Table 20.1Selected Vaccine-preventable Diseases and Vaccines

Category Tuberculosis Diphtheria Tetanus Pertussis Poliomyelitis Measlesa Rubella Hib Hepatitis B Yellow fever Meningococcal disease Japanese encephalitis
Causative agentMycobacterium tuberculosisToxin-producing bacterium (Corynebacterium diphtheriae)Toxin-producing bacterium (Clostridium tetani)Bacterium (Bordetella pertussis)Virus (serotypes 1, 2, and 3)VirusVirusBacterium (Haemophilus influenzae type B)VirusVirusNeisseria meningitis groups A, B, C, Y, W135Virus
ReservoirHumans (some bovine)HumansAnimal intestines; soilHumansHumansHumansHumansHumansHumansMonkeys and humansHumansBirds and mammals
SpreadAirborne droplet nuclei from sputum-positive personsClose respiratory or cutaneous contactSpores enter the body through wounds or the umbilical cord stumpClose respiratory contactFecal-oral; close respiratory contactClose respiratory contact and aerosolized dropletsClose respiratory contact and aerosolized dropletsClose respiratory contactBlood, perinatal, household, occupational, or sexual transmissionBites by infected mosquitoesClose respiratory contactBites by infected mosquitoes
Transmission periodAs long as sputum acid-fast bacilli are positiveUsually under two weeks; some chronic carriersNo person-to-person transmissionUsually under three weeks (starts before cough is apparent)A few days before and after acute symptomsFour days before rash until two days afterwardA few days before to seven days after rash; up to one year of age in congenitally infectedChronic carriage for monthsUp to lifelong chronic carriage and transmissionInfected individuals can transmit the disease when bitten by a mosquito vector during the viremic phase (the first three or four days of illness)Chronic carriage for monthsUnknown, rare cases for several months
Subclinical infectionCommon but not important in transmissionCommonNoMild illness common: may not be diagnosedMore than 100 subclinical infections for each paralytic caseMay occur in children under one, but relative minimalCommonCommonCommon, especially in infantsCommonCommonCommon
Duration of natural immunityNot known; reactivation of old infection commonly causes diseaseLasting protective immunity not produced by infection; second attack possibleLasting protective immunity not produced by infection; second attack possibleIncomplete and waning protectionLifelong type- specific immunityLifelongLifelongUncertain; no protection against carriage and those previously infected may develop some disease (epiglottitis)If develops, lifelongLifelongUncertain; no protection against carriageLifelong
Risk factors for infection (for unvaccinated individuals)High population densities in regions with historically poor control; low socioeconomic status; poor access to care; immunodeficiency; malnutrition; alcoholism; diabetesCrowding; low socioeconomic statusWound contaminated by soil; umbilical cord; agricultural workYoung age; crowdingPoor environmental hygiene and sanitationHighly transmissible agent with nearly 100 percent infectivity except for isolated populations; crowding, low socioeconomic statusHighly transmissible; crowding; low socioeconomic statusFailure to breastfeed; crowding; low socioeconomic status; immune deficiency, including HIVCarrier mother, sibling, or sex partner; multiple sex partners; intravenous drug use; unsafe injection practicesYoung age; forest workers; season (late rainy season, early dry season)Crowding; respiratory viral infections, especially influenzaYoung age; forest workers; season
Case-fatality ratebSee chapter 162 to 20 percent25 to 90 percentUp to 10 percent in infants and children2 to 10 percent0.05 to 10.0 percentLess than 0.1 percentMeningitis, 5 to 90 percent; pneumonia 5 to 25 percentAcute, more than 1 percent; chronic; 25 percent (delayed)10 to 40 percentUntreated 90 to 100 percent; treated 5 to 20 percent5 to 30 percent
Vaccine (number of doses); routeBCG attenuated Mycobacterium bovis (1); intradermalDiphtheria toxoid (three to five primary including booster doses in most countries); intramuscularTetanus toxoid (three to five in children, including booster doses in many countries; five for women of childbearing age; adult boosters for injury prevention); intramuscularKilled whole-cell or acellular pertussis (three to five, including booster doses in most countries); intramuscularLive (OPV) (three to four primary plus campaigns);c killed (IPV) (three to four)Measles (two); subcutaneousRubella (one or two); subcutaneousCapsular polysaccharide linked to protein Hib (three to five); intramuscularHepatitis B surface antigen (three to four); intramuscularYellow fever attenuated live virus (1 plus boosters); subcutaneousVaccines for A, C, Y, Wi35 only; unconjugated polysaccharides given subcutaneously or intramuscularly: one dose with repeat three to five years later for high-risk persons; conjugated: for C only or A, C, Y, + Wi35, one dose given intramuscularlyLive attenuated (two, China only); killed (two); booster commonly used but of uncertain value
Vaccine efficacy0 to 80 percent for pulmonary tuberculosis; 75 to 86 percent for meningitis and miliary tuberculosisMore than 87 percentMore than 95 percent (more than 80 percent after two doses) in infants70 to 90 percentOPV: more than 95 percent in industrial countries; 72 to 98 percent in developing countries; lower protection against type 3 than 1 and 2; IPV: more than 95 percent95 percent at 12 months of age; 85 percent at 9 months of age from one dose, more than 98 percent from two doses95 percent (at 12 months and up)More than 95 percent for invasive disease75 to 95 percent; efficacy against chronic infection in infants born to carrier mothers; more than 95 percent for exposure at older ages90 to 98 percentUnconjugated polysaccharides: poor efficacy under two years of age; conjugated polysaccharides: approximately 95 percent and up serogroup specificLive attenuated: 90 percent (after one dose at one year); 94 to 100 percent (after two doses one to two months apart); inactivated: 80 percent (declining to 55 percent after one year; no decrease in another study)
Duration of immunity after primary seriesUnknown; some evidence that immunity wanes with timeVariable: probably around five years; longer in presence of natural boosting or booster doses10 years or moreUnknown; wanes with timePresumed lifelong for both OPV and IPV, but unknownLifelong in most; rare cases of waning immunity after one dose, not twoLifelong in most; presumed rare cases of waning immunity after one dose, not twoUnknown, but lasts for at least three years beyond period of greatest exposureMore than 15 years; further follow-up is continuingFor at least 10 years and possibly for lifeUnconjugated wanes rapidly for children under five, more than three to five years for older children; conjugated uncertainUnknown, may be lifelong
ScheduleGiven at or near birth in populations at high riskThree-dose schedule recommended at 6, 10, and 14 weeks in developing countries for DTP vaccine; other schedules in common use; booster doses at 18 months and four to six years also suggestedNormally given as DTP vaccine to children; unimmunized pregnant women should be given two doses of tetanus toxoid or tetanus reduced diphtheria toxoid, and a total of five doses is required to provide protection through all childbearing yearsUsually given in childhood as combination vaccine (DTP)OPV: four doses (birth, 6, 10, and 14 weeks) in polioendemic countries; birth dose may be omitted elsewhere with fourth dose given later; supplemental doses (up to 10) given in national campaigns for eradication; IPV: three to four doses: 2, 4, 6 to 18 months, and four to six yearsFirst dose at 9 or 12 to 15 months); a second opportunity to receive a dose of measles vaccine (either through routine [18 months or four to six years] or supplemental immunization activities) should be provided for all childrenFirst dose at 12 to 15 months; when given, a second dose with measles vaccineThree or four doses; usually given during the same visit as for DTPSeveral schedules: at birth, 6, and 14 weeks; with first three doses of DTP; birth dose needed if mother is a carrier and recommended if perinatal transmission of hepatitis B is frequent; four doses total can be given although only three are requiredOne dose at 9 to 12 months with measles in countries where yellow fever poses a riskUnconjugated: one dose at two years or older and second dose three to five years later for high risk; conjugate C: three doses at two, three, and four or two, four, and six months for infants; one dose for older children and adults; conjugate A, C, Y, Wi35 currently only approved for one dose at 11 years or olderLive: one year and two years; killed: days 0, 7, and 30 followed by booster two years later and then every three years
Status as of the end of 2001158 countries using BCG; 85 percent coverageAll countries; 78 percent coverageChildhood: all countries; 78 percent coverageAll countries; 78 percent coverageAll countries; 79 percent routine, plus supplemental coverageRoutine first dose all countries, 77 percent coverage; second opportunity, 164 out of 192 countries110 countries in 200389 countries; global coverage less than 18 percent147 countries; global coverage 42 percent29 of 43 countries at risk using vaccine; 30 percent coverage in target populationEuropean countries, Canada (and United States in 2005)Southeast Asia
CommentsReasons for varying efficacy are multifactorial, including differences in vaccinesRecent trends to lower antibody levels in adults without booster doses because of waning immunity and less natural boostingFive doses in adults provide protection for more than 20 yearsVariability in whole cell vaccines; acellular vaccines used in some developed countriesPrimary series gives incomplete protection in developing countriesLower efficacy when maternal antibody presentLower efficacy when maternal antibody presentNoneEfficacy lower if injected into fatNoneNoneNone

Sources: WHO 2002, 2004.

DTP = diphtheria-tetanus-pertussis; IPV = inactivated polio vaccine; OPV = oral polio vaccine.

a. Measles vaccine is given as measles, measles-rubella, or measles-mumps-rubella vaccine. The latter two vaccines are routinely used in industrial countries and are increasingly being adopted in other countries. The World Health Organization recommends that the combination measles-rubella or measles-mumps-rubella vaccines be introduced only after careful evaluation of public health priorities within each country and following the establishment of an adequate program for measles control as demonstrated by high coverage rates as part of a well-functioning childhood immunization program.

b. Note that variations in case-fatality rates are related to access to care, type of care administered, setting, age at onset of disease, and other factors. The ranges presented in this table reflect both uncertainty as to actual case-fatality rates and the variability of populations.

c. As of 2003, an injected IPV is given alone or in combination with OPV in 31 countries. IPV is currently not recommended for routine use in developing countries because of its relatively high cost and uncertain efficacy when given at 6, 10, and 14 weeks. The usual recommended IPV schedule is 2, 4, and 6 to 18 months. Routine use of OPV is expected to cease following polio eradication. Stockpiles of monovalent OPV for each of the three virus types are under development to protect against vaccine-associated paralytic poliomyelitis and outbreaks of circulating vaccine-derived polioviruses.

From: Chapter 20, Vaccine-preventable Diseases

Cover of Disease Control Priorities in Developing Countries
Disease Control Priorities in Developing Countries. 2nd edition.
Jamison DT, Breman JG, Measham AR, et al., editors.
Washington (DC): World Bank; 2006.
Copyright © 2006, The International Bank for Reconstruction and Development/The World Bank Group.

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