2 doses at 3 months and 5 months of age.  Followed by a booster dose between the ages of 12 to 24 months.

Babies less than 12 months old (but who have missed the primary schedule)

2 doses at least 4 weeks apart.  The 3rd (booster) dose at least 8 weeks after the 2nd dose.

Children more than 12 months old to 6 years old

One single dose is needed.  With the exception that children with asplenia, splenic dysfunction or who are immunocompromised should receive 2 doses of the Pneumococcal vaccine with a interval of 8 weeks between the 2 doses.

The influenza vaccines are designed to be effective for a particular winter season i.e. December 2009 to March 2010 for the coming Northern Hemisphere winter (exact dates as calculated by wolframalpha).  The next Southern Hemisphere winter will be from June to September 2010 (exact dates as calculated by wolframalpha).

Therefore, when we decide to be protected for the upcoming winter season lasting from Dec 09 to Mar 2010 i.e. the Northern Hemisphere winter, we just need to pop down to our nearest friendly family doctor for the shot.  In general, the Clinic will stock the influenza vaccine for the upcoming winter season.

But if I am travelling to Australia which is in the Southern Hemisphere, does it mean I should get the Southern Hemisphere vaccine?  The simple answer is ‘No’.  The reason is that the current upcoming winter is in the Northern Hemisphere.  Therefore, the strains of influenza virii prevalent in Australia would be the same as that in the Northern Hemisphere countries.  For this, we should probably thank the advent of wide-spread and economical air travel.

To generalise, no matter where you are (or are going to travel to) in the world, get the Southern Hemisphere vaccine in the first half of the year.  For the second half of the year, you should get the Northern Hemisphere injection.

People who should get their flu shots

A/Brisbane/59/2007 (H1N1)-like virus

A/Brisbane/10/2007 (H3N2)-like virus

B/Brisbane/60/2008-like virus

This NH 2009 vaccine does not contain the H1N1 pandemic strain.  Thus the need to take both the NH 2009 as well as the H1N1 vaccines.

2.  The Southern Hemisphere (SH) 2010 winter season influenza vaccine contains the following strains*:

A/California/7/2009 (H1N1)-like virus (the pandemic strain)

A/Perth/16/2009 (H3N2)-like virus

B/Brisbane/60/2008-like virus

The recommended H3N2 strain for SH 2010 vaccine (A/Perth/16/2009) is antigenically different from that in the NH 2009 vaccine (A/Brisbane/10/2007).  The relative contribution of the H1N1, H3N2 and B strains to influenza illness in the months ahead cannot be predicted.  Thus, the need for vaccination with the new vaccine available in Feb/Mar 2010 once it is available  —> because the strain of H3N2 protected against, in the Feb/Mar 2010 vaccine will be different.

* The composition of the influenza vaccines is determined by a panel of WHO experts.  This WHO panel of experts sits every 6 months to predict the likely prevalent strains of influenza virii causing illness in the forthcoming winter based on their expert opinion.

Translation to English: 2 vaccines (1 for ‘normal’ flu and 1 for H1N1) are needed for full protection against Influenza from end 2009 to early 2010.

2.  Persons who have been vaccinated with the NH 2009 and the H1N1-2009 vaccines in 2009 should also be vaccinated with the Southern Hemisphere (SH) 2010 seasonal Influenza vaccine when it is becomes available in February/March 2010.

Translation to English: when the new flu vaccine becomes available in Feb or Mar 2010, please get that shot as well for full protection against Influenza from middle to end 2010.

For those who are so inclined, the rationale for the 2 recommendations by MOH are over here.

Southern Hemisphere?  Northern Hemisphere?  An explanation of these possibly confusing terms used in connection with the influenza vaccines.

People who should get their flu shots

1.  Chicken pox is commonly known as a childhood illness presenting with an initial fever which lasts for 2 to 4 days.  After the fever settles, a rash would appear (small “bubbles” or vesicles with clear fluid inside) which appear progressively in 3 to 4 crops over the next ~14 days.

2.  However, in Singapore, it is very common for young adults in their twenties or thirties to come down with a Chicken pox infection.  This delay in young Singaporeans catching Chicken pox could be explained by the general high hygiene standards, good health and good living conditions found in Singapore.

3.  Consequences of Chicken pox infection:

     i.  for children and young adults - they risk missing 2 weeks of important school work or even school-leaving examinations  such as PSLE/’O’ & ‘A’ levels/undergraduate examinations.  (The last I would be familiar with, since I missed one of my important medical school examinations and hence had to re-sit the paper.)

     ii.  for working adults - they risk missing 2 weeks of important or urgent work at the office because they have to be on medical leave away from work for 14 days.  In the highly competitive work environment in Singapore, it is probably needless to say that, this is undesirable.

     iii.  Scarring.  Ironically, scarring due to Chicken pox is more of a problem for young adults (who would likely be more concerned about their appearance) compared to children.  This is due to the fact that adults tend to have more vesicles or poxes compared to children.  Also, adult skin (alas) do not heal as well or as completely compared to children’s skin.  All these work against the adult Chicken pox sufferer, who is likely to have more pitting scars.

     iv.  Complications of Chicken pox infection.  Another unfortunate fact for adult sufferers of Chicken pox is that they are more prone to the complications of Chicken pox.  These are: pneumonitis (Chicken pox virus entering the lung to cause inflammation and infection, encephlitis (infection of the brain).  I had a patient in his thirties, who was ill with Chicken pox.  He fell asleep, and his family could not wake him up even 24hrs later.  He had developed enephalitis secondary to Chicken pox.  At this point, they sent him to the A&E of a restructured hospital which promptly admitted him.  This patient of mine did not wake up for another 48hrs, and he had to stay in the Intensive Care Unit (ICU) for 2 months.  For most of these 2 months, he had to be hooked up to a ventilator to help him to breathe.  He had also developed pneumonitis secondary to Chicken pox (a double whammy).  Fortunately, he did survive to relate this tale of his to me after it was all over, but not before racking up a gigantic medical bill.

     v.  Shingles aka Herpes zoster aka 蛇丹 or simply 蛇.  Everybody who catches Chicken pox has the virus hidden latent in their bodies, specifically in their nerves.  Although, this does not lead to grave illnesses for us (I caught Chicken pox ‘naturally’ myself too), the re-activation of these virus particles hidden in our nerves can be quite unpleasant.  This re-activation disease is called Herpes zoster with the common name of Shingles.  Shingles usually present with a pre-rash tingling or painful sensation over the skin where the rash will appear.  A few days later, grouped “bubbles” or vesicles will appear, usually on the chest, back or abdomen.  (In contrast, for Chicken pox, the vesicles are scattered over the body.)  The vesicles usually burst leaving an area of broken skin on the body.  When this happens, a secondary bacterial infection of the skin can occur.

The area of the skin where the vesicles appear is painful, and the pain is often severe enough to cause sleepless nights.  The vesicles do heal in 1 to 2 weeks, depending on the immune system of the patient.  Healing can be accelerated with treatment (anti-viral tablets, appropriate skin treatment and cream).  However, even though the vesicles heal relatively quickly (particularly with appropriate treatment), the pain due to Shingles may take a protracted course.  It is not unknown for the nerve pain (or neuralgia) due to Shingles to last for a few months.

Okay, now that I know the facts about Chicken pox, how do I protect myself or my loved ones against it?

Two words: get vaccinated.

Check with your parents or other family members if you had Chicken pox before, since you might be too young to remember.  If your parents or family members are unsure about your history of Chicken pox, you can do a blood test to check your Chicken pox status. 

As for your children who have not had Chicken pox - make sure to get them vaccinated.  Children above 12 months of age and not currently having febrile illnesses can be vaccinated.

Our Clinic is using a single-dose vaccine.  This is sufficient because this particular brand of vaccine is made from the original strain of Chicken pox virus stock.  There are other Chicken pox vaccines out there where it is necessary to have 2 doses i.e. a total of 2 injections over 6 months.  Naturally, 2 doses would mean double the cost (or more). 

Common questions:

Qn 1:  Why not let it “come out naturally” i.e. get infected “naturally”?  This is what the older folks at home advice me.

Ans: There is nothing “natural” about catching an infection.  Refer to point 3 above on “consequences of Chicken pox infection”, in particular about scarring and complications of Chicken pox.  Prevention is always better than treatment after the fact.  And with regards to Shingles, Chicken pox vaccination can prevent a person from ever contracting the infection.  If a person has never been infected with Chicken pox, it follows that he or she will also never experience Shingles and its unpleasant symptoms.

Don’t be like me.  I caught Chicken pox “naturally” and now I stand the chance of getting Shingles in my older years or when my immune system is weaker.  Unfortunately for me (and other adults who have already caught Chicken pox before), there were no Chicken pox vaccine during my childhood years.  Fortunately, its not too late for our children.  Get them vaccinated today*.  I have already vaccinated both my kids, have you?

* Children above 12 months of age and not currently having febrile illnesses can be vaccinated.

Qn 2:  I (unfortunately) have not vaccinated myself against Chicken pox but I came into contact with my colleague/niece/nephew/neighbour’s kid, a confirmed case of Chicken pox, a few days ago.  What do I do now?

Ans:  The good news is that you can still take steps to protect yourself.  You can get a post-exposure vaccination against Chicken pox.  With post-exposure vaccination, there is still a chance that you will not get infected.  And even if you do develop Chicken pox, it is likely to be of the (much milder) variety.  

Qn 3:  I (unfortunately) have not vaccinated myself against Chicken pox but I came into contact with my colleague/niece/nephew/neighbour’s kid, a confirmed case of Chicken pox, 1 to 2 weeks ago.  I have not seen your Clinic’s website, in particular Qn 2 and its accompanying answer above.  I am starting to have small blisters or “bubbles” on my body.  What do I do now?  Should I allow the illness to run its course, like what my older relatives have adviced me - “to let all the poxes come out”?

Ans:  All is not lost.  Please come down to the Clinic to start treatment for Chicken pox infection.  It is important to start treatment within 48hrs (at most 72hrs) of devoloping poxes on the body.  The advantage of treatment is that it very significantly reduces the length of the illness (and the  accompanying need to stay away from school/work) - refer point 3 part i & ii above.  Treatment also significantly reduces the number of poxes that a patient will develop.  This in turn, reduces the risk of pitted scars on the face and on the rest of the body.

Another important reason to get treated for a Chicken pox infection is to reduce the risk of serious complication - refer point 3 part iv above.  I really don’t need another patient to tell me about his/her ordeal with serious complications of Chicken pox.

In summary, Chicken pox may be known as a childhood illness, but its consequences are often serious indeed.  In Singapore, residents often get infected when they are young adults in an important phase of their lives, with serious repercussions.

Please call the Clinic at 6258 6096 before coming down to the Clinic for Chicken pox vaccination - ocasionally, we run out of stocks of the Chicken pox Vaccine.

1.  Adults with chronic conditions such as Diabetes Mellitus, Hypertension, Hypercholesterolaemia, Stroke, Chronic Lung Diseases (Chronic Bronchitis, Emphysema), Heart Diseases, Kidney Failure, chronic liver diseases etc i.e. your elderly parents & relatives.

2.  Adults who have weak immune systems e.g. post-splenectomy (those with their spleens removed), HIV patients, Cancer, Leukaemia etc

3.  Adults staying at long-term care facilities or institutions.

Background information

1.  Pneumococci (aka Streptococcus pneumoniae) can cause non-invasive infections (less serious) such as otitis media, sinusitis and bronchitis, and invasive infections (much more serious) such as pneumonia, meningitis and febrile bacteremia.

2.  The average number of cases of invasive Pneumococcal disease over the period 1995-2004 was 67 per 100,000 among the elderly aged >65 years.  For comparison, the rates were 12.4 per 100,000 for children aged 5-14 years, and 4.5 per 100,000 for teens and adults aged 15-64 years.

3.  The highest case fatality rate was 8.4% occurring in the elderly above 75 years of age.

4.  Treatment of Pneumococcal infections is getting more difficult with increasing resistance of the bacteria to even strong antibiotics.  This means that the old adage, prevention is better than cure is particularly true for Pneumococcal infections.

5.  Don’t wait any longer, get your elderly parents and relatives vaccinated today!

Please call us at 6258 6096 to confirm availability of Adult Pneumococcal Vaccine before coming down to the Clinic.

Background information

1.  The Pneumococcal bacteria causes meningitis (infection of the covering of the brain), pneumonia (lung infection), otitis media (middle ear infection), sinusitis (infection of the bony spaces in the face),  septicaemia (generalised blood infection).  Complications of serious Pneumococcal infections are: hospitalisation, hearing loss, mental retardation, or even death.

2.  What are the practical implications of a vaccine being made compulsory?  In Singapore, when a child registers for kindergarten/school, a vaccination certificate is needed.  Thus, if a child has not completed the full course of Pneumococcal vaccinations, he/she will not be able to obtain a vaccination certificate and will thus be unable to register for kindergarten/school.

3.  Media releases thus far indicate that the Pneumococcal vaccinations will not be subsidised by the government.  Parents can make use of funds in their Children Development Account (CDA) or medisave to pay for these vaccinations

4.  Y S Teo Family Clinic & Surgery is an approved institution for Baby Bonus Scheme, as well as Medisave Claims.

* Previously I wrote that the Pneumococcal vaccine has been made compulsory for all children in Singapore.  This is incorrect, what is true is that the Pneumococcal vaccine (a total of 3 doses) has been included into the National Childhood Immunisation Programme.

For newborn babies, the Ministry of Health has recommended for vaccination at 3 and 5 months of age.  The 3rd (which is the last) dose is when baby is between 12 months to 24 months of age.

Now you may ask, how about Pneumococcal Vaccination for Adults?

1.  They are caused by different virii  Flu (or Influenza) is caused by the Influenza virii.  There are 3 types of Influenza Virii: Type A, B & C.  Colds are caused by Rhinovirus, Coronavirus, Adenovirus, Enterovirus, Respiratory Syncytial Virus etc (there are altogether about 200 different virii that can cause the common cold).

2.  Flu symptoms are usually more severe  Flu and colds share similar symptoms such as fever, cough, runny nose, scratchy throat etc.  However the symptoms for flu are usually more severe, so sufferers of flu usually have fever higher than 38 degree celcius, with whole body ache (even to the point of not wanting to get out of bed).  Flu symptoms last longer as well, someone with flu usually takes a week to 10 days to fully recover.  Someone with cold, would usually recover in 3 to 4 days.  This is why it makes sense to get vaccinated against Influenza.

3.  Complications of Influenza   People can and have succumbed (i.e. die due) to Influenza even before we ever had or knew about “Asian Bird Flu” or “Swine Flu”.  The serious complications, due to Influenza, leading to deaths are: viral pneumonitis (lung inflammation), secondary bacterial pneumonia (lung infection), encephalitis (inflammation of the brain), pericarditis (inflammation of the ‘covering’ surrounding the heart.

Persons with weaker immune systems e.g. more than 50 years old, persons with underlying chronic medical problems etc are the ones who are at higher risk of the above serious complications of Influenza.  Complete list of Persons at risk of Complications from Influenza.

The following persons-at-risk should be vaccinated (Flu Vaccine):

1.  All those above 50 years (CDC recommendation)

2.  Adults and children with Chronic Pulmonary (e.g. Asthma, Chronic Obstructive Lung Disease etc), & Cardiovascular Diseases (e.g. Coronary Artery Disease, Hypertension etc).  The largest patient population in this group are Asthmatics.

3.  Adult and children with Kidney and Metabolic diseases (e.g. Renal Impairment/Failure, Diabetes Mellitus Type I & II).

4.  Children receiving long-term aspirin therapy and hence at risk of developing Reye’s Syndrome if they are infected with Influenza.

5.  Residents of nursing homes and other long-term care facilities.

6.  Family members of above persons listed in 1 to 5 because they are at risk of transmitting Influenza.

7.  Travellors going to Flu-prone or Flu-hit countries.