NHS GRAMPIAN IMMUNISATION PROGRAMMES ANNUAL REPORT 2010/11

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1 NHS GRAMPIAN IMMUNISATION PROGRAMMES ANNUAL REPORT 2010/11 NHS GRAMPIAN IMMUNISATION STEERING GROUP March

2 Table of Content 1. Purpose of this report.3 2. Uptake of immunisation: key points during Update on key actions during Issues arising during Conclusions Key actions for Tables 9 List of Tables 1. Table 1: primary immunisation uptake rates by 12 months old 9 2. Table 2: primary and booster immunisation uptake rates by 24 months old Table 3: primary and booster immunisation uptake rates by 5 years old Table 4: primary and booster immunisation uptake rates by 6 years old Table 5: immunisation uptake rates by SIMD category Table 6: human papilloma virus vaccine uptake in year 3 of the programme Table 7: Seasonal flu vaccination uptake Table 8: Seasonal flu vaccination uptake by clinical risk group in people aged under 65 years Table 9: BCG Table 10: Hepatitis B..14 2

3 1. Purpose of this report Last year the Immunisation Steering Group produced its first comprehensive report describing the organisation and delivery of UK immunisation programmes within Grampian. It is intended to produce a similarly comprehensive report every 5 years, with briefer interim reports published annually during the intervening period. This is our first interim report: its purpose is intended to provide readers with information on local immunisation uptakes during the last financial year and a brief update on issues which arose during the course of the year. Readers seeking detailed information about current UK immunisation policy, including rationale, scope and content of the UK immunisation programme, can find this at Comprehensive immunisation uptake information at national level and for all health boards and community health partnerships can be found at 2. Uptake of immunisation during : key points Our aim is to minimise the risk to Grampian children from serious illness due to infection caused by the bacteria and viruses listed below. In every case our objective is to try to ensure at least 95% of children are protected through vaccination at as early an age as possible. So, whilst the overall uptake of a vaccine is important, it is also essential to make sure vaccines are administered at the most appropriate ages. Delay in take-up of vaccination means a child is left vulnerable to infection at an age when, if infected, he or she is usually at highest risk of a poor outcome. We offer vaccination to all children against the following infections: Tetanus (T) Diphtheria (D) Whooping Cough (P) Polio (IPV) Haemophilus Influenzae B (Hib) Meningococcus C (MenC) Measles, Mumps, Rubella (MMR) Pneumococcus (PCV) We offer vaccination to children in certain higher risk groups against: Tuberculosis (BCG) Hepatitis B (HepB) We offer vaccination to all eligible teenage girls against Human Papilloma Virus infection (HPV). We also offer influenza vaccination annually to children and adults in selected higher risk groups. In addition, pneumococcal vaccination is offered to adults in specific higher risk groups. Information about uptake of this vaccination is not collected systematically and will not be further discussed in this report. 3

4 Tables showing uptake rates for each of the vaccines offered in the childhood and seasonal flu programmes are shown in the last section of this report. The key points to note are: There were good uptakes in Grampian of the primary courses of childhood vaccinations (for DTP, IPV, Hib, MenC, PCV, MMR1). Uptakes at a Grampian level consistently exceeded 95% at 12 months, 24 months, 5 and 6 years of age and were comparable with the Scottish average. With three minor exceptions, vaccine uptakes of over 95% were consistently achieved within the three Grampian areas. There were fairly good uptakes in Grampian of booster vaccinations at 24 months and 5 years of age (for Hib/MenC, PCV, DTP/IPV/Hib, MMR2). Although not consistently achieving 95% uptake, Grampian uptakes exceeded the Scottish average. Uptakes of booster vaccinations at 6 years were generally slightly lower and fell below those achieved in Scotland as a whole. Uptakes of the primary courses and booster vaccinations at 12 and 24 months of age were consistently good, and of a similar level, across all social groups within Grampian. In addition, uptakes amongst more deprived children in Grampian (SIMD 1-3) were generally better than those achieved in Scotland as a whole. The very good MMR uptake in Grampian deserves special mention: at 95.1% (MMR1 at 24 months old) and 92.6% (MMR2 at 5 years), local uptake significantly exceeded the Scottish average. Although there is still some way to go to achieve 95% uptake of two doses of MMR by school age, the trend over recent years has been steadily upwards. The goal of achieving a high level of protection by the time children start to socialise within school is within sight and is key to minimising the risk of local outbreaks of this serious infection saw the third year of implementation of the HPV programme. The uptake of this vaccine within Grampian remained good overall and compared well against the Scottish average. However, the uptake fell very significantly during the year within Aberdeen City ; completion of the three dose course falling to 76.2% (compared with 91.2% in the previous year). The fall in uptake was the result of a planned reduction in the number of opportunities for girls to get HPV vaccination within Aberdeen City schools (from five vaccination sessions in every school each year to three sessions). Uptake of flu vaccination was 75.9% amongst those aged 65 years or more within Grampian, exceeding the Scottish average of 75.4% by a small margin and also the national target of 75%. However, Grampian uptake in people at higher clinical risk aged below 65 years was only 54%, being slightly poorer than the Scottish average of 56.1% and well below the national target of 60%. 4

5 Very limited information is available for regarding uptake of BCG amongst children assessed as being at higher risk. Whilst the number of BCGs being administered to this group is reported, lack of accurate information about the number of children at higher risk means uptake cannot be assessed. Improved arrangements for data collection through SIRS (Scottish Immunisation Recording Scheme) will be implemented in and enable more meaningful information to be reported. A small number of babies born to Hepatitis B positive mothers were identified as requiring post-exposure Hepatitis B vaccine prophylaxis. To be effective, it is important the required four doses of Hepatitis B vaccine are administered at the recommended ages (birth, 1 month, 2 months and 12 months old). At age 12 months, the infant should have a blood sample taken and tested for the presence of Hepatitis B virus to determine if the prophylaxis has been effective in preventing infection. Although the majority of infants received the required four doses of vaccine, few received it within the necessary timescale. To date, none of the infants who have reached 12 months of age have had serology undertaken. 3. Update on key actions identified for implementation during A number of actions were identified as priorities to be taken forward during the year, subject to availability of resource. Success in implementation has been mixed. An extensive local campaign was mounted during the autumn and winter of to encourage unvaccinated girls who had left school, but who still remained eligible for Human Papilloma Virus (HPV) vaccination, to complete the three dose course of injections. Specific funds from the Scottish Government were used to support the campaign. The girls involved were a hard to reach group and over 300 came forward for vaccination. This represents a significant achievement by the primary care and public health staff involved. An exercise was undertaken to check appropriate arrangements are in place to promote uptake of vaccination by children in hard to reach groups of the population. Apart from one exception, we were able to confirm the needs of these groups are being actively addressed by the services concerned. The exception is in relation to the children of Travellers; although substantial efforts are made by a small number of practices to promote immunisation to these children and their parents, there remains concern that more could be done. Enquiry revealed evidence to suggest the issue is much wider than a need to promote access to, and uptake of, immunisation services. Considerably more needs to be done within Grampian to improve access by the travelling community to the full range of primary care services. As a result, the Public Health leads in the three Community Health Partnerships (s) are taking forward work to address this issue together with primary care services within their localities. 5

6 There has been continued recruitment of staff involved in delivering vaccination to the NHS Education Scotland (NES) e-learning course aimed at improving their knowledge and competence. During , a further 88 staff involved with vaccination were recruited to undertake the course bringing the number of students currently undertaking the course in Grampian to 210. Twenty students successfully completed the course during the year. Currently there are more than 60 course mentors throughout Grampian. Limited time within the Health Protection team has delayed the proposed initiative to provide practices with quarterly information on vaccination uptake by their own patients. However, it is intended to pilot this during the coming flu season with flu vaccination uptake information. If practices and managers find this useful in helping identify where targeted support is needed to improve uptakes, the approach will be rolled-out to cover all childhood immunisations later in Issues arising during the course of Cold Chain There continues to be a disappointing flow of incidents where there has been a failure to maintain the cold chain. An audit of these incidents was conducted over a three month period during the autumn of This reported a total of 34 incidents, which resulted in over 19k of vaccine being withdrawn from use and destroyed. The majority of the incidents were potentially avoidable, being the result of failures by staff to record vaccine fridge temperatures accurately or to act promptly in relation to a temperature reading outside the required C range. Early in 2011, a cold chain incident in a general practice required revaccination to be offered to a total of 260 patients. The cost of destroyed vaccine in this one incident was in excess of 3k with replacement vaccine costs of over 1k. There is continuing effort by staff in the Health Protection Team and the Pharmacy Service to encourage and support primary care services to improve their cold chain practice. Currently, a local initiative is being developed to provide a web-based training programme aimed at improving knowledge and management of the cold chain. It is intended to meet the needs of any member of staff (clinical and non-clinical) who has cold chain responsibilities. It will be easy to access and free of charge. In addition, NHS Grampian senior management has been requested to give consideration to requiring general practices to meet the costs of replacement of destroyed vaccine resulting from a failure within the practice to maintain the cold chain. Datix Reports The Datix system is a method for recording patient and staff safety incidents and the action taken to reduce any continuing risk. Reporting of incidents to the system is limited to NHS Grampian-employed staff, therefore excluding staff employed within the majority of general practices. 6

7 Accordingly, the number of incidents reported to the Datix system is likely to under-represent the actual number of vaccine incidents over the last year. During this period 30 vaccine incidents were reported to Datix. Of these, 63% occurred because staff did not check records thoroughly prior to administering vaccine. This resulted in patients receiving the wrong vaccine, unnecessary repeat doses, vaccine at inappropriate intervals and even expired vaccine. Whilst individual human error gave rise to the majority of incidents, in a quarter of cases the incident was attributed to a system failure within practices to have an appropriately robust process in place to ensure consistent implementation of NHS Grampian vaccine handling policy. The majority of these instances of system failure resulted in cold chain disruption. To improve standards and reduce the number of errors made, it is clear staff need reminding of the importance of: checking patient records thoroughly before administering vaccine checking expiry dates before administering vaccine checking fridge temperatures daily and reporting any deviation from +2 0 C to +8 0 C immediately accurate recording of details of vaccine given. Measles Measles is a highly infectious and potentially severe disease that can be prevented by a safe and effective vaccine. When given in two doses, at least 98% of vaccine recipients develop protective immunity against the infection. Measles is re-emerging in Europe. More than 30,000 measles cases were reported by European countries in 2010, a five-fold increase compared to the annual average for the preceding five years. 85% of the reported cases were unvaccinated. The high incidence is continuing in 2011, with significant outbreaks ongoing in France, Spain and Belgium. It is estimated that, in a non-immune population, each case of measles can, on average, be expected to generate secondary cases (compare with Influenza at 1.4 to 4 cases). Consequently, there is a real risk of measles infection being imported into Grampian and a clear need to maintain uptake of MMR vaccine at the highest possible level. The MMR uptake figures in the following table refer to the cohorts of children who attained the ages of 2, 5 and 6 years during the period from April 2010 to March The figures in brackets are the average Scottish uptakes. 7

8 MMR uptake in NHSG (Scotland) for the financial year ending March 2011 NHSG Aberdeen City Aberdeenshire Moray Children aged 2 yrs: % who received 1 dose 95.1 * (93.2) Children aged 5 yrs: % who received 1 dose % who received 2 doses 96.2 (96.1) 92.6 (89.9) Children aged 6 yrs: % who received 1 dose % who received 2 doses 95.2 (96) 92.2 (92.8) NHSG had the highest mainland board uptake of the first dose of MMR in the cohort of children reaching 2 years of age during Based on the above vaccination uptake figures the current level of immunity in the Grampian child population can be estimated as 86% in two year-olds, 95% in five year-olds and 94% in six year-olds. Whilst good, this still means that 1 out of every 5-6 two year-olds and 1 in every 20 five and six year-olds remain susceptible to measles infection. All children under the age of 12 months should be considered as non-immune. Given the above, the most likely local scenario following identification of a case of measles in a child will be spread of infection resulting in a cluster of secondary cases. Despite our existing high levels of vaccine uptake, urgent public health action will be needed to minimise the size of the cluster. 3. Conclusions Immunisation uptakes within the childhood programme remain generally good as does flu vaccination uptake amongst people aged 65 years and older. Substantial ongoing effort by vaccinators will be required to ensure these uptake levels continue to be sustained. Particular emphasis needs to be placed on improving uptake of booster vaccinations at the recommended ages. The fall in HPV uptake within Aberdeen City is of concern and requires early action within Aberdeen City. The delay in delivering post-exposure Hepatitis B vaccine prophylaxis, and failure to implement appropriate serology testing at 12 months of age, in infants identified as being at higher risk is unacceptable. 8

9 The relatively poor uptake of flu vaccination amongst people at higher clinical risk aged less than 65 years is disappointing and requires particular additional consideration during the seasonal flu campaign. There needs to be continued action to maintain awareness of cold chain issues and promote structured learning around vaccination-related issues for all involved in the planning and delivery of immunisation programmes. 4. Key actions for ) Explore ways to reverse the fall in HPV uptake with Aberdeen City. 2) Work with Aberdeen Maternity Hospital, Royal Aberdeen Children s Hospital and general practices to improve the delivery of postexposure prophylaxis Hepatitis B vaccination and serology testing to babies born to HBsAg positive mothers. 3) Implement improved recording of BCG risk status and BCG vaccination. 4) Focus on improving uptake of flu vaccination in those at higher clinical risk aged under 65 years during the seasonal flu vaccination campaign. 5) Continue to promote uptake and completion of the e-learning programme by vaccinators. Continue to utilise all available mechanisms for raising awareness of cold chain issues and other vaccination-related issues to all relevant staff. Promote adoption of lessons learned. TABLES TABLE 1 Primary Immunisation Uptake Rates by 12 months old Evaluation year: 1 April 2010 to 31 March 2011 Born 1/4/09 to 31/3/10 % completed course by 12 months No in cohort DTP/IPV/Hib MenC PCV NHSG Ab City Abshire Moray Scotland Source: SIRS 9

10 TABLE 2 Primary and Booster Immunisation Uptake Rates by 24 months old Evaluation year: 1 April March 2011 Born 1/4/08 to 31/3/09 % completed primary course by 24 months % completed booster course by 24 months No in DTP/IPV/Hib MenC PCV MMR1 Hib/MenC PCV cohort NHSG Ab City Abshire Moray Scotland Source: SIRS TABLE 3 Primary and Booster Immunisation Uptake Rates by 5 years old Evaluation year: 1 April 2010 to 31 March 2011 Born 1/4/05 to 31/3/06 % completed primary course by 5 years % completed booster by 5 years No in cohort DTP/IPV/Hib MenC MMR1 DTP/IPV/Hib MMR2 NHSG Ab City Abshire Moray Scotland Source: SIRS 10

11 TABLE 4 Primary and Booster Immunisation Uptake Rates by 6 years old Evaluation year: 1 April 2010 to 31 March 2011 Born 1/4/04 to 31/3/05 % completed primary course by 6 years % completed booster course by 6 years No in cohort DTP/IPV/Hib MenC MMR1 DTP/IPV/Hib MMR2 NHSG Ab City Abshire Moray Scotland Source: SIRS TABLE 5 Primary Immunisation Uptake Rates by 12 months, and Uptake Rates for MMR1, Hib/MenC and PCV by 24 months by SIMD 2009 category SIMD =most deprived 5 = least deprived Born 1 Jan to 31 Dec 2009 % completed primary course at 12 mths of age DTP/IPV/Hib MenC PCV No in cohort Born 1 Jan to 31 Dec 2008 % completed course at 24 months of age MMR1 Hib/MenC PCV SIMD 2009 No in cohort NHS Grampian Total Scotland Total Source: SIRS 11

12 TABLE 6 Human Papilloma Virus: Uptake in Year 3 of the HPV programme (1 September 2010 to 31 August 2011) HPV immunisation uptake rates for girls in second year of secondary school (S2) in school year 2010/11, (uptake by S2 girls in the previous academic year, , for comparison) Evaluation year: 1 September 2010 to 31 August 2011 No in cohort % uptake of first dose % uptake of second dose % uptake of third dose NHS Grampian 3007 (2894) 91.9 (93.4) 90.5 (92.5) 83.3 (91.0) Ab City 927 (877) 90.8 (93.4) 88.2 (92.5) 76.2 (91.2) Abshire 1496 (1456) 93.0 (94.2) 92.3 (93.5) 87.8 (92.0) Moray 571 (543) 91.6 (91.7) 90.5 (90.6) 84.2 (88.6) Scotland 28932(28778) 91.8 (93.6) 90.2 (92.5) 81.0 (90.9) Source: SIRS TABLE 7 Seasonal Flu Vaccination Uptake (October 2010 to March 2011) The Scottish Government target flu vaccination uptake for people aged 65 years and older was 75%. The target uptake for people at increased clinical risk aged 64 years or less was 60%. % uptake of flu vaccination People at risk NHS Grampian Scotland Aged 65 yrs and older Aged 64 yrs or less and at increased clinical risk of complications from flu Source: HPS 12

13 TABLE 8 Flu Vaccination Uptake in people aged 64 years or less by individual clinical risk group (October 2010 to March 2011) % uptake of flu vaccination Clinical Risk Group NHS Grampian Scotland Chronic respiratory disease Chronic heart disease Chronic kidney disease Chronic liver disease Chronic neurological disease Multiple Sclerosis and other degenerative disorders Diabetes Immunosuppression Pregnancy and at other clinical risk Pregnancy and not at other clinical risk Carer* TOTAL all clinical risk groups Source: HPS The Scottish Government definition of Carer was someone who, without payment, provides help and support to a partner, child, relative, friend or neighbour, who could not manage without their help. This could be due to age, physical or mental illness, addiction or disability. TABLE 9 Estimated number of BCG vaccines given per year in the BCG programme Neonates Number Neonates 720 Pre school (Aberdeen and Aberdeenshire) 160 School ( Aberdeen, Aberdeenshire and Moray plus 150 Moray pre school) 13

14 TABLE 10 Hepatitis B vaccine given as post-exposure prophylaxis (PEP) to babies born to mothers who are chronic carriers of Hepatitis B virus (i.e. HBsAg positive) During , a total of 11 babies born in Grampian were identified as being eligible for Hepatitis B vaccine prophylaxis. Uptake Average age at which dose given / serology done (target age) Dose 1 100% <24 hours (Birth) Dose 2 100% 37 days (1 month) Dose 3 100% 97 days (2 months) Dose 4 86%* 417 days (12 months) Serology (to determine HBsAg status) Nil - (12 months) * 7 of the 11 infants were eligible for vaccination with dose 4 at the time of writing this report. Of these, 6 had received dose 4. Hepatitis B vaccination is also offered to other infants and children identified as being at higher risk of Hepatitis B infection according to criteria defined within the national immunisation policy. Currently, there is no national or local accurate and systematic collection of data about the numbers of children identified, or their uptake of Hepatitis B vaccination, so it is not possible to provide information about implementation of this practice. 14

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