Until GANFYD has more content, you might like to try NHS Immunisation Information. Detailed information - the Immunisation "Green Book", including updated chapters, is available at via the Department of Health's web site. A new paper edition has just been published. It is available from HMSO or (for UK health professionals), your local health authority.
If you're interested in joining a discussion list for people professionally involved in vaccination (whether as a healthcare professional advising patients, giving the jabs, or making vaccine policy you might want to join the vaccimmuk Yahoo! group.
See also Artificial induction of immunity. When considering vaccination and immunisation, we are generally referring to stimulating the body's immune system to provide protection should it encounter a particular pathogen.
In modern parlance "immunity" is the state of protection from infection that you hope to provide; and "vaccination" describes the process intended to provide this immunity.
In addition to preventing infections, vaccination may also be used to treat infections (by stimulating a stronger immune response than natural infection); and also to prevent or treat other conditions such as high blood pressure.
The term "vaccination" is derived from the Latin for "cow" - because the first vaccine was the cowpox virus administered in 1796 by Edward Jenner (1749-1823), used to prevent smallpox. In 1980, as a result of huge and sustained public health efforts and enabled by Jenner's work, the World Health Assembly officially declared "the world and its peoples" free from endemic smallpox. Pasteur adopted the word for subsequent immunisations including Rabies which was a killed virus preparation.
The word "vaccination" is nowadays used to mean the process of giving a product containing antigens, with the intention that the body will generate antibodies to these antigens, thus giving the person immunity to pathogenic organisms expressing these antigens (active immunity).
Attacks on vaccination began in 1798, and were based on a variety of spurious ideas including god's will, but could later have included some useful alarms on cross-infection. Sadly, the strident idiocy with which they were made and which persists in many cases in present day arguments, made it difficult to discern any sense in them. In modern times there is an overlap between anti-vaccine activity and denialists on smoking and global warming and evolution, a general attack on science and rationality for the most part for immediate profit.
Before some expensive, rarely required or relatively hazardous immunisation procedures are conducted, and after some courses of immunisation whose effectiveness is either variable or crucial, an attempt may be made to determine whether the individual is immune to the disease in question. A biological assay by exposing the individual to the wild virulent disease seems both difficult and harsh and since diseases are not perfectly successful in infecting individuals on one exposure also lacking in sensitivity. There are limits to the reliability of such tests, which tend to be proxy rather direct tests of the immune function that gives protection from the disease. See main article determining immunity
Immunisation is any process that provides an individual with immunity to a pathogen. This may be achieved through natural infection or through vaccination. It can also be achieved by giving the individual immunoglobulin containing antibodies to the pathogen.
Active immunisation may give individuals "immune memory", meaning that their immune system is "primed", and able rapidly to generate antibodies if the same antigens are encountered in the future; or it may generate antibodies without generating immune memory. Many simple polysaccharide vaccines do not generate immune memory (and may only generate humoral immunity. In contrast, most live organism vaccines and conjugate vaccines generally do generate immune memory, and sometimes also cell-mediated immunity.
There is a wealth of information on vaccination and immunisation on Ganfyd - see the Vaccination category for a list of related pages.
(See Conjugate vaccines.)
Vaccine policy is formed with advice from the Joint Committee on Vaccination and Immunisation and input from a wide range of organisations.
The Health Protection (Vaccination) Regulations, due to come into force on 1 April, give JCVI recommendations extra force.
Vaccination benefits not just the individual who is vaccinated, but also the wider community - at least where vaccination prevents infection and onward transmission of disease, as is the case with most (but not all) vaccines - see Universal vaccination and herd immunity below. There are, therefore, significant ethical dimensions to decisions about vaccine policy; and at some times and places compulsory vaccination is or has been imposed.
Controversy remains as to whether vaccine damage has actually occurred in many of the patients awarded such payments - see, e.g. The vanishing victims by Brian Deer.
Fault and compensation
British law requires demonstrating fault in order to award compensation. Since people in similar condition require similar care or would benefit to similar extents regardless of the cause, there is something to be said for a system of no fault compensation, not least that the legal process in many countries appears to consume around half of any resources available, while providing assistance to around half of those needing it. No-fault compensation for assorted conditions has been implemented in New Zealand, some of the results are troublesome.
See also negligence
National Body Statements
Canadian Pediatric Society statements on immunisation (Incl Andrew Wakefield).
Supply and availability of vaccines in the UK
The vaccines used for many of the routine NHS childhood vaccine programmes are provided via a company called Movianto UK (formerly via Healthcare Logistics).
A monthly newsletter on the availability of vaccines, "Vaccine Update" is produced by the Public Health England. It is available at their website, here, or on request.
Other vaccines must be ordered through general pharmaceutical supplies channels, or via the manufacturers.
NHS Employers have a good website with a page of information about the vaccination programme in England, and links to the most recent (currently) contractual arrangements such as the GMS statement of financial entitlements (SFE).
Monitoring of vaccination uptake
Nationally used for:
- Evaluating the programmes
- Monitoring time trends
- Feedback to public health professionals and policy makers
- Targeting areas of low coverage
- Measuring vaccine effectiveness
- Modelling, planning and policy development
Locally used for:
- Early ’analysis’ and follow-up of defaulters
- Comparison between different vaccination providers, e.g. -
- General practitioners
- Health visitors
- Validation of data held locally
- Local public health reports
Cover system for collecting data on childhood vaccination
The main system used for monitoring vaccination uptake in England and Wales is the Cover system for child health vaccination. This system is good, but far from perfect: in most areas vaccinators (mainly GP practices; and there mainly practice nurses) have to send data separately for this system, in addition to sending data to their primary care organisation for payment purposes: two data collection systems are used; and since vaccinators obtain little or no benefit - especially if they do not use it for call and recall purposes - from completing the child health system forms, data is not always adequate. A system that collects data from GP computer systems, without further intervention required by the user, and is "topped up" with data about vaccinations given in other settings, would proved more complete data.
It is also recognised that COVER data only collects data on completed vaccinations given by the ages of 1, 2, and 5 years - so if vaccinations are given late, but still reduce the number of susceptibles in the community and thus the effective reproductive number the COVER statistics may not reflect overestimate the risk of an epidemic.
Systems for collecting data on vaccinations given to teenagers and adults
Some data are collected via KC50 data; but data on vaccinations given outside the childhood programmes (including teenage vaccination) are relatively poor.
Payments for vaccination
The ways that health care providers are paid for vaccinating patients in the UK are complicated. They are part of the means used to implement health policy.
Universal vaccination and herd immunity
UK policy recommends that some vaccines are provided "universally" - i.e. to everybody. Examples include the routine childhood vaccines. In all cases this is because the individual protection the vaccines provide is important; and in some cases there are huge advantages to the population if the number of individuals who are susceptible to a particular condition is so low that a person with the disease is unlikely to spread it to more than another person (herd immunity) In this situation payment/reimbursement is generally designed to incentivise vaccination - and in particular, incentives to vaccinate while the child is most vulnerabe to the disease, should they encounter it.
UK policy recommends that some vaccines are provided to people in "target groups".
People may be in target groups because:
- They would be more than usually likely to be vulnerable if infected - e.g. the recommendations concerning the vaccination of old people, or people with pre-existing conditions against influenza and pneumococcal disease; or
- They are more likely to be exposed to a condition, e.g. quarantine workers and rabies; or
- They are more likely to spread the condition to others who may be more vulnerable, e.g. vaccinating health care workers, carers, and (in North America) children, against influenza.
'fitfortravel'fitfortravel is a public access website provided by the NHS (Scotland) and compiled by a team from Health Protection Scotland.[Health Protection Scotland] It gives travel health information for people travelling abroad from the UK but emphasises that they should talk over individual needs with their own doctor. One may click on a map or select a destination. Travax is a similar more technical site restricted to doctors. Travax - registration required It has the same basic information but goes into medical detail.
Payment for travel vaccines is particularly confusing. Some vaccinations are paid for on the NHS; others have to be paid for by the patient. There is no obvious logic to this.
Guidance on which vaccines can be charged for and which must be given "under the NHS" is available from the BMA website (subscription/membership might be necessary to access this site).
There are interesting ethical and technical-legal points about vaccinating people who perceive themselves to be at risk from particular conditions, but who are not in the target group for the vaccine, or when a vaccine exists for the conditions, but is not recommended in the UK. In some cases there may be a small potential benefit to the population if the person is vaccinated, but insufficient benefit to justify a policy which would recommended they receive the vaccine (e.g. an adult who has not had chicken pox would only be recommended it if they were a health care worker; somebody who is not - or does not wish to admit to being - in a risk group might wish to have hepatitis B or A vaccine; and if they are vaccinated they are less likely to get expensively ill with the condition, or to pass it on to others...
In some cases a GP might be able to make a case for vaccinating them on clinical grounds, and prescribe the vaccine on the NHS. In some cases this is explicitly forbidden, and the vaccine can only be prescribed privately, in which case restrictions about private practice might apply (specifically preventing GPs from providing certain private services to their registered patients).
Approaches to vaccination payments
See main article: buying immunisation
Which vaccines are available in the UK?
(See also Vaccination in the UK - a summary of when vaccines were introduced.) Vaccines in the routine UK vaccination schedule protect against the diseases listed below.
It is recommended, of course, that all women are fully vaccinated according to the routine schedule prior to pregnancy.
- MMR vaccination is particularly important, as rubella (the R component of MMR) is a potent teratogen, causing congenital rubella syndrome. As MMR is a live virus vaccine - and despite good evidence that the vaccine virus is not teratogenic - MMR vaccination is contraindicated in pregnancy.
- Tetanus vaccination - tetanus is a terrible complication of pregnancy, preventable by vaccination. Tetanus vaccine comprises a toxoid, which can safely be given in pregnancy - in some countries tetanus vaccine during pregnancy is or has been routine practice.
Vaccinations given during pregnancy not only reduce the mother's risk of contracting the disease during pregnancy (with a consequent reduction in the risk of adverse consequences for the fetus); but they also boost maternal antibody levels. From about 32 weeks of pregnancy, maternal antibodies cross the placenta into the fetus, providing the newborn infant with passive immunity that can persist for several months. The following vaccines are currently given:
- Influenza - there is good evidence that influenza infection can be more serious (higher hospital admission, morbidity and mortality rates) during pregnancy; can cause premature birth or low birth weight; and that vaccination also reduces the neonate's risks of contracting and being ill with influenza.
- Pertussis - pertussis (whooping cough) infection can be very unpleasant at any age; but in young infants - due to the small size of their airways - it can be very serious, causing brain damage or death. Neither infection nor vaccination induce permanent immunity, so the disease continues to circulate. The best way to protect infants - until they can be effectively vaccinated themselves - is to boost their mothers' antibody levels by vaccinating them while pregnant.
Work is underway on other vaccines that may be given in pregnancy, including e.g. group B streptococcus.
- Pertussis (aka Whooping cough)
- Haemophilus influenzae type B
- Hepatitis B (added to the routine infant vaccination programme
(The above are protected against using DTaP/IPV/Hib/HepB vaccine (DTaP/IPV/Hib until) in infancy, with DTaP/IPV or dTaP/IPV as a pre-school booster, and a further booster of dT/IPV after the age of 10 years.)
(The above are protected against using MMR vaccine.)
are available (and provided on the NHS to target groups, or clinically indicated, or privately on request) against other diseases, including:
- Hepatitis A
- Hepatitis B (added to routine infant programme )
- Japanese encephalitis
- Meningococcal disease groups A, W135 and Y
- Pneumococcal disease
- Smallpox and vaccinia
- Tick borne encephalitis
- Varicella zoster virus (different vaccines for chickenpox and shingles)
- Yellow fever
Which vaccines are available in other countries?
This World Health Organisation web page allows you to look up vaccination schedules in different countries. Or you can get detailed information on specific countries here.
- Names of Vaccines and Other Immunobiologics Used in U.S. and Foreign Markets
- Translation of Vaccine-Related Terms Into English
- Administering vaccines
- Immunisation "Green Book"
- needles and needle sizes
- Vaccimmuk Yahoo! group
- Natural experiments in medicine
Training for vaccination practitioners
The HPA has developed some minimum standards for vaccination training, and a curriculum. It also runs training events. See this page for more details.
Health Protection Scotland and NHS Education Scotland have developed an online training package - there's more information about this at Health Protection Scotland's training resources web page.
- Vaccination "e-learning" modules from CDC - click on Understanding the Basics.
- Doctors Net training module on childhood vaccinations (possibly restricted to DNUK members).
- ↑ Tissot AC, Maurer P, Nussberger J, Sabat R, Pfister T, Ignatenko S, et al. Effect of immunisation against angiotensin II with CYT006-AngQb on ambulatory blood pressure: a double-blind, randomised, placebo-controlled phase IIa study. Lancet;371(9615):821-827 (abstract only)
- ↑ Samuelsson O, Herlitz H. Vaccination against high blood pressure: a new strategy. Lancet;371(9615):788-789
- ↑ AJ Dawson. An ethical argument in favour of routine hepatitis B vaccination in very low-incidence countries. Lancet Inf Dis:5(2):120-5
- ↑ DA Salmon, SP Teret, R MacIntyre, D Salisbury, MA Burgess, NA Halsey. Compulsory vaccination and conscientious or philosophical exemptions: past, present, and future Lancet 367(9508):436–42
- ↑ Committee to Review Adverse Effects of Vaccines Board on Population Health and Public Health Practice, Stratton K, Ford A, Rusch E, Clayton EW, editors. Adverse effects of vaccines: evidence and causality (prepublication copy - uncorrected proofs). Washington DC: The National Academies Press,
- ↑ Mrs. Anne McGuire, Parliamentary Under-Secretary of State for Work and Pensions, quoted in Hansard, 3 May: Column 46WS
- ↑ Oster G, Edelsberg J, Hennegan K, Lewin C, Narasimhan V, Slobod K, Edwards MS, Baker CJ. Prevention of group B streptococcal disease in the first 3 months of life: would routine maternal immunization during pregnancy be cost-effective? Vaccine. Aug 20; 32(37):4778-85.(Link to article – subscription may be required.)
- ↑ PL/CMO/2006/1, PL/CNO/2006/1,PL/CPHO/2006/1. Important changes to the childhood immunisation programme. Department of Health. London