Drug reference
Mantoux test ▶BY INTRADERMAL INJECTION ▶Child: 2 units for one dose ▶Adult: 2 units for one dose Mantoux test (if first test is negative and a further test is considered appropriate) ▶BY INTRADERMAL INJECTION ▶Child: 10 units for 1 dose ▶Adult: 10 units for 1 dose Vaccines DOSE EQUIVALENCE AND CONVERSION ▶2 units is equivalent to 0.1 mL of 20 units/mL strength. ▶10 units is equivalent to 0.1 mL of 100 units/mL strength.
PDF page 1383
CAUTIONS, FURTHER INFORMATION ▶Mantoux test Response to tuberculin may be suppressed by viral infection, sarcoidosis, corticosteroid therapy, or immunosuppression due to disease or treatment and the MMR vaccine. If a tuberculin skin test has already been initiated, then the MMR should be delayed until the skin test has been read unless protection against measles is required urgently. If a child has had a recent MMR, and requires a tuberculin test, then a 4 week interval should be observed. Apart from tuberculin and MMR, all other live vaccines can be administered at any time before or after tuberculin. Acute illness. minor illnesses CAUTIONS, FURTHER INFORMATION Vaccination may be postponed if the individual is suffering from an acute illness; however, it is not necessary to postpone immunisation in patients with minor illnesses without fever or systemic upset. ▶Impaired immune response and drugs affecting immune response Immune response to vaccines may be reduced in immunosuppressed patients and there is also a risk of generalised infection with live vaccines. Specialist advice should be sought for those being treated with high doses of corticosteroids (dose equivalents of prednisolone: adults, at least 40 mg daily for more than 1 week; children, 2 mg/kg (or more than 40 mg) daily for at least 1 week or 1 mg/kg daily for 1 month), or other immunosuppressive drugs, and those being treated for malignant conditions with chemotherapy or generalised radiotherapy. Live vaccines should be postponed until at least 3 months after stopping high-dose systemic corticosteroids and at least 6 months after stopping other immunosuppressive drugs or generalised Vaccines radiotherapy (at least 12 months after discontinuing immunosuppressants following bone-marrow transplantation). The Royal College of Paediatrics and Child Health has produced a statement, Immunisation of the Immunocompromised Child (2002)(available at www.rcpch. ac.uk). ▶Predisposition to neurological problems When there is a personal or family history of febrile convulsions, there is an increased risk of these occurring during fever from any cause including immunisation, but this is not a contra- indication to immunisation. In children who have had a seizure associated with fever without neurological deterioration, immunisation is recommended; advice on the management of fever (see Post-immunisation Pyrexia in Infants) should be given before immunisation. When a child has had a convulsion not associated with fever, and the neurological condition is not deteriorating, immunisation is recommended. Children with stable neurological disorders (e.g. spina bifida, congenital brain abnormality, and peri-natal hypoxic-ischaemic encephalopathy) should be immunised according to the recommended schedule. When there is a still evolving neurological problem, including poorly controlled epilepsy, immunisation should be deferred and the child referred to a specialist. Immunisation is recommended if a cause for the neurological disorder is identified. If a cause is not identified, immunisation should be deferred until the condition is stable.
PDF pages 1383, 1402
Available from ImmForm (SSI brand). The strength of tuberculin PPD in currently available products may be different to the strengths of products used previously for the Mantoux test; care is required to select the correct strength.
PDF page 1383
CONTRA-INDICATIONS, FURTHER INFORMATION ▶Impaired immune response Public Health England advises severely immunosuppressed patients should not be given live vaccines (including those with severe primary immunodeficiency).
PDF page 1401
Contra-indicated in patients with a confirmed anaphylactic reaction to a preceding dose of a vaccine containing the same antigens or vaccine component (such as antibacterials in viral vaccines).
PDF page 1402
MHRA/CHM ADVICE (UPDATED NOVEMBER 2017) Following reports of death in neonates who received a live attenuated vaccine after exposure to a tumor necrosis factor alpha (TNF-a) inhibitor in utero, the MHRA has issued the following advice: . any infant who has been exposed to immunosuppressive treatment from the mother either in utero during pregnancy or via breastfeeding should have any live attenuated vaccination deferred for as long as a postnatal influence on the immune status of the infant remains possible; . in the case of infants who have been exposed to TNF-a inhibitors and other immunosuppressive biological medicines in utero, PHE advise that any live attenuated vaccination (e.g. BCG vaccine) should be deferred until the infant is age 6 months; . PHE advise if there is any doubt as to whether an infant due to receive a live attenuated vaccine may be immunosuppressed due to the mother’s therapy, including exposure through breast-feeding, specialist advice should be sought.
PDF page 1401
▶Common or very common Appetite decreased. arthralgia (frequency not known in elderly). diarrhoea (uncommon in elderly). dizziness (uncommon in elderly). fatigue. fever. headache. irritability. lymphadenopathy (uncommon in elderly). malaise. myalgia. nausea (uncommon in elderly). skin reactions (rare in elderly). vomiting (uncommon in elderly) ▶Uncommon Hypersensitivity (frequency not known in elderly)
PDF page 1402
Live vaccines should not be administered routinely to pregnant women because of the theoretical risk of fetal infection but where there is a significant risk of exposure to disease, the need for vaccination usually outweighs any possible risk to the fetus. Termination of pregnancy following inadvertent immunisation is not recommended. There is no evidence of risk from vaccinating pregnant women with inactivated viral or bacterial vaccines or toxoids.
PDF page 1402
Although there is a theoretical risk of live vaccine being present in breast milk, vaccination is not contra-indicated for women who are breast-feeding when there is significant risk of exposure to disease. There is no evidence of risk from vaccinating women who are breast- feeding, with inactivated viral or bacterial vaccines or toxoids.
PDF page 1402
There can be variation in the licensing of different medicines containing the same drug. Forms available from special-order manufacturers include: solution for injection Solution for injection ▶Tuberculin purified protein derivative (Non-proprietary) Tuberculin purified protein derivative 20 tuberculin unit per 1 ml Tuberculin PPD RT 23 SSI 20 tuberculin units/ml solution for injection 1.5ml vials | 1 vial s Tuberculin purified protein derivative 100 tuberculin unit per 1 ml Tuberculin PPD RT 23 SSI 100 tuberculin units/ml solution for injection 1.5ml vials | 1 vial s Vaccination Vaccination, general principles Active immunity Active immunity can be acquired by natural disease or by vaccination. Vaccines stimulate production of antibodies and other components of the immune mechanism; they consist of either: . a live attenuated form of a virus (e.g. measles, mumps and rubella vaccine) or bacteria (e.g. BCG vaccine), or . inactivated preparations of the virus (e.g. influenza vaccine) or bacteria, or . detoxified exotoxins produced by a micro-organism (e.g. tetanus vaccine), or . extracts of a micro-organism, which may be derived from the organism (e.g. pneumococcal vaccine) or produced by recombinant DNA technology (e.g. hepatitis B vaccine). Live attenuated vaccines usually produce a durable immunity, but not always as long-lasting as that resulting from natural infection. Inactivated vaccines may require a primary series of injections of vaccine to produce an adequate antibody response, and in most cases booster (reinforcing) injections are required; the duration of immunity varies from months to many years. Some inactivated vaccines are adsorbed onto an adjuvant (such as aluminium hydroxide) to enhance the antibody response. Vaccines and HIV infection Vaccines HIV-positive individuals with or without symptoms can receive the following live vaccines: . MMR (but avoid if immunity significantly impaired; use of normal immunoglobulin should be considered after exposure to measles), varicella-zoster vaccine against chickenpox (but avoid if immunity significantly impaired— consult product literature; varicella–zoster immunoglobulin should be considered after exposure to chickenpox or herpes zoster), rotavirus; and the following inactivated vaccines: . anthrax, cholera (oral), diphtheria, haemophilus influenzae type b, hepatitis A, hepatitis B, human papillomavirus, influenza (injection), meningococcal, pertussis, pneumococcal, poliomyelitis, rabies, tetanus, tick-borne encephalitis, typhoid (injection). HIV-positive individuals should not receive: . BCG, influenza nasal spray (unless stable HIV infection and receiving antiretroviral therapy), typhoid (oral), yellow fever (if yellow fever risk is unavoidable, specialist advice should be sought). The above advice differs from that for other immunocompromised patients; Immunisation Guidelines for HIV-infected Adults issued by British HIV Association (BHIVA) are available at www.bhiva.org and, Immunisation of HIV- infected Children issued by Children’s HIV Association (CHIVA) are available at www.chiva.org.uk Vaccines and asplenia, splenic dysfunction, or complement disorders The following vaccines are recommended for individuals with asplenia, splenic dysfunction, or complement disorders (including those taking complement inhibitors) depending on the age at which their condition is diagnosed: . Influenza vaccine p. 1392; . Meningococcal groups A with C and W135 and Y vaccine p. 1385 and meningococcal group B vaccine (rDNA, component, adsorbed) p. 1384; . 13-valent pneumococcal polysaccharide conjugate vaccine (adsorbed) p. 1385 and/or 23-valent pneumococcal polysaccharide vaccine p. 1386. Patients on complement inhibitor therapy with eculizumab p. 1077 are not at increased risk of pneumococcal disease and do not require 23-valent pneumococcal polysaccharide vaccine or additional doses of 13-valent pneumococcal polysaccharide conjugate vaccine (adsorbed). Additional booster doses of other vaccines should be considered depending on the individual’s underlying condition—specialist advice may be required. For information on specific indications for immunisation of vulnerable groups, see Chapter 7, Immunisation of individuals with underlying medical conditions, in Immunisation against infectious disease- ‘The Green Book’. Children first diagnosed or presenting aged under 1 year should be immunised according to the Immunisation schedule p. 1364. During their first year they should also be given 2 doses of meningococcal groups A with C and W135 and Y vaccine at least 4 weeks apart, and a dose of 13-valent pneumococcal polysaccharide conjugate vaccine (adsorbed) p. 1385 (in order to have received a total of 2 doses of 13-valent pneumococcal polysaccharide conjugate vaccine (adsorbed) with an 8 week interval). 8 weeks following their routine 1 year booster vaccines, they should receive a booster dose of meningococcal groups A with C and W135 and Y vaccine. An additional dose of 13-valent pneumococcal polysaccharide conjugate vaccine (adsorbed) should be given at least 8 weeks after the routine 13-valent pneumococcal polysaccharide conjugate vaccine (adsorbed) booster p. 1385 scheduled at 1 year. After their second birthday, a dose of 23-valent pneumococcal polysaccharide vaccine p. 1386 should be given at least 8 weeks after the last dose of 13-valent pneumococcal polysaccharide conjugate vaccine (adsorbed). The influenza vaccine should be given annually in children aged 6 months or older. Children first diagnosed or presenting aged 1 year to under 2 years should be immunised according to the Immunisation schedule p. 1364, including any routine vaccines due at 1 year of age if not yet administered. 8 weeks following the routine 1 year booster vaccines a dose of meningococcal groups A with C and W135 and Y vaccine should be given. An additional dose of 13-valent pneumococcal polysaccharide conjugate vaccine (adsorbed) p. 1385 should be given at least 8 weeks after the 1 year 13-valent pneumococcal polysaccharide conjugate vaccine (adsorbed) booster dose p. 1385. After their second birthday, a dose of 23-valent pneumococcal polysaccharide vaccine p. 1386 should be given at least 8 weeks after the last dose of 13-valent pneumococcal polysaccharide conjugate vaccine (adsorbed). The influenza vaccine should be given annually. Children first diagnosed or presenting aged 2 years to under 10 years should be immunised according to the Immunisation schedule p. 1364. Additionally, they should be given a dose of meningococcal groups A with C and W135 and Y vaccine and 23-valent pneumococcal polysaccharide vaccine p. 1386. For children who have not received the full routine immunisation for meningococcal group B vaccine (rDNA, component, adsorbed), ensure that 2 doses, 8 weeks apart have been given since their first birthday. For children who have not received any 13-valent pneumococcal polysaccharide conjugate vaccine (adsorbed) p. 1385 previously, a single dose should be given, followed by a dose of 23-valent pneumococcal polysaccharide vaccine at least 8 weeks later. The influenza vaccine should be given annually. Individuals first diagnosed aged 10 years and over regardless of previous immunisations, should be given a dose of 23-valent pneumococcal polysaccharide vaccine p. 1386, meningococcal group B vaccine (rDNA, component, adsorbed) and meningococcal groups A with C and W135 and Y vaccine. After 4 weeks, an additional dose of meningococcal group B vaccine (rDNA, component, adsorbed) should be given. The influenza vaccine should be given annually. Vaccines and antisera availability Anthrax vaccine p. 1382 and yellow fever vaccine, live p. 1397, botulism antitoxin p. 1361, diphtheria antitoxin p. 1361, and snake and spider venom antitoxins are available from local designated holding centres. For antivenom, see Poisoning, emergency treatment p. 1430. Routine immunisation schedule When to immunise Vaccine given and dose schedule (for details of dose, see under individual vaccines) ▶Bacillus Calmette-Guérin vaccine p. 1382 (at birth, see Bacillus Calmette-Guérin vaccine Neonates at risk only p. 1365). ▶Hepatitis B vaccine p. 1389 (at birth, 4 weeks, and 1 year, see Hepatitis B vaccine p. 1368). 8 weeks ▶Diphtheria with tetanus, pertussis, hepatitis B, poliomyelitis and haemophilus influenzae type b vaccine p. 1381 (Infanrix hexa ®). First dose. ▶Meningococcal group B vaccine (rDNA, component, adsorbed) p. 1384 (Bexsero ®). First dose. ▶Changes have been made to the immunisation schedule for children born on or after 1st January 2020, see 12 weeks. For children born on or before 31st December 2019, give pneumococcal polysaccharide conjugate vaccine (adsorbed) p. 1385 (Prevenar 13 ®). First dose. ▶Rotavirus vaccine p. 1395 (Rotarix ®). First dose. 12 weeks ▶Diphtheria with tetanus, pertussis, hepatitis B, poliomyelitis and haemophilus influenzae type b vaccine (Infanrix hexa ®). Second dose. ▶For children born on or after 1st January 2020, give pneumococcal polysaccharide conjugate vaccine (adsorbed) (Prevenar 13 ®). Single dose. ▶Rotavirus vaccine (Rotarix ®). Second dose. 16 weeks ▶Diphtheria with tetanus, pertussis, hepatitis B, poliomyelitis and haemophilus influenzae type b vaccine (Infanrix hexa ®).Third dose. ▶Meningococcal group B vaccine (rDNA, component, adsorbed) (Bexsero ®). Second dose. ▶For children born on or before 31st December 2019, give pneumococcal polysaccharide conjugate vaccine (adsorbed) (Prevenar 13 ®). Second dose. ▶Measles, mumps and rubella vaccine, live p. 1393 (MMR VaxPRO ® or Priorix ®). First dose. 1 year (on or after first birthday) ▶Meningococcal group B vaccine (rDNA, component, adsorbed) (Bexsero ®). Single booster dose. ▶Pneumococcal polysaccharide conjugate vaccine (adsorbed) (Prevenar 13 ®). Single booster dose regardless of birth date. ▶Haemophilus influenzae type b with meningococcal group C vaccine p. 1383 (Menitorix ®). Single booster dose. 2–10 years on 31st August 2019 (including ▶Influenza vaccine p. 1392. Each year from September. Note: live attenuated influenza nasal spray is recommended (Fluenz Tetra ®). If contra-indicated and child is in a clinical risk children in reception class and school years 1, 2, 3, 4, 5, and 6). group, use inactivated influenza vaccine (see Influenza vaccine p. 1369). ▶Diphtheria with tetanus, pertussis and poliomyelitis vaccine p. 1381 (Boostrix-IPV ® or 3 years and 4 months, or soon after Repevax ®). Single booster dose. ▶Measles, mumps and rubella vaccine, live (MMR VaxPRO ® or Priorix ®). Second dose. ▶Human papillomavirus vaccines p. 1391 (Gardasil ®). 2 dose schedule; second dose 11–14 years. First dose of HPV vaccine will 6–24 months after first dose. Only Gardasil ® is offered as part of the national immunisation be offered to individuals aged 12–13 years programme. For individuals who started the schedule with Cervarix ®, but did not complete in England, Wales, and Northern Ireland, and the vaccination course, the course can be completed with Gardasil ®. Ideally one vaccine those aged 11–13 years in Scotland. For individuals aged 15 years and over, see should be used for the entire course. Human papillomavirus vaccine p. 1368. ▶Meningococcal groups A with C and W135 and Y vaccine p. 1385 (Nimenrix ® or Menveo ®). 13–15 years Single booster dose. ▶Diphtheria with tetanus and poliomyelitis vaccine p. 1380 (Revaxis ®). Single booster dose. 13–18 years Note: Can be given at the same time as the dose of meningococcal groups A with C and W135 and Y vaccine at 13–15 years of age. Females of child-bearing age susceptible to ▶Measles, mumps and rubella vaccine, live. Females of child-bearing age who have not received 2 doses of a rubella-containing vaccine or who do not have a positive antibody test rubella for rubella should be offered rubella immunisation (using the MMR vaccine)—exclude pregnancy before immunisation, and avoid pregnancy for one month after vaccination. Pregnant females ▶Acellular pertussis-containing vaccine administered as diphtheria with tetanus, pertussis and poliomyelitis vaccine (Boostrix-IPV ® or Repevax ®). 1 dose from the 16th week of pregnancy, preferably after the fetal anomaly scan (weeks 18–20). ▶Influenza vaccine (inactivated). Single dose administered from September, regardless of the stage of pregnancy (see Influenza vaccine p. 1369). Enquiries for vaccines not available commercially can also be made to: Vaccines and Countermeasures Response Department Public Health England Wellington House 133–155 Waterloo Road London SE1 8UG vaccinesupply@phe.gov.uk Vaccines In Scotland information about availability of vaccines can be obtained from a Specialist in Pharmaceutical Public Health. In Wales enquiries for vaccines not available commercially should be directed to: Welsh Medicines Information Centre University Hospital of Wales Cardiff CF14 4XW (029) 2074 2979 Routine immunisations during adult life When to immunise Vaccine given and dose schedule (for details of dose, see under individual vaccines) ▶Meningococcal groups A with C and W135 and Y vaccine (Nimenrix ® or Menveo ®). Single Under 25 years, those entering university dose. Note: Should be offered to those aged under 25 years entering university who have who are at risk of meningococcal disease not received the meningococcal groups A with C and W135 and Y vaccine over the age of 10 years. During adult life, if not previously ▶Diphtheria with tetanus and poliomyelitis vaccine. immunised or 5 dose course is incomplete 65 years ▶Pneumococcal polysaccharide vaccine p. 1386. From 65 years ▶Influenza vaccine (inactivated). Each year from September (see Influenza vaccine p. 1369). ▶Varicella-zoster vaccine p. 1396. Single dose. 70 years In Northern Ireland: Pharmacy and Medicines Management Centre Northern Health and Social Care Trust Beech House Antrim Hospital Site Bush Road Vaccines Antrim BT41 2RL rphps.admin@northerntrust.hscni.net For further details of availability, see under individual vaccines. Useful Resources Recommendations reflect advice from Immunisation against Infectious Disease- ‘The Green Book’. Public Health England, (2013). Chapters from the handbook (including updates since 2013) are available at: www.gov.uk/government/collections/immunisation-against- infectious-disease-the-green-book Immunisation schedule Routine immunisations, sources of information The Joint Committee on Vaccination and Immunisation have issued a statement on immunisation prioritisation during the COVID-19 pandemic, available at: www.gov.uk/ government/publications/jcvi-statement-on-immunisation- prioritisation/statement-from-jcvi-on-immunisation-prioritisation The following recommendations reflect advice produced by Public Health England. Recommendations specific to each vaccine can be found in Immunisation against infectious disease– ‘The Green Book’. Public Health England at: www.gov.uk/government/collections/immunisation-against- infectious-disease-the-green-book The immunisation schedule reflects advice from ‘The complete routine immunisation schedule’ produced by Public Health England (2019). For the most up to date immunisation schedule, see: www.gov.uk/government/ publications/the-complete-routine-immunisation-schedule The Influenza immunisation recommendations reflect advice from the ‘National flu immunisation programme plan 2019/2020’ produced by Public Health England, Department of Health and Social Care, and NHS England. For the most up-to-date letter, see: www.gov.uk/government/publications/ national-flu-immunisation-programme-plan Vaccines for the immunisation schedule should be obtained from ImmForm at: www.immform.dh.gov.uk Preterm birth Babies born preterm should receive all routine immunisations based on their actual date of birth. The risk of apnoea following vaccination is increased in preterm babies, particularly in those born at or before 28 weeks gestational age. If babies at risk of apnoea are in hospital at the time of their first immunisation, they should be monitored for respiratory complications for 48–72 hours after immunisation. If a baby develops apnoea, bradycardia, or desaturation after the first immunisation, the second immunisation should also be given in hospital with similar monitoring. Individuals with unknown or incomplete immunisation history For children born in the UK who present with an inadequate or unknown immunisation history, investigation into immunisations received should be carried out. Outstanding doses should be administered where the routine childhood immunisation schedule has not been completed. For advice on dosing schedules for missed vaccinations, and the immunisation of individuals coming to the UK, consult Chapter 11, The UK immunisation schedule, in Immunisation against infectious disease– ‘The Green Book’. Public Health England, available at: www.gov.uk/government/ publications/immunisation-schedule-the-green-book-chapter-11 Immunisations for healthcare and laboratory staff Vaccine-preventable diseases that can be transmitted from person to person are a risk for staff and patients in healthcare environments, and staff in laboratory environments. Therefore, all staff must be up-to-date with their routine immunisations. In addition, specific immunisations are recommended for certain staff groups due to the risk of acquiring or passing on infection. For detailed recommendations, consult Chapter 12, Immunisation of healthcare and laboratory staff in Immunisation against infectious disease– ‘The Green Book’. Public Health England, available at: www.gov.uk/government/ publications/immunisation-of-healthcare-and-laboratory-staff- the-green-book-chapter-12 Anthrax vaccine Overview Anthrax vaccine p. 1382 is made from antigens from inactivated Bacillus anthracis adsorbed onto an adjuvant. Anthrax immunisation is indicated for individuals who handle infected animals or process infected animal products where there is a potential risk of occupational exposure to B. anthracis. It is also recommended for occupations where workers are at risk of one-off high level exposures to anthrax (e.g. following a deliberate or accidental release of spores). A 4-dose regimen is used for primary immunisation; a single booster dose should be given at 10-year intervals on up to 3 occasions to workers at potential continuous low level risk of exposure to anthrax. In those with potential intermittent high level exposure, a single booster dose should be offered just before entering situations with a specific high exposure risk. If such opportunities do not arise, a single booster dose should be given at 10-year intervals on up to 3 occasions to sustain protection. In the event of proven or high probability of exposure to anthrax spores, a single booster dose should be given, in addition to antibacterial prophylaxis, except when a dose has been given in the preceding 12 months. Advice on the treatment of previously unvaccinated individuals with a proven or high probability of exposure to anthrax spores can be found at: www.gov.uk/government/ publications/chemical-biological-radiological-and-nuclear- incidents-recognise-and-respond. All suspected cases of anthrax must be notified to the local health protection unit. Where there is a community level outbreak, specialist advice should be sought from Public Health England (tel. 020 8200 4400) or, in Scotland, Health Protection Scotland (tel. 0140 300 1191). Useful Resources Recommendations reflect Chapter 13, Anthrax, in Immunisation against infectious disease– ‘The Green Book’. Public Health England. February 2017. www.gov.uk/government/publications/anthrax-the-green-book- chapter-13 Bacillus Calmette-Guérin vaccine Overview The Bacillus Calmette-Guérin vaccine p. 1382 (BCG vaccine) contains a live attenuated strain derived from Mycobacterium bovis which is indicated for the prevention of Tuberculosis p. 612. BCG vaccine is recommended for the following individuals if immunisation has not previously been carried out and they are tuberculin-negative: . all neonates and infants (aged 0–12 months) living in areas of the UK where the annual incidence of tuberculosis is 40 cases per 100 000 or greater; . all neonates and infants (aged 0–12 months) with a parent or grandparent born in a country where the annual incidence of tuberculosis is 40 cases per 100 000 or greater; . previously unvaccinated children (aged 1–5 years) with a parent or grandparent born in a country where the annual incidence of tuberculosis is 40 cases per 100 000 or greater (tuberculin testing is not usually required); . previously unvaccinated children (aged 6–15 years) with a parent or grandparent born in a country where the annual incidence of tuberculosis is 40 cases per 100 000 or greater; . previously unvaccinated children (aged under 16 years) with close contact to cases of sputum smear-positive pulmonary or laryngeal tuberculosis; . previously unvaccinated children (aged under 16 years) who were born in, or lived for at least 3 months in a country where the annual incidence of tuberculosis is 40 cases per 100 000 or greater; . previously unvaccinated individuals at occupational risk (irrespective of age). This includes healthcare workers or laboratory staff who have direct contact with patients with tuberculosis or potentially infectious clinical materials, and veterinary and abattoir staff handling animals or animal materials that could be infected with tuberculosis. BCG vaccination can also be considered for staff working with prisoners, homeless people, people with drug and alcohol misuse, and those who work with refugees and asylum seekers. Although protection provided by BCG vaccine may decrease with time, there is no evidence that repeat vaccination offers significant additional protection and therefore repeat BCG vaccination is not recommended. The Bacillus Calmette-Guérin vaccine is contra-indicated in all HIV-infected individuals. For advice on BCG vaccination in immunosuppressed individuals, consult Chapter 32: Tuberculosis - ‘The Green Book’, Public Health England (see Useful resources). For advice on drug treatment, see Tuberculosis p. 612; for the treatment of infection following vaccination, seek expert advice. Travel The risk of a traveller acquiring tuberculosis infection depends on several factors including the incidence of tuberculosis in that country, the duration of travel, the degree of contact with the local population, the work setting of the traveller (if any), the reason for travel, and the susceptibility and age of the traveller. BCG vaccine is recommended for previously unvaccinated, tuberculin-negative individuals aged under 16 years, or for healthcare workers at high risk of exposure to patients with tuberculosis, who intend to travel for 3 months or more in a country where the annual incidence of tuberculosis is 40 cases per 100 000 or greater, or where the risk of multi-drug resistant tuberculosis is high. The risk of tourists acquiring tuberculosis infection is low and BCG vaccine is not required if no other factors are present. Vaccines A list of countries where the annual incidence of tuberculosis is 40 cases per 100 000 or greater, is available at www.gov.uk/government/publications/tuberculosis-tb-by- country-rates-per-100000-people. Tuberculin skin testing The tuberculin skin test (Mantoux test) is used to assess an individual’s sensitivity to tuberculin protein when BCG vaccination is being considered or as an aid to diagnosis of tuberculosis. A tuberculin skin test involves administration of tuberculin purified protein derivative p. 1361 by intradermal injection. It is necessary before BCG vaccination for: . individuals aged 6 years and over; . children aged under 6 years living in a country for more than 3 months with an annual tuberculosis incidence of 40 cases per 100 000 or greater; . those who have had close contact with a person with known tuberculosis; . those who have a family history of tuberculosis within the last 5 years. BCG vaccination can be given up to three months following a negative tuberculin test. The BCG vaccine should not be administered to an individual with a positive tuberculin test—it is unnecessary and may cause a more severe local reaction. Those with a Mantoux test induration of 5 mm and greater should be referred to a tuberculosis clinic for assessment of the need for further investigation and treatment. All suspected cases of tuberculosis must be notified to the local health protection unit. Where there is a community level outbreak, specialist advice should be sought from Public Health England (tel. 020 8200 4400) or, in Scotland, Health Protection Scotland (tel. 0140 300 1191). Useful Resources Recommendations reflect Chapter 32, Tuberculosis, in Immunisation against infectious disease– ‘The Green Book’. Public Health England, August 2018. www.gov.uk/government/publications/tuberculosis-the-green- book-chapter-32 Botulism antitoxin Overview A polyvalent botulism antitoxin p. 1361 is available for the post-exposure prophylaxis of botulism and for the treatment of persons thought to be suffering from botulism. It specifically neutralises the toxins produced by Clostridium botulinum types A, B, and E. It is not effective against infantile botulism as the toxin (type A) is seldom, if ever, found in the blood in this type of infection. Useful Resources Advice reflects that in the handbook Immunisation against Infectious Disease (2013), which in turn reflects the guidance of the Joint Committee on Vaccination and Immunisation (JCVI). The advice also incorporates changes announced by the Chief Medical Officer and Health Department Updates. Chapters from the handbook (including updates since 2013) are available at: www.gov.uk/government/collections/immunisation-against- infectious-disease-the-green-book Cholera vaccine Overview Oral cholera vaccine p. 1383 contains inactivated Inaba Vaccines (including El-Tor biotype) and Ogawa strains of Vibrio cholerae, serotype O1 together with recombinant B-subunit of the cholera toxin produced in Inaba strains of V. cholerae, serotype O1. Oral cholera vaccine is licensed for adults and children from 2 years of age who are travelling to endemic or epidemic areas on the basis of current recommendations. Immunisation should be completed at least one week before potential exposure. However, there is no requirement for cholera vaccination for international travel. After a full risk assessment, immunisation can be considered for the following individuals: . relief or disaster aid workers; . persons with remote itineraries in areas where cholera epidemics are occurring and there is limited access to medical care; . travellers to potential cholera risk areas, for whom vaccination is considered potentially beneficial; . individuals at occupational risk, such as laboratory workers who may be regularly exposed to cholera. For dosing schedule, see cholera vaccine. Immunisation with cholera vaccine does not provide complete protection and all travellers to a country where cholera exists should be warned that scrupulous attention to food, water, and personal hygiene is essential. All suspected cases of cholera must be notified to the local health protection unit. Where there is a community level outbreak, specialist advice should be sought from Public Health England (tel. 020 8200 4400) or, in Scotland, Health Protection Scotland (tel. 0140 300 1191). Contacts Contacts of patients with cholera should maintain high standards of personal hygiene to avoid becoming infected. Cholera vaccine should not be used in the management of contacts of cases or in controlling the spread of infection. Useful Resources Recommendations reflect Chapter 14, Cholera, in Immunisation against infectious disease– ‘The Green Book’. Public Health England, December 2013. www.gov.uk/government/publications/cholera-the-green-book- chapter-14 Diphtheria vaccine Overview Diphtheria-containing vaccines are prepared from the toxin of Corynebacterium diphtheriae and adsorption on aluminium hydroxide or aluminium phosphate improves antigenicity. The vaccine stimulates the production of the protective antibody. The quantity of diphtheria toxoid in a preparation determines whether the vaccine is defined as ‘high dose’ or ‘low dose’. Vaccines containing the higher dose of diphtheria toxoid are used for primary immunisation of children under 10 years of age. Vaccines containing the lower dose of diphtheria toxoid are used for primary immunisation in adults and children over 10 years. Single-antigen diphtheria vaccine is not available and adsorbed diphtheria vaccine is given as a combination product containing other vaccines. For primary immunisation of children aged between 2 months and 10 years, vaccination is recommended usually in the form of 3 doses (separated by 1-month intervals) of diphtheria with tetanus, pertussis, hepatitis B, poliomyelitis and haemophilus influenzae type b vaccine p. 1381 (Infanrix hexa ®) (see Immunisation schedule). In unimmunised individuals aged over 10 years the primary course comprises of 3 doses of adsorbed diphtheria [low dose], tetanus and poliomyelitis (inactivated) vaccine. A booster dose should be given 3 years after the primary course (this interval can be reduced to a minimum of 1 year if the primary course was delayed). Children under 10 years should receive either adsorbed diphtheria, tetanus, pertussis (acellular, component) and poliomyelitis (inactivated) vaccine oradsorbed diphtheria [low dose], tetanus, pertussis (acellular, component) and poliomyelitis (inactivated) vaccine . Individuals aged over 10 years should receive adsorbed diphtheria [low dose], tetanus, and poliomyelitis (inactivated) vaccine. A second booster dose, of adsorbed diphtheria [low dose], tetanus and poliomyelitis (inactivated) vaccine, should be given 10 years after the previous booster dose (this interval can be reduced to a minimum of 5 years if previous doses were delayed). Diphtheria-containing vaccines for children over 10 years and adults A low dose of diphtheria toxoid is sufficient to recall immunity in individuals previously immunised against diphtheria but whose immunity may have diminished with time; it is insufficient to cause serious reactions in an individual who is already immune. Preparations containing low dose diphtheria should be used for adults and children over 10 years, for both primary immunisation and booster doses. Travel Those intending to travel to areas with a risk of diphtheria infection should be fully immunised according to the UK schedule. If more than 10 years have lapsed since completion of the UK schedule, a dose of adsorbed diphtheria [low dose], tetanus and poliomyelitis (inactivated) vaccine should be administered. Contacts Staff in contact with diphtheria patients or with potentially pathogenic clinical specimens or working directly with C. diphtheriae or C. ulcerans should receive a booster dose if fully immunised (with 5 doses of diphtheria-containing vaccine given at appropriate intervals); further doses should be given at 10-year intervals if risk persists. Individuals at risk who are not fully immunised should complete the primary course; a booster dose should be given after 5 years and then at 10-year intervals. Adsorbed diphtheria [low dose], tetanus and poliomyelitis (inactivated) vaccine is used for this purpose; immunity should be checked by antibody testing at least 3 months after completion of immunisation. Advice on the management of cases, carriers, contacts and outbreaks must be sought from health protection units. The immunisation history of infected individuals and their contacts should be determined; those who have been incompletely immunised should complete their immunisation and fully immunised individuals should receive a reinforcing dose. See advice on antibacterial treatment to prevent a secondary case of diphtheria in a non-immune individual. Useful Resources Advice reflects that in the handbook Immunisation against Infectious Disease (2013), which in turn reflects the guidance of the Joint Committee on Vaccination and Immunisation (JCVI). The advice also incorporates changes announced by the Chief Medical Officer and Health Department Updates. Chapters from the handbook (including updates since 2013) are available at: www.gov.uk/government/collections/immunisation-against- infectious-disease-the-green-book Haemophilus influenzae type B conjugate vaccine Overview Haemophilus influenzae type b (Hib) vaccine is made from capsular polysaccharide; it is conjugated with a protein such as tetanus toxoid to increase immunogenicity, especially in young children. Haemophilus influenzae type b vaccine immunisation is given in combination with diphtheria, tetanus, pertussis, hepatitis B and poliomyelitis vaccine (Infanrix hexa ®), as a component of the primary course of childhood immunisation (see Immunisation schedule). For infants under 1 year, the course consists of 3 doses of a vaccine containing Haemophilus influenzae type b component with an interval of 1 month between doses. A booster dose of Haemophilus influenzae type b vaccine (combined with meningococcal group C conjugate vaccine) should be given at 1 year of age, on or after the child’s first birthday. Children 1–10 years who have not been immunised against Haemophilus influenzae type b need to receive only 1 dose of Haemophilus influenzae type b vaccine (combined with meningococcal group C conjugate vaccine). However, if a primary course of immunisation has not been completed, children born before August 2017 should be given 3 doses of the combined vaccine they were started on. The risk of infection falls sharply in older children and the vaccine is not normally required for children over 10 years. Haemophilus influenzae type b vaccine may be given to those over 10 years who are considered to be at increased risk of invasive H. influenzae type b disease (such as those with sickle-cell disease or complement deficiency, or those receiving treatment for malignancy). Invasive Haemophilus influenzae type b disease After recovery from infection, unimmunised and partially immunised index cases under 10 years of age should complete their age-specific course of immunisation. Previously vaccinated cases under 10 years of age should be given an additional dose of haemophilus influenzae type b vaccine (combined with meningococcal group C conjugate vaccine) if Hib antibody concentrations are low or if it is not possible to measure antibody concentrations. Index cases of any age with asplenia or splenic dysfunction should complete their immunisation according to the recommendations below; fully vaccinated cases with asplenia or splenic dysfunction should be given an additional dose of haemophilus influenzae type b vaccine (combined with meningococcal group C conjugate vaccine) if they received their previous dose over 1 year ago. See also use of rifampicin p. 615 in the prevention of secondary cases of Haemophilus influenzae type b disease. Useful Resources Advice reflects that in the handbook Immunisation against Infectious Disease (2013), which in turn reflects the guidance of the Joint Committee on Vaccination and Immunisation (JCVI). The advice also incorporates changes announced by the Chief Medical Officer and Health Department Updates. Chapters from the handbook (including updates since 2013) are available at: www.gov.uk/government/collections/immunisation-against- infectious-disease-the-green-book Hepatitis A vaccine Overview Hepatitis A vaccine p. 1388 is prepared from formaldehyde- inactivated hepatitis A virus grown in human diploid cells. Immunisation is recommended for: . laboratory staff who work directly with the virus; . staff and residents of homes for those with severe learning difficulties; . workers at risk of exposure to untreated sewage; . individuals who work with primates; Vaccines . patients with haemophilia or other conditions treated with plasma-derived clotting factors; . patients with severe liver disease; . travellers to high-risk areas; . individuals who are at risk due to their sexual behaviour; . parenteral drug abusers. Immunisation should be considered for: . patients with chronic liver disease including chronic hepatitis B or chronic hepatitis C; . prevention of secondary cases in close contacts of confirmed cases of hepatitis A, within 14 days of exposure to the primary case (within 8 weeks of exposure to the primary case where there is more than 1 contact in the household). A booster dose is usually given 6–12 months after the initial dose. A second booster dose can be given 20 years after the previous booster dose to those who continue to be at risk. Specialist advice should be sought on re- immunisation of immunocompromised individuals. For rapid protection against hepatitis A after exposure or during an outbreak, in adults a single dose of a monovalent vaccine is recommended; for children under 16 years, a single dose of the combined vaccine Ambirix ® can also be used. Public Health England recommends the use of intramuscular normal immunoglobulin p. 1358 in addition to hepatitis A vaccine for prevention of infection in close contacts (of confirmed cases of hepatitis A) who are 60 years of age or over, have chronic liver disease, or HIV infection, or who are immunosuppressed. For further guidance, see Immunoglobulins p. 1354. Post-exposure prophylaxis is not required for healthy children under 1 year of age, so long as all those involved in nappy changing are vaccinated against hepatitis A. However, children 2–12 months of age can be given a dose of hepatitis A vaccine if it is not possible to vaccinate their carers, or if the child becomes a source of infection to others [unlicensed use]; in these cases, if the child goes on to require long-term protection against hepatitis A after the first birthday, the full course of 2 doses should be given. Useful Resources Advice reflects that in the handbook Immunisation against Infectious Disease (2013), which in turn reflects the guidance of the Joint Committee on Vaccination and Immunisation (JCVI). The advice also incorporates changes announced by the Chief Medical Officer and Health Department Updates. Chapters from the handbook (including updates since 2013) are available at: www.gov.uk/government/collections/immunisation-against- infectious-disease-the-green-book Hepatitis B vaccine Overview Hepatitis B vaccine p. 1389 contains inactivated hepatitis B virus surface antigen (HBsAg) adsorbed onto an adjuvant. It is made biosynthetically using recombinant DNA technology. From August 2017, vaccination against hepatitis B is recommended as part of the routine immunisation schedule. Primary immunisation (see Routine immunisation schedule) requires 3 doses, administered at intervals of 1 month from the age of 2 months, to be given as part of the combined diphtheria with tetanus, pertussis, hepatitis B, poliomyelitis and haemophilus influenzae type b vaccine p. 1381 (Infanrix hexa ®). As part of the selective neonatal immunisation programme, vaccination is recommended for neonates whose mothers have had acute hepatitis B during pregnancy or are positive for hepatitis B surface antigen (regardless of e-antigen markers). Hepatitis B vaccination is started Vaccines immediately after birth with a dose of the monovalent hepatitis B vaccine (no later than 24 hours after delivery), followed by a second dose at 4 weeks; the routine immunisation combination vaccine (Infanrix hexa ®) at weeks 8, 12 and 16; and a further dose of the monovalent hepatitis B vaccine at one year of age. Neonates born to highly infectious mothers should also receive hepatitis B immunoglobulin p. 1357 at the same time as the first dose of monovalent hepatitis B vaccine, but administered at a different site—more detailed guidance is given in the handbook Immunisation against Infectious Disease (www.gov.uk/government/publications/hepatitis-b-the- green-book-chapter-18). Following significant exposure to hepatitis B (e.g. through needle-stick injury or unprotected sex) and for pre- exposure prophylaxis in high-risk groups, an ‘accelerated schedule’ using the single, monovalent hepatitis B vaccine is recommended immediately, with the second dose given 1 month after the initial dose, and the third dose given 2 months after the initial dose. For those at continued high risk following exposure, a fourth dose should be given 12 months after the first dose. More detailed guidance is given in the handbook Immunisation against Infectious Disease. Specific hepatitis B immunoglobulin can also be indicated for use with the vaccine in those accidentally inoculated and in neonates at special risk of infection. If hepatitis B immunoglobulin is indicated, it should be given as soon as possible, ideally at the same time or within 24 hours of the first dose of vaccine, but not after seven days have elapsed since exposure. See also Hepatitis B immunoglobulin in Immunoglobulins p. 1354. In the UK, groups at high-risk of hepatitis B include: . parenteral drug misusers, their sexual partners, and household contacts; other drug misusers who are likely to ‘progress’ to injecting; . individuals who change sexual partners frequently; . close family contacts of a case or individual with chronic hepatitis B infection; . individuals with haemophilia, those receiving regular blood transfusions or blood products, and carers responsible for the administration of such products; . patients with chronic renal failure including those on haemodialysis. Haemodialysis patients should be monitored for antibodies annually and re-immunised if necessary. Home carers (of dialysis patients) should be vaccinated; . individuals with chronic liver disease; . healthcare personnel (including trainees) who have direct contact with blood or blood-stained body fluids or with patients’ tissues; . laboratory staff who handle material that may contain the virus; . other occupational risk groups such as morticians and embalmers; . staff and patients of day-care or residential accommodation for those with severe learning difficulties; . staff and inmates of custodial institutions; . those travelling to areas of high or intermediate prevalence who are at increased risk or who plan to remain there for lengthy periods; . families adopting children from countries with a high or intermediate prevalence of hepatitis B; . foster carers and their families. Following a primary course of immunisation, most people do not require a reinforcing dose of a hepatitis B-containing vaccine. A single booster dose should be offered to healthcare workers approximately five years after primary immunisation, to patients on renal dialysis with anti-HBs levels below 10mlU/mL, and at the time of a subsequent significant exposure. Immunisation does not eliminate the need for common sense precautions for avoiding the risk of infection from known carriers by the routes of infection which have been clearly established, consult Guidance for Clinical Health Care Workers: Protection against Infection with Blood-borne Viruses (available at www.dh.gov.uk/). Accidental inoculation of hepatitis B virus-infected blood into a wound, incision, needle-prick, or abrasion may lead to infection, whereas it is unlikely that indirect exposure to a carrier will do so. A combined hepatitis A and B vaccine p. 1387 is also available. Useful Resources Advice reflects that in the handbook Immunisation against Infectious Disease (2013), which in turn reflects the guidance of the Joint Committee on Vaccination and Immunisation (JCVI). The advice also incorporates changes announced by the Chief Medical Officer and Health Department Updates. Chapters from the handbook (including updates since 2013) are available at: www.gov.uk/government/collections/immunisation-against- infectious-disease-the-green-book Human papillomavirus vaccine Overview The human papillomavirus vaccines p. 1391 consist of virus- like particles prepared from the major protein of the viral coat or capsid and mimic the structure of the native virus, but do not contain any viral DNA. The vaccines are available as a bivalent vaccine (Cervarix ®, containing human papillomavirus (HPV) types 16 and 18), a quadrivalent vaccine (Gardasil ®, containing HPV types 6, 11, 16 and 18), and a nine-valent vaccine (Gardasil 9 ®, containing HPV types 6, 11, 16, 18, 31, 33, 45, 52 and 58). All are adjuvanted and used for the prevention of cervical and anal cancers, and pre-cancerous genital (cervical, vulvar, and vaginal) and anal lesions associated with HPV types 16 and 18. Gardasil ® and Gardasil 9 ® are also effective at preventing genital warts. The vaccines may also provide some cross-protection against infection caused by other high-risk HPV types. Although there is emerging evidence on interchangeability of the HPV vaccines, the same vaccine product should be used for an entire course. Only Gardasil ® is offered as part of the national HPV programme and is recommended for eligible individuals aged 11 to 25 years, and for men who have sex with men aged up to and including 45 years of age. As the vaccines do not protect against all strains of HPV, safe sex precautions should always be practiced; and for all females, routine cervical screening should continue at the scheduled age. Children aged 9 to 14 years The human papillomavirus vaccines are licensed for individuals from 9 years of age, however, vaccination in children aged 9 to 10 years is not offered as part of the national programme. A 2 dose schedule is recommended for children who receive the first dose before the age of 15 years. The first dose is usually given to children from 11 years, with the second dose given 6–24 months after the first dose. See Immunisation schedule p. 1364 for guidance on immunisation in different countries within the UK. 2 doses given less than 6 months apart should not be considered adequate to provide long term protection. A third dose should be given according to human papillomavirus vaccines dosing schedule. Children and adults aged 15 to 25 years Under the national programme in England, individuals remain eligible to receive the HPV vaccine up to the age of 25 years if they did not receive the vaccine when scheduled. A 3 dose schedule is recommended, with the second and third dose given 1 month and 4–6 months after the first dose respectively. All 3 doses should be given within a 12-month period (see human papillomavirus vaccines). In cases where the second dose is given late and there is a high likelihood that the individual will not return, or it is not practical for the third dose to be given after three months, then the third dose can be given at least one month after the second dose. Where appropriate, immunisation with the HPV vaccine should be offered to individuals aged under 25 years coming into the UK, as they may not have been offered protection in their country of origin. If they are aged 25 years and over, and commenced, but did not complete their vaccination, it is reasonable to complete their vaccination in the UK. Vaccination of men who have sex with men and other at risk individuals Men aged 15—45 years, who have sex with other men and attend Specialist Sexual Health Services or HIV clinics are eligible for vaccination if they have not previously been vaccinated. Immunisation should still be offered to eligible men who have sex with men, regardless of CD4 cell count, antiretroviral therapy use, viral load, or if known to be immunocompromised at the time of immunisation. A 3 dose schedule of Gardasil ® should be given, with administration of doses aligned with clinic appointments. All 3 doses should be given within a 24 month period, but if the course has not been completed before the age of 46, it can still be completed provided the first dose was given as part of the pilot or national programme. There may be considerable benefit in offering the HPV vaccination to individuals who attend Sexual Health Services or HIV clinics, who are not eligible under the national programme and are deemed to have a similar risk profile to that seen in men who have sex with men. This includes some transgender individuals, sex workers, and men and women living with HIV infection. For these individuals a 3 dose schedule of Gardasil ® is recommended. Refer to the British HIV Association for further information on the use of human papillomavirus vaccines in individuals with HIV infection. See www.bhiva.org/guidelines for further information. Booster doses Protection from human papillomavirus vaccines is maintained for at least 10 years, although protection is expected to last longer. There is no recommendation for the need for booster doses. Useful Resources Recommendations reflect Chapter 18a, Human papillomavirus, in Immunisation against infectious disease- ‘The Green Book’. Public Health England, July 2019. www.gov.uk/government/publications/human-papillomavirus- hpv-the-green-book-chapter-18a HPV vaccination programme for men who have sex with men (MSM) - Clinical and operational guidance. Public Health England, April 2018. www.gov.uk/government/collections/hpv-vaccination-for-men- who-have-sex-with-men-msm-programme Influenza vaccine Overview While most viruses are antigenically stable, the influenza viruses A and B (especially A) are constantly altering their antigenic structure as indicated by changes in the haemagglutinins (H) and neuraminidases (N) on the surface Vaccines of the viruses. It is essential that influenza vaccine p. 1392 in use contain the H and N components of the prevalent strain or strains as recommended each year by the World Health Organization. The influenza vaccines recommended for immunisation are the adjuvanted trivalent influenza vaccine (inactivated), high dose trivalent influenza vaccine (inactivated), cell- grown quadrivalent influenza vaccine (inactivated), standard egg-grown quadrivalent influenza vaccine (inactivated), and live attenuated influenza vaccine. The choice of vaccine is dependent on the person’s age and contra-indications. The ideal time for immunisation is between September and early November. Immunisation is recommended for people at high risk from influenza, and to reduce transmission of infection. Annual immunisation is strongly recommended for individuals aged 6 months and over with the following conditions: . chronic respiratory disease; . chronic heart disease; . chronic liver disease; . chronic renal disease at stage 3, 4 or 5; . chronic neurological disease; . complement disorders; . diabetes mellitus; . immunosuppression because of disease (including asplenia or splenic dysfunction) or treatment (including prolonged systemic corticosteroid treatment [for over 1 month at dose equivalents of prednisolone p. 716: adult and child over 20 kg, 20 mg or more daily; child under 20 kg, 1 mg/kg or more daily], and chemotherapy); . HIV infection (regardless of immune status); . morbid obesity (BMI of 40 kg/m2 and above). Annual influenza vaccine is also recommended for: . children of specific ages, see Immunisation schedule p. 1364; . all pregnant women (including those who become pregnant during the flu season); . all adults aged 65 years and over (including those becoming 65 by 31 March 2020); . residents of nursing or residential homes for the elderly and other long-stay facilities; . carers of individuals whose welfare may be at risk if the carer falls ill; . household contacts of immunocompromised individuals; . frontline health and social care workers. Children aged 6 months to less than 2 years of age in clinical risk groups should be offered the standard egg- grown quadrivalent inactivated influenza vaccine. Children aged 2–17 years of age (including those in clinical risk groups) should be offered the live attenuated influenza vaccine, administered as a nasal spray (Fluenz tetra ®). The live attenuated vaccine is thought to provide broader protection than inactivated vaccines. If the child is in a clinical risk group and the live attenuated vaccine is contra- indicated or otherwise unsuitable, offer standard egg-grown quadrivalent inactivated influenza vaccine. Children aged 6 months to less than 9 years of age in clinical risk groups who have not had the influenza vaccine previously should be offered two doses of the appropriate influenza vaccine, four weeks apart. Adults aged 18 to 64 years of age in clinical risk groups, pregnant females, and other eligible groups should be offered either the standard egg-grown quadrivalent inactivated influenza vaccine or the cell-grown quadrivalent inactivated influenza vaccine. Adults aged 65 years and over should be offered either the adjuvanted trivalent inactivated influenza vaccine or the cell-grown quadrivalent inactivated influenza vaccine. The high dose trivalent inactivated influenza vaccine is equally suitable but is not eligible for reimbursement under the NHS flu vaccination 2019/2020 programme . Vaccines In the 2019/2020 national influenza immunisation programme, annual influenza vaccine will be offered to all children aged 2–10 years on 31st August 2019 (including those in reception class and school years 1, 2, 3, 4, 5, and 6). For the management of influenza, see Influenza p. 698. Information on pandemic influenza, avian influenza, swine influenza, and annual flu programme may be found at www.gov.uk/government/collections/pandemic-flu-public-health- response and at www.gov.uk/government/collections/annual-flu- programme. Useful Resources Recommendations reflect Chapter 19, Influenza, in Immunisation against infectious disease– ‘The Green Book’. Public Health England. April 2019. www.gov.uk/government/publications/influenza-the-green-book- chapter-19 ‘National flu immunisation programme plan 2019/2020’ Public Health England, Department of Health and Social Care, and NHS England. March 2019. www.gov.uk/government/publications/national-flu-immunisation- programme-plan Japanese encephalitis vaccine Overview Japanese encephalitis is a mosquito-borne viral encephalitis caused by a Flavivirus. Japanese encephalitis vaccine p. 1393 (IXIARO) ® is an inactivated vaccine adsorbed onto an adjuvant. It is recommended for individuals who are going to reside in an area where Japanese encephalitis is endemic or epidemic. Travellers to South and South-East Asia and the Far East should be immunised if staying for a month or longer in endemic areas during the transmission season. Other travellers with shorter exposure periods should also be immunised if the risk is considered sufficient. Immunisation is also recommended for laboratory staff at risk of exposure to the virus. The primary immunisation course of 2 doses should be completed at least one week before potential exposure to Japanese encephalitis virus. In adults (aged under 65 years) and children (aged 2 months and over) at ongoing risk (including laboratory staff and long-term travellers), a single booster dose should be given 12 months after the primary immunisation course. A booster dose can be considered in adults aged 65 years and over, but the immune response is lower than in younger adults. For other travellers, a single booster dose should be given within 12–24 months after primary immunisation, before potential re-exposure to the Japanese encephalitis virus. Travellers aged 18–64 years should be offered a second booster dose at 10 years if they remain at risk. Cases of Japanese encephalitis should be managed with supportive treatment. Up-to-date information on the risk of Japanese encephalitis in specific countries can be obtained from the National Travel Health Network and Centre. Useful Resources Recommendations reflect Chapter 20, Japanese encephalitis, in Immunisation against infectious disease– ‘The Green Book’. Public Health England, June 2018. www.gov.uk/government/publications/japanese-encephalitis-the- green-book-chapter-20 National Travel Health Network and Centre nathnac.net Measles, Mumps and Rubella vaccine Overview Measles vaccine has been replaced by a combined measles, mumps and rubella vaccine, live p. 1393 (MMR vaccine). Measles, mumps and rubella vaccine, live aims to eliminate measles, mumps, and rubella (German measles) and congenital rubella syndrome. Every child should receive two doses of measles, mumps and rubella vaccine, live by entry to primary school, unless there is a valid contra- indication. Measles, mumps and rubella vaccine, live should be given irrespective of previous measles, mumps, or rubella infection or vaccination. The first dose of measles, mumps and rubella vaccine, live is given to children at 1 year of age, on or after their first birthday. A second dose is given before starting school at 3 years and 4 months of age, or soon after (see Immunisation Schedule). Children presenting for pre-school booster who have not received the first dose of measles, mumps and rubella vaccine, live should be given a dose of measles, mumps and rubella vaccine, live followed 3 months later by a second dose. At school-leaving age or at entry into further education, measles, mumps and rubella vaccine, live immunisation should be offered to individuals of both sexes who have not received 2 doses during childhood. In those who have received only a single dose of measles, mumps and rubella vaccine, live in childhood, a second dose is recommended to achieve full protection. If 2 doses of measles, mumps and rubella vaccine, live are required, the second dose should be given one month after the initial dose. The decision on whether to vaccinate adults should take into consideration their vaccination history, the likelihood of the individual remaining susceptible, and the future risk of exposure and disease. Measles, mumps and rubella vaccine, live should be used to protect against rubella in seronegative women of child- bearing age (see Immunisation Schedule); unimmunised healthcare workers who might put pregnant women and other vulnerable groups at risk of rubella or measles should be vaccinated. Measles, mumps and rubella vaccine, live may also be offered to previously unimmunised and seronegative post-partum women (see measles, mumps and rubella vaccine, live)—vaccination a few days after delivery is important because about 60% of congenital abnormalities from rubella infection occur in babies of women who have borne more than one child. Immigrants arriving after the age of school immunisation are particularly likely to require immunisation. Contacts Measles, mumps and rubella vaccine, live may also be used in the control of outbreaks of measles and should be offered to susceptible children aged over 6 months who are contacts of a case, within 3 days of exposure to infection. Children immunised before 12 months of age should still receive two doses of measles, mumps and rubella vaccine, live at the recommended ages. If one dose of measles, mumps and rubella vaccine, live has already been given to a child, then the second dose may be brought forward to at least one month after the first, to ensure complete protection. If the child is under 18 months of age and the second dose is given within 3 months of the first, then the routine dose before starting school at 3 years and 4 months of age (or soon after) should still be given. Children aged under 9 months for whom avoidance of measles infection is particularly important (such as those with history of recent severe illness) can be given normal immunoglobulin after exposure to measles; routine measles, mumps and rubella vaccine, live immunisation should then be given after at least 3 months at the appropriate age. Measles, mumps and rubella vaccine, live is not suitable for prophylaxis following exposure to mumps or rubella since the antibody response to the mumps and rubella components is too slow for effective prophylaxis. Children and adults with impaired immune response should not receive live vaccines (see advice on HIV). If they have been exposed to measles infection they should be given normal immunoglobulin. Travel Unimmunised travellers, including children over 6 months, to areas where measles is endemic or epidemic should receive measles, mumps and rubella vaccine, live. Children immunised before 12 months of age should still receive two doses of measles, mumps and rubella vaccine, live at the recommended ages. If one dose of measles, mumps and rubella vaccine, live has already been given to a child, then the second dose should be brought forward to at least one month after the first, to ensure complete protection. If the child is under 18 months of age and the second dose is given within 3 months of the first, then the routine dose before starting school at 3 years and 4 months of age (or soon after) should still be given. Useful Resources Advice reflects that in the handbook Immunisation against Infectious Disease (2013), which in turn reflects the guidance of the Joint Committee on Vaccination and Immunisation (JCVI). The advice also incorporates changes announced by the Chief Medical Officer and Health Department Updates. Chapters from the handbook (including updates since 2013) are available at: www.gov.uk/government/collections/immunisation-against- infectious-disease-the-green-book Meningococcal vaccine Overview Almost all childhood meningococcal disease in the UK is caused by Neisseria meningitidis serogroups B and C. Meningococcal group C conjugate vaccine protects only against infection by serogroup C and Meningococcal group B vaccine protects only against infection by serogroup B. The risk of meningococcal disease declines with age— immunisation is not generally recommended after the age of 25 years. Tetravalent meningococcal vaccines that cover serogroups A, C, W135, and Y are available. Although the duration of protection has not been established, the meningococcal groups A, C, W135, and Y conjugate vaccine is likely to provide longer-lasting protection than the unconjugated meningococcal polysaccharide vaccine. The antibody response to serogroup C in unconjugated meningococcal polysaccharide vaccines in young children may be suboptimal [not currently available in the UK]. Meningococcal group B vaccines, Bexsero ®, and Trumenba ® are licensed in the UK against infection caused by Neisseria meningitidis serogroup B. The use of Bexsero ® is recommended in the Immunisation Schedule. Bexsero ® contains 3 recombinant Neisseria meningitidis serogroup B proteins and the outer membrane vesicles from the NZ 98/254 strain, in order to achieve broad protection against Neisseria meningitidis serogroup B. Trumenba ® contains 2 recombinant Neisseria meningitidis serogroup B proteins. The proteins are adsorbed onto an aluminium compound to stimulate an enhanced immune response. Childhood immunisation Meningococcal group C conjugate vaccine provides long- term protection against infection by serogroup C of Neisseria meningitidis. Immunisation consists of 1 dose given at 12 months of age (as the haemophilus influenzae type b with Vaccines meningococcal group C vaccine p. 1383) and a second dose given at 13–15 years of age (as the meningococcal groups A with C and W135 and Y vaccine p. 1385) (see Immunisation Schedule). Meningococcal group B vaccine provides protection against infection by serogroup B of Neisseria meningitidis. Immunisation consists of 1 dose given at 2 months of age, a second dose at 4 months of age, and a booster dose at 12 months of age (see Immunisation Schedule above). Unimmunised children aged under 12 months should be given 1 dose of meningococcal group B vaccine (rDNA, component, adsorbed) p. 1384 followed by a second dose of meningococcal group B vaccine (rDNA, component, adsorbed) two months later. They should then be vaccinated according to the Immunisation Schedule (ensuring at least a two month interval between doses of meningococcal group B vaccines). Unimmunised children aged 12–23 months should be given 2 doses of meningococcal group B vaccine (rDNA, component, adsorbed) separated by an interval of two months if they have received less than 2 doses in the first year of life. Unimmunised children aged 2–9 years should be given a single dose of meningococcal group C vaccine (as the haemophilus influenzae type b with meningococcal group C vaccine) followed by a booster dose of meningococcal groups A with C and W135 and Y vaccine at 13–15 years of age. From 2015, unimmunised individuals aged 10–25 years, including those aged under 25 years who are attending university for the first time, should be given a single dose of meningococcal groups A with C and W135 and Y vaccine; a booster dose is not required. Patients under 25 years of age with confirmed serogroup C disease, who have previously been immunised with meningococcal group C vaccine, should be offered meningococcal group C conjugate vaccine before discharge from hospital. Travel Individuals travelling to countries of risk should be immunised with meningococcal groups A, C, W135, and Y conjugate vaccine, even if they have previously received meningococcal group C conjugate vaccine. If an individual has recently received meningococcal group C conjugate vaccine, an interval of at least 4 weeks should be allowed before administration of the tetravalent (meningococcal groups A, C, W135, and Y) vaccine. Vaccination is particularly important for those living or working with local people or visiting an area of risk during outbreaks. Immunisation recommendations and requirements for visa entry for individual countries should be checked before travelling, particularly to countries in Sub-Saharan Africa, Asia, and the Indian sub-continent where epidemics of meningococcal outbreaks and infection are reported. Country-by-country information is available from the National Travel Health Network and Centre (www.nathnac. org/). Proof of vaccination with the tetravalent meningococcal groups A with C and W135 and Y vaccine is required for those travelling to Saudi Arabia during the Hajj and Umrah pilgrimages (where outbreaks of the W135 strain have occurred). Contacts For advice on the immunisation of laboratory workers and close contacts of cases of meningococcal disease in the UK and on the role of the vaccine in the control of local outbreaks, consult Guidance for Public Health Management of Meningococcal Disease in the UK at www.gov.uk/phe. Also see for antibacterial prophylaxis for prevention of secondary cases of meningococcal meningitis. The need for immunisation of laboratory staff who work directly with Neisseria meningitidis should be considered. Useful Resources Vaccines Advice reflects that in the handbook Immunisation against Infectious Disease (2013), which in turn reflects the guidance of the Joint Committee on Vaccination and Immunisation (JCVI). The advice also incorporates changes announced by the Chief Medical Officer and Health Department Updates. Chapters from the handbook (including updates since 2013) are available at: www.gov.uk/government/collections/immunisation-against- infectious-disease-the-green-book Pertussis vaccine Overview Pertussis vaccine is given as a combination preparation containing other vaccines. Acellular vaccines are derived from highly purified components of Bordetella pertussis. Primary immunisation against pertussis (whooping cough) requires 3 doses of an acellular pertussis-containing vaccine (see Immunisation schedule), given at intervals of 1 month from the age of 2 months. All children up to the age of 10 years should receive primary immunisation with a combination vaccine of diphtheria with tetanus, pertussis, hepatitis B, poliomyelitis and haemophilus influenzae type b vaccine p. 1381 (Infanrix hexa ®). A booster dose of an acellular pertussis-containing vaccine should ideally be given 3 years after the primary course, although, the interval can be reduced to 1 year if the primary course was delayed. Children aged 1–10 years who have not received a pertussis-containing vaccine as part of their primary immunisation should be offered 1 dose of a suitable pertussis-containing vaccine; after an interval of at least 1 year, a booster dose of a suitable pertussis-containing vaccine should be given. Immunisation against pertussis is not routinely recommended in individuals over 10 years of age. Vaccination of pregnant women against pertussis In response to the pertussis outbreak, the UK health departments introduced a temporary programme (October 2012) to vaccinate pregnant women against pertussis, and this programme will continue until further notice. The aim of the programme is to boost the levels of pertussis–specific antibodies that are transferred through the placenta, from the mother to the fetus, so that the newborn is protected before routine immunisation begins at 2 months of age. Pregnant women should be offered a single dose of acellular pertussis-containing vaccine (as adsorbed diphtheria [low dose], tetanus, pertussis (acellular, component) and poliomyelitis (inactivated) vaccine; Boostrix-IPV ®) between 16 and 32 weeks of pregnancy. Public Health England has advised (2016) that the vaccine is probably best offered after the fetal anomaly scan at around 18–20 weeks. Pregnant women should be offered a single dose of acellular pertussis-containing vaccine up to the onset of labour if they missed the opportunity for vaccination at 16–32 weeks of pregnancy. A single dose of acellular pertussis-containing vaccine may also be offered to new mothers, who have never previously been vaccinated against pertussis, until the child receives the first vaccination. While this programme is in place, women who become pregnant again should be offered vaccination during each pregnancy to maximise transplacental transfer of antibody. Contacts Vaccination against pertussis should be considered for close contacts of cases with pertussis who have been offered antibacterial prophylaxis. Unimmunised or partially immunised contacts under 10 years of age should complete their vaccination against pertussis. A booster dose of an acellular pertussis-containing vaccine is recommended for contacts aged over 10 years who have not received a pertussis-containing vaccine in the last 5 years and who have not received adsorbed diphtheria [low dose], tetanus, and poliomyelitis (inactivated) vaccine in the last month. Side-effects Local reactions do not contra-indicate further doses. The vaccine should not be withheld from children with a history to a preceding dose of: . fever, irrespective of severity; . persistent crying or screaming for more than 3 hours; . severe local reaction, irrespective of extent. Useful Resources Advice reflects that in the handbook Immunisation against Infectious Disease (2013), which in turn reflects the guidance of the Joint Committee on Vaccination and Immunisation (JCVI). The advice also incorporates changes announced by the Chief Medical Officer and Health Department Updates. Chapters from the handbook (including updates since 2013) are available at: www.gov.uk/government/collections/immunisation-against- infectious-disease-the-green-book Pneumococcal vaccine Overview The pneumococcal polysaccharide conjugate vaccine (adsorbed) p. 1385 and the pneumococcal polysaccharide vaccine p. 1386 protect against infection with Streptococcus pneumoniae (pneumococcus). Both vaccines contain polysaccharide from capsular pneumococci. The pneumococcal polysaccharide vaccine contains purified polysaccharide from 23 capsular types of pneumococcus, whereas the pneumococcal polysaccharide conjugate vaccine (adsorbed) contains polysaccharide from either 10 capsular types (Synflorix ®) or 13 capsular types (Prevenar 13 ®). Both vaccines are inactivated. Prevenar 13 ® is the 13-valent pneumococcal polysaccharide conjugate vaccine (adsorbed) used in childhood immunisation. For children born on or before December 31st 2019, the schedule consists of 3 doses given at separate intervals. For children born on or after January 1st 2020, the schedule consists of 2 doses given at separate intervals. For more information, see Immunisation schedule p. 1364. Children who present late for vaccination should be immunised according to Children with unknown or incomplete vaccination histories. The 23-valent pneumococcal polysaccharide vaccine is recommended for all adults aged 65 years and over, and for adults and children aged 2 years and over in the following at- risk groups: . asplenia or splenic dysfunction (including homozygous sickle cell disease and coeliac syndrome which could lead to splenic dysfunction); . chronic respiratory disease (including severe asthma treated with continuous or frequent use of a systemic corticosteroid); . chronic heart disease; . chronic renal disease; . chronic liver disease; . diabetes mellitus requiring insulin or anti-diabetic medication; . immunosuppression because of disease (e.g. HIV infection, and genetic disorders affecting the immune system) or treatment (including prolonged systemic corticosteroid treatment for over 1 month at dose equivalents of prednisolone: adult and child 20 kg and over, 20 mg or more daily; child under 20 kg, 1 mg/kg or more daily, and chemotherapy); . presence of cochlear implant; . conditions where leakage of cerebrospinal fluid may occur. The 23-valent pneumococcal polysaccharide vaccine should also be considered for those at risk of occupational exposure to metal fume (e.g. welders). Where possible, the vaccine should be given at least 2 weeks (ideally 4–6 weeks) before splenectomy, chemotherapy or radiotherapy; patients should be given advice about the increased risk of pneumococcal infection. If it is not possible to vaccinate at least 2 weeks before splenectomy, chemotherapy or radiotherapy, the vaccine should be given at least 2 weeks after the splenectomy, and at least 3 months after completion of chemotherapy or radiotherapy. Vaccination advice for patients with leukaemia or those who have had a bone marrow transplant, and information on patient cards and leaflets for individuals with apslenia, are available in Chapter 25, Pneumococcal, in Immunisation against infectious disease- ‘The Green Book’. Vaccination regimens may differ depending on the individual’s age, risk of pneumococcal disease, vaccination history, and immune status. Individuals in at-risk groups may require additional protection. For information on revaccination with 23-valent pneumococcal polysaccharide vaccine for individuals in whom the antibody concentration is likely to decline rapidly, see Revaccination. Children with unknown or incomplete vaccination histories Individuals born on or before December 31st 2019 Unimmunised or partially immunised children who present late for vaccination and before the age of 1 year should receive 2 doses of the 13-valent pneumococcal polysaccharide conjugate vaccine (adsorbed) 2 months apart, and a booster dose on or after their first birthday, at least 2 months after the previous dose (intervals can be reduced to 1 month to allow the immunisation schedule to be completed promptly). Children aged 1 year to under 2 years who are unimmunised or partially immunised should receive a single dose of the 13-valent pneumococcal polysaccharide conjugate vaccine (adsorbed). Individuals born on or after January 1st 2020 Unimmunised or partially immunised children who present late for vaccination and before the age of 1 year should receive a single dose of the 13-valent pneumococcal polysaccharide conjugate vaccine (adsorbed), and a booster dose on or after their first birthday, at least 4 weeks after the previous dose. Children aged 1 year to under 2 years who are unimmunised or partially immunised should receive a single dose of the 13-valent pneumococcal polysaccharide conjugate vaccine (adsorbed). For the management of children who received one or more doses of 10-valent pneumococcal polysaccharide conjugate vaccine (adsorbed) in another country, refer to Chapter 25 (for infants born on or after 1 January 2020), Pneumococcal, in Immunisation against infectious disease- ‘The Green Book’. Individuals with an at-risk condition born on or before December 31st 2019 Children diagnosed with at-risk conditions aged under 2 years Children diagnosed with an at-risk condition aged under 1 year should receive the 13-valent pneumococcal polysaccharide conjugate vaccine (adsorbed) according to the Immunisation schedule p. 1364. Those who present late for vaccination should be immunised according to Children with unknown or incomplete vaccination histories. A single dose of the 23-valent pneumococcal polysaccharide vaccine should then be given at 2 years of age, at least 2 months after the last dose of 13-valent pneumococcal polysaccharide conjugate vaccine (adsorbed). Vaccines Children aged under 2 years who are severely immunocompromised, or those with asplenia, splenic dysfunction or complement disorders, should have an additional dose of the 13-valent pneumococcal polysaccharide conjugate vaccine (adsorbed), given at least 2 months after the booster dose due on or after their first birthday (the interval can be reduced to 1 month to allow the immunisation schedule to be completed promptly). A single dose of the 23-valent pneumococcal polysaccharide vaccine should then be given at 2 years of age, at least 2 months after the last dose of 13-valent pneumococcal polysaccharide conjugate vaccine (adsorbed). For further information on vaccination in individuals with asplenia, splenic dysfunction, or complement disorders, see Vaccination, general principles p. 1361. Children diagnosed with at-risk conditions aged 2 years to under 10 years Children diagnosed or first presenting with an at-risk condition who have completed their routine immunisation schedule should receive a single dose of 23-valent pneumococcal polysaccharide vaccine, at least 2 months after the last dose of 13-valent pneumococcal polysaccharide conjugate vaccine (adsorbed). Children previously unvaccinated or partially vaccinated with the 13-valent pneumococcal polysaccharide conjugate vaccine (adsorbed) should receive a single dose of the 13-valent pneumococcal polysaccharide conjugate vaccine (adsorbed), followed by a single dose of the 23-valent pneumococcal polysaccharide vaccine at least 2 months later. For further information on vaccination in individuals with asplenia, splenic dysfunction, or complement disorders, see Vaccination, general principles p. 1361. Severely immunocompromised children may have a sub- optimal immunological response to the vaccine and should be given an additional dose of the 13-valent pneumococcal polysaccharide conjugate vaccine (adsorbed), even if they are fully vaccinated. This should be followed by a single dose of the 23-valent pneumococcal polysaccharide vaccine, at least 2 months after the last dose of 13-valent pneumococcal polysaccharide conjugate vaccine (adsorbed). If the 23-valent pneumococcal polysaccharide vaccine has already been given, the 13-valent pneumococcal polysaccharide conjugate vaccine (adsorbed) should be given at least 6 months after. Individuals diagnosed with at-risk conditions aged 10 years and over Individuals diagnosed or first presenting with an at-risk condition should be given a single dose of the 23-valent pneumococcal polysaccharide vaccine p. 1386; no additional 23-valent pneumococcal polysaccharide vaccine is required at 65 years of age. For further information on vaccination in individuals with asplenia, splenic dysfunction, or complement disorders, see Vaccination, general principles p. 1361. Severely immunocompromised individuals should be given a single dose of the 13-valent pneumococcal polysaccharide conjugate vaccine (adsorbed) p. 1385 followed by the 23-valent pneumococcal polysaccharide vaccine at least 2 months after, irrespective of their previous pneumococcal vaccinations. If the 23-valent pneumococcal polysaccharide vaccine has already been given, the 13-valent pneumococcal polysaccharide conjugate vaccine (adsorbed) should be given at least 6 months after. Individuals with an at-risk condition born on or after January 1st 2020 Children diagnosed with at-risk conditions aged under 1 year Children in an at-risk group (excluding those with asplenia, splenic dysfunction or complement disorder, or who are severely immunocompromised) should receive the 13-valent Vaccines pneumococcal polysaccharide conjugate vaccine (adsorbed) according to the Immunisation schedule p. 1364. Those who present late for vaccination should be immunised according to Children with unknown or incomplete vaccination histories. A single dose of the 23-valent pneumococcal polysaccharide vaccine should then be given at 2 years of age, at least 8 weeks after the last dose of 13-valent pneumococcal polysaccharide conjugate vaccine (adsorbed). Children who are severely immunocompromised, or those with asplenia, splenic dysfunction or complement disorders, should receive 2 doses of the 13-valent pneumococcal polysaccharide conjugate vaccine (adsorbed) at least 8 weeks apart (commencing no earlier than 6 weeks of age), followed by a single booster dose given on or after their first birthday. An additional dose of 13-valent pneumococcal polysaccharide conjugate vaccine (adsorbed) should be given at least 8 weeks after the booster dose. A single dose of the 23-valent pneumococcal polysaccharide vaccine should then be given at 2 years of age, at least 8 weeks after the last dose of 13-valent pneumococcal polysaccharide conjugate vaccine (adsorbed). For further information on vaccination in individuals with asplenia, splenic dysfunction, or complement disorders, see Vaccination, general principles p. 1361. Children diagnosed with at-risk conditions aged 1 year to under 2 years Children in an at-risk group (excluding those with asplenia, splenic dysfunction or complement disorder, or who are severely immunocompromised) should receive their 13-valent pneumococcal polysaccharide conjugate vaccine (adsorbed) booster dose according to the Immunisation schedule p. 1364. Those who present late for vaccination should be immunised according to Children with unknown or incomplete vaccination histories. A single dose of the 23-valent pneumococcal polysaccharide vaccine should then be given at 2 years of age, at least 8 weeks after the last dose of 13-valent pneumococcal polysaccharide conjugate vaccine (adsorbed). Children who are severely immunocompromised, or those with asplenia, splenic dysfunction or complement disorders, should receive their 13-valent pneumococcal polysaccharide conjugate vaccine (adsorbed) booster dose according to the Immunisation schedule p. 1364. Those who present late for vaccination should be immunised according to Children with unknown or incomplete vaccination histories. An additional dose of the 13-valent pneumococcal polysaccharide conjugate vaccine (adsorbed) should be given at least 8 weeks after the booster dose. A single dose of the 23-valent pneumococcal polysaccharide vaccine should then be given at 2 years of age, at least 8 weeks after the last dose of 13-valent pneumococcal polysaccharide conjugate vaccine (adsorbed). For further information on vaccination in individuals with asplenia, splenic dysfunction, or complement disorders, see Vaccination, general principles p. 1361. Children diagnosed with at-risk conditions aged 2 years to under 10 years Children diagnosed or first presenting with an at-risk condition (excluding those severely immunocompromised) who have completed their routine immunisation schedule should receive a single dose of 23-valent pneumococcal polysaccharide vaccine, at least 8 weeks after the last dose of 13-valent pneumococcal polysaccharide conjugate vaccine (adsorbed). Children diagnosed or first presenting with an at-risk condition (excluding those severely immunocompromised) who are previously unimmunised or partially immunised with the 13-valent pneumococcal polysaccharide conjugate vaccine (adsorbed), should receive a single dose of the 13-valent pneumococcal polysaccharide conjugate vaccine (adsorbed), followed by a single dose of the 23-valent pneumococcal polysaccharide vaccine at least 8 weeks later. For further information on vaccination in individuals with asplenia, splenic dysfunction, or complement disorders, see Vaccination, general principles p. 1361. Severely immunocompromised children should be given a single dose of the 13-valent pneumococcal polysaccharide conjugate vaccine (adsorbed), regardless of immunisation status. This should be followed by a single dose of the 23-valent pneumococcal polysaccharide vaccine, at least 8 weeks after the last dose of 13-valent pneumococcal polysaccharide conjugate vaccine (adsorbed). Individuals diagnosed with at-risk conditions aged 10 years and over Individuals diagnosed or first presenting with an at-risk condition (excluding those who are severely immunocompromised) should be given a single dose of the 23-valent pneumococcal polysaccharide vaccine. The 23-valent pneumococcal polysaccharide vaccine is not required for individuals with asplenia, splenic dysfunction or complement disorders if they have already received a dose within the previous 2 years (due to a theoretical risk of pneumococcal serotype-specific hypo-responsiveness with revaccination). For further information on vaccination in individuals with asplenia, splenic dysfunction, or complement disorders, see Vaccination, general principles p. 1361. Severely immunocompromised individuals should be given a single dose of the 13-valent pneumococcal polysaccharide conjugate vaccine (adsorbed), followed by a single dose of the 23-valent pneumococcal polysaccharide vaccine at least 8 weeks after. The 13-valent pneumococcal polysaccharide conjugate vaccine (adsorbed) or additional 23-valent pneumococcal polysaccharide vaccine are not required if a 23-valent pneumococcal polysaccharide vaccine has already been received within the previous 2 years, due to a theoretical risk of pneumococcal serotype-specific hypo- responsiveness with re-vaccination. Revaccination Revaccination is not recommended for any clinical risk groups or age groups, except for individuals in whom the antibody concentration is likely to decline rapidly (e.g. asplenia, splenic dysfunction, or chronic renal disease), where revaccination is recommended every 5 years. Management of cases For the management of cases, contacts and outbreaks, refer to Chapter 25, Pneumococcal, in Immunisation against infectious disease- ‘The Green Book’ (see Useful resources). Useful Resources Recommendations reflect Chapter 25 (for infants born up to and including 31 December 2019), Pneumococcal, in Immunisation against infectious disease- ‘The Green Book’. Public Health England, January 2018. www.gov.uk/government/publications/pneumococcal-the-green- book-chapter-25 Recommendations reflect Chapter 25 (for infants born on or after 1 January 2020), Pneumococcal, in Immunisation against infectious disease- ‘The Green Book’. Public Health England, January 2020. www.gov.uk/government/publications/pneumococcal-the-green- book-chapter-25 Poliomyelitis vaccine Overview Two types of poliomyelitis vaccines (containing strains of poliovirus types 1, 2, and 3) are available, inactivated poliomyelitis vaccine (for injection) and live (oral) poliomyelitis vaccine. Inactivated poliomyelitis vaccines, only available in combined preparation, is recommended for routine immunisation. A course of primary immunisation consists of 3 doses of a combined preparation containing inactivated poliomyelitis vaccines, starting at 2 months of age with intervals of 1 month between doses (see Immunisation schedule). A course of 3 doses should also be given to all unimmunised adults; no adult should remain unimmunised against poliomyelitis. Two booster doses of a preparation containing inactivated poliomyelitis vaccines are recommended, the first before school entry and the second before leaving school (see Immunisation schedule). Further booster doses are only necessary for adults at special risk, such as travellers to endemic areas, or laboratory staff likely to be exposed to the viruses, or healthcare workers in possible contact with cases; booster doses should be given to such individuals every 10 years. Live (oral) poliomyelitis vaccine is no longer available for routine use; its use may be considered during large outbreaks, but advice should be sought from Public Health England. The live (oral) vaccine poses a very rare risk of vaccine-associated paralytic polio because the attenuated strain of the virus can revert to a virulent form. For this reason the live (oral) vaccine must not be used for immunosuppressed individuals or their household contacts. The use of inactivated poliomyelitis vaccines removes the risk of vaccine-associated paralytic polio altogether. Travel Unimmunised travellers to areas with a high incidence of poliomyelitis should receive a full 3-dose course of a preparation containing inactivated poliomyelitis vaccines. Those who have not been vaccinated in the last 10 years should receive a booster dose of adsorbed diphtheria [low dose], tetanus and poliomyelitis (inactivated) vaccine . Information about countries with a high incidence of poliomyelitis can be obtained from www.travax.nhs.uk/ or from the National Travel Health Network and Centre (www.nathnac.org/). Useful Resources Advice reflects that in the handbook Immunisation against Infectious Disease (2013), which in turn reflects the guidance of the Joint Committee on Vaccination and Immunisation (JCVI). The advice also incorporates changes announced by the Chief Medical Officer and Health Department Updates. Chapters from the handbook (including updates since 2013) are available at: www.gov.uk/government/collections/immunisation-against- infectious-disease-the-green-book Rabies vaccine Overview Rabies vaccine p. 1394 contains inactivated rabies virus cultivated in either human diploid cells or purified chick embryo cells; vaccines are used for pre- and post-exposure prophylaxis. Pre-exposure prophylaxis Immunisation should be offered to those at high risk of exposure to rabies— laboratory staff who handle the rabies virus, those working in quarantine stations, animal handlers, veterinary surgeons and field workers who are likely to be bitten by infected wild animals, certain port officials, and bat handlers. Transmission of rabies by humans has not been Vaccines recorded but it is advised that those caring for patients with the disease should be vaccinated. Immunisation against rabies is also recommended where there is limited access to prompt medical care for those living in areas where rabies is enzootic, for those travelling to such areas for longer than 1 month, and for those on shorter visits who may be exposed to unusual risk. Immunisation against rabies is indicated during pregnancy if there is substantial risk of exposure to rabies and rapid access to post-exposure prophylaxis is likely to be limited. Up-to-date country-by-country information on the incidence of rabies can be obtained from the National Travel Health Network and Centre (www.nathnac.org/) and, in Scotland, from Health Protection Scotland (www.hps.scot.nhs. uk/). Immunisation against rabies requires 3 doses of rabies vaccine, with further booster doses for those who remain at frequent risk. To ensure continued protection in persons at high risk (e.g. laboratory workers), the concentration of antirabies antibodies in plasma is used to determine the intervals between doses. Post-exposure management Following potential exposure to rabies, the wound or site of exposure (e.g. mucous membrane) should be cleansed under running water and washed for several minutes with soapy water as soon as possible after exposure. Disinfectant and a simple dressing can be applied, but suturing should be delayed because it may increase the risk of introducing rabies virus into the nerves. Post-exposure prophylaxis against rabies depends on the level of risk in the country, the nature of exposure, and the individual’s immunity. In each case, expert risk assessment and advice on appropriate management should be obtained from the local Public Health England Centre or Public Health England’s Virus Reference Department, Colindale (tel. (020) 8200 4400) or the PHE Colindale Duty Doctor (tel. (020) 8200 6868), in Wales from the Public Health Wales local Health Protection Team or Public Health Wales Virus Reference Laboratory (tel. (029) 2074 7747), in Scotland from the local on-call infectious diseases consultant, and in Northern Ireland from the Public Health Agency Duty Room (tel (028) 9055 3997/(028) 9063 2662) or the Regional Virology Service (tel. (028) 9024 0503). There are no specific contra-indications to the use of rabies vaccine for post-exposure prophylaxis and its use should be considered whenever a patient has been attacked by an animal in a country where rabies is enzootic, even if there is no direct evidence of rabies in the attacking animal. Because of the potential consequences of untreated rabies exposure and because rabies vaccination has not been associated with fetal abnormalities, pregnancy is not considered a contra-indication to post-exposure prophylaxis. For post-exposure prophylaxis of fully immunised individuals (who have previously received pre-exposure or post-exposure prophylaxis with cell-derived rabies vaccine), 2 doses of cell-derived vaccine are likely to be sufficient; the first dose is given on day 0 and the second dose is given between day 3–7. Rabies immunoglobulin p. 1359 is not necessary in such cases. Post-exposure treatment for unimmunised individuals (or those whose prophylaxis is possibly incomplete) comprises 5 doses of rabies vaccine given over 1 month (on days 0, 3, 7, 14, and the fifth dose is given between day 28–30); also, depending on the level of risk (determined by factors such as the nature of the bite and the country where it was sustained), rabies immunoglobulin is given to unimmunised individuals on day 0 or within 7 days of starting the course of rabies vaccine. The immunisation course can be discontinued if it is proved that the individual was not at risk. Vaccines Useful Resources Advice reflects that in the handbook Immunisation against Infectious Disease (2013), which in turn reflects the guidance of the Joint Committee on Vaccination and Immunisation (JCVI). The advice also incorporates changes announced by the Chief Medical Officer and Health Department Updates. Chapters from the handbook (including updates since 2013) are available at: www.gov.uk/government/collections/immunisation-against- infectious-disease-the-green-book Rotavirus vaccine Overview Rotavirus vaccine p. 1395 is a live, oral vaccine that protects young children against gastro-enteritis caused by rotavirus infection. The recommended schedule consists of 2 doses, the first at 8 weeks of age, and the second at 12 weeks of age (see Immunisation schedule p. 1364). The first dose of rotavirus vaccine must be given between 6 weeks and under 15 weeks of age and the second dose should be given after an interval of at least 4 weeks; the vaccine should not be started in children 15 weeks of age or older. Ideally, the full course should be completed before 16 weeks of age to provide protection before the main burden of disease, and to avoid a temporal association between vaccination and intussusception; the course must be completed before 24 weeks of age. Children who inadvertently receive the first dose of rotavirus vaccine at 15 weeks of age or older should still receive a second dose after at least 4 weeks, providing that they will still be under 24 weeks of age at the time. The rotavirus vaccine virus is excreted in the stool and may be transmitted to close contacts; however, vaccination of children with immunosuppressed close contacts may protect the contacts from wild-type rotavirus disease and outweigh any risk from transmission of vaccine virus. Carers of a recently vaccinated child should be advised of the need to wash their hands after changing the child’s nappies. Useful Resources Recommendations reflect Chapter 27b, Rotavirus, in Immunisation against infectious disease– ‘The Green Book’. Public Health England, August 2015. www.gov.uk/government/publications/rotavirus-the-green-book- chapter-27b Smallpox vaccine Overview Limited supplies of smallpox vaccine are held at the Specialist and Reference Microbiology Division, Public Health England Colindale (Tel. (020) 8200 4400) for the exclusive use of workers in laboratories where pox viruses (such as vaccinia) are handled. If a wider use of the vaccine is being considered, Guidelines for smallpox response and management in the post-eradication era should be consulted at www.gov.uk/phe. Useful Resources Advice reflects that in the handbook Immunisation against Infectious Disease (2013), which in turn reflects the guidance of the Joint Committee on Vaccination and Immunisation (JCVI). The advice also incorporates changes announced by the Chief Medical Officer and Health Department Updates. Chapters from the handbook (including updates since 2013) are available at: www.gov.uk/government/collections/immunisation-against- infectious-disease-the-green-book Tetanus vaccine Overview Tetanus vaccine contains a cell-free purified toxin of Clostridium tetani adsorbed on aluminium hydroxide or aluminium phosphate to improve antigenicity. Primary immunisation for children under 10 years consists of 3 doses of a combined preparation containing adsorbed tetanus vaccine, with an interval of 1 month between doses (see Routine immunisation schedule). Following routine childhood vaccination, 2 booster doses of a preparation containing adsorbed tetanus vaccine are recommended, the first before school entry and the second before leaving school. The recommended schedule of tetanus vaccination not only gives protection against tetanus in childhood but also gives the basic immunity for subsequent booster doses. In most circumstances, a total of 5 doses of tetanus vaccine is considered sufficient for long term protection. For primary immunisation of adults and children over 10 years previously unimmunised against tetanus, 3 doses of adsorbed diphtheria [low dose], tetanus and poliomyelitis (inactivated) vaccine are given with an interval of 1 month between doses (see Diphtheria-containing vaccines for children over 10 years and adults). When an individual presents for a booster dose but has been vaccinated following a tetanus-prone wound, the vaccine preparation administered at the time of injury should be determined. If this is not possible, the booster should still be given to ensure adequate protection against all antigens in the booster vaccine. Very rarely, tetanus has developed after abdominal surgery; patients awaiting elective surgery should be asked about tetanus immunisation and immunised if necessary. Parenteral drug abuse is also associated with tetanus; those abusing drugs by injection should be vaccinated if unimmunised—booster doses should be given if there is any doubt about their immunisation status. All laboratory staff should be offered a primary course if unimmunised. Wounds Wounds are considered to be tetanus-prone if they are sustained more than 6 hours before surgical treatment or at any interval after injury and are puncture-type (particularly if contaminated with soil or manure) or show much devitalised tissue or are septic or are compound fractures or contain foreign bodies. All wounds should receive thorough cleansing. . For clean wounds: fully immunised individuals (those who have received a total of 5 doses of a tetanus-containing vaccine at appropriate intervals) and those whose primary immunisation is complete (with boosters up to date), do not require tetanus vaccine; individuals whose primary immunisation is incomplete or whose boosters are not up to date require a reinforcing dose of a tetanus-containing vaccine (followed by further doses as required to complete the schedule); non-immunised individuals (or those whose immunisation status is not known or who have been fully immunised but are now immunocompromised) should be given a dose of the appropriate tetanus-containing vaccine immediately (followed by completion of the full course of the vaccine if records confirm the need) . For tetanus-prone wounds: management is as for clean wounds with the addition of a dose of tetanus immunoglobulin given at a different site; in fully immunised individuals and those whose primary immunisation is complete (with boosters up to date) the immunoglobulin is needed only if the risk of infection is especially high (e.g. contamination with manure). Antibacterial prophylaxis (with benzylpenicillin, co- amoxiclav, or metronidazole) may also be required for tetanus-prone wounds. Useful Resources Advice reflects that in the handbook Immunisation against Infectious Disease (2013), which in turn reflects the guidance of the Joint Committee on Vaccination and Immunisation (JCVI). The advice also incorporates changes announced by the Chief Medical Officer and Health Department Updates. Chapters from the handbook (including updates since 2013) are available at: www.gov.uk/government/collections/immunisation-against- infectious-disease-the-green-book Tick-borne encephalitis vaccine Overview Tick-borne encephalitis vaccine, inactivated p. 1396 contains inactivated tick-borne encephalitis virus cultivated in chick embryo cells. It is recommended for immunisation of those working in, or visiting, high-risk areas (see International Travel). Those working, walking or camping in warm forested areas of Central and Eastern Europe, Scandinavia, Northern and Eastern China, and some parts of Japan, particularly from April to November when ticks are most prevalent, are at greatest risk of tick-borne encephalitis. For full protection, 3 doses of the vaccine are required; booster doses are required every 3–5 years for those still at risk. Ideally, immunisation should be completed at least one month before travel. Useful Resources Advice reflects that in the handbook Immunisation against Infectious Disease (2013), which in turn reflects the guidance of the Joint Committee on Vaccination and Immunisation (JCVI). The advice also incorporates changes announced by the Chief Medical Officer and Health Department Updates. Chapters from the handbook (including updates since 2013) are available at: www.gov.uk/government/collections/immunisation-against- infectious-disease-the-green-book Typhoid vaccine Overview Typhoid vaccine p. 1387 is available as a Vi capsular polysaccharide (from Salmonella typhi) vaccine for injection and a live, attenuated Salmonella typhi vaccine for oral use. Typhoid immunisation is advised for: . travellers to areas where typhoid is endemic and whose planned activities put them at higher risk (country-by- country information is available from the National Travel Health Network and Centre); . travellers to endemic areas where frequent or prolonged exposure to poor sanitation and poor food hygiene is likely; . laboratory personnel who, in the course of their work, may be exposed to Salmonella typhi. Capsular polysaccharide typhoid vaccine is given as a single dose, usually by intramuscular injection. Children under 2 years [unlicensed] may respond suboptimally to the vaccine, but children aged between 1–2 years should be Vaccines immunised if the risk of typhoid fever is considered high (immunisation is not recommended for infants under 12 months). A single booster dose should be given at 3-year intervals in adults and children over 2 years of age who remain at risk from typhoid fever. Oral typhoid vaccine is a live, attenuated vaccine contained in an enteric-coated capsule recommended in individuals aged 5 years and over. One capsule taken on alternate days for a total of 3 doses, provides protection 7–10 days after the last dose. If travelling from a non- endemic area to an area where typhoid is endemic, a booster consisting of 3 doses is recommended every 3 years. The oral typhoid vaccine should be avoided in immunosuppressed and HIV-infected individuals. Prevention of typhoid primarily depends on improving sanitation and water supplies in endemic areas and on scrupulous personal, food and water hygiene. All suspected cases of typhoid fever must be notified to the local health protection unit. Where there is a community level outbreak, specialist advice should be sought from Public Health England (tel. 020 8200 4400) or, in Scotland, Health Protection Scotland (tel. 0140 300 1191). Useful Resources Recommendations reflect Chapter 33, Typhoid, in Immunisation against infectious disease– ‘The Green Book’. Public Health England, May 2019. www.gov.uk/government/publications/typhoid-the-green-book- chapter-33 National Travel Health Network and Centre nathnac.net Varicella-zoster vaccine Overview The live varicella-zoster vaccine p. 1396, Varilrix ® and Varivax ®, are licensed for immunisation against varicella (chickenpox) in seronegative individuals. They are not recommended for routine use in children, but can be given to seronegative healthy children over 1 year who come into close contact with individuals at high risk of severe varicella infections. The Department of Health recommends these vaccines for seronegative healthcare workers who come into direct contact with patients. Those with a history of chickenpox or shingles can be considered immune, but healthcare workers with a negative or uncertain history should be tested. Rarely, the varicella-zoster vaccine virus has been transmitted from the vaccinated individual to close contacts. Therefore, contact with the following should be avoided if a vaccine-related cutaneous rash develops within 4–6 weeks of the first or second dose: . varicella-susceptible pregnant women; . individuals at high risk of severe varicella, including those with immunodeficiency or those receiving immunosuppressive therapy; Healthcare workers who develop a generalised papular or vesicular rash on vaccination should avoid contact with patients until the lesions have crusted. Those who develop a localised rash after vaccination should cover the lesions and be allowed to continue working unless in contact with patients at high risk of severe varicella. National shingles immunisation programme The aim of the national shingles immunisation programme is to lower the incidence and severity of shingles in older people using the high potency, live varicella-zoster vaccine, Zostavax ®. It is recommended that vaccination is routinely offered to people aged 70 years. A catch-up programme has also been rolled out (since 2013) in those aged 70-79 years, Vaccines as this age group is likely to have the greatest benefit from vaccination. In the 2016–2017 immunisation programme, varicella- zoster vaccine is recommended in adults who were 70 or 78 years of age on 1st September 2016. Patients who were eligible for vaccination in the first 3 years of the programme but have not been vaccinated against herpes zoster remain eligible until their 80th birthday; this includes patients who were aged 71–73 or 79 on 1st September 2016. Patients who have reached 80 years are no longer eligible for vaccination. A single dose of Zostavax ® is likely to give protection for at least 7 years, but the need for, or timing of, a booster dose has not been established. Although Zostavax ® is not recommended for the treatment of shingles or post-herpetic neuralgia, it can be given to those with a previous history of shingles; ideally the vaccine should be delayed until systemic antiviral therapy has been completed. Varicella-zoster immunoglobulin p. 1360 is used to protect susceptible individuals at increased risk of severe varicella infection (see Immunoglobulins p. 1354). Useful Resources Advice reflects that in the handbook Immunisation against Infectious Disease (2013), which in turn reflects the guidance of the Joint Committee on Vaccination and Immunisation (JCVI). The advice also incorporates changes announced by the Chief Medical Officer and Health Department Updates. Chapters from the handbook (including updates since 2013) are available at: www.gov.uk/government/collections/immunisation-against- infectious-disease-the-green-book Yellow fever vaccine MHRA/CHM advice: stronger precautions in people with weakened immunity and in those aged 60 years or older The MHRA and CHM have released important safety information regarding the use of the live yellow fever vaccine in those with weakened immunity, and in those aged 60 years or older. For further information, see Important safety information for yellow fever vaccine, live p. 1397. Overview Yellow fever vaccine, live is an attenuated preparation of yellow fever virus grown in chick eggs. Yellow fever vaccine, live is recommended for: . laboratory workers handling infected material; . individuals aged 9 months or older who are travelling to, or living in areas or countries with a risk of yellow fever transmission; . individuals aged 9 months or older who are travelling to, or living in countries that require an International Certificate of Vaccination or Prophylaxis (ICVP) for entry (information about countries at risk of yellow fever is available from the National Travel Health Network and Centre). Children aged under 9 months are at higher risk of vaccine-associated encephalitis, with the risk being inversely proportional to age. Children aged under 6 months should not be vaccinated. Children aged 6–9 months should only be vaccinated following a detailed risk assessment, and vaccination is generally only recommended if the risk of yellow fever transmission is high (such as during epidemics/outbreaks). If travel is unavoidable, seek expert advice on whether to vaccinate. Yellow fever vaccine, live should be avoided in individuals with primary or acquired immunodeficiency due to a congenital condition or disease process, and in individuals who are immunosuppressed as a result of treatment. If the yellow fever risk is unavoidable in HIV-infected individuals, consult the British HIV Association (bhiva.org/ vaccination-guidelines) or other specialist advice. For additional guidance on the suitability of immunisation against yellow fever, standardised checklists are available from: National Travel Health Network and Centre (see Useful resources) or Health Protection Scotland (www.Travax.nhs.uk). A single-dose of yellow fever vaccine, live confers life-long immunity against yellow fever disease. Immunisation should be performed at least 10 days before travelling to an endemic area to allow protective immunity to develop and for the ICVP (if required) to become valid. Reinforcing immunisation is not needed, except for a small subset of individuals at continued risk who may not have developed long-term protection from their initial yellow fever vaccine, live vaccination–seek expert advice. All suspected cases of yellow fever must be notified to the local health protection unit. Where there is a community level outbreak, specialist advice should be sought from Public Health England (tel. 020 8200 4400) or, in Scotland, Health Protection Scotland (tel. 0140 300 1191). Useful Resources Recommendations reflect Chapter 35, Yellow fever, in Immunisation against infectious disease- ‘The Green Book’. Public Health England, January 2020. www.gov.uk/government/publications/yellow-fever-the-green- book-chapter-35 National Travel Health Network and Centre travelhealthpro.org.uk Vaccines for travel Immunisation for travel See advice on Malaria, treatment p. 649. No special immunisation is required for travellers to the United States, Europe, Australia, or New Zealand, although all travellers should have immunity to tetanus and poliomyelitis (and childhood immunisations should be up to date); Tick-borne encephalitis vaccine is recommended for immunisation of those working in, or visiting, high-risk areas. Certain special precautions are required in non- European areas surrounding the Mediterranean, in Africa, the Middle East, Asia, and South America. Travellers to areas that have a high incidence of poliomyelitis or tuberculosis should be immunised with the appropriate vaccine; in the case of poliomyelitis previously immunised travellers may be given a booster dose of a preparation containing inactivated poliomyelitis vaccine. For guidance on immunisation against tuberculosis, see Travel in Bacillus Calmette-Guérin vaccine p. 1365. For guidance on immunisation against yellow fever, see Yellow fever vaccine p. 1378. Immunisation against meningococcal meningitis is recommended for a number of areas of the world. Protection against hepatitis A is recommended for travellers to high-risk areas outside Northern and Western Europe, North America, Japan, Australia and New Zealand. Hepatitis A vaccine is recommended and it is likely to be effective even if given shortly before departure; Public Health England recommends travellers can be vaccinated with hepatitis A vaccine up to the day of travel, and no longer recommends the use of normal immunoglobulin for travel prophylaxis. Special care must also be taken with food hygiene. Hepatitis B vaccine is recommended for those travelling to areas of high or intermediate prevalence who intend to seek employment as healthcare workers or who plan to remain there for lengthy periods and who may therefore be at increased risk of acquiring infection as the result of medical or dental procedures carried out in those countries. Short-term tourists or business travellers are not generally at increased risk of infection but may put themselves at risk by their sexual behaviour when abroad. Prophylactic immunisation against rabies is recommended for travellers to enzootic areas on long journeys or to areas out of reach of immediate medical attention. Travellers who have not had a tetanus booster in the last 10 years and are visiting areas where medical attention may not be accessible should receive a booster dose of adsorbed diphtheria [low dose], tetanus and poliomyelitis (inactivated) vaccine, even if they have received 5 doses of a tetanus- containing vaccine previously. Typhoid vaccine is indicated for travellers to countries where typhoid is endemic, but the vaccine is no substitute for personal precautions. There is no requirement for cholera vaccination as a condition for entry into any country, but oral cholera vaccine should be considered for backpackers and those travelling to situations where the risk is greatest (e.g. refugee camps). Regardless of vaccination, travellers to areas where cholera is endemic should take special care with food hygiene. Advice on diphtheria, on Japanese encephalitis, and on tick-borne encephalitis is included in Health Information for Overseas Travel. Food hygiene In areas where sanitation is poor, good food hygiene is important to help prevent hepatitis A, typhoid, cholera, and other diarrhoeal diseases (including travellers’ diarrhoea). Food should be freshly prepared and hot, and uncooked vegetables (including green salads) should be avoided; only fruits which can be peeled should be eaten. Only suitable bottled water, or tap water that has been boiled or treated with sterilising tablets, should be used for drinking. Information on health advice for travellers Health professionals and travellers can find the latest information on immunisation requirements and precautions for avoiding disease while travelling from: nathnac.net. The handbook, Health Information for Overseas Travel (2010), which draws together essential information for healthcare professionals regarding health advice for travellers, can also be obtained from this website. Immunisation requirements change from time to time, and information on the current requirements for any particular country may be obtained from the embassy or legation of the appropriate country or from: National Travel Health Network and Centre UCLH NHS Foundation Trust 3rd Floor Central 250 Euston Road London NW1 2PG Tel: 0845 602 6712 (Monday and Friday: 9–11 a.m. and 1–2 p.m., Tuesday to Thursday: 9–11 a.m. and 1–3:30 p.m. For healthcare professionals only) www.travelhealthpro.org.uk/ Travel Medicine Team Health Protection Scotland Meridian Court 5 Cadogan Street Glasgow G2 6QE Tel: (0141) 300 1130 (2–4 p.m. Monday to Wednesday, 9:30–11:30 a.m. Friday; for registered TRAVAX users only) www.travax.nhs.uk Vaccines (TRAVAX is free for NHS Scotland users (registration required); subscription fee may be payable for users outside NHS Scotland) Welsh Assembly Government Tel (029) 2082 5397 (9 a.m.–5:30 p.m. weekdays) Department of Health, Social Services and Public Safety Castle Buildings Stormont Belfast BT4 3SQ Tel: (028) 9052 2118 (9 a.m.–5 p.m. weekdays) www.health-ni.gov.uk/contact VACCINES Vaccines f
PDF pages 1383, 1384, 1385, 1386, 1387, 1388, 1389, 1390, 1391, 1392, 1393, 1394, 1395, 1396, 1397, 1398, 1399, 1400, 1401
If alcohol or disinfectant is used for cleansing the skin it should be allowed to evaporate before vaccination to prevent possible inactivation of live vaccines. When 2 or more live vaccines are required (and are not available as a combined preparation), they can be administered at any time before or after each other at different sites, preferably in a different limb; if more than one injection is to be given in the same limb, they should be administered at least 2.5 cm apart. See also Bacillus Calmette-Guérin vaccine p. 1382, and Cautions, further information in measles, mumps and rubella vaccine, live p. 1393. Vaccines should not be given intravenously. Most vaccines are given by the intramuscular route, although some are given by either the intradermal, deep subcutaneous, or oral route. The intramuscular route should not be used in patients with bleeding disorders such as haemophilia or thrombocytopenia, vaccines usually given by the intramuscular route should be given by deep subcutaneous injection instead. The Department of Health has advised against the use of jet guns for vaccination owing to the risk of transmitting blood borne infections, such as HIV. Particular attention must be paid to instructions on the use of diluents. Vaccines which are liquid suspensions or are reconstituted before use should be adequately mixed to ensure uniformity of the material to be injected. l HANDLING AND STORAGE Care must be taken to store all vaccines under the conditions recommended in the product literature, otherwise the preparation may become ineffective. Refrigerated storage is usually necessary; many vaccines need to be stored at 2–8°C and not allowed to freeze. Vaccines should be protected from light. Reconstituted vaccines and opened multidose vials must be used within the period recommended in the product literature. Unused vaccines should be disposed of by incineration at a registered disposal contractor. VACCINES › BACTERIAL AND VIRAL VACCINES, COMBINED eiiii F 1379
PDF page 1402
2 units for one dose
First-line fragment. Read the complete Indications and Dose section above.
PDF page 1383
2 units for one dose
First-line fragment. Read the complete Indications and Dose section above.
PDF page 1383
10 units for 1 dose
First-line fragment. Read the complete Indications and Dose section above.
PDF page 1383
10 units for 1 dose
First-line fragment. Read the complete Indications and Dose section above.
PDF page 1383
