Background

The assessment of skin for clinical signs and symptoms is important when identifying adverse events following immunisation (AEFI). Most dermatological assessment guidelines commonly refer to the presentation of symptoms in patients with light skin tones.

The skin is one of the most complex organs in the body. It consists of 3 layers, with each layer performing different roles. The colour of a person’s skin is influenced by the amount of melanin (natural pigment) which is produced by the melanocytes located in the epidermis (outer layer of the skin), with darker toned skin having more melanin present than lighter toned skin. The amount of melanin will affect the appearance of AEFI on a patient’s skin and therefore AEFI, such as pallor, cyanosis, erythema and urticaria, may appear differently in varied skin tones. This can pose a challenge for immunisation providers to identify symptoms of AEFI in a timely manner.

Pallor

Pallor refers to the pale appearance of the skin, nail beds and mucous membranes. Pallor is not always a symptom of disease.

Pallor may be difficult to detect in dark toned skin and may present as ashen or grey. In brown toned skin the skin will present more yellowish in colour. An alternative method for identifying pallor in darker skin tones can be assessing the palmer surface which can appear paler.

Following immunisation, pallor can be noted in events such as vasovagal syncope (fainting) and hypotonic hypo-responsive episodes (HHE). 

Cyanosis

Cyanosis is a symptom of decreased oxygen in the bloodstream. There are 2 types of cyanosis:

  • Peripheral cyanosis, which is observed in the extremities including hands, fingertips and feet.
  • Central cyanosis, which is detected in central parts of the body including head, torso and mucous membranes and is often more serious.

In those with light skin tones, cyanosis will present as a bluish/purple hue. In patients with naturally yellow toned skin, cyanosis may cause a grayish-greenish appearance. In those with darker skin tones, cyanosis may be trickier to assess and may be observed as grey or white.

Following immunisation, cyanosis may occur in the setting of HHE, apnoea, breath holding episode or high fever.

Erythema

Erythema describes a red appearance of skin caused by the dilation of superficial blood vessels and increased blood flow. It often occurs with skin trauma, inflammation, infection or rash.

Erythema is clearly visible on light toned skin. It may appear red or cause a purplish discoloration on some darker toned skins however it is difficult to see on very dark skin. Assessing the affected site or area for other signs including warmth, swelling or induration can assist in clinical assessment and diagnosis of erythema.

Following immunisation, erythema can be widespread or localised at the injection site.

Urticaria

Urticaria, or hives, occur when the mast cells that lie within the skin release histamine that irritates nerve endings and causes local blood vessels to dilate and leak fluid. They can appear anywhere on the body and can be transient in nature. The cause is often not known however, they may be associated with infections or allergy.

On light toned skin, hives appear as itchy, raised red welts. They often have a white center or wheal which looks like a mosquito bite and are surrounded by an erythematous ring. In darker toned skin, hives appear as raised lumps however the colour changes to the skin may not be as obvious.

Following immunisation, hives can occur anywhere on the body and may occur in the setting of an allergic reaction.

Resources

Images

Other resources

Authors: Georgina Lewis (Clinical Manager SAEFVIC, Murdoch Children’s Research Institute), Mel Addison (SAEFVIC Research Nurse, Murdoch Children’s Research Institute), Francesca Machingaifa (SAEFVIC Research Nurse, Murdoch Children’s Research Institute) and Rachael McGuire (SAEFVIC Research Nurse, Murdoch Children’s Research Institute)

Date: September 2020

Materials in this section are updated as new information and vaccines become available. The Melbourne Vaccine Education Centre (MVEC) staff regularly reviews materials for accuracy.

You should not consider the information in this site to be specific, professional medical advice for your personal health or for your family’s personal health. For medical concerns, including decisions about vaccinations, medications and other treatments, you should always consult a healthcare professional.

 

The development of a nodule at the injection site is a known but rare adverse event following immunisation (AEFI). Nodules are defined as the presence of a palpable, firm, discrete or well-demarcated soft tissue lump at the site of immunisation in the absence of heat, erythema (redness) or signs of abscess.

Nodules can occur following any vaccine.  They usually present in the days or weeks following immunisation and are most often reported following vaccines given in infancy or childhood. A nodule can persist for weeks and sometimes months. They are usually asymptomatic but can be tender and/or itchy. They are often reported by parents to feel like a ‘pea’ size lump under the skin. They usually resolve spontaneously without treatment or investigation.

It is unclear what causes a nodule however, vaccine components (e.g. aluminium), local inflammatory reactions or immune-mediated responses have been implicated as possible contributing factors. 

Very rarely, a nodule may persist and become symptomatic for the vaccinee (see rare or persisting subcutaneous nodules below).

Implications and considerations for future vaccines

It is recommended that future vaccines continue to be given according to the immunisation schedule. The history of, or presence of, a nodule is not a contraindication to future vaccines.

Ensure correct vaccine administration for both intramuscular and subcutaneous vaccines. Deep intramuscular (IM) injection for IM vaccines should be considered to minimise the risk of potential recurrence of a nodule. Where possible, avoid vaccination at a site of an existing nodule.

Rare or persisting subcutaneous nodules

Some nodules can become symptomatic and last for months or even years and are referred to as persisting subcutaneous nodules. Pruritus (itch) is the most concerning symptom that motivates parents to seek medical attention. Ongoing pruritus can alter the appearance of the skin leading to excoriation, hair growth and pigmentation changes. Intensified itching and a change in size of the nodule has been reported when a child is unwell with a viral infection or even following subsequent vaccinations given at a different anatomical site.

Treatment of persisting subcutaneous nodules

A conservative approach to treatment is recommended and is usually to provide symptomatic relief of pruritus. Any treatments would need to be provided following medical review and can include topical corticosteroids or dressings to protect the area from rigorous scratching. Referral to a Specialist Immunisation Clinic should be considered for specialist consultation.

Any AEFI should be reported to the vaccine safety service in your state. In Victoria reports can be made to SAEFVIC online via AEFI-CAN or by telephone on 1300 882 924 (option 1) during business hours.

Resources

Authors: Mel Addison (SAEFVIC Research Nurse, Murdoch Children’s Research Institute), Rachael McGuire (SAEFVIC Research Nurse, Murdoch Children’s Research Institute) and Georgina Lewis (Clinical Manager, SAEFVIC, Murdoch Children’s Research Institute)

Date: September 2020

Materials in this section are updated as new information and vaccines become available. The Melbourne Vaccine Education Centre (MVEC) staff regularly reviews materials for accuracy.

You should not consider the information in this site to be specific, professional medical advice for your personal health or for your family’s personal health. For medical concerns, including decisions about vaccinations, medications and other treatments, you should always consult a healthcare professional.

In effort to meet the needs of our community during the COVID-19 pandemic, Monash Health and the Royal Children’s Hospital have launched drive-through immunisation clinics to make it easier for people to receive their immunisations. Receiving scheduled and additional vaccinations such as influenza remains essential, and both services aim to provide this in a safe setting outside of the hospital environment.

Families are reminded that it is safe and recommended to attend your local immunisation service (GP or local council) to receive scheduled vaccinations, however drive-through clinics are also available in Clayton and Parkville. A full list of Victorian council immunisation services can be accessed here.

Monash Health Immunisation drive-through clinic in Clayton

The drive-through clinic has been operational since April 2020 and has administered over 4500 vaccinations to Monash Health and Monash Children’s Hospital patients and their families, staff members and the general community.

The Monash Immunisation service provides a whole-of-life service, with a primary focus on the Monash Health patient community and the family members of this vulnerable patient cohort. However, the service is also available to the local community for vaccinations on the National Immunisation Program (NIP) for all ages as well as pertussis (whooping cough) and influenza immunisation for antenatal and postnatal mothers and partners.

Clinic details:

  • Monash Hall, 264 Clayton Road, Clayton 3168
  • Operating hours: 9am – 3pm weekdays
  • No referral or booking is required

Contact:

The Royal Children’s Hospital drive-through clinic in Parkville

The Royal Children’s Hospital drive-through clinic was launched in August 2020 and aims to provide immunisations to the Royal Children’s Hospital patient community, their family members as well as the general community locally for all scheduled vaccines.

  • Royal Children’s Hospital carpark, 50 Flemington Road, Parkville 3052
    • Left hand turn off Flemington Road (follow signs)
  • Operating hours: 9am – 1pm Tuesday and Wednesdays only (until 15 September 2020)
  • Bookings are mandatory (no referral required) and can be made here
  • As part of the COVID-19 visitor screening process, you will be contacted before your appointment and asked a series of standardised health questions

Contact:

Author: Daniela Say (MVEC Immunisation Fellow, Murdoch Children’s Research Institute), Nigel Crawford (Director SAEFVIC, Murdoch Children’s Research Institute), Sonja Elia (Nurse Practitioner and Manager Immunisation Service, RCH), Joanne Hickman (NUM Monash Immunisation, Monash Health), Jim Buttery (Paediatrician/ ID physician, Monash Health), Jeremy Carr (Paediatrician/ ID physician, Monash Health), Karen Bellamy (Immunisation Nurse, Monash Health)

Date: September 2020

Materials in this section are updated as new information and vaccines become available. The Melbourne Vaccine Education Centre (MVEC) staff regularly reviews materials for accuracy.

You should not consider the information in this site to be specific, professional medical advice for your personal health or for your family’s personal health. For medical concerns, including decisions about vaccinations, medications and other treatments, you should always consult a healthcare professional.

MVEC supports all scientific efforts to rapidly develop safe and effective SARS CoV-2 vaccine(s). This includes technology developed over 50 years ago and has been a proven way to support the production of viral vaccines that have saved so many lives around the world.

Background

In the early 1960’s foetal embryo fibroblast cells were first obtained from 2 elective terminations of pregnancy in order to grow vaccine viruses. These same cell lines have continued to grow in laboratory conditions since this time and have been used in the development of various vaccines including rubella, measles, hepatitis A and rabies vaccines.

How is foetal tissue used in vaccine development?

Vaccine viruses are grown within foetal cell lines because they are human and will mimic how viruses will act when infecting a human host. They can be sustained over time and have been shared by multiple vaccine researchers and developers and are clearly outlined to regulatory authorities, such as the Therapeutic Goods Administration (TGA) in Australia and the Food and Drug Administration (FDA) in America. 

There are three current SARS CoV-2 vaccine candidates that have used this technology as part of their development.  They are the Oxford AstraZeneca (UK); Johnson and Johnson (Jansen research US) and CanSino biologics (China). All of these vaccines are in the class called ‘Virus vectors’ and use an adenovirus (common human virus) to help carry the DNA of the SARS CoV-2 spike protein, the part of the virus researchers are targeting to produce a protective immune response.

Why don’t we try to use vaccines without these foetal embryonic cell lines?

The SARS CoV-2 pipeline is progressing at pandemic speed and it was important to utilise proven technologies to support vaccine development. Replication of viruses in the laboratory can be difficult, so these established platforms, as detailed above, is scientifically justifiable There is also a hypothetical concern for transmission of animal diseases if animal embryonic cell lines were to be used for this purpose.

It is also uncertain how many of the SARS CoV-2 vaccines will be shown to be safe and effective, so given the impact of the pandemic and lives that may be saved by vaccine(s), we should be open to discussing these products and addressing ethics issues that are being raised as part of COVID-19 vaccine readiness planning.

Religious and ethical implications

Even though foetal cells lines are used to grow vaccine viruses, the resultant vaccine does not contain these cells, fragments of these cells, or any DNA recognisable as human. During the manufacturing process, the foetal cells often burst when the vaccine virus grows, and the resulting vaccine virus is purified before being used in the final vaccine product.

In 2005, Pope Benedict XVI as head of the Catholic Church, released a statement in support of using vaccines derived from foetal cell lines, outlining that they “may be considered in order to avoid a serious risk not only for one’s own children but also, and perhaps more specifically, for the health conditions of the population as a whole – especially for pregnant women”. They may be “morally justified as an extrema ratio due to the necessity to provide for the good of one’s children and of the people who come in contact with the children” [refer to Moral reflections on vaccines prepared from cells derived from aborted human foetuses].

Resources

Authors: Nigel Crawford (Director, SAEFVIC, Murdoch Children’s Research Institute), Rachael McGuire (SAEFVIC Research Nurse, Murdoch Children’s Research Institute), and Georgina Lewis (SAEFVIC Clinical Manager, Murdoch Children’s Research Institute)

Date: August 2020

Materials in this section are updated as new information and vaccines become available. The Melbourne Vaccine Education Centre (MVEC) staff regularly reviews materials for accuracy.

You should not consider the information in this site to be specific, professional medical advice for your personal health or for your family’s personal health. For medical concerns, including decisions about vaccinations, medications and other treatments, you should always consult a healthcare professional.

 

 

Immunosuppression occurs when a person’s immune system is weakened, resulting in a decreased ability to fight infections. Causes of immunosuppression may include having certain medical conditions (e.g. autoimmune disease, cancer, transplants, functional or anatomical asplenia, advancing age and HIV) or taking specific medications (e.g. corticosteroids, disease-modifying antirheumatic drugs [DMARDs] or cancer therapies). Seroprotection from immunisation can be suboptimal in this patient group and therefore additional doses of vaccines may be recommended. Some vaccines (live-attenuated vaccines) may be contraindicated.

The degree of immune compromise should be assessed to determine individual vaccination strategies.

Many vaccines can be given pre-emptively to people who anticipate immune compromise in the future (e.g. a patient undergoing a planned splenectomy should be immunised prior to surgery).

Recommended vaccines

Inactivated vaccines are safe to administer to the immunocompromised individual but efficacy may be reduced.

Influenza

Annual influenza vaccination is recommended for all immunocompromised patients.

Those < 9-years of age are recommended to receive 2 doses of influenza vaccine, administered a minimum of 4 weeks apart, in the first year of influenza immunisation. Transplant recipients (solid organ or haematopoietic stem cell) should also receive 2 doses of influenza vaccine, a minimum of 4 weeks apart, in the first year following transplant. This is regardless of age or previous influenza vaccine history.

Where a major shift in the circulating influenza virus occurs, such as in an influenza pandemic situation, 2 doses a minimum of 4 weeks apart, should be considered regardless of patient age or immunisation history to ensure optimal immune response.

Refer to MVEC: Influenza vaccine recommendations for more information.

Pneumococcal

The timing of vaccination, the number of doses and the type of vaccine(s) depend on a person’s age and underlying risk for invasive pneumococcal disease (IPD).

Refer to Australian Immunisation Handbook: Pneumococcal for more information.

Meningococcal

Those taking certain therapies or with specific medical conditions (particularly those with asplenia) require extra doses of meningococcal vaccines. This applies to both MenACWY (quadrivalent) and MenB (meningococcal B) vaccines.

Refer to MVEC: Meningococcal vaccines in special risk and immunosuppressed patients for more information.

Contraindicated vaccines

Live-attenuated vaccines (see Table 1) are contraindicated in the majority of immunocompromising situations due to the risk of adverse events or vaccine-related disease. It is important to carefully review a patient’s history to identify suitability to receive a live-attenuated vaccine. Specialist immunisation advice can be sought by contacting the Victorian immunisation hotline on 1300 882 924 if clarification is required.

Table 1: Live-attenuated vaccines

Disease Brand name
Rotavirus^ Rotarix®
MMR (measles-mumps-rubella)^ Priorix®, MMR II®
MMRV (measles-mumps-rubella-varicella)^ Priorix-tetra®, ProQuad®
Varicella (chickenpox)^ Varilrix®, Varivax®
Zoster (shingles)^ Zostavax®
Tuberculosis BCG (varying brands)
Yellow fever¥ Stamaril®
Typhoid  Vivotif®
Japanese encephalitis¥ Imojev®

^recommended vaccine on the National Immunisation Program (NIP)
#recommended vaccine on NIP for select patient group only
¥available vaccine for travel

Household contacts of immune suppressed individuals should be up to date with all vaccines (including annual influenza). It is safe for household contacts to receive live-attenuated vaccines.

Precaution: Mothers who are receiving immunosuppressive therapy and breastfeeding (or those who received immunosuppressive medication during pregnancy) should seek advice from an Specialist Immunisation Clinic around the safety of live-attenuated vaccines for their child (e.g.oral rotavirus vaccine or BCG). Inactivated vaccines should be administered as per the NIP.

Inadvertent administration of a live-attenuated vaccine to an immunosuppressed person

In the event that a live-attenuated vaccine has been administered inadvertently the following steps should take place:

  • Establish how severely they are immunocompromised and the level of risk for vaccine-associated adverse effects. This will inform appropriate management (e.g. need for antiviral therapy)
  • Open disclosure with the patient and discuss the implications as well as any signs and symptoms to monitor for.
  • Seek specialist advice and notify state or territory public health authorities (refer to MVEC: Adverse events reporting Australia). In Victoria, you can seek advice from SAEFVIC.

Resources

Authors: Georgina Lewis (Clinical Manager, SAEFVIC, Murdoch Children’s Research Institute), Francesca Machingaifa (SAEFVIC Research Nurse, Murdoch Children’s Research Institute) and Rachael McGuire (SAEFVIC Research Nurse, Murdoch Children’s Research Institute) 

Date: August 2020

Materials in this section are updated as new information and vaccines become available. The Melbourne Vaccine Education Centre (MVEC) staff regularly reviews materials for accuracy.

You should not consider the information in this site to be specific, professional medical advice for your personal health or for your family’s personal health. For medical concerns, including decisions about vaccinations, medications and other treatments, you should always consult a healthcare professional.

 

 

MVEC is supportive of breastfeeding at the time of childhood immunisations. In this information page, we detail the different types of vaccines and indications for having a more detailed discussion with your healthcare provider. Immunising breastfeeding mothers will not impact their ability to produce breastmilk.

Inactivated (e.g. seasonal influenza and whooping cough) and live-attenuated vaccines (e.g. measles-mumps-rubella) are generally safe to administer to women who are breastfeeding.

In some instances, antibodies created by the mother in response to a vaccine can be passed onto the infant via breastmilk (passive immunity) to be absorbed orally and provide short term protection. Any maternal antibodies passed onto a baby via breastmilk does not interfere with a baby’s immune response to their own vaccines.

In addition, there are no concerns for a breastfeeding mother to have contact with someone who has recently received either a live-attenuated or an inactivated vaccine.

Influenza

Annual influenza immunisation is safe and recommended for breastfeeding mothers. Babies less than 6-months of age are at greatest risk from disease yet cannot receive influenza vaccines until they are 6-months of age. Maternal immunisation will provide protection for mothers as well as providing some passive protection for babies through the secretion of antibodies until they are old enough to receive their own influenza vaccine [refer to MVEC: Influenza vaccine recommendations].

Measles-mumps-rubella (MMR)

The MMR vaccine is a live-attenuated vaccine and therefore immunisation should be avoided in the 28 days prior to a pregnancy and is contraindicated during pregnancy. However, it is safe for immunisation to occur at any time following delivery including whilst breastfeeding with no concerns for the mother or the breastfed infant.

Hepatitis B

It is safe for mothers who are positive for the hepatitis B virus to breastfeed their baby as long as the infant receives a dose of hepatitis B immunoglobulin (HBIG) at birth as well as all scheduled doses of hepatitis B vaccine commencing with the birth dose.

Yellow fever vaccines

The live-attenuated yellow fever vaccination should be avoided in breastfeeding mothers. Anyone travelling to a yellow fever endemic area should have a specialist travel consultation to provide individual travel advice and discuss immunisation recommendations. There is some evidence to suggest that yellow fever vaccine virus can be transmitted to infants via breastmilk. Infants are not recommended to receive the yellow fever vaccine until a minimum of 9-months of age due to its side effects profile [refer to Australian Immunisation Handbook: Yellow fever].

Resources

There are a lot of excellent resources that review the evidence and support the administration of routine vaccines to breastfeeding mothers.

Authors: Dr Nigel Crawford (Director SAEFVIC, Murdoch Children’s Research Institute), Rachael McGuire (Research Nurse SAEFVIC, Murdoch Children’s Research Institute) and Georgina Lewis (Clinical Manager SAEFVIC, Murdoch Children’s Research Institute) 

Date: August 2020

Materials in this section are updated as new information becomes available. The Melbourne Vaccine Education Centre (MVEC) staff regularly review materials for accuaracy.

You should not consider the information in this site to be specific, professional medical advice for your personal health or for your family’s personal health. For medical concerns, including decisions about vaccinations, medications and other treatments, you should always consult a healthcare professional.

Background

Eczema, or atopic dermatitis, is a skin condition affecting many people of all ages but is most common in infants and young children. It affects approximately 40% of babies and children worldwide and often appears in the first year of life. Many children grow out of eczema around the age of 5 years however, there are some individuals who will have eczema throughout their life.

Eczema, along with asthma, allergy and allergic rhinitis are more formally known as atopic conditions. Of those children with moderate to severe eczema, a small number will go on to develop food allergy, asthma of childhood and/or allergic rhinitis.

It is not well understood why some individuals develop eczema or other atopic conditions however, there is research and clinical trials currently underway looking into possible genetic, immunological and environmental causes for eczema.

Immunisation implications

Although there is no causal relationship between vaccines and eczema identified in the literature it is recognised that a flare of eczema may occur following immunisation.

Parents of infants and children with eczema can be confident that vaccines do not cause atopic disease, and should be reassured that while children may experience a flare of eczema in the days following their vaccines, this is not considered a contraindication to immunisation.  It is important that eczema management continues, including the use of moisturisers, topical steroids and barrier creams in order to treat any symptoms that may occur. Families should seek medical advice from their local GP or eczema specialist if they are concerned.

It is important to also note that the use of topical steroids to treat active eczema is not a contraindication to any vaccination. If there is active eczema present, an alternate injection site could be considered to reduce the risk of infection (or abscess) at the injection site. If no other site is deemed suitable, cleaning the site with an alcohol based wash/single use alcohol swab and allowing the site to dry completely before injecting could be considered. BCG vaccination should be deferred if there is active eczema at the injection site.

Resources

Authors: Mel Addison (SAEFVIC Research Nurse, Murdoch Children’s Research Institute)

Date: July 2020

Materials in this section are updated as new information and vaccines become available. The Melbourne Vaccine Education Centre (MVEC) staff regularly reviews materials for accuracy.

You should not consider the information in this site to be specific, professional medical advice for your personal health or for your family’s personal health. For medical concerns, including decisions about vaccinations, medications and other treatments, you should always consult a healthcare professional.