4 Immunisation risks

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Contents

• Objectives
• The risk of not immunising all children
• Side effects of immunisation
• Discussing risks and benefits of immunisation with parents
• Contraindications to immunisation
• The cold chain
• Case studies

Objectives

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

1. List the risks of not immunising all children
2. Describe common side effects of immunisation
3. Discuss risks and benefits of immunisation with parents
4. List contraindications to immunisation
5. Understand the importance of the cold chain

The risk of not immunising all children

4-1 What is the greatest risk of not immunising children?

The greatest risk is that a child who is not fully immunised may become ill or even die of a disease that can be prevented by immunisation. Immunisation is so effective that it is dangerous not to fully immunise a child.

The greatest risk is not to fully immunise a child

4-2 How many children in South Africa are fully immunised

About 80% but the immunisation rate is as low as 70% in some provinces. It is important to get the rate of fully immunised children as high as possible. The goal should be 100%.

About 80% of all children in South Africa are fully immunised

4-3 Why are some children not fully immunised?

There are many reasons why some children are not fully immunised:

• Lack of easy access to clinics
• Lack of vaccines at the clinic
• Failure of staff to immunise the child
• Belief that the child cannot be immunised if it is not well
• Parents may believe that immunisation is expensive
• Parents hear incorrect information that immunisation is dangerous

4-4 Should malnourished children be immunised?

Yes. It is very important to immunise underweight children as they are at greatest risk of dying from serious infections such as measles.

Malnourished children must be immunised

4-5 Is it safe to immunise a child with a mild infection?

Yes. Children with a mild upper respiratory tract infection or mild diarrhoea can be safely immunised. A common mistake is to ask parents to bring their child back to be immunised when it is well. Often these children are not brought back and as a result catch a serious infection such as measles.

It is safe to immunise a child with a mild infection

4-6 What does it cost to have a child immunised?

Routine immunisation is free in all public clinics and hospitals in South Africa. In the private sector immunisations have to be paid for.

Immunisation is free in public health facilities in South Africa

4-7 Can immunising one child help to protect other children?

Yes. The spread of many infections like measles and polio can be prevented by immunising all children. The infection then cannot spread from one child to another as they are all immunised. This is the way that smallpox has been totally prevented worldwide and not seen for many years in South Africa.

Parents need to understand that failure to fully immunise one child places other unimmunised children also at risk.

4-8 What is herd immunity?

When most children are immunised against a serious infection there is very little chance that the infection could spread and cause an epidemic. Therefore immunising all children (“the herd”) helps protect each individual child.

Side effects of immunisation

4-9 Can immunisations have side effects?

Like any other medication, immunisation can cause side effects. These are usually mild and not a clinical problem. However, there are some rare but serious side effects. The risk of a serious side effect is much smaller than the huge benefits of immunisation.

In the past some immunisations did cause more severe side effects but these vaccines are no longer used.

The risk of a serious side effect after immunisation is very small

4-10 What are the commonest side effects of immunisation?

The commonest side effect of immunisation is mild swelling, redness and tenderness over the site of the injection. This usually does not need any treatment and the parents can be reassured that it will recover in a few days. If the child needs pain medication, paracetamol (Panado) can be used. Do not use aspirin in children as it can be dangerous.

If a child becomes unwell within a few days after immunisation it should be taken to the nearest clinic to be assessed.

4-11 What is a side effect of BCG immunisation?

Usually a small ulcer forms within six weeks at the site of the BCG immunisation. This heals and is not a problem. If an abscess forms refer the child to the local health clinic or hospital.

4-12 Is there a risk of using oral polio vaccine?

Oral polio is a weakened but live vaccine which multiplies in the baby’s bowel. Very, very rarely (about one in a million children) immunisation with oral polio vaccine can cause muscle paralysis. However the risk is much smaller than the risk of wild polio in countries where polio still occurs. Once polio is no longer a risk the oral immunisation can be stopped and only intramuscular vaccine used. As the intramuscular vaccine is a dead vaccine it cannot multiply and cause paralysis.

In South Africa there is still a risk that an immigrant child or adult may bring polio infection into the country if they come from another country which still has polio and does not immunise all children. When this risk disappears we will use only the intramuscular polio vaccine.

4-13 What is a common side effect of measles immunisation?

A few days after the immunisation some children develop a mild pink rash and mild fever. If needed the mother can give the child paracetamol for the fever.

Discussing risks and benefits of immunisation with parents

4-14 How should a community health worker answer questions about side effects?

They should explain that immunisation is both safe and effective. However, warn parents that there may be some redness, swelling and tenderness for a few days at the site of the injection. Serious side effects are very rare. If a child becomes seriously ill within a week of an immunisation it must be taken immediately to a health facility.

Educating parents about the benefits and safety of immunisation is an important task for all community health workers.

Community health workers should educate parents about the benefits and safety of immunisations

4-15 What are the false beliefs about immunisations?

Some people incorrectly believe that immunisation is not needed, is dangerous and can cause serious diseases. These beliefs are not correct. Therefore it is important to educate the public about the importance and safety of immunisations.

4-16 Where may parents get false information about immunisations?

Magazines and the internet sometimes give incorrect information claiming that immunisation is dangerous and can harm the child or cause serious illnesses. Some religious or traditional beliefs teach that immunisation should not be used.

Contraindications to immunisation

4-17 What does a contraindication to immunisation mean?

A contraindication is a situation where it is better for the child not to have that immunisation. This is usually because there is an increased danger of a serious side effect to the immunisation.

4-18 What are the contraindications to immunisation?

There are only a few contra-indications to immunisation:

• If a child is ill enough to be admitted to hospital the immunisations should be delayed until the child is well enough to go home. The immunisation may be given at discharge.
• If a child has had a serious reaction to a previous immunisation it should be referred to a health facility for a check up to assess whether further immunisations should be given.
• BCG should not be given after 1 year in children who missed their BCG immunisation.
• The full dose of diphtheria immunisation (D) should not be used after 18 months. Thereafter the reduced dose vaccine (d) is used.

4-19 Should children who are born to an HIV positive mother be immunised?

Yes. Even children who are HIV infected should be fully immunised.

Babies that are born to an HIV positive mother must still be immunised

The cold chain

4-20 Is there a risk of an immunisation failing?

It is very rare for an immunisation to fail and not provide the child with protection. However an immunisation may fail if either:

• It is not given correctly
• It is not stored and transported correctly

4-21 What is a cold chain?

All vaccines need to be stored under the correct conditions or they will be damaged. Both light and heat can damage vaccines. This is very important for live vaccines (BCB, oral polio, Rotavirus, measles). Therefore exposing vaccines to sunlight, warming or freezing can result in the immunisation failing.

The cold chain is the method used to make sure that vaccines are kept cold from the time that they are made until they are transported to the health facility and while they are stored at the health facility. Vaccines need to be kept cold if they are moved again to a site where immunisations are being given.

The cold chain is very important to protect vaccines from warming up and being damaged

4-22 How should vaccines be stored in a clinic?

A clinic fridge is used to keep the vaccines at 2 to 8 degrees C. Vaccines are best stored on the middle shelf. Do not use the vaccine fridge to store anything else and do not freeze vaccines. A fridge thermometer must be kept on the middle shelf and the temperature measured and recorded. Bottles of water should be stored on the bottom shelf as this helps to maintain the correct temperature in the fridge if there is a power failure.

4-23 What is a cool box?

Keeping vaccines cold when they are moved out of the fridge to take them to another clinic in rural regions is particularly difficult when a transport fridge is not available. Under these circumstances, a cool box is used. Usually, a cool box consists of a polystyrene container with a lid. Frozen ice packs (they should rattle when shaken) are placed inside the cool box on the bottom and sides as well as under the lid. Keep the lid close to protect the vaccines from sunlight. Do not allow the vaccines to freeze.

A cool box is used to keep vaccines cold when they are moved out of a fridge

Case study 1

An HIV positive mother brings her underweight six-month-old child to a well baby clinic. A community health worker who is helping at the clinic notices that some immunisations have been missed. The mother says they were not given as the baby had a runny nose.

1. Is it safe to immunise a child if the mother is HIV positive?

Yes. As these children are at an increased risk of serious infections it is important to fully immunise them.

2. Should the immunisations be missed if a child had a runny nose?

No. A mild infection is not a contraindication to immunisation.

3. Is it safe to immunise a very sick child?

If the child is sick enough to be admitted to hospital the immunisations should be delayed.

4. Is it safe to immunise this underweight child?

Yes as malnutrition is not a contraindication to immunisation if the child is well enough to go home.

Case study 2

A worried mother brings her six-month-old child to a clinic two days after receiving his routine immunisation. At the site of the measles immunisation there is an area of redness, mild swelling and tenderness.

1. Should the mother be worried about the area of redness, swelling and tenderness?

This is common after an immunisation. The mother should be reassured that it will recover in a few days.

2. What can be used to help reduce the pain?

The mother can give the child half a teaspoon (2.5 ml) of paracetamol (Panado) every six hours. Usually this is not needed.

3. The mother asks if there are other side effects of measles immunisation?

Some children have a mild rash and mild fever a few days after the immunisation.

4. What would you say if the mother says she will not bring her child back for the second measles immunisation?

You should explain to the mother the importance of immunisation and tell her that the mild side effects are better than the child getting measles which can be a serious illness.

Case study 3

Vaccines and bottles of milk are kept in the kitchen fridge at a local clinic. A community health worker moves some of the vaccines into a cool box as they are being taken to a well baby clinic for immunisations.

1. How should vaccines be stored at a health facility?

It is important that they are kept cool at 2 to 8 degrees in a vaccine fridge. The fridge should not be used to store milk or other food as the door should not be frequently opened. This will drop the temperature in the fridge. It is best if the vaccines are kept on the middle shelf of the fridge.

2. What is a cool box?

This is a container that is used to keep vaccines cool and out of the sunlight when they are moved to an immunisation clinic.

3. The community health worker asks why vaccines should be kept cool and in the dark?

Because they will be damaged if they get warm or are exposed to bright sunlight.