3 The immunisation schedule

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Contents

• Objectives
• Routine immunisations
• Advising parents about immunisation visits
• Catch up immunisations
• The immunisation record
• Case studies

Objectives

When you have completed this chapter you should be able to:

1. Describe the South African immunisation schedule
2. Advise parents when to return for the next immunisation
3. Understand the need for catch up immunisations
4. Complete the immunisation record

Routine immunisations

3-1 What is the South African immunisation schedule?

The South African immunisation schedule is the national protocol for giving childhood immunisations. This schedule may vary slightly in private practice and also in children who have been immunised in another country. If possible the national schedule should be used. Most immunisations are given a number of times as the child gets older.

It is important to use the national immunisation schedule

3-2 What is included in the immunisation schedule?

It gives the child’s age and method for each immunisation. The schedule can be divided into four parts to make it easier to remember:

• Immunisations after delivery
• Immunisations at six, 10 and 14 weeks
• Immunisations at six, 12 and 18 months
• Immunisation at six, 10 (grade 4) and 12 years

The schedule is given as a table with details for each immunisation. It is very important that the immunisation schedule is closely followed.

The schedule gives the age when each immunisation should be given

3-3 When are the first immunisations given after delivery?

These are usually given before the baby is discharged home from the delivery facility. Often this is about six to 12 hours after birth. If a baby is not well or has to stay in hospital for a few weeks after birth, the immunisations are given when the baby is ready for discharge home. It is best if these immunisations are given before the mother and baby are discharged home rather than at the first clinic visit. Otherwise they may be forgotten.

3-4 What immunisations are given after delivery?

Two immunisations are routinely given to all babies after they are born:

• BCG (tuberculosis)
• Oral polio. This is written in the immunisation record as OPV0. It is called OPV0 and not OPV1 as the first polio immunisation in an old schedule only started at six weeks.

BCG and oral polio immunisations are given after delivery

3-5 What immunisations are given at six weeks?

Four immunisations are given at six weeks:

• Oral polio. This is called OPV1 which is confusing as it is actually the second oral polio immunisation
• RV1 (Rotavirus)
• PCV1 (Pneumococcus)
• Hexavalent 1 which consists of six vaccines (six-in-one vaccine):
  • Diphtheria
  • Tetanus
  • Pertussis (whooping cough)
  • Hib (Haemophilus)
  • IPV (intramuscular polio vaccine)
  • HBV (Hepatitis B) Also called HepB

These six vaccines are all given at the same time as a single injection. This avoids having to give the baby six separate injections. If hexavalent vaccine is not available pentavalent vaccine containing only the first five vaccines can be used. The HBV vaccine will then have to be given separately at the same time.

3-6 What immunisations are given at 10 weeks?

Only hexavalent 2 is given at 10 weeks. This is the second time this immunisation is given.

3-7 What immunisations are given at 14 weeks?

At 14 weeks three immunisations are given:

• RV2
• PCV2
• Hexavalent 3

This is the second and last time that RV immunisation is given, the second time that PCV immunisation is given and the third time that hexavalent immunisation is given.

3-8 When are further immunisations given after 14 weeks?

A further series of immunisations are given to older children at:

• Six, nine, 12 and 18 months
• Six and 12 years

3-9 What immunisation is given at six months?

Measles (measles1) immunisation is the only immunisation given at six months.

3-10 What immunisation is given at nine months?

Only PCV3 immunisation is given at nine months.

3-11 What immunisation is given at 12 months?

At 12 months only measles 2 is given.

3-12 What immunisation is given at 18 months?

Only hexavalent 3 is given at 18 months. This ends the second series of immunisations.

3-13 What immunisations are given at six and 12 years?

Only the tetanus and reduced dose diphtheria (Td) immunisation is given at six and 12 years. A smaller dose of diphtheria vaccine (d) is used as the risk of side effects to a full dose of diphtheria vaccine (D) is more common in older children. These immunisations sometimes are given by a nurse at the school but usually parents will have to take their child to the local clinic.

3-14 Which immunisation is given to children in grade 4?

Girls are given HPV immunisation by intramuscular injection into the left shoulder in grade 4 (9 years). A second dose is given six months later. In future HPV immunisation may also be given to boys at the same age. This will help to prevent sexual spread of the virus. It is important to give HPV immunisation at an age before children may start sexual activity.

It helps if community health workers remind parents that older children at six, 10 and 12 years of age also need to be immunised. Some parents think that only babies and young children need to be immunised.

Advising parents about immunisation visits

3-15 How should you advise parents on when to bring their children for their next immunisations?

It is important that immunisations are given at the correct time and that there is the correct time interval between immunisations. This makes sure that the immunisations are most effective. Parents should therefore understand when to bring their children for the next immunisation. They should be shown the immunisation schedule. Explain to them how the schedule works and how each immunisation is recorded. It is very useful to give them a clinic appointment card giving the date of the next immunisation visit.

Parents need to understand when to come for the next immunisation visit

Catch up immunisations

3-16 Why is an immunisation sometimes missed?

Ask the mother or caregiver whether any immunisations have been missed. It is possible that an immunisation was given but was not recorded. It may not have been given because:

• The mother did not take the child for immunisations. This may be a result of ignorance, distance, cost, fear or other social reasons
• The clinic may not have had the vaccine needed. Unfortunately vaccine outages (stock-outs) are common in some districts
• The clinic may not have given the immunisation even if the vaccine was available

The immunisation record must be checked at every visit to a healthcare facility or general practice. Every healthcare visit is an opportunity to give catch-up immunisations.

It is very important that the immunisation record is checked every time a child has a healthcare visit

3-17 What are catch-up immunisations?

These are immunisations which have been missed and not given at the correct time. All missing immunisations should be given so that the child catches up on their immunisation schedule.

3-18 Can catch-up immunisations be given at a hospital or private doctor visit?

Yes. This is an excellent opportunity for review of the child’s record and to give any missing immunisations. It is unusual for a child to be too sick to be given catch-up immunisations.

3-19 How can a community healthcare worker help to identify missing immunisations?

An important part of a healthcare worker’s duty is to check all children’s immunisation record every time a home visit is made. Any child with one or more missing immunisations must be referred to their local primary care clinic. It is very important that all children are fully immunised for their age.

Healthcare workers must check each child’s immunisation record when doing home visits

3-20 What may be the result of missing immunisations?

The child may not be protected against the illnesses for which immunisations are given. It is very unfortunate if a child becomes ill with an infection such as measles because the child was not fully immunised.

Immunisations protects children against important illnesses

3-21 What should a community health worker do if they find a child has missed an immunisation?

Refer the mother and child to the nearest clinic. Do not scold the mother but explain how important it is that her child has all the immunisation given at the correct age.

The immunisation record

3-22 Why is an accurate immunisation record important?

It is very important that healthcare workers complete every child’s immunisation record accurately as this is the formal record of their immunisations. It is the way that the completeness of immunisations can be assessed at hospital, clinics and in general practice. It is also needed by crèches and schools.

Many parents with their children move from one district or province to another where the schedule of immunisations needs to be continued. This can only be done correctly if the child has an accurate immunisation record.

3-23 Where is the immunisation record kept?

This should be in the child’s Road-to-Health booklet. However children from another country may have a separate immunisation record.

3-24 How should the immunisation record be completed?

Every time an immunisation is given it must be accurately recorded. Both the date when the immunisation is given as well as the signature of the person who gave the immunisation must be filled into the correct column on the immunisation record.

Case study 1

A community health worker visits a pregnant woman at home. The woman asks about routine immunisations that her child will need. She had listened to a radio programme on the national immunisation schedule that mentioned the importance of immunisations.

1. She asks what is the national immunisation schedule?

This is the list of routine immunisations which are given to all children when they reach certain ages such as BCG at birth and measles immunisation at six and 12 months.

2. She asks where should she take her baby for immunisations?

BCG and the first oral polio immunisation will be given at the facility where she delivers. The other immunisations will be given at her local health clinic.

3. Will they will be expensive?

No. All immunisations on the national immunisation schedule are free at public health facilities.

4. Are immunisations to protect against one disease only given once?

BCG is only given once but all the other immunisations are given a number of times. For example hexavalent immunisation is given four times. This makes sure that the body responds well by making a lot of antibodies to protect against infection.

Case study 2

After a normal pregnancy a woman delivers her first baby at term in a primary care delivery clinic. After six hours both mother and baby are well and the nurse says that the baby must have her first immunisations. The nurse asks a community health worker to explain to the mother which immunisations are needed before discharge.

1. Why can the immunisations not be started when the child is older?

Many of the serious infections occur in young children. Therefore it is important to start immunisations as soon as possible.

2. What type of polio immunisation is given soon after birth?

Oral polio vaccine is used. Later the baby will also get the intramuscular polio vaccine which forms part of the hexavalent vaccine.

3. How should the immunisations be recorded?

Each immunisation must be carefully recorded in the child’s Road-to-Health booklet. The person giving the immunisation should add the date plus her signature.

4. How will the mother know when to bring her child for the next immunisation?

She will be told by the clinic. A community health worker can show the mother on the immunisation record when the child will be the correct age for the next immunisation.

Case study 3

A group of community health workers are discussing ways to improve access to health. One of them suggests that the child’s immunisation record should be checked every time a home visit is made.

1. Do you agree that always checking a child’s immunisation record on home visits is important?

Yes. This is one way the community health workers can help to get all children fully immunised.

2. Should a child’s immunisation record be checked at every clinic or hospital visit?

Yes. A clinic or hospital visit is an important opportunity to screen children for missed immunisations.

3. What is a catch-up immunisation?

These are immunisations which are given later than usual to a child who had missed the immunisation at the correct age. Catch-up immunisations are important so that the child can be fully immunised.

4. What should a community health worker do if they find a child has missed an immunisation?

Refer the mother and child to the nearest clinic. Do not scold the mother but explain how important it is that her child has all the immunisation given at the correct age.