What if a child has never been immunized?

Children in Canada are routinely immunized against nine infectious diseases: diphtheria, tetanus, pertussis, poliomyelitis, Haemophilus influenzae type b (Hib) infection, measles, mumps, rubella and hepatitis B. Vaccines for these diseases are administered following immunization schedules that vary slightly between provinces and territories (1). A varicella vaccine was licensed in Canada in December 1998 (2), but is not yet routinely used in most provincial or territorial childhood programs (Prince Edward Island is initiating a childhood varicella immunization program in 2000). Despite high overall vaccine coverage (estimated at 82% to 95% for individual vaccine antigens when assessed at 24 months of age [3]), there remain individuals or pockets of children in Canada who are susceptible to infection because they have never been or are incompletely immunized against one or more of these nine infectious diseases. New immigrants from countries who have not had one or more of the above-mentioned childhood vaccines make up part of this never-immunized group, especially if ‘catch-up’ immunizations are not provided after their arrival in Canada (4). Some children are not immunized because they have valid medical contraindications (5), they missed immunization appointments, or their parents declined to have them immunized. Some parents have religious reasons for declining immunizations, while others hold mistaken beliefs that the infectious diseases either do not cause serious harm or no longer occur in Canada (6). Infectious diseases that are rare in Canada, such as diphtheria and poliomyelitis, may be reintroduced into the country from abroad. Cases of measles, mumps, rubella, pertussis, tetanus, Hib and hepatitis B are still reported in Canada. Examples include the recent outbreaks of rubella in Manitoba (7) and mumps in British Columbia (8). Because the immunization coverage in Canadian children is generally high, physicians may wrongly assume that children are fully immunized by the time that they enter school. Children's records should be checked to ensure that their immunizations are up-to-date whenever they are exposed to vaccine-preventable infections. Table 1 (middle column) outlines the preventive steps that physicians and public health authorities recommend when faced with a susceptible child who has been exposed to one of these infections. This often involves one or a combination of the following steps: using immune globulin preparations to provide immediate protection; starting the primary immunization series to provide either immediate (eg, postexposure immunization for measles, varicella and hepatitis A) or future protection; prescribing antibiotic prophylaxis; and excluding the child from school or daycare to prevent further exposure or spread of the infection. For fully immunized children, these steps may be eliminated (see Table 1, right-hand column for comparison). Parents should be encouraged to inform their physicians when their unimmunized child is exposed to a vaccine-preventable illness so that the appropriate steps can be taken during a bona fide exposure. Unbeknownst to the parents, a susceptible child may be exposed to infectious persons who are asymptomatic or the child may sustain a wound that becomes contaminated with Clostridium tetani and tetanus may develop without an opportunity to provide preventive measures. Parents of unimmunized children are often unaware that a blood product (immune globulin) may be administered in the absence of prior immunity to certain infections. A ‘catchup’ primary immunization series that is initiated only after exposure has occurred will not usually induce immunity in time to prevent or reduce the severity of the infection (with the exception of measles, varicella and hepatitis A, where postexposure immunization is effective in preventing illness). Therefore, avoiding the primary series during infancy simply delays the immunization until after an infectious exposure has occurred. Preventive steps for both unimmunized and fully immunized children after a close contact with a confirmed vaccine-preventable infectious disease Perform throat swab culture for diphtheria to determine if the child has been infected. Prescribe erythromycin or penicillin to prevent (or treat) infection. Recommend the of the primary diphtheria immunization series for future diphtheria only if the child is with or not for the throat swab culture as may be to prevent or Children who have of but who are asymptomatic should antibiotic but not the child from school or daycare until in the are and no longer the child if or infection is a of diphtheria only if more have the to the immunity against Perform throat swab culture for diphtheria to determine if the child has been infected. Prescribe erythromycin or penicillin to prevent (or treat) infection, of immunization or the child from school or daycare the only if or until infection is the child a for culture to determine if the child has been infected. Prescribe erythromycin for can prevent in but not the Some in Canada recommend erythromycin for more recent there are no and no for the of or for against infection. Recommend the of the primary immunization series for future vaccine is licensed for in persons of age in for the of this vaccine are by the the child from school or daycare if the child a is or the child has at of the erythromycin is the child should be from school or daycare until are a of vaccine as a if has been more after the for the of vaccine in persons of age are by the Prescribe erythromycin for of the that the primary vaccine series was because the vaccine only and individuals may Some in Canada recommend erythromycin for more recent there are no and no for the of or for against infection. the child from school or daycare only if the child a is or the child has at of the erythromycin For in Clostridium tetani may have been tetanus immune globulin to provide immediate Recommend the of the primary tetanus series for the primary series is not or may be for from school or daycare is not a of tetanus if has been more the when with contaminated where a is if has been more the is not for of wound the child has an where is from school or daycare is not Canada, the of by was reported in if an unimmunized child is in close contact with a of by a of vaccine is to prevent infection. Recommend the of the unimmunized primary series with vaccine for future an of the where the of the primary series with is that has a of in primary vaccine and so in their the child from school or daycare until has been A vaccine is not for a fully immunized child who is exposed to from school or daycare is not the child is months of antibiotic with for is for the susceptible child and the susceptible child may Hib from these Recommend the of the primary series of Hib for children months of age (or only one of Hib vaccine if the child is between and months of from school or daycare is not if antibiotic is is not for the child and there is child in the who is months of age of immunization or between and months of age who is immunized. from school or daycare is not Recommend a of vaccine of the exposure not this is the A of vaccine may be administered one to months after the immune globulin if is of exposure this should not be if is vaccine was not administered and was recommend a ‘catch-up’ months after the to provide future with the one to months the child from school or daycare (eg, for at and up to after the with if immunization with either vaccine or is not to the child and the vaccine is not if the child has of vaccine in the a of vaccine not if the child has only one prior is not the child has an disease where the immunization with vaccine was from school or daycare is not the child is to have an with mumps vaccine after exposure is not to prevent illness from this but will against recommend immunization not with a of mumps is not effective for the of mumps and is not the child from school or daycare (eg, for up to after the of in the with mumps, if immunization with mumps vaccine is not to the A mumps vaccine is not if the child has at one of mumps vaccine in the from school or daycare is not with rubella vaccine after exposure is not to prevent illness from this but will against Therefore, recommend immunization not with a of rubella may prevent or reduce the severity of rubella in of age after a exposure to an infectious may not prevent the from with rubella, with the of if the infection during the of age from school (eg, for up to after the of illness in the with to the and of children and age from school or daycare is A rubella vaccine is not if the child has at one of rubella vaccine in the is not the child has an disease where immunization with rubella vaccine was from school or daycare is not of infection is if the exposure involves a contaminated with hepatitis B from or with a with an of hepatitis B or a hepatitis B or a to a who is a hepatitis B is provided by hepatitis B immune globulin and initiating the primary immunization series of of hepatitis B of infection is for children who in the with who is a hepatitis B is not but the of the primary series of of hepatitis B vaccine is a exposure to the blood or of an the hepatitis B may be if the immunity to hepatitis is not from school or daycare is not Perform throat swab culture for diphtheria to determine if the child has been infected. Prescribe erythromycin or penicillin to prevent (or treat) infection. Recommend the of the primary diphtheria immunization series for future diphtheria only if the child is with or not for the throat swab culture as may be to prevent or Children who have of but who are asymptomatic should antibiotic but not the child from school or daycare until in the are and no longer the child if or infection is a of diphtheria only if more have the to the immunity against Perform throat swab culture for diphtheria to determine if the child has been infected. Prescribe erythromycin or penicillin to prevent (or treat) infection, of immunization or the child from school or daycare the only if or until infection is the child a for culture to determine if the child has been infected. Prescribe erythromycin for can prevent in but not the Some in Canada recommend erythromycin for more recent there are no and no for the of or for against infection. Recommend the of the primary immunization series for future vaccine is licensed for in persons of age in for the of this vaccine are by the the child from school or daycare if the child a is or the child has at of the erythromycin is the child should be from school or daycare until are a of vaccine as a if has been more after the for the of vaccine in persons of age are by the Prescribe erythromycin for of the that the primary vaccine series was because the vaccine only and individuals may Some in Canada recommend erythromycin for more recent there are no and no for the of or for against infection. the child from school or daycare only if the child a is or the child has at of the erythromycin For in Clostridium tetani may have been tetanus immune globulin to provide immediate Recommend the of the primary tetanus series for the primary series is not or may be for from school or daycare is not a of tetanus if has been more the when with contaminated where a is if has been more the is not for of wound the child has an where is from school or daycare is not Canada, the of by was reported in if an unimmunized child is in close contact with a of by a of vaccine is to prevent infection. Recommend the of the unimmunized primary series with vaccine for future an of the where the of the primary series with is that has a of in primary vaccine and so in their the child from school or daycare until has been A vaccine is not for a fully immunized child who is exposed to from school or daycare is not the child is months of antibiotic with for is for the susceptible child and the susceptible child may Hib from these Recommend the of the primary series of Hib for children months of age (or only one of Hib vaccine if the child is between and months of from school or daycare is not if antibiotic is is not for the child and there is child in the who is months of age of immunization or between and months of age who is immunized. from school or daycare is not Recommend a of vaccine of the exposure not this is the A of vaccine may be administered one to months after the immune globulin if is of exposure this should not be if is vaccine was not administered and was recommend a ‘catch-up’ months after the to provide future with the one to months the child from school or daycare (eg, for at and up to after the with if immunization with either vaccine or is not to the child and the vaccine is not if the child has of vaccine in the a of vaccine not if the child has only one prior is not the child has an disease where the immunization with vaccine was from school or daycare is not the child is to have an with mumps vaccine after exposure is not to prevent illness from this but will against recommend immunization not with a of mumps is not effective for the of mumps and is not the child from school or daycare (eg, for up to after the of in the with mumps, if immunization with mumps vaccine is not to the A mumps vaccine is not if the child has at one of mumps vaccine in the from school or daycare is not with rubella vaccine after exposure is not to prevent illness from this but will against Therefore, recommend immunization not with a of rubella may prevent or reduce the severity of rubella in of age after a exposure to an infectious may not prevent the from with rubella, with the of if the infection during the of age from school (eg, for up to after the of illness in the with to the and of children and age from school or daycare is A rubella vaccine is not if the child has at one of rubella vaccine in the is not the child has an disease where immunization with rubella vaccine was from school or daycare is not of infection is if the exposure involves a contaminated with hepatitis B from or with a with an of hepatitis B or a hepatitis B or a to a who is a hepatitis B is provided by hepatitis B immune globulin and initiating the primary immunization series of of hepatitis B of infection is for children who in the with who is a hepatitis B is not but the of the primary series of of hepatitis B vaccine is a exposure to the blood or of an the hepatitis B may be if the immunity to hepatitis is not from school or daycare is not This column to a child who has not of the vaccine and is the primary immunization series or should be as a combination vaccine to to the child (eg, if vaccine is provide if tetanus or diphtheria is provide diphtheria, tetanus and vaccine or tetanus and diphtheria is age This column to a child who has the of the primary series of the vaccine most child is immune to the in where of the series only immunity (eg, or daycare may vary between public health public health for the Preventive steps for both unimmunized and fully immunized children after a close contact with a confirmed vaccine-preventable infectious disease Perform throat swab culture for diphtheria to determine if the child has been infected. Prescribe erythromycin or penicillin to prevent (or treat) infection. Recommend the of the primary diphtheria immunization series for future diphtheria only if the child is with or not for the throat swab culture as may be to prevent or Children who have of but who are asymptomatic should antibiotic but not the child from school or daycare until in the are and no longer the child if or infection is a of diphtheria only if more have the to the immunity against Perform throat swab culture for diphtheria to determine if the child has been infected. Prescribe erythromycin or penicillin to prevent (or treat) infection, of immunization or the child from school or daycare the only if or until infection is the child a for culture to determine if the child has been infected. Prescribe erythromycin for can prevent in but not the Some in Canada recommend erythromycin for more recent there are no and no for the of or for against infection. Recommend the of the primary immunization series for future vaccine is licensed for in persons of age in for the of this vaccine are by the the child from school or daycare if the child a is or the child has at of the erythromycin is the child should be from school or daycare until are a of vaccine as a if has been more after the for the of vaccine in persons of age are by the Prescribe erythromycin for of the that the primary vaccine series was because the vaccine only and individuals may Some in Canada recommend erythromycin for more recent there are no and no for the of or for against infection. the child from school or daycare only if the child a is or the child has at of the erythromycin For in Clostridium tetani may have been tetanus immune globulin to provide immediate Recommend the of the primary tetanus series for the primary series is not or may be for from school or daycare is not a of tetanus if has been more the when with contaminated where a is if has been more the is not for of wound the child has an where is from school or daycare is not Canada, the of by was reported in if an unimmunized child is in close contact with a of by a of vaccine is to prevent infection. Recommend the of the unimmunized primary series with vaccine for future an of the where the of the primary series with is that has a of in primary vaccine and so in their the child from school or daycare until has been A vaccine is not for a fully immunized child who is exposed to from school or daycare is not the child is months of antibiotic with for is for the susceptible child and the susceptible child may Hib from these Recommend the of the primary series of Hib for children months of age (or only one of Hib vaccine if the child is between and months of from school or daycare is not if antibiotic is is not for the child and there is child in the who is months of age of immunization or between and months of age who is immunized. from school or daycare is not Recommend a of vaccine of the exposure not this is the A of vaccine may be administered one to months after the immune globulin if is of exposure this should not be if is vaccine was not administered and was recommend a ‘catch-up’ months after the to provide future with the one to months the child from school or daycare (eg, for at and up to after the with if immunization with either vaccine or is not to the child and the vaccine is not if the child has of vaccine in the a of vaccine not if the child has only one prior is not the child has an disease where the immunization with vaccine was from school or daycare is not the child is to have an with mumps vaccine after exposure is not to prevent illness from this but will against recommend immunization not with a of mumps is not effective for the of mumps and is not the child from school or daycare (eg, for up to after the of in the with mumps, if immunization with mumps vaccine is not to the A mumps vaccine is not if the child has at one of mumps vaccine in the from school or daycare is not with rubella vaccine after exposure is not to prevent illness from this but will against Therefore, recommend immunization not with a of rubella may prevent or reduce the severity of rubella in of age after a exposure to an infectious may not prevent the from with rubella, with the of if the infection during the of age from school (eg, for up to after the of illness in the with to the and of children and age from school or daycare is A rubella vaccine is not if the child has at one of rubella vaccine in the is not the child has an disease where immunization with rubella vaccine was from school or daycare is not of infection is if the exposure involves a contaminated with hepatitis B from or with a with an of hepatitis B or a hepatitis B or a to a who is a hepatitis B is provided by hepatitis B immune globulin and initiating the primary immunization series of of hepatitis B of infection is for children who in the with who is a hepatitis B is not but the of the primary series of of hepatitis B vaccine is a exposure to the blood or of an the hepatitis B may be if the immunity to hepatitis is not from school or daycare is not Perform throat swab culture for diphtheria to determine if the child has been infected. Prescribe erythromycin or penicillin to prevent (or treat) infection. Recommend the of the primary diphtheria immunization series for future diphtheria only if the child is with or not for the throat swab culture as may be to prevent or Children who have of but who are asymptomatic should antibiotic but not the child from school or daycare until in the are and no longer the child if or infection is a of diphtheria only if more have the to the immunity against Perform throat swab culture for diphtheria to determine if the child has been infected. Prescribe erythromycin or penicillin to prevent (or treat) infection, of immunization or the child from school or daycare the only if or until infection is the child a for culture to determine if the child has been infected. Prescribe erythromycin for can prevent in but not the Some in Canada recommend erythromycin for more recent there are no and no for the of or for against infection. Recommend the of the primary immunization series for future vaccine is licensed for in persons of age in for the of this vaccine are by the the child from school or daycare if the child a is or the child has at of the erythromycin is the child should be from school or daycare until are a of vaccine as a if has been more after the for the of vaccine in persons of age are by the Prescribe erythromycin for of the that the primary vaccine series was because the vaccine only and individuals may Some in Canada recommend erythromycin for more recent there are no and no for the of or for against infection. the child from school or daycare only if the child a is or the child has at of the erythromycin For in Clostridium tetani may have been tetanus immune globulin to provide immediate Recommend the of the primary tetanus series for the primary series is not or may be for from school or daycare is not a of tetanus if has been more the when with contaminated where a is if has been more the is not for of wound the child has an where is from school or daycare is not Canada, the of by was reported in if an unimmunized child is in close contact with a of by a of vaccine is to prevent infection. Recommend the of the unimmunized primary series with vaccine for future an of the where the of the primary series with is that has a of in primary vaccine and so in their the child from school or daycare until has been A vaccine is not for a fully immunized child who is exposed to from school or daycare is not the child is months of antibiotic with for is for the susceptible child and the susceptible child may Hib from these Recommend the of the primary series of Hib for children months of age (or only one of Hib vaccine if the child is between and months of from school or daycare is not if antibiotic is is not for the child and there is child in the who is months of age of immunization or between and months of age who is immunized. from school or daycare is not Recommend a of vaccine of the exposure not this is the A of vaccine may be administered one to months after the immune globulin if is of exposure this should not be if is vaccine was not administered and was recommend a ‘catch-up’ months after the to provide future with the one to months the child from school or daycare (eg, for at and up to after the with if immunization with either vaccine or is not to the child and the vaccine is not if the child has of vaccine in the a of vaccine not if the child has only one prior is not the child has an disease where the immunization with vaccine was from school or daycare is not the child is to have an with mumps vaccine after exposure is not to prevent illness from this but will against recommend immunization not with a of mumps is not effective for the of mumps and is not the child from school or daycare (eg, for up to after the of in the with mumps, if immunization with mumps vaccine is not to the A mumps vaccine is not if the child has at one of mumps vaccine in the from school or daycare is not with rubella vaccine after exposure is not to prevent illness from this but will against Therefore, recommend immunization not with a of rubella may prevent or reduce the severity of rubella in of age after a exposure to an infectious may not prevent the from with rubella, with the of if the infection during the of age from school (eg, for up to after the of illness in the with to the and of children and age from school or daycare is A rubella vaccine is not if the child has at one of rubella vaccine in the is not the child has an disease where immunization with rubella vaccine was from school or daycare is not of infection is if the exposure involves a contaminated with hepatitis B from or with a with an of hepatitis B or a hepatitis B or a to a who is a hepatitis B is provided by hepatitis B immune globulin and initiating the primary immunization series of of hepatitis B of infection is for children who in the with who is a hepatitis B is not but the of the primary series of of hepatitis B vaccine is a exposure to the blood or of an the hepatitis B may be if the immunity to hepatitis is not from school or daycare is not This column to a child who has not of the vaccine and is the primary immunization series or should be as a combination vaccine to to the child (eg, if vaccine is provide if tetanus or diphtheria is provide diphtheria, tetanus and vaccine or tetanus and diphtheria is age This column to a child who has the of the primary series of the vaccine most child is immune to the in where of the series only immunity (eg, or daycare may vary between public health public health for the who not immunized during childhood may and be exposed to these vaccine-preventable infectious diseases in health may not be the of or from these infectious diseases. and to be immunized their persons may be into these Parents should be that is never to or the immunization series because immunizations may be following the schedules by Parents who remain that immunizations provide against these infectious diseases should be encouraged to to their children that they not immunized during and are still susceptible to not these infectious this when these children may to make up their against these especially starting and a (with of a child with rubella

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