Vaccinations

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.

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

• In endemic areas, tick-borne encephalitis vaccine may be added to the general immunization programme (see e.g. http://thl.fi/en/web/infectious-diseases-and-vaccinations/vaccines-a-to-z/tbe-or-tick-vaccine-).
• Basic protection against tick-borne encephalitis includes 3 i.m. injections at months 0, 1-3 and 10-15 (Encepur^® ) or 0, 1-3 and 6-15 (TicoVac^® ).
• The first booster dose is recommended to be given after 3 years and the next boosters every 10 years if the person still is exposed to the TBE virus. In persons over 50 years of age boosters are recommended every 3 or 5 years depending on the product.

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

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

• Pneumococcal polysaccharide vaccine contains purified antigens (23 surface polysaccharides).
• Given according to individual consideration to children over 5 years of age and to adults who belong to risk groups (see also http://thl.fi/en/web/infectious-diseases-and-vaccinations/vaccines-a-to-z/pneumococcal-vaccines/pneumococcal-vaccinations-for-at-risk-groups).
• One vaccine dose is sufficient. No revaccinations are required. If the person has earlier received a pneumococcal conjugate vaccine, there should be at least an 8-week and preferably a 12-month interval between the vaccinations.
• The vaccination is not given to children under 2 years of age because of the poor immunogenicity of the vaccine in this age group.
• The protective effect has only been demonstrated against invasive pneumococcal diseases.

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

• Hib vaccine contains purified antigen (polysaccharide) conjugated with a carrier protein Conjugate Vaccines for Preventing Haemophilus Influenzae Type B Infection.
• The number of doses required and the vaccination schedule depend on the age at which the vaccination is started.
• Recommended for splenectomized patients

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

• Hepatitis A vaccinecontains whole inactivated viruses or virosomes.
• Two doses given at 6-12-month interval are required to reach life-long protection.
• For travellers to areas where the risk of hepatitis A is moderate to high Viral Hepatitis (see also http://www.who.int/news-room/fact-sheets/detail/hepatitis-a)
• For persons in whom a hepatitis A infection may lead to unusually serious consequences (patients with chronic hepatitis, carriers of hepatitis C or B)

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 contains viral surface structures that are produced in e.g. baker's yeast.
• 3 doses given at a schedule of 0, 1 and 6 months are required to reach life-long protection.
• To travellers who stay a longer time in countries with a moderate risk of hepatitis caused by virus B e.g. in association with a car accident or dental care (see also http://thl.fi/en/web/infectious-diseases-and-vaccinations/vaccines-a-to-z/hepatitis-vaccines/hepatitis-b-vaccine http://www.who.int/news-room/fact-sheets/detail/hepatitis-b). For this group, the combined A+B vaccine is usually given to provide protection against both A and B hepatitis.
• The vaccine is also quite commonly given to persons who work in health care and rescue occupations where exposure to blood is possible Occupational Exposure to Blood and Body Secretions.

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

• Oral typhoid fever vaccine contains live attenuated bacteria and polysaccharide vaccine contains purified antigens.
• Administered either as one i.m. injection from 2 years of age onwards, or as peroral capsules every 2 days, 3 capsules in total, from 5 years of age onwards (protection for about 3 years).
• For people travelling to endemic or epidemic areas or to crisis/emergency areas, if food hygiene is poor (see also http://www.who.int/immunization/diseases/typhoid/en/).

Cholera vaccine

• Cholera vaccine contains inactivated bacteria.
• Administered in 2 oral doses at 2-6-week interval from 6 years of age onwards (protection for about 2 years).
• For travellers to endemic or epidemic areas or to crisis/emergency areas, if food hygiene is poor (see also http://www.who.int/immunization/diseases/cholera/en/).
• The preventive effect is around 50% Oral Vaccines for Preventing Cholera.

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

• Contains purified antigens (serogroups A, C or A, C, W, Y).
• As a secondary alternative to meningococcal conjugated vaccine for people travelling to endemic and epidemic areas of meningococcal infections (see also http://www.who.int/ith/vaccines/meningococcal/en/)
• For splenectomized patients

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.

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.

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.