Tag: immunization schedule

Why Do We Combine Vaccines?

Do you know why they combine multiple vaccines into a single shot?

Have you ever wondered why we combine vaccines? It's not a conspiracy...
It’s not a conspiracy…

Not surprisingly, your answer likely says a lot about what you think about vaccines

Why Do We Combine Vaccines?

Combination vaccines aren’t new.

The DPT vaccine was one of the first vaccines to be combined and that was way back in 1948. Before that, protection against diphtheria, tetanus, and pertussis came from three separate injections.

Want your child to get single antigen vaccines instead of a combo because you think they are getting too much in a combination vaccine? Keep in mind that the original DTP vaccine contained 3,002 antigens in each dose. And now, they get about 650 antigens from all of the vaccines they get during their whole childhood!

Which combination vaccine came next?

No, it wasn’t MMR.

How many antigens did kids get with this old schedule?

When the first polio vaccines came out, kids got three separate vaccines against the three strains of polio. They were later combined into the single polio vaccines.

And to reduce the number of injections even further, from 1959 to 1968, Quadrigen, a DTP/Polio combination was available!

And then came the MMR combination vaccine in 1971, combining protection against measles, mumps, and rubella into one shot.

Are you starting to see why we combine vaccines?

It helps reduce the number of injections that a child receives at one visit.

It has nothing to do with trying to hide any proof of a vaccine injury, after all, most parents still get their kids the same vaccines, whether or not they are combined.

Is it to save money?

In general, combination vaccines are about the same price as individual vaccines. Some are a little more and some are a little less.

It is typically easier to order, store, and administer a combination vaccine than each of the individual vaccines separately though, which can save moey. Using combination vaccines may also help to reduce errors.

Still, combining vaccines has never been about anything more than reducing the number of shots that kids have to get to be protected.

“So, at a doctor’s visit, your child may only get two or three shots to protect him from five diseases, instead of five individual shots. Fewer shots may mean less pain for your child and less stress for you.”

CDC on Combination Vaccines

Combination vaccines allow kids today to get 10 vaccines to protect them against 14 vaccine preventable diseases, but as few as 23 individual shots by age five years.

“Combination vaccines were associated with improved completion and compliance and should be encouraged among children who are undervaccinated or who received single-antigen vaccines only.”

Kurosky et al on Effect of combination vaccines on completion and compliance of childhood vaccinations in the United States

And it helps to keep vaccination rates up!

More on Combination Vaccines

Vaccines and Profiting Pediatricians

Why do some people think that pediatricians are only in it for money, working to maximize profits over the health and safety of the kids that they care for?

As they traditionally rank among the lowest paid medical doctors, even with the millions in vaccine bonuses they supposedly get, if pediatricians are only in it for the money, they are doing it wrong...
As they traditionally rank among the lowest paid medical doctors, even with the millions in vaccine bonuses they supposedly get, if pediatricians are only in it for the money, they are doing it wrong…

The usual suspects…

Vaccines and Profiting Pediatricians

Even if you believed that the average pediatrician would put profits over the health and safety of their patients, your next thought should then be why on earth would they ever vaccinate anyone…

Consider the rotavirus vaccine.

We hear a lot about the cost savings from decreased hospitalizations and ER visits because of the rotavirus vaccine.

“During the pre-rotavirus vaccine era, it was estimated that 410,000 physician visits; 205-272,000 ED visits; and 55,000–70,000 hospitalizations were attributable to rotavirus infections in U.S. children, costing approximately $1 billion annually.”

It is important to remember that for every visit to the emergency room, many more visited their pediatrician.

“National diarrhea-related healthcare visits during rotavirus season decreased by 48% (95% CI: 47%-48%) in 2008 and by 35% (95% CI: 34%-35%) in 2009 compared with the mean rate from the 2005 and 2006 rotavirus seasons.”

Yen et al on Decline in rotavirus hospitalizations and health care visits for childhood diarrhea following rotavirus vaccination in El Salvador

And now they don’t…

Pediatricians also see fewer kids with ear infections thanks to Prevnar and we rarely see a child with chickenpox.

“There was an overall downward trend in OM-related health care use from 2001 to 2011. The significant reduction in OM visit rates in 2010-2011 in children younger than 2 years coincided with the advent of PCV-13.”

Marom et al on Trends in Otitis Media–Related Health Care Use in the United States, 2001-2011

If the idea is to keep kids sick, then why vaccinate and protect them from diseases that would fill up our offices with sick kids?

“Using household-reported data we found a pattern of increased use of well visits and decreased sick visits across the last decade and half, resulting in a net decrease of roughly a third of a visit per child since 2002. The pattern was consistent for privately and publicly insured children. Multiple factors likely account for these trends, including the possibility that greater use of well visits and improvements in medicine may be helping to improve child health.”

Trends in Pediatric Well and Sick Visits, 2002-16

And contrary to the very warped idea that pediatricians vaccinate kids to promote vaccine injuries that keep kids sick, we know that propaganda about the unhealthiest generation is just that – propaganda.

More on Those Profiting Pediatricians

Did the National Childhood Vaccine Injury Act of 1986 Cause the Immunization Schedule to Triple?

Why do some parents think that the National Childhood Vaccine Injury Act of 1986 caused the immunization schedule to triple?

The National Childhood Vaccine Injury Act did not cause the immunization schedule to triple.

The usual suspects…

Did the National Childhood Vaccine Injury Act of 1986 Cause the Immunization Schedule to Triple?

It is not just folks holding anti-vax propaganda signs though.

“In 1986, Congress—awash in Pharma money (the pharmaceutical industry is No. 1 for both political contributions and lobbying spending over the past 20 years)—enacted a law granting vaccine makers blanket immunity from liability for injuries caused by vaccines. If vaccines were as safe as many claim, would we need to give pharmaceutical companies immunity for the injuries they cause? The subsequent gold rush by pharmaceutical companies boosted the number of recommended inoculations from 12 shots of five vaccines in 1986 to 54 shots of 13 vaccines today. A billion-dollar sideline grew into the $50 billion vaccine industry behemoth.”

Robert F Kennedy, Jr on The Harlem vaccine forum

It is a common anti-vax talking point that the immunization schedule ballooned in 1986, with passage of the National Childhood Vaccine Injury Act.

It didn’t.

The National Childhood Vaccine Injury Act did not cause the immunization schedule to triple.

In fact, it is very easy to see that most new vaccines weren’t added to the immunization schedule until the late 1990s and after.

  • hepatitis B – 1981
  • Hib – 1985
  • hepatitis B vaccine (improved) – 1986
  • Hib (improved) – 1988
  • Varivax – 1995
  • DTaP – 1996 (replaces DTP)
  • hepatitis A vaccine – 1996
  • RotaShield – 1998 (quickly withdrawn)
  • LYMErix – 1998 (later withdrawn)
  • Prevnar – 2000
  • FluMist – 2004
  • Menactra – 2005 (replaces the Menomune vaccine approved in 1981)
  • Tdap – 2006
  • RotaTeq – 2006
  • Gardasil – 2006
  • Trumenba – 2014

And the immunization schedule did not change very much at all after passage of the National Childhood Vaccine Injury Act.

What about Bobby Kennedy‘s other point? Why did we need the National Childhood Vaccine Injury Act if vaccines are safe?

Protection from frivolous lawsuits.

What we need now is protection from this kind of misinformation that continues to scare parents away from vaccinating and protecting their kids!

More on the Immunization Schedule

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