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Negative attitudes toward immunizations have existed since they
were developed even though they're important for population
health. Learn what you can do to educate your patients.
By Amanda Perkins, MSN, RN
Immunizations:
What nurses should know
Copyright (c) 2018 Wolters Kluwer Health, Inc. All rights reserved.
 August is
National Immunization
      Awareness Month
Immunizations:
What nurses should know
Negative attitudes toward vaccines have existed since they were
developed even though they're important for population health.
Learn what you can do to educate parents, patients, and families.
By Amanda Perkins, MSN, RN
Immunization refusals from both parents and patients have
increased in the last 10 years. This is alarming because follow
ing the CDC recommended immunization schedule can prevent
approximately 322 million illnesses, 21 million hospitalizations,
and 732,000 deaths. The World Health Organization (WHO) es
timates that if all available vaccines were adopted so that 90%
of all people were covered globally, 2 million deaths per year
could be prevented in children under age 5. Immunizations are
associated with healthier, longer lives, and are a cost-effective
way to prevent debilitating illness, disability, and death. In
fact, treating a child with measles costs 23 times more than the
measles, mumps, and rubella (MMR) vaccine.
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Immunization preventable
diseases
-  Influenza
-  Measles
-  Meningococcal disease
-  Pneumococcal disease
-  Rabies
-  Tetanus
-  Typhoid fever
Immunizations are important because
they protect against a variety of illnesses
and greatly minimize the risks associated
with immunization preventable diseases,
such as paralysis, blindness, deafness, and
infertility (see Immunization preventable
diseases). Immunizations prevent 2 to 3
million childhood deaths per year world
wide, according to the WHO. Although
globally more than 100 million children
will be immunized before their first birth
day, approximately 24 million will remain
unvaccinated.
This article discusses how immuni
zations work, different types of immu
nizations, contraindications, safety,
misconceptions, and your role in patient
education.
How they work
Infections occur when bacteria or viruses
enter a person's body, attack the body,
and multiply within the body. The im
mune system has certain tools that can
be used to fight infections, such as red
blood cells that are necessary for car
rying oxygen to the body's tissues and
organs; white blood cells (WBCs), includ
ing macrophages, B lymphocytes, and T
lymphocytes; and antibodies. Immuniza
tions help our bodies build antibodies
that mount a defense against certain
illnesses.
Macrophages are WBCs that ingest,
digest, and destroy foreign material with
in the body. These cells are also respon
sible for ingesting and digesting dead or
dying cells. When macrophages act, they
leave behind antigens-markers that sit
on the cells' surface and identify them as
self or foreign.
B lymphocytes are defensive WBCs
responsible for creating antibodies-pro
teins that prevent the development of
infection by destroying foreign organisms
in the body. The antibodies that are creat
ed by B lymphocytes find antigens; when
foreign material is detected, the antibod
ies attack it using antigens as a guide.
T lymphocytes are also defensive
WBCs. Unlike B lymphocytes, the T lym
phocytes attack infected cells. They're
sometimes referred to as memory cells
because they remain in the body and act
quickly if they encounter the same germs
at a different time.
All of these factors contribute to immu
nity-the body's ability to protect itself
from disease. Types of immunity include
natural, innate, and acquired. Because
acquired immunity is the type that occurs
with immunization, it's what we'll discuss
in this article.
Acquired immunity can be passive or
active, occurring through the adminis
tration of vaccines or immunoglobulins
(antibodies). Passive immunity occurs
when antibodies are obtained from a
source outside of the body. Artificially
acquired passive immunity occurs as
the result of the administration of pre
formed antibodies. It's important to
be aware that this type of immunity is
only temporary. Active immunity, on the
other hand, occurs when antibodies are
actively produced by a person's body.
This can happen after an infection, from
which the body creates antibodies, or as
the result of vaccination, which stimu
lates the production of antibodies and
memory cells.
Immunizations assist in the develop
ment of immunity because they imitate
an infection. Illness doesn't develop, but
it causes the production of T lymphocytes
and antibodies. Vaccine administration
may cause mild symptoms, such as a
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-
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fever, due to the body working to build
immunity. After immunity is achieved, T
lymphocytes and B lymphocytes remain
and will be able to fight the infection in
the future. Because it can take a few weeks
for the body to produce lymphocytes after
an immunization, infection can occur if an
individual becomes infected right before
or after vaccine administration.
Different types
When developing immunizations, manu
facturers must consider the specific
germs, how the germs infect cells, and
how the immune system responds to
these germs. The types of immunizations
that may be administered include live,
attenuated vaccines; inactivated vaccines;
toxoid vaccines; subunit vaccines; and
conjugate vaccines.
Live, attenuated vaccines are admin
istered to prevent infection with viruses.
These vaccines contain a living virus
that's been weakened, hindering its abil
ity to cause disease. Live, attenuated
vaccines are effective because they're
the closest thing to a natural infection.
Examples include the MMR vaccine and
the varicella (chicken pox) vaccine.
Inactivated vaccines are also used to
fight viruses. The virus is inactivated or
killed during the process of making the
vaccine. With these types of vaccines,
multiple doses are often needed to pro
duce immunity. An example is the polio
vaccine.
Toxoid vaccines are administered to
prevent diseases caused by bacteria that
produce toxins within the body. When
these vaccines are manufactured, the
toxins are weakened, leading to toxoids
that allow the body to mount an immune
response without causing an illness. An
example is the diphtheria and tetanus
portion of the diphtheria, tetanus, and
pertussis (DTaP) vaccine.
Subunit vaccines contain parts of a
virus or bacteria. These vaccines typically
produce fewer adverse reactions because
did you know?
History of immunizations
Before immunizations, inoculations were used
in much the same way, with the goal of pre
venting disease. With inoculation, a disease
such as smallpox was deliberately given to
people, causing a mild form of the disease,
followed by immunity. There's evidence that
inoculations were in use for smallpox as early
as 1000 C.E.
In 1777, George Washington ordered the
mass inoculation of members of the army
against smallpox. At that time, Europe was
known for infecting individuals with a less
deadly form of smallpox with good outcomes.
In 1796, Edward Jenner used cowpox material
to create immunity to smallpox. Immunization
has since led to the eradication of smallpox.
In 1885, Louis Pasteur developed the rabies
vaccine. From 1885 through the 1930s, there
was a rapid increase in the development of
immunizations.
In the early 19th century, infectious diseases
were the leading cause of death. In the early
20th century, 100 out of 1,000 U.S. children died
before age 1. As a result of immunizations, infec
tious diseases have dropped to the eighth lead
ing cause of death and the number of children
living to see their first birthday has increased,
with only 7 out of 1,000 children dying before
age 1 as the result of an infectious disease.
In the early 1970s, immunizations for approx
imately 70 diseases were in use, primarily for
individuals considered to be high risk, such
as travelers and those in the military. In the
mid-1980s, evidence demonstrated that immu
nization programs could protect millions from
disease and death in a relatively short period of
time. In the 1990s, there was a drive for univer
sal childhood immunizations; global coverage
reached approximately 80%. The 1990s also
gave rise to the VAERS.
In 2015, there were 592 cases of measles
and 4 separate outbreaks of mumps on col
lege campuses in the United States. Of those
infected with these immunization preventable
diseases, most weren't vaccinated. At this
time, the United States has immunization laws
requiring vaccination before a child enters
school. However, 19 states allow exemptions
for personal beliefs.
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they aren't made up of entire viruses or
bacteria. The pertussis component of the
DTaP vaccine is an example of a subunit
vaccine.
Conjugate vaccines are used to guard
against bacteria that have antigens with
an outer coating of polysaccharides.
These polysaccharides disguise the anti
gen, making it harder for the immune
system to recognize. Conjugate vaccines
connect the polysaccharides to recog
nizable antigens, helping the immune
system mount a response. An example is
the Haemophilus influenzae type B, or Hib,
vaccine.
Research is underway for a variety of
immunizations, including malaria, tuber
culosis, and AIDS. Research is also ongo
ing for needleless vaccines, such as aerosol
formulations, adhesive skin patches, sub-
lingual delivery, and oral pills.
Who shouldn't be immunized?
Before administering immunizations,
you should understand that each one has
its own cautions and/or recommenda
tions. In general, immunizations should
be avoided if a patient is allergic to any
of the vaccine components. For example,
many influenza vaccines contain egg so
should be avoided in individuals with
an egg allergy. Most vaccines are contra
indicated in individuals with moderate-
to-severe illness. These individuals are
often good candidates for vaccines once
the illness has passed. Lastly, any patient
who's experienced a serious adverse
event after vaccine administration may
not be an appropriate candidate.
Immunization contraindications
-  If allergic to any components of the vaccine
-  Pregnancy or actively trying to become pregnant
-  Breastfeeding
-  Compromised immune system
-  Current illness or recent illness
-  Previous serious adverse event
-  History of Guillain-Barre syndrome
sheet
cheat
Live, attenuated vaccines shouldn't
be administered to those with weakened
immune systems, especially children.
Before administering live, attenuated
vaccines, ensure that your patient has
an intact and well-functioning immune
system. Additionally, live, attenuated vac
cines may not be appropriate during preg
nancy because they can create risks for
the developing fetus. Individuals who've
ever been diagnosed with Guillain-Barre
syndrome may need to avoid certain
vaccines, such as the influenza vaccine,
because these vaccines have been shown
to increase the risk of developing Guillain-
Barre syndrome.
Are they safe?
Immunizations are tested and monitored
for safety. It can take up to 10 years for
an immunization to move from a concept
to a licensed vaccine. The licensing pro
cess holds immunizations to very high
safety standards. Testing and evaluation
must occur before the FDA licenses and
the CDC recommends an immunization.
Throughout this process, the FDA pro
vides supervision. Before the licensing
of an immunization, clinical trials are
conducted, initially in small groups, then
with thousands of volunteers. Testing
determines the safe dose and how the
immune system reacts. All safety issues
must be addressed before an immuniza
tion is licensed.
Once an immunization is licensed,
safety monitoring is an ongoing process
that continues for as long as the immuni
zation is in use. After a vaccine is manu
factured, it's lot tested to ensure sterility,
purity, and potency. The FDA reviews the
results of lot tests and inspects manufac
turing facilities. The influenza vaccine
requires yearly testing and manufactur
ing facility inspection; all other vaccine
manufacturing facilities are inspected
every 2 years.
A variety of organizations play a role
in monitoring and evaluating the safety
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of immunizations. The Vaccine Safety
Datalink is a collaboration between the
CDC and U.S. healthcare organizations
that uses medical record databases to
track immunization safety. The FDA
Postlicensure Rapid Immunization Safety
Monitoring System, or PRISM, uses health
insurance company databases to moni
tor and evaluate safety issues associated
with immunizations. The Clinical Immu
nizations Safety Assessment Project is a
collaboration between the CDC and medi
cal research center immunization safety
experts that conducts clinical vaccine
safety research and evaluates complex
cases associated with vaccine adverse
reactions. Additional research and testing
is conducted nationally by government
organizations such as the National Insti
tutes of Health.
The CDC and FDA Vaccine Adverse
Event Reporting System (VAERS) is open
to anyone who suspects an adverse event
occurrence as the result of a vaccine,
including healthcare personnel, patients,
and parents. This early warning system is
used to detect safety problems with vac
cines administered in the United States. In
addition, the National Childhood Vaccine
Injury Act requires that healthcare work
ers report serious vaccine adverse events.
Examples of serious adverse events
include hospitalization, prolonged hos
pitalization, disability, birth defects, and
death. It's always best practice to report
even if you're unsure if the patient's signs
and symptoms are vaccine related. Patient
consent isn't required when reporting
to the VAERS. Once a report is submit
ted, you may be contacted for additional
information such as the patient's medical
record. Adverse events associated with
vaccines rarely occur and, as a result, the
benefits of immunizations greatly out
weigh the associated risks.
Misconceptions
Fear of many diseases has declined,
in part, due to the effectiveness of
consider this
You're the infection control nurse within your
organization. You find that compliance rates
for immunizations, specifically the influenza
vaccine, are quite low among your facility's
employees. Upper management has asked you
to address this issue. You send out a question
naire and round on the nursing units within the
hospital. You find the most common reasons
for nurse refusal of the vaccine are reports that
it makes them sick, doubts that the vaccination
is effective, perceived immunity, and lack of
time to get the vaccine. What would you do?
How should you proceed?
immunizations. This can be both a posi
tive and a negative. It's positive that the
rate of these diseases has declined. It's
negative because an increasing number of
people are choosing alternative vaccine
schedules (any immunization schedule
that doesn't follow the CDC recom
mended schedule). At this time, 1 out
of 10 parents reports using an alternative
vaccine schedule. Additionally, 1% to 2%
of American parents refuse immuniza
tions, whereas 11% to 19% are hesitant or
chose to delay immunizations.
The following are reasons provided
for following alternative vaccine sched
ules: concerns about adverse reactions;
pain with administration; lack of vaccine
schedule awareness; poor communication
by healthcare providers; and distrust of
the government, the healthcare system,
or those advocating for immunizations.
Additional fears cited by parents/patients
include concern that vaccines will lead to
autism, diabetes, arthritis, and autoim
mune diseases.
Many fears associated with immu
nizations arose as the result of a study
published by a physician in 1998 that
purported to identify a link between vac
cination and autism. Although this study
created resistance to vaccinations, also
called the "anti-vax" movement or "anti
vaxxers," it was later determined that the
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on the web
Vaccine schedule:
www.cdc.gov/vaccines/schedules/easy-to
read/child-easyread.html
Vaccine storage and handling:
www.cdc.gov/vaccines/hcp/admin/storage/
index.html
Vaccines licensed for use in the United States:
www.fda.gov/BiologicsBloodVaccines/
Vaccines/ApprovedProducts/ucm093833.htm
VAERS table of reportable events following
vaccination:
https://vaers.hhs.gov/docs/VAERS_Table_of_
Reportable_Events_Following_Vaccination.pdf
lead author fabricated information so that
he could gain financially. This physician
subsequently lost his license as a result
of his unethical behavior. Although the
information presented in the study was
found to be false and there's extensive
literature that shows no link between
autism and immunizations, the fear that it
created remains.
Why nurses refuse
Some healthcare providers, including
nurses, are vaccine hesitant or resistant.
A recent study showed that the U.S.
vaccination rate for influenza among
healthcare workers was 36%. This is im
portant to address because immunization
preventable diseases in healthcare work
ers can lead to transmission of disease to
vulnerable populations.
The rationales provided by nurses
who don't want to receive immuniza
tions include fear of adverse events;
doubt regarding efficacy; organizational
issues; feeling that they don't belong to a
high-risk group; self-perception of being
immune; and believing that certain ill
nesses, such as influenza, aren't serious
diseases. Resistance to vaccination among
nurses may also be due to the need for
autonomy. Many nurses report that they
prefer to make the decision to be vacci
nated versus being told to be vaccinated.
For those working in leadership roles, it
may be beneficial to avoid mandating vac
cines because this may lead to decreased
compliance.
Noncompliance among nurses can be
addressed in a variety of different ways.
It's always important to provide infor
mation on vaccine effectiveness, adverse
reactions, and patient benefits. Research
has shown that administering immuni
zations in the workplace can increase
compliance. Educational offerings about
vaccination can be provided in person,
via social media, and/or through a
web-based platform by staff development
specialists or infection control nurses.
Your role as educator
When it comes to immunization aware
ness and acceptance, education that's
based on scientific data is essential to dis
sipate patient fears. Teach parents and/or
patients about immunization preventable
diseases, the current vaccines available,
vaccine scheduling, and known common
and adverse reactions. Consistency in
the message about immunizations goes a
long way in building trust.
When providing education about the
importance of immunizations to parents
and/or patients, it's important to under
stand their fears and concerns. Factors
influencing the decision to immunize
include information/knowledge about
immunizations; past personal experiences;
past experiences of family and/or friends;
perception of immunization importance;
perception of risks and social pressure/
responsibility; and religious or moral con
victions. It's necessary to take all of these
factors into consideration. Identify and
address issues that cause mistrust and
work to increase trust. It's also important to
remember that education and communica
tion aren't only necessary for patients and
their families, but they may also be needed
for healthcare workers who may have res
ervations about immunizations themselves.
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A healthy start
As nurses, you're entrusted with the care
and safety of your patients. One way
to ensure that you keep your patients
healthy is through immunizations. 
REFERENCES
Anderson VL. Promoting childhood immunizations.
J Nurse Pract. 2015;11(1):1-10.
Baron-Epel O, Madjar B, Grefat R, Rishpon S. Trust and
the demand for autonomy may explain the low rates of
immunizations among nurses. Hum Vaccin Immunother.
2013;9(1):100-107.
Centers for Disease Control and Prevention. Vaccines and
immunizations. www.cdc.gov/vaccines.
Eby AZ. Impacting parental vaccine decision-making.
Pediatr Nurs. 2017;43(1):22-29, 34.
Filsinger AL, Dwek R. George Washington and the first
mass military inoculation. www.loc.gov/rr/scitech/
GW&smallpoxinoculation.html.
Hagemeister MH, Stock NK, Ludwig T, Heuschmann P,
Vogel U. Self-reported influenza vaccination rates and
attitudes towards vaccination among health care workers:
results of a survey in a German university hospital. Public
Health. 2018;154:102-109.
The College of Physicians of Philadelphia. The history of
vaccines. www.historyofvaccines.org/timeline#EVT_48.
U.S. Department of Health and Human Services. Vaccine
safety. www.vaccines.gov/basics/safety/index.html.
Vaccine Adverse Event Reporting System. Information for
healthcare providers. https://vaers.hhs.gov/about.html.
Williams LS, Hopper PD. Understanding Medical-Surgical
Nursing. 5th ed. Philadelphia, PA: F.A. Davis Company;
2011.
World Health Organization. State of the World's Vaccines
and Immunization. 3rd ed. Geneva, Switzerland: World
Health Organization; 2009.
World Health Organization. 10 facts on immunization.
www.who.int/features/factfiles/immunization/en.
Amanda Perkins is an  of Nursing at Vermont
Tech in Randolph, Vt., and a Nursing made Incredibly Easy! Editorial
Board Member.
The author and planners have disclosed no potential conflicts of
interest, financial or otherwise.
DOI-10.1097/01.NME.0000534111.98635.e4
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