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CHILDHOOD IMMUNISATIONS

Prevention of infectious diseases

Immunisation is one of the most successful and cost effective health protection interventions, and is a cornerstone of public health. High immunisation rates are key to preventing the spread of infectious disease, complications and possible early death among individuals and to protecting the population's health through both individual and herd immunity. 

In the UK, routine vaccinations for the under-5s are usually carried out in GP surgeries; in some areas they are given by health visitors. The UK childhood vaccination programme has been successful in reducing the incidence of vaccine-preventable diseases but recently there has been a significant increase in cases of measles, and the UK had its measles-free status withdrawn in August 2019. 

The UK immunisation schedule aims to provide early protection against diseases that are most dangerous for the very young, particularly diseases such as whooping cough, rotavirus and those due to pneumococcal, Hib and meningococcal infections. Further vaccinations are offered throughout life when people reach an age where they can derive the most benefit or where the programme will provide optimal control of the disease for the whole population.

Recommendations for the age at which vaccines should be given are made according to the age-specific risk for the disease, the risk of complications, the ability to respond to the vaccine, and the impact on spread in the population – so it is important to follow the schedule as closely as possible.

The schedule covers the following vaccine-preventable infections:

 

 

Influenza vaccine

The phased introduction of the childhood influenza vaccination programme began in 2013 with the inclusion of children aged two and three years in the routine programme. Each year, more school age groups are being added to the programme, and those eligible should be vaccinated each winter, usually between October and January, although vaccination may still be of some benefit if given later.In 2015, the routine immunisation against meningitis C was replaced with the multivalent, conjugate MenACWY vaccine, due to the increase in cases of meningococcal group W, particularly among students attending university. 

HPV vaccine

HPV vaccination was introduced in 2008 for girls aged 12 – 13 years. If offers protection against cervical cancer and genital warts, as well as other premalignant genital lesions (cervical, vulvar and vaginal). In 2014, the number of doses of HPV vaccine was reduced from 3 to 2. Ideally the doses should be given 12 months apart (minimum 6 months, maximum 24 months).

Since September 2019, boys aged 12-13 years (school year 8) have been eligible for the HPV vaccine. This aims not only to prevent HPV-related cancers in boys - notably penile, genital and anal cancers and some head and neck cancers, but also to increase herd immunity among girls. It is estimated that the HPV vaccine currently used will have prevented almost 100,000 cancers by 2058, when the people who were vaccinated as teenagers reach the age groups that would typically be affected by HPV-related cancers. 

Non-routine immunisations given at birth

Tuberculosis (for neonates at risk)

Hepatitis B (for neonates whose mothers are Hepatitis B positive and children at high risk - see Green Book, chapter 18)

Training

Everyone who advises on or administers immunisations should be appropriately trained, competent and regularly updated. Vaccines are most usually administered under Patient Group Directions (PGDs) and Patient Specific Directions (PSDS) which enable a wide range of healthcare professionals to provide immunisations without the need for a personal prescription and full medical assessment by a doctor.

UK immunisations reference

The online-only version of the Green Book is regularly updated and provides comprehensive guidance. You can check for updates online, or subscribe to the monthly Vaccine Update e-newsletter. Letters issued by the Chief Medical Officer give important policy updates. An algorithm helpful in the event of uncertain or incomplete immunisation history is available at the HPA website. Up to date information on the routine childhood immunisation schedule is available from Public Health England.

Vaccine administration

Vaccines are prescription only medicines (POMs). Nurses without a prescribing qualification can administer them under a Patient Group Direction (PGD) or a Patient Specific Direction (PSD) See Nurse Prescribing. Before administering vaccine:

1. Ensure that it is needed: is it the correct vaccine and the correct patient?

2. Ensure the patient is fit to receive it.

3. Obtain consent from the person with parental responsibility (Green Book, Chapter 2): a) there is no legal requirement for consent to immunisation to be given in writing, but a signed consent form is a record of the decision and discussions that have taken place with the person giving consent on a child's behalf, and b) consent should be sourght on the occasion of each immunisation visit.  Informed consent can be given only after information has been offered on the benefits and possible adverse effects of the vaccine, and the risks of withholding immunisation. 

4. Check that the vaccine is in date, that the cold chain has not been interrupted and that resuscitation equipment is available in case of an anaphylactic reaction.

5. Give intramuscularly unless a bleeding disorder is present and then by deep subcutaneous route.

6. Consider methods of reducing the trauma of the event for the child.

7. Discuss action to be taken in the event of a possible adverse reaction.

8. Record the vaccine given, the date, and the vaccine’s batch number, and expiry date in the patient’s medical notes. If applicable, 'decommission' the vaccine as required by the Falsified Medicines Directive. (See https://www.gov.uk/government/publications/vaccine-update-issue-293-april-2019 )  If giving more than one vaccine, document limb and site for each.

9. Advise that the individual stays on the premises for 10 min post-vaccination, leaving only when it is clear that the individual is experiencing no side-effects from the vaccination.

See also Anaphylaxis, Vaccine storage

 

Contraindications

 

There are very few genuine reasons why an immunisation should not be given. General contradictions for all vaccines are:

  • acute illness, especially fever (>38oC): postpone until recovered (a cold without acute illness is not a contraindication)
  • a true anaphylactic reaction to a previous dose or to any component of the vaccine.

 

Reactions

 

Severe reaction (see below) to a preceding dose is no longer considered a contraindication.

Local reaction: where induration involves most of the surface of thigh or upper arm.

General reaction: fever >39.5oC within 24 h, convulsions or encephalopathy within 72 h, or prolonged inconsolable or high-pitched screaming for more than 4 h or other signs in the child of a major systemic reaction.

 

Practice Nurse featured articles

 

 

Vaccinations – in safe hands? Diane Baylis 

Masterclass: Childhood immunisation Dr Mary Lowth 

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