Friday, 16 August 2013

Look East - Japan

We are often reminded to "Look East". Today I will discuss Japan's vaccination schedule and compare it with our Malaysian schedule.

Japan's schedule is often applauded for being flexible and non-aggressive compared to other countries. Babies in Japan start vaccines at 3 months old, unlike Malaysian newborns who start on Day 1 or Day 2 of life.

Japan Vaccination Schedule 2012
Table 1: Japan Vaccination Schedule 2012
Source: http://www.nih.go.jp/niid/images/vaccine/schedule/2012/ImmEN121101.pdf

Japan Schedule Example for Standard Vaccination
  • 3 months (between 3 months to 7.5 years)
    • DPT+IPV - 1st dose
  • 4 months (between 4-6 months)
    • BCG - 1st dose
  • 6 months
    • DPT+IPV - 2nd dose
  • 18 months
    • DPT+IPV - 3rd dose
  • 1 year old (between 1-2 years)
    • Measles+Rubella - 1st dose (available as single antigen vaccine)
  • 3 years old (between 3-7.5 years)
    • Japanese Encephalitis  – 1st & 2nd dose (at interval of 1-4 weeks)
  • 4 years old
    • Japanese Encephalitis  – 3rd dose
  • 6 years old
    • Measles+Rubella - 2nd dose
  • 9 years old
    • Japanese Encephalitis  – 4th dose
  • 11 years old (between 11-13 years)
    • Diptheria+Tetanus - 1st dose
  • 13 years old (between 13-14 years)
    • Measles+Rubella - 3rd dose
  • 18 years old (between 18-19 years)
    • Measles+Rubella - 4th dose

I will highlight the key differences:

A newborn in Malaysia receives BCG and Hepatitis B (1st dose) on Day 1 or 2. This is followed at 1 month old with Hepatitis B (2nd dose) and 2 months old with DTaP + IPV + Hib (1st dose). Japan's schedule does not even include the Hepatitis B vaccine due to the baby's relatively low risk of Hepatitis B infection. Hepatitis B is transmitted by blood and bodily fluids, from mother to baby during delivery, contaminated blood transfusions and is mainly considered to be a sexually transmitted disease. Oh yes, it could also be due to the Hepatitis B lawsuit. A delayed schedule also allows time for the baby to develop his/her immune system. From birth till about 4-6 months of age, babies often possess what is called an "open gut". Colustrum from breastmilk repairs damaged tissue and seals the mucus layer of the intestines, making it impermeable to toxins and parasites. The immune response is enhanced and the first line of defense in the bowel is brought back to normal function. As the intestinal lining is healed, food allergies are reduced and often disappear entirely. It is estimated that 80% of our body's immune system is in the guts and antibiotics from vaccines are known to disrupt the gut flora. Hence the importance of exclusive breastfeeding during the first few months.

Why is DTP scheduled at 3 months (Japan) instead of 2 months (Malaysia). Perhaps because it was linked to infant deaths.

In addition, the Haemophilus Influenzae type B (Hib) is also not in the Japan standard schedule perhaps because it was linked to infant deaths. Lately I've also been hearing about a campaign to have pneumococcal vaccine included into the government schedule. Let's Look East again - why would an advanced country such as Japan NOT include pneumococcal vaccine in its standard schedule. Well, it was suspended due to infant deaths.

In fact, the MMR (mumps, measles, rubella) combined vaccine was banned from Japan due to the adverse reactions and infant deaths. Japan has a system to collect vaccine incident reports and pay compensation to victims of vaccine injury. In Malaysia, there is a little-known system to file reports for adverse reactions to vaccines called the Garis Panduan Farmakovigilans. However I have not heard of any allocation for compensation to vaccine injury victims in Malaysia.

And now the latest HPV incident whereby Japan has withdrawn its recommendation for the HPV vaccine. By the way, HPV is on the Malaysian schedule since year 2010 and is administered to 13 year old girls.

From Table 1, there is a whole timeframe allowed for delayed vaccination and they also provide parents with guidelines prior to vaccination and a checklist. This is a vast difference from my experience at the Malaysian government clinic (Klinik Kanak-kanak Ibu & Anak, KKIA) whereby I was informed there might be mild fever, some swelling or soreness at the injection site and handed a bottle of paracetamol. Oh yes, and also scolded if I brought my baby 1 or 2 weeks later than scheduled and receive the sarcastic comment that I might be "too busy with my work" to look after my child properly.

Here's a look at what parents in Japan receive prior to vaccinating their child, from Tokyo Urban Baby blog.

Information about BCG includes post-vaccination cautions such as how to clean the injection site, possibility of lymph nodes swelling. They also include information about compensation for relevant injury due to vaccination which is continually paid until the completion of treatment or improvement from injury. Wow, that is a caring government! My experience from the Malaysian counterpart is usually dismissal, where got lah? Its so rare, nothing to do with vaccines lah, or its just colic (for persistent crying or screaming more than 3 hours - actually its a sign of brain inflammation).

They even take a medical health history that asks about immune deficiency, rashes, reactions to past vaccines and even include family members who might have a serious reaction to vaccines. They are taking into consideration family medical background and history in ascertaining the risks and benefits for vaccinating a child. Most importantly, they even ask for consent from the parents/guardians after giving benefits and side effects information. Well done Japan National Institute of Health Sciences!

I often hear the words, the benefits outweigh the risks, or I'm a kiasu parent and want to make sure my child receives as much protection as possible, or my child seems alright after vaccination. We need to consider the long-term price that needs to be paid for limited vaccine efficacy (the efficacy ranges based on each individual's immune response to the vaccine) for a selected few strains of viruses or bacteria in the vaccine and waning immunity from vaccines..

P/s: Vaccination is not mandatory in Japan. Vaccination is not mandatory in Malaysia. "The schedule is compulsory although it is not strictly enforced or enforceable policy." Source. And yes, you can still register for government school in Malaysia without vaccinations.

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