TRIPASS XR تري باس

 

strain of the virus can revert to a virulent form. For this

reason the live (oral) vaccine must not be used for

immunosuppressed individuals or their household contacts.

The use of inactivated poliomyelitis vaccines removes the

risk of vaccine-associated paralytic polio altogether.

Travel

Unimmunised travellers to areas with a high incidence of

poliomyelitis should receive a full 3-dose course of a

preparation containing inactivated poliomyelitis vaccines.

Those who have not been vaccinated in the last 10 years

should receive a booster dose of adsorbed diphtheria [low

dose], tetanus and poliomyelitis (inactivated) vaccine .

Information about countries with a high incidence of

poliomyelitis can be obtained from www.travax.nhs.uk/ or

from the National Travel Health Network and Centre

(www.nathnac.org/).

Useful Resources

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)

are available at:

www.gov.uk/government/collections/immunisation-againstinfectious-disease-the-green-book

Rabies vaccine

Overview

Rabies vaccine p. 1324 contains inactivated rabies virus

cultivated in either human diploid cells or purified chick

embryo cells; vaccines are used for pre- and post-exposure

prophylaxis.

Pre-exposure prophylaxis

Immunisation should be offered to those at high risk of

exposure to rabies— laboratory staff who handle the rabies

virus, those working in quarantine stations, animal handlers,

veterinary surgeons and field workers who are likely to be

bitten by infected wild animals, certain port officials, and bat

handlers. Transmission of rabies by humans has not been

recorded but it is advised that those caring for patients with

the disease should be vaccinated.

Immunisation against rabies is also recommended where

there is limited access to prompt medical care for those

living in areas where rabies is enzootic, for those travelling

to such areas for longer than 1 month, and for those on

shorter visits who may be exposed to unusual risk.

Immunisation against rabies is indicated during pregnancy

if there is substantial risk of exposure to rabies and rapid

access to post-exposure prophylaxis is likely to be limited.

Up-to-date country-by-country information on the

incidence of rabies can be obtained from the National Travel

Health Network and Centre (www.nathnac.org/) and, in

Scotland, from Health Protection Scotland (www.hps.scot.nhs.

uk/).

Immunisation against rabies requires 3 doses of rabies

vaccine, with further booster doses for those who remain at

frequent risk. To ensure continued protection in persons at

high risk (e.g. laboratory workers), the concentration of

antirabies antibodies in plasma is used to determine the

intervals between doses.

Post-exposure management

Following potential exposure to rabies, the wound or site of

exposure (e.g. mucous membrane) should be cleansed under

running water and washed for several minutes with soapy

water as soon as possible after exposure. Disinfectant and a

simple dressing can be applied, but suturing should be

delayed because it may increase the risk of introducing

rabies virus into the nerves.

Post-exposure prophylaxis against rabies depends on the

level of risk in the country, the nature of exposure, and the

individual’s immunity. In each case, expert risk assessment

and advice on appropriate management should be obtained

from the local Public Health England Centre or Public Health

England’s Virus Reference Department, Colindale (tel. (020)

8200 4400) or the PHE Colindale Duty Doctor (tel. (020) 8200

6868), in Wales from the Public Health Wales local Health

Protection Team or Public Health Wales Virus Reference

Laboratory (tel. (029) 2074 7747), in Scotland from the local

on-call infectious diseases consultant, and in Northern

Ireland from the Public Health Agency Duty Room (tel (028)

9055 3997/(028) 9063 2662) or the Regional Virology Service

(tel. (028) 9024 0503).

There are no specific contra-indications to the use of

rabies vaccine for post-exposure prophylaxis and its use

should be considered whenever a patient has been attacked

by an animal in a country where rabies is enzootic, even if

there is no direct evidence of rabies in the attacking animal.

Because of the potential consequences of untreated rabies

exposure and because rabies vaccination has not been

associated with fetal abnormalities, pregnancy is not

considered a contra-indication to post-exposure

prophylaxis.

For post-exposure prophylaxis of fully immunised

individuals (who have previously received pre-exposure or

post-exposure prophylaxis with cell-derived rabies vaccine),

2 doses of cell-derived vaccine are likely to be sufficient; the

first dose is given on day 0 and the second dose is given

between day 3–7. Rabies immunoglobulin p. 1292 is not

necessary in such cases.

Post-exposure treatment for unimmunised individuals (or

those whose prophylaxis is possibly incomplete) comprises

5 doses of rabies vaccine given over 1 month (on days 0, 3, 7,

14, and the fifth dose is given between day 28–30); also,

depending on the level of risk (determined by factors such as

the nature of the bite and the country where it was

sustained), rabies immunoglobulin is given to unimmunised

individuals on day 0 or within 7 days of starting the course of

rabies vaccine. The immunisation course can be

discontinued if it is proved that the individual was not at

risk.

Useful Resources

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)

are available at:

www.gov.uk/government/collections/immunisation-againstinfectious-disease-the-green-book

Rotavirus vaccine

Overview

Rotavirus vaccine p. 1325 is a live, oral vaccine that protects

young children against gastro-enteritis caused by rotavirus

infection. The recommended schedule consists of 2 doses,

the first at 2 months of age, and the second at 3 months of

age (see Immunisation schedule). The first dose of rotavirus

vaccine must be given between 6–15 weeks of age and the

second dose should be given after an interval of at least

4 weeks; the vaccine should not be started in children

15 weeks of age or older. Ideally, the full course should be

completed before 16 weeks of age to provide protection

before the main burden of disease, and to avoid a temporal

1306 Vaccination BNF 78

Vaccines

14

association between vaccination and intussusception; the

course must be completed before 24 weeks of age.

The rotavirus vaccine virus is excreted in the stool and

may be transmitted to close contacts; however, vaccination

of those with immunosuppressed close contacts may protect

the contacts from wild-type rotavirus disease and outweigh

any risk from transmission of vaccine virus. Carers of a

recently vaccinated baby should be advised of the need to

wash their hands after changing the baby’s nappies.

Useful Resources

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)

are available at:

www.gov.uk/government/collections/immunisation-againstinfectious-disease-the-green-book

Smallpox vaccine

Overview

Limited supplies of smallpox vaccine are held at the

Specialist and Reference Microbiology Division, Public

Health England Colindale (Tel. (020) 8200 4400) for the

exclusive use of workers in laboratories where pox viruses

(such as vaccinia) are handled.

If a wider use of the vaccine is being considered, Guidelines

for smallpox response and management in the post-eradication

era should be consulted at www.gov.uk/phe.

Useful Resources

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)

are available at:

www.gov.uk/government/collections/immunisation-againstinfectious-disease-the-green-book

Tetanus vaccine

Overview

Tetanus vaccine contains a cell-free purified toxin of

Clostridium tetani adsorbed on aluminium hydroxide or

aluminium phosphate to improve antigenicity.

Primary immunisation for children under 10 years consists

of 3 doses of a combined preparation containing adsorbed

tetanus vaccine, with an interval of 1 month between doses

(see Routine immunisation schedule). Following routine

childhood vaccination, 2 booster doses of a preparation

containing adsorbed tetanus vaccine are recommended, the

first before school entry and the second before leaving

school.

The recommended schedule of tetanus vaccination not

only gives protection against tetanus in childhood but also

gives the basic immunity for subsequent booster doses. In

most circumstances, a total of 5 doses of tetanus vaccine is

considered sufficient for long term protection.

For primary immunisation of adults and children over

10 years previously unimmunised against tetanus, 3 doses of

adsorbed diphtheria [low dose], tetanus and

poliomyelitis (inactivated) vaccine are given with an

interval of 1 month between doses (see Diphtheria-containing

vaccines for children over 10 years and adults).

When an individual presents for a booster dose but has been

vaccinated following a tetanus-prone wound, the vaccine

preparation administered at the time of injury should be

determined. If this is not possible, the booster should still be

given to ensure adequate protection against all antigens in

the booster vaccine.

Very rarely, tetanus has developed after abdominal

surgery; patients awaiting elective surgery should be asked

about tetanus immunisation and immunised if necessary.

Parenteral drug abuse is also associated with tetanus;

those abusing drugs by injection should be vaccinated if

unimmunised—booster doses should be given if there is any

doubt about their immunisation status.

All laboratory staff should be offered a primary course if

unimmunised.

Wounds

Wounds are considered to be tetanus-prone if they are

sustained more than 6 hours before surgical treatment or at

any interval after injury and are puncture-type (particularly

if contaminated with soil or manure) or show much

devitalised tissue or are septic or are compound fractures or

contain foreign bodies. All wounds should receive thorough

cleansing.

. For clean wounds: fully immunised individuals (those who

have received a total of 5 doses of a tetanus-containing

vaccine at appropriate intervals) and those whose primary

immunisation is complete (with boosters up to date), do

not require tetanus vaccine; individuals whose primary

immunisation is incomplete or whose boosters are not up

to date require a reinforcing dose of a tetanus-containing

vaccine (followed by further doses as required to complete

the schedule); non-immunised individuals (or those whose

immunisation status is not known or who have been fully

immunised but are now immunocompromised) should be

given a dose of the appropriate tetanus-containing vaccine

immediately (followed by completion of the full course of

the vaccine if records confirm the need)

. For tetanus-prone wounds: management is as for clean

wounds with the addition of a dose of tetanus

immunoglobulin given at a different site; in fully

immunised individuals and those whose primary

immunisation is complete (with boosters up to date) the

immunoglobulin is needed only if the risk of infection is

especially high (e.g. contamination with manure).

Antibacterial prophylaxis (with benzylpenicillin, coamoxiclav, or metronidazole) may also be required for

tetanus-prone wounds.

Useful Resources

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)

are available at:

www.gov.uk/government/collections/immunisation-againstinfectious-disease-the-green-book

Tick-borne encephalitis vaccine

Overview

Tick-borne encephalitis vaccine, inactivated p. 1325

contains inactivated tick-borne encephalitis virus cultivated

in chick embryo cells. It is recommended for immunisation

of those working in, or visiting, high-risk areas (see

International Travel). Those working, walking or camping in

warm forested areas of Central and Eastern Europe,

Scandinavia, Northern and Eastern China, and some parts of

Japan, particularly from April to November when ticks are

BNF 78 Vaccination 1307

Vaccines

14

most prevalent, are at greatest risk of tick-borne

encephalitis. For full protection, 3 doses of the vaccine are

required; booster doses are required every 3–5 years for

those still at risk. Ideally, immunisation should be completed

at least one month before travel.

Useful Resources

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)

are available at:

www.gov.uk/government/collections/immunisation-againstinfectious-disease-the-green-book

Typhoid vaccine 07-Nov-2018

Overview

Typhoid vaccine p. 1317 is available as a Vi capsular

polysaccharide (from Salmonella typhi) vaccine for injection

and a live, attenuated Salmonella typhi vaccine for oral use.

Typhoid immunisation is advised for:

. travellers to areas where typhoid is endemic and whose

planned activities put them at higher risk (country-bycountry information is available from the National Travel

Health Network and Centre);

. travellers to endemic areas where frequent or prolonged

exposure to poor sanitation and poor food hygiene is

likely;

. laboratory personnel who, in the course of their work, may

be exposed to Salmonella typhi.

Capsular polysaccharide typhoid vaccine is given as a

single dose, usually by intramuscular injection. Children

under 2 years [unlicensed] may respond suboptimally to the

vaccine, but children aged between 1–2 years should be

immunised if the risk of typhoid fever is considered high

(immunisation is not recommended for infants under

12 months). A single booster dose should be given at 3-year

intervals in adults and children over 2 years of age who

remain at risk from typhoid fever.

Oral typhoid vaccine is a live, attenuated vaccine

contained in an enteric-coated capsule recommended in

individuals aged 6 years and over. One capsule taken on

alternate days for a total of 3 doses, provides protection

7–10 days after the last dose. If travelling from a nonendemic area to an area where typhoid is endemic, a booster

consisting of 3 doses is recommended every 3 years. The oral

typhoid vaccine should be avoided in immunosuppressed

and HIV-infected individuals.

Prevention of typhoid primarily depends on improving

sanitation and water supplies in endemic areas and on

scrupulous personal, food and water hygiene.

All suspected cases of typhoid fever 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).

Useful Resources

Recommendations reflect Chapter 33, Typhoid, in

Immunisation against infectious disease– ‘The Green Book’.

Public Health England, August 2015.

www.gov.uk/government/publications/typhoid-the-green-bookchapter-33

National Travel Health Network and Centre

nathnac.net

Varicella-zoster vaccine

Overview

The live varicella-zoster vaccine p. 1326, Varilrix ® and

Varivax ®, are licensed for immunisation against varicella

(chickenpox) in seronegative individuals. They are not

recommended for routine use in children, but can be given to

seronegative healthy children over 1 year who come into

close contact with individuals at high risk of severe varicella

infections. The Department of Health recommends these

vaccines for seronegative healthcare workers who come into

direct contact with patients. Those with a history of

chickenpox or shingles can be considered immune, but

healthcare workers with a negative or uncertain history

should be tested.

Rarely, the varicella-zoster vaccine virus has been

transmitted from the vaccinated individual to close contacts.

Therefore, contact with the following should be avoided if a

vaccine-related cutaneous rash develops within 4–6 weeks of

the first or second dose:

. varicella-susceptible pregnant women;

. individuals at high risk of severe varicella, including those

with immunodeficiency or those receiving

immunosuppressive therapy;

Healthcare workers who develop a generalised papular or

vesicular rash on vaccination should avoid contact with

patients until the lesions have crusted. Those who develop a

localised rash after vaccination should cover the lesions and

be allowed to continue working unless in contact with

patients at high risk of severe varicella.

National shingles immunisation programme

The aim of the national shingles immunisation programme

is to lower the incidence and severity of shingles in older

people using the high potency, live varicella-zoster vaccine,

Zostavax ®. It is recommended that vaccination is routinely

offered to people aged 70 years. A catch-up programme has

also been rolled out (since 2013) in those aged 70-79 years,

as this age group is likely to have the greatest benefit from

vaccination.

In the 2016–2017 immunisation programme, varicellazoster vaccine is recommended in adults who were 70 or

78 years of age on 1st September 2016. Patients who were

eligible for vaccination in the first 3 years of the programme

but have not been vaccinated against herpes zoster remain

eligible until their 80th birthday; this includes patients who

were aged 71–73 or 79 on 1st September 2016. Patients who

have reached 80 years are no longer eligible for vaccination.

A single dose of Zostavax ® is likely to give protection for at

least 7 years, but the need for, or timing of, a booster dose

has not been established. Although Zostavax ® is not

recommended for the treatment of shingles or post-herpetic

neuralgia, it can be given to those with a previous history of

shingles; ideally the vaccine should be delayed until

systemic antiviral therapy has been completed.

Varicella-zoster immunoglobulin p. 1292 is used to protect

susceptible individuals at increased risk of severe varicella

infection (see Immunoglobulins p. 1287).

Useful Resources

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)

are available at:

www.gov.uk/government/collections/immunisation-againstinfectious-disease-the-green-book

1308 Vaccination BNF 78

Vaccines

14

Yellow fever vaccine 19-Mar-2019

Overview

Yellow fever vaccine, live p. 1327 is an attenuated

preparation of yellow fever virus grown in chick eggs. Yellow

fever vaccine, live is recommended for:

. laboratory workers handling infected material;

. individuals aged 9 months or older who are travelling to,

or living in areas or countries with a risk of yellow fever

transmission;

. individuals aged 9 months or older who are travelling to,

or living in countries that require an International

Certificate of Vaccination or Prophylaxis (ICVP) for entry

(information about countries at risk of yellow fever is

available from the National Travel Health Network and

Centre).

Children aged under 9 months are at risk of vaccineassociated encephalitis, with the risk being inversely

proportional to age. Children aged under 6 months should

not be vaccinated. Children aged 6–9 months should only be

vaccinated following a detailed risk assessment, and

vaccination is generally only recommended if the risk of

yellow fever transmission is high (such as during

epidemics/outbreaks). If travel is unavoidable, seek expert

advice on whether to vaccinate.

A single-dose of yellow fever vaccine, live confers life-long

immunity against yellow fever disease. Immunisation should

be performed at least 10 days before travelling to an endemic

area to allow protective immunity to develop and for the

ICVP (if required) to become valid.

Reinforcing immunisation is not needed, except for a

small subset of individuals at continued risk who may not

have developed long-term protection from their initial

yellow fever vaccine, live vaccination–seek expert advice.

Yellow fever vaccine, live should be avoided in HIVinfected and immunosuppressed individuals. If the yellow

fever risk is unavoidable, consult the British HIV Association

(bhiva.org/vaccination-guidelines.aspx) or other specialist

advice.

All suspected cases of yellow fever 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).

Useful Resources

Recommendations reflect Chapter 35, Yellow fever, in

Immunisation against infectious disease– ‘The Green book’.

Public Health England, January 2019.

www.gov.uk/government/publications/yellow-fever-the-greenbook-chapter-35

National Travel Health Network and Centre

nathnac.net

Vaccines for travel

Immunisation for travel

See advice on Malaria, treatment p. 613.

No special immunisation is required for travellers to the

United States, Europe, Australia, or New Zealand, although

all travellers should have immunity to tetanus and

poliomyelitis (and childhood immunisations should be up to

date); Tick-borne encephalitis vaccine is recommended for

immunisation of those working in, or visiting, high-risk

areas. Certain special precautions are required in nonEuropean areas surrounding the Mediterranean, in Africa,

the Middle East, Asia, and South America.

Travellers to areas that have a high incidence of

poliomyelitis or tuberculosis should be immunised with

the appropriate vaccine; in the case of poliomyelitis

previously immunised travellers may be given a booster dose

of a preparation containing inactivated poliomyelitis

vaccine. BCG immunisation is recommended for travellers

aged under 16 years proposing to stay for longer than

3 months (or in close contact with the local population) in

countries with an incidence of tuberculosis greater than 40

per 100 000 (list of countries where the incidence of

tuberculosis is greater than 40 cases per 100 000 is available

from www.gov.uk/phe); it should preferably be given 3 months

or more before departure.

Yellow fever immunisation is recommended for travel to

the endemic zones of Africa and South America. Many

countries require an International Certificate of Vaccination

from individuals arriving from, or who have been travelling

through, endemic areas; other countries require a certificate

from all entering travellers (consult the Department of

Health handbook, Health Information for Overseas Travel,

www.dh.gov.uk).

Immunisation against meningococcal meningitis is

recommended for a number of areas of the world.

Protection against hepatitis A is recommended for

travellers to high-risk areas outside Northern and Western

Europe, North America, Japan, Australia and New Zealand.

Hepatitis A vaccine is recommended and it is likely to be

effective even if given shortly before departure; Public

Health England recommends travellers can be vaccinated

with hepatitis A vaccine up to the day of travel, and no

longer recommends the use of normal immunoglobulin for

travel prophylaxis. Special care must also be taken with food

hygiene.

Hepatitis B vaccine is recommended for those travelling

to areas of high or intermediate prevalence who intend to

seek employment as healthcare workers or who plan to

remain there for lengthy periods and who may therefore be

at increased risk of acquiring infection as the result of

medical or dental procedures carried out in those countries.

Short-term tourists or business travellers are not generally at

increased risk of infection but may put themselves at risk by

their sexual behaviour when abroad.

Prophylactic immunisation against rabies is

recommended for travellers to enzootic areas on long

journeys or to areas out of reach of immediate medical

attention.

Travellers who have not had a tetanus booster in the last

10 years and are visiting areas where medical attention may

not be accessible should receive a booster dose of adsorbed

diphtheria [low dose], tetanus and poliomyelitis (inactivated)

vaccine, even if they have received 5 doses of a tetanuscontaining vaccine previously.

Typhoid vaccine is indicated for travellers to countries

where typhoid is endemic, but the vaccine is no substitute

for personal precautions.

There is no requirement for cholera vaccination as a

condition for entry into any country, but oral cholera

vaccine should be considered for backpackers and those

travelling to situations where the risk is greatest (e.g. refugee

camps). Regardless of vaccination, travellers to areas where

cholera is endemic should take special care with food

hygiene.

Advice on diphtheria, on Japanese encephalitis, and on

tick-borne encephalitis is included in Health Information for

Overseas Travel.

Food hygiene

In areas where sanitation is poor, good food hygiene is

important to help prevent hepatitis A, typhoid, cholera, and

other diarrhoeal diseases (including travellers’ diarrhoea).

Food should be freshly prepared and hot, and uncooked

vegetables (including green salads) should be avoided; only

fruits which can be peeled should be eaten. Only suitable

BNF 78 Vaccination 1309

Vaccines

14