm. In 1998, a British physician named Andrew Wakefield published a study in Great Britain’s Lancet magazine that linked the MMR vaccine to autism. The report received a lot of media attention, resulting in British immunization rates decreasing from 91 percent in 1997 to almost 80 percent by 2003, accompanied by a subsequent rise in measles cases (Devlin 2008). A prolonged investigation by the British Medical Journal proved that not only was the link in the study nonexistent, but that Dr. Wakefield had falsified data in order to support his claims (CNN 2011). Dr. Wakefield was discredited and stripped of his license, but the doubt still lingers in many parents’ minds.

In the United States, many parents still believe in the now discredited MMR-autism link and refuse to vaccinate their children. Other parents choose not to vaccinate for various reasons like religious or health beliefs. In one instance, a boy whose parents opted not to vaccinate returned home to the U.S. after a trip abroad; no one yet knew he was infected with measles. The boy exposed 839 people to the disease and caused 11 additional cases of measles, all in other unvaccinated children, including one infant who had to be hospitalized.

A baby with a rash on its face — Figure $\PageIndex{4}$: The MMR vaccine has made this picture fairly uncommon until a rash of people in Western countries started anti-vaxer movements - A baby with measles[11]

According to a study published in Pediatrics (2010), the outbreak cost the public sector $10,376 per diagnosed case. The study further showed that the intentional non-vaccination of those infected occurred in students from private schools, public charter schools, and public schools in upper-socioeconomic areas (Sugerman et al. 2010).[12]

The Immunization Schedule

On-time vaccination throughout childhood is essential because it helps provide immunity before children are exposed to potentially life-threatening diseases. Vaccines are tested to ensure that they are safe and effective for children to receive at the recommended ages.[13]

Fully vaccinated children in the U.S. are protected against sixteen potentially harmful diseases. Vaccine-preventable diseases can be very serious, may require hospitalization, or even be deadly — especially in infants and young children.[14]

Here is the schedule from the CDC to ensure a child is fully vaccinated:

CDC recommended vaccine schedule for birth to 6 years

Table $\PageIndex{1}$: Vaccine-Preventable Diseases - chickenpox, diphtheria, HiB, Hepatitis A and B, flu, measles, mumps, pertussis, polio, pneumococcal, rotavirus, rubella and tetanus - how they are transmitted through direct contact, air, or skin contact, their main symptoms and complications.[16]

Disease	Vaccine	Disease spread by	Disease symptoms	Disease complications
Chickenpox	Varicella vaccine protects against chickenpox.	Air, direct contact	Rash, tiredness, headache, fever	Infected blisters, bleeding disorders, encephalitis (brain swelling), pneumonia (infection in the lungs), death
Diphtheria	DTaP* vaccine protects against diphtheria.	Air, direct contact	Sore throat, mild fever, weakness, swollen glands in neck	Swelling of the heart muscle, heartfailure, coma, paralysis, death
Hib	Hib vaccine protects against Haemophilus influenzae type b.	Air, direct contact	May be no symptoms unless bacteria enter the blood	Meningitis (infection of the covering around the brain and spinal cord), intellectual disability, epiglottitis (life-threatening infection that can blockthe windpipe and lead to serious breathing problems), pneumonia (infection in the lungs), death
Hepatitis A	HepA vaccine protects against hepatitis A.	Direct contact, contaminated food or water	May be no symptoms, fever, stomach pain, loss of appetite, fatigue, vomiting, jau ndice (yellowing of skin and eyes), dark urine	Liverfailure,arthralgia (joint pain), kidney, pancreatic and blood disorders, death
Hepatitis B	HepB vaccine protects against hepatitis B.	Contact with blood or body fluids	May be no symptoms, fevei, headache, weakness, vomiting, jaundice (yellowing of skin and eyes), joint pain	Chronic liver infection, liver failure, liver cancer, death
Influenza (Flu)	Flu vaccine protects against influenza.	Air, direct contact	Fever, muscle pain, sore throat, cough, extreme fatigue	Pneumonia (infection in the lungs), bronchitis, sinus infections, ear infections, death
Measles	MMR** vaccine protects against measles.	Air, direct contact	Rash, fever, cough, runny nose, pinkeye	Encephalitis (brain swelling), pneumonia (infection in the lungs), death
Mumps	MMR**vaccine protects against mumps.	Air, direct contact	Swollen salivary glands (under the jaw), fever, headache, tiredness, muscle pain	Meningitis (infection of the covering around the brain and spinal cord), encephalitis (brain swelling), inflammation of testicles or ovaries, deafness, death
Pertussis	DTaP* vaccine protects against pertussis (whooping cough).	Air, direct contact	Severe cough, runny nose, apnea (a pause in breathing in infants)	Pneumonia (infection in the lungs), death
Polio	IPV vaccine protects against polio.	Air, direct contact, through the mouth	May be no symptoms, sore throat, fever, nausea, headache	Paralysis, death
Pneumococcal	PCV13 vaccine protects against pneumococcus.	Air, direct contact	May be no symptoms, pneumonia (infection in the lungs)	Bacteremia (blood infection), meningitis (infection of the covering around the brain and spinal cord), death
Rotavirus	RV vaccine protects against rotavirus.	Through the mouth	Diarrhea, fever, vomiting	Severe dianhea, dehydration, death
Rubella	MMR** vaccine protects against rubella.	Air, direct contact	Sometimes rash, fever, swollen lymph nodes	Very serious in pregnant women—can lead to miscarriage, stillbirth, premature delivery, birth defects
Tetanus	DTaP* vaccine protects against tetanus.	Exposure through cuts in skin	Stiffness in neckand abdominal muscles, difficulty swallowing, muscle spasms, fever	Broken bones, breathing difficulty, death

Attributions:

Child Growth and Development by Jennifer Paris, Antoinette Ricardo, and Dawn Rymond, 2019, is licensed under CC BY 4.0 (for introduction, potential side effects, immunization schedules and opposition to vaccines)

[1] Image by Ramstein Air Base is in the public domain

[2] Vaccines for Your Children: Protect Your Child at Every Age by the CDC is in the public domain

[3] Image by Maria Immaculata Hospital is licensed under CC BY-SA 4.0

[4] Disease Prevention and Healthy Lifestyles references Contemporary Health Issues by Judy Baker, Ph.D., licensed under CC BY-SA 4.0

[5] Making the Vaccine Decision by the CDC is in the public domain

[6] Image by the CDC is in the public domain

[7] Disease Prevention and Healthy Lifestyles references Contemporary Health Issues by Judy Baker, Ph.D., licensed under CC BY-SA 4.0

[8] Making the Vaccine Decision by the CDC is in the public domain

[9] Disease Prevention and Healthy Lifestyles references Contemporary Health Issues by Judy Baker, Ph.D., licensed under CC BY-SA 4.0

[10] Making the Vaccine Decision by the CDC is in the public domain

[11] Image by CDC Global is licensed under CC BY 2.0

[12] Disease Prevention and Healthy Lifestyles references Contemporary Health Issues by Judy Baker, Ph.D., licensed under CC BY-SA 4.0