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

The WHO Regional Office for Europe organises meetings on immunisationprogrammes for national experts from all countries of the European Union (EU) and data on the 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 keep this information up to date since immunisation policies are often adapted inresponse to epidemiological changes and the development of new vaccines.Furthermore, policies may vary between regions within the same country.Belgium, Denmark, Italy, and Spain have decided not to use or to discontinueBCG immunisation. Other countries immunise children at high risk only: neonatesin Austria, Germany, and Luxemburg, or at 6 months of age in the Netherlandsand Sweden. Some countries immunise children at a particular age: at birth inFinland, Ireland, and Portugal, at 6 years in France and Greece, and at 12 years in the United Kingdom. France and the United Kingdom immunise high riskchildren at birth.

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

Diphtheria, Tetanus, Pertussis (DPT), and Poliomyelitis

Although diphtheria, tetanus, pertussis and polio immunisations are generally combined in young children, vaccination schedules vary so much that it isclearer to present them individually.

Diphtheria

All the countries of the European Union give at least three doses of diphtheriavaccine during the first two years of life. France, Greece, Ireland, Luxemburg,Portugal, and the United Kingdom start at 2 months; Austria, Belgium, Finland,Germany, Italy, the Netherlands, Spain, and Sweden at 3 months; and Denmark at 5 months. Consecutive injections are usually separated by one or two months,but there are nine months between the second and third doses in Denmark.Booster doses are given in most countries one year after the third injection,then approximately every 5 years. Childhood immunisation stops at the age of 6years in Belgium, Ireland, Italy, and Portugal, 10 years in the Netherlands and Sweden, 15 years in Austria, Greece, and Luxemburg, 15 to 19 years in the United Kingdom, and 18 to 20 years in France. Only Austria, Finland and Germany systematically maintain adult immunity with tetanus toxoid and a low dose ofdiphtheria vaccine (th) every 10 years. the recent epidemic of diphtheria in the former Soviet Union led WHO to recommend systematic immunisation of travellers to these states.

Tetanus

Tetanus and diphtheria vaccinations are always given in combination to youngchildren. Primary immunisation of children consists of four doses of tetanusantitoxin in their first 2 years in Austria, Belgium, Finland, France, Germany,Greece, Italy, Luxemburg, the Netherlands, Portugal, and Spain, but only threedoses in Denmark, Ireland, Sweden, and the United Kingdom. Children in the United Kingdom receive a fourth dose at school entry. A booster dose is givenat the age of 15 to 16 years. Boosters of tetanus vaccine in adults are givenmore systemically than for diphtheria: in addition to Austria, Finland andGermany, they are recommended every 10 years in the French, Greek and Portuguese programmes.

Pertussis

Denmark, Ireland, Spain, and the United Kingdom give three doses of pertussisvaccine in the first year of life. Austria, Belgium, Finland, France, Germany,Greece, Luxemburg and the Netherlands recommend four doses; three in the firstand one in the second year. Italy and Portugal recommend 5 doses: 3 in the first year, one in the second year, and a booster in the sixth year. Swedendoes not immunise against pertussis, but immunisation policies may change inthe 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 than a whole cell vaccine.

Poliomyelitis

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

Measles, Mumps, and Rubella (MMR)

All countries in the European Union have introduced MMR immunisation in the second year in their child immunisation schedules. Belgium, France, Italy,Luxemburg, and the United Kingdom currently recommend only one dose. In 1994 analysis of surveillance data, including mathematical modelling, in the UnitedKingdom led the Department of Health to conduct a national campaign ofvaccination against measles and rubella for children aged 5 to 16 years of age to prevent a measles epidemic predicted for 1995 and 1996. Most of the othercountries in Europe recommend two doses of combined MMR vaccine. the second dose is given at the age of 6 in Austria, Finland and Germany and between 9 and 10 in Denmark, Greece, Ireland, the Netherlands, Portugal, Spain, and Sweden. Among the countries that have not yet included a second dose of MMR vaccine,three recommend immunisation against rubella for girls aged 12 to 13 and, in France, 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 other European countries followed as soon as the conjugate PRP-Tbecame available. In Austria, Denmark, Finland, Germany, Ireland, Luxemburg,Sweden, and the United Kingdom three doses are given, the first between 2 and 5 months and the third between 4 and 18 months. In Belgium, France, and theNetherlands four doses are given starting at 2 or 3 months. the first 3 dose sare each separated by a month, and, the fourth is given at 11, 13, or 15months. Greece, Italy, Portugal, and Spain have not introduced routine immunisation against Hib.

Hepatitis B virus (HBV)

Most countries in the European Union immunise health care workers and "highrisk" groups. Austria, Finland, France, Italy, Greece, Netherlands and the United Kingdom also immunise children born of HBsAg positive mothers. Italy and France now immunise all infants and cohorts of children aged 10 to 12 years for 12 years in order to quickly increase the protection in young people. In Spain, some autonomous communities have chosen to immunise infants and others have chosen to immunise children aged 10 to 12 years. Ireland and Sweden have no systematic immunisation policy against hepatitis B.

Conclusion

All countries in the EU share the same aims for the control, elimination, oreradication of vaccine preventable diseases, as defined by WHO. Important variations exist in strategies for child immunisation and programmes set up to achieve these aims. All countries aim to immunise all children against hiphtheria, tetanus, poliomyelitis, measles, rubella, and mumps by the age of 2 years. On the other 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 health caresystems, established immunisation practices, and the results of national surveys than on real differences in the epidemiology of infectious diseases. Harmonisation of immunisation policies within the EU could be considered while maintaining some flexibility in schedules. It is difficult to compare theeffectiveness of immunisation programmes, particularly their impact on themorbidity and mortality of the target diseases, due to variations in the epidemiological surveillance of infectious diseases between countries in the Europe Union. One of the goals of collaborative projects currently underdevelopment is to streng then and harmonise surveillance activities.

Calendriers vaccinaux dans l'Union Européenne - Août 1995

w = week / m = month / y = year

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

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