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Immunisation Against Infectious Disease 1996

"The Green Book"

Note: this 1996 edition of the Green Book has been posted on the DH website to make it available to those who can not obtain copies of the printed version and as an historic record of immunisation advice at that time. Where possible, links have been provided next to the chapter headings below to more up-to-date sources of information.


This 1996 edition of Immunisation against Infectious Disease (the ‘Green Book’) almost exactly coincides with the bicentenary of Jenner’s remarkable demonstration that an individual could be rendered immune to smallpox by the inoculation of James Phipps with material obtained from a cowpox vesicle. Recent changes in immunity brought about by immunisation have been equally remarkable. The 1992 edition of the ‘Green Book’ coincided with the introduction of Haemophilus influenzae b vaccine (Hib). Haemophilus influenzae meningitis, epiglottis and other serious infections from this organism have now virtually disappeared from paediatric wards.

In 1992, the changing age distribution of measles was noted and some modification in immunisation strategy anticipated. Mass measles-rubella immunisation to prevent an epidemic of measles in school-age children was conducted during November 1994. The Measles/Rubella Immunisation Campaign reached over 8 million children and necessitated an enormous exercise in planning and implementation throughout the UK. It also involved a vast number of doctors, nurses and other health personnel, particularly in the school health service, and we are greatly indebted to them for its success. Susceptibility to measles in this target population has dropped dramatically and the few cases of measles since the campaign occur mostly in adults or infants too young to have been protected by immunisation. The inclusion of rubella vaccine has greatly reduced the susceptibility to rubella in males and therefore the risk to susceptible pregnant women. It is logical to follow up this campaign by introducing a two-dose strategy for MMR vaccine to prevent further accumulations of susceptible children which could sustain future epidemics of measles, and to allow the termination of the schoolgirl rubella immunisation programme. Other changes reflect the continuing importance of surveillance and of monitoring the epidemiology of infection not only in this country but world-wide: the outbreaks of diphtheria in eastern Europe and the resurgence of tuberculosis are two problems of particular concern.

The Joint Committee on Vaccination and Immunisation (JCVI) continues to pay close attention to vaccine safety. Particular care was taken to monitor and investigate the apparent adverse reactions that occurred during the Measles/Rubella Immunisation Campaign. In this edition separate chapters are devoted to adverse reactions and to the problem of anaphylaxis; and information is provided on the vaccine damage payments scheme. It is always difficult to distinguish true vaccine reactions from coincidental events in a child’s life, but doctors are urged to be meticulous in reporting reactions and in obtaining the details and appropriate specimens that will help in their thorough investigation.

I should like to record my gratitude and that of my colleagues on the Joint Committee to all those who worked on this Handbook, but particularly to the editors Dr David Salisbury and Dr Norman Begg, their contributors in the Department of Health, and to Mrs Maureen Ambler.

A G M Campbell MB FRCP(Edin) DCH

Chairman, Joint Committee on Vaccination and Immunisation (JCVI)

Foreword: The Legacy of Jenner

Two hundred years ago, Edward Jenner was able to demonstrate that vaccination with material from cowpox provided protection against smallpox, which at that time was one of the most feared infectious diseases. Before then, few people reached adulthood without having caught smallpox and the case fatality rates were often around 10%. At the end of the eighteenth century, smallpox caused one fifth of all deaths in Glasgow and nine out of ten people who died of smallpox were under 5 years of age. One hundred and seventy years later, smallpox virus was extinct. Through that course of events, we have seen all of the key lessons of immunisation, and hopefully learnt from them. Few medical procedures or treatments can compare with the enormous benefit to humanity from immunisation, one of the safest and most cost effective of interventions.

Within a remarkably short time of Jenner’s first publication of his observations, thousands of people were being vaccinated. By the beginning of the nineteenth century, vaccination was being undertaken in many European countries. Yet an anti-vaccination lobby was already making its efforts felt. A cartoon by Gillray in 1802 shows vaccine recipients growing cowlike parts, and spurious information about the risks of vaccination was often quoted as if it were true. To overcome such resistance, vaccination was encouraged through the Vaccination Acts of 1840, 1841 and 1853 making vaccination successively universal, free, and finally compulsory. The Acts of 1861, 1867 and 1871 made vaccination enforceable by the appointment of Vaccination Officers and ultimately parents were liable to repeated fines until their children were vaccinated.

Legislation to make immunisation compulsory was widely unpopular and all legislation enforcing compulsion was finally withdrawn in 1948.

The last large epidemic of smallpox (variola major) was in London in 1901- 02. After that time, importations continued, notably from Africa and Asia, a pattern that has been repeated with poliomyelitis and measles. By the mid 1970s, it was clear that the risk of death from the complications of smallpox vaccination outweighed the predicted number of deaths that would follow importations, because of the success of the global programme of smallpox eradication. Smallpox vaccination was then abandoned, apart from the requirements for international travel. The world’s last naturally occurring case of smallpox was in Somalia in October 1977. In May 1980, the World Health Assembly accepted that smallpox had been eradicated worldwide. The principles of its eradication - the use of an effective vaccine, with a strategy that focused on surveillance, along with a global coalition towards a concerted action, fulfilled a prophecy made by Jenner that “the annihilation of the Small Pox, the most dreadful scourge of the human species, must be the final result of this practice”. We are now in a position to expect the global eradication of poliomyelitis within a few years, and hopefully, measles eradication will follow.

Two hundred years after Jenner’s first observations, we are seeing a new era beginning for vaccines. With the application of genetic manipulation techniques, better understanding of processes of infection and immunity, and a widespread recognition that investment in disease prevention is one of the best uses of resources, we can expect ever more vaccines, and ever more diseases eradicated.

Sir Kenneth Calman
Chief Medical Officer

Download Full Document in PDF pdf
(286 pages, 1.9mb)

Please note: this is a large document and may take a long time to download and print. If you only require one chapter we recommend you print from the list below. Certain chapters have been updated, these are included alongside the original chapters in the list below.

Download the Document in Chapters in PDF pdf


Further information on many of the subject areas covered by the green book can be accessed through the main public health page.

For policy statements regarding immunisation please visit the Chief Medical Officer's Updates page.


copyright: © | last updated: 19 December, 2003