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Vaccine update: issue 320, April 2021, European Immunisation Week special edition

Published 30 April 2021

#VaccinesWork to bring us closer

This year European Immunisation week is focussing on the way in which vaccines allow us to live our lives to the full, keeping our families and communities free from the threat of vaccine preventable diseases.

Nothing has brought this threat into sharper focus than the COVID-19 pandemic and the sacrifices that this has caused for so many of us in our efforts to keep us all safe.

Along with other measures like mask-wearing and physical distancing, equitably protecting people with safe and effective vaccines will help end the pandemic and bring us all closer again.

Vaccines are one of the greatest scientific innovations of all time. In the past century, they have brought us closer to ending polio and helped us eradicate smallpox. Thanks to vaccines, today billions of people live healthy lives protected from vaccine-preventable diseases like measles and whooping cough.

In the last 30 years, across the world, child deaths have decreased by over 50%, thanks in large part to vaccines. Vaccines now help protect against more than 20 diseases, from pneumonia to cervical cancer and Ebola.

Immunisation helps children grow into healthy adults. Vaccinated, healthy children can attend school and reap the benefits of education. These benefits continue throughout our lives as we continue with that early protection and gain further value from the vaccines offered to us throughout our life course.

Immunisation reaches more people than any other health service, connecting families with health care systems. The benefits of vaccination stretch from the individual, to our families, our communities and the world. The value this brings to all our lives should never be underestimated.

PHE has produced Social media cards to promote uptake of routine vaccinations and the need to get up to date and have the important protection from infectious disease that is everyone’s right.

Immunization agenda 2030 (IA2030)

The IA2030 strategy – to extend the benefits of vaccines to everyone, everywhere – is underpinned by 4 core principles: it puts people in the centre, is led by countries, implemented through broad partnerships and driven by data. The IA2030 strategy systematically applies the core principles across each of the strategic priorities.

People centred

Responding to populations needs. The design, management and delivery of immunisation services should be shaped by and responsive to the needs of individuals and communities, including addressing barriers to access to immunisation services due to age, location, social and cultural norms and gender-related factors.

Country owned

Driving progress from the bottom up. Countries should establish targets that represent the local context and should be held accountable for achieving them.

Partnership based

Aligning efforts to maximise impact. Immunisation partners should align and coordinate their actions to increase efficiency, build on complementarity and involve sectors beyond immunisation for mutual benefit.

Data-guided

Promoting evidence-based decision-making. High-quality, “fit-for-purpose” data will be used to track progress, improve programme performance and form the basis of decision-making at all levels.

Animal bites: rabies and other infections

As the warmer weather approaches and lockdown restrictions are being lifted, it is important for people to be aware of the risks of rabies and other infections if they come into contact with wild animals and bats, even in this country. Those travelling overseas are often aware of the risks of rabies, but those on staycations here in the UK are often unaware that bats in this country may harbour rabies-like-viruses, and that bites from other animals can lead to a wide variety of infections, both bacterial and viral.

Some of the infections that can be caught from cat and dog bites include pasteurella multocida, capnocytophaga canimorsus, bartonella henselae (cat scratch disease); leptospirosis, hantavirus, rat bite fever and lymphocytic choriomeningitis virus (LCMV) can be acquired from rodent bites; and even ‘seal finger’ and unusual mycoplasma infections can occur following bites from seals. Rarely, bites from animals can cause unusual presentations, therefore it is important to take a thorough history to ensure relevant exposures to animals are picked up.

Rabies-like viruses in bats in the UK

While we don’t have rabies in terrestrial animals in the UK, risks do exist from contact with bats in this country. Rabies-like viruses (bat lyssaviruses) can be found in many countries around the world, including in the UK. Rabies can be passed on to people through a bat bite, scratch or contact with the bat’s saliva. It is therefore important that all bat bites, scratches or other exposures, whether in the UK or abroad, should be assessed promptly by a health professional so that they can arrange rabies post-exposure treatment if needed.

During the Spring and Summer months, bat activity increases and, particularly in hot dry weather, the bats may get exhausted or dehydrated, be found on the ground and then picked up by people. Bat bites can occur if someone handles a bat without wearing appropriate protective gloves, so never pick up a bat with bare hands. Bat bites in the UK are felt rather than seen and may not always bleed or leave an obvious mark on the skin.

PHE has developed a leaflet for the public and health professionals explaining the rabies risks from bat contact. This covers what people should do if they find an injured or grounded bat as well as what to do if they come into contact with a bat. Further information is available in the ‘Bat contact and rabies risks’ leaflet and copies can be ordered using product code 400321BT from the Health Publications website.

Overseas travellers

It is important that all travellers check whether rabies is present in the place they are visiting. This information can be found on the TravelHealthPro country information pages. Pre-exposure rabies vaccination may be appropriate for some travellers depending on where they are travelling to and what activities they will be doing there. Further information is available in the Green Book.

Travellers should be reminded to avoid contact with animals while they are aboard. They should be advised not to touch, feed or pat wild or domestic animals, even within temples, zoos or sanctuaries. Children are at greatest risk of rabies as they are more likely to touch animals and may not then tell their parents or guardians.

Rabies risk and travel leaflet

A leaflet with further advice for overseas travellers can be ordered for GP surgeries, hospitals, travel clinics or other locations using product code 400322RT from the Health Publications website.

Actions following an animal or bat bite anywhere in the world

If someone is bitten, scratched or licked by any animal, they should immediately wash and thoroughly flush the area with soap and lots of water. Medical attention should be sought locally and travellers overseas should not wait until they return to the UK to start a course of rabies post-exposure treatment if required.

For some animal bites, a course of antibiotics may be required and for puncture wounds an assessment of their tetanus risk should be undertaken with a tetanus booster if indicated. Further advice on the management of animal bites is available.

Rabies guidelines

Updated guidelines on managing rabies post-exposure treatment were published by PHE in April 2019. The Rabies and Immunoglobulin Service (RIgS) team is based in PHE’s National Infection Service at Colindale and are available to assist health professionals with enquiries and rabies post-exposure risk assessments. They can be contacted Monday-Friday 09:00-17:00 on 0330 128 1020.

RIgS no longer hold vaccine or rabies immunoglobulin. Rabies vaccine should be available in all trusts in England for prompt initiation of post-exposure treatment if needed. Further information is available in the ‘Letter to A&E consultants and pharmacists: important information regarding rabies post-exposure treatment’.

Contact details for the provision of specialist advice on the assessment of the risk and appropriate management of potential rabies exposures in Northern Ireland, Scotland and Wales can be found in the Green Book.

Extension to the Shingles immunisation programme for those who missed vaccination during lockdown

Individuals become eligible for routine vaccination against shingles when they become 70 years of age and all those aged up to and including 79 years, are now eligible to receive the vaccine until they become 80 years of age.

NHS England had previously advised that individuals who were eligible for the Shingles vaccination programme who turned 80 years during the COVID-19 pandemic and missed the opportunity to be vaccinated, either due to lockdown or because they were shielding at home and unable to attend their general practice, could continue to be vaccinated up to the 31 March 2021. This has now been further extended until 31 July 2021.

There are no contractual changes to this programme: offer of vaccination is opportunistic or if requested for the catch up cohort (those aged 71 to 79 years). GPs will continue to be reimbursed the standard item of service fee which should continue to be claimed manually.

As this cohort will not be included in the Shingles PGD, a Patient Specific Direction (PSD) should be used by practices for this specific cohort of patients.

Pneumococcal polysaccharide vaccine (PPV23) – supply and administration

Due to increased global demand, supplies of Pneumovax®23 (pneumococcal polysaccharide vaccine, PPV23) have been constrained since 2017. In consequence, PHE issued guidance on prioritisation of available stock in Vaccine Update, most recently in March 2021.

In line with other national immunisation programmes, PHE will supply this vaccine for the routine immunisation programme and immunisation of those with underlying medical conditions, rather than providers locally procuring the vaccine.

The vaccine will be available to order via PHE’s ImmForm website from 1 June 2021. Details of ordering controls will be made available on ImmForm news item and Vaccine Update in due course.

Additional information is available in a PHE and NHS England and NHS Improvement bipartite letter.

Once the change occurs in June, providers are asked to prioritise previously un-vaccinated individuals and booster doses in the same order of priority that has been recommended since late 2017 and set out in table below.

Unvaccinated individuals in the high-risk priority groups, such as those with asplenia, dysfunction of the spleen, immunosuppression, cerebrospinal fluid (CSF) leaks and cochlear implants should be offered PPV23 first. Data on uptake of PPV23 indicates that only 18% of 2 to 64 year olds becoming asplenic between 1 April 2018 and 31 March 2019, had received PPV23 up to the end of March 2020.

Following vaccination of high-risk groups, providers may then offer PPV23 to previously unvaccinated individuals in moderate risk groups such as those with diabetes and chronic heart, lung, liver and kidney disease.

Once high and moderate-risk groups have been offered PPV23, individuals in lower risk groups, such as those requiring boosters and healthy over 65 year olds, can then be offered PPV23. Providers may wish to offer PPV23 to healthy over 65 year olds alongside the influenza vaccine during the 2021 to 2022 flu vaccination season.

National stocks of PCV13 (Prevenar13), or separately procured PCV10 (Synflorix), should not be used in place of PPV23 as protection from the childhood PCV13 programme has reduced pneumococcal disease due to these serotypes across all ages. PPV23 helps provide additional protection against serotypes that are not covered by PCV13 or PCV10.

Priority groups for PPV23 vaccination

Clinical risk group	Examples (decision based on clinical judgement)
High priority
Asplenia or dysfunction of the spleen	This also includes conditions such as homozygous sickle cell disease and coeliac syndrome that may lead to splenic dysfunction.
Immunosuppression	Due to disease or treatment, including patients undergoing chemotherapy leading to immunosuppression, bone marrow transplant, asplenia or splenic dysfunction, HIV infection at all stages, multiple myeloma or genetic disorders affecting the immune system (for example IRAK-4, NEMO, complement deficiency). Individuals on or likely to be on systemic steroids for more than a month at a dose equivalent to prednisolone at 20mg or more per day (any age), or for children under 20kg, a dose of 1mg or more per kg per day.
Individuals with cerebrospinal fluid leaks	This includes leakage of CSF such as following trauma or major skull surgery (does not include CSF shunts).
Individuals with cochlear implants	It is important that immunisation does not delay the cochlear implantation.
Moderate priority
Chronic respiratory disease	This includes chronic obstructive pulmonary disease (COPD), including chronic bronchitis and emphysema; and such conditions as bronchiectasis, cystic fibrosis, interstitial lung fibrosis, pneumoconiosis and bronchopulmonary dysplasia (BPD). Children with respiratory conditions caused by aspiration, or a neurological disease (for example cerebral palsy) with a risk of aspiration. Asthma is not an indication, unless so severe as to require continuous or frequently repeated use of systemic steroids (as defined in Immunosuppression below).
Chronic heart disease	This includes those requiring regular medication and/or follow-up for ischaemic heart disease, congenital heart disease, hypertension with cardiac complications, and chronic heart failure.
Chronic kidney disease	Nephrotic syndrome, chronic kidney disease at stages 4 and 5 and those on kidney dialysis or with kidney transplantation.
Chronic liver disease	This includes cirrhosis, biliary atresia and chronic hepatitis.
Diabetes	Diabetes mellitus requiring insulin or oral hypoglycaemic drugs. This does not include diabetes that is diet controlled.
Low priority
Healthy individuals aged 65 years and over. Booster doses for asplenics, those with splenic dysfunction and chronic kidney disease.

Give COVID the jab video

A new YouTube video from Romany filmmaker Jake Bowers encouraging Gypsy, Roma, Traveller and Showmen to ‘Give COVID the jab’ and get vaccinated.

Give COVID the jab

Vaccine supply for the routine vaccination programme

Reporting an ordering discrepancy via ImmForm

You can now report delivery problems and order discrepancies online via your ImmForm account. For more information, please see the ImmForm Help Guide – How To Report An Order Discrepancy, which will be available in due course via the help guides link on the ImmForm home page.

Vaccines for the 2020 to 2021 children’s flu programme supplied by PHE

Fluarix® Tetra remains available to order for children in England. PHE does not supply any flu vaccines for patients aged 18 years and over.

All batches of Fluenz® Tetra issued for the 2020 to 2021 children’s flu programme have now expired.

Please ensure that all remaining stock is removed from fridges and disposed of in line with local policies. Any disposed stock should be recorded through the stock incident page.

Providing a second dose of flu vaccine after all Fluenz® Tetra has expired

If you still need to give a second dose of flu vaccine 4 weeks after the first dose (for example, for children in clinical risk groups aged 2 to under 9 years who have not received influenza vaccine before), then it is safe and effective to give inactivated vaccine (Fluarix® Tetra) as a second dose.

All influenza vaccines for the 2020 to 2021 season

Information on all influenza vaccines that were available in the UK for the 2020 to 2021 season is available.

May bank holidays order and delivery schedules for routine vaccinations

Due to the May bank holidays, there will be no deliveries or order processing by Movianto UK on Monday 3 May and Monday 31 May 2021. Please see the table below for revised order and delivery dates.

For customers with standard delivery dates of Monday, please be aware that:

• after 26 April, your next available delivery day will be 10 May 2021
• after 24 May, your next available delivery day will be 7 June 2021

You are reminded to be prepared for the break in deliveries and to order accordingly. Please make sure you have sufficient room in your fridge for any additional vaccine you wish to stock over this holiday period.

Early May bank holiday – Monday 3 May 2021

Delivery date	Order cut-off date	Order cut-off time
Monday 26 April	Thursday 22 April	11:55 AM
Tuesday 27 April	Friday 23 April	11:55 AM
Wednesday 28 April	Monday 26 April	11:55 AM
Thursday 29 April	Tuesday 27 April	11:55 AM
Friday 30 April	Wednesday 28 April	11:55 AM
Monday 3 May	Closed – no deliveries or order processing
Tuesday 4 May	Thursday 29 April	11:55 AM
Wednesday 5 May	Friday 30 April	11:55 AM
Thursday 6 May	Tuesday 4 May	11:55 AM
Friday 7 May	Wednesday 5 May	11:55 AM
Monday 10 May	Thursday 6 May	11:55 AM

Late May bank holiday – Monday 31 May 2021

Delivery date	Order cut-off date	Order cut-off time
Monday 24 May	Thursday 20 May	11:55 AM
Tuesday 25 May	Friday 21 May	11:55 AM
Wednesday 26 May	Monday 24 May	11:55 AM
Thursday 27 May	Tuesday 25 May	11:55 AM
Friday 28 May	Wednesday 26 May	11:55 AM
Monday 31 May	Closed – no deliveries or order processing
Tuesday 1 June	Thursday 27 May	11:55 AM
Wednesday 2 June	Friday 28 May	11:55 AM
Thursday 3 June	Tuesday 1 June	11:55 AM
Friday 4 June	Wednesday 2 June	11:55 AM
Monday 7 June	Thursday 3 June	11:55 AM

Please be advised that emergency or ‘out of schedule’ deliveries cannot be arranged for failure to place orders in good time.

Viper antivenom has changed

The viper antivenom product supplied via ImmForm has recently changed from ViperaTAb® to Viperfav®. The products have different active ingredients, formulations and presentations:

Product	ViperaTAb®	Viperfav®
Source of immune sera	Ovine	Equine
Licensed status	Unlicensed in the UK	Unlicensed in the UK
Storage	Store in a refrigerator between 2°C and 8°C	Store in a refrigerator between 2°C and 8°C
Presentation	Each pack includes 2 x 4ml vials, containing 100mg Fab fragments each	Each pack includes 1 x 4ml vial containing F(ab’) 2 fragments
Initial treatment recommendation	The initial dose of ViperaTAb® is the contents of 2 x 4ml vials (1 pack per patient)	The initial dose of Viperfav® is the contents of 1 x 4ml vial (1 pack per patient)

Recommendations for the treatment of common adder bites and the administration of Viperfav® can be found on TOXBASE. To minimise wastage, please use all locally held stocks of in date ViperaTAb® to treat eligible patients, before switching to Viperfav®.

Change to dTaP/IPV vaccine for both the pre-school booster and maternal pertussis dTaP/IPV programmes

Boostrix-IPV® is currently supplied for both the pre-school booster and maternal pertussis dTaP/IPV programmes. This has recently changed from Repevax®.

The 2 vaccines are equivalent. To minimise wastage, please use all your locally held stocks of Repevax® to vaccinate eligible individuals, before switching to Boostrix-IPV®. There is no other change to the pre-school booster or maternal pertussis immunisation programme.

Further details about this programme can be found in chapter 24 of the Green Book.

Update to Bexsero Patient Information Leaflet

Every pack of Bexsero (Meningitis B vaccine, 10 doses) is supplied with a pad of 10 Patient Information Leaflets (PILs), as well as there being a single PIL inside each Bexsero pack. Since September 2020, an updated version of the PIL pad has been distributed with Bexsero orders. Please dispose of the single PIL from inside the pack, as it will be out of date. We will advise further when the PIL supplied in the pack is in line with the PIL pad.

MMR vaccine ordering

To rebalance central supplies of both MMR vaccines please consider ordering M-M-RvaxPRO® as your first choice, which is available without restriction.

Customers in England and Wales who require Priorix®, for example because you serve communities that do not accept vaccines containing porcine gelatine, may order up to 6 packs of Priorix® per ImmForm account per week. For assistance please contact the ImmForm Helpdesk at helpdesk@immform.org.uk.

Customers in Scotland should refer to their local ordering restrictions.

The EU Falsified Medicines Directive (FMD) and Delegated Regulation as applicable to PHE supplied vaccines for the national immunisation programme

From 11pm on 31 December 2020, when the UK’s EU exit transition period ended, the ‘safety features’ Delegated Regulation (2016/161) under the EU Falsified Medicines Directive (FMD; 2011/62/EU) no longer applied in Great Britain.

This means that in Great Britain, end users of the majority of prescription-only medicines, including the FMD-compliant products supplied by PHE via ImmForm, are no longer required to verify or decommission the unique identifiers on serialised packs. Serialised packs can nonetheless continue to be dispensed for as long as they are still in date.

Registering for a new or updating your existing ImmForm vaccine ordering account

When you register for or update an existing ImmForm account, PHE as a wholesaler of vaccines need to verify the requesting customer.

Please ensure you have your professional regulatory body registration number or Wholesaler Dealer Licence and an organisation code which can be verified when requesting updates or requesting a new vaccine ordering account.

For more information, please see the ImmForm helpsheet – how to register.

Vaccine supply for the non-routine programme

Hepatitis A vaccine

Adult

• GSK: Havrix Adult pre-filled syringe (PFS) singles and packs of 10 are available
• Sanofi Pasteur: Avaxim PFS singles and packs of 10 are available
• MSD: VAQTA Adult is available

Paediatric

• GSK: Havrix Paediatric PFS singles and packs of 10 are available
• MSD: VAQTA Paediatric is available

Hepatitis B vaccine

Adult

• GSK: Engerix B PFS singles and packs of 10 are available
• GSK: Engerix B single vials are discontinued
• GSK: Engerix B vials packs of 10 are discontinued
• GSK: Fendrix is available
• MSD: HBVAXPRO 10 µg is unavailable until late April 2021
• MSD: HBVAXPRO 40 µg is available

Paediatric:

• GSK: limited supplies of Engerix B Paediatric singles are available
• MSD: HBVAXPRO 5µg is available

Combined hepatitis A and B vaccine

• GSK: Twinrix Adult singles and packs of 10 are available
• GSK: Twinrix Paediatric is available
• GSK: Ambirix is available

Combined hepatitis A and typhoid vaccine

• Sanofi Pasteur: Viatim is available

Typhoid vaccine

• Sanofi Pasteur: Typhim singles and packs of 10 are available
• Emergent: Vivotif is available

Rabies vaccine

• Valneva: Rabipur is currently available – orders should be placed directly with Valneva or via your preferred wholesaler. Vaccine supply contact details:
  Valneva UK
  Telephone: 01252 761 007
• Sanofi Pasteur: Rabies BP is currently available without restriction

Pneumococcal polysaccharide vaccine (PPV)

• MSD: supply of Pneumovax 23 (PPV23) PFS is currently limited

Pneumococcal polysaccharide conjugate vaccine (PCV)

• Pfizer: Prevenar 13 is currently available

Varicella Zoster vaccine

• GSK: VARILRIX is available
• MSD: VARIVAX is available
• MSD: ZOSTAVAX is currently available without restrictions

Diphtheria, tetanus and poliomyelitis (inactivated) vaccine

• Sanofi Pasteur: Revaxis is available

Diphtheria, tetanus, pertussis (acellular) and poliomyelitis (inactivated) vaccine

• GSK: Supply of Boostrix-IPV is currently limited
• Sanofi Pasteur: Repevax is available without restrictions

MMR vaccine

• MSD: MMR Vaxpro is currently available without restrictions
• GSK: Priorix is currently available

Meningitis ACWY vaccine

• GSK: Menveo is available
• Pfizer: Nimenrix is currently available

Yellow fever vaccine

• Sanofi Pasteur: Stamaril is available

Human papillomavirus vaccine (HPV)

• MSD: GARDASIL is available but will be discontinued in May 2021
• MSD: Gardasil 9 is currently available
• GSK: Cervarix has been discontinued

Cholera vaccine

• Valneva: Dukoral is available

Japanese encephalytis vaccine

• Valneva: Ixiaro is available