Immunization Schedules

Recommendations from the National Advisory Committee on Immunization (NACI)

Few measures in preventive medicine are of such proven value and as easy to implement as routine immunization against infectious diseases. Immunization carried out as recommended in the following schedules will provide good basic protection for most children against the diseases shown.

Following a standard schedule ensures that the maximal achievable protection is achieved. However, modifications of the recommended schedule may be necessary because of missed appointments or inter-current illness. Interruption of a recommended series does not require starting the series over again, regardless of the interval elapsed. Children, youth and adults with interruptions to their vaccines should be vaccinated to complete the appropriate schedule for their current age.

Similar vaccines are now available from different manufacturers but may not be identical. It is therefore essential for the user to read the appropriate chapter in the most current Canadian Immunization Guide, as well as the manufacturer’s package insert.

Immunization Schedules for Infants and Children

Notes

	Symbols with brackets around them imply that these doses may not be required, depending upon the age of the child or adult. Refer to the relevant chapter for that vaccine for further details.
	Diphtheria, tetanus, acellular pertussis and inactivated polio virus vaccine (DTaP-IPV): DTaP-IPV(± Hib) vaccine is the preferred vaccine for all doses in the vaccination series, including completion of the series in children who have received one or more doses of DPT (whole cell) vaccine (e.g., recent immigrants). In Tables 1 and 2, the 4-6 year dose can be omitted if the fourth dose was given after the fourth birthday.
	Haemophilus influenzae type b conjugate vaccine (Hib): the Hib schedule shown is for the Haemophilus b capsular polysaccharide - polyribosylribitol phosphate (PRP) conjugated to tetanus toxoid (PRP-T). For catch up, the number of doses depends on the age at which the schedule is begun (see Haemophilus Vaccine chapter). Hib vaccine is not usually required past age 5 years.
	Measles, mumps and rubella vaccine (MMR): a second dose of MMR is recommended for children at least 1 month after the first dose for the purpose of better measles protection. For convenience, options include giving it with the next scheduled vaccination at 18 months of age or at school entry (4-6 years) (depending on the provincial/territorial policy) or at any intervening age that is practical. In the catch-up schedule (Table 2), the first dose should not be given until the child is ≥ 12 months old. MMR should be given to all susceptible adolescents and adults.
	Varicella vaccine (Var): children aged 12 months to 12 years should receive one dose of varicella vaccine. Susceptible individuals ≥ 13 years of age should receive two doses at least 28 days apart.
	Hepatitis B vaccine (HB): hepatitis B vaccine can be routinely given to infants or pre-adolescents, depending on the provincial/territorial policy. Where infant immunization for hepatitis B is undertaken, a combined DTaP-IPV-Hib-HB product may be used as an alternative to separately administered hepatitis B and DTaP-IPV-Hib vaccines. For infants born to chronic carrier mothers, the first dose should be given at birth (with hepatitis B immunoglobulin), otherwise the first dose can be given at 2 months of age to fit more conveniently with other routine infant immunization visits. The second dose should be administered at least 1 month after the first dose, and the third at least 2 months after the second dose, but these may fit more conveniently into the 4 and 6 month immunization visits. A two-dose schedule for adolescents is an option (see Hepatitis B Vaccine chapter).
	Pneumococcal conjugate vaccine - 7-valent (Pneu-C-7): recommended for all children under 2 years of age. The recommended schedule depends on the age of the child when vaccination is begun (see Pneumococcal Vaccine chapter). In jurisdictions with a routine three-dose schedule, infants should be evaluated at 6 months of age for high risk conditions before administration of the third dose and a decision made at that time as to whether the reduced-dose schedule would be appropriate.
	Pneumococcal polysaccharide - 23-valent (Pneu-P-23): recommended for all adults ≥ 65 years of age (see Pneumococcal Vaccine chapter).
	Meningococcal C conjugate vaccine (Men-C): recommended for children under 5 years of age, adolescents and young adults. The recommended  schedule depends on the age of the individual (see Meningococcal Vaccine chapter) and the conjugate vaccine used. If Men-C is given before 12 months of age, one additional dose in the second year of life (ideally between 12-18 months) is recommended. If given after 12 months of age, one dose in infancy / early childhood is sufficient. One additional dose is recommended in early adolescence even if meningococcal conjugate vaccine was received as part of a routine infant or 1-year old vaccination program. Either meningococcal C conjugate or quadrivalent meningococcal conjugate vaccine may be used.
	Diphtheria, tetanus, acellular pertussis vaccine - adult/adolescent formulation (Tdap): a combined adsorbed "adult type" preparation for use in people ≥ 7 years of age, contains less diphtheria toxoid and pertussis antigens than preparations given to younger children and is less likely to cause reactions in older people.
	Diphtheria, tetanus vaccine (Td): a combined adsorbed "adult type" preparation for use in people ≥ 7 years of age, contains less diphtheria toxoid antigen than preparations given to younger children and is less likely to cause reactions in older people. It is given to adults not immunized in childhood as the second and third doses of their primary series and subsequent booster doses; Tdap is given only once under these circumstances as it is assumed that previously unimmunized adults will have encountered Bordetella pertussis and have some pre-existing immunity.
	Human papillomavirus (HPV): HPV vaccine is recommended for routine use in females between 9 and13 years of age, before the onset of sexual intercourse. The recommended schedule is 3 doses at 0, 2 and 6 months, with a minimum interval of one month between the first two doses. HPV vaccine is also recommended for females between 14 and 26 years who would also benefi t from the vaccine.
	Influenza vaccine (Inf): recommended for all children 6-23 months of age and all persons ≥ 65 years of age. Previously unvaccinated children < 9 years of age require two doses of the current season's vaccine with an interval of at least 4 weeks. The second dose within the same season is not required if the child received one or more doses of Influenza vaccine during the previous Influenza season (see Influenza Vaccine chapter).
	IPV Inactivated polio virus

Source: Canadian Immunization Guide, Seventh Edition, 2006

Immunizations Recommended for Adults

Prevention of infection by immunization is a lifelong process. There are a number of vaccines that all adults (≥ 18 years) require. There are also other vaccines that need to be tailored to meet individual variations in risk resulting from occupation, foreign travel, underlying illness, lifestyle and age.

Immunizations recommended for adults - Routine

All adults should be immunized against diphtheria, tetanus, pertussis, measles, mumps, rubella and varicella. The schedule for adults who have no record or an unclear history of prior immunization as well as for booster dosing of those who have completed a prior primary series is shown in Table 5.

Table 5. Adult Immunization Schedule - Routinely for All

Vaccine	Dosing schedule (no record or unclear history of immunization)	Booster schedule (primary series completed)
Tetanus and diphtheria given as Td; and pertussis given as Tdap	Doses 1 and 2, 4-8 weeks apart and dose 3 at 6-12 months later; one of the doses should be given as Tdap for pertussis protection	Td every 10 years; 1 dose should be given as Tdap if not previously given in adulthood
Measles, mumps and rubella given as MMR	1 dose for adults born in or after 1970 without a history of measles or those individuals without evidence of immunity to rubella or mumps; second dose for selected groups	Not routinely required
Varicella	Doses 1 and 2, at least 4 weeks apart for susceptible adults (no history of natural disease or seronegativity)	Not currently recommended

All Canadian adults require maintenance of immunity to tetanus and diphtheria, preferably with combined (Td) toxoid and a single dose of acellular pertussis vaccine. The first priority is to ensure that children receive the recommended series of doses, including the school leaving dose at 14 to 16 years of age, and that adults have completed primary immunization with Td. Currently, only a single dose of acellular pertussis (given as Tdap) is recommended in adulthood because the duration of protection from Tdap has yet to be determined. For adults not previously immunized against pertussis only one dose of Tdap is required as it is assumed that most adults will have some degree of immunity due to prior pertussis infection.

Combined measles, mumps, rubella vaccine (MMR) is preferred for vaccination of individuals not previously immunized against one or more of these viruses. Adults born before 1970 may be considered immune to measles. Adults born in 1970 or later who do not have documentation of adequate measles immunization or who are known to be seronegative should receive MMR vaccine. One additional dose of vaccine should be offered only to adults born in 1970 or later who are at greatest risk of exposure and who have not already received two doses or demonstrated immunity to measles. These people include travellers to a measles-endemic area, health care workers, students in post-secondary educational settings and military recruits. MMR is recommended for all adults without a history of mumps or mumps immunization. MMR vaccine should also be given to all adults without a history of rubella vaccination. Female adolescents and women of childbearing age should be vaccinated before pregnancy or post-partum, unless they have documented evidence of detectable antibody or prior vaccination. In addition, it is also important that health care workers of either sex be actively immunized against rubella because they may, through frequent face-to-face contact, expose pregnant women to rubella.

A history of chickenpox infection is adequate evidence of varicella immunity. Serologic testing should be performed in adults without a history of disease, as the majority of such adults will be immune and do not require the varicella vaccine. It is particularly important to promote varicella immunization with immigrants and refugees from tropical countries, women of childbearing age, those who are at occupational risk of exposure, including health care and child care workers, household contacts of immunocompromised persons, those with cystic fibrosis, and those susceptible adults exposed to a case of varicella. There are no data at present to guide recommendations for varicella booster dosing in adults following the primary vaccination series.

Immunizations for adults - Specific Risk Groups

There are several specific groups of adults for whom certain vaccines are recommended because of the presence of risk factors for disease, and these are summarized in Table 6. In many cases, individual factors, and in particular the presence of underlying co-morbid illnesses, define groups that specifically benefit from certain vaccines. However, there are two commonly encountered groups of healthy adults who require assessment for a series of vaccines: health care workers and international travelers. In both of these groups, the priority should be to ensure that routinely recommended immunizations are completed and booster doses provided as indicated.

Table 6. Adult Immunization Schedule - Specific Risk Situations

Vaccine or toxoid	Indication	Schedule
Influenza	Adults ≥ 65 years; Adults < 65 years at high risk of Influenza-related complications, their household contacts, health care workers, and all those wishing to be protected against influenza.	Every autumn using current recommended vaccine formulation
Pneumococcal polysaccharide	Adults ≥ 65 years; Adults < 65 who have conditions putting them at increased risk of pneumococcal disease	1 dose
Hepatitis A	Occupational risk, life-style, travel and living in areas lacking adequate sanitation. Outbreak control, post-exposure immunoprophylaxis. Patients with chronic liver disease.	2 doses 6-12 months apart
Hepatitis B	Occupational risk, life-style, post-exposure immunoprophylaxis. Patients with chronic liver disease.	3 doses at 0, 1 and 6 months
Bacille Calmette- Guérin (BCG)	Rarely used. Consider for high-risk exposure in selected cases.	1 dose
Cholera	High-risk exposure in travelers to endemic area(s)	1 oral dose of live attenuated vaccine; 2 doses at least 1 week apart but not greater than 6 weeks of oral inactivated vaccine
Japanese encephalitis	Travel to endemic area(s) or other exposure risk	3 doses at days 0, 7 and 30
Poliomyelitis	Travel to endemic area(s) or other risk group	Primary series doses 1 and 2, 4-8 weeks apart and dose 3 at 6-12 months later; 1 booster dose if > 10 years since primary series
Meningococcal conjugate	Young adults	1 dose
Meningococcal polysaccharide	High-risk exposure groups	1 dose
Rabies, pre-exposure use	Occupational or high-risk travelers	3 doses at days 0, 7 and 21
Typhoid	High-risk travelers to endemic area(s) or other high-risk exposure	Parenteral capsular polysaccharide 1 dose; live attenuated 3-4 oral doses depending on preparation
Yellow fever	Travel to endemic area(s) or if required for foreign travel	1 dose with booster every 10 years if required
Smallpox	Laboratory staff working with vaccinia or other orthopoxviruses	1 dose

Health care workers, including hospital employees, other staff who work or study in hospitals (e.g., students in health care disciplines and contract workers), other health care personnel (e.g., those working in clinical laboratories, nursing homes and home care agencies) and child care workers, are at risk of exposure to communicable diseases because of their contact with patients or material from individuals with infections, both diagnosed and undiagnosed.

Hepatitis B is the most important vaccine-preventable infectious occupational disease for health care workers. The risk of being infected is a consequence of the prevalence of virus carriers in the population receiving care, the frequency of exposure to blood and other body fluids and the contagiousness of hepatitis B virus. Hepatitis B vaccine is recommended for health care workers and others who may be exposed to blood or blood products, or who may be at increased risk of sharps injury, bites or penetrating injuries (for example, clients and staff of institutions for the developmentally challenged). Annual Influenza immunization is recommended for all health care personnel who have contact with individuals in high-risk groups. Such personnel include physicians, nurses and others in both hospital and outpatient settings; employees of chronic care facilities; and providers of home care, visiting nurses and volunteers. Influenza immunization of health care workers has been shown to reduce the mortality and morbidity of patients under their care in long-term settings and to reduce worker illness and absenteeism during the Influenza season. Other vaccines may be indicated for certain workers at particularly high risk of exposure, such as laboratory workers in specialized reference or research facilities. These include but are not limited to typhoid, meningococcal, BCG, rabies, and smallpox vaccines. An individualized risk-benefit assessment is required.

International travelers represent another defined group requiring specific vaccine consideration. Ensuring that traveling adults have completed a primary series of routine vaccinations is the first priority (Table 6). This is particularly important because many vaccine-preventable diseases remain endemic in developing countries. Although completion of primary polio vaccination is adequate in most adults, a one-time polio booster (> 10 years since primary vaccination) is recommended for adults who have not had a previous booster and are traveling to polio-endemic countries. It is also important that travelers who are in specific risk groups for routine vaccines (such as pneumococcal and Influenza vaccines in those ≥ 65) receive the ones indicated. With travel-specific vaccines, an individualized approach is required that considers a patient's health status, risk of exposure and complications from vaccine-preventable illness, as well as location and duration of travel. Most commonly these include consideration for immunization against yellow fever, Japanese encephalitis, typhoid, cholera, meningococcal disease, rabies, and hepatitis A and B, as listed in Table 6.

Adults ≥ 65 years of age and those with conditions that increase their chances of complications should receive one dose of pneumococcal vaccine and yearly Influenza vaccine. Opportunities to increase Influenza vaccination should be taken; it is estimated that less than one-half of high-risk Canadians receive Influenza vaccine annually. Increasing the rate of Influenza vaccination of health care workers and household contacts of individuals with increased risk of Influenza complications will not only affect the vaccinated individuals but may also result in substantial secondary benefit to others.

Hepatitis A vaccination is recommended for those at increased risk of exposure (see the Canadian Immunization Guide, Seventh Edition, 2006, Hepatitis A Vaccine chapter). Universal immunization against hepatitis B is recommended in childhood in Canada, and opportunities should be provided for adults to receive hepatitis B vaccine. Adults who are at increased risk of exposure to hepatitis B by virtue of their occupation, lifestyle or environment should receive the vaccine at the earliest possible clinical encounter. Patients may be vaccinated simultaneously for hepatitis A and B using a combined vaccine. Because of their increased risk for complications, all non-immune patients with chronic liver disease should be vaccinated against hepatitis A and B.

Cholera vaccine should be considered for high-risk travelers to choleraendemic countries (please refer to the Canadian Immunization Guide, Seventh Edition, 2006, Immunization of Travellers chapter).

Meningococcal C conjugate vaccines are recommended for immunization of young adults to prevent the increased risk of serogroup C meningococcal disease in these age groups. Meningococcal vaccine is recommended for certain groups with increased risk of meningococcal disease (please refer to the Canadian Immunization Guide, Seventh Edition, 2006, Meningococcal Vaccine chapter). Such individuals include those with functional or anatomic asplenia; persons with complement, properdin or factor D deficiency; military recruits; research, industrial and clinical laboratory personnel who are routinely exposed to Neisseria meningitidis cultures; and travelers to high-risk areas. In cases in which risk is restricted to group C disease, monovalent serogroup C meningococcal conjugate vaccine may be preferred. Meningococcal vaccine is also used for outbreak management.

Although oral poliovirus vaccine is no longer used in Canada, individuals who have received a primary vaccination series with this vaccine are considered immune. Immunization of adults against poliovirus should be considered for those at increased risk (see the Canadian Immunization Guide, Seventh Edition, 2006, Poliomyelitis Vaccine chapter).

Rabies vaccine should be offered, before exposure, to those individuals at high risk as a result of occupational or travel exposure to rabid animals. These may include veterinarians, laboratory workers, animal control and wildlife workers, spelunkers, trappers and hunters, and travelers to endemic countries where there may be limited access to safe and effective post-exposure prophylaxis.

Typhoid vaccine is recommended for high-risk international travelers, including those with prolonged (> 4 weeks) exposure in an endemic region or those with shorter duration of stay in particularly high-risk situations (please refer to the Canadian Immunization Guide, Seventh Edition, 2006, Typhoid Vaccine chapter). Although routine vaccination of health care workers is not required, laboratory workers who frequently handle live cultures of Salmonella typhi should be vaccinated.

Naturally occurring smallpox has been eradicated worldwide, and as a result vaccination is highly restricted. Laboratory workers who handle vaccinia or other orthopoxviruses should be considered for vaccination.

Source: Canadian Immunization Guide, Seventh Edition, 2006

Travellers