Vaccination reaction referrals

Scope

This referral pathway will cover referral for vaccination requests, allergic reactions, large local reactions.

The " Green Book" is the Department of Health (DOH) recommendations about vaccinations and each chapter is regularly updated. Please look at this website for detailed information.

Out of scope

Provision of routine immunisations

Assessment

The NHS vaccinations schedule changes as per new evidence, and should be checked regularly. The most up to date version can be found at the NHS choices vaccination page.

Vaccines are contraindicated in patients who have had:

  • A confirmed anaphylactic reaction to a previous dose of a vaccine containing the same antigens.
  • A confirmed anaphylactic reaction to another component contained in the relevant vaccine.
Possible non allergic reactions

Large local reactions can be common post vaccination, and do not require further treatment and is not a contra-indication to further vaccination in the community.

Meningitis B vaccine is strongly associated with fever and this should be actively treated and avoided if possible with paracetamol.

BCG – the BCG vaccine can sometimes lead to local infections, abscesses and erosions such as large discharging ulcers. These sometimes require treatment.

Cellulitis can occur due to the inoculation of skin flora; this can be treated as per normal cellulitis pathways.

Infants may be distressed and fractious post immunisations, and paracetamol should be recommended. The change in bowel habit (consistency and colour) should be mentioned before the rotavirus vaccination.

Possible allergic reactions

The common allergens present in vaccines are:

  • Gelatin: Gelatin from pork is present in some vaccines; namely, MMR, shingles and the nasal flu vaccine. This should be inquired about prior to vaccination. If the patient has a gelatin allergy, then this should be given in a hospital setting.
  • Antibiotics: Neomycin is found in the MMR vaccine. This is present in tiny amounts but could theoretically cause a reaction. Streptomycin and polymyxin B can also be present.
  • Egg: Egg is present in the Nasal flu vaccine, the "Green Book" provides up to date information on giving egg allergic children the 'flu' vaccine. Essentially it is safe; children with a history of severe anaphylaxis to egg which has previously required intensive care should be referred to specialists for immunisation in hospital. Egg allergic children with asthma can receive the vaccine if their asthma is well controlled.
Myth busting

There have previously been concerns about vaccines, and there are still some myths surround vaccination:

  • Thiomersal (mercury) is no longer used in any of the vaccines routines given in the NHS childhood immunisation schedule. The amount of Thiomersal used in any other vaccines is very small and has not been found to be a risk. The World Health Organisation has released a statement on this subject here.
  • Several "killed" vaccines do contain small amounts of aluminium as an adjuvant to improve the immune response and reduce the amount of antigen used in the vaccine. This is a very small amount and deemed to be safe. It is, however, the cause of the small lump or redness at injection site.
  • The MMR vaccine does not contain any egg. There is no contra-indication to giving the MMR vaccine to an egg allergic patient in the primary care setting. The British Society of Allergy and Immunology press release can be found below:

BSACI Recommendations for Combined Measles, Mumps and Rubella (MMR) Vaccination in Egg-Allergic children.

Management

Treat any allergic reactions with oral cetirizine syrup.

Large local reaction treat with cold compress and paracetamol.

Referral

Referral Criteria

Refer to secondary care if:

  • Documented previous anaphylaxis to any vaccine or its component
  • Egg allergic children requiring the yellow fever or Japanese encephalitis vaccines
  • Documented previous anaphylaxis to egg which required ITU support, for the 'flu vaccine.
  • BCG reactions such as abscesses and large discharging ulcers

Referral Instructions

e-Referral Service Selection

  • Specialty: Children and adolescent
  • Clinic Type: Allergy
  • Service: DRSS-South Devon & Torbay-Children's & Adolescent Services-NEW Devon CCG - 99P

Referral Forms

DRSS referral form

Torbay and South Devon seeking advice form

Supporting Information

Patient Information

NHS choices vaccinations

Evidence

Department of Health 'Green Book'

Green Book chapter 19 - Influenza

Pathway Group

This guideline has been signed off by South Devon and Torbay CCG

Publication date: August 2017

Review date: July 2019

 

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