pink book | Principles of Vaccination | Epidemiology of VPDs (2023)

A. Patricia Wodi, MD and Valerie Morelli, BA

On this page

  • Immunology and vaccine-preventable diseases
  • types of immunity
  • Classification of vaccines
  • thanks
  • Selected references

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Immunology and vaccine-preventable diseases

To understand how vaccines work and the basis for recommendations on their use, it is helpful to understand the basic function of the human immune system. The following description is simplified; Many excellent immunology textbooks provide additional detail.

Immunity is the human body's ability to tolerate the presence of endogenous substances and eliminate foreign substances. This discriminatory ability to eliminate foreign substances is performed by a complex system of interacting cells called the immune system. Because most organisms (eg, bacteria, viruses, and fungi) are identified as foreign, the ability to identify and eliminate these substances provides protection against infectious disease. Immunity is generally specific to a single organism or a group of closely related organisms.

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The immune system develops a defense against antigens, which are substances that can stimulate the immune system. This defense is known as the immune response and usually involves the production of:

  • Protein molecules (immunoglobulins or antibodies, the main component of humoral immunity) from B lymphocytes (B cells)
  • Specific cells including T lymphocytes (aka cell-mediated immunity)

The most effective immune responses are generally generated in response to antigens present in a living organism. However, an antigen need not necessarily be present in a living organism to elicit an immune response. Some antigens such as Viruses such as hepatitis B surface antigen are readily recognized by the immune system and provide adequate protection even when not transmitted with the live hepatitis B virus. Other materials are less potent antigens and the immune response they elicit may not provide good protection.

types of immunity

There are two basic mechanisms for acquiring immunity: passive and active.

Passive Immunity

Passive immunity is protection from antibodies or antitoxins produced by one animal or human and transferred to another. Passive immunity provides immediate protection against infection, but this protection is temporary. The antibodies are broken down over a period of weeks to months and the recipient is no longer protected.

The most common form of passive immunity is that which an infant receives from the mother. Antibodies, particularly the class of antibodies called IgG, are transported across the placenta mainly during the last 1 to 2 months of pregnancy. As a result, a full-term infant has the same type of antibodies as the mother. These antibodies can protect the infant from certain diseases in the first few months after birth. Maternal antibodies provide better protection against some diseases (eg, measles, rubella, tetanus) than others (eg, polio, whooping cough).

Passive immunity can also be acquired by transfusing blood products. Some blood products (eg, washed or reconstituted red blood cells) contain a relatively small amount of antibody, while others (eg, intravenous immunoglobulin and plasma products) contain a large amount.

Besides blood products used for transfusions, there are three other important sources of antibodies used in human medicine. These are homologous pooled human antibody, homologous human hyperimmune globulin and heterologous hyperimmune serum.

Homologous pooled human antibody, also known as immunoglobulin, is made by combining the antibody fraction, specifically the class of antibodies called IgG, from the blood of thousands of adult donors. Because it comes from many different donors, it contains antibodies to many different antigens. It is mainly used for the prophylaxis of hepatitis A and measles and for the treatment of certain congenital immunoglobulin deficiencies.

Human Hyperimmunoglobulin Homologsare antibody products that contain high titers of antibodies that target more specific antigens. These products are made from donated human plasma with high levels of the antibody of interest. Since hyperimmune globulins are human derived, they are mainly polyclonal and contain many types of antibodies at lower levels. Hyperimmunoglobulins are used for post-exposure prophylaxis in several diseases including hepatitis B, rabies, tetanus and chickenpox.

Heterologes Hyperimmunserum, also called antitoxin, is produced by animals, mostly horses, and contains antibodies against only one antigen. Antitoxins are available in the United States to treat botulism and diphtheria. These products can cause serum sickness, an immune response to equine protein.

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Immunoglobulin products from human sources are primarily polyclonal; they contain many types of antibodies. Monoclonal antibody products have many uses, including diagnosis of certain types of cancer (colon, prostate, ovarian, breast), treatment of cancer (B-cell chronic lymphocytic leukemia, non-Hodgkin's lymphoma), prevention of transplant rejection, and treatment of autoimmune diseases (Crohn's disease, rheumatoid arthritis) and infectious diseases.

While certain antibody products such as immunoglobulins interfere with the immune response to live virus vaccines, monoclonal antibody products do not because they are directed against an antigen or a closely related group of antigens. A monoclonal antibody product, palivizumab (Synagis), is available to prevent respiratory syncytial virus (RSV) infection. Because Synagis contains only RSV antibodies, it will not affect the response to a live vaccine.

Active Immunity

Active immunity is protection created by a person's own immune system. The immune system is stimulated by an antigen to produce antibody-mediated and cell-mediated immunity. Unlike passive immunity, which is temporary, active immunity usually lasts for many years, often for life.

One way to gain active immunity is to survive infection with the disease-causing form of the organism. In general, individuals who have recovered from an infectious disease have lifelong immunity to that disease (there are exceptions, such as malaria). The persistence of protection for many years after infection is referred to as immunological memory. After the immune system is exposed to an antigen, certain memory B cells continue to circulate in the blood and reside in the bone marrow for many years. Upon renewed exposure to the antigen, these memory cells begin to rapidly replicate and produce antibodies to restore protection.

Another way to create active immunity is vaccination. Vaccines contain antigens that stimulate the immune system to produce an immune response that often resembles that produced by natural infection. However, vaccination does not expose the recipient to the disease and its possible complications.

Many factors can influence the immune response to vaccination. These include the presence of maternal antibodies, the type and dose of antigen, the route of administration, and the presence of an adjuvant (e.g., aluminum-containing material added to improve the immunogenicity of the vaccine). Host factors such as age, diet, genetics, and comorbidities can also affect the immune response. The more similar a vaccine is to the disease-causing form of the organism, the better the immune response to the vaccine.

Classification of vaccines

There are two basic types of vaccines:

  1. Live, muffled and
  2. Disabled. Their properties are different and determine how each type is used.

live attenuated vaccines

Live vaccines are derived from "wild" viruses or bacteria. These wild viruses or bacteria are weakened (weakened) in a laboratory, usually through repeated cultivation. For example, the measles virus used today as a vaccine was isolated in 1954 from a child suffering from measles. Almost 10 years of serial passage with tissue culture media were required to transform wild-type virus into attenuated vaccine virus.

In order to elicit an immune response, live attenuated vaccines must be replicated in the vaccinated individual. A relatively small dose of virus or bacteria administered will replicate in the body and generate enough of the organism to stimulate an immune response.

Although live attenuated vaccines replicate, they do not usually cause diseases like those caused by the wild-type organism. When a live attenuated vaccine causes disease, it is usually much milder than the natural disease and is considered an adverse reaction to the vaccine.

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The immune response to a live attenuated vaccine is virtually identical to that of a natural infection because the immune system does not distinguish between infection with an attenuated vaccine virus and infection with a wild virus. Injected live attenuated vaccines produce immunity in most recipients with one dose. However, a small percentage of recipients do not respond to the first dose of an injected live attenuated vaccine (such as measles, mumps and rubella [MMR]) and a second dose is recommended to achieve an extremely high level of immunity in the population. Orally administered live attenuated vaccines require more than one dose to produce immunity.

A live attenuated vaccine can cause serious or fatal infections as a result of uncontrolled growth of the vaccine virus or bacteria. However, this only occurs in people with a weakened immune system (eg, due to leukemia, treatment with certain drugs, or human immunodeficiency virus [HIV] infection).

A live attenuated vaccine virus could theoretically revert to its original pathogenic form. This is known to be the case only with live (oral) polio vaccines, which are no longer available in the United States.

Active immunity against a live attenuated vaccine may not develop because the vaccine virus is disrupted by circulating antibodies. Antibodies from any source (e.g., transplacental transmission to infants, transfusion of blood products) can interfere with the replication of the vaccinee and result in a weak or no response to the vaccine (also known as vaccine failure).

Live attenuated vaccines are fragile and can be damaged or destroyed by heat and light. They must be stored and handled with care. The live, attenuated viral vaccines currently available and routinely recommended in the United States are MMR, chickenpox, rotavirus, and influenza (intranasal). Other live vaccines that are not routinely recommended include adenovirus vaccine (used by the military), typhoid fever vaccine (Ty21a), and bacille Calmette-Guerin (BCG). BCG is not used as a vaccine in the United States but is used to treat bladder cancer.

Inactivated vaccines

Inactivated vaccines are not live and cannot replicate. These vaccines cannot cause disease even in an immunocompromised person. Inactivated antigens are less affected by circulating antibodies than live antigens, so they can be given when antibodies are present in the blood (eg, in infancy or after receiving antibody-containing blood products).

The immunity provided by inactivated vaccines is generally not as long-lasting as that provided by live attenuated vaccines. Multiple doses over a period of time are required to achieve sustained immunity. In general, the first dose does not create protective immunity, but rather "primes" the immune system. After the second or third dose, a protective immune response develops. Unlike live vaccines, which elicit an immune response very similar to a natural infection, the immune response to an inactivated vaccine consists primarily of the production of antibodies. Little or no cellular immunity results. Antibody titers against inactivated antigens decrease over time. As a result, some inactivated vaccines may require periodic supplemental doses to increase or "boost" antibody titers.

Inactivated vaccines include inactivated whole-cell vaccines (eg, polio, hepatitis A, and rabies vaccines), subunit vaccines (eg, influenza and pneumococcal vaccines), toxoids (eg, diphtheria and tetanus toxoid) and recombinant vaccines (eg, hepatitis B, human papillomavirus [HPV], and influenza [Flublok brand]).

Inactivated whole cell vaccinesContain bacteria or viruses that have been killed by a physical or chemical process. Whole-cell inactivated viral vaccines for polio, hepatitis A, and rabies are available in the United States. A vaccine made from killed pertussis (whooping cough) bacteria is available outside the United States.

subunit vaccinescontain some of the bacteria or viruses. The part of the organism selected is that part needed to elicit a protective immune response. Antigens in subunit vaccines can be protein, polysaccharide, or a combination of polysaccharide and protein molecule (i.e., conjugate vaccine).

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Conjugated subunit vaccines (e.g.Haemophilus influenzaeType b and pneumococcal conjugate vaccines are made by chemically attaching a polysaccharide from the bacterial surface to a protein molecule through a process called conjugation. Conjugation of a polysaccharide antigen to a protein molecule produces long-lasting protective immunity against the polysaccharide antigen.

The immune response to a pure polysaccharide vaccine is typically T cell independent, meaning these vaccines can stimulate B cells without the help of helper T cells. T-cell independent antigens, including polysaccharide vaccines, are not consistently immunogenic in children under 2 years of age, probably due to immune system immaturity. Attaching the polysaccharide antigen to a protein makes it possible to prevent bacterial infections in populations where a polysaccharide vaccine is ineffective or only provides temporary protection.

toxoid vaccinesare made using inactivated toxins produced by bacteria. These protein-based toxins are inactivated by heat, chemicals, or other methods. Some bacteria (e.g. tetanus, diphtheria) cause disease by producing toxins. The immune system's ability to recognize and eliminate these toxins provides protection against the disease.

Recombinant Vaccinesare produced by recombinant DNA technology. Recombinant DNA technology allows DNA from two or more sources to be combined. Hepatitis B, human papillomavirus (HPV) and influenza vaccines (Flublok brand) are made by inserting a segment of the appropriate viral gene into the gene of a yeast cell or virus. The modified yeast cell or virus produces pure hepatitis B surface antigen, HPV capsid protein, or influenza hemagglutinin as it grows. Meningococcal serogroup B vaccines are proteins and outer membrane vesicles created by recombinant technology.


The editors thank Jennifer Hamborsky, Andrew Kroger, Ginger Redmon, and Skip Wolfe for their contributions to this chapter.

Selected references

American Academy of Pediatrics. Active and passive immunization. In: Kimberlin D, Brady M, Jackson M, et al., eds.Red Book: 2018 Report of the Infectious Diseases Committee. . . . 31. Aufl. Itasca, IL: American Academy of Pediatrics;2018:13–64.

Plotkin S. Correlates of vaccine-induced immunity.Clin Infect Dis2008;47:401–9.

Plotkin S. Vaccines, vaccination and vaccinology.J Infect Dis2003;187:1347–59.

Siegrist C. Vaccine Immunology. In: Plotkin S, Orenstein W, Offit P, et al., Hrsg. Plotkinsvaccinations.7th ed. Elsevier;2018:16-34.

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What is the CDC pink book? ›

The Epidemiology and Prevention of Vaccine-Preventable Diseases, a.k.a. the “Pink Book,” provides physicians, nurses, nurse practitioners, physician assistants, pharmacists, and other healthcare professionals with the most comprehensive information on routinely used vaccines and the diseases they prevent.

What is the CDC Pink Book vaccine Administration? ›

Administration involves a series of actions: assessing patient vaccination status and determining needed vaccines, screening for contraindications and precautions, educating patients, preparing and administering vaccines properly, and documenting the vaccines administered.

How many VPDs are there? ›

VPDs are 25 viral and bacterial diseases listed by the World Health Organization (WHO) that can be prevented by vaccination.

What are the 13 vaccines? ›

Catch-up vaccinations
  • HPV.
  • Tetanus, diphtheria, and whooping cough (pertussis) (Tdap)
  • Meningococcal disease (MenACWY)
  • Hepatitis A (HepA)
  • Hepatitis B (HepB)
  • Polio (IPV)
  • Measles, mumps, rubella (MMR)
  • Chickenpox (Varicella)

How do I get the yellow CDC book? ›

Purchase a Copy. Or call 1-800-451-7556. Ask for ISBN# 978-0-19-092893-3 for paperback and 978-0-19-006597-3 for hardback. You can also order a copy from major online booksellers, such as Amazon and Barnes & Noble.

What is pink book training? ›

The Centers for Disease Control and Prevention's (CDC's) Epi/Vac Pink Book Webinar Series aims to provide an overview of the principles of vaccination, general recommendations, immunization strategies for providers, and specific information about vaccine-preventable diseases and the vaccines that prevent them.

How do I get a Vams CDC? ›

Creating an account
  1. Ask your employer or organization to register you as a user if they are using the VAMS tool. ...
  2. Check your inbox for a registration email from ...
  3. Click the registration link in the email. ...
  4. Follow the directions to create and verify your password in the system.

Is it better to inject a vaccine slow or fast? ›

Some vaccinators favour a slow rate of injection (around 8-10 sec/mL) while others prefer a more rapid rate of injection (around 2-4 sec/mL). The slow injection method leads to a longer needle dwelling time with the increased possibility of the needle moving around and causing pain by damaging muscle tissue.

Is Pfizer Covid vaccine called Comirnaty? ›

On August 23, 2021, FDA announced the first approval of a COVID-19 vaccine. The vaccine has been known as the Pfizer-BioNTech COVID-19 Vaccine, and the approved vaccine is marketed as Comirnaty, for the prevention of COVID-19 in individuals 12 years of age and older.

What are the 12 vaccine preventable diseases? ›

Total of 12 vaccine-preventable diseases are covered against which free immunization is provided:
  • Diphtheria.
  • Pertussis.
  • Tetanus.
  • Polio.
  • Measles.
  • Rubella, severe form of Childhood Tuberculosis.
  • Hepatitis B.
  • Meningitis.

What are vaccine preventable diseases VPDs? ›

These diseases can cause long-term illness, hospitalization, and even death. Examples of VPDs are: whooping cough (pertussis), chicken pox (varicella), measles, meningococcal disease, and pneumococcal diseases.

How many vaccine preventable deaths? ›

Immunization Prevents Death Worldwide

4 million deaths worldwide are prevented by childhood vaccination every year.

How many years is a pneumonia shot good for? ›

People who need a pneumonia vaccine should get both shots: first, the PCV13 shot and then the PPSV23 shot a year or more later. For most people, one of each shot should be enough to protect them for their entire lives.

What is Tdap vaccine called? ›

Tdap (Adacel® and Boostrix®) provides protection against tetanus, diphtheria, and whooping cough.

Is the yellow book free? ›

Available to download for free in PDF, epub, and Kindle ebook formats.

What is the full name of the yellow book for CDC? ›


CDC Health Information for International Travel (“The Yellow Book”) has been a trusted resource for over 50 years.

How do I get proof of yellow fever vaccine? ›

The yellow fever vaccine protects against yellow fever. After you have received the vaccine you are given a yellow fever vaccine certificate to prove that you have received the vaccine and are protected from infection. This certificate is designed to fit inside your passport, and is valid for life.

What is Vietnam pink book? ›

The Pink Book, or more legally known as the “Certificate of Land Use Right and Ownership of House and Other Assets on the Land,” is a document that every property owner in Vietnam, foreign or not, should secure for the legality of their ownership.

Where is zoster vaccine administered? ›

Zostavax (zoster vaccine live) is administered subcutaneously as a single dose in the deltoid region. The vaccine should not be injected intramuscularly. However, it is not necessary to repeat vaccination if it is administered intramuscularly.

Which immunizations are subcutaneous? ›

Live, attenuated injectable vaccines (e.g., MMR, varicella, yellow fever) and certain non-live vaccines (e.g., meningococcal polysaccharide) are recommended by the manufacturers to be administered by subcutaneous injection.

How do i print a COVID certificate? ›

To access your certificate, you can download the COVIDCert NI app. Or, you can log in at the link below for a printable PDF version: Log in to the COVID certificate service.

How do I register my vaccines with Vams? ›

Information for General Public Users (Vaccine Recipients) using VAMS
  1. Schedule a COVID-19 vaccine appointment (for yourself or someone else) at a vaccination clinic.
  2. Pre-register for a vaccine without scheduling an appointment.
  3. Manage a current appointment.
  4. Update your information.

How to add a vaccination to vams? ›

On the Recipient Management tab, select Record Past Vaccination(s), then select Record Individually within VAMS. Click Record Past Vaccinations. Search for the healthcare professional who administered the vaccine by name or email address. This can be your own name or email address if you are recording for yourself.

Does the COVID vaccine go into your muscle? ›

First, mRNA COVID-19 vaccines are given in the upper arm muscle or upper thigh, depending on the age of who is getting vaccinated. After vaccination, the mRNA will enter the muscle cells.

Why do you pinch the skin before an injection? ›

Needle insertion

Insert needle at an 45o angle to the skin. Pinch up on SQ tissue to prevent injecting into muscle. Aspiration before injection is not required.

Do you put the bevel up or down for subcutaneous injection? ›

Be sure to insert the needle with the bevel up and insert all the way to the end of the needle. This will help you inject the medicine correctly. Release the skin, holding the syringe in place. If your healthcare provider has told you to pull back on the plunger to check for blood, then do so.

What is Green Book Covid? ›

The Green Book is an online resource from Public Health England (PHE) and is regularly updated to reflect the latest evidence, guidance and recommendations on all vaccinations. The Green Book has a chapter on COVID-19 vaccination, which offers guidance on storage, dosage, priority groups and potential adverse effects.

Is CDC journal peer reviewed? ›

We publish peer-reviewed articles of interest to public health researchers and practitioners. If you would like more information on a specific problem or condition, please visit the homepage for the Centers for Disease Control and Prevention (CDC) at or call the CDC information number at 1-800-232-4636.

Why did CDC change their name? ›

Finally, in October 1992, Congress changed CDC's official name to the Centers for Disease Control and Prevention, to recognize CDC's leadership role in prevention. Today, CDC is both the nation's prevention agency and a global leader in public health.

Does the CDC accept private donations? ›

CDC ensures that when we engage with the private sector, we are good stewards of the funds entrusted to us. We maintain our scientific integrity by participating in a gift review process that is rigorous and transparent. CDC's gift acceptance policy requires a comprehensive gift review prior to accepting a gift.

Where can I find the green book? ›

Green Book, a comedy drama movie starring Viggo Mortensen, Mahershala Ali, and Linda Cardellini is available to stream now. Watch it on Spectrum TV, ROW8, Prime Video, Vudu, Redbox. or Apple TV on your Roku device.

What does the Green Book provide? ›

The Green Book is guidance issued by HM Treasury on how to appraise policies, programmes and projects. It also provides guidance on the design and use of monitoring and evaluation before, during and after implementation.

What does NCOV stand? ›

plural NCOs. abbreviation for non-commissioned officer: a member of the armed forces who has achieved the rank of officer by rising from the lower ranks rather than by receiving a commission.


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