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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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ImmunisationDepartment,
MCA2005‘thepersondeliveringthetreatmentornursingcaremakesthedecisionaboutwhethertodeliverthecare,eventhoughthetreatmentmayhavebeenprescribedbysomeoneelse’
ImmunisationDepartment,
WiderangeofInformationavailablebasedoncurrentscientificevidenceandclinicaladvice
•NHS ImmunisationInformation:LeafletsPostersFact sheetsWebsite: www.phe.gov.uk(Translations/interpreters available)•Green book•Manufacturers PIL & SPC
ImmunisationDepartment,
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.
ImmunisationDepartment,
Adolescentsandyoungchildren
• Youngpeoplecanconsenttotheirowntreatmentprovidedtheyare:
üAged16-17yearsüConsidered“Frasercompetent”(Gillick)X Parentcannotover-ridecompetentchild’sconsenttotreatmentüparentscanover-ridecompetentchild’srefusalfortreatmentinanemergency
ImmunisationDepartment,
ConfidentialityofPersonalInformation- RelatedLegislation
• DataProtectionAct(www.dataprotection.gov.uk)• The1998DataProtectionActsetstandardswhichmustbesatisfiedwhenobtaining,holding,usingordisposingofpersonaldata
• TheDataProtectionActcoversanythingwithpersonalidentifiableinformation(e.g.health,personnel,occupational,finance,suppliers,andcontractors)
• YouarerequiredbylawtocomplywiththeDataProtectionAct1998
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ImmunisationDepartment,
Caldicott Report• March1996theDepartmentofHealthpublishedguidanceonthe‘ProtectionandUseofPatientInformation’
• Caldicott CommitteewasestablishedtoreviewandimprovethewaytheNationalHealthServicehandlesandprotectspatientinformation
• Identified6principles,similarinmanyrespectstotheprinciplesoutlinedintheDataProtectionAct
ImmunisationDepartment,
Caldicott principles1. Justifythepurpose(s)forusingpatientdata2. Don'tusepatient-identifiableinformationunlessitisabsolutelynecessary3. Usetheminimumnecessarypatient-identifiableinformation4. Accesstopatient-identifiableinformationshouldbeonastrictneedto
knowbasis5. Everyoneshouldbeawareoftheirresponsibilitiestomaintain
confidentiality6. Understandandcomplywiththelaw,inparticulartheDataProtectionAct
AsanemployeeoftheTrust/GPpracticeyouarerequiredtofollowtheCaldicott principlesaslaiddownbytheNHSExecutive
AllNHSorganisationsarenowrequiredtohaveaCaldicottGuardian.
ImmunisationDepartment,
Prescribing
Avaccinemayonlybeadministered:• Againstaprescriptionwrittenmanuallyorelectronicallybyaregisteredmedicalpractitioneroranotherauthorisedprescriber
• AgainstaPatientSpecificDirectionorPatientGroupDirection
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ImmunisationDepartment,
PatientSpecificDirections• HealthCareAssistantscanonlyworktoPSDs• TheycannotlegallyworktoaPGD• RolesthataHCAundertakes– theymusthavebeenappropriatelytrained.AssessedbytheRegisteredPractitionerascompetent.
• TheHCAcannotindependentlyassess,treatorchangeapatient’streatment,itisoutoftheirremittomakea‘judgementcall’ontheirown
• TheyundertakedelegatedtasksRef:[email protected]
ImmunisationDepartment,
WhenshouldaPSDbeused?• TheusualmethodforsupplyandadministrationofvaccinesintheroutineimmunisationprogrammeisviaaPSD.(HCAsshouldNOT administerChildhoodimmunisations,apartfromtheIntra-nasalFluvaccines)
• ImmunisationauthorisedbyGPorindependentnurseprescriberat6-8weekcheck
• RecordedasaninstructioninPersonalChildHealthRecordorredbook
• Pleasenote:Goodpracticedictatestheimmuniserchecktherecipientisfitandwellandtherearenocontraindications,priortovaccination.
ImmunisationDepartment,
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
ImmunisationDepartment,
WhatisClinicalGovernance?
• FrameworkthroughwhichNHSorganisationsareaccountableforcontinuouslyimprovingstandardsofpatientcareandthequalityoftheirservices
• Safeguardinghighstandardsofhealthcaredelivery• Creatinganenvironmentofconsistenthighqualityandclinicalcareexcellence.
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ImmunisationDepartment,
HowdoesthisrelatetoImmunisation?
• Clinicalgovernanceisrelevantacrossallareaofimmunisationpractice,e.g.
• Ensuringallimmunisersaretrainedandregularlyupdated• Vaccinesarecorrectlystoredandhandled• AdherencetoClinicalgovernanceframeworkshouldbemonitoredthroughregularauditofthevaccineserviceofferedbytheTrust.
ImmunisationDepartment,
• 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¶cetamolinformation&”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
Diphtheria, tetanus, pertussis, polio, Hib and hepatitis B
Infanrix hexa DTaP/IPV/Hib/HepB (thigh)
Rotavirus Rotarix Rotavirus (oral)
16 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)
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)
12 weeks ✓ DTaP/IPV/Hib/HepB (Infanrix hexa) ✓
DTaP/IPV/Hib/HepB (Infanrix hexa)
16 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:[email protected]: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
CCG
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
• 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®ularlychanges&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.
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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• [email protected] - forallimms enquiries• NathNac www.nathnac.net• JaneChiodini – TravelHealthSpecialistwww.janechiodini.co.uk
• immForm websiteforvaccineordering,coldchainincidentreporting,vaccineupdatedatacollections,helpsheets www.immform.dh.gov.uk
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UsefulReferences
• DepartmentofHealth:Immunisationagainstinfectiousdisease2006.www.dh.gov.uk/greenbook
• Greenbook:www.gov.uk/government/collections/immunisation-against-infectious-disease-the-green-book
• VaccineUpdateNewsletter– [email protected]• SPCs&PILS– www.medications.org.uk/emc
ImmunisationDepartment,
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)
ImmunisationDepartment,
NMCRevalidation• Nowrequiredwhenrenewingregistration• Registeron-linewithNMC– nmc.org.uk• Alltheformscanbedownloaded• Keeparecordofalltrainingandyoucanalsoinclude• Discussionswithcolleagues,meetings