Routine Vaccinations

UK vaccination schedule as of May 2018

AgeDiseasesVaccines
2 monthsDiphtheria
Tetanus
Pertussis
PolioMeningitis B
Rotavirus
Hib
PneumococcusHep B
DTaP/IPV/Hib/HepB  (Infanrix hexa)
Pneumococcal Conjugate vaccine (PCV)
Rotavirus (Rotarix)MenB (Bexsero)
3 monthsDiphtheria
Tetanus
Pertussis
Rotavirus
Polio
Hib
DTaP/IPV/Hib/HepB  (Infanrix hexa)
Rotavirus (Rotarix)
4 monthsDiphtheria
Tetanus
PertussisMeningitis B
Polio
Hib
Pneumoccocus
DTaP/IPV/Hib/HepB (Infanrix hexa)
PCV vaccine
MenB (Bexsero)
12 monthsHib
Pneumococcus
Meningitis C MMRHib/MenC (Menitorix)
PCVMMR
3 years and 4 monthsDiphtheria
Tetanus
Pertussis
Polio
MMR
DTaP/IPV Infanrix IPV or Repevax,
MMR
Girls aged 12-13Cervical CancerHPV (Human papilloma vaccine) – Gardasil
13-18 (usually age 14)Diphtheria
Tetanus
PolioTd/IPV (Revaxis)

MenACWY (Menveo or Nimenrix)

Age 65PneumococcalPneumococcal Polysaccharide Vaccine (PPV)
Age 65+Influenza – annuallyInactivated influenza vaccine – various brands
Age 70ShinglesShingles (Zostavax)

In addition, all children aged 2 to 8 years old should receive an annual Flu vaccination – this is a live attenuated vaccination – Fluenz Tetra. It is given intranasally.

*DTaP – Diphtheria, Tetanus and Pertussis
*IPV – Inactivated poliovirus vaccine
*Td – Tetanus and Diphtheria vaccine

All the vaccinations are “inactive”, except for MMR and the flu vaccine, which are combinations of modified live vaccines (we call these “live attenuated vaccines”).

  • Live attenuated vaccines are more likely to cause generalised side effects (see below), and expert advice should be sort before administering to immunocompromised patients

Schedules vary between countries (and between states within countries). Note that in many developed countries it is also common to vaccinate against varicella (chicken pox) in childhood.

General side effects

  • Swelling at the site of the injection
  • Fever
  • Malaise
  • Anaphylaxis (Very rare)
  • Symptoms of mild disease in the case of MMR
  • Don’t give vaccine if the child has a fever /acute illness at the planned time of vaccination. However, if there is no fever, and a minor infection (e.g. cough or cold), it is still appropriate to vaccinate.
  • Febrile Convulsionscan occur after vaccination in some patients, particularly if there is a family history. Advice on how to reduce / prevent fever to such families may be beneficial.
  • Immunocompromised children should not receive live vaccines. The exception to the rule is that MMR can be given to children with HIV.

Other vaccinations

  • TB (BCG vaccination)given at birth to babies who are likely to come into contact with TB. This is usually when there is:
    • Someone known to have TB, or previously had TB within the family
    • The family originates (within 2 generations) from a country known to have a high TB risk; e.g. if the child’s parents or grandparents had previously lived in Pakistan.
    • Routine TB vaccination no longer occurs in the UK
  • Hep B (Hep B vaccination) – given at birth to babies whose mother, or other close family contacts, are Hep B positive. Advice should also e given about sharing toothbrushes and other household items.

Levels of protection

VaccinationProvides Immunity?Info
Polio
(IPV vaccine)
Aka Salk vaccine
In most casesGiven IM. Uses an inactive form of the virus (i.e. dead!). The live oral vaccination (OPV) no longer widely used in the developed world, but does provide contact immunity, and thus is useful in the developing world.
Immunity declines with time, but this is not necessarily a problem in developed countires due to herd immunity, and the basic level of protection still afforded by previous vaccination.
The Polio virus needs a large reservoir of infected hosts to sustain itself in a population. As a result, with vaccination programs in the Western World, it is no longer present in many countries. It is thought that eventually it will be eradicated completely by world-wide use of vaccination.
Side effects are not particularly common
DTaP
Diphtheria
Tetanus
Pertussis
In most casesThe DTaP vaccine is now used in most developed countries, as it uses cell products (acellular) and not whole cells, instead of the full cells used in the older DTP vaccine. This reduces the side effects of the vaccine, but make it more expensive, so DTP is still used in many developing countries. DTP vaccine causes severe neurological deficits in 1 in 14,000 cases – thought to be the result of the pertussis used. Other side effects of the old DTP vaccine include fever, agitation, and unusual crying patterns (continuing for hours, often high-pitched).
Booster vaccinations (usually the Tdap vaccine) are required every 10 years for continued immunity.
If a child has serious side effects with the DTaP vaccine, (fever, soreness, vomiting, decreased apetitie, seizures, anaphylaxis), then the Td vaccine is a safe alternative for Diphtheria and Tetanus immunity, as most of the side effects are related to the pertussis component of the vaccine. Pertussis vaccine controversy – in the 1970’s there was a supposed link between the pertussis vaccine and neurological complications, with subsequent drop in vaccination rate, and epidemics of whooping cough. It is now thought that these are rare, are more likely to be caused by pertussis infection than by the vaccine. However, any child with neurological signs should not receive the vaccine until these resolve.
HibYes
(95-100% of cases)
Uses cell products, often known as the conjugate vaccine. Side effects are rare. Hib causes meningitis, pneumonia and epiglottitis. The incidence of all these conditions has dramatically declined since the introduction of the vaccination in the 1980’s.
MMRYes (99% cases after 2 doses)Contains three live viruses. The second dose is not a ‘booster’ but is another dose of the vaccine to hopefully provide immunity to those that did not develop it the first time around (5-10% of cases). Measles is now considered eradicated in many western countries. There is absolutely no link with autism.
Side effects:

  • Rash, fever, loss of apetitie about 10 days after jab (due to measles virus). Lasts 2-3 days
  •  Swollen lymph nodes (due to mumps virus). Lasts 3-4 days
  • Stiff swollen joints [RARE] (due to rubella vaccine) – lasts 3 days

Contraindications
Immunodeficiency of non-HIV origin
Allergy to neomycin or kanamycin
Allergy to egg products – vaccine should still be given but with medical supervision and recuss equipment present.

PCV
Pneumococcus
Yes – but see infoUses bacterial proteins. Does provide immunity, but only against 7 of ~90 pneumococcal strains.
MenC  Another conjugate vaccine containing bacterial products. Protects against Meningitis C, but not other forms of Meningitis. Possible side-effects just involve fever and soreness at injection site.

Side effects can still occur in acellular, conjugate and inactive vaccinations – however these are usually related to the immune response, and not to the vaccination products themselves. They are usually self limiting, and may last from a few hours to a few days. They will include things like:

  • Fever
  • Soreness (at the injection site)
  • Aching limbs
  • Drowsiness
  • Also – always be wary of allergy / anaphylaxis!

Live vaccines

Essentially cause a ‘mild’ form of the disease they are designed to protect against.
They are more likely to give lifelong protection than inactivated versions, but are also higher risk, with a greater range and incidence of side effects, and a small chance, in some individuals, that they can develop a full-blown version of the disease they were vaccinated against.

  • Live vaccines will tendto produce life-long immunity after 1-2 doses.

Many people will have few (if any) side effects, whilst some may experience symptoms consistent with a mild form of the disease. Rarely, they can cause severe symptoms, usually in ‘at risk’ patients (e.g. immunocompromised), and thus such individuals may not be vaccinated, and instead, rely on ‘herd immunity’ for their protection.

Herd Immunity

Infectious disease relies on a chain of individuals to infect. If this chain is broken (i.e. the disease comes into contact with an immune individual), then the disease cannot be passed on.

  • The higher the proportion of the population that is immune, the lower the likelyhood of an infected individual coming into contact with another susceptible host.
  • Thus if the ‘chain is broken’, unvaccinated individuals are also protected to some extent due to the reduced pool of infected individuals from which to contract the disease.
  • The herd immunity threshold  is the percentage of individuals that need to be vaccinated for herd immunity to be an effective method of protecting the rest of the population. This value varies according to the disease, but is typically 75-95%.
    • Thus, in a simple scenario, if a government wishes to eradicate a disease from their population, and they intend to vaccination everybody, they need a vaccine that is only 75-95% effective. On the other hand, they could have a vaccine that is 100% effective, and they need only vaccinate 75-95F of the population.
    • In reality, they will likely use a mixture of the above two scenarios, as a small proportion of the population (i.e. those with serious disease / immunocompromised etc) cannot be vaccinated.

Children are particularly good at carrying disease and infecting others. This is partly related to their physiology, partly due to their levels of hygiene (e.g. hand washing behaviours, sticking things in their mouths etc) and partly because they come into contact with so many other individuals (e.g. at school and nursery). Vaccination schemes in children also reduce the incidence of disease in the adult population, as the infectious agents have a vastly reduced pool of hosts.

Contact Immunity

This is possible with some live vaccines. In the vaccinated individual, the live virus is able to replicate, and be passed onto others, who then also receive the benefits, as if they had been vaccinated. The most widely used of these vaccines is the OPV polio vaccine.
The main problem with using live viruses, is that some vaccinated individuals may develop severe symptoms of the disease they have been vaccinated against. And with the contact immunity phenomenon, even those who have not been vaccinated, but who ‘catch’ the virus from a vaccinated individual may develop the disease. The risk however, is very small, and is usually confined to immunosupressed individuals.

References

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