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Changes to the childhood immunisation programme

The aim of any immunisation programme is the protection of the individual, their family and community from preventable infectious diseases. The decision to introduce new vaccines and the modification of the existing programme was made on the advice of the Joint Committee on Vaccination and Immunisation, based on scientific evidence from properly conducted studies. Groups that lack scientific knowledge and misrepresent the safety and effectiveness of the national childhood immunisation programme may jeopardise these changes, and it is important for all nurses in primary care to understand the evidence that underpin changes and to support immunisation as a safe and effective medical intervention.

The changes
The following changes to the routine childhood
programme were introduced on 4 September 2006:(1)

  • Pneumococcal conjugate vaccine (PCV [Prevenar®; Wyeth]) for all children at two and four months of age with a booster dose at 13 months age. Previous recommendations for at-risk children under five years of age still apply, and specific information can be found in The Green Book.(2)
  • A catch-up programme for all children up to two years of age who are at most risk from pneumococcal infection.
  • The amendment of the MenC schedule to give two doses of vaccine in the first year of life and a booster dose in the second year.
  • The addition of a booster dose of Hib vaccine in the second year of life.

The booster doses of MenC and Hib will be given as part of a combined Hib/Men C vaccine (Menitorix™; GlaxoSmithKline) only for those reaching 12 months of age from the implementation date.

Pneumococcal infection
Pneumococcal infection is most common in babies, young children and the elderly (see Figure 1) and is caused by Streptococcus pneumoniae. More than 90 serotypes have been identified, of which seven are responsible for 82% of disease in children under five years of age. The infection can vary from commoner, less serious diseases, such as otitis media, milder pneumonia and noninvasive bronchitis, to major causes of invasive pneumococcal disease (IPD), including meningitis, septicaemia and severe pneumonia.

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As there is worldwide evidence  of antibiotic resistance to S pneumoniae, protection by immunisation becomes increasingly important.(4)
Each year, around 5,000 cases of invasive pneumococcal disease occur in England and Wales, of which around 530 are in children under two years and of which one-third present as pneumococcal meningitis. Estimates vary, but around 50 children under two years of age will die from invasive pneumococcal disease each year,5 two-thirds of which are from pneumococcal meningitis.1 Of those who survive pneumococcal meningitis, up to 50% will be left with permanent disabilities, including deafness, cerebral palsy and blindness.(6)

Meningococcal C
Meningococcal groups B and C used to account for the majority of meningococcal cases in the UK. Following the MenC vaccine campaign in 1999, the number of laboratory-confirmed group C cases fell by over 90% in those age groups immunised and by two-thirds in other age groups because of herd immunity.(7,8)
Research has shown that two doses of MenC vaccine provide the same level of protection as three doses in the first year of life.(9) The introduction of a MenC booster as part of the combined Hib/MenC in the second year of life will extend protection against this serious disease through the early childhood years. As yet there is no vaccine against meningococcal B infection.

Haemophilus influenzae type B (Hib)
Haemophilus influenzae type B (Hib) was a common cause of bacterial meningitis in children under five  before the introduction of the vaccine in 1992. The public health success of this programme has resulted in a marked reduction in Hib disease in children, particularly in cases and deaths from Hib meningitis. However, from 1998, a gradual rise in Hib disease was detected, which was successfully reversed through the Hib catch-up programme in 2003, so that rates of the disease are now back to extremely low levels.(10) To ensure that protection against Hib disease is maintained throughout early childhood, and to reduce the risk of a further resurgence of the disease in future, a routine Hib booster dose has been introduced in the second year of life as a combined Hib/MenC vaccine.

Administration of the new vaccines
Infants will be offered different combinations of vaccines at the two- to four-month visits, with three injections at four months of age. This means that there will be no additional visits in the first year of life.
All vaccines for infants should be administered into the anterolateral aspect of the thigh. WHO recommends that the deltoid should not be used in children under 15 months of age, because of the radial nerve and the muscle mass not being properly developed.(11) Where three immunisations are recommended, the anterolateral aspect of the thigh in infants aged four months can easily accommodate two injections 2.5cm apart. The DH recommends that PCV be administered separately, only because it is a new vaccine and to allow any
localised reaction to be easily linked to the vaccine.
The DH recommends all three vaccines at four months of age be given at the same time to ensure children are fully protected from serious disease as early as possible. Although parents have the right to refuse one or all injections, healthcare workers should never recommend delaying as this could leave them open to criticism if relevant vaccine-preventable infection occurred in the interim.
A new 12-month vaccination visit will be introduced for the administration of the Hib/MenC and at the 13-month visit; the PCV booster will be offered at the same time as MMR. Because there are no data to show efficacy of the vaccines when administered simultaneously, Hib/MenC, PCV and MMR cannot be administered at the same time.
A child who has not completed the primary course (and is under one year of age) should have the outstanding doses at appropriate intervals (see Table 1). A child aged one and under two years of age should have a single dose of PCV.(12)

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Logistics
Nurses involved in all aspects of childhood immunisations can help reduce parental anxiety by having a good knowledge of the reasons for changes to the schedule and that the new pneumococcal vaccine has been successfully used in other countries. Information delivered in a confident manner will help parents make informed choices and reduce their anxiety.
Surgeries can order the vaccines freely, but should follow the recommendations for ordering as described in the new chapter three of The Green Book - "Storage, distribution and disposal of vaccines".(13)
Prevenar and Menitorix, as newly licensed vaccine products, are subject to enhanced surveillance. They have "black triangle" status, and all serious and nonserious suspected adverse drug reactions for both adults and children should be reported to the Commission on Human Medicines (CHM) via the Yellow Card reporting scheme available in the British National Formulary or www.yellowcard.gov.uk or by phone - 0808 100 3352.

Conclusion
In conclusion, the continued commitment and hard work of primary healthcare teams will ensure the success of these changes, with a consequent reduction of morbidity and mortality from these vaccine-presentable diseases.

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References

  1. Department of Health. Important changes to the childhood immunisation programme. Available from:
    http://www.dh.gov.uk/AboutUs/MinistersAndDepartmentLeaders/ChiefMedicalO...
  2. Department of Health. The Green Book. Chapter 25. Pneumococcal. 2006. Available from:
    http://www.dh.gov.uk/assetRoot/04/13/82/16/04138216.pdf
  3. Health Protection Agency. Centre for infections. Available from: http://www.hpa.org.uk
  4. Appelobaum PC. Antimicrobial resistance in Streptococcus pneumoniae: an overview. Clin Infect Dis 1992;15:77-83.
  5. Ispahani P, Slack RC, Donald FE, Weston VC, Rutter N. Twenty-year surveillance of invasive pneumococcal disease in Nottingham: serogroups responsible and implications for immunisation. Arch Dis Child 2004;89:757-62.
  6. Bedford H,  de Louvois J, Halket S, Peckham C, Hurley R, Harvey D. Meningitis in infancy in England and Wales: follow-up at age 5 years. BMJ 2001;323:533-6.
  7. Trotter CL, Andrews NJ, Kaczmarski EB, Miller E, Ramsay ME. Effectiveness of meningococcal serogroup C conjugate vaccine 4 years after introduction. Lancet 2004;364(9431):365-7.
  8. Trotter CL, Ramsay ME, Slack MP. Rising incidence of Haemophilus influenzae type b disease in England and Wales indicates a need for a second catch-up vaccination campaign. Commun Dis Public Health 2003;6(1):55-8.
  9. Southern J, Crowley-Luke A, Borrow R, Andrews N, Miller E. Immunogenicity of one, two or three doses of a meningococcal C conjugate vaccine conjugated to tetanus toxoid, given as a three-dose primary vaccination course in UK infants at 2, 3 and 4 months of age with acellular pertussis containing DTP/Hib vaccine. Vaccine 2006;24:215-9.
  10. McVernon J, Andrews N, Slack MPE, Ramsay ME. Risk of vaccine failure after Haemophilus influenzae type B (Hib) combination vaccines with acellular pertussis. Lancet 2004;361:1521-3.
  11. WHO. Ensuring safe injections. Available from:
    http://www.who.int/vaccines-documents/iip/PDF/Module4.pdf
  12. Health Protection Agency. Frequently asked questions about the New Immunisation Schedule. Available from:http://www.hpa.org.uk
  13. Department of Health. Storage, distribution and disposal of vaccines. Available from:
    http://www.dh.gov.uk/assetRoot/04/13/77/92/04137792.pdf