immunisation update 2017 course aim · (mmr) but not any other commonly used live vaccines. 8/29/17...

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ImmunisationUpdate2017

CourseAim

• ToensurethattheHealthCarePractitionerhasthetheoreticalknowledgerequiredtoadministervaccinationssafely.

LearningoutcomesAttheendofthetrainingdelegateswill:1. BeawareofthevaccinesavailableforInfluenza,

PneumococcalDisease,Shingles&B12deficiency2. Reviewthecontraindicationstovaccines&thecorrect

storageandadministrationofvaccines3. Definethelegislativeboundarieswhengivingvaccinations4. Beawareofhowtorecognise&dealwithadverseevents

followingimmunisation5. BeawareofanyrecentchangestotheUKadult&childhood

routineimmunisationprogramme6. Identifyrecentissuesregardingvaccinations,includingcold

chainincidents7. Reviewcurrentpracticeandidentifyareasforimprovement8. Beawareoftheimportanceofaccuraterecordkeeping.

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WhatisVitaminB12?• OneofthevitaminBcomplexwhichareessentialfortheworkingofcertainenzymesinthebody

• Generallyfoundinthesamefoods• VitaminBcomplexincludesthiamine(vitaminB1)riboflavin(VitaminB2)pyridoxine(VitaminB6)&Cyanocobalamin(VitaminB12)

WhydoesalackofvitaminB12causeproblems?

• Becauseitcausesthebodytoproduceabnormallylargeredbloodcellsthatcan’tfunctionproperly

WhatcausesvitaminB12orfolatedeficiency?Mostcommonreason• Perniciousanaemia – lackofabsorptionofvitaminB12Lesscommon• LackofB12indiet,especiallyifhavevegandiet• CertainmedicationsMorecommoninolderpeople• Affectsaround1in10peopleaged75&over• Around1in20peopleaged65-74yrsMostcasesofB12&folatedeficiencycanbeeasilytreatedwithinjectionsortablets.

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PerniciousAnaemia• Anautoimmuneconditionaffectingthestomach• NormallyB12iscombinedinthestomachwithaprotein(intrinsicFactor)

• Thismixisthenabsorbedintothebodyinpartofthegut(distalileum)

• Perniciousanaemia causestheimmunesystemtoattackthecellsinthestomachthatproducetheintrinsicfactor,makingthebodyunabletoabsorbvitaminB12

• Exactcauseisunknown,butismorecommoninwomenaround60yearsofage,peoplewithafamilyhistoryofthecondition&thosewithotherautoimmuneconditions,e.g.Addison’sdiseaseorvitiligo.

Diet• SomepeopledevelopvitaminB12deficiencyasaresultofinsufficientvitaminB12intheirdiet

• Adietincludingmeat,fish&dairyproductsusuallyprovidessufficientvitaminB12

• Somepeopleonavegandietorwhohaveagenerallypoordietcanbecomedeficient

• StoresofvitaminB12inthebodycanlast2-4yearswithoutbeingreplenished,soitcantakelongerforanyproblemstodevelopafteradietarychange.

Othercauses• Somestomachconditionsoroperations,e.g.gastrectomy,canpreventabsorptionofvitaminB12

• SomeconditionsaffectingtheintestinescanalsostopvitaminB12absorption,e.g.Crohn’sdisease

• SomemedicationscanleadtoareductionintheamountofvitaminB12absorbed,e.g.protonpumpinhibitors(PPIs)totreatindigestioncanmakevitaminB12absorptionworse.

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SymptomsofB12orfolatedeficiencyanaemia

Diagnosis• BasedonsymptomsandbloodtestsThebloodtestscheck:• Ifthereisalowerlevelofhaemoglobin thannormal• Iftheredbloodcellsarelargerthannormal• ThelevelofvitaminB12intheblood• TheleveloffolateinthebloodN.B.SomepeoplehaveproblemsevenwithnormallevelsofthesevitaminsormayhavelowlevelsbutnosymptomsThereforeit’sveryimportanttotakesymptomsintoaccountwhenmakingadiagnosis.

Treatment• Dependsonthecause• Mostpeopleeasilytreatedwithinjectionsortabletstoreplacethemissingvitamins

• VitaminB12deficiencyanaemia isusuallytreatedwithinjectionsofvitaminB12(hydroxocobalamin)

• Amount&frequencydependsondiagnosis.

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Sideeffects• Nausea,Headache,Dizziness,Fever• Hypersensitivityreaction(rash,itching,etc)• Injectionsitereactions• Rarely– AnaphylaxisCautions• Donotuseforanaemia ofpregnancy• Patient’sonchloramphenicoltreatmentmayrespondpoorlytotheinjection

• Serumconcentrationsofthisinjectionmaybeloweredbyoralcontraceptives

• IfconcernedrefertoGP/PracticeNurse.

HydroxocobalaminOnlyadministeronceyou’resurethat:• YouhaveaPSDforthepatient• Youhavethecorrectpatient’shydroxocobalamin• Youhavethecorrectpatient• Youhavethecorrectdose• Checkwhentheyhadthepreviousdose– isthisthecorrecttimeintervalbetweendoses?

RecordingRecordcarefullyonthepatient’snotes:• Discussionregardingtheprocedure&whatyouaregiving

• Consent• Sitegiven• Batchnumber&expirydate• Adviceregardingpossibleadverseeffects&howtoobtainhelpifrequired

• Nextappointment

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SourcesofVitaminB12inthediet

HerpesZoster(Shingles)

WhatisHerpesZoster?(Shingles)• Causedbyreactivationofalatentvaricella

zostervirusinfection– usuallydecadesaftertheprimaryinfection

• PrimaryVZVinfectionusuallyoccursinchildhood&causeschickenpox(varicella)

• Followingtheprimaryinfectionthevirusentersthesensorynerves– travelsalongnervetothesensorydorsalrootganglia&formsapermanentdormantinfection

• Reactivationofthedormantvirusleadstotheclinicalmanifestationofshingles– associatedwithimmunosuppressivetherapy,HIVinfection,malignancy&/orincreasingage.

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Shingles– signs&symptoms• Abnormalskinsensations&painintheaffectedareaofskin(dermatome)

• Headache,photophobia,malaise,lesscommonlyfever• Withindaysorweeks– aunilateralfluidfilledrashappears• Affectedareacanbeverypainfulwithtingling,prickingornumbnessoftheskin&intenseitching

• Rashlasts2-4weeks• Persistentpain(PostHerpeticNeuralgia)candevelop• Ifpainpersistorappearsmorethan90daysaftertherashthisisPHN (Oxman,etal.,2005)

• Paincanlast3-6monthsorlonger&canbetriggeredbystimulationofaffectedarea(windontheface)

(katz,etal.,2004)

ShinglesVaccine• Zostavax - Livevaccine• 1dosevaccine– 0.65ml,I.Minjection(deepsub-cutforbleedingdisorders)

• Availableasanoff-whitecompactcrystallineplug(inavial)

• Reconstitutewiththediluentprovidedinprefilledsyringe(clearcolourlessfluid)

• 2separateneedlesprovided• Notgivenifpatientonanti-viralmedication.Donotgive

within48hrsofcessationoftreatment• Revaccinationtimenotyetdetermined– possibly5years

(GreenBookchapterupdated26-2-2016,chapter28a)

ContraindicationsVaccineshouldnotbegiventothosewho:• Haveaweakenedimmunesystem• Havehadaseriousallergicreaction(includingananaphylacticreactiontoapreviousdoseofthesubstancesinthevaccine,e.g.neomycinandgelatine

• Havehadaseriousallergicreaction(includingananaphylacticreaction)to apreviousdoseofthe chickenpoxvaccine

• HaveanuntreatedTBinfection.(ContraindicatedforZostavax (Shingles),Varivax (ChickenPox)&MMRVaxPRO(MMR)butnotanyothercommonlyusedlivevaccines.

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ShinglesImmunisationprogramme2017/18• From1st April2017programmechangestothedateapatientturns70years(routinecohort)&78years(catchupcohort)

• Thiscouldimpactonvaccinesupply,thereforecontinuetovaccinatemainlyduringinfluenzaseason

• Patientswhoattaintheageof70or78canbeopportunisticallyimmunisedatanypointintheyear

• Patientsremaineligibleforshinglesvaccineupuntiltheir80thbirthday

• Thosewhoareeligiblebutmissedthevaccinecanbeimmunisedopportunistically

• Seenewshinglesposters

Vaccineupdate.Issue261.April2017

Shinglesvaccinecoverage,UK–September2016– February2017• Provisionalvaccinecoverageestimatesshow42.0%ofthe70yearoldroutinecohortand42.4%ofthe78yearoldcatch-upcohortwerevaccinateduptotheendofFebruary2017

• Thisis4.0%lowerfortheroutineand3.6%lowerforthecatch-upcohort comparedtoFebruary2016

• Previouscohortsremaineligibleforvaccination &itisimportanttheshinglesvaccineisofferedtoeligiblepatientsfromthecurrentandpreviouscohorts(bygeneralpractice)topreventthesignificantburdenofdiseaseassociatedwithshinglesamongolderadultsinEngland.

Eligible since Dates of birth (routine cohort) Dates of birth (catch-up cohort)

2013/14 02/09/1942 to 01/09/1943

2014/15 02/09/1943 to 01/09/1944

2015/16 02/09/1944 to 01/09/1945

2016/17 02/09/1945 to 01/09/1946 01/04/1937 to 01/09/1938 (up to their 80th birthday)

2017/18 Born on or after 02/09/1946 and aged 70 years

Born on or after 02/09/1938 and aged 78 (up to their 80th birthday)

Individualswithexistingeligibilityforthenationalshinglesvaccinationprogramme

Vaccineupdate.Issue261,April2017

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PneumococcalDisease• PneumococcaldiseaseisthetermusedtodescribeinfectionscausedbythebacteriumStreptococcuspneumoniae(alsocalledpneumococcus)

• Incubationperiodnotclearlydefinedbutcanbe1-3days• Transmissionbyaerosol,dropletsordirectcontactwithrespiratorysecretionsofsomeonecarryingtheorganism

• Invasivepneumococcaldiseaseisamajorformofmorbidity&mortality,particularlyaffectingtheveryyoung,elderly,patientswithabsentornon-functioningspleen

NotifiableDisease

Vaccines• 2typesofpneumococcalvaccine:

• Pneumococcalpolysaccharidevaccine(PPV23)• Pneumococcalconjugatevaccine(PCV13)Previnar

• Bothareinactivatedvaccines• NeithercontainthiomersalPPV-mosthealthyadultsdevelopagoodantibodyresponsetoasingledosebythe3rd weekafterimmunisation.AntibodyresponsemaybereducedinthosewithimmunologicalimpairmentorwithabsentordysfunctionalspleenPoorantibodyresponsetoPPVseeninchildrenunder2years.

Pneumococcalconjugatevaccine(PCV13)PrevinarDosage&schedule.Forinfantsunder1yearofage:• Firstdoseof0.5mlofPCV13ateightweeksofage.• Seconddoseof0.5mlat16weeksofage(atleasttwomonthsafterthefirstdose).

• Athirddoseof0.5mlshouldbegivenaftertheirfirstbirthday(atleast2monthsafterthelastPCV13dose).

Unimmunisedorpartiallyimmunisedchildrenagedoneyearanduptotwoyearsofage:• Asingledoseof0.5mlofPCV13.

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PneumococcalpolysaccharideVaccine(PPV23)Adultsover65yearsandatriskgroupsaged2yearsorover:• Asingledoseof0.5mlPPV23• Re-immunisationrecommendedforindividualswithnospleen,splenicdysfunctionorchronicrenaldisease

• Althoughevidencesuggestsadeclineinprotectionwithtime(Shapiroetal.,1991)therearenostudiesshowingadditionalprotectionfromboostingindividualswithotherindications,e.g.age,thereforeroutinerevaccinationisnotcurrentlyrecommended.

Atriskgroups• Asplenia orsplenicdysfunction• Chronicrespiratorydisease• Chronicheartdisease• Chronickidneydisease• Chronicliverdisease• Diabetes• Immunosuppression– duetodiseaseortreatment• Individualswithcochlearimplants• Individualswithcerebrospinalfluidleaks,e.g.followingtraumaormajorskullsurgery.

Influenza- disease• Ahighlyinfectious,acuteviralinfectionoftherespiratorytract• 3typesofvirus:A,B,C.A&Bareresponsibleformostclinicalillness

• Incubationof1-5days(average2-3)althoughmaybelongerespeciallyinpeoplewithimmunedeficiency

• Suddenonsetoffever,chills,headache,myalgiaandextremefatigue.

• Drycough,sorethroatandstuffynose.Forotherwisehealthyindividuals,infuenza isunpleasantbutusuallyself-limitingwithrecoveryusuallywithintwotosevendays

• Riskofseriousillnessfromfluishigherinchildrenunder6months,thosewithLTC’s,immunosuppressed&pregnancy.

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InfluenzaVirusesAviruses• Causeoutbreaksmostyears&aretheusualcauseofepidemics

• Live&multiplyinwildfowlformweretheycanbetransmittedtohumans

• AlsocarriedbyothermammalsBviruses• Tendtocauselessseveredisease&smalleroutbreaks• Predominantlyfoundinhumans• Burdenofdiseasemostlyinchildren.

PossiblecomplicationsoffluCommon• Bronchitis• Otitismedia(children),sinusitis• SecondarybacterialpneumoniaLesscommon• Meningitis,encephalitis,meningoencephalitis• PrimaryinfluenzapneumoniaRiskofmoreseriousillnessishigherin:• Childrenunder6months• Olderpeople• Thosewithunderlyingconditions,e.g.LTC’s• Pregnantwomen.

Fluvaccineeffectiveness• Efficacycalculatedatbetween50-60%foradults18-65years

• Lowerefficacyinelderlyalthoughimmunisationshowntoreduceincidenceofseverdiseaseincludingbronchopneumonia,hospitaladmissions&mortality

• 2014/15thefluvaccineonlyprovidedlimitedprotectionagainstinfectionasthemainA(H3N2)strainthatcirculateddifferedfromtheA(H3N2)strainselectedforthevaccine

• However,throughoutthelastdecade,therehasgenerallybeenagoodmatchbetweenthestrainsoffluinthevaccine&thosethatsubsequentlycirculated.

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Fluprogramme2017/18• Fluplan– Winter2017/18• Fluletter2017/18– sentoutMarch2017

Hasyoursarrived?

FluProgramme2017/18-TargetgroupsJCVIadvisethatthefollowinggroupsbeoffered‘fluvaccine

• Allthoseagedtwoandthree(butnotfouryearsorolder)on31August2017(i.e.dateofbirthonorafter1September2013andonorbefore31August2015)

• Allchildreninreceptionclassandschoolyears1,2,3and4• Allprimaryschool-agedchildreninformerprimaryschoolpilotareas• Peopleagedfromsixmonthstolessthan65yearsofagewithaseriousmedicalconditionsuchas:• A chronic(long-term)respiratorydisease,suchassevereasthma,• Chronicobstructivepulmonarydisease(COPD)orbronchitisochronicheartdisease,suchasheartfailure

• Chronickidneydiseaseatstagethree,fourorfive• Chronicliverdisease

Targetgroups• Chronicneurologicaldisease,suchasParkinson’sdiseaseormotorneuronedisease,orlearningdisability

• Diabetes• Splenicdysfunction• A weakenedimmunesystemduetodisease(suchasHIV/AIDS)ortreatment(suchascancertreatment)

• Morbidlyobese(definedasBMIof40andabove)• Allpregnantwomen(includingthosewhobecomepregnantduringfluseason)

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Morbidlyobesepatients• JCVIhasadvisedmorbidlyobesepatients(BMIof40orabove)couldbenefitfromfluvaccinationas:• Theyarefoundtobeathigherriskofhospitalisation&deathfollowingpandemicinfluenzainfection

• Manyinthisgroupwillalreadybeeligibleduetocomplicationsofobesitythatplacetheminanotherriskcategory

• Thesepatient’swillattractapaymentunderthedirectedenhancedservices(DES).

Targetgroups• Peopleaged65yearsorover(includingthosebecomingage65yearsby31March2018)

• Peoplelivinginlong-stayresidentialcarehomesorotherlong-staycarefacilities.Thisdoesnotinclude,forinstance,prisons,youngoffenderinstitutions,oruniversityhallsofresidence

• Peopleinreceiptofacarersallowance,orthosewhoarethemaincarerofanolderordisabledpersonwhosewelfaremaybeatriskifthecarerfallsill

• Considerationshouldalsobegiventothevaccinationofhouseholdcontactsofimmunocompromisedindividuals,specificallyindividualswhoexpecttosharelivingaccommodationonmostdaysoverthewinterand,therefore,forwhomcontinuingclosecontactisunavoidable

• FrontlineH&SCWshouldbeofferedvaccinebytheiremployers.

Whoelseshouldreceivefluvaccine?• HCP’sshoulduseclinicaljudgementtotakeintoaccounttheriskoffluexacerbatinganyunderlyingdiseaseaswellastheriskofseriousillnessfromfluitself

• Fluvaccineshouldbeofferedtosuchpatientseveniftheyaren’tintheclinicalriskgroups

• Childcontactsofveryseverelyimmunocompromisedindividualsshouldbegiveninactivatedvaccine.

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Vaccinationofclinicalriskgroups• Increasingfluvaccineuptakeinclinicalriskgroupsisimportantasthesepeopleareatincreasedriskofdeathorseriousillness

• Foranumberofyearsonlyabouthalfofpatientsaged6monthstounder65inatriskgroupshavebeenvaccinated

• Thosewithliverdisease&chronicneurologicaldiseasehavesomeofthehighestmortalityrates,yet,theyhavelowfluvaccineuptakeratescomparedwiththoseinotherclinicalriskgroups

• Vaccineuptakeforallthoseinatriskgroupsneedstoimprove– particularlyinthosewithchronicliverdisease&neurologicaldisease

WhydofrontlineH&SCWneedtobevaccinated?• Dutyofcaretoprotecttheirpatients&serviceusersfrominfection

• VaccinationprotectsH&SCW’s&reducesriskofspreadingflutotheirpatients,serviceusers,colleagues&familymembers

• Evidencethatvaccinationsignificantlylowersratesofflu-likeillness,hospitalisation&mortalityintheelderlyinlong-termhealthcaresettings

• Reducestransmissionofflutovulnerablepatients,someofwhommayhaveimpairedimmunity&maynotrespondwelltoimmunisation

• Helpsreducesicknessabsence&contributestokeepingtheNHS&careservicesrunningthroughwinterpressures.

KeymessagestoH&SCW’s• Dutyofcare• Vaccinationprotectsyou,patients&family• Everyoneissusceptibletoflu,evenifingoodhealth• Youcanbeinfected,havenosymptomsbutstillpassvirustoothers

• Goodinfectioncontrolisn’tsufficientonitsown• Impactoffluonfrail&vulnerablepeoplecanbefatal• Fluvaccinationhasgoodsafetyrecord• Throughoutlast10yearsthere’sbeenagoodtomoderatematchbetweenthestrainsoffluvirusinthevaccine&thosecirculating

• Positiverolemodelforpatients.

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CommissioningforQuality&Innovation(CQUIN)• NHSEnglandhaspublisheda2yearCQUINcovering2017/18&2018/19whichincludesanindicatortoimproveuptakeoffluvaccinationforfrontlinestaffwithinproviders

• Nationalambitionisthataminimum75%ofstaffinTrustsarevaccinated,however,asthismaymeanasignificantincreaseinworkthefirstyeartargetis70%risingto75%inthe2nd year

• ExamplesofeligiblestaffisavailableinFluplanWinter2017/18.

Whygivefluvaccineinpregnancy?• Pregnantwomenareatincreasedriskfromcomplicationsiftheycontractflu

• Itmaybeassociatedwithprematurebirth&smallerbirthsize&weight

• Fluvaccinationduringpregnancyprovidespassiveimmunityagainstflutoinfantsinthefirstfewmonthsoflife

• Studiesshowthatinactivatedfluvaccinecanbesafelyadministeredatanytimeduringpregnancy

• Nocurrentevidencetoshowanyincreasedrisktomotherorbaby

• Vaccineshouldbeofferedduringeverypregnancy.

Whyofferfluvaccinetochildren?• Extensionoftheseasonalfluvaccinationprogrammetoallchildrenaimstolowerthepublichealthimpactoffluby:• Providingdirectprotection-preventingalargenumberoffluinfectionsinchildren

• Providingindirectprotection – byloweringflutransmissionfromchildren:• Tootherchildren• Toadults• Tothoseinclinicalatriskgroupsofanyage.

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Children’sprogramme2017/18tobedelivered:• All2&3yearolds(butnot4yearsorolder)on31st August2017tobevaccinatedinGeneralPractice

• 4yearoldstobeofferedfluvaccinationthroughschoolbasedprogramme

• 4to8yearolds(butnot9yearsorolderon31August2017)i.e.thoseinreceptionclass&schoolyears1-4,tobevaccinatedinschool

• Allprimaryschool-agedchildreninformerprimaryschoolpilotareawillcontinuetobeofferedvaccinationinschools.

Liveattenuatedinfluenzavaccine(LAIV)• Aliveattenuatedintranasalsprayistherecommendedvaccineforthechildhoodfluprogramme

• Ithasbeenshowntobemoreeffectiveinchildrencomparedwiththeinactivatedfluvaccines

• Itmayoffersomeprotectionagainststrainsnotcontainedinthevaccineaswellastothosethatare&haspotentialtoofferbetterprotectionagainstvirusstrainsthathaveundergoneantigenicdrift(2ormorevirusescombinetoformasubtype)

• LAIVcomprisesaweakenedwholelivevirus,whichinducesbetterimmunememoryasitreplicatesnaturalinfection,therebyofferingbetterlong-termprotectiontochildren

• Aswellasbeingweakened,thelivevirusesinLAIVhavebeenadaptedtocoldsotheycan’treplicateefficientlyatbodytemperature

• Ithasagoodsafetyprofileinchildrenaged2years&older.

WhogetsLAIV?• Alleligiblechildrenwhennotmedicallycontraindicated,includingthoseinclinicalriskgroups

• Ifcontraindicatedtheyshouldbeofferedasuitableinactivatedalternative

• Childrennotinclinicalatriskgroups(&wherenotcontraindicated)shouldonlybeofferedLAIV

• Theyaren’teligibleforinactivatedvaccine• LAIVhasanexpirydate18weeksaftermanufacture

Atriskchildreneligibleforfluvaccinationviatheschoolbasedprogrammemaybeofferedvaccinationingeneralpracticeiftheschoolsessionislateintheseason,parentspreferit,orifchildabsentonthedayvaccinationwasofferedinschool.

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2nd doseofFluenz Tetra• ThepatientinformationleafletprovidedwithLAIVstatesthatchildrenshouldbegiventwodosesofthisvaccineiftheyhavenothadfluvaccinebefore.

• However,theJCVIconsidersthataseconddoseofthevaccineprovidesonlymodestadditionalprotection

• ThereforechildrenNOTinclinicalriskgroupsonlyrequire1doseofLAIV

• Childreninclinicalriskgroupsaged2tolessthan9yearswhohavenotreceivedfluvaccinebeforeshouldbeofferedtwodosesofLAIV(givenatleastfourweeksapart).

ContraindicationstoLAIVLAIVshouldnotbegiventochildrenwhoare:• Clinicallyseverelyimmunodeficientduetoconditionsortherapy• Acute&chronicleukemia's• Lymphoma• HIVinfectionnotonhighlyactiveantiretroviraltherapy• Cellularimmunedeficiencies• Highdosecorticosteroids

• Receivingsalicylatetherapy• Knowntobepregnant• Havesevereasthmaoractivewheezing• Childrentakinghighdoseinhaledsteroidshouldonlybegivenlivefluvaccineontheadviceoftheirspecialist.

PrecautionsAcutelyunwell:• DeferuntilrecoveredHeavynasalcongestion:• Deferlivevaccineuntilresolvedor,ifthechildisinariskgroupconsiderinactivatedfluvaccinetoprovideprotectionwithoutdelay

Usewithantiviralagentsagainstflu:• LAIVshouldNOTbeadministeredatthesametimeorwithin48hoursofcessationoftreatment

• Administrationoffluantiviralagentswithin2weeksofadministrationofLAIVmayadverselyaffecttheeffectivenessofthevaccine.

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Severeasthmaoractivewheezing• Livefluvaccineisnotrecommendedforchildren&adolescentswithsevereasthmaoractivewheezing,e.g.thosewhoarecurrentlytakingorhavebeenprescribedoralsteroidsforrespiratorydiseaseinthelast14days

• Childrencurrentlytakingahighdoseinhaledsteroid–Budesonide>800mcg/dayorequivalent(e.g.Fluticasone>500mcg/day)shouldonlybegivenLAIVontheadviceoftheirspecialist

Asthesechildrenareinadefinedfluriskgroup,thosewhocannotreceiveLAIVshouldreceiveaninactivatedfluvaccine.

Severeasthmaoractivewheezing• VaccinationwithLAIVshouldbedeferredinchildrenwithahistoryofactivewheezinginthepast72hoursorthosewhohaveincreaseduseofbronchodilatorsintheprevious72hours.

• Ifconditionnotimprovedafterafurther72hourstheninactivatedfluvaccineshouldbeofferedtoavoiddelayingprotectioninthishigh-riskgroup.

Eggallergy- adults• Mostfluvaccinesarepreparedfromfluvirusesgrowninembryonatedhens’eggs– leavingthefinalvaccinewithwithvaryingamountsofegg– dependingonthevaccine

• Adultswitheggallergycanbeimmunisedinanysettingusinganinactivatedfluvaccinewithanovalbumincontentlessthan0.12µg/ml(equivalentto<0.06µgfor0.5mldose)

• Adultswithsevereanaphylaxistoeggthathaspreviouslyrequiredintensivecareshouldbereferredtospecialistsforimmunisationinhospital

• Thereisnoovalbumin-freevaccineavailablefor2017/18fluseason

• SeeJuly2017VaccineUpdateorindividualSPC’sforovalbumincontent.

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Eggallergy- children• ChildrenwitheggallergycansafelybevaccinatedwiththeLAIVinanysetting(Primarycare&schools)

• Thosewithbotheggallergy&clinicalriskfactorsthatcontraindicateLAIV(e.g.immunosuppression)shouldbeofferedaninactivatedfluvaccinewithaverylowovalbumincontent(lessthan0.12µg/ml)

• Childrenwithahistoryofsevereanaphylaxistoeggthathasrequiredintensivecare,shouldbereferredtospecialistsforimmunisationinhospital

• LAIVisotherwisenotcontraindicatedinchildrenwitheggallergy.Egg-allergicchildrenwithasthmacanreceiveLAIViftheirasthmaiswellcontrolled.

Riskoftransmissionoflivevaccinevirus• Thereistheoreticalpotentialfortransmissionofliveattenuatedvirustoimmunocompromisedcontacts

• Riskisfor1-2weeksfollowingvaccination• ExtensiveuseoftheLAIVinUSwithnoreportedinstancesofillnessorinfectionsfromthevaccinevirusamongstimmunocompromisedpatientsinadvertentlyexposedtovaccinatedchildren

• Whereclosecontactwithveryseverelyimmunocompromisedpatients(e.g.bonemarrowtransplantpatientsrequiringisolation)islikelyorunavoidable(householdmembers)considerandappropriateinactivatedfluvaccineinstead.

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ExposureofHCW’stoLAIV• TheoreticallytheremaybesomelowlevelexposuretothevaccinevirusesforthoseadministeringLAIV&/orfromrecentlyvaccinatepatients

• InUS- NoreportedinstancesofillnessorinfectionsfromthevaccinevirusamongstHCWinadvertentlyexposed

• Riskofacquiringvaccinevirusesfromenvironmentisunknown,butprobablylow

• Thevaccinevirusesarecold-adapted&attenuated&thereforeunlikelytocausesymptomaticinfluenza

• Asaprecaution,veryseverelyimmunocompromisedindividualsshouldnotadministerLAIV

• OtherHCW’swhohavelesssevereimmunosuppressionorarepregnant,shouldfollownormalclinicalpracticetoavoidinhalingthevaccine&ensurethattheythemselvesareappropriatelyvaccinated.

InadvertentadministrationofLAIV• IfanimmunocompromisedindividualreceivesLAIV,thedegreeofimmunosuppressionshouldbeassessed

• Ifpatientisseverelyimmunocompromised,antiviralprophylaxisshouldbeconsidered

• Otherwisetheyshouldbeadvisedtoseekmedicaladviceiftheydevelopflu-likesymptomsinthe4daysfollowingadministrationofthevaccine

• Ifantiviralsareusedforprophylaxisortreatment,patientshouldalsobeofferedinactivatedfluvaccineinordertomaximisetheirprotectionintheforthcomingfluseason(thiscanbegivenstraightaway).

CommonlyreportedadversereactionsFollowinginactivatedfluvaccine:• Pain,swellingorrednessatinjectionsite,lowgradefever,malaise,shivering,fatigue,headache,myalgia&arthralgia

• AsmallpainlessnodulemayformatinjectionsiteThesesymptomsusuallydisappearwithin1-2dayswithouttreatmentFollowingLAIV• Nasalcongestion/rhinorrhoea,reducedappetite,weakness&headache

Rarely,aftereithervaccine,anaphylaxiscanoccur.

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Whichvaccine&howmanydoses?Vaccinetype Authorised ageindication Dose

Liveattenuatedintranasal vaccine

Children aged2tounder18years(ifnocontraindications)

Singleapplicationineachnostrilof0.1mlChildrenNOTinclinicalriskgroupsonlyrequire1doseofthisvaccineChildreninclinicalriskgroupsaged2tounder9whohavenotreceivedfluvaccinebeforeshouldreceivea2nd doseatleast4weekslater.

Inactivatedintramuscularvaccine(numberofdifferentbrands)

Childrenaged6months&olderadults(N.B. someofthevaccinesarenotauthorised foryoungchildren)

Singleinjectionof0.5mlChildren aged6monthstounder9yearswhohaven’treceivedfluvaccinebeforeshouldreceivea2nd doseatleast4weekslater

Inactivatedintradermalvaccine-Intanza

Adultsaged60years&older

Singleinjectionof0.1ml

Eligible cohort

Which vaccine

Setting in which it is normally offered Key notes Children in clinical risk

groups Children not in clinical risk groups

6 months to less than 2 years old

Offer suitable inactivated flu vaccine. Not applicable General practice Eligibility is based on age

at which they present

2 and 3 years olds (but not 4 years or older) on 31 August 2017*

Offer LAIV. If LAIV is medically contraindicated, then offer suitable inactivated flu vaccine.

Offer LAIV (unless medically contraindicated)

General practice

Children who turn 2 years of age after 31 August 2017 are not eligible Children who were 3 and turn 4 after 31 August 2017 remain eligible

Children in reception class and school years 1, 2, 3 and 4 (aged 4 to 8 years on 31 August 2017)**

Offer LAIV. If LAIV is medically contraindicated, then offer suitable inactivated flu vaccine.

Offer LAIV (unless medically contraindicated)

School based provision

At risk children may be offered vaccination in general practice if the school session is late in the season or parents prefer it

Children in school year5 and above (aged 9 yearsor older on 31 August 2017) and less than 18 years old

Offer LAIV. If LAIV is medically contraindicated, then offer suitable inactivated u vaccine.

Not applicable General practice

Eligibility and the type of vaccine to offer children under 18 is as follows:

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Typesoffluvaccines- 2017/18Twomaintypesofvaccineavailable:• Inactivated– byinjection• Liveattenuated– bynasalapplicationNoneofthefluvaccinescancauseclinicalinfluenza• Trivalent:fluvaccinescontain2subtypesofinfluenzaA&onetypeBvirus

• Quadrivalent:vaccinescontain2subtypesofinfluenzatypeAbothBvirustypes

Theliveintranasalvaccine(offeredtochildrenaged2years&over)isaquadrivalentvaccine,asistheinactivatedvaccine(recommendedforchildrenaged3&above)whocan’treceivetheLAIV.ThiscontainsbothlineagesofBviruses&thereforemayprovidebetterprotectionagainstthecirculatingBstrainsthantrivalentfluvaccines.

FluvaccinationcompositionTrivalentvaccineswillcontain3viruses:• AnA/Michigan/45/2015(H1N1)pdm09– likevirus• AnA/HongKong/4801/2014(H3N2)– likevirus• AB/Brisbane/60/2008– likevirusInadditionthequadrivalentvaccinewillcontain:• B/Phuket/3073/2013– likevirusNoneofthefluvaccinesfor2017/18containthiomersalasanaddedpreservative.

Inactivatedfluvaccines• Anumberofmanufacturershaveproducedvaccinefor2017/18– see‘Thenationalfluimmunisationprogramme2017/18letteravailableonPHEwebsite

• MostofinactivatedvaccinesareadministeredIM,however,Intanza (SanofiPasteur)isadministeredintradermally

• Allcurrentlyavailablefluvaccinescontaineggprotein• Somefluvaccinesarerestrictedforuseinparticularagegroups.

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Fluvaccinepresentation&dosage• InactivatedfluvaccinesforIMadministrationsuppliedassuspensionsinpre-filledsyringescontaining0.5mldose

• IfSPCforIMinactivatedfluvaccinestatesyoungchildrencanbegiveneither0.25mlor0.5mldose,give0.5mldose

• Intanza,forintradermaladministrationissuppliedinamicro-needleinjectionsystem

• LAIV– suppliedasanasalspraysuspensioninaspecialsingleuse,pre-filled,nasalapplicator.Noreconstitutionordilutionrequired.Eachapplicatorcontains0.2ml(0.1mlpernostril)

AdministrationofLAIV• LAIVisaliveattenuatednasalvaccine&mustnotbeinjected

• Donotattempttoattachaneedle• LAIVcanbeadministeredatthesametimeasoratanyintervalfromothervaccines,includinglivevaccines

• Patientshouldbreathenormally– noneedtoactivelyinhaleorsniff

• Thevaccineisrapidlyabsorbedsononeedtorepeateitherhalfofdoseifpatientsneezes,blowstheirnoseortheirnosedripsfollowingadministration.

Vaccinesavailablefor2017/18• AllfluvaccinesforchildrenarepurchasedcentrallybyPHE.• Forchildreninclinicalriskgroupsunder18yearsofagewhereLAIViscontraindicated,suitableinactivatedinfluenzavaccinesareprocuredcentrallyandshouldbeoffered

• Thequadrivalentinactivatedinfluenzavaccine(FluarixTMTetra®)isauthorised forchildrenagedfromthreeyearsandispreferredbecauseoftheadditionalprotectionoffered

• Childrenagedfrom6monthstolessthan3yearsshouldbegiveninactivatedinfluenzavaccine(SplitVirion)BP®

• Fluenz TetraandinactivatedinjectablevaccinescanbeorderedthroughtheImmForm website.

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2017/18changestothefluprogramme• Morbidlyobese:Vaccinationofthemorbidlyobese(definedasBMIof40andabove)willattractapaymentunderthedirectedenhancedservices(DES)in2017/18.

• ReceptionYear(childrenaged4-5years):Thesechildrenwillnowbeofferedfluvaccination(LAIV)inreceptionclass,ratherthanthroughgeneralpractice.NopaymentwillbemadeundertheDESiftheyarevaccinatedingeneralpractice(unlessthechildisinanatriskgroup)

• SchoolYear4(childrenaged8-9years):Aspartofthephasedroll-outofthechildren’sprogramme,thisyearchildreninschoolyear4willalsobeofferedthevaccination.

CommunityPharmacySeasonalInfluenzaVaccinationAdvancedService• Servicetocontinuein2017/18• Eligibleadultsaged18years&overwillhavethechoiceofgettingfluvaccineatapharmacy

Fluseason• Commencevaccinationprogrammeassoonasvaccinearrivesinpractice

• AimforprogrammetobecompletedideallybyendDecember2017beforeflucirculationusuallypeak

• UseclinicaljudgementasitmaybeappropriatetoofferfluvaccinebetweenJanuary– Marchtothoseunvaccinated,e.g.newlyatriskpatientsincludingpregnantwomenwhoweren’tpregnantatthebeginningofthevaccinationperiod

• Theenhancedservicespecificationforfluincludespaymentforvaccinesgivenupuntil31st March.

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Vaccineuptakeambition• Longtermaimistoachieve75%uptakeinalleligiblegroups,however,interimtargetshavebeensetasuptakeissomewayoff75%target

• Asakeyobjectiveinthechildren’sprogrammeisreductionofflutransmission,theambitionbeyond2017/18willbebasedonlevelsofvaccineuptakeneededtoachievethisimpact.

VaccineuptakeambitionEligiblegroup UptakeambitionRoutineprogrammeAged65yrs&over 75%,reflecting WHOtargetforthis

groupHealthcareworkers Thetrust-levelambitionistoreach

75%&animprovementineveryTrust.2017/18– CQUINtargetremains

Agedunder65‘atrisk’,includingpregnantwomen

2017/18-at least55%inallclinicalriskgroups.Maintainhigherrateswherethosehavealreadybeenachieved.Ultimatelytheaimisfor75%uptake.

Children’sprogrammeChildrenaged2-8yrs In2017/18uptakelevelsbetween40-

65%tobeattainedbyeveryprovider

Nationalfluimmunisationprogramme2017/18letter

InactivatedfluvaccineforthosewithcontraindicationstoLAIV• ChildrenforwhomLAIViscontraindicatedshouldbeofferedasuitablealternativeinactivatedvaccine

• Someinactivatedfluvaccineshavebeenassociatedwithhighratesoffebrileconvulsionsinchildren

• Someinactivatedfluvaccinescontaintoomuchovalbuminforeggallergicchildren

• CheckSPCforvaccinesuitabilitybeforeadministration• Fluarix Tetraisthepreferredvaccineforchildrenaged3oroverwhocan’treceiveFluenz Tetra

• Children6monthsto<3yearsshouldbegiveninactivatedinfluenzavaccine(SplitVirion)BP.

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Bewareofproductconfusion• Fluenz Tetra– istheLAIVgivenasanasalspraytochildrenaged2yearstolessthan18years

• Fluarix Tetra– isaninactivatedvaccinelicensedfrom3yearsofagethatcanbegiventochildrenwhoCANNOTreceivetheliveintranasalvaccine,the65yearolds&over,theunder65yearoldsatrisk,pregnantwomen&healthcareworkers

Donotconfusethe2‘Tetra’brandsFluenz isthenazal fluvaccineFluarix isthearminjectedvaccine.

RecordingoffluvaccinegivenBecausethere’savarietyoffluvaccinesontheUKmarketit’simportanttorecordthefollowinginformation:• Vaccinename,productname,batchnumber&expirydate• Doseadministered• Dategiven• Route/siteused• Name&signatureofvaccinatorRecordin:• Patient’s&GPrecords• Redbook– ifachild• PracticeITsystem• Childhealthinformationsystem– ifachild

Orderingcontrols• Allocationsbasedcontrols(similartolastyear)inplacefor2017/18forcentrallyorderedvaccines,e.g.LAIVforchildrentotrytopreventvaccinewastage(Seepage2ofVaccineUpdate268.August2017)

GeneralPrinciplesforLAIVordering• LAIVissuppliedina10-dosepack:1pack=10doses• Ordersmallamountsweeklyandreceiveweeklydeliveries• Berealisticabouttheamountofvaccinethatyouexpecttoneed• Spreadyourordersoverthecourseofthefluvaccinationseason–laterorderedstockwillhavealaterexpirydateandwilllastlonger

• Holdnomorethan2weeksstockinyourfridge;localstockpilingcancausedelaysorrestrictionsonstockbeingreleasedtotheNHS,andincreasestheriskofsignificantlossofstockifthereisacoldchainfailureinyourpractice

Forallothereligiblepopulationsapartfromchildren,providersremainresponsiblefororderingvaccinesdirectlyfromthemanufacturers.

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ControlsoninactivatedfluvaccineorderingTheinactivatedinfluenzavaccines,procuredbyPHEforchildrenwhoarecontraindicatedforFluenz Tetraandinaclinicalriskgroup,willalsobesubjecttothefollowingorderingcontrols:• Inactivatedinfluenzavaccine(splitvirion)BPwillhaveaninitialcapof5dosesperorderperweek,and

• Fluarix Tetra®willhaveanordercapof30dosesperorderperweek.ThesecontrolswillalsoberegularlyreviewedandupdatesonchangeswillbeprovidedontheImmFormnewsitem.

Beaware• Noneoftheinfluenzavaccinesfor2017/18containthiomersal

• Somefluvaccinesarerestrictedforuseinparticularagegroups.AlwayschecktheSummaryofProductCharacteristics(SPC)Seepg.24-26ofNationalFluimmunisationprogramme

• Moredetailedinformationonthecharacteristicsoftheavailablevaccines,includingeggcontentwillbepublishedonthePHEimmunisationwebsite

• DistributiongenerallystartslateSeptember,however,delayscouldoccursoallowflexibilityinthesessionsscheduled- especiallytheearlierones.

Datacollection• FluvaccineuptakedataiscollectedviatheImmFormsystem

• Over90%GPpracticesareabletomakeautomateddatareturns

• IfautomatedreturnsfailforthemonthlydataGP’smustsubmitreturnsmanually

• Monthlydatacollectionswilltakeplaceover4months• 1st datacollectionwillbeNovember2017forvaccinesadministeredbyendOctober2017

• FinaldatacollectionFebruary2018forvaccinesadministeredbytheendofJanuary2018.

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DatacollectionofHCW• PHEwillberesponsibleformonthlycollectionoffluvaccineuptakedata

• DatafromgeneralpracticewillbecollectedviatheImmForm dataentrytool

Datacollectionofschoolagedchildren• PHEresponsibleformonthlycollectionsoffluvaccineuptakeforchildreninreceptionclassandinschoolyears1-4over4monthsviatheImmForm dataentrytool.

GeneralPracticechecklisttoachievehighuptake• Identifyanamedleadresponsibleforfluvaccinationprogrammeandforliaisingwithallinvolved

• Updatepatientregistersthroughoutfluseason– addingnewlypregnantwomen&newlydiagnosedpatient’swithLTC’s

• Submitaccuratedataonpatient’seligible&uptake• Ordersufficientvaccinefortheseason• Inviteeligiblepatientstoattendclinics.Thisisarequirementoftheenhancedservicespecification

• Followuppatients(especiallyinatriskgroups)ifdon’trespond

• Startvaccinationassoonaspossibleafterreceiptofvaccinesupply.

GeneralPracticechecklisttoachievehighuptake• Collaboratewithmaternityservices• Offerfluvaccinationopportunistically• Makeallreasonableefforttoensurehouseboundpatientsarevaccinated

• Collaborationbetweenpractices&/orCCGwithcommunitypharmacists,communityhealth&socialcaretruststoensureresidentsofcare/nursinghomesreceivethevaccine

PHEareencouragingpracticestoreviewtheirsystemsinlightoftheabovechecklist.

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Keymessages• Fluimmunisationisoneofthemosteffectiveinterventionstoreduceharmfromflu&pressuresonH&SCservicesduringthewinter

• Importanttoincreasefluvaccineuptakeinclinicalriskgroupsbecauseofincreasedriskofdeath&seriousillnessifthesepeoplecatchflu

• Foranumberofyears,onlyaroundhalfofpatient’saged6mnthstounder65yearsinclinicalriskgroupshavebeenvaccinated

• Influenzainpregnancycancausecomplicationssoneedtoencouragevaccinationinthesewomen

• EncouragevaccinationofH&SCW• Bypreventingfluinfectionthroughvaccination,secondarybacterialinfection,e.g.pneumoniaareprevented.Thisreducesneedforantibiotics&helpspreventantibioticresistance.

ContraindicationstoVaccines

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TrueContraindicationstovaccines• Vaccinationinmoderatelyorseverelyunwellindividuals• Livevaccinesinimmunocompromisedindividuals• Anaphylaxistopreviousdoseofvaccineoravaccine

componentSevereallergicreactions(notanaphylaxis)areNOTacontraindication.Specialistadviceshouldbesoughtbeforecontinuing

ThefollowingarealsoNOTcontraindicationstovaccination:• Familyhistoryofanyadversereactionsfollowingimmunisation• Previoushistoryofpertussis,measles,rubellaormumpsinfection• Prematurity:immunisationshouldnotbepostponed• StableneurologicalconditionssuchascerebralpalsyandDown’ssyndrome

• Contactwithaninfectiousdisease• Asthma,eczema,hayfeveror‘snuffles’• Treatmentwithantibioticsorlocally-acting(eg topicalorinhaled)steroids

• Child’smotherispregnant• Childbeingbreastfed• Historyofjaundiceafterbirth• Underacertainweight• Overtheagerecommendedinimmunisationschedule• ‘Replacement’corticosteroids

Commonvaccine-inducedadverseeventsfollowingimmunisation• Pain,swellingorrednessatinjectionsite• Fever,malaise,myalgia,irritability,headache,lossofappetite.Timingofthesereactionsvary,e.g.fevercanstartwithinafewhoursoftetanuscontainingvaccines,butcanoccur7-10daysaftermeaslescontainingvaccines

MMR– 6-10daysaftervaccine:• Measlesvaccinesstartstowork&maycausefever,measles-likerash,lossofappetite.(Notinfectious)

2-3weeksaftervaccine• Mumpsvaccinemaycausemumps-likesymptoms(fever,swollenglands)

Rubellavaccinemaycauseabriefrash&slightlyraisedtemperature12-14daysafterinjection,butmorerarelyarashcanoccurupto6weekslater.

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LiveVaccines- Reminder

Disposaloflivevaccines• PGDsallsay:Equipmentusedforimmunisation,includingusedvials,ampoules,orpartiallydischargedvaccinesinasyringeorotherapplicator,shouldbedisposedofbysealinginaproper,puncture-resistant,lidded,yellow ‘sharps’receptacleforincineration

• Referencingthenationalguidance:Department of Health (DH) Safe management of healthcare waste Health Technical Memorandum 07-01. [Online] London: DH, 2013. Available from: https://www.gov.uk/government/publications/guidance-on-the-safe-management-of-healthcare-waste

• Live (attenuated) vaccines are not cytotoxic products and do not need to be disposed of in a purple bin (i.e. whether used or expired unused a yellow bin is fine)

Incompletevaccinationstatus!• Immunisationschedule• Foreignimmunisationschedule

http://vaccine-schedule.ecdc.europa.eu/Pages/Scheduler.aspx• Catchupschedule

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Storage&managementofvaccines

Administrationofvaccines

LegalAspectsofVaccination

ImmunisationDepartment,

Whatshouldweensurewhenseekingconsent?• Thattheclienthascapacitytoconsent.• Iftheydon’tisittemporary/permanent?• Thattheyhavehadsufficient,appropriateinformationtomakethedecision• Whatimmunisation(s)aretobegiven• Whichdisease(s)willbeprevented• Benefitsandrisksofimmunisationv.risksofdisease(s)• Possiblesideeffectsandhowtotreat• Anyfollow-up/actionrequired• Anynewinformation• Agreementtoproceed

• Thattheyareabletoretaintheinformation• Thattheyareabletocommunicatetheirdecision• Thattheyhavegiventheirconsentfreely&voluntarilySeekconsentpriortoeachintervention.

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MCA2005‘thepersondeliveringthetreatmentornursingcaremakesthedecisionaboutwhethertodeliverthecare,eventhoughthetreatmentmayhavebeenprescribedbysomeoneelse’

WiderangeofInformationavailablebasedoncurrentscientificevidenceandclinicaladvice

•NHS ImmunisationInformation:LeafletsPostersFact sheetsWebsite: www.phe.gov.uk(Translations/interpreters available)•Green book•Manufacturers PIL & SPC

Writtenconsent• No legalrequirementforconsenttobeinwriting• Signatureonaconsentformnotconclusiveproofthatconsenthasbeengiven

• Shouldrecordthedecisionsanddiscussionsthathavetakenplaceandtypeofinformationsuppliedtosupportthedecision

• Whereindividuals/parent(s)disagreewithimmunisation,thisshouldbeshared/recordedwithallmembersofthePrimaryHealthCareTeam

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Whoconsentsforachild?Thosewithparentalresponsibility:• Mother• Fatherifmarriedtomotheratbirth,orsubsequentlymarriedher

• SinceDecember2003- Biologicalfather,ifnamedonbirthcertificate

• Unmarriedfatherifhasparentalresponsibilityordergrantedbythecourt,residenceorder,parentalresponsibilityagreement

• Stepparentifmarriedtothechild’sparentwhohasparentalresponsibility

• Grandparent/childmindercanbringchildforimmunisationsaslongasthepersonwithparentalresponsibilityhasconsentedinadvance.

Adolescentsandyoungchildren

• Youngpeoplecanconsenttotheirowntreatmentprovidedtheyare:

üAged16-17yearsüConsidered“Frasercompetent”(Gillick)X Parentcannotover-ridecompetentchild’sconsenttotreatmentüparentscanover-ridecompetentchild’srefusalfortreatmentinanemergency

ConfidentialityofPersonalInformation- RelatedLegislation

• DataProtectionAct(www.dataprotection.gov.uk)• The1998DataProtectionActsetstandardswhichmustbesatisfiedwhenobtaining,holding,usingordisposingofpersonaldata

• TheDataProtectionActcoversanythingwithpersonalidentifiableinformation(e.g.health,personnel,occupational,finance,suppliers,andcontractors)

• YouarerequiredbylawtocomplywiththeDataProtectionAct1998

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Caldicott Report• March1996theDepartmentofHealthpublishedguidanceonthe‘ProtectionandUseofPatientInformation’

• Caldicott CommitteewasestablishedtoreviewandimprovethewaytheNationalHealthServicehandlesandprotectspatientinformation

• Identified6principles,similarinmanyrespectstotheprinciplesoutlinedintheDataProtectionAct

Caldicott principles1. Justifythepurpose(s)forusingpatientdata2. Don'tusepatient-identifiableinformationunlessitisabsolutelynecessary3. Usetheminimumnecessarypatient-identifiableinformation4. Accesstopatient-identifiableinformationshouldbeonastrictneedto

knowbasis5. Everyoneshouldbeawareoftheirresponsibilitiestomaintain

confidentiality6. Understandandcomplywiththelaw,inparticulartheDataProtectionAct

AsanemployeeoftheTrust/GPpracticeyouarerequiredtofollowtheCaldicott principlesaslaiddownbytheNHSExecutive

AllNHSorganisationsarenowrequiredtohaveaCaldicottGuardian.

Prescribing

Avaccinemayonlybeadministered:• Againstaprescriptionwrittenmanuallyorelectronicallybyaregisteredmedicalpractitioneroranotherauthorisedprescriber

• AgainstaPatientSpecificDirectionorPatientGroupDirection

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PatientSpecificDirections• HealthCareAssistantscanonlyworktoPSDs• TheycannotlegallyworktoaPGD• RolesthataHCAundertakes– theymusthavebeenappropriatelytrained.AssessedbytheRegisteredPractitionerascompetent.

• TheHCAcannotindependentlyassess,treatorchangeapatient’streatment,itisoutoftheirremittomakea‘judgementcall’ontheirown

• TheyundertakedelegatedtasksRef:Tanis.Hand@rcn.org.uk

WhenshouldaPSDbeused?• TheusualmethodforsupplyandadministrationofvaccinesintheroutineimmunisationprogrammeisviaaPSD.(HCAsshouldNOT administerChildhoodimmunisations,apartfromtheIntra-nasalFluvaccines)

• ImmunisationauthorisedbyGPorindependentnurseprescriberat6-8weekcheck

• RecordedasaninstructioninPersonalChildHealthRecordorredbook

• Pleasenote:Goodpracticedictatestheimmuniserchecktherecipientisfitandwellandtherearenocontraindications,priortovaccination.

ScopeandLimitationsofPGDs• PGDsarenotaformofprescribingbutprovidealegalframeworkforthesupplyand/oradministrationofvaccines

• PtsmaypresentdirectlytoahealthcareprofessionalusingPGDsintheirservice,withoutseeingadoctor

• HealthcareprofessionalsworkingwithPGDisresponsibleforassessingthatthepatientfitsthecriteriainthePGD

• HealthcareprofessionalssigninguptoPGDsmustbefullycompetentqualifiedandtrainedinallaspectsofimmunisation

N.B:THEIMMUNISATIONPGDsTHATPHEISSUETOPRACTICESARECHANGINGHaveyoureceivedyouremailandPGDforadministrationofPertussisat16weeksofpregnancy?

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PGDs§ Itisnotanaidememoire,andnotasubstitutefor(orasubstituteforaknowledgeof)SPCs/PILs/theGreenBook/nationalletters/servicespecifications– eachhasitsownfunction,oftentheyoverlap,sometimestheyconflict(wetrytoavoidtheseconflictsbywritinglocallytailoredPGDs)

§ StaffusingPGDsmustadhereexactly toall ofthecontentBUT§ Mustalsokeepuptodate,andbeawareofe.g.:§ Thedetailofthecontractunderwhichtheyareworking(can’tvaccinateoutsideofthisevenifthePGDallowsit)

§ Anychanges(e.g.tonationalschedules,contracts)whichhaverenderedthePGDoutofdate

§ Anyrecentdrugalertswhichmeansthevaccinemustnotbegiven.

RetentionofexpiredPGDsThesamerulesapplytoPGDrecordsastoallotherpatientrecords:• Foradults,allPGDdocumentationmustbekeptforeightyears,forchildrenitmustbekeptuntilthechildis25yearsold,orforeightyearsafterachild’sdeath

• InadditiontopatientrecordsrelatingtothePGD,localarrangementsshouldbeinplacetoretainthemastercopiesofthePGD,listsofauthorisedpractitioners&recordsofversionnumbers

• See:https://www.sps.nhs.uk/articles/how-long-should-pgd-documentation-be-kept-i-e-master-authorised-copy-of-the-pgd-lists-of-authorised-practitioners-and-patient-supplyadministration-records/

• FullinformationaboutretentionofNHSrecords(updatedJuly2016)isavailablefrom:http://systems.digital.nhs.uk/infogov/iga/resources/rmcop

WhatisClinicalGovernance?

• FrameworkthroughwhichNHSorganisationsareaccountableforcontinuouslyimprovingstandardsofpatientcareandthequalityoftheirservices

• Safeguardinghighstandardsofhealthcaredelivery• Creatinganenvironmentofconsistenthighqualityandclinicalcareexcellence.

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HowdoesthisrelatetoImmunisation?

• Clinicalgovernanceisrelevantacrossallareaofimmunisationpractice,e.g.

• Ensuringallimmunisersaretrainedandregularlyupdated• Vaccinesarecorrectlystoredandhandled• AdherencetoClinicalgovernanceframeworkshouldbemonitoredthroughregularauditofthevaccineserviceofferedbytheTrust.

• Chapter2Consent.ImmunisationAgainstInfectiousDisease(TheGreenBook)http://www.dh.gov.uk/assetRoot/04/09/67/03/04096703.pdf

• ThishasbeenendorsedbythelegaladvisorstotheDH,theNMC,RCNandCPHVA.

AdverseEventScenarios

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Pertussis–whoopingcough• Highlyinfectiousdisease• Initialcatarrhalstage,followedbyanirritatingcoughthatgraduallybecomesparoxysmal,usuallywithin1-2weeks,followedbyacharacteristic‘whoop’orvomiting

• Inadults&olderchildrenoftenno‘whoop’justapersistentcough– oftenmakingdiagnosisdifficult

• Transmissionofinfectionbyrespiratorydroplet• Incubationperiod6-20days&casesareinfectiousfrom6daysafterexposureto3weeksafteronsetofparoxysms.

NotifiableDisease

PertussisinEnglandandWales• Pertussiscontinuestopeakevery3-4yearsthoughwithfarfewernotificationsthaninthepre-vaccineera(800casesperyearonaverage)

• Numbershavebeenathistoriclowlevelsforover20yearsbutariseintheincidenceofcaseswasnotedin2011whenanunexpectedincreaseinlaboratoryconfirmedcasesinthe15+agegroupwasobserved.Theincreaseinthisagegroupcontinuedtotheendof2011

• Whilstconfirmedcaseswerehighinotheragegroupstheywereinlinewiththeexpected3-4yearlydiseasepeaks,with2008beingthelastpeakyear

• Theincreasecontinuedinto2012andextendedintootheragegroups,includinginfantslessthan3months.Thisyounginfantgroupisconsideredthekeyindicatorofpertussisactivity.

Reasonsfortheincrease• Completeexplanationisnotclear,butmanyotherdevelopedcountrieshaveexperiencedrecentincreasesinincidence

• USA,Canada,Australia,theNetherlands,Norway,France• Mostofthesecountriesswitchedfromwholecelltoacellularpertussiswithinthelast10-12years

• Thedurationofprotectionfromacellularpertussisisthoughttolastlessthan10years

• Modelspredictthatthechangetoacellularpertussisislikelythereasonfortheresurgenceinthedisease.

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Routineimmunisation• 8,12,16weeksofage• Pre-school(3years4monthsofage)• Despitehighlevelsofvaccinecoverage(95%)from2010therewasanincreaseinpertussisactivity

• 2012pertussisoutbreak– mainlyininfantsunder3monthsofage,sotooyoungtobevaccinated

• October2012DHintroducedtemporaryprogrammetoofferpertussisvaccinetopregnantwomenbetween28-32weeks

• February2016JCVIadvisedthatpregnantwomencanbevaccinatedfrom16weeksgestation

• Programmewilllastuntilatleast2019.

Pertussisvaccinationinpregnancy• From16-32weeksgestation• Advisedtohaveittopassonimmunitytounbornchildtoprotectthemuntiltheyhavefirstimmunisation

• Boostrix IPV(Dipt/Tet/Polio/Pertussis)• Vaccinationrecommendedfrom20weeksineachpregnancy

Changestochildhoodvaccines• Infanrix hexa (DTaP/IPV/Hib/HepB)toreplacePediacel &Infanrix-IPV+Hib (DtaP/IPV+Hib)forprimarybabyimmunisationslaterthisyear

• Babieswillthereforebeprotectedagainstdiphtheria,tetanus,pertussis,polio,HibandHepatitisBvirus

• ThechangeisachangetothevaccineusedandNOTtotheimmunisationschedule

• Currentplanningassumptionisthatbabiesbornonorafter1st August2017willbeofferedInfanrix hexa fromlateSeptember/earlyOctober2017,at8,12&16weeks

• Exactdatesdependontheremainingavailabilityofpentavalentvaccine.

(Vaccineupdate:Issue261,April2017)

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WhatisHepatitisB?• Aviralinfectionthatattackstheliver&cancauseacute&chronicdisease

• ManynewinfectionswithHepB virusaresub-clinicalormayonlycauseaflu-likeillness

• Mostlyasymptomaticininfants• AcuteHBVinfectionoccasionallyleadstosudden&severeliverdamagewhichcanbefatal

• ChronicHBVinfectioncanresultinprogressiveliverdisease

• Thiscanleadtocirrhosis(developmentofscartissue)&anincreasedriskofdevelopinglivercancer.

HowisHBVtransmitted?• Highlytransmissiblethroughinfectedblood&bodilyfluids.Mostlytransmitted:• Throughvaginaloranalintercourse• Asaresultofblood-to-bloodcontactfromsharingneedlesorotherequipmentbypeoplewhoinjectdrugsorthrough‘needlestick’injuries

• Throughperinataltransmissionfrommothertochild• Transmissionhasalsofollowedbitesfrominfectedpersons,althoughthisisrare

• TransfusionassociatedinfectionsnowrareinUKasdonors&donationsarescreened

• Itcansurviveoutsidethebodyforatleast7days

ClinicalPresentation• Manynewinfectionsshownosignsofinfection• Ifsymptomaticthesymptomsofacuteinfectionstartslowly&maypresentasflulikeillness,withorwithoutmildfeverorsymptomsmaybenon-specific

• Anorexia,nausea,vomiting&achingintherightupperabdomenmaybepresent

• Followedbymalaise,reducedappetite,jointpain&jaundicewithprogressivedarkeningofurine&lighteningoffaeces

• Symptomscanlastseveralweekstomonths• Ifsymptomsdon’tsuggesthepatitis,infectiononlydetectedthroughabnormalLFT’s&/orpresenceofserologicalmarkersofinfection,e.g.hepatitisBsurfaceantigen(HBsAG)

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UKHepatitisBepidemiology• UKaverylow-prevalencecountryforHep B

• 0.3-0.4%UKpopulationinfected• Prevalenceoftheinfectionvariesacrossthecountry

• Prevalenceratesinantenatalwomenvaryfrom0.05to0.08%insomeruralareasbutriseto1%ormoreincertaininnercityareas

• Higherprevalenceratesinthoseborninhighlyendemiccountries,manyofwhomwillhavebeeninfectedatbirthorinearlychildhood

• Incidenceofacuteinfectionislowbuthigheramongthosewithcertainbehavioural oroccupationalriskfactors.

WhyaddHepatitisBtotheschedule?• HepatitisBisaviralinfectionthatattackstheliver&cancausehepaticnecrosis,cirrhosis&anincreasedriskofdevelopinglivercancer

• Infanrix hexa isalreadylicensedin97countries&approximately150milliondoseshavebeengiventoinfantsworldwide

• Multiplestudiesshowittobesafe&highlyimmunogenic• Anyadverseeventsaremildtomoderate&thesameasthosefollowingadministrationofthepentavalentvaccines.

Whyisitofferedtoallinfants?• In1992theWorldHealthAssemblyrecommendedeverycountyshouldhaveauniversalHepatitisBimmunisationprogramme

• Becausetheprevalence&incidenceintheUKwaslowtheintroductionofamonovalentHep Bvaccinewouldn’thavebeencosteffective

• Recentlyacombinationvaccineforinfantshasbecomeavailable

• In2014theJCVIre-evaluatedthebenefits&costeffectiveness&recommendedtheuseofthehexavalentvaccineforallinfants.

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Recommendedvaccine• Brandname:Infanrix hexa• Multi-componentinactivatedvaccinefromGSK• Licensedforusefrom6weeksofage• Routinelyrecommendedforinfantsaspartoftheprimaryimmunisationscheduleat8,12&16weeks

• Canalsobeusedforcatch-upimmunisationforchildrenuptotheir10th birthdayifthey’vemissedoutondosesofprimaryimmunisation.

Whoiseligible?• Allbabiesbornonorafter 1st August2017willbecomeeligible8weeksaftertheirbirth

• ThevaccineisexpectedtobemadeavailabletoorderonlinethroughtheImmForm websitefrom1stSeptember2017

• Movianto UKwilldistributeInfanrix hexa®foruseintheroutinechildhoodprimaryimmunisationschedule

• Infantsbornbefore1stAugust2017shouldcompletethecoursewithpentavalentvaccine(Pediacel®orInfanrix-IPV+Hib®)

• Infanrix hexa®shouldonlybegiventobabiesbornbefore1stAugustifthereisnolocallyheldvaccinestockandnofurtherPediacel®orInfanrix- IPV+Hib®canbeorderedthroughImmForm orifpentavalentvaccineisnotreadilyavailable.

ShortageofmonovalentHep B• Topreservemonovalentvaccineforbirth&4weekdosesininfantsborntoHep Bpositivemums,orderingforInfanrix hexa viaImmForm hasopenedearly

• Infanrix hexa canbegiventothesebabiesat8weeksoldinsteadofmonovalenthep Bvaccine(evenifbornbefore1August2017)

• Toavoidconfusion,ifababystartsonInfanrix hexa theyshouldcompletetheirprimaryvaccinecoursewithit

• Allotherbabiesbornbefore1Augustshouldcontinuewithpentavalentvaccineiftheycommencedonit.

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Isitanewvaccine?• No.FirstlicensedforuseinEuropeinOctober2000• Licensedforusein97othercountries,includingCanada,Australia&NewZealand

• Approximately150milliondoseshavebeengiventoinfantsinEurope&acrosstheworld

• Itprotectsagainsttetanus,diphtheria,whoopingcough,polio&HibPLUS hepatitisB.

Isitsafe&effective?• Safetyprofileisexcellent• Anyadverseeventsaremildtomoderate

• SameasthoseexperiencedfollowingadministrationofPediacel &Infanrix-IPV+Hib vaccines

• Includesredness,swelling&tendernessattheinjectionsite,fever,irritability,lossofappetite,diarrhoea&vomiting

• Multiplestudiesshowinfanrix hexa tobesafe&highlyimmunogenicforallitscomponenttoxoids/antigens

VaccineScheduling• 8,12&16weeksofage• FirstdoseofInfanrix hexa®canbegivenfromsixweeks(ifrequiredinexceptionalcircumstancese.g.traveltoanendemiccountry)butnotbefore

• TheminimumintervalbetweendosesofInfanrix hexa®isfourweeks• Itcanbeadministeredatthesametimeas,oratanytimebeforeorafter,anyothervaccine

• Ifprimarycourseisinterrupted,resumebutdon’trepeat,allowinganintervaloffourweeksbetweentheremainingdoses

• Aswiththepentavalentvaccines,Infanrix hexa®shouldbegiventoprematureinfantsattheappropriatechronologicalage,accordingtotheschedule

• BoosterdosesofhepatitisBwillnotusuallyberequiredforchildrenvaccinatedaccordingtotheroutinechildhoodschedule.

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ContraindicationsInfanrix hexa®shouldnotbeadministeredtothosewhohavehad:• AconfirmedanaphylacticreactiontoapreviousdoseofthevaccineOR

• Aconfirmedanaphylacticreactiontoanycomponentofthevaccine(thisincludesformaldehyde,neomycinandpolymyxin)

• ThereareveryfewindividualswhocannotreceivetheInfanrix hexa®vaccine

Wherethereisdoubt,insteadofwithholdingimmunisation,appropriateadviceshouldbesoughtfromamemberofthelocalScreeningandImmunisationorHealthProtectionteam

PrecautionsAsforpentavalentvaccine,thereareveryfewoccasionswhendeferralofimmunisationwithInfanrix hexa®isrequired• Ifinfantisacutelyunwell(e.g.feverabove38.50C),immunisationmaybepostponeduntiltheyhavefullyrecovered

Thisistoavoidwronglyattributinganynewsymptomortheprogressionofsymptomstothevaccine• Thepresenceofaneurologicalconditionisnotacontraindicationtoimmunisationbutifevidenceofcurrentneurologicaldeterioration,deferralofDTaP/IPV/Hib/HepBvaccinationmaybeconsideredtoavoidincorrectattributionofanychangeintheunderlyingcondition

Riskofdeferralshouldbebalancedagainstriskofinfectionandvaccinationshouldbegivenpromptlyoncediagnosisand/orexpectedcourseoftheconditionbecomesclear.

Precautions(2)Prematureinfants• Veryprematureinfants(28weeksorearlier)whoareinhospitalshouldhaverespiratorymonitoringfor48-72hrs.whengiventheir1st immunisation,particularlythosewithaprevioushistoryofrespiratoryimmaturity

• Iftheprematureinfanthasapnoea,bradycardiaordesaturationsafterthe1st immunisation,thesecondshouldalsobegiveninhospital,withrespiratorymonitoringfor48-72hrs.

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Systemic&localreactionsfollowingapreviousimmunisation• ChildrenwhohavehadasystemicorlocalreactionfollowingapreviousimmunisationwithDTaP/IPV/Hib/HepB orDTaP/IPV/Hibincluding:•fever,irrespectiveofitsseverity•hypotonic-hyporesponsive episodes(HHE)•persistentcryingorscreamingformorethanthreehours,or•severelocalreaction,irrespectiveofextent

cancontinuetoreceivesubsequentdosesofDTaP/IPV/Hib/HepB vaccine.

VaccinecompositionAfterreconstitution,1dose(0.5ml)contains:• Diphtheriatoxoid• Tetanustoxoid• Bordetellapertussisantigens• HepatitisBsurfaceantigen(HBs)

• Poliovirus(inactivated)(IPV)• Haemophilus influenzae typebpolysaccharide(polyribosylribitol phosphate,PRP)•conjugatedtotetanustoxoidascarrierprotein

Adjuvants:• Aluminium hydroxide,hydrated(Al(OH)3)

• Aluminium phosphate(AlPO4)

Excipients:• Lactoseanhydrous• Sodiumchloride(NaCl)• Medium199containingprincipallyaminoacids,mineralsalts,vitamins

• WaterforinjectionsThevaccinemaycontaintracesofformaldehyde,neomycinandpolymyxin whichareusedduringthemanufacturingprocessItdoesnotcontainporcinegelatine

orthiomersal

Vaccinepresentation• TheDTaP/IPV/HepB componentispresentedasacloudywhitesuspensioninapre-filledglasssyringe.Uponstorage,aclearliquidandawhitedepositmaybeobserved

• ThefreezedriedHibvaccineispresentedasawhitepowderinaglassvial

• Thevaccineissuppliedinsingledosepackscontainingthesyringe,vialandtwoneedles:

• - Greenneedleforreconstitution- Blueneedleforvaccineadministration

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Preparingthevaccine• Shakethepre-filledsyringe(DTaP/IPV/HepB)toobtainaconsistent,cloudy,whitesuspension

• Attachgreenneedle(supplied)tothepre-filledsyringe&injecttheentirecontentsintothevialcontainingtheHibvaccine

• Shakethevialvigorouslyuntilthepowderhascompletelydissolved

• Withdrawtheentiremixturebackintothesyringe• Inspectthesuspensionforanyforeignobjectorabnormalappearance.Discardthevaccineifeitherobserved

• Puttheblueneedle(supplied)ontothesyringeandadministerIM

DoNOTforgettoreconstitutetheHIBcomponent

Storage&administration• Storeat+2° to+8°C• Storeinoriginalpackaging• AdministerIMinanterolateralaspectofthethigh• Administerviadeepsubcutaneousinjectionininfantswithableedingdisorder

• ItcanbeadministeredinthesamelegasthePCVatthe8&16weekimmunisationappointment(minimumof2.5cmapart.)

Postimmunisationcare• Sameaswiththeadministrationofthepentavalentvaccines• WhenPCVgivenatsametimeastheDTaP-containingcombinationvaccines,therateoffeverishigherthanwheneithervaccineadministeredalone

• IncurrentUKschedule,infantsreceivethesevaccinesalongsideMenB vaccinationat8&16weeksofage

• Offeringprophylacticparacetamol(asperrecommendations)withtheinfantdosesofMenB isexpectedtoalsoreducetherateoffeverattributedtoco-administrationofPCV

SeeMenB vaccine&paracetamolinformation&”whattoexpectaftervaccinations”leafletforfurtherInformation.

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AdministrationofInfanrix hexaItshouldonlybesupplied&administered:• Againstaprescriptionwrittenmanuallyorelectronicallybyaregisteredmedicalpractitionerorotherauthorisedprescriber

• AgainstaPSD(ifnouptodatePGDinplacetherewouldneedtobeaPSDinplacecoveringeachnamedpatientattendingtheclinic)

• AgainstaPGD

PossibleadversereactionsMostcommonlyreported(seeninmorethan1in10dosesofthevaccine)• Lossofappetite,fever(>38°C)abnormalcrying,irritability&restlessness

• Localswelling,pain&rednessatinjectionsiteHypersensitivityreactions,suchasangioedema,urticariaandanaphylaxiscanoccurbutarerare,ascanconvulsions(withorwithoutfever)andhypotonic- hyporesponsiveepisodes(alsorare)SuspectedadversereactionsshouldbereportedtotheMHRAusingtheYellowCardreportingschemeat:https://yellowcard.mhra.gov.uk/

Age Diseases protected against Vaccines used

8 weeks

Diphtheria, tetanus, pertussis, polio, Hib and hepatitis B

Infanrix hexa DTaP/IPV/Hib/HepB (thigh)

Pneumococcal Prevenar 13 Pneumococcal conjugate vaccine (PCV) (thigh)

Meningococcal group B Bexsero MenB (left thigh)

Rotavirus Rotarix Rotavirus (oral)

12 weeks

Rotavirus Rotarix Rotavirus (oral)

16 weeks

Pneumococcal Prevenar 13 Pneumococcal conjugate vaccine (PCV) (thigh)

Meningococcal group B Bexsero MenB (left thigh)

Vaccineupdate.Issue261.April2017

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WhatdoesitmeanforbabiesborntoHepatitisBpositivemothers?• HepatitisBscreeninginpregnancywillcontinue• SelectiveimmunisationforneonatesborntoHepatitisBpositivemotherswillcontinue

• ThesebabiesareexposedtohepatitisBduringdelivery&areathighriskofacquiringpersistentHep Binfectionwithouttimelyimmunisationstartingimmediatelyatbirth

• DrybloodspotteststilltobecarriedoutbyPNat12m(doesn’tlookforimmunity-looksforinfection.)

Age Routine childhood Babies born to hepatitis B infected mothers

Birth ✗ ✓

Monovalent HepB(Engerix B or HBvaxPRO Paediatric) (with HBIG if indicated)

4 weeks ✗ ✓ Monovalent HepB(Engerix B or HBvaxPRO Paediatric)

8 weeks ✓ DTaP/IPV/Hib/HepB (Infanrix hexa) ✓

DTaP/IPV/Hib/HepB (Infanrix hexa)

1 year ✗ ✓

Monovalent HepB(Engerix B or HBvaxPROPaediatric) Test for HBsAg

HepatitisBintheimmunisationscheduleforroutinechildhood&selectiveneonatalhepatitisBprogrammesfollowingintroductionofInfanrix hexa

Noneedforboosterat3years&4monthsifcompletedscheduleasabove

Orderingrestrictionsforinfanrix IPVHib• Tobalancecentralstocks,ordersforinfanrix IPVHibarerestrictedto3dosesperorderperweekinEngland&Wales.SimilarrestrictionsareinplaceinScotland&NorthernIreland

• Pediacel isavailablewithoutrestriction• PreferabletousethesameDTaP/IPV+Hib containingvaccineforall3dosesoftheprimarycourse,however,doNOT delayvaccinationbecausethevaccineusedforpreviousdosesisn’tavailable

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Avoidingvaccinewaste• FollowingtheintroductionofInfanrix hexa®forbabiesbornonorafter1August,inordertoavoidanywastage,anyremainingstocksofPediacel®andInfanrix-IPV+Hib®(DTaP/IPV+Hib)shouldbeusedforbabieswhohavealreadystartedcourseswithPediacel®orInfanrix-IPV+Hib®(secondorthirddose),or

• Ifvaccinestillremainsthenasatemporarymeasurethiscanbeusedforpre-schoolboostingattheageof3yearsand4months.

• Oncethesestocksareusedup,pre-schoolboostingshouldrevertbacktoRepevax®(dTaP/IPV).

PGD’s• 2newnationalPGDtemplateshavebeendevelopedtosupporttheintroductionofDTaP/IPV/Hib/HepB intotheroutinechildhoodimmunisationprogramme• APGDtemplatefortheadministrationofDTaP/IPV/Hib/HepB &DTaP/IPV/HibBoosterPGDtemplate

• TheboosterPGDtemplatewasdevelopedtofacilitatetheuseofremainingsuppliesofPediacel orInfanrix/IPV+HibforthePSB.Thisistopreventvaccinewastage,shouldsuppliesofthepentavalentvaccineremainfollowingintroductionofthehexavalentvaccineintotheroutineprogramme

• ThenewPGD’swillbepublishedshortly.

Vaccineupdate.Issue266,July2017.

Furtherinformation• Leafletsforparents– page5.VaccinationUpdate,issue266,July2017

• Theredbook– insertpageshavebeenupdatedtoincludethehexavalentvaccine&theacceleratedscheduleforbabiesborntoHep Bpositivemum’s

• Thenewinsertscomeinpadsof25(7partsperinsert).Soifyouorder5padsyouwillhaveinsertsfor125babies.Theyarefreetoorderanddeliveryisalsofree

• PleaseorderfromtheHarlowPrintingLimitedbyeither:Emailrebeccao@harlowprinting.co.ukOrtelephone:01914969735

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MMRgivenbefore1st birthday• ”AnydoseofMMRgivenbefore1st birthdayshouldbediscounted&2furtherdosesgivenattheappropriateage”(GreenBook.Chapter11)

• Advisethattheprimaryimmunisationscanbecountedasvaliddosesifgivenuptoaweekearly(eitherinadvertentlyordeliberately,e.g.fortravelreasons,doesnotapplytoMMR

• DosesofMMRgivenatanytimepriortothe1st birthdayarenot countedasvaliddoses

Thisisbecausematernalantibodiesmaystillbepresentwhichneutralizesthevaccinevirus,preventingthechildfrommakinganantibodyresponsethemselves.Oncethematernalantibodieswane,thechildisleftunprotected.

MenACWYvaccination• FromApril2017,allthoseaged17&18(born01/09/1998-31/08/1999)becameeligibleforMenACWY vaccination&willbeinvitedbytheirGPforvaccinationassetoutinthe2017/18GMScontract

• It’simportantthatallofthiscohort,notonlyschoolleavers&thosegoingtohighereducationareofferedthevaccination

• MenW casescontinuedtoincreaseinthecurrent2016/17epidemiologicalyearinallagegroupsexceptinfants&15-19yearolds.

Leics/Lincs MenACWYeligibilityv1LLNSIT06.03.17 Uncontrolledwhenprinted

MenACWY• Aroundathirdofcasesin15-19yearoldhavebeenfatal,nodeathsininfants

• EarlydatafromfirstcohortvaccinatedundertheMenACWY programmefoundtherewere69%fewerMenW casesthanpredictedinthefirstyearaftertheprogrammestarted.

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Rotavirus– thedisease• Rotavirusesareribonucleicacid(RNA)viruses• Theyareclassifiedbasedontheouterlayerproteins• Thereareatleast15Gtypes&28Ptypes,butonly10G&11Ptypesidentifiedinhumans(Desselberger etal.,2001)

• Highlycontagious• Rotavirusinfectionsinhumanscausegastroenteritisusuallylasting3-8days

• Characterisedbymildfever,severediarrhoea,vomiting,stomachcramps

• Almostallchildrenwillhaveatleastoneepisodeofrotavirusbeforereaching5yearsofage.

Rotavirus– thedisease• IntheUKrotavirusinfectionisseasonal,occurringmostlyJanuarytoMarch

• Peopleofanyagecanbeinfected,butmostinfectionsoccurinchildrenbetween1month&4years

• Infectionsinnewbornsiscommonbuttendstobemildorasymptomatic(probablyduetoprotectionbycirculatingmaternalantibodies(Grillner etal.,1985;Bishop,1994)

• Immunityisdevelopedafter1episodeofRotavirusinfection,butimmunitycanbeshortlived(Bishop1994)

• 2nd &subsequentinfectionsareoftenasymptomatic,unlessitisadifferentgenotypeoftheinfection.

Rotavirus– thevaccine• 2vaccinesauthorised byEuropeanMedicinesAgency

• Rotarix (GSK)- vaccineofferedaspartofUKchildhoodimmunisationprogramme

• RotaTeq SanofiPasteurMSD)• VaccinesareNOT interchangeable,thereforeusesamevaccineforthecoursetoachievefullprotection

Presentation- clear,colourlessliquid tobeadministeredorallySchedule– 1st dose(1.5ml)orallyat8weeks2nd dose(1.5ml)atleast4weeksafterthefirstPreferableforthe2dosesofRotarix becompletedbefore16weeks(withatleast4weeksbetweeneachdose)Thisprovidesearlyprotection&avoidsriskofIntussuseption.

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Impactofthevaccinationprogramme• Vaccinehasbeeninusefornearly3yearsnow• Therewasan80%reductioninrotavirusdiseaseinthe6monthsposttheintroductionofthevaccine.Thisreductionwasseeninallagegroupsandrangedfrom40-85%

• Thegreatestreductionwasseenintheunder1s• Itisestimatedthatinthefirstyearthevaccinationprogrammepreventedalmost11,000casesofgastroenteritisandreducedhospitalisationsby50,000

• Theimpacthasbeensustainedinthesecondandthirdyears.

Rotarix• WHOrecommendsthatthefirstdosebegivenbeforeinfantis15weeksofage&2nd doseby24weeksofage

• Ifcourseisinterrupted,resumethecourse(DONOTrepeatit)providedthe2nd doseisgivenbefore24weeks

• Ifchildreceives1st doseafter15weeksorolder,2nd doseshouldstillbegiven4weekslater– aslongastheyareunder24weeksattimeofseconddose

• Nospecificclinicalactiontobetakenif1st dosegivenafter15weeksofageor2nd doseafter24weeks,butrememberagerestrictionsforRotarix – evenifinfantisunabletostartorcompletethe2doseschedulebecauseoftheserestrictions.

ChangetoRotarix presentation

• Rotarix suppliedbyGSKwillchangefromanoralsyringetoatubelaterthisyear

• It’slikelythiswillstartbeingissuedbyPHEinNovember&furtherguidanceontheuseoftheRotarix tubewillbepublishedbyPHEpriortothis.

• Seepage11ofVaccineUpdateIssue264,June2017.

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Vaccinesupplyfornon-routineprogrammeSeepage15onwardsofVaccineUpdateissue269,August2017HepatitisAadults• GSK:Havrix PFSsingles&Havrix PFSpacksof10arecurrentlyunavailable,it’sunlikelytobeavailableuntil2018

• SanofiPasteur:LimitedsuppliesofAvaxim areavailable.Likelytobeorderrestrictionsinplace

• MSD:limitedsupplyofVAQTAadultisavailablewithsomestockbeingdeliveredmid-September.LimitedsuppliesofVAQTAforremainderof2017

Paediatric• GSK:Havrix Paediatric singlesunavailableuntilOctober2017.Restrictedsuppliesforremainderof2017

• GSK:Havrix Paediatric packsof10hassupplyconstraintsforremainderof2017

• MSD:VAQTAPaediatric isunavailableuntilmidOctober.

OutbreakofHep A• OutbreakofHepatitisAinEnglandsinceJuly2016• Atotalof586hepatitisAcaseshavebeenreportedsince1stJuly2016upto30thApril2017

• Ofthesecases,almost350areoutbreakrelated• HepatitisAvaccineishighlyeffectiveinpreventinginfectionifgivenpriortoexposure

• Hep Ainlowsupply.SeevaccineupdateAugust2017forfurtherdetails– pg.15.

NonprogrammevaccinesupplyHepatitisBadults• GSK:Engerix BPFSsingles– supplyconstraintsuntilSeptember&thenwillbeunavailableuntilearly2018

• Packsof10areunavailableuntillate2017• GSK:Engerix Bvialsareavailable,supplyislimited• GSK:Fendrix isavailablebutmaybeconstrainedifdemandremainshigh

• MSD:HBVAXPRO10μgisunavailableuntilearlySeptember• MSD:HBVAXPRO40μgisunavailableuntillateAugust.Paediatric• GSK:Engerix BPaediatric singlesunavailableinAugust,thenconstrainedsuppliesforremainder2017

• GSK:Ambirix availablebutsuppliesconstrainedforremainder2017• MSD:HBVAXPRO5μg.Limitedstocksavailable.

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NonprogrammevaccinesupplyCombinedhepatitisAandhepatitisBvaccine• GSK:Suppliesoftheadultpresentation(Twinrix)andpaediatric presentation(Twinrix Paediatric)constraineduntillate2017.

• GSK:Ambirix currentlyavailableCombinedHepatitisAandTyphoid:• GSK:Hepatyrix isunavailableuntil2019• SanoPasteur:ViATim iscurrentlyunavailable.SupplieslikelytobeavailablefromOctober.

Nonprogrammevaccinesupply• Typhoid:

• GSK:Typherix isunavailableuntilatleast2019• SanoPasteur:Typhim isavailablewithnoorderrestrictions

• PaxVax:Vivotif isavailable.

NonprogrammevaccinesupplyRabies• GSK:Rabipur isavailable• SanofiPasteur:licensedRabiesVaccineBPisoutofstock.PPV

• MSD:LimitedstockofPneumococcalPolysaccharideVaccine(PPVorPneumovax II).ReplenishmentdueearlySeptember.

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NonprogrammevaccinesupplyVaricellaZostervaccine• GSK:Varilrix iscurrentlyavailable.• MSD:VARIVAXiscurrentlyavailable.Diphtheria,tetanusandpoliomyelitis(inactivated)vaccine

• SanofiPasteur:Revaxis availablewithnoorderrestrictions

Measles• TherearecurrentlyseverallargemeaslesoutbreaksacrossEuropewithRomaniaandItalybeingtheworstaffectedcountries

• Despitesignificantprogressmadetowardsmeasleseliminationglobally,measlesremainsendemicinmanycountriesaroundtheworld

• Inresponse,NaTHNaC hasissuedaremindertotravellerstoensuretheyareuptodatewiththeirMMRvaccination.

Measles• Measlescanbemoresevereinteenagersandadultsandsomemayneedhospitaltreatment

• Measlesisextremelyinfectiousandsummereventslikemusicfestivalsandfairswherepeoplemixcloselywitheachotherprovidetheidealplacefortheinfectiontospread

• LastyearPHEreported52confirmedmeaslescasesbetweenmid-Juneandmid-October,knowntobelinkedtomusicandartsfestivalsinEnglandandWales

• Nearlyhalfofthesecaseswereinyoungpeopleaged15to19years

• Severalindividualswhoacquiredmeaslesatonefestivalthenattendedanotherfestivalwhileinfectious,resultinginmultipleinterlinkedoutbreaks. VaccineupdateJune2017.

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BCGvaccinesupply&ordering• Globalsupplynolongerconstrained&isconsideredsufficienttomeetcountryrequirements

• UseofBCGforoccupationalhealthpurposesremainsthelowestpriority

• Thoseatespeciallyhighriskshouldbeassessedonanindividualbasis

SeeVaccineUpdate– specialedition.Issue265.July2017.

Strategiesforimprovingimmunisationrates

Uptaketarget

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Table1:Completedprimaryimmunisationsat12monthsbyLocalAuthorityArea,Derbyshire/NottinghamshireandEngland:Annual2015/16,Q1,Q2&Q32016/17.AllTargets95%

Table1a:CompletedMeningitisBimmunisationsat12monthsbyLocalAuthorityArea,Derbyshire/NottinghamshireandEngland:Q2andQ32016/17

12mMenB%UpperTierLAName Q2

2016/17Q3

2016/17Nottingham 88.9 90.2Nottinghamshire 94.3 96.4DerbyNotts 91.1 93.4England 91.6 92.2

Source:QuarterlyCOVERdatahttps://www.gov.uk/government/statistics/cover-of-vaccination-evaluated-rapidly-cover-programme-2016-to-2017-quarterly-dataNHSDigitalhttp://content.digital.nhs.uk/catalogue/PUB21651n/a:notavailablenationallyduetodataqualityissue-:nodata*Q2LAdata–NationalCaveat–notforonwarddistributionorpublication

UpperTierLAName

12mDTaP/IPV/Hib% 12mMenC%Annual15/16

Q116/17

Q216/17 Q316/17

Annual15/16

Q116/17 Q216/17

Q316/17

Nottingham 91.1 90.2 91.6 91.8 94.1 94.7 95.5 93.2Nottinghamshire 95.6 95.5 95.4 97.1 - 96.2 97.2 97.4DerbyNotts - 93.9 94.0 94.3 - 95.7 95.8 95.2England 93.6 93.0 92.9 93.4 95.1 95.2 94.7 93.6

UpperTierLAName

12mPCV% 12mRota%Annual15/16

Q116/17

Q216/17 Q316/17

Annual15/16

Q116/17 Q216/17

Q316/17

Nottingham 90.7 90.3 91.8 91.9 n/a 86.4 87.9 89.5Nottinghamshire 95.2 96.1 95.4 97.1 - 93.4 93.0 95.9DerbyNotts - 94.2 94.0 94.3 - 91.5 91.5 92.8England 93.5 93.1 93.1 93.6 89.7 89.5 89.3 90.1

FluUptake2016/1765andover

Under65(at-

riskonly)

AllPregnantWomen

AllAged2

AllAged3

AllAged4

MansfieldandAshfield72.5 48.3 40.6 36.4 41.7 34.5

NewarkandSherwood73.5 49.8 49.6 47.8 49.9 37.9

NottinghamCity70.3 46.2 37.5 34.5 36.4 29.1

NottinghamN/E72.1 49.1 45.4 45.1 50.1 37

NottinghamWest75.1 53.5 50.8 45.5 53.7 42.8

Rushcliffe78.6 51.9 53.5 61.4 62.9 52.8

AllDerbyNottsCCGS73.4 49.4 45 44.3 46.9 38.2

EnglandAverage70.5 48.5 44.9 39 41.6 33.8

Howcanwemakeadifferencetouptake?• Thewholepracticehavearesponsibilitytopromoteimmunisations

• Information&promotionalservicesavailableinwidercommunity

• Systemsinplaceforreviewingtherecordsofnewpatients• Accessibilitytoservices,location,time,numberofappointments

• Widerangeofrecallmethodsusedinarobustrecallsystem• Materialsavailableinalternativelanguages• Opportunistic&outreachvaccination• Awarenessofvulnerableorhardtoreachpopulations• Goodlinkswithcommunityhealth&socialcareworkers.

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UsefulResourcestohelpincreaseuptake1.PHEImmunisationWebpage

•https://www.gov.uk/government/collections/immunisation• 2.DHOrderline• https://www.orderline.dh.gov.uk/ecom_dh/public/home.jsf• 3.eHealthscope• 4.ImmFormhttps://portal.immform.dh.gov.uk/Logon.aspx?returnurl=%2f

• 5.ScreeningandImmunisationTeamENGLAND.SCRIMMS@nhs.net

• PaulKalinda– CoordinatorTel:07710152580• AlisonCampbell– CoordinatorTel:07721231702

TheSchoolsImmunisationProgrammeTheSchoolAgeImmunisationService(SAIS)arecommissionedtoofferthefollowingimmunisationprogrammestothefollowingteenagecohorts.• Y8HPVProgramme:Toallgirls• Y9HPVProgramme:Togirlsrequiringseconddose,orcatch-upoffirstdose.

• Y9MenACWYandTd/IPVProgramme:• Y11MenACWY:ShouldyoureceiveanyparentalqueriesretheabovevaccinationsorstudentswhohavemissedschooltheirschoolimmunisationsessionpleasedirectparentstotherelevantSAIS,contactdetailsbelow:• DerbyshireCommunityHealthServices(DerbyshireCounty)01283707170

• NottinghamCityCare(DerbyCity):01158839637• NottinghamshireHealthcareFoundationTrust:01158835055

SchoolsimmunisationprogrammeREMINDER:Theaboveimmunisationprogrammesarenolongercommissionedfromgeneralpractice.Generalpracticewillnotbepaidforadministeringthesevaccinationsunlessthereareexceptionalcircumstances.ShouldyourequireguidancepriortovaccinationregardingthesecircumstancespleasecontactyourScreeningandImmunisationco-ordinator.

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Summary• Effectiveimmunisationservicesneedsacoordinatedapproachandaleadinthepractice

• Youplayanessentialroleinensuringchildrenareprotectedfromseriousdisease.Parentslooktoyou!

• Ensurerobustcallandrecallsystemswhichmeettheneedsofallthetargetpopulation

• Keepuptodatewithimmunisationtraininginc.changestoschedule

• CommunicationbetweenHealthcareProfessionalsisvital.

Communicatingwithpatients&parents

VaccinecontroversiesParentsQuestionthe:

• Effectiveness• Safety• NecessityofrecommendedvaccinesResult:

• Reductioninuptake• Outbreaks• Deaths

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MenBPetitionThousandssignpetitionaftermumsharesimageofgirl'smeningitis

MattDawsonpulledthepetitiontogether– over800,000Signatures.Programmewasn’tchangedastherewouldbenobenefittovaccinatingolderchildren.

HealthCareProfessionals• Areuniquelypositionedtoinfluencedecisionsonimmunisations(midwives)

• Educationempowersindividualstomakeinformeddecisions• Inviteswithinformationleaflets• Remindersaimtoadviseparents/individualsofvaccinesthataredue/overdue

• LettersfromthepatientsGP• Birthdaycards.

Resources1.PHEImmunisationWebpage

•https://www.gov.uk/government/collections/immunisation• 2.DHOrderline• https://www.orderline.dh.gov.uk/ecom_dh/public/home.jsf• 3.TheGreenBook– consent• https://www.gov.uk/government/collections/immunisation-against-infectious-disease-the-green-book

• 4.TedTalks– immunisation• https://www.ted.com/topics/vaccines• 5.VaccineUpdate• https://www.gov.uk/government/collections/vaccine-update

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FAQs4injectionsatage1year,isthistoomuchformychild?

• NO reasonNOT togiveall4atthesametime– noincreasedriskofsideeffectsandallwillworkjustaseffectivelyaswhengivenseparately

• Researchshowsparentspreferoneappointment– shouldNOToffertosplit(risksofnotbeingfullyvaccinated,wastesanappointmentslottoo)

• Ifparentrequestsandinsists(despiteeffortstopersuadeotherwise):• Assumingchildhasreceivedany/allMenB andPCVdoses*,giveMMRand

Hib/MenC atfirstappointment,giveMenBandPCVat2nd appointment§ Why?– becausechildnaïveforMMRandMenC– worstcasescenariothey

don’tcomebackatleasttheyhavesome protectionagainstallantigens§ 2nd appointment– assoonaspossible(nominimumintervalsbetween

differentvaccines,justallowanylocalreactiontosubside– after1week)

*Ifnot,needtomakeaclinicaljudgementregardinggreatestrisk.MenBagreaterriskthanMenCintermsofcasenumbers,soifnothadMenBgivethatat1stappointment&Hib/MenCat2nd

SeeVaccineupdateissue264.June2017.Pg.2.

Childmovespositionwhenyouadministertheimmunisation,someofthevaccineislost• OKtorepeat,onlywaytoguaranteethatdefinitelyhadsufficientasamountreceivedcannotbequantified

§ Besttodothisatonce – otherwisenotappropriatelyprotected

• Nominimumintervalbecauseyou’rerepeatingthesamedosenottryingtoboostapreviousdose

§ IfnotrepeatedimmediatelythenaimtodoASAP(thoughpotentiallyincreasedriskofreactionifwithinusualminimuminterval,especiallyiftetanus-containing,preferredminimuminterval1m)

• Ultimately:parentschoice– aslongastheyunderstandtherelativerisksasabove.

RecentCQCfindings• ‘CQCrecentlycompletedthefirstroundofinspectioningeneralpracticesinEngland.Theyfoundthatmostpracticeswererunningveryefficientimmunisationservices.Theimms scheduleiscomplex&regularlychanges&theskill,expertise&timeneededtodeliverthevaccinationprogrammesisoftenunderestimated.

• CQCrecognises theenormouscontributionGPN’smaketothesuccessfuldeliveryofimmunisationservices.Therewereissueswithstorageofvaccines&misunderstandingsaroundthelegalframeworks,theseareoutlinedinnextfewslides.’

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Coldchain• Vaccinesmustbestoredbetween2°C&8°C• CQCfoundsomepracticeswererecordingfridgetemperaturesoutsidethisrangewithnoactiontaken

• Recordingofthefridgetemperatureisdelegatedtostaffwhodonotunderstandthecorrectproceduretofollowifthetemperatureisoutsideoftherequiredrange

• Fridgeisoverstockedwithvaccineswithairlessabletocirculatebetweenboxesofvaccines

• Useofdata-loggerbeingusedasjustificationfornotrecordingdailytemperatures

• Failuretore-setthetemperaturewhenminimum&maximumtemperaturesrecorded

• Fridgetemperaturesettoohighresultinginfrequentrisetoabove8°Cwhendooropened.

CQCfindings• Nodefinedresponsibilityforensuringstockrotationofvaccines&unclearsystemforensuringrefrigerationofvaccinesondelivery

• CQCrecommendsvaccinecoldchainmonitoringisundertakenbysuitablytrainedstaff&thatwheretemperaturesoutsidetherecommendedrangearefound,appropriateactionistakeninkeepingwithpracticepolicy.

Legalframework• Lackofunderstandingregardingthenecessityforlegalauthorisationforadministrationofvaccines

• OutofdatePGD’swithnoalternativesysteminplace• HCA’snamedonPGD’s• NovalidsysteminplacetoauthoriseHCA’stoadministervaccines,e.g.noPSD’s.

8/29/17

Coverageofeligiblepopulation• Occasionallylowuptakeisreportedforindividualvaccines,e.g.pneumococcalconjugatevaccinethatisoutofstepwithothervaccinesgivenatthesametime

• CQCrecommendthatpracticesliaisewiththeirlocalCHIStoensurerecordsofallvaccinesadministeredareappropriatelynotifiedtoCHIS

• Toaddresslowuptake,CQCconsiderwhetherthefollowingareinplace:• Addingalertstorecordsofnon-attenders• Contacting&remindingparents&provisionofappointmentsatvariedtimes&days

• CQCalsoaskifthepracticeisprovidingNHStravelvaccines(typhoid,hepatitisA,tetanus/diphtheria/polio&cholera)

• Practiceshaveanobligationtoprovidethesevaccinestoeligiblepatientsfreeofcharge,unlesstheyhaveoptedoutofthispartofthecontract&madealternativearrangements.

Recordkeeping

DocumentationTheCode(NMC)- Section10– ‘Keepclear&accuraterecordsrelevanttoyourpractice’• 10.1- Completeallrecordsatthetimeorassoonaspossibleafteranevent,recordingifthenotesarewrittensometimeaftertheevent

• 10.2 - Identifyanyrisksorproblemsthathavearisenandthestepstakentodealwiththem,sothatcolleagueswhousetherecordshavealltheinformationtheyneed

• 10.3 - Completeallrecordsaccuratelyandwithoutanyfalsification,takingimmediateandappropriateactionifyoubecomeawarethatsomeonehasnotkepttotheserequirements

• 10.4 - Attributeanyentriesyoumakeinanypaperorelectronicrecordstoyourself,makingsuretheyareclearlywritten,datedandtimed,anddonotincludeunnecessaryabbreviations,jargonorspeculation

• 10.5 - Takeallstepstomakesurethatallrecordsarekeptsecurely,and• 10.6 - Collect,treatandstorealldataandresearchfindingsappropriately.

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Whattorecord• Nameofvaccine&productname• Expirydate&batchnumber• Dategiven• Siteofinjection• Modeofinjection(i.e.IM)• Name&signatureofpersongivingvaccination/ensureit’syouloggedontothecomputer

Documentation• Whathappensinpractice?• Whorecordstheinformation?• Whataboutrecordinginformationaftertheclinic?• Doyouhaveenoughtime?• Doyouneedtothinkabouttheprocess?• ReportsuspectedAdverseDrugReactions(ADRs)toCommitteeofSafetyofMedicinesusingtheYellowCardschemewww.mhra.gov.uk/yellowcard

Usefulcontacts• england.llimms@nhs.net - forallimms enquiries• NathNac www.nathnac.net• JaneChiodini – TravelHealthSpecialistwww.janechiodini.co.uk

• immForm websiteforvaccineordering,coldchainincidentreporting,vaccineupdatedatacollections,helpsheets www.immform.dh.gov.uk

8/29/17

UsefulReferences

• DepartmentofHealth:Immunisationagainstinfectiousdisease2006.www.dh.gov.uk/greenbook

• Greenbook:www.gov.uk/government/collections/immunisation-against-infectious-disease-the-green-book

• VaccineUpdateNewsletter– vaccineupdate@phe.gov.uk• SPCs&PILS– www.medications.org.uk/emc

Usefulreferences• DHReferenceguidehttp://www.dh.gov.uk/assetRoot/04/01/90/79/04019079.pdf

• Consent:whatyouhavearighttoexpect:aguideforchildrenandyoungpeople

• http://www.dh.gov.uk/assetRoot/04/01/90/21/04019021.pdf• Consent:whatyouhavearighttoexpect:aguideforparents• http://www.dh.gov.uk/assetRoot/04/01/91/68/04019168.pdf

• ChildrenAct,1989,section2(7)

NMCRevalidation• Nowrequiredwhenrenewingregistration• Registeron-linewithNMC– nmc.org.uk• Alltheformscanbedownloaded• Keeparecordofalltrainingandyoucanalsoinclude• Discussionswithcolleagues,meetings

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