1. The immunisation schedule May 2016

2. 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

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

4. 1st Sept 2015
January 2016

5. 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

6.
January 2016

7. 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

8. 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

9. Laboratory confirmed cases invasive meningococcal disease
England and Wales
January 2016

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

11. 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 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

12. January 2016

13. Who are we vaccinating?
Invasive meningococcal disease by age England & Wales (2006/ /11)

14. 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 months (with catch-up for those born between 1st May & 30th June)
Men B PHE guidance: vaccination-introduction-from-1-september-2015

15. January 2016

16. 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

17. 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)

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

19. 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 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

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

21. 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

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

23. 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:
tachment_data/file/437901/150622_ACWY_bipartite_letter. pdf
January 2016

24. Shingles Initially introduced in 2013 Working towards vaccinating
all year olds
Live attenuated vaccine by IM or SC injection
Initially SC now IM preferred
See:
January 2016

25. 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

26. 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 fewer deaths and 11 000 fewer hospitalisations due to flu each year
January 2016

27. 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

28. 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: programme-qa-for-healthcare-professionals
January 2016

29. 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:
vaccination-in-pregnancy-advice-for-healthcare-professionals
PHE Pertussis in pregnancy guidance:
immunisation-for-pregnant-women-resources-and-training
January 2016

30. 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

31. 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

32. 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

33. Transfer of maternal antibodies Passive immunity
Administration of antibodies
January 2016

34. 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

35. January 2016

36. Lab confirmed pertussis cases in England 1998-2014
January 2016

37. Vaccination during pregnancy
January 2016

38. 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

39. 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

40. April 2015
January 2016

41. 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

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

43. Further reading/resources
Green Book online: against-infectious-disease-the-green-book
Algorithm for uncertain/incomplete vaccination status: of-individuals-with-uncertain-or-incomplete-immunisation- status
January 2016