Childhood Immunisations and Vaccinations Update

Vaccinations are the most effective, efficient and cost-effective intervention for health; they save over 2 million lives each year. The Hib vaccination has reduced cases from 800 cases to only 12. Due to vaccination, there is now less than one case of meningitis C each year in the UK. The pneumococcal vaccine saves on average about 50 lives each year.

It is now the HPA’s requirement that all nurses who immunise are to update their skills yearly with half a day’s worth of training (this might be formal training or self-directed study).

Immunoglobulins

Post-infection or for those at high risk, immunoglobulins can be given; these are short-acting, and are processed from blood plasma (therefore not suitable for JWs). Even years after a person’s booster vaccination is due, it is likely that there is some residual immunological memory, so that if the body comes into contact with a virus it can remember how to produce the antibodies required to fight it even though there is likely to be very little of the relevant antibody currently in the blood.

Live Vaccines and the Immuno-Compromised

Hib, pneumococcal, flu and Menvio (ACWY) should be offered to patients with splenectomies. Live vaccines such as yellow fever and MMR are to be used with caution in those who are immuno-compromised/suppressed. Two live vaccines can be given on the same day in opposing limbs, if they are not given at the same time, there needs to be a gap of 4 weeks between the two. This is also the case for adults receiving the MMR for the first time. The booster should then be given 4 weeks later. Separate MMR vaccines are not licensed in the UK and can cost up to £1000 for a course. The combined MMR, however, is licensed and well researched. The stigma surrounding the MMR remains to a certain extent although the claims made by Dr Wakefield have proved to be spurious; his research has since been discredited after it was found that he had falsified many of the results, and has therefore been struck off the register. There is absolutely no link between MMR and bowel conditions or autism. If an initial course of MMR was given separately, and the patient then requires a combined booster, two doses of combined MMR will need to be given, (starting the course from the beginning, as though no vaccine had been given at all). MMR can still be given to people with anaphylactic reaction to eggs. However, if the nurse or patient is concerned then this can be given in a controlled environment in hospital as an outpatient if preferred. Faith groups were consulted about the MMR combined vaccine, and none of them expressed any concern about the initial development of the vaccine which involved cells taken from a foetus aborted due to medical reasons. It is important to stress that the vaccines since then do not have any trace of this.

Population Immunity and Public Health

Population immunity (previously ‘herd’ immunity) can be achieved with an 80% take-up of the vaccine. This is possible with vaccines such as MMR, but not all vaccines will achieve population immunity such as tetanus (depends on the vector – if its person to person, population immunity can be achieved, if another vector is involved, then it cannot – such as tetanus as this is present in the soil).

Meningococcal B vaccine would deal with the biggest sector of meningitis. (This form of meningitis involves the non-blanching rash).

Adult cases of whooping cough are increasing. It can be treated with antibiotics only in the early stages, although mostly people do not realise they have pertussis until later. The childhood vaccine for this can wear off in later adulthood.

Changes and Current Best Practice

Research has shown that the cold chain is most often broken in general practice. Therefore it’s important to ensure that vaccines are put immediately into the fridge after receipt. It is also important to ensure that vaccines are kept in a pharmacy fridge, not a regular domestic fridge, as with a pharmacy fridge the temperature can be better regulated to ensure constant temperature throughout the appliance.

Paracetamol and ibuprofen can be given post vaccination if there are symptoms of feverish, although it is generally sufficient to take off surplus clothing and use distraction for children. Such medication was advised as prophylaxis, but this is no longer recommended because if it is given close to the time of vaccination, it can interact with the body’s production of antibodies, with the potential of making the vaccine less effective. It is advised that if necessary, medication can be given 4 hours post-vaccination, although most children will not need this at all.

Yellow fever can be given deep sub-cut with an orange needle (25G, 25mm). Either orange or blue needles can be used for vaccination. There is now no longer any need to draw back for IM injections, nor is there any need to swab skin with alcohol. If the skin is visibly dirty, then soap and water can be used. Alcohol swabs can affect MMR take-up.

There is no need to keep people on the premises post-vaccination; as long as they are well, they may leave.

If a person faints, check pulse – a regular faint will maintain a normal pulse, anyphylaxis can cause the pulse to be erratic.

Diphtheria, tetanus, pertussis, haemophilus influenzae type B, pneumococcus and meningococcal group C are bacteria, whereas polio, measles, mumps, rubella and papillomavirus types 16 and 18 are viruses. There is now research into whether men also should receive vaccination for human papillomavirus.

Changes in Vaccination Schedule

There is no such thing as overloading the immune system. This was an objection to the new guidance that the initial dose of MMR can now be given at 12-13 months along with the PCV and Hib/MenC vaccines. This change was brought in to improve take up of all these vaccines and reduce the number of visits to vaccine clinics for each child. It also needs to be considered that the third primary visit at 4 months includes 3 vaccines also.

Concerns about Vaccination

It’s also important to remember that more children end up in hospital for not having had vaccines than for reactions/complications with receiving them. The disease is more serious than any potential side effect of the vaccine.

Thimerosal was initially used in vaccines (derived from mercury) but is not used in UK vaccines any more, and also has not been linked with any harm to patients. More mercury is ingested from eating one tin of tuna than from having a lifetime of vaccinations.

Consent

Verbal consent must be received; implied consent is no longer legally sufficient. Consent must be verbal (or written) and well-informed. Check the patient/parent has no further questions or concerns before proceeding. Check that the person bringing in the child for vaccination has parental responsibility if brought in by a person other than the child’s mother. If parents disagree on whether or not to vaccinate, further advice should be sought. This can be escalated through the PCT. Adolescents under 16 can be considered Fraser/Gillick competent – if they consent to intervention this can be valid. If however, their parents consent and they do not, their lack of consent is not valid.

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