Childhood vaccinations

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The vaccination of a very young child with a severe undetermined health problem is sometimes postponed until the health problem is better defined to avoid side effects of vaccination affecting the understanding of the underlying problem. A child with an immune deficiency or receiving immunosuppressants may require an individual vaccination schedule. They may be recommended to receive extra doses or more vaccines and even avoid some.

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Medicines can affect the effectiveness and, in rare cases, the safety of vaccines. Sometimes, it is necessary to postpone vaccination until the effects of other medicines are over. This applies mainly to chicken pox and measles vaccines, but the vaccination schedule can usually be maintained.

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Continuing vaccinations without special monitoring or intervention is often possible, even if side effects have occurred. Still, some medicines are recommended to reduce specific side effects, and in more severe cases, a specialist evaluation may be necessary before vaccinations are continued. It is rare for a child to stop using a vaccine, usually due to an allergy.

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Egg protein vaccines are not used in general vaccinations in Iceland, but vaccines recommended for certain groups, such as influenza vaccines, may contain egg protein.

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It is often possible to vaccinate a child who is, e.g. with ear infections or other illnesses if it is easy to predict the progress of the illness and the effect of vaccination on that progress.

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Diphtheria is a disease caused by bacteria that is very infectious and starts on the upper airways. The disease manifests as a severe sore throat with an oblique oral and nasal mucosa covering. The bacteria produce a toxin that is absorbed into the bloodstream and harms the body's tissues, such as the heart muscle, kidneys and nervous system. Antibiotics kill the bacteria but do not prevent the toxic effect. Diphtheria can become a severe disease and can lead to death, but 40-50% of those who do not receive treatment for the disease die from it.

The epidemiology

Diphtheria was a common disease in the past but is rare today because of its intensity and extensive nature. The last diphtheria was diagnosed in Iceland in 1953. The disease is easily transmissible between humans and shows the experience of many Eastern European countries that this disease, like other diseases, can spread if vaccinations are relaxed. Unvaccinated children under five years of age and adults over 60 years of age are the most exposed to infection.

Pathways of infection and incubation

Diphtheria is highly infectious. Transmission of the bacterium occurs via droplet or aerosol infestation from the respiratory tract, i.e. coughing, sneezing and laughing, which then spreads via hand to mucous membranes of the mouth or nose. It takes only 2-4 days after infection and until symptoms of the disease appear. The bacteria can also spread to the body through skin wounds. There are examples of asymptomatic individuals being able to carry the disease without getting sick.

Symptoms

The symptoms of the disease can vary for individuals. The most common symptoms are a severe sore throat with a grey coat covering the mucous membranes of the mouth and throat and possible difficulty in swallowing and breathing. Add to this enlarged lymph nodes in the neck, hoarse voice and blurred voice, rapid heartbeat, sore nasal mucosa, swollen upper gums, low temperature, double vision and discomfort.

The disease can become severe. A thick film accompanying the infection can lie over the airways and prevent the person from breathing. The bacteria then release a toxin that can be carried by the blood to various organs, including the kidneys, heart, and nervous system, impairing their function or causing permanent damage, even paralysis.
If the diphtheria bacteria penetrates the body through the skin, symptoms are usually milder, but in addition to other symptoms, yellow patches or tenderness of the skin may develop.

Diagnosis

In the beginning, the symptoms of diphtheria resemble severe throat inflammation with heat congestion and swollen lymph glands. But what distinguishes diphtheria from other similar diseases is a toxin that the bacteria releases that form thick grey plates that sit on the nasal, pharyngeal and respiratory membranes and can cause breathing and swallowing problems. The disease can be diagnosed by taking samples from the neck and putting them in culture.

Treatment

It almost always requires hospitalisation of those who become ill with diphtheria and are kept in isolation. When the analysis is available, antibodies are given to the toxic bacteria, as well as penicillin. Other consequences of bacterial toxin release, such as cardiac muscle and kidney, are explicitly treated. The patient may need to be ventilated when the disease is severe. Vaccination of the infected person in their immediate environment is necessary to prevent further spread. Once the patient has recovered from the illness at 4-6 weeks, they need vaccination to prevent them from contracting the disease again later.

Prevention

Vaccination is the only defence against the disease. Diphtheria is very rare today because of its intensity and widespread nature. Vaccination against diphtheria must be repeated every ten years if there is a risk of infection. The chance of transmission may occur when travelling to underdeveloped countries or regions where diphtheria is endemic.

Diseases subject to registration

Diseases subject to registration are those that can spread widely in society and, at the same time, threaten public health. Doctors must notify The Chief Epidemiologist of persons sickened by rubella with the personal identification number of the infected person. Still, reports to the Chief Epidemiologist are also received from laboratories that confirm the diagnosis. The purpose of reporting an infectious disease is to prevent the spread of infection through targeted measures, e.g. isolation, treatment of the infected, and tracking of transmission between individuals. Information about the probable transmission place, transmission time, and symptoms must accompany notifications to satisfy these conditions. In this way, infected persons can be linked epidemiologically, the effects of the infection can be assessed, and a response can be taken.

• Please also look at the information about diphtheria on the European Centre for Disease Prevention and Control (ECDC) website.

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Tetanus is a severe infection caused by a bacterium called Clostridium tetani. This bacterium is present in nature, such as in soil and livestock droppings, but it is found in the intestines of humans and animals (herbivores) without causing harm. When the bacterium enters a wound, it produces a toxin that affects the human central nervous system, causing stiffness and convulsions that can be life-threatening.

Epidemiology
The tetanus bacterium is found in all countries. It is most common in hot countries but also in this country, especially in the summer. Infections caused by the bacterium are rare in countries where vaccination against it is standard, but the death rate is high in countries where vaccination is not carried out.

Modes of transmission and gestation period
Infection occurs due to dirt entering puncture wounds or open wounds. The bacterium takes residence in the wound and begins to produce a toxin that travels through the body through the bloodstream, mainly affecting the central nervous system and muscles. From the time of infection, it can take anywhere from one day to one month for symptoms to appear, but it is most common for them to appear after 6-8 days. Contagion does not spread between people.

Symptoms
The first symptoms of infection may be fever, sweating, rapid pulse, irritability, and localised pain in the muscles closest to the wound. Jaw stiffness, contraction of facial muscles, and difficulty swallowing and breathing may also be seen. The spasms and stiffness can spread throughout the body, e.g. to the abdominal and back muscles, and cause respiratory and cardiac arrest.

Diagnosis
The disease is usually diagnosed by history and symptoms. The bacteria can also be detected in a swab from the wound.

Treatment
There is an antidote that works if acted upon quickly enough. Other treatments include wound care, antibiotics, and anti-convulsions. A severe infection caused by tetanus requires hospitalisation.

Prevention
The only sure protection is vaccination. In this country, children are vaccinated at 3, 5, and 12 months of age and revaccinated at 4 and 14 years of age. Since the protective effect of vaccination does not last a lifetime, revaccination is recommended if more than ten years have passed since the last vaccination in a person who gets dirt in a wound. Periodic revaccination of adults is not recommended.

Tetanus is a disease subject to registration.

See more:
http://www.ecdc.europa.eu/en/healthtopics/tetanus/Pages/index.aspx

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Whooping cough is a severe respiratory infection in children, especially in the first months of life, but in adolescents and adults the disease is known by chronic and persistent coughing, but it is more common that the infection simply causes cold symptoms in these age groups. The infection is caused by a toxin-producing bacterium that causes severe coughing fits that can be life-threatening in children within the first six months of life.

Epidemiology

In the years around 1930-1940, thousands of people died from whooping cough, but the introduction of a vaccine against the disease has dramatically reduced the mortality rate from it. The spread of the disease has been increasing in the last 20 years, however, and the World Health Organization believes that between 20–40 million cases occur every year in the world, mostly in developing countries.

Despite good participation in pertussis vaccination, outbreaks have occurred every 3–5 years in many countries among adults and older children. The reason is that the protective effect of the vaccination is greatest in the first years following vaccination and repeated booster doses are needed to maintain the protection. Moreover, vaccination does not completely protect against infection, but primarily against serious illness.

Transmission routes and incubation periods

Human-to-human transmission occurs via respiratory (e.g. coughing, sneezing) techniques. Individuals are infectious from the onset of symptoms and generally for two weeks after the onset of cough. The incubation period of the disease, the period between the time an individual becomes infected and the onset of symptoms, is usually around 2–3 weeks.

Symptoms of the disease

Symptoms are, at first, mild colds, followed by a growing cough, mucus build-up, and severe coughing fits, especially at night. After about two weeks, symptoms progress to growth with an intense coughing fit accompanied by characteristic sucking sounds upon inhalation. Other symptoms include sneezing, runny nose and fever. Symptoms of the disease may persist for up to 10 weeks. Young children in the first six months of life are particularly prone to severe consequences of the infection, which may include respiratory arrest, seizures, pneumonia, brain dysfunction and death.

Diagnosis

Confirmation of the disease can be achieved by nasopharyngeal biopsy and bacterial DNA search (PCR test). Samples should be taken as soon as possible after the onset of illness. The throat smear is a much smaller sample for pertussis detection than the nasopharyngeal smear.

Culture of the bacteria from the nose/nasopharynx and serological testing are possible tests that are currently under-represented.

Treatment

Treatment depends on the severity of the disease. Antibiotics do little good, except very early on in the disease process, primarily to reduce the transmission of the bacteria to others. Other treatments include rest, fluid intake, and nutrition. Small children with pertussis often need to remain in the hospital for long periods.

Prevention

Vaccination is effective in preventing the disease in young children. It is essential to start vaccinating young children because the disease is most dangerous in children under six months of age. In Iceland, children are vaccinated at 3, 5 and 12 months of age and revaccinated at ages 4 and 14. The vaccine does not protect for longer than ten years, so there is a chance of infection later in life. Regular immunisation of adults has been recommended in many countries, but routine revaccination of health care workers is recommended only for health care professionals in Iceland.

Vaccination of pregnant women significantly reduces the disease in children in the first year, especially children under three months of age who have not been vaccinated themselves. Since 2019, all pregnant women have been offered pertussis vaccination in antenatal care.

Stopping pertussis spread

Once symptoms start, individuals with pertussis should reduce contact with infants to a minimum of two weeks after the start of coughing (if vaccinated within ten years) or longer (unvaccinated or more than ten years after the last dose). People with whooping cough are generally contagious when symptoms appear and for 2 weeks after the cough starts, often total about 4 weeks. Unvaccinated people can be contagious for longer.

• Avoid being around young children (<1 year old) and pregnant women while you are contagious.

• Avoid large gatherings for approx. two weeks and use a face mask if you have to go places where there are others while symptoms are severe.

If a child in kindergarten or school gets pertussis, it is right for the child's family to alert the school so that other children's relatives can be informed about pertussis infection at school. Families in a vulnerable position due to whooping cough can then receive advice from their doctor on measures to reduce the risk of infection within the family.

How to Avoid Children from Whooping Cough?

• Vaccination against pertussis with the two-dose vaccine is a safe protection.

• In Iceland, pertussis vaccinations are given at 3, 5, and 12 months of age and revaccinated at 4 and 14 years of age.

Complications of pertussis

Most of the time, whooping cough improves without causing significant problems. Those at highest risk of complications are children under one year of age, especially under six months of age and unvaccinated.

The risk of complications is reduced in older children and adults and in the vaccinated population in general.

Vaccination of pregnant women significantly reduces the disease in children in the first year, especially children under three months of age who have not been vaccinated themselves. Vaccination against pertussis is recommended during each pregnancy.

In children under six months of age and particularly under three months of age who are not vaccinated, there is a high risk of serious illness with complications such as respiratory arrest, seizures, pneumonia, encephalitis and even death.

Common complications

Under one year of age:

• Respiratory arrest

• Pneumonia

• Seizures

Older children and adolescents (in relation to coughing fits):

• Fainting

• Broken rib

Uncommon complications

Under one year of age:

• Encephalitis

• Death

See more:

• European Centre for Disease Prevention and Control (ECDC)

• World Health Organization (WHO)

• Pertussis (whooping cough) diagnosed in Iceland - First cases since 2019. News published on April 10, 2024

Diseases subject to registration

Diseases subject to registration can spread widely in society and, at the same time, threaten public health. Doctors must notify The Chief Epidemiologist of persons sickened by whooping cough with the personal identification number of the infected person. Still, reports to the Chief Epidemiologist are also received from laboratories that confirm the diagnosis. The purpose of reporting an infectious disease is to prevent the spread of infection through targeted measures, e.g., isolation, treatment of the infected, and tracking of transmission between individuals. Information about the probable transmission place, transmission time, and symptoms must accompany notifications to satisfy these conditions. In this way, infected persons can be linked epidemiologically, the effects of the infection can be assessed, and a response can be taken.

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Polio

Polio is an infectious disease caused by a virus that can affect the body's nervous system and cause paralysis, leading to death. Those most at risk of contracting the disease are newborns, young children, and unvaccinated individuals. The risk of being paralysed by the disease increases with age.

Epidemiology

Since the vaccination against the disease began in 1955, significant success has been achieved, and the disease has almost been eradicated worldwide. However, polio still threatens young children in poorer countries where access to vaccines is limited.

Modes of transmission and incubation period

The polio virus is highly contagious and can be transmitted to humans by aerosol transmission, i.e., by spray from the respiratory system (e.g., sneezing) and faecal contamination in drinking water and food. The virus can be present for weeks in the stools of infected people. Hygiene is essential to prevent infection, and good hand washing is the most important.

Symptoms

The vast majority of those who get sick, about 90-95%, get mild flu-like symptoms, manifesting as general weakness, fever, decreased appetite, nausea, vomiting, sore throat, constipation, and stomach pain. More severe symptoms include pain and reduced strength in the body's musculoskeletal system, neck stiffness, muscle atrophy, hoarseness, difficulty breathing, and swallowing. In the most severe cases, there will be muscle paralysis, paralysis of the bladder, and symptoms such as restlessness, involuntary drooling, and a distended abdomen.

Analysis

In addition to a medical examination, the polio virus can be diagnosed by measuring antibodies against the virus in the blood and cerebrospinal fluid. The virus can also be detected in a stool or urine sample and a throat swab.

Treatment

No treatment or medication can cure the disease. In general, treatment is aimed at reducing symptoms.

Prevention

Vaccination is effective in preventing disease in young children. It is essential to start vaccinating young children because the disease is most dangerous for the youngest children. In this country, children are vaccinated at the ages of 3, 5, and 12 months and revaccinated at the age of 14. The vaccine does not protect for more than ten years, so there is a possibility of getting infected later in life. It is recommended that adults get vaccinated against polio every ten years if they travel to countries with a risk of infection.

Diseases subject to registration

Diseases subject to registration are those that can spread widely in society and, at the same time, threaten public health. Doctors must notify The Chief Epidemiologist of persons sickened by polio with the personal identification number of the infected person. Still, reports to the Chief Epidemiologist are also received from laboratories that confirm the diagnosis. The purpose of reporting an infectious disease is to prevent the spread of infection through targeted measures, e.g. isolation, treatment of the infected, and tracking of transmission between individuals. Information about the probable transmission place, transmission time, and symptoms must accompany notifications to satisfy these conditions. In this way, infected persons can be linked epidemiologically, the effects of the infection can be assessed, and a response can be taken.

See also:

Polio and Post-Polio Syndrome

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Haemophilus influenzae is a group of bacteria that are classified according to their type. Haemophilus influenzae b or Hib can cause severe conditions such as meningitis, tracheitis, pneumonia, sepsis, and arthritis, as well as other mild infections that may persist, including upper respiratory, sinus, and ear infections. The most severe infections due to the bacteria are tracheitis, blood infections, and meningitis, which can be life-threatening, and this is the type of infection mainly discussed here.

Epidemiolog

Hib was the most common cause of bacterial meningitis in children from two months to five years of age. About 10% of those who developed Hib meningitis died. Vaccination against this bacteria has been very effective. Since the vaccination against Hib began in Iceland in 1989, no cases of meningitis or other serious bacterial infections have been reported. Still, before that time, approximately ten children per year were diagnosed with meningitis. Children who have not been vaccinated are at particular risk, especially if they are of preschool age. Adults can also become infected with the bacteria.

Transmission and incubation periods

Haemophilus influenzae bacteria are most often transmitted by respiratory droplets (e.g. coughs and sneezing), and persons who carry the bacteria can still pass the virus on to others despite not having symptoms.

Symptoms

The symptoms of Hib meningitis are similar to those of other bacterial or viral meningitis. The main symptoms can be fever, headache, photophobia, stiff neck, joint pain, vomiting, reduced level of consciousness, seizures, agitation in young children, and refusal of food. Hib-associated blood infections can occur at all ages. Tracheitis is most common in the age group 5–10 years.

Diagnosis

Diagnosing Haemophilus influenzae B infection early is essential so treatment can start as soon as possible. Samples from the site of infection identify the bacteria.

Treatment

The primary treatment for Haemophilus influenza B is antibiotics. Other treatments look at rest, fluid intake, and nutrition.

Prevention

A vaccine against Haemophilus influenza b has been in use since the 1980s. The vaccine is part of a vaccine against pertussis, diphtheria, tetanus, and poliomyelitis (given as a single injection). Children are vaccinated at 3, 5, and 12 months of age, and the vaccination coverage offers about 95% protection. The participation in vaccination against these diseases in Iceland has been decent in recent years, at 95%. Parents are encouraged to continue good participation in vaccinations because this is the only way to keep this severe infectious disease out of the country. Individuals exposed to infection can be given appropriate antibiotics as a preventative measure.

Diseases subject to registration

Diseases subject to registration are those that can spread widely in society and, at the same time, threaten public health. Doctors must notify the chief epidemiologist of persons infected by Haemophilus influenzae B with the personal identification number of the infected person. Still, reports to the chief epidemiologist are also received from laboratories that confirm the diagnosis. The purpose of reporting an infectious disease is to prevent the spread of infection through targeted measures, e.g. isolation, treatment of the infected, and tracking of transmission between individuals. Information about the probable transmission place, transmission time, and symptoms must accompany notifications to satisfy these conditions. In this way, infected persons can be linked epidemiologically, the effects of the infection can be assessed, and a response can be taken.

See more on ECDC's website.

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Pneumococci (Streptococcus pneumoniae) are bacteria that can cause severe and life-threatening diseases, especially in young children and adults over 60. The bacterium is found in the nose and throat mucous membranes in all age groups, especially young children, without causing any symptoms. The bacteria can infect, spread throughout the body, and cause disease.

The most common infections caused by pneumococci are acute and persistent otitis media, sinus infections, and pneumonia in young children. The most dangerous infections are meningitis and sepsis, which can occur as separate diseases or together and are called invasive infections. Today, pneumococci are the most common cause of bacterial meningitis.

Epidemiology
Diseases caused by pneumococci have been a persistent health problem in this country. The frequency of serious infections caused by these bacteria is higher in this country than in many neighbouring countries. Invasive pneumococcal infections have been relatively stable recently. Still, as a general rule, about 50 people a year are diagnosed with a severe infection, of which about 10 are children under the age of 5, and then it is mainly adults over sixty who get infected. Invasive infections are rare in children and adults in other age groups. After general vaccination against pneumococci was included in childhood vaccinations in 2011, the number of invasive infections in children decreased. The mortality rate caused by these diseases is about 10% in this country.

Modes of transmission and gestation period
The bacterium is transmitted from person to person through aerosols from the respiratory tract. It is believed that only 1-3 days pass from infection until symptoms of the disease appear.

Symptoms
Infections caused by pneumococci often follow the common cold or flu; therefore, the symptoms often resemble infections caused by other bacteria or viruses. Common infections caused by pneumococci are middle ear infections, inflammation of the sinuses, mucous membranes of the eyes, and pneumonia. Symptoms of meningitis or sepsis can come on very quickly with high fever, neck stiffness, restlessness, and lethargy, followed by convulsions, loss of consciousness, and shock. This should always be kept in mind in children under three years of age with unexplained fever and apparent illness.

Diagnosis
Pneumococci can be diagnosed under a microscope and by the culture of samples.

Treatment
Patients with severe pneumococcal infections should be treated with antibiotics as soon as possible in a hospital. There are about a hundred pneumococcal serotypes, most of whom are sensitive to penicillin, but antibiotic resistance has become more prevalent in Iceland. It is important to follow your doctor's advice when taking antibiotics and finish the recommended dose.

Prevention
Vaccination against the disease is the most potent prevention. Vaccinating against the most dangerous strains of the bacterium can prevent up to 90% of infections caused by pneumococci in children under five. Vaccination can also be expected to reduce acute and persistent otitis media in children by up to 30% and pneumonia in the same age group by up to 37%. It is also expected that the annual use of antibiotics in this group will decrease by up to a quarter, which would reduce the risk of the spread of antibiotic-resistant pneumococci. Since 2011, children in this country have been vaccinated against pneumococci at 3, 5, and 12 months of age.

Vaccines
Today, there are two types of pneumococcal vaccines: polysaccharide and protein-based. Polysaccharide vaccines have been on the market for some time and have been recommended for use in individuals over 60 and with immunosuppressive diseases. Please have a look here for instructions on how to use pneumococcal vaccines (in Icelandic). However, polysaccharide vaccines do not benefit children under two, so protein-based vaccines are on the market for this age group.

The side effects of both vaccines are mild and similar to the side effects of other vaccines.
Serious side effects have not been described.

Diseases subject to registration
Diseases subject to registration are those that can spread widely in society and, at the same time, threaten public health. Doctors must notify The Chief Epidemiologist of persons sickened by pneumococci with the personal identification number of the infected person. Still, reports to the Chief Epidemiologist are also received from laboratories that confirm the diagnosis. The purpose of reporting an infectious disease is to prevent the spread of infection through targeted measures, e.g. isolation, treatment of the infected, and tracking of transmission between individuals. Information about the probable transmission place, transmission time, and symptoms must accompany notifications to satisfy these conditions. In this way, infected persons can be linked epidemiologically, the effects of the infection can be assessed, and a response can be taken.

See also information about pneumococci on the website of the European Center for Disease Control (ECDC)

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Meningitis and sepsis caused by meningococcal bacteria, Neisseria meningitides, cause so-called meningococcal disease. Such infections usually lead to death if not treated quickly with appropriate diagnosis and treatment. The disease is most common in children but can occur at any age. Its spread is often random, but it can sometimes become an epidemic. It is, therefore, essential to monitor the disease closely so that action can be taken if the number of cases becomes high.

Epidemiology and prevention

The disease has historically been a serious health problem in Iceland. In the last decade of the 20th century, meningococcal disease was particularly prevalent here, with an incidence of about three times higher than in the other Nordic countries due to unknown causes. The highest incidence rose to 11 cases per 100,000 inhabitants per year. The mortality rate in the region has been about 8.6% of diagnosed cases, but generally, about 10% mortality is expected in meningococcal disease, despite treatment. Meningococci are divided into many different types, but the most pathogenic ones are types A, B, C, W, X, and Y. The serotypes have different geographical distributions. In Iceland, types B and C have mainly caused disease, but since vaccination against meningococcal C began in Iceland in 2002, this serotype has disappeared from view in Iceland. Several European countries have had outbreaks of serotype C in the last 5 years, but the vaccine is not widely used in most European countries. Serotype B has been the most common cause of meningococcal disease in many parts of the West, including Iceland after 2002. A Type B vaccine was in development for a long time, but now there are 2 vaccines on the European market. One is used in infants, e.g. in the United Kingdom, and can also be given to adolescents, while the other is for use only in older people. Currently, meningococcal B is very low in Iceland and vaccines are therefore not included in our vaccination program. They are available with a prescription at an individual's expense.

Infections due to serotypes X and W have been on the rise in Europe in recent years. Serotype W vaccine is currently used in infant vaccinations and is also available where tourist vaccinations are carried out, but a type X vaccine has not been developed. There are indications that one of the envelope type B vaccines may have cross-immunological activity against envelope type X, but further studies are needed.

A vaccine against serotypes A, B, C, W, and Y (pentavalent vaccine) is under development, at least for older children and adults.

Symptoms

The symptoms of the disease can be subtle and initially resemble the common cold or flu. Infants often become ill with nonspecific symptoms such as decreased consciousness, restlessness, refusal to feed, nausea or diarrhoea, and fever.

Specific symptoms include occiput stiffness or bulging of the occiput if they are still open and punctate and reddish rashes that do not clear when pressure is applied. Late symptoms include high-pitched screams, loss of consciousness, head tilt, shock, widespread bruises and obvious bleeding into the skin.

In older children and adults, nonspecific symptoms include headache, nausea, and back and joint pain. Specific symptoms include occiput, photophobia, confusion, and spotting or bruising.

Meningitis or sepsis should always be considered in a child with unexplained fever and illness. Neck stiffness is not always present, so looking for skin bleeding or bruising is essential. If fever and skin bleeding occur together, the patient must go to the hospital immediately.

Treatment

Patients with meningococcal disease need to be treated with antibiotics as soon as possible in the hospital. Despite powerful modern medicine, the death rate of the disease is high, almost 9% in this country.

When a person is diagnosed with a severe meningococcal infection, people in the immediate environment may need prophylactic medication. If an outbreak occurs due to a coat type for which vaccination is available, it is essential to use appropriate vaccinations to control the spread.

Diseases subject to registration

Diseases subject to registration are those that can spread widely in society and, at the same time, threaten public health. Doctors must notify The Chief Epidemiologist of persons sickened by meningococcal bacteria with the personal identification number of the infected person. Still, reports to the Chief Epidemiologist are also received from laboratories that confirm the diagnosis. The purpose of reporting an infectious disease is to prevent the spread of infection through targeted measures, e.g. isolation, treatment of the infected, and tracking of transmission between individuals. Information about the probable transmission place, transmission time, and symptoms must accompany notifications to satisfy these conditions. In this way, infected persons can be linked epidemiologically, the effects of the infection can be assessed, and a response can be taken.

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Chickenpox is caused by a varicella zoster (herpes zoster) virus related to the herpes simplex (cell) virus. This is usually a mild disease but can, in rare cases, cause chickenpox to become a severe illness. Following infection with chickenpox, the virus takes hold of the nerves in the body and lies hidden.  It can later recur and cause herpes zoster, which is characterised by painful local rashes.

Epidemiology

In Iceland, almost everyone gets chickenpox at some point, but the disease is less common in the southern part of the world. An Icelandic study published in 2009 revealed that 97.5% of Icelandic children develop varicella (chickenpox) antibodies at 1–10 years and 50% at 1–4 years old. It is, therefore, clear that many Icelandic children receive varicella during their preschool years.

Chickenpox does not seem to be a large epidemic like many other childhood diseases, but it persists in the community throughout the year. Seasonal fluctuations are often on the disease rate, and most cases occur in the middle of winter until spring.

Symptoms

The disease lasts 7–10 days in children but longer in adults. Most of the time, the infection is not dangerous, and most people get chickenpox once.

The disease starts with a skin rash that affects the body and face but can also affect the scalp and extremities. Sometimes, the rash spreads to mucous membranes and genitals. Weakness and mild fever are often observed for one to two days before the onset of the rash, and the fever continues in children and adolescents for 2–3 days concurrently with the rash. The rash starts as tiny red bubbles that become oozing blisters in a few hours; the blisters then become sores in 1–2 days, forming scabs and drying up. New bubbles may be added for 3–6 days. The severity of a rash that each person experiences varies greatly. Other symptoms may include headache, sore throat, loss of appetite, and possibly vomiting.

The main complications that can follow chickenpox are skin infections and pneumonia. In some cases, chickenpox can cause encephalitis and myocarditis. Severe varicella infections are more common in adolescents and adults than younger children. Deaths are but occur even in previously healthy children. Immunosuppressive disorders such as leukaemia, steroid therapy (e.g. for asthma; non-inhaled steroids), and immunosuppressive therapy, such as after organ transplantation or because of cancer, significantly increase the risk of severe varicella and complications.

In 2009, an article was published about the epidemiology of chickenpox in Iceland and the complications seen in Icelandic children (Icelandic). It revealed that 58 children had been admitted to Landspítali Hospital over a 20-year period with severe complications from varicella.

Shingles can appear anytime after chickenpox disease, even repeatedly and often in the same place on the body. The large intestine rash is mainly localised to one local skin nerve. They are usually itchy but can also be very painful and are called hellfire (helvetesild in Norwegian). Symptoms typically resolve after a few weeks, but very few develop persistent neuropathy. If shingles appear on the head or face, they can cause blindness.

Diagnosis

Rash of varicella is a disease characteristic and is diagnosed as such. The virus can also be differentiated by culture from rash or blood analysis in case of doubt, as does the shingles.

Transmission routes and incubation period

Chickenpox is a highly infectious disease most common in children. It is transmitted from person to person by aerosols from the respiratory tract and by direct contact with the fluids from rashes.

The incubation period of the disease, i.e. the period between infecting the individual and the onset of symptoms, can be 10–21 days. People can infect others for up to three days before they develop a rash and remain infectious until all the bubbles have burst and dried up. Individuals with shingles can transmit chickenpox to others.

If an individual has not had chickenpox, there is a 90% chance that they will contract the disease, and someone in the home will get sick, while there is a 10–35% chance that children in a school environment will get infected. Individuals with shingles can also spread the virus, but the risk of infection for susceptible individuals in the household is around 20%, much lower than for chickenpox.

Treatment is mainly staying still, drinking well, and reducing the itch. The itch can be relieved by cold bakes or baths. Oatmeal, diet, soda, and potato flour have been used in baking or bathing to reduce itching. Drugs are also available to apply and foam for external use, which reduces the itching. These medicines will only temporarily relieve the itching, and when they are used, it should be kept in mind that they may cause a brief stinging sensation. If the itch becomes so severe that it interferes with the child's sleep, itch-resistant antihistamines can be given to the child, although they may have a drowning effect. The physician should provide advice about the choice of such a medicinal product and the appropriate dose for the child. Antipyretics may be administered, but care must be taken not to contain acetylsalicylic acid (aspirin).

Varicella can also be treated with specific antiviral drugs, and it is best to start the treatment in the first 1–2 days of the illness. This treatment is most appropriate for immunosuppressed individuals or those who treat immunosuppressed individuals or others at risk for severe infections and complications of varicella.

Prevention

In 1995, a live varicella vaccine was introduced, which is very effective and safe. There has been considerable interest in its use. Vaccination against varicella is now part of the general vaccination of children in Iceland born in 2019 or later. Vaccines may continue to be administered to older children and adults who do not have severe immunosuppression at the expense of the individuals themselves.

Chickenpox is a disease subject to registration by the Chief Epidemiologist, as it is a public health threat.

When chickenpox is suspected or confirmed, doctors, directors of laboratories, hospital wards, and other healthcare facilities must send the Chief Epidemiologist information, but only if the patient is hospitalised.

Measles is a highly contagious viral disease with flu-like symptoms that usually appear 7–12 days after infection, followed by a measles rash a few days later.

The illness typically lasts 7–10 days.

The best protection against measles is vaccination with two doses of the MMR vaccine (measles, rubella, and mumps), given at 18 months and again at 12 years in Iceland. Pregnant women should avoid vaccination and pregnancy for one month after vaccination.

• Preventing Measles Infection

Could I have measles?

If you have had measles before or had two vaccinations of the MMR vaccine you are unlikely to have measles.

Initial symptoms of measles include:

• cold symptoms

• red and watery eyes

• fever over 38°C

• small white dots on the inside of the cheeks

• loss of appetite

• fatigue, and irritability.

A rash usually appears 2–4 days after the first symptoms and disappears within a week.

Measles rash

A rash usually appears 2–4 days after the first symptoms and fades and then disappears within a week.

The worst feeling is usually during the 1–2 days after the rash appears.

• The rash consists of small reddish-brown areas or slightly raised spots, which may coalesce into larger spots.

• Appear first on the head and neck, then spread over the whole body.

• Sometimes itch.

• Can resemble rashes that accompany other childhood diseases, e.g. rubella, fifth disease (roseola), etc.

• The rash is very unlikely measles if you have been vaccinated with two doses of measles vaccine.

How to treat measles?

To treat measles symptoms:

• Take paracetamol or ibuprofen to reduce fever and aches. Feeling better promotes increased fluid intake and lowering temperature reduces fluid loss.

• Drink plenty of water to prevent dehydration.

• Dim the lights to reduce sensitivity to light.

• Clean around the eyes with a damp cotton pad.

• Ensure good ventilation.

In severe cases, a person with measles may need to be hospitalized:

• If the person does not drink enough, especially children

• If the person is short of breath

• Sharp chest pain

• Coughing up blood

• Drowsiness

• Confusion

• Convulsions/seizures

Preventing the spread of measles

Isolate yourself for at least 5 days from when the rash started to prevent the spreading of the infection. Avoid work, school, gatherings, and close contact with young children and pregnant women.

Infected persons are generally infectious for 4 days before symptoms and for 4 days after the rash appears, but can be infectious for longer if still symptomatic.

If a child in daycare or school has measles the school needs to be notified so the appropriate measures can be taken.

How to prevent measles

• Measles can be prevented by vaccination with two doses of the MMR vaccine. The vaccine is safe and protects against measles, mumps and rubella.

• In Iceland, the MMR vaccine is given at 18 months and 12 years

• Pregnant women should not be vaccinated

• Those with a history of measles are protected and do not need vaccination

If a person cannot be vaccinated but has been exposed to an infection, it is possible to give them immunoglobulin, which is a blood product. This applies to:

• Children under 6 months of age.

• Pregnant women who are not fully vaccinated or who have not had measles before.

• People with a weakened immune system.

Complications of measles

Most of the time, measles gets better without causing additional problems. Those who are most at risk of developing complications are:

• Children under 1 year of age.

• Malnourished children.

• Children with a weakened immune system, e.g. due to leukemia.

• Teenagers and adults.

The lowest risk of complications is in school-age children.

If a pregnant person gets measles, there is a high risk of miscarriage, premature birth, and other problems in the mother and fetus/newborn.

Common complications

• Diarrhea and vomiting can lead to dehydration.

• Middle ear infections can cause ear pain.

• Other infections, e.g. eye infections, pneumonia, etc.

• Increased frequency of various bacterial infections for a few months after.

Rare complications

• Blindness and other visual problems

• Meningitis or encephalitis (a life-threatening condition)

• Measles pneumonia (a life-threatening condition)

• Liver failure

• Subacute sclerosing panencephalitis can occur late in about 1 in 1000 people who get measles, usually 7–10 years after the measles infection, and is fatal.

Further information

• Measles infection prevention Published February 2024

• European Centre for Disease and Prevention - ECDC. Measles

• World Health Organization - WHO. Measles

• A case of measles in Iceland. News 3.2.2024

Diseases subject to registration

Diseases subject to registration are those that can spread widely in society and, at the same time, threaten public health. Doctors must notify The Chief Epidemiologist of persons sickened by measles with the personal identification number of the infected person. Still, reports to the Chief Epidemiologist are also received from laboratories that confirm the diagnosis. The purpose of reporting an infectious disease is to prevent the spread of infection through targeted measures, e.g., isolation, transmission place, treatment of the infected, and tracking of transmission between individuals. Information about the probable transmission place, transmission time, and symptoms must accompany notifications to satisfy these conditions. In this way, infected persons can be linked epidemiologically, the effects of the infection can be assessed, and a response can be taken.

-Automatic translation

Mumps is an acute and highly contagious viral infection that affects children more often than adults. The infection is usually safe and resolves quickly, but is known to cause serious complications, especially in adolescents and adults. Most people only get mumps once in their lives.

• Infection Prevention

Epidemiology

In 2005/2006 and 2015, an epidemic of mumps occurred in Iceland, mainly individuals in their twenties who had not been infected with mumps as children or had received adequate vaccination against the disease. The prevalence of the disease has decreased in Iceland since vaccination against it began in 1989. It is preferably those born before that time who have not had the disease who are prone to contracting it, and then unvaccinated individuals.

Infection routes and incubation periods

Mumps are transmitted through saliva and respiratory droplets and contact with them, but the droplets are large enough to spread close to the infected person (<1 meter). A person who develops mumps is contagious from two days before and for five days after symptoms appear.

To break the transmission routes, it is recommended that a person with mumps avoid being around others from the time the disease is diagnosed until 5 days have elapsed from the onset of the inflammation by staying home from work or school, preferably alone in a room if others in the household are susceptible to mumps. If those caring for the sick person are susceptible to the mumps (have not had mumps or are not vaccinated), they should wear a protective mask to their senses if they are nearby (less than 1 meter), wear gloves if saliva or mucus needs to be touched from the airways, and wash their hands after contact with contaminated surfaces during the infectious period. Routine cleaning with soap and water and wiping the main environmental contact surfaces of the infected person with a surface-active disinfectant (e.g. 70 % environmental alcohol) during illness.

Symptoms of the disease

The symptoms of the disease are usually mild in children but affect adolescents and adults more heavily. The main symptoms are fever, weakness, inflammation and sore salivary glands, headache, difficulty chewing, and loss of appetite. Teenagers and adults have more complications than children. Serious complications may include encephalitis, hearing loss, and inflammation of the breast, pancreas, ovaries, or testicles. Inflammation of the last counted organs can cause infertility.

Diagnosis

Suspicion of the disease is obtained by physical examination, but confirmation is obtained by blood antibody testing or culture of the virus in saliva.

Treatment

There is no specific treatment for the mumps virus. Individuals with mumps are advised to drink well, stay at rest, and use painkillers. Children should be kept at home until symptoms of the disease have resolved. In more severe cases, patients may need to be hospitalized.

Prevention

Vaccination against mumps began in Iceland in 1989 as part of childhood vaccinations. Today, children are vaccinated with MMR (mumps, measles, and rubella vaccine together in one shot) at 18 months and 12 years of age as part of a general childhood vaccination program, providing good protection against the disease.

Post-exposure vaccination is not beneficial in preventing mumps illness, therefore vaccination of people with known exposure is not recommended until at least 3 weeks after last contact with an infectious person. However, it is appropriate that unvaccinated or under-vaccinated household members, schoolmates, and colleagues of the exposed receive vaccination as soon as possible, to reduce the risk of further spread. Vaccination is not recommended for those who have had mumps unless they lack measles vaccination.

Who should receive MMR vaccination for mumps in the local area without direct exposure:

Who should not get MMR vaccination:

Diseases subject to registration

Diseases subject to registration are those that can spread widely in society and, at the same time, threaten public health. Doctors must notify The Chief Epidemiologist of persons sickened by mumps with the personal identification number of the infected person. Still, reports to the Chief Epidemiologist are also received from laboratories that confirm the diagnosis. The purpose of reporting an infectious disease is to prevent the spread of infection through targeted measures, e.g., isolation, treatment of the infected, and tracking of transmission between individuals. Information about the probable transmission place, transmission time, and symptoms must accompany notifications to satisfy these conditions. In this way, infected persons can be linked epidemiologically, the effects of the infection can be assessed, and a response can be taken.

-Automatic translation

Rubella is a viral disease that usually causes mild symptoms in children but can be more severe in adults. In rare cases, this viral infection can cause arthritis and encephalitis in healthy individuals. If a woman gets sick from rubella during pregnancy, there is a risk of severe fetal damage, especially if it happens in the first three months of pregnancy. Fetal damage can include hearing loss, blindness, deformities, heart defects, growth retardation, and even miscarriage. If a girl has not been vaccinated, it is considered an advantage that she will get the disease before she reaches puberty.

Epidemiology
General vaccination against rubella in recent decades has prevented epidemics caused by the disease in this country. From time to time, however, cases occur among the unvaccinated. Those most at risk of getting the disease are a relatively large group of unvaccinated men who were born before 1988 and have not had the disease.

Modes of transmission and gestation period
The disease is transmitted through the atmosphere (aerosol transmission) between people, and it can take two to three weeks for symptoms to appear. The disease is most contagious when it has peaked, but it is also infectious the week before the rash appears and the week after it disappears.

Symptoms
Symptoms can vary from person to person, but the most common symptom is a red or brownish rash that often starts around the ears or on the face but quickly spreads over the body and can almost become one continuous slab. It is also usually accompanied by a mild fever, enlarged lymph nodes on the neck, and a headache. The symptoms typically go away in three days. These symptoms can resemble other viral diseases, such as measles and chicken pox. There are examples where disease symptoms can be so mild that the person will not be aware of them.

Diagnosis
It is possible to determine whether it is rubella by taking a swab from the throat or with a blood sample that looks for antibodies.

Treatment
There is no special treatment for the disease; other than that, people are advised to take it easy while it progresses. Everyone in the immediate environment of the sick person is at risk of infection if they have not been vaccinated against rubella or have contracted the disease.

Prevention
By vaccinating everyone in society, it is possible to prevent an outbreak of rubella. Vaccination against rubella began in Iceland in 1977 for women of childbearing age who did not have antibodies against the virus, but that system was discontinued in 2001. General vaccination of all 18-month-old children began in 1989 with the MMR vaccine. Revaccination began in 9-year-old children in 1997, but in 2001, the revaccination was raised to 12 years. Therefore, for both sexes, full vaccination is at 18 months and 12 years.

Pregnant women who do not have antibodies against rubella are advised to get vaccinated after the birth of the child so that almost all women of childbearing age in this country are immune to rubella. It is estimated that 90% of fetuses can be harmed if the mother becomes infected during the first trimester. Girls vaccinated against rubella should avoid becoming pregnant in the following three months.

Diseases subject to registration
Diseases subject to registration are those that can spread widely in society and, at the same time, threaten public health. Doctors must notify The Chief Epidemiologist of persons sickened by rubella with the personal identification number of the infected person. Still, reports to the Chief Epidemiologist are also received from laboratories that confirm the diagnosis. The purpose of reporting an infectious disease is to prevent the spread of infection through targeted measures, e.g., isolation, treatment of the infected, and tracking of transmission between individuals. Information about the probable transmission place, transmission time, and symptoms must accompany notifications to satisfy these conditions. In this way, infected persons can be linked epidemiologically, the effects of the infection can be assessed, and a response can be taken.

See also information about rubella on The European Center for Disease Control website (ECDC).

-Automatic translation

HPV and vaccination against HPV infections and cervical cancer

The Human Papilloma Virus (HPV) is the primary cause of premalignant cervical lesions and cancers. The virus is widespread, and it is estimated that around 80% of women become infected at some point in their lives. The virus is sexually transmitted and is mainly common in sexually active young people.

HPV has more than 100 subtypes. Approximately 40 of these can cause genital infections in both men and women, of which 15–17 are strains associated with cancer (high-risk strains). Infection with high-risk strains of HPV can lead to premalignant cervical disease and cervical cancer. These same species can also cause infections in other organs that can progress to cancer, such as the rectum, vagina, and external genitals of both women and men. Still, the virus can also cause cancer of the oral cavity, throat, and bronchi and can be transmitted through oral sex. HPV of other types (low-risk strains) may cause, for example, genital mutilation.

Epidemiology

Cervical cancer is the second most common cancer in women worldwide. About 1700 women with premalignant cervical lesions are diagnosed each year in Iceland, and 15-20 women with cervical cancer. The average age of women with pre-cancerous lesions is around 30 years, and women with cervical cancer are about 45 years, with 80% of the latter surviving for five years or more from diagnosis.

The incidence of HPV in other cancers in Iceland is not as well known but has been increasing in Iceland and many parts of the world in recent decades. It has been confirmed that HPV 16 is the most common type of virus in pharyngeal cancers. HPV is estimated to contribute to the development of 5% of all cancers worldwide.

Symptoms

Infections caused by the virus can be persistent, but in most cases, the body's immune system destroys them within a few months without any consequences. If an infection becomes established and persists, the risk of pre-cancerous changes and subsequent cancer increases if nothing is done.

Premature cervical lesions do not cause noticeable symptoms of infection, but if the lesions progress to cancer, symptoms are:

• Vaginal bleeding after sex

• Abnormal vaginal discharge

• Genital pain

These symptoms are not just limited to cervical cancer. Infections from other causes can cause the same kind of symptoms. If you notice these symptoms, you must seek medical attention, even though the last cervical smear may have been as expected.

HPV-related cancers, such as those of the rectum, oropharynx, or external genitals, may present as rounds or thicknesses and may cause pain and bleeding.

Treatment

There is no treatment for HPV infections,  but precancerous changes can be detected with a smear from the cervix. If the precursor changes are mild, their development is monitored, and the body's immune system works on the infection. This is done by regular medical check-ups, which take a cell roar from the cervix, which is sent to the Cancer Society's cell laboratory for further examination of cell changes under a microscope and for a specific search for HPV.

Severe and persistent premalignant changes are treated with cone cutting, but if cancer has already developed, three primary methods are used, i.e. surgery, radiation, and chemotherapy.

The vaccine

In Iceland, two vaccines have been used against the types of HPV that mainly cause cervical cancer. The vaccines are Cervarix and Gardasil 9. The latter vaccine contains antigens against the types of virus (HPV-6/11) that cause genital warts.

The vaccine Cervarix contains antigens HPV-16 and HPV-18, which are by far the most common high-risk strains of the HPV virus. In addition, the vaccine has shown significant cross-immunity against type 31/33/45, which can also cause cancer. Cervarix was used in general vaccinations for girls in 2011–2023. Gardasil 9 also contains antigen HPV-16/18 and antigen high-risk strains 31/33/45/52/58. It is now used regardless of gender for all 12-year-olds. The HPV vaccines do not protect against all strains of the virus that can cause cervical cancer, but vaccination can prevent the majority of cancer cases. The duration of the vaccine's effects cannot be certain, but all indications are that this period is many years, possibly lifelong.

Vaccination

With parliament's approval at the end of 2010, health authorities began vaccinations against the HPV in the autumn of 2011. Girls born in 1998 and 1999 were the first to be vaccinated, but in the beginning, the vaccination only applied to 12-year-old girls to prevent the development of cervical cancer. From 2023, the vaccination covers all 12-year-olds, regardless of gender, making the HPV vaccination part of the general vaccination scheme for all children.

Vaccination is primarily preventive but does not cure diseases caused by HPV infection. The vaccine is given in two injections at least six months apart. A single dose provides considerable protection, and vaccinations in some countries are now targeted at one dose. In Iceland, information on the benefits of vaccination to reduce the spread of HPV infections is still emerging, and it has not been considered timely to reduce the dose from two to one.

Older individuals have the option to receive the vaccine by prescription and by paying for it.

Since vaccination does not provide complete protection against oncogenic HPV, women need to have regular cervical cancer screening with cervical smears for diagnosis of premalignant lesions or early cancer. Broader spectrum vaccines and more widespread vaccinations globally will potentially reduce the usefulness of screening in the future. However, screening is still essential in preventing cancer development, while HPV is still widespread in the community.