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Vaccine Preventable Diseases (VPD) By the end of this session you will be able to: • For each disease: • Describe the main signs and symptoms, mode of transmission and period of infectivity of each different vaccine preventable disease in the U.K • Describe the historical impact of vaccination on the epidemiology of the disease • Explain the current incidence of each disease in the UK • Describe the nature and frequency of acute symptoms and potential long term complications • Know where to access further information about each disease January 2016 Diphtheria • Bacterial respiratory infection caused by toxigenic strains of Corynebacterium diphtheria or Corynebacterium ulcerans • Airborne transmission via droplets • Incubation period 2-7 days • Affects all ages but moist serious in very old and very young January 2016 Features • Early signs: mild fever, swollen neck glands, anorexia, malaise, cough • 2-3 days: membrane of dead cells forms in throat, tonsils, larynx or nose which may narrow or occlude the airway leading to respiratory distress • Toxins may travel through bloodstream = extensive organ damage, neurological & cardiac complications • Death occurs in 5-10% cases January 2016 Cases & deaths 1914-2009, England & Wales January 2016 Diphtheria issues • Before vaccination introduced it was a leading cause of death in children • Cases in the UK are very low with most being attributed to recent travel to endemic countries • Vaccination uptake is vital – epidemic in Soviet Union between 1990-1998 resulted in 157,000 cases and 5,000 deaths January 2016 Vaccination schedule Sept 2015 (up to 18 years) Age Diseases protected against 2 months Diphtheria, tetanus, whooping cough, polio, Hib, Pneumococcal, Rotavirus, and Meningococcal group B (Men B) 3 months Diphtheria, tetanus, whooping cough, polio, Hib, Meningococcal group C (Men C) and Rotavirus 4 months Diphtheria, tetanus, whooping cough, polio, Hib, Pneumococcal and Men B 12-13 months Hib/Men C Pneumococcal, Measles, mumps & rubella (MMR) and Men B 2-6yrs 3yrs 4m Children’s flu vaccine (live vaccine) Diphtheria, tetanus, whooping cough, polio MMR (pre-school immunisations) 1213yrs 1318yrs Low dose Diphtheria “d” not “D” HPV (cervical cancer) girls only 2 x doses 6 months apart Diphtheria, tetanus, polio (school leavers immunisations) Men ACWY 7 Tetanus • Caused by Clostridium tetani – a bacterium • Non- communicable (no herd immunity) • Bacteria form spores that can survive in the environment for years • Tetanus may occur if a wound or cut is infected by soil or manure • Incubation period 4-21 days • Affects people of all ages • People who recover from tetanus do not have natural immunity therefore need to be immunised January 2016 Features • Initially: muscle stiffness of the jaw (“Lockjaw”) 50% cases • Followed by: neck stiffness, difficulty swallowing, stiffness of stomach muscles, muscle spasms, sweating and fever • Complications Include; • Fractures • Hypertension • Laryngospasm • Pulmonary embolism • Aspiration • Death January 2016 Neonatal tetanus • More frequent in developing countries • Infant born without protective passive immunity • Infection of the umbilical Cord Stump • High fatality rate without treatment https://alicespringstomind.wordpress.com/2013/09/21/development-projects-abound/ January 2016 Cases & deaths, England & Wales 1969-2008 total notified cases 30 25 20 15 10 5 0 1969 1972 1975 1978 1981 1984 1987 1990 1993 1996 1999 2002 2005 2008 years 45 plus years 15 to 44 years under 15 years January 2016 More recent data (England) • January to December 2014: • 7 cases • 1 death • 80+ female • Immunisation status unknown • Cases aged 15-87 • 2 born after 1961 so eligible for vaccination (and were vaccinated appropriately) • 5 born before 1961 (so immunisation status varied) • 5 cases occurred during June & July • all involved lacerations sustained in either: home/garden/woodland/sta ble/street • No cases among people who inject drugs January 2016 Vaccination schedule Sept 2015 (up to 18 years) Age Diseases protected against 2 months Diphtheria, tetanus, whooping cough, polio, Hib, Pneumococcal, Rotavirus, and Meningococcal group B (Men B) 3 months Diphtheria, tetanus, whooping cough, polio, Hib, Meningococcal group C (Men C) and Rotavirus 4 months Diphtheria, tetanus, whooping cough, polio, Hib, Pneumococcal and Men B 12-13 months Hib/Men C Pneumococcal, Measles, mumps & rubella (MMR) and Men B 2-6yrs 3yrs 4m Children’s flu vaccine (live vaccine) Diphtheria, tetanus, whooping cough, polio MMR (pre-school immunisations) 1213yrs HPV (cervical cancer) girls only 2 x doses 6 months apart 1318yrs Diphtheria, tetanus, polio (school leavers immunisations) Men ACWY 13 Tetanus issues • 5 doses of tetanus at appropriate intervals • Early treatment with tetanus immunoglobulin for heavily contaminated wounds • Early recognition of potential tetanus wounds • Continued vigilance for early signs and symptoms of tetanus in IDUs January 2016 Pertussis (whooping cough) • Respiratory infections caused by bacterium Bordatella pertussis • Spread easily from person-to-person in droplets produced by coughing or sneezing • Most dangerous in children under 1 year, most severe in young infants • Incubation period 6-20 days with a range of 4 - 21 days • Infectious from 6 days after exposure to 3 weeks after onset of cough • Duration of illness can be 2-3 months January 2016 Features • Initial cold like symptoms • Gradually worsening cough developing into paroxysms of coughing which are characterised by whoop Complications: • Respiratory – the majority of cases involve some degree of collapsed lung and/or pneumonia • Neurological – lack of oxygen leading to altered consciousness, convulsions, permanent brain damage, death • Severe weight loss and dehydration due to vomiting • Sudden death - babies may stop breathing, apnoeic attacks • Despite low levels of disease, pertussis remains a significant cause of death in infants <6m January 2016 Vaccination schedule Sept 2015 (up to 18 years) Age Diseases protected against 2 months Diphtheria, tetanus, whooping cough, polio, Hib, Pneumococcal, Rotavirus, and Meningococcal group B (Men B) 3 months Diphtheria, tetanus, whooping cough, polio, Hib, Meningococcal group C (Men C) and Rotavirus 4 months Diphtheria, tetanus, whooping cough, polio, Hib, Pneumococcal and Men B 12-13 months Hib/Men C Pneumococcal, Measles, mumps & rubella (MMR) and Men B Offered to all pregnant women with each pregnancy 2-6yrs 3yrs 4m Children’s flu vaccine (live vaccine) Diphtheria, tetanus, whooping cough, polio MMR (pre-school immunisations) 1213yrs HPV (cervical cancer) girls only 2 x doses 6 months apart 1318yrs Diphtheria, tetanus, polio (school leavers immunisations) Men ACWY 17 100 80 150,000 60 100,000 40 50,000 20 2005 2000 1995 1990 1985 1980 1975 1970 1965 1960 1955 1950 0 1945 0 vaccine coverage 200,000 1940 notifications of pertussis Whooping cough notifications and vaccine coverage: England and Wales, 1940-2009 years notifications coverage January 2016 January 2016 Uptake rates Apr-Aug 2014 55.6% Change to acellular Current issues • Incidence in infants – accelerated schedule • Passive protection via maternal vaccination – recently extended • Uptake in infants close to 95% WHO recommendations • Vaccine highly effective but protection wanes over time • Adolescent booster under consideration Poliomyelitis • Viral infection with three types – I, II & III • Virus enters via the mouth after contact with faeces or pharyngeal secretions • Replicates in pharynx and GI tract • Invades local lymph tissue • Enters blood stream and may infect cells of central nervous system causing aseptic meningitis • More rarely replicates in and destroys the motor neurones which activate the muscles (~1:100 infections) January 2016 Features • Often asymptomatic (>95% cases) • May have mild influenza type symptoms Paralytic polio • In >1% cases • The use of one or both arms or legs may be lost and breathing may not be possible without help of a respirator. • The degree of recovery varies from person to person January 2016 Change to IPV from OPV Vaccination • Before vaccine introduced in 1950s there were up to 750 deaths per year • No cases of naturally contracted polio in the UK since 1984 • Now only endemic in Nigeria, Afghanistan and Pakistan (WHO, 2015) • Eradication by 2018 is a WHO resolution January 2016 January 2016 Haemophilus influenzae type b - Hib • Caused by infection with Haemophilus influenzae bacteria • 6 (a-f) capsular serotypes cause disease in man • Transmission occurs from coughing, sneezing, close contact with infected person. • Healthy individuals can carry Hib bacteria in their nose and throat without symptoms January 2016 Features of Hib disease • Most common presentation of invasive Hib is meningitis, frequently accompanied by bacteraemia (60%) • 15% of cases present with epiglottitis • Bacteraemia without any other concomitant infection, occurs in 10% of cases • Remainder made up of cases of septic arthritis, osteomyelitis, cellulitis, pneumonia, and pericarditis January 2016 Complications of Hib meningitis • Deafness • Convulsions • Intellectual impairment • Case fatality rate 2-5% in spite of effective antimicrobial therapy In England & Wales before 1992: • 1 child in 600 developed some form of Hib disease by 5th birthday • Hib meningitis caused 30 deaths each year • Approximately 80 children a year were left with deafness or permanent brain damage January 2016 Invasive Hib infections by age group 1990-2008 England and Wales January 2016 Vaccination schedule Sept 2015 (up to 18 years) Age Diseases protected against 2 months Diphtheria, tetanus, whooping cough, polio, Hib, Pneumococcal, Rotavirus, and Meningococcal group B (Men B) 3 months Diphtheria, tetanus, whooping cough, polio, Hib, Meningococcal group C (Men C) and Rotavirus 4 months Diphtheria, tetanus, whooping cough, polio, Hib, Pneumococcal and Men B 12-13 months Hib/Men C Pneumococcal, Measles, mumps & rubella (MMR) and Men B 2-6yrs 3yrs 4m Children’s flu vaccine (live vaccine) Diphtheria, tetanus, whooping cough, polio MMR (pre-school immunisations) 1213yrs HPV (cervical cancer) girls only 2 x doses 6 months apart 1318yrs Diphtheria, tetanus, polio (school leavers immunisations) Men ACWY Increased efficacy when given at 1yr+ 32 Meningococcal disease • Caused by infection with bacteria Neisseria meningitidis • 12 groups identified – A,B,C,E,H,I,K,L,W,X,Y & Z • Historically, groups B,C, W & Y were most common in the UK • 5-11% adults and 25% adolescents carry the bacteria in their nose and throat without symptoms • Transmission occurs through aerosol, droplet or direct contact with respiratory secretions January 2016 • Most common presentation of meningococcal disease is meningitis and septicaemia (or both) • Other presentations include pneumonia, myocarditis, endocarditis, pericarditis, arthritis, conjunctivitis, urethritis, pharyngitis and cervicitis January 2016 IMD in Europe (2009) data from PHE January 2016 Confirmed cases meningococcal infection (E & W) January 2016 Epidemiology and schedule changes • Men C initially given on accelerated schedule of 2,3 & 4 months (1999) with catch up in young adults but for infants, protection waned rapidly • In 2006 additional dose given at 12 months to extend protection • Changing epidemiology of MenW = replace MenC with MenACWY vaccine • 2015 MenB introduced to schedule January 2016 Vaccination schedule Sept 2015 (up to 18 years) Age Diseases protected against 2 months Diphtheria, tetanus, whooping cough, polio, Hib, Pneumococcal, Rotavirus, and Meningococcal group B (Men B) 3 months Diphtheria, tetanus, whooping cough, polio, Hib, Meningococcal group C (Men C) and Rotavirus 4 months Diphtheria, tetanus, whooping cough, polio, Hib, Pneumococcal and Men B 12-13 months Hib/Men C Pneumococcal, Measles, mumps & rubella (MMR) and Men B 2-6yrs 3yrs 4m Children’s flu vaccine (live vaccine) Diphtheria, tetanus, whooping cough, polio MMR (pre-school immunisations) 1213yrs HPV (cervical cancer) girls only 2 x doses 6 months apart 1318yrs Diphtheria, tetanus, polio (school leavers immunisations) Men ACWY 38 Pneumococcal disease Spectrum of pneumococcal infection •Bacterium - Streptococcus pneumoniae Meningitis •Carried in the nose and throat Sinusitis (common) Invasive Pneumococcal Disease (bacteramia) Otitis Media Pneumonia •Transmitted through infected droplets through coughing, sneezing & close contact •Asymptomatic carriage possible Soft Tissue Infection (rare) Arthritis (rare) Peritonitis (rare) •Over 90 serotypes identified but most invasive disease in UK children caused by 8-10 of these Invasive Pneumococcal infection, England & Wales, incidence per 100,000 by age group 2000 80 70 60 50 40 30 20 10 0 <1 month 1-11 months 1-4 years 5-9 years 10-14 years 15-44 years 45-64 years 65-74 years >75 years Invasive disease • Prior to introduction of vaccine in childhood schedule, 1 in 6000 children under 5y acquired IPD each year • Risk is highest during the first year of life and in the winter months • Boys are at greater risk than girls • Factors such as attendance at day care and lack of breast feeding are associated with a higher risk of pneumococcal disease IPD may present as bacteraemia, meningitis or pneumonia • Bacteraemia: • - most common and life-threatening form of IPD in children. • - can cause septicaemia which can lead to organ damage and carries a high mortality rate • - around 50 children under 2ys died from IPD each year prior to introduction of vaccine At 2,4 & 12 months UK Immunisation schedule Sept 2015 (18yrs+) Age Diseases protected against 65yrs+ Pneumococcal disease (polysaccharide vaccine) 65yrs+ Influenza (each year) 70yrs Shingles • JCVI are reviewing adult vaccination with PPV23 • The efficacy of PPV in protecting adults against community acquired pneumonia (CAP) is being examined • In 2013/2014 74% of invasive disease in adults 65-69 were caused by serotypes found in PPV23 • Decline in rates of invasive pneumococcal disease and CAP in adults caused by the 13 serotypes in childhood PCV vaccine – indirect impact in a different population Rotavirus • Different strain classified (G and P types) by outer layer proteins – 10G and 11P types found in humans • Highly contagious – most often faecal-oral route but respiratory transmission can occur • Causes gastroenteritis which can lead to complications associated with dehydration • Before vaccination, it was estimated that virtually all children would have had a rotavirus infection before 5th birthday • Still a major cause of death in children in developing countries Vaccination • Live attenuated vaccine given orally (introduced in 2013) • 2 x doses at 2 & 3 months (4 weeks apart) • Observation of the infant’s age at vaccination is crucial to avoid the potential risk of intussusception STOP PRESS……. • Rotavirus is similar to norovirus (winter vomiting bug) • Similar symptoms and transmission • Different sections of population affected – rotavirus more associated with infants and young children Measles, mumps, rubella • All three are viral infections • All spread via similar methods • Varying incubation periods – this accounts for the side effects post vaccination Measles • Morbillivirus • Nose and throat secretions and airborne droplets via coughing & sneezing • Incubation = 7-18 days Early symptoms January 2016 Huge risk of complications with measles • In 30% cases • Mostly in infants, adults & immunocompromised people • Diarrhoea is a major problem for infants • Pneumonia in 1-6/100 cases = commonest cause of death • Otitis media, encephalitis • SSPE – rare but fatal complication of measles infection January 2016 January 2016 January 2016 1600 1400 1200 1000 800 1348 600 1144 990 400 739 438 200 308 2009 2008 2007 2006 2001 2005 2000 77 2004 70 2003 100 2002 92 1999 1997 11 1996 0 191 56 1998 177 January 2016 Measles notifications, E & W by age and region (Aug 2015) January 2016 Mumps • Paramyxovirus • Incubation 14-25 days • Headache, fever • Parotid swelling • Meningism can develop • 30% cases in children asymptomatic • Most severe in adults January 2016 Complications • Pancreatitis (4%) • Oophoritis (5% women) • Orchitis (25% men) • Neuro complications – meningitis, deafness • Before routine vaccination, mumps commonest cause of viral meningitis in childre • Nephritis, cardiac abnormalities and rarely death January 2016 Current issues for Mumps • Two doses of MMR are required for full protection from mumps • Cases still occurring in Universities since 2005 outbreak • Opportunistic vaccination at “teenage” booster and university entrance for those who have only received 1 MMR vaccine January 2016 Rubella • “German measles” caused by Toga virus • Direct or droplet contact with NP secretions • Incubation 14-21 days • General malaise, low fever, swollen lymph glands & conjunctivitis • Rash • Swollen joints & joint pain more common in adults January 2016 Congenital rubella syndrome • Risk if infected during pregnancy • Risk of foetal damage estimated at: 90% in first 10 weeks 10-20% by 16 weeks Rare after 20 weeks • Birth defects include cardiac, auditory, ophthalmic & neuro problems • Before 1970 (routine vaccination) up to 70 cases of CRS reported each year • Ratio of therapeutic abortions 10:1 January 2016 Girls & nonimmune women of childbearing age PHE data, E & W 2012-2013 (Dec 2015) • In the 10 years between 2005 and 2014 there have been 7 cases of CRS born in the UK (PHE, 2015). • Increased risk in immigrant women January 2016 Human Papillomavirus • Over 100 types (over 40 of these affect genital area) • High risk types (16,18) cause cancer and account for 70% of all cervical cancers • Low risk types (6,11) cause genital warts • Infection via direct contact – skin to skin (skin & mucosal sites) • HPV infection often asymptomatic and can resolve spontaneously January 2016 January 2016 Vaccination introduced in Sept 2008 • Two licensed vaccines: • Gardasil: protects against HPV 6,11,16,18 • Cervarix: protects against HPV 16,18 • Normal 2 x dose schedule (3 x doses if starting over 15 yrs) • Latest studies show protection 7 years post vaccination – ongoing • HPV could prevent 2/3 of cervical cancers in women under 30 by 2025 BUT uptake needs to be at 80% • UK is on target for achieving this as uptake is good January 2016 Local uptake Doses given 1st September 2013 to 31st August 2014 Locality Total No. of girls in Cohort 11 Dose one Number Dose one and tw o % All three doses Number % Number % NORTH YORKSHIRE AND HUMBER AREA TEAM EAST RIDING OF YORKSHIRE LOCAL AUTHORITY 1834 1767 96.3 1751 95.5 1638 89.3 KINGSTON UPON HULL, CITY OF LOCAL AUTHORITY 1178 1082 91.9 1058 89.8 976 82.9 NORTH EAST LINCOLNSHIRE LOCAL AUTHORITY 812 773 95.2 768 94.6 743 91.5 NORTH LINCLONSHIRE LOCAL AUTHORITY 926 817 88.2 813 87.8 783 84.6 NORTH YORKSHIRE LOCAL AUTHORITY 2766 2363 85.4 2353 85.1 2317 83.8 YORK LOCAL AUTHORITY 1504 1430 95.1 1418 94.3 1389 92.4 January 2016 Varicella (chicken pox) and shingles • Varicella – primary infection with varicella zoster virus (VZV) • Shingles (or herpes zoster) caused by reactivation of latent VZV infection • This is why shingles cannot occur in people unless they have had chickenpox • Virus from shingles can cause chicken pox in susceptible people • No evidence that this happens the other way around January 2016 Varicella • Highly infectious • Personal contact, droplet spread, infected articles • Most common in children <10 years old • 10-21 days incubation, infectious 1-2 days before appearance of rash • Peak March-May • Initial flu-like symptoms (prodromal phase) • Vesicular spots appear often in crops most commonly on trunk January 2016 Complications • Viral pneumonia, secondary bacterial infections & encephalitis Those at most risk: • Adults • Immunocompromised • Pregnant women • Neonates • Congenital varicella syndrome (first 20 weeks) • Limb shortening, poor muscle development, cataracts, growth retardation… • Later infection = preterm delivery or neonatal varicella infection January 2016 Shingles • Abnormal skin sensations & pain (dermatome) • Sometimes headache & photophobia • Vesicular rash with dermatomal distribution • Risk and severity of shingles increases with age JAMA, 2011 January 2016 Complications • Post Herpetic Neuralgia (PHN) • Depends on area affected – e.g. facial palsy or ophthalmic involvement (conjunctivitis, retinitis, glaucoma…) • Disseminated disease – lungs, liver, gut, brain leading to associated infections, e.g. pneumonia, hepatitis • Most likely with severe immunosuppression January 2016 The vaccines Varicella (no plans to introduce to routine schedule) Shingles (Sept 2014) • Live vaccine • Live vaccine – Zostavax (Subcutaneous) • 2 licenced in UK • 1 licenced in UK • 2 dose schedule • Selective programme • HCW – protect those patients/clients at risk & personal protection • 1 dose schedule – being monitored • Mass programme (70yrs+) • Contacts of immunocompromised January 2016 Influenza • Viral infection types A, B & C • Fever, chills, headache, myalgia, fatigue • Transmission is by droplets, aerosol, or through direct contact with respiratory secretions of someone with the infection • Type A causes yearly outbreaks – antigenic drift results in new subtype. Also found in animals. • Type B also subject to antigenic drift but much less frequently, burden of disease in children • Type C minor respiratory illness only January 2016 In more vulnerable individuals can lead to complications of: • -secondary bronchitis • -bacterial pneumonia • -otitis media (in children) Severe cases may lead to: • -meningitis • -encephalitis • -meningoencephalitis • -death (at least 3000-4000 each winter) January 2016 Who is most at risk? • Very old & very young • Pregnant women – uptake not ideal • People (including children) with LTCs • People with depressed immunity So these groups should be offered vaccination – every year (or with every pregnancy) January 2016 Vaccination • Because of the changing nature of influenza viruses, the WHO monitors the epidemiology of influenza viruses throughout the world • Each year the WHO makes recommendations about the strains to be included in vaccines for the forthcoming winter for the northern and southern hemispheres • Trivalent (2 x A & 1 X B) and quadrivalent (2 x A & 2 x B) • Live attenuated and inactivated vaccines available Use in children – intranasal vaccine Use in adults – IM/SC January 2016 Vaccine uptake 2015/2016 (in England, PHE) GP Data with 96.5% of practices responding Group % uptake 14/15 % uptake 15/16 65+ 68.5 66.9 All ages at risk 44.4 39.3 Pregnant women 38.5 38.3 Aged 2 (not risk group) 30.6 28.9 Aged 3 (not risk group) 32.6 29.9 Ages 4 (not risk group) 25.2 23.9 January 2016 Hepatitis B • Viral infection of the liver • 100x times more infectious than HIV • Major cause of morbidity and mortality worldwide • Transmission via body fluids • Perinatal, parenteral, sexual transmission • Acute symptoms include – malaise, upper right abdo pain, mild fever • Chronic infection complications include hepatic cirrhosis, hepatic carcinoma, necrosis January 2016 Vaccination • Selective for neonates born to high risk mothers • Can prevent over 90% infection • There are many other groups considered high risk and offered vaccination • E.g. travel, occupation, exposure (contact with infected individuals) and lifestyle • Routinely offered in US, Australia, France….UK? January 2016 Tuberculosis • Caused by Mycobacterium tuberculosis • Usually attacks the lungs (pulmonary – 60% of UK cases), but other parts of the body, including the bones, joints and brain can also be affected (extrapulmonary) • Only the pulmonary form of TB disease is infectious • Transmission occurs through coughing of infectious droplets and usually requires prolonged close contact with an infectious case • Initial infection may be eliminated, progress to active TB over following weeks or months or remain latent (no symptoms, bacteria remain in body) • People of all ages can contract tuberculosis • Risk of disease is highest in children <3yrs, older people and with weakened immunity January 2016 Symptoms & treatment • General weakness, weight loss, fever and night sweats • Pulmonary TB: persistent cough, haemoptysis, chest pain • In young children, the only sign may be stunted growth or failure to thrive • Course of two or more anti-tuberculosis drugs for at least six months • A failure to take the prescribed medication, or to complete their course of therapy or to have been given ineffective treatments may lead to multi-drug resistant TB, which can spread to others January 2016 Some epidemiology (PHE, 2014) January 2016 TB rates 2011-2013 (PHE, 2014) January 2016 Vaccination – Bacille, Calmette, Guerin 1953 Mass programme 11-13 yr olds 2005 Mass programme replaced with selective programme Why? BCG vaccination – efficacy of vaccine uncertain Problems post vaccination (local reactions) 2000s – 8,000 cases but predominantly in those born abroad 10,000 vaccines to prevent 1 case 1950s – 50,000 cases 1980s - 5,800 cases More cost effective to target prevention in high risk groups January 2016 BCG recommended for: • All babies, at or soon after birth, living in areas where the incidence of TB is 40/100,000 or greater • Children (<16yrs) whose parents or grandparents have lived in a country with a TB prevalence of 40/100,000 or higher • Previously unvaccinated new immigrants from high prevalence countries countries for TB • Contacts of cases of TB • Travellers (<16yrs) to countries with high TB prevalence for >3m • Occupational e.g. Healthcare workers <35yrs January 2016 Information & data used in this presentation was taken from: • Immunisation against infectious disease (Green Book online): https://www.gov.uk/government/collections/immunisation-againstinfectious-disease-the-green-book • Public Health England (and search specific infection): https://www.gov.uk/government/organisations/public-health-england • WHO (and search specific infection): http://www.who.int/en/ • JCVI minutes: https://www.gov.uk/government/groups/jointcommittee-on-vaccination-and-immunisation • Vaccine Preventable Diseases (HPA original slides): http://webarchive.nationalarchives.gov.uk/20140714084352/http://ww w.hpa.org.uk/EventsProfessionalTraining/HealthProtectionAcademy/A dditionalOpportunitiesAndInformation/ImmunisationTrainingResource s/hpacadvacc05SlideSetsforCoreCurriculumTeaching/ January 2016