Guidance

Immunoglobulins - how and when to issue out of hours

Updated 20 February 2024

Applies to England

Post-exposure prophylaxis out of hours

Outside the Rabies and Immunoglobulin Service (RIgS) working hours, clinical advice is available on the website and through the Colindale Duty Doctor service at evenings, weekends and bank holidays. Apart from for anti-toxins (botulinum or diphtheria), all vaccine and immunoglobulin issues can wait until the next day, so for advice after 5.30pm callers should wait and call the following morning to speak to RIgS or the Colindale Duty Doctor service.

There is no need to call RIgS before administering rabies vaccine, and any vaccine used in good faith as part of rabies post-exposure treatment will be replaced by the team if notified the following working day. If vaccine and/or immunoglobulin are required out of working hours and cannot wait until the next working day, the product may be collected from a local stockholder or be issued for delivery through Movianto the next day.

The UK Health Security Agency (UKHSA) cannot issue products to hospitals or GP clinics outside of England.

Hepatitis A

Post-exposure hepatitis A vaccine can prevent infection with hepatitis A in close and household contacts if given within 14 days of exposure. Human normal immunoglobulin (HNIG) is used to further attenuate infection in those who are at higher risk of severe hepatitis A (those with underlying liver disease) and those who respond less rapidly to vaccine (those aged 60 years and over or with liver disease or immunosuppression).

HNIG issues for hepatitis A

Contacts aged 60 years and over

The exposed individual should receive their first dose of vaccine (sourced locally) up to 14 days after exposure.

HNIG will not be issued at all for calls received after the cut-off time required to allow administration of the product within 14 days from the date of onset of jaundice.

Contacts with underlying liver disease and immunosuppression

The exposed individual should receive their first dose of vaccine (sourced locally) up to 28 days after exposure.

HNIG will not be issued at all for calls received after the cut-off time required to allow administration of the product within 28 days from the date of onset of jaundice.

Further details are available at:

Public health control and management of hepatitis A.

Hepatitis A: the green book, chapter 17.

Measles

Historical evidence suggested that HNIG can prevent or attenuate measles if given within 4 to 5 days of exposure in the household setting. HNIG was therefore offered to individuals at higher risk of severe measles following contact with a case. Due to changes in the donor population, however, tolerable doses of the current intramuscular HNIG preparations contain insufficient levels of measles antibody to provide protection against infection.

Immunosuppressed individuals

Immunosuppressed individuals should receive locally sourced IVIG, ideally within 3 days from exposure

Pregnant women or infants

HNIG products are available in the NHS and should be locally available. A small stock of Subgam (HNIG) is available for issue through Movianto but will not be issued at all for calls received after the cut-off time on the fifth day from the date of exposure.

Further details are available at:

Guidelines on post-exposure prophylaxis for measles.

National measles guidelines.

Hepatitis B

Infants at high risk of hepatitis B infection

Neonatal hepatitis B vaccination is highly effective (greater than 90%) at preventing infection in infants born to infected mothers. In those infants born to women with markers of high infectivity, hepatitis B immunoglobulin (HBIG) is given, in addition to vaccine, to further reduce the risk of transmission.

The additional benefit of HBIG over hepatitis B vaccine in preventing perinatal transmission of hepatitis B is small and therefore the priority for these infants is the timely administration of the birth dose of hepatitis B vaccine, which should be sourced locally.

HBIG should be ordered through UKHSA in the antenatal period when a pregnant woman is identified as having hepatitis B infection with evidence of high infectivity (see Green Book).he product is normally posted to the requesting maternity unit around 8 weeks before the estimated date of delivery (EDD).

Hepatitis B vaccine, and HBIG if indicated, should ideally be given within 24 hours of birth, but can be given later although there is no evidence that vaccine or HBIG will prevent infection when given more than 7 days after birth. Late vaccination can be considered to provide protection against future exposure.

Other exposure groups

HBIG is also recommended, in addition to vaccine, for individuals who receive an exposure (such as a needle-stick injury) from a known hepatitis B positive source, or an unknown source in a known non-responder to vaccination.

Babies born to hepatitis B infectious mothers and other exposure groups

HBIG is normally issued in the antenatal period and posted to the hospital before the baby delivers. If HBIG is indicated but is not available on-site, vaccine should be given as soon as possible, and arrangements made to source HBIG by calling the RIgS team or Duty Doctor between 9:00 and 5:30 pm 7 days a week.

Other exposure groups

Out of hours the exposed individual should receive their first dose of vaccine (sourced locally). If required, arrangements should be made to source HBIG preferably by calling the RIgS team or Duty Doctor between 9:00 and 5:30 pm 7 days a week. HBIG should be given within 24 to 48 hours of vaccination. Non-responders who received a first dose of HBIG should be scheduled to receive a second dose if the source is confirmed positive and no response to the booster documented.

Further details are available at:

Hepatitis B immunoglobulin (HBIG) for infants born to hepatitis B infected mothers

Hepatitis B: guidance, data and analysis

Rabies

Rabies vaccine is the main component of rabies post-exposure treatment; the additional benefit of human rabies immunoglobulin (HRIG) is for mopping up local virus at the site of exposure.

Many GPs and all hospital trusts should have local stock of the vaccine, and this stock should be used where possible. In these circumstances, replacement rabies vaccines will be ordered by the RIgS team, if the team are contacted the next working day.

Treatment should ideally commence within 24 hours of presentation, except for high-risk head and neck exposures when treatment should commence as soon as possible.

For previously untreated patients

Check whether there is locally available vaccine and use that where possible. Colindale will replace any vaccine that is used in good faith for post exposure treatment. It is more important to start the vaccine promptly than to try to source the HRIG which can be ordered by RIgS Team the next day if necessary. There is no need to contact the RIgS team before administering the vaccine

For individuals who have had their first dose of post-exposure treatment

Dose 2 of vaccine (and HRIG if required) will normally be issued through Movianto the next working day, unless this would mean that the vaccine could be delayed more than 48 hours after its expected date. In this case vaccine (and HRIG if required) should be obtained as above.

If indicated, HRIG is only required within the first 7 days after the first dose of vaccine. For calls received after the cut-off for same day issue, HRIG, if required, will be issued for collection on the next day. HRIG will not be issued for calls received after the cut-off on the sixth day from the date the first dose of vaccine was administered.

Doses 3 or 4 or 5 of vaccine will always be issued the next working day.

For patients who had received pre-exposure vaccination

The first dose of post-exposure vaccination can generally be issued on the next working day through RIgS team except where this would result in a delay of more than 48 hours from presentation (for example, at bank holiday weekends), in which case the product may be collected from a local stockholder or be issued out of hours for Movianto delivery the next day.

Dose 2 will always be issued on the next working day.

Further details are available at:

Guidelines on managing rabies post-exposure treatment.

Varicella zoster

Immunosuppressed and pregnant contacts

Oral aciclovir or valaciclovir is now recommended for susceptible immunosuppressed individuals and all pregnant women unless there are significant concerns of renal toxicity or malabsorption.

For those identified as susceptible, and who would otherwise be offered varicella zoster immunoglobulin (VZIG), antivirals (oral aciclovir or valaciclovir) should be given from day 7 to day 14 after exposure. If the patient presents after day 7 of exposure, a 7 day course of antivirals can be started up to day 14 after exposure, if necessary.

Infants and neonate contacts

Post-exposure prophylaxis with VZIG is not usually required for neonates born more than 7 days after the onset of maternal chickenpox, or in those whose mothers develop shingles before or after delivery as these neonates will have maternal antibody. VZIG is only indicated for the neonate if they are directly exposed postnatally in the first week of life.

Post-exposure prophylaxis with VZIG is not indicated for neonates (less than 7 days old) whose mothers have been exposed during pregnancy and have been found to be varicella zoster virus antibody (VZV IgG) negative unless the mother develops chickenpox.

If the mother develops chickenpox 4 days before to 2 days after delivery, then prophylactic aciclovir (10 mg/kg 8 hourly for 10 days) should be considered. In addition aciclovir for the mother should also be considered (see section on pregnant women).

Further details are available at:

Guidelines on post exposure prophylaxis (PEP) for varicella and shingles .

Other products

Diphtheria

Diphtheria antitoxin can be issued urgently at weekends and out of hours. Where there is no local stock-holder, at weekend and bank holidays a 5 hour delivery can been arranged by the BMS on-call.

Further details are available at:

Diphtheria anti-toxin (DAT): information for healthcare professionals

Public health control and management of diphtheria guidelines

Botulism

Botulinum antitoxin should be issued urgently at weekends and out of hours from one of the local stock-holders if indicated – there is a list of these on the intranet. In the unlikely event that there is no local stock-holder, at weekend and bank holidays a 5 hour delivery can been arranged by the BMS on-call.

Further details are available at:

Botulism: clinical and public health management

Tetanus

Tetanus immunoglobulin, or human normal immunoglobulin, is not issued by UKHSA but should be sourced by the NHS.

Further details are available at:

Tetanus: advice for health professionals