Copyright EMAP Publishing 2017
This article is not for distribution
Nursing Practice
Discussion
Vaccination
Keywords: Antimicrobial resistance/
Infection prevention/Immune system
This article has been
double-blind peer reviewed
In this article...
● W
hy vaccination is key in the global effort to reduce antimicrobial resistance
● Different immune responses the human body deploys against infectious agents
● The role of health and social care staff in increasing vaccination uptake
The role of vaccination in preventing
antimicrobial resistance
Talking
points
1
Growing
resistance to
antibiotics is
putting their use
to treat routine
infections at risk
across the world
Vaccination is
one of the most
successful and
cost-effective
interventions in
healthcare
A high uptake
of vaccination
helps prevent
infections, thereby
reducing the need
for antimicrobials
Health and
social care
staff need to ask
patients about their
vaccination history
and encourage
them to accept
appropriate vaccines
2
3
4
Authors Pauline F MacDonald is programme director for immunisation programmes;
Karen Shaw is infection prevention and control lead for antimicrobial resistance and
healthcare-associated infections programme; both at Public Health England.
Abstract Antimicrobial resistance will soon threaten the routine treatment of
common infections across the world. Vaccination is one of the strategies needed to
counter this threat. Vaccines prompt the human body to issue an immune response
to an invading organism, preventing infection from occurring in the first place,
thereby reducing the need to use antimicrobials. This article, part of an occasional
series on AMR, sums up the challenges and solutions, and discusses the need for all
health and social care professionals to promote vaccination.
Citation MacDonald PF, Shaw K (2017) The role of vaccination in preventing
antimicrobial resistance. Nursing Times [online]; 113: 3, 18-20.
A
ntimicrobial
resistance
is
increasingly recognised as one
of the major global public health
threats; it puts at risk the treatment of routine infections with antibiotics.
Resistant infections currently claim 700,000
lives annually and it has been estimated that
10 million lives each year will be at risk by
2050, with an economic impact of approximately US$100 trillion (O’Neill, 2016a).
The World Health Organization has
made it clear that all government sectors
and society need to act to reduce this threat.
It established a formal tripartite alliance
between public health, animal health and
food safety under the ‘One Health’ approach.
This partnership recognised that addressing
health risks across human, animal and ecosystem interfaces requires a collaborative
approach with clear roles and responsibilities (WHO, 2014). In tackling AMR, a full
range of interventions must be taken
across human and animal health.
The role of vaccination
Vaccination is an essential tool against
AMR, as preventing infections in the first
Nursing Times [online] March 2017 / Vol 113 Issue 3
18
place negates the need for antibiotics.
There is a great deal of evidence that vaccination is one of the most successful and
cost-effective interventions in healthcare
(WHO, 2013). Past successes include:
l T
he eradication of smallpox;
l A
reduction in the incidence of polio;
l A
reduction in illness, disability and
death from diphtheria, tetanus,
whooping cough, measles, Haemophilus
influenza type B and epidemic
meningococcal A meningitis (WHO,
2013).
In the UK in 2012, the Joint Committee
on Vaccination and Immunisation proposed extending the national flu immunisation programme to all children aged
2-17 years. A pilot was undertaken and the
results from a range of surveillance indicators were encouraging. There were:
l F
ewer GP consultations for influenzalike illness;
l Less swab positivity in primary care;
l Fewer hospitalisations;
l A lower percentage of attendances at
emergency departments due to respiratory
illness (Public Health England, 2014).
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Nursing Practice
Discussion
Rotavirus vaccination has had a vast
impact globally with a 90% reduction in
related hospitalisations in resource-poor
countries after its implementation (Kollaritsch et al, 2015). England and Wales saw a
77% decline in laboratory-confirmed rotavirus infections and a 26% decline in allcause acute gastroenteritis hospitalisations (Atchison et al, 2015).
These successful immunisation programmes show that vaccination significantly reduces the burden of infections,
including viral infections, therefore
reducing the need for antimicrobial use. In
the past, many people have been inappropriately prescribed antimicrobials for viral
infections such as coughs and colds, or
influenza. While antibiotics are of no use
in treating these viral infections, vaccination will significantly reduce the risk of
acquiring flu, and if there are fewer people
with influenza, there will be fewer people
seeking to take antibiotics (PHE, 2015a).
Reducing the overall use of antimicrobials
will reduce the overall burden of AMR.
The immune system
For an infection to develop it requires a
number of steps and certain conditions to
be met; this is known as the chain of infection (Shaw, 2016). Of central importance in
the chain of infection is the susceptible
host – someone who is at risk of developing an infection if all the right conditions are met. Several factors make individuals more susceptible to infection
depending on their immune system and
ability to defend against the invading
organism (Zabriskie, 2009).
The immune system provides a complex defence against micro-organisms.
The first-line protective measure is a
physical barrier, the epithelial system
(skin, gastrointestinal tract and respiratory tract), which prevents the entrance
of micro-organisms or toxic agents both
physically and with some unique additional mechanisms that offer protection
against invaders (Delves, 2016).
When micro-organisms do penetrate
physical barriers, the body has two
immune responses:
l Innate (natural) immunity;
l Adaptive (acquired) immunity.
Innate immunity
Innate immunity is when the body provides an immediate response to the
invading organism, which is known as an
antigen. In innate immunity, the body
does not require past exposure to the
antigen in the form of an immunologic
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Box 1. Immunisation
programmes to reduce HCAIs
lRotavirus
lRespiratory syncytial virus antibodies
(passive immunity)
lInfluenza
lShingles
lMeasles, mumps and rubella
lBacillus Calmette-Guérin vaccine
(against tuberculosis)
lPneumococcal disease
lMeningococcal disease
lSalmonella typhi (against typhoid
fever)
HCAI = healthcare-associated infection
memory, allowing an immediate response.
The innate immune responses include:
l P
hagocytic cells (neutrophils,
monocytes and macrophages), which
ingest and destroy the invading
antigen;
l N
atural killer cells, which destroy
virus-infected cells and some tumour
cells;
l P
olymorphonuclear leukocytes
(neutrophils, eosinophils, basophils,
mast cells) and mononuclear cells
(monocytes and macrophages), which
are phagocytic cells and, together, set
up the inflammatory response and
produce symptoms such as redness,
heat, pain, swelling and loss of function
(Delves, 2016).
Adaptive immunity
Adaptive immunity requires prior exposure to the antigen and can take time to
develop following the initial exposure. The
immune system remembers the exposure
or antigen and responds to subsequent
exposures. Adaptive immunity involves
the lymphocytes known as T cells and
B cells. Cell-mediated immunity is derived
from certain T-cell responses and humoral
immunity is derived from B-cell responses.
The B cells secrete antigen-specific antibodies and together they work to destroy
the invaders (Delves, 2016).
Adaptive immunity can be either passive or active.
Passive immunity
Passive immunity is provided by the
transfer of antibodies from an immune
individual to another individual. This happens naturally with cross-placental transfer
of a mother’s antibodies to her child, but
can also be provided via blood transfusion,
blood products or immunoglobulins.
Nursing Times [online] March 2017 / Vol 113 Issue 3
19
Passive immunity is temporary, only
lasting as long as the antibodies maintain
their avidity (that is, the strength of their
binding with the antigen) and continue to
circulate. It is variable in its ability to protect the host from infection.
Active immunity
Active immunity is acquired as a result of
natural infection or exposure to organisms
(for example, measles) or by vaccination
(for example, the measles, mumps and
rubella vaccination). Whether as a result of
exposure to an organism or a vaccination,
the host will develop both antibody- and
cell-mediated immunity responses, which
can provide long-lasting protection
against an organism or group of related
organisms (Department of Health, 2013).
Preventing AMR with vaccination
In 2013 the DH and the Department for
Environment, Food and Rural Affairs published a five-year antimicrobial resistance
strategy for 2013 to 2018 (DH and DEFRA,
2013). In the battle against increasing
AMR in the UK and across the world, there
is an imperative to implement strategies
other than antimicrobial use to prevent
and treat infections. The role of vaccines is
highlighted numerous times throughout
the strategy.
While the majority of AMR is seen in
bacteria and their associated antibacterial
drugs, there are also issues with emergent
resistance among viruses to current antiviral drugs (O’Neill, 2016b; Strasfeld and
Chou, 2010).
Vaccines that prevent or reduce the
incidence of bacterial, fungal and viral
infections will help to reduce reliance on
antibiotics and antivirals; since there is a
direct correlation between antibiotic use
and the emergence of resistance, reducing
the amount of antimicrobial drugs used
will have an impact on resistance.
Vaccines are also important in the prevention and control of communityacquired infections and healthcare-associated infections (HCAIs). Box 1 lists current
immunisation programmes aimed at preventing infections that are associated
with transmission, outbreaks, morbidity
and mortality in various health and social
care settings.
There are many other communityacquired infections and HCAIs for which
no vaccines are currently available, but
many technological and scientific advances
are being made to expand the portfolio of
vaccines against viral and bacterial infections (Moxon and Siegrist, 2011). Box 2 lists
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Nursing Practice
Discussion
the organisms that have a major impact in
healthcare settings or are known to be
resistant to antibiotics against which vaccines are currently being developed.
There are numerous major global infections for which vaccines do not yet exist;
for example, there are no vaccines against
campylobacter, hepatitis C, herpes simplex and rhinovirus. Exciting and challenging developments are likely in the
fields of vaccinology, infection prevention
and AMR, so this is an area we should all
monitor with interest.
The role of health professionals
Nurses have a critical role in maximising
uptake of vaccination. They are in a unique
position to promote health and wellbeing
because of the range of roles and settings
in which they work (All-Party Parliamentary Group on Global Health, 2016).
Our nursing leadership framework
Leading Change Adding Value (NHS England,
2016) calls on nurses to be positive role
models and champions for the prevention
of AMR through infection prevention and
control messages, so ownership is seen as
everybody’s business. In a similar call for
action, the Public Health England framework All Our Health calls on health professionals to:
“use their knowledge, skills and
relationships, working with patients
and the population to prevent illness,
protect health and promote wellbeing.”
(PHE, 2015b)
The section of the PHE framework on
AMR calls health and social care workers to
support the uptake of all immunisations,
vaccination and screening programmes
(PHE, 2015c).
Most health professionals are familiar
with the infection prevention agenda but
fewer may be aware of the UK’s AMR
strategy (DH and DEFRA, 2013). However,
unless they are directly involved in delivering immunisation services and programmes, many may not appreciate the
role their patients’ or clients’ vaccination
status can play in the health of those
patients and clients, and that of the people
around them.
All health and social care staff are urged
to ask the people in their care about their
vaccination history. While this would
seem most pertinent when caring for children, the vaccination status of adolescents
and adults should also be checked. If
necessary, vaccines should be provided or
the individual directed to their GP to
discuss missing immunisations. Many
Box 2. Organisms tackled by
vaccines under development
Vaccines are currently being developed
against the following organisms:
lGroup B streptococcus
lStaphylococcus aureus
lRespiratory syncytial virus
lNorovirus
lClostridium difficile
lTuberculosis*
lHIV
lEscherichia coli
lCandida
lPseudomonas aeruginosa
*A new TB vaccine is needed because the
current Bacillus Calmette-Guérin vaccine is a
live vaccine associated with some morbidity.
It fails to produce an adequate immune
response in some adults. Furthermore,
production challenges have resulted in a
global shortage of the Statens Serum Institut
brand of BCG in recent years.
Source: O’Neill (2016b)
individuals will have at-risk conditions
and comorbidities that make them more
vulnerable to infections. For example, in
autumn, older people and those at risk
should be asked about their influenza and
pneumococcal vaccine history. The full UK
Immunisation schedule can be accessed at
bit.ly/PHEImmunisationSchedule.
Conclusion
Vaccines and knowledge of individuals’
immune status can contribute enormously
to infection prevention for those individuals and for health and social care populations. The appropriate use, and high
uptake, of vaccines among eligible groups
will help to reduce infection and the subsequent need for antimicrobials, thereby
helping to combat increasing AMR. Plotkin
and Plotkin (2004) reiterated the WHO’s
assertion that:
“the two public health interventions
that have had the greatest impact on
the world’s health are clean water
and vaccines.”
Nurses are the largest health and social
care workforce, and therefore have a real
opportunity to make a difference in the prevention of the global threat of AMR by promoting and educating about vaccination.
All health and social care workers should
ask their patients and clients about their
vaccination history and encourage uptake of
missing vaccines for which they are eligible.
They should also get involved when possible
in promoting vaccination, for example by
Nursing Times [online] March 2017 / Vol 113 Issue 3
20
participating in World Immunisation Week
2017: Vaccines Work (24-30 April; bit.ly/
WHOImmunizationWeek2017). NT
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For more on this topic go online...
lPrevention by breaking the chain
of infection
Bit.ly/NTChainInfection
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