Side Effects of pneumococcal polysaccharide vaccine: A Synthesis of Findings from 28 Studies

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Original Abstract of the Article

Main Research Findings

Multiple studies have shown that pneumococcal polysaccharide vaccine (PPV23) is effective in preventing pneumococcal infections. 9 、 10 17 . PPV23 is an important preventive measure, especially for the elderly and immunocompromised individuals. 15 、 28 . It has also been confirmed that PPV23 is effective as a booster dose in children who have received the primary immunization of heptavalent pneumococcal conjugate vaccine (PCV7). 18 .

Reasons for Side Effects

Pneumococcal polysaccharide vaccine is made by attenuating a substance called pneumococcal capsular polysaccharide. This polysaccharide is recognized as foreign by the immune system, stimulating the production of antibodies. 9 、 10 . However, in some individuals, the immune response to this polysaccharide may be excessive, leading to side effects. 6 、 4 、 3 .

Common Side Effects

Injection Site Reactions

The most common side effect of pneumococcal polysaccharide vaccine is pain, swelling, and redness at the injection site. 9 、 10 . These reactions are usually mild and resolve within a few days. 18 . However, severe reactions can occur in rare cases. 2 .

Systemic Reactions

Systemic reactions include fever, headache, muscle aches, and fatigue. 9 、 10 . These reactions are also usually mild and resolve within a few days. 18 . However, severe reactions can occur in rare cases. 6 、 4 、 3 .

Other Side Effects

Other side effects include dizziness, nausea, vomiting, diarrhea, and rash. 9 、 10 . These reactions are usually mild and resolve within a few days. 18 . However, severe reactions can occur in rare cases. 1 .

Measures to Cope with Side Effects

Injection Site Reactions

Injection site reactions can be relieved with cold compresses and analgesics. 9 、 10 . Consult a doctor if severe reactions persist. 2 .

Systemic Reactions

Systemic reactions can be relieved with antipyretics and analgesics. 9 、 10 . Consult a doctor if severe reactions persist. 6 、 4 、 3 .

Other Side Effects

Other side effects are usually mild and resolve within a few days. 9 、 10 . However, consult a doctor if severe reactions persist. 1 .

Comparison between Studies

Commonalities of Studies

Multiple studies have shown that pneumococcal polysaccharide vaccine is effective in preventing pneumococcal infections. 9 、 10 17 . These studies also confirmed the increase in antibody titers after vaccination. 9 、 10 .

Differences between Studies

There are differences in the effectiveness and frequency of side effects between studies. 9 、 10 17 . This is thought to be due to various factors such as the age and health status of the study participants, the type and dose of the vaccine. 18 .

Points to Note for Application to Real Life

Pneumococcal polysaccharide vaccine is an effective vaccine for preventing pneumococcal infections. 9 、 10 17 . However, like all vaccines, there is a risk of side effects. 18 、 6 、 4 . It is important to consult a doctor before getting vaccinated to understand your own risks and benefits. 3 .

Limitations of Current Research

There is still not enough research on the side effects of pneumococcal polysaccharide vaccine. 9 、 10 17 . Further research is needed, especially on long-term side effects. 18 .

Future Research Directions

Further research is needed to better understand the side effects of pneumococcal polysaccharide vaccine. 9 、 10 17 . In particular, it is necessary to investigate long-term side effects and the risk of side effects in specific populations. 18 .

Conclusion

Pneumococcal polysaccharide vaccine is an effective vaccine for preventing pneumococcal infections. 9 、 10 17 . However, like all vaccines, there is a risk of side effects. 18 、 6 、 4 . It is important to consult a doctor before getting vaccinated to understand your own risks and benefits. 3 .

Literature analysis of 28 papers
Positive Content
25
Neutral Content
1
Negative Content
2
Article Type
10
1
1
1
28
1.

[Bronchospasm and flushing after vaccination with 23 serotype pneumococcal polysaccharide in chronic patients].

Author: Fernández-PradaM, Martínez-TorrónA, Cuervo-LageM J, Ruiz-SalazarJ, Martínez-OrtegaC, Fernández-NovalF, Huerta-GonzálezI

Pneumococcal vaccine efficacy
Systemic adverse reactions

A study of 23-serotype pneumococcal polysaccharide vaccine (PNEUMOVAX23®) revealed a range of potential systemic adverse reactions, including the incidence of specific reactions, with similar cases reported in the literature and pharmacovigilance.

Journal ArticleAn article published in an academic or professional journal that reports original research or scholarly analysis.
Observational StudyResearch that observes and collects data on participants' behavior and outcomes in their natural state, without intervention.

Language : Spanish

3.

Systemic inflammatory reaction after pneumococcal vaccine: a case series.

Author: von EltenKelley A, DuranLaurie L, BanksTaylor A, CollinsLimone C

Pneumococcal polysaccharide vaccine
Fever
leukocytosis
Local reactions

Fever, leukocytosis, and large local reactions following the pneumococcal polysaccharide vaccine (PS23) are uncommon but can pose challenges in diagnosis and management.

Case ReportsIn the medical field, a report that describes in detail a unique case, an unusual medical condition, or the effect of a treatment. Provides new insights and possibilities for treatment through individual patient cases.
Journal ArticleAn article published in an academic or professional journal that reports original research or scholarly analysis.

Language : English

4.

Protracted fever with cellulitis-like reaction in pneumococcal polysaccharide-vaccinated children.

Author: HuangDaniel Tsung-Ning, ChiuNan-Chang, ChiHsin, HuangFu-Yuan

Cellulitis-like reaction
Protracted fever

This study reviewed the records of 17 children who experienced protracted fever and cellulitis-like reaction after receiving the 23-valent pneumococcal polysaccharide vaccine (PPV23).

Journal ArticleAn article published in an academic or professional journal that reports original research or scholarly analysis.

Language : English

5.

Severe protracted fever following pneumococcal vaccine.

Author: LeeArnold, GoyalRishi, ShanHui Yi

Pneumonia prevention
Protracted fever

This case report describes a 40-year-old healthy man who developed severe protracted fever for 9 days after receiving a polyvalent pneumococcal polysaccharide vaccine.

Case ReportsIn the medical field, a report that describes in detail a unique case, an unusual medical condition, or the effect of a treatment. Provides new insights and possibilities for treatment through individual patient cases.
Journal ArticleAn article published in an academic or professional journal that reports original research or scholarly analysis.

Language : English

6.

Severe febrile systemic reaction to pneumococcal vaccine.

Author: HasanSyed, YousefMahmoud, ShridharaniSachin

Reduce infections
Erythema
Fever
Induration
Pain
Systemic symptoms

This case report describes a 38-year-old male who developed severe and prolonged local and systemic symptoms after receiving a dose of Pneumovax, requiring hospitalization. While Pneumovax is generally safe, rare cases of severe side effects have been reported in the literature.

Case ReportsIn the medical field, a report that describes in detail a unique case, an unusual medical condition, or the effect of a treatment. Provides new insights and possibilities for treatment through individual patient cases.
Journal ArticleAn article published in an academic or professional journal that reports original research or scholarly analysis.

Language : English

7.

Negligible adjuvant effect for antibody responses and frequent adverse events associated with IL-12 treatment in humans vaccinated with pneumococcal polysaccharide.

Author: HedlundJ, LangerB, KonradsenH B, OrtqvistA

Side effects

Recombinant human IL-12 (rhIL-12) did not significantly enhance the antibody response to 23-valent pneumococcal polysaccharide vaccine (PPV) in healthy volunteers. rhIL-12 recipients experienced a high incidence of local and systemic side effects, making its use unacceptable.

Clinical TrialA clinical trial is a planned study conducted on humans to evaluate the efficacy and safety of pharmaceuticals, medical devices, and treatment methods. It aims to explore the possibilities of new treatments and improve the health of patients.
Comparative StudyResearch that compares multiple groups/interventions to determine differences/similarities in outcomes/characteristics.
Journal ArticleAn article published in an academic or professional journal that reports original research or scholarly analysis.
Randomized Controlled TrialA clinical trial that randomly assigns participants to treatment and control groups to evaluate the effects of an intervention.
Research Support, Non-U.S. Gov'tResearch funding provided by government agencies outside the United States.

Language : English

8.

Immunogenicity and safety of concomitant MF59-adjuvanted influenza vaccine and 23-valent pneumococcal polysaccharide vaccine administration in older adults.

Author: SongJoon Young, CheongHee Jin, TsaiT F, ChangHyun-Ah, ChoiMin Joo, JeonJi Ho, KangSeong Hee, JeongEun Ju, NohJi Yun, KimWoo Joo

Improves vaccine uptake

This study investigates the safety and immunogenicity of concomitant administration of adjuvanted trivalent inactivated influenza vaccine (aIIV3) and 23-valent pneumococcal polysaccharide vaccine (PPSV23) in older adults.

Journal ArticleAn article published in an academic or professional journal that reports original research or scholarly analysis.
Randomized Controlled TrialA clinical trial that randomly assigns participants to treatment and control groups to evaluate the effects of an intervention.
Research Support, Non-U.S. Gov'tResearch funding provided by government agencies outside the United States.

Language : English

9.

Safety and immunogenicity of 23-valent pneumococcal polysaccharide vaccine in 2 to 70 year old healthy people in China: A phase III double blind, randomized clinical trial.

Author: LiGuifan, LiangQi, ShiJichun, HuYuemei, LiHong, WeiWenjin, ZhuFengcai, YeQiang

Good immunogenicity
Tolerability
General reactions
Local reactions

The 23-valent pneumococcal polysaccharide vaccine (PPV23) showed good immunogenicity and tolerability in 2 to 70 y old healthy people.

Journal ArticleAn article published in an academic or professional journal that reports original research or scholarly analysis.
Randomized Controlled TrialA clinical trial that randomly assigns participants to treatment and control groups to evaluate the effects of an intervention.

Language : English

10.

Immunogenicity and safety of a 23-valent pneumococcal polysaccharide vaccine in Chinese healthy population aged >2 years: A randomized, double-blinded, active control, phase III trial.

Author: KongYujia, ZhangWei, JiangZhiwei, WangLing, LiChanjuan, LiYanping, XiaJielai

Pneumococcal infection prevention

A 23-valent pneumococcal polysaccharide vaccine was found to be well-tolerated and immunologically non-inferior to a standard pneumococcal vaccine in a study of Chinese adults and children.

Clinical Trial, Phase IIIA Phase III trial is a trial that further rigorously verifies the efficacy and safety of a new drug or treatment, whose efficacy and safety have been confirmed in a Phase II trial, in a large number of patients, and evaluates whether it is superior to existing treatments.
Journal ArticleAn article published in an academic or professional journal that reports original research or scholarly analysis.
Multicenter StudyResearch conducted in collaboration with multiple research institutions. It aims to collect a wide range of data and obtain more generalizable results.
Randomized Controlled TrialA clinical trial that randomly assigns participants to treatment and control groups to evaluate the effects of an intervention.
Research Support, Non-U.S. Gov'tResearch funding provided by government agencies outside the United States.

Language : English

11.

Immunogenicity and safety of a 13-valent pneumococcal conjugate vaccine in adults 18-49 years of age, naive to 23-valent pneumococcal polysaccharide vaccine.

Author: BryantK A, FrenckR, GurtmanA, RubinoJ, TreanorJ, ThompsonA, JonesT R, SundaraiyerV, BaxterL M, GruberW C, EminiE A, ScottD A, Schmoele-ThomaB

Pneumococcal conjugate vaccine

This study evaluated the immunogenicity, tolerability, and safety of the 13-valent pneumococcal conjugate vaccine (PCV13) and the 23-valent pneumococcal polysaccharide vaccine (PPSV23) in adults. PCV13 was found to be immunogenic, safe, and well-tolerated in both PPSV23-naive adults aged 60-64 years and adults aged 18-49 years.

Journal ArticleAn article published in an academic or professional journal that reports original research or scholarly analysis.
Randomized Controlled TrialA clinical trial that randomly assigns participants to treatment and control groups to evaluate the effects of an intervention.
Research Support, Non-U.S. Gov'tResearch funding provided by government agencies outside the United States.

Language : English

12.

Safety and immunogenicity of a single dose 23-valent pneumococcal polysaccharide vaccine in Russian subjects.

Author: CipreroKaren, ZykovKirill A, BrikoNikolay I, ShekarTulin, SterlingTina M, BitievaElizaveta, StekJon E, MuseyLuwy

Pneumococcal disease prevention

This study highlights the safety and cost-effectiveness of the 23-valent pneumococcal polysaccharide vaccine (PPV23) in reducing the burden of pneumococcal disease (PD), a significant cause of pneumonia, bacteremia, and meningitis.

Clinical TrialA clinical trial is a planned study conducted on humans to evaluate the efficacy and safety of pharmaceuticals, medical devices, and treatment methods. It aims to explore the possibilities of new treatments and improve the health of patients.
Journal ArticleAn article published in an academic or professional journal that reports original research or scholarly analysis.
Multicenter StudyResearch conducted in collaboration with multiple research institutions. It aims to collect a wide range of data and obtain more generalizable results.
Research Support, Non-U.S. Gov'tResearch funding provided by government agencies outside the United States.

Language : English

13.

Immunogenicity and safety of an inactivated quadrivalent influenza vaccine co-administered with a 23-valent pneumococcal polysaccharide vaccine versus separate administration, in adults ≥50years of age: Results from a phase III, randomized, non-inferiority trial.

Author: Ofori-AnyinamOpokua, Leroux-RoelsGeert, DrameMamadou, AerssensAnnelies, MaesCathy, AmanullahArshad, SchuindAnne, LiPing, JainVarsha K, InnisBruce L

improved uptake
vaccine effectiveness
pain

This phase 3, placebo-controlled, observer-blind trial compared co-administration versus separate administration of an inactivated quadrivalent influenza vaccine (IIV4) with a 23-valent pneumococcal polysaccharide vaccine (PPV23) in adults at high risk of complications from influenza and pneumococcal infection. The study found that co-administration did not reduce antibody responses to either vaccine and may improve vaccine uptake.

Clinical Trial, Phase IIIA Phase III trial is a trial that further rigorously verifies the efficacy and safety of a new drug or treatment, whose efficacy and safety have been confirmed in a Phase II trial, in a large number of patients, and evaluates whether it is superior to existing treatments.
Equivalence TrialA clinical trial designed to show that a new treatment is equivalent in efficacy/safety to an existing treatment.
Journal ArticleAn article published in an academic or professional journal that reports original research or scholarly analysis.
Multicenter StudyResearch conducted in collaboration with multiple research institutions. It aims to collect a wide range of data and obtain more generalizable results.
Randomized Controlled TrialA clinical trial that randomly assigns participants to treatment and control groups to evaluate the effects of an intervention.

Language : English

14.

Immunogenicity and safety of the adjuvanted recombinant zoster vaccine co-administered with the 23-valent pneumococcal polysaccharide vaccine in adults ≥50 years of age: A randomized trial.

Author: MaréchalCéline, LalHimal, PoderAiri, FergusonMurdo, EnweonyeIgwebuike, HeinemanThomas C, HervéCaroline, RheaultPaul, TalliJaak, WautersDominique, OostvogelsLidia

Pneumococcal vaccine efficacy
Safe co-administration
Zoster vaccine efficacy
Vaccine side effects

Co-administration of RZV and PPSV23 in adults ≥50 years resulted in no immunologic interference. The vaccine response rate was >98% in both groups and humoral immune responses were non-inferior to sequential administration. The vaccine was safe and well tolerated.

Clinical Trial, Phase IIIA Phase III trial is a trial that further rigorously verifies the efficacy and safety of a new drug or treatment, whose efficacy and safety have been confirmed in a Phase II trial, in a large number of patients, and evaluates whether it is superior to existing treatments.
Journal ArticleAn article published in an academic or professional journal that reports original research or scholarly analysis.
Multicenter StudyResearch conducted in collaboration with multiple research institutions. It aims to collect a wide range of data and obtain more generalizable results.
Randomized Controlled TrialA clinical trial that randomly assigns participants to treatment and control groups to evaluate the effects of an intervention.
Research Support, Non-U.S. Gov'tResearch funding provided by government agencies outside the United States.

Language : English

17.

Open-label trial of immunogenicity and safety of a 13-valent pneumococcal conjugate vaccine in adults ≥ 50 years of age in Mexico.

Author: TinocoJuan Carlos, JuergensChristine, Ruiz PalaciosGuillermo M, Vazquez-NarvaezJorge, Enkerlin-PauwellsHermann Leo, SundaraiyerVani, PathiranaSudam, KalininaElena, GruberWilliam C, ScottDaniel A, Schmoele-ThomaBeate

Pneumococcal disease protection
Safety in adults
Strong immune response

This open-label multicenter clinical trial assessed the immunogenicity and safety of a 13-valent pneumococcal conjugate vaccine (PCV13) in adults ≥ 50 years of age not previously vaccinated with the 23-valent pneumococcal polysaccharide vaccine (PPSV23).

Clinical TrialA clinical trial is a planned study conducted on humans to evaluate the efficacy and safety of pharmaceuticals, medical devices, and treatment methods. It aims to explore the possibilities of new treatments and improve the health of patients.
Journal ArticleAn article published in an academic or professional journal that reports original research or scholarly analysis.
Multicenter StudyResearch conducted in collaboration with multiple research institutions. It aims to collect a wide range of data and obtain more generalizable results.
Research Support, Non-U.S. Gov'tResearch funding provided by government agencies outside the United States.

Language : English

18.

Immunogenicity and safety of 23-valent pneumococcal polysaccharide vaccine as a booster dose in 12- to 18-month-old children primed with 3 doses of 7-valent pneumococcal conjugate vaccine.

Author: ThisyakornUsa, ChokephaibulkitKulkanya, KosalaraksaPope, BenjaponpitakSuwat, PancharoenChitsanu, ChuenkitmongkolSunate

Pneumococcal disease prevention

A randomized, controlled phase III study evaluated the immunogenicity and safety of PPV23 as a booster dose in toddlers primed with PCV7. Boosting with PPV23 was immunogenic and well tolerated, leading to higher antibody concentrations against certain serotypes compared to PCV7.

Clinical Trial, Phase IIIA Phase III trial is a trial that further rigorously verifies the efficacy and safety of a new drug or treatment, whose efficacy and safety have been confirmed in a Phase II trial, in a large number of patients, and evaluates whether it is superior to existing treatments.
Journal ArticleAn article published in an academic or professional journal that reports original research or scholarly analysis.
Multicenter StudyResearch conducted in collaboration with multiple research institutions. It aims to collect a wide range of data and obtain more generalizable results.
Randomized Controlled TrialA clinical trial that randomly assigns participants to treatment and control groups to evaluate the effects of an intervention.
Research Support, Non-U.S. Gov'tResearch funding provided by government agencies outside the United States.

Language : English

19.

Safety, reactogenicity and immunogenicity of a novel pneumococcal protein-based vaccine in adults: a phase I/II randomized clinical study.

Author: Leroux-RoelsGeert, MaesCathy, De BoeverFien, TraskineMagali, RüggebergJens U, BorysDorota

Pneumococcal disease protection

This study evaluated the safety, reactogenicity, and immunogenicity of new pneumococcal vaccines containing pneumolysin toxoid (dPly) and histidine-triad protein D (PhtD) in adults.

Clinical Trial, Phase IThe first stage of clinical trials in humans. Evaluates the safety, tolerability, and pharmacokinetics of a new drug/treatment.
Clinical Trial, Phase IIA Phase II trial is a trial that further evaluates the efficacy and safety of a new drug or treatment, whose safety has been confirmed to some extent in a Phase I trial, in a small number of patients.
Journal ArticleAn article published in an academic or professional journal that reports original research or scholarly analysis.
Randomized Controlled TrialA clinical trial that randomly assigns participants to treatment and control groups to evaluate the effects of an intervention.
Research Support, Non-U.S. Gov'tResearch funding provided by government agencies outside the United States.

Language : English

20.

Post-licensure rapid immunization safety monitoring program (PRISM) data characterization.

Author: BakerMeghan A, NguyenMichael, ColeDavid V, LeeGrace M, LieuTracy A

Surveillance for vaccine safety

This study evaluated the capabilities of the Post-Licensure Rapid Immunization Safety Monitoring (PRISM) program, a system using electronic health information to monitor vaccine safety.

Comparative StudyResearch that compares multiple groups/interventions to determine differences/similarities in outcomes/characteristics.
Evaluation StudyResearch that systematically evaluates the effectiveness of a particular program or policy. It measures its outcomes and provides important information for future decision-making.
Journal ArticleAn article published in an academic or professional journal that reports original research or scholarly analysis.

Language : English

21.

Vaccines for preventing herpes zoster in older adults.

Author: GagliardiAnna M Z, Gomes SilvaBrenda Nazaré, TorloniMaria R, SoaresBernardo G O

Herpes zoster prevention

Herpes zoster, or shingles, is a painful condition caused by the reactivation of varicella zoster virus (VZV). The natural aging process is associated with a reduction of cellular immunity which predisposes to herpes zoster. Vaccination with an attenuated form of VZV activates specific T cell production, therefore avoiding viral reactivation.

Journal ArticleAn article published in an academic or professional journal that reports original research or scholarly analysis.
Meta-AnalysisA statistical technique that integrates the results of multiple studies to draw more general conclusions about a particular issue.
ReviewAn article that critically examines existing research on a particular topic and summarizes the current state of knowledge in the field.
Systematic ReviewA review that systematically collects, evaluates, and integrates relevant research to answer a specific research question.

Language : English

22.

[Pneumococcal vaccine in adults: comparison of recommendations and discussion of its role].

Author: BorsuK, KrammischH, FranckhM, GietD

Pneumococcal infection prevention
Pneumococcal drug resistance

This study reviewed pneumococcal vaccine recommendations in six countries and highlighted the need for a more effective vaccine. The researchers concluded that while awaiting a more effective vaccine, the current vaccine has a limited place in preventive medicine strategies.

Comparative StudyResearch that compares multiple groups/interventions to determine differences/similarities in outcomes/characteristics.
Journal ArticleAn article published in an academic or professional journal that reports original research or scholarly analysis.

Language : French

23.

Revaccination with the 23-valent pneumococcal polysaccharide vaccine in middle-aged and elderly persons previously treated for pneumonia.

Author: TörlingJan, HedlundJonas, KonradsenHelle Bossen, OrtqvistAke

Boost immune response
Local reactions

Revaccination with the 23-valent pneumococcal polysaccharide vaccine (PPV) in elderly patients after 5-10 years is safe and induces a significant immune response in the majority of individuals. Revaccination resulted in significant increases of the geometric mean antibody concentration (GMC) and the geometric mean antibody fold increase (GMFI).

Clinical TrialA clinical trial is a planned study conducted on humans to evaluate the efficacy and safety of pharmaceuticals, medical devices, and treatment methods. It aims to explore the possibilities of new treatments and improve the health of patients.
Journal ArticleAn article published in an academic or professional journal that reports original research or scholarly analysis.

Language : English

25.

Immunization of renal transplant recipients with pneumococcal polysaccharide vaccine.

Author: KazancioğluR, SeverM S, Yüksel-OnelD, EraksoyH, YildizA, CelikA V, KayacanS M, BadurS

Vaccination for immunosuppressed patients
Diminished immune response
Loss of protective antibodies

Streptococcus pneumoniae vaccination is recommended for immunosuppressed patients, but they may have a reduced immune response and loss of protective antibodies.

Journal ArticleAn article published in an academic or professional journal that reports original research or scholarly analysis.
Research Support, Non-U.S. Gov'tResearch funding provided by government agencies outside the United States.

Language : English

26.

Immunogenicity and tolerance of a 7-valent pneumococcal conjugate vaccine in nonresponders to the 23-valent pneumococcal vaccine.

Author: ZielenS, BühringI, StrnadN, ReichenbachJ, HofmannD

Improved immunogenicity
Protection for high-risk patients

A new 7-valent pneumococcal conjugate vaccine is more effective in people who did not respond to the 23-valent pneumococcal vaccine. The vaccine was well-tolerated and had no serious side effects.

Journal ArticleAn article published in an academic or professional journal that reports original research or scholarly analysis.
Research Support, Non-U.S. Gov'tResearch funding provided by government agencies outside the United States.

Language : English

28.

Pneumococcal immunization in adult diabetics.

Author: LedermanM M, SchiffmanG, RodmanH M

Pneumonia prevention
Safe for diabetics
Minimal side effects

Adult insulin-treated diabetics responded similarly to healthy controls after receiving 14-valent pneumococcal polysaccharide vaccine. Antibody response was not affected by age, sex, duration of diabetes, or other factors. Side effects were minimal. Pneumococcal immunization is safe and may reduce pneumonia risk in diabetics.

Journal ArticleAn article published in an academic or professional journal that reports original research or scholarly analysis.
Research Support, Non-U.S. Gov'tResearch funding provided by government agencies outside the United States.
Research Support, U.S. Gov't, P.H.S.Research funding provided by the Public Health Service (PHS).

Language : English

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