WHO estimates that three million cases of disease could be avoided annually with an appropriate prevention by vaccination.



Global Vaccination (attach this please with the previous sections)

WHO estimates that three million cases of disease could be avoided annually with an appropriate prevention by vaccination.

Immunization System in Malasyia (more info please add to US)

Religious Views of Vaccination (Malaysia) (please attach this with the previous sections)

Grabenstein (2013) noted that polio immunization is obligatory when disease risk is high and the vaccine shown to have benefits far outweighing its risks.

National Immunization Program (NIP)

The Malaysian National Immunization Program (NIP) was introduced in the early 1950s and it has been given free to the children for their protection against major childhood diseases. The immunization program offers protection against major childhood diseases that can be prevented with vaccines including diphtheria, tetanus, pertussis, Haemophilus influenzae type b, hepatitis B, measles, mumps, rubella, tuberculosis, polio and some diseases caused by the human papillomavirus. This program is available at all government clinics across the country.

Parents are responsible for ensuring that their children are protected from dangerous infectious diseases that can be prevented with a vaccine. Below is the national immunization schedule to ensure your child receives the vaccination at the right time (Malaysian MOH, 2017).

Vaccine Safety Surveillance

National Centre of Adverse Drug Reactions (ADR) Monitoring, National Pharmaceutical Control Bureau (NPCB) is responsible to monitor the safety of medicines and vaccines that are registered in Malaysia. NPCB is responsible for collecting all reporting adverse events related pharmaceutical products including vaccines. All reported adverse events will be documented and serious cases following vaccination will be investigated promptly to identify the cause of the adverse events. NPCB will make further investigation in terms of product quality and regulatory action will be taken based on the results of the investigation. Types of regulatory action that can be taken are the suspension of the product registration, product recall or cancellation of the product registration.

ADR reporting system has been introduced in Malaysia to enable health providers to participate in monitoring the safety of medicines and vaccines by reporting the adverse events. Ministry of Health Malaysia (MOH) has organized trainings to the health professionals on the importance of reporting of Adverse events following immunization (AEFIs) as described in the Guidelines for the Pharmacovigilance of Vaccines. Ongoing training will be conducted more actively to increase awareness among health care providers to report AEFI and importance of disseminating the information to parents/guardians.

Currently, the AEFI reporting system has been extended to the public whereby the parents/guardians of children who experience any adverse events can report to us by themselves (Malaysian MOH, 2017).


Immunization System in the US (more info please add to US)

In the United States of America (US), vaccines almost eliminated congenital rubella, tetanus, and diphtheria, and significantly reduced the incidence of pertussis, rubella, measles, and mumps. In the US, vaccination is considered primarily the responsibility of individual health care providers and health care systems serving patients.

WIC (Kindly make it 5 lines)

The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) is a categorical federal grant program administered by the U.S. Department of Agriculture through state health departments. The program provides supplemental foods, health-care referrals, and nutrition education to low-income pregnant, breastfeeding, or postpartum women, as well as to infants and children aged <5 years. Between 8.5 and 8.9 million people participated in this program in 2013. In collaboration, WIC and state vaccination programs assess regularly the vaccination coverage levels of WIC participants and develop new strategies and aggressive outreach procedures in sites with coverage levels <90%. Vaccination programs and private providers are encouraged to refer eligible children to obtain WIC nutritional services.

Vaccination of Children and Adolescents (Kindly make it 4-5 lines)

Physicians and other pediatric vaccination providers should adhere to the standards for child and adolescent vaccination practices. These standards are published by the National Vaccine Advisory Committee and define appropriate vaccination practices for both public and private sectors. The standards provide guidance on practices that eliminate barriers to vaccination, including eliminating unnecessary prerequisites for receiving vaccinations, eliminating missed opportunities to vaccinate, improving procedures to assess vaccination needs, enhancing knowledge about vaccinations among parents and providers, and improving management and reporting of adverse events. In addition, the standards address the importance of recall and reminder systems and using assessments to monitor clinic or office vaccination coverage levels. Health-care providers should simultaneously administer as many vaccine doses as possible as indicated on the Recommended Immunization Schedules for Persons Aged 0 Through 18 Years.

Adolescent-Specific Issues I need only the current status and the challenges

Vaccinations are recommended throughout life, including during adolescence. The age range for adolescence is defined as 11-21 years by many professional associations, including the American Academy of Pediatrics and the American Medical Association. Definitions of these age cutoffs differ depending on the source of the definition and the source’s purpose for creating a definition. Vaccination of adolescents is critical for preventing diseases for which adolescents are at particularly high or increasing risk, such as meningococcal disease and human papillomavirus infection. Three vaccines recommended for adolescents have been licensed since 2005: MenACWY and Tdap were licensed in 2005, and HPV was licensed in 2006. A second dose of varicella vaccine is recommended for persons who received 1 dose of varicella vaccine after age 12 months. In addition, annual seasonal influenza vaccination is recommended for persons aged >6 months who have no contraindications. To ensure vaccine coverage, clinicians and other health-care providers who treat adolescents must review vaccination history on every occasion that an adolescent has an office visit.

National goals for vaccination coverage for adolescents aged 13-15 years were included in Healthy People 2020. Targets of 80% coverage were specified for one dose of Tdap, one dose of meningococcal conjugate vaccine, and 3 doses of HPV vaccine. Results of the published 2014 National Immunization Survey—Teen indicate that coverage rates for 13-17 years olds is 87.6% for one dose of Tdap and 79.3% for one dose of meningococcal vaccine. Coverage rates for 13-17 years olds for HPV vaccine are considerably lower—39.7% for females and 21.6% for males.

Ensuring adolescents receive routine and catch-up vaccination and achieving high levels of vaccination coverage present challenges. In general, adolescents do not visit health care providers frequently. Health care providers should promote annual preventive visits ( 11 ), including one specifically for adolescents aged 11 and 12 years. The annual visits should be used as opportunities to provide routinely recommended vaccine doses, additional catch-up doses needed for lapsed vaccine series, vaccines recommended for high-risk groups, additional doses that might have been recently recommended, and other recommended health-care services. Additional strategies include adolescent immunizations at community-based venues such as pharmacies and schools.

All vaccine doses should be administered according to ACIP vaccine-specific statements and with the most recent schedules for both routine and catch-up vaccination. Before leaving any visit for medical care, adolescents should be encouraged to schedule return visits for any additional vaccine doses needed. During visits that occur outside of influenza season, providers should discuss and recommend seasonal influenza vaccination and make explicit plans for vaccination, including timing and anticipated setting (e.g., health care provider’s office, school, or pharmacy). Catch-up vaccination with multidose adolescent vaccines generally can occur according to the routine dosing schedule for these vaccines, although in some circumstances the clinician or health care provider might use minimum intervals for vaccine doses. These circumstances include an outbreak that increases risk for disease or the likelihood that doses will be missed in the future (e.g., because of transportation challenges). Because of lack of efficacy data for HPV vaccine administration using minimum intervals, providers are encouraged, when possible, to use routine dosing intervals for females aged 11-26 years and males aged 11-21 years who have not yet received 3 HPV vaccine doses as recommended ( 3,4 ).

One of the challenges of adolescent vaccination is ensuring that current, complete vaccination histories are available. Insurers, covered services, or reimbursement levels can change, and these changes might affect reimbursement for vaccine doses and vaccination services directly while also causing disruptions in an adolescent’s access to vaccination providers or venues. In circumstances in which a vaccination record is unavailable, vaccination providers should attempt to obtain this information from various sources (e.g., parent, previous providers, or school records). More detail about how to obtain these records is available from CDC. With the exception of influenza and pneumococcal polysaccharide vaccines, if documentation of a vaccine dose is not available, the adolescent should be considered unvaccinated for that dose. Regardless of the venue in which an adolescent receives a dose of vaccine, that vaccine dose should be documented in the patient’s chart or in an office log, and the information should be entered into an IIS. The adolescent also should be provided with a record that documents the vaccination history.

Adult Vaccination (Kindly make it 4-5 lines)

In 2013, the National Vaccine Advisory Committee published updated standards for adult vaccination ( 12 ). These standards are targeted to distinct groups involved in adult vaccination, including immunizing providers, non-immunizing providers, professional health-care organizations, and public health departments. All health-care providers, whether they provide immunizations or not, should incorporate immunization needs assessment into every clinical encounter, strongly recommend needed vaccine(s) and either administer vaccine(s) or refer patients to a provider who can immunize, stay up-to-date on, and educate patients about vaccine recommendations, implement systems to incorporate vaccine assessment into routine clinical care, and understand how to access immunization information systems (i.e., immunization registries) ( 12 ).

Vaccination rates in adults are considered suboptimal. New Healthy People 2020 goals include specific subsets of adults, including institutionalized adults aged ≥18 years (for pneumococcal vaccines) and noninstitutionalized adults at high risk aged >18 years (for pneumococcal vaccines).

The most substantial barrier to vaccination coverage is lack of knowledge about these vaccines among adult patients and adult providers. Other barriers are cost (incomplete Medicare coverage for recommended vaccines) and the lack of financing mechanisms for newly licensed and recommended vaccines. Effective for private health insurance plans drafted or updated after September 2010, coverage for all immunizations that are included on the immunization schedule(s) must be covered without deductibles or co-pays, when delivered by an in-network provider. For this reason, cost may present less of a barrier to adult vaccination as time passes.

A common challenge for health-care providers is vaccinating adults with unknown vaccination records. In general (except for influenza and pneumococcal polysaccharide vaccines), adults should receive a vaccine dose if the dose is recommended and no record of previous administration exists. If an adult has a record of military service and does not have records available, providers can assume that the person has received all vaccines recommended by the military at the time of service entry. Serologic testing might be helpful in clarifying immune status if questions remain, because at different times and depending on military assignments, there might be inter-service and individual differences.

Evidence-based Interventions to Increase Vaccination Coverage (Kindly make it 4-5 lines)

The independent, nonfederal Task Force on Community Preventive Services, whose membership is appointed by CDC, provides public health decision-makers with recommendations on population-based interventions to promote health and prevent disease, injury, disability, and premature death. The recommendations are based on systematic reviews of the scientific literature about effectiveness and cost-effectiveness of these interventions. In addition, the task force identifies critical information about the other effects of these interventions, the applicability to specific populations and settings, and the potential barriers to implementation. Additional information, including updates of published reviews, is available from The Community Guide.

Beginning in 1996, the task force systematically reviewed published evidence on the effectiveness and cost-effectiveness of population-based interventions to increase coverage of vaccines recommended for routine use among children, adolescents, and adults. A total of 197 articles were identified that evaluated a relevant intervention, met inclusion criteria, and were published during 1980-1997. Reviews of 17 specific interventions were published in 1999 ( 13,14,16,17 ). Using the results of their review, the task force made recommendations about the use of these interventions ( 15 ). Several interventions were identified and recommended on the basis of published evidence. Follow-up reviews were published in 2000, and a review of interventions to improve the coverage of adults at high risk was conducted in 2005. The interventions and the recommendations are summarized in this section of this report (Table 11-1). Interventions designated for adults younger than 65 years at high risk for influenza, invasive pneumococcal disease, and hepatitis B, include provider reminder systems or a menu of items (combinations of strategies ) (Table 11-2). In 1997, the task force categorized vaccination requirements for child care, school, and college as a recommended strategy.

The Current Status

Since 1995, all states receiving federal funds for vaccination programs have been required to conduct annual assessments of vaccination rates both in public health clinics and in private provider offices. Primarily to aid local and state health departments in their efforts to conduct assessments and assist providers, CDC has developed numerous software applications to measure vaccination rates in provider practices.

Other General Programmatic Issues

With availability of safe and effective vaccines for 18 vaccine-preventable diseases, the capacity for realizing the potential benefits of these products in the United States depends on reaching children, adolescents, and adults through dedicated, knowledgeable vaccination providers and efficient, strong vaccination programs at local, state, and federal levels.

For Healthcare Professionals

Each year, the Advisory Committee on Immunization Practices (ACIP) approves immunization schedules recommended for persons living in the United States. The adult immunization schedule provides a summary of ACIP recommendations on the use of licensed vaccines routinely recommended for adults aged 19 years or older. The adult immunization schedule is also approved by the American College of Physicians (ACP), the American Academy of Family Physicians (AAFP), the American College of Obstetricians and Gynecologists (ACOG), and the American College of Nurse-Midwives (ACNM).

Immunization System in Saudi Arabia

Ministry of Health

There are more than 2,000 primary health care centers throughout the Kingdom. A ministry official said all children’s vaccines are available in these centers except the one against hepatitis A, which is experiencing a global shortage. Last year, 90 percent of children in the Kingdom were immunized, resulting in a sharp drop in the incidence of rubella (German measles). However, the MOH implements its immunization program in line with the Atlanta-based Center for Disease Control and Prevention (CDC) and the World Health Organization (WHO).

The Current Status of MOH

According to Rukban et al. (2005), immunization in Riyadh is mainly conducted by males, Pediatricians and doctors with no postgraduate qualification. Self-confidence is relatively higher among Pediatricians, holders of PhD and MS, physicians working in private hospitals and those with more than four years of experience. National and International protocols were less frequently used. The majority of immunization providers did not have enough experience in dealing with situations not related to childhood immunization.

However, Saudi Arabia demands proof of recent meningococcal vaccination (with a polysaccharide or conjugate tetravalent vaccine) as a visa requirement for pilgrims and guest workers (WHO, 2015). Some polio-free countries may also require travellers resident in countries or areas reporting wild polioviruses to be immunized against polio in order to obtain a n entry visa, as in the case of Saudi Arabia. Travellers should be provided with a written record of all vaccines administered (patien t-retained record), preferably using the International Certificate of Vaccination or Prophyl axis (which is required in the case of yellow fever vaccination). The certificate can be a ccessed on the WHO website (WHO, 2015).

Vaccine Safety Surveillance

In Saudi Arabia, the Ministry of Health (MOH) operates the Expanded Programme on Immunization (EPI) through the National Immunization program (NIP) department. NIP is responsible for setting up policy guidelines and standards for selection, supply and utilization of vaccines in the country. NIP has done a tremendous job and some of the notable achievements of the program include achieving immunization coverage of over 95 % for all primary immunization, establishing a cold chain system, engaging state a nd district authorities in monitoring vaccine use, training and developing healthcare providers as well as establishing linkages and networking with international stakeholders.

Likewise, the National Regulatory Authorities – NRAs (Saudi Food and Drugs Aut hority – SFDA) monitor the safety of all medical products including vaccines. The SFDA uses spontaneous pharmacovigilance system to collect any suspected adverse drug reactions experienced by patients. The SFDA is also responsible for authorization of marke ting all medicines including vaccines. All vaccine manufacturers are required by law to register their products before supplying and distributing them in the country. The overall goal is t he protection of the health and wellbeing of the entire population particularly infants, children and pregnant women and the general population who depend on vaccines to protect them from serious vaccine preventable diseases (VPD).

School Health Program

School Health Program is delivered by the Ministry of National Guard Health Affairs. The school health team is organizing scheduled pre-school clinic, which is targeting the students who are entering the 1st new school grades (NGHA, 2014). School Immunization contains:

· Complete obligatory vaccinations for those entering KG & Elementary school (4-6 years): MMR, DPT, Varicella & polio.

· Tetanus vaccine for females in 1st grade high schools.

· Meningitis Vaccine for 1st, 4th Elementary school, 1st intermediate & 1st grade secondary.

· Other vaccinations such as measles

Health Services in the Pilgrimage (Hajj) Season

During the month of Ramadan or during Umrah and Hajj pilgrimages, millions of Muslims from highly diverse geographical regions visit these holy places mostly via Jeddah City. These individuals remain in contact with each other for an extended period of time reaching up to 1 month during some occasions (Hashem, 2016). This could introduce not only new or highly pathogenic strains but also resistant viruses into Saudi Arabia, particularly during peak influenza seasons. Thus, healthcare services in the hajj season provide preventive and curative care for all pilgrims, irrespective of their nationality. Preventive care includes health education programmes, vaccination and chemoprophylaxis for all pilgrims via quarantine services at airports and land ports (Almalki, FitzGerald, & Clark, 2011).

The Saudi Thoracic Society has recently published its guidelines for influenza immunization with particular emphasis on Hajj and Umrah. Implementation of these guidelines will undoubtedly require the involvement of the Saudi Ministry of Hajj, its counterpart agencies in other countries and public health agencies worldwide. An accumulating body of evidence suggests that influenza infections are very common during Hajj and pilgrims can import influenza back to their home countries. Importantly, the incidence of influenza infection among vaccinated individuals is not uncommon most probably due to strain mismatch. Furthermore, pilgrims from countries where influenza circulates year-round or influenza seasons are usually ahead of the season in Saudi, which extends from September to March, could complicate the situation even more. Therefore, inclusion of both influenza vaccines from the Northern and Southern Hemispheres could be considered for all pilgrims when the two vaccines are different.

Another critical point to consider is that current epidemiological and virological data on circulating influenza viruses in Saudi Arabia are seriously deficient, and there is no existing influenza surveillance program in the Kingdom. Only limited number of studies have reported and/or characterized circulating influenza viruses during few Hajj seasons. Therefore, it is important to monitor circulating influenza viruses by launching and implementing an active human influenza surveillance program in Saudi Arabia with particular emphasis on Hajj and Umrah seasons. Such program can provide significant virological, molecular, and epidemiological information on circulating influenza strains, and its associated morbidity and mortality to decision-makers globally to make informed decisions and to undertake effective control measures in order to decrease the disease burden (Hashem, 2016).

Recommendations. Continual vigilance to improve public health effectiveness and efficiency should become best practice—ie, the state-of-the-art policies, planning, communications, surveillance, and operations in stressful and emergency conditions should be continually reviewed. Furthermore, after-action reviews should be done to improve future performance on the basis of real-time experience. Noteworthy is that the recommendations generated during this meeting were based on the current status of the pandemic and therefore might need revision, dependent on the changes in virus characteristics and epidemiology of infections with the 2009 pandemic influenza A H1N1 virus (Memish et al., 2009).


· To achieve an effective disease prevention program, we should have qualified doctors, cooperative patients and well-developed health system. Doctors’ mistakes and poor knowledge of immunizations could be very harmful. Therefore, it is important to evaluate the competence of immunization providers.

· To improve immunization services, physicians should be given the appropriate training. This training would have a positive impact on their performance. Frequent distribution of national and international protocols on immunization, as well as proper regular auditing practice would hopefully improve and sustain an effective service.

· Several studies documented considerable delays in the administration of primary vaccinations due to difficulties with the appointment, non-febrile upper respiratory tract illness, and most of the parents were not concerned at all regarding the vaccination delay (Hasanain, & Jan, 2002).

Religious Views of Vaccination

faith type alone is not linked to vaccination issues and interacts with other national factors: Saudi Arabia – a country with 100% Muslim respondents – has a very low religious objection rate (2%) (Grabenstein, 2013).

Recommendations at the end of the paper for all the systems

According to CDC 2017), the following are recommendations regarding interventions to improve coverage of vaccines recommended for routine use among children, adolescents, and adults

1- Increase community demand for vaccination

· Client reminder or recall systems

· Requirements for entry to schools, child- care facilities, and colleges

· Community education alone

· Community-based interventions implemented in combination

· Clinic-based education

· Patient or family incentives

· Patient or family monetary sanctions

· Client-held medical records

2- Enhance access to vaccination services

· Reducing out-of-pocket costs

· Enhancing access through the U.S. Department of Agriculture’s Women, Infants, and Children (WIC) program

· Home visits, outreach, and case management targeted to particularly hard-to-reach populations to increase vaccination rates

· Enhancing access at schools

· Expanding access in health-care settings

· Enhancing access at organized child care centers

3- Focus on providers

· Provider reminder or recall systems

· Provider assessment and feedback

· Standing orders

· Provider education alone

· Health-care systems-based interventions integrated in combination

· Immunization information systems


Almalki, M., FitzGerald, G., & Clark, M. (2011). Health care system in Saudi Arabia: an overview/Aperçu du système de santé en Arabie saoudite. Eastern Mediterranean health journal17(10), 784.‏

Memish, Z. A., McNabb, S. J. N., Mahoney, F., Alrabiah, F., Marano, N., Ahmed, Q. A., … & El Bushra, H. (2009). Establishment of public health security in Saudi Arabia for the 2009 Hajj in response to pandemic influenza A H1N1. The Lancet374(9703), 1786-1791.‏


Al-Rukban, M. O., Al-Migbal, T. H., Al-Mutlaq, A. A., Al-Marshady, M. A., Al-Salhi, A. H., Al-Rsheed, A. A., … Al-Thagafi, S. A. (2005). CHARACTERISTICS OF IMMUNIZATION PROVIDERS IN RIYADH AND THEIR SELF-PERCEPTION OF COMPETENCY. Journal of Family & Community Medicine12(1), 35–41.

Vaccine-preventable diseases and vaccines WHO (2015) http://www.who.int/ith/ITH-Chapter6.pdf

Hasanain, F. H., & Jan, M. M. (2002). Delays in primary vaccination of infants living in Western Saudi Arabia. Saudi medical journal23(9), 1087-1089.‏

NGHA (2014) http://ngha.med.sa/English/MedicalCities/Jeddah/FCM/Pages/SHP.aspx

Grabenstein, J. D. (2013). What the world’s religions teach, applied to vaccines and immune globulins. Vaccine31(16), 2011-2023.‏

CDC (2017) https://www.cdc.gov/vaccines/hcp/acip-recs/general-recs/programs.html

Hashem, A. M. (2016). Influenza immunization and surveillance in Saudi Arabia. Annals of Thoracic Medicine11(2), 161. http://doi.org/10.4103/1817-1737.180022


Malaysian Ministry of Health (MOH). Surveillance of Adverse Events Following Immunization


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