Important changes to the childhood immunisation programme

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Important changes to the childhood immunisation
programme
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Changes from 4th September 2006

• The addition of a pneumococcal conjugate vaccine
  (PCV) at 2, 4 and 13 months of age
• A dose of MenC vaccine at 3 and 4 months
• A booster dose of Hib and MenC vaccine (given as
  a combined Hib/MenC vaccine) at 12 months of age.
  

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The childhood immunisation schedule
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Why are these changes being made?

• to protect children lt 2 years of age who are at
  increased risk of pneumococcal disease
• to boost childrens protection against Hib and
  MenC infections through their early childhood
  years

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Facts about pneumococcal disease
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What is pneumococcal disease?

• Describes infections caused by the bacterium
  S.pneumoniae
• Over 90 serotypes identified
• 20 30 serotypes responsible for majority of
  disease
• 7 serotypes responsible for 82 of disease in
  children under 5 years of age

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Pneumococcal infection

• Major cause of serious disease
• meningitis, septicaemia and severe pneumonia
  (invasive pneumococcal disease - IPD)
• Less serious, but commoner diseases
• otitis media, milder pneumonia and bronchitis
  (non invasive)

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Severity of disease

• dependent on which part of the body is affected

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http//www.hpa.org.uk/infections/topics_az/pneumoc
occal/pneumo_powerpoint_2006.ppt366,4,Slide 4
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Pneumococcal infection

• Most common in
• the very young babies and children under 2
  years of age
• the very old over 65 years of age
• younger age groups with concurrent medical
  conditions

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Invasive pneumococcal disease rates by age per
100,000 population per year
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Pneumococcal infection

• 5000 cases of invasive pneumococcal disease (IPD)
  per year
• 530 children IPD lt 2 years (England Wales)
• Around 50 children lt 2yrs die from IPD per yr1
• 2 thirds from pneumococcal meningitis
• 50 who survive pneumococcal meningitis have
  disabilities2

1. IspahaniP, Slack RC, Donald FE, et al (2004)
Twenty-year surveillance of invasive pneumococcal
disease in Nottingham serogroups responsible and
implication for immunisation. Arch Dis Child 89
757-62 2. Bedford H, de Louvois J, Halket et al
(2001) Meningitis in infancy in England and
Wales follow-up at 5 years. BMJ 323 533-6
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Why change the Hib and MenC immunisation schedule?
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Evidence for changes

• Regular reviews of immunisation programmes to
  ensure all children have the best possible
  protection against preventable diseases
• Research shows that longer-term protection
  against Hib and meningococcal C disease is
  achieved by modifying the existing programme

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Evidence for changes

• Studies show two doses of MenC in the first year
  of life provides the same level of protection as
  three doses
• No additional or increased protection from giving
  three doses of MenC in the first year of life
• An additional dose in the second year of life
  gives longer-term protection against
  meningococcal C disease

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Evidence for changes

• Studies show an additional booster dose of Hib
  vaccine is needed in the second year of life to
  ensure that
• Hib disease levels remain low
• protection given to children continues well into
  their childhood

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What do the changes mean?

• No additional visits in the first year of life
• Infants will be offered different combinations of
  vaccines at the 2, 3 and 4 month visits
• Three injections will be offered to infants at 4
  months of age
• A new 12 month vaccination visit will be
  introduced

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Three injections for infants

• Its been done before during the Hib booster
  campaign 2003
• Infant anterolateral thigh can accommodate two
  injections along the length of the thigh
• At least 2.5cms (1 inch) apart so that reactions
  dont overlap
• Record which vaccine was injected at which point
  on limb
• Common practice in United States where e.g. DTaP,
  Hep B, Hib and PCV may all be given in same visit

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Simultaneous administration
DTaP/IPV/Hib
PCV
MenC
World Health Organisation (2004)
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Why keep PCV separate?

• To allow any localised reaction to be easily
  linked to the particular vaccine

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Order of injections given

• Prepare all 3 injections immediately prior to
  immunising
• 2 in 1 leg, PCV in other
• DH do not specify which leg
• Local decisions - may consider recommending
  always using the same leg

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Can the deltoid be used?

• It is not recommended that immunisations be
  given in the arm of infants under one year of age
  because
• Risk of hitting radial nerve
• Muscle mass not properly developed

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Can one vaccine be delayed?

• DH recommends all three vaccines be given at the
  same time to ensure children are fully protected
  from serious disease as early as possible
• Parents have the right to refuse one or all
  injections
• HCW should never recommend delaying
• Could leave HCW open to criticism if relevant
  vaccine preventable infection occurred in the
  interim

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12 month visit

• A single dose of Hib/MenC
• No catch-up for Hib/MenC booster
• Cannot be administered (at the moment) with PCV
  MMR at 13 months as no data to show compatibility

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13 month visit

• 1st MMR and booster PCV
• Cannot be administered (at the moment) with
  combined Hib/MenC vaccine as no data to show
  compatibility
• PCV catch-up for all children aged gt 2 months and
  lt 2 years of age

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Pneumococcal catch-up programme

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Children over 2 months and under 8 months of age
at the start of the programme.

• Children born 04.02.06 - 03.07.06
• (gt 2 months but lt 8 months of age)
• Two doses of PCV two months apart with booster at
  13 months

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Children over 8 months of age at the start of the
programme.

• Children born 04.08.05 - 03.02.06 (8 months
  13 months of age)
• A single dose of PCV at 13 months of age

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Children over 12 months of age at the start of
the programme.

• Children born 05.09.04 - 03.08.05 (gt 13 months -
  lt 2 years of age)
• A single dose of PVC

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At-risk children

• Asplenia or dysfunction of the spleen
• Chronic respiratory disease
• Chronic heart disease
• Chronic renal disease
• Chronic liver disease
• Diabetes
• Immunosuppression
• Cochlear implants
• CSF leaks
• lt 5s with previous history of invasive disease

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At-risk children

• It is important that at-risk children of any
  age up to 5 years receive a complete course of
  PCV vaccination as soon as possible (regardless
  of catch-up scheduling)

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At-risk children

• PCV routinely at 2, 4 and 13 months of age
• At-risk children lt 12 months of age2 doses of
  PCV (one month apart if necessary) before 12
  months and one at 13 months of age
• At-risk children gt 12 months and lt 5 years of age
  should be offered a single dose of PCV
• All at-risk children should be offered a single
  dose of pneumococcal polysaccharide vaccine (PPV)
  when they are two years of age or over and at
  least 2 months after the final dose of PCV

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At-risk children

• Children aged 2 months and under 5 years of age
  with asplenia, splenic dysfunction or who are
  immunocompromised, require a second dose 2 months
  after the first dose as they may have a
  sub-optimal immunological response to the first
  dose of vaccine
• All children lt 5 years with previous history of
  IPD should have PCV irrespective of previous
  vaccination history
• At-risk children presenting for first
  pneumococcal immunisation aged 5 years and over
  should be offered a single dose of PPV

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Vaccination of children with unknown or
incomplete vaccination status

• Following completion of the catch-up
  programme, children who have not completed the
  routine programme require
• Children lt 12 months of age
• 2 doses of PCV, 2 months apart and further dose
  at 13 months of age
• Children gt 12 months and lt 2 years of age
• should be offered a single dose of PCV

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Supplies

• Week commencing 7th and 14th August 2006first
  allocated delivery of two week supply on usual
  delivery date
• Week commencing 21st and 28th Augustno
  deliveries
• Week commencing 4th September 2006 campaign
  starts
• Week commencing 4th and 11th September
  2006second allocated delivery of two week supply
• Free ordering from midday 13th September 2006

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Further information

• CMO Letters
• www.dh.gov.uk/PublictionsAndStatistics/LettersAndC
  irculars/DearColleagueLetters/fs/en
• www.dh.gov.uk/AboutUs/MinistersAndDepartmentLeader
  s/ChiefMedicalOfficer/CMOPublications/CMOLetters/f
  s/en
• NHS Immunisation website
• www.immunisation.nhs.uk
• The Green Book
• www.dh.gov.uk/PolicyAndGuidance/HealthAndSocialCar
  eTopics/GreenBook/fs/en