Several important changes were made to the UK vaccination schedule for 2013/2014. These include three new vaccines (intranasal influenza, oral rotavirus and subcutaneous shingles), a change to the schedule for meningitis C vaccination, and an extension of the temporary programme for pertussis vaccination of pregnant women. Here we provide a reminder of the changes to the vaccination schedule in the UK, highlight the importance in offering the vaccines and outline some practical considerations.
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Influenza vaccine for children
The aim of the influenza vaccination programme is to protect people most at risk from serious illness and death from influenza, and to reduce transmission of the infection.1 Until recently, annual inactivated influenza vaccine has been offered to people aged 65 years and over, and all people aged 6 months or older in clinical risk groups (chronic renal, heart, liver, neurological or respiratory disease; diabetes; immunosuppression; asplenia or dysfunction of the spleen; pregnancy).1 The UK's Joint Committee on Vaccination and Immunisation now recommends that routine annual flu vaccination be extended to include healthy children aged 2–16 years, with full coverage of this age group phased in over several seasons.2 The extension is expected to lower influenza transmission in the community and in turn reduce flu-related illnesses, GP consultations, hospital admissions and death.2 The first stage of the extended flu vaccination programme, introduced for the 2013/2014 season, includes all children aged 2 and 3 years (on the 1st of September 2013). At the same time, there are geographical pilot schemes for vaccinating children aged 4–10 years.
The vaccine preparation for use in children is a live attenuated virus vaccine in the form of a nasal spray suspension (Fluenz) and is licensed for prophylaxis of influenza in those aged 2–17 years old.3 Live attenuated influenza vaccine has been found to give greater protection against culture-confirmed and symptomatic influenza in children than inactivated influenza vaccine.4 The intranasal vaccine is usually given as a single divided dose (one 0.1mL spray in each nostril). The child can breathe normally while the vaccine is being administered with no need to inhale or sniff.3 As the vaccine is absorbed quickly, it is likely to be effective even if a child has a runny nose or sneezes immediately after the spray.2 Although the Summary of Product Characteristics for Fluenz says that children not previously vaccinated against seasonal influenza should receive a second dose after at least 4 weeks,3 studies have shown that a single dose gives adequate protection in children and so this is what is recommended in Immunisation against infectious diseases (the ‘Green Book’).1 There is an exception for children aged between 2 years and less than 9 years in clinical risk groups who have never before received influenza vaccine: they should receive a second dose of vaccine at least 4 weeks later.1 Children aged 2 and 3 years who cannot receive the intranasal vaccine (e.g. because they are immunosuppressed as a result of disease or treatment, or on high doses of systemic corticosteroids) can receive the inactivated influenza vaccine by injection.1 In a change to the previous recommendations, children and adolescents aged 2 years to less than 18 years in clinical risk groups should also be offered the intranasal vaccine (rather than the inactivated influenza injectable vaccine) provided they have no contraindications to the live attenuated vaccine.1 Children aged 6 months to less than 2 years in clinical risk groups should be offered inactivated influenza vaccine. There is a helpful flow chart on page 203 of the ‘Green Book’, which outlines who should receive which vaccine.1 Centrally supplied Fluenz is for use in 2- and 3-year-old children only, and so for other uses vaccine supplies must be purchased separately.5
As the intranasal vaccine is a live attenuated virus vaccine, vaccinees should avoid contact for 1–2 weeks with people who are very severely immunocompromised (e.g. bone marrow transplant patients requiring isolation), because of a potential for transmission of the disease. Where close contact with very severely immunocompromised patients (e.g. household members) is likely or unavoidable, appropriate alternative inactivated influenza vaccines should be considered.1 The vaccine should not be used in children receiving salicylates because of a potential risk of Reye's syndrome. It should not be used in children with egg allergy and is not recommended for children with active wheeziness at the time of vaccination or in those with severe asthma.2 Decreased appetite, headache, nasal congestion, rhinorrhoea and malaise are very common unwanted effects of the vaccine (reported in at least 10% of patients), and myalgia and pyrexia are common (in around 1–10%).3
It is important to note that Fluenz has a shelf life of only 18 weeks.3
Meningitis C (Men C) vaccine
Meningococcal disease, which occurs as a result of a systemic bacterial infection with Neisseria meningitidis, most often presents as meningitis and/or septicaemia. The incidence of meningococcal disease is highest in children under 1 year of age with a secondary peak in young people aged 15–19 years.1 The objective of the Men C routine vaccination programme is to protect people aged under 25 years from the disease and individuals outside this age range who may be at increased risk from meningococcal C disease. Under the new schedule (which came into effect on 1 June 2013) only one dose, rather than two doses, of Men C vaccine is required in infancy (at 3 months of age), followed by the first booster (at 12–13 months of age) in combination with Haemophilus influenzae type B (Hib) vaccine, and a second (new) booster for adolescents (at around 14 years of age). The dose at 4 months has been removed from the schedule on the basis of evidence that a single dose of some types of Men C vaccine at 3 months of age is sufficiently immunogenic in infants to provide protection against meningococcal C disease in the first year of life.1 In addition, a catch-up programme is planned (August 2014) to offer the vaccine to first-time university entrants under the age of 25 years, that is those who will not have been vaccinated under the revised schedule at around age 14 years.6
The routine pertussis immunisation programme aims to provide at least four doses of pertussis-containing vaccine (recommended at 2, 3, and 4 months of age, and at 3 years 4 months).1,7 A temporary programme of pertussis vaccination was introduced for pregnant women in October 2012 in response to an increase in outbreaks of pertussis in the UK, with the highest rates of disease in infants aged under 3 months, including several deaths among young babies.8 This temporary programme is to be continued until further notice.9 The Department of Health (DH) recommends vaccination of pregnant women at between 28 and 38 weeks' gestation.9 The aim is to boost pertussis antibodies, which may then be passed from mother to baby and so protect the infant in the first months after birth. Pertussis vaccine is only available in combination with other vaccines (diphtheria, tetanus, polio) and the DH advises that the combination vaccine Repevax be used as a pertussis booster in pregnant women.7 The vaccine can be given at the same time as influenza vaccine.8 The Summary of Product Characteristics for Repevax states that the vaccine is not recommended in pregnancy, although it is not contraindicated.10 There is no evidence of risk to pregnancy with inactivated vaccines or toxoids such as those included in the vaccine.8
Rotaviruses are ribonucleic acid (RNA) viruses contained in a protein capsule. Rotavirus infection is highly contagious, mainly transmitted by the faeco-oral route and usually occurs in the winter and early spring. People of any age can be affected, but it typically affects children aged 1 month to 4 years. Rotavirus infection in humans causes gastroenteritis that lasts 3–8 days.1 It is characterised by mild fever with severe diarrhoea, vomiting and stomach cramps, and can lead to dehydration. Nearly all children will have at least one episode of rotavirus gastroenteritis before reaching 5 years old.1 Around 12,700 children with rotavirus gastroenteritis are hospitalised in England and Wales every year.1 The aim of the vaccination programme is to reduce the severity of the infection in infants. Studies in Belgium suggest that hospitalisation of children due to rotavirus gastroenteritis may be reduced by 64–80% following vaccination.11
Rotavirus vaccination has been added to the routine schedule for all babies when they present for vaccination at 2 months and at 3 months of age.7 Rotavirus vaccine (brand name Rotarix) is a live attenuated virus given orally. The vaccine protects against rotavirus infection due to the most common infection-causing serotypes. It is over 85% effective at protecting against severe rotavirus gastroenteritis in the first 2 years of life.1 The full course of vaccination is two doses of vaccine given at least 4 weeks apart. The minimum age for the first dose is 6 weeks. A course of vaccination should not be started in infants older than 15 weeks. If the first dose is received before 15 weeks, the course should be completed by the time the infant is 24 weeks old. There is no need to restrict food or drink consumption before or after the dose.1
The vaccine is contraindicated in infants with a history of intussusception, uncorrected congenital malformation of the gastrointestinal tract that would predispose to intussusceptions, and severe combined immunodeficiency disorder.11 Live virus can be excreted in the stools after vaccination and so contacts of recent vaccinees should be advised to take care with personal hygiene (e.g. wash hands after changing nappies). Diarrhoea and irritability have been reported commonly (in around 1–10% of patients).11
Over 50,000 cases of shingles occur in people aged 70 years and over each year in England and Wales.1 The severity of shingles generally increases with age and can lead to post-herpetic neuralgia that can last for 3–6 months or longer and require hospitalisation.1 A new national shingles immunisation programme started on 1 September 2013, with the aim of lowering the incidence and severity of shingles in older people.1 In clinical trials, compared with placebo, varicella zoster vaccine decreased the incidence of herpes zoster from 11.1 to 5.4 episodes per 1,000 person-years, p<0.001) and post-herpetic neuralgia (from 1.4 to 0.5 per 1,000 person-years, p<0.001).12 The vaccine can be given at the same time (in a different body part) as seasonal influenza vaccine and the same time as 23-valent pneumococcal polysaccharide vaccine in eligible patients.1
The live attenuated shingles vaccine (Zostavax) is given as a single 0.65mL subcutaneous injection. The vaccine is licensed for use from the age of 50 years and is effective in this age group, but the burden of shingles disease is generally not as severe when compared with that in older people. Initially, the vaccine is only being provided to people aged 70 years (routine programme) or 79 years (catch-up programme) on 1 September 2013 because of limited stock of the vaccine.5 Given that the duration of protection is not known to last more than 10 years and the need for a second dose is not known, the vaccine is not recommended to be offered routinely to people below the age of 70 years. The vaccine has limited effectiveness in people over the age of 80 years and is therefore less cost-effective in this population.1 The vaccine is not indicated for prevention of primary varicella zoster infection (chickenpox) and should not be used in children and adolescents. Also, the vaccine is not recommended for treating shingles or post-herpetic neuralgia. Patients who have shingles or post-herpetic neuralgia should wait until symptoms have ceased before being considered for shingles immunisation. However, the natural boosting that occurs following an episode of shingles limits the benefit of offering zoster vaccine immediately after recovery. Ideally, shingles vaccine should be delayed until therapy with anti-viral drugs, such as aciclovir, is completed as they may reduce response to the vaccine.1
Shingles vaccine is contraindicated in people with immunodeficiency (e.g. due to acute and chronic leukaemias, lymphoma, other conditions affecting the bone marrow or lymphatic system, HIV/AIDs, cellular immune deficiencies), or who are on immunosuppressive therapy (including high-dose corticosteroid therapy) and those with active untreated tuberculosis.12 The ‘Green Book’ notes that live vaccine should not be given to patients receiving immunosuppressive drugs (e.g. azathioprine, cyclosporin, methotrexate, cyclophosphamide, leflunomide and the newer cytokine inhibitors) alone or in combination with lower doses of steroids, until at least 6 months after terminating such treatment.1 Low-doses of methotrexate (<0.4mg/kg/week), azathioprine (<3.0mg/kg/day) or 6mercaptopurine (<1.5mg/kg/day) are not considered sufficiently immunosuppressive and are not contraindications for administration of zoster vaccine.1 Guidance issued in Wales reminds healthcare professionals of the importance of carefully checking whether any contraindication to the use of shingles vaccine exists, because immunosuppressive therapies are often administered in the hospital setting and details may not be listed in the primary care record.13
It is possible for the virus to be transmitted to susceptible contacts from vaccinees whether or not they develop a varicella-like rash. Redness, pain, swelling and itching at the site of injection are reported very commonly (in more than 10% of patients) and headache and pain in extremities commonly (in around 1–10%).12
Detailed information for health professionals is published online in Immunisation against infectious diseases.1 Information for the public is available online from each of the devolved health services:
England—The NHS vaccination schedule (NHS choices)14
Northern Ireland—Immunisation and vaccinations (nidirect)15
Scotland—Immunisation Scotland (Healthier Scotland/NHS Health Scotland)16
Wales—Immunisation (Llywodraeth Cymru, Welsh Government)17
Detailed prescribing information is available in the Summary of Product Characteristics for each product.
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
Files in this Data Supplement:
- Data supplement 1 - Online supplement