Vaccination of Infectious Disease

By Shoshana Weiner

Introduction: Why do we use vaccination?

          Immunization is the ability to “artificially induce the body to resist infection.”  The idea that immunity was possible originated in observations that those who survived the course of a disease rarely ever contracted the same disease again: “In 430 B.C., Thucydides recorded that while the plaque was raging in Athens, the sick and dying would have received no attention had it not been for those individuals who had already contracted the disease and recovered and recognized their ‘immune’ status.”  [28]

            The use of inoculations to protect the host from disease is thought to have started in India or China around 200 BCE. [26]  Inoculation is the introduction of a disease causing agent that allows the host to acquire immunity without having to experience the more severe form of the disease.  One of the earliest disease targets of inoculation was smallpox.  Around 1000 CE, the Chinese inhaled dried powders from the crusts of smallpox lesions, and, around the fifteenth century, it became common practice to inject these powders into the skin with a type of pin. [28]

            The term vaccination came from a later approach to smallpox inoculation.  In 1796, an English physician named Edward Jenner “observed that milkmaids stricken with a viral disease called cowpox [vaccinia] were rarely victims of a similar disease, smallpox… In an experiment…, Jenner took a few drops of fluid from a pustule of a woman who had cowpox and injected the fluid into a healthy young boy who had never had cowpox or smallpox. Six weeks later, Jenner injected the boy with fluid from a smallpox pustule, but the boy remained free of …smallpox.” [3]  The French coined the term vaccination, which specifically refers to the use of cowpox (vaccinia) to immunize humans against smallpox (variola). [27]    

            The use of this new vaccine has protected the global community from the morbid consequences of smallpox epidemics.  In the time of Jenner “…a million people died from smallpox each year in Europe alone…. Those who survived were often left with grim reminders of their ordeals: blindness, deep scars, and deformities.” [3]  In 1979, after a 10-year program executed by the World Health Organization (WHO), the spread of smallpox was eradicated. [4] 

            Many other diseases have been controlled through the use of vaccination.  Within the United States, the incidence of measles has been reduced by 98%, and Haemophilus influenzae type b infection in children has been reduced by more than 99%.  “The incidence of diphtheria dropped from 206,000 cases and 15,520 deaths in 1921 to an average of just two to three reported cases each year since 1980.” [4]  Despite these breakthroughs, the public has raised many concerns about the safety and necessity of vaccination.  This chapter hopes to explore some of the issues surrounding vaccination.  What vaccinations are recommended?  Are vaccines safe?  What factors determine the success of a vaccination program?  Hopefully the information presented in this chapter along with suggested additional resources will help the reader to make educated decisions about personal and global vaccination.


What are Vaccinations and how do they Work?


            The immune system is designed to combat foreign invaders that enter the body before symptoms arise.  The body accomplishes this in part by special immune cells that make proteins called antibodies in response to an infection.  Antibodies act as “fingerprints” for a certain invader.  That way, if the body encounters the same pathogen in the future, the immune system can quickly recognize the invader, and an expedited immune response will be possible. Vaccines work by providing the body with a set of “fingerprints” before the body is naturally invaded.  [1, 2]  

            Vaccines are made from either a modified microbe or part of a microbe that tricks the body into thinking it is being invaded.  Therefore, antibodies against the microbe can be made without the person getting sick. [1] 

            Vaccines are not 100% protective. “Most childhood vaccines are effective for 85 percent to 95 percent of recipients. During a disease outbreak, a number of vaccinated people will…catch the disease. However, those who were immunized usually have a less serious illness.” [2]  Vaccinated individuals can obtain a disease because either they fail to make antibodies or the vaccine may have been stored incorrectly thereby making it ineffective.  In addition, some vaccines require multiple injections since the immune system may gradually lose antibodies for a microbe over time. [1]  


Below are explanations of the different types of vaccines adapted from The National Institute of Allergy and Infectious Disease.  For a complete copy of their explanations, please visit their website [3]:

Different Types of Vaccines

Weakened Microbes. Live microbes are weakened by growing them for many generations in animals or in tissue cultures in the laboratory. These weakened microbes can be inoculated into humans to provide protection from their disease-causing counterparts.

            Examples: oral polio vaccine, vaccines for mumps, measles, and rubella

Killed Microbes. A number of vaccines have been developed from whole organisms that have been killed. These inactivated microbes stimulate the immune system without causing disease.

            Examples: polio, influenza

Inactivated Toxins (Toxoids). Some bacteria cause disease by producing toxins that invade the bloodstream. Inactivated toxins have been used successfully.

            Examples: tetanus, diphtheria

Subunit Vaccines.  These vaccines use only part of a bacterium or virus. 

            Examples: typhoid and hepatitis B, whooping cough

Conjugate Vaccines. Certain bacteria have an outer coat that cannot be recognized by the immature immune systems of young infants and, therefore, vaccines made from these bacteria are not effective in babies.  Vaccines are made that link together proteins or inactivated toxins from a second organism to the outer coat of the bacteria. This enables a baby's immune system to respond to the combined vaccine and produce antibodies against the disease-causing bacteria.

            Examples: pneumonia and meningitis (Haemophilus influenzae type b)

Additional Constituents of Vaccines [12]

Preservatives (phenol, 2-phenoxyethanol, Thiomersal): Prevention of bacterial and      fungal   contamination

Adjuvants (aluminum hydroxide, aluminum phosphate, potassium aluminum sulfate,       also known as alum): Aluminum salts are added for their role in helping to      activate an immune response to the vaccine.

Additives (sugars- sucrose, lactose, etc.; amino acids- glycine, monosodium salt of       glutamic acid; proteins- gelatin, human serum albumin): Used to stabilize            vaccines in the face of freeze-drying or heat

Manufacturing Residues

            Inactivating Agents (formaldehyde, B-propiolactone, glutaraldehyde): Used to eliminate the harmful effects of pathogens in vaccines by preventing harmful effects of bacterial toxins and inhibiting viral replication.

            Antibiotics (neomycin, streptomycin, polymyxin B, chlortetracycline, amphotericin B): Used to prevent bacterial contamination during production.

            Cellular Residuals (Proteins) Vaccines are made in “two diploid cell strains of human origin (MRC-5 and WI-38), simian-derived continuous and diploid cell lines, chick embryo and chick embryo fibro-blasts” [17], as well as in baker’s yeast [12].  Some proteins, such as egg proteins, may be left in the vaccine due to these processes.

            Animal and human sera (Serum from cows, pigs, horses, rabbits or humans) “Animal sera are frequently added to culture media to provide nutrients for microbial growth.  Some media are serum-free or may be of synthetic, semi-synthetic or yeast origin.” [17] 


Vaccination Safety

“Before vaccines can be used, they must meet strict safety standards established by the Food and Drug Administration (FDA)…  During this time the vaccine undergoes three phases of clinical trials. Once vaccines are licensed and put in use, the FDA and the Centers for Disease Control and Prevention (CDC) continue to monitor their safety. Vaccines are also subject to ongoing research and review by doctors, researchers and public health officials.” [4]

However, vaccines do not do their job without some side effects.  “Most effects are minor and temporary, such as a sore arm, mild fever or swelling at the injection site.” [4]  When When serious side effects occur, they are reported to the Vaccine Adverse Event Report System (VAERS).  The Vaccine Adverse Event Report System, created by the FDA and the CDC, can be reached at

When adverse side-effects do occur, it is possible for the patient to receive compensation through the National Childhood Vaccine Injury Act of 1986 (PL-99-660).  For more details, please see the section about Vaccination Law.

Below is a short discussion about some of the additives commonly found in vaccines.


            Adjuvants have been observed to cause erythema, subcutaneous nodules, contact hypersensitivity, and granulomatous inflammation.



            After 2001, thimerosal has been removed from most vaccines, or only remains in very small amounts.  Thimerosal is an organic compound that is metabolized to ethylmercury and thiosalicylate.  The mercury or thiosalicylate components of thiomersal may produce hypersensitivity reactions, with severe reactions occurring rarely.  Apart from these reactions,thimerosal has been implicated to have a role in the “claimed link between measles, mumps and rubella (MMR) vaccination and autism.” [17]  However, the studies that reported this link have been recognized as flawed, in addition to the actual retraction of data interpretation. [18,19]

            A 2004 review examined the literature linking thimerosal to autism.  The review looked at “10 epidemiologic studies and 2 pharmacokinetic studies of ethylmercury.”  The study concluded that “the design and quality of the studies showed significant variation. The preponderance of epidemiologic evidence does not support an association between thimerosal-containing vaccines and ASD. Epidemiologic studies that support an association are of poor quality and cannot be interpreted. Pharmacokinetic studies suggest that the half-life of ethylmercury is significantly shorter when compared with methylmercury.” [19]

            An addition study looked at mercury concentrations in the blood of full-term infants.  The concentrations were found to be “well below the level thought to be associated with adverse effects.” [17]

            Lastly, the half-life of ethylmercury, about 7 days, is much faster than that of methylmercury.  Therefore, there is a lower chance of toxic reactions due to the short exposure time [12,17].  However, more research needs to be done, specifically to examine the effects of thimerosal on low birthweight premature infants. [17]


            “2-Phenoxyethanol is an alternative to thiomersal. One report describes generalised eczema occurring after vaccination where 2-phenoxyethanol was found to be the sensitizing agent.”



Antibiotics may contribute to allergic reactions, including anaphylaxis, and local skin reactions.[17]  It is worth noting that neomycin is the only antibody that can be found in detectable quantities, and that most antibiotics that are known to be responsible for immediate-type hypersensitivity reactions are not used in the production of vaccines.  These include penicillins, cephalosporins and sulfonamides. [12]


Bovine Products

            “Use of bovine-derived products in vaccine manufacture, such as gelatin or bovine sera, has prompted concern about whether this poses a risk of BSE. BSE is transmitted by prions, which may lead to Creutzfeldt-Jakob disease (vCJD) in humans.

Despite administration of tens of millions of doses of vaccines manufactured using bovine-derived material, there are no reported cases of BSE transmission via human or animal vaccination.

            “Australian, European and US regulatory bodies have developed guidelines for use of bovine material in vaccine manufacture to minimise risk of BSE transmission.

Bovine material must be sourced from countries where no recorded cases of BSE have occurred and an appropriate system of monitoring and reporting of BSE in animals has been implemented. Alternatively, bovine material may be sourced from specific donor herds where animal health is routinely monitored.  Use of manufacturing processes, such as heat sterilization and chemical treatment, reduces or removes BSE infectivity from bovine products.” [17]

            In addition, allergic reactions to gelatin are possible.



Formaldehyde has been observed to cause DNA damage, which leads to cancerous changes in cells grown in culture.  However, these in vitro results have not been found to be relevant in vivo.  Formaldehyde has not found to be a cause of cancer in humans, and animals did not develop cancers upon exposure to large quantities. [12,17]


Egg Proteins

            The amount of egg protein found in influenza vaccines is enough to induce a severe and possible fatal hypersensitivity reaction in children that have egg allergies. [12]

This is particularly relevant for children with asthma, general allergies and severe atopic dermatitis [17].  Despite these allergies, “current guidelines and evidence suggest that patients with egg allergies, other than anaphylaxis, may be vaccinated safely.”.[17]


Yeast Proteins

Allergies to baker’s yeast may not cause severe reactions, since antibodies for yeast proteins have not been found in vaccine recipients.  However, immediate-type hypersensitivity has been observed in Hepatitis B recipients.[17]


Live vaccines

Vaccines made from weaker forms of live vaccines “carry a risk of organisms reverting to virulent forms that cause infection rather than immunity.” [17]


What Vaccines are Available?


Vaccinations are available for the following infectious diseases listed by the National Network for Immunization Information [6]: 


For specific information about vaccine availability, history, side effects, dosage, effectiveness, and recommended recipients, select the vaccine of interest from the vaccination list on the National Network for Immunization Information website.




“Anthrax is caused by Bacillus anthracis and is most common among wild and domestic animals such as cattle, sheep, and goats.  It is most common in agricultural regions, and human cases are usually from occupational exposure.  It is a potential agent for biological warfare so the Department of Defense vaccinates active military personnel.  Anthrax occurs in three forms:  cutaneous (skin), inhalation, and gastrointestinal.  The spores can survive in the soil or animal hides for years.  It can also be acquired by eating undercooked meat from infected animals.  Most anthrax cases are the cutaneous form when the bacteria enter a preexisting skin wound.  It then forms a characteristic black ulcer.  Untreated, this form has a 20% mortality.  Inhalation anthrax is similar to a cold, but then progresses to great difficulty breathing resulting in shock and usually death.  Intestinal anthrax causes severe gastrointestinal symptoms including vomiting blood, and is fatal in 25-60% of cases.  Treatment is with penicillin G.  Spread of anthrax from person to person is highly unlikely.” [32] 






“Diphtheria is caused by the bacterium Corynebacterium diphtheriae.  It causes upper respiratory infection with nasal discharge, sore throat, fever, and the formation of a whitish membrane on the tonsils, nasal septum, and pharynx.  This may progress to hoarseness and cough with obstruction of the airway.  Most cases are in children who are not immunized.  It is passed through the air, usually by coughing.  Treatment includes antitoxin along with antibiotics, usually penicillin and erythromycin.  Having disease does not necessarily confer immunity, so patients should be immunized following resolution of the disease.  Patients with diphtheria must be isolated while contagious.  Contacts of the case must be cultured and boosters given.” [32]


Haemophilus influenzae type b (Hib)


“In children this bacteria can cause meningitis, pneumonia, periorbital cellulites (infection around the eye), epiglottitis (infection and swelling in the lower throat), and septicemia (infection in the blood).  The bacteria are spread through secretions.  Treatment involves intravenous antibiotics.  Those who are exposed to the bacteria can take rifampin to help prevent spread of the disease.” [32]



Hepatitis A


“Hepatitis A is a virus that causes disease in the liver.  Many people do not have any symptoms when infected.  Symptomatic people usually have sudden onset of fever, fatigue, nausea, dark urine, and jaundice (yellow skin and eyes).  Symptoms persist for weeks to months.  Diagnosis is made by an antibody test from the blood.  Hep A is transmitted by the fecal-oral route.  Treatment is supportive.  There is a vaccine available for those at high risk.” [32]



Hepatitis B


“Hepatitis B virus affects the liver.  Many cases resolve on their own, but some persist and cause lifelong infection, cirrhosis (scarring of the liver), liver cancer, all of which can lead to liver failure and death.  Most people do not have acute disease when infected.  Acute infections are similar to hepatitis A (see above).  HBV is spread by blood and body fluids.  Risk factors include unsafe sexual practices, IV drug abuse, and working with blood products.  Diagnosis is made by antibody tests from the blood.  There is no cure for hep B.  There is a vaccine available that all children and adults at risk should receive.  Prevention involves vaccination as well as safe sexual practices and not sharing needles.” [32] 





“There are 3 influenza viruses: A, B, and C.  It is spread through droplets from secretions.   Cases can vary from asymptomatic to severe.  Usually it causes a respiratory infection with fever/chills, headache, fatigue, and runny nose.  Complications include pneumonia, myositis (muscle inflammation) and Reye syndrome (a post-viral encephalopathy).  Diagnosis is through detection of viral antigen in the nose or through serological tests from the blood.  Treatment is to alleviate symptoms.  Aspirin should not be used since it increases the risk of developing Reye syndrome.” [32] 


Lyme Disease


“Lyme disease is caused by the bacteria Borrelia burgdorferi and is transmitted by the black-legged tick, Ixodes scapularis.  Risk factors include being outdoors, especially in the summer/fall months and in wooded areas.  The illness starts as a circular, red rash around the tick bite that expands in size.  This is accompanied by flu-like symptoms and joint pain and swelling.  If untreated, nerve palsies and heart problems can occur.  Diagnosis is by antibody tests in the blood or spinal fluid.  Treatment is with tetracycline.  Prevention includes wearing protective clothing and insect repellant when outdoors in tall grass or wooded areas.  When removing ticks from the body, it is important to remove the mouthparts attached to the skin.  Removed ticks can be checked for lyme disease by the Ohio dept of health.” [32] 





“Measles is a highly contagious viral disease that has been largely controlled through immunization.  It is spread through nasal and mouth secretions and occasionally through the air.  Symptoms appear in 2 stages: 1) runny nose, cough, and fever, possibly red eyes and photosensitivity, and 2) higher fever and red rash beginning on the face, then spreading over the body.  White spots known as Koplik spots may appear inside the mouth.  Complications include pneumonia, which is usually the cause of death in fatal cases.  There is no specific treatment.  Vaccination or having the disease confers permanent immunity.” [32] 



Meningococcal Disease


“Meningococcal disease includes meningitis and meningococcemia (disseminated infection in the blood) by the bacteria Neisseria meningitides.  Many people carry the bacteria and are asymptomatic.  It is passed by droplets.  Symptoms of meningitis include altered mental status, stiff neck, photophobia, fever, and possibly seizures.  Symptoms of meningococcemia are acute onset of fever/chills, malaise, and rash of pink or purple bumps.  It can quickly progress to blood clotting abnormalities, shock, coma, and death.  Diagnosis of both illnesses is made by Gram stain of spinal fluid or culture of the blood or spinal fluid.  Treatment requires hospitalization and intravenous antibiotics.  Patients should be isolated until they have received 24 hours of antibiotics.  High risk contacts of cases should receive rifampin.  There is a vaccine available but only to control outbreaks.  It is not recommended for the general population.” [32] 




“Mumps is caused by a paramyxovirus passed in oral secretions.  It causes painful swelling of any of the salivary glands, mainly the parotid, and fever.  Other symptoms may occur such as loss of appetite, abdominal pain, and headache.  Among males, 20% have accompanying orchitis (inflamed testicle).  Complications of more severe disease include pancreatitis, deafness, and meningitis.  Diagnosis is by recovering the virus from saliva, urine, or spinal fluid.  Treatment is supportive.  In Ohio, a case must be isolated for 9 days after the onset of gland swelling. The incidence of mumps has greatly decreased since the inception of the MMR  (measles, mumps, rubella) vaccine.” [32]



Pertussis (Whooping Cough)


“Whooping cough is caused by the bacteria Bordatella pertussis.  It has become rare due to the DTP and DTaP vaccines.  The disease is airborne and is only found in humans.  Disease course is divided into 3 stages: 1) catarrhal, which resembles the common cold and lasts 1-2 weeks, 2) paroxysmal, describing the violent coughing paroxysms that end in the characteristic “whoop” inhalation and sometimes vomiting.  This stage lasts 4-6 weeks.  3) convalescent, where the whoop and vomiting stop and the cough begins to disappear over several weeks.  Diagnosis is by isolating the organism or through DNA tests.  Treatment is only effective if given during the catarrhal stage of the illness.  The drug of choice is erythromycin.  In Ohio, cases must be isolated for 3 weeks following the onset of paroxysms if they did not receive appropriate antibiotics.  Those who received therapy in time must be isolated for 5 days after therapy is started.  Contacts of cases should either be immunized or given a course of erythromycin if they are less than 1 year old.  Prevention involves receiving the recommended immunizations.” [32] 


Pneumococcal Disease


Streptococcus pneumoniae is a group of “strep” bacteria also known as pneumococci. Pneumococci live in the nose and throats of people of all ages. Pneumococci can infect many different sites, some common—like the middle ear and the sinuses—and some less common but more serious, including the lungs (pneumonia), central nervous system (meningitis), and blood stream (bacteremia).”




“Polio is caused by poliovirus types 1, 2, and 3.  It has been eradicated in the Western hemisphere due to the massive immunization campaign over the past few decades.  Humans are the only source.  Poliovirus is passed by the fecal-oral route and can be found in contaminated water sources such as swimming pools.  Up to 90-95% of infections are asymptomatic, 4-8% of infections are mild and similar to a flu-like illness, 1-2% result in nonparalytic poliomyelitis characterized by aseptic meningitis, and only 0.1-2% of polio cases result in paralytic disease.  Paralytic polio manifests as flaccid paralysis of one or more limbs with loss of reflexes but maintained sensation.  In most cases, muscle function returns completely, but some cases have residual disability.  Diagnosis is confirmed by isolating the virus in spinal fluid, stool, or oral secretions.  Serologic tests are also available.  There is no specific treatment.  Immunization is the most important prevention.” [32] 




“The rabies virus is transmitted from infected animals and affects the central nervous system.  It is fatal once symptoms occur.  Transmission is usually from a bite of a rabid animal.  Early symptoms are irritability, headache, anxiety, and fever.  These progress to paralysis, muscle spasms, seizures, delirium, and death.  Patients often have an intense fear of water.  Rabies can be prevented by immediate wound cleansing, the administration of rabies immune globulin, and 5 doses of the rabies vaccine.  Exposure from a rabid animal does not always result in disease.  Prevention on a community scale is accomplished by minimizing the number of stray animals, and avoiding contact with wild animals.” [32] 




“Rotavirus is an intestinal virus that infects virtually all children by three years of age. It is the most common cause of diarrhea in children, including hospital-acquired diarrhea, and childcare center outbreaks are common. The disease usually lasts a week or longer and can cause persistent infection in immunocompromised people. Most rotavirus infections are mild, but about 1 in 50 cases develop severe dehydration. Each year in the U.S., rotavirus results in the hospitalization of 50,000 infants younger than two years of age. In developing countries, rotavirus leads to an estimated 480,000 to 640,000 deaths each year.”




Rubella virus is an airborne infection that causes German measles.  The disease starts with a few days of fever, headache, malaise, conjunctivitis, runny nose, sore throat, cough, and swollen lymph nodes.  These symptoms then disappear with the appearance of the characteristic rash.  The rash consists of fine, pink bumps starting at the hair line and spreading downward.  It lasts only 48 hours.  The disease is especially dangerous in pregnant women since it can be devastating for the fetus.  Diagnosis depends on antibody tests.  There is no specific therapy.  Patients should be isolated for 7 days after the onset of rash in order to protect susceptible pregnant women.  The MMR vaccine has greatly reduced the incidence of rubella and is the best form of prevention.” [32] 




“Smallpox is caused by a virus known as Variola.  It was declared eliminated in 1980 due to worldwide vaccination, although stores of the virus are found in the US and Russia.  It is airborne and highly contagious.  Symptoms include sudden onset of fever, exhaustion, and malaise.  After several days the temperature drops and a rash appears on the face and arms, then spreading to the rest of the body.  The rash develops into vesicles filled with fluid or pus that eventually scab and leave scars.  These lesions are also highly infectiou.  Treatment is supportive, there is no cure.  The disease is fatal in 30% of cases.  Cases must be isolated as long as they are infectious.  Since the disease has been eradicated, the public is no longer immunized against it, thus making them susceptible to a biologic attack using this virus.” [32]





“Tetanus is caused by the bacteria Clostridium tetani.  Spores of the bacteria are found in the soil.  They can then be introduced into a puncture wound.  The bacteria do not need oxygen to grow.  Symptoms include excitability and generalized muscle spasms particularly of the neck.  Symptoms are due to a neurotoxin released by the bacteria.  Diagnosis can be made by culture but is usually clinical.  Treatment is with tetanus immune globulin or with an equine variety to counter the toxin.  Penicillin G or tetracycline is also given to kill the bacteria.  Prevention involves getting a booster tetanus shot every 10 years.” [32]





“TB is caused by the bacteria Mycobacterium tuberculosis that is spread through the air.  Many people are infected with TB, as seen by a positive PPD test on the skin but no bacteria in the sputum, but a far smaller number actually develop disease.  Those with weakened immune systems are much more likely to develop active disease.  Symptoms are fever, night sweats, weight loss, and cough.  Diagnosis is made by seeing the bacteria on sputum smear and by characteristic lesions on chest X-ray.  Several drugs are used to treat TB although resistance is developing.  The most common drugs are isoniazid, rifampin, ethambutol, and streptomycin.  Drugs must be taken for several months.  Those with evidence of disease even if it is not active should take several months of isoniazid.  Prevention involves using respiratory precautions among infected individuals.” [32] 



Typhoid Fever


“Typhoid is caused by the bacteria Salmonella typhi and occurs only in humans.  It is passed by the fecal-oral route.  Some people are carriers of the bacteria but do not suffer disease.  Symptoms include a high fever, loss of appetite, abdominal pain, and rash.  Severe cases can cause bowel obstruction.  Diagnosis is by stool culture.  Therapy includes ampicillin, trimethoprim-sulfamethoxazole, and ciprofloxacin.  There is a vaccine available for those traveling to endemic countries.  Prevention involves hygienic food preparation.” [32] 


Varicella (Chickenpox)


“Chicken pox are caused by varicella-zoster virus (VZV).  Humans are the only host.  Transmission is either airborne or through direct contact.  It is usually a disease of children.  Symptoms are a skin eruption of vesicles that are quite itchy.  Fever and malaise may also be present.   Complications include Reye syndrome, pneumonia, arthritis, and aseptic meningitis.  Those infected as older children or adults are more likely to develop complications.  Diagnosis can be made by isolating the virus from the lesions or by antibody tests.  Treatment is symptomatic.  Aspirin should not be used.  Immunity is conferred after one infection.  Cases should be isolated until the 6th day after the rash started or until all the lesions are dry.  There is now a vaccine available.” [32] 


Yellow Fever


“This disease is caused by a virus transmitted by mosquitoes.  It is only found in Africa and South America.  Many countries have regulations regarding yellow fever vaccination even though the illness is rare among travelers.  Symptoms are fever, jaundice (yellow skin and eyes), headache, myalgias, and light sensitivity.  More severe disease damages the liver, kidneys, and heart and may be accompanied by hemorrhage.  Diagnosis is by antibody tests.  Therapy is supportive.  Vector control is the best prevention.” [32] 


Vaccination Law


The Centers for Disease Control update the laws of vaccination on the website [5].   


Patients must be informed

“By law, parents, guardians, or patients must be given information in writing about the risks and benefits of vaccination before a vaccine is administered.”  This information typically comes in the form of Vaccination Information Statements (VIS).  These are one page, doubled-sided, documents prepared by the CDC that state the risks and benefits of vaccination. 


Some of these vaccines are covered by the National Childhood Vaccine Injury Act of 1986 (PL-99-660) [29]:




Haemophilus influenzae type B



Hepatitis B






Some of the vaccines are not covered by this act, but have a VIS that must be deseminated if the vaccine is purchased under CDC contract. The legal basis is the “Duty to Warn” clause in CDC’s vaccine contracts.

VIS’s in this category (as of January 2000) are [29]:



Hepatitis A

Pneumococcal Polysaccharide

Lyme disease


When combination vaccines are given, all relevant VIS’s must be given.


You can obtain copies of these information sheets by calling the CDC National Immunization Program information hotline at 1-800-232-2522 (English) or 1-800-232-0233 (Spanish), or you can obtain copies online at


For more general information about VIS’s and the National Childhood Vaccine Injury Act of 1986 (PL-99-660), you can see the CDC’s publication “What you need to know about Vaccine Information Statements” at


National Childhood Vaccine Injury Act of 1986 (PL-99-660)


The National Childhood Vaccine Injury Act of 1986 (PL-99-660) is a vaccine safety and compensation system which (1) created a no-fault compensation alternative to suing vaccine manufacturers and providers on behalf of citizens injured or killed by vaccines; (2) helps prevent future vaccine injuries through education and an adverse reaction reporting system; and (3) creates incentives for the production of safer vaccines.” [30]


Below is an explanation of the compensation laws of this act from the National Vaccine Information Center Website [30]:

Compensation is divided into two parts:  

1)     Injuries or deaths prior to October 1, 1988 (no matter how long ago the injury occurred):

·         A citizen may choose to pursue a lawsuit unrestricted.

·         A citizen could have filed a claim in the compensation system by January 31, 1991

·         If the claim was not filed by 1/31/91, the statute of limitations has run out.

 2)     Injuries or deaths occurring after October 1, 1988:

·         A citizen is required to apply for federal compensation prior to pursuing a lawsuit.

·         The system will offer to pay up to $250,000 for a vaccine associated death.

·         The system will offer to pay for all past and future unreimbursed medical expenses, custodial and nursing home care; up to $250,000 pain and suffering; and loss of earned income.

·         If a citizen rejects the award or is turned down, a lawsuit may be filed.

·         Claims must be filed within 24 months of a death and 36 months of an injury.

·         Restrictions may apply to lawsuits.

·         The system is funded by a surcharge on each dose of vaccine sold.  

The NVIC publication, The Compensation System and How It Works, is available for a $5 donation and can be bought at

Immigration immunization laws

“Under new immigration laws passed in 1996 and in effect as of July 1, 1997, all individuals seeking permanent entry into the U.S. must prove that they have been inoculated against all vaccine-preventable diseases. This includes infants and children being brought into the country for international adoption.”


School immunization laws

            “Each state has immunization requirements, sometimes called ‘school laws,’ that must be met before a child may enter school... In most states, a parent must bring written proof of a child's immunizations from the health provider or clinic at the time of school registration.”  It is possible to obtain exemptions due to medical contraindications, or religious and philosophical beliefs.  “Religious exemptions are allowed in 48 states (West Virginia and Mississippi do not), and 15 states offer philosophical exemptions.  The requirements for documentation of medical, religious, or philosophical exemptions vary.”

            You can find out what the requirements for your state at  

            Select the state of interest from the list provided at the upper right hand corner of           the website.

Adult immunization laws

“There are no legally mandated vaccinations for adults, except for persons entering military service.  Some employers require certain immunizations for those employees who work with people who are sick or vulnerable to disease, or those who handle or are exposed to dangerous substances, such as certain bacteria or viruses. Hospitals, for example, may require some staff to have influenza or hepatitis B vaccine.” 


Travel immunization laws

“Immunizations were once required for persons traveling overseas. None are required at this time, but some vaccinations are recommended.”  Some diseases that are not common in the United States are still prevalent in other parts of the world.  Therefore, specific vaccinations are recommended when traveling to areas of possible exposure. For information about recommended vaccinations when traveling abroad, you can talk to your primary care physician or visit the following CDC website:


Current Federal and State Laws


To find out about current legislature, check out this National Vaccine Information Center Website:

What Vaccines are Recommended?


            Below are the recommended vaccinations from the Centers for Disease Control (CDC).  Every year the vaccination schedule is revised.  It is important to check with the CDC or with a healthcare provider in order to make sure the proper vaccines are administered in a timely fashion.









Pregnant Women

"Risk to a developing fetus from vaccination of the mother during pregnancy is primarily theoretical. No evidence exists for the risk from vaccinating pregnant women with inactivated virus or bacterial vaccines or toxoids. Benefits of vaccinating pregnant women usually outweigh potential risks when the likelihood of disease exposure is high, when infection would pose a risk to the mother or fetus, and when the vaccine is unlikely to cause harm." Committee on Immunization Practices (ACIP) General Recommendations on Immunization, p. 18. [20]

In general, pregnant women should not be given live-virus vaccines.  If a woman is giving a vaccine within four weeks of pregnancy, the woman should be counseled about possible side-effects for the fetus. 

Below is a general chart delineating the proper treatment of pregnant woman [20]:


Should be considered if otherwise indicated

Contraindicated during pregnancy


Hepatitis A



Hepatitis B



Influenza (Inact.)



Influenza (LAIV)












Polio (IPV)












Travel & Other







Japanese Encephalitis



Meningococcal (MPSV4)



Meningococcal (MCV4)






Typhoid (Parenteral & Ty21a)






Yellow Fever




Current Technology Development and Research


            Currently, there are many clinical trials currently being conducted in order to determine the safety and efficacy of vaccination.  In addition, there many projects in search for new vaccines that can tackle diseases, such as AIDS.  One way vaccination can be improved, and new vaccines can be created is through the development of new technologies.

New Vaccine Biotechnology

"Recombinant" Vaccines

 Scientists are currently working on making vaccines by changing the genetic structure of infectious pathogens.  An important gene for organism survival can be removed thereby allowing the host to acquire immunity without acquiring disease.  Another method of this technology is to add a gene into an organism that will enode a protein of a pathogen.  Injection with this organism will lead to the mass production of this protein that will induce an immune response directed toward the pathogen protein.  One more method is to inject a naked fragment of a pathogen’s genetic material.  The body’s cells can use this DNA to make proteins.  These proteins can induce an immune response in the host.  These vaccines, in particular, could result in lifelong immunity.  This technology is currently being used to make vaccines for malaria, influenza, and HIV. [3]

Genome Sequencing

Many projects are being condected to determine the genetic sequence of pathogens.  These sequences could be used to create new vaccines, such recombinant vaccines.  Thus far, a complete sequence has been determined for the malaria parasite Plasmodium falciparum. [3]

Edible Vaccines

 “Researchers have found that edible vaccines can safely and effectively trigger an immune response against the Escherichia coli bacterium and the Norwalk virus. Scientists are now attempting to genetically engineer potatoes, bananas, and tomatoes that, when eaten, will initiate an immune response against harmful intestinal bacteria and viruses.” [3]

Slow Release Vaccines


 A consortium of British private companies and a university facility is working on producing a slow release vaccine  The group is working on nanotechnology that will help count down on the amount of booster shots needed, and can increase the amount of time for which a vaccine is effective.  “They stabilize the vaccine by embedding it in tiny microspheres, made of calcium phosphate glass, which dissolve in the body fluids after injection…Proprietary nanoparticles within the microsphere ensure the vaccine release will be slower and the vaccine continues to be released into the body over a longer time period.”[9]  In addition, MNLpharma is working to develop an imino sugar adjuvant for the new vaccines. [9]

Stable Liquid Vaccines

“Cambridge Biostability's stable liquid vaccines can be stored safely without the need for a cold chain and do not require reconstitution or bactericides, which are major causes of vaccine safety and wastage problems.”[9]

New Disease Targets


Current information about new vaccines can be obtained from the Red Book:





Acquired Immune Deficiency Syndrome (AIDS) is caused by the Human Immunodeficiency Virus (HIV).  HIV attacks the CD4 cells of the immune system thereby making it difficult for AIDS patients to fight off infections.  Currently there are more than 30 candidate AIDS vaccines.  Small trials are being conducted in 19 countries on six continents. [35]  For more information about the search for an AIDS vaccine, the International AIDS Vaccine Initiative is a good resource:


HPV (Human papillomavirus)


There are over 100 different types of Human papillomavirus (HPV).  About 30 of these viruses are sexual transmitted and infect the genital area of men and women.  10 of these 30 can lead to development of genital warts and cancer of the cervix, vulva, vagina, anus, or penis.  There have been many clinical trials testing the effectiveness and safety of HPV vaccines.  For example, a phase 3 trial called FUTURE II reported in October 2005 that a vaccine called Gardasil was an effective and safe method for preventing HPV infection. 
The researchers found that 90% of new infections were prevented, and that the vaccine protected against the number 6, 11, 16 and 18 strains of virus.  Future research is needed to design vaccines against the other strains of virus, to look at which vaccines may be useful for women who are already infected with HPV, and to know how long the vaccines can provide protection.  Merck is waiting to hear from the FDA about its application to sell Gardasil, and GlaxoSmithKline is planning to apply to the FDA for approval of their Cervarix vaccine by the end of the year. [37] For more information about HPV vaccine research go to


Avian Flu

“Avian influenza is an infection caused by avian (bird) influenza (flu) viruses. These influenza viruses occur naturally among birds... There are many different subtypes of type A influenza viruses. These subtypes differ because of changes in certain proteins on the surface of the influenza A virus (hemagglutinin [HA] and neuraminidase [NA] proteins). There are 16 known HA subtypes and 9 known NA subtypes of influenza A viruses… ‘Human influenza virus’ usually refers to those subtypes that spread widely among humans… Of the known viruses that affect humans, H5N1 is of the most concern since H5N1 has caused the largest number of detected cases of severe disease and death in humans. In the current outbreaks in Asia and Europe more than half of those infected with the virus have died… There currently is no commercially available vaccine to protect humans against H5N1. Research studies to test a vaccine to protect humans against H5N1 virus began in April 2005, and a series of clinical trials is under way.” [38] For more information about the H5N1 vaccine development process, visit the CDC’s Avian influenza Vaccine website at

Dangers  of Vaccine Exemptions and Non-Compliance:

Vaccine Protection Beyond the Individual


            The ability for individuals to obtain exemption from vaccination is important for the protection of personal freedom and the protection of those with vaccine contraindications.  However, exemptions and non-compliance can put a population at risk for spreading disease.  There will always be a fraction of the population that is not immune, even if 100% of the population receives a vaccine because no vaccine is 100% effective.  Even if individual immunity is not perfect, a critical amount of people need to be immune in order to protect the whole population.  This phenomenon is called herd immunity, where “protection is achieved through obtaining a high enough level of immunity to a disease so as to make exposure to the organism that causes the disease extremely unlikely” [13].  The immunity necessary within a population depends on the disease and ranges from 83%-94%.  If too many people are exempted, than this percentage may not be reached.

            If vaccinations are ended prematurely, a large population can see the recurrence of a disease as the people who still contain the pathogen are able to renew the spread of infection.  Japan’s 1979 whooping cough epidemic serves as an example: “In 1974, Japan had a successful pertussis (whooping cough) vaccination program, with nearly 80% of Japanese children vaccinated. That year only 393 cases of pertussis were reported in the entire country, and there were no deaths from pertussis. But then rumors began to spread that pertussis vaccination was no longer needed and that the vaccine was not safe, and by 1976 only 10% of infants were getting vaccinated. In 1979 Japan suffered a major pertussis epidemic, with more than 13,000 cases of whooping cough and 41 deaths. In 1981 the government began vaccinating with acellular pertussis vaccine, and the number of pertussis cases dropped again.” [24] 

            In addition to preserving immunity, exemption also raises ethical problems within a society.  Those who receive vaccinations share in the risk of obtaining negative side effects, while those that are exempt can benefit from herd immunity without having to share these risks.  However, the price of exemption is not completely free.  Current research is exploring the consequences, and it had been found that exempted individuals have an increased risk of contracting measles, pertussis and tetanus. [14-16]

            Even when a country has eradicated a disease, recurrence can occur in this case because “the germs that cause the diseases still exist in other parts of the world.” [4]  When Nigeria took a hiatus from their polio vaccination program, the infection began to spread to other countries that were considered free from the disease. [7]  More recently, there is a Mumps outbreak in Iowa with at total number of “300 confirmed, probable, or suspected cases of mumps through April 3.” [33]  One theory of the source for the outbreak is that a college student may have brought back the pathogen from England, where mumps has been spreading over the previous two years. [34]

            In order to maintain herd immunity, it is important to regulate the amount of people obtaining exemptions.  In some states, gaining an exemption is actually easier than acquiring vaccinations for children.  For example, the state of California only requires parents to sign a prepared form. [11]  Under these circumstances, parents may be tempted to obtain exemption instead of going through the hassle of vaccination. 

            Exemptions can be limited by making the process more difficult.  Such provisions that make it harder to obtain exemption have been implemented in Arkansas and include a notarized statement, attendance at an educational session where the risks and benefits of vaccination are explained, and the signing of a statement acknowledging that a child can be removed from school during an outbreak. [11]  Perhaps a discussion specifically with a primary health care provider will further decrease the exemption rates, especially since they are a common source of vaccination. [10,11]

            Australia has used financial incentives to increase immunization rates.  In 1998, stipends were provided to practices with vaccination records of 90% children younger than 7.  The1999 Family Assistance Act awarded universal healthcare benefits and stipends to parents who either have proof of vaccination, or have prove from a healthcare provider that the risks and benefits of vaccination have been explained with the decision of exemption.

            Although the granting of exemption is an important practice in personal rights, it needs to be monitored in order to maintain communal immunity to life-threatening diseases.  It has been observed that the more difficult it is to obtain an exemption, the lower the number of people seeking exemption. [10, 11]  More efforts should be made to increase the difficulty for obtaining an exemption and to understand the affects of exemption and compulsory laws on the spread of disease. [10]


Barriers to Disease Eradication: Polio as an Example


            With over 200 years of vaccination, smallpox is the only disease that has been successfully eradicated.  There are many factors that make vaccination difficult.  The attempts to eradicate polio exemplify these barriers.  The Global Polio Eradication Initiative was started in 1988.  At this time in history, 125 countries reported cases of polio.  Although the number of cases and affected countries has decreased, eradication has not been possible. [4]  There are many barriers to finishing this initiative.  Besides the economics and logistics of getting the vaccine to everyone that needs it, there are political, educational, cultural, and motivational influences, as well as scientific limitations.

            Thus far $4 billion has been spent, and more will need to be spent until eradication is complete. [7].  What is the money being spent on?  Besides the purchasing of the vaccine, additional costs are needed for storage at cold temperature and vaccine delivery.  In addition, vaccination is not a “one shot” deal: “Here and elsewhere, eradicating polio means finding ways to get polio drops into the mouths of every child under 5 — over and over. Because it can take many doses to effectively immunize a child in parts of the world where the disease circulates intensely, eradication requires repeated sweeps.”[7]  In order to obtain immunity, it can possibly take up to 10 doses, and these doses need to be delivered months apart [7]. 

            Cultural requirements need to be worked around in order to provide enough workers to deliver the vaccinations.  According to Nigerian Muslim custom, only a woman can enter a household if the husband is not home.  In addition, mothers were the best at convincing other members of the community to accept the vaccines.  The combination of these cultural influences made mothers the best candidates for delivering vaccines.  However, many men prohibited their wives from leaving the household because they wanted the jobs for themselves. [7]  This catch 22 decreased the amount of the most effective workers. 

            Even if the vaccine reaches the door of every family, the family still needs to accept the vaccine.  Due to a lack of confidence in the program and other political set backs, the vaccine cannot always reach its target.  There is a general feeling of hostility towards the public health workers.  One woman Indian woman shouts “‘We have a lot of other problems, and you don't care about those…All you have is drops. My children get other diseases, and we don't get help.’"[7]  A skepticism has developed as public health workers drop by time and again to administer vaccinations without addressing day to day concerns.  This prolonged project wears on both the recipients and the workers.  The recipients are getting tired of hearing promises of eradication, and the public health workers get anxious as the numbers infected drop without the final goal of total eradication in site: “The closer a disease is to eradication, they say, the harder won the gains. Interest lags as the number of cases falls. Fatigue sets in among volunteers, donors and average people. “[7]

            Further set backs in the polio eradication program were caused by misconceptions about the vaccine.  For example, in 2003, the northern states of Nigeria stopped all vaccination due to rumors that the polio vaccine either contained the AIDS virus or was “part of a Western plot to sterilize Muslim girls. “ [7]  The vaccines were not reinstated for months until the safety of the vaccine could be assured.  In response to this lag, “18 once polio-free countries have had outbreaks traceable to Nigeria… In 2001, there were fewer than 500 confirmed cases of polio paralysis in the world. Last year (2005), the number jumped to more than 1,900…”[7].

            Limitations come from the vaccine itself.  The polio vaccine that started the eradication process is a modified live virus.  As explained in the safety section, these types of vaccines have the ability to mutate back into the wild type virus.  This occurs in about one in three million doses of the polio virus. [8]  These are the vaccines of choice because they are easy to administer and they provide a strong immunity by protecting against three strains of the virus.  However, the vaccine requires many injections as described above.  In order to address this issue, and to attempt to expedite the eradication process, other countries, such as India, are starting to use a faster acting vaccine that only vaccinates for the most common strain of the virus.  The use of this vaccine has not been successful as of now. [8]  Even after the infection is eradicated, vaccination is still required in order to sustain community-wide immunity.  A small number of people have an immune-system defect that allows them to produce and excrete virus without getting sick, thereby “creating a reservoir that could, theoretically, cause a new outbreak“ if the virus comes into contact with unvaccinated individuals [8].  This concerned was realized in the United States when five children from a Minnesotan Amish community contracted the polio virus from a carrier containing the immune system defect. [25]

            In addition to the scientific challenges, additional barriers to disease eradication have also been observed within the United States.  Just as the importance of polio vaccination was lost for a poor Indian woman in the economic and health disparities she faced daily, the importance of smallpox vaccination was lost in poor communities of Milwaukee in reaction to their health disparities: “In 1894, smallpox sparked a month of rioting in Milwaukee. The cause wasn't the disease itself, but the city's policy of seizing sick children in immigrant Polish and German neighborhoods and taking them to isolation hospitals, while leaving wealthy families alone, saying their larger houses and abundant servants would isolate them. With rioters flinging hot water and pepper in the eyes of the police and their horses, a vaccination drive collapsed and the epidemic spread.”[8]  When the city of Milwaukee ignored the differential treatment given to different classes, it risked the health of the city’s residents.

            Misinformation has also led to the inappropriate utilization of vaccination in the United States.  In Nigeria, the public linked the polio vaccine with AIDS, while the United States joined the global concern over a link between MMR vaccination and autism.[13, 21-23]  In this case, there was a decrease in MMR vaccination.  These misconceptions can lead to increases in exemptions and noncompliance, which can result in the revival of infectious disease.  On the other hand, increased demand for a vaccination has developed over misperceived risks and benefits of the flu vaccination during the 2004-2005 flu vaccine shortage [13]  During this shortage, there were cases of stolen vaccines and unreasonable price hikes in respond to the irrational demand.  These irrational demands for vaccine many prevent those who are within risk groups from obtaining vaccination.  Dr. May writes, “In many cases, the fears motivating irrational behavior are the result of media coverage that heighten a sense of risk” [13]  Frequently the media hyperbolizes the coverage of vaccination side effects in order to produce a more sensational story.  Although these views may help to sell papers, they leave the public with an incorrect perspective of the risks and benefits of vaccination. 

            The United States has become desensitized to the dangers of the infectious diseases due to their lack of first hand experience.  This lack of experience can result in a jaded attitude towards vaccination.  This is different from the Nigerian skepticism, which has formed from a decrease in polio prevalence in conjunction with an seemingly endless promise of eradication. [13]  The fear of vaccination side effects has overpowered the fear of contracting the actual disease: “The DTP vaccine results in adverse events such as convulsions or shock for 1 in 1,750; acute encephalopathy for 0-10.5 in 1,000,000; and the MMR vaccine results in encephalitis or severe allergic reaction for 1 in 1,000,000.  These risks are extremely low when compared to the adverse consequences from contracting vaccine-preventable disease (for pertussis, encephalitis for 1 in 20; death for 1 in 200; for measles, encephalitis for 1 in 2,000; death for 1 in 3,000” [13]  By better informing the public of the risks involved in not vaccinating in addition to the associated side effects, individuals will be able to make better decisions about their vaccination practices and their support of vaccination programs.




            The discovery of a vaccination does not necessarily result in the eradication of disease.  Public health efforts must be made to provide the public with accurate and balanced information about the benefits and risks of vaccination.  Continued research is necessary in order to uncover scientific barriers to eradication in addition to finding improved ways of producing effective and safe immune responses.  Finally, the overall health and quality of life of every individual must be considered in order to maintain trust in vaccination programs.  Less fortunate members of society can become skeptical of preventative measures when active efforts to improve current health and economic problems are absent.  Vaccination cannot be successful if it is viewed only as an effort to free society from infectious disease.  Vaccination needs to be part of an overall commitment to improve the health of the global community.



For More Information:


General Information:


National Immunization Program

            Sponsored by the Centers for Disease Control



National Vaccine Information Center


                        NVIC Store Tab has a list of suggested books and resources



            Links to Many Sites about Vaccination


List of Websites recommended by the World Health Organization for vaccine safety



For articles in the news about vaccination



Information about the immune system and a good general overview



Vaccine Information Statements: Distribution is required by law when giving a vaccine



New Vaccine Information:



Specific Questions:


CDC National Immunization Program information hotline

            1-800-232-2522 (English)

            1-800-232-0233 (Spanish)


Traveling Information



To Report Adverse Reactions:

Vaccine Adverse Event Reporting Service



International Information:


World Health Organization Sites




Global Polio Eradication Initiative



Global Alliance for Vaccines and Immunization



Global Immunizations and Vaccinations from the CDC





1)  State Government of Victoria Department of Human Services. November 2005

             “Vaccines Explained.”



2)  Mayo Clinic. August 18, 2005.

3)  National Institute of Allergy and Infectious Diseases. November 20, 2003.   

4)  Mayo Clinic. August 18, 2005.

5)  Centers for Disease Control.“Immunization Laws.” March 26, 2006.



6)  National Network for Immunization Information.


7)  Dugger, Celia W. and McNeil Jr., Donald G. “Rumor, Fear and Fatigue Hinder Final           Push to End Polio.” The New York Times. March 20, 2006.


8)  McNeil Jr., Donald G. “When a Disease Loses its most Potent Ally, Fear.” The New           York Times. March 26, 2006.


9) Roumeliotis, Gregory. “Researchers give 'one-off vaccines' a shot” March 20, 2006.     


10) Salmon DA, Teret SP, MacIntyre CR, Salisbury D, Burgess MA, Halsey NA. (2006)        Compulsory Vaccination and Conscientious or Philosophical Exemptions: past,    present and future. The Lancet. 367: 436-442.


11)  Salmon DA, Sapsin JW, Teret S, Jacobs RF, Thompson JW, Ryan K, Halsey N. (2005)  Public Health and the Politics of School Immunization Requirements.   American Journal of Public Health. 95(5): 778-783.


12)  Offit PA, Jew RK. (2003) Addressing Parents’ Concerns: Do Vaccines Contain    Harmful Preservatives, Adjuvants, Additives, or Residuals?  Pediatrics. 112:         1394-1397.


13) May T. (2005) Public Communication, Risk Perception, and the Viability of            Preventative Vaccination Against Communicable Diseases Bioethics. 19(4): 407-            421.


14) Salmon DA, Haber M, Gangarosa EJ, Phillips L, Smith NJ, and Chen RT (1999).   Health Consequences of Religious and Philosophical Exemptions From      Immunization Laws: Individual and Societal Risk of Measles. JAMA 282:47-53


15)  Feikin DR, Lezotte DC, Hamman RF, Salmon DA, Chen RT, and Hoffman RE      (2000). Individual and Community Risks of Measles and Pertussis Associated        With Personal Exemptions to Immunization. JAMA 284:3145-3150.


16)  Fair E, Murphy TV, Golaz A, Wharton M. (2002) Philosophic Objection to           Vaccination as a Risk for Tetanus Among Children Younger Than 15 Years          Pediatrics 109(1): e2.


17)  Eldred BE, Dean AJ, McGuire TM, Nash AL. (2006) Vaccine components and    constituents: responding to consumer concerns. The Medical Journal of Australia.           184 (4): 170-175


18)  Murch SH, Anthony A, Casson DH, et al. (2004) Retraction of an interpretation.   Lancet. 363: 750.


19)  Parker SK, Schwartz B, Todd J, Pickering LK. (2004) Thimerosal-containing       vaccines and autistic spectrum disorder: a critical review of published original   data. Pediatrics 114: 793-804.


20)  Centers for Disease Control. July 2005. Guidelines for Vaccinating Pregnant Women   


21)  "Deadly Immunity" Kennedy Jr., Robert F. Rolling Stone. June 20, 2005.

22)  Kennedy Jr., Robert F. "Autism, Mercury, and Politics" The Boston Globe. July 1,             2005.

23)  Ropeik, David. "Commentary: Connection Between Vaccines and Autism." National          Public Radio, Morning Edition, 6/11/04,


24)  Centers for Disease Control. ”Why Immunize?” July 11, 2003.


25)  Harris, Gardiner. “5 Cases of Polio in Amish Group Raise New Fears.” The           NewYork Times. November 8, 2005.


26) Smithsonian National Museum of American History. “What ever happened to Polio?”

            April 20, 2006.


27) Harris, Fraser. “Edward Jenner and Vaccination.” April 20, 2006.               Vaccination/Chap1.html


28)  “History of Immunology.” April 20, 2006.    


29) Centers for Disease Control. “What you need to know about Vaccine Information   Statements.” April 20, 2006.   


30) National Vaccine Information Center. “The Vaccine Injury Compensation Program.”           April 20, 2006.


31) National Vaccine Information Center. “Federal Bills and State Bills” April 20, 2006.           


32) Stuebing, Beth “Reportable Infectious Diseases in the United States and Specifically            Ohio.” April 22, 2006.


33) Hittt, Miranda. “Mumps Epidemic Hits Iowa : Iowa Notes 300 Confirmed or          Probable Cases of Mumps” WebMD Medical News. April 4, 2006



34) Welte, Melanie S. “Mumps epidemic spreading across Iowa

            Star Tribune. March 31, 2006.


35) International AIDS Vaccine Initiative “Progress toward an AIDS vaccine since 2000”         April 21, 2006.


36) Cancer Research UK. “Cervical Cancer Vaccine” March 20, 2006.



37)  Rubin, Rita.  “HPV vaccines show progress, but need for booster in question” USA           Today. April 4, 2006.          vaccines_x.htm


38) Centers for Disease Control “Key Facts About Avian Influenza (Bird Flu) and Avian           Influenza A (H5N1) Virus” February 7, 2006.     info/facts.htm