Immunisation schedule for school children

At school age comes the one decision about vaccination that has a direct bearing on gynaecology: the HPV vaccination. It is given from the age of nine, protects against around ninety per cent of cervical cancers – and in Austria is not taken up by a considerable proportion of families. This page places it within the rest of the school programme.

What is due at school age

A considerable part of this takes place in Austria as school vaccination, organised by the school medical service. What is not covered there or has been missed can be caught up with the paediatrician, the GP or at a public vaccination centre.

Compared with the first year of life, school age is quiet as far as vaccination goes: few appointments, no basic courses but boosters and catching up – with one exception, the HPV vaccination, which begins here anew and for which there is no equivalent later point in time.

The HPV vaccination

It is the reason why this page is on a gynaecological website.

Human papillomaviruses are transmitted through skin and mucous membrane contact. About eight in ten sexually active people become infected at least once in their lives; the great majority of infections clear up by themselves. If a high-risk type persists over years, cervical cancer can develop from it over ten to fifteen years.

Practically every cervical cancer goes back to such an infection. That is unusual: with hardly any other cancer can a single necessary cause be named so clearly – and precisely for that reason this cancer is the only one that can largely be prevented with a vaccination.

The nine-valent vaccine used in Austria covers the types responsible for around ninety per cent of cervical cancers, plus the causes of genital warts. This is set out in detail on the page HPV – human papillomaviruses.

Why so early

The vaccination works best before first sexual intercourse, because no encounter with the types it contains has taken place by then. It is therefore recommended from the completed ninth year of life.

There is a second reason, which is less well known: the immune response is stronger at this age than later. That is why two doses six to twelve months apart are enough up to the 15th birthday, while from 15 three doses are provided for.

How effective it is can now be read off counted cases and not merely off models. A Swedish study of more than 1.6 million women showed that with vaccination before the age of 17 the frequency of invasive cervical cancer fell by around 88 per cent.

The early timing is the point at which the conversation regularly sticks. Parents of a nine-year-old find it inappropriate to talk about a sexually transmitted infection. The answer to that is simple and is rarely put this way: it is not about sexuality but about a point in time at which a vaccination still works completely. You do not fasten a seat belt because you are expecting a crash either.

Why boys are vaccinated too

In Austria the HPV vaccination is in the free programme for girls and boys alike – and not only in order to protect girls.

HPV also causes cancers of the penis, the anus and the throat. The number of HPV-related throat cancers in men has been rising for years; in some countries it has now overtaken the number of cervical cancers. The benefit for those vaccinated themselves is thus direct.

On top of this comes the effect on spread. If only half an age group is vaccinated, the viruses keep circulating; if the whole age group is vaccinated, the frequency falls for everyone – for the unvaccinated as well. In Australia, which vaccinated early and widely, infections with the covered types have fallen dramatically.

The booster against diphtheria, tetanus, whooping cough and polio

Between the seventh and ninth year of life a booster is due, usually as a four-in-one vaccine. It follows on from the six-in-one vaccination of the first year of life; hepatitis B and Haemophilus influenzae b are no longer included, because no further booster is needed for them.

The whooping cough component is the most important. Protection after the basic course lasts only a few years, and school children are one of the commonest sources of infection for infants in the household. Anyone expecting a baby who has a school-age child should keep an eye on that child's booster – see whooping cough.

After that a further booster is provided for in adolescence, and in adulthood every ten years, and from 60 every five.

Meningococci ACWY

Between the tenth and thirteenth year of life vaccination is given against meningococci of groups A, C, W and Y, a single dose. The timing is deliberate: the second peak of the illness lies between fifteen and twenty-four years.

Adolescents and young adults carry the organism in the throat more often and pass it on more often – close contact, shared drinks, halls of residence, sports teams. Vaccination at school age puts protection in place just before that.

The vaccination against meningococci B is a different one and is given as early as infancy; see meningococcal disease and Bexsero.

What is caught up

School age is the last occasion on which anybody systematically looks at the vaccination record before it stops happening for years. That is why what is missing is checked at the same time.

Measles-mumps-rubella: two doses count as complete protection. If only one is in the record, the second is caught up – at any age and free of charge. For girls this is the point at which a pregnancy can later be planned without stress: the MMR vaccination is a live vaccine and is not possible in pregnancy. See rubella and measles.

Chickenpox: for the same reason. Anyone who has not had the illness and is not vaccinated should catch it up at school age.

Hepatitis B: if the basic course did not take place in infancy.

Tick-borne encephalitis: important in Austria because of how widespread it is. The basic course consists of three doses, after which boosters follow according to the relevant schedule.

How safe the HPV vaccination is

Because this vaccination is discussed more than any other in the school programme, the safety data belong here.

Well over 500 million doses have been given worldwide. The commonest side effects are local and brief: pain, redness and swelling at the injection site, less often headache, tiredness or slight fever for one to two days.

Two claims persist stubbornly and both have been investigated. A connection with chronic fatigue syndrome or with autoimmune disease could not be found in large registry studies covering millions of vaccinated girls – the frequency of illness was the same in the vaccinated and the unvaccinated. And an influence on later fertility is neither biologically plausible nor discernible in the data; if anything the opposite applies, because a conisation avoided preserves the function of the cervix.

What does occur are circulatory reactions in adolescents immediately after the vaccination – dizziness up to a brief faint. That is not a reaction to the vaccine but to the situation, and the reason why people stay seated for a quarter of an hour after the vaccination. At a school vaccination session, where many adolescents are vaccinated together, it occurs more frequently, because it can spread.

The vaccination rate in Austria is markedly below that of countries where the fall in cancers is already measurable. That is not a medical problem but an organisational one: the vaccination is free of charge, it is effective, and it is nevertheless often not taken up.

Who decides at school age

Up to the fourteenth birthday those with custody give consent; for a routine vaccination the consent of one parent is enough. If the parents disagree, the vaccination is not given.

From the age of fourteen a person in Austria counts as capable of deciding in medical matters, provided they understand what is at stake – and can then consent to a vaccination or refuse it themselves, even against their parents' wishes.

In practice this matters above all with the HPV vaccination. A fourteen-year-old who missed it in the school programme can have it caught up herself. In practice the conversation is nevertheless usually held together, because a decision that is supported at home is the better one. More on the legal framework is on the page vaccination information sheet.

What adolescents should know themselves

This page is addressed to parents, but part of it belongs said to adolescents themselves – and in their own words, not those of a form.

The HPV vaccination is not a statement about you. It is given to everyone because it works best before you come into contact with the virus. It is not an assumption about when or whether someone has sex.

It hurts briefly and then not any more. The arm is tender for one to two days; for most people nothing more happens. If injections make you dizzy, say so beforehand – then the vaccination is given lying down. That is common and no reason to feel awkward.

You are entitled to have a say. From fourteen you decide in medical matters yourself if you understand what is involved. Before that too your opinion belongs in the conversation, and you may ask as often as you like.

An appointment with a gynaecologist is first of all a conversation. What is examined is what has been discussed and understood – no more. You can bring someone with you or come alone, and you can say at any time that you want something to stop.

The first appointment at a gynaecological practice

For girls the first gynaecological appointment of their own often falls in this age range – sometimes because of the HPV vaccination, sometimes because of the first period, because of questions about the cycle or later because of contraception.

Such an appointment does not have to include an examination. It can be a conversation, and what is examined is decided by the patient. Anyone who only wants to talk can do so; anyone who wants someone with them brings them along; anyone who wants to speak alone can do that too.

It is also the appointment at which the vaccination record can be gone through. Between the last school vaccination and the next opportunity there are otherwise often ten years and more – and it is precisely in this time that the deadlines fall which count later: the HPV vaccination in the free programme up to the 21st birthday, rubella and measles protection before a pregnancy, the tetanus booster.

How a school vaccination session works

In Austria some of these vaccinations are carried out through the school medical service. The process is similar everywhere and is rarely explained.

Before the session parents are sent an information sheet and a consent form. Without a signed form no vaccination is given – the commonest reason for a missed school vaccination is a form that has not come back.

On the day, brief questions are asked about acute illness, allergies and earlier reactions. Anyone with a fever that day is not vaccinated and is given a replacement appointment – or has to catch the vaccination up outside school.

After the vaccination the adolescents stay for a quarter of an hour. That is particularly important with school vaccinations, because circulatory reactions occur more frequently in a group.

The vaccination is entered in the vaccination record. Send it along with your child – without it the vaccination is given, but the entry is then missing where somebody will look later. Adding it afterwards is possible and tiresome.

Important for parents: a school vaccination does not replace the informing conversation. If you have questions that are not answered on the information sheet, clarify them beforehand – with the school doctor, the paediatrician or at this practice where HPV is concerned.

If the school vaccination was missed

That happens often – because of illness on the day, because of a form that was not returned, because of a change of school.

Catching up is possible with all the vaccinations named here. A series that has been started is continued and not begun again, no matter how much time has passed. With the HPV vaccination it is worth bearing in mind that from the 15th birthday three doses are needed instead of two – one reason not to put it off too long.

The HPV vaccination remains free of charge in Austria up to the completed 21st year of life. It stays recommended up to the completed 30th year, self-funded from 21 on – and possible beyond that as well, if it is wanted. The terms of this programme have been extended and prolonged several times; the current position can be told to you by the public vaccination centre or by this practice.

The transition into adulthood

After the last school vaccination the care that reminds you of appointments by itself comes to an end. What comes after that depends on somebody thinking of it – and that is exactly where the gaps arise that come to light later in preconception advice.

Three things continue and are regularly overlooked. The tetanus and diphtheria booster is due every ten years, usually together with whooping cough; the commonest answer to the question about the last vaccination is “some time after a cut”. The tick-borne encephalitis booster follows a schedule of its own and is often not continued after moving out of the parental home. And the HPV vaccination remains free of charge up to the 21st birthday – a deadline that expires without anyone giving a reminder. It stays recommended up to 30, though at your own expense from 21 on.

For young women the gynaecological appointment is the obvious opportunity to catch this. It takes place anyway, usually yearly, and it falls in exactly the age range in which these deadlines converge.

For completeness, that includes what has to be dealt with before a pregnancy and cannot be caught up afterwards: the live vaccines against measles, mumps, rubella and chickenpox. Two doses at least four weeks apart, then a month's interval before a pregnancy – around two months in all. That is little if you plan for it and annoying if it occurs to you when the test is positive.

What happens next

For advice about the HPV vaccination, for a check of the vaccination record or for a first gynaecological appointment: arranging an appointment. Bring the vaccination record with you – it is the opportunity to settle in one appointment what otherwise stays open for years. What else is provided for at what age is shown by the screening planner; the vaccinations of the first years of life are on the page immunisation schedule for infants and small children.