Vaccinations during childhood

There are many ways to protect your child against childhood diseases, but vaccination is strongly recommended for protection against certain childhood diseases.

A young child’s immune system does not work as well as the immune system in older children and adults because it is still immature. Therefore more doses of vaccine are needed.

In the first months of life, a baby is protected from most infectious diseases by antibodies from the mother, which are transferred during pregnancy. When the antibodies wear off, the baby is at risk of serious infections and so the first immunisations are given before these antibodies have gone.

In Australia, there are two primary reasons every child should be immunised:

• Immunisation is the safest and most effective way of providing protection and is far less likely to catch a disease if there are cases in the community.
• If enough people in your community are immunised, the infection can no longer be spread from person to person and the disease will die out.

A number of Australian Government initiatives in recent years have contributed to a fairly impressive immunisation success story. These include funding immunisation-related financial incentives for parents and providers and the National Childhood Immunisation Register. The Government also funds state and territory governments to purchase vaccines.

The National Immunisation Program (NIP) Schedule lists the diseases for which immunisation is available and the ages at which doses should be given for those currently funded under the NIP.

In Australia vaccines are provided free under the NIP for the ages outlined in the Schedule, though a GP consultation fee may be charged for the visit.

How is a vaccine made?
Most vaccines contain purified fragments taken from dead bacteria or viruses (germs). Some vaccines contain live viruses, but in a weak form that will not bring about the disease.

How do vaccines work?
Vaccines “teach” the immune system how to recognise and fight certain germs, bacteria and viruses before a particular disease can gain a foothold. By giving the body a small “sample” of the germ, it can develop resistance without actually contracting the disease.

Why give babies and children vaccines?
Certain vaccine-preventable diseases can infect babies within the first few months of life. Vaccinating these babies helps provide them with protection when it is needed. Some of these immunisations have to be repeated to make sure the baby/child remains protected.

The safety of vaccines
In the past decade numerous changes in vaccine production and administration have reduced side-effects and resulted in safer vaccines. This process never stops and research continues to develop improved vaccines.

All vaccines currently available in Australia have to successfully pass stringent safety testing before being approved for use by the Therapeutic Goods Administration (TGA). This testing is required by law and is usually done over many years during the vaccine’s development.

Side effects of vaccines
The different vaccinations’ side effects will be discussed with each vaccine. The most typical side-effects include a slight fever, drowsiness and soreness at the injection site. Though extremely rare, vaccines can cause other side-effects such as high temperatures. If your child develops a high fever (more than 39ºC), or appears to be in severe pain, seek medical attention immediately.

The flu injection
In Australia children aged six months and older can receive influenza vaccine annually (unless they have a medical contraindication to vaccination). However, the vaccine dosage and number of doses required for children varies with age.

However, one brand of influenza vaccine, Fluvax® (bioCSL), is not registered for use in children aged six months to five years and is not to be given to children of this age. Other brands of influenza vaccine can be used in this age group. This is due to an association between this vaccine and high fever and febrile convulsions in children in the 2010 influenza season.

Childhood vaccines funded under the National Immunisation Program
The routine childhood immunisations given through the National Immunisation Program currently provide protection against 13 diseases:

• Diphtheria 
• Haemophilus influenzae type B (Hib) 
• Hepatitis B
• Measles
• Meningococcal C
• Mumps
• Whooping cough (pertussis) 
• Pneumococcal disease
• Polio (poliomyelitis)
• Rotaviral gastroenteritis
• Rubella (German measles)
• Tetanus
• Chickenpox (varicella)

Routine immunisation schedule in Australia:
Birth: Hepatitis B

2 months:
• Diphtheria
• Tetanus
• Pertussis
• Polio
• Hib*
• Hepatitis B
• Pneumococcal*
• Rotavirus*

4 months:
• Diphtheria
• Tetanus
• Pertussis
• Polio
• Hib*
• Hepatitis B
• Pneumococcal*
• Rotavirus*

6 months:
• Diphtheria
• Tetanus
• Pertussis
• Polio
• Hib*
• Hepatitis B (or at 12 months)
• Pneumococcal*
• Rotavirus *

12 months:
• Measles*
• Mumps
• Rubella
• Hib*
• Hepatitis B (or at 6 months)
• Meningococcal C

18 months:
• Measles*
• Mumps
• Rubella
• Varicella
• Pneumococcal*

4 years:
• Diphtheria
• Tetanus
• Pertussis
• Polio
• Measles *
• Mumps
• Rubella

* Hib vaccine: Four doses are due at two, four, six and 12 months old when PRP-T Hib containing vaccine is used.

* Rotavirus vaccine: Three doses are due at two, four and six months old when RotaTeq vaccine is used.

* Pneumococcal vaccine: Four doses are due at two, four, six and 18 months old when Synflorix vaccine is used.

* MMR vaccine: This is only to be given at four years if MMRV vaccine was not given at 18 months.

Route of administration for vaccines used in Australia

* IPV-containing combination vaccines are administered by IM injection; IPV (IPOL) is administered by SC injection.

(Graph courtesy of The Australian Immunisation Handbook.)

Inactivated poliomyelitis vaccine protects against the following: Poliomyelitis
• The dose of the IPV-containing combination vaccines is 0.5 ml to be given by IM injection.
• The primary course consists of three doses of vaccine. An interval of two months between doses is recommended but the minimum interval can be as short as one month for catch-up in children or adults.
• IPV (IPOL) or IPV-containing vaccines are recommended for infants at two, four and six months old.
• A booster dose of IPV (IPOL) or IPV-containing vaccine is recommended at four years old.

Side effects
• Rigors (shivering)
• Asthenia (weakness)
• Myalgia (pain in the muscles)
• Arthralgia (severe pain in joints)

When to be worried
• Inconsolable crying
• Muscle weakness

When to take baby to a doctor or casualty ward
• Persistent, inconsolable crying

Vaccination should be postponed in case of
• Acute illness
• Within three months of prior administration of immunoglobulins

Treatment
• People in contact with recently immunised babies should be advised of the need for strict personal hygiene, particularly hand washing after nappy changes for 3-4 days after vaccination.
• Put soiled nappies in a plastic bag before discarding for 3-4 days after vaccination.

BCG vaccine SSI Tuberculosis vaccine protects against the following: Tuberculosis
• In Australia, BCG vaccination is not recommended for general use. It is generally only recommended for certain groups including Aboriginal neonates in areas of high incidence of TB (such as the Northern Territory, Far North Queensland, northern areas of Western Australia and South Australia); neonates and children five years and under who will be travelling or living in countries or areas with a high prevalence of TB for extended periods; neonates born to parents with leprosy or a family history of leprosy.
• Children in Australia are only given the vaccine of they are over five years and will be travelling or living in countries or areas with a high prevalence of TB for extended periods. 
• If children are vaccinated, they should receive 0.05 ml of the reconstituted vaccine intradermally.
• Children older than one year should receive 0.1 ml.
• The injection is to be given slowly, strictly intradermally, into the upper layer of skin of the right arm in the region over the distal insertion of the deltoid muscle.

Side effects
• Small, red area after three weeks
• Small papule, with scaling and scabbing, after six weeks
• Formation of a small vesicle
• Ulcer, two to four weeks after vaccination
• Healing taking from two to five months.
• Small flat scar forming after one year

When to be worried
• Enlargement of auxiliary lymph nodes

Take the baby to a doctor or casualty ward
• Enlargement of auxiliary lymph node

Vaccination should be postponed in case of
• Acute illness
• High fever
• Serious skin disease

Treatment
• Do not open vesicle or ulcer.
• Do not apply any ointment directly on to injection site.
• It is advisable to watch for any side effects.
• Remain at clinic for at least 20 minutes after injection.

If in doubt, contact your doctor or healthcare provider immediately.

Infanrix-hexa injection, protects against the following: Diphtheria, Tetanus, Pertussis, Poliomylitis, Haemophilus influenzae type B
• Injection in right upper thigh, 0.5 ml intramuscularly
• After one year, in the right upper arm

Side effects
• Redness at the injection site
• Fever
• Diarrhoea/vomiting
• Feeding/sleeping disturbances
• Irritability

When to be worried
• Redness and swelling more than 5cm at injection site
• Fever more than 39ºC
• Drowsiness
• Inconsolable crying

Take baby to doctor or casualty ward
• Fever more than 40ºC
• Convulsions, with or without fever, within three days of vaccination
• Hypotonic reactions (collapse or shock-like state)
• Rash
• Persistent, inconsolable crying lasting more than three hours and occurring within 48 hours of vaccination

Vaccination should be postponed in case of
• Fever more than 39ºC
• Acute illness
• Hypersensitivity to any components of the vaccine
• Severe reaction to previous injections

Treatment
• Only administer Panadol if temperature is higher than 38ºC. 
• Six- and eight-week-old babies: Panadol infant drops, 0.6 ml, four to six hourly x 2 for fever.
• 10- and 14-week-old babies: Panadol syrup, 2.5 ml, four to six hourly x 2 for fever. 
• Older babies: Panadol syrup 5 ml, four to six hourly x 2 for fever. 
• Apply hot face cloth (tested on mother’s forearm for correct temperature before applying to baby) on the injection spot every time you change the nappy, for 2 days.
• Do not apply any ointment directly on injection site.
• It is advisable to observe for any side effects.
• Remain at clinic for at least 20 minutes after injection.
• If in doubt, contact your doctor or healthcare provider immediately for advice.

Prevenar13 injection is a Pneumococcal infection vaccine that protects against the following: Pneumonia and Otitis media, caused by Streptococcus pneumoniae, Meningitis, Bacteremia
• Injection in right upper thigh, 0.5 ml intramuscularly. 
• After one year in the right upper arm. 
• Children generally get four doses of the vaccine, at least four weeks apart, starting at six weeks old. Four is the maximum number of doses required.
• Each dose will be given on a separate occasion.

Side effects
• Swelling, pain and tenderness
• Fever
• Diarrhoea/Vomiting
• Decreased appetite
• Drowsiness/restless sleep
• Irritability
• Crying

When to be worried
• Redness and swelling more than 2,4cm at injection site, interfering with movement
• Fever more than than 39ºC
• Seizures, hypotonic-hypo responsive episode
• Rash
• Lymphadenopathy, localised to the region of injection site

Take baby to doctor or casualty ward
• Fever more than 40ºC
• Convulsions with or without fever within 3 days of vaccination
• Hypotonic reactions (collapse or shock-like state)
• Hypersensitivity reaction, including face oedema dyspnoea, bronchospasm (struggling to breathe)
• Injection-site pruritis (swelling, red and very sore)
• Lymphadeopathy, localized to the region of injection site
• Wheezing

Vaccination should be postponed in case of
• Fever more than 39ºC
• Acute illness
• Hypersensitivity to the vaccine including Diphtheria toxoid
• Not be given to infants with thrombocytopenia or any coagulation disorders
• Sickle cell disease
• People who have ever had an allergic reaction to pneumococcal or diphtheria vaccines, or any of the ingredients listed in the Prevenar 13 vaccine should not be given the vaccine.

Treatment
• Only give Panadol syrup if temperature is higher than 38ºC. 
• Six and eight week old babies: Panadol Infant drops, 0.6 ml, four to six hourly x 2 for fever. • 10- and 14-week-old babies: Panadol syrup, 2.5 ml four to six hourly x 2 for fever. 
• Older babies: Panadol syrup, 5 ml four to six hourly x 2 for fever. 
• Apply hot face cloth (tested on mother’s forearm for correct temperature before applying to baby) on the injection spot, every time you change the nappy, for two days.
• Do not apply ointment directly on injection site.
• It is advisable to observe for any side effects.
• Stay at clinic for at least 20 min. after injection.
• If in doubt, contact your doctor or healthcare provider immediately for advice.

Hepatitis B vaccines against the Hepatitis B virus
• Monovalent hepatitis B vaccines:
- Engerix-B
- H-B-Vax II
• Combination vaccines that contain hepatitis B:
- Infanrix hexa
- Twinrix Junior (360/10)
- Twinrix (720/20)
• The Australian infant schedule consists of a dose of monovalent hepatitis B vaccine given at birth, followed by three doses of a hepatitis B-containing combination vaccine, given at two, four and six months old.
• If an infant did not receive the birth dose within the first seven days of life, catch-up of that dose is not necessary. Such infants then only require three doses of a hepatitis B-containing combination vaccine, given at two, four and six months of age.
• For infants, the final dose of the primary course should not be administered before reaching 24 weeks old.
• This schedule has been shown to be equally immunogenic when compared with giving monovalent hepatitis B vaccine in a three-dose schedule at birth, one to two months and six to 18 months old; this hepatitis B vaccine schedule is often used overseas.
• Children born overseas who have received hepatitis B vaccine in this three-dose schedule can also be considered to have completed the primary vaccination course.
• Injection in right upper thigh, 0.5 ml intramuscularly. 

Side effects
• Redness at the injection site
• Fever
• Diarrhoea/vomiting
• Feeding/sleeping disturbances
• Irritability

When to be worried
• Redness and swelling more than 5cm at injection site
• Fever more than than 39ºC
• Drowsiness
• Inconsolable crying

Take baby to doctor or casualty ward
• Fever more than 40ºC
• Convulsions with or without fever within three days of vaccination
• Hypotonic reactions (collapse or shock-like state)
• Rash
• Persistent inconsolable crying lasting more than three hours, occurring within 48 hours of vaccination

Vaccination should be postponed in case of
• Fever more than 39ºC
• Acute illness
• Hypersensitivity to any components of the vaccine
• Severe reaction to previous injections

Treatment
• Only give Panadol syrup if temperature is higher than 38ºC. 
• Six- and eight-week-old babies: Panadol Infant drops, 0.6 ml four to six hourly x 2 for fever. 
• 10- and 14-week-old babies: Panadol syrup, 2.5 ml four to six hourly x 2 for fever. 
• Apply hot face cloth (tested on mother’s forearm for correct temperature before applying to baby) on the injection spot every time you change the nappy, for two days.
• Do not apply any ointment directly on injection site.
• It is advisable to observe for any side effects.
• Remain at clinic for at least 20 minutes after injection.
• If in doubt, contact your clinic/clinic sister immediately for advice.

Rotarix and RotaTeq are Rotavirus gastro vaccines and protect against the following: Gastroenteritis caused by rotavirus
• Two oral rotavirus vaccines are available in Australia: Rotarix and RotaTeq.
• Rotarix is recommended for use in a two-dose course in infants and upper age limits apply. The 1.5 ml dose of vaccine should be administered orally from the oral applicator on to the inside of the infant’s cheek.
• RotaTeq is recommended for use in a three-dose course in infants and upper-age limits apply. It is taken orally in a 2 ml dose on to the inside of the infant’s cheek.
• Completion of a course of rotavirus vaccine should be with vaccine from the same manufacturer whenever possible.
• The vaccination course of Rotarix consists of two doses, at two and four months old. The first dose should be given between six and 14 weeks old (i.e. prior to turning 15 weeks old), and the second dose should be given by 24 weeks old (i.e. prior to turning 25 weeks old). The interval between the two doses should not be less than four weeks.
• The vaccination course of RotaTeq consists of three doses, at two, four and six months old. The first dose should be given between six and 12 weeks old (i.e. prior to turning 13 weeks old), and all doses should be given by 32 weeks old (i.e. prior to turning 33 weeks old). The interval between doses should be at least four weeks.
• Method of administration: oral only.
• Repeat if infant vomits, spits it out or regurgitates.
• Vaccination of older infants, children or adults is not recommended.

Side effects
• Irritability
• Loss of appetite
• Diarrhoea
• Vomiting
• Flatulence
• Abdominal pain
• Fever
• Fatigue

When to be worried
• Fever more than than 39ºC
• Drowsiness
• Inconsolable crying

Take baby to doctor or casualty ward
• Fever more than 40ºC
• Convulsions with or without fever within 3 days of vaccination
• Hypotonic reactions (collapse or shock-like state)
• Persistent, inconsolable crying lasting more than three hours, occurring within 48 hours of vaccination.

Vaccination should be postponed in case of
• History of chronic gastrointestinal disease
• Uncorrected congenital malformation of the gastrointestinal tract
• Diarrhoea or vomiting

Treatment
• People in contact with recently immunised babies should be advised of the need for strict personal hygiene, particularly hand-washing after nappy changes for three to four days after the event.
• Put soiled nappies in plastic bag before discarding for three to four days after immunisation.
• It is advisable to observe for any side effects.
• Stay at clinic for at least 20 minutes after injection.
• If in doubt contact your doctor or healthcare provider immediately for advice.

Measles vaccines in Australia protect against measles
• Monovalent measles vaccine is not available in Australia.
• Measles vaccination is provided using either measles-mumps-rubella (MMR) or measles-mumps-rubella-varicella (MMRV) vaccines.
• Two quadrivalent combination vaccines containing live attenuated measles, mumps, rubella and varicella viruses (MMRV) are registered in Australia.
• Trivalent measles-mumps-rubella (MMR) vaccines: M-M-R II and Priorix. 
• Quadrivalent measles-mumps-rubella-varicella (MMRV) vaccines: Priorix-tetra and ProQuad. • The dose of Priorix (MMR) vaccine for both children and adults is 0.5ml to be given by either SC or IM injection.
• The dose of M-M-R II (MMR) vaccine for both children and adults is 0.5ml to be given by SC injection.
• For children more than 14 years old, the dose of MMRV vaccine is 0.5ml to be given by SC injection. Priorix-tetra may also be given by IM injection.
• MMRV vaccines are not recommended for use in persons aged +/-14- years-old.
• When two doses of MMR-containing vaccine are required the minimum interval between doses is four weeks.

Side effects
• Malaise (general feeling of being ill)
• Fever
• Cough
• Coryza (inflammation of the mucous membrane of the nose)
• Rash
• Pharyngitis
• Headache

When to be worried
• Fever more than than 39ºC
• Drowsiness
• Inconsolable crying

Take baby to doctor or casualty ward
• Fever more than 40ºC
• Convulsions with or without fever within three days of vaccination
• Hypotonic reactions (collapse or shock-like state)
• Persistent, inconsolable crying lasting more than three hours, occurring within 48 hours of vaccination

Vaccination should be postponed in case of
• Acute respiratory infection
• Immuno-compromised patients
• Immune deficiency syndrome
• Human gabba globulin: for three months afterwards 
• Egg protein and neomycin allergy

Treatment
• Only give Panadol syrup if temperature is higher than 38ºC
• Panadol syrup: 5 ml, four to six hourly x 2 for fever
• Apply hot face cloth (tested on mother’s forearm for correct temperature before applying to baby) on the injection spot, every time you change the nappy, for two days afterwards.
• Do not apply any ointment directly on to injection site.
• After five to 10 days it may look as if your baby has measles, a runny nose, a cough, red and watery eyes, mild fever and a rash on the face and upper neck. These are not infections and only last for two to three days.
• Put Calamine lotion on rash.
• It is advisable to observe for any side effects.
• Stay at clinic for at least 20 minutes after injection.
• If in doubt, contact your doctor or healthcare provider immediately for advice.

Td (tetanus, diphtheria) vaccines protect against the following: Diphtheria (reduced dosage) and Tetanus Toxiod vaccine adsorbed on aluminumhydroxine

• Tetanus and dipetheria vaccines available in Australia for children under the age of 10 include:
- Infanrix hexa (DTPa-hepB-IPV-Hib; diphtheria-tetanus-acellular pertussis-hepatitis B-inactivated poliovirus-Haemophilus influenzae type b).
- Infanrix IPV (DTPa-IPV; diphtheria-tetanus-acellular pertussis-inactivated poliovirus).
- Pediacel (DTPa-IPV-Hib; diphtheria-tetanus-acellular pertussis-inactivated poliovirus-Haemophilus influenzae type b).
- Quadracel (DTPa-IPV; diphtheria-tetanus-acellular pertussis-inactivated poliovirus).
- Tripacel (DTPa; diphtheria-tetanus-acellular pertussis).

• The dose of all diphtheria-containing vaccines is 0.5 ml, to be given by injection into the muscle.
• The recommended three-dose primary schedule is at two, four and six months old. The first dose can be given as early as six weeks old due to the high morbidity and occasional mortality associated with pertussis in very young infants.
• If the first dose is given at six weeks old the next scheduled doses should still be given at four months and six months old.
• A booster dose of diphtheria-containing vaccine, usually provided as DTPa-IPV, is recommended at four years old but can be given as early as three and a half years.

Side effects
• Redness at the injection site
• Fever

When to be worried
• Redness and swelling more than five centimetres at injection site
• Fever more than than 39ºC
• Drowsiness
• Inconsolable crying

Take child to doctor or casualty ward
• Fever more than 40ºC
• Convulsions with or without fever within three days of vaccination
• Hypotonic reactions (collapse or shock-like state)
• Rash
• Persistent, inconsolable crying lasting more than three hours, occurring within 48 hours of vaccination

Vaccination should be postponed in case of
• Fever more than 39ºC
• Acute illness
• Hypersensitivity to any components of the vaccine
• Severe reaction to previous injections

Treatment
• Only give Panadol syrup if temperature is higher than 38ºC
• Panadol syrup: 10 ml twice 6 hourly
• Apply hot face cloth (tested on mother’s forearm for correct temperature before applying to the injection site) four times a day
• Do not apply ointment directly on to injection site

References:
- Immunise Australia Program. FAQs.
- The National Centre for Immunisation Research and Surveillance. INFLUENZA VACCINES FOR AUSTRALIANS.
- The Australian Immunisation Handbook: Poliomyelitis. Rotavirus. Measles. Diptheria
- Hepatitis B Pneumococcal polysaccharide conjugate vaccine: Prevenar 13