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Immunizations - childhood vaccination programme - Management
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Which children require additional immunization against pneumococcal disease, tuberculosis, hepatitis B, chickenpox, or influenza?

  • Pneumococcal disease:
      • Children over 2 years of age with comorbidities such as asplenia or splenic dysfunction; chronic heart, renal, liver, or respiratory disease (but not non-severe asthma); diabetes; or immunosuppression, may require additional immunization with the pneumococcal polysaccharide vaccine (PPV — Pneumovax II®).
      • Children aged 1–2 years of age with the above comorbidities who have completed their three doses of Prevenar® should be offered an additional dose of Prevenar 13®. For further information see the CKS topic on Immunizations - pneumococcal.
  • Influenza: additional immunization to protect against influenza may be required in children over 6 months of age with comorbidities such as chronic heart, renal, liver, or respiratory disease (including asthma), or who have immunosuppression. For further information, see the CKS topic on Immunizations - seasonal influenza.
  • Tuberculosis (TB): vaccination with Bacillus Calmette–Guérin (BCG) is now targeted at children most at risk. Typically this is children from countries where TB is prevalent, or children who have a parent of grandparent from a country where TB is prevalent.
  • Hepatitis B: children born to a mother or living with parents who are known to have hepatitis B, or whose parents are intravenous drug users, should be vaccinated. Children who receive regular blood transfusions (e.g. for haemophilia) should also be vaccinated.
  • Chickenpox: vaccination is recommended for susceptible children who are contacts of people who are immunocompromised (e.g. they have a sibling with leukaemia or parent undergoing chemotherapy).
Additional information
  • This is a summary of the present guidelines and is not comprehensive. For further information, consult the 'Green Book' at www.dh.gov.uk.
  • Adults over 65 years of age require immunization against pneumococcal disease or influenza, as do some adults with chronic diseases. For further information, see the CKS topics on Immunizations - pneumococcal and Immunizations - seasonal influenza.
  • Other vaccinations may be required if the child is due to travel to countries where diseases not usually present in the UK are endemic, including other strains of meningitis. For further information, see the CKS topic on Immunizations - travel.
Basis for recommendation

These recommendations are based on government policy as discussed in Immunisation against infectious disease (the 'Green Book'), published by the Department of Health [DH, 2006d].

  • Vaccinations against influenza, tuberculosis, hepatitis B, and chickenpox are not part of the Childhood Immunization Programme, but are recommended when:
    • The child is at greater than normal risk of the disease.
    • The consequences of infection to the child are greater than normal.
    • The child is in contact with a person for whom infection would pose a greater than normal risk.
  • Additional vaccination with the pneumococcal polysaccharide vaccine (PPV) and the new pneumococcal conjugate vaccine (Prevenar 13®) is required in some children who are at high risk of pneumococcal disease, to provide immunity into adulthood, principally against pneumococcal pneumonia [Salisbury, 2010].

How should I immunize children at high risk of pneumococcal disease?

  • Give an additional dose of PPV on or after the child's second birthday. For children with no spleen or splenic dysfunction, re-vaccination with PPV is recommended every 5 years.
  • For children aged 1–2 years, offer an additional dose of Prevenar 13® (pneumococcal conjugate vaccine) to those who have already completed the course of three doses of Prevenar®.
  • See the CKS topic on Immunizations - pneumococcal for further information.
Basis for recommendation

These are pragmatic recommendations that represent good clinical practice.

  • Many parents find the process of having their children immunized distressing. Explaining the benefits of vaccination and giving reassurance about the limited nature of the adverse effects should help allay fears.
  • CKS could find no controlled trials that investigated the efficacy of paracetamol or ibuprofen in reducing pain or fever following vaccination.
    • One systematic review, including a randomized controlled trial, found evidence that the prophylactic use of paracetamol or ibuprofen was effective in relieving post-vaccination symptoms in children receiving diphtheria-tetanus-whole pertussis (DTwP) vaccine [Manley and Taddio, 2007]. However, the review found no evidence that analgesia relieved adverse effects caused by diphtheria-tetanus-acellular pertussis vaccine (DTaP).
    • As paracetamol and ibuprofen have been shown to reduce fever and pain in conditions such as the common cold and influenza [Eccles, 2006], it can be reasonably extrapolated that they may be effective in relieving these symptoms on an 'as required' basis after vaccination.

How should I immunize children at high risk of complications from influenza?

  • Immunize the child annually between September and early November using a thiomersal-free preparation, where possible. For further information, see the CKS topic on Immunizations - seasonal influenza.
Basis for recommendation

This recommendation is based on government policy as discussed in Immunisation against infectious disease (the 'Green Book'), published by the Department of Health [DH, 2006d].

How should I immunize children at risk of tuberculosis?

  • Vaccination against tuberculosis is performed by trained staff in a designated centre. Tuberculin testing is required before administration of the Bacillus Calmette–Guérin vaccine (BCG) in children older than 6 years of age. A positive response may indicate the presence of disease, previous infection, or a previous BCG.
    • There is no need to vaccinate people with a positive test as this may provoke adverse reactions.
    • Referral to a chest specialist should be considered.
Basis for recommendation

These are pragmatic recommendations based on standard clinical practice and information in the 'Green Book', published by the Department of Health [DH, 2006a].

How should I immunize children at risk of hepatitis B?

  • A variety of schedules and doses are used depending on the child's age, response to the vaccine, and desired speed of response, but typically three doses, with or without a fourth booster, are used. For details more information, see the CKS topic on Hepatitis B.
Basis for recommendation

These are pragmatic recommendations as discussed in Immunisation against infectious disease (the 'Green Book'), published by the Department of Health [DH, 2006e].

  • Five vaccines are licensed for the prevention of hepatitis B in the UK; three single vaccines (Engerix®, Fendrix®, and HBvaxPRO®); and two with combined protection against hepatitis A and B (Twinrix Adult® and Twinrix Paediatric®).

How should I immunize children against chickenpox?

  • The schedule depends on the child's age:
    • Children 1–13 years of age: give a single dose of varicella vaccine (Varilrix® or Varivax®).
    • Children and adults 13 years of age and over: give two doses of varicella vaccine, spaced 4–8 weeks apart.
Basis for recommendation

These are pragmatic recommendations as discussed in Immunisation against infectious disease (the 'Green Book'), published by the Department of Health [DH, 2006c].

How should I administer vaccines in children requiring additional immunization?

  • Obtain written or verbal consent from a person with parental responsibility, at the time of vaccination.
    • Adults over 18 years of age are presumed to be competent to consent to treatment provided they can comprehend and retain the information they are given, they believe it, and they can consider the facts and make an informed decision.
    • Young people 16 and 17 years of age are also presumed to be competent using the same criteria as older adults.
    • Younger people can also give consent if they fully understand what is involved, but ideally someone with parental responsibility should also be involved.
    • Consent may be given in writing, orally, or implied by cooperation.
  • Check that the vaccine is correct and has not expired. Wash the site with soap and water only if it is visibly dirty.
  • Routes of administration:
    • Vaccines for hepatitis B, influenza and PPV are usually administered intramuscularly using a 23-gauge (blue) or 25-gauge (orange) needle, unless the child has a bleeding disorder (in which case use the subcutaneous route to reduce the risk of bleeding).
      • For children less than 1 year of age, use the anterolateral aspect of the thigh.
      • For children over 1 year of age, use the deltoid muscle.
    • The varicella vaccine is given by deep subcutaneous injection.
    • BCG is usually given by intradermal injection at designated centres.
  • Record the site of administration. If an additional vaccine is required on the same day, use separate limbs if possible, or inject at sites at least 2.5 cm apart.
  • After administration, ensure any bleeding has stopped and check the child has no symptoms of anaphylaxis before they leave.
    • Anaphylaxis is extremely rare, and usually becomes apparent within 10 minutes. By the time the site has been checked for bleeding and documentation has been completed, most reactions will have become apparent.
    • It is prudent to have a final assessment of the person before letting them leave the premises.
Basis for recommendation

These recommendations are based on good clinical practice and are consistent with recommendations given in the 'Green Book' [DH, 2006d].

  • Getting consent before vaccination fulfils both a clinical function (to foster trust and cooperation with parents or guardians) and a legal function, namely to ensure that a person's right to autonomy has been addressed in order to prevent a charge of battery [Vaccine Administration Task Force, 2001].
  • Over the age of 1 year, either the deltoid muscle or the anterior aspect of the thigh can be used for administration.
    • The deltoid muscle is preferred for most people as it is convenient, providing easy access.
    • The gluteal muscle should be avoided, however. It is unlikely the needle will penetrate through adipose tissue into the muscle, and this may cause a poor immunological response to the vaccine. In addition, there is a risk of damage to underlying structures such as the sciatic nerve.

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