Tag: booster doses

Why Are Vaccine Schedules Different in Each Country?

Anti-vaccine folks often point in differences in the immunization schedules in various countries to try and make a case that some countries do things better than others.

Is that true?

Why Are Vaccine Schedules Different in Each Country?

The ACIP and CDC set the immunization schedule in the United States, but it shouldn’t be surprising that other countries have their own systems to set their schedules.

Each country vaccinates according to their own needs, so none of their schedules are wrong, even though they are all a little different.
Each country vaccinates according to their own needs, so none of their schedules are wrong, even though they are all a little different.

And no, just because they are all a little different, that doesn’t mean that any are wrong.

That’s easy to understand once you do just a little research on how these immunization schedules are set up.

The WHO immunization schedule.
The WHO immunization schedule.

The WHO immunization schedule is set by the Strategic Advisory Group of Experts (SAGE) on Immunization.

WHO vaccine position paper development is "a complex, rigorous, multifaceted process."
WHO vaccine position paper development is “a complex, rigorous, multifaceted process.”

It’s basically a summary of WHO position papers.

The WHO recommendations help other countries develop optimal immunization schedules.

The Communicable Diseases Act in Sweden regulates the 13 factors that the Public Health Agency of Sweden must account for when proposing changes in the national vaccination programme to the Government.
The Communicable Diseases Act in Sweden regulates the 13 factors that the Public Health Agency of Sweden must account for when proposing changes in the national vaccination programme to the Government. 

Many countries also have their own National Immunization Technical Advisory Group that sets their immunization schedule.

So their immunization schedule is right for their country, even if it doesn’t match the United States schedule.

Australia’s Vaccine Schedule

In Australia, for example, the National Immunisation Program (NIP) Schedule is set by National Immunisation Committee (NIC), which reports to the Australian Health Protection Principal Committee (AHPPC) of the Australian Health Ministers Advisory Council (AHMAC) through the Communicable Diseases Network Australia (CDNA).

The Australian Technical Advisory Group on Immunisation (ATAGI) also provides technical advice on the operation of the National Immunisation Program.

Combination vaccines mean infants in Australia get fewer shots, but the same number of vaccines.
Combination vaccines mean infants in Australia get fewer shots, but the same number of vaccines.

Notice any differences between Australia’s vaccine schedule and the US schedule?

  • they give the routine second dose of MMR earlier, at 18 months
  • they don’t give a second dose of the chickenpox vaccine
  • they give the routine first dose of the meningococcal vaccine earlier, at 12 months
  • the hepatitis A and flu vaccines are only given to high risk kids

While there are some minor differences, it is fairly similar to the US immunization schedule.

“There is a legislative requirement for all vaccines provided under the NIP or the PBS to undergo a thorough and objective assessment process.”

National Immunisation Strategy for Australia

Why the earlier dose of meningococcal vaccine?

This is a good example of why immunization schedules vary between countries.

“The notification rate for meningococcal disease to the National Notifiable Diseases Surveillance System peaked at 4.3 per 100 000 in 2002 and declined to 0.4 per 100 000 in 2013.”

Meningococcal disease

Meningococcal disease incidence rates in the United States were much lower, about 0.6 per 100,000, when they started giving meningococcal vaccines in Australia (2001).

The UK Vaccine Schedule

But aren’t the immunization schedules from other countries supposed to be a lot different from the US schedule?

Let’s look at another…

The Joint Committee on Vaccination and Immunisation (JCVI) advises UK health departments on immunisation.
The Joint Committee on Vaccination and Immunisation (JCVI) advises UK health departments on immunisation.

It’s not the easiest schedule to read, but you should notice that vaccines for hepatitis A and chickenpox are missing, but younger children get extra meningococcal shots.

You may also have noticed yet another dosage schedule for the Prevnar 13 vaccine.

While the United States gives a three dose primary series and a booster, many other countries give either a three dose primary series alone or a two dose primary series with a booster.

“A large and growing body of evidence from immunogenicity studies, as well as clinical trials and observational studies of carriage, pneumonia and invasive disease, has been systematically reviewed; these data indicate that schedules of 3 or 4 doses all work well, and that the differences between these regimens are subtle, especially in a mature program in which coverage is high and indirect (herd) effects help enhance protection provided directly by a vaccine schedule.”

Whitney et al on Dosing schedules for pneumococcal conjugate vaccine: considerations for policy makers.

That doesn’t mean that they are all guessing at the dose! All of these schedules are well studied and in this case, there isn’t much difference.

There are even studies that suggest giving only one primary dose, combined with one booster dose might work, but only in areas where pneumococcal disease is already well controlled and infants would be protected by indirect herd immunity.

But that doesn’t mean that other schedules would work just as well too. For example, giving the doses later or on a slower schedule would not be better.

Why not?

Infants are most at risk for many of these diseases, especially Hib and pneumococcal disease, when they are young and delaying when infants get vaccinated simply leaves them unprotected and at risk to get sick for a longer period of time. You also want infants to be protected by the time they lose the passive protection they get from their maternal antibodies.

What about the chickenpox vaccine?

Will the UK get the chickenpox vaccine soon?

While the UK has not added the chickenpox vaccine to their schedule because their models predicted an increase in cases of shingles (which has happened anyway) with a decrease in exogenous boosting (the theory that exposure to chickenpox lowers your risk of shingles), they are now looking at this again.

“This study confirms that severe complications of varicella, including death, continue to occur in the UK and Ireland.”

Cameron et al on Severe complications of chickenpox in hospitalised children in the UK and Ireland

Mostly it has been said that the chickenpox vaccine isn’t on the schedule because they have not thought it to be cost effective.

Iceland’s Vaccine Schedule

When anti-vaccine folks talk about immunization schedules from other countries, they aren’t usually talking about the UK or Australia though.

They are talking about Iceland, the country that they believe gives far fewer vaccines than the United States.

You thought they gave even fewer vaccines in Iceland, didn't you?
You thought they gave even fewer vaccines in Iceland, didn’t you?

Vaccines for flu, chickenpox, hepatitis A, and hepatitis B and also available for those who are considered high risk.

Extra vaccines are available for high risk kids.

Want to follow Iceland’s immunization schedule?

Then you should move to Iceland.

Hopefully you are starting to see that immunization schedules are different in each country because each country has different rates of disease, different populations, and different healthcare systems.

Iceland is a small country (338,349 people), with high vaccination rates, and universal health care. Compare that to the United States, with 327,200,000 people, clusters of unvaccinated people, and lots of people without health care.

It should be easy to see that what works in one country might not work in the other…

Vaccine Schedule Comparison by Country

What about other countries?

Austria’s immunization schedule for 2019 includes all of the same vaccines as the US schedule, plus the vaccine for Japanese encephalitis (if high risk).
Austria’s immunization schedule for 2019 includes all of the same vaccines as the US schedule, plus the vaccine for Japanese encephalitis (if high risk).

On the immunization schedule in Austria, the columns in red are for vaccines that are recommended and free. The blue columns are also recommended, but they aren’t free.

The chickenpox vaccine was just added to Japan's routine vaccine schedule, but they still don't give the combined MMR vaccine. They do still have autistic kids, so does that finally prove that the MMR vaccine is not associated with autism?
The chickenpox vaccine was just added to Japan’s routine vaccine schedule, but they still don’t give the combined MMR vaccine. They do still have autistic kids, so does that finally prove that the MMR vaccine is not associated with autism?

Japan has two separate schedules – the routine schedule for everyone (in dark blue above) and the voluntary schedule, with extra vaccines. Note that the primary series of infant vaccines are given at 2, 3, and 4 months.

The latest vaccine schedule in Germany.
The latest vaccine schedule in Germany.

Germany also gives their primary series of infant vaccines at 2, 3, and 4 months.

In contrast to the 16 diseases that kids in the US are vaccinated against, Sweden uses vaccines for just 9.
In contrast to the 16 diseases that kids in the US are vaccinated against, Sweden uses vaccines for just 9.

Sweden is the other country that anti-vaccine folks like to talk about a lot. Mostly because they think that Sweden recently banned mandatory vaccination. They didn’t.

And note that kids in Sweden can get vaccinated at school!

The Norwegian immunization program makes heavy use of combination vaccines.
The Norwegian immunization program makes heavy use of combination vaccines.

Norway is studying adding chickenpox and Shingles vaccines to their schedule.

Switzerland now offers a few optional vaccines for folks who want them, including the meningococcal vaccine, HPV vaccines for boys, and the shingles vaccine for seniors.
Switzerland now offers a few optional vaccines for folks who want them, including the meningococcal vaccine, HPV vaccines for boys, and the shingles vaccine for seniors.

Although they only use a two dose primary series, Switzerland gives many of the same vaccines as the United States.

The 2018 vaccination schedule in the Netherlands. New additions in 2020 will be the rotavirus vaccine or high risk infants, Tdap in pregnancy, and MenACWY for teens.
The 2018 vaccination schedule in the Netherlands. New additions in 2020 will be the rotavirus vaccine or high risk infants, Tdap in pregnancy, and MenACWY for teens.

Are you surprised to see that infants in Holland get more vaccines before they turn 12 month old than infants in the United States and an extra set by four months?

While most vaccines are free, you can pay extra to get vaccines that are already on the United States schedule in most other countries.
While most vaccines are free, you can pay extra to get vaccines that are already on the United States schedule in most other countries.

Even if they aren’t routine in other countries, all of the same vaccines that are offered in the United States, including vaccines to protect kids against rotavirus, chickenpox, and hepatitis A, are available in most other countries.

Vaccination schedule for children and adolescents in Israel.
Vaccination schedule for children and adolescents in Israel.

The latest immunization schedule in Israel includes hepatitis B, DTaP, polio, pneumococcal, rotavirus, MMR, chickenpox, HPV, and flu vaccines.

The 2019 Immunization Schedule for South Korea includes almost all of the US vaccines, plus BCG and Japanese encephalitis vaccines.
The 2019 Immunization Schedule for South Korea includes almost all of the US vaccines, plus BCG and Japanese encephalitis vaccines.

What’s missing in South Korea’s immunization schedule? Meningococcal vaccines. But they do have some that we don’t give in the United States.

What’s missing in Denmark?

Vaccines for rotavirus, chickenpox, hepatitis A or B, and meningococcal disease are not offered for free, but are still available in Denmark.

Folks who don’t vaccinate their kids!

Denmark has very high immunization rates – over 97% for infants and toddlers!

In addition to free vaccines, the Danish vaccine program offers these vaccines that folks can ask for and pay for themselves. Some people in high risk groups can get them free.

What don’t these different immunization schedules influence?

Prevalence rates of autism, SIDS, and other things that scare parents away from vaccinating and protecting their kids.

The One Wrong Way to Give Vaccines

Since the immunization schedules from all of these countries are just a little bit different, does that support the idea that an individualized approach to vaccinating kids is a good idea?

There is no science and nothing that says altering any vaccine schedule is a safer or more effective way to do things.
There is no science and nothing that says altering any vaccine schedule is a safer or more effective way to do things.

Of course not!

"Later and slower" is not part of any immunization plan.
“Later and slower” is not part of any immunization plan.

In many countries, even if they are missing protection against a few diseases that we routinely vaccinate against in the United States, many get their vaccines earlier! And all start by three months and don’t split up the schedule to just give one or two vaccines at a time.

Everyone knows that later and slower just leaves kids unprotected for longer periods of time. More risks. No extra benefits.

More on Vaccine Schedules Around the World

Do You Need Another Dose of the MMR Vaccine?

The measles outbreaks have a lot of people concerned about measles.

And that means measles and vaccines are getting a lot of extra attention.

Unfortunately, getting extra attention doesn’t always translate into getting great advice, especially when it is leading a lot of folks into thinking they need to rush out and get another dose of MMR or to check their titers to make sure they are protected.

Do You Need Another Dose of the MMR Vaccine?

So are you protected against measles?

Have you had two doses of MMR? (Remember, kids typically get their first dose at age 12-15 months and a second dose when they are 4-6 years old, with early doses in high-risk situations.)

If you have documentation of two doses of MMR (or a measles containing vaccine), then you can confidently say that you are protected. No, it’s not 100% protection, but it’s close.

“Documented age-appropriate vaccination supersedes the results of subsequent serologic testing. If a person who has 2 documented doses of measles- or mumps-containing vaccines is tested serologically and is determined to have negative or equivocal measles or mumps titer results, it is not recommended that the person receive an additional dose of MMR vaccine. Such persons should be considered to have presumptive evidence of immunity.”

Prevention of Measles, Rubella, Congenital Rubella Syndrome, and Mumps, 2013: Summary Recommendations of the Advisory Committee on Immunization Practices (ACIP)

If you haven’t had two doses of MMR, then know that two doses are your best protection against measles.

Have you heard that people born before 1989 may need another dose?

What is the significance of the year 1989?

The recommendation to give a routine second dose of MMR started in 1990, so folks born much before then likely only had one dose, unless they were considered high risk and had the second dose before traveling out of the country, starting a healthcare job, or going to college, etc.

Instead of 1989, the typical cutoff year for protection is around 1986, since those kids would have been turning four years old in 1990, so would have gotten their second dose of MMR on schedule. If you were born before 1986, you would have started kindergarten before the recommendation to get a second dose.

The other years that are important are 1963 to 1967, as that’s when the very first measles vaccine was used, a vaccine that was later found to not be very effective. If that is the only time you were vaccinated, then you should be vaccinated again.

What about 1957?

In general, if you were born before 1957, we assume that you had measles because most people had measles back then. Maybe you didn’t though, so in a high-risk situation, like traveling out of the country or in the middle of an outbreak, this could be a good situation to check your measles titer to confirm that you are immune. If you aren’t, then get two doses of MMR.

How many doses of MMR have you had?
How many doses of MMR have you had?

So here are your scenarios:

  • Were you born before 1957? Then you probably had measles, but can check your titers to make sure you are immune, especially if you will be in a high-risk situation, like near an outbreak or traveling.
  • Did you get a dose of measles vaccine between 1963 and 1967? If this was your only dose, then you should get a dose of MMR now.
  • Did you get a measles vaccine between 1968 and 1971, before the MMR became available? That counts as a dose of measles containing vaccine. If that is your only dose, then you might get another dose of MMR, if you will be in a high-risk situation, like near an outbreak or traveling.
  • Have you only had only one dose of MMR or other measles containing vaccine, which is more likely if you were born well before 1990? Then get another dose of MMR if you will be in a high-risk situation, like near an outbreak or traveling.
  • Have you had two doses of MMR vaccine or or other measles containing vaccine (and have your immunization records to prove it)? Then you should be protected. You don’t need to check your titers and you don’t need a third dose of MMR.

What if you aren’t sure? Then get at least one more dose of MMR.

If you don’t think that you were ever vaccinated against measles, then you might get two doses of MMR.

If you aren’t sure, but think that you already were vaccinated, then this would be a good situation to check your titer. Be prepared to get your MMR vaccines again if you are negative though.

Do all adults need two doses of MMR?

Surprisingly no, although that is considered the best protection against measles, there was never a general catch up program for older folks with the recommendation to get a second dose in 1990. So if you have had one dose of MMR and aren’t at any extra risk to get measles – no travel, no nearby outbreaks, and not a health professional, etc., then one dose might be enough… for now.

More on MMR Vaccines

Are the Tdap and DTaP Vaccines the Same Thing?

You have probably already figured out the Tdap and DTaP aren’t the same vaccine, after all, if they were, why would they have different names, right?

Are the Tdap and DTaP Vaccines the Same Thing?

I bet you don’t know the difference between the two vaccines though.

Yes, they both are both combination vaccines that protect against diphtheria, tetanus, and pertussis.

The difference is that one (DTaP) is used as the primary series for infants and younger children (age 6 years and under) and the other (Tdap) is given to older children (age 7 years and above), teens, and adults.

Okay, that’s not the only difference.

The DTaP vaccine actually contains more diphtheria and pertussis antigens than Tdap, which is why it has the capital “D” and “P” in its name. The amount of tetanus toxoid antigens are about the same in both vaccines.

So Tdap contains the same amount of tetanus toxoid, plus a reduced amount of diphtheria and acellular pertussis antigens, as compared to DTaP.

While you would think that older children and adults would get the vaccine with the higher amount of antigens, since they are bigger, that’s not how this works. Vaccines typically start working at the injection site, so body size isn’t a key factor in determining the amount of ingredients.

As a booster dose of vaccine, the lower amount of antigens works just fine and helps reduce the risk of side effects from repeated doses that you might get with higher antigen counts.

More on Tdap vs DTaP

Everything You Need to Know About the Measles Vaccine

The measles vaccine is one of the most effective vaccines we have.

It is also one of the safest, having very few serious side effects.

Everything You Need to Know About the Measles Vaccine

So why are some parents still afraid to allow their kids to get vaccinated and protected, putting them at risk to get measles, a life-threatening disease?

“Existing evidence on the safety and effectiveness of MMR vaccine supports current policies of mass immunisation aimed at global measles eradication and in order to reduce morbidity and mortality associated with mumps and rubella.”

Cochrane Systematic Review on Vaccines for measles, mumps and rubella in children

Let’s see if you still are after we get all of your questions about the measles vaccine answered…

Schools in California were closed for at least two weeks in 1917 because of measles epidemics.
Schools in California were closed for at least two weeks in 1917 because of measles epidemics.
  1. How long has the measles vaccine been around? The very first measles vaccine was licensed by John Enders in 1963. An improved measles vaccine was developed by Maurice Hilleman and licensed in 1968, and that is the measles vaccine that we still use today, at least in the United States. It was combined into the MMR vaccine in 1971.
  2. How effective is the measles vaccine? A single dose of the measles vaccine is about 93% effective at preventing a measles infection. Two doses (the second dose was added to the routine immunization schedule in 1994) are up to 97% effective. That’s why almost all of the people who get measles in an outbreak are unvaccinated.
  3. How long does immunity from the measles vaccine last? Immunity from the measles vaccine is thought to be life-long. It is important to understand that the second dose isn’t a booster dose, but is instead for those few folks who don’t respond to the first dose.
  4. Who should get the measles vaccine? Everyone without a true medical contraindication should get the measles vaccine (MMR), with the first dose at 12-15 months and a second dose at 4-6 years.
  5. Can my kids get their measles vaccine early? An advanced immunization schedule is available for kids in an outbreak or if they will be traveling out of the country. The first dose can be given as early as age 6-months, but is repeated when the child is 12 months because of concerns of interference with maternal antibodies. The official second dose can be given early too, as early as 4 weeks after the first dose, as long as the child is at least 12 months old.
  6. Do I need a booster dose of the measles vaccine? People who are fully immunized do not need a booster dose of the MMR vaccine, but it is important to understand whether or not you are really fully immunized to see if you need a second dose. Some adults who are not high risk are considered fully vaccinated with only one dose, while others should have two doses. Are you at high risk to get measles? Do you travel, live in an area where there are measles outbreaks, go to college, or work as a health care professional?
  7. Should I check my measles titers? In general, it is not necessary to check your titers for measles. If you haven’t had two doses of the MMR vaccine, then get a second dose. If you have had two doses of the MMR vaccine, then you are considered protected. Keep in mind that there is no recommendation to get a third dose of MMR for measles protection, although it is sometimes recommended for mumps protection during a mumps outbreak.
  8. If my child gets a rash after getting his MMR, does that mean that he has measles? No. This is a common, very mild vaccine reaction and not a sign of measles.
  9. Can the measles vaccine cause seizures? The MMR vaccine can cause febrile seizures. It is important to remember that without other risk factors, kids who develop febrile seizures after a vaccine are at the same small risk for developing epilepsy as other kids. And know that vaccines aren’t the only cause of febrile seizures. Vaccine-preventable diseases can cause both febrile seizures and more serious non-febrile seizures.
  10. Why do people think that that the measles vaccine is associated with autism? It is well known that this idea originated with Andrew Wakefield, but the real question should be why do some people still think that vaccines are associated with autism after so much evidence has said that they aren’t?
  11. What are the risks of the measles vaccine? Like other vaccines, the MMR vaccine has mild risks or side effects, including fever, rash, and soreness at the injection site. Some more moderate reactions that can rarely occur include febrile seizures, joint pain, and a temporary low platelet count. More serious reactions are even rarer, but can include deafness, long-term seizures, coma, or lowered consciousness, brain damage, and life-threatening allergic reactions.
  12. Why are there so many reports of measles vaccine deaths? There are extremely few deaths after vaccines. The reports of measles vaccine deaths you see on the Internet are just reports to VAERS and are not actually reports that have been proven to be caused by a vaccine. As with other vaccines, the risks from having a vaccine-preventable disease are much greater than the risks of the vaccine. The only reason that it might not seem like that now is because far fewer people get measles now than they did in the pre-vaccine era, when about 500 people died with measles each year.
  13. When did they take mercury out of the measles vaccine? Measles vaccines, including the MMR, have never, ever contained mercury or thimerosal.
  14. Why do we still have outbreaks if we have had a measles vaccine since 1963? In the United States, although the endemic spread of measles was declared eliminated in 2000, many cases are still imported from other countries. As measles cases increase around the world, that is translating to an increase in outbreaks here. Even though overall vaccination rates are good, because there are many pockets of susceptible people in areas that don’t vaccinate their kids, they get hit with outbreaks.
  15. Can we eradicate measles? Because measles is so contagious, the vaccine does have failures, and some folks still don’t get vaccinated, there is some doubt that we can eradicate measles without a better vaccine. That doesn’t mean that the current measles vaccines can’t prevent outbreaks though…

Are you ready to get your kids their MMR vaccine so that they are vaccinated and protected against measles, mumps, and rubella?

If not, what other questions do you have?

While you are thinking, here is a question for you – Do know why they used to call measles a harmless killer?

More on the Everything You Need to Know About the Measles Vaccine