Childhood immunisation

• Introduction to childhood immunisation
• What is immunisation?
• Why is childhood immunisation so important?
• Which vaccinations will my child need
• What do the vaccinations protect against
• Myths about childhood immunisation
• How can i make immunisation easier for my child

Introduction to childhood immunisation

Childhood immunisation is an effective way of protecting your child against a number of infectious diseases. To ensure life-long protection, it is important that childhood immunisation begins as early as possible, and that all the appropriate doses and boosters are given. The schedule of immunisations recommended for Australian children is outlined below.

What is immunisation?

Immunisation is the process of being vaccinated against a disease, and becoming immune to the disease as a result. In Australia, the process of immunisation usually begins in early childhood. For more information on how immunisation works, or adult immunisation schedules, see the separate article.

Why is childhood immunisation so important?

Childhood immunisation is the best way of protecting your child against infectious disease, and all of the vaccines we use in Australia are highly effective. Compared to the risks of the disease we are protecting against, the risk associated with any vaccination is very small. By vaccinating your child, you are protecting them against developing potentially serious illnesses.
In addition, the more people in our community are immunised against a disease, the less likely it is that any infection that does occur will be able to spread from person to person. This is how diseases like smallpox and polio have been virtually eliminated from many countries.

Which vaccinations does my child need?

The vaccinations recommended by the Australian National Immunisation Program Schedule are listed below.

• Birth: Hepatitis B;
• 2 months: Diphtheria–Tetanus–Pertussis (DTPa); Hepatitis B; Haemophilus influenzae type b (Hib); Poliomyelitis (IPV); Pneumococcal C vaccine (7vPCV);
• 4 months: Diphtheria-Tetanus-Pertussis (DTPa); Hepatitis B; Haemophilus influenzae type b (Hib); Poliomyelitis (IPV); Pneumococcal C vaccine (7vPCV);
• 6 months: Diphtheria-Tetanus-Pertussis (DTPa); Hepatitis B (or may be given at 12 months); Haemophilus influenzae type b (Hib); Poliomyelitis (IPV); Pneumococcal C vaccine (7vPCV);
• 12 months: Hepatitis B (or may be given at 6 months); Poliomyelitis (IPV); Measles–Mumps–Rubella (MMR); Meningococcal C conjugate vaccine (MenCCV);
• 18 months: Chickenpox (Varicella zoster (VZV));
• 4 years: Diphtheria-Tetanus-Pertussis (DTPa); Measles-Mumps-Rubella (MMR); Poliomyelitis (IPV).

Older children:

• 10-13 years: Varicella zoster (VZV) vaccination ONLY for children who have no history of vaccination or infection; Hepatitis B vaccination ONLY for children who have not received a primary course of vaccination;
• 15-17 years: Diphtheria-Tetanus-Pertussis booster (dTpa, adult/adolescent formulation).

All of these vaccines are free in Australia for your child.

What do the vaccinations protect against?

Hepatitis B
Hepatitis B is a viral illness which is transmitted mostly through the blood, or through sexual contact. Children born to infected mothers are particularly at risk. The virus infects the liver and produces an inflammation (‘hepatitis’) which may become chronic, or life-long, in up to 25% of those infected. This can lead to problems such as liver failure, liver cancer, or death.
The hepatitis B vaccines currently in use in Australia contain a very small modified portion of the hepatitis B virus, and a small amount of aluminium salt in the first (birth) dose. The initial course of Hepatitis B vaccination is four doses, given at birth, 2, 4 and 6 or 12 months of age. Children who have not received this primary course should be vaccinated at 10-13 years.
Side effects of hepatitis B vaccination are usually mild, but may include soreness at the injection site, fever, nausea or joint pain.

Diphtheria-Tetanus-Pertussis
The diphtheria-tetanus-pertussis vaccine is a combination vaccine which protects against all three diseases.
Diphtheria is a bacterial illness which can affect both children and adults. It infects the mouth and throat and produces a toxin which causes a membrane to grow inside the throat. This membrane can block the air supply to the lungs and lead to choking or suffocation. The toxin may also spread throughout the body and lead to paralysis or heart failure.
Tetanus is a disease caused by the Clostridium tetani bacteria. Unlike other diseases we vaccinate against, tetanus is caught not from other people, but from contact with infected soil or manure. The bacteria usually enter the body through a small cut or wound, and then multiply and produce another toxin which attacks the body’s nervous system. It causes severe muscle spasms which usually start in the jaw or neck (causing ‘lockjaw’). In time, the effects may spread to the lungs and heart, causing death.
Pertussis, or ‘whooping-cough’, is a bacterial illness spread by coughing or sneezing. Infection often occurs in epidemics in the community. It may cause a severe cough which may last up to 3 months, and may require admission to hospital. Some children vomit after the coughing attacks. Pertussis may lead to a number of complications, including pneumonia, seizures (convulsions), brain or lung damage, or even death.
The DTP vaccine contains small amounts of modified diphtheria and tetanus toxins, along with a small modified portion of the pertussis bacteria. The initial course of diphtheria-tetanus-pertussis vaccination is three doses, given at 2, 4 and 6 months of age. These are often combined with other vaccinations such as the polio vaccine to reduce the number of injections your child receives.
A booster dose of diphtheria–tetanus–pertussis should be given at 4 years. In addition, a booster dose of the adult/adolescent formulation dTpa vaccine should be given at 15-17 years to ensure ongoing protection.
Side effects of DTPa vaccination include soreness and swelling around the vaccination site, and mild fever.

Haemophilus influenzae type b (Hib)
Haemophilus influenzae is a bug commonly found in the nose and throat of healthy people, where it can survive for many years without causing disease. Some types of the bacteria, however, such as Haemophilus influenzae type b (Hib), are capable of invading the rest of the body and causing severe disease, including meningitis (inflammation around the brain), epiglottitis (swelling of the throat which may block breathing) and joint infection. Young children under 5 years of age are particularly at risk of severe disease.
Vaccination against Haemophilus influenzae type b was first introduced in Australia in 1993. Since this time, the vaccination program has been very effective at reducing the number of children suffering from disease caused by Hib. The Hib vaccines we use contain a purified portion of one of the proteins which make up the bacteria, attached to another protein which helps stimulate the immune system.
The initial course of Haemophilus influenzae type b vaccination is either three doses given at 2, 4 and 12 months; or four doses given at 2, 4, 6 and 12 months, depending on the type of vaccine used. Pre-term babies may require an extra dose, as their immune system may not respond as well as term babies.
Side effects of the Hib vaccine are very rare. One in twenty children who receive the vaccine may experience mild swelling, redness and pain at the site of the injection. Uncommonly, mild fever and irritability may occur. More serious side effects have not been reported.

Poliomyelitis
Poliomyelitis (polio) is a disease virtually unheard of in our community these days, but was once a common infection in Australian children. It is caused by a gastrointestinal virus which affects the nervous system, causing muscle stiffness, paralysis and even death.
In Australia, universal childhood immunisation against polio has been in place since the 1950s, and has resulted in the elimination of the disease in this country. Vaccination remains very important, however, because polio is still in existence worldwide, and there is a risk that infection may be imported from overseas and re-establish in Australia if our immunisation program is not maintained.
In the past, vaccination schedules in Australia recommended the use of the Sabin oral polio vaccine (OPV), which was given as several drops of liquid onto the tongue. This vaccine is no longer in use, due to the very small risk that the recipient of the vaccine might develop poliomyelitis.
The vaccine we now use is the inactivated polio vaccine (IPV). It contains small amounts of the killed polio virus, and must be given in three separate doses given at 2, 4 and 6 months, followed by a booster dose at 4 years of age. The IPV may be combined with other vaccinations such as DTPa to reduce the number of injections your child receives.
Side effects of the IPV include soreness, swelling or redness at the injection site. Some children may also experience muscle aches, mild fever, or loss of appetite. There is absolutely no risk that your child will develop polio following the IPV immunisation.

Pneumococcal
Pneumococcal disease is a potentially life-threatening illness caused by infection with a type of bacteria called Streptococcus pneumoniae. The bacteria may travel to many different areas of the body, producing disease including meningitis (inflammation around the brain), septicaemia (poisoning of the blood), or pneumonia (infection of the lungs). Milder forms of disease in children include otitis media (middle ear infection). The Streptococcus bacteria are usually transmitted from person to person by coughing or sneezing. Children particularly at risk of pneumococcal disease include Indigenous children, and children with chronic disease or impaired immunity.
There are two types of pneumococcal vaccine in use in Australia.
The 23-valent pneumococcal polysaccharide vaccine (23vPPV) protects against 23 types of pneumococcal bacteria, but does not work well in young children. This vaccine is usually reserved for use in adults, or given as a booster dose in children who are particularly at risk.
The vaccine used to immunise babies and young children is the pneumococcal conjugate vaccine (7vPCV). This protects against 7 types of the bacteria and is highly effective in infants. The initial course requires three doses, given at 2, 4 and 6 months of age. Some children particularly at risk of infection may require additional booster doses.
Side effects of the pneumococcal vaccine may include redness, swelling or soreness at the vaccination site. Uncommonly, children may experience vomiting, diarrhoea and decreased appetite. There is no risk that your child will develop pneumococcal disease from the vaccine.

Meningococcal C disease
Meningococcal disease is another bacterial illness transmitted between people by coughing or sneezing. Disease onset is often very sudden; a child may become seriously unwell within hours with inflammation around the brain (meningitis) or blood poisoning (septicaemia). Children under 5 years of age are particularly at risk.
Though meningococcal disease and pneumococcal disease sound similar, it is important to recognise that they are caused by different types of bacteria. Immunisation against pneumococcal disease will not protect your child from meningococcal disease, and vice versa.
Two different vaccination courses are required. Childhood immunisation against meningococcal disease uses a vaccine called the meningococcal C conjugate vaccine (MenCCV). This protects only against one type, or serogroup, of the meningococcal bacteria. There are no vaccines currently available for use in young children which are effective against the other strains of bacteria. The vaccine contains a very small amount of a part of the killed bacteria. The meningococcal C conjugate vaccine (MenCCV) requires just one dose at 12 months of age.
Side effects of the vaccine may include redness, swelling and pain at the injection site. Some children experience fever, headaches, irritability and decreased appetite. Very rarely, the vaccine may cause seizures. Vaccination cannot cause meningococcal disease in your child.

Measles-Mumps-Rubella (MMR)
Measles is a highly contagious viral disease capable of causing fever, rash, cough, runny nose and conjunctivitis. The main risk of measles infection is of the complications, which may include pneumonia (in 4% of cases), middle ear infection or inflammation of the brain (encephalitis). Very rarely, measles infection may be followed subacute sclerosing panencephalitis (SSPE), a destructive disease of the brain which always results in death.
Mumps is another viral illness, characterised by swelling of the salivary glands along with fever and headache. It is spread by coughing, sneezing, or direct contact, and is commonest in 5-9 year old children. Complications of mumps infection include inflammation of the tissues around the brain (meningitis), inflammation of the brain (encephalitis), or permanent deafness. In older males, mumps may cause painful swelling of the testes which may rarely result in infertility.
Infection with the rubella virus in children or adults usually produces a mild illness which may include rash, swollen glands, joint pain and muscle pains. It is commonly known as German measles. Though complications of rubella infection do sometimes occur, they are rare. The true danger of rubella infection lies in the risk of Congenital Rubella Syndrome, which may occur if a non-immune pregnant woman becomes infected during the first half of pregnancy. This can have devastating consequences for the baby, which may be born deaf, blind, with heart defects, or mentally retarded. Vaccination programs aim to ensure that all women are immune to rubella before they become pregnant, and that the spread of rubella in our community is limited by immunising all children and adults.
The MMR combined vaccine used in Australia protects against all three of the above diseases. It contains small amounts of reduced-strength live measles, mumps and rubella viruses, and so is not suitable for use in pregnant women. The initial course of MMR vaccination is two doses at 12 months and 4 years of age.
Side effects of the MMR vaccine may include low-grade fever, rash, or swelling of the salivary glands. These will resolve within a few days. Paracetamol may be used to reduce the fever. Very rarely (in approximately one per million cases), a child may develop inflammation of the brain (encephalitis) following the MMR vaccine. Approximately one in 30,000 children may experience bruising and bleeding following the vaccine, which will improve without treatment.

Chickenpox (Varicella zoster virus)
The varicella zoster virus causes the disease we know as chickenpox, with a mild fever, runny nose, cough, and blistering rash over the trunk and face. This is a highly infectious illness spread by contact with fluid in the blistering rash, or through sneezing and coughing. In most healthy children, chickenpox will be mild and last only 5-10 days. Children with other medical conditions or who have a weak immune system for some other reason may be at risk of complications including pneumonia or encephalitis (inflammation of the brain).
People who are infected for the first time as adults also tend to develop more serious disease than children. If a pregnant woman develops chickenpox, there is a small risk that her baby will have congenital malformations, deafness, or skin scarring as a result.
Chickenpox vaccination in Australia is recommended for all children at 18 months of age, unless the child has already had the disease. The vaccine we use contains a small amount of inactivated live virus, and is not suitable for use in pregnant women.
Side effects of chickenpox vaccination are rare, but may include pain, redness or swelling at the injection site, or mild fever.

Myths about childhood immunisations

1. Immunisations are no longer necessary in Australia – our health and hygiene standards are too high for these diseases to be a concern.
   False. Despite excellent health care, immunisation is the only effective way of protecting children against these diseases, many of which are transferred from person to person by simple things like coughing or sneezing. In addition, there is no effective treatment for many of the diseases we immunise against, or their complications, once infection has become established.
2. Children who have already had a disease don’t need to be immunised against it.
   False. It is important that your child receive all the recommended vaccinations, even if you think they have already had a disease. This is because the vaccine may cover against other types of the disease, or your child may have been too young at the time of the infection to develop adequate protection. It is safe to give vaccinations to a child who has already had a disease – it may even boost their immunity higher and give them additional protection.
3. Immunisations can lead to development of diseases like autism or asthma.
   False. There is no evidence that any vaccinations currently listed on the Australian schedule can lead to development of autism, asthma, inflammatory bowel disease, chronic fatigue syndrome, allergies or multiple sclerosis. Nor is there any link between vaccinations and Sudden Infant Death Syndrome (SIDS).
4. There is no point to immunisation, since some children will develop the disease despite being immunised.
   While it is true that no vaccine is 100% effective, the likelihood of your child developing a disease after they have been immunised against it is very small. Furthermore, if they do develop the disease, their symptoms are likely to be much milder than if they had not been immunised, and their chance of developing dangerous complications will be lower.
5. My child has missed one or more of their vaccinations, and now it’s too late for them to be given.
   While vaccinations are most effective if given according to the schedule listed above, it is usually still worth giving your child a missed vaccination, even if it is several months or even years later than recommended. Your GP or health practitioner will be able to work out a catch-up schedule for your child to ensure they receive any missed vaccinations at an appropriate time.

How can I make immunisation easier for my child?

Children often find receiving vaccinations distressing. Some suggestions to help make the process easier for both parents and children include:

• Older children should be told if they are going to receive a vaccination, at least an hour in advance. It is important to be honest with them about the fact that it may hurt, while still emphasising that the injection is something very important to help them avoid getting sick. Children who are prepared generally fare better than those who are taken by surprise.
• Remain in the room and stay calm while the vaccination is given. It can be distressing for parents to see their child in pain, but if you are anxious or worried, your child is more likely to become upset.
• If you are unable to be in the room with your child when the vaccination is given, consider asking a grandparent or close friend to be with them instead.
• Distraction techniques, such as the presence of a favourite toy or blanket, may help.
• Telling your child to take a big breath in and blow it out just before the injection is given can help them relax.
• Some crying following an immunisation, especially in younger children, is normal. Do not allow yourself or your child to become distressed by it.
• Rewards, such as a jellybean or other special treat after a vaccination is given, may make the next visit less difficult.

Paracetamol
It is no longer necessary to give every child paracetamol before vaccination. This is because the vaccines we use have been designed to cause as few side effects as possible. In some cases, though, if a child develops a fever or becomes unsettled after immunisation, paracetamol may help. Check the formulation carefully and do not exceed six doses of paracetamol in 24 hours. If you are concerned, always speak to a doctor, pharmacist or child health nurse first.

Record-keeping
Finally, it is also very important to keep a record of your child’s immunisations. This should be done in the Child Health Record, which would have been given to you by the hospital or birth centre where your child was born. A record will also be kept in the Australian Childhood Immunisation Register (ACIR), which can help you keep track of your child’s immunisation history.

More information

For more information on immunisation, including the childhood immunisation scedule, types of vaccines, preconception screening, as well as some useful videos, see Immunisation.

 

References

1. Braunwald E, Fauci AS, Kasper DL, et al. Harrison’s Principles of Internal Medicine (16th edition). New York: McGraw-Hill Publishing; 2005. [Book]
2. Drutz JE. Standard childhood immunizations [online]. Waltham, MA: UpToDate; 2006 [cited 29 July 2006]. Available from: URL link
3. The Australian Immunisation Handbook [online]. Canberra, ACT: National Health and Medical Research Council; 2003 [cited 29 July 2006]. Available from: URL link
4. Robinson MJ, Robertson D (eds). Practical Paediatrics (5th edition). Sydney, NSW: Churchill Livingstone; 2003. [Book]

This treatment is used for the following diseases:

• Chickenpox (Varicella Zoster Virus)
• Diphtheria
• Hepatitis B virus
• Measles (Rubeola)
• Meningococcal septicaemia (Meningococcemia, Meningococcal bacteremia)
• Mumps (Epidemic parotitis)
• Rubella (German Measles)
• Tetanus (Lockjaw)
• Whooping Cough (Pertussis)