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.
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
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
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
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.
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
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
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
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
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
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
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
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
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.
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
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.
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
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
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
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
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
. 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).
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
Tick-borne encephalitis vaccine
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
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.
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
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
. travellers to endemic areas where frequent or prolonged
exposure to poor sanitation and poor food hygiene is
. 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
consisting of 3 doses is recommended every 3 years. The oral
typhoid vaccine should be avoided in immunosuppressed
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).
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
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
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
. varicella-susceptible pregnant women;
. individuals at high risk of severe varicella, including those
with immunodeficiency or those receiving
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
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).
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
Yellow fever vaccine 19-Mar-2019
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
. 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
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.
fever risk is unavoidable, consult the British HIV Association
(bhiva.org/vaccination-guidelines.aspx) or other specialist
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).
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
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
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
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,
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
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
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
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
Advice on diphtheria, on Japanese encephalitis, and on
tick-borne encephalitis is included in Health Information for
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
No comments:
Post a Comment
اكتب تعليق حول الموضوع