Immunizations are given to protect children against the potentially serious outcome of preventable infectious diseases. We are very fortunate to no longer see our young patients suffering from the devastating infectious illnesses that were so common only 60 years ago and can now be prevented. An excellent overview on immunity was published in 2014 by Eula Bliss (“On Immunity – An Inoculation”) and I highly recommend the book to anyone interested in the ethics, philosophy and history of immunizations.
I strongly recommend to all our patients that they follow the Immunization Schedule recommended (and routinely up-dated) by the Canadian Pediatric Society based on the data reported by the Public Health Agency of Canada’s National Advisory Committee on Immunization. These web-sites, as well as Toronto Public Health, allow you to access more detailed information about the immunizations, their side-effects and the diseases they prevent.
Many parents have been confused by media reports and information found on the internet about supposed side-effects of immunizations. To help parents make well-informed decisions, the Canadian Pediatric Society has posted suggestions designed to guide parents in evaluating health care information they find on the Internet. These suggestions can be accessed through the CPS web-site.
The first immunizations are given at the 2-month Well-Baby-Visit. Two shots are given: Pediacel® (Diphtheria -Tetanus – Pertussis/Whooping Cough – Polio – Haemophilus influenzae type B) and Prevnar-13® (Pneumococcal vaccine). Hemophilus influenzae is not a flu vaccine, despite the slightly suggestive name. Prevnar-13® and HIB vaccine protect against sepsis and meningitis caused by S. pneumoniae and H. influenzae. Rotarix® to protect against rotaviral gastroenteritis is given by mouth at two and four months.
The immunizations given at 2 and 4 months are identical (see chart); at six months we only give one shot (Pediacel®).
Side effects of these immunizations are usually mild and include fever, discomfort, swelling or redness in the area of the shot (this is caused by the immune reaction we purposefully initiate with the vaccine to produce antibodies against the germs). Sometimes infants will be cranky and irritable. Occasionally there will be a lump at the site of the injection palpable in the thigh for several weeks. Please do not hesitate to call the office if you have any concern. If fever lasts more than 48 hours, another explanation than the immunization should be sought.
Pediatricians used to recommend the use of acetaminophen before the shots to decrease side-effects. This recommendation is no longer valid as there is a concern that the acetaminophen might interfere with the effectiveness of the immunization.
We recommend the use of acetaminophen (Tempra®, Tylenol®) after the shots only if the infant develops a fever and seems uncomfortable. In that case a dose of 80 mg acetaminophen (contained in 1 ml of Tempra® or Tylenol® Infant Drops) should be given every four hours for up to three doses.
I do not recommend the routine use of ibuprofen (Advil®, Motrin®) to treat fever, as this medication can – albeit rarely – lead to serious side-effects affecting the kidneys. I do not recommend taking this risk unless the use of such medication is necessary (treatment of inflammation or arthritis).
Immunizations at 2, 4 and 6 months are given in the leg (at these ages there are less side-effects if the shots are given into the legs than the arms because of the larger muscle mass in the thigh). Immunizations thereafter are given in the arm (once children walk they sometimes limp if the shots are given into the leg, causing concern for their parents).
|2 Months||Diphtheria-Tetanus-Pertussis-Polio-Hib (Pediacel®)||Prevnar-13® and Rotarix®|
|4 Months||Diphtheria-Tetanus-Pertussis-Polio-Hib (Pediacel®)||Prevnar-13® and Rotarix®|
|6 Months||Diphtheria-Tetanus-Pertussis-Polio-Hib (Pediacel®)|
|12 Months||Measles-Mumps-German Measles (MMR-II® or Priorix®)||Menjugate® (we give the third dose of Prevnar-13® at 15 months to avoid giving three shots at 12 months)|
|15 Months||Varicella (Chickenpox) (Varilrix® or Varivax®)||Prevnar-13®|
|18 Months||Diphtheria-Tetanus-Pertussis-Polio-Hib (Pediacel®)||MMR (we do not wait till 4-6 years but give the second MMR at 18 months to protect children earlier)|
|4-6 Years||Diphtheria-Tetanus-Pertussis-Polio (Adacel – Polio®)||Varicella (Varilrix® or Varivax®)|
|14-16 Years||Diphtheria-Tetanus-Pertussis (Adacel®)|
After a child’s first birthday, they will receive their first immunization against Measles, Mumps and German Measles (MMR-II® or Priorix®) and against Meningococcus Serotype C (Menjugate®). Note: Public Health will not recognize any MMR® given before the first birthday as a valid immunization against measles.
Menjugate® (together with Prevnar-13® and the HIB vaccine given earlier) is the third meningitis shot an infant receives. Please note that children can still get sick with meningitis caused by other germs. Meningitis is an inflammation of the meninges, the thin layer of tissues surrounding the brain and spinal cord. Older infants and children with meningitis are often unable to bend their neck so that their chin touches their chest when they have meningitis. This sign is less useful in younger infants.
Side effects of the MMR vaccine occur in about 10% of infants. Symptoms include fever up to 48 hours in duration occuring between 4 and 14 days after the immunization as well as a faint, red spotted rash on the trunk. No treatment is needed but acetaminophen can be used to treat the fever if the infant seems uncomfortable. The dose is 10 to 15 mg/kg for each dose, four hours apart. For the average one year old, with a weight of approx. 10 kg (22 lbs) this translates into approximately 120-160 mg acetaminophen, contained in 1.5 – 2.0 ml of Tempra® or Tylenol® Infant Drops.
Please note that there is no evidence linking the MMR shots to inflammatory bowel disease, ulcerative colitis, or autism.
At 15 months infants receive the immunization against varicella/chicken-pox (Varilrix® or Varivax®) and their third dose of Prevnar-13®. The schedule was recently changed to allow for the elimination of the third dose of Prevnar-13® at six months which was replaced by a third dose at twelve months (with the exception of children in higher risk categories). Unfortunately, this makes it necessary to give three shots simultaneously at twelve months. As I am not in favour of this, and am giving the third shot of Prevnar-13® at 15 months, to avoid three shots at a year. The immunization against varicella is given to prevent deaths from Streptococcal flesh-eating disease (not just to prevent chickenpox), a disease that can over-power an immune system already weakened by varicella. The vaccine is about 80% effective and cases of chickenpox in vaccinated patients occur but are usually mild – because of the partial immunity. Side effects are rare, and include fever (usually mild) and a few spots that look similar to small chicken-pox lesions around the injection site. Varicella (Chickenpox) during pregnancy can cause serious problems for the fetus and this is another important reasons why we aim to protect all mothers against this disease.
At 18 months, children receive a booster for Pediacel® and MMR-II®.
At 4-6 years, children receive Adacel-Polio® – the booster for Diphtheria – Pertussis (Whooping Cough) – Tetanus – Polio and their second shot against chickenpox (varicella).
Beginning in August 2011, Public Health is funding a second Varicella (Chickenpox) vaccination that can be given between four and six years as the combined MMRV (Measles, Mumps, German Measles, Varicella) immunization to children who have not yet had their second MMR shot or as a second dose of Varivax® (Chickenpox).
Please note that the combined MMRV can not be used at the one year check-up (as there is an increased risk for febrile seizures at that age).
10 years later, between 14 and 16 years of age, adolescents receive a booster for Diphtheria – Pertussis (Whooping Cough) and Tetanus (Adacel®)
Further Information on Vaccinations:
Rotavirus Vaccine protects against a form of gastroenteritis (stomach flu) caused by the Rotavirus. Rotarix, a live attenuated oral vaccine against rotavirus, has been publicly funded since the beginning of August 2011. It is an oral vaccine, given by mouth. It is administered during the two and four month well-baby visits. It tastes very sweet and is cold as it has to be kept in the fridge. It is interesting how some infants love to take it while others refuse and spit it out. Even so, enough virus is ingested to provide immunity.
Menactra is a meningitis vaccine that can be given after the age of two years and protects against four serotypes of Meningococcus: A, C, Y and W-135 (Menjugate® protects only against serotype C). It is currently offered to students in school (grade 7). Alternatively, Menactra® can be purchased in the pharmacy and given at an earlier age or, if an adolescent has not yet had this immunization, before entering College or University. I recommend this vaccine to our patients.
Bexsero® is a multicomponent meningococcal B vaccine that protects against a type of meningococcus that Menjugate® and Menactra® cannot protect against. Until the government makes this vaccine available it can be purchased in the drugstore and administered to infants older than 2 months. If given to infants 2-5 months of age, three doses more than one month apart and a booster in the second year of life are given. For infants 6-11 months of age, 2 doses more than 2 months apart and a booster in the second year of life are given. If given to children 12 months to 10 years, 2 doses more than two months apart are given, the need for a booster is not established. When given to children or adolescents 11-17 years of age, two doses more than one month apart are given, the need for a further booster is not yet established. Because Bexsero can cause high fever, we recommend administration at a time different from the other routine vaccinations.
Immunization is not routinely recommended, except for travel. It can be purchased in the pharmacy. Two doses are needed six months apart.
Immunization is provided in school (grade 7). Alternatively, the vaccine may be purchased in the pharmacy and given at any age. A two and three dose regimen is available. I recommend this vaccine to our patients.
Hepatitis A and B:
Immunization against both Hepatitis A and B can be given simultaneously using Twinrix®.
Gardasil® is offered to students in grade 7 to protect against the HPV virus and prevent cervical cancer. I recommend this vaccine to our patients.
- MOST RECENT FLU SHOT UPDATE FROM TORONTO PUBLIC HEALTH OCTOBER 11, 2016 (valid for the 2017/2018 Season): FROM DR. VINITA DUBEY, AN EXCELLENT PUBLIC HEALTH OFFICIAL: I agree with your concerns about vaccine hesitancy regarding the flu vaccine, especially in the midst of different recommendations for flu vaccination between the US and Canada. We know it is very confusing for parents, and even for clinicians who are not as up-to-date with the recommendations from various bodies.
At Toronto Public Health we support the Canadian National Advisory Committee on Immunization’s (NACI) recommendations before our American counterparts (ACIP). There are always different recommendations between the two groups. For example, ACIP has not yet gone to a 2-dose adolescent HPV vaccination program while we have in Canada.
With the help of Public Health Ontario, we had the opportunity to understand where the NACI recommendation got its evidence and how it was able to make a different recommendation for the same vaccine. On Wednesday October 11th, Public Health Ontario presented rounds on the data. In summary, based on some RCTs from Canada, and even studies from Europe, Flumist was not less effective than injection vaccine, but it was equivalent. Also, Flumist is a live attenuated cold adapted temperature sensitive vaccine. The H1N1 vaccine component used the A/California strain in previous vaccines; it was very labile and temperature sensitive. The vaccine was distributed in the summer months. There is some question as to whether this caused the H1N1 component of the vaccine to be less effective as we know that perfect cold chain procedures are not always adhered to. In the current Flumist vaccine, the A/Bolivia strain is used for the H1N1 component which is seen to be more temperature stable. In Canada, UK and Finland, the reduced vaccine effectiveness for the H1N1 strain was not seen.
The recommendation from Canada is that either vaccine-nasal spray or injection, can be used in children 2 to 17 years of age. Some parents and children may prefer the nasal spray. We know that the rates of needle phobia can be about 10%. If you do not feel comfortable recommending the nasal spray vaccine, you can certainly give the injectable vaccine for children. NACI has said they are equally efficacious.
As for the issue of vaccine hesitancy, I think the response to parents is that our surveillance of vaccines is working. NACI has previously had Flumist as a preferential recommendation, which it downgraded. The US based their decision on US only data and did not look at other European or Canadian data.
In summary, the issue is complex. Different studies show different things for different strains.
- Up-date for Flu-shot recommendations for the 2017/2018 Season: We recommend the yearly flu shot for all our patients once they are older than six months. You may request flu shots for your children – the shots are now available -whenever you see your doctor for a visit (unless your child is too ill for an immunization), or you can make an appointment with our nurse Jane Marie Swain if your child is between six months and five years old. Once your child is five years old, flu shots can be given in your local drug store by the pharmacist (ask the pharmacist for availability). As well, flu shots for the whole family are available in your local Toronto Public Health Flu Clinic. You can use the intranasal flu vaccine FLUMIST® available in the local drug store for children older than two years.
The CPS and the AAP recommend that infants 6 months and older, children, and adolescents up to 17 years of aged be offered the new quadrivalent shot against Influenza A and B while adults should receive the trivalent vaccine. The current CPS recommendations can be found here. The vaccine is usually available by mid-October; we recommend that you take your child and your whole family to your local Public Health flu clinic or – if this is not possible – make an appointment for your child with our nurse, Mrs. Jane-Marie Swain, for just the flu-shots. Please contact your doctor first if your child is severely allergic to eggs, thimerosal or neomycin or had an allergic reaction to a previous flu shot.
Information for Vaccines for Travel: