This site is intended for health professionals only

Update: UK child immunisation programme

Over the years, the UK immunisation programme has continually evolved to meet expectations, creating a culture in which vaccines, both established and new, are regularly reviewed and amended to ensure increased efficacy of vaccines and better protection for the public. To ensure the immunisation programme continues to meet the current demands and public expectations, the Joint Committee on Vaccination and Immunisation (JCVI) has recommended a number of changes to the schedule for 2013. 

Rotavirus 

In July 2013, a new vaccine to protect infants against rotavirus will be introduced into the infant immunisation programme. Rotavirus is the leading cause of gastroenteritis in infants and young children.1 Rotavirus infection in the UK is seasonal, occurring mostly from January to March. People of any age can be infected but most infections occur in young children, who will develop at least one episode of rotavirus gastroenteritis by five years.2 In most cases, symptoms resolve within three to eight days, although severe infections can result in hospitalisation, mainly for rehydration. In England and Wales (E&W), rotavirus gastroenteritis is responsible for around 130,000 GP consultations and 13,000 hospitalisations every year.3,4,5 Fortunately, the infection is rarely fatal, with only three to four annual deaths potentially attributable to rotavirus in E&W.6 

Two oral rotavirus vaccines have been licensed, Rotateq® and Rotarix®. UK infants will receive Rotarix® (GSK Biologicals) at two and three months of age. Rotarix® contains a live attenuated human rotavirus strain and is >85% effective at protecting against severe rotavirus gastroenteritis in

The symptoms of IS are often non-specific and include excessive crying, irritability, abdominal distension, drawing legs up, vomiting and blood in the stool. IS can be life-threatening and parents should be advised to seek prompt medical attention if their infant becomes unwell following vaccination. Overall, the benefits of vaccination in preventing the consequences of rotavirus infection outweigh the small potential risk of IS in young children. An extensive surveillance programme is in place to monitor the effectiveness and safety of the rotavirus vaccination programme in E&W. 

Influenza 

Influenza, commonly known as 'the flu,' is a highly contagious infection of the respiratory tract caused by influenza viruses. Of the three known types (A, B and C), influenza A and B are responsible for most clinical Illness. Most infections in healthy children and adults are self-limiting and resolve within two to seven days. Occasionally, however, serious complications can occur and include pneumonia and meningo-encephalitis, which may result in death. The risk of serious illness is higher in young children particularly

Most cases in the UK tend to occur during an eight to 10 week period during winter. The timing, extent and severity of influenza will depend on the circulating influenza strains. The surface proteins of the influenza viruses are continually changing, often resulting in minor changes in the circulating viruses from one season to another, with occasional larger changes occurring periodically and sometimes resulting in epidemics. Immunity from previous circulating influenza strains may not protect completely against new strains, therefore, necessitating annual vaccination. The WHO monitors the epidemiology of influenza viruses globally and makes annual recommendations about strains to be included in vaccines for the forthcoming winter. Currently, most influenza vaccines are trivalent, containing two influenza A and one B subtype, although a quadrivalent vaccine had been licensed recently

Influenza immunisation has been recommended in the UK since the late 1960s, with the aim of directly protecting those at higher risk of severe influenza.11 In 2000, the programme was extended to include all people aged ≥65 years and, in 2010, pregnant women were also offered the vaccine. In July 2012, the Joint Committee on Vaccination and Immunisation (JCVI) recommended an extended influenza vaccination programme for all children aged two to 16 years (~9 million children) annually. Although such a programme is likely to be very costly, it is expected to result in 11,000 fewer hospitalisations and 2,000 fewer influenza-related deaths each year, even if just 30% of children receive the vaccine. By vaccinating children, it is anticipated that adults will also benefit through herd protection, since children are the main reservoirs for the virus. 

Due to the seasonal nature of influenza, the vaccine will need to be given during a six to eight week period. However, a number of questions have to be answered before this programme is fully implemented, mainly related to how best to deliver such a large-scale programme so rapidly and on an annual basis. It is, therefore, planned that the programme will be rolled out in phases. In September 2013, the influenza vaccine will be offered to two-year-olds only (~650,000 children). Additionally, a number of pilot programmes will be assessed in primary and pre-school children this year and in secondary school next year, with plans for a full rollout in 2015.12

The vaccine to be used in the childhood programme is Fluenz® (Astra Zeneca), a live and attenuated intranasal vaccine that is licensed for two to 17-year-olds.13 The vaccine is immunogenic and safe in children, with several studies reporting higher effectiveness compared to inactivated influenza vaccines. Since Fluenz® does not require an injection, it should be more acceptable to children and parents alike. As with all live vaccines, it cannot be given to children with immune deficiency and is also contra-indicated in severe asthma or severe egg allergy.13 

Meningococcal capsular group C

Neisseria meningitidis is a major cause of meningitis and septicaemia worldwide. The incidence of meningococcal disease is highest in young children, followed by adolescents, particularly when they enter higher education in a college or university setting. Of the 12 known capsular groups, A, B, C, W and Y are responsible for most invasive infections. The introduction of routine meningitis C conjugate vaccine (MenC) in 1999 has led to virtual elimination of meningitis C in the UK, with capsular group B (meningitis B) currently responsible for almost 90% of all invasive meningococcal infections.14,15  Until September 2006, infants received the MenC conjugate vaccine at two, three and four months with no booster in the second year of life. Subsequent studies, however, demonstrated rapid waning of protective antibodies with this schedule.16-19 At the same time, clinical trials demonstrated that the protection provided by two MenC doses in infancy was comparable to three doses.20 From September 2006, therefore, the schedule was amended to include two MenC doses at three and four months, followed by a 12-month Hib/MenC booster with Menitorix® (GSK Biologicals).  Although meningitis C is rare in the UK, recent studies have shown that most children who were only immunised in infancy (and are now reaching adolescence) currently do not have protective antibodies against meningitis C.21 Moreover, a recent clinical trial found that a single MenC dose at three months of age was sufficient to protect infants until they received their routine 12-month booster.22 As a consequence, the following changes have been made to the MenC vaccination programme: 

 - Infant programme: from 1 June 2013, infants will receive a single dose of Menjugate Kit® or Neisvac-C® at three months followed by Menitorix® at 12 months. 

 - Teenage booster: a booster dose of MenC vaccine (Meningitec® or Menjugate kit®) will be introduced during the 2013-14 academic year and will be offered to adolescents at around 14 years alongside the teenage tetanus, diphtheria and polio vaccine (Td/IPV). 

 - New starters at universities: a time-limited catch-up programme for older adolescents who may be partially or incompletely vaccinated against meningitis C will commence in 2014-15 due to the increased risk of acquiring the infection while at university for the first time. This programme is likely to remain in place only until those eligible for the teenager booster reach university age.

MMR catch-up programme

In April 2013, a national measles, mumps and rubella (MMR) catch up programme was announced with the aim of increasing the uptake of MMR vaccine in as many partially or unvaccinated 10-16 years olds as possible. The programme was introduced in response to a national measles outbreak in Wales and a significant increase in laboratory-confirmed cases in England.23 In 2012, there were 1,913 laboratory-confirmed cases, the highest recorded since 1994. The age distribution of cases in 2013 showed a peak among 10-14 year-olds, with the highest attack rates in the cohort born during 1997-2006. These children may have missed their MMR vaccine because of the ill-founded MMR scare during that time. 

The MMR catch up programme continues to be implemented throughout the UK and was recently extended to offer protection to any individual over one year of age who may not have received two doses of the MMR vaccine. Healthcare providers, including NHS Occupational Health departments, have been encouraged to review all their records to ensure that all patients/parents/staff have received two doses of the MMR vaccine, irrespective of age and any history of previous measles, mumps or rubella infection. 

Pertussis temporary maternal vaccination programme

In 2012, a national outbreak of pertussis infection was declared in the UK following a significant increase in cases since mid-2011. The outbreak was the largest seen in the UK for over a decade, resulting in 14 infant deaths.24 Infants aged

Conclusion

This year represents an exciting stage for the national childhood immunisation programme, with changes to existing vaccination schedules and the introduction of new vaccines. This year will also see the introduction of a new shingles vaccination programme for adults aged 70 and 79 years which will commence in September 2013. Overall, these changes are likely to have a significant impact on the burden of infectious diseases across all ages in the coming years through direct and indirect protection. Ongoing surveillance of vaccine-preventable diseases must remain a key priority in order to monitoring the long-term impact of the national immunisation programme.

 

References

1. NHS Choices. www.nhs.uk/conditions/Rotavirus-gastroenteritis/Pages/Introduction.aspx " target="_blank">Gastroenteritis in Children. 

2. Glass RI, Parashar UD, Bresee JS et al. Rotavirus vaccines: current prospects and future challenges. Lancet 2006;368(9532):323-32.

3. Djuretic T, Ramsay M, Gay N et al. An estimate of the proportion of diarrhoeal disease episodes seen by general practitioners attributable to rotavirus in children under 5 y of age in England and Wales. Acta Paediatr Suppl 1999;88(426): 38-41. 

4. Ryan MJ, Ramsay M, Brown D et al. Hospital admissions attributable to rotavirus infection in England and Wales. J Infect Dis 1996;174(Suppl 1):S12-8. 

5. Jit M, Edmunds WJ. Evaluating rotavirus vaccination in England and Wales. Part II. The potential cost-effectiveness of vaccination. Vaccine 2007;25(20):3971-9.

6. Jit M, Pebody R, Chen M et al. Estimating the number of deaths with rotavirus as a cause in England and Wales. Hum Vaccin 2007;3(1):23-6.

7. Tate JE, Cortese MM, Payne DC, Curns AT, Yen C, Esposito DH, Cortes JE, Lopman BA, Gentsch JR, Parachar UD. Uptake, impact, and effectiveness of rotavirus vaccination in the United States: review of the first 3 years of postlicensure data. Pediatr Infect Dis J 2011;30(1 Suppl):S56-60.

8. Gay N, Ramsay M, Waight P. Rotavirus vaccination and intussusception. Lancet 1999;354:956. 

9. Department of Health, 2013 Immunisation against infectious diseases: Rotavirus. TSO Publishing, Crown Copyright. 

10. Rotarix. Summary of Product Characteristics (SPC)

11. Department of Health. 2013. Immunisation against infectious diseases: Influenza. TSO Publishing, Crown Copyright. 

12. Department of Health. 2013. Press Release: Millions more protected against disease through improved vaccination programme.

13. Fluenz nasal spray suspension Influenza vaccine (live attenuated, nasal) Summary of Product Characteristics (SPC).

14. Department of Health, 2013. Immunisation against infectious diseases: Meningococcal C. TSO Publishing, Crown Copyright. 

15. Campbell H, Andrews N, Borrow R, et al. Updated post-licensure surveillance of meningococcal C conjugate vaccine in England and Wales: effectiveness, validation of serological correlate of protection and modelling predictions of the duration of herd immunity. Clin Vaccine Immunol 2010;17:840-7. 

16. Campbell H et al. Meningococcal C conjugate vaccine: the experience in England and Wales. Vaccine 2009;27(Suppl 2):B20-9.

17. Borrow R et al. Kinetics of antibody persistence following administration of a combination meningococcal serogroup C and Haemophilus influenza type b conjugate vaccine in healthy infants in the United Kingdom primed with a monovalent meningococcal serogroup C vaccine. Clin Vaccine Immunol 2010;17: 154-9. 

18. Kitchin N et al. Antibody persistence in UK pre-school children following primary series with an acellular pertussis-containing pentavalent vaccine given concomitantly with meningococcal group C conjugate vaccine, and response to a booster dose of an acellular pertussis-containing quadrivalent vaccine. Vaccine 2009;27:5096-102.

19. Perrett KP et al. Antibody persistence after serogroup C meningococcal conjugate immunisation of United Kingdom primary-school children in 1999-2000 and response to a booster: a phase 4 clinical trial. Clin Infect Dis 2010;50:1601-10.

20. Southern J, Borrow R, Andrews N, Morris R, Waight P, Hudson M, Balmer P, Findlow H, Findlow J, Miller E. Immunogenicity of a reduced schedule of meningococcal group C conjugate vaccine given concomitantly with the Prevenar and Pediacel vaccines in healthy infants in the United Kingdom. Clin Vaccine Immunol 2009;16:194-9. 

21. Ishola DA Jr, Borrow R, Findlow H, Findlow J, Trotter C, Ramsay ME. Prevalence of serum bactericidal antibody to serogroup C Neisseria meningitidis in England a decade after vaccine introduction. Clin Vaccine Immunol 2012;19:1126-30. 

22. Findlow H, Borrow R, Andrews N, Waight P, Sheasby E, Matheson M, England A, Goldblatt D, Ashton L, Findlow J, Miller E. Immunogenicity of a single dose of meningococcal group C conjugate vaccine given at 3 months of age to healthy infants in the United Kingdom. Pediatr Infect Dis J 2012;31:616-22.

23. Public Health England. MMR catch up programme. 2013. 

24. Department of Health. Temporary programme of pertussis vaccination of pregnant women. CMO letter. 21st September 2012. 

25. Joint Committee on Vaccination and Immunisation. Update on prenatal pertussis immunisation programme. 2013.