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NCIS and CDS - Subsidized Children Vaccinations

National Childhood Immunization Schedule

The National Childhood Immunization Schedule

The National Childhood Immunization Schedule (NCIS) has been developed and revamped over the years by Singapore’s Ministry of Health (MOH) to ensure the protection of children growing up in Singapore from preventable diseases. The development of new vaccines and combinations over time has allowed for less vaccinations, but a greater area of coverage, as MOH constantly keeps up-to-date with new vaccines, basing heavily on scientific evidence and vaccine safety, and also taking into account what other countries’ NCIS covers as well.

Due to the rolling out of certain vaccines years ago, we have successfully eradicated diseases such as local cases and transmission of Tuberculosis, polio, diphtheria, and rarely ever do healthcare workers in Singapore come across cases of Measles, Mumps and Rubella locally. We have our previous successful compulsory vaccinations to thank for the eradication of these diseases, and can only hope that more diseases can be eradicated with the uptake of vaccines recommended in the NCIS.

As of 1st November 2020, all vaccines recommended in the NCIS will be fully-subsidized for Singapore citizens and Permanent Residents (PR) at the polyclinics, as well as CHAS-approved GP private clinics. We are pleased to inform that Intemedical Kovan clinic is a part of this initiative as well, and is able to offer complete subsidies to eligible babies and children.

Compulsory Vaccines in Singapore

Of all the vaccines available in the market presently, only 2 vaccines are considered compulsory in Singapore – diphtheria (which is often combined with pertussis and tetanus vaccinations) and measles (which is often combined with the mumps and rubella vaccinations). Thankfully, uptake of recommended vaccinations is high, unlike other countries which may face a growing problem with “anti-vaccination” protestors. Hopefully, this does not affect the herd immunity level of our population, and cause diseases that can be protected with a simple vaccine to resurface again.

How do vaccines work?

Vaccines are usually cultured from the actual live virus or bacteria itself, and most are then inactivated such that it is unable to cause disease. Each vaccine usually contains very small amounts of the inactivated virus/bacteria, and once injected, it tricks our immune system into thinking that the body is under attack by the virus/bacteria. When this happens, immune antibodies are formed, which is what protects us from future disease. It is important to note, however, that vaccines do not have a 100% preventive rate, as many other factors can come into play, such as a person’s immune system not reacting as robustly as expected to produce sufficient antibodies, which can happen when a person is vaccinated while fighting a cold and most of the battle gear are directed in the direction of the cold virus, as well as antibody levels waning over time. Hence, sometimes, multiple doses of a vaccine are recommended, or booster doses once every couple of years. Usually once a vaccine is given, even if it does not provide 100% protection to that person, it typically causes milder symptoms, and a faster recovery.

Recommended Childhood Vaccines in Singapore

Credit: healthub.sg

(a) Bacillus Calmette-Guerin (BCG) – This vaccine provides against Tuberculosis and is usually administered to the child at birth. In the past, a booster dose of the BCG vaccine was also initially recommended and carried out at the age of 11/12 years old, but it was subsequently decided as of 1st July 2001, based on scientific studies as well as epidemiological data that there was no need for a booster dose to be given. Hence, each child born since approximately 1989/1990 has been receiving only one dose of BCG vaccine.

(b) Hepatitis B – The Hepatitis B vaccine protects against the Hepatitis virus, a virus that affects the liver of the person who contracts it. The first dose of the Hepatitis B vaccine is typically given at birth, along with the BCG vaccine. Babies born to mums who are infected with Hepatitis B are often given an additional injection to help eradicate any Hepatitis B virus that may have transmitted from mum to baby. At least 3 doses at birth, 2 and 6 months of age of the Hepatitis B vaccination is required in healthy babies to obtain adequate immunity in an average baby. Booster doses or repeat 3-dose vaccinations are not uncommon in adulthood as well as antibody levels wane with time.

(c) Diphtheria, Pertussis & acellular Pertussis – The Diphtheria vaccine protects against infection caused by Corynebacterium diphtheriae, which produces toxins resulting in a wide range of symptoms from mild respiratory symptoms such as a sore throat, to severe skin infections, heart failure, and even death. Tetanus infection is caused by the bacteria Clostridium tetani. It can result in severe symptoms such as “lockjaw”, with the patient being unable to open his/her mouth at all resulting in respiratory compromise, involuntary muscle spasms and contractions throughout the body, sometimes severe enough to cause fractures, as well as seizures. The bacteria is usually found in the environment, soil, and on rusty equipment, hence injuries breaching the skin layer are the typical methods of transmission and contracting of Tetanus. Pertussis, most commonly known as “whooping cough”, is caused by the bacteria Bordetella pertussis. It can cause symptoms similar to a common cold or flu, but eventually develops to worsening coughing fits with the characteristic “whoop” on breathing in before coughing. The Diphtheria, Tetanus and Pertussis vaccines have long been combined into just one vaccine (DTaP & Tdap) for quite some time now. 3 doses of this combination of vaccines at 2, 4 and 6 months of age are usually required in babies, followed by 1 more booster dose as an infant at 18 months, and 1 more booster at the age of 10/11 years old.

(d) Polio – Poliomyelitis is caused by the poliovirus, resulting in total or hemiparalysis (being paralyzed and unable to move/feel on one side of the body) when the spinal cord is affected, or just one limb, when it spares the cord. The muscles of that limb eventually wastes away due to prolonged disuse. Effects resulting from the poliovirus are rarely ever reversible, even with intensive physiotherapy. The Inactivated Polio Vaccine (IPV) is given in 3 injectable doses, followed by an injected booster at 18 months of age, and the oral polio vaccine at the age of 10/11 years old. The Oral Polio Vaccine (OPV) is gradually being phased out in many countries and it will not be long that Singapore follows suit as well.

(e) Haemophilus influenzae type b (Hib) – The Hib bacteria can cause severe, often life-threatening symptoms of meningitis (brain inflammation) such as seizures, headache, and stiff neck, and can cause severe complications such as pneumonia, blood infection and joint infections. Children under the age of 5 are particularly susceptible to Hib, due to their lowered immunity. The Hib vaccine was introduced to the then NCIS just recently back in 2013. It is usually given in combination with DTaP and IPV as a “5-in-1” vaccine, or along with Hepatitis B as well as a “6-in-1” vaccine. The Hib vaccine is usually given as a series of 3 shots at 2, 4 and 6 months of age, followed by a booster shot at 18 months old.

(f) Pneumococcal conjugate – The Pneumococcal Conjugate vaccine is used to protect children from infection from Streptococcus pneumoniae, whose symptoms may range from a mild flu-like illness to respiratory distress and ultimately death. There are currently 2 recommended vaccines on the market, one covers 10 strains (PCV10) while the other covers 13 strains (PCV13) of the Pneumococcal conjugate. The more commonly used vaccine in the market is the PCV13. 2 doses, at 4 and 6 months, followed by a booster shot at 12 months of age, is recommended in the guidelines. Our clinic carries the PCV13 vaccine.

(g) Pneumococcal polysaccharide – The Pneumococcal polysaccharide vaccine (PPSV23), similar to the Pneumococcal conjugate vaccine, covers against the pneumococcal bacteria as well, but the vaccine was manufactured using a different method, allowing it to cover strains that the PCV13 was unable to. It covers for 23 strains of the pneumococcus bacteria. Vaccination in children between the ages of 2 to 17 years old is only recommended in certain underlying medical conditions or with suppressed immune systems.

(h) Measles, Mumps & Rubella – The Measles, Mumps & Rubella (MMR) vaccine has been very widely used and used in combination. Of these 3, the measles vaccine is a compulsory vaccination by law, and children attempting to enrol into pre-schools and primary schools will be denied entry if proof of vaccination is not being able to be shown. It protects against the Measles virus, which causes generalized rashes over the body, Mumps virus, which causes painful inflammation of the salivary glands, as well as Rubella virus, which causes a rash. In a pregnant woman, contracting the Rubella virus can be extremely dangerous for the unborn foetus, and result in birth defects. The MMR vaccine is given in 2 doses, at 12 and 15 months of age.

(i) Varicella – The Varicella Zoster, or the more colloquially termed “chickenpox”, causes generalized blister-like rashes that can take up to 2 weeks to heal completely, and is extremely infectious, passing from an infected child to another easily. The Varicella Zoster Vaccine (VZV) was only recently added to the list of vaccines under the NCIS. The vaccine is available as a stand-alone, or in combination with the MMR vaccination as MMRV. However, due to concerns of increased rates of febrile seizures (without lasting complications) occurring within 7 to 10 days of administration of the first dose of MMRV in children aged between 12 to 23 months of age, the national recommendation is to give the 1st dose of MMR and VZV as separate vaccines (at the same time) at 12 months of age, then to give the combined 2nd dose MMRV at 15 months of age.

(j) Human Papillomavirus – The Human Papillomavirus (HPV) is a virus that is responsible for more than 97% of cervical cancer cases, in particular, strains 16 and 18. Other strains of HPV cause symptoms such as genital warts, and can be sexually-transmitted. There are a number of HPV vaccines out in the market presently – Cervarix, Gardasil-4, and Gardasil-9. Only Cervarix is being used in school-based vaccination programmes. Gardasil-4 is claimable, and hence included under the NCIS. For females below the age of 15 years old, the vaccine is often given as a 2-dose regimen at 12-13 years of age, and then 6 to 12 months later at the age of 14-15 years. If the vaccination is started after the age of 15 years, the 3-dose regimen is recommended, at 0 months, 1 to 2 months depending on vaccine, and then finally at 6 months from the 1st dose. Our clinic carries the Gardasil-4 and Gardasil-9 vaccines.

(k) Influenza – Influenza virus, commonly known as the flu, can cause symptoms ranging from a mild respiratory tract infection, to a full blown pneumonia with respiratory failure. As such, it is recommended to get the influenza vaccine on an annual basis. In children, influenza vaccine is within the NCIS for those aged 6 months to 5 years of age. For these children, their first administration of influenza would compose of a 2-dose, 1 month apart vaccinations. Those 5 to 17 years of age are covered under the NAIS only if they are suffering from specific medical conditions that predispose them to influenza complications. Any influenza vaccination initiated before the age of 10 years old will require the 2-dose regimen for the first year. Subsequently, vaccinations should be administered once a year, unless specified otherwise by health authorities.

Other Childhood Vaccines available in Singapore but not in the NCIS

(a) Rotavirus – Rotavirus (RV) causes severe gastrointestinal symptoms such as diarrhoea, vomiting and abdominal pain, and is easily passed between children especially when good hand hygiene is not observed. There are currently 2 RV vaccines in the market – Rotarix and Rotateq. Studies have not shown that one vaccine is superior to the other in terms of protection, however Rotarix follows a 2-dose regime while Rotateq follows a 3-dose regime. Both vaccines are administered orally. Hence, Rotarix is the more convenient vaccine to take. Rotarix is usually administered at a minimum of 6 weeks old, followed by the 2nd dose at least 4 weeks later. Administration of the 1st dose should ideally be before 16 weeks of age, while the 2nd dose should not exceed 24 weeks of age. Our clinic carries the Rotarix vaccine.

(b) Hepatitis A – The Hepatitis A virus leads to infection and inflammation of the liver, which, in severe cases, can lead to acute liver failure. The virus can be passed from person to person through close contact, sexual contact, as well as contact with contaminated food and water, especially seafood/shellfish. This can be easily preventable with the Hepatitis A vaccine. This involves 2 doses of the vaccine, spaced 6 months apart. Any persons between the ages of 1 to 17 should receive the reduced paediatric dose of the vaccine. Those vaccinated before the age of 1 typically develop suboptimal response to the vaccine, and hence should be disregarded and start afresh with the 2 doses after the age of 1.

(c) Hepatitis A & Hepatitis B – There is currently an available combination of Hepatitis A with Hepatitis B vaccine that allows for fewer vaccines required to be administered. The 3-dose series at 0 months, 1 month, followed by 6 months after the 1st dose. The Twinrix JUNIOR vaccine is just half the dose of the usual Twinrix vaccine for adults. This can be used for children ages 1 through 17 years. However, due to the nature of our NCIS, the Hepatitis B vaccine is commonly administered as a 6-in-1 vaccine. This vaccine may apply to foreigners who settle in Singapore and are looking to catch up on their vaccines.

(d) DengueThe Dengue fever epidemic has been something that authorities have been struggling to keep under control amidst the COVID-19 pandemic. However, less lime light is shone on Dengue despite the number of new cases being significantly more than the COVID-19 virus. Dengue fever does not spread from person by respiratory droplets or contact with someone who has been diagnosed by it, instead it is transmitted from a bite from the Aedes aegypti or Aedes albopictus. Common symptoms include a persistent fever past 3 days, muscle aches, bone pain and joint pain, headaches (especially behind the eyes), generalized non-itchy rash, easy bruising/bleeding, and abdominal symptoms. Dengvaxia is a vaccine for the Dengue virus, which was only rolled out a few years ago in 2015, and approved in use since 2016. Dengvaxia protects against the 4 serotypes of the Dengue virus, with focus of efficacy placed more on the first 2 serotypes' efficacy than the the other 2. The reason why the vaccine was created was because clinicians realized that patients with a prior history of Dengue infection, tend to suffer from more severe symptoms and complications on their 2nd infection. Eligibility criteria to qualify for Dengvaxia is strict though, which includes previous documented Dengue infection (or undergo a Dengue IgG antibody blood test to confirm previous infection), and the vaccine is only available to persons aged 12 through to 45 years. There is significant importance of a previous Dengue infection in order to administer the vaccine, as multiple studies all over the world have shown that patients without prior history who get vaccinated with Dengvaxia, tend to suffer from severe Dengue symptoms when they are bitten by an Aedes mosquito. The vaccine comprises of 3 doses, with each dose scheduled 6 months apart.

(e) Meningococcal polysaccharide – This vaccine protects against the Neisseria meningitidis bacteria that can most commonly lead to brain infection/inflammation (meningitis). In Singapore, it is not widely used due to herd immunity, causing cases locally to be so low that there is no need for prevention. The Meningococcal vaccine is often given to travellers for Hajj and Umrah. Only one dose is required. The brand that we carry in the clinic is Menactra, and protects against Meningococcal ACYW135. Menactra should be used in caution in adults aged 55 and above due to the lack of scientific studies on possible complications as well as efficacy, above 55 years old. Nimenrix vaccine is used for young travellers above the age of 2 years old, and can be pre-ordered into our clinic if required. Travellers who have certain medical conditions may require 2 doses of the vaccine instead of 1, in order to generate sufficient antibodies for protection.

(f) Typhoid - Typhoid fever is caused by a bacteria called Salmonella typhi. Salmonella may be something most people are aware of and have heard of in the past. It causes high fever and severe gastrointestinal symptoms such as severe abdominal pain, fever, excessive vomiting and severe diarrhoea. For most patients who ends fatally-affected, it tends to be a result of severe dehydration. If left untreated, the symptoms may persist for as long as weeks and months. Studies have shown that up to 30% of those afflicted with the Typhoid fever end up dying from it. The bacteria is most commonly found in soil, unsanitary places, sometimes roadside food stalls, and becomes a problem only when after coming into contact with it, the person ingests it, sometimes subconsciously and unknowingly. The typhoid vaccine is hence recommended to persons aged 2 years and older, with time of vaccination recommended 2 weeks before possible exposure, and repeat vaccinations once every 2 years for persons who remain at risk. The bacteria is currently commonly found in many regions in the world, the most common being East and Southeast Asia, Africa, the Caribbean, and Central and South America. Travellers to these areas or persons living in these areas are recommended to get the vaccine.

(g) Japanese Encephalitis - Japanese Encephalitis (JE) is a relatively uncommon infection seen in Singapore in general compared to many other diseases. It is spread via the bites of mosquitoes (Culex tritaeniorhynchus), and is most commonly found in Asia, especially in rural and periurban settings. Not all travellers become symptomatic when bitten by a mosquito carrying the JE virus. Those who do though suffer from symptoms such as fever, headache, vomiting, confusion, difficulty moving, and serious complications such as brain swelling and coma. The expected mortality rate for those who get the infected is expected to be as high as 30% of those affected. Unfortunately, there has not yet been a cure found for infection of the JE virus. Current circulating viruses now in these endemic countries have been found to be resistant and ineffective to previous possible cures found. The JE vaccine is recommended in travellers to areas where JE is endemic, particularly if they are travelling to rural and suburban places, and also planning a long stay of a month of move in these areas. It is administered as 2-dose regimen, given 1 month apart, with the last dose recommended to be given at least 1 week before travel. The current vaccine is licensed and tested to be given to persons aged at least 2 months old. The dose of the vaccine for children aged 2 months to 3 years of age, is half of what is provided in the vaccine itself.

The following table summarizes a list of prices of vaccines in our clinic (subject to changes) that are included in the NCIS, but non-subsidized and applicable to those who are not eligible for the subsidy, as well as prices of vaccines not included within the NCIS:

Please note that patients seen in the clinic who only require a vaccination without needing a consult of other symptoms they may have which may/may not result in prescription of medications, or ordering of investigative tests, will have their consultation fee WAIVED completely in goodwill. Hence, they would only be required to pay for the cost of the vaccine (if applicable), with or without the Childhood Development Screening (if applicable) charge, when checking out of the clinic.

If you are not a local, and are an expatriate for example, you may notice that our country’s vaccine guidelines may differ from your country in terms of types of vaccines, timing of vaccines given, or number of doses recommended. Rest assured that at Intemedical Kovan, we allow for flexibility, and would gladly follow your country’s guidelines if it is more familiar and convenient with you, or you can also switch over to our local guidelines if it is comfortable for you to.

Please note that patients seen in the clinic who only require a vaccination without needing a doctor’s consultation of other symptoms they may have which may/may not result in the prescription of medications, or ordering of investigative tests, will have their consultation fee WAIVED completely in goodwill. Hence, they would only be required to pay for the cost of the vaccine when checking out of the clinic.

If you would like to make an appointment with Intemedical Kovan for vaccination, kindly go through our appointment portal, call us at 6243 3036, or WhatsApp us at 8879 9404 with the patient’s name, date of birth, age at point of intended vaccination, and vaccination required. It is preferred that patient calls prior to coming down so that we are able to check and provide you with the current stock level of the non-reserved vaccines, and to be able to inform you if we are out of stock, and able to advise that you make a pre-order for that vaccine so that we can replenish the stock and reserve one vaccine for you. This especially applies to the vaccines that are not administered very frequently in our clinic.

Childhood Developmental Screening

The Childhood Developmental Screening (CDS) allows a continuous and gradual monitoring of a child’s growth, especially in the crucial first few years of their lives. All babies born in Singapore are provided with a Health Booklet at birth by the hospital. The health booklet contains information about the baby at birth, vaccination schedules, growth charts and percentiles, developmental checklist, safety checklist, teeth growth chart etc. It is very crucial that this book be kept in a safe and accessible place, and brought along for any doctor visit especially in the first 2 years of life.

MOH has now standardized recommended CDS touch points, which involves measurements of growth (height, weight, occipitofrontal circumference) to compare to a chart and determine the child’s growth percentile in relation to their peers, physical examination by a doctor, and developmental checklist which parents are encouraged to fill up prior to the consultation based on day-to-day activities of the child. There is also a safety checklist component included where the doctor explains about what safety measures should be particularly looked out for, for a child of a certain age. The doctor will fill in the physical examination findings in the health booklet, as well as check for any vaccinations that may be due for that visit. If there is, the vaccinations can be administered as long as the baby is well, and this vaccination information is also recorded into the heath booklet. Subsequently, all vaccination records will be uploaded into the National Immunization Records portal, which makes it easier for the government to check on the vaccination status of a particular child, especially with regards to the compulsory immunizations.

To note, as of 1st November 2020, all CDS-incurred charges will be completely subsidized by MOH in both polyclinics, as well as CHAS-approved GP private clinics.

These are the recommended touch-points for CDS:

Credit: moh.gov.sg

Our recommendation at Intemedical Kovan would be arranging the touch-points for CDS at the ages of 2, 4, 6, 12, 30 (2.5 years old) and 48 (4 years old) months of age, mostly in conjunction with the timing of the vaccine due at that time, to allow convenience to parents who will not be required to come on too many separate visits, which would also impose a higher risk of catching a bug while waiting in the clinic, alongside people who are sick and displaying symptoms especially. However, we also do allow for flexibility to suit the needs of the parents as well.

Should there be any concern with regards to a child’s growth, developmental delay or mental impairment, the child will be referred to an appropriate specialist.

How to make an appointment with Intemedical Kovan?

Appointment Portal: https://forms.gle/HyGy59i9mYx4sEi96

(most direct and fuss-free)

WhatsApp: 8879 9404

(available during clinic opening hours, 8am to 12am)

Mobile: 8879 9404

(messaging preferred)

Landline: 6243 3036

(please be aware that the phone might be engaged due to high call volume)

Credit: MOH, CDC, FDA, HealthHub