Immunological products and vaccines

14 Immunological products and vaccines

14.1 Active immunity

660 When two live virus vaccines are required (and are not available as a combined preparation) they should be

14.2 Passive immunity

663 given either simultaneously at different sites or sepa-

14.3 Storage and use

663 rated by an interval of at least 4 weeks. For interactions see Appendix 1 (vaccines).

14.4 Vaccines and antisera

663 See also Cautions under individual vaccines

14.5 Immunoglobulins

681 Contra-indications Vaccines are contra-indicated in

14.6 International travel

684 those who have a confirmed anaphylaxic reaction to a preceding dose of a vaccine containing the same anti-

gens or vaccine component (such as antibacterials in viral vaccines). The presence of the following excipients in vaccines and immunological products has been noted under the relevant entries:

14.1 Active immunity

Gelatin

Neomycin Streptomycin

Gentamicin

Penicillins Thiomersal

Polymyxin B Active immunity can be acquired by natural disease or

Kanamycin

by vaccination. Vaccines stimulate production of anti- Hypersensitivity to egg with evidence of previous anaphy- bodies and other components of the immune mechan-

lactic reaction, contra-indicates influenza vaccine, tick- ism; they consist of either:

borne encephalitis vaccine, and yellow fever vaccine. 1. a live attenuated form of a virus (e.g. measles, mumps and

See also Cautions under MMR vaccine.

cines rubella vaccine) or bacteria (e.g. BCG vaccine), or

See also Vaccines and HIV infection, below.

2. inactivated vac preparations of the virus (e.g. influenza

vaccine) or bacteria, or Live vaccines may be contra-indicated temporarily in individuals who are:

3. extracts of and or detoxified exotoxins produced by a micro-

immunosuppressed (see Impaired immune Live attenuated vaccines usually produce a durable

organism (e.g. tetanus vaccine).

response, below); immunity, but not always as long-lasting as that result-

pregnant (see Pregnancy and breast-feeding, oducts ing from natural infection.

below).

pr Inactivated vaccines may require a primary series of See also Contra-indications under individual vaccines. al injections of vaccine to produce adequate antibody Impaired immune response Immune response to vac-

response and in most cases booster (reinforcing) injec- cines may be reduced in immunosuppressed patients tions are required; the duration of immunity varies from

and there is also a risk of generalised infection with live unologic vaccines. Severely immunosuppressed patients should months to many years. Some inactivated vaccines are

adsorbed onto an adjuvant (such as aluminium hydro- not be given live vaccines (including those with severe Imm xide) to enhance the antibody response.

primary immunodeficiency). Specialist advice should be sought for those being treated with high doses of corti-

14 costeroids (dose equivalents of prednisolone: adults, at

Advice in this chapter reflects that in the handbook

Immunisation against Infectious Disease (2006), which least 40 mg daily for more than 1 week; children, 2 mg/ in turn reflects the guidance of the Joint Committee

kg daily for at least 1 week or 1 mg/kg daily for 1 on Vaccination and Immunisation (JCVI).

month), or other immunosuppressive drugs 1 , and Chapters from the handbook are available at

those being treated for malignant conditions with www.dh.gov.uk

chemotherapy or generalised radiotherapy 1 ; 2 . For spe- The advice in this chapter also incorporates changes

cial reference to HIV infection, see below. announced by the Chief Medical Officer and Health

The Royal College of Paediatrics and Child Health has Department Updates.

produced a statement, Immunisation of the Immunocom- promised Child (2002) (available at www.rcpch.ac.uk ).

Cautions Most individuals can safely receive the Pregnancy and breast-feeding Live vaccines should majority of vaccines. Vaccination may be postponed if

not be administered routinely to pregnant women the individual is suffering from an acute illness, however, it is not necessary to postpone immunisation in patients

1. Live vaccines should be postponed until at least 3 months with minor illnesses without fever or systemic upset.

after stopping high-dose systemic corticosteroids and at least 6 months after stopping other immunosuppressive

See also Predisposition to Neurological Problems, drugs or generalised radiotherapy (at least 12 months after below. For individuals with bleeding disorders, see

discontinuing immunosuppressants following bone-mar- Route of administration, below. If alcohol or disinfectant

row transplantation). is used for cleansing the skin it should be allowed to

2. Use of normal immunoglobulin should be considered after exposure to measles (see p. 681) and varicella–zoster

evaporate before vaccination to prevent possible inacti- immunoglobulin considered after exposure to chickenpox vation of live vaccines.

or herpes zoster (see p. 682).

BNF 57

14.1 Active immunity 661

because of the theoretical risk of fetal infection but where there is a significant risk of exposure to disease

Post-immunisation pyrexia in infants (e.g. to yellow fever), the need for vaccination usually

The parent should be advised that if pyrexia devel- outweighs any possible risk to the fetus. Termination of

ops after childhood immunisation, the infant can be pregnancy following inadvertent immunisation is not

given a dose of paracetamol and, if necessary, a recommended. Although there is a theoretical risk of

second dose given 6 hours later; ibuprofen may be live vaccine being present in breast milk, vaccination is

used if paracetamol is unsuitable. The parent should not contra-indicated for women who are breast-feeding

be warned to seek medical advice if the pyrexia when there is significant risk of exposure to disease.

persists.

There is no evidence of risk from vaccinating pregnant For post-immunisation pyrexia in an infant aged 2–3 women, or those who are breast-feeding, with inacti-

months, the dose of paracetamol is 60 mg; the dose vated viral or bacterial vaccines or toxoids. For use of

of ibuprofen is 50 mg (on doctor’s advice). An oral specific vaccines during pregnancy or breast-feeding,

syringe can be obtained from any pharmacy to give see under individual vaccines.

the small volume required. Side-effects Injection of a vaccine may be followed by Further information on adverse effects associated with

local reactions such as pain, inflammation, redness, and specific vaccines can be found under individual vac- lymphangitis. An induration or sterile abscess may

cines.

develop at the injection site. Gastro-intestinal distur- bances, fever, headache, irritability, loss of appetite,