Printed on: November 21st, 2024

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Vaccination schedules

Vaccination schedules

The two public health interventions that have had the greatest impact on the world’s health are clean water and vaccines (World Health Organization).

‘Immunisation for infectious diseases’, known fondly as The Green Book, has not been published in paper format since 2006, but is regularly updated, online only, by Public Health England. 

This article was last updated in July 2024.

Public Health England (PHE) issues its advice following due consideration of the evidence on:

• The prevalence and burden of disease.
• Vaccine safety and efficacy.
• Impact and cost-effectiveness of immunisation strategies.

There are no plans to reprint the Green Book, but you can access the virtual versions:

• Online - don’t forget to bookmark this site, it’s handy!: gov.uk – Green Books: chapter 11 – The UK immunisation schedule

For the most up-to-date complete routine immunisation schedule, see: gov.uk – complete routine immunisation schedule

Remember, an incomplete vaccinations status in children can be a marker for safeguarding issues.

See the article on Antenatal vaccinations in the online handbook.

In November 2023, the Joint Committee on Vaccination and Immunisation released guidance on planned changes to the UK childhood immunisation programme (gov.uk - JCVI statement on a childhood varicella (chickenpox) vaccination programme, 2023). There are 3 main changes:

• Varicella: introduction of varicella vaccination.
  • To be given as a combination with MMR in a new MMRV vaccine.
• MMR: a change to the ages when the MMR is given.
  • The new combination MMRV will be offered at 12 months and 18 months of age (earlier than the existing preschool booster of MMR).
• Meningitis: a change to meningitis vaccination programme.
  • An additional dose of the Hib-containing multivalent vaccine usually given earlier in infancy will be given at 18 months.
  • We will no longer be giving a MenC booster at 12 months.
• The existing preschool booster of dTa/IPV will be unchanged.  

The rationale:

• The changes in meningitis vaccination are due to withdrawal of the Hib/MenC vaccine currently used (Menitorix, GSK). There is no equivalent vaccine available, hence an adjustment needing to be made to the programme.
• It is anticipated that bringing forward the second dose of MMR may improve uptake because this has been shown in previous outbreak responses in London.
• Successful adolescent uptake of the meningitis C vaccine, MenACWY, at age 14 has shown good indirect protection for infants against MenC. This, along with a significant reduction in prevalence of the disease, has led to the JCVI decision that the MenC booster at 12 months is no longer required.
• The overarching aim of the Hib vaccination is to achieve herd immunity (rather than individual infant protection). The decision to boost this at 18 months is to bring this dose in line with the rest of the vaccination schedule.

These changes will be introduced together when supplies of the Hib/MenC vaccine Menitorix are exhausted, which the JVCI anticipates will happen in 2025. Until this occurs, we should continue to follow the existing schedule outlined in our table below. The Green Book has not yet been updated.

A pre-COVID Lancet systematic review of worldwide respiratory syncytial virus (RSV) mortality found that it was the most common pathogen isolated in infants and young children with lower respiratory tract infections. There were 33 million cases in children under 60 months in 2019 (Lancet 2022;399:2047). 1 in 50 deaths worldwide in children aged 0–60 months were caused by RSV, and that rose to 1 in 28 in children aged 28 days–6 months.

From 1 September 2024, the UKHSA has introduced two new RSV vaccination programmes: one for older adults and one for those who are pregnant (gov.uk - respiratory syncytial virus (RSV) vaccination programme). The recommended vaccine is Abrysvo (Pfizer), which is an inactivated bivalent recombinant protein vaccine. There is no animal content in the vaccine, and the only contraindication is known anaphylaxis to the vaccine or its ingredients. If individuals are acutely unwell with fever, vaccination should be delayed until recovery. As this is a newly licensed vaccine, any adverse reactions should be reported via the yellow card scheme.

The aim of the vaccine in older adults is to reduce the incidence and severity of RSV infection, with consequent reductions in hospitalisation.

• Offer the vaccine to all adults turning 75y on or after 1 September 2024.
• There will be a one-off catch-up campaign for those aged 75–79y on 1 September 2024.

Use with other vaccines:

• Ideally, the RSV vaccine should not be given at the same time as the seasonal influenza or COVID vaccinations in older adults. We can use them together if there is a specific clinical need, e.g. the patient might not return for a second appointment.
• The JCVI does not recommend a specific interval between RSV vaccination and other immunisations.

The aim of the vaccination schedule in pregnancy is to reduce RSV infection and morbidity in infants through maternal transmission of immunity.

From 1 September 2024:

• Offer the vaccine to all women ≥28 weeks pregnant up to birth.
• Offer it in each pregnancy, regardless of the interval between pregnancies.

Trial data presented by UKHSA showed that vaccination of mothers was 70% effective at preventing severe RSV in infants for 6 months from delivery. There was a slight, non-statistically significant increase in preterm delivery in women who had received Abrysvo, but no increased mortality, and the JCVI did not have safety concerns about use of the vaccine in this group.

Use with other vaccines:

• Ideally, there should be a gap between administration of the pertussis vaccine (at 20 weeks gestation) and the RSV vaccine (at 28 weeks gestation). There is some evidence suggesting that effectiveness of the pertussis vaccine may be reduced if the two vaccines are given together. However, the JCVI advises that they can be co-administered if necessary (for example, if we are concerned a woman may not return for a later vaccination appointment).
• In pregnant women, unlike in older people, the JCVI does not recommend separation of seasonal influenza, COVID and RSV vaccines.

Passive immunisation refers to the process whereby individuals are given antibodies from an external source, rather than being given a trigger to produce their own antibodies against a disease.

Since 2010, the JCVI has recommended the use of monoclonal antibody immunisation to provide passive immunity against RSV to some of the highest-risk infants (gov.uk – respiratory syncytial virus: the green book, chapter 27a). This will continue alongside the maternal immunisation programme. Immunisation is given to infants based on their respiratory, cardiac or immune risk factors, gestational age at birth AND chronological age at the start of the RSV season. There are two licensed immunisations – Nirsevimab and Palivizumab – which work by inhibiting RSV from entering the host cell. Nirsevimab is given once at the start of the high-risk season, and is preferred over Palivizumab, which requires monthly doses during the RSV season (maximum of 5 doses). You’ll be relieved to learn that both vaccines are managed by paediatric teams!

In November 2023, the JCVI reviewed and updated the guidance on varicella zoster vaccination in children (gov.uk - JCVI statement on a childhood varicella (chickenpox) vaccination programme). The view of the committee was that routine childhood immunisation against varicella zoster should be offered to children in the UK in a 2-dose schedule. This was a change from previous guidance in 2009 which felt the vaccine was not cost-effective.

The planned schedule:

• The JCVI advises a combination vaccine of varicella with MMR (MMRV) to be given at 12 and 18 months of age.
• It recommends a single-dose catch-up programme for children over 18 months, up to and including 5 years of age.

The rationale:

• It was previously thought that exposure to circulating varicella infections in children ‘boosted’ the immunity of adults against varicella, and therefore reduced the risk of shingles. More recent data from Cambridge reviewed by the JCVI indicated that this effect had been overestimated.
• Worldwide data from existing vaccination programmes has shown a significant reduction in varicella-related hospitalisation, including indirect effects on infants in the younger cohort not yet eligible for vaccination.
• A Bristol-based study looked at the impact of childhood chickenpox on quality of life in children, and the impact on work and education for children and their caregivers. It found that complications from chickenpox are costly, common and place a burden on health services and employers. This, along with a reduction in the cost of the vaccine, led to the JCVI advising that this vaccination is now cost-effective.
• The decision to use a combination MMRV vaccine was made to avoid the need for multiple injections. Studies have shown a small increase in the risk of febrile seizures following vaccination where the MMRV is given compared with giving MMR and a separate varicella vaccine at the same time. This increased risk is small (CDC data estimates approximately 1 additional event per 2300 doses given), and this risk was felt to be acceptable by the JCVI.

In the UK immunisation schedule, there are 3 vaccines which contain porcine gelatine: Fluenz Tetra, MMR VaxPro and Zostavax shingles vaccine . This may raise concerns for some of our patients. Religious leaders in the Kashrut and Medicines Information Service have issued a statement to reassure some members of our Jewish communities that “according to Jewish laws, there is no problem with porcine or other animal derived ingredients in non-oral products.”

However, there remains diversity of belief in the British Jewish and Muslim communities, meaning that some people may feel unable to accept any vaccine containing porcine gelatine.

In this situation, we can offer alternatives (UKHSA Guidance accessed October 2023, gov.uk – vaccines and porcine gelatine):

• MMR VaxPro can be replaced with MMR Priorix, which is as effective and does not contain gelatine.
• Zostavax is being phased out through 2023 and replaced with Shingrix, which does not contain gelatine.
• Fluenz Tetra: we can offer an inactivated influenza vaccine instead, although parents should be advised that this may be less effective that the nasal vaccine in this age group.

The table below outlines the immunisation schedule for children born on or after 1 February 2022 (gov.uk - the complete routine immunisation schedule from 1 September 2023).

The JCVI has advised changes to the childhood vaccination programme which will come into place sometime in 2025. We have included some information on these in the article above, but have not made changes to this table as, currently (until 2025), this remains the recommended UK childhood immunisation schedule.

This has been added to the routine infant immunisation schedule from Autumn 2017 at 8, 12 and 16w, and, from 2025, will be offered to babies at 18 months of age as the new vaccination schedules are rolled out. It is not an additional injection, but rather has been incorporated into the DTaP/IPV/Hib/HepB as the hexavalent Infanrix vaccine. This will be given to all infants, not just those at high risk.

A different schedule remains for babies of mothers identified as being hepatitis B-positive during pregnancy. They still receive a dose of hepatitis B vaccine within 24h of birth, then at 4, 8, 12 and 16w. They will then be tested at 1y of age to see if they have contracted the infection.

There have been some big changes in the HPV vaccination programme recently.

NHS - who should have the HPV vaccine?

• HPV vaccination is now offered on the NHS to:
  • 12–13-year-old girls through schools’ immunisation programme.
  • 12–13-year-old boys (from September 2019) through schools’ immunisation programme.
• People who miss the vaccine can request it up to the age of 25y on the NHS regardless of whether they have become sexually active. This can be done through primary care or schools’ immunisation service.
• Men who have sex with men can request vaccination up to age 45y. This may be through primary care or sexual health services.

From September 2023, the JCVI has advised a single-dose schedule for most people.

• This applies to:
  • The routine adolescent HPV vaccination programme.
  • Eligible MSM (men who have sex with men) under 25y.
• People who have begun their vaccination programme and received one dose of vaccine by September 2023 will be considered fully vaccinated.
• This does not apply to:
  • Eligible MSM (men who have sex with men) aged 25–45y, who will remain on the 2-dose schedule.
  • Those who are immunocompromised or HIV positive, who will remain on the 3-dose schedule.

It was estimated that, in 2010, there were 2700 HPV-related cervical cancers and 1400 HPV-related non-cervical cancers in women, and 1000 cases of HPV-related male cancers.

A large multinational systematic review and meta-analysis looked at this (Lancet 2019;394:497).

• In girls who were vaccinated, after 5–8 years:
  • There was a massive drop in the rates of HPV 16 and 18 (by 83% in women aged 13–19y and 66% in women aged 20–24y).
  • There was also a reduction in the incidence of other strains against which they had not been immunised (because of cross immunity and herd immunity).
  • The incidence of anogenital warts also fell (by 67% in women aged 15–19y and 54% in women aged 20–24y).
  • Among those who were screened (we don’t screen these groups in the UK but they do elsewhere), there was a fall in the incidence of CIN2 or higher (by 51% in women aged 15–19y and 31% in women aged 20–24y).
• In men, who were NOT vaccinated:
  • There was no reduction in HPV rates.
  • There was a reduction in anogenital warts (incidence fell by 48% in those aged 15–19y and 32% in those aged 20–24y).

The JCVI initially rejected the meningitis B vaccination (Bexsero) because immunity seemed to wane rapidly, and the cost–benefit analysis showed that it would only be cost-effective if available at a low cost.

However, after renegotiation of the costs, it was introduced from 1 September 2015.

• Bexsero (Novartis) meningitis B vaccine is a 3-dose course, offered at age 2m, 4m and 12m.
• It is a multicomponent protein vaccine (not live).
• The only contraindication is a previous anaphylactic reaction to the vaccine or its components.
• Ideally, it should be given as the only injection in the left thigh (to allow monitoring of reactions).
• The most common side-effects are injection-site pain, fever and irritability. Fever is a particular issue.

Studies suggest that significant fever (>38°C) is an issue when Bexsero is administered alongside other routine infant immunisations. The JCVI recommends prophylactic use of paracetamol at the time of immunisation. Studies show that this reduces fever without affecting immunogenicity of either Bexsero or the other routine infant immunisations.

Those administering the vaccine should advise parents to give liquid paracetamol at the time of, or shortly after, the vaccine, and repeat for 2 further doses at 4–6h intervals.

One study has looked at the effectiveness of Bexsero in the UK since its introduction into the routine immunisation schedule (NEJM 2020;382:309):

• There has been good uptake, with 87.9% of children receiving all three doses by 2y.
• From September 2015 (date of introduction) until August 2018, the incidence of meningococcal group B disease reduced by 75% in age groups eligible for vaccination (incidence rate ratio 0.25, CI 0.19–0.36).
• Following the 12m booster, protection was seen against meningococcal group B disease for at least 2y (this is important because the highest rates of meningococcal group B disease in England are in the first 3y of life).

This vaccine was added to the UK programme because of an increase in rates of infection of a particularly deadly strain of meningitis W. This is particularly an issue in student communities where adolescents live in close contact. Rates of infection had quadrupled over the previous 4y, from 42 to 155 cases.

It is hoped that vaccinating adolescents will boost herd immunity, especially in infants and children.

• From Autumn 2015, it was added to the school vaccination programme at age 14.
• From 2022, the Men ACWY ‘catch-up’ programme for ‘Freshers’ at university has ended.
• The vaccine used (Nimenrix) is a multicomponent protein vaccine and requires only a single dose. It needs reconstituting and should be used immediately.
• Contraindications are previous anaphylactic reaction to this vaccine or its constituents.

• Rotavirus is a common cause of severe diarrhoeal illness in infants across the world. Mortality is low in the UK, but morbidity in the UK, and elsewhere, can be significant.
• In the UK, prior to the vaccination programme, rotavirus affected 140 000 children under 5 each year. 10% (14 000 children!) require hospitalisation. 
• Since introducing the vaccination programme in 2013, hospitalisation rates have fallen by a whopping 84%, with only 2200 children requiring hospitalisation in the year July 2015–June 2016!
• Rotarix (GlaxoSmithKline) is a monovalent live attenuated vaccine given ORALLY at 2m and 3m of age.
• Like the other childhood immunisations, it should not be given before 6w of age.
• Unlike the other immunisations, there is an upper age limit: the first dose can be given up to, but not beyond, 14w 6d, and the second dose can be given up to, but not beyond, 23w 6d. This is due to a theoretical increased risk of intussusception (inversion of one portion of the intestine within another) if used beyond this age.

Two publications looked at the effectiveness of rotavirus vaccination programmes. A Cochrane meta-analysis (Cochrane 2012;CD008521) looked at all RCTs comparing vaccination with placebo, no intervention or another vaccine. There were 29 trials with more than 100 000 participants where Rotarix was the vaccine used.

• In high-income countries, vaccination prevented 86% (RR 0.14, CI 0.07–0.26) of severe diarrhoeal illness.
• There were a similar number of adverse reactions in the vaccine and placebo groups.

Belgium has been vaccinating infants against rotavirus with Rotarix since 2006. A small prospective cohort study compared the immunisation status of children admitted to hospital with confirmed rotavirus with age-matched children admitted to the same hospitals for other reasons (BMJ 2012;345:e4752). 

• The study estimated effectiveness (preventing admission) to be around 90% (79–96%), similar to the Cochrane study.
• The vaccine seems to give long-term protection, offering similar levels of protection some years after vaccination.
• Rotarix, despite being a monovalent vaccine, offered protection against non-related strains of rotavirus.

The JCVI advice on which seasonal influenza vaccine is advised for specific groups is published in the JCVI annual influenza letter. We can also exercise professional judgement and recommend influenza vaccine to individuals not in a risk group if we feel that influenza is likely to exacerbate their condition.

A visual guide to which group should be given which vaccine in the 2023–24 season can be found at the UKHSA – flu vaccines 2023 to 2024 season.

• It is a live attenuated virus. It can be given at the same time as other vaccines, including live vaccines.
• It is given nasally: a single dose = one squirt up each nostril, see below.
• A SINGLE dose (1 squirt up each nostril) is required EXCEPT for those aged 2–9y who are in a clinical risk groups (see table at end of document) AND who have never had a flu jab of any kind: these children need to have 2 doses at least 4w apart (the SPC says all children need 2 doses, but the JCVI recommends that because of only modest additional protection from the second dose, only those children aged 2–9y in at-risk groups actually need 2 doses).
• Because it is a live vaccination, it is possible for those who have been immunised to transmit the virus for 1–2w to those who are severely immunocompromised (e.g. bone marrow patients requiring isolation). In these situations, if contact cannot be avoided (e.g. household members), offer an inactivated injection instead of the nasal vaccine.
• In those who cannot be given the nasal vaccine, offer the inactivated injection instead. Remember that children aged 6m–9y who have never had the flu jab before need 2 doses of the inactivated injection at least 4w apart.
• It can be kept out of the fridge for 12h, but after this point it needs to be binned.
• It has a short shelf-life (18w) and, by the time we receive it, some of this will have passed already.
  • Be particularly careful to check the expiry date before administration.
• Fluenz contains porcine gelatine. Children whose parents refuse LAIV due to the porcine gelatine content can be offered an inactivated influenza vaccine instead, although they should be advised that this may be less effective than the nasal vaccine in this age group.
• Thiomersal: no flu vaccines have thiomersal added as a preservative, although the SPC states that traces of thiomersal may be present, left over from the manufacturing process. There is no latex in any of the flu vaccines.

• A US trial has questioned the effectiveness of intranasal influenza vaccination (NEJM 2017;377:534). It looked at immunisation effectiveness in children aged 6m to 17y over the winter of 2015–16:
  • In this study, the live attenuated vaccine was not observed to be effective at all! The inactivated influenza vaccine (IM injection) was shown to be 60% effective.
• The DTB reviewed the evidence for the use of Fluenz, looking at the above paper as well as others (DTB 2017:55;114). It commented that it is likely to be a cost-effective intervention because use is likely to benefit those immunised, as well as reduce disease burden in the rest of the community.
• The JCVI reviewed results from UK trials in 2016/17 showing consistently good effectiveness for the intranasal flu vaccine.
  • The JCVI feels strongly that there is benefit to continuing with the UK intranasal flu vaccination programme at present. It provides protection to both children and the wider population. It will continue to keep the programme under review.

• More than 1 in 10 will experience nasal congestion, rhinorrhoea, headache, decreased appetite and malaise.
• More than 1 in 100 will get pyrexia and myalgia.
• More than 1 in 1000 will get epistaxis, rash, and hypersensitivity reaction, including facial oedema and urticaria.
• Fewer than 1 in 10 000 will get anaphylaxis (very rare).

Do not give Fluenz to those who are:

• Aged less than 2y.
• Actively wheezing on the day of immunisation OR with severe asthma (BTS step 4) (lack of data on safety/efficacy).
• Severely immunocompromised (leukaemias, lymphomas, HIV not on HAART, primary immunodeficiency, steroids).
• Under 18y and on aspirin, because of an association of Reye’s syndrome with aspirin and wild-type influenza.

It can be given to those on inhaled corticosteroids, low-dose oral corticosteroids or corticosteroids as replacement therapy (e.g. in adrenal insufficiency), and to those with HIV who are stable on antiretrovirals.

Fluenz is derived from eggs and contains low levels of ovalbumin, an egg-derived protein. For this reason, there has been long-standing concern about its safety in children with a history of egg allergy, despite the fact that no study has ever shown that it is capable of provoking a severe allergic reaction.

A BMJ study of more than 700 children with a history of egg allergy showed that (BMJ 2016;351:h6291):

• No participants experienced a systemic reaction to the vaccine.
• 9 participants experienced mild symptoms potentially consistent with a local IgE-mediated reaction.
• It was well tolerated by children with a history of asthma or wheeze.

This study supports the DH guidance that:

“With the exception of children with severe anaphylaxis to egg requiring intensive care, children with egg allergy can be safely vaccinated with Fluenz (nasal live attenuated flu vaccine) in any setting, including primary care and schools.”

1 in 4 people get shingles in their lifetime: it is caused by reactivation of the latent varicella zoster virus, some years after an initial chickenpox infection. As we get older, general and specific immunity wanes, so the risk of reactivation increases. In addition, shingles tends to be worse in older people, and post-herpetic neuralgia is more common.

In England and Wales, 30 000 people in their 70s get shingles each year. Around 1 in a 1000 of those who get shingles over 70 die during an infection (although some possibly of a comorbidity rather than shingles itself).

• The vaccine was introduced in 2013.
• It is not offered to those aged 80y or over as effectiveness declines with age.

From September 2023, Shingrix is replacing Zostavax in the UK immunisation programme (Green Book on immunisation, accessed October 2023).

Eligible adults are:

• Those aged 60–79y.
  • Rollout will begin in 2023, with individuals turning 65 or 70y on or after September 2023. From 2028, this will extend to those turning 60 or 65y. By 2033, the routine offer will be at age 60y. People will remain eligible until their 80th birthday (UKHSA 2023, Immunocompetent patients: timeline for the phased implementation of the change to eligible age (publishing.service.gov.uk)).
• Severely immunosuppressed individuals aged 50y and over (with no upper age limit).

Where an individual has turned 80 years of age following their first dose of Shingrix, a second dose should be provided before the individual’s 81st birthday to complete the course.

• A recombinant subunit vaccine (NOT a live vaccine).
• Involves two intramuscular injections 2–12m apart (one dose does not give significant protection – both are needed).
• For severely immunosuppressed adults, the second dose should be given ideally 8 weeks to 6 months after the first dose.
• Reduces the risk of herpes zoster infection by 97%.
• Protection declines slightly after 4 years, beyond which the efficacy is not known.
• The need for booster doses has not yet been determined by the JCVI.
• The JVCI Green Book chapter 28a advises that Shingrix can be co-administered with any vaccines. Previously, we were advised that for adjuvanted influenza vaccine (aQIV), we should leave 7 days between Shingrix and the aQIV influenza vaccine (in the 2023 schedule, this would be the vaccine offered to >65y only), but this has now been superseded due to US interim trial data showing good safety profiles.

• Zostavax can still be given while supplies remain.
• A live attenuated vaccine, given as a single intramuscular injection (or deep subcutaneous injection in those with a bleeding disorder).
• It should be kept in the fridge and, after reconstitution, it should be used immediately (definitely within 30min).
• It has a short shelf life so do check the expiry date carefully before administering it.
• Contains porcine gelatine.

Zostavax is a live vaccine, and therefore should not be given to those:

• With primary or acquired immunodeficiency, including:
  • Bone marrow disorders: acute and chronic leukaemias, lymphoma.
  • Immunosuppression due to HIV/AIDS.
  • Cellular immune deficiencies.
• On immunosuppressives, including high-dose corticosteroids. This does NOT include inhaled steroids or low-dose systemic steroids, or patients taking steroids as replacement therapy (for example, in adrenal insufficiency). Methotrexate (<0.4mg/kg/w), azathioprine (<3mg/kg/d) and mercaptopurine (<1.5mg/kg/d) are NOT contraindications because they do not offer sufficient immunosuppression to cause concern.
• With active untreated TB.
• With confirmed anaphylaxis to previous varicella vaccine.
• With confirmed anaphylactic reaction to any of the vaccine components, which include gelatine and neomycin.

Topical aciclovir is NOT a contraindication to immunisations.

• More than 1 in 10 will get erythema, pain, swelling and itching at the injection site.
• More than 1 in 100 will get haematoma, pain, induration, warmth at injection site or headaches.
• Fewer than 1 in 10 000 will get chickenpox.

Since introduction, there has been (DTB 2018;56(10):115):

• A 35% reduction in consultations for shingles in the age group immunised (that’s 17 000 fewer consultations)!
• A 50% reduction in the incidence of post-herpetic neuralgia in the age group immunised.

That would suggest that, over 3 years, the vaccine has reduced shingles by 60% and post-herpetic neuralgia by 70–88% (slightly better figures than in the trials!). This data was based on the live vaccine Zostavax.

Uptake is around 35%.

A BMJ clinical trial has shown that the live vaccine (no longer in use in the UK) was highly effective (BMJ 2023;383:e076321):

• 67% effective in the first year against recurrence of zoster.
• 83% effective against postherpetic neuralgia.
• 90% effective against hospital admission with shingles.

The way the vaccination programme is being run, it can be confusing to know who is eligible and when. The PHE shingles eligibility calculator may help patients (and clinicians!) work out who is eligible (see link in useful resources, below).

Historically, Public Health England recommended that if more than one live vaccine was needed in an individual, they should either be given on the same day or at least 4w apart. However, it has reviewed the evidence and changed its recommendations (PHE April 2015).

A reminder on the live vaccines currently used in the UK:

All combinations can now be given at any time interval, with the exception of the following combinations with MMR:

No article on vaccinations would be complete without a discussion on the tricky topic of vaccine hesitancy. We have based our summary on a 2023 BJGP editorial (BJGP 2023;73(732):295). In 2023, all UK childhood vaccination levels were below the recommended 95% coverage for herd immunity.

Vaccine hesitancy describes the motivational state of being conflicted about getting vaccinated, which may lead to delay in vaccination or refusal of vaccines despite availability. Around 20–30% of the UK population describe themselves as vaccine-hesitant, and rates are only slightly lower than this in medical professionals. It is less extreme than being anti-vaccine (<2% of the population), and vaccine-hesitant individuals are theoretically persuadable to considering vaccination.

Vaccine hesitancy is influenced by individual and societal understanding of health; social and cultural factors; public health policy; past experiences; and by the perceived risk/importance of having or avoiding the vaccination.

As individual clinicians, we are unlikely to be able to influence many of these factors. However, we can make the individual feel understood, and create a personalised response to their concerns. We may be a trusted individual to that patient, or be able to adapt our approach to our own local communities. We can rethink our consultation style, considering moving from ‘information-giving’ towards a more relational discussion using motivational interviewing techniques (see our article on Motivating behaviour change).

If you play a role in increasing vaccine uptake at practice, PCN or ICS level, you might find this open-access paper about strategies to engage with high-risk and hesitant communities useful in starting discussions (Pediatr Infect Dis J. 2022;41(5):e243).

Changes to the immunisations schedule for the UK HPV vaccination will be offered to all 12–13-year-old girls AND boys from September 2019. From autumn 2023, this is a single-dose schedule for MOST people. There is a planned 2025 introduction of a varicella vaccination: to be given as a combination with the MMR in a new MMRV vaccine. MMR: the new combination MMRV will be offered at 12 months and 18 months of age. Meningitis: an additional dose of the Hib-containing multivalent vaccine usually given earlier in infancy will be given at 18 months. We will no longer be giving a MenC booster at 12 months. The shingles vaccine has shown a reduction in disease incidence and complications. Zostavax (a live vaccine) is being phased out and replaced with Shingrix, which is not live. If in doubt, check the Green Book online. Things change fast in immunisations!

Useful resources: Websites (all resources are hyperlinked for ease of use in Red Whale Knowledge) gov.uk – complete routine immunisation schedule (a handy A4 diagram outlining immunisations schedules – for your surgery pinboard?) gov.uk – Green Books: chapter 11 – The UK immunisation schedule NES Scot - shingles vaccination eligibility calculator 2023/24