Indications scabies (but see notes above)
Cautions children (not recommended, see also under Dose, below), avoid contact with eyes and mucous membranes; do not use on broken or secondarily infected skin
Breast-feeding suspend feeding until product has been washed off
Side-effects skin irritation, burning sensation especially on genitalia and excoriations, occasionally rashes
Dose
Apply over the whole body; repeat without bathing on the following day and wash off 24 hours later; a third application may be required in some cases
Note Not recommended for children — dilution to reduce irritant effect also reduces efficacy. Some manufacturers recommend application to the body but to exclude the head and neck. However, application should be extended to the scalp, neck, face, and ears
Benzyl Benzoate Application, BP (Non-proprietary) 
Application, benzyl benzoate 25% in an emulsion basis, net price 500 mL = £2.50
Dimeticone
Dimeticone coats head lice and interferes with water balance in lice by preventing the excretion of water; it is less active against eggs and treatment should be repeated after 7 days.
DIMETICONE
Indications head lice
Cautions avoid contact with eyes; children under 6 months, medical supervision required
Side-effects skin irritation
Dose
Rub into dry hair and scalp, allow to dry naturally, shampoo after minimum 8 hours (or overnight); repeat application after 7 days
Hedrin® (Thornton & Ross)
Lotion, dimeticone 4%, net price 50 mL = £2.98, 120 mL spray pack = £7.13, 150 mL = £6.92
Note Patients should be told to keep hair away from fire and flames during treatment
Malathion
Malathion is recommended for scabies, head lice and crab lice (for details see notes above).
The risk of systemic effects associated with 1–2 applications of malathion is considered to be very low; however, applications of malathion liquid repeated at intervals of less than 1 week or application for more than 3 consecutive weeks should be avoided since the likelihood of eradication of lice is not increased.
MALATHION
Indications see notes above and under preparations
Cautions avoid contact with eyes; do not use on broken or secondarily infected skin; children under 6 months, medical supervision required
Side-effects skin irritation and hypersensitivity reactions; chemical burns also reported
Dose
Head lice, rub 0.5% preparation into dry hair and scalp, allow to dry naturally, remove by washing after 12 hours (see also notes above); repeat application after 7 days
Crab lice, apply 0.5% aqueous preparation over whole body, allow to dry naturally, wash off after 12 hours or overnight; repeat application after 7 days
Scabies, apply 0.5% preparation over whole body, and wash off after 24 hours; if hands are washed with soap within 24 hours, they should be retreated; see also notes above; repeat application after 7 days
Note For scabies, manufacturer recommends application to the body but not necessarily to the head and neck. However, application should be extended to the scalp, neck, face, and ears
Permethrin
Permethrin is effective for scabies and crab lice (for details see notes above). Permethrin is active against head lice but the formulation and licensed methods of application of the current products make them unsuitable for the treatment of head lice.
PERMETHRIN
Indications see notes above and under Dose
Cautions avoid contact with eyes; do not use on broken or secondarily infected skin; children under 6 months, medical supervision required for cream rinse (head lice); children aged 2 months–2 years, medical supervision required for dermal cream (scabies)
Side-effects pruritus, erythema, and stinging; rarely rashes and oedema
Dose
Scabies, apply 5% preparation over whole body and wash off after 8–12 hours; CHILD (see also Cautions, above) apply over whole body including face, neck, scalp and ears; if hands washed with soap within 8 hours of application, they should be treated again with cream (see notes above); repeat application after 7 days
Note Manufacturer recommends application to the body but to exclude head and neck. However, application should be extended to the scalp, neck, face, and ears
Larger patients may require up to two 30-g packs for adequate treatment
Crab lice, ADULT over 18 years, apply 5% cream over whole body, allow to dry naturally and wash off after 12 hours or after leaving on overnight; repeat application after 7 days
Lyclear® Creme Rinse (Omega Pharma) 
Cream rinse, permethrin 1% in basis containing isopropyl alcohol 20%, net price 59 mL = £3.55, 2 × 59-mL pack = £6.46
Excipients include cetyl alcohol
Dose head lice, not recommended, therefore no dose stated (insufficient contact time)
Lyclear® Dermal Cream (Omega Pharma)
Dermal cream, permethrin 5%, net price 30 g = £5.71. Label: 10, patient information leaflet
Excipients include butylated hydroxytoluene, wool fat derivative
13.10.5 Preparations for minor cuts and abrasions
Some of the preparations listed are used in minor burns, and abrasions. They are applied as necessary but should not be used on large wounds or for prolonged periods because of the possibility of hypersensitivity. The effervescent effect of hydrogen peroxide (section 13.11.6) is used to clean minor cuts and abrasions. Preparations containing camphor and sulfonamides should be avoided. Preparations such as magnesium sulfate paste are also listed but are now rarely used to treat carbuncles and boils as these are best treated with antibiotics (section 5.1.1.2).
Cetrimide Cream, BP
Cream, cetrimide 0.5% in a suitable water-miscible basis such as cetostearyl alcohol 5%, liquid paraffin 50% in freshly boiled and cooled purified water, net price 50 g = £1.11
Proflavine Cream, BPC
Cream, proflavine hemisulfate 0.1%, yellow beeswax 2.5%, chlorocresol 0.1%, liquid paraffin 67.3%, freshly boiled and cooled purified water 25%, wool fat 5%, net price 100 mL = £2.40
Excipients include beeswax, wool fat
Note Stains clothing
Preparations for boils
Magnesium Sulfate Paste, BP
Paste, dried magnesium sulfate 45 g, glycerol 55 g, phenol 500 mg, net price 25 g = 97p, 50 g = £2.01
Note Should be stirred before use
Dose apply under dressing
Collodion
Flexible collodion may be used to seal minor cuts and wounds that have partially healed.
Collodion, Flexible, BP
Collodion, castor oil 2.5%, colophony 2.5% in a collodion basis, prepared by dissolving pyroxylin (10%) in a mixture of 3 volumes of ether and 1 volume of alcohol (90%), net price 10 mL = 30p. Label: 15
Contra-indications allergy to colophony in elastic adhesive plasters and tape
Skin tissue adhesive
Tissue adhesives are used for closure of minor skin wounds and for additional suture support. They should be applied by an appropriately trained healthcare professional. Skin tissue adhesives may cause skin sensitisation.
Dermabond ProPen® (Ethicon)
Topical Skin Adhesive, sterile, octyl 2-cyanoacrylate, net price 0.5 mL = £18.92
Epiglu® (Schuco)
Tissue adhesive, sterile, ethyl-2-cyanoacrylate 954.5 mg/g, polymethylmethacrylate, net price 4 × 3-g vials = £149.50 (with dispensing pipettes and pallete)
Histoacryl® (B. Braun)
Tissue adhesive, sterile, enbucrilate, net price 5 × 200-mg unit (blue) = £32.00, 10 × 200-mg unit (blue) = £67.20, 5 × 500-mg unit (clear or blue) = £34.65, 10 × 500-mg unit (blue) = £69.30
13.11 Skin cleansers, antiseptics, and desloughing agents
Soap or detergent is used with water to cleanse intact skin; emollient preparations such as aqueous cream (section 13.2.1.1) or emulsifying ointment (section 13.2.1) can be used in place of soap or detergent for cleansing dry skin.
An antiseptic is used for skin that is infected or that is susceptible to recurrent infection. Detergent preparations containing chlorhexidine or povidone–iodine, which should be thoroughly rinsed off, are used. Emollients may also contain antiseptics (section 13.2.1).
Antiseptics such as chlorhexidine or povidone–iodine are used on intact skin before surgical procedures; their antiseptic effect is enhanced by an alcoholic solvent. Antiseptic solutions containing cetrimide can be used if a detergent effect is also required.
Hydrogen peroxide, an oxidising agent, can be used in solutions of up to 6 % for skin disinfection, such as cleansing and deodorising wounds and ulcers; hydrogen peroxide is also available as a cream for superficial bacterial skin infections.
For irrigating ulcers or wounds, lukewarm sterile sodium chloride 0.9% solution is used, but tap water is often appropriate.
Potassium permanganate solution 1 in 10 000, a mild antiseptic with astringent properties, can be used for exudative eczematous areas; treatment should be stopped when the skin becomes dry. It can stain skin and nails especially with prolonged use.
13.11.1 Alcohols and saline
ALCOHOL
Indications skin preparation before injection
Cautions flammable; avoid broken skin; patients have suffered severe burns when diathermy has been preceded by application of alcoholic skin disinfectants
Industrial Methylated Spirit, BP
Solution, 19 volumes of ethanol and 1 volume approved wood naphtha, net price ‘66 OP’ (containing 95% by volume alcohol) 100 mL = 50p; ‘74 OP’ (containing 99% by volume alcohol) 100 mL = 39p. Label: 15
Surgical Spirit, BP
Spirit, methyl salicylate 0.5 mL, diethyl phthalate 2%, castor oil 2.5%, in industrial methylated spirit, net price 100 mL = 20p. Label: 15
SODIUM CHLORIDE
Indications see notes above; nebuliser diluent (section 3.1.5); sodium depletion (section 9.2.1.2); electrolyte imbalance (section 9.2.2.1); eye (section 11.8.1); oral hygiene (section 12.3.4)
Sodium Chloride (Non-proprietary)
Solution (sterile), sodium chloride 0.9%, net price 25 × 20-mL unit = £4.95, 200-mL can = £2.65, 1 litre = 80p
Flowfusor® (Fresenius Kabi)
Solution (sterile), sodium chloride 0.9%, net price 120-mL Bellows Pack = £1.53
Irriclens® (ConvaTec)
Solution in aerosol can (sterile), sodium chloride 0.9%, net price 240-mL can = £3.49
Irripod® (C D Medical)
Solution (sterile), sodium chloride 0.9%, net price 25 × 20-mL sachet = £5.84
Miniversol® (Aguettant)
Solution (sterile), sodium chloride 0.9%, net price 30 × 45-mL unit = £13.20; 30 × 100-mL unit = £19.50
Normasol® (Mölnlycke)
Solution (sterile), sodium chloride 0.9%, net price 25 × 25-mL sachet = £6.42; 10 × 100-mL sachet = £7.80
Stericlens® (C D Medical)
Solution in aerosol can (sterile), sodium chloride 0.9%, net price 100-mL can = £2.06, 240-mL can = £3.13
13.11.2 Chlorhexidine salts
CHLORHEXIDINE
Indications see under preparations; bladder irrigation and catheter patency solutions (see section 7.4.4)
Cautions avoid contact with eyes, brain, meninges and middle ear; not for use in body cavities; alcoholic solutions not suitable before diathermy or for use on neonatal skin; in preterm neonates, use sparingly, do not allow solution to pool, and monitor for skin reactions — risk of severe chemical burns
Side-effects occasional sensitivity; also reported chemical burns in preterm neonates
Chlorhexidine 0.05% (Baxter)
2000 Solution (sterile), pink, chlorhexidine acetate 0.05%, net price 1000 mL = 77p
For cleansing and disinfecting wounds and burns
Cepton® (LPC)
Skin wash (= solution), red, chlorhexidine gluconate 1%, net price 150 mL = £3.64
For use as skin wash in acne
ChloraPrep® (CareFusion)
Cutaneous solution, sterile, chlorhexidine gluconate 2% in isopropyl alcohol 70%, net price (all with single applicator) 0.67 mL (with SEPP® applicator) = 30p, 1.5 mL (with FREPP® applicator) = 55p, 1.5 mL = 55p, 3 mL = 85p, 10.5 mL = £2.92, 26 mL = £6.50; (all with single applicator, with tint) 3 mL = 89p, 10.5 mL = £3.07, 26 mL = £6.83
For skin disinfection before invasive procedures; CHILD under 2 months, not recommended
Note Flammable
Hibiscrub® (Mölnlycke)
Cleansing solution, red, chlorhexidine gluconate 4%, perfumed, in a surfactant solution, net price 250 mL = £4.25, 500 mL = £5.25, 5 litres = £24.00
Excipients include fragrance
Use instead of soap for pre-operative hand and skin preparation and for general hand and skin disinfection
Hibi® Liquid Hand Rub+ (Mölnlycke)
Solution, chlorhexidine gluconate 0.5%, in isopropyl alcohol 70%, net price 500 mL = £5.25
To be used undiluted for hand and skin disinfection
Hibitane Obstetric® (Derma UK)
Cream, chlorhexidine gluconate solution 5% (≡ 1% chlorhexidine gluconate), in a pourable water-miscible basis, net price 250 mL = £9.00
For use in obstetrics and gynaecology as an antiseptic and lubricant (for application to skin around vulva and perineum and to hands of midwife or doctor)
Hydrex® (Ecolab)
Solution, chlorhexidine gluconate solution 2.5% (≡ chlorhexidine gluconate 0.5%), in denatured ethanol 70%, net price 600 mL (clear) = £3.49; 600 mL (pink) = £3.49, 200-mL spray = £1.77, 500-mL spray = £3.01
For pre-operative skin disinfection
Note Flammable
Surgical scrub, chlorhexidine gluconate 4% in a surfactant solution, net price 250 mL = £3.39, 500 mL = £3.59
Excipients include fragrance
For pre-operative hand and skin preparation and for general hand disinfection
Unisept® (Medlock)
Solution (sterile), pink, chlorhexidine gluconate 0.05%, net price 25 × 25-mL sachet = £5.54; 10 × 100-mL sachet = £6.83
For cleansing and disinfecting wounds and burns and swabbing in obstetrics
13.11.3 Cationic surfactants and soaps
13.11.4 Iodine
POVIDONE–IODINE
Indications skin disinfection
Cautions broken skin (see below)
Large open wounds The application of povidone–iodine to large wounds or severe burns may produce systemic adverse effects such as metabolic acidosis, hypernatraemia and impairment of renal function.
Contra-indications corrected gestational age under 32 weeks; avoid regular use in patients with thyroid disorders or those receiving lithium therapy
Renal impairment avoid regular application to inflamed or broken mucosa
Pregnancy sufficient iodine may be absorbed to affect the fetal thyroid in the second and third trimester
Breast-feeding avoid
Side-effects rarely sensitivity; may interfere with thyroid function tests
Betadine® (Ayrton Saunders)
Dry powder spray, povidone–iodine 2.5% in a pressurised aerosol unit, net price 150-g unit = £2.63
For skin disinfection, particularly minor wounds and infections; CHILD under 2 years not recommended
Note Not for use in serous cavities
Savlon® Dry (Novartis Consumer Health)
Powder spray, povidone–iodine 1.14% in a pressurised aerosol unit, net price 50-mL unit = £2.51
For minor wounds
Videne® (Ecolab)
Alcoholic tincture, povidone–iodine 10%, net price 500 mL = £5.43
To be applied undiluted in pre-operative skin disinfection
Antiseptic solution, povidone–iodine 10% in aqueous solution, net price 500 mL = £5.43
To be applied undiluted in pre-operative skin disinfection and general antisepsis
Surgical scrub, povidone–iodine 7.5% in aqueous solution, net price 500 mL = £5.43
To be used as a pre-operative scrub for hand and skin disinfection
13.11.5 Phenolics
Triclosan has been used for disinfection of the hands and wounds, and for disinfection of the skin before surgery.
13.11.6 Oxidisers and dyes
HYDROGEN PEROXIDE
Indications see under preparations below
Cautions large or deep wounds; avoid on healthy skin and eyes; bleaches fabric; incompatible with products containing iodine or potassium permanganate
Hydrogen Peroxide Solution, BP
Solution 6% (20 vols), net price 200 mL = 54p
Solution 3% (10 vols), net price 200 mL = 53p
For skin disinfection, particularly cleansing and deodorising wounds and ulcers
Note The BP directs that when hydrogen peroxide is prescribed, hydrogen peroxide solution 6% (20 vols) should be dispensed.
Important Strong solutions of hydrogen peroxide which contain 27% (90 vols) and 30% (100 vols) are only for the preparation of weaker solutions
POTASSIUM PERMANGANATE
Indications cleansing and deodorising suppurating eczematous reactions and wounds
Cautions irritant to mucous membranes
Dose
Wet dressings or baths, approx. 0.01% solution
Note Stains skin and clothing
Potassium Permanganate Solution
Solution, potassium permanganate 0.1% (1 in 1000) in water
Dose to be diluted 1 in 10 to provide a 0.01% (1 in 10 000) solution
13.11.7 Desloughing agents
Alginate, hydrogel and hydrocolloid dressings (Appendix 5) are effective at wound debridement. Sterile larvae (maggots) (available from BioMonde) are also used for managing sloughing wounds and are prescribable on the NHS.
Desloughing solutions and creams are of little clinical value. Substances applied to an open area are easily absorbed and perilesional skin is easily sensitised; gravitational dermatitis may be complicated by superimposed contact sensitivity to substances such as neomycin or lanolin.
For further information on wound management products see Appendix 5.
13.12 Antiperspirants
Aluminium chloride is a potent antiperspirant used in the treatment of hyperhidrosis. Aluminium salts are also incorporated in preparations used for minor fungal skin infections associated with hyperhidrosis.
In more severe cases specialists use glycopyrronium bromide as a 0.05% solution in the iontophoretic treatment of hyperhidrosis of plantar and palmar areas. Botox® contains botulinum toxin type A complex and is licensed for use intradermally for severe hyperhidrosis of the axillae unresponsive to topical antiperspirant or other antihidrotic treatment (section 4.9.3).
ALUMINIUM SALTS
Indications see under Dose below
Cautions avoid contact with eyes or mucous membranes; avoid use on broken or irritated skin; do not shave axillae or use depilatories within 12 hours of application; avoid contact with clothing
Side-effects skin irritation
Dose
Hyperhidrosis affecting axillae, hands or feet, apply liquid formulation at night to dry skin, wash off the following morning, initially daily then reduce frequency as condition improves — do not bathe immediately before use
Hyperhidrosis, bromidrosis, intertrigo, and prevention of tinea pedis and related conditions, apply powder to dry skin
Anhydrol® Forte (Dermal)
Solution (= application), aluminium chloride hexahydrate 20% in an alcoholic basis, net price 60-mL bottle with roll-on applicator = £2.51. Label: 15
Excipients none as listed in section 13.1.3.
Driclor® (Stiefel)
Application, aluminium chloride hexahydrate 20% in an alcoholic basis, net price 75-mL bottle with roll-on applicator = £3.01. Label: 15
Excipients none as listed in section 13.1.3.
Note A 30-mL pack is on sale to the public
GLYCOPYRRONIUM BROMIDE
Indications iontophoretic treatment of hyperhidrosis; drying secretions (see Prescribing in Palliative Care); maintenance treatment of chronic obstructive pulmonary disease (section 3.1.2); other indications, see section 15.1.3
Cautions see notes (Antimuscarinics) in section 1.2 (but poorly absorbed and systemic effects unlikely)
Contra-indications see notes (Antimuscarinics) in section 1.2 (but poorly absorbed and systemic effects unlikely); also infections affecting the treatment site
Side-effects see notes (Antimuscarinics) in section 1.2 (but poorly absorbed and systemic effects unlikely); also tingling at administration site
Dose
Consult product literature; only 1 site to be treated at a time, max. 2 sites treated in any 24 hours, treatment not to be repeated within 7 days
13.13 Topical circulatory preparations
These preparations are used to improve circulation in conditions such as bruising, superficial thrombophlebitis, chilblains and varicose veins but are of little value. Chilblains are best managed by avoidance of exposure to cold; neither systemic nor topical vasodilator therapy is established as being effective. Sclerotherapy of varicose veins is described in section 2.13.
Rubefacients are described in section 10.3.2.
Hirudoid® (Genus) 
Cream, heparinoid 0.3% in a vanishing-cream basis, net price 50 g = £3.99
Excipients include cetostearyl alcohol, hydroxybenzoates (parabens)
Gel, heparinoid 0.3%, net price 50 g = £3.99
Excipients include propylene glycol, fragrance
Dose apply up to 4 times daily in superficial soft-tissue injuries and superficial thrombophlebitis
14 Immunological products and vaccines
14.1 Active immunity
Active immunity can be acquired by natural disease or by vaccination. Vaccines stimulate production of antibodies and other components of the immune mechanism; they consist of either:
a live attenuated form of a virus (e.g. measles, mumps and rubella vaccine) or bacteria (e.g. BCG vaccine), or
inactivated preparations of the virus (e.g. influenza vaccine) or bacteria, or
detoxified exotoxins produced by a micro-organism (e.g. tetanus vaccine), or
extracts of a micro-organism, which may be derived from the organism (e.g. pneumococcal vaccine) or produced by recombinant DNA technology (e.g. hepatitis B vaccine).
Live attenuated vaccines usually produce a durable immunity, but not always as long-lasting as that resulting from natural infection.
Inactivated vaccines may require a primary series of injections of vaccine to produce an adequate antibody response, and in most cases booster (reinforcing) injections are required; the duration of immunity varies from months to many years. Some inactivated vaccines are adsorbed onto an adjuvant (such as aluminium hydroxide) to enhance the antibody response.
Advice in this chapter reflects that in the handbook Immunisation against Infectious Disease (2006), which in turn reflects the guidance of the Joint Committee on Vaccination and Immunisation (JCVI).
Chapters from the handbook are available at www.immunisation.dh.gov.uk
The advice in this chapter also incorporates changes announced by the Chief Medical Officer and Health Department Updates.
Cautions Most individuals can safely receive the majority of vaccines. Vaccination may be postponed if the individual is suffering from an acute illness; however, it is not necessary to postpone immunisation in patients with minor illnesses without fever or systemic upset. See also Predisposition to Neurological Problems, below. For individuals with bleeding disorders, see Route of Administration, below. If alcohol or disinfectant is used for cleansing the skin it should be allowed to evaporate before vaccination to prevent possible inactivation of live vaccines.
When 2 or more live vaccines are required (and are not available as a combined preparation), they can be administered at any time before or after each other at different sites, preferably in a different limb; if more than one injection is to be given in the same limb, they should be administered at least 2.5 cm apart (but see also BCG Vaccines). Yellow fever and MMR vaccines should not be administered on the same day; there should be a 4-week minimum interval between the vaccines. When protection is rapidly required, the vaccines can be given at any interval and an additional dose of MMR may be considered. Varicella–zoster and MMR vaccines can be given on the same day or separated by a 4-week minimum interval. When protection is rapidly required, the vaccines can be given at any interval and an additional dose of the vaccine given second may be considered. For interactions see Appendix 1 (vaccines).
See also Cautions under individual vaccines.
Contra-indications Vaccines are contra-indicated in those who have a confirmed anaphylactic reaction to a preceding dose of a vaccine containing the same antigens or vaccine component (such as antibacterials in viral vaccines). The presence of the following excipients in vaccines and immunological products has been noted under the relevant entries:
Gelatin
Gentamicin
Kanamycin
Neomycin
Penicillins
Polymyxin B
Streptomycin
Thiomersal
Hypersensitivity to egg Individuals with evidence of previous anaphylactic reaction to egg should not be given tick-borne encephalitis vaccine, and yellow fever vaccine should only be considered under the guidance of a specialist. Individuals with a history of egg allergy can be immunised with either an egg free influenza vaccine, if available, or an influenza vaccine with an ovalbumin content less than 120 nanograms/mL (facilities should be available to treat anaphylaxis). Vaccines with an ovalbumin content more than 120 nanograms/mL or where content is not stated should not be used in individuals with egg allergy. If an influenza vaccine containing ovalbumin is being considered in those with a history of anaphylaxis to egg or egg allergy with uncontrolled asthma, these individuals should be referred to a specialist in hospital. See also Cautions under MMR vaccine.
See also Vaccines and HIV infection, below.
Live vaccines may be contra-indicated temporarily in individuals who are:
immunosuppressed (see Impaired Immune Response, below);
pregnant (see Pregnancy and Breast-feeding, below).
See also Contra-indications under individual vaccines.
Impaired immune response Immune response to vaccines may be reduced in immunosuppressed patients and there is also a risk of generalised infection with live vaccines. Severely immunosuppressed patients should not be given live vaccines (including those with severe primary immunodeficiency). Specialist advice should be sought for those being treated with high doses of corticosteroids (dose equivalents of prednisolone: adults, at least 40 mg daily for more than 1 week; children, 2 mg/kg daily for at least 1 week or 1 mg/kg daily for 1 month), or other immunosuppressive drugs310, and those being treated for malignant conditions with chemotherapy or generalised radiotherapy310, 311. However, with the exception of severe combined immunodeficiency, the benefit from rotavirus vaccination is likely to outweigh the risk in other types of immunosuppression; if there is any doubt, advice should be sought from a specialist. For special reference to HIV infection, see below.
The Royal College of Paediatrics and Child Health has produced a statement, Immunisation of the Immunocompromised Child (2002) (available at www.rcpch.ac.uk).
Pregnancy Live vaccines should not be administered routinely to pregnant women because of the theoretical risk of fetal infection but where there is a significant risk of exposure to disease (e.g. to yellow fever), the need for vaccination usually outweighs any possible risk to the fetus. Termination of pregnancy following inadvertent immunisation is not recommended. There is no evidence of risk from vaccinating pregnant women with inactivated viral or bacterial vaccines or toxoids. For use of specific vaccines during pregnancy, see under individual vaccines.
Breast-feeding Although there is a theoretical risk of live vaccine being present in breast milk, vaccination is not contra-indicated for women who are breast-feeding when there is significant risk of exposure to disease. There is no evidence of risk from vaccinating women who are breast-feeding, with inactivated viral or bacterial vaccines or toxoids. For use of specific vaccines during breast-feeding, see under individual vaccines.
Side-effects Injection of a vaccine may be followed by local reactions such as pain, inflammation, redness, and lymphangitis. An induration or sterile abscess may develop at the injection site. Gastro-intestinal disturbances, fever, headache, irritability, loss of appetite, fatigue, myalgia, and malaise are among the most commonly reported side-effects. Other side-effects include influenza-like symptoms, dizziness, paraesthesia, asthenia, drowsiness, arthralgia, rash, and lymphadenopathy. Hypersensitivity reactions, such as bronchospasm, angioedema, urticaria, and anaphylaxis, are very rare but can be fatal (see section 3.4.3 for management of allergic emergencies).
Oral vaccines such as cholera, live poliomyelitis, rotavirus, and live typhoid can also cause gastro-intestinal disturbances such as nausea, vomiting, abdominal pain and cramps, and diarrhoea.
See also Predisposition to Neurological Problems, below.
Some vaccines (e.g. poliomyelitis) produce very few reactions, while others (e.g. measles, mumps and rubella) may cause a very mild form of the disease. Occasionally more serious adverse reactions can occur — these should always be reported to the CHM (see Adverse Reactions to Drugs).
See also Preterm Birth.
Post-immunisation pyrexia in infants
The parent should be advised that if pyrexia develops after childhood immunisation, and the infant seems distressed, a dose of paracetamol can be given and, if necessary, a second dose can be given 4–6 hours later. Ibuprofen can be used if paracetamol is unsuitable, but if a second dose of ibuprofen is required, it is given 6 hours after the first dose. The parent should be warned to seek medical advice if the pyrexia persists.
For post-immunisation pyrexia in an infant aged 2–3 months, the dose of paracetamol is 60 mg; the dose of ibuprofen is 50 mg (on a doctor’s advice). An oral syringe can be obtained from any pharmacy to give the small volume required.
Predisposition to neurological problems
When there is a personal or family history of febrile convulsions, there is an increased risk of these occurring during fever from any cause including immunisation, but this is not a contra-indication to immunisation. In children who have had a seizure associated with fever without neurological deterioration, immunisation is recommended; advice on the management of fever (see Post-immunisation pyrexia in infants, above) should be given before immunisation. When a child has had a convulsion not associated with fever, and the neurological condition is not deteriorating, immunisation is recommended.
Children with stable neurological disorders (e.g. spina bifida, congenital brain abnormality, and perinatal hypoxic-ischaemic encephalopathy) should be immunised according to the recommended schedule.
When there is a still evolving neurological problem, including poorly controlled epilepsy, immunisation should be deferred and the child referred to a specialist. Immunisation is recommended if a cause for the neurological disorder is identified. If a cause is not identified, immunisation should be deferred until the condition is stable.
Further information on adverse effects associated with specific vaccines can be found under individual vaccines.
Vaccines and HIV infection HIV-positive individuals with or without symptoms can receive the following live vaccines:
MMR (but avoid if immunity significantly impaired), varicella-zoster vaccine against chickenpox (but avoid if immunity significantly impaired — consult product literature)311, rotavirus;
and the following inactivated vaccines:
anthrax, cholera (oral), diphtheria, haemophilus influenzae type b, hepatitis A, hepatitis B, human papillomavirus, influenza (injection), meningococcal, pertussis, pneumococcal, poliomyelitis, rabies, tetanus, tick-borne encephalitis, typhoid (injection).
HIV-positive individuals should not receive:
BCG, influenza nasal spray (unless stable HIV infection and receiving antiretroviral therapy), typhoid (oral), yellow fever312
Note The above advice differs from that for other immunocompromised patients; Immunisation Guidelines for HIV-infected Adults issued by British HIV Association (BHIVA) are available at www.bhiva.org and, Immunisation of HIV-infected Children issued by Children’s HIV Association (CHIVA) are available at www.chiva.org.uk
Vaccines and asplenia The following vaccines are recommended for asplenic patients or those with splenic dysfunction:
haemophilus influenzae type b; influenza; meningococcal A, C, W135, and Y conjugate; pneumococcal.
For antibiotic prophylaxis in asplenia see Table 2. Summary of Antibacterial Prophylaxis.
Route of administration Vaccines should not be given intravenously. Most vaccines are given by the intramuscular route, although some are given by either the intradermal, deep subcutaneous, or oral route. The intramuscular route should not be used in patients with bleeding disorders such as haemophilia or thrombocytopenia, vaccines usually given by the intramuscular route should be given by deep subcutaneous injection instead.
Note The Department of Health has advised against the use of jet guns for vaccination owing to the risk of transmitting blood-borne infections, such as HIV.
Immunisation schedule
Vaccines for the childhood immunisation schedule should be obtained from local health organisations or from ImmForm (www.immform.dh.gov.uk) — not to be prescribed on FP10 (HS21 in Northern Ireland; GP10 in Scotland; WP10 in Wales).
Preterm birth
Babies born preterm should receive all routine immunisations based on their actual date of birth. The risk of apnoea following vaccination is increased in preterm babies, particularly in those born at or before 28 weeks gestational age. If babies at risk of apnoea are in hospital at the time of their first immunisation, they should be monitored for 48 hours after immunisation. If a baby develops apnoea, bradycardia, or desaturation after the first immunisation, the second immunisation should also be given in hospital with similar monitoring. Seroconversion may be unreliable in babies born earlier than 28 weeks’ gestation or in babies treated with corticosteroids for chronic lung disease; consideration should be given to testing for antibodies against Haemophilus influenzae type b, meningococcal C, and hepatitis B after primary immunisation.
| When to immunise (for preterm infants — see note above) | Vaccine given and dose schedule (for details of dose, see under individual vaccines) |
|---|---|
Neonates at risk only |
|
2 months |
|
3 months |
|
4 months |
|
12–13 months |
|
Between 3 years and 4 months, and 5 years |
|
11–14 years (females only) 1 | |
13–15 years |
|
13–18 years |
|
During adult life, women of child-bearing age susceptible to rubella |
|
During adult life, those entering or being at university who are at risk of meningococcal group C disease |
|
During adult life, if not previously immunised |
|
70 years |
|
________
1. First dose of HPV vaccine will be offered to females aged 12–13 years of age in England, Wales, and Northern Ireland, and 11–14 years of age in Scotland.
2. If a 3-dose course of HPV vaccine has been started under the 2013/2014 programme, where possible, the course should be completed.
3. The two human papillomavirus vaccines are not interchangeable and, ideally, one vaccine product should be used for the entire course. However, for those females who started the schedule with Cervarix® under the national immunisation programme, but did not complete the vaccination course, the course can be completed with Gardasil®.
High-risk groups
For information on high-risk groups, see section 14.4 under individual vaccines
BCG Vaccines
Hepatitis A Vaccine
Hepatitis B Vaccine
Influenza Vaccine
Pneumococcal Vaccines
Tetanus Vaccines
14.2 Passive immunity
Immunity with immediate protection against certain infective organisms can be obtained by injecting preparations made from the plasma of immune individuals with adequate levels of antibody to the disease for which protection is sought (see under Immunoglobulins, section 14.5). The duration of this passive immunity varies according to the dose and the type of immunoglobulin. Passive immunity may last only a few weeks; when necessary, passive immunisation can be repeated.
Antibodies of human origin are usually termed immunoglobulins. The term antiserum is applied to material prepared in animals. Because of serum sickness and other allergic-type reactions that may follow injections of antisera, this therapy has been replaced wherever possible by the use of immunoglobulins. Reactions are theoretically possible after injection of human immunoglobulins but reports of such reactions are very rare.
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