Toolkit for Physicians

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• Seasonal influenza is an infectious respiratory disease caused by two types of influenza viruses A and B.
• It circulates every winter in the North Hemisphere affecting 5-15% of the population every year.
• Influenza viruses can cause from mild to severe illness and occasionally lead to premature death.
• By understanding how you can prevent influenza, you can contribute to reducing the number of cases, hospitalizations and premature deaths.
• Influenza is preventable.

Seasonal influenza spreads from person to person:

  • by direct contact through droplets from an infected person coughing or sneezing.

  • by indirect contact through fomites, i.e. when droplets or secretions from nose or throat settle on surface areas such as hands or objects (like keyboards or door handles). The virus can survive in certain areas for a few hours depending on the conditions and can infect others through the transfer from the hands to mucous membranes.


fever | sore throat | rhinorrhea | dry cough | fatigue | headache | myalgias

Usually influenza symptoms have acute onset and are more severe than similar symptoms of common colds. Fever is usually high (>38.5°C). However, as mild or asymptomatic infections can occur (up to 30%), you might inadvertently infect your patients or your colleagues.

Vaccination annually against seasonal influenza is the most effective way of prevention and is the most tangible and measurable means to control the transmission of influenza viruses between staff and patients, especially those at higher risk of developing influenza related complications.
• Risk groups comprise elderly people and those with chronic medical conditions including:


  • asthma and other respiratory diseases
  • diabetes and other endocrine diseases
  • cardiovascular diseases
  • kidney diseases
  • liver diseases
  • metabolic diseases
  • neurological diseases, especially if they affect respiration physiology
  • immunodepression

• Complications can occur in anyone but are far more common for patients in risk groups.
• Common influenza complications include pneumonia, otitis media, sinusitis, dehydration and worsening of chronic medical conditions, such as congestive heart failure, asthma, or diabetes. In elderly people, influenza can cause and/or worsen cardiovascular and cerebrovascular conditions (heart attacks and strokes).
• Complications may lead to hospitalization (about 5%) and premature death, especially in elderly people and individuals with underlying medical conditions1.

Immunization against seasonal influenza is recommended for all health and social care staff directly involved in patient care working in:

  • medical practices
  • hospitals
  • health centres
  • nursing homes for the elderly

This includes:

  • medical staff
  • nurses
  • ambulance and pre-hospital personnel
  • other care staff
  • other health professionals
  • pharmacists
  • administrative staff with patient contact

• Compared to adults working in non-health care settings, healthcare workers are at signicantly higher risk of influenza.3
• About 30% of cases are asymptomatic, however still able to transmit the virus. Infected healthy adults are known to be contagious one day before and up to 5-7 days after symptom onset. Children and immune compromised patients can transmit the influenza virus for much longer.

• Higher vaccination coverage against influenza among healthcare professionals can reduce influenza-related illness, and even deaths in a healthcare facility.
• This is particularly relevant in settings such as nursing homes where patients are at higher risk for influenza-related complications and are known to have a lower immune response to vaccines.3
• The reduction is equivalent to preventing five deaths, two admissions to hospital with influenza-like illness, seven general practitioner consultations for influenza-like illness and nine cases of influenza-like illness per 100 residents.4


• Influenza seasons are unpredictable and can begin as early as October and last until May.
• Vaccination should ideally be done in mid-autumn each year.
• About two weeks are needed for antibody production.
• One dose of influenza vaccine is needed intramuscularly.


Influenza viruses change each year (antigenic drift) which is is why a new influenza vaccine has to be given. The influenza vaccine is formulated to keep up with the influenza virus subtypes as they change.
Annual influenza vaccination amongst healthcare professionals is important to protect yourself, your colleagues and especially your at-risk patients. Influenza may be particularly serious for patients at higher risk of developing influenza-related complications.

Common symptoms

· Fever, sore throat, runny nose, dry cough, fatigue, headache, and muscle ache
· Croup and bronchiolitis common in children

Common Complications

• Pneumonia
• Otitis media
• Sinusitis
• Myocarditis
• Pericarditis
• Worsening of chronic medical condition present before inuenza illness (e.g. congestive heart failure)

Rare complications

• Sepsis
• Encephalopathy
• Death

Common adverse events (<1 in 100 doses)

• Soreness/pain, redness and/or swelling around the injection site
• Short-term fever (1–2 days), may be high (>39.0 °C) in children
• Short-term fatigue (1–2 days)
• Myalgia (1–2 days)
• Adverse reactions are more common in children not previously exposed to the vaccine or virus than in adults

Rare and Very rare adverse events (<1 in a 10,000 doses)

• Urticaria
• Anaphylaxis
• Paresthesias
• Guillain-Barré syndrome <1 in 1,000,000 doses diosed)

1. Comparison of clinical features and outcomes of medically attended influenza A and inuenza B in a defined population over four seasons: 2004-2005 through 2007-2008. Irving et al., Influenza and Other Respiratory Viruses. 2012 Jan;6(1):37-43. doi: 10.1111/j.1750-2659.2011.00263.x. Epub 2011 May 25.

2. H1N1 hemagglutinin-inhibition seroprevalence in Emergency Department Health Care workers after the first wave of the 2009 influenza pandemic. Pediatr Emerg Care 2011 Sep;27(9):804-7. doi: 10.1097/PEC.0b013e31822c125e.

3. Incidence of Influenza in healthy adults and healthcare workers: a systematic review and meta-analysis - PLoS One 2011; 6 (10):e26239

4. Effectiveness of an influenza vaccine programme for care home staff to prevent death, morbidity and health service use among residents: cluster randomised controlled trial - BMJ 2006; 333:1241

Note: Text in this fact sheet is derived and adapted from the ECDC Communication Toolkit for Healthcare workers and People in high risk groups.
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Hepatitis B

  • causes acute liver infection and may lead to fulminant liver failure and liver necrosis.
  • is the most common infection acquired in a hospital, either through needle sticks or through contaminated instruments.
  • may lead to lifelong infection by the hepatitis B virus, which, if left untreated, may lead to liver cancer.

    2 Billion people are affected by hepatitis B
    which leads to an estimated 780,000 deaths annually (WHO, 2014)

Hepatitis B is still very common in the European Union countries, reported at a rate of 3.45/100.000 population (ECDC-2013) with the majority of cases referring to the age group 25-34 year olds (33.2%). Surveillance at the European level is undergoing revision in order to record acute, as well as chronic infections.


Incubation period: 30-180 days (usually around 75 -90 days)

During the acute phase, manifestations range from subclinical or anicteric hepatitis to icteric hepatitis or fulminant hepatitis. The symptoms and clinical signs can last a few weeks up to six months and they include jaundice, dark urine, malaise, fatigue, anorexia, nausea, vomiting and abdominal pain, arthralgias.


Currently no specic treatment exists to cure acute hepatitis B infection. Usually supportive therapy is needed. Liver transplant is the only available treatment in the cases of liver necrosis. New antiviral agents are used for chronic hepatitis B infections.

  • Healthcare workers as hepatitis B is an occupational hazard due to clinical work and contact with patients.
  • Family members and household contacts of chronic carriers of hepatitis B.
  • Other high risk groups include Men who have Sex with Men (MSM), IV drug users (IVDUs), patients in dialysis, persons employed in prisons, psychiatric or long-term care facilities for persons with special needs.
  • Travelers to countries endemic for hepatitis B (e.g. South-East Asia, Sub-Saharan Africa, the Amazon Basin, parts of the Middle East, the central Asian Republics and some parts of Eastern Europe) .
  • Any adult who has no immunity, is recommended to receive hepatitis B vaccination.
  • Persons with hypersensitivity to yeast or any vaccine component.
  • Persons who experienced severe allergic reaction (e.g. anaphylaxis) with rst dose.
  • Not contraindicated in pregnant women, persons with multiple sclerosis, other neurodegenerative disease, or autoimmune disorders.


    The hepatitis B vaccine is a recombinant DNA vaccine and should be administered intramuscularly, in a 3-dose schedule (0, 1, 6 months).

    One to two months after the 3 doses, it is recommended for HCWs to test for protective antibodies:
  • Anti-HBs >10mIU/mL: full immunity
  • Anti-HBs < 10mIU/mL: need to repeat full 3-dose series and test again for antibody response

  • One to two months after second vaccination schedule is completed:
  • 2nd Anti-HBs >10mIU/mL: full immunity
  • 2nd Anti-HBs < 10mIU/mL: non responder.

  • Antibody protection lasts >20 years, probably more, therefore no booster doses are required.
    After an occupational exposure, such as a needle stick:
  • HCWs who are vaccinated should test for protective antibody titers. If anti-HBs>10mIU/mL, no action is required.
  • HCWs who are not vaccinated, or have low titers should receive HepB Immune Globulin and the rst (or a booster dose) of Hepatitis B vaccine as soon as possible (within 24 hours).

  • Attention: HepB Immune Globulin should not be administered in the same site nor with the same syringe as the HepB vaccine.

is 50% effective in preventing hepatitis B


are 75-80% effective in preventing hepatitis B


are 95% effective in preventing hepatitis B

• Chronic hepatitis B (between 1/10 and 1/20 adult patients)
- Cirrhosis (between 1/3 and 1/6 patients with chronic hepatitis B)
- Hepatocellular carcinoma (up to 1/4 (25%) patients with chronic hepatitis B, if left untreated)
• Fulminant hepatitis with acute hepatic necrosis (1-6/1,000 patients with acute hepatitis B)
- Death (up to 2/3 (75%) of patients with fulminant hepatitis)

The 3-dose vaccine schedule protects up to 95% from Hepatitis B.
Possible side effects include:
Mild (between 1/10-1/1,000 doses, represent the vast majority of reported side effected)
• Redness, swelling or pain at the site of the injection (usually 1/ 30 doses, but maybe up to 1/3 doses)
• Low grade fever (1-6/100 doses)
• Headache
Moderate (rare, between 1/1,000- 1/10,000 doses)
• Fatigue
Severe (very rare, between 1/10,000- 1/1,000,000 vaccinated)
• Anaphylaxis (1/600,000 doses)

1. BZgA, Germany:

2. ECDC- Communication Toolkit on Immunisation:

3. WHO Europe: Vaccines and immunization,

4. NIH, USA:

5. Immunization Action Coalition,

6. National Centre for Immunisation Research and Surveillance,

Disclaimer: The consortium partners declare no relevant conict of interest with direct bearing on the subject matter of the HproImmune project. This pertains to relationships with pharmaceutical companies, biomedical device manufacturers and other companies with relation to vaccines.

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  • measles caused hundreds of thousands of cases and deaths, mostly in children, before systematic vaccinations started in the 60s,
  • measles is one of the most contagious diseases and quite effec- tively transmits from person to person, when not immune,
  • adults need proof of immunity against measles, mumps or rubella or proof of receiving 2 doses of MMR vaccine,
  • all women of child bearing age should know their immunity status against rubella (German Measles),
  • in the event of a mumps outbreak a 3rd dose of MMR vaccine may assist in controlling the transmission,

Sub-optimal coverage with the MMR vaccine has led to pockets of susceptible populations in the EU countries and the reporting of outbreaks of all three diseases in the last years:

Before universal measles vaccination, the disease was endemic in Europe and caused seasonal outbreaks every 2-5 years. The introduction of the measles vaccine in the 60’s led to >99% decrease in the number of cases until about 2001. Since then a signi cant number of measles cases is reported in EU countries in late winter and early spring, peaking in 2011 (>30,000).

Mumps still occurs frequently in the EU countries, where almost 950,000 cases of mumps were noti ed between 2001-2008.

Incidence of rubella in the EU countries peaked in 2008, but cases occur annually. In 2013-14 a large outbreak is reported mainly in Poland.


Incubation period: 10-12 days (rash appears approximately 14 days after infection)


Measles is caused by an RNA virus and usually starts with cough, runny nose, conjunctivitis, and fever. An enanthem (Köplik’s spots) appears on the buccal mucosa 1-2 days before the rash. An erythematous maculopapular rash appears 2-4 days after the prodromal syndrome and spreads from the head to the rest of the body. The rash tends to coalesce and blanches on pressure at the beginning.
Mortality is more common in young infants, in malnourished children, and among immune-compromised patients. Adults are more likely to suffer complications.


There is no speci c treatment for measles; supportive care is needed.


Incubation period: 12-25 days (usually 16-18 days)


Mumps is caused by an RNA virus. It presents usually with swol- len salivary glands (most frequently the parotids), fever, head- ache, myalgia and anorexia.
Up to 20-30% of patients are asymptomatic, while <10% of patients manifest symptoms of viral meningitis.


There is no speci c treatment for mumps; supportive care is needed.


Incubation period: 12-13 days (approximately 14 days)


Rubella is caused by an RNA virus, manifesting with a maculo- papular rash, lymphadenopathy (frequently of the occipital lymphnodes), transient arthritis (mostly in women), upper respiratory infection and sometimes fever. Up to 20- 50% of cases may be asymptomatic.
Rubella has serious consequences in pregnant women causing during the rst trimester fetal death or severe congenital defects known as congenital rubella syndrome (CRS).


There is no speci c treatment for rubella; supportive care is needed.

• Health care workers (HCWs) before starting clinical work, as well as supporting services and volunteers before contact with patients.

• Any susceptible HCW exposed to measles, mumps or rubella can receive the MMR vaccine within 72hrs of the exposure in order to prevent or modify the disease in some cases.

  • MMR is given subcutaneously or intramuscu- larly in a 2- dose schedule at least 4 weeks apart.
  • If you have received at least one dose of the vaccine in the past (on or after 12 months of age), one more dose can be administered at any time.
  • MMR vaccine contains live attenuated measles, mumps and rubella viruses.

C: history of severe allergic reaction to rst dose of the vaccine C: history of anaphylactic reaction to neomycin;
C: history of allergic reaction
C: altered immunity or immunode ciency (e.g. leukemia, lymphoma, HIV, hereditary immunide ciencies etc)
C: pregnancy

Precautions if:
P: history of thrombocytopenia or thrombocytopenic purpura
P: recently(<11months) receipt of antibody-containing blood product


  • About 1 in 3 patients develops a complication
  • Adults are at higher risk for complications
  • Otitis media, 1 in 15 cases
  • Secondary pneumonia or severe bronchitis, 1 in 15 cases
  • Diarrhea, 1 in 12 cases
  • Seizures, 1 in 140 -170 cases
  • Myelitis with transient paralysis
  • Encephalitis, 1/1,000-2,000 cases leading frequently to neurologic sequelae
  • Subacute Sclerosing Panencephalitis (SSPE), 7-10 years after the disease (1/100,000 cases)
  • Death, up to 1-3 in 1,000 infants, especially if immune-compromised or malnourished.


  • Adults are at higher risk for complications
  • Orchitis, 1 in 10-30 men after puberty
  • Oophoritis, 1 in 100 women after puberty
  • Mastitis
  • Arthritis
  • Myocarditis
  • Pancreatitis, up to 1 in 30 case
  • Thyroiditis
  • Glomerulonephritis
  • Transverse myelitis
  • Encephalitis or meningitis up to 1/300-1/6,000 cases, cerebellar ataxia
  • Neuritis of auditory nerve resulting usually to unilateral sensorineural hearing loss (1/20,000 cases)


  • Arthralgia and arthritis up to 1 in 15 women
  • Febrile seizures
  • Otitis media
  • Vomiting and diarrhea
  • Pneumonia
  • Thrombocytopenia (1 in 3,000 cases)
  • Encephalitis (1 in 6,000 cases), with mortality up to 50%
  • Infection during the 1st trimester of pregnancy may lead up to 1 in 5 to the development of Congenital Rubella Syndrome (CRS) with congenital cataracts, deafness and heart disease. In addition, rubella may cause fetal death,spontaneous abortion, and premature labor.


on or after 12 months of age

  • 95% protection against measles

  • 80% protection against mumps

  • 90% protection against rubella, probably long-lasting.


administered 4-6 weeks apart

  • 99.7% protection against measles; however up to 5% of immunized persons may lose immunity over time.

  • 80-95% protection against mumps; however there are indications of waning immunity.


(most frequent)
  • Mild rash (1 in 25 doses)


  • Temporary arthralgias (1 in 5 doses) or arthritis (1 in 10 doses mostly in small peripheral joints of teenage and adult women 7-21 days after immunization)
  • Febrile seizures (1/3,000 doses in infants)
  • Idiopathic Thrombocytopenic Purpura (ITP) within 6 weeks of immunization <1 in 24,000 doses.


(rare & very rare)
  • Pruritus
  • Aseptic meningitis within 3-5 wks
  • Transient paresthesia and pain in extremities
  • Febrile seizures for children 12-23 mos
  • Parotitis
  • Orchitis
  • Severe allergic reaction: this may occur with any of the vaccines (< 1/1,000,000 doses)

1. BZgA, Germany:

2. ECDC- Communication Toolkit on Immunisation:

3. WHO Europe: Vaccines and immunization,

4. NIH, USA:

5. Immunization Action Coalition,

6. National Centre for Immunisation Research and Surveillance,

Disclaimer: The consortium partners declare no relevant conict of interest with direct bearing on the subject matter of the HproImmune project. This pertains to relationships with pharmaceutical companies, biomedical device manufacturers and other companies with relation to vaccines.

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  • Td is a toxoid vaccine, i.e. contains inactivated tetanus and diphtheria toxin.
    Lower case letters d and p mean smaller quantity of diphtheria and pertussis antigen contained in the adult vaccine as compared with the vaccine used for children <7years old. In addition ap means acelullar, i.e. not whole cell, as the pertussis vaccines used in the past.
  • Every adult needs a booster dose for tetanus every 10 years and once in your adult life you need to receive the Tdap vaccine against tetanus, diphtheria and pertussis, even if you were vaccinated as a child.
  • Every time you receive or administer the tetanus vaccine it is advised to use the Td vaccine, in order to boost against diphtheria, too.
  • Cases of respiratory diphtheria have re-emerged in the EU countries, due to decreasing vaccination coverage.
  • Pertussis immunity (either due to natural disease or after immunization) wanes over time.

Tetanus is rare in the European Union countries, although about 130 cases are reported annually, according to the ECDC (2013).

Diphtheria used to kill thousands of people before the vaccine was systematically used. The most recent epidemic of diphtheria in Europe was recorded in the former Soviet republics in the mid 90’s, although some countries remain endemic for diphtheria (e.g. Caribbean and Latin America).

Pertussis remains a signi cant public health problem in Europe as >10,000 cases are reported annually in the EU, while currently (2013) signi cant pertussis outbreaks are reported in the USA.


SYMPTOMS Incubation period: 3-21 days

Clostridium tetani usually enters wounds through the contamination with soil or other material, as its spores are found everywhere, especially in rural areas. Anaerobic conditions in a necrotic wound lead to their vegetation and the production of tetanospasmin the toxin that causes the symptoms of tetanus. The disease presents with a descending pattern: trismus (spasm of the jaw muscles), followed by neck stiffness, dysphagia and stiffness of the abdominal muscles. This may progress to severe generalized muscle spasms due to any external stimulus, which last for several minutes. Other symptoms include fever, sweating, high blood pressure and tachycardia or arrhythmias. Spasms continue for 3-4 weeks and recovery is slow. Tetanus is not transmitted from person to person.


There is no speci c treatment for tetanus, but a booster Td or Tdap vaccine dose and passive immunization with human Tetanus Immune Globulin (TIG) are used for tetanus prophylaxis.


SYMPTOMS Incubation period: usually 2-7 days (but up to 10 days)

Diphtheria is caused by toxigenic strains of Corynebacterium diphtheriae and may present in various forms, based on the site of the disease, although most serious when it affects the respiratory tract. The disease starts gradually with cold symptoms and mild cases resemble streptococcal pharyngitis. In severe cases the diphtheria exotoxin leads to the formation of grayish pseudo-membranes within 2-3 days in the pharynx and larynx (pharyngeal and tonsillar diphtheria), which may cause airway obstruction. Diphtheria is transmitted from person to person via droplets during close contact. Fully vaccinated persons may be carriers of C. diphtheria in their pharynx.


Prompt administration of equine diphtheria antitoxin (DAT) is needed to prevent life-threatening complications, as it neutralizes unbound toxin. Macrolides and penicillin are used to limit toxin production and C. diphtheriae, and prevent the transmission to close contacts.

PERTUSSIS (whooping cough)

SYMPTOMS Incubation period: usually 7-10 days (but up to 6 weeks)

The disease usually starts as a mild upper respiratory infection (catarrhal stage), deteriorating to severe cough attacks about one week later, which persist for about 6-10 weeks or even longer (paroxysmal stage). Coughing attacks are characteristic (whoop) and young infants may present apnea and bradycardia attacks. They are more frequent at night (up to 15 per day) and decrease gradually over 2-3 weeks (convalescent stage). Pertussis is transmitted from person to person via droplets.


Macrolides (erythromycin, clarithromycin, azithromycin), if given early, may prevent severe disease and later in the course, help prevent the spread of Bordetella pertussis to close contacts. Protection from pertussis lasts for 5–8 years after natural infection, as well as after vaccination.

  • All healthcare workers and all adults need to have received 4 -5 doses of DTaP vaccine as children. Alternatively, if adults cannot prove vaccination history, they can be immunized with one dose Tdap (dose 0), followed by Td vaccine after 1mo (4-6wks) and a second dose after 6-12 mos. After that booster doses of Td are recommended every 10 years

  • All healthcare workers, who come in contact with patients, and all adults who come in contact with infants <12months old, are advised to receive one dose of Tdap in their lifetime.

  • Any patient who has developed a severe allergic reaction after receiving a dose of Td or Tdap vaccine should not receive any more doses.

Immunization history
Minor clean wound
Open deeper wounds contaminated with soil, saliva, dirt or feces, or wounds with necrotic tissue, burns or frostbites
Full primary DTaP series (4 or 5 doses) and/or last Td booster <5 years ago
clean and dress wound appropriately, no booster needed
Td or Tdap only
Full primary DTaP series (4 or 5), last Td booster >5-10 years ago
Td or Tdap only
Td or Tdap and TIG*
Unknown history of immunization or primary series <3 doses DTaP
Td or Tdap only
Td or Tdap and TIG*

clinical ef cacy against tetanus

clinical ef cacy against diphtheria
of Tdap

recipients produce antibodies against pertussis
*TIG: Tetanus Immune Globulin


  • Painful spasms in response to stimuli
  • Apnea and laryngospasm, may warrant mechanical ventilation
  • Seizures
  • Bone fractures due to severe muscle spasms
  • Aspiration pneumonia
  • Hypertension and arrhythmias
  • Pulmonary embolism
  • Death up to 1 in 10 cases


  • Upper airway obstruction and acute respiratory failure
  • Dysphagia and dysphonia
  • Myocarditis
  • Arrhythmias and heart block
  • Acute tubular necrosis
  • Delayed peripheral nerve dysfunction
  • Mortality up to 1 in 10 cases, which goes up to 1 in 5 in children < 5years or adults > 40 years


  • Up to 1 in 2 infants with pertussis may need hospitalization
  • Pneumonia (up to 1 in 20 cases, going up to 1/ 8-9 in infants)
  • Seizures (1 in 50 cases)
  • Dehydration and anorexia
  • Pneumothorax
  • Epistaxis
  • Subdural hematoma
  • Hernia
  • Rib fractures
  • Encephalitis (up to 1 in 200- 400 cases)
  • Apnea, especially infants <7 months old
  • Mortality about 1 in a 100 infants <2 months, dropping to 1 in 200 in infants 2-11 months

• 97% of vaccinated are protected against diphtheria practically 100% of vaccinated are protected against tetanus
• 84-89% of vaccinated are protected against pertussis. After one Tdap dose 92% of adults produce antibodies.

Antibody protection wanes without booster doses (after 5-8 years for pertussis and after 10 years for tetanus).


(most frequent, and 8/10 of reported side effects)
  • Redness and swelling at the site of the injection
  • Local pain at the site of the injection
  • Mild fever (up to 38°C)
  • Headache
  • Malaise
  • Mild nausea, vomiting or diarrhea


  • High fever (>39°C)
  • Significant headache (1/300 adults)
  • Local swelling at the site of injection that interfered with activities
  • Nausea, vomiting, diarrhea that interfered with activities (up to 1/100 adults who receive the vaccine)


(rare & very rare)
  • Severe pain and bleeding at the site of the injection
  • Severe allergic reaction: this may occur with any of the vaccines about 1 in 1,000,000 doses

1. BZgA, Germany:

2. ECDC- Communication Toolkit on Immunisation:

3. WHO Europe: Vaccines and immunization,

4. NIH, USA:

5. Immunization Action Coalition,

6. National Centre for Immunisation Research and Surveillance,

Disclaimer: The consortium partners declare no relevant conict of interest with direct bearing on the subject matter of the HproImmune project. This pertains to relationships with pharmaceutical companies, biomedical device manufacturers and other companies with relation to vaccines.

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Varicella (chickenpox) is still very common in the European Union countries, and is a seasonal disease with incidence peaks during winter and spring. Outbreaks occur usually in pre-school and school children.
Periodic larger outbreaks may occur with an inter-epidemic cycle of 2 to 5 years.
Vaccination recommendations are not harmonized among member states.
Surveillance systems for varicella are also not harmonized and not all countries collect data on varicella cases.

Incubation period: 9-21 days (usually 14 days)

Varicella begins with mild upper airway symptoms, which can be followed by fever and a pruritic rash emerging initially on the face and chest, then spreading to the extremities. The rash can be found also on the scalp, it’s initially maculopapular and develops rapidly to vesicles and then to pustules. All phases of the rash can be seen at the same time. An enanthem may appear in the buccal or genital mucosa. Patients also usually complain of malaise, loss of appetite and headache.


Varicella in children is usually self-limiting and no treatment is needed besides relief of pruritus and prevention of secondary skin infections. Antivirals such as acyclovir and valacyclovir are usually recommended for adults who are at higher risk for compli- cations or for immune compromised persons. Varicella-Zoster immune globulin (or IV gamma globulin) is recommended for immunecompromised patients or for pregnant women and their neonates within 72 hours after exposure to varicella.

  • Any healthcare worker who has no immunity (de nitive history of the natural disease or history of two doses of the vaccine) is recommended to receive the varicella vaccine, due to increased risk for complications
  • Healthcare workers in particular, who come in contact with neonates or immunocompromised patients, should be vaccinated against varicella
  • A vaccine against herpes zoster has also been licensed in many countries and is recommended in one dose usually for persons ≥ 60-65 years of age regardless of their immunity to varicella.

  • As a live vaccine it is usually contraindicated in persons with congenital or acquired immune de ciencies.
  • May be considered in clinically stable HIV-infected children or adults with CD4+ T-cell levels ≥15%, including those receiving highly active antiretroviral therapy (HAART).
  • The tetravalent vaccine with MMR has not been studied in immunocompromised patients.

  • Adults without proven immunity to varicella are at higher risk for complications from the natural disease.
  • Varicella is an airborne highly contagious disease.
  • The varicella vaccine contains live attenuated virus and can also be found as a tetravalent vaccine with Measles, Mumps and Rubella (MMRV).
  • Varicella can be particularly severe and life threatening to:
    • immunocompromised patients
    • pregnant women around delivery time and their neonates, who cannot be protected by maternal antibodies.

    Health care workers (HCWs) before starting clinical work, esp. with immunecompromised patients such as in oncology, neonatology or intensive care units.
    Any HWC who has been exposed to varicella without immunity (de nitive history of the natural disease or history of two doses of the vaccine).

  • If the vaccine is administered within 3-5 days of exposure to varicella, patients may develop only mild symptoms.
  • Pregnant HCWs exposed to varicella should receive Varicella Zoster immune globulin or IVIG.

  • The varicella vaccine contains live attenuated varicella zoster virus and should be given in two doses 4 -8 weeks apart, subcutaneously or intramuscularly.

is 70-90% effective in preventing varicella


are almost 98% effective. Antibodies remain for at least 10-20 years.

  • Dehydration
  • Skin and soft tissue bacterial infections, usually with Group A streptococcus (GAS). Invasive GAS can lead to toxic shock syndrome, fasciitis and sepsis
  • Pneumonia/pneumonitis (1/400 adults, higher in pregnant women and immunecom- promised)
  • Haemorrhagic varicella
  • CNS: encephalitis, meningitis, cerebellar ataxia (1/4,000 children)
  • Hepatitis, mainly in immunocompromised individuals
  • Arthritis
  • Osteomyelitis
  • Congenital varicella syndrome: if infection in the 1st or early 2nd trimester, then in 4/1,000 - 2/100 pregnancies
  • Herpes zoster (up to 1-2/10 persons after primary varicella infection can develop shingles in their lifetime)

Two doses of the vaccine are 98% effective against varicella. Possible side effects include:


(most frequent >1/10 doses)
  • Redness at the site of the injection
  • Local pain at the injection site (2-3/10)
  • Mild fever (up to 38°C)
  • Headache
  • Fatigue
  • Mild nausea, vomiting or diarrhea


(rare >1/1,000 doses)
  • Mild rash that looks like chickenpox (up to 3/100 doses)


(very rare 1/10,000- 1/1,000,000 doses)
  • Febrile seizures, up to 3-4/10,000 vaccinated children 12-23 months old. Not reported in older children and adults.
  • Herpes zoster from the vaccine strain

1. BZgA, Germany:

2. ECDC- Communication Toolkit on Immunisation:

3. WHO Europe: Vaccines and immunization,

4. NIH, USA:

5. Immunization Action Coalition,

6. National Centre for Immunisation Research and Surveillance,

Disclaimer: The consortium partners declare no relevant conict of interest with direct bearing on the subject matter of the HproImmune project. This pertains to relationships with pharmaceutical companies, biomedical device manufacturers and other companies with relation to vaccines.

Myths and Misconceptions Vaccines Recommended for Health Professionals
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It is true that some diseases are nowadays very rare or even eliminated from the European Union countries, e.g. poliomyelitis or diphtheria, due to national immunization programmes1-8.

However, most of these vaccine preventable diseases (VPDs) still exist or are even widespread in other parts of the world. As our world is currently more connected than ever in human history due to population movements (travelling and migration ows), “disease somewhere is disease everywhere”. Vaccine preventable diseases have many times been imported in a country through returning travelers.

At the same time pockets of unvaccinated populations are common in many EU countries and many outbreaks of VPDs such as measles, mumps, rubella and pertussis are reported in communities with anti-vaccination beliefs or in hard-to-reach populations (e.g. migrants and Roma) and spreading to many countries due to decreasing vaccination coverage9-10.

Whenever the vaccination coverage levels dropped, outbreaks have occurred. This is the reason that measles outbreaks have been continuously occurring through EU countries in the last years: UK, France, Bulgaria, Italy, Netherlands, and Germany. A significant rubella outbreak with thousands of cases has been reported in Poland in 2012-1411.

Due to the long lasting civil war in Syria and the subsequent drop of the vaccination coverage, an outbreak of poliomyelitis rose in the country towards the end of 2013, which threatens the polio-free status of European countries through the movement of refugee populations12.

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Studies have repeatedly demonstrated that the recommended vaccines are no more likely to cause adverse effects when given in combination than when they are administered separately. At the same time, when administering polyvalent or combination vaccines, studies have shown that there is no difference in the production of adequate and speci¬ c antibodies against all components, as compared with separate administration. In addition, less injections and visits are needed for achieving full protection.

New techniques in the production of vaccines have allowed the reduction of the number of antigens included in the vaccines used today. During the 1960s a baby received >3,000 antigens in the vaccines that were used at the time. In comparison the currently recommended vaccines for an infant contain only 50-70 different antigens4-8, 13.

It is important to remember that getting vaccinated does not only protect oneself but also contributes to building “herd immunity” (diagramme 1-3) which protects even persons who cannot be vaccinated or who do not respond to vaccines (see Figures 1-3)13. These persons remain susceptible to disease, and their only hope of protection is that people around them have been successfully vaccinated.

Deciding to receive a vaccine is actually a decision with important rami cations for the society as a whole14.

It is also important to remember that the so called childhood vaccine preventable diseases such as measles, rubella, mumps and varicella (chickenpox), are more severe for adults who are more at risk for complications, while most of them (with the exception of varicella) have no speci c treatment available.

In some cases it is true that immunity after natural infection lasts longer. However, the risks from suffering one of the vaccine preventable diseases are far more than the risks of immunization with any of the existing licensed vaccines.

This is especially true as the susceptible population has shifted to a large extent to adults and the percent of immune compromised persons in our population is higher as compared to some years ago. It is common with many vaccine preventable diseases that adults are at higher risk for complications compared to children who used to be the most affected population in the past. Finally, we need to remember that as a consequence of vaccine development for the management of these diseases, no other treatment advances have been made for decades, so clinicians can only offer supportive care to patients instead of speci c treatment options. (See also individual fact sheets for the risks of each disease vs. the respective vaccine risks)4-8, 13.

The vast majority of vaccine side effects are minor, usually local reactions such as soreness or pain at the injection site and mild fever. More serious side effects are rare, in the order of 1 in thousands or million doses administered.

Any serious event or condition that happens within six months of the immunization should be reported to the relevant authority. However, in many instances and especially in the case of deaths or other serious possible side effects the cause-effect relationship with the vaccine cannot be clearly established, as many of these incidents may happen by coincidence.

A number of systems for the monitoring of the post-licensure pro_le of each vaccine are operating in Europe and the USA and each case of severe side effects is investigated thoroughly4-8, 12, 14-15.

The hepatitis B vaccine causes Multiple Sclerosis (MS) or exacerbates the progression of the disease.
Several studies investigated the possible relationship between hepatitis B vaccine and demyelinating disease, in particular multiple sclerosis (MS). The results of published scienti c studies do not support the suggestion that hepatitis B vaccine causes or worsens signi cantly demyelinating diseases4-8, 13, 17.

The hepatitis B vaccine is associated with arthritis and alopecia.
Recent data from more studies do not verify this correlation between the hepatitis vaccine and arthritis or loss of hair4-8, 13.

MMR causes autism disorders.
This myth refers to children, but due to the increased publicity and the questions and misconceptions arising from this, it is included. Some parents of children with autism believe that there is a link between measles, mumps, rubella (MMR) vaccine and autism. This is partly attributed to the publication in 1998 of a small case series by a team of British gastroenterologists describing 12 children with gastrointestinal and behavior problems. In this paper the patients' symptoms were correlated with receiving MMR or becoming sick with measles. This paper and the subsequent media and internet attention has led many parents to question the need of MMR and/or immunizations in general. Of note is the fact that the particular researcher was discredited as he presented false data and eventually was retracted by the journal, and the author lost his medical license.

There is no evidence that any vaccine can cause autism or any kind of behavioral disorder. Typically, symptoms of autism are rst noted by parents as their child begins to have dif culty with delays in speaking after age one, which coincides with the age when 1st dose of the MMR vaccine is recommended. Since this is also an age when autism commonly becomes apparent, it is not surprising that autism follows MMR immunization in some cases. By far the most logical explanation is coincidence, not cause and effect. Large epidemiological studies in various countries have not indicated a link between increased risk of autism spectrum disorders and MMR vaccination. Additionally, in Japan following the above mentioned controversial publication, they elected to administer each component vaccine (measles, mumps and rubella) separately; however no decrease in the diagnosis of autism was seen. Multiple factors in uence the development of autism spectrum disorders, the incidence of which is rising. These include increasing maternal and paternal age and increased awareness for these disorders of parents, pediatricians and teachers, which allows earlier diagnosis18-22.

Flu vaccine did not prevent me from getting sick last year.
Flu vaccination cannot make you sick with influenza. Several other viruses such as rhinoviruses, respiratory syncytial virus (RSV), coronaviruses, adenoviruses, circulate more or less at the same time as influenza and cause the common cold, with symptoms very similar to influenza, i.e. congestion, fever (usually lower than u), headache. The most commonly used seasonal influenza vaccine is an inactivated split virus trivalent vaccine, i.e. contains only parts from 3 different u viruses each year (2 influenza A and 1influenza B virus) grown in eggs. New seasonal influenza vaccines are also quadrivalent, i.e. they contain 2 influenza A and 2 influenza B vaccines. Each year WHO laboratories around the world collect data and expert epidemiologists make an educated guess as to the subtypes that need to be included in the seasonal u vaccine. Its effectiveness depends mostly on the correspondence of the vaccine viruses with the subtypes of influenza viruses that actually circulate in the particular season.

Flu vaccine effectiveness in healthy adults is on average 40-70% in “good” years, when the vaccine t is good. Vaccine effectiveness is lower in people >65 years of age, but immunized elderly are protected against severe outcomes, complications and death23-25.

Flu vaccine can cause paralysis (Guillain - Barré syndrome)
Several studies have investigated this association between the seasonal influenza vaccine and Guillain-Barré syndrome, which is a rare complication of various infections, including influenza (e.g. gastroenteritis with Campylobacter, infection with cytomegalovirus (CMV) or Epstein Barr virus (infectious mononucleosis)). The incidence of this syndrome increases with age.

Several studies have shown that Guillain-Barré syndrome occurs in a frequency < 1/1,000,000 doses of seasonal influenza vaccine, rate which is comparable to the incidence of the syndrome in the general population24-26.

Flu is not a very serious disease, even if I get sick I will get better soon.
Although the majority of people infected with influenza become sick for 5-7 days and then recover completely, influenza is a serious disease. It causes sickness in about 5-15% of the population every season, of which about up to 1-3% die every year in Europe mainly persons with underlying diseases.

Risk groups for influenza complications have been recognized for a long time now and include mainly asthma and other respiratory diseases, diabetes and other endocrine diseases, cardiovascular diseases, renal diseases, liver diseases, metabolic diseases (diabetes, Addison’s disease etc), neurological and neuromuscular diseases affecting respiratory functions and suppressed immune function (congenital or acquired). However, it has been shown from recent studies that influenza can kill perfectly healthy children, pregnant women or adults (young and middle aged) even without any risk factor or underlying condition.

Influenza complications affect mainly the upper airways (sinusitis, otitis media), the lower respiratory system (bronchitis, respiratory insuf ciency, Acute Respiratory Distress Syndrome (ARDS)), the cardiovascular system (heart attacks, strokes, myocarditis) or the Central Nervous System (encephalitis)23-28.


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3. Project Tycho, Data for Health


5. CDC- Vaccines and Immunizations: Some Common Misconceptions About Vaccination and How to Respond to Them (



8. Immunization Action Coalition (IAC):

9. ECDC-Measles Atlas:

10. ECDC-Measles and Rubella Monitoring, April 2014 (

11. CDC, 2013 Provisional Pertussis Surveillance Report, Jan 3, 2014 (

12. ECDC-Rapid Risk Assessment International spread of wild-type poliovirus in 2014 declared a Public Health Emergency of International Concern under the International Health Regulations (IHR) – May 2014 (

13. : Vaccine Basics

14. The ethical negligence of parents who refuse to vaccinate their children --Eric Kodish, MD director of the Cleveland Clinic’s Center for Ethics, Humanities and Spiritual Care. At, Accessed June 26,2014

15. Zhou W, Pool V, Iskander JK et al. Surveillance for safety after immunization: Vaccine Adverse Event Reporting System (VAERS)--United States, 1991-2001. MMWR Surveill Summ. 2003 Jan 24;52(1):1-24.

16. Adverse Effects of Vaccines: Evidence and Causality. Committee to Review Adverse Effects of Vaccines; Institute of Medicine; Stratton K, Ford A, Rusch E, Clayton EW, editors. Washington (DC): National Academies Press (US); 2011 Aug. Accessed at

17. Ascherio A, Zhang S, Hernan M, Olek M, Coplan P, Brodovicz K. [Hepatitis B vaccination and the risk of multiple sclerosis: case-control studies]. Gastroenterol Clin Biol. 2001 Oct;25(10):927-9

18. The Incidental Economist blog-Contemplating health care with a focus on research, an eye on reform. Healthcare Triage: Vaccines and Autism, Jan 2014 at

19. Taylor LE, Swerdfeger AL, Eslick GD. Vaccines are not associated with autism: An evidence-based meta-analysis of case-control and cohort studies. Vaccine. 2014 Jun 17;32(29):3623-9. doi: 10.1016/j.vaccine.2014.04.085

20. Yoshimasu K, Kiyohara C, Takemura S, Nakai K. A meta-analysis of the evidence on the impact of prenatal and early infancy exposures to mercury on autism and attention deficit/hyperactivity disorder in the childhood. Neurotoxicology. 2014 Jun 19. pii: S0161-813X(14)00098-9. doi: 10.1016/j.neuro.2014.06.007

21. National Research Council. Immunization Safety Review: Vaccines and Autism. Washington, DC: The National Academies Press, 2004

22. Bogowicz P., Waller J., Wilson D., Foster K. Consequences of incomplete measles vaccine uptake in healthcare workers during an outbreak in North East England, J Hosp Infection 2014;86(2): 144-46, doi:10.1016/j.jhin.2013.12.002

23. MT Osterholm, NS Kelley, A Sommer, EA Belongia, Efficacy and effectiveness of influenza vaccines: a systematic review and meta-analysis Lancet 2011; DOI:10.1016/S1473-3099(11)70295-X

24. CDC-Seasonal Influenza: Misconceptions about Seasonal Flu and Flu Vaccines (

25. CDC-Seasonal Influenza: Seasonal Influenza Vaccine Safety: A Summary for Clinicians (

26. Fiore T, Uyeki T, Broder K et al. Prevention and control of seasonal influenza with vaccines: Recommendations of the Advisory Committee on Immunization Practices. 2010. MMWR Recomm Rep. 2010;59:(RR-8):1-66.

27. H1N1 hemagglutinin-inhibition seroprevalence in Emergency Department Health Care workers after the 1st wave of the 2009 in¬fluenza pandemic. Pediatr Emerg Care 2011 Sep;27(9):804-7. doi: 10.1097/PEC.0b013e31822c125e.

28. Incidence of Infl¬uenza in healthy adults and healthcare workers: a systematic review and meta-analysis - PLoS One 2011; 6 (10):e26239