Tag: shingles

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 Denmark 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 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

Should I Stop Calling Chickenpox and Measles Diseases?

Sherri Tenpenny wants us to stop calling chickenpox and measles diseases.

She thinks that we should call them infections instead…

Should I Stop Calling Chickenpox and Measles Diseases?

If you are like most people, you are probably thinking to yourself and maybe even shouting at your computer screen right now, “who cares what you call them, just get vaccinated and stop the outbreaks!”

When you vaccinate to avoid an infection, what you are potentially doing is preventing a death!
When you vaccinate to avoid an infection, what you are potentially doing is preventing a death!

Believe it or not, there is actually some precedent for changing the way we talk about diseases. While you may still refer to them as STDs, or sexually transmitted diseases out of habit, the prefererable term is actually STI, or sexually tranmistted infection.

Of course, this has nothing to do with Tenpenny’s reasoning.

“Why the change? The concept of ‘disease,’ as in STD, suggests a clear medical problem, usually some obvious signs or symptoms. But several of the most common STDs have no signs or symptoms in the majority of persons infected. Or they have mild signs and symptoms that can be easily overlooked. So the sexually transmitted virus or bacteria can be described as creating ‘infection,’ which may or may not result in ‘disease.’ This is true of chlamydia, gonorrhea, herpes, and human papillomavirus (HPV), to name a few.

For this reason, for some professionals and organizations the term ‘disease’ is being replaced by ‘infection.'”

ASHA on STDs/STIs

In fact, their definitions sound nothing like Tenpennys…

Unfortunately, many STIs, even if they aren’t causing symptoms and disease, can still be contagious.

Measles and chickenpox don’t do that. Although you can be contagious just before you start to have symptoms, you will very quickly develop symptoms.

It is true that some viruses and bacteria can lead to subclinical infections, in which you develop immunity without ever developing symptoms, but that doesn’t usually happen with measles and chicken pox.

Polio is one of the best examples of when it does happen. Remember, nearly 75% of kids who got polio never had any symptoms. Tragically, those symptoms could be severe in the small percentage who did.

So as usual, Sherri Tenpenny is wrong.

Chickenpox and measles are infections that cause disease. And while most people recover after 7 to 10 days of symptoms, including a high fever and rash, some don’t.

Both also put you at risk for long-term complications, namely shingles and SSPE.

Remember, if you listen to folks like her and skip or delay your child’s vaccines and they get chickenpox or measles, the only thing you are doing is causing more people to get sick. A catchy slogan won’t prevent that or keep your kids healthy.

More on Diseases vs Infections

What Percentage of Adults Are up to Date on Their Immunizations?

Are you up to date on your vaccines?

What about everyone else?

What Percentage of Adults Are up to Date on Their Immunizations?

Can you guess why this question comes up so often?

Yup.

There is no plan to force adults to get vaccinated...
There is no plan to force adults to get vaccinated…

It’s about herd immunity.

If most adults aren’t immune because they haven’t been vaccinated or don’t get boosters, then since we aren’t seeing that many outbreaks, herd immunity itself must be a myth.

The thing is though, adults were either born in the pre-vaccine era and likely earned their natural immunity or were born in the vaccine era and are vaccinated and immune.

It is also important to understand that herd immunity is disease specific, so when we talk about herd immunity for measles, it doesn’t matter if everyone has herd immunity levels of protection against hepatitis A or Hib.

And adults do get a few boosters and some vaccines that are only recommended for adults, including the shingles vaccine.

In addition, some vaccines, like Hib and Prevnar, have indirect effects, protecting adults even though they aren’t vaccinated, because vaccinated kids are less likely to become infectious.

But back to the original question, how many adults are up to date on their immunizations?

“While modest gains occurred in vaccination coverage for pneumococcal, Tdap, hepatitis A (persons with chronic liver conditions), herpes zoster, and HPV vaccination, coverage did not improve for other vaccinations and many adults remained unvaccinated with recommended vaccines. “

Vaccination Coverage Among Adults in the United States, National Health Interview Survey, 2016

While most adults are immune to what were once common childhood diseases, like measles and mumps, because they were either vaccinated or had the disease naturally, many could do better with newer vaccines that weren’t available when they were kids.

More on Adult Vaccination Statistics

The Shingles Vaccine Shortage

Shingrix became the second shingles vaccine to be licensed in the United States, becoming the preferred shingles vaccine in 2017.

“Shingrix provides strong protection against shingles and PHN. Two doses of Shingrix is more than 90% effective at preventing shingles and PHN. Protection stays above 85% for at least the first four years after you get vaccinated.”

What Everyone Should Know about Shingles Vaccine

The first, Zostavax, was licensed in 2006.

Both are for older adults.

The Shingles Vaccine Shortage

Having a new and better shingles vaccine is good!

High levels of demand for shingles vaccine has lead to shortages and Shingrix manufacturing facilities are already at maximum capacity.
High levels of demand for shingles vaccine has lead to shortages and Shingrix manufacturing facilities are already at maximum capacity.

Not being able to actually get the vaccine and get vaccinated and protected isn’t so good. There has been a shortage of the vaccine due to high levels of demand since last year.

“Recombinant zoster vaccine (RZV) is recommended for the prevention of herpes zoster and related complications for immunocompetent adults aged ≥50 years.”

Recommendations of the Advisory Committee on Immunization Practices for Use of Herpes Zoster Vaccines

Fortunately, we will likely see more doses of the vaccine available this year and everyone will eventually be able to get vaccinated. In addition to your doctor or favorite pharmacy, the Shingrix Vaccine Locator might help you find a dose until the shortage is over.

More on the Shingles Vaccine Shortage