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Important changes to the childhood immunisation programme. 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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changes from 4 th 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.

Changes from 4th September 2006
why are these changes being made
to protect children < 2 years of age who are at increased risk of pneumococcal disease

to boost children’s protection against Hib and MenC infections through their early childhood years

Why are these changes being made?
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

What ispneumococcal disease?
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)

Pneumococcal infection
severity of disease

Severity of disease

dependent on which part of the body is affected

pneumococcal infection1
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

Pneumococcal infection
pneumococcal infection2
5000 cases of invasive pneumococcal disease (IPD) per year

530 children IPD < 2 years (England & Wales)

Around 50 children < 2yrs die from IPD per yr1

2 thirds from pneumococcal meningitis

50% who survive pneumococcal meningitis have disabilities2

Pneumococcal infection

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

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

Evidence for changes
meningococcal infection
Serogroups:B and C account for majority of disease in the UKA, W135, Y, 29E and Z in other countries

Prior to MenC (1999/2000)vaccine campaign group C, disease accounted for 40% of cases – now < 10%

High overall fatality rate

Serious sequelae in survivors

Meningococcal infection
meningococcal disease cont
Most common presentation of meningococcal disease is meningitis and septicaemia

Disease onset is sudden

1 in 8 people who recover are left with long term complications

Case fatality rate is high but varies with age, serogroup, clinical presentation and prompt treatment

Meningococcal disease (cont)
symptoms of meningitis or septicaemia
Symptoms of Meningitis or Septicaemia
  • Rash
  • Fever/ Vomiting
  • Cold hands and feet
  • Rapid breathing
  • Joint/ stomach/ muscle ache
  • Drowsiness/ LOC
  • Stiff neck
  • Dislike of bright lights

Photo courtesy of CDC

meningococcal c disease in england and wales
Throughout the last 80 years irregular upsurges of meningococcal disease have occurred

Historically approximately 60-70% of all meningococcal infections were serogroup B

In 1998/99 a significant increase in incidence of group C disease was noted in infants, teenagers and young adults.

Meningococcal C disease in England and Wales
introduction of men c conjugate vaccine in the uk
Development and evaluation of MenC vaccine accelerated in response to increase in disease

Phased introduction between November 1999 to September 2000

Routine immunisation of infants (with DTP-Hib)

Catch-up for all under 18 years

targeting of the vaccine supplies against the highest risk groups

given with other routine vaccines where possible

Since 2002 inclusion of all under 25 years

Introduction of Men C conjugate vaccine in the UK
evidence for changes1
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

Evidence for changes
features of hib disease
Most common presentation of invasive Hib is meningitis, frequently accompanied by bacteraemia (60%)

15% of cases present with epiglottitis

Septicaemia without any other concomitant infection, occurs in 10% of cases

Remainder made up of cases of septic arthritis, osteomyelitis, cellulitis, pneumonia, and pericarditis

Features of Hib disease
complications of hib meningitis
Complications of Hib meningitis
  • Deafness
  • Convulsions
  • Intellectual impairment
  • Case fatality rate 2-5% in spite of effective antimicrobial therapy

Courtesy of Children’s Immunization Project, St. Paul, Minnesota

hib disease in england and wales
Before 1992:

1 child in 600 developed some form of Hib disease by 5th birthday

Hib Meningitis caused 30 deaths each year

Approximately 80 children a year were left with deafness or permanent brain damage

Hib disease in England and Wales
introduction of hib conjugate vaccine in the uk
Pure polysaccharide vaccines (1985-1989) not effective in infants under 18 months in whom risk of disease was highest

October 1992

Hib conjugate vaccine introduced into routine routine infant vaccination at 2, 3 and 4 months of age

October 1992-1993

Catch-up vaccination offered to all children under four years of age

Three doses under 13 months of age

One dose for 13 months and older

Introduction of Hib conjugate vaccinein the UK
reasons for increase
Short term exacerbation of the problem related to lower efficacy vaccine

Infanrix-Hib used in response to vaccine shortage

Accelerated schedule without booster

1993 Catch-up programme contributed to control of Hib

Effect was probably temporary

Protection from infant vaccination declines rapidly

Efficacy of vaccine higher when given over age of 1 year

Action in response: Booster programme for children aged 6 months – 4 years (2003)

Reasons for increase
evidence for changes2
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

Evidence for changes
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

What do the changes mean?
three injections for infants
It’s 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 don’t 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

Three injections for infants
simultaneous administration
Simultaneous administration




World Health Organisation (2004)

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

Order of injections given
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

Can the deltoid be used?
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

Can one vaccine be delayed?
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

12 month visit
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 > 2 months and < 2 years of age

13 month visit
children over 2 months and under 8 months of age at the start of the programme
Children born 04.02.06 - 03.07.06

(> 2 months but < 8 months of age)

Two doses of PCV two months apart with booster at 13 months

Children over 2 months and under 8 months of age at the start of the programme.
at risk children
Asplenia or dysfunction of the spleen

Chronic respiratory disease

Chronic heart disease

Chronic renal disease

Chronic liver disease



Cochlear implants

CSF leaks

< 5s with previous history of invasive disease

At-risk children
at risk children1
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) At-risk children
at risk children2
PCV routinely at 2, 4 and 13 months of age

At-risk children < 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 > 12 months and < 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

At-risk children
at risk children3
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 > 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

At-risk children
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 < 12 months of age

2 doses of PCV, 2 months apart and further dose at 13 months of age

Children > 12 months and < 2 years of age

should be offered a single dose of PCV

Vaccination of children with unknown or incomplete vaccination status
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

when will manchester introduce the changes
11 September 2006– Start new childhood immunisation schedule

Early 2007 Date to be confirmed - Start catch up programme

When will Manchester Introduce the changes?
child health support
Will generate appointments for children in line with new schedule

Will generate appointments for those children to be included in the catch up dependant on age of child and where they will fit into the catch up programme

If you wish to amend your appointments contact Child Health: 958 4090/4099

Child health support
practical considerations
Bulky presentation of vaccine

Fridge capacity

Extra 12 month immunisation visit plus extra visit for those children over 2 months and under 8 months at start of the programme

Prevenar and Menitorix vaccines both carry black triangle for adverse reaction reporting ▼

Practical Considerations
in summary
The routine childhood vaccination programme continues to deliver significant public health benefits.

The proposed new primary changes will protect babies as early as possible from serious diseases such pneumococcal meningitis.

The proposed booster doses in the second year of life will extend protection against Hib, meningococcal and pnumococcal meningitis further.

In Summary
further information
CMO Letters

NHS Immunisation website

The ‘Green Book’

Further information

Rosemary McCann GMHPU

Judith Moreton and David Salisbury DH

Additional slides:

Julie Annakin and Leasa Benson