Painless or normal vaccine. What should my child take?

The debate for painless versus normal vaccine has been there for quite a long time leaving parents confused. So, let’s get all the facts right!

All vaccines are not available in painless versus painful variant. Only DPT vaccine is available in these two formats.


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WHAT IS DPT VACCINE?

This combination vaccine protects against three diseases:

Diphtheria: Diphtheria is a bacterial infection causing a thick covering in the back of the throat. It can lead to breathing problems, paralysis, heart failure, and even death.

Tetanus: Tetanus (lockjaw) is a serious disease that causes painful tightening of muscles, usually all over the body. It can lead to "locking" of the jaw so the patient cannot open his mouth or swallow. Tetanus leads to death in about 1 in 10 cases.

Pertussis: Pertussis, also known as whooping cough or 100 day cough, is a highly contagious respiratory disease. Pertussis is known for uncontrollable, violent coughing which often makes it hard to breathe. After fits of many coughs, someone with pertussis often needs to take deep breathes which result in a "whooping" sound. Pertussis most commonly affects infants and young children and can be fatal, especially in babies less than 1 year of age. Since the 1980s, the number of reported pertussis cases has increased. These increases have been noted in both infants younger than age 1 year, ages 11-18 years and adults.

WHAT EXACTLY IS MEANT BY PAINLESS AND NORMAL DPT VACCINE?

  • DPT/DwPT vaccine: Normal/whole cell/painful vaccine as it is called, it contains the entire killed pertussis bacteria with the cell covering inside the vaccine
  • DaPT vaccine: Painless/ acellular vaccine as it is called, it contains the killed pertussis bacteria with the cell covering removed. The cell covering of pertussis bacteria is responsible for most of the side effects of DPT vaccine like fever, pain, etc

WHEN ARE THESE VACCINES GIVEN?

  • Given as an injection in the muscle in the side or front of the thighs
  • First/ Primary doses are given at 6/ 10/ 14 weeks OR 2/ 4/ 6 Months
  • Booster 1 is given at 15-18 months
  • Booster 2 is given at 4.5-5 years
  • In case you miss any dose, consult the doctor. The doctor will put up a new schedule depending on the dose missed
WHEN ARE SUBSEQUENT BOOSTER SHOTS GIVEN?
  • Everyone from age 10 up should receive a booster vaccine, called Tdap. It's a combined tetanus, diphtheria, and acellular pertussis booster vaccine with smaller doses of bacteria inside the vaccine
  • If normal DPT vaccine has been given as the primary immunization, Td booster shots every 10 years would suffice
  • Normal DPT vaccine shouldn’t be given after 10 years of age
ARE THERE ANY SIDE EFFECTS WITH THESE VACCINES?

Side effects are usually seen in whole cell vaccine and rarely seen in acellular vaccine.

  • Pain and redness at the site
  • Swelling at vaccination site: In most cases, this swelling subsides within 48-72 hours after vaccination. Sometimes the swelling at the injection site becomes firm, nodular and may persist for several days to weeks. It may soften and form a sterile abscess. It usually disappears on its own, sometimes leaving thick skin behind which eventually also goes

    When to worry about the swelling?

    If the swelling is painful and warm on touch and child not able to move legs at the end of 5-7 days, it could be an abscess or pus collecting there. Consult your doctor immediately. An ultrasound and drainage might be required

  • Fever lasting upto 48 hours
  • Fussiness, irritability, mild drowsiness or poor appetite may be seen for 24-48 hours after vaccination
Rarely (1 in 1 million doses)-
  • Very high fever (fever >105 F)
  • Hypotonic hypo responsive episodes (HHE)/collapse like/shock like state, wherein the child stops responding and collapses
  • Seizures or fits, usually within 7 days of giving the vaccine

The serious side effects are attributed to the cell of pertussis toxin generally.

HOW DO I TAKE CARE FOR MY BABY AFTER THE DOSE?

  • Your child may experience fever, soreness, and some swelling and redness in the area where the shot was given. Give acetaminophen (paracetamol) in doses of 10-15mg/kg/dose if fever, pain, swelling causes distress to your child every 4-6 hours for the first 2 days
  • Ice fomentation/pack help to numb the pain, if packs not available use a few ice cubes in a napkin or towel and compress the site lightly for 5 minutes and repeat after some time
  • It is safe to give a bath or a gentle massage the next day. Continue breastfeeding as usual
  • There is no need to immobilize the limbs
DO NOT HESITATE TO CALL OR VISIT THE DOCTOR IF:
  • Severe symptoms develop after immunization, including:
  • Convulsions/fits
  • Fever above 105°F (40.5°C)
  • Difficulty in breathing or other signs of allergy
  • Drowsiness, shock or collapse
  • Uncontrolled crying for more than 3 hours
  • Severe tender swelling on the legs beyond 48-72 hours
  • High grade fever beyond 48-72 hours
  • Reduced leg movements beyond 48-72 hours
ARE THERE ANY CONTRAINDICATIONS TO THE VACCINE?

DwPT and DaPT:

  • Not be used in patients with history of severe allergic reaction (anaphylaxis) to previous doses.

Use DaPT in place of DwPT if the following develop after DwPT use:

  • Persistent inconsolable crying of more than 3 hours duration
  • Hyperpyrexia (fever>105 C)
  • Hypotonic hypo responsive episodes (HHE) within 48 hours of DwPT
  • Seizures with or without fever within 7 days of administration

It is not contraindicated in children with non progressive brain illnesses like cerebral palsy, febrile convulsions, epilepsy.

CAN THE DPT VACCINE BE ADMINISTERED IN COMBINATION WITH ANY OTHER VACCINES?

YES, commonly administered combinations are:

  • DwPT+HBV+HIB: EASY FIVE, COMVAC5, SHAN 5, PENTAVAC
  • DwPT+HIB: EASY FOUR, COMVAC 4,SHAN 4, QUADROVAX
  • DaPT+IPV+HIB: PENTAXIM
  • DaPT+IPV+HIB+HBV: HEXAXIM
  • DwPT+HBV+HIB+IPV: EASY SIX
  • Tdap: BOOSTRIX, ADACEL
  • TDaP: INFANRIX
WHAT IS THE BIG BROUHAHA BETWEEN NORMAL AND PAINLESS VACCINE?

Let's get our basics right first:

  • Painless vaccines are not exactly painless. They pain while getting injected. Some parents think that painless vaccines don’t pain while getting injected
  • Painless vaccines can also give rise to mild fever, pain and swelling at injection site but the severity and frequency is much lesser
  • Both of them are equally effective after three doses. They protect around 80-85% for all three illnesses
  • Painless vaccine effectiveness starts fading after 5-6 years after last shot. This can very well be backed up booster shots every 5 years. The effectiveness of three doses of painful vaccine lasts longer
  • Painful vaccine can give rise to life threatening complications as mentioned, although the incidence is rare(1 in 1 million doses)
  • Animal studies have shown that animals vaccinated with painless vaccine can transfer the pertussis bacteria to others in the community without getting signs and symptoms of pertussis. Normal vaccine prevents against the transmission as well and hence protects the community from pertussis. We have not yet got results in humans though
  • Painless vaccines are very costly, approximately 4 to 6 times the normal vaccines
  • Both vaccines are available as combinations with Hepatitis B and H. influenza B vaccine. But painful vaccine is not yet available in India as combination with IPV, though its expected soon. So, your child has to take IPV as a separate vaccine
  • Parents can always interchange between the painless and normal vaccine. You can always communicate to your pediatrician regarding the same for future vaccination planning

In a nut shell, parent has to decide whether they want to take the risk of rare life threatening complication of normal DPT vaccine versus the risk of pertussis outbreak later on in life. If they choose the first option, keeping a watch for complications is important and if they take the second option, booster shots should follow till 10 years of age. The last shot of Td may be considered 10 years after Tdap dose.

Some golden rules to be followed:

  • If anyone in your family gets infected with pertussis, vaccinate all family members, including the affected person
  • If vaccination status is in doubt, better to take the booster shots, especially in adolescent and college going children
  • Discuss with your pediatrician rather than your neighbour or net blogger to reach to a conclusion
WHAT ARE THE CURRENT RECOMMENDATIONS?

Keeping in mind our country's dynamics, IAP recommends DTwP for primary immunisation whereas AAP (American Academy of Pediatrics) and CDC recommends DTaP for children >7 years age. Our personal opinion is that parents should take an informed decision along with their pediatrician.

Disclaimer : "This handout is made on standard medical guidelines and is purely informative. Not to be used for treatment. The handout is IP of TPN. Any commercial use or misuse by third party will invite legal action"

TPN Team

This article has been written by core team of pediatricians of The Pediatric Network which keeps parents updated on current issues relevant to children. The articles are thoroughly researched, reviewed and updated as per the latest information available.