Neonates at risk only ▶ Bacillus Calmette-Guérin vaccine p. 1313 (at birth, see BCG vaccine p. 1297)
▶ Hepatitis B vaccine p. 1319 (at birth, see Hepatitis B vaccine p. 1300)
8 weeks ▶ Diphtheria with tetanus, pertussis, hepatitis B, poliomyelitis and haemophilus influenzae
type b vaccine p. 1312 (Infanrix hexa®). First dose
▶ Meningococcal group B vaccine (rDNA, component, adsorbed) p. 1314 (Bexsero®). First
▶ Pneumococcal polysaccharide conjugate vaccine (adsorbed) p. 1316 (Prevenar 13®). First
▶ Rotavirus vaccine p. 1325 (Rotarix®). First dose
12 weeks ▶ Diphtheria with tetanus, pertussis, hepatitis B, poliomyelitis and haemophilus influenzae
type b vaccine (Infanrix hexa®). Second dose
▶ Rotavirus vaccine (Rotarix®). Second dose
16 weeks ▶ Diphtheria with tetanus, pertussis, hepatitis B, poliomyelitis and haemophilus influenzae
type b vaccine (Infanrix hexa®).Third dose
▶ Meningococcal group B vaccine (rDNA, component, adsorbed) (Bexsero®). Second dose
▶ Pneumococcal polysaccharide conjugate vaccine (adsorbed) (Prevenar 13®). Second dose
▶ Meningococcal group B vaccine (rDNA, component, adsorbed) (Bexsero®). Single booster
▶ Pneumococcal polysaccharide conjugate vaccine (adsorbed) (Prevenar 13®). Single booster
▶ Haemophilus influenzae type b with meningococcal group C vaccine p. 1314 (Menitorix®).
2–10 years on 31st August 2019 (including
children in reception class and school years
▶ Influenza vaccine p. 1322 each year from September. Note: live attenuated influenza nasal
spray is recommended (Fluenz Tetra®). If contra-indicated and child is in clinical risk group,
use inactivated influenza vaccine (see Influenza vaccine p. 1301)
▶ Measles, mumps and rubella vaccine, live (MMR VaxPRO® or Priorix®). Second dose
11–14 years (females only). First dose of
HPV vaccine will be offered to females aged
12–13 years of age in England, Wales, and
Northern Ireland, and 11–13 years of age in
Scotland. For females aged 15 years and
older, see Human papillomavirus vaccine
▶ Human papillomavirus vaccines p. 1321 (Gardasil®). 2 doses; second dose 6–24 months
after first dose. If a 3-dose course of HPV vaccine has been started, where possible, the
course should be completed (2 doses less than 6 months apart does not provide long-term
protection). Only Gardasil® is offered as part of the national immunisation programme.
Therefore for those females who started the schedule with Cervarix®, but did not complete
the vaccination course, the course can be completed with Gardasil®. Ideally one vaccine
should be used for the entire course.
13–15 years ▶ Meningococcal groups A with C and W135 and Y vaccine p. 1315 (Nimenrix® or Menveo®).
Note: Can be given at the same time as the dose of meningococcal groups A with C and
W135 and Y vaccine at 13–15 years of age.
Females of child-bearing age susceptible to
▶ Measles, mumps and rubella vaccine, live females of child-bearing age who have not
received 2 doses of a rubella-containing vaccine or who do not have a positive antibody test
for rubella should be offered rubella immunisation (using the MMR vaccine)—exclude
pregnancy before immunisation, and avoid pregnancy for one month after vaccination.
Pregnant females ▶ Acellular pertussis-containing vaccine administered as diphtheria with pertussis,
poliomyelitis vaccine and tetanus (Boostrix-IPV®). 1 dose from the 16th week of
pregnancy, preferably after the fetal anomaly scan (weeks 18–20)
▶ Influenza vaccine (inactivated). Single dose administered from September, regardless of the
stage of pregnancy (see Influenza vaccine p. 1301)
Routine immunisations during adult life
Under 25 years, those entering university
who are at risk of meningococcal disease
▶ Meningococcal groups A with C and W135 and Y vaccine (Nimenrix® or Menveo®). Single
dose. Note: Should be offered to those aged under 25 years entering university who have
not received the meningococcal groups A with C and W135 and Y vaccine over the age of
During adult life, if not previously
immunised or 5 dose course is incomplete
▶ Diphtheria with poliomyelitis and tetanus vaccine
65 years ▶ Pneumococcal polysaccharide vaccine p. 1316
70 years ▶ Varicella-zoster vaccine p. 1326 Single dose
. pneumococcal polysaccharide vaccine.
Children first diagnosed under 1 year of age should be
vaccinated according to the Immunisation Schedule.
Additionally, one dose of meningococcal groups A with C
and W135 and Y vaccine should be given during infancy
followed by a second dose at least one month apart. Two
months following the routine 12 month booster vaccines,
give a dose of meningococcal groups A with C and W135 and
Y vaccine and an additional dose of 13-valent pneumococcal
polysaccharide vaccine. An additional dose of haemophilus
influenzae type b with meningococcal group C vaccine and
23-valent pneumococcal polysaccharide vaccine should be
given after the second birthday. The influenza vaccine
should be administered annually in children aged 6 months
Children first diagnosed between 1 and 2 years of age should
be vaccinated according to the Immunisation Schedule,
including the 12 month boosters. Two months after the
routine 12 month booster vaccines, give a dose of
meningococcal groups A with C and W135 and Y vaccine and
an additional dose of 13-valent pneumococcal
polysaccharide vaccine. An additional dose of haemophilus
influenzae type b with meningococcal group C vaccine and
23-valent pneumococcal polysaccharide vaccine should be
given after the second birthday. The influenza vaccine
should be administered annually.
Children first diagnosed over 2 years of age should be
vaccinated according to the Immunisation schedule,
including the 12 month boosters. The child should receive
one additional booster dose of haemophilus influenzae type
b with meningococcal group C vaccine along with the
23-valent pneumococcal polysaccharide vaccine, followed by
one dose of meningococcal groups A with C and W135 and Y
vaccine after 2 months. The influenza vaccine should be
Vaccines and antisera availability
Anthrax vaccine p. 1312 and yellow fever vaccine, live
p. 1327, botulism antitoxin p. 1293, diphtheria antitoxin
p. 1293, and snake and spider venom antitoxins are available
from local designated holding centres.
For antivenom, see Poisoning, emergency treatment
Enquiries for vaccines not available commercially can also
Vaccines and Countermeasures Response Department
In Scotland information about availability of vaccines can be
obtained from a Specialist in Pharmaceutical Public Health.
In Wales enquiries for vaccines not available commercially
Welsh Medicines Information Centre
Pharmacy and Medicines Management Centre
Northern Health and Social Care Trust
rphps.admin@northerntrust.hscni.net
For further details of availability, see under individual
Advice reflects that in the handbook Immunisation against
Infectious Disease (2013), which in turn reflects the guidance
of the Joint Committee on Vaccination and Immunisation
(JCVI). The advice also incorporates changes announced by
the Chief Medical Officer and Health Department Updates.
Chapters from the handbook (including updates since 2013)
www.gov.uk/government/collections/immunisation-againstinfectious-disease-the-green-book
Immunisation schedule 23-Apr-2019
Routine immunisations, sources of information
The following recommendations reflect advice produced by
Public Health England. Recommendations specific to each
vaccine can be found in Immunisation against infectious
disease– the ‘Green Book’. Public Health England at:
www.gov.uk/government/collections/immunisation-againstinfectious-disease-the-green-book
The immunisation schedule reflects advice from ‘The
complete routine immunisation schedule’ produced by
Public Health England (2018). For the most up to date
immunisation schedule see: www.gov.uk/government/
publications/the-complete-routine-immunisation-schedule
The Influenza immunisation recommendations reflect
advice from the ‘National flu immunisation programme plan
2019/2020’ produced by Public Health England, Department
of Health and Social Care, and NHS England. For the most
up-to-date letter, see: www.gov.uk/government/publications/
national-flu-immunisation-programme-plan
Vaccines for the immunisation schedule should be
obtained from ImmForm at: www.immform.dh.gov.uk
Babies born preterm should receive all routine
immunisations based on their actual date of birth. The risk of
apnoea following vaccination is increased in preterm babies,
particularly in those born at or before 28 weeks gestational
age. If babies at risk of apnoea are in hospital at the time of
their first immunisation, they should be monitored for
respiratory complications for 48–72 hours after
immunisation. If a baby develops apnoea, bradycardia, or
desaturation after the first immunisation, the second
immunisation should also be given in hospital with similar
Individuals with unknown or incomplete
For children born in the UK who present with an inadequate
or unknown immunisation history, investigation into
immunisations received should be carried out. Outstanding
doses should be administered where the routine childhood
immunisation schedule has not been completed.
For advice on dosing schedules for missed vaccinations,
and the immunisation of individuals coming to the UK,
consult Chapter 11, The UK immunisation schedule, in
Immunisation against infectious disease– ‘The Green Book’.
Public Health England, available at: www.gov.uk/government/
publications/immunisation-schedule-the-green-book-chapter-11
Immunisations for healthcare and laboratory staff
Vaccine-preventable diseases that can be transmitted from
person to person are a risk for staff and patients in
healthcare environments, and staff in laboratory
environments. Therefore, all staff must be up-to-date with
their routine immunisations. In addition, specific
immunisations are recommended for certain staff groups
due to the risk of acquiring or passing on infection. For
detailed recommendations, consult Chapter 12,
Immunisation of healthcare and laboratory staff in
Immunisation against infectious disease– ‘The Green Book’.
Public Health England, available at: www.gov.uk/government/
publications/immunisation-of-healthcare-and-laboratory-staffthe-green-book-chapter-12
Anthrax vaccine p. 1312 is made from antigens from
inactivated Bacillus anthracis adsorbed onto an adjuvant.
Anthrax immunisation is indicated for individuals who
handle infected animals or process infected animal products
where there is a potential risk of occupational exposure to B.
anthracis. It is also recommended for occupations where
workers are at risk of one-off high level exposures to anthrax
(e.g. following a deliberate or accidental release of spores).
A 4-dose regimen is used for primary immunisation; a
single booster dose should be given at 10-year intervals on
up to 3 occasions to workers at potential continuous low
level risk of exposure to anthrax. In those with potential
intermittent high level exposure, a single booster dose
should be offered just before entering situations with a
specific high exposure risk. If such opportunities do not
arise, a single booster dose should be given at 10-year
intervals on up to 3 occasions to sustain protection.
In the event of proven or high probability of exposure to
anthrax spores, a single booster dose should be given, in
addition to antibacterial prophylaxis, except when a dose has
been given in the preceding 12 months.
Advice on the treatment of previously unvaccinated
individuals with a proven or high probability of exposure to
anthrax spores can be found at: www.gov.uk/government/
publications/chemical-biological-radiological-and-nuclearincidents-recognise-and-respond.
All suspected cases of anthrax must be notified to the local
health protection unit. Where there is a community level
outbreak, specialist advice should be sought from Public
Health England (tel. 020 8200 4400) or, in Scotland, Health
Protection Scotland (tel. 0140 300 1191).
Recommendations reflect Chapter 13, Anthrax, in
Immunisation against infectious disease– ‘The Green Book’.
Public Health England. February 2017.
www.gov.uk/government/publications/anthrax-the-green-bookchapter-13
Bacillus Calmette-Guérin vaccine p. 1313 should be given
intradermally by operators skilled in the technique.
by a local lesion which starts as a papule 2 or more weeks
after vaccination; the lesion may ulcerate then subside over
several weeks or months, leaving a small, flat scar. A dry
dressing may be used if the ulcer discharges, but air should
BCG is recommended for the following groups if BCG
immunisation has not previously been carried out and they
are negative for tuberculoprotein hypersensitivity:
. neonates with a family history of tuberculosis in the last
. all neonates and infants (0–12 months) born in areas
where the incidence of tuberculosis is greater than 40 per
. neonates, infants, and children under 16 years with a
parent or grandparent born in a country with an incidence
of tuberculosis greater than 40 per 100 000;
. new immigrants aged under 16 years who were born in, or
lived for more than 3 months in a country with an
incidence of tuberculosis greater than 40 per 100 000;
. new immigrants aged 16–35 years from Sub-Saharan
Africa or a country with an incidence of tuberculosis
. contacts aged under 36 years of those with active
respiratory tuberculosis (for healthcare or laboratory
workers who have had contact with clinical materials or
patients with tuberculosis, age limit does not apply);
. healthcare workers and laboratory staff (irrespective of
age) who are likely to have contact with patients, clinical
materials, or derived isolates; other individuals under
35 years (there is inadequate evidence of protection by
BCG vaccine in adults aged over 35 years; however,
vaccination is recommended for healthcare workers
irrespective of age because of the increased risk to them or
their patients) at occupational risk including veterinary
and other staff who handle animal species susceptible to
tuberculosis, and staff working directly with prisoners, in
care homes for the elderly, or in hostels or facilities for the
. individuals under 16 years intending to live with local
people for more than 3 months in a country with an
incidence of tuberculosis greater than 40 per 100 000.
List of countries or primary care trusts where the incidence
of tuberculosis is greater than 40 cases per 100 000 is
Bladder instillations of BCG are licensed for the
management of bladder carcinoma.
See also Tuberculosis p. 578 for advice on
chemoprophylaxis; for the treatment of infection following
vaccination, seek expert advice.
Tuberculosis Diagnostic Agents
The Mantoux test is recommended for tuberculin skin testing,
but no licensed preparation is currently available. Guidance
for healthcare professionals is available at www.dh.gov.uk/
In the Mantoux test, the diagnostic dose is administered
by intradermal injection of tuberculin purified protein
The Heaf test (involving the use of multiple-puncture
apparatus) is no longer available.
Two interferon gamma release assay (IGRA) tests are also
available as an aid in the diagnosis of tuberculosis infection:
QuantiFERON ® TB Gold and T-SPOT ®. TB. Both tests
measure T-cell mediated immune response to synthetic
antigens. For further information on the use of interferon
gamma release assay tests for tuberculosis, see www.gov.uk/
Advice reflects that in the handbook Immunisation against
Infectious Disease (2013), which in turn reflects the guidance
of the Joint Committee on Vaccination and Immunisation
(JCVI). The advice also incorporates changes announced by
the Chief Medical Officer and Health Department Updates.
Chapters from the handbook (including updates since 2013)
www.gov.uk/government/collections/immunisation-againstinfectious-disease-the-green-book
A polyvalent botulism antitoxin p. 1293 is available for the
post-exposure prophylaxis of botulism and for the treatment
of persons thought to be suffering from botulism. It
specifically neutralises the toxins produced by Clostridium
botulinum types A, B, and E. It is not effective against
infantile botulism as the toxin (type A) is seldom, if ever,
found in the blood in this type of infection.
Advice reflects that in the handbook Immunisation against
Infectious Disease (2013), which in turn reflects the guidance
of the Joint Committee on Vaccination and Immunisation
(JCVI). The advice also incorporates changes announced by
the Chief Medical Officer and Health Department Updates.
Chapters from the handbook (including updates since 2013)
www.gov.uk/government/collections/immunisation-againstinfectious-disease-the-green-book
Oral cholera vaccine p. 1313 contains inactivated Inaba
(including El-Tor biotype) and Ogawa strains of Vibrio
cholerae, serotype O1 together with recombinant B-subunit
of the cholera toxin produced in Inaba strains of V. cholerae,
Oral cholera vaccine is licensed for adults and children
from 2 years of age who are travelling to endemic or
epidemic areas on the basis of current recommendations.
Immunisation should be completed at least one week before
potential exposure. However, there is no requirement for
cholera vaccination for international travel. After a full risk
assessment, immunisation can be considered for the
. relief or disaster aid workers;
. persons with remote itineraries in areas where cholera
epidemics are occurring and there is limited access to
. travellers to potential cholera risk areas, for whom
vaccination is considered potentially beneficial;
. individuals at occupational risk, such as laboratory
workers who may be regularly exposed to cholera.
For dosing schedule, see cholera vaccine.
Immunisation with cholera vaccine does not provide
complete protection and all travellers to a country where
cholera exists should be warned that scrupulous attention to
food, water, and personal hygiene is essential.
All suspected cases of cholera must be notified to the local
health protection unit. Where there is a community level
outbreak, specialist advice should be sought from Public
Health England (tel. 020 8200 4400) or, in Scotland, Health
Protection Scotland (tel. 0140 300 1191).
Contacts of patients with cholera should maintain high
standards of personal hygiene to avoid becoming infected.
Cholera vaccine should not be used in the management of
contacts of cases or in controlling the spread of infection.
Recommendations reflect Chapter 14, Cholera, in
Immunisation against infectious disease– ‘The Green Book’.
Public Health England, December 2013.
www.gov.uk/government/publications/cholera-the-green-bookchapter-14
Diphtheria-containing vaccines are prepared from the toxin
of Corynebacterium diphtheriae and adsorption on aluminium
hydroxide or aluminium phosphate improves antigenicity.
The vaccine stimulates the production of the protective
antibody. The quantity of diphtheria toxoid in a preparation
determines whether the vaccine is defined as ‘high dose’ or
‘low dose’. Vaccines containing the higher dose of diphtheria
toxoid are used for primary immunisation of children under
10 years of age. Vaccines containing the lower dose of
diphtheria toxoid are used for primary immunisation in
adults and children over 10 years. Single-antigen diphtheria
vaccine is not available and adsorbed diphtheria vaccine is
given as a combination product containing other vaccines.
For primary immunisation of children aged between
2 months and 10 years, vaccination is recommended usually
in the form of 3 doses (separated by 1-month intervals) of
diphtheria with tetanus, pertussis, hepatitis B, poliomyelitis
and haemophilus influenzae type b vaccine p. 1312 (Infanrix
hexa ®) (see Immunisation schedule). In unimmunised
individuals aged over 10 years the primary course comprises
of 3 doses of adsorbed diphtheria [low dose], tetanus and
poliomyelitis (inactivated) vaccine.
A booster dose should be given 3 years after the primary
course (this interval can be reduced to a minimum of 1 year if
the primary course was delayed). Children under 10 years
should receive either adsorbed diphtheria, tetanus,
pertussis (acellular, component) and poliomyelitis
(inactivated) vaccine oradsorbed diphtheria [low dose],
tetanus, pertussis (acellular, component) and
poliomyelitis (inactivated) vaccine . Individuals aged over
10 years should receive adsorbed diphtheria [low dose],
tetanus, and poliomyelitis (inactivated) vaccine.
A second booster dose, of adsorbed diphtheria [low dose],
tetanus and poliomyelitis (inactivated) vaccine, should be
given 10 years after the previous booster dose (this interval
can be reduced to a minimum of 5 years if previous doses
Diphtheria-containing vaccines for children over 10 years and
A low dose of diphtheria toxoid is sufficient to recall
immunity in individuals previously immunised against
diphtheria but whose immunity may have diminished with
time; it is insufficient to cause serious reactions in an
individual who is already immune. Preparations containing
low dose diphtheria should be used for adults and children
over 10 years, for both primary immunisation and booster
Those intending to travel to areas with a risk of diphtheria
infection should be fully immunised according to the UK
schedule. If more than 10 years have lapsed since completion
of the UK schedule, a dose of adsorbed diphtheria [low
dose], tetanus and poliomyelitis (inactivated) vaccine
Staff in contact with diphtheria patients or with potentially
pathogenic clinical specimens or working directly with C.
diphtheriae or C. ulcerans should receive a booster dose if
fully immunised (with 5 doses of diphtheria-containing
vaccine given at appropriate intervals); further doses should
be given at 10-year intervals if risk persists. Individuals at
risk who are not fully immunised should complete the
primary course; a booster dose should be given after 5 years
and then at 10-year intervals. Adsorbed diphtheria [low
dose], tetanus and poliomyelitis (inactivated) vaccine is
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