Toolkit for Nurse and Other Specialties

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• Every year the flu infects between 1 in 25 to 1 in 7 persons, during the winter months.
• Although for most people a flu infection is just a mild or unpleas- ant experience, for certain people at high risk it can lead to serious, even life-threatening complications.
• Influenza can be serious also for healthy children and adults who have no underlying disease.
• Studies have shown that health care workers just because of their work, have more than 3 times higher chance to catch the flu compared to other healthy adults.
• Up to 1 in 3 persons infected with the flu virus may have none or only mild symptoms, but they can still transmit the virus and infect others.


Seasonal influenza is caused by human influenza viruses (type A and B), which infect the airways (nose, throat, bronchi and sometimes lungs).

It is transmitted from person to person through coughing and sneezing or indirectly through touching objects contaminated with the virus (e.g. keyboards, telephones etc). Symptoms usually present abruptly and include usually high fever (>38.5 ̊C), sore throat, headache, runny nose, dry cough, joint and muscle aches and feeling very tired (fatigue). Some people may even have vomiting and diarrhea, though it is more common in children.

• However, a signi cant percent (up to 30%) of infected persons may not have symptoms but are still able to transmit the virus.
• Influenza can be very serious for certain patients.
• Elderly people and patients with chronic diseases may experience severe deterioration of their conditions, secondary infections or other severe lung complications. Flu can sometimes cause and/or worsen certain heart conditions which could then result in heart attacks and strokes.
• Sometimes even healthy persons without history of a chronic condition experience severe complications with influenza.


    For most persons influenza may require only supportive care such as fever medication, uids and rest. However, there are antiviral medicines that speci cally ght influenza viruses. Antivirals should be prescribed by a doctor and are most effective when treatment starts very early after symptoms begin.

Healthcare workers who come in contact with patients should be vaccinated every year to protect themselves and their patients.

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

Persons >60 years of age

Risk groups:

  • asthma and other respiratory diseases
  • diabetes and other endocrine diseases
  • heart diseases
  • kidney diseases
  • liver diseases
  • metabolic diseases
  • neurological diseases
  • weakened immune system


<6 months old cannot get vaccinated.


with severe life-threatening allergy to a u shot in the past or to any of the ingredients of the vaccine (egg protein, gelatin and antibiotics) should consult their doctor.

• Healthcare workers should get vaccinated every year usually in the autumn before the start of the influenza season.
• Ideally immunization should take place in the workplace.
• One shot is needed per year. Persons getting vaccinated for the first time in their lives for influenza should receive two doses at least 4 weeks apart.
• It takes about 15 days after vaccination to produce enough protective antibodies.

Flu viruses are constantly changing through mutations and it is not unusual for new u viruses to circulate each year. Getting vaccinated each year is the single most effective prevention measure against seasonal influenza.

  • This depends each year on the similarity of the vaccine strains and the ones contained in the vaccine.

  • When this match is good, vaccine effectiveness is estimated around 50-60%.

  • However, studies have shown that the u vaccine has various bene ts such as reduction of u-related hospitalizations for adults up to 61%.

  • Older people often have weaker immune response to the vaccine.

Common Complications

  • Pneumonia
  • Ear infection (otitis)
  • Sinus infection
  • Inflammation of the heart (myocarditis) or muscles (myositis)
  • Pericarditis (Inflammation of the heart sac)
  • Worsening of chronic medical condition (e.g. congestive heart failure or asthma attack)
    Rare complications
  • Blood infection (sepsis)
  • Inflammation of the brain (encephalitis)
  • Multi-organ failure (e.g. respiratory and kidney failure)
  • Death

Common adverse events

  • 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)
  • Muscle aches (1–2 days)
  • Adverse reactions are more common in children not previously exposed to the vaccine or virus than in adults

Rare adverse event

  • Allergic reaction (urticaria)

Very rare adverse events

  • Severe allergic reaction (anaphylaxis)
  • Feeling of tingling or burning in various parts of the body (paresthesias)
  • Guillain-Barré syndrome (<1/1,000,000)

1. BZgA, Germany:

2. ECDC- Communication Toolkit on Immunisation:

3. WHO Europe: Vaccines and immunization,

4. CDC, USA:

5. NIH, USA:

6. Immunization Action Coalition,

7. 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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Hepatitis B

  • attacks the liver and can cause acute, sometimes life threatening illness.
  • is the most common infection acquired in a hospital?
  • Lifelong infection by the hepatitis B virus, if left untreated, can lead to liver cancer later in life?

    2 Billion people are affected by Hepatitis B
    and, according to WHO (2014), every year about 780,000 people die from the effects of hepatitis B infection

Hepatitis B is still very common in Europe and all over the world. In Europe the majority of the reported cases refer to young adults 25-24 year old.


Patients present symptoms usually 75-90 days after the expo- sure, some with very mild symptoms, some showing typical symptoms of liver infection and some going on to develop overwhelming liver infection. Jaundice (yellow color of the skin and eyes) is a typical symptom, although it is not always present. Patients with hepatitis B complain about dark urine, fatigue, loss of appetite, nausea, vomiting and abdominal pain, joint pains.


Currently no speci c treatment exists to cure acute hepatitis B infection. Usually supportive therapy is needed. New antiviral agents are in use for chronic hepatitis B infections.

  • Healthcare workers who come in contact with patients, as they are at high risk for hepatitis B due to their occupation.
  • Anyone with a family member who is a carrier 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.


    The hepatitis B vaccine contains genetic material of the virus and should be administered with an injection in the muscle, in a 3-dose schedule at 0-1-6 months.

    One to two months after the 3 doses are completed, it is recommended for HCWs to get tested in order to establish that they have suf cient protective antibodies.

    Antibody protection lasts >20 years, probably more, therefore no boosters are needed.

    After an occupational exposure, such as a needle stick, HCWs need to be tested for protective antibodies. Some, or the ones who are not vaccinated, may need to receive ready antibodies and a vaccine dose, as soon as possible.

Is 50% effective in preventing hepatitis B


are 75-80% effective in preventing hepatitis B


are 95% effective in preventing hepatitis B

Lifelong hepatitis B infection (1 in 20, up to 1in 10 adult patients), which may lead to

  • Cirrhosis (1 in 6 and up to 1 in 3 patients with lifelong infection with Hep B)
  • Liver cancer (up to 1 in 4 patients, following of lifelong hepatitis B infection, if left untreated)

Overwhelming liver infection leading to death of liver cells (1-6/1,000 acute infections)

  • Death (2 out of 3 patients with overwhelming infection)

Three doses of the vaccine protect 95 out of 100 vaccinated persons from Hepatitis B.

Possible side effects include:

Mild (most frequent)

  • Redness, swelling or pain at the site of the injection (usually 1 in 30 doses, but may be up to 1 in 3 doses)
  • Low grade fever (1-6/100 doses)
  • Headache

Moderate (rare, <1,000 doses)

  • Fatigue

Severe (very rare, <10,000 doses)

  • Acute severe allergic reaction (anaphylaxis) (1/600,000 doses)

1. BZgA, Germany:

2. ECDC- Communication Toolkit on Immunisation:

3. WHO Europe: Vaccines and immunization,

4. CDC, USA:

5. NIH, USA:

6. Immunization Action Coalition,

7. 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 used to cause hundreds of thousands of cases in children before the introduction of systematic measles vaccination in the 60s.
  • Measles is extremely effective in human to human transmission; it is transmitted via respiratory droplets.
  • Adults need to have 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 if they are immune to rubella (e.g. they have passed the disease or they have received the vaccine).

As the coverage with the MMR vaccine has decreased in many EU coun- tries, a number of outbreaks of measles, mumps and rubella have been reported in the last 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, which peaked 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 2013-2014 large outbreaks were reported in Poland.



Measles is caused by a virus and usually starts with cough, runny nose, red eyes, and fever about 10-12 days after infection. A reddish rash appears 2-4 days after the initial symptoms and spreads from the head to the rest of the body. Bad outcome, even death, 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.



Mumps presents with swollen salivary glands (mainly the parotids), fever, headache, pain in the muscles and joints, loss of appetite about 15 days after exposure to the virus. A signi cant number of patients may exhibit no symptoms.


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



Rubella presents with a rash, swollen lymph nodes, temporary joint pain (mostly in women), upper respiratory infection and sometimes mild fever, usually after 14 days of exposure. Up to 1 in 2-4 cases of cases may be without symptoms. Rubella has serious consequences during early pregnancy, when the disease causes serious defects to the unborn baby (eyes, heart, brain) called congenital rubella syndrome. A signi cant number of patients (up to 1 in 2) may exhibit no symptoms.


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.


  • about 1 in 3 patients develops a complication
  • Adults are at higher risk for complications
  • Ear infection, 1 in 15 cases
  • Secondary pneumonia or severe bronchitis, 1 in 15 cases
  • Diarrhea, 1 in 12 cases
  • Seizures(fits), 1 in 140-170cases
  • Neurological complications can involve the spinal cord (transient paralysis) or the brain (encephalitis, 1/1,000-2,000 cases) leading frequently to permanent neurologic sequelae
  • Subacute Sclerosing Panencephalitis (SSPE) is a very rare complication, which follows 7-10 years after the disease (1/100,000 cases) causing complete disorganization of the brain
  • Death, up to 1-3 in 1,000 infants, especially if immune-compromised or malnourished.


  • Adults at higher risk for complications
  • Inflammation of the testicles, 1 in 10-30 men after puberty
  • Inflammation of the ovaries, 1 in 100 women after puberty
  • Inflammation of breasts
  • Inflammation of joints
  • Inflammation of the heart muscle
  • Inflammation of pancreas, up to 1 in 30 cases
  • Inflammation of thyroid gland
  • Nephritis
  • Meningitis or inflammation of the brain (encephalitis) up to 1 in 300 to 1 in 6,000 cases
  • Hearing loss due to nerve inflammation up to 1 in 20,000 cases


  • Joint pain and arthritis up to 1 in 15 women
  • Febrile seizures
  • Ear infection
  • Vomiting and diarrhea
  • Pneumonia
  • Decreased platelets in the blood, which help clotting (Thrombocytopenia, 1 in 3,000 cases)
  • In ammation of the brain (encephaitis 1 in 6,000 cases)
  • Infection during the 1st trimester of pregnancy may lead up to 1 in 5 babies to develop Congenital Rubella Syndrome (CRS) with eye, ear and heart problems. 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 their immunity over time.

  • 80-95% protection against mumps; however some immunized persons loose their immunity over time.


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


  • Seizures with fever (1/3,000 doses in infants)
  • Temporary joint pain (1 in 5 doses) or arthritis (1 in 10 cases -mostly in small peripheral joints of teenage and adult women 7-21 days after immunization)
  • Temporary decrease of platelets in the blood, which assist in clotting (1 in 24.000 doses)


  • Itching
  • Transient swelling of salivary glands and lymph nodes.
  • Inflammation of the brain (encephalitis) or the brain covering (meningitis), up to 1/
  • Temporary pain and tingling sensation in extremities
  • Febrile seizures
  • Very rare: inflammation of the testicles (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. CDC, USA:

5. NIH, USA:

6. Immunization Action Coalition,

7. 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 the vaccine appropriate for adults which protects against tetanus (lockjaw) and diphtheria, while Tdap also includes protection against pertussis (whooping cough).
    Lower case letters d and p mean smaller quantity of diphtheria and pertussis factors in this vaccine, compared with the one used for young children.
  • Every adult needs a booster dose for tetanus (lockjaw) 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.
  • Diphtheria used to kill thousands of children before systematic immunizations started in the '50s and '60s.
  • Pertussis (whooping cough) outbreaks are common in the last years; usually adults with milder symptoms transmit the disease to young children.

Tetanus is rare in the European Union countries, although about 130 cases are reported every year mostly from rural areas.

Diphtheria used to kill thousands of people, mostly children, before the vaccine was systematically used. The most recent epidemic of diphtheria was recorded in the former Soviet Republics in the mid 90’s. However, deaths from diphtheria have been diagnosed in EU countries in the last years (2014- 2015).

Every year >10,000 cases of pertussis are reported in the EU. Between 2012-2015 signi cant whooping cough outbreaks are reported in the USA.



People become infected with tetanus through the contamination of an open wound with soil, where the bacterium spores (a resistant form of the organism) live. The rst and most frequent symptom is spasm of the jaw muscles, followed by stiffness of the neck, dif culty in swallowing and stiffness of the abdominal muscles. Patients react violently to any stimulation with severe muscle spasms. The illness also causes fever, sweating, high blood pressure and fast heart rate.


There is no speci c treatment for tetanus, but doctors use the tetanus vaccine and ready antibodies from humans or horses to prevent the disease or its complications.



Diphtheria is a serious bacterial disease caused by a toxin-producing bacterium. It starts with cold symptoms, such as runny nose and cough. Progressively one of its forms may cause a thick grey coating at the back of the throat, which makes it dif cult to breathe or swallow. 1-2% of patients may present only skin ulcers (cutaneous diphtheria).


Ready antibodies against diphtheria toxin from horses (antitoxin) are used to prevent complications, while at the same time erythromycin is used to eradicate the diphtheria bacterium from the patient's throat.

PERTUSSIS (whooping cough)


Pertussis causes serious and prolonged cough. The disease usually starts as a cold and severe coughing spells develop one week later. The cough can persist for weeks (also called “the 100-day cough”), comes in attacks and sometimes can cause very young babies to stop breathing. Adults may experience persistent cough or milder symptoms.


There is no specific treatment for pertussis, but specific antibiotics may be given to the patient and the people who are in close contact to prevent the spread of the disease.

  • All healthcare workers and all adults need to have received full series (4-5 doses) of tetanus vaccines as children. If this history cannot be established then one dose of Tdap is recommended followed by two more doses of Td. 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, need to receive one dose of Tdap in their lifetime.

  • After an injury depending on:
    • your vaccination history,
    • the date of your last Td booster,
    • the type of your injury,
    your physician may administer a booster dose of Td or Tdap and possibly additional ready antibodies (tetanus immune globulin).


  • Muscle spasms can cause
  • bone fractures
  • spasm of vocal cords, which may lead to need for mechanical ventilation, and
  • loss of muscle and consequent kidney failure (rhabdomyolisis)
  • Aspiration of stomach contents in the lungs
  • Survivors may have neurologic sequelae
  • Death up to 1 in 10 patients


  • inflammation of the heart muscle (myocarditis), which can lead to heart insufficiency
  • abnormal heart rhythm (heart block)
  • nerve inflammation (neuritis) with temporary paralysis
  • Secondary pneumonia
  • Respiratory insufficiency
  • Ear infection
  • Low number of platelets
  • Loss of protein in urine
  • Death up to 1 in 10-20 patients with respiratory diphtheria; may go up to 1 in 5 children <5 years or adults > 40 years.


  • Pneumonia (up to 1 in 4-5 infants)
  • Ear Infection
  • Loss of appetite
  • Dehydration
  • Hospitalization, up to 1 in 2 infants with pertussis
  • Seizures up to 1 in 50 patients, mostly infants
  • Inflammation of the brain (encephalitis/encephalopathy in up to 1 in 200 infants)
  • Pneumothorax
  • Nose bleeds
  • Subdural hematoma
  • Hernia
  • Rib fractures
  • Apnea, especially in infants <7 months old
  • Death about 1 in 100 infants <2 months and 1 in 200 infants 2-11 months

Full vaccination (4 or 5 doses) offers
• 97% clinical protection against diphtheria
• practically 100% protection against tetanus and
• about 85% protection against pertussis.
Antibody protection diminishes over time; after 5-8 years for pertussis and after 10 years for tetanus.


(most frequent)
  • Redness and swelling at the site of the injection
  • Local pain at the site of the injection
  • Mild fever (up to 38°C)
  • Headache
  • Tiredness
  • 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)


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

1. BZgA, Germany:

2. ECDC- Communication Toolkit on Immunisation:

3. WHO Europe: Vaccines and immunization,

4. CDC, USA:

5. NIH, USA:

6. Immunization Action Coalition,

7. 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.

VARICELLA (chickenpox)
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Chickenpox (varicella) is still very common in the European Union countries, and vaccination recommendations are not harmonized.


Chikenpox begins with cold symptoms about two weeks after exposure to a sick person, followed by high fever and an itchy rash showing up rst on the scalp, the face and chest, then spreading to the rest of the body and changing very quickly to blisters. The rash may also appear inside the mouth or genitals. Patients also usually complain of tiredness, loss of appetite and headache.


Chickenpox in children is usually self-limiting and no treatment is needed besides relief of the itching and prevention of skin infections. Speci c antiviral drugs are usually recommended for adults who are in higher risk for complications or for immune compromised persons. Ready antibodies may also be needed for immune compormised persons or pregnant women with chickenpox.

  • Chickenpox is more severe in infants, adolescents and adults as compared to children?
  • The chickenpox (varicella) vaccine contains a live weakened virus?
  • Chickenpox (varicella) can be life threatening to persons with weak immune systems?
  • Chickenpox (varicella) can be life threatening to pregnant women and their babies around delivery time?
  • The same virus that causes chickenpox (varicella) also causes shingles (herpes zoster) later in life?

Healthcare workers who come in contact with neonates or immunocompromised patients.
Any adult who has no immunity (de nitive history of the natural disease or history of two doses of the vaccine).

• Persons with a history of disease affecting the immune system or taking medications which lower the immune response cannot usually be vaccinated against chickenpox.

    Before starting to work with patients, particularly patients with cancer, neonates or in intensive care.
    If you have been exposed to chickenpox (varicella) and have no immunity (de nitive history of the natural disease or history of two doses of the vaccine), you need to get the chickenpox (varicella) vaccine as soon as possible.
  • • If you receive the vaccine within 3-5 days of your exposure to chickenpox (varicella), you can prevent the disease or you may develop only mild symptoms.
  • • If you are pregnant and you have been exposed to chickenpox (varicella), you may need to receive ready antibodies (immune globulin).

  • The chickenpox (varicella) vaccine contains live weakened chickenpox (varicella) zoster virus and should be given in two doses 4 -8 weeks apart, with an injection either under the skin or in the muscle.

is 70-90% effective in preventing varicella


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

  • Dehydration
  • Skin and soft tissue infection, usually from bacteria living on the skin, but sometimes leading to life-threatening soft tissue infections
  • Pneumonia (usually in adults)
  • Inflammation of the brain leading to difficulties with balance and walking (encephalitis, cerebellitis)
  • Bleeding (hemorrhagic varicella) • Blood infection (sepsis)
  • Joint infections (septic arthritis) • Bone infections (osteomyelitis)
  • Toxic shock syndrome


(most frequent >1/10 persons vaccinated)
  • Local pain at the site of the injection (2-3/10)


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


(very rare 1/10,000- 1/1,000,000 persons vaccinated)
  • Seizures (fits) with fever, up to 3-4/10,000 vaccinated children 12-23 months old. Not reported in older children and adults.
  • Shingles (later in life).

1. BZgA, Germany:

2. ECDC- Communication Toolkit on Immunisation:

3. WHO Europe: Vaccines and immunization,

4. CDC, USA:

5. NIH, USA:

6. Immunization Action Coalition,

7. 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.

Figure 1
Figure 2
Figure 3

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


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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

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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

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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

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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

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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