2 Childhood Immunisation (Revised Mar 2017)

SHP Doctors Guidebook: CHILDHOOD IMMUNISATION
Updated as of March 2017
CHILDHOOD IMMUNISATION
Scope Page
1. Background Information 2
2. Common reasons for which Vaccine Room Nurses refer patients to the doctor & the 3
approach to management
o The patient who represents Out-Of-Schedule 4

General ConsiderationsAscertaining Validity of Vaccine Doses Given 5
Minimum Age, Minimum Intervals, 4-Day Rule
Spacing of Live Vaccines
o The patient with missed or delayed doses 6
o The patient who is unwell with an intercurrent illness 6

o The patient who is on antibiotics, antivirals or steroids 6
o The Patient who needs more than one vaccine on that visit (Co-administration 7
of Vaccines)
o The patient with a vulnerable (e.g. pregnant) family member 7
o The patient with allergies (egg, antibiotics, latex) 7
o The pregnant patient 9
o Infants born to mothers with chronic hepatitis B infection 10
o Newborns with low birth weight 10
o The patient who has been exposed to an infection 10
3. National Childhood Immunization Schedule (NCIS) for Singapore 11
4. Table of Minimum Intervals & Minimum Ages for vaccines administered at SHP 12-13
5. Adverse Reactions Following Vaccination 14
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Background Information
1. The purpose of childhood vaccination is for active immunization against infectious diseases as well as to ensure herd immunity in the population.
2. Vaccine Requirements: Some vaccines are mandatory by law and most are required for by the Ministry of Education for registration to Primary 1.
Most international schools also have similar requirements. Vaccines that are compulsory by law include Diphtheria & Measles.
Vaccination against Diphtheria and Measles is the requirement of the law

Diphtheria was made compulsory in 1977.
Measles vaccination was introduced from Oct 1976 and made compulsory in August 1985 for children ages 1-2years.
Infectious Diseases Act requires that:
Primary course of Diphtheria be given

1. within 12 months of the birth of the child; or
2. within 12 months after the arrival of the child in Singapore (if born outside Singapore), if no proof of prior vaccination.
Booster diphtheria vaccination be given:
1. 12 months after the primary diphtheria vaccination (1st booster) ; and
2. within 12 months after the child has attained the age of 6 years (2nd booster), unless the child has already received the 1st booster
within 2 years prior to attaining age 6 years.
Measles vaccination:
1. between one year and two years of age, or
2. within 12 months after the arrival of the child in Singapore (if born outside Singapore and no proof of prior infection / vaccination)
Penalty: fine not exceeding $10,000 or to imprisonment for a term not exceeding 6 months or both.
Vaccines that are required for Primary 1 registration are listed on the Monistry of Education website: http://www.moe.gov.sg/education/admissions/primary-one-
registration/
All parents should produce the immunisation certificates (BCG, diphtheria, pertussis, tetanus, poliomyelitis, measles, mumps, rubella and Hepatitis B) of their
children at the time of registration. Documentary evidence of immunisation can be downloaded from the National Immunisation Registry website.
[http://www.nir.hpb.gov.sg/nir/eservices/eservice.jsp ]
Common Reasons for Referral of Patients from the Vaccine Room Nurse
Most children in Singapore will come to SHP according to their scheduled visits and are vaccinated according to the National Immunization Guidelines.
STANDING ORDERS: The vaccine room nurses will administer the childhood vaccines according to the Standing Orders. Standing Orders are
documents which are specific to each vaccine. They are available for viewing on the SHP Intranet.
The Standing Order enables to vaccine room nurse to administer the vaccine according to schedule without the doctor having to order any vaccine.
However, there will be instances where the vaccine room nurse is unable to proceed with vaccination, and the patient may be referred to the doctor.
Such instances may arise for the following reasons:

o The patient had arrived out-of-schedule
o There is a situation where risk-benefit discussion between the doctor and the patient / parent is useful
o There is any doubt / ambiguity as to the risk / benefit of vaccination
o The patient / parent has any query regarding the vaccine
This segment of the document aims to guide the doctor on the management of instances where the patient is referred by the vaccine room nurses.
1. The patient who represents Out-Of-Schedule

2. The patient with missed or delayed doses
3. The patient who is unwell with an intercurrent illness
4. The Patient who needs more than one vaccine on that visit (Co-
administration of Vaccines)
5. The patient with a vulnerable (e.g. pregnant) family member
6. The patient with allergies (egg, antibiotics, latex)
7. The pregnant patient
8. Infants born to mothers with chronic hepatitis B infection
9. Newborns with low birth weight
10. The patient who has been exposed to an infection
The patient who presents out-of-schedule
Examples of this would include a patient who:

comes earlier than scheduled
comes later than scheduled (i.e. has a lapsed schedule e.g. defaulted visits for a year)
comes for continuation of a different schedule (e.g. a child from overseas who has had one or more doses given according to a schedule different from
that practiced locally / at SHP)
To recommend further doses of vaccines for any patient, we need to:

1. Refer to the Singapore National Immunization Schedule. Any child who intends to stay in Singapore for long term should follow a local schedule as these
are based on local disease epidemiology.
2. Ascertain all previous doses of vaccines given (generally, it is better to accept only documented evidence, not verbal accounts from patients / parents)
3. Ascertain whether previous doses of vaccines are valid doses. Invalid doses should be discounted and repeated. [see approach to ascertaining dose
validity below]
4. Ascertain which vaccines are more urgent, especially if several vaccines are due if several vaccines are due, can they be combined,
5. Strike a balance between rapid completion of necessary doses and co-administration of many doses of vaccine at the same visit.
Be mindful of the various sources of data to support your decision: While there are clear guidelines from ACIP & CDC, Singapore has our own recommendations.
MOH Circulars supersede all other recommendations. Ask for guidance from senior doctors when in doubt.
General ConsiderationsAscertaining Validity of Vaccine Doses Given
Consideration Remarks
Minimum Age For a dose of vaccine to be valid, it must generally not be given before the minimum age allowed for that vaccine. However, administering
a dose a few days earlier the minimum age is unlikely to have a substantially negative effect on the immune response to that dose (see
4-day Grace Period below)
Refer to Table on Recommended and minimum ages and intervals between vaccine doses (Pages 12-13)
Minimum Interval Vaccines should also be spaced apart adequately. Giving doses of vaccines at shorter recommended intervals may lessen antibody
response. However as with minimum age, administering a dose a few days earlier the minimum interval is unlikely to have a substantially
negative effect on the immune response to that dose (see 4-day Grace Period below)
Refer to Table on Recommended and minimum ages and intervals between vaccine doses (Pages 12-13)
The 4-day Grace A 4-day grace is allowed, regarding the minimum age & minimum interval rule.
Period
Vaccine doses administered 4 days before the minimum interval or age are considered valid; In other words, doses of any vaccine
administered 5 days earlier than minimum interval or age are invalid and should be repeated. The repeat dose should be spaced after
the invalid dose by the minimum interval & according to minimum age.
Because of the unique schedule for rabies vaccine (not available at SHP), the 4-day guideline does not apply to this vaccine.
Example 1: the minimum age for MMR vaccine is age 1 year. MMR which is administered 2 days before the first birthday is counted as
valid, while a dose which is administered 1 week short of the first birthday should NOT be counted as valid.
Example 2: the minimum interval between the first and second doses of DTaP is 4 weeks. If the second dose is administered, say 3
weeks after the first dose, the second dose is not valid and should be readministered 4 weeks after the wrong dose
Live Vaccines Live, attenuated vaccine, if not administered should be spaced at least 4 weeks from any other live, attenuated vaccine if not given at the
same visit. As an example, if 1st primary dose of MMR inadvertently administered at age 11 months, that dose is not valid. MMR
should be re-administered again when the child is aged 12 months [spaced at least 4 weeks from the invalid dose]
Missed / Delayed Doses

It is not necessary to restart immunization because of an extended interval between doses (e.g. due to missed appointments or defaults) i.e. for missed doses,
just continue the regime by administering the missed dose.
If there is any doubt about which, if any, doses have been given, restart the primary course. If the child has not had any immunizations and is aged 12 months
and above, the priority is to give MMR first, polio and DTaP (i.e. Infanrix-IPV-Hib) can be given at same time as MMR (at separate injection sites) or allow an
interval of 4 weeks. Subsequent doses of DTaP-IPV-HIb can be administered until the primary schedule is complete. Children above age 7 years should be
given Tdap instead of full-dose pertussis / diphtheria vaccines. Since SHP does not provide Tdap to patients, they should be referred to School Health Services
or tertiary hospitals for Tdap.
The patient who is unwell with an intercurrent illness

Mild febrile illnesses (e.g. upper respiratory infection with mild symptoms, otitis media, and mild diarrhoea) are not contraindication to vaccination.
Vaccines can also be given if the child is in the recovery phase of illness.
Pros and cons of vaccinating a sick child should be discussed with parents.
If a child has a moderate or severe acute illness (e.g. fever above 38oC), vaccination with both live and inactivated vaccines may be delayed until the
illness has improved.
Fever may make the clinical course of any illness less clear (we are unsure if the fever is due to the vaccine or part of the intercurrent illness) and
potentially future affect decision making.
A sick child may be fussy and have a harder time tolerating any vaccine reaction.
The patient who is on antibiotics, antivirals or steroids
Antibiotics Antibiotics have no effect on response to:

inactivated, vaccines or toxoids
live, attenuated vaccines, except live oral typhoid vaccine
Antivirals Antiviral drugs are usually not prescribed for children with coughs and colds. Antiviral drugs may affect vaccine replication in some
circumstances. Antiviral drugs against herpes viruses (e.g., acyclovir) might reduce the efficacy of live, attenuated varicella and zoster
vaccines.
Stop at least 24 hours before administration of varicella or zoster vaccine
Delay use or resumption of antiviral therapy for 14 days after vaccination
No data exist to suggest effect of commonly used antiviral drugs on rotavirus vaccine or MMR
Steroids Aerosolized steroids, such as asthma preventers are not contraindications to vaccination, nor are short (less than 14 days) course high-dose
steroids given for asthma exacerbations. But live-virus vaccination should be deferred for at least 1 month after discontinuation of high-dose
systemic steroids given longer than 14 days.
The Patient who needs more than one vaccine on that visit (Co-administration of Vaccines)
In most cases, different vaccines can be given simultaneously but at different sites. For infants and younger children, if more than 2 vaccines are to be
administered in single limb, the anterolateral thigh preferred (greater muscle mass) Location of the injections should be sufficiently separated (1 inch if
possible) to differentiate local reactions. Locations of various injections should be clearly documented in electronic medical notes.
If live vaccines are not administered during the same visit, they should be separated by an interval of 4 weeks or more.
The Patient with a Vulnerable (e.g. Pregnant) Family Member
For live-attenuated vaccines, there is a rare possibility of the vaccine-strain pathogen causing disease in the recipient, who may then transmit it to
susceptible household contacts (i.e. pregnant women or immunosuppressed patients). While transmission of measles and mumps vaccine viruses to
household members or other close contacts has never been reported, chickenpox vaccine virus transmission has been described. As such,
administering a live-attenuated vaccine to a person living with susceptible household contacts may seem risky.
However, the chance of diseases caused by a vaccine-strain virus is very remote. On the contrary, there is a higher chance of catching a wild strain of
the virus. In addition, the household contact transmission rate for the varicella-zoster virus is very high. Hence, the most effective way to protect
immunosuppressed patients or pregnant women against chickenpox is to vaccinate their close contacts. In such cases, the benefits of vaccinating the
child likely outweigh the risks.
In other words, most live-attenuated vaccines can be given to those who are in close contact with pregnant women or immunosuppressed patients,
except for the smallpox vaccine. Some protection from herd immunity can also be conferred on those who are not eligible for live-attenuated vaccines.
The Patient with Allergies
Ascertaining the nature of the allergic reaction is important.
Anaphylactic reactions [e.g. generalized urticaria (hives), angioedema (perioral / periorbital), wheezing, hypotension, or shock] occur within minutes or
hours of receiving the vaccine, and require medical attention. A severe (anaphylactic) allergic reaction following a dose of vaccine will almost always
contraindicate a subsequent dose of that vaccine.
Other forms of allergy such as localized contact urticaria, allergic contact dermatitis are not contraindications to the vaccine. A child may be allergic to
the vaccine antigen or to a vaccine component such as animal protein, antibiotic, preservative, or stabilizer.
The Patient with Allergies (continued)
Allergy Comments
Egg The most common animal protein allergen is egg protein (ovalbumin) found in some vaccines.
Influenza vaccines are prepared using embryonated chicken eggs and should not be given to children with egg-anaphylaxis. Asking parents if
the child can eat eggs without adverse effects is a reasonable way to screen for those who might be at risk from receiving yellow fever and
influenza vaccines. Those with a history of anaphylactic reactions to egg/egg proteins should not be vaccinated. The other vaccine which
contains eg protein is the Yellow Fever vaccine which SHP does not carry.
Chickenpox vaccine is derived from human diploid cell culture, does not contain ovalbumin and can be administered in children with previous
egg-anaphylaxis.
As for the MMR vaccine, the measles & mumps component are derived from chick embryo culture, while the rubella component which is derived
from human diploid cell culture. There are lots of studies to show safety of MMR vaccine in egg-allergic children. It appears that gelatin, rather
than ovalbumin, may be the cause of allergic reactions to MMR. Thus egg allergy has been listed as a false contraindication to MMR in the Jan
2011 ACIP General Recommendations for Vaccination, which also mentioned that persons with severe egg allergy can receive measles- /
mumps-containing vaccines without skin testing / desensitization. But in view of historical concerns and for the fact that despite extensive
purification, product inserts for MMR vaccine does not guarantee that the measles & mumps component of MMR are free of ovalbumin, children
with history of egg-anaphylaxis should should be referred to KKH for administration of MMR.
Vaccine Prepared In Persons with prior history of egg anaphylaxis

(ie systemic reactions extending beyond just
skin)
Influenza Vaccine embryonated chicken eggs Not to vaccinate at SHP > refer
Measles & Mumps chick embryo fibroblast tissue Not to administer MMR at SHP > refer
component of MMR culture (may still contain trace
amounts of ovalbumin)
Rubella component of MMR Human diploid cell culture
Varicella vaccine Human diploid cell culture Can proceed with Chickenpox vaccine
The Patient with Allergies (continued)
Allergy Comments
Antibiotic Allergy Certain vaccines contain trace amounts of neomycin. Persons who have experienced an anaphylactic reaction to neomycin should not
receive these vaccines.
Most often, neomycin allergy presents as contact dermatitis, which is not a contraindication for administration of vaccines that contain
neomycin.
Penicillin allergy is not a contraindication to vaccination because none of the currently licensed vaccines contains penicillins or any of its
derivatives.
Latex Allergy The most common type of latex sensitivity is contact-dermatitis with latex-containing gloves.
If a person reports a severe (anaphylactic) allergy to latex, vaccines supplied in vials or syringes that contain natural rubber should not be
administered unless the benefit of vaccination clearly outweighs the risk of an allergic reaction to the vaccine.
For latex allergies other than anaphylactic allergies (e.g. a history of contact allergy to latex gloves), vaccines supplied in vials or syringes
that contain dry natural rubber or natural rubber latex can be administered.
The Pregnant Patient
In general, inactivated vaccines may be administered to pregnant women [an exception is human papillomavirus (HPV) vaccine, which should be deferred during
pregnancy because of a lack of safety and efficacy data for this vaccine in pregnant women] for whom they are indicated.
Pregnant women are at increased risk of complications of influenza. Pregnant women can receive inactivated influenza vaccine at any trimester.
Live attenuated vaccines (e.g. chickenpox) should not be administered to pregnant women.
Infants born to Mothers with Chronic Hepatitis B Infection.
All infants born of mothers who are Hepatitis B Carriers, regardless of their e Ag status should receive Hepatitis B Vaccine & Hepatitis B Immunoglobulins
(HBIg) within 12 hours of birth, administered at different injection sites.
Infants born to mothers whose Hepatitis B status is unknown should receive the first dose of Hepatitis B vaccine within 12 hours of birth and the mother should
have blood drawn to determine Hepatitis B status. If she is found to be a carrier, the infant should receive HBIg no later than 7 post-natal day.
Newborns with Low Birth Weight
Occasionally a child with low birth weight might be referred to SHP for Dose 1 of Hepatitis B to be given at age 1 month. A child with birthweight (less than 2,000
grams) will still be given Hep B Vaccination if otherwise well. However that dose of Hep B Vaccine is not counted, and the primary course is commenced at age 1
month. In other words, these children gets 4 doses of Hep B Vaccines (at ages 0 month, 1 month, 2-3 months & 6-7 months)
Decreased seroconversion rates might occur among preterm infants with very low birth weight (less than 2,000 grams) after administration of hepatitis B vaccine
at birth. However, by 1 month chronological age, all preterm infants, regardless of initial birth weight or gestational age are as likely to respond as adequately as
older and larger infants. The vaccination schedule should be the same as that for any other infant.
Patients who have been exposed to an infection e.g. a family member who has chickenpox
Exposure to an infectious disease is not a contraindication to vaccination. In fact, Varicella vaccine is recommended as post-exposure vaccination for
unvaccinated healthy people aged 12 months and without other evidence of immunity, to prevent or modify the disease. The vaccine should be administered as
soon as possible within 5 days after exposure to rash, if there are no contraindications to use. Among children, protective efficacy was reported as 90% when
vaccination occurred within 3 days of exposure. No data are available regarding a potential benefit of administering a second dose to 1-dose vaccine recipients
after exposure. However, administration of the second dose should be considered for these people to bring them up-to-date on vaccination.
Likewise, MMR can be administered to a child with positive contact history to measles. Measles vaccine, given as MMR, may be effective if given within the first
3 days (72 hours) after exposure to measles. Immune globulin may be effective for as long as 6 days after exposure. Post-exposure prophylaxis with MMR
vaccine does not prevent or alter the clinical severity of mumps or rubella and is not recommended as a preventive measure. However, it is not harmful to
receive MMR after exposure to mumps or rubella and if the child is due for the vaccine, it should be administered as scheduled.
Singapore National Childhood Immunization Schedule Indicating Minimum Ages & Minimum Intervals.
Adapted from MOH Circular No. 16/2013, dated 23 May 2013
Vaccine Birth 1 mth 3 mths 4 mths 5mths 6 mths 12 mths 15 mths 18 mths 6-7yrs 10-11yrs (P5)
Tuberculosis BCG
Hepatitis B HepB HepB HepB
D1 D2 D3
If<2kg, 1st dose not Min Age: 4 wks Min Age: 5 mths
counted. Restart Min Interval Min Int btwn D2-3 = 8 wks
series when btwn D12 = 4 btwn D1-3 = 16 wks
weight2kg wks
Dipht, Tetanus DTaP,IPV,HIb DTaP,IPV,HIb DTaP,IPV,HIb DTaP,IPV,HIb Tdap* &

& Pertuss, D1 D2 D3 B1 OPV**
Min Age: 6 wks Min Age: 10 wks Min Age: 14 wks Min Age: 12 mths
Polio & HIb Min Interval btwn D1-2 = Min Interval btwn D2-3 = Min Interval btwn B2
4 wks 4 wks D3-B1 = 6 mths
Rotavirus Rota D1 Rota D2

Min Age: 6 wks Min Age: 10 wks
Dose 1 MUST be Min Interval btwn D1-2 =
administered 4 wks
BEFORE 16 Dose 2 MUST be
weeks administered BEFORE
24 weeks
MMR MMR MMR

D1 D2
Min Age: 12 mths Min Age: 12 mths
Min Interval btwn D1-2 = 4 wks
PCV13 PCV PCV PCV
D1 D2 B1
Min Age: 6 wks Min Age: 10 wks Min Age of final booster
Min Interval btwn Min Interval btwn D1-2 = (regardless of number of
D1-2 = 4 wks 4 wks doses is 12 mths
Min Interval btwn final
booster & preceding dose,
is 8 wks
HPV For females of age 9-13 years inclusive (i.e. before 14th birthday) - 2-dose regime scheduled at 0 & 6 months [MOH Circular 28/2016]
- and for females of age 14 -25 inclusive (i.e. before 26th birthday) - 3-dose regime scheduled at 0, 1 & 6 months
For the 3-dose primary regime, the minimum interval btwn dose 1-2 is 4 wks, btwn dose 2-3 is 12 wks
* Booster dose recommended if 5 years from last dose of primary series ** Minimum age for final booster of OPV, regardless of dose number is age 4years. Usually only 1 booster is required
but extra doses ensure high coverage rates for eradication purposes.
The following table shows minimum ages & minimum intervals for vaccine doses. The information is adapted from Table 1. General Recommendations for
Immunization Practices, ACIP, CDC Jan 2011 accessible at: http://www.cdc.gov/mmwr/pdf/rr/rr6002.pdf and is tailored to Singapore NCIS and SHP schedule.
Recommended and minimum ages and intervals between vaccine doses
Vaccine Dose number Recommended Minimum age for Minimum Remarks
age for this this dose interval to next
dose (NCIS) dose
HepB HepB-1 Birth Birth 4 weeks Brands interchangeable. Below age 20 years 0.5ml dose, 20 years and
above 1.0ml dose
HepB-2 1 month 4 weeks 8 weeks Between Dose 1-2, min interval 4 weeks
Between Dose 1-3, min interval 16 weeks
HepB-3 6 months 5 months ---
DTaP/IPV/Hib DTaP/IPV/HIb-Dose1 3 months 6 weeks 4 weeks

(Infanrix-IPV+HIb) DTaP/IPV/HIb-Dose2 4 months 10 weeks 4 weeks
DTaP/IPV/HIb-Dose3 5 months 14 weeks 6 months
DTaP/IPV/HIb- 18 months 12 months 6 months

Booster1
Tdap and OPV 10-11 years 4 years ---

(given as Booster2)
MMR MMR-1 12 months 12 months 4 weeks
MMR-2 14-18 months 13 months ---
PCV13 PCV-1 3 months 6 weeks 4 weeks Singapore uses a 3-dose primary series schedule instead of the 4-dose
series. Min Age of final booster (regardless of number of doses is 12 mths
PCV-2 5 months 10 weeks 8 weeks Min Interval btwn final booster & preceding dose, is 8 wks
PCV-3 (considered 12 months 14 weeks ---

Booster1)
Recommended and minimum ages and intervals between vaccine doses

Vaccine Dose Recommended age Minimum age for Minimum Remarks
number for this dose acc to this dose interval to next
NCIS dose
Varicella Varicella-1 12 months 12 months See remarks Minimum Interval between Dose 1-2 is 6 weeks if the patient is of age 13 years
and above.
Varicella-2 See remarks 15 months --- Below age 13 years, minimum interval is 12 weeks (3 months) to ensure longer
protection.
HPV HPV-1 See remarks 9 years 4 weeks Females of age 9-13 years inclusive (i.e. before 14th birthday) can be given the 2-
dose regime scheduled at 0 & 6 months [MOH Circular 28/2016]
HPV-2 See remarks 12 weeks
Females of age 14-25 years inclusive (i.e. before 26th birthday) can be given the
HPV-3 See remarks --- 3-dose regime scheduled at 0, 1 & 6 months.
For the 3-dose primary regime, the minimum interval btwn:

Dose 1-2 is 4 weeks
Dose 2-3 is 12 weeks
Rotavirus Rotavirus-1 3 months 6 weeks 4 weeks Dose 1 MUST be administered before age 16 weeks.
Dose 2 MUST be administered before age 24 weeks.
Rotavirus-2 4 months 10 weeks ---
HepA Adult HepA-1 See remarks See remarks 6 months SHP does not carry the paediatric HepA vaccine which is of a different dose (half
the adult dose). The paediatric formulation can be administered from age 1 year
TM
(Vaqta 50)
HepA-2 See remarks See remarks --- onwards but minimum age for the adult formulation is 18 years.
Minimum interval between dose 1 and dose 2 is 6 months.
Vaqta may be used as booster for persons who have had an initial dose of other
inactivated hepatitis A vaccines (eg Havrix) ie interchangeable.
Influenza Influenza, 6 months 6 months 4 weeks (See For children aged 6 months till <3years, dosage is 0.25ml
inactivated remarks) For those aged 3 years onwards, dosage is 0.5ml
Annual vaccination is recommended
For those below age 9 years who are nave (first-timers) to the influenza vaccine, a
st
second dose 4 weeks after the 1 is recommended, followed by subsequent
annual single dose.
Adverse Reactions Following Vaccination

Vaccine adverse reactions fall into three general categories:
1. Local reactions (generally least severe, most frequent)

most common with inactivated vaccines, particularly those, such as DTaP, that contain an adjuvant
may occur with up to 80% of vaccine doses, depending on type of vaccine
manifest as pain, swelling, and redness at injection site
generally occur within a few hours of the injection and are usually mild and self-limited
on rare occasions, local reactions may be very exaggerated. Severe local reactions with haemorrhage & skin necrosis are referred to as Arthus
reactions and may warrant deferral of vaccine, e.g. deferral of tetanus- and/or diphtheria toxoid-containing vaccine
2. Systemic Adverse Reactions

more generalized events and include fever, malaise, myalgias (muscle pain), headache, loss of appetite, and others.
common and nonspecific; they may occur in vaccinated persons because of the vaccine or may be caused by something unrelated to the vaccine,
like a concurrent viral infection.
Systemic adverse reactions following live vaccines are usually mild, and occur 721 days after the vaccine was given (i.e., after an incubation
period of the vaccine virus)
were relatively frequent with previously used whole-cell pertussis (eg DTP) but less common with inactivated vaccines currently in use, including
acellular pertussis vaccine (DTaP).
may occur following receipt of live attenuated vaccines eg chickenpox, MMR.
Patient education tips:

o Live attenuated vaccines must replicate in order to produce immunity
o Adverse reactions that follow live attenuated vaccines, such as fever or rash, represent symptoms produced from viral replication and are
similar to a mild form of natural disease.
3. Allergic reactions (generally most severe, least frequent)

This is a rare but absolute contraindication to subsequent doses of the vaccine. It is almost always due to hypersensitivity to 1 or more vaccine
components.
The reaction may be delayed by a few minutes; therefore children should stay in clinic for 20-30 minutes after immunisation.
In the rare occasion that anaphylaxis develops, alert Code Blue and manage as an emergency.

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SHP Doctors Guidebook: CHILDHOOD IMMUNISATION

Updated as of March 2017

o The patient who represents Out-Of-Schedule 4

o The patient with missed or delayed doses 6

o The patient who is unwell with an intercurrent illness 6

3. National Childhood Immunization Schedule (NCIS) for Singapore 11

5. Adverse Reactions Following Vaccination 14

Vaccination against Diphtheria and Measles is the requirement of the law

Infectious Diseases Act requires that:

Primary course of Diphtheria be given

Such instances may arise for the following reasons:

1. The patient who represents Out-Of-Schedule

The patient who presents out-of-schedule

Examples of this would include a patient who:

To recommend further doses of vaccines for any patient, we need to:

General ConsiderationsAscertaining Validity of Vaccine Doses Given

Missed / Delayed Doses

The patient who is unwell with an intercurrent illness

The patient who is on antibiotics, antivirals or steroids

Antibiotics Antibiotics have no effect on response to:

The Patient with a Vulnerable (e.g. Pregnant) Family Member

The Patient with Allergies

Ascertaining the nature of the allergic reaction is important.

The Patient with Allergies (continued)

Vaccine Prepared In Persons with prior history of egg anaphylaxis

Rubella component of MMR Human diploid cell culture

The Patient with Allergies (continued)

The Pregnant Patient

Infants born to Mothers with Chronic Hepatitis B Infection.

Newborns with Low Birth Weight

Dipht, Tetanus DTaP,IPV,HIb DTaP,IPV,HIb DTaP,IPV,HIb DTaP,IPV,HIb Tdap* &

Rotavirus Rota D1 Rota D2

MMR MMR MMR

HepB-3 6 months 5 months ---

DTaP/IPV/Hib DTaP/IPV/HIb-Dose1 3 months 6 weeks 4 weeks

DTaP/IPV/HIb-Dose3 5 months 14 weeks 6 months

DTaP/IPV/HIb- 18 months 12 months 6 months

Tdap and OPV 10-11 years 4 years ---

MMR MMR-1 12 months 12 months 4 weeks

MMR-2 14-18 months 13 months ---

PCV-3 (considered 12 months 14 weeks ---

Recommended and minimum ages and intervals between vaccine doses

For the 3-dose primary regime, the minimum interval btwn:

Adverse Reactions Following Vaccination

1. Local reactions (generally least severe, most frequent)

2. Systemic Adverse Reactions

Patient education tips:

3. Allergic reactions (generally most severe, least frequent)

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