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Hello, everyone and welcome to er er middle primary care. We are gonna be talking about the vaccination schedule today with Jeeps. Um If you are new to the platform, welcome. Uh Delighted you could join us. Uh We have over 2000 healthcare organizations and societies contributing to the wealth of knowledge that's on this platform. So please take a look, search for any topic you like and I'm sure you're gonna find it just a little bit of housekeeping. If you want to at the top, there is a follow for middle primary care care. Click on that and you'll be notified about further events. Um, questions, pop them in the chat. We wanna get through as many as we can at the end. Um Your feedback will come to you right at the end in an hour's time, your feedback back will be in your inbox and once completed, your attendant certificate will be on your medal account. Um And that's it. Um So I'm gonna hand you straight over. All right, thank you, Jeeves. Hi, everyone. Um My name is G Uria, I'm a A GP in Nottingham. Um And I also work in a few other areas, one of which has been as clinical advisor to vaccination and screening for NHS England for the last couple of years. Um, I'm really delighted to be here with you today. And what I'm going to try to do is talk you through the vaccination schedule. Now, I know, uh, this is a subject that comes up particularly for GPS time after time in our A KT S and exams. I know that it's an issue for many doctors and often it's the sort of thing that you end up googling to have to check, um, to be able to kind of work out exactly what is needed when and what I'm going to try and do is talk you through the schedule as it currently stands the way I break it down to try and make it easy to remember. Highlight all the important bits that I think are relevant for you and your clinical practice. Um, and, and, and try and talk you through as well. Some of the challenges that we face, um, when trying to administer the vaccination schedule and some of the issues that are associated um, for the patients that we serve. Um, I'm gonna try and do that in the hour that we have. Um, I'm probably not gonna try and cover some of the more seasonal er, vaccines that we do because it would be too challenging to try and do that in an hour. You could probably spend an hour on its own, talking about COVID and, er TB and some of those things. So I'm gonna try and go through childhood, through adulthood with the vaccination schedule for you. Now, um, if you come on to my next slide, er, I'm gonna try and do my best, er, Chris Witty with my colleagues here, er, to try and to do this. Um The first thing I'm gonna flag is just that the contraindications for almost all of these vaccines are almost identical in the sense that you know, the contraindications for almost all of them, except those that are flag as we go through are that you shouldn't have them if you have a history of serious allergic reaction to any, any previous dose of the vaccine. So that's difficulty breathing, tongue swelling, er, compromise of your airway. Um When you, when you've had previous vaccines, equally, if you've had a serious allergic reaction to anything that's in the vaccine, I'll flag some of these ingredients to you as we go on. Um, but those are important things to bear in mind as we go through it next slide please. And then just to talk you through again, er, the common side effects which apply to virtually all of these vaccines which are of course swelling or pain where the injection has been given. Often you may have a high temperature for a few days. Uh Sometimes you can feel more tired, you can have an impact on your appetite. Um One of the other things that you may notice is that you feel a bit of nausea. A lot of people experience things like a bit of, uh, diarrhea, runny poo. Um, and some people can feel particularly irritable after it's happened. Um, it's really important to say that it's helpful to give things like paracetamol to ease any of these CMPs. And that's the case for all of these different age groups that I'm gonna talk through. Um, that is something that will help you both with things like slight temperature. It will help you with swelling or pain at injection site and it's gonna help you with the irritability as well, particularly where you are vaccinating young Children. And I often will encourage parents to give paracetamol um just prior to coming in for their vaccination as well. Next slide, please. Um The way that I break down the vaccination schedule I think is quite specific. Um, and you know what I like to start with is vaccines that we give to Children under one year old. It's really nice and easy to remember in that sense because it is eight weeks, 12 weeks and 16 weeks, there is a four week gap between these doses. Um and it's a, a nice way of being able to group them up. I've, I've got these tables here at the end of this. I'm gonna have references to the entire vaccination schedule. Er, what I'm also gonna include if, when you get slides is there's a link to every single vaccine and it's patient information leaflet, er, if you want to go into any more detail on any of those subjects. Um Now starting with the first vaccine, um which is the, or the first set of vaccinations it's given at eight weeks. And what we're talking about is the six in one vaccine. Um The important thing to remember with the 16 1 vaccine. If we go to the next slide, please is that you've got three doses of this, but we're going to revisit parts of the 61 vaccine later in the vaccination schedule. So it's in some ways the most important one to remember because it captures some of the illnesses that we spend much of the vaccination schedule trying to protect you from. Now, it's six serious illnesses that we're trying to protect um our Children from uh diphtheria, hepatitis B, hemophilia, influenza type B, polio tetanus and whooping cough. Now, I've included a couple of pictures of some of those elements. For example, you've got uh an example of the presentation of diphtheria there on the right. Um And this vaccine is incredibly, incredibly effective at protecting people um from from these conditions. It's important to say if you've had an allergic reaction to something like neomycin polymyxin or poly. So at 80 which is some of the constituent ingredients. Um those would be reasons not to have this over and above those that we've already discussed. And if you have a background of epilepsy, for example, it's worth speaking to someone before you have the vaccine. Now, there are two types of six in one vaccine that we use. Infra and Vellis. Now these are the, the the two types that we tend to use. Um and you know, effectively these are the way in which we are now protecting in this country from each of these different conditions, but it's given at 8, 12 and 16 weeks. So at all three points in the under ones in their schedule. Ok. Er, if you go to the next slide, please, we're gonna move on to our, er, our next vaccine which is given at that eight week point, er, which is the rotavirus. Now, um this is given at eight weeks and it's given again, er, actually at 16 weeks, it says 12 there, but it's 16 weeks that you see. Er, no, in fact, that's right. It's 12 weeks, sorry, apologies. So it's eight weeks and 12 weeks that you will get the rotavirus. Now, we know this is an incredibly effective vaccine, it prevents infection in 80% of Children. Now, that is er, phenomenal efficacy. It's given as a liquid that squirt it into the baby's mouth. And the only reasons that you would not be able to have this again from the caveat we gave of serious anaphylaxis would be if you have severe combined immunodeficiency. Um, if you have intussusception, which is a condition where your bowel isn't working appropriately if you have a fructose intolerance or a glucose or galactose malabsorption. So, issues to do with your gut can be a big factor into whether you might not be suitable for this vaccine. But they're the only real contraindications other than if the mother of the child was using biological medications for particular conditions whilst pregnant or whilst breastfeeding. Um now we use the rotor Rotarix vaccine er here in this country. Um and it is important to say that whilst it's important to get these on time at the eight and 12 week marks, you can have them slightly delayed, er if you happen to have missed them. So you can for example, have the first dose up to 15 weeks and for the second dose up to 24 weeks. Now, the important thing to remember as well is that for a few weeks, the that the child has will contain a weakened version of the virus and it's always worth flagging that as well just so that people are aware to make sure they take proper precautions, use hand hygiene, et cetera when handling the er often painless supply of food that our our, you know, our babies and young people provide us next slide, please er coming on to the er the men B vaccine. Er so this is to prevent meningococcal group B bacteria. Now this is a particularly important vaccine it's given at eight weeks, it's given at 16 weeks and then it's given at that one year point. Meningococcus, meningococcal infections can be really serious. They cause meningitis infection in the brain and they can often cause sepsis as well. Now, these conditions can lead to brain damage, they can lead to amputation, sometimes they can even lead to, to death. And the UK was actually the one of the first group of countries in the world that produced a vaccine into its national program. We use something called the Bexsero vaccine. Um and this is actually given as a single injection into the baby's thigh. Now, you know, almost 8000 people um including more than 5000 babies and toddlers, er had this vaccine during clinical trials to test their safety. And since the vaccine was licensed in 2015, there's been almost 5 million doses given to Children in the UK. Um And it, it, it's important to remember that meningitis B is a really serious cause of life threatening infection. We know that it is um the leading killer of babies and young Children in the UK. Um There are 12 groups of meningococcal bacteria, but we know this is the most prevalent. Um whilst most young Children recover from this infection, we know one in 20 die with it, which is why it's been such an important step to introduce it into our vaccination program and the way that the meningitis B vaccine works, er, is we use three major proteins found on the surface of most er, meningococcal bacteria, er, and on the outer membrane of one of the other strains. And together what they do is they stimulate the immune system to protect against future exposure to meningococcal er bacteria. Now, this is men B that we're talking about, which is the biggest, er, certainly, er, cause of these types of infections. Er, but you will notice when we come on to them that there are two other types of meningococcal or meningitis vaccines that we will er, reference and that's the men ac Wy vaccine, which we give to 14 year olds to freshers at university at the point that they encounter many, many people from lots of different places. Er, and there's also the group C vaccine that we give to Children at one year old that we're going to, er, come on to in a second. And that's given with the er, hemophilia influenza type B in er vaccination as well. Not as the HIB Men C vaccine. Er, next slide, please. Um So now that's the eight week vaccines that we've talked about that we give again at the different points that I've mentioned, er, the vaccine that I'm gonna reference now is the pneumococcal vaccine. So at 12 weeks, you're gonna have your six in one second dose, your rotavirus second dose and then you're gonna have your pneumococcal vaccine. Um this is given at 12 weeks and again, at one year, it protects against pneumonia, it protects against sepsis and actually, it also offers a little bit of protection against meningitis. Um, it's recommended for people at higher risk of infection. So that's generally babies. Er, the group that we're talking about now and we'll reference it again when we get to the over 65 population. So, the pneumococcal vaccine again is preventing um these conditions. And uh what we tend to use is two different types of vaccine. We use the Pneumovax pneumococcal vaccine for adults and Children over two. But for our babies under two years old, which is this group, we tend to use the Prevenar pneumococcal vaccine. Again, the leaflets for both of these are going to be provided. It also has other knock on protections as well because it also protects against types of sinusitis and ear infection because of its effectiveness. And again, the same allergy guidelines apply as a contraindication, but it's known to provide the best protection against pneumococcal infections. And you know, there is still a chance that you might get a pneumococcal infection, but you should have protection usually by three weeks from when you've had the vaccine. Now, most people only need one dose of this. Um and the protection only starts to reduce usually five years after you've had er, your vaccination, we'll come onto this again. Er, when we talk about the over 65 population because for some groups, they will need a top up or they will need additional er, doses of that vaccine. So that's the pneumococcal vaccine given at 12 weeks and one year. If we move on to the next slide, please, um, what I've not talked about here but, er, but er, we'll do in a moment is the men B vaccine, um which is, is the other vaccine that's given the second dose of at 16 weeks that's given at eight weeks, it's given at 16 weeks and again at one year, next slide, please. So talking about childhood. So the group from one year onwards. So at the one year mark, we give something called the HIB or men C vaccine. Er this is the first dose er that you have of the HIB men C vaccine. Um This is given to one year old babies after they've had three doses of the six in one vaccine. And that's the really important part of this is it's an additional set of protections to that six in one vaccine that we've talked about. Um now, er this is er, particularly important because if your child has miss this, you can go back and have it, but it's best to have it er, after you've had all three doses of the six and one vaccine. So one of the things that we often do is we can actually delay this even up to the age of 10 to make sure we've had the six in one vaccines before we have this additional, er, vaccination, it's given as an injection into the upper arm or into the thigh. Er, and we use a vaccine called mento. Um, Children are also given a vaccination dose when they're 13 or 14. Usually school year of nine or 10, er, just to boost that protection against meningitis. C. Um, and that is the, er, hib men C, er, vaccination. Next slide please. Er, I can't actually see the top of these slides but I think what we're on to is the Mmr er, now the Mmr vaccine is given at one year, it's given at three years and it's given at eight months. Um, and this protects against um serious illnesses like measles, mumps and rubella. Now these are highly infectious conditions that can easily spread between unvaccinated people. We know that the Mmr has been a hugely effective component of our defense against these infections and we've seen a drop even where there are unvaccinated members of the population because by herd immunity by protecting that many people, we can reduce the risk of transmission even to those unvaccinated. We have of course seen in the news in some areas, outbreaks and recover occurrences of things like measles because of that unvaccinated with that unvaccinated number and in those populations and, and that I think has highlighted for many of us just how important getting vaccinated is as these conditions can lead to serious problems. You can end up with meningitis. That brain infection. We talked about things like lasting hearing loss or problems during pregnancy as well. Um Now usually this is two doses of single injection into the muscle of the thigh or the upper arm. Now, two doses are needed to ensure full protection. So that's one year and again at three years and eight months. Um and after two doses, we know that 99% of people will be protected against measles and rubella. We know that 88% of people having those two doses will be protected against mumps. Um Many years ago, Andrew Wakefield published a heavily criticized piece of work um based on inaccurate data, suggesting there was a link between the Mr and and autism. This has been hugely damaging to the vaccination program. And though very much dis disproved, many people often feel a sense of anxiety around the Mmr for that reason, it's worth saying that there are many studies that have, that have investigated this now. Um And I have included within the slides as well. Um You know, some of the evidence around this and particularly a paper that reviewed this allegation and disproves it based on the data. That's the Oxford University Vaccine Knowledge Project, which has a website with a list of Mmr studies and all of their findings to help clarify any confusion that exists around this. And there's a really useful resource if you're in discussions with patients that might have anxieties because of that. Now, there are two types of vaccine er that we use. There is priorix and Mr Mmr Vax Pro. If we go to the next slide, please, thank you so much. Oh, in fact, we can we go back one slide cos I appear not to have talked about this enough. Um So it's important to say that Mmr Vax Pro contains porcine gelatin to ensure the vaccine remains safe and effective during storage. Um However, you know, you have the alternative of being able to use priorix instead for people that perhaps have issues with the presence of porcine gelatin in the Mmr Vax vaccination. It's important to say there are sources on the NHS website as well around this, particularly for communities um and people of religious beliefs or cultural beliefs that may find that they have a preference and there's some really helpful information on vaccination itself as well. Next slide, please. Um So, er coming on from this er, to er, the next er vaccine in our sort of er, list I can't. Is this the flu vaccine? Yes, perfect. So this is the 2 to 15 years. So we've talked about the first year of life and the one year point vaccinations which are HIB MEN C Mmr pneumococcal vaccine Men B, which I'll have to come back and, and talk about cos I think we've missed a slide here somewhere. Um But 2 to 15 years, we have the children's flu vaccine. Um Now this is given each winter in the UK, it's given every year until Children finish year 11 of secondary school. Um We use the fluens tetra nasal spray vaccine. Um Now this contains porcine gelatin. So again, pork products and egg and for those reasons, there is also an alternative, the cell based quadrivalent influenza vaccine, which can be given as an injection instead which does not contain the gelatin or the egg. So you have an alternative uh that can be used in communities populations or in patients that may have an allergy or an issue with using these vaccines. Um Now we give these vaccines every year to prevent um a condition that we no often leads to hospital care because of it. So flu, we know hospitalizes thousands of Children across the UK. And for that reason, we provide this additional protection to try and prevent our Children ending up in, in hospital or needing intensive care because of these illnesses. Um It's important to say that it usually takes 14 days for it to work. Next slide, please. Uh So here we have the, at the three year and four month point, the four in one booster preschool booster vaccine. Now we talked earlier about the six in one and we talked about the fact that it included diphtheria, polio tetanus and whooping cough vaccination points right through um that 1st 16 weeks of life at eight weeks 12 weeks and 16 weeks. Now, effectively the four in one is additional protection against four of those different constituent er, diseases that we are trying to protect against it. Boosts the protection that they provide. There are two types, there's Boostrix IPV four in one vaccine or repa VX four in one vaccine. Children can still have this up to the age of 10. Um And you know, again, er, this particular vaccine also contains neomycin polymyxin and much like the su in one, those are the reasons er to er, potentially not give this vaccine, er, if they have a serious allergic reaction to any of those parts as well as to the vaccination itself. Um And again, it's important to reflect on the fact that this is an important part of the protection that we are giving against these very serious conditions. Next slide, please. So, at 12 to 13 years and this is arguably a relatively recent breakthrough. Uh We have now introduced something called the HPV vaccine. This is the human papilloma virus vaccination that we give. Now human papilloma virus actually refers to a group or a range of different types of viruses, most of which are harmless. However, we know that certain types um can be spread through skin contact quite commonly through things like sexual intercourse or sexual contact. Um and they are linked with an increased risk of cervical cancer of mouth cancer, anal cancer, penile cancer. And we know it's also associated with a higher risk of genital warts as well. Um Now, um it's important to say that the only reasons to not have this or is if you had a serious allergic reaction as we've talked about. Um And important to say that there's no evidence this is harmful. If you're pregnant, though, you can be advised to wait until you aren't pregnant any longer to be able to have this. Um And you can have this vaccine also whilst you are breastfeeding. Um It is the Gardasil nine HPV vaccine that is used in this country. Um and we offer it to all school aged Children in year eight, age 12 to 13. So they, you know, so our Children will get this in secondary school or in community clinics for those not in a traditional school, shall we say? Um, now, what we also do at the moment is we offer it to all girls under 25 and all boys born after the first of September 2006, who might have missed having that vaccine at school. And we also offer it er, to men under 45 who, er, have sex with other men um or other people at risk of HPV. And they can access this via sex health clinics or HIV clinics as well. We also offer it to people with weakened immune systems and it's important to say that for those 25 to 45 age group candidates they may need two doses and people with a weakened immune system may need three doses ideally given within a 12 month period to make sure that that protection is there. Since this vaccine has come into play, there has been an enormous drop in the number of young people getting conditions linked to HPV. And that includes cervical cancer. It includes genital warts and you may know, er, from experiences perhaps having a, a smear test um that we now test for HPV alongside the cervical smear as an indicator of risk of er, types of cancer as well. Um We looking at the research suspect that over time, the HPV vaccine will save thousands of lives here in the UK. Um So this is a really significant er development er in, in vaccination and in public health, er, next slide please. Um So this is me just talking about the HPV vaccine and saying all the things that I've just described to you. Er, anyway, um which are, you know, the groups when they can have their vaccination, how to access it. And again, the prospective number of lives saved, er, using this er vaccination next slide, please. And at 14 years old, we then offer the three in one teenage booster. This is at 14 years, as I've mentioned, er earlier on, we talked about that six in one vaccine given, er, at 8, er 12, and 16 weeks and we talked about the four in one given at three years and four months. So now at 14 years, you have the three in one booster which is tetanus diphtheria and polio. So you'll notice this is a common strand right through the vaccination schedule to protect against these conditions. It is a single injection given into the muscle of the upper upper arm usually given at secondary school. Er, so in year nine and at the same time at the men ac Wy vaccine, which I'll come on to talk about, this is the revax vaccine. And again, I'll include all the information, um the patient information leaflets er for each of these er in the slides. When you get them. Next slide, please. Now we talked about meningitis, particularly the men, the men B vaccine that we talked about earlier. Um but also the men C vaccine that we, we discussed at one year. Um Now the men ac Wy er vaccine er is, is a game about preventing meningitis and septicemia. It's routinely offered to people at school years nine and 10. But importantly, it's also something we offer to our fresher students going to university for the first time. We offer it to people traveling on pilgrimage or harsh um or travelers to countries with high rates. Most notably, places like, for example, South America, we use the um NRI vaccine to do this. It's given by single injection into the upper arm and it protects against those four strains of meningococcal bacteria ac W and Y causing these conditions. Now, um anyone born on or after the first of September 96 who was eligible or missed it is still eligible up until their 25th birthday. So particularly those who are about to go to university perhaps later on or um for those who are about to go on pilgrimage or any of these kind of traveling experiences in some of those countries should be alert to the fact that they can still get that vaccine. Um and it's worth making an appointment to, to get that protection as well. Um It's something we particularly flag in first year university students because there was a period of time where there was a huge spike in the number of cases of meningitis at university because people didn't have um these uh protections in place. And what we do is we use the sugar coating found on the surface of these types of bacteria and it triggers your body's immune system to develop antibodies against those sugar coatings um without actually causing the disease. Um Now, the only preconditions again beyond anaphylaxis for this, the only contraindications are people who might have a bleeding disorder or hemophilia or those who are currently pregnant or breastfeeding. And in those situations, we would seek specialist advice er, to make sure that you're suitable and safe to have er, those vaccines. Er, next slide please. Er, fantastic. Er, we're on to the adult, er, end of the vaccination schedule, er, and, and keeping well in time, which is good. Um, the first of which is about the flu vaccine, which is given every year. Um, after turning 65 next slide, please. Um, now the flu vaccine is generally recommended for people um who are at higher risk of getting seriously ill from flu. We know that many people will get the flu and not necessarily have as severe symptoms as other, other people. And therefore we try and protect those at highest risk where we know that the risk of not just death but hospitalization are particularly high. So for those aged over 65 people with long term health conditions, uh people who are pregnant or living in a care home, we also protect the carers of people who are older, disabled or with long term health conditions or that live with people with weakened immune systems. We also offer this to all frontline health and social care workers. I don't think you can work in the hospital setting and not at wintertime, come across countless people asking you if you've had your flu jab yet to try and make sure that everyone is protected because we know that we're at higher risk due to exposure to this. Um, and er, you know, it's important to say that this is part of making sure that our population is staying safe over the winter period. It's been part of our, um, getting winter strong campaign this year, coming into the winter period, it usually takes about 14 days to work. Um, and er, protection from the flu vaccine usually goes down with time. Er, and the flu strain, the vaccines protect against are updated every year, which is why it will be a different vaccine. Er, hypothetically each year, er, that you are given to try and protect against those strains that we think are prevalent or coming or particularly harmful, er, in that winter period. Next slide, please. Er, fantastic. Some of the flu vaccines used in the UK can contain egg protein. Er, you'll notice, er, I've given some of the examples of the types that we use for the over 60 fives. There's in a, you can give any of those type but there's also the influvac subunit tetra quadrivalent form that we use in younger people. And as I mentioned, it takes about 18 days to work. Next slide, please. Er, the pneumococcal vaccine that we talked about earlier, er, which we obviously use as well in young people, um protects against pneumonia and meningitis. And for those over 65 we give, er, two types. One is called Pneumovax, er, which is the type that we're using for adults. I mentioned earlier, we had a type given to babies under two, which is the, er, Prevenar form. Um, usually by about three weeks you will have protection from when you've had the vaccine and most people only need one dose of this for long term protection. But we know that there are particularly vulnerable communities. So people with chronic long term health conditions from heart failure to Parkinson's disease, et cetera, who we offer additional protection to by offering them the pneumococcal vaccine. Next slide please. And then coming on to the shingles vaccine. Now, um we offer the er shingles vaccine um to all adults turning 65. Um all those aged 70 to 79 or those who are 50 over with a severely weakened immune system. Um, now it's important to say that when we're talking about that and we've referenced that several times through this. But, um, this includes people who might have conditions like blood cancer HIV or AIDS, people who've had a stem cell transplant, radiotherapy chemotherapy or people that take certain types of very strong immune modulating medications that weaken your immune system. Um, you'll be given usually, er, in that category two doses um, of this particular medication. Um, and it's important to say that this often causes confusion for people because of that slightly complicated eligibility criteria. But to simplify, you're offered two doses of the vaccine usually six and 12 months apart for anyone who's turning 65 on or after usually September 2023. Um, and, er, for those aged 70 to 79 the eligibility comes back. Er, so depending on the type of vaccine you have, you're either given one or two doses the reason for that is we normally offer Zoster Vax, which is a weakened version of the er virus. Now, this isn't one that we would give to people with those severely weakened immune systems because it contains a weakened version of that virus that in someone with a weaker immune system could potentially cause more harm. And therefore what we suggest to use instead is called Shingrix. And that's why you might have two doses of the Shingrix. In that scenario, shingles itself is a condition that causes an incredibly painful rash. But sometimes the pain from that rash can be long lasting. People often will find that they have pain for some time after an infection like this and it can indeed cause hearing loss or blindness. I often do these talks for groups like age concern UK, for example, in London and a few other places and quite often, I don't need to explain too much about the shingles vaccine because invariably we will have a contributor from the audience who will talk about their own experience of shingles. And it usually convinces most people that they definitely don't want, er, to end up contracting this, er, quite, quite painful and uncomfortable, er, illness. Next slide please. Um, and then I'm just gonna talk very briefly about er, vaccines specifically, er, for pregnant women. Um, so the flu vaccine, which we've already talked about, er, is something that's very important to make sure that they are prepared for potential flu um, infections or, or strains that might be at that time. But then also specifically to talk about the 16 week pregnancy, er, stage at which we offer the whooping cough or pertussis er vaccine. In fact, we offer this at 16 to 32 weeks anywhere in that time period. If you, er, moves on to the next slide, please. Um, this has risen sharply, the rates of this condition, whooping cough or pertussis rather, we used to call it the 100 day cough. Um And we know that often it's the Children that struggle with pertussis infection. And the reason that we offer it at 16 to 30 two weeks is that actually getting vaccinated whilst pregnant is a really effective way of protecting the child from developing whooping cough in the first few weeks of life. We know that the immunity that you get from the vaccine passes to your baby through the placenta, providing what we call passive protection. It's used routinely in pregnant women in the UK and we've done this since 2012. Um It has a 91% reduced risk of the child becoming ill in the first few weeks of their life due to whooping cough, which is a really considerable reduction in risk. Um There is no whooping cough only vaccine. Er, so the vaccine that you given is Boostrix IPV, which also offers a degree of protection against polio diphtheria and tetanus. Um So a really important vaccine that is about protecting Children. But given via pregnant mothers during that phase to offer that passive protection to their Children. Next slide, please. Er, and what we've done now is we've walked you through the entire, er, vaccination schedule. Now, obviously I've not included, er, COVID, I've not included TB in some of these because we could spend an hour just talking about those vaccines alone. But I wanted to talk about some of the things that I've alluded to inferred um about or reflected in the talk that we've done so far, which are about um vaccine hesitancy. There is uh notably often concern about vaccination and anxiety about vaccination, not just in individuals but in communities and in populations. And I think it's really important to think about that in the context of er vaccine hesitancy to understand why I spent many years working in the east end of London, er, in an area called, er, in areas like Hackney and Tower Hamlets where we had populations who were, er, very anxious about vaccination. And I think it's helpful to look at this through a particular lens to understand the reasons for why. That is um the, you know, there is this theory of this model of determinants of vaccine hesitancy that I think is very useful in thinking about this and it, it talks about the three CS of vaccine hesitancy, one of which is about um is, is, is about complacency, is what's happening? Is this illness? Important is vaccination important. Will it make a difference to my life? Is there a risk to me of this infection or illness? And often because we do not communicate those things well to these populations. Um They don't understand the importance of vaccination where I worked in Hackney. For example, during the COVID pandemic, the rates of morbidity and mortality amongst minority ethnic communities was absolutely huge because vaccination rates were much, much lower. And I think that much more could have been done to communicate particularly to these populations. The importance of vaccination and the additional risk that many of those populations er, had of, of adverse outcomes from infection. One of the other reasons is about convenience. How accessible are er, is vaccination to some of these populations? Often, er, people will be asked to register a GP. We know in some populations they don't often like coming in with, with forms of ID, they don't necessarily have a GP, they struggle to access it because of a language barrier, er, or because of insecurity about their immigration status. And um what we often also find is that our vaccination centers, our GP practices are not always er in er local access to some of those communities that might struggle with mobility, that might struggle to access some of those services um or struggle to get in as well as not seeing necessarily the benefit of vaccination. The other part of this is about confidence and this is a huge element. It's about trust and often, um particularly we saw in the pandemic because of the way that um many handled vaccination, people often didn't trust organizations and leaders, er, when they said you need to have this vaccination er to help make yourself safe, to make the population safe, er, to protect your family, your friends as well as yourself. And that is an enormous thing and particularly in some of the communities that I've worked in over the years. I think about, for example, the huge orthodox Jewish community in places like Stanford Hill, I think about, for example, uh you know, the Afro Carribean communities in the east end of London or indeed in South London. Um you know, the Children of the windrush generation for whom there is an intrinsic and understandable mistrust of large organizations and nations saying you can come into this center, provide your ID and you will have this service. There is an understandable mistrust of government, especially in communities where there is a cultural history of having been awfully experimented on. And for those reasons, it's so important to have conversations, build relationships with communities, work with community leaders to help them understand the importance of vaccination, to understand the benefits of it, to make sure the services we offer are accessible to these populations, but also to rebuild that trust with communities. So they know their local services. Are there their local GP is there, their local nurse is there to be able to advise them to give them honestly the information that some of the information that we provided and help them to be able to overcome any barriers and make informed decisions about their care. And it may be they make decisions not to seek vaccination. But it's important that they have all of this information in front of them to make those decisions and that they have access to the right resources in languages in context that speak to them in the right way. And that are easy to understand. You know, we talked earlier particularly about the mmr the measles um uh mumps and rubella vaccine. And we talked about the impact of er inaccurate studies and information and the fear that that caused and generated and the importance of engaging with people about that and providing accurate information so they can make the right decisions or so they can make informed decisions, not the right decision, that's the wrong language. But um so that they can make decisions based on the information and see the benefits, the pros, the cons of each of these things. It's important that right through this, I've reflected where for example, there is egg or porcine gelatin because for some communities, they are not the vaccines that you want to stock or supply and in some patient populations where you need to offer the alternative to respect their religious convictions. Now, with each of these, there are resources um on the um resources that list at the end of this slide which contain er views and input from local imams religious leaders, community leaders um on each of these different types of vaccination to support communities making decisions on these. Um Next slide, please. And I've included a link here but on each page of the slides which I'm hoping will be shared with you. You will find that there is um, information for you um, on each of the different vaccines that we've talked about. Er, I'm just mindful that one of the slides appeared to have fallen off, which was the men B vaccine, um, which is, er, the one given at eight weeks, 16 weeks and one year. Um, it's important to say this is the Bexsero vaccine. I'm not sure if I covered it. Er, but it's a single injection into the thigh. Um, and it's usually given alongside the six in one pneumococcal vaccine. Um, and I think that's pretty much what I need to say about that. Um, ok, I think I've covered everything su but I'm really happy to take any questions. I appear to have left exactly 14 minutes. Which is, that's pretty good. That's pretty good. So, if you have, if you have any questions, do put them in the, um, the, the chat box, I have to say you were saying about um, the convenience of vaccinations and I live in Northern Ireland and when we had, uh, when everyone was getting vaccinated for COVID, um, there were people who lived on, um, on, er, council estates. I don't know what the right terminology, housing estates and, and they couldn't actually get to the nearest place and if they could, they didn't have a driving license, cos they couldn't drive and they also didn't have a passport. So they had no, and they didn't have any form of like ID. So thankfully, local community got together and a local uh pharmacy said, look, come to me, I'll give, you know, bring your HSC number, is it or whatever that number is, bring that in. I can look you up on my database cos I've got access to you. We can just go through a few details and we can give you the vaccine. So it's it is that working around things, isn't it? And actually there, there is a diff, you know, you can, you can do something. But anyway, right, we have some questions, they're plan and delivery such a huge part of this. And we've got lots of questions as we go. Is that all right? Yep. I'm going to pop them up on the screen. Can you see it on the screen? Oh, yeah. When having a conversation about mmr and the patient wants to delay first dose to ensure the child is not autistic, it's reasonable. Um So it's important to say that I think this is based around the concerns of that Andrew Wakefield study, which has been completely disproved by the scientific community. Um So what I would suggest is, please do share some of the Oxford um literature that I've that I've put into the slides which demonstrate that there is not a relationship between the Mr and autism. Hopefully that will help that patient to make an informed decision about whether they can, they want to give the Mmr or not, you know, the mmr can be delivered in a split format. I know that privately that is available, but it is, we know not as effective as the complete. Mmr, we've talked about that two dose protection and how much protection that offers when you've had the full course. Um again, it is possible to delay any of the vaccines that I've kind of highlighted within the time frames I've described. But again, for protection, er, you know, the most effective thing to do is to have the vaccinations in line with the vaccination schedule. Um So II hope that that answers that question, but also gives you the resources and tools that you need to be able to have that conversation, to inform, to understand the concerns that exist for that patient to help understand where that's coming from. It may be that that's something they've encountered via social media or information that's been given to them by someone. How can you help to educate, inform, but also help them to share that accurate information within those communities to help inform beyond just your interaction with that patient, er, with a child who develops viral wheeze asthma exacerbation, food allergies and other atopic conditions with will flu vaccine, er, cause a wheeze exacerbation. Er, not, not, not, not necessarily, we've talked about the fact that um, the oral flu vaccine, er, that we've described, if you're using the nasal spray, people who have, for example, an egg allergy, er, we might actually use the injection instead of er, the, the nasal spray in that situation. Er, because we know that that can be a way of overcoming that. Um, so, er, for example, if you have an allergic reaction to gelatin neomycin, er, which often will be in the nasal spray, we will give, er, instead of fluenz tetra, we will give the cell based quadrivalent influenza vaccine instead. Um, and that injection, er, hopefully will, will, will, will deal with those concerns. It's important to say that for anyone um having the vaccine, if they have an active fever, at that point, we will often delay until that fever is resolved. It should settle within 7 to 10 days. But we also often encourage parents to give paracetamol before they come in so that we can give them er, vaccination and protection on that basis. So, coming back to my first slide, as long as there is no anaphylactic er, contraindication broadly, other than the exceptions I've given you so far, er, it is reasonable to give the vaccination in those situations. I hope that answers your question, er, with the baby vaccinations, is there evidence to suggest it's better to give paracetamol calpol before or after, er, the immunizations, we tend to advise giving it shortly before. So that protection is in place, er, for when you have the vaccination itself. I've, I've given the example of paracetamol because it's applicable to every single one of those age groups. But obviously, as you start to get a little bit older, it means you can use things like Ibuprofen as well. Um obviously bearing in mind that for some people with certain health conditions, it may be that ibuprofen is not the suitable er, mechanism, er, certain, so it is a suitable agent, I should say er, to use. So, absolutely, I would recommend paracetamol just prior to, er, immuni er, just prior to vaccination, er, to offer that pain relief, that temperature reduction, that reduced irritability. And it's something that you can continue to take um for a few days to help you with any side effects or sequelae that we know commonly exists for a few days after vaccination. Er, what's the difference between er, the two, flu vaccines? Er, so you have Fluenz Tetra, er, which is the nasal spray flu vaccine, er, which contains a small amount of gelatin, er, as well as some of the other ingredients that we've talked about. Um, for anyone that can't have that, er, you can have the flu vaccine in which is a cell based quadrivalent influenza vaccine. I've put all of the information about that, er, into the slides, er, as well as what we use for the kind of over 60 fives as well, if you want to read up more on any of those specifics. But broadly speaking for the children's one, there's a nasal spray and there's an injection. Uh, do you also get passive immunity effect with diphtheria and tetanus as well as vaccinating, er, pregnant mum? I'm not, I'm not entirely sure, I've seen the data around the protection against pertussis, the whooping cough. Um, and that's certainly that passive protection is created by having that at that 16 to 32 week point. Um, and then what we use is the 60 the six in one to give protection later on in childhood at those points of incidents. Um, so I hope that answers that, er, can you buy the Gardasil nine vaccine privately if you are now over the age limit, er, you may well be able to, I'm not entirely certain, I, I'm not an expert on the private sector side of this, more sort of the NHS and what we provide, I'm afraid. So I, I'm afraid I have to say, II don't know precisely, I'm sure you probably could. Er, but again, it's about the evidence base and does this, um, provide an evidence based protection for you Um if a vaccine is not properly stored left overnight, I assume the vaccine will be denatured. Er, but the then had a reaction fever and flu to it. Does that mean the vaccine is still working? Um I would not give a vaccine er, that has not been stored appropriately. Um You must ensure and there is a very tight handling chain that exists as policy in almost all practices handling vaccine to ensure it's appropriately stored at the right temperatures that fridges are maintained and that you have back up plans, er, backup plans, even in the event of power cuts, er, or other issues that might influence a building that things are stored in to ensure vaccines are not compromised. They can only be given during dates of which er before the expiry date. Er, and there are really tight protocols and procedures to make sure vaccines that we give are safe and effective. I hope that answers that. Um how does a uni student get these vaccines? Is this promoted at enrollment and self referral to the GP? Er, yes, absolutely. There's huge, huge campaigns um actually um about this vaccination. So that's the men ac wy er, which is given, er, as, as I mentioned in year nine and 10, but also to our freshers, I shouldn't say that really at my age now. But our first year medical students, er, or university students, medical students, where am I university students um at higher risk because they're mixing with lots of new people who are knowingly carry er, that bacteria. Um It's important to say that they can access that via a local GP er, but usually as well, university services will provide a prompt, encouraging people to do that. But what I'd encourage you as a clinician is if you encounter someone about, for example, go on haj pilgrimage or start at university or go traveling to places like South America, et cetera, please do prompt them to make sure they book in and get that vaccination as well. That's perfect. That's us. Look at that. I know. Yeah, I was gonna say we can have a coffee, we can chat about anything. Now, can I ask, can I ask you a question if you've been, um, er, asked to come in for your flu vaccine at the end of January or February? Is it still worth getting it or not? Uh, sorry. Can you say that again? I was just distracted by the chat. That's good. If you, if you are asked by your GP to come in for a flu vaccine at the sort of like the end of January, February, is it still worth getting it or is it like? Yeah, absolutely. We know that there's a, a long tail to flu and actually our, our winters do seem to get longer and longer, don't they? But, um, you know, there's still value in the protection at whatever point in the winter period that you get it. Um, and you know, we, we have that long tail for that reason. Er, so if you are invited to get a vaccination, please do, er, contact and book and if you are the clinician speaking to patients, please do prompt them to make sure they get the protections that they need. I can see, I think it's one of my colleagues Heggie Wyatt in the chat who's sharing a really helpful resource as well. Um, and you know, so there's that and reflecting on the fact that there's a boosting of, of having it every year because obviously it protects against different strains, which is great. Perfect. If you've got a colleague, can she ask some really difficult questions? Then? I mean, I'm sure she's probably tempted to, she knows more about it than I do. Certainly as someone that ran much of the vaccination program in our, in our certainly dealt with much of the storage and administration in our practice at Lower Clapton. So really fantastic to see her realize she can't talk to me here other than through the chat. But, hi Heggie. Hello. Now, if you've got any questions you want to pop in the chat that, you know, he can't answer, please do so, I think that's it. I think we've got all our questions. We will put this on, catch up. Um, so, and, um, you'll, we'll let you know about it, the slides will pop on catch up too so you can get those um feedback will be coming to you uh in about three minutes in your inbox. Please fill it out. Once you've completed that, then your er attendance certificate will be on your med account. Um If that's it, if Elena isn't gonna give us any uh questions, then um we will say goodbye, we will end it now if that's ok, everyone. So thank you very much. Please come along. Please follow middle primary care. So you know uh about other events coming up and let us know. Also we've got threads. You can actually pop on the thread within medical primary care, the topics that you want to see coming up within this series. And we would love to get your feedback on that so we can actually put these events on for you. Ok? So thank you very much, everyone. We will say goodbye now. Thank you guys. Thank you so much. Really appreciate you all taking the time. I know it's the middle of a Wednesday afternoon. Um If anyone has anything, they want to kind of follow up on or ask, please do drop me an email or a uh you know, send me a message on Twitter or something and thank you all for taking the time. Really help.