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Part 2: The Growing Years - From Infancy to Adolescence  >  Immunisation

IMMUNISATION

To Immunise Or Not To Immunise
In favour of immunisation, it is said that 10 children die and 10 are disabled every minute in developing countries due to the 6 vaccine-preventable diseases — measles, tetanus, tuberculosis, polio, diphtheria and pertusis (whooping cough).

Those who are against immunisation say that more harm than good is done by immunisation. The latter group includes some of the finest people I know. I have learnt a lot from them in keeping myself and others fit. But so far, they have not been able to convince me that children should not be immunised at all, although it is true that in July 1999, distribution of rotavirus vaccine for the prevention of diarrhoea due to rotavirus was halted in the U. S. A. because of intussusception following administration of the vaccine. Intussusception is a serious disease of the abdomen that may need surgery. 

After having considered the risk-benefit ratio, I recommend immunisation for all the children who come under my care. But I do not refuse treatment to a child whose mother has not immunised her as a matter of principle.


THE 6 VACCINES
BCG (Bacille Calmette-Guérin) vaccine is meant to protect the child against tuberculosis. Although doubts have been raised about its efficacy in the past, most experts recommend it because BCG may protect the child against serious types of tuberculosis affecting the central nervous system, bones and joints.

If administration of the BCG vaccine is delayed, your doctor will ask for a skin test (Mantoux test with 5 TU). If the test is positive, BCG is not given. If the test is strongly positive, the doctor will ask for a chest X-ray and decide if your child needs treatment for tuberculosis.

The polio vaccine, administered orally, is now routinely given in some hospitals at birth, This is called the zero dose. If you are debating whether to immunise your child or not, you may inform the hospital authorities that you would not like to have the zero dose given to your baby. 

DPT (also called Triple antigen) is meant to protect against diphtheria, pertusis and tetanus. DT (also called Dual antigen) does not have the pertusis component in it. Children above the age of 7 years are not given DPT and are only given DT or TT (Tetanus Toxoid). The National Immunisation Schedule recommends DT at 5 years. If your doctor instead recommends DPT at 5 years, follow his advice.


IMMUNISATION SCHEDULE
The table below gives the National Immunisation Schedule recommended by the Government of India.


NATIONAL IMMUNISATION SCHEDULE 

** If given for the first time at this age, give 2 doses at 4-week intervals
** For pregnant mothers, 2 doses of ‘M’ at 4-week intervals


The following table gives the schedule suggested by the Indian Academy of Pediatrics (IAP)


IAP IMMUNISATION TIMETABLE

Some Important Points About Immunisation
Do not unnecessarily delay your child’s course of vaccinations. If immunisation is due, do not postpone it just because your child has a mild cough, cold or diarrhoea. But if the child with diarrhoea is given oral polio vaccine, remember to give an extra dose of oral polio vaccine at a later date in consultation with your doctor.

However, do not immunise the child if she is acutely ill, Manage the illness and give her the vaccines later on. 

If your child had a severe reaction following a DPT or if she has a history of convulsions, do discuss it with your doctor, He may consider giving her DT in place of DPT to complete her immunisation schedule.

The schedule table suggests that DPT and OPV should be given at an interval of 4 weeks. Do stick to this routine. But if for some reason, the gap between the 2 doses becomes more than 4 weeks, you do not have to repeat the whole course again. Just give the remaining dose that is due to complete the course. In the long run, doses given after a longer gap give as good protection as those given at fixed intervals. However, as long as the course is not completed, your child runs the risk of getting these diseases; so avoid delaying the doses as far as possible. 

There is no need to starve your child for long periods before or after the administration of oral polio vaccine. A gap of 10 to 15 minutes may be kept to avoid vomiting.

In a fully immunised child, there is no need to give TT for minor injuries. However, if she gets hurt when her DPT booster is due, the booster will give protection against tetanus as well.

Some authorities recommend 5 doses of oral polio vaccine (OPV) for the primary course instead of the 3 recommended as per the National Schedule. They feel that the child gets better protection with 5 doses. I tend to agree with them. Opt for the 3 doses if you are not sure whether you should or should not immunise your child. Also, some doctors prefer to give 2 doses of OPV before starting the course of DPT injections in areas where and in seasons when polio is prevalent. This is based on the assumption that if the child is carrying the polio virus in her system, any injection might precipitate a paralytic attack of polio. On the other hand, by delaying the DPT injections, you may be exposing the child to the risk of getting whooping cough that can cause serious problems in a small baby. My practical advice is to give OPV at birth and then at 1, 2, 3 and 4 months, and to give DPT injections at 2, 3 and 4 months. 

Recently, our government has initiated an annual pulse polio immunisation programme under which all children below 5 years are given extra doses of oral polio vaccine on the same day at 6-week intervals throughout India in an attempt to eradicate poliomyelitis from the country.   

BCG is given over the left shoulder. After about a month, a small swelling appears at the site of the injection, which may break into an ulcer with a little watery discharge. This discharge may continue for about 6 weeks. Eventually, the ulcer heals, leaving a small permanent scar. Some children may get enlargement of the glands in the armpits or above the clavicle (the collarbone) secondary to BCG. The ulcer does not require any ointment or medicinal powder. Also, children who develop enlargement of the glands need not be started on anti-TB drugs. Consult your paediatrician if the glandular swelling increases and an abscess forms. Reimmunisation is to be considered in those who do not show a scar after having had BCG. 

The thigh is a better place for giving infants injections than the buttocks. Ensure that the needle used is disposable or is properly sterilised. Some children do get a nodular swelling at the site of the injection. This may remain for months without causing any problem. There is no need to apply any ointment on it.

The vaccines are not effective if they are not preserved properly in a refrigerator or in an icebox. Without this precaution, your sense of security is false. Also note that the refrigerator should be used exclusively for storing the vaccines, because frequent opening of the refrigerator for other things can affect temperature control. You have a right to ask the health worker whether this care has been taken.

Quite a few children get fever a couple of hours after the DPT injection. The temperature is usually less than 102°F (38.9%) and does not last more than 24 hours. I recommend a dose of paracetamol be given soon after the injection. This should be repeated 4 hours later, if required. If the fever lasts for more than 24 hours, your doctor will probably look for some other cause of fever.

Following measles vaccine, your child may get a mild measles-like illness with fever and rash after about a week. No treatment is required for this.

Do keep a record of all the immunisations given to your child so that she completes the course as per schedule. Incidentally, if your child goes abroad for studies, the colleges there often want to know the details of the vaccines your child has had.


OTHER VACCINES
MMR (Measles, Mumps and Rubella) vaccine confers immunity against measles, mumps and rubella (German measles). It is given at 15 months of age. Children who have not received the measles vaccine at 9 months can be given MMR vaccine after their first birthday. Many doctors like to prescribe another dose of MMR vaccine at 12 years of age to provide added protection.

Hepatitis B vaccine is given to prevent jaundice caused by Hepatitis B or Serum Hepatitis virus, which can be passed from an infected mother to her newborn baby or from one affected member of the family to another. The common mode of infection is through contaminated needles or contaminated surgical instruments. As this disease can cause serious liver disease, more and more doctors are now recommending this vaccine. The vaccine is given in 3 doses; the first one shortly after birth, the second dose one month later and the third at 6 months of age. Older children of all ages can be given the 3 doses with an interval of one month between the first and second dose and 6 months between the first and third dose.

Vaccines against Chickenpox, Hepatitis A and Haemophilus Influenza Type B are also available. You may give them after consulting your doctor.

There are 3 different vaccines against Typhoid, namely,

• Whole cell killed vaccine (usually known as TA vaccine)
   
• Oral typhoid vaccine, and
   
• Vi polysaccharide vaccine.

The TA is very cheap, but it frequently causes side effects such as local pain and swelling and fever lasting 2 or 3 days.

The other two vaccines are expensive, but have very few side effects.

These vaccines are recommended where typhoid is widely prevalent. Injections of TA or Vi vaccine may be given at 2 years of age, followed by subsequent doses at 3-year intervals. Oral vaccine can be given at 6 years of age and repeated at 3 to 5-year intervals according to the manufacturer’s recommendations.

In localities where typhoid is not widely prevalent, typhoid vaccine may be avoided. I recommend hygienic precautions for prevention of not only typhoid but also other water and food-borne diseases like hepatitis A and diarrhoea. Proper hand washing, boiling of water, eating fresh food and keeping food covered are some of the measures that are recommended to avoid such illnesses.


CONCLUSION
To conclude, I urge you to take care to keep your child healthy and follow the general principles of hygiene. Do not depend wholly upon these vaccines. It is possible that they might not have been stored properly; this does happen sometimes. In such cases, you may have a false sense of security.

Also, all vaccines do not provide cent per cent protection.