A Specific Approach to the Question: 'Why Don't You Vaccinate?'

Oddly, I’ve shared research and published literature on the topic of vaccination, immunology and epidemiology for half a decade - but I have yet to provide a reason as to why I currently choose an alternative schedule for my children.

Now, there are many catchy posts and blogs out there that go on to list ‘x’-number of reasons on why they don’t vaccinate – and this is nice for people looking for a convenient list to compare their knowledge and beliefs against (or to criticize the heck out of).
My list is a bit different…. my list and reasons below are disease/vaccine specific.
To be honest, when people ask me why we do not give consent to vaccinate I don’t know exactly what to say.
For starters, which disease are they referring to?
For some diseases, my reasons to decline overlap, some may only partially affect my reason, while others are more prominent. Some vaccines are more easily declined then others based on the risks of infection and the treatment involved in recovery.
Another reason of hesitation in addressing this question: most people expect some all-encompassing novel reason.
I’m sorry, but that does not exist…at least, not that I’ve come across.
Some people may expect me to say vaccines don’t work, but I don’t believe that in the slightest. In fact, with each national vaccine campaign, epidemiology (and herd immunity) is modified in varying degrees, benefiting some while actually placing another group at higher risk than before.[*][*][*]
Ultimately, I have many reasons why I choose I decline, and the reasons may be modified depending on the disease.
In this post, I want to address the ever-so-popular confrontational question, “Why don’t you vaccinate”, in a very specific approach. Each disease will be discussed separately from medical and governmental sources. I will also provide a brief reason why I decline that particular vaccine for the recommended age group.
(My daughters are healthy children with no underlying medical conditions. I have no family history adverse vaccine reactions. The reasons listed are my own. I recommend anyone interested in this subject to learn more about informed vaccine choices and to ask their medical provider to furnish literature to review prior to the administration of any pharmaceutical medication.)


Hepatitis B
Viral infection of the liver
The Hepatitis B vaccine was one of the easiest vaccines to decline based purely on the risk of the disease to my newborn and waning protection over time.
Also, I did not have hepatitis B infection while pregnant.

Vaccine Schedule/Recommendation:[*]
4-dose series, HepB vaccine to all newborns: Birth, 1 month, 2 months, 6 months

The Disease:
Hepatitis B is a virus that infects the liver. The incubation period ranges from 45 to 160 days. Clinical signs and symptoms occur more often in adults than in infants or children, who usually have an asymptomatic acute course. Approximately 50% of adults who have acute infections are asymptomatic. [*]
Initial symptoms may include an onset of jaundice which usually lasts from 3 to 10 days. The icteric phase is variable but usually lasts from 1 to 3 weeks and is characterized by jaundice and light or gray stools. [*]
Approximately 5% of all acute HBV infections progress to chronic infection. [*]
While most acute HBV infections in adults result in complete recovery, fulminant hepatitis (a rare and fatal form of acute hepatitis B) occurs in about 1% to 2% of acutely infected persons. [*]
Approximately 90% of infants who acquire HBV infection from their mothers at birth become chronically infected. This is way all pregnancy mothers are tested prenatally for hepatitis infection. Transmission from mother to infant is prevented by giving the infant HBIG (Hepatitis B Immune Globulin). [*]

Unprotected sex, blood transfusions, re-use of contaminated needles & syringes, and vertical transmission. [*]
Hepatitis B is spread when blood, semen, or other body fluid infected with the Hepatitis B virus enters the body of a person who is not infected.

People can become infected with the virus during activities such as:
•Birth (spread from an infected mother to her baby during birth)
•Sex with an infected partner
•Sharing needles, syringes, or other drug-injection equipment
•Sharing items such as razors or toothbrushes with an infected person
•Direct contact with the blood or open sores of an infected person
•Exposure to blood from needles or other sharp instruments

The three major risk groups (according to the CDC):

•heterosexuals with contact with infected persons or multiple partners
•injection-drug users
•men who have sex with men)

These populations are not reached effectively by targeted programs, so a new strategy to eliminate hepatitis B was recommended in 1991 which included prenatal testing routine vaccination of infants. [*]
Lifetime risk for Hepatitis B is 4% in the USA.[*]
Current prevalence of hepatitis b infection is 0.55%. [*]

Protection from the vaccine:
Among children age 6-19 years, just about 50% showed markers of vaccine-induced immunity, with little difference across racial/ethnic groups.[*]
Hepatitis B vaccination-induced protective antibodies can last for up to 15 years, but appears to fall off over time when they are more likely to be at risk.[*]

 In one study, in just 5 years, efficacy of the vaccine fell to 67%.[*]
The most common adverse reaction following hepatitis B vaccine is pain at the site of injection. Hepatitis B vaccine has been alleged to cause or exacerbate multiple sclerosis (MS). A 2004 retrospective study in a British population found a slight increase in risk of MS among hepatitis B vaccine recipients.[*] 
More than 95% of people who become infected as adults or older children will stage a full recovery and develop protective immunity to the virus. Of those infected between the age of one to six, 70% will clear the infection. [*]
There is no medication available to treat acute Hepatitis B. During this short-term infection, doctors usually recommend rest, adequate nutrition, and fluids, although some people may need to be hospitalized. [*]

Stomach flu
The risks of complications due to rotavirus are extremely low. These risks are lowered further when, according to some research, the duration of breastfeeding is extended.
Also, although the rotavirus vaccine is recommended by the Advisory Committee on Immunization Practices (ACIP), it is not mandated in any state.
We declined this vaccine because the risk of moderate to severe complication and death from rotavirus are not enough for us to risk adverse reaction to vaccination (not even if the risk is rare).

Vaccine Schedule/Recommendation:[*]
Rotarix (2 dose series) 2 and 4 months
RotaTeq (3 dose series) 2, 4, and 6 months

The Disease:
The incubation period for rotavirus diarrhea is short, usually less than 48 hours. The clinical manifestations of infection vary and depend on whether it is the first infection or reinfection. The first infection after 3 months of age is generally the most severe. [*]
Infection may range from asymptomatic to self-limited watery diarrhea, or may result in severe dehydrating diarrhea with fever and vomiting. Up to one-third of infected children may have a temperature greater than 102°F (39°C). The gastrointestinal symptoms generally resolve in 3 to 7 days. [*]
The disease is more prevalent during fall and winter. The reason for this seasonal pattern is unknown. [*]
The virus is transmitted by the faecal-oral route (via contact with contaminated hands, surfaces and objects). It infects and damages the cells that line the small intestine and causes gastroenteritis (which is often called "stomach flu" despite having no relation to influenza). [*]
Infection with rotavirus is nearly universal, with almost all children infected by 5 years of age. A vaccine to prevent rotavirus gastroenteritis was first licensed in August 1998 but was withdrawn in 1999 because of its association with intussusception. Second-generation vaccines were licensed in 2006 and 2008. [*]
Approximately 37 death per year before the vaccine was introduced. Rotavirus is not a reportable disease so current mortality data is not available. [*]
Boys are twice as likely as girls to be admitted to hospital. [*]
Rotavirus infection is more prevalent during fall and winter.The reason for this seasonal pattern is unknown. [*]
Infants younger than 3 months of age have relatively low rates of rotavirus infection, most likely due to of passive maternal antibody and breastfeeding. [*]
Groups at increased risk for rotavirus infection are those with increased exposure to virus. These include children in hospital wards (nosocomial rotavirus), young children attending day care centers, and elderly people in nursing homes.[*][*]
Protection from the vaccine:
The immune correlates of protection from rotavirus are poorly understood. [*]

 After completion of a three-dose RV5 regimen, the efficacy of rotavirus vaccine against rotavirus gastroenteritis of any severity was 74%. [*]
The duration of immunity from rotavirus vaccine is not known. [*]
Rotavirus is usually an easily managed disease of childhood. Treatment includes hydration. The WHO also recommends zinc supplementation. [*]
Rotavirus infections rarely cause other complications and for a well-managed child the prognosis is excellent.[*]

Other protective effects:
Breast feeding
There is evidence of a protective concurrent effect of breastfeeding against rotavirus infection in infants, particularly in children 6 months and younger.[*] 
Earlier studies in relation to breastfeeding and the rotavirus indicated that the duration of breastfeeding was important in protection. [*]
Epithelial barrier integrity, known to be superior in the breastfed infant as compared to the bottle-fed infant, promotes epidermal growth factor strengthen epithelial barrier development. It is thought by some that the integrity of the intestinal mucosa maybe a significant factor that may protect from potentially invasive rotaviral disease.[*]  
Toxin-mediated bacterial infection
The low prevalence of diphtheria in the US (2 cases in the 21st century, last of which was 2003 – see below for reference) is one major factor in deciding to decline this part of the combination vaccine. The risk of my daughter(s) contracting diphtheria and exhibiting symptoms is very small.
The waning protection of the vaccine is also of concern. 
I choose not to place my daughters at risk for known/unknown vaccine adverse effects (DTaP or Tdap) purely for the sake of herd immunity against diphtheria, especially if the effectiveness of the vaccine will wane substantially after 10 years and dependence of boosters throughout life are apparent.
If my daughters decide to vaccinate themselves when they are older against diphtheria, that is their choice. Right now, it is my responsibility to assess the risk of disease and the benefits of this vaccine until they can do that for themselves.
Vaccine Schedule/Recommendation:[*]
5-dose DTap 2, 4, 6, 15-18 months and 4-6 years
No vaccine is available in the US for diphtheria alone. Vaccination for diphtheria must be obtain in a combination vaccine in conjunction with pertussis and tetanus (Tdap, DTap) or tetanus alone (Td).

The Disease:
Diphtheria is an acute, toxin-mediated disease caused by the bacterium Corynebacterium diphtheriae.[*]
The incubation period of diphtheria is 2–5 days. Diphtheria causes a characteristic swollen neck. Symptoms of diphtheria include fever of 100.4°F or above, chills, fatigue, bluish skin coloration, sore throat, hoarseness, cough, headache, and difficulty swallowing. [*]

Diphtheria is an infectious disease spread by direct physical contact or breathing the aerosolized secretions of infected individuals.[*]
Human carriers are the reservoir for C. diphtheriae and are usually asymptomatic. In outbreaks, high percentages of children are found to be transient carriers (one who harbors disease organisms in their body without manifest symptoms). [*]

Diphtheria occurs worldwide, but clinical cases are more prevalent in temperate zones. In the United States during the pre-toxoid era, the highest incidence was in the Southeast during the winter. [*] 
In the US, there were 53 reported cases of diphtheria between 1980 and 2000, only a total of 2 cases of diphtheria have been reported in the 21st century, the last of which was in 2003. [*]
The overall case-fatality rate for diphtheria is 5%–10%, with higher death rates (up to 20%) among persons younger than 5 and older than 40 years of age. The case-fatality rate for diphtheria has changed very little during the last 50 years. [*]

Protection from the vaccine:
The duration for diphtheria vaccine is 10 years. [*]
The diphtheria cases recently reported in Eastern Europe illustrate a waning immunity to diphtheria among many adults.[*]

Antibiotics are used in patients or carriers to eradicate C. diphtheriae and prevent its transmission to others (metronidazole, erythromycin, procaine penicillin G). [*]
Persons with suspected diphtheria should be given antibiotics and antitoxin in adequate dosage and placed in isolation after the provisional clinical diagnosis is made and appropriate cultures are obtained. Respiratory support and airway maintenance should also be administered as needed. [*]
On average, there are 29 cases of tetanus reported annually (see below for reference). Given this and the information that 75% of the deaths in the US are patients older than 60 years, tetanus is not a vaccine we consider for my daughter’s age group.
To add, the tetanus component to the vaccine seems to be more adverse then the other components (pertussis, diptheria). This, in combination with the lack of evidence on efficacy of the tetanus toxoid, we currently decline.
Vaccine Schedule/Recommendation:[*]
5-dose DTap 2, 4, 6, 15-18 months and 4-6 years
Booster administered every ten years.
No vaccine is available in the US for tetanus alone however, vaccination for tetanus in children is recommended in a combination vaccine in conjunction with pertussis and tetanus (Tdap, DTap) or tetanus alone (Td). For those who have contradictions to aP, TD is recommended.
The adult booster for tetanus also combines diphtheria (Td).

The Disease:
Tetanus is an acute, often fatal, disease caused by an exotoxin produced by the bacterium Clostridium tetani. It is characterized by generalized rigidity and convulsive spasms of skeletal muscles. The muscle stiffness usually involves the jaw (lockjaw) and neck and then becomes generalized.[*]
C. tetani usually enters the body through a wound. In the presence of anaerobic (low oxygen) conditions, the spores germinate. [*]
The typical clinical manifestations of tetanus are caused when tetanus toxin interferes with release of neurotransmitters, blocking inhibitor impulses. This leads to unopposed muscle contraction and spasm. [*]
The time between an injury and the occurrence of the first symptoms is typically less than two weeks but may range from 5 days to 15 weeks. [*]  
Infection generally occurs through wound contamination and often involves a cut or deep puncture wound.[*] 
Tetanus is not contagious from person to person. It is the only vaccine-preventable disease that is infectious but not contagious. [*]

Organisms are found primarily in the soil and intestinal tracts of animals and humans. [*]

 Transmission is primarily by contaminated wounds. The wound may be major or minor. In recent years, however, a higher proportion of patients had minor wounds, most likely because severe wounds are more likely to be properly managed and cleaned. Tetanus may follow elective surgery, burns, deep puncture wounds, crush wounds, otitis media (ear infections), dental infection, animal bites, abortion, and pregnancy. [*]
All wounds should be well cleaned to prevent tetanus. [*]

From 1998-2000, 75% of the deaths in the US were in patients older than 60 years.[*]
Heroin users, particularly persons who inject themselves subcutaneously, appear to be at high risk for tetanus. [*]
From 2001 - 2008, the last years for which data have been compiled, a total of 233 tetanus cases was reported, an average of 29 cases per year. Among the 197 cases with known outcomes the case-fatality rate was 13%. [*]
Tetanus occurs worldwide but is most frequently encountered in densely populated regions in hot, damp climates with soil rich in organic matter. [*]
Protection from the vaccine:
Efficacy of the tetanus toxoid has never been studied in a vaccine trial. [*]
Because of waning antitoxin titers, most persons have antitoxin levels below the optimal level 10 years after the last dose of DTaP, DTP, DT, or Td. Additional booster doses of tetanus and diphtheria toxoids are required every 10 years to maintain protective antitoxin titers. The first booster dose of Td may be given at 11 or 12 years of age if at least 5 years have elapsed since the last dose of DTaP, DTP, or DT. The Advisory Committee on Immunization Practices (ACIP) recommends that this dose be administered as Tdap. [*]
Severe systemic reactions such as generalized urticaria (hives), anaphylaxis, or neurologic complications have been reported after receipt of tetanus toxoid. A few cases of peripheral neuropathy and Guillain-Barré syndrome (GBS) have been reported following tetanus toxoid administration. [*]
Exaggerated local reactions are occasionally reported following receipt of a diphtheria- or tetanus-containing vaccine. These reactions present as extensive painful swelling, often from shoulder to elbow. They generally begin 2–8 hours after injections and are reported most often in adults. [*]
Rarely, severe systemic reactions such as generalized urticaria, anaphylaxis, or neurologic complications have been reported following administration of diphtheria toxoid. [*]

Immune globulin, given intramuscularly, is the immediate treatment of unimmunized individuals exposed to material likely to contain the tetanus bacteria. Treatment includes bed rest and quiet conditions. Antimicrobial drugs, such as penicillin, are used to eradicate the bacteria.[*] 
A single intramuscular dose of tetanus immune globulin (TIG)  (3,000 to 5,000 units) is generally recommended for children and adults, with part of the dose infiltrated around the wound if it can be identified. [*]

Whooping Cough
The DTaP vaccine was more challenging to decline when my girls were younger (less then 12 months old). Pertussis infection can be very serious in infants and the vaccine can lessen symptoms if the disease is contracted.
My girls are older now and because clinical manifestation of the disease is age dependent,  I give less consideration to the disease then I did in the past.
The risk of my children (when they were younger than 12 months) of dying from pertussis was still very low without the vaccine (0.000004%), this reason in combination with the evidence that vaccinated children show an increase in the colonization of parapertussis (40-fold increase) in the lungs compared to those unvaccinated – we currently declined this vaccine.
This is definitely not one of the easier choice vaccines to decline. I continue to re-visit the published literature on the aP (acellular pertussis) vaccine and the epidemiology of pertussis and parapertussis infection within the United States.
Vaccine Schedule/Recommendation:[*]
5-dose DTap 2, 4, 6, 15-18 months and 4-6 years
Booster of Tdap at 11-12 years.

Booster of Tdap to pregnant mothers during each pregnancy (3rd trimester).
The Disease:
Pertussis, commonly called whooping cough — is a highly contagious bacterial disease caused most commonly by Bordetella pertussis, though Bordetella parapertussis has also been associated with this condition in humans.[*]
The infection with B. pertussis results in a wide spectrum of clinical manifestations, depending on the age and immune status of the host, and ranges from mild respiratory symptoms to a severe cough illness, which may be accompanied by the hallmark inspiratory whoop.[*] 
The incubation period of pertussis is commonly 7–10 days. The clinical course of the illness is divided into three stages:[*]
The catarrhal stage: characterized by the onset of a runny nose, sneezing, low-grade fever, mild coughing - similar to the common cold. Lasting approximately 1-2 weeks. [*]
The paroxysmal stage: Fever is generally minimal throughout the course of the illness, the cough gradually becomes more intense. [*]
The paroxysmal stage: It is during this stage that the diagnosis of pertussis is usually suspected. Characteristically, the patient has bursts of numerous, rapid coughs, apparently due to difficulty expelling thick mucus from the tracheobronchial tree. At the end of the paroxysm, a long inspiratory effort is usually accompanied by a characteristic high-pitched whoop. [*]
Many people do not develop the characteristic whoop. Sometimes, a persistent hacking cough is the only sign that an adolescent or adult has whooping cough.[*]
In infected person will not appear to be ill between attacks. [*]
Recovery is gradual. The cough becomes less paroxysmal and disappears in 2 to 3 weeks. [*]
The most common complication, and the cause of most pertussis-related deaths, is secondary bacterial pneumonia. Young infants are at highest risk for acquiring pertussis-associated complications. [*]
B. pertussis is a strict human pathogen with no known animal or environmental reservoir, maintenance of the organism within the population is thought to require continuous transmission of the disease from infected to naive hosts. [*] 

Pertussis is often described as being highly infectious (with household contact studies showing an infection rate between 58% and 100%).

Although pertussis is typically described as being highly infectious, efficient transmission requires close contact or prolonged exposure. [*]
As expected for an airborne exposure, the rate of transmission is dependent upon distance between the infected and naive individual.[*]

Before the vaccine was developed, whooping cough was considered a childhood disease. Now whooping cough primarily affects children too young to have completed the full course of vaccinations and teenagers and adults whose immunity has faded. [*]   
With greater than 27, 000 reported cases in the United States in 2010, the highest number since the 1950s, pertussis is the most commonly occurring vaccine-preventable disease. This resurgence is occurring throughout the industrial world despite similar high rates of vaccination.[*]
Deaths associated with whooping cough are rare but most commonly occur in infants.[*]
Without Vaccination (based on 2010 data):[*][*]
Risk pertussis infection under 12 months = 0.007%
Risk of death = 0.000004%

With Vaccination(based on 2010 data):[*][*]
Risk of pertussis infection under 12 months = 0.005%
Risk of death = 0.000002%
Protection from the vaccine:
The protective power of the diphtheria, tetanus, acellular pertussis vaccination (DTaP) wanes with time.  Each year that elapses after vaccination is associated with a 36% increased risk of acquiring pertussis. [*]
The waning protection of the vaccine is one reason why was have been witnessing a gradually increasing since the early 1980s.[*]
Another reason: Although this disease is most often attributed to Bordetella pertussis infection, it is also caused by the closely related pathogen, B. parapertussis. Acelluar pertussis vaccination has been documented in leading to a 40-fold enhancement of B. parapertussis colonization in the lungs of mice.[*][*]
As with all injected vaccines, administration of DTaP may cause local reactions, such as pain, redness, or swelling. Local reactions have been reported in 20%–40% of children after the first three doses. Local reactions appear to be more frequent after the fourth and/or fifth doses. Mild systemic reactions such as drowsiness, fretfulness, and low-grade fever may also occur. [*]
Swelling involving the entire thigh or upper arm has been reported after booster doses of certain acellular pertussis vaccines. The limb swelling may be accompanied by erythema, pain and fever. Although the swelling may interfere with walking, most children have no limitation of activity. The pathogenesis and frequency of substantial local reactions and limb swelling are not known. [*]
The medical management of pertussis cases is primarily supportive. [*]
Treatment for older children and adults usually can be managed at home.[*]
Infants are typically hospitalized for treatment because whooping cough is more dangerous for that age group. If your child can't keep down liquids or food, intravenous fluids may be necessary. Your child will also be isolated from others to prevent the infection from spreading. [*]
Antibiotics kill the bacteria causing whooping cough and help speed recovery. Family members may be given preventive antibiotics. [*]
Other recommendations include: [*]
-Get plenty of rest
-Drink plenty of fluids
-Vaporize the room (soothe irritated lungs and to help loosen respiratory secretions)
-Breathe clean the air (keeping your home free of irritants that can trigger coughing spells, such as tobacco smoke)
Haemophilus B
The most recent data I was able to obtain on invasive Hib infection was from 2009. That year, 35 children (younger than 5 years) died from invasive Hib infection.
Coupling the low risk of death from Hib infection with the other factors that do not make my children high risk (see below for risk factors and the role long term breastfeeding has on infection), we currently decline this vaccine.
According to the CDC (see below for reference), in the prevaccine era, the majority of children acquired immunity by 5–6 years of age through asymptomatic infection by Hib bacteria.

 The vaccine is not recommended for those over 5 yrs of age, my oldest who is approaching 5 years old will not be a candidate for this vaccine in a few months. This makes the choice to decline more straightforward as well.
Vaccine Schedule/Recommendation:[*]
4-dose series of conjugate vaccine at 2, 4, 6 months
Booster 12-15 months
Haemophilus b conjugate vaccine is recommended for all children 2 months to 5 years of age[*]
Hib vaccine is not routinely recommended for patients older than 5 years of age.[*]
The Disease:
Most strains of Haemophilus influenzae bacteria, including Hib, usually live in a person’s nose or throat without causing disease. Severe infections can result when the bacteria invade parts of the body that are normally free from germs, like blood or spinal fluid. This is known as "invasive disease."[*] 
The exact mode of invasion to the bloodstream is unknown. [*] 
Since the introduction of Hib conjugate vaccines in the 1990s, the epidemiology of invasive H influenzae disease has changed substantially, with most infections now caused by non-Hib strains. [*]
The most striking feature of Hib disease is age-dependent susceptibility. Hib disease is not common beyond 5 years of age (however, this epidemiology is changing due to the vaccination of infants, see below for more detail). In the prevaccine era, most children acquired immunity by 5–6 years of age through asymptomatic infection by Hib bacteria. [*]
Humans (asymptomatic carriers) are the only known reservoir. Hib does not survive in the environment on inanimate surfaces. The primary mode of Hib transmission is presumably by respiratory droplet spread, although firm evidence for this mechanism is lacking. [*]
Several studies in the prevaccine era described a bimodal seasonal pattern in the United States, with one peak during September through December and a second peak during March through May. The reason for this bimodal pattern is not known. [*]   
The contagious potential of invasive Hib disease is considered to be limited. However, certain circumstances, particularly close contact with a case-patient (e.g., household, child care, or institutional setting) can lead to outbreaks or direct secondary transmission of the disease. [*]    
In 2009, among children younger than 5 years of age, 35 cases of invasive disease due to Hib were reported in the United States. [*]
Risk factors for Hib disease include exposure factors and host factors that increase the likelihood of exposure to Hib. Exposure factors include household crowding, large household size, child care attendance, low socioeconomic status, low parental education levels, and school-aged siblings. Host factors include race/ethnicity (elevated risk among African Americans, Hispanics, Native Americans—possibly confounded by socioeconomic variables that are associated with both race/ethnicity and Hib disease), chronic disease (e.g., sickle cell anemia, antibody deficiency syndromes, malignancies, especially during chemotherapy), and possibly gender (risk is higher for males). [*]
Protective factors (effect limited to infants younger than 6 months of age) include breastfeeding and passively acquired maternal antibody. [*]
Protection from the vaccine:
(Concerns: Serotype replacement and increasing adult mortality)
Although the reduction in carriage achieved by conjugate vaccines is beneficial from the perspective of herd immunity, it has raised concerns about the possibility of serotype replacement.[*]
Because the protection offered by conjugate vaccines is specific to the capsular type(s) included in the vaccine, it has been suggested that reducing carriage of these vaccine types may leave open an ecologic niche that will be filled by serotypes not included in the vaccine. [*]
As the prevalence of Hib has decreased, other encapsulated serotypes seem to have emerged as major causes of invasive disease.[*]
Strain replacement of Hib with serotype f and non-typeable strains in children under 5 years has been documented. [*]
Also, invasive H. influenzae infection, once a childhood concern, has now been documented in disproportionately affecting the elderly and is associated with a high mortality rate.[*]
Although vaccination of infants resulted in an initial decline in Hib infections in adults, a resurgence in reported cases occurred in 2002-3. Childhood vaccination programs  may have unanticipated effects on the epidemiology of Hib disease in older age groups.[*] 
The incidence of H. influenzae invasive disease has shifted toward adults. In a study conducted in the Atlanta, Georgia, USA, metropolitan area before Hib vaccine introduction, adults comprised 24% of all invasive H. influenzae cases (6). A more recent population-based report from Illinois showed adults accounting for 77% of invasive cases. [*]
Most (51%) invasive disease occurred in persons [greater than or equal to] 65 years of age. [*]
A vaccine, like any medicine, is capable of causing serious problems, such as severe allergic reactions. The risk of Hib vaccine causing serious harm or death is extremely small.[*]
When Haemophilus influenzae bacteria causea a non-invasive infection, like bronchitis or an ear infection, complications are rare and typically not severe. If appropriate, antibiotics will be given to prevent complications.[*]
Hospitalization is generally required for invasive Hib disease. Antimicrobial therapy with an effective third-generation cephalosporin (cefotaxime or ceftriaxone), or chloramphenicol in combination with ampicillin should be begun immediately. The treatment course is usually 10 days.[*]
As for invasive Hib B infection, the complications can be different. For example, if meningitis occurs, a person can suffer from brain damage or hearing loss. Bacteremia (blood infection) can result in loss of limb(s). [*]
Other protective effects:
Breast feeding
There is a long-lasting protective effect of breastfeeding on the risk for invasive Hib infection. Data has shown a  decreased risk for invasive Hib infection with long duration of breastfeeding.[*][*]
The colonization of H. influenzae in the throat is inhibited by the presence of breast milk.[*] 
Streptococcus Pneumoniae
Several other parents I know that follow a delayed/select vaccine schedule choose to include Prevnar 13. The vaccine has been very effective at modifying epidemiology of infection of the 13 strains (out of the 80 circulating) it currently includes.
Out of all vaccines available, this is the one that I would most likely administer (if I had to pick one).
We choose to decline Pzifer’s Prevnar 13 product because the risk of my daughters becoming seriously ill from this disease is very low (they do not have any pre-existing conditions that place them at high risk of invasive infection). We also consider that up to 70% of adults are asymptomatic carriers and the relationship between antibody titer and protection from pneumococcal invasive disease is still not certain.
We also consider that there is the lack of clinical safety data to review comparing the vaccine against a placebo group and the severe adverse reaction rate. According to the clinical safety data from the manufacturer, 8.2% of infants and toddlers reported severe reactions after 1-dose vaccination. A child will be administered this product 4 times (if vaccinating on schedule). The manufacturer’s clinical data did not utilize a saline placebo group in establishing safety, Prevnar 13 was tested against Prevnar 7.

Vaccine Schedule/Recommendation:[*]
Routine vaccination with Pneumococcal conjugate vaccine (PCV-13) is recommended ages 2, 4, 6 months with a booster at age 12 through 15 months. (Unvaccinated children 7 months of age or older require fewer doses)
Booster vaccination with Pneumococcal polysaccharide vaccine (PPSV23) is recommended at age 65 or older. A booster is also recommended starting at age 19 if a person smokes or has asthma.[*] 
The Disease:
Pneumonia has many possible causes. The most common are bacteria and viruses in the air we breathe. A person’s body usually prevents these germs from infecting the lungs but sometimes these germs can overpower the immune system.[*] 
Symptoms of pneumococcal infection include sudden onset of fever and fatigue, sneezing and cough with mucus and shortness of breath. The infection may start with start with a general feeling of being unwell, a low grade fever and a cough that doesn’t include mucus before symptoms worsen. Symptoms of pneumococcal meningitis (brain inflammation) include stiff neck (inability to touch the chin to chest without moderate to severe pain in the back of the neck and head); headache; extreme fatigue or seizures. [*]
The major clinical syndromes of pneumococcal disease are pneumonia, bacteremia, and meningitis. The immunologic mechanism that allows disease to occur in a carrier is not clearly understood. However, disease most often occurs when a predisposing condition exists, particularly pulmonary disease. [*]
The relationship between antibody titer and protection from pneumococcal invasive disease is not certain. [*]

S. pneumoniae is a human pathogen. Transmission of S. pneumoniae occurs as the result of direct person-to-person contact via respiratory droplets and by autoinoculation (autoinoculation means to “self spread”- aka spreading the bacteria to another part of your body) in persons carrying the bacteria in their upper respiratory tract. [*]
Pneumococci are common inhabitants of the respiratory tract . The carrier rate in asymptomatic healthy adults varies between 40% and 70%.[*][*]
Rates of asymptomatic carriage vary with age, environment, and the presence of upper respiratory infections. Only 5%–10% of adults without children are carriers. [*]
Pneumococcal infections are more common during the winter and in early spring when respiratory diseases are more prevalent. [*]
Conditions that increase the risk of invasive pneumococcal disease include decreased immune function from disease or drugs, functional or anatomic asplenia, chronic heart, pulmonary including asthma, liver, or renal disease, smoking cigarettes, and cerebrospinal fluid, or CSF leak. [*]

Before introduction of PCV7, rates of PC7-type invasive pneumococcal disease among children in this age were around 80 cases per 100,000 population (0.0008%).  After the introduction of PCV7, rates of disease due to these 7 serotypes dropped dramatically to less than 1 case per 100,000 (0.00001%).[*] 
Approximately 10% of all patients with invasive pneumococcal disease die of their illness, but case-fatality rates are higher for the elderly and patients with certain underlying illnesses. [*]
Children with functional or anatomic asplenia, particularly those with sickle cell disease, and children with human immunodeficiency virus (HIV) infection are at very high risk for invasive disease, with rates in some studies more than 50 times higher than those among children of the same age without these conditions. [*]
Rates are also increased among children of certain racial and ethnic groups (Alaska Native, African American, and certain American Indian groups). The reason for this increased risk by race and ethnicity is not known. [*]
Attendance at a child care center has also been shown to increase the risk of invasive pneumococcal disease among children younger than 59 months of age. [*]
Protection from the vaccine:
Data from the Active Bacterial Core surveillance (ABCs) system suggest that the use of pneumococcal conjugate vaccine has had a major impact on the incidence of invasive disease among young children.
However, there is evidence that mass use of the PCV-7 vaccine placed pressure on some of the 80 other pneumococcal strains to cause invasive disease and was responsible for increasing the rates of otitis media caused by serotypes not included in the seven-valent vaccine, particularly the 19A strain.[*][*][*][*][*]

 To alleviate this problem, a new vaccine replaced the PCV7 to include serotype 19A (PCV13).
The PPSV23 booster, shows antibody levels declining after 5–10 years (and decrease more rapidly in some groups than others). In fact, this vaccine does not produce a sustained increase (“boost”) in antibody titers. Available data does not indicate a substantial increase in protection in the majority of revaccinated persons. [*]
Despite multiple studies conducted during >30 years, the efficacy and effectiveness of 23-valent pneumococcal polysaccharide vaccine (PPSV) in children and adults remain poorly defined and the subject of controversy. Furthermore, repeated doses of PPSV are associated with hyporesponsiveness, when antibody levels after a second antigenic challenge are lower than after the first administration.[*] 
Local reactions (such as pain, swelling or redness) following PCV13 occur in up to half of recipients. [*]
Approximately 8% of local reactions are considered to be severe (e.g., tenderness that interferes with limb movement). [*]
The manufacturer product insert indicates that when Prevnar is given at the same time as HIB, pertussis and polio vaccines, it may lower the efficacy of those vaccines for some children. There is no data on what happens when Prevnar vaccine is given in combination with MMR or chicken pox vaccines.[*]
Resistance to penicillin and other antibiotics is common. In some areas of the United States, up to 40% of invasive pneumococcal isolates are resistant to penicillin. Treatment will usually include a broad-spectrum cephalosporin, and often vancomycin, until results of antibiotic sensitivity testing are available. [*]
Breastfeeding inhibits the attachment of Streptococcus pneumoniae and Haemophilus influenzae.[*]
As of 1994, wild-type polio has been declared eradicated in the Western Hemisphere – this provides a very minimal risk for my daughters (or myself) to be exposed to the polio virus and/or exhibit symptoms and/or suffer adverse complications.
We currently do not travel internationally (or to those countries that have polio in circulation).
These reasons, coupled with the understanding that most all (95%) polio infections are inapparent/asymptomatic – we currently decline this vaccine.
Vaccine Schedule/Recommendation:[*]
Routine vaccination includes administration of inactivated poliovirus vaccine (IPV) at ages 2, 4, 6–18 months, with a booster at age 4–6 years.

The Disease:
Poliomyelitis is a viral disease that can affect nerves and has the potential to lead to partial or full paralysis.[*]
The response to poliovirus infection is highly variable, there are three basic patterns of polio infection: subclinical infections, nonparalytic, and paralytic. Approximately, 95% of all polio infections are inapparent or asymptomatic. [*][*]
Some subclinical infection symptoms include: general discomfort or uneasiness (malaise), headache, slight fever, and sore throat. [*]

Humans are the only known reservoir of poliovirus, which is transmitted most frequently through contact with stool of an infected person (known as fecal-oral transmission) with inapparent infections. [*][*]
Less frequently, polio transmission can occur through contact with infected respiratory secretions or saliva (oral-oral transmission).
This spread of poliovirus can happen via:[*]
•Eating food or drinking liquids that are contaminated with poliovirus. Poliovirus is commonly found in sewage water.
•Touching surfaces or objects contaminated with poliovirus (for example, when changing diapers), and then placing the contaminated hand in the mouth.

The virus enters through the mouth, and primary multiplication of the virus occurs at the site of implantation in the pharynx and gastrointestinal tract. [*]
The incubation period for poliomyelitis is commonly 6 to 20 days with a range of 3 to 35 days. [*]
Polio is eradicated in most parts of the world (except for three countries Afghanistan, Nigeria and Pakistan). [*]
In 2012, about 220 cases were reported worldwide, and almost all were in these 3 countries. [*]
In September 1994, an international commission certified the Western Hemisphere to be free of indigenous wild poliovirus. [*]
From 1980 through 1999, a total of 152 confirmed cases of paralytic poliomyelitis were reported in the US. 95% of these cases were vaccine-associated paralytic polio (VAPP) caused by live oral polio vaccine. [*]
In order to eliminate VAPP from the United States, ACIP recommended in 2000 that  IPV be used exclusively in the United States. [*]
The death-to-case ratio for paralytic polio is generally 2%–5% among children and up to 15%–30% for adults (depending on age). [*]
Fewer than 1% of all polio infections result in flaccid paralysis. [*]
Protection from the vaccine:
Duration of immunity is not known.[*]
The efficacy of 2 doses of IPV is 90% after 2 doses, 99% after 3 doses. [*]
As for the OPV, theoretically, one may require 10-15 doses of OPV to reach near 100% efficacy (children under 5 years in northern India had received on average 19 doses of OPV).[*] 
One major challenge to the wild poliovirus eradication is the poor immunogenicity of OPV in lower-income countries. Routine schedules where four or five doses of trivalent OPV are administered are not always sufficiently protective.[*] 
Research into the causes of OPV failure and interventions to improve its immunogenicity is ongoing. [*]
Since IPV contains trace amounts of streptomycin, neomycin, and polymyxin B, there is a possibility of allergic reactions in persons sensitive to these antibiotics. [*]
The goal of treatment is to control symptoms while the infection runs its course. [*]
The treatment and outlook depend on the form of the disease (subclinical >95%, or paralytic 1-2%) and the body area affected. [*][*]
Symptoms are treated based on their severity. Treatment may include: [*]
•Antibiotics for urinary tract infections
•Moist heat (heating pads, warm towels) to reduce muscle pain and spasms
•Painkillers to reduce headache, muscle pain, and spasms (narcotics are not usually given because they increase the risk of breathing trouble)
•Physical therapy, braces or corrective shoes, or orthopedic surgery to help recover muscle strength and function

We currently decline annual influenza vaccine administration to our daughters (and ourselves).
The safety data on the influenza vaccine is severely limited in children (despite the CDC’s recommendation to vaccinate children 6 months and older). I also find the mounting evidence that repeat exposure to the vaccine increases other non-influenza respiratory illness, to say the least, very discouraging.
Approximately all influenza related deaths (90%) occur in persons that are 65 years and older.
My children have no pre-existing conditions (such as asthma or immune-compromised illness).
These factors converge and reinforce our decision not to administer this vaccine.
Vaccine Schedule/Recommendation:[*]
Routine vaccination: Administer inactivated influenza vaccine annually to all children beginning at age 6 months. 

Administer 2 doses (separated by at least 4 weeks) to children (6mos – 8yrs) who are receiving influenza vaccine for the first time.
The Disease:
Influenza is a highly infectious viral illness. [*]
Following respiratory transmission, the influenza virus attaches to and penetrates respiratory epithelial cells in the trachea and bronchi. Viral replication occurs, which results in the destruction of the host cell. Virus is shed in respiratory secretions for 5–10 days. [*]
The incubation period for influenza is usually 2 days, but can vary from 1 to 4 days. The severity of influenza illness depends on the prior immunologic experience with antigenically related virus variants. In general, only about 50% of infected persons will develop the classic clinical symptoms of influenza. [*]

 “Classic” influenza disease is characterized by the abrupt onset of fever, myalgia, sore throat, nonproductive cough, and headache. Additional symptoms may include rhinorrhea (runny nose), headache, substernal chest burning and ocular symptoms (e.g., eye pain and sensitivity to light). [*]
Systemic symptoms and fever usually last from 2 to 3 days, rarely more than 5 days. [*]

Humans are the only known reservoir of influenza types B and C. Influenza A may infect both humans and animals. [*]
Influenza is primarily transmitted from person to person via large virus-laden droplets (particles more than 5 microns in diameter) that are generated when infected persons cough or sneeze. These large droplets can then settle on the mucosal surfaces of the upper respiratory tracts of susceptible persons who are near (within 3 feet) infected persons. [*]
Transmission may also occur through direct contact or indirect contact with respiratory secretions such as when touching surfaces contaminated with influenza virus and then touching the eyes, nose or mouth. [*]
Adults can transmit influenza from the day before symptom onset to approximately 5 days after symptoms begin. Children can transmit influenza to others for 10 or more days. [*]
Influenza occurs throughout the world. [*]
Peak influenza activity in the United States occurred most frequently in January and February. [*]
Persons 65 years of age and older account for approximately 90% of deaths attributed to influenza. [*]
Protection from the vaccine:
Multiple manufacturers produce inactivated influenza vaccine each year for the U.S. market. [*]
Immunity following inactivated influenza vaccination is less than 1 year because of waning of vaccine-induced antibody and antigenic drift of circulating influenza viruses. [*]
At best, vaccines might be effective against only influenza A and B, which represent about 10% of all circulating viruses[*]
In children under the age of two, the efficacy of inactivated vaccine was similar to placebo. [*]
Analysis of safety data from influenza vaccines (in children) is not able to be reviewed due to the lack of standardization in the information published, but very little information was found on the safety of inactivated vaccines, the most commonly used vaccine in young children. [*]
Influenza vaccines were associated with serious harms such as narcolepsy and febrile convulsions. [*]
There is no evidence that the influenza vaccine decreases complications, such as pneumonia, or transmission.[*]
The inactivated influenza vaccine has been documented (2012) in resulting in 5.5 times more incidents of respiratory illness in vaccinated individuals.  This phenomenon is known as virus interference.[*] 
In the majority of cases, nothing more than bed rest and plenty of fluids is recommended for treatment of influenza. In some cases, you may be prescribed an antiviral medication, such as oseltamivir (Tamiflu) or zanamivir (Relenza).[*][*]
We currently decline to vaccinate against the measles virus. This is for several reasons….
The current incidence rate in the US (0.7 per 1 million population) is low.
While I understand that approximately 30% of reported measles cases do have at least one complication reported, I also know that the most common reaction reported is diarrhea.
We understand that severe complications from measles can be avoided though supportive care that ensures good nutrition, adequate fluid intake and treatment of dehydration.[*] 
On a personal note, I have witnessed a severe adverse reaction to this vaccine (thrombocytopenia). While I can comprehend that the risk of this reaction (or any other severe reaction) from this vaccine is considered low, I must admit that experiencing first hand a severe reaction in a young child against MMR is quite numbing. In my opinion, the risk is not worth it.  
Vaccine Schedule/Recommendation:[*]
Routine vaccination: administer the first dose of MMR II vaccine at age 12 through 15 months, and the second dose (MMR II or MMR-V) at age 4 through 6 years.
Administer 1 dose of MMR vaccine to infants aged 6 through 11 months before departure from the United States for international travel.
The Disease:
Measles is caused by the measles virus.
The infection occurs in sequential stages over a period of two to three weeks:[*]
-Infection/incubation (7-14 days): no signs or symptoms of measles during this time.
-Nonspecific signs and symptoms (2-3 days):  mild to moderate fever, often accompanied by a persistent cough, runny nose, inflamed eyes (conjunctivitis) and sore throat. [*]
-Acute illness and rash: the rash is consists of small red spots, some of which are slightly raised. The face breaks out first, particularly behind the ears and along the hairline. Over the next few days, the rash spreads down the arms and trun. At the same time, fever rises sharply, often as high as 104 or 105 F (40 or 40.6 C). The measles rash gradually recedes, fading first from the face and last from the thighs and feet. [*]
-Communicable period (8 days): a person with measles can spread the virus to others for about eight days, starting four days before the rash appears and ending when the rash has been present for four days. [*]
People who don't have enough vitamin A in their diets are more likely to contract measles and to have more-severe symptoms.[*]
The highly contagious virus is spread by coughing and sneezing, close personal contact or direct contact with infected nasal or throat secretions. [*]
The virus remains active and contagious in the air or on infected surfaces for up to two hours. It can be transmitted by an infected person from four days prior to the onset of the rash to four days after the rash erupts. [*]
Worldwide, there are estimated to be 20 million cases (with more than half of all deaths associated with measles occur in India).[*]
Before 1963, more than 50% of persons had measles by age 6, and more than 90% had measles by age 15.[*]
In 2000, the United States achieved measles elimination (defined as interruption of year-round endemic measles transmission).
During 2011, a total of 222 measles cases (incidence rate: 0.7 per 1 million population) were reported to CDC.[*]
The majority of cases are now imported from other countries or linked to imported cases. Most imported cases originate in Asia and Europe and occur both among U.S. citizens traveling abroad and persons visiting the United States from other countries.
Approximately 30% of reported measles cases have one or more complications (diarrhea was reported in 8% of measles cases, making this the most commonly reported complication of measles). Complications of measles are more common among children younger than 5 years of age and adults 20 years of age and older.
The overwhelming majority (more than 95%) of measles deaths occur in countries with low per capita incomes and weak health infrastructures.[*]
No deaths caused by the measles virus were reported for 2011 in the US. [*]
Measles is more severe in malnourished children, particularly those with vitamin A deficiency. Complications include diarrhea, dehydration, stomatitis, inability to feed, and bacterial infections (skin and elsewhere).

Protection from the vaccine:
The measles vaccine produces a mild, noncommunicable infection. Measles antibodies develop in approximately 95% of children vaccinated at 12 months of age and 98% of children vaccinated at 15 months of age.[*]
Approximately 2%–5% of children who receive only one dose of MMR vaccine fail to respond to it. MMR vaccine failure may occur because of passive antibody in the vaccine recipient, damaged vaccine, incorrect records, or possibly other reasons. Most persons who fail to respond to the first dose will respond to a second dose. [*]
Although the titer of vaccine-induced antibodies is lower than that following natural disease, both serologic and epidemiologic evidence indicate that vaccine-induced immunity appears to be long-term. [*]
Fever is the most common adverse reaction following MMR vaccination. Although measles, mumps, and rubella vaccines may cause fever after vaccination, the measles component of MMR vaccine is most often associated with this adverse reaction. After MMR vaccination, 5% to 15% of susceptible persons develop a temperature of 103°F (39.4°C) or higher, usually occurring 7 to 12 days after vaccination and generally lasting 1 or 2 days. Most persons with fever are otherwise asymptomatic. [*]
Measles- and rubella-containing vaccines, including MMR, may cause a transient rash. Rashes, usually appearing 7 to 10 days after MMR or measles vaccination, have been reported in approximately 5% of vaccinees. [*]
Rarely, MMR vaccine may cause thrombocytopenia within 2 months after vaccination (I personally know someone who has suffered this reaction one week following this vaccine). Estimates of the frequency of clinically apparent thrombocytopenia from Europe are one case per 30,000–40,000 vaccinated susceptible persons, with a temporal clustering of cases occurring 2 to 3 weeks after vaccination. The clinical course of these cases was usually transient and benign, although hemorrhage occurred rarely. [*]

Severe complications from measles can be avoided though supportive care that ensures good nutrition, adequate fluid intake and treatment of dehydration.[*] 
Maintain bedrest and provide quiet activities for children. If there is sensitivity to light, keep room darkly lit.[*]
Remove eye secretions with warm saline or water and encourage children not to rub eyes. [*]
Administer anti-itch medication and tepid sponge baths. [*]
A cool mist vaporizer can be used to relieve cough. [*]
Isolate child until fifth day of rash. [*]
Other protective effects
Vitamin A
People who don't have enough vitamin A in their diets are more likely to contract measles and to have more-severe symptoms.[*]
Vitamin A supplements have been shown to reduce the number of deaths from measles by 50%. [*] 
We decline this vaccine because mumps is generally a benign self-limited disease that produces lifelong immunity with severe side effects beign extremely rare.[*]
The number of mumps cases has dropped dramatically in the US, so the odds of getting mumps is low. Considering this and that 70% of cases of mumps are asymptomatic or have nonspecific symptoms, we decline the MMRII/MMR-V. [*]
Also, the effectiveness of the mumps component of the MMRII/MMRV depends on wild-type mumps (unvaccinated individuals) to provide boosters throughout life. Because of this, (and the growing evidence of waning immunity over time) mumps outbreaks among vaccinated populations are reported world-wide.
Vaccine Schedule/Recommendation:[*]
Routine vaccination: administer the first dose of MMR II vaccine at age 12 through 15 months, and the second dose (MMR II or MMR-V) at age 4 through 6 years.
Administer 1 dose of MMR vaccine to infants aged 6 through 11 months before departure from the United States for international travel.
The Disease:
Mumps is a viral infection that primarily affects the parotid glands — one of three pairs of saliva-producing (salivary) glands, situated below and in front of your ears. If you or your child contracts mumps, it can cause swelling in one or both parotid glands. [*][*]
The incubation period of mumps is 14 to 18 days (range, 14 to 25 days). Onset of mumps infection include symptoms that are nonspecific, and include headache, low-grade fever, body weakness and muscle pain. [*]

As many as 20% of mumps infections are asymptomatic. In an addition to that, 40% to 50% may have only nonspecific or primarily respiratory symptoms. [*]
Parotitis (inflammation of one or both parotid glands, the major salivary glands located on either side of the face, in humans)  is the most common manifestation and occurs in 30% to 40% of infected persons. Symptoms tend to decrease after 1 week and usually resolve after 10 days. [*]
Central nervous system (CNS) involvement in the form of aseptic meningitis occurs asymptomatically in 50% to 60% of patients. Symptomatic meningitis (headache, stiff neck) occurs in up to 15% of patients and resolves in 3 to 10 days. Adults are at higher risk for this complication than are children, and boys are more commonly affected than girls (3:1 ratio). [*]
Orchitis (testicular inflammation) is the most common complication in postpubertal males. It occurs in as many as 50% of postpubertal males. Pain and swelling may subside in 1 week, but tenderness may last for weeks. Approximately 50% of patients with orchitis have some degree of testicular atrophy, but sterility is rare. [*][*]
Oophoritis (ovarian inflammation) occurs in 5% of postpubertal females. It may mimic appendicitis. There is no relationship to impaired fertility. [*]
Although it has not been proved, contracting mumps while you're pregnant, especially early on, may lead to miscarriage. [*]

Mumps is a human disease. Although persons with asymptomatic or nonclassical infection can transmit the virus, no carrier state is known to exist. [*]
Mumps is spread through airborne transmission or by direct contact with saliva. [*]

Mumps outbreaks still occur in the United States, and mumps is still common in many parts of the world. [*][*]
The number of mumps cases has dropped dramatically in the US, so the odds of getting mumps is low. Complications of mumps, such as hearing loss, are potentially serious, but rare (approximately 1 per 20,000 reported cases). [*][*]

Protection from the vaccine:
Pertaining to the mumps component on the MMR II vaccine, the effectiveness of 1 dose declined from 96% in 2-year-olds to 66% in 11- to 12-year-olds. The  effectiveness of 2 doses declined from 99% in 5- to 6-year-olds to 86% in 11- to 12-year-olds. [*]
There is growing evidence of waning immunity over time and mumps outbreaks among vaccinated populations are reported world-wide.[*][*]
Unvaccinated individuals that acquire natural immunity provide boosts to vaccinated populations and increase vaccine effectiveness.[*]
Allergic reactions, including rash, pruritus, and purpura, have been temporally associated with vaccination, but these are transient and generally mild. [*]
There's no specific treatment for mumps. [*]
Supportive care should be given as needed.[*]
Mumps is generally a benign self-limited disease that produces lifelong immunity. Severe side effects are extremely rare.[*]
German Measles
The risk to my daughter health from rubella infection is extremely low considering rubella presents symptoms that are so mild that treatment usually isn't necessary.

The signs and symptoms of rubella are often so mild that they're difficult to notice.
Prevention of CRS (congential rubella syndrome) is the main objective of rubella vaccination. Congenital rubella occurs when the rubella virus in a pregnant mother affects the developing baby in the first 3 months of pregnancy. After the fourth month, the mother's rubella infection is less likely to harm the developing baby.
My daughters are too young to become pregnant at this time. This disease/vaccine is not relevent to their wellness. When they are older and can have children, they will have the power to decide if they want to be vaccinated against rubella.
Vaccine Schedule/Recommendation:[*]
Routine vaccination: administer the first dose of MMR II vaccine at age 12 through 15 months, and the second dose (MMR II or MMR-V) at age 4 through 6 years.
Administer 1 dose of MMR vaccine to infants aged 6 through 11 months before departure from the United States for international travel.

The Disease:
Rubella, also called German measles or three-day measles, is a contagious viral infection best known by its distinctive red rash.[*]
Rubella is not the same as measles (rubeola), though the two illnesses do share some characteristics, including the red rash. However, rubella is caused by a different virus than measles and is neither as infectious nor usually as severe as measles. [*]
The signs and symptoms of rubella are often so mild that they're difficult to notice (up to 50% of infections may be subclinical or inapparent), especially in children. If signs and symptoms do occur, they generally appear between two and three weeks after exposure to the virus. [*] [*]
In older children and adults, there is often a 1 to 5 day prodrome (early onset symtpoms) with low-grade fever, malaise, and upper respiratory symptoms preceding the rash. The rash usually occurs initially on the face and then progresses from head to foot. It lasts about 3 days. The rash is fainter than measles rash and does not coalesce. [*]
Prevention of CRS (congential rubella syndrome) is the main objective of rubella vaccination programs in the United States. [*]
Rubella is a human disease. There is no known animal reservoir. Although infants with CRS may shed rubella virus for an extended period, a true carrier state has not been described. [*]
Rubella is spread from person to person via airborne transmission or droplets shed from the respiratory secretions of infected persons. Rubella may be transmitted by persons with subclinical or asymptomatic cases (up to 50% of all rubella virus infections). [*]
Rubella is only moderately contagious. The disease is most contagious when the rash first appears, but virus may be shed from 7 days before to 5–7 days or more after rash onset. [*]
Infants with CRS (congential rubella syndrome) shed large quantities of virus from body secretions for up to 1 year and can therefore transmit rubella to persons caring for them who are susceptible to the disease. [*]
Prevention of CRS (congential rubella syndrome) is the main objective of rubella vaccination. [*]
Deafness is the most common and often the sole manifestation of congenital rubella infection, especially after the fourth month of gestation. Manifestations of CRS may be delayed from 2 to 4 years. [*]

Since 1997, the mothers of the majority of infants with CRS were Hispanic women, many of whom were born in Latin American or Caribbean countries where rubella vaccine is routinely not used or has only recently begun to be used. [*]
Many rash illnesses can mimic rubella infection, and as many as 50% of rubella infections may be subclinical/asymptomatic. [*]
If you're pregnant, you'll likely undergo a routine screening for immunity to rubella. [*]
Protection from the vaccine:
Several reports indicate that reinfection following exposure may occur in vaccinated persons who have low levels of detectable antibody. The frequency and consequences of this phenomenon are unknown. [*]
Rarely, clinical reinfection and fetal infection have been reported among women with vaccine-induced immunity. Rare cases of CRS have occurred among infants born to women who had documented serologic evidence of rubella immunity before they became pregnant. [*]

 Although vaccine virus may be isolated from the pharynx, vaccinees do not transmit rubella to others, except occasionally in the case of the vaccinated breastfeeding woman. In this situation, the infant may be infected, presumably through breast milk, and may develop a mild rash illness. [*]

Joint symptoms, such as arthralgia (joint pain) and arthritis (joint redness and/or swelling), are associated with the rubella component of MMR II. [*]
When acute joint symptoms occur, or when pain or paresthesias not associated with joints occur, the symptoms generally begin 1–3 weeks after vaccination, persist for 1 day to 3 weeks. [*]
Rarely, transient peripheral neuritic complaints, such as paresthesias and pain in the arms and legs, have been reported. [*]

No treatment will shorten the course of rubella infection, and symptoms are so mild that treatment usually isn't necessary.[*]
However, doctors often recommend isolation from others — especially pregnant women — during the infectious period. [*]
Support of an infant born with congenital rubella syndrome varies depending on the extent of the infant's problems. [*]
Tell friends, family and co-workers — especially pregnant women — about your diagnosis if they may have been exposed to the disease. [*]

My daughters are healthy and are not considered high-risk for complications from varicella.
In healthy children, chickenpox typically requires no medical treatment at all, with the clinical course being generally mild.
Complications are infrequent among healthy children.

We choose to decline this vaccine because we understand that the vaccine efficacy depends on the circulation of wild-type chickenpox infection.
With varicella, we are in a precarious situation. Since contracting the wild-type strain of chickenpox is extremely limited, when a a child is vaccinated (which will lay dormant in their nervous system) in hopes of a child become immune or elciting a more mild reaction then they would in adulthood - we are setting them up in an environment that does not offer boosters throughout life (unless you become dependent on more vaccine boosters).
We also understand that as a result of the implementation of a varicella vaccination program, shingles incidence is expected to increase (a much more serious infection than chickenpox). Studies have demonstrated that the vaccine virus can become latent and later reactivate to cause shingles in both healthy and immunocompromised persons/children.[*]

We currently decline this vaccine. As with all the vaccines listed here, my daughters will have the opportunity to choose whether or not to vaccinate themselves when they are older and understand the risk/benefits of the disease and vaccine.
(I would like to note that I do not support ‘chickenpox parties’. I write about my reasons here.)
Vaccine Schedule/Recommendation:[*]
Administer the first dose of varicella vaccine (Varivax) at age 12 through 15 months, and the second dose at age 4 through 6 years (MMR-V or Varivax).
The Disease:
Chickenpox (varicella) is a viral infection by the varicella zoster virus (VZV) that causes an itchy, blister-like rash. [*][*]
The recurrent infection (herpes zoster, aka shingles) has been recognized since ancient times. Primary varicella infection (chickenpox) was not reliably distinguished from smallpox until the end of the 19th century. [*]
The clinical course in healthy children is generally mild, with malaise, pruritus (itching), and temperature up to 102° for 2 to 3 days. Adults may have more severe disease and have a higher incidence of complications. Respiratory and gastrointestinal symptoms are absent. [*]
Acute varicella is generally mild and self-limited. [*]
Varicella is a human disease. No animal or insect source or vector is known to exist. [*]
Infection with VZV occurs through the respiratory tract. The most common mode of transmission of VZV is believed to be person to person from infected respiratory tract secretions. Transmission may also occur by respiratory contact with airborne droplets or by direct contact or inhalation of aerosols from vesicular fluid of skin lesions of acute varicella or zoster. [*]
The period of communicability extends from 1 to 2 days before the onset of rash through the first 4 to 5 days, or until lesions have formed crusts. [*]
Varicella is highly contagious. It is less contagious than measles, but more so than mumps and rubella. [*] 
Varicella and herpes zoster occur worldwide. [*]
Chickenpox is highly contagious to people who haven't had the disease nor been vaccinated against it. Before routine chickenpox vaccination, virtually all people had been infected by the time they reached adulthood. [*]
Some data suggest that in tropical areas, varicella infection occurs more commonly among adults than children. The reason(s) for this difference in age distribution are not known with certainty, but may be related to lack of childhood varicella infection in rural populations. [*]
The estimated death rate for chicken pox is 1.4 per 100,000 cases (0.000014%) in normal children, but rises to 30.9 deaths per I 00,000 cases (0.0309 %) in adults. The death rate is 7% in children with leukemia. [*]
Secondary bacterial infections of skin lesions with Staphylococcus or Streptococcus are the most common cause of hospitalization and outpatient medical visits. [*]
Complications are infrequent among healthy children. They occur much more frequently in persons older than 15 years of age and infants younger than 1 year of age. Adults account for only 5% of reported cases of varicella but approximately 35% of mortality. [*]
Protection from the vaccine:
The push to research and license the varicella vaccine stems from the complication and mortality rate among high-risk persons. [*]
These groups include children with leukemia, or persons receiving steroids, e.g., patients with cancer, arthritis, kidney disease, organ transplants, or asthma. Steroids are known to suppress immunity, leaving the patient sometimes defenseless against what would normally be harmless diseases. Immunocompromised persons comprise only an estimated 0. 1% of all chicken pox cases. [*]
About 15 to 20% of healthy vaccinated children will develop breakthrough varicella (breakthrough varicella is defined as disease with symptom onset that occurs >42 days after vaccination). [*]
The transmission rate for breakthrough cases caused by the vaccine is comparable to that for unvaccinated cases. [*]

If you've had chickenpox or the varicella vaccine, you are at risk of shingles. [*]
Shingles can lead to its own complication — a condition in which the pain of shingles persists long after the blisters disappear. This complication, called postherpetic neuralgia, can be severe. [*]
The virus is thought to be more common in older adults and people with weakened immune systems. [*]
Two studies utilizing mathematical models predicted that if exposure to wild-type varicella is important in maintaining immunity to varicella and shingles, the shingles incidence will increase in the short to medium term (over 10 to 40 years and up to 70 years) as a result of the implementation of a varicella vaccination program. [*]
One study estimated that boosting due to exposure to wild-type varicella (which is lost once the vaccination program started) could last up to an average of 20 years. [*]
Studies have demonstrated that the vaccine virus can become latent and later reactivate to cause herpes zoster in both healthy and immunocompromised persons.[*]

In otherwise healthy children, chickenpox typically requires no medical treatment. Your doctor may prescribe an antihistamine to relieve itching. But for the most part, the disease is allowed to run its course. [*]
Don't give anyone with chickenpox — child or adult — any medicine containing aspirin because this combination has been associated with a condition called Reye's syndrome.[*]

Hepatitis A
Hep A
My daughters do not possess an increased risk of hepatitis A (such as a man who has sexual contact with other men, are HIV positive, or use injected illicit drugs).
If they did somehow contract Hep A, the symptomatic illness is directly related to age. In children younger than 6 years of age, the majority of infections are asymptomatic.
We decline this vaccine mainly due of these two reasons.

Vaccine Schedule/Recommendation: [*]
Routine vaccination includes 2-dose Hep A vaccine series for children starting at age 12 months followed by a second dose 6-18 months later.

The Disease:
Hepatitis A is a highly contagious liver infection caused by the hepatitis A virus. The hepatitis A virus is one of several types of hepatitis viruses that cause inflammation that affects your liver's ability to function. [*]

Humans are the only natural reservoir of the virus. [*]
HAV infection is acquired primarily by the fecal-oral route by either person-to-person contact or ingestion of contaminated food or water. Because the virus is present in blood during the illness prodrome, HAV has been transmitted on rare occasions by transfusion. [*]
The incubation period of hepatitis A is approximately 28 days (range 15–50 days). The clinical course of acute hepatitis A is indistinguishable from that of other types of acute viral hepatitis. The illness typically has an abrupt onset of fever, malaise, anorexia, nausea, abdominal discomfort, dark urine and jaundice. Clinical illness usually does not last longer than 2 months, [*]
Children generally have asymptomatic or unrecognized illnesses, so they may serve as a source of infection[*]

Practicing good hygiene — including washing your hands often — is one of the best ways to protect against hepatitis A. [*]
In the prevaccine era, hepatitis A caused about 100 deaths per year in the United States. The case-fatality rate among persons of all ages with reported cases was approximately 0.3%[*]

A person is at increased risk of hepatitis A if they: [*]
-Travel or work in regions with high rates of hepatitis A
-Are a man who has sexual contact with other men (10% of cases) [*]
-Are HIV positive
-Use injected or noninjected illicit drugs (6% of cases) [*]
-Live with another person who has hepatitis A (14% of cases) [*]
-Receive clotting-factor concentrates for hemophilia or another medical condition

The likelihood of symptomatic illness from HAV infection is directly related to age. In children younger than 6 years of age, 70% infections are asymptomatic. [*]
In older children and adults, infection is usually symptomatic, with jaundice occurring in more than 70% of patients. [*]

In rare cases, hepatitis A can cause acute liver failure, which is a loss of liver function that occurs suddenly. People with the highest risk of this complication include those with chronic liver diseases and older adults. Acute liver failure requires hospitalization for monitoring and treatment. [*]

Protection from the vaccine:
Both vaccines are highly immunogenic. More than 95% of adults will develop protective antibody within 4 weeks of a single dose of either vaccine, and nearly 100% will seroconvert after receiving two doses. [*]
Data concerning the long-term persistence of antibody and immune memory are limited because the current vaccines have been available only since 1995 and 1996. Estimates of antibody persistence derived from kinetic models of antibody decline indicate that protective levels of anti-HAV could be present for 20 years or longer. Other mechanisms (e.g., cellular) may contribute to long-term protection, but this is unknown. The need for booster doses will be determined by postmarketing surveillance studies. [*]
For both vaccines, the most commonly reported adverse reaction following vaccination is a local reaction at the site of injection. Injection site pain, erythema, or swelling is reported by 20% to 50% of recipients. [*]


Mild cases of hepatitis A don't require treatment, and most people who are infected recover completely with no permanent liver damage. [*]

No specific treatment exists for hepatitis A. Your body will clear the hepatitis A virus on its own. In most cases of hepatitis A, the liver heals completely in a month or two with no lasting damage. [*]

Immune globulin (IG) is typically used for postexposure prophylaxis of hepatitis A in susceptible persons.[*]

Small studies of milk thistle treatment for liver disease have shown mixed results. Many of the studies have been poorly designed, making it difficult for researchers to draw conclusions about the usefulness of milk thistle. [*]


Bacterial Meningitis
(Groups A, C, Y and W-135)
My daughters are not yet old enough to be vaccinated for meningococcal.
I include the following information for those of you that do have children 11 yrs or older.

Vaccine Schedule/Recommendation: [*]
Meningococcal conjugate vaccine is recommended for infants and children with certain health conditions, however the two-dose series starts for all healthy children at age 11 years with a second booster at age 16 years.
Adolescents aged 11 through 18 years with human immunodeficiency virus (HIV) infection should receive a 2-dose primary series of MCV4, with at least 8 weeks between doses.

Vaccines available:

Menveo (Meningococcal polysaccharide groups A, C, Y, W135 and Diphtheria)

Menactra (Meningococcal polysaccharide groups A, C, Y, W135 and Diphtheria)

Menomune (Meningococcal polysaccharide groups A, C, Y, W135)

Menhibrix (Meningococcal groups C & Y, Haemophilus b , Tetanus)

The Disease:

Meningococcal disease is an acute, potentially severe illness caused by the bacterium Neisseria meningitidis. [*]

N. meningitidis strains are grouped on the basis of their capsular polysaccharides, 12 serogroups have been identified (A, B, C, H, I, K, L, X, Y, Z, 29E, and W135). [*]
The prominent outer membrane proteins of N. meningitidis have been designated class 1 through class 5. [*]
A handful of serotypes are associated with most cases of meningococcal disease, whereas other serotypes within the same serogroup rarely cause disease.[*]
The disease meningitis is caused by a number of different bacteria and viruses. Bacterial causes include Haemophilus influenzae, Escherichia coli, Streptococcus pneumoniae, Streptococcus pyogenes, Staphylococcus aureus, and Neisseria meningitidis. Although a variety of cocci cause meningitis, the term meningococcus is reserved for the Gram-negative, bean-shaped diplococcus, Neisseria meningitidis. [*]
The incubation period of bacterial meningococcal disease is 3 to 4 days, with a range of 2 to 10 days. [*]

Meningitis is an inflammation of the membranes (meninges) surrounding your brain and spinal cord. [*]
The swelling associated with meningitis often triggers the "hallmark" signs and symptoms of this condition, including headache, fever and a stiff neck. [*]
Meningococcal sepsis (bloodstream infection or meningococcemia) occurs without meningitis in 5% to 20% of invasive meningococcal infections. [*]

Meningitis typically results from contagious infections. Common bacteria or viruses that can cause meningitis can spread through coughing, sneezing, kissing, or sharing eating utensils, a toothbrush or a cigarette. You're also at increased risk if you live or work with someone who has the disease. [*]
Humans are the only natural reservoir of meningococcus. As many as 10% of adolescents and adults are asymptomatic transient carriers of N. meningitidis, most strains of which are not pathogenic [*]
Primary mode is by respiratory droplet spread or by direct contact. [*]

Between 5 and 30% of normal individuals are carriers at any given time, yet few develop meningococcal disease. Carriage rates are highest in older children and young adults. [*]
Meningococcal meningitis occurs both sporadically (mainly groups B and C meningococci) and in epidemics (mainly group A meningococci), with the highest incidence during late winter and early spring. [*]
Meningococcal disease occurs throughout the year, However, the incidence is highest in the late winter and early spring. [*]
The communicability of N. meningitidis is generally limited. In studies of households in which a case of meningococcal disease has occurred, only 3%–4% of households had secondary cases. [*]


Prior to 2000, an estimated 1,400 to 2,800 cases of meningococcal disease occurred each year in the United States, a rate of 0.5 to 1.1 per 100,000 population. [*]

Most cases of meningitis in the U.S. are caused by a viral infection, but bacterial infections also can lead to meningitis. [*]
Bacterial meningitis commonly affects people under 20, especially those living in community settings. [*]

Infants with meningococcal meningitis rarely display signs of meningeal irritation. Irritability and refusal to take food are typical; vomiting occurs early in the disease and may lead to dehydration. Fever is typically absent in children younger than 2 months of age[*]
In older children and adults, specific symptoms and signs are usually present, with fever and altered mental status the most consistent findings. [*]
Factors that may compromise your immune system — including AIDS, alcoholism, diabetes and use of immunosuppressant drugs — also make you more susceptible to meningitis. Removal of your spleen, an important part of your immune system, also may increase your risk. [*]
Large outbreaks of serogroup A meningococcal disease occur in the African “meningitis belt,” an area that extends from Ethiopia to Senegal. Rates of endemic meningococcal disease in this area are several times higher than in industrialized countries. In addition, outbreaks occur every 8–12 years with attack rates of 500–1000 cases per 100,000 population. [*]

Protection from the vaccine:

A peak in disease incidence among persons 18 to 21 years of age persists, even after routine vaccination of adolescents was recommended in 2005. From 2000–2004 to 2005–2009, the estimated annual number of cases of serogroups C and Y meningococcal disease decreased 74% among persons aged 11 through 14 years but only 27% among persons aged 15 through 18 years. [*]
Cases of meningococcal disease caused by serogroups C and Y among persons who were vaccinated with meningococcal conjugate vaccine have been reported. In 2010, CDC received 12 reports of serogroup C or Y meningococcal disease among persons who had received a meningococcal conjugate vaccine. The mean age of these persons was 18.2 years (range: 16 through 22 years). The mean time since vaccination was 3.25 years (range: 1.5–4.6 years). [*]
Two meningococcal conjugate vaccines are licensed in the United States. [*]
Menactra (sanofi pasteur) was licensed in 2005 (recommended for 9months - 55 years). [*]

Menveo (Novartis) was licensed in the United States in 2010 (recommended for 2yrs - 55yrs) [*]

Neither contain a preservative or an adjuvant. [*]

A protective level of antibody is usually achieved within 7–10 days of vaccination. Among infants and children younger than 5 years of age, the level of antibody against serogroup A and C polysaccharide decreases substantially during the first 3 years following a single dose of vaccine. In healthy adults, antibody levels also decrease, but antibodies are detectable as long as 10 years after vaccination. Although vaccine-induced protection likely persists in school-aged children and adults for at least 3 years, the efficacy of the group A vaccine in children younger than 5 years of age may decrease markedly within this period. In one study, efficacy declined from more than 90% to less than 10% 3 years after vaccination among children who were younger than 4 years of age when vaccinated. Efficacy was 67% among children who were older than 4 years of age at vaccination.[*]

The treatment depends on the type of meningitis you or your child has. [*]
Acute bacterial meningitis requires prompt treatment with intravenous antibiotics and, more recently, cortisone medications, to ensure recovery and reduce the risk of complications, such as brain swelling and seizures. The antibiotic or combination of antibiotics that your doctor may choose depends on the type of bacteria causing the infection. Your doctor may recommend a broad-spectrum antibiotic until he or she can determine the exact cause of the meningitis. [*]
Penicillin is the drug of choice to treat meningococcemia and meningococcal meningitis. Although penicillin does not penetrate the normal blood-brain barrier, it readily penetrates the blood-brain barrier when the meninges are acutely inflamed. [*]
Many antibiotics are effective for N. meningitidis infection, including penicillin. Few penicillin-resistant strains of meningococcus have been reported in the United States. Once N. meningitidis infection has been confirmed, penicillin alone is recommended. [*]
Wash your hands. Careful hand-washing is important to avoiding exposure to infectious agents. Teach your children to wash their hands often, especially before they eat and after using the toilet, spending time in a crowded public place or petting animals. Show them how to wash their hands vigorously, covering both the front and back of each hand with soap and rinsing thoroughly under running water. [*]
Practice good hygiene. Don't share drinks, foods, straws, eating utensils, lip balms or toothbrushes with anyone else. Teach children and teens to avoid sharing these items too. [*]
Stay healthy. Maintain your immune system by getting enough rest, exercising regularly, and eating a healthy diet with plenty of fresh fruits, vegetables and whole grains. [*]
Cover your mouth. When you need to cough or sneeze, be sure to cover your mouth and nose.[*]

I have presented a brief list which was specific in referencing why we currently decline the vaccines that are recommended by the ACIP for my daughters.
This lists omits several other reasons which also provides confirmation to our choice, I do this purposefully because these reasons only give support to the foundation understanding the disease (prevalence, risk, transmission, treatment).
If you are curious about vaccines, (from my own experience) I recommend learning about the which diseases are recommended for your child by referencing the vaccine schedule and then becoming educated about that disease. Once you have accomplished this, you are more competent in weighing the choice of using a vaccine in prevention.
Although this list provides references throughout (from the CDC, WHO, MayoClinic and others), please do not use this as medical advice. I continue to reexamine my vaccine choices. I encourage you to continue your research as well