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Protocol for Childhood Immunisation

VIEWS: 82 PAGES: 41

									Policy Type:     Clinical
Definition:      Policy                                            C li
Owner Group:     Primary Care Directorate                          n ic




                                                                   Clinical Policy
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  Protocol for Childhood Immunisation
     Adopted from Birmingham Specialist Trust




Applicable To:                              Nursing and Therapy Staff
Communication Method:                       Line Manager
Consequence of Non Adherence:               Disciplinary

Policy Author/Source:                       BEN PCT
Trust Policy Index Number:                  1.4
Version Number:                             2

Approval Body:                              Trust Board
Date Approved:                              April 1998
Review Date:
                        CHILDHOOD IMMUNISATION PROTOCOL


      This Protocol must be used alongside the Trust Administration of
     Medicines Policy and in conjunction of the UKCC Standards October
                                    1992


         Diversity Statement for Clinical Policies

1.       Introduction

2.       Aims and Objectives

3.       Summary of Roles and Responsibilities

4.       Current Schedule

5.       Consent

6.       Professional Nursing Responsibility

7.       Training

8.       Evaluation and Monitoring

9.       Protocols / Procedures :    9.1    Storage and handling

                                     9.2    Pre-school immunisation

                                     9.3    School immunisation

                                     9.4    Adverse reactions / Anaphylaxis

                                     9.5    Clerical

                                     9.6    Opportunistic Immunisation

                                     9.7    Mass Campaigns

10.      Specific Vaccine Information



Appendices




                                                                         Page 2 of 41
              Diversity Statement for Clinical Policies

This policy endeavours to deliver care in such a way as to treat patients fairly
and respectfully regardless of gender, race, ethnicity, religion/belief, sexual
orientation and/or disability.

The care and treatment provided will respect the individuality of each patient.

Birmingham East & North PCT is caring, committed and competent in its core
values and these will be developed to ensure equality and fairness becomes
the working culture.

In line with the PCT’s strategy and plans for race and equality all clinical
policies and protocols are reviewed against the values, standards and
targets contained within the strategy for fairness and equality.




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                 CHILDHOOD IMMUNISATION PROTOCOL


1.   INTRODUCTION

     Immunisation of children against infectious disease is of proven benefit
     in significantly lowering the incidence, morality and morbidity rates for
     what were common childhood diseases. Improving and maintaining
     high uptake rates for immunisations is essential for the health of the
     population of North Birmingham.

     This policy is intended to support all staff, both within BENPCT and in
     Primary Health Care Teams. In the provision of immunisation services
     to the relevant age groups. The policy should be used in
     conjunction with the current volume of Immunisation against
     Infectious Disease issued by the Joint Committee on Vaccines
     and Immunisation (“the Green Book”), the BENPCT
     Administrations of Medicines Policy and any other relevant
     documents such as letters issued by the Chief Medical Officer.


2.   AIMS AND OBJECTIVES

     The aim of providing immunisation services to immunise all children
     resident in North Birmingham in accordance with the national schedule
     currently recommended by the Joint Committee on Vaccination and
     Immunisation (JCVI), unless there is a specific contraindication.

     Target uptake rates of 95% have been set nationally. This is intended
     to ensure adequate herd immunity where relevant.

     This aim will be achieved by:

           Maintaining a high commitment to immunisation among all
           relevant staff.

           Maintaining a high standard of professional education and
           knowledge about immunisation among all relevant staff.

           Providing accessible and acceptable venues for all children and
           their families where immunisation can be carried out.

           Promoting public education and acceptance of immunisation.

           Providing an accurate and efficient system for recording
           immunisation status of children resident in the District, and for
           measuring uptake rates.




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                         CHILDHOOD IMMUNISATION PROTOCOL


3.    SUMMARY OF ROLES AND RESPONSIBILITIES

3.1   The roles and responsibilities are for the Immunisation Co-ordinator for
      the city of Birmingham, who will be a consultant in Communicable
      Disease Control. Operational Co-ordinators for BENPCT will be the
      Consultant Community Paediatrician (Child Health) and the Clinical
      Support Manager.

3.2   North Birmingham Immunisation Group (NBIG) is responsible for
      ensuring the implementation of this policy and for the development of a
      district wide strategy to maximise immunisation uptake (see appendix A
      for terms of reference).

      This group will consist of the three co-ordinators detailed in 3.1, plus
      the Child Health Information Department Manager, a Pharmacy
      representative, a General Practitioner, a practice nurse, a
      representative from the primary care commissioning section of
      Birmingham Health Authority, a School Nurse, a Health Visitor, plus
      others as required.

3.3   Nursing Staff – Health Visitors, School Nurses and Practice Nurses all
      have a vital role in advising and educating families about immunisation.
      In addition, only appropriately trained staff will carry out vaccinations in
      accordance with the current schedule and with the detailed protocols
      contained in policy.

3.4   Information Staff – The Child Health Department staff will maintain and
      update the Child Health System (CHS) in order to record all
      immunisations given to children resident in North Birmingham and to
      schedule appointments for pre-school vaccinations. They will also
      carry put regular input of data to the national COVER system (Cover of
      Vaccinations Evaluated Rapidly), co-ordinated by the Public Health
      Laboratory Service. Development of the School Health Module of the
      CHS will enable scheduling and recording of all school age
      immunisations.

3.5   General Practitioners – The majority of pre-school immunisations are
      carried out by GPs or within GP surgeries, and families are strongly
      encouraged to utilise this route. In addition, many GPs undertake
      immunisation of school age children in accordance with the national
      schedule, including those who have missed immunisation during school
      health sessions. GPs are in the best position to ensure opportunistic
      immunisation of children who are hard to reach through routine
      channels, by using other types of contact with families. Continuing
      education of families by GPs is essential to maintain satisfactory
      uptake rates.




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                  CHILDHOOD IMMUNISATION PROTOCOL


3.6   Community Medical Staff - As a significant proportion of pre-school
      surveillance is carried out by community doctors in Northern
      Birmingham, these contacts continue to be an essential route for
      reinforcement of appropriate advice on immunisation. Community
      doctors will support and advise other colleagues as necessary, and will
      undertake opportunistic immunisations wherever possible. Some
      sessions in schools will continue to be carried out by community
      doctors, though this role is now largely carried out by nursing staff.

3.7   Hospital Staff – Certain vaccinations, e.g. neonatal BCG and Hepatitis
      B immunisation are usually given within a hospital setting. Other
      vaccinations may be given on an opportunistic basis or as part of
      treatment e.g. in paediatric units and Accident & Emergency units.
      Details of immunisations given in such circumstances must
      always be forwarded to the Child Health Department for inclusion
      on the Child Health System. In addition, acute unit staff have an
      important role in advising families about immunisation, including
      contraindications and non-contraindications in relation to acute and
      chronic illness. Under certain circumstances, e.g. children with
      problem histories, immunisation may be carried out in hospital.




                                                                   Page 6 of 41
                     CHILDHOOD IMMUNISATION PROTOCOL


4.    CURRENT STANDARD IMMUNISATION SCHEDULE


Vaccine                             Age                       Notes

Hib DTP, & Polio                    2 months – 1st dose       Primary course
                                    3 months – 2nd dose
                                    4 months – 3rd dose

MMR 1st dose                        12-15 months

MMR 2nd dose, Booster DT            3-5 years                 Prior to school
& Polio                                                       entry

Heaf Test / BCG                     12 years, School Year 8

Booster Td & polio                  14-15 years, School Year 11

Additional vaccinations for selected groups:

Neonatal BCG                        At birth                  For selected
                                                              groups

Hepatitis B                         At birth – 1st dose       For babies born
                                    1 month – 2nd dose        to Hepatitis B
                                                              carrier
                                    2 months – 3rd dose       mothers
                                    12 months – 4th dose

Note the following abbreviations:

D = paediatric diphtheria

T = tetanus

P = pertussis

Hib = Haemophilus influenzae b

MMR = measles, mumps & rubella

BCG = Bacillus Calmette-Guerin (Tuberculosis)

d = adult dose diphtheria




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                  CHILDHOOD IMMUNISATION PROTOCOL


5.    CONSENT

5.1   Pre-school Children

      Informed consent for the administration of an immunisation must
      always be obtained from a parent or person with a parental
      responsibility. It is not a legal requirement but it is good practice for
      written consent to be obtained prior to immunising a child. The
      written consent which is obtained prior to the occasion on which the
      immunisation will be carried out is in fact consent for the child to be
      given all the vaccines in the Personal Child Health Record (PCHR or
      ‘red book’). Verbal confirmation of consent is not absolutely essential
      but it is good practice and should therefore be obtained on each
      occasion that an immunisation is undertaken.

      Where a child is presented for immunisation by an adult other than the
      parent or person with parental responsibility, e.g. a childminder, then
      confirmation of the parent’s consent is acceptable if written in the
      Personal Child Health Record, or can be obtained verbally e.g. by
      telephone only in an emergency (e.g. opportunistic immunisation).
      When obtaining consent by telephone it is essential to check proof of
      identity by asking the consenting adult to state the child’s date of birth.
      [Parents who were or have been married to each other at or after the
      time of the child’s conception each have a parental responsibility for the
      child otherwise the mother alone has parental responsibility.
      Unmarried fathers can obtain parental responsibility by court order or
      by agreement with the mother. Mothers and married parents only lose
      parental responsibility if their child is adopted. People other than
      parents can acquire parental responsibility by the private appointment
      of a guardian or an order of court.]

5.2   School age Children

      For all children a signed consent form must be obtained before
      vaccination can be given. In the majority of cases this will have been
      signed by a parent or person with parental responsibility. However, for
      a child under the age of 16 years, case law guidance indicates that an
      individual child has the right to give or withhold consent provided that
      the individual practitioner considers that the child has sufficient
      understanding of the issues to make an informed choice. There is no
      lower age limit set in law, but an arbitrary cut off age of 14 years will be
      considered appropriate for immunisation purposes.

      Prior to accepting consent or refusal from a child, a full discussion of
      the procedure must be undertaken by the practitioner who will carry out
      the immunisation. This must include making any written information on




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                   CHILDHOOD IMMUNISATION PROTOCOL

      the immunisation available to the child, with the opportunity for the child
      to have any questions answered. If the practitioner has any doubt
      about the child’s ability to understand the procedure fully, or if there are
      any doubts about understanding of language used then consent by the
      child is not acceptable.

      Therefore:

             If a parent had not returned a consent form, and the child is
             considered to be of sufficient understanding and wishes to be
             given the immunisation, then the written consent of the child is
             acceptable.

             If a parent has given consent, but the child after due explanation
             and consideration refuses consent, the immunisation should not
             be given.

             If a parent has refused consent, and a child wishes to have the
             immunisation, it must be borne in mind that the parent may have
             information that is not available to the child. It is necessary
             therefore to discuss further with both parent and child before
             giving the immunisation.



6.    PROFESSIONAL NURSING RESPONSIBILITY

6.1   The Department of Health guidance indicates that responsibility for
      immunisation may be delegated to a nurse provided that the following
      conditions are fulfilled:

             The nurse is willing to be professionally accountable for this
             work.

             The nurse has received training and is competent in all aspects
             of immunisation, including the contraindications to specific
             vaccines.

             Adequate training has been given in the recognition and
             treatment of anaphylaxis.




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                   CHILDHOOD IMMUNISATION PROTOCOL

6.2   The legal framework set by the terms of Medicines Act 1968, and the
      professional framework of the UKCC’s guidance, Standards for the
      Administration of Medicines 1992 enable the administration of
      immunisations by nursing staff via a number of possible routes:

             An individual prescription within a child’s records.

             A patient – specific protocol arrangement agreed between nurse
             and doctor/employer.

             A group protocol arrangement.

6.3   For the purposes of immunisation in school, a group protocol
      arrangement is acceptable. Such a protocol would include details of
      which drugs can be administered, the target group, the procedure for
      ascertaining any relevant contraindications, and the procedure for
      treatment of any reactions. The protocol must be drawn up in writing,
      be agreed by the nursing staff concerned and be signed by the
      Immunisation Co-ordinators.

      This immunisation policy constitutes a group protocol for this purpose.

6.4   For pre-school immunisations, undertaken by health visitors, the
      immunisation must be prescribed by a doctor. This may take the
      format of an individual practice agreement between GP, HV and
      practice nurse and the scheduling sheets may be considered to be the
      prescription.

      For immunisations carried out within BENPCT health centres by HVs,
      again the schedule for planned immunisation could be considered to be
      the prescription, if checked and signed by a doctor. However, the
      majority of immunisations carried out in this setting are likely to be
      opportunistic and therefore not scheduled. In this situation a
      prescription could be written and signed in for the PCHR by a
      community doctor. To enable opportunistic immunisation to be carried
      out wherever possible, this can be written in advance e.g. at the 6 week
      check. With future revisions of the PCHR, an appropriate format in the
      record will be devised.


7.    STAFF TRAINING/EDUCATION


7.1   Staff of BENPCT

7.1.1 All staff involved with the administration of immunisations will be issued
      with the current ‘Green Book’ (Immunisations against Infectious
      Disease, HMSO). If sufficient copies of the green book are not


                                                                     Page 10 of 41
                   CHILDHOOD IMMUNISATION PROTOCOL

       available then every member of staff should have access to them, i.e.
       there should be at least one copy of the green book in every
       clinic.

7.1.2 Copies of this policy will be issued to all health visitors, school nurses,
      child health medical and clerical staff, along with any subsequent
      amendments.

7.1.3 Any relevant updating information issued by the Department of Health
      will be circulated to relevant staff or incorporated into the
      policy/amendments.

7.1.4 New staff appointed, or any staff being trained prior to undertaking
      immunisation for the first time, will receive the following training:

              Attendance at a training session in immunisation theory, to be
              organised jointly by the Consultant Community Paediatrician and
              the Director of Nursing. This session will include training in drug
              administration.
              Attendance at one immunisation session as an observer
              Undertaking immunisation during one session with supervision
              by a community doctor or nurse with a minimum of one year’s
              immunisation experience.
              Attendance at one session on resuscitation (if undertaking
              immunisation without a Doctor present or on a domiciliary basis).

7.1.5 Existing staff will attend updating sessions including resuscitation skills
      on a yearly basis, or in accordance with any changes in immunisation
      policy or schedule.

7.2    Member of the Primary Health Care Team

7.2.1 Appropriate immunisation training will be offered to General
      Practitioners and Practice Nurses in conjunction with the primary care
      commissioning team of the Health Authority, particularly in relation to
      any new immunisations or developments in the immunisation schedule.

7.2.2 Advice on any aspect of childhood immunisation is always available
      from the clinical Immunisation Co-ordinators, Dr. A Wood and Dr. L M
      Rabb, or member of their teams.




                                                                       Page 11 of 41
                  CHILDHOOD IMMUNISATION PROTOCOL


8.    EVALUATION AND MONITORING

8.1   One of the major roles of the North Birmingham Immunisation Group is
      to monitor uptake rates and develop strategies to improve and maintain
      these.

8.2   In order for such strategies to be effective it is essential the information
      systems from which uptake rates are derived are maintained as
      accurately as possible, particularly given the mobility of sections of the
      target population. Maintenance of the database, while primarily the
      responsibility of the Child Health Department, is dependent on the
      prompt return of information from clinical colleagues. This includes
      information both on immunisations given and on other changes in
      circumstances e.g. name and address changes. Close collaboration
      with the Information department of Birmingham Health Authority and
      the development of compatible information systems is an essential part
      of this process.

8.3   The District participates in the national COVER (Cover of Vaccine
      Evaluated Rapidly) system which was merged with Korner statistics on
      immunisation over the 1995-1996 period. COVER data is available
      quarterly and will form the basis for local monitoring.

8.4   In addition, uptake rates on a locality basis e.g. constituency level or
      sub-constituency level, are available from the Child Health System and
      will enable a targeted approach to those areas with particular uptake
      problems.

8.5   Details of uptake rates by GP practice derived from target payments
      data will be made available to the NBIG by the Health Authority and
      monitored so that practices achieving low uptakes can be identified and
      assisted. This will involve both a clinical approach and an
      organisational approach and the primary care facilitator role within the
      Health Authority is seen as being a key part of the process.

8.6   The Child Health Information Department will feed back to the
      individual GPs and Health Visitors on a regular basis details of children
      who remain un-immunised, and of any immunisation clinic backlog to
      enable local action to resolve this.




                                                                       Page 12 of 41
                   CHILDHOOD IMMUNISATION PROTOCOL


9.0   PROTOCOLS AND PROCEDURES

9.1   Storage and Handling of Vaccines

9.1.1 These guidelines have been produced in order that vaccines are used,
      stored and transported in such a way to ensure their safety and
      maximum efficacy and are based on the best available information at
      the time of writing.

9.1.2 Transport – Maintaining the ‘cold chain’ is essential; repeated wide
      fluctuations in temperature of vaccines (even if they are actually out of
      the refrigerator for a short time) may lead to a breakdown of the
      constituents.

      The use of cool boxes is mandatory whenever vaccines are
      transported, even during short periods of time between pharmacies and
      GP practices. Ice packs should be not be frozen, to avoid the risk of
      freezing and rendering the vaccines ineffective. Packs should always
      be kept chilled in the coldest part of the refrigerator ready for use. If
      possible, the coolbox itself should also be chilled overnight prior to use.
      Enough chilled packs should be used to cover the bottom of the box
      and at the top to cover all the vaccines. Whenever updated
      recommendations about the most effective types of coolboxes and their
      methods of use become available, the information will be circulated to
      all users.

      Coolboxes are inefficient at keeping vaccines between 2 and 8oC, but
      are better than nothing. To minimise the time out of the fridge,
      vaccines should be packed into the coolbox as late as possible and
      must be refrigerated immediately on reaching their destination. When
      NHS or Trust transport is used, the driver must obtain a signature of
      receipt at the destination of the vaccine. The person receiving and
      signing for the vaccine is then responsible for refrigerating the vaccine
      immediately. When taxis are use they should return the coolbox to the
      issuing site once the vaccines have been transported.

      When vaccines are to be used at an outlying destination with no fridge,
      e.g. a school, only sufficient vaccines for that session should be taken
      from the clinic refrigerator (see 9.1.6)




                                                                     Page 13 of 41
                  CHILDHOOD IMMUNISATION PROTOCOL


9.1.3 Storage:

      One person plus a deputy per premises (e.g. GP surgery, clinic) should
      be responsible for the safe storage and care of vaccines.

      Vaccines should be stored in a locked fridge, preferably a specially
      designed drug fridge, which should never be used for storing food.

      Refrigerators suitable for the storage of vaccines and other
      pharmaceutical preparations are available on Central Contact for
      purchase by NHS users.

      SUPPLIER: LEC Refrigeration Ltd., Shripney Road, Bognor Regis,
      West Sussex, PO22 9NQ. Tel: 01243 863161

      Optional extras include a temperature recorder and audiovisual alarm
      system.

      SUPPLIER: Electrolux Ltd., Leisure Division, Luton Works, Oakley
      Road, Luton, Bedforshire, LU4 9QQ. Tel: 01582 573225

      Further information of suitable models can be obtained from :

      The Buying Agency. Tel: 0151 227 4262

      GPs wishing to purchase these items should in the first instance
      approach the primary care commissioning section of the Health
      Authority.

      To avoid accidental switching off, the fridge should be wired into the
      socket or the switch taped over and labelled ‘Do not switch off’.

      The fridge must not be packed too tightly; vaccines should not be
      pushed against the walls but stored in the middle of the fridge to allow
      cold air to freely circulate. Ideally no more than 50% of the internal
      volume should be filled, therefore only small quantities of the vaccine
      should be ordered at a time.
      Vaccines must not be placed in or against the freezer compartment.

      Large quantities of vaccine may go out of date. Stock must always be
      rotated so that older stock is used first.

      Vaccines should always be protected from light, i.e. kept in their box
      and within a coolbox or fridge.




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                        CHILDHOOD IMMUNISATION PROTOCOL

       The fridge temperature should be monitored with a minimum –
       maximum thermometer as well as the outside thermometer. The
       temperature should be between 2 and 8oC with an optimum
       temperature of 4oC. If the fridge is performing consistently, the
       monitoring can be done once a week, preferably immediately after a
       weekend and reset on Friday evening. The temperature should be
       recorded on a chart or in a notebook in the following format:
Date   Current Temp.   Max. Temp.   Min. Temp.   Checked by (signature)   Thermometer
                                                                          reset (tick)



       Keep fridge openings to a minimum as temperature rises considerably
       each time the fridge door is opened.

       Thermometers may be purchased from reputable laboratory suppliers
       some of whom are listed below.

               a. Gallenkamp, Belton Road, Loughborough, Leicestershire
                  LE11 0TR

                  Tel: 01509 237371

               b. Jencons (Scientific) Ltd., Cherrycourt Way Industrial Estate,
                  Stanbridge Road, Leighton Buzzard, Bedfordshire LU7 8UA

                  Tel: 01525 382010

               c. BDH Ltd., Apparatus Division, PO Box 8, Dagenham, Essex
                  RM8 1RY

                  Tel: 0181 590 7700

               d. Chave and Jackson Ltd., 6 & 7 Broad Street, Hereford,
                  Herefordshire HR4 9AE

                  Tel: 01432 272152

               e. Brannan Thermometers, S Brannan and Sons Ltd., Cleator
                  Moor, Cumbria CA25 5QE

                  Tel: 01946 810413




                                                                            Page 15 of 41
                  CHILDHOOD IMMUNISATION PROTOCOL


9.1.4 Disposal

      At the end of a session, any unused reconstituted or otherwise opened
      vaccine (including multidose vials) must be disposed of in a sharps box
      after removing packaging.

      Small quantities of expired vaccine, spoons for administering Polio
      vaccine, and any other contaminated waste may be disposed of in the
      same way.

9.1.5 Spillages and Breakages

      Vaccine spilt on skin should be washed off thoroughly with soap and
      water.

      With gloved hands, spilt vaccine should be wiped up and soiled swabs
      disposed of in sharps box. Broken vials should be carefully disposed of
      in a sharps box. Wash surfaces thoroughly with hot water and dispose
      of gloves into clinical waste or sharps box if the former is not available.
      Then wash hands thoroughly with soap and water.

      Eyes should be washed with large volumes of 0.9% sodium chloride
      and medical advice sought.

9.1.6 Vaccines used in the absence of a refrigerator

      Vaccines should be kept in the coolbox until just before use.

      If any vaccine is left over, it must be marked ‘taken from fridge on
      ………… (date)’ before returning to the refrigerator. This vaccine must
      be used up at the next session or within on month of the date on the
      box (7 days in the case of polio vaccine). If any vaccine is left after this
      time, dispose of as in 9.1.4.

      Coolboxes containing vaccines must never be left unattended in cars.

9.1.7 In case of fridge breakdown or accidental switching off:

      As soon as a malfunction is suspected, read the maximum – minimum
      thermometer. If the maximum temperature is above 8oC transfer the
      vaccines immediately to another fridge. Make sure that the vaccines
      are easily identifiable e.g. put in a labelled envelope.

      Then identify exactly how long the fridge has been switched off.




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                    CHILDHOOD IMMUNISATION PROTOCOL


     If the temperature has gone up considerably and for more than 36
     hours:

     Polio – use within 7 days then discard
     Diptheria / tetanus/ perussis – discard
     MMR/Hib/BCG/PPD for Heaf – use within one month then discard.

     If the minimum temperature records zero or below, discard all vaccines.

     If any vaccine is discarded for the above reasons, an untoward
     occurrence form should be completed and sent to the constituency
     manager.


9.1.8 Use of vaccines

           a. Reconstituted vaccine must be used within the
              manufacturers recommended period – varying from 1 to 4
              hours.

           b. The identity of the vaccine, its colour (see data sheet) and
              expiry date should be checked before administration.


           c. Check that the correct storage conditions have been
              observed.

           d. The date of vaccination, title of vaccine, batch number of
              vaccine and diluent should be recorded in the child’s notes.

           e. Where necessary the injection site may be swabbed with an
              alcohol impregnated wipe. It is important to allow the skin to
              dry before vaccinating.

           f. When used, sugar lumps for polio administration should be
              prepared immediately prior to use. They must not be
              prepared in advance as this may decrease potency.

           g. Single dose vaccines should be used wherever possible. If a
              full immunisation session has been organised, 10 dose vials
              may be used (one vial will normally yield 8 doses).
              Multi-dose vials, including polio, must not be kept after the
              end of the session. Any vaccine remaining at the end of a
              session must be destroyed (see 9.1.4). If fewer that 7
              children are expected, it is more economical to use single
              doses.




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                  CHILDHOOD IMMUNISATION PROTOCOL

      Further information can be obtained from the following:

      Drug information departments at City, Heartlands and Good Hope
      Hospitals

      The Community Services Pharmacist on 0121 378 2211 ext. 2290

      Pasteur Merieux MSD Vaccine Information Service 01628 773737


9.2   PROTOCOL FOR PRE-SCHOOL IMMUNISATIONS

9.2.1 The Health Visitor will discuss immunisation with the parents or carers
      at the primary visit. Parents should be strongly encouraged to attend
      their GP for immunisations although it is possible for the child to
      receive these at a community health clinic under exceptional
      circumstances. The standard form indicating the vaccinations agreed
      to and the venue should be completed and returned to the Child Health
      Department as soon as possible, for this to be entered on the Child
      Health System.

      It is useful for the Health Visitor to obtain written consent on page 16 (in
      the immunisation section) of the PCHR at this visit. This can be helpful
      if a child is presented for immunisation by an adult other than the
      parent / person with parental responsibility. It is anticipated that at the
      next revision of the PCHR, a specific section for consent will be
      included. However currently this will need to be written in.

9.2.2 At all health contacts with HV, GP or Community doctor, immunisation
      status should be checked and appropriate advice given. Opportunistic
      immunisations should be carried out wherever possible (see separate
      protocol).

9.2.3 If the immunisation course is started late, the recommended time
      intervals of one month between elements of the primary course, and of
      three years between the last of the primary injections and the pre-
      school booster should be observed. If any course of immunisation is
      interrupted it should be resumed and completed as soon as possible,
      but not recommended. It is now considered acceptable to immunise
      children with sequences of Hib vaccine from different manufacturers.
      Acellular pertussis vaccine can be used to complete a pertussis course.
      IPV can be used to complete oral polio course or vice versa.

9.2.4 All immunisations should be administered in accordance with the
      guidance contained in the Green Book and with the Administration of
      Medicines Policy.




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                  CHILDHOOD IMMUNISATION PROTOCOL

9.2.5 Children who are newly arrived to the UK are particularly vulnerable
      group. Every effort must be made to clarify their immunisation status
      and to give any outstanding vaccines. Advice should be sought from
      the Immunisations Co-ordinators where previous history is unavailable.

9.2.6 Children attending their GP for immunisation:

      All GPs are offered the opportunity to use the computerised
      immunisation appointment system. For those who accept this system,
      appointments will be generated at the appropriate times. Lists of the
      children due to be appointed will sent to the GP practice in advance of
      the appointments being sent to the parents, to enable any corrections
      to be made by practice staff e.g. if any child has been immunised
      previously.

      GPs who opt not to use the Trust appointments system are therefore
      responsible for the scheduling of immunisation appointments, for their
      patients.

      It is the GP’s responsibility to ensure that details of immunisations
      given are entered on the appropriate record sheet and returned to the
      Child Health Department for entry on the Child Health System. This
      applies to both scheduled and any unscheduled immunisations given.

      It is also the GP’s responsibility to ensure that the appropriate section
      of the PCHR is completed.

      Lists of children who fail to attend 2 appointments will be sent to the GP
      and HV on regular basis. Any corrections to this list must be notified to
      the Child Health Department. Any remaining children will require follow
      up by the Primary Health Care Team including HV’s, by such means as
      flagging of relevant records, domiciliary immunisations etc.

9.2.7 Children attending a community clinic:

      Children whose parents have opted for immunisation at a clinic will
      have appointments scheduled as above. The child’s GP will be notified
      of each immunisation given, in addition to notifying the Child Health
      Department. If the immunisation given by a HV, then the vaccine must
      be prescribed by a Doctor. It is the responsibility of the practitioner
      carrying out the immunisation to ensure that details are entered on the
      appropriate record sheet and that this is returned to the Child Health
      Department, as well as completing the PCHR.




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                   CHILDHOOD IMMUNISATION PROTOCOL


9.2.8 Premature Infants

      Babies who are born prematurely must be immunised promptly as they
      may be particularly at risk from illnesses such as pertussis. The normal
      schedule should be commenced at the age of 2 months from the actual
      date of birth, rather than the expected date of birth. The normal time
      intervals between immunisations should be observed.

      It is very rare for pertussis immunisation to be contradicted in
      premature infants and of this is the case, will usually be indicated on
      the Neonatal discharge summary. If this is not clear, then it is essential
      to check with the Neonatologist discharge summary. If this is not clear,
      then it is essential to check with the Neonatologist looking after the
      baby or one of the Immunisation Co-ordinators before omitting
      pertussis vaccine.

      Occasionally an immunisation course will be commenced while the
      baby is still an in-patient. This does not usually include oral (OPV)
      polio vaccination (because of concern over dissemination of vaccine-
      strain virus within a neonatal unit), though IPV would not carry this
      hazard. It is important to check exactly which immunisations have
      been given.

      Hospital staff must ensure that all immunisations given in such
      cases are reported to the Child Health Department using a
      standard form, and are documented in the PCHR.

      Details must also be included in the discharge summary.


9.3   PROTOCOL FOR IMMUNISATION OF SCHOOL AGE CHILDREN

      Procedures for school immunisation schedules

9.3.1 School immunisation cards should be sent from Child Health to the
      school nurses well in advance of the schools being booked by the Child
      Health Manager or Deputy Manager in conjunction with the school
      nurses. The cards for BCG or Td and Polio are usually distributed to
      pupils at registration or assembly. Once the cards have been
      completed by the parent/guardian they should be returned to school
      and sent back to the Child Health Department via the school nurse at
      least four weeks prior to the date arranged.

9.3.2 Child Health clerks are allocated schools by the Child Health
      Manager/Deputy Manager. They are responsible to checking each
      individual card. They should check that the child’s date of birth, the




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                   CHILDHOOD IMMUNISATION PROTOCOL

       home address and the GP’s name are all indicated as well as check
       that the parent/guardian’s signature relates to that of the child. They

9.3.3 should also check for foster children and telephone Social Services to
      confirm details on the card. The procedure for checking the cards are
      the same for both BCG and Td and Polio, except in the case of the
      latter, should the card indicate that the child has had Tetanus or Polio
      the staff should check to ensure that this is correct via the GP. If one
      out of the three has been given, this is flagged up by the clerk to the
      school nurse so that only appropriate vaccinations are given.

9.3.4 Such immunisations are normally carried out on school premises, but
      this protocol applies equally to those carried out in clinics or other
      venues.

9.3.5 Parents will be informed on the dates of immunisation sessions by
      letter circulated via the school.

9.3.6 Relevant class lists for the target group plus details of any children with
      previous immunisations outstanding will be obtained from the school by
      the designated school nurse in advance of the session.

9.3.7 A team consisting of at least two appropriately trained nurses and a
      clerk will conduct the session, the dates having been agreed in
      advance with the school. One nurse, usually the designated nurse for
      the school, will take the lead in organising the session, and particularly
      in any planning and discussion with school staff on the day. This is
      particularly important if there are any problems with the facilities
      supplied or with the conduct of the children.

9.3.8 The work area where the session will be undertaken will be prepared
      by the team prior to children being called from their classes. A senior
      member of the school staff must be informed that the session is taking
      place, and the location of the nearest telephone must be identified at
      the start in case of an emergency.

9.3.9 Equipment required i.e., disposables, vaccines and anaphylaxis kits will
      be brought to the session by the nursing team. Vaccines must be
      transported from the pharmacy or other storage site in a coolbox (see
      procedure on storage and handling of vaccines). Expiry dates of the
      vaccine and adrenaline must be checked before commencing the
      session. At the end of the session, and unused, opened vaccine
      should be disposed of in the sharps box along with the sharps and
      syringes used, and the box returned to the clinic base for disposal.

9.3.10 Clerical staff will ensure that the child has the correct consent card (see
       clerical procedures) but it is the responsibility of the nurse to check that
       the details are correct and that the card is appropriately signed.


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                   CHILDHOOD IMMUNISATION PROTOCOL


       Consent obtained from a child must be in accordance with the
       procedure detailed previously (see 5.2).

9.3.11 Appropriate questioning to ensure that the child is well on the day, has
       not had any immunisations in the previous 3 weeks, and is not on any
       medication which would constitute a contraindication, is the
       responsibility of the nurse. Laminated cards with the relevant
       questions may be used for children who are old enough. If a nurse is
       uncertain as to whether an immunisation should be given, advice must
       be sought from the designated school doctor, or another member of the
       medical team. If this is not possible, the injection should be deferred.

9.3.12 Immunisation is carried out in accordance with the Administration of
       Medicines Policy. The non-dominant arm should be used wherever
       possible unless the child requests that a specific arm is used.

9.3.13 The batch number and date must be entered on the consent card and
       signed by the nurse giving the injection. Clerical staff may assist in
       filling in batch numbers etc., but the responsibility for making sure that
       this is done rests with the nurse.

9.3.14 Up to date class lists should be marked to indicate which children have
       been immunised and which remain outstanding. A copy of this must be
       returned to the Child Health Department along with the completed
       consent cards. A further copy should be retained by the school nurse
       along with consent cards for those who have not been immunised to
       enable immunisation to take place at a future date. This may be during
       further planned sessions or on occasions when the school is visited for
       other reasons.

9.3.15 After immunisation each child should be given a card indicating the
       vaccine given. If a child attending the immunisation session is not
       immunised, parents should be notified in writing, giving the reason and
       offering appropriate advice. In the case of BCG the card gives
       information about the immunisation reaction as well as any precautions
       that may be needed following immunisation. The Child Health
       department should also send out cards to each and every child’s GP
       indicating what vaccinations were given at school. After visiting the
       school the clerk is required to follow the school through by doing the
       paperwork and figure sheets.

       At the end of the school year, staff may assist with the children who
       have been missed for any reason should the school nurse wish to go
       into the school again. Those children who have not received BCG
       within the same academic school year will do so automatically the next
       year in school. If children fail to received Td or Polio a note is sent to
       their GP asking them to kindly follow the children up as they are of


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                   CHILDHOOD IMMUNISATION PROTOCOL

       school leaving age. The Child Health department will supply the
       vaccine to the GPs to assist them to do this.

9.3.16 The BCG cards have to have the Heaf test grades recorded. These
       are 0-4.

       0 – 1 Negative

       2      Positive

       3 – 4 Strongly positive

       All grades 3 – 4 are referred to the Chest Clinic. Letters are sent to
       parents and the child’s GP to notify them about the referral to the Chest
       Clinic.

9.3.17 Every opportunity should be taken to ensure that the children who miss
       an immunisation in school for whatever reason are included in future
       school visits.

9.3.18 Well Children’s Clinic

       School children newly arrived to the country should all be offered the
       opportunity to attend for a health review at this clinic via their schools.
       Part of this visit involves checking immunisation status, and bringing
       this up to date. In some cases this means starting a primary course,
       and families are referred to their GP for completion of the course. The
       relevant school nurse will follow these children up to ensure that the
       course is completed. Children should be inspected for the presence of
       Bcg Scar if they have arrived from a country considered to be at high
       risk for contact with TB (see Green Book). If no scar is present, they
       should be referred to the Chest Clinic for Heaf testing and vaccination.


9.4    ADVERSE REACTIONS / ANAPHYLAXIS

9.4.1 Minor infections e.g. upper respiratory tract infections without fever or
      any systemic upset or the taking of antibiotics are not reasons to
      postpone an immunisation. If a child is suffering from any acute illness
      with fever or constitutional upset, then the immunisation should be
      postponed.

9.4.2 Mild reactions to immunisation are not uncommon, and the only action
      required for the majority of these is reassurance. Parents should be
      advised on the nature of mild and major reactions. The Personal Child
      Health Record (Red Book) had advice on management of minor and
      worrying symptoms in The Help Pages. Only severe reactions
      constitute a contraindication to further immunisations, therefore it is


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                     CHILDHOOD IMMUNISATION PROTOCOL

      essential to document carefully any reported reaction so that
      appropriate advice can be given in the future.

9.4.3 Severe reactions to a previous dose constitute a contraindication to any
      further doses. The following are considered severe reactions:

      Local – extensive area of redness and swelling which becomes
      indurated and involves most of the antero-lateral surface of the thigh or
      a major part of the circumference of the arm.

      General – fever > 39.5oC within 48 hours of immunisation

                 -    anaphylaxis

                 -    prolonged high pitched screaming for > 4 hours

                 -    prolonged unresponsiveness

                 -    convulsions or encephalopathy within 72 hours.

9.4.4 Severe reactions should be notified to the Committee of Safety of
      Medicines using the standard Yellow Card system. Sample cards
      can be found within the British National Formulary, and a copy should
      be sent to the Immunisation Co-ordinator, who would also advise on
      how to proceed with the immunisation course.

9.4.5 For mild local reactions e.g. pain or redness at the site, mild fever,
      analgesics / anti-pyretics should be advised. Medical advice should be
      sought for more serious reactions, and parents should be advised to
      report the reaction when next attending for immunisation.

9.4.6 Anaphylaxis kits for nurses will have adrenaline alone. In clinics were
      doctors do immunisations, the kits will contain hydrocortisone and
      chlorpheniramine in addition to adrenaline. All kits should be checked
      in accordance with agreed procedures.

9.4.7 Management of anaphylaxis following immunisation – see separate
      sheet




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                   CHILDHOOD IMMUNISATION PROTOCOL


MANAGEMENT OF ANAPHYLAXIS AFTER IMMUNISATION

1.   Establish Diagnosis – Is it faint or an anaphylactic reaction?

     Symptoms and signs of anaphylactic reaction:

              Airway               Hoarseness, stridor, difficulty swallowing saliva

              Breathing            Not breathing, wheeze

              Circulation          Weak or absent pulse, pallor, limpness

              Other                Urticarial or other rash

2.   Action

     Shout for HELP

     Assess RESPONSIVENESS

     If responsive go to 5


3.   If UNRESPONSIVE

     Secure a clear airway

     Look, listen and feel for breathing (5 seconds)

     Check central pulse (5 seconds)


4.   If NO PULSE OR BREATHING

     Call for an ambulance

     One minute of CPR

     Give 1/1000 Adrenaline deep IM or if possible IV

     Continue resuscitation




                                                                         Page 25 of 41
                    CHILDHOOD IMMUNISATION PROTOCOL


5.   IF BREATHING AND PALPABLE PULSE

     Place in the recovery position

     Check airway is still secure

     Call for ambulance

     Give 1/1000 adrenaline deep IM, repeat after 10 minutes if no improvement

     If possible give oxygen


6.   IF A DOCTOR IS PRESENT

     IV drugs are better that IM, but do not allow delay

     Give hydrocortisone IV

     Give chlorpheniramine IV


7.   AFTER ARRIVAL AT HOSPITAL

     All cases of anaphylaxis require admission

     Complete a yellow card

     Ensure all notes are clearly marked with allergy

     Ensure the GP is informed


8.   DRUG DOES – ADRENALINE                1/1000

     < 1 year              0.05 ml

     1 year                0.1 ml

     2 years               0.2 ml

     3 – 4 years           0.3 ml

     5 years               0.4 ml

     6 – 10 years          0.5 ml

     < 10 years            1 ml




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                  CHILDHOOD IMMUNISATION PROTOCOL


9.5   CLERICAL PROCEDURES

Procedure for GP Vaccine supply

      The Pharmacy departments of the main acute hospitals Heartlands,
      City and Good Hope, order the vaccines and distribute them to the
      Child Health Department at Yardley Green Hospital, local Child Health
      clinics around City Hospital and the Cottage Hospital respectively
      where they can be collected by GPs.

Procedures for pre-school immunisation

      Pre-school immunisation is mainly done by GPs. Under exceptional
      circumstances this can be done in the child health clinics.

      Most GPs use the computerised appointments system though some
      still do manual appointments. For those who use the computerised
      system, the Child Health department generates the schedules a
      fortnight in advance. The first immunisation appointments are
      scheduled when a child is 8 weeks old. The computer scheduled
      appointment envelopes go directly to parents, and the green schedule
      forms go to the GP or clinic indicating details of children due for
      immunisations with dates and times of appointments. At the top of this
      form is printed a date by which the form should be returned to the Child
      Health department. This is very important so that appointments are not
      regenerated. The information on the forms may be entered on the
      computer as 1, 2 or 3.

      1 = Given

      2 = Failed to attend with reason (further appointment sent)

      3 = Failed to attend without reason (computer will appoint two more
          times, then issue no further appointments)


Procedures for ordering vaccines for the school immunisation sessions


The vaccines for the BCG programme and Diptheria, Tetanus and Polio are
ordered through the three Pharmacies at Heartlands Hospital, City Hospital
and Good Hope Hospital in August or September. The amount is calculated
from the completion of the school immunisation cards returned to child health.
It would depend on the shelf life as to how many vaccines would be ordered at
any one time by the Child Health Manager or Deputy Manager.




                                                                    Page 27 of 41
                   CHILDHOOD IMMUNISATION PROTOCOL


9.6    OPPORTUNISTIC IMMUNISATION


9.6.1 Maintaining high uptake rates in North Birmingham presents many
      challenges. Attendance rates at scheduled appointments can be poor
      and many families will require diligent follow-up to ensure that children
      receive the appropriate schedule. Thus at all contacts with health
      professionals within the community and hospital settings, immunisation
      status must be checked and the opportunity taken to immunise those
      children who are not up to date.

9.6.2 Where contacts are made in the setting of a community child health
      clinic, then opportunistic immunisation should be offered if the
      immunisation is more that 4 months overdue. In other circumstances
      the parents should be advised to attend their GP to complete the
      course. If the practitioner considers that it is very unlikely that the child
      will attend, then the immunisation should be given. The 4 month time
      limit is to ensure that the GP has opportunity to immunise the child, and
      to minimise effects on target payments. Both the GP and the Child
      Health System must be informed promptly and the immunisation
      documented in the PCHR.

9.6.3 If a child attending a hospital is identified as being behind schedule,
      and this has been verified with the Child Health System (by contacting
      the Child Health Department, tel. 0121 766 6611 ext. 2893) and GP,
      then immunisation should be offered prior to discharge. The Child
      Health System and GP must be notified promptly and the immunisation
      documented in the PCHR.

9.6.4 If a school child is identified as being behind schedule, then
      immunisation should be offered immediately if there is consent,
      appropriate equipment and personnel. Otherwise the child should be
      booked in for the next school visit, consent obtained and the parents
      informed of the proposed date by letter.




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                  CHILDHOOD IMMUNISATION PROTOCOL


9.7   MASS CAMPAIGN

9.7.1 In the event of a mass immunisation campaign being called for by
      either Central Government or the local Purchasers, the following
      principles will apply:

            The campaign will be organised by the local Child Health Teams
             of School Nurses and Child Health Doctors in a manner which is
             sensitive to the relationships already established with schools
             and in a fashion which meets the needs of local populations.
            A timetable will be established, which, whilst acknowledging the
             requirements made by the Purchasers Central Government or
             epidemiological needs, is realistic in terms of the workload to be
             covered.
            BENPCT will consult all interested parties both within and
             outside the Health Service to work together to achieve the
             campaign aim.
            Educational information material will be made available as will
             promotional material from a central BENPCT source in order to
             maximise the publicity and ensure high immunisation uptake.
            BENPCT will seek to deliver the requirements laid upon it but
             will request that Purchasers acknowledge operational and
             resource requirements, which result from the additional
             workload.
            The Trust Board will seek to negotiate a suitable variation in
             regular and planned contractual obligations which takes full
             account of the additional pressures created by a mass
             campaign.
            The campaign will be implemented within a specific protcol.




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                   CHILDHOOD IMMUNISATION PROTOCOL


VACCINE INFORMATION


       Details of individual vaccines, relevant contraindications and specific
       guidance on usage are contained in the ‘Green Book’. Additional
       information on Hepatitis B and the school leavers Tetanus/Diptheria
       (Td) immunisation is given in this section.


10.1   HEPATITIS B IMMUNISATION

10.1.1 It is now Department of Health policy that all babies of Hepatitis B
       carrier mothers are offered immunisation with the aim of preventing
       mother to child transmission of the virus at or around the time of birth,
       and providing long term protection. Babies infected perinatally have a
       very high risk of becoming chronic carriers themselves. A significant
       proportion will develop chronic hepatitis and some will develop
       hepatocellular carcinoma.

       It appears that the uptake of Hepatitis B immunisation is poor in
       Birmingham, and every effort must be made by all relevant staff to
       ensure that at risk babies are immunised.

10.1.2 Pregnant women are screened during pregnancy and in those who are
       Hepatitis B surface antigen positive (HbsAg + ve), e-antigen status is
       assessed. Depending on the exact status, a recommendation is made
       by the Regional Virus Laboratory (Dr. E.H. Boxall), as to whether
       Hepatitis B immunoglobulin (HBIG) should be offered in addition to
       immunisation. A letter giving details of the recommendation is sent to
       the mother’s GP, Consultant Obstetrician and the Consultant
       Paediatrician in charge of neonatal services. In addition, a copy of the
       GP letter is sent to the relevant Community Paediatrician so that HVs
       can be informed.

10.1.3 The mother’s hepatitis B status and need for neonatal immunisation
       should be discussed with the mother during the antenatal period, by
       either the GP or the Obstetric team.

10.1.4 After birth, immunisation of the baby is discussed again with parents by
       the Paediatric staff, and consent obtained. Immunisation dosage is 10
       mcg (0.5ml) given at birth, 1 month, 2 months and 12 months.




                                                                      Page 30 of 41
                  CHILDHOOD IMMUNISATION PROTOCOL


10.1.5 The first does of Hepatitis B vaccine must be given within 48 hours of
       birth, with HBIG given in a contralateral site at the same time in those
       where this recommended. This first dose should be given in hospital.
       A specific parent-held record format immunisation card is available and
       should be completed and issued to the parents.

10.1.6 Subsequent immunisations at 1 month, 2 months and 12 months.

      Until recently there were two policies in place. In old West and North
      districts, these babies are followed up by Consultant Paediatricians at
      the City Hospital and Good Hope Hospital respectively and are
      immunised in outpatient clinics. In the old East District, subsequent
      immunisations were given by GPs. Now babies will be immunised in
      Heartlands Hospital Outpatients Clinic.

      It is NOT currently possible for the Child Health System to schedule for
      Hepatitis B so extra vigilance is required to ensure that is given.
      Hepatitis B immunisations ARE recorded on the Child Health
      System and must be notified using the standard forms for pre-
      school immunisation notification (both in hospital and primary
      care).

      Any change of practice will be notified to all.

10.1.7 HVs should take note of the antenatal notification and ensure that
       Hepatitis B immunisation is discussed at all contacts to encourage
       uptake.

10.1.8 Those babies at highest risk of developing the carrier state should have
       a blood test at 12 months. They can be identified as those who have
       been given immunoglobin (HBIG) at birth. This blood test would
       usually be done at the hospital unless the GP has agreed to do it.




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                   CHILDHOOD IMMUNISATION PROTOCOL


10.2   SCHOOL LEAVERS / TETANUS / DIPTHERIA (Td) IMMUNISATION

10.2.1 During 1993, a major epidemic of diphtheria occurred in Russia and
       surrounding countries. There is also evidence of a decline in
       antibodies to diphtheria with increasing age in England & Wales. In
       view of this, a decision was made by the JCVI to add diphtheria to the
       routine schedule of tetanus toxoid for school leavers, from October
       1994.

10.2.2 A new vaccine is available for this purpose; low dose diphtheria toxiod
       in combination with tetanus toxiod, known as Td, available from Meriux.
       The dose is only 0.5 ml by intramuscular or deep subcutaneous
       injection. The contraindications for this vaccine are the same as for
       tetanus and diphtheria vaccines given separately, as specified in the
       Green Book.

10.2.3 Paediatric combined diphtheria and tetanus vaccine, DT, made by
       Evans medical and merieux should not be used for this age group as
       the dose of diphtheria toxoid is higher in this preparation than in Td. Its
       use may result in significant adverse reactions.

10.2.4 A Schick test is not required prior to giving the vaccine.

10.2.5 Combined Td should be offered to all children aged 14 plus except in
       the following situation:

       If there is a documented history of tetanus immunisation since the pre-
       school booster i.e. a fifth dose, (verified within records, by the GP, or
       with a very clear history from parent or child) then it is not necessary to
       give a further dose of tetanus toxoid. Low dose diphtheria vaccine for
       adults (d) is now available and this should be offered instead. If it is not
       available then paediatric diphtheria vaccine (made by Evans Medical)
       can be used in these circumstances, at a dose of 0.1 ml.

       If diphtheria only vaccine is not available, then it is safe to give
       combined Td even if there has been a fifth dose of tetanus given
       previously. The only known complication is a sore arm at the injection
       site, and the children should be warned of this possibility. There is no
       minimum time limit specified between a previous dose of tetanus toxoid
       and Td.

10.2.6 Booster immunisations carried out in general practice for this age
       group should be with Td. In addition, any child over the age of 13 who
       is given tetanus immunisation by their GP because of injury should be
       offered Td. The child and parent should b advised that further
       immunisation with these antigens prior to leaving school is not


                                                                       Page 32 of 41
                   CHILDHOOD IMMUNISATION PROTOCOL

       necessary. The Child Health System must be notified of any such
       immunisations given in the primary care setting so that children are not
       offered this within school.

10.3   NEONATAL BCG VACCINATION

10.3.1 Acute and / or Maternity units must offer BCG to all vunerable neonates
       including:
              Those with a family history of TB
              Those where the family originates from Asia, including
              Southeast Asia, Africa, Caribbean countries, China or the middle
              East
              Others who may travel to endemic areas

10.3.2 Where a midwife identifies a family history of tuberculosis antenatally,
       the notes must be marked to ensure that this is brought to the attention
       of the Paediatric staff carrying out the neonatal check.

10.3.3 Paediatric junior staff who will be carrying out BCG immunisation must
       be appropriately trained and supervised in this procedure. It is then the
       responsibility of the Paediatric SHO to discuss BCG immunisation with
       the parent and obtain written consent on the standard card. The
       immunisation will be given intradermally by the SHO in the standard
       site i.e. the upper left arm, before discharge. Extra vigilance is required
       to ensure that babies admitted to the Neonatal Unit receive BCG prior
       to discharge. The standard card should be returned to the Child Health
       Department at Yardley Green Unit, and a record card must be given to
       the parents confirming that the immunisation has been given. This
       must also be documented in the case notes and within any discharge
       summary.

10.3.4 Contraindications to BCG in infants are positive HIV status in the
       mother, immunodeficiency, malignancy, pyrexia or sepsis. An
       alternative site should be used if there is skin sepsis or other skin
       lesions on the left upper arm. The site of injection must be
       documented in such cases.

10.3.5 If a baby cannot be given the vaccine before discharge for some
       reason, arrangements should be made for the baby to receive this at a
       hospital out-patient appointment, e.g. baby clinic or at Birmingham
       Chest Clinic (see below). It is essential that this is completed by 3
       months of age. Beyond that it is necessary to perform a Heaf test or
       mantoux before giving BCG.

10.3.6 The HV is responsible for checking at the primary visit that all
       vulnerable babies on her case load have received BCG, contacting the




                                                                       Page 33 of 41
       hospital of birth if necessary. BCG immunisation must be documented
       in the PCHR at this stage. If any baby has not been immunised, then
                   CHILDHOOD IMMUNISATION PROTOCOL

       an out-patient appointment must be made via the Paediatric secretaries
       (City Hospital and Good Hope Hospital), or a referral made to
       Birmingham Chest Clinic, 151 Great Charles Street, Queensway,

       Birmingham, B3 (for those born at Heartlands and the Maternity
       Hospitals) as soon as possible.

10.3.7 In exceptional circumstances, arrangements can be made for the baby
       to attend a community clinic for the immunisation by contacting the
       clinical medical officer or senior clinical medical officer for the patch.

10.3.8 Any complications of BCG immunisation e.g. abscess formation, noted
       by health professionals should be reported using the Yellow card
       system with a copy to the Immunisation Co-ordinator.

10.3.9 BCG vaccine may be given concurrently with another live vaccine, but
       if they are not given at the same time, there should be a three week
       gap between the two (except polio). No other vaccination should be
       administered in the arm used for BCG for there months.




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                  CHILDHOOD IMMUNISATION PROTOCOL


APPENDICES


Appendix A


North Birmingham Immunisation Group – Terms of Reference


1.    To review and advise on Immunisation policies within the District and to
      develop an integrated district wide strategy in order to achieve the
      maximum immunisation uptake within the District, in line with the
      Department of Health Guidelines.

2.    To implement and monitor the Immunisation service.

3.    To ensure accurate information is maintained to support the
      Immunisation Programme.

4.    To ensure the organisation of an efficient and effective recall system for
      all clients.

5.    To ensure that an accurate record of all immunisations given to any
      child in the district is provided to any professional caring for the child
      and the parent / carer.

6.    To ensure that the appropriate training is available on an ongoing basis
      for all staff involved in the immunisation programme.

7.    To ensure that advice is given re the appropriate systems for the
      storage and transport of vaccines.

8.    To co-ordinate Health Promotion activities within the District on
      Immunisation issues.

9.    To ensure that a source of clinical management advice concerning the
      immunisation programme is available within the District.

10.   To ensure that a rapid response is possible should a particular
      Immunisation need arise.




                                                                        Page 35 of 41
                   CHILDHOOD IMUNISATION PROTOCOL

Appendix B


Checklist for Immunisation in School



Please read the following questions carefully.



   1. Have you got a fever, or an upset stomach with diarrhoea and
      vomiting?


   2. Do you have any serious illnesses which need regular checks?


   3. Are you taking any medicines or tablets regularly, or having treatment
      at a hospital?


   4. Have you had any injections in the last three months?


   5. Are you allergic to any medicines?


   6. Have you had a tetanus injection since starting school?


   7. Have you previously has a bad reaction to an injection?


   8. Is it possible that you might be pregnant?


If you answer YES to any of these questions or are unsure, please tell
the school nurse BEFORE the injection.




                                                                   Page 36 of 41
                 CHILDHOOD IMMUNISATION PROTOCOL


CHECKLIST FOR HEAF TESTING




Please read the following questions carefully


   1.    Do you have any sort of viral illness today e.g. a cold?



   2.    Do you have a serious illness which needs regular checks?



   3.    Are you taking any medicines or tablets, or having regular hospital
         treatment?



   4.    Have you had any injection in the last three weeks?




If you answer YES to any of the above questions, or are unsure, please
tell the school nurse BEFORE the skin test.




                                                                    Page 37 of 41
                  CHILDHOOD IMMUNISATION PROTOCOL


IMMUNISATION CHECKLIST FOR SCHOOL NURSE


If someone answers YES to a question on the checklist, the following notes
may be helpful.

These must be used in conjunction with the current ‘Green Book’. If in doubt,
discuss with school doctor or another member of the medical team.



Q1.   If febrile postpone immunisation. Cough or cold without fever is not a
      reason to postpone immunisation, but a severe viral infection may
      affect the Heaf test.

Q2.   Do not give live vaccines if the child has a malignant disease e.g.
      leukaemia or immunodeficiency. Do not give BCG if HIV positive.

Q3.   Do not give live vaccines if the child is receiving high dose steroids (i.e.
      Prednisolone 2mg/kh/day for more that one week or 1mg/kg/day for
      one month), or immunosuppressive treatment.

      A three month gap should elapse after remission or completion of
      immunosuppressive treatment, before any live vaccines are considered
      or 3 months after levels have reached that are not associated with
      immunosuppression.

Q4.   Severe anaphylactic reaction to penicillin, streptomycin, neomycin or
      polymyxin is a contraindication to polio immunisation. Similarly severe
      reaction to neomycin or polymyxin is a contraindication to rubella/MMR.
      However, severe reactions are very rare. Mild reactions e.g. a rash do
      not constitute a contraindication.

Q5.   For all live vaccines (except polio), there must be a three week gap
      between injections. BCG may be given at the same time as another
      live vaccine but in a different site. The arm used for BCG must not be
      used for immunisation for three months.

      If immunoglobulin has been given e.g. to protect against Hepatitis A, a
      three moth gap should elapse before immunisation.

Q6.   If there is a documented history of tetanus immunisation, then low dose
      diphtheria vaccine for adults (d) should be given. Combined Td should
      be given if there is doubt or if diphtheria-only vaccine is not available.




                                                                       Page 38 of 41
                  CHILDHOOD IMMUNISATION PROTOCOL


Q7.   If the reaction is severe, immunisation should be omitted. If in doubt,
      ask for further advice from a member of the medical team before
      advising against immunisation.

Q8.   If pregnancy is suspected or confirmed, postpone immunisation with
      live vaccines.




                                                                    Page 39 of 41
                  CHILDHOOD IMMUNISATION PROTOCOL


3.    SUMMARY ROLES AND RESPONSIBILITIES


3.1   The roles and responsibilities are for the Immunisation Co-ordinator for
      the city of Birmingham, who will be a Consultant in Communicable
      Disease Control. Operational Co-ordinators for BENPCT will be the
      Consultant Community Paediatrician (Child Health) and the Clinical
      Support Manager.

3.2   North Birmingham Immunisation Group (NBIG) is responsible for
      ensuring the implementation of this policy and for the development of a
      district wide strategy to maximise immunisation uptake (see appendix A
      for terms of reference).

      This group will consist of the three co-ordinators detailed in 3.1, plus
      the Child Health Information Department Manager, a Pharmacy
      representative, a General Practitioner, a practice nurse, a
      representative from the primary care commissioning section of
      Birmingham Health Authority, a School Nurse, a Health Visitor, plus
      others as required.

3.3   Nursing Staff – Health Visitors, School Nurses and Practice Nurses all
      have a vital role in advising and educating families about immunisation.
      In addition, only appropriately trained staff will carry out vaccinations in
      accordance with the current schedule and with the detailed protocols
      contained in this policy.

3.4   Information Staff – The Child Health Department staff will maintain and
      update the Child Health System (CHS) in order to record all
      immunisations given to children resident in North Birmingham and to
      schedule appointments for pre-school vaccinations. They will also
      carry out regular input of data to the national COVER System (Cover of
      Vaccinations Evaluated Rapidly), co-ordinated by the Public Health
      Laboratory Service. Development of the School Health Module of the
      CHS will enable scheduling and recording of all school age
      immunisations.

3.5   General Practitioners – The majority of pre-school immunisations are
      carried out by GPs or within GP surgeries, and families are strongly
      encouraged to utilise this route. In addition many GPs undertake
      immunisation of school age children in accordance with the national
      schedule, including those who have missed immunisation during the
      school health sessions. GPs are in the best position to ensure
      opportunistic immunisation of children who are hard to reach through
      routine channels, by using other times of contact with families.


                                                                       Page 40 of 41
      Continuing education of families by GPs is essential to maintain
      satisfactory uptake rates.
                 CHILDHOOD IMMUNISATION PROTOCOL


3.6   Community Medical Staff – As a significant proportion of pre-school
      surveillance is carried out by community doctors in Northern
      Birmingham, these contacts continue to be an essential route for
      reinforcement of appropriate advice on immunisation. Community
      doctors will support and advise other colleagues as necessary, and will
      undertake opportunistic immunisations wherever possible. Some
      sessions in schools will continue to be carried out by community
      doctors though this role is now largely carried out by nursing staff.

3.7   Hospital Staff – Certain vaccinations, e.g. neonatal BCG and Hepatitis
      B immunisation are usually given within a hospital setting. Other
      vaccinations may be given on an opportunistic basis or as part of
      treatment e.g. in paediatric units and Accident & Emergency units.
      Details of immunisations given in such circumstances must
      always be forwarded to the Child Health Department for inclusion
      on the Child Health System. In addition, acute unit staff have an
      important role in advising families about immunisation, including
      contraindications and non-contraindications in relation to acute and
      chronic illness.




                                                                   Page 41 of 41

								
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