Free PGEA for those who have not waded through the new Green
Immunisations Book from cover to cover.
These are highlights of the 1996 Green Book on Vaccinations
as presented by the Communicable
Diseases team in Southampton. This is a local interpretation and
might not be totally agreed throughout the country. However, this
summary may be useful for other members of the primary team including
practice nurses, health visitors, GP Registrars etc. Note also this is my
interpretation of what was said. If in doubt check the book.
Childhood Vaccinations
It is important to clearly document any adverse reaction and do yellow
card reporting. The earlier schedule for infant immunisation is
producing less reactions. Febrile illnesses remain a contraindication,
partly due to risk of inducing febrile convulsion, partly because you
get a poorer antibody response.
Reactions that do occur are generally to the Pertussis component. In
the event of a significant generalised reaction (defined page 163,
para 24.6 i.e. it has to be spectacular) give DT plus Acellular
Pertussis in future. Reactions are less frequent with current adsorbed vaccine
compared with previous plain one.
If at risk of diphtheria over the age of 10 give the dilute version
eg. for travel. They go on to
recommend any young person aged 10 to 16 who needs a tetanus for a
specific reason e.g. school trip, tetanus prone wound should be given
Td rather than just Tetanus.
Acellular Pertussis Vaccine
is available on a named patient basis, and is available for completion
of the course after a severe DPT reaction. It produces less reactions
but is less immunogenic, and much more expensive.
HIB
There are different types of HIB vaccine which are interchangeable.
Local reactions are less frequent with subsequent doses. It can be
given with DPT but if there is a reaction give at different sites.
MMR
Live vaccine, 2 doses separated by a minimum of 3 months. No longer
given with dilute immunoglobulin. Contraindicated in the presence of a
current viral infection. No age limit. Must not be given within 1
month of BCG or within 3 weeks of Yellow Fever. Egg allergy is said
not to be a problem, even anaphylaxis (!) though in the latter the
child should be referred to the paediatricians to be vaccinated to be
on the safe side! The 2nd MMR is needed for better coverage of the
Measles component. The mumps and rubella produce excellent responses
to one vaccination.
Rubella
There is apparently no recorded case of congenital rubella syndrome in any one
who has been immunised and shown to have a antibody response at some
time. The vaccine appears to give protection even when there is no
recorded antibody response at a later date. When there have been two
documented sero-positive results further screening in or after
pregnancy is unnecessary except in the event of suspected rubella or
rubella like rash.
Polio
It is permissible for infants to swim before and after! The virus is
polished off by chlorine in the water. It must not be given with oral
typhoid as they compete for the same gut sites. Boosters only needed
for endemic regions and for Health Care Workers ONLY if nursing
current polio cases. Otherwise there is a danger of Health Care
Workers putting immuno-compromised patients e.g. transplantation, HIV
at risk from virus excretion. If the parents (or if necessary
grandparents) have no documented history of polio vaccination, give
them the 3 dose course too.
Hepatitis A
1st dose lasts 1 year, 2nd 10 years, 90% effective at 14 days, 99%
effective at 1 month. Existing grounds are for long haul travellers to
endemic regions and sewage workers who are exposed to handling sewage.
There are new recommendations:
chronic liver disease
haemophiliacs (subcutaneous)
promiscuous homosexuals
but check antibodies first, and also give good hygiene advice.
Hepatitis B
The incidence may be dropping; 2000 reported cases p.a. in the 80s,
1994 there were 629 cases. Of these 2 to 10% go on to become carriers
and 25% of carriers get liver disease. It works best in young people.
There is a new category: those who adopt children from areas of risk
e.g. Far end of Europe, SE Asia, S America. Others are: babies born to
mothers who are chronic carriers or have had acute hep.B in pregnancy,
parenteral drug misusers, people with frequent sexual partner changes,
close contacts of a case or carrier, haemophiliacs, chronic renal
failure but may need higher dose, health care workers & students,
staff and residents for those with severe learning difficulties,
morticians and embalmers, prisoners, those going to work in high
prevalence areas. Tourists only at risk if too randy. Boost those at
risk 5 yearly. For post exposure incidents, good table on page 106.
Influenza
A new group, asplenics, has been added.
Meningococcal Vaccine
800 cases of meningococcal disease C yearly with 10% mortality.
Vaccine only covers groups A and C, works after 5 to 7 days, lasts for
3 years. Doesn't work for kids under 2. Recommended for asplenics if
going to areas of increased risk e.g. sub Saharan Africa and Saudi
Arabia, India, Nepal. Otherwise only recommended to backpackers and
people intending to work with local people for more than a month in
these high risk areas. Needed in Saudi Arabia as can't enter the
country otherwise.
Regarding prophylaxis, Ciprofloxacin single dose 500mg likely to
become a standard licenced treatment within the next year. It was
used in the Cardiff outbreak recently.
Pneumococcal vaccine
Is recommended for the same at risk group as per influenza vaccine and
note also for coeliacs.
Post Splenectomy
This is a special group. They should have the following vaccines:
Pneumococcal, HIB, Influenza yearly, Meningococcal for travel to high
risk areas. Antibiotic prophylaxis. At high risk from Malaria and tick
bites therefore special care abroad.
Rabies
New category Registered Bat Handlers.
After possible exposure, it's well summarised in the book, page 183
onwards. Risk from bats is very low. The recent incident was thought
to be a cross channel flyer.
Typhoid
Same indications as Hepatitis A abroad.
The single dose injection is probably the best value and most
appropriate. 80% coverage at 3 years. The oral form wasn't thought to
be as good value at this meeting.
Cholera
No longer available.
Specific Immunoglobulins (HNIG)
Don't give live vaccine for 3 weeks before or 3 months afterwards.
Measles:
don't test for antibodies. Measles in at risk people is serious
therefore get it in fast.
Hep A
normally given on CCD advice re. travellers & contacts.
Varicella-Zoster
In very short supply so only to pregnant women, neonates, immune
suppressed where antibodies are negative and there is a serious
exposure.
Tetanus
they felt we should follow the book for tetanus prone wounds, even
presumably puncture wounds like fish hooks though it seems wasteful.
HIV Patients
need to have had the following live vaccines:
measles, mumps, rubella and
Inactive vaccines:
pertussis, diphtheria, tetanus, polio, typhoid, hepatitis B, HIB and
can also have Pneumococcal, rabies if at risk, hepatitis A and
meningococcal. But do not give BCG or Yellow Fever.
Priority Children for Vaccination are:
ones with asthma, CHD, chronic lung disease, Downs, HIV, small for
dates and v. prem, hyposplenics, those on dialysis, haemophiliacs and
post. Transplants.
Bern
Dr Bernard Bedford
Waterside Health Centre
Beaulieu Road
Hythe, Hampshire, SO45 5WX
email: [log in to unmask]
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