Tag: primary series

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

Why Do Some Vaccines Need Boosters?

Vaccines work.

They aren’t perfect though, which is why some vaccines need booster doses to help them provide long lasting protection.

Why Do Some Vaccines Need Boosters?

To be clear, just because you get more than one dose of a vaccine, that doesn’t make it a booster dose.

For example, infants get multiple doses of the DTaP, polio, Hib, hepatitis B, Prevnar, and rotavirus vaccines, but those are part of the primary series for those vaccines. They aren’t boosters.

“A “classical” prime-boost immunization schedule is, thus, to allow 4 to 6 months to elapse between priming and booster doses, hence the generic “0-1-6 month” (prime-prime-boost) schedule. Secondary antigen exposure thus results in the production of higher-affinity antibodies than primary responses.”

Plotkin’s Vaccines (Seventh Edition)

Getting the booster shot in a vaccine series is important to get full protection.
Getting the booster dose in a vaccine series is important to get full protection.

Classic booster doses are the:

But why do we need these booster doses?

While one or more doses of the primary series of the vaccine leads to the production of plasma cells and protective antibodies, the booster dose then causes a secondary immune response and the production of more long-lived plasma cells. That’s how we get higher levels of protective antibodies that will last longer.

Which Vaccines Don’t Need Boosters?

In general, live vaccines don’t need booster doses.

So why do we get a second dose of MMR?

This isn’t a classic booster dose. It protects the small percentage of people who don’t respond to the first dose.

Some folks may need a booster dose of the MMR vaccine in certain circumstances though, specifically if they are caught up in a mumps outbreak.

What to Know About Vaccine Booster Doses

Some vaccines need booster doses to help you get full protection. Don’t skip them.

More on Vaccine Booster Doses

Your Baby’s First Vaccines

Your baby’s first vaccines are very important.

While they don’t provide instant protection, they do start your baby on the path to eventually getting protected from 16 different vaccine-preventable diseases.

Your Baby’s First Vaccines

Rotavirus vaccines are associated with a very small risk of intussusception, but that is not a good reason to miss the benefits of this vaccine.
The rotavirus vaccine will be among your baby’s first vaccines. Photo by Vincent Iannelli, MD

After the birth dose of the hepatitis B vaccine, your baby’s first vaccines when you visit your pediatrician for their two month check up will include:

  • DTaP – diptheria – tetanus – pertussis
  • IPV – polio
  • Hepatitis B
  • Hib – haemophilus influenzae type b
  • Prevnar 13 – pneumococcal disease
  • Rotavirus

Sound like too many? Those vaccines work to protect your baby against eight vaccine-preventable diseases! Before these vaccines were routine, when infants got fewer immunizations, they got more disease.

And it doesn’t mean that your baby has to get six shots.

The rotavirus vaccine is oral – your baby drinks it.

And many of the other vaccines can be given as a combination vaccine, either Pediarix (combines DTaP-IPV-HepB) or Pentacel (combines DTaP-IPV-Hib), to reduce the number of individual shots your baby needs to get even more.

While that still means multiple injections, there are things you can do to minimize the pain during and after the vaccines, from breastfeeding and holding your baby to simply trying to get them distracted.

Your Baby’s Next Vaccines

After their first vaccines at two months, your baby will complete their primary series of vaccines with repeated dosages of the same vaccines at four and six months.

Why do we need to repeat the same vaccines?

Because that’s often what it takes to help us build up an immune response to a vaccine, especially at this age.

These first vaccines prime the immune system, which when followed by a later booster vaccine, provide good protection against each disease.

start your baby on the path to eventually getting protected from 16 different vaccine-preventable diseases.
Ari Brown, MD explains why you shouldn’t delay or skip your child’s vaccines.

And the requirement of multiple dosages of a vaccine is a small price to pay to be able to skip the symptoms and risk of more serious consequences that come from getting a natural infection and natural immunity.

Did your baby have a reaction to their first set of vaccines?

While some fever, pain, and fussiness is not unexpected, be sure to tell your health care provider if your baby had a reaction that you think was more severe, like a high fever or non-stop crying for several hours.

Can you expect a reaction to your baby’s second set of shots if they had a reaction to the first? Probably not. Side effects, even those that are serious, rarely happen again, even when the same vaccines are given.

Your Baby’s Vaccines

While you certainly shouldn’t skip or delay any of these vaccines, you should know that:

  • the routine age for starting these vaccines is at two months, but
  • if necessary, they can be given as early as when a baby is six weeks old.
  • the routine interval between dosages of the primary series of these vaccines is two months, but
  • if necessary (usually as part of a catch-up schedule), these vaccines can be usually be given as soon as four weeks apart, although the third dose in the series of DTaP, IPV, and Hepatitis B vaccines shouldn’t be given any sooner than at age six months.
  • infants who will be traveling out of the United States should get an early MMR vaccine – as early as six months of age

And if your baby is at least six months old during flu season, then they will also need two doses of the flu shot given one month apart. The minimum age to get a flu shot is six months, and kids get two doses during their first year of getting vaccinated against the flu to help the vaccine work better.

Learn more about if you are on the fence. Your baby needs to be vaccinated and protected.

What to Know About Your Baby’s First Vaccines

Your baby’s first vaccines are safe and necessary to start them on a path to eventually getting protected from 16 different vaccine-preventable diseases.

More on Your Baby’s First Vaccines

Updated February 7, 2018