Infants should not skip vaccinations for infectious diseases during circuit breaker, doctors say

SINGAPORE — With the number of Covid-19 cases here still not showing signs of abating, Ms Rynette Tan, 30, toyed with the idea of delaying her two-month-old’s vaccination shots for diseases such as hepatitis B and rotavirus infection during the circuit breaker period.

Ms Tan did not think it would be a good idea to take her baby to the polyclinic during this time of restricted movement of people and reduced business activity to slow the spread of the coronavirus.

“I was worried about exposing my baby to people who may be unwell at the polyclinic.”

Ms Tan is the managing director of babywearing consultancy and business 13Thirteen. Babywearing is the practice of wearing or carrying a baby in a sling or carrier. Despite her initial concerns, Ms Tan has now decided to go ahead with the scheduled appointment next week.

She realised that there are certain timelines for specific vaccines that she wants her baby to take. For example, the rotavirus vaccination is given only to very young babies. The first dose of the rotavirus vaccine is typically given at around two months of age or before a child is 15 weeks old.

Rotavirus can cause severe watery diarrhoea, vomiting, fever and abdominal pain. Babies and young children who get rotavirus infection can become dehydrated very easily and require hospitalisation.

Even with regulations tightening during the circuit breaker period that will last until June 1, doctors and paediatricians are urging parents to adhere to the national childhood immunisation schedule and not delay their babies’ vaccination shots.

This is in line with the World Health Organization’s guidelines for countries to prioritise routine immunisation of children in essential service during the Covid-19 pandemic.

Under the revised list of essential services announced by the Government on Tuesday, childhood vaccinations remain essential and should continue as scheduled.

Most of the vaccinations in the recommended National Childhood Immunisation Schedule are given from the time the infant is born to 18 months of age. 

However, some parents here have chosen to defer their children’s routine shots, prompting doctors to warn that such delays could have grave repercussions.

Dr Alison Joanne Lee, a paediatrician in private practice at SBCC Baby and Child Clinic, a member of Healthway Medical Group, observed that a third of the patients at the group’s clinics have delayed their routine childhood vaccinations during the circuit breaker.

“Many families are now choosing to stay away from clinics so attendances have dropped in the private and government sector,” she said.

WHY CHILDREN SHOULD NOT SKIP VACCINATIONS

Doctors interviewed by TODAY said that the risks of children acquiring dangerous infections such as measles and whooping cough is serious even during the Covid-19 pandemic.

Dr Chan Poh Chong from the National University Hospital (NUH), who is head and senior consultant at the division of general ambulatory paediatrics and adolescent medicine, said that appointment phone lines for essential medical and health visits, including childhood vaccinations, are still open at NUH during the circuit breaker period and parents can call in to make an appointment.

“The risk of babies and young children infected with vaccine-preventable infections like measles, whooping cough and pneumococcal disease is still present in spite of the Covid-19 pandemic. We do not want to see young children sickened by these conditions as a result of delaying their vaccinations,” Dr Chan said.

Pneumococcal disease, for instance, is a type of bacterial infection that can attack different parts of the body and cause serious infection of the lungs, brain, middle ear, membrane or lining of the brain and spinal cord.

Services at the Children's Walk-In Clinic at KK Women’s and Children’s Hospital (KKH) have been temporarily suspended after disease risk was raised to Dorscon Orange level. However, Associate Professor Thoon Koh Cheng, head and senior consultant of infectious disease service at the hospital’s department of paediatrics, said that paediatric patients without scheduled appointments at KKH can continue to receive their vaccinations in polyclinics, general practitioner clinics and paediatric clinics.

Consultant paediatrician Liew Woei Kang said that the vaccines available to children protect them against important infectious diseases. These diseases have a severity that could be worse than Covid-19.

Dr Liew practises at the Paediatric Allergy Immunology Rheumatology Centre in Mount Elizabeth Novena Specialist Centre.

He pointed out that Singapore saw one of the largest increase of measles infections last year in tandem with a global increase. He warned that a resurgence of vaccine-preventable infectious diseases is “very likely” if immunisations are delayed.

Measles, for instance, is highly contagious and can lead to severe respiratory or neurological complications. It can be prevented through two doses of the MMR (mumps, measles, rubella) vaccine that is given to children between 12 and 18 months old.

Dr Lee of SBCC Baby and Child Clinic said: “It can take about four to six weeks to attain peak immunity after vaccination, so even during this period of social isolation, routine childhood immunisations should not be delayed.”

Dr Liew said that another reason to adhere to the vaccination schedule is this: “Immunisation visits are frequently combined with a developmental assessment, growth and health check on the baby. This helps identify other medical illnesses that need to be dealt with.”

WHAT ARE THE VITAL VACCINATIONS?

Children are encouraged to get vaccinated based on the immunisation schedule (www.nir.hpb.gov.sg) by the Ministry of Health and the type of vaccinations vary according to age.

In Singapore, vaccination against measles and diphtheria are compulsory under the Infectious Diseases Act.

Vaccinations reduce the risk of death and lifelong complications, Dr Lee said.

Apart from the compulsory vaccinations, Dr Lee said that important vaccines for young children in Singapore are:

• From 0 to 6 months: Vaccines for hepatitis B and pneumococcal, and the combined “five-in-one” or six-in-one” vaccines that protect against whooping cough (pertussis), polio, tetanus, diphtheria and haemophilus influenza B.

• From 12 to 18 months: Vaccine for MMR (measles, mumps and rubella), pneumococcal booster and five-in-one booster vaccines.

• Optional but recommended vaccines include those for hepatitis A, rotavirus, chickenpox, influenza and meningococcal disease, which is any illness caused by a bacteria known as meningococcus that can include infections of the lining of the brain and spinal cord (meningitis) and bloodstream infections.

• Some of the optional vaccines can be given together with a routine vaccine during the circuit breaker period. For example, chickenpox vaccine can be optionally given as a combined vaccine with MMR.

• Influenza vaccine is important for children with chronic disease such as asthma and neurological conditions such as cerebral palsy. Parents should seek their doctor’s advice on whether to schedule a flu jab for their child.

Dr Chan of NUH said that optional vaccines such as those for influenza are still recommended for young and at-risk children during the circuit breaker period when they go for their routine vaccinations as well as health and developmental assessments from birth to 18 months.

Dr Chan said that parents should discuss the risk and benefits of getting the optional vaccines with their healthcare providers.

“By being immunised against these diseases, babies and children would at least be protected from these common illnesses and not develop symptoms that are mistaken for Covid-19 infection.

“Although most children are not at infant care or childcare centres or nurseries at this time, there is still a risk of infection, especially with older siblings and family members all staying at home,” he said.

WHY ARE BOOSTER SHOTS JUST AS IMPORTANT?

For booster shots, it is also advisable to adhere to the schedule.

Dr Liew said that most vaccines consist of primary doses, followed by booster doses, which are based on large-scale vaccine studies and recommendations.

“These schedules are important so that the immune system is appropriately ‘trained’ to remember the infectious disease the vaccine is meant to protect,” he explained.

WHAT IF YOUR CHILD MISSES CERTAIN SHOTS?

If parents miss a routine vaccination for their child, the doctors said that they should get it done. Children who missed a vaccination dose can pick up from where they left off, Dr Lee said.

Dr Liew said that some vaccinations can be delayed by a few weeks or when the child is ill. Parents should discuss with their vaccine provider in situations like that.

He said: “Some flexibility is accorded to parents who tell me they prefer to split up the vaccines, hence reducing fever risk (one of the possible post-vaccination side effect), or if they prefer to reduce visits but have two to three vaccinations done each visit.”

He added that combination vaccines can also reduce the total number of shots and visits babies need. For instance, the six-in-one vaccine (either GSK Infanrix Hexa or Sanofi Hexaxim) is equivalent to the five-in-one vaccine of diphteria, pertussis, tetanus, poliovirus, Haemophilus influenzae type b (Hib), and the hepatitis B vaccine.

Associate Prof Thoon of KKH said it is important to note that there is no need to re-vaccinate the child for those vaccinations that he or she had already received.

“The vaccination schedule can proceed from the point where it was interrupted as long as the minimum interval period between vaccine doses continues to be observed,” he said.

WHAT SAFETY PRECAUTIONS ARE IN PLACE?

Regulations state that only one parent can accompany their child for medical appointments at public healthcare institutions. Other precautionary measures include declaring symptoms and travel history.

Private clinics also have safety measures in place. For example, some precautions that Dr Liew has taken at his clinic include increasing the time intervals between each patient and deferring reviews for patients with stable chronic illnesses.

He also schedules different sessions for sick or feverish patients to not clash with babies due for their vaccinations. For example, feverish patients may be asked to go to the clinic in the late morning or afternoon after babies are cleared for their vaccinations.

“This is a good time to catch up on immunisations because most clinics are less crowded,” Dr Liew added.

Ms Tan, who has changed her mind about skipping her child’s vaccinations, called up a polyclinic in advance.

She said: “The nurse was reassuring. She mentioned taking the first appointment of the day or after lunch so that I can be in and out of the polyclinic fast.

“She also told me how everyone is screened at the second level of the polyclinic (at Punggol polyclinic) and if there’s someone showing signs of Covid-19, they will be filtered to another area immediately. It is reassuring because there are well-thought-out systems in place.”

The downside, however, is that only one parent can accompany their baby, she said.

“I can manage on my own now but it is easier when my husband is around, for instance, while changing diapers and helping me to get things from the diaper bag,” Ms Tan said.

Dr Chan of NUH said that parents should continue to practise safe distancing and good hand hygiene during clinic visits, and return home as soon as possible after their appointment.