Immunisation in New Zealand Strategic Directions

Transcription

1 Immunisation in New Zealand Strategic Directions

2 Published in December 2003 by the National Immunisation Programme, Ministry of Health PO Box 5013, Wellington, New Zealand ISBN (Internet) This document is available on the Ministry of Health s website:

3 Foreword Unfortunately, diseases that are preventable by vaccination still occur in New Zealand, and have a significant impact on the health of New Zealanders, particularly our children. The burden of vaccine preventable disease also tends to be inequitably distributed, falling heavily on Mäori and Pacific populations. The principles of the New Zealand Health Strategy (King, 2000) acknowledge the special relationship between the Crown and Mäori under the Treaty of Waitangi, the need to improve the health status of those currently disadvantaged, and good health and wellbeing for all New Zealanders throughout their lives. A quality immunisation programme will reflect these principles and contribute to the achievement of important New Zealand Health Strategy goals and objectives: reducing the incidence and impact of infectious diseases, reducing inequalities in health status, improving access to appropriate child health services, Mäori development in health, and better physical health. The Ministry s Statement of Intent 2003/4 and this document, which presents the National Immunisation Programme s priorities for immunisation services in the next three years, both seek to deliver on these requirements. The implementation of the Primary Health Care Strategy, the National Immunisation Register and outreach immunisation services, and the roll-out of the Meningococcal B vaccine, have the potential to greatly help us to reach national immunisation coverage targets and to significantly reduce vaccine-preventable disease in our community. Achieving this goal requires effective communication strategies and support for the health professionals who deliver services to the community. Close collaboration of Primary Health Organisations and Well Child/Tamariki Ora providers is crucial to achieving high immunisation coverage in children. The supporting strategies in this document set out the key areas where the National Immunisation Programme will work to ensure robust policy and technical expertise is available to support a quality immunisation programme in New Zealand. Karen O Poutasi Director General of Health Immunisation in New Zealand: Strategic Directions iii

4 Immunisation in New Zealand: Strategic Directions iv

5 Contents Foreword Executive Summary iii vi Part A: Where Are We Now? The impact of vaccine-preventable diseases in New Zealand 1 Why are vaccine-preventable diseases still occurring? 2 New challenges and opportunities 2 Limited health resources and the need to establish priorities 3 The changing health sector environment 3 The international environment 3 Key links with other strategies 4 Part B: Where Do We Want To Be? Goal 5 Objective 5 Immunisation coverage targets 5 Key principles 5 Implementation priorities for Part C: How Do We Get There? Priorities 7 Supporting strategies 11 Appendix 1: Vaccine-Preventable Diseases: Summary of Strategies, Responsibilities and Partnerships 19 Appendix 2: How Do We Get There? Addressing Priority Areas and Strategic Directions 20 References 21 Immunisation in New Zealand: Strategic Directions v

6 Executive Summary Immunisation is one of the most cost-effective and successful preventive health interventions known. It is an important component of both well child and adult preventive health services. Over the last century in New Zealand there has been a dramatic decline in vaccine-preventable diseases, much of it due to the effectiveness and quality of the National Immunisation Programme (NIP). However, New Zealand has not yet achieved our immunisation targets of 95 percent coverage in children and over 75 percent in adults and high-risk groups for influenza vaccination. Coverage is inequitable, with lower rates in Mäori and Pacific children and adults. This document presents the strategic directions for the NIP for to achieve these ambitious targets, recognising the key roles that District Health Boards (DHBs), primary care, public health services and a wide range of community organisations play in immunisation promotion, the provision of immunisation services, and vaccine-preventable disease control. It will form the basis of the NIP s annual plans and work programme with the health sector over the next three years. Implementation priorities for are to: implement the National Immunisation Register, as a critical supporting tool for vaccinators, DHBs and the NIP; and as a basis for further implementation of electronic collection of well child information over time achieve a significant reduction in meningococcal B disease, through introduction of the MeNZB vaccine in 2004/05 (subject to licensure) improve access to immunisation services in primary care and outreach settings to reduce inequalities in immunisation coverage (and thus the risk of vaccine-preventable disease), prioritising equitable coverage for Mäori and Pacific peoples develop an effective communication and promotion strategy for immunisation as a key component of child and adult health. Achieving these priorities requires a robust NIP that works collaboratively with DHBs, public health services, primary care and communities to implement nationally consistent policies. The implementation of the Primary Care Strategy is an important factor, which will enhance access to immunisation services and the ability of New Zealand to achieve its immunisation coverage targets. The NIP will play a lead role in funding and co-ordinating immunisation activities, ongoing vaccinator workforce development, and the evaluation of programme activities. Research, immunisation coverage monitoring and disease surveillance are the other essential activities that will support the NIP s work. Immunisation in New Zealand: Strategic Directions vi

7 Part A: Where Are We Now? The impact of vaccine-preventable diseases in New Zealand Immunisation, along with access to clean water, is the public health intervention that has had the greatest impact on health globally (World Health Organisation 2003). Immunisation not only protects individuals, but through the effect of herd immunity benefits the whole community. International evidence points to childhood immunisation as one of the most cost-effective activities in health care (World Bank Washington 1993). Although polio, diphtheria and tetanus are now rare, and serious Haemophilus influenzae type B (Hib) disease has been reduced by 90 percent in New Zealand thanks to immunisation (Wilson et al 2002), vaccine-preventable diseases continue to cause avoidable illness and death in New Zealand. We cannot afford to be complacent about past successes. Without adequate vaccination programmes, vaccine-preventable diseases often occur as large outbreaks, requiring regional or national population-based approaches for their control. Compared with other developed countries our immunisation coverage at age two years is low (in Australia, for example, over 90 percent of one-year-olds are fully immunised (National Centre of Immunisation Research and Surveillance 2002), and New Zealand rates of vaccine-preventable disease are consequently higher. Pertussis (whooping cough) is the childhood vaccine-preventable disease that is currently least well controlled. National epidemics continue to occur at four- to five-yearly intervals and the rate of disease during inter-epidemic periods appears to be increasing (Sneyd and Baker 2003). There are over 50 cases of pertussis a month in New Zealand (the peak number in November 2001 was over 550), with one death recorded in Hospitalisation data for 2002 showed that admission rates for Mäori were 2.7 times higher than rates for Europeans and 3.2 times higher than rates for Pacific peoples, despite Mäori having lower notification rates than Europeans (Sneyd and Baker 2003). In New Zealand there were 27 cases of measles notified in the first half of 2003 (ESR 2003). This can be compared to other countries such as Scotland, which in March 2002 had the first cases of measles in two years. The cost of measles epidemic control compared with prevention by immunisation is high. In the 1997 New Zealand epidemic, treatment costs were approximately $7.5 million (excluding opportunity costs and disability costs) equivalent to over 50 percent of the total national immunisation budget of that time. Influenza is a vaccine-preventable disease that occurs every winter, and it is estimated that between 53,000 and 156,000 New Zealanders consult their general practitioners annually because of influenza-like illness. This places a huge burden on both the primary and secondary health care sectors. In a recent US study (Nichol and Goodman 2002), influenza vaccination of healthy elderly persons (over 65 years) was associated with a 36 percent reduction in hospitalisation for pneumonia or influenza, an 18 percent reduction in hospitalisation for all respiratory conditions, and a 40 percent reduction in deaths. Similar benefits are likely in New Zealand. Immunisation in New Zealand: Strategic Directions

8 Data for the 2001 influenza season estimates there was 62 percent coverage of eligible people aged 65 years and older, and approximately 29 percent coverage of those under 65 years of age with eligible chronic conditions. Data for the seasons are incomplete, but are expected to be only marginally higher. Improving influenza coverage is likely to result in significant health gain and is a highly cost-effective intervention. Vaccine-preventable diseases disproportionately affect the poorest, most marginalised and most vulnerable groups in our society. Mäori and Pacific peoples in particular suffer disproportionately high rates of hospitalisation for these diseases as a result of their lower coverage rates and other risk factors, such as lower socioeconomic status. For example, in New Zealand the worst outcomes for influenza are in the elderly, and are higher for Mäori than for non-mäori (Jennings et al 2001). Thus improved coverage, particularly among Mäori and Pacific peoples, can potentially contribute to more equitable health outcomes. This strategic plan also recognises that structural and intermediary causes (such as low income, lack of transport, poor housing and institutional racism) must be addressed in tackling health inequalities, along with the required changes being made to health services. Why are vaccine-preventable diseases still occurring? Disease transmission will be prevented in a community only when high immunisation coverage is achieved (90 95 percent of the total population, depending on the disease). * Therefore, to be effective in preventing disease, and subsequent morbidity and mortality from that disease, an immunisation programme must achieve high coverage levels. New Zealand has failed to meet the targets set in the Immunisation 2000 strategy (Ministry of Health and Public Health Commission 1995). Immunisation coverage in New Zealand is lower than is required to prevent epidemics of some vaccine-preventable diseases such as measles. Achieving higher coverage in Mäori and Pacific children is a priority, as previous survey data suggest coverage in these populations is significantly lower than in other New Zealanders. Improving coverage in these groups would contribute to reducing health inequalities. New Zealand also has obligations to meet present and future global disease targets that require high immunisation coverage (such as the eradication of polio and measles). New challenges and opportunities Vaccine technology is rapidly changing and progressing, with new and combined vaccines becoming available. These need regular assessment and consideration for inclusion in the New Zealand Immunisation Schedule. An example is the current development of the Meningococcal B (MeNZB) vaccine for the specific strain causing the majority of cases in the ongoing epidemic in New Zealand. It is planned that this vaccine, after completion of the clinical trials and pilot phase, will be rolled out in a national campaign in 2004/05 and will be considered for inclusion in the childhood immunisation schedule after that. * Coverage means the proportion of the population at any time who are either immunised with a specific vaccine or who have completed the immunisation series for a specific vaccine-preventable disease. Immunisation in New Zealand: Strategic Directions

9 Another challenge to improving immunisation coverage is that as vaccine-preventable diseases have become more rarely seen in New Zealand, the community perception of the risks and benefits of immunisation has changed. There is a reduction in parental acceptance of any adverse events following immunisation (AEFI). This requires good communication with parents by health professionals, and monitoring of serious adverse events to assure confidence in the safety of the immunisation programme. Consumer information is rapidly and more effectively becoming available to the public, largely through the Internet. This provides opportunities for information dissemination, but also opportunities for counter-immunisation messages to be distributed widely. Limited health resources and the need to establish priorities Some actions will have immediate gains in terms of vaccine-preventable disease control, while others will have longer-term benefits. It is important to remain vigilant against vaccinepreventable diseases that are currently well controlled, recognising that maintaining this control requires an ongoing commitment of resources and to surveillance. The introduction of new vaccines also requires cost-benefit analyses to ensure resources are spent to best effect. The changing health sector environment Immunisation is both a personal and a population health strategy, delivered by a mix of personal and public health services and providers. Reaching coverage targets requires collaboration throughout the health sector to ensure effective strategies for immunising and following up individuals. There needs to be a balance between national leadership from the National Immunisation Programme (NIP), and agreed District Health Board (DHB) and provider initiatives and responsibilities. Improved access to primary care through primary health organisation (PHO) access and other new funding, and the increased focus of PHOs on the health needs of their enrolled populations, should reinforce the collaborative approach between providers that is required for effective immunisation services. The National Immunisation Register will be another key tool in improving integration between maternity, primary care, immunisation and well child services. The international environment In the age of international travel and migration, vaccine-preventable diseases do not recognise national boundaries. This is well illustrated by recent outbreaks of rubella in the Pacific. The Pacific and Asian regions are particularly important to New Zealand, given the large proportion of family, migrant, trade and travel connections we have with these regions. It is important that New Zealand maintains strong links with regional and international bodies that have the same disease eradication goals, both for sharing technical expertise and collaborating in global and regional immunisation strategy implementation. The Western Pacific Region of WHO (WPRO), of which New Zealand is a member state, has committed to a plan of action for measles elimination, although a target date has not been set (this will be done in the annual review process). Immunisation in New Zealand: Strategic Directions

10 Key links with other strategies The New Zealand Health Strategy sets the overarching guide for planning, developing and funding health services in New Zealand. He Korowai Oranga (the Mäori Health Strategy), Whakatätaka (the Mäori Health Action Plan ), the Strategic and Action Plan for Public Health, the Pacific Health Action Plan, the Child Health Information Strategy and the Well Child/Tamariki Ora Framework are the other key strategic initiatives to which this immunisation plan has links. The Primary Health Care Strategy and implementation of Primary Health Organisations will play a significant part in ensuring that children and adults who historically have had poorer access will be better served. This plan also acknowledges and builds on the input from previous consultation on the Integrated Approach to Infectious Disease (Ministry of Health 2001), which identified vaccinepreventable diseases as the top priority for effort in infectious disease control in New Zealand. Immunisation in New Zealand: Strategic Directions

11 Part B: Where Do We Want To Be? Goal To improve the health of all New Zealanders by controlling or eliminating vaccine-preventable diseases. Objective To ensure the delivery of safe and effective vaccination programmes to all children and their families in New Zealand. Immunisation coverage targets The two immunisation coverage targets are: 95 percent of children in all ethnic groups are fully vaccinated at age two years by percent or more of the defined high-risk adult population is vaccinated annually against influenza. Key principles The key principles are to: ensure an effective, high-quality national immunisation programme is maintained, with delivery of accessible, appropriate and equitable immunisation services recognise Crown commitment to fulfilling the special relationship between iwi and the Crown under the Treaty of Waitangi: Mäori participation at all levels partnership in service planning and implementation protection and improvement of Maori health status support whänau ora, recognising the contribution of immunisation to the health of families throughout the lifespan. recognise the important role of primary care in improving access for children and adults to appropriate and acceptable immunisation services. That is, 95 percent of all two-year-olds have received all antigens on the national schedule, as appropriate for their age. Immunisation in New Zealand: Strategic Directions

12 Implementation priorities for The implementation priorities are to: 1. implement the National Immunisation Register, as a critical supporting tool for vaccinators, DHBs and the NIP; and as a basis for further implementation of electronic collection of well child information over time 2. achieve a significant reduction in Meningococcal B disease by introducing the MeNZB vaccine in 2004/05 (subject to licensure) 3. improve access to immunisation services in primary care and outreach settings to reduce inequalities in immunisation coverage (and thus the risk of vaccine-preventable disease), prioritising equitable coverage for Mäori and Pacific peoples 4. develop an effective communication and promotion strategy for immunisation, as a key component of child and adult health. These priority areas will be supported by strengthening ongoing NIP activities, including disease and coverage surveillance, development of a sustainable financing strategy, robust policy and technical advisory mechanisms, workforce development, research and evaluation. Immunisation in New Zealand: Strategic Directions

13 Part C: How Do We Get There? Priorities Priority 1: Implement the National Immunisation Register The National Immunisation Register is a key tool for achieving New Zealand s immunisation targets, and is crucial to the roll-out of the Meningococcal B (MeNZB) vaccine programme. It will provide accurate data on a child s immunisation status, as well as robust information on local, regional and national immunisation coverage, which is currently lacking. All children will be registered on the Register at birth (with an opt-off proviso), and immunisation data entered on it will be available to authorised health providers caring for children so they can ensure immunisations are up to date and complete. The Register will notify a child s health professional if a child is overdue for an immunisation, so parents can be reminded appropriately, and will assist in following up highly mobile children, including those referred to outreach immunisation services. The Child Health Information Strategy aims to provide better coordination of preventive and early intervention services for children and young people through implementation of electronic information networks ( Kidslink ). It is anticipated that the Register will be the basis for further integration of this well child data over time. Priority 1 milestones Date Responsibility Establish privacy and stewardship of information frameworks, standard operational processes, relevant documentation and resources Completed by end 2003 NIP, Ministry of Health Further develop IT software enhancements NIP, software developers Pilot National Immunisation Register (NIR) enhancements in the Counties-Manukau and Waitemata DHBs 2004 NIP, software developers, Counties-Manukau DHB, Waitemata DHB Roll-out the NIR nationally NIP, DHBs, primary health organisations (PHOs), lead maternity carers, GPs, practice nurses, immunisation facilitators (district and regional), public health services, other vaccinators Use the NIR to evaluate coverage and guide improved vaccine delivery, including the planned roll-out of the Meningococcal B (MeNZB) vaccine Reports of vaccination coverage on one-yearolds available nationally Reports of vaccination coverage on two-yearolds available nationally NIP, DHBs, PHOs, vaccinators 2006 NIP, DHBs, PHOs, vaccinators 2007 NIP, DHBs, PHOs, vaccinators Review inclusion of influenza data on the NIR 2005 onwards NIP, Ministry of Health Immunisation in New Zealand: Strategic Directions

14 Priority 2: Achieve a significant reduction in Meningococcal B disease Due to its size and complexity, the Meningococcal B Vaccine Strategy (MVS) is managed as a specific project within the Public Health Directorate, but the MVS team works closely with the NIP. Implementation of the proposed national roll-out of MeNZB will require building on, and integration with, existing immunisation services. The aim of the MVS is to vaccinate all individuals aged between six months and 20 years (subject to licensure), with three doses, six weeks apart, in a national campaign. The MVS roll-out will rely on a functioning National Immunisation Register to monitor coverage and safety, and estimate vaccine efficacy. The national roll-out will have a significant impact on the routine immunisation programme, as it will require a significant amount of planning, logistical expertise and workforce commitment. Priority 2 milestones Date Responsibility Safety and immunogenicity trials MVS team, Ministry of Health, Chiron Corporation, University of Auckland Plan MVS roll-out and integration with NIP work plans to maximise Ministry of Health and health sector resources and achieve optimal MeNZB uptake MVS team, NIP Pilot programme (subject to trial results) 2004 MVS team and Counties-Manukau DHB Roll-out MVS nationally (subject to trial results, licensure and vaccine production) Ministry of Health (MVS and NIP teams), DHBs, providers Plan for, and introduce the MeNZB vaccine to the immunisation schedule as appropriate NIP, Immunisation Programme Advisory Committee (IMPACT) Priority 3: Improve access to immunisation services and reduce inequalities in immunisation coverage The priorities for are: implementing outreach immunisation services (facilitation and community-based vaccination), alongside the National Immunisation Register. These services are being implemented in 16 priority DHBs, building on existing primary care and well child services and focusing on building the capacity of Mäori and Pacific providers to ensure the needs of whänau and their tamariki are met (whänau ora) improving access to primary care (where most individuals are immunised) through PHO development, primary care quality indicator incentives, adequate remuneration and regular review of immunisation benefits improving access to services for adult immunisation. Immunisation in New Zealand: Strategic Directions

15 Priority 3 milestones Date Responsibility Immunisation Programme Advisory Committee (IMPACT) to advise on strategies to address inequalities in immunisation coverage and monitor progress on reduction in inequalities NIP, IMPACT Implement outreach immunisation programmes during 2003 and onwards with Mäori and Pacific primary care and well child providers, accompanying the roll-out of the NIR Continue implementing the Primary Health Care Strategy, giving priority to improving access for low-income groups Develop a sustainable financing strategy, including a review of funding to maintain adequate, nationally consistent immunisation benefits. (See also Supporting Strategy 3.) 2003 onwards NIP with DHBs, Mäori and Pacific providers, immunisation facilitators, public health services Ministry of Health, DHBs, PHOs and their providers NIP, Finance and Corporate and Information Directorate (Ministry of Health), DHBs Support opportunistic vaccination by providing quality data about individual and population immunisation status (via NIR implementation) 2004 onwards (see milestone 1) NIP, DHBs, immunisation facilitators, vaccinators Give priority to improving overall influenza vaccination coverage, and reducing inequalities in influenza vaccine coverage between Mäori and non-mäori 2004 onwards NIP, National Influenza Immunisation Strategy Group (NIISG), DHBs, primary care providers Priority 4: Develop an effective communication and promotion strategy for immunisation The NIP aims to ensure the needs of health providers and communities for appropriate information about immunisation are met, particularly acknowledging that the needs of communities with lower coverage should be addressed effectively. This requires the development of a co-ordinated, consistent communication strategy at national, regional and local levels, with a focus on reducing inequalities in immunisation coverage. Recognising that GPs, practice nurses, public health nurses, midwives and other health professionals are a key source of immunisation information for parents and individuals (Ashby- Hughes and Nickerson 1999), there is a clear link between this priority area, and workforce development and ongoing health professional education (see Supporting Strategy 4). Nongovernmental organisations, such as the Mäori Women s Welfare League, Plunket, other well child providers and child advocacy groups, as well as the community health worker workforce, play significant roles in promoting immunisation, and need to be more effectively utilised. Adequate resourcing of this strategy is critical, and needs to be addressed as part of the overall financing strategy (see Supporting Strategy 3). Immunisation in New Zealand: Strategic Directions

16 Priority 4 milestones Date Responsibility Evaluate and revise existing immunisation resources, including website development Develop and refine the NIP communication strategy, with a strong focus on meeting the needs of Mäori communities Design and evaluate strategies for local immunisation promotion, information and education for specific groups (eg, for Pacific, migrant and refugee, and low-income communities) Revise and distribute updates to the Immunisation Handbook to health care providers 2003 NIP with input from consumers and providers NIP and key stakeholders 2003 onwards NIP with input from consumers and providers NIP with input from IMPACT technical working group Expand immunisation promotion and resources (Ministry of Health website, television, radio, the Internet) and media strategies, including translation of key resources, as per the communication strategy and available budget Build on non-governmental organisations support for immunisation (eg, Plunket, child advocacy groups, Mäori Women s Welfare League, Pacific community groups and churches) 2003 onwards NIP with key stakeholders (eg, vaccinators, consumers, lead maternity carers, IMAC, Folio) NIP, Ministry of Health Promote influenza vaccine uptake, particularly among those with low current coverage, including Mäori and health care workers Annually NIP, NIISG, DHBs, providers Immunisation in New Zealand: Strategic Directions

17 Supporting strategic activities 1 Maintain and enhance strategic leadership of the National Immunisation Programme within the health sector The NIP within the Ministry of Health leads immunisation policy and planning in New Zealand. It is vital the NIP is maintained as an effective team that has the capacity to carry out key national functions. These functions include overall implementation of this plan, policy development and oversight of standards, securing adequate funding levels, service development and monitoring, vaccine purchase and distribution, oversight of communication issues, and directing research to complement the strategic direction. The NIP also oversees and co-ordinates national service contracts (eg, the Health Research Council joint immunisation research strategy, vaccine purchase and distribution, immunisation co-ordination and vaccinator training). The NIP must maintain effective relationships with DHBs, primary care and well child providers and other key stakeholders in order to implement national policies successfully. Supporting Strategy 1 milestones Date Responsibility Develop the NIP and establish ongoing funding; review as necessary Establish Immunisation Programme Advisory Committee (IMPACT) and working groups to advise the NIP on strategic and technical issues Set and monitor immunisation targets and quality indicators for DHBs and PHOs 2003 onwards NIP, Public Health Directorate, Ministry of Health 2003 NIP 2004 onwards NIP, DHBs, PHOs Immunisation in New Zealand: Strategic Directions

18 2 Strengthen the national immunisation policy framework A quality immunisation programme requires robust technical and policy advice. There must be clear processes for assessing new and existing vaccines, including cost-benefit analysis of new vaccines and enhanced surveillance of potentially vaccine-preventable diseases. Regular review of the National Immunisation Schedule is essential, including the need for new control strategies, and additional funding for new vaccines and/or high-risk population groups. Supporting Strategy 2 milestones Date Responsibility Technical working group established under IMPACT 2003 NIP Undertake two-yearly immunisation schedule review (including consideration of new vaccines and/or new combination vaccines), with revision of Immunisation Handbook as required (review) 2006 (implementation) IMPACT technical working group, NIP Review information on pneumococcal disease epidemiology in New Zealand and the pneumococcal vaccine, in order to develop policy and funding for the vaccine in New Zealand Review legislation pertaining to immunisation as part of development of the Public Health Bill Review and approve existing national standards (cold chain monitoring, GP audit etc), and develop other necessary quality standards Evaluate the effectiveness of delivery of the neonatal Hepatitis B programme to the children of carrier (HBsAg positive) mothers Evaluate the effectiveness of delivery of the neonatal Bacillus Calmette-Guerin (BCG) vaccine (since the 2002 policy decision to increase coverage in high-risk groups to 80 percent of eligible infants by 2005) Develop the MeNZB (Meningococcal B) vaccine pilot and roll-out NIP, Ministry of Health, Medsafe NIP, Ministry of Health IMPACT, NIP NIP NIP, DHBs, immunisation providers See Priority 2 See Priority 2 Immunisation in New Zealand: Strategic Directions

19 3 Ensure adequate and sustainable immunisation funding Maintaining a quality immunisation programme requires ongoing, sustainable resources. As vaccines are developed and improved, cost-benefit and affordability become significant issues. The level of immunisation benefit also requires regular review, and other forms of incentives to increase coverage need assessment. Supporting Strategy 3 milestones Date Responsibility Develop a sustainable financing framework for immunisation for the next five or more years NIP, Corporate and Information Directorate, Ministry of Health Review options for sustainable increases in immunisation benefit and/or alternative payment mechanisms in primary care, in collaboration with DHBs, PHOs and GP organisations and ongoing NIP, DHBs Work with DHBs and PHARMAC to review the process for vaccine tenders (influenza vaccine initially) NIP, DHBs, PHARMAC Carry out a cost-benefit analysis for any new vaccines added to the National Immunisation Schedule Ongoing Medsafe, NIP, PHARMAC Immunisation in New Zealand: Strategic Directions

20 4a Further develop and maintain a highly skilled and motivated immunisation workforce A highly skilled and motivated workforce that can meet the community s diverse needs is critical to providing optimal immunisation services. Workforce developments that will enhance immunisation promotion, ensure vaccinator standards are met, and increase overall capacity for implementing mass campaigns are essential requirements for the NIP. GPs, primary care and public health nurses, and other vaccinators are key to the immunisation workforce. A clear framework for co-ordinating immunisation services at the district level is also important, given the implementation of new services such as outreach and the National Immunisation Register. Supporting Strategy 4a milestones Date Responsibility Carry out a needs analysis, scope and determine strategy for meeting future immunisation workforce training needs (including undergraduate and postgraduate training) NIP Establish and review regularly the national standards for vaccinator training and accreditation Increase and/or enhance existing training courses for vaccinators to ensure MVS requirements are met, and increase and/or enhance existing training courses for information sharers (eg, lead maternity carers) 2003 onwards 2003 onwards NIP, with key stakeholders (eg, training providers, Medical Officers of Health) NIP, MVS Review the authorisation process for independent vaccinators Develop immunisation resources for training undergraduate health professionals, GPs, nurses and lead maternity carers Develop postgraduate and continuing education resources for GPs, practice nurses, and information sharers (eg, lead maternity carers) NIP, Ministry of Health, medical officers of health, vaccinators NIP, Royal NZ College of General Practitioners (RNZCGP), College of Nurses Aotearoa (NZ), NZ College of Practice Nurses, NZ College of Midwives, training providers NIP, RNZCGP, College of Nurses Aotearoa (NZ), NZ College of Practice Nurses, NZ College of Midwives, training providers Immunisation in New Zealand: Strategic Directions

21 4b Develop a national framework for immunisation facilitation Immunisation co-ordination functions have varied around the country, due in part to differing local needs and historical patterns of contracting. Several reviews have recommended greater national consistency and development of a standard national framework for co-ordination. Co-ordinators are skilled in immunisation promotion, provider support, and cold chain and immunisation auditing, and have collaborative relationships with a range of health providers in primary care and public health. Development of the National Immunisation Register, based around DHB populations, has further signalled the need for a revision of co-ordinator roles. Preliminary changes have been made to the service specifications for local co-ordinators (for new contracts from January 2003), who are now called district immunisation facilitators. These changes will be gradually introduced nationally over 2003/04, and all immunisation facilitation contracts aligned, with ongoing review over 2004/5. The new title reflects the intended focus on DHB populations, and on immunisation strategies to improve coverage and programme quality for that population. It is intended that district immunisation facilitators will play a key role in implementing the National Immunisation Register because of their expertise and knowledge about local providers. District immunisation facilitators will be able to access Register data to assist providers to immunise individual children and to use in evaluating DHB coverage. They will play a key role in monitoring outreach strategies and developing new strategies, services and quality standards. Immunisation facilitation and co-ordination functions at all levels (district, regional and national) require ongoing consultation and discussion with DHBs and providers to ensure that they maintain alignment with the strategic directions laid out in this document and with the changing health sector, and that they evolve to meet those changing needs. In recognition that improving the inequitable immunisation coverage of Mäori children is a key priority for the NIP, a number of Mäori-specific immunisation facilitation roles have been established in the Auckland and Midland regions. These positions will play a key role in supporting Mäori providers and mentoring outreach service providers in 2003/04. They will be evaluated formally after two years. Two Pacific positions are also being piloted in the Auckland region in 2003/04, in response to the needs of Pacific providers and the lower immunisation coverage rates of Pacific children. Initially, these positions are being placed with the Immunisation Advisory Centre in Auckland, with the support of a Pacific fono. A formal evaluation of this service will take place after 18 months. Immunisation in New Zealand: Strategic Directions

22 Supporting Strategy 4b milestones Date Responsibility Implement revised service specifications for facilitation/coordination (district and regional) in all DHBs Review service specifications annually as the National Immunisation Register progresses and contracts end in 2005 January 2003 onwards NIP, IMAC, other providers, district immunisation facilitators NIP, DHBs, IMAC, other providers, district immunisation facilitators Evaluate the appropriateness and effectiveness of national, regional and district immunisation co-ordination and facilitation roles as the National Immunisation Register is implemented and PHOs develop NIP Support Mäori-specific immunisation facilitation roles in Auckland and Midland regions Pilot two Pacific immunisation facilitation roles in the Auckland region, and evaluate them in NIP, IMAC, Mäori providers NIP, Pacific fono and providers, IMAC Evaluate the effectiveness of Mäori- and Pacific-specific immunisation facilitation services as part of the overall evaluation of national, regional and district co-ordination and facilitation 2006 NIP, DHBs Immunisation in New Zealand: Strategic Directions

23 5 Enhance surveillance of vaccine-preventable diseases and outbreak preparedness Good surveillance of vaccine-preventable diseases in the community is essential to evaluate the effectiveness and quality of the NIP and ensure optimal vaccine-preventable disease control. This surveillance includes integration and analysis of disease incidence data (from notification, laboratory and hospital discharge sources), immunisation coverage data, and vaccine adverse event data. Where disease elimination is the goal, accelerated disease control and enhanced surveillance of specific diseases (eg, measles) is necessary. Supporting Strategy 5 milestones Date Responsibility Support the regional WPRO Plan of Action for measles elimination, and enhance measles surveillance (with serological confirmation of all sporadic cases) 2003 Ministry of Health (Communicable Disease (CD) team) Support policy and legislation to allow laboratory notification (Public Health Bill) Revise the Schedule of Notifiable Diseases and other surveillance systems to include diseases that have or will become vaccine-preventable To be confirmed legislative programme to be advised Ministry of Health, Government Ministry of Health, Government Review sentinel surveillance for influenza, varicella, pneumococcal disease, and other potential vaccinepreventable diseases 2003 Ministry of Health (CD team), ESR Undertake a national serological survey to measure population immunity and vulnerability to important vaccine-preventable diseases Scoping NIP Integrate and analyse data on adverse events following immunisation, with coverage and disease data; IMPACT technical working group to regularly review adverse events data as part of its brief Use epidemic modelling to identify the need for and inform vaccine-preventable disease control strategies, including outbreak preparedness Maintain and revise the National Influenza Pandemic Plan Continue to support the National Pandemic Planning Committee, to meet as required 2003 ongoing NIP, IMPACT; Medsafe, Centre for Adverse Reactions Monitoring on NIP, CD team, Ministry of Health 2003 onwards Ministry of Health (CD team) 2003 onwards Ministry of Health (CD team) 6 Research and evaluation to build an evidence-based programme There needs to be a strong evidence base for immunisation programme development and the evaluation of new strategies. There is a range of New Zealand-specific immunisation research issues, both qualitative and quantitative. In 2003 the NIP initiated an immunisation research programme with the Health Research Council, which aims to fund relevant research and build New Zealand immunisation research capacity. A further aspect of programme activity is the audit and evaluation of immunisation strategies to provide quality services and reach coverage targets, and evaluation of the NIP overall. Immunisation in New Zealand: Strategic Directions

24 Supporting Strategy 6 milestones Date Responsibility Develop a joint programme of immunisation research with the Health Research Council, with applied research as a priority Monitor and audit performance standards for DHBs and immunisation providers in existing contracts (quarterly and annual reporting against district, annual and strategic plans) NIP, Health Research Council 2004 onwards Ministry of Health (NIP, DHB Funding and Planning), DHBs, Public Health Services Evaluate progress in improving coverage, via national coverage survey in 2004, HealthPAC data and NIR data from 2005 Evaluate progress in controlling vaccinepreventable diseases, based on hospital discharge and notifiable disease data Ongoing NIP, HealthPAC Ministry of Health (NIP, CD team), ESR 7 Monitoring and evaluation of this plan Coverage rates for childhood vaccines (by age cohort, ethnicity and area) will be measured over time by the National Immunisation Register, which is scheduled to be nationally operational by The national notifiable disease surveillance system and hospital discharge data for vaccine-preventable diseases provide useful measures of progress towards the goal of reducing the incidence and impact of these diseases. Monitoring of vaccine-preventable disease incidence and distribution will continue to be performed by the Institute of Environmental and Scientific Research (ESR). The NIP will monitor annual progress on the milestones identified. Given the changing incidence of disease and the availability of new vaccines, this role will include updating the strategy as required and incorporating changes in the annual operational plan of the NIP. Immunisation in New Zealand: Strategic Directions

25 Appendix 1: Vaccine-Preventable Diseases: Summary of Strategies, Responsibilities and Partnerships Healthy public policy (central and regional government) NIP and Ministry of Health Develop the National Immunisation Register, allowing access to individual immunisation records by authorised health providers, and providing regional and national coverage data Improve access to immunisation services, including improved access to primary care and implementation of outreach immunisation services Develop integrated communication and promotion strategies tailored to the needs of different groups Enhance the policy framework for the assessment of benefits and the costs of new vaccines Promote key role of PHOs Introduce Meningococcal B vaccine Undertake influenza pandemic and outbreak planning Intersectoral actions to reduce vaccinepreventable diseases Provide quality child care, parental leave and education policies Develop housing policies to address overcrowding Educate all levels on the benefits of immunisation Promote the role of Corrections, Armed Forces, Police and Education in vaccination of their populations Ensure new migrants are appropriately immunised (New Zealand Immigration Service/Health) Health services (DHBs, health providers, public health services) Set local immunisation targets in line with national ones Increase accessibility of immunisation services, including flexible provider hours, outreach vaccination services and opportunistic vaccination policies Recognise and promote key role of primary care in immunisation Enhance linkages to well child providers Design specific services to meet the needs of tamariki Mäori Provide services that meet the needs of Pacific populations Ensure resources for promotion and education are available in Mäori, Pacific and other appropriate languages Promote vaccination for high-risk adult groups, including refugees and immigrants Provide appropriate services for Mäori and Pacific adults (specifically to improve access to influenza vaccination) Participate in influenza pandemic planning at district level Supportive environments (regional councils, local authorities, schools, etc) Support proimmunisation, child-friendly policies Enable early childhood centre and school-based options for vaccination Support appropriate adult vaccination programmes, especially for workers in highrisk occupations Encourage worker education and promotion of vaccination through unions and employers Collaborate with pandemic planning measures Support MeNZB vaccine roll-out Community action and personal skills Participate in the development of appropriate information and communication strategies Involve non-health providers and key community leaders in the promotion of immunisation marae, church and other communitybased programmes (eg, community sites, Pacific churches) Involve older people s support groups (eg, Grey Power) in the promotion of influenza vaccination Surveillance Enhance immunisation coverage data through development of the National Immunisation Register Enhance surveillance of vaccinepreventable diseases (including laboratory notification and serological confirmation for measles) Plan for outbreaks (modelling and prediction of outbreaks, outbreak response and pandemic planning, health workforce planning) Review sentinel and other forms of community surveillance of influenza, pneumococcal disease, and varicella Carry out seroprevalence and coverage surveys to confirm routine surveillance and coverage data Research and evaluation Develop the joint immunisation research programme with the Health Research Council Evaluate the effectiveness of current strategies, and alternative means of providing immunisation services Evaluate outbreak and control measures Enhance monitoring of adverse vaccine reactions Immunisation in New Zealand: Strategic Directions

26 Appendix 2: How Do We Get There? Addressing Priority Areas and Strategic Directions Achieving immunisation coverage targets - 95% Implementation of the National Immunisation Register Reduction in Meningococcal B disease, through introduction of MeNZB vaccine The implementation priorities Communication and promotion of immunisation: whānau, community, and health professionals Reducing inequalities in coverage and improving access! Outreach immunisation services! PHO development! Supporting whānau ora! Enhancing opportunistic immunisation! Enhancing and linkages to well child providers The supporting strategies Strategic national leadership and co-ordination Strengthening immunisation policy Sustainable financing strategy Workforce development Surveillance, disease control and outbreak preparedness Research and evaluation Immunisation in New Zealand: Strategic Directions

27 References Ashby-Hughes B, Nickerson N Provider endorsement: the strongest cue in prompting high-risk adults to receive influenza and pneumococcal immunizations. Clinical Excellence for Nurse Practitioners 3: Institute of Environmental Science and Research Ltd Monthly Surveillance Report (June) (unpublished). Jennings L Sue Huang Q, Baker M, et al Influenza surveillance and immunisation in NZ New Zealand Public Health Report 8(2). King A New Zealand Health Strategy Wellington: Ministry of Health Ministry of Health Integrated Approach to Infectious Disease. Wellington: Ministry of Health. Ministry of Health and Public Health Commission Immunisation Wellington: Ministry of Health. National Centre for Immunisation Research and Surveillance, University of Sydney Immunisation Coverage: Australia Canberra: Commonwealth of Australia. Nichol KL, Goodman M Cost effectiveness of influenza vaccination for healthy persons between ages 65 and 74 years Vaccine 2002 May 15;20 Suppl 2:S21-4 Sneyd E, Baker M Infectious Diseases in New Zealand: 2002 annual surveillance summary. Porirua: Institute of Environmental Science & Research Ltd. Wilson N, Wenger J, Mansoor O, et al The beneficial impact of Hib vaccine on disease rates in New Zealand children. New Zealand Medical Journal 115(1159): U122. World Health Organisation Diseases and Vaccines: The history of vaccination. World Health Organization. URL: Accessed 20 August World Bank Washington World Bank Development Report: Investing in health. Washington DC: World Bank. Immunisation in New Zealand: Strategic Directions