Immunoglobulin preparations for post-exposure treatment

The following immunoglobulin preparations for intramuscular use are issued by the immunisation department of the Public Health England centre for infections and also by certain regional Public Health England and NHS laboratories:

human varicella-zoster immunoglobulin (VZIG)
human hepatitis B immunoglobulin (HBIG)
human rabies immunoglobulin (RIG)
human normal immunoglobulin (HNIG).

Vaccine preparations for post-exposure treatment

The following vaccine preparations for post-exposure prophylaxis are available:

Rabies vaccine: issued by the immunisation department of the Public Health England centre for infections and by regional Public Health England diagnostic centres via trust pharmacies.
Human hepatitis B vaccine: normally available from trust pharmacies, but usually stocked in A&E, occupational health, neonatal unit, GP surgeries and genitourinary medicine departments.
Hepatitis A vaccine: normally available from community pharmacies and GP surgeries.
MMR vaccine: normally available from community pharmacies and GP surgeries.

Information and directives about specific post-exposure treatments

For varicella (chickenpox)-zoster (shingles) click here
For hepatitis B click here
For rabies click here
For measles, hepatitis A and polio click here

Immunoglobulins (IGs) are concentrated antibody preparations, which provide immediate short-term protection against disease after exposure to infectious agents. All vulnerable individuals at high risk of developing severe disease or serious complications from the disease are eligible for immunoglobulin post-exposure treatment.

Immunoglobulin and rabies vaccine stock and issuing centres

UHS Pharmacy and the immunisation department at Public Health England, Colindale, stock and issue the following preparations for intramuscular or subcutaneous (in case of bleeding disorders) use: hepatitis B virus specific immunoglobulin, rabies virus specific immunoglobulin, varicella-zoster virus specific immunoglobulin and human normal immunoglobulin (HNIG) for hepatitis A, measles and polio viruses.

Prescribing of IG preparations and rabies vaccine

The prescribing doctor (UHS or external) must complete a risk assessment and provide the completed risk assessment form along with a signed prescription to the UHS Pharmacy (contact on-call pharmacist out-of-hours). Copies of the risk assessment and prescription forms are available to download from staff net and extranet websites accessible from NHS computers (see below). Pharmacists are not authorised to dispense IG preparations without completed risk assessments and signed prescriptions both handed to the main dispensary at Southampton General Hospital.

Collection and administration of IG preparations and rabies vaccine

Outpatients can collect the IGs at the UHS Pharmacy, but need to go to their surgery for the administration. GPs should make sure that the exposed person makes an appointment with the surgery for the injection of IGs. For urgent cases, in order to avoid delays, the IG preparations can be administered in A&E at Southampton General Hospital by prior arrangement. In these cases the doctor prescribing the IGs is responsible for contacting A&E through switchboard (023 80 777222) and for directing the patient to the place of administration.

Route, site and volume of injection of immunoglobulin preparations and vaccines for post-exposure treatment

Immunoglobulin for post-exposure prophylaxis should be administered by intramuscular injection into a large muscle mass such as the upper outer quadrant of the buttock. Rabies immunoglobulin should be instead completely administered into or around the wound site or sites when this is possible. However, individuals with bleeding disorders should instead receive immunoglobulin by deep subcutaneous injection. When a large volume of injection is to be given (more than 3ml is to be given to young children and infants, or more than 5ml to older children and adults), the immunoglobulin should be divided into smaller amounts and administered to different sites.

Hepatitis B and rabies vaccines should be administered by intramuscular injection in the deltoid area or in the antero-lateral thigh. However, individuals with bleeding disorders should instead receive immunoglobulin by deep subcutaneous injection.

When immunoglobulin preparations and vaccines are administered simultaneously, they should be given at separate injection sites.

Non-UK pooled plasma has been used since March 1999 due to theoretical risk of the transmission of nvCJD. All immunoglobulins are prepared from HIV, hepatitis B and hepatitis C negative donors. Vaccines and immunoglobulins are purchased by the Department of Health specifically for use within the NHS and are available from Public Health England free of charge; however, they can be purchased directly from BPL when the clinicians wish to use them outside of the national Joint Committee of Vaccination and Immunisation guidance (BPL Tel: +44 (0) 20 8957 2200 - 24hrs service; website: www.bpl.co.uk). Private clinics requiring these products should source them directly from the manufacturer wherever possible.

References

The Green Book, Immunisation against infectious diseases, Department of Health (www.gov.uk)
Immunoglobulin Handbook, Public Health England (www.hpa.org.uk)
http://www.hpa.org.uk/topics/infectiousdiseases/infectionsaz/
Rabies: http://www.who.int/mediacentre/factsheets/fs099/en/

Telephone numbers in case of queries

Contact Southampton Public Health microbiology laboratory:

During routine working hours: 023 8120/5101 or 6408.
Out of routine working hours, including weekends and bank holidays: contact the microbiologist on-call through switchboard (023 8077 7222).

Post exposure treatment against varicella-zoster, hepatitis A and B, rabies, measles and polio viruses