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HannaNohynek
TuijaLeino

Vaccinations

Essentials

Schedule

Basic rules

  • Protection as early as possible
  • Immunization is done according to a schedule that causes as few problems as possible (need to consider neutralizing antibodies from the mother, and the child's own immunological maturity).
  • The target of a national immunization programme is to cover the whole population or a defined high-risk part of the population in which vaccination is sufficiently cost-effective.
  • National policies vary, but usually the vaccinations included in the national immunization programme are voluntary and free of charge.

Deviations from the schedule

  • If vaccination series was interrupted, it should be continued, no need to restart.
  • It is hardly worthwhile to shorten the recommended intervals between vaccinations as it usually would weaken the efficacy of the vaccination in short- or long-term.
  • Yet, if the child has clearly passed the recommended age for vaccination, the second dose (or booster) can be given after an interval shorter than usual (does not apply to rotavirus vaccine).
  • The minimum interval between two injections of the same vaccine is usually at least one month.
  • Several vaccinations can be given at the same time.
    • Use different vaccination sites to avoid interference and to recognize local reactions.
  • Vaccines containing inactivated microbes or their purified antigens can be given together with each other or with vaccines containing live attenuated microbes at the same visit or by any schedule in relation to each other.
  • Two vaccines both containing live attenuated microbes should be given at the same visit or at an interval of at least one month.
    • Do not give immunoglobulin simultaneously with MMR, varicella or yellow fever vaccination: vaccination - 3 to 4 weeks - immunoglobulin - 6 to 12 weeks - vaccination.

Finnish national immunization programme

National immunization programme in Finland as of September 1, 2017

Target groupAgeVaccine
Whole population2 monthsRotavirusVaccines for Preventing Rotavirus Diarrhoea: Vaccines in Use
3 monthsDTaP-IPV-Hib, PCVPneumococcal Conjugate Vaccines for Preventing Invasive Pneumococcal Disease and Pneumonia in Children Under Two Years of Age, rotavirus
5 monthsDTaP-IPV-Hib, PCV, rotavirus
6-35 monthsInfluenza (1. time 2 doses at one month interval, then 1 dose yearly)
12 monthsDTaP-IPV-Hib, PCV
12 monthsMMR
18 monthsChickenpox (vaccinations during the transition period: see more details in text below)
4 yearsDTaP-IPV
6 yearsMMRV (MMR for those who have had chickenbox)
14-15 yearsdtap
65 yearsInfluenza
11-12 yearsHPV (vaccination of boys started in 2020)
Risk groupsBCG, dtap, HBV, HAV, influenza, pneumococcus, tick-borne encephalitis

Vaccines used in the Finnish national immunization programme

AbbreviationVaccineAdministration
BCGTuberculosis vaccine (Bacillus Calmette-Guérin), contains live attenuated bacteriai.d.
DTaP-IPV-HibDiphtheria (D), tetanus (T), acellular pertussis (aP), polio (IPV), and Haemophilus influenzae type b (Hib) vaccinei.m.
DTaP-IPVDiphtheria (D), tetanus (T), acellular pertussis (aP), and polio (IPV) vaccinei.m.
dtapDiphtheria (d), tetanus (t), and acellular pertussis (ap) vaccinei.m.
DTDiphtheria (D) and tetanus (T) vaccinei.m.
dTDiphtheria (d) and tetanus (T) vaccinefor booster immunization, i.m.
HibHaemophilus influenzae type b (Hib) vaccine, contains purified antigens (bacterial surface polysaccharides conjugated with toxoid)i.m./s.c.
IPVPolio vaccine containing inactivated type 1, 2, and 3 virusess.c./i.m. depending on the preparation
PCVPneumococcal conjugate vaccines (children < 6 years Synflorix® , adults Prevenar 13® ), contain purified antigens (bacterial surface polysaccharides conjugated with a carrier protein)i.m.
MMRMeasles (morbilli, M), mumps (M), and rubella (R) vaccine, contains live attenuated virusess.c./i.m. depending on the preparation
MMRVMeasles (morbilli, M), mumps (M), rubella (R) and chickenpox (varicella, V) vaccine, contains live attenuated virusess.c.
HAVHepatitis A vaccine, contains inactivated (killed) virusesi.m. (exceptionally s.c.)
HBVHepatitis B vaccine, contains purified surface antigeni.m. (exceptionally s.c.)
HAV and HBVHepatitis A and hepatitis B vaccinei.m. (exceptionally s.c.)
HPVPapillomavirus vaccine, contains surface proteins of the virusi.m.
InfluenzaInfluenza vaccine, contains purified surface antigens, or virus fragments from three different influenza virus strains, or live attenuated virusesi.m./s.c. or nasal spray depending on the product
RotaRotavirus vaccine, contains live attenuated virusesp.o.
ChickenpoxChickenpox (Varicella) vaccine, contains live attenuated viruses. The vaccine used in the national immunization programme is Varivax® i.m./s.c.
TBETick-borne encephalitis vaccinei.m.
PPVPneumococcal polysaccharide vaccinei.m.
Markings describing different amounts of antigens in the vaccines
D, T, PHigher amount of antigens
d, t, pLower amount of antigens

Need for booster vaccinations

  • The first tetanus vaccine booster in adult age is given at the age of 25 as dtap combination vaccine.
  • dT booster is needed at 20-year intervals (a booster at the age of 45 and 65). This policy was changed in Finland in March 2018 (earlier the interval was 10 years). In persons over 65 years old, the booster is needed at 10-year intervals. Notice that using less frequent booster vaccinations in Finland assumes that persons below 65 years of age have received the childhood vaccinations.
  • IPV (polio) booster is needed in special situations only (consider for travellers heading for countries where polio virus is still encountered).

Chickenpox (varicella) vaccine in the national immunization programme Live Attenuated Varicella Vaccine for Healthy Children, Vaccines for Post-Exposure Prophylaxis Against Varicella (Chickenpox) in Children and Adults

  • Included as of the 1st of September 2017 in the national immunization programme in Finland. Chickenpox vaccine is offered to all children who were born in 2006 or later and who have not had chickenpox.
    • Patient history regarding earlier chickenpox suffices. It does not need to be established by blood tests.
  • Specific guidance regarding the transition period is available.
    • Children between 1.5 and 11 years are vaccinated during the first year.
    • Children who were 5 years old or younger at the onset of the programme are given a booster dose when they turn 6 years old.
    • Children who were between 6 and 11 years old at the onset of the programme are given a booster dose at the age of 12.
  • Chickenpox vaccine contains live attenuated viruses.
  • Contraindications
    • Severe immunodeficiencies
    • Pregnancy
      • Getting pregnant should be avoided for 1 month after the vaccination
    • Neomycin has caused anaphylaxia

Vaccinations for special groups in the national immunization programme

BCG vaccine BCG Vaccine in the Prevention of Tuberculosis, Does the Efficacy of BCG Vaccine Decline with Time?

  • BCG vaccination is recommended if
    • the mother, father or sibling of the child, or another person with whom the child is living has a history of diagnosed tuberculosis
    • the child him-/herself or the mother, father, sister or brother of the child, or another person with whom the child is living was born in a country with a high prevalence of tuberculosis (incidence at least 50/100 000/year)
    • the child is within a year due to move to a country with a high prevalence of tuberculosis (incidence at least 50/100 000/year) for longer than one month.
  • In rare cases that usually require a physician to take a stand the child may need BCG vaccination even if he/she does not belong to any of the risk groups mentioned above.
  • A community health nurse at the maternity clinic will assess the need for BCG vaccination before the delivery by interviewing the pregnant mother during a follow-up visit. The need for vaccination of a newborn infant may also be assessed at the maternity hospital.
  • One dose of the vaccine is administered as intradermal injection in the left upper arm.
  • Usually newborn babies are vaccinated but the vaccine may be given to children up to the age of 7 years.
  • When vaccinating children over 6 months of age it must be ensured before the vaccination by Mantoux tuberculin test that the child does not have active tuberculosis and has not been vaccinated with BCG. In exclusion of latent tuberculosis and in diagnosing tuberculosis Diagnosing Tuberculosis also immunological methods, so-called IGRA tests, can be employed.

Hepatitis B vaccine Hepatitis B Immunisation in Persons Not Previously Exposed to Hepatitis B or with Unknown Exposure Status, Vaccines for Preventing Hepatitis B in Health-Care Workers

  • Hepatitis B vaccine is given free of charge as a part of the national programme to the target groups listed below.
    • Newborn infants of HBsAg carriers (both mothers and fathers) at the age of 0, 1, 2 and 12 months. If the mother is a carrier, one dose (125 IU) of HB immunoglobulin must also be given before the first vaccination Hepatitis B Immunization for Newborn Infants of Hepatitis B Surface Antigen-Positive Mothers.
    • Children born in Finland to parents who have their origins in a country where hepatitis B is common
    • Newborn infants whose mother has hepatitis C infection
    • Children less than 5 years of age who attend a day-care group that includes a child who is infected with hepatitis B
    • People living in the same household as those with an acute HBV infection or with a known HBsAg carrier state
    • Men who have sex with men
    • Sex partners of people with acute HBV infection or with a known HBsAg carrier status
    • Haemophiliacs with regular substitution therapy
    • Users of intravenous drugs, their sex partners, and people living in the same household. Most essential is the vaccination of the newborn children if either of the parents uses intravenous drugs.
    • Professional prostitutes
    • People at hazard because of a needle stick injury or other exposure to blood when according to risk assessment the protection is considered necessary Occupational Exposure to Blood and Body Secretions
    • Students who are at risk of acquiring HBV-infection when working as trainees
  • Given at 0, 1 and 6 months, to newborn infants at 0, 1, 2 and 12 months. In newborns, make particularly sure that the whole hepatitis B vaccination schedule is completed because an infection in a small child leads to life-long infection in up to 90% of cases.

Hepatitis A vaccine Hepatitis A Immunisation in Persons Not Previously Exposed to Hepatitis A

  • Hepatitis A vaccine is given free of charge as a part of the national programme to the target groups listed below.
    • Users of intravenous drugs, their sex partners and and people living in the same household
    • Haemophiliacs who receive plasma-based preparations
  • According to current knowledge, two doses of the vaccine provide a life-long protection against hepatitis A. The age of the vaccinee has to be at least 12 months at the time of the first dose. The second dose is given 6-12 months after the first one.

Human papillomavirus (HPV) vaccine Effect of Human Papillomavirus 16/18 L1 Virus Like Particle Vaccine Among Women with Pre-Existing Infection, HPV Vaccines Against Human Papillomavirus

  • The vaccine contains surface proteins of human papillomavirus. Does not contain inner structures of the virus. The products also contain aluminium-based adjuvants.
  • The vaccine prevents those HPV infections that most commonly lead to cancer. There are several products at the market, including 2, 4 or 9 HPV types.
  • Two doses given at an interval of about 6 months are sufficient for girls and boys who receive the vaccine at the age indicated by the national immunization programme, i.e. at the age of 11-12 years. If the vaccination is started or completed later, 3 doses are necessary from the age of 14 or 15 years onwards, depending on the product.
  • In some countries, e.g. in Australia, the United States and Finland, the vaccine is included in the national immunization programme for boys as well. In Finland the vaccinations started in 2020 and also boys in secondary school (age 13-15 years) are vaccinated.

Influenza vaccine Influenza Vaccination in Asthma: Efficacy and Side Effects, Influenza Vaccine for Patients with Chronic Obstructive Pulmonary Disease, Protection Against Influenza after Annually Repeated Vaccination, Vaccines for Preventing Influenza in Healthy Adults, Influenza Vaccine for Children and Adults with Bronchiectasis, Influenza Vaccines for Preventing Cardiovascular Disease

  • The national recommendations for influenza vaccination are yearly reviewed. Free vaccination against seasonal influenza is recommended to those for whom influenza would pose an essential health risk or who would significantly benefit from the vaccination (same injectable inactivated vaccine to all age groups; from the age of 2 years onwards, a nasal spray vaccine is also available).
    • Professionals who work in direct contact with customers in health care, social care or pharmaceutical services
    • Pregnant women Viral Influenza Vaccinations in Pregnancy for Improving Maternal, Neonatal and Infant Health Outcomes
    • All people over 65 years of age
    • All children between 6 and 35 months of age
    • Patients who belong to the risk group because of their primary disease or treatment they receive
    • Individuals in near contact with persons susceptible to serious influenza; especially those in near contact with newborn infants or elderly or immunocompromised persons
    • Persons entering military service
  • The efficacy of the vaccine significantly varies from season to season. Influenza vaccination may prevent almost 70% of serologically confirmed and about 25% of clinically diagnosed influenza infections. Vaccination reduces the rate of hospitalization in the elderly Vaccines for Preventing Influenza in the Elderly.

Tick-borne encephalitis vaccine

Chickenpox (varicella) vaccine

  • Chickenpox vaccine (see above) is recommended in particular to healthy persons who are in close contact with at-risk patients, i.e. persons with immunodeficiencies or organ transplant patients, since immunodeficient patients themselves often cannot be vaccinated.
    • In organ transplantation cases the vaccination should be given before the transplantation.

Staff vaccinations for the protection of patients

  • Legislation on infection control may require that personnel working in specific settings within social and health care is vaccinated or has naturally acquired immunity against certain diseases. Find out about local legislation regarding such requirements.
  • In Finland the legislation was recently changed and applies as of March 2018 to all sfaff members and students. The following diseases/vaccines are included in the regulation:
  • Some contraindications to the vaccinations may apply, e.g. if the staff member or student is pregnant or is for some reason in immunosuppressive state. here

Use of vaccines outside the national immunization programme Vaccines for Preventing Malaria, Vaccines for Herpes Zoster in Older Adults, Vaccination Against Mycobacterium Leprae, Vaccines for Preventing Smallpox

Pneumococcal conjugate vaccine (PCV) Pneumococcal Vaccines for Preventing Otitis Media, Pneumococcal Conjugate Vaccines for Preventing Invasive Pneumococcal Disease and Pneumonia in Children Under Two Years of Age

  • Pneumococcal conjugate vaccinecontains purified antigens.
  • The first-choice pneumococcal vaccine; there is also evidence on a protective effect against non-invasive diseases. Revaccination is not required.
  • To children over 5 years of age and to adults who are at risk of acquiring severe pneumococcal infection or its complications due to their age, living conditions, disease or medication http://thl.fi/en/web/infectious-diseases-and-vaccinations/vaccines-a-to-z/pneumococcal-vaccines/pneumococcal-vaccinations-for-at-risk-groups. Such diseases and patient groups include e.g.
    • heart failure
    • chronic pulmonary disease (COPD, emphysema, but not asthma)
    • type 1 diabetes
    • hepatic insufficiency
    • renal insufficiency
    • alcoholism
    • permanent institutional care
    • age 65 years or more
    • bone marrow or organ transplant recipients
    • persons with immunodeficiencies
    • continuous systemic glucocorticoid therapy or other immunosuppressive medication.

Pneumococcal polysaccharide vaccine , Pneumococcal Vaccines for Bronchiectasis, Pneumococcal Vaccines for Patients with Chronic Obstructive Pulmonary Disease

Hib vaccine Haemophilus Influenzae Vaccination for the Prevention of Acute Exacerbations of Chronic Bronchitis

Hepatitis A vaccine Hepatitis A Immunisation in Persons Not Previously Exposed to Hepatitis A

Hepatitis B vaccine , Hepatitis B Immunisation in Persons Not Previously Exposed to Hepatitis B or with Unknown Exposure Status, Vaccines for Preventing Hepatitis B in Health-Care Workers

Japanese encephalitis vaccine Vaccines for Preventing Japanese Encephalitis

  • Japanese encephalitis vaccine contains inactivated viruses.
  • Basic immunization is achieved with 2 doses given at an interval of 28 days; also an accelerated schedule with an interval of 7 days can be applied in persons aged 18 to 65 years (see also http://www.who.int/ith/vaccines/japanese_encephalitis/en/).
  • The first booster dose is given 12 to 24 months after the basic series, the second booster after 6 to 10 years.
  • For travellers to endemic and epidemic areas of the disease (countries in the South-Eastern Asia east of India), especially if the travel includes visits to the countryside or spending lots of time in the nature (see also http://www.who.int/travel-advice/vaccines).

Yellow fever vaccine

  • Yellow fever vaccine contains live attenuated viruses (not to be given to immunocompromised persons).
  • Can be given to persons from one year of age upwards; during an epidemic from the age of 9 months upwards. One dose gives protection for tens of years. The requirement of a booster vaccination every 10 years in international traffic has been abandoned in July 2016, but for the moment not all countries follow these directions. During the transition period it is important to check out the country-specific requirements.
  • For travellers to Equatorial Africa, Central and South America (see also http://www.who.int/immunization/diseases/yellow_fever/en/)
  • According to the International Health Regulations, a vaccination certificate may be required when crossing borders of countries in the endemic regions.

Tick-borne encephalitis vaccineVaccines for Preventing Tick-Borne Encephalitis

  • Recommended for permanent and periodic residents who move around in the nature in areas with significant risk of acquiring tick-born encephalitis (TBE). TBE vaccine may be considered for travellers who stay or spend a lot of time in the nature in endemic areas. Consult national and regional recommendations.
  • TBE is endemic in many countries, e.g. the Baltic countries, Northern, Central and Eastern Europe, and in Russia.
  • TBE vaccine may be given to children aged 1 year or older and to adults.

Typhoid fever vaccine Vaccines for Preventing Typhoid Fever, Oral Vaccines for Preventing Cholera

Cholera vaccine

Meningococcal vaccine (polysaccharide) Polysaccharide Vaccines for Preventing Serogroup A Meningococcal Meningitis

Meningococcal conjugated vaccine

  • 3 preparations are available, one containing purified meningococcal serogroup C antigens only, the 2 others containing antigens of the serogroups A, C, W and Y, conjugated to a carrier protein.
    • Men C Conjugate Vaccines for Preventing Meningococcal C Meningitis and Septicaemia: for infants aged 2-11 months 2 doses at an interval of at least 2 months; for children over 12 months of age and for adolescents and adults, one dose is sufficient. Evidence on the need of booster vaccination is insufficient for the time being.
    • Men A,C,W,Y vaccine may be given to persons of the age of 1 or 2 years onwards depending on the product. One dose is sufficient to provide protection. There is no knowledge on the need of booster vaccination for the time being.
  • For people travelling to endemic and epidemic areas of meningococcal infections (see also http://www.who.int/ith/vaccines/meningococcal/en/)
  • For splenectomized patients

Rabies vaccine

  • Rabies vaccine contains inactivated viruses.
  • In preventive purpose, 3 doses are given at 0, 7 and 21 or 28 days.
  • For people working with wild animals in endemic areas, or working in developing countries for long periods (see also http://www.who.int/ith/vaccines/rabies/en/)
  • As a part of treatment after being bitten by an infected animal Suspicion of Rabies Exposure. The amount and timing of doses depend on earlier immunization status, on the extent and location of the bite and on possible concomitant administration of immunoglobulin. The vaccine is usually given on days 0, 3, 7, 14 and 28 after the bite.

Zoster vaccine

  • There are two different vaccines in use.
    • Zoster vaccine containing live attenuated viruses is administered as a single dose.
    • The usual vaccination series of zoster vaccine containing purified antigen includes 2 doses.
  • Indicated for the prevention of herpes zoster and particularly of the prolonged pain syndrome (postherpetic neuralgia) associated with it.
  • From the age 50 years upwards intramuscularly
    • The vaccine containing purified antigen may be administered also to people who have turned 18 and are at an increased risk of acquiring zoster.

Vaccination techniques

  • S.c. (subcutaneously)
    • Outer side of the thigh or upper arm
  • I.m. (intramuscularly)
  • I.d. (intradermally; BCG)
    • Left upper arm (BCG)
    • A pale wheal should appear after successful vaccination.
  • P.o. (orally)
  • Nasal spray
    • The vaccine substance is sprayed in both nostrils (live attenuated influenza virus).

Vaccines in general use

Adverse effects Adverse Events after Immunisation with Aluminium-Containing Vaccines

  • Only a small share of vaccinations causes adverse reactions, the majority of which are mild and self-limiting local reactions. An anaphylactic reaction is almost the only situation where rapid actions are required.

Local reactions

  • Erythema, swelling, pain, warmth at the site of vaccination are common.
  • Treatment: immobilization of the site of vaccination (e.g. swaddling), cold compress
  • Symptomatic medication (analgesics, antihistamines)
  • Routine prophylactic administration of an analgesic or antipyretic drug is not recommended as it may decrease the immunological response to the vaccine.

Generalized reactions

  • Fever, itching rash, irritability
    • Symptomatic treatment
  • Anaphylactic reaction Anaphylaxis
    1. Adrenaline 1:1 000 i.m. 0.1 ml/10 kg(for an adult 0.5 ml i.m.)
    2. Adequate follow-up

Avoidance, follow-up and compensation of adverse effects

  • Ask about allergy to eggs or vaccine components Hypersensitivity to Drugs.
  • For contraindications see below.
  • Record adverse reactions accurately.
  • Inform health authorities when a severe and unexpected adverse reaction is suspected.
  • Nowadays, possible adverse effects of vaccines are investigated by combining register data (hypothesis testing). Reporting about individual cases of suspected adverse effects (signal detection) is not anymore the most important means of getting information about harms suspected to be associated with vaccines.
  • Depending on how vaccine related liability issues have been agreed upon, countries have different practices for compensation of adverse effects of vaccines.

Contraindications

  • The following conditions are not contraindications for vaccination:
    • a history of the disease against which the vaccination is aimed at
    • incubation period of an infectious disease
    • a mild infectious disease (e.g. rhinitis, otitis media or diarrhoea)
    • antimicrobial medication
    • local glucocorticoids or a small dose of systemic glucocorticoids
    • atopic diseases (atopic rhinitis, asthma, dermatitis)
    • dermatites, limited skin infections
    • history of convulsions in the family
    • stable neurological disease
    • Down's syndrome, developmental disability
    • chronic cardiac, liver, lung, or renal disease, rheumatoid arthritis or diabetes
    • neonatal jaundice
    • pre-term infant, small for date
    • malnutrition
    • breast-feeding
    • pregnancy of the mother (the child of a pregnant woman can be vaccinated).

Real contraindications for vaccination

  • An infection with fever: all vaccines
    • Vaccination is given as soon as the patient has recovered.
    • If the vaccination is being given because of an ongoing epidemic, an infection with fever is not a contraindication.
  • Immunodeficiency
    • Vaccination with vaccines containing inactivated microbes and their purified antigens is safe.
    • Vaccines containing live attenuated bacteria or viruses are contraindicated, with a few exceptions.
    • HIV infected patients
      • MMR can be given also to symptomatic HIV infected patients
      • BCG vaccination must not be given to any patient with HIV infection, including asymptomatic patients.
  • Severe adverse reaction from an earlier vaccination: the same vaccine
    • Anaphylaxis, shock, encephalitis, encephalopathy, convulsions
    • Febrile convulsions are not a contraindication: provide antipyretics after the vaccination
  • A convulsive disorder that is under investigation
    • Consider postponing vaccines that contain pertussis antigen.
    • Vaccinations are continued after the investigations have ruled out a progressive central nervous system disease.
  • Pregnancy: vaccinations are not usually recommended, with the exception of situations where pregnancy predisposes to the disease (influenza), vaccination of the pregnant mother may provide protection to the newborn (influenza, tetanus, pertussis) or when vaccination is warranted by the epidemiological situation (polio, yellow fever, pertussis, influenza).
    • An accidental MMR or varicella vaccination is not an indication for termination of pregnancy.
  • Hypersensitivity to some vaccine constituent
    • Hypersensitivity to eggs
      • If food containing eggs causes anaphylactic symptoms:
        • vaccines that are produced in fertilised eggs (influenza and yellow fever vaccines) may usually be given safely, but the patient should be monitored for 2 hours after the vaccination
        • vaccines that are produced in the skin cells of a chick embryo (MMR and TBE vaccines) may be given normally.
    • Mild hypersensitivity to eggs (eggs cause skin or intestinal symptoms): may be vaccinated normally. Allergic symptoms are possible when giving vaccines that are produced in fertilised eggs.
    • Severe hypersensitivity to antimicrobial drugs (a history of systemic symptoms)
      • Neomycin: rabies (depending on preparation) and varicella vaccines. A specialist in allergology decides about MMR vaccine.

Evidence Summaries