PERFORMANCE AGAINST IMMUNISATION TIER 1 TARGETS

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1 AGENDA ITEM March 2014 PERFORMANCE AGAINST IMMUNISATION TIER 1 TARGETS Executive Lead: Executive Director of Public Health Author: Consultant in Public Health Medicine Contact Details for further information: Dr Tom Porter (029) SITUATION Immunisation is a safe and effective intervention to protect children and adults from illness, disability and death due to a range of diseases. From 2013/14, some specific performance measures related to childhood immunisation and seasonal flu vaccination uptake became Tier 1 targets for Local Health Boards. This paper reports on progress in meeting these targets in Cardiff and Vale University Health Board (UHB). BACKGROUND The Tier 1 targets for immunisation are summarised below, and trends in performance to date against these targets is given in Tables 2 and 3. Table 1. Immunisation Tier 1 targets Childhood vaccination Children aged 4 who are fully up to date with their immunisations 95% Seasonal flu vaccination Over 65s receiving flu vaccine 75% Under 65s in eligible at-risk groups receiving flu vaccine 75% Pregnant women receiving flu vaccine 75% Frontline healthcare workers who receive flu vaccine 50% The Cardiff and Vale Immunisation Steering Group maintains and performance manages a detailed immunisation plan to improve uptake, and a separate rolling plan to increase uptake of seasonal flu vaccine. Significant new work has been undertaken this year to improve seasonal flu uptake and childhood vaccine uptake. Performance Against Immunisation Page 1 of 5 People, Performance & Delivery Committee

2 Table 2. Performance against childhood immunisation Tier 1 target C&V Wales Tier 1 Jul-Sep 13 (latest) Apr-Jun 13 Jul-Sep 13 (latest) Childhood vaccination Children aged 4 who are fully up to date with their immunisations* 95% 86% 84% 87.2% * Defined as, PCV and HibMenC (due 13 months); and 4 in 1 and MMR2 (due 3 years 4 months) Table 3. Performance against seasonal flu Tier 1 targets, at 11 February 2014 C&V Wales 2013/14 (to date) 2012/13 (end of season) 2013/14 (to date) Seasonal flu vaccination Over 65s receiving flu vaccine 75% 69.2% 69.3% 67.8% Under 65s in eligible at-risk groups 75% 51.3% 51.5% 50.5% receiving flu vaccine Pregnant women receiving flu vaccine 75% 44.5% 44% 41.7% Frontline healthcare workers who receive flu vaccine 50% 43.5% 36.5% (all staff) 41.4% Seasonal flu vaccine uptake figures for staff, over 65s, and under 65s in at-risk groups, are generally a reliable indicator of recent performance. However, the other figures should be interpreted with caution, because: Uptake by age 4 is a new measure which has only recently been reported. Although this remains a useful overall measure of vaccine uptake, the clinical relevance of the threshold which has been set for the target (95%) is unclear (see footnote for explanation), and interpretation is difficult. 1 The current combined uptake for Cardiff and Vale of 86%, for example, represents uptake ranging from 90.6% (MMR2) to 93.8% (HibMenC). A more meaningful combined target, equivalent to 95% uptake of individual vaccinations and therefore providing herd immunity, would be 90.25%. Childhood immunisation figures are often reported with a significant time lag since immunisation was due. For example, two of the vaccinations which contribute to the age 4 figure above are due to be given when the child is 12-1 For individual vaccinations under the previous COVER system, 95% targets were directly related to the level at which herd immunity is reached in a population (i.e. if 95% of people in a cohort are vaccinated, the remaining 5% are protected passively because disease is unlikely to circulate in the community). However, in order to reach a combined target of 95%, a much higher level of vaccination against individual diseases is required, equivalent to 97.5% uptake. This is because individual uptake rates are multiplied together to reach the combined uptake rather than averaged. A more meaningful combined target, equivalent to 95% uptake of individual vaccinations and therefore providing herd immunity, would be 90.25%. Performance Against Immunisation Page 2 of 5 People, Performance & Delivery Committee

3 13 months old, so uptake figures now reflect parental behaviours and UHB actions in Any changes in uptake quarter by quarter will also generally represent historic changes in behaviour and historic UHB actions. Uptake figures for pregnant women are known to be a significant underestimate of true uptake (by around 15-20% absolute uptake). An audit at point of childbirth is considered to more reliable and these figures are not yet available. For example, in 2012/13 reported uptake of 44% for Cardiff and Vale contrasted with a figure of 61.6% uptake on manual audit. The uptake figures shown here should not be used as a guide to absolute uptake, but may be of value in showing relative uptake compared with the rest of Wales. These performance measures do not capture the whole immunisation schedule, and do not reflect other key uptake figures of population health importance such as teenage uptake of MMR and HPV vaccination, nor equity of uptake. Therefore assurance on population health coverage of immunisations cannot be gained based on these figures alone. Figures for other vaccinations are regularly monitored and relevant actions put in place by the Immunisation Steering Group. ASSESSMENT Uptake at age 4 Uptake of vaccination at age 4 has increased significantly over the past three quarters, but longer term trends for this measure are difficult to assess as it is a new measure. Key barriers to meeting the target are: o A lack of timely practice-level data on uptake, to help practices understand their uptake, target their efforts appropriately, and share best practice with local surgeries. This is being addressed with new reports being developed by Public Health Wales which are being piloted in Cardiff and Vale from March o An inflated denominator (eligible population) figure used in the calculation for uptake. This is a result of a very high turnover (movements in and out) of children in Cardiff in particular, and means that many children who are on our database do not actually live in Cardiff, so we are not physically able to vaccinate them. To improve this, new Child Health protocols and systems are being developed. Core Child Health capacity is essential to maintain any such system. o The potentially unrealistic combined target threshold of 95%, which necessitates achieving 97.5% uptake of individual vaccines. The clinical benefit and achievability of such a target is unclear. Prudent use of UHB resources would necessitate a clearer understanding of the benefits of 97.5% uptake of vaccinations compared with 95%, once 95% individual uptake (the level at which herd immunity is established) has been achieved in C&V. Taking these factors into account, it is thought 95% individual uptake of vaccines should be achieved in Q2 2014/15 (Jul-Sep 2014) and reflected by Q3 2014/15 (Oct-Dec 2014) in the enhanced, more timely reporting being piloted in Cardiff and Vale. Improvements in the currently reported aggregate performance measure will only potentially be reflected in 3 years time based on actions and changes in uptake now (see commentary above). Performance Against Immunisation Page 3 of 5 People, Performance & Delivery Committee

4 Seasonal flu vaccination Uptake of seasonal flu vaccine among the public aged over 65 and under 65 in at-risk groups has failed to shift significantly towards the target across Wales over the past few years, and a Flu Summit has been set up nationally in March to examine barriers to uptake and potential solutions, with wide stakeholder involvement. Cardiff and Vale UHB representatives will attend this summit. A number of other interventions are being undertaken locally in Cardiff and Vale, detailed in the rolling flu action plan. Uptake among over 65s is relatively close to the 75% target and although little movement has been seen in the last few seasons towards the target, with novel mechanisms to engage the public and offer vaccination in 2014/15 it is thought that the 75% target can be achieved in 2014/15. Uptake among under 65s is significantly below the 75% target and even if something radical changes in public behaviour and UHB actions in 2014, it may still take more than one season for the target to be reached. Variations in clinical practice need to be addressed, such as ensuring that all GP practices proactively invite all under 65 eligible for flu vaccination at the start of the season. This is part of the contractual obligation for practices providing flu vaccination, but practice varies widely within Cardiff and Vale and across Wales. This is an example of inverse care, with patients already aware of flu vaccination and engaging with primary care services more likely to be vaccinated early in the season. Uptake among pregnant women is not yet known, but is thought to be close to 75% if not yet reached. Uptake among staff has increased significantly this year, and is on track to exceed 50% in 2014/15. There is significant variation in uptake between Clinical Boards and improving uptake among the lower performing Clinical Boards is a key aim for 2014/15. RECOMMENDATION The People, Performance and Delivery Committee is asked to: NOTE steady improvements in immunisation rates. NOTE significant challenges to meeting the performance targets. For the age 4 measure this relates as much to the way uptake is measured and the threshold calculated, as clinical uptake. SUPPORT ongoing efforts to improve uptake, in particular ensuring robust Child Health processes are in place. SUPPORT flu vaccination of staff. NOTE the actions being taken to improve the uptake of flu vaccination for staff. Financial Impact No direct impact, but maintaining and improving Child Health processes is key to data quality and may require additional investment depending on whether current efforts to improve the system are successful or not Performance Against Immunisation Page 4 of 5 People, Performance & Delivery Committee

5 Quality, Safety and Experience Offering a wider range of vaccinations to residents will reduce morbidity Standards for Health Services Relevant to Standard 3 Health promotion, protection and improvement Risks and Assurance Equality and diversity There is a risk relating to failure to meet Immunisation targets in the Public Health risk register, and an overall risk for the UHB of failure to meet one or more Tier 1 targets. Detailed plans are in place to improve immunisation uptake to meet the Tier 1 targets Although generally helpful in improving uptake, overall uptake performance measures mask inequalities by geography and ethnicity. There is therefore a risk of inadvertently exacerbating inequalities in an effort to meet the overall uptake target. Performance Against Immunisation Page 5 of 5 People, Performance & Delivery Committee