The immunisation schedule May 2016

After clean water, vaccination is the most effective public health intervention in the world for saving lives and promoting good health (HPA, 2013). January 2016

Focus of session Meningococcal vaccination Shingles Flu vaccination for children Vaccinating during pregnancy Administration of live vaccines January 2016

1st Sept 2015 January 2016

What is meningococcal disease? Invasive bacterial infection caused by Neisseria meningitidis, AKA the meningococcus Important clinical and public health problem: rare but serious disease onset is sudden and often dramatic The most common clinical presentations are meningitis and septicaemia: significant morbidity and mortality Significant case fatality rate ~10% but varies with age, capsular group, and clinical presentation: 1 in 8 survivors have long term complications Brain damage, deafness, epilepsy, limb/digit loss, cognitive deficit January 2016

http://www.bbc.co.uk/news/uk-england-35603938 http://www.bbc.co.uk/news/uk-england-london-35602045 January 2016

Meningococcal Capsular Groups There are 12 known meningococcal groups, each possessing a distinct outer polysaccharide (sugar) capsule. The organism is associated with both asymptomatic carriage and invasive disease >95% of cases are sporadic but occasional outbreaks occur, e.g. in families, schools, universities January 2016

Global distribution of invasive meningococcal disease Harrison LH, Trotter CL, Ramsay ME. Global Epidemiology of Meningococcal Disease, in Vaccines against Meningococcus, 2009; 27 Suppl 2:B51-63. January 2016

Laboratory confirmed cases invasive meningococcal disease England and Wales January 2016

MenB disease by age-group (England & Wales, 2008-13) January 2016

Meningococcal Disease in England The UK (and ROI) have the highest incidence of IMD in Europe In England, capsular groups B, W and Y are responsible for nearly all meningococcal infections across all age groups Routine meningococcal C (MenC) conjugate vaccination introduced in 1999 has nearly eliminated invasive MenC disease in England MenB still accounts for 70% of all laboratory-confirmed meningococcal cases in England and >90% of cases in children and adolescents January 2016

January 2016

Who are we vaccinating? Invasive meningococcal disease by age England & Wales (2006/07-2010/11)

The vaccines – Men B Bexsero® – developed with 4 antigens (OMV + 3 proteins) Reverse vaccinology Extensively trialled in infants & children – no safety concerns UK is first county to use this vaccine routinely Aim to provide protection at peak age of 5 months Protection to last into 2nd year of life Given at 2-4-12 months (with catch-up for those born between 1st May & 30th June) Men B PHE guidance: https://www.gov.uk/government/publications/menb- vaccination-introduction-from-1-september-2015

January 2016

Vaccination schedule Sept 2015 (up to 18 years) Age Diseases protected against 2 months Diphtheria, tetanus, whooping cough, polio, Hib, Pneumococcal, Rotavirus, and Meningococcal group B (Men B) 3 months Diphtheria, tetanus, whooping cough, polio, Hib, Meningococcal group C (Men C) and Rotavirus 4 months Diphtheria, tetanus, whooping cough, polio, Hib, Pneumococcal and Men B 12-13 months Hib/Men C Pneumococcal, Measles, mumps & rubella (MMR) and Men B 2-6yrs 3yrs 4m Children’s flu vaccine (live vaccine) Diphtheria, tetanus, whooping cough, polio MMR (pre-school immunisations) 12-13yrs HPV (cervical cancer) girls only 2 x doses 6 months apart 13-18yrs Diphtheria, tetanus, polio (school leavers immunisations) Men ACWY

Administration Left thigh (ideally on it’s own so that local reactions can be more accurately monitored) Accurate recording Bexsero® is associated with higher rates of local and systemic reactions when give with other routine infant vaccinations, but pattern predictable (peak at 6 hours and resolution the following day post vaccination)

Dosage & timing of infant Paracetamol suspension (120mg/5ml) for the routine immunisation programme at 2 + 4 months January 2016

Men ACYW - JCVI recommendations: February 2015 In view of rapid increase in cases, known virulence of clonal complex 11 and international experience JCVI considered situation a public health emergency Optimal strategy difficult to decide based on wide age distribution Option to replace MenC doses with quadrivalent conjugate (ACWY) warrant urgent consideration Infants at highest risk but current MenC – single dose of quadrivalent not sufficient Toddler dose is given as Hib-MenC – still need the Hib booster Teenagers are at high risk AND known to have high carriage rates Vaccination for school years 10-13 should have rapid impact on carriage and therefore have impact on disease in all age groups Speed of effect will depend on speed of catch-up campaign January 2016

MenW cases by age group England, 2010/11-2014/15* January 2016

Vaccination schedule Sept 2015 (up to 18 years) Age Diseases protected against 2 months Diphtheria, tetanus, whooping cough, polio, Hib, Pneumococcal, Rotavirus, and Meningococcal group B (Men B) 3 months Diphtheria, tetanus, whooping cough, polio, Hib, Meningococcal group C (Men C) and Rotavirus 4 months Diphtheria, tetanus, whooping cough, polio, Hib, Pneumococcal and Men B 12-13 months Hib/Men C Pneumococcal, Measles, mumps & rubella (MMR) and Men B 2-6yrs 3yrs 4m Children’s flu vaccine (live vaccine) Diphtheria, tetanus, whooping cough, polio MMR (pre-school immunisations) 12-13yrs HPV (cervical cancer) girls only 2 x doses 6 months apart 13-18yrs Diphtheria, tetanus, polio (school leavers immunisations) Men ACWY

Men ACWY – The vaccines Menveo® and Nimenrix ® are the two vaccines recommended for the routine MenACWY immunisation programme for adolescents Conjugate vaccines

Administration – the schedule Catch up to run from Autumn 2015 into 2016 Aimed at adolescents in years 9, 10, 11, 12 & 13 and some university students Full details regarding the ACYW catch up see: https://www.gov.uk/government/uploads/system/uploads/at tachment_data/file/437901/150622_ACWY_bipartite_letter. pdf January 2016

Shingles Initially introduced in 2013 Working towards vaccinating all 70-79 year olds Live attenuated vaccine by IM or SC injection Initially SC now IM preferred See: https://www.gov.uk/government/collections/shingles-vaccination-programme January 2016

Flu vaccination in the UK Late 1960s: annual flu immunisation recommended to directly protect those in clinical risk groups who are at a higher risk of flu associated morbidity and mortality 2000: flu vaccine policy extended to include all people aged 65 years or over 2010: pregnancy added as a clinical risk category for routine flu immunisation 2013: phased introduction of an annual childhood flu vaccination programme for all children aged 2-16y began with vaccine offered to all children aged 2 and 3 years and seven geographical pilots in primary school aged children 2014: phased introduction of childhood flu vaccination programme continued with vaccine offered to all children aged 2, 3 and 4 years and geographical pilots in primary and secondary school aged children 2015: offer to all 2, 3 & 4 year old children and children of school year 1 & 2 age January 2016

Why vaccinate children against flu? Extension of the seasonal flu vaccination programme to all children aims to appreciably lower the public health impact of flu by: Providing direct protection thus preventing a large number of cases of flu in children Providing indirect protection by lowering flu transmission from children to other children, to adults and to those in the clinical risk groups of any age Reducing flu transmission in the community will avert many cases of severe flu and flu- related deaths in older adults and people with clinical risk factors Annual administration of flu vaccine to children is expected to substantially reduce flu- related illness, GP consultations, hospital admissions and deaths It has been estimated that if just 30% of children had the flu vaccine, there could be 2000 fewer deaths and 11 000 fewer hospitalisations due to flu each year January 2016

Which vaccine? Two main types of vaccine available: Inactivated – by injection Live - by nasal application Trivalent vaccines = 2 x A and 1 x B virus types (most inactivated vaccines are trivalent) Quadrivalent vaccines 2 x A and 2 x B virus types As quadrivalent vaccines may be better matched and therefore may provide better protection against the circulating B strain(s) than trivalent flu vaccines, the live intranasal vaccine offered to children aged 2yrs and over is a quadrivalent vaccine, as is the inactivated vaccine recommended for children aged 3years and above who cannot received live vaccine January 2016

Fluenz Tetra® More effective than inactivated vaccines Attenuated whole live virus Q - So can it cause flu then? A - No - in addition to being attenuated, (weakened), the live viruses in Fluenz Tetra® have been adapted to cold so that they cannot replicate efficiently at body temperature Usual contraindications apply PHE flu in children guidance: https://www.gov.uk/government/publications/childhood-flu- programme-qa-for-healthcare-professionals January 2016

Why vaccinate during pregnancy? Pregnant women may be greater risk if infection is acquired Passive protection is important for newborns PHE Flu in pregnancy guidance: https://www.gov.uk/government/publications/influenza- vaccination-in-pregnancy-advice-for-healthcare-professionals PHE Pertussis in pregnancy guidance: https://www.gov.uk/guidance/pertussis-whooping-cough- immunisation-for-pregnant-women-resources-and-training January 2016

What happens in the pregnant immune system? Innate immunity Same immediate response Non specific Fast Adaptive immunity Highly specific T & B cells Antibody production Takes time January 2016

Flu Flu infection during pregnancy maternal complications May be associated with preterm birth and SGA babies Immunisation with inactivated vaccine recommended Any stage of pregnancy – with each pregnancy WHO recommendations for uptake are 75% January 2016

Vaccine uptake 2015/2016 (in England, PHE) GP Data with 96 Vaccine uptake 2015/2016 (in England, PHE) GP Data with 96.5% of practices responding January 2016

Transfer of maternal antibodies Passive immunity Administration of antibodies January 2016

Transfer of maternal antibody (passive immunity) IgG crosses the placenta – most after 32 weeks and reaches maternal levels by 33 weeks IgG1, IgG2, IgG3, IgG4 Relies heavily on quantity and ability of transfer but can provide newborn with passive protection against many vaccine preventable diseases (VPDs) – tetanus, polio, measles, HBV, mumps, diphtheria…. Predominantly IgA in breast milk January 2016

January 2016

Lab confirmed pertussis cases in England 1998-2014 January 2016

Vaccination during pregnancy January 2016

Pertussis vaccination (in pregnancy) Vaccination containing low dose (d not D) diphtheria 28-32 weeks ideally (up to 38 weeks ok) Uptake? Data from PHE April 2014-March 2015 Prenatal pertussis vaccine coverage in England January 2016

Interval Spacing of vaccines Doses of the same inactivated vaccine – 4 weeks apart (or 8w for PCV) Live vaccines (same or different) – 4 weeks apart No interval need be observed between: live and inactivated vaccines doses of different inactivated vaccines No evidence exists that inactivated vaccines interfere with the immune response to other inactivated vaccines or to live vaccines An inactivated vaccine can be administered either simultaneously or at any time before or after a different inactivated vaccine or live vaccine January 2016

April 2015 January 2016

Recommendations for giving more than one live attenuated vaccine in current use in the UK Vaccine combinations Recommendations Yellow fever & MMR 4 weeks between NOT on same day Varicella (and zoster) & MMR OR okay to be given on same day Mantoux testing & MMR If recent MMR given then wait 4 weeks before Mantoux If Mantoux initiated then delay MMR until after test read UNLESS measles protection urgently required All other live vaccines (BCG, rotavirus, LAIV, oral typhoid, yellow fever, varicella, zoster & MMR) and Mantoux testing Apart from combinations listed above can be given at any time before or after each other. January 2016

Thank you! With acknowledgement to Public Health England for use/adaptation of slides January 2016

Further reading/resources Green Book online: https://www.gov.uk/government/collections/immunisation -against-infectious-disease-the-green-book Algorithm for uncertain/incomplete vaccination status: https://www.gov.uk/government/publications/vaccination- of-individuals-with-uncertain-or-incomplete-immunisation- status January 2016