A Quiet Place

Peter Doshi, MA, a doctoral candidate at the Massachusetts Institute of Technology, and currently a Visiting Researcher with the Faculty of Medicine at the University of Tokyo, spoke at the National Vaccine Information Center conference on the difference between the childhood vaccine programs in the US and Japan.

Japan, a country of 130 million people with low infant mortality and high life expectancy, has had a completely voluntary vaccination system since 1994. No system exists to check vaccine status in schools in Japan. Recommended vaccines are free and one must pay out of pocket for elective vaccines. Vaccination coverage rates are high, according to Doshi, because the Japanese public has high trust in authority and high expectations for vaccine safety. The Japanese culture values quality control and product excellence.

During the first six months of life, the Japanese child receives only two vaccines: Polio (OPV) and BCG, while the US child receives multiple doses of eight or nine vaccines. During the first year of life, the Japanese child receives 14 doses of vaccines while the US child receives 33 doses. And, in the first two years of life if all recommended vaccines are administered, the Japanese child receives 17 doses of seven vaccines and the US child receives 23 doses of 10 vaccines.

In Japan, generally only one injection is given at a time. Contrast this to the US in which monovalent (single dose) vaccines for measles, mumps and rubella are not even available. According to the US Advisory Committee on Immunization Practices (ACIP), there is no medical reason to administer the measles, mumps and rubella antigens separately and ACIP guidelines do not support their use. Based on this input and on manufacturing constraints, Merck stopped making these three monovalent vaccines in 2008 despite strong demand from parents.

In Japan, inactivated vaccines are administered six days apart and live vaccines 27 days apart. In contrast, the CDC recommends combining vaccines and states that no time is needed between them.

Japanese health officials take the possibility of vaccine reactions seriously. They ask all parents to fill out a detailed immunization questionnaire and to record any possible vaccine reactions in the Mother-Child Handbook that the government provides. Parents must read the handbook and give consent before their child receives vaccines. They are directed to take their child’s temperature before a vaccination is administered, as Japanese health officials believe that vaccinations may worsen an already sick child. The handbook also asks that parents observe their children’s behavior for 30 minutes following vaccination.

In Japan, vaccinations are not given to children if they have fever or an acute illness or have shown any abnormal symptoms following a previous dose of a vaccine. In contrast, the CDC says, “A mild illness or fever is usually not a reason to delay an immunization.”

What led to the voluntary system in Japan? The Japanese found that mandatory vaccinations did not guarantee compliance and saw adverse events associated with vaccines as a social problem. In 1962 childhood vaccines first became mandatory in Japan and by 1974 Japanese children were required to receive four vaccines. When there were problems with vaccines, the government took action. In 1975, after two successive deaths following the whole cell pertussis vaccine, the vaccine was temporarily suspended. When the vaccine was resumed it was only recommended for those over two years of age and by 1981, a new vaccine, the acellular pertussis vaccine was developed and introduced in Japan. Tragically, the acellular pertussis vaccine was not licensed in the US until 1991.

In 1989, when the MMR vaccine was causing three cases of aseptic meningitis for every 1000 vaccines, the vaccine was taken off the market and reformulated. Subsequent vaccines only included measles and rubella, not mumps. In 1987 the Japanese law was relaxed and the detailed immunization questionnaire for parents was begun. In 1994 mandatory mass vaccines in Japan ended. Perhaps because of the mutual trust inherent in the Japanese system, 2006 showed high rates of vaccine compliance for the first dose: 98% were vaccinated with the DPT vaccine; 97% with polio; 97% with measles, and 100% with rubella.