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Immunizations - childhood vaccination programme - Management
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What is the immunization schedule for children less than 1 year of age?
- At 2 months of age — one dose of vaccine for diphtheria, tetanus, pertussis, polio, and H. influenzae type b (DTaP/IPV/Hib — Pediacel®); and one dose of pneumococcal conjugate vaccine (PCV — Prevenar®).
- At 3 months of age — one dose of DTaP/IPV/Hib; and one dose of vaccine for group C meningococcal disease (MenC — Meningitec®, Menjugate Kit®, or NeisVac-C®).
- At 4 months of age — one dose of DTaP/IPV/Hib; one dose of PCV; and one dose of MenC.
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].
- Although the license for MenC states that doses should be given 2 months apart, evidence from UK studies suggest that a one-month interval provides adequate immunogenicity, and this is the schedule recommended by the Department of Health.
- The diseases prevented by vaccines used in the Childhood Immunization Programme cause (or have caused in the past) extensive morbidity and mortality. In most cases, the incidence of these diseases has been greatly reduced by use of vaccines, and in some cases diseases have been virtually eradicated in the UK.
- The quality of evidence to support the use of vaccines depends largely on when the vaccine was introduced. The efficacy of vaccine components that have been in use for decades, for instance, is usually evident by the marked fall in incidence of the disease it protects against compared with the period prior to the vaccine's introduction. Newer vaccines are more likely to have evidence from controlled trials to support their effectiveness and safety.
- For further information, see individual diseases in Supporting evidence.
What advice should I give to parents of children less than 1 year of age?
- Explain the benefits of vaccination to the parents, in particular that it helps prevent serious illness in children, especially potentially severe disease such as meningitis, whooping cough, and tetanus.
- Reassure that vaccinations are safe, and serious adverse effects are very rare. Pain, swelling, and reddening at the site of injection are most common and systemic effects, should they occur, are usually limited to mild fever.
- If pain or fever is problematic, advise paracetamol or ibuprofen.
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 found 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.
What should I do if a child less than 1 year of age has missed doses?
- Complete the full primary course of immunizations without delay (doses already given do not need to be repeated). This consists of:
- Three doses of DTaP/IPV/Hib spaced at least 1 month apart.
- Two doses of PCV spaced 2 months apart.
- Two doses of MenC spaced 1 month apart.
- For the latest information on announcements about catch-up recommendations from the chief medical officer, see www.immunisation.nhs.uk.
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].
- It is appropriate for children under 1 year of age to receive primary vaccination if they present late or have missed doses.
- Although the license for MenC states that doses should be given 2 months apart, evidence from UK studies suggest that a one-month interval provides adequate immunogenicity, and this is the schedule recommended by the Department of Health.
- In the chapter entitled The UK immunisation programme, the 'Green Book' states that 'If any course of immunisation is interrupted, it should be resumed and completed as soon as possible. There is no need start any course of immunisation again' [DH, 2006b].
What should I do if a child less than 1 year of age has not been immunized or has an unknown immunization status?
- If the child presents without a reliable immunization history, attempt to clarify what vaccines they have had wherever possible.
- If the history cannot be clarified, it should be assumed that they have not been vaccinated, and the following vaccinations given (to be completed before the age of 1 year):
- Three doses of diphtheria, tetanus, pertussis, poliomyelitis, Haemophilus influenzae type b vaccine (DTaP/IPV/Hib — Pediacel®), spaced 1 month apart.
- One dose of meningococcal disease group C booster vaccine (MenC — Meningitec®, Menjugate Kit®, or NeisVac-C®), separated by 2 months.
- Two doses of pneumococcal conjugate vaccine (PCV — Prevenar 13®) separated by 2 months.
Basis for recommendation
These are pragmatic recommendations as discussed in Immunisation against infectious disease (the 'Green Book'), published by the Department of Health [DH, 2006d].
How should I administer vaccines in a child under 1 year of age?
- Obtain written or verbal consent from a person with parental responsibility at the time of vaccination.
- A person with parental responsibility should give consent for the vaccination on behalf of the child.
- 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 if it is visibly dirty.
- Administer the vaccine by intramuscular injection into the anterolateral aspect of the thigh 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).
- If the child is anxious or nervous, several measures can be tried. These include adopting a calm, sympathetic approach, giving full explanations (a common misperception is that an immunization jab is the same as a blood test), preparing and administering the vaccine out of sight of the child, and using distraction techniques.
- Record the site of administration. If two vaccines are required on the same day, use separate legs 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 child 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].
- The site of administration depends on the child's age:
- The anterolateral aspect of the thigh is appropriate in children less than 1 year of age as the deltoid muscle is not considered to be well-enough developed for intramuscular injection (over the age of 1 year, either the deltoid muscle or the anterior aspect of the thigh can be used for administration, but the deltoid is generally more convenient).
- The gluteal muscle should be avoided. The needle may not 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.
Prescriptions
Diphtheria, tetanus, pertussis/polio/Hib vaccine (DTaP/IPV/Hib)
Age from 2 to 11 months
Diphtheria, tetanus, pertussis/polio/Hib (Pediacel®)
Pediacel vaccine suspension for injection 0.5ml vials
Give 0.5ml by intramuscular injection.
Supply 1 0.5ml vial.
Pneumococcal conjugate vaccine (PCV)
Age from 2 to 11 months
Pneumococcal conjugate vaccine (Prevenar 13®)
Prevenar 13 vaccine suspension for injection 0.5ml pre-filled syringes
Give 0.5ml by intramuscular injection.
Supply 1 0.5ml vial.
Meningococcal group C vaccine (MenC)
Age from 3 to 11 months
Meningococcal group C vaccine (Meningitec®)
Meningitec suspension for injection 0.5ml vials
Give 0.5ml by intramuscular injection.
Supply 1 0.5ml vial.
Meningococcal group C vaccine (Menjugate Kit®)
Menjugate vaccine powder and solvent for suspension for injection 0.5ml vials
Give 0.5ml by intramuscular injection.
Supply 1 0.5ml vial.
Meningococcal group C vaccine (NeisVac-C®)
NeisVac-C suspension for injection 0.5ml pre-filled syringes
Give 0.5ml by intramuscular injection.
Supply 1 0.5ml vial.
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