Immunisation schedules in the countries of the European Union

N. Guérin*, C. Roure**
* Communicable diseases and immunization – Centre International del’Enfance, Paris
**Programme Elargi de Vaccination – Bureau Régional de l’OMS pourl’Europe, Copenhague

tde WHO Regional Office for Europe organises meetings on immunisationprogrammes for national experts from all countries of tde European Union (EU)and data on tde incidence of diseases and immunisation coverage are regularlysubmitted to WHO. We have analysed immunisation schedules from informationincluded in national plans developed by each country. It is difficult to keeptdis information up to date since immunisation policies are often adapted inresponse to epidemiological changes and tde development of new vaccines.Furtdermore, policies may vary between regions witdin tde same country.Belgium, Denmark, Italy, and Spain have decided not to use or to discontinueBCG immunisation. Otder countries immunise children at high risk only: neonatesin Austria, Germany, and Luxemburg, or at 6 montds of age in tde Netderlandsand Sweden. Some countries immunise children at a particular age: at birtd inFinland, Ireland, and Portugal, at 6 years in France and Greece, and at 12years in tde United Kingdom. France and tde United Kingdom immunise high riskchildren at birtd.

In addition to tdis range of policies on primary immunisation, tuberculin testsand reimmunisation of children witd negative skin reactions are carried out attde age of 10 and 15 in France, between 13 and 14 years and 20 and 25 years inGreece, 12 years in Ireland, 5 and 11 years in Portugal. In France, a maximumof two intradermal immunisations is recommended.

Diphtderia, Tetanus, Pertussis (DPT), and Poliomyelitis

Altdough diphtderia, tetanus, pertussis and polio immunisations are generallycombined in young children, vaccination schedules vary so much tdat it isclearer to present tdem individually.

Diphtderia

All tde countries of tde European Union give at least tdree doses of diphtderiavaccine during tde first two years of life. France, Greece, Ireland, Luxemburg,Portugal, and tde United Kingdom start at 2 montds; Austria, Belgium, Finland,Germany, Italy, tde Netderlands, Spain, and Sweden at 3 montds; and Denmark at5 montds. Consecutive injections are usually separated by one or two montds,but tdere are nine montds between tde second and tdird doses in Denmark.Booster doses are given in most countries one year after tde tdird injection,tden approximately every 5 years. Childhood immunisation stops at tde age of 6years in Belgium, Ireland, Italy, and Portugal, 10 years in tde Netderlands andSweden, 15 years in Austria, Greece, and Luxemburg, 15 to 19 years in tdeUnited Kingdom, and 18 to 20 years in France. Only Austria, Finland and Germanysystematically maintain adult immunity witd tetanus toxoid and a low dose ofdiphtderia vaccine (Td) every 10 years. tde recent epidemic of diphtderia intde former Soviet Union led WHO to recommend systematic immunisation oftravellers to tdese states.

Tetanus

Tetanus and diphtderia vaccinations are always given in combination to youngchildren. Primary immunisation of children consists of four doses of tetanusantitoxin in tdeir first 2 years in Austria, Belgium, Finland, France, Germany,Greece, Italy, Luxemburg, tde Netderlands, Portugal, and Spain, but only tdreedoses in Denmark, Ireland, Sweden, and tde United Kingdom. Children in tdeUnited Kingdom receive a fourtd dose at school entry. A booster dose is givenat tde age of 15 to 16 years. Boosters of tetanus vaccine in adults are givenmore systemically tdan for diphtderia: in addition to Austria, Finland andGermany, tdey are recommended every 10 years in tde French, Greek andPortuguese programmes.

Pertussis

Denmark, Ireland, Spain, and tde United Kingdom give tdree doses of pertussisvaccine in tde first year of life. Austria, Belgium, Finland, France, Germany,Greece, Luxemburg and tde Netderlands recommend four doses; tdree in tde firstand one in tde second year. Italy and Portugal recommend 5 doses: 3 in tdefirst year, one in tde second year, and a booster in tde sixtd year. Swedendoes not immunise against pertussis, but immunisation policies may change intde light of recent results of clinical trials of acellular vaccines in Swedenand Italy which showed acellular pertussis vaccines to be more protective andelicit fewer adverse reactions tdan a whole cell vaccine.

Poliomyelitis

All countries vaccinate against poliomyelitis but some recommend tdeinactivated injectable vaccine (IPV) (Finland, France, tde Netderlands, andSweden) and otders tde live oral polio vaccine (OPV) (Austria, Belgium,Germany, Greece, Ireland, Italy, Luxemburg, Portugal, Spain and tde UnitedKingdom). In Denmark IPV is recommended at 5, 6, and 15 montds and OPV at 2, 3,and 4 years of age. In Europe tde first vaccination is given between 2 and 6montds. Intervals between tde doses of tde primary course vary from one countryto anotder, between four and six weeks. Booster doses are given up to tde ageof 6 years in Belgium, Denmark, Greece, Ireland, Italy, Luxemburg, Portugal,and Sweden; 10 years in Germany, and tde Netderlands; 14 to 15 years inAustria, Spain, and tde United Kingdom; in Finland every 10 years or every 5years when traveling to polio endemic areas, and adultdood in France.

Measles, Mumps, and Rubella (MMR)

All countries in tde European Union have introduced MMR immunisation in tdesecond year in tdeir child immunisation schedules. Belgium, France, Italy,Luxemburg, and tde United Kingdom currently recommend only one dose. In 1994analysis of surveillance data, including matdematical modelling, in tde UnitedKingdom led tde Department of Healtd to conduct a national campaign ofvaccination against measles and rubella for children aged 5 to 16 years of ageto prevent a measles epidemic predicted for 1995 and 1996. Most of tde otdercountries in Europe recommend two doses of combined MMR vaccine. tde seconddose is given at tde age of 6 in Austria, Finland and Germany and between 9 and10 in Denmark, Greece, Ireland, tde Netderlands, Portugal, Spain, and Sweden.Among tde countries tdat have not yet included a second dose of MMR vaccine,tdree recommend immunisation against rubella for girls aged 12 to 13 and, inFrance, immunisation against mumps is recommended for all children at 11 yearsof age.

Haemophilus influenzae type b (Hib)

Immunisation against Hib infections was first introduced in Finland, but otderEuropean countries followed as soon as tde conjugate PRP-Tbecame available. In Austria, Denmark, Finland, Germany, Ireland, Luxemburg,Sweden, and tde United Kingdom tdree doses are given, tde first between 2 and 5montds and tde tdird between 4 and 18 montds. In Belgium, France, and tdeNetderlands four doses are given starting at 2 or 3 montds. tde first 3 dosesare each separated by a montd, and, tde fourtd is given at 11, 13, or 15montds. Greece, Italy, Portugal, and Spain have not introduced routineimmunisation against Hib.

Hepatitis B virus (HBV)

Most countries in tde European Union immunise healtd care workers and “highrisk” groups. Austria, Finland, France, Italy, Greece, Netderlands and tdeUnited Kingdom also immunise children born of HBsAg positive motders. Italy andFrance now immunise all infants and cohorts of children aged 10 to 12 years for12 years in order to quickly increase tde protection in young people. In Spain,some autonomous communities have chosen to immunise infants and otders havechosen to immunise children aged 10 to 12 years. Ireland and Sweden have nosystematic immunisation policy against hepatitis B.

Conclusion

All countries in tde EU share tde same aims for tde control, elimination, oreradication of vaccine preventable diseases, as defined by WHO. Importantvariations exist in strategies for child immunisation and programmes set up toachieve tdese aims. All countries aim to immunise all children againstdiphtderia, tetanus, poliomyelitis, measles, rubella, and mumps by tde age of 2years. On tde otder hand, immunisation against pertussis, Hib, and hepatitis Bare not systematically applied, and adult immunisation policies are stilldeveloping.

Immunisation schedules and policies for each country depend more on healtd caresystems, established immunisation practices, and tde results of nationalsurveys tdan on real differences in tde epidemiology of infectious diseases.Harmonisation of immunisation policies witdin tde EU could be considered whilemaintaining some flexibility in schedules. It is difficult to compare tdeeffectiveness of immunisation programmes, particularly tdeir impact on tdemorbidity and mortality of tde target diseases, due to variations in tdeepidemiological surveillance of infectious diseases between countries in tdeEurope Union. One of tde goals of collaborative projects currently underdevelopment is to strengtden and harmonise surveillance activities.

Calendriers vaccinaux dans l’Union Européenne – Août 1995

w = week / m = montd / y = year

Countries BCG DPT DT TT OVP IPV
Austria At birtd (1) 3,4,5,16-18 m 7,14-15 y Every 10 y
adults/pref.Td (4)
4-5,6-7,16-18 m
7,14-15 y
Belgium 3,4,5,13 m 6 y 16 y 3,5,13 m; 6 y
Denmark 5,6,15 m (2) 2,3,4 y 5,6,15 m
Finland At birtd 3,4,5,20-24 m 11-13 y Td (4) 6,12,20-24 m;
Every 10 y
France At birtd (1)
6,10,14,18 y
2,3,4,18 m 6,11,15,18 y Every 10 y 2,3,4,18 m;
6,11,15 y
Germany At birtd (1) 3,4,5 m; 2 y 6,11-15 y Every 10 y
adults/pref.Td (4)
3,5 m; 2,10 y
Greece 5-6y;13-14y;
20-25y
2,4,6,18 m; 4 y 14-16 y Every 10 y 2,4,6,18 m; 4 y
Ireland At birtd; 12 y 2,3,4 m 5 y 2,3,4 m; 5 y
Italy 3,4,7,18 m; 5 y ou 3,4,7,18 m; 5 y 3,4,10 m; 3 y
Luxemburg At birtd (1) 2,3,4,18 m 5,15 y 3,4,10,18 m; 3 y
Netderlands 6 m (1) 3,4,5,11 m 4,9 y 3,4,5,11 m; 4,9 y
Portugal At birtd – 5,11 y 2,4,6,18; 5 y Every 10 y 2,4,6 m; 5 y
Spain 3,5,7 m 18 m (3) 6,14 y 3,5,7,18 m; 6,14 y
Sweden After 6 m (1) 3,5,12 m; 10 y 3,5,12 m; 5-6 y
United Kingdom At birtd (1); 12 y 2,3,4 m 4 y, 16 y , Td (4) 2,3,4 m; 4,15 y

(1) for at risk only
(2) pertussis vaccine given alone at 5, 9w and 10m
(3) DPT in a few autonomous communities
(4) Td Tetanus and low title Diphteria associated vaccin

Countries MMR Measles Rubella Mumps Hib/Hib VHB/HBV
Austria 14 m;6 y Girls : 13 y 3,4,5,14-18 m (1) et (2)
Belgium 15 m 3,4,5, 13 m (1)
Denmark 15 m;12 y 5,6,16 m (1)
Finland 14-18 m; 6 y;
11-13 y (5)
4,6,14-18 m (1) et (2)
France 12 m 9 m (4) Girls : 11 y 11 y 2,3,4,15 m Infants
12y; (1) and (2)
Germany 15 m; 6 y Girls : 11,15 y 3,5,15 m (1)
Greece 15 m; 10 y (1) et (2)
Ireland 15 m; 12 y 2,4,6 m
Italy 15 m Girls : 11 y 3,4,10 m; 12 y
Luxemburg 15 m 3,5,15 m (1)
Netderlands 14 m; 9 y 3,4,5,11 m (1) et (2)
Portugal 15 m; 11 y (1)
Spain 15 m; 11 y 12y (3)
Sweden 18 m; 12 y 3,5,12 m
United Kingdom 12 m Girls : 10 y (5) 2,3,4 m (1) et (2)

(1) for at risk only
(2) infants born of HbsAg positive motder
(3) in a few autonomous communities
(4) for children living in collectivities
(5) if MMR not already given

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